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Course: Pediatric Nursing

Topic: Nursing Care in the Neonatal Intensive Care Unit (NICU)

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Module Goals

Learners will be able to:

Discuss the role of the nurse in the Neonatal INtensive Care Unit (NICU) setting
Identify fetal development milestones
Explain nursing considerations for care of neonates in the NICU
Identify common neonatal conditions seen in the NICU

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Nurse Role in NICU

Attends deliveries of premature neonates or high risk deliveries to care for neonate, anticipating the fetus needs.
Incorporates family centered care of neonate.
Engages with the interdisciplinary team to provide best care possible for the neonate.

Gomez-Cantarino et al., 2020

Contact info: info@nursesinternational.org

While a neonate is any infant through day 28 of life, many premature infants stay in NICU until they are ready for discharge. Nursing care of the neonate is quite varied and can look vastly different based on NICU setting. While some neonatal intensive care nurses may work at high level NICUs with many ventilated patients, other neonatal intensive care units may offer only non-invasive respiratory support. Meeting the nutritional needs of neonates may look like anything from total parenteral nutrition to exclusively breast or bottle feeding. The nurse provides the highest level of care possible at the nurse’s facility.
The nurse should use family centered care of the neonate, encouraging parents to be engaged in as much care of the infant as possible. We know this empowers parents to eventually be the primary caregivers at home and statistically may lead to an earlier discharge for the neonate (Gomez-Cantarino, S., et al., 2020). Family centered care should also be culturally competent, incorporating aspects of the neonate’s culture where appropriate.
The nurses does not care for the neonate in isolation, but rather involves the whole interdisciplinary team. This may include occupational therapy (for bottle feeding or developmental milestone assessment), a child life specialist (for developmentally appropriate interaction), a lactation nurse (to assist with breastfeeding), physicians, or advanced practice providers

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Nurse Role in NICU (Continued)

Neonate

Neonate is any infant through day 28 of life
Ranges from premature ventilated patient to full term patient with elevated bilirubin levels

Gomez-Cantarino et al., 2020

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Fetal Development

Central Nervous System: Conception through delivery
Cardiac: Conception through week 8
Pulmonary: Week 4 through week 36
Limbs: Week 4 through week 8
Eyes: Week 4 through delivery
Teeth: Week 6 through delivery
Hard and soft palate: Week 6 through week 8
Ears: Week 4 through week 20

CDC, 2022

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Fetal Development

CDC, 2022

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Nursing Considerations in NICU

Thermoregulation

Support through isolettes/incubator
warming mattress
warmed delivery room
radiant warmer
plastic coverings (never over face)
humidified air and oxygen

Hydration and fluid support

Knobel-Dail, 2014

Younesian et al., 2015

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Nursing Considerations in NICU

Nutrition and feeding

Nasogastric tube feedings
parenteral nutrition,
breast or bottle feeding

suck-swallow-breath ability of neonate not present until 32 weeks gestation

Knobel-Dail, 2014

Younesian et al., 2015

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Nursing Considerations in NICU

Respiratory support

Dependant on neonate’s individual needs

May require intubation with ventilator
Continuous positive airway pressure (CPAP)
Oxygen via nasal cannular
Or proper position for airway exchange on room air

Gomez-Cantarino, et al., 2020

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Nursing Considerations in NICU

Developmental support for the Neonate

Positioning, swaddling
Support parental involvement - multiple benefits, including continuity of neonate care on discharge and potential for earlier NICU discharge

Gomez-Cantarino, et al., 2020

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Nursing Considerations in NICU

The nurse anticipates what the neonate will need if born premature.
Type of respiratory and nutritional support utilized depends on infant needs, provider, and facility.

CDC, 2022

Petrillo et al., 2019

Sanchez-Garcia, 2020

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Nursing Considerations in NICU

If born at:

22-32 weeks: Requires advanced respiratory support, thermoregulation,nutritional support.
32-36 weeks: May require some respiratory support, thermoregulation support, may need nutritional support.
36-40 weeks: Likely to adapt to extrauterine life with little assistance.

CDC, 2022

Petrillo et al., 2019

Sanchez-Garcia, 2020

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Critical Thinking Question

Discuss the importance of thermoregulation in the premature newborn.

How is this maintained in the NICU?

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Common Neonatal Conditions

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Transient Tachypnea of the Newborn (TTN)

Caused by delayed absorption and clearance of alveolar fluid
More common in children whose mothers had asthma
Presents within 2 hours of birth and can last up to 3 days after birth
Lung sounds can be clear or have rales
Treatment is supportive (ie: oxygen or albuterol inhaler)
This is a self-limiting condition

Hermansen & Mahajan, 2015

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Respiratory Distress Syndrome (RDS)

Occurs in premature neonates (<34 weeks)
Thought to be caused by surfactant deficiency and under development of lungs
Most common in white male neonates and neonates from diabetic mothers
May note grunting, tachypnea, retractions, cyanosis on assessment

Hermanson & Mahajan, 2015

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Respiratory Distress Syndrome (RDS)

Giving a laboring mother IV corticosteroids 24 hours prior to delivery may decrease respiratory distress
Treatment includes respiratory support with CPAP and lung surfactant
Takes longer to resolve and requires more intervention than TTN

Hermansen & Mahajan, 2015

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Meconium Aspiration Syndrome (MAS)

Caused by aspiration of fetal meconium (stool)

Amniotic fluid likely stained with meconium at delivery

Occurs in term and post term neonates
MAS can lead to bacterial infection, pneumonia, lung irritation

Hermansen & Mahajan, 2015

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Meconium Aspiration Syndrome (MAS) Continued

May note tachypnea, grunting, retractions, cyanosis on assessment.
May require intubation with deep suctioning.
Treat with CPAP and supplemental oxygen.

Hermansen & Mahajan, 2015

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Persistent Pulmonary Hypertension (PPH)

In healthy neonate, physiologic changes after delivery decrease pulmonary vascular resistance and increase pulmonary perfusion.
PPH occurs when underlying respiratory problems prevent these healthy physiologic changes.
Risk factors include maternal diabetes, cesarean section, maternal obesity, black race.

Hermansen & Mahajan, 2015

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Persistent Pulmonary Hypertension (Continued)

Loud second heart sound and murmur may be heard on assessment, may have respiratory distress or oxygen needs.
Diagnosed with echocardiogram.
Treatment commonly includes oxygen, may require ventilatory support, pulmonary vasodilator (inhaled nitric oxide or sildenafil).

Hermansen & Mahajan, 2015

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Apnea of Prematurity

A pause in breathing for more than 15-20 seconds in a neonate born <37 weeks gestation.
Apnea lasting longer than 20 seconds may cause bradycardia.
Etiology poorly understood, likely due to immature responses to hypoxia and hypercapnia along with immature pulmonary reflexes.

Zhao et al., 2011

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Apnea of Prematurity (Continued)

Treatment

prone positioning
methylxanthine administration (ie: IV caffeine or theophylline
intermittent nasal positive airway pressure
continuous positive airway pressure (CPAP)

Zhao et al., 2011

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Patent Ductus Arteriosus

Reese & Laughon, 2015

In healthy neonates, Ductus Arteriosus typically closes within a few days due to physiologic changes.
In premature neonates, Ductus Arteriosus closure may take days to weeks.

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Patent Ductus Arteriosus (Continued)

Reese & Laughon, 2015

Murmur may be noted on assessment.

Treatment may include surgical closure,

medical management with NSAID, or

monitoring upon discharge if still patent.

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Intraventricular Hemorrhage

Occurs mainly in neonates born <32 weeks gestation.

Complex etiology, likely due to alterations in cerebral blood flow, delicate vasculature, and genetics.

No specific nursing or medical interventions have proven effective in prevention.

McCrea & Ment, 2008

Gross et al., 2021

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Intraventricular Hemorrhage (Continued)

Cranial ultrasounds may be used for screening.

Treatment may include administration of phenobarbital, indomethacin or ibuprofen, activated factor VII.

McCrea & Ment, 2008

Gross et al., 2021

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Necrotizing Enterocolitis

Occurs when any part of the bowel becomes necrotic
Etiology poorly understood, but mortality linked to:

Prematurity
severity of underlying diagnosis
,and low birth weight

Signs may include:

abdominal distension
high gastric residual
frank blood in stool

Guthrie et al., 2003

Clark et al., 2012

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Necrotizing Enterocolitis

Risk factors include:

low birth weight
antenatal glucocorticoids
vaginal delivery
need for ventilatory support,
exposure to glucocorticoids and indomethacin
umbilical artery catheter
and low APGAR score

Guthrie et al., 2003

Clark et al., 2012

Treatment may include:

bowel rest,
antibiotic administration,
surgical intervention

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Necrotizing Enterocolitis

Risk factors include:

low birth weight
antenatal glucocorticoids
vaginal delivery
need for ventilatory support,
exposure to glucocorticoids and indomethacin
umbilical artery catheter
and low APGAR score

Guthrie et al., 2003

Clark et al., 2012

Treatment may include:

bowel rest,
antibiotic administration,
surgical intervention

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What Would The Nurse Do?

A nurse is taking care of an infant 12 hours after birth. While assessing the infant the nurse obtains the following vital signs:

Heart rate: 149

Respiratory rate: 65

SpO2: 88%

Temperature: 37.2 C (98.9 F)

The infant's lungs are clear to auscultation.

The infant is alert and feeding well. What should the nurse do next?

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Blausen.com staff (2014). 'Medical gallery of Blausen Medical 2014'. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

CDC. (2022). Fetal Development Chart - cdc.gov. Fetal Development Chart. Retrieved May 20, 2022, from https://www.cdc.gov/vitalsigns/fasd/Fetal-Dev-Chart.pdf

Clark, R. H., Gordon, P., Walker, W. M., Laughon, M., Smith, P. B., & Spitzer, A. R. (2012). Characteristics of patients who die of necrotizing enterocolitis. Journal of Perinatology, 32(3), 199-204.

Contact info: info@nursesinternational.org

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References

Gómez-Cantarino, S., García-Valdivieso, I., Moncunill-Martínez, E., Yáñez-Araque, B., & Ugarte Gurrutxaga, M. I. (2020). Developing a Family-Centered Care Model in the Neonatal Intensive Care Unit (NICU): A New Vision to Manage Healthcare. International journal of environmental research and public health, 17(19), 7197. https://doi.org/10.3390/ijerph17197197

Gross, M., Engel, C., & Trotter, A. (2021). Evaluating the Effect of a Neonatal Care Bundle for the Prevention of Intraventricular Hemorrhage in Preterm Infants. Children, 8(4), 257. https://doi.org/10.3390/children8040257

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References

Guthrie, S. O., Gordon, P. V., Thomas, V., Thorp, J. A., Peabody, J., & Clark, R. H. (2003). Necrotizing enterocolitis among neonates in the United States. Journal of perinatology, 23(4), 278-285.

Hermansen, C. & Mahajan, A. (2015). Newborn Respiratory Distress. Am Fam Physician. 2015 Dec 1;92(11):994-1002y: from cause to treatment. Eur J Pediatr 170, 1097–1105 (2011). https://doi.org/10.1007/s00431-011-1409-6

Knobel-Dail, R. B. (2014). Role of effective thermoregulation in premature neonates. Research and Reports in Neonatology, 4, 147+. https://www.dovepress.com/getfile.php?fileID=21517

Contact info: info@nursesinternational.org

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References

McCrea, H. J., & Ment, L. R. (2008). The diagnosis, management, and postnatal prevention of intraventricular hemorrhage in the preterm neonate. Clinics in perinatology, 35(4), 777–vii. https://doi.org/10.1016/j.clp.2008.07.014

Petrillo, F., Gizzi, C., Maffei, G. et al. (2019). Neonatal respiratory support strategies for the management of extremely low gestational age infants: an Italian survey. Ital J Pediatr 45 (44). https://doi.org/10.1186/s13052-019-0639-5

Contact info: info@nursesinternational.org

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References

Reese, J., & Laughon, M. M. (2015). The Patent Ductus Arteriosus Problem: Infants Who Still Need Treatment. The Journal of pediatrics, 167(5), 954–956. https://doi.org/10.1016/j.jpeds.2015.08.023

Sánchez-García, A. M., Zaragoza-Martí, A., Murcia-López, A. C., Navarro-Ruiz, A., & Noreña-Peña, A. (2020). Adequacy of Parenteral Nutrition in Preterm Infants According to Current Recommendations: A Study in A Spanish Hospital. International journal of environmental research and public health, 17(6), 2131. https://doi.org/10.3390/ijerph17062131

Contact info: info@nursesinternational.org

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References

Younesian, S., Yadegari, F., & Soleimani, F. (2015). Impact of Oral Sensory Motor Stimulation on Feeding Performance, Length of Hospital Stay, and Weight Gain of Preterm Infants in NICU. Iranian Red Crescent medical journal, 17(7), e13515. https://doi.org/10.5812/ircmj.17(5)2015.13515

Zhao, J., Gonzalez, F., & Mu, D. (2011). Apnea of prematurity: from cause to treatment. European journal of pediatrics, 170(9), 1097–1105. https://doi.org/10.1007/s00431-011-1409-6

Contact info: info@nursesinternational.org

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