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At-Risk Newborn Twila Brown, PhD, RN
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Who Is an At-Risk Infant?
Risk of morbidity or mortality Prenatal and intrapartal risk factors Neonatal factors Gestational age Size Anticipate complications Assessments at birth - Apgar score
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High Risk Infant: Overview of Class
Congenital anomalies Characteristics and potential problems Preterm & postterm Small for gestational age & large for gestational age General concerns Thermoregulation Hypoglycemia Respiratory distress and complications Hyperbilirubinemia Psychosocial neonate & family needs
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Congenital Anomalies Diaphragmatic Hernia
Abdominal contents herniate through diaphragm Respirations are compromised Signs Respiratory distress and cyanosis Barrel shape chest, scaphoid abdomen Asymmetric chest expansion Absent breath sounds on effected side Bowel sounds in chest
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Congenital Anomalies: Diaphragmatic Hernia
Interventions Oxygen Respiratory support without over inflating Gastric decompression Head of bed elevated Turn to affected side ECMO Surgical repair
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Congenital Anomalies: Tracheo-Esophageal Fistula
Connection between the trachea and esophagus Proximal esophagus ends in blind pouch and distal esophagus joined to trachea Signs Increased oral secretions Coughs and choking Abdominal distention Not able to pass nasal or oral gastric tube Struggles with feeding
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Congenital Anomalies: Tracheo-Esophageal Fistula
Interventions Withhold feedings Elevate head of bed Suction to blind pouch to decrease aspiration Surgery
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Congenital Anomalies: Neurotubular Defects
Tissue protruding through vertebral column Meningocele Meningomyelocele Impairment Location and magnitude of defect determines extent of neuro impairment Sensory impairment follows motor, affects bladder and anal sphincter, contractures and deformities
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Congenital Anomalies: Neurotubular Defects
Intervention Pregnancy -- Folic acid and Alpha fetal protein Sterile, moist, normal saline dressing Prevent infection Decrease trauma Monitor for changes in fluid and heat loss Surgical repair, keep prone with legs flexed, no diaper over incision Long term: hydrocephalus, wheelchair, braces, catheterization
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Congenital Anomalies: Gastrocele and Omphalocele
Gastroschisis Abdominal contents protrude through wall No sac covering intestines Omphalocele Abdominal contents protrude into umbilical cord Covered by translucent sac Associated with other anomalies
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Congenital Anomalies: Gastrocele and Omphalocele
Interventions Warm, moist, sterile dressing and plastic wrap Maintain hydration and temperature Position supine or side Gastric decompression Surgical repair Complications
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Congenital Anomalies: Choanal Atresia
Occlusion at nasopharnyx Signs Snorting respirations Difficulty breathing with feedings Cyanosis Interventions Assess patency of nares Maintain airway with oral airway Position with head of bed elevated
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Congenital Anomalies: Cleft Lip and Palate
Fissure involving nares, nasal septum, or connecting oral and nasal cavity Intervention Feedings with special nipples Feed upright and burp frequently Prevent aspiration Clean mouth after feedings
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Congenital Anomalies: Heart Defects
Signs Cyanosis Heart murmur Heart failure Most common defects Patent ductus arteriosus Ventricular septal defect Coarctation of the aorta Hypoplastic left heart Tetralogy of Fallot Transposition of the great vessels
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Substance-abusing Mother: Fetal Alcohol Syndrome
Facial abnormalities Behaviors Difficulty establishing respirations Sleeplessness - Jittery Hyperalert states - Hyper reflexes Inconsolable crying - Poor sucking Irritability - Lethargy
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Substance-abusing Mother: Fetal Alcohol Syndrome
Long-term complications Hypotonic and poor coordination Mental retardation or normal intelligence Speech and learning disabilities Hyperactivity and impulsivity Growth retardation Intervention Treat respiratory distress Reduce environmental stimulation Extra feeding time
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Substance-abusing Mother: Drug Dependence
Pregnant woman increased risk of Abruptio placentae, abortion, preterm labor, precipitous labor Neonate increased risk of Intrauterine asphyxia Respiratory problems Urogenital malformation Cerebrovascular complications Low birth weight and head circumference Drug withdrawal
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Substance-abusing Mother: Drug Dependence
Key assessment findings Tachypnea - Sensitive to stimuli High-pitched cry - Low birth weight Jitteriness - Hyperactive Moro reflex Poor sleeping - Increased reflexes Irritability - Diarrhea & vomiting Interventions Swaddling - Calm environment Frequent feeding - Medication Promote bonding
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Inborn Error of Metabolism: Phenyleketonuria (PKU)
Condition affects protein metabolism No enzyme to convert phenylalanine to tyrosine Affects development of brain and CNS Mental retardation if untreated CNS damage minimized if treatment before age 3 months
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Inborn Error of Metabolism: Phenyleketonuria (PKU)
Assessment Positive Guthrie test – 24 hrs after feedings Failure to thrive - Microcephaly Vomiting - Hyperactivity Skin lesions - Irritability Repetitive motions Seizures and tremors Musty odor from skin and urine Intervention Low-phenylalanine formula Teach parents allowed foods in the diet
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Inborn Error of Metabolism: Congenital Hypothyroidism
Enzymatic defect, lack of idodine in maternal diet, or maternal drugs can depress thyroid tissue Causes growth and mental retardation Assessment Large tongue = Prolonged jaundice Umbilical hernia = Poor feeding Mottled skin = Low-pitch cry Large fontanelles = Poor weight gain Hypotonia = Delayed development Intervention: Monitor thyroid medication
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Identification of At-Risk Newborns
Gestational age Preterm Post-term Size of neonate Small for gestational age Large for gestational age
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Large for Gestational Age
Birth weight at or above the 90th percentile Etiology Large parents Multiparous women Males larger than female Assessment findings Poor muscle tone and motor skills Difficult to arouse and maintain an alert state
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Large for Gestational Age
Complications Birth trauma – ceohalopelvic disproportion Asphyxia Meconium aspiration Polycythemia Hypoglycemia
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Infant of Diabetic Mother
Severe diabetes associated with vascular complications may have small babies Mothers with classes A and C may have LGA High glucose stimulates fetal insulin increase Complications Hypoglycemia Hypocalcemia Hyperbilirubinemia Birth trauma
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Infant of a Diabetic Mother
Complications Polycythemia Respiratory distress syndrome Congenital birth defects Interventions Test blood glucose Cord blood; q hr X 4; q 4hr for 24 hrs If blood glucose is < 40 mg/dl Feeding IV fluid of 10% dextrose water
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Small for Gestational Age
Birth weight at or below the 10th percentile Intrauterine growth retardation Deficiency of nutrients through the placenta Poor nutrition Smoking or drug use Pregnancy induced hypertension Advanced diabetes Intrauterine infection
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Small for Gestational Age
Physical characteristics Decreased subcutaneous tissue Loose skin Thin/dry umbilical cord Alert for size Dubowitz changes Problems Hypothermia Hypoglycemia Asphyxia Meconium aspiration
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Small for Gestational Age
Problems Hypocalcemia Feeding difficulties Polycythemia Interventions Support respirations Provide neutral thermal environment Provide appropriate nutrition and hydration Monitor blood glucose levels Cluster care Provide skin care
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Post-term Infant Infant born after 42 weeks gestation
Most continue to be well nourished Postmaturity syndrome Calcium deposits decrease placenta function Results in lack of oxygen and nutrients Physical characteristics Absent vernix and decreased lanugo Dry, cracked, parchment-like skin, peeling Hard, long nails Abundant scalp hair
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Post-term Infant Physical characteristics Loose skin
Decreased subcutaneous fat Problems Hypothermia Hypoglycemia Asphyxia Meconium aspiration Polycythemia Interventions Supportive
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Premature Infant Born before the 37th week gestation
Physical characteristics Skin is thin, smooth, shiny, with visible veins Minimal subcuatneous fat deposits Lanugo over body Minimal sole and palm creases Large head Ears have soft cartilage Genitals Posture is extended Reflexes absent or weak -- suck, gag
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Premature Infant Problems Hypothermia Hypoglycemia
Respiratory distress syndrome Apnea and bradycardia Patent ductus arteriosus Hyperbilirubinemia Anemia Intraventricular hemorrhage Retinopathy of prematurity Necrotizing entercolitis
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Apnea & Bradycardia Bradycardia: heart rate less than 100 bpm
Apnea: not breathing for > 15 to20 seconds Causes of apnea Obstructed airway Hypothermia or hyperthermia Hypoglycemia Sepsis Respiratory distress
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Apnea and Bradycardia Causes of apnea Anemia Hypercapnea Sepsis
Hypocalcemia Seizure Vagal response Dehydration CNS depression Intraventricular hemorrhage
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Apnea and Bradycardia Interventions Tactile stimulation Suction airway
Provide oxygen Provide mechanical ventilation Correct underlying cause Administer CNS stimulants Caffeine or theophylline
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Intraventricular hemorrhage
Hemorrhage in the ventricles of the brain May cause motor deficits Hydrocephalus Sight and hearing loss Causes Capillary walls vulnerable to hypoxic events Hypoxia & high CO2 dilates cerebral vessels Changes in intravascular pressure
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Intraventricular hemorrhage
Signs May be no signs Bulging fontanel Signs of intracranial pressure Interventions Keep cerebral blood flow constant Prevent hypoxia Prevent increased blood pressure Elevate head of bed
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Anemia Causes Iron stored late Short life of RBC Blood drawing
Hemorrhage Interventions Transfuse Packed red blood cells Iron suppliments and erythopoientin Signs Pallor Tachypnea Dyspnea Tachycardia Activity intolerance Feeding difficulty
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Retinopathy of Prematurity
Progressive disorder of retina vessels Scar tissue and retina detachment Causes Fragile retinal vessels Fluctuating oxygen administration levels lead to rapid vasodilation and vasoconstriction Also occurs with hypoxemia, intraventricular hemorrhage, infection, acidosis, exposure to bright lights
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Retinopathy of Prematurity
Interventions Decrease intracranial pressure Careful O2 administration Decrease lighting in NICU Eye exams May regress spontaneously Laser/cryosurgery Vitamin E
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Necrotizing entercolitis
Cause Bowel eschemia during hypoxia Gas forming bacteria invade damaged cells of intestinal wall Cells rupture causing air in surface of bowel Damages bowel wall and causes bleeding Milk in bowel provides rich media for bacteria growth
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Necrotizing entercolitis
Abdominal signs Pneumotosis in bowel wall Free air in abdomen if perforated Distended and shiny abdomen Gastric retention Blood in stools No bowel sounds Signs of sepsis
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Necrotizing entercolitis
Interventions NPO Nasal gastric tube for decompression X-rays to follow deterioration of bowel Antibiotics Surgery – resection of damaged portion Monitor for abdomen distension Hematest stools Long-term IV therapy Decrease O2 consumption
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Nutrition for the Preterm
Inability to nipple feed until wks Gag reflex Suck/swallow/breathe coordination Tires easily and worsens respiratory distress Require different composition of formula Increased metabolic rate Difficulty consuming calories Low iron and glycogen stores Equipment
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Nutrition for the Preterm
IV total parenteral nutrition and lipids Gavage feedings Calorie requirement Fluid requirement High insensible water loss Urine output Signs of feeding intolerance
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References Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning. Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. ( 2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall. Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders. Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.
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