WEEK 8 - FINALS
NURSING CARE OF THE HIGH RISK NEWBORN
INTRODUCTION (Problems related to Maturity)
NURSING PROCESS OVERVIEW: ASSESSMENT
Obvious congenital anomalies and gestational
age (number of weeks the newborn remained in
utero).
First assessment is done under a prewarmed
radiant heat warmer to guard against
heat loss.
Continuing assessment of high-risk infants
involves the use of technology and equipment
such as cardiac, apnea, oxygen saturation, and
blood pressure monitoring.
Common sense observations by a nurse:
Carefully evaluate comments from fellow nurses
such as an infant “isn’t himself” or “breathes
irregularly.”
These comments, although not evidence based,
are the same observations that parents who
know their baby well report at healthcare
Visits.
NURSING DIAGNOSIS
• Ineffective airway clearance related to the
presence of mucus or amniotic fluid in the
airway
• Ineffective tissue oxygenation related to
breathing difficulty
• Ineffective thermoregulation related to
immature status
• Risk for deficient fluid volume related to
insensible water loss
• Risk for imbalanced nutrition, less than body
requirements, related to the lack of strength for
effective sucking
• Risk for infection related to lowered immune
response due to prematurity
• Risk for impaired parenting related to illness in
newborn at birth
• Deficient diversional activity (lack of
stimulation) related to illness at birth
• Readiness for developmental care to decrease
over stimulation easily caused by necessary
lifesaving procedures
OUTCOME IDENTIFICATION AND PLANNING
Be certain when establishing expected
outcomes that they are consistent with a
newborn’s potential.
A goal that implies complete recovery from a
major illness, for example, may be unrealistic
for one newborn but completely appropriate for
another.
IMPLEMENTATION
Interventions for any high-risk newborn are
best carried out by:
A consistent caregiver
Focus on conserving the baby’s energy and
providing a thermoneutral environment to
prevent exhaustion and hypothermia.
Painful procedures should be kept to a
minimum to help the infant achieve a sense of
comfort and balance.
Assisting parents to participate in care such as
bathing or feeding their infant can help make
the child real to them for the first time and can
set the stage for effective bonding.
OUTCOME EVALUATION
• Infant maintains a patent airway.
• Infant demonstrates an ability to suck
effectively.
• Infant tolerates procedures without
accompanying apnea, bradycardia, or
oxygen desaturation.
• Infant demonstrates growth and development
appropriate for gestational age, birth weight,
and condition.
• Infant maintains a body temperature of 98.6°F
(37.0°C) in an open crib with one added blanket.
• Parents visit at least once and make three  Early preterm (born between 24 and 34
telephone calls to the neonatal nursery weeks)
weekly. Neonatal assessments such as:

• Parents demonstrate positive coping skills and  Inspection for sole creases
behaviors in response to the newborn’s  Skull firmness
condition and ability to care for their newborn.  Ear cartilage
 Neurologic development
 LMP pf mother
The Newborn at Risk Because of Altered  Sonographic estimation to determine
Gestational Age or Birth Weight - pg 1492 gestational age

 Term infants- week 38 & before week 42  Lack of lung surfactant, bcos this does not
of pregnancy form until 34th week of pregnancy

 Preterm infants - before the beginning of TABLE 26.1 Contrasts Between Small-For-
the 38th week of pregnancy Gestational-Age and Preterm Infants

 Post term infants or post mature - Infants

born after the end of week 41 of
pregnancy

 Appropriate for gestational age (AGA) -

between 10th & 90th percentiles of weight
for their gestational age, whether preterm,
term, or post term

 Small for gestational age (SGA)- fall below

the 10th percentile of weight

NOTE: The percentile lines include 5%, 10%,

25%, 50%, 75%, 90%, and 95%.

 Large for gestational age (LGA)- above the

90th percentile in weight are considered

Other terms used include:

• Low–birth-weight (LBW) infant: one weighing

less than 2,500 g at birth
Common Factors Associated With Preterm
• Very-low-birth-weight (VLBW) infant: one Birth
weighing less than 1500 g at birth

• Extremely-low-birth-weight (ELBW) infant:

one weighing less than 1,000 g at birth

THE PRETERM INFANT

 A preterm infant is traditionally defined as

a live-born infant born before end of week
37 of gestation.

 Late preterm (born between 34 and 37

weeks)
 f) Plantar creases.
PICTURES g) Breast tissue.
h) Ears.
i) Male genitalia.
j) Female genitalia.

 Preterm infant’s head appears

disproportionately large (≥3 cm greater
than chest size).

 The skin is ruddy because of little

subcutaneous fat beneath it, making veins
easily noticeable.

 Acrocyanosis may be present.

 Newborns delivered > 28 weeks of

gestation are covered with vernix caseosa.

 < 28 weeks of gestation), the vernix will be

lacking.

 Lanugo is usually scant

 Both anterior and posterior fontanelles will

be small.

 There are few or no creases on the soles of

the feet.

Figure 26.7 Examples of physical examination Eyes:

findings and reflex tests used to judge
gestational age.  most preterm infants appear small in
relation to term infants.
a) A resting posture.
b) Wrist flexion.  Pupillary reaction is present.
c) Recoil of extremities (legs)
d) The scarf sign.  Has myopia (nearsightedness)
e) Heel to ear.
Ears:
 The ears appear large in relation to the
head.
 The cartilage of the ear is immature &
allows the pinna to fall forward.
Neurologic:
 Reflexes such as sucking with coordinated
swallowing & breathing will be absent if an
infant’s age is below 33 weeks;
 Deep tendon reflexes such as the Achilles
tendon reflex will also be markedly
diminished.
 If the infant does cry, the cry is weak and
high pitched.
Potential Complications
Because of immaturity, preterm infants are
prone to several specific conditions:
Anemia of Prematurity
 Preterm infants develop a normochromic,
normocytic anemia (don’t have enough
red blood cells to provide adequate
oxygen)
 Which make infants appear pale, lethargic,
& anorectic.
 Low levels of vitamin E
What to do?
 Blood drawing for electrolytes
 Complete blood counts
 Blood gas analysis
 Delaying cord clamping at birth to reduce
development of anemia
Acute bilirubin encephalopathy (ABE)
 Indirect or unconjugated bilirubin
 Less serum albumin
 Jaundice
What to do?
 Phototherapy
 Exchange transfusion
Persistent Patent Ductus Arteriosus
 Lack surfactant
 Pulmonary artery hypertension (PAH) -
blood can’t flow through your lungs
What to do?
 For preterm: administer IV therapy w/
CAUTION
 For term: Indomethacin or ibuprofen to
cause closure of a patent ductus arteriosus
for ventilation.
NOTE: Indomethacin is associated w/ ADVERSE
EFFECTS such as ↓ renal function, ↓ platelet
count, and gastric irritation.
 Carefully monitor urine output
 Observe for bleeding, especially at
injection sites, if this is prescribed.
Periventricular/Intraventricular Hemorrhage
 Periventricular hemorrhage (bleeding into
the tissue surrounding the ventricles)
 Intraventricular hemorrhage (bleeding into
the ventricles)
 Intraventricular hemorrhage occurs most  Dry
often in VLBW (very low birth weight)
 Cracked
infants and is classified as:
 Almost leatherlike skin from lack of fluid
• Grade 1, bleeding in the periventricular
 Absence of vernix
germinal matrix regions or germinal matrix,
occurring in one ventricle
 Meconium stained
• Grade 2, bleeding within the lateral ventricle
 Fingernails grown
without dilation of the ventricle
 Alertness 2-week-old baby than a
• Grade 3, bleeding causing enlargement of the
newborn
ventricles

• Grade 4, bleeding in the ventricles and What to do?

intraparenchymal hemorrhage
 Sonogram to measure the biparietal
 Long-term effect of hemorrhage may be diameter of the fetus.
the development of hydrocephalus
 Nonstress test or complete biophysical
What to do? profile to determine if placenta is still
functioning.
 Cranial ultrasound performed after the
first few days of life  Cesarean birth may be indicated if a
nonstress test reveals placental
compromised.

POST MATURE SMALL FOR GESTATIONAL AGE

 SGA (also called microsomia) if the birth

weight is below the 10th percentile.
• Preterm: before week 38 of gestation
• Term: between weeks 38 and 42
• Post term: past 42 weeks

 SGA infants are small for their age bcos

they have experienced intrauterine growth
restriction (IUGR) or failed to grow at the
expected rate in utero.

ETIOLOGY: COMMON FACTORS (SGA)

 Lack of adequate nutrition

POSTTERM INFANT
 Adolescents bcos only eat less
A postterm infant is one born after the 41st
week of a pregnancy.
 Chromosomal abnormality
Placenta appears to function effectively for only
 Intrauterine infection such as rubella or
40 weeks.
toxoplasmosis
Past the 40 weeks, fetus s begins to lose weight
 Most common cause of IUGR is a placental
(postterm syndrome)
issue
SGA infant:
 Women with systemic diseases that ↓
blood flow to the placenta ( diabetes
 mellitus or gestational hpn)
 Women who smoke heavily or use opiates
ASSESSMENT for Post Mature
APPEARANCE for Post Mature
Infant who suffers nutritional deprivation/
Measurement:
 early in pregnancy: ↓ average in weight,
length, and head circumference.
 late in pregnancy: ↑ in cell size, may have
only a reduction in weight.
Poor skin turgor:
 Large head, the rest of the body is so small.
 Skull sutures may be widely separated.
 Hair may be dull and lusterless.
 Infant may have a small liver.
 Abdomen may be sunken.
 Umbilical cord often appears dry and may
be stained yellow.
Infant’s age is more advanced than the
weight/Overall wasted appearance:
 Sole creases
 Ear cartilage
Laboratory Findings for SGA
↑ hematocrit level
↑ RBC (polycythemia) - ↑ blood viscosity &
thrombus formation & hyperbilirubinemia
What to do?
 Exchange transfusion: hematocrit level
is > 65% to 70%
 IV glucose: ↓ 45 mg/dl
THE LARGE-FOR-GESTATIONAL-AGE INFANT
(LGA)
 LGA (also termed macrosomia) if the birth
weight is above the 90th percentile.
 Baby appears deceptively healthy at birth
but immature development.
ETIOLOGY: LGA
 Overproduction of nutrients and growth
hormone in utero.
 This happens most often to infants of
women who are obese or who have
diabetes mellitus.
 Multiparous women may also have large
babies because with each succeeding
pregnancy,babies tend to grow larger.
 Beckwith– Wiedemann syndrome, a rare
condition characterized by overgrowth &
congenital anomalies such as omphalocele.
Omphalocele - birth defect in which the
infant's intestine or other abdominal organs
stick out of the belly button, or navel

ASSESSMENT: LGA
 Woman’s uterus appears to be unusually
large for the date of pregnancy.
 Sonogram can confirm the suspicion.
 Nonstress test to assess the placenta’s
ability to sustain a large fetus.
 Lung maturity may be assessed by
amniocentesis.
 If an infant’s large size was not detected
during pregnancy, it may be first
recognized during labor when the baby
appears too large to descend through the
pelvic rim.
 If this happens, a cesarean birth may be
necessary because shoulder dystocia (the
wide fetal shoulders cannot pass
 Or needs significant manipulation to pass
through the outlet of the pelvis) would halt
vaginal birth at that point.
APPEARANCE for LGA
 At birth, LGA infants may show:
 Immature reflexes
 Low scores on gestational
examinations in relation to their size. T
 Extensive bruising or a birth injury such as
a broken clavicle or Erb–Duchenne
paralysis
 Prominent caput succedaneum (swelling,
or edema, of an infant’s scalp)
 Cephalohematoma or molding (trauma or
pressure to the head during labor)
Cardiovascular Dysfunction: LGA
Polycythemia may occur in an LGA fetus as the
fetus attempts to fully oxygenate more than the
average amount of body tissue.
Observe for signs of:
 Hyperbilirubinemia
 Heart rate
 Cyanosis
Polycythemia vera - a type of blood cancer. It
causes your bone marrow to make too many
red blood cells.
Hypoglycemia : LGA
 LGA infants also need to be carefully
assessed for hypoglycemia in the early
hours of life.
 Because large infants require large
amounts of nutritional stores to sustain
their weight.
age
  Sepsis
Assessment for Large for Gestational Age
 Slow to transition to extrauterine life

 Pneumonia

 Low level or absence of surfactant

 Phospholipid that normally lines the alveoli

 Reduces surface tension

 Surfactant does not form until the 34th

week of gestation

Assessment for RDS

Signs of RDS:

 Low body temperature

 Nasal flaring

 Sternal and subcostal retractions

 Tachypnea (more than 60 breaths/min)

 Cyanotic mucous membranes

Acute Neonatal Conditions: RESPIRATORY  Po2 and oxygen saturation levels fall in
DISTRESS SYNDROME (RDS) room air

 Fine rales and diminished breath sounds

because of poor air entry

 Seesaw respirations

 Heart failure

 Pale gray skin

 Periods of apnea

 Bradycardia

 Respiratory distress syndrome (RDS) A.K.A  Pneumothorax

hyaline membrane disease, most seen in
premature babies.

Causes of RDS:

 Meconium aspiration syndrome (MAS) -

newborn breathes a mixture of meconium
and amniotic fluid into the lungs around
the time of delivery
Therapeutic Management for RDS 2.) Oxygen Administration

 Administration of oxygen is often

necessary to maintain correct Po2 & pH
levels.

 May be administered in a variety of ways:

I. simple cannula or mask

II. continuous positive airway pressure

(CPAP)

III. Positive end-expiratory pressure (PEEP)

 A possible complication of oxygen

therapy in immature or very ill infant:

I. ROP ( Retinopathy of Prematurity) - eye

disease

1) Surfactant Replacement (picture pink) (Lung II. Bronchopulmonary dysplasia (BPD) A.K.A
lavage) chronic lung disease

2) Oxygen Administration (CPAP) 3.) Ventilation

3) Ventilation (I/E 1:2)  Normally, on a ventilator, inspiration is

shorter than expiration, or there is an
4) Additional Therapy: Nitric Oxide (potent vascular inspiratory/expiratory (I/E) ratio of 1:2.
dilator)
 Infant ventilators are therefore available
5) Extracorporeal Membrane Oxygenation (ECMO) with a reversed I/E ratio (2:1).

6) Supportive Care (warm)  Complications of any type of ventilation:

1.) Surfactant Replacement I. Pneumothorax

II. Impaired cardiac output
 RDS can be largely prevented by the administration
of surfactant at birth for an infant at risk because
of low gestational age. 4.) Additional Therapy: Nitric Oxide

 Immediately after birth, synthetic surfactant is  Potent vascular dilator - help to

administered into an endotracheal tube by a oxygenate a newborn’s lungs
syringe or catheter (lung lavage)
 This causes systemic vasodilation.

 The nitric oxide enters the alveoli on

ventilation & redirects the pulmonary
blood by dilating the pulmonary
arterioles.
5.) Extracorporeal Membrane Oxygenation
 Most effective when given between weeks
Extracorporeal membrane oxygenation 24 and 34 of pregnancy
(ECMO) - 1st developed as a means of
oxygenating blood during cardiac surgery.  Steroid does not take effect before 24 to
48 hours
 Management of ECMO:

MECONIUM ASPIRATION SYNDROME - pg 1530

 Severe hypoxemia in newborns
 Meconium is present in the fetal bowel as
 Meconium aspiration early as 10 weeks of gestation.

 RDS  If hypoxia occurs, a vagus reflex is

stimulated, resulting in relaxation of the
 Pneumonia rectal sphincter.

 Diaphragmatic hernia - protrusion of  This releases meconium into the amniotic

abdominal fluid.

 Breech babies expel meconium.

Note: Used as a mainstay of therapy for RDS
but rarely needed bcos surfactant lavage is  Appearance of green to greenish black
so effective. from the staining.

6.) Supportive Care Assessment for MAS

 Infant with RDS must be kept WARM.  Difficulty establishing respiration at birth

 Because cooling ↑ acidosis in newborns,  Low APGAR score

& for the newborn with RDS.
 Tachypnea, retractions, & cyanosis
What to do?
 Infant should be placed on warmer, &
I. Provide hydration resuscitation should begin including the
initiation of positive pressure ventilation as
II. Nutrition w/ iv fluids necessary.

III. Glucose or gavage feedings bcos  After the initiation of respirations, an

respiratory effort makes infant too infant’s respiratory rate may remain rapid
exhausted to suck (tachypnea)

 Coarse bronchial sounds may be heard on

Prevention for RDS auscultation.

 RDS rarely occurs in mature infants.
 If level of lecithin obtained from amniotic
fluid exceeds sphingomyelin by a 2:1 ratio:
C.S
 Tocolytic agent such as magnesium sulfate
can help prevent preterm birth .
 2 injections of glucocorticosteroid
(betamethsone)
 Air trapping cause enlargement of the
anteroposterior diameter of the chest
(barrel chest)
 Pulse oximetry / blood gase: ↓ PO2 and an
↑ PCO2
 Chest X-ray will show bilateral coarse
infiltrates in the lungs, with spaces of
hyperaeration (a peculiar honeycomb
effect).
 The diaphragm will be pushed downward
Assessment for Neonatal Sepsis
 by the over expanded lungs.

Therapeutic Management for MAS

 Amnioinfusion to dilute the amount of

meconium in the amniotic fluid

 Cesarean birth - stained amniotic fluid is

identified during labor

 Oxygen administration & assisted

ventilation

 Antibiotic therapy (pneumonia)

Therapeutic Management for Neonatal Sepsis
 Surfactant (for lung compliance)

 Observe the infant for air tapping

(pneumothorax)

 Complication (ductus arteriosus remaining

open)

 Observe an infant closely for signs of heart

failure such as increased heart rate or
respiratory distress

 Physiotherapy with percussion and Assessment: HYPERBILIRUBINEMIA

vibration may be helpful to encourage the
removal of remnants of meconium from
the lungs

 Administered nitric oxide

 Maintained on ECMO to ensure adequate

oxygenation

NEONATAL SEPSIS
Therapeutic Management for
Hyperbilirubinemia

 Ports halogen light or special blue

florescent light

 And the distance is 12 to 30 inches

 Pale yellow - breastfeeding and sweet

smelling

SIDS (Sudden Infant Death Syndrome)