HIGH RISK NEWBORN

Barbara B. Rees, RN, DSN

Identification of High Risk Infants

Assess for congenital anomalies
Determine Gestational Age Assessment

Priority Needs of Newborns

Initiating and Maintaining Respirations Establishing Extrauterine Balance Fluid and Electrolyte Balance Temperature Regulation Adequate Nutritional Intake Parent-Infant Bonding

HIGH RISK NEWBORN

GESTATIONAL AGE ASSESSMENT MOST COMMON PROBLEMShypoglycemia, hypocalcemia, resp. distress, hypothermia SGA AGA LGA

Small for Gestational Age

<2500 g (5 1/2 lbs) Commonly due to placenta abnormality, decreased blood flow, smoking, narcotics Appearance

SGA INFANTS- COMMON COMPLICATIONS

PERINATAL ASPHYXIA ASPIRATION SYNDROME HEAT LOSS HYPOGLYCEMIA HYPOCALCEMIA POLYCEMIA MENTAL DEVELOPMENT

LGA INFANTS
Causes: a. Diabetic Mother b. Babies with Transposition of the Great Vessels c. Multiparous Mothers

Hypoglycemia
Threat to Brain Cells Less than 30 mg/100 ml of blood = harmful After birth levels fall Infants prone to hypoglycemia Treatment

Appropriate for Gestational Age

Healthiest Babies
Between 3000 - 4000 g

Preterm Infant
Less than 37 weeks Less than 3500 g = LBW 1000 - 1500 g = VLBW 500 - 1000 g = Extremely VLBW

PRETERM INFANTS
SMALL AND SCRAWNY LARGE HEAD TRANSLUCENT SKIN, VISABLE BLOOD VESSELS ABUNDANT LUNAGO SOLES OF FEET- minimal creases MALES- few scrotal rugae, & testes undescended

PRETERM INFANTS- Potential Complications

Anemia Kernicterus Persistent Patent Ductus Arteriosus Periventricular/Intraventricular Hemorrhage

PRETERM INFANTS-Nursing Diagnosis

Impaired Gas Exchange Risk for Fluid Volume Deficit Risk for Altered Nutrition Risk for Infection Risk for Altered Parenting Diversional Activity Deficit Risk for Disorganized Infant Behavior

POSTERM INFANTS
ABSENT LANUGO LITTLE VERNIX CASEOSA ABUNDANT SCALP HAIR SKIN CRACKED & PARCHMENTLIKE WASTED APPEARANCE

RESPIRATORY DISTRESS SYNDROME

CAUSE- Surfactant Production WORK HARDER- Use more O2 & expend more energy, get hypoxic, hypercapnia, metabolic acidosis, vasoconstriction RISK- <2500g, <28 weeks, male, IDM SIGNS DIAGNOSIS TREATMENT & PREVENTION

ILLNESS IN THE NEWBORN

TRANSIENT TACHYPNEA MECONIUM ASPIRATION SYNDROME SUDDEN INFANT DEATH SYNDROME PERIVENTRICULAR LEUKOMALACIA HEMOLYTIC DISEASE OF THE NEWBORN

MANAGEMENT OF HIGH RISK INFANT

PHYSICAL ASSESSMENT THERMOREGULATION- need neutral thermal environment, use brown fat CONSEQUENCES OF COLD STRESShypoxia, metabolic acidosis, hypoglycemia GLUCOSE & CALCIUM PROTECT FROM INFECTION

MANAGEMENT OF HIGH RISK INFANT

HYDRATION- IVF for calories, electrolytes & H2O NUTRITION- no coordination of sucking until 32-34 weeks; not synchronized until 36-37 weeks; gag reflex not developed until 36 weeks EARLY FEEDING- within 3-6 hours BREAST FEEDING GAVAGE FEEDING- <32 wks. or <1500g

MANAGEMENT OF HIGH RISK INFANT

SKIN CARE OF PREMATURE- increased sensitivity & fragile MEDICATION - caution DECREASE STRESS

DEVELOPMENTAL INTERVENTION
BEFORE 33 WEEKS- minimum stimulation 34-36 WEEKS- stimulate senses but dont tire out

NURSING CARE
PAIN CONTROL FACILITATE PARENT-CHILD RELATIONSHIP NEONATAL LOSS- see, hold, photo; support groups, baptize

PRETERM INFANTS
GIRLS- labia and clitoris prominent INACTIVE & LISTLESS- extremities remain in any position placed IMMATURE LUNGS, SUCK, TEMP

HYPERBILIRUBINEMIA
INCREASED UNCONJUGATED FORM (0.2-1.4mg/dl) JAUNDICE WITHIN 24 HOURS AFTER 1-2 WKS. TERM; 2 WKS PRETERM TOTAL > 12-13 mg/dl INCREASE >5 mg/dl/day DIRECT >1.5-2 mg/dl

HYPERBILIRUBINEMIA
DIRECT COOMBS TEST- ABO/Rhdetect the infants antibodies coating the RBS (circulating erythrocytes)

TYPES OF HYPERBILIRUBINEMIA
PHYSIOLOGICAL JANUDICE BREAST-FEEDING ASSOCIATED JAUNDICE BREAST MILK JAUNDICE HEMOLYTIC DISEASE- Blood antigen incompatibility a. Treatment- phototherapy, exchange transfusion, prevention (RhoGAM) b. Nursing Care

EXCHANGE TRANSFUSION
CRITERIA- + Direct Coombs, Hg<12g/dl, Bilirubin > 20 mg/dl AMOUNT - 2X blood volume of infant UMBILICAL VEIN CHECK FOR HYPOCALCEMIA MONITOR VS, RADIENT WARMER

HYPOGLYCEMIA
SGA, LGA, IDM, STRESSED, INTERUTERINE MALNUTRITION JITTERY, HIGH-PITCHED CRY, LETHARGIC Dx- glucose <40 1st 24 hours or <50 after 24 hours, heel stick PREVENT- early feedings

HYPOCALCEMIA
RISK- preterm with hypoxia, IDM, hypoglycemic Dx- serum calcium <7 mg/dl Tx- increase milk feedings, cal. supplements, Vit D

NEONATAL SEIZURES
NOT ORGANIZED SIGN OF BRAIN DISTURBANCE MOST COMMON CAUSE- Asphyxia & Hypoglycemia Dx- EEG, lab test, CAT scan Treatment and Nursing Care

HYPOXIC-ISCHEMIC ENCEPHALOPATHY
COMPLICATION OF HYPOXEMIA
RISK SIGNS

SEPSIS
SUSCEPTIBLE- Diminished nonspecific and specific immunity ETIOLOGY- Infected amniotic fluid, +BGS DIAGNOSIS- Cultures TREATMENT- Ampicillin & Gentamycin

NECROTIZING ENTERCOLITIS
SICK PRETERM & HIGH-RISK ISCHEMIA & NECROSIS OF GI TRACT RELATIONSHIP WITH FORMULA SIGNS- Abdominal Distention, etc. TREATMENT- D/C oral feedings, Antibiotics, Observations

BULLOUS IMPETIGO
STAPHYLOCOCCUS AUREUS- red moist denuded area with very little crusting WARM SALINE COMPRESSES,
ANTIBIOTICS PREVENT SPREAD

INFANTS OF DIABETIC MOTHERS(IDM)

BLOOD SUGAR- Hypoglycemic <40 in 1st 24 hours, 40-50 later TRANSIENT HYPERGLYCEMIA LGA- Fat deposits & excessive growth HYPOGLYCEMIA- Within 1/2-4 hours CHECK BLOOD SUGAR

NARCOTIC-ADDICTED INFANTS
WITHDRAWAL AUTONOMIC NERVOUS SYSTEMHyperirritability, suck vigorously but poor suckers TREATMENT- Sedative/Hypnotic, Antianxiety PROGNOSIS- Neuro and growth problems NURSING- Decrease stimuli, nutrition, snuggle, protect skin

COCAINE EXPOSURE
CNS STIMULANT RISK SIDS NEURO DEPRESSION/EXCITABILITY SMALL HEAD CIRCUMFERENCE, LBW, LOWER BIRTH LENGTH TREATMENT- Supportive, occ. sedative

FETAL ALCOHOL SYNDROME

MOM CHRONIC ALCOHOLIC
MENTAL RETARDATION CHARACTERISTICS- Growth retardation, CNS manifestations, facial characteristics, fail to thrive

MATERNAL SMOKING
GROWTH RETARDATION
INCREASED ABORTION EMOTIONAL DEFICITS INCREASED SIDS

MATERNAL INFECTION
T- Toxoplasmosis O- Other ( hepatitis, measles, mumps, HIV) R- Rubella- pregnant no contact C- Cytomegalovirus infection-pregnant no contact H- Herpes simplex- Stop transmission S- Syphilis (Gonococcal conjunctivitis & chylamydial conjunctivitis)

CONGENITAL ABNORMALITIES
DOWNS SYNDROME- Extra chrosome 21 a. GREATER RISK IN WOMEN >35 b. CHARACTERISTICS- Mental retardation, low set ears, head round, short stubby fingers, bridge of nose flat, tongue thick, heart defects

CONGENITAL ABNORMALITIES
CHEMICAL AGENTS a. BETWEEN 15-90 DAYS OF GESTATION
b. PREVENTION

CONGENITAL HYPOTHYROIDISM
INADEQUATE THYROXINE (T4)
CLINICAL SIGNS- Hypotonia, widespread fontanelles, large thyroid, prolonged jaundice

TREATMENT- Thyroid hormone replacement

PHENYLKETONURIA
ABSENSE OF PHENYLALANINE HYDROXYLASE AFFECTS DEVELOPMENT OF BRAIN AND CNS SCREENING OF NEWBORNS, REPEAT SCREENING TREATMENT- Diet restricts phenylalanine (Lofenalac), meat and diary products restricted

GALACTOSEMIA
DISORDER OF GALACTOSE METABOLISM GLACTOSE ACCUMULATES IN BLOOD ORGANS SIGNS- Lethargy, hypotonia, diarrhea TREATMENT- Eliminate galactose (Prosobee)