High Risk Newborn
Mary L. Dunlap MSN, APRN
Fall 10
Preterm Infant
• Infant born prior to the completion of
the 37th week
• Organs immature
• Lack physical reserves
• Survivability related to weight /
gestational age
Preterm Infant
Respiratory last to mature
• Surfactant deficiency-RDS
• Unstable chest wall-atelectasis
• Immature respiratory centers-apnea
• Small passages-obstructions
• Unable to clear fluid-TTN
Preterm Infant
Cardiovascular
• Difficulty transitioning from fetal to
neonatal circulatory pattern
• Congenital anomalies due to continued
fetal circulation
• Fragile blood vessels (brain)
• Impaired regulation of B/P
Preterm Infant
Gastrointestinal
• Lack neuromuscular coordination suckswallow-breath
• Hypoxia shunts blood from the gutischemia and intestinal wall damage
• Risk for malnutrition -wt. loss
• Small stomach-compromised metabolic
function
Preterm Infant
Renal System
• Slow glomerular filtration rate
• Reduced ability to concentrate urine
• Risk: fluid retention, electrolyte
imbalance, drug toxicity
Preterm Infant
Immune system
• Deficiency of IgG
• Impaired ability to produce antibodies
• Thin skin- limited protection barrier
Preterm Infant
Central nervous system
• Long term disability due to injury
• Difficulty maintaining temperature
• Compounded by lack of brown fat
Preterm Infant
Nursing Management
• Varies with
gestational
Promote
Oxygenation
• Maintain body
temperature
• nutritional needs
• Prevent infections
• Provide stimulation
• Pain management
Small for Gestational Age
• SGA weight- less than 5lb 8 oz and
below the 10th% at term
• IUGR- High risk growth does not meet
the norm and is pathologic
• Symmetric IUGR- poor growth rate of
head, abdomen and long bone
• Asymmetry IUGR- head long bones
spared
Small for Gestational Age
Characteristics
• Decreased breast
• Head larger than
tissue
body
• Scaphoid abdomen • Wasted
(sunken)
appearance to
extremities
• Wide sutures
• Thin umbilical cord • Reduced fat stores
Small for Gestational Age
Common Problems
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Perinatal asphyxia
Hypothermia
Hypoglycemia
Polycythemia
Meconium Aspiration
Large for Gestational Age
Characteristics
• LGA weight- Larger than 9 lbs and
above the 90th%
• Large body-plump full face
• Body size is proportionate
• Poor motor skills
• Difficulty in regulating behavioral state
(arouse to quiet alert state)
Large for Gestational Age
Common Problems
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Birth TraumaHypoglycemia
Polcythemia
Hyperbilirubinemia
Post term Infant
• Gestation > 42 weeks
• Must determine if EDC is truly post
term
• After 42 weeks placenta loses ability
to nourish the fetus
Post term Infant
Characteristics
• Newborn
emaciated
• Meconium
stained
• Hair and nails
long
• Dry peeling skin
• Creases cover
soles
• Limited vernix
and lanugo
Infant of Diabetic Mother
• Mother can have pregestational or
gestational diabetes
• Increasing numbers of type 2
• Related to increase in morbidity &
mortality
• Congenital abnormalities
Infant of Diabetic Mother
• Congenital abnormalities- during first
trimester due to fluctuations in BS and
ketoacidosis
• Macrosomia- develops last trimester due
to maternal hyperglycemia- excessive
fetal growth
• Tight control over glucose levels needed
( less than 1-0mg/dl)
Infant of Diabetic Mother
Common Problems
• Congenital
Abnormalities
• Macrosomia
• Birth Trauma
• Perinatal
Asphyxia
• RDS
• Hypoglycemia
• Hyperbilirubinem
ia
• Polycythemia
Infant of Diabetic Mother
Infant Characteristics
• Rosy cheeks
• Short neck
• Wide shoulders
• Excessive subcutaneous fat
• Distended abdomen
Infant of Diabetic Mother
Nursing Management
• Monitor glucose level q. 3 to 4 hrs. level no
above 40 mg/dl
• Until stable monitor q. 3-4 hrs
• Feed q. 2-3 hrs
• IV glucose
• Monitor serum bilirubin levels
• Maintain thermal environment
Respiratory Distress
Syndrome
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RDS caused by lack of surfactant
Poor gas exchange & ventilation
Seen in preterm newborns
Cesarean births without labor
Infants of diabetic mothers
Respiratory Distress Syndrome
Symptoms
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Tachypnea
Expiratory grunting
Nasal flaring
Retractions
See-saw respiration
Chest x-ray- alveolar atelectasis (ground
glass pattern) & dilated bronchioles ( dark
streaks within granular pattern)
Respiratory Distress Syndrome
Nursing Management
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Thermoregulation
O2 administration
Mechanical ventilation if needed
Hold parenteral feedings
Monitor VS & O2 sats
Provide nutrition ( gavage feedings)
Transient Tachypnea
Newborn TTN
• Mild respiratory condition
• Result of delayed absorption of fluid
• Last about 3 days
Transient Tachypnea
Newborn TTN
Symptoms
• Respiratory rate as high as 100-140
• Labored breathing
• Grunting nasal flaring
• Retractions
• Chest x-ray shows lymphatic engorgement
( retained lung fluid)
Transient Tachypnea Newborn
Nursing Care
• Mainly supportive
• Monitory VS & O2 Sats
• Provide supplemental O2
Meconium Aspiration
• Fetus inhales meconium into the lungs
while in utero
• Meconium blocks the airway
preventing exhalation
• Meconium irritates the airway making
breathing difficult
• Meconium aspiration related to fetal
distress during labor.
Meconium Aspiration
Symptoms
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Cyanosis
Rapid breathing
Labored breathing
Apnea
X-ray patches or streaks of meconium
& trapped air
Meconium Aspiration Nursing
Management
• Assess for risk factors prior to
delivery
• Suction at delivery prior to newborn
crying
• Supplemental O2
• Mechanical ventilation
• Antibiotic therapy
Hyperbilirubinemia
• Excess of bilirubin in the bloodelevated bilirubin level > 5mg/dl
• Heme from erythrocytes break down
forms unconjugated bilirubin
• Jaundice
• Physiologic
• Pathologic
Hyperbilirubinemia Causes
• Drugs/Medical conditions disrupt
conjugation and albumin binding sites
• Decreased hepatic function
• Increased erythrocyte production
• Enzymes in breast milk
Hyperbilirubinemia
Physiologic
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Develops in 3-4 days after term birth
Develops3-5 days after preterm birth
Term birth resolves 7 days
Preterm birth resolves 9-10 days
Unconjugated bilirubin level <
12mg/100 ml
Hyperbilirubinemia
Pathologic
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Develop after first day
Persists beyond 7 days
Bilirubin > 12.9mg/100 term
Bilirubin > 15mg/100 preterm
Increases > 5mg/100ml in 24hrs
Hyperbilirubinemia Nursing
Management
• Phototherapy
• Increase feeding to q 2-3 hrs
Phenylketonuria PKU
• Inability to metabolize phenylalanineamino acid found in protein
• Affect brain and CNS development
• Interferes with the production of
melanin, epinephrine & thyroxine
• Both parents must pass the gene on
Phenylketonuria PKU
Symptoms
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Seizures
Irritability
Tremors
Jerking movements arms & legs
Hyperactivity
Unusual hand posturing
Phenylketonuria PKU
• Diagnosed with PKU screening prior
to discharge from hospital
Hemolytic Disorders
• Hemolytic disease occurs when blood groups
of mother and newborn are different
• Antibodies are present or formed in response
to antigen from fetal blood crossing placenta
and entering maternal circulation
Hemolytic Disorders
• Maternal antibodies of IgG class
cross placenta, causing hemolysis of
fetal RBCs
–Fetal anemia
–Neonatal jaundice
–Hyperbilirubinemia
Hemolytic Disorders
• Rh incompatibility (isoimmunization)
–Only Rh-positive offspring of Rhnegative mother is at risk
–If fetus is Rh positive and mother
Rh negative, mother forms
antibodies against fetal blood cells
Hemolytic Disorders
• ABO incompatibility
–Occurs if fetal blood type is A, B, or
AB, and maternal type is O
–Incompatibility arises because
naturally occurring anti-A and anti-B
antibodies are transferred across
placenta to fetus
–Exchange transfusions required
occasionally
Neonatal Infections
Sepsis
–Bacterial, viral, fungal
–Patterns
• Early onset or congenital
• Nosocomial infection—late onset
Neonatal Infection
Septicemia
• Pneumonia
• Bacterial meningitis
• Gastroenteritis is sporadic
Neonatal Infections
• TORCH infections
– Toxoplasmosis
– Gonorrhea
– Syphilis
– Varicella-zoster
– Hepatitis B virus (HBV)
– Human immunodeficiency virus
(HIV) and acquired
immunodeficiency syndrome
(AIDS)