Newborn at Risk - Baptist Health School of userfiles/pdfs/course-materials/Newborn at Risk.pdf · NEWBORN

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    NURSING MANAGEMENT OF THENEWBORN AT RISK:Utilizing the Nursing Process andCritical Thinking

    Lecture Objectives:

    1. Describe risk factors associated with thebirth and transition of an infant of adiabetic mother.

    2. Discuss maternal substance abuse andthe newborn.

    3. Identify the principles of high risk infantcare in meeting the special needs of thepreterm newborn.

    4. Discuss gestational problems in theneonate.

    5. Discuss infection and the newborn.

    Lecture Objectives: (cont.)Discuss hemolytic disorder in the newborn.Develop a plan of care to meet the needs ofparents of high risk infants.Discuss the treatment and complications ofrespiratory distress syndrome.Describe nursing interventions for nutritionalcare of the preterm infant.Discuss thermoregulation and its role in thecare of the preterm infant.

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    Reading Assignment:

    Wong, Perry, & Hockenberry (2006).Maternal Child Nursing Care.

    Chapter 27-28, pp 795-869

    Infants with GestationalAgeRelated Problems

    High Risk NewbornInfants who are born considerably beforeterm and survive are particularly susceptibleto development of sequelae related topreterm birth

    Necrotizing enterocolitisBPDIntraventricular and periventricularhemorrhageRetinopathy of prematurity

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    High Risk NewbornHigh risk infant classification

    Birth weightGestational agePredominant pathophysiologic problems

    Preterm Infants

    Organ systems are immature and lackadequate physiologic reserves to functionin extrauterine environmentPotential problems and needs of preterminfant weighing 2000 g differ from those ofterm, postterm, or postmature infant ofequal weightPhysiologic disorders and anomaliesaffect infants response to treatment

    Preterm Infants

    Closer infants are to term, the easier theiradjustment to external environmentVarying opinions exist about practical andethical dimensions of resuscitation ofextremely low-birth-weight infants

    Birth weight is 1000 g or less

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    Care ManagementAssessment

    Respiratory functionCardiovascular functionMaintaining body temperatureCentral nervous system functionMaintaining adequate nutritionMaintaining renal functionMaintaining hematologic status

    Care Management

    Assessment (contd)Protection from infectionSkin care

    Growth and development potentialParental adaptation to preterm infant

    Parental tasksParental responsesParenting disorders

    Care ManagementPlan of care and implementation

    Physical careMaintaining body temperature

    Warming the hypothermic infantWeaning infant from incubator

    Oxygen therapyOxygen hoodNasal cannulaContinuous positive airway pressure (CPAP)

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    Care Management

    Plan of care and implementationOxygen therapy (contd)

    Mechanical ventilationSurfactant administrationExtracorporeal membrane oxygenation therapy(ECMO)High-frequency ventilationNitric oxide therapy

    Care Management

    Plan of care and implementation (contd)Weaning from respiratory assistanceNutritional care

    Types of nourishmentWeight and fluid loss or gain

    HydrationInsensible water loss (IWL)

    Elimination patternsOral feeding

    Care Management

    Plan of care and implementationNutritional care (contd)

    Gavage feedingGastronomy feedingAdvancing infant feedingsNonnutritive sucking

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    Care ManagementPlan of care and implementation(contd)

    Environmental concernsDevelopmental care

    PositioningReducing inappropriate stimuliInfant communicationInfant stimulationKangaroo care

    Care ManagementPlan of care and implementation(contd)

    Parental supportParent education

    Cardiopulmonary resuscitation

    Complications of Prematurity

    Respiratory distress syndrome (RDS)Patent ductus arteriosus (PDA)Periventricular-intraventicularhemorrhageNecrotizing enterocolitisComplications of oxygen therapy

    Retinopathy of prematurity (ROP)Bronchopulmonary dysplasia (BPD)

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    The Postmature Infant

    Meconium aspiration syndrome (MAS)Persistent pulmonary hypertension of thenewborn (PPHN)

    Other Problems Related toGestation

    Small for gestational age (SGA) andintrauterine growth restriction (IUGR)

    Perinatal asphyxiaHypoglycemiaHeat loss

    Other Problems Related toGestation

    Large for gestational age(LGA)(weighing more than 4000 g atbirth)

    Birth trauma serious hazardWith breech or shoulderpresentationAsphyxia or CNS injuryOversized infant at risk due to size

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    Other Problems Related toGestation

    Infants of diabetic mothersPathophysiologyCongenital anomaliesMacrosomiaBirth trauma and perinatalasphyxiaRespiratory distress syndomeHypoglycemiaHypocalcemia andhypomagnesemia

    Other Problems Related toGestation

    Infants of diabetic mothers (contd)CardiomyopathyHyperbilirubinemia and polycythemiaNursing care

    Discharge Planning

    Home care needs of infants parentsare assessedInformation provided about infant careReferrals for appropriate resourcesReferrals for home health assistanceTransport to regional center

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    Key PointsPreterm infants at risk for problemsrelated to the immaturity of their organsystemsRespiratory distress syndrome,retinopathy of prematurity, andchronic lung disease(bronchopulmonary dysplasia) areassociated with prematurityHigh risk infants must be observed forrespiratory distress and other earlysigns of physiologic distress

    Key PointsMetabolic abnormalities of diabetesmellitus adversely affect embryonicand fetal developmentAdaptation of parents to preterm orhigh risk infants differs from that ofparents of full-term infantsParents need special instruction (e.g.,CPR, oxygen therapy, suctioning,developmental care) before they takea high risk infant home

    Key Points

    Infants born to diabetic mothers are atrisk for hypoglycemia and RDSSGA infants are considered to be at riskbecause of fetal growth restrictionNonreassuring fetal status amongpostmature infants is related toprogressive placental insufficiency thatcan occur in postterm pregnancy

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    Key Points

    Specially trained nurses may transporthigh risk infants to and from special careunits

    The Newborn at Risk:Acquired and Congenital


    Acquired and CongenitalProblems

    Conditions or circumstancessuperimposed on normal course ofevents associated with birth andadjustment to extrauterine existenceBirth trauma includes physical injuriessustained during labor and birthCongenital anomalies: gastrointestinal(GI) malformations, neural tubedefects, abdominal wall defects, andcardiac defects

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    Birth Trauma

    Injury sustained during labor and birthBirth injuries may be avoidable

    Careful assessment of risk factors andappropriate planning of birth

    Ultrasonography allows antepartum diagnosis ofmacrosomia, hydrocephalus, and unusualpresentationsElective cesarean birth chosen for somepregnancies to prevent significant birth injury

    Birth Trauma

    Small percentage of significant birthinjuries are unavoidable despite skilledand competent obstetric care

    Especially with difficult or prolonged laborWhen the infant is in an abnormalpresentation

    Some injuries cannot be anticipated untilthe circumstances are encounteredduring childbirth

    Birth TraumaCare management

    Skeletal injuriesPeripheral nervous systeminjuries

    Brachial paralysisFacial paralysisPhrenic nerve injury

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    Birth TraumaCare management (contd)

    Central nervous system injuriesIntracranial hemorrhage (ICH)Subdural hematomaSubarachnoid hemorrhageSpinal cord injuries

    Neonatal InfectionsSepsis

    Bacterial, viral, fungalPatterns

    Early onset or congenitalNosocomial infectionlateonset

    SepticemiaPneumoniaBacterial meningitisGastroenteritis is sporadic

    Neonatal Infections

    AssessmentPlan of care/implementationCare management

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    Neonatal InfectionsTORCH infections

    ToxoplasmosisGonorrheaSyphilisVaricella-zosterHepatitis B virus (HBV)Human immunodeficiency virus (HIV) andacquired immunodeficiency syndrome(AIDS)

    Neonatal InfectionsTORCH infections (contd)

    Rubella infectionCytomegalovirus infection(CMV)Herpes simplex virus (HSV)

    Parvovirus B19

    Neonatal InfectionsBacterial infections

    Group BstreptococcusEscherichia coliTuberculosisChlamydia

    Fungal infectionsCandidiasis

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    Substance AbuseAlcohol

    Fetal alcohol syndrome

    TobaccoMarijuanaCocainePhencyclidine (PCP, or angeldust)HeroinMethadone

    Substance Abuse

    Miscellaneous substancesMethamphetaminesPhenobarbitalCaffeine

    Critical Periods in Human Embryogenesis

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    Hemolytic DisordersHemolytic disease occurs when bloodgroups of mother and newborn aredifferent

    Most commonRh incompatibilityABO incompatibility

    Occur when maternal antibodies arepresent naturally, or form in response toantigen from fetal blood crossing placentaand entering maternal circulation

    Hemolytic Disorders

    Maternal antibodies of IgG class crossplacenta, causing hemolysis of fetalRBCs

    Fetal anemiaNeonatal jaundiceHyperbilirubinemia

    Hemolytic Disorders

    Rh incompatibility (isoimmunization)Only Rh-positive offspring of Rh-negative mother is at riskIf fetus is Rh positive and mother Rhnegative, mother forms antibodiesagainst fetal blood cells

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    Hemolytic Disorders

    ABO incompatibilityOccurs if fetal blood type is A, B, orAB, and maternal type is OIncompatibility arises becausenaturally occurring anti-A and anti-Bantibodies are transferred acrossplacenta to fetusExchange transfusions requiredoccasionally

    Hemolytic DisordersOther hemolytic disorders