1. High Risk Newborn

2. Weight and Growth Weight Growth
Low Birth Weight (LBW) = <2500 grams
Very Low Birth Weight (VLBW) = <1500 grams
Extremely Low Birth Weight (ELBW) = <1000 grams
Growth
Small for Gestational Age (SGA) < 10th percentile
Appropriate for Gestational Age (AGA) 10th – 90th percentile
Large for Gestational Age (LGA) > 90th percentile

3. Birth
Preterm-born between 20 wks and the end of the 37th week gestation
Term-born between 38 and 42 wks gestation
Posterm-born after 42 wks gestation

4. IUGR/Macrosomia Symmetric-occurs 1st trimester, usually SGA
Asymmetric-occurs later in pg, low birth wgt and larger head circ usually, might have chance of normal G&D later
Macrosomia->4000 gm

5. Corrected age for preterm infants
Gestational + postnatal age =corrected age till ~2 ½ yrs old
Preterm babies “catch up” between 2 & 3 years of age usually

6. General Information
G & D-many at risk newborns may have complications that lead to problems with growth and development later
Parental adaptation tasks-anticipatory grief, responses, bonding, communication, care

7. Nursing care Continuous assessment & analysis of physiologic status
Developmental care, positioning, touch
NICU environment
Working with parents-understand fear, sorrow, concern; explain; allow to vent; initiate parental touch ASAP; Kangaroo care; comunication

8. Abnormal Heart Rate Signs
Tachycardia causes
Hypovolemia/shock
Acidosis
Sepsis
Anemia
Arrhythmia

9. Abnormal Heart Rate con’t
Bradycardia causes
Hypoxia
Asphyxia
Acidosis
Hypothermia
Sepsis
Congenital heart block

10. Abnormal Blood Pressure
Hypotension causes
Shock
Acidosis
Sepsis
Hypertension causes
Usually renal in origin

11. Abnormal Respirations
Tachypnea
first sign of many illnesses/problems; attempt to increase tidal volume
Grunting
forced exhalation through partially closed glottis
Retracting
lungs want to stay deflated
Nasal flaring
making nostrils larger to get more air
Apnea
> 20 seconds duration; pathologic if in 1st hrs; sepsis, RDS, BPD, CNS dysfunction

12. Respirations Early signs of resp distress-flaring, grunting
Further signs-retractions, see-saw breathing, cyanosis
Apnea->20 seconds of no resps
Periodic breathing-normal in nb; 5-10 sec pause, then sec compensatory increased breathing
NB’s are nose breathers for ~ 3 wks
Blood pH ; O2 sat->92%; PaO2->60-70 mmHg (indicates hypoxia if less than)

13. Oxygen Therapy Warm, humidified air
Assess O2 sat cont & ABG’s every 1-2 hr
Delivery systems-hood; nasal cannula; mask; CPAP; PEEP; high frequency; (endotracheal tube for PEEP, high frequency, maybe CPAP)

14. Abnormal Temperature Acceptable range (36.5-37.2C)
Goal is neutral thermal environment (NTE)
Hypothermia leads to increased O2 consumption; depletion of glycogen stores
Hyperthermia – rarely seen

15. Abnormal Fluids, Electrolytes, Nutrition
Weight loss of approximately 5-10% (term)
Weight loss of approximately 15-20% (preterm)
Insensible water loss (IWL)-increase of water loss & ability to retain water
TPN – start within 24 hours if not eating
Enteral – continuous; gavage; nippling

16. Preterm Disease Processes/Complications
Respiratory Distress Syndrome (RDS)
Surfactant deficiency decreases surface tension; inadequate alveolar space; “ground glass” pattern on xray
Signs/sxs-respiratory difficulty
Risks-
Increased risk-preterm birth, male, white
Decreased risk-PIH, prenatal steroid
Treatment – surfactant replacement therapy; respiratory support/therapy; NTE; conservative fluid management; early nutritional support

17. Preterm Disease Processes/Complications (cont’d)
Retinopathy of Prematurity (ROP)
Oxygen levels too high causing vasoconstriction, then hemorrhage and scarring; capillaries “friable”
Prevent
Treatment- laser therapy, Vitamin E
Brochopulmonary Dysplasia (BPD)
COPD of prematurity
Risk factors – prolonged intubation; oxygen therapy/ventilation > 28 days high risk
Signs-tachypnea, retractions, flaring, exercise intolerance, tachycardia, crackles

18. BPD (cont) Treatment Prevention by proper vent mgt
Proper fluid and nutrition mgt (add calories to smaller amt of fluid)
Respiratory support
Meds
Diuretics, bronchodilators, nitric oxide

19. Preterm Disease Processes/Complications (cont’d)
Germinal Matrix-Intraventricular Hemorrhage (GMH-IVH)
32-44% of preterm infants < 1500 grams; decreased incidence d/t prenatal steroid & postnatal surfactant use
Do cranial US by day 7 to diagnose
Causes-increased cerebral blood flow & venous pressure; increased tendency to bleed from capillary friability and elevated PT and PTT levels
Risk factors-prematurity, asphyxia, acidosis, BP spikes

20. GMH-PVH (cont’d) Grades I-III Grade I has no neuro seqeula; III worst
Clinically silent presentation
Complications
Hydrocephalus
Neurologic defects
Prevention
Prenatal steroids
Minimal stimulation
Elevate HOB
BP control
Observe for pneumothorax

21. Processes/Complications
Necrotizing Enterocolitis (NEC)
Cause unknown, but associated with asphyxia, RDS, polycythemia, shock, early feedings; may occur in preterm, term or postterm
Signs/sxs-nonspecific, decreased activity, hypotonia, pallor, recurrent apnea & bradycardia, decreased O2 sats, abdominal distention, bile aspirates, vomiting, bloody stooly stools

22. Processes/Complications
Transient Tachypnea of Newborn (TTN)
Retained fetal lung fluid, mostly in term babies
Risk factors
Elective C/S babies
Male babies
Improves within 3 days; observe closely first 24 hours; provide resp support

23. Processes/Complications (cont’d)
Sepsis
Risk factors
PROM; preterm birth; maternal infection
Signs/sxs
generalized illness; hypothermia; lethargy; cyanosis; pallor; tachypnea; bradycardia or tachycardia; poor feeding

24. Sepsis (cont’d) I/T ratio .2 or higher; bands > 6; CRP + Treatment
O2 therapy
Antibiotics
Prevention-handwashing & good prenatal care

25. Term/Postterm Disease Processes/Complications (cont’d)
Meconium Aspiration Syndrome (MAS)
Risk factors
Postterm birth
PIH; maternal hypertension
Meconium aspiration at birth
Treatment – resp support, CPT, suction, nitric oxide**
Complications – PPHN*

26. Congenital Anomalies
Neural tube -anencephaly; microcephaly; hydrocephaly; myelomeningocele (spina bifida)
GI -oomphalocele; gastrochisis; imperforate anus; tracheoesophagel fistula; cleft lip &/or palate
Respiratory -choanal atresia; diaphragmatic hernia
Skeletal musculoskeletal -developmental hip dysplasia; clubfoot; polydactyly

27. Congenital Anomalies
Musculoskeletal- hip dysplasia; clubfoot; polydactyly
Genitourinary-hypospadias; epispadias; exstrophy of the bladder; ambiguous genitalia; teratoma

28. Acquired Problems of the Newborn
Birth Injuries
Soft tissue
Skeletal
Peripheral Nervous System
Central Nervous System

29. Acquired Problems of the Newborn
Substance Abuse
Alcohol
Cocaine
Heroin
Amphetamines
Caffeine
Tobacco
Methadone
Marijuana

30. Acquired Problems of the Newborn
Infants of diabetic mothers (IDM)
Sepsis
Infections

31. Hemolytic Disorders of the Newborn
Hyperbilirubinemia

32. Case Study: Preterm Newborn
Laura, 32 weeks gestation, is born and admitted to the NICU. She is experiencing respiratory distress.
What clinical manifestations would indicate Laura is experiencing resp. distress?

33. Case Study: Preterm Newborn
What guidelines should the nurse follow to ensure safety & effectiveness of oxygen admin by hood for Laura?

34. Case Study: Preterm Infant
Laura received surfactant. State the rationale for this treatment.

35. Case Study: Preterm Newborn
Explain the concept of neutral thermal environment (NTE) and discuss how to maintain it.

36. Case Study: Preterm Newborn
Intermittent gavage feedings are ordered for Laura. What are standards of practice for ensuring safety and max effectiveness?

37. Case Study: Preterm Newborn
How would you be sure to provide developmentally appropriate care for Laura?

38. Case Study: Preterm Newborn
How could the nurse help Laura’s parents cope with her health status and care?

39. Case Study: Preterm Newborn
During her stay, Laura will be poked and prodded. How should nurse assess her pain status?