10 NURSING CARE OF HIGH RISK NEWBORN Flashcards
Newborn Priorities
- Initiation & Maintenance of Respirations
- Establishment of Extrauterine Circulation
- Maintenance of Fluid & Electrolyte Balance
- Control of Body Temperature
- Establish Adequate Nutritional Intake
- Establishment of Waste Elimination
- Prevention of Infection
- Establishment of Infant - Parent Relationship
- Developmental Needs
A live born infant born before the end of week 37 gestation
Preterm Infant
Born between 34 and 37 weeks
Late Preterm
Born between 24 and 34 weeks
Early Preterm
Common Factors Associated with Preterm Birth
● Low socioeconomic level
● Poor nutritional status
● Lack of prenatal care
● Multiple pregnancy
● Previous early birth
● Race
● Cigarette smoking
● Age of the mother (younger than age 20)
● Order of birth
● Closely spaced pregnancies
● Abnormalities of the mother’s reproductive system, such as intrauterine septum
● Infections (UTI)
● Obstetric complications, such as premature rupture of membranes or premature separation of the placenta
● Early induction of labor
● Elective cesarean birth
Disproportionately large (> 3cm greater than
chest size)
Head
Small
Fontanelles
Small, hazy vitreous humor, myopia
Eyes
Large, immature cartilage, pinna falls forward
Ears
Ruddy; vernix caseosa, lanugo, few or (-) creases on soles of feet
Skin
(-) sucking, swallowing and breathing
reflexes, diminished Achilles tendon reflex; less active and rarely cries
Neurologic
Potential Complications of Preterm Infant
● Anemia of Prematurity
● Acute Bilirubin Encephalopathy
● Periventricular/Intraventricular Hemorrhage
● Retinopathy of Prematurity
Occurs from a combination of immaturity of
the hematopoietic system combined with the
destruction of RBCs because of low levels of Vitamin E, a substance that normally protects RBCs against oxidation.
Anemia of Prematurity
The infant will appear pale and may be lethargic and anorectic.
Anemia of Prematurity
Excessive blood drawing for electrolyte or blood gas analysis can potentiate the problem.
Anemia of Prematurity
This is the destruction of brain cells by invasion of indirect or unconjugated bilirubin.
Acute Bilirubin Encephalopathy
Also be called “Kernicterus”
Acute Bilirubin Encephalopathy
Tissue surrounding the ventricles
Periventricular hemorrhage
Bleeding into the ventricles
Intraventricular hemorrhage
It is an acquired ocular disease that leads to partial or total blindness in children, caused by vasoconstriction of immature retinal blood vessels with high concentration of oxygen as the causative agent
Retinopathy of Prematurity
Provide early screening and detection in infants: <___ weeks of gestation and weight <___ g
(3.3 pounds).
30, 1500
Decrease exposure preterm infant to ___, ___
bright, direct lighting
Use supplemental ___ judiciously and monitor ___ blood levels carefully
oxygen
Surgical repair of detached retina.
Laser photocoagulation
Anti vascular endothelial growth factor drug
Avastin (bevacizumab)
Nursing Diagnosis for Preterm Infant
● 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
requirements, related to additional nutrients needed for maintenance of rapid growth, possible sucking difficulty, and small stomach
● Ineffective thermoregulation related to immaturity
● Risk for infection related to immature immune
defenses in the preterm infant
● Risk for impaired parenting related to interference with parent-infant attachment resulting from hospitalization of infant at birth
Nursing Management for Preterm Infant
● Keep the infant warm during resuscitation
● Carryout all procedures gently
● Intravenous fluid should be given via a continuous infusion pump
● Intravenous sites must be checked conscientiously
● Monitor the baby’s weight, urine output and specific gravity, and serum electrolytes.
● Measure urine output by weighing diapers
● Schedule Feeding
● Be certain that a radiant heat warmer is warmed
● Linen and equipment used with preterm infants must not be shared with other infants.
● Allow the mother to feed her infant with supervision
● Encourage parents to begin interacting with their infant in as normal a manner as possible
Birth weight is below 10th percentile
The Small for Gestational Age Infant “Microsomia”
Common Factors Associated with SGA
● Nutrition
● Age of the Mother (Adolescent)
● Chromosomal abnormality
● Intrauterine infection
● Placental issues
● Diabetes mellitus
● Gestational hypertension
● Smoking
Appearance of SGA
● Below average weight, length and head circumference
● Poor Skin turgor
● Skull sutures widely separated
● Dull and lusterless hair
● Small Liver
● Sunken abdomen
● Dry umbilical cord
Laboratory Findings of SGA
● High hematocrit
● Increase RBCs (polycythemia)
● Hyperbilirubinemia
● Hypoglycemia
Nursing Diagnosis for SGA
● 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 Management for SGA
- Closely observe both respiratory rate and character in the first few hours of life.
- Careful control of environment is essential to keep the infant’s body temperature in a neutral zone
- Encourage parents to provide toys suitable for their child’s chronological age
Birth weight is above the 90th percentile
The Large for Gestational Age Infant “Macrosomia”
Common Factors Associated with LGA
● Overproduction of nutrients & growth hormones
● Obesity
● Diabetes mellitus
● Multiparity
● Beckwith-Wiedemann syndrome
Appearance of LGA
● Immature reflexes
● Poor Apgar Score
● Extensive bruising
● Birth injury (broken clavicle or Erb-Duchenne
paralysis)
● Caput succedaneum, cephalohematoma, or molding
Assessment Criteria for LGA: Skin color for ___, ___, ___
ecchymosis, jaundice, and erythema
Assessment Criteria for LGA: Motion of extremities on spontaneous movement and
in response to a _____ to detect clavicle
fracture
Moro’s reflex
Assessment Criteria for LGA: Asymmetry of the _____ or unilateral lack of movement
anterior chest
Assessment Criteria for LGA: Eyes for evidence of unresponsive or dilated pupils; vomiting, bulging fontanelles, and a high-pitched cry suggestive of _____
increased intracranial pressure
Assessment Criteria for LGA: Activities such as jitteriness, lethargy, and uncoordinated eye movements that suggest _____
seizure activity
Nursing Diagnosis for LGA
● Ineffective breathing pattern related to possible birth
trauma in the LGA newborn
● Risk for imbalanced nutrition less than body
requirements, related to additional nutrients needed to
maintain weight and prevent hypoglycemia
Nursing Management for LGA
- Careful observation
- Offer both the mother and baby feeding support.
- Encourage parents to treat their baby as a fragile newborn who needs warm nurturing not as a tough big infant who has grown past that stage.
Born after 41st week of a pregnancy
Post Term Infant
Appearance of Post Term Infant
● Dry, cracked, almost leather like skin
● (-) Vernix
● SGA
● Less amniotic fluid
● Meconium stained
● Fingernails will have grown well
● Alert like 2 week old baby
Common Factors Associated with Post Term Infant
● DOB
● Polycythemia
● Increase Hematocrit
● Hypoglycemia
● Decrease Subcutaneous fat levels
Therapeutic Management for Post Term
● Sonogram
● Non-Stress Test/EFM
Nursing Management for Post Term
- Make sure a woman spends enough time with her newborn
- Control possible hypoglycemia/meconium aspiration
- Educate mother on the importance of follow up care
Occurs when a fetus has been subjected to asphyxia or other intrauterine stress that
causes relaxation of the anal sphincter and passage of meconium into the amniotic fluid
Meconium Aspiration Syndrome
Assessment of Meconium Aspiration Syndrome
● Difficulty establishing respiration
● Low Apgar score
● Tachypnea
● Retractions
● Cyanosis
● Barrel chest
● Poor gas exchange
● Bilateral coarse infiltrates
Therapeutic Management for Meconium Aspiration Syndrome
● Amnioinfusion - dilute the amount of meconium in amniotic fluid
● C-Section
● Antibiotic Therapy
● Surfactant
● Oxygen & Assisted Ventilation
Nursing Management for Meconium Aspiration Syndrome
● Observe infant closely for signs of trapping air in the alveoli
● Observe infant closely for signs of heart failure
● Maintain a temperature-neutral environment
● Perform chest physiotherapy with percussion and vibration
Hyaline membrane disease is most often in newborns who are born prematurely
Respiratory Distress Syndrome (RDS)
Compounds that lower the surface tension (or
interfacial tension) between two liquids, between a gas and a liquid, or between a liquid and a solid.
Surfactant
Assessment for RDS
● Low body temperature
● Nasal Flaring
● Sternal and subcostal retractions
● Tachypnea (>60bpm)
● Cyanosis
● Seesaw respiration
● Heart failure (decreased urine output and edema)
● Pale gray skin
● Periods of apnea
● Bradycardia
● Pneumothorax
Diagnosis for RDS
Chest Xray
Blood Gas
Therapeutic Management for RDS
Surfactant replacement
Oxygen administration
Ventilation
Nitric Oxide
Extracorporeal Membrane Oxygenation (ECMO)
Supportive Care
Surfactant: _____ infant before administration
Suction
Surfactant: Assess infant’s RR, rhythm, O2 saturation and color before _____.
administration
Surfactant: Ensure proper ___ placement before dosing
ET
Surfactant: Change infant’s position during administration to encourage the drug to flow on both _____.
Lungs
Surfactant: Assess infant’s RR, color, and pulse oximetry or ___ after administration.
ABG
Surfactant: Do not suction ET for _____ after administration.
1 hour
Prevention of RDS
● Magnesium Sulfate
● Betamethasone Sodium Phosphate and
Betamethasone Acetate
A cessation in respirations lasting longer than 20 seconds, accompanied by bradycardia and/or cyanosis
Apnea
Nursing Management of Apnea
● Flicking the soles of the foot
● Suction gently and only when needed
● Maintain a neutral thermal environment
● Indwelling NGTs
● Observe post feeding of infant
● Caffeine
● No to rectal temperature taking
Rapid rate of respirations, up to 80 breaths/min.
Transient Tachypnea of the Newborn (TTN)
Assessment for TTN
● Rapid breathing
● Mild retractions
● Nasal flaring
● Fluid in the lungs
● Respiratory acidosis
● Hypercapnia
● Hypoxemia
Therapeutic Management for TTN
Oxygen Administration
Excessive destruction of red blood cells, which leads to elevated bilirubin levels
Hemolytic Disease of the Newborn
(Hyperbilirubinemia)
The major causes of increased erythrocyte destruction are ___ and ___ incompatibility.
Rh and ABO
The mother’s blood type is Rh negative and the fetal blood type is Rh positive, this introduction of fetal blood causes sensitization to occur and the woman begins to form antibodies against the specific antigen.
Rh Incompatibility
The maternal blood type is “O” and the fetal blood type is either “A or B” type blood. Hemolysis can become a problem with a first pregnancy.
ABO incompatibility
O is incompatible with
A or B
B is incompatible with
A or AB
A is incompatible with
B or AB
Assessment for Hemolytic Disease of the Newborn
● Anemia
● Jaundice (1st 24H)
● Hyperbilirubinemia
● Hypoglycemia
Diagnostic Evaluation for Hemolytic Disease of the Newborn
● Coomb’s Test (Direct or Indirect)
● Percutaneous Umbilical Blood Sampling (PUBS)
● Amniocentesis
Therapeutic Management for Hemolytic Disease of the Newborn
● Early feeding - Phototherapy
● Exchange Transfusion - Blood Transfusion
● Erythropoietin
Phototherapy: Infant’s eyes must always be covered while under _____ lights
bilirubin
Phototherapy: Commercial phototherapy mask or eye coverings must be used at _____ times.
all
Phototherapy: Stools are often _____
Bright green
Phototherapy: Urine may be _____
dark colored
Exchange Transfusion: It should be done under a _____ to keep the infant warm
radiant heat warmer
Exchange Transfusion: _____ must be maintained at room temperature.
Donor blood
Exchange Transfusion: Use only _____ to warm the blood
commercial blood warmers
Exchange Transfusion: The type of blood used for the transfusion is _____ blood.
“O” Rh Negative
Exchange Transfusion: Post transfusion closely monitor vital signs; signs of umbilical vessel bleeding or infection; and _____ levels
bilirubin
Conjunctivitis of the newborn
Ophthalmia Neonatorum
An infection that occurs at birth or during the first month of life, Neisseria gonorrhoeae and Chlamydia trachomatis
Ophthalmia Neonatorum
Assessment for Ophthalmia Neonatorum
● conjunctivae – fiery red, covered with thick pus
● Swollen/Edematous eyelids
Therapeutic Management for Ophthalmia Neonatorum
● IV Antibiotics - Ceftriaxone
● Ophthalmic Solution - Erythromycin
● Lavage
Nursing Management for Ophthalmia Neonatorum
● Keep the eye clean
● Wipe from the inner canthus downward & outward
● Warm moist compress
● Instill medications immediately
Transmitted to the newborn through contact with infected vaginal blood at birth when the mother is positive for the virus (HBsAg+).
Hepatitis B Virus Infection
Infants born to mothers whose HBsAg status is
positive should receive HepB and hepatitis B immune globulin (HBIG), ___ ml, within ___ hours of birth at two different injection sites.
0.5, 12
The vaccine is given intramuscularly in the _____ in newborns or in the _____ for older infants.
vastus lateralis, deltoid
Nursing Management for Hepatitis B Virus Infection
● Infant should be bathed ASAP after birth
● Suction gently
● Immunization
● Breastfeed once HBIG has been administered
Gastrointestinal disease wherein the the bowel
develops necrotic patches, interfering with digestion and possibly leading to a paralytic ileus, perforation and peritonitis.
Necrotizing Enterocolitis
Assessment for Necrotizing Enterocolitis
Distended (often shiny) abdomen
Blood in the stools or gastric contents
Gastric retention
Localized abdominal wall erythema
Bilious vomitus
Diagnostic Evaluation
● Xray (Abdominal)
● Blood Tests
○ CBC
○ Acid Base Balance
○ Electrolytes
● Stool
● Occult Blood Test
Therapeutic Management for Necrotizing Enterocolitis
- Discontinuation of all oral feeding
- Minimal Enteral Feedings
- Breast milk
- Probiotics (Lactobacillus acidophilus and
Bifidobacterium infantis) - Abdominal decompression via nasogastric suction
- Administration of IV antibiotics
- Correction electrolyte abnormalities, acid–base imbalances, and hypoxia
- Replacing oral feedings with parenteral fluids
- Abdominal radiographs
- Surgical interventions - ileostomy, jejunotomy, or colostomy
Nursing Management for Necrotizing Enterocolitis
● Prompt recognition of warning signs
● Vital Signs Monitoring
● Avoid rectal temperature taking
● Undiaper and in supine position
● Nutritional and hydration needs
● Administer antibiotics
● Breast milk
● Infection Control
