HIGH RISK NEONATESPresented by Ann Hearn RNC, MSN

CLASSIFICATION OF HIGH RISK NEWBORNS

Gestational Age

Preterm (Late Preterm) Term Postterm

Gestational Age & Birth Weight

SGA AGA LGA

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Respiratory and Cardiac Thermoregulation Digestive Renal

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Respiratory and Cardiac

Lack of surfactant Pulmonary blood vessels Ductus arteriosus

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Respiratory - Nursing Interventions Maintain airway Administer O2 Monitor O2 saturation Monitor heart/respiratory rates

S/S respiratory distress Cyanosis Tachicardia Retractions Expiratory grunting Nasal flaring Apnic episodes

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Thermoregulation

Increased body surface Decreased brown fat Thin Skin Lack of flexion Decrease sub-q fat

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Thermal Neutrality – Nursing Interventions Incubator or radian warmer Warm surfaces Warm humidified oxygen Warm ambient humidity Warm feedings Keep skin dry and head covered

ISOLETTE/ RADIANT or INCUBATOR OPEN WARMER

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Digestive

Poor gag reflex Small stomach capacity Relaxed cardiac sphincter Poor suck and swallow reflex Difficult fat, protein and lactose digestion Absorption

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Nutrition and Hydration – Nursing Interventions Daily weights Monitor I&O Accurate IV rates Accurate OGT feedings Monitor urine pH and specific gravity

Signs of dehydration Weight loss Poor skin turgor Dry oral mucus membranes Decreased urinary output Increased specific gravity

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Pre-feeding assessment Measure abdominal girth Bowel sounds Gastric residual Sucking and gag reflexes

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Renal Decreased glomerular filtration rate Inability to concentrate urine or excrete excess Decreased ability of kidneys to buffer Decreased drug excretion time

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Prevention of Infection – Nursing Interventions Initial scrub / strict hand washing

Visitors & staff Reverse isolation Single infant equipment Short / no artificial nails Maintain sterile technique

IV start and dressing changes Procedures

Clean incubators weekly Position changes; use of sheepskin Judicious use of tape on skin

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Signs and Symptoms of Infection Behavioral changes Physiological changes

Tonus Color Temperature Skin Feeding Hyperbilirubinemia Heart rate Respiratory rate

PHYSIOLOGIC CHALLENGES OF THE PREMATURE INFANT

Facilitating Parent-Infant Attachment Prepare parents for first visit Establish safe/trusting environment Encourage visitation Involved in care taking Repeat explanations Promote touching, talking, rocking, cuddling Refer to infant by name Allow parents to phone as desired

DISORDERS OF INFANTS IN NICU

SGA and IUGR Infants of Diabetic Mothers Postmature Infant Infants of Addicted Mothers Respiratory Distress Syndrome Meconium Aspiration Syndrome Hyperbilirubinemia Retinopathy of Prematurity Necrotizing Entercolitis Infectious Diseases - TORCH

ASSOCIATED COMPLICATIONS OF:

Asphyxia Aspiration syndrome Hypothermia Hypoglycemia Polycythemia

Congenital malformations

Intrauterine infections Continued growth

difficulties Cognitive difficulties

SGA IUGR

Nursing Interventions: Monitor heart rate, respiratory rate, temperature and blood glucose.

INFANTS OF DIABETIC MOTHERS

INFANTS OF DIABETIC MOTHERS

Clinical manifestations IDM Ruddy color Macrosomia Excessive adipose tissue Hypoglycemia

Increase risk of birth injuries.

INFANTS OF DIABETIC MOTHERS

Why Hypoglycemia? High levels of glucose cross the placenta In response, fetus produces high levels of insulin High levels of insulin production continues after

cord cut Depletes the infant’s blood glucose

INFANTS OF DIABETIC MOTHERS

Nursing Interventions for Hypoglycemia Assess for signs/symptoms

Tremors Cyanosis Apnea Temperature instability Poor feeding Hypertonia / Lethargy

Assess blood glucose Intervene if < 40mg/dl:

Feed infant If no improvement:

IV of D10W

POST MATURE INFANT

Post term: infant born after __?__ wks Physical manifestations:

Dry, cracking, parchment-like skin Loose appearing skin

No vernix or lanugo Long fingernails Profuse scalp hair Long, thin body appearance

POST MATURE INFANT

Complications of post term: Hypoglycemia Meconium aspiration Congenital anomalies Seizure activity Cold stress

Nursing considerations Monitor blood sugars per protocol Evaluate respiratory status Assess for seizure activity Treat cold stress.

INFANTS OF ADDICTED MOTHERS Clinical Manifestations of Infant Withdrawal:

IRRITABILITY Hyperactivity Shrill cry Exaggerated reflexes Facial scratches Short non-quiet sleep

Sneezing, coughing, yawning Poor feeding

Disorganized vigorous suck Vomiting Diarrhea

Tachypnea Sweating Excoriated skin

INFANTS OF ADDICTED MOTHERS

Nursing Interventions for Infant Withdrawal: Swaddle with hands near mouth Offer pacifier Place in quiet dimly lit area of the nursery Protect skin from excoriation Monitor V/S Provide small frequent feedings Position with HOB elevated Weigh every 8 hours (if vomiting & diarrhea) Assess with Finnegan Abstinence Scale Administer morphine, phenobarbitol, methadone

FETAL ALCOHOL SYNDROME - FAS

FETAL ALCOHOL SYNDROME - FAS

Clinical Manifestations: Jitteriness Abdominal distention Exaggerated rooting and sucking reflexes

Affected body systems: CNS

GI system

Long-term psychosocial implications: Feeding difficulties Mental retardation

RESPIRATORY DISTRESS SYNDROME - RDS Pathophysiology

Primary absence, deficiency or alteration in the production of surfactant

Surfactant, atelectasis = lack of gas exchange

Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction.

Clinical manifestations: Cyanosis Tachypnea Nasal flaring Retracting Apnea

RESPIRATORY DISTRESS SYNDROME - RDS

Nursing Care Plan Page 826-828

MECONIUM ASPIRATION SYNDROME

Meconium stained amniotic fluid Aspirated into the trachobronchial tree Occurs either in utero or after birth with the first

breaths.

Meconium in the lungs causes air to become trapped and results in alveoli over-distension and rupture.

MECONIUM ASPIRATION SYNDROME Measures for Prevention of Meconium Aspiration

After delivery of the infant’s head but before shoulders Suction oropharynx and nasopharynx (no longer recommended)

If THICK meconium, after delivery of the infant’s body

Crying Not crying

- Stimulate - Do not stimulate- Suction with - Visualize the vocal cords and bulb syringe provide direct suction with

endotracheal tube, then stimulate. If THIN meconium, no visualization performed.

MECONIUM ASPIRATION SYNDROME

Intubation Suction

MECONIUM ASPIRATION SYNDROME

Nursing Interventions: Maintain adequate oxygenation and ventilation Regulate temperature Accurate IV fluid administration Assess for hypoglycemia Administer antibiotics Provide caloric requirements Provide support care if on ECMO

HYPERBILIRUBINEMIA

Pathophysiology Bilirubin is released in serum when RBC lyse Conjugation in liver = water soluble & excretable Rate & amount of conjugation dependent upon:

Rate of hemolysis Bilirubin load Maturity of liver Presence of albumin-binding sites

Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin released into the serum.

Results in jaundice where the unconjucated bilirubin is deposited in the tissue.

HYPERBILIRUBINEMIA

Hemolytic Disease (Pathologic Hyperbilirubinemia) Results from incompatibility between mother’s

blood type or Rh factor and that of the fetus Maternal antibodies develop from + fetal antigen Antibodies cross placental into fetal circulation Antibodies attach to and destroy fetal RBCs. Fetal RBCs lyse & release bilirubin into fetal

circulation

HYPERBILIRUBINEMIA

Additional assessments: Maternal, paternal, and fetal blood type and Rh

factor

Newborn Skin color, sclera, oral mucosa Hypotonia, diminished reflexes, lethary and seizures

HYPERBILIRUBINEMIA

Positive Coombs Test Direct coombs test reveals antibody-coated Rh

positive RBCs in the newborn

Nursing Interventions for Phototherapy Exposure of skin Cover eyes (remove for feeding/parent visit) Monitor temperature Increase fluids Assess for dehydration Perform T-Bili q 12 – 24 hr as ordered

HYPERBILIRUBINEMIA

Exchange Transfusion Treat anemia Remove sensitized RBCs that will soon lyse Remove serum bilirubin Provides albumin to increase bilirubin binding

sites

HYPERBILIRUBINEMIA

Rhogam Provides temporary passive immunity which

prevents permanent active immunity (antibody formation)

Given within 72 hours of delivery Prevents production of maternal antibodies

HYPERBILIRUBINEMIA

ABO incompatibility Occurs when type O pregnant woman with A, B

or AB blood type fetus If woman has anti A or anti B antibodies, these

antibodies cross the placental barrier Results in hemolysis of fetal RBCs

HYPERBILIRUBINEMIA

Complications of Hemolytic Disease Kernicterus – Deposits of conjugated and

unconjugated bilirubin in the basal ganglia of the brain Neurologic damage

Hydrops fetalis – severe anemia Marked edema Cardiac decompensation Multiple organ failure Possible death

HYPERBILIRUBINEMIA

RETINOPATHY OF PREMATURITY

Formation of immature blood vessels in the retina constrict and become necrotic

Most common in infants < 28 weeks gestation

Also associated with O2 therapy

RETINOPATHY OF PREMATURITY

Nursing Interventions to Prevent ROP Administer O2 in concentration ordered Ensure proper ventilatory settings

NECROTIZING ENTEROCOLITIS

NEC - Inflammatory disease of the intestinal tract caused by ischemia, infection, and/or prematurity of the gut. Preterm infant at increased risk

undeveloped protective intestinal mucin layer slow careful introduction to oral feedings

Early detection: Measure abdominal girth daily Assess color of abdomen Assess residual feeding Assess bowel sounds Assess S/S sepsis

INFECTIOUS DISEASES: TORCH

Toxoplasmosis Other

Syphillis Hepititis B

Rubella Cytomegalovirus Herpes Simplex II HIV

TOXOPLASMOSIS

Protozoan infection in the pregnant woman Raw or under cooked meats Cat feces

Affects on the fetus Blindness Deafness Convulsions Microcephaly Hydrocephaly Severe mental impairment

OTHER

Syphilis

Hepatitis B

OTHER

Syphillis S/S of Newborn:

Rhinitis Excoriated upper lip Red rash around mouth and anus Copper colored rash of face, palms and soles Irritability Edema Cataracts.

Treatment: Culture orifices Isolation Penicillin

OTHER

Hepatitis B Transmission

Placental Birth Breast milk

Treatment If mother + HbSAG administer to newborn

Hepitisis B vaccine HBIG

RUBELLA

S/S of Newborn Congenital cataracts Deafness Congenital heart defects Sometimes fatal

MMR Immunization of mother Give when not pregnant

CYTOMEGALOVIRUS

Herpatic virus Crosses placental barrier Direct contact at birth

S/S of Newborn Severe neurological problems Eye abnormalities Hearing loss Microcephaly Hydrocephaly Cerebral palsy Mental delays

HERPES SIMPLEX II

Transmission: Direct contact at birth

S/S of Newborn Microcephaly Mental delays Seizures Retinal dysplasia Apnea Coma

HIV/AIDS

Transmission: < 2% Transplacentally Exposure at birth Breast milk

Nursing Interventions Protect self from body fluids Labs - + antibody titer Administer AZT Provide care like that of any other newborn