High Risk Infant

HIGH RISK INFANTS

The high-risk neonate: can be defined as a newborn, regardless of gestational age or birth weight, who has a greater-than-average chance of morbidity or mortality, because of conditions or circumstances superimposed on the normal course of events associated with birth and the adjustment to extra uterine existence.

Premature Infants

DefinitionA baby born before 37 weeks of pregnancy is considered premature, that is, born

before complete maturity. Slightly fewer than 12 percent of all babies are premature. Overall, the rate of premature births is rising, mainly due to the large numbers of multi-ple births in recent years. Twins and other multiples are about six times more likely to be premature than single birth babies. The rate of premature single births is slightly in-creasing each year.

According to the March of Dimes, about 13 percent of babies born in the US are born preterm, or before 37 completed weeks of pregnancy. Of the babies born preterm:

• 71 percent are born between 34 and 36 weeks of gestation (the time from con-ception to birth)•about 13 percent are born between 32 and 33 weeks of gestation•about 6 percent are born at less than 28 weeks of gestationOther terms often used for prematurity are preterm and "preemie." Many prema-

ture babies also weigh less than 2,500 grams (5.5 pounds) and may be referred to as low birthweight (LBW).

Premature infants born between 34 and 37 weeks of pregnancy are often called late preterm or near-term infants. Late preterm infants are often much larger than very premature infants but may only be slightly smaller than full-term infants.

Late preterm babies usually appear healthy at birth but may have more difficulties adapting than full-term babies. Because of their smaller size, they may have trouble maintaining their body temperature. They often have difficulty with breastfeeding and bottle feeding, and may need to eat more frequently. They usually require more sleep and may even sleep through a feeding, which means they miss much-needed calories.

Late preterm infants may also have breathing difficulties, although these are often identified before the infants go home from the hospital. These infants are also at higher risk for infections and jaundice, and should be watched for signs of these conditions. Late preterm infants should be seen by a care provider within the first one or two days after going home from the hospital.

Causes of prematurityThere are many factors linked to premature birth. Some directly cause early labor

and birth, while others can make the mother or baby sick and require early delivery. The following factors may contribute to a premature birth:

Maternal factors:○ preeclampsia (also known as toxemia or high blood pressure of pregnancy)○ chronic medical illness (such as heart or kidney disease)

○ infection (such as group B streptococcus, urinary tract infections, vaginal Iinfections, infections of the fetal/placental tissues)

○ drug use (such as cocaine)○ abnormal structure of the uterus○ cervical incompetence (inability of the cervix to stay closed during pregnancy)○ previous preterm birth

Factors involving the pregnancy:○ abnormal or decreased function of the placenta ○ placenta previa (low lying position of the placenta) ○ placental abruption (early detachment from the uterus) ○ premature rupture of membranes (amniotic sac) ○ polyhydramnios (too much amniotic fluid)

Factors involving the fetus:○ when fetal behavior indicates the intrauterine environment is not healthy○ multiple gestation (twins, triplets or more)

Characteristics of prematurityThe following are the most common characteristics of a premature baby. However,

each baby may show different characteristics of the condition. Characteristics may in-clude:

•small baby, often weighing less than 2,500 grams (5 pounds 8 ounces) •thin, shiny, pink or red skin, able to see veins•little body fat •little scalp hair, but may have lots of lanugo (soft body hair) •weak cry and body tone •genitals may be small and underdevelopedThe characteristics of prematurity may resemble other conditions or medical prob-

lems. Always consult your baby's physician for a diagnosis.

Treatment of prematurity:Specific treatment for prematurity will be determined by your baby's physician

based on:•your baby's gestational age, overall health, and medical history •extent of the disease •tolerance for specific medications, procedures, or therapies •expectations for the course of the disease•your opinion or preference

Treatment may include:•prenatal corticosteroid therapy

One of the most important parts of care for premature babies is a medication called a corticosteroid. Research has found that giving the mother a steroidmedication at least 48 hours prior to delivery greatly reduces the incidence and severity of respiratory disease in the baby. Another major benefit of steroid treat-ment is lessening of intraventricular hemorrhage (bleeding in the baby's brain).

Although studies are not clear, prenatal steroids may also help reduce the inci-dence of NEC and PDA. Mothers may be given steroids when preterm birth is likely between 24 and 34 weeks of pregnancy. Before that time, or after, the medication usually is not effective.

Premature babies usually need care in a special nursery called the Neonatal Intensive Care Unit (NICU). The NICU combines advanced technology and trained health professionals to provide specialized care for the tiniest patients. The NICU team is led by a neonatologist, who is a pediatrician with additional training in the care of sick and premature babies.

Care of premature babies may also include:•temperature-controlled beds•monitoring of temperature, blood pressure, heart and breathing rates, and oxygen levels•giving extra oxygen by a mask or with a breathing machine •mechanical ventilators (breathing machines) to do the work of breathing for thebaby•intravenous (IV) fluids - when feedings cannot be given, or for medications•placement of catheters (small tube) into the umbilical cord to give fluids and medi-cations and to draw blood•x-rays (for diagnosing problems and checking tube placement)•special feedings of breast milk or formula, sometimes with a tube into the stomach if a baby cannot suck. Breast milk has many advantages for premature babies as it contains immunities from the mother and many important nutrients.•medications and other treatments for complications, such as antibiotics

•Kangaroo Care - a method of caring for premature babies using skin-to-skin contact with the parent to provide contact and aid parent-infant attachment. Studies have found that babies who "kangaroo" may have shorter stays in the NICU.

POSTMATURE INFANTS

DefinitionThe normal length of pregnancy is from 37 to 41 weeks. Postmaturity refers to any

baby born after 42 weeks gestation or 294 days past the first day of the mother's last menstrual period. About 6 percent of all babies are born at 42 weeks or later. Other terms often used to describe these late births include post-term, postmaturity, prolonged pregnancy, and post-dates pregnancy.

Causes of postmaturity?It is not known why some pregnancies last longer than others. Postmaturity is

more likely when a mother has had one or more previous post-term pregnancies. Some-times a mother's pregnancy due date is miscalculated because she is not sure of her last menstrual period. A miscalculation may mean the baby is born earlier or later than expected.

Symptoms of postmaturityThe following are the most common symptoms of postmaturity. However, each

baby may show different symptoms of the condition. Symptoms may include:•dry, peeling skin•overgrown nails•abundant scalp hair•visible creases on palms and soles of feet•minimal fat deposits•green/brown/yellow coloring of skin from meconium staining (the first stool passed during pregnancy into the amniotic fluid)

Symptoms of postmaturity may resemble other conditions or medical problems. Al-ways consult your baby's physician for a diagnosis.

DiagnosisPostmaturity is usually diagnosed by a combination of assessments, including the

following:•your baby's physical appearance •length of the pregnancy •your baby's assessed gestational age

Treatment of postmaturity:Specific treatment for postmaturity will be determined by your baby's physician

based on:•your baby's gestational age, overall health, and medical history •extent of the condition •your baby's tolerance for specific medications, procedures, or therapies •expectations for the course of the condition •your opinion or preferenceIn a prolonged pregnancy, testing may be done to check fetal well-being and iden-

tify problems. Tests often include ultrasound, non-stress testing (how the fetal heart rate responds to fetal activity), and estimation of the amniotic fluid volume.The decision to induce labor for post-term pregnancy depends on many factors. During labor, the fetal heart rate may be monitored with an electronic monitor to help identify changes in the heart rate due to low oxygenation. Changes in a baby's condition may require a cesarean delivery.

Special care of the postmature baby may include:•checking for respiratory problems related to meconium (baby's first bowel move-ment) aspiration.•blood tests for hypoglycemia (low blood sugar).

Prevention of postmaturity:Accurate pregnancy due dates can help identify babies at risk for postmaturity.

Ultrasound examinations early in pregnancy help establish more accurate dating by

measurements taken of the fetus. Ultrasound is also important in evaluating the placenta for signs of aging.

LARGE FOR GESTATIONAL AGE

DefinitionLarge for gestational age (LGA) is a term used to describe babies who are born

weighing more than the usual amount for the number of weeks of pregnancy. LGA ba-bies have birthweights greater than the 90th percentile for their gestational age, mean-ing that they weigh more than 90 percent of all babies of the same gestational age.

The average baby weighs about 7 pounds at birth. About 10 percent of all babies weigh more than 4,000 grams (8 pounds, 13 ounces). Rarely do babies weigh over 10 pounds.

Although most LGA babies are born at term (37 to 41 weeks of pregnancy), a few premature babies may be LGA.

Causes of large for gestational age (LGA)Some babies are large because their parents are large; genetics does play a part.

Birthweight may also be related to the amount of a mother's weight gain in pregnancy. Excessive weight gain can translate to increased fetal weight.

By far, maternal diabetes is the most common cause of LGA babies. Diabetes dur-ing pregnancy causes the mother's increased blood glucose (sugar) to circulate to the baby. In response, the baby's body makes insulin. All the extra sugar and the extra in-sulin production can lead to excessive growth and deposits of fat, thus, a larger baby.

DiagnosisDuring pregnancy, a baby's birthweight can be estimated in different ways. The

height of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This measurement, in centimeters, usually corresponds with the number of weeks of pregnancy. If the measurement is high for the number of weeks, the baby may be larger than expected. Other diagnostic procedures may include the following:

•Ultrasound (a test using sound waves to create a picture of internal structures) is a more accurate method of estimating fetal size. Measurements can be taken of the fe-tus' head and limbs and compared with a growth chart to estimate fetal weight.

•A mother's weight gain can also influence a baby's size. Large maternal weight gains in pregnancy may correspond with a big baby.Babies are weighed within the first few hours after birth. The weight is compared with the baby's gestational age and recorded in the medical record. The birthweight must be compared to the gestational age. Generally, a baby weighing more than 4,000 grams (8 pounds, 13 ounces) is considered LGA.

Treatment for large for gestational age (LGA):Specific treatment for large for gestational age will be determined by your baby's

physician based on:•your baby's gestational age, overall health, and medical history •extent of the condition

•your baby's tolerance for specific medications, procedures, or therapies •expectations for the course of the condition •your opinion or preferenceIf ultrasound examinations during pregnancy show a fetus is quite large, some

physicians may recommend early delivery before the baby grows much bigger. A mother may need induction of labor, or a planned cesarean delivery if the baby is esti-mated to be very large.

After delivery, a LGA baby will be carefully examined for any birth injuries. Blood glucose testing is also performed to check for hypoglycemia. Early feeding with a glu-cose/water solution is sometimes needed to counter the low blood sugar.

Prevention of large for gestational age (LGA):Prenatal care is important in all pregnancies, and especially to monitor fetal

growth when a baby seems to be too small or too large. Examinations during pregnancy that show a large baby can help identify a mother who may have undetected diabetes, or other problems. Careful management of diabetes in pregnancy can help lower some of the risks to the baby.

SMALL FOR GESTATIONAL AGE

DefinitionSmall for gestational age (SGA) is a term used to describe a baby who is smaller

than the usual amount for the number of weeks of pregnancy. SGA babies usually have birthweights below the 10th percentile for babies of the same gestational age. This means that they are smaller than 90 percent of all other babies of the same gestational age.

SGA babies may appear physically and neurologically mature but are smaller than other babies of the same gestational age. SGA babies may be proportionately small (equally small all over) or they may be of normal length and size but have lower weight and body mass. SGA babies may be premature (born before 37 weeks of pregnancy), full term (37 to 41 weeks), or post term (after 42 weeks of pregnancy).

Causes small for gestational age (SGA)?Although some babies are small because of genetics (their parents are small),

most SGA babies are small because of fetal growth problems that occur during preg-nancy. Many babies with SGA have a condition called intrauterine growth restriction (IUGR).

IUGR occurs when the fetus does not receive the necessary nutrients and oxygen needed for proper growth and development of organs and tissues. IUGR can begin at any time in pregnancy. Early-onset IUGR is often due to chromosomal abnormalities, maternal disease, or severe problems with the placenta. Late-onset growth restriction (after 32 weeks) is usually related to other problems.

Some factors that may contribute to SGA and/or IUGR include the following:•Maternal factors:

○ high blood pressure○ chronic kidney disease

○ advanced diabetes ○ heart or respiratory disease ○ malnutrition, anemia ○ infection ○ substance use (alcohol, drugs) ○ cigarette smoking

•Factors involving the uterus and placenta: ○ decreased blood flow in the uterus and placenta ○ placental abruption (placenta detaches from the uterus) ○ placenta previa (placenta attaches low in the uterus) ○ infection in the tissues around the fetus

•Factors related to the developing baby (fetus): ○ multiple gestation (twins, triplets, etc.) ○ infection ○ birth defects○ chromosomal abnormality

DiagnosisThe baby with SGA is often identified before birth. During pregnancy, a baby's size

can be estimated in different ways. The height of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This measurement in centimeters usually corresponds with the number of weeks of pregnancy after the 20th week. If the mea-surement is low for the number of weeks, the baby may be smaller than expected.

Although many SGA babies have low birthweight, they are not all premature and may not experience the problems of premature babies. Other SGA babies, especially those with IUGR, appear thin, pale, and with loose, dry skin. The umbilical cord is often thin, and dull-looking rather than shiny and fat. They sometimes have a wide-eyed look.

Other diagnostic procedures may include the following:• Ultrasound Ultrasound (a test using sound waves to create a picture of internal structures) is a more accurate method of estimating fetal size. Measurements can be taken of the fetus' head and abdomen and compared with a growth chart to es-timate fetal weight. The fetal abdominal circumference is a helpful indicator of fetal nutrition.•Doppler flow another way to interpret and diagnose IUGR during pregnancy is Doppler flow, which use sound waves to measure blood flow. The sound of moving blood produces wave-forms that reflect the speed and amount of the blood as it moves through a blood vessel. Blood vessels in the fetal brain and the umbilical cord blood flow can be checked with Doppler flow studies.•Mother’s weight gain A mother's weight gain can also indicate a baby's size. Small maternal weight gains in pregnancy may correspond with a small baby•Gestational assessment Babies are weighed within the first few hours after birth. The weight is compared with the baby's gestational age and recorded in the medi-cal record. The birthweight must be compared to the gestational age. Some physi-cians use a formula for calculating a baby's body mass to diagnose SGA.

Treatment of babies who are small for gestational age (SGA):Specific treatment for SGA will be determined by your baby's physician based on: •your baby's gestational age, overall health, and medical history

•extent of the condition •your baby's tolerance for specific medications, procedures, or therapies•expectations for the course of the condition•your opinion or preferenceBabies with SGA may be physically more mature than their small size indicates.

But they may be weak and less able to tolerate large feedings or to stay warm.

Treatment of the SGA baby may include:•temperature controlled beds or incubators •tube feedings (if the baby does not have a strong suck) •checking for hypoglycemia (low blood sugar) through blood tests •monitoring of oxygen levels

Babies who are SGA and are also premature may have additional needs including oxy-gen and mechanical help to breathe.

Prevention of small for gestational age (SGA):Prenatal care is important in all pregnancies, and especially to identify problems

with fetal growth. Stopping smoking and use of substances such as drugs and alcohol are essential to a healthy pregnancy. Eating a healthy diet in pregnancy may also help.

SUDDEN INFANT DEATH SYNDROME (SIDS)

- defined as the sudden death of an infant under 1 year of age that remains unexplained after a complete postmortem examination, including an investigation of the death scene and a review of the case history.

- it tends to occur at a higher-than-usual rate in infants of adolescent mothers, infants of closely-spaced pregnancies, and underweight and pre-term infants. Also prone to SIDS are infants with bronchopulmonary dysphasia, twins and infants of narcotic dependent mothers.

- the peak age of incidence is 2 to 4 months of age.

CAUSE/ETIOLOGY

Although the cause of SIDS is unknown, a number of theories about its cause have been postulated:

- prolonged but unexplained apnea

- viral respiratory or botulism infection

- pulmonary edema

- possible lack of surfactant in alveoli

- sleeping prone (respiratory muscles are restricted)

- impaired arousal responsiveness to increased carbon dioxide or decreased oxygen

- genetic predisposition to SIDS

- maternal smoking (both prenatally and postnatally)

- poor prenatal care

- low maternal age

- cot sleeping

- soft bedding

- intrathoracic hemorrhages

Signs and Symptoms

- lifeless infant

MEDICAL DIAGNOSIS

- A SIDS diagnosis should not be made if any of these three steps are not conducted:

1. complete autopsy

2. examination of a death scene

3. review of infant’s clinical/health history

NURSING DIAGNOSES

Ineffective Coping Mechanism: feelings of extreme guilt related to loss of child

secondary to Sudden Infant Death Syndrome

Complicated Grieving Process related to loss of child secondary to Sudden Infant

Death Syndrome

Deficient Knowledge: feelings of guilt and anxiety related to lack of knowledge on

the actual cause of sudden child loss

Risk for Injury to the infant related to environmental stressors

Risk for sudden infant Death syndrome related to poor prenatal care

PREVENTION

At least some cases of sudden infant death syndrome can be prevented. Parents can take a number of actions that will reduce the risk of SIDS for their babies. These actions include the following:

Sleep position. At one time, parents were taught to put their babies on their stom-achs when they went to bed. That position was thought to prevent the baby from choking in its sleep. Experts now suggest that babies sleep on their backs or their sides. In these positions, they are less likely to have their faces covered in pillows and blankets.

Good prenatal care. Women should get the best possible medical care while they are pregnant. This care will ensure that they are themselves healthy. Expectant mothers should be warned about the risks of smoking, alcohol intake, and drug use. A healthy mother's body is the best protection the newborn baby can have. Good prenatal care also involves education for the mother. She should be taught the best techniques for caring for her new baby.

Proper bedding. Soft bedding, such as beanbags, waterbeds, and soft mattresses, increase the risk for SIDS. Babies should sleep on firm mattresses with no soft or fluffy materials nearby. Soft stuffed toys should not be placed in a crib while the baby sleeps.

Room temperature. A baby's room should be kept at a temperature that is comfortable for the parents. A baby who becomes too warm may sleep too deeply and may find it more difficult to wake up if it has trouble breathing.

Diet. Some studies show that babies who are breast-fed are at lower risk for SIDS. Mother's milk may provide additional protection against infections that can cause SIDS in infants.

Bed sharing with parents. Opinions differ as to whether bed sharing between mother and baby increases or decreases the risk of SIDS. Bed sharing may encourage breast-feeding, which decreases the risk of SIDS. Parents who bed share may also be more aware of any problems their baby has breathing. On the other hand, some studies show that bed-sharing increases the risk of SIDS. In any case, parents should remember cautions about the use of bedding if their babies sleep with them. They should also remember that an adult's bed does not have the same safety features of an infant's crib.

Secondhand smoke. The baby's room should be kept free of tobacco smoke at all times.

Electronic monitoring. Electronic devices are now available that allow parents to listen in while their baby is sleeping. These devices sound an alarm if the baby stops breathing. So far, however, there is no scientific evidence that electronic devices reduce the risk of SIDS. The U.S. National Institutes of Health recommends their use only for babies known to be at risk for SIDS. These babies include premature infants, infants who have had previous breathing problems, or infants with siblings who have died of SIDS.

Use of pacifiers (*if breastfed, introduction of pacifier should be delayed after 1 month to ensure that breast feeding is firmly established; *infants should not be

forced to take it,* it should not be sweet coated, *must not be reinserted once infant falls asleep)

Avoid overheating (infant’s room should be at a temperature of comfort for a lightly clothed adult, infant free from heavy wrapping or thick blankets)

Avoid development of positional plagiocephaly Encourage “tummy time” when the infant is awake and observed. This will also en-

hance motor development.

Avoid having the infant spend excessive time in car-seat carriers and “bouncers,” in which pressure is applied to the occupant. Upright “cuddle time” should be encour-aged.

Alter the supine head position during sleep. Techniques for accomplishing this in-clude placing the infant to sleep with the head to one side for a week and then changing to the other and periodically changing the orientation of the infant to out-side activity (eg, the door of the room).

Particular care should be taken to implement the aforementioned recommendations for infants with neurologic injury or suspected developmental delay.

Consideration should be given to early referral of infants with plagiocephaly when it is evident that conservative measures have been ineffective. In some cases, orthotic devices may help avoid the need for surgery.)

A separate but proximate sleeping environment is recommended: The risk of SIDS has been shown to be reduced when the infant sleeps in the same room as the mother. A crib, bassinet, or cradle that conforms to the safety standards of the Consumer Product Safety Commission and ASTM (formerly the American Society for Testing and Materials) is recommended.

MANAGEMENT

There is no management for SIDS in infants. Management is focused on parents, family and significant others.

1. Carefully explain to the parents the infant’s actual cause of death to help them gain an understanding.

2. Counseling and Health Teaching

3. Provide emotional support.

4. Help provide support systems such as friends and support groups for the affected families. Referrals to other parents who have lost a child to SIDS is often considered to provide continuous and periodic evaluation of their progress.

5. The next infant of the affected families is usually placed under strict program monitoring. Ex: CONI in England, Wales and Northern Ireland. This will reduce risk of SIDS occurrence and reduce the parent’s/caregiver’s feeling of fear and insecurity.

PICTURES

RESPIRATORY DISTRESS SYNDROME

- also known as HYALINE MEMBRANE DISEASE (HMD)

- refers to a condition of surfactant deficiency and physiologic immaturity of the thorax.

- seen almost exclusively in preterm infants but may also be associated with multifetal pregnancies, infants of diabetic mothers, cesarean section delivery , delivery before 37 weeks’ gestation, asphyxia, those who for any reason have decreased blood perfusion of the lungs, such as occurs with meconium aspiration and a history of previous RDS.

- the pathologic feature of RDS is a hyaline-like (fibrous) membrane formed from an exudate of an infants blood that begins to line the terminal bronchioles, alveolar ducts, and alveoli. This membrane prevents exchange of oxygen and carbon dioxide at the alveolar-capillary membrane.

CAUSE/ETIOLOGY

The cause of RDS is a low level or absence of surfactant, the phospholipid that normally lines the alveoli and reduces surface tension on expiration to keep the alveoli from collapsing on expiration.

S/S

subtle signs appear at first:

- low body temperature

- nasal flaring

- sternal and subcostal retractions

- tachypnea (more than 60 respirations per minute)

- cyanotic mucous membranes

as distress increases, an infant may exhibit:

- seesaw respirations (on inspiration, the anterior chest wall retracts and the abdomen protrudes; on expiration, the sternum rises)

- heart failure; evidenced by decreased urine output and edema of the extremities

- pale gray skin/cyanosis

- periods of apnea

- bradycardia

- pneumothorax

NG. DIAGNOSES

Ineffective Breathing Pattern: nasal flaring related to respiratory distress secondary to absence of surfactant in the alveoli

Ineffective Airway Clearance: cyanosis related to respiratory distress secondary to presence of exudate in the alveoli

Impaired Gas Exchange: cyanosis related to respiratory distress secondary to alveolar-capillary membrane changes

MANAGEMENT

The supportive measures most crucial to a favorable outcome are:

- maintain adequate ventilation and oxygenation with either an oxygen hood or mechanical ventilation

- maintain acid-base balance

- maintain a neutral-thermal environment

- maintain adequate tissue perfusion and oxygenation

- prevent hypotension

- maintain adequate hydration and electrolyte status

Surfactant Replacement Oxygen Administration Ventilation Extracorporeal Membrane Oxygenation Liquid Ventilation Nitric Oxide Supportive Care

The most essential nursing function is to observe and assess the infant’s response to therapy. Continuous monitoring and close observation are mandatory because an infant’s status can change rapidly and because oxygen concentration and ventilation parameters are prescribed according to the infant’s blood gas measurements, tcPO2, and pulse oximetry readings.

MECONIUM ASPIRATION SYNDROME

- meconium is present in the fetal bowel as early as 10 weeks’ gestation

- babies born breech may expel meconium into the amniotic fluid from pressure on the buttocks

- the appearance of the fluid at birth is green to greenish black from the staining

- an infant may aspirate meconium either in utero or with the first breath after birth.

-MECONIUM can cause severe respiratory distress in three ways:

It causes inflammation of the bronchioles It can block small bronchioles by mechanical plugging It can cause a decrease in surfactant production - Hypoxemia, carbon dioxide retention, and intrapulmonary and extra pulmonary shunting occur

- a secondary infection of injured tissue may lead to pneumonia

Signs & Symptoms:

- tachypnea

- retractions

- cyanosis

- coarse bronchial sounds may be heard on auscultation

- enlargement of the anteroposterior diameter of the chest( barrel chest)

- bilateral coarse infiltrates in the lungs with spaces of hyper aeration as shown in the x-ray

Management:

- Amniotransfusion

- infants may need to be treated with oxygen administration and assisted ventilation after birth and tracheal suction

- Antibiotic therapy

- infants must be observed closely for signs of trapping air in the alveoli

- maintain a temperature-neutral environment

- chest physiotherapy with clapping and vibration

Nursing Diagnosis:

Ineffective airway clearance: cyanosis related to inhalation of foreign substance Risk for infection related to immature immune system

Problem/Need/Cues

Nursing Diagnosis

Scientific Basis

Plan of care

Interventions Rationale

Physiologic Deficit:

Aspiration

Objective cues:

-Pre

sence of thick(dark)meconium during suctioning( in nose & mouth)

-slight nasal flaring of newborn

-cyanosis

-newborn has faint cries

Vital Signs;

Temp- 36.8 C

HR-125bpm

RR-63bpm

Subjective cues:

Ineffective airway clearance: cyanosis related to inhalation of foreign substance

Meconium is present in the fetal bowel as early as 10 weeks’ gestation. An infant with hypoxia in utero experiences a vagal reflex relaxation of the rectal sphincter, which releases me conium into the amniotic fluid.

An infant may aspirate me conium either in utero or with the first breath after birth. me conium can cause severe respiratory distress in three ways: inflammation of the bronchioles

After 8 hrs. of holistic nursing care, the newborn will be able to:

1. main-

tain clear airway as evidenced by absence of respiratory distress such as:

-nasal flaring

-dyspnea

Measures to:

1. position head midline

2. assist in naso & oral suctioning

3. report further signs of respiratory distress

4. maintain a temperature- neutral environment

1. to maintain open airway

2. to clear airway when secretions are blocking airway

3. to ascertain newborn’s status

Source:

NANDA 10th ed. by Doenges, p. 75- 76

4. to prevent increasing the metabolic oxygen demands of the newborn

5. to

“ nangla-

gum jud ang bata,” as verbalized by the nurse

because it is a foreign substance, it can block small bronchioles by mmechanical plugging and

5. provide chest physiotherapy with clapping and vibration

encourage removal of remnants of me conium from the lungs

Source:

Maternal Child Health Nursing 5th Ed. By Pilliteri, p. 783

mechanical plugging and it can cause a decrease in surfactant production through lung cell trauma.

Source:

Maternal Child Health Nursing 5th ed. By Pilliteri, p. 782

SEPTICEMIA/SEPSIS

-refers to generalized bacterial infection in the blood stream

ETIOLOGY

Predisposing Factors:

1. premature placental delivery

- leaves infants vulnerable to most common viral, bacterial, fungal and parasitic infections

2. Prematurity

- there is interruption of transplacental transmission of immune substances (low IgG, no IgM and IgA; thus infant is more susceptible to viral, gram negative bacterial infection and others)

3. Diminished opsonization ability, monocyte dysfunction and inefficient function of circulating leukocytes and other deficiencies (e.g. hypofunctioning adrenal gland- inflammatory response)

-hampers the defense mechanism of the infant

CAUSES

- transplacental transmisission of infection

-ingestion or aspiration of infected amniotic fluid

RISK FACTORS

-prolonged rupture of membranes

(more time for transfer of pathogens)

-maternal infection

-prematurity, low birth weight

- dystocia, trauma during delivery

The five major types of antibodies are:

IgA. IgA antibodies are found in areas of the body such the nose, breathing pas-sages, digestive tract, ears, eyes, and vagina. IgA antibodies protect body surfaces that are exposed to outside foreign substances. This type of antibody is also found in saliva, tears, and blood. About 10% to 15% of the antibodies present in the body are IgA anti-bodies. A small number of people do not make IgA antibodies.

IgG. IgG antibodies are found in all body fluids. They are the smallest but most common antibody (75% to 80%) of all the antibodies in the body. IgG antibodies are very important in fighting bacterial and viral infections. IgG antibodies are the only type of antibody that can cross the placenta in a pregnant woman to help protect her baby (fetus).

IgM. IgM antibodies are the largest antibody. They are found in blood and lymph fluid and are the first type of antibody made in response to an infection. They also cause other immune system cells to destroy foreign substances. IgM antibodies are about 5% to 10% of all the antibodies in the body.

IgE. IgE antibodies are found in the lungs, skin, and mucous membranes. They cause the body to react against foreign substances such as pollen, fungus spores, and animal dander. They may occur in allergic reactions to milk, some medicines, and some poisons. IgE antibody levels are often high in people with allergies.

IgD. IgD antibodies are found in small amounts in the tissues that line the belly or chest. How they work is not clear.

TYPES

Early-onset sepsis ( less than 3 days after birth)

-acquired in the perinatal period

-direct contact from maternal GI and GU tract

-Late-onset sepsis (1-3 weeks after birth)

-is primarily nosocomial

-staphylococci, klebsiella, enterococci, E. coli, and Pseudomonas or Candida species

SIGNS AND SYMPTOMS

- changes in appearance and behavior

Nonspecific signs of infection:

Hypothermia Changes in color, tone, activity and feeding behavior

Sudden episodes of apnea

Hypoglycemia,hypocalcemia, heroin withdrawal, CNS disorders

MANIFESTATIONS OF CLINICAL SEPSIS

General

Infant “not doing well” Poor temperature control (hypothermia/hyperthermia)

Circulatory System

Pallor, cyanosis, mottling

Cold, clammy, skin

Hypotension

Edema

Irregular heart beat

Respiratory system

irregular respira-tions , apnea, or tachypnea

cyanosis

grunting

dyspnea

retractions

CNS

Diminished activ-ity—lethargy, hy-poreflexia, coma

Increased activity—irritability, tremors, seizures

Full fontanel

Increased/ de-creased tone

Abnormal eye movements

GI

Poor feeding Vomiting

Diarrhea/de-creased stooling

Abdominal dis-tention

Hepatomegaly

Hemoccult-posi-tive stools (benzi-dine-based tests, ex:hematest)

Hematopoietic System

Jaundice Pallor

Petechiae, ecchy-mosis

splenomegaly

Diagnostic Evaluation

Isolation of specific organisms thru blood, urine, CSF tests

- changes in neutrophil morphology may suggest a neonatal infection

- leukopenia is usually an ominous sign

C-reactive protein and interleukins [specifically IL-6 (infections, burns, trauma)]

Diagnoses

Risk for infection related to poor aseptic technique

Impaired Skin Integrity: jaundice related to liver infection

Therapeutic Management

antibiotic therapy

circulatory support

respiratory support

supportive therapy ( O2 Administration)

Nursing Care Management

- Provide an optimum thermoregulated environment

- anticipate potential problems such as dehydration/hypoxia

-Promote aseptic technique

-Continuously monitor for signs of complications

- secure everyone maintains all phases of contact isolation/ standard precautions

PICTURES

HYPERBILIRUBINEMIA

- is the elevated level of bilirubin in the blood.

Etiology- Physiologic (developmental) factors (prematurity)- Association with breast-feeding or breast milk- Rh Incapability

Signs and Symptoms- Jaundice- Increased unconjugated bilirubin level of 20 mg/dl- Poor excretion of bilirubin through feces or urine

Nursing Diagnosis- Ineffective tissue perfusion: jaundice related to abnormal blood

profile(increased breakdown of products of red blood cells such as bilirubin)

Management- Initiate breastfeeding within 1st hour of life - If formula feeding, assist parents in initiation of early feeding- Assess skin for jaundice every 4 hours- Monitor intake and output with each occurrence- Maintain of accurate record of urine and stool output- Assist in phototherapy of the infant as ordered by the physician- Instruct parents regarding newborn care

Assessment Diagnosis Scientific Basis Objectives of Intervention Evaluation

Physiologic Deficit

Objective Cues:- jaundice- increased unconjugated bilirubin level of 8 mg/dl- poor excretion of bilirubin through feces or urine

Subjective Cues:“hala ui ako anak kay ng yellow, na unsa man ni cya dong!” as verbalized by the mother.

Ineffective tissue perfusion: jaundice related to prematurity of the infant

Jaundice occurs because as red blood cells are destroyed, indirect bilirubin is released. Indirect bilirubin is fat-soluble and cannot be excreted from the body. Under normal circumstances, the liver enzymes glucuronyl transferase converts indirect bilirubin to direct bilirubin (water-soluble) and combines with bile for excretion of the body with feces. In preterm infants or those with extreme hemolysis, the liver cannot convert indirect to direct bilirubin, so jaundice becomes extreme.

Maternal and Child Nursing:

Care

After 8 hours of holistic nursing care: the patient will be able to manifest decreased level of bilirubin as evidenced by 4 mg/dl

Measures to:

1. initiate breastfeeding within 1st hours of life

2. if formula feeding, assist parents in initiation of early feeding

3. Assess skin for jaundice every 4 hours

4. monitor intake and output with each occurrence

5. maintain of accurate record of urine and stool output

6. Instruct parents regarding newborn care

7. Assist in phototherapy of the infant as ordered by the physician

- to promote breast mile intake and stooling

- promote milk intake and stooling to help decrease level of bilirubin

- to detect rising of bilirubin levels

- to evaluate effectiveness of breastfeeding or formula intake by measuring urine and stool output

- to provide accurate record of output to evaluate effectiveness of feedings

- to promote physical care of newborn

- to speed up conversion potential of

Vol.1, page 786.Adele Pillitteri.

the liver