Newborn at Risk Flashcards by Jess St John

Weight <2500g (5.5lbs)

low birth weight (LBW)

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Weight <1500g (3.3lbs)

very low birth weight (VLBW)

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Weight <1000g (2.2lbs)

extremely low birth weight (ELBW)

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Neonatal resuscitation is __________ focused

Neonatal resuscitation is respiratory focused. Not cardiac.

Babies are respiratory driven.

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Weight below the 10th percentile for age

SGA: Small for gestational age

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Weight between the 10th and 90th percentile for gestational age

AGA: Appropriate for gestational age

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Weight above the 90th percentile for gestational age

LGA: Large for gestational age

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SGA Characteristics

Wasted muscle tissue
Lack of brown fat
Scaphoid abdomen (sunken in)
Eyes appear large, “wise old man” look
Long fingernails
Meconium-stained thin cord often present

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Conditions affecting SGA newborn

Cold stress/temperature instability- prolonged hypothermia with no brown fat reserves
Pain- if life-saving interventions indicated (ex. IV’s), they may be painful
Hypoglycemia- due to muscle wasting and low brown fat
Polycythemia- venous hematocrit ≥ 65% Red Baby!

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LGA Characteristics

May be genetically large
More commonly exposed to imbalance of nutrients in utero

Ex. Infant of a diabetic mother

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Conditions affecting LGA newborn

Hypoglycemia- chronic hyperglycemia in utero due to elevated maternal glucose levels (uncontrolled GDM)

Hypocalcemia- calcium levels should be > 7.5 mg/dL in preterm newborns and 8 mg/dL in term newborns. Low calcium levels can produce seizures in the newborn and may be present along with hypoglycemia

Birth injuries- one of two types: neurological injuries or bone fractures

Brachial plexus injuries (BPI)- occur when the nerves are stretched and leave the arm without function

Fractures- involve the clavicle, or long bones of the humerus or femur

Transient tachypnea of the newborn (TTN)- delayed clearance of fetal lung fluid

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LGA newborns & shoulder dystocia

Nerve damage/paralysis:
-Brachial plexus injury (affects upper arm)
-Erb’s Palsy (affects upper and lower arm)
-Klumpke’s Palsy (affects hand and possibly eyelid on contralateral side)

Most completely recover. Follow up w/ therapy.

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Born before 37 weeks

preterm

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Born between 37-41 weeks

term

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born on or over 42 weeks

post-term

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-Born after 42 weeks’ gestation (3-14% of all pregnancies)
-Most are of normal size and healthy, may or may not be LGA
-Large fetus may have a difficult time passing through birth canal
-Potential problems: cephalopelvic disproportion and shoulder dystocia

post-term newborn

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Post-term complications

Polycythemia (red baby!)
Meconium aspiration
Oligohydramnios
Congenital anomalies
Seizures
Hypoglycemia
Cold stress

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Baby gets stressed during birth and poops, inhales meconium which is sticky and blocks airways/atelectasis develops (collapse portions/entire lung) leading to hypoxia

meconium aspiration

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Post-term assessment findings

Dry, cracked skin without vernix or lanugo
Long fingernails
Profuse scalp hair
Long, thin body with loose skin and nonexistent fat layers
Meconium staining, tinting the nails, skin, and umbilical cord green

Preterm newborn - systems affects

· Resp: surfactant deficiency
· Thermogenesis: Low. No brown fat > insensible H2O loss
· Gastrointestinal: poor oral feedings, high caloric needs
· Renal: Low GFR, bad kidneys
· Immune: no passive IgG antibodies
· Neuro: brain bleeds and delayed reactivity

Preterm newborn complications

intracranial hemorrhage, respiratory distress syndrome, apnea of prematurity, anemia of prematurity, retinopathy of prematurity, necrotizing enterocolitis

Related to rapid birth and birth trauma

Fragile blood vessels in highly vascularized areas

Can cause changes in activity level, seizures, decreased HCT, full anterior fontanelle

intracranial hemorrhage (ICH)

Lack of surfactant and underdevelopedalveoli

Atelectasis with congestion and edema in lung spaces

S/S: grunting, retractions, nasal flaring, cyanosis, tachypnea, decreased breath sounds, respiratory acidosis, apnea

Respiratory distress syndrome (RDS)

Spontaneous pause in breathing that can be accompanied by pallor, hypotonia, cyanosis, bradycardia, O2 desaturation

Continuous cardiorespiratory and O2 saturation monitoring

Treat with caffeine

Apnea of prematurity

Due to multiple blood draws, rapid growth, and erythropoietin release Assess HCT level, blood transfusions, replace erythropoietin

Anemia of prematurity

Due to immature retinal vasculature followed by hypoxia Can lead to blindness The longer O2 exposure the higher the risk Wean off O2 as soon as possible (limit amount of O2) Prevent O2 fluctuations Routine checks by an ophthalmologist

Retinopathy of prematurity (ROP)

Due to an ischemic bowel episode, might see bloody stools Check abdominal circumference, bowel sounds, stool hematest, stool frequency, stop feedings immediately

Necrotizing enterocolitis (NEC)

Nursing care of preterm newborn

Maintain respiratory function Maintain thermoneutral environment Balance fluids and electrolytes Provide adequate nutrition Prevent infection Promote parent-infant attachment

Hyperbilirubinemia: Yellow discoloring of the skin and sclera Newborns produce more bilirubin than adults do because of greater production and faster breakdown of red blood cells in the first few days of life. Normally, the liver filters bilirubin from the bloodstream and releases it into the intestinal tract. A newborn's immature liver often can't remove bilirubin quickly enough, causing an excess of bilirubin.

Jaundice

Risk factors for jaundice

bruising, neonatal hypoxia, congenital infection, Rh incompatibility, inadequate oral intake Encourage feeding with human milk to encourage stooling

Complications of jaundice

Kernicterus – bilirubin in the basal ganglia Cerebral palsy Developmental delays Hearing loss/perceptual impairment Delayed speech development Hyperactivity Muscle incoordination Learning difficulties Death

-Can occur if the mother is Rh negative or has blood type O -Rh incompatibility (erythroblastosis fetalis) Rh-negative mother Rh-positive fetus -Maternal antibodies cross the placenta and destroy fetal red blood cells -Treated with RhoGAM around 28 weeks

Hemolytic Disease of the Newborn

Med that stops your blood from making antibodies that attack Rh-positive blood cells.

RhoGAM

O mother A or B fetus Results in jaundice Rarely results in severe hemolytic disease

ABO Incompatibility

-Incidence: 55-95% of substance exposed infants become symptomatic -Withdrawal: depending on substance of choice and its half-life, withdrawal can become evident between 6 hours to 8 days of life -Increased risk of premature delivery, low birth weight, microcephaly (small head), long term cognitive/behavioral problems Substances: cocaine, heroin, methadone, oxycodone, fentanyl, buprenorphine, Xanax Withdrawal signs/onset vary depending on substance

Neonatal abstinence syndrome (neonatal opioid withdrawal syndrome) NAS/NOWS

Signs of withdrawal Neurological Excitability

-Irritability -High, pitched crying -Excessive/continuous crying -Difficulty sleeping -Tremors (disturbed and undisturbed) -Excoriation -Exaggerated Moro -Hypertonicity -Myoclonic jerks -Excessive sucking -Seizures

Signs of withdrawal Autonomic Dysregulation

Tachypnea Nasal flaring Increased RR Stuffiness Hyperthermia Sweating Sneezing Mottling Yawning

Signs of withdrawal GI dysfunction

Diarrhea --> diaper rash Hyperphagia Regurgitation Vomiting Poor feeding

Scoring tool for NAS/NOWS

-Finnegan -Eat, sleep, console (ESC)

Treatment goals of NAS/NOWS

Relieve signs of withdrawal Improve feeding & weight progress Prevent seizures Mitigate poor neurological outcomes

Blood infection in infants younger than 90 days old

sepsis Early-onset sepsis – first week of life Late-onset sepsis – between days 8 and 89

-Acquired while the infant is in the NICU -Two most common: MRSA & Candida -Related to invasive procedures and the infant's immature immune system -Presents as sepsis, UTIs, meningitis, or pneumonia -Preventing infections: WASH HANDS, clean phones, no jewelry, do not visit if sick

Nosocomial Infections

S/Sx of sepsis

Respiratory distress Lethargy or irritability Hypotonia Pallor, duskiness, or cyanosis Cool and clammy skin Temperature instability Feeding intolerance Hyperbilirubinemia Tachycardia followed by apnea/ bradycardia

Tx of sepsis

Control the infant's environment Prevent the spread of infection Antibiotic treatment -Broad-spectrum before septic workup -Specific antibiotics after workup Physiologic supportive care Encourage parental interaction

-Typically diagnosed in utero -Intestines herniate through abdominal wall -Monitor color of bowel (should be beefy red) -Omphalocele: covered by sac -Keep abdominal contents sterile -Positioned in silo above the defect to reduce over a few days -Give fluids, antibiotics, surgical repair -pain management

Gastroschisis

End of Life Care

Palliative care Home with hospice care Lift visitor restrictions Pain management Spiritual/religious care Memory boxes/keepsakes Organ donation Grief support for parents Let parents be involved w/decisions May need ethics committee involved