1
The High Risk Newborn
Lecture 8
I.
Levels of Care for the High Risk Newborn
A.
Assessment for need of NICU/tertiary care center
1.
maternal transport with fetus in utero preferred
a.
decreases neonatal morbidity/mortality
b.
mother and infant not separated at birth
2.
B.
II.
if unable to transport before delivery:
a.
notify supervisor of need for transfer team
b.
have emergency personnel to stabilize baby
Transfer/multidisciplinary approach
1.
transfer team consists of:
a.
MD’s
b.
RN’s
c.
RT’s
2.
keep parents undated on infant’s condition
a.
teach about equipment helping baby
b.
start discharge teaching early
3.
get mother and infant together ASAP
4.
talk about possibility of return to primary center of care
a.
may be frightened to move baby again
b.
may feel insecure with change in staff
The Preterm Neonate
A.
Risk Factors
1.
before 37 weeks, lack sufficient organ maturity
2.
lack adequate reserves of bodily nutrients
3.
low SES of the mother
4.
exposure to environmental dangers, I.E. toxic chemical
5.
pre-existing maternal conditions-heart disease, diabetes, etc
6.
maternal age and parity
7.
medical conditions R/T the pregnancy-GDM, PIH, infection
8.
obstetrical complications-cord prolapse, abruptio placenta
2
B.
Physical characteristics and system alterations
1.
Respiratory
a.
at 22 weeks gestation, surfactant begins
production
b.
24-26 weeks-inadequate alveolar size and surfactant
c.
27-28 weeks-alveoli start to open, surfactant
inadequate
d.
29-30 weeks-growth of alveoli and surfactant level
e.
34-36 weeks-mature alveoli, surfactant level
adequate
(surfactants-surface-active phospholipids
lecithin-increases after 24 weeks
sphingomyelin-constant amount
when L/S ratio is 2:1=lungs mature)
f.
noticeable cyanosis, retractions, grunting,
decreased tissue perfusion
g.
apneic episodes-15-20 cessation of breathing
2.
CV
a.
b.
c.
d.
↓ pulmonary arteriole musculature
↓ pulmonary vascular resistance→↑ L→ R
shunting thru ductus arteriosus→ into lungs
↓ BP, ↓ cap refill time, ↑ resp. distress
3.
Thermoregulation
a.
lack glycogen stores in liver-created in 3rd Δ
b.
↓ brown fat
c.
larger body surface
d.
posture of extension
e.
less able to ↑ metabolism for heat
4.
GI
a.
b.
c.
d.
e.
f.
g.
5.
poor gag, suck, swallow-coordinated after
34 weeks
incompetent cardiac sphincter
small stomach capacity
↓ bile acids, pancreatic lipase = ↓ absorption
of nutrients, malabsorption
nutritional loss associated with vomiting/diarrhea
work of sucking = ↑ BMR, ↑ O2 usage
feeding intolerance
Renal
a.
at 35 weeks, kidneys have limited ability to dilute
or concentrate urine
b.
↓ GFR secondary to renal blood flow
c.
at risk for edema (overhydration) or dehydration
d.
↓ buffering = acidosis
3
e.
longer to excrete drugs from the system
6.
Hepatic
a.
↓ glycogen stores = hypoglycemia
b.
↓ iron stores
c.
impaired conjugation of bilirubin
7.
Immunologic
a.
don’t receive passive immunity
b.
IgG-not until last trimester
8.
Hematologic
a.
increased capillary friability
b.
tendency to bleed
c.
blood loss from frequent lab work
d.
↓ production of RBC’s
9.
CNS
a.
high risk of brain hemorrhage from thin, fragile
vessel walls
b.
up to 34 weeks, the germinal matrix lines the
ventricles
c.
birth damage to immature structures
d.
may have been exposed to recurrent anoxic
episodes
C.
10.
Risk of infection
a.
thin, fragile skin
b.
friable blood vessels
c.
↓ storage of immunoglobulins
d.
inability to make antibodies
11.
Fluid/electrolytes
a.
need 80-150 kcal/kg/dy-↑ than term infants
b.
need protein 3-4 g/kg/dy-term 2-2.5g
c.
need addition iron, calcium, K
d.
usually get supplemental Vit. E (multi vitamin)
Common complications of Preterm
1.
Patent Ductus Arteriosus
a.
noticeable by Day 3
b.
RDS improves
c.
L→R
d.
increases pulmonary blood flow
e.
L ventricular failure
f.
pulmonary edema
g.
CHF
-S & S
4
continuous/systolic murmur
bounding pulses
tachycardia
tachypnea
hepatomegaly
-Tx
echocardiogram
restrict fluid-give diuretics
indomethacin-0.2 mg/kg
-stimulates closure of ductus
surgery
2.
Apnea
a.
cessation of breathing > 20 seconds
b.
usually occurs < 36 weeks gestation
c.
R/T immature nervous system
d.
may be R/T
temp instability
maternal drugs in labor
h/o maternal drug abuse
infection
metabolic disorders
asphyxia
abdominal distention
e.
assessment
-observe breathing pattern
-stimulate-slap soles of feet
-suction-use with free-flow oxygen
watch for dusky, cyanosis, bradycardia
-prepare for possible intubation
-think possible septic workup
f.
tx
-oxygen per order-usually started if PaO2<92%
warmed and humidified
nasal cannula, hood, PPV, ET tube
Danger-excessive oxygen can lead to
retinopathy of prematurity or
bronchopulmonary dysplasia
-report ABG changes
-theophylline-CNS stimulant-stimulates resp ctr
relaxes smooth muscle of bronchial airway
and pulmonary blood vessels
-surfactant administration
-ECMO NOT used with premies due to risk of
intraventricular hemorrhage
5
3.
Intraventricular Hemorrhage-most common type of
intracranial hemorrhage
a.
most susceptible-< 1500 gms, < 34 weeks
b.
triggered by
hypoxia
no venous pressure changes
↑ osmolarity in blood-overuse of volume
expanders
c.
S &S
-hypotonia
-hypotension
-lethargy
-metabolic acidosis
-temp instability
-seizures
-nystagmus
-low Hct
-bulging fontanelles -apnea
-decerebrate posturing
d.
Tx
-tx the symptoms
-phenobarb-sedative, ↓ seizure activity
-serial spinal taps
-VP shunt
-mainly observational and supportive care
4.
Retinopathy of Prematurity (ROP)
a.
at risk at < 36 weeks, < 1500 gms
b.
higher risk-<1000 gms
c.
oxygen tensions too high may lead to
vasoconstriction
d.
at the end of oxygen therapy:
vascularization of retina→constriction of vessels→
disintegration of vessels→new vessels→rupture→
retinal hemorrhage→scar tissue→detachment→
blindness
e.
assessment
-ophalmoscope exam-4-6 weeks
-some damage may spontaneously heal
f.
Tx
-laser photocoagulation
-Vit. E therapy
-decrease ambient light
-circumferential cryopexy
5.
Bronchopulmonary Dysplasia
a.
caused by barotraumas from pressure ventilation
and oxygen toxicity
b.
etiology is multifactorial
c.
S&S
-tachypnea
-retractions
-nasal flaring -↑ work to breath
6
d.
e.
f.
-tachycardia
Tx
-oxygen
-nutrition
-fluid restriction
-medications: diuretics, steroids, bronchodilators
key management is thru prevention
if untreated-can lead to death from cardiorespiratory failure
6.
Necrotizing Enterocolitis
a.
inflammatory disease of GI mucosa
b.
causes unknown-up to 25-30% mortality rate
c.
contributing factors
-asphyxia
-UAC
-infection
-PDA
-RDS
-anemia/ischemia
-congenital heart disease
-early enteral feedings
d.
breastfed babies have lower risk of NEC
e.
S&S
-hypotonia
-decreased activity
-recurrent apnea
-pallor
-decreased perfusion
-hypotension
-temp instability
-cyanosis
-abdominal distention
-diarrhea
-vomiting blood/bile
f.
Dx
-x-ray
-lab reports
-abnormal electrolyte levels
g.
Tx
-mainly supportive
-no feedings-rest the gut-trying probiotics
-use of TPN
-tx of infection
-surgical dissection of perforated/deteriorated
area
7.
Other neurological concerns
a.
hearing-1:50 loss of hearing
-↑ risk R/T congenital virus
-perinatal asphyxia
-birth trauma
-certain medications-gentamycin
b.
speech impairments
c.
cerebral palsy
d.
hydrocephalus
e.
seizure disorders
f.
lower IQ’s
7
h.
D.
III.
learning disabilities
Nursing Care
1.
Methods of feeding
a.
depend on gestational age, physical condition,
neuro status
b.
nipple feeding-34 weeks ok
-need coordinated suck and swallow
-needs to have gag reflex, RR < 60, and steady
wt. gain
c.
gavage-< 34 weeks gestation
-used if infant has
poor gag/swallow
neuro insult
losing wt. due to energy expenditure
d.
TPN-central or peripheral lines
e.
lipids-peripheral, no filter
f.
fluid requirements
-80-100 ml/kg/dy-Day 1
-100-120 ml/kg/dy-Day 2
-150 ml/kg/dy-Day 3
-gradually increase
2.
Assessments
a.
vital signs-watch for temp for heat loss
b.
urine-ck protein, glucose, SG
c.
strict I & O
-watch for vomiting, diarrhea
-watch IV site for infiltration
d.
watch for gastric residual ↑ 2 ml
e.
guaiac stools
f.
assess for abdominal distention
3.
Goals
a.
b.
c.
d.
e.
f.
g.
i.
maintenance of respiratory function
maintenance of neutral thermal environment
maintenance of fluid/lytes
prevention of infection
prevention of fatigue
adequate nutrition
promotion of attachment
promotion of sensory stimulation
Dysmature Neonates
A.
Care of the Post Term Neonate
1.
Problems
a.
post maturity syndrome
b.
hypoglycemia-depleted glycogen stores
8
c.
d.
e.
f.
g.
2.
3.
B.
meconium aspiration-stress
polycythemia-↑ RBC production R/T hypoxia
congenital anomalies-unknown
seizure activity-R/T hypoxia
cold stress-R/T less sub Q fat
Assessment
a.
post maturity syndrome
-dry, crackling skin
-mec staining
-long fingernails
-profuse scalp hair
-wasted appearance
b.
meconium aspiration syndrome
-watch for mec stained infant
-may not show signs of resp. depression at birth
-if mec migrates to terminal airways-becomes
meconium aspiration syndrome
mechanical obstruction
-if mec aspirated in utero→chemical pneumonitis
c.
persistent pulmonary HTN (PPHN)
-pulmonary artery hypertension
-R to L shunting
-may need ECMO (extracorporeal membrane
oxygenation therapy)
Tx
-tx the S & S-ECMO, inhaled nitric oxide, etc
Care of the SGA/IUGR neonate
1.
Causes
a.
maternal
-smoker
-heart disease
-poor nutrition
-PIH
-substance abuse
-chronic HTN
-advanced DM
-toxic chemical
-infection
exposure
-small stature
-<16, >40 yrs old
-lack of PN care
-low SES
b.
placental
-infarcts
-single umbilical artery
-abnormal cord insertion
-calcifications
c.
fetal
-multiple gestation
-TORCH-toxoplasmosis
other infections, i.e. hepatitis
rubella
cytomegalovirus
herpes (type II)
9
C.
2.
Problems
a.
perinatal asphyxia
-associated with h/o
smoker
low SES
preeclampsia
multifetal gestation
infections
DM
-watch for respiratory depression at birth
b.
hypoglycemia
-higher metabolic rate
-RBS < 40 mg/dl in term infant
<25 mg/dl in premie
-poor feeders, jittery, hypothermic
-watch for lethargy, floppy, seizures
c.
heat loss
-less muscle and brown fat mass
-little ability to control skin capillaries
-need to maintain thermoneutrality
d.
hypocalcemia-R/T birth asphyxia
e.
polycythemia-R/T ↑ RBC’s R/T stress
3.
Tx
a.
b.
c.
d.
e.
maintain clear airway
prevent cold stress
feeding per hospital protocol
stabilize temperature
nursing support similar to premies
Care of the LGA Neonate
1.
Causes
a.
IDM/GDM
b.
genetics
c.
multips
d.
ethnic grps
e.
obesity
2.
Problems
a.
CPD-↑ risk for C/S birth
b.
birth traumas-vacuum, forceps, asphyxia
shoulder dystocias, fx clavicle
c.
hypoglycemia/polycythemia
4.
Tx-tx the S & S
10
IV.
Common Respiratory Complications
A.
Respiratory Distress Syndrome(hyaline membrane disease)
1.
Lung disorder usually affecting premies
a.
infants <1500 gms = 56% risk of RDS
b.
caused by lack of surfactant
2.
Causes
a.
↓ risk of incidence/severity
-African-Americans
-maternal steroid therapy
-stressors such as PIH
-PROM
-IUGR
-maternal drug use
b.
↑ risk of incidence/severity
-↓ in gestation age
-maternal hypotension
-Caucasians
-maternal diabetes
-C/S birth without labor
-second-born twin
-males
-perinatal asphyxia
3.
Problems
a.
lack sufficient surfactant
b.
weak respiratory muscles
g.
epithelial debris in airways
h.
leads to ↓ oxygenation, cyanosis, and resp./
metabolic acidosis
i.
can lead to R to L shunting and opening of
foramen ovale and ductus arteriosus
4.
S&S
a.
b.
c.
d.
e.
f.
5.
Tx
a.
b.
c.
tachypnea
grunting/nasal flaring
retractions
hypotension
cyanosis
self-limiting disease
-usually abates in 72 hours
-disappearance coincides with production of
surfactant in type 2 cells of alveoli
supportive-adequate ventilation/oxygenation
surfactant administration
oxygen therapy per orders
11
d.
e.
f.
g.
h.
B.
C.
V.
monitoring of acid/base balance
prevent cold stress
abx therapy for infection
proper nutrition and I & O’s
possible need for blood transfusion R/T frequent
lab work
Transient Tachypnea of the Newborn
1.
similar to RDS
2.
R/T asphyxia in utero-fluid in lungs
3.
x-ray shows over expansion/hyperinflation of lungs
4.
Tx-oxygen, ck for possible acidosis
5.
usually improves in 24-48 hrs, well in 2-5 days
Meconium Aspiration-see post term neonate
Neonate with Sepsis
A.
Risk factors
1.
maternal
-low SES
-poor nutrition
2.
3.
B.
intrapartum
-PROM
-chorioamnionitis
-premature labor
-poor PN care
-substance abuse
-maternal fever
-prolonged labor
-maternal UTI
neonatal
-twins
-male
-birth asphyxia
-mec aspiration
-galactosemia
-absence of spleen
-LBW/premie -prolonged hospitalization
Mode of transmission
1.
vertical
a.
in utero
b.
at birth
c.
TORCH
2.
horizontal
a.
after birth
b.
environmental, i.e. Staph
12
C.
D.
E.
Causes of susceptibility
1.
lack immunity
2.
phagocytosis less efficient
3.
dysmaturity
Causes of infection
1.
Early onset-within 24 hours of birth
a.
group B strep
b.
Haemophilus influenza
c.
Listeria
d.
E. Coli
e.
Strep. Pneumoniae
f.
more common with PROM, maternal fever,
chorio, and premature labor
g.
higher mortality rate-10-25%
2.
Acquired infections-seen after 2 weeks of age
a.
may be from birth canal or environment
b.
Staph aureus
c.
Staph epidermidis
d.
Psedomonas
e.
group B strep
3.
Viral infections
a.
may cause miscarriage, stillbirth, intrauterine
infections, and congenital malformations
b.
may cause chronic infection with subtle
manifestations
c.
may need isolation from other neonates
4.
Fungal infections
a.
greatest concern to immuno-compromised
or premature neonates
b.
thrush may be present in otherwise healthy kids
Location of infection
1.
Septicemia is infection in the blood system
2.
Pneumonia-most common form of neonatal infection
-one of the leading causes of perinatal death
3.
Bacterial meningitis affect 1 in 2500 live births
4.
Gastroenteritis not as common
13
F.
S&S
1.
Respiratory
-apnea
-grunting
-retractions
2.
CV
-bradycardia -decreased CO
-tachycardia -hypotension
-decreased perfusion
3.
CNS
-temp instability
-hypotonia
-seizures
4.
5.
G.
H.
VI.
-tachypnea
-nasal flaring
-decreased O2 sat
GI
-vomiting
-diarrhea
Skin
-jaundice
-petechiae
-lethargy
-irritability
-abdominal distention
-residuals > 50%
-pallor
Sepsis workup
1.
lab work
-blood (CBC with diff)
looking for ↓ neutrophils, ↑ bands(immature WBC)
-urine
-CSF
-gastric aspiration
-culture nose, throat, skin, umbilical cord
2.
chest x-ray
Tx
1.
Tx the symptoms-i.e. abx, O2, isolation
2.
Assess handwashing techniques of the staff
3.
Encourage breastfeeding-passive immunity
The Neonate with Hyperbilirubinemia
A.
Types
1.
Physiologic jaundice
a.
occurs in 60-70% of term infants, 80% preterm
b.
arises 24 hours after delivery
14
2.
B.
Causes
1.
Maternal factors
a.
Rh/ABO incompatibility
-fetal antigen crosses placenta
-maternal antibodies cross placenta
-cause hemolysis of fetal RBC’s
(erythroblastosis fetalis→hydrops fetalis)
b.
infection
c.
diabetes
d.
oxytocin in labor
e.
drugs
2.
C.
Fetal/newborn factors
a.
premies
b.
hepatic cell damage
c.
polycythemia
d.
intestinal obstruction
e.
pyloric stenosis
f.
biliary atresia (absent or closed bile ducts)
g.
blood swallowed by fetus
Nursing care
1.
Lab work
a.
direct comb-ck for maternal antibodies in
infant’s blood
b.
ck infant’s blood type
c.
serum bili level
2.
VII.
Pathologic jaundice
a.
hyperbilirubinemia→kernicterus
(bilirubin encephalopathy)
b.
apparent within 24 hours of birth
c.
serum bili of > 5mg/dl in cord blood
d.
serum bili > 15mg/dl at any time
Tx
a.
b.
c.
early, frequent feedings
phototherapy
exchange transfusions
-if Rh incompatibility-use O neg blood
The Neonate born to a diabetic mother
A.
Problems
1.
congenital anomalies
-believed to be caused by fluctuation in glucose &
episodes of ketoacidosis
-congenital heart lesions
coarctation of the aorta
15
transposition of the greater vessel
atrial/ventricular septal defects
-CNS
anacephaly
hydrocephaly
encephalocele
meningomyelocele
-MS
caudal regression syndrome-problems of the
lower extremities
B.
C.
2.
macrosomia/birth trauma
-excessive glucose in blood = ↑ fetal insulin production
-enlargement of internal organ except brain
-high risk for fx of clavicle/scapula, cephalohematoma
3.
RDS
-4-6X more likely to develop than in normal infants
4.
hypoglycemia, hypocalcemia, hypomagnesemia
-hypocalcemia present in 50% of IDM’s
-hypomagnesemia from maternal renal loss R/T DM
5.
hyperbilirubinemia/polycythemia
-excess RBC production leads to ↑ bili
Pathophysiology
1.
Normally:
maternal blood more alkaline pH than CO2-rich fetal
blood→exchange of O2 & CO2 across placenta
2.
Maternal acidosis:
↓ in gas exchange
3.
Goal:
Maternal control of BS thru pregnancy with PN care
Nursing care
1.
Pediatric staff at delivery
2.
Implement neonatal glucose testing per protocol
3.
If RBS < 40 mg/dl, supplement with formula or IV prn
4.
Check serum bilirubin and calcium levels
6.
Reduce adverse environmental factors
16
VIII.
The Neonate born to a Substance Abusing Mother
A.
Common characteristics
1.
Fetal alcohol syndrome
a.
eyes
-epicanthal folds
-strabismus
-ptosis -drooping lid
-hypoplastic retinal vessels
b.
c.
d.
e.
f.
g.
h.
i.
j.
mouth
-poor suck
-cleft lip
-cleft palate
-small teeth
ears-deafness
skeleton
-fusion of cervical vertebrae
-restricted bone growth
heart
-atrial/ventricular septum defects
-Tetralogy of Fallot
-patent ductus arteriosus
kidney
-renal hypoplasia
-hydronephrosis
-urogenital sinus
liver
-hepatic fibrosis
immune system
-increase infections -otitis media
-upper resp. infections
-immune deficiencies
tumors-nonspecific neoplasms
skin
-abnormal palmar
-irregular hair
2.
Cocaine
a.
prematurity/SGA
b.
microcephaly/developmental delays
c.
poor feeder/diarrhea
d.
hyperactivity/difficult to console
e.
congenital anomalies
3.
Heroin
a.
LBW
b.
SGA
c.
neonatal withdrawal issues
4.
Amphetamines
a.
SGA/LBW/premie
b.
poor wt. gain
c.
lethargy
17
B.
5.
Tobacco
a.
Premie/LBW/IUGR
b.
risk for SIDS
c.
risk for bronchitis/pneumonia
d.
developmental delays
6.
Marijuana
a.
possible neonatal tremors
b.
LBW
Nursing Care
1.
Needs multidisciplinary approach for both neonate
and parents
2.
Supportive care
a.
fluid and electrolyte balance
b.
nutrition
c.
infection control
d.
respiratory care
3.
Quiet, soothing environment during withdrawal period
4.
Pharmacological tx-morphine, phenobarb, diazepam,
paregorics (tincture of opium), &
methadone vs buprenorphine (article)
01/16