High Risk Newborn Mary L. Dunlap MSN, APRN Fall 10

Preterm Infant Infant born prior to the completion of the 37th week Organs immature Lack physical reserves Survivability related to weight / gestational age

Preterm Infant Respiratory last to mature Surfactant deficiency-RDS Unstable chest wall-atelectasis Immature respiratory centers-apnea Small passages-obstructions Unable to clear fluid-TTN

Preterm Infant Cardiovascular Difficulty transitioning from fetal to neonatal circulatory pattern Congenital anomalies due to continued fetal circulation Fragile blood vessels (brain) Impaired regulation of B/P

Preterm Infant Gastrointestinal Lack neuromuscular coordination suck- swallow-breath Hypoxia shunts blood from the gut- ischemia and intestinal wall damage Risk for malnutrition -wt. loss Small stomach-compromised metabolic function

Preterm Infant Renal System Slow glomerular filtration rate Reduced ability to concentrate urine Risk: fluid retention, electrolyte imbalance, drug toxicity

Preterm Infant Immune system Deficiency of IgG Impaired ability to produce antibodies Thin skin- limited protection barrier

Preterm Infant Central nervous system Long term disability due to injury Difficulty maintaining temperature Compounded by lack of brown fat

Preterm Infant Nursing Management Varies with gestational Promote Oxygenation Maintain body temperature nutritional needs Prevent infections Provide stimulation Pain management

Small for Gestational Age SGA weight- less than 5lb 8 oz and below the 10th% at term IUGR- High risk growth does not meet the norm and is pathologic Symmetric IUGR- poor growth rate of head, abdomen and long bone Asymmetry IUGR- head long bones spared

Small for Gestational Age Characteristics Decreased breast tissue Scaphoid abdomen (sunken) Wide sutures Thin umbilical cord Head larger than body Wasted appearance to extremities Reduced fat stores

Small for Gestational Age Common Problems Perinatal asphyxia Hypothermia Hypoglycemia Polycythemia Meconium Aspiration

Large for Gestational Age Characteristics LGA weight- Larger than 9 lbs and above the 90th% Large body-plump full face Body size is proportionate Poor motor skills Difficulty in regulating behavioral state (arouse to quiet alert state)

Large for Gestational Age Common Problems Birth Trauma- Hypoglycemia Polcythemia Hyperbilirubinemia

Post term Infant Gestation > 42 weeks Must determine if EDC is truly post term After 42 weeks placenta loses ability to nourish the fetus

Post term Infant Characteristics Newborn emaciated Meconium stained Hair and nails long Dry peeling skin Creases cover soles Limited vernix and lanugo

Infant of Diabetic Mother Mother can have pregestational or gestational diabetes Increasing numbers of type 2 Related to increase in morbidity & mortality Congenital abnormalities

Infant of Diabetic Mother Congenital abnormalities- during first trimester due to fluctuations in BS and ketoacidosis Macrosomia- develops last trimester due to maternal hyperglycemia- excessive fetal growth Tight control over glucose levels needed ( less than 1-0mg/dl)

Infant of Diabetic Mother Common Problems Congenital Abnormalities Macrosomia Birth Trauma Perinatal Asphyxia RDS Hypoglycemia Hyperbilirubinemia Polycythemia

Infant of Diabetic Mother Infant Characteristics Rosy cheeks Short neck Wide shoulders Excessive subcutaneous fat Distended abdomen

Infant of Diabetic Mother Nursing Management Monitor glucose level q. 3 to 4 hrs. level no above 40 mg/dl Until stable monitor q. 3-4 hrs Feed q. 2-3 hrs IV glucose Monitor serum bilirubin levels Maintain thermal environment

Respiratory Distress Syndrome RDS caused by lack of surfactant Poor gas exchange & ventilation Seen in preterm newborns Cesarean births without labor Infants of diabetic mothers

Respiratory Distress Syndrome Symptoms Tachypnea Expiratory grunting Nasal flaring Retractions See-saw respiration Chest x-ray- alveolar atelectasis (ground glass pattern) & dilated bronchioles ( dark streaks within granular pattern)

Respiratory Distress Syndrome Nursing Management Thermoregulation O2 administration Mechanical ventilation if needed Hold parenteral feedings Monitor VS & O2 sats Provide nutrition ( gavage feedings)

Transient Tachypnea Newborn TTN Mild respiratory condition Result of delayed absorption of fluid Last about 3 days

Transient Tachypnea Newborn TTN Symptoms Respiratory rate as high as 100-140 Labored breathing Grunting nasal flaring Retractions Chest x-ray shows lymphatic engorgement ( retained lung fluid)

Transient Tachypnea Newborn Nursing Care Mainly supportive Monitory VS & O2 Sats Provide supplemental O2

Meconium Aspiration Fetus inhales meconium into the lungs while in utero Meconium blocks the airway preventing exhalation Meconium irritates the airway making breathing difficult Meconium aspiration related to fetal distress during labor.

Meconium Aspiration Symptoms Cyanosis Rapid breathing Labored breathing Apnea X-ray patches or streaks of meconium & trapped air

Meconium Aspiration Nursing Management Assess for risk factors prior to delivery Suction at delivery prior to newborn crying Supplemental O2 Mechanical ventilation Antibiotic therapy

Hyperbilirubinemia Excess of bilirubin in the blood-elevated bilirubin level > 5mg/dl Heme from erythrocytes break down forms unconjugated bilirubin Jaundice Physiologic Pathologic

Hyperbilirubinemia Causes Drugs/Medical conditions disrupt conjugation and albumin binding sites Decreased hepatic function Increased erythrocyte production Enzymes in breast milk

Hyperbilirubinemia Physiologic Develops in 3-4 days after term birth Develops3-5 days after preterm birth Term birth resolves 7 days Preterm birth resolves 9-10 days Unconjugated bilirubin level < 12mg/100 ml

Hyperbilirubinemia Pathologic Develop after first day Persists beyond 7 days Bilirubin > 12.9mg/100 term Bilirubin > 15mg/100 preterm Increases > 5mg/100ml in 24hrs

Hyperbilirubinemia Nursing Management Phototherapy Increase feeding to q 2-3 hrs

Phenylketonuria PKU Inability to metabolize phenylalanine- amino acid found in protein Affect brain and CNS development Interferes with the production of melanin, epinephrine & thyroxine Both parents must pass the gene on

Phenylketonuria PKU Symptoms Seizures Irritability Tremors Jerking movements arms & legs Hyperactivity Unusual hand posturing

Phenylketonuria PKU Diagnosed with PKU screening prior to discharge from hospital

Hemolytic Disorders Hemolytic disease occurs when blood groups of mother and newborn are different Antibodies are present or formed in response to antigen from fetal blood crossing placenta and entering maternal circulation Most common Rh incompatibility ABO incompatibility

Hemolytic Disorders Maternal antibodies of IgG class cross placenta, causing hemolysis of fetal RBCs Fetal anemia Neonatal jaundice Hyperbilirubinemia

Hemolytic Disorders Rh incompatibility (isoimmunization) Only Rh-positive offspring of Rh-negative mother is at risk If fetus is Rh positive and mother Rh negative, mother forms antibodies against fetal blood cells

Hemolytic Disorders ABO incompatibility Occurs if fetal blood type is A, B, or AB, and maternal type is O Incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across placenta to fetus Exchange transfusions required occasionally

Neonatal Infections Sepsis Bacterial, viral, fungal Patterns Early onset or congenital Nosocomial infection—late onset

Neonatal Infection Septicemia Pneumonia Bacterial meningitis Gastroenteritis is sporadic

Neonatal Infections TORCH infections Toxoplasmosis Gonorrhea Syphilis Varicella-zoster Hepatitis B virus (HBV) Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)