Essential procedures in the care of high risk newborn

By: JESSA ANNE R. BORRE

Identify high risk newborn danger signs

The high-risk neonate is defined as a newborn, regardless

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

high-risk period begins at the time of viability (the gestational age at which survival outside the uterus is believed to be possible, or as early as 23 weeks of gestation)up to 28 days after birth and includes threats to life and health that occur during the prenatal, perinatal, and postnatal periods.

LATE-PRETERM INFANT ASSESSMENT AND INTERVENTIONS

RISK FACTORS

ASSESSMENT INTERVENTION

Respiratory distress

Assess for cardinal signs of respiratory distress (nasal flaring,grunting, tachypnea, central cyanosis, retractions) andpresence of apnea, especially during feedings.

Perform gestational age assessment.Observe for signs of respiratory distress; monitor oxygenationby pulse oximetry; provide supplemental oxygen judiciously.

Hypoglycemia Monitor for signs and symptoms of hypoglycemia.Assess feeding ability (latch-on, nipple-feeding).Assess thermal stability and signs and symptoms of respiratorydistress.Monitor bedside glucose in infants with additional risk factors(IDM, prolonged labor, respiratory distress, poor feeding).

Initiate early feedings of human milk or formula.Avoid dextrose water or water feedings.Provide IV dextrose as necessary for hypoglycemia.

RISK FACTORS

ASSESSMENT INTERVENTIONS

Thermal instability

Monitor axillary temperature every 30 min immediatelypostpartum until stable; thereafter every 1-4 hr depending ongestational age and ability to maintain thermal stability.

Provide skin-to-skin care in immediate postpartum period forstable infant.Implement measures to avoid excess heat loss (adjustenvironmental temperature, avoid drafts).Bathe only after thermal stability has been maintained for 1 hr.

LATE-PRETERM INFANT ASSESSMENT AND INTERVENTIONS

RISK FACTORS ASSESSMENT INTERVENTION

Jaundice Observe for jaundice in first 24 hr.Evaluate maternal-fetal history for additional risk factors thatmay cause increased hemolysis and circulating levels ofunconjugated bilirubin (Rh, ABO, spherocytosis, bruising).

Monitor transcutaneous bilirubin and note risk zone onhour-specific nomogram

Feeding problems

Assess suck-swallow and breathing.Assess for respiratory distress, hypoglycemia, thermal stability.Assess latch-on, maternal comfort with feeding method.Determine weight loss (should be ≤10% of birth weight).

Initiate early feedings (human milk or formula).Ensure maternal knowledge of feeding method and signs ofinadequate feeding (sleepiness, lethargy, color changesduring feeding, apnea during feeding, decreased or absenturine output).

LATE-PRETERM INFANT ASSESSMENT AND INTERVENTIONS

RISK FACTORS ASSESSMENT INTERVENTIONS

Neurodevelopmentalproblems

Assess for respiratory distress, neonatal jaundice,hypoglycemia, and thermal instability.Assess neurodevelop-mental status.Assess for seizure activity

Perform newborn screening, including hearing test.Implement individualized developmental care.Encourage parents to keep follow-up appointments withprimary care provider for evaluation of growth anddevelopment (including cognitive function and achievementof appropriate milestones).

RISK FACTORS

ASSESSMENT INTERVENTIONS

Infection Evaluate maternal-fetal history for risk factors that maycontribute to neonatal septicemia.Assess for signs and symptoms of neonatal infection.

Use Standard Precautions, especially hand washing betweeninfants and contact with surfaces that may harbor bacteria(e.g., keyboards, telephones).Maintain thermal stability.Administer hepatitis B vaccine.Encourage breast-feeding and assist mother-baby pair withbreast-feeding.Encourage parents to decrease infant exposure to respiratoryviruses post discharge and obtain vaccines as appropriate toprevent development of respiratory viruses (e.g., influenza).

Classification According to Size• Low-birth-weight (LBW) infant—An infant whose birth weight

is less than2500 g (5.5 lb), regardless of gestational age• Very low–birth-weight (VLBW) infant—An infant whose birth

weight isless than 1500 g (3.3 lb)• Extremely low–birth-weight (ELBW) infant—An infant whose

birthweight is less than 1000 g (2.2 lb)• Appropriate-for-gestational-age (AGA) infant—An infant

whose weightfalls between the 10th and 90th percentiles on intrauterine growth

curves• Small-for-date (SFD) or small-for-gestational-age (SGA)

infant—Aninfant whose rate of intrauterine growth was slowed and whose birthweight falls below the 10th percentile on intrauterine growth curves• Intrauterine growth restriction (IUGR)—Found in infants

whose intrauterinegrowth is retarded (sometimes used as a more descriptive term for the

SGA infant)• Large-for-gestational-age (LGA) infant—An infant whose birth

weightfalls above the 90th percentile on intrauterine growth charts

Evaluating Respiratory Syndrome

MAJOR FACTORS IN RESPIRATORY DISTRESS SYNDROME

CAUSE EFFECT

Increased pulmonary vascularresistance

Alveolar collapse; atelectasis;increased difficulty breathing

Impaired gas exchange Hypoxemia and hypercapnia withrespiratory acidosis

Increased transudation of fluidinto lungs

Hypoperfusion of pulmonary circulation

Hypoperfusion (with hypoxemia)

Tissue hypoxia and metabolic acidosis

Hyaline membrane formation;impaired gas exchange

Increased surface tension of alveoli(surfactant deficiency)

SYMPTOMS.The symptoms usually appear within minutes of birth,

although they may not be seen for several hours. Symptoms may include:

  Bluish color of the skin and mucus membranes

(cyanosis) Brief stop in breathing (apnea)  Decreased urine output Grunting Nasal flaring Rapid breathing Shallow breathing Shortness of breath and grunting sounds while

breathing  Unusual breathing movement -- drawing back of the

chest muscles with breathing

Silver-man Anderson Index

Perform to observe for signs of respiratory distress:

Chest lag Retractions nasal flaring expiratory grunting

Score 10   = Severe respiratory distressScore ≥ 7  = Impending respiratory failureScore 0     = No respiratory distress

BAPTIZING AN INFANT

BAPTIZING AN INFANT

Who can baptize in the absence of priest?

A health care provider who is Catholic In the absence of the health care giver who

is Catholic, anyone may baptize provided he/ she:

1. has the use of reason;2. believes in the sacrament;3. has intention of doing what the Catholic

Church desires &4. uses the proper form

When can a nurse or midwife baptize an infant?

A. Birth of an abortusB. Delivery of an stillbornC. whenever an infant/child is in immediate

danger of deathD. And in all these situations, it should be

that the abortus fetus/ infant is a member of a Catholic family

Preparation for Baptism

A. Verify the religionB. Prepare the necessary utensils:

pitcher of pure waterC. Ask the mother what name she

would like to give her baby, if feasable

After baptism

A. Record the baptism in infant’s chart and in the chaplain’s roster of baptism if there is one in then hospital or health care agency.

B. Inform the parents of the baptism if they were not present during the emergency baptismal rite

SUPPORING THE FAMILY IN GRIEF

FACTORS AFFECTING GRIEF AND GRIEF RESPONSES

A. Personal resources and stressors:1. age and coping skills2. previous experiences3. level of education, socio economic status4. physical and mental health5. individual and family developmental

stage B. Meaning of the loss to the mother/ parents

C. Circumstances of the loss

D. Sociocultural resources and stressors

Normal characteristics of stages of Grief (Davidson)

A. Shock and disbelief: 24hrs- 3 weeks

1. Resistance to stimuli and denial2. Difficulty in making judgments3. Emotional outburst4. Stunned feelings grieving person feels numb, which

is a defense mechanism that allows them to survive emotionally.

B. Searching and Yearning: 3weeks- 4months with occasional recurrence

1. Anger and guilt2. restlessness and impatience3. Testing of reality  grieving person longing or yearning

for the deceased to return. Many emotions are expressed during this time and may include weeping, anger, anxiety, and confusion.

C. Disorientation: Intensify lifts by 7 months

1. Disorganization2. guilt3. awareness of reality and increasing

acceptance of death

desired to withdraw and disengage from others and activities they regularly enjoyed. Feelings of pining and yearning become less intense while periods of apathy, meaning an absence of emotion, and despair increase.

D. Reorganization : 18 months- 24months1. sense of release2. better judgment3. renewed energy and the ability to plan for

the future final phase, the grieving person begins

to return to a new state of “normal”. Weight loss experienced during intense grieving may be regained, energy levels increase, and an interest to return to activities of enjoyment returns. Grief never ends but thoughts of sadness and despair are diminished while positive memories of the deceased take over.

Engel (1954) Phases of Grief

I. Shock and Disbelief • Person refuses to accept the loss• Stunned and numb responses (“Not

me?”, “No”)

II. Developing awareness• Presence of physical and emotional

responses (anger, feeling empty, crying, “Why me?”)

V. Idealization• Exaggeration of the good qualities of the

person or object lost• Followed by the acceptance of the loss

and need to focus on the loss is lessened

VI. Outcome• Dealing with the loss a common life

occurrence

Engel (1954) Phases of Grief

Phases of Death and Dying (Kobler Ross, 1969)

1. Denial & Isolation• Client denies he will die• may repress that is discussed or isolate

self from reality• Nursing Implications

– Support emotional needs without supporting denial

2. Anger• Express anger and retaliates to family

members, staff, physician or supreme being

• Becomes demanding and accusing • Maybe precipitated by guilt which will

lead to anxiety and low self-esteem.

Phases of Death and Dying (Kobler Ross, 1969)

• A positive way to maintain hope• Nursing implications:

– Nurses must provide information regarding the need for decision making.

Phases of Death and Dying (Kobler Ross, 1969)

Phases of Death and Dying (Kobler Ross, 1969)

3. Bargaining• Client is willing to do anything to avoid loss

or change the prognosis.• Bargaining is commonly addressed to the

Supreme Being in an attempt to postpone death

• A positive way to maintain hope

Phases of Death and Dying (Kobler Ross, 1969)

Nursing implications:A. Provide support and empathyB. Allow and encourage the couple to

grieve/show emotions freelyC. Assess risk of harm to self and refer

accordingly.D. Recognize and accept initial griefE. Response of disbelief, shock,

confusionF. - Do not leave the couple alone, stay with them