High Risk Newborn

Weight and Growth Weight Growth Low Birth Weight (LBW) = <2500 grams Very Low Birth Weight (VLBW) = <1500 grams Extremely Low Birth Weight (ELBW) = <1000 grams Growth Small for Gestational Age (SGA) < 10th percentile Appropriate for Gestational Age (AGA) 10th – 90th percentile Large for Gestational Age (LGA) > 90th percentile

Birth Preterm-born between 20 wks and the end of the 37th week gestation Term-born between 38 and 42 wks gestation Posterm-born after 42 wks gestation

IUGR/Macrosomia Symmetric-occurs 1st trimester, usually SGA Asymmetric-occurs later in pg, low birth wgt and larger head circ usually, might have chance of normal G&D later Macrosomia->4000 gm

Corrected age for preterm infants Gestational + postnatal age =corrected age till ~2 ½ yrs old Preterm babies “catch up” between 2 & 3 years of age usually

General Information G & D-many at risk newborns may have complications that lead to problems with growth and development later Parental adaptation tasks-anticipatory grief, responses, bonding, communication, care

Nursing care Continuous assessment & analysis of physiologic status Developmental care, positioning, touch NICU environment Working with parents-understand fear, sorrow, concern; explain; allow to vent; initiate parental touch ASAP; Kangaroo care; comunication

Abnormal Heart Rate Signs Tachycardia causes Hypovolemia/shock Acidosis Sepsis Anemia Arrhythmia

Abnormal Heart Rate con’t Bradycardia causes Hypoxia Asphyxia Acidosis Hypothermia Sepsis Congenital heart block

Abnormal Blood Pressure Hypotension causes Shock Acidosis Sepsis Hypertension causes Usually renal in origin

Abnormal Respirations Tachypnea first sign of many illnesses/problems; attempt to increase tidal volume Grunting forced exhalation through partially closed glottis Retracting lungs want to stay deflated Nasal flaring making nostrils larger to get more air Apnea > 20 seconds duration; pathologic if in 1st 24-48 hrs; sepsis, RDS, BPD, CNS dysfunction

Respirations Early signs of resp distress-flaring, grunting Further signs-retractions, see-saw breathing, cyanosis Apnea->20 seconds of no resps Periodic breathing-normal in nb; 5-10 sec pause, then 10-15 sec compensatory increased breathing NB’s are nose breathers for ~ 3 wks Blood pH-7.32-7.49; O2 sat->92%; PaO2->60-70 mmHg (indicates hypoxia if less than)

Oxygen Therapy Warm, humidified air Assess O2 sat cont & ABG’s every 1-2 hr Delivery systems-hood; nasal cannula; mask; CPAP; PEEP; high frequency; (endotracheal tube for PEEP, high frequency, maybe CPAP)

Abnormal Temperature Acceptable range (36.5-37.2C) Goal is neutral thermal environment (NTE) Hypothermia leads to increased O2 consumption; depletion of glycogen stores Hyperthermia – rarely seen

Abnormal Fluids, Electrolytes, Nutrition Weight loss of approximately 5-10% (term) Weight loss of approximately 15-20% (preterm) Insensible water loss (IWL)-increase of water loss & ability to retain water TPN – start within 24 hours if not eating Enteral – continuous; gavage; nippling

Preterm Disease Processes/Complications Respiratory Distress Syndrome (RDS) Surfactant deficiency decreases surface tension; inadequate alveolar space; “ground glass” pattern on xray Signs/sxs-respiratory difficulty Risks- Increased risk-preterm birth, male, white Decreased risk-PIH, prenatal steroid Treatment – surfactant replacement therapy; respiratory support/therapy; NTE; conservative fluid management; early nutritional support

Preterm Disease Processes/Complications (cont’d) Retinopathy of Prematurity (ROP) Oxygen levels too high causing vasoconstriction, then hemorrhage and scarring; capillaries “friable” Prevent Treatment- laser therapy, Vitamin E Brochopulmonary Dysplasia (BPD) COPD of prematurity Risk factors – prolonged intubation; oxygen therapy/ventilation > 28 days high risk Signs-tachypnea, retractions, flaring, exercise intolerance, tachycardia, crackles

BPD (cont) Treatment Prevention by proper vent mgt Proper fluid and nutrition mgt (add calories to smaller amt of fluid) Respiratory support Meds Diuretics, bronchodilators, nitric oxide

Preterm Disease Processes/Complications (cont’d) Germinal Matrix-Intraventricular Hemorrhage (GMH-IVH) 32-44% of preterm infants < 1500 grams; decreased incidence d/t prenatal steroid & postnatal surfactant use Do cranial US by day 7 to diagnose Causes-increased cerebral blood flow & venous pressure; increased tendency to bleed from capillary friability and elevated PT and PTT levels Risk factors-prematurity, asphyxia, acidosis, BP spikes

GMH-PVH (cont’d) Grades I-III Grade I has no neuro seqeula; III worst Clinically silent presentation Complications Hydrocephalus Neurologic defects Prevention Prenatal steroids Minimal stimulation Elevate HOB BP control Observe for pneumothorax

Processes/Complications Necrotizing Enterocolitis (NEC) Cause unknown, but associated with asphyxia, RDS, polycythemia, shock, early feedings; may occur in preterm, term or postterm Signs/sxs-nonspecific, decreased activity, hypotonia, pallor, recurrent apnea & bradycardia, decreased O2 sats, abdominal distention, bile aspirates, vomiting, bloody stooly stools

Processes/Complications Transient Tachypnea of Newborn (TTN) Retained fetal lung fluid, mostly in term babies Risk factors Elective C/S babies Male babies Improves within 3 days; observe closely first 24 hours; provide resp support

Processes/Complications (cont’d) Sepsis Risk factors PROM; preterm birth; maternal infection Signs/sxs generalized illness; hypothermia; lethargy; cyanosis; pallor; tachypnea; bradycardia or tachycardia; poor feeding

Sepsis (cont’d) I/T ratio .2 or higher; bands > 6; CRP + Treatment O2 therapy Antibiotics Prevention-handwashing & good prenatal care

Term/Postterm Disease Processes/Complications (cont’d) Meconium Aspiration Syndrome (MAS) Risk factors Postterm birth PIH; maternal hypertension Meconium aspiration at birth Treatment – resp support, CPT, suction, nitric oxide** Complications – PPHN*

Congenital Anomalies Neural tube -anencephaly; microcephaly; hydrocephaly; myelomeningocele (spina bifida) GI -oomphalocele; gastrochisis; imperforate anus; tracheoesophagel fistula; cleft lip &/or palate Respiratory -choanal atresia; diaphragmatic hernia Skeletal musculoskeletal -developmental hip dysplasia; clubfoot; polydactyly

Congenital Anomalies Musculoskeletal- hip dysplasia; clubfoot; polydactyly Genitourinary-hypospadias; epispadias; exstrophy of the bladder; ambiguous genitalia; teratoma

Acquired Problems of the Newborn Birth Injuries Soft tissue Skeletal Peripheral Nervous System Central Nervous System

Acquired Problems of the Newborn Substance Abuse Alcohol Cocaine Heroin Amphetamines Caffeine Tobacco Methadone Marijuana

Acquired Problems of the Newborn Infants of diabetic mothers (IDM) Sepsis Infections

Hemolytic Disorders of the Newborn Hyperbilirubinemia

Case Study: Preterm Newborn Laura, 32 weeks gestation, is born and admitted to the NICU. She is experiencing respiratory distress. What clinical manifestations would indicate Laura is experiencing resp. distress?

Case Study: Preterm Newborn What guidelines should the nurse follow to ensure safety & effectiveness of oxygen admin by hood for Laura?

Case Study: Preterm Infant Laura received surfactant. State the rationale for this treatment.

Case Study: Preterm Newborn Explain the concept of neutral thermal environment (NTE) and discuss how to maintain it.

Case Study: Preterm Newborn Intermittent gavage feedings are ordered for Laura. What are standards of practice for ensuring safety and max effectiveness?

Case Study: Preterm Newborn How would you be sure to provide developmentally appropriate care for Laura?

Case Study: Preterm Newborn How could the nurse help Laura’s parents cope with her health status and care?

Case Study: Preterm Newborn During her stay, Laura will be poked and prodded. How should nurse assess her pain status?