High Risk Newborn Chapter 23

1. High Risk NewbornChapter 23 Mary L. Dunlap MSN Fall 2014

2. Birth Weight Variations • Appropriate for gestational age (AGA) • Small for gestational age (SGA) • Large for gestational age (LGA)

3. 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 • Symmetric IUGR- poor growth rate of head, abdomen and long bone • Asymmetry IUGR- head long bones spared (after 28 wks.)

4. SGA Characteristics • Decreased breast tissue • Scaphoid abdomen (sunken) • Wide sutures • Thin umbilical cord • Head larger than body • Wasted appearance to extremities • Reduced fat stores

5. SGA Common Problems • Perinatal asphyxia • Hypothermia- lack of brown fat • Hypoglycemia- lack of glycogen stores • Polycythemia- increase rate of production due to hypoxia • Meconium Aspiration

6. 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

7. LGA • Weight- Larger than 9 lbs. and above the 90th% • Infant can be preterm, term, or post-term

8. LGA Characteristics • Large body-plump full face • Body size is proportionate • Poor motor skills • Difficulty in regulating behavioral state (arouse to quiet alert state)

9. LGA Common Problems • Birth Trauma • Hypoglycemia • Polycythemia • Hyperbilirubinemia • Shoulder dystocia

10. LGA Nursing Management Hypoglycemia • Screen newborn for hypoglycemia • Encourage feedings • IV glucose Hyperbilirubinemia • Hydration • Phototherapy

11. Gestational Age Variations • Preterm newborn • Late Preterm • Post-term newborn • Term newborn

12. Post Term Newborn • Gestation > 42 weeks • Must determine if EDC is truly post term • After 42 weeks placenta loses ability to nourish the fetus

13. Post term NewbornCharacteristics • Newborn emaciated • Meconium stained • Hair and nails long • Dry peeling skin • Creases cover soles • Limited vernix and lanugo

14. Nursing Management • Prepare for the delivery • NICU care • Monitor blood glucose levels and treat as required • Initiate feedings as soon as possible • Monitor temperature and respiratory characteristics • Assess for polycythemia and hyperbilirubinemia

15. Preterm Infant • Infant born prior to the completion of the 37th week • Organs immature • Lack physical reserves • Survivability related to weight and gestational age

16. Preterm Infant Causes based on research: • Infection • Maternal or fetal stress • Bleeding • Stretching

17. Immediate Delivery Care • Evaluate prenatal risk factor • Rapid assessment • Basic equipment Box 23.2 pg. 795 • ABC’s of resuscitation Box 23.3

18. 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

19. 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

20. Preterm Infant Gastrointestinal • Lack neuromuscular coordination suck- swallow-breath • Perinatal Hypoxia shunts blood from the gut • Small stomach-compromised metabolic function • Risk for malnutrition -wt. loss

21. Preterm Infant Renal System • Slow glomerular filtration rate • Reduced ability to concentrate urine • Risk: fluid retention, electrolyte imbalance, drug toxicity

22. Preterm Infant Immune system • Deficiency of IgG (trans-placental transfer after 34 wks.) • Impaired ability to produce antibodies • Thin skin- limited protection barrier

23. Preterm Infant Central nervous system • Long term disability due to injury • Immature temperature-regulating center • Susceptible to hypoglycemia

24. Preterm Characteristics • 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

25. Nursing Assessment • Review prenatal record for risk factors • Head to toe assessment • Monitor respiratory effort • Monitor V.S. • Monitor for hypoglycemia

26. Nursing Management Varies with gestational age • Promote oxygenation • Promote Thermoregulation • Promote optimal nutrition

27. Nursing Management Continue • Prevent infections • Provide stimulation • Pain management Prevention & Management Box23.4 pg. 800 Nonpharmacologic Techniques Box 23.5 pg.801 • Pharmacologic agents

28. Nursing ManagementContinue • Promote bonding • Quite environment • Promote parent coping • Discharge Planning Box 23.6 pg 803 Nursing Care plan 23.1 pg 792-794

29. Perinatal Loss • Table 23.2 pg 805

30. Chapter 24Newborn at Risk

31. Acquired vs. Congenital Acquired disorders • Typically occur at, or soon after, birth • Problems or conditions experienced by the woman during her pregnancy or at birth • Possibly no identifiable cause for the disorder Congenital disorders • Present at birth; usually due to some type of malformation occurring during the antepartal period; typically some problem with inheritance

32. Neonatal Asphyxia • Failure to establish adequate, sustained respirations after birth • Pathophysiology: insufficient oxygen delivery to meet metabolic demands

33. Nursing Assessment • Asses for risk factors • newborn’s color • work of breathing • heart rate • Temperature • Apgar scores

34. Nursing Management • Immediate resuscitation • Continued observation • Neutral thermal environment • Blood glucose levels • Parental support and education

35. 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

36. 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)

37. Transient Tachypnea Newborn Nursing Care • Mainly supportive • Monitory VS & O2 Sats • Provide supplemental O2 • IV fluids • Gavage feedings

38. 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

39. Nursing Assessment Symptoms • Noted at birth or within in a few hours • Expiratory grunting • Nasal flaring • Chest wall retractions • Seesaw respirations • Generalized cyanosis

40. 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

41. Silverman-Anderson Tool

42. RDSNursing Management Supportive care • Thermoregulation- prevent cold stress • O2 administration • Fluid management • Nutritional support • Surfactant replacement therapy • Monitor VS & O2 sats

43. 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.

44. Nursing Assessment Symptoms • Cyanosis • Tachypnea • Course & rhonchi • Labored breathing • Apnea • X-ray patches or streaks of meconium & trapped air

45. Meconium Aspiration Nursing Management • Assess for risk factors prior to delivery • Neutral Thermal environment • Supplemental O2 • Medications • Monitor response to treatment

46. 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

47. Persistent Pulmonary Hypertension Nursing Assessment • Tachypnea within 12 hours after birth • Marked cyanosis, grunting, and retractions • Systolic ejection murmur • Blood pressure • Oxygen saturation • Echocardiogram

48. 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

49. 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 hypoxemia (because of assisted ventilation and high oxygen exposure), acidosis, or shock.

50. 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.