High Risk Newborn Lecture

Preterm Infant

Born before 38 weeks gestation Immaturity of all systems

Physical assessment

Gestational age <37 weeks Resp. irregular Bowel sounds diminished Temp below 97.8 Hypoglycemia Poor suck and swallow Poor flexion

Psychosocial Assessment

Parents shock & disbelief Fear holding baby Grieve for “perfect” baby Financial concerns Fear for Baby’s life

Goals

safe effective environment Maintain resp & nutrition & temp Promote interaction with parents Education of parents in care

Implementations

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.

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

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 Hypoxia Inc. BP, Inc. head pressure

• (do not place in Trendlenberg position)

Chest percussion Assess: fontanels for increase in size

• seizures, apnea, bradycardia, drop in Hct

Preterm Case Study

Baby Girl Petite

Small for Gestational Age

Definition= below 10th percentile on growth chart

Problems: Congenital problems• fetal distress• hypoglycemia• polycythemia• infection• aspiration of Meconium

SGA

Nursing Care for SGA

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 Baby Boy Slim

Large for Gestational Age

Defined- Above the 90th percentile on growth chart

Problems: Birth trauma• Infant of Diabetic Mother• Hypoglycemia• Respiratory Distress Syndrome (RDS)• Hypotension• Sepsis

Nursing Care of LGA

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

Description: born after 42 weeks gestation Problems: Hypoglycemia

• meconium aspiration (MAS)• polycythemia• seizure activity• cold stress

Physical Characteristics of Postterm wide-eyed & alert (irritable) Skin- no lanugo, dry, cracked, parchment-like 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

Baby Girl Green

Cold Stress in Infants

Excessive heat loss Use of compensatory mechanism

• inc. respirations• non-shiver themogenisis

Preterm and SGA at risk

COLD STRESS

D ec . O xyg en

A te lec tas is

D ec . S u rfac tan tP rod u c tion

A c id em ia

H yp oxem ia

D ec . b lood flowto lu n g s

P u lm on aryvasocon s tric t ion

re leaseo f n orep in p h erin e

COLD STRESS

H yp erb iliru b in em ia

In c . F a tty ac id s

In c . A n aerob ic M etab o lism

H yp og lycem ia

U se o fG lu cose

In c . O xyg encon su m p tion

In c . M etab o licR ate

Signs & Symptoms of Cold Stress

Inc. Resp (sx Non Shiver Thermogenesis) Dec. Skin temp Dec. peripheral profusion Dec. Blood Glucose (using to generate heat)

Nursing Care for Cold Stress

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

Complication of Premie• r/t dec. blood flow to GI tract• 2 º to hypoxia or shock

Signs & Symptoms

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

GI rest (NPO) Antibiotics Surgery TPN NG or gavage feedings advance to bottle feedings

Case Study Necrotizing Enterocolitis Tiny Tim

Infant of a Diabetic Mother

Risk of Hypoglycemia Blood Glucose < 40 mg/dl R/T overstimulated fetal insulin production

Assessment

Predisposing Factors for Hypoglycemia• Preterm or premature birth• Large for Gestational age• Maternal diabetes• Hypertension• Infant stress

Signs and Symptoms 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 Larry Large

Goals

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

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 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 Elevated bilirubin level r/t :

• Breast Milk: reduced excretion of bilirubin• Extravascular hemolysis: bruises,

cephalohematoma, petechiae• Others: polycythemia, drugs, hypoglycemia,

hypoxia

Assessment biliflash above indication line

Assessment Con’t

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 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

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

Phototherapy: Bili Light or Blanket• 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

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 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 Enc. parents to visit Share information about condition, bili

levels, weight Provide auditory stimulation

• (music, humming)

Case Study Jaundice

Baby Mary

Prenatally Drug Exposed Case Study Patient- Kim Brown

Respiratory Distress Syndrome

Formally hyaline membrane disease Surfactant is absent, deficient of altered Symptoms occur within 6-12 hours of birth

Other Causes of Respiratory difficulty Aspiration Syndromes

• fluid or meconium• diminished pulmonary perfusion, present at birth

Apnea due to prematurity• apnea >20 sec. cyanosis, hypotonia, acidosis

Pneumonia apparent 2-5 days after birth Wet Lung Syndrome

• excessive pulmonary fluid (C-section)

RDS leading to Respiratory FailureBecause of Dec Surfactant

Dec lung compliance

Atelectasis

Dec P O2Anaerobic Metabolism

Acidosis

Inc Work Load

Dec Ventil

Inc CO2Pulmonary & Peripheral Vasoconstriction

R to L shunt

Pulm artery Pressure

Dec Pulm blood flow

Poor peripheral perfusion

Dec Surfactant

Metabolic

Resp

Assessment

Risk factors i.e. prematurity Flaccid extremities & edema Hypothermia, hypotension Skin pale or cyanotic Respiratory grunting, retractions, nasal

flaring• diminished breath sounds, tachypnea, abn. x-ray

or ABG

Expected Outcomes

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

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

I&O, urine pH, Daily Wt. Nutrition- NPO IV fluid 60-150 ml/Kg in

24 hr• gavage feed, advance to nipple, ck residual

Support for parents• explain, visits, include in care, share info• allow to express fears, anxiety, shock

Pharmacotherapy

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

Oxygen by hood Continuous airway pressure Volume ventilation Warm & humidify Oxygen Assess ABG q 4h via UAC

Case Study

Respiratory Distress Syndrome