NEONATAL INTENSIVE CARE NURSING

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First published 2000 by Routledge
11 New Fetter Lane, London EC4P 4EE
Simultaneously published in the USA and Canada
by Routledge
29 West 35th Street, New York, NY 10001
Routledge is an imprint of the Taylor & Francis Group
This edition published in the Taylor & Francis e-Library, 2002.
© 2000 Selection and editorial matter Glenys Boxwell; individual
chapters © the authors
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and
recording, or in any information storage or retrieval system, without
permission in writing from the publishers.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Neonatal intensive care nursing/edited by Glenys Boxwell.
Includes bibliographical references and index.
1. Neonatal intensive care. 2. Infants (Newborn)—Diseases—Nursing.
3. Intensive care nursing. I. Boxwell, Glenys, 1957–
[DNLM: 1. Intensive Care, Neonatal—methods. 2. Neonatal
Nursing—methods. 3. Infant, Newborn, Diseases—nursing. 4. Infant,
Premature, Diseases—nursing.
WY157.3 N438 2000]
RJ253.5 .N467 2000
618.92´01—dc21
99–055486
ISBN 0-415-20339-2 (Print Edition)
ISBN 0-203-18614-1 Master e-book ISBN
ISBN 0-203-18737-7 (Glassbook Format)

Contents

List of figures xii
List of tables xiv
Notes on contributors xv
Preface xix
Acknowledgements xxii
Abbreviations xxiii
Glossary xxvi
1 Advanced neonatal nursing
practice 1
F
IONA ALLAN
Introduction 2
Factors influencing the
development of the neonatal
nurse role 2
The developmental history of
the Advanced Neonatal Nurse
Practitioner role 4
Legal aspects of advanced
neonatal nursing practice 5
Potential areas in neonatal care
for advancing neonatal nursing
practice 6
Evidence-based neonatal care 7
Conclusion 10
References 10
2 Developmentally focused
nursing care 14
T
ILLY REID AND
YVONNE FREER
Introduction 15
Theories on developmentally
focused care 15
Behavioural assessment 19
Sleep-wake states 21
Behaviour 24
The NICU environment 24
Noise hazard 26
Light hazard 26
Handling 28
Contingent care 28
Postural support 30
Equipment 32
Prone position 32
Supine position 33
Side-lying position 34
Developmental models of care 34
Conclusion 38
References 38
3 Resuscitation of the newborn 43
G
LENYS BOXWELL
Introduction 44
Asphyxia 44
Anticipation 46
ABC(D and E) of resuscitation 47
Airway 48
Breathing 48
Circulation 50
Drugs 51
Meconium stained liquor 56
Evaluation of resuscitation 57
Conclusion 58
Case study 59
References 59
4 Management of thermal
stability 64
P
AULINE FELLOWS
Introduction 65
Embryology 65
Mechanisms of heat gain 66
Vasoconstriction 66
Thermal receptors 66
Non-shivering thermogenesis 67
Thermoneutrality 69
Mechanisms of heat loss 70
Conduction 70
Convection 70
Radiation 70
Evaporation 71
Heat exchanged through the
respiratory tract 71
Surface area 71
Immature skin 71
Transepidermal water loss (TEWL) 72
Respiratory water loss 73
Thermal instability 73
Hypothermia73
Cold stress 74
Neonatal cold injury 74
Re-warming in severe
hypothermia75
Hyperthermia76
Management of thermal stability
at delivery 76
The healthy infant 76
Delivery by cesarean section 77
The asphyxiated infant 77
Meconium stained liquor 77
The low birth weight infant 77
Management of thermal stability
in the NICU 79
Radiant warmers 79
Incubators 80
Radiant warmers vs incubators 81
Humidity 81
Skin 83
Heated water-filled mattresses 83
Thermal status during transport 84
Temperature measurement 85
Continuous monitoring 85
Intermittent temperature
recordings 86
Localised hypothermia following
birth asphyxia 86
Conclusion 87
Case study 88
References 89
5 Management of respiratory
disorders 96
J
OAN CAMERON AND
JULIE HAINES
Introduction 97
The development of the
respiratory system 97
Respiration in the neonate 100
Respiratory distress syndrome
(RDS) 101
Pneumonia103
Meconium aspiration syndrome
(MAS) 104
Pneumothorax 106
Pulmonary haemorrhage 107
Acid base balance 108
Respiratory support 113
Continuous positive airway
pressure (CPAP) 113
Positive-pressure ventilation 114
High frequency ventilation
(HFV) 119
High frequency jet ventilation
(HFJV) 119
High frequency flow interrpution
(HFFI) 119
High frequency oscillation (HFO) 120
Negative extrathoracic pressure 121
Extracorporeal membrane
oxygenation (ECMO) 121
Nitric oxide (NO) 122
Liquid ventilation 123
Conclusion 123
Case study 124
References 124
6 Cardiovascular management 129
M
ARGARET H OWAT
Introduction 130
Cardiac embryology 130
Development of the heart 130
Formation of the four chambers of the
heart 132
The endocardial cushions 132
The atria 132
The ventricles 132
Formation of the aortic and pulmonary
trunks 133
The fetal circulation 133
Transition from fetal to neonatal
circulation 136
Cardiac function 137
The cardiac cycle 137
Blood pressure 137
Regulation of blood pressure 138
The management of blood
pressure 138
Congenital heart defects 139
Patent ductus arteriosus 140
Transposition of the great arteries 141
Hypoplastic left heart syndrome 142
Coarctation of the aorta 143
Congestive heart failure 144
Nursing management 145
Clinical assessment 145
Physical examination 145
Evaluation of the pulses, peripheral
perfusion and blood pressure 146
Palpation of the chest wall and the
liver 147
Auscultation 147
Care plan 147
Family support 148
Case study 149
References 149
7 Brain injury in the premature
infant 152
V
ICTORIA CULLENS
Introduction: the vulnerability of the
premature infant brain 153
Subependymal germinal matrix 153
Periventricular vascular anatomic
factors 153
Alterations to cerebral blood flow 154
Hypoxic-ischaemic reperfusion
injury 154
Risk factors for brain injury 154
Periventricular-intraventricular
haemorrhage (PIVH) 156
Clinical features 156
Parenchymal haemorrhagic
infarction 157
Periventricular leukomalacia (PVL) 157
Management 158
Prevention of brain injury in the
premature infant 158
Pharmacological interventions 159
Acute management 159
Post-haemorrhagic ventricular
dilatation 159
Nursing management 160
The outcome of brain injury in the
premature infant 160
Periventricular-intraventricular
haemorrhage 160
Parenchymal haemorrhagic
infarction 161
Periventricular leukomalacia 161
Case study 161
References 162
8 Haematological problems 164
J
ACKIE D ENT
Introduction 165
Jaundice in the newborn 165
Physiology of bilirubin production165
Bilirubin metabolism and excretion 165
Predisposing factors to physiological
jaundice in the newborn 167
Other causes of jaundice 167
Rhesus incompatibility 167
ABO incompatibility 169
G6PD deficiency 169
Breast feeding 170
Management of jaundice 170
Investigation of jaundice 171
Phenobarbitone 172
Intravenous albumin 172
Metalloporphyrins 172
Phototherapy 173
Exchange transfusion 175
Kernicterus (bilirubin
encephalopathy) 177
Haemorrhagic disease of the
newborn/vitamin K deficient
bleeding 177
Disseminated intravascular
coagulation (DIG) 180
Signs of DIC 180
Management 181
Anaemia 181
Top-up transfusions 183
Iron supplementation 184
Recombinant erythropoietin 184
Conclusion 184
Case studies 184
References 185
9 Pain and comfort in neonatal
intensive care 188
P
AMELA EAST
Introduction 189
Theory of pain 190
Infant response to pain and distress191
Chemical responses 192
Behavioural response 192
Physiological response 194
Assessment of pain in a non-verbal
client group 194
Pain assessment tools 195
Potential consequences of untreated
pain 198
Relief strategies 199
Non-pharmacological measures 199
Pharmacological measures 201
Conclusion 205
Case studies 206
References 207
10 Fluid and electrolyte balance211
DEE BERESFORD AND
G
LENYS BOXWELL
Introduction 212
Embryological development 212
Physiology of urine production 212
Sodium balance 213
Hyponatraemia 214
Hypernatraemia 215
Potassium balance 215
Hypokalaemia 216
Hyperkalaemia 216
Chloride balance 216
Calcium and phosphate balance 217
Water management 217
Fluid requirements 218
Monitoring fluid balance 218
Glucose homeostasis 220
Renal handling of glucose 220
Hypoglycaemia 221
Hyperglycaemia 223
Acute renal failure 224
Investigations 224
Management 225
Dialysis 226
Peritoneal dialysis 226
Continuous haemofiltration 228
Conclusion 229
Case studies 229
References 231
11Nutritional management of
the infant in the NICU
K
AYE SPENCE 234
Introduction 235
The gastrointestinal system 236
Outcomes of nutrition 238
Growth 239
Assessment 240
Feeding the NICU infant 241
Requirements 242
Parenteral nutrition 243
Enteral nutrition 244
Methods 245
Specific problems in the NICU 248
Family support 249
Conclusion 251
Case studies 251
Further reading 254
References 254
12Neonatal infection 259
G
LENYS BOXWELL
Introduction 260
Acquisition of antenatal infection 260
Acquisition of intrapartum infection 262
Late onset and nosocomial infection263
The susceptible host 264
Signs of neonatal sepsis 268
Respiratory signs 268
Thermal signs 269
Cardiovascular signs 269
Skin signs 269
Abdominal signs 270
Neurological signs 270
Investigations 270
Surface swabs and site cultures 270
Haematological tests 272
Cerebrospinal fluid 273
Urine 273
Management of the infected
newborn 274
General supportive therapy 274
Antimicrobial therapy 276
Adjunctive therapies 279
Conclusion 279
Case study 280
References 280
13Diagnostic and therapeutic
procedures 285
E
LIZABETH HARLING
Introduction 286
Gastric tube placement 286
Naso/orogastric tube 286
Transpyloric tube 287
Endotracheal tube placement 289
Chest drain placement 291
Blood sampling 294
Capillary blood sampling 294
Venous blood sampling 296
Arterial blood sampling 297
Peripheral vein cannulation 298
Peripheral artery cannulation 300
Peripheral venous longline 301
Umbilical vessel catheterisation 303
Umbilical vein catheterisation
(UVC) 303
Umbilical artery catheterisation
(UAC) 305
Lumbar puncture 307
Urine sample collection 309
Suprapubic aspiration 309
Case studies 310
References 314
14Neonatal anaesthesia 316
B
EVERLEY GUARD AND
LIAM BRENNAN
Introduction 317
Preoperative assessment 317
Problems of prematurity affecting
anaesthesia 317
Associated congenital/chromosomal
abnormalities 318
Familial anaesthetic problems 320
Preoperative investigations and
preparation 320
Investigations 320
Preparation 321
Premedication 321
Transfer to the operating theatre 322
The operating theatre environment322
Intraoperative management 322
Induction of anaesthesia 322
Airway management 323
Maintenance of anaesthesia 324
Emergence from anaesthesia and
extubation 324
Analgesia 325
Opioids 325
Paracetamol 326
Non-steroidal anti-inflammatory
drugs 326
Local anaesthesia 326
Fluid therapy 329
Maintenance fluid 329
Replacement of fluid lost by
evaporation/sequestration 329
Replacement of blood loss 330
Anaesthetic equipment 330
Airway equipment 330
Breathing systems 332
Ventilators 334
Equipment for maintenance of
body temperature 334
Equipment for intravenous fluid
administration 335
Anaesthetic monitoring 335
Cardiovascular monitoring 335
Respiratory monitoring 336
Temperature monitoring 337
Postoperative care 337
Postoperative apnoeas 337
Post-extubation stridor 338
Respiratory insufficiency 338
Assessing the need for postoperative
ventilation 339
Conclusion 339
Case study 340
References 340
15Surgical aspects of neonatal
intensive care nursing 343
STEVIE BOYD
Introduction 344
General principles of management 344
Thermoregulation 345
Respiratory function 345
Gastric decompression 345
Fluid and electrolyte balance 345
Pharmacological support 347
Transportation 347
Postoperative considerations 347
Most commonly encountered
congenital disorders 347
Oesophageal atresia (OA) and
tracheo-oesophageal fistula
(TOF) 347
Case study 351
Mechanical intestinal obstruction 352
Congenital diaphragmatic hernia
(CDH) 358
Abdominal wall defects 362
Most commonly encountered
acquired disorders 366
Necrotising enterocolitis (NEC) 366
Case study 368
Spontaneous bowel perforation 368
Miscellaneous disorders 369
Cystic hygroma 369
Teratoma 370
Ovarian cyst 370
Testicular torsion 371
Biliary atresia 371
Conclusion 372
References 373
16Neonatal transport 377
S
TEVIE BOYD
Introduction 378
The transport team 378
Transport vehicles 380
Hazards of transportation 380
Equipment required for transporting
a sick neonate 382At the referral unit 383
At the referring unit 384
The parents 385
The return journey 385
Back at the referral unit 386
Legalities involved with transporting
a sick neonate 386
Conclusion 387
References 387
17Family support 389
C
ATH HENSON
Introduction 390
Family support—a definition 390
Family-centred care 390
The components of family support 391
The caregiver group 391
The recipient group—the infants
and their families 392
The neonatal environment 393
Strategies for providing family support
in the neonatal setting 394
Supporting the family in the
antenatal period 394
Supporting the family during the
admission period 394
Being aware of the profound effects
of separation 396
Supporting the family during the
discharge preparation period 397
Supporting the family of the dying
infant 398
Basic principles of family support 399
Working in partnership with
parents 399
Facilitating parents’ attachment
with their infant 403
Planning programmes of family
support 404
Conclusion 405
Case studies 406
References 409
18Ethics and neonatal nursing 412
H
ELEN MCBEAN
Introduction 413
Ethical theories: an overview 413
Utilitarianism or consequentialism413
Deontological or Kantian theory 414
Virtue-based theory 414
Rights-based theory 414
Ethical principles 415
Respect for autonomy 415
Non-maleficence 416
Beneficence 417
Justice 417
Fetal rights 419
Respecting maternal autonomy:
the giving of informed consent 420
Should fetal rights exist? 421
Ethics in practice 423
Case study 424
Conclusion 426
Legal references 427
References 427
19Medication in the newborn 430
C
ATHERINE HALL
Introduction 431
Pharmacokinetics 431
Therapeutic drug monitoring (TDM) 436
Unlicensed medicines 437
Drug administration 438
Conclusion 439
Case study 439
References 440
Appendix: Normal values in the
neonate 443
Index 445