HIGH RISK NEWBORNS

SGA
Preterm, term, postterm (+) IUGR or failed to grow at expected rate Causes: Mothers nutrition (Adolescents) Placental anomaly Developmental defect Placental damage Systemic disease (DM) Smokers or use of narcotics Intrauterine infection Chromosomal abnormality

Assessment: Perinatal assessment FH than expected Ultrasound: small size BPP: Poor placental perfusion NST Placental grading AF amount Ultrasound exam

 Appearance Small liver Poor skin turgor Large head Widely separated skull sutures Hair is dull Sunken abdomen Cord appears dry and stained yellow Better developed neurological responses, sole creases, ear cartilage Skull may be firmer Alert and active

 Lab. Findings hct >65 70% exchange transfusion RBC blood viscosity acrocyanosis Hypoglycemia (<40 mg/dl)

 Nursing Diagnoses:
Ineffective breathing pattern r/t underdeveloped body systems Resuscitation Observe RR and character Risk for Ineffective thermoregulation r/t lack of SC fat Control environment Risk for Impaired Parenting r/t Childs High Risk Status and Possible Cognitive or Neuro. Impairment from lack of Nutrition in Utero Discuss to parents ways to promote infants development Provide toys suitable for age

LGA
Causes: Overproduction of GH in utero DM mothers Multiparous women Conditions associated with LGA Transposition of Great Vessels Beckwith syndrome Ompahocele

 Assessment: Uterus is unusually large for the date of pregnancy Sonogram Confirm NST assess placental perfusion Assess lung maturity by Amniocentesis CPD, Shoulder dystocia

 Appearance: Immature reflexes Extensive bruising or birth injury Ecchymosis, jaundice, erythema Clavicle or cervical nerve injuries Asymmetry of anterior chest Unresponsive or dilated pupils Seizure Prominent caput succedaneum, cephalhematoma or Molding CV Dysfunction Polycythemia (+) Stress on the heart (+) Cyanosis Transposition of Great Vessels Hypoglycemia glucose to sustain the weight (+) DM mother glucose in utero insulin production continues up to 24 hrs of life Rebound hypoglycemia

 Nursing Diagnoses: Ineffective Breathing Pattern r/t Possible Birth trauma Risk for Imbalanced Nutrition Less than body requirements r/t additional nutrition needed to maintain weight and prevent hypoglycemia Breastfeed immediately Supplemental formula feedings Risk for Impaired Parenting r/t High risk status Needs the same developmental care Encourage parents to treat their baby as a fragile NB

PRETERM
<37 wks AOG Weight <2,500 g (5 lb 8 oz) at birth Lack of surfactant

 Causes:

PRETERM

Low socio economic level Poor nutritional status Lack of prenatal care Multiple pregnancy Previous early birth Cigarette smoking Age of the mother Order of birth Closely spaced pregnancies Abnormalities of the mothers reproductive system Infections OB complications Early induction of labor Elective CS

 Assessment:
History: Pregnancy history Appearance: Appears small and underdeveloped Head is disproportionately large (3 cm or > chest) Skin is unusually ruddy Veins are easily noticeable

 Acrocyanosis Covered with vernix caseosa Lanugo is usually extensive Few or no creases on soles of feet Eyes are small Myopia Immature ear cartilage, pinna falls forward Ears appears large in relation to head Less active, rarely cries (+) Cry; weak and high pitched

 Potential Complications: Anemia Normochromic, normocytic anemia Reticulocyte count Pale,lethargic and anorectic Keep a record of the amount of blood drawn Give DNA recombinant erythropoietin BT, Vit. E and iron Kernicterus Acidosis albumin bind to indirect bilirubin (+) Jaundice phototherapy or exchange transfusion

Persistent PDA surfactant blood from pulmonary artery to lungs Pulmonary artery PDA Hydrate Give Indomethacin or Ibuprofen Complication of Indomethacin: Oliguria monitor UO closely Periventricular/ Intraventricular Bleeding (+) Fragile capillaries and immature cerebral vascular development (+) Rapid change in cerebral BF capillaries rupture Hypoxia Pneumothorax

 Nursing Diagnoses: Impaired Gas Exchange R/T Immature Pulmonary Function <32 weeks: Periodic respiration, (-) Bradycardia True apnea: >20 secs surfactant alveolar collapse (+) Breech expel meconium aspiration inflammation or pneumonia

 Give mother O2 Maternal analgesia and anesthesia Preterm must be resuscitated within 2 mins after birth Keep infant warm Carry out all procedures gently 100% O2: 2 Dangers: Pulmonary edema Retinopathy of prematurity

 Risk for Deficient Fluid Volume R/T Insensible Water Loss at birth and small stomach capacity Normal glucose: 40-60 mg/100 ml Specific gravity: 1.003 1.030 UO: 1 ml/kg/hr IVF 160-200 ml/kg/BW umbilical venous catheter Monitor weight, UO and specific gravity and electrolytes Measure UO by weighing diapers Preterm: 40-100 ml/kg x 24 hrs ; 1.012 Term: 10-20 ml/kg x 24 hrs ; 1.030 Test urine for glucose and ketones Keep a record of all blood drawn Check for blood in stool Determine possible cause of hypovolemia

 Risk for Imbalanced Nutrition Less than Body Requirements R/T Additional Nutrients Needed for Maintenance of rapid growth, possible sucking difficulty and small stomach Feeding Schedule IVF feeding may be delayed TPN Breast, gavage or bottle feeding Get CXR before feeding (+) Air in stomach Small, frequent feeding (1-2 ml every 2-3 hrs) Preterm: 115 140 cal/kg/ BW Term: 100 110 cal

 Gavage Feeding (+) Gag reflex 32 weeks 32-34 weeks, ill, (+) RDS Gavage feeding Bottle feeding or breast feeding is gradually introduced Give softer nipple Observe preterm infant closely Offer pacifier Aspirate stomach secretions measure replace >2 ml not allowed (-) Digestion NEC Formula: 24 cal/oz preterm 20cal/oz term Vit. K 0.5 ml Give Vit. E prevent hemolytic anemia Breastmilk: Prevents NEC

 Ineffective Thermoregulations R/T Immaturity

Keep NB warm during transportation Heat shield or plastic wrap

Risk for Infection

Linen and equipment must not be shared Staff members must be free of infection Hand washing and gowning

Risk for Impaired Parenting

Rocking, singing and talking and gentle holding Kangaroo care Encourage the mother to express breastmilk Encourage mother to come to the hospital and hold the baby before and after gavage or bottle feeding Photograph of baby Notes to convey messages from the baby to them can be taped to the incubator Sibling should not visit if they have colds or fever, (+) immunization, (-) exposure to communicable diseases

 Deficient Diversional Activity (Lack of stimulation)

Organize procedures Shield from noise and light Pain should be kept into minimum Look directly at an infant in the straight forward position Provide some talk time Gentle stroke an infants back

Risk for disorganized infant behavior

Modify environment; reduce stimuli Dim the lights; cover the incubator, turn infant to the side, contain body with rolled towels Offer non-nutritive sucking Maintain quiet hour

Parental health-seeking behaviors

Overprotection is not necessary Basic immunization

 Post term

POST TERM

>42 weeks Placenta functions effectively for only 40 weeks (+) Postterm syndrome: SGA characteristics
Dry Cracked (leather like) (-) Vernix

Light weight meconium stained Fingernails have grown well Alertness = 2 weeks old (+) Difficulty establishing respiration Hypoglycemia SC tissue temperature regulation difficult Polycythemia, hct nutrition and O2 (+) Neurologic symptoms

 Due to blood perfusion of lungs; surfactant (+) Hyaline like (fibrosis) membrane formed from an exudate of infants blood lines terminal bronchioles, alveolar ducts and alveoli prevents exchange of O2 and CO2 Pathophysiology:
surfactant (+) areas of hypoinflation pulmonary resistance blood shunts to foramen ovale and ductus arteriosus lung perfusion surfactant (+) Hypoxia, Co2 (+) Lactic acid acidosis vasoconstriction pulmonary perfusion surfactant production alveoli collapse with expiration

RESPIRATORY DISTRESS SYNDROME

 Assessment:
Lowbody temperature Nasal flaring Retractions Tachypnea (>60) Cyanosis Expiratory grunting distress
Seesaw respiration Heart failure Pale, gray skin Periods of apnea Bradycardia Pneumothorax

CXR: Diffuse pattern of radiopaque areas ground glass (haziness) Blood gas: Respiratory acidosis C/S: R/O -hemolytic group B strep
May start Penicillin or Ampicillin + Gentamycin or Kanamycin

 Management:
Surfactant replacement
Sprayed into lungs by syringe or catheter by ET tube Head held upright and tilted downward AW should not be suctioned (+) Ventilator needs close observation

O2 administration
Continuous Positive Pressure (CPAP) or Assisted Ventilation with Positive End Expiratory Pressure (PEEP) Keep alveoli from collaping Cx: Retinopathy of prematurity

 Management:
Ventilation
Normal I/E ratio: 1:2 Infant ventilators: 2:1 Complications: Pneumothorax Impaired CO ICP and arterial pressure Hemorrahge Limit fluid intake pulmonary artery pressure Indomethacin or Ibuprofen closure of PDA Complications: Renal function platelet function Gastric irritation

 Additional Therapy
Muscle relaxants Pancuronium (Pavulon) IV spontaneous respiratory function Pressure mechanical ventilation Pneumothorax Needs critical observation Frequent ABG Atropine and Prostigmine should be available

 Liquid Ventilation Use of Perflourocarbons (+) O2 Perflourocarbons pick up and carry O2 distends the lungs exchange of O2 Can be used to deliver O2 Nitric Oxide Cause of pulmonary vasodilation

Prevention:
Sonogram Document: Lecithin should exceed Sphingomyelin (2:1) MgSO4 or Terbutaline prevent preterm birth Steroids Lecithin Betamethasone 12-24 hrs; 24-34 wks AOG (takes effects before 24-48 hrs)

MECONIUM ASPIRATION SYNDROME

(+) Meconium at 10 weeks AOG (+) Breech expel meconium in amniotic fluid (+) Hypoxia (+) Vagal reflex relaxation of rectal sphincter Appearance; Green to greenish black May be aspirated in utero or with 1st breath (+) Respiratory distress:
(+) Inflammation of bronchioles Mechanical plugging surfactant production

Hypoxemia, CO2, (+) shunting (+) secondary infection Pneumonia

 Assessment:
Apgar score Tachypnea, retractions, cyanosis Suction with bulb syringe or catheter while at the perineum Do not administer O2 under pressure Enlargement of AP diameter (barrel chest) ABG: pO2, pCO2 CXR: Bilateral coarse infiltrates in the lungs, (+) spaces of hyperaeration (honeycomb effect) Diaphragm pushed downward

 Management:
Amniotransfusion CS birth Tracheal suction, O2, assist ventilation Antibiotic therapy Observe closely for signs of trapping air in the alveoli Observe for signs of heart failure due to shunting of blood from pulmonary artery to aorta (HR, respiratory distress) Maintain a temperature neutral environment Chest physiotherapy ECMO

SIDS
Unexplained death in infancy Commons among:
Infants of adolescent mother Closely spaced pregnancy Underweight and preterm infants Bronchopulmonary dysplasia Twins Narcotic dependents

Peak age: 2-4 mos.

 Contributory Factors:
Prolonged, unexplained apnea Viral respiratory or botulism Pulmonary edema Brainstem abnormality Neurotransmitter deficiency HR abnormalities Distorted familial breathing patterns arousal response surfactant Sleeping prone

Infants are well nourished Slight head cold Dies with laryngospasm Blood flecked sputum or vomitus in mouth or on bed clothes Autopsy:
Petechiae in the lungs Mild inflammation and congestion in respiratory tract

Inform parents that the death was unexplained

Give assurance that SIDS is a disease of infants

HYPERBILIRUBINEMIA
Hemolytic Disease of the NB
Rh incompatibility
Mother: Rh (-) Fetus: Rh (+) Sensitization: Mother begins producing antibodies against D antigen (72 hrs) 2nd pregnancy: D antibody destroy fetal RBC Requires intrauterine transfusions May induce preterm labor Administer Phenobarbital to women speeds liver maturity

ABO Incompatibility
Mother: Type O Fetus: Type A or B or AB Not born anemic Hemolysis begins with birth; may continue up to 2 wks Preterm: Not affected Increase reticulocyte count

 Assessment:
Percutaneous umbilical blood sampling
anti-Rh titer (Indirect Coombs test) Mother (+) Abs Fetal erythrocytes

(-) Pale Enlarged liver and spleen (+) Edema Severe anemia Heart failure (Hydrops Fetalis) (+) Progressive jaundice (+) Preterm: (+) Hemolysis Liver cannot convert indirect to direct bilirubin (+) Breastfeeding: (+) Prenanediol Progesterone interferes with conjugation of indirect bilirubin Normal bilirubin: 0-3 mg/100ml >20mg/dl or 12 mg/dl in preterm Kernicterus Hypoglycemia Hgb

 Management:
Early feeding peristalsis
Bilirubin incorporated into feces

Phototherapy
Specialized light: Quartz halogen, cool white day light or special blue fluorescent light 12-30 inches above the bassinet or incubator Infant is undressed except for diaper Term NB: Bilirubin 15 mg/dl; Preterm: 10-12 mg/dl Eyes must always be covered Stool: Bright green, loose, irritating to skin; Urine: Dark colored Assess skin turgor, I/O DHN Monitor axillary temperature Infant should be removed for feeding

 Exchange Transfusion
Aspirate stomach Umbilical vein is catheterized Draw small amounts of blood (2-10 ml) replace with equal amounts of donor blood Blood is exchanged slowly 1-3 hrs (automatic pumps) End: hct, bilirubin, Ca+, glucose, culture Repeat exchange transfusion Done for hyperbilirubinemia or polycythemia, blood incompatibility, heart failure Keep NB warm Blood should be given at room temperature

Use only commercial blood warmers Albumin may be administered 1-2 hrs before Monitor rate of flow of albumin Blood type used: OMonitor HR, RR and BP Blood contain acid-citrate-dextrose (ACD) as anticoagulant Ca acidosis Ca gluconate is given every 100 ml of blood Citrate-Phosphate Dextrose (preservative) hyperglycemia insulin hypoglycemia Heparinized blood interferes with clotting glucose hypoglycemia Give Protamine sulfate Observe infant for umbilical vessel bleeding (+) Redness or inflammation (+) infection Report changes with V/S Take and record glucose 1 hr after Monitor bilirubin 2 or 3 days after May administer erythropoietin

SEPSIS
Early onset - birth to 7 days
Pathogens: group B strep, E.coli, Klebsiella, Listeria

Late onset - 7 to 28 days

Pathogens: early onset pathogens PLUS Staph. aureus, Neisseria gonorrhea

 Symptoms: poor feeding, vital sign instability, leukocytosis, leukopenia, thrombocytopenia, hypoglycemia, hyperbilirubinemia, altered consciousness Evaluation: CBC with diff (band/pmn>0.2 or ANC<1000 suggests bacterial infection), CXR, blood culture, urine culture, consider LP

 Ampicillin(100 mg/kg/24 hrs) PLUS gentamicin (3-5 mg/kg/24 hrs) Ampicillin(100 mg/kg/24 hrs) PLUS cefotaxime (100-150 mg/kg/24 hrs)