High Risk Neonates

Presented by Ann Hearn

RNC, MSN

Classification of High Risk

Newborns
Gestational Age

Preterm
(Late Preterm)
Term
Postterm

Gestational Age
& Birth Weight
SGA
AGA
LGA

Physiologic Challenges of the

premature infant

Physiologic Challenges of the

premature infant

Respiratory and Cardiac

Thermoregulation
Digestive
Renal

Physiologic Challenges of the

premature infant
Respiratory and Cardiac
Lack of surfactant
Pulmonary blood vessels
Ductus arteriosus

Physiologic Challenges of the

premature infant
Respiratory - Nursing Interventions

Maintain airway
Administer O2
Monitor O2 saturation
Monitor heart/respiratory rates

S/S respiratory distress

Cyanosis
Tachicardia
Retractions
Expiratory grunting
Nasal flaring
Apnic episodes

Physiologic Challenges of the

premature infant
Thermoregulation
Increased body surface
Decreased brown fat
Thin Skin
Lack of flexion
Decrease sub-q fat

Physiologic Challenges of the

premature infant
Thermal Neutrality Nursing
Interventions
Incubator or radian warmer
Warm surfaces
Warm humidified oxygen
Warm ambient humidity
Warm feedings
Keep skin dry and head covered

ISOLETTE/
RADIANT or
INCUBATOR
OPEN
WARMER

Physiologic Challenges of the

premature infant
Digestive
Poor gag reflex
Small stomach capacity
Relaxed cardiac sphincter
Poor suck and swallow reflex
Difficult fat, protein and lactose
digestion
Absorption

Physiologic Challenges of the

premature infant
Nutrition and Hydration Nursing
Interventions

Daily weights
Monitor I&O
Accurate IV rates
Accurate OGT feedings
Monitor urine pH and specific gravity

Signs of dehydration

Weight loss
Poor skin turgor
Dry oral mucus membranes
Decreased urinary output
Increased specific gravity

Physiologic Challenges of the

premature infant
Pre-feeding assessment
Measure abdominal girth
Bowel sounds
Gastric residual
Sucking and gag reflexes

Physiologic Challenges of the

premature infant
Renal
Decreased glomerular filtration rate
Inability to concentrate urine or
excrete excess
Decreased ability of kidneys to
buffer
Decreased drug excretion time

Physiologic Challenges of the

premature infant
Prevention of Infection Nursing
Interventions
Initial scrub / strict hand washing
Visitors & staff

Reverse isolation
Single infant equipment
Short / no artificial nails
Maintain sterile technique
IV start and dressing changes
Procedures

Clean incubators weekly

Position changes; use of sheepskin
Judicious use of tape on skin

Physiologic Challenges of the

premature infant
Signs and Symptoms of Infection
Behavioral changes
Physiological changes

Tonus
Color
Temperature
Skin
Feeding
Hyperbilirubinemia
Heart rate
Respiratory rate

Physiologic Challenges of the

premature infant
Facilitating Parent-Infant Attachment
Prepare parents for first visit
Establish safe/trusting environment
Encourage visitation
Involved in care taking
Repeat explanations
Promote touching, talking, rocking,
cuddling
Refer to infant by name
Allow parents to phone as desired

Disorders of Infants in NICU

SGA and IUGR

Infants of Diabetic Mothers
Postmature Infant
Infants of Addicted Mothers
Respiratory Distress Syndrome
Meconium Aspiration Syndrome
Hyperbilirubinemia
Retinopathy of Prematurity
Necrotizing Entercolitis
Infectious Diseases - TORCH

Associated Complications
of:
SGA

IUGR

Congenital
malformations
Intrauterine infections
Continued growth
difficulties
Cognitive difficulties

Asphyxia
Aspiration syndrome
Hypothermia
Hypoglycemia
Polycythemia

Nursing Interventions: Monitor heart rate, respiratory rate,

temperature and blood glucose.

Infants of Diabetic Mothers

Infants of Diabetic Mothers

Clinical manifestations IDM
Ruddy color
Macrosomia
Excessive adipose tissue
Hypoglycemia
Increase risk of birth injuries.

Infants of Diabetic Mothers

Why Hypoglycemia?
High levels of glucose cross the
placenta
In response, fetus produces high
levels of insulin
High levels of insulin production
continues after cord cut
Depletes the infants blood glucose

Infants of Diabetic Mothers

Nursing Interventions for
Hypoglycemia
Assess for signs/symptoms

Tremors
Cyanosis
Apnea
Temperature instability
Poor feeding
Hypertonia / Lethargy

Assess blood glucose

Intervene if < 40mg/dl:
Feed infant
If no improvement:
IV of D10W

Post Mature Infant

Post term: infant born after __?__
wks
Physical manifestations:
Dry, cracking, parchment-like skin
Loose appearing skin
No vernix or lanugo
Long fingernails
Profuse scalp hair
Long, thin body appearance

Post Mature Infant

Complications of post term:

Hypoglycemia
Meconium aspiration
Congenital anomalies
Seizure activity
Cold stress

Nursing considerations

Monitor blood sugars per protocol

Evaluate respiratory status
Assess for seizure activity
Treat cold stress.

Infants of Addicted Mothers

Clinical Manifestations of Infant
Withdrawal:
IRRITABILITY
Hyperactivity
Shrill cry
Exaggerated reflexes
Facial scratches
Short non-quiet sleep

Sneezing, coughing, yawning

Poor feeding
Disorganized vigorous suck
Vomiting
Diarrhea

Tachypnea
Sweating
Excoriated skin

Infants of Addicted Mothers

Nursing Interventions for Infant
Withdrawal:

Swaddle with hands near mouth

Offer pacifier
Place in quiet dimly lit area of the nursery
Protect skin from excoriation
Monitor V/S
Provide small frequent feedings
Position with HOB elevated
Weigh every 8 hours (if vomiting & diarrhea)
Assess with Finnegan Abstinence Scale
Administer morphine, phenobarbitol,
methadone

Fetal Alcohol Syndrome FAS

Fetal Alcohol Syndrome FAS

Clinical Manifestations:
Jitteriness
Abdominal distention
Exaggerated rooting and sucking reflexes

Affected body systems:

CNS
GI system

Long-term psychosocial implications:

Feeding difficulties
Mental retardation

Respiratory Distress Syndrome

- RDS
Pathophysiology
Primary absence, deficiency or alteration
in the production of surfactant
Surfactant,
atelectasis = lack of
gas exchange
Leads to hypoxia and acidosis which further inhibit
surfactant production and causes pulmonary
vasoconstriction.

Clinical manifestations:
Cyanosis
Tachypnea
Nasal flaring
Retracting
Apnea

Respiratory Distress Syndrome

- RDS
Nursing Care Plan
Page 826-828

Meconium Aspiration
Syndrome
Meconium stained amniotic fluid
Aspirated into the trachobronchial
tree
Occurs either in utero or after birth
with the first breaths.

Meconium in the lungs causes air

to become trapped and results in
alveoli over-distension and
rupture.

Meconium Aspiration
Syndrome
Measures for Prevention of Meconium Aspiration
After delivery of the infants head but before shoulders
Suction oropharynx and nasopharynx (no longer
recommended)

If THICK meconium, after delivery of the infants body

Crying

Not crying

- Stimulate - Do not stimulate

- Suction with
- Visualize the vocal cords and
bulb syringe
provide direct suction with
endotracheal tube, then stimulate.
If THIN meconium, no visualization performed.

Meconium Aspiration
Syndrome
Intubation

Suction

Meconium Aspiration
Syndrome
Nursing Interventions:
Maintain adequate oxygenation and
ventilation
Regulate temperature
Accurate IV fluid administration
Assess for hypoglycemia
Administer antibiotics
Provide caloric requirements
Provide support care if on ECMO

Hyperbilirubinemia
Pathophysiology
Bilirubin is released in serum when RBC lyse
Conjugation in liver = water soluble &
excretable
Rate & amount of conjugation dependent upon:

Rate of hemolysis
Bilirubin load
Maturity of liver
Presence of albumin-binding sites

Hyperbilirubinemia occurs when the body cannot

conjugate the bilirubin released into the serum.
Results in jaundice where the unconjucated
bilirubin is deposited in the tissue.

HYPERBILIRUBINEMIA
Hemolytic Disease (Pathologic
Hyperbilirubinemia)
Results from incompatibility between mothers
blood type or Rh factor and that of the fetus
Maternal antibodies develop from + fetal
antigen
Antibodies cross placental into fetal circulation
Antibodies attach to and destroy fetal RBCs.
Fetal RBCs lyse & release bilirubin into fetal
circulation

HYPERBILIRUBINEMIA
Additional assessments:
Maternal, paternal, and fetal blood type
and Rh factor
Newborn
Skin color, sclera, oral mucosa
Hypotonia, diminished reflexes, lethary and seizures

HYPERBILIRUBINEMIA
Positive Coombs Test
Direct coombs test reveals antibodycoated Rh positive RBCs in the newborn

HYPERBILIRUBINEMIA
Nursing Interventions for
Phototherapy
Exposure of skin
Cover eyes (remove for feeding/parent
visit)
Monitor temperature
Increase fluids
Assess for dehydration
Perform T-Bili q 12 24 hr as ordered

HYPERBILIRUBINEMIA
Exchange Transfusion
Treat anemia
Remove sensitized RBCs that will soon
lyse
Remove serum bilirubin
Provides albumin to increase bilirubin
binding sites

HYPERBILIRUBINEMIA
Rhogam
Provides temporary passive immunity
which prevents permanent active
immunity (antibody formation)
Given within 72 hours of delivery
Prevents production of maternal
antibodies

HYPERBILIRUBINEMIA
ABO incompatibility
Occurs when type O pregnant woman
with A, B or AB blood type fetus
If woman has anti A or anti B antibodies,
these antibodies cross the placental
barrier
Results in hemolysis of fetal RBCs

HYPERBILIRUBINEMIA
Complications of Hemolytic Disease
Kernicterus Deposits of conjugated and
unconjugated bilirubin in the basal
ganglia of the brain
Neurologic damage

Hydrops fetalis severe anemia

Marked edema
Cardiac decompensation
Multiple organ failure
Possible death

Retinopathy of Prematurity
Formation of immature blood vessels
in the retina constrict and become
necrotic
Most common in infants < 28 weeks
gestation
Also associated with O2 therapy

RETINOPATHY OF
PREMATURITY
Nursing Interventions to Prevent ROP
Administer O2 in concentration ordered
Ensure proper ventilatory settings

Necrotizing Enterocolitis
NEC - Inflammatory disease of the
intestinal tract caused by ischemia,
infection, and/or prematurity of the gut.
Preterm infant at increased risk
undeveloped protective intestinal mucin layer
slow careful introduction to oral feedings

Early detection:

Measure abdominal girth daily

Assess color of abdomen
Assess residual feeding
Assess bowel sounds
Assess S/S sepsis

Infectious Diseases: TORCH

Toxoplasmosis
Other
Syphillis
Hepititis B

Rubella
Cytomegalovirus
Herpes Simplex II
HIV

Toxoplasmosis
Protozoan infection in the pregnant woman
Raw or under cooked meats
Cat feces

Affects on the fetus

Blindness
Deafness
Convulsions
Microcephaly
Hydrocephaly
Severe mental impairment

OTHER
Syphilis
Hepatitis B

Other
Syphillis
S/S of Newborn:

Rhinitis
Excoriated upper lip
Red rash around mouth and anus
Copper colored rash of face, palms and soles
Irritability
Edema
Cataracts.

Treatment:
Culture orifices
Isolation
Penicillin

OTHER
Hepatitis B
Transmission
Placental
Birth
Breast milk

Treatment
If mother + HbSAG administer to newborn
Hepitisis B vaccine
HBIG

Rubella
S/S of Newborn
Congenital cataracts
Deafness
Congenital heart defects
Sometimes fatal

MMR Immunization of mother

Give when not pregnant

Cytomegalovirus
Herpatic virus
Crosses placental barrier
Direct contact at birth
S/S of Newborn

Severe neurological problems

Eye abnormalities
Hearing loss
Microcephaly
Hydrocephaly
Cerebral palsy
Mental delays

Herpes Simplex II
Transmission:
Direct contact at birth

S/S of Newborn

Microcephaly
Mental delays
Seizures
Retinal dysplasia
Apnea
Coma

HIV/AIDS
Transmission: < 2%
Transplacentally
Exposure at birth
Breast milk

Nursing Interventions

Protect self from body fluids

Labs - + antibody titer
Administer AZT
Provide care like that of any other newborn