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Assessment and Management of High Risk Neonate PDF
Assessment and Management of High Risk Neonate PDF
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.
▪ 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.
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:
▪ Small for gestational age (SGA): when plotted on intrauterine growth chart,
they lie below 10th percentile.
▪ Appropriate for gestational age (AGA): When plotted on intrauterine growth
chart, they lie between 10th and 90th percentile.
▪ 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 10th – 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.
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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:
▪ Weigh daily, measure length and head circumference.
▪ Describe general body shape and size, posture at rest, presence and
location of edema.
▪ Describe any apparent deformities.
▪ Describe any signs of distress: Poor color, mouth open, grimace-
furrowed brow.
ii- Respiratory assessment:
▪ Describe shape of chest (barrel, concave), system, presence of
incisions, chest tubes or other deviation.
▪ Describe use of accessory muscle: nasal flaring or substantial,
intercostal or subclavicular retractions.
▪ Determine respiratory rate and regularity.
▪ Describe breath sounds: stridor, crackles, wheezing, and grunting,
equality of breath sounds.
▪ Determine whether suctioning is needed.
▪ Describe cry if not incubated.
▪ If incubated, describe size of tube, type of ventilator and setting, and
method of securing tube.
▪ Determine oxygen saturation by pulse oximetry.
iii- Cardiovascular assessment:
▪ Determine heart rate, heart sounds, including any murmurs.
▪ Describe infant’s color: cyanosis, pallor, plethora, jaundice- assess the
color of the lips, nail beds, mucous membranes.
▪ Determine blood pressure and cuff size.
▪ Describe monitors, their parameters and whether alarms are in “on
position”.
iv- Gastrointestinal assessment:
▪ Determine presence of abdominal distention, increase in circumference,
shiny skin and state of umbilicus.
▪ 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).
▪ Describe amount, color, consistency and odor of any emesis.
▪ Palpate liver margin.
▪ Describe amount, color and consistency of stools, check for occult
blood.
▪ Describe bowel sound: presence or absence.
v- Genitourinary assessment:
▪ Describe any abnormalities of genitalia.
▪ Describe amount, color, PH, lab stick finding, and specific gravity of
urine.
▪ Check weight (the most accurate measure of hydration).
vi- Neurologic- Musculoskeletal assessment:
▪ Describe infant’s movement: random, purposeful, jittery, twitching, level
of activity with stimulation, evaluation based on gestational age.
▪ Describe infant’s position or attitude: flexed, extended.
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▪ Describe reflexes: Moro, sucking, Babiniski, plantar reflex and other
expected reflexes.
▪ Determine level of response.
▪ Determine changes in head circumference: size and tension of
fontanels, suture lines.
vii- Temperature:
▪ Determine skin and axillary temperature.
▪ Determine relationship to environmental temperature.
viii- Skin assessment:
▪ Describe any discoloration, reddened area, signs of irritation, abrasions.
Observe for monitoring equipment, infusions, or other apparatus coming in
contact with skin.
▪ Determine texture and turgor of skin; dry, smooth.
▪ Describe any rash, skin lesion or birthmarks.
▪ Determine whether intravenous infusion device is in place and observe
for sign of infiltration.
ix- Monitoring physiological data:
▪ Vital signs:
- Temp: 36.5-37.3°C.
- Pulse: 120-150 beat /min.
- Respiration: 40-60 cycle/ Min.
▪ 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.
▪ Blood glucose (protocol of hypoglycemia).
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 O2
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).
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▪ Regulate parenteral fluid closely to avoid dehydration over hydration
or extravasation.
▪ Avoid administering hypertonic fluid (e.g. undiluted medication,
concentrated glucose infusions) to prevent excess solute load on
immature kidneys and fragile veins.
▪ 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:
▪ Clean skin with plain water (see appendix of sponge bath).
▪ 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).
▪ Use minimal tape / adhesive.
▪ 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:
▪ Decrease environmental stimulation because of stress responses,
especially increased blood pressure, increase risk of elevated ICP.
▪ Establish a routine that provides undisturbed sleep /rest periods.
▪ Use minimal handling.
▪ Organize care during waking hours.
▪ Close and open draps and dim lights to allow for day/night schedule.
▪ Remain calm, limit number of visitors and staff near infant at one
time.
▪ Keep equipment’s noise to minimum.
▪ 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:
▪ Recognize that infants, regardless of gestational age feel pain.
▪ Use non-pharmacologic pain measure appropriate to infant’s age
and condition as touch, music, cuddling and roching.
▪ Encourage parents to provide comfort measures.
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▪ Administer analgesics as ordered.
▪ Monitor for side effects of opiods, especially respiratory depression.
▪ Assess effectiveness of non-pharmacologic and pharamcologic pain
measures.
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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.
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