Assessment and Management of

High Risk Neonates

Out line:
 Definition.
 Predisposing factors.
 Methods used in determination of gestational age.
 Classification of newborns.
 Problems associated with Preterm, SGA, and Posterm infants.
 Assessment:
1. The initial assessment using the Apgar scoring system. (Refer to the
module of assessment of normal newborn).
2. Transitional assessment during the periods of reactivity. (Refer to the
module of assessment of normal newborn).
3. Assessment of clinical gestational age and birth weight.
4. Systematic assessment.
イ Nursing management.
1. Assessment.
2. Nursing Diagnosis.
3. Planning.
4. Implementation.
5. Evaluation.

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Definition:
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 threats to life and health that occur during prenatal, perinatal and
postnatal period.
It can also be defined as a neonate exposed to any condition that makes his life
in danger.

Factors Predisposing to High-Risk Neonate:

Maternal Factors:
High-risk pregnancies as in lack of antenatal care, poor socioeconomic
condition, previous history of obstetric complications as abortion, toxemias, placental
insufficiency, stillbirth. Medical illness of mother as diabetes mellitus, heart and
kidney diseases and severe infection. Complications of labor and delivery as
prolonged rupture of membranes, cesarean section and stillbirth.
Neonatal Factors:
As neonatal asphyxia, neonatal infection, congenital anomalies, prematurity,
post-maturity, low Apgar score, hypoglycemia and others.
At birth, all infants should have a complete gestational age assessment. The
purpose of this assessment is to compare a given infant against standardize norms
of neonatal growth based on gestational age. It also includes evaluation of physical
characteristics of the infant for the degree of maturity. This assessment helps to
identify infants that are Preterm, post-term, small or large for gestational age. Then
observe, report, help in medical treatment and intervene in nursing management.

Definition of Gestational Age:

The course of time from day one of menstrual cycle in which conception
occurred till birth.

Methods used in Determination of Gestational Age:

1. Physical and neurological examinations.
2. L.M.P.
3. Obstetric history.
4. Lab tests.
5. Fetal ultrasonic scanning.

Classification of Newborn:
Classification of newborn at birth by both gestational age and weight provides a
more satisfactory method for predicting mortality risk and providing guidelines for
management of neonates.
In using gestational age neonates can be classified as:
Preterm: The neonate is born before term i.e. is less than 38 weeks of gestation.
Term: The neonate is born between 38-42 weeks of gestation.
Post term: The neonate is born is born after 42 weeks of gestation. (Fig.1)

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When using gestational age and birth weight, newborn can be
classified as:
ロ Small for gestational age (SGA): when plotted on intrauterine growth
chart, they lie below 10th percentile.
ハ Appropriate for gestational age (AGA): When plotted on intrauterine
growth chart, they lie between 10th and 90th percentile.
ニ Large for gestational age (LGA): When plotted on intrauterine growth
chart, they lie above 90th percentile. (Fig.1)

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Classification of High-risk Infants:
According to size:
1. Low- birth-weight (LBW) infant:
An infant whose birth weight is less than 2500 gm regardless of gestational
age.
2. Very-Low-Birth weight (VLBW):
An infant whose birth weight is less than 1500 gm.
3. Very-Very-Low-Birth-Weight (VVLBW) or extremely low (ELBW):
An infant whose birth weight is less than 1000 gm.
4. Moderately-Low Birth Weight (MLBW):
An infant whose birth weight is 1500- 2500 kg.
5. Appropriate for Gestational Age (AGA) infant:
An infant whose weight falls between the 10 th – 90th percentiles.
6. Small- for-Date (SFD) or Small for- Gestational Age (SGA) Infant:
An infant whose intrauterine growth was slowed and whose birth weight falls
below the 10th percentile on intra-uterine growth curves.
7. Intrauterine Growth Retardation (IUGR):
Found in infants whose intrauterine growth is retarded (sometimes used as
a more descriptive term for the SGA infant).
8. Large for Gestational Age (LGA) infant:
An infant whose birth weight falls above the 90 th percentile on intrauterine
growth charts.

Problems Associated with Preterm, SGA and Post

term infants:
Preterm Problems:
These are related to:
1. Size: As temperature instability- hypothermia.
2. Immaturity: Such as;
i- Respiratory Problems: - Apnea.
- Respiratory Distress Syndrome.(RDS)
ii- Metabolic Problems: - Hyperbilirubinemia.
- Hypoglycemia.
iii- Hematological Problems: - intracranial Hemorrhage.
iv- Other problems: - Infections.
- Congenital Abnormalities.
SAG Problems:
i- Congenital –Congenital abnormalities, intrauterine infection.
ii- Metabolic – Hypoglycemia.
iii- Hematological – Pulmonary Hemorrhage.
Post Term Problems:
i- Intrauterine Asphyxia.
ii- Meconium Aspiration.

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Assessment:
1. Assessment of Clinical Gestational Age:
The frequently used method of determining gestational age is the simplified
assessment of gestation age by Ballard, Novack and Driver (1979, Fig. 2). It
assesses six external physical and six neuromuscular signs. Physical signs as, skin,
lanugo, planter surface, breast, eye/ear and genitals (male), genitals (female).
Neuromuscular signs as posture, square window (wrist), arm recoil, popliteal angle,
scarf sign and heal to ear sign. Each sign has a number score, and the cumulative
score correlates with a maturity rating for 26-44 (Fig. 2).
The new Ballard and Scale, a revision of the original scale, can be used with
newborns as young as 20 weeks of gestation. The tool has the same physical and
neuromuscular sections but includes –1 and –2 scores that reflect signs of extremely
premature infants such as fused eye lids, imperceptible breast tissue, sticky friable
transparent skin, no lanugo and square – window (flexion of wrist) angle of greater
than 90 degrees (see Fig. 2). The total numerical, score for both external physical
and neuromuscular criteria is plotted on maturity rating graph in Fig 2 and the
estimated gestational age obtained.

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Estimation of Gestational Age by Maturity Rating:
Neuromuscular Maturity:

Physical Maturity:

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2. Systemic Assessment of High-Risk Neonates:
i- General assessment:
イ Weigh daily, measure length and head circumference.
ロ Describe general body shape and size, posture at rest, presence
and location of edema.
ハ Describe any apparent deformities.
ニ Describe any signs of distress: Poor color, mouth open, grimace-
furrowed brow.
ii- Respiratory assessment:
イ Describe shape of chest (barrel, concave), system, presence of
incisions, chest tubes or other deviation.
ロ Describe use of accessory muscle: nasal flaring or substantial,
intercostal or subclavicular retractions.
ハ Determine respiratory rate and regularity.
ニ Describe breath sounds: stridor, crackles, wheezing, and
grunting, equality of breath sounds.
ホ Determine whether suctioning is needed.
ヘ Describe cry if not incubated.
ト If incubated, describe size of tube, type of ventilator and setting,
and method of securing tube.
チ Determine oxygen saturation by pulse oximetry.
iii- Cardiovascular assessment:
イ Determine heart rate, heart sounds, including any murmurs.
ロ Describe infant’s color: cyanosis, pallor, plethora, jaundice-
assess the color of the lips, nail beds, mucous membranes.
ハ Determine blood pressure and cuff size.
ニ Describe monitors, their parameters and whether alarms are in
“on position”.
iv- Gastrointestinal assessment:
イ Determine presence of abdominal distention, increase in
circumference, shiny skin and state of umbilicus.
ロ Determine any signs of regurgitation; time related to feeding,
character and amount of residual if gavage- fed. If Nasogastric tube in
place, describe type of suction, drainage (color, consistency).
ハ Describe amount, color, consistency and odor of any emesis.
ニ Palpate liver margin.
ホ Describe amount, color and consistency of stools, check for
occult blood.
ヘ Describe bowel sound: presence or absence.
v- Genitourinary assessment:
イ Describe any abnormalities of genitalia.
ロ Describe amount, color, PH, lab stick finding, and specific gravity
of urine.
ハ Check weight (the most accurate measure of hydration).
vi- Neurologic- Musculoskeletal assessment:
イ Describe infant’s movement: random, purposeful, jittery,
twitching, level of activity with stimulation, evaluation based on gestational
age.
ロ Describe infant’s position or attitude: flexed, extended.

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 ハ Describe reflexes: Moro, sucking, Babiniski, plantar reflex and
other expected reflexes.
ニ Determine level of response.
ホ Determine changes in head circumference: size and tension of
fontanels, suture lines.
vii- Temperature:
イ Determine skin and axillary temperature.
ロ Determine relationship to environmental temperature.
viii- Skin assessment:
イ Describe any discoloration, reddened area, signs of irritation,
abrasions. Observe for monitoring equipment, infusions, or other apparatus
coming in contact with skin.
ロ Determine texture and turgor of skin; dry, smooth.
ハ Describe any rash, skin lesion or birthmarks.
ニ Determine whether intravenous infusion device is in place and
observe for sign of infiltration.
ix- Monitoring physiological data:
イ Vital signs:
-ロ Temp: 36.5-37.3°C.
-ハ Pulse: 120-150 beat /min.
-ニ Respiration: 40-60 cycle/ Min.
ロ Blood examination is a necessary part of the ongoing
assessment and monitoring of risk newborn’s progress. The tests most
often performed are blood glucose, Bilirubin, calcium, and hematocrit and
blood gases.
ハ Blood glucose (protocol of hypoglycemia).

General Nursing Management:

Assessment:
It is important for the nurse to assess the condition of high-risk newborn as
previously discussed to reach one or more nursing diagnosis.

Nursing Diagnosis:
 Ineffective breathing pattern related to pulmonary and neuromuscular
immaturity, decreased energy and fatigue.
 Ineffective thermo-regulation related to immature temperature control and
decreased subcutaneous body fat.
 High risk for infection related to deficit immunologic defenses.
 Altered nutrition: less than body requirement related to inability to ingest
nutrients because of immaturity or illness.
 High risk for fluid volume deficit or excess related to immature physiologic
characteristics of Preterm infant.
 High risk for impaired skin integrity related to immature skin structure.
Immobility decreased nutrition state, invasive procedures.
 High risk for injury from increased intra-cranial pressure related to immature
central nervous system and physiologic stress response.
 Pain related to procedure, diagnosis and treatment.
 Altered growth and development related to Preterm birth, unnatural neonatal
intensive care unit (NICU) environment, and separation from parents.

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  Altered family process related to situational crisis, knowledge deficit, and
interruption of parental attachment process.

Planning:
The following are basic goals for care of all high-risk infants:
1. Exhibit adequate oxygenation.
2. Maintain stable body temperature.
3. Protect the infant from nosocomial infection.
4. Receive adequate hydration and nutrition.
5. Maintain skin integrity.
6. Experience no pain.
7. Receive appropriate development care.
8. Receive appropriate family support, including, preparation for home care.

Implementation:
1. Respiratory Support:
Assess for deviations of respiratory function, observe for signs of distress,
grunting, cyanosis, nasal flaring and apnea, many infants require
supplemental oxygen and assisted ventilation.
Nursing Intervention:
 Position for optimum air exchange (place prone when feasible or
side lying) since this position results in improved oxygenation better
tolerated.
 Suction to remove accumulated mucus from nasopharynx, trachea.
 Carry out regimen prescribed for oxygen therapy (appendix of O 2
therapy).
 Closely monitor blood gases measurement.
 Maintain neutral thermal environment to conserve utilization of O 2 .
 Apply and manage monitoring equipment correctly.
 Observe and assess infant’s response to ventilation and
oxygenation therapy.
 Observe any deviation.

2. Thermoregulation:
After the establishment of respiration, the most crucial need of high-risk
infant is the application of external warmth, to delay or prevent the
effects of cold stress; infants are placed in a heated environment
immediately after birth. This is especially important for the pre-term
infant, whose very high skin surface relative to body mass promotes
heat loss.
Nursing Intervention:
 Place infant in incubator, radiant warmer or warmly clothed in open
crib.
 Regulate servocontrolled unit or air temperature control as needed.
 Monitor for signs of hyperthermia- redness, flushing.
 Check temperature of infant in relation to temperature of heating
unit.
 Avoid situation that might predispose infant to heat loss such as
exposure to cool air, drafts, bathing or cold scales.

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  Monitor for signs of hypothermia- cold extremities, cyanosis
(protocol of thermo-regulation).

3. Protection from Infection:

High-risk neonates are particularly susceptible to infection. The source of
infection rise in direct relationship to the number of person and pieces of
equipment coming in contact with the infant.
Nursing Intervention:
 Ensure that all care givers wash hands before and after handling the
infant.
 Ensure that all equipments in contact with infant are clean or sterile.
 Ensure strict asepsis or sterility with invasive procedures.
 Prevent persons with upper respiratory tract or communicable
infections from coming into direct contact with infant.
 Isolate infants who have infections.
 Emphasize health care workers and parents to administer antibiotics
as ordered.
 Ensure that the incubator must be clean and sterilized to combat
infections (protocol of infection control).
4. Nutrition:
Optimum nutrition is critical in the management of LBW Preterm infants, but
there are difficulties in providing their nutritional needs. An infant’s need for
rapid growth and daily maintenance must be met in the presence of several
anatomic and physiologic disabilities.
Nursing Intervention:
 Encourage breast-feeding if strong sucking, swallowing and gag
reflexes.
 Use gavage feeding if infant tires easily or has weak sucking, gag or
swallowing reflexes.
 Assist mothers with expressing, breast milk to establish and
maintain lactation until infant can be breast-fed.
 Assist parenteral fluid or total parenteral nutrition therapy as
ordered.
 Monitor for signs of intolerance to protein and glucose.
 Follow until protocol for advancing volume and concentration of
formula.
5. Hydration:
Adequate hydration is important in Preterm infants because their extracellular
water content is higher, their body surface is larger, and the capacity for
osmotic diuresis is limited in preterm infants, underdevelopment kidneys.
Therefore, these infants are highly vulnerable to water depletion.
Nursing Intervention:
イ Monitor fluid and electrolytes closely with therapies that increase
insensible water loss (IWL) e.g. phototherapy, radiant warmer.
ロ Ensure adequate parenteral/oral fluid intake.
ハ Assess state of hydration (e.g. skin turgor, edema, weight,
mucous membrane, urine specific gravity, electrolytes, fontanel).

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 ニ Regulate parenteral fluid closely to avoid dehydration over
hydration or extravasation.
ホ Avoid administering hypertonic fluid (e.g. undiluted medication,
concentrated glucose infusions) to prevent excess solute load on
immature kidneys and fragile veins.
ヘ Monitor urinary output and laboratory values for evidence of
dehydration or over hydration (adequate urinary output), strict
measurement of urine output is indicated (forms of nursing care).
6. Skin Care:
Assess skin for any discoloration, redness, sings of irritation and skin turgor
because the skin of infant was very delicate.
Nursing Intervention:
イ Clean skin with plain water (see appendix of sponge bath).
ロ Provide daily cleaning of eye, oral, cord and diaper area, and
any areas of skin breakdown (for infant who are not feeding, wipe the
mouth and tongue with Nestatin daily using a cotton piece until they are
advancing to feeds).
ハ Use minimal tape / adhesive.
ニ Use a protective skin barrier between skin and all tape/ adhesive
especially premature babies (protocol of nursing care for infants in the
NICU).
7. Minimal Stress:
Preterm infants are subject to stress just as other human beings. They are
biologically deficient in their capacity to cope with or adapt to environmental
stresses. Stress affects hypothalamus function, causing adverse effects on
growth, heat production and neurologic mechanisms.
Nursing Intervention:
イ Decrease environmental stimulation because of stress
responses, especially increased blood pressure, increase risk of
elevated ICP.
ロ Establish a routine that provides undisturbed sleep /rest periods.
ハ Use minimal handling.
ニ Organize care during waking hours.
ホ Close and open draps and dim lights to allow for day/night
schedule.
ヘ Remain calm, limit number of visitors and staff near infant at one
time.
ト Keep equipment’s noise to minimum.
チ Maintain adequate oxygenation because hypoxia increases
cerebral blood flow.
8. Neonatal Pain:
Both preterm and full term perceives and react to pain in much the same
manner as children and adult. The response of neonate to pain is evidenced
by cardio respiratory changes, increase in heart rate and blood pressure, and
decrease PO2 or oxygen saturation, sweating. Crying associated with pain is
more intense. Facial features include eye squeeze, brow bulge, open mouth.
Nursing Intervention:
イ Recognize that infants, regardless of gestational age feel pain.

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 ロ Use non-pharmacologic pain measure appropriate to infant’s age
and condition as touch, music, cuddling and roching.
ハ Encourage parents to provide comfort measures.
ニ Administer analgesics as ordered.
ホ Monitor for side effects of opiods, especially respiratory
depression.
ヘ Assess effectiveness of non-pharmacologic and pharamcologic
pain measures.

9. Care to Promote Growth and Development:

Much attention had been focused on the effects of early intervention or its lack
on both normal and preterm infants. Findings indicate that infants are able to
respond to a greater variety of stimuli. The atmosphere and activities of the
NICU are over stimulating.
Nursing Intervention:
 Provide optimum nutrition to ensure steady weight gain and brain
growth (see appendix of growth measurements).
 Provide regular periods of undisturbed rest to decrease
unnecessary O2 use and caloric expenditure.
 Provide age – appropriate development intervention simulate all the
sense of infant and observe their response e.g. visual, tactile, auditory,
olfactory and taste.
 Promote parent-infant interaction since it is essential for normal
growth and development.
10.Family Support and Involvement:
The birth of a preterm infant is an unexpected and stressful event for which
families are emotionally unprepared.
Nursing Intervention:
 Give information to help parents understand most important aspects
of care.
 Encourage parents to ask questions about child’s status.
 Be honest; respond to questions with correct answer to establish
trust.
 Encourage mother and father to visit the infant so that attachment
process in initiated.
 Help parents by demonstrating infant care and offer support.
 Encourage siblings to visit infant.
 Explain to family members the infant condition and why he cannot
come home soon.
Discharge Planning and Home Care:
 Assess readiness of family to care for infant in home setting to
facilities parents’ transition to home with infant.
 Teach necessary infant care techniques and observation.
 Reinforce medical follow up.
 Refer to appropriate agencies or services so that needed
assistances are provided.

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Evaluation:
The effectiveness of nursing intervention is determined by continuous
reassessment and evaluation of care based on the following observational guidelines
and expected outcomes:
 Take vital sings and perform respiratory assessments at time intervals based
on infant’s condition and needs. Observe infant’s respiratory efforts and response
to therapy.
 Measure abdominal skin and axillary temperature at specified intervals.
 Observe infant’s behavior and appearance for evidence of sepsis.
 Assess for hydration: assess and measure fluid intake, observe infant during
feeding, measure amount of formula or parental intake, weight daily.
 Observe infant’s response to pain and pain relief interventions.
 Observe infant’s response to developmental care.
 Observe parental interaction with infant, interview family regarding their
feelings and readiness for home care.

Admission Criteria for High Risk Unit:

 Preterm.
 Post term.
 Hyperbilirubinemia.
 Respiratory disorders.
 Hemolytic disorders.
 Neonatal seizures.
 Sepsis.
 Hypoglycemia.

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