Pediatric Nursing: APGAR, High-Risk Newborns

• These study notes cover pediatric nursing care for mothers and children at risk or with acute and chronic problems.

APGAR Scoring System

• APGAR score assesses a newborn's condition at 1 and 5 minutes after birth.
• A score of 7-10 indicates a healthy newborn.
• A score of 3-6 indicates moderate depression.
• A score of 0-2 indicates severe depression.
• If the 5-minute APGAR score is less than 7, it should be performed at 10 minutes.

High-Risk Newborns

• Categories include SGA (Small for Gestational Age), LGA (Large for Gestational Age), premature (<37 weeks gestation), and postmature (>42 weeks gestation).

LGA (Large for Gestational Age)

• Can result from various obstetrical situations, including maternal diseases like diabetes or maternal genetic predispositions.
• Genetic abnormalities such as Beckwith-Wiedemann Syndrome can lead to LGA infants.
• Complications include birth trauma, hemorrhage, asphyxia, or even death.

Fractured Humerus (in LGA newborns)

• Symptoms: pain, tenderness, edema, and decreased movement of the affected arm.

Hypoglycemia in LGA Infants

• LGA infants can develop hyperinsulinemia due to maternal hyperglycemia.

SGA (Small for Gestational Age)

• Infants whose weight is below the 10th percentile for gestational age.

Clinical Findings for LGA

• Includes gestational age, birth trauma or injury, respiratory distress, hypoglycemia

Infants of Diabetic Mothers: Clinical Findings

• Excessive size and weight.
• Facial and cheek edema.
• Hypocalcemia and hypoglycemia.
• Respiratory distress signs: tachypnea, cyanosis, retractions, grunting, nasal flaring.
• High incidence of congenital anomalies.
• High incidences of hypoglycemia, respiratory distress, hypocalcemia, and hyperbilirubinemia.

Other Risk Injuries in LGA Newborns

• Broken clavicle symptoms include swelling, pain, tenderness, or reluctance to use the affected extremity.

Nursing Interventions for High-Risk Newborns

• Monitor for respiratory distress signs.
• Monitor bilirubin and blood glucose levels.
• Monitor weight.
• Feed early: 10% glucose in water, breast milk, or formula.
• Administer IV glucose for hypoglycemia if prescribed.
• Monitor for edema, tremors, seizures, apnea, and acidosis.
• Monitor for shrill or intermittent cries.
• Evaluate lethargy.

LGA Specifics

• LGA neonates plot at or above the 90th percentile on the intrauterine growth curve.

LGA: Nursing Interventions

• Monitor vital and glucose levels.
• Monitor for hypoglycemia signs.
• Monitor infection signs.
• Initiate measures to prevent sepsis or aspiration.
• Provide stimulation through touching and cuddling.

Hypoglycemia

• Abnormally low glucose levels in the blood: <30 mg/dl in the first 72 hours or <45 mg/dl after the first 3 days of life.
• Normal glucose ranges: 40-60 mg/dl in a 1-day-old neonate or 50-90 mg/dl in a neonate older than 1 day.
• Clinical findings: increased respiratory rate, twitching, nervousness, tremors, cyanosis, and unstable temperature.

Hypoglycemia: Nursing Interventions

• Provide low blood glucose through early feedings.
• Administer oral or IV glucose per orders.
• Monitor blood glucose and for feeding problems.
• Monitor for apneic episodes.

SGA: Clinical Findings

• Fetal distress or temperature instability.
• Hypoglycemia or polycythemia signs: ruddy appearance, cyanosis, jaundice.
• Signs of infection or meconium aspiration.

SGA: Assessment

• Physical signs: Lack of subcutaneous fat, scaphoid abdomen, disproportionately large head (asymmetric intrauterine growth retardation).
• Maternal history: Cardiovascular or renal disease, diabetes, medications, substance use, or placental insufficiencies.
• Neonatal causes: Inborn errors of metabolism, congenital anomalies, or multiple gestation.
• Postnatal complications: Increased susceptibility to infection, respiratory compromise, neurological challenges, death, hypoglycemia, or risk of hypothermia.

SGA: Clinical Findings

• Neonates plot at or below the 10th percentile on the intrauterine growth curve.

SGA: Nursing Interventions

• Maintain airway and body temperature.
• Observe for respiratory distress signs.
• Monitor for infection and prevent sepsis.
• Monitor glucose levels and signs of hypoglycemia.
• Initiate feeding and watch for aspiration.
• Provide stimulation via touching and cuddling.

Premature Infant

• Born earlier than 37 weeks of gestation.
• Extremely preterm: <28 weeks.
• Very preterm: 28-32 weeks.
• Moderate to late preterm: 32-37 weeks.

Premature Infant: Statistics

• Globally 15 million babies are born too early each year.
• Over 1 million children die annually from preterm complications.

Premature Infant: Risk Factors

• Maternal hypertension or preeclampsia
• Multiple gestation or renal/cardiac disease.
• History of preterm labor.
• Substance use and abuse
• Late initiation of prenatal care.
• Lower socioeconomic level

Premature Infant: Complications

• Hypoglycemia or Respiratory instability.
• Neurological problems and necrotizing enterocolitis.
• Respiratory Distress Syndrome (RDS).

Premature Infant: Clinical Findings

• Irregular respirations or temperature below normal.
• Feeding: Poor suck and swallow reflexes.
• Gastrointestinal: Diminished bowel sounds.
• Urinary output: Increased or decreased.
• Physical Appearance: Thin extremities, minimal creasing on soles and palms, skin thin with visible blood vessels, may appear jaundiced.
• Genitalia: Undescended testes in boys or narrow labia in girls.

Premature Infant: Primary concerns

• Immaturity of all body systems

Premature Infant: Interventions

• Monitor vitals every 2 hours.
• Maintain cardiopulmonary functions.
• Administer oxygen and humidification.
• Monitor intake and output and electrolyte balance.
• Monitor daily weight or maintain warming device.
• Position carefully.
• Avoid exposure to infections; provide stimulation.

Post-mature Infant

• Defined as a neonate born after 42 weeks of gestation
• Placenta loses its ability to transport nutrients, oxygen, and waste products.
• Problems: Meconium aspiration, malnutrition, asphyxia, death.
• Assessment: Dry infant with crackling skin, absence of vernix and lanugo, long/thin extremities.
• Clinical Findings: Hypoglycemia, parchment-like skin without lanugo, long fingernails and thin body, wasting of fat; meconium staining.

Post-mature Infant: Interventions

• Provide normal newborn care and monitor temperature.
• Monitor for hypoglycemia or meconium aspiration.
• Monitor I&O and electrolyte balance.

Respiratory Distress Syndrome (RDS)

• Respiratory dysfunction in neonates due to delayed lung maturation or lack of surfactant.
• Surfactant reduces surface tension in alveoli, thereby aiding the lungs to remain open during exhalation.
• RDS can also arise from non-pulmonary issues like sepsis, cardiac defects or airway obstruction.
• Preterm infants born before lungs are ready for gas exchange are prone to RDS.
• Impaired secretion of surfactant results in uneven expansion and alveolar collapse.

RDS: Contributing Factors

• Includes immaturity of chest wall and lung, inadequate pulmonary surfactant, reduced blood flow, and interstitial or alveolar lung water.
• Risk Factors: Prematurity, maternal diabetes, genetic factors, perinatal asphyxia, second-born twins, and cesarean section without labor

RDS: Clinical Manifestations

• Tachypnea (80-100 breaths/min), dyspnea, retractions, fine crackles, expiratory grunt, cyanosis or metabolic acidosis, or elevated CO2

RDS: More Severe Manifestations

• Pallor and cyanosis, poor muscle tone and response, or specific chest X-ray findings

RDS: Therapeutic Management

• Maintain ventilation, acid-base balance, and a neutral thermal environment; ensure tissue perfusion, and avoid hypotension.
• Maintain hydration and electrolyte balance or administer betamethasone to enhance the production of surfactant.

RDS: Medical Management

• Includes ventilatory and antibiotic support, surfactant administration, and provision of intravenous fluids as needed for nutrition or hydration

RDS: Complications

• Includes Pneumothorax, Bronchopulmonary Dysplasia (BPD), Retinopathy of Prematurity (ROP), and Hyperbilirubinemia
• Inhaled Nitric Oxide (INO) supports pulmonary function.

RDS: Nursing Diagnoses

• Ineffective Airway Clearance or Breathing Pattern or Impaired Gas Exchange or Risk for Trauma.
• Interventions: Providing appropriate stimulation, avoiding infection or oxygen administration.

Post-mature Infant

• This is a neonate born after 42 weeks of gestation.
• The placenta loses its ability to transport nutrients, oxygen, and waste products.
• Problems: Meconium aspiration, malnutrition, asphyxia, death
• Signs: Dry and cracked skin, absence of vernix and lanugo, long and thin extremities.
• Clinical Findings: Hypoglycemia, parchment-like skin without lanugo and long fingernails, muscle wasting.

Post-mature Infant: Nursing Interventions

• Provide normal newborn care
• Monitor for hypoglycemia or meconium aspiration.
• Monitor temperature and I&O.

Sudden Infant Death Syndrome (SIDS)

• Sudden and unexplained death of child younger than 1 year.
• Happens even after post-mortem investigation, death scene investigation, and case history review.
• The cause is unknown.
• Risk Factors: Prone sleeping position, maternal smoking, brainstem abnormality, and socioeconomic factors.
• Pathologic Findings: Pulmonary edema and intrathoracic hemorrhage.

SIDS: Interventions

• Monitor jaundice and skin color in natural light.
• Promote hydration to maintain blood volume and encourage frequent feeding.
• Educate families using supine sleeping position and a safe sleep environment and discouraging smoking and bed-sharing.

Hyperbilirubinemia Interventions

• Inspect skin in natural light
• Encourage frequent feedings to get rid of meconium

Retrolental Fibroplasia (ROP)

• Condition affecting retina of premature infants.

Necrotizing Enterocolitis (NEC)

• Serious gastrointestinal condition affecting preterm infants.

Preterm Newborn: Interventions

• Monitor respiratory rate and color, support respirations, and monitor blood gases.
• Schedule eye exams, suction, and administer surfactant.

Preterm Newborn: Nursing Interventions

• Position the infant for stability or provide nutrition.

Common complications of RDS

• Pneumothorax
• Bronchopulmonary Dysplasia (BPD)
• Retinopathy of Prematurity (ROP)

Erythroblastosis Fetalis

• This is a condition characterized by the destruction of red blood cells.

Erythroblastosis Fetalis: Clinical Findings

• Anemia, jaundice, enlarged placenta, edema, and ascites.

Erythroblastosis Fetalis: Nursing Interventions

• Perform early blood typing and Rh testing to determine the mother's blood type and administer Coombs' test during pregnancy.

Erythroblastosis Fetalis: Treatment

• Provide phototherapy
• Administer Rho(D) immune globulin.

Neonatal Sepsis

• Invasive infection that primarily involves bacteria invading the bloodstream, and can have severe consequences for newborns.
• May develop either early(within 24 hours) or late (after 24 hours).

Neonatal Sepsis: Factors

• Prematurity and Low Birth Weight or Maternal Infections.
• Early Onset Sepsis: Occurs within the first 24 hours after birth, due to infections passed down from mother.
• Late Onset Sepsis: Develops after 24 hrs, due to hospital-acquired infections.
• Treatment includes antibiotic therapy or supportive therapy.

Common Pathogens causing Neonatal Sepsis

• Bacterial Infections
• Viral Infections
• Fungal Infections

Nursing Interventions

• Monitor Vital Signs and respiratory function closely.
• Fluid and Electrolyte Management.
• Monitor Organ Function.

Statistics & Global Impact

• Sepsis is a leading cause of death among children under the age of five across the globe.

Therapeutic Management

• Maintain ventilation and hygiene
• Administer Antibiotics

Symptoms of Neonatal Sepsis

• Body temperature changes.(fever or hypothermia).
• Breathing problems. (apnea, tachypnea)
• Jaundice (yellow skin and whites of the eyes).

Neonatal Sepsis:: Prevention and Early Recognition:

• Prenatal care and infection control.

Late-Onset Sepsis: Prevention

• Premature delivery and prolonged Catheters use

Supportive Therapy

• Oxygen and Respiratory and Hemodynamic management

Diagnosis of Sepsis in Children

• Requires clinical and Lab assessments

Known GBS statues

• Antibiotics should be given

If the following are present the treatment for sepsis in children:

1. Oxygen therapy
2. IV fluid resuscitation

Hypotheses/Proposed Causes of SIDS

1. Brainstem Abnormality
2. Maternal Smoking
3. Poor Prenatal Care and Low Maternal Age

Monitor for Jaundice: Nursing Interventions

• Examine newborn's skin color in natural light.

SIDS Pathologic Findings

• Pulmonary Edema and Intrathoracic Hemorrhage are common findings at autopsy

Rh Incompatibility and Rhogam Administration

• Key Mechanisms: The Mother’s immune system produces antibodies which attack fetal red blood cells

Anti - Rh antibodies

• cause hemolysis.

Nursing consideration for eye examination

• Schedule eye exams before discharge for premature newborns who required (02) support to assess retinal damage

Nursing Interventions

• Monitor for signs of infection and hyperbilirubinemia
• Initiate feeding and assist with nutrition

Sepsis in Older Children:: Causes and Risks

• Wound infections.
• Other infections (MRSA)
• High Fever
• Low or no urine output
• Rapid breathing, shortness of breath and Heart Rate(tachycardia)

Early on set Sepsis occurs

• In the first 24 hrs. after birth

Prevention SIDS

• Avoid prone (stomach) position
• Use safe environment for sleep
• Encourage, support, and teach breastfeeding

SIDS risk Factors: to avoid

• Vary the infants head position
• avoid overheating
• Discourage bed sharing

SIDS Definition:

• Sudden and unexplained death for reasons that are not known and cannot explained

Inhaled Nitric Oxide (INO) or Oxygen is used in case/Treatment

• In severe Cases of SIDS

Meconium Aspiration Syndrome (MAS):

• Occurs in new borns when a new born breathes in mixed fluid around the the lungs mixed

Complications of Meconium Aspiration Syndromes (MMAS):

• Air Syndrome Leaks

4. Causes of Asphyxia and Seizures

Meconium Aspiration syndrome treatment

• Barrel Shaped Chest and heart rate may be seen on the new borns.

Oxygen Support.

• Oxygen A face Mask can be can be used with for the baby`s lungs or ECMO

Phototherapy – Nursing Interventions

1. Newborn Expose skin to lights
2. Monitor the lights for Intensity
3. Hydration and Fluid management

Monitor bilirubin levels. Nursing consideration

• In the first 24- 48 hrs. can be given
• The therapy is given is when the baby has Kernicterus, which can cause damage to the new borns

ABO Incompatibility

• Occurs from Mother has A or B antigen
• Can also affect first baby if the mother has A or B antigen
• Can be less serve because they Typically do not cross the placenta
• Check for a poor feeding pattern(sucking reflex), weak , and signs of infection

If mom is Rh + positive

• Will give Rhogam during the pregnancy

Management for labor

Nursing intervention Support or Provide oxygen therapy

Late onset Sepsis

• caused by Prolonged or Premature delivery

Premature On set Sepsis:

• Ampicillin and gentamicin

Management of Sepsis in Older children

• Antibiotics is to provide nutrition support

Signs of Deterioration in New Born

• Monitor breathing ( oxygen) and temperature
• Isolation- is provided to prevent additional infection
• Maintain body temperature to avoid hypothermia

Treatment for SIDS in children:

• Oxygen thereapy 02
• IV fluids resuscitation is needed

GBS

• All pregnant Women should be Screen using both the Rectal and vaginal Cultures

Baby is crying and active after birth, in order to manage : MAS

• Do not suction

If the baby shows : MAS the treatment would be

Suctioning: A tube may be placed in the baby's trachea

Causes of RH incompatibility

• Mother negative and the baby is positive negative Mother with a positive Fetus: The Mother may sensitized positive blood cells to Rh producing the anti -Rh antibodies anti - Rh, These attack to fetus red blood cells causing hemolysis The Mother

What should happen the mother is unsensitized and what test need to be done: for RH incompatibility

• Rhogam afterbirth, week of gestation and perform procedure

How do you reduce, maintain normal and avoid metabolic conditions in the hospital as part of treatment - SIDS:

• Use warmth measures ( Maintain body temperature)

Study notes on pediatric nursing care, including APGAR scoring and management of high-risk newborns such as SGA, LGA, premature, and postmature infants. Covers complications and special considerations for each category. Focuses on conditions like fractured humerus in LGA newborns.