HIGH RISK NEWBORN
Monday, 24 January 2022 4:45 pm
PROBLEMS RELATED TO MATURITY
PRETERM NEWBORN
• Description: A neonate born before 37 weeks of gestation
• Primary concern relates to immaturity of all body systems
• Cause: unknown
• Maternal factors: age, smoking, poor nutrition, Placental problem , Preeclampsia/ eclampsia
• Fetal factors: multiple pregnancy, infection
• Other factors: poor socioeconomic status, environmental exposure to harmful substance
• Placenta Abruptio vs placenta previa
Assessment
○ Respirations are irregular with periods of apnea
○ Body temperature is below normal
○ Skin is thin, with visible blood vessels and minimal subcutaneous fat pads, may appear jaundiced (Poikilothermic-
easily take on the temperature of the environment)
○ Poor sucking and swallowing reflexes
○ Bowel sounds are diminished
○ extremities are the, with minimal creasing on soles and palms
○ extension of extremities and does not maintain flexion
○ abundance of lanugo hair
○ labia are narrow in girls
○ testes are undescended in boys
○ sqaure window wrist
Common or special problem of preterm neonates
1. Respiratory Distress Syndrome
Hyaline membrane disease
□ due to lung immaturity; deficient in surfactant
2. Hyperbilirubinemia
high level of bilirubin in the blood,
neonate become jaundice due to immaturity of the liver
Kernicterus staining of brain cells with bilirubin, causing irreversible brain damage
treatment: phototherapy
3. Infection - not able to receive IgG globulins
4. Cold stress- less subcutaneous tissue, poikilothermic
5. Anemia – less iron stores
Management
1. Improving respiratory function- Oxygen therapy, Mechanical ventilator
2. Maintaining body temperature- Isolette – maintains ideal temperature, humidity and oxygen concentration isolates
infant from infection, Kangaroo Care
3. Preventing infection- Handwashing
4. Promoting nutrition- Gavage feeding, Milk feeding
5. Promoting Sensory stimulation- Gentle touch, speaking gently and softly, music box or low tuned radio
Nursing Interventions
1. Monitor vital signs every 2 to 4 hours
2. Administer oxygen and humidification as prescribed. 3. Monitor intake and output
3. Monitor daily weight.
4. Maintain newborn in a warming device.
5. Reposition every 1 to 2 hours, and handle newborn carefully
6. Avoid exposure to infections.
7. Provide newborn with appropriate stimulation, such as touch
8. Suctioning of secretions as needed
9. Monitor for signs of infection
10. Provide skin care
11. Provide complete explanations for parents
POST-TERM NEWBORN
• Description:
○ Neonate born after 42 weeks of gestation
○ About 12% of all infants are post-term
○ Causes of delayed birth is unknown
• Maternal factors:
○ First pregnancies between the ages 15 to 19years
○ Woman older than 35 years
○ Multiparity
• Fetal factors:
○ Fetal anomalies such as anencephaly
Assessment
○ Depleted subcutaneous fat: old looking “old man facies”
○ Parchment-like skin (dry, wrinkled and cracked) without lanugo
○ Fingernails long and extended over ends of fingers
○ Abundant scalp hair
○ Long and thin body
○ Sign of meconium staining
○ Nails and umbilical cord (yellow to green)
COMPLICATIONS OF POST MATURITY
1. The placenta begins to aged toward the end of pregnancy, and may not function as efficiently as before.
2. The failing placental function will place infant at risk for intrauterine hypoxia during labor and delivery.
3. MECONIUM ASPIRATION SYNDROME
4. HYPOGLYCEMIA - FROM NUTRITIONAL DEPRIVATION AND POOR STORAGE OF GLYCOGEN AT BIRTH
5. POLYCYTHEMIA- increase RBC
Management
1. Ultrasound is done to evaluate fetal development, amount of amniotic fluids and the placenta signs of aging
2. To reduce the chance of meconium aspiration, upon delivery of newborn’s head and just before the baby takes his
first breath suctioning of the mouth and nose is done
Nursing management
1. Closely monitor the newborn cardiopulmonary status
2. Administer supplemental oxygen therapy as needed
3. Frequent monitoring of blood sugar; assess for sign of hypoglycemia
4. Provide thermoregulated environment– use of isolette or radiant heat warmer
5. Monitor for signs of meconium aspiration syndrome
DIFFERENCES PRETERM FULL TERM
Posture “Relaxed attitude” limbs more extended More flexed attitude
Ear Ear cartilages are poorly developed, may fold easily Well formed cartilages
Sole Only fine wrinkles Well and deeply creased
Female genitalia Clitoris is prominent; labia majora poorly developed Clitoris is not as prominent; labia majora fully developed
Male genitalia Scrotum is under developed and not pendulous, with Scrotum is fully developed, pendulous, rugated
minimal rugae
Scarf sign Elbow is easily brought across the chest with little or With resisting attempt when elbow is brought to the
no resistance midline of the chest
Grasp reflex Weak Strong, allowing the infant to be lifted up from the
mattress
PROBLEMS RELATED TO GESTATIONAL WEIGHT
SMALL FOR GESTATIONAL AGE
• (SGA) babies are those whose birth weight lies below the 10th percentile for that gestational age
• 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)
• Intrauterine growth restriction (IUGR) - is the most common underlying condition leading to SGA newborn
• Some factors that may contribute to SGA are 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
Placental anomaly is the most common cause of IUGR
○ Factors related to the fetus
multiple gestation (twins)
infection
chromosomal abnormality
Assessment
○ Respiratory distress - hypoxic episodes
○ Loose and dry skin ,little fat, little muscle mass
○ Wasted Appearance
○ Small liver
○ Head is larger compared to body
○ Wide skull sutures
○ Poor skin turgor
○ Sunken abdomen
Babies with SGA may have problems at birth such as:
○ Respiratory distress (asphyxia)
○ Meconium aspiration
○ Hypoglycemia
○ Difficulty maintaining normal body temperature
○ Polycythemia too many red blood cells
Nursing Interventions
○ Observe for signs of respiratory distress
○ Maintain body temperature
○ Monitor for infection and initiate measures to prevent sepsis
○ Monitor blood glucose levels and for signs of hypoglycemia
○ Initiate early feedings and monitor for signs of aspiration.
○ Provide stimulation, such as touch and cuddling
LARGE FOR GESTATIONAL AGE
• Description: Neonate who is plotted at or above the 90th percentile on the intrauterine growth curve
• Weigh more than 4,000 grams
• Cause – unknown (genetic factors and maternal conditions)
• Maternal diabetes – is the most widely known contributing factor
• Increase insulin acts as a fetal growth hormone
• Macrosomia – an unusually large newborn with birth weight of more than 4500grams
Assessment
• large, obese
• Lethargic and limp
• May feed poorly
• Sign and symptoms of birth trauma
Bruising
Broken clavicle
Evidence of molding
Cephalhematoma
Caput succedaneum
Problems of LGA babies
1. Hypoglycemia (low blood sugar) of baby after delivery
2. Respiratory distress
3. Hyperbilirubinemia
4. Potential complications related to increase in body size:
a. Leading cause of breech position and shoulder dystocia
b. Fractured skull, clavicles, cervical or brachial plexus injury and erb’s palsy
Management
Routine newborn care with special emphasis on the following:
1. Monitor vital signs frequently, especially respiratory status.
2. Monitor blood glucose levels and for signs of hypoglycemia
3. Initiate early feedings
4. Note any signs of birth trauma or injury
5. Monitor for infection and initiate measures to prevent sepsis
6. Provide stimulation, such as touch and cuddling.
COMMON ACUTE CONDITIONS OF NEWBORN
RESPIRATORY DISTRESS SYNDROME (RDS)
• Description: Serious lung disorder caused by immaturity and inability to produce surfactant, resulting in hypoxia and
acidosis
• Surfactant – a biochemical compound that reduces surface tension inside the air sac
• decrease in surfactant results to lung collapse, thus greatly reducing infant’s vital supply of oxygen
• Damaged lung cells combines with other substance present in the lungs to form fibrous substance called hyaline
membrane (Hyaline membrane disease)
• this membrane lines the alveoli and blocks gas exchange in the alveoli
Assessment
1. Expiratory grunting –major- is the body's way of trying to keep air in the lungs so they will stay open
2. Tachypnea
3. Nasal flaring
4. Retractions
5. Seesaw – like respirations (chest wall retracts and the abdomen protrudes)
6. Decreased breath sounds
7. Apnea
8. Pallor and cyanosis
9. Hypothermia
Management
○ Oxygen therapy- hood, nasal prong, mask, endotracheal tube , CPAP (Continuous
Positive Airway Pressure) or PEEP (Positive End –Expiratory Pressure) may be used
○ Muscle relaxants – Pancuronium (Pavulon)
Reduces muscular resistance
Prevents pneumothorax
Prepare Atropine or Neostigmine Methylsulfate
○ Liquid Ventilation- Uses perfluorocarbons – substances used in industry to assess leaks
○ Nitric Acid- Causes pulmonary vasodilation – increases blood flow to the alveoli
Nursing Interventions
1. Monitor color, respiratory rate, and degree of effort in breathing.
2. Support respirations as prescribed
3. Monitor arterial blood gases and oxygen saturation levels
(arterial blood gases from umbilical artery).so that oxygen administered to the newborn is at the lowest possible
concentration necessary to maintain adequate arterial oxygenation.
RETINOPATHY OF PREMATURITY
• Vascular disorder involving gradual replacement of retina by fibrous tissue and blood vessels
• Primarily caused by prematurity and use of supplemental oxygen (longer than 30 days)
• Oxygen administration should never be more than 40% unless hypoxia is documented
• Any premature newborn who required oxygen support should be scheduled for an eye examination before discharge to
assess for retinal damage.
• Bronchopulmonary Dysplasia- over expanded lungs prolonged use of O2
Management:
○ Suction every 2 hours or more often as necessary.
○ Prepare to administer surfactant replacement therapy (instilled into the endotracheal tube)
○ Administer respiratory therapy (percussion and vibration)
○ Provide nutrition
○ Support bonding
○ Encourage as much parental participation in newborn's care as condition allows.
HYPERBILIRUBINEMIA
• Description: is an abnormally high level of Bilirubin in the blood; results to jaundiced
• In physiologic jaundiced:
○ occurs on the second day to seventh day
○ average increase of 2mg/dl; not exceeding 12mg/dl
• Pathological Jaundice of Neonates
○ Any of the following features characterizes pathological jaundice:
○ Clinical jaundice appearing in the first 24 hours.
○ Increases in the level of total bilirubin by more than 12 mg/dl
• Therapy is aimed at preventing Kernicterus, which results in permanent neurological damage resulting from the
deposition of bilirubin in the brain cells.
• Causes:
○ Immaturity of the liver
○ Rh or ABO incompatibility
○ Infections
○ Birth trauma
○ Maternal diabetes
○ Medications
Assessment
○ Jaundice
○ Dark concentrated urine
○ Enlarged liver
○ Poor muscle tone
○ Lethargy
○ Poor sucking reflex
Management
1. Phototherapy
• is use of intense florescent lights to reduce serum bilirubin levels
• The use of blue lights overhead or in blanket –device wrapped around infant
• is use of intense florescent lights to reduce serum bilirubin levels in the newborn
• Injury from treatment, such as: eye damage, dehydration, or sensory deprivation
• Possible complication of phototherapy: eye damage, dehydration, sensory deprivation
• Wallaby blanket-a blanket which, when wrapped around the infant’s torso, delivers effective therapy to
jaundiced babies
• no need to cover the baby’s eyes as all light treatment is delivered through the blanket
2. Exchange blood transfusion via umbilical catheter-for very severe cases
• infants blood – remove = 5 / 10ml at a time