Chapter 19

1. Chapter 19 Caring for the Newborn at Risk

2. Risk Factors for Newborns • Intrauterine development • Intrapartum development • Extrauterine development

3. A & P Review • Lung maturity • Circulatory maturity • Neurological maturity

4. Classification of High-Risk Newborns Gestational Age (GA) • Preterm (born before 37 weeks) • Term (born between 38 and 42 weeks) • Postterm (born after 42 weeks)

5. Classification of High-Risk Newborns Birth Weight • Low birth weight (LBW) (<2500 g) • Very low birth weight (VLBW) (<1500 g) • Extremely low birth weight (ELBW) (<1000 g)

6. Intrauterine Growth Restriction (IGUR) • A term used to denote a lack of intrauterine fetal growth that usually results in an SGA newborn

7. Small-for-Gestational-Age Infants (SGA) • Infants born at any gestational age who have a birth weight that falls below the 10th percentile on the growth charts

8. Conditions Affecting theSGA Newborn • Hypothermia • Pain • Hypoglycemia • Polycythemia

9. Large-for-Gestational- Age Infants (LGA) • Infants born who are over the 90th percentile on the growth chart

10. Conditions AffectingLGA Newborn • Chronic hyperglycemic state • Transient tachypnea of the newborn • Hypoglycemia • Hypocalcemia • Hypomagnesemia • Birth injuries • Brachial plexus injuries • Fractures

11. The Premature Newborn • Severe prematurity • 23 to 26 weeks • Moderate prematurity • 26 to 30 weeks

12. Physical Assessmentof the Premature Newborn • Skin • Head • Chest • Cardiac • Abdomen • Musculoskeletal • Genitalia • Neurological/sensory

13. Conditions Affecting the Premature Newborn

14. Respiratory Distress Syndrome (RDS) • Atelectasis with congestion and edema in lung spaces • Lecithin-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) levels low • Underdeveloped alveoli • Signs and symptoms begin shortly after birth Nursing Care: • Provide oxygenation • Maintain mechanical ventilation • Assist with endotracheal intubation (ET) • Administer syntheic surfactant via ET • Wean ASAP to prevent complications

15. Apnea of Prematurity • Apnea >15 to 20 seconds accompanied by pallor, hypotonia, cyanosis, and bradycardia Nursing Care: • Monitor cardiorespiratory (C-R) status • Apply continuous pulse oximeter • Watch for A and B spell

16. Jaundice • Diagnosed in term infants with a serum bilirubin level >12.9 mg/dL and in preterm infants >15mg/dL Nursing Care: • Based on underlying cause • Give phototherapy • Ensure hydration (electrolyte solution) Complications: • Bilirubin encephalopathy • Kernicterus

17. Retinopathy of Prematurity • Result of immature retinal vasculature followed by hypoxia • Inversely related to gestational age • Risk factors • Diagnosis –– 5 stages Nursing Care: • Fluctuations in concentrations of oxygen must be prevented • Wean off oxygen ASAP • Decrease constant bright lights • Encourage routine examinations

18. Anemia of prematurity Hemoglobin below 35% and 45% Nursing Care: Administer recombinant human erythropoieten SC Sudden Infant Death Syndrome (SIDS) “Back to Sleep” Educate parents about prevention

19. The Post term Newborn Newborns in utero after the optimal growth time (42 weeks) • Skin is parchment-like • Fingers are long and peeling • Muscle wasting is present

20. Conditions Affecting the Postterm Newborn Meconium Aspiration Pneumonia — meconium aspirated at birth • Meconium-stained skin, nails, and umbilical cord • Initial respiratory distress • Rales and rhonchi on auscultation Nursing Care: • Give chest physiotherapy (CPT) • Monitor mechanical ventilation • Administer medications

21. Persistent Pulmonary Hypertension of the Newborn Vascular resistance in pulmonary system • Meconium-stained amniotic fluid • Brief respiratory distress at birth, then resolves and returns about 12 hours later • Centrally cyanotic and tachypenic • Audible murmur Nursing Care: • Extracorporeal membrane oxygenation (ECMO) • See Chapter 19 Nursing Care Plan

22. Additional Conditions Affecting the High-Risk Newborn • Metabolic conditions • Neurologic conditions • Gastrointestinal conditions • Infections

23. Metabolic Conditions • Phenylketonuria (PKU) • Phenylalanine-free diet, elimination of protein • Galactosemia • Galactose-free diet • Maple Syrup Urine Disease • Low-protein diet, thiamine supplements

24. Metabolic Conditions • Homocystinuria • Diet therapy ― high doses vitamin B6 • Methionine and cystine restriction • Biotinidase Deficiency • Pantothenic acid or biotin (types of B vitamins)

25. Neurological Conditions Intraventricular and Periventricular Hemorrhage[categorized by extent and involvement (grades)] Nursing Care: • Recognize seizures • Administer antiseizure medications • Prevent cerebral damage • Maintain adequate oxygenation • Educate parents

26. Neurological Conditions • Anencephaly (skull and cerebrum are malformed) • Encephalocele (protrusion of brain through a skull defect) • Microcephaly (smaller than normal head circumference) • Holoprosencephaly (cerebral matter fails to form as two distinct hemispheres)

27. Gastrointestinal Conditions Cleft Lip and Palate ― has genetic and environmental predispositions Nursing Care: • Provide adequate nutrition • Feed in upright position • Surgery: CL ― 3 months, CP ― before 18 months • Educate and provide emotional support for parents

28. Gastrointestinal Conditions Necrotizing Enterocolitis • Ischemic episode of the bowel; can produce septicemia Nursing Care: • Ensure that oral feedings are stopped • Discuss possible surgery

29. Abdominal Wall Defects Gastroschisis and Omphalocele Nursing Care: • Surgery within 2 to 4 hours • Cover abdominal contents with moist gauze and wrap in plastic • Position carefully • Place NG/OG • IVF at 1.5 times normal maintenance • Postoperative care focuses on fluids, electrolyte balance, nutritional support, infection protection, pain management, and keeping parents informed

30. Infections in the Newborn Herpes Simplex • HSV-1 acquired from people with herpes lesions of the mouth • HSV-2 acquired through a genital infection Nursing Care: • Acyclovir (Avirax) • Ensure proper developmental stimulation Neonatal Sepsis • Systemic infection Nursing Care: • Review diagnostic workup • Give antibiotics for a minimum of 48 hours

31. Developmental Delay Neonatal Abstinence Syndrome (NAS) • Drug-abusing mother • Irritability Nursing Care: • Laboratory tests done to reveal if drugs are in the newborn’s system • Use neonatal abstinence scoring tool every 3 hours

32. Care of the High-Risk Newborn • Blood Pressure • Nutritional Care • Developmental Care • Noise • Lighting • Handling • Positioning

33. Neonatal Intensive Care Unit • Educate parents on what to expect, rules of the unit, and expectations • Create partnership with parents • Encourage touch • Provide discharge planning

34. Classification of the Neonatal Intensive Care Unit • Level I ― provides well newborn care and stabilization of high-risk newborns • Level II ― provides premature care (give oxygen and intravenous therapy given) • Level III ― provides care to ventilate newborns

35. Transporting the Preterm Newborn • Transport is done if more technologically advanced care is needed • Transport team comprised of professionals • STABLE program