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High Risk Newborn Lecture
Preterm Infant
Born before 38 weeks gestation Immaturity of all systems
Physical assessment
Gestational age <37 weeks Resp. irregular Bowel sounds diminished Temp below 97.8 Hypoglycemia Poor suck and swallow Poor flexion
Psychosocial Assessment
Parents shock & disbelief Fear holding baby Grieve for “perfect” baby Financial concerns Fear for Baby’s life
Goals
safe effective environment Maintain resp & nutrition & temp Promote interaction with parents Education of parents in care
Implementations
Antibiotics Fluids & electrolytes (bicarb & Ca) Oxygen, Chest therapy Coordinate labs & tests Monitor Temp, apical P, Resp Handle carefully, reposition Tactile stimulation for apnea, suction prn
Implementations Con’t.
Avoid exposure to infection Gavage feed q 2-3 hr, Premie formula freeze breast milk psychological support, share info, reinforce
positives share caretaking responsibilities with parents allow to ventilate feelings
Nutrition of the Preterm Infant
Initially needs 80-100 ml/Kg/day may need more fluid if lower birth weight
Requires 120-150 cal/Kg/day oral intake for growth
Supplemental multivitamins, Vit E, folic acid and calcium
Desired weight gain 20-30 g/day Desired initial weight loss only 1-2% per
day
Risk of Intraventricular Hemorrhage Hypoxia Inc. BP, Inc. head pressure
• (do not place in Trendlenberg position)
Chest percussion Assess: fontanels for increase in size
• seizures, apnea, bradycardia, drop in Hct
Preterm Case Study
Baby Girl Petite
Small for Gestational Age
Definition= below 10th percentile on growth chart
Problems: Congenital problems• fetal distress• hypoglycemia• polycythemia• infection• aspiration of Meconium
SGA
Nursing Care for SGA
Maintain airway & temperature Sx resp distress Monitor glucose level, sx hypoglycemia Provide NTZ, minimize heat loss Provide Feedings, touch, support, teaching Evaluate Hct, sx sepsis,
Case Study Small for Gestational Age Baby Boy Slim
Large for Gestational Age
Defined- Above the 90th percentile on growth chart
Problems: Birth trauma• Infant of Diabetic Mother• Hypoglycemia• Respiratory Distress Syndrome (RDS)• Hypotension• Sepsis
Nursing Care of LGA
Maintain Resp. Observe for sx sepsis (& prevent)
Monitor Temp, minimize heat loss Sx hypoglycemia, monitor Glucose levels Initiate early feedings Provide touch & cuddling Support parents & teach
Postterm Infant
Description: born after 42 weeks gestation Problems: Hypoglycemia
• meconium aspiration (MAS)• polycythemia• seizure activity• cold stress
Physical Characteristics of Postterm wide-eyed & alert (irritable) Skin- no lanugo, dry, cracked, parchment-like Fingernails long, over ends Scalp hair profuse Body long and thin (fat & muscle wasting) Meconium staining of nails & umbilical cord
Case Study for Postterm Infant
Baby Girl Green
Cold Stress in Infants
Excessive heat loss Use of compensatory mechanism
• inc. respirations• non-shiver themogenisis
Preterm and SGA at risk
COLD STRESS
D ec . O xyg en
A te lec tas is
D ec . S u rfac tan tP rod u c tion
A c id em ia
H yp oxem ia
D ec . b lood flowto lu n g s
P u lm on aryvasocon s tric t ion
re leaseo f n orep in p h erin e
COLD STRESS
H yp erb iliru b in em ia
In c . F a tty ac id s
In c . A n aerob ic M etab o lism
H yp og lycem ia
U se o fG lu cose
In c . O xyg encon su m p tion
In c . M etab o licR ate
Signs & Symptoms of Cold Stress
Inc. Resp (sx Non Shiver Thermogenesis) Dec. Skin temp Dec. peripheral profusion Dec. Blood Glucose (using to generate heat)
Nursing Care for Cold Stress
Warm slowly (too rapid may cause apnea) check skin temp q 15 min. maintain Neutral Thermal Environment Monitor BGK for hypoglycemia Give feeding or glucose (IV) to inc. Blood
Glucose
Necrotizing Enterocolitis
Complication of Premie• r/t dec. blood flow to GI tract• 2 º to hypoxia or shock
Signs & Symptoms
Dec. bowel sounds or none Inc. abd. Girth Bowel loops No meconium or OB + stool Temp instability Inc. apnea, bradycardia Inc. in feeding residuals
Treatment
GI rest (NPO) Antibiotics Surgery TPN NG or gavage feedings advance to bottle feedings
Case Study Necrotizing Enterocolitis Tiny Tim
Infant of a Diabetic Mother
Risk of Hypoglycemia Blood Glucose < 40 mg/dl R/T overstimulated fetal insulin production
Assessment
Predisposing Factors for Hypoglycemia• Preterm or premature birth• Large for Gestational age• Maternal diabetes• Hypertension• Infant stress
Signs and Symptoms Jitteriness, twitching, seizures Poor-feeding, weak sucking reflex Irregular respiration cyanosis, respiratory
distress Edema (bloated appearance) Weak, high-pitched cry Poor muscle tone Low blood sugar & low serum calcium
levels
Case Study- Infant of Diabetic Mother Larry Large
Goals
Environment will be safe without signs of hypoglycemia
Parents will ask questions re care of infant & signs and symptoms
Parents will be able to demonstrate proper infant care.
Implementation
Assess parental awareness & understanding Assess feelings of guilt Assess vital signs, BGK, serum Ca &
seizures Administer 10% glucose IV as ordered Facilitate early full feedings Prevent infection
Hyperbilirubinemia Elevated bilirubin level r/t :
• Physiologic Jaundice: 3-5 days > 12 mg/dl• Prematurity: liver not able to metabolize bili• ABO, Rh incompatibilities: Mother “O” Baby
A,B, AB mom’s antibodies cross placenta
O
A,B,AB
Hyperbilirubinemia Elevated bilirubin level r/t :
• Breast Milk: reduced excretion of bilirubin• Extravascular hemolysis: bruises,
cephalohematoma, petechiae• Others: polycythemia, drugs, hypoglycemia,
hypoxia
Assessment biliflash above indication line
Assessment Con’t
serum bili 8-12 mg/dl at 1-2 days and > 12 mg/dl 3-5 days
palpable spleen, enlarged liver poor feeding, edema vomiting, fever, dark urine
Kernicterus Diminished Moro reflex Poor sucking Difficult feeding High pitched cry Setting sun eyes Irritability or Seizures Opisthotonos
• muscle spasms • back arching)
Baby with Jaundice
Baby Under Bili Lights
Goals
Pt will have bili level less than 12 mg/dl, no signs of jaundice
Parents will state they feel supported, counseled, educated
Parents will demo correct care measures for infant with jaundice
Implementations
Phototherapy: Bili Light or Blanket• Undress• Shield eyes (remove for feeding) & genitals• Monitor temp q 2hr• Fluids q2 hr to avoid dehydration• Change position q 2 hr• Weigh q12 hr, I &O, assess hydration
Implementations Con’t
Observe stools & urine for darkening Observe for tanning (bronze baby
syndrome) Plexiglas shield between infant & light Record number of lights used and hours Monitor bili levels Q 6-8 hr
Management of Exchange Transfusion NPO, aspirate stomach contents, suction
airway prior Informed consent signed by parents Check blood typing Restrain infant Place under radiant warmer Incremental amt. of blood withdrawn &
infused VS q 15 min, glucose levels, Ca levels, Bili
levels
Implementations Con’t Enc. parents to visit Share information about condition, bili
levels, weight Provide auditory stimulation
• (music, humming)
Case Study Jaundice
Baby Mary
Prenatally Drug Exposed Case Study Patient- Kim Brown
Respiratory Distress Syndrome
Formally hyaline membrane disease Surfactant is absent, deficient of altered Symptoms occur within 6-12 hours of birth
Other Causes of Respiratory difficulty Aspiration Syndromes
• fluid or meconium• diminished pulmonary perfusion, present at birth
Apnea due to prematurity• apnea >20 sec. cyanosis, hypotonia, acidosis
Pneumonia apparent 2-5 days after birth Wet Lung Syndrome
• excessive pulmonary fluid (C-section)
RDS leading to Respiratory FailureBecause of Dec Surfactant
Dec lung compliance
Atelectasis
Dec P O2Anaerobic Metabolism
Acidosis
Inc Work Load
Dec Ventil
Inc CO2Pulmonary & Peripheral Vasoconstriction
R to L shunt
Pulm artery Pressure
Dec Pulm blood flow
Poor peripheral perfusion
Dec Surfactant
Metabolic
Resp
Assessment
Risk factors i.e. prematurity Flaccid extremities & edema Hypothermia, hypotension Skin pale or cyanotic Respiratory grunting, retractions, nasal
flaring• diminished breath sounds, tachypnea, abn. x-ray
or ABG
Expected Outcomes
O2 sat >95%, Resp 30-50/ min Resp without nasal flaring, grunting,
retractions Clear Breath sounds, Apnea <10 sec. VS WNL Maintains temp, nutrition, no sx infection Parents express fears & concerns
Implementations
Assess respirations Prevent fatigue by spacing activities and
decrease handling Suction prn, Chest physiotherapy (percussion) Position with neck sl. hyperextended & change
q2h Lower O2 slowly Monitor VS & temp of environment
Oxygen Hood
Implementations Con’t
I&O, urine pH, Daily Wt. Nutrition- NPO IV fluid 60-150 ml/Kg in
24 hr• gavage feed, advance to nipple, ck residual
Support for parents• explain, visits, include in care, share info• allow to express fears, anxiety, shock
Pharmacotherapy
Antibiotics- PCN, Gentamicin IV fluids via umbilical artery catheter IV bicarbonate (corrects acidosis) Assess UAC for infection, hemorrhage,
thrombus
Umbilical Artery Catheter
Enhance Respiratory Function
Oxygen by hood Continuous airway pressure Volume ventilation Warm & humidify Oxygen Assess ABG q 4h via UAC
Case Study
Respiratory Distress Syndrome