1. Hi Risk Newborn: assessment &nursing management
Selwa Yousif Abdeldafie
Assistant Professor in Pediatric Nursing/University of Hafr Albatin KSA 2017

2. Students of Internship Nursing

3. Objectives:
Upon completion of this presentation the students will be able to:
Identify different neonatal problems and risks.
Discuss the classifications of hi risk neonate.
Assess the at risk neonate.
Plan and provide care for the hi risk neonate.

4. Definition
Any Newborn exposed to any condition that make the survival rate of him/her at danger.

5. Classification of High Risk Newborn
Gestational Age
Preterm
(Late Preterm)
Term
Postterm
Gestational Age & Birth Weight
SGA
AGA
LGA
Preterm < 37 wks SGA – below 10th percentile
Late preterm 34.0 – 36.6 wks AGA – Between 10th & 90th percentile
Term wks LGA - > 90th percentile
Post term >42 wks IUGR – pregnancy circumstances that contribute to growth restriction. May be maternal, placental or fetal.
Gestational age and birth weight are criteria used to measure neonatal maturity and mortality risks. As weight and gestation increase, neonatal mortality risks decrease.

6. Identification of some High-risk Neonates:
1-Low Birth Weight infant is any live born baby weighing 2500 gram or less at birth. 2- Very low birth weight (VLBW) : <1500 gm 3-Extream low birth weight (ELBW):<1000 gm). .

7. 1- Preterm: When the infant is born before term. i. e
1- Preterm: When the infant is born before term. i.e.: before 38 weeks of gestation. 2- Premature: When the infant is born before 37weeks of gestation. 3- Post term: When the infant is born after 42 weeks of gestation

8. Assessment

9. Examination by Apgar score
Sign
Score = 0
Score = 1
Score = 2
Heart Rate
Absent
Below 100 per minute
Above 100 per minute
Respiratory Effort
Weak, irregular, or gasping
Good, crying
Muscle Tone
Flaccid
Some flexion of arms and legs
Well flexed, or active movements of extremities
Reflex/Irritability
No response
Grimace or weak cry
Good cry
Color
Blue all over, or pale
Body pink, hands and feet blue
Pink all over

10. Interpretation of APGAR score
Good APGAR:
Heart rate – above 100
Respiratory Effort – spontaneous with cry
Muscle tone – flexed with movement
Reflex response – active, prompt cry
Color – pink or acrocyanosis.
0-3 infant needs resuscitation
4-7 Gentle stimulation – Narcan injection I.m
8-10 – no action needed

11. Measurements: Body weight. Head circumference.
Abdominal circumference - the distance around the abdomen.
Length or height.

12. Measurements Cont. vital signs:
Temperature - able to maintain stable body temperature 98.6° F (37° C) in normal room environment
Pulse - normally 120 to 160 beats per minute
Breathing rate - normally 30 to 60 breaths per minute

13. Preterm Infant
[< 37 wks]
Calculated by gestational age; not weight.
Preterm: fetus has been doing well in utero but trigger initiates labor & infant is born early.
Problems: poor thermoregulation, hypoglycemia, intracranial bleed, RDS, NEC, immature kidney function, infection.
80-90% of infant mortality in 1st yr. life esp. VLBW infant.

14. Causes
Preeclampsia
Chronic medical illness.
Infection .
Drug use (such as cocaine)
Cervical incompetence (inability of the cervix to stay closed during pregnancy)
Previous preterm birth.

15. Signs of prematurity RDS, apnea of prematurity. PDA and hypotension
hypoglycemia
Immune-system immaturity that increases the risk of infection
IVH (intra ventricular hemorrhage)

16. Signs of prematurity cont.
Skin immaturity and fragility
Thermoregulation
GI issues
Fluid and electrolyte imbalances related to immature renal function
Developmental issues related to the CNS

17. Prevention of prematurity
Identifying mothers at risk for preterm labor
Prenatal education of the symptoms of preterm labor.
-Avoiding heavy or repetitive work or standing for long periods of time which can increase the risk of preterm labor.
Early identification and treatment of preterm labor.

18. Problems and Management of preterm infant
Surfactant coats the inside of the alveoli. It prevents collapse (atelectasis) and keeps alveoli open at the end of expiration.
It is given via endotracheal tube.
Prophylactic therapy appears more beneficial than rescue therapy.

19. Problems and Management of preterm infant Cont.
Criteria for identifying at-risk infants who would benefit from prophylactic treatment are unclear.
Multiple doses lead to improved clinical outcomes.

20. Physiologic Challenges of the premature infant

21. Physiologic Challenges of the premature infant
Respiratory distress (S/S ):
Cyanosis
Tachycardia
Retractions
Expiratory grunting
Nasal flaring
Apnic episodes

22. Respiratory - Nursing Interventions:
Maintain airway
Administer O2
Monitor O2 saturation
Monitor heart/respiratory rates

23. Physiologic Challenges of the premature infant
Thermoregulation (challenges):
Decreased brown fat
Thin Skin
Lack of flexion
Decrease sub-q fat

24. Physiologic Challenges of the premature infant
Thermal Neutrality – Nursing Interventions:
Incubator or radian warmer
Warm surfaces
Warm humidified oxygen
Warm feedings
Keep skin dry and head covered

25. ISOLETTE/ RADIANT or INCUBATOR OPEN WARMER

26. Physiologic Challenges of the premature infant
Digestive
Poor gag reflex
Small stomach capacity
Relaxed cardiac sphincter
Poor suck and swallow reflex
Difficult fat, protein and lactose digestion
Absorption

27. Physiologic Challenges of the premature infant
Pre-feeding assessment
Measure abdominal girth
Bowel sounds
Gastric residual
Sucking and gag reflexes

29. RDS Nursing Care Any nurse caring for an infant with RDS must:
Be familiar with RDS pathophysiology
Recognize symptoms of RDS
Initiate interventions as indicated

30. RDS Nursing Care cont. Maintain good oxygen saturation levels.
Recognize importance of weaning oxygen and other ventilator parameters.
Recognize complications arising from RDS, intubation and mechanical ventilation.
Utilize proper endotracheal suctioning techniques.

31. RDS Nursing Care cont. Provide mouth and skin care.
Maintain proper positioning.
Provide adequate fluid and electrolyte balance.
Monitor blood glucose levels.
Reduce environmental stressors.
Provide parental support.

32. Apnea of Prematurity 50% of NICU infants
Periods of cessation of respiration for longer than 10 seconds to 15 seconds
Apneic episodes frequently accompanied by cyanosis, bradycardia, pallor or hypotonia
Exact cause unknown but thought to be due to immature CNS.

33. Apnea of Prematurity nursing management
Cardiac and respiratory monitoring until no apnea episodes for 5 to 7 days
Neutral thermal environment.
Careful positioning; avoid flexion and hyperextension of the neck

34. Apnea of Prematurity nursing management
Assess infant’s color, perfusion, respiratory rate, heart rate, position and oxygen saturation.
Document frequency and severity of episodes and type and amount of stimulation required to interrupt the event.
Ensure bag and mask set-ups with oxygen available at infant bedside.

35. Postmaturity
Postmaturity refers to any baby born after 42 weeks gestation or 294 days past the first day of the mother's last menstrual period. Other terms often used to describe these late births include post-term, prolonged pregnancy, and post-dates pregnancy.

36. Causes Post maturity
It is not known why some pregnancies last longer than others. Postmaturity is more likely when a mother has had one or more previous post-term pregnancies. A miscalculation may mean the baby is born earlier or later than expected.

37. Symptoms of Post maturity
Dry, loose, peeling skin and lanugo absent.
Overgrown nails
Abundant scalp hair
Visible creases on palms and soles of feet
Minimal fat deposits
Green, brown, or yellow coloring of skin from meconium staining (the first stool passed during pregnancy into the amniotic fluid)
More alert and "wide-eyed"

38. Diagnosis of Post maturity
Postmaturity is usually diagnosed by a combination of assessments, including the following:
the baby's physical appearance
Length of the pregnancy

39. Infants of Diabetic Mothers

40. Infants of Diabetic Mothers
Clinical manifestations IDM
Ruddy color
Macrosomia
Excessive adipose tissue
Hypoglycemia
Increase risk of birth injuries.

41. Infants of Diabetic Mothers
Why Hypoglycemia?
High levels of glucose cross the placenta
In response, fetus produces high levels of insulin
High levels of insulin production continues after cord cut depletes the infant’s blood glucose

42. Nursing Interventions for Hypoglycemia
Assess for signs/symptoms
Tremors
Cyanosis
Apnea
Temperature instability
Poor feeding
Hypertonia / Lethargy
Assess blood glucose and Intervene if < 40mg/dl.
Feed infant If no improvement, give IV of D10%W

43. Any question?