High Risk Newborn
Chapter 23 & 24
Mary L. Dunlap MSN
Fall 2015
Birth Weight Variations
• Appropriate for gestational age (AGA)
• Small for gestational age (SGA)
• Large for gestational age (LGA)
SGA
• SGA weight- less than 5lb 8 oz and
below the 10th% at term
• IUGR- High risk growth does not meet
the expected growth pattern and is
pathologic
SGA
Characteristics
• Decreased
breast tissue
• Scaphoid
abdomen
(sunken)
• Wide sutures
• Thin umbilical
cord
• Head larger than
body
• Wasted
appearance to
extremities
• Reduced fat
stores
SGA
Common Problems
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•
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•
Perinatal asphyxia
Hypothermia- lack of brown fat
Hypoglycemia- lack of glycogen stores
Polycythemia- increase rate of
production due to hypoxia
• Meconium Aspiration
Nursing Management
• Initiate early and frequent oral feedings
• Monitor for hypoglycemia
• IV infusion of 10% dextrose if unable to
maintain glucose level.
• Weigh daily
• Promote rest periods to decrease
metabolic requirements
• Monitor for Polycythemia
LGA
• Weight- Larger than 9 lbs. and above
the 90th%
• Infant can be preterm, term, or postterm
LGA
Characteristics
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•
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Large body-plump full face
Body size is proportionate
Poor motor skills
Difficulty in regulating behavioral state
(arouse to quiet alert state)
LGA
Common Problems
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•
•
•
•
Birth Trauma
Hypoglycemia
Polycythemia
Hyperbilirubinemia
Shoulder dystocia
LGA
Nursing Management
Hypoglycemia
• Screen newborn for hypoglycemia
• Encourage feedings
• IV glucose
Hyperbilirubinemia
• Hydration
• Phototherapy
Gestational Age Variations
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•
•
•
Preterm newborn
Late Preterm
Post-term newborn
Term newborn
Post Term Newborn
• Gestation > 42 weeks
• Must determine if EDC is truly post
term
• After 42 weeks placenta loses ability
to nourish the fetus
Post term Newborn
Characteristics
• Newborn
emaciated
• Meconium
stained
• Hair and nails
long
• Dry peeling skin
• Creases cover
soles
• Limited vernix
and lanugo
Nursing Management
• Monitor blood glucose levels and treat as
required
• Initiate feedings as soon as possible
• Monitor temperature and respiratory
characteristics
• Assess for polycythemia and
hyperbilirubinemia
Preterm Infant
• Infant born prior to the completion of
the 37th week
• Organs immature
• Lack physical reserves
• Survivability related to weight and
gestational age
Preterm Infant
Causes based on research:
• Infection
• Maternal or fetal stress
• Bleeding
• Stretching
Immediate Delivery Care
•
•
•
•
Evaluate prenatal risk factor
Rapid assessment
Basic equipment Box 23.2 pg. 795
ABC’s of resuscitation Box 23.3
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 associated with
continued fetal circulation
• Fragile blood vessels (brain)
• Impaired regulation of B/P
Preterm Infant
Gastrointestinal
• Lack neuromuscular coordination suckswallow-breath
• Perinatal Hypoxia shunts blood from
the gut
• Small stomach-compromised metabolic
function
• Risk for malnutrition -wt. loss
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 (trans-placental
transfer after 34 wks.)
• Impaired ability to produce antibodies
• Thin skin- limited protection barrier
Preterm Infant
Central nervous system
• Long term disability due to injury
• Immature temperature-regulating
center
• Susceptible to hypoglycemia
Preterm
Characteristics
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Wt less than 5.5lb
Head larger than chest
Poor muscle tone
Minimal fat
Thin transparent skin
Undescended testicles & minimal
scrotal rugae
• Prominent labia & clitoris
Nursing Assessment
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Review prenatal record for risk factors
Head to toe assessment
Monitor respiratory effort
Monitor V.S.
Monitor for hypoglycemia
Nursing Management
Varies with gestational age
• Promote oxygenation
• Promote Thermoregulation
• Promote optimal nutrition
Nursing Management
Continue
• Prevent infections
• Provide stimulation
• Pain management
Prevention & Management Box23.4 pg. 800
Nonpharmacologic Techniques Box 23.5 pg.801
• Pharmacologic agents
Nursing Management
Continue
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Promote bonding
Quite environment
Promote parent coping
Discharge Planning Box 23.6 pg 803
Nursing Care plan 23.1 pg 792-794
Neonatal Asphyxia
• Failure to establish adequate,
sustained respirations after birth
• Pathophysiology: insufficient oxygen
delivery to meet metabolic demands
Nursing Assessment
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•
•
Asses for risk factors
newborn’s color
work of breathing
heart rate
Temperature
Apgar scores
Nursing Management
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Immediate resuscitation
Continued observation
Neutral thermal environment
Blood glucose levels
Parental support and education
Transient Tachypnea Newborn
TTN
• Mild respiratory condition
• Result of delayed or incomplete
absorption of fluid from the lungs
• Occurs within a few hours of birth
• Resolves over 24-72 hour period
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
• IV fluids
• Gavage feedings
Respiratory Distress Syndrome
• RDS result of lung immaturity and
surfactant deficiency
• Poor gas exchange & ventilation
• Seen in preterm newborns
• Cesarean births without labor
• Infants of diabetic mothers
Nursing Assessment
Symptoms
• Noted at birth or within in a few hours
• Expiratory grunting
• Nasal flaring
• Chest wall retractions
• Seesaw respirations
• Generalized cyanosis
Nursing Assessment
Symptoms
• Tachypnea- rates above 60
• Fine inspiratory crackles
• Tachycardia- rates above 150-180
• Silverman-Anderson index assessment
• Chest x-ray- alveolar atelectasis (ground
glass pattern)
• Lab test done to r/o infection and sepsis
Silverman-Anderson Tool
RDS
Nursing Management
Supportive care
• Thermoregulation- prevent cold stress
• O2 administration
• Fluid management
• Nutritional support
• Surfactant replacement therapy
• Monitor VS & O2 sats
Meconium Aspiration
• Fetus inhales meconium into the lungs
while in utero
• Meconium blocks the airway preventing
exhalation
• Meconium irritates the airway making
breathing difficult (chemical pneumonia)
• Meconium aspiration related to fetal
distress during labor.
Nursing Assessment
Symptoms
• Cyanosis
• Tachypnea
• Course & rhonchi
• Labored breathing
• Apnea
• X-ray patches or streaks of meconium
& trapped air
Meconium Aspiration Nursing
Management
• Assess for risk factors prior to delivery
• Neutral Thermal environment
• Supplemental O2
• Medications
• Monitor response to treatment
Persistent Pulmonary
Hypertension
• Marked pulmonary hypertension causing
right to left extrapulmonary shunting and
hypoxemia
• Cause occur idiopathically or as a
complication of perinatal asphyxia,
meconium aspiration syndrome,
congenital heart defects
Persistent Pulmonary
Hypertension
Nursing Assessment
• Tachypnea within 12 hours after birth
• Marked cyanosis, grunting, and
retractions
• Systolic ejection murmur
• Blood pressure
• Oxygen saturation
• Echocardiogram
Persistent Pulmonary
Hypertension
Nursing Management
• Monitoring of oxygenation, perfusion,
and blood pressure
• Immediate resuscitation; oxygen therapy
• Respiratory support
• Medications
• Clustering of care
• Parental support and education
Retinopathy
• Developmental abnormality affecting
immature blood vessels of the retina
• Five stages from mild to severe based on
severity, location by zones in the retina,
and proportion of retinal circumference
• If a newborn is premature, vessels may
cease to develop.
• ROP typically develops in both eyes due
to hyperoxemia (because of assisted
ventilation and high oxygen exposure),
acidosis, or shock.
Retinopathy
• Review prenatal history for risk factors
(hypertension, substance abuse,
preeclampsia, heavy cigarette smoking, or
placental insufficiency).
• Assess newborn’s gestational age and
weight; newborns weighing less than
1,500 grams or born at 28 weeks’
gestation or less are at risk.
• Evaluate the newborn’s history for duration
of intubation and use of oxygen therapy,
intraventricular hemorrhage, and sepsis.
Retinopathy
• Administer oxygen therapy cautiously—
ensure lowest concentration and shortest
duration
• Assist with scheduling ophthalmic exam;
administer mydriatic eye agent 1 hour
before appointment
• Protect newborn’s eyes from light
• Provide support to parents by giving them
information and providing details about the
condition and follow-up examinations
Periventricular-Intraventricular
Hemorrhage
• Bleeding in the brain due to fragility of
cerebral vessels; most common in the
first 72 hours after birth; Grades I to V
Periventricular-Intraventricular
Hemorrhage
Nursing Assessment
• Possibly no symptoms
• Risk factors
• Unexplained drop in hematocrit,
pallor, poor perfusion, seizures,
lethargy, weak suck, high-pitched cry,
Hypotonia
• Cranial ultrasonography
Periventricular-Intraventricular
Hemorrhage
Nursing Management
• Prevention
• Correction of anemia, acidosis,
hypotension
• Flexed contained positioning
• Daily head circumferences
• Clustering of care; limiting of stimulation
• Parental support
Necrotizing Entercolitis
• Pathologic mechanisms: Bowel
ischemia, bacterial flora, and effect of
feeding
Necrotizing Entercolitis
Nursing Assessment
• Risk factors (see Box 24.1)
• Signs and symptoms: abdominal
distention and tenderness, bloody
stools, feeding intolerance (bilious
vomiting), sepsis, lethargy, apnea,
shock
• KUB: air in bowel wall; dilated bowel
loops
Necrotizing Entercolitis
Necrotizing Entercolitis
Nursing Management
• Maintenance of fluid and nutritional
status; IV fluids
• Bowel rest and antibiotic therapy
• Surgery with proximal enterostomy
• Supportive care
• Family education
Infant of Diabetic Mother
• High levels of maternal glucose
crossing placenta, stimulating
increased fetal insulin production
leading to somatic fetal growth
Infant of Diabetic Mother
• Congenital abnormalities- during first
trimester due to fluctuations in BS and
ketoacidosis
• Macrosomia- develops last trimester
due to maternal hyperglycemiaexcessive fetal growth
• Tight control over glucose levels
needed ( less than 105 mg/dl)
Infant of Diabetic Mother
Common Problems
• Congenital
Abnormalities
• Macrosomia
• Birth Trauma
• Perinatal
Asphyxia
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•
•
•
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RDS
Hypoglycemia
Hyperbilirubinemia
Polycythemia
Birth trauma
Infant of Diabetic Mother
Infant Characteristics
• Rosy cheeks
• Short neck
• Wide shoulders
• Excessive subcutaneous fat
• Distended abdomen
Nursing Management
• Monitor glucose level q. 3-4 h keep level
above 40 mg/dl until stable
• Feed q. 2-3 h to create a constant level
• IV glucose
• Monitor serum bilirubin levels
• Maintain neutral thermal environment to
prevent cold stress
Newborns of Substance-Abusing
Mothers
• Most common substances: tobacco,
alcohol, and marijuana Table 24.4
• Fetal alcohol syndrome: physical and
mental disorders appearing at birth
and remaining problematic throughout
the child’s life
Box 24.2
Newborns of Substance-Abusing
Mothers
• Fetal alcohol spectrum disorders
• Alcohol-related birth defects
• Neonatal abstinence syndrome: drug
dependency acquired in utero
manifested by neurologic and
physical behaviors
Newborns of Substance-Abusing
Mothers
Nursing Assessment
• Maternal history; risk behaviors,
toxicology
• Newborn behaviors (see Box 24.3);
• WITHDRAWAL assessment
Birth Trauma
Injuries due to the forces of labor and
birth
• Fractures
• Brachial plexus injury
• Cranial nerve trauma
• Head trauma
Table 24.3
Nursing Assessment
Risk factors
• Physical and neurologic assessment:
bruising, bumps, swelling, paralysis,
symmetry of structure and function
Nursing Management
• Supportive
• Assessment for resolution or
complications
• Support and education
• Realistic appraisal of situation
• Community referral for ongoing followup and care
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 < 12.9
mg/100 ml
Hyperbilirubinemia Pathologic
• Present at birth or develops within 24
hrs.
• Persists beyond 7 days
• Bilirubin > 12.9mg/100 term
• Bilirubin > 15mg/100 preterm
• Increases > 5mg/100ml in 24hrs
Hyperbilirubinemia Nursing
Management
• Phototherapy- eye shield, turn q2hrs.
monitor temperature 3-4 hrs.
• Increase feeding to q 2-3 hrs.
• Bili level q 6 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
• 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, Group B Strip
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)