1. Christina Hernandez RN, MSN
High Risk Neonate
Christina Hernandez RN, MSN

2. The High Risk Newborn
Susceptible to illness or death due to dysmaturity, immaturity, physical disorders, or complications at birth.
Risk Factors:
Low socioeconomic status, poor nutrition
Exposure to environmental dangers
Obstetric factors such as age, parity, or other premature births
Medical conditions related to the pregnancy such as PIH, PROM, or infection

3. Gestational Age

4. Classification of High Risk Newborns
Gestational Age
Preterm – less than 37 weeks gestation
(Late Preterm – 34 – 36.6 weeks gestation)
Term – weeks gestation
Postterm – greater than 42 weeks gestation
LGA – large for gestational age - above the 90th percentile
AGA – appropriate for gestational age – between the 10th and 90th percentile
SGA – small for gestational age – below the 10th percentile

5. Assessment of Gestational Age
Ballard Scale or Dubowitz scale
Neuromuscular characteristics
Physical Characteristics

6. Classification of High Risk Newborn
Large for Gestational Age
LGA
Appropriate for Gestational Age
AGA
Small for Gestational Age
SGA
Maturity and Intrauterine Growth Grid

7. The Preterm Infant

9. Characteristics of Preterm Infants
Appear frail & weak
Underdeveloped flexor muscles & muscle tone
Head is larger in comparison with the rest of the body
Lack subcutaneous fat (white fat)
Skin appears red and translucent
Barely apparent small flat nipples
Plantar creases are absent in infants <32 wks
The pinna of the ear is soft and flat
Female –
Male –

10. Physiologic challenges of the premature infant - Respiratory
Insufficient production of surfactant
Immaturity of alveolar system
Immaturity of musculature and insufficient calcification of bony thorax
Respirations 40-60/min., shallow, irregular, usually diaphragmatic.

11. Nursing interventions - Respiratory
Assess for signs of Respiratory Distress
Nasal Flaring
Circumoral Cyanosis
Expiratory Grunting
Retractions
Tachypnea
Apneic episodes
Administer O2
Warmed and humidified
Oxihood
Nasal Cannula
CPAP
Analyze oxygen concentration.

12. Nursing interventions - Respiratory
Positioning
Position with head slightly elevated and neck slightly extended
Side-lying or prone
Suctioning
Only use when necessary
Be gently so as not to damage fragile mucus membranes

13. Physiologic Challenges in the preterm infant - Thermoregulation
Heat regulation unstable
Body temperature may be normal but it fluctuates
Higher ratio of body surface in proportion to body weight.
Lack of subcutaneous fat
Poor capillary response to environmental changes.
Decreased brown fat
Thinner skin

14. Signs of Inadequate Thermoregulation
Axillary temperature <36.3 or >36.9 degrees C
Abdominal skin temperature <36 or >36.5 degrees C
Poor feeding or feeding intolerance
Irritability
Lethargy
Weak cry or suck
Decreased muscle tone
Cool skin temperature
Skin pale, mottled, or acrocyanotic
Signs of hypoglycemia
Signs of respiratory difficulty
Poor weight gain

15. Nursing Interventions - Thermoregulation
GOAL: Neutral thermal environment.
Thermal Neutrality – Nursing Interventions
Incubator or radiant warmer
Warm surfaces
Warm humidified oxygen
Warm ambient humidity
Warm feedings
Keep skin dry and head covered

16. Radiant Warmer/
Open Warmer
Isolette / Incubator

17. Physiologic Challenges- Fluid & Electrolyte Balance
Preterm infants lose fluid very easily
Rapid respiratory rate and use of oxygen increase fluid lose from the lungs
Lack of keratin, which helps maintain water in the skin
Large surface area & lack of flexion increases insensible water losses
Radiant warmers heighten insensible water loss

18. Physiologic Challenges- Fluid & Electrolyte Balance
Development of kidneys is not complete until approximately 35 weeks.
In ability of preterm kidneys to concentrate or dilute urine.
Kidneys unable to regulate electrolytes.

19. Physiologic Challenges- Fluid & Electrolyte Balance
Dehydration
Overhydration
Urine output >2 ml/kg/hour
Urine specific gravity >1.020
Weight loss greater than expected
Dry skin and mucous membranes
Sunken anterior fontanel
Poor tissue turgor
Blood: Elevated sodium, protein, and hematocrit levels
Urine output >5 ml/kg/hour
Urine specific gravity <1.001
Edema
Weight gain greater than expected
Bulging fontanels
Blood: Decreased sodium, protein, and hematocrit levels
Moist breath sounds
Difficulty breathing

20. Nursing Interventions- Fluid and Electrolyte Balance
Weigh diapers (1gm = 1ml of urine)
Obtain specific gravity
Carefully regulate IV fluids
Dilute IV medications in as little fluid that is recommended (include medications on intake measurements)
Assess IV sites frequently

21. Physiologic Challenges- Skin
The Preterm infants skin is:
Fragile
Transparent
Permeable

22. Nursing Interventions- Skin
Nursing Care
No use of alcohol or betadine on skin
All skin products should be rinsed off with water
No use of adhesives, use pectin barriers and back tape with cotton
Use semi-permeable adhesives such as tegaderm
Reposition frequently, as tolerated

23. Physiologic Challenges- Infection
Exposure to maternal infections
Lack of transfer of immunoglobulin G (IgG) from mother during third trimester
Immature immune response to infection
Subject to invasive procedures (IV’s, lab’s)
Prolonged hospital stays

24. Signs and Symptoms of Infection in the preterm infant
Behavioral changes
Color changes
Temperature instability
Cool, clammy skin
Feeding intolerance
Hyperbilirubinemia
Tachycardia followed by apnea and bradycardia

25. Nursing Interventions- Infection
Maintain skin integrity
Maintain sterile technique with procedures
‘Scrub’ before entering – EVERYONE
Hand sanitizer at every bedside and used in between care
No entry if sick – EVERYONE
No artificial nails / short nails
Single infant incubators, clean weekly
Report early signs of infection immediately
Assess infants response to treatment (possible resistance)
Position change, use sheepskin

26. Physiologic Challenges – Hepatic System
Poor glycogen stores -increased susceptibility to hypoglycemia.
Inability to conjugate bilirubin - increase hyperbilirubinemia.
Decrease ability to produce clotting factors, low plasma prothrombin levels.

27. Physiologic Challenges – Renal System
Decreased glomerular filtration rate
Inability to concentrate urine
Decreased ability of kidneys to buffer
Decreased drug excretion time

28. Pain in preterm infants
High-pitched, intense, harsh cry
Whimpering, moaning
“Cry face”
Eyes squeezed shut
Mouth open
Grimacing
Bulging or furrowing of brow
Tense, rigid muscles or flaccid muscle tone
Rigidity or flailing of extremities
Color changes: Red, dusky, pale
Increased or decreased heart rate and respirations, apnea
Decreased oxygen saturation
Increased blood pressure
Sleep-wake pattern changes

29. Nursing Interventions
Swaddle, wake slowly
Pacifier, may use Sucrose
Medications

30. Signs of Overstimulation in Preterm Infants
Oxygenation changes
Behavior changes
Respirations
Pulse
Blood pressure
Oxygen saturation levels
Color
Sneezing, coughing, hiccupping
Posture
Facial expression
Gaze
Regurgitation
Yawning
Fatigue

31. Physiologic Challenges – Digestive System
Decreased gag and suck reflexes
Hypotonic cardiac sphincter
Suck and swallow reflexes may be uncoordinated
Small stomach capacity
Vomiting
Intolerance of fats
Immature absorption of nutrients

32. Maintaining Nutrition
Nursing Care
Assess Daily weights
Monitor I&O
Accurate IV rates to prevent circulatory overload
Provide feedings via nasogastric if unable to feed orally
Initiate oral feedings and assess for tiring
with feedings
Monitor urine pH and specific gravity
Involve parents in feedings

33. Nursing Interventions
Pre-feeding assessment
Respirations
Measure abdominal girth
Bowel sounds
Gastric residual
Sucking , swallowing , and gag reflexes

34. Readiness for Nipple Feeding
Rooting
Sucking on gavage tube, finger, or pacifier
Able to tolerate holding
Respiratory rate <60 breaths per minute
Presence of gag reflex

35. Signs of Nonreadiness for Nipple Feedings
Respiratory rate >60 breaths per minute
No rooting or sucking
Absence of gag reflex
Excessive gastric residuals

36. Parenting Facilitating Parent-Infant Attachment
Prepare parents for first visit
Equipment, tubes etc.
Establish safe/trusting environment
Provide support, reassurance, encouragement
Encourage visitation
Involved in care taking
Repeat explanations
Promote touching, talking, rocking, cuddling
Refer to infant by name
Allow parents to phone as desired

37. Common Complications of Preterm Infants

38. Respiratory Distress Syndrome

39. Respiratory Distress Syndrome
Pathophysiology
Primary absence, deficiency or alteration in the production of surfactant
Decrease in Surfactant = increase in atelectasis = lack of gas exchange
Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction.
Common Clinical manifestations:
Nasal Flaring
Circumoral cyanosis
Expiratory grunting
Retracting
Tachypnea

40. Respiratory Distress Syndrome-Nursing Interventions
Maintain airway, oxygenation, ventilation
Supplemental oxygen:
Nasal prongs
Oxyhood
Continuous positive airway pressure (CPAP)
Intubation with endotracheal tube

41. Surfactant Replacement Therapy
Surfactant preparation can be lifesaving and reduces complications, such as pneumothorax.
Administered through an endotracheal tube
Surfactant treatments may be repeated several times during the first days until respiratory distress syndrome resolves.

42. Respiratory Distress Syndrome-Nursing Interventions
Nutrition Support
Newborns with RDS may be given food and water by the following means:
Tube feeding—a tube is inserted through the baby's mouth and into the stomach
Parenteral feeding—nutrients are delivered directly into a vein
Support to Parents
Allow parents to hold and feed
when possible.
Assist to decrease their fears

43. Periventricular-Intraventricular Hemorrhage

44. Periventricular-Intraventricular Hemorrhage
Rupture of fragile blood vessels around the ventricles of the brain
Usually associated with hypoxia
Diagnosed via cranial ultrasound
Signs – lethargy, poor muscle tone, decreased reflexes, seizures, apnea or cyanosis, full or bulging fontanels
Nursing Care – daily measure FOC, observe for changes in LOC

45. Retinopathy of Prematurity

46. Retinopathy of Prematurity
Formation of immature blood vessels in the retina constrict and become necrotic
Most common in infants < 28 weeks gestation
Also associated with O2 therapy

47. Retinopathy of Prematurity
Nursing Interventions to Prevent ROP
Administer O2 in concentration ordered
Ensure proper ventilatory settings

48. Necrotizing Enterocolitis

49. Necrotizing Enterocolitis
An inflammatory disease of the intestinal tract frequently complicated with perforation of the gut.
NEC develops when there is asphyxia or hypoxia in which cardiac output tends to be directed more toward the heart and brain and away from the abdominal organs.
The intestinal cells become ischemic and damaged and stop secreting protective mucus infection occurs.
Perforation may occur with overwhelming sepsis.

50. Necrotizing Enterocolitis Signs and Symptoms
Early:
Increase in gastric aspirate - >5-25 ml.
Increase in abdominal girth
Decrease bowel sounds, abdominal tenderness or rigidity of abdominal wall.
Subtle:
Lethargy, sudden listlessness, temperature instability, decrease urine output, occult blood in stools, poor color, and apneic periods.
Dramatic:
Massive abdominal distention, vasomotor collapse.

51. Necrotizing Enterocolitis Treatment and Nursing Care
Surgery: Resection of necrotic sections and possible temporary colostomy. This allows bowel to recover.
Medical:
NPO with NG tube.
Peripheral or central hyperalimentation
Antibiotic therapy.
Continue to monitor for changes in condition.
Gradually introduce oral feedings

52. Post-Term Newborn Greater than 42 weeks gestation

53. Post Mature Infant Physical manifestations: Dry, cracking,
parchment-like skin
Reduced subcutaneous
tissue -Loose appearing
skin
No vernix or lanugo
Long fingernails
Profuse scalp hair
Long, thin body appearance
Often meconium stained skin, cord, nails

54. Post Mature Infant Complications of post term: Hypoglycemia
Meconium aspiration
Congenital anomalies
Seizure activity
Cold stress

55. Small for Gestational Age Below the 10th percentile

56. Risk Factors Maternal factors: High blood pressure.
Chronic kidney disease.
Advanced diabetes.
Heart or respiratory disease.
Malnutrition, anemia.
Infection.
Substance use (alcohol, drugs); Cigarette smoking.
Factors involving the uterus and placenta:
Decreased blood flow in the uterus and placenta.
Placental abruption (placenta detaches from the uterus).
Placenta previa (placenta attaches low in the uterus).
Infection in the tissues around the fetus.
Factors related to the developing baby (fetus):
Multiple gestation (twins, triplets, etc.).
Birth defects.
Chromosomal abnormality.

57. Complications of the SGA Newborn
Asphyxia
Aspiration syndrome
Hypothermia
Hypoglycemia
Polycythemia

58. Large for Gestational Age Greater than 90th percentile

59. What condition is associated with the newborn being LGA?

60. Complications of the LGA newborn
Birth Trauma
Increase of Cesarean births
Hypoglycemia
Polycythemia
Hyperviscosity

61. Asphyxia of the Newborn

62. Asphyxia Lack of oxygen and increase of carbon dioxide in the blood
Occurs in utero or after birth
S/S asphyxia after birth:
Cessation of respirations and rapid fall in heart rate
Interventions:
Primary apnea: stimulation and O2
Secondary apnea: positive pressure ventilation &/or chest compressions
Naloxone 0.1mg/kg IM (if narcotics given to expectant mother shortly before birth)

63. Meconium Aspiration Syndrome

64. Meconium Aspiration Syndrome
Meconium stained amniotic fluid
Aspirated into the trachobronchial tree
Occurs either in utero or after birth with the first breaths.
Meconium in the lungs causes air to become trapped and results in alveoli over-distension and rupture.

65. Meconium Aspiration Syndrome
Measures for Prevention of Meconium Aspiration
After delivery of the infant’s head while shoulders and chest are still in the birth canal,
Suction oropharynx and nasopharynx
After delivery of the infant’s body
Crying Not crying
- Stimulate Do not stimulate
- Suction with Direct tracheal suction
bulb syringe with endotracheal tube

66. Meconium Aspiration Syndrome
Intubation
Suction

67. Meconium Aspiration Syndrome
Nursing Interventions:
Maintain adequate oxygenation and ventilation
Regulate temperature
Accurate IV fluid administration
Assess for hypoglycemia
Administer antibiotics
Prevent caloric requirements
Provide support care if on ECMO

68. Hyperbilirubinemia

69. Unconjugated bilirubin is a break-down product of destroyed RBC’s.
Hyperbilirubinemia
Pathophysiology
Unconjugated bilirubin is a break-down product of destroyed RBC’s.
Unconjugated bilirubin is normally transferred in the plasma firmly bound to albumin to the liver where conjugation occurs.
Conjugated bilirubin is water soluble and can then be excreted into the bile and eliminated with the feces.
Unconjugated bilirubin is not in excretable form and remains in the circulation causing problems.
Hyperbilirubinemia occurs when the body cannot conjugate the bilirubin released into the serum.

70. Causes of Hyperbilirubinemia
Hemolytic disease (Rh and ABO incompatibility)
Extravascular bleed (cephalhematoma)
Bilirubin conjugation defects (breastmilk jaundice, asphyxia)
Hypoalbumin
Physiologic jaundice (occurs after the first 24 hours of birth. Mainly due to immature liver and lack of glucoronyl transferase).

71. Hyperbilirubinemia
Clinical Manifestations:
Sclerae appearing yellow before skin appears yellow – usually in the first 24 hours after delivery
Skin appearing light to bright yellow – advances from head to toe
Lethargy
Dark, amber concentrated urine
Poor feeding
Dark stools

72. Hyperbilirubinemia Bilirubin levels on Cord Blood Coombs Test
Diagnosis:
Bilirubin levels on Cord Blood
Average level of Unconjugated bilirubin is 2 mg/dl at birth
Bilirubin levels should NOT exceed 5 mg/dl
Coombs Test
may be done on the fetal cord blood (direct Coombs test) or on the maternal blood (indirect Coombs test).
Tests for the presence of maternal antibodies attached on the infant’s red blood cells.
The test is positive if there are maternal antibodies.

73. Hyperbilirubinemia Nursing Care
Careful observation of infant for signs of increased jaundice
Careful observation for and prevention of acidosis/hypoxia and hypoglycemia, which decrease binding of bilirubin to albumin and contribute to jaundice.
Maintain adequate hydration
Avoid cold stress
Phototherapy – use of “bili” lights, special fluorescent
Exchange Transfusion

74. Hyperbilirubinemia Nursing Care
Nursing Interventions for Phototherapy
Exposure of skin
Cover eyes (remove for feeding/parent visit)
Monitor temperature – prone to hyperthermia or hypothermia
Reposition newborn every 2 hours
Increase fluids
Assess for dehydration
Perform T-Bili q 12 – 24 hr as ordered
Explain need to keep under phototherapy except during feedings and diaper changes.
Explain to parents and allow them to hold during feedings

75. Hyperbilirubinemia Phototherapy
Side Effects to Phototherapy
Frequent loose, green stools
Skin rash
Increased basal body metabolism
Dehydration
Hyperthermia

76. Hyperbilirubinemia Exchange Transfusion
Treat anemia
Remove sensitized RBCs that will soon lyse
Remove serum bilirubin
Provides albumin to increase bilirubin binding sites

77. Hyperbilirubinemia Rhogam
Provides temporary passive immunity which prevents permanent active immunity (antibody formation)
Given within 72 hours of delivery
Prevents production of maternal antibodies

78. Hyperbilirubinemia ABO incompatibility
Occurs when type O pregnant woman with A, B or AB blood type fetus
If woman has anti A or anti B antibodies, these antibodies cross the placental barrier
Results in hemolysis of fetal RBCs

79. Hyperbilirubinemia Complications of Hemolytic Disease
Kernicterus – Deposits of conjugated and unconjugated bilirubin in the basal ganglia of the brain
Neurologic damage
Hydrops fetalis – severe anemia
Marked edema
Cardiac decompensation
Multiple organ failure
Possible death

80. Infections
TORCHA

81. Infectious Diseases: TORCH
Toxoplasmosis
Other
Syphillis
Hepititis B
Rubella
Cytomegalovirus
Herpes Simplex II
HIV - AIDs

82. Toxoplasmosis Protozoan infection in the pregnant woman
Raw or under cooked meats
Infected Cat feces
Transmission: transplacental
Affects on the fetus
Retinochoroiditis (inflammation of the retina and choroid of the eye. Blindness
Deafness
Convulsions
Microcephaly
Hydrocephaly
Severe mental impairment

83. Other - Syphillis Transmission: Transplacental
Clinical Manifestations:
Rhinitis (Snuffles)
Excoriated upper lip
Red rash around mouth and anus
Copper colored rash of face, palms and soles
Irritability
Edema
Cataracts.
Treatment:
Culture orifices
Isolation
Penicillin

84. Other – Hepatitis B (administer within 12 hours of birth) Transmission
Placental
Birth
Breast milk
Treatment
If mother + HbSAG - administer to newborn:
Hepitisis B vaccine
HBIG
(administer within 12 hours of birth)

85. Rubella Transmission: transplacental S/S of Newborn
Congenital cataracts
Deafness
Congenital heart defects
Sometimes fatal
Intellectual disability
(Affects are greatest if infected in 1st trimester)
MMR Immunization of mother
Give when not pregnant – usually in immediate postpartum period.
Newborns are infectious:
CONTACT ISOLATION

86. Cytomegalovirus Herpatic virus Transmission: Crosses placental barrier
Direct contact at birth
Breast milk
S/S of Newborn
Severe neurological problems
Eye abnormalities
Hearing loss
Microcephaly
Hydrocephaly
Enlarged liver
Cerebral palsy

87. Herpes Simplex II Transmission: Direct contact at birth S/S of Newborn
Custer of vesicles
Lethargy
Encephalitis
Mental delays
Seizures
Retinal dysplasia
Apnea
Coma
CONTACT ISOLATION - culture vesicles
Treatment: Antivial drugs

88. HIV/AIDS Transmission: Diagnosis: Transplacentally Exposure at birth
Breast milk
Diagnosis:
Serology tests are performed within 48 hours of birth;
repeated at 3 and 6 months
HIV antibody
ELISA
CD4 + T-cell

89. HIV/ AIDS Diagnosis HIV infected (two or more positive tests for HIV)
Perinatally exposed (born to a mother know to be infected with HIV)
Seroconverter (born to a mother known to be infected with HIV but has had two negative HIV tests

90. HIV / AIDS Nursing Interventions
HIV infected mothers should be identified and begin treatment with AZT during pregnancy and in labor
All infants born to an infected mother should be treated prophylactically
6 weeks of AZT orally after birth
Bactrim and Septra
Provide care like that of any other newborn

91. Infant of Diabetic Mother
IDM

92. Excessive fetal growth?
What causes
the
Excessive fetal growth? .

93. Complications of Infants of Diabetic Mothers
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
Polycythemia
Respiratory Distress Syndrome

94. Infants of Diabetic Mothers
Why are they prone to 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

95. Infants of Diabetic Mothers
Clinical Manifestations:
Large size – Macrosomia; enlarged spleen, heart, liver
Tremors
Cyanosis
Apnea
Temperature instability
Poor sucking and feeding
Hypotonic muscle tone / Lethargy
Nursing Interventions
Assess blood glucose
Intervene if < 45mg/dl:
Feed infant
Revaluate blood sugar minutes pc
If no improvement:
IV of D10W

96. Newborn of Substance Abuse Mother

97. Infant of Addicted Mother
The newborn of an alcoholic or drug-dependent mother will also be alcohol or drug dependent.
After birth, when an infant’s connection with the maternal blood supply is severed, the neonate suffers withdrawal.
In addition, the drugs ingested by the mother may be teratogenic, resulting in congenital anomalies.

98. Fetal Alcohol Syndrome – FAS Clinical Manifestations

99. Fetal Alcohol Syndrome - FAS
Clinical Manifestations:
Jitteriness
Abdominal distention
Exaggerated rooting and sucking reflexes
Affected body systems:
CNS GI system
Long-term psychosocial implications:
Feeding difficulties
Mental retardation

100. Infants of Addicted Mothers Clinical Manifestations of Infant Withdrawal
Central Nervous System
IRRITABILITY
Hyperactivity
Shrill cry
Exaggerated reflexes
Facial scratches
Short non-quiet sleep
Sneezing, coughing, yawning
Gastroinestional System
Poor feeding
Disorganized vigorous suck
Vomiting and/or Diarrhea
Vasomotor and Cutaneous Signs
Tachypnea
Sweating
Excoriated skin

101. Infants of Addicted Mothers Nursing Care
Soothing:
Swaddle with hands near mouth
Offer pacifier
Place in quiet dimly lit area of the nursery
Protect skin from excoriation
Monitor V/S
Feeding
Provide small frequent feedings
Position with HOB elevated
Weigh every 8 hours (if vomiting & diarrhea)
Assess with Finnegan Abstinence Scale
Administer morphine, phenobarbitol, methadone

102. Affects of Smoking on the Fetus during pregnancy
Nicotine
Causes vasoconstriction
Reduces placental blood circulation
Carbon Monoxide
Inactivates fetal and maternal hemaglobin
Reduced amount of oxygen to fetus results in prematurity or low birth weight

103. Christina Hernandez RN, MSN chernan1@austincc.edu
Thank you!
Christina Hernandez RN, MSN