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

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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

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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

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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

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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.

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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.

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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.

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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

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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

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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

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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

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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

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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

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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.

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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.).

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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

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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

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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:

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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

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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 ) (