Week 1 & 2 Care of High-Risk Newborns to Maturity PDF

# Care of the High-Risk Newborn to maturity ## Dr. Jeff Leigh T Reburon ## Mr. Gerly Mark Redoble # Importance of The Subject * A Nurse should learn how to take care of a well child as well as the ill ones or the ones who have significant variation in gestational age or weight. * Learning to reco...

# Care of the High-Risk Newborn to maturity ## Dr. Jeff Leigh T Reburon ## Mr. Gerly Mark Redoble # Importance of The Subject * A Nurse should learn how to take care of a well child as well as the ill ones or the ones who have significant variation in gestational age or weight. * Learning to recognize these infants at birth and organizing care for them will help both in their present and future health. # Risk Factors that could lead to illnesses in a newborn: * Younger/older than average maternal age. * Disease conditions (diabetes, HIV infections) * Pregnancy complications (placenta previa, abruptio) * Unhealthy maternal lifestyle (drug abuse, alcoholic, smoking) * Dysmature infants. (born before term or post term, or a child who is under or overweight.) **Note:** being able to predict an infant is high risk allows advanced preparation so that specialized, skilled health care personnel can be present at the child's birth. (to perform interventions such as resuscitation, etc.) # Newborn priorities in first days of life: * Initiation 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 parent-infant relationship * Developmental care/ physiologic stimulation # Initiation and maintenance of respiration. * Most deaths occur during the 1st 48 hours after birth from newborn's inability to initiate and maintain respirations. * An infant who has difficulty initiating effective breathing on the first hours of life may experience neurologic dysfunctions. (cerebral hypoxia.) * Newborns who are not able to establish respiration within the 1st 2 minutes will likely develop respiratory acidosis. (anaerobic respirations, leading to lactic acid production.) * Asphyxia in utero (cord compression, maternal anesthesia, placenta previa, abruption placenta) may also lead to respiratory acidosis. # Dangers of Delayed Breathing * If breathing is ineffective, circulation is affected. * Ductus arteriosus fails to close. Because of increased pressure on the left side of the heart (O2), blood circulation becomes ineffective. * (LV to Aorta to DA to PA.) * Because of poor circulation and struggling to breathe, the infant uses serum glucose quickly. This will lead to hypoglycemia, which will add up to the problem. # Factors predisposing Respiratory difficulty * Low birth weight (<2,500 grams @ birth) * Maternal hx of diabetes * Premature rupture of membranes * Maternal use of narcotics (drugs) * Meconium staining * Cord prolapse. * Lowered apgar score (<7 @1 or 5 minutes) * Postmaturity * SGA * Breech * Multiple birth * Fetal distress * Chest, heart or respiratory tract anomalies # Resuscitation (neonate)- defined as the administration of emergency measures to support newborn adaptation to extrauterine life. * Set up equipments before birth and test for functioning. (resuscitation bags, suction, oxygen) * Dry child with blanket & place child in radiant warmer * Establish and maintain airway. (neck slightly extended. Place rolled blanket under shoulders.) * Suction mouth then nose with bulb aspirator. * Use tactile stimulation. (stimulate crying) * Intubating the child to remove meconium, repeat process until return is clear * Monitor heart rate and respiration * Expand the lungs. Use proper fitting, sealed resuscitation bag with 100% O2 @ 40-60cpm until newborn's color becomes pink. * Administer chest compressions of less than 80bpm until infant's heart rate is more than 80bpm. * Auscultate breath sounds * Secure airway and administer drugs as ordered. **NOTE:** if respiratory depression becomes severe, a newborn's heart may fail. (Cardiac massage is also included in resuscitation.) # Clearing the Airway. * Term newborns- bulb aspirator to remove mucus and prevent aspiration during initiation of first breath and establish a clear airway. * If the infant is hard up in initiating first breath, suction the mouth and nose again, rub the back for tactile stimulation. * Dry the newborn to prevent chilling. (if the body tries to raise temperature, there is a need for more oxygen. Infant is unable to supply needed oxygen since breathing has not been initiated yet.) * WOF ('c',) *meconium stained babies- don't rub back to stimulate breathing, nor administer O2 by high pressure. (may push meconium down into the NB's airway.) (give 02 mask without pressure, intubate baby for deep suctioning.) * Primary apnea- seen on the first seconds of life in a severely depressed NB. NB takes several weak gasps of air followed immediately by an apnea. Heart rate begins to fall. * ('c',) WOF: if NB enters this state, resuscitation attempts are generally successful. * Secondary apnea- after 1-2 minutes of apnea, an infant again tries to initiate respirations with few strong gasps. * Child cannot maintain this effort longer than 4-5 minutes. Resp effort will be weaker again, HR will fall further, until infant stops gasping. * (T_T)SWOF: resuscitation measures become difficult and may be ineffective. Always start resuscitation as if secondary apnea is occurring. # Promoting Lung Expansion. * Once an airway is established, newborn's lungs should be expanded. * Term NBs- inflates lungs adequately with the 1st breath. Sound of baby crying is a proof of good lung expansion. * If NB is breathing spontaneously but cannot sustain effective respiration, give O2 by mask to aid lung expansion @ rate of 40-60cpm. * ('c',) WOF: mask should cover the nose and mouth for O2 administration to be effective. * Mask should not cover the eye. (can cause mechanical eye injury, cornea becomes dry.) * Prevent cooling and drying of nasal mucousa. (warm temp of 32-34*C, humidified 60-80%. * (T_T)SWOF: do not let oxygen levels fluctuate. (may cause bleeding from immature cranial nerves.) * Do not administer pressure above what is necessary. (may cause ruptured lung alveoli.) * Auscultate both lungs to make sure both sides are aerated. # Drug Therapy. * If respiratory depression is related to maternal use of Meperidine (Demerol) or morphine (cc are narcotic analgesics) given to the mother during labor, narcotic antagonists are given. * (Painless Delivery) * DOC: naloxone (narcan)- pure narcotic antagonist. Reverses effects such as respiratory depression. * Administered parenterally into an umbilical vessel or intramuscularly (Vastus Lateralis). # Other drugs used in resuscitation * Atropine- reduces bronchial secretions to keep airway clear during resuscitation; reduces vagus nerve effects. reduces possible apnea. * Calcium Chloride- increases heart contractility. (Prevents Cardiac Arrhythmia) * Dopamine- increases blood perfusion by increasing BP. * Epinephrine- strengthens cardiac contractions, increases HR and BP. * Sodium Bicarbonate- relieves respiratory acidosis. * Surfactants- administered by endotracheal tube @ birth. Prevents symptoms of respiratory distress syndrome. # Establishing Extrauterine Circulation. * If respiratory function cannot be initiated and maintained, this may lead to lack of cardiac function. * If NB has no audible HR/ if CR is <80bpm- closed-chest massage should be given. * Hold an infant with fingers supporting the back. * Depress the sternum with 2 fingers. (1-2 cms depth, @ 100time /minute. * Lung ventilation @ 30 times/ minute should be continued. * Lung ventilation is interspersed with cardiac massage at a rate of 1:5. (1blow, 5 massage.) # Maintaining Fluid and Electrolyte balance. * Hypoglycemia- decreased blood glucose. Results from the effort exerted from first breathing. * Dehydration- results from insensible water loss f respiration. (Lactated Ringer's solution or 5% dext given.) (Na, K, glucose are added as necessary, de electrolyte analysis.) * Rate of fluid administration should be carefully m level can cause patent ductus arteriosus or heart f * Placing a NB in a radiant warmer- will require m increase water loss from convection and radiation # Regulating Temperature. * High-risk NB's have difficulty maintaining a normal temperature. It is important to keep NB in a neutral environment. (if child chills, energy expenditure is increased, leading to increased oxygen consumption. * Because of low oxygen supply, cells undergo anaerobic metabolism; which leads to lactic acid production, which is deposited in the bloodstream, leading to metabolic acidosis.) * Acidosis- increases possible kernicterus (brain cells invaded by bilirubin.) * Prevent chilling by: wiping the infant dry, cover head with a cap and place in a radiant warmer, or skin-to-skin with mother.