High Risk Neonate

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High Risk Neonate
2013-10-26 11:46:53
High Risk Neonate

High Risk Neonate Care
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  1. What are some common complications of the SGA newborn?
    • 1. Asphyxia
    • 2. Aspiration Syndrome
    • 3. Hypothermia
    • 4. Hypoglycemia
    • 5. Polycythemia
  2. When a mother has been diagnosed with Gestational diabetes, what are some complications the newborn experiences?
    • 1. Hypoglycemia
    • 2. Hypocalcemia
    • 3. Hyperbilirubinemia
    • 4. BirthTrauma
    • 5. Polycythemia
    • 6. Respiratory Distress Syndrome
    • 7. Congenital birth defects
  3. What at the clinical manifestations of Fetal Alcohol syndrome?
    • 1. Abnormal structural development of CNS dysfunction (ie: mental retardation, microcephaly and hyperactivity) 
    • 2. Growth deficiencies- Head and linear growth most affected
    • 3. Distinctive facial abnormalities-short palpebral fissures; epicanthal folds, broad nasal bridge, flattened midfacies, short, upturned or beaklike nose, abnormal small lower jaw
    • 4. Associated anomalies- primarily septal and valvular defects, optic nerve hypoplasia, conductive and sensorineural hearing loss, kidneys and congenital dislocated hips. 
  4. What are the symptoms an infant with FAS (Fetal Alcohol Syndrome) may present during the first week of life?
    • 1. sleeplessness
    • 2. excessive arousal states
    • 3. inconsolable crying
    • 3. abnormal reflexes
    • 4. hyperactivity with little ability to maintain alertness and attentiveness to environment
    • 5. jitteriness
    • 6 abdominal distention
    • 7. exaggerated mouth behaviors (ie; Hyperactive rooting and increased non-nutritive sucking. 
    • 8. Seizures are common
  5. What is the goal when caring for a drug dependent  newborn?
    • Care of the drug dependent newborn is based on reducing withdrawal symptoms and promoting adequate respiration, temperature and nutrition. 
    • 1. Perform neonatal abstinence scoring per hospital protocol
    • 2. Monitoring temperature for hypothermia
    • 3. Carefully monitoring pulse and respiration every 15 minutes until stable; stimulation is apnea occurs
    • 4. Proper positioning on the right side lying or semi-fowlers to avoid possible aspiration of the vomitus or secretions 
    • 5. Administering medications as ordered, such as oral morphine, tincture of opium, and paregoric 
    • 6. Monitory frequency of diarrhea and vomiting and weight infant every 8 hours during withdrawal 
    • 7. Swaddling with hands near mouth to minimize injury and help achieve a more organized behavioral state (offer pacifier for non-nutritive, excessive sucking. Gentle, vertical rocking can be successful in calming an infant who is out of control). 
    • 8. Protect face and extremities by using mittens and soft sheets or sheepskin. 
    • 9. Place newborn in a quiet, dimly lit area in the nursery.
  6. Explain the difference between physiological and pathological hyperbilirubinemia.
    Physiological- appears after the 1st 24 hours, happens most often in infants who are: Low birth weight, Newborns of diabetic moms, and newborns with feeding difficulties after birth

    Pathlogic= worse; appears during the 1st 24 hours of life with levels rising at a rapid rate. Associated with hemolytic disease such as: RH incompatibility, ABO incompatibility
  7. Infants who require oxygen at birth are at risk for this eye condition.....
    Retinopathy of Prematurity
  8. List some of the recommendations nurse teach parents  to avoid SIDS.
    • 1. Have infant sleep on back
    • 2. Avoid the use of loose bedding, toys, and pillows.
    • 3. Use a sleeper rather than a blanket
    • 4. Use a firm mattress
    • 5. Do not expose to tobacco smoke
    • 6. Do not overheat
  9. What is Bronchopulmonary Dysplasia?
    • Its diagnosed when the infant has been on supplemental oxygen for at least 28 days after birth.  
    • This can lead to atelactasis and hyperexpansion. 
    • Requires positive pressure ventilation
  10. Identification of a High Risk Neonate
    • Low socioeconomic levels
    • Limited access to care or no prenatal care
    • Exposure to toxic chemicals or illicit drugs
    • Maternal conditions
    • Maternal age or parity
    • Medical conditions associated with pregnancy:
    • Abruptio placentae, oligohydraminos, preterm labor, PROM, preeeclampsia 
  11. Nursing care for High Risk Neonate:
    • Depends on observing physiologic status
    • Must be directed towards:
    • 1. Decreasing physiologically stressful situations
    • 2. Observing for subtle signs of change in clinical condition. 
    • 3. Conserving infants energy for healing and growth
    • 4. Providing developmental stimulation and maintenance of sleep cycles 

    • Smaller than 90% of babies
    • May be preterm, term or post term
    • Commonly seen with mothers who smoke or have high blood pressure
  13. Intrauterine Growth Restriction (IUGR)
    Advanced gestation and limited fetal growth

    This describes the fetus in the womb NOT the same as SGA
  14. How to resuscitate a newborn
    • 1.Initial steps in stabilization (warmth, positioning, clearing the airway as necessary, drying, stimulating, and repositioning)
    • 2. Oxygen administration 8L/min 40% O2 unless in crisis then 100% O2.
    • 3. Positive pressure ventilation
    • 4. Chest compressions
    • 5. Administration of epinephrine, volume expansion or both
  15. Respiratory Distress Syndrome (RDS)
    The result of a primary absence, deficiency or alteration in the production of sulfactant
  16. Respiratory Distress Syndrome (RDS)
    Two main risk factors

    Surfactant deficiency disease
  17. Respiratory Distress Syndrome (RDS) 
    Who is at risk?
    • 1. Preterm infants- born before lungs are fully developed or inefficient for gas exchange
    • 2. Low birth weight infants-usually have interrupted development of surfactant 
    • 3. Infants of Diabetics mothers- lecithen pathways may not mature as rapidly
  18. Respiratory Distress Syndrome: Clinical Signs
    • 1.Pallor or mottling
    • 2. Central Cyanosis
    • 3. Tachypnea "rapid breathing"
    • 4. Nasal flaring
    • 5. Expiratory grunting
    • 6. Retractions
    • 7. Hypercapnia
    • 8. Respiratory acidosis
    • 9. Hypotonia and diminished response to stimulie
  19. Respiratory Distress Syndrome (RDS)
    How can the nurse reduce stress on the Respiratory system?
    • Keep warm
    • Monitor RR
  20. Respiratory Distress Syndrome: 

    Does this occur immediately after birth or in a few hours?
    immediately after birth
  21. Transient Tachypnea of the Newborn
    Excess fluid in the lungs; Newborns will usually experience little or no difficulty at the onset of breathing, however, shortly after birth they will begin grunting, flaring, mild cyanosis, and tachypnea. 

    • Keep baby NPO
    • Clears up completely within 48 to 72 hours
  22. What causes Transient Tachypnea of the Newborn?
    They may have had intrauterine or intrapartal asphysia caused by maternal over sedation, maternal bleeding, prolapsed cord, breech birth, or maternal diabetes. The newborn then fails to clear airway of lung fluid, mucus and other debris or an excess of fluid in the lungs caused by aspiration of amniotic or tracheal fluid occurs more in c-sections
  23. What is the respiratory rate for a newborn experiencing Transient Tachypnea?
    Tachypnea presents by 6 hours of age, respiratory rates consistently greater than 60 breaths/min.
  24. What causes Meconium Aspiration to occur?
    Meconium stained fluid may be aspirated into the tracheobronchial tree in utero or during the first few births taken by the newborn. The syndrome primarily affects term, SGA, post term newborns and those who have experienced a long labor
  25. What causes Intrauterine Growth Restriction?
    • Maternal factors
    • Maternal disease
    • Environmental factors
    • Placental factors
    • Fetal factors
  26. What is Large for Gestational Age (LGA)?
    Birth weight is at or above the 90th percentile

    They are more difficult to arouse to a quiet alert state

    They can have more difficulty feeding
  27. What is a well know condition that is associated with excessive fetal growth?
    Gestational Diabetes
  28. What are the risk factors for a LGA newborn?
    • Genetic predisposition
    • Multiparous women
    • Male infants
  29. Complications of LGA
    Birth trauma--shoulder dystocia

    Increased incidence of C-sections and oxytocin induced births

    Hypoglycemia (most common in IDM)
  30. Infant of a diabetic mother (IDM)
    • Close observation the first few hours
    • Typical IDM (poor control) is LGA
    • Macrosomic,ruddy
    • Excessive adipso (fat) issue
    • Umbilical cord is thick and placenta is large
  31. Complication of IDM
    • Hypoglycemia 
    • Hypocalcemia-d/t low blood sugars
    • Hyperbilirubinemia
    • Birth trauma
    • Polycythemia d/t hypoxia
    • Respiratory Distress Syndrome- less mature lungs
  32. Hypoglycemia in infants
    Blood glucose level <40mg/dl

    Most common disorder 

    • Risk factors: 
    • IDM
    • SGA/Premature
    • Cold stress infants
    • Mothers who received an epidural during labor
  33. Hypoglycemia in infants: Goal Therapy
    • Assess and identify infants at risk
    • S/S: Lethargy, jitterness, poor feeding, respiratory distress, seizures, high pitched cry
  34. Hypoglycemia in infants: Prevention 

    Initiate early feedings and reduce stressors Maintain Norma-thermic environment hypoglycemia continues...to NICU for IV fluids---glucose IV 

    *****Keep baby calm 
  35. Hypoglycemia in infants
    • Routine Screening
    •    Glucometer 
    •    IStat or serum blood glucose-can obtain          blood sample by a heel stick
    • Initiate early feedings (within 1 hour of birth or IV glucose)
  36. Nursing Management for Post term
    • Assess for:
    • Hypoglycemia
    • Respiratory issues d/t hypoxia
    • Polycythemia
    • Cold Stress

    • Interventions: 
    • Support and educate parents (include in plan of care and be available)
    • Encourage early/frequent feedings
    • Promote respiratory function (elevate HOB, suctioning PRN) 
    • Provide nonmothermic environment (KEEP BABY WARM) 
  37. Nursing Management of Preterm
    • Assess for:
    • Cardiovascular/ Respiratory Issues--ductus arterious which doesnt close right at times
    • Ability to suck and swallow (huge problem) gavage feeding which prevents aspiration
    • Cold stress
    • Alterations in Hydration status

    • Interventions: Provide developmentally supportive care ( skin to skin)
    • Promote respiratory function
    • Strict interventions to prevent infection (3 minute scrub prior to visiting infant) 
    • Parental or gavage feeding 
    • Provide normothermic environment--KEEP BABY WARM!!! 

    • Sudden unexpected death during sleep 
    • under 1 year of age 
    • No explanation
    • Multiple risk factors: Table 48-2 p. 1320
  39. SIDS Nursing Management
    • Be supportive
    • Empathetic
    • Support groups
    • Help get siblings in touch with their emotions

    • Prevention--promote Back to Sleep
    • avoid unnecessary stuff on the crib

    **Encourage time time--->great for neck, head and shoulders***
    • Effects of unhealthy intrauterine environment 
    •     Exposure to teratogens

    Insufficient uteroplacental circulation

    Inadequate nutrition

    • Exposures to stressors can lead to:
    •     IUGR, Congenital anomalies and preterm       birth
  41. Fetal Distress
    Asphyxia--Results in circulatory, respiratory, & biochemical changes

    Goal ---> identify those at risk so resuscitation can begin ASAP

    • Assessment--
    • Apgar score of what? APGAR <7 Bad, >7 APGAR good  
    • Meconium in amniotic fluid
    • Priority Nursing Diagnosis
    • Nonreassuring fetal heart rate
    • Difficult; traumatic birth
    • Unresponsive apneic episodes
    • inadequate ventilation
    • SGA
    • Congenital anomalies of lungs and/or heart
    • Prematurity
    • Cardiac event
    • Multiple births
    • Male infants
  43. Asphyxia Interventions
    • As soon as the baby is born:
    • quickly dry and stimulate the baby
    • Suction secretions
    • KEEP BABY WARM!!! 
    • Assess the need for respiratory/cardiac resuscitation 
    • ****As always, proceed from simple noninvasive procedures to more complex, invasive procedures
  44. Meconium Aspiration Syndrome
    • Happens when baby inhales meconium 
    • Occurs in 18-29% of all pregnancies
    • Sticks to the airway and aveoli
    • **Suctioned from the airways before the infant draws their 1st breath

    Nurses monitor the amniotic fluid for meconium
  45. Meconium Aspiration
    Etiology- Asphyxia

    Assessment- late decels-->hypoxic environment, meconium aspiration, barrel chest, yellowish/greenish baby

    Interventions- suction, head down position, radiatent warmers, O2 prn/possible vent
  46. Metabolic complications: Hyperbilirubinemia
    Jaundice-develops from the deposit of bilirubin in the skin**usually starts from face to feet***

    Normally the placenta clears unconjugated (indirect) bilirubin in utero, therefore at birth it usually <3mmg/dl

    After delivery, the neonates liver must start to conjugate bilirubin 

    Most neonates can do this well, but those who do not develop hyperbilirubinemia
  47. Metabolic complications Hyperbilirubinemia: Prevention
    • Prevention
    • Initiate early, frequent feedings
    • This stimulates the gastriocolic reflex and facilitates bowel elimination-->remember bilirubin is excreted in the stool!! 

    Administer Rhogam to all the unsensitized (those with negative indirect coombs) mothers who are RH negative after delivery of the baby
  48. Metabolic complications Hyperbilirubinemia--Phototherapy
    • Draw frequent bili levels
    • No ointments or lotion on skin
    • Keep baby undressed with diaper on
    • Keep eyes covered with bili mask
    • Frequent feedings
    • Observe stool--> will be bright green
  49. Neonatal infections---Sepsis
    Infants are susceptible to infection because of their immature immune system

    **Hypoglycemia can indication infection

    • S&S--
    • Behavioral changes "not doing well"
    • Lethargy and irritability

    • Color changes: pallor, cyanosis
    • Temperature instability-
    • Hypothermia
    • Skin is cool and clammy

    • Poor feeding- most common sign of sepsis
    • Apnea or respiratory distress
  50. Risk Factors of Sepsis
    • Maternal factors: 
    • Low economic status 
    • Poor prenatal status
    • Poor nutrition
    • Substance abuse
    • GBS carriers
    • STD's
    • Intrapartum Risk factors:
    • ROM later than 18 hours 
    • Maternal fever 
    • Chorioamnionitis 
    • Prolonged labor
    • Premature labor 
    • Maternal UTI
  51. Risk factors for Sepsis: Newborn
    • Neonatal risk factors: 
    • Twin gestation
    • Male 
    • Birth asphyxia
    • Meconium aspiration
    • congenital anomalies
    • absence of spleen
    • Low birth weight or prematurity (Nasocromial infections 15% high risk situations)
    • Prolonged hospitalizations
  52. Neonatal Effects of Commonly abused substances
    • Alcohol 
    • Cocaine
    • Heroin, Amphetamines, Tobacco
    • Marijuana
    • Prescription drugs

    Goal of caring a drug dependent newborn: to reduce withdrawal symptoms and promote adequate respiration  temperature and nutrition 
  53. Neonatal Effects of commonly abused substances--S&S
    • Irritability 
    • Disturbed sleep pattern
    • Tremors
    • Frequent sneezing
    • Shrill high pitched cry
    • Convulsions
    • Yawning
    • Hiccups
    • Gazed aversion
  54. Nursing care for Neonate of Commonly abused substances
    • Monitor: 
    • Vital Signs
    • Medications
    • I&O, weight

    • Aspiration Precautions: 
    • Place infant in a side laying position
    • Feeding in a sitting position with the chin down
    • Swaddle in a flexed position
    • Offer pacifier
    • Introduce 1 stimuli at a time when infant is quiet, alert state
  55. NICU Care
    • Provide supportive environment
    • Birth of child requiring NICU care elicits the grief response in parents
    • Promote a positive nurse/parent relationship
    • Support parents for initial visits to the newborn..AGAIN...LOVER FOR THE POSITIVES!
    • Explain equipment and assist the parents in understanding the need for interventions
    • Facilitate attachment--skin to skin
    • Promote interaction ASAP