Nursing Care of High-Risk Newborns PDF

Nursing Care of the Newborn With Special Needs and the Newborn at Risk Ch. 23 & 24 Objectives Identify birth weight variations and common associated issues. Discuss the common characteristics and medical management of preterm and postterm infants. Discuss respiratory...

Nursing Care of the Newborn With Special Needs and the Newborn at Risk Ch. 23 & 24 Objectives Identify birth weight variations and common associated issues. Discuss the common characteristics and medical management of preterm and postterm infants. Discuss respiratory distress syndrome and the approach to treatment. Describe risk factors associated with the birth and transition of an infant of a diabetic mother (hypoglycemia). Discuss pathologic vs. physiologic jaundice, and the guidelines for treatment. Summarize assessment and care of the newborn with soft tissue, skeletal, and neurologic injuries caused by birth trauma. Copyright © 2017 Wolters Kluwer · All Rights Reserved Objectives Identify maternal conditions that place the newborn at risk for infection and describe methods used identify infections in the newborn. Identify clinical manifestations of infection in the newborn. Describe the nurse's role in the diagnosis of neonatal sepsis. Identify the effects of maternal use of alcohol, recreational drugs, and tobacco on the fetus and newborn. Understand the needs of infants with meconium aspiration syndrome. Copyright © 2017 Wolters Kluwer · All Rights Reserved Birth Weight Variations Factors Affecting Fetal Growth – Maternal nutrition – Genetics – Placental function – Environmental factors Birth weight variations – AGA: average for gestational age – SGA: small for gestational age – LGA: large for gestational age Copyright © 2017 Wolters Kluwer · All Rights Reserved SGA Newborns SGA: weight 90th percentile on a growth chart; weight >4,000 g (8 lb 13 oz) at term Nursing Assessment – Large body, plump, full faced – Proportional increase in body size – Poor motor skills – Difficulty regulating behavioral states Risk Factors – Maternal diabetes mellitus – Multiparity – – Maternal obesity Prior history of a macrosomic infant – – Male fetus Postdates gestation – Genetics Copyright © 2017 Wolters Kluwer · All Rights Reserved LGA Newborns Common Problems – Birth trauma – Hypoglycemia – Hyperbilirubinemia – Asphyxia Nursing Management – Vital sign monitoring – Blood glucose level monitoring – Initiation of oral feedings with IV glucose supplementation as needed – Continued monitoring for signs and symptoms of polycythemia and hypoglycemia – Hydration – Phototherapy for increased bilirubin levels Copyright © 2017 Wolters Kluwer · All Rights Reserved Question Is the following statement True or False? An LGA newborn has a wasted appearance. a. True b. False Copyright © 2017 Wolters Kluwer · All Rights Reserved Answer B. False An LGA newborn usually has a large body and is plump and full faced. Copyright © 2017 Wolters Kluwer · All Rights Reserved Gestational Age Variations Precise knowledge of newborn’s gestational age is imperative for effective postnatal management Both postterm and preterm infants are high risk and need special care Gestational Age Variations – Postterm: a newborn born after the completion of 42 weeks – Preterm: a newborn born before the completion of 37 weeks – Late Preterm: a newborn born between 34+0 and 36+6 weeks Copyright © 2017 Wolters Kluwer · All Rights Reserved Postterm Newborn Inability of placenta to provide adequate oxygen and nutrients to fetus after 42 weeks – Show progressive placental dysfunction – Significant increase in fetal and neonatal mortality – Fetal distress during labor due to placental degradation Nursing Assessment – Dry, cracked, wrinkled skin – possibly meconium stained – Long, thin extremities; long nails – Wide eyed, alert expression – Abundant hair on scalp – Thin umbilical cord – Limited vernix and lanugo Copyright © 2017 Wolters Kluwer · All Rights Reserved Postterm Newborn Common Problems – Perinatal asphyxia – Hypoglycemia – Hypothermia – Polycythemia – Meconium aspiration Nursing Management – Resuscitation – Blood glucose level monitoring – Initiation of feedings; IV dextrose 10% – Prevention of heat loss – Evaluation for polycythemia – Parental support Copyright © 2017 Wolters Kluwer · All Rights Reserved Preterm Newborn Prematurity accounts for the largest number of admissions to NICUs Prematurity and LBW are the 2nd leading causes of infant death in the U.S. Immaturity of most organ systems places infants at risk for a variety of neonatal complications Nursing Assessment – Weight 60) – Heart rate >150 to 180 – Fine inspiratory crackles Copyright © 2017 Wolters Kluwer · All Rights Reserved Respiratory Distress Syndrome: Nursing Management Supportive care; close monitoring Respiratory modalities: ventilation, HFNC, CPAP, PEEP; exogenous surfactant; oxygen therapy Antibiotics for positive cultures; correction of metabolic acidosis Fluids and vasopressors; gavage or IV feedings Blood glucose level monitoring Clustering of care; prone or side-lying position Parental support and education Copyright © 2017 Wolters Kluwer · All Rights Reserved Meconium Aspiration Syndrome Inhalation of particulate meconium with amniotic fluid into lungs; secondary to hypoxic stress Terminal meconium vs. meconium stained fluid Risk Factors – Placental insufficiency – Maternal hypertension – Umbilical cord compression – Oligohydramnios – Maternal drug abuse Nursing Assessment – Staining of amniotic fluid, nails, skin, or umbilical cord – Barrel-shaped chest; prolonged tachypnea, increasing respiratory distress; intercostal retractions, end-expiratory grunting, cyanosis Copyright © 2017 Wolters Kluwer · All Rights Reserved Meconium Aspiration Syndrome: Nursing Management Suctioning at birth Adequate tissue perfusion Decrease in oxygen demand and energy expenditure Neutral thermal environment Parental support and education Copyright © 2017 Wolters Kluwer · All Rights Reserved Question Is the following statement True or False? The underlying problem associated with meconium aspiration syndrome in utero involves hypoxic stress. a. True b. False Copyright © 2017 Wolters Kluwer · All Rights Reserved Answer A. True Meconium may be passed in utero secondary to hypoxic stress. Copyright © 2017 Wolters Kluwer · All Rights Reserved  Infants of Diabetic Mothers High levels of maternal glucose crossing placenta, stimulating increased fetal insulin production leading to somatic fetal growth Nursing Assessment – Full rosy cheeks – Ruddy skin color – Short neck – Buffalo hump – Massive shoulders – Distended upper abdomen – Excessive subcutaneous fat tissue – Hypoglycemia, Hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia Copyright © 2017 Wolters Kluwer · All Rights Reserved Infants of Diabetic Mothers: Nursing Management The most important management if IDMs is careful monitoring of serum glucose levels Prevention of hypoglycemia (oral feedings, neutral thermal environment, rest periods) – Treated as soon as symptoms are identified Supportive therapy includes oxygen, intravenous IV line and monitoring Maintenance of fluid and electrolyte balance (calcium level monitoring, fluid therapy, bilirubin level monitoring) Parental support and education Copyright © 2017 Wolters Kluwer · All Rights Reserved Hypoglycemia in the Newborn Plasma glucose levels less than 40 mg/dL The most common metabolic disorder in newborns Risk Factors – LGA, SGA, IDM Nursing Assessment Nursing Management – Hypotonia – Early feeding via breast feeding or – Lethargy formula is important – Jitteriness – Supportive therapy includes – Poor feeding oxygen, intravenous IV line and monitoring – Cyanosis – Apnea – Hypothermia – Seizures Copyright © 2017 Wolters Kluwer · All Rights Reserved Birth Trauma Injuries due to the forces of labor and birth Types: fractures, brachial plexus injury, cranial nerve trauma, head trauma, cephalhematoma, caput succedaneum, forceps or vacuum trauma Nursing Assessment – Bruising – Bumps – Swelling – Paralysis – Symmetry of structure and function Copyright © 2017 Wolters Kluwer · All Rights Reserved Birth Trauma Nursing Management – Primary Supportive – Focuses on assessing for resolution of trauma – Monitor for complications Hyperbilirubinemia/jaundice Copyright © 2017 Wolters Kluwer · All Rights Reserved Hyperbilirubinemia Imbalance in rate of bilirubin production and elimination; total serum bilirubin level >5 mg/dL Pathologic jaundice – Occurs within the first 24 hours of life – Often caused by Rh isoimmunization or ABO incompatibility – Requires phototherapy or exchange transfusion Physiologic jaundice – Occurs after the first 24 hours of life, usually at day 2-3 – Usually the result of immature liver’s inability to process excess old red blood cells – Often resolves on it’s own Copyright © 2017 Wolters Kluwer · All Rights Reserved Hyperbilirubinemia (cont.) Nursing Assessment – Jaundice-yellowing of skin or eyes – Signs of Rh incompatibility – Bilirubin levels Nursing Management – Reduction of bilirubin levels Early feeding and elimination Phototherapy Exchange transfusions Copyright © 2017 Wolters Kluwer · All Rights Reserved Newborn Infections Neonatal sepsis: bacterial, fungal, or viral microorganisms or their toxins in blood or other tissues Continues to be one of the most significant causes of neonatal morbidity and mortality Ig(A) and Ig(M) require time to reach optimum levels after birth Early onset or congenital sepsis: usually manifests within 24 – 48 hours after birth; acquired in the perinatal period GBS Most common causative agent Late onset sepsis: occurs approximately 7 – 30 days of age; is considered to be an infection acquired in the hospital or community Copyright © 2017 Wolters Kluwer · All Rights Reserved Neonatal Infections: Nursing Management Nursing Assessment – Hypothermia – Respiratory distress – Lethargy – Nonspecific symptoms – Elevated C-reactive protein – “left shift” – Positive cultures Nursing Management – Antibiotic therapy (ampicillin/gentamycin) – Circulatory, respiratory, nutritional, and developmental support – Education for prevention and early recognition – Primary disease prevention – Family education Copyright © 2017 Wolters Kluwer · All Rights Reserved Newborns of Substance-Abusing Mothers Most common substances: tobacco, alcohol, and marijuana Fetal alcohol syndrome: physical and mental disorders appearing at birth and remaining problematic throughout the child’s life Fetal alcohol spectrum disorders Alcohol-related birth defects Neonatal abstinence syndrome: drug dependency acquired in utero manifested by neurologic and physical behaviors Copyright © 2017 Wolters Kluwer · All Rights Reserved Newborns of Substance-Abusing Mothers: Nursing Assessment and Management Nursing Assessment – Maternal history; risk behaviors, toxicology – Newborn behaviors; WITHDRAWAL assessment Nursing Management – Comfort promotion; stimuli reduction – Nutrition – Prevention of complications – Parent–newborn interaction Copyright © 2017 Wolters Kluwer · All Rights Reserved