High risk newborn part two

• Identifications of at-risk newborns

  • No prenatal care
  • Exposure to environmental dangers
  • Preexisting maternal conditions: diabetes
  • Maternal factors: nutrition, HTN, obesity
  • Pregnancy related medical conditions: preeclampsia and gestational diabetes
  • Pregnancy complications: chorioamnionitis and placental abruption/previa
  • Labor complications: shoulder dystocia, breech and instrumental assisted delivery
• Classifications

  Very premature: <32 weeks

  Premature: <37 weeks

  Late premature: 34-36 6/7 weeks

  Low birth weight: <2500 grams

  Very low birth weight: <1500 grams

  Extremely low birth weight: <1000 grams
• Late-Preterm

  -Born between 34 to 36 6/7 weeks

  -Thermal instability

  -Feeding problems

  -Respiratory distress

  -Hypoglycemia/jaundice
• Postterm infants

  • Delivery after 42 weeks, >4000 grams
  • Decreased placental functioning
  • Complications: CPD, shoulder dystocia, and meconium aspiration
  • Postmaturity syndrome: skin dry/cracked/peeling, calcifications of placenta, oligohydramnios and starved appearance
  • Postterm syndrome: hypoglycemia, meconium aspiration syndrome, polycythemia, congenital anomalies, seizures and cold stress
• Nursing care postterm infants

  • Maintain a NTE
  • Meconium staining
  • Respiratory distress, meconium aspiration syndrome
  • Early and frequent feedings
  • Labs: blood glucose and hematocrit
  • Monitor daily weights and fluid & electrolytes (I&O)
  • Administer oxygen as ordered
  • Meconium aspiration syndrome warrants NICU
• SGA complications

  • Intrauterine asphyxia-cesarean delivery
  • Meconium aspiration syndrome
  • Hypothermia
  • Hypoglycemia
  • Hypocalcemia
  • Polycythemia
• IUGR Factors

  Maternal: parity, multiple gestation, smoking, no prenatal care, age, and malnutrition in last trimester

  Maternal disease: heart disease, substance abuse, PKU, HTN and diabetes

  Environment: high altitude, x-ray exposure, toxins and prescription drugs

  Placental size, abnormal cord insertion, and placental previa

  Fetal-congenital infection, female sex, and chromosomal abnormalities.
• LGA

  Weight above the 90th percentile

  Risk factors:

  -Diabetic mother

  -Multiparous mother

  -genetic disposition

  -males

  -certain genetic disorder
• LGA complications

  • shoulder dystocia: asphyxia, fractured clavicle, plexus palsy
  • hypoglycemia
  • respiratory distress
  • polycythemia
  • increase in oxytocin-induced births
  • increase in cesarean birth rate
• Complications of premature birth

  • Respiratory distress syndrome
  • Bronchopulmonary dysplasia/chronic lung disease
  • Retinopathy of prematurity
  • Patent ductus arteriosus
  • necrotizing enterocolitis
  • sepsis
  • disrupted nutrition
  • at risk for cardiovascular, metabolic, neurologic and thermal dysregulation
• Surfactant

  • decreases surface tension
  • decreases work of breathing
  • decreases leak of proteins & water which leads to pulmonary edema
  • decreases atelectasis
  • increases alveolar stability on expiration
• Respiratory distress syndrome S/S

  • *Retractions*
  • grunting
  • nasal flaring
  • tachypnea/apnea
  • decreased breath sounds
  • crackles, rales
  • cyanosis, pallor
  • tachycardia
  • hypothermia
  • hypoglycemia
  • hypotonic
  • hypoxia and acidosis
• Respiratory distress syndrome management

  • Maintain thermoregulation
  • Maintain PaO2 greater than 60 mmHg
  • Use warmed and humidified O2
  • CPAP/Bubble CPAP
  • Give surfactant
  • Monitor blood gases
• Neutral thermal environment

  • Higher proportionate body surface area
  • cannot sweat or shiver
  • decreased brown fat
  • cold stress

  Management: radiant warmer, decrease insensible losses, mist tent, and saran wrap
• PDA

  S/S:

  -Murmur

  -Active precordium

  -Wide pulse pressure

  -Bounding pulse

  -Tachycardia/tachypnea

  Dx:

  -Echocardiogram

  Tx:

  -Indomethacin

  -Surgical ligation
• Bronchopulmonary dysplasia

  • Chronic lung disease
  • Cause: mechanical ventilation and prolonged oxygenation
  • S/S: retractions, wheezing, rales, rhonchi, hypoxia, bronchospasm, edema, decreased urine output, weight gain, and respiratory acidosis
  • Dx: chest x ray
  • Tx: blood gas monitoring, bronchodilators, corticosteroids, diuretics, oxygen therapy, CPT, monitor I&O, nutrition, and daily weights
• Intraventricular hemorrhage

  Grade 3 and 4 produce seizures
• Necrotizing enterocolitis

  • Inflammation and necrosis of the bowel
  • S/S: apnea, bradycardia, increased feeding residuals, emesis, heart rate abnormalities, low BP, abdominal redness, distention, bowel loops and tenderness.
  • Dx: abdominal x ray
  • Labs: CBC, CRP, blood cultures, electrolytes, Blood gases, coags
  • Tx: gastric decompression, NPO, antibiotics, IV fluids, monitor I&O
• Retinopathy of prematurity

  • Sensory impairment
  • Retina is not completely vascularized: fluid leakage/bleeding causes scar tissue that damages the retina
  • Neonates born prior to 30 weeks gestation & 4-6 weeks of age do eye exams
  • Tx: target saturations for oxygenation, intravitreal medication injection, laser, cryotherapy and vitreoretinal surgery.