High-risk neonate.pdf

HIGH-RISK NEONATE HIGH RISK NEONATE has a greater than average chance of morbidity or mortality regardless of gestational age or birth because of conditions or circumstances superimposed on the weight normal cours...

HIGH-RISK NEONATE HIGH RISK NEONATE has a greater than average chance of morbidity or mortality regardless of gestational age or birth because of conditions or circumstances superimposed on the weight normal course or events associated with births and adjustments to extra uterine existence. CLASSIFICATION OF HIGH-RISK INFANTS ACCORDING TO SIZE Low-birth weight- (LBW)- an infant whose birth weight is less than 2500 g regardless of gestational age Extremely-low-birth-weight – (ELBW)- infant whose birth weight is less than 1000 g Very-Low Birth weight – (VLBW)- infant whose birth weight is less than 1500 g Moderately-low Birth weight- (MLBW) – infant whose birth weight is 1501 to 2500 g Appropriate-for-gestational age (AGA)- an infant whose weight falls between the 10th and 90tth percentile of intrauterine growth curves  Small-for-date (SFD) or Small-for-gestational age- (SGA)- infant whose weight falls between the 10th and 90th percentiles on intrauterine growth curves Intrauterine growth retardation (IUGR)- ACCORDING found in infants whose intrauterine growth is TO SIZE retarded sometimes used as a more descriptive term for the SGA infant Large-for-gestational-age (LGA) infant- an infant whose birth weight falls above the 90th percentile on intrauterine growth charts  Premature (preterm) infant- an infant born before completion of 37 weeks of gestation, regardless of birth weight ACCORDING TO Full-term infant- an infant born between the beginning of the 38 weeks and the GESTATIONAL completion of the 42 weeks of gestation, AGE regardless of birth weight Postmature (postterm) infant- an infant born after 42 weeks of gestational age, regardless of birth weight Live birth- birth in which the neonate manifests any heartbeat, breathes, or displays voluntary movement, regardless of gestational age Fetal birth- death of the fetus after 20 weeks of gestation and before delivery, with absence of any ACCORDING signs of life after birth Neonatal death- death that occurs in the first 27 days of life; early neonatal death occurs in the first week of life; late neonatal death occurs at 7 to 27 days TO Perinatal mortality- describe the total number of fetal MORTALITY and early neonatal deaths per 1000 live births Postnatal death- death that occurs at 28 days to 1 year MANIFESTATIONS OF ACUTE PAIN IN THE NEONATE PHYSIOLOGIC REPONSES Vital signs: observe for Oxygenation variations Increased heart rate Decreased transcutaneous oxygen saturation Increased blood pressure (tcPo2) Rapid, shallow respirations Decreased arterial oxygen saturation (Sao2) PHYSIOLOGIC REPONSES Skin: observe color and character Other observations Pallor or flushing Increased muscle tone Diaphoresis Dilated pupils Palmar sweating Decreased vagal nerve tone Increased intracranial pressure Laboratory evidence of metabolic or endocrine changes Hyperglycemia Lowered pH Elevated corticosteroids  Vocalizations: observe quality, timing, and duration – Crying – Whimpering – Groaning Facial expression: observe characteristics, timing, orientation of eyes and mouth – Grimaces – Brow furrowed – Chin quivering BEHAVIORAL – Eyes tightly closed – Mouth open and squarish RESPONSES BEHAVIORAL RESPONSES Body movements and posture: observe type, Changes in state: observe sleep, appetite, quality, and amount of movement or lack of activity level movement; relationship to other factors Limb withdrawal Changes in sleep/wake cycles Thrashing Changes in feeding behavior Rigidity Changes in activity level Flaccidity Fussiness, irritability Fist clenching Listlessness  1. Initiation and maintenance of respirations 2. Establishment of extrauterine circulation ALL NEWBORNS 3. Control of body temperature HAVE EIGHT PRIORITY NEEDS 4. Intake of adequate nourishment IN THE FIRST 5. Establishment of waste elimination FEW DAYS OF 6. Prevention of infection LIFE 7. Establishment of an infant–parent relationship 8. Developmental care, or care that balances physiologic needs and stimulation for best development  Low birth weight FACTORS Maternal history of diabetes PREDISPOSING INFANTS TO Premature rupture of membranes RESPIRATORY Maternal use of barbiturates or narcotics close to DIFFICULTY IN birth THE FIRST FEW Meconium staining DAYS OF LIFE Irregularities detected by fetal heart monitor during labor  FACTORS PREDISPOSING INFANTS TO RESPIRATORY DIFFICULTY IN THE FIRST FEW DAYS OF LIFE Cord prolapse Lowered Apgar score (7) at 1 or 5 minutes Postmaturity Small for gestational age Breech birth Multiple birth Chest, heart, or respiratory tract anomalies  place an infant on the back and slide a folded towel or bulb syringe is required, pad under the shoulders to raise them slightly so the head is in a neutral position Do not suction for longer DEEPER a catheter (8F to 12F) over the infant’s tongue to the than 10 seconds at a time (count seconds as you suction) to avoid removing SUCTIONING back of the throat excessive air from an infant’s lungs Bradycardia or cardiac arrhythmias can occur because of vagus Use a gentle touch stimulation (at the posterior oropharynx) from vigorous suctioning.  laryngoscope has been inserted deep tracheal suctioning can be performed. SUCTIONING Endotracheal tube can be inserted oxygen administered by a positive-pressure bag and mask with 100% oxygen at 40 to 60 breaths per minute. PRIMARY APNEA 01 02 03 several weak gasps immediately stop the heart rate of air breathing begins to fall  After 1 or 2 minutes of apnea (a pause in respirations longerthan 20 seconds with accompanying bradycardia again tries to initiate respirations with a few strong gasps SECONDARY APNEA a newborn cannot maintain this effort longer than 4 or 5 minutes. the respiratory effort will become weaker again and the heart rate will fall further until the newborn stops the gasping effort altogether  An obstetrician, pediatrician, neonatologist, anesthesiologist, or neonatal nurse practitioner skilled Laryngoscopes are equipped with different-size blades. Size 0 or 1 is used with newborns LARYNGOSCOPE The endotracheal tube fits inside the laryngoscope INSERTION Infants under 1000 g need a 2.5-mm endotracheal tube; those over 3000 g need a 4.0-mm tube. gentle care during insertion is crucial  An infant who breathes The mask spontaneously but should cover then cannot sustain effective respirations both the mouth may need oxygen by and the nose to bag and mask to aid be effective. lung expansion. OXYGEN ADMINISTRATION It should not cover the Administer 100% eyes, because it can cause oxygen by face mask eye injury mechanically and pressure bag at a from the mask or drying of rate of 40 to 60 the cornea from oxygen compressions per administration. minute NURSING CARE Be certain to listen to both lungs to If the resuscitation continues for over be sure both lungs are being aerated. 2 minutes inserting an orogastric tube and leaving the distal end open help deflate the stomach decrease the possibility that vomiting and aspiration of stomach contents from over distention will occur  narcotic antagonist such as naloxone (Narcan) 0.01 to 0.1 mg/kg body DRUG weight injected into an umbilical vessel or intramuscularly into a thigh THERAPY will relieve the depression If an infant has no audible heartbeat, or if the cardiac rate is below 80 beats per minute, closed-chest massage should be started Hold an infant with fingers supporting the back and depress the sternum with two fingers ESTABLISHING EXTRAUTERINE Depress the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 CIRCULATION times per minute Lung ventilation at a rate of 30 times per minute should be continued and interspersed with the cardiac massage at a ratio of 1:3.  DEHYDRATION MAY RESULT FROM INCREASED INSENSIBLE WATER LOSS FROM RAPID INFANTS WITH HYPOGLYCEMIA ARE TREATED INITIALLY WITH 10% DEXTROSE IN WATER TO MAINTAINING FLUID AND RESPIRATIONS RESTORE THEIR BLOOD GLUCOSE LEVEL. ELECTROLYTE BALANCE FLUIDS SUCH AS RINGER’S ELECTROLYTES (PARTICULARLY LACTATE OR 5% DEXTROSE IN SODIUM AND POTASSIUM) AND WATER ARE COMMONLY USED GLUCOSE ARE ADDED AS TO MAINTAIN FLUID AND NECESSARY, DEPENDING ON ELECTROLYTE LEVELS. ELECTROLYTE ANALYSIS It is important to keep newborns in a neutral-temperature environment, one that is neither too hot nor too cold, as doing so places less demand on them to maintain a minimal metabolic rate necessary for effective body functioning If the environment is too hot, they must decrease metabolism to cool their body. REGULATING If it is too cold, they must increase metabolism to warm TEMPERATURE body cells. An infant’s PO2 level falls and PCO2 increases And may open fetal right-to-left shunts again To supply glucose to maintain increased metabolism, an infant begins anaerobic glycolysis---pours acid into the bloodstream ACID BASE increased risk of kernicterus (invasion of brain cells with unconjugated BALANCE An infant becomes bilirubin) as more bilirubin-binding sites acidotic are lost and more bilirubin is free to pass out of the bloodstream into brain cells.  wipe an infant dry cover the head with a cap place the baby immediately under a pre-warmed radiant warmer or in warmed incubator IMMEDIATE skin-to-skin against the mother. NEWBORN CARE Additional measures use of plastic wrap, plastic shields, or warmed mattresses Air, incubator, or radiant warmer temperatures should be kept regulated to maintain an infant’s axillary temperature at 97.8° F (36.5° C). PRETERM NEONATE PRETERM INFANT live-born infant born before the end of week 37 of gestation; weight of less than 2500 g (5 lb 8 oz) at birth The maturity of a newborn is determined by physical findings such as – sole creases – skull firmness – ear cartilage – neurologic findings that reveal gestational age A preterm infant is immature and small but well proportioned for age  Low socioeconomic level Poor nutritional status COMMON Lack of prenatal care FACTORS Multiple pregnancy ASSOCIATED Previous early birth WITH Race (nonwhites have a higher incidence of prematurity than whites) PRETERM Cigarette smoking BIRTH Age of the mother (highest incidence is in mother younger than age 20) Order of birth (early termination is highest in first pregnancies and in those beyond the fourth pregnancy) COMMON FACTORS ASSOCIATED WITH PRETERM BIRTH Abnormalities of the mother’s reproductive system, such as intrauterine septum Infections (especially urinary tract infection) Obstetric complications, such as premature rupture of membranes or premature separation of the placenta Early induction of labor Elective cesarean birth Closely spaced pregnancies  The head is disproportionately large (3 cm greater than chest size) skin is generally unusually ruddy veins are easily noticeable ASSESSMENT OF high degree of acrocyanosis may be present PRETERM vernix caseosa- 24 to 36 weeks (covered)