NCM 102

HIGH RISK NEWBORN

PROBLEMS RELATED TO MATURITY

PRETERM NEWBORN
Description: A neonate born before 37 weeks of gestation
Primary concern relates to immaturity of all body systems
Cause: unknown
Maternal factors: age, smoking, poor nutrition, Placental problem , Preeclampsia/ eclampsia
Fetal factors: multiple pregnancy, infection
Other factors: poor socioeconomic status, environmental exposure to harmful substance

Assessment
 Respirations are irregular with periods of apnea
 Body temperature is below normal
 Skin is thin, with visible blood vessels and minimal subcutaneous fat pads, may appear
jaundiced (Poikilothermic-easily take on the temperature of the environment)
 Poor sucking and swallowing reflexes
 Bowel sounds are diminished

Common or special problem of preterm neonates

1. Respiratory Distress Syndrome
 Hyaline membrane disease
 due to lung immaturity; deficient in surfactant
2. Hyperbilirubinemia
 high level of bilirubin in the blood,
 neonate become jaundice due to immaturity of the liver
 Kernicterus staining of brain cells with bilirubin, causing irreversible brain damage
3. Infection - not able to receive IgG globulins
4. Cold stress- less subcutaneous tissue, poikilothermic
5. Anemia – less iron stores

Management
1. Improving respiratory function- Oxygen therapy, Mechanical ventilator
2. Maintaining body temperature- Isolette – maintains ideal temperature, humidity and oxygen
concentration isolates infant from infection, Kangaroo Care
3. Preventing infection- Handwashing
4. Promoting nutrition- Gavage feeding, Milk feeding
5. Promoting Sensory stimulation- Gentle touch, speaking gently and softly, music box or
low tuned radio

Nursing Interventions
1. Monitor vital signs every 2 to 4 hours
2. Administer oxygen and humidification as prescribed.
3. Monitor intake and output
4. Monitor daily weight.
5. Maintain newborn in a warming device.
6. Reposition every 1 to 2 hours,and handle newborn carefully
7. Avoid exposure to infections.
8. Provide newborn with appropriatestimulation, such as touch
9. Suctioning of secretions as needed
10. Monitor for signs of infection
11. Provide skin care
12. Provide complete explanations for parents
POST-TERM NEWBORN
Description: Neonate born after 42 weeks of gestation
About 12% of all infants are post-term
Causes of delayed birth is unknown
Maternal factors: First pregnancies between the ages 15 to 19years
Woman older than 35 years
Multiparity
Fetal factors: Fetal anomalies such as anencephaly

Assessment
 Depleted subcutaneuos fat: old looking “old man facies”
 Parchment-like skin (dry,wrinkled and cracked) without lanugo
 Fingernails long and extended over ends of fingers
 Abundant scalp hair
 Long and thin body
 Sign of meconium staining
 Nails and umbilical cord (yellow to green)

COMPLICATIONS OF POST MATURITY

1. The placenta begins to aged toward the end of pregnancy, and may not function as
efficiently as before.
2. The failing placental function will place infant at risk for intrauterine hypoxia during labor and
delivery.
3. MECONIUM ASPIRATION SYNDROME
4. HYPOGLYCEMIA - FROM NUTRITIONAL DEPRIVATION AND POOR STORAGE OF
GLYCOGEN AT BIRTH
5. POLYCYTHEMIA- increase RBC

Management
1. Ultrasound is done to evaluate fetal development, amount of amniotic fluids and the placenta
signs of aging
2. To reduce the chance of meconium aspiration, upon delivery of newborn’s head and just
before the baby takes his first breath suctioning of the mouth and nose is done

Nursing management
1. Closely monitor the newborn cardiopulmonary status
2. Administer supplemental oxygen therapy as needed
3. Frequent monitoring of blood sugar; assess for sign of hypoglycemia
4. Provide thermoregulated environment– use of isolette or radiant heat warmer
5. Monitor for signs of meconium aspiration syndrome

DIFFERENCES PRETERM FULL TERM

 Posture “Relaxed attitude” limbs more extended More flexed attitude
Ear Ear cartilages are poorly developed, Well formed cartilages
may fold easily
Sole Only fine wrinkles Well and deeply creased
Female genitalia Clitoris is prominent; labia majora Clitoris is not as prominent; labia
poorly developed majora fully developed
Male genitalia Scrotum is under developed and not Scrotum is fully developed,
pendulous, with minimal rugae pendulous, rugated
Scarf sign Elbow is easily brought across the With resisting attempt when elbow
chest with little or no resistance is brought to the midline of the
chest
Grasp reflex Weak Strong, allowing the infant to be
lifted up from the mattress

PROBLEMS RELATED TO GESTATIONAL WEIGHT

SMALL FOR GESTATIONAL AGE

 (SGA) babies are those whose birth weight lies below the 10th percentile for that gestational
age
 SGA babies may be:
o premature (born before 37 weeks of pregnancy),
o full term (37 to 41 weeks), or
o post term (after 42 weeks of pregnancy)
 Intrauterine growth restriction (IUGR) - is the most common underlying condition leading to
SGA newborn
 Some factors that may contribute to SGA are the following:
o Maternal factors:
 high blood pressure
 chronic kidney disease
 advanced diabetes
 heart or respiratory disease
 malnutrition, anemia
 infection
 substance use (alcohol, drugs)
 cigarette smoking
 Placental anomaly is the most common cause of IUGR
o Factors related to the fetus
 multiple gestation (twins)
 infection
 chromosomal abnormality
 Assessment
o Respiratory distress - hypoxic episodes
o Loose and dry skin ,little fat, little muscle mass
o Wasted Appearance
o Small liver
o Head is larger compared to body
o Wide skull sutures
o Poor skin turgor
o Sunken abdomen
 Babies with SGA may have problems at birth such as:
o Respiratory distress (asphyxia)
o Meconium aspiration
o Hypoglycemia
o Difficulty maintaining normal body temperature
o Polycythemia too many red blood cells
  Nursing Interventions
o Observe for signs of respiratory distress
o Maintain body temperature
o Monitor for infection and initiate measures to prevent sepsis
o Monitor blood glucose levels and for signs of hypoglycemia
o Initiate early feedings and monitor for signs of aspiration.
o Provide stimulation, such as touch and cuddling

LARGE FOR GESTATIONAL AGE

1. Description: Neonate who is plotted at or above the 90 th percentile on the intrauterine growth
curve
2. Weigh more than 4,000 grams
3. Cause – unknown (genetic factors and maternal conditions)
4. Maternal diabetes – is the most widely known contributing factor
5. Increase insulin acts as a fetal growth hormone
6. Macrosomia – an unusually large newborn with birth weight of more than 4500grams

Assessment
7. large, obese
8. Lethargic and limp
9. May feed poorly
10. Sign and symptoms of birth trauma
 Bruising
 Broken clavicle
 Evidence of molding
 Cephalhematoma
 Caput succedaneum

Problems of LGA babies

1. Hypoglycemia (low blood sugar) of baby after delivery
2. Respiratory distress
3. Hyperbilirubinemia
4. Potential complications related to increase in body size:
a. Leading cause of breech position and shoulder dystocia
b. Fractured skull, clavicles, cervical or brachial plexus injury
and erb’s palsy

Management
Routine newborn care with special emphasis on the following:
a) Monitor vital signs frequently, especially respiratory status.
b) Monitor blood glucose levels and for signs of hypoglycemia
c) Initiate early feedings
d) Note any signs of birth trauma or injury
e) Monitor for infection and initiate measures to prevent sepsis
f) Provide stimulation, such as touch and cuddling.

COMMON ACUTE CONDITIONS OF NEWBORN

RESPIRATORY DISTRESS SYNDROME (RDS)
 Description: Serious lung disorder caused by immaturity and inability to produce surfactant,
resulting in hypoxia and acidosis
 Surfactant – a biochemical compound that reduces surface tension inside the air sac
 Decrease in surfactant results to lung collapse,thus greatly reducing infant’s vital supply of oxygen
 Damaged lung cells combines with other substance present in the lungs to form fibrous substance
called hyaline membrane (Hyaline membrane disease)
  this membrane lines the alveoli and blocks gas exchange in the alveoli

 Assessment
1. Expiratory grunting –major- is the body's way of trying to keep air in the lungs so they will
stay open
2. Tachypnea
3. Nasal flaring
4. Retractions
5. Seesaw – like respirations (chest wall retracts and the abdomen protrudes)
6. Decreased breath sounds
7. Apnea
8. Pallor and cyanosis
9. Hypothermia
 Management to provide adequate oxygen to the baby
a) Oxygen therapy- hood, nasal prong, mask, endotracheal tube , CPAP (Continuous
Positive Airway Pressure) or PEEP (Positive End –Expiratory Pressure) may be used
b) Muscle relaxants – Pancuronium (Pavulon)
 Reduces muscular resistance
 Prevents pneumothorax
 Prepare Atropine or Neostigmine Methylsulfate
c) Liquid Ventilation- Uses perfluorocarbons – substances used in industry to assess leaks
d) Nitric Acid- Causes pulmonary vasodilation – increases blood flow to the alveoli
 Nursing Interventions
1. Monitor color, respiratory rate, and degree of effort in breathing.
2. Support respirations as prescribed
3. Monitor arterial blood gases and oxygen saturation levels (arterial blood gases from
umbilical artery).so that oxygen administered to the newborn is at the lowest possible
concentration necessary to maintain adequate arterial oxygenation.

RETINOPATHY OF PREMATURITY
 Vascular disorder involving gradual replacement of retina by fibrous tissue and blood vessels
 Primarily caused by prematurity and use of supplemental oxygen (longer than 30 days)
 Oxygen administration should never be more than 40% unless hypoxia is documented
 Any premature newborn who required oxygen support should be scheduled for an eye
examination before discharge to assess for retinal damage.
 Bronchopulmonary Dysplasia- over expanded lungs prolonged use of O2
 Management:
 a) Suction every 2 hours or more often as necessary.
b) Prepare to administer surfactant replacement therapy (instilled into the endotracheal
tube)
c) Administer respiratory therapy (percussion and vibration)
d) Provide nutrition
e) Support bonding
f) Encourage as much parental participation in newborn's care as condition allows.

HYPERBILIRUBINEMIA
 Description: is an abnormally high level of Bilirubin in the blood; results to jaundiced
 In physiologic jaundiced:
 occurs on the second day to seventh day
 average increase of 2mg/dl; not exceeding 12mg/dl
 Pathological Jaundice of Neonates
 Any of the following features characterizes pathological jaundice:
 Clinical jaundice appearing in the first 24 hours.
 Increases in the level of total bilirubin by more than 12 mg/dl
 Therapy is aimed at preventing Kernicterus, which results in permanent neurological damage
resulting from the deposition of bilirubin in the brain cells.
 Causes:
a) Immaturity of the liver

b) Rh or ABO incompatibility

c) Infections

d) Birth trauma

e) Maternal diabetes

f) Medications

 Assessment

 Jaundice

 Dark concentrated urine

 Enlarged liver

 Poor muscle tone

 Lethargy

 Poor sucking reflex

 Management

1. Phototherapy

- is use of intense florescent lights to reduce serum bilirubin levels

-The use of blue lights overhead or in blanket –device wrapped around infant

- is use of intense florescent lights to reduce serum bilirubin levels in the newborn
- Injury from treatment, such as: eye damage, dehydration, or sensory deprivation

- Possible complication of phototherapy: eye damage, dehydration, sensory deprivation

- Wallaby blanket-a blanket which, when wrapped around the infant’s torso, delivers effective
therapy to jaundiced babies

- no need to cover the baby’s eyes as all light treatment is delivered through the blanket

2. Exchange blood transfusion via umbilical catheter-for very severe cases

 infants blood – remove = 5 / 10ml at a time

 Nursing Interventions

1. Expose as much of the newborn's skin as possible.

2. Cover the genital area, and monitor the genital area for skin irritation or breakdown.

3. Cover the newborn's eyes with eye shields or patches; make sure that eyelids are closed
when shields or patches are applied.

4. Remove the shields or patches at least once per shift (during a feeding time) to inspect
the eyes for infection or irritation and to allow eye contact and bonding with parents.

5. Monitor skin temperature closely.

6. Increase fluids to compensate for water loss.

7. Expect loose green stools and green urine.

8. Monitor the newborn's skin colorwith the fluorescent light turned off, every 4 to 8
hours.

9. Monitor the skin for bronze baby syndrome- a grayish-brown discoloration of the skin.

10. Reposition newborn every 2 hours.

11. Provide stimulation.

12. After treatment, continue monitoring for signs of hyperbilirubinemia, because rebound
elevations are normal after therapy is discontinued.

13. Turn off phototherapy lights before drawing blood specimen for serum bilirubin levels
and avoid allowing blood specimen to remain uncovered under fluorescent lights (to
prevent the breakdown of bilirubin in the blood specimen).

14. Monitor for the presence of jaundice; assess skin and sclera for jaundice.

15. Examine the newborn's skin color in natural light.

16. Press finger over a bony prominence or tip of the newborn's nose to press out capillary
blood from the tissues.
 17. Jaundice starts at the head first, spreads to the chest, abdomen, and then the arms and
legs, followed by the hands and feet

18. Keep newborn well hydrated to maintain blood volume.

19. Facilitate early, frequent feeding to hasten passage of meconium and encourage
excretion of bilirubin.

20. Report to the physician any signs of jaundice in the first 24 hours of life and any
abnormal S&S

21. Prepare for phototherapy, and monitor the newborn closely during the treatment.
MECONIUM ASPIRATION SYNDROME (MAS)
 occurs when infants take meconium into their lungs during or before delivery
 Occurs in term or post-term infants
 During fetal distress there is increases intestinal peristalsis, relaxing the anal sphincter and
releasing meconium into the amniotic fluid.
 Aspiration can occur in utero or with the first breath.
 Meconium can block the airway partially or completely and can irritate the newborn’ airway,
causing respiratory distress
 Assessment:
1. Respiratory distress is present at birth:
- tachypnea,
- cyanosis,
- retractions,
- nasal flaring,
- grunting,
- crackles, and rhonchi may be present.
- infant's nails, skin, and umbilical cord may be stained a yellow-green color.
 CAUSES and RISK FACTORS:
1. Common to post mature
2. Maternal history of diabetes
3. Hypertension
4. Difficult delivery
5. Poor intrauterine growth
 Management
a) Suctioning must be done immediately after the head is delivered before the first breath is
taken;
b) Vocal cords should be viewed to see if the airway is clear before stimulation and crying
Extracorporeal membrane oxygenation (ECMO)- Cardiopulmonary bypass to support gas
exchange allows the lungs to rest
 Nursing interventions
1. Observing neonates respiratory status closely
2. Ensuring adequate oxygenation
3. Administration of antibiotic therapy
4. Maintain thermoregulation

SEPSIS
 Description: Generalized infection resulting from the presence of bacteria in the blood
 Major common cause is group B beta- hemolytic streptococci
 Contributing factors:
1. Prolonged rupture of membranes
2. Prolonged or difficult labor
3. Maternal infection
 4. Cross contamination
5. Aspiration
 Assessment findings – often does not have specific sign of illness
1. Poor feeding
2. Irritability
3. Lethargy
4. Pallor
5. Tachypnea
6. Tachycardia
7. Abdominal distention
8. Temperature instability – difficulty keeping temperature within normal range
 Diagnosis:
1. Blood, urine, and cerebrospinal fluid cultures
2. Routine CBC, urinalysis, fecalysis
3. Radiographic test
 Management
1. Intensive antibiotic therapy
2. IV fluids
3. Respiratory therapy
 Nursing interventions- Routine newborn care with special emphasis on the following:
1. Monitor vital signs, assess for periods of apnea or irregular respirations..
2. Administer oxygen as prescribed
3. Provide isolation as necessary- Monitor and limit visitors
4. Handwashing before after handling neonate

SUDDEN INFANT DEATH SYNDROME

 Sudden death of any young child that is unexpected by history and which thorough postmortem
examination fails to demonstrate adequate cause of death
 Usually occurs during sleep
 Diagnosis is made after autopsy
 High incidence in preterm infants, infants with abnormalities in respiration
 Unknown cause : may be related to a brainstem abnormality in the neurological regulation of
cardio-respiratory control
 Nursing Role:
1. Care is directed at supporting parents/family
2. Provide a room for the family to be alone
3. Reinforce that death was not their fault
4. Provide appropriate support referrals
5. Explain how parents can receive autopsy results
 Prevention:
1. Infants should be placed in the supine position for sleep.
2. Soft moldable mattresses and bedding, such as pillows or quilts, should not be used for
bedding.
3. Stuffed animals should be removed from the crib while the infant is sleeping.
4. Discourage bed sharing (sleeping with an adult).
5. Home apnea monitor to infant with near miss SIDS

CONGENITAL HEART DEFECT

ACYANOTIC TYPE
A. ATRIAL SEPTAL DEFECT
• Abnormal opening in the septum between left and right atria
• Usually detected after neonatal period
S/S: - decrease activity tolerance
 - dyspnea
+ murmur – upper left sternal border
Mgt: Surgery – 2 and 4 yrs of age
B. VENTRICULAR SEPTAL DEFECT
• Opening in the septum between ventricles, causing a left to right shunt
• Small VSD – asymptomatic
• Large –hypertrophy and/or failure of right ventricle
S/S: increase respiratory effort
Frequent respiratory infection
+ murmur – heard best @ lower left sternal border
Congestion - pulmonary
Mgt : Surgery
C. PATENT DUCTUS ARTERIOSUS
• Connects pulmonary trunk to aorta
S/S: + murmur – machinery type @ middle to upper left sternal border
poor feeding
tiring easily
Mgt: Indomethacin
Surgery – ligation
D. COARCTATION OF AORTA
• Narrowing of the aorta
• Significant decrease in blood flow to abdomen and legs
• Blood shunted to head and arms
S/S: BP /pulse – higher in arms than legs
High pulse pressure in carotid and radial pulses
Warm upper body
Mgt: surgery – angioplasty – repaired of narrowed vessel
E. VALVULAR DEFECTS
a. right side – tricuspid
pulmonic valve
b. left side – mitral
aortic valve
S/S: palpitations
Pain
Edema
Weakness, dizziness
Mgt: Surgery – valvotomy, valvuloplasty
valve replacement

CYANOTIC TYPE
A. TRANSPOSITION OF GREAT VESSELS
 Aorta arises from right ventricle, pulmonary artery arises from left ventricle oxygenated blood
therefore circulates through left side of heart to lungs and back to left side
 unoxygenated blood enters the right atrium from body ,goes back to right ventricle and back to
circulation without being oxygenated

S/S:
 Blueness of the skin
 Shortness of breath
 Poor feeding
 Clubbing of the fingers or toes
 peripheral hypoxemia
 severe progressive pulmonary hypertension.
 Complications:
 Arrythmias
  Heart failure

Mgt: Balloon Atrial Septostomy (Rashkind Procedure)

B. TETRALOGY OF FALLOT
 This condition is characterized by the following four defects:
 an abnormal opening, or ventricular septal defect, that allows blood to pass from the
right ventricle to the left ventricle without going through the lungs
 a narrowing (stenosis) at or just beneath the pulmonary valve that partially blocks the
flow of blood from the right side of the heart to the lungs
 the right ventricle is more muscular than normal
 the aorta lies directly over the ventricular septal defect
 Tetralogy of Fallot results in cyanosis (bluish color of the skin and mucous membranes due to
lack of oxygen).
 Cyanosis develops within the first few years of life.
 First presentation may include poor feeding, fussiness, tachypnea, and agitation.
 Cyanosis occurs and demands surgical repair.
 Dyspnea on exertion is common.
 Hypoxic "tet" spells are potentially lethal, unpredictable episodes that occur even in
noncyanotic patients with TOF. These spells can be aborted with relatively simple procedures.
 Birth weight is low.
 Growth is retarded.
 Development and puberty may be delayed.
 Right ventricular predominance on palpation
 May have a bulging left hemithorax
 Systolic thrill at the lower left sternal border
 Single S2 - Pulmonic valve closure not heard
 Systolic ejection murmur
 Cyanosis and clubbing - Variable
 Squatting position
 Scoliosis - Common
 Retinal engorgement
 Hemoptysis

Mgt: Tet Spells

 Knee-chest position: This provides a calming effect, reduces systemic venous return.
 Oxygen therapy
 Morphine sulfate - decrease systemic venous return.
 Surgery: Blalock Taussig Shunt