Neonate , High Risk

1. HIGH RISK NEONATES
Presented by Ann Hearn RNC, MSN

2. CLASSIFICATION OF HIGH RISK NEWBORNS
 Gestational Age
 Preterm
 (Late Preterm)
 Term
 Postterm
 Gestational Age & Birth
Weight
 SGA
 AGA
 LGA

3. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT

4. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Respiratory and Cardiac
 Thermoregulation
 Digestive
 Renal

5. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Respiratory and Cardiac
 Lack of surfactant
 Pulmonary blood vessels
 Ductus arteriosus

7. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Respiratory - Nursing Interventions
 Maintain airway
 Administer O2
 Monitor O2 saturation
 Monitor heart/respiratory rates
 S/S respiratory distress
 Cyanosis
 Tachicardia
 Retractions
 Expiratory grunting
 Nasal flaring
 Apnic episodes

8. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Thermoregulation
 Increased body surface
 Decreased brown fat
 Thin Skin
 Lack of flexion
 Decrease sub-q fat

9. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Thermal Neutrality – Nursing Interventions
 Incubator or radian warmer
 Warm surfaces
 Warm humidified oxygen
 Warm ambient humidity
 Warm feedings
 Keep skin dry and head covered

10. ISOLETTE/ RADIANT or
INCUBATOR OPEN WARMER

11. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Digestive
 Poor gag reflex
 Small stomach capacity
 Relaxed cardiac sphincter
 Poor suck and swallow reflex
 Difficult fat, protein and lactose digestion
 Absorption

12. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Nutrition and Hydration – Nursing Interventions
 Daily weights
 Monitor I&O
 Accurate IV rates
 Accurate OGT feedings
 Monitor urine pH and specific gravity
 Signs of dehydration
 Weight loss
 Poor skin turgor
 Dry oral mucus membranes
 Decreased urinary output
 Increased specific gravity

13. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Pre-feeding assessment
 Measure abdominal girth
 Bowel sounds
 Gastric residual
 Sucking and gag reflexes

14. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Renal
 Decreased glomerular filtration rate
 Inability to concentrate urine or excrete excess
 Decreased ability of kidneys to buffer
 Decreased drug excretion time

15. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Prevention of Infection – Nursing Interventions
 Initial scrub / strict hand washing
 Visitors & staff
 Reverse isolation
 Single infant equipment
 Short / no artificial nails
 Maintain sterile technique
 IV start and dressing changes
 Procedures
 Clean incubators weekly
 Position changes; use of sheepskin
 Judicious use of tape on skin

16. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Signs and Symptoms of Infection
 Behavioral changes
 Physiological changes
 Tonus
 Color
 Temperature
 Skin
 Feeding
 Hyperbilirubinemia
 Heart rate
 Respiratory rate

17. PHYSIOLOGIC CHALLENGES OF THE
PREMATURE INFANT
 Facilitating Parent-Infant Attachment
 Prepare parents for first visit
 Establish safe/trusting environment
 Encourage visitation
 Involved in care taking
 Repeat explanations
 Promote touching, talking, rocking, cuddling
 Refer to infant by name
 Allow parents to phone as desired

19. DISORDERS OF INFANTS IN NICU
 SGA and IUGR
 Infants of Diabetic Mothers
 Postmature Infant
 Infants of Addicted Mothers
 Respiratory Distress Syndrome
 Meconium Aspiration Syndrome
 Hyperbilirubinemia
 Retinopathy of Prematurity
 Necrotizing Entercolitis
 Infectious Diseases - TORCH

20. ASSOCIATED COMPLICATIONS OF:
 Asphyxia
 Aspiration syndrome
 Hypothermia
 Hypoglycemia
 Polycythemia
 Congenital
malformations
 Intrauterine infections
 Continued growth
difficulties
 Cognitive difficulties
SGA IUGR
Nursing Interventions: Monitor heart rate, respiratory rate, temperature
and blood glucose.

21. INFANTS OF DIABETIC MOTHERS

22. INFANTS OF DIABETIC MOTHERS
 Clinical manifestations IDM
 Ruddy color
 Macrosomia
 Excessive adipose tissue
 Hypoglycemia
Increase risk of birth injuries.

23. INFANTS OF DIABETIC MOTHERS
 Why Hypoglycemia?
 High levels of glucose cross the placenta
 In response, fetus produces high levels of insulin
 High levels of insulin production continues after cord
cut
 Depletes the infant’s blood glucose

24. INFANTS OF DIABETIC MOTHERS
 Nursing Interventions for Hypoglycemia
 Assess for signs/symptoms
 Tremors
 Cyanosis
 Apnea
 Temperature instability
 Poor feeding
 Hypertonia / Lethargy
 Assess blood glucose
 Intervene if < 40mg/dl:
 Feed infant
 If no improvement:
 IV of D10W

25. POST MATURE INFANT
 Post term: infant born after __?__ wks
 Physical manifestations:
 Dry, cracking, parchment-like skin
 Loose appearing skin
 No vernix or lanugo
 Long fingernails
 Profuse scalp hair
 Long, thin body appearance

26. POST MATURE INFANT
 Complications of post term:
 Hypoglycemia
 Meconium aspiration
 Congenital anomalies
 Seizure activity
 Cold stress
 Nursing considerations
 Monitor blood sugars per protocol
 Evaluate respiratory status
 Assess for seizure activity
 Treat cold stress.

27. INFANTS OF ADDICTED MOTHERS
 Clinical Manifestations of Infant Withdrawal:
 IRRITABILITY
 Hyperactivity
 Shrill cry
 Exaggerated reflexes
 Facial scratches
 Short non-quiet sleep
 Sneezing, coughing, yawning
 Poor feeding
 Disorganized vigorous suck
 Vomiting
 Diarrhea
 Tachypnea
 Sweating
 Excoriated skin

28. INFANTS OF ADDICTED MOTHERS
 Nursing Interventions for Infant Withdrawal:
 Swaddle with hands near mouth
 Offer pacifier
 Place in quiet dimly lit area of the nursery
 Protect skin from excoriation
 Monitor V/S
 Provide small frequent feedings
 Position with HOB elevated
 Weigh every 8 hours (if vomiting & diarrhea)
 Assess with Finnegan Abstinence Scale
 Administer morphine, phenobarbitol, methadone

29. FETAL ALCOHOL SYNDROME - FAS

30. FETAL ALCOHOL SYNDROME - FAS
 Clinical Manifestations:
 Jitteriness
 Abdominal distention
 Exaggerated rooting and sucking reflexes
 Affected body systems:
 CNS
GI system
 Long-term psychosocial implications:
 Feeding difficulties
 Mental retardation

31. RESPIRATORY DISTRESS SYNDROME - RDS
 Pathophysiology
 Primary absence, deficiency or alteration in the
production of surfactant
 Surfactant, atelectasis = lack of gas exchange
 Leads to hypoxia and acidosis which further inhibit surfactant
production and causes pulmonary vasoconstriction.
 Clinical manifestations:
 Cyanosis
 Tachypnea
 Nasal flaring
 Retracting
 Apnea

32. RESPIRATORY DISTRESS SYNDROME - RDS
 Nursing Care Plan
 Page 826-828

33. MECONIUM ASPIRATION SYNDROME
 Meconium stained amniotic fluid
 Aspirated into the trachobronchial tree
 Occurs either in utero or after birth with the first breaths.
 Meconium in the lungs causes air to become
trapped and results in alveoli over-distension and
rupture.

34. MECONIUM ASPIRATION SYNDROME
 Measures for Prevention of Meconium Aspiration
 After delivery of the infant’s head but before shoulders
 Suction oropharynx and nasopharynx (no longer recommended)
 If THICK meconium, after delivery of the infant’s body
Crying Not crying
- Stimulate - Do not stimulate
- Suction with - Visualize the vocal cords and
bulb syringe provide direct suction with
endotracheal tube, then stimulate.
 If THIN meconium, no visualization performed.

35. MECONIUM ASPIRATION SYNDROME
Intubation Suction

36. MECONIUM ASPIRATION SYNDROME
 Nursing Interventions:
 Maintain adequate oxygenation and ventilation
 Regulate temperature
 Accurate IV fluid administration
 Assess for hypoglycemia
 Administer antibiotics
 Provide caloric requirements
 Provide support care if on ECMO

37. HYPERBILIRUBINEMIA
 Pathophysiology
 Bilirubin is released in serum when RBC lyse
 Conjugation in liver = water soluble & excretable
 Rate & amount of conjugation dependent upon:
 Rate of hemolysis
 Bilirubin load
 Maturity of liver
 Presence of albumin-binding sites
Hyperbilirubinemia occurs when the body cannot
conjugate the bilirubin released into the serum.
Results in jaundice where the unconjucated bilirubin is
deposited in the tissue.

38. HYPERBILIRUBINEMIA
 Hemolytic Disease (Pathologic Hyperbilirubinemia)
 Results from incompatibility between mother’s blood
type or Rh factor and that of the fetus
 Maternal antibodies develop from + fetal antigen
 Antibodies cross placental into fetal circulation
 Antibodies attach to and destroy fetal RBCs.
 Fetal RBCs lyse & release bilirubin into fetal circulation

40. HYPERBILIRUBINEMIA
 Additional assessments:
 Maternal, paternal, and fetal blood type and Rh factor
 Newborn
 Skin color, sclera, oral mucosa
 Hypotonia, diminished reflexes, lethary and seizures

41. HYPERBILIRUBINEMIA
 Positive Coombs Test
 Direct coombs test reveals antibody-coated Rh positive
RBCs in the newborn

42.  Nursing Interventions for Phototherapy
 Exposure of skin
 Cover eyes (remove for feeding/parent visit)
 Monitor temperature
 Increase fluids
 Assess for dehydration
 Perform T-Bili q 12 – 24 hr as ordered
HYPERBILIRUBINEMIA

43.  Exchange Transfusion
 Treat anemia
 Remove sensitized RBCs that will soon lyse
 Remove serum bilirubin
 Provides albumin to increase bilirubin binding sites
HYPERBILIRUBINEMIA

44.  Rhogam
 Provides temporary passive immunity which prevents
permanent active immunity (antibody formation)
 Given within 72 hours of delivery
 Prevents production of maternal antibodies
HYPERBILIRUBINEMIA

45.  ABO incompatibility
 Occurs when type O pregnant woman with A, B or AB
blood type fetus
 If woman has anti A or anti B antibodies, these
antibodies cross the placental barrier
 Results in hemolysis of fetal RBCs
HYPERBILIRUBINEMIA

46.  Complications of Hemolytic Disease
 Kernicterus – Deposits of conjugated and unconjugated
bilirubin in the basal ganglia of the brain
 Neurologic damage
 Hydrops fetalis – severe anemia
 Marked edema
 Cardiac decompensation
 Multiple organ failure
 Possible death
HYPERBILIRUBINEMIA

47. RETINOPATHY OF PREMATURITY
 Formation of immature blood vessels in the retina
constrict and become necrotic
 Most common in infants < 28 weeks gestation
 Also associated with O2 therapy

48. RETINOPATHY OF PREMATURITY
 Nursing Interventions to Prevent ROP
 Administer O2 in concentration ordered
 Ensure proper ventilatory settings

49. NECROTIZING ENTEROCOLITIS
 NEC - Inflammatory disease of the intestinal tract
caused by ischemia, infection, and/or prematurity of
the gut.
 Preterm infant at increased risk
 undeveloped protective intestinal mucin layer
 slow careful introduction to oral feedings
 Early detection:
 Measure abdominal girth daily
 Assess color of abdomen
 Assess residual feeding
 Assess bowel sounds
 Assess S/S sepsis

50. INFECTIOUS DISEASES: TORCH
 Toxoplasmosis
 Other
 Syphillis
 Hepititis B
 Rubella
 Cytomegalovirus
 Herpes Simplex II
 HIV

51. TOXOPLASMOSIS
 Protozoan infection in the pregnant woman
 Raw or under cooked meats
 Cat feces
 Affects on the fetus
 Blindness
 Deafness
 Convulsions
 Microcephaly
 Hydrocephaly
 Severe mental impairment

52. OTHER
 Syphilis
 Hepatitis B

53. OTHER
 Syphillis
 S/S of Newborn:
 Rhinitis
 Excoriated upper lip
 Red rash around mouth and anus
 Copper colored rash of face, palms and soles
 Irritability
 Edema
 Cataracts.
 Treatment:
 Culture orifices
 Isolation
 Penicillin

54. OTHER
 Hepatitis B
 Transmission
 Placental
 Birth
 Breast milk
 Treatment
 If mother + HbSAG administer to newborn
 Hepitisis B vaccine
 HBIG

55. RUBELLA
 S/S of Newborn
 Congenital cataracts
 Deafness
 Congenital heart defects
 Sometimes fatal
 MMR Immunization of mother
 Give when not pregnant

56. CYTOMEGALOVIRUS
 Herpatic virus
 Crosses placental barrier
 Direct contact at birth
 S/S of Newborn
 Severe neurological problems
 Eye abnormalities
 Hearing loss
 Microcephaly
 Hydrocephaly
 Cerebral palsy
 Mental delays

57. HERPES SIMPLEX II
 Transmission:
 Direct contact at birth
 S/S of Newborn
 Microcephaly
 Mental delays
 Seizures
 Retinal dysplasia
 Apnea
 Coma

58. HIV/AIDS
 Transmission: < 2%
 Transplacentally
 Exposure at birth
 Breast milk
 Nursing Interventions
 Protect self from body fluids
 Labs - + antibody titer
 Administer AZT
 Provide care like that of any other newborn