High Risk Newborn And Family

HIGH RISK NEWBORN & FAMILY

ASSESSMENT  NURSING

HISTORY  PHYSICAL ASSESSMENT  DIAGNOSTIC

ASSESSMENT Obvious

congenital anomalies Gestational age

IMMEDIATE NEEDS OF THE NEWBORN

AIRWAY 2. BREATHING 3. CIRCULATION 4. WARMTH 1.

Immediate Assessment of the Newborn 

The newborn infant should undergo a complete P.E within 24 hours of birth.  NOTE

:

 It

is easier to listen to the heart and lungs first when the infant is quiet

 Warmth

the stethoscope before using to decrease the likehood of making the infant cry

Newborn Priorities in first day of life 1. 2. 3. 4. 5. 6. 7. 8.

Initiation and maintenance of respiration Establishment of extrauterine circulation Control of body temperature Intake of adequate nourishment Establishment of waste elimination Prevention of infection Establishment of an infant-parent relationship Developmental care or care that balances physiologic needs and stimulation for best development

DIAGNOSIS  Ineffective

airway clearance  Ineffective cardiovascular tissue perfusion  Ineffective thermoregulation  Risk for imbalance of nutrition  Risk for parenting  Deficit diversional activity (lack of stimulation)

Planning/Implementation

ALTERED GESTATIONAL AGE OR BIRTHWEIGHT  Infant

is evaluated as soon as possible after birth to determine :  Weight  Gestational

 Birthweight  Colorado

age

is plotted on a Growth Chart

intrauterine Growth Chart ( LUBCHENCO CHART)

Pre

term – born before the 38th week

Full

term – born at 38 to 42 weeks

Post

term – born after 42 weeks

BIRTHWEIGHT

Appropriate Gestational Age (AGA) – BW within 10-90th percentile  Small Gestational Age (SGA) – BW is < 10th percentile  Large Gestational Age (LGA) – BW > 90th percentile 

LBW – BW < 2,500 grams  VLBW – BW 1000-1,500 grams  Extremely-VLBW – 500-1000g 

GESTATIONAL AGE  It

is determine in the first 4 hours after birth so that age related problems can be identified and appropriate care can be initiated.  Second assessment is done within 24 hours.  New ballard Score is the most commonly used tool 

It has 2 element External physical characteristics  Neuromuscular maturity 

GESTATIONAL ASSESSMENT (DUBOWITZ) FINDING

0 – 36

37 – 38

39 & OVER

SOLE CREASES ANTERIOR

OCCASIONAL CREASES IN ANTERIOR 2/3

SOLE COVERED W/ CREASES

BREAST NODULE 2 DIAMETER (MM)

4

7

SCALP HAIR

FINE & FUZZY

FINE & FUZZY

COARSE & SILKY

EAR LOBE

PLIABLE, NO CARTILAGE

SOME CARTILAGE

STIFFENED BY THICK CARTILAGE

TESTES & SCROTUM

TESTES IN LOWER CANAL, SCROTUM SMALL, RUGAE

SOME CARTILAGETESTES PENDULOUS, INTERMEDIATE

TRANSVERSE CREASE ONLY

SCROTUM FALL, EXTENSIVE RUGAE

posture

Square window

Popliteal angle

Scarf sign

Heel to ear

creases

Breast

Causes of Small –for-Gestational-Age Infant ( SGA)        

SGA infant experienced intrauterine growth restriction (IUGR) Most common cause of IUGR is PLACENTAL ANOMALY Mother’s nutrition during pregnancy play a major rule in fetal growth. severe DM mother PIH Mother who smokes heavily Use of narcotics Baby with Rubella & chromosomal abnormality

SGA  PRENATAL

ASSESSMENT:

 Fundic

height  ultrasound  Biophysical profile  NST  Placental

grading  Amniotic fluid amount

What do they look like???  SGA

appearance

 Infant 

suffer nutritional deprivation

EARLY in pregnancy  

Increase in number of body cells Below average Weight, length & head circumference 

 Late  

in Pregnancy

Increase in cell size Below average weight

Most SGA APPEAR LIKE??  Wasted

appearance  Small liver  Poor skin turgor  Large head  Skull suture widely separated – lack of normal bone growth  Dull hair  Sunken abdomen  Cord dry & stained yellow

Common problem of SGA  Birth

asphyxia – common problem

 Underdeveloped

chest muscles

 Risk

of meconium aspiration syndrome due to anoxia during labor.

 Lack

of subcutaneous fat

 Less

able to control body temperature

DIAGNOSTICS  CBC  High

hematocrit  Increase RBC ( polycythemia)  Blood

glucose

 Hypoglycemia

<40mg/dl

Outcome Evaluation:  Gain

weight & height – end of first year  Discuss ways to parents to promote infant development.  Needs adequate stimulation to reach normal growth & developmental milestone  Encourage

parents to provide suitable toys as per chronological age not physical size.

LARGE-for-Gestational-Age Infant (LGA)

LGA  Macrosomia

– above 90th percentile on an intrauterine growth chart for that gestational age  CAUSES:  Overproduction

of growth hormone in utero  Infant with DM mother  Obese mother  Multiparous women

LGA  Assessment:  Uterus

unusually large for the date of pregnancy  UTZ , NST  amniocentesis for lung maturity

LGA appearance  Immature

reflexes  Skin color ecchymosis, jaundice & erythema  Low score on Gestational age examination  Extensive bruising & birth injury Broken clavicle  Erb-Duchenne paralysis – cervical nerve injury 

 Prominent

caput succedaneum, cephalhematoma or molding

LGA - DIAGNOSTICS  Increase

serum bilirubin  hypoglycemia

LGA – outcome evaluation  Infant

need careful watching  Encourage parents to nurture infant

PRETERM INFANT

Preterm infant  Live-born

infant born before the end of 37 weeks of gestation  Weight less than 2,500 ( 5lbs 8 oz )  Immature and small but well proportioned for age

PRETERM  High

Risk for :

Respiratory distress syndrome (RDS)  Hypoglycemia  Intracranial hemorrhage 

 Mortality

: 80-90%  CAUSES: Exact cause : rarely known  Low socioeconomic- inadequate nutrition  Lack of prenatal care  Age of mother – younger than age 20  PROM 

PRETERM  POTENTIAL  Anemia

COMPLICATION:

of prematurity  Kernicterus  PDA  Intraventricular/Periventricular Hemorrhage  RDS – HMD  Apnea  Necrotizing enterocolitis  Retinopathy of prematurity

Management 1. 2. 3. 4. 5. 6.

Maintain patent airway Incubator care VS monitoring O2 therapy Feeding Infection precautions

Preterm 

infant

Nutrition  Feeding

schedule  Gavage feeding  Formula  Breast milk

ILLNESS IN THE NEWBORN

ILLNESS IN THE NEWBORN 1. 2. 3. 4. 5. 6. 7.

RDS TRANSIENT TACHYPNEA OF THE NB MECONIUM ASPIRATION SYNDROME APNEA SUDDEN INFANT DEATH SYNDROME HEMOLYTIC DISEASE OF THE NB HEMORRHAGIC DISEASE OF THE NB

Respiratory distress syndrome 

2 types 1. 2.

Hyaline membrane disease(HMD) Transient tacypnea of the NB (TTN)

Respiratory distress syndrome >HMD( hyaline membrane disease)

Common:1. preterm infant 2.infant of diabetic mother 3.meconium aspiration

Pathologic feature :

hyaline-like membrane formed fr an exudate of infant blood line the terminal bronchioles, alveolar.duct,and alveoli this membrane prevent exchange of O2 and CO2 at alveolar-capillary membrane

RDS  Causes: Low

level or absence of surfactant

Surfactant

–

phospholipid lines the alveoli that reduces surface tension on expiration  keep the alveoli from collapsing on expiration  Form @ 34 wks AOG 

Assessment  S/Sx:

initial 1.low body temperature 2.nasal flaring 3.sternal and subcostal retraction 4.tachypnea 5. cyanotic mucus membrane

Assessment  S/Sx:

late 1. seesaw respiration 2. heart failure 3. pale gray skin 4. period of apnea 5. bradycardia 6. pneumothorax

Diagnosis: Clinical sign : grunting, cyanosis in room air, nasal flaring, retraction and shock Chest X-ray: reveal diffuse pattern of radio opaque areas

MANAGEMENT 1. surfactant replacement 2. oxygen administration 3.Ventilation 4. Additional therapy: - Indomethacin or Ibuprofen – to close PDA - muscle relaxant increase pulmonary blood flow

PILLITTERI pp 778 Vol 1

Prevention:

Steroid quicken the formation of lecithins given 12 and 24 hours prior to delivery most effective when given between weeks 24- 34 of pregnancy

Transient Tachypnea of the Newborn

Transient Tachypnea of the Newborn  RR

@ birth – up to 80/min when crying  Normal RR – 30-60/ min  S/sx:  Rapid

RR – 80-120/min  Mild retraction  No marked cyanosis  Mild hypoxia & hypercapnia

Causes: Transient tachypnea of the newborn result from slow absorption of lungs fluid reflect slight decrease in production of mature surfactant limit the amount of alveolar surface area available to an infant for oxygenation exchange infant tend to increase RR and depth

TTN - Peak in intensity at approx. 36hrs in life @ 72hrs of life spontaneously fade as lung fluid is absorbed common: 1.infant born via CS 2.infants whose mother received extensive fluid administration during labor 3. preterm infants

TTN Management:

1. Close observation 2.O2 administration

MECONIUM ASPIRATION SYNDROME

MECONIUM ASPIRATION SYNDROME - Meconium present in fetal bowel as early as 10 wks gestation

Meconium aspiration - Infant

may aspirate meconium either in utero or in first breath after birth.

Cause severe respiratory distress in 3 ways: 1.causes inflammation of bronchioles because a foreign substance 2.block small bronchioles by mechanical

it’s

plugging

3. cause a decrease in surfactant production through lung cell trauma

Meconium aspiration sign and symptoms: 1. tachypnea 2. Retraction 3. Cyanosis 4. Barrel chest – due to air trapping DIAGNOSTICS: CXR: bilateral coarse infiltrates ( honey comb effect) ABG: dec. 02 & inc. Pc02

Meconium aspiration Syndrome Management: 1.suctioning with bulb syringe or catheter while at the perineum 2.severe aspiration infant might intubate 3. don’t administer O2 under pressure 4. antibiotic therapy 5. chest physiotherapy and chest clapping 

APNEA

Apnea :  >pause

in respiration longer than 20 secs. With accompanying bradycardia commonly seen in: 1.preterm infant 2.infection 3.hyperbilirubinemia 4.hypoglycemia

APNEA MANAGEMENT: 1. gently shaking an infant or flicking the sole of the feet 2. Closely observe all NB esp. Preterm 3. always suction the secretion gently to minimize nasopharyngeal irritation 4. Use gently handling to avoid excessive fatigue 5. never take rectal temperature in infant prone to apnea cause vagal stimulation w/c result to Apnea

APNEA  Drug

use to stimulate respiration

 Theophylline  Caffeine

 They

sodium benzoate

help increase infant sensitivity to carbon dioxide ensuring better respiratory function.

Sudden Infant Death Syndrome SID is a sudden unexplained death in infancy Cause is unknown who are at risk: 1. infant of adolescent mother 2.infant of closely spaced pregnancies 3.underweight infant 4. preterm infant

SIDS Contributory factors: 1. viral respiratory infection 2.botulism infection 3. brain stem abnormalities 4.neurotransmitter deficiency 5. heart rate abnormality 6.decrease arousal responses 7. possible lack of surfactant in alveoli 8. sleeping prone

Nsg Care  Support

parents – view second child as an individual child not as a replacement for the one who died  New baby born to a family in which a SIDS infant died is screened – sleep study as precaution within the first 2 wks of life.  New baby placed on continuous apnea monitoring

Hemolytic disease of the newborn  ABO

incompatibility: set up is mother’s type is O baby’s type is A, B, AB Sign and symptom- primarily jaundice Mgt: 1.phototherapy 2.if with severe jaundice can do exchange transfusion 3.initiation of early feeding

 RH incompatibility:

mother is RH(-)( has D antigen) baby is RH (+) Sign and symptoms: kernicterus hydrops fetalis (edema) ( lethal state)

 Therapeutic

management

 Initiation

of early feeding  Phototherapy  Continuously

exposed to specialized light – cool white day light or blue fluorescent light  Light placed 12-30 inches above the NB bassinet or incubator at 25-28 hours of age  Bilirubin level : term 15 mg/dl

Preterm – 10-12 mg/dl  Exchange

transfusion-

 Nursing  Stool

care phototherapy

of infant – bright green & loose  Urine darked colored  Assess skin turgor  Assess I & O – to ensure hydration  Monitor temp  When infant is feeding removed from phototherapy – for interaction

Hemorrhagic disease of newborn

Hemorrhagic disease of newborn due to deficiency of vitamin K bleeding occurs on 2nd to 5th day of life complication: subdural hemorrhage - fatal Sign and symptoms: 1. petechiae 2.vomit fresh blood or pass black tarry stool

Hemorrhagic disease of newborn Management:1. 2.

IM /IV administration of vitamin K if with severe bleeding transfusion of fresh whole blood can be done

NEWBORN AT RISK DUE TO MATERNAL INFECTION/ILLNESS 1. 2. 3. 4. 5. 6. 7.

Beta-hemolytic, Group B Streptococcal Infection Hepatitis B Virus Infection Herpes Virus Infection HIV Mother Infant Of Diabetic Mother Infant Of Drug Dependent Mother Infant With Fetal Alcohol Syndrome

Beta-hemolytic, Group B Streptococcal Infection  GBS

– major cause of infection of NB  Natural habitant – female genital tract  MOT : spread from baby to baby by contact  Risk : prolonged rupture of membrane

Beta-hemolytic, Group B Streptococcal Infection  S/sx  Early

onset

 First   



day of life – Pneumonia

Tachypnea Apnea Shock – dec urine output, extreme paleness or hypotonia Can die within 24 hours of life

Beta-hemolytic, Group B Streptococcal Infection  S/sx  late

onset Occurs at 2-4 weeks of age- meningitis Lethargy, fever , loss of appetite  Bulging fontanelles – increased ICP  Mortality 15% 

Beta-hemolytic, Group B Streptococcal Infection  Diagnostics

mother’s vaginal culture  Blood culture of NB 

 Therapeutic  Ampicillin

management

IV @ 28 wks AOG & during labor ( reduce NB exposure)  Bld test positive : gentamicin, ampicillin & penicillin

Hepatitis B Virus Infection  Transmitted

to the NB through contact with infected vaginal blood at birth – mother is HBsAg+  Destructive illness  70-90% of infected infant can become chronic carrier  Complication : liver cancer later in life

Hepatitis B Virus Infection  Vaccinate

the NB

 Hepatitis

B vaccine + immune serum globulin (HBIG)within 12H – decrease possibility of infection.

 Bathed

infant as soon as possible after birth – removed blood  Gentle suctioning- avoid trauma  Breastfed infant – if HBIG is given

Herpes Virus Infection  HSV-2  Common

Multiple sexual partner

MOT:  Contracted

through the placenta – if mother has primary infection during pregnancy .  Vaginal secretion of mother.

Herpes Virus Infection  S/sx:  Herpes

vesicles clustered with reddened base – covering the skin  Severe neurologic damage  If acquired at birth: ( D4 & D7 of life)  Loss

of appetite  Low grade fever & lethargy  Dyspnea , jaundice, purpura , convulsion & shock  Death occur within hours or days

Herpes Virus Infection  Diagnosis:  Culture

from vesicles  Blood serum analyzed for IgM antibodies  Therapeutic  Acyclovir

Mgt:

( zovirax)  Advised CS- minimize newborn exposure  Isolate infant

Infant Of Diabetic Mother  Macrosomia-

LGA  Chance to have Congenital anomaly – cardiac  Limp / lethargic first day of life – hypoglycemia  Greater chance of birth injury  hyperbilirubinemia Pp 791 pillitteri

Infant Of Diabetic Mother  Diagnostics  Serum

glucose <40 mg/dl NB

 Therapeutic

Mgt

 Fed

early with formula or administered a continuous infusion of glucose

Pp 791 pillitteri

Infant Of Drug Dependent Mother  

SGA infant Infant show withdrawal syndrome       

Irritability , disturbed sleep pattern Constant movement Tremors Frequent sneezing Shrill high pitched cry , hyperreflexia Convulsion Tachypnea , vomiting , diarrhea

Infant Of Drug Dependent Mother 

withdrawal period Opiate – signs usually begin 24- 48 HOL max: 10 days , last 2 weeks  Heroin – begin first 2 wks of life 

ave.onset 72 HOL last 8-16 wks or longer

Methadone –begin 24-28 HOL reappear : 2-4 wks of age no sign : 2-3 wks old  Cocaine : no predictable sequence 

Infant Of Drug Dependent Mother 

CARE  Swaddled

infant  Small isolation nursery – avoid excessive stimulation  Darkened room  Infant Heroin addicted mother – quiet if given pacifier  Maintain fluid & electrolyte  IV infusion if with diarrhea & vomiting

Infant Of Drug Dependent Mother 

DRUG USED TO COUNTERACT WITHDRAWAL SYMPTOMS  Phenobarbital  Chlorpromazine

( thorazine)  Diazepam ( valium)

avoid breastfeeding – to avoid passing narcotics  Mother need treatment for withdrawal symptoms & follow care. 

Infant With Fetal Alcohol Syndrome  Alcohol

crosses the placenta , same concentration as present in the maternal bloodstream.  s/sx : Growth retardation  Microcephaly  Cerebral palsy  Thin upper lip  Tremor  Irritable, sleep disturbance  Weak sucking reflex  Behavioral problem 

Infant With Fetal Alcohol Syndrome  Follow

infant for any future problem  Mother needs follow up- reduce alcohol intake

END