Nursing Care of High-Risk Newborn (Part 1)

• A preterm infant is traditionally defined as a live-born infant born before the end of week 37 of gestation; another criterion used is a weight of less than 2500 g (5 lb 8 oz) at birth.
• Physical findings that determine maturity of newborn

  1. Sole creases
  2. Skull firmness
  3. Ear cartilage
  4. Neurologic findings that reveal gestational age
  5. Mother's report of the date of her LMP & sonographic estimations of gestational age
• Possible tests for premature infant

  1. Breathing and heart rate monitor
  2. Fluid input and output
  3. Blood tests
  4. Echocardiogram
  5. Ultrasound scan
  6. Eye exam
• Late preterm - born between 34 and 36 completed weeks of pregnancy
• Moderately preterm - born between 32 and 34 weeks of pregnancy
• Very preterm - born at less than 32 weeks of pregnancy
• Extremely preterm - born at or before 25 weeks of pregnancy
• Characteristics of Premature Infant:

  1. Small size, with a disproportionately large head
  2. Sharper looking, less rounded features than a full-term baby's features, due to a lack of fat stores
  3. Fine hair (lanugo) covering much of the body
  4. Both anterior and posterior fontanelles are small
  5. There are few or no creases on the soles of the feet.
• Characteristics of Premature Infant:

  1. Ears appear large in relation to the head. The cartilage of the ear is immature and allows the pinna to fall forward.
  2. Low body temperature, especially immediately after birth in the delivery room, due to a lack of stored body fat
  3. Labored breathing or respiratory distress
  4. Lack of reflexes for sucking and swallowing, leading to feeding difficulties
  5. Preterm neonate, 24 to 36 weeks, typically is covered with vernix caseosa.. However, in very preterm newborns (less than 25 weeks’ gestation), vernix is absent because it is not formed this early in pregnancy.
• Gestational Age

  SGA - 22-44 wk

  Preterm Infant - <37 wk
• Birth weight

  SGA - <10th percentile

  Preterm - normal
• Congenital malformations

  SGA - strong possibility

  Preterm - possibility
• Pulmonary problems

  SGA - Meconium aspiration, Pulmonary hemorrhage, Pneumothorax

  Preterm - Respiratory distress syndrome
• Hyperbilirubinemia

  SGA - possibility

  Preterm - very strong possibility
• Hypoglycemia

  SGA - very strong possibility

  Preterm - possibility
• Intracranial hemorrhage

  SGA - strong possibility

  Preterm - possibility
• Apnea episodes

  SGA - Possibility

  Preterm - Very strong possibility
• Feeding problems

  SGA - most likely bc of accompanying problem such as hypoglycemia

  Preterm - small stomach capacity, immature sucking reflex
• Weight gain in nursery

  SGA - rapid

  Preterm - slow
• Initiation & maintenance of RESPIRATIONS in premature infants

  1. Resuscitation
  2. Airway
  3. Drug therapy
  4. Lung expansion
• Capillary fragility - the reason why preterm infants are probe to hemorrhage
• Surfactant - may be given to preterm infants if natural surfactant hasn't formed in the lungs yet
• Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of Life

  1. Low birth weight
  2. Maternal history of diabetes
  3. Premature rupture of membranes
  4. Maternal use of barbiturates or narcotics close to birth
  5. Meconium staining
  6. Irregularities detected by fetal heart monitor during labor
  7. Cord prolapse
  8. Lowered Apgar score (7) at 1 or 5 minutes
  9. Postmaturity
  10. Small for gestational age
  11. Breech birth
  12. Multiple birth
  13. Chest, heart, or respiratory tract anomalies
• The neonatal intensive care unit (NICU) or special care nursery - provides round-the-clock care for your premature baby
• Incubator - kept warm to help your baby maintain normal body temperature.
• Supportive care (Premature Infants)

  Having a feeding tube – receive fluids and nutrients through an IV tube and Breast milk may be given through NGT.
• Sodium, Potassium levels - should be monitored when replenishing fluids in premature infants
• Bilirubin lights - treat infant jaundice
• Blood transfusion - raise blood volume
• Surfactant - a medication used to treat respiratory distress syndrome
• Fine-mist (aerosolized) or IV medication - medications that strengthen breathing and heart rate
• Diuretics - medications to manage excess fluid
• An injection of medication into the eye to stop the growth of new blood vessels that could cause retinopathy of prematurity
• Medicine that helps close the heart defect known as patent ductus arteriosus
• Bone marrow does not increase its production until approximately 32 weeks.
• Acute Bilirubin Encephalopathy - destruction of brain cells by invasion of indirect bilirubin.
• Acute Bilirubin Encephalopathy - This invasion results from the high concentrations of indirect bilirubin that forms in bloodstream from an excessive breakdown of red blood cells.
• Persistent Patent Ductus Arteriosus

  Lungs lack of surfactant and have difficulty in moving blood from the pulmonary artery into the lungs. This condition leads to pulmonary artery hypertension, which may interfere with closure of the ductus arteriosus.
• Periventricular hemorrhage - bleeding into tissue surrounding the ventricles
• Intraventricular hemorrhage - bleeding into the ventricles