Nancy Pares, RN, MSN Metro Community College NURS 2410 Unit 4 Nancy Pares, RN, MSN Metro Community College

Objective 1 Discuss pathophysiology and nursing process for high risk newborn

Identification of At-risk Newborn Low socioeconomic level of the mother Limited or no prenatal care Exposure to environmental dangers Preexisting maternal conditions Maternal factors such as age or parity Medical conditions related to pregnancy Pregnancy complications

Feeding Guidelines Table 32–1 Suggested feeding guidelines for the preterm infant.

Early Feeding Skills (EFS) Table 32–2 Examples of efs items within each section.

Preterm Infant: Respiratory Alterations Inadequate surfactant production Muscular coat of pulmonary blood vessels is not completely developed Greater risk for the ductus arteriosis to remain open

Fetal/Neonatal Risk Factors for Resuscitation Nonreassuring fetal heart rate pattern Difficult birth Fetal scalp/capillary blood sample-acidosis pH<7.20 Meconium in amniotic fluid Prematurity Macrosomia or SGA

Respiratory Distress Assessment Table 33–1 Clinical assessments associated with respiratory distress.

Respiratory Distress Assessment Table 33–1 (continued) Clinical assessments associated with respiratory distress.

Respiratory Distress Assessment Table 33–2 Oxygen monitors.

Fetal/Neonatal Risk Factors for Resuscitation (continued) Male infant Significant intrapartum bleeding Structural lung abnormality or oligohydramnios Congenital heart disease Maternal infection Narcotic use in labor

Fetal/Neonatal Risk Factors for Resuscitation (continued) An infant of a diabetic mother Arrhythmias Cardiomyopathy Fetal anemia

Respiratory Distress Syndrome (RDS) Deficiency or absence of surfactant Atelectasis Hypoxemia, hypercarbia, academia May be due to prematurity or surfactant deficiency

Figure 33–5 RDS chest x-ray Figure 33–5 RDS chest x-ray. Chest radiograph of respiratory distress syndrome characterized by a reticulogranular pattern with areas of microatelectasis of uniform opacity and air bronchograms. SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.

RDS: Nursing Care Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration Education and support of family

Figure 33–9 Premature infant under oxygen hood Figure 33–9 Premature infant under oxygen hood. Infant is nested and has a nonnutritive sucking pacifier. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

Transient Tachypnea of the Newborn (TTN) Failure to clear lung fluid, mucus, debris Exhibit signs of distress shortly after birth Symptoms Expiratory grunting and nasal flaring Subcostal retractions Slight cyanosis

TTN: Nursing Care Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration Support and educate family

Meconium Aspiration Syndrome (MAS) Mechanical obstruction of the airways Chemical pneumonitis Vasoconstriction of the pulmonary vessels Inactivation of natural surfactant

MAS: Nursing Care Assess for complications related to MAS Maintain adequate respiratory status Maintain adequate nutritional status Maintain adequate hydration

Persistent Pulmonary Hypertension (PPHN) Blood shunted away from lungs Increased pulmonary vascular resistance (PVR) Primary Pulmonary vascular changes before birth resulting in PVR Secondary Pulmonary vascular changes after birth resulting in PVR

PPHN: Nursing Care Minimize stimulation Maintain adequate respiratory status Observe for signs of pneumothorax Maintain adequate nutritional status Maintain adequate hydration status Support and educate family

Figure 33–10 Chest x-ray of a left-sided pneumothorax Figure 33–10 Chest x-ray of a left-sided pneumothorax. A rupture of the alveoli sacs allows air to leak through the pleura, forming collections of air outside the lung (air shows on x-ray as dark area over lung). SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.

Genetic disorders This information will be discussed in greater detail later in the course. For the purposes of this unit, know that certain disorders are genetic

Congenital Anomalies Table 32–3 Congenital anomalies: identification and care in newborn period.

Congenital Anomalies Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

Congenital Anomalies Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

Congenital Anomalies Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

Congenital Anomalies Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

Congenital Anomalies Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

Congenital Anomalies Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

Congenital Anomalies Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

Cardiac Defects Table 32–7 Cardiac defects of the early newborn period.

Cardiac Defects Table 32–7 (continued) Cardiac defects of the early newborn period.

Cardiac Defects Table 32–7 (continued) Cardiac defects of the early newborn period.

Cardiac Defects Table 32–7 (continued) Cardiac defects of the early newborn period.

Cardiac Defects Table 32–7 (continued) Cardiac defects of the early newborn period.

Infants at Risk for HIV/AIDS Table 32–6 Issues for caregivers of infants at risk for HIV/AIDS.

Infants Born to HIV/AIDS Infected Mothers: Consequences Prematurity SGA Failure to thrive Enlarged spleen and liver Swollen glands

Infants Born to HIV/AIDS Infected Mothers: Consequences Recurrent respiratory infection Rhinorrhea Recurrent GI problems Persistent or recurrent candidiasis

Nursing Care of the Infant Born to HIV/AIDS Infected Mothers Provide comfort Keep the newborn well nourished Keep the infant protected from infections Facilitate growth, development, and attachment

Sepsis Risk factors Maternal infection (group B streptococcus most common) Long labor, prolonged rupture of the membranes Maternal fever, chorioamnionitis Fetal distress, aspiration

Sepsis (continued) Assessment findings Management Unstable temperature, poor tone, poor sucking Management Antibiotics Supportive care

Signs and Symptoms of Sepsis Lethargy or irritability Hypotonia Hypotension Pallor, duskiness, or cyanosis Cool and clammy skin

Signs and Symptoms of Sepsis (continued) Temperature instability Feeding intolerance Hyperbilirubinemia Tachycardia followed by apnea/bradycardia

Symptoms of Syphilis Rhinitis Red rash around the mouth and anus Irritability Generalized edema and hepatosplenomegaly Congenital cataracts SGA and failure to thrive

Syphilis: Nursing Management Initiate isolation Administer penicillin Provide emotional support for the family

Gonorrhea Symptoms Nursing management Conjunctivitis Corneal ulcerations Nursing management Administration of ophthalmic antibiotic ointment Referral for follow-up

Symptoms of Herpes Small cluster vesicular skin lesions over the entire body DIC Pneumonia Hepatitis Hepatosplenomegaly Neurologic abnormalities

Herpes: Nursing Management Careful hand washing and gown and glove isolation Administration of IV vidarabine or acyclovir Initiation of follow-up referral Support and education of parents

Chlamydia Symptoms Nursing management Pneumonia Conjunctivitis Administration of ophthalmic antibiotic ointment Referral for follow-up

Maternally Transmitted Infections Table 33–6 Maternally transmitted newborn infections.

Maternally Transmitted Infections Table 33–6 (continued) Maternally transmitted newborn infections.

Antibiotic/antiviral Therapy Table 33–7 Neonatal sepsis antibiotic/antiviral therapy.

Nursing Care of the Drug-Exposed Newborn Neonatal abstinence scoring Monitoring VS and pulse oximetry until stable Small frequent feedings IV therapy if needed Positioning on the right side-lying or semi- Fowler’s Monitoring frequency of diarrhea and vomiting

Nursing Care of the Drug-Exposed Newborn Weigh infant every 8 hours during withdrawal Swaddle infant Protect face and extremities from excoriation Place infant in quiet, dimly lighted area of the nursery Administration of medications

Newborn Withdrawal Table 32–4 Clinical manifestations of newborn withdrawal.

Neonatal Abstinence Table 32–5 Neonatal abstinence score sheet.

Neonatal Abstinence Table 32–5 (continued) Neonatal abstinence score sheet.

Figure 33–14 Potential sites for heel sticks Figure 33–14 Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot and the important longitudinally oriented fat pad of the heel, which in later years could impede walking.

Figure 33–15 Heel stick. With a quick, piercing motion, puncture the lateral heel with a microlance. Be careful not to puncture too deeply.

Postmaturity Syndrome Hypoglycemia Meconium aspiration and oligohydramnios Polycythemia Congenital anomalies Seizures Cold stress

Care of the Premature Infant Delivery prior to 37 weeks’ gestation Factors Multiple gestation, PROM, incompetent cervix

Assessment of the Preterm Newborn Physical characteristics Gestational age Maternal prenatal risk factors Delivery risk factors Physical assessment Family assessment

The Premature Infant (continued) Assessment Gestational age assessment Neurologic assessment Physical characteristics Thin skin, soft cartilage, absent plantar creases Abundant lanugo and vernix Genitalia characteristic of prematurity

Review of Systems and Potential Complications Cardiovascular Patent ductus arteriosis Hypotension Central nervous system Intraventricular hemorrhage Posthemorrhagic hydrocephalus Hematologic system Anemia Polycythemia Hepatic system Hyperbilirubinemia Phototherapy

Review of Systems (continued) Gastrointestinal system Dysmotility Necrotizing enterocolitis Gastroesophageal reflux Immune system Infection Integumentary system Epidermal stripping Absorption of chemical agents Crib with head elevated for reflux

Review of Systems (continued) Ophthalmologic system Retinopathy of prematurity Renal system Oliguria Glycosuria Respiratory system Respiratory distress syndrome Bronchopulmonary dysplasia Apnea of prematurity Pneumonia Preterm infant in an oxygen hood

Preterm Infant: GI Alterations Poorly developed gag reflex Incompetent esophageal cardiac sphincter Poor sucking and swallowing reflexes Difficulty meeting caloric needs for growth Inability to handle the increased osmolarity of formula protein Difficulty with absorbing saturated fats

Preterm Infant: GI Alterations (continued) Difficulty with lactose digestion Deficiency of calcium and phosphorous Increased basal metabolic rate and increased oxygen requirements Feeding intolerance Potential for the development of necrotizing enterocolitis (NEC)

Preterm Infant: Alterations in Thermogenesis Unavailability of glycogen and brown fat Inability to increase oxygen consumption High ratio of body surface area to body weight Extended position increases body surface area Decreased ability to vasoconstrict superficial blood vessels

Preterm Infant: Kidney Alterations Lower glomerular filtration rate (GFR) Limited ability to concentrate urine or excrete large amounts of fluid Excrete glucose at a lower serum glucose level Buffering capacity is reduced Excretion time of drugs is longer

Preterm Infants: Liver Alterations Glycogen stores are used rapidly Glycogen stores are affected by asphyxia and cold stress Low iron stores Conjugation is impaired

Preterm Infants: Other Alterations Immunologic Lack of passive IgG antibodies Skin is easily excoriated Neurologic Increased risk for IVH & ICH Delayed or absent reactivity

Hydrocephalus: Nursing Assessments Occipital-frontal baseline measurements Daily head circumferences Skin integrity Signs and symptoms of infection Signs of widening of suture lines

Hydrocephalus: Nursing Interventions Assist with head ultrasounds and transillumination Change position frequently Clean skin creases Keeping a sheepskin under the head Postoperatively position head off the operative site

Intrauterine growth restriction Small for gestational age Large for gestational age Post term infant

Intrauterine Growth Restriction Infants <10th percentile for weight at birth May be symmetric or asymmetric Factors may be fetal, maternal, or placental Complications Hypoxia, hypothermia, hypoglycemia, polycythemia, hyperbilirubinemia, meconium aspiration

Intrauterine Growth Restriction (continued) Nursing implications Prevent heat loss Monitor blood glucose, feed early Monitor for respiratory complications Management of hyperbilirubinemia

Small-for-gestational-age Maternal factors Maternal disease Environmental factors Placental factors Fetal factors

Triplets Manifesting Different Rates of Growth

Large for Gestational Age Infant Infants >90th percentile for weight at birth Factors Maternal diabetes, parental obesity Complications Difficult delivery, birth trauma, hypoglycemia Nursing implications Assess for birth injury Monitor for hypoglycemia

Impact of Maternal Diabetes Mellitus (DM) on the Newborn LGA SGA Hypoglycemia Hypocalcemia Hyperbilirubinemia

Impact of Maternal Diabetes Mellitus (DM) on the Newborn Birth trauma Polycythemia RDS Congenital malformations

Infants of Diabetic Mothers Risk factors Congenital anomalies Macrosomia (>4,000 gm) Hypoglycemia Respiratory distress syndrome

Infants of Diabetic Mothers (continued) Prevention of complications Normoglycemia during gestation and labor Deliver when lungs are mature Prepare for delivery of large infant Monitor for hypoglycemia

Hypoglycemia Symptoms Lethargy or jitteriness Poor feeding and sucking Vomiting Hypothermia and pallor Hypotonia, tremors Seizure activity, high pitched cry, exaggerated moro reflex

Hypoglycemia: Nursing Care Routine screening for all at risk infants Early feedings D10W infusion

Risk Factors for Hyperbilirubinemia Table 33–3 Risk factors for development of severe hyperbilirubinemia in infants of 35 or more weeks’ gestation (in approximate order of importance).

Lab Evaluation of Jaundice Table 33–4 Laboratory evaluation of the jaundiced infant of 35 or more weeks’ gestation.

Checklist for in-room Phototherapy Table 33–5 Instructional checklist for in-room phototherapy.

Hyperbilirubinemia Excess bilirubin in the blood resulting in jaundice Can be caused by physiologic or pathologic processes Normal RBC breakdown Rh or ABO incompatibility

Hyperbilirubinemia (continued) Complications Kernicterus Erythroblastosis fetalis Hydrops fetalis Assessment findings Jaundice, elevated bilirubin levels

Management of Hyperbilirubinemia Encourage frequent feedings Exposure to sunlight Phototherapy Shield infant’s eyes Monitor body temperature Monitor weight Monitor fluid intake Weigh diapers Note frequency of stools

Physiologic Hyperbilirubinemia Appears after first 24 hours of life Disappears within 14 days Due to an increase in red cell mass

Pathologic Hyperbilirubinemia Appears within first 24 hours of life Serum bilirubin concentration rises by more than 0.2 mg/dL per hour Bilirubin concentrations exceed the 95th percentile Conjugated bilirubin concentrations are greater than 2 mg/dL Clinical jaundice persists for more than 2 weeks in a term newborn

Causes of Pathologic Hyperbilirubinemia Hemolytic disease of the newborn Erythroblastosis fetalis Hydrops fetalis ABO incompatibility

Treatment of Pathologic Hyperbilirubinemia Resolving anemia Removing maternal antibodies and sensitized erythrocytes Increasing serum albumin levels Reducing serum bilirubin levels Minimizing the consequences of hyperbilirubinemia

Phototherapy: Nursing Care Maximize exposure of the skin surface to the light Periodic assessment of serum bilirubin levels Protect the newborn’s eyes with patches Measure irradiance levels with a photometer Good skin care and reposition infant at least every 2 hours Maintain an NTE and adequate hydration and nutrition

Figure 33–18 Infant receiving phototherapy Figure 33–18 Infant receiving phototherapy. The phototherapy light is positioned over the incubator. Bilateral eye patches are always used during photo light therapy to protect the baby’s eyes. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

Nutrition and Fluid Management Fluids Strict I&O, weigh diapers Electrolyte management Management of sodium and potassium levels Glucose homeostasis Feeding Gavage or nipple method Types: formula or breast milk Gavage feeding tube

Developmental Care of the Preterm Infant Light Sound Temperature Positioning and containment strategies Handling and touching Nonnutritive sucking

Cold Stress Increase in oxygen requirements Increase in utilization of glucose Acids are released in the bloodstream Surfactant production decreases

Figure 33–13 Cold stress chain of events Figure 33–13 Cold stress chain of events. The hypothermic, or cold-stressed, newborn attempts to compensate by conserving heat and increasing heat production. These physiologic compensatory mechanisms initiate a series of metabolic events that result in hypoxemia and altered surfactant production, metabolic acidosis, hypoglycemia, and hyperbilirubinemia.

Cold Stress: Nursing Care Observe for signs of cold stress Maintain NTE Warm baby slowly Frequent monitoring of skin temperature Warming IV fluids Treat accompanying hypoglycemia

Objective 2 Explain the assessment and nursing interventions associated with birth injuries

Trauma and Birth Injuries Fractures Clavicle, long bones, skull most common Risks Large infant, breech, difficult labor Assessment Impaired mobility Management Immobilization, traction, casting

Trauma and Birth Injuries (continued) Facial Palsy Usually related to use of forceps Brachial Palsy Usually related to difficult delivery such as shoulder dystocia Assessment Impaired mobility of arm Paralysis may be temporary or permanent

Needs of Parents of At-risk Infants Realistically perceiving the infant’s medical condition and needs Adapting to the infant’s hospital environment Assuming primary caretaking role Assuming total responsibility for the infant upon discharge Possibly coping with the death of the infant if it occurs

Facilitating Parental Attachment Facilitating family visits Allowing the family to hold and touch the baby Giving the family a picture of the baby Liberal visiting hours Encouraging the family to get involved in the care

Figure 33–20 Mother of a 26 weeks’ gestational age infant with respiratory distress syndrome on a ventilator is getting acquainted with her baby. Physical contact is vital to the bonding process and should be encouraged whenever possible. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.