Soins infirmiers aux prématurés

 Soins infirmiers aux prématurés

Définition 

 

Enfants nés avant 37 semaines d'aménorrhée. Accueil en réa néonatale si < 34 semaines d'aménorrhée ou problèmes respiratoires. Il existe toujours un boxe prêt.

Espérance de vie entre 22 et 24 semaines. Déclaration de naissance obligatoire dès 22. La fréquence est de 5 à 6 % en France, avec une légère tendance à la hausse.

 

Prématuré normal

Si >36 semaines et > 2,4 kg :

Bonnet sur la tète

Position dorsale

Berceau près de la mère

Pas de T° rectale : aisselle toutes les 3h

 

II. Étiologies

 

Obstétricales

- grossesse multiple

- placenta praevia

- malformations fotales

- béance du col

- maladies maternelles (toxémie, Hta)

Diverses

- âge >40 ans

- activité excessive

- accident gynécologique

- maman ne faisant que des prématurés...

III. Clinique

- aspect fragile

- petit poids et taille

- bien proportionné

- faible agitation

- peau érythrosique (fine voire transparente)

- panicule adipeux sous cutané minime

- tégument doux

- oedèmes des extrémités

 

ImmaturitéRisques (maladies)surveillance
ThermorégulationHypothermie (acidose, apnée)- prévenir le refroidissement à la naissance(incubateur)
- surveillance de la température toutes les 4 H en axillaire
- tunnel (éviter la déperdition de chaleur)
- bonnet
Centres respiratoires- pauses et apnées
- bradycardie et cyanose
- hypoxie =séquelles neuro
- surveillance respiration par monitorage
- surv apparition de signes de lutte respiratoire
- aide respiratoire (Hood, ventilation assistée)
-bonne position du thorax
- tension et coloration
Pulmonairesrisque de maladie des membranes hyalines = détresse respiratoire
Fragilité vasculairerisque d'hémorragie surtout cérébraletraitement à la vitamine K
Hépatique- ictère physiologique constant ou prolongé plus ou moins grave (environ 15 j)
- hypoglycémie (faible quantité de glycogène dans le foie)
- hémorragie par baisse des facteurs de coagulation
- surveillance du taux de bilirubine
- coloration du bébé
- surv de la photothérapie
- surv toutes les 3 H de la glycémie
Digestive- mécanique et sécrétoire
- retard d'élimination du méconium assez fréquent
- difficulté à ingérer des nutriments =parésie intestinale (résidu gastrique, ballonnements, régurgitation, vomissement,...)
- nécrose intestinale (entérite ulcéronécrosante)
- date et heure du méconium
- poids
- aspect des selles
- en cas d'entérite:
vomissements bilieux
état de choc
arrêt immédiat de l'alimentation entérale et mise sous aspiration digestive (chirurgie si nécrose)
Appareil hématopoïétiqueanémie 
Rénale- difficulté à concentrer ses urines
- oedèmes fréquents
- surveillance de l diurèse
- ECBU
Système nerveux- hypotonie
- réflexes archaïques en baisse selon le degré de prématurité
- surveillance du comportement
- signes anormaux (convulsions) à signaler
Immunitaire- sensibilité aux infections :
fragilité de la peau
escarres
poche à urine
- asepsie
- attention aux postures

 

 

IV. Préparation du box

 

Incubateur

 

- Maintenir une température constante chez l'enfant.  = environ 36°5.

- Air humidifié = eau stérile ou eau + chlorexidine.

- Draps stériles ; couches stériles.

- Matériel de surveillance prêt : scope cardio-respiratoire (avec cordon et 3 électrodes dans la couveuse, alarme au dessous de 80 p et au dessus de 200 p, alarme pour une apnée supérieure à 10 à 15 secondes). Un oxymètre de pouls(mesure de la saturation en O2 de l'hémoglobine). Un appareil de mesure de PO2 et PCO2 cutanée (électrode chauffée à 43° : changer le site de l'électrode toutes les 3 heures pour éviter les brûlures).

 

Matériel de réanimation

 

- Masque et ballon avec manomètre O2.

- Respirateur (air humidifié et réchauffé) : les pressions et l'O2 sont des prescriptions. Vérifier la température du réchauffeur et l'humidification.

- Aspirateur réglé à -300 mmhg prêt en permanence. Les sondes d'aspiration sont à usage unique. Un enfant intubé est aspiré toutes les 3 à 4 heures environ.

- Pompe à perfusion prête + 2 pousses seringues prêts.

- Une sonde gastrique + une moustache (sparadrap).

- Tout le matériel de prélèvement + thermomètre + mètre ruban.

- Blouses de boxe.

V. Arrivée de l'enfant

- Vérifier le poste et préparer le respirateur.

- Préparer une balance.

- Hygiène très importante : se laver les mains et mettre une blouse de boxe.

- Observer la coloration de l'enfant :

- Ballonner l'enfant et si il est intubé,  préparer le respirateur.

- Évaluer l'état de détresse respiratoire si non intubé.

- Peser l'enfant si possible.

- Mettre l'enfant dans l'incubateur (brancher les scopes).

- Prendre la température de l'enfant en rectal pour la première fois.

- Aspiration nasale et buccale pour dégager les voies aériennes.

- Sonde gastrique par la bouche.

- Prélèvement bactériologiques nez / bouche / oreilles.

- Poser un collecteur à urines (ECBU et surveillance de la diurèse) à reste en place ± 24 heures.

- Prélèvements sanguin (1,3 ml par tube) : numération, groupe, ionogramme, CRP, TP, TCK, hémocultures, dextro et gaz du sang.

-Utiliser la sérotec prélevée chez la mère (ALAT, HIV, hépatites).

- Voies d'abord : KT périphérique ou KT veineux ombilical (en stérile) peut rester 5 à 10 jours. KT central possible (risque infectieux ö). KT ombilical artériel possible.

- Désinfection oculaire.

- Prendre périmètre crânien, mesurer la taille.

- Faire tous les gestes avec douceur, dans le calme, observer les réactions de l'enfant, lui parler.

- Tous les gestes et paramètres sont notés dans un cahier de boxe.

 

VI. Les soins quotidiens

 

S'occuper des parents, leur expliquer, leur donner un livret d'accueil, leur donner des nouvelles le plus vite possible.

 

Score de Silverman :

Ce score échelle de 0 à 10, permet d'apprécier l'état des fonctions ventilatoire du nouveau né en appréciant 5 critères côtés de 0 à 2.  

 

Critère

Cotation

0

1

2

Balancement thoraco-abdominal

Respiration synchrone

Thorax immobile

Respiration paradoxale

Tirage

absent

intercostal

Intercostal + sus sternal

Entonnoir xiphoïdien

absent

modéré

intense

Battement des ailes du nez

absent

modéré

intense

Geignement expiratoire

absent

Au stéthoscope

A l'oreille

Un score supérieur à 5 signe une détresse respiratoire nécessitant une prise en charge active précoce.

 

Soins infirmiers pour l' intubation :

 

- aspiration gastrique pour vider l'estomac

- aspiration des voies aériennes supérieures

- sondes sans ballonnet (bien les fixer = moustaches)

- intubation par le nez

- noter sur le cahier de boxe le repère de profondeur, et vérifier à chaque soins si la sonde a bougé

- aspiration toutes les 3 à 4 heures

L'enfant est sédaté : suit mieux la machine et tolère mieux les aspirations.

 -noter les paramètres de la machine sur le cahier de boxe et les vérifier.

 

Le prématuré est dépendant dans tous ses besoins.

 

Respiration et circulation

Maladies de membranes hyalines = surfactant artificiel.

Surveillance :

- Fréquence respiratoire

- Saturation (N = 95%)

- PO2 cutanée (entre 50 et 100 mmhg) si PO2> 100 risque de cécité.

- PCO2 entre 30 et 45 mmhg.

- Gaz du sang au talon (éviter l'os), prélèvement dans un tube en verre (éviter les bulles d'air) ou sur KT ombilical artériel.

- Dextro.

- Vérifier la perméabilité des voies aériennes supérieures, l'assurer avec désobstruction rhino-pharyngée = sérum j ou aspiration. Immaturité des centres respiratoires : risques d'apnées avec bradycardies.

 

Thermorégulation

Centres immatures : mauvaise régulation. Déperditions par la tête + peu de graisse.

Incubateur : atmosphère chauffée et humidifiée (car déshydratation rapide), protection contre les infections.

36°5 au début puis adaptation aux besoins de l'enfant.

Température prise toutes les 3 h en axillaire.

Toilette rapide pour éviter les refroidissements.

 

Digestion, Alimentation

Pas d'alimentation entérale au début. Perfusion IV (toujours si < 29 semaines)

Succion inefficace avant 35 à 36 semaines.

Nutrition entérale à débit continu è gavage

Sonde gastrique (ch 6) (24 à 48 h) ou sonde de Lewin (à changer tous les 15 j / 3 sem) + moustaches + stéthoscope + seringue 20ml.

Pose de la sonde par la bouche, le plus rapidement possible, sur une déglutition de l'enfant. Vérifier la position de la sonde avec 2ml d'air.

Stimulation intestinale : 8 x 0,5 ou 1 ml de lait pour stimuler la production d'enzymes.

Gavage en continu ou bolus possible / lait changé toutes les 3h / seringue changée 1x/24h / normales, embouts différents.

Contrôler la position de la sonde avant la pose.

Mettre des moufles à l'enfant pour éviter qu'il n'arrache la sonde.

Vérifier la tolérance digestive, les reflux, régurgitations.

Surélever l'enfant (orthostatique) à Surveiller les oedèmes des jambes.

 

Élimination

Surveillance abdomen : ballonnement et souplesse.

Fréquence des selles et aspect.

Aide à l'élimination :

Massages abdominaux

Suppositoires de glycérine

Lavements 2ml de sérum j

- douleurs abdominales : mimique, pleurs à la palpation, jambes repliées.

- élimination rénale : collecteur à urines changé 1x/24h ou pesée des couches.

- oedèmes de paupières, cou, bras, jambes.

Complication : entérocolite ulcéronécrosante Ballonnement abdominal, peau rouge ou bleutée autour de l'ombilic, dégradation de l'état de l'enfant à arrêt alimentation, aspiration digestive.

 

Immaturité neurologique

Risque : hémorragie intra ventriculaire.

Respecter le sommeil et le besoin de calme de l'enfant. Boxe seul pour les plus petits, préserver les moments de repos sans soins. Limiter l'éclairage agressif. Ne rien poser sur la couveuse.

Surveillance neuro : échographie transfontanellaire. EEG.

Surveillance du tonus, surveillance mouvements anormaux.

 

Hygiène

Peau fragile.

Au début, l'hygiène n'est pas une priorité.

Préparer le matériel, faire vite et avec douceur. Linge propre rentré par le haut de la couveuse, salle sortie par le bas.

Incubateur passé au savon doux à l'intérieur.

 

Besoin de sécurité

Limites dans l'incubateur (linges doux, matelas d'eau...).

Prévenir les positions vicieuses (genoux plus bas que les hanches).

Construction du schéma corporel (massages).

 

Besoins relationnels

Pas d'heures de visites : les parents sont tout le temps les bienvenus.

Accueil très important. Prise en charge des familles :

Hiatus entre enfant prématuré et enfant désiré, culpabilité des mères, caractère dramatique de la naissance.

Éloignement de l'enfant, craintes pour la vie de l'enfant (négation de la naissance, anticipation de la mort de l'enfant, désinvestissement des parents).

Faire participer au maximum les parents à la vie de l'enfant, ne rien leur cacher, les convaincre qu'on ne leur cachera rien. Mettre l'enfant dans les bras de ses parents, peau à peau, leur permettre d'être présents chaque jour.

 

15 votes. Moyenne 3.07 sur 5.

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