Nursing Care of a Family With High-Risk

Newborn
High-Risk Newborn
• DYSMATURE INFANT – infant born before term or
postterm, or who is underweight or overweight for
gestational age
• GESTATIONAL AGE - number of weeks an infant
remained in utero
 Nine priority areas of care for any newborn:
1. Ineffective airway clearance related to presence of mucus or amniotic fluid in
airway
2. Ineffective cardiovascular tissue perfusion related to breathing difficulty
3. Risk for deficient fluid volume related to insensible water loss
4. Ineffective thermoregulation related to newborn status and stress from birth
weight variation
5. Risk for imbalanced nutrition, less than body requirements related to lack of
energy for sucking
6. Risk for infection related to lowered immune response in newborn
7. Risk for impaired parenting related to illness in newborn at birth
8. Deficient diversional activity (lack of stimulation) related to illness at birth
9. Readiness for developmental care to decrease overstimulation easily caused by
necessary life-saving procedures
 Expected outcomes include:
• Infant maintains a patent airway.
• Infant tolerates all procedures without accompanying apnea.
• Infant demonstrates growth and development appropriate for
gestational age, birth weight, and condition.
• Infant maintains body temperature at 98.6° F (37.0° C) in open
crib with one added blanket.
• Parents visit at least once and make three telephone calls to
neonatal nursery weekly.
• Parents demonstrate positive coping skills and behaviors in
response to newborn’s condition.
Newborn Priorities in the First Days of Life
1. Initiation and maintenance of respirations
2. Establishment of extrauterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant–parent relationship
8. Developmental care, or care that balances physiologic
needs and stimulation for best development
Initiating and Maintaining Respirations
• Most deaths occurring during the first 48 hours after
birth result from the newborn’s inability to establish or
maintain adequate respirations
• Respiratory Acidosis – this is rapidly corrected by the
spontaneous onset of respirations
– Increases if respiration does not begin
– By 2 minutes, the chance of developing of severe
acidosis is high
Factors
Predisposing
Infants to
Respiratory
Difficulty in
the First Few
Days of Life
 Resuscitation
• If breathing is ineffective, circulatory shunts, particularly
the ductus arteriosus, fails to close
– Infant struggles with breathing
– Infant may become hypoglycemic, in attempt to breathe
and circulate blood, infant uses glucose quickly
• Resuscitation follows an organized process:
(a) establish and maintain an airway,
(b) expand the lungs, and
(c) initiate and maintain effective ventilation
• If respiratory depression becomes severe, a
newborn’s heart will fail
• Resuscitation then must also include cardiac massage
Airway
• If respiration does not begin spontaneously, suction the
infant’s mouth and nose with a bulb syringe and rub the
back
• Keep the infant dry to prevent chilling
– Chilling increases oxygen consumption
– Warmed, blow-by oxygen by face mask or positive-
pressure mask may be administered
• If AF is meconium stained, do not stimulate infant to breath
– Give oxygen by mouth without pressure
Airway
• Deep suctioning via laryngoscope
– Suction the trachea
– Catheter (8F or 12F) inserted over the infant’s tongue
to the back of the throat
– Do not suction for longer than 10 seconds at a time
– Vigorous suctioning may cause vagus stimulation (at
the posterior oropharynx)
• Bradycardia or cardiac arrhythmias can occur
Laryngoscopes are equipped
with different-size blades.
Size 0 or 1 is used with
newborns. The endotracheal
tube fits inside the
laryngoscope. Infants under
1000 g need a 2.5-mm
endotracheal tube; those
over 3000 g need a 4.0- mm
tube. Because preterm
infants are prone to
hemorrhage because of
capillary fragility, gentle care
during insertion is crucial
• Deep tracheal suctioning via laryngoscope
– oxygen administration by a positive-pressure bag and mask
with 100% oxygen at 40 to 60 breaths per minute via ET
• Primary Apnea – weak gasps of air and then almost
immediately stop breathing
– After 1 or 2 minutes of apnea (a pause in respirations longer
than 20 seconds with accompanying bradycardia), an infant
again tries to initiate respirations with a few strong gasps.
• Secondary Apnea – weaker respirations, further decrease in HR
until respirations stop
Lung Expansion
• Sound of the baby crying is proof that lung expansion is good
• Important not to let oxygen levels in a newborn fluctuate, as
fluctuation can cause bleeding from immature cranial vessels
• Excessive force can rupture lung alveoli
• Monitor oxygen level
– Pulse oxyimetry
– Auscultation of breathing sounds
• listen to both lungs
• Stomach may fill with oxygen if O2 is given under
pressure
– Oro-gastric tube may be inserted to deflate the
stomach and decrease the possibility that vomiting
and aspiration of stomach contents from
overdistention will occur.
 Drug Therapy
• If mother has been
taking narcotic agents
(morphine or
meperidine) during
labour, narcotic agonist
(naloxone) may be given
to NB to reverse
respiratory depression
 Ventilation Maintenance
• Ventilation – continued respirations
– Needed to maintain cardiovascular changes
•  in RR – first sign of obstruction or respiratory compromise
– look for retractions (inward sucking of the anterior chest wall on
inspiration)
– Keep the infant warm to prevent acidosis
– Elevate head to 15 degrees to allow abdominal contents fall away
from the diaphragm
– Suction secretions if present
• Bag before suctioning to increase level of oxygen
• Determine the cause of respiratory distress and intervene appropriately
Chest
Retraction
Establishing Extrauterine Circulation
• If an infant has no audible heartbeat, or if the cardiac
rate is below 80 beats per minute, closed-chest
massage should be started
• If heart sounds are not resumed above 80 beats per
minute after 30 seconds of combined positive-
pressure ventilation and cardiac compressions, 0.1 to
0.3 mL/kg epinephrine (1:10,000) may be sprayed into
the endotracheal tube to stimulate cardiac function
• Hold an infant with
fingers supporting the
back and depress the
sternum with two
fingers .
• Depress the sternum
approximately one third
of its depth (1 or 2 cm)
at a rate of 100 times
per minute.
Maintaining Fluid and Electrolyte Balance
• Hypoglycemia may occur from resuscitation
– 10% dextrose in water to restore their blood glucose leve
• Dehydration may result from increased insensible water loss
from rapid respirations
– Ringer’s lactate or 5% dextrose in water
– Sodium, potassium, and glucose may be added as necessary
– Monitor urine output (2 mL/kg/hr) and urine specific
gravity greater (1.015 to 1.020)
• Monitor fluid administration as high fluid intake can lead
to patent ductus arteriosus or heart failure or
intracranial hemorhhage
• A newborn under radiant warmer may need more fluid
due to water loss from radiation and convection.
• If an infant has hypotension without hypovolemia, a
vasopressor such as dopamine may be given to increase
blood pressure and improve cell perfusion
• WOF signs of hypovolemia if bleeding is present
(placenta previa or twin-to-twin transfusion)
Regulating Temperature
• All high-risk infants may have difficulty maintaining a normal temperature
• They must be in a neutral-temp environment
– Too hot – decrease metabolism to cool body
– Too cold – increase metabolism to warm cells
• Provide warmth by:
– Immediate drying
– Skin-to-skin contact/kangaroo care
– Proper clothing
– Place under radiant warmer/incubator
 Metabolism
What happens when a
 O2 newborn is exposed to
Consumption
cold environment?

 O2 available vasoconstriction
of blood vessels

Cells become
Pulmonary veins
hypoxic
affected,  PO2  Lung surfactant pdn
 pulmonary
perfusion may open Compromised
fetal right-to- Lung function
left shunts
 Glucose
consumption
In short, because of becoming
chilled, heart action, breathing, and
Anaerobic electrolytic balance are all affected.
glycolysis

Acid
production

acidosis

KERNICTERUS Invasion of brain cells with unconjugated bilirubin

• Radiant Heat Sources /Incubator
 Establishing Adequate Nutritional Intake
• Infants who experienced severe asphyxia at birth usually receive
intravenous fluids
• Signs of hunger – rooting reflex, sucking reflex, crying
•  in RR, NEC ruled out, gavage feeding may be introduced
• Breastfeeding should be strictly implemented if not CI
• Manual expression of milk or breast pump if BF is not possible
– Infant is too immature to suck
– Milk should be stored in nonshiny plastic bags or bottles to avoid
the infant being exposed to polycarbonate, which can leech into
stored milk and possibly cause chromosomal aberrations
Gavage Feeding
Establishing Waste Elimination
• most immature infants void within 24 hours of birth
• Immature infants also may pass stool later than the
term infant because meconium has not yet reached
the end of the intestine at birth
• If infant is having hypotension, kidney perfusion is not
enough for urine to be produced
• If voiding occurs during resuscitation, it means
hypotension is improving
 Preventing Infection
• Infection, like chilling, increases O2 demand
• In PROM, pneumonia or skin lesions may likely to occur after birth
• Common viruses that may affect the fetus in utero are CYTOMEGALOVIRUS and
TOXOPLASMOSIS Virus
– Congenital anomalies may result from contracting this viruses by the mother
during pregnancy
• most prevalent perinatal infections are those contracted from the vagina during birth
– Early-onset sepsis is most commonly caused by group B streptococcus, E. coli,
Kelbsiella, and Listeria monocytogenes.
– Late-onset, or nosocomial, infections are more commonly caused by
Staphylococcus aureus, Enterobacter, and Candida
• Proper handwashing and standard precautions should be observed when caring for
infants
Establishing Parent–Infant Bonding
• Be certain that the parents of a high-risk newborn
are kept informed of what is happening during
resuscitation at birth.
• Urge parents to spend time with their infant in the
intensive care nursery as the infant improves.
• If an infant dies despite newborn resuscitation
attempts, parents need to see the infant without
being covered by a myriad of equipment
 Anticipating Developmental Needs
• High-risk newborns need special care to ensure that the amount of pain
they experience during procedures is limited to the least amount
possible
• Follow-up of High-Risk Infants at Home
– assess parents’ level of knowledge about their child’s condition and
development
– safety of their home for the care of such a small infant needs to be
evaluated
– Car Seat Challenge – all preterm infants be assessed for
cardiorespiratory stability in their car seat prior to discharge
• some preterm infants experience episodes of oxygen desaturation, apnea, or
bradycardia when seated in standard car safety seats
• High-Risk Infants and Child Abuse
– Preterm children are at high risk for abuse
• This is probably because of the separation of the child
from the family at birth, which interferes with bonding
The Newborn At Risk Because of Altered Gestational Age or Birth Weight

• Term Infants – Infants born after the beginning of week

38 and before week 42 of pregnancy
• Approximately 90% of all live births are term
• Preterm Infants – Infants born before term (less than the
full 37th week of pregnancy), regardless of their birth
weight account for approximately 7% to 19% of all births
• Postterm, Dysmature, or Postmature – Infants born after
the onset of week 43 of pregnancy
• Appropriate for Gestational Age (AGA) – Infants who fall
between the 10th and 90th percentiles of weight for their age
• Small for Gestational Age (SGA) – Infants who fall below the
10th percentile of weight for their age
• Large for Gestational Age (LGA) – infants who fall above the
90th percentile in weight
• Low-Birth-Weight infants - Infants weighing under 2500g
• Very-Low-Birth-Weight infants (VLBW) - weighing 1000 to
1500 g
• Extremely Very-Low-Birth-Weight – infants weighing 500 to
1000 g
The Small-for-Gestational-Age Infant
• may be born preterm (before week 38 of gestation), term
(between weeks 38 and 42), or postterm (past 42 weeks)
• Caused by intrauterine growth restriction (IUGR) or failed to
grow at the expected rate in utero
• different from infants whose weight is low but who are
average for gestational age
• Common complications are perinatal asphyxia, meconium
aspiration, hypoglycemia, polycythemia and instability of
body temperature
• Etiology
– lack of adequate nutrition (mother)
– Pregnant adolescents
– MC: placental anomaly
– DM and PIH
– Smoking
– Use of narcotics
– intrauterine infection such as rubella or toxoplasmosis
– chromosomal abnormality
• Assessment:
– Less fundal height
– UTZ to check for fetal size, AF, placental function
– Poor placental function leads toor fetal performance during labor
• CS is recommended
– Infant is below average in weight, length, and head circumference
– Small liver – difficulty regulating glucose, protein, and bilirubin levels after birth
– Poor skin turgor
– Large head and a small body
– Dull and lusterlesss hair
– Skull sutures are wide, skull is firmer
– may have better-developed neurologic responses, sole creases, and ear cartilage than
expected for a baby of that weight.
– unusually alert and active for that weight
– Congenital anomalies may occur from poor nutritional intrauterine environment
• Laboratory Findings:
– high hematocrit level
– Polycythemia
• increased blood viscosity
– Acrocyanosis
– Blood vessels may be blocked and there is thrombus formation
– If Hct is 65% to 70%, exchange transfusion may be needed
– Hypoglycemia – (below 45 mg/dL)
 The Large-for-Gestational-Age Infant
• Macrosomia
• birth weight is above the 90th percentile
• Immature development
• overproduction of growth hormone in utero
• infants of women with diabetes mellitus or women who are obese
• Infant of multiparous women
• Other conditions associated with LGA infants
– transposition of the great vessels
– Beckwith syndrome (a rare condition characterized by overgrowth),
– congenital anomalies such as omphalocele
• Assessment:
– Large uterus for pregnancy date
– nonstress test to assess the placenta’s ability to sustain a
large fetus during labor may be performed
– Lung maturity assessed by amniocentesis
– Immature reflexes
– low scores on gestational age examinations in relation to
their size
– Broken clavicle or Erb-Duchene paralysis
– prominent caput succedaneum, cephalhematoma, or
molding
• Cardiovascular Dysfunction
– Hyperbilirubinemia due to bruising and polycythemia
– Polycythemia in attempt to oxygenate all body tissues
• Extra load on the heart – monitor HR
• transposition of the great vessels – cyanosis occurs
• Hypoglycemia
– Rebound hypoglycemia
• Hyperglycemia in utero results in increased insulin production
which continue up to 24 hours of life
• an LGA infant needs to be breastfed immediately to prevent
hypoglycemia
• Increased intracranial pressure from birth
– pressure on the respiratory center
– decrease in respiratory function
• diaphragmatic paralysis may occur because of cervical
nerve trauma as the head is bent sideways to allow for
birth of the large shoulders
– prevents active lung motion on the affected side
• If an infant was born by cesarean birth, transient fluid
can remain in the lungs and interfere with effective gas
exchange
 A Preterm Infant
• live-born infant born before the end of week 37 of gestation; another
criterion used is a weight of less than 2500 g (5 lb 8 oz) at birth
• observe closely for the specific problems of prematurity, such as
respiratory distress syndrome, hypoglycemia, and intracranial
hemorrhage
• All preterm infants need intensive care
• Lacks lung surfactant
• A preterm infant is immature and small but well proportioned for age
• appears to have been doing well in utero
• low birth weight infants
• maturity of a newborn is determined by physical
findings such as sole creases, skull firmness, ear
cartilage, and neurologic findings that reveal
gestational age, as well as the mother’s report of the
date of her last menstrual period and sonographic
estimations of gestational age
• Etiology:
– inadequate nutrition before and during pregnancy
– IVF – may result to multiple prenancy
– Iatrogenic (health care–caused) issues
• elective cesarean birth and inducing labor
Assessment
– appears small and underdeveloped – Eyes are small
– head is disproportionately large (3 – varying degrees of myopia
cm greater than chest size) – ears appear large, pinna to fall
– Little subcutaneous fat forward
– Veins are easily noticeable – sucking and swallowing absent if less
– high degree of acrocyanosis than 33 weeks
– Covered with vernix caseosa, but – DTR absent like Achilles tendon
with less than 25 weeks, vernix is refelex
absent – Weak and high-pitched cry
– Extensive lanugo – Less active ad rarely cries
– Anterior and posterior fontanelles
are small
– Few or no sole creases
 Potential Complications (Preterm)
• Anemia of Prematurity
– normochromic, normocytic anemia
– Low reticulocyte count
– infant will appear pale and may be lethargic and anorectic
– immaturity of the hematopoietic system combined with
destruction of red blood cells because of low levels of vitamin
E, which normally protects red blood cells against oxidation
– Excessive blood drawing for electrolyte or blood gas analysis
can potentiate the problem
– Tx: DNA recombinant erythropoietin, BT, Vitamin E, iron
• Kernicterus
– destruction of brain cells by invasion of indirect bilirubin
– Indirect bilirubin is from the excessive destruction of RBCs
– Acidosis that results from poor respiratory exchange makes
brain cells more susceptible to the effect of indirect bilirubin
– Preterm has less albumin where indirect bilirubin should
bind and be deactivated
– If jaundice occurs, exchange transfusion or phototherapy to
prevent excessively high indirect bilirubin levels
Persistent Patent Ductus Arteriosus
Lack of surfactant • Administer intravenous therapy cautiously to
preterm infants to avoid increasing blood
Non compliant
lungs pressure and further compounding this problem.
• Indomethacin or ibuprofen to close the patent
Difficulty in moving
ductus arteriosus
blood from the • side effect of indomethacin is oliguria,
pulmonary artery monitor urine output
into the lungs

Pulmonary Interferes with closure of

hypertension the ductus arteriosus
Periventricular/Intraventricular Hemorrhage
• bleeding into the tissue surrounding the ventricles or intraventricular hemorrhage
(bleeding into the ventricles)
• occur in as many as 50% of infants of very low birth weight
• preterm infants have both fragile capillaries and immature cerebral vascular
development
– When there is a rapid change in cerebral blood pressure, such as with hypoxia,
intravenous infusion, ventilation, or pneumothorax, capillaries rupture.
– An infant experiences brain anoxia distal to the rupture.
– Hydrocephalus may occur from bleeding into the aqueduct of Sylvius with
resulting clotting and obstruction of the aqueduct.
– Preterm infants often have a cranial ultrasound performed after the first few
days of life to detect if a hemorrhage has occurred.
• Other Potential Complications
– Preterm infants are particularly susceptible
to several illnesses in the early postnatal
period, including respiratory distress
syndrome, apnea, retinopathy of prematurity
and necrotizing enterocolitis
• Periodic respirations
– irregular respiratory pattern – a few quick breaths, a
period of 5 to 10 seconds without respiratory effort, a
few quick breaths again, and so on
– Preterm below 32 weeks
– No bradycardia
• True Apnea
– pause in respirations is more than 20 seconds and
bradycardia
• Other problems in preterm newborn:
1. Impaired gas exchange related to immature
pulmonary functioning
• Preterm infants have great difficulty initiating respirations
at birth because pulmonary capillaries are still so
immature.
• Lung surfactant does not form in adequate amounts until
about the 34th to 35th week of pregnancy
• Inadequate lung surfactant leads to alveolar collapse with
each expiration
2. Risk for deficient fluid volume related to insensible
water loss at birth and small stomach capacity
• A preterm newborn experiences a high insensible water
loss because of a large body surface relative to total
body weight.
• Preterm infants also cannot concentrate urine well
because of immature kidney function.
– Because of this, a high proportion of body fluid is excreted
• Risk for imbalanced nutrition, less than body requirements, related to
additional nutrients needed for maintenance of rapid growth, possible sucking
difficulty, and small stomach
– Nutrition problems can arise with a preterm infant because the infant’s body
is attempting to continue to maintain the rapid rate of intrauterine growth
– a preterm newborn requires a larger amount of nutrients than the mature
infant.
– If these nutrients are not supplied, an infant can develop hypocalcemia
(decreased serum calcium) or azotemia (low protein level in blood)
– Delayed feeding and a resultant decrease in intestinal motility may also add
to hyperbilirubinemia
– An immature cardiac sphincter (between the stomach and esophagus) allows
regurgitation to occur readily.
• The lack of a cough reflex may lead an infant to aspirate regurgitated formula.
• Ineffective thermoregulation related to immaturity
– Preterm newborns have a great deal of difficulty maintaining
body temperature because they have a relatively large
surface area per kilogram of body weight.
– do not flex their body well but remain in an extended
position, rapid cooling from evaporation is more likely to
occur
– lack brown fat – the special tissue present in newborns to
maintain body temperature
– Preterm infants also cannot shiver
– immature central nervous system and hypothalamic control
• Risk for infection related to immature immune defenses in
preterm infant
– skin of a preterm baby is easily traumatized and therefore
offers less resistance to infection
– have a lowered resistance to infection
– have difficulty producing phagocytes to localize infection
and have a deficiency of IgM antibodies because of
insufficient production
– Staff members must be free of infection, and handwashing
and gowning regulations should be strictly enforced
• Feeding Schedule of a Preterm Infant
– infant needs 115 to 140 calories per kilogram of
body weight per day
– delayed until an infant has stabilized his or her
respiratory effort from birth
– IV to prevent hypoglycemia
– TPN until stable and maybe fed by other means
(tube or oral)
– The presence of air in the stomach shows that the
route to the stomach is clear
• Gavage Feeding
– gag reflex is not intact until 32 weeks’ gestation
– Infants who are born before 32 to 34 weeks’ gestation
and those who are ill or experiencing respiratory
distress are usually started on gavage feedings
– continuous drip feedings at about 1 mL/hr
– Offering a pacifier during gavage feeding can help
strengthen the sucking reflex, better prepare an
infant for bottle feeding or breastfeeding, and provide
oral satisfaction
• Formula
– caloric concentration of formulas: 24 cal/oz
– iron, calcium, and phosphorus and electrolytes such as
sodium, potassium, and chloride supplementation
may be necessary
– Vit. K – 0.5 ml
– Vit. A – important in improving healing and possibly
reducing the incidence of lung disease
– Vit. E – important in preventing hemolytic anemia in
preterm infants
• Risk for impaired parenting related to interference with
parent–infant attachment resulting from hospitalization
of infant at birth
– Rocking, singing, and talking to them and gentle
holding are measures to help preterm infants develop
a sense of trust in people, which will enable them to
relate satisfactorily to people in the future
– skin-to-skin contact
• Breast Milk
– The immunologic properties of breast milk apparently
play a major role in preventing neonatal necrotizing
enterocolitis, as well as increase immune defenses
– BM of mothers with preterm babies has higher
sodium content
• high level of sodium is necessary for fluid retention in the
preterm infant
– Breast milk is 20 cal/oz
 The Postterm Infant
• born after the 42nd week of a pregnancy
• Results from miscalculated gestational age or labor not induced
until 43 weeks
• may be lightweight
• Less AF
• Fingernails will have grown well beyond the end of the fingertips
• may demonstrate an alertness much more like a 2-week-old baby
than a newborn
• placenta appears to function effectively for only 40 weeks
– Fetus may die or develop postterm syndrome
• Postterm Syndrome
– have many of the characteristics of the SGA infant:
dry, cracked, almost leather-like skin from lack of
fluid, and absence of vernix
• Sonogram to check for biparietal diameter of the fetus
• Nonstress test to check for the function of placenta
– CS if placenta is not functioning well
• Infant may have difficulty establishing respirations
• Presence of meconium in AF
• Hypoglycemia
• Low subcutaneous fat
• Difficulty in temperature regulation
• Polycythemia – elevated Hct
• All postterm infants need follow-up care until at least school age
to track their developmental abilities