High Risk Newborn

Mary L. Dunlap MSN, APRN Fall 10

Preterm Infant

• Infant born prior to the completion of the 37 th week • Organs immature • Lack physical reserves • Survivability related to weight / gestational age

Preterm Infant Respiratory last to mature

• Surfactant deficiency-RDS • Unstable chest wall-atelectasis • Immature respiratory centers-apnea • Small passages-obstructions • Unable to clear fluid-TTN

Preterm Infant Cardiovascular

• Difficulty transitioning from fetal to neonatal circulatory pattern • Congenital anomalies due to continued fetal circulation • Fragile blood vessels (brain) • Impaired regulation of B/P

Preterm Infant Gastrointestinal

• Lack neuromuscular coordination suck swallow-breath • Hypoxia shunts blood from the gut ischemia and intestinal wall damage • Risk for malnutrition -wt. loss • Small stomach-compromised metabolic function

Preterm Infant Renal System

• Slow glomerular filtration rate • Reduced ability to concentrate urine • Risk: fluid retention, electrolyte imbalance, drug toxicity

Preterm Infant Immune system

• Deficiency of IgG • Impaired ability to produce antibodies • Thin skin- limited protection barrier

Preterm Infant Central nervous system

• Long term disability due to injury • Difficulty maintaining temperature • Compounded by lack of brown fat

Preterm Infant Nursing Management

• Varies with gestational Promote Oxygenation • Maintain body temperature • nutritional needs • Prevent infections • Provide stimulation • Pain management

Small for Gestational Age

• SGA weight- less than 5lb 8 oz and below the 10 th % at term • IUGR- High risk growth does not meet the norm and is pathologic • Symmetric IUGR- poor growth rate of head, abdomen and long bone • Asymmetry IUGR- head long bones spared

Small for Gestational Age Characteristics

• Decreased breast tissue • Scaphoid abdomen (sunken) • Wide sutures • Thin umbilical cord • Head larger than body • Wasted appearance to extremities • Reduced fat stores

Small for Gestational Age Common Problems

• Perinatal asphyxia • Hypothermia • Hypoglycemia • Polycythemia • Meconium Aspiration

Large for Gestational Age Characteristics

• LGA weight- Larger than 9 lbs and above the 90 th % • Large body-plump full face • Body size is proportionate • Poor motor skills • Difficulty in regulating behavioral state (arouse to quiet alert state)

Large for Gestational Age Common Problems

• Birth Trauma • Hypoglycemia • Polcythemia • Hyperbilirubinemia

Post term Infant

• Gestation > 42 weeks • Must determine if EDC is truly post term • After 42 weeks placenta loses ability to nourish the fetus

Post term Infant Characteristics

• Newborn emaciated • Meconium stained • Hair and nails long • Dry peeling skin • Creases cover soles • Limited vernix and lanugo

Infant of Diabetic Mother

• Mother can have pregestational or gestational diabetes • Increasing numbers of type 2 • Related to increase in morbidity & mortality • Congenital abnormalities

Infant of Diabetic Mother

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Congenital abnormalities- during first trimester due to fluctuations in BS and ketoacidosis

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Macrosomia- develops last trimester due to maternal hyperglycemia- excessive fetal growth

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Tight control over glucose levels needed ( less than 1-0mg/dl)

Infant of Diabetic Mother Common Problems

• Congenital Abnormalities • Macrosomia • Birth Trauma • Perinatal Asphyxia • RDS • Hypoglycemia • Hyperbilirubinem ia • Polycythemia

Infant of Diabetic Mother Infant Characteristics

• Rosy cheeks • Short neck • Wide shoulders • Excessive subcutaneous fat • Distended abdomen

Infant of Diabetic Mother Nursing Management

• Monitor glucose level q. 3 to 4 hrs. level no above 40 mg/dl • Until stable monitor q. 3-4 hrs • Feed q. 2-3 hrs • IV glucose • Monitor serum bilirubin levels • Maintain thermal environment

Respiratory Distress Syndrome

• RDS caused by lack of surfactant • Poor gas exchange & ventilation • Seen in preterm newborns • Cesarean births without labor • Infants of diabetic mothers

Respiratory Distress Syndrome Symptoms

• Tachypnea • Expiratory grunting • Nasal flaring • Retractions • See-saw respiration • Chest x-ray- alveolar atelectasis (ground glass pattern) & dilated bronchioles ( dark streaks within granular pattern)

Respiratory Distress Syndrome Nursing Management

• Thermoregulation • O2 administration • Mechanical ventilation if needed • Hold parenteral feedings • Monitor VS & O2 sats • Provide nutrition ( gavage feedings)

Transient Tachypnea Newborn TTN

• Mild respiratory condition • Result of delayed absorption of fluid • Last about 3 days

Transient Tachypnea Newborn TTN Symptoms

• Respiratory rate as high as 100-140 • Labored breathing • Grunting nasal flaring • Retractions • Chest x-ray shows lymphatic engorgement ( retained lung fluid)

Transient Tachypnea Newborn Nursing Care

• Mainly supportive • Monitory VS & O2 Sats • Provide supplemental O2

Meconium Aspiration

• Fetus inhales meconium into the lungs while in utero • Meconium blocks the airway preventing exhalation • Meconium irritates the airway making breathing difficult • Meconium aspiration related to fetal distress during labor.

Meconium Aspiration Symptoms

• Cyanosis • Rapid breathing • Labored breathing • Apnea • X-ray patches or streaks of meconium & trapped air

Meconium Aspiration Nursing Management

• Assess for risk factors prior to delivery • Suction at delivery prior to newborn crying • Supplemental O2 • Mechanical ventilation • Antibiotic therapy

Hyperbilirubinemia

• Excess of bilirubin in the blood elevated bilirubin level > 5mg/dl • Heme from erythrocytes break down forms unconjugated bilirubin • Jaundice • Physiologic • Pathologic

Hyperbilirubinemia Causes

• Drugs/Medical conditions disrupt conjugation and albumin binding sites • Decreased hepatic function • Increased erythrocyte production • Enzymes in breast milk

Hyperbilirubinemia Physiologic

• Develops in 3-4 days after term birth • Develops3-5 days after preterm birth • Term birth resolves 7 days • Preterm birth resolves 9-10 days • Unconjugated bilirubin level < 12mg/100 ml

Hyperbilirubinemia Pathologic

• Develop after first day • Persists beyond 7 days • Bilirubin > 12.9mg/100 term • Bilirubin > 15mg/100 preterm • Increases > 5mg/100ml in 24hrs

Hyperbilirubinemia Nursing Management

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Phototherapy Increase feeding to q 2-3 hrs

Phenylketonuria PKU

• Inability to metabolize phenylalanine amino acid found in protein • Affect brain and CNS development • Interferes with the production of melanin, epinephrine & thyroxine • Both parents must pass the gene on

Phenylketonuria PKU Symptoms

• Seizures • Irritability • Tremors • Jerking movements arms & legs • Hyperactivity • Unusual hand posturing

Phenylketonuria PKU

• Diagnosed with PKU screening prior to discharge from hospital

Hemolytic Disorders

• Hemolytic disease occurs when blood groups of mother and newborn are different • Antibodies are present or formed in response to antigen from fetal blood crossing placenta and entering maternal circulation

Hemolytic Disorders

• Maternal antibodies of IgG class cross placenta, causing hemolysis of fetal RBCs –Fetal anemia –Neonatal jaundice –Hyperbilirubinemia

Hemolytic Disorders

• Rh incompatibility (isoimmunization) –Only Rh-positive offspring of Rh negative mother is at risk –If fetus is Rh positive and mother Rh negative, mother forms antibodies against fetal blood cells

Hemolytic Disorders

• ABO incompatibility –Occurs if fetal blood type is A, B, or AB, and maternal type is O –Incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across placenta to fetus –Exchange transfusions required occasionally

Neonatal Infections Sepsis

–Bacterial, viral, fungal –Patterns • Early onset or congenital • Nosocomial infection—late onset

Neonatal Infection

Septicemia • Pneumonia • Bacterial meningitis • Gastroenteritis is sporadic

Neonatal Infections

• TORCH infections – Toxoplasmosis – Gonorrhea – Syphilis – Varicella-zoster – Hepatitis B virus (HBV) – Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)