Download pdf - Newborn at Risk - Baptist Health School of Nursinguserfiles/pdfs/course-materials/Newborn at Risk.pdf · NEWBORN AT RISK: Utilizing the Nursing Process and Critical Thinking Lecture

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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 ofparent’s of high risk infants.Discuss the treatment and complications ofrespiratory distress syndrome.Describe nursing interventions for nutritionalcare of the preterm infant.Discuss thermoregulation and it’s 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 GestationalAge–Related 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 infant’s 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 (cont’d)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 (cont’d)

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

Care Management

Plan of care and implementation (cont’d)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 (cont’d)

Gavage feedingGastronomy feedingAdvancing infant feedingsNonnutritive sucking

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Care ManagementPlan of care and implementation(cont’d)

Environmental concernsDevelopmental care

PositioningReducing inappropriate stimuliInfant communicationInfant stimulationKangaroo care

Care ManagementPlan of care and implementation(cont’d)

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


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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Infants of diabetic mothersPathophysiologyCongenital anomaliesMacrosomiaBirth trauma and perinatalasphyxiaRespiratory distress syndomeHypoglycemiaHypocalcemia andhypomagnesemia


Infants of diabetic mothers (cont’d)CardiomyopathyHyperbilirubinemia and polycythemiaNursing care

Discharge Planning

Home care needs of infant’s 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

Problems

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 (cont’d)

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

Neonatal InfectionsSepsis

Bacterial, viral, fungalPatterns

Early onset or congenitalNosocomial infection—lateonset

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 (cont’d)

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

Glucose-6-phosphate dehydrogenasedeficiency (G-6-PD)Other metabolic and inherited conditionsthat increase hemolysis and may causejaundice in infant

GalactosemiaCrigler-Najjar diseaseHypothyroidism

Congenital Anomalies

Most common major congenitalanomalies that cause serious problemsin neonate are:

Congenital heart diseaseNeural tube defectsCleft lip or palateClubfootDevelopmental dysplasia of the hip

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Central nervous systemanomalies

Encephalocele andanencephalySpina bifidaHydrocephalusMicrocephaly


Cardiovascular system anomaliesCongenital heart defects (CHDs)

Anatomic abnormalities in the heartPresent at birth, although notdiagnosed immediately


Respiratory systemanomalies

Choanal atresia andlaryngeal webCongenital diaphragmatichernia

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Gastrointestinal system anomaliesCleft lip and palateEsophageal atresia andtracheoesophageal fistulaOmphalocele and gastroschisisGastrointestinal obstructionImperforate anus


Musculoskeletal systemanomalies

Developmental dysplasia of thehip

Acetabular dysplasia orpreluxationSubluxationDislocation


Musculoskeletal system anomalies(cont’d)

ClubfootTalipes varus—inversion or bending inwardTalipes valgus—eversion or bending outwardTalipes equinus—plantar flexion in which toes arelower than heelTalipes calcaneus—dorsiflexion in which toes arehigher than heel

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Musculoskeletal systemanomalies (cont’d)

PolydactylyHands or feet with extradigitsHereditary


Genitourinary systemanomalies

Hypospadias and epispadiasExstrophy of the bladderAmbiguous genitaliaTeratoma

Care ManagementGenetic diagnosisNewbornscreening

PhenylketonuriaGalactosemiaHypothyroidism

Cytologic studiesDermatoglyphics

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Key PointsIdentification of maternal and fetal riskfactors in antepartum and intrapartumperiods is vital for planning adequate careof high risk infantsSmall percentage of significant birthinjuries may occur despite skilled andcompetent obstetric careMetabolic abnormalities of diabetesmellitus in pregnancy adversely affectembryonic and fetal development

Key Points

Infection in newborn may be acquired:In uteroAt birthIn breast milkWithin nursery

Most common maternal infectionsassociated with congenital malformationsrepresented by acronym TORCH

Key PointsHIV transmission from mother to infantoccurs:

Transplacentally at various gestational agesPerinatally by maternal blood and secretionsBy breast milk

Preterm infants are at risk for problemsrelated to the immaturity of organ systemsHyperbilirubinemia has variety of etiologicfactors, including maternal-fetal Rh andABO incompatibility

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Key PointsInjection of Rho(D) immune globulin inRh-negative and Coombs’test–negative women minimizespossibility of isoimmunizationNurse often observes signs ofnewborn drug withdrawal andneonatal abstinence syndrome, andobtains information from maternalhistoryMajor congenital defects are now theleading cause of death in termneonates

Key Points

Curative and rehabilitative problems of achild with a congenital disorder are oftencomplex, requiring multidisciplinaryapproach to care

Key PointsParents often need specialinstructions before they take home ahigh risk infant

Cardiopulmonary resuscitation (CPR)Oxygen therapyNutrition requirements

Supportive care given to parents ofinfants with an abnormal conditionmust begin at birth or at time ofdiagnosis and continue for years