You are on page 1of 93

HIGH RISK NEWBORN

&
FAMILY
ASSESSMENT

 NURSING HISTORY
 PHYSICAL ASSESSMENT
 DIAGNOSTIC
ASSESSMENT

Obvious congenital anomalies


Gestational age
IMMEDIATE NEEDS OF THE
NEWBORN

1. AIRWAY
2. BREATHING
3. CIRCULATION
4. WARMTH
Immediate Assessment of the
Newborn
 The newborn infant should undergo a
complete P.E within 24 hours of birth.
 NOTE :
 It is easier to listen to the heart and lungs
first when the infant is quiet

 Warmth the stethoscope before using to


decrease the likehood of making the infant
cry
Newborn Priorities in first day of life

1. Initiation and maintenance of respiration


2. Establishment of extrauterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Developmental care or care that balances
physiologic needs and stimulation for best
development
DIAGNOSIS

 Ineffective airway clearance


 Ineffective cardiovascular tissue perfusion
 Ineffective thermoregulation
 Risk for imbalance of nutrition
 Risk for parenting
 Deficit diversional activity
(lack of stimulation)
Planning/Implementation
ALTERED GESTATIONAL AGE OR
BIRTHWEIGHT
 Infant is evaluated as soon as possible
after birth to determine :
 Weight

 Gestational age
 Birthweight is plotted on a Growth Chart
 Colorado intrauterine Growth Chart
( LUBCHENCO CHART)
Preterm – born before the 38th
week

Full
term – born at 38 to 42
weeks

Postterm – born after 42


weeks
BIRTHWEIGHT

 Appropriate Gestational Age (AGA) – BW


within 10-90th percentile
 Small Gestational Age (SGA) – BW is < 10th
percentile
 Large Gestational Age (LGA) – BW > 90th
percentile

 LBW – BW < 2,500 grams


 VLBW – BW 1000-1,500 grams
 Extremely-VLBW – 500-1000g
GESTATIONAL AGE
 Itis determine in the first 4 hours after birth so
that age related problems can be identified
and appropriate care can be initiated.
 Second assessment is done within 24 hours.
 New ballard Score is the most commonly used
tool
 It has 2 element
 External physical characteristics
 Neuromuscular maturity
GESTATIONAL ASSESSMENT
(DUBOWITZ)

FINDING 0 – 36 37 – 38 39 & OVER


SOLE CREASES ANTERIOR OCCASIONAL SOLE COVERED
TRANSVERSE CREASES IN W/ CREASES
CREASE ONLY ANTERIOR 2/3

BREAST NODULE 2 4 7
DIAMETER (MM)

SCALP HAIR FINE & FUZZY FINE & FUZZY COARSE &
SILKY
EAR LOBE PLIABLE, NO SOME STIFFENED BY
CARTILAGE CARTILAGE THICK
CARTILAGE
TESTES & TESTES IN LOWER SOME CARTILAGETESTES
CANAL, SCROTUM INTERMEDIATE PENDULOUS,
SCROTUM SMALL, RUGAE SCROTUM FALL,
EXTENSIVE RUGAE
posture

Square window
Popliteal angle
Scarf sign

Heel to ear
creases

Breast
Causes of Small –for-Gestational-Age
Infant ( SGA)
 SGA infant experienced intrauterine growth restriction (IUGR)
 Most common cause of IUGR is PLACENTAL ANOMALY
 Mother’s nutrition during pregnancy play a major rule in fetal
growth.
 severe DM mother
 PIH
 Mother who smokes heavily
 Use of narcotics
 Baby with Rubella & chromosomal abnormality
SGA

 PRENATAL ASSESSMENT:
 Fundic height
 ultrasound

 Biophysical profile
 NST

 Placental grading
 Amniotic fluid amount
What do they look like???

 SGA appearance
 Infant suffer nutritional deprivation
 EARLY in pregnancy
 Increase in number of body cells
 Below average

Weight, length & head circumference
 Late in Pregnancy
 Increase in cell size
 Below average weight
Most SGA APPEAR LIKE??
 Wasted appearance
 Small liver
 Poor skin turgor
 Large head
 Skull suture widely separated – lack of normal
bone growth
 Dull hair
 Sunken abdomen
 Cord dry & stained yellow
Common problem of SGA

 Birth asphyxia – common problem


 Underdeveloped chest muscles
 Risk
of meconium aspiration syndrome due to
anoxia during labor.
 Lack of subcutaneous fat
 Less able to control body temperature
DIAGNOSTICS

 CBC
 High hematocrit
 Increase RBC ( polycythemia)

 Blood glucose
 Hypoglycemia <40mg/dl
Outcome Evaluation:

 Gain weight & height – end of first year


 Discuss ways to parents to promote
infant development.
 Needs adequate stimulation to reach
normal growth & developmental
milestone
 Encourage parents to provide suitable toys
as per chronological age not physical size.
LARGE-for-Gestational-Age
Infant (LGA)
LGA

 Macrosomia – above 90th percentile on


an intrauterine growth chart for that
gestational age
 CAUSES:
 Overproduction of growth hormone in utero
 Infant with DM mother

 Obese mother

 Multiparous women
LGA

 Assessment:
 Uterus unusually large for the date of
pregnancy
 UTZ , NST

 amniocentesis for lung maturity


LGA appearance
 Immature reflexes
 Skin color ecchymosis, jaundice & erythema
 Low score on Gestational age examination
 Extensive bruising & birth injury
 Broken clavicle
 Erb-Duchenne paralysis – cervical nerve injury

 Prominentcaput succedaneum,
cephalhematoma or molding
LGA - DIAGNOSTICS

 Increaseserum bilirubin
 hypoglycemia
LGA – outcome evaluation

 Infant
need careful watching
 Encourage parents to nurture infant
PRETERM INFANT
Preterm infant

 Live-born infant born before the end of


37 weeks of gestation
 Weight less than 2,500 ( 5lbs 8 oz )
 Immature and small but well
proportioned for age
PRETERM
 High Risk for :
 Respiratory distress syndrome (RDS)
 Hypoglycemia
 Intracranial hemorrhage

 Mortality
: 80-90%
 CAUSES:
 Exact cause : rarely known
 Low socioeconomic- inadequate nutrition
 Lack of prenatal care
 Age of mother – younger than age 20
 PROM
PRETERM
 POTENTIAL COMPLICATION:
 Anemia of prematurity
 Kernicterus
 PDA
 Intraventricular/Periventricular Hemorrhage
 RDS – HMD
 Apnea
 Necrotizing enterocolitis
 Retinopathy of prematurity
Management

1. Maintain patent airway


2. Incubator care
3. VS monitoring
4. O2 therapy
5. Feeding
6. Infection precautions
Preterm infant
 Nutrition
 Feeding schedule
 Gavage feeding

 Formula

 Breast milk
ILLNESS IN THE NEWBORN
ILLNESS IN THE NEWBORN

1. RDS
2. TRANSIENT TACHYPNEA OF THE NB
3. MECONIUM ASPIRATION SYNDROME
4. APNEA
5. SUDDEN INFANT DEATH SYNDROME
6. HEMOLYTIC DISEASE OF THE NB
7. HEMORRHAGIC DISEASE OF THE NB
Respiratory distress syndrome

 2 types
1. Hyaline membrane disease(HMD)
2. Transient tacypnea of the NB (TTN)
Respiratory distress
syndrome
>HMD( hyaline membrane
disease)
Common:1. preterm infant
2.infant of diabetic
mother
3.meconium aspiration
Pathologic feature
:
hyaline-like membrane formed fr an
exudate of infant blood

line the terminal bronchioles,


alveolar.duct,and alveoli

this membrane prevent exchange of O2


and CO2 at alveolar-capillary membrane
RDS

 Causes:
Low level or absence of surfactant
Surfactant –
 phospholipid lines the alveoli that
reduces surface tension on expiration
 keep the alveoli from collapsing on

expiration
 Form @ 34 wks AOG
Assessment
 S/Sx:
initial 1.low body temperature
2.nasal flaring
3.sternal and subcostal
retraction
4.tachypnea
5. cyanotic mucus membrane
Assessment
 S/Sx:

late 1. seesaw respiration


2. heart failure
3. pale gray skin
4. period of apnea
5. bradycardia
6. pneumothorax
Diagnosis:

Clinical sign :
grunting, cyanosis in room air,
nasal flaring, retraction and
shock

Chest X-ray:
reveal diffuse pattern of radio
opaque areas
MANAGEMENT
1. surfactant replacement
2. oxygen administration
3.Ventilation
4. Additional therapy:
- Indomethacin or Ibuprofen – to close PDA
- muscle relaxant increase pulmonary
blood flow

PILLITTERI pp 778
Vol 1
Prevention:

Steroid

quicken the formation of lecithins


given 12 and 24 hours prior to
delivery
most effective when given between
weeks 24- 34 of pregnancy
Transient Tachypnea of the
Newborn
Transient Tachypnea of the
Newborn

 RR @ birth – up to 80/min when crying


 Normal RR – 30-60/ min
 S/sx:
 Rapid RR – 80-120/min
 Mild retraction

 No marked cyanosis

 Mild hypoxia & hypercapnia


Causes: Transient tachypnea of the
newborn
result from slow absorption of lungs fluid

reflect slight decrease in production of mature


surfactant

limit the amount of alveolar surface area


available to an infant for oxygenation
exchange

infant tend to increase RR and depth


TTN

- Peak in intensity at approx. 36hrs in life


@ 72hrs of life spontaneously fade as lung
fluid is absorbed
common:
1.infant born via CS
2.infants whose mother received
extensive fluid administration during labor
3. preterm infants
TTN Management:

1. Close observation
2.O2 administration
MECONIUM ASPIRATION
SYNDROME
MECONIUM ASPIRATION
SYNDROME
- Meconium present in fetal bowel
as early as 10 wks gestation
Meconium aspiration
- Infant may aspirate meconium either in utero or in
first breath after birth.

Cause severe respiratory distress in 3 ways:

1.causes inflammation of bronchioles because it’s


a foreign substance

2.block small bronchioles by mechanical plugging

3. cause a decrease in surfactant production


through lung cell trauma
Meconium aspiration
sign and symptoms:
1. tachypnea
2. Retraction
3. Cyanosis
4. Barrel chest – due to air trapping
DIAGNOSTICS:
CXR: bilateral coarse infiltrates ( honey comb
effect)
ABG: dec. 02 & inc. Pc02
Meconium aspiration
Syndrome
Management:
1.suctioning with bulb syringe or catheter while
at the perineum
2.severe aspiration infant might intubate
3. don’t administer O2 under pressure
4. antibiotic therapy
5. chest physiotherapy and chest clapping


APNEA
Apnea :

 >pause in respiration longer than 20 secs.


With accompanying bradycardia
commonly seen in:
1.preterm infant
2.infection
3.hyperbilirubinemia
4.hypoglycemia
APNEA
MANAGEMENT:
1. gently shaking an infant or flicking the
sole of the feet
2. Closely observe all NB esp. Preterm
3. always suction the secretion gently to
minimize nasopharyngeal irritation
4. Use gently handling to avoid excessive
fatigue
5. never take rectal temperature in infant
prone to apnea cause vagal
stimulation w/c result to Apnea
APNEA

 Drug use to stimulate respiration


 Theophylline

 Caffeine sodium benzoate

 They help increase infant sensitivity to


carbon dioxide ensuring better respiratory
function.
Sudden Infant Death
Syndrome
SID is a sudden unexplained death in
infancy
Cause is unknown
who are at risk:
1. infant of adolescent mother
2.infant of closely spaced pregnancies
3.underweight infant
4. preterm infant
SIDS
Contributory factors:
1. viral respiratory infection
2.botulism infection
3. brain stem abnormalities
4.neurotransmitter deficiency
5. heart rate abnormality
6.decrease arousal responses
7. possible lack of surfactant in alveoli
8. sleeping prone
Nsg Care
 Support parents – view second child as
an individual child not as a replacement
for the one who died
 New baby born to a family in which a
SIDS infant died is screened – sleep
study as precaution within the first 2 wks
of life.
 New baby placed on continuous apnea
monitoring
Hemolytic disease of the
newborn
 ABO incompatibility:
set up is mother’s type is O
baby’s type is A, B, AB
Sign and symptom- primarily jaundice

Mgt:
1.phototherapy
2.if with severe jaundice can do
exchange transfusion
3.initiation of early feeding
 RH incompatibility:

mother is RH(-)( has D antigen)


baby is RH (+)
Sign and symptoms: kernicterus
hydrops fetalis
(edema) ( lethal
state)
 Therapeutic management
 Initiation
of early feeding
 Phototherapy
 Continuously exposed to specialized light – cool white
day light or blue fluorescent light
 Light placed 12-30 inches above the NB bassinet or
incubator at 25-28 hours of age
 Bilirubin level : term 15 mg/dl

Preterm – 10-12 mg/dl


 Exchange transfusion-
 Nursing care phototherapy
 Stool of infant – bright green & loose
 Urine darked colored

 Assess skin turgor

 Assess I & O – to ensure hydration

 Monitor temp

 When infant is feeding removed from phototherapy


– for interaction
Hemorrhagic disease of
newborn
Hemorrhagic disease of
newborn
due to deficiency of vitamin K
bleeding occurs on 2nd to 5th day of life
complication: subdural hemorrhage - fatal
Sign and symptoms:
1. petechiae
2.vomit fresh blood or pass black tarry
stool
Hemorrhagic disease of
newborn

Management:-

1. IM /IV administration of vitamin K


2. if with severe bleeding
transfusion of fresh whole blood
can be done
NEWBORN AT RISK DUE TO
MATERNAL INFECTION/ILLNESS
1. Beta-hemolytic, Group B Streptococcal
Infection
2. Hepatitis B Virus Infection
3. Herpes Virus Infection
4. HIV Mother
5. Infant Of Diabetic Mother
6. Infant Of Drug Dependent Mother
7. Infant With Fetal Alcohol Syndrome
Beta-hemolytic, Group B
Streptococcal Infection

 GBS – major cause of infection of NB


 Natural habitant – female genital tract
 MOT : spread from baby to baby by
contact
 Risk : prolonged rupture of membrane
Beta-hemolytic, Group B
Streptococcal Infection

 S/sx
 Early onset
 First day of life – Pneumonia
 Tachypnea
 Apnea
 Shock – dec urine output, extreme paleness or
hypotonia
 Can die within 24 hours of life
Beta-hemolytic, Group B
Streptococcal Infection

 S/sx
 late
onset
Occurs at 2-4 weeks of age- meningitis
 Lethargy, fever , loss of appetite
 Bulging fontanelles – increased ICP

 Mortality 15%
Beta-hemolytic, Group B
Streptococcal Infection

 Diagnostics
 mother’s vaginal culture
 Blood culture of NB

 Therapeutic management
 Ampicillin IV @ 28 wks AOG & during labor
( reduce NB exposure)
 Bld test positive : gentamicin, ampicillin &
penicillin
Hepatitis B Virus Infection

 Transmitted to the NB through contact


with infected vaginal blood at birth –
mother is HBsAg+
 Destructive illness
 70-90% of infected infant can become
chronic carrier
 Complication : liver cancer later in life
Hepatitis B Virus Infection

 Vaccinate the NB
 HepatitisB vaccine + immune serum globulin (HBIG)-
within 12H – decrease possibility of infection.
 Bathed infant as soon as possible after birth –
removed blood
 Gentle suctioning- avoid trauma
 Breastfed infant – if HBIG is given
Herpes Virus Infection

 HSV-2
 Common Multiple sexual partner
MOT:
 Contracted through the placenta – if mother
has primary infection during pregnancy .
 Vaginal secretion of mother.
Herpes Virus Infection

 S/sx:
 Herpes vesicles clustered with reddened base
– covering the skin
 Severe neurologic damage
 If acquired at birth: ( D4 & D7 of life)
 Loss of appetite
 Low grade fever & lethargy

 Dyspnea , jaundice, purpura , convulsion & shock

 Death occur within hours or days


Herpes Virus Infection

 Diagnosis:
 Culturefrom vesicles
 Blood serum analyzed for IgM antibodies

 Therapeutic Mgt:
 Acyclovir ( zovirax)
 Advised CS- minimize newborn exposure

 Isolate infant
Infant Of Diabetic Mother

 Macrosomia- LGA
 Chance to have Congenital anomaly –
cardiac
 Limp / lethargic first day of life –
hypoglycemia
 Greater chance of birth injury
 hyperbilirubinemia

Pp 791
pillitteri
Infant Of Diabetic Mother

 Diagnostics
 Serum glucose <40 mg/dl NB

 Therapeutic Mgt
 Fedearly with formula or administered a
continuous infusion of glucose

Pp 791
pillitteri
Infant Of Drug Dependent Mother
 SGA infant
 Infant show withdrawal
syndrome
 Irritability , disturbed
sleep pattern
 Constant movement
 Tremors
 Frequent sneezing
 Shrill high pitched cry ,
hyperreflexia
 Convulsion
 Tachypnea , vomiting ,
diarrhea
Infant Of Drug Dependent Mother

 withdrawal period
 Opiate – signs usually begin 24- 48 HOL max: 10 days , last
2 weeks
 Heroin – begin first 2 wks of life
ave.onset 72 HOL
last 8-16 wks or longer
 Methadone –begin 24-28 HOL
reappear : 2-4 wks of age
no sign : 2-3 wks old
 Cocaine : no predictable sequence
Infant Of Drug Dependent Mother

 CARE
 Swaddled infant
 Small isolation nursery – avoid excessive
stimulation
 Darkened room
 Infant Heroin addicted mother – quiet if
given pacifier
 Maintain fluid & electrolyte
 IV infusion if with diarrhea & vomiting
Infant Of Drug Dependent Mother

 DRUG USED TO COUNTERACT


WITHDRAWAL SYMPTOMS
 Phenobarbital
 Chlorpromazine ( thorazine)
 Diazepam ( valium)

 avoid breastfeeding – to avoid passing


narcotics
 Mother need treatment for withdrawal
symptoms & follow care.
Infant With Fetal Alcohol Syndrome

 Alcohol crosses the placenta , same


concentration as present in the maternal
bloodstream.
 s/sx :
 Growth retardation
 Microcephaly
 Cerebral palsy
 Thin upper lip
 Tremor
 Irritable, sleep disturbance
 Weak sucking reflex
 Behavioral problem
Infant With Fetal Alcohol Syndrome

 Follow infant for any future problem


 Mother needs follow up- reduce alcohol
intake
END

You might also like