Chapter7 Nursing Care of High-Risk Newborn and Family

1.CLASSIFICATION OF NEWBORNS AND CHARACTERISTICS OF NORMAL NEWBORNS

Classification of Newborns

Neonatal period is defined as the first four weeks of life after birth,the infants in this period are named as newborns.

（一） Gestational Classification

1． Term newborn:newborn who gives birth from 37 up to 42 completed weeks

2． Preterm newborn:newborn who gives birth from 28 up to 37 completedweeks

3． Post-term newborn:newborn who gives birth during or after 42 completed weeks

（二） Birth Weight Classification

1.Normal birth weight newborn

newborn with birth weight between 2.5kg to 4.0kg

2． Low-birth-weight(LBW) newborn： newborn with birth weight less than 2.5kg

Very low birth weight(VLBW) newborn：newborn with birth weight less than 1.5kg

Extremely low birth weight(ELBW) new: newborn with birth weight less than 1.0kg

3.Giant infant newborn：newborn with birth weight more than 4.0kg,including normal and abnormal newborn

（三） Wejight for Gestational Age

1． Newborn small-for-gestational (SGA) ) :newborn with birth weight

below the 10th percentile on an intrauterine growth curve for that age.

2． Newborn appropriate for gestational age (AGA) : newborn with birth weight between the 10th and 90th percentiles of same gestational age

3.Newborn large for gestational age (LGA) ：newborn with birth weight above the 90th centile of same gestational age 。

新生儿分类 按胎龄分类 按出生体重分类 按胎龄和体重关系分类

三. 根据体重与胎龄关系

小于胎龄儿：SGA，< 第 10 百分位

适于胎龄儿：AGA， 第10－90 百分位

大于胎龄儿：LGA， >第 90 百分位

小 样 儿：足月，体重 < 2500克500750

24 26 28 30 32 34 36 38 40 42 44 46 48 （周）

10001250150017502000

2250

27503000

35003750

2500

40004250450047505000

3250

小于

胎龄

第10百分位

适于胎龄

平均体重

大于

胎龄

第90百分位

（四） High-risk Neonate (high risk infant )

The high-risk neonatecan be defined as a newborn,regardless of gestational age or birth weight,who has a greater-than-average chance of morbidity or mortality because of conditions or circumstances superimposed on the normal course of events associated with birth and the adjustment to extrauterine existence.

Characteristics of Normal Newborns

Chapter7 Nursing Care of High-Risk Newborn and Family

( 第七章 高危新生儿及其家庭的护理 )

1． Appearance

2． Respiratory System3． Circulatory System4． Digestive Syste5． Hemotologic System6． Urinary System7． Nervous System

8． Immunologic System( 免疫系统 )

9． Thermoregulation( 体温调节 )

新生儿体温调节中性温度：又称适中温度，是一种适宜的环境温度，能保持中性温度：又称适中温度，是一种适宜的环境温度，能保持 新生儿正常体温，而耗氧量最少。新生儿正常体温，而耗氧量最少。

不同出生体重早产儿的适中温度—————————————————————————— 出生 暖 箱 温 度出生 暖 箱 温 度 体重体重 —————————————————————— （（ kgkg ） ） 35 34 33 32℃ ℃ ℃ ℃35 34 33 32℃ ℃ ℃ ℃—————————————————————————— 1.0 1.0 初生初生 1010 天内→ 天内→ 1010 天后 → 天后 → 33 周后 → 周后 → 55 周以周以后后

1.5 ———— 1.5 ———— 初生初生 1010 天内 → 天内 → 1010 天后→ 天后→ 44 周以周以后后

2.0 ———— 2.0 ———— 初生初生 22 天内 → 天内 → 22 天后→ 天后→ 33 周以周以后后

＞＞ 2.5 ———— ————— 2.5 ———— ————— 初生初生 22 天内 → 天内 → 22 天以天以后后———————————————————————————

10. Energy Requirement and Fluid and Electrolyte Balance

11. Endocrine System

12.Special Physiological Phenomena

(1)physiologic weight

(2)physiologic jaundice

(3)physiologicbreast enlargement during the first 3~5days,disappear 2~3 weeks

(4)fask menstruation during the first 5~7 days.

NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE

All infants have eight needs that take precedence over all other in first few days of life:

（一 ） Initiating and Maintaining Respirations

Resuscitation comprises three organized steps

(a)    establishing and maintaining an airway

(b)   expanding the lungs

(c)  initiating andmaintaining effective ventilation

( 二 ） Establishing Extra-Uterine Circulation

（三） Control of body temperature

（四） Intake of adequate nourishment

（五） Establishment of waste elimination

（六） Prevention infection

（ 七 ） Establishing of an infant-parent relationshi

（ 八 ） Developmental care that balances rest and stimulation for mental development

3.NURSING CARE OF THE NEWBORNS AT RISK BECAUSE OF ALTERED GESTATIONAL AGE OR BIRTH WEIGHT

Nursing of the Small-for-Gestational-Age Infants

EtiologyClinical Manifestation

1.Prenatal Assessment

2.Appearance

Laboratory Finding

Nursing diagnosis ：1.High risk for altered respiratory

function

2.High risk for ineffective thermoregulation

3． High risk for altered parenting

Related Interventions 1 ． Birth asphyxia is a common

proble for small-for-gestational-age infants,because they are at risk for developing meconium aspiration syndrome due to anoxia labor

2 ． A careful controlled environment is essential to keep the infant’s body temperature in neutral zone

3 ． Promote early parental bonding with the child

Nursing of the Large-for –Gestational-Age Infant

Etiology

Clinical Manifestation1． Prenatal Assessment

2． Appearance

3． Cardiovascular Dysfunction

4． Hypoglycemia

Nursing diagnosis

1. High risk for altered respiratory function

2． High risk for nutrition alteration

3． High risk for altered parenting

Related Interventions

1.Careful assessment of respiration function should be performed,oxygen administration maybe necessary for some LGA infant

2． Prevent hypoglycemia

3 ． A large-for- Gestational-Age infant needs the same developmental care that all other infants need

4.NURSING OF THE PRETERM AND POST-TERM

INFANTS

4.NURSING OF THE PRETERM AND POST-TERM INFANTS

Nursing Care of Preterm infants

Etiology

Clinical Manifestation ：1． Appearance

一、正常足月儿和早产儿的外观特点 早产儿 足月儿

皮肤 发亮、水肿、毳毛多 肤色红润、皮下脂肪丰满、 毳毛少 头发 乱如绒线头 头发分条清楚 耳壳 软，可折叠，耳舟不清楚 软骨发育好，耳舟清楚，直挺 指甲 未达指尖 达到或超过指尖 乳腺 无结节或结节 <4mm 结节 >4mm , 平均 >7mm

跖纹 足底纹理少 足纹遍及整个足底外生殖器 男婴睾丸未降 , 阴囊少皱裂 ; 男婴睾丸已降 , 阴囊多皱裂 ;

女婴大阴唇不发育 , 女婴大阴唇发育 ,

不能遮盖小阴唇 可遮盖小阴唇和阴蒂

2． Respiratory System

3. Fluid and Nutrients Requirement

4． Temperature Regulation

5． Immune System

Potential Complication

1． Anemia of Prematurity

2． Kernicterus

3. Persistent Patent Ductus Arteriosus

4.Periventricular/Intraventricular hemorrhage

5． Other Potential Complications

Nursing diagnosis ：1.High risk for altered respiratory

function

2.High risk forfluid volume deficit

3． High risk for nutrition alteration

4． High risk for hypothermia

5． High risk for infection

6． High risk for altered parenting

Related Interventions

1． Oxygen Therapy at Birth

2． Intravenous Fluid Administration

3． Reasonable Feeding

4 ． The Infant Must Be Kept Under a Radiant Heat Warmer in a Delivery Room

5． Linen and Equipment Used With the Preterm Infant Must Be Clean to Reduce the Chances of Infection

6． Developmental Care

Appendix :Nursing Care of Newborns in Incubator

Nursing of the Post-Term Infants

5.NURSING CARE OF NEWBORNS WITH HYPOXIC-ISCHEMIC ENCEPHALOPATHY

Hypoxic-ischemic encephalopathy(HIE),or hypoxic-ischemic reperfusion injury,is the mostcommon cause of neurologic observed in term and preterm infant, which may result in neonatal death or which may be manifest later as cerebral palsy or mental deficieny.

Etiology： Hypoxia、 Ischemia

Clinical Manifestation ：

Related Interventions

1． Seizure Control2． Supportive Care

 

6.NURSING CARE OF NEWBORNS WITH INTRACRANIAL

HEMORRHAGE

Intracanial hemorrhage of the newborn is the most commom type of brain injury,arising from hypoxia or birth trauma.The incidence is high in preterm infant.The prognosis is not optimized

Etiology: Hypoxia and Ischemia、 BirthTrauma、 Others

Clinical Manifestation ：General Symptoms

（一） Types of Intracranial Hemorrhage

1.Periventricular/Intraventricular Hemorrhage(P/IVH)

2． Subdural Hemorrhage(SDH)

3． Subarachnoid Hemorrhage(SAH)

Therapeutic Management

1 ． The treatment of ICH is aimed at prevention: prevention of prematurity and any events that may lead to ICH is foremost.

2. The maintenance of adequate oxygenation 。

3．Medical treatment

4 ． Control seizure ,calm patients by sedation,and reduce intracranial pressure

Related Interventions

1 ． Nursing care is directed toward prevention of fluctuations in cerebral BP

2 ． Avoiding interventions that cause crying

3.Rapid volume expansion following hypotension and administration of hyperosmolar solution such as NaHCO3 should be avoided

7.NURSING CARE OF NEWBORNS WITH HYALINE MEMBRANE DISEAS

Hyaline membrane disease ， also termed respiratory distress syndrome(RDS) of the newborn,most often occurs in preterm infants,infants of diabetic mothers,infants born by cesarean birth,or those who for any reason have decreased blood perfusion of the lungs.The membrane prevents exchange of oxygen and dioxide at the alveolar-blood interface

Etiology and Pathology ： HMD occurs when there is not enough of a substance in the lungs called surfactant

Clinical Manifestation

Nursing diagnosis ： 1.Failure to maintain spontaneous

respiration

2． Impaired gas exchange

3． High risk of infection

4 ． High risk of altered nutrition,less than body requirement

Management

1.Surfactant Replacement and Rescue

2.Oxygen Administration

3.Ventilation

4.Supportive Care

8.NURSING CARE OF NEWBORNS WITH NEONATAL PNEUMONIA

aspiration and infective pneumonia

Aspiration Pneumonia

Etiology and Pathology

Clinical Manifestation

Infective Pneumonia

Etiology ： Infection in Utero 、 Infection at

Birth、 Infection after Birth

Clinical Manifestation

Therapeutic Management and Nursing Care

1.Clean aspiration as soon as possible,and maintain airway patent

2.General treatment such as oxygen therapy,keeping body warm.

3. Combat any potential infection

4． Respiratory support

9.NURSING CARE OF NEWBORNS WITH GASTROESOPHAGEAL REFLUX

Gastroesophaheal reflux is the spontaneous passage of acidic gastric contents from the stomach into the esophagus

Clinical Manifestation ：vomiting ， growth ， retardation, aspiration pneumonia, and esophagitis

Collaborative Management

1． Positioning

2． Thickening Milk

3． Antiacid Drugs

4． Surgical Intervention

10.NURSING CARE OF NEWBORNS WITH NEONATAL JAUNDICE

Neonatal jaundice is a sign that the neonate’s blood contains an excessive amount of bilirubin and makes skin and eye yellowed

Classification1． Physiologic Jaundice

2． Nonphysiologic Jaundice

Risk Factors for Severe Hyperbilirubinemia

1． Breast-Feeding

2. Low Birth Weigh and Prematurity

3． Ethnicity

4． Hemolytic Conditions

5． Polycythemia

6． Extravasated Blood

7.Sepsis,Hypothyroidism,and Galactosemia

Hemolytic Disease of Newborn

Hemolytic Disease of Newborn ：Hemolytic disease of the newbornoccurs when fetal red cells cross the placenta and make mother to be immunized with the production of IgG which transferred to the fetus and cause hemolysis of fetal red cells.

Clinical Manifestation

1．When the Mother’s Antibodies Attack the Red Blood Cells,They Are Broken Down and Destroyed

2． Kernicterus

Management

1.Treat the Underlying Disorder

2.Avoid Unnecessary Stimulation

3.Ensure Adequate Hydration,Caloric Intake,Stooling

4． Phototherapy

5． Exchange Transfusion

11.NEONATAL SEPSIS

infection is a major cause of fatality during the first month of life.Neonatal sepsis may be categorized as early or late onset

Clinical Manifestation

Treatment and Nursing Strategies1． Antibiotics

2． Diet

3． Others

Complications ：Pneumonia、 bacteremia

12.NURSING CARE OF NEWBORNS WITH NEONATAL COLD INJURE SYNDROME

Neonatal cold injury syndrome results in hypothermia and multiple organs dysfunction because of coldness.Sclerema neonatorum(SN)

Etiology

Clinical Manifestation

新生儿寒冷损伤综合征的病情分度

℃ 体温（ ） 硬肿范围

分度 ————————— 器官功能改变

肛温 腋－肛温差 （％） ≥ 轻 ３５ 负值 ＜２０ 无明显改变

中 ＜３５ ０或正值 ２５～５０ 不吃不哭反应差心率慢

重 ＜３５ 负值 ＞５０ 休克DIC肺出血肾衰

或＜３０

Collaborative Management1.Rewarming the Cold Neonate,and

Assess the Temperature Regular to Determine the Severity of Hypothermia

2.Antibiotics3． Systemic Steroids

4.Establishing Adequate Nutritional Intake

Complications( 并 发 症 ) ：pulomonary hemorrhage( 肺 出血 )、 shock( 休克 )

13.Nursing Care of Newborns with Neonatal Hypoglycemia

Management and Nursing Care

1． Enteral Feeding

2． IV Therapy

3． Other Agents

4． Close Observation