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At-Risk Newborn

At-Risk Newborn. Twila Brown, PhD, RN. Who Is an At-Risk Infant?. Risk of morbidity or mortality Prenatal and intrapartal risk factors Neonatal factors Gestational age Size Anticipate complications Assessments at birth - Apgar score. High Risk Infant: Overview of Class .

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At-Risk Newborn

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  1. At-Risk Newborn • Twila Brown, PhD, RN

  2. Who Is an At-Risk Infant? • Risk of morbidity or mortality • Prenatal and intrapartal risk factors • Neonatal factors • Gestational age • Size • Anticipate complications • Assessments at birth - Apgar score

  3. High Risk Infant: Overview of Class • Congenital anomalies • Characteristics and potential problems • Preterm & postterm • Small for gestational age & large for gestational age • General concerns • Thermoregulation • Hypoglycemia • Respiratory distress and complications • Hyperbilirubinemia • Psychosocial neonate & family needs

  4. Congenital Anomalies Diaphragmatic Hernia • Abdominal contents herniate through diaphragm • Respirations are compromised • Signs • Respiratory distress and cyanosis • Barrel shape chest, scaphoid abdomen • Asymmetric chest expansion • Absent breath sounds on effected side • Bowel sounds in chest

  5. Congenital Anomalies: Diaphragmatic Hernia • Interventions • Oxygen • Respiratory support without over inflating • Gastric decompression • Head of bed elevated • Turn to affected side • ECMO • Surgical repair

  6. Congenital Anomalies: Tracheo-Esophageal Fistula • Connection between the trachea and esophagus • Proximal esophagus ends in blind pouch and distal esophagus joined to trachea • Signs • Increased oral secretions • Coughs and choking • Abdominal distention • Not able to pass nasal or oral gastric tube • Struggles with feeding

  7. Congenital Anomalies: Tracheo-Esophageal Fistula • Interventions • Withhold feedings • Elevate head of bed • Suction to blind pouch to decrease aspiration • Surgery

  8. Congenital Anomalies: Neurotubular Defects • Tissue protruding through vertebral column • Meningocele • Meningomyelocele • Impairment • Location and magnitude of defect determines extent of neuro impairment • Sensory impairment follows motor, affects bladder and anal sphincter, contractures and deformities

  9. Congenital Anomalies: Neurotubular Defects • Intervention • Pregnancy -- Folic acid and Alpha fetal protein • Sterile, moist, normal saline dressing • Prevent infection • Decrease trauma • Monitor for changes in fluid and heat loss • Surgical repair, keep prone with legs flexed, no diaper over incision • Long term: hydrocephalus, wheelchair, braces, catheterization

  10. Congenital Anomalies: Gastrocele and Omphalocele • Gastroschisis • Abdominal contents protrude through wall • No sac covering intestines • Omphalocele • Abdominal contents protrude into umbilical cord • Covered by translucent sac • Associated with other anomalies

  11. Congenital Anomalies: Gastrocele and Omphalocele • Interventions • Warm, moist, sterile dressing and plastic wrap • Maintain hydration and temperature • Position supine or side • Gastric decompression • Surgical repair • Complications

  12. Congenital Anomalies: Choanal Atresia • Occlusion at nasopharnyx • Signs • Snorting respirations • Difficulty breathing with feedings • Cyanosis • Interventions • Assess patency of nares • Maintain airway with oral airway • Position with head of bed elevated

  13. Congenital Anomalies: Cleft Lip and Palate • Fissure involving nares, nasal septum, or connecting oral and nasal cavity • Intervention • Feedings with special nipples • Feed upright and burp frequently • Prevent aspiration • Clean mouth after feedings

  14. Congenital Anomalies: Heart Defects • Signs • Cyanosis • Heart murmur • Heart failure • Most common defects • Patent ductus arteriosus • Ventricular septal defect • Coarctation of the aorta • Hypoplastic left heart • Tetralogy of Fallot • Transposition of the great vessels

  15. Substance-abusing Mother: Fetal Alcohol Syndrome • Facial abnormalities • Behaviors • Difficulty establishing respirations • Sleeplessness - Jittery • Hyperalert states - Hyper reflexes • Inconsolable crying - Poor sucking • Irritability - Lethargy

  16. Substance-abusing Mother: Fetal Alcohol Syndrome • Long-term complications • Hypotonic and poor coordination • Mental retardation or normal intelligence • Speech and learning disabilities • Hyperactivity and impulsivity • Growth retardation • Intervention • Treat respiratory distress • Reduce environmental stimulation • Extra feeding time

  17. Substance-abusing Mother: Drug Dependence • Pregnant woman increased risk of • Abruptio placentae, abortion, preterm labor, precipitous labor • Neonate increased risk of • Intrauterine asphyxia • Respiratory problems • Urogenital malformation • Cerebrovascular complications • Low birth weight and head circumference • Drug withdrawal

  18. Substance-abusing Mother: Drug Dependence • Key assessment findings • Tachypnea - Sensitive to stimuli • High-pitched cry - Low birth weight • Jitteriness - Hyperactive Moro reflex • Poor sleeping - Increased reflexes • Irritability - Diarrhea & vomiting • Interventions • Swaddling - Calm environment • Frequent feeding - Medication • Promote bonding

  19. Inborn Error of Metabolism: Phenyleketonuria (PKU) • Condition affects protein metabolism • No enzyme to convert phenylalanine to tyrosine • Affects development of brain and CNS • Mental retardation if untreated • CNS damage minimized if treatment before age 3 months

  20. Inborn Error of Metabolism: Phenyleketonuria (PKU) • Assessment • Positive Guthrie test – 24 hrs after feedings • Failure to thrive - Microcephaly • Vomiting - Hyperactivity • Skin lesions - Irritability • Repetitive motions • Seizures and tremors • Musty odor from skin and urine • Intervention • Low-phenylalanine formula • Teach parents allowed foods in the diet

  21. Inborn Error of Metabolism: Congenital Hypothyroidism • Enzymatic defect, lack of idodine in maternal diet, or maternal drugs can depress thyroid tissue • Causes growth and mental retardation • Assessment • Large tongue = Prolonged jaundice • Umbilical hernia = Poor feeding • Mottled skin = Low-pitch cry • Large fontanelles = Poor weight gain • Hypotonia = Delayed development • Intervention: Monitor thyroid medication

  22. Identification of At-Risk Newborns • Gestational age • Preterm • Post-term • Size of neonate • Small for gestational age • Large for gestational age

  23. Large for Gestational Age • Birth weight at or above the 90th percentile • Etiology • Large parents • Multiparous women • Males larger than female • Assessment findings • Poor muscle tone and motor skills • Difficult to arouse and maintain an alert state

  24. Large for Gestational Age • Complications • Birth trauma – ceohalopelvic disproportion • Asphyxia • Meconium aspiration • Polycythemia • Hypoglycemia

  25. Infant of Diabetic Mother • Severe diabetes associated with vascular complications may have small babies • Mothers with classes A and C may have LGA • High glucose stimulates fetal insulin increase • Complications • Hypoglycemia • Hypocalcemia • Hyperbilirubinemia • Birth trauma

  26. Infant of a Diabetic Mother • Complications • Polycythemia • Respiratory distress syndrome • Congenital birth defects • Interventions • Test blood glucose • Cord blood; q hr X 4; q 4hr for 24 hrs • If blood glucose is < 40 mg/dl • Feeding • IV fluid of 10% dextrose water

  27. Small for Gestational Age • Birth weight at or below the 10th percentile • Intrauterine growth retardation • Deficiency of nutrients through the placenta • Poor nutrition • Smoking or drug use • Pregnancy induced hypertension • Advanced diabetes • Intrauterine infection

  28. Small for Gestational Age • Physical characteristics • Decreased subcutaneous tissue • Loose skin • Thin/dry umbilical cord • Alert for size • Dubowitz changes • Problems • Hypothermia • Hypoglycemia • Asphyxia • Meconium aspiration

  29. Small for Gestational Age • Problems • Hypocalcemia • Feeding difficulties • Polycythemia • Interventions • Support respirations • Provide neutral thermal environment • Provide appropriate nutrition and hydration • Monitor blood glucose levels • Cluster care • Provide skin care

  30. Post-term Infant • Infant born after 42 weeks gestation • Most continue to be well nourished • Postmaturity syndrome • Calcium deposits decrease placenta function • Results in lack of oxygen and nutrients • Physical characteristics • Absent vernix and decreased lanugo • Dry, cracked, parchment-like skin, peeling • Hard, long nails • Abundant scalp hair

  31. Post-term Infant • Physical characteristics • Loose skin • Decreased subcutaneous fat • Problems • Hypothermia • Hypoglycemia • Asphyxia • Meconium aspiration • Polycythemia • Interventions • Supportive

  32. Premature Infant • Born before the 37th week gestation • Physical characteristics • Skin is thin, smooth, shiny, with visible veins • Minimal subcuatneous fat deposits • Lanugo over body • Minimal sole and palm creases • Large head • Ears have soft cartilage • Genitals • Posture is extended • Reflexes absent or weak -- suck, gag

  33. Premature Infant • Problems • Hypothermia • Hypoglycemia • Respiratory distress syndrome • Apnea and bradycardia • Patent ductus arteriosus • Hyperbilirubinemia • Anemia • Intraventricular hemorrhage • Retinopathy of prematurity • Necrotizing entercolitis

  34. Apnea & Bradycardia • Bradycardia: heart rate less than 100 bpm • Apnea: not breathing for > 15 to20 seconds • Causes of apnea • Obstructed airway • Hypothermia or hyperthermia • Hypoglycemia • Sepsis • Respiratory distress

  35. Apnea and Bradycardia • Causes of apnea • Anemia • Hypercapnea • Sepsis • Hypocalcemia • Seizure • Vagal response • Dehydration • CNS depression • Intraventricular hemorrhage

  36. Apnea and Bradycardia • Interventions • Tactile stimulation • Suction airway • Provide oxygen • Provide mechanical ventilation • Correct underlying cause • Administer CNS stimulants • Caffeine or theophylline

  37. Intraventricular hemorrhage • Hemorrhage in the ventricles of the brain • May cause motor deficits • Hydrocephalus • Sight and hearing loss • Causes • Capillary walls vulnerable to hypoxic events • Hypoxia & high CO2 dilates cerebral vessels • Changes in intravascular pressure

  38. Intraventricular hemorrhage • Signs • May be no signs • Bulging fontanel • Signs of intracranial pressure • Interventions • Keep cerebral blood flow constant • Prevent hypoxia • Prevent increased blood pressure • Elevate head of bed

  39. Causes Iron stored late Short life of RBC Blood drawing Hemorrhage Interventions Transfuse Packed red blood cells Iron suppliments and erythopoientin Signs Pallor Tachypnea Dyspnea Tachycardia Activity intolerance Feeding difficulty Anemia

  40. Retinopathy of Prematurity • Progressive disorder of retina vessels • Scar tissue and retina detachment • Causes • Fragile retinal vessels • Fluctuating oxygen administration levels lead to rapid vasodilation and vasoconstriction • Also occurs with hypoxemia, intraventricular hemorrhage, infection, acidosis, exposure to bright lights

  41. Retinopathy of Prematurity • Interventions • Decrease intracranial pressure • Careful O2 administration • Decrease lighting in NICU • Eye exams • May regress spontaneously • Laser/cryosurgery • Vitamin E

  42. Necrotizing entercolitis • Cause • Bowel eschemia during hypoxia • Gas forming bacteria invade damaged cells of intestinal wall • Cells rupture causing air in surface of bowel • Damages bowel wall and causes bleeding • Milk in bowel provides rich media for bacteria growth

  43. Necrotizing entercolitis • Abdominal signs • Pneumotosis in bowel wall • Free air in abdomen if perforated • Distended and shiny abdomen • Gastric retention • Blood in stools • No bowel sounds • Signs of sepsis

  44. Necrotizing entercolitis • Interventions • NPO • Nasal gastric tube for decompression • X-rays to follow deterioration of bowel • Antibiotics • Surgery – resection of damaged portion • Monitor for abdomen distension • Hematest stools • Long-term IV therapy • Decrease O2 consumption

  45. Nutrition for the Preterm • Inability to nipple feed until 35-36 wks • Gag reflex • Suck/swallow/breathe coordination • Tires easily and worsens respiratory distress • Require different composition of formula • Increased metabolic rate • Difficulty consuming calories • Low iron and glycogen stores • Equipment

  46. Nutrition for the Preterm • IV total parenteral nutrition and lipids • Gavage feedings • Calorie requirement • Fluid requirement • High insensible water loss • Urine output • Signs of feeding intolerance

  47. References • Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning. • Olds, S.B., London, M.L., Ladewig, P.W., & Davidson, M.R. ( 2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall. • Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders. • Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.

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