High Risk Newborn Lecture
Preterm Infant
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Born before 38 weeks gestation
Immaturity of all systems
Physical assessment
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Gestational age <37 weeks
Resp. irregular
Bowel sounds diminished
Temp below 97.8
Hypoglycemia
Poor suck and swallow
Poor flexion
Psychosocial Assessment
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Parents shock & disbelief
Fear holding baby
Grieve for “perfect” baby
Financial concerns
Fear for Baby’s life
Goals
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safe effective environment
Maintain resp & nutrition & temp
Promote interaction with parents
Education of parents in care
Implementations
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Antibiotics
Fluids & electrolytes (bicarb & Ca)
Oxygen, Chest therapy
Coordinate labs & tests
Monitor Temp, apical P, Resp
Handle carefully, reposition
Tactile stimulation for apnea, suction prn
Implementations Con’t.
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Avoid exposure to infection
Gavage feed q 2-3 hr, Premie formula
freeze breast milk
psychological support, share info, reinforce
positives
share caretaking responsibilities with
parents
allow to ventilate feelings
Nutrition of the Preterm Infant
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Initially needs 80-100 ml/Kg/day may need
more fluid if lower birth weight
Requires 120-150 cal/Kg/day oral intake for
growth
Supplemental multivitamins, Vit E, folic
acid and calcium
Desired weight gain 20-30 g/day
Desired initial weight loss only 1-2% per
day
Risk of Intraventricular
Hemorrhage
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Hypoxia
Inc. BP, Inc. head pressure
• (do not place in Trendlenberg position)
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Chest percussion
Assess: fontanels for increase in size
• seizures, apnea, bradycardia, drop in Hct
Preterm Case Study
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Baby Girl Petite
Small for Gestational Age
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Definition= below 10th percentile on
growth chart
Problems: Congenital problems
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fetal distress
hypoglycemia
polycythemia
infection
aspiration of Meconium
SGA
Nursing Care for SGA
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Maintain airway & temperature
Sx resp distress
Monitor glucose level, sx hypoglycemia
Provide NTZ, minimize heat loss
Provide Feedings, touch, support, teaching
Evaluate Hct, sx sepsis,
Case Study Small for Gestational
Age
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Baby Boy Slim
Large for Gestational Age
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Defined- Above the 90th percentile on
growth chart
Problems: Birth trauma
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Infant of Diabetic Mother
Hypoglycemia
Respiratory Distress Syndrome (RDS)
Hypotension
Sepsis
Nursing Care of LGA
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Maintain Resp. Observe for sx sepsis (&
prevent)
Monitor Temp, minimize heat loss
Sx hypoglycemia, monitor Glucose levels
Initiate early feedings
Provide touch & cuddling
Support parents & teach
Postterm Infant
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Description: born after 42 weeks gestation
Problems: Hypoglycemia
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meconium aspiration (MAS)
polycythemia
seizure activity
cold stress
Physical Characteristics of
Postterm
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wide-eyed & alert (irritable)
Skin- no lanugo, dry, cracked, parchmentlike
Fingernails long, over ends
Scalp hair profuse
Body long and thin (fat & muscle wasting)
Meconium staining of nails & umbilical
cord
Case Study for Postterm Infant
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Baby Girl Green
Cold Stress in Infants
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Excessive heat loss
Use of compensatory mechanism
• inc. respirations
• non-shiver themogenisis
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Preterm and SGA at risk
COLD STRESS
Dec. Surfactant
Production
release
of norepinpherine
Atelectasis
Pulmonary
vasoconstriction
Dec. Oxygen
Dec. blood flow
to lungs
Hypoxemia
Acidemia
COLD STRESS
Inc. Anaerobic Metabolism
Inc. Metabolic
Rate
Inc. Fatty acids
Inc. Oxygen
consumption
Hyperbilirubinemia
Use of
Glucose
Hypoglycemia
Signs & Symptoms of Cold Stress
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Inc. Resp (sx Non Shiver Thermogenesis)
Dec. Skin temp
Dec. peripheral profusion
Dec. Blood Glucose (using to generate heat)
Nursing Care for Cold Stress
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Warm slowly (too rapid may cause apnea)
check skin temp q 15 min.
maintain Neutral Thermal Environment
Monitor BGK for hypoglycemia
Give feeding or glucose (IV) to inc. Blood
Glucose
Necrotizing Enterocolitis
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Complication of Premie
• r/t dec. blood flow to GI tract
• 2 º to hypoxia or shock
Signs & Symptoms
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Dec. bowel sounds or none
Inc. abd. Girth
Bowel loops
No meconium or OB + stool
Temp instability
Inc. apnea, bradycardia
Inc. in feeding residuals
Treatment
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GI rest (NPO)
Antibiotics
Surgery
TPN
NG or gavage feedings
advance to bottle feedings
Case Study Necrotizing
Enterocolitis
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Tiny Tim
Infant of a Diabetic Mother
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Risk of Hypoglycemia
Blood Glucose < 40 mg/dl
R/T overstimulated fetal insulin production
Assessment
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Predisposing Factors for Hypoglycemia
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Preterm or premature birth
Large for Gestational age
Maternal diabetes
Hypertension
Infant stress
Signs and Symptoms
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Jitteriness, twitching, seizures
Poor-feeding, weak sucking reflex
Irregular respiration cyanosis, respiratory
distress
Edema (bloated appearance)
Weak, high-pitched cry
Poor muscle tone
Low blood sugar & low serum calcium
levels
Case Study- Infant of Diabetic
Mother
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Larry Large
Goals
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Environment will be safe without signs of
hypoglycemia
Parents will ask questions re care of infant
& signs and symptoms
Parents will be able to demonstrate proper
infant care.
Implementation
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Assess parental awareness & understanding
Assess feelings of guilt
Assess vital signs, BGK, serum Ca &
seizures
Administer 10% glucose IV as ordered
Facilitate early full feedings
Prevent infection
Hyperbilirubinemia
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Elevated bilirubin level r/t :
• Physiologic Jaundice: 3-5 days > 12 mg/dl
• Prematurity: liver not able to metabolize bili
• ABO, Rh incompatibilities: Mother “O” Baby
A,B, AB mom’s antibodies cross placenta
O
A,
B,
AB
Hyperbilirubinemia
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Elevated bilirubin level r/t :
• Breast Milk: reduced excretion of bilirubin
• Extravascular hemolysis: bruises,
cephalohematoma, petechiae
• Others: polycythemia, drugs, hypoglycemia,
hypoxia
Assessment
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biliflash above indication line
Assessment Con’t
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serum bili 8-12 mg/dl at 1-2 days and > 12
mg/dl 3-5 days
palpable spleen, enlarged liver
poor feeding, edema
vomiting, fever, dark urine
Kernicterus
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Diminished Moro reflex
Poor sucking
Difficult feeding
High pitched cry
Setting sun eyes
Irritability or Seizures
Opisthotonos
• muscle spasms
• back arching)
Baby with Jaundice
Baby Under Bili Lights
Goals
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Pt will have bili level less than 12 mg/dl, no
signs of jaundice
Parents will state they feel supported,
counseled, educated
Parents will demo correct care measures for
infant with jaundice
Implementations
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Phototherapy: Bili Light or Blanket
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Undress
Shield eyes (remove for feeding) & genitals
Monitor temp q 2hr
Fluids q2 hr to avoid dehydration
Change position q 2 hr
Weigh q12 hr, I &O, assess hydration
Implementations Con’t
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Observe stools & urine for darkening
Observe for tanning (bronze baby
syndrome)
Plexiglas shield between infant & light
Record number of lights used and hours
Monitor bili levels Q 6-8 hr
Management of Exchange
Transfusion
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NPO, aspirate stomach contents, suction
airway prior
Informed consent signed by parents
Check blood typing
Restrain infant
Place under radiant warmer
Incremental amt. of blood withdrawn &
infused
VS q 15 min, glucose levels, Ca levels, Bili
levels
Implementations Con’t
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Enc. parents to visit
Share information about condition, bili
levels, weight
Provide auditory stimulation
• (music, humming)
Case Study Jaundice
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Baby Mary
Prenatally Drug Exposed Case
Study
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Patient- Kim Brown
Respiratory Distress Syndrome
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Formally hyaline membrane disease
Surfactant is absent, deficient of altered
Symptoms occur within 6-12 hours of birth
Other Causes of Respiratory
difficulty
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Aspiration Syndromes
• fluid or meconium
• diminished pulmonary perfusion, present at
birth
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Apnea due to prematurity
• apnea >20 sec. cyanosis, hypotonia, acidosis
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Pneumonia apparent 2-5 days after birth
Wet Lung Syndrome
• excessive pulmonary fluid (C-section)
RDS leading to Respiratory Failure
Because of Dec Surfactant
Dec lung compliance
Atelectasis
Metabolic
Dec P O2
Anaerobic
Metabolism
Pulm
artery
Pressure
Dec Ventil
Acidosis
Resp
Pulmonary & Peripheral
Vasoconstriction
R to
L shunt
Inc Work
Load
Dec Pulm
blood
flow
Dec Surfactant
Inc CO2
Poor
peripheral
perfusion
Assessment
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Risk factors i.e. prematurity
Flaccid extremities & edema
Hypothermia, hypotension
Skin pale or cyanotic
Respiratory grunting, retractions, nasal
flaring
• diminished breath sounds, tachypnea, abn. xray or ABG
Expected Outcomes
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O2 sat >95%, Resp 30-50/ min
Resp without nasal flaring, grunting,
retractions
Clear Breath sounds, Apnea <10 sec.
VS WNL
Maintains temp, nutrition, no sx infection
Parents express fears & concerns
Implementations
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Assess respirations
Prevent fatigue by spacing activities and
decrease handling
Suction prn, Chest physiotherapy
(percussion)
Position with neck sl. hyperextended &
change q2h
Lower O2 slowly
Monitor VS & temp of environment
Oxygen Hood
Implementations Con’t
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I&O, urine pH, Daily Wt.
Nutrition- NPO IV fluid 60-150 ml/Kg in
24 hr
• gavage feed, advance to nipple, ck residual
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Support for parents
• explain, visits, include in care, share info
• allow to express fears, anxiety, shock
Pharmacotherapy
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Antibiotics- PCN, Gentamicin
IV fluids via umbilical artery catheter
IV bicarbonate (corrects acidosis)
Assess UAC for infection, hemorrhage,
thrombus
Umbilical Artery Catheter
Enhance Respiratory Function
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Oxygen by hood
Continuous airway pressure
Volume ventilation
Warm & humidify Oxygen
Assess ABG q 4h via UAC
Case Study
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Respiratory Distress Syndrome