Nursing: High-Risk Newborn Care

Nursing Care of At-Risk/High Risk/Sick Newborn

• Course module 2, unit 6, week 7 covers nursing care for at-risk, high-risk, and sick newborns
• End-of-unit student outcomes include awareness of deviations from normal, systematic assessment skills, and understanding pathophysiology and plan modification

The High-Risk Neonate

• A high-risk neonate faces a greater-than-average chance of morbidity or mortality, irrespective of gestational age or birth conditions
• The high-risk period spans from the time of viability until 28 days after birth, encompassing prenatal, perinatal, and postnatal threats.
• Prompt assessment and intervention in perinatal emergencies can significantly improve outcomes and reduce long-term disabilities.

Classification of High-Risk Newborns

• High-risk newborns are classified based on birthweight, gestational age, and primary pathophysiologic problems.
• Common issues relate to maturity, chemical imbalances, and immature organ systems

Classification According to Size:

• Low-birthweight (LBW) is defined as an infant weighing less than 2500 grams (5.5 lbs), regardless of gestational age.
• Very low-birthweight (VLBW) is defined as an infant weighing less than 1500 grams (3.3 lbs).
• Extremely low-birthweight (ELBW) is defined as an infant weighing less than 1000 grams (2.2 lbs).
• Appropriate-for-gestational-age (AGA) indicates an infant whose weight is between the 10th and 90th percentiles.
• Small-for-date (SFD) or small-for-gestational age (SGA) refers to infants with slowed intrauterine growth and birth weights below the 10th percentile.
• Intrauterine growth restriction (IUGR) occurs in infants with restricted intrauterine growth
• Large-for-gestational-age (LGA) denotes an infant whose birth weight is above the 90th percentile.

Classification According to Gestational Age

• Preterm infant: Born before 37 weeks of gestation, regardless of birth weight
• Full-term infant: Born between 38 and 42 weeks of gestation, regardless of birth weight
• Post-term infant: Born after 42 weeks of gestation, regardless of birth weight
• Late-preterm infant: Born between 34 and 36 weeks of gestation, regardless of birth weight

Classification According to Mortality

• Live birth: A neonate shows any heartbeat, breathes, or voluntary movement, regardless of gestational age.
• Fetal death: Death of the fetus after 20 weeks of gestation but before delivery, with no signs of life after birth
• Neonatal death: Death within the first 27 days of life; early death in the first week, late death at 7-27 days
• Perinatal mortality: Total number of fetal and early neonatal deaths per 1000 live births
• Postnatal death: Death occurring from 28 days to 1 year after birth

Assessment of the High-Risk Newborn

• A brief yet comprehensive assessment is given to newborns at birth to identify problems needing immediate attention
• Assessment focuses on cardiopulmonary and neurological functions.
• Apgar score and evaluation for congenital anomalies or neonatal distress are determined

Physical Assessment

• A thorough, systematic physical exam is an essential part of caring for a high-risk infant
• General assessment includes weight, body shape/size, posture, breathing ease, edema, anomalies, and signs of distress
• Respiratory assessment includes chest shape/symmetry, chest tubes/deviations, respiratory distress signs, rate/regularity, breath sounds, suctioning
• Cardiovascular assessment encompasses heart rate/rhythm, heart sounds, PMI determination, infant’s color (including mucous membranes/lips), blood pressure
• Gastrointestinal assessment includes abdominal distention, regurgitation signs/timing, residual character/amount, suction drainage type, emesis amount/consistency
• Genitourinary assessment includes genitalia abnormalities, and urine amount/weight/color/pH/specific gravity.
• Neurologic-musculoskeletal assessment includesinfant's movements/position/attitude, activity level/stimulation, reflexes
• Temperature, skin assessment including discoloration, irritation signs, lesions, birthmarks etc are observed.
• Subtle changes in feeding behavior, activity, SpO2, or vital signs can indicate an underlying problem

Observation

• Observational assessments vary with the infant's condition severity
• Critically ill infants require close respiratory function assessments, including pulse oximetry, electrolytes, and blood gases

Problems Related to Maturity

Preterm Infants

• Immaturity increases the risk for neonatal complications and predisposes infants to life long issues.
• Socioeconomic factors, multiple pregnancies, gestational hypertension, and placental problems increase preterm delivery risk

Characteristics of Preterm Infants

• They has distinct characteristics at various development stages
• Physical appearance changes as the fetus matures, appearing very small with little or no subcutaneous fat
• Skin is bright pink, smooth, and shiny with visible blood vessels.
• Abundant lanugo is present
• Soft ear cartilage and minimal creases on soles/palms are found.
• Soft skull/rib bones, and fused eyes before 26 weeks
• Male infants have few scrotal rugae and undescended testes
• Prominent labia minora and clitoris in females are noted.
• Preterm infants are inactive and listless
• Extremities maintain extension and remain in placed positions
• They are unable to maintain body temperature
• They have limited ability to excrete solutes in urine and increased susceptibility to infection
• Pliable thorax, immature lungs, and an immature regulatory center causes periodic breathing, hypoventilation, and apnea.
• Biochemical alterations like hyperbilirubinemia/hypoglycemia, and higher extracellular water content are more prevalent
• When preterm delivery is expected, NICU is alerted.
• A team approach is implemented
• Those not needing resuscitation are moved quickly to a heated incubator in the NICU for weighing and starting IV access
• Oxygen and other therapeutic interventions may be needed
• Resuscitation is done in the delivery area until NICU is accessible

Post-Term Infants

• Post-term infants are born after 42 weeks from the mothers last menstrual period.
• Cause of delayed birth is unknown.
• They display absence of lanugo, vernix caseosa is rare, hair is abundant.
• Skin is cracked- parchment like peeling
• Wasted physical appearance due to nutrition deprivation is common
• Subcutaneous fat depletion causes a thin, elongated appearance.
• Vernix caseosa remaining in folds will be stained deep yellow or green indicating meconium in the amniotic fluid.
• Prone to fetal distress, macrosomia, and meconium aspiration syndrome (MAS) is common

Gestational Weight Problems:

• Classifying infants by birthweight and gestational age better predicts mortality risks/manages neonates than gestational age or birthweight alone
• Infant’s weight, length, head circumference are plotted to identify normal gestational age values
• Infants with weight between the 10th and 90th percentiles (AGA) grew at a normal rate
• Those whose weight is more than the 90th percentile (LGA) grew at an accelerated rate
• Those whose weight is less than the 10th percentile (SGA) grew at a restricted rate
• Lower birthweight influences higher mortality

Small-for-Gestational Age (SGA) Infant

• SGA occurs when birth weight is below the 10th percentile on intrauterine growth curve for the age
• They may be preterm, term, or post term
• SGA happens due to intrauterine growth restriction (IUGR) or failure to grow as expected in utero
• Maternal nutrition plays a role in fetal growth, thus malnutrition is a contributor to IUGR
• Pregnant adolescents are at high IUGR incidence
• Most common IUGR cause is a placental anomaly where there are not enough nutrients from uterine arteries, or inefficient nutrient transport
• Placental damage limits placental function because area that has placental separation gets infarcted/fibrosed
• Surface available to exchange nutrients becomes reduced
• Systemic diseases decreasing flow can cause higher SGA risk. Examples include severe diabetes mellitus or pregnancy induced hypertension
• Heavy smokers/narcotic users commonly have SGA infants.
• Infant contact with intrauterine infection like Rubella, toxoplasmosis, or a chromosomal abnormality can contribute
• SGA infant can be detected in utero when fundal height becomes gradually less.
• Sonograms detect the decreased size
• Biophysical profiles including Non-stress tests, placental grading/amniotic fluid, and ultrasound exams can provide placental function info
• Poor placental function indicates the infant cannot handle labor because contractions cause hypoxia
• Severe deprivation causes infants with under average weight, length, and head circumference generally.
• Later pregnancy deprivation causes merely a reduction in weight
• Regardless, infants tend to have overall wasted appearance
• Infants may have small livers, causing problems regulating glucose/protein/bilirubin after birth.
• Large heads appear due to small body size
• Skull sutures may be very far apart due to lack of bone growth.
• Dull and lusterless hair, and abdomen can be sunken
• Cord is often dry and yellow
• Advanced age gives developed neurologic responses, sole creases and ear cartilage
• Skull firmer and infants alert and active

Blood Studies of SGA Infants

• Blood studies at birth display high hematocrit (low plasma due to a lack of fluid in the uterus) with more red blood cells (polycythemia)
• High red blood cell counts are produced because anoxia during intrauterine life causes development/stimulation.
• Creates extra heart work because viscous blood is hard to effectively flow
• Acrocyanosis (blue hands and feet) may be prolonged/marked more extremely
• Decreased glycogen causes hypoglycemia (low glucose, below 45mg/dL)

Large-for-Gestational Age Infant

• Infant is termed LGA (macrosomia) id birth weight is over the 90th percentile for gestational age on an intrauterine growth chart
• Infants appear healthy initially, developmental maturity may be immature when the exam is performed
• LGA exposed to high growth hormones in utero.
• Causes are mostly women with diabetes or obesity
• Women with poorly controlled diabetes may cause fetuses with extreme macrosomia
• Multiparous women have tendency towards them due to growing babies.
• Other conditions are transposition of great vessels, beckwith syndrome, congenital anomalies such as omphalocele, etc
• Suspicion happens when a woman's uterus is large for pregnancy dates
• Abdominal size can appear wrong, as flexed babies take lesser place.
• rapid growth is suspected, non-stress test helps assess large fetus stability
• Lung maturity through amniocentesis can determine fetus maturity
• Discovery may happen during labor as baby cannot descend through pelvic rim
• Show underdeveloped reflexes and gestational age scores linked to size at birth.
• Bruises/ injuries possible
• Watch closely for Hyperbilirubinemia(high bilirubin level)
• Polycythemia creates more heart stress
• Care of LGA infants is the same as for preterm infants
• Monitor heart rate
• Note cyanosis as it is related to transposition of great vessels.
• Ensure proper nutritional store amounts, prevent hypoglycemia
• Monitor glucose levels
• If mother's diabetes is not well controlled, elevated blood levels in utero prompts greater insulin produce, that will continue for a day, leading to rebound hypoglycemia

Management of the High-Risk Newborn

• ICU Neotates constantly monitored in thermal environments
• Equipments like heart/respiratory/temperature rate monitors are with alarms
• Hands-on assessment such as blood sounds/breath tones required

Initiating and Maintaining Respirations

• Prognosis relies on early moment management/first moments
• The most early infant mortality is breathing difficulties/maintaining respiration
• Hypoxia can result as sequelae of bad respirology
• Assuring respirology is main goal. Ventilations, oxygen assist necessary
• Placement for correct flow is needed
• Babies born respiratory acidosis. Should go within minutes. If none, condition worsen
• Arteriosus can fail if baby ineffective air
• Blood runs through duct where arteries meet, ineffective pumping
• High glucose lost, hypoglycemia and high efforts compounds the respiratory failure
• Following order, a-assuring open airway, b-expanding lungs, and c effective ventilation is what ensures success. Finally cardiac massage in failure needed

Establishing Extrauterine Circulation

• Quick cardiac function maintain or concurrence, or it dies
• 80bpm, start close chest compressions
• Two fingers, and sternum depression is how compression done
• Time for ventilating is around 30bpm along compression
• Maintain monitoring transcutaneously
• Assess through heart to test adequacy
• For no improvements after some time, spray with 1:10000 epi. Follow guidelines, transfer for heart testing

Fluid and Electrolyte balance/imbalance

• Restore glucose via 10% dextrose, dehydration
• Use lactates etc to keep balance
• Ensure observation to prevent
• Warmers will need more fluids

Thermoneutrality

• A normal temp is what's needed
• Babies struggle with temperature, stress, environment
• NEUTRAL temp is required
• Less metabolism needed
• Body over/under function causes stress to correct, and leads to hypoxia as blood use raises to adapt
• Vessels constricted, function effected from reduced oxagen
• Dry baby
• Wipe a dry head after birth
• Heat balance ensures minimum calorie needs met
• Warmer lights and incubators best here. Cotton blanket a fine too

Nutritional Intake

• Ingestion functions need develop
• 32-34w for intake
• 36-37w well synchronized in gestational age
• Breast with protein etc is good from enteral/parental route

Steps towards breastfeeding with neonatres

• Breastfeed for protection
• Express is no suckling, and ready for suckling
• Nurtitive sucking
• Pacifiers may devleop sucking refluxes

Waste Elimination

• Immature elimination and fluids with functions need testing and checkup. Document
• Stools late
• Tests determine cause

Protection against infection

• Infection risk increases to adaption. Stresses metabilism more so
• Prenatal infection can cause.
• Care necessary here
• Isolation precautions key. Hands are important

Skin care

• Immature. alkaline soaps can damage skin
• Oxide zinc and washables help and heal

Parent-infant bonding

• High risk keep them updated
• Tell parents. visit and touch babies
• Give access and help them care once get home
• Allow with deaths access. Grieve

Acute Conditions of the Neonate

• Acute conditions like RDS etc, follow a careful guide.
• A family hx, asphyxia, etc can accompany it
• Non-pulmonary distress result exposure issues due to etc

Respiratory distress syndrome

• Lack of surfactant
• 24 week mark. Type 2 is most mature at 36 weeks
• Air inflation issue and collapse of air alveoli
• Inefective pressure from tissues, hypo and hypercapnia can result or prolong it further in anaerobics
• Apparent signs occur breathing normal, color normal too- breathing gets too rapid or min
• Infants retract
• Distress occurs

Meconium Aspiration Syndrome

• Stress and relaxation of anl sphincter.
• aspiration w first breath in utero
• Once ingested gasps force intake via hypoxia
• Thick mass trapped in tract
• Results, deactivations etc. lung visualization etc
• In stable moniter closely

Apnea of prematury

• Periodic breather is preterm babies characteristic
• Rapid breath and slow/ no breath
• Prematurity extends this
• Hypoxia, or low oxygen, cause this
• Apnea caused due to lack of muscle from CNS or respiratory system and diaphragm. Can be central etc
• Apnea may be infection related
• Toxicity should be watched for caffeine

Neonatal Sepsis

• This generalized bacteriol infection blood stream , because nonspecific the reduced, immunity. This can signal result delayed diagnosis treat
• Aquired , placenta , ingestion organisms contact .
• Early infants can also be seen on days .
• Direct infection with matternal to is what occurs.
• Organisms the what occurs . It is coli the

Hyperbilirubinemia

• Excess billirubin level accumulation
• Breakdown hemogoblin red cels
• Bili makes maintain , excretions
• Possiblility are physiological . Secretions combined and genetic perdis positions

Risk hyperbilirubinemia

• Race life obseeved bruising breastfeeding hemolysis
• • Common billirubin
• Billirubin 4 measure