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

2. 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.

3. 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.

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

5. 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.

6. 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?

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

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

9. 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

10. 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.

11. 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)

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

13. 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

14. 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

15. 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

16. Care Management (Cont.)

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

18. 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

19. 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

20. 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

21. 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

22. Care Management (Cont.)

23. 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.

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

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

26. 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)

27. Respiratory Distress Syndrome

28. 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

29. 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

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

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

32. 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

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

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

35. 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

36. 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

37. 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.

38. 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.

39. 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

40. 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.

41. 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.

42. 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.

43. 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.

44. 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.

45. 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.