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The High Risk NewbornThe High Risk Newborn
Susceptible to illness or death due to dysmaturity, Susceptible to illness or death due to dysmaturity, immaturity, physical disorders, or complications at immaturity, physical disorders, or complications at birth.birth.
Risk Factors:Risk Factors: Low socioeconomic status, poor nutritionLow socioeconomic status, poor nutrition Exposure to environmental dangersExposure to environmental dangers Obstetric factors such as age, parity, or other premature Obstetric factors such as age, parity, or other premature
birthsbirths Medical conditions related to the pregnancy such as PIH, Medical conditions related to the pregnancy such as PIH,
PROM, or infectionPROM, or infection
Classification of High Risk Classification of High Risk NewbornsNewborns
Gestational AgeGestational Age Preterm – less than 37 weeks gestationPreterm – less than 37 weeks gestation
(Late Preterm – 34 – 36.6 weeks gestation)(Late Preterm – 34 – 36.6 weeks gestation) Term – 38-41 weeks gestationTerm – 38-41 weeks gestation Postterm – greater than 42 weeks gestationPostterm – greater than 42 weeks gestation
LGA – large for gestational age - above the 90LGA – large for gestational age - above the 90thth percentile percentile AGA – appropriate for gestational age – between the 10AGA – appropriate for gestational age – between the 10 thth
and 90and 90thth percentile percentile SGA – small for gestational age – below the 10SGA – small for gestational age – below the 10thth percentile percentile
Assessment of Gestational AgeAssessment of Gestational Age
Ballard Scale or Dubowitz scale Ballard Scale or Dubowitz scale Neuromuscular characteristicsNeuromuscular characteristics Physical CharacteristicsPhysical Characteristics
Classification of High Risk NewbornClassification of High Risk Newborn
Large for Gestational AgeLGA
Appropriate for Gestational AgeAGA
Small for Gestational AgeSGA
Maturity and Intrauterine Growth Grid
Characteristics of Preterm InfantsCharacteristics of Preterm Infants
Appear frail & weakAppear frail & weak Underdeveloped flexor muscles & muscle toneUnderdeveloped flexor muscles & muscle tone Head is larger in comparison with the rest of the bodyHead is larger in comparison with the rest of the body Lack subcutaneous fat (white fat)Lack subcutaneous fat (white fat) Skin appears red and translucentSkin appears red and translucent Barely apparent small flat nipplesBarely apparent small flat nipples Plantar creases are absent in infants <32 wksPlantar creases are absent in infants <32 wks The pinna of the ear is soft and flatThe pinna of the ear is soft and flat Female – Female – Male –Male –
Physiologic challenges of the Physiologic challenges of the premature infant - Respiratorypremature infant - Respiratory
Insufficient production of surfactant Insufficient production of surfactant
Immaturity of alveolar system Immaturity of alveolar system
Immaturity of musculature and insufficient Immaturity of musculature and insufficient calcification of bony thorax calcification of bony thorax
Respirations 40-60/min., shallow, irregular, usually Respirations 40-60/min., shallow, irregular, usually diaphragmatic. diaphragmatic.
Nursing interventions - RespiratoryNursing interventions - Respiratory
Assess for signs of Respiratory DistressAssess for signs of Respiratory Distress Nasal FlaringNasal Flaring Circumoral CyanosisCircumoral Cyanosis Expiratory GruntingExpiratory Grunting RetractionsRetractions Tachypnea Tachypnea Apneic episodesApneic episodes
Administer OAdminister O22 ◦ Warmed and humidifiedWarmed and humidified◦ OxihoodOxihood◦ Nasal CannulaNasal Cannula◦ CPAPCPAP◦ Analyze oxygen concentration. Analyze oxygen concentration.
Nursing interventions - RespiratoryNursing interventions - Respiratory
PositioningPositioning Position with head slightly elevated and neck slightly Position with head slightly elevated and neck slightly
extendedextended Side-lying or proneSide-lying or prone
SuctioningSuctioning Only use when necessaryOnly use when necessary Be gently so as not to damage fragile mucus membranesBe gently so as not to damage fragile mucus membranes
Physiologic Challenges in the Physiologic Challenges in the preterm infant - Thermoregulationpreterm infant - Thermoregulation
Heat regulation unstableHeat regulation unstable Body temperature may be normal but it fluctuatesBody temperature may be normal but it fluctuates Higher ratio of body surface in proportion to body Higher ratio of body surface in proportion to body
weight.weight. Lack of subcutaneous fat Lack of subcutaneous fat Poor capillary response to environmental changes.Poor capillary response to environmental changes. Decreased brown fatDecreased brown fat Thinner skinThinner skin
Signs of Inadequate ThermoregulationSigns of Inadequate Thermoregulation
Axillary temperature <36.3 or >36.9 degrees CAxillary temperature <36.3 or >36.9 degrees C Abdominal skin temperature <36 or >36.5 degrees CAbdominal skin temperature <36 or >36.5 degrees C Poor feeding or feeding intolerancePoor feeding or feeding intolerance IrritabilityIrritability LethargyLethargy Weak cry or suckWeak cry or suck Decreased muscle toneDecreased muscle tone Cool skin temperatureCool skin temperature Skin pale, mottled, or acrocyanoticSkin pale, mottled, or acrocyanotic Signs of hypoglycemiaSigns of hypoglycemia Signs of respiratory difficultySigns of respiratory difficulty Poor weight gainPoor weight gain
Nursing Interventions - Nursing Interventions - ThermoregulationThermoregulation
GOAL: Neutral thermal environmentGOAL: Neutral thermal environment..
Thermal Neutrality – Nursing InterventionsThermal Neutrality – Nursing Interventions Incubator or radiant warmerIncubator or radiant warmer Warm surfacesWarm surfaces Warm humidified oxygenWarm humidified oxygen Warm ambient humidityWarm ambient humidity Warm feedingsWarm feedings Keep skin dry and head coveredKeep skin dry and head covered
Physiologic Challenges-Physiologic Challenges-Fluid & Electrolyte BalanceFluid & Electrolyte Balance
Preterm infants lose fluid very easilyPreterm infants lose fluid very easily Rapid respiratory rate and use of oxygen Rapid respiratory rate and use of oxygen
increase fluid lose from the lungsincrease fluid lose from the lungs Lack of keratin, which helps maintain water in Lack of keratin, which helps maintain water in
the skinthe skin Large surface area & lack of flexion increases Large surface area & lack of flexion increases
insensible water lossesinsensible water losses Radiant warmers heighten insensible water lossRadiant warmers heighten insensible water loss
Physiologic Challenges-Physiologic Challenges-Fluid & Electrolyte BalanceFluid & Electrolyte Balance
Development of kidneys is not complete until Development of kidneys is not complete until approximately 35 weeks.approximately 35 weeks.
In ability of preterm kidneys to concentrate or In ability of preterm kidneys to concentrate or dilute urine.dilute urine.
Kidneys unable to regulate electrolytes.Kidneys unable to regulate electrolytes.
Physiologic Challenges-Physiologic Challenges-Fluid & Electrolyte BalanceFluid & Electrolyte Balance
DehydrationDehydration
Urine output >2 ml/kg/hourUrine output >2 ml/kg/hour
Urine specific gravity >1.020Urine specific gravity >1.020
Weight loss greater than expectedWeight loss greater than expected
Dry skin and mucous membranesDry skin and mucous membranes
Sunken anterior fontanelSunken anterior fontanel
Poor tissue turgorPoor tissue turgor
Blood: Elevated sodium, protein, Blood: Elevated sodium, protein,
and hematocrit levelsand hematocrit levels
OverhydrationOverhydration
Urine output >5 ml/kg/hourUrine output >5 ml/kg/hour
Urine specific gravity <1.001Urine specific gravity <1.001
EdemaEdema
Weight gain greater than expectedWeight gain greater than expected
Bulging fontanelsBulging fontanels
Blood: Decreased sodium, Blood: Decreased sodium,
protein, and hematocrit levelsprotein, and hematocrit levels
Moist breath soundsMoist breath sounds
Difficulty breathingDifficulty breathing
Nursing Interventions- Nursing Interventions- Fluid and Electrolyte BalanceFluid and Electrolyte Balance
Weigh diapers (1gm = 1ml of urine)Weigh diapers (1gm = 1ml of urine) Obtain specific gravityObtain specific gravity Carefully regulate IV fluidsCarefully regulate IV fluids Dilute IV medications in as little fluid that is Dilute IV medications in as little fluid that is
recommended (include medications on intake recommended (include medications on intake measurements)measurements)
Assess IV sites frequentlyAssess IV sites frequently
Physiologic Challenges-Physiologic Challenges-SkinSkin
The Preterm infants skin is:The Preterm infants skin is:• FragileFragile• TransparentTransparent• PermeablePermeable
Nursing Interventions-Nursing Interventions-SkinSkin
Nursing CareNursing Care No use of alcohol or betadine on skinNo use of alcohol or betadine on skin All skin products should be rinsed off with waterAll skin products should be rinsed off with water No use of adhesives, use pectin barriers and back No use of adhesives, use pectin barriers and back
tape with cottontape with cotton Use semi-permeable adhesives such as tegadermUse semi-permeable adhesives such as tegaderm Reposition frequently, as tolerated Reposition frequently, as tolerated
Physiologic Challenges-Physiologic Challenges-InfectionInfection
Exposure to maternal infectionsExposure to maternal infections Lack of transfer of immunoglobulin G (IgG) Lack of transfer of immunoglobulin G (IgG)
from mother during third trimesterfrom mother during third trimester Immature immune response to infectionImmature immune response to infection Subject to invasive procedures (IV’s, lab’s)Subject to invasive procedures (IV’s, lab’s) Prolonged hospital staysProlonged hospital stays
Signs and Symptoms of Infection Signs and Symptoms of Infection in the preterm infantin the preterm infant
Behavioral changesBehavioral changes Color changesColor changes Temperature instabilityTemperature instability Cool, clammy skinCool, clammy skin Feeding intoleranceFeeding intolerance HyperbilirubinemiaHyperbilirubinemia Tachycardia followed by apnea and bradycardiaTachycardia followed by apnea and bradycardia
Nursing Interventions-Nursing Interventions-InfectionInfection
Maintain skin integrityMaintain skin integrity Maintain sterile technique with proceduresMaintain sterile technique with procedures ‘‘Scrub’ before entering – EVERYONEScrub’ before entering – EVERYONE Hand sanitizer at every bedside and used in between careHand sanitizer at every bedside and used in between care No entry if sick – EVERYONENo entry if sick – EVERYONE No artificial nails / short nailsNo artificial nails / short nails Single infant incubators, clean weeklySingle infant incubators, clean weekly Report early signs of infection immediatelyReport early signs of infection immediately Assess infants response to treatment (possible resistance)Assess infants response to treatment (possible resistance) Position change, use sheepskinPosition change, use sheepskin
Physiologic Challenges –Physiologic Challenges –Hepatic SystemHepatic System
Poor glycogen stores -increased susceptibility to Poor glycogen stores -increased susceptibility to hypoglycemia.hypoglycemia.
Inability to conjugate bilirubin - increase Inability to conjugate bilirubin - increase hyperbilirubinemia.hyperbilirubinemia.
Decrease ability to produce clotting factors, low Decrease ability to produce clotting factors, low plasma prothrombin levels.plasma prothrombin levels.
Physiologic Challenges – Physiologic Challenges – Renal SystemRenal System
Decreased glomerular filtration rateDecreased glomerular filtration rate
Inability to concentrate urineInability to concentrate urine
Decreased ability of kidneys to bufferDecreased ability of kidneys to buffer
Decreased drug excretion timeDecreased drug excretion time
Pain in preterm infantsPain in preterm infants
High-pitched, intense, harsh cryHigh-pitched, intense, harsh cry Whimpering, moaningWhimpering, moaning ““Cry face”Cry face” Eyes squeezed shutEyes squeezed shut Mouth openMouth open GrimacingGrimacing Bulging or furrowing of browBulging or furrowing of brow Tense, rigid muscles or flaccid muscle toneTense, rigid muscles or flaccid muscle tone Rigidity or flailing of extremitiesRigidity or flailing of extremities Color changes: Red, dusky, paleColor changes: Red, dusky, pale Increased or decreased heart rate and respirations, apneaIncreased or decreased heart rate and respirations, apnea Decreased oxygen saturationDecreased oxygen saturation Increased blood pressureIncreased blood pressure Sleep-wake pattern changesSleep-wake pattern changes
Nursing InterventionsNursing Interventions
Swaddle, wake slowlySwaddle, wake slowly Pacifier, may use SucrosePacifier, may use Sucrose MedicationsMedications
Signs of OverstimulationSigns of Overstimulationin Preterm Infantsin Preterm Infants
Oxygenation changesOxygenation changes RespirationsRespirations PulsePulse Blood pressureBlood pressure Oxygen saturation levelsOxygen saturation levels ColorColor Sneezing, coughing, Sneezing, coughing,
hiccuppinghiccupping
Behavior changesBehavior changes PosturePosture Facial expressionFacial expression GazeGaze RegurgitationRegurgitation YawningYawning FatigueFatigue
Physiologic Challenges –Physiologic Challenges –Digestive SystemDigestive System
Decreased gag and suck reflexesDecreased gag and suck reflexes Hypotonic cardiac sphincter Hypotonic cardiac sphincter Suck and swallow reflexes may be Suck and swallow reflexes may be
uncoordinateduncoordinated Small stomach capacity Small stomach capacity VomitingVomiting Intolerance of fatsIntolerance of fats Immature absorption of nutrientsImmature absorption of nutrients
Maintaining NutritionMaintaining Nutrition
Nursing CareNursing Care Assess Daily weightsAssess Daily weights Monitor I&OMonitor I&O Accurate IV rates to prevent circulatory overloadAccurate IV rates to prevent circulatory overload Provide feedings via nasogastric if unable to feed orallyProvide feedings via nasogastric if unable to feed orally Initiate oral feedings and assess for tiring Initiate oral feedings and assess for tiring
with feedingswith feedings Monitor urine pH and specific gravityMonitor urine pH and specific gravity Involve parents in feedingsInvolve parents in feedings
Nursing InterventionsNursing Interventions
Pre-feeding assessmentPre-feeding assessment RespirationsRespirations
Measure abdominal girthMeasure abdominal girth
Bowel soundsBowel sounds
Gastric residual Gastric residual
Sucking , swallowing , and gag reflexesSucking , swallowing , and gag reflexes
Readiness for Nipple FeedingReadiness for Nipple Feeding
RootingRooting
Sucking on gavage tube, finger, or pacifierSucking on gavage tube, finger, or pacifier
Able to tolerate holdingAble to tolerate holding
Respiratory rate <60 breaths per minuteRespiratory rate <60 breaths per minute
Presence of gag reflexPresence of gag reflex
Signs of Nonreadiness for Nipple Signs of Nonreadiness for Nipple FeedingsFeedings
Respiratory rate >60 breaths per minuteRespiratory rate >60 breaths per minute
No rooting or suckingNo rooting or sucking
Absence of gag reflexAbsence of gag reflex
Excessive gastric residualsExcessive gastric residuals
ParentingParenting
Facilitating Parent-Infant AttachmentFacilitating Parent-Infant Attachment Prepare parents for first visitPrepare parents for first visit
Equipment, tubes etc.Equipment, tubes etc. Establish safe/trusting environmentEstablish safe/trusting environment
Provide support, reassurance, encouragementProvide support, reassurance, encouragement Encourage visitationEncourage visitation Involved in care takingInvolved in care taking Repeat explanationsRepeat explanations Promote touching, talking, rocking, cuddlingPromote touching, talking, rocking, cuddling Refer to infant by nameRefer to infant by name Allow parents to phone as desiredAllow parents to phone as desired
Respiratory Distress SyndromeRespiratory Distress Syndrome PathophysiologyPathophysiology
Primary absence, deficiency or alteration in the production of surfactantPrimary absence, deficiency or alteration in the production of surfactant
Decrease in Surfactant = increase in atelectasis = lack of gas exchangeDecrease in Surfactant = increase in atelectasis = lack of gas exchange
Leads to hypoxia and acidosis which further inhibit surfactant Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction.production and causes pulmonary vasoconstriction.
Common Clinical manifestations:Common Clinical manifestations: Nasal FlaringNasal Flaring Circumoral cyanosisCircumoral cyanosis Expiratory gruntingExpiratory grunting RetractingRetracting TachypneaTachypnea
Respiratory Distress Syndrome-Respiratory Distress Syndrome-Nursing InterventionsNursing Interventions
Maintain airway, oxygenation, ventilationMaintain airway, oxygenation, ventilation Supplemental oxygen: Supplemental oxygen:
Nasal prongsNasal prongs OxyhoodOxyhood
Continuous positive airway pressure (CPAP)Continuous positive airway pressure (CPAP)
Intubation with endotracheal tubeIntubation with endotracheal tube
Surfactant Replacement TherapySurfactant Replacement Therapy
Surfactant preparation can be lifesaving and Surfactant preparation can be lifesaving and reduces complications, such as pneumothorax. reduces complications, such as pneumothorax.
Administered through an endotracheal tubeAdministered through an endotracheal tube
Surfactant treatments may be repeated several Surfactant treatments may be repeated several times during the first days until respiratory distress times during the first days until respiratory distress syndrome resolves.syndrome resolves.
Respiratory Distress Syndrome-Respiratory Distress Syndrome-Nursing InterventionsNursing Interventions
Nutrition SupportNutrition Support Newborns with RDS may be given food and water by the Newborns with RDS may be given food and water by the
following means: following means: Tube feeding—a tube is inserted through the baby's mouth Tube feeding—a tube is inserted through the baby's mouth
and into the stomach and into the stomach Parenteral feeding—nutrients are delivered directly into a Parenteral feeding—nutrients are delivered directly into a
veinvein
Support to ParentsSupport to Parents Allow parents to hold and feed Allow parents to hold and feed
when possible.when possible. Assist to decrease their fearsAssist to decrease their fears
Periventricular-IntraventricularPeriventricular-IntraventricularHemorrhageHemorrhage
Rupture of fragile blood vessels around the ventricles of the Rupture of fragile blood vessels around the ventricles of the brainbrain
Usually associated with hypoxiaUsually associated with hypoxia
Diagnosed via cranial ultrasoundDiagnosed via cranial ultrasound
Signs – lethargy, poor muscle tone, decreased reflexes, Signs – lethargy, poor muscle tone, decreased reflexes, seizures, apnea or cyanosis, full or bulging fontanelsseizures, apnea or cyanosis, full or bulging fontanels
Nursing Care – daily measure FOC, observe for changes in Nursing Care – daily measure FOC, observe for changes in LOCLOC
Retinopathy of PrematurityRetinopathy of Prematurity
Formation of immature blood vessels in the Formation of immature blood vessels in the retina constrict and become necroticretina constrict and become necrotic
Most common in infants < 28 weeks gestationMost common in infants < 28 weeks gestation
Also associated with O2 therapyAlso associated with O2 therapy
Retinopathy of PrematurityRetinopathy of Prematurity
Nursing Interventions to Prevent ROPNursing Interventions to Prevent ROP Administer O2 in concentration orderedAdminister O2 in concentration ordered
Ensure proper ventilatory settingsEnsure proper ventilatory settings
Necrotizing EnterocolitisNecrotizing Enterocolitis
An inflammatory disease of the intestinal tract An inflammatory disease of the intestinal tract frequently complicated with perforation of the gut.frequently complicated with perforation of the gut.
NEC develops when there is asphyxia or hypoxia in which NEC develops when there is asphyxia or hypoxia in which cardiac output tends to be directed more toward the heart and cardiac output tends to be directed more toward the heart and brain and away from the abdominal organs. brain and away from the abdominal organs.
The intestinal cells become ischemic and damaged and stop The intestinal cells become ischemic and damaged and stop secreting protective mucus infection occurs. secreting protective mucus infection occurs.
Perforation may occur with overwhelming sepsis.Perforation may occur with overwhelming sepsis.
Necrotizing EnterocolitisNecrotizing EnterocolitisSigns and SymptomsSigns and Symptoms
Early:Early: Increase in gastric aspirate - >5-25 ml. Increase in gastric aspirate - >5-25 ml. Increase in abdominal girth Increase in abdominal girth Decrease bowel sounds, abdominal tenderness or rigidity Decrease bowel sounds, abdominal tenderness or rigidity
of abdominal wall.of abdominal wall. Subtle: Subtle:
Lethargy, sudden listlessness, temperature instability, Lethargy, sudden listlessness, temperature instability, decrease urine output, occult blood in stools, poor color, decrease urine output, occult blood in stools, poor color, and apneic periods.and apneic periods.
Dramatic:Dramatic: Massive abdominal distention, vasomotor collapse.Massive abdominal distention, vasomotor collapse.
Necrotizing EnterocolitisNecrotizing EnterocolitisTreatment and Nursing CareTreatment and Nursing Care
Surgery:Surgery: Resection of necrotic sections and possible Resection of necrotic sections and possible temporary colostomy. This allows bowel to recover.temporary colostomy. This allows bowel to recover.
Medical:Medical: NPO with NG tube. NPO with NG tube. Peripheral or central hyperalimentation Peripheral or central hyperalimentation Antibiotic therapy. Antibiotic therapy. Continue to monitor for changes in condition.Continue to monitor for changes in condition. Gradually introduce oral feedingsGradually introduce oral feedings
Post Mature InfantPost Mature Infant
Physical manifestations:Physical manifestations: Dry, cracking, Dry, cracking,
parchment-like skinparchment-like skin Reduced subcutaneousReduced subcutaneous
tissue -Loose appearingtissue -Loose appearing
skinskin No vernix or lanugoNo vernix or lanugo Long fingernailsLong fingernails Profuse scalp hairProfuse scalp hair Long, thin body appearanceLong, thin body appearance Often meconium stained skin, cord, nailsOften meconium stained skin, cord, nails
Post Mature InfantPost Mature Infant
Complications of post term:Complications of post term: HypoglycemiaHypoglycemia Meconium aspirationMeconium aspiration Congenital anomaliesCongenital anomalies Seizure activitySeizure activity Cold stressCold stress
Small for Gestational AgeSmall for Gestational AgeBelow the 10Below the 10thth percentile percentile
Risk FactorsRisk Factors Maternal factors:Maternal factors:
◦ High blood pressure. High blood pressure. ◦ Chronic kidney disease. Chronic kidney disease. ◦ Advanced diabetes. Advanced diabetes. ◦ Heart or respiratory disease. Heart or respiratory disease. ◦ Malnutrition, anemia. Malnutrition, anemia. ◦ Infection. Infection. ◦ Substance use (alcohol, drugs); Cigarette smoking. Substance use (alcohol, drugs); Cigarette smoking.
Factors involving the uterus and placenta:Factors involving the uterus and placenta: ◦ Decreased blood flow in the uterus and placenta. Decreased blood flow in the uterus and placenta. ◦ Placental abruption (placenta detaches from the uterus). Placental abruption (placenta detaches from the uterus). ◦ Placenta previa (placenta attaches low in the uterus). Placenta previa (placenta attaches low in the uterus). ◦ Infection in the tissues around the fetus. Infection in the tissues around the fetus.
Factors related to the developing baby (fetus):Factors related to the developing baby (fetus): ◦ Multiple gestation (twins, triplets, etc.). Multiple gestation (twins, triplets, etc.). ◦ Infection. Infection. ◦ Birth defects. Birth defects. ◦ Chromosomal abnormality. Chromosomal abnormality.
Complications of the SGA Complications of the SGA NewbornNewborn
Asphyxia Asphyxia
Aspiration syndrome Aspiration syndrome
HypothermiaHypothermia
Hypoglycemia Hypoglycemia
PolycythemiaPolycythemia
Large for Gestational AgeLarge for Gestational AgeGreater than 90Greater than 90thth percentile percentile
What condition is associated with the What condition is associated with the newborn being LGA?newborn being LGA?
Complications of the LGA Complications of the LGA newbornnewborn
Birth Trauma Birth Trauma
Increase of Cesarean birthsIncrease of Cesarean births
HypoglycemiaHypoglycemia
PolycythemiaPolycythemia
HyperviscosityHyperviscosity
AsphyxiaAsphyxia
Lack of oxygen and increase of carbon dioxide in the bloodLack of oxygen and increase of carbon dioxide in the blood Occurs in utero or after birthOccurs in utero or after birth
S/S asphyxia after birth:S/S asphyxia after birth: Cessation of respirations and rapid fall in heart rateCessation of respirations and rapid fall in heart rate
Interventions:Interventions: Primary apnea: stimulation and O2Primary apnea: stimulation and O2 Secondary apnea: positive pressure ventilation &/or chest Secondary apnea: positive pressure ventilation &/or chest
compressionscompressions Naloxone 0.1mg/kg IM (if narcotics given to expectant Naloxone 0.1mg/kg IM (if narcotics given to expectant
mother shortly before birth)mother shortly before birth)
Meconium Aspiration SyndromeMeconium Aspiration Syndrome
Meconium stained amniotic fluidMeconium stained amniotic fluid Aspirated into the trachobronchial treeAspirated into the trachobronchial tree Occurs either in utero or after birth with the first Occurs either in utero or after birth with the first
breaths.breaths.
Meconium in the lungs causes air to become Meconium in the lungs causes air to become trapped and results in alveoli over-distension and trapped and results in alveoli over-distension and rupture.rupture.
Measures for Prevention of Meconium AspirationMeasures for Prevention of Meconium Aspiration After delivery of the infant’s head while shoulders and After delivery of the infant’s head while shoulders and
chest are still in the birth canal, chest are still in the birth canal, Suction oropharynx and nasopharynx Suction oropharynx and nasopharynx
After delivery of the infant’s bodyAfter delivery of the infant’s body
CryingCrying Not crying Not crying
- Stimulate- Stimulate - Do not stimulate - Do not stimulate- Suction with- Suction with - Direct tracheal suction - Direct tracheal suction bulb syringebulb syringe with endotracheal tube with endotracheal tube
Meconium Aspiration SyndromeMeconium Aspiration Syndrome
Nursing Interventions:Nursing Interventions: Maintain adequate oxygenation and ventilationMaintain adequate oxygenation and ventilation Regulate temperatureRegulate temperature Accurate IV fluid administrationAccurate IV fluid administration Assess for hypoglycemiaAssess for hypoglycemia Administer antibioticsAdminister antibiotics Prevent caloric requirementsPrevent caloric requirements Provide support care if on ECMOProvide support care if on ECMO
Meconium Aspiration SyndromeMeconium Aspiration Syndrome
Hyperbilirubinemia PathophysiologyPathophysiology
Unconjugated bilirubin is a break-down product of destroyed RBC’s. Unconjugated bilirubin is a break-down product of destroyed RBC’s.
Unconjugated bilirubin is normally transferred in the plasma firmly bound to Unconjugated bilirubin is normally transferred in the plasma firmly bound to albumin to the liver where conjugation occurs. albumin to the liver where conjugation occurs.
Conjugated bilirubin is water soluble and can then be excreted into the bile and Conjugated bilirubin is water soluble and can then be excreted into the bile and eliminated with the feces. eliminated with the feces.
Unconjugated bilirubin is not in excretable form and remains in the circulation Unconjugated bilirubin is not in excretable form and remains in the circulation causing problems.causing problems.
Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin released into the serum.released into the serum.
Causes of Hyperbilirubinemia
Hemolytic disease (Rh and ABO incompatibility)Hemolytic disease (Rh and ABO incompatibility) Extravascular bleed (cephalhematoma)Extravascular bleed (cephalhematoma) Bilirubin conjugation defects (breastmilk jaundice, Bilirubin conjugation defects (breastmilk jaundice,
asphyxia)asphyxia) HypoalbuminHypoalbumin Physiologic jaundice (occurs after the first 24 hours of Physiologic jaundice (occurs after the first 24 hours of
birth. Mainly due to immature liver and lack of birth. Mainly due to immature liver and lack of glucoronyl transferase).glucoronyl transferase).
Hyperbilirubinemia
Clinical Manifestations:Clinical Manifestations: Sclerae appearing yellow before skin appears Sclerae appearing yellow before skin appears
yellow – usually in the first 24 hours after deliveryyellow – usually in the first 24 hours after delivery Skin appearing light to bright yellow – advances Skin appearing light to bright yellow – advances
from head to toefrom head to toe LethargyLethargy Dark, amber concentrated urineDark, amber concentrated urine Poor feedingPoor feeding Dark stoolsDark stools
Hyperbilirubinemia Diagnosis:Diagnosis:
Bilirubin levels on Cord BloodBilirubin levels on Cord Blood Average level of Unconjugated bilirubin is 2 mg/dl at birthAverage level of Unconjugated bilirubin is 2 mg/dl at birth Bilirubin levels should NOT exceed 5 mg/dlBilirubin levels should NOT exceed 5 mg/dl
Coombs TestCoombs Test may be done on the fetal cord blood (direct Coombs test) may be done on the fetal cord blood (direct Coombs test)
or on the maternal blood (indirect Coombs test). or on the maternal blood (indirect Coombs test). Tests for the presence of maternal antibodies attached on Tests for the presence of maternal antibodies attached on
the infant’s red blood cellsthe infant’s red blood cells. . The test is positive if there are maternal antibodiesThe test is positive if there are maternal antibodies..
Hyperbilirubinemia Nursing Care
Careful observation of infant for signs of increased Careful observation of infant for signs of increased jaundicejaundice
Careful observation for and prevention of Careful observation for and prevention of acidosis/hypoxia and hypoglycemia, which decrease acidosis/hypoxia and hypoglycemia, which decrease binding of bilirubin to albumin and contribute to binding of bilirubin to albumin and contribute to jaundice.jaundice.
Maintain adequate hydrationMaintain adequate hydration Avoid cold stressAvoid cold stress Phototherapy – use of “bili” lights, special fluorescent Phototherapy – use of “bili” lights, special fluorescent Exchange TransfusionExchange Transfusion
HyperbilirubinemiaNursing Care
Nursing Interventions for PhototherapyNursing Interventions for Phototherapy Exposure of skinExposure of skin Cover eyes (remove for feeding/parent visit)Cover eyes (remove for feeding/parent visit) Monitor temperature – prone to hyperthermia or Monitor temperature – prone to hyperthermia or
hypothermiahypothermia Reposition newborn every 2 hoursReposition newborn every 2 hours Increase fluidsIncrease fluids Assess for dehydrationAssess for dehydration Perform T-Bili q 12 – 24 hr as orderedPerform T-Bili q 12 – 24 hr as ordered Explain need to keep under phototherapy except during Explain need to keep under phototherapy except during
feedings and diaper changes.feedings and diaper changes. Explain to parents and allow them to hold during feedingsExplain to parents and allow them to hold during feedings
HyperbilirubinemiaPhototherapy
Side Effects to PhototherapySide Effects to Phototherapy Frequent loose, green stoolsFrequent loose, green stools Skin rashSkin rash Increased basal body metabolismIncreased basal body metabolism DehydrationDehydration HyperthermiaHyperthermia
HyperbilirubinemiaExchange Transfusion
Exchange TransfusionExchange Transfusion Treat anemiaTreat anemia Remove sensitized RBCs that will soon lyseRemove sensitized RBCs that will soon lyse Remove serum bilirubinRemove serum bilirubin Provides albumin to increase bilirubin binding Provides albumin to increase bilirubin binding
sitessites
Hyperbilirubinemia
RhogamRhogam Provides temporary passive immunity which Provides temporary passive immunity which
prevents permanent active immunity (antibody prevents permanent active immunity (antibody formation)formation)
Given within 72 hours of deliveryGiven within 72 hours of delivery
Prevents production of maternal antibodiesPrevents production of maternal antibodies
ABO incompatibilityABO incompatibility Occurs when type O pregnant woman with A, B or Occurs when type O pregnant woman with A, B or
AB blood type fetusAB blood type fetus If woman has anti A or anti B antibodies, these If woman has anti A or anti B antibodies, these
antibodies cross the placental barrierantibodies cross the placental barrier Results in hemolysis of fetal RBCsResults in hemolysis of fetal RBCs
Hyperbilirubinemia
Complications of Hemolytic DiseaseComplications of Hemolytic Disease Kernicterus – Deposits of conjugated and Kernicterus – Deposits of conjugated and
unconjugated bilirubin in the basal ganglia of the brainunconjugated bilirubin in the basal ganglia of the brain Neurologic damageNeurologic damage
Hydrops fetalis – severe anemiaHydrops fetalis – severe anemia Marked edemaMarked edema Cardiac decompensationCardiac decompensation Multiple organ failureMultiple organ failure Possible deathPossible death
Hyperbilirubinemia
Toxoplasmosis Other
Syphillis Hepititis B
Rubella Cytomegalovirus Herpes Simplex II HIV - AIDs
Infectious Diseases: TORCH
Protozoan infection in the pregnant woman Raw or under cooked meats Infected Cat feces
Transmission: transplacental
Affects on the fetus Retinochoroiditis (inflammation of the retina and choroid of the
eye. Blindness Deafness Convulsions Microcephaly Hydrocephaly Severe mental impairment
Toxoplasmosis
Transmission: Transplacental Clinical Manifestations:
Rhinitis (Snuffles) 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 - Syphillislis
Other – Hepatitis B
Transmission Placental Birth Breast milk
Treatment If mother + HbSAG - administer to newborn:
Hepitisis B vaccine HBIG
(administer within 12 hours of birth)
Transmission: transplacental S/S of Newborn
Congenital cataracts Deafness Congenital heart defects Sometimes fatal Intellectual disability
(Affects are greatest if infected in 1st trimester)
MMR Immunization of mother Give when not pregnant – usually in immediate postpartum period. Newborns are infectious:
CONTACT ISOLATION
Rubella
Herpatic virus Transmission:
Crosses placental barrier Direct contact at birth Breast milk
S/S of Newborn Severe neurological problems Eye abnormalities Hearing loss Microcephaly Hydrocephaly Enlarged liver Cerebral palsy
Cytomegalovirus
Transmission: Direct contact at birth S/S of Newborn
Custer of vesicles Lethargy Encephalitis Mental delays Seizures Retinal dysplasia Apnea Coma
CONTACT ISOLATION - culture vesicles Treatment: Antivial drugs
Herpes Simplex II
Transmission: TransplacentallyTransplacentally Exposure at birthExposure at birth Breast milkBreast milk
Diagnosis: Serology tests are performed within 48 hours of birth;Serology tests are performed within 48 hours of birth;
repeated at 3 and 6 monthsrepeated at 3 and 6 months HIV antibodyHIV antibody ELISAELISA CD4 + T-cell CD4 + T-cell
HIV/AIDS
HIV infected (two or more positive tests for HIV)
Perinatally exposed (born to a mother know to be infected with HIV)
Seroconverter (born to a mother known to be infected with HIV but has had two negative HIV tests
HIV/ AIDSDiagnosis
Nursing Interventions HIV infected mothers should be identified and begin
treatment with AZT during pregnancy and in labor
All infants born to an infected mother should be treated prophylactically◦ 6 weeks of AZT orally after birth◦ Bactrim and Septra
Provide care like that of any other newborn
HIV / AIDSIDS
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
Polycythemia
Respiratory Distress Syndrome
Complications of Infants of Diabetic Mothers
Why are they prone to 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
Clinical Manifestations: Large size – Macrosomia; enlarged spleen, heart, liver Tremors Cyanosis Apnea Temperature instability Poor sucking and feeding Hypotonic muscle tone / Lethargy
Nursing Interventions Assess blood glucose
Intervene if < 45mg/dl: Feed infant
Revaluate blood sugar 30-45 minutes pc If no improvement:
IV of D10W
Infants of Diabetic Mothers
The newborn of an alcoholic or drug-dependent mother will also be alcohol or drug dependent.
After birth, when an infant’s connection with the maternal blood supply is severed, the neonate suffers withdrawal.
In addition, the drugs ingested by the mother may be In addition, the drugs ingested by the mother may be teratogenic, resulting in congenital anomalies.teratogenic, resulting in congenital anomalies.
Infant of Addicted Mother
Clinical Manifestations: Jitteriness Abdominal distention Exaggerated rooting and sucking reflexes
Affected body systems: CNS
GI system
Long-term psychosocial implications: Feeding difficulties Mental retardation
Fetal Alcohol Syndrome - FAS
Central Nervous Systemo IRRITABILITY
• Hyperactivity• Shrill cry• Exaggerated reflexes• Facial scratches• Short non-quiet sleep
Sneezing, coughing, yawning Gastroinestional System
o Poor feedingo Disorganized vigorous sucko Vomiting and/or Diarrhea
Vasomotor and Cutaneous Signso Tachypneao Sweatingo Excoriated skin
Infants of Addicted MothersClinical Manifestations of Infant Withdrawal
Soothing: Swaddle with hands near mouth Offer pacifier Place in quiet dimly lit area of the nursery
Protect skin from excoriation Monitor V/S Feeding
Provide small frequent feedings Position with HOB elevated Weigh every 8 hours (if vomiting & diarrhea)
Assess with Finnegan Abstinence Scale Administer morphine, phenobarbitol, methadone
Infants of Addicted Mothers Nursing Care
Affects of Smoking on the Fetus during pregnancy
NicotineNicotine Causes vasoconstrictionCauses vasoconstriction Reduces placental blood circulationReduces placental blood circulation
Carbon MonoxideCarbon Monoxide Inactivates fetal and maternal hemaglobinInactivates fetal and maternal hemaglobin
Reduced amount of oxygen to fetus results in Reduced amount of oxygen to fetus results in prematurity or low birth weightprematurity or low birth weight
Thank you!Thank you!
Christina Hernandez RN, MSNChristina Hernandez RN, MSN
[email protected]@austincc.edu