NCM 209: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS
LECTURE 1: HIGH RISK NEWBORN
2nd SEMESTER │A.Y. 2022 – 2023
PROBLEMS RELATED TO MATURITY
PRETERM NEW BOW N
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A neonate born before 37 weeks of gestation
Primary concern relates to immaturity of all
body systems
Cause: unknown
Maternal factors: age, smoking, poor nutrition,
Placental problem, Preeclampsia/eclampsia
Fetal factors: multiple pregnancy, infection
Other factors: poor socioeconomic status,
environmental exposure to harmful substance
Always know MANAGEMENT
PRETERM
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High risk of sudden infant death syndrome
(SIDS)
Least weight – 1,500 grams
Normal weight of newborn – 2,500 g
DETERMINE:
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Low birth weight
Very low BW
Extreme low BW
Always note down the weight – important
determinant of health
SAMPLE OF DEVICES ATTACHED TO THE
NEWBORN
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Overhead warmer
Bilirubin lights – cover baby’s eyes (to prevent
jaundice)
Temperature monitor
ECG & BP monitor
IV pump
Umbilical acting catheter
O2 saturation monitor
Feeding tube
Ventilator
Ms. Florence Puno
2. Placenta previa – placenta completely or
partially covers the cervix; the baby can’t go out
ASSESSMENT
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Respirations are irregular with periods of apnea
Body temperature is below normal
Skin is thin, with visible blood vessels and
minimal subcutaneous fat pads, may appear
jaundiced
Poikilothermic – easily take on the temperature
of the environment
Poor sucking and swallowing reflexes
Bowel sounds are diminished
Extremities are thin, with minimal creasing on
soles & palms
Abundance of lanugo hair
Labia are narrow in girls
Testes are underdeveloped in boys (they don’t
pass down from the belly to the scrotum)
SQUARE WINDOW WRIST
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To check for wrist resistance
Determine flexibility of the wrist
Apply gentle pressure
From dorsum closed to the fingers
SCARF SIGN
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To check for elbow placement
“the baby’s elbow can move up to the chest”
Preterm – can go beyond the midline
COMMON OR SPECIAL PROBLEM OF
PRETERM NEONATES
1.
2.
3.
4.
5.
Respiratory Distress Syndrome
Hyperbilirubinemia
Infection
Cold stress
Anemia
MATERNAL FACTORS
RESPIRATORY DISTRESS SYNDROME
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Preeclampsia/ eclampsia
- High BP in pregnancy
- Emergency – deliver immediately
FETAL FACTORS
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If the mother didn’t have proper nutrition, fetus
is affected
PLACENTA
1. Placenta abruption – placenta separates from
the inner wall of uterus before birth
PRELIMINARIES │6 UNITS
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a.k.a hyaline membrane disease
- problem in hyaline membranes (mass of
dead cells
Due to lung immaturity
Deficient in surfactant (most important to reduce
surface tension)
Baby needs oxygen
Chest retraction (extraction)
Problem with gas exchange (O2 & CO2)
Common cause of morbidity & mortality
Transcribed by: Guinomla, Rohanie B.
HYPERBILIRUBINEMIA
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High level of bilirubin in the blood
- Bilirubin is a product of RBC
- There is RBC destruction, wala nang mag
carry ng oxygen
Neonate become jaundice due to immaturity of
the liver
Kemicterus – staining of brain cells with
bilirubin, causing irreversible brain damage
may also lead to unconjugated/ conjugated
bilirubin
NI: phototherapy – for bilirubin to fall on a safe
level
INFECTION
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Not able to receive IgG globulins
Immunization of the mother are passed onto the
unborn baby, there are some antibodies but
easily gone, so give baby immunization
Exchange of antibodies happen in placenta
COLD STRESS
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Less subcutaneous tissue
Poikilothermic
ANEMIA
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a.k.a anemia prematurity
Less iron stores
Infants normally have low RBC blood factor
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Monitor intake and output, & electrolyte balance
Monitor daily weight.
Maintain newborn in a warming device.
Reposition every 1 to 2 hours, and handle
newborn carefully
Avoid exposure to infections.
Provide newborn with appropriate stimulation,
such as touch
Suctioning of secretions as needed
Monitor for signs of infection
a. Fever
b. Chills
c. Swelling
Provide skin care
Provide complete explanations for parents
POST-TERM NEW BORN
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Neonate born after 42 weeks of gestation
About 12% of all infants are post-term
Causes of delayed birth is unknown
Maternal factors:
- First pregnancies between the ages 15 to
19years
- Woman older than 35 years
- Multiparity
 Fetal factors:
- Fetal anomalies such as anencephaly
 Cause is unknown
 Serious birth defect
 Brain didn’t properly develop
MANAGEMENT
1. Improving respiratory function
- Oxygen therapy
- Mechanical ventilator
2. Maintaining body temperature
- Isolette – maintains ideal temperature,
humidity, and oxygen concentration isolates
infant from infection
- Kangaroo Care – unang yakap to maintain
body temp, method of holding the baby that
promotes skin-to-skin contact; upright
position
3. Preventing infection
- Handwashing
4. Promoting nutrition
- Gavage feeding – breastmilk or formula
milk; gavage tube directly to stomach (NGT)
- Milk feeding
5. Promoting Sensory stimulation
- Gentle touch, speaking gently and softly,
music box or low tuned radio
Nursing Interventions
1. Monitor vital signs every 2 to 4 hours
2. Administer oxygen and humidification as
prescribed.
PRELIMINARIES │6 UNITS
ASSESSMENT
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Depleted subcutaneous fat: old looking "old
man facies"
Parchment-like skin (dry, wrinkled and cracked)
without lanugo
Fingernails long and extended over ends of
fingers
Abundant scalp hair
Long and thin body
Sign of meconium staining
Nails and umbilical cord (yellow to green)
COMPLICATIONS OF POST MATURITY
1. The placenta begins to aged toward the end
of pregnancy, and may not function as
efficiently as before.
2. The failing placental function will place
infant at risk for intrauterine hypoxia during
labor and delivery.
3. MECONIUM ASPIRATION SYNDROME
- green in color
- found in amniotic fluid
4. HYPOGLYCEMIA
- Low blood sugar
Transcribed by: Guinomla, Rohanie B.
-
From nutritional deprivation and poor
storage of glycogen at birth
- Has too little glucose stored
5. POLYCYTHEMIA
- Increase circulating RBC
Grasp reflex
NURSING MANAGEMENT
1. Closely monitor the newborn
cardiopulmonary status.
2. Administer supplemental oxygen therapy as
needed
3. Frequent monitoring of blood sugar: assess
for sign of hypoglycemia
- Temperature
- Skin
- Cyanotic
- Sudden apnea
4. Provide thermoregulated environment
- use of isolette or radiant heat warmer
5. Monitor for signs of meconium aspiration
syndrome
- Labored breathing
- Retraction
- Granting sound
- Cyanosis
SMALL FOR GESTATIONAL AGE
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FULL TERM
Posture
“relaxed attitude”
limbs more
extended
More flexed
attitude
Ear
Ear cartilages
are poorly
developed, may
fold easily
Well-formed
cartilages
Sole
Only fine
wrinkles
Well & deeply
creased
Female
genitalia
Clitoris is
prominent; labia
majora poorly
developed
Clitoris is not as
prominent; labia
majora fully
developed
Male genitalia
Scrotum is under
developed & not
pendulous, with
minimal rugae
Scrotum is fully
developed,
pendulous,
rugated
Elbow is easily
brought across
the chest with
little or no
resistance
With resisting
attempt when
elbow is brought
to the midline of
the chest
Scarf sign
PRELIMINARIES │6 UNITS
(SGA) babies are those whose birth weight lies
below the 10th percentile for that gestational
age
SGA babies may be:
premature (born before 37 weeks of
pregnancy),
full term (37 to 41 weeks), or
post term (after 42 weeks of pregnancy)
Intrauterine growth restriction (IUGR) – the most
common underlying condition leading to SGA
newborn
- Placental anomaly – the most common
cause of IUGR
Determine fetal growth problem
SOME FACTORS THAT MAY CONTRIBUTE TO
SGA ARE THE FOLLOWING:
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PRETERM
Strong, allowing
the infant to be
lifted up from the
mattress
PROBLEMS RELATED TO
GESTATIONAL WEIGHT
MANAGEMENT
1. Ultrasound is done to evaluate fetal
development, amount of amniotic fluids and
the placenta signs of aging
2. To reduce the chance of meconium
aspiration, upon delivery of newborn's head
and just before the baby takes his first
breath suctioning of the mouth and nose is
done
Weak
Maternal factors:
 high blood pressure
 chronic kidney disease
 advanced diabetes
 heart or respiratory disease
 malnutrition, anemia
 infection
 substance use (alcohol, drugs)
 cigarette smoking
Factors related to the fetus
 multiple gestation (twins)
 infection
 chromosomal abnormality
ASSESSMENT
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Respiratory distress - hypoxic episodes
Loose and dry skin little fat, little muscle mass
Wasted Appearance
Small liver
Head is larger compared to body
Wide skull sutures
Poor skin turgor
Sunken abdomen
BABIES WITH SGA MAY HAVE PROBLEMS AT
BIRTH SUCH AS:
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Respiratory distress (asphyxia)
Meconium aspiration
Hypoglycemia
Difficulty maintaining normal body temperature
Transcribed by: Guinomla, Rohanie B.
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Polycythemia – too many red blood cells
NURSING INTERVENTIONS
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Observe for signs of respiratory diseases
Maintain body temperature
Monitor for infection and initiate measures to
prevent sepsis
Monitor blood glucose levels and for signs of
hypoglycemia
Initiate early feedings and monitor for signs of
aspiration.
Provide stimulation, such as touch and cuddling
LARGE FOR GESTATIONAL AGE
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Neonate who is plotted at or above the 90th
percentile on the intrauterine growth curve
Weigh more than 4,000 grams
Cause-unknown (genetic factors and maternal
conditions)
Maternal diabetes- is the most widely known
contributing factor
Increase insulin acts as a fetal growth hormone
Macrosomia - an unusually large newborn with
birth weight of more than 4500grams
ASSESSMENT
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large, obese – check head
Lethargic and limp
May feed poorly
Sign and symptoms of birth trauma
o Bruising
o Broken clavicle
o Evidence of molding
o Cephalhematoma
o Caput succedaneum
PROBLEMS OF LGA BABI ES
1. Hypoglycemia (low blood sugar) of baby after
delivery
2. Respiratory distress
3. Hyperbilirubinemia
4. Potential complications related to increase in
body size:
a. Fractured skull, clavicles, cervical, or
brachial plexus injury (network of nerves
along the spine), Cerb’s palsy
b. There is no treatment other than lifting the
child gently to prevent discomfort.
Occasionally, the arms on the affected side
may be immobilized
MANAGEMENT
Routine newborn care with special emphasis on the
following:
PRELIMINARIES │6 UNITS
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Monitor vital signs frequently, especially
respiratory status.
Monitor blood glucose levels and for signs of
hypoglycemia
Initiate early feedings
Note any signs of birth trauma or injury
Monitor for infection and initiate measures to
prevent sepsis
Provide stimulation, such as touch and
cuddling.
COMMON ACUTE CONDITIONS OF
NEWBORN
RESPIRATORY DISTRESS SYNDROME
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Serious lung disorder caused by immaturity and
inability to produce surfactant, resulting in
hypoxia and acidosis
Surfactant – a biochemical compound that
reduces surface tension inside the air sac
Decrease in surfactant results to lung collapse,
thus greatly reducing infant's vital supply of
oxygen
ASSESSMENT
1. Expiratory grunting
o Such as crying, moaning
o major symptom
o body's way of trying to keep air in the lungs
so they will stay open
2. Tachypnea
3. Nasal flaring
4. Retractions
5. Seesaw-like respirations (chest wall retracts
and the abdomen protrudes)
o Respiratory failure
o Chest inner, abdomen protrude
o Tired muscles for breathing; may lead to
collapse of lungs
6. Decreased breath sounds
7. Apnea
8. Pallor and cyanosis
9. Hypothermia
MANAGEMENT
a. Oxygen therapy – hood, nasal prong, mask,
endotracheal tube, CPAP (Continuous Positive
Airway Pressure) or PEEP (Positive End Expiratory Pressure) may be used
o Like nasal/ face mask; depends on the
concentration of oxygen needed
o CPAP for obstructive apnea
b. Muscle relaxants – Pancuronium (Pavulon)
o Reduces muscular resistance
o Prevents pneumothorax
Transcribed by: Guinomla, Rohanie B.
o
Prepare Atropine or Neostigmine
Methylsulfate
c. Liquid Ventilation – Uses perfluorocarbons
o substances used in industry to assess
leaks
d. Nitric Acid – Causes pulmonary vasodilation
o increases blood flow to the alveoli
NURSING INTERVENTIONS
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Monitor color, respiratory rate, and degree of
effort in breathing.
Support respirations as prescribed
Monitor arterial blood gases and oxygen
saturation levels (arterial blood gases from
umbilical artery) so that oxygen administered to
the newborn is at the lowest possible
concentration necessary to maintain adequate
arterial oxygenation.
RETINOPATHY OF PREMATURITY
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Vascular disorder involving gradual replacement
of retina by fibrous tissue and blood vessels
Primarily caused by prematurity and use of
supplemental oxygen (longer than 30 days)
Oxygen administration should never be more
than 40% unless hypoxia is documented
Any premature newborn who required oxygen
support should be scheduled for an eye
examination before discharge to assess for
retinal damage.
Bronchopulmonary Dysplasia – over expanded
lungs prolonged use of 02
MANAGEMENT:
a) Suction every 2 hours or more often as
necessary.
b) Prepare to administer surfactant
replacement therapy (instilled into the
endotracheal tube)
c) Administer respiratory therapy (percussion
and vibration)
d) Provide nutrition
e) Support bonding
f) Encourage as much parental participation in
newborn's care as condition allows.
HYPERBILIRUBINEMIA
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Abnormally high level of Bilirubin in the blood:
results to jaundiced
 In physiologic jaundiced
o occurs on the second day to seventh day
o average increase of 2mg/dl; not exceeding
12mg/d
 Pathological Jaundice of Neonates
o Any of the following features characterizes
pathological jaundice:
PRELIMINARIES │6 UNITS
o
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Clinical jaundice appearing in the first 24
hours.
o Increases in the level of total bilirubin by
more than 12 mg/dl
Therapy is aimed at preventing Kernicterus,
which results in permanent neurological
damage resulting from the deposition of bilirubin
in the brain cells.
Causes:
a. Immaturity of the liver
b. Rh or ABO incompatibility
c. Infections
d. Birth trauma
e. Maternal diabetes
f. Medications
ASSESSMENT
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Jaundice
Dark concentrated urine
Enlarged liver
Poor muscle tone
Lethargy
Poor sucking reflex
MANAGEMENT
1. Phototherapy
o Use of intense fluorescent light to reduce
serum bilirubin levels
o Use of blue light overhead or in-blanket
device
o Wallaby blanket – blanket which, when
wrapped around the torso, delivers effective
therapy to jaundiced babies; no need to
cover eyes because all light treatment are
delivered via blanket
o Possible complications: eye damage,
dehydration, sensory deprivation
2. Exchange blood transfusion via umbilical
catheter-for very severe cases
o infants blood – remove 5/10ml at a time
NURSING INTERVENTIONS
1. Expose as much of the newborn's skin as
possible.
2. Cover the genital area, and monitor the genital
area for skin irritation or breakdown.
3. Cover the newborn's eyes with eye shields or
patches; make sure that eyelids are closed
when shields or patches are applied.
4. Remove the shields or patches at least once
per shift (during a feeding time) to inspect the
eyes for infection or irritation and to allow eye
contact and bonding with parents.
5. Monitor skin temperature closely.
6. Increase fluids to compensate for water loss.
7. Expect loose green stools and green urine.
Transcribed by: Guinomla, Rohanie B.
8. Monitor the newborn's skin color with the
fluorescent light turned off, every 4 to 8 hours.
9. Monitor the skin for bronze baby syndromeo a grayish-brown discoloration of the skin.
10. Reposition newborn every 2 hours.
11. Provide stimulation.
12. After treatment, continue monitoring for signs of
hyperbilirubinemia, because rebound elevations
are normal after therapy is discontinued.
13. Turn off phototherapy lights before drawing
blood specimen for serum bilirubin levels and
avoid allowing blood specimen to remain
uncovered under fluorescent lights (to prevent
the breakdown of bilirubin in the blood
specimen).
14. Monitor for the presence of jaundice: assess
skin and sclera for jaundice.
15. Examine the newborn's skin color in natural
light.
16. Press finger over a bony prominence or tip of
the newborn's nose to press out capillary blood
from the tissues.
17. Jaundice starts at the head first, spreads to the
chest, abdomen, and then the arms and legs,
followed by the hands and feet
18. Keep newborn well hydrated to maintain blood
volume.
19. Facilitate early, frequent feeding to hasten
passage of meconium and encourage excretion
of bilirubin.
20. Report to the physician any signs of jaundice in
the first 24 hours of life and any abnormal S/S
21. Prepare for phototherapy, and monitor the
newborn closely during the treatment.
MECONIUM ASPIRATION SYNDROME
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occurs when infants take meconium into their
lungs during or before delivery
Occurs in term or post-term infants
During fetal distress there is increases intestinal
peristalsis, relaxing the anal sphincter and
releasing meconium into the amniotic fluid.
Aspiration can occur in utero or with the first
breath.
Meconium can block the airway partially or
completely and can irritate the newborn airway,
causing respiratory distress
ASSESSMENT:
1. Respiratory distress is present at birth:
o Tachypnea
o Cyanosis
o Retractions
o Nasal flaring
o Grunting
o Crackles, and rhonchi may be present
PRELIMINARIES │6 UNITS
o
Infant’s nails, skin, and umbilical cord may
be stained a yellow-green color
CAUSES AND RISK FACTORS
1.
2.
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5.
Common to post mature
Maternal history of diabetes
Hypertension
Difficult delivery
Poor intrauterine growth
MANAGEMENT
a. Suctioning must be done immediately after the
head is delivered before the first breath is taken;
b. Vocal cords should be viewed to see if the
airway is clear before stimulation and crying
Extracorporeal membrane oxygenation (ECMO) –
Cardiopulmonary bypass to support gas exchange
allows the lungs to rest
NURSING INTERVENTIONS
1.
2.
3.
4.
Observing neonates respiratory status closely
Ensuring adequate oxygenation
Administration of antibiotic therapy
Maintain thermoregulation
SEPSIS
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Generalized infection resulting from the
presence of bacteria in the blood
Major common cause is group B betahemolytic streptococci
CONTRIBUTING FACTORS:
1.
2.
3.
4.
5.
Prolonged rupture of membranes
Prolonged or difficult labor
Maternal infection
Cross contamination
Aspiration
ASSESSMENT FINDINGS
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7.
8.
 often does not have specific sign of illness
Poor feeding
Irritability
Lethargy
Pallor
Tachypnea
Tachycardia
Abdominal distention
Temperature instability
o difficulty keeping temperature within normal
range
DIAGNOSIS:
1. Blood, urine, and cerebrospinal fluid cultures
2. Routine CBC, urinalysis, fecalysis
Transcribed by: Guinomla, Rohanie B.
3. Radiographic test
MANAGEMENT
1. Intensive antibiotic therapy
2. IV fluids
3. Respiratory therapy
NURSING INTERVENTIONS
1. Routine newborn care with special emphasis on
the following:
2. Monitor vital signs, assess for periods of apnea
or irregular respirations.
3. Administer oxygen as prescribed
4. Provide isolation as necessary- Monitor and
limit visitors
5. Handwashing before after handling neonate
SUDDEN INFANT DEATH SYNDROME
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Sudden death of any young child that is
unexpected by history and which thorough
postmortem examination fails to demonstrate
adequate cause of death
Usually occurs during sleep
Diagnosis is made after autopsy
High incidence in preterm infants, infants with
abnormalities in respiration
Unknown cause: may be related to a brainstem
abnormality in the neurological regulation of
cardio-respiratory control
NURSING ROLE:
1.
2.
3.
4.
5.
Care is directed at supporting parents/family
Provide a room for the family to be alone
Reinforce that death was not their fault
Provide appropriate support referrals
Explain how parents can receive autopsy
results
PREVENTION:
1. Infants should be placed in the supine position
for sleep.
2. Soft moldable mattresses and bedding, such as
pillows or quilts, should not be used for bedding.
3. Stuffed animals should be removed from the
crib while the infant is sleeping.
4. Discourage bed sharing (sleeping with an adult)
5. Home apnea monitor to infant with near miss
SIDS
KERNICTERUS
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25 mg/dl or higher
Toxicity starts at 8-12 mg/dl in sick or LBW
PRELIMINARIES │6 UNITS
Transcribed by: Guinomla, Rohanie B.