Nursing Care of the High Risk Newborn Chapter 34 Nursing Care of the High Risk Newborn Copyright © 2016 by Elsevier Inc. All rights reserved.

Learning Objectives Compare characteristics of preterm, late preterm, early term, and postterm neonates. Discuss respiratory distress syndrome and the approach to treatment. Compare methods of oxygen therapy. Analyze appropriate nursing interventions for nutritional care of the preterm infant. Discuss the pathophysiology of retinopathy of prematurity and bronchopulmonary dysplasia and the risk factors that predispose preterm infants to these problems. Discuss pain assessment and management in the preterm infant.

Learning Objectives (Cont.) Describe the signs and symptoms of perinatal asphyxia. Analyze the pathophysiology of meconium aspiration syndrome and its clinical signs. Plan developmentally appropriate care for high risk infants. Discuss the needs of parents of high risk infants. Describe nursing care for late preterm infants. List specific discharge teaching needs for parents of late preterm infants. Evaluate a neonatal transport plan. Discuss nursing interventions for families of preterm and high risk infants experiencing anticipatory loss and grief.

High Risk Newborn High risk infants are classified according to the following factors: Birth weight Gestational age Predominant pathophysiologic problems

Preterm Infants Majority of high risk infants are those born in less than 37 weeks Organ systems are immature and lack adequate reserves of bodily nutrients. Potential problems and care needs of a preterm infant weighing 2000 g differ from those of a term, postterm, or postmature infant of equal weight.

Preterm Infants (Cont.) Extremely low birth weight (ELBW) Birth weight is 1000 g or less Practical and ethical dimensions of resuscitation Everyone involved should participate in discussions: Should resuscitation be attempted, and to what extent should it be continued? Who should decide? Is the cost of resuscitation justified? Do the benefits of technology outweigh the burdens in relation to the quality of life?

Physiologic Functions Respiratory function Cardiovascular function Maintaining body temperature Neutral thermal environment Central nervous system function

Physiologic Functions (Cont.) Maintaining adequate nutrition Maintaining renal function Maintaining hematologic status Resisting infection

Growth and Development Potential Difficult to predict with accuracy Corrected age Age of the preterm infant is corrected by adding gestational age and postnatal age Milestones are corrected until age 2½ VLBW survivors: 15% to 25% have neurologic or cognitive disability

Care Management Maintaining body temperature High risk infant susceptible to heat loss Unable to increase metabolic rate Transepidermal water loss is greater Should be transferred from delivery in a prewarmed incubator Rapid changes in body temperature may cause apnea.

Maintaining Body Temperature Preterm infants are susceptible to temperature instability as a result of numerous factors; Large surface area in relation to weight Minimal insulating subcutaneous fat Limit stores of brown fat (an internal source for the generation of heat present in normal term infants) Friable (easily damaged) capillaries Inadequate muscle mass activity (rendering the preterm infant unable to produce its own heat)

Care Management (Cont.) Respiratory care Neonatal resuscitation Oxygen therapy Hood therapy Nasal cannula Continuous positive airway pressure (CPAP) Mechanical ventilation High-frequency ventilation

Preterm Infant Respiratory Function Numerous problems may affect the respiratory system of preterm infants may include; decreased number of functional alveoli, decreased surfactant levels, In combination, these deficits severely hinder the infant’s respiratory effort and can produce respiratory distress or apnea

Preterm Infant Respiratory Function Early signs of respiratory distress include flaring of the nares and expiratory grunt Retractions may begin as subcostal, suprasternal, or clavicular retractions If the infant shows increasing respiratory effort, for example seesaw breathing patterns, retractions, A compromised infant’s color progresses from pink, to circumoral cyanosis, and then to generalized cyanosis

Cardiovascular Function Evaluation of heart rate and rhythm, skin color, blood pressure, perfusion, pulses, oxygen saturation , Nurse must be prepared to intervene if symptoms of hypovolemia, shock or both Symptoms include hypotension, slow capillary refill (longer than 3 seconds), and continued respiratory distress despite the provision of oxygen and ventilation

Care Management (Cont.)

Care Management (Cont.) Respiratory care (Cont.) Surfactant administration Additional therapies Nitric oxide therapy Extracorporeal membrane oxygenation Partial liquid ventilation Weaning from respiratory assistance

Maintaining Adequate Nutrition The goal of the neonatal nutrition is to promote normal growth and development The preterm infant has the following disadvantages with regard to intake The nurse must continuously assess the infant’s ability to take in and digest nutrients Some preterm infants require gavage or intravenous (IV) feedings instead of oral feedings

Maintaining Renal Function The preterm infant’s immature renal system is unable to; adequately excrete metabolites and drugs, concentrate urine Intake and output, as well as specific gravity must be assessed

Maintaining Hematologic Status The preterm infant also is particularly predisposed to hematologic problems because of the following problems: Increased capillary friability Increased tendency to bleed (prolonged prothrombin and partial thromboplastin time) Slowed production of red blood cells resulting from rapid decrease in erythropoiesis after birth Loss of blood due to frequent blood sampling for laboratory tests

Care Management (Cont.) Nutritional care Weight and fluid loss or gain Insensible water loss Elimination patterns Oral feeding Gavage feeding Gastronomy feedings Parenteral fluids—TPN Advancing feedings Nonnutritive sucking

Care Management (Cont.)

Care Management (Cont.) Skin care Increased sensitivity and fragility Braden Q or Neonatal Skin Condition Scoring (NSCS) should be used daily. Avoid the use of soap. Environmental concerns Neonatal intensive-care unit (NICU) infants are exposed to high levels of auditory input.

Care Management (Cont.) Developmental care Positioning Reducing inappropriate stimuli Infant communication Infant stimulation Kangaroo care

Care Management (Cont.) Parental adaptation to the preterm infant Parental tasks Anticipatory grief Parental responses Parental support Maladaptation Parent education

Complications in High Risk Infants Respiratory distress syndrome (RDS) Complications associated with oxygen therapy Retinopathy of prematurity (ROP) Bronchopulmonary dysplasia (BPD) Patent ductus arteriosus (PDA)

Respiratory Distress Syndrome

Central Nervous System The preterm infant’s central nervous system (CNS) is susceptible to injury as a result of the following problems: Birth trauma that includes damage to immature structures Bleeding from fragile capillaries Recurrent anoxic episodes

Complications in High Risk Infants (Cont.) Germinal matrix hemorrhage–intraventricular hemorrhage (GMH-IVH) Usually occurs in infants less than 34 weeks History of hypoxia, birth asphyxia Necrotizing enterocolitis Intestinal ischemia Bacterial colonization Enteral feeding

Complications in High Risk Infants (Cont.) Infant pain responses Pain assessment Memory of pain Consequences of untreated pain in infants Pain management

Complications in High Risk Infants (Cont.) Late preterm infant (LPI) Respiratory distress Thermoregulation Nutrition Hypoglycemia Hyperbilirubinemia Infection

Hypoglycemia Most common in the macrocosmic infant Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis Hypocalcemia and Hypomagnesemia Occurs in 50 % of the newborns Signs of hypocalcemia are similar to hypoglycemia but occur between 24 and 36 hours of age

Complications in High Risk Infants (Cont.) Postmature infants Meconium aspiration syndrome (MAS) Persistent pulmonary hypertension of the newborn (PPHN)

Other Problems Related to Gestation Small for gestational age (SGA) and intrauterine growth restriction (IUGR) Perinatal asphyxia Hypoglycemia Hyperglycemia Polycythemia Heat loss

Other Problems Related to Gestation (Cont.) Large for gestational age (LGA) Weighing 4000 g or more at birth LGA despite gestation when the weight is greater than the 90th percentile Can be preterm, postterm, or infants of diabetic mothers

Discharge Planning Home care needs of infant’s parents are assessed Information provided about infant care Referrals for appropriate resources Referrals for home health assistance Appropriate immunizations, metabolic screening, and hearing evaluation Transport to and from regional centers

Transport to and from a Regional Center If a hospital is not equipped to care for a high risk mother and fetus or a high risk infant, transfer to a specialized perinatal or tertiary care center is arranged. Reasons that it is ideal for maternal transfer to occur with fetus in utero: The associated neonatal morbidity and mortality are decreased. Infant-parent attachment is supported, thereby avoiding separation of the parents and infant.

Anticipatory Grief Experienced when told of the impending death of infant Prepares and protects parents who are facing a loss Parents who have an infant with a debilitating disease, but one that may not threaten life of child, also may experience anticipatory grief.

Anticipatory Grief (Cont.) Loss of an infant Health care professionals can help by doing the following: Involving family in infant’s care Providing privacy Answering questions Preparing family for inevitability of death Growing emphasis on hospice and palliative care for infants and their families

Key Points Preterm infants are at risk for problems stemming from the immaturity of their organ systems. Nurses who work with preterm, late preterm, and other high-risk infants observe them for respiratory distress and other early symptoms of physiologic disorders. The adaptation of parents to preterm, late preterm, or high risk infants differs from that of parents to normal term infants.

Key Points (Cont.) Nurses can facilitate the development of a positive parent-child relationship. Nurses’ skills in interpreting data, making decisions, and initiating therapy in newborn intensive care units are crucial to ensuring infants’ survival. Pain management requires vigilant ongoing assessment, anticipation of painful events, and early interventions to prevent and diminish such a response.

Key Points (Cont.) Nurses need to assess the macroenvironments and microenvironments of the infant and family to create a developmentally positive atmosphere. Developmental care is a philosophy that embraces family-centered care and awareness of the effect of environmental stimuli on the physical and psychologic well-being of the infant and family.

Key Points (Cont.) Parents need special instruction (e.g., cardiopulmonary resuscitation [CPR], oxygen therapy, suctioning, developmental care) before they take home a high risk infant. SGA infants are considered at risk because of fetal growth restriction. The high incidence of fetal distress among postmature infants is related to the progressive placental insufficiency that can occur in a postterm pregnancy.

Key Points (Cont.) Multidisciplinary health care teams including specially trained nurses transport high risk infants to and from special care units. Parents need assistance as they cope with anticipatory grief or loss and grief.

Question Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal (GI) mucosa that can progress to perforation of the bowel. Care is supportive; however, risk factors may decrease the risk of NEC. In order to develop an optimal plan of care for this infant, the nurse must understand that which intervention has the greatest effect on lowering the risk of NEC? Early enteral feedings Breastfeeding Exchange transfusion Prophylactic probiotics ANS: B Feedback A Incorrect: Early enteral feedings of formula or hyperosmolar feedings are known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. B Correct: A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the GI tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn’s disease, and celiac illness. The neonatal intensive care unit (NICU) nurse can be very supportive of the mother in terms of providing her with equipment to pump, ensuring privacy, and encouraging skin-to-skin contact. C Incorrect: Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. D Incorrect: Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as the encouragement of breastfeeding; however, it is another strategy that the health care providers of these extremely fragile infants may have at their disposal.