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Neonatal Respiratory Distress Including CPAP

Clinical Learning Resource

Response Booklet

January 2015

Neonatal respiratory distress including CPAP: Clinical Learning Resource Response Booklet

Published by the State of Queensland (Queensland Health), January 2015

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ContentsOverview of the resource............................................................................4

How to use this response booklet...............................................................4

Assessment................................................................................................4

Resources required to complete the package.............................................5

Unit 1: Physiology of Respiratory Distress of the Newborn...................6Activity 1...............................................................................................6

Unit 2: Physiology of CPAP...................................................................8Activity 2...............................................................................................8Activity 3...............................................................................................9Activity 4.............................................................................................11

Clinical Scenario.........................................................................................11

Unit 3: Humidification of CPAP............................................................14Activity 5.............................................................................................14Activity 6.............................................................................................15

Unit 4: Complications of CPAP............................................................16Activity 7.............................................................................................16

Clinical Scenario.........................................................................................16Activity 8.............................................................................................18Activity 9.............................................................................................19

Unit 5: Nursing Care of the Baby on CPAP.........................................20Activity 10...........................................................................................20Activity 10.1........................................................................................22Activity 10.2........................................................................................24Activity 10.3........................................................................................25Activity 10.4........................................................................................26Activity 10.5........................................................................................27Activity 11...........................................................................................28

References................................................................................................32

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Overview of the resource This Clinical Learning Resource Package Response Booklet is to be used in conjunction with the Neonatal respiratory distress including administration of CPAP CLR and response booklet. Please review the contents of the learning resource package and answer in the appropriate spaces within this response booklet.

How to use this response bookletTo use this response booklet:

Read through the reading material, including recommended readings and related policies and guidelines

Complete written activities within this booklet and discuss your answers with a resource person

Complete the clinical skills assessment tool (Appendix 4) on completion of this package

AssessmentAssessment of this resource package response booklet will be demonstrated through successful completion of specific activities utilising the resources provided or identified throughout the CLR, or others available from your Hospital Health Service /Facility. Resource staff, Clinical Facilitators or Nurse Educators should review and discuss the responses of all activities listed in the CLR to determine knowledge and awareness of the specific issues addressed. To gain competency for administering CPAP to neonates, the following must be completed:

Completion and assessment of this CLR response booklet Successful completion of the Clinical Skills Assessment Tool (CSAT) will be upon

direct supervision by a Resource Person, Clinical Facilitator or Nurse Educator competent in the care of the baby on CPAP in accordance with the Clinical Assessment Guidelines within the package.

Completion of this resource package and associated competency is optional for nurses/midwives with previous experience in the care of the baby requiring CPAP, i.e. previous completion of an accredited education program in neonatal nursing, including recent experience in the care of the baby requiring CPAP.

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Resources required to complete the package Recommended readings or textbooks Access to QHEPS Access to Health Service Policy website Resource person or Clinical Facilitator or Nurse Educator Queensland Clinical Guideline - Neonatal respiratory distress including CPAP

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Unit 1: Physiology of Respiratory Distress of the NewbornActivity 1

Utilising the information in your reading and the Queensland Clinical Guideline Neonatal respiratory distress including CPAP1 answer the following in your response booklet:

a) Identify the clinical signs of respiratory distress of the newborn

b) List the major causes of respiratory distress of the newborn and identify for each cause, rationale for why it happens

1a) Clinical signs of respiratory distress

1b) Major causes of respiratory distress Rationale for why it happens

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1b) Major causes of respiratory distress continued

Rationale for why it happens

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Unit 2: Physiology of CPAPActivity 2

Cathy has just started work in the nursery and you are assigned to preceptor her on her first day caring for a baby on CPAP. Below please describe how you would teach Cathy the following:

a) The main respiratory issues that CPAP is used for

b) How CPAP reduces babies’ respiratory symptoms

Main respiratory issues and how CPAP reduces symptoms

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Activity 3

Cathy comments that she is unfamiliar with using short bi-nasal prongs and bubble CPAP. After a demonstration applying these devices and caring for a baby on these types of CPAP she asks you about the advantages and disadvantages of each system. Using an evidence based approach document your response below

Short bi-nasal prongsAdvantages Disadvantages

Mask CPAPAdvantages Disadvantages

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Bubble CPAPAdvantages Disadvantages

Ventilator CPAPAdvantages Disadvantages

Nasopharyngeal TubeAdvantages Disadvantages

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Activity 4

Read through the following clinical scenario and answer the subsequent questions.

Clinical ScenarioLucy was born in a tertiary referral centre, at 28 weeks gestation via caesarean section, after her mother’s pregnancy induced hypertension dramatically worsened. Today, five weeks after birth, she has been transferred to the Level 2 nursery for ongoing care. The Nurse/Midwife taking over the care of Lucy noted that on the discharge summary from the tertiary centre, Lucy was ventilated for 7 days and then extubated to nasal CPAP via an infant ventilator.

4 Using the above scenario, please consider and respond to the following questions.

a) Why would you elect to not use ETT CPAP?

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4 Using the above scenario, please consider and respond to the following questions.

b) Is nasal CPAP immediately after extubation in preterm infants necessary? (Refer to the Cochrane Library for the most recent systematic review). Write your conclusions here:

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Reference

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Reading further into Lucy’s discharge summary, it is noted that a couple of days after having her CPAP ceased, she was recommenced on CPAP for apnoea of prematurity.

4 Using the above scenario, please consider and respond to the following questions.

c) Referring back to Reading 2 and 4, identify how CPAP may reduce apnoea in infants with this condition.

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Unit 3: Humidification of CPAP Activity 5

Inadequately humidified ventilatory gases delivered to intubated babies can cause significant respiratory morbidity. Explain seven (7) respiratory changes that occur as a result of poor humidification.

Seven respiratory changes due to poor humidification

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Activity 6

Consider the management of humidification for ventilation of gases in your nursery. Review your nursery’s policy and practices and examine the configuration of the circuit used in the nursery. Using your readings and appendix 3, answer the following questions.

Where is/are the heater wire/s located?

Where is the gas temperature probe positioned? Why?

Which of the inspiratory and expiratory limbs is positioned uppermost at the manifold? Why?

Set temperature for water chamber/inspiratory gas? Is there a deliberate differential? Why?

Is rain-out ever a problem with the configuration used in the nursery? Identify the circumstances (i.e. environmental temperatures) when this occurs and how this could be corrected.

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Unit 4: Complications of CPAPActivity 7

Read through the following clinical scenario and answer the subsequent questions.

Clinical ScenarioDaisy was born in a regional hospital at 41 weeks gestational age via caesarean section. Daisy’s mother had reported decreased fetal movements and upon examination was found to have poor CTG readings leading to an emergency caesarean section. Daisy was born in poor condition with Apgar’s of 3 at 1 minute and 7 at 5 minutes. She required bag and mask intermittent positive pressure ventilation (IPPV) and by ten minutes of age was pink and active.

Though Daisy was breathing, she had moderate chest recession, nasal flaring, and occasional grunting. Daisy was commenced on CPAP with additional oxygen and was taken to the Special Care Nursery. Shortly after, she was commenced on IV antibiotics for her respiratory distress. One hour later, Daisy’s pulse oximetre was alarming and suggested sudden desaturation into the 70’s. Upon closer inspection, the nurse observed that though Daisy was still breathing, she had cyanotic lips and a general dusky appearance. The nurse suctioned Daisy’s mouth and increased her oxygen.

Daisy’s oxygen saturations did not improve; the nurse pressed the emergency alarm and the paediatrician attended. A chest x-ray was ordered while the doctor examined Daisy. Auscultation showed decreased breath sounds on the right side, and a slight chest asymmetry. Chest x-ray confirmed the diagnosis of tension pneumothorax and insertion of an intercostal catheter (ICC) was performed using a sterile technique. Daisy was later weaned back to 21%FiO2 and two days later had the ICC removed.

Reflecting on the above scenario, please answer the following questions.

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7 Identify eight (8) clinical signs of a pneumothoraxa)

7 Discuss the required nursing care of Daisy after insertion of an ICC. b)

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Activity 8

Consider the current nursing management of abdominal distension and the prevention strategies used in your nursery.

How often do babies in your nursery have gastric aspirates? Is gastric venting a routine procedure? How do you differentiate between CPAP belly and signs of

NEC?

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Activity 9

Consult the Queensland Clinical Guideline: Neonatal respiratory distress including CPAP1 and complete the activity below.

9 Identify the signs of failure of CPAP as described in the guideline and the nursing actions that would be initiated

a)

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Unit 5: Nursing Care of the Baby on CPAPActivity 10

Utilising your readings and local resources, list the measurements needed to determine the appropriate equipment size to minimise trauma and maximise efficacy of CPAP (Prior to application)

CPAP type Measurements needed prior to CPAP application

HudsonTMProng CPAP

Mask CPAP

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Fisher & PaykelTM

Midline or ‘snorkel’ CPAP

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Activity 10.1

In an effort to minimise nasal trauma, how do you ensure the following?

a) Right sized prongs (fit)

b) Position prongs appropriately

c) Prongs are secure (bonnet size)

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d) Infant positioned for comfort and containment

e) Prevent ‘drag’ on nares by circuit tubing

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Activity 10.2

In order to address airway patency, how would the following strategies be addressed?

a) Removal of nasal secretions (frequency/technique)

b) Prevention of drying of secretions

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Activity 10.3

In order to maintain mean airway pressure, how will the following strategies will be addressed?

a) Maintain prongs in nares

b) Prong size prevents air leak

c) Minimise and address oral air leaks

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Activity 10.4

In an effort to reduce gastric distention, how would you address the following?

a) Nursing assessment of the baby’s abdomen

b) Gastric decompression

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Activity 10.5

Despite the increased pressure Jack shows no signs of improvement. Outline below why higher levels of CPAP may not improve Jack’s condition.

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Activity 11

In your response booklet, formulate a nursing care plan based on Jack’s scenario. Utilise the QCG, local policy, readings provided within this package and nursing experience to formulate a plan of care for baby Jack. Some ideas have been put in below to get you started……

CPAP Cares (frequency, equipment required)

Frequency of positioning changes

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Skin assessment

Cardiorespiratory assessment

Kangaroo cuddle

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Communication with family

Suction

Feeds

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Analgesia

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References1. Queensland Clinical Guidelines. Neonatal respiratory distress including CPAP. 2014:1-21.

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