High-Risk Newborn Care: Nursing Priorities

• Pediatric Nursing (Sick Clients) Lecture

Care of a Family with a High-Risk Newborn

• Addresses nursing priorities in the first days of life.

Nursing Priorities in the First Day of Life

• All newborns share a number of needs that take priority in the first few days of life.
• Priority needs include:
  • Initiation and maintenance of respirations
  • Establishment of extrauterine circulation
  • Maintenance of fluid and electrolyte balance
  • Control of body temperature
  • Intake of adequate nourishment
  • Establishment of waste elimination
  • Prevention of infection
  • Establishment of an infant-parent/caregiver relationship, developmental care, and balancing physiologic needs with stimulation

Initiation and Maintenance of Respiration

• Most newborn deaths occur during the first 48 hours after birth.
• Deaths often result from a newborn's inability to establish and maintain respirations.

Factors Predisposing Infants to Respiratory Difficulty:

• Low birth weight (LBW)
• Maternal diabetes mellitus (DM)
• Prolonged rupture of membranes (PROM)
• Maternal use of barbiturates or narcotics close to birth
• Irregularities in fetal heart tones (FHT)
• Cord prolapse
• Meconium staining
• Low Apgar score (<7)
• Postmaturity
• Small for gestational age (SGA)
• Breech birth
• Multiple birth
• Chest, heart, or respiratory tract anomalies

Resuscitation

• If respirations do not begin, respiratory acidosis increases; severe acidosis develops in 2 minutes.
• Resuscitation becomes necessary, following an established process:
  • Establishing and maintaining an airway
  • Expanding the lungs
  • Initiating and maintaining effective ventilation
• Severe respiratory depression can lead to heart failure, necessitating cardiac massage.

Airway

• Use a bulb syringe to aspirate mucus and amniotic fluid from the mouth and nose, but not routinely.
• If a newborn does not breathe spontaneously, suction the mouth and nose again using a bulb syringe and rub the back to stimulate respiration.
• Ensure the infant is dry to prevent chilling, which increases oxygen demand.
• In the presence of meconium-stained amniotic fluid, avoid stimulating the newborn to breathe by rubbing the back or administering O2 under pressure to prevent pushing meconium further down the airway.
• Administer oxygen without pressure, wait for a laryngoscope to be passed, and suction the trachea before administering O2 under pressure.
• Suction gently for no more than 10 seconds.

Lung Expansion

• Crying indicates good lung expansion through vocal cord vibration.
• Newborns who breathe spontaneously but cannot sustain effective respirations may require O2 via bag and mask.

Ventilation Maintenance

• The mask should cover both the mouth and nose without covering the eyes.
• Administer 100% O2.
• Oxygen should be warmed and humidified.
• Fluctuating O2 levels can rupture immature cranial blood vessels, and excessive pressure can rupture lung alveoli.
• Monitor O2 levels with pulse oximetry and auscultate both lungs.

Drug Therapy

• For respiratory depression due to maternal narcotic use (morphine or meperidine), administer a narcotic antagonist like naloxone (Narcan) via an umbilical vessel or IM, typically at 0.01 to 0.1 mg/kg body weight.

Ventilation Maintenence

• Increased respiratory rate (RR) is often the first sign of obstruction or respiratory compromise.
• Retractions involve inward sucking of the anterior chest wall on inspiration.
• Place newborns with difficulty maintaining respirations under an infant warmer with clothing removed from the chest to prevent acidosis.
• Position the newborn on their back with the head of the mattress elevated about 15 degrees to allow abdominal contents to fall away from the diaphragm.
• Suction secretions and monitor O2 levels.

Establishing Extrauterine Circulation

• If a newborn has no audible heartbeat or a heart rate (HR) < 60 bpm, start closed-chest massage.
• Support the infant's back with fingers while depressing the sternum with 2 fingers, about 1/3 of its depth or 1 to 2 cm.
• If heart sounds are not resumed > 60 bpm after 30 seconds of CPR, administer 0.1 to 0.3 ml/kg of epinephrine (1:10,000) into the ET tube to stimulate cardiac function.

Maintaining Fluid and Electrolyte Balance

• After initial resuscitation, hypoglycemia can result from the energy expended in initiating breathing.
• Dehydration may result from increased insensible H2O loss due to rapid respirations.
• Administer fluids such as Ringer's lactate or 10% dextrose in H2O, with potential additions of Na, K, and glucose.
• Very high fluid intakes can lead to patent ductus arteriosus (PDA) or heart failure.
• Monitor urine output and specific gravity; less than 2 ml/kg/hr (UO <) or a specific gravity higher than 1.015 to 1.020 (sp. Gravity >) may indicate dehydration.
• Hypovolemia, possibly due to fetal blood loss (placenta previa or twin-to-twin transfusion), presents with hypotension, tachycardia, tachypnea, decreased CVP, decreased peripheral tissue perfusion, and developing acidosis.
• NSS or Lactated Ringer's solution increases blood volume.

Regulating Temperature

• A neutral temperature environment minimizes metabolic rate demands.
• Chilling increases metabolism, requiring more oxygen.
• To save oxygen, vasoconstriction occurs; if prolonged, pulmonary perfusion decreases, pO2 level falls, and CO2 level increases.
• Decreased pO2 may open fetal right-to-left shunts and halt surfactant production.
• Supply glucose for increased metabolism, anaerobic glycolysis occurs, pouring acid into the bloodstream.
• The infant becomes acidotic, increasing the chance for kernicterus as more bilirubin is free to pass into the bloodstream.
• Dry the newborn, cover the head with a cap, and place immediately under a pre-warmed radiant warmer or in a warmed incubator or skin-to-skin contact.
• Maintain an infant's axillary temperature at 97. 8°F (36. 5°C).
• Avoid placing the infant directly on cool x-ray tables, scales, etc.

Radiant Heat Sources

• Radiant heat warmers are open beds with an overhead radiant source using servocontrol probes on the skin to continuously monitor temperature.
• Place the probe on the abdomen between the umbilicus and xiphoid process.
• Alarms sound if the temperature falls below 95. 9°F (35. 5°C) and 97. 7°F (36. 5°C).
• Convection and radiation losses are reduced with a plastic bridge or shield placed over the child.
• Placed under an infant: additional warming pad.

Kangaroo Care

• Uses skin-to-skin contact to maintain body heat.
• The infant is only dressed in a diaper and a head covering.
• The parent is seated in a chair and holds the infant snug against the chest, skin to skin using a blanket for coverage.

Establishing Adequate Nutritional Intake

• Infants with severe asphyxia usually receive IVF to prevent exhaustion from sucking or until necrotizing enterocolitis(NEC) has been ruled out.
• Gavage feedings if the infant is tachypnic and has been ruled out for NEC, offering a pacifier for nonnutritive oral stimulation at feeding times.
• Exceptions: those too immature to have a sucking reflex and those with transesophageal fistula(TEF) awaiting surgery.

Establishing Waste Elimination

• Must void within 24 hours of birth.

Preventing Infection

• Infection increases metabolic demands, stressing the immature immune system with common microbes: cytomegalovirus, toxoplasmosis, GBS septicemia, thrush, and herpes infections.
• Prevention involves good handwashing techniques and skin care.

The Newborn at Risk Because of Altered Gestational Age or Birth Weight

• The Colorado Intrauterine Growth Chart plots the birth weight.
• Term infants are born after the beginning of week 38 and before week 42 (calculated from the 1st day of the LMP).
• Preterm infants are born less than the 37th week.
• Postterm infants are born after the onset of week 43.
• Appropriate for gestational age (AGA) refers to infants whose birth weights (BWs) fall between the 10th and 90th percentiles for their age, regardless of gestational age.
• Small for gestational age (SGA) refers to infants who fall below the 10th percentile of weight for their age.
• Large for gestational age ( LGA) refers to infants who fall above the 90th percentile in weight.
• Low birth weight infants ( LBW) weigh less than 2,500 g at birth. 
• Very-low-birth-weight infants (VLBW) weigh 1,000 to 1,500 g.
• Extremely-very-low-birthweight (EVLBW) infants weigh from 500 to 1,000 g.

The Small for Gestational Age Infant (SGA)

• They are small for their age due to intrauterine growth retardation or failure to grow in utero at the expected rate.

SGA Infant Cause

• Poor maternal nutrition
• Pregnant adolescent- with own nutritional and growth needs + increased needs of pregnancy
• Placental anomaly- either the placenta did not obtain enough nutrients or it was inefficient at transporting nutrients to the fetus
• Placental damage- partial placental separation, developmental defects of the placenta
• Systemic diseases- DM, PIH where the blood vessel lumens are narrowed
• Mothers who smoke or take narcotics
• Intrauterine infection
• Chromosomal abnormalities.

SGA Assessment

• Fundal height is progressively less than expected
• Poor biophysical profile
• Appearance : below average in weight, length and head circumference (HC)( if deprivation occurs late in pregnancy(reduction only in weight)
• Overall wasted appearance
• Small liver- difficulty regulating glucose, protein & bilirubin levels after birth
• Poor skin turgor
• Appears to have a large head because the body is so small
• Skull sutures may be widely separated because of a lack of normal bone growth
• Hair is dull and lusterless
• Abdomen may be sunken
• Cord appears dry & may be stained yellow

SGA Laboratory Findings

• High hematocrit due to lack of fluid in utero and polycythemia (due to anoxia)
• Acrocyanosis may be prolonged and persistent
• Hypoglycemia is a common problem

Large for Gestational Age/Macrosomia

• A weight above the 90th percentile charted on an intrauterine growth chart.

LAge for Gestation Age Causes

• overproduction of growth hormone in utero (mothers who are obese or with gestational diabetes, also known as DM)
• Multiparous women
• Other conditions: transposition of great vessels, Beckwith- Wiedemann syndrome, omphalocele

LGA Assessment

• Size of uterus is unusually large for the date of pregnancy.
• Cesarean section (CS) may be necessary due to cephalopelvic disproportion (CPD biparietal diameter is closer to 10 than the usual 9 cm) or shoulder dystocia.
• Perform a non-stress test (NST).

LGA Appearance

• Immature reflexes or low scores on gestational age examinations in relationship to their size
• Extensive bruising or birth injury (broken clavicle or Erb- Duchenne Paralysis from trauma)
• Prominent caput succedaneum or cephalhematoma or molding

LGA Cardiovascular Dysfunction

• Hyperbilirubinemia or polycythemia due to absorption of blood from bruising.
• Polycythemia fully oxygenates all body tissues.
• Heart may be under great stress.
• If cyanosis is pesent, there may be a sign of Transposition of great vessels

LGA Hypoglycemia

• Monitor in the early hours
• The newborn uses up nutritional stores readily to sustain weight.
• If mom has gestational diabetes, the fetus has high blood glucose levels, causing increased production of insulin.
• After birth, increased insulin levels continue for up to 24 hours, causing rebound hypoglycemia.

The Post Term Infant

• Infants born after the 42nd week of pregnancy.
• Labor is usually induced at 2 weeks post term to avoid postmature births.
• Increased risk because the placenta functions effectively only for 40 weeks

Postterm Syndrome

• Includes dry, cracked, almost leather-like skin from lack of fluid
• Absent vernix
• Lightweight, which is attributable to weight loss due to poor placental perfusion
• Meconium-stained amniotic fluid
• Fingernails grown beyond the end of fingertips
• Alertness like a 2-week-old-baby
• Low subcutaneous fat(SC) deposits, which contributes to poor temperature regulation
• Hypoglycemia develops, from glycogen
• Polycythemia to compensate for lack of oxygen

Postterm Management

• Perform ( NST or BPP )non-stress test or biophysical profile when pregnancy becomes post term.
• Control or prevent hypoglycemia and meconium aspiration.
• Follow up care to check neurologic symptoms that may have occurred due to lack of nutrients and oxygen in utero

Premature Infants

• Infants are born before the end of the 37th week of gestation.
• Premature infants weigh < 2,500 g (5 lb 8 oz) at birth.
• Maturity is determined by LMP and UTZ results, physical findings like sole creases, skull firmness, ear cartilage, and neurologic findings.
• Premature babies need to be differentiated from SGA infants, they are immature and small -but well proportioned for age.
• Most premature infants are LBW infants

Cause for Premature Infants

• Low socioeconomic level due to the results of inadequate nutrition,
• Poor nutritional status
• Lack of prenatal care
• Multiple pregnancy
• Previous early birth
• Race ( non-whites have a higher incidence) Age of mother ( highest in those < 20 years old)
• Cigarette smoking
• Order of birth (highest in 1st pregnancies & beyond the 4th pregnancy)
• Closely- spaced pregnancies
• Reproductive system
• abnormalities of the mother
• Infections (esp. UTI)
• Obstetric complications (PROM, abruption placenta)
• Early induction of labor
• Elective CS

Premature Infant Assessment and Appearance

• Small & underdeveloped Head is disproportionately large (3 cm or more > chest size)
• Ruddy skin- little SC fat, veins are noticeable, high degree of acrocyanosis
• Very preterm Newborn's ( 24 to 26 weeks) have no vernix Extensive lanugo covering the back, forearms, forehead, and sides of face Anterior & posterior fontanelles are small
• Few or no sole creases.
• Eyes appear small but pupillary reaction is present. M- yopia due to lack of eye globe depth. Ear cartilage is immature & allows pinna to fall forward, ear larger relative to head.
• Neurologic function is immature less than 33 weeks, absent sucking reflex diminished deep tendon reflex.
• Less active as compared to mature newborn & rarely cries (weak & high-pitched)

Potential Complications of Preterm Infants

• Prematurity leads to Anemia, occurring because of a low reticulocyte count because the BM does not increase production until 32 weeks.
• Pale, lethargic, anorexic
• Immaturity of the hematopoietic system+ RBC hemolysis due to low levels of Vitamin E, which protects RBC's against oxidation

Anemia Management for Premature Infants

• Avoid excessive drawing of blood
• Erythropoietin
• Blood transfusions
• Vitamin E
• Iron ( Provided by a preterm formula)

Kernicterus

• Is the destruction of brain cells from Direct bilirubin in the blood as a result of excessive hemolysis
• Preterm infants are more prone because acidosis makes the brain cells more susceptible. Preterms also have less serum albumin to bind as indirect Bilirubin to inactivate.
• Kernicterus may occur at lower levels equal to 12 mg over 100 ml's of Indirect bilirubin
• Managed by phototherapy or exchange transfusion to lessen indirect bilirubin.

Persistent Patent Ductus Arteriosus

• Preterms typically lack surfactant, thus have difficulty moving blood from the pulmonary artery to the lungs
• This then leads to pulmonary artery hypertension, which may interfere with the closure of the ductus arteriosus.

Management for Persistent Patent Ductus Arteriosus

• Administer intravascular therapy (IVT) cautiously to avoid increasing blood pressure(BP) Indomethacin helps close the ductus arteriosus- note side effect includes oliguria monitor urine output Ibuprofen

Management for Periventricular/Intraventricular Hemorrhage

• Bleeding into the tissue surrounding the ventricles or inside the ventricles itself.
• It results due to fragile capillaries and immature cerebral vascular development
• rapid changes in cerebral BP (hypoxia, IV infusions, ventilation, or pneumothorax) lead to capillaries rupture.
• Brain anoxia can occur distal to the rupture- Hydrocephalus may occur from obstruction of the aqueduct Other Potential risks includes:
• Respiratory distress syndrome
• Apnea
• Retinopathy prematurity
• Necrotizing enterocolitis

General Premature Infant Management

• Minimize maternal anesthesia and analgesia to help initiate initial breath (within 2 minutes after birth)
• Monitor urine output for the 1st few days
• Monitor blood glucose every 4 to 6 hours(Normal Range (NR is 40 to 60 mg/100 ml )
• Administer intravenous (IV) fluids within hours to fulfill fluid & glucose requirements
• Total parenteral nutrition (TPN until stable
• Begin Breast, gavage, or bottle feedings as soon as Newborn, or (NB) tolerates them to prevent deterioration of intestinal villi. Offer a pacificier to strenghen suckling

General Illnesses That Occur in Newborns

• Gavage feedings are given continuously or every few hours via tubes through the nose or mouth (every 1 ml hour)
• Breast milk may be given via gavage feeding to prevent Nec.
• Preterms need 115 to 140 calories per kilogram of body weight daily.

Respiratory Distress Syndrome

• Formerly known as “Hyaline membrane disease."
• Common in preterms, infants of diabetic moms, cesarean section birth, and those who experience meconium aspiration
• Is a condition where the pathologic makeup is the result of hylaine like(fibrous) membrane which forms an exudate of the infant's blood

Main Cause for Respiratory Distress Syndrome

• This is due to a lack of Surfactant , that normally forms on the 34th week of gestation

Pathophysiology for Respiratory Distress Syndrome

• 40- 70 cm H2O is required for the initial breath
• But only requires 15 -20 cm H2O to maintain quiet respirations. If alveoli collapse with each respirations , forceful inspirations are required to inflate them Areas where an infant's lungs become hypo inflated pulmonary resistance
• Where a infants lung becomes hyper inflated they will often require an increase in pulmonary resistance
• Poor perfusion will depresses production of surfactant even. Poor oxygen (O2) exchange will leads to tissue hypoxia
• Releases lactic acid from the tissue- this in addition to the increase in CO2 causes the formation of hylaine membrane on the alveolar surface
• Severe acidosis continues until gas exchange becomes to sustain life with ventilator support- Note: Acidosis causes vasoconstriction

General Assessment for those with Respiratory Distress Syndrome

• Difficulty breathing at birth
• Low body temperature(Low temp)
• Nasal flaring
• Sternal & subcostal retractions- tachypnea is greater than 60 respirations per minute
• Cyanotic mucous membranes , Period of apnea , Bradycardia ,Pneumothorax
• Expiratory grunting, attributed to closure of the glottis , Fine rales and diminished breath sounds
• Seesaw respirations is often noted as being located within the chest wall and on expiration rises

General Dx for Respiratory Distress Syndrome

• Heart failure, evidenced by decreased urine output & edema of extremities , pale gray skin Clinical signs Clinical Dx:
• grunting, cyanosis in room air, tachypnea, nasal flaring, retractions & shock Chest xray diffuse pattern of radiopaque areas resembling ground-glass (haziness) can only be detected Blood gas will reveal respiratory acidosis Beta-hemolytic streptococcal infection may mimic Respiratory Distress Syndrome (RDS)
• Cultures may be done to rule this out and antibiotics (penicillin or ampicillin) may be given while culture reports are pending

Therapeutic Management for Respiratory Distress Syndrome

• Surfactant Replacement
• Surfactant Replacement -Immediately given after birth
• The administered synthetic surfactant is typically administered into the Endotracheal Tube by a syringe or catheter and goes through the lung lava

General Position for Respiratory Distress Syndrome

• Tipped to an upright position , and adjust ventilator setting to acommedate for improved lung function
• Oxygen (O2) Administration, maintain correct PO2 and pH levels
• ff surfactant administration can be administered via cannuala or assisted ventilation using postive end expiratory
• Avoids retinopathy of prematurity.

Other Management

• Nitric Oxide
• Can causes pulmonary vasodilation decreasing
• Extracoporeal membrance oxygenation blood is removed by gravity in a venous catheter in the right atrium if the heart.
• The blood machine is circulated by the extracoporeal membrance machine

Management to Reduce Pneumonia , Diaphragmatic Hernia

• Monitor L/S ratio during pregnancy (Normal 2:1) , and Avoid premature LandD (Tocolytic agents ), Betamethasone is given to to the mother at 12 and 24 hours itis given between 24 to 34 weeks
• Liquid ventilation -use perfluorocarbon which picks up Oxygen & helps helps to keep alveoli open

Transient Tachynea of the Newborn

• Rates can reach 80 beats and is higher in rate.
• At some rate some can get 60 seconds.
• Mild hypoxia and hypercapnia Feedings may be be dufficult.
• common can be delivered by c-section, or normal.

Synden Infant Syndrome

CAUSE IS UNKNOWN.

Risk Factors

Adolecents mother, Twins, and Drug abusers.

Contributing Factors

Prolonged Pneumonia.

APNEA

Is a pause in respiration longer than 20 seconds with - Acrompanying bradycardia and beginning cyanosis.

• In perterms its due to the respiratror.
• Monitor is used in home its an alarm for safety.

Hyperbilburinemia

• An elevates levels and blood in the blood.

Hemlytic Disease Of the Newborn

• Mother Builds anitbodies with antibodides.

Rh incompatibility.

Forms Antiboddes again.

Assessment

• Rising antih tiber titer is in mother. Positive direrect.

Theatruptic

• early feeding easy feeding by stimluation. Photothepay to decrease.

Homorrhagric

Lacks Vit K.

• vitamin K is by acteria. Vit K is by days in 2 and 5.

Tranfusion

Transfer in mono t twins.

The Newborn at Risk Because of Maternal Infection of ILlness

BETA Group B

• Is in a natureal Inhabitnat.
• If Mother is beta then there is IV.

Assessing

High risk with memebran is positive.

Generlized

• Can cross placebal battrer.

Other Assessment

• Aclovir
• CS birth is advidese. Infections.