WEEK 8 - FINALS • Deficient diversional activity (lack of

NURSING CARE OF THE HIGH RISK NEWBORN stimulation) related to illness at birth

INTRODUCTION (Problems related to Maturity) • Readiness for developmental care to decrease

over stimulation easily caused by necessary
NURSING PROCESS OVERVIEW: ASSESSMENT lifesaving procedures

Obvious congenital anomalies and gestational OUTCOME IDENTIFICATION AND PLANNING

age (number of weeks the newborn remained in
utero). Be certain when establishing expected
outcomes that they are consistent with a
First assessment is done under a prewarmed newborn’s potential.
radiant heat warmer to guard against
heat loss. A goal that implies complete recovery from a
major illness, for example, may be unrealistic
Continuing assessment of high-risk infants for one newborn but completely appropriate for
involves the use of technology and equipment another.
such as cardiac, apnea, oxygen saturation, and
blood pressure monitoring. IMPLEMENTATION

Common sense observations by a nurse: Interventions for any high-risk newborn are
best carried out by:
Carefully evaluate comments from fellow nurses
such as an infant “isn’t himself” or “breathes A consistent caregiver
irregularly.”
Focus on conserving the baby’s energy and
These comments, although not evidence based, providing a thermoneutral environment to
are the same observations that parents who prevent exhaustion and hypothermia.
know their baby well report at healthcare
Visits. Painful procedures should be kept to a
minimum to help the infant achieve a sense of
NURSING DIAGNOSIS comfort and balance.

• Ineffective airway clearance related to the Assisting parents to participate in care such as
presence of mucus or amniotic fluid in the bathing or feeding their infant can help make
airway the child real to them for the first time and can
set the stage for effective bonding.
• Ineffective tissue oxygenation related to
breathing difficulty OUTCOME EVALUATION

• Ineffective thermoregulation related to • Infant maintains a patent airway.

immature status
• Infant demonstrates an ability to suck
• Risk for deficient fluid volume related to effectively.
insensible water loss
• Infant tolerates procedures without
• Risk for imbalanced nutrition, less than body accompanying apnea, bradycardia, or
requirements, related to the lack of strength for oxygen desaturation.
effective sucking
• Infant demonstrates growth and development
• Risk for infection related to lowered immune appropriate for gestational age, birth weight,
response due to prematurity and condition.

• Risk for impaired parenting related to illness in • Infant maintains a body temperature of 98.6°F
newborn at birth (37.0°C) in an open crib with one added blanket.
• Parents visit at least once and make three  Early preterm (born between 24 and 34
telephone calls to the neonatal nursery weeks)
weekly. Neonatal assessments such as:

• Parents demonstrate positive coping skills and  Inspection for sole creases
behaviors in response to the newborn’s  Skull firmness
condition and ability to care for their newborn.  Ear cartilage
 Neurologic development
 LMP pf mother
The Newborn at Risk Because of Altered  Sonographic estimation to determine
Gestational Age or Birth Weight - pg 1492 gestational age

 Term infants- week 38 & before week 42  Lack of lung surfactant, bcos this does not
of pregnancy form until 34th week of pregnancy

 Preterm infants - before the beginning of TABLE 26.1 Contrasts Between Small-For-
the 38th week of pregnancy Gestational-Age and Preterm Infants

 Post term infants or post mature - Infants

born after the end of week 41 of
pregnancy

 Appropriate for gestational age (AGA) -

between 10th & 90th percentiles of weight
for their gestational age, whether preterm,
term, or post term

 Small for gestational age (SGA)- fall below

the 10th percentile of weight

NOTE: The percentile lines include 5%, 10%,

25%, 50%, 75%, 90%, and 95%.

 Large for gestational age (LGA)- above the

90th percentile in weight are considered

Other terms used include:

• Low–birth-weight (LBW) infant: one weighing

less than 2,500 g at birth
Common Factors Associated With Preterm
• Very-low-birth-weight (VLBW) infant: one Birth
weighing less than 1500 g at birth

• Extremely-low-birth-weight (ELBW) infant:

one weighing less than 1,000 g at birth

THE PRETERM INFANT

 A preterm infant is traditionally defined as

a live-born infant born before end of week
37 of gestation.

 Late preterm (born between 34 and 37

weeks)
 f) Plantar creases.
PICTURES g) Breast tissue.
h) Ears.
i) Male genitalia.
j) Female genitalia.

 Preterm infant’s head appears

disproportionately large (≥3 cm greater
than chest size).

 The skin is ruddy because of little

subcutaneous fat beneath it, making veins
easily noticeable.

 Acrocyanosis may be present.

 Newborns delivered > 28 weeks of

gestation are covered with vernix caseosa.

 < 28 weeks of gestation), the vernix will be

lacking.

 Lanugo is usually scant

 Both anterior and posterior fontanelles will

be small.

 There are few or no creases on the soles of

the feet.

Figure 26.7 Examples of physical examination Eyes:

findings and reflex tests used to judge
gestational age.  most preterm infants appear small in
relation to term infants.
a) A resting posture.
b) Wrist flexion.  Pupillary reaction is present.
c) Recoil of extremities (legs)
d) The scarf sign.  Has myopia (nearsightedness)
e) Heel to ear.
Ears:  Blood drawing for electrolytes

 The ears appear large in relation to the  Complete blood counts

head.
 Blood gas analysis
 The cartilage of the ear is immature &
allows the pinna to fall forward.  Delaying cord clamping at birth to reduce
development of anemia
Neurologic:
Acute bilirubin encephalopathy (ABE)
 Reflexes such as sucking with coordinated
swallowing & breathing will be absent if an  Indirect or unconjugated bilirubin
infant’s age is below 33 weeks;
 Less serum albumin
 Deep tendon reflexes such as the Achilles
tendon reflex will also be markedly  Jaundice
diminished.
What to do?
 If the infant does cry, the cry is weak and
high pitched.  Phototherapy

 Exchange transfusion
Potential Complications
Persistent Patent Ductus Arteriosus

 Lack surfactant

 Pulmonary artery hypertension (PAH) -

blood can’t flow through your lungs

What to do?

 For preterm: administer IV therapy w/

CAUTION

 For term: Indomethacin or ibuprofen to

cause closure of a patent ductus arteriosus
for ventilation.
Because of immaturity, preterm infants are
prone to several specific conditions: NOTE: Indomethacin is associated w/ ADVERSE
Anemia of Prematurity EFFECTS such as ↓ renal function, ↓ platelet
count, and gastric irritation.
 Preterm infants develop a normochromic,
normocytic anemia (don’t have enough  Carefully monitor urine output
red blood cells to provide adequate
oxygen)  Observe for bleeding, especially at
injection sites, if this is prescribed.
 Which make infants appear pale, lethargic,
& anorectic. Periventricular/Intraventricular Hemorrhage

 Low levels of vitamin E  Periventricular hemorrhage (bleeding into

the tissue surrounding the ventricles)

 Intraventricular hemorrhage (bleeding into

What to do? the ventricles)
 Intraventricular hemorrhage occurs most  Dry
often in VLBW (very low birth weight)
 Cracked
infants and is classified as:
 Almost leatherlike skin from lack of fluid
• Grade 1, bleeding in the periventricular
 Absence of vernix
germinal matrix regions or germinal matrix,
occurring in one ventricle
 Meconium stained
• Grade 2, bleeding within the lateral ventricle
 Fingernails grown
without dilation of the ventricle
 Alertness 2-week-old baby than a
• Grade 3, bleeding causing enlargement of the
newborn
ventricles

• Grade 4, bleeding in the ventricles and What to do?

intraparenchymal hemorrhage
 Sonogram to measure the biparietal
 Long-term effect of hemorrhage may be diameter of the fetus.
the development of hydrocephalus
 Nonstress test or complete biophysical
What to do? profile to determine if placenta is still
functioning.
 Cranial ultrasound performed after the
first few days of life  Cesarean birth may be indicated if a
nonstress test reveals placental
compromised.

POST MATURE SMALL FOR GESTATIONAL AGE

 SGA (also called microsomia) if the birth

weight is below the 10th percentile.
• Preterm: before week 38 of gestation
• Term: between weeks 38 and 42
• Post term: past 42 weeks

 SGA infants are small for their age bcos

they have experienced intrauterine growth
restriction (IUGR) or failed to grow at the
expected rate in utero.

ETIOLOGY: COMMON FACTORS (SGA)

 Lack of adequate nutrition

POSTTERM INFANT
 Adolescents bcos only eat less
A postterm infant is one born after the 41st
week of a pregnancy.
 Chromosomal abnormality
Placenta appears to function effectively for only
 Intrauterine infection such as rubella or
40 weeks.
toxoplasmosis
Past the 40 weeks, fetus s begins to lose weight
 Most common cause of IUGR is a placental
(postterm syndrome)
issue
SGA infant:
 Women with systemic diseases that ↓
blood flow to the placenta ( diabetes
 mellitus or gestational hpn)
Laboratory Findings for SGA
 Women who smoke heavily or use opiates
↑ hematocrit level

ASSESSMENT for Post Mature ↑ RBC (polycythemia) - ↑ blood viscosity &

thrombus formation & hyperbilirubinemia

What to do?

 Exchange transfusion: hematocrit level

is > 65% to 70%

 IV glucose: ↓ 45 mg/dl

THE LARGE-FOR-GESTATIONAL-AGE INFANT

(LGA)

 LGA (also termed macrosomia) if the birth

APPEARANCE for Post Mature weight is above the 90th percentile.

Infant who suffers nutritional deprivation/  Baby appears deceptively healthy at birth
Measurement: but immature development.

 early in pregnancy: ↓ average in weight, ETIOLOGY: LGA

length, and head circumference.
 Overproduction of nutrients and growth
 late in pregnancy: ↑ in cell size, may have hormone in utero.
only a reduction in weight.
 This happens most often to infants of
Poor skin turgor: women who are obese or who have
diabetes mellitus.
 Large head, the rest of the body is so small.
 Multiparous women may also have large
 Skull sutures may be widely separated. babies because with each succeeding
pregnancy,babies tend to grow larger.
 Hair may be dull and lusterless.
 Beckwith– Wiedemann syndrome, a rare
 Infant may have a small liver. condition characterized by overgrowth &
congenital anomalies such as omphalocele.
 Abdomen may be sunken.
Omphalocele - birth defect in which the
 Umbilical cord often appears dry and may infant's intestine or other abdominal organs
be stained yellow. stick out of the belly button, or navel

Infant’s age is more advanced than the

weight/Overall wasted appearance:

 Sole creases

 Ear cartilage
  Extensive bruising or a birth injury such as
a broken clavicle or Erb–Duchenne
paralysis

 Prominent caput succedaneum (swelling,

or edema, of an infant’s scalp)

 Cephalohematoma or molding (trauma or

pressure to the head during labor)

Cardiovascular Dysfunction: LGA

Polycythemia may occur in an LGA fetus as the

fetus attempts to fully oxygenate more than the
average amount of body tissue.

Observe for signs of:

 Hyperbilirubinemia

ASSESSMENT: LGA  Heart rate

 Woman’s uterus appears to be unusually  Cyanosis

large for the date of pregnancy.
Polycythemia vera - a type of blood cancer. It
 Sonogram can confirm the suspicion. causes your bone marrow to make too many
red blood cells.
 Nonstress test to assess the placenta’s
ability to sustain a large fetus. Hypoglycemia : LGA

 Lung maturity may be assessed by  LGA infants also need to be carefully

amniocentesis. assessed for hypoglycemia in the early
hours of life.
 If an infant’s large size was not detected
during pregnancy, it may be first  Because large infants require large
recognized during labor when the baby amounts of nutritional stores to sustain
appears too large to descend through the their weight.
pelvic rim.

 If this happens, a cesarean birth may be

necessary because shoulder dystocia (the
wide fetal shoulders cannot pass

 Or needs significant manipulation to pass

through the outlet of the pelvis) would halt
vaginal birth at that point.

APPEARANCE for LGA

 At birth, LGA infants may show:

 Immature reflexes

 Low scores on gestational age

examinations in relation to their size. T
  Sepsis
Assessment for Large for Gestational Age
 Slow to transition to extrauterine life

 Pneumonia

 Low level or absence of surfactant

 Phospholipid that normally lines the alveoli

 Reduces surface tension

 Surfactant does not form until the 34th

week of gestation

Assessment for RDS

Signs of RDS:

 Low body temperature

 Nasal flaring

 Sternal and subcostal retractions

 Tachypnea (more than 60 breaths/min)

 Cyanotic mucous membranes

Acute Neonatal Conditions: RESPIRATORY  Po2 and oxygen saturation levels fall in
DISTRESS SYNDROME (RDS) room air

 Fine rales and diminished breath sounds

because of poor air entry

 Seesaw respirations

 Heart failure

 Pale gray skin

 Periods of apnea

 Bradycardia

 Respiratory distress syndrome (RDS) A.K.A  Pneumothorax

hyaline membrane disease, most seen in
premature babies.

Causes of RDS:

 Meconium aspiration syndrome (MAS) -

newborn breathes a mixture of meconium
and amniotic fluid into the lungs around
the time of delivery
Therapeutic Management for RDS 2.) Oxygen Administration

 Administration of oxygen is often

necessary to maintain correct Po2 & pH
levels.

 May be administered in a variety of ways:

I. simple cannula or mask

II. continuous positive airway pressure

(CPAP)

III. Positive end-expiratory pressure (PEEP)

 A possible complication of oxygen

therapy in immature or very ill infant:

I. ROP ( Retinopathy of Prematurity) - eye

disease

1) Surfactant Replacement (picture pink) (Lung II. Bronchopulmonary dysplasia (BPD) A.K.A
lavage) chronic lung disease

2) Oxygen Administration (CPAP) 3.) Ventilation

3) Ventilation (I/E 1:2)  Normally, on a ventilator, inspiration is

shorter than expiration, or there is an
4) Additional Therapy: Nitric Oxide (potent vascular inspiratory/expiratory (I/E) ratio of 1:2.
dilator)
 Infant ventilators are therefore available
5) Extracorporeal Membrane Oxygenation (ECMO) with a reversed I/E ratio (2:1).

6) Supportive Care (warm)  Complications of any type of ventilation:

1.) Surfactant Replacement I. Pneumothorax

II. Impaired cardiac output
 RDS can be largely prevented by the administration
of surfactant at birth for an infant at risk because
of low gestational age. 4.) Additional Therapy: Nitric Oxide

 Immediately after birth, synthetic surfactant is  Potent vascular dilator - help to

administered into an endotracheal tube by a oxygenate a newborn’s lungs
syringe or catheter (lung lavage)
 This causes systemic vasodilation.

 The nitric oxide enters the alveoli on

ventilation & redirects the pulmonary
blood by dilating the pulmonary
arterioles.
5.) Extracorporeal Membrane Oxygenation
 Most effective when given between weeks
Extracorporeal membrane oxygenation 24 and 34 of pregnancy
(ECMO) - 1st developed as a means of
oxygenating blood during cardiac surgery.  Steroid does not take effect before 24 to
48 hours
 Management of ECMO:

MECONIUM ASPIRATION SYNDROME - pg 1530

 Severe hypoxemia in newborns
 Meconium is present in the fetal bowel as
 Meconium aspiration early as 10 weeks of gestation.

 RDS  If hypoxia occurs, a vagus reflex is

stimulated, resulting in relaxation of the
 Pneumonia rectal sphincter.

 Diaphragmatic hernia - protrusion of  This releases meconium into the amniotic

abdominal fluid.

 Breech babies expel meconium.

Note: Used as a mainstay of therapy for RDS
but rarely needed bcos surfactant lavage is  Appearance of green to greenish black
so effective. from the staining.

6.) Supportive Care Assessment for MAS

 Infant with RDS must be kept WARM.  Difficulty establishing respiration at birth

 Because cooling ↑ acidosis in newborns,  Low APGAR score

& for the newborn with RDS.
 Tachypnea, retractions, & cyanosis
What to do?
 Infant should be placed on warmer, &
I. Provide hydration resuscitation should begin including the
initiation of positive pressure ventilation as
II. Nutrition w/ iv fluids necessary.

III. Glucose or gavage feedings bcos  After the initiation of respirations, an

respiratory effort makes infant too infant’s respiratory rate may remain rapid
exhausted to suck (tachypnea)

 Coarse bronchial sounds may be heard on

Prevention for RDS auscultation.

 RDS rarely occurs in mature infants.  Air trapping cause enlargement of the
anteroposterior diameter of the chest
 If level of lecithin obtained from amniotic (barrel chest)
fluid exceeds sphingomyelin by a 2:1 ratio:
C.S  Pulse oximetry / blood gase: ↓ PO2 and an
↑ PCO2
 Tocolytic agent such as magnesium sulfate
can help prevent preterm birth .  Chest X-ray will show bilateral coarse
infiltrates in the lungs, with spaces of
 2 injections of glucocorticosteroid hyperaeration (a peculiar honeycomb
(betamethsone) effect).
 The diaphragm will be pushed downward
Assessment for Neonatal Sepsis
 by the over expanded lungs.

Therapeutic Management for MAS

 Amnioinfusion to dilute the amount of

meconium in the amniotic fluid

 Cesarean birth - stained amniotic fluid is

identified during labor

 Oxygen administration & assisted

ventilation

 Antibiotic therapy (pneumonia)

Therapeutic Management for Neonatal Sepsis
 Surfactant (for lung compliance)

 Observe the infant for air tapping

(pneumothorax)

 Complication (ductus arteriosus remaining

open)

 Observe an infant closely for signs of heart

failure such as increased heart rate or
respiratory distress

 Physiotherapy with percussion and Assessment: HYPERBILIRUBINEMIA

vibration may be helpful to encourage the
removal of remnants of meconium from
the lungs

 Administered nitric oxide

 Maintained on ECMO to ensure adequate

oxygenation

NEONATAL SEPSIS
Therapeutic Management for
Hyperbilirubinemia

 Ports halogen light or special blue

florescent light

 And the distance is 12 to 30 inches

 Pale yellow - breastfeeding and sweet

smelling

SIDS (Sudden Infant Death Syndrome)