High Risk Newborn

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High Risk Newborn

• Mary L. Dunlap MSN, APRN
• Fall 10

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Preterm Infant

• Infant born prior to the completion of the 37th
  week
• Organs immature
• Lack physical reserves
• Survivability related to weight / gestational age

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Preterm Infant

• Respiratory last to mature
• Surfactant deficiency-RDS
• Unstable chest wall-atelectasis
• Immature respiratory centers-apnea
• Small passages-obstructions
• Unable to clear fluid-TTN

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Preterm Infant

• Cardiovascular
• Difficulty transitioning from fetal to neonatal
  circulatory pattern
• Congenital anomalies due to continued fetal
  circulation
• Fragile blood vessels (brain)
• Impaired regulation of B/P

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Preterm Infant

• Gastrointestinal
• Lack neuromuscular coordination suck-
  swallow-breath
• Hypoxia shunts blood from the gut- ischemia and
  intestinal wall damage
• Risk for malnutrition -wt. loss
• Small stomach-compromised metabolic function

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Preterm Infant

• Renal System
• Slow glomerular filtration rate
• Reduced ability to concentrate urine
• Risk fluid retention, electrolyte imbalance,
  drug toxicity

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Preterm Infant

• Immune system
• Deficiency of IgG
• Impaired ability to produce antibodies
• Thin skin- limited protection barrier

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Preterm Infant

• Central nervous system
• Long term disability due to injury
• Difficulty maintaining temperature
• Compounded by lack of brown fat

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Preterm Infant Nursing Management

• Varies with gestational Promote Oxygenation
• Maintain body temperature
• nutritional needs

• Prevent infections
• Provide stimulation
• Pain management

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Small for Gestational Age

• SGA weight- less than 5lb 8 oz and below the
  10th at term
• IUGR- High risk growth does not meet the norm
  and is pathologic
• Symmetric IUGR- poor growth rate of head, abdomen
  and long bone
• Asymmetry IUGR- head long bones spared

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Small for Gestational Age Characteristics

• Decreased breast tissue
• Scaphoid abdomen (sunken)
• Wide sutures
• Thin umbilical cord

• Head larger than body
• Wasted appearance to extremities
• Reduced fat stores

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Small for Gestational AgeCommon Problems

• Perinatal asphyxia
• Hypothermia
• Hypoglycemia
• Polycythemia
• Meconium Aspiration

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Large for Gestational Age Characteristics

• LGA weight- Larger than 9 lbs and above the 90th
  
• Large body-plump full face
• Body size is proportionate
• Poor motor skills
• Difficulty in regulating behavioral state (arouse
  to quiet alert state)

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Large for Gestational AgeCommon Problems

• Birth Trauma-
• Hypoglycemia
• Polcythemia
• Hyperbilirubinemia

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Post term Infant

• Gestation gt 42 weeks
• Must determine if EDC is truly post term
• After 42 weeks placenta loses ability to nourish
  the fetus

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Post term Infant Characteristics

• Newborn emaciated
• Meconium stained
• Hair and nails long

• Dry peeling skin
• Creases cover soles
• Limited vernix and lanugo

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Infant of Diabetic Mother

• Mother can have pregestational or gestational
  diabetes
• Increasing numbers of type 2
• Related to increase in morbidity mortality
• Congenital abnormalities

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Infant of Diabetic Mother

• Congenital abnormalities- during first trimester
  due to fluctuations in BS and ketoacidosis
• Macrosomia- develops last trimester due to
  maternal hyperglycemia- excessive fetal growth
• Tight control over glucose levels needed ( less
  than 1-0mg/dl)

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Infant of Diabetic MotherCommon Problems

• Congenital Abnormalities
• Macrosomia
• Birth Trauma
• Perinatal Asphyxia

• RDS
• Hypoglycemia
• Hyperbilirubinemia
• Polycythemia

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Infant of Diabetic Mother

• Infant Characteristics
• Rosy cheeks
• Short neck
• Wide shoulders
• Excessive subcutaneous fat
• Distended abdomen

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Infant of Diabetic MotherNursing Management

• Monitor glucose level q. 3 to 4 hrs. level no
  above 40 mg/dl
• Until stable monitor q. 3-4 hrs
• Feed q. 2-3 hrs
• IV glucose
• Monitor serum bilirubin levels
• Maintain thermal environment

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Respiratory Distress Syndrome

• RDS caused by lack of surfactant
• Poor gas exchange ventilation
• Seen in preterm newborns
• Cesarean births without labor
• Infants of diabetic mothers

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Respiratory Distress SyndromeSymptoms

• Tachypnea
• Expiratory grunting
• Nasal flaring
• Retractions
• See-saw respiration
• Chest x-ray- alveolar atelectasis (ground glass
  pattern) dilated bronchioles ( dark streaks
  within granular pattern)

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Respiratory Distress SyndromeNursing Management

• Thermoregulation
• O2 administration
• Mechanical ventilation if needed
• Hold parenteral feedings
• Monitor VS O2 sats
• Provide nutrition ( gavage feedings)

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Transient TachypneaNewborn TTN

• Mild respiratory condition
• Result of delayed absorption of fluid
• Last about 3 days

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Transient TachypneaNewborn TTN

• Symptoms
• Respiratory rate as high as 100-140
• Labored breathing
• Grunting nasal flaring
• Retractions
• Chest x-ray shows lymphatic engorgement (
  retained lung fluid)

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Transient Tachypnea Newborn Nursing Care

• Mainly supportive
• Monitory VS O2 Sats
• Provide supplemental O2

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Meconium Aspiration

• Fetus inhales meconium into the lungs while in
  utero
• Meconium blocks the airway preventing exhalation
• Meconium irritates the airway making breathing
  difficult
• Meconium aspiration related to fetal distress
  during labor.

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Meconium Aspiration Symptoms

• Cyanosis
• Rapid breathing
• Labored breathing
• Apnea
• X-ray patches or streaks of meconium trapped
  air

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Meconium Aspiration Nursing Management

• Assess for risk factors prior to delivery
• Suction at delivery prior to newborn crying
• Supplemental O2
• Mechanical ventilation
• Antibiotic therapy

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Hyperbilirubinemia

• Excess of bilirubin in the blood-elevated
  bilirubin level gt 5mg/dl
• Heme from erythrocytes break down forms
  unconjugated bilirubin
• Jaundice
• Physiologic
• Pathologic

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Hyperbilirubinemia Causes

• Drugs/Medical conditions disrupt conjugation and
  albumin binding sites
• Decreased hepatic function
• Increased erythrocyte production
• Enzymes in breast milk

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Hyperbilirubinemia Physiologic

• Develops in 3-4 days after term birth
• Develops3-5 days after preterm birth
• Term birth resolves 7 days
• Preterm birth resolves 9-10 days
• Unconjugated bilirubin level lt 12mg/100 ml

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Hyperbilirubinemia Pathologic

• Develop after first day
• Persists beyond 7 days
• Bilirubin gt 12.9mg/100 term
• Bilirubin gt 15mg/100 preterm
• Increases gt 5mg/100ml in 24hrs

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Hyperbilirubinemia Nursing Management

• Phototherapy
• Increase feeding to q 2-3 hrs

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Phenylketonuria PKU

• Inability to metabolize phenylalanine- amino acid
  found in protein
• Affect brain and CNS development
• Interferes with the production of melanin,
  epinephrine thyroxine
• Both parents must pass the gene on

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Phenylketonuria PKU Symptoms

• Seizures
• Irritability
• Tremors
• Jerking movements arms legs
• Hyperactivity
• Unusual hand posturing

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Phenylketonuria PKU

• Diagnosed with PKU screening prior to discharge
  from hospital

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Hemolytic Disorders

• Hemolytic disease occurs when blood groups of
  mother and newborn are different
• Antibodies are present or formed in response to
  antigen from fetal blood crossing placenta and
  entering maternal circulation

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Hemolytic Disorders

• Maternal antibodies of IgG class cross placenta,
  causing hemolysis of fetal RBCs
• Fetal anemia
• Neonatal jaundice
• Hyperbilirubinemia

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Hemolytic Disorders

• Rh incompatibility (isoimmunization)
• Only Rh-positive offspring of Rh-negative mother
  is at risk
• If fetus is Rh positive and mother Rh negative,
  mother forms antibodies against fetal blood cells

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Hemolytic Disorders

• ABO incompatibility
• Occurs if fetal blood type is A, B, or AB, and
  maternal type is O
• Incompatibility arises because naturally
  occurring anti-A and anti-B antibodies are
  transferred across placenta to fetus
• Exchange transfusions required occasionally

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Neonatal Infections

• Sepsis
• Bacterial, viral, fungal
• Patterns
• Early onset or congenital
• Nosocomial infectionlate onset

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Neonatal Infection

• Septicemia
• Pneumonia
• Bacterial meningitis
• Gastroenteritis is sporadic

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Neonatal Infections

• TORCH infections
• Toxoplasmosis
• Gonorrhea
• Syphilis
• Varicella-zoster
• Hepatitis B virus (HBV)
• Human immunodeficiency virus (HIV) and acquired
  immunodeficiency syndrome (AIDS)