High Risk Neonatal Nursing Care- 17 Flashcards
Very premature:
Neonates born at less than 32 weeks’ gestation
Premature
Neonates born between 32 and 34 weeks’ gestation.
Late premature
Neonates born between 34 and 37 weeks’ gestation.
Low birth weight
Less than 2,500 g at birth
Very low birth weight:
Less than 1,500 g at birth
Extremely low birth weight:
Less than 1,000 grams at birth
Types of risk factors
nonmodifiable risk factors-things you can’t change
Treatable/modifiable factors- things you can change.
Symmetric IUGR,
generalized proportional reduction in the size of all structures and organs except for heart and brain, occurs early in pregnancy and affects general growth.
Asymmetric IUGR
disproportional reduction in the size of structures and organs, results from maternal or placental conditions that occur later in pregnancy and impede placental blood flow.
IUGR
intrauterine growth restriction
Neonates with IUGR are at risk
● Labor intolerance
● Meconium aspiration related to asphyxia during labor.
● Hypoglycemia
● Hypocalcemia
IUGR s/s
● Large head in relationship to the body.
● Long nails.
● Large anterior fontanel.
● Decreased amounts of Wharton’s jelly present in the umbilical cord.
● Thin extremities and trunk.
● Loose skin due to a lack of subcutaneous fat.
● Dry, flaky, and/or meconium-stained skin. ●size below 10th percentile ● RDS can occur ● polycythemia ● hypothermia
large for gestational age (LGA)
has a weight above the 90th percentile
LGA risk factors
● Maternal diabetes
● Multiparity
● Previous macrosomic baby
● Prolonged pregnancy
LGA at risk for
● Cesarean births.
● Operative vaginal delivery.
● Shoulder dystocia.
● Breech presentation.
● Birth trauma.
● Cephalopelvic disproportion.
● Hypoglycemia.
● Hyperbilirubinemia.
Hyperbilirubinemia
increased levels of bilirubin in the blood
Physiological jaundice
results from hyperbilirubinemia that commonly occurs after the first 24 hours of birth and during the first week of life.
physiological characteristics of the neonate place it at risk for physiological jaundice:
● Increased RBC volume
● RBC life span of 70 to 90 days, compared to 120 days in adults
● High bilirubin production (6 to 8 mg/kg/day)
● Neonates reabsorb increased amounts of unconjugated bilirubin in the intestine
● Decreased hepatic uptake of bilirubin from the plasma
● Diminished conjugation of bilirubin in the liver
Physiological Jaundice s/s
●Physiological jaundice is typically visible after 24 hours of life.
● Total serum bilirubin levels generally peak on day 3 of life in term neonates and on days 5 or 6 in preterm neonates
● Jaundice is characterized by a yellowish tint to the skin and sclera of the eyes.
● As total serum bilirubin levels rise, jaundice will progress from the newborn’s head down toward the trunk and lower extremities.
Pathological Jaundice
results when various disorders exacerbate physiological processes that lead to hyperbilirubinemia of the newborn
Pathological Jaundice s/s
● Jaundice that occurs within the first 24 hours of life
● Total serum bilirubin levels that increase by more than 5 mg/dL per day
● Jaundice lasting more than 1 week in a term newborn or more than 2 weeks in a premature neonate day
● Risk factors, medical management, and nursing actions are similar for both physiological and pathological jaundice.
side effects of phototherapy:
● Eye damage
● Loose stools
● Dehydration
● Hyperthermia
● Lethargy
● Skin rashes
● Abdominal distention
● Hypocalcemia
● Lactose intolerance
● Thrombocytopenia
● Bronze baby syndrome: Dark gray-brown pigmentation of skin that disappears after phototherapy is discontinued.
Phototherapy
most widely used and effective treatment for hyperbilirubinemia.
CNS injuries risk factors
● Prematurity
● Birth trauma
● Breech delivery or other malpresentations
● Precipitous labor
● Difficult labor, traumatic delivery, and use of forceps
● Hypoxia, asphyxia, hypotension, ischemia, respiratory distress.
SUBDURAL HEMORRHAGE
Tear of the dura overlying the cerebellum or cerebral hemispheres.
SUBARACHNOID HEMORRHAGE
Intracranial hemorrhage into the cerebrospinal fluid–filled space between the pial and arachnoid membranes on the surface of the brain.
Most common neonatal intracranial hemorrhage.
INTRACEREBELLAR HEMORRHAGE
Hemorrhage in the cerebellum from primary bleeding or from extension of intraventricular or subarachnoid hemorrhage into the cerebellum.
Occurs more commonly in preterm, LBW neonates.
CNS injury nursing actions
● Review maternal prenatal and intrapartal histories for risk factors.
● Perform physical assessment of the neonate, including evaluation of tone, reflexes, and behavior.
● Maintain respiratory support as needed.
● Obtain laboratory tests as per order.
● Ensure that ordered diagnostic tests are completed.
● Assist with diagnostic procedures such as lumbar puncture.
● Administer medications as per order.
● Manage neonates receiving cooling therapy.
● Provide the family with support and information
Complications of high maternal levels of glucose during pregnancy are:
● Congenital anomalies
● IUGR, perinatal asphyxia, and SGA
● Neurological damage and seizures
● Risk of childhood obesity and type 2 diabetes
DIABETIC MOTHERS s/s
● Macrosomia
● Fractured clavicle and/or brachial nerve damage
● Hypoglycemia
● Hypocalcemia and hypomagnesemia
● Polycythemia
● Hyperbilirubinemia
● Low muscle tone
● Poor feeding abilities
● Respiratory distress
DIABETIC MOTHERS nursing actions
● Assess neonate for signs of respiratory distress, birth trauma, congenital anomalies, hypoglycemia, hypocalcemia, polycythemia, and hyperbilirubinemia.
● Monitor blood glucose per agency protocol.
● Provide early and frequent feedings to treat and prevent hypoglycemia.
● Obtain laboratory tests as per orders.
● Maintain a neutral thermal environment to reduce energy needs.
Infections
the immune system of a neonate is immature, placing the infant at risk for infection during the first several months of life
Transplacental transfer
Infection is transmitted to the fetus through the placenta
Ascending infection
Infection ascends into the uterus related to prolonged rupture of membranes.
intrapartal exposure:
The neonate is exposed to infection during the birth process (e.g., herpes virus).
Horizontal transmission (nosocomial infection) is transmitted from hospital equipment or staff to the neonate
Group B Streptococcus (GBS)
primary cause of neonatal meningitis and sepsis in the United States.
All pregnant women should be routinely screened for vaginal and rectal GBS colonization at 35 to 37 weeks’ gestation.
GBS s/s
● Leukocytosis: An elevated white blood cell (WBC) count (greater than 25,000/mm3)
● Leukopenia: A low WBC count (lower than 1,750/mm3)
● Neutrophilia: Increased neutrophil count
● Neutropenia: Decreased neutrophil count (less than 1,500/mm3) is strongly predictive of infection.
● An immature to total neutrophil ratio greater than 0.20 is suggestive of infection.
● Thrombocytopenia: Platelet count below 100,000/mm3 can be related to viral infection or bacterial sepsis
GBS nursing actions
● Assess maternal and neonatal histories for factors that may place a neonate at risk for infection
● Monitor vital signs, I&O, and weight.
● Assess neonate for signs of infection
● Provide respiratory support as needed.
● Monitor glucose and electrolytes.
● Obtain laboratory tests as per order.
● Assist with diagnostic tests such as lumbar puncture for CSF.
● Administer antibiotics as per orders.
● Administer feedings, intravenous fluid, and parenteral nutrition as per orders.
● Utilize standard precautions.
● Provide parents with information
Signs of Neonatal Withdrawal
- Apnea
- Behavior irregularities
- Diarrhea
- Dysmature swallowing
- Excessive crying
- Excessive/frantic sucking
- Excoriated skin
- Fever
- High-pitched cry
- Hyperreflexia
- Hypertonia
- Irritability/restlessness
- Lacrimation
- Nasal congestion
- Poor feeding
- Seizures
- Skin mottling
- Sleep problems
- Sneezing
- Sweating
- Tachypnea
- Tremors
- Vomiting
- Wakefulness
- Weight loss or failure to gain weight
- Yawning
Neonatal abstinence syndrome (NAS)
group of signs and neurological behaviors exhibited by neonates resulting from the abrupt discontinuation of intrauterine exposure to various substances, including heroin, nicotine, alcohol, cannabis, opiates, cocaine, and methamphetamines
Signs of FAS
● Distinctive facial features: Small eyes, thin upper lip, and short nose.
● Heart defects.
● Joint, limb, and finger deformities.
● Delayed physical growth, both intrauterine and postbirth.
● Vision problems.
● Hearing problems.
● Mental retardation.
● Behavior disturbances
FAS
wide spectrum of physical, cognitive, and behavioral abnormalities associated with maternal alcohol use during pregnancy
Alcohol-related neurodevelopmental disorder involves abnormalities of the central nervous system and include:
● Neurological problems (e.g., poor hand-eye coordination and fine motor skills, and neurosensory hearing loss).
● Decreased cranial size, brain abnormalities.
● Cognitive and behavioral problems
FAS nursing actions
● Review maternal history, including risk factors of substance use and history of current or past substance use.
● Assess the neonate, including gestational age.
● Assess for congenital anomalies and physical and behavioral signs of withdrawal/neonatal abstinence syndrome.
● Monitor vital signs.
● Obtain toxicology screening as per order.
● Use a scoring tool to assess for signs of withdrawal on neonates who are at high risk for neonatal abstinence syndrome
● Care for neonates experiencing neonatal abstinence syndrome
● Allow the neonate to rest during feedings.
● Position the neonate upright during feedings.
● Utilize nipples that have a slower flow if the neonate has a strong, frantic suck.
● Utilize gavage feedings if the neonate is unable to organize a productive su
● Care for the mother of a neonate with neonatal abstinence syndrome:
● Provide nonjudgmental, honest, supportive care.
● Teach what to expect in regard to the neonate’s behavior. Educate about strategies that will provide comfort to her infant during withdrawal.
● Teach her how to feed her infant.
