HIGH RISK INFANTS

The high-risk neonate: can be defined as a newborn, regardless of gestational

age or birth weight, who has a greater-than-average chance of morbidity or mortality,
because of conditions or circumstances superimposed on the normal course of events
associated with birth and the adjustment to extra uterine existence.

Premature Infants
Definition
A baby born before 37 weeks of pregnancy is considered premature, that is, born
before complete maturity. Slightly fewer than 12 percent of all babies are premature.
Overall, the rate of premature births is rising, mainly due to the large numbers of
multiple births in recent years. Twins and other multiples are about six times more likely
to be premature than single birth babies. The rate of premature single births is slightly
increasing each year.
According to the March of Dimes, about 13 percent of babies born in the US are
born preterm, or before 37 completed weeks of pregnancy. Of the babies born preterm:
• 71 percent are born between 34 and 36 weeks of gestation (the time from
conception to birth)
•about 13 percent are born between 32 and 33 weeks of gestation
•about 6 percent are born at less than 28 weeks of gestation
Other terms often used for prematurity are preterm and "preemie." Many
premature babies also weigh less than 2,500 grams (5.5 pounds) and may be referred
to as low birthweight (LBW).
Premature infants born between 34 and 37 weeks of pregnancy are often called
late preterm or near-term infants. Late preterm infants are often much larger than very
premature infants but may only be slightly smaller than full-term infants.
Late preterm babies usually appear healthy at birth but may have more difficulties
adapting than full-term babies. Because of their smaller size, they may have trouble
maintaining their body temperature. They often have difficulty with breastfeeding and
bottle feeding, and may need to eat more frequently. They usually require more sleep
and may even sleep through a feeding, which means they miss much-needed calories.
Late preterm infants may also have breathing difficulties, although these are often
identified before the infants go home from the hospital. These infants are also at higher
risk for infections and jaundice, and should be watched for signs of these conditions.
Late preterm infants should be seen by a care provider within the first one or two days
after going home from the hospital.

Causes of prematurity
There are many factors linked to premature birth. Some directly cause early labor
and birth, while others can make the mother or baby sick and require early delivery. The
following factors may contribute to a premature birth:

Maternal factors:
○ preeclampsia (also known as toxemia or high blood pressure of pregnancy)
○ chronic medical illness (such as heart or kidney disease)
○ infection (such as group B streptococcus, urinary tract infections, vaginal I
 infections, infections of the fetal/placental tissues)
○ drug use (such as cocaine)
○ abnormal structure of the uterus
○ cervical incompetence (inability of the cervix to stay closed during pregnancy)
○ previous preterm birth

Factors involving the pregnancy:

○ abnormal or decreased function of the placenta
○ placenta previa (low lying position of the placenta)
○ placental abruption (early detachment from the uterus)
○ premature rupture of membranes (amniotic sac)
○ polyhydramnios (too much amniotic fluid)

Factors involving the fetus:

○ when fetal behavior indicates the intrauterine environment is not healthy
○ multiple gestation (twins, triplets or more)

Characteristics of prematurity
The following are the most common characteristics of a premature baby. However,
each baby may show different characteristics of the condition. Characteristics may
include:
•small baby, often weighing less than 2,500 grams (5 pounds 8 ounces)
•thin, shiny, pink or red skin, able to see veins
•little body fat
•little scalp hair, but may have lots of lanugo (soft body hair)
•weak cry and body tone
•genitals may be small and underdeveloped
The characteristics of prematurity may resemble other conditions or medical
problems. Always consult your baby's physician for a diagnosis.

Treatment of prematurity:
Specific treatment for prematurity will be determined by your baby's physician
based on:
•your baby's gestational age, overall health, and medical history
•extent of the disease
•tolerance for specific medications, procedures, or therapies
•expectations for the course of the disease
•your opinion or preference
Treatment may include:
•prenatal corticosteroid therapy
One of the most important parts of care for premature babies is a medication
called a corticosteroid. Research has found that giving the mother a steroid
medication at least 48 hours prior to delivery greatly reduces the incidence and
severity of respiratory disease in the baby. Another major benefit of steroid
treatment is lessening of intraventricular hemorrhage (bleeding in the baby's
brain). Although studies are not clear, prenatal steroids may also help reduce the
 incidence of NEC and PDA. Mothers may be given steroids when preterm birth is
likely between 24 and 34 weeks of pregnancy. Before that time, or after, the
medication usually is not effective.

Premature babies usually need care in a special nursery called the Neonatal
Intensive Care Unit (NICU). The NICU combines advanced technology and trained
health professionals to provide specialized care for the tiniest patients. The NICU
team is led by a neonatologist, who is a pediatrician with additional training in the
care of sick and premature babies.

Care of premature babies may also include:

•temperature-controlled beds
•monitoring of temperature, blood pressure, heart and breathing rates, and oxygen
levels
•giving extra oxygen by a mask or with a breathing machine
•mechanical ventilators (breathing machines) to do the work of breathing for the
baby
•intravenous (IV) fluids - when feedings cannot be given, or for medications
•placement of catheters (small tube) into the umbilical cord to give fluids and
medications and to draw blood
•x-rays (for diagnosing problems and checking tube placement)
•special feedings of breast milk or formula, sometimes with a tube into the stomach
if a baby cannot suck. Breast milk has many advantages for premature babies as it
contains immunities from the mother and many important nutrients.
•medications and other treatments for complications, such as antibiotics
•Kangaroo Care - a method of caring for premature babies using skin-to-skin
contact with the parent to provide contact and aid parent-infant attachment.
Studies have found that babies who "kangaroo" may have shorter stays in the
NICU.

POSTMATURE INFANTS
Definition
The normal length of pregnancy is from 37 to 41 weeks. Postmaturity refers to any
baby born after 42 weeks gestation or 294 days past the first day of the mother's last
menstrual period. About 6 percent of all babies are born at 42 weeks or later. Other
terms often used to describe these late births include post-term, postmaturity, prolonged
pregnancy, and post-dates pregnancy.

Causes of postmaturity?
It is not known why some pregnancies last longer than others. Postmaturity is
more likely when a mother has had one or more previous post-term pregnancies.
Sometimes a mother's pregnancy due date is miscalculated because she is not sure of
her last menstrual period. A miscalculation may mean the baby is born earlier or later
than expected.
Symptoms of postmaturity
The following are the most common symptoms of postmaturity. However, each
baby may show different symptoms of the condition. Symptoms may include:
•dry, peeling skin
•overgrown nails
•abundant scalp hair
•visible creases on palms and soles of feet
•minimal fat deposits
•green/brown/yellow coloring of skin from meconium staining (the first stool passed
during pregnancy into the amniotic fluid)

Symptoms of postmaturity may resemble other conditions or medical problems.

Always consult your baby's physician for a diagnosis.

Diagnosis
Postmaturity is usually diagnosed by a combination of assessments, including the
following:
•your baby's physical appearance
•length of the pregnancy
•your baby's assessed gestational age

Treatment of postmaturity:
Specific treatment for postmaturity will be determined by your baby's physician
based on:
•your baby's gestational age, overall health, and medical history
•extent of the condition
•your baby's tolerance for specific medications, procedures, or therapies
•expectations for the course of the condition
•your opinion or preference
In a prolonged pregnancy, testing may be done to check fetal well-being and
identify problems. Tests often include ultrasound, non-stress testing (how the fetal heart
rate responds to fetal activity), and estimation of the amniotic fluid volume.
The decision to induce labor for post-term pregnancy depends on many factors. During
labor, the fetal heart rate may be monitored with an electronic monitor to help identify
changes in the heart rate due to low oxygenation. Changes in a baby's condition may
require a cesarean delivery.

Special care of the postmature baby may include:

•checking for respiratory problems related to meconium (baby's first bowel
movement) aspiration.
•blood tests for hypoglycemia (low blood sugar).

Prevention of postmaturity:
Accurate pregnancy due dates can help identify babies at risk for postmaturity.
Ultrasound examinations early in pregnancy help establish more accurate dating by
measurements taken of the fetus. Ultrasound is also important in evaluating the
placenta for signs of aging.

LARGE FOR GESTATIONAL AGE

Definition
Large for gestational age (LGA) is a term used to describe babies who are born
weighing more than the usual amount for the number of weeks of pregnancy. LGA
babies have birthweights greater than the 90th percentile for their gestational age,
meaning that they weigh more than 90 percent of all babies of the same gestational
age.
The average baby weighs about 7 pounds at birth. About 10 percent of all babies
weigh more than 4,000 grams (8 pounds, 13 ounces). Rarely do babies weigh over 10
pounds.
Although most LGA babies are born at term (37 to 41 weeks of pregnancy), a few
premature babies may be LGA.

Causes of large for gestational age (LGA)

Some babies are large because their parents are large; genetics does play a part.
Birthweight may also be related to the amount of a mother's weight gain in pregnancy.
Excessive weight gain can translate to increased fetal weight.
By far, maternal diabetes is the most common cause of LGA babies. Diabetes
during pregnancy causes the mother's increased blood glucose (sugar) to circulate to
the baby. In response, the baby's body makes insulin. All the extra sugar and the extra
insulin production can lead to excessive growth and deposits of fat, thus, a larger baby.

Diagnosis
During pregnancy, a baby's birthweight can be estimated in different ways. The
height of the fundus (the top of a mother's uterus) can be measured from the pubic
bone. This measurement, in centimeters, usually corresponds with the number of weeks
of pregnancy. If the measurement is high for the number of weeks, the baby may be
larger than expected. Other diagnostic procedures may include the following:
•Ultrasound (a test using sound waves to create a picture of internal structures) is
a more accurate method of estimating fetal size. Measurements can be taken of the
fetus' head and limbs and compared with a growth chart to estimate fetal weight.
•A mother's weight gain can also influence a baby's size. Large maternal weight
gains in pregnancy may correspond with a big baby.
Babies are weighed within the first few hours after birth. The weight is compared with
the baby's gestational age and recorded in the medical record. The birthweight must be
compared to the gestational age. Generally, a baby weighing more than 4,000 grams (8
pounds, 13 ounces) is considered LGA.

Treatment for large for gestational age (LGA):

Specific treatment for large for gestational age will be determined by your baby's
physician based on:
•your baby's gestational age, overall health, and medical history
 •extent of the condition
•your baby's tolerance for specific medications, procedures, or therapies
•expectations for the course of the condition
•your opinion or preference
If ultrasound examinations during pregnancy show a fetus is quite large, some
physicians may recommend early delivery before the baby grows much bigger. A mother
may need induction of labor, or a planned cesarean delivery if the baby is estimated to
be very large.
After delivery, a LGA baby will be carefully examined for any birth injuries. Blood
glucose testing is also performed to check for hypoglycemia. Early feeding with a
glucose/water solution is sometimes needed to counter the low blood sugar.

Prevention of large for gestational age (LGA):

Prenatal care is important in all pregnancies, and especially to monitor fetal
growth when a baby seems to be too small or too large. Examinations during pregnancy
that show a large baby can help identify a mother who may have undetected diabetes,
or other problems. Careful management of diabetes in pregnancy can help lower some
of the risks to the baby.

SMALL FOR GESTATIONAL AGE

Definition
Small for gestational age (SGA) is a term used to describe a baby who is smaller
than the usual amount for the number of weeks of pregnancy. SGA babies usually have
birthweights below the 10th percentile for babies of the same gestational age. This
means that they are smaller than 90 percent of all other babies of the same gestational
age.
SGA babies may appear physically and neurologically mature but are smaller than
other babies of the same gestational age. SGA babies may be proportionately small
(equally small all over) or they may be of normal length and size but have lower weight
and body mass. SGA babies may be premature (born before 37 weeks of pregnancy),
full term (37 to 41 weeks), or post term (after 42 weeks of pregnancy).

Causes small for gestational age (SGA)?

Although some babies are small because of genetics (their parents are small),
most SGA babies are small because of fetal growth problems that occur during
pregnancy. Many babies with SGA have a condition called intrauterine growth restriction
(IUGR).
IUGR occurs when the fetus does not receive the necessary nutrients and oxygen
needed for proper growth and development of organs and tissues. IUGR can begin at
any time in pregnancy. Early-onset IUGR is often due to chromosomal abnormalities,
maternal disease, or severe problems with the placenta. Late-onset growth restriction
(after 32 weeks) is usually related to other problems.
Some factors that may contribute to SGA and/or IUGR include the following:
•Maternal factors:
○ high blood pressure
 ○ chronic kidney disease
○ advanced diabetes ○ heart or respiratory disease
○ malnutrition, anemia ○ infection ○ substance use (alcohol, drugs)
○ cigarette smoking

•Factors involving the uterus and placenta:

○ decreased blood flow in the uterus and placenta
○ placental abruption (placenta detaches from the uterus)
○ placenta previa (placenta attaches low in the uterus)
○ infection in the tissues around the fetus

•Factors related to the developing baby (fetus):

○ multiple gestation (twins, triplets, etc.)
○ infection
○ birth defects
○ chromosomal abnormality

Diagnosis
The baby with SGA is often identified before birth. During pregnancy, a baby's size
can be estimated in different ways. The height of the fundus (the top of a mother's
uterus) can be measured from the pubic bone. This measurement in centimeters usually
corresponds with the number of weeks of pregnancy after the 20th week. If the
measurement is low for the number of weeks, the baby may be smaller than expected.
Although many SGA babies have low birthweight, they are not all premature and
may not experience the problems of premature babies. Other SGA babies, especially
those with IUGR, appear thin, pale, and with loose, dry skin. The umbilical cord is often
thin, and dull-looking rather than shiny and fat. They sometimes have a wide-eyed look.
Other diagnostic procedures may include the following:
• Ultrasound Ultrasound (a test using sound waves to create a picture of internal
structures) is a more accurate method of estimating fetal size. Measurements can
be taken of the fetus' head and abdomen and compared with a growth chart to
estimate fetal weight. The fetal abdominal circumference is a helpful indicator of
fetal nutrition.
•Doppler flow another way to interpret and diagnose IUGR during pregnancy is
Doppler flow, which use sound waves to measure blood flow. The sound of moving
blood produces wave-forms that reflect the speed and amount of the blood as it
moves through a blood vessel. Blood vessels in the fetal brain and the umbilical
cord blood flow can be checked with Doppler flow studies.
•Mother’s weight gain A mother's weight gain can also indicate a baby's size.
Small maternal weight gains in pregnancy may correspond with a small baby
•Gestational assessment Babies are weighed within the first few hours after birth.
The weight is compared with the baby's gestational age and recorded in the
medical record. The birthweight must be compared to the gestational age. Some
physicians use a formula for calculating a baby's body mass to diagnose SGA.
Treatment of babies who are small for gestational age (SGA):
Specific treatment for SGA will be determined by your baby's physician based on:
 •your baby's gestational age, overall health, and medical history
•extent of the condition
•your baby's tolerance for specific medications, procedures, or therapies
•expectations for the course of the condition
•your opinion or preference
Babies with SGA may be physically more mature than their small size indicates.
But they may be weak and less able to tolerate large feedings or to stay warm.

Treatment of the SGA baby may include:

•temperature controlled beds or incubators
•tube feedings (if the baby does not have a strong suck)
•checking for hypoglycemia (low blood sugar) through blood tests
•monitoring of oxygen levels
Babies who are SGA and are also premature may have additional needs including
oxygen and mechanical help to breathe.

Prevention of small for gestational age (SGA):

Prenatal care is important in all pregnancies, and especially to identify problems
with fetal growth. Stopping smoking and use of substances such as drugs and alcohol
are essential to a healthy pregnancy. Eating a healthy diet in pregnancy may also help.
SUDDEN INFANT DEATH SYNDROME (SIDS)

- defined as the sudden death of an infant under 1 year of age that remains unexplained
after a complete postmortem examination, including an investigation of the death scene
and a review of the case history.

- it tends to occur at a higher-than-usual rate in infants of adolescent mothers, infants of

closely-spaced pregnancies, and underweight and pre-term infants. Also prone to SIDS
are infants with bronchopulmonary dysphasia, twins and infants of narcotic dependent
mothers.

- the peak age of incidence is 2 to 4 months of age.

CAUSE/ETIOLOGY

Although the cause of SIDS is unknown, a number of theories about its cause have
been postulated:
- prolonged but unexplained apnea
- viral respiratory or botulism infection
- pulmonary edema
- possible lack of surfactant in alveoli
- sleeping prone (respiratory muscles are restricted)
- impaired arousal responsiveness to increased carbon dioxide or decreased oxygen
- genetic predisposition to SIDS
- maternal smoking (both prenatally and postnatally)
- poor prenatal care
- low maternal age
- cot sleeping
- soft bedding
- intrathoracic hemorrhages
Signs and Symptoms
- lifeless infant

MEDICAL DIAGNOSIS

- A SIDS diagnosis should not be made if any of these three steps are not conducted:

1. complete autopsy

2. examination of a death scene

3. review of infant’s clinical/health history

NURSING DIAGNOSES

Ineffective Coping Mechanism: feelings of extreme guilt related to loss of child

secondary to Sudden Infant Death Syndrome

Complicated Grieving Process related to loss of child secondary to Sudden Infant

Death Syndrome

Deficient Knowledge: feelings of guilt and anxiety related to lack of knowledge on

the actual cause of sudden child loss

Risk for Injury to the infant related to environmental stressors

Risk for sudden infant Death syndrome related to poor prenatal care

PREVENTION

At least some cases of sudden infant death syndrome can be prevented. Parents can
take a number of actions that will reduce the risk of SIDS for their babies. These actions
include the following:

• Sleep position. At one time, parents were taught to put their babies on their
stomachs when they went to bed. That position was thought to prevent the baby
from choking in its sleep. Experts now suggest that babies sleep on their backs or
their sides. In these positions, they are less likely to have their faces covered in
pillows and blankets.

• Good prenatal care. Women should get the best possible medical care while they
are pregnant. This care will ensure that they are themselves healthy. Expectant
mothers should be warned about the risks of smoking, alcohol intake, and drug use.
A healthy mother's body is the best protection the newborn baby can have. Good
prenatal care also involves education for the mother. She should be taught the best
techniques for caring for her new baby.
• Proper bedding. Soft bedding, such as beanbags, waterbeds, and soft mattresses,
increase the risk for SIDS. Babies should sleep on firm mattresses with no soft or
fluffy materials nearby. Soft stuffed toys should not be placed in a crib while the baby
sleeps.
• Room temperature. A baby's room should be kept at a temperature that is
comfortable for the parents. A baby who becomes too warm may sleep too deeply
and may find it more difficult to wake up if it has trouble breathing.
• Diet. Some studies show that babies who are breast-fed are at lower risk for SIDS.
Mother's milk may provide additional protection against infections that can cause
SIDS in infants.
• Bed sharing with parents. Opinions differ as to whether bed sharing between
mother and baby increases or decreases the risk of SIDS. Bed sharing may
encourage breast-feeding, which decreases the risk of SIDS. Parents who bed share
may also be more aware of any problems their baby has breathing. On the other
hand, some studies show that bed-sharing increases the risk of SIDS. In any case,
parents should remember cautions about the use of bedding if their babies sleep
with them. They should also remember that an adult's bed does not have the same
safety features of an infant's crib.
• Secondhand smoke. The baby's room should be kept free of tobacco smoke at all
times.
• Electronic monitoring. Electronic devices are now available that allow parents to
listen in while their baby is sleeping. These devices sound an alarm if the baby stops
breathing. So far, however, there is no scientific evidence that electronic devices
reduce the risk of SIDS. The U.S. National Institutes of Health recommends their use
only for babies known to be at risk for SIDS. These babies include premature
 infants, infants who have had previous breathing problems, or infants with siblings
who have died of SIDS.
• Use of pacifiers (*if breastfed, introduction of pacifier should be delayed after 1
month to ensure that breast feeding is firmly established; *infants should not be
forced to take it,* it should not be sweet coated, *must not be reinserted once infant
falls asleep)
• Avoid overheating (infant’s room should be at a temperature of comfort for a lightly
clothed adult, infant free from heavy wrapping or thick blankets)

• Avoid development of positional plagiocephaly

• Encourage “tummy time” when the infant is awake and observed. This will also
enhance motor development.
• Avoid having the infant spend excessive time in car-seat carriers and “bouncers,” in
which pressure is applied to the occupant. Upright “cuddle time” should be
encouraged.
• Alter the supine head position during sleep. Techniques for accomplishing this
include placing the infant to sleep with the head to one side for a week and then
changing to the other and periodically changing the orientation of the infant to
outside activity (eg, the door of the room).
• Particular care should be taken to implement the aforementioned recommendations
for infants with neurologic injury or suspected developmental delay.
• Consideration should be given to early referral of infants with plagiocephaly when it
is evident that conservative measures have been ineffective. In some cases, orthotic
devices may help avoid the need for surgery.)
• A separate but proximate sleeping environment is recommended: The risk of
SIDS has been shown to be reduced when the infant sleeps in the same room as
the mother. A crib, bassinet, or cradle that conforms to the safety standards of the
Consumer Product Safety Commission and ASTM (formerly the American Society
for Testing and Materials) is recommended.

MANAGEMENT

There is no management for SIDS in infants. Management is focused on

parents, family and significant others.

1. Carefully explain to the parents the infant’s actual cause of death to help them gain
an understanding.

2. Counseling and Health Teaching

3. Provide emotional support.

4. Help provide support systems such as friends and support groups for the affected
families. Referrals to other parents who have lost a child to SIDS is often considered to
provide continuous and periodic evaluation of their progress.

5. The next infant of the affected families is usually placed under strict program
monitoring. Ex: CONI in England, Wales and Northern Ireland. This will reduce risk of
SIDS occurrence and reduce the parent’s/caregiver’s feeling of fear and insecurity.

PICTURES
RESPIRATORY DISTRESS SYNDROME

- also known as HYALINE MEMBRANE DISEASE (HMD)

- refers to a condition of surfactant deficiency and physiologic immaturity of the thorax.

- seen almost exclusively in preterm infants but may also be associated with multifetal
pregnancies, infants of diabetic mothers, cesarean section delivery , delivery before 37
weeks’ gestation, asphyxia, those who for any reason have decreased blood perfusion
of the lungs, such as occurs with meconium aspiration and a history of previous RDS.

- the pathologic feature of RDS is a hyaline-like (fibrous) membrane formed from an

exudate of an infants blood that begins to line the terminal bronchioles, alveolar ducts,
and alveoli. This membrane prevents exchange of oxygen and carbon dioxide at the
alveolar-capillary membrane.

CAUSE/ETIOLOGY

The cause of RDS is a low level or absence of surfactant, the phospholipid that normally
lines the alveoli and reduces surface tension on expiration to keep the alveoli from
collapsing on expiration.
S/S

 subtle signs appear at first:

- low body temperature

- nasal flaring

- sternal and subcostal retractions

- tachypnea (more than 60 respirations per minute)

- cyanotic mucous membranes

 as distress increases, an infant may exhibit:

- seesaw respirations (on inspiration, the anterior chest wall retracts and the abdomen
protrudes; on expiration, the sternum rises)

- heart failure; evidenced by decreased urine output and edema of the extremities

- pale gray skin/cyanosis

- periods of apnea

- bradycardia

- pneumothorax

NG. DIAGNOSES

Ineffective Breathing Pattern: nasal flaring related to respiratory distress secondary to

absence of surfactant in the alveoli

Ineffective Airway Clearance: cyanosis related to respiratory distress secondary to

presence of exudate in the alveoli

Impaired Gas Exchange: cyanosis related to respiratory distress secondary to alveolar-

capillary membrane changes

MANAGEMENT
 The supportive measures most crucial to a favorable outcome are:

- maintain adequate ventilation and oxygenation with either an oxygen hood or

mechanical ventilation

- maintain acid-base balance

- maintain a neutral-thermal environment

- maintain adequate tissue perfusion and oxygenation

- prevent hypotension

- maintain adequate hydration and electrolyte status

 Surfactant Replacement
 Oxygen Administration
 Ventilation
 Extracorporeal Membrane Oxygenation
 Liquid Ventilation
 Nitric Oxide
 Supportive Care

 The most essential nursing function is to observe and assess the infant’s response to
therapy. Continuous monitoring and close observation are mandatory because an
infant’s status can change rapidly and because oxygen concentration and ventilation
parameters are prescribed according to the infant’s blood gas measurements, tcPO2,
and pulse oximetry readings.
MECONIUM ASPIRATION SYNDROME

- meconium is present in the fetal bowel as early as 10 weeks’ gestation

- babies born breech may expel meconium into the amniotic fluid from pressure on the
buttocks

- the appearance of the fluid at birth is green to greenish black from the staining

- an infant may aspirate meconium either in utero or with the first breath after birth.

-MECONIUM can cause severe respiratory distress in three ways:

 It causes inflammation of the bronchioles

 It can block small bronchioles by mechanical plugging
 It can cause a decrease in surfactant production
- Hypoxemia, carbon dioxide retention, and intrapulmonary and extra pulmonary
shunting occur

- a secondary infection of injured tissue may lead to pneumonia

Signs & Symptoms:

- tachypnea

- retractions

- cyanosis

- coarse bronchial sounds may be heard on auscultation

- enlargement of the anteroposterior diameter of the chest( barrel chest)

- bilateral coarse infiltrates in the lungs with spaces of hyper aeration as shown in the x-
ray

Management:

- Amniotransfusion

- infants may need to be treated with oxygen administration and assisted ventilation
after birth and tracheal suction
- Antibiotic therapy

- infants must be observed closely for signs of trapping air in the alveoli

- maintain a temperature-neutral environment

- chest physiotherapy with clapping and vibration

Nursing Diagnosis:

 Ineffective airway clearance: cyanosis related to inhalation of foreign substance

 Risk for infection related to immature immune system
Problem/N Nursing Scientific Plan of Interventions Rationale
eed/Cues Diagnosis Basis care

Physiologic Ineffective Meconium After 8 hrs. Measures

Deficit: airway is present in of holistic to:
clearance: the fetal nursing
Aspiration cyanosis bowel as care, the
related to early as 10 newborn
inhalation weeks’ will be able
Objective of foreign gestation. to:
cues: substance An infant
with 1. main-
-Pre
hypoxia in tain clear
sence of utero airway as
thick(dark) experiences evidenced 1. to maintain
meconium a vagal by 1. position open airway
during reflex absence of head midline
suctioning( relaxation of respiratory
in nose & the rectal distress
sphincter, 2. to clear
mouth) such as:
which 2. assist in airway when
-slight releases me -nasal naso & oral secretions are
nasal conium into flaring suctioning blocking
flaring of the amniotic airway
newborn -dyspnea
fluid. 3. to ascertain
-cyanosis An infant newborn’s
may 3. report status
-newborn
aspirate me further signs Source:
has faint
conium of
cries
either in respiratory NANDA 10th
Vital Signs; utero or distress ed. by
with the first Doenges, p.
Temp- 36.8 breath after 75- 76
C birth. me
4. to prevent
HR- conium can
increasing the
125bpm cause
metabolic
severe
RR-63bpm oxygen
respiratory
demands of
distress in 4. maintain a
the newborn
three ways: temperature-
Subjective inflammatio neutral
cues: n of the environment
bronchioles 5. to
“ nangla- because it encourage
is a foreign removal of
gum jud remnants of
substance,
ang bata,” me conium
it can block
as from the lungs
small
verbalized 5. provide
bronchioles
 mechanical
plugging
and it can
cause a
decrease in
surfactant
production
through lung
cell trauma.

Source:

Maternal
Child Health
Nursing 5th
ed. By
Pilliteri, p.
782

SEPTICEMIA/SEPSIS
-refers to generalized bacterial infection in the blood stream

ETIOLOGY

Predisposing Factors:

1. premature placental delivery

- leaves infants vulnerable to most common viral, bacterial, fungal and parasitic
infections

2. Prematurity

- there is interruption of transplacental transmission of immune substances (low IgG, no

IgM and IgA; thus infant is more susceptible to viral, gram negative bacterial infection
and others)

3. Diminished opsonization ability, monocyte dysfunction and inefficient function

of circulating leukocytes and other deficiencies (e.g. hypofunctioning adrenal
gland- inflammatory response)

-hampers the defense mechanism of the infant

CAUSES

- transplacental transmisission of infection

-ingestion or aspiration of infected amniotic fluid

RISK FACTORS

-prolonged rupture of membranes

(more time for transfer of pathogens)

-maternal infection

-prematurity, low birth weight

- dystocia, trauma during delivery

The five major types of antibodies are:

 • IgA. IgA antibodies are found in areas of the body such the nose, breathing
passages, digestive tract, ears, eyes, and vagina. IgA antibodies protect body
surfaces that are exposed to outside foreign substances. This type of antibody is
also found in saliva, tears, and blood. About 10% to 15% of the antibodies
present in the body are IgA antibodies. A small number of people do not make
IgA antibodies.
• IgG. IgG antibodies are found in all body fluids. They are the smallest but most
common antibody (75% to 80%) of all the antibodies in the body. IgG antibodies
are very important in fighting bacterial and viral infections. IgG antibodies are the
only type of antibody that can cross the placenta in a pregnant woman to help
protect her baby (fetus).
• IgM. IgM antibodies are the largest antibody. They are found in blood and lymph
fluid and are the first type of antibody made in response to an infection. They
also cause other immune system cells to destroy foreign substances. IgM
antibodies are about 5% to 10% of all the antibodies in the body.
• IgE. IgE antibodies are found in the lungs, skin, and mucous membranes. They
cause the body to react against foreign substances such as pollen, fungus
spores, and animal dander. They may occur in allergic reactions to milk, some
medicines, and some poisons. IgE antibody levels are often high in people with
allergies.
• IgD. IgD antibodies are found in small amounts in the tissues that line the belly or
chest. How they work is not clear.

TYPES

 Early-onset sepsis ( less than 3 days after birth)

-acquired in the perinatal period

-direct contact from maternal GI and GU tract

 -Late-onset sepsis (1-3 weeks after birth)

-is primarily nosocomial

-staphylococci, klebsiella, enterococci, E. coli, and Pseudomonas or Candida species

SIGNS AND SYMPTOMS

- changes in appearance and behavior

Nonspecific signs of infection:

• Hypothermia
• Changes in color, tone, activity and feeding behavior
• Sudden episodes of apnea
• Hypoglycemia,hypocalcemia, heroin withdrawal, CNS disorders

MANIFESTATIONS OF CLINICAL SEPSIS

General

• Infant “not doing well”

• Poor temperature control (hypothermia/hyperthermia)

Circulatory System

• Pallor, cyanosis, • Cold, clammy, • Edema

mottling skin • Irregular heart
• Hypotension beat

Respiratory system

• irregular apnea, or • grunting

respirations , tachypnea • dyspnea
• cyanosis • retractions

CNS

• Diminished • Increased activity • Increased/

activity—lethargy, —irritability, decreased tone
hyporeflexia, tremors, seizures • Abnormal eye
coma • Full fontanel movements

GI

• Poor feeding • Abdominal (benzidine-based

• Vomiting distention tests,
• Diarrhea/decreas • Hepatomegaly ex:hematest)
ed stooling • Hemoccult-
positive stools
Hematopoietic System

• Jaundice
• Pallor
• Petechiae,
ecchymosis
• splenomegaly
Diagnostic Evaluation

• Isolation of specific organisms thru blood, urine, CSF tests

- changes in neutrophil morphology may suggest a neonatal infection

- leukopenia is usually an ominous sign

• C-reactive protein and interleukins [specifically IL-6 (infections, burns,

trauma)]

Diagnoses

Risk for infection related to poor aseptic technique

Impaired Skin Integrity: jaundice related to liver infection

Therapeutic Management

antibiotic therapy

circulatory support

respiratory support

supportive therapy ( O2 Administration)

Nursing Care Management

- Provide an optimum thermoregulated environment

- anticipate potential problems such as dehydration/hypoxia

-Promote aseptic technique

-Continuously monitor for signs of complications

- secure everyone maintains all phases of contact isolation/ standard precautions

PICTURES
HYPERBILIRUBINEMIA
- is the elevated level of bilirubin in the blood.

Etiology
- Physiologic (developmental) factors (prematurity)
- Association with breast-feeding or breast milk
- Rh Incapability

Signs and Symptoms

- Jaundice
- Increased unconjugated bilirubin level of 20 mg/dl
- Poor excretion of bilirubin through feces or urine

Nursing Diagnosis
- Ineffective tissue perfusion: jaundice related to abnormal blood
profile(increased breakdown of products of red blood cells such as
bilirubin)

Management
- Initiate breastfeeding within 1st hour of life
- If formula feeding, assist parents in initiation of early feeding
- Assess skin for jaundice every 4 hours
- Monitor intake and output with each occurrence
- Maintain of accurate record of urine and stool output
- Assist in phototherapy of the infant as ordered by the physician
- Instruct parents regarding newborn care
Assessment Diagnosis Scientific Basis Objectives of Intervention Evaluation
Care
Physiologic Ineffective Jaundice Measures to:
Deficit tissue occurs After 8 hours of
perfusion: because as red holistic nursing 1. initiate - to promote
Objective jaundice blood cells are care: the patient breastfeeding breast mile
Cues: related to destroyed, will be able to within 1st hours intake and
- jaundice prematurity of indirect manifest of life stooling
- increased the infant bilirubin is decreased level
unconjugated released. of bilirubin as 2. if formula - promote
bilirubin level Indirect evidenced by 4 feeding, assist milk intake
of 8 mg/dl bilirubin is fat- mg/dl parents in and stooling
- poor soluble and initiation of to help
excretion of cannot be early feeding decrease
bilirubin excreted from level of
through feces the body. 3. Assess skin bilirubin
or urine Under normal for jaundice
circumstances, every 4 hours - to detect
the liver rising of
Subjective enzymes 4. monitor bilirubin
Cues: glucuronyl intake and levels
“hala ui ako transferase output with
anak kay ng converts each - to evaluate
yellow, na indirect occurrence effectiveness
unsa man ni bilirubin to of
cya dong!” as direct bilirubin breastfeeding
verbalized by (water-soluble) or formula
the mother. and combines intake by
with bile for measuring
excretion of the 5. maintain of urine and
body with accurate record stool output
feces. In of urine and
preterm infants stool output - to provide
or those with accurate
extreme record of
hemolysis, the output to
liver cannot 6. Instruct evaluate
convert indirect parents effectiveness
to direct regarding of feedings
bilirubin, so newborn care
jaundice - to promote
becomes 7. Assist in physical care
extreme. phototherapy of of newborn
the infant as
ordered by the - to speed up
Maternal and physician conversion
Child Nursing: potential of
Vol.1, page the liver
786.
Adele Pillitteri.