High Risk Newborn exam 2

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

< 2500 gms or 5.5lbs

<1500 gms or 3.3lbs

<1000 gms or 2.2lbs

appropriate for gestational age; Small for gestational age ( weight < 10th percentile); Intrauterine Growth restrictions

• S= weight, length and head circumference are all affected
• A= Head circumference is normal but weight is < the 10th percentile

• < 37 weeks;
• > 38 weeks- 42 weeks; 
• >42 weeks

• 1= provides basic newborn care;
• 2= care for infants with moderate- high risk problems;
• 3= provides care for extremely high risk infants

• 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

• Encourage visits
• encourage parent-infant attachment (skin to skin contact-"kangaroo care") 
• Pictures
• Infant toys

• 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

• 50% no etiology
• rupture of membranes accounts for roughly 25-30%
• Maternal complications (some modifiable and some non 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

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

• change in feeding behaviors 
• in activity 
• color (circomoral)
• O2 stats
• vital signs

• 0-3: severe distress
• 4-6: moderate difficulty 
• 7-10: should adapt to extrauterine life

• Apgar score 
• look for congenital anomalies
• birth weight
• gestational age (estimation of maturity)

• assess vitals 
• continuous pulse ox
• I&O 
• Labs 
• O2 therapy
• skin integrity

• arterial catheter 
• umbilical venous catheter

• urine bag
• can obtain urine sampling using cotton ball placed in diaper 
• weigh diapers (1gm=1mL)
• include meds and blood products, every mL counts

• glucose, bilirubin, calcium, hematocrit, electrolyes, blood gases 
• order single blood test to reduce amount of blood drawn

supplemental O2 and assisted ventilation

• 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

• Handwashing 
• minimizing number of people and equipment who come in contact with neonate

• 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

• 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

• PIPP scale 
• increased HR, RR, BP, ICP 
• decreased O2 sats 
• cry, grimace, pain 
• clenched fists

• RTC low does morphine 
• EMLA cream for invasive procedures (numbs the area but constricts vessels 
• concentrated oral glucose solutions

parenteral feedings due to inability to digest formal (minimal enteral feedings)

• 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

• Observe for:
• suck and gag reflex
• sucking on gavage tube
• rooting reflex 
• wakefulness before scheduled gavage feeding 

 

• 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

steroids to stimulate gluconeogenesis or diazoxide given to supress insulin secretion

• hypoxic
• metabolic acidosis 
• hypoglycemia

• may be asymptomatic 
• apnea
• bradycardia
• cyanosis 
• high pitched cry 
• hypotonia/ floppy
• irregular resps
• jitteriness
• lethargy, poor feeding
• seizures 
• tachypnea
• temperature instability

• 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

• 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)

• asymptomatic 
• late signs: tremors twitching seizures
• hyperexcitiblity, irritability 
• high pitched cry, laryngospasm
• tachycardia
• apnea
• EKG changes

• 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

• 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

• 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

• 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

• 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)

• 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

• 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

def: pregnancy exceeds 42 weeks

• 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

• 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

• 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

• observe for hypoglycemia 
• observe for resp distress
• monitor Temp
• Allow skin to slough off naturally; use neutral pH soap only

• 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%