Nursing Care of the Newborn at Risk

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Nursing Care of the Newborn at Risk
2015-04-02 22:35:56

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  1. Nursing Priorities
    if not breathing
    • 1. Initiating and maintaining respiration (if they aren't breathing) visually- is the baby doing what they are suppose to do- we will have to do this for them if not breathing
    • - resuscitation: establish and maintain airway, expand lungs, initiate and maintain effective ventilation
    • - Airway- suction mouth and nose. tracheal suction if meconium is present
    • - lung expansion
    • - Drug therapy (p 817)
    • - ventilation maintenance: observe for incre RR, chest retraction, nasal flaring
  2. ABCD's of newborn resuscitation
    • Airway: sniff position, suction mouth and nose, tracheal suction if meconium not present. if vigorous you don't want to stimulate them bc they are at risk for meconium being in their lungs
    • breathing: positive pressure ventilation (PPV) apnea, gasping (nurse may start to breath for baby), 40-60 breaths per a minute.
    • Circulation: start chest compression if HR < 60 after 30 sec of PPV (3 compression, 1 breath) (usually if we correct respiratory everything goes into place)
    • Drugs: epinephrine if all else fails (like breaths, HR)
  3. Neonatal Asphyxia
    • failure to establish adequate, sustain respirations after birth
    • Pathophysiology: insufficient oxygen delivery to meet metabolic needs. vital organs are deprived of oxygen- delayed transition
    • Nursing assessment: risk factors, color of NB, work of breathing, HR, temperature and APGAR score
    • Nursing management: immediate resuscitation, observation, neutral thermal enviroment, blood glucose levels, parental support and education
  4. newborn priorities
    Circulation, fluid, temp
    • 2. esta extrauterine circulation
    • 3. maintain fluid and electrolytes: hypoglycemia, hypovolemia, dehydration
    • 4. regulating temperature: decre temp can seriously impact heart action, breathing, electrolyte balance
    • - radiant heat source
    • - incubators
    • - kangaroo care
    • (preterm babies do not have any brown fat)
  5. Newborn priorities:
    nutrition, waste elimination, infection
    • 5. establish adequate nutritional intake: gavage feeding to decr metabolic demand)
    • (preterm respiratory distress- don't feed well bc breathing too fast- oxy hood, IV dextrose, gavage feeding)
    • 6. Waste elimination: preterm babies may not void or have meconium within the 1st 24 hr)
    • 7. Preventing infection: cause may prenatal, perinatal, postnatal
  6. New priorities:
    • 8. esta. parent infant bonding
    • provide reassurance, information and confidence
    • - developmental needs: catch up developmentally (depend on how premature they are,¬† preterm babies car seat test)
    • - f/u on high risk infants at home: home care referral, car seat test
    • - preterm infants are at high risk for abuse: mom gets stress, money is an issue, good support for these families, they don't develop bonding
  7. Birth weight Variation
    • AGA (appropriate for gestational age): 80% normal percentile
    • SGA (small for gestational age): 5'8
    • LGA (large for gestational age): bigger than 4000g 8'13
  8. birth weight variation low birth weight
    • low birth weight: infant weighing < 2,500gram or 5.5lbs
    • very low birth weight: infant weighing < 1,500gram or 3'5lbs
    • extremely low: infants weighing , 1,000g or 2'3lbs- usually your 24 week gestational babies
  9. If they are not term?
    • you need to graph them
    • see where their size is...different from gestational age
    • you should graph to see what their needs are and where they are developing ie do they need sugars
  10. Small for gestational age (too small)
    • conditions affecting fetal growth
    • - < 28 weeks leading to overall growth restrictions (never catching up to size0
    • - > 28w intrauterine malnutrition ( normal growth potential with optimal postnatal nutrition)
    • IUGR for some SGA newborns (asymmetric v symmetric) rate of growth does not measure to expected growth pattern may be a pathological cause- baby weight starting to drop- maybe placenta isn't prefusing
    • Contributing factors (see box 23-1)
    • hypertension, what is going on with mom
  11. SGA newborns: Assessment: typical characteristics
    • head disportionately large compare to rest of body
    • wasted appearance of extremities: loose skin
    • reduce subcutaneuos fat stores
    • decrease amt of breast tissue
    • scaphiod abdomen (sunken apprearance)
    • wide skull sutures
    • poor muscle tone over buttocks and cheeks
    • thin umbilical cord
  12. SGA: common problem
    • prenatal aphaxia bc placenta not perfusing
    • hypothermia: not enough brown fat
    • hypoglycemia: low blood sugar bc not enough stored to regulate temp
    • polycemia: high hematocrit >65. blood is thick. hypoxic environment- bc they need more oxygen. more at risk for jaundice bc rbc don't break down. liver not able to conjugate baby stress
    • meconium aspiration: stress
  13. SGA newborns: nursing management
    • weight, length, head circumference measurement
    • serial blood glucose monitoring
    • vital sign monitoring
    • early and frequent oral feeding: IV dextrose 10% if unable to feed or glucose < 40
    • anticipatory guidance: support parents, answer questions, help them adjust
    • monitor for polycethemia
  14. Large for Gestational Age newborns
    • Risk factor for newborns > 4000grams
    • - maternal diabetes or glucose intolerance
    • - multiparity
    • - prior hx of macrosomic infant
    • - post date gestation
    • - maternal obesity
    • - male fetus - tend to be bigger
    • - genetics
  15. LGA assessment common characteristicsq
    • large body plump full face
    • proportionally increase in body size
    • poor motor skills
    • difficulty regulating behavior states
    • lazy, sleepy, difficult to arouse
  16. LGA common problems
    • birth trauma- shoulder dystocia
    • hypoglycemia- bc they don't feed well
    • polycythemia- stress
    • hyperbilrubinemia- extra blood cells you have to break down at risk for jaundice
  17. LGA Newborns: nursing management
    • Vital signs monitoring
    • blood glucose level monitoring
    • initiating oral feedings (feed right away and check bs after feeding)
    • IV glucose supplement as per MD order (wont eat/cant will put them on this)
    • continue monitoring for polycythemia and hypoglycemia
    • hydration
    • phototherapy for increase bilirubin
  18. Birth Trauma
    • issues due to forces of labor and birth
    • Types: fractures of clavicle, brachial plexus injury, cranial nerve trauma (cephlahematoma, caput succedaneum)
    • Nursing assessment
    • - risk factors: c-section macrosomic babies
    • - physical assessment, brusing, moving arms, symmetry of structure or function
  19. Gestational age variation
    • term: born on the 1st 38-42 wk
    • preterm: born before the completion of 37 weeks
    • late preterm: born between 34-36 6/7 (more frequent monitoring bc not enough surfactant)
    • post preterm: born after 42 wk
  20. What if you do not know gestational age
    • use ballard score to tell you how old the baby is
    • posture
    • wrist bends
    • recoil
    • skin
  21. Postterm newborn
    • placenta not able to provide adequate oxygen and nutrition to the baby after 42w
    • dry, cracked, wrinkle skin: possible meconium stained- stressed not prefused
    • long, thin extremities: long nails, creases cover entire soles of feet
    • wide eyed alert expression
    • abundant hair on scalp
    • thin umibical cord
    • limited vernix and lanugo
  22. postterm: common problems
    • perinatal asphyxia: placental deprivation, oligohydraminos
    • Hypoglycemia: aging placenta, hypoxia secondary to depleted glycogen reserves burn Hypothermia: loss of subcutaneous fat second to placenta insufficiency
    • Polycythemia: intrauterine hypoxia triggers increased RBC production to compensate for lower oxygen levels
    • meconium aspiration: commonly associated with chronic intrauterine hypoxia
  23. Postterm: nursing management
    • resuscitation
    • blood glucose level monitoring
    • initiation of feedings: IV dextrose 10%
    • prevention of heat loss
    • evaluation for polycythemia
    • parental support- not the best looking babies
  24. Preterm newborn
    • body system immaturity affecting transition to extrauterine life. incr risk for complication
    • prematurity is now the leading cause of death in the first month of life and second leading cause of all infant deaths
    • respiratory system
    • CV
    • GI
    • renal system
    • immune system
    • CNS
  25. Effects of Prematurity on Body systems: respiratory system
    • insufficient surfactant allows alveoli to collapse each expiration
    • inadequate number and maturity of alveoli
    • unstable chest wall- very careful if you have to bag
    • immature respiratory control centers
    • inability to clear fluid from passages
    • signs of respiratory distress typically develop within 1-2 hr after birth
  26. Effects of prematurity of body systems:
    Cardiac blood flow
    • right to left shunting PDA doesn't close (mixing of blood, deoxy with oxy_
    • fluid/fibrin leak from capillaries
    • hyaline membranes to form in the bronchioles, alveolar ducts, and alveoli
    • also known as bronchopulmonary dysplasia (chronic lung damage)
    • lungs because stiff and non compliant resulting in mechanical ventilation
    • RESPIRATORY DISTRESS SYNDROME- bad cause baby can't breath
  27. effects of prematurity of body systems:
    CV, immune
    • CV
    • - difficult to transition to newborn circulation
    • - risk for fetal pattern circulation may persist, causing blood flow to bypass lungs
    • - rupture of fragile blood vessels in the brain causing intracranial hemmorhage (brain not fully developed)
    • Immune system
    • - defiency of IgG: prevents virus and bacteria. get this at 34wks
    • - thin skin and fragile blood vessels provided limited protective barrier
  28. effects of prematurity of body systems:
    • lack coordination that you need to eat. lack suck and swallow and breathing until 33-
    • 34
    • poor gag and cough reflex
    • perinatal hypoxia causing shunting of blood from the gut to get to more vital organs
    • increase risk of necrotizing enterocolitis (NEC)
    • gavage feedings if can't feed
  29. effects of prematurity of body system: hepatic
    immature liver
    • increase risk for hyperbilirubin- unable to conjugate blood
    • immature production of clotting factor
    • increase risk of hypoglycemia
    • prolonged drug metabolism related to immature liver
    • bruises easily
  30. effects of prematurity of body systems: renal and CNS
    • Renal
    • - decrease GFR
    • - limited ability to clear drugs from their system
    • - risk for fluid retention and electrolyte disturbance
    • CNS
    • - susceptible injury and insult to the CNS
    • - risk for cold stress
  31. effects of prematurity of body systems: temp
    • lack of subcutaneous fat to insulate body
    • large body surfaces area in proportion to body weight
    • small muscle mass
    • absent sweat or shiver mechanism
    • incre insensible fluid loss
    • when they are stressed they burn more brown fat
  32. effects of prematurity of body systems: neuromuscular
    • immature control of vital function
    • increased risk of intraventricular hemorrhage
    • increased risk of apnea
    • poor muscle tone
    • weak or absent reflexes
    • ¬†weak, feeble cry
  33. Preterm assessment
    common characteristics
    • weight < 5.5 small
    • scawny apprearance
    • poor muscle tone
    • minimal subcutaneous fat
    • undescended testes
    • plentiful lanugo
    • poorly formed ear pinna
    • fused eyelids
    • soft spongy skull bones
    • matted scalp hair
    • absent to a few creases over soles and palms
    • minimal scotal rugae
    • prominent labia and clitoris
    • thin transparent skin
    • abundant vernix
  34. preterm common problems
    • hypothermia
    • hypoglcymia
    • hyperbilirubinemia
    • problems related to immaturity of body systems
  35. Preterm nursing management
    • oxygenation
    • thermal regulation
    • infection prevention
    • stimulation
    • pain management
    • growth and development
    • prenatal support: high risk status; possible perinatal loss
    • discharge perparation