CHAPTER 5

NURSING CARE OF THE HIGH RISK NEWBORN

High Risk Newborn

 Incidence of illness and death is increased because of:

 PREMATURITY

 DYSMATURITY

 POSTMATURITY

 CONGENITAL ANOMALIES

 ACQUIRED PHYSICAL PROBLEMS OR BIRTH

COMPLICATIONS
 Often the product of high risk conditions in the mother in
the various stages of childbearing
BASIC NSG. ACTIONS IN High Risk NBs

 Detect early
 Keep newborn warm.
 RATIONALE: The presence of a congenital defect, acquired
injuries, and other metabolic disorders predispose the
newborn to HYPOTHERMIA
 Provide immediate supportive care
 Report/refer promptly
DANGER SIGNS OF NB DISTRESS
 Difficult Respiration or Tachypnea/ Increase Rate
 > 60 bpm
 Earliest sign of various problems
 Respiratory in origin
 ASPHYXIA
 RESPIRATORY DISTRESS
 SEPSIS

 Lethargy, Failure to Suck

 May be due to hypoglycemia, hypothermia, brain damage, sepsis
and prematurity
DANGER SIGNS OF NB DISTRESS
 Cyanosis (generalized or central)
 Central cyanosis that increases with crying, sucking or
activity is likely because of a CONGENITAL HEART DEFECT
 Central cyanosis that decreases with crying is likely because
of a RESPIRATORY PROBLEM, often upper airway (nasal)
obstruction
 RATIONALE:
 The NB is an obligate nose breather because his mouth is close
and opens only when crying
 If the NB cries with no apparent cause, check the nares/nostrils
for secretions or for congenital anomalies: CHOANAL ATRESIA
DANGER SIGNS OF NB DISTRESS
 Excessive Mucus/Drooling
 A danger sign of congenital defect ESOPHAGEAL ATRESIA or
TRACHEOESOPHAGEAL ATRESIA
 Assess for maternal polyhydramnios
 SAFETY ALERT:
 In suspected esophageal atresia, NEVER place the NB in Trendelenburg
position; instead elevate head slightly
 The mc type of esophageal atresia is the fistula type
 Placing the head down can drain gastric contents to the lungs via the
fistula and can cause respiratory distress and aspiration pneumonia
 Maintain a slight head-up position, frequent suctioning and NPO and
refer PROMPTLY.
DANGER SIGNS OF NB DISTRESS

 Sac or Dimpling at the Lower Back over the Lumbar

Region: SPINA BIFIDA
 SAFETY ALERT:
 Position the NB on his abdomen (prone position) or his side
(lateral) NEVER supine
 Cover sac with sterile saline soak to keep it moist

 Absent or Sluggish Moro Reflex: BRAIN DAMAGE

 Moro reflex is the best index of CNS integrity in the NB;
absence signifies brain damage or injury
DANGER SIGNS OF NB DISTRESS
 Twitching, Seizures or Tremors: Hypoglycemia, Brain damage
 SAFETY ALERTS:
 For any suspicion of head/brain injury, never position the baby with the
head down, as this will increase intracranial pressure and cause further
brain damage
 Prevent episode of convulsion by gentle handling, and by decreasing
environmental stimuli

 Blue-Stained (Greenish) Vomitus: intestinal obstruction,

intussusception, Hirschsprung’s disease
 SAFETY ALERTS:
 If there is any suspicion of GI obstruction do not feed infant
 Prevent aspiration
DANGER SIGNS OF NB DISTRESS

 Yellowish Discoloration of the Sclera, Skin in the first 24

hours: hemolytic disease or erythroblastosis fetalis
 SAFETY ALERTS
 The first thing to do when the NB is yellowish is to identify how old
the newborn is:
 Jaundice in the first 24 hours is pathologic
 Jaundice between 2-7 days is physiologic due to fetal
polycythemia and liver immaturity
DANGER SIGNS OF NB DISTRESS

 Meconium Staining of Skin and Nails: Chronic hypoxia

 Often from placental insufficiency in postmaturity

 Amniotic fluid is meconium stained in cephalic presentation

 No passage of Meconium in 1-2 days or Meconium from

an Inappropriate Opening (Fistula):
 Imperforated anus, the most common congenital anomaly
that is not compatible with life
HIGH RISK CONDITIONS
Birth Injuries
HEAD INJURIES

 The head is the most commonly injured part, as this is

the biggest part of the baby’s body to pass through the
narrow birth canal
 It is also the most commonly presenting part
HEAD INJURIES
CAPUT SUCCEDANEUM CEPHALHEMATOMA
DEFINITION Presence of edematous fluid in Presence of blood between the
the presenting part periosteum and the flat bone of the
skull

CAUSE Pushing when the cervix is not yet Pressure from bony pelvis or blades of
fully dilated-pressing fetal head forceps
against soft cervix

CHARACTERISTIC Bilateral Unilateral

S Crosses suture line Does not cross suture line
Self-resolve in 3-5 days with little Disappears in few weeks
symptoms May have jaundice as it resolves
HEAD INJURIES
 INTRACRANIAL HEMORRHAGE
 Precipitating Factors:
 Forceps delivery
 Precipitate labor
 Premature birth (soft cranial bones)
 Signs of increase ICP
 Tense, bulging fontanels
 High-pitched, shrill cry
 Projectile vomiting
 Lethargy, failure to suck
 Twitching/tremors
 Absent MORO reflex
 VS: decrease PR and RR
 Nursing Implementation
 Decrease environmental stimuli
 Gentle minimal handling
 Avoid Trendelenburg position, instead slight head of bed, 30-45 degrees head
elevation
NERVE INJURIES
 FACIAL NERVE INJURY (Bell’s Palsy) : 7th cranial nerve injury
 Cause
 Unknown
 Viral
 Autoimmune (congenital/acquired)
 Difficult forceps delivery
 Signs
 Complete paralysis of one side of the face– inability to move muscles on affected
side – asymmetry in facial movements
 Loss of expression on affected side
 Displacement of mouth toward unaffected side
 Inability to close eyelids (both or affected side only)
 Only one eye is closed during sleep
 Forceps mark on the face
 Complete recovery in 3-5 weeks in majority of cases
NERVE INJURIES
 FACIAL NERVE INJURY (Bell’s Palsy) : 7th cranial nerve
injury
 Nursing Implementation
 Detect early: check for symmetry in the facial movements of
infants delivered by forceps
 Administer ordered drugs: corticosteroid to decrease edema and
analgesic for pain
 Provide care to the affected eye
 Artificial tears to prevent corneal drying
 Ointment and eye patch during sleep to keep eyelid closed
 Reassure parents that most cases are temporary
NERVE INJURIES

 BRACHIAL NERVE PARALYSIS

 Upper arm paralysis

 ERB DUCHENNE PARALYSIS/ Erb’s Palsy

 Most common neurologic injury in NB

 CAUSE
 Difficult in rotating and delivering the shoulders (often because of the
presence of large-sized babies)
 Injury to the brachial plexus or subsequent injury to the 5th and 6th
cervical nerves
BRACHIAL NERVE PARALYSIS

 Signs
 In supine position, one or both arms extended with hand
extension, unmoving (normally, flexed and moving)
 Decreased muscle tone, grasp reflex and negative arm recoil
on the affected side – WAITER’S SIGN
 Asymmetry in arm movements

 Incomplete tonic neck reflex (fencing)

 Asymmetrical Moro reflex

BRACHIAL NERVE PARALYSIS

 Prognosis
 Majority of cases are resolved in 2 weeks of life

 Nursing Implementation
 Position at rest: place arm gently in flexed position

 Arm support when holding

 Arm strengthening exercises that passively flex and extend

the arm
 Teach parents about position and simple exercises
BONE INJURY
 Clavicle fracture; clavicle-the bone most commonly injured in
delivery and childhood
 Signs:
 INCOMPLETE FRACTURE
 No pain or disability noticed at birth but a large callus will be discovered
at fracture site by 2-3 weeks
 COMPLETE FRACTURE
 Signs evident at birth
 Refusal to move affected arm
 Tenderness at the site
 Crying with pain upon movement of the arm
 Hypermobility of the bone
 Hematoma and visible angulation
 Incomplete Moro reflex
BONE INJURY
 Diagnosis: Xray
 Treatment:
 Figure of eight bandage and/or a triangular sling for about 2 weeks
 Remodeling of the bone, which corrects a residual deformity
 Completed in 6 months in the younger child
 Completed within one year in the older child (over 10 years)
 Nursing Implementation
 Apply appropriate sling/bandage
 Cotton or gauze placed in each axilla to protect infant’s skin from rubbing against the
bandage
 Tighten bandage daily to fit snugly around the shoulders
 Avoid lifting the affected arm
 Triangular sling to support the elbow and to hold the arm up to prevent sagging of the
shoulder
 Parental teaching: parents are asked to demonstrate positioning and handling of the
infant in the sling during bathing, dressing and feeding; tightening and reapplication
if it comes off
PREMATURE INFANT

Born after 20 weeks

and before 37 weeks
AOG
A preterm is low in
birth weight
 Weight is 2.5 kg or
less
Risk Factors
 Maternal infection – viral/rubella
 Multiple/multifetal pregnancy
 Malnutrition
 Bleeding complications of pregnancy
 PIH, DM, cardiac disorder
 PROM
 Severe isoimmunization
 Trauma
 Incompetent cervix
Assessment Findings
 Physical appearance
 Old man facies
 Head: disproportionately large
 Hair: lanugo, fine, fuzzy
 Ears: flat
 Thorax: small
 Breast buds: 5mm or below
 Abdomen: relatively large, protruding
 Testes: commonly undescended (cryptorchidism)
 Scrotum: pink, fine rugae
 Labia: underdeveloped
 Skin: increased lanugo, thin and red and wrinkled, visible capillaries, decrease
subcutaneous fats
 Muscle tone: poor
 Nails: soft
Altered Physiology
 Respiratory System
 Poorly developed lungs/respiratory muscles
 Decreased surfactant - prone to atelectasis and respiratory
distress syndrome (RDS)
 Difficulty breathing with apnea and cyanosis
 Poor/ unstable chest walls - retractions
 Poor gag/ cough reflex - aspiration
 Poor thermal control
 Poikilothermia: infant easily takes on the temperature of the
environment: can stabilize temp. at a lower level 35C-36C
 Decreased subcutaneous fats, muscle, fat and glycogen deposit
 Decreased activity; decreased sweat glands
Altered Physiology
 Digestive System
 Poor sucking and swallowing (before 32-34 weeks)
 Small stomach - decrease gastric capacity
 Poor cardiac sphincter tone - vomiting/regurgitation
 Decreased enzymes – decreased tolerance
 Decreased bile salts – decreased digestion and absorption of fats and
fat-soluble vitamins A,D,E, and K
 Decreased ability to release insulin in response to glucose
 Poor glucose to glycogen conversion and vice versa
 Liver Function
 Decreased vitamin K – bleeding
 Decreased hemoglobin and blood production – anemia
 Poor bilirubin conjugation – hyperbilirubinemia
 Poor sugar storage and release - hypoglycemia
Altered Physiology
 Renal System: immature function
 Decreased ability to conserve and excrete urine
 Decreased ability to concentrate urine – DHN
 Decreased ability to acidify urine
 Increased sodium and decreased potassium excretion
 Imbalanced glomerular tubular function: (+) sugar, (+) protein, (+)
amino acid and (+) sodium in the urine
 Nervous System
 Centers of vital function are poorly developed
 Poor reflexes
 Low responses to stimuli
 Poor muscle tone
Altered Physiology

 Immune System
 No IgM and IgG at birth

 Decreased phagocytosis, chemotaxis (reaction to chemical

stimuli)
 Decreased anti-inflammatory response due to decreased
adrenal gland functioning
 Integumentary System
 Sensitive because of permeability and collagen instability

 Thin skin – increased risk of toxicity from topical applications

 Delayed skin pH recovery to acidity after washing

Associated Problems

 Hyaline membrane disease (HMD) or respiratory distress

syndrome (RDS)
 Hypothermia – decreased temperature below 36.5C
 Hypoglycemia
 Sepsis
 Hyperbilirubinemia
 Bleeding and anemia
 Nutritional problems
Nursing Implementation
 Maintain respirations at <60 bpm
 Monitor pattern of respiration; check every 1-2 hours
 Suction gently as necessary
 Administer oxygen as ordered; frequently checked concentration
to prevent toxicity and blindness (Retrolental fibroplasia).
Observe oxygen precautions.
 Auscultate lungs to assess expansion; turn every 1-2 hrs. for
better lung expansion and to prevent exhaustion
 Monitor for apnea; encourage breathing with gentle rubbing of
back and feet
 Evaluate ABG results and electrolytes
Nursing Implementation
 Maintain thermoneural body temperature; prevent cold
stress
 Maintain in incubator or radiant warmer if temperature is not
stable as ordered; maintain appropriate humidity
 Turn gently to increase body heat
 Monitor temp. per axilla; maintain axilla temp. between 97F
and 99.5F
 Keep dry; change wet diapers and blankets immediately
 Use heat source when bathing the infant. Wash small parts
of the body one at a time, then dry first before proceeding to
the next part.
Nursing Implementation
 Meet nutritional, fluid and electrolytes needs: feed according
to abilities
 Use “preemie” nipple if the baby started bottle-feeding and has
good sucking
 Use small, rubber-tipped syringe or dropper if sucking is poor or if
sucking causes much fatigue and tachypnea
 Use gavage feeding as ordered for poor sucking and swallowing
 SAFETY ALERTS
 The most important nursing action before gavage feeding is to check for
the patency/placement of the tube
 The best technique is to aspirate gastric content and check for acidic pH
 Return the aspirate amount in order to prevent metabolic alkalosis
Nursing Implementation
 Feed slowly and carefully as regurgitation and vomiting are
more common in these infants
 Monitor I&O, weight, passage of stools, signs of DHN,
hypoglycemia and hyperbilirubinemia
 Provide supplementary vitamins
 Vit. C to prevent infection
 Iron to prevent anemia

 Implement BF or use mother’s pumped breast milk whenever

appropriate
Nursing Implementation

 Prevent Bleeding
 Administer Vit. K injection as ordered

 Handle gently and carefully

 Monitor potential bleeding sites (umbilicus, injection sites,

skin and urine)
Nursing Implementation
 Prevent infection
 Implement meticulous handwashing before and after handling the
infant.
 Provide skin care giving special attention to the:
 Scalp (prevents “cradle cap”/seborrheic dermatitis)
 Periumbilical area (prevents omphalitis or inflammation of the cord)
 Creases at the perianal region (prevents diaper rash/ ammoniacal
dermatitis)
 Monitor temp.
 Administer prophylactic antibiotic as ordered
 Maintain high vit. C, Fe, and CHON formula as ordered to increase
resistance to infection and promote growth and development
 Provide meticulous but careful skin care and reposition to prevent
breakdown
Nursing Implementation

 Provide support to the parents.

 Encourage verbalization of concerns, fears, and anxiety

 Provide complete explanations about treatments,

procedures, and plans as appropriate
 Encourage involvement in the care of the infant. Encourage
frequent visits. Promote confidence with infant care before
discharge
 Refer to self-help groups
POSTMATURE NEWBORN

 Delivered after the

completion of 42 weeks of
pregnancy or one that
exceeds 294 days, from
the first day of LMP
 Problems result from
progressive inefficiency of
an aging placenta
Assessment Findings
 Behavior: wide awake and mentally alert
 Skin features are secondary to prolonged malnutrition and DHN
 Dry, cracked, desquamating, parchment-like appearance of the
skin
 Yellowish-greenish from meconium staining
 Absent lanugo and vernix
 Depleted stored fats/subcutaneous tissues
 Old man’s look
 Long nails and scalp hair
 May have signs of distress due to aspiration of meconium (MAS)
 NURSING IMPLEMENTATION
 Generally like the care given to premature infants