HIGH RISK NEWBORN

Barbara B. Rees, RN, DSN

Identification of High Risk

Infants
Assess for congenital anomalies
Determine Gestational Age Assessment

Priority Needs of Newborns

Initiating and Maintaining Respirations
Establishing Extrauterine Balance
Fluid and Electrolyte Balance
Temperature Regulation
Adequate Nutritional Intake
Parent-Infant Bonding

HIGH RISK NEWBORN

GESTATIONAL AGE ASSESSMENT
MOST COMMON PROBLEMShypoglycemia, hypocalcemia, resp. distress,
hypothermia
SGA
AGA
LGA

Small for Gestational Age

<2500 g (5 1/2 lbs)
Commonly due to placenta abnormality,
decreased blood flow, smoking, narcotics
Appearance

SGA INFANTS- COMMON

COMPLICATIONS
PERINATAL ASPHYXIA
ASPIRATION SYNDROME
HEAT LOSS
HYPOGLYCEMIA
HYPOCALCEMIA
POLYCEMIA
MENTAL DEVELOPMENT

LGA INFANTS
Causes:
a. Diabetic Mother
b. Babies with Transposition of the Great
Vessels
c. Multiparous Mothers

Hypoglycemia
Threat to Brain Cells
Less than 30 mg/100 ml of blood = harmful
After birth levels fall
Infants prone to hypoglycemia
Treatment

Appropriate for Gestational Age

Healthiest Babies
Between 3000 - 4000 g

Preterm Infant
Less than 37 weeks
Less than 3500 g = LBW
1000 - 1500 g = VLBW
500 - 1000 g = Extremely VLBW

PRETERM INFANTS
SMALL AND SCRAWNY
LARGE HEAD
TRANSLUCENT SKIN, VISABLE BLOOD
VESSELS
ABUNDANT LUNAGO
SOLES OF FEET- minimal creases
MALES- few scrotal rugae, & testes
undescended

PRETERM INFANTS- Potential

Complications
Anemia
Kernicterus
Persistent Patent Ductus Arteriosus
Periventricular/Intraventricular Hemorrhage

PRETERM INFANTS-Nursing
Diagnosis
Impaired Gas Exchange
Risk for Fluid Volume Deficit
Risk for Altered Nutrition
Risk for Infection
Risk for Altered Parenting
Diversional Activity Deficit
Risk for Disorganized Infant Behavior

POSTERM INFANTS
ABSENT LANUGO
LITTLE VERNIX CASEOSA
ABUNDANT SCALP HAIR
SKIN CRACKED & PARCHMENTLIKE
WASTED APPEARANCE

RESPIRATORY DISTRESS
SYNDROME
CAUSE- Surfactant Production
WORK HARDER- Use more O2 & expend
more energy, get hypoxic, hypercapnia,
metabolic acidosis, vasoconstriction
RISK- <2500g, <28 weeks, male, IDM
SIGNS
DIAGNOSIS
TREATMENT & PREVENTION

ILLNESS IN THE NEWBORN

TRANSIENT TACHYPNEA
MECONIUM ASPIRATION SYNDROME
SUDDEN INFANT DEATH SYNDROME
PERIVENTRICULAR LEUKOMALACIA
HEMOLYTIC DISEASE OF THE
NEWBORN

MANAGEMENT OF HIGH
RISK INFANT
PHYSICAL ASSESSMENT
THERMOREGULATION- need neutral
thermal environment, use brown fat
CONSEQUENCES OF COLD STRESShypoxia, metabolic acidosis, hypoglycemia
GLUCOSE & CALCIUM
PROTECT FROM INFECTION

MANAGEMENT OF HIGH
RISK INFANT
HYDRATION- IVF for calories, electrolytes &
H2O
NUTRITION- no coordination of sucking until
32-34 weeks; not synchronized until 36-37
weeks; gag reflex not developed until 36 weeks
EARLY FEEDING- within 3-6 hours
BREAST FEEDING
GAVAGE FEEDING- <32 wks. or <1500g

MANAGEMENT OF HIGH
RISK INFANT
SKIN CARE OF PREMATURE- increased
sensitivity & fragile
MEDICATION - caution
DECREASE STRESS

DEVELOPMENTAL
INTERVENTION
BEFORE 33 WEEKS- minimum
stimulation
34-36 WEEKS- stimulate senses but dont
tire out

NURSING CARE
PAIN CONTROL
FACILITATE PARENT-CHILD
RELATIONSHIP
NEONATAL LOSS- see, hold, photo;
support groups, baptize

PRETERM INFANTS
GIRLS- labia and clitoris prominent
INACTIVE & LISTLESS- extremities
remain in any position placed
IMMATURE LUNGS, SUCK, TEMP

HYPERBILIRUBINEMIA
INCREASED UNCONJUGATED FORM
(0.2-1.4mg/dl)
JAUNDICE WITHIN 24 HOURS
AFTER 1-2 WKS. TERM; 2 WKS PRETERM
TOTAL > 12-13 mg/dl
INCREASE >5 mg/dl/day
DIRECT >1.5-2 mg/dl

HYPERBILIRUBINEMIA
DIRECT COOMBS TEST- ABO/Rhdetect the infants antibodies coating the
RBS (circulating erythrocytes)

TYPES OF
HYPERBILIRUBINEMIA
PHYSIOLOGICAL JANUDICE
BREAST-FEEDING ASSOCIATED JAUNDICE
BREAST MILK JAUNDICE
HEMOLYTIC DISEASE- Blood antigen
incompatibility
a. Treatment- phototherapy, exchange
transfusion, prevention (RhoGAM)
b. Nursing Care

EXCHANGE TRANSFUSION
CRITERIA- + Direct Coombs, Hg<12g/dl,
Bilirubin > 20 mg/dl
AMOUNT - 2X blood volume of infant
UMBILICAL VEIN
CHECK FOR HYPOCALCEMIA
MONITOR VS, RADIENT WARMER

HYPOGLYCEMIA
SGA, LGA, IDM, STRESSED,
INTERUTERINE MALNUTRITION
JITTERY, HIGH-PITCHED CRY,
LETHARGIC
Dx- glucose <40 1st 24 hours or <50 after
24 hours, heel stick
PREVENT- early feedings

HYPOCALCEMIA
RISK- preterm with hypoxia, IDM,
hypoglycemic
Dx- serum calcium <7 mg/dl
Tx- increase milk feedings, cal.
supplements, Vit D

NEONATAL SEIZURES
NOT ORGANIZED
SIGN OF BRAIN DISTURBANCE
MOST COMMON CAUSE- Asphyxia &
Hypoglycemia
Dx- EEG, lab test, CAT scan
Treatment and Nursing Care

HYPOXIC-ISCHEMIC
ENCEPHALOPATHY
COMPLICATION OF HYPOXEMIA
RISK
SIGNS

SEPSIS
SUSCEPTIBLE- Diminished nonspecific
and specific immunity
ETIOLOGY- Infected amniotic fluid, +BGS
DIAGNOSIS- Cultures
TREATMENT- Ampicillin & Gentamycin

NECROTIZING
ENTERCOLITIS
SICK PRETERM & HIGH-RISK
ISCHEMIA & NECROSIS OF GI TRACT
RELATIONSHIP WITH FORMULA
SIGNS- Abdominal Distention, etc.
TREATMENT- D/C oral feedings,
Antibiotics, Observations

BULLOUS IMPETIGO
STAPHYLOCOCCUS AUREUS- red moist
denuded area with very little crusting
WARM SALINE COMPRESSES,
ANTIBIOTICS
PREVENT SPREAD

INFANTS OF DIABETIC
MOTHERS(IDM)
BLOOD SUGAR- Hypoglycemic <40 in
1st 24 hours, 40-50 later
TRANSIENT HYPERGLYCEMIA
LGA- Fat deposits & excessive growth
HYPOGLYCEMIA- Within 1/2-4 hours
CHECK BLOOD SUGAR

NARCOTIC-ADDICTED
INFANTS
WITHDRAWAL
AUTONOMIC NERVOUS SYSTEMHyperirritability, suck vigorously but poor
suckers
TREATMENT- Sedative/Hypnotic, Antianxiety
PROGNOSIS- Neuro and growth problems
NURSING- Decrease stimuli, nutrition,
snuggle, protect skin

COCAINE EXPOSURE
CNS STIMULANT
RISK SIDS
NEURO DEPRESSION/EXCITABILITY
SMALL HEAD CIRCUMFERENCE,
LBW, LOWER BIRTH LENGTH
TREATMENT- Supportive, occ. sedative

FETAL ALCOHOL
SYNDROME
MOM CHRONIC ALCOHOLIC
MENTAL RETARDATION
CHARACTERISTICS- Growth retardation,
CNS manifestations, facial characteristics,
fail to thrive

MATERNAL SMOKING
GROWTH RETARDATION
INCREASED ABORTION
EMOTIONAL DEFICITS
INCREASED SIDS

MATERNAL INFECTION
T- Toxoplasmosis
O- Other ( hepatitis, measles, mumps, HIV)
R- Rubella- pregnant no contact
C- Cytomegalovirus infection-pregnant no
contact
H- Herpes simplex- Stop transmission
S- Syphilis (Gonococcal conjunctivitis &
chylamydial conjunctivitis)

CONGENITAL
ABNORMALITIES
DOWNS SYNDROME- Extra chrosome
21
a. GREATER RISK IN WOMEN >35
b. CHARACTERISTICS- Mental
retardation, low set ears, head round, short
stubby fingers, bridge of nose flat, tongue
thick, heart defects

CONGENITAL
ABNORMALITIES
CHEMICAL AGENTS
a. BETWEEN 15-90 DAYS OF
GESTATION
b. PREVENTION

CONGENITAL
HYPOTHYROIDISM
INADEQUATE THYROXINE (T4)
CLINICAL SIGNS- Hypotonia, wide-spread
fontanelles, large thyroid, prolonged
jaundice
TREATMENT- Thyroid hormone
replacement

PHENYLKETONURIA
ABSENSE OF PHENYLALANINE
HYDROXYLASE
AFFECTS DEVELOPMENT OF BRAIN
AND CNS
SCREENING OF NEWBORNS, REPEAT
SCREENING
TREATMENT- Diet restricts phenylalanine
(Lofenalac), meat and diary products
restricted

GALACTOSEMIA
DISORDER OF GALACTOSE
METABOLISM
GLACTOSE ACCUMULATES IN BLOOD
ORGANS
SIGNS- Lethargy, hypotonia, diarrhea
TREATMENT- Eliminate galactose
(Prosobee)