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High Risk Neonate

High Risk Neonate. Christina Hernandez RN, MSN. The High Risk Newborn. Susceptible to illness or death due to dysmaturity, immaturity, physical disorders, or complications at birth. Risk Factors: Low socioeconomic status, poor nutrition Exposure to environmental dangers

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High Risk Neonate

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  1. High Risk Neonate Christina Hernandez RN, MSN

  2. The High Risk Newborn • Susceptible to illness or death due to dysmaturity, immaturity, physical disorders, or complications at birth. • Risk Factors: • Low socioeconomic status, poor nutrition • Exposure to environmental dangers • Obstetric factors such as age, parity, or other premature births • Medical conditions related to the pregnancy such as PIH, PROM, or infection

  3. Gestational Age

  4. Classification of High Risk Newborns • Gestational Age • Preterm – less than 37 weeks gestation (Late Preterm – 34 – 36.6 weeks gestation) • Term – 38-41 weeks gestation • Postterm – greater than 42 weeks gestation • LGA – large for gestational age - above the 90th percentile • AGA – appropriate for gestational age – between the 10th and 90th percentile • SGA – small for gestational age – below the 10th percentile

  5. Assessment of Gestational Age • Ballard Scale or Dubowitz scale • Neuromuscular characteristics • Physical Characteristics

  6. Classification of High Risk Newborn Large for Gestational Age LGA Appropriate for Gestational Age AGA Small for Gestational Age SGA Maturity and Intrauterine Growth Grid

  7. The Preterm Infant

  8. Characteristics of Preterm Infants • Appear frail & weak • Underdeveloped flexor muscles & muscle tone • Head is larger in comparison with the rest of the body • Lack subcutaneous fat (white fat) • Skin appears red and translucent • Barely apparent small flat nipples • Plantar creases are absent in infants <32 wks • The pinna of the ear is soft and flat • Female – • Male –

  9. Physiologic challenges of the premature infant - Respiratory • Insufficient production of surfactant • Immaturity of alveolar system • Immaturity of musculature and insufficient calcification of bony thorax • Respirations 40-60/min., shallow, irregular, usually diaphragmatic.

  10. Nursing interventions - Respiratory • Assess for signs of Respiratory Distress • Nasal Flaring • Circumoral Cyanosis • Expiratory Grunting • Retractions • Tachypnea • Apneic episodes • Administer O2 • Warmed and humidified • Oxihood • Nasal Cannula • CPAP • Analyze oxygen concentration.

  11. Nursing interventions - Respiratory • Positioning • Position with head slightly elevated and neck slightly extended • Side-lying or prone • Suctioning • Only use when necessary • Be gently so as not to damage fragile mucus membranes

  12. Physiologic Challenges in the preterm infant - Thermoregulation • Heat regulation unstable • Body temperature may be normal but it fluctuates • Higher ratio of body surface in proportion to body weight. • Lack of subcutaneous fat • Poor capillary response to environmental changes. • Decreased brown fat • Thinner skin

  13. Signs of Inadequate Thermoregulation • Axillary temperature <36.3 or >36.9 degrees C • Abdominal skin temperature <36 or >36.5 degrees C • Poor feeding or feeding intolerance • Irritability • Lethargy • Weak cry or suck • Decreased muscle tone • Cool skin temperature • Skin pale, mottled, or acrocyanotic • Signs of hypoglycemia • Signs of respiratory difficulty • Poor weight gain

  14. Nursing Interventions - Thermoregulation GOAL: Neutral thermal environment. • Thermal Neutrality – Nursing Interventions • Incubator or radiant warmer • Warm surfaces • Warm humidified oxygen • Warm ambient humidity • Warm feedings • Keep skin dry and head covered

  15. Radiant Warmer/ Open Warmer Isolette / Incubator

  16. Physiologic Challenges-Fluid & Electrolyte Balance • Preterm infants lose fluid very easily • Rapid respiratory rate and use of oxygen increase fluid lose from the lungs • Lack of keratin, which helps maintain water in the skin • Large surface area & lack of flexion increases insensible water losses • Radiant warmers heighten insensible water loss

  17. Physiologic Challenges-Fluid & Electrolyte Balance • Development of kidneys is not complete until approximately 35 weeks. • In ability of preterm kidneys to concentrate or dilute urine. • Kidneys unable to regulate electrolytes.

  18. Physiologic Challenges-Fluid & Electrolyte Balance Dehydration Overhydration Urine output >5 ml/kg/hour Urine specific gravity <1.001 Edema Weight gain greater than expected Bulging fontanels Blood: Decreased sodium, protein, and hematocrit levels Moist breath sounds Difficulty breathing • Urine output >2 ml/kg/hour • Urine specific gravity >1.020 • Weight loss greater than expected • Dry skin and mucous membranes • Sunken anterior fontanel • Poor tissue turgor • Blood: Elevated sodium, protein, and hematocritlevels

  19. Nursing Interventions- Fluid and Electrolyte Balance • Weigh diapers (1gm = 1ml of urine) • Obtain specific gravity • Carefully regulate IV fluids • Dilute IV medications in as little fluid that is recommended (include medications on intake measurements) • Assess IV sites frequently

  20. Physiologic Challenges-Skin • The Preterm infants skin is: • Fragile • Transparent • Permeable

  21. Nursing Interventions-Skin • Nursing Care • No use of alcohol or betadine on skin • All skin products should be rinsed off with water • No use of adhesives, use pectin barriers and back tape with cotton • Use semi-permeable adhesives such as tegaderm • Reposition frequently, as tolerated

  22. Physiologic Challenges-Infection • Exposure to maternal infections • Lack of transfer of immunoglobulin G (IgG) from mother during third trimester • Immature immune response to infection • Subject to invasive procedures (IV’s, lab’s) • Prolonged hospital stays

  23. Signs and Symptoms of Infection in the preterm infant • Behavioral changes • Color changes • Temperature instability • Cool, clammy skin • Feeding intolerance • Hyperbilirubinemia • Tachycardia followed by apnea and bradycardia

  24. Nursing Interventions-Infection • Maintain skin integrity • Maintain sterile technique with procedures • ‘Scrub’ before entering – EVERYONE • Hand sanitizer at every bedside and used in between care • No entry if sick – EVERYONE • No artificial nails / short nails • Single infant incubators, clean weekly • Report early signs of infection immediately • Assess infants response to treatment (possible resistance) • Position change, use sheepskin

  25. Physiologic Challenges –Hepatic System • Poor glycogen stores -increased susceptibility to hypoglycemia. • Inability to conjugate bilirubin - increase hyperbilirubinemia. • Decrease ability to produce clotting factors, low plasma prothrombin levels.

  26. Physiologic Challenges – Renal System • Decreased glomerular filtration rate • Inability to concentrate urine • Decreased ability of kidneys to buffer • Decreased drug excretion time

  27. Pain in preterm infants • High-pitched, intense, harsh cry • Whimpering, moaning • “Cry face” • Eyes squeezed shut • Mouth open • Grimacing • Bulging or furrowing of brow • Tense, rigid muscles or flaccid muscle tone • Rigidity or flailing of extremities • Color changes: Red, dusky, pale • Increased or decreased heart rate and respirations, apnea • Decreased oxygen saturation • Increased blood pressure • Sleep-wake pattern changes

  28. Nursing Interventions • Swaddle, wake slowly • Pacifier, may use Sucrose • Medications

  29. Signs of Overstimulationin Preterm Infants Oxygenation changes Behavior changes Posture Facial expression Gaze Regurgitation Yawning Fatigue • Respirations • Pulse • Blood pressure • Oxygen saturation levels • Color • Sneezing, coughing, hiccupping

  30. Physiologic Challenges –Digestive System • Decreased gag and suck reflexes • Hypotonic cardiac sphincter • Suck and swallow reflexes may be uncoordinated • Small stomach capacity • Vomiting • Intolerance of fats • Immature absorption of nutrients

  31. Maintaining Nutrition • Nursing Care • Assess Daily weights • Monitor I&O • Accurate IV rates to prevent circulatory overload • Provide feedings via nasogastric if unable to feed orally • Initiate oral feedings and assess for tiring with feedings • Monitor urine pH and specific gravity • Involve parents in feedings

  32. Nursing Interventions • Pre-feeding assessment • Respirations • Measure abdominal girth • Bowel sounds • Gastric residual • Sucking , swallowing , and gag reflexes

  33. Readiness for Nipple Feeding • Rooting • Sucking on gavage tube, finger, or pacifier • Able to tolerate holding • Respiratory rate <60 breaths per minute • Presence of gag reflex

  34. Signs of Nonreadiness for Nipple Feedings • Respiratory rate >60 breaths per minute • No rooting or sucking • Absence of gag reflex • Excessive gastric residuals

  35. Parenting • Facilitating Parent-Infant Attachment • Prepare parents for first visit • Equipment, tubes etc. • Establish safe/trusting environment • Provide support, reassurance, encouragement • Encourage visitation • Involved in care taking • Repeat explanations • Promote touching, talking, rocking, cuddling • Refer to infant by name • Allow parents to phone as desired

  36. Common Complications ofPreterm Infants

  37. Respiratory Distress Syndrome

  38. Respiratory Distress Syndrome • Pathophysiology • Primary absence, deficiency or alteration in the production of surfactant • Decrease in Surfactant = increase in atelectasis= lack of gas exchange • Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction. • Common Clinical manifestations: • Nasal Flaring • Circumoral cyanosis • Expiratory grunting • Retracting • Tachypnea

  39. Respiratory Distress Syndrome-Nursing Interventions • Maintain airway, oxygenation, ventilation • Supplemental oxygen: • Nasal prongs • Oxyhood • Continuous positive airway pressure (CPAP) • Intubation with endotracheal tube

  40. Surfactant Replacement Therapy • Surfactant preparation can be lifesaving and reduces complications, such as pneumothorax. • Administered through an endotracheal tube • Surfactant treatments may be repeated several times during the first days until respiratory distress syndrome resolves.

  41. Respiratory Distress Syndrome-Nursing Interventions Nutrition Support • Newborns with RDS may be given food and water by the following means: • Tube feeding—a tube is inserted through the baby's mouth and into the stomach • Parenteral feeding—nutrients are delivered directly into a vein Support to Parents • Allow parents to hold and feed when possible. • Assist to decrease their fears

  42. Periventricular-IntraventricularHemorrhage

  43. Periventricular-IntraventricularHemorrhage • Rupture of fragile blood vessels around the ventricles of the brain • Usually associated with hypoxia • Diagnosed via cranial ultrasound • Signs – lethargy, poor muscle tone, decreased reflexes, seizures, apnea or cyanosis, full or bulging fontanels • Nursing Care – daily measure FOC, observe for changes in LOC

  44. Retinopathy of Prematurity

  45. Retinopathy of Prematurity • Formation of immature blood vessels in the retina constrict and become necrotic • Most common in infants < 28 weeks gestation • Also associated with O2 therapy

  46. Retinopathy of Prematurity • Nursing Interventions to Prevent ROP • Administer O2 in concentration ordered • Ensure proper ventilatory settings

  47. Necrotizing Enterocolitis

  48. Necrotizing Enterocolitis • An inflammatory disease of the intestinal tract frequently complicated with perforation of the gut. • NEC develops when there is asphyxia or hypoxia in which cardiac output tends to be directed more toward the heart and brain and away from the abdominal organs. • The intestinal cells become ischemic and damaged and stop secreting protective mucus infection occurs. • Perforation may occur with overwhelming sepsis.

  49. Necrotizing EnterocolitisSigns and Symptoms • Early: • Increase in gastric aspirate - >5-25 ml. • Increase in abdominal girth • Decrease bowel sounds, abdominal tenderness or rigidity of abdominal wall. • Subtle: • Lethargy, sudden listlessness, temperature instability, decrease urine output, occult blood in stools, poor color, and apneic periods. • Dramatic: • Massive abdominal distention, vasomotor collapse.

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