highrisk newborns

7/31/2019 Highrisk Newborns

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HIGH RISK NEWBORNS


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SGA Preterm, term, postterm

(+) IUGR or failed to grow at expected rate

Causes:

Mothers nutrition (Adolescents)

Placental anomaly

Developmental defect

Placental damage

Systemic disease (DM)

Smokers or use of narcotics

Intrauterine infection

Chromosomal abnormality


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Assessment:

Perinatal assessment

FH than expectedUltrasound: small size

BPP: Poor placental perfusion

NSTPlacental grading

AF amount

Ultrasound exam


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Appearance

Small liver

Poor skin turgor

Large head

Widely separated skull sutures

Hair is dull

Sunken abdomen Cord appears dry and stained yellow

Better developed neurological responses, solecreases, ear cartilage

Skull may be firmer Alert and active


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Lab. Findingshct >65 70% exchange

transfusion

RBC blood viscosityacrocyanosis

Hypoglycemia (


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Nursing Diagnoses: Ineffective breathing pattern r/t underdeveloped body

systems

Resuscitation

Observe RR and character

Risk for Ineffective thermoregulation r/t lack of SC fat Control environment

Risk for Impaired Parenting r/t Childs High Risk

Status and Possible Cognitive or Neuro. Impairment

from lack of Nutrition in Utero Discuss to parents ways to promote infants

development

Provide toys suitable for age


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Assessment:

Uterus is unusually large for the date ofpregnancy

Sonogram Confirm

NST assess placental perfusion

Assess lung maturity by Amniocentesis CPD, Shoulder dystocia


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Appearance:

Immature reflexes

Extensive bruising or birth injury

Ecchymosis, jaundice, erythema

Clavicle or cervical nerve injuries

Asymmetry of anterior chest

Unresponsive or dilated pupils

Seizure

Prominent caput succedaneum, cephalhematoma or Molding CV Dysfunction

Polycythemia

(+) Stress on the heart

(+) Cyanosis Transposition of Great Vessels

Hypoglycemia

glucose to sustain the weight

(+) DM mother glucose in utero insulin production continues up to 24 hrs of life Rebound hypoglycemia


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Nursing Diagnoses:

Ineffective Breathing Pattern r/t Possible Birthtrauma

Risk for Imbalanced Nutrition Less than bodyrequirements r/t additional nutrition needed tomaintain weight and prevent hypoglycemia

Breastfeed immediately

Supplemental formula feedings

Risk for Impaired Parenting r/t High risk status

Needs the same developmental care

Encourage parents to treat their baby as a fragileNB


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PRETERM


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PRETERM Causes:

Low socio economic level Poor nutritional status

Lack of prenatal care

Multiple pregnancy

Previous early birth

Cigarette smoking

Age of the mother

Order of birth

Closely spaced pregnancies

Abnormalities of the mothers reproductive system Infections

OB complications

Early induction of labor

Elective CS


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Assessment:

History:

Pregnancy history

Appearance: Appears small and underdeveloped

Head is disproportionately large (3 cm or >chest)

Skin is unusually ruddy

Veins are easily noticeable


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Acrocyanosis

Covered with vernix caseosa

Lanugo is usually extensive

Few or no creases on soles of feet Eyes are small

Myopia

Immature ear cartilage, pinna falls forward

Ears appears large in relation to head

Less active, rarely cries

(+) Cry; weak and high pitched


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Potential Complications:

Anemia

Normochromic, normocytic anemia

Reticulocyte count

Pale,lethargic and anorectic

Keep a record of the amount of blood drawn

Give DNA recombinant erythropoietin BT, Vit. E and iron

Kernicterus

Acidosis

albumin bind to indirect bilirubin

(+) Jaundice phototherapy or exchangetransfusion


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Persistent PDA

surfactantblood from pulmonary artery tolungs Pulmonary artery PDA

Hydrate

Give Indomethacin or Ibuprofen

Complication of Indomethacin: Oliguria

monitor UO closelyPeriventricular/ Intraventricular Bleeding

(+) Fragile capillaries and immature cerebralvascular development

(+) Rapid change in cerebral BF capillariesrupture

Hypoxia

Pneumothorax


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Nursing Diagnoses:

Impaired Gas Exchange R/T Immature Pulmonary Function

20 secs surfactant alveolar collapse

(+) Breech expel meconium aspiration inflammation or pneumonia


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Give mother O2

Maternal analgesia and anesthesia

Preterm must be resuscitated within 2 mins after

birth

Keep infant warm

Carry out all procedures gently

100% O2: 2 Dangers:

Pulmonary edema

Retinopathy of prematurity


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Risk for Deficient Fluid Volume R/T Insensible WaterLoss at birth and small stomach capacity

Normal glucose: 40-60 mg/100 ml

Specific gravity: 1.003 1.030

UO: 1 ml/kg/hr

IVF 160-200 ml/kg/BW umbilical venous catheter

Monitor weight, UO and specific gravity andelectrolytes

Measure UO by weighing diapers

Preterm: 40-100 ml/kg x 24 hrs ; 1.012

Term: 10-20 ml/kg x 24 hrs ; 1.030

Test urine for glucose and ketones

Keep a record of all blood drawn

Check for blood in stool

Determine possible cause of hypovolemia


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Risk for Imbalanced Nutrition Less than Body Requirements

R/T Additional Nutrients Needed for Maintenance of rapid

growth, possible sucking difficulty and small stomach Feeding Schedule

IVF feeding may be delayed

TPN

Breast, gavage or bottle feeding Get CXR before feeding

(+) Air in stomach

Small, frequent feeding (1-2 ml every 2-3 hrs)

Preterm: 115 140 cal/kg/ BW

Term: 100 110 cal


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Gavage Feeding

(+) Gag reflex 32 weeks 32-34 weeks, ill, (+) RDS Gavage feeding

Bottle feeding or breast feeding is graduallyintroduced Give softer nipple Observe preterm infant closely Offer pacifier

Aspirate stomach secretions measure replace >2 ml not allowed (-) Digestion NEC

Formula: 24 cal/oz preterm

20cal/oz term Vit. K 0.5 ml Give Vit. E prevent hemolytic anemia

Breastmilk: Prevents NEC


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Ineffective Thermoregulations R/T Immaturity

Keep NB warm during transportation Heat shield or plastic wrap

Risk for Infection

Linen and equipment must not be shared

Staff members must be free of infection

Hand washing and gowning


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Risk for Impaired Parenting

Rocking, singing and talking and gentle holding

Kangaroo care

Encourage the mother to express breastmilk

Encourage mother to come to the hospital and hold thebaby before and after gavage or bottle feeding

Photograph of baby

Notes to convey messages from the baby to them can betaped to the incubator

Sibling should not visit if they have colds or fever, (+)immunization, (-) exposure to communicable diseases


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Deficient Diversional Activity (Lack of stimulation)

Organize procedures Shield from noise and light

Pain should be kept into minimum Look directly at an infant in the straight forward position Provide some talk time Gentle stroke an infants back

Risk for disorganized infant behavior Modify environment; reduce stimuli Dim the lights; cover the incubator, turn infant to the side, contain

body with rolled towels

Offer non-nutritive sucking Maintain quiet hour

Parental health-seeking behaviors Overprotection is not necessary Basic immunization


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POST TERM Post term

>42 weeks Placenta functions effectively for only 40 weeks

(+) Postterm syndrome: SGA characteristics Dry Cracked (leather like)

(-) Vernix Light weight meconium stained Fingernails have grown well Alertness = 2 weeks old

(+) Difficulty establishing respiration Hypoglycemia SC tissue temperature regulation difficult Polycythemia, hct

nutrition and O2 (+) Neurologic symptoms


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RESPIRATORY DISTRESS

SYNDROME Due to blood perfusion of lungs; surfactant (+) Hyaline like (fibrosis) membrane formed from

an exudate of infants blood lines terminalbronchioles, alveolar ducts and alveoli

prevents exchange of O2 and CO2 Pathophysiology:

surfactant (+) areas of hypoinflation pulmonaryresistance blood shunts to foramen ovale and ductus

arteriosus

lung perfusion

surfactant (+) Hypoxia, Co2 (+) Lactic acid acidosis

vasoconstrictionpulmonary perfusionsurfactant production alveoli collapse withexpiration


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Assessment: Lowbody temperature Nasal flaring

Retractions Tachypnea (>60) Cyanosis Expiratory grunting distress

Seesaw respiration Heart failure Pale, gray skin Periods of apnea Bradycardia Pneumothorax

CXR: Diffuse pattern of radiopaque areas groundglass (haziness)

Blood gas: Respiratory acidosis C/S: R/O -hemolytic group B strep

May start Penicillin or Ampicillin + Gentamycin or

Kanamycin

Management:


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Management:

Surfactant replacement

Sprayed into lungs by syringe or catheter by ET tube

Head held upright and tilted downward

AW should not be suctioned

(+) Ventilator needs close observation

O2 administration

Continuous Positive Pressure (CPAP) or Assisted Ventilation

with Positive End Expiratory Pressure (PEEP) Keep alveolifrom collaping

Cx: Retinopathy of prematurity

Management:


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Management:

Ventilation

Normal I/E ratio: 1:2

Infant ventilators: 2:1

Complications:

Pneumothorax

Impaired CO

ICP and arterial pressure

Hemorrahge

Limit fluid intakepulmonary artery pressure

Indomethacin or Ibuprofen closure of PDA

Complications:

Renal function platelet function

Gastric irritation


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Additional Therapy

Muscle relaxants Pancuronium (Pavulon) IVspontaneous respiratory

function

Pressure mechanical ventilation

Pneumothorax

Needs critical observation

Frequent ABG

Atropine and Prostigmine should be available


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Liquid Ventilation

Use of Perflourocarbons

(+) O2 Perflourocarbons pick up and carry O2 distends

the lungs

exchange of O2 Can be used to deliver O2

Nitric Oxide

Cause of pulmonary vasodilation

Prevention:

Sonogram

Document: Lecithin should exceed Sphingomyelin (2:1)

MgSO4 or Terbutaline prevent preterm birth

SteroidsLecithin

Betamethasone 12-24 hrs; 24-34 wks AOG (takes effectsbefore 24-48 hrs)


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MECONIUM ASPIRATIONSYNDROME

(+) Meconium at 10 weeks AOG

(+) Breech expel meconium in amniotic fluid

(+) Hypoxia (+) Vagal reflex relaxation of rectal

sphincter Appearance; Green to greenish black

May be aspirated in utero or with 1st breath

(+) Respiratory distress:

(+) Inflammation of bronchioles Mechanical plugging

surfactant production

Hypoxemia, CO2, (+) shunting

(+) secondary infection Pneumonia


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Assessment:

Apgar score

Tachypnea, retractions, cyanosis

Suction with bulb syringe or catheter while at theperineum

Do not administer O2 under pressure

Enlargement of AP diameter (barrel chest) ABG: pO2, pCO2

CXR: Bilateral coarse infiltrates in the lungs, (+) spaces ofhyperaeration (honeycomb effect)

Diaphragm pushed downward


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Management:

Amniotransfusion

CS birth

Tracheal suction, O2, assist ventilation

Antibiotic therapy

Observe closely for signs of trapping air in the alveoli

Observe for signs of heart failure due to shunting ofblood from pulmonary artery to aorta (HR, respiratory

distress)

Maintain a temperature neutral environment

Chest physiotherapy ECMO


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SIDS Unexplained death in infancy

Commons among:

Infants of adolescent mother

Closely spaced pregnancy

Underweight and preterm infants Bronchopulmonary dysplasia

Twins

Narcotic dependents

Peak age: 2-4 mos.

Contributory Factors:


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y Prolonged, unexplained apnea Viral respiratory or botulism Pulmonary edema Brainstem abnormality

Neurotransmitter deficiency HR abnormalities Distorted familial breathing patterns arousal response surfactant Sleeping prone

Infants are well nourished Slight head cold Dies with laryngospasm Blood flecked sputum or vomitus in mouth or on bed clothes Autopsy:

Petechiae in the lungs Mild inflammation and congestion in respiratory tract

Inform parents that the death was unexplained

Give assurance that SIDS is a disease of infants


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HYPERBILIRUBINEMIA Hemolytic Disease of the NB

Rh incompatibility Mother: Rh (-)

Fetus: Rh (+)

Sensitization: Mother begins producing antibodiesagainst D antigen (72 hrs)

2ndpregnancy: D antibody destroy fetal RBC Requires intrauterine transfusions

May induce preterm labor

Administer Phenobarbital to women speeds liver maturity

ABO Incompatibility

Mother: Type O Fetus: Type A or B or AB

Not born anemic

Hemolysis begins with birth; may continue up to 2 wks

Preterm: Not affected

Increase reticulocyte count


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Assessment: Percutaneous umbilical blood sampling

anti-Rh titer (Indirect Coombs test) Mother (+) Abs Fetal erythrocytes

(-) Pale Enlarged liver and spleen (+) Edema Severe anemia Heart failure (Hydrops Fetalis)

(+) Progressive jaundice (+) Preterm: (+) Hemolysis Liver cannot convert

indirect to direct bilirubin (+) Breastfeeding: (+) PrenanediolProgesterone interferes with conjugation of indirect bilirubin

Normal bilirubin: 0-3 mg/100ml >20mg/dl or 12 mg/dl in preterm Kernicterus

Hypoglycemia Hgb


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Management: Early feedingperistalsis

Bilirubin incorporated into feces

Phototherapy Specialized light: Quartz halogen, cool white day light

or special blue fluorescent light

12-30 inches above the bassinet or incubator

Infant is undressed except for diaper Term NB: Bilirubin 15 mg/dl; Preterm: 10-12 mg/dl

Eyes must always be covered

Stool: Bright green, loose, irritating to skin; Urine: Darkcolored

Assess skin turgor, I/O DHN

Monitor axillary temperature

Infant should be removed for feeding


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Exchange Transfusion

Aspirate stomach

Umbilical vein is catheterized

Draw small amounts of blood (2-10 ml) replace with

equal amounts of donor blood

Blood is exchanged slowly 1-3 hrs (automatic pumps)

End: hct, bilirubin, Ca+, glucose, culture

Repeat exchange transfusion

Done for hyperbilirubinemia or polycythemia, bloodincompatibility, heart failure

Keep NB warm

Blood should be given at room temperature


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Use only commercial blood warmers Albumin may be administered 1-2 hrs before Monitor rate of flow of albumin Blood type used: O-

Monitor HR, RR and BP Blood contain acid-citrate-dextrose (ACD) as anticoagulant

Ca acidosis Ca gluconate is given every 100 ml of blood

Citrate-Phosphate Dextrose (preservative) hyperglycemia

insulin

hypoglycemia Heparinized blood interferes with clotting

glucose hypoglycemia Give Protamine sulfate

Observe infant for umbilical vessel bleeding

(+) Redness or inflammation (+) infection

Report changes with V/S Take and record glucose 1 hr after Monitor bilirubin 2 or 3 days after May administer erythropoietin


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SEPSIS

Early onset - birth to 7 days Pathogens: group B strep, E.coli, Klebsiella,

Listeria

Late onset - 7 to 28 days Pathogens: early onset pathogens PLUS

Staph. aureus, Neisseria gonorrhea


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Symptoms: poor feeding, vital signinstability, leukocytosis, leukopenia,thrombocytopenia, hypoglycemia,

hyperbilirubinemia, altered consciousness Evaluation: CBC with diff (band/pmn>0.2

or ANC


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Ampicillin(100 mg/kg/24 hrs) PLUSgentamicin (3-5 mg/kg/24 hrs)

Ampicillin(100 mg/kg/24 hrs) PLUScefotaxime (100-150 mg/kg/24 hrs)

highrisk newborns

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