Nursing Care of a Family with

a High-risk Newborn

asurat 1
Newborn priorities in first days
of life
1. Initiation and maintenance of respirations
2. Establishment of extrauterine circulation
3. Control of body temperature
4. Intake of adequate nourishment
5. Establishment of waste elimination
6. Prevention of infection
7. Establishment of an infant-parent
relationship
8. Developmental care or care that balances
physiologic needs and stimulation for best
development
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1. Initiation and maintenance of
respirations

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Initiation and maintenance of
respirations
• Establish respiration immediately to
prevent:
a.Respiratory acidosis
b.Falling of blood pH and bicarbonate
c.Cerebral hypoxia

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Causes of asphyxia/acidosis
while inside the utero
• Cord compression
• Maternal anesthesia
• Placenta previa
• Abruptio placenta

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Factors predisposing infants to
respiratory difficulty in the 1st few
days of life
• Low birth weight
• Maternal history of diabetes
• Premature rupture of membranes
• Maternal use of barbiturates or
narcotics close to birth
• Meconium staining
• Irregularities detected by fetal heart
monitor during labor
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Factors predisposing infants to
respiratory difficulty in the 1st few days
of life
• Cord prolapse
• Lowered apgar score (<7) AT 1-5
MINUTES
• Postmaturity
• Small for gestational age
• Breech birth
• Multiple birth
• Chest, heart or respiratory tract
anomalies
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Resuscitation
• If breathing is ineffective circulatory shunts ( ductus
arteriosus) fails to close
because:
 There is increase pressure in the left side than
at the right side of the heart
 Blood circulates through a patent ductus
arteriosus left to right or from aorta to
pulmonary artery

RESULT: newborn struggles to breathe and circulate

blood uses available serum glucose
hypoglycemic
• Resuscitation is done for those newborns who fails to take
first breath
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Resuscitation process
a. Establish and maintain an airway
 bulb syringe suction (mouth then nose)
 Rub the back ( be sure that the baby is dry)
 If a newborn has to attempt to raise body
temperature because of chilling, this will
increase the need for oxygen which the baby
cannot supply because breathing has not yet
initiated.
 warmed, blow-by oxygen by face mask or positive
pressure mask may be administered

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• If meconium stained:
 DO NOT stimulate an infant to breathe by
rubbing the back or administering air or
oxygen under pressure
EFFECT: could push meconium down into
an infant’s airway compromising
respiration
 GIVE oxygen by mask without pressure
 Wait for a laryngoscope to be passed and
the trachea to be deep suctioned before
giving oxygen under pressure
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• If for deep suctioning:
Place an infant on the back and slide a folded towel
or pad under the shoulders to raise them slightly to
the head is in a neutral position.
Slide a catheter (French 8- French 12) over the
infant’s tongue to the back of the throat
Do not suction for longer than 10 seconds – to
avoid removing excessive air from an infant’s lungs
Use a gentle touch
 bradycardia or cardiac arrhythmias can occur
because of vagus stimulation from vigorous
suctioning

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• An infant who still makes no effort at
spontaneous respiration requires immediate
laryngoscopy to open the airway.

• Laryngoscope deep tracheal suctioning

endotracheal tube insertion

Oxygen administration by a positive

pressure bag and mask with 100%
oxygen at 40 to 60 breaths/minute

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• Primary apnea – period of halted respiration
- a pause in respiration longer
than 20 seconds with an
accompanying bradycardia)after 1
or 2 minutes)
Resuscitation attempts are generally successful

Secondary apnea – respiratory effort will

become weaker, heart rate
will fall, stops breathing
Resuscitation attempts become difficult and
ineffective
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• Size of • Size of
laryngscope: endotracheal tube
0 – 1cm = newborn Infants under 100 g
= 2.5mm

Over 3000g = 4.0

mm

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Resuscitation process
b. Lung expansion
- Once an airway has been established,
newborn’s lungs need to be expanded
- Lungs are inflated by the first breath
- Cry – proof of lung expansion
- 40 cm H20 = pressure to open the lung
alveoli for the first time
- 15- 20 cm H2o – pressure to continue
inflating alveoli
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• The levels of oxygen should not fluctuate
effect: can cause bleeding from immature
cranial vessels

• No pressure above what is necessary

Effect: excessive force can rupture lung alveoli

 To be certain that oxygen is reaching the lungs

with resuscitation- monitor the newborn’s
oxygen level with pulse oximetry and
auscultating the chest.
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• If air can be heard on only one side or
sounds are not symmetric
reason: the endotracheal tube is probably
at the bifurcation of the trachea and
blocking one of the main stem bronchi.
• When oxygen is given under pressure, the
stomach quickly fills with oxygen( causes
vomiting and aspiration of stomach
contents)

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• If resuscitation continues for over 2
minutes,
 insert an orogastric tube and leaving
the distal end open
reasons:
o will help deflate the stomach
o decreases the posibilility of vomiting and
aspiration of stomach contents from
overdistention
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• Administration of narcotic ( morphine
or mepedridine (Demerol) during labor
causes respiratory depression.
• Narcan (narcotic antagonist)-
Naloxone
 injected into the umbilical vessel
Or injected intramuscularly into a thigh
Relieves depression
Dose: 0.01 to 0.1 mg/kg body weight
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 Other drugs used in resuscitation
Drug use Drug use
4. Epinephrine Strengthens or
1. Atrophine Reduces bronchial
initiates cardiac
secretions
contractions
Increases heart rate
Reduces vagus
and blood pressure
nerve effects
5. Lidocaine Counteracts
Relives bradycardia ventricular
arrhythmias
2. Calcium chloride Increases heart 6. Sodium Corrects metabolic
contractility bicarbonate/ acidosis
tromethamine
3. Dopamine Increases systemic Do not give this
blood perfusion by unless ventilation is
increasing blood adequate or
pressure through acidosis can be
beta agonistaracelifloressuratNCM
action 109 increased by 20
retained CO2
Resuscitation process
c. Ventilation Maintenance
- An increase respiratory rate in a
newborn is the first sign of
obstruction or respiratory
compromise.
- If RR is increased = undress the
baby’s chest and look for retractions

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• Interventions:
 Places under a warmer and remove the
clothing from the chest= this prevents
acidosis
 Place the infant in supine and elevate the
bed at 15 degrees= this allows the
abdominal contents to fall away from the
diaphragm, offering additional breathing
space.
 Suction secretions
 Monitor oxygen level
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2. Establishment of extrauterine
circulation

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Establishment of extrauterine
circulation
• If an infant has NO audible heartbeat or if the cardiac rate is
below 80 beats/minute

Action: closed chest massage should be started

 hold an infant with fingers supporting the
back and depress the sternum with two
fingers
 Depress the sternum approximately 1/3 of its
depth (1 or 2 cm) at a rate of 100 times/min.
 Lung ventilation at a rate of 30x/min
 Ratio: 1:3

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• If heart sounds are not resumed
above 80 bpm after 30 seconds of
combined positive pressure
ventilation and cardiac compression
Action: spray epinephrine 0.1 to 0.3
ml/kg (1:10,000) into endotracheal
tube to stimulate cardiac function.

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3. Maintaining Fluid and
Electrolyte Balance

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• Lactated Ringers solution or 5% dextrose are
commonly used to maintain fluid and electrolytes
levels.
• Sodium, potassium and glucose are needed.
• Rate of fluid administration must be carefully
monitored
WHY? Can lead to patent ductus arteriosus or
heart failure

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• Use of radiant warmer may increase in
water loss from convection and radiation.
Therefore: the newborn requires fluid
than he or she is placed in a
double walled incubator.
• Monitor urine output and specific gravity to
determine dehydration.
 A Urine Output of <2ml/kg/hr or a
specific gravity >1.luid intake.015 to 1.020
suggests inadequate

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• If an infant has hypotension without
hypovolemia, a vasopressor such as
dopamine may be given to increase
BP and improve cell perfusion.
• If hypovolemia is present, the cause
is fetal blood loss from placenta
previa or twin-twin transfusion.

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• If hypovolemia is present observe the
ff:
 Tachypnea
 Pallor
 Tachycardia
 Decreased arterial blood pressure
 Decreased central venous pressure
 Decreased tissue perfusion of
peripheral tissue
 Metabolic acidosis
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4. Regulating Temperature

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• All high risk infants have difficulty
maintaining a normal temperature.
• Maintain a neutral temperature
environment
• If the environment is TOO HOT,
metabolism decreases
• If the environment is TOO COLD,
increases metabolism
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• The increased metabolism requires
increased oxygen
• Without oxygen
----hypoxic
----vasoconstriction of blood
vessels occurs
-----decreased pulmonary
perfusion(if prolong)
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• ------PO2 lever falls and PCO2
increases
• Decrease PO2
effect: may open fetal right to left
shunts
surfactant production may stop

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To prevent newborn from becoming
chilled after birth:
 Wipe an infant dry
 Cover the head with a cap
 Place the baby immediately under a
prewarmed radiant warmer or in a
warmed incubator ( 97.8 F/36.5C)
 Skin-skin
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5. Establishing adequate
nutritional intake

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• Infants with severe asphyxia at birth
receive IVF
Reason: for them not to be
exhausted from sucking or until
necrotizing enterocolitis has been
ruled out.

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• If RR is rapid and with NEC
Action: gavage feeding
preterm infants should be
breastfed/ manually express
breastmilk
Expressed breastmilk should be stored in a
nonshiny plastic bags or bottles to avoid the
infant being exposed to polycarbonate

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6. Establishing waste
elimination

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• Immature infants void within 24
hours of birth
Reason: BP may not be adequate to
optimally supply their kidneys

• Immature infants pass stool late than

term
Reason: meconium has not yet
reached the end of the intestine at
birth
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7. Preventing infection

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• Infection from prenatal, perinatal and
postnatal causes
• PROM
• pneumonia
• Skin lesions

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Viruses that causes
infection
Early onset sepsis Late onset sepsis
Grp b Streptococcus Staphylococcus aureus
E. Coli enterbacter
Kelbsiella candida
Listeria monocytogenes

Common viruses that affects the

utero
Cytomegalovirus
toxoplasmosis

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8. Establishing Parent-infant
bonding

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• Be certain that the parents of a high
risk newborns are kept informed
• If an infant dies despite newborns
resuscitation attempts, parents need
to see the infant without being
covered by a myriad of equipment

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9. Anticipating Developmental
Needs

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• High risk newborns need special
care to ensure that the amount of
pain they experience during the
procedures is limited to the least
amount possible’
• Follow up of high risk infants at
home

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The end!

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