High Risk Newborn

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At risk newborn:

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One who is susceptible to illness or even death because of dysmaturity, immaturity, physical disorders or complications during or after birth.

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Factors that affect fetal growth:

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Environmental, maternal, placental, fetal conditions

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Pre term means:

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Born before completion of 37 weeks gestation, regardless of birth weight

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Term means:

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Born b/t the beginning of week 38 and the end of week 42, regardless of birth weight

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Post-term means:

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Born after completion of week 42 of gestation, regardless of birth weight

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Post mature means:

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Born after 42 weeks of gestation and showing the effects of progressive placental insufficiency, regardless of birth weight

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SGA Small for gestational age:

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Weight is below the 10th percentile

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LGA large for gestational age:

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weight is above the 90th percentile for age

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IUGR Dysmaturity:

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Rate of growth does not meet expectation

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Appropriate for gestational age: AGA

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weight is between the 10th and 90th percentile of age

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Immaturity:

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Not fully developed

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Low birth weight LBW:

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less than 2500 grams

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Moderately low birth weight MLBW:

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1501-2500 grams

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Very low birth weight VLBW:

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less than 1500 grams

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Respiratory distress syndrome assessment:

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Grunting, nasal flaring, retractions, crackles, pallor,tachypnea.

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Respiratory distress syndrome etiology:

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lack of surfactant, infection and cold stress

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Respiratory distress syndrome treatment:

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Usually self limited until cells produce surfactant and lungs develop. Supportive care: (vent, cpap) surfactant, oxygen

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Chronic lung disease: Bronchopulmonary dysplasia:

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Interstitial edema and thickening of bronchial walls. Can last for years, until teenage years.

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Chronic lung disease assessment:

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Tachypnea, grunting, retractions, nasal flaring, crackles, wheeze, decreased breath sounds.

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Chronic lung disease treatment:

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Supportive care, diuretics, O2 to keep O2 sats >93, bronchodilators, corticosteroids

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Chronic lung disease prevention:

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Corticosteroids, reduce prematurity, use O2 sparingly to keep O2 sat >93%. Bethamethasone given to mom, helps develop baby's lungs

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Meconium aspiration syndrome:

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Etiology: fetal stress. Assessment: Amniotic fluid color and consistency. Treatment: Suction airway on perineum. If not vigorous at birth, intubate, visualize cords and suction. Can lead to pneumonia

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Retinopathy of prematurity: ROP

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Injury to retinal vessels before they are fully developed, for example from oxygen therapy. Exam by opthalmologist, prevention of prematurity is key. Use O2 judiciously, developmental care. Laser surgery, vitamin E.

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Necrotizing enterocolitis (NEC):

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Etiology: Acute inflammatory disease of GI mucosa possibly causes by intestinal ischemia, bacteria and formula feeding.

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Nec assessment:

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Abdominal distention, vomiting, increased residual aspirates, bloody stools, erythema of abdominal wall

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NEC treatment:

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Bowel rest, antibiotics, drains, surgery. Early recognition is key: watch abdomen, do girths, auscultate, aspirate for residuals.

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Intraventricular hemorrhage: IVH:

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Bleeding into ventricle of the brain.

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IVH etiology:

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Increased cerebral pressure, acidosis, hypoxia, coagulopathy, rapid volume expansion.

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IVH prevention:

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Slightly elevate head of bed, no rapid infusion of fluids, neutral thermal environment.Monitor BP, head circumference

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Thermoregulation:

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Factors influencing temp instability, less SQ fat, Limited brown fat, less control of skin capillaries, poor tone, immature regulating center in brain, increased insensible losses, decreased caloric intake and higher BMI, nonshivering thermogenesis, Norepinephrine stimulates brown fat metabolism and pulmonary vasoconstriction. Increased O2 consumption and decrease in O2 supply, less oxygen available for glucose metabolism leading to anaerobic metabolism, lactic acidosis, brown fat increases non-esterified free fatty acids and they compete with albumin binding site risk for hyperbilirubinemia

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Maintaining adequate thermoregulation:

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Monitor temp, conduction, convection, radiation, evaporation, incubator, over the bed warmer, kangaroo care

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Nutritional concerns of thermoregulation:

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Sucking and swallowing not coordinated, enteral feeds-peg tube, gavage, TPN, provide non nutritive sucking, breast milk/formula/fortifiers, Strict I&O, Weight

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Developmental care:

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Recreating womb, decrease sensory stimuli infant stimulation.

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Cluster care:

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group activities and avoid unnecessary handling, containment, kangaroo care, parent support, education, and involvement

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Parental tasks:

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Anticipatory grief, acknowledgement of failure to deliver a full term infant, loss of expected baby, resumption of process of relating to infant, understanding needs of high risk infant

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SGA and IUGR: Less than 10%

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Growth patterns, symmetric, asymmetric

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SGA and IUGR associated problems:

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Perinatal asphyxia (poor oxygenation or perfusion through placenta), meconium aspiration, hypothermia, hypoglycemia, hypocalcemia, polycythemia, learning problems

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LGA >90%

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Most common condition associated with LGA is maternal distress. Sugar passes through placenta. Insulin doesnt. Baby produces insulin. Then sugar turns to fat.

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Complications of LGA:

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Birth trauma, increase incidence of cesarean, vacuum or forceps delivery, increase use of oxytocin, hypoglycemia

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Infant of a diabetic mother:

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Fetal pancreas produces large amounts of insulin in response to excess glucose from mom. Fetal insulin causes high rate of fetal growth with large deposits of adipose tissue, at risk for hypoglycemia and respiratory distress, assess for signs of hypoglycemia

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Nursing care of infant of a diabetic mother:

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Monitor infant glucose levels, assist early breastfeeding or formula frequently, provide neural thermal environment to prevent cold stress --> hypoglycemia

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Post mature infant:

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Any infant that is born after 42 completed weeks gestation, higher mortality rate, increase chance of passing meconium in utero, Hypoglycemia, placenta gets old and doesn't provide nutrients to baby. Baby's skin will be wrinkled

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S/S of hypoglycemia:

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Tremors, jitterness, seizure, abnormal cry (high pitched or weak), apnea, irregular respirations and cyanosis, lethargy, hypotonia, refusal to feed

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Special concerns of full term infant:

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Transient tachypnea of the newborn, pathologic jaundice, infant of a diabetic mother, abstinence syndrome, sepsis neonatorum

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Transient Tachypnea of the newborn:

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Develop rapid respirations soon after birth, cause is unknown, thought to be delay in absorption of fluid, S/S similar to RDS, respirations as high as 150 breaths per minute, resolves within 24 hours. Assess respiratory status, Intervention: respiratory support

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Pathologic jaundic:

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Yellowing of the skin due to bilirubin in blood (lysis of RBC), If it appears withint first 24 hr of birth, suspect blood antigen (ABO incompatibility), goal is to prevent kernicterus, Assessment: skin color, feeding, alertness. Treatment: bililights, IV fluids, frequent breastfeeding, exchange transfusion

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Physiologic jaundice:

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Destruction of Hgb. Unconjugated bilirubin from hgb travels in blood stream to be conjugated in the liver.

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Immature liver function:

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Function is to conjugate bilirubin, excreted in bile.

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Key points of hyperbilirubinemia:

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80% of newborns experience physiologic jaundice by day three, onset 2-3 days and peaks at 4-6 days, direct bili is conjugated, indirect bili is unconjugated, total bili is a combo (newborn bili)

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Nursing goal of hyperbilirubinemia:

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Prevent kernicterous

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Management of jaundice:

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Monitor labs, total and direct bilirubin, TcB, blood glucose, CBC, thermoregulation, frequent feeds, phototherapy, iv fluids, exchange transfusion

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Abstinence syndrome:

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Low birthweight, can go through withdrawal, hyperactivity, irritability, high pitched cry, hypertonicity, convulsions, vomiting, poor feeding, diarrhea,

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Nursing care of infant going thru withdrawal:

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Need to decrease sensory stimuli, kangaroo care, cluster care, containment, frequent small feeds, good skin care, medicate to withdraw slowly

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Sepsis neonatorum:

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systemic infection with bacteria in bloodstream

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Sepsis neonatorum diagnosis:

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Cbc with diff, cx of blood, csf, urine, trachea, gastric aspirate, crp is increased, cxr, blood glucose not in normal range

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Sepsis neonatorum s/s:

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S/s are subtle- temp instability, resp problems, changes in feeding habits

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Sepsis neonatorum treatment:

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Identify those at risk, prevent spread of infection, support parents, monitor, look for subtle changes, abx, antiviral agents, Iv fluids, oxygen