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Define 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 weight or gestational age
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Describe the classifications for high risk infants
- Low Birth Weight (LBW): less than 2500 grams (5.5lbs)
- VLBW: <1500grams (3.3 lbs)
- ELBW: <1000grams
- AGA: appropriate for gestational age
- SGA: wt<10th percentile
- IUGR: symmetric (wt, length, HC all affected) or asymmetric (HC is normal but Wt is not)
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Define preterm, term, and postterm
- Premature: <37 complete weeks gestation
- Full term: 38-42 weeks gestation
- post-term: >42 weeks
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Describe the 3 levels of care for newborns in the NICU
- Level 1: provides basic care
- Level 2: care for infants with moderate to high risk problems
- Level 3: provides care for extremely high risk infants
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If a newborn needs to be transported from one facility to another, what is the best way to do so?
- Its best to transport the pregnant mother prior to delivery
- Sick neonates transported in isolette or warmer via ambulance, helicopter or airplane
- Care is provided by team of nurses, physicians, and resp therapists
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Define fetal mortality, neonatal mortality, and perinatal mortality
- Fetal mortality: total # of deaths of fetus past 20 wks gestation
- Neonatal Mortality: total number of deaths within the first 27 days of life per 1000 live births
- Perinatal Mortality: total number of fetal and early neonatal deaths (1st seven days of life) per 100 live births
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Name newborn complications that necessitate care in the NICU
- Perinatal asphyxia
- Meconium aspiration
- Respiratory distress
- Birth injuries
- Transient tachycardia
- Prematurity
- Postmaturity
- Hydrocephalus
- Sepsis
- Seizures
- Necotizing entercolitis
- Meningitis
- Congenital heart disease
- Congenital birth defects
- Congenital infection
- Substance Abuse withdraw
- Hyperbilirubinemia
- Intestinal obstruction
- Endocrine disorders
- Inborn errors of metabolism
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How can you promote newborn development while in the NICU?
- Encourage visitation
- Encourage parent-infant attachment
- Pictures of family/parents
- Infant toys
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What complications is a premature newborn at risk for due to underdeveloped organ systems?
- Respiratory: system lacks surfactant and is compromised by small muscle mass and immature nervous system, leading to atelectasis
- Brain: susceptible to hemorrhage and anoxia
- GI: lacks enzymes for protein and Vit K metabolism.
- Immune system: weak and susceptible to infection
- Reflex: suck reflex is absent, weak, or ineffective leading to the need for gavage feeding
- Cardio: difficult maintaining BP, renal perfusion, and oxygenation
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What can cause preterm labor leading to the premature newborn?
- Maternal DM
- HTN & preeclampsia
- Placenta Previa
- Placenta Abruptio
- Maternal Infection
- 50% of preterm births have no etiology
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What subtle changes should the nurse be aware of for a high risk newborn?
- feeding behaviors
- activity
- color
- O2 Sats
- Vital signs
- Increased physiological stress can cause death if not corrected within minutes
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What initial assessments are done at birth?
- Apgar score (know the breakdown)
- Congenital Anomolies
- Birth weight and gestational age assessment (ballard)
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What are the expected newborn vital signs?
- Apical pulse for 1 full minute:
- Pulse ox:>94%
- BP: 50-60/25-35(monitored by arterial catheter or umbilical venous catheter (observe for blanching in buttocks, genitalia, legs, feet))
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How can I/O be done on a newborn?
- Weigh diapers, 1 gm= 1ml
- Can obtain sample with sample bag or well placed cotton ball
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Why is a neutral thermal environment important for a newborn and how can you promote thermoregulation?
- Cold stress causes 02 consumption leading to resp distress and hypoglycemia as well as metabolic acidosis
- Baby should have thermo sensor when in incubator to maintain temp
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What are nosocomial infections of the newborn directly related to?
- Number of infections increase with the number of persons in contact with the newborn and the equipment
- HANDWASHING IS KEY!!!
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Why is hydration important and what is the newborn at risk of with IV fluids?
- Neonates are vulnerable to both dehydration and fluid overload, therefore IVs and PICCs lines need to be monitored hourly
- Infiltration of hypertonic solutions could cause severe tissue damae
- Monitor for CHF and pulmonary edema as well as tachypnea, crackles in the lungs, and periorbital edema
- When taking I/O, be sure to include all meds and blood products because every ml counts!!
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What are some ways to maintain skin integrity for the newborn?
- Assess the skin frequently as it is thin and fragile
- Bathe every 2-3 days with pH cleansers
- Do not remove the vernix
- Cleanse eyes, oral, and diaper areas daily
- Decrease use of adhesives
- Do not use alcohol and remove iodine after all procedures
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How can you assess pain in a newborn? What are some s/s of pain and how is it managed?
- Assess using the PIPP scale:
- Increase in vitals
- Decrease in O2 sats
- Cry/high pitched cry
- Groan or grimace
- Clenched fists
- Pain is managed by: RTC lose doses of morphine, EMLA cream for invasive procedures, concentrated oral glucose solution
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How do newborns receive nutrition?
- Babies of VLBW will receive parenterel nutrition due to the inability to digest
- Babies cannot breast feed if they lack the suck and swallow reflexes
- Babies may bottle feed if they can suck, swallow, and finish feed within 30 minutes (to reduce energy expenditure)
- If the baby is being gavage fed, the placement should be checked q4. Residuals should be checked and replaced with each feeding. Feeding is by the flow of gravity. Be sure to place 1-2 drops of milk in mouth during gavage feeding and provide oral stimulation
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What are some signs of readiness for bottle feeding for a newborn who has been fed by gavage?
- suck and gag reflex (sucking on the gavage tube)
- Rooting reflex
- Wakefulness prior to scheduled gavage feeding
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What causes hypoglycemia in the neonate? What are the risk factors?
- Limited glucose stores due to limited fat and decreased liver enzymes
- Increased demand for glucose
- Risk factors include: maternal diabetes, sepsis, shock, perinatal asphyxia, and delay of feeding
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What bs indicated neonatal hypoglycemia? What is intractable hypoglycemia and how it is treated?
- <40mg/dl
- Intractable hypoglycemia is not preventable
- Treated with steroids tostimulate gluconeogensis or diazoxide give to suppress insulin secretion
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What are the clinical manifestations of hypoglycemia in the newborn?
- Asymptomatic
- ApneaBradycardia
- Cyanosis
- High pitched cry
- Hypotonia
- Irregular respirations
- Jitteriness
- Lethargy, poor feeding
- Seizures
- Tachypnea
- Temperature instability
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What nursing care can be done for a neonate with hypoglycemia?
- IV glucose if bs i very very low
- Feeding the infant if the bs is moderately low, then monitor glucose in response to feeding
- Decrease stressors such as cold stress and resp distress
- Initiate feedings asap in healthy infants
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Why is a neonate at risk for hypocalcemia? What levels indicate hypocalcemia in the newborn?
- Results due to inadequate storage of calcium
- Total serum calcium <7.0 in preterm infant for <7.8 in full term infant
- Preterm of stressed infant may have prolonged hypocalcemia
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What are the manifestations of hypocalcemia in the neonate?
- Asymptomatic
- Tremors, twitching, seizing (late signs)
- Hyperexcitibility, irritability
- High pitched cry and laryngospasm
- Tachypnea
- Apnea
- EKG changes
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What nursing care can be provided for a neonate with hypocalcemia?
- Parenteral and oral calcium gluconate
- Initiation of feedings will raise levels
- Cardiac Monitoring
- Decrease stimuli that may precipitate seizure activity
- Offer pacifier and provide quiet environment
- Observe for s/s of hypercalcemia (vomiting, bradycardia, arrhythmias)
- *for any infant that is jittery or twitching, get the blood glucose and calcium levels!!!
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What causes neonatal sepsis and how is it diagnosed?
- Occurs when bacteria or other endotoxins gain access to blood stream, causing systemic signs and symptoms (usually acquired prenatally)
- early sepsis: 1-3 days of age
- late sepsis: 1-3 weeks of age
- diagnostic eval: CBC, urinalysis, CSF, H/H
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What are the clinical manifestations of neonatal sepsis?
- Early s/s may be vague and non-specific (look for small changes!)
- Increase or decrease in HR, RR, BS
- Decrease in B/P
- Irreg respirations, grunting, retractions
- pallor or cyanosis, lethargy, seizures
- Abdominal distention; enlarged liver and spleen
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What nursing care can be provided for a neonate suffering from sepsis?
- SUPPORTIVE CARE
- O2, fluids, electrolyte balance, monitor temp
- D/C oral feedings until stabilized
- HOURLY Urine output
- Monitor for development of DIC- serial platelet counts and maintain hemat >40
- Thermoregulation
- Observe and assess for response to treatments
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What is Retinopathy of Prematurity (ROP)
- Retina vessels constrict in response to hyperoxemia, and this leads to necrosis
- RISK when neonates are on O2 therapy and Sats rise above 97%
- Progressive vascular growth of the retina leads to eventual blindness from scar formation and retinal detachment
- ALL PREMATURE INFANT who received supplemental O@, were <35 wks gestation, or weighed <1800 grams at birth need an opthalmologic evaluation for ROP
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What nursing care can be done to encourage development, especially between 34-36 weeks for the premature newborn?
- Dim the lights
- Bring photos of parents
- Cluster care to provide at least 50 minute of undisturbed sleep
- Sin to skin/kangaroo care with parents
- decrease stimulation
- QUIET environment (yacker tracker)
- co-bedding of twins
- Provide firm boundaries to substitute for swaddling and provide secure feeling (similar to being in utero)
- 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 milk under nose
- Pacifier dipped in breast milk offered during gavage feedings
- Non-nutrituve breast feeding to promote sucking and attachment to mother
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What are signs of stress in the neonate?
- Tachypnea
- Mottled, dusky, pale
- Hiccups gagging, choking
- Tremors, startles, twitches
- Fluctuating tone or high pitched cry
- Arm or leg extensions
- Floppy (hypotonic)
- Hyperextension of neck
- Arching of Back
- Restlessness
- Physiologic instability
- Grimacing
- Clenching of fists
- Disorganized states
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What is the postmature (42 wks+) infant at risk of?
At risk for problems due to placental dysfunction secondary to compromised blood flow: nutritional deficiency and hypoglycemia, hypoxia & asphyxia, IUGR, loss of subcut fat leading to hypothermia, loss of vernix and macerated skin, passage of meconium due to inadequate O2 to the digestive system leading to meconium staining or aspiration
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What are the clinical manifestations of a post term newborn?
- growth retardation
- dehydration
- dry, cracked, wrinkled, parchment like skin
- Long, thin arms and legs with hanging skin folds due to loss of subcut fat
- Long fingernails
- Advanced hardness of skull
- No vernix or lanugo
- Macerated skin
- Meconium staining
- Hyperalertness or apprehension
- possible seizure activity if stressed during birth
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What therapeutic management and nursing care can be done for the post term infant?
- 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 caused by dehydration
- Observe for s/s of hypoglycemia
- Observe for s/s of resp distress
- Monitor temp
- Allow skin to slough off naturally; use neutral pH soap only
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