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High Risk Newborn Chapter 23

High Risk Newborn Chapter 23. Mary L. Dunlap MSN Fall 2014. Birth Weight Variations. Appropriate for gestational age (AGA) Small for gestational age (SGA) Large for gestational age (LGA). SGA. SGA weight- less than 5lb 8 oz and below the 10 th % at term

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High Risk Newborn Chapter 23

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  1. High Risk NewbornChapter 23 Mary L. Dunlap MSN Fall 2014

  2. Birth Weight Variations • Appropriate for gestational age (AGA) • Small for gestational age (SGA) • Large for gestational age (LGA)

  3. SGA • SGA weight- less than 5lb 8 oz and below the 10th% at term • IUGR- High risk growth does not meet the expected growth pattern and is pathologic • Symmetric IUGR- poor growth rate of head, abdomen and long bone • Asymmetry IUGR- head long bones spared (after 28 wks.)

  4. SGA Characteristics • Decreased breast tissue • Scaphoid abdomen (sunken) • Wide sutures • Thin umbilical cord • Head larger than body • Wasted appearance to extremities • Reduced fat stores

  5. SGA Common Problems • Perinatal asphyxia • Hypothermia- lack of brown fat • Hypoglycemia- lack of glycogen stores • Polycythemia- increase rate of production due to hypoxia • Meconium Aspiration

  6. Nursing Management • Initiate early and frequent oral feedings • Monitor for hypoglycemia • IV infusion of 10% dextrose if unable to maintain glucose level. • Weigh daily • Promote rest periods to decrease metabolic requirements • Monitor for Polycythemia

  7. LGA • Weight- Larger than 9 lbs. and above the 90th% • Infant can be preterm, term, or post-term

  8. LGA Characteristics • Large body-plump full face • Body size is proportionate • Poor motor skills • Difficulty in regulating behavioral state (arouse to quiet alert state)

  9. LGA Common Problems • Birth Trauma • Hypoglycemia • Polycythemia • Hyperbilirubinemia • Shoulder dystocia

  10. LGA Nursing Management Hypoglycemia • Screen newborn for hypoglycemia • Encourage feedings • IV glucose Hyperbilirubinemia • Hydration • Phototherapy

  11. Gestational Age Variations • Preterm newborn • Late Preterm • Post-term newborn • Term newborn

  12. Post Term Newborn • Gestation > 42 weeks • Must determine if EDC is truly post term • After 42 weeks placenta loses ability to nourish the fetus

  13. Post term NewbornCharacteristics • Newborn emaciated • Meconium stained • Hair and nails long • Dry peeling skin • Creases cover soles • Limited vernix and lanugo

  14. Nursing Management • Prepare for the delivery • NICU care • Monitor blood glucose levels and treat as required • Initiate feedings as soon as possible • Monitor temperature and respiratory characteristics • Assess for polycythemia and hyperbilirubinemia

  15. Preterm Infant • Infant born prior to the completion of the 37th week • Organs immature • Lack physical reserves • Survivability related to weight and gestational age

  16. Preterm Infant Causes based on research: • Infection • Maternal or fetal stress • Bleeding • Stretching

  17. Immediate Delivery Care • Evaluate prenatal risk factor • Rapid assessment • Basic equipment Box 23.2 pg. 795 • ABC’s of resuscitation Box 23.3

  18. Preterm Infant Respiratory last to mature • Surfactant deficiency-RDS • Unstable chest wall-atelectasis • Immature respiratory centers-apnea • Small passages-obstructions • Unable to clear fluid-TTN

  19. Preterm Infant Cardiovascular • Difficulty transitioning from fetal to neonatal circulatory pattern • Congenital anomalies associated with continued fetal circulation • Fragile blood vessels (brain) • Impaired regulation of B/P

  20. Preterm Infant Gastrointestinal • Lack neuromuscular coordination suck- swallow-breath • Perinatal Hypoxia shunts blood from the gut • Small stomach-compromised metabolic function • Risk for malnutrition -wt. loss

  21. Preterm Infant Renal System • Slow glomerular filtration rate • Reduced ability to concentrate urine • Risk: fluid retention, electrolyte imbalance, drug toxicity

  22. Preterm Infant Immune system • Deficiency of IgG (trans-placental transfer after 34 wks.) • Impaired ability to produce antibodies • Thin skin- limited protection barrier

  23. Preterm Infant Central nervous system • Long term disability due to injury • Immature temperature-regulating center • Susceptible to hypoglycemia

  24. Preterm Characteristics • Wt less than 5.5lb • Head larger than chest • Poor muscle tone • Minimal fat • Thin transparent skin • Undescended testicles & minimal scrotal rugae • Prominent labia & clitoris

  25. Nursing Assessment • Review prenatal record for risk factors • Head to toe assessment • Monitor respiratory effort • Monitor V.S. • Monitor for hypoglycemia

  26. Nursing Management Varies with gestational age • Promote oxygenation • Promote Thermoregulation • Promote optimal nutrition

  27. Nursing Management Continue • Prevent infections • Provide stimulation • Pain management Prevention & Management Box23.4 pg. 800 Nonpharmacologic Techniques Box 23.5 pg.801 • Pharmacologic agents

  28. Nursing ManagementContinue • Promote bonding • Quite environment • Promote parent coping • Discharge Planning Box 23.6 pg 803 Nursing Care plan 23.1 pg 792-794

  29. Perinatal Loss • Table 23.2 pg 805

  30. Chapter 24Newborn at Risk

  31. Acquired vs. Congenital Acquired disorders • Typically occur at, or soon after, birth • Problems or conditions experienced by the woman during her pregnancy or at birth • Possibly no identifiable cause for the disorder Congenital disorders • Present at birth; usually due to some type of malformation occurring during the antepartal period; typically some problem with inheritance

  32. Neonatal Asphyxia • Failure to establish adequate, sustained respirations after birth • Pathophysiology: insufficient oxygen delivery to meet metabolic demands

  33. Nursing Assessment • Asses for risk factors • newborn’s color • work of breathing • heart rate • Temperature • Apgar scores

  34. Nursing Management • Immediate resuscitation • Continued observation • Neutral thermal environment • Blood glucose levels • Parental support and education

  35. Transient Tachypnea Newborn TTN • Mild respiratory condition • Result of delayed or incomplete absorption of fluid from the lungs • Occurs within a few hours of birth • Resolves over 24-72 hour period

  36. Transient Tachypnea Newborn TTN Symptoms • Respiratory rate as high as 100-140 • Labored breathing • Grunting nasal flaring • Retractions • Chest x-ray shows lymphatic engorgement ( retained lung fluid)

  37. Transient Tachypnea Newborn Nursing Care • Mainly supportive • Monitory VS & O2 Sats • Provide supplemental O2 • IV fluids • Gavage feedings

  38. Respiratory Distress Syndrome • RDS result of lung immaturity and surfactant deficiency • Poor gas exchange & ventilation • Seen in preterm newborns • Cesarean births without labor • Infants of diabetic mothers

  39. Nursing Assessment Symptoms • Noted at birth or within in a few hours • Expiratory grunting • Nasal flaring • Chest wall retractions • Seesaw respirations • Generalized cyanosis

  40. Nursing Assessment Symptoms • Tachypnea- rates above 60 • Fine inspiratory crackles • Tachycardia- rates above 150-180 • Silverman-Anderson index assessment • Chest x-ray- alveolar atelectasis (ground glass pattern) • Lab test done to r/o infection and sepsis

  41. Silverman-Anderson Tool

  42. RDSNursing Management Supportive care • Thermoregulation- prevent cold stress • O2 administration • Fluid management • Nutritional support • Surfactant replacement therapy • Monitor VS & O2 sats

  43. Meconium Aspiration • Fetus inhales meconium into the lungs while in utero • Meconium blocks the airway preventing exhalation • Meconium irritates the airway making breathing difficult (chemical pneumonia) • Meconium aspiration related to fetal distress during labor.

  44. Nursing Assessment Symptoms • Cyanosis • Tachypnea • Course & rhonchi • Labored breathing • Apnea • X-ray patches or streaks of meconium & trapped air

  45. Meconium Aspiration Nursing Management • Assess for risk factors prior to delivery • Neutral Thermal environment • Supplemental O2 • Medications • Monitor response to treatment

  46. Persistent Pulmonary Hypertension • Marked pulmonary hypertension causing right to left extrapulmonary shunting and hypoxemia • Cause occur idiopathically or as a complication of perinatal asphyxia, meconium aspiration syndrome, congenital heart defects

  47. Persistent Pulmonary Hypertension Nursing Assessment • Tachypnea within 12 hours after birth • Marked cyanosis, grunting, and retractions • Systolic ejection murmur • Blood pressure • Oxygen saturation • Echocardiogram

  48. Persistent Pulmonary Hypertension Nursing Management • Monitoring of oxygenation, perfusion, and blood pressure • Immediate resuscitation; oxygen therapy • Respiratory support • Medications • Clustering of care • Parental support and education

  49. Retinopathy • Developmental abnormality affecting immature blood vessels of the retina • Five stages from mild to severe based on severity, location by zones in the retina, and proportion of retinal circumference • If a newborn is premature, vessels may cease to develop. • ROP typically develops in both eyes due to hypoxemia (because of assisted ventilation and high oxygen exposure), acidosis, or shock.

  50. Retinopathy • Review prenatal history for risk factors (hypertension, substance abuse, preeclampsia, heavy cigarette smoking, or placental insufficiency). • Assess newborn’s gestational age and weight; newborns weighing less than 1,500 grams or born at 28 weeks’ gestation or less are at risk. • Evaluate the newborn’s history for duration of intubation and use of oxygen therapy, intraventricular hemorrhage, and sepsis.

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