High Risk Neonate
Christina Hernandez RN, MSN
The High Risk Newborn


Susceptible to illness or death due to dysmaturity,
immaturity, physical disorders, or complications at
birth.
Risk Factors:




Low socioeconomic status, poor nutrition
Exposure to environmental dangers
Obstetric factors such as age, parity, or other premature
births
Medical conditions related to the pregnancy such as PIH,
PROM, or infection
Gestational Age
Classification of High Risk
Newborns

Gestational Age
 Preterm – less than 37 weeks gestation
(Late Preterm – 34 – 36.6 weeks gestation)
 Term – 38-41 weeks gestation
 Postterm – greater than 42 weeks gestation



LGA – large for gestational age - above the 90th percentile
AGA – appropriate for gestational age – between the 10th
and 90th percentile
SGA – small for gestational age – below the 10th percentile
Assessment of Gestational Age

Ballard Scale or Dubowitz scale


Neuromuscular characteristics
Physical Characteristics
Classification of High Risk Newborn
Large for Gestational Age
LGA
Appropriate for Gestational Age
AGA
Small for Gestational Age
SGA
Maturity and Intrauterine Growth Grid
The Preterm Infant
Characteristics of Preterm Infants










Appear frail & weak
Underdeveloped flexor muscles & muscle tone
Head is larger in comparison with the rest of the body
Lack subcutaneous fat (white fat)
Skin appears red and translucent
Barely apparent small flat nipples
Plantar creases are absent in infants <32 wks
The pinna of the ear is soft and flat
Female –
Male –
Physiologic challenges of the
premature infant - Respiratory

Insufficient production of surfactant

Immaturity of alveolar system

Immaturity of musculature and insufficient
calcification of bony thorax

Respirations 40-60/min., shallow, irregular, usually
diaphragmatic.
Nursing interventions - Respiratory

Assess for signs of Respiratory Distress







Nasal Flaring
Circumoral Cyanosis
Expiratory Grunting
Retractions
Tachypnea
Apneic episodes
Administer O2
◦
◦
◦
◦
◦
Warmed and humidified
Oxihood
Nasal Cannula
CPAP
Analyze oxygen concentration.
Nursing interventions - Respiratory
 Positioning
 Position with head slightly elevated and neck slightly
extended
 Side-lying or prone
 Suctioning
 Only use when necessary
 Be gently so as not to damage fragile mucus membranes
Physiologic Challenges in the
preterm infant - Thermoregulation

Heat regulation unstable






Body temperature may be normal but it fluctuates
Higher ratio of body surface in proportion to body
weight.
Lack of subcutaneous fat
Poor capillary response to environmental changes.
Decreased brown fat
Thinner skin
Signs of Inadequate Thermoregulation












Axillary temperature <36.3 or >36.9 degrees C
Abdominal skin temperature <36 or >36.5 degrees C
Poor feeding or feeding intolerance
Irritability
Lethargy
Weak cry or suck
Decreased muscle tone
Cool skin temperature
Skin pale, mottled, or acrocyanotic
Signs of hypoglycemia
Signs of respiratory difficulty
Poor weight gain
Nursing Interventions Thermoregulation
GOAL: Neutral thermal environment.

Thermal Neutrality – Nursing Interventions






Incubator or radiant warmer
Warm surfaces
Warm humidified oxygen
Warm ambient humidity
Warm feedings
Keep skin dry and head covered
Isolette / Incubator
Radiant Warmer/
Open Warmer
Physiologic ChallengesFluid & Electrolyte Balance





Preterm infants lose fluid very easily
Rapid respiratory rate and use of oxygen
increase fluid lose from the lungs
Lack of keratin, which helps maintain water in
the skin
Large surface area & lack of flexion increases
insensible water losses
Radiant warmers heighten insensible water
loss
Physiologic ChallengesFluid & Electrolyte Balance



Development of kidneys is not complete until
approximately 35 weeks.
In ability of preterm kidneys to concentrate or
dilute urine.
Kidneys unable to regulate electrolytes.
Physiologic ChallengesFluid & Electrolyte Balance
Dehydration
Overhydration

Urine output >2 ml/kg/hour

Urine output >5 ml/kg/hour

Urine specific gravity >1.020

Urine specific gravity <1.001

Weight loss greater than expected

Edema

Dry skin and mucous membranes

Weight gain greater than expected

Sunken anterior fontanel

Bulging fontanels
Poor tissue turgor


Blood: Decreased sodium,

protein, and hematocrit levels
Blood: Elevated sodium, protein,
and hematocrit levels

Moist breath sounds

Difficulty breathing
Nursing InterventionsFluid and Electrolyte Balance





Weigh diapers (1gm = 1ml of urine)
Obtain specific gravity
Carefully regulate IV fluids
Dilute IV medications in as little fluid that is
recommended (include medications on intake
measurements)
Assess IV sites frequently
Physiologic ChallengesSkin

The Preterm infants skin is:
• Fragile
• Transparent
• Permeable
Nursing InterventionsSkin

Nursing Care





No use of alcohol or betadine on skin
All skin products should be rinsed off with water
No use of adhesives, use pectin barriers and back
tape with cotton
Use semi-permeable adhesives such as tegaderm
Reposition frequently, as tolerated
Physiologic ChallengesInfection





Exposure to maternal infections
Lack of transfer of immunoglobulin G (IgG)
from mother during third trimester
Immature immune response to infection
Subject to invasive procedures (IV’s, lab’s)
Prolonged hospital stays
Signs and Symptoms of Infection
in the preterm infant







Behavioral changes
Color changes
Temperature instability
Cool, clammy skin
Feeding intolerance
Hyperbilirubinemia
Tachycardia followed by apnea and bradycardia
Nursing InterventionsInfection










Maintain skin integrity
Maintain sterile technique with procedures
‘Scrub’ before entering – EVERYONE
Hand sanitizer at every bedside and used in between care
No entry if sick – EVERYONE
No artificial nails / short nails
Single infant incubators, clean weekly
Report early signs of infection immediately
Assess infants response to treatment (possible resistance)
Position change, use sheepskin
Physiologic Challenges –
Hepatic System

Poor glycogen stores -increased susceptibility to
hypoglycemia.

Inability to conjugate bilirubin - increase
hyperbilirubinemia.

Decrease ability to produce clotting factors, low
plasma prothrombin levels.
Physiologic Challenges –
Renal System

Decreased glomerular filtration rate

Inability to concentrate urine

Decreased ability of kidneys to buffer

Decreased drug excretion time
Pain in preterm infants














High-pitched, intense, harsh cry
Whimpering, moaning
“Cry face”
Eyes squeezed shut
Mouth open
Grimacing
Bulging or furrowing of brow
Tense, rigid muscles or flaccid muscle tone
Rigidity or flailing of extremities
Color changes: Red, dusky, pale
Increased or decreased heart rate and respirations, apnea
Decreased oxygen saturation
Increased blood pressure
Sleep-wake pattern changes
Nursing Interventions



Swaddle, wake slowly
Pacifier, may use Sucrose
Medications
Signs of Overstimulation
in Preterm Infants
Oxygenation changes






Respirations
Pulse
Blood pressure
Oxygen saturation levels
Color
Sneezing, coughing,
hiccupping
Behavior changes






Posture
Facial expression
Gaze
Regurgitation
Yawning
Fatigue
Physiologic Challenges –
Digestive System







Decreased gag and suck reflexes
Hypotonic cardiac sphincter
Suck and swallow reflexes may be
uncoordinated
Small stomach capacity
Vomiting
Intolerance of fats
Immature absorption of nutrients
Maintaining Nutrition

Nursing Care







Assess Daily weights
Monitor I&O
Accurate IV rates to prevent circulatory overload
Provide feedings via nasogastric if unable to feed orally
Initiate oral feedings and assess for tiring
with feedings
Monitor urine pH and specific gravity
Involve parents in feedings
Nursing Interventions

Pre-feeding assessment

Respirations

Measure abdominal girth

Bowel sounds

Gastric residual

Sucking , swallowing , and gag reflexes
Readiness for Nipple Feeding

Rooting

Sucking on gavage tube, finger, or pacifier

Able to tolerate holding

Respiratory rate <60 breaths per minute

Presence of gag reflex
Signs of Nonreadiness for Nipple
Feedings

Respiratory rate >60 breaths per minute

No rooting or sucking

Absence of gag reflex

Excessive gastric residuals
Parenting

Facilitating Parent-Infant Attachment
 Prepare parents for first visit


Establish safe/trusting environment







Equipment, tubes etc.
Provide support, reassurance, encouragement
Encourage visitation
Involved in care taking
Repeat explanations
Promote touching, talking, rocking, cuddling
Refer to infant by name
Allow parents to phone as desired
Common Complications of
Preterm Infants
Respiratory Distress Syndrome
Respiratory Distress Syndrome

Pathophysiology
 Primary absence, deficiency or alteration in the production of surfactant

Decrease in Surfactant = increase in atelectasis = lack of gas exchange

Leads to hypoxia and acidosis which further inhibit surfactant
production and causes pulmonary vasoconstriction.

Common Clinical manifestations:
 Nasal Flaring
 Circumoral cyanosis
 Expiratory grunting
 Retracting
 Tachypnea
Respiratory Distress SyndromeNursing Interventions

Maintain airway, oxygenation, ventilation
 Supplemental oxygen:
 Nasal prongs
 Oxyhood

Continuous positive airway pressure (CPAP)

Intubation with endotracheal tube
Surfactant Replacement Therapy

Surfactant preparation can be lifesaving and
reduces complications, such as pneumothorax.

Administered through an endotracheal tube

Surfactant treatments may be repeated several
times during the first days until respiratory distress
syndrome resolves.
Respiratory Distress SyndromeNursing Interventions
Nutrition Support
 Newborns with RDS may be given food and water by the
following means:
 Tube feeding—a tube is inserted through the baby's mouth
and into the stomach
 Parenteral feeding—nutrients are delivered directly into a
vein
Support to Parents
 Allow parents to hold and feed
when possible.
 Assist to decrease their fears
Periventricular-Intraventricular
Hemorrhage
Periventricular-Intraventricular
Hemorrhage

Rupture of fragile blood vessels around the ventricles of the
brain
Usually associated with hypoxia

Diagnosed via cranial ultrasound



Signs – lethargy, poor muscle tone, decreased reflexes,
seizures, apnea or cyanosis, full or bulging fontanels
Nursing Care – daily measure FOC, observe for changes in
LOC
Retinopathy of Prematurity
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
Necrotizing Enterocolitis

An inflammatory disease of the intestinal tract
frequently complicated with perforation of the
gut.

NEC develops when there is asphyxia or hypoxia in which
cardiac output tends to be directed more toward the heart
and brain and away from the abdominal organs.

The intestinal cells become ischemic and damaged and stop
secreting protective mucus infection occurs.

Perforation may occur with overwhelming sepsis.
Necrotizing Enterocolitis
Signs and Symptoms



Early:
 Increase in gastric aspirate - >5-25 ml.
 Increase in abdominal girth
 Decrease bowel sounds, abdominal tenderness or rigidity of
abdominal wall.
Subtle:
 Lethargy, sudden listlessness, temperature instability,
decrease urine output, occult blood in stools, poor color,
and apneic periods.
Dramatic:
 Massive abdominal distention, vasomotor collapse.
Necrotizing Enterocolitis
Treatment and Nursing Care

Surgery: Resection of necrotic sections and possible
temporary colostomy. This allows bowel to recover.

Medical:
 NPO with NG tube.
 Peripheral or central hyperalimentation
 Antibiotic therapy.
 Continue to monitor for changes in condition.
 Gradually introduce oral feedings
Post-Term Newborn
Greater than 42 weeks gestation
Post Mature Infant

Physical manifestations:
 Dry, cracking,
parchment-like skin
 Reduced subcutaneous
tissue -Loose appearing
skin
 No vernix or lanugo
 Long fingernails
 Profuse scalp hair
 Long, thin body appearance
 Often meconium stained skin, cord, nails
Post Mature Infant

Complications of post term:
 Hypoglycemia
 Meconium aspiration
 Congenital anomalies
 Seizure activity
 Cold stress
Small for Gestational Age
Below the 10th percentile
Risk Factors



Maternal factors:
◦
High blood pressure.
◦
Chronic kidney disease.
◦
Advanced diabetes.
◦
Heart or respiratory disease.
◦
Malnutrition, anemia.
◦
Infection.
◦
Substance use (alcohol, drugs); Cigarette smoking.
Factors involving the uterus and placenta:
◦
Decreased blood flow in the uterus and placenta.
◦
Placental abruption (placenta detaches from the uterus).
◦
Placenta previa (placenta attaches low in the uterus).
◦
Infection in the tissues around the fetus.
Factors related to the developing baby (fetus):
◦
Multiple gestation (twins, triplets, etc.).
◦
Infection.
◦
Birth defects.
◦
Chromosomal abnormality.
Complications of the SGA
Newborn

Asphyxia

Aspiration syndrome

Hypothermia

Hypoglycemia

Polycythemia
Large for Gestational Age
Greater than 90th percentile
What condition is associated with the
newborn being LGA?
Complications of the LGA
newborn

Birth Trauma

Increase of Cesarean births

Hypoglycemia

Polycythemia

Hyperviscosity
Asphyxia of the Newborn
Asphyxia



Lack of oxygen and increase of carbon dioxide in the blood
 Occurs in utero or after birth
S/S asphyxia after birth:
 Cessation of respirations and rapid fall in heart rate
Interventions:
 Primary apnea: stimulation and O2
 Secondary apnea: positive pressure ventilation &/or chest
compressions
 Naloxone 0.1mg/kg IM (if narcotics given to expectant
mother shortly before birth)
Meconium Aspiration Syndrome
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 while shoulders and
chest are still in the birth canal,


Suction oropharynx and nasopharynx
After delivery of the infant’s body
Crying
- Stimulate
- Suction with
bulb syringe
Not crying
- Do not stimulate
- Direct tracheal suction
with endotracheal tube
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
 Prevent caloric requirements
 Provide support care if on ECMO
Hyperbilirubinemia
Hyperbilirubinemia

Pathophysiology



Unconjugated bilirubin is a break-down product of destroyed RBC’s.
Unconjugated bilirubin is normally transferred in the plasma firmly bound to
albumin to the liver where conjugation occurs.

Conjugated bilirubin is water soluble and can then be excreted into the bile and
eliminated with the feces.

Unconjugated bilirubin is not in excretable form and remains in the circulation
causing problems.
Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin
released into the serum.
Causes of Hyperbilirubinemia





Hemolytic disease (Rh and ABO incompatibility)
Extravascular bleed (cephalhematoma)
Bilirubin conjugation defects (breastmilk jaundice,
asphyxia)
Hypoalbumin
Physiologic jaundice (occurs after the first 24 hours of
birth. Mainly due to immature liver and lack of
glucoronyl transferase).
Hyperbilirubinemia

Clinical Manifestations:
 Sclerae appearing yellow before skin appears
yellow – usually in the first 24 hours after delivery
 Skin appearing light to bright yellow – advances
from head to toe
 Lethargy
 Dark, amber concentrated urine
 Poor feeding
 Dark stools
Hyperbilirubinemia

Diagnosis:
 Bilirubin levels on Cord Blood



Average level of Unconjugated bilirubin is 2 mg/dl at
birth
Bilirubin levels should NOT exceed 5 mg/dl
Coombs Test



may be done on the fetal cord blood (direct Coombs
test) or on the maternal blood (indirect Coombs test).
Tests for the presence of maternal antibodies attached
on the infant’s red blood cells.
The test is positive if there are maternal antibodies.
Hyperbilirubinemia
Nursing Care






Careful observation of infant for signs of increased
jaundice
Careful observation for and prevention of
acidosis/hypoxia and hypoglycemia, which decrease
binding of bilirubin to albumin and contribute to
jaundice.
Maintain adequate hydration
Avoid cold stress
Phototherapy – use of “bili” lights, special fluorescent
Exchange Transfusion
Hyperbilirubinemia
Nursing Care

Nursing Interventions for Phototherapy
 Exposure of skin
 Cover eyes (remove for feeding/parent visit)
 Monitor temperature – prone to hyperthermia or
hypothermia
 Reposition newborn every 2 hours
 Increase fluids
 Assess for dehydration
 Perform T-Bili q 12 – 24 hr as ordered
 Explain need to keep under phototherapy except
during feedings and diaper changes.
 Explain to parents and allow them to hold during
feedings
Hyperbilirubinemia
Phototherapy

Side Effects to Phototherapy
 Frequent loose, green stools
 Skin rash
 Increased basal body metabolism
 Dehydration
 Hyperthermia
Hyperbilirubinemia
Exchange Transfusion

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
Infections
TORCHA
Infectious Diseases: TORCH


Toxoplasmosis
Other






Syphillis
Hepititis B
Rubella
Cytomegalovirus
Herpes Simplex II
HIV - AIDs
Toxoplasmosis

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
Other - Syphillis


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 – Hepatitis B

Transmission




Placental
Birth
Breast milk
Treatment

If mother + HbSAG - administer to newborn:


Hepitisis B vaccine
HBIG
(administer within 12 hours of birth)
Rubella


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
Cytomegalovirus


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


Herpes Simplex II


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
HIV/AIDS

Transmission:




Transplacentally
Exposure at birth
Breast milk
Diagnosis:




Serology tests are performed within 48 hours of birth;
repeated at 3 and 6 months
HIV antibody
ELISA
CD4 + T-cell
HIV/ AIDS
Diagnosis

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 / AIDS

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
Infant of Diabetic Mother
IDM
Complications of Infants of Diabetic
Mothers

Hypoglycemia

Hypocalcemia

Hyperbilirubinemia

Polycythemia

Respiratory Distress Syndrome
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
Newborn of Substance
Abuse Mother
Infant of Addicted Mother


The newborn of an alcoholic or drugdependent 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.
Fetal Alcohol Syndrome – FAS
Clinical Manifestations
Fetal Alcohol Syndrome - FAS

Clinical Manifestations:




Affected body systems:


Jitteriness
Abdominal distention
Exaggerated rooting and sucking reflexes
CNS
GI system
Long-term psychosocial implications:


Feeding difficulties
Mental retardation
Infants of Addicted Mothers
Clinical Manifestations of Infant Withdrawal



Central Nervous System
o IRRITABILITY
• Hyperactivity
• Shrill cry
• Exaggerated reflexes
• Facial scratches
• Short non-quiet sleep
 Sneezing, coughing, yawning
Gastroinestional System
o Poor feeding
o Disorganized vigorous suck
o Vomiting and/or Diarrhea
Vasomotor and Cutaneous Signs
o Tachypnea
o Sweating
o Excoriated skin
Infants of Addicted Mothers
Nursing Care

Soothing:






Protect skin from excoriation
Monitor V/S
Feeding





Swaddle with hands near mouth
Offer pacifier
Place in quiet dimly lit area of the nursery
Provide small frequent feedings
Position with HOB elevated
Weigh every 8 hours (if vomiting & diarrhea)
Assess with Finnegan Abstinence Scale
Administer morphine, phenobarbitol, methadone
Affects of Smoking on the Fetus
during pregnancy

Nicotine



Causes vasoconstriction
Reduces placental blood circulation
Carbon Monoxide

Inactivates fetal and maternal hemaglobin
Reduced amount of oxygen to fetus results in
prematurity or low birth weight
Thank you!
Christina Hernandez RN, MSN
chernan1@austincc.edu