A preterm girl with big problems – case report with applied nursing procedures

INTRODUCTION

According to the data published by the Polish Central Statistical Office, the total number of births in 2022 is estimated at 306,155. In the same year, 1187 babies were born before the completion of 28 weeks of gestation (5.27%) [1]. The causes of premature birth are complex and multifaceted. Newborns born before the 28^th week of gestation, which corresponds to a birth weight of less than 1000 g, are severely underdeveloped, thus requiring multi-specialised and advanced medical and nursing care [2]. These babies have a high probability of developmental disorders and life-threatening conditions resulting from an insufficient intrauterine growth period.
The purpose of this study is to present knowledge and introduce the reader to the care of a newborn born in the 25^th week of gestational age (foetal gestation) based on an individual case study.

MATERIAL AND METHODS

Analysis was conducted using the medical records of a child born prematurely – a patient of the Neonatal Intensive Care Unit – with the consent of the doctor in charge of the unit. Also, available literature defining the problem of prematurity and the standards of nursing care for the premature infant was used.

CASE REPORT

A female neonate from first pregnancy, born naturally in the 25^th week of gestational age (g.a), with extremely low body weight of 750 g (> 50^th percentile), head circumference 27 cm (> 97th percentile), and body length 35 cm (> 90^th percentile). The pregnancy was not under gynaecological surveillance (conscious choice of the woman), the mother was febrile on the day of delivery, a group B Streptococcus screening test (GBS) revealed status unknown. The baby was assessed on the Apgar scale: 1 min – 1 pt, 3 min – 4 pts, 5 min – 6 pts, 10 min – 8 pts. After birth, the child’s general condition was severe, requiring treatment in the Neonatal Intensive Care Unit (NICU) and continuous monitoring of vital functions. The neonate, experiencing respiratory failure due to immature lungs, required intubation, mechanical ventilation, and 2 doses of intratracheal exogenous surfactant. After insertion of a central venous catheter (CVC), an infusion of catecholamines was administered to support cardiac output. During treatment, broad-spectrum empiric antibiotic therapy (vancomycin and meropenem) was administered due to diagnosed congenital pneumonia. From the 10^th day of birth, decrease in blood saturation was observed, and intravenous caffeine citrate solution, initially 20 mg/kg body weight and then in a maintenance dose of 5 mg/kg body weight (BW), was included in the treatment. Due to the large number of inflammatory secretions in the respiratory tract, frequent bronchoaspirations were performed. Total parenteral nutrition (TPN) according to an individual nutritional prescription and trophic nutrition were started. What is more, antifungal prophylaxis (fluconazole and nystatin) was administered. Physical examination revealed an enlarged head circumference (27 cm) -> 97^th percentile, large convex anterior fontanel (3 × 4 cm), posterior fontanel (2 × 2 cm), and wide cranial sutures (up to 1 cm). Parenteral nutrition was provided, and from the 19^th day of life only enteral nutrition was provided via gavage tube. Due to anaemia, the neonate required supplementary transfusion with red blood cell concentrate. As a result of the treatment administered, the patient’s clinical condition improved. On the 16^th day of life, a control transcranial ultrasound examination showed grade III intraventricular haemorrhage (IVH), symmetrical dilatation of the cerebral ventricular system, lateral ventricular span 31.9 mm, cranial width 59 mm, and Evans index 0.54. On the 22^nd day of life, another transcranial ultrasound examination was performed to assess the dynamics of hydrocephalus progression; the Evans index was found to be 0.57. The patient was referred to the Paediatric Anaesthesiology and Intensive Care Unit (PICU) for further treatment and, if necessary, implantation of a Rickham valve system. Since admission to the PICU, the girl had her pain monitored with the COMFORT scale every 4 hours and received modified intravenous analgosedation as required (paracetamol 7.5 mg/kg BW, morphine 0.05-0.1 mg/kg BW, intravenous form of phenobarbital 5-10 mg/kg BW). In the PICU, the consulting surgeon performed transcranial puncture of the brain ventricles several times to evacuate excess cerebrospinal fluid. Due to increasing post-haemorrhagic expansion of the cranial fluid space, the decision was made to qualify for surgical decompression of hydrocephalus in the operating theatre. A Rickham reservoir was initially placed, and a ventriculo-peritoneal valve was implanted at a later stage. During treatment in the ICU, central catheter dysfunction was observed. A follow-up ultrasound examination showed the presence of thrombi with a diameter of 4 mm and 10 mm in the lumen of the inferior vena cava. Anticoagulant treatment with low-molecular-weight heparin was applied. Central access was again obtained, this time to the superior vena cava via internal jugular access. Both this and the previous central vein cannulation were performed using ultrasound, and the subsequent position of the CVC was confirmed by X-ray. Due to the clinical picture consistent with bronchopulmonary dysplasia (BPD), steroid therapy was included according to the 3-day protocol used in the PICU: intravenous dexamethasone in doses of 0.15-0.1-0.05 mg/kg BW. The patient had multiple ophthalmological consultations during her hospital stay. In one consultation, an aggressive form of bilateral retinopathy of prematurity was confirmed. The ophthalmologist qualified the child for intravitreal administration of anti-VEGF at a specialised centre. An ophthalmologic examination after the procedure revealed regression of the retinopathy of prematurity and withdrawal of the “plus” symptom. In a subsequent transcranial ultrasound of the head, the ventricular system was significantly dilated, with a lateral ventricular span of 51 mm, cranial width of 78 mm index, and Evans’ index of 0.65. Furthermore, fluid cavities, possibly corresponding to malar cavities in the anterior horns and lateral ventricles, as well as poor furrowing of the cerebral cortex were found. The catheter of the drainage system in the lumen of the right lateral ventricle with the tip located medially. There were no features of increased intracranial pressure. The infant currently is in a stable general condition; respiratory and circulatory systems are efficient. The child is active and reactive to external stimuli. Because her clinical condition has improved, the patient has been transferred to the Infant Pathology Unit at the age of 3 months and 7 days from birth (corrected age – approximately 38 weeks).

DISCUSSION

Premature birth is a global medical problem that is difficult to solve and eliminate despite significant clinical advances, development of diagnostic methods, and improvements in the level of medical care. Worldwide, prematurity is the leading cause of death in children under 5 years of age [3]. Moreover, it should be emphasised that children born prematurely require special and skilled nursing care, which is no less important than medical care. This includes, among other things, monitoring of basic vital functions, proper nutrition of the child, providing an ambient temperature, ensuring the correct pulmonary hygiene, protecting against infections, or shaping a bond between parents and child [4].
In the presented case, special attention is paid to the complications of prematurity having a serious impact on the patient’s clinical condition. Respiratory distress syndrome resulted from immaturity of the respiratory system, including surfactant deficiency and concurrent congenital pneumonia [5]. In the case described, it was necessary to administer exogenous surfactant endotracheally twice [6]. The nurse’s role in this procedure was to prepare the formula (warming up, carefully scooping it into a syringe) and then assist with even distribution in the airway – after the doctor administered it through the side port of the endotracheal tube – gentle finger tapping the chest, combined with ventilation. Respiratory failure required instrumentalisation of the airway and the use of respiratory replacement therapy, followed by passive oxygen therapy for a total of more than 28 days, which led to the diagnosis of bronchopulmonary dysplasia [7].
Caring for an intubated neonate is an extremely important nursing skill in the ICU. It involves aspiration of airway secretions, and control of the position and patency of the endotracheal tube. This means that the nurse is responsible for positioning and repositioning the patient, and providing physical therapy of the respiratory system, which prevents the development of foci of atelectasis. Active heating and humidification of the respiratory gases is necessary during ventilation [8]. That is to say that an important part of the therapy is the nurse’s assessment and recording of ventilation parameters, such as respiratory rate, peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP), humidifier temperature, and oxygen concentration in the respiratory mixture, which should be checked at fixed intervals, such as every hour (this is the case in the described unit). In addition, the current depth of the endotracheal tube’s position is recorded daily on a nursing observation sheet - information that is very important in the case of extremely premature infants because a difference of a few millimetres can result in the tube moving either into one main bronchus or extending completely beyond the vocal cords (unintentional extubation).
Intraventricular haemorrhage (IVH) is a pathology resulting from vascular immaturity of the developing brain and abnormalities of blood circulation within it [9]. In grade III haemorrhage, ventricular dilatation occurs, which progress-es to the hydrocephalus stage in about 15% of cases [10]. The most common complication after intraventricular haemorrhage is post-haemorrhagic hydrocephalus (PHH) [11]. According to the standards for the treatment of post-haemorrhagic hydrocephalus in premature infants, in the case described here, a Rickham reservoir was implanted first, and after reaching an adequate weight, a ventriculo-peritoneal valve system was implanted [12]. Minimal handling, control of the stressful environment and painful procedures, positioning of preterm head midline, elevating the incubator headboard, and maintenance of normoglycaemia and normothermia have been identified as helpful nursing practices in prevention of IVH.
Another serious complication of prematurity that occurred in the girl’s case was advanced, rapidly progressive retinopathy, which forced the treatment team to send the patient on the second day after ventriculo-peritoneal valve im-plantation to a centre located 170 km away for anti-VEGF administration [13]. The most important risk factors include low gestational age (according to a recent study, the incidence of retinopathy in premature infants born before the 29^th week of g.a is 43%), low birth weight, and oxygen treatment [8]. Normally, the first ophthalmologic examination should be performed 4 weeks after birth, and subsequent examinations are performed in accordance with the ophthalmologist’s recommendation. Most often in the case of extremely premature infants they are repeated weekly, such as in this case. Nursing interventions consist of monitoring and, if necessary, reducing oxygen supply under pulse oximeter control (in consultation with the doctor), instilling pupil-dilating drops (1% tropicamidum), and assisting during the eye examination
The key aspects in the proper development of a prematurely born child are adequate nutrition, covering energy and fluid requirements, and ensuring that normal weight gains are achieved [14]. Parenteral nutrition is a part of the therapeutic management of premature infants treated in the NICU. In the analysed case, the child was fed parenterally through a central catheter (due to the osmolarity of nutritional fluids exceeding safe administration through the peripheral venous route) and enteral nutrition through a gavage inserted into the stomach. Total enteral nutrition started on the 19^th day of life with good tolerance of the nutritional mixture. The nursing staff’s tasks in terms of feeding patients in the ICU include caring for the central venous catheter, checking its patency, connecting/replacing feeding bags, determining daily weight, maintaining a fluid balance, and administering food through a gastric tube. Activities performed during nutritional treatment should be recorded in the nursing record.
A trend in medical care in Poland that is steadily gaining importance is so-called developmentally focused care. The goal is to develop cognitive abilities and provide physical and emotional support to newborns at high risk for developmental disorders. The concept involves the use of neuroprotective measures, such as modifying the ward environment by protecting the child from noises or excessive lighting, and emphasises the importance of positioning, touch, sleep hygiene, and family care [15].
The primary role in positioning patients is played by nursing staff, whose task is to properly lay the patient, taking into consideration the individual needs of the child. In the PICU, so-called “sockets” and rollers made of a tetra diaper are used for this purpose. The treatment team should periodically change the positioning of the child’s body (at least every 3-4 h), using gentle slow movements and avoiding sudden motions of lifting [15].

CONCLUSIONS

The nursing crew is a part of the therapeutic team, playing an important role in the care of premature newborns. The extreme severity of the baby’s condition in the analysed case was due to the immaturity of the organs, which had a significant impact on the functioning of the body systems. It is important to note that the presence of so many complications associated with prematurity constitutes many challenges. It requires nursing and medical staff to work together to optimise the treatment. To be exact, caring for the premature infant with monitoring of vital functions, proper nutrition, respiratory care, and systematic positioning increased her chances of survival. Importantly, the education of the parents by the nursing team provides an opportunity for the correct management of an infant burdened with health problems in the future.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References