What is the definition of the "high risk newborn" Any neonate who is in danger of serious illness or death as a result of prenatal, perinatal or neonatal condition regardless of birth weigh or gestational age What classifies a baby as "low birth weight?" < 2500 gms or 5.5lbs What classifies a baby as "very low birth weight?" <1500 gms or 3.3lbs What classifies a baby as Extremely low birth weight?" <1000 gms or 2.2lbs What does AGA stand for? SGA? IUGR? appropriate for gestational age; Small for gestational age ( weight < 10th percentile); Intrauterine Growth restrictions What is symmetric IUGR? Asymmetric? S= weight, length and head circumference are all affected A= Head circumference is normal but weight is < the 10th percentile Gestational age: what is considered preterm according to Gosling? full term? post term? < 37 weeks; > 38 weeks- 42 weeks;  >42 weeks what kind of care does the level 1 nursery provide? level 2? level 3? 1= provides basic newborn care; 2= care for infants with moderate- high risk problems; 3= provides care for extremely high risk infants What is the best way to transport a newborn from one facility to another? If possible, it is more desirable to transport the baby when still in utero;  sick neonates are transported in isolette or warmer via ambulance, helicopter, or airplane care is provided by a team of nurses, physicians and respiratory therapists How can the nurse promote development in a newborn older than 34 weeks? Encourage visits encourage parent-infant attachment (skin to skin contact-"kangaroo care")  Pictures Infant toys Prematurity is dangerous because it affects all organ systems. What complications occur? Resp: it lacks surfactant is compromised by small muscle mass and immature nervous system   Brain: susceptible to hemorrhage and anoxia Cardio: difficulty maintaining blood pressure, renal perfusion, and oxygenation  GI: lacks enzymes for protein metabolism; suck reflex is absent weak or ineffective Immune: deficient; increased risk for infection What is the pathophys of preterm births? 50% no etiology rupture of membranes accounts for roughly 25-30% Maternal complications (some modifiable and some non modifiable) What maternal complications dealing with preterm birth are modifiable? unplanned pregnancy, single, low education, poverty (or unsafe environment), domestic violence, life stress, number of implanted embryos in assisted fertility, low pre-pregnancy weight, obesity, incompetent cervix, GU infections, infections, periodontal disease, substance/alchoal abuse, long hours of employment/standing, late or no prenatal care, air pollution, and some health issues (HTN, diabetes, anemia, clotting problems What maternal complications dealing with preterm birth are non-modifiable? Previous preterm, multiple abortions, race/ethnic group, uterine/cervical anomaly, multiple gestation, polyhydramnios, oligohydramnios, PIH, placenta previa (after 22 weeks), DES exposure, short interval between pregnancies, abruptio placenta parity (0 or >4), premature ROM, bleeding in first trimester The subtle changes that the nurse should look for in the high risk newborn? change in feeding behaviors  in activity  color (circomoral) O2 stats vital signs what does an Apgar of 0-3 mean? what does an Apgar of 4-6 mean? what does an Apgar of 7-10 mean? 0-3: severe distress 4-6: moderate difficulty  7-10: should adapt to extrauterine life what should the initial assessment include? Apgar score  look for congenital anomalies birth weight gestational age (estimation of maturity) What is the therapeutic management for the preterm neonate? assess vitals  continuous pulse ox I&O  Labs  O2 therapy skin integrity how do you monitor BP in the preterm? arterial catheter  umbilical venous catheter how do you measure I&O in newborns/preterms? urine bag can obtain urine sampling using cotton ball placed in diaper  weigh diapers (1gm=1mL) include meds and blood products, every mL counts Most common labs in the neonate? glucose, bilirubin, calcium, hematocrit, electrolyes, blood gases  order single blood test to reduce amount of blood drawn What is the nursing care for adequate oxygenation? supplemental O2 and assisted ventilation What is the nursing care for thermoregulation? maintain neutral thermal environment with incubators and warming units maintain a core temp with minimal 02 consumption with minimal caloric consumption  avoid clod stress attach thermo sensor to infants abdomen while in incubator how does the nurse prevent nosocomial infections in the neonate? Handwashing  minimizing number of people and equipment who come in contact with neonate Nursing care for maintaining adequate hydration? Iv's, PICCs must be monitored hourly (infiltration of hypertonic solutions could cause severe issue damage)  monitor for CHF, and pulmonary edema (tachypnea, crackles in lungs, and periorbital edema I&O How does the nurse maintain skin integrity? assess daily, bathe every 2-3 days with neutral pH cleansers do not remove vernix cleanse eyes, oral, and diaper areas daily use adhesives as minimally as possible  remove iodine after procedures  no alcohol assess for breakdown ( blanchable skin on buttocks, genitalia, legs or feet)  use transparent dressings to arms, elbows, knees use sheepskin or gel beds  use emolients free of preservatives dyes and perfumes  NO adhesive remover How does the nurse assess pain in the neonate PIPP scale  increased HR, RR, BP, ICP  decreased O2 sats  cry, grimace, pain  clenched fists Pain management in the newborn RTC low does morphine  EMLA cream for invasive procedures (numbs the area but constricts vessels  concentrated oral glucose solutions How does the very low birth weight infant feed? parenteral feedings due to inability to digest formal (minimal enteral feedings) When is breast milk indicated? Bottle feed? Gavage feed? Breast milk: if there is adequate suck and swallow reflexes; if not return to orogastric tube Breast milk feedings Bottle: only if able to suck, swallow and breath simultaneously and complete feeding in 30 minutes( if taking longer, too much wasting of energy)  Gavage: used when oral feeding is not safe syringe; with OG tube, through mouth; check residuals and replace; flow by gravity. place 1-2 drops of milk in mouth during feeding; providing oral stimulation How to determine readiness for bottle feeding; Observe for: suck and gag reflex sucking on gavage tube rooting reflex  wakefulness before scheduled gavage feeding    How is Hypoglycemia defined in the premature neonate? why is it caused? Risk factors? Diagnostic used? def: abnormally low blood sugar in the neonate; <40mg/dL  cause: access to glucose is limited due to the immature liver enzymes (can't metabolize food) or there is an increase demand for glucose risk factors: maternal diabetes, sepsis, shock, perinatal asphyxia, delay of feedings  Diagnostic: heel stick How do you treat intractable hypoglycemia? steroids to stimulate gluconeogenesis or diazoxide given to supress insulin secretion What are the complications of cold stress? hypoxic metabolic acidosis  hypoglycemia What are the clinical manifestations of hypoglycemia may be asymptomatic  apnea bradycardia cyanosis  high pitched cry  hypotonia/ floppy irregular resps jitteriness lethargy, poor feeding seizures  tachypnea temperature instability what is the nursing care for hypoglycemia IV glucose for very low glucose level feeding infant for moderate level  monitor glucose in response to feeding decrease stressors: cold stress, respiratory distress initiate early feedings in healthy infant reassess for hyperglycemia How is hypocalcemia defined? def: serum calcium < 7.0 (in a premie) or < 7.8 in full term infant cause: results from inadequate store of calcium (preterm or stressed infant may have prolonged hypocalcemia) What are the clinical manifestations of hypocalcemia asymptomatic  late signs: tremors twitching seizures hyperexcitiblity, irritability  high pitched cry, laryngospasm tachycardia apnea EKG changes Nursing care for infants with hypocalcemia parental and oral calcium gluconate  initiation of feedings will raise levels  cardiac monitor  decrease stimuli (that may cause seizure)  offer pacifier and provide quiet environment  observe for s/s of hypercalcemia: vomiting, bradycardia, arrythmias  Any infant who is jittery or twitching get blood glucose and calcium levels! reassess for hypercalcemia How is neonatal sepsis defined? Def: systemic infection  Cause: occurs when bacteria or their endotoxins gain access to the blood stream; usually prenatally acquired early sepsis: 1-3 days of age Late sepsis: 1-3 weeks of age   Diagnostic: cultures of blood, urine, CSF, CBC H&H  Treatment: aggressive antibiotic therapy what are the clinical manifestations of Neonatal sepsis? Early signs: vague (resp or GI symptoms) could be increased or decreased temperature, HR, RR, and BS decresed BP irregular breathing, grunting, retractions pallor or cyanosis, lethargy or seizures  poor feeding, vomiting and diarrhea abdominal distention, enlarged liver or spleen What is the nursing care for neonatal sepsis? Supportive Care:  O2, fluids/electrolyte balance, temperature D/C oral feedings until stable hourly urine output monitor for development of DIC (serial platelet counts and maintain hematacrit > 40) thermoregulation observe and assess response to treatment ( report changes in resp status, muscle tone, feeding intolerance, and temp How is Retinopathy of Prematurity (ROP) defined? In response to hyperoxemia, retina vessels constrict which leads to necrosis that may eventually cause blindness from scar formation and retinal detachment progressive vascular regrowth of retina ( all premature infants who received supplemental oxygen, were <35 gestation or weighed <1800 grams at birth need and ophthalmologic evaluation for ROP) What can the nurse due to aid in developmental care (in babies 34-36 weeks) Dim lights/photos/decrease stimulation sleep 50 mins undisturbed kangaroo care QUIET environment  co-bedding of twins provide "nesting" play soft music for short periods of time flexion position, with hands to face at midline  sling hammock avoid quick movements cotton ball dipped in breastmilk under nose/pacifier dipped in milk during gavage non-nutritive breast feeding what are signs and symptoms of stress in the neonate? Tachypnea mottled, dusky, pale hiccups, gagging, choking, yawing tremors, startles, twitches  fluctuationg tone arm or leg extension  floppy hyperextension of neck arching of back (severe stress)  diffuse activity; restless physiologic instability  grimacing  clenching of fists  disorganized states how is postmaturity defined? def: pregnancy exceeds 42 weeks Postmaturity places the newborn at risk for problems due to what? what are those complications? placental dysfunction secondary to compromised blood flow complications:  nutritional deficiency  hypoxia and asphyxia  growth retardation ( not enough nutrients from placenta) loss of subQ fat which leads to wrinkles Loss of vernix which leads to macerated skin passage of meconium due to inadequate O2 to digestive system What are the clinical manifestations of Postmaturity? growth retardation  dehydration  dry, cracked, wrinkled, parchment-like skin  long thin arms and legs with hanging skin folds long fingernails advanced hardness of skull  no vernix or lanugo  macerated skin meconium staining of skin hyperalertness or apprehension  possible seizure activity if stressed during birth what is the therapeutic management of post maturity? Respiratory support/ ventilation  monitor calcium levels, hematocrit, blood sugar  aggressive management of fluids and nutrition to avoid further weight loss  partial exchange transfusions may be necessary due to polycythemia Nursing care of post mature neonate observe for hypoglycemia  observe for resp distress monitor Temp Allow skin to slough off naturally; use neutral pH soap only what are the healthy newborns normal vitals? Temp- 97.7 before first bath; stabilizes at 98.6 Pulse- 125-190 RR- (no less than 30) 30-40 (up to 60) BP- 70/50 (1.5 in cuff)  O2-95-100%