NUR 4955

High Risk Newborn & Newborn Complications

Infant morbidity and mortality

Leading causes of death

Congenital malformations Prematurity

The lower the GA, the higher the morbidity, mortality & long term complications
Cerebral Palsy Sensory, cognitive & visual disabilities Difficulties with assimilation within society The lower the GA, higher cost to society

Initial Assessment

Overall appearance Vital signs Size Gestational age Maternal complications?

Small for Gestational Age

Small for gestation age (SGA) and Intrauterine growth restriction (IUGR) < 10% on growth chart Perinatal mortality 8X that of AGA

Patterns of SGA & IUGR

Symmetrical (SGA)

Chronic prolonged restriction in growth Utero-placental insufficiency Weight, length, HC, CC

Asymmetrical (IUGR)
Acute compromise of utero-placental blood flow Head appears larger compared to body Brain growth spared Begins later in gestation (28wks)

Pathophysiology

Placenta not functioning

nutrition O2

Characteristics

Sparse scalp hair Wide suture lines

Scaphoid abdomen
Loose, dry skin Appear malnourished

Complications of SGA
Perinatal asphyxia Chronic hypoxia no reserve to meet demands of L & D Aspiration syndrome Hypoxia gasping during birth aspiration of amniotic fluid or meconium Heat loss Diminished sub q fat Depletion of brown fat

Complications of SGA

Hypoglycemia
metabolic rate r/t heat loss Use glycogen stores for energy

Hypocalcemia
Secondary to birth asphyxia

Polycythemia
Hypoxia RBCs jaundice

Focus of Nursing Care

Observation for subtle changes Interpreting lab data Conserving infants energy Developmental stimulation

Assisting development of attachment

Involve family in planning

Poor Outcomes for SGA R/T

Congenital Malformation Intrauterine Infection Continued Growth Difficulties Learning Difficulties

Large for Gestational Age

> 90% on growth chart

Weighing 4000 g or more at birth

Etiology/Causes
Genetic predisposition Multiparas Male infants Gestational Diabetes

Pathophysiology of IDM

If mom hyperglycemic, glucose crosses placenta = fetal weight Fetus produces more insulin to enhance utilization of glucose At birth glucose from mom but insulin remains high = hypoglycemia

Complications of IDM

Hypoglycemia
2-4 hours of life

Hypo-calcemia and hypo-magnesemia

Stress of delivery

Polycythemia
extracellular vol

Hyperglycemia & hyper-insulinemia O2 consumption fetal hypoxia

Complications of IDM

Hyperbilirubinemia & Polycythemia

extracellular vol HCT

RDS

Insulin antagonizes cortisol-induced stimulation of L/S and PG

Congenital birth defects (cardiac) Birth trauma

Birth Trauma

Peripheral nervous system injuries Erb-duchenne palsy Facial paralysis Central nervous system injuries Intracranial hemorrhage Spinal cord injuries Skeletal injuries Soft tissue injuries

Premature/Preterm Infants

< 37 completed wks gestation

Care Management

Respiratory & Cardiovascular

surfactant atelectasis hypoxia, inefficient pulmonary blood flow, depletion of energy Incomplete development of pulmonary blood vessels pulmonary arterioles not constricting in response to O2 levels lower pulmonary vascular resistance left-to right shunting PDA

Nursing Care Respiratory

Maintain patency Prone position Position to facilitate drainage of mucous Cardio-respiratory monitor Pulse oximeter

Nursing Care Respiratory

O2
Hood therapy, Nasal cannula CPAP Mechanical ventilation Surfactant administration Extracorporeal membrane oxygen therapy (ECMO) High-frequency ventilation Nitric oxide therapy

Feeding tube when suck & gag reflexes intact

Thermoregulation

Heat loss high

High ratio of body surface to body wt sub Q fat Thin permeable skin Position of extension ability to vasoconstrict

Heat production low

Nursing Care Thermoregulation

Warm & humidify O2 Warmed Isolette Keep dry to prevent evaporative heat loss Warm formula Wean to crib slowly

1500 grams, 5 days weight gain Taking PO feeds RR & HR stable

Alterations in Reactivity Periods & Behavioral States

Periods of activity delayed for several days Disorganized in sleep/wake patterns Unable to attend well to human face & objects Neurologically weaker responses

Suck Muscle tone States of arousal

The Parents

Assist parent adjustment

Teach to providing developmentally appropriate care

Nursing Care Parent-Infant Attachment

Photographs First name on isollete Weekly card with footprint, wt & length Telephone # of nursery Early parental involvement Skin to skin

Kangaroo Care

Key Point about Developmental Care

A philosophy that embraces family-centered care and awareness of the impact of environmental stimuli on the physical/psychological well-being of the infant and family.

Nursing Care: Developmentally Supportive Care

Lower noise level Blanket over isolette Containment Nesting Avoid sudden postural changes Sheepskin or H2O bed Provide objects to grasp Stroking, rocking, cuddling, quiet singing/talking

Taking Baby Home

Parents need special instruction before they take home a high risk infant
CPR Oxygen therapy Suctioning Developmental Care

Infant Pain Response

Infant pain responses

Pain assessment Memory of pain Consequences of untreated pain in infants Pain management

Renal
ability to excrete drugs Limited ability to concentrate urine or excrete excess fluids risk for fluid retention & over-hydration Excrete glucose as low serum glucose level glycosuria with hyperglycemia buffering capacity of kidney metabolic acidosis

Nursing Care Fluid & Electrolyte

Assess dehydration/over-hydration Weigh Everyday

Same time, scale, state of dress

I&O
Output 1-3 ml/kg/hr Weigh diapers

Hourly intake if IVs

Gastro-intestinal

Difficulty with digestion & absorption Poor gag reflex, incompetent cardiac sphincter Small stomach capacity Requires a high concentration of whey to casin ratio in formula Deficiency of Ca & phosphorous Increased BMR & O2 requirements r/t fatigue from sucking Feeding intolerance & NEC r/t blood flow to intestines

Nutritional & Fluid Management

High caloric need (110-130 kcal/kg/day) Need for supplemental vitamins Need Vitamin E - r/t diet high in fats which they need Nutritional intake adequate if gaining 20-30 gms/day Initial weight loss 10-15%

Nursing Care - Nutrition

120 cal/kg/day Before feeding

Measure abdominal girth Auscultate for bowel sounds

Watch for signs of feeding intolerance

+ Guiac stools Lactose in stools Vomiting & diarrhea Abdominal distention Weight loss or plateau

Nursing Care - Nutrition

Signs of readiness for oral feeding

Strong gag Non-nutritive sucking Rooting 34 wk gestation or greater & 1500 grams Gaining 20-30 grams/day

Nursing Care Nutrition Bottle Fed

Soft, smaller nipple Semi sitting position Burp Q -1 oz Feeding last no longer than 15-20 min

Nursing Care Nutrition - Breast Feeding

Put to breast when

Suck & swallow developed Consistent weight gain Control body temp outside isolette

Football hold May take 45 min (sleep and rest periods) Pump and gavage until able to nurse

Nursing Care Nutrition - Gavage

Adjunct to nipple feeding

Nasogastric or orogastric route
Gavage Gastronomy feeding

Complications

Apnea of prematurity
PDA RDS
surfactant

20sec or > or , 20 sec + cyanosis & bradycardi

pulmonary arteriole musculature & hypoxem

GMH-IVH - Hemorrhage

Germinal matrix lines brain ventricles & is high susceptible to hypoxia

Complications

Anemia
Rapid rate of growth Shorter RBC life Excessive blood sampling iron stores

Hypocalcemia NEC

Necrotizing Enterocolitis

Long Term Outcomes

Retinopathy

of prematurity (ROP) Bronchopulmonary Dysplasia (BPD) r/t damage to alveoli from CPAP therapy & high O2 concentrations Speech defects Neurological deficits Auditory defects

Nursing Care Infection Prevention

Strict hand washing Maintain asepsis

Change position regularly

Sheepskin

Avoid chemical skin preps/tape

Post-term
> 42 weeks gestation Post-maturity syndrome

Dont tolerate prolonged pregnancy

Placenta degenerates Poor oxygenation Poor nutrition Poor waste removal

Characteristics
Loose, dry peeling skin Meconium staining Long fingernails Alert faces Look old & worried

Postmaturity Complications

Hypoglycemia
Nutritional deprivation

Meconium aspiration
hypoxia

Polycythemia
R/t hypoxia

Seizure activity
R/t hypoxia

Cold stress
sub Q fat

Congenital anomalies

Meconium Staining
Occurs in 10-15% of all live births Predominantly in Term, SGA, or Postterm infants Cause may be in utero hypoxia Almost never observed in infants less than 34 weeks gestation

Aspiration Syndromes
Fetal stress or distress or developmental Process:

Gasping of fluid, blood, meconium etc. into lung with breathing Rapid distal migration with first breaths

Prevention
Delay first breath Intubate and suction

Aspiration Signs and Symptoms

Barrel chest Tachypnea Grunting, retractions, Pallor, cyanosis CO2 retention, acidosis Rales, decreased breath sounds Stained nails, cord & skin

Substance Abuse

Alcohol
Fetal alcohol syndrome (FAS) Fetal alcohol effects (FAEs)

Heroin Methadone Marijuana Cocaine

Fetal Alcohol Spectrum Disorder

Leading cause of mental retardation SGA/IUGR Life long affecting learning, behavior, relationships Speech/hearing/language Eating, sleeping

Triad for Diagnosis

Facial abnormalities Growth deficits CNS abnormalities or Neurobehavioral disabilities

FAS 1st Week 1st Month

Sleeplessness Inconsolable crying Abnormal reflexes Hyperactivity Jitteriness Excessive mouthing behaviors Hyperactive rooting Increased non nutritive sucking

Long Term Complications

Failure to thrive ability to block out repetitive stimuli Severe mental retardation or normal Impulsivity Cognitive impairment Speech/language abnormalities

Cocaine
Greatest impact on perinatal morbidity Increase risk for:

Spontaneous abortion/stillbirth STDs, HIV Abruptio placenta Prematurity

LBW - low birth weight

Heroin and Methadone

Results in IUGR, prematurity, stillbirths, but no documented congenital anomalies Methadone - better infant outcomes then heroin such as: fewer infections, larger birth weight Withdrawal symptoms may be more severe in methadone exposed infants. Long-term - increased risk for SIDS
X 10-15

Risks to Infants with NAS

Intrauterine asphyxia
maternal withdrawal fetal withdrawal hyperactivity increased O2 consumption asphyxia

Intrauterine infection r/t addicts life style Alterations in body weight

Observe for Withdrawal S & S

Most common
Poor weight gain
diarrhea, vomiting

Tremors Seizures SIDS Irritable

Nursing Care

Temperature regulation Monitor P & R q 15 m till stable Small, frequent feedings IV prn hydration Medication-Phenobarbital Position on R side aids in digestion Weight Q8H during withdrawal Swaddle with hands near mouth Gentle vertical rocking Quiet, dimly lit area

Nursing Care

Quiet dimly lit environment Extra time & patience with fdg Monitor VS Observe for seizures Observe for RDS Mom can breastfeed
alcohol will intoxicate newborn inhibits letdown

Support parents & reinforce + parenting skills

Substance Abuse
Other substances Nicotene Caffeine

Critical thinking
Assessments on SGA, LGA, Pre/Postterm What causes them? What are their major problems?

System by system

Which are the priorities? How do you solve them? Developmental delays. Parental involvement and care.

Example
The mother admits to alcohol What will the baby look like? How will the baby act? What problems is the baby likely to have? How will you respond to them? What are your interventions?

Feeding, diapering, sleeping, stimulation, pt education, medications, collarboration

What does the mother need to know?

Next Week
Exam 3 50 questions All multiple choice All on the high risk and complications of pregnancy, birth and newborn Use the critical thinking topics to help focus your preparation Room 256 12:30 Review at 1:45