Nursing Care for the High Risk Newborn & Family
High Risk Newborn
During pregnancy, screening for high is essential.
Dysmature-infant who is born before term or postterm, who is under or overweight for gestational age.
Assessment:
At birth for anomalies and gestational age (number of weeks in utero).
Monitors, 1:1nursing care, common sense.
Goals may not be full recovery.
Focus on conserving energy, temp,
Nursing Process
Minimize pain, parent teaching, support, and referrals.
Outcome Evaluation:
Long term follow up and care.
Patent airway, growth and development, temp, visits by parents, coping skills.
High Risk Newborn
Newborn Priorities in First Days of Life
Initiations and maintenance of respirations
Establishment of extrauterine circulation
Control of body temperature
Intake of adequate nourishment
Establishment of waste elimination
Prevention of infection
Establishment of an infant-parent relationship
Developmental care, balance physical and mental development.
High Risk Newborn
May require special equipment and/or care measures.
Difficulty may appear during intrapartum period, at birth or at initial APGAR.
Initiating and Maintaining Respirations:
Prognosis depends on how the first moments of life are managed.
Most deaths occur during the 1st 48 hours
Due to inability to establish or maintain adequate airway.
Cerebral hypoxia, residual neurologic dysfunction
High Risk Newborn
Most infants have some degree of respiratory acidosis.
Blood pH and bicarbonate buffer system may fail if not corrected quickly. (2 min)
May already have some degree of asphyxia due to cord compression, maternal anesthesia, placental previa or preterm separation of the placenta.
Resuscitation:
Factors – low birth wt., diabetes,
High Risk Newborn
Circulatory shunts particularly ductus arteriosus, fail to close
Infant uses available serum glucose quickly, may become hypoglycemic, compounds the problem.
Establish and maintain airway
Expanding the lungs
Initiating and maintaining effective ventilation.
If not sufficient the heart will fail. CPR
High Risk Newborn
Airway:
Suction with bulb syringe and rub back to see if skin stimulation initiates respirations.
Dry infant, may need warmed O2
Lay on back , head and shoulders elevated
Suction 10 seconds (vagus stimulation)
Laryngoscope, deep suctioning, endotracheal tube inserted, O2 100% @ 40 to 60 breaths per minute.
Primary apnea-several week gasps of air then stops breathing. Halted respirations.
High Risk Newborn
After 1 to 2 minutes of apnea the infant tries to initiate respirations with strong gasps. Can not maintain this – 4 to 5 minutes moves to secondary apnea.
Can occur in utero.
Team-OB, Ped, neonatologist, anesthesiologist, NP
Laryngoscope size 0-1 for newborns.
Risk of hemorrhage.
High Risk Newborn
Lung Expansion:
Crying is proof that lungs have expanded.
Mask cover both nose and mouth.
Pressure needed to open lungs alveoli for 1st time is 40cm H2O then 15 to 20 cm.
Auscultate chest. Pulse ox.
If meconium do not stimulate. Wait for suction.
Watch that both sides are aerated.
High Risk Newborn
Drug Therapy:
Narcan- for respiratory depression due to Morphine. Inject into umbilical vessel or IM. 0.01 to 0.1 mg/kg body weight.
Ventilation Maintenance:
Monitor for next few hours.
Increasing respiratory rate is 1st sign.
Check for retractions, place under warmer and remove clothing from chest, elevate HOB 15 degrees, suction, O2, pulse Ox.
High Risk Newborn
Establishing Extrauterine Circulation:
Cardiac function is not so quickly restored.
If < 80 bpm do closed chest massage.
Depress sternum with 2 fingers 1 to 2 cm rate 100 / minute. Respirations 30/ minute.
Palpate femoral pulse
After not > 80/min in 30 sec. Spray in ET epinephrine 0.1 to 0.3 mL/kg.
Transport to NICU.
High Risk Newborn
Maintaining Fluid And Electrolyte Balance:
Hypoglycemia may result. Check glucose.
Dehydration-IV RL or D5%W, Na, K
Monitor closely the rate of fluid due to patent ductus arteriosus or heart failure.
Urine output < 2mL/kg/h or SG >1.015 to 1.020 (kidney or ADH secretion).
Hypotension
Hypovolemia
RL to increase blood volume.
High Risk Newborn
Regulating Temperature:
Neutral temperature environment. Less demand on infant and maintains metabolic rate.
Give O2 to increase metabolic rate (become hypoxic)
Decreased PO2 level may open fetal right to left shunts again.
Surfactant
Risk of kernicterus (invasion of brain cells with unconjugated bilirubin).
High Risk Newborn
Radiant Heat Source:
Open beds with over head radiant heat source.
Probe is placed between umbilicus and xiphoid process of infant.(not on rib cage).
May also need a warming pad under infant.
Isolettes:
Incubator (portholes lose heat if opened for long intervals).
Check temperature frequently.
High Risk Newborn
When improved, weaning by setting temp 2 degree below infant’s temp. in 30 min check infants temp. if maintained reduce by another 2 degrees until room temp is reached.
Kangaroo Care:
Skin to skin contact to maintain body heat.
Diaper and hat on infant, cover both with a blanket, dim lights.
High Risk Newborn
Establishing Adequate Nutritional Intake
Establish respiratory rate and rule out NEC necrotizing enterocolitis.
IV fluids, gavage feedings.
Preterm breast fed if possible (express milk) can be used in gavage feeding.
Pacifier at feeding times if sucking reflex is present.
Establishing Waste Elimination
Document any voiding. Kidneys perfused.
Document any meconium or stool.
High Risk Newborn
Preventing Infection:
Infection increases metabolic demand.
Stresses immature immune system.
Can be prenatal, perinatal or postnatal.
Cytomegalovirus and toxoplasmosis viruses
Congenital anomalies
From vagina-group B strep septicemia, thrush from candida and herpes.
Postnatal is from health care personal.
High Risk Newborn
Establishing Parent Infant Bonding:
Visit NICU before birth, afterwards visit and bond.
Keep parents informed, give name and number of contact person.
See baby after death.
Developmental Needs:
Most high risk infants catch up growth occurs once stabilized from trauma.
Home care visits.
High Risk Newborn
Follow Up of High Risk Infants at Home:
Asses their level of knowledge.
Educate and refer to home care agency.
High Risk Infants and Child Abuse:
Parents become more protective.
Due to separation from the family, bonding was not complete.
Altered Gestational Age or Birth Weight
Assessed at birth and placed on growth chart.
Term infants-38 to 42 weeks pregnancy.
High Risk Newborn
Preterm infants-less than 37 weeks regardless of birth weight.
Postterm infants-after 43 weeks
AGA-appropriate for gestational age-between 10th to 90th percentile of weight.
SGA-small for gestational age-below 10th percentile of weight for their age.
LGA-large for gestational age-above 90th percentile of weight for their age.
Low birth weight-under 2500 g
Very low birth weight-less than 1500 g.
High Risk Newborn
Small for Gestational Age Infant:
IUGR-intrauterine growth restriction or retardation.
Failed to grow at expected rate in utero.
Cause:
Mother’s nutrition plays a major role
Adolescents
Placental anomaly
Systemic diseases – diabetes, hypertension
Smokers, narcotic use, infections
High Risk Newborn
Assessment:
Prenatal care; fundal height, sonogram, poor placental function,
Appearance:
Below average; weight, length, and head circumference. Overall wasted appearance. Small liver, poor skin turgor, wide sutures, dull hair, sunken abdomen, cord dry and stained yellow.
Lab Findings:
High Hct, RBC, and decreased glucose.
High Risk Newborn
Large for Gestational Age Infant:
Macrosomia
May appear healthy but exam reveals immature development.
Cause:
Over production of growth hormone in utero.
Mother with diabetes
Muitiparous women
Transposition of great vessels.
High Risk Newborn
Assessment:
Uterus unusually lg for date of pregnancy.
Sonogram
Nonstress test
Amniocentesis-lung maturity
Cesarean birth.
Appearance:
Immature reflexes, low score on gestational age exam.
Bruising, injury,extreme molding.
High Risk Newborn
Cardiovascular Dysfunction:
Cyanosis, polycythemia, hyperbilirubinemia
Hypoglycemia:
Uses up nutritional stores
High glucose levels if mother is diabetic and will increase for 24 hours, rebound.
Preterm Infant:
Before end of week 37of gestation
Birth weight < 2500g (5 lb 8 oz) at birth.
Need NICU
Preterm
Lack lung surfactant = RDS
Maturity determined by sole creases, skull firmness, ear cartilage, neurologic findings, mothers report of date of last period and sonogram.
Incidence:
7% whites, 14% African American.
Causes:
Nutrition
Testing by amniocentesis, ultrasound best.
Preterm
Assessment:
History – do not refer to smoking or working 12 hour shift contributed to preterm delivery.
Guilt may deter bonding. Support.
May not realize she is in labor.
May not feel well or have flu like symptoms.
Appearance:
Small and underdeveloped
Head lg 3 cm or more than chest, ruddy skin
Preterm
Noticeable veins, acrocyanosis.
Vernix-24 to 36 week covered, < 25 weeks none.
Lanugo extensive-back, forearms, forehead, sides of face.
Fontanelles small
Few or no creases on soles of feet.
Small eyes, pinna falls forward, ears lg, absent swallowing or sucking if <33 weeks
Reflexes poor, rarely cries (week high pitch)
Preterm
Potential Complications
Anemia of Prematurity:
Normochromic, normocytic anemia
Reticulocyte low
Pale, lethargic, anorectic
Due to hematopoietic system and destruction of RBC due to low levels of vitamin E
Give DNA recombinant erythropoietin, blood transfusion, vitamin E, iron
Preterm
Kernicterus:
Destruction of brain cells by invasion of indirect bilirubin.
More prone due to acidosis
Less serum albumin to bind indirect bilirubin (low as 12mg/100 mL)
If jaundice – phototherapy or exchange transfusion.
Persistent Patent Ductus Arteriosus:
Lack surfactant – lungs noncompliant.
Preterm
More difficult to move blood from pulmonary artery into lungs.
Causes pulmonary artery hypertension, which may interfere with closure of the ductus arteriosus.
Indomethacin given may initiate closure of patent ductus arteriosus.
Periventricular/Intraventricular Hemorrhage:
Bleeding into tissues surrounding the ventricles or into the ventricles.
Occurs in 50% of low birth wt. baby’s
Preterm
Fragile capillaries and immature cerebral vascular development.
Do cranial ultrasound to detect if hemorrhage has occurred.
Other Potential Complications
Difficulty initiating respirations
Give mother O2 by mask during birth.
Resuscitate within 2 minutes after birth.
Keep warm, periodic respirations.
Preterm
Water loss due to lg body surface
Unable to concentrate urine, excretes high proportion of fluids. 40 to 100mL /kg/24h
Needs 160 to 200 mL of fluid /kg of body wt. (IV 27 gauge needles)
Umbilical venous catheter.
Monitor wt., urine output, specific gravity, serum electrolytes.
Blood glucose q 4-6 hours (40 to 60 mg/dl
Keep record of all blood drawn.
Preterm
Nutrition – requires lg. amount.
Immature reflexes, sm stomach,
Feeding Schedule
TPN until stable, chest x-ray before first feeding.
Needs 115 to140 calories/kilogram of body wt /day
May take 1 to 2 mL every 2 to 3 hours.
Gavage Feeding
Gag reflex not intact until 32 weeks
Preterm
Give 1 mL /hour
Introduce breast or bottle feeding gradually as infant matures.
Pacifier helps strengthen sucking reflex
Formula
Caloric concentration 24 cal/oz
Minerals and electrolytes
Vitamin K 0.5 mL, E, A.
Breast Milk
Best, mother can express. High in sodium
Preterm
Difficulty maintaining body temperature.
Baby remains extended.
Little subcutaneous fat, and brown fat.
No shivering, or sweating.(immature CNS)
Skim is easily traumatized and less resistant to infections. Has difficulty producing phagocytes and has deficient of IgM antibodies.
1st and 2nd periods of reactivity observed in 1 h and 4 hours are delayed.
Preterm
Reactivity may not appear for 12 to 18 hours, (conserve energy).
Infant needs loving attention.
Give information and support.
Sibling visitation and restrictions.
Schedule visits, procedures, rest, decrease pain.
Prepare for discharge.
Plans for beyond the immediate newborn period.
Postterm Infant
After 42 weeks of pregnancy.
Induction of labor at 2 weeks postterm.
Risks:
Placenta functions effectively for 40 weeks.
Infant develops postterm syndrome:
Dry, cracked, almost leather like skin.
Absence of vernix
Lightweight
Less amniotic fluid, meconium staining.
Long fingernails
Postterm
Alertness more like a 2 week old baby.
Sonogram
Nonstress test or biophysical profile.
Cesarean birth may be indicated.
At birth, difficulty establishing respirations.
Hypoglycemia
Low SQ fat, temperature regulation difficult
Polycythemia, dehydration.
Elevated hematocrit.
Woman becomes anxious and angry.
Postterm
Feels the baby should be extra strong and healthy since it was in utero longer.
Track developmental abilities until school age.
Neurological symptoms that become apparent when fine motor tasks attempted.
Illness In The Newborn
Respiratory Distress Syndrome RDS:
Formerly termed hyaline membrane disease
Occurs in perterm infants, infants of diabetic mothers, cesarean births, for any reason for decreased blood perfusion of the lungs.
Patho: hyaline-like (fibrous) membrane comprising products formed from an exudate of the infant’s blood that lines the terminal bronchioles, alveolar ducts, and alveoli. Prevents the exchange of oxygen
Illness In The Newborn
and carbon dioxide at the alveolar-capillary membrane.
Cause: low level or absence of surfactant.
High pressure is required to fill lungs with air for the first time and overcome the pressure of lung fluid.
Areas of hypoinflation occur and pulmonary resistance is increased,
Blood shunts through the foramen ovale and the ductus arteriosus as it did during fetal life. Surfactant decreases even further.
Illness In The Newborn
Poor O2 leads to tissue hypoxia, which causes release of lactic acid. Increased CO2 > severe acidosis > vasoconstriction and decreased pulmonary perfusion >decreased surfactant production > alveoli collapsing.
Assessment:
After resuscitation may seem stable or may have subtle signs:
Low body temperature
Nasal flaring
Sternal and subcostal retractions
Illness In The Newborn
Tachypnea > 60/minute
Cyanotic mucous membranes
With in several hours:
Expiratory grunting, indicates prolonged expiratory time, compensatory mechanism from closure of the glottis.
Increases pressure in alveoli on expiration
Helps keep alveoli from collapsing
Makes O2 exchange more complete
Illness In The Newborn
Disease progresses infants become cyanotic
PO2 and O2 saturation levels fall
Rales and diminished breath sounds
Exhibits:
Seesaw respirations
Heart failure
Pale gray skin
Periods of apnea
Bradycardia
Pneumothorax
Illness In The Newborn
Diagnosis made on signs of :
Grunting, cyanosis in room air, tachpnea, nasal flaring, retractions and shock.
Chest X-Ray (ground glass-haziness)
Blood gas studies (umbilicial vessel catheter- for acidosis)
Group B strep mimics RDS
Cultures of blood,CSF and skin to rule out infection.
Tx.
Administration of surfactant through
Illness In The Newborn
endotracheal tube at birth. Infant is held upright and then tilted downward.
Oxygen administration:
Necessary to maintain correct PO2 and pH levels.
CPAP or PEEP
Retinopathy is possible complication.
Ventilation:
Inspiration shorter than expiration normally
Fear of pneumothorax
Illness In The Newborn
Impaired cardiac output
Increased intracranial and arterial pressure and hemorrhage.
Indomethacin may be used to cause closure of patent ductus artheriosus
Monitor I&O and for bleeding.
Pavulon IV-muscle relaxant-allows mechanical ventilation to work. Keep Atropine and Prostigmin immediately available.
Illness In The Newborn
EMCO-Extracorporeal Membrane Oxygenation.
For chronic severe hypoxemia in newborns with meconium aspiration, RDS, pneumonia, diaphragmatic hernia, near drowning victims or infants with severe lung infections.
Blood is removed by gravity using a venous catheter in rt. atrium of heart to EMCO-oxygenated and rewarmed-returned to infants aortic arch.
Illness In The Newborn
ECMO is used for 4 to 7 days
Risk of intracranial hemorrhage, possibly due to anticoagulants.
Liquid Ventilation:
Use of perfluorocarbons
Weight of the fluid helps distend the lung, O2 is carried with it and spreads over the lung surfaces and O2 exchange occurs.
Nitric Oxide:
Causes pulmonary vasodilation and can
Illness In The Newborn
help increase blood flow to the alveoli when persistent pulmonary hypertension is present.
Supportive Care:
Keep warm, hydrate, nutrition with IV fluids, glucose or gavage feedings.
Prevention:
RDS rarely occurs in mature infants.
Tocolytic agents- terbutaline,
Steroids quicken formation of lecithin production pathways.
Illness In The Newborn
2 injections of glucocorticosteroid- betamethasone to the mother at 12 and 24 hours before birth.
Sometimes there is no warning that preterm birth is imminent.
Transient Tachypnea of the Newborn
At birth a newborn may have a respiratory rate of 80breaths /min, then within 1 hour it slows to 30 to 60 breaths /min.
Rate remains high at 80 to120 breaths/min.
Illness In The Newborn
Slow absorption of lung fluid.
Occurs more often in:
Infants born cesarean,thoracic cavity is not compressed by force of vaginal birth, less lung fluid is expelled than normal.
Infants whose mothers received extensive fluid administration during labor
Preterm infants.
Monitor for fatigue, respiratory obstruction.
Peaks at 36 hours of life, fades by 72 hours.
Illness In The Newborn
Meconium Aspiration Syndrome
Meconium is present in fetal bowel at 10 weeks gestation.
Fluid at birth is green to greenish black.
Infant may aspirate meconium in utero or with first breath at birth.
Causes distress by:
1. Inflammation of bronchioles
2. Block small bronchioles by mechanical plugging.
Illness In The Newborn
3. Decrease in surfactant production through lung cell trauma.
Hypoxemia, CO2 retention, and intrapulmonary and extrapulmonary shunting occur
Secondary infection of injured tissue may lead to pneumonia.
Assessment;
Apgar score low, tachypnea, retractions, and cyanosis occur.
Suction before shoulders are delivered.
Illness In The Newborn
Intubate and suction, no O2.
Coarse bronchial sounds, retractions
Barrel chest
Blood gases
Chest X-ray-bilateral coarse infiltrates in the lungs.
Tx.
Amniotransfusion-to dilute amniotic fluid
After tracheal suction, O2
Antibiotic