Nancy Pares, RN, MSN Metro Community College. Discuss pathophysiology and nursing process for high risk newborn.

NURS 2410 Unit 4Nancy Pares, RN, MSN

Metro Community College

Discuss pathophysiology and nursing process for high risk newborn

Objective 1

Low socioeconomic level of the mother Limited or no prenatal care Exposure to environmental dangers Preexisting maternal conditions Maternal factors such as age or parity Medical conditions related to pregnancy Pregnancy complications

Identification of At-risk Newborn

Feeding Guidelines

Early Feeding Skills (EFS)

Inadequate surfactant production Muscular coat of pulmonary blood vessels is

not completely developed Greater risk for the ductus arteriosis to

remain open

Preterm Infant: Respiratory Alterations

Nonreassuring fetal heart rate pattern Difficult birth Fetal scalp/capillary blood sample-acidosis

pH<7.20 Meconium in amniotic fluid Prematurity Macrosomia or SGA

Fetal/Neonatal Risk Factors for Resuscitation

Respiratory Distress Assessment

Respiratory Distress Assessment

Respiratory Distress Assessment

Male infant Significant intrapartum bleeding Structural lung abnormality or

oligohydramnios Congenital heart disease Maternal infection Narcotic use in labor

Fetal/Neonatal Risk Factors for Resuscitation (continued)

An infant of a diabetic mother Arrhythmias Cardiomyopathy Fetal anemia

Fetal/Neonatal Risk Factors for Resuscitation (continued)

Deficiency or absence of surfactant Atelectasis Hypoxemia, hypercarbia, academia May be due to prematurity or surfactant

deficiency

Respiratory Distress Syndrome (RDS)

Figure 33–5 RDS chest x-ray. Chest radiograph of respiratory distress syndrome characterized by a reticulogranular pattern with areas of microatelectasis of uniform opacity and air bronchograms. SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.

Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration Education and support of family

RDS: Nursing Care

Figure 33–9 Premature infant under oxygen hood. Infant is nested and has a nonnutritive sucking pacifier. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

Failure to clear lung fluid, mucus, debris Exhibit signs of distress shortly after birth Symptoms

◦ Expiratory grunting and nasal flaring◦ Subcostal retractions◦ Slight cyanosis

Transient Tachypnea of the Newborn (TTN)

Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration Support and educate family

TTN: Nursing Care

Mechanical obstruction of the airways Chemical pneumonitis Vasoconstriction of the pulmonary vessels Inactivation of natural surfactant

Meconium Aspiration Syndrome (MAS)

Assess for complications related to MAS Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration

MAS: Nursing Care

Blood shunted away from lungs Increased pulmonary vascular resistance

(PVR) Primary

◦ Pulmonary vascular changes before birth resulting in PVR

Secondary◦ Pulmonary vascular changes after birth resulting

in PVR

Persistent Pulmonary Hypertension (PPHN)

Minimize stimulation Maintain adequate respiratory status Observe for signs of pneumothorax Maintain adequate nutritional status Maintain adequate hydration status Support and educate family

PPHN: Nursing Care

Figure 33–10 Chest x-ray of a left-sided pneumothorax. A rupture of the alveoli sacs allows air to leak through the pleura, forming collections of air outside the lung (air shows on x-ray as dark area over lung). SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.

Genetic disorders◦This information will be discussed in greater detail later in the course.

◦For the purposes of this unit, know that certain disorders are genetic

Congenital Anomalies

Congenital Anomalies

Congenital Anomalies

Congenital Anomalies

Congenital Anomalies

Congenital Anomalies

Congenital Anomalies

Congenital Anomalies

Cardiac Defects

Cardiac Defects

Cardiac Defects

Cardiac Defects

Cardiac Defects

Infants at Risk for HIV/AIDS

Prematurity SGA Failure to thrive Enlarged spleen and liver Swollen glands

Infants Born to HIV/AIDS Infected Mothers: Consequences

Recurrent respiratory infection Rhinorrhea Recurrent GI problems Persistent or recurrent candidiasis

Infants Born to HIV/AIDS Infected Mothers: Consequences

Provide comfort Keep the newborn well nourished Keep the infant protected from infections Facilitate growth, development, and

attachment

Nursing Care of the Infant Born to HIV/AIDS Infected Mothers

Risk factors◦ Maternal infection (group B streptococcus most

common)◦ Long labor, prolonged rupture of the membranes◦ Maternal fever, chorioamnionitis◦ Fetal distress, aspiration

Sepsis

Assessment findings◦ Unstable temperature, poor tone, poor sucking

Management◦ Antibiotics◦ Supportive care

Sepsis (continued)

Lethargy or irritability Hypotonia Hypotension Pallor, duskiness, or cyanosis Cool and clammy skin

Signs and Symptoms of Sepsis

Temperature instability Feeding intolerance Hyperbilirubinemia Tachycardia followed by apnea/bradycardia

Signs and Symptoms of Sepsis (continued)

Rhinitis Red rash around the mouth and anus Irritability Generalized edema and

hepatosplenomegaly Congenital cataracts SGA and failure to thrive

Symptoms of Syphilis

Initiate isolation Administer penicillin Provide emotional support for the family

Syphilis: Nursing Management

Symptoms◦ Conjunctivitis◦ Corneal ulcerations

Nursing management◦ Administration of ophthalmic antibiotic ointment◦ Referral for follow-up

Gonorrhea

Small cluster vesicular skin lesions over the entire body

DIC Pneumonia Hepatitis Hepatosplenomegaly Neurologic abnormalities

Symptoms of Herpes

Careful hand washing and gown and glove isolation

Administration of IV vidarabine or acyclovir Initiation of follow-up referral Support and education of parents

Herpes: Nursing Management

Symptoms◦ Pneumonia◦ Conjunctivitis

Nursing management◦ Administration of ophthalmic antibiotic ointment◦ Referral for follow-up

Chlamydia

Maternally TransmittedInfections

Maternally TransmittedInfections

Antibiotic/antiviral Therapy

Neonatal abstinence scoring Monitoring VS and pulse oximetry until

stable Small frequent feedings IV therapy if needed Positioning on the right side-lying or semi-

Fowler’s Monitoring frequency of diarrhea and

vomiting

Nursing Care of the Drug-Exposed Newborn

Weigh infant every 8 hours during withdrawal

Swaddle infant Protect face and extremities from

excoriation Place infant in quiet, dimly lighted area of

the nursery Administration of medications

Nursing Care of the Drug-Exposed Newborn

Newborn Withdrawal

Neonatal Abstinence

Neonatal Abstinence

Figure 33–14 Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot and the important longitudinally oriented fat pad of the heel, which in later years could impede walking.

Figure 33–15 Heel stick. With a quick, piercing motion, puncture the lateral heel with a microlance. Be careful not to puncture too deeply.

Hypoglycemia Meconium aspiration and oligohydramnios Polycythemia Congenital anomalies Seizures Cold stress

Postmaturity Syndrome

Care of the Premature Infant Delivery prior to 37

weeks’ gestation Factors

◦ Multiple gestation, PROM, incompetent cervix

Physical characteristics Gestational age Maternal prenatal risk factors Delivery risk factors Physical assessment Family assessment

Assessment of the Preterm Newborn

Assessment◦ Gestational age assessment◦ Neurologic assessment◦ Physical characteristics

Thin skin, soft cartilage, absent plantar creases Abundant lanugo and vernix Genitalia characteristic of prematurity

The Premature Infant (continued)

Review of Systems and Potential Complications

Cardiovascular◦ Patent ductus arteriosis◦ Hypotension

Central nervous system◦ Intraventricular hemorrhage◦ Posthemorrhagic

hydrocephalus Hematologic system

◦ Anemia◦ Polycythemia

Hepatic system◦ Hyperbilirubinemia

Phototherapy

Review of Systems (continued)

Gastrointestinal system◦ Dysmotility◦ Necrotizing enterocolitis◦ Gastroesophageal reflux

Immune system◦ Infection

Integumentary system◦ Epidermal stripping◦ Absorption of chemical

agents

Crib with head elevated for reflux

Review of Systems (continued) Ophthalmologic system

◦ Retinopathy of prematurity Renal system

◦ Oliguria◦ Glycosuria

Respiratory system◦ Respiratory distress

syndrome◦ Bronchopulmonary

dysplasia◦ Apnea of prematurity◦ Pneumonia

Preterm infant in an oxygen hood

Poorly developed gag reflex Incompetent esophageal cardiac sphincter Poor sucking and swallowing reflexes Difficulty meeting caloric needs for growth Inability to handle the increased osmolarity

of formula protein Difficulty with absorbing saturated fats

Preterm Infant: GI Alterations

Difficulty with lactose digestion Deficiency of calcium and phosphorous Increased basal metabolic rate and

increased oxygen requirements Feeding intolerance Potential for the development of necrotizing

enterocolitis (NEC)

Preterm Infant: GI Alterations (continued)

Unavailability of glycogen and brown fat Inability to increase oxygen consumption High ratio of body surface area to body

weight Extended position increases body surface

area Decreased ability to vasoconstrict

superficial blood vessels

Preterm Infant: Alterations in Thermogenesis

Lower glomerular filtration rate (GFR) Limited ability to concentrate urine or

excrete large amounts of fluid Excrete glucose at a lower serum glucose

level Buffering capacity is reduced Excretion time of drugs is longer

Preterm Infant: Kidney Alterations

Glycogen stores are used rapidly Glycogen stores are affected by asphyxia

and cold stress Low iron stores Conjugation is impaired

Preterm Infants: Liver Alterations

Immunologic◦ Lack of passive IgG antibodies◦ Skin is easily excoriated

Neurologic◦ Increased risk for IVH & ICH◦ Delayed or absent reactivity

Preterm Infants: Other Alterations

Occipital-frontal baseline measurements Daily head circumferences Skin integrity Signs and symptoms of infection Signs of widening of suture lines

Hydrocephalus: Nursing Assessments

Assist with head ultrasounds and transillumination

Change position frequently Clean skin creases Keeping a sheepskin under the head Postoperatively position head off the

operative site

Hydrocephalus: Nursing Interventions

Intrauterine growth restriction

Small for gestational age

Large for gestational age

Post term infant

Infants <10th percentile for weight at birth May be symmetric or asymmetric Factors may be fetal, maternal, or placental Complications

◦ Hypoxia, hypothermia, hypoglycemia, polycythemia, hyperbilirubinemia, meconium aspiration

Intrauterine Growth Restriction

Nursing implications◦ Prevent heat loss◦ Monitor blood glucose, feed early◦ Monitor for respiratory complications◦ Management of hyperbilirubinemia

Intrauterine Growth Restriction (continued)

Maternal factors Maternal disease Environmental factors Placental factors Fetal factors

Small-for-gestational-age

Triplets Manifesting Different Rates of Growth

Infants >90th percentile for weight at birth Factors

◦ Maternal diabetes, parental obesity Complications

◦ Difficult delivery, birth trauma, hypoglycemia Nursing implications

◦ Assess for birth injury◦ Monitor for hypoglycemia

Large for Gestational Age Infant

LGA SGA Hypoglycemia Hypocalcemia Hyperbilirubinemia

Impact of Maternal Diabetes Mellitus (DM) on the Newborn

Birth trauma Polycythemia RDS Congenital malformations

Impact of Maternal Diabetes Mellitus (DM) on the Newborn

Risk factors◦ Congenital anomalies◦ Macrosomia (>4,000 gm)◦ Hypoglycemia◦ Respiratory distress syndrome

Infants of Diabetic Mothers

Prevention of complications◦ Normoglycemia during gestation and labor◦ Deliver when lungs are mature◦ Prepare for delivery of large infant◦ Monitor for hypoglycemia

Infants of Diabetic Mothers (continued)

Lethargy or jitteriness Poor feeding and sucking Vomiting Hypothermia and pallor Hypotonia, tremors Seizure activity, high pitched cry,

exaggerated moro reflex

Hypoglycemia Symptoms

Routine screening for all at risk infants Early feedings D10W infusion

Hypoglycemia: Nursing Care

Risk Factors for Hyperbilirubinemia

Lab Evaluation of Jaundice

Checklist for in-room Phototherapy

Excess bilirubin in the blood resulting in jaundice

Can be caused by physiologic or pathologic processes◦ Normal RBC breakdown ◦ Rh or ABO incompatibility

Hyperbilirubinemia

Complications◦ Kernicterus◦ Erythroblastosis fetalis◦ Hydrops fetalis

Assessment findings◦ Jaundice, elevated bilirubin levels

Hyperbilirubinemia (continued)

Encourage frequent feedings Exposure to sunlight Phototherapy

◦ Shield infant’s eyes◦ Monitor body temperature◦ Monitor weight◦ Monitor fluid intake◦ Weigh diapers◦ Note frequency of stools

Management of Hyperbilirubinemia

Appears after first 24 hours of life Disappears within 14 days Due to an increase in red cell mass

Physiologic Hyperbilirubinemia

• Appears within first 24 hours of life• Serum bilirubin concentration rises by more

than 0.2 mg/dL per hour• Bilirubin concentrations exceed the 95th

percentile• Conjugated bilirubin concentrations are

greater than 2 mg/dL • Clinical jaundice persists for more than 2

weeks in a term newborn

Pathologic Hyperbilirubinemia

Hemolytic disease of the newborn Erythroblastosis fetalis Hydrops fetalis ABO incompatibility

Causes of Pathologic Hyperbilirubinemia

Resolving anemia Removing maternal antibodies and

sensitized erythrocytes Increasing serum albumin levels Reducing serum bilirubin levels Minimizing the consequences of

hyperbilirubinemia

Treatment of Pathologic Hyperbilirubinemia

Maximize exposure of the skin surface to the light

Periodic assessment of serum bilirubin levels Protect the newborn’s eyes with patches Measure irradiance levels with a photometer Good skin care and reposition infant at least

every 2 hours Maintain an NTE and adequate hydration and

nutrition

Phototherapy: Nursing Care

Figure 33–18 Infant receiving phototherapy. The phototherapy light is positioned over the incubator. Bilateral eye patches are always used during photo light therapy to protect the baby’s eyes. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

Nutrition and Fluid Management Fluids

◦ Strict I&O, weigh diapers Electrolyte management

◦ Management of sodium and potassium levels

Glucose homeostasis Feeding

◦ Gavage or nipple method◦ Types: formula or breast

milk

Gavage feeding tube

Developmental Care of the Preterm Infant

Light Sound Temperature Positioning and

containment strategies Handling and touching Nonnutritive sucking

Increase in oxygen requirements Increase in utilization of glucose Acids are released in the bloodstream Surfactant production decreases

Cold Stress

Figure 33–13 Cold stress chain of events. The hypothermic, or cold-stressed, newborn attempts to compensate by conserving heat and increasing heat production. These physiologic compensatory mechanisms initiate a series of metabolic events that result in hypoxemia and altered surfactant production, metabolic acidosis, hypoglycemia, and hyperbilirubinemia.

Observe for signs of cold stress Maintain NTE Warm baby slowly Frequent monitoring of skin temperature Warming IV fluids Treat accompanying hypoglycemia

Cold Stress: Nursing Care

Explain the assessment and nursing interventions associated with birth injuries

Objective 2

Fractures◦ Clavicle, long bones, skull most common◦ Risks

Large infant, breech, difficult labor◦ Assessment

Impaired mobility◦ Management

Immobilization, traction, casting

Trauma and Birth Injuries

Facial Palsy◦ Usually related to use of forceps

Brachial Palsy◦ Usually related to difficult delivery such as

shoulder dystocia◦ Assessment

Impaired mobility of arm◦ Paralysis may be temporary or permanent

Trauma and Birth Injuries (continued)

Realistically perceiving the infant’s medical condition and needs

Adapting to the infant’s hospital environment

Assuming primary caretaking role Assuming total responsibility for the infant

upon discharge Possibly coping with the death of the infant

if it occurs

Needs of Parents of At-risk Infants

Facilitating family visits Allowing the family to hold and touch the

baby Giving the family a picture of the baby Liberal visiting hours Encouraging the family to get involved in

the care

Facilitating Parental Attachment

Figure 33–20 Mother of a 26 weeks’ gestational age infant with respiratory distress syndrome on a ventilator is getting acquainted with her baby. Physical contact is vital to the bonding process and should be encouraged whenever possible. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.