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Chapter 19

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  1. Chapter 19 Caring for the Newborn at Risk

  2. Risk Factors for Newborns • Intrauterine development • Intrapartum development • Extrauterine development

  3. A & P Review • Lung maturity • Circulatory maturity • Neurological maturity

  4. Classification of High-Risk Newborns Gestational Age (GA) • Preterm (born before 37 weeks) • Term (born between 38 and 42 weeks) • Postterm (born after 42 weeks)

  5. Classification of High-Risk Newborns Birth Weight • Low birth weight (LBW) (<2500 g) • Very low birth weight (VLBW) (<1500 g) • Extremely low birth weight (ELBW) (<1000 g)

  6. Intrauterine Growth Restriction (IGUR) • A term used to denote a lack of intrauterine fetal growth that usually results in an SGA newborn

  7. Small-for-Gestational-Age Infants (SGA) • Infants born at any gestational age who have a birth weight that falls below the 10th percentile on the growth charts

  8. Conditions Affecting theSGA Newborn • Hypothermia • Pain • Hypoglycemia • Polycythemia

  9. Large-for-Gestational- Age Infants (LGA) • Infants born who are over the 90th percentile on the growth chart

  10. Conditions AffectingLGA Newborn • Chronic hyperglycemic state • Transient tachypnea of the newborn • Hypoglycemia • Hypocalcemia • Hypomagnesemia • Birth injuries • Brachial plexus injuries • Fractures

  11. The Premature Newborn • Severe prematurity • 23 to 26 weeks • Moderate prematurity • 26 to 30 weeks

  12. Physical Assessmentof the Premature Newborn • Skin • Head • Chest • Cardiac • Abdomen • Musculoskeletal • Genitalia • Neurological/sensory

  13. Conditions Affecting the Premature Newborn

  14. Respiratory Distress Syndrome (RDS) • Atelectasis with congestion and edema in lung spaces • Lecithin-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) levels low • Underdeveloped alveoli • Signs and symptoms begin shortly after birth Nursing Care: • Provide oxygenation • Maintain mechanical ventilation • Assist with endotracheal intubation (ET) • Administer syntheic surfactant via ET • Wean ASAP to prevent complications

  15. Apnea of Prematurity • Apnea >15 to 20 seconds accompanied by pallor, hypotonia, cyanosis, and bradycardia Nursing Care: • Monitor cardiorespiratory (C-R) status • Apply continuous pulse oximeter • Watch for A and B spell

  16. Jaundice • Diagnosed in term infants with a serum bilirubin level >12.9 mg/dL and in preterm infants >15mg/dL Nursing Care: • Based on underlying cause • Give phototherapy • Ensure hydration (electrolyte solution) Complications: • Bilirubin encephalopathy • Kernicterus

  17. Retinopathy of Prematurity • Result of immature retinal vasculature followed by hypoxia • Inversely related to gestational age • Risk factors • Diagnosis –– 5 stages Nursing Care: • Fluctuations in concentrations of oxygen must be prevented • Wean off oxygen ASAP • Decrease constant bright lights • Encourage routine examinations

  18. Anemia of prematurity • Hemoglobin below 35% and 45% Nursing Care: • Administer recombinant human erythropoieten SC • Sudden Infant Death Syndrome (SIDS) • “Back to Sleep” • Educate parents about prevention

  19. The Post term Newborn Newborns in utero after the optimal growth time (42 weeks) • Skin is parchment-like • Fingers are long and peeling • Muscle wasting is present

  20. Conditions Affecting the Postterm Newborn Meconium Aspiration Pneumonia — meconium aspirated at birth • Meconium-stained skin, nails, and umbilical cord • Initial respiratory distress • Rales and rhonchi on auscultation Nursing Care: • Give chest physiotherapy (CPT) • Monitor mechanical ventilation • Administer medications

  21. Persistent Pulmonary Hypertension of the Newborn Vascular resistance in pulmonary system • Meconium-stained amniotic fluid • Brief respiratory distress at birth, then resolves and returns about 12 hours later • Centrally cyanotic and tachypenic • Audible murmur Nursing Care: • Extracorporeal membrane oxygenation (ECMO) • See Chapter 19 Nursing Care Plan

  22. Additional Conditions Affecting the High-Risk Newborn • Metabolic conditions • Neurologic conditions • Gastrointestinal conditions • Infections

  23. Metabolic Conditions • Phenylketonuria (PKU) • Phenylalanine-free diet, elimination of protein • Galactosemia • Galactose-free diet • Maple Syrup Urine Disease • Low-protein diet, thiamine supplements

  24. Metabolic Conditions • Homocystinuria • Diet therapy ― high doses vitamin B6 • Methionine and cystine restriction • Biotinidase Deficiency • Pantothenic acid or biotin (types of B vitamins)

  25. Neurological Conditions Intraventricular and Periventricular Hemorrhage[categorized by extent and involvement (grades)] Nursing Care: • Recognize seizures • Administer antiseizure medications • Prevent cerebral damage • Maintain adequate oxygenation • Educate parents

  26. Neurological Conditions • Anencephaly (skull and cerebrum are malformed) • Encephalocele (protrusion of brain through a skull defect) • Microcephaly (smaller than normal head circumference) • Holoprosencephaly (cerebral matter fails to form as two distinct hemispheres)

  27. Gastrointestinal Conditions Cleft Lip and Palate ― has genetic and environmental predispositions Nursing Care: • Provide adequate nutrition • Feed in upright position • Surgery: CL ― 3 months, CP ― before 18 months • Educate and provide emotional support for parents

  28. Gastrointestinal Conditions Necrotizing Enterocolitis • Ischemic episode of the bowel; can produce septicemia Nursing Care: • Ensure that oral feedings are stopped • Discuss possible surgery

  29. Abdominal Wall Defects Gastroschisis and Omphalocele Nursing Care: • Surgery within 2 to 4 hours • Cover abdominal contents with moist gauze and wrap in plastic • Position carefully • Place NG/OG • IVF at 1.5 times normal maintenance • Postoperative care focuses on fluids, electrolyte balance, nutritional support, infection protection, pain management, and keeping parents informed

  30. Infections in the Newborn Herpes Simplex • HSV-1 acquired from people with herpes lesions of the mouth • HSV-2 acquired through a genital infection Nursing Care: • Acyclovir (Avirax) • Ensure proper developmental stimulation Neonatal Sepsis • Systemic infection Nursing Care: • Review diagnostic workup • Give antibiotics for a minimum of 48 hours

  31. Developmental Delay Neonatal Abstinence Syndrome (NAS) • Drug-abusing mother • Irritability Nursing Care: • Laboratory tests done to reveal if drugs are in the newborn’s system • Use neonatal abstinence scoring tool every 3 hours

  32. Care of the High-Risk Newborn • Blood Pressure • Nutritional Care • Developmental Care • Noise • Lighting • Handling • Positioning

  33. Neonatal Intensive Care Unit • Educate parents on what to expect, rules of the unit, and expectations • Create partnership with parents • Encourage touch • Provide discharge planning

  34. Classification of the Neonatal Intensive Care Unit • Level I ― provides well newborn care and stabilization of high-risk newborns • Level II ― provides premature care (give oxygen and intravenous therapy given) • Level III ― provides care to ventilate newborns

  35. Transporting the Preterm Newborn • Transport is done if more technologically advanced care is needed • Transport team comprised of professionals • STABLE program • Home Work#3: ATI Practice test A & B