High Risk Neonates

1. High Risk Neonates Presented by Ann Hearn RNC, MSN

2. The High Risk Newborn • A High-Risk Newborn is one who is susceptible to illness (morbidity) or even death (mortality) due to: • dysmaturity • immaturity • physical disorders • complications of birth • In most cases, the infant is the product of a pregnancy involving one or more predictable risk factors, including the following: • Low socioeconomic level of the mother, poor nutrition • Exposure to environmental dangers such as toxic chemicals • Preexisting maternal conditions such as heart disease, diabetes • Obstetric factors such as age or parity, other premature births • Medical conditions related to pregnancy such as hypertension, Premature rupture of membranes, infection, etc.

3. Classification of High Risk Newborns • Gestational Age • Preterm • (Late Preterm) • Term • Postterm • Gestational Age & Birth Weight • SGA • AGA • LGA

4. Assessment of Gestational Age • Ballard Scale or Dubowitz scale • Neuromuscular characteristics • Physical Characteristics • Scoring of all characteristics determines the gestational age

5. Associated Complications of: SGA IUGR • Asphyxia • Aspiration syndrome • Hypothermia • Hypoglycemia • Polycythemia • Congenital malformations • Intrauterine infections • Continued growth difficulties • Cognitive difficulties Nursing Interventions: Monitor heart rate, respiratory rate, temperature and blood glucose.

6. The Premature Infant Born before 37 weeks gestation

7. Physiologic Challenges of the premature infant

8. Physiologic Challenges of the premature infant • Respiratory • Thermoregulation • Digestive • Renal (fluid & electrolyte) • Infection • Pain

9. Physiologic Challenges of the premature infant • Respiratory • Insufficient production of surfactant • Immaturity of alveolar system • Immaturity of musculature • Respirations 40-60, shallow, irregular, usually diaphragmatic

10. Physiologic Challenges of the premature infant • Respiratory Nursing Interventions • Assess for S/S respiratory distress • Cyanosis • Retractions • Expiratory grunting • Nasal flaring • Apnicepisodes • Maintain airway • Administer O2 • Monitor O2 saturation • Monitor heart/respiratory rates

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

12. Physiologic Challenges of the premature infant • Thermoregulation • Increased body surface area compared to body mass • Decreased brown fat • Thin skin • Vessels close to skin • Decrease sub-q fat • Lack of flexion

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. Physiologic Challenges of the premature infant • Thermal Neutrality – Nursing Interventions • Incubator or radian warmer • Warm surfaces • Warm humidified oxygen • Warm ambient humidity • Warm feedings • Keep skin dry and head covered

15. ISOLETTE/ RADIANT or INCUBATOR OPEN WARMER

16. Fluid and Electrolyte Balance Dehydration • Urine output <2 ml/kg/hour • Urine specific gravity >1.01 • Weight loss greater than expected • Dry skin and mucous membranes • Sunken anterior fontanel • Poor tissue turgor • Blood: Elevated sodium, protein, and hematocrit levels Overhydration • Urine output >5 ml/kg/hour • Urine specific gravity <1.002 • Edema • Weight gain greater than expected • Bulging fontanels • Moist breath sounds • Difficulty breathing • Blood: Decreased sodium, protein, and hematocrit levels

17. Physiologic Challenges of the premature infant • Hydration – Nursing Interventions • Daily weights • Monitor I&O • Parental fluids • Feedings • Oral medications • 1gm = 1ml urine • Regurgitation/emesis • Stool • Accurate IV rates, assess site • Accurate OGT feedings • Monitor urine pH & specific gravity

18. Physiologic Challenges of the premature infant • Renal • Decreased glomerular filtration rate • Inability to concentrate urine or dilute urine • Poor electrolyte regulation

19. Physiologic Challenges of the premature infant • Skin • Fragile • Permeable • Easily damaged • Nursing interventions • Little use of tape and back with cotton • Rinse disinfectants off with water • Assess skin for infection • Avoid pressure points • Reposition frequently as tolerated

20. Physiologic Challenges of the premature infant - Immune System • Lack of passive immunity from mother; deficient placental transmission. • Inability to produce own antibodies - immature system. • Exposure to procedures and prolonged hospital stay. • Skin is thin and offers little protection from disease causing organisms.

21. Physiologic Challenges of the premature infant • Prevention of Infection – Nursing Interventions • Initial scrub / strict hand washing • Visitors & staff • Reverse isolation • Single infant equipment • Short / no artificial nails • Maintain sterile technique • IV start and dressing changes • Procedures • Clean incubators weekly • Position changes; use of sheepskin • Judicious use of tape on skin

22. Physiologic Challenges of the premature infant • Signs and Symptoms of Infection • Behavioral changes • Physiological changes • Tonus • Color • Temperature • Skin • Feeding • Hyperbilirubinemia • Heart rate • Respiratory rate

23. ??? What are the signs and symptoms of pain in a premature infant??? High-pitched, intense, harsh cry Whimpering, moaning “Cry face”, grimacing, furrowing of brow Eyes squeezed shut Mouth open 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

24. Nursing Care

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

26. Physiologic Challenges of the premature infant • Nutrition • Poor suck and swallow reflex • Decreased gag reflex • Relaxed cardiac sphincter • Small stomach capacity • Intolerance of fats • Immature absorption of nutrients

27. Physiologic Challenges of the premature infant • Pre-feeding assessment: • Measure abdominal girth • Bowel sounds • Gastric residual • Sucking and gag reflexes

28. nutrition • Feeding methods: • Parenteral • PO • NGT • Direct Breastfeeding

29. Physiologic Challenges of the premature infant • Facilitating Parent-Infant Attachment • Prepare parents for first visit • Establish safe/trusting environment • Encourage visitation • Involve in care taking • Repeat explanations • Promote touching, talking, rocking, cuddling • Refer to infant by name • Allow parents to phone as desired

31. Common complications of preterm infants

32. Respiratory Distress Syndrome

33. Respiratory Distress Syndrome - RDS • Pathophysiology • Primary absence, deficiency or alteration in the production of surfactant • Surfactant, atelectasis= lack of gas exchange • Leads to hypoxia and acidosis which further inhibit surfactant production and causes pulmonary vasoconstriction. • Clinical manifestations: • Cyanosis • Tachypnea • Nasal flaring • Retracting • Apnea

34. Respiratory Distress Syndrome-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.

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

36. Respiratory Distress Syndrome-Nursing Interventions Nutrition Support • Newborns with RDS may fed 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

37. Periventricular-IntraventricularHemorrhage (PIVH)

38. 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

39. Retinopathy of Prematurity

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

41. RETINOPATHY OF PREMATURITY Nursing Interventions to Prevent ROP Administer O2 in concentration ordered Ensure proper ventilatory settings

42. Necrotizing Enterocolitis

43. NEC - Inflammatory disease of the intestinal tract caused by ischemia, infection, and/or prematurity 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. Necrotizing Enterocolitis

44. 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.

45. Necrotizing EnterocolitisTreatment and Nursing Care • Surgery: Resection of necrotic sections and possible temporary colostomy. This allows bowel to recover. • Medical: • NPO with NG tube. • Peripheral or central hyperalimentation • Antibiotic therapy. • Continue to monitor for changes in condition. • Gradually introduce oral feedings

46. Post-Term NewbornGreater than 42 weeks gestation

47. Post Mature Infant • Physical manifestations: • Dry, cracking, parchment-like skin • Reduced subq tissue – Skin appears loose • No vernix or lanugos • Long fingernails • Profuse scalp hair • Long, thin body appearance • Often meconium stained skin, cord and nails

48. Post Mature Infant • Complications of post term: • Hypoglycemia • Meconium aspiration • Congenital anomalies • Seizure activity • Cold stress • Nursing considerations • Monitor blood sugars per protocol • Evaluate respiratory status • Assess for seizure activity • Treat cold stress.

49. Small for Gestational AgeBelow the 10th percentile

50. SGA - Risk Factors: • Maternal factors: • High blood pressure. • Chronic kidney disease. • Advanced diabetes. • Heart or respiratory disease. • Malnutrition, anemia. • Infection. • Substance use (alcohol, drugs); Cigarette smoking. • Factors involving the uterus and placenta: • Decreased blood flow in the uterus and placenta. • Placental abruption (placenta detaches from the uterus). • Placenta previa (placenta attaches low in the uterus). • Infection in the tissues around the fetus. • Factors related to the developing baby (fetus): • Multiple gestation (twins, triplets, etc.). • Infection. • Birth defects. • Chromosomal abnormality.