HIGH RISK NEWBORN

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HIGH RISK NEWBORN

• Barbara B. Rees, RN, DSN

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Identification of High Risk Infants

• Assess for congenital anomalies
• Determine Gestational Age Assessment

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Priority Needs of Newborns

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

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HIGH RISK NEWBORN

• GESTATIONAL AGE ASSESSMENT
• MOST COMMON PROBLEMS- hypoglycemia,
  hypocalcemia, resp. distress, hypothermia
• SGA
• AGA
• LGA

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Small for Gestational Age

• lt2500 g (5 1/2 lbs)
• Commonly due to placenta abnormality, decreased
  blood flow, smoking, narcotics
• Appearance

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SGA INFANTS- COMMON COMPLICATIONS

• PERINATAL ASPHYXIA
• ASPIRATION SYNDROME
• HEAT LOSS
• HYPOGLYCEMIA
• HYPOCALCEMIA
• POLYCEMIA
• MENTAL DEVELOPMENT

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LGA INFANTS

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

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Hypoglycemia

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

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Appropriate for Gestational Age

• Healthiest Babies
• Between 3000 - 4000 g

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Preterm Infant

• Less than 37 weeks
• Less than 3500 g LBW
• 1000 - 1500 g VLBW
• 500 - 1000 g Extremely VLBW

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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

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PRETERM INFANTS- Potential Complications

• Anemia
• Kernicterus
• Persistent Patent Ductus Arteriosus
• Periventricular/Intraventricular Hemorrhage

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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

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POSTERM INFANTS

• ABSENT LANUGO
• LITTLE VERNIX CASEOSA
• ABUNDANT SCALP HAIR
• SKIN CRACKED PARCHMENTLIKE
• WASTED APPEARANCE

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RESPIRATORY DISTRESS SYNDROME

• CAUSE- Surfactant Production
• WORK HARDER- Use more O2 expend more energy,
  get hypoxic, hypercapnia, metabolic acidosis,
  vasoconstriction
• RISK- lt2500g, lt28 weeks, male, IDM
• SIGNS
• DIAGNOSIS
• TREATMENT PREVENTION

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ILLNESS IN THE NEWBORN

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

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MANAGEMENT OF HIGH RISK INFANT

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

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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- lt32 wks. or lt1500g

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MANAGEMENT OF HIGH RISK INFANT

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

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DEVELOPMENTAL INTERVENTION

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

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NURSING CARE

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

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PRETERM INFANTS

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

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HYPERBILIRUBINEMIA

• INCREASED UNCONJUGATED FORM (0.2-1.4mg/dl)
• JAUNDICE WITHIN 24 HOURS
• AFTER 1-2 WKS. TERM 2 WKS PRETERM
• TOTAL gt 12-13 mg/dl
• INCREASE gt5 mg/dl/day
• DIRECT gt1.5-2 mg/dl

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HYPERBILIRUBINEMIA

• DIRECT COOMBS TEST- ABO/Rh- detect the infants
  antibodies coating the RBS (circulating
  erythrocytes)

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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

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EXCHANGE TRANSFUSION

• CRITERIA- Direct Coombs, Hglt12g/dl, Bilirubin gt
  20 mg/dl
• AMOUNT - 2X blood volume of infant
• UMBILICAL VEIN
• CHECK FOR HYPOCALCEMIA
• MONITOR VS, RADIENT WARMER

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HYPOGLYCEMIA

• SGA, LGA, IDM, STRESSED, INTERUTERINE
  MALNUTRITION
• JITTERY, HIGH-PITCHED CRY, LETHARGIC
• Dx- glucose lt40 1st 24 hours or lt50 after 24
  hours, heel stick
• PREVENT- early feedings

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HYPOCALCEMIA

• RISK- preterm with hypoxia, IDM, hypoglycemic
• Dx- serum calcium lt7 mg/dl
• Tx- increase milk feedings, cal. supplements, Vit
  D

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NEONATAL SEIZURES

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

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HYPOXIC-ISCHEMIC ENCEPHALOPATHY

• COMPLICATION OF HYPOXEMIA
• RISK
• SIGNS

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SEPSIS

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

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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

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BULLOUS IMPETIGO

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

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INFANTS OF DIABETIC MOTHERS(IDM)

• BLOOD SUGAR- Hypoglycemic lt40 in 1st 24 hours,
  40-50 later
• TRANSIENT HYPERGLYCEMIA
• LGA- Fat deposits excessive growth
• HYPOGLYCEMIA- Within 1/2-4 hours
• CHECK BLOOD SUGAR

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NARCOTIC-ADDICTED INFANTS

• WITHDRAWAL
• AUTONOMIC NERVOUS SYSTEM- Hyperirritability, suck
  vigorously but poor suckers
• TREATMENT- Sedative/Hypnotic, Antianxiety
• PROGNOSIS- Neuro and growth problems
• NURSING- Decrease stimuli, nutrition, snuggle,
  protect skin

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COCAINE EXPOSURE

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

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FETAL ALCOHOL SYNDROME

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

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MATERNAL SMOKING

• GROWTH RETARDATION
• INCREASED ABORTION
• EMOTIONAL DEFICITS
• INCREASED SIDS

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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)

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CONGENITAL ABNORMALITIES

• DOWNS SYNDROME- Extra chrosome 21
• a. GREATER RISK IN WOMEN gt35
• b. CHARACTERISTICS- Mental retardation, low set
  ears, head round, short stubby fingers, bridge of
  nose flat, tongue thick, heart defects

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CONGENITAL ABNORMALITIES

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

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CONGENITAL HYPOTHYROIDISM

• INADEQUATE THYROXINE (T4)
• CLINICAL SIGNS- Hypotonia, wide-spread
  fontanelles, large thyroid, prolonged jaundice
• TREATMENT- Thyroid hormone replacement

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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

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GALACTOSEMIA

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