Class 11 Nursing care of the High Risk Newborn – Flashcards
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Recognizing the "sick" Neonate
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Perinatal History, Physical Assessment, Diagnostic Data: 1st 28 days is neonatal, after 1 month old is infant, Review history to anticipate problems that may occur
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Perinatal History: Perinatal Fetal Distress
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Abnormal fetal heart rate pattern, meconium staining, PROM, precipitous delivery, Late Decelerations occur, Risk for asphyxia
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Perinatal History: Cesarean Delievery
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Done due to: breech, fetal distress, placenta previa/abruptio, CPD, Failure to progress, Risk for asphyxia
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Neonatal Physical Assessment "Red Flags"
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Appearance/skin: Pale, Cyanotic, mottled (sign of cold stress, poor perfusion) Respiratory: Tachypnea, etc Cardiovascular: Abnormal heart sound CNS: Hypertonic/hypotonic muscle tone Morphology: cogenital anomaly, asymmetry GI: abdominal distention, Excessive Mucous emesis
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Diagnostic Data
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Decrease oxygen saturation not above 90% ABG, Hypoglycemia, Decrease H&H, Septic work-up (look at WBC), X-ray and ultrasound
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What can affect or influence the neonate's size
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Hypertension can affect lungs, maternal thyroid, diabetes, nutritional status, age of mother
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Small for Gestational Age (SGA)
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Birth weight less that 10th percentile for weight for weeks of gestation on growth chart
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SGA: Symmetric IUGR
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Involves entire body, weight, height and head circumference all fall below 10th percentile Causes: Chromosomal/congenital anomalies, infections or drugs early in pregnancy, hand to catch up with growth, affects life
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SGA: Asymmetric IUGR
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Weight less then 10th percentile, height and head circumference normal (can catch up to growth) Late onset in pregnancy; assoc. with poor nutrition, preeclampsia Causes: placental insufficiency, maternal smoking, increase BP, poorly controlled diabetes Usually in 3rd trimester, Brain and heart size normal just not growing well
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Problems of SGA infants
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Risk of perinatal asphyxia due to chronic low levels of oxygen in utero, respiratory difficulties, more prone to meconium aspiration, hypoglycemia not enough nutrients for placenta, polycythemia increase RBC, increase viscosity, more sluggish, clotting; temp instability, has brown fat to generate heat once used they lose it
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SGA/IUGR Appearance
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"wasted" appearance (suckin in abd) Small amount of sub q tissue Meconium stained skin, nails, and cord Minimal amount of breast tissue, loose dry skin that appears oversized, sparse scalp hair, alert, wide eyes (assoc with intruterine hypoxia) Thin, limp umbilical cord, appearance varies depending on early/late
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Nursing Care SGA
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Priority diagnoses: Ineffective thermoregulation, risk for injurt due to hgypoglycemia, risk for imbalance nutrition: less than body requirements Goal: Infant will maintain stable temp, gain weight, normal glucose Priority Interventions: Assess temp, maintain neutral thermal environment, assess for hypoglycemia, daily weights
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Large for gestational Age (LGA)
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Birth weight above the 90th percentile for weeks of gestation on growth chart Causes: Genetics (certain ethnic groups and large parents), Maternal diabetes or glucose intolerance, prior history of macrosomia
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LGA Appearance
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Large body and appears plump and full-faces May have evidence of birth trauma: Soft tissue injuries: bruising, cephalhematoma, Skeletal injuries: fractures, Nerve damage: brachial plexus, facial
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Risk for LGA Infants
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Increase incidence dystocia (leading to delivery by cesarean birth or use of vacuum or forceps) Hypoglycemia due to abrupt withdraw of glucose Polycythemia due to prolonged second stage Jaundice due to bilirubin breakdown product of RBC If preterm, risk for RDS If postterm risk for MAS
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Late Preterm
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New category: #5-37 weeks baby is born, usually in well baby, won't want to feed
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Preterm Infant
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Born before the completion of 37 weeks gestation Prematurity is leading cause of death within first month of life and 2nd leading cause of all infant deaths Early born, greater chance of complications
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Risk factors for preterm Birth
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Maternal Infections, AMA, Multi-gest, poly/oligohydraminos, poor maternal nutrition, substance abuse, smoking, preeclampsia hypertension, previous preterm delivery
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Preterm infant Appearance
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Tone: Flaccid, Skin: Thin, transparent with visible weints Minimal sub q fat Presence of Lanugo, esp over face and back Abundant vernix, sole/palm creases: absent to few Head: large in proprotion to body Ears: Poorly formed pinna with soft pliable cartilage
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Preterm Infant physical problems
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Respiratory due to lungs last to develop Cardiovascular (Murmur shunt not closed) Thermoregulation Hypoglycemia Fluid/ Electrolyte imbalances Infection Neurologic (hypotonia, weak cry/ suck) Dematologic Developmental/Behavioral
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Management of the Preterm Infant (after one month)
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Goals of care and intervention: Support transition to extrauterine life, support resp, maintain neutral thermal environment, maintain fluid/electrolyte balance, prevent complication
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Management of Preterm Neonate (about a month)
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Multidisciplinary approach, involves parents, assess for signs of bonding and attachment Nursing Diagnosis: Risk for impaired attachment, bonding, parenting
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Post term infant
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Infant born beyond 42 weeks gestation, 12% of pregnancies Higher mortality rate than infants born at term, May be SGA, LGA or "dysmature" (weight less than established normal parameter for estimated Gestational Age)
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Problems of post term infant
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Meconium, Aspiration, increase uterine stress, Perinatal asphyxia, hypoglycemia, birth trauma, inadequate temp regulation due to loss of sub q fat, Dermatologic (skin more wrinkled, drying)
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Post term neonate appearance
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Wide-eyed, aleart (assoc. with intrauterine hypoxia), dry cracked, loose, wrinkled, peeling skin, creases that cover entire soles of feet, abundant hair on scalp, long fingernails,. little or no vernix and lanugo, meconium-stained skin, cord and nails is common
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Management of Post term neonate
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Support transition to extrauterine life: resp support if needed, assess for signs or symptoms of post maturity, birth injury, if large, hypothermia, monitor glucose levels, signs or symptoms of hypoglycemia, early feedings
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Transient Tachypnea of the Newborn (TTN)
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Condition of rapid resp caused by retained lung fluid, 1-2% of all live births, most commonly seen in babies with elective c-section, narcotics
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Transient tachypnea Newborn Care
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Starts at birth, Self-limiting; resolves within 1st 3 days of life, diagnosed by x-ray (hyperexpansion and increase lung fluid), supportive measures until infant reabsorb fluid)
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TTN Assessment findings
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Tachypnea (increase 60 BPM) Grunting (expiratory) Nasal Flaring, barrel shaped chest, mild intercostal retraction, possible mild cyanosis
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TTN Management or interventions
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Supplemental oxygen therapy (oxyhood, plastic shell), IV therapy, continuous monitoring, Thermoregulation, ABG's (acidosis), Gavage/ enteral feeds if Resp is less than 60
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Meconium Aspiration Syndrome (MAS)
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Seen in term and post term infants, Hypoxic event in utero causes anal sphincter to relax releasing meconium into amniotic fluid, Meconium obstructs glottis, trachea, and smaller airways either partially or completely when inhaled in utero or when infant takes 1st breath after birth
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What occurs in MAS
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Fetal Asyphyxia leads to Peristalsis and relaxation of anal sphincter= meconium in amniotci fluid=subsequent fetal hypoxia=gasping fetal respirations=aspiration of meconium
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MAS signs and Symptoms
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Mild: tachypnea, Cyanosis, Rales/Rhochi Moderate: Grunting, Nasal flaring, retractions CXR shows patchy in filtrates unevenly distributed thru out lungs, overdistended barrel-shaped chest Auscultation of lungs decreases air movement with rales and rhonchi Light Meconium: some degree of resp problem but resolve easily Thick meconium: more profound effect, increase risk of serious problems
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MAS Management
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Suction, Supplemental oxygen, more severe the MAS, the more likely the neonate will need to be on a ventilator, Chest PT: Gently percussion to lossen, Continuous monitoring for complication, thermoregulation, cold stress Outcomes/Prognosis: Mild=excellent, Severe=neurological deficits or death
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Infection or sepsis
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Major cause of neonatal death during 1st month of life, Group B streptococci and E.coli causes most early onset sepsis
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Transmission with Infection/sepsis
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Vertical: Transplacental, ascending, intrapartum examples: CMV, GBS, Chlamydia Horixontal: Hospital acquired infection (Nosocomal infection), Example Staph
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Clinical Manifestation of Sepsis
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"just doesn't look right" Poor feeding, vomiting, abdominal distention, lethargic or irritable; hypotonia; temp instability (most commonly hypothermia); decrease oxygen saturation; decrease peripheral perfusion (poor color, duskiness, cyanosis), Tachypnea, glucose instability, tachycardia initially followed by apnea/bradycardia spells
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Diagnostic Data for Neonatal Sepsis
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WBC: range varies widely-NOT HELPFUL, LOOK AT CBC DIFF, NEUTROPENIA (<1500/mm3), needed to eat up bacteria, most accurate predictor of infection, low neutrophil and high band count indicate infection present, C-reactive protein (Inflammation marker), Cultures urine, blood, lumbar puncture
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Nursing Care for Infection/ Sepsis
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PREVENTION!! Strict handwashing, control environment, early assessment and advocacy; atraumatic diagnostic testing, antimicrobial therapy, respiratory support, thermoregulation, glycemic control
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Risk factors for developing neonatal Infection
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Premature Baby, SGA, stressed, Prolonged Labor, PROM, Mom with infection during Labor
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Hyperbilirubinemia Incidence
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Affects 60-70% of term/late preterm infants in 1st weeks of life and virtually all preterm infants have, manifested by jaundice, leading cause of hospital readmissions in 1st 2 weeks of life
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Sources of Bilirubin
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75-80% of bilirubin is from the breakdown of the RBC, new born has more RBC's per kg/body weight, Lifespan of neonatal RBC is shorter than that of adult, Newborn jaundice results from imbalance in rate of bilirubin production and bilirubin elimination, Liver helps process bilirubin does not function well due to not fully developed, placenta not functioning
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2 Forms of Bilirubin: Conjugated Direct
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Water-soluble, easily excreated in urine and Stool, nontoxic form, needs to be in this form to be removed
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2 Forms of Bilirubin: Unconjugated Indirect
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Fat Soluble, Toxic to body tissues, it can more easily cross blood=brain barrier but is harder to eliminate, bilirubin TOXIC
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Factors that increase hyperbilirubinemia
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Hemolysis of excessive erythrocytes, Short fetal RBC Life, Liver immarturity, Lack of Intestinal Flora at birth, Delayed feeding or delayed meconium passage, Birth Trauma leading to bruising, cephalhematoma, Fatty acids from cold stress, asphyxia
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Neonatal Risk factors for Hyperbilirubinemia
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Birth trauma: Cephalhematoma, bruising, instrumental delivery; excessive weight loss after birth; infections: TORCH; infrequent feedings; male gender; polycythemia; prematurity' previous sibling with hyperbilirubinemia
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Maternal Risk Factors for Hyperbilirubinemia in Newborns
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Blood type ABO or Rh incompatibility, Breastfeeding, Drugs: Diazepam, Oxytocin, due to high dose and long term, Ethnicity: asian, native american; Maternal illness, gestational diabetes
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Physiologic Jaundice
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Nonpathological or developmental jaundice FULL TERM INFANT: Appears after 24 hours (usually 2nd or 3rd day of life), Peaks in 3-4 days after discharge if vaginal delivery PRETERM INFANT: Appears at same time or later after 48 hours, peaks in 5-7 days at 8-12 mg/dl
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Normal Physiologic Jaundice
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Typically begins on head and progresses downward, Jaundice of face occurs at 5-7mg/dl
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Pathological Jaundice
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Jaundice appears within 1st 24 hours of life, factors interfering with bilirubin conjugation that may lead to toxic levels without treatment, concern of kernicitas, if baby is not feeding well sits in baby and becomes fat soluble
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Treatment based on Bilirubin Levels
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After 24 hours bilirubin greater than 15 phototherapy is needed
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Nursing care for the Infant Receiving Phototherapy
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Thermoregulation, eye covering, monitor irradiance, skin and eye care, turn frequently, hydration and nutrition, Monitor Bilirubin Levels, Parent teaching
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Infant of a diabetic Mother Fetal Complications
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Macrosimia (>4000g), IUGR with maternal microvascular disease, Birth injury, resp distress syndrome, hypoglycemia, hypocalcemia, polycythemia, hyperviscosity, hyperbilirubinemia, congenital anomalies, cardiomegaly
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Nursing care of the IDM
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Assess for Resp Difficulty, complications, trauma, anomalies, signs or symptoms hypoglycemia, Monitor for BG at birth every 2-4 hours until stable about 40mg/dl, feeding immediately via oral or feeding tube, thermoregulation
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Hypocalcemia
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less than 7.0mg/dl Associated with other disorders such as IDM, prematurity, LBW, asphyxia Signs or symptoms are irritability, tremors, poor feeding, high pitched cry, tachycardia, apnea, muscle twitching, seizures Treatment: early feedings, monitor Ca levels, oral or IV calcium gluconate, give with feedings can cause GI upset, bradycardia (take HR)
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Neonatal Alcohol Withdrawal
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Onset birth 12 hours, Sign or symptoms are tremors, hypertonia, weak suck and poor feeding, opithotonos, poor sleep, cry more, exaggerated mouth movements
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Fetal Alcohol Syndrome Clinical Manifestations
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Microcephaly Facial Anomales: SHort palpebral fissures, flat mid face, smooth philtrum, thin upper lip, intercanthal folds Low birth weight, impaired fine motor skills
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FAS Nursing Care
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Assess and prevent strategies, Post-natal careful assessment, document head circumference, length and birth weight, exam facial features, neuro exam signs or symptoms of withdrawal, genetic consultation, family counseling, parent skills class
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Signs of intrauterine drug exposure
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Irritability, Jitteriness, tremors, seizures, GI dysfunction, regurgitation, vomiting, diarrhea, tachypnea, apnea, yawning, sneezing, nasal stuffiness, poor feeders but suck continuously, high pitched cry, difficult to console, increase muscle tone, muscular rigidity, fever, diaphoresis, mottling
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Phenylketonuria (PKU
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Autosomal recessive disorder of amino acid metabolism, lack liver enzyme, Phenylalanine accumulates in blood Clinical Manifestations: Musty-smelling urine, vomiting, poor feedings, irritability, eczema when left untreated leads to mental retardation
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Screening For PKU
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Blood sample (Gunthrie Test) At least 48 hours of feeding (to ensure adequate intake of protein) If screening performed at only 24 hours repeat within 2-3 weeks
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Treatement for PKU
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Special Formula, Low protein diet for life, Avoid aspartame (equal/ nutrasweet), monitor levels of phenylalanine (between 2-8 mg/dl) greater than 10mg causes mental retardation; less than 2 mg causes growth retardation, Life long dietary restriction of phenylalanine
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Developmental Dysplasia of the Hip
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Incidence higher in females, first borns, breech Treatment success increase if done before 2 months old assessment use Ortolani's Signs
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Treatment of DDH
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X-ray, Psychosocial support, Pavlik harness 0-6 months keeps hips in flexion, realigns hip over 3-6 months Hip spica cast for severe deformity or late discovery, braces or splint after cast/ harness parent ed-use deviced, skin care, diapering
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Talipes Equinovarius (Club Foot)
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Assessment and recognition, Treatment with manipulation and serial casting surgery, Nursing Care is Cast Care (Neurovascular checks),. family Support
