Nursing care of Client At-Risk/

High- Risk/ Sick/ Life

Threatening Conditions/
Acutely Ill/ Multi-Organ
Problems/ High Acuity and
Emergency Situations
(Acute & Chronic)

SY:2021-2022
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 Alterations in
Oxygenation in Response
to Altered Cardiac &
Tissue Perfusion &
Transport
 Problems Related
to Prematurity,
Post maturity
 Problems Related
to Gestational
weight (LGA, SGA)
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M odels excellence.
 Preterm birth
Key facts:
•Every year, an estimated 15 million babies are born preterm
•Preterm birth complications are the leading cause of death among
children under 5 years of age
•Three-quarters of these deaths could be prevented with current, cost-
effective interventions.
•Across 184 countries, the rate of preterm birth ranges from 5% to 18%
of babies born.

https://www.who.int/news-room/fact-sheets/detail/preterm-birth

19 February 2018
Preterm
Infant
 Preterm Infant

•live born infant born before the

end of week 37 of gestation
•weight of less than2,500g (5lb 8
oz) at birth
• A preterm infant is immature and small but well proportioned for
age.

• Preterm infants are invariably low birth weight infants

Causes
 high correlation between low socioeconomic level and early
termination of pregnancy
 inadequate nutrition before and during pregnancy
 Iatrogenic causes, such as elective caesarean birth and inducing
labor according to dates rather than fetal maturity
 the exact cause of premature labor and early birth is rarely known
Assessment
•detailed pregnancy history may
sometimes reveal the reason for
a preterm
•pregnancy behaviors such as
cigarette smoking or working a
12 hour shift that may have
contributed to preterm
Appearance

• small and underdeveloped

• head is disproportionately large (cm or more
greater than chest size)
• skin is generally unusually ruddy because the
infant little subcutaneous fat
Appearance

• Veins are easily noticeable, and a high degree of acrocyanosis

may be present.
• Vernix is absent because it is not formed this early in pregnancy
(< 25 wks. gestation), covered w/ vernix caseosa (24-36 wks.
gestation)
• Lanugo is usually extensive, covering the back, forearms,
forehead, and sides of the face.
Appearance
• Both anterior and posterior fontanelles are small.
• There are few or no creases on the soles of the feet.
• Has varying degrees of myopia (nearsightedness) because of lack of
eye globe depth.
Appearance
• The cartilage of the ear is immature and
allows the pinna to fall forward.
• The ears appear large in relation to the head.
• Less active, if the infant does cry, the cry is
weak and high-pitched.
•Neurologic function is difficult to
evaluate
•Sucking & swallowing reflexes – absent
if below 33 weeks
•Achilles tendon reflex markedly
diminished
Problems Related to Prematurity

1. Breathing problems:
•Apnea
•Bronchopulmonary dysplasia
•Respiratory distress syndrome
2. Infections or neonatal sepsis
3. Anemia
Problems Related to Prematurity

4. Periventricular/Intraventricular
hemorrhage
5. Kernicterus (Newborn jaundice)
6. Necrotizing enterocolitis
7. Patent ductus arteriosus
8. Retinopathy of prematurity
Apnea of prematurity (AOP)

• This is a pause in breathing for 15 to 20 seconds or more.

• It may happen together with a slow heart rate called bradycardia.

Bronchopulmonary dysplasia (BPD)

• This is a lung disease that can develop in premature babies as well as

babies who have treatment with a breathing machine.

• Babies with BPD have a higher risk of lung infections than other
babies and BPD sometimes leads to lung damage.
Respiratory distress syndrome (RDS)

• A lack of lung surfactant makes them extremely vulnerable to

respiratory distress syndrome
Infections or Neonatal Sepsis

• Premature babies can get infections more easily than other babies
because their immune systems aren’t fully developed.
• The immune system protects the body from infection.
• Infection in premature babies can lead to sepsis, when the body has
an extreme response to infection. Sepsis can be life-threatening.
Anemia of Prematurity

• develop a normochromic , normocytic anemia

• The reticulocyte count is low because the bone marrow does not
increase its production until approximately 32 weeks
• infant appear pale and may be lethargic and anorectic
• may need blood transfusion and Vitamin E and iron provided by
preterm formula
Periventricular/Intraventricular
Hemorrhage
• Preterm infants are prone to periventricular hemorrhage and
intraventricular hemorrhage
• occurs because preterm infants have both fragile capillaries and
immature cerebral vascular development
• An infant experiences brain anoxia distal to the rupture
• cranial ultrasound done after the first few days of life to detect if a
hemorrhage has occurred
Kernicterus

• destruction of brain cells by invasion of indirect bilirubin

• This invasion results from the high concentration of indirect bilirubin
in the blood from excessive breakdown of red blood cells
Kernicterus

• have less serum albumin available to bind indirect bilirubin and

therefore inactivate its effect
• If jaundice occurs
Necrotizing Enterocolitis (NEC)
• is an acute injury of the small or large intestines that causes
inflammation and injury to the bowel lining and that primarily affects
preterm infants.
• It typically occurs within 2 weeks of birth and presents as feeding
difficulties, abdominal swelling, hypotension, and other signs of sepsis.
• When NEC is suspected, infants are treated with antibiotics and bowel
rest (i.e., no feedings).
Peristent Patent Ductus Arteriosus
• preterm infants lacks surfactant , their lungs are noncompliant , so it
is more difficult for them to move blood from the pulmonary artery
in the lungs
• leads to pulmonary artery hypertension , which may interfere with
closure of the ductus arteriosus.
• Indomethacin may be administered
• side effect of indomethacin is oliguria
• Ibuprofen may be administered prophylactically to achieve this same
result.
Retinopathy of prematurity (ROP)

• is the most common eye abnormality in preterm infants.

• It is a neovascular retinal disorder, and its incidence increases with
decreasing gestational age and decreasing birth weight.
• It is multifactorial in etiology, with the primary determinant being
immaturity with an avascular retina
Nursing Diagnoses
• Impaired gas exchange related to immature
pulmonary functioning
• Risk for deficient fluid volume related to
insensible water loss at birth and small
stomach capacity.
• Risk for imbalanced nutrition , less than
body requirement related to additional
nutrients needed maintenance of rapid
growth , possible sucking difficulty , and
small stomach
• Ineffective thermoregulation related to
maturity
Nursing Diagnoses

• Risk for infection related to immature defense

in preterm infant
• Deficient diversional activity (lack of
stimulation) related to preterm infant’ rest
needs.
• Parental health seeking behaviour related to
preterm infant’s needs for health
maintenance
Interventions
Nursing Considerations

• Monitor baby’s weight, urine output and specific gravity

and serum electrolyte to ensure adequate fluid intake
• Hand washing and gowning regulations must be strictly
enforced.
• Procedures should be organized to maximize the amount
of rest available to infant.
Nursing Considerations

• An infant must be kept warm during

resuscitation procedures.
• Giving 100% oxygen to preterm infants
during resuscitation
• The preterm newborn experience a high
insensible water loss and cannot
concentrate urine well because of
immature kidney function.
Nursing Considerations

• Positioning and Handling

• Normal neuromaturation can therefore be
promoted by positioning the infant in a
manner that mimics the infant’s position in the
intrauterine environment with extremity
flexion and hip adduction, the avoidance of
neck and trunk extension, and the promotion
of body symmetry.
• More comfortable breathing, better
oxygenation, and more time in deep sleep have
been noted in preterm and sick infants in the
prone position.
Nursing Considerations
• Positioning and Handling
• use positioning aids, rolled blankets, or swaddling to position
preterm infants symmetrically with their extremities flexed,
shoulders placed forward, and hips adducted to promote normal
neuromaturation.
• Kangaroo care provides skin-to-skin care by placing the naked
preterm infant in an upright position between the mother’s breasts
and allows unlimited breast-feeding.
Neurodevelopmental Support

• The elements that make up the provision of

neurodevelopmental support include NICU
design and lighting, nursing routines and
care plans, feeding methods, management
of pain, attention to sensory input, activity
and signs of stress, and the involvement of
the parents in the care of their infants.
Neurodevelopmental Support

• NICUs therefore seek to implement

strategies that mimic the intrauterine
environment and that provide more
appropriate stimuli that are geared to the
infant’s state of alertness and responses
Neurodevelopmental Support

• Family-centered NICU care

• providing families with comfortable seating, rocking
chairs, privacy, and liberal visiting hours;
• encouraging them to bring in family photos or tapes of
their voices;
• And, saving bathing and feeding for family visits.
Neurodevelopmental Support
• Family-centered NICU care
• Breast-Feeding
• Besides providing milk that is more easily
digested by vulnerable preterm infants,
breast-feeding facilitates attachment by
ensuring that the mother has a primary role
in her baby’s recovery
• Preterm infants fed breast milk have lower
risks of infection and NEC, learn to nipple
feed better, have higher cognitive scores, and
may have a lower risk of chronic
gastrointestinal diseases and allergies
Interventions

Feeding schedule

May be fed by total parenteral nutrition.

Most preterm infants have a chest xray before a first feeding
A preterm needs 115 to 140 calories per kg. of body weight per day
Feeding Schedule

Feedings may be as small as 1 or 2 ml every 2 to 3 hours.

Breast, gavage or bottle feedings are begun as soon as an infant is
able to tolerate
Gavage Feeding
• A gag reflex is not intact until 32 weeks gestation.
• Gavage feedings may be given intermittently every few hours or
continuously via tubes.
• Infants may be fed by continous drip feeding at about 1ml/hr.
• Offering pacifier during
gavage feeding.
Formula
The caloric concentration of formula used for preterm infants is
usually 24cal/oz
Breastmilk
play a major role in preventing necrotizing enterocolitis
Postterm
Infant
• born after the 42nd week of pregnancy
• They may be lightweight from a recent weight loss that occurred
because of the poor placental function.
• Post term baby is likely to have difficulty establishing respirations,
especially if meconium aspirations occurred
Appearance

• infant with postmaturity syndrome is unusually alert and wide eyed

and has worried look
• infant may be thin with loose skin and little subcutaneous fat
• Pale skin
Appearance
• The umbilical cord is thin with little wharton’s jelly.
• There is little or no lanugo and vernix caseosa, but infants has
abundant hair on the head and long nails .
• The skin is wrinkled , cracked, and peeling.
Assessment

• Post term infants should be assessed for

hypoglycemia because of rapid use of
glycogen stores.
• If loss of subcutaneous fat has occurred ,
the infant is at risk for low temperature
Diagnostic Procedure

• Postterm is diagnosed based on the neonate's gestational age.

• Postmaturity is diagnosed based on the gestational age and physical

examination findings.
Complications
• Perinatal asphyxia due to placental insufficiency as well as cord
compression secondary to oligohydramnios.
• Meconium aspiration syndrome may be unusually severe because
amniotic fluid volume is decreased and thus the aspirated meconium is
less dilute.
• Persistent pulmonary hypertension often occurs after meconium
aspiration.
Complications
• Neonatal hypoglycemia - caused by insufficient glycogen stores at
birth.
Nursing Management
1. Manage meconium aspiration syndrome.
•Suction the infant’s mouth and nares while the head is on the
perineum and before the first breath is taken to prevent aspiration of
meconium that is in the airway.
•Perform chest physiotherapy with suctioning to remove excess
meconium and secretions.
•Provide supplemental oxygen and respiratory support as needed.
 Nursing Management
2. Obtain serial blood glucose measurements.
3. Provide early feeding to prevent hypoglycemia, if not contraindicated by
respiratory status.
4. Maintain skin integrity.
•Keep the skin clean and dry.
•Avoid the use of powders, creams, and lotions.
•Avoid the use of tape.
Therapeutic Management

• Specific treatment involves identification and treatment of birth

injuries and complications as they arise.
Small for Gestational
Age Infant
 Small for Gestational Age

• the birth weight is below the 10th percentile on an intrauterine

growth curve for that age
• SGA infants may be born preterm, term, or post term
• experienced intrauterine growth restriction (IUGR) or failed to
grow at the expected rate in utero
CAUSES
common cause of IUGR is a placental anomaly
did not obtain sufficient nutrients from the uterine arteries
Placental damage , such as partial placental separation with
bleeding
Women with systemic diseases such as severe DM or PIH
 Causes

• Fetus contracted an intrauterine infection: rubella or toxoplasmosis

or chromosomal abnormality
Assessment
• The SGA infant may be detected in utero when fundal height during
pregnancy becomes progressively less than expected
• sonogram can then demonstrate the decreased size.
Assessment
• A biophysical profile including non stress test , placental grading,
amniotic fluid amount and ultrasound examination – placental
function
Hypoxia - Cesarean birth is the birth method of choice.
Appearance
• an infant has an overall wasted appearance .
• have small liver , which may cause difficulty regulating glucose ,
protein ,and bilirubin levels after birth.
• poor skin turgor and generally appear to have a large head
because the rest of the body is small .
Appearance
 Skull structures may be widely separated from lack of normal
bone growth.
 Hair is dull and lusterless.
 Abdomen may be sunken.
• The cord often appear dry and may be stained yellow.
Appearance
• better developed neurologic responses, sole creases, and ear
cartilage than expected for a baby of that weight .
• The skull may be firmer and the infant seem unusually alert and
active for that weight.
LABORATORY FINDINGS:

• increase in the total number of RBC (polycythemia )

• a high hematocrit level
• increase in RBC
• decreased blood glucose or level below 40mg/dl)
Nursing Diagnoses

• Ineffective breathing pattern related to underdeveloped

body systems at birth.
• Risk for ineffective thermoregulation related to lack of
subcutaneous fat
• Risk for impaired parenting related to child’s high risk
status and possible cognitive or neurologic impairment
from lack of nutrients in utero.
Nursing consideration

• Supportive care
• Underlying conditions and complications are treated.
• There is no specific intervention for the SGA state, but prevention is aided by
prenatal advice on the importance of avoiding alcohol, tobacco, and illicit
drugs.
Nursing Considerations

• Closely observe both respiratory rate and character in the

first few hours of life.

• Infant’s temperature is maintained at 36.5 ᵒC (97.8ᵒF)

axillary.
Evaluation

• Parents express interest in infant and ask question

about what the child’s care needs will be at home.
• Encourage parents to provide toys suitable for their
child’s chronologic age , not physical size
Prognosis

• If asphyxia can be avoided, neurologic prognosis for term SGA infants

is quite good.
• However, later in life there is probably increased risk of ischemic
heart disease, hypertension, and stroke, which are thought to be
caused by abnormal vascular development.
Large for Gestational
Age Infant
Large for Gestational Age
• also termed as (macrosomia )
• birth weight is above the 90th percentile on an intrauterine
growth chart for the gestational age
Causes

• subjected to an overproduction of growth hormone in utero

happens most often to infants of mothers with DM and women
who are obese .
• Multiparous women are also prone to deliver large babies.
Causes:

• Other conditions associated with LGA infants include

 transposition of great vessels
Beckwith syndrome ( a rare condition characterized by overgrowth )
 congenital anomalies such as omphalocele
Assessment
• a woman’s uterus is unusually large for the date of
pregnancy .
• If a fetus does seem to be growing at an abnormal
rapid rate, a sonogram can confirm the suspicion.
• A non stress test to assess the placenta’s ability to
sustain the large fetus during labor.
Assessment
• lung maturity may be assessed by amniocentesis
• If an infant’s large size was not detected during pregnancy ,
it may be recognized during labor when the baby cannot
descend through the pelvic rim
• Cesarean birth may be necessary because of cephalopelvic
disproportion or shoulder dystocia
Appearance
• At birth show mature reflexes and low scores on gestational age
examinations in relation to his or her size. (Low 5-minute Apgar score).
• A baby may have extensive bruising or a birth injury such as broken
clavicle or Erb Duchenne paralysis .
• head is large, it may have been exposed to more than the usual
amount of pressure during birth
Complications
• birth trauma
• hypoglycemia
• hyperviscosity
• hyperbilirubinemia
Nursing Diagnoses
• Ineffective breathing pattern related to
possible birth trauma in large for
gestational age newborn
• Risk for imbalanced nutrition less than
body requirement related to additional
nutrients needed to maintain weight and
hypoglycemia
• Risk for impaired parenting related to high
risk status of large for gestational age infant
Evaluation

• Some LGA infants have difficulty

establishing respirations at birth because
of birth trauma .

• A diaphragmatic paralysis may occur due

to cervical nerve trauma
Evaluation

• If an infant is born in Cesarean birth transient fluid can

remain in the lungs and interfere with effective gas
exchange.

• Infants weight follows percentile growth curve: skin

turgor ; specific gravity of urine is 1.003 to 1.030;
serum glucose is above 40mg/dl .
Nursing Considerations

• the LGA infants needs to be breastfed immediately to

prevent hypoglycemia
• Do not over stimulate this infant’s ability to suck
effectively at birth .
• Encourage parents to treat their baby as a fragile newborn
who needs warm nurturing not as tough big infant who
has grown past that stage.
Observe closely for signs of:
hyperbilirubinemia

Polycythemia

Hypoglycemia
Key Points
• Maternal DM is the major cause of large-for-gestational-age infants.
• Large size itself increases risk of birth injury (eg, clavicle or extremity
long bone fracture) and perinatal asphyxia.
• IDM also may have metabolic complications immediately after
delivery, including hypoglycemia, hypocalcemia, and polycythemia.
Key Points
•Infants of diabetic mothers are also at
risk of respiratory distress syndrome
and congenital anomalies.

•Good control of maternal glucose levels

minimizes risk of complications.
Thank you.