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NURSING MANAGEMENT OF THENEWBORN AT RISK:Utilizing the Nursing Process andCritical Thinking
Lecture Objectives:
1. Describe risk factors associated with thebirth and transition of an infant of adiabetic mother.
2. Discuss maternal substance abuse andthe newborn.
3. Identify the principles of high risk infantcare in meeting the special needs of thepreterm newborn.
4. Discuss gestational problems in theneonate.
5. Discuss infection and the newborn.
Lecture Objectives: (cont.)Discuss hemolytic disorder in the newborn.Develop a plan of care to meet the needs ofparent’s of high risk infants.Discuss the treatment and complications ofrespiratory distress syndrome.Describe nursing interventions for nutritionalcare of the preterm infant.Discuss thermoregulation and it’s role in thecare of the preterm infant.
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Reading Assignment:
Wong, Perry, & Hockenberry (2006).Maternal Child Nursing Care.
Chapter 27-28, pp 795-869
Infants with GestationalAge–Related Problems
High Risk NewbornInfants who are born considerably beforeterm and survive are particularly susceptibleto development of sequelae related topreterm birth
Necrotizing enterocolitisBPDIntraventricular and periventricularhemorrhageRetinopathy of prematurity
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High Risk NewbornHigh risk infant classification
Birth weightGestational agePredominant pathophysiologic problems
Preterm Infants
Organ systems are immature and lackadequate physiologic reserves to functionin extrauterine environmentPotential problems and needs of preterminfant weighing 2000 g differ from those ofterm, postterm, or postmature infant ofequal weightPhysiologic disorders and anomaliesaffect infant’s response to treatment
Preterm Infants
Closer infants are to term, the easier theiradjustment to external environmentVarying opinions exist about practical andethical dimensions of resuscitation ofextremely low-birth-weight infants
Birth weight is 1000 g or less
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Care ManagementAssessment
Respiratory functionCardiovascular functionMaintaining body temperatureCentral nervous system functionMaintaining adequate nutritionMaintaining renal functionMaintaining hematologic status
Care Management
Assessment (cont’d)Protection from infectionSkin care
Growth and development potentialParental adaptation to preterm infant
Parental tasksParental responsesParenting disorders
Care ManagementPlan of care and implementation
Physical careMaintaining body temperature
Warming the hypothermic infantWeaning infant from incubator
Oxygen therapyOxygen hoodNasal cannulaContinuous positive airway pressure (CPAP)
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Care Management
Plan of care and implementationOxygen therapy (cont’d)
Mechanical ventilationSurfactant administrationExtracorporeal membrane oxygenation therapy(ECMO)High-frequency ventilationNitric oxide therapy
Care Management
Plan of care and implementation (cont’d)Weaning from respiratory assistanceNutritional care
Types of nourishmentWeight and fluid loss or gain
HydrationInsensible water loss (IWL)
Elimination patternsOral feeding
Care Management
Plan of care and implementationNutritional care (cont’d)
Gavage feedingGastronomy feedingAdvancing infant feedingsNonnutritive sucking
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Care ManagementPlan of care and implementation(cont’d)
Environmental concernsDevelopmental care
PositioningReducing inappropriate stimuliInfant communicationInfant stimulationKangaroo care
Care ManagementPlan of care and implementation(cont’d)
Parental supportParent education
Cardiopulmonary resuscitation
Complications of Prematurity
Respiratory distress syndrome (RDS)Patent ductus arteriosus (PDA)Periventricular-intraventicularhemorrhageNecrotizing enterocolitisComplications of oxygen therapy
Retinopathy of prematurity (ROP)Bronchopulmonary dysplasia (BPD)
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The Postmature Infant
Meconium aspiration syndrome (MAS)Persistent pulmonary hypertension of thenewborn (PPHN)
Other Problems Related toGestation
Small for gestational age (SGA) andintrauterine growth restriction (IUGR)
Perinatal asphyxiaHypoglycemiaHeat loss
Other Problems Related toGestation
Large for gestational age(LGA)(weighing more than 4000 g atbirth)
Birth trauma serious hazardWith breech or shoulderpresentationAsphyxia or CNS injuryOversized infant at risk due to size
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Other Problems Related toGestation
Infants of diabetic mothersPathophysiologyCongenital anomaliesMacrosomiaBirth trauma and perinatalasphyxiaRespiratory distress syndomeHypoglycemiaHypocalcemia andhypomagnesemia
Other Problems Related toGestation
Infants of diabetic mothers (cont’d)CardiomyopathyHyperbilirubinemia and polycythemiaNursing care
Discharge Planning
Home care needs of infant’s parentsare assessedInformation provided about infant careReferrals for appropriate resourcesReferrals for home health assistanceTransport to regional center
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Key PointsPreterm infants at risk for problemsrelated to the immaturity of their organsystemsRespiratory distress syndrome,retinopathy of prematurity, andchronic lung disease(bronchopulmonary dysplasia) areassociated with prematurityHigh risk infants must be observed forrespiratory distress and other earlysigns of physiologic distress
Key PointsMetabolic abnormalities of diabetesmellitus adversely affect embryonicand fetal developmentAdaptation of parents to preterm orhigh risk infants differs from that ofparents of full-term infantsParents need special instruction (e.g.,CPR, oxygen therapy, suctioning,developmental care) before they takea high risk infant home
Key Points
Infants born to diabetic mothers are atrisk for hypoglycemia and RDSSGA infants are considered to be at riskbecause of fetal growth restrictionNonreassuring fetal status amongpostmature infants is related toprogressive placental insufficiency thatcan occur in postterm pregnancy
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Key Points
Specially trained nurses may transporthigh risk infants to and from special careunits
The Newborn at Risk:Acquired and Congenital
Problems
Acquired and CongenitalProblems
Conditions or circumstancessuperimposed on normal course ofevents associated with birth andadjustment to extrauterine existenceBirth trauma includes physical injuriessustained during labor and birthCongenital anomalies: gastrointestinal(GI) malformations, neural tubedefects, abdominal wall defects, andcardiac defects
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Birth Trauma
Injury sustained during labor and birthBirth injuries may be avoidable
Careful assessment of risk factors andappropriate planning of birth
Ultrasonography allows antepartum diagnosis ofmacrosomia, hydrocephalus, and unusualpresentationsElective cesarean birth chosen for somepregnancies to prevent significant birth injury
Birth Trauma
Small percentage of significant birthinjuries are unavoidable despite skilledand competent obstetric care
Especially with difficult or prolonged laborWhen the infant is in an abnormalpresentation
Some injuries cannot be anticipated untilthe circumstances are encounteredduring childbirth
Birth TraumaCare management
Skeletal injuriesPeripheral nervous systeminjuries
Brachial paralysisFacial paralysisPhrenic nerve injury
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Birth TraumaCare management (cont’d)
Central nervous system injuriesIntracranial hemorrhage (ICH)Subdural hematomaSubarachnoid hemorrhageSpinal cord injuries
Neonatal InfectionsSepsis
Bacterial, viral, fungalPatterns
Early onset or congenitalNosocomial infection—lateonset
SepticemiaPneumoniaBacterial meningitisGastroenteritis is sporadic
Neonatal Infections
AssessmentPlan of care/implementationCare management
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Neonatal InfectionsTORCH infections
ToxoplasmosisGonorrheaSyphilisVaricella-zosterHepatitis B virus (HBV)Human immunodeficiency virus (HIV) andacquired immunodeficiency syndrome(AIDS)
Neonatal InfectionsTORCH infections (cont’d)
Rubella infectionCytomegalovirus infection(CMV)Herpes simplex virus (HSV)
Parvovirus B19
Neonatal InfectionsBacterial infections
Group BstreptococcusEscherichia coliTuberculosisChlamydia
Fungal infectionsCandidiasis
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Substance AbuseAlcohol
Fetal alcohol syndrome
TobaccoMarijuanaCocainePhencyclidine (PCP, or “angeldust”)HeroinMethadone
Substance Abuse
Miscellaneous substancesMethamphetaminesPhenobarbitalCaffeine
Critical Periods in Human Embryogenesis
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Hemolytic DisordersHemolytic disease occurs when bloodgroups of mother and newborn aredifferent
Most commonRh incompatibilityABO incompatibility
Occur when maternal antibodies arepresent naturally, or form in response toantigen from fetal blood crossing placentaand entering maternal circulation
Hemolytic Disorders
Maternal antibodies of IgG class crossplacenta, causing hemolysis of fetalRBCs
Fetal anemiaNeonatal jaundiceHyperbilirubinemia
Hemolytic Disorders
Rh incompatibility (isoimmunization)Only Rh-positive offspring of Rh-negative mother is at riskIf fetus is Rh positive and mother Rhnegative, mother forms antibodiesagainst fetal blood cells
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Hemolytic Disorders
ABO incompatibilityOccurs if fetal blood type is A, B, orAB, and maternal type is OIncompatibility arises becausenaturally occurring anti-A and anti-Bantibodies are transferred acrossplacenta to fetusExchange transfusions requiredoccasionally
Hemolytic DisordersOther hemolytic disorders
Glucose-6-phosphate dehydrogenasedeficiency (G-6-PD)Other metabolic and inherited conditionsthat increase hemolysis and may causejaundice in infant
GalactosemiaCrigler-Najjar diseaseHypothyroidism
Congenital Anomalies
Most common major congenitalanomalies that cause serious problemsin neonate are:
Congenital heart diseaseNeural tube defectsCleft lip or palateClubfootDevelopmental dysplasia of the hip
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Congenital Anomalies
Central nervous systemanomalies
Encephalocele andanencephalySpina bifidaHydrocephalusMicrocephaly
Congenital Anomalies
Cardiovascular system anomaliesCongenital heart defects (CHDs)
Anatomic abnormalities in the heartPresent at birth, although notdiagnosed immediately
Congenital Anomalies
Respiratory systemanomalies
Choanal atresia andlaryngeal webCongenital diaphragmatichernia
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Congenital Anomalies
Gastrointestinal system anomaliesCleft lip and palateEsophageal atresia andtracheoesophageal fistulaOmphalocele and gastroschisisGastrointestinal obstructionImperforate anus
Congenital Anomalies
Musculoskeletal systemanomalies
Developmental dysplasia of thehip
Acetabular dysplasia orpreluxationSubluxationDislocation
Congenital Anomalies
Musculoskeletal system anomalies(cont’d)
ClubfootTalipes varus—inversion or bending inwardTalipes valgus—eversion or bending outwardTalipes equinus—plantar flexion in which toes arelower than heelTalipes calcaneus—dorsiflexion in which toes arehigher than heel
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Congenital Anomalies
Musculoskeletal systemanomalies (cont’d)
PolydactylyHands or feet with extradigitsHereditary
Congenital Anomalies
Genitourinary systemanomalies
Hypospadias and epispadiasExstrophy of the bladderAmbiguous genitaliaTeratoma
Care ManagementGenetic diagnosisNewbornscreening
PhenylketonuriaGalactosemiaHypothyroidism
Cytologic studiesDermatoglyphics
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Key PointsIdentification of maternal and fetal riskfactors in antepartum and intrapartumperiods is vital for planning adequate careof high risk infantsSmall percentage of significant birthinjuries may occur despite skilled andcompetent obstetric careMetabolic abnormalities of diabetesmellitus in pregnancy adversely affectembryonic and fetal development
Key Points
Infection in newborn may be acquired:In uteroAt birthIn breast milkWithin nursery
Most common maternal infectionsassociated with congenital malformationsrepresented by acronym TORCH
Key PointsHIV transmission from mother to infantoccurs:
Transplacentally at various gestational agesPerinatally by maternal blood and secretionsBy breast milk
Preterm infants are at risk for problemsrelated to the immaturity of organ systemsHyperbilirubinemia has variety of etiologicfactors, including maternal-fetal Rh andABO incompatibility
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Key PointsInjection of Rho(D) immune globulin inRh-negative and Coombs’test–negative women minimizespossibility of isoimmunizationNurse often observes signs ofnewborn drug withdrawal andneonatal abstinence syndrome, andobtains information from maternalhistoryMajor congenital defects are now theleading cause of death in termneonates
Key Points
Curative and rehabilitative problems of achild with a congenital disorder are oftencomplex, requiring multidisciplinaryapproach to care
Key PointsParents often need specialinstructions before they take home ahigh risk infant
Cardiopulmonary resuscitation (CPR)Oxygen therapyNutrition requirements
Supportive care given to parents ofinfants with an abnormal conditionmust begin at birth or at time ofdiagnosis and continue for years