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1
Nurses ’Knowledge regarding Nursing Care of preterm
Infants in Wad Medani Pediatric Teaching Hospital,
Gezira State, Sudan (2015)
Elkhansa Ibrahim Daffalla Elzubeir
B. SC in Nursing Science (2012)
University Of Gezira
A Dissertation
Submitted To University for Partial Fulfillment for the
Requirements for Award of the Degree of Master of
Science
In
Pediatric Nursing
Department of Nursing
Faculty of Applied Medical Sciences
2
Nurses' Knowledge regarding Nursing Care of Preterm Infant in
WadMedaniPediatric Teaching Hospital, Gezira State, Sudan
(2015).
Elkhansa Ibrahim Daffalla Elzubeir
Examination Committee:
Name Position Signature
Dr. Ietimad Ibrahim Abd Elrahman Kambal Chair Person ………………….
Dr. Saida Abd Elmjeed External Examiner ………………….
Dr. Amna Eltoum Ibrahim Hassan Internal Examiner ………………….
Date of Exmination: 1/9/2015
3
4
Nurses' Knowledge regarding Nursing Care of Preterm Infant in
WadMedaniPediatric Teaching Hospital, Gezira State, Sudan
(2015).
Elkhansa Ibrahim Daffalla Elzubeir
Supervision Committee:
Name Position Signature
Dr. Ietimad Ibrahim Abd Elrahman Kambal Main Supervisor ………………….
Dr. Bothyna Bassyonie Elssyed C0- Supervisor ………………….
Date of Exmination: 1/9/2015
5
Dedication
To the formation of patience , optimism and hope
To each of the following in the presence of god and his messenger,
My dear mother
To those who have demonstrated to me what is the most beautiful
of my brother to the big heart, My dear father
To the people who paned our way of science and knowledge
All our teachers distinguished to the taste of most beautiful
moment with my friends I guide this research
6
7
Acknowledgment
Firstly I wish to thank God for Affording me the time and the ability needed
to face difficulty.
I am heartedly thankful to my main supervisor Dr. Ietimad Ibrahim Abd-
Elrhman Kambal and my Co-advisor Dr. Bothyna Bassyonie Elssyed Etewawhose
encouragement, guidance and support from the initial to the final level enabled me to
develop an understanding of the subject.
Thanks for all those who helped me in collection, analysis and typing of this
thesis.
I Lastly my thanks and appreciation to my family whose showed tolerance and
supported me emotionally and financially.
8
Nurses' Knowledge regarding Nursing Care of Preterm Infantin WadMedani
Pediatric Teaching Hospital, Gezira State, Sudan (2015).
Elkhansa Ibrahim DaffallaElzubeir
Abstract
Preterm birth refers to the birth of less than 37 weeks gestational age. Liable of many
complications such as respiratory difficulties, pneumonia, respiratory distress syndrome,
apnea of prematurity. A subspecialty of nursing, neonatal nursing, focuses on providing
care to newborn infant and families when the newborn’s health condition require more
support than traditional postnatal wards. A descriptive hospital based study was
conducted in wad medani Pediatric Teaching Hospital aimed at assessing nurse’s
knowledge regarding nursing care of preterm infant in Pediatric Teaching Hospital from
October 2014 to April 2015. The sample size consisted of all available (62) nurses who
work in the hospital were included in the study during the period of the study 2014-
2015. Data was collected using a questionnaire designed by the study. The data was
analyzed performed by statistical package for social sciences (SPSS). The results
showed that (80.7%and79) of the study sample responded with correct complete answers
regarding definition and causes of preterm infants respectively, while (16.1% and
19.4%) of them responded with correct incomplete answers. (82.3% and 50%) of the
study sample responded with correct complete answers regarding symptom for delivery
of preterm infant and the method of respiration of preterm infant respectively, while
(17.7% and 35.5%) of them responded with correct incomplete answers. In contrast this
result showed that (80% and 85.5%) of the study responded with correct complete
answers regarding nursing care for infant and precaution that can be taken to maintain
the temperature of preterm infant respectively, while (16.1% and 14.5%) of them
responded with correct incomplete answers. (56.5% and 62.2%) of the study sample
responded with correct complete answers regarding the method of give oxygen to the
preterm infant and the problems that occur for preterm infant respectively , while (32.3%
and 37.1%) of them responded with correct incomplete answers. (32.3% and 62.9%) of
the study sample responded with correct complete answers regarding the preterm infant
care at home and feeding of preterm infant respectively, while (46.8% and 29%) of them
responded with correct incomplete answers. The study concluded that nurses’
knowledge regarding care of preterm infant were inadequate. The study recommended
that routine and periodic training program must be done to all nurses to improve
knowledge about of preterm in pediatric teaching Hospital.
9
ود مدني مستشفى في بالطفل الخديج التمريضية لعناية تجاها معرفة الممرضين والممرضات
م. 2015 ،السودان الجزيرة ،ولاية التعليمي للأطفال
الخنساء إبراهيم دفع الله الزبير
ملخص الدراسة
كثيرة مثل صعوبة .تجعله عرضة لمضاعفات الحمل عمر من أسبوعا 37قلمن الولادة طفل المبكرة الولادة تشير
في التنفس، ذات الرئة، متلازمة ضائقة التنفس. يتمثل دور التمريض على توفير الرعاية للطفل المولود والأسر
في وصفية راسة تد أجري عندما تكون حالة المولود تحتاج إلى دعم أكثر من الكلمات التقليدية بعد الولادة. وقد
الرعاية التمريضية للأطفال الخدج في الفترة من اتجاه الممرض معرفةقييم الت تهدف الأطفال التعليمي مستشفى
للأطفالممرضة تعمل في مستشفى ود مدني التعليمي 62م.يتكون حجم العينة من 2015إلى أبريل 2014أكتوبر
حليل البيانات باستخدام في هذه الفترة وتم جمع البيانات باستخدام الأسئلة المركبة التي تم عملها بواسطة الباحث. تم ت
٪{ 79.0٪ و 80.7: }نتائجنا تال ( وأظهرSPSSالتحليل الإحصائي للعلوم الاجتماعية)
منعينةالدراسةأعطتإجاباتكاملةصحيحةفيمايتعلقبتعريفوأسبابالولادةالتي أدت إلى ولادة الطفل الخديج على التوالي،
إجابات أعطت منعين الدراسة٪{ 50.0٪ و 82.3} غير مكتملة. الصحيحة ٪ أعطت إجاب19.4٪ و 16.1 فيحينان
٪ و 17.7 فيحينان ،التوالي جعل للطفل الخدي طرق التنفسالخديج ولادة الطفل عن أعراض صحيحة ة كامل
الدراسة معينة٪{ 85.5٪ و }80.7 النتاجان تهذه ظهر لمقابلا ا غير مكتملة. في إجابات صحيحة٪ أعطت 35.5
درجة على للحفاظ تخاذها التأتيم=التمريضية للطفل والاحتياط الرعاية شأنفي الصحيحة الكاملة عطت إجاباا
٪ و 56.5غير مكتملة . } تصحيحه إجاب عطت منهما٪ 14.5٪ و 16.1 لي فيحينان ليلاتوا الخديجالطفل حرارة
لا الخدج والمشاكالأطفال إلى الأكسجين عطاء إ طريقة كاملة عن الصحيحة أعطت إجاب الدراسة معينة٪{ 62.9
غير مكتملة. إجابات صحيحةعطت منهما٪ 37.1٪ و 32.3 فيحينان، التوالي لأطفال الخدج على أن تحدث لتئمكن
الأطفال وتغذية المنزل الخديجينعن العناية بالطفل كاملة تصحيحه جابا أعطتا لدراسة منعينا٪{ 62.9٪ و 32.3}
غير مكتملة. أوضحت الدراسة أن معرفة الصحيحة جاب تا ط ع أ ٪ منهم29.0٪ و 46.8 فيحينان، للتوالي الخدج
الممرضات لعناية الطفل الخديج غير كافية. توصي الدراسة بأنه يجب إعطاء الممرضات برنامج التدريب الروتيني
والتدريب على فترات لتحسين المعرفة عن الطفل الخديج في مستشفى الأطفال التعليمي.
10
List of contents
Topic Page
Dedication iii
Acknowledgement iv
Abstract V
vi ملخص الدراسة
List of tables vii
List of Figures viii
Contents ix
List of abbreviations xi
CHAPTER ONE INTRODUCTION
1. Introduction 1
1.1 Background 1
1.2 Problem Statements 1
1.3 Justification 3
1.4 Objectives 4
1.4.1 General Objective 4
1.4.2 Specific Objectives 4
CHAPTER TWO LITERATURE REVIEW
2.1 Definition and description of preterm babies 5
2.2 Causes of prematurity 5
2.3 Risk factors of prematurity 5
2.4 Exams and test to premature infant 6
2.5 Incidence of prematurity 6
2.6 Characteristics of preterm baby 6
2.7 High risk condition related to prematurity 7
2.8 Treatment of prematurity 15
2.9 Maintaining Nutrition balance 24
2.10 Nursing care to maintain skin integrity 25
2.11 Invasive procedure 26
2.12 Infection control measurement 27
2.13 Discharge the premature infant 27
2.14 Follow-up care 28
2.15 Prevention of prematurity 28
2.16 Prognosis of prematurity 29
2.17 Previous Studies 30
11
CHAPTER THREE MATERIALS AND METHODS
3.1 Study Design 34
3.2. Study Area 34
3.3 Study Population 35
3.3.1 Inclusion Criteria 35
3.3.2Exclusion Criteria 35
3.4 Sample Size 36
3.5 Data Collection Tool 36
3.6 Sample Technique 36
3.7 Data analysis 36
CHAPTER FOUR RESULTS AND DISCUSSION
4.1 Results 37
4.2 Discussion 52
CHAPTER FIVE CONCLUSION AND RECOMMENDATIONS
5.1 Conclusion 56
5.2 Recommendations 57
References 58
Appendixes 63
12
List of Tables
Table Title Page
(3.1) Distribution of Manpower in Pediatric Teaching Hospital {2015} 35
(4.1) Distribution of the study sample according to their gender and age groups: 37
(4.2) Distribution of the study sample according to their level of education 38
(4.3) Distribution of the study sample according to their knowledge about Definition
and Causes of delivery preterm infant 42
(4.4) Distribution of the study sample according to their knowledge about Symptoms
for delivery of preterm infants and The method of respiration of preterm infant 43
(4.5) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 44
(4.6) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 45
(4.7) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 46
(4.8) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 47
(4.9) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 48
(4.10) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 49
(4.11) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 50
(4.12) Distribution of the study sample according to their knowledge about nursing care
of preterm infant 51
13
14
List of Figures
Figure Title Page
(4.1) Distribution of the study sample according to their years of
experience 39
(4.2) Distribution of the study sample according to receiving training
program before regarding nursing care of preterm infant 40
(4.3) Distribution of the study sample according to their source of
knowledge regarding nursing care of preterm infant 41
15
List of Abbreviations
NS Nephrotic Syndrome
MCD Mesangioproliferative Glomerulonephritis
FSGS Focal Segmental Glomerulosclerosis
WHO World Health Organization
WD Western Diet
DPP-4 Dipeptidyl Peptidase-4
IR Insulin Resistance
MRI Magnetic Resonance Imaging
TEM Transmission Electron Microscopy
MPGN Mesangial Proliferative Glomerulonephritis
RPGN Rapidly Progressive Glomerulonephritis
GFR Glomerular Filtration Rate
MN Membranous Nephropathy
SLE Systemic lupus Erythematosus
FSGS Focal segmental Glomerulosclerosis
MCD Minimal Change Disease
CMP Comprehensive Metabolic Panel
LMWH Low Molecular Weight Heparin
OAC Oral Anticoagulants
16
Chapter One
1. Introduction
1.1 Background:
Preterm birth refers to the birth of a baby less than 37 weeks gestational age.
Premature birth, commonly used as a synonym for preterm birth, refers to the
birth to baby before its organs mature enough to allow normal post natal
survival, growth and development as a child. Premature infants are at greater risk for
short and long term complications, including disabilities and impediments in growth and
mental development. Significant progress has been made in the care of premature
infants, but not in reducing the prevalence of preterm birth. Prematurity is the major
cause of neonatal mortality in developed countries. In the normal human fetus, several
organ systems mature between 34 and 37 weeks, and the fetus reaches adequate
maturity by the end of this period. The lungs are one of the last organs to develop in the
womb, these premature babies typically spend the first days/weeks of their life on a
ventilator. Premature can be reduced to a some extent by using drugs to accelerate
maturation of the fetus and to a extent by preventing preterm birth. (Goldenberg, 2008).
Nurses are in a key position to disseminate knowledge provide proper care for preterm.
Preterm infant usually show physical signs of prematurity in reverse proportion to the
gestational age. They are at risk for numerous medical problems affecting different
organs systems. (Goldenberg, 2008).
1.2 Problem Statements:
Worldwide: Preterm birth a planned teaching program was conducted in the year
of 2006 in Gwalior (M.P) regarding Preterm birth and its side effect management on
knowledge, attitude and practice by using knowledge questionnaire. California birth
certificate data linked with maternal and neonatal hospital discharge data in 1999 were
used (N = 520, 739). Hyperemesis was defined by ICD-9 codes. The frequency,
estimated charges, and demographic characteristics associated with hyperemesis patients
17
were assessed. Maternal and neonatal perinatal outcomes were compared by maternal
hyperemesis status. Hyperemesis complicated 2,466 of 520,739 births. The average
length of stay was 2.6 days and the average charge was $5,932. singleton hyperemesis
infants were smaller (29.21% vs. 20.8%; P <. 0001). Hyperemesis occurs in 473 of
100,000 live births and is associated with significant charges. Infants of mothers with
hyperemesis have lower birth weights and the mothers are more likely to have infants
that are small for gestational age. A simple random technique was utilized for selecting
a sample ,in this study the sample size is 30 in number. The aim of this study was to
assess and evaluate the knowledge, attitude and practice of nursing personnel regarding
administration of chemotherapy and its side effect of management. The major finding of
this, shows that mean posttest practice score [44.2] of nursing personnel was
significantly higher than their mean pretest practice score [26.4]as evident by ‘t’ value
[29]= 26.47p <0.05. (WHO 2007)
In developed countries: Preterm babies is the most, chronic kidney disease in
developed countries. The estimated incidence of preterm ranges between 2-7 cases in
children per 100,000 children per year. Childhood nephritic syndrome can occur at any
age but is most common between the ages of 1.5 and 5 years. It seems to affect boys
more often than girls. This high rate of affected individuals possess a significant public
health problem. {Fahim, Sahar S, 2009}.
In Sudan: Research done in Wad Medani Teaching Hospital by Amel Mahmud,
2003 – University of Gezira about the quality of care of neonate with critical care
condition. The author said that the birth of the baby is a wonderful yet very complex
process. Many physical and emotional changes occur for the mother and the baby at the
time of birth a baby must make physical adjustment to adapt with the external life. Many
baby systems change dramatically from the way they functioned during fetal life being
born prematurely, having a difficult delivery, or birth defects can make these changes
even more challenging. The study aimed to determine the causes and level of neonatal
morbidity and mortality, to determine the midwifery and nursing role in immediate care
of all neonates, and to examine the quality of equipment and the nursing role in the care
of neonate with critical care condition. The study depended on primary data based on a
18
simple random sample of (171) babies from neonate care survey in Wad Medani
pediatrics hospital 2003.
The study shows a high level of neonatal mortality and morbidity (11.7%). May
be due to poor antenatal care, delivery itself (place and the quality of birth attendance),
while the time is very important determinant for neonatal morbidity and mortality, most
baby take more time from decision to seeking care to admission. The quality and
availability of the equipment in the nursery is not adequate because it is either not
existent or not operating. (Amel, 2003).
1.3 Justification:
The preterm baby delivered before 37 weeks of gestational age with un complete
functional system, so they need proper care, which must started immediately at birth e.g.
he have un mature respiratory system with low surfactant level, the deficiency of oxygen
to the brain can lead to brain death.
Premature infant's accounts for the majority of high risk newborns, preterm
faces a variety of physiologic handicaps. The premature need to stay in the postnatal
ward or to be placed in special unit called a neonatal intensive care unit (NICU), or
special care baby unit. The babies need (proper observation and care from competence
nurses and careful assessment and other therapeutic interventions as need, so current
investigation their knowledge and attitudes are urgent to upgrade their known results in
enhancing their role.
19
1.4 Objectives:
1.4.1 General Objective:
To study nurses' knowledge regarding nursing care of preterm infant in
Pediatric Teaching Hospital, 2015.
1.4.2 Specific Objectives:
Assess nurses' knowledge regarding preterm infant such as feeding, temperature,
oxygen incubator …etc.).
20
2. Literature Review
2.1 Definition and Description of preterm babies
Preterm baby is that borne less than 37 weeks of pregnancy regardless of the
birth weight. The newborn whose gestation age uncertain would have to be appraised by
both obstetricians "by sonograghy, measuring biparietal diameters of the head and
biochemical of amniotic fluid and by pediatrician by "neurological and general physical
examination. (Lorrain,BR. Et al. (2008).
2.2 Causes of prematurity:
The cause of preterm labor is unknown. Multiple pregnancies, make up about
15% of all premature births. Health conditions and events in the mother may contribute
to preterm labor e.g., Diabetes, heart diseases, infection (such as a urinary tract infection
or infection of the amniotic membrane), kidney diseases. An "insufficient" or weakened
cervix, also called cervical incompetence. Birth defects of the uterus and history of
preterm delivery (Lippincott Williams and Wilking 2006). any changes in the health of
pregnant woman as poor nutrition before or during pregnancy, preeclampsia – the
development of high blood pressure and protein in the urine after the 20th
week of
pregnancy, premature rupture of the membranes (placenta previa) also patients who had
under gone previous induced abortions have been shown to have a higher risk of preterm
birth only if the termination was performed surgically but not medically. (Lippincott
Williams and Wilking 2006).
2.3 Risk factors of Prematurity:
Number of factors have been identified linked to higher risk of preterm birth e.g.
African – American ethnicity. Age of the mother (younger than 18 or older than 35
years), lack of prenatal care, low socioeconomic status, use of tobacco, cocaine, or
amphetamines, abdominal massage, which is cultural practice, also has a role about 19%
of preterm birth among women in developing countries, women with vaginal bleeding
21
during pregnancy are at higher risk for preterm birth, Poly hydramnios or too little
oligohydramnios are also at risk. (Goldenbirg, RL Culhare, JF,Iams, JD. Romero. 2008)
2.4.Exam and test to a premature infant
Blood gas analysis, blood tests to check glucose, calcium, and bilirubin level.
Continuous cardio respiratory monitoring chest X-ray with fine, diffuse reticulo granular
or “ground glass” pattern and air bronchograms (clerkship 2004)
2.5. Incidence of prematurity
Preterm birth occur in approximately 7% of live birth of white infants and rate of
14% of African live birth preterm babies death account for 80%-90% of infant mortality
in first year of life. 9.6% of all birth were preterm in 2005 at U.S.A, which translates to
about 12.9 million births definable as preterm. Approximately 85% of this Barden was
concentrated in Africa and Asia, where 10.9 million births were preterm about 0.5
million preterm births occurred in Europe and the same number in north America while
0.9 million occurred in Latin America and the Caribbean. The highest rates occurred in
Africa, where 11.9% and 10.6%, respectively, of births were preterm Europe, where
6.2% of the births were preterm, had the lowest rate.
2.6. Characteristics of preterm baby
The appearances of preterm at birth depend upon the gestational age. A premature
infant will have a lower birth weight, than a full-term infant. Common physical signs of
prematurity are soft flexible ear cartilage. The preterm infants lies in a “relaxed attitude”
limbs more extended, his body size is a small. The head is disproportional large than
chest (3 cm or greater). Preterm’s abdomen appears large as compared with limbs. His
posture like frog leg position. Both anterior and posterior fontanels are large, the skull
bone are soft.(Madlon. K,2007).
The skin of preterm baby has less subcutaneous fat and his veins are easily
noticeable. The preterm baby24-26 week, typically covered with vernix caseosa, but in
very immature less than 25 weeks gestation vernix is absent. Lanugos are usually
22
extensive covering back, forehead, forearms and sides of the face. There are few or no
creases of soles of feet. The hair is fine and feathery. (Gils trap, 2002). The nipple areola
is poorly developed and barely visible and the cord is white, fleshy and glistening. The
genitalia is not fully developed, in male the testes may be in the inguinal canal or in the
abdominal cavity, there are minimal rugae are present. In female labia majora fail to
cover the labia minora, it’s appear widely separated, the clitoris is very prominent.
Neurological signs include, Grasp reflex of preterm infants is week. Also heel to
era maneuver of preterm infant’s heel is easily brought to the ear, meeting with no
resistance. Musculoskeletal swallowing reflexes will be absent before 33 weeks
gestation. Deep tendon reflexes such as chills are diminished. Preterm baby is much less
active than mature baby and rarely cries, if he does, the cry is week. Scarf sign the
preterm infants elbow may be easily brought across the chest with little or no resistance.
The eyes of preterm baby
Most preterm appear small pupil reaction is present; ophthalmoscope examination
is extremely difficult because vitreous humor is hazy. The eye is bulge and orbital ridges
are prominent, preterm baby has degree of myopia because of eye globe depth. (Parul
data,2009).
2.7. High risk conditions related to prematurity
Premature babies are susceptible to number of problems and illness in early
postnatal period including the following:
23
2.7.1. Respiratory difficulties
There numerous deficits in the respiratory system, Decreased number of alveoli,
deficit surfactant level, smaller lumen in the respiratory system, greater collapsibility of
respiratory passage, Immature and friable capillaries in the lungs. These conditions lead
to rapid shallow and irregular respiration with apneal attack. Also lack of lung surfactant
make the preterm baby extremely vulnerable to respiratory distress syndrome, so
breathing work is greatly increase. (Annamma, 2009)
2.7.2.Pneumonia
Pneumonia can be acquire In the uterus through transaplacental transfer of organism
and aspiration of pathogens from amniotic fluid of mothers with chorioamnionitis or
During/After delivery through aspiration of infected materials. The signs and symptoms
of pneumonia are lethargy or irritability, poor feeding Temperature instability,
tachycardia, apnea, cyanosis, retractions, grunting, nasal flaring and retractions.
Pneumonia treats by early identification of neonate at risk of morbidity and mortality.
Eradicate the pathogen with medication. Monitor respiratory status, oxygen support, and
mechanical ventilation. Watch for worsening apnea, bradycardia, suctioning, blood
products minimal handling to avoid extra stress and watch for seizures.
2.7.3. Respiratory distress syndrome (R D S)
Incidence 10% for all premature infant ,and 50% for 26 weeks to 28 weeks. Risk
factor for RDS are low gestational age .Male ,born to diabetic mother ,born after an
asphyxia insult before birth, born after maternal –fetal hemorrhage ,multiple gestation
.RDS Complex respiratory disease characterized by diffuse alveolar atelectasis of the
lungs. Primarily caused by a deficiency of surfactant, this leads to higher surface tension
at the surface of alveoli, which interferes with normal exchange of oxygen and carbon
dioxide. Signs and symptoms of RDS include difficulty in establishing normal
respiration, expiratory grunting while the infant is not crying, intercostals and sterna
retractions due to increased rib cage compliance and decreases lung compliance, nasal
24
Flaring, cyanosis, tachypnea, treatment and nursing care are prevent & minimize
atelectasis, treat underlying cardiovascular infections, thermoregulation, pain
management. Maintain po2 & oxygen saturation levels, Recognize importance of
weaning oxygen and other ventilator parameters. Utilize proper endotracheal suctioning
techniques and provide mouth & skin care. Also maintain proper positioning, provide
adequate fluid & electrolyte balance. Monitor blood glucose levels, reduce
environmental stressors. (Dole SM, 2007).
2.7.4 Bronchopulmonary dysplasia
A secondary disease that develops in neonates treated with positive pressure
ventilation and oxygen for primary lung problems such as RDS, the clinical features are
hypoxemia with prolonged oxygen requirement, tachypnea with increased work of
breathing, episodic bronchospasm with wheezing, abnormal postures of neck and upper
trunk. BPD treatment by preventive measures begins prenatally with preventing
prematurity and using a single course of antenatal steroids. Careful use of oxygen and
exogenous surfactant treatment, Wean ventilator and oxygen support slowly. Pre
oxygenation(increasing FiO2 just before suction) may help prevent hypoxemia with
suctioning .Kangaroo care promotes bonding .use sucrose with nonnutritive sucking
before painful procedure to decrease pain (Parnl data,2009)
2.7.5 Apnea of prematurity
Apneal episodes frequency accompanied by cyanosis, bradycardia, pallor or
hypotonic the exact cause unknown but thought to be due to immature CNS.
Apnea managed by, cardiac and respiratory monitoring until no apnea episodes for
5 to 7 days, Neutral thermal environment, careful position ,avoid flexion and
hyperextension of the neck ,Attention to gastric tube placement and infusion rate
during tube feeding .the nurse should assess infants color, perfusion, respiratory rate
,heart rate, position and oxygen saturation. Document frequency and severity of episodes
25
and type and amount of stimulation required to interrupt the event and ensure dag and
mask set-ups oxygen available at infant bedside (Narayan I,2003).
2.7.6 Patent ducts arteriosis (PDA):
The most common cardiac complication in premature infants, incidence
inversely related to gestational age, occurs in 80% of infants with a birth weight
<1.200g. The general symptoms are congestive heart failure, increased need for oxygen,
inability to wean from ventilator, widened pulse, an active pericardium, bounding
peripheral pulses and tachycardia. Management with fluid restriction and diuretics may
be the initial approach. Indomethacin has been effective in closing PDAs. (Dosage
depends on weight, gestation and renal function). Continually assess high-risk infants for
pulse, heart rte, pulse pressure, perfusion, and auscultation for the presence of a murmur.
Assess infant after indomethacin for closure, decreased urine output and
thrombocytopenia, teach and reassure parents. (Emily, S. 2009).
2.7.7 Thermal irregularity:
The smaller and immature the infant, the greater the difficulties in temperature
control. The major problem is hypothermia and there are physical and physiological
reasons for this size alone places the small infant at a thermal disadvantage heat
production is related to mass which is low-heat loss is related to surface area which is
relatively high. Lack of subcutaneous tissues means poor insulation of the heated core
from the cool surrounding. A poor developed stratum corneum result in a very high
evaporative water and there for heat loss. The ability to conserve heat by
vasoconstriction and increase heat production by metabolism is reduced overheating is
rarely a problem unless the infant is warmed by a very powerful device where is
uncontrolled. (Adams, S. 2006).
Preterm babies has high surface area to body weight ratio and little subcutaneous
fats over the first few days, they lose water rapidly through their skin, these physical
characteristic make it difficult to them to maintain thermal stability unless special
measurement are taken. The baby temperature may fall (1-3c) during first 2 hours.
26
Because preterm baby cannot shiver or sweat to regulate body temperature he depend on
environmental control of keeping him warm. (Gilstrap, L. 2002).
2.7.8.Nutritional deficiencies
As ability of preterm infant to suckle is limited and had small stomach capacity,
they often required to be fed for some weeks after birth using nasogastric tube. Recent
work suggests that breast milk which may be fortified with commercial calories and
minerals supplementations, formulated specially for very low birth infant (under 1.5kg),
resulting in rapid growth and development regurgitation of milk in to esophagus is
common among preterm babies, as shown by esophageal PH monitoring, and even the
presence of an endotracheal tube does not prevent it from being aspirated in to the lung.
(Robert M.2007).
When the lungs are normal ,the tube feeding has little or no effect on lung function
,but when the lung are abnormal a tube feed of only 5ml of milk has been show to
produce a small reduction in arterial po2 for about 30min. During suckling, a fall in
arterial po2 and a small rise in arterial pco2 has been shown in preterm infants. It is
important to be aware of this effect in babies recovering from respiratory distress
syndrome and those with bronchopulmonary dysplasia. (Adams, 2006).
Hypoglycemia considered in preterm infant when blood glucose is less than
20mg/ml during the first day or less than 30mg/dl on subsequent days. It may seen as
secondary problem to prenatal stresses like asphyxia, hypothermia, infection
polycythemia, respiratory distress and neurological disturbances. The signs in preterm
are apnea with cyanosis and tachypnea with irregular breathing. The baby should be
nursed in worm or thermonutral environment with careful observation of at risk
situation and prevention of hypoxia and hypothermia. In symptomatic infant with
convulsions ,25percent dextrose 2ml/kg intravenously is given as a bolus. If there are no
convulsions, 10% dextrose 2ml/kg/iv bolus is given followed by continuous infusion of
10 percent dextrose at a rate of 6-8 mg/kg/minute. Blood glucose level to be checked
every ½ hourly. Infusion rate to be reduced only if last two glucose estimation is more
than 60mg /dl( Parnl data, 2009).
27
Liability to infection
Preterm infants have delicate surface and limited immunological complement and
they are more susceptible to infection, they have low level of IgG at birth but IgM begin
to rise during few weeks after birth reached a peak at tenth month. Preterm infants do
not show signs and symptoms that seen in term infants such as fever, shivering and
sweating. Clinical state change from bacteremia to septicemia, associated meningitis can
be easily pass undetected. Therefore, in any infection it is necessary to perform aseptic
screening of urine, blood and cerebrospinal fluid by culturing, and according to the
culture, broad spectrum antibiotics can be given (Nassir Gamal 2000).
Neonatal sepsis
Deficiencies in neonatal host defenses predispose to infection due to defect in
anatomic barriers (Injuries during delivery, skin abrasion or during invasive procedure in
the nursery like umbilical artery catheter & endotracheal tube) (Nassir Gamal 2011).
Necrotizing Enterocolitis
It is the most common neonatal intestinal emergency; it is characterized by
intestinal ischemia, most often involving the terminal ileum. It has three major factors
include bowel wall ischemia, bacterial invasion of the bowel wall and enteral feedings.
The neo porn may have generalized symptoms of early sepsis including temperature
instability, lethargy, feeding intolerance abdominal distension and bloody stool. The
goal of management is to stabilize the neonate, treat infection in addition to resting the
intestinal tract by discontinuation of oral feeding, initiating intravenous access for fluid
and antibiotics and applying nasogastric tube to decompress gastrointestinal tract (Parul
Data 2009).
28
Hematologic problems
The preterm hematologic problems occur as a result of many factors, e.g. increase
capillary friability ,increase tendency to bleed, slowed production of red blood cells
(because of rapid decrease in erythropoiesis after birth) and also loss of blood from
frequent laboratory tests and decreased red blood cell survival related to relatively larger
size of the RBCs and increased permeability to sodium and potassium( Nasser Gamal,
2011).
Intraventricular hemorrhage: occurred as small hemorrhage in the lateral ventricles in
the brain, in preterm especially who had hypoxia or severe respiratory problems .few
infant develop hydrocephalus.(American Academy of pediatrics 2000).
2.7.13.Neonatal jaundice
The preterm baby has usually physiological jaundice and liability to develop
kernictreus result from high concentration of indirect bilirubin in the blood and
excessive break down of red cells. Pathological jaundice occurs in the 24hours.
This may be due to increased production caused by blood group incompatibility,
hereditary spherocytosis, non spherocytic hemolytic anemia, G-6-P deficiency,
thalassemia vitamin k3 induced hemolytic, and pyloric stenosis or large bowel
obstruction.
Other causes include decreased clearance caused by in born error of metabolism.
Drugs and hormones, Hypothyroidism cystic fibrosis and criggler Nagger syndrome. So
this baby managed with careful nursing, phototherapy and exchange transfusion and
rehydration. (Parnl data, 2009).
2.7.14 intra ventricular hemorrhage
29
50% of premature will die, associated primarily with prematurity Infants 28 weeks
gestation. The baby can be stable; sometimes only decreased hematocrit or hemoglobin
level .may involve over several hours and include decreased activity ,hypotonic ,alter
consciousness ,respiratory disturbance, can develop rapidly ,with seizures ,decelerate
posturing ,fixed pupil.(Balesteri,et al ,2000).
2.7.15.Anemia of prematurity
Premature infant less than 32 weeks gestational age, has a lower hemoglobin
concentration and more rapid postnatal decline of hemoglobin level, which achieves a
nadir 1 to 12 months after birth. The blood volume of preterm infant is 90-100ml/kg.
The physiologic anemia noted at 1 to month of age in preterm infants in a normal
process that does not result in signs of illness and does not require any treatment. It is
believed to be related to several factors, including increased tissue oxygenation
experienced at birth, shortened red blood cells life span, and low erythropoietin levels.
(Robert M.2006).
2.7.16.Retinopathy of prematurity (ROP)
An acquired ocular disease that leads to partial or total blindness in children. It
occurs due to effect of oxygen toxicity of the developing blood vessel of the premature
infants retina. The preventive precaution for preterm with oxygen therapy must have
PO2level monitored by pulse oximerer .when blood PO2 level is high than 100mmgh
the risk of disease increase .the goal of treatment for ROP is prevention of blindness,
surgical therapies-laser photocoagulation and cry therapy .(Gerald B .et al 2006).
2.7.17THE Renal problem
The premature newborn have immature renal function is unable adequately excrete
metabolites , to concentrate the urine ,to maintain the balance in acid –base ,fluid ,or
electrolytes.
30
2-7-18.Central nervous system problem
The preterm baby’s central nervous system susceptible to injury from various
sources ,e.g. birth trauma with damage to immature structures ,impaired coagulation
process, including prolonged prothrombin time ,recurrent anoxic episodes.( Robert
M.2006).
2-7-19 Prematurity and intrauterine growth retardation
More recently .infant of extremely low birth weight ,less than 750g,have been
referred to as immature neonate .historically was defined by a birth weight of 2500 or
less, but today infant who weigh 2500 or less at birth ,”low birth weight infant
(LBW).are consider to be premature with a shortened gestational period .to be intra
uterine growth retardation for their gestational age or both .prematurity and intra
uterine growth retardation (IUGR) are associated with increase neonatal morbidity and
mortality(Gerald B .et al 2006).
2.8.Treatment of prematurity:
The nurse has important role in the management of the preterm babies since they
need specialized environment, optimal heat balance, and reasonable degree of isolation,
ambient oxygen and closely observation. When premature labor develops and cannot be
stopped, the health care term will prepare for high-risk birth. The mother may be moved
to a center that specifically cares for preterm infants in, neonatal intensive care unit.
After birth the baby is admitted to a high-risk nursery. The infant is placed under a
warmer or in a clear, heated box called an incubator, which controls the air temperature.
Monitoring machines track the baby’s breathing, heart rate, and level of oxygen in the
blood. Infants usually unable to coordinate sucking and swallowing before 34weeks
gestation. Therefore, the baby may have a small, soft feeding tube placed through the
nose or mouth into the stomach of premature or sick infants, nutrition may be given
through a vein until the baby is stable enough to receive al nutrition in the stomach. If
the infant has breathing problems, a tube may be placed into the trachea, a machine
called ventilator will help the baby breathe. Some babies whose breathing problems are
31
less severe receive continuous positive airway pressure (CPAP) with small tube in the
nose rather than the trachea. Or they may receive only extra oxygen. Oxygen may be
given by ventilator, CPAP, nasal prongs, or an oxygen hood over the baby’s head.
(Sandral, et al, 2006).
2.8.1. Delivery room management risks:
Tendency to have difficulty with transition, Vulnerable to cold stress, lung
immaturity and RDS, intracranial hemorrhage, hypoglycemia, potential foe oxygen
related injuries, high risk for developing NEC. The nurse must avoid rough handling
during resuscitation, Reduce heat loss even if resuscitation not required. Preterm infant
may require endotracheal intubation and surfactant administration soon after birth.
Administer medication slowly as recommended, follow glucose level carefully,
glycogen stores may be decreased. Infant may experience hypoglycemia secondary to
Prenatal compromise, Maintain normal oxygen range after resuscitation. (Robert , et al,
2006).
2.8.2 Surfactant therapy
Surfactant coats the inside of the alveoli; it prevents collapse (atelectasis) & keeps
alveoli open at the end of expiration, prophylactic therapy appears more beneficial than
rescue therapy, It is given via endotracheal tube, Multiple doses lead to improved
clinical outcomes. (Emily slone, et at, 2009).
2.8.3. On admission to the nursery
The baby should be weighed and measured (head circumference, chest and height).
Placed in cot or incubator, rectal temperature should be taken. After brief medical
examination the following observation should be charting by the nursing staff hourly
respiration rate, counted for one minute. Incubator &room temperature , recorded at the
same time and Environmental oxygen concentration.
The finding should be entered on remark and nurse should be record observation
such as “becoming active” “sucking movement” “remains lethargic” any abnormal
32
behavior should be recorded and reported. Ongoing care: this directed particularly
towards maintenance of respiration, baby temperature, and establishment of feeding and
prevention of complication. (King. M. et at, 2000).
2.8.4. Maintaining of respiration:
Preterm baby has normally irregular breathing (a few quick breath or period of 15-
20 seconds without respiratory effort he has true apnea not associated with Bradycardia).
Preterm baby can nurse without O2 therapy, oxygen should be given if only respiratory
difficulty or if any sign of hypoxia noted such as increased rapid pulse, Rapid shallow
respiration, flaring of nares, Cyanosis, dyspnea, Grunting, retraction. (Geraled, et al,
2006).
2.8.5. Preterm on O2 therapy
O2 concentration should not be exceeding 70% in the cot or incubator particularly
if the baby weight less than 1800g because 100%oxygen lead to pulmonary edema and
retinopathy of prematurity. When O2 is being administrated to any preterm baby arterial
oxygen should be continuously monitored and concentration of O2 in the incubator
should be measured and charted. (Randi G, et al, 2006).
Methods of oxygen administration:
1. Incubators Oxygen: In incubator O2 concentration under 40% can be achieved
but higher concentration require reduction in the incubator air intake by use of
special red disc or can be achieved by delivery in to a blood. O2 should be
warmed and humidified. (Nasser Gamal,2010).
2. Oxygen hood: Is a clear plastic shell round the baby head allows easy access to
the chest, trunk and extremities &permits control inspirited O2& gas temperature
and humidity.
Gas flow rate equal or greater than 10-15L/min.
33
3. Face mask: Face mask for preterm should be available in the emergency tray.
Flow rate of it 8L/minute. Excessive pressure on the face should be avoided.
Suitable size to fit the contours of the baby is less than 5ml; volume space
correctly positioned mask should cover the child nose and mouth but not the
eyes. (Nasser Gamal.2010).
Whatever the route of administration of the nurse should:
1.Wash hands before and after procedure.
2.Inspect the baby response to O2 therapy.
3.Maintaining the flow rate of O2.
4.Maintaining suitable level of distal water in humidifier bottle.
5.Maintain the child in position than promotes lung expansion.
6.Assesst vital signs and breathing pattern.
7.Monitoring O2 saturation (saO2).
In most case it is possible to reduce and finally discontinue oxygen by age of 24 to 36
hour although very small baby may require short intermittent for several days
particularly following handling. Some time the child needs airway patent by aspiration
of secretion through a suction machine or wall outlets. Catheter size in preterm baby
from 5-6 French. (King. E.M, et al, 2000).
2.8.6.Procedure of suctioning:
1. Wash hands and wear sterile gloves.
2.Semi prone position or semi lying position with patient head turn to one side for oral
suctioning or neck hyper extended for nasal suctioning.
3.Set the pressure on the section for wall unit 50- 90mmhg and for portable unit 2-
5mmhg.
34
4.Pick up the sterile catheter and attach it to the suction unit.
5.Make approximate measures for insertion, on the tube, appropriate measure is the
distance between the tip of the nose and ear lobe. Hold the catheter at this mark.
6.Moisture the catheter tip by dipping in the saline or sterile water.
7.Gently insert catheter nostril and posterior pharynx.
8.Apply suction by your finger on occluding on/off part.
9.Withdraw the catheter gently on rotating movement, both inserting the catheter and
suctioning should not take more than 5 seconds.
10.Wipe the catheter with sterile gauze, flushing it with sterile water.
11.Record the baby’s response to the suctioning, the type, and amount odor of
suctioning material.
12.Reassess respiratory rate, heart rate and chest sound. (David Hull/ Derk. 2002).
35
2.8.8.Maintaining thermal stability:
At delivery room and operating theater are usually kept at a temperature
considered suitable for adults but which is cold for the new born. The naked infant loses
heat by convection and radiation and by evaporation of amniotic fluid from the wet skin.
The body temperature of a small preterm can easily fall by 1c every 5min and this is
particularly likely to occur if delivery takes place unexpectedly at home. The fall of
temperature is associated with an increase risk of acidosis, hypoxia and respiratory
distress. (Robert, et al, 2007).
The newborn infant should be dried at delivery, wrapped in a warm dry blanket and
given to the mother to hold -skin to skin contact with the mother is an effective way of
maintaining body warmth. Exposure for weighing, cord care and fixing of name bands
should be minimizing and bathing avoided. A supplementary heat source such as a
radiant warmer is necessary. (Madlon-kay, et al, 2007).
Nursing consideration:-
1.Most healthy term and preterm infants can be nursed closed and wrapped in a cot in
a warm room. This is both comfortable and thermally safe.
2.Very small infant may need to be nursed clothed in an incubator to provide
sufficiently warm ambient temperature.
3.Heated water-filled mattress can be used to provide conductive heat to a preterm
infant nursed in a cot in the usual way. The mattress is a polyvinylchloride bag filled
with 10 liters of water which is heated electrically by a foil pad and controlled to provide
a set temperature between 35 and 38 c degree. Its advantages are that it is cheap simple
and does not depend on a constant unbroken supply of electricity (because of its stored
heat), so that is particular useful in developing countries. It is also more comfortable for
the infants and appealing to their mothers, but is only of use if the infants are healthy
and does not need to be nursed naked for observation and access. (Madlon-kay, et al,
2007).
36
4.the incubator provides a warm environment suitable for nursing small or risk infant
,particularly if they need to be naked for observation and assess ,air within the Perspex is
warmed by a heater and circulated by a fan .
The heater output can be controlled into ways; in air made the incubator air temperature
is set to appoint between 30and 37 and the heater is thermostatically 4.the incubator
provides a warm environment suitable for nursing small or risk infant ,particularly if
they need to be naked for observation and assess ,air within the Perspex is warmed by a
heater and circulated by a fan .
5.The heater output can be controlled into ways; in air made the incubator air
temperature is set to appoint between 30and 37c and the heater is thermostatically
controlled to reach and maintain this temperature.
In servo mode a thermostat probe is taped to the infant’s abdominal skin and the
desired skin temperature is set- the heater output varies to provide an air temperature
which maintains the set skin temperature. In practice air mood controls is simpler to use,
safer and result in a very constant ambient air temperature regardless of the condition of
the infant and the amount of care he is receiving. Servo control result in wide fluctuation
in air temperature during periods of handling, the probe can become detected or wet, and
the infants own attempts at thermoregulation are overridden so that a fever is disguised.
(Clerk ship, et al,2004).
Incubator
An incubator (or open warmer or isolate) is an apparatus used to maintain
environmental conditions suitable for a neonate (newborn baby). It is used in preterm
babies or for some ill full-term babies. Protection from cold temperature, infection,
noise, drafts and excess handling Incubators may be described as bassinets enclosed in
plastic, with climate control equipment designed to keep them warm and limit their
exposure to germs.
37
Hypothermia
It occurs when body temperature is below 36.3c axillary. Signs and symptoms:
Cold feet, weak sucking ability, or inability to nurse, Lethargy weak cry, skin color
changes from paleness and cyanosis to peripheral mottling or plethora, tachypnea, and
tachycardia, lethargy, Apnea and Brady cardia. High risk of hypoglycemia, metabolic
acidosis , respiratory distress, and abnormal clotting factors (intraventricular
hemorrhage, pulmonary hemorrhage) (Margaret, et al, 2003).
Nursing care for hypothermia
1.The incubator should always be warmed before placing a newborn.
2.The use of double walled incubator.
3.The newborn is clothed and warmly warped in blanket when removed from the
warm environment of the incubator for feeding or cuddling.
4.Inside or outside the incubator, head covering is effective in preventing that loss.
5.Compare the newborns temperature with the temperature in the incubator
(axillary temperature procedure).
6.Monitoring of body temperature should be recorded hourly for hour and then
four hourly until stabilization unless exposed to nursing and medical procedure.
7.Rectal temperature is suitable for preterm baby.
8.Devotion in the baby temperature from 36.5-36c should alert nurse and
physician 1 heat regulation to illness.
9.Monitor the signs of hypothermia (redness and flushing).
10.Avoid situation that might predispose to heat loss such as exposure to cool
air, draft or cold mattress.
38
11.Incubator temperature should be as the same time of checking body
temperature, normally heating temperature is 30-23c.
12.If the baby’s skin temperature or air temperature control, check of servo
control function desired set point is 36c.
13.Incubator phototherapy will increase body temperature about 0.5c so such
premature baby needs extra metabolic demands. (Titus, et al 2005).
Hyperthermia
Body temperature is above 37.5c axillary. Signs and symptoms are cry, Warm skin
that may appear flushed or pink initially and pale later, sweating, although it isn’t
apparent due to the inability of the newborn to sweat, pattern similar to hypothermia
may develop as the problem continues: increased metabolic rate, irritability, tachycardia
and tachypnea, Dehydration, intracranial hemorrhage, heat stroke, and death.
(Malden,2007)
Nursing care for hyperthermia
Cool the newborn by removal external heat source by removing any thing
that block heat loss such as radiant warmer.
Check the heating control for proper function and proper position.
Consider source of heat e.g. direct sun light, heater and lights as possible
causes of hyperthermia. Excessive covering with blankets and a hat and
elevated environmental temperature can cause a newborns body temperature
to rise into febrile range.
Remove extra blankets.
Observe for manifestation of infection, or central nervous disorders.
During the cooling process skin, axillary, and environment temperature
should be monitored and record every 30 minutes. (Sophie,2000).
39
2.9.Maintaining nutrition balance:
Preterm baby is attempting to continue to maintain rapid rate of intrauterine
growth, because of this he require larger amount of nutrition.
Nursing considerations:
1.Maintaining parental fluid as often order, to prevent hypoglycemia 10% dextrose
with water 60-80ml/kg/day.
2.Feeding may be delayed until baby has stabilized respiratory effort from birth.
3.Monitor the signs of intolerance to parental therapy specially protein and
glucose.
4.Breast milk, gavages or bottle feeding are began as soon as baby able to
tolerate.
5.Assess readiness to nipple feeds, and ability to suckle, coordinate, swallow and
breathing. Usually the baby weight more than (1500g).
6.Suckling, swallowing and gag reflexes are present usually at gestational age 34-
25weeks.
7.Preterm baby need 225 to 140 calories/kg/day.
8.If baby tired easily, has week sucking gag or bad swallowing reflex start Oro
gastric feeding.
9.Observe the baby during feeding, both oral and gavaging feeding because full
stomach may cause respiratory distress.
10.Because preterm baby has small stomach capacity he must be given small
amount frequently often 20ml every 2 to 3 hour.
40
Procedure of gavages feeding:
Wash hand and collect equipment.
Position the baby supine support him well keep head and neck a little straight.
Measure the tube size 5 for approximate length of insertion from the nose of
the baby to ear lobe and then to end of the xiphoid process mark the point with
a small piece of tape.
Dip the tube in sterile water to moister.
Insert the tip of the tube in the one nostril guiding it towards the back of the
baby throat, quickly insert to the tape mark.
Check placement of the tube by injection air while listening for the sound of
gurgling through the stethoscope placed over his stomach; or by syringe pull out
stomach contents if appear in the tube and fix the tube with plaster. (Latha
G,2004).
2.10.Nursing care to maintain skin integrity
Decrease mobilization and invasive procedure as possible.
Maintain dry skin and change dipper frequently.
Both should be decrease infrequently every 2-3 days for baby under 32 weeks
bath with sterile water only, clean eyes daily.
Don’t rub preterm skin during bath nor completely remove vernix.
Don’t apply powder or antibiotics ointment.
Decrease use of adhesive as possible.
If used it should be transparent one.
Secure pulse 0x meter probe and electrodes with elasticized dressing material.
On removal of plaster apply water or petroleum jell and then support skin under
it with one hand and gently peeling with other hand.
Use iodine or saline following invasive procedure. (Kaplan,..2003)
41
2.11. Invasive procedure:
Intravenous canalization:
1.Select appropriate size of the canella in preterm baby, size 24-26.
2.Select appropriate vein, usually in preterm is the hand wrist, antecubital sites and
scalp veins.
3.Tighten tourniquet above the vein where needle will be inserted.
4.Cleance the area of needle insertion with iodine using a firm circular swabbing
motion outward from the centre and allow skin to dry for 30 seconds.
5.Using the thumb of non dominant hand, apply a slight traction on the distal vein to
help stabilization during vein puncture.
6.Insert the needle through the skin at 20-30 degree with long side the vein, catheter
placement is confirm with blood return, put a normal saline to flash and fit the
catheter with plaster.
7.Remove tourniquet.
8.Fit the tube with plaster and should be secured if fluid is ready connect canula to
infusion set. (American Academy of pediatrics, 2002).
42
2.12.Infection control measurement
1.Staff:-
Intensive neonatal nursing staff ratio 1-2 nurse-baby.
Intermediate neonatal nursing staff ratio 2-3 nurse-baby.
Staff member and care giver should practice hand washing, wearing uniform,
special shoes, mask gown and head covers prior entering the unit.
No employees with respiratory tract infection or other infections, working in the
unit employee should be vaccinated against Hepatitis B, tetanus and infectious
disease.
Staff completing infectious control programmed study.
Environment:-
Food and drink not to be in unit.
Live plant and flower not to be in unit.
Sterile solution not to be opened.
Visitors are restricted and not contact the baby and do scrubbing 2-3 minutes
before entering.
Floor swept every 8 hours with disinfectant.
Walls and windows cleaned weakly.
Cardiac monitors and pulse ox meters should be disinfect between babies.
Linen should change every day and when wet.
Container of disposable syringe should be sealed and replace when ¾ full.
Disinfect incubator with when baby change clean by chloride to same baby after
5-7 days, nurses keep equipments clean and disinfected. (Emily lone, 2009).
2.13.Discharge the premature infant
Very immature infants are usually discharged when they reach 2000-2500g. but
weight or post conceptual age alone no longer determines the time of discharge, careful
assessment of infants progress and the home environments also influence the decision
43
factors such as the support of the mother at home and stability of the home situation play
a part in timing of discharge. The infant must at the very least be stable, eating well, and
showing steady weight gain at the home of discharge, the staff should observe the
parents caring for the infant to confirm that the parent are capable of managing whatever
special care the infant requires. Infant with special requirement, e.g., oxygen therapy,
may be discharged if the family clearly can manage to provide the additional support to
the infant at home. The ability of a social worker or visiting nurse make such discharge
decisions easier. (Gerald B.et al 2006)
2.14.Follow-up care:
Refers to follow-up visit to an ambulatory setting, for the purpose of tracking the
achievement of behavioral and developmental landmarks in infant who have received
neonatal intensive care for infant discharged from level 2 nurseries, follow-up care can
be provided by the pediatrician, with consultative visits at special care facilities as
required. Infants discharged nurseries required specialized follow-up care, because many
families need help with physical or neurologic problems and management ,the family
needs ongoing support during the first few years of the Child’s life. The frequency of
repeated hospitalization in many infants who have experienced complications (e.g.
chronic lung disease and the attendant growth disturbances) after neonatal intensive care
underscores the need for such support. (Ramanathan, et al, 2001).
2.15.Prevention of prematurity
One of the most important steps to preventing prematurity is to receive adequate
prenatal care for any pregnant woman to identify and treat risk factors as possible.
Statistics clearly show that early and good prenatal care reduces the chance of premature
birth. Premature labor can sometimes be treated or delayed by a medication that blocks
uterine contractions. Many times, however, attempts to delay premature labor are not
successful. Betamethasone (a steroid medication) given to mothers in premature labor
can reduce the severity of some of the prematurity complications of the baby.
44
2.16. Prognosis of prematurity
Prematurity used to be a major cause of infant deaths, improved medical and
nursing techniques have increased the survival of prematurity infants. The longer of
pregnancy, the greater the chance of survival of babied born at 38weeks, at least 90%
Survive. Prematurity can have long-term effects. Many premature infant have medical,
developmental, or behavioral problems that continue into childhood or are permanent.
The more premature an infant and small birth weight is risk of complications. (American
Academy of pediatrics. 2000).
45
Previous studies:
Worldwide: Mini Deborah A.V, (2008) The title of his study "To evaluate the
effectiveness of a self instructional module on care of preterm babies with respiratory
distress syndrome for pediatric staff nurses working at selected hospitals in Bangalore.
The objectives of the study are to: to assess the knowledge of pediatric staff nurses
regarding care of preterm babies with respiratory distress syndrome. Prepare a self
instructional module on care of preterm babies with respiratory distress syndrome.
Evaluate the effectiveness of the self instructional module on care of preterm babies with
respiratory distress syndrome. Determine association between the knowledge of the staff
nurses regarding care of preterm babies with respiratory distress syndrome and selected
demographic variables. The results showed that all (100) of the study subject were
knowledgeable, practices and attitudes regarding care of preterm babies by using self
instructional module on caring of preterm babies. Preterm babies: In this study it refers
to babies who are born before the completion of 37 weeks of gestation, irrespective of
their birth weight. In this study it refers to registered staff nurses who are working in
neonatal intensive care units, pediatric intensive care units, and pediatric medical and
surgical wards. (Mini Deborah A.V, 2008)
Developed Countries: Howe TH1, et al (2007): The background: A great deal
of attention has focused on understanding preterm infant feeding behaviors and on
strategies to support the preterm infant during this period; however, comprehensive
descriptions of the feeding behavior of preterm infants that incorporate an examination
of multiple subsystem levels are lacking. OBJECTIVE: To examine various physical
indicators related to preterm infants' bottle-feeding performance. METHODS: This was
a retrospective, descriptive, exploratory study using a convenience sample. Medical
records of 116 preterm infants were reviewed from the initiation of bottle-feeding until
46
discharge from the neonatal intensive care unit. This study examined bottle-
feeding performance (volume intake in milliliters per minute) as well as postmenstrual
age, weight at each observed feed, oral motor skills, signs of distress, feeding
techniques, feeding experience, gender, and Apgar scores at 5 minutes. Oral motor skills
were measured by the Neonatal Oral Motor Assessment Scale. (Howe TH1, et al 2007).
RESULTS: Linear mixed-effects models were used to examine the relationship
between bottle-feeding performance and the remaining variables. Postmenstrual age,
weight at each observed feed, oral motor skills, feeding experience, and feeding
techniques were found to be significant predictors of feeding performance at the .05
level. CONCLUSIONS: Multiple factors, both intrinsic and extrinsic, play a role in
determining an infant's bottle-feeding performance. In addition to age and weight, the
presently employed conventional criteria, oral motor skills, feeding practice, and feeding
techniques also contribute to infants' feeding performance. Arbitrary age (34 weeks
gestational age) and weight criteria (1,500 g) should not be the only indicators for oral
feeding. (Howe TH1, et al 2007).
The Association of Women’s Health, Obstetric and Neonatal Nurses
(AWHONN) 2012 Women’s Health and Perinatal Nursing Care Quality Measures
Advisory Panel developed an introductory set of nursing care quality measures with
background information, rationale, and specifications for each measure. These draft
measures (sometimes termed “nurse sensitive” measures) are being shared publicly at
this stage in their development (prior to validity and reliability testing) in an effort to
stimulate and promote the further development, refinement, and utilization of women’s
health and perinatal measurement in the United States. This is the first published set of
draft measures to specifically address the women’s health and perinatal populations.
More than 350,000 registered nurses provide health care to women and newborns in the
United States. Indeed, nurses are the primary providers of bedside care for women and
newborns. This is especially true when a woman gives birth in a hospital. The actions of
nurses have significant effects, either positive or negative, on patient outcomes.
Therefore, measuring nursing care quality is a necessary component of any effort to
improve health care provided to women and newborns.
47
Measuring nursing care quality in the United States is particularly needed now.
Currently, the United States is ranked 46th in the world for maternal mortality (World
Health Organization, United Nations Children’s Fund, United Nations Population Fund,
& World Bank, 2012) and 30th in the world for infant mortality (Mac Dorman &
Mathews, 2009). In addition, maternal morbidity increased by 75% for delivery and
114% for postpartum hospitalizations when comparing 1998-1999 data to 2008- 2009
data (Callaghan, Creanga, & Kuklina, 2012).
Preterm birth a planned teaching programme was conducted in the year of 2006
in Gwalior (M.P) regarding Preterm birth and its side effect management on knowledge,
attitude and practice by using knowledge questionnaire. California birth certificate data
linked with maternal and neonatal hospital discharge data in 1999 were used (N = 520,
739). Hyperemesis was defined by ICD-9 codes. The frequency, estimated charges, and
demographic characteristics associated with hyperemesis patients were assessed.
Maternal and neonatal perinatal outcomes were compared by maternal hyperemesis
status. Hyperemesis complicated 2,466 of 520,739 births. The average length of stay
was 2.6 days and the average charge was $5,932. singleton hyperemesis infants were
smaller (29.21% vs. 20.8%; P <. 0001).
Hyperemesis occurs in 473 of 100,000 live births and is associated with
significant charges. Infants of mothers with hyperemesis have lower birth weights and
the mothers are more likely to have infants that are small for gestational age. A simple
random technique was utilized for selecting a sample ,in this study the sample size is 30
in number. The aim of this study was to assess and evaluate the knowledge, attitude and
practice of nursing personnel regarding administration of chemotherapy and its side
effect of management. The major finding of this, shows that mean post test practice
score [44.2] of nursing personnel was significantly higher than their mean pre test
practice score [26.4]as evident by ‘t’ value [29]= 26.47p <0.05. (WHO 2007)
In Developing Countries: Borkowski W, (2007) His study under title "To
investigate the impact of social and health factors on respiratory distress syndrome
among preterm neonates". A descriptive survey design was used based on 4098 reports
on preterm deliveries. Multifactor logistic regression was done. The study findings
48
showed an incidence of 10.3% for respiratory distress syndrome among preterm
newborns. University education of the mother has reduced the odds for RDS by half, as
well as considerable pregnancy weight gain (OR = 0.61) and smoking before pregnancy
(OR = 0.57). Respiratory distress syndrome is seen more in cases of caesarean section
(OR=2.68) and adverse obstetric history (OR=1.61). Cesarean section before labor
verses cesarean section after the onset of labor increase the odds for RDS (OR=1.46).
The study finally concludes that certain health and social factors are related to the
occurrence of respiratory distress syndrome in preterm babies. (Borkowski W, 2007).
In Sudan: Mahmud A, (2003). Study done in Wad Medani Teaching Hospital by
Mahmud A, (2003) – University of Gezira about the quality of care of neonate with
critical care condition. The author said that the birth of the baby is a wonderful yet very
complex process. Many physical and emotional changes occur for the mother and the
baby at the time of birth a baby must make physical adjustment to adapt with the
external life. Many baby systems change dramatically from the way they functioned
during fetal life being born prematurely, having a difficult delivery, or birth defects can
make these changes even more challenging. The study aimed to determine the causes
and level of neonatal morbidity and mortality, to determine the midwifery and nursing
role in immediate care of all neonates, and to examine the quality of equipment and the
nursing role in the care of neonate with critical care condition. The study depended on
primary date based on a simple random sample of (171) babies from neonate care survey
in Wad Medani pediatrics hospital 2003. The study shows a high level of neonatal
mortality and morbidity (11.7%). May be due to poor antenatal care, delivery itself
(place and the quality of birth attendance), while the time is very important determinant
for neonatal morbidity and mortality, most baby take more time from decision to seeking
care to admission. The quality and availability of the equipment in the nursery is not
adequate because it is either not existent or not operating. (Mahmud A, 2003).
49
3. Materials and Methods
3.1 Study Design
A descriptive hospital based study was conducted in wad medani Pediatrics
Teaching Hospital aimed at assessing nurses’ knowledge regarding nursing care of
preterm infant in Pediatric Teaching Hospital, October 2014 - April 2015.
3.2 Study area:
The study was conducted in Pediatric Teaching Hospital, the capital of Gezira
State which is a large agricultural area, located in the central region of Sudan which
established at 1987. The locality is about 189km south of Khartoum State. Pediatric
teaching hospital is a level one district hospital serves about a lot of poor rural people. It
received patients from the whole state and neighboring states {Algadarif and Sinnar}.
There are sixteen wards in this hospital {respiratory unit, GI ward, ICU, Neonatal unit
and general wards}. The capacity of the intensive care unit is about 60 beds. {Statistical
Department of Pediatric Teaching Hospital October 2014 - April 2015}.
50
Table {3.1}: Distribution of Manpower in Pediatric Teaching Hospital
{2015}:
Position Number
Consultants 13
Registrars 21
Medical officers 10
House officers 49
Sisters 7
Nurses 165
Pharmacists 7
Assistant pharmacists 5
Nutritionists 5
Assistant nutritionists 11
Total 293
{Statistical Department of Pediatric Teaching Hospital 2014}.
3.3 Study Population:
All (62 ) registered pediatric nurses working at the hospital wards, during the
period of the study were included in the study.
3.3.1 Inclusion criteria:
All {62} available registered trained nurses who work at the hospital were
included in the study.
3.3.2 Exclusion criteria:
Under training nurses were not involved in this study.
3.4 Sample Size:
51
All {62} available nurses who work in the hospital were included in the study
during the period 2014.
3.5 Data Collection tool:
One tool for data collection was used a structured questionnaire was designed by
the researcher including data about socio-demographic characteristics, data about the
nurses’ knowledge and data about nurses’ attitudes regarding nursing management of
preterm infant (definition, complications, management …etc) during the period of the
study.
3.6 Sample Technique:
Official letters for the head manager and matron of pediatric teaching hospital
for approval to collect the data.
Explanation for the pediatric nurses about the study questionnaire.
Questionnaire was distributed for each available nurse to fill within 15-20
minutes under the researcher guidance.
3.7 Data analysis:
The data collected was incorporated and entered in the computer, described and
analyzed by using statistical package for social sciences {SPSS}.
52
4. Results and Discussion
4.1 Results:
Analysis of Demographic Data:
Table {4.1}: Distribution of the study sample according to their gender and age
groups:
( no=62)
Gender No %
Male 0 0%
Female 62 100%
Total 62 100%
Age groups No %
20 – 24 years 7 11.3%
25 – 29 years 25 40.3%
30 – 34 years 18 29.0%
35 and more 12 19.4%
Total 62 100%
Table {4.1} shows that all {100%} of the study sample were females and {40.3%} of
them at age range between 25 – 29 years, while 29.0% of them their age ranged between
30 – 34 years.
53
Table {4.2}: Distribution of the study sample according to their level of education:
(no=62)
Educational level No %
Technical diploma 2 2.3%
Diploma 17 27.4%
Bachelor 32 51.6%
Post graduate 11 17.7%
Total 62 100%
Table {4.2} revealed that {51.6%} of the study sample their level of education were
bachelor, while {27.4%} were diploma and only 17.7% post graduate.
54
No=62
Figure {4.1} Distribution of the study sample according to their years of
experience:
Figure {4.1} illustrates that 14.5% of the study sample their years of experience range
from 1 to 5 years, while 56.5% of them their experiences were range between 6 to 10
years.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
more than 10years
from 6 to 10 yearsFrom 1 to 5 years
29.00%
56.50%
14.50%
55
No=62
Figure {4.2} Distribution of the study sample according to receiving training
program before regarding nursing care of preterm infant:
Figure {4.2} illustrate that only 66% of the study sample had received training program
regarding care of preterm infant, while 34% of them didn’t
Yes 66%
No 34%
56
N=62
Figure {4.3} Distribution of the study sample according to their source of
knowledge regarding nursing care of preterm infant:
Figure {4.3} illustrate that 79.0% of the study sample their source of knowledge about
nursing care of preterm infant from university while 11.3% of them from colleagues.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
InternetCollegauesUnuversityBooks andReferences
8.10% 11.30%
79.00%
1.60%
57
Table {4.3}: Distribution of the study sample according to their knowledge about
Definition and Causes of delivery preterm infant:
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
Definition of preterm infant 50 80.7 10 16.1 2 3.2 62 100
Causes of delivery preterm infant 49 79.0 12 19.4 1 1.6 62 100
Table {4.3} shows that {80.7% and 79.0%} of the study sample responded with correct
complete answers regarding definition and causes of delivery lead to delivery preterm
infants respectively.
58
Table {4.4}: Distribution of the study sample according to their knowledge about
Symptoms for delivery of preterm infants and The method of respiration of
preterm infant
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
Symptoms for delivery of preterm
infants 51 82.3 11 17.7 0 0.0 62 100
The method of respiration of preterm
infant 31 50.0 22 35.5 9 14.5 62 100
Table {4.4} revealed that {82.3% and 50.0%} of the study sample responded with
correct complete answers regarding symptoms for delivery of preterm infants and the
method of respiration of preterm infants respectively.
59
Table {4.5}: Distribution of the study sample according (Nursing care for instant of
preterm infant, Precautions that can be taken to maintain normal temperature of
the preterm infant) :
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
Nursing care for instant of preterm
infant 50 80.7 10 16.1 2 3.2 62 100
Precautions that can be taken to
maintain normal temperature of the
preterm infant
53 85.5 9 14.5 0 0.0 62 100
Table {4.4} shows that {80.7% and 85.5%} of the study sample responded with correct
complete answers regarding nursing care for instant and precautions that can be taken to
maintain normal temperature of preterm infants respectively.
60
Table {4.6}:Distribution of the study sample according to their knowledge about
nursing care of preterm infant regarding (The causes that lead to decreased the
temperature of the preterm infant, Regulate the temperature of the preterm infant)
:
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
The causes that lead to decreased the
temperature of the preterm infant 50 80.7 12 19.3 0 0.0 62 100
Regulate the temperature of the
preterm infant 48 77.4 12 19.3 2 3.2 62 100
Table {4.6} illustrates that {80.7% and 77.4%} of the study sample responded with
correct complete answers regarding the causes that lead to decreased the temperature of
the preterm infants and regulate the temperature of preterm infants respectively, while
19.3% and 19.3% of them responded with correct incomplete answers.
61
Table {4.7}: Distribution of the study sample according to their knowledge about
nursing care of preterm infant regarding (How is giving the oxygen to the preterm
infant , The complications expected to increase the proportion of oxygen and how
to treated them) :
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
How is giving the oxygen to the
preterm infant 45 72.6 14 22.6 3 4.8 62 100
The complications expected to
increase the proportion of oxygen
and how to treated them
40 64.5 20 32.3 2 3.2 62 100
Table {4.7} revealed that {72.6% and 64.5%} of the study sample responded with
correct complete answers regarding how is giving the oxygen to the preterm infants and
what are the complications expected to increase the proportion of oxygen and how to
treated them respectively, while 22.6% and 32.3% of them responded with correct
incomplete answers.
62
Table {4.8}: Distribution of the study sample according to their knowledge about
nursing care of preterm infant regarding (How to avoid the increase in oxygen,
Secretion Fluid in the respiratory tract) :
( no = 62)
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
How to avoid the increase in oxygen 38 61.3 21 33.9 3 4.8 62 100
Secretion Fluid in the respiratory
tract 20 32.3 28 45.2 14 22.1 62 100
Table {4.8} illustrates that {61.3% and 32.3%} of the study sample responded with
correct complete answers regarding how to avoid the increases in oxygen and the
secretion fluid in the respiratory tract in the preterm infants respectively, while 33.9%
and 45.2% of them responded with correct incomplete answers.
63
Table {4.9}: Distribution of the study sample according to their knowledge about
nursing care of preterm infant regarding (The method to give oxygen to the
preterm infants , Problems that occur for preterm infants ) :
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
The method to give oxygen to the
preterm infants 35 56.5 20 32.3 7 11.2 62 100
Problems that occur for preterm
infants 39 62.9 23 37.1 0 0.0 62 100
Table {4.9} shows that {56.5% and 62.9%} of the study sample responded with correct
complete answers regarding the method of give oxygen to the preterm infants the
problems that occur for preterm infants respectively, while 32.3% and 37.1% of them
responded with correct incomplete answers.
64
Table {4.10}: Distribution of the study sample according to their knowledge about
nursing care of preterm infant regarding (Risk factors that lead to the birth of
preterm infants, Clinical symptoms of preterm infants) :
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
Risk factors that lead to the birth of
preterm infants 30 48.3 32 51.7 0 0.0 62 100
Clinical symptoms of preterm infants 33 53.2 29 46.8 0 0.0 62 100
Table {4.10} revealed that {48.3% and 53.2%} of the study sample responded with
correct complete answers regarding the risk factors that lead to the birth of preterm
infants and clinical symptoms of preterm infants respectively, while 51.7% and 46.8% of
them responded with correct incomplete answers.
65
Table {4.11}: Distribution of the study sample according to their knowledge about
nursing care of preterm infant regarding (Preterm infants care at home, Feeding
of preterm infants ):
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
Preterm infants care at home 20 32.3 29 46.8 13 20.9 62 100
Feeding of preterm infants 39 62.9 18 29.0 5 8.1 62 100
Table {4.11} revealed that {32.3% and 62.9%} of the study sample responded with
correct complete answers regarding the preterm infants care at home and feeding of
preterm infants respectively, while 46.8% and 29.0% of them responded with correct
incomplete answers.
66
Table {4.12}: Distribution of the study sample according to their knowledge about
nursing care of preterm infant regarding (What the method to give phototherapy
for jaundice to prevent complications of the preterm infants , How to follow weight
of preterm infants, and Common causes of preterm infant death ):
No=62
Nurses’ knowledge
Correct
complete
answers
Correct
incomplete
answers
Incorrect Total
No % No % No % No %
What the method to give
phototherapy for jaundice to prevent
complications of the preterm infants
35 56.5 22 35.4 5 8.1 62 100
How to follow weight of preterm
infants 17 27.4 32 51.6 13 21.0 62 100
Common causes of preterm infant
death 36 58.1 18 29.0 8 12.9 62 100
Table {4.12} revealed that {56.5%, 27.4% and 58.1%} of the study sample responded
with correct complete answers regarding the method to give phototherapy for jaundice
to prevent complications of the preterm infants, How to follow weight of preterm
infants and Common causes of preterm infant death respectively, while 35.4%, 51.6%
and 29.0% of them responded with correct incomplete answers.
67
4.2 Discussion
Preterm birth refers to the birth of a baby of less than 37 weeks gestational age.
Premature birth, commonly used as a synonym for preterm birth, refers to the birth to
baby before its organs mature enough to allow normal post natal survival, and growth
and development as a child. A descriptive hospital based study was conducted in
intensive care in Wad Medani Pediatric Teaching Hospital aimed at assessing nurses’
knowledge and attitudes regarding nursing management of preterm infant in Wad
Medani Pediatric Teaching Hospital, Gezira State, Sudan 2014. Study Population
consisted of all registered pediatric nurses working at the hospital wards, during the
period of the study were included in the study.
The sample size consisted of all {62} available nurses who work in the hospital
were included in the study during the period 2014. The data was collected by using a
structured questionnaire was designed by the researcher for the purpose of the study.
The data was analyzed by using statistical package for social sciences {SPSS}.
The results showed that: all {100%} of the study sample were females and
{40.3%} of them at age range between 25 – 29 years, while 29.0% of them their age
ranged between 30 – 34 years. {51.6%} of the study sample their level of education
were bachelor, while {27.4%} were diploma and only 17.7% post graduate.
On the other hand the results showed that 14.5% of the study sample their years
of experience range from 1 to 5 years, while 56.5% of them their experiences were
range between 6 to 10 years. 66% of the study sample had received training
program regarding care of preterm infant, while 34% of them didn’t . Also the
results showed that 79.0% of the study sample their source of knowledge about
nursing care of preterm infant from university while 11.3% of them from
colleagues.
Regarding Nurses' Knowledge this results showed that {80.7% and 79.0%} of
the study sample responded with correct complete answers regarding definition and
68
causes of delivery lead to delivery preterm infants respectively, while 16.1% and 19.4%
of them responded with correct incomplete answers. {82.3% and 50.0%} of the study
sample responded with correct complete answers regarding symptoms for delivery of
preterm infants and the method of respiration of preterm infants respectively, while
17.7% and 35.5% of them responded with correct incomplete answers.
In contrast this results showed that {80.7% and 85.5%} of the study sample
responded with correct complete answers regarding nursing care for instant and
precautions that can be taken to maintain the temperature of preterm infants respectively,
while 16.1% and 14.5% of them responded with correct incomplete answers. This results
is similar to study done by (Callaghan, Creanga, & Kuklina, 2012), which revealed that:
Measuring nursing care quality in the United States is particularly needed now.
Currently, the United States is ranked 46th in the world for maternal mortality (World
Health Organization, United Nations Children’s Fund, United Nations Population Fund,
& World Bank, 2012) and 30th in the world for infant mortality (MacDorman &
Mathews, 2009). In addition, maternal morbidity increased by 75% for delivery and
114% for postpartum hospitalizations when comparing 1998-1999 data to 2008- 2009
data (Callaghan, Creanga, & Kuklina, 2012).
This results is similar to study done In Sudan: Study done in Wad Medani
Teaching Hospital by Mahmud A, (2003) – University of Gezira about the quality of
care of neonate with critical care condition. The study aimed to determine the causes and
level of neonatal morbidity and mortality, to determine the midwifery and nursing role
in immediate care of all neonates, and to examine the quality of equipment and
the nursing role in the care of neonate with critical care condition. The study shows a
high level of neonatal mortality and morbidity (11.7%). May be due to poor antenatal
care, delivery itself (place and the quality of birth attendance), while the time is very
important determinant for neonatal morbidity and mortality, most baby take more time
from decision to seeking care to admission. The quality and availability of the
equipment in the nursery is not adequate because it is either not existent or not
operating. (Mahmud A, 2003).
69
And also similar to study done by WHO (2007). The aim of this study was to
assess and evaluate the knowledge and attitudes and practice of nursing personnel
regarding administration of chemotherapy and its side effect of management. The major
finding of this, shows that mean post test practice score [44.2] of nursing personnel was
significantly higher than their mean pretest practice score [26.4]as evident by ‘t’ value
[29]= 26.47p <0.05. (WHO 2007)
On the other hand this results showed that {80.7% and 77.4%} of the study
sample responded with correct complete answers regarding the causes that lead to
decreased the temperature of the preterm infants and regulate the temperature of preterm
infants respectively, while 19.3% and 19.3% of them responded with correct incomplete
answers.
In contrast this results showed that {72.6% and 64.5%} of the study sample
responded with correct complete answers regarding how is giving the oxygen to the
preterm infants and what are the complications expected to increase the proportion of
oxygen and how to treated them respectively, while 22.6% and 32.3% of them
responded with correct incomplete answers. {61.3% and 32.3%} of the study sample
responded with correct complete answers regarding how to avoid the increases in
oxygen and the fluid in the respiratory tract in the preterm infants respectively, while
33.9% and 45.2% of them responded with correct incomplete answers. {56.5% and
62.9%} of the study sample responded with correct complete answers regarding the
method of give oxygen to the preterm infants and the problems that occur for preterm
infants respectively, while 32.3% and 37.1% of them responded with correct incomplete
answers. {48.3% and 53.2%} of the study sample responded with correct complete
answers regarding the risk factors that lead to the birth of preterm infants and clinical
symptoms of preterm infants respectively, while 51.7% and 46.8% of them responded
with correct incomplete answers. {32.3% and 62.9%} of the study sample responded
with correct complete answers regarding the preterm infants care at home and feeding of
preterm infants respectively, while 46.8% and 29.0% of them responded with correct
incomplete answers. This results is similar to study done by Howe TH1, et al (2007)
which stated that: Linear mixed-effects models were used to examine the relationship
70
between bottle-feeding performance and the remaining variables. Postmenstrual age,
weight at each observed feed, oral motor skills, feeding experience, and feeding
techniques were found to be significant predictors of feeding performance at the .05
level. (Howe TH1, et al 2007) {56.5%, 27.4% and 58.1%} of the study sample
responded with correct complete answers regarding the method to give phototherapy for
jaundice to prevent complications of the preterm infants, How to follow weight of
preterm infants and Common causes of preterm infant death respectively, while 35.4%,
51.6% and 29.0% of them responded with correct incomplete answers.
71
5. Conclusion and Recommendations
5.1 Conclusion:
It is concluded that:
Nurses’ knowledge regarding care of preterm infant were inadequate especially
regarding definition, signs and symptoms, diagnosis and treatment.
As regard to nurses’ attitudes it study that nurses’ attitudes regarding of preterm
infant were inadequate.
72
5.2 Recommendations:
Based on the conclusion of this study it recommended will be:
Routine and periodic training program must be done to all nurses.
Proper and continues monitoring and supervision of nurses’ performance
is essential.
Logbook for care of pediatric patients must be design and available in the
hospitals.
73
References:
Adams – Chapman I. (2006). Neurodevelpmental outcome of the preterm infant.(2006)
947-964.
Amani Ali Mohamed (2006). Assessment of pediatric nurses knowledge, practice and
attitudes regarding nursing management.
Amel Mahmoud Mohamed (2003). The quality of care of neonate with critical care
condition in neonatal intensive care unit at Wad Medani Teaching Hospital.
American Academy of Pediatrics (AAP) (2004). Management of infant at risk. Page
549-57.
American Academy of Pediatrics (AAP) (2000). Neonatal morbidity and prenatal
mortality in preterm birth (2000). 43 – 49.
American Academy of Pediatrics for prenatal care, (2002). Gils tarp LC< oh W, eds.
5 thed (2002).
American Academy of Pediatrics (AAP) (2004). In Gilstrap LC, oh W, eds.
Guidelines for prenatal care (2004).
Annamma Jacob. (2009). Maternal and neonatal nursing care plans. First Edition
(2009) page 409.
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) 2012
Women’s Health and Perinatal Nursing Care Quality (WHP-NCQ).
Ballard (Eds), (2002). Avery's disease of the newborn (479 – 483). Printed in
Philadelphia by W.B. Sautrnders.
Balistreri WF. Cholestasis. In: Behran RE, Kleim Gman RM, Jenson HB (2000).
Eds. Nelson textbook of pediatrics: 1195-1202.
74
Borkowski W, Mielniczuk H. Social and health factors of respiratory distress
syndrome in preterm infants. American Medical Journal. 2007 Nov; 78(11): 856-
60.
BT Basavanthappa (2006). Textbook of Midwifery and Reproductive health Nursing
(2006). First edition, page 658.
Chin, P. L. and Kramer, M. K. (2000). Theory and nursing: A systemic approach (5th
ed). St. Louis, Mo: Mosby.
Colletti JE, Kothari S, Jackson DM, Kilgore KP, Barringer K (November 2007).
Cremer, R. J. P. W. Perryman, D. H. Richards. (2010). Problems with prematurity.
The Lancet 271: (1086-1092).
David Hull, Derek I. Jonhson. (2005). 22 Essential of pediatric 4th
edition.
Dobbs, R. H. R. J. Cremer (2001). Archives of disease in childhood 50 (11); 823-826.
Dr. Chiyere Ezeake. (2005). Consultant pediatrician at the Lagos University teaching
hospital in Nigeria.
Dole, N. Savitz DA. (2003) Maternal stress and preterm birth (2003).
Dola SM, Gross SI, Merkatz, et al (2007). The contribution of birth defects to preterm
birth and low birth weight. Obstetrics and gynecology.
Elhassan M. Elhassan, Ahmed A. Hassan, Omer, A. Mirghani. (2009). Morbidity
and mortality pattern of neonates admitted into nursery unit in Wad Medani
hospital, Sudan.
Emily Slone. Mickinney, Susan Rowen James, Sharon Smith Murray. (2009).
Maternal child nursing, third edition (2009). High risk neonate, page 717.
Gerald – Men Stein – Sandral – Gardner (2006). Neonatal intensive care – six
edition.
75
Gilbert, WM. Nesbit TS. Danielson B. (2003). The cost of prematurity quantification
by birth weight (2003) 488-492.
Gomez M. Bielza, C. Fernandez Del Pozo JA. Rios-Insua S. (2007). Complications of
prematurity, 26: 198-206.
Golden Berg RL. Culhare, JF. Iams, JD. Romero. (2008). Epidemiology and causes
of preterm birth.
Howe TH1, Sheu CF, Hinojosa J, Lin J, Holzman IR. (2007). The Impact training
program of nurses by Multiple factors related to bottle-feeding performance in
preterm infants. Nurse Res. 2007 Sep-Oct;56(5):307-11. New York University,
New York, USA.
WHO (2007). Assess and evaluate the knowledge and attitudes and practice of nursing
personnel regarding administration of chemotherapy and its side effect of
management.
World Health Organization, (2012). United Nations Children’s Fund, United Nations
Population Fund,
& World Bank, 2012
King, M.E. Lyn, Dyer, M. (2000). Illustrated manual of nursing techniques. PP 102. J.
B. Lippincott, Philadelphia.
Kaempf JW. Tomlinson M. Arduza, C. (2006). Medical staff guidelines for
periviability infants. Pregnancy counseling and medical treatment of extremely
premature.
Kingman, MD. Hal, D. Jenson, MD. Richard E. Behrman, MD. (2007). Essential of
pediatric.
Lap took A. Jackson, GL. (2006). Impact on nursery of admission (2006). 24-2.
76
Latha, G. Stead, S. Mattew. Kaufman. Clerckship. (2004). First aid for the pediatrics.
642-649.
Lorrain, BR. Et al. (2008). Neonatal neurodevelopment examinations as a predictor of
neuromotor outcome in premature infants, pediatrics.
Lippincott Williams and Wilking. (2006). Maternal and child health nursing.
Lynn C. Garfunkel. Jeffrey Kaeczorowski; Cynthia Christy (2002). Mosby's
pediatric diagnosis and treatment of prematurity.
Madlon. Kay, Diane, J. Peiatrics, (2007). Management of prematurity.
Mahmud A, (2003) – The quality of care of neonate with critical care condition.
University of Gezira about Wad Medani Teaching Hospital Sudan (2003).
MacDorman & Mathews, 2009
Medical care of the sick new born. Sophie H. Piero and Angelo Ferra va. 3rd
edition
(2000).
Mona Mohamed Ahmed. (2005). Assessment of nursing knowledge and practice about
nursing management of newborn at risk are Khartoum teaching hospital. Academy
of medical sciences.
Myles textbook for midwives (2003). Margaret Acooper for Worded by Gillian
Fletcher. Diane M. Fraser. 14th
edition (2003).
Mini Deborah A.V, (2008) Evaluate the effectiveness of a self instructional module on
care of preterm babies with respiratory distress syndrome for pediatric staff nurses
working at selected hospitals in Bangalore
Narayananl, Banwalikar J, Mehta R, et al, (2003). Pediatrics (2003).
Nassir Gamal (2010). Manual of Pediatrics.
Nassir Gamal (2000). Clinical cases in Pediatrics.
77
Nassir Gamal (2011). Manual of Pediatrics.
Nassir Gamal. Dar Alelm (2003). Manual of Pediatrics.
Pediatric advance life support. American heart association. Dallas, Texas. National
center. www.Americanheart.org.
Ramanathan, K. Paul, V.K., Deorari, A.K., (2001). Kangaroo mother care in very low
birth weight in infant.
Robert, M. Khiegman. Elzabeth, N. Jacobson. (2007). Nelson textbook of pediatric.
Callaghan, Creanga, & Kuklina, (2012).
78
Appendix
شفى الأطفال استبيان لتقويم معلومات الممرضين والممرضات تجاه العناية التمريضية بالطفل الخديج في مست
التعليمي، ولاية الجزيرة
أ(المعلومات الشخصية:
.العمر:1
سنة ) ( 29-25سنة ) ( ب( 24-20أ(
فأكثر ) ( 35سنة ) ( د( 34-30ج(
.الجنس:2
(أنثى ) (أ(ذكر ) ( ب
.المؤهل التعليمي:3
أ(فني تمريض ) ( ب(دبلوم تمريض ) (
ج(بكالاريوس ) ( د(ماجستير ) (
.عدد سنوات الخبرة في تمريض الأطفال حديثي الولادة:4
سنوات ) ( 10-5سنوات ) ( ب( 5-أ( من سنة
سنوات ) ( 10ج(أكثر من
.هل حضرت دورة تدريبية عن رعاية الأطفال الخدج؟5
أ(نعم ) ( ب(لا ) (
. إذا كانت الإجابة بنعم أذكر عدد الدورات6
................................................................................................................
79
. مصدر المعلومات عن رعاية الأطفال الخدج:7
أ( الكتب والمراجع ) ( ب(الجامعة ) (
) ( د(الإنترنت ) ( ج(الزملاء
ب( معلومات الممرضين والممرضات:
.الطفل الخديج هو:1
أسبوع ) ( 37أسبوع ) ( ب( عمره أكثر من 37أ( عمره أقل من
أسبوع ) ( 40) ( د(عمره أقل من أسبوع 32ج(عمره
. ما هي الأسباب التي تؤدي إلى ولادة الطفل الخديج:2
أ( انفصال المشيمة ) ( ب( الحصبة الألمانية ) (
) ( د(اختلاف فصيلة الدم ) ( ج(الأدوية
.العوامل الخطرة لولادة الطفل الخديج ؟3
أ( مشاكل في الأيض و الإستقلاب) ( ب(مشاكل في التحكم في درجة الحرارة ) (
د(فقد الدم ) ( ج(مشاكل في الدم والكبد ) (
ه(يرقان ) (
.طريقة التنفس عند الطفل الخديج؟4
أ(سرعة التنفس مع عدم الانتظام ) ( ب( بطء التنفس ) (
د( التنفس عادي ) ( نتظم مع انقطاع ) ( ج(التنفس غير م
. الرعاية التمريضية الفورية للطفل الخديج؟5
ب(قياس محيط الرأس ) ( أ(قياس وزن وطول الطفل ) (
اس سرعة التنفس في الدقيقة ) (د(قي ج(وضع الطفل في الحضانة ) (
(ما هي الاحتياطات التي يمكن إتباعها للمحافظة على درجة حرارة الطفل؟6
أ(الحاضنة ) ( ب( درجة حرارة ثابتة ) (
80
) ( ر عالي) ( د(وضعه في سري ج(جهاز تدفئة
.الأسباب التي تؤدي لانخفاض درجة حرارة الطفل الخديج:7
أ(مساحة الجلد واسعة مقارنة مع قلة وزنه فلا يستطيع توليد حرارة كافية ) (
) ( ب(عدم وجود مخزون كافي من الدهون
ج(عدم قدرته على تنظيم درجة حرارته نظرا لقلة احتياطاته الحرارية وفعالية عضلاته ) (
د(قلة الشعر في الجسم ) (
تنظيم درجة حرارة الطفل الخديج؟.8
) ( أ(وضع الطفل الخديج في الحاضنة
ب(تأمين درجة حرارة مناسبة ) (
ج(المحافظة على مستوى حرارة داخلية منتظمة مع نسبة رطوبة ملائمة ) (
ما ذكر صحيح ) ( د( كل
(متى يتم إعطاء الأكسجين للطفل الخديج؟9
أ(منع اختلال الشبكية ) (
رئتين ) (ب(إذابة الأكسجين لل
ج(انقطاع التنفس ) (
) ( د(كل ما ذكر خطأ
وكيفية تجنبها؟. ما هي المضاعفات المتوقعة لزيادة نسبة الأكسجين 10
أ( ورم الرئة ) (
) ( ب(اعتلال الشبكية
ج(كل ما ذكر خطأ ) (
81
.كيفية تجنب الزيادة في الأكسجين:11
) ( أ(مراقبة الأكسجين في الحاضنة
) ( ب(مراقبة أكسجين الشريان
) ( %70ج(إنقاص الأكسجين إلى
) ( د(كل ما ذكر خطأ
.في حالة وجود سوائل في مجرى الجهاز التنفسي الآتي صحيح أم خطأ؟12
) ( دقيقة 40أ(دقيقة ) ( ب(
) ( ثواني 5دقيقة ) ( د( 20ج(
.طريقة إعطاء الأكسجين للطفل الخديج:13
) ( أ(عن طريق الحاضنة ) ( ب(كمامة الوجه
ج(Oxygenic) ( ) ( د( كل ما ذكر خطأ
تحدث للطفل الخديج؟.ما هي المشاكل التي 14
) ( أ(متلازمة ضائقة التنفس ) ( ب(انقطاع التنفس
) ( ج(نزف رئوي ) ( د(مشاكل قلبية
.العوامل الخطرة التي تؤدي إلى ولادة طفل خديج:15
) ( ب(الحمل بتوأم أو أكثر ) (ل ومجرى البولأ(التهاب المهب
ج(التدخين ) ( د(عيوب الرحم ) (
ه(إجراء عملية سابقة ) (
82
.الأعراض السريرية للطفل الخديج:16
) ( أسبوع 32جرام إذا كان عمر الحمل أقل من 1500قل من أ(الوزن أ
) ( ب(الجلد أحمر شفاف
) ( ج(شعر الرأس قصير والأظافر قصيرة وناعمة
) ( د(العين بيضاء اللون
.رعاية الطفل الخديج في المنزل:17
) ( أ(التنفس دون أجهزة الدعم ) ( ب(الحفاظ على درجة حرارة الجسم
) ( (الرضاعة الطبيعية أو الصناعية) ( د( زيادة الوزنج
.تغذية الطفل الخديج:18
) ( أ(توفير جميع العناصر الغذائية الضرورية كالبروتين والفيتامينات والمعادن
) ( ل المناسب للنمو ب(سعرات حرارية وعناصر غذائية لتحقيق المعد
) ( ج(إعطاء الطفل كاربوهيدرات عالية
) ( د(كل ما ذكر صحيح
علاج الضوئي لليرقان لمنع المضاعفات للطفل الخديج:.ال19
) ( أ(تغطية العين لتجنب شبكية العين
ب(في الأولاد تغطية المناطق الحساسة ) (
ب الجفاف ) (ج(تجن
د(قياس وزن الطفل يوميا لتجنب فقدان الوزن ) (
( كيفية متابعة وزن الطفل:20
83
) ( أ(الوزن يوميا
ب(وزن الطفل أسبوعيا ) (
أيام ) ( 10ج(وزن الطفل كل
د(كل ما ذكر صحيح ) (
( ما هي الأسباب الشائعة لوفاة الطفل الخديج؟21
مشيمة ) (أ(المشيمة المزاحة ) ( ب( انفصال ال
ج(ورم وراء المشيمة ) ( د(تشوهات الرحم ) (
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