High Risk Neonate Christina Hernandez RN, MSN. The High Risk Newborn Susceptible to illness or death due to dysmaturity, immaturity, physical disorders,

High Risk NeonateHigh Risk Neonate

Christina Hernandez RN, MSNChristina Hernandez RN, MSN

The High Risk NewbornThe High Risk Newborn

Susceptible to illness or death due to dysmaturity, Susceptible to illness or death due to dysmaturity, immaturity, physical disorders, or complications at immaturity, physical disorders, or complications at birth.birth.

Risk Factors:Risk Factors: Low socioeconomic status, poor nutritionLow socioeconomic status, poor nutrition Exposure to environmental dangersExposure to environmental dangers Obstetric factors such as age, parity, or other premature Obstetric factors such as age, parity, or other premature

birthsbirths Medical conditions related to the pregnancy such as PIH, Medical conditions related to the pregnancy such as PIH,

PROM, or infectionPROM, or infection

Gestational AgeGestational Age

Classification of High Risk Classification of High Risk NewbornsNewborns

Gestational AgeGestational Age Preterm – less than 37 weeks gestationPreterm – less than 37 weeks gestation

(Late Preterm – 34 – 36.6 weeks gestation)(Late Preterm – 34 – 36.6 weeks gestation) Term – 38-41 weeks gestationTerm – 38-41 weeks gestation Postterm – greater than 42 weeks gestationPostterm – greater than 42 weeks gestation

LGA – large for gestational age - above the 90LGA – large for gestational age - above the 90thth percentile percentile AGA – appropriate for gestational age – between the 10AGA – appropriate for gestational age – between the 10 thth

and 90and 90thth percentile percentile SGA – small for gestational age – below the 10SGA – small for gestational age – below the 10thth percentile percentile

Assessment of Gestational AgeAssessment of Gestational Age

Ballard Scale or Dubowitz scale Ballard Scale or Dubowitz scale Neuromuscular characteristicsNeuromuscular characteristics Physical CharacteristicsPhysical Characteristics

Classification of High Risk NewbornClassification of High Risk Newborn

Large for Gestational AgeLGA

Appropriate for Gestational AgeAGA

Small for Gestational AgeSGA

Maturity and Intrauterine Growth Grid

The Preterm InfantThe Preterm Infant

Characteristics of Preterm InfantsCharacteristics of Preterm Infants

Appear frail & weakAppear frail & weak Underdeveloped flexor muscles & muscle toneUnderdeveloped flexor muscles & muscle tone Head is larger in comparison with the rest of the bodyHead is larger in comparison with the rest of the body Lack subcutaneous fat (white fat)Lack subcutaneous fat (white fat) Skin appears red and translucentSkin appears red and translucent Barely apparent small flat nipplesBarely apparent small flat nipples Plantar creases are absent in infants <32 wksPlantar creases are absent in infants <32 wks The pinna of the ear is soft and flatThe pinna of the ear is soft and flat Female – Female – Male –Male –

Physiologic challenges of the Physiologic challenges of the premature infant - Respiratorypremature infant - Respiratory

Insufficient production of surfactant Insufficient production of surfactant

Immaturity of alveolar system Immaturity of alveolar system

Immaturity of musculature and insufficient Immaturity of musculature and insufficient calcification of bony thorax calcification of bony thorax

Respirations 40-60/min., shallow, irregular, usually Respirations 40-60/min., shallow, irregular, usually diaphragmatic. diaphragmatic.

Nursing interventions - RespiratoryNursing interventions - Respiratory

Assess for signs of Respiratory DistressAssess for signs of Respiratory Distress Nasal FlaringNasal Flaring Circumoral CyanosisCircumoral Cyanosis Expiratory GruntingExpiratory Grunting RetractionsRetractions Tachypnea Tachypnea Apneic episodesApneic episodes

Administer OAdminister O22 ◦ Warmed and humidifiedWarmed and humidified◦ OxihoodOxihood◦ Nasal CannulaNasal Cannula◦ CPAPCPAP◦ Analyze oxygen concentration. Analyze oxygen concentration.

Nursing interventions - RespiratoryNursing interventions - Respiratory

PositioningPositioning Position with head slightly elevated and neck slightly Position with head slightly elevated and neck slightly

extendedextended Side-lying or proneSide-lying or prone

SuctioningSuctioning Only use when necessaryOnly use when necessary Be gently so as not to damage fragile mucus membranesBe gently so as not to damage fragile mucus membranes

Physiologic Challenges in the Physiologic Challenges in the preterm infant - Thermoregulationpreterm infant - Thermoregulation

Heat regulation unstableHeat regulation unstable Body temperature may be normal but it fluctuatesBody temperature may be normal but it fluctuates Higher ratio of body surface in proportion to body Higher ratio of body surface in proportion to body

weight.weight. Lack of subcutaneous fat Lack of subcutaneous fat Poor capillary response to environmental changes.Poor capillary response to environmental changes. Decreased brown fatDecreased brown fat Thinner skinThinner skin

Signs of Inadequate ThermoregulationSigns of Inadequate Thermoregulation

Axillary temperature <36.3 or >36.9 degrees CAxillary temperature <36.3 or >36.9 degrees C Abdominal skin temperature <36 or >36.5 degrees CAbdominal skin temperature <36 or >36.5 degrees C Poor feeding or feeding intolerancePoor feeding or feeding intolerance IrritabilityIrritability LethargyLethargy Weak cry or suckWeak cry or suck Decreased muscle toneDecreased muscle tone Cool skin temperatureCool skin temperature Skin pale, mottled, or acrocyanoticSkin pale, mottled, or acrocyanotic Signs of hypoglycemiaSigns of hypoglycemia Signs of respiratory difficultySigns of respiratory difficulty Poor weight gainPoor weight gain

Nursing Interventions - Nursing Interventions - ThermoregulationThermoregulation

GOAL: Neutral thermal environmentGOAL: Neutral thermal environment..

Thermal Neutrality – Nursing InterventionsThermal Neutrality – Nursing Interventions Incubator or radiant warmerIncubator or radiant warmer Warm surfacesWarm surfaces Warm humidified oxygenWarm humidified oxygen Warm ambient humidityWarm ambient humidity Warm feedingsWarm feedings Keep skin dry and head coveredKeep skin dry and head covered

Isolette / Incubator Radiant Warmer/Open Warmer

Physiologic Challenges-Physiologic Challenges-Fluid & Electrolyte BalanceFluid & Electrolyte Balance

Preterm infants lose fluid very easilyPreterm infants lose fluid very easily Rapid respiratory rate and use of oxygen Rapid respiratory rate and use of oxygen

increase fluid lose from the lungsincrease fluid lose from the lungs Lack of keratin, which helps maintain water in Lack of keratin, which helps maintain water in

the skinthe skin Large surface area & lack of flexion increases Large surface area & lack of flexion increases

insensible water lossesinsensible water losses Radiant warmers heighten insensible water lossRadiant warmers heighten insensible water loss


Development of kidneys is not complete until Development of kidneys is not complete until approximately 35 weeks.approximately 35 weeks.

In ability of preterm kidneys to concentrate or In ability of preterm kidneys to concentrate or dilute urine.dilute urine.

Kidneys unable to regulate electrolytes.Kidneys unable to regulate electrolytes.


DehydrationDehydration

Urine output >2 ml/kg/hourUrine output >2 ml/kg/hour

Urine specific gravity >1.020Urine specific gravity >1.020

Weight loss greater than expectedWeight loss greater than expected

Dry skin and mucous membranesDry skin and mucous membranes

Sunken anterior fontanelSunken anterior fontanel

Poor tissue turgorPoor tissue turgor

Blood: Elevated sodium, protein, Blood: Elevated sodium, protein,

and hematocrit levelsand hematocrit levels

OverhydrationOverhydration

Urine output >5 ml/kg/hourUrine output >5 ml/kg/hour

Urine specific gravity <1.001Urine specific gravity <1.001

EdemaEdema

Weight gain greater than expectedWeight gain greater than expected

Bulging fontanelsBulging fontanels

Blood: Decreased sodium, Blood: Decreased sodium,

protein, and hematocrit levelsprotein, and hematocrit levels

Moist breath soundsMoist breath sounds

Difficulty breathingDifficulty breathing

Nursing Interventions- Nursing Interventions- Fluid and Electrolyte BalanceFluid and Electrolyte Balance

Weigh diapers (1gm = 1ml of urine)Weigh diapers (1gm = 1ml of urine) Obtain specific gravityObtain specific gravity Carefully regulate IV fluidsCarefully regulate IV fluids Dilute IV medications in as little fluid that is Dilute IV medications in as little fluid that is

recommended (include medications on intake recommended (include medications on intake measurements)measurements)

Assess IV sites frequentlyAssess IV sites frequently

Physiologic Challenges-Physiologic Challenges-SkinSkin

The Preterm infants skin is:The Preterm infants skin is:• FragileFragile• TransparentTransparent• PermeablePermeable

Nursing Interventions-Nursing Interventions-SkinSkin

Nursing CareNursing Care No use of alcohol or betadine on skinNo use of alcohol or betadine on skin All skin products should be rinsed off with waterAll skin products should be rinsed off with water No use of adhesives, use pectin barriers and back No use of adhesives, use pectin barriers and back

tape with cottontape with cotton Use semi-permeable adhesives such as tegadermUse semi-permeable adhesives such as tegaderm Reposition frequently, as tolerated Reposition frequently, as tolerated

Physiologic Challenges-Physiologic Challenges-InfectionInfection

Exposure to maternal infectionsExposure to maternal infections Lack of transfer of immunoglobulin G (IgG) Lack of transfer of immunoglobulin G (IgG)

from mother during third trimesterfrom mother during third trimester Immature immune response to infectionImmature immune response to infection Subject to invasive procedures (IV’s, lab’s)Subject to invasive procedures (IV’s, lab’s) Prolonged hospital staysProlonged hospital stays

Signs and Symptoms of Infection Signs and Symptoms of Infection in the preterm infantin the preterm infant

Behavioral changesBehavioral changes Color changesColor changes Temperature instabilityTemperature instability Cool, clammy skinCool, clammy skin Feeding intoleranceFeeding intolerance HyperbilirubinemiaHyperbilirubinemia Tachycardia followed by apnea and bradycardiaTachycardia followed by apnea and bradycardia

Nursing Interventions-Nursing Interventions-InfectionInfection

Maintain skin integrityMaintain skin integrity Maintain sterile technique with proceduresMaintain sterile technique with procedures ‘‘Scrub’ before entering – EVERYONEScrub’ before entering – EVERYONE Hand sanitizer at every bedside and used in between careHand sanitizer at every bedside and used in between care No entry if sick – EVERYONENo entry if sick – EVERYONE No artificial nails / short nailsNo artificial nails / short nails Single infant incubators, clean weeklySingle infant incubators, clean weekly Report early signs of infection immediatelyReport early signs of infection immediately Assess infants response to treatment (possible resistance)Assess infants response to treatment (possible resistance) Position change, use sheepskinPosition change, use sheepskin

Physiologic Challenges –Physiologic Challenges –Hepatic SystemHepatic System

Poor glycogen stores -increased susceptibility to Poor glycogen stores -increased susceptibility to hypoglycemia.hypoglycemia.

Inability to conjugate bilirubin - increase Inability to conjugate bilirubin - increase hyperbilirubinemia.hyperbilirubinemia.

Decrease ability to produce clotting factors, low Decrease ability to produce clotting factors, low plasma prothrombin levels.plasma prothrombin levels.

Physiologic Challenges – Physiologic Challenges – Renal SystemRenal System

Decreased glomerular filtration rateDecreased glomerular filtration rate

Inability to concentrate urineInability to concentrate urine

Decreased ability of kidneys to bufferDecreased ability of kidneys to buffer

Decreased drug excretion timeDecreased drug excretion time

Pain in preterm infantsPain in preterm infants

High-pitched, intense, harsh cryHigh-pitched, intense, harsh cry Whimpering, moaningWhimpering, moaning ““Cry face”Cry face” Eyes squeezed shutEyes squeezed shut Mouth openMouth open GrimacingGrimacing Bulging or furrowing of browBulging or furrowing of brow Tense, rigid muscles or flaccid muscle toneTense, rigid muscles or flaccid muscle tone Rigidity or flailing of extremitiesRigidity or flailing of extremities Color changes: Red, dusky, paleColor changes: Red, dusky, pale Increased or decreased heart rate and respirations, apneaIncreased or decreased heart rate and respirations, apnea Decreased oxygen saturationDecreased oxygen saturation Increased blood pressureIncreased blood pressure Sleep-wake pattern changesSleep-wake pattern changes

Nursing InterventionsNursing Interventions

Swaddle, wake slowlySwaddle, wake slowly Pacifier, may use SucrosePacifier, may use Sucrose MedicationsMedications

Signs of OverstimulationSigns of Overstimulationin Preterm Infantsin Preterm Infants

Oxygenation changesOxygenation changes RespirationsRespirations PulsePulse Blood pressureBlood pressure Oxygen saturation levelsOxygen saturation levels ColorColor Sneezing, coughing, Sneezing, coughing,

hiccuppinghiccupping

Behavior changesBehavior changes PosturePosture Facial expressionFacial expression GazeGaze RegurgitationRegurgitation YawningYawning FatigueFatigue

Physiologic Challenges –Physiologic Challenges –Digestive SystemDigestive System

Decreased gag and suck reflexesDecreased gag and suck reflexes Hypotonic cardiac sphincter Hypotonic cardiac sphincter Suck and swallow reflexes may be Suck and swallow reflexes may be

uncoordinateduncoordinated Small stomach capacity Small stomach capacity VomitingVomiting Intolerance of fatsIntolerance of fats Immature absorption of nutrientsImmature absorption of nutrients

Maintaining NutritionMaintaining Nutrition

Nursing CareNursing Care Assess Daily weightsAssess Daily weights Monitor I&OMonitor I&O Accurate IV rates to prevent circulatory overloadAccurate IV rates to prevent circulatory overload Provide feedings via nasogastric if unable to feed orallyProvide feedings via nasogastric if unable to feed orally Initiate oral feedings and assess for tiring Initiate oral feedings and assess for tiring

with feedingswith feedings Monitor urine pH and specific gravityMonitor urine pH and specific gravity Involve parents in feedingsInvolve parents in feedings

Nursing InterventionsNursing Interventions

Pre-feeding assessmentPre-feeding assessment RespirationsRespirations

Measure abdominal girthMeasure abdominal girth

Bowel soundsBowel sounds

Gastric residual Gastric residual

Sucking , swallowing , and gag reflexesSucking , swallowing , and gag reflexes

Readiness for Nipple FeedingReadiness for Nipple Feeding

RootingRooting

Sucking on gavage tube, finger, or pacifierSucking on gavage tube, finger, or pacifier

Able to tolerate holdingAble to tolerate holding

Respiratory rate <60 breaths per minuteRespiratory rate <60 breaths per minute

Presence of gag reflexPresence of gag reflex

Signs of Nonreadiness for Nipple Signs of Nonreadiness for Nipple FeedingsFeedings

Respiratory rate >60 breaths per minuteRespiratory rate >60 breaths per minute

No rooting or suckingNo rooting or sucking

Absence of gag reflexAbsence of gag reflex

Excessive gastric residualsExcessive gastric residuals

ParentingParenting

Facilitating Parent-Infant AttachmentFacilitating Parent-Infant Attachment Prepare parents for first visitPrepare parents for first visit

Equipment, tubes etc.Equipment, tubes etc. Establish safe/trusting environmentEstablish safe/trusting environment

Provide support, reassurance, encouragementProvide support, reassurance, encouragement Encourage visitationEncourage visitation Involved in care takingInvolved in care taking Repeat explanationsRepeat explanations Promote touching, talking, rocking, cuddlingPromote touching, talking, rocking, cuddling Refer to infant by nameRefer to infant by name Allow parents to phone as desiredAllow parents to phone as desired

Common Complications ofCommon Complications ofPreterm InfantsPreterm Infants

Respiratory Distress SyndromeRespiratory Distress Syndrome

Respiratory Distress SyndromeRespiratory Distress Syndrome PathophysiologyPathophysiology

Primary absence, deficiency or alteration in the production of surfactantPrimary absence, deficiency or alteration in the production of surfactant

Decrease in Surfactant = increase in atelectasis = lack of gas exchangeDecrease in Surfactant = increase in atelectasis = lack of gas exchange

Leads to hypoxia and acidosis which further inhibit surfactant Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction.production and causes pulmonary vasoconstriction.

Common Clinical manifestations:Common Clinical manifestations: Nasal FlaringNasal Flaring Circumoral cyanosisCircumoral cyanosis Expiratory gruntingExpiratory grunting RetractingRetracting TachypneaTachypnea

Respiratory Distress Syndrome-Respiratory Distress Syndrome-Nursing InterventionsNursing Interventions

Maintain airway, oxygenation, ventilationMaintain airway, oxygenation, ventilation Supplemental oxygen: Supplemental oxygen:

Nasal prongsNasal prongs OxyhoodOxyhood

Continuous positive airway pressure (CPAP)Continuous positive airway pressure (CPAP)

Intubation with endotracheal tubeIntubation with endotracheal tube

Surfactant Replacement TherapySurfactant Replacement Therapy

Surfactant preparation can be lifesaving and Surfactant preparation can be lifesaving and reduces complications, such as pneumothorax. reduces complications, such as pneumothorax.

Administered through an endotracheal tubeAdministered through an endotracheal tube

Surfactant treatments may be repeated several Surfactant treatments may be repeated several times during the first days until respiratory distress times during the first days until respiratory distress syndrome resolves.syndrome resolves.

Respiratory Distress Syndrome-Respiratory Distress Syndrome-Nursing InterventionsNursing Interventions

Nutrition SupportNutrition Support Newborns with RDS may be given food and water by the Newborns with RDS may be given food and water by the

following means: following means: Tube feeding—a tube is inserted through the baby's mouth Tube feeding—a tube is inserted through the baby's mouth

and into the stomach and into the stomach Parenteral feeding—nutrients are delivered directly into a Parenteral feeding—nutrients are delivered directly into a

veinvein

Support to ParentsSupport to Parents Allow parents to hold and feed Allow parents to hold and feed

when possible.when possible. Assist to decrease their fearsAssist to decrease their fears

Periventricular-IntraventricularPeriventricular-IntraventricularHemorrhageHemorrhage

Periventricular-IntraventricularPeriventricular-IntraventricularHemorrhageHemorrhage

Rupture of fragile blood vessels around the ventricles of the Rupture of fragile blood vessels around the ventricles of the brainbrain

Usually associated with hypoxiaUsually associated with hypoxia

Diagnosed via cranial ultrasoundDiagnosed via cranial ultrasound

Signs – lethargy, poor muscle tone, decreased reflexes, Signs – lethargy, poor muscle tone, decreased reflexes, seizures, apnea or cyanosis, full or bulging fontanelsseizures, apnea or cyanosis, full or bulging fontanels

Nursing Care – daily measure FOC, observe for changes in Nursing Care – daily measure FOC, observe for changes in LOCLOC

Retinopathy of PrematurityRetinopathy of Prematurity


Formation of immature blood vessels in the Formation of immature blood vessels in the retina constrict and become necroticretina constrict and become necrotic

Most common in infants < 28 weeks gestationMost common in infants < 28 weeks gestation

Also associated with O2 therapyAlso associated with O2 therapy


Nursing Interventions to Prevent ROPNursing Interventions to Prevent ROP Administer O2 in concentration orderedAdminister O2 in concentration ordered

Ensure proper ventilatory settingsEnsure proper ventilatory settings

Necrotizing EnterocolitisNecrotizing Enterocolitis

Necrotizing EnterocolitisNecrotizing Enterocolitis

An inflammatory disease of the intestinal tract An inflammatory disease of the intestinal tract frequently complicated with perforation of the gut.frequently complicated with perforation of the gut.

NEC develops when there is asphyxia or hypoxia in which NEC develops when there is asphyxia or hypoxia in which cardiac output tends to be directed more toward the heart and cardiac output tends to be directed more toward the heart and brain and away from the abdominal organs. brain and away from the abdominal organs.

The intestinal cells become ischemic and damaged and stop The intestinal cells become ischemic and damaged and stop secreting protective mucus infection occurs. secreting protective mucus infection occurs.

Perforation may occur with overwhelming sepsis.Perforation may occur with overwhelming sepsis.

Necrotizing EnterocolitisNecrotizing EnterocolitisSigns and SymptomsSigns and Symptoms

Early:Early: Increase in gastric aspirate - >5-25 ml. Increase in gastric aspirate - >5-25 ml. Increase in abdominal girth Increase in abdominal girth Decrease bowel sounds, abdominal tenderness or rigidity Decrease bowel sounds, abdominal tenderness or rigidity

of abdominal wall.of abdominal wall. Subtle: Subtle:

Lethargy, sudden listlessness, temperature instability, Lethargy, sudden listlessness, temperature instability, decrease urine output, occult blood in stools, poor color, decrease urine output, occult blood in stools, poor color, and apneic periods.and apneic periods.

Dramatic:Dramatic: Massive abdominal distention, vasomotor collapse.Massive abdominal distention, vasomotor collapse.

Necrotizing EnterocolitisNecrotizing EnterocolitisTreatment and Nursing CareTreatment and Nursing Care

Surgery:Surgery: Resection of necrotic sections and possible Resection of necrotic sections and possible temporary colostomy. This allows bowel to recover.temporary colostomy. This allows bowel to recover.

Medical:Medical: NPO with NG tube. NPO with NG tube. Peripheral or central hyperalimentation Peripheral or central hyperalimentation Antibiotic therapy. Antibiotic therapy. Continue to monitor for changes in condition.Continue to monitor for changes in condition. Gradually introduce oral feedingsGradually introduce oral feedings

Post-Term NewbornPost-Term NewbornGreater than 42 weeks gestationGreater than 42 weeks gestation

Post Mature InfantPost Mature Infant

Physical manifestations:Physical manifestations: Dry, cracking, Dry, cracking,

parchment-like skinparchment-like skin Reduced subcutaneousReduced subcutaneous

tissue -Loose appearingtissue -Loose appearing

skinskin No vernix or lanugoNo vernix or lanugo Long fingernailsLong fingernails Profuse scalp hairProfuse scalp hair Long, thin body appearanceLong, thin body appearance Often meconium stained skin, cord, nailsOften meconium stained skin, cord, nails

Post Mature InfantPost Mature Infant

Complications of post term:Complications of post term: HypoglycemiaHypoglycemia Meconium aspirationMeconium aspiration Congenital anomaliesCongenital anomalies Seizure activitySeizure activity Cold stressCold stress

Small for Gestational AgeSmall for Gestational AgeBelow the 10Below the 10thth percentile percentile

Risk FactorsRisk Factors Maternal factors:Maternal factors:

◦ High blood pressure. High blood pressure. ◦ Chronic kidney disease. Chronic kidney disease. ◦ Advanced diabetes. Advanced diabetes. ◦ Heart or respiratory disease. Heart or respiratory disease. ◦ Malnutrition, anemia. Malnutrition, anemia. ◦ Infection. Infection. ◦ Substance use (alcohol, drugs); Cigarette smoking. Substance use (alcohol, drugs); Cigarette smoking.

Factors involving the uterus and placenta:Factors involving the uterus and placenta: ◦ Decreased blood flow in the uterus and placenta. Decreased blood flow in the uterus and placenta. ◦ Placental abruption (placenta detaches from the uterus). Placental abruption (placenta detaches from the uterus). ◦ Placenta previa (placenta attaches low in the uterus). Placenta previa (placenta attaches low in the uterus). ◦ Infection in the tissues around the fetus. Infection in the tissues around the fetus.

Factors related to the developing baby (fetus):Factors related to the developing baby (fetus): ◦ Multiple gestation (twins, triplets, etc.). Multiple gestation (twins, triplets, etc.). ◦ Infection. Infection. ◦ Birth defects. Birth defects. ◦ Chromosomal abnormality. Chromosomal abnormality.

Complications of the SGA Complications of the SGA NewbornNewborn

Asphyxia Asphyxia

Aspiration syndrome Aspiration syndrome

HypothermiaHypothermia

Hypoglycemia Hypoglycemia

PolycythemiaPolycythemia

Large for Gestational AgeLarge for Gestational AgeGreater than 90Greater than 90thth percentile percentile

What condition is associated with the What condition is associated with the newborn being LGA?newborn being LGA?

Complications of the LGA Complications of the LGA newbornnewborn

Birth Trauma Birth Trauma

Increase of Cesarean birthsIncrease of Cesarean births

HypoglycemiaHypoglycemia

PolycythemiaPolycythemia

HyperviscosityHyperviscosity

Asphyxia of the NewbornAsphyxia of the Newborn

AsphyxiaAsphyxia

Lack of oxygen and increase of carbon dioxide in the bloodLack of oxygen and increase of carbon dioxide in the blood Occurs in utero or after birthOccurs in utero or after birth

S/S asphyxia after birth:S/S asphyxia after birth: Cessation of respirations and rapid fall in heart rateCessation of respirations and rapid fall in heart rate

Interventions:Interventions: Primary apnea: stimulation and O2Primary apnea: stimulation and O2 Secondary apnea: positive pressure ventilation &/or chest Secondary apnea: positive pressure ventilation &/or chest

compressionscompressions Naloxone 0.1mg/kg IM (if narcotics given to expectant Naloxone 0.1mg/kg IM (if narcotics given to expectant

mother shortly before birth)mother shortly before birth)

Meconium Aspiration SyndromeMeconium Aspiration Syndrome


Meconium stained amniotic fluidMeconium stained amniotic fluid Aspirated into the trachobronchial treeAspirated into the trachobronchial tree Occurs either in utero or after birth with the first Occurs either in utero or after birth with the first

breaths.breaths.

Meconium in the lungs causes air to become Meconium in the lungs causes air to become trapped and results in alveoli over-distension and trapped and results in alveoli over-distension and rupture.rupture.

Measures for Prevention of Meconium AspirationMeasures for Prevention of Meconium Aspiration After delivery of the infant’s head while shoulders and After delivery of the infant’s head while shoulders and

chest are still in the birth canal, chest are still in the birth canal, Suction oropharynx and nasopharynx Suction oropharynx and nasopharynx

After delivery of the infant’s bodyAfter delivery of the infant’s body

CryingCrying Not crying Not crying

- Stimulate- Stimulate - Do not stimulate - Do not stimulate- Suction with- Suction with - Direct tracheal suction - Direct tracheal suction bulb syringebulb syringe with endotracheal tube with endotracheal tube



IntubationIntubation

SuctionSuction

Nursing Interventions:Nursing Interventions: Maintain adequate oxygenation and ventilationMaintain adequate oxygenation and ventilation Regulate temperatureRegulate temperature Accurate IV fluid administrationAccurate IV fluid administration Assess for hypoglycemiaAssess for hypoglycemia Administer antibioticsAdminister antibiotics Prevent caloric requirementsPrevent caloric requirements Provide support care if on ECMOProvide support care if on ECMO


HyperbilirubinemiaHyperbilirubinemia

Hyperbilirubinemia PathophysiologyPathophysiology

Unconjugated bilirubin is a break-down product of destroyed RBC’s. Unconjugated bilirubin is a break-down product of destroyed RBC’s.

Unconjugated bilirubin is normally transferred in the plasma firmly bound to Unconjugated bilirubin is normally transferred in the plasma firmly bound to albumin to the liver where conjugation occurs. albumin to the liver where conjugation occurs.

Conjugated bilirubin is water soluble and can then be excreted into the bile and Conjugated bilirubin is water soluble and can then be excreted into the bile and eliminated with the feces. eliminated with the feces.

Unconjugated bilirubin is not in excretable form and remains in the circulation Unconjugated bilirubin is not in excretable form and remains in the circulation causing problems.causing problems.

Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin released into the serum.released into the serum.

Causes of Hyperbilirubinemia

Hemolytic disease (Rh and ABO incompatibility)Hemolytic disease (Rh and ABO incompatibility) Extravascular bleed (cephalhematoma)Extravascular bleed (cephalhematoma) Bilirubin conjugation defects (breastmilk jaundice, Bilirubin conjugation defects (breastmilk jaundice,

asphyxia)asphyxia) HypoalbuminHypoalbumin Physiologic jaundice (occurs after the first 24 hours of Physiologic jaundice (occurs after the first 24 hours of

birth. Mainly due to immature liver and lack of birth. Mainly due to immature liver and lack of glucoronyl transferase).glucoronyl transferase).

Hyperbilirubinemia

Clinical Manifestations:Clinical Manifestations: Sclerae appearing yellow before skin appears Sclerae appearing yellow before skin appears

yellow – usually in the first 24 hours after deliveryyellow – usually in the first 24 hours after delivery Skin appearing light to bright yellow – advances Skin appearing light to bright yellow – advances

from head to toefrom head to toe LethargyLethargy Dark, amber concentrated urineDark, amber concentrated urine Poor feedingPoor feeding Dark stoolsDark stools

Hyperbilirubinemia Diagnosis:Diagnosis:

Bilirubin levels on Cord BloodBilirubin levels on Cord Blood Average level of Unconjugated bilirubin is 2 mg/dl at birthAverage level of Unconjugated bilirubin is 2 mg/dl at birth Bilirubin levels should NOT exceed 5 mg/dlBilirubin levels should NOT exceed 5 mg/dl

Coombs TestCoombs Test may be done on the fetal cord blood (direct Coombs test) may be done on the fetal cord blood (direct Coombs test)

or on the maternal blood (indirect Coombs test). or on the maternal blood (indirect Coombs test). Tests for the presence of maternal antibodies attached on Tests for the presence of maternal antibodies attached on

the infant’s red blood cellsthe infant’s red blood cells. . The test is positive if there are maternal antibodiesThe test is positive if there are maternal antibodies..

Hyperbilirubinemia Nursing Care

Careful observation of infant for signs of increased Careful observation of infant for signs of increased jaundicejaundice

Careful observation for and prevention of Careful observation for and prevention of acidosis/hypoxia and hypoglycemia, which decrease acidosis/hypoxia and hypoglycemia, which decrease binding of bilirubin to albumin and contribute to binding of bilirubin to albumin and contribute to jaundice.jaundice.

Maintain adequate hydrationMaintain adequate hydration Avoid cold stressAvoid cold stress Phototherapy – use of “bili” lights, special fluorescent Phototherapy – use of “bili” lights, special fluorescent Exchange TransfusionExchange Transfusion

HyperbilirubinemiaNursing Care

Nursing Interventions for PhototherapyNursing Interventions for Phototherapy Exposure of skinExposure of skin Cover eyes (remove for feeding/parent visit)Cover eyes (remove for feeding/parent visit) Monitor temperature – prone to hyperthermia or Monitor temperature – prone to hyperthermia or

hypothermiahypothermia Reposition newborn every 2 hoursReposition newborn every 2 hours Increase fluidsIncrease fluids Assess for dehydrationAssess for dehydration Perform T-Bili q 12 – 24 hr as orderedPerform T-Bili q 12 – 24 hr as ordered Explain need to keep under phototherapy except during Explain need to keep under phototherapy except during

feedings and diaper changes.feedings and diaper changes. Explain to parents and allow them to hold during feedingsExplain to parents and allow them to hold during feedings

HyperbilirubinemiaPhototherapy

Side Effects to PhototherapySide Effects to Phototherapy Frequent loose, green stoolsFrequent loose, green stools Skin rashSkin rash Increased basal body metabolismIncreased basal body metabolism DehydrationDehydration HyperthermiaHyperthermia

HyperbilirubinemiaExchange Transfusion

Exchange TransfusionExchange Transfusion Treat anemiaTreat anemia Remove sensitized RBCs that will soon lyseRemove sensitized RBCs that will soon lyse Remove serum bilirubinRemove serum bilirubin Provides albumin to increase bilirubin binding Provides albumin to increase bilirubin binding

sitessites

Hyperbilirubinemia

RhogamRhogam Provides temporary passive immunity which Provides temporary passive immunity which

prevents permanent active immunity (antibody prevents permanent active immunity (antibody formation)formation)

Given within 72 hours of deliveryGiven within 72 hours of delivery

Prevents production of maternal antibodiesPrevents production of maternal antibodies

ABO incompatibilityABO incompatibility Occurs when type O pregnant woman with A, B or Occurs when type O pregnant woman with A, B or

AB blood type fetusAB blood type fetus If woman has anti A or anti B antibodies, these If woman has anti A or anti B antibodies, these

antibodies cross the placental barrierantibodies cross the placental barrier Results in hemolysis of fetal RBCsResults in hemolysis of fetal RBCs

Hyperbilirubinemia

Complications of Hemolytic DiseaseComplications of Hemolytic Disease Kernicterus – Deposits of conjugated and Kernicterus – Deposits of conjugated and

unconjugated bilirubin in the basal ganglia of the brainunconjugated bilirubin in the basal ganglia of the brain Neurologic damageNeurologic damage

Hydrops fetalis – severe anemiaHydrops fetalis – severe anemia Marked edemaMarked edema Cardiac decompensationCardiac decompensation Multiple organ failureMultiple organ failure Possible deathPossible death

Hyperbilirubinemia

Infections

TORCHATORCHA

Toxoplasmosis Other

Syphillis Hepititis B

Rubella Cytomegalovirus Herpes Simplex II HIV - AIDs

Infectious Diseases: TORCH

Protozoan infection in the pregnant woman Raw or under cooked meats Infected Cat feces

Transmission: transplacental

Affects on the fetus Retinochoroiditis (inflammation of the retina and choroid of the

eye. Blindness Deafness Convulsions Microcephaly Hydrocephaly Severe mental impairment

Toxoplasmosis

Transmission: Transplacental Clinical Manifestations:

Rhinitis (Snuffles) 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 - Syphillislis

Other – Hepatitis B

Transmission Placental Birth Breast milk

Treatment If mother + HbSAG - administer to newborn:

Hepitisis B vaccine HBIG

(administer within 12 hours of birth)

Transmission: transplacental S/S of Newborn

Congenital cataracts Deafness Congenital heart defects Sometimes fatal Intellectual disability

(Affects are greatest if infected in 1st trimester)

MMR Immunization of mother Give when not pregnant – usually in immediate postpartum period. Newborns are infectious:

CONTACT ISOLATION

Rubella

Herpatic virus Transmission:

Crosses placental barrier Direct contact at birth Breast milk

S/S of Newborn Severe neurological problems Eye abnormalities Hearing loss Microcephaly Hydrocephaly Enlarged liver Cerebral palsy

Cytomegalovirus

Transmission: Direct contact at birth S/S of Newborn

Custer of vesicles Lethargy Encephalitis Mental delays Seizures Retinal dysplasia Apnea Coma

CONTACT ISOLATION - culture vesicles Treatment: Antivial drugs

Herpes Simplex II

Transmission: TransplacentallyTransplacentally Exposure at birthExposure at birth Breast milkBreast milk

Diagnosis: Serology tests are performed within 48 hours of birth;Serology tests are performed within 48 hours of birth;

repeated at 3 and 6 monthsrepeated at 3 and 6 months HIV antibodyHIV antibody ELISAELISA CD4 + T-cell CD4 + T-cell

HIV/AIDS

HIV infected (two or more positive tests for HIV)

Perinatally exposed (born to a mother know to be infected with HIV)

Seroconverter (born to a mother known to be infected with HIV but has had two negative HIV tests

HIV/ AIDSDiagnosis

Nursing Interventions HIV infected mothers should be identified and begin

treatment with AZT during pregnancy and in labor

All infants born to an infected mother should be treated prophylactically◦ 6 weeks of AZT orally after birth◦ Bactrim and Septra

Provide care like that of any other newborn

HIV / AIDSIDS

Infant of Diabetic Mother

IDM

Hypoglycemia

Hypocalcemia

Hyperbilirubinemia

Polycythemia

Respiratory Distress Syndrome

Complications of Infants of Diabetic Mothers

Why are they prone to 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

Clinical Manifestations: Large size – Macrosomia; enlarged spleen, heart, liver Tremors Cyanosis Apnea Temperature instability Poor sucking and feeding Hypotonic muscle tone / Lethargy

Nursing Interventions Assess blood glucose

Intervene if < 45mg/dl: Feed infant

Revaluate blood sugar 30-45 minutes pc If no improvement:

IV of D10W

Infants of Diabetic Mothers

Newborn of Substance Abuse Mother

The newborn of an alcoholic or drug-dependent mother will also be alcohol or drug dependent.

After birth, when an infant’s connection with the maternal blood supply is severed, the neonate suffers withdrawal.

In addition, the drugs ingested by the mother may be In addition, the drugs ingested by the mother may be teratogenic, resulting in congenital anomalies.teratogenic, resulting in congenital anomalies.

Infant of Addicted Mother

Fetal Alcohol Syndrome – FASClinical Manifestations

Clinical Manifestations: Jitteriness Abdominal distention Exaggerated rooting and sucking reflexes

Affected body systems: CNS

GI system

Long-term psychosocial implications: Feeding difficulties Mental retardation

Fetal Alcohol Syndrome - FAS

Central Nervous Systemo IRRITABILITY

• Hyperactivity• Shrill cry• Exaggerated reflexes• Facial scratches• Short non-quiet sleep

Sneezing, coughing, yawning Gastroinestional System

o Poor feedingo Disorganized vigorous sucko Vomiting and/or Diarrhea

Vasomotor and Cutaneous Signso Tachypneao Sweatingo Excoriated skin

Infants of Addicted MothersClinical Manifestations of Infant Withdrawal

Soothing: Swaddle with hands near mouth Offer pacifier Place in quiet dimly lit area of the nursery

Protect skin from excoriation Monitor V/S Feeding

Provide small frequent feedings Position with HOB elevated Weigh every 8 hours (if vomiting & diarrhea)

Assess with Finnegan Abstinence Scale Administer morphine, phenobarbitol, methadone

Infants of Addicted Mothers Nursing Care

Affects of Smoking on the Fetus during pregnancy

NicotineNicotine Causes vasoconstrictionCauses vasoconstriction Reduces placental blood circulationReduces placental blood circulation

Carbon MonoxideCarbon Monoxide Inactivates fetal and maternal hemaglobinInactivates fetal and maternal hemaglobin

Reduced amount of oxygen to fetus results in Reduced amount of oxygen to fetus results in prematurity or low birth weightprematurity or low birth weight

Thank you!Thank you!

Christina Hernandez RN, MSNChristina Hernandez RN, MSN

[email protected]@austincc.edu

Documents

High Risk Neonate Christina Hernandez RN, MSN. The High Risk Newborn Susceptible to illness or death due to dysmaturity, immaturity, physical disorders,