h igh r isk n eonates presented by ann hearn rnc, msn
TRANSCRIPT
HIGH RISK NEONATESPresented by Ann Hearn RNC, MSN
CLASSIFICATION OF HIGH RISK NEWBORNS
Gestational Age
Preterm (Late Preterm) Term Postterm
Gestational Age & Birth Weight
SGA AGA LGA
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Respiratory and Cardiac Thermoregulation Digestive Renal
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Respiratory and Cardiac
Lack of surfactant Pulmonary blood vessels Ductus arteriosus
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Respiratory - Nursing Interventions Maintain airway Administer O2 Monitor O2 saturation Monitor heart/respiratory rates
S/S respiratory distress Cyanosis Tachicardia Retractions Expiratory grunting Nasal flaring Apnic episodes
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Thermoregulation
Increased body surface Decreased brown fat Thin Skin Lack of flexion Decrease sub-q fat
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Thermal Neutrality – Nursing Interventions Incubator or radian warmer Warm surfaces Warm humidified oxygen Warm ambient humidity Warm feedings Keep skin dry and head covered
ISOLETTE/ RADIANT or INCUBATOR OPEN WARMER
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Digestive
Poor gag reflex Small stomach capacity Relaxed cardiac sphincter Poor suck and swallow reflex Difficult fat, protein and lactose digestion Absorption
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Nutrition and Hydration – Nursing Interventions Daily weights Monitor I&O Accurate IV rates Accurate OGT feedings Monitor urine pH and specific gravity
Signs of dehydration Weight loss Poor skin turgor Dry oral mucus membranes Decreased urinary output Increased specific gravity
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Pre-feeding assessment Measure abdominal girth Bowel sounds Gastric residual Sucking and gag reflexes
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Renal Decreased glomerular filtration rate Inability to concentrate urine or excrete excess Decreased ability of kidneys to buffer Decreased drug excretion time
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Prevention of Infection – Nursing Interventions Initial scrub / strict hand washing
Visitors & staff Reverse isolation Single infant equipment Short / no artificial nails Maintain sterile technique
IV start and dressing changes Procedures
Clean incubators weekly Position changes; use of sheepskin Judicious use of tape on skin
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Signs and Symptoms of Infection Behavioral changes Physiological changes
Tonus Color Temperature Skin Feeding Hyperbilirubinemia Heart rate Respiratory rate
PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT
Facilitating Parent-Infant Attachment Prepare parents for first visit Establish safe/trusting environment Encourage visitation Involved in care taking Repeat explanations Promote touching, talking, rocking, cuddling Refer to infant by name Allow parents to phone as desired
DISORDERS OF INFANTS IN NICU
SGA and IUGR Infants of Diabetic Mothers Postmature Infant Infants of Addicted Mothers Respiratory Distress Syndrome Meconium Aspiration Syndrome Hyperbilirubinemia Retinopathy of Prematurity Necrotizing Entercolitis Infectious Diseases - TORCH
ASSOCIATED COMPLICATIONS OF:
Asphyxia Aspiration syndrome Hypothermia Hypoglycemia Polycythemia
Congenital malformations
Intrauterine infections Continued growth
difficulties Cognitive difficulties
SGA IUGR
Nursing Interventions: Monitor heart rate, respiratory rate, temperature and blood glucose.
INFANTS OF DIABETIC MOTHERS
INFANTS OF DIABETIC MOTHERS
Clinical manifestations IDM Ruddy color Macrosomia Excessive adipose tissue Hypoglycemia
Increase risk of birth injuries.
INFANTS OF DIABETIC MOTHERS
Why Hypoglycemia? High levels of glucose cross the placenta In response, fetus produces high levels of insulin High levels of insulin production continues after
cord cut Depletes the infant’s blood glucose
INFANTS OF DIABETIC MOTHERS
Nursing Interventions for Hypoglycemia Assess for signs/symptoms
Tremors Cyanosis Apnea Temperature instability Poor feeding Hypertonia / Lethargy
Assess blood glucose Intervene if < 40mg/dl:
Feed infant If no improvement:
IV of D10W
POST MATURE INFANT
Post term: infant born after __?__ wks Physical manifestations:
Dry, cracking, parchment-like skin Loose appearing skin
No vernix or lanugo Long fingernails Profuse scalp hair Long, thin body appearance
POST MATURE INFANT
Complications of post term: Hypoglycemia Meconium aspiration Congenital anomalies Seizure activity Cold stress
Nursing considerations Monitor blood sugars per protocol Evaluate respiratory status Assess for seizure activity Treat cold stress.
INFANTS OF ADDICTED MOTHERS Clinical Manifestations of Infant Withdrawal:
IRRITABILITY Hyperactivity Shrill cry Exaggerated reflexes Facial scratches Short non-quiet sleep
Sneezing, coughing, yawning Poor feeding
Disorganized vigorous suck Vomiting Diarrhea
Tachypnea Sweating Excoriated skin
INFANTS OF ADDICTED MOTHERS
Nursing Interventions for Infant Withdrawal: Swaddle with hands near mouth Offer pacifier Place in quiet dimly lit area of the nursery Protect skin from excoriation Monitor V/S Provide small frequent feedings Position with HOB elevated Weigh every 8 hours (if vomiting & diarrhea) Assess with Finnegan Abstinence Scale Administer morphine, phenobarbitol, methadone
FETAL ALCOHOL SYNDROME - FAS
FETAL ALCOHOL SYNDROME - FAS
Clinical Manifestations: Jitteriness Abdominal distention Exaggerated rooting and sucking reflexes
Affected body systems: CNS
GI system
Long-term psychosocial implications: Feeding difficulties Mental retardation
RESPIRATORY DISTRESS SYNDROME - RDS Pathophysiology
Primary absence, deficiency or alteration in the production of surfactant
Surfactant, atelectasis = lack of gas exchange
Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction.
Clinical manifestations: Cyanosis Tachypnea Nasal flaring Retracting Apnea
RESPIRATORY DISTRESS SYNDROME - RDS
Nursing Care Plan Page 826-828
MECONIUM ASPIRATION SYNDROME
Meconium stained amniotic fluid Aspirated into the trachobronchial tree Occurs either in utero or after birth with the first
breaths.
Meconium in the lungs causes air to become trapped and results in alveoli over-distension and rupture.
MECONIUM ASPIRATION SYNDROME Measures for Prevention of Meconium Aspiration
After delivery of the infant’s head but before shoulders Suction oropharynx and nasopharynx (no longer recommended)
If THICK meconium, after delivery of the infant’s body
Crying Not crying
- Stimulate - Do not stimulate- Suction with - Visualize the vocal cords and bulb syringe provide direct suction with
endotracheal tube, then stimulate. If THIN meconium, no visualization performed.
MECONIUM ASPIRATION SYNDROME
Intubation Suction
MECONIUM ASPIRATION SYNDROME
Nursing Interventions: Maintain adequate oxygenation and ventilation Regulate temperature Accurate IV fluid administration Assess for hypoglycemia Administer antibiotics Provide caloric requirements Provide support care if on ECMO
HYPERBILIRUBINEMIA
Pathophysiology Bilirubin is released in serum when RBC lyse Conjugation in liver = water soluble & excretable Rate & amount of conjugation dependent upon:
Rate of hemolysis Bilirubin load Maturity of liver Presence of albumin-binding sites
Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin released into the serum.
Results in jaundice where the unconjucated bilirubin is deposited in the tissue.
HYPERBILIRUBINEMIA
Hemolytic Disease (Pathologic Hyperbilirubinemia) Results from incompatibility between mother’s
blood type or Rh factor and that of the fetus Maternal antibodies develop from + fetal antigen Antibodies cross placental into fetal circulation Antibodies attach to and destroy fetal RBCs. Fetal RBCs lyse & release bilirubin into fetal
circulation
HYPERBILIRUBINEMIA
Additional assessments: Maternal, paternal, and fetal blood type and Rh
factor
Newborn Skin color, sclera, oral mucosa Hypotonia, diminished reflexes, lethary and seizures
HYPERBILIRUBINEMIA
Positive Coombs Test Direct coombs test reveals antibody-coated Rh
positive RBCs in the newborn
Nursing Interventions for Phototherapy Exposure of skin Cover eyes (remove for feeding/parent visit) Monitor temperature Increase fluids Assess for dehydration Perform T-Bili q 12 – 24 hr as ordered
HYPERBILIRUBINEMIA
Exchange Transfusion Treat anemia Remove sensitized RBCs that will soon lyse Remove serum bilirubin Provides albumin to increase bilirubin binding
sites
HYPERBILIRUBINEMIA
Rhogam Provides temporary passive immunity which
prevents permanent active immunity (antibody formation)
Given within 72 hours of delivery Prevents production of maternal antibodies
HYPERBILIRUBINEMIA
ABO incompatibility Occurs when type O pregnant woman with A, B
or AB blood type fetus If woman has anti A or anti B antibodies, these
antibodies cross the placental barrier Results in hemolysis of fetal RBCs
HYPERBILIRUBINEMIA
Complications of Hemolytic Disease Kernicterus – Deposits of conjugated and
unconjugated bilirubin in the basal ganglia of the brain Neurologic damage
Hydrops fetalis – severe anemia Marked edema Cardiac decompensation Multiple organ failure Possible death
HYPERBILIRUBINEMIA
RETINOPATHY OF PREMATURITY
Formation of immature blood vessels in the retina constrict and become necrotic
Most common in infants < 28 weeks gestation
Also associated with O2 therapy
RETINOPATHY OF PREMATURITY
Nursing Interventions to Prevent ROP Administer O2 in concentration ordered Ensure proper ventilatory settings
NECROTIZING ENTEROCOLITIS
NEC - Inflammatory disease of the intestinal tract caused by ischemia, infection, and/or prematurity of the gut. Preterm infant at increased risk
undeveloped protective intestinal mucin layer slow careful introduction to oral feedings
Early detection: Measure abdominal girth daily Assess color of abdomen Assess residual feeding Assess bowel sounds Assess S/S sepsis
INFECTIOUS DISEASES: TORCH
Toxoplasmosis Other
Syphillis Hepititis B
Rubella Cytomegalovirus Herpes Simplex II HIV
TOXOPLASMOSIS
Protozoan infection in the pregnant woman Raw or under cooked meats Cat feces
Affects on the fetus Blindness Deafness Convulsions Microcephaly Hydrocephaly Severe mental impairment
OTHER
Syphilis
Hepatitis B
OTHER
Syphillis S/S of Newborn:
Rhinitis Excoriated upper lip Red rash around mouth and anus Copper colored rash of face, palms and soles Irritability Edema Cataracts.
Treatment: Culture orifices Isolation Penicillin
OTHER
Hepatitis B Transmission
Placental Birth Breast milk
Treatment If mother + HbSAG administer to newborn
Hepitisis B vaccine HBIG
RUBELLA
S/S of Newborn Congenital cataracts Deafness Congenital heart defects Sometimes fatal
MMR Immunization of mother Give when not pregnant
CYTOMEGALOVIRUS
Herpatic virus Crosses placental barrier Direct contact at birth
S/S of Newborn Severe neurological problems Eye abnormalities Hearing loss Microcephaly Hydrocephaly Cerebral palsy Mental delays
HERPES SIMPLEX II
Transmission: Direct contact at birth
S/S of Newborn Microcephaly Mental delays Seizures Retinal dysplasia Apnea Coma
HIV/AIDS
Transmission: < 2% Transplacentally Exposure at birth Breast milk
Nursing Interventions Protect self from body fluids Labs - + antibody titer Administer AZT Provide care like that of any other newborn