highrisk newborns
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HIGH RISK NEWBORNS
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SGA Preterm, term, postterm
(+) IUGR or failed to grow at expected rate
Causes:
Mothers nutrition (Adolescents)
Placental anomaly
Developmental defect
Placental damage
Systemic disease (DM)
Smokers or use of narcotics
Intrauterine infection
Chromosomal abnormality
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Assessment:
Perinatal assessment
FH than expectedUltrasound: small size
BPP: Poor placental perfusion
NSTPlacental grading
AF amount
Ultrasound exam
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Appearance
Small liver
Poor skin turgor
Large head
Widely separated skull sutures
Hair is dull
Sunken abdomen Cord appears dry and stained yellow
Better developed neurological responses, solecreases, ear cartilage
Skull may be firmer Alert and active
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Lab. Findingshct >65 70% exchange
transfusion
RBC blood viscosityacrocyanosis
Hypoglycemia (
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Nursing Diagnoses: Ineffective breathing pattern r/t underdeveloped body
systems
Resuscitation
Observe RR and character
Risk for Ineffective thermoregulation r/t lack of SC fat Control environment
Risk for Impaired Parenting r/t Childs High Risk
Status and Possible Cognitive or Neuro. Impairment
from lack of Nutrition in Utero Discuss to parents ways to promote infants
development
Provide toys suitable for age
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Assessment:
Uterus is unusually large for the date ofpregnancy
Sonogram Confirm
NST assess placental perfusion
Assess lung maturity by Amniocentesis CPD, Shoulder dystocia
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Appearance:
Immature reflexes
Extensive bruising or birth injury
Ecchymosis, jaundice, erythema
Clavicle or cervical nerve injuries
Asymmetry of anterior chest
Unresponsive or dilated pupils
Seizure
Prominent caput succedaneum, cephalhematoma or Molding CV Dysfunction
Polycythemia
(+) Stress on the heart
(+) Cyanosis Transposition of Great Vessels
Hypoglycemia
glucose to sustain the weight
(+) DM mother glucose in utero insulin production continues up to 24 hrs of life Rebound hypoglycemia
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Nursing Diagnoses:
Ineffective Breathing Pattern r/t Possible Birthtrauma
Risk for Imbalanced Nutrition Less than bodyrequirements r/t additional nutrition needed tomaintain weight and prevent hypoglycemia
Breastfeed immediately
Supplemental formula feedings
Risk for Impaired Parenting r/t High risk status
Needs the same developmental care
Encourage parents to treat their baby as a fragileNB
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PRETERM
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PRETERM Causes:
Low socio economic level Poor nutritional status
Lack of prenatal care
Multiple pregnancy
Previous early birth
Cigarette smoking
Age of the mother
Order of birth
Closely spaced pregnancies
Abnormalities of the mothers reproductive system Infections
OB complications
Early induction of labor
Elective CS
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Assessment:
History:
Pregnancy history
Appearance: Appears small and underdeveloped
Head is disproportionately large (3 cm or >chest)
Skin is unusually ruddy
Veins are easily noticeable
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Acrocyanosis
Covered with vernix caseosa
Lanugo is usually extensive
Few or no creases on soles of feet Eyes are small
Myopia
Immature ear cartilage, pinna falls forward
Ears appears large in relation to head
Less active, rarely cries
(+) Cry; weak and high pitched
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Potential Complications:
Anemia
Normochromic, normocytic anemia
Reticulocyte count
Pale,lethargic and anorectic
Keep a record of the amount of blood drawn
Give DNA recombinant erythropoietin BT, Vit. E and iron
Kernicterus
Acidosis
albumin bind to indirect bilirubin
(+) Jaundice phototherapy or exchangetransfusion
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Persistent PDA
surfactantblood from pulmonary artery tolungs Pulmonary artery PDA
Hydrate
Give Indomethacin or Ibuprofen
Complication of Indomethacin: Oliguria
monitor UO closelyPeriventricular/ Intraventricular Bleeding
(+) Fragile capillaries and immature cerebralvascular development
(+) Rapid change in cerebral BF capillariesrupture
Hypoxia
Pneumothorax
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Nursing Diagnoses:
Impaired Gas Exchange R/T Immature Pulmonary Function
20 secs surfactant alveolar collapse
(+) Breech expel meconium aspiration inflammation or pneumonia
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Give mother O2
Maternal analgesia and anesthesia
Preterm must be resuscitated within 2 mins after
birth
Keep infant warm
Carry out all procedures gently
100% O2: 2 Dangers:
Pulmonary edema
Retinopathy of prematurity
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Risk for Deficient Fluid Volume R/T Insensible WaterLoss at birth and small stomach capacity
Normal glucose: 40-60 mg/100 ml
Specific gravity: 1.003 1.030
UO: 1 ml/kg/hr
IVF 160-200 ml/kg/BW umbilical venous catheter
Monitor weight, UO and specific gravity andelectrolytes
Measure UO by weighing diapers
Preterm: 40-100 ml/kg x 24 hrs ; 1.012
Term: 10-20 ml/kg x 24 hrs ; 1.030
Test urine for glucose and ketones
Keep a record of all blood drawn
Check for blood in stool
Determine possible cause of hypovolemia
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Risk for Imbalanced Nutrition Less than Body Requirements
R/T Additional Nutrients Needed for Maintenance of rapid
growth, possible sucking difficulty and small stomach Feeding Schedule
IVF feeding may be delayed
TPN
Breast, gavage or bottle feeding Get CXR before feeding
(+) Air in stomach
Small, frequent feeding (1-2 ml every 2-3 hrs)
Preterm: 115 140 cal/kg/ BW
Term: 100 110 cal
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Gavage Feeding
(+) Gag reflex 32 weeks 32-34 weeks, ill, (+) RDS Gavage feeding
Bottle feeding or breast feeding is graduallyintroduced Give softer nipple Observe preterm infant closely Offer pacifier
Aspirate stomach secretions measure replace >2 ml not allowed (-) Digestion NEC
Formula: 24 cal/oz preterm
20cal/oz term Vit. K 0.5 ml Give Vit. E prevent hemolytic anemia
Breastmilk: Prevents NEC
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Ineffective Thermoregulations R/T Immaturity
Keep NB warm during transportation Heat shield or plastic wrap
Risk for Infection
Linen and equipment must not be shared
Staff members must be free of infection
Hand washing and gowning
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Risk for Impaired Parenting
Rocking, singing and talking and gentle holding
Kangaroo care
Encourage the mother to express breastmilk
Encourage mother to come to the hospital and hold thebaby before and after gavage or bottle feeding
Photograph of baby
Notes to convey messages from the baby to them can betaped to the incubator
Sibling should not visit if they have colds or fever, (+)immunization, (-) exposure to communicable diseases
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Deficient Diversional Activity (Lack of stimulation)
Organize procedures Shield from noise and light
Pain should be kept into minimum Look directly at an infant in the straight forward position Provide some talk time Gentle stroke an infants back
Risk for disorganized infant behavior Modify environment; reduce stimuli Dim the lights; cover the incubator, turn infant to the side, contain
body with rolled towels
Offer non-nutritive sucking Maintain quiet hour
Parental health-seeking behaviors Overprotection is not necessary Basic immunization
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POST TERM Post term
>42 weeks Placenta functions effectively for only 40 weeks
(+) Postterm syndrome: SGA characteristics Dry Cracked (leather like)
(-) Vernix Light weight meconium stained Fingernails have grown well Alertness = 2 weeks old
(+) Difficulty establishing respiration Hypoglycemia SC tissue temperature regulation difficult Polycythemia, hct
nutrition and O2 (+) Neurologic symptoms
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RESPIRATORY DISTRESS
SYNDROME Due to blood perfusion of lungs; surfactant (+) Hyaline like (fibrosis) membrane formed from
an exudate of infants blood lines terminalbronchioles, alveolar ducts and alveoli
prevents exchange of O2 and CO2 Pathophysiology:
surfactant (+) areas of hypoinflation pulmonaryresistance blood shunts to foramen ovale and ductus
arteriosus
lung perfusion
surfactant (+) Hypoxia, Co2 (+) Lactic acid acidosis
vasoconstrictionpulmonary perfusionsurfactant production alveoli collapse withexpiration
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Assessment: Lowbody temperature Nasal flaring
Retractions Tachypnea (>60) Cyanosis Expiratory grunting distress
Seesaw respiration Heart failure Pale, gray skin Periods of apnea Bradycardia Pneumothorax
CXR: Diffuse pattern of radiopaque areas groundglass (haziness)
Blood gas: Respiratory acidosis C/S: R/O -hemolytic group B strep
May start Penicillin or Ampicillin + Gentamycin or
Kanamycin
Management:
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Management:
Surfactant replacement
Sprayed into lungs by syringe or catheter by ET tube
Head held upright and tilted downward
AW should not be suctioned
(+) Ventilator needs close observation
O2 administration
Continuous Positive Pressure (CPAP) or Assisted Ventilation
with Positive End Expiratory Pressure (PEEP) Keep alveolifrom collaping
Cx: Retinopathy of prematurity
Management:
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Management:
Ventilation
Normal I/E ratio: 1:2
Infant ventilators: 2:1
Complications:
Pneumothorax
Impaired CO
ICP and arterial pressure
Hemorrahge
Limit fluid intakepulmonary artery pressure
Indomethacin or Ibuprofen closure of PDA
Complications:
Renal function platelet function
Gastric irritation
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Additional Therapy
Muscle relaxants Pancuronium (Pavulon) IVspontaneous respiratory
function
Pressure mechanical ventilation
Pneumothorax
Needs critical observation
Frequent ABG
Atropine and Prostigmine should be available
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Liquid Ventilation
Use of Perflourocarbons
(+) O2 Perflourocarbons pick up and carry O2 distends
the lungs
exchange of O2 Can be used to deliver O2
Nitric Oxide
Cause of pulmonary vasodilation
Prevention:
Sonogram
Document: Lecithin should exceed Sphingomyelin (2:1)
MgSO4 or Terbutaline prevent preterm birth
SteroidsLecithin
Betamethasone 12-24 hrs; 24-34 wks AOG (takes effectsbefore 24-48 hrs)
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MECONIUM ASPIRATIONSYNDROME
(+) Meconium at 10 weeks AOG
(+) Breech expel meconium in amniotic fluid
(+) Hypoxia (+) Vagal reflex relaxation of rectal
sphincter Appearance; Green to greenish black
May be aspirated in utero or with 1st breath
(+) Respiratory distress:
(+) Inflammation of bronchioles Mechanical plugging
surfactant production
Hypoxemia, CO2, (+) shunting
(+) secondary infection Pneumonia
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Assessment:
Apgar score
Tachypnea, retractions, cyanosis
Suction with bulb syringe or catheter while at theperineum
Do not administer O2 under pressure
Enlargement of AP diameter (barrel chest) ABG: pO2, pCO2
CXR: Bilateral coarse infiltrates in the lungs, (+) spaces ofhyperaeration (honeycomb effect)
Diaphragm pushed downward
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Management:
Amniotransfusion
CS birth
Tracheal suction, O2, assist ventilation
Antibiotic therapy
Observe closely for signs of trapping air in the alveoli
Observe for signs of heart failure due to shunting ofblood from pulmonary artery to aorta (HR, respiratory
distress)
Maintain a temperature neutral environment
Chest physiotherapy ECMO
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SIDS Unexplained death in infancy
Commons among:
Infants of adolescent mother
Closely spaced pregnancy
Underweight and preterm infants Bronchopulmonary dysplasia
Twins
Narcotic dependents
Peak age: 2-4 mos.
Contributory Factors:
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y Prolonged, unexplained apnea Viral respiratory or botulism Pulmonary edema Brainstem abnormality
Neurotransmitter deficiency HR abnormalities Distorted familial breathing patterns arousal response surfactant Sleeping prone
Infants are well nourished Slight head cold Dies with laryngospasm Blood flecked sputum or vomitus in mouth or on bed clothes Autopsy:
Petechiae in the lungs Mild inflammation and congestion in respiratory tract
Inform parents that the death was unexplained
Give assurance that SIDS is a disease of infants
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HYPERBILIRUBINEMIA Hemolytic Disease of the NB
Rh incompatibility Mother: Rh (-)
Fetus: Rh (+)
Sensitization: Mother begins producing antibodiesagainst D antigen (72 hrs)
2ndpregnancy: D antibody destroy fetal RBC Requires intrauterine transfusions
May induce preterm labor
Administer Phenobarbital to women speeds liver maturity
ABO Incompatibility
Mother: Type O Fetus: Type A or B or AB
Not born anemic
Hemolysis begins with birth; may continue up to 2 wks
Preterm: Not affected
Increase reticulocyte count
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Assessment: Percutaneous umbilical blood sampling
anti-Rh titer (Indirect Coombs test) Mother (+) Abs Fetal erythrocytes
(-) Pale Enlarged liver and spleen (+) Edema Severe anemia Heart failure (Hydrops Fetalis)
(+) Progressive jaundice (+) Preterm: (+) Hemolysis Liver cannot convert
indirect to direct bilirubin (+) Breastfeeding: (+) PrenanediolProgesterone interferes with conjugation of indirect bilirubin
Normal bilirubin: 0-3 mg/100ml >20mg/dl or 12 mg/dl in preterm Kernicterus
Hypoglycemia Hgb
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Management: Early feedingperistalsis
Bilirubin incorporated into feces
Phototherapy Specialized light: Quartz halogen, cool white day light
or special blue fluorescent light
12-30 inches above the bassinet or incubator
Infant is undressed except for diaper Term NB: Bilirubin 15 mg/dl; Preterm: 10-12 mg/dl
Eyes must always be covered
Stool: Bright green, loose, irritating to skin; Urine: Darkcolored
Assess skin turgor, I/O DHN
Monitor axillary temperature
Infant should be removed for feeding
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Exchange Transfusion
Aspirate stomach
Umbilical vein is catheterized
Draw small amounts of blood (2-10 ml) replace with
equal amounts of donor blood
Blood is exchanged slowly 1-3 hrs (automatic pumps)
End: hct, bilirubin, Ca+, glucose, culture
Repeat exchange transfusion
Done for hyperbilirubinemia or polycythemia, bloodincompatibility, heart failure
Keep NB warm
Blood should be given at room temperature
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Use only commercial blood warmers Albumin may be administered 1-2 hrs before Monitor rate of flow of albumin Blood type used: O-
Monitor HR, RR and BP Blood contain acid-citrate-dextrose (ACD) as anticoagulant
Ca acidosis Ca gluconate is given every 100 ml of blood
Citrate-Phosphate Dextrose (preservative) hyperglycemia
insulin
hypoglycemia Heparinized blood interferes with clotting
glucose hypoglycemia Give Protamine sulfate
Observe infant for umbilical vessel bleeding
(+) Redness or inflammation (+) infection
Report changes with V/S Take and record glucose 1 hr after Monitor bilirubin 2 or 3 days after May administer erythropoietin
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SEPSIS
Early onset - birth to 7 days Pathogens: group B strep, E.coli, Klebsiella,
Listeria
Late onset - 7 to 28 days Pathogens: early onset pathogens PLUS
Staph. aureus, Neisseria gonorrhea
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Symptoms: poor feeding, vital signinstability, leukocytosis, leukopenia,thrombocytopenia, hypoglycemia,
hyperbilirubinemia, altered consciousness Evaluation: CBC with diff (band/pmn>0.2
or ANC
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Ampicillin(100 mg/kg/24 hrs) PLUSgentamicin (3-5 mg/kg/24 hrs)
Ampicillin(100 mg/kg/24 hrs) PLUScefotaxime (100-150 mg/kg/24 hrs)