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NCM 102 A
CARE OF THE HIGH
RISK CHILD
CLAIRE ALVAREZ
ONGCHUA RN,MN
CARE OF THE HIGH
RISK
NEWBORN
Newborn classification
Based on
GESTATIONAL AGE
BIRTH WEIGHT
BIRTH WEIGHT AND GESTATION
Classification
Based on Gestational Age
Preterm (premature) born at 37 weeks' gestation
or less
Term born between the beginning of week 38
and the end of week 41 of gestation
Post-term (postmature) born at 42 weeks'
gestation or more
Based on Birth Weight
Chromosomal abnormalities.
Anatomic abnormalities, such as
tracheoesophageal atresia or fistula and
intestinal obstruction.
Fetoplacental unit dysfunction.
The premature infant has altered physiology because
of immature and typically poorly developed systems.
The severity of any problem that occurs depends
somewhat on the gestational age of the infant.
Systems and situations that are most likely to cause
problems in the premature infant include:
Respiratory system.
Digestive system.
Thermoregulation.
Immune system.
Neurologic system.
Physiologic Challenges of the premature
infant
Testes - undescended.
Labia majora - undeveloped.
Rugae of scrotum - fine.
Sole of foot is smooth.
36 weeks' gestation - anterior 1/3 of foot is creased.
Head circumference
Abdominal girth
Heel to crown.
Shoulder to umbilicus - used to calculate
proper length of catheter for umbilical arterial
catheter placement.
Weight in grams.
Assess gestational age using a tool such as the Ballard
scoring system (recommended by Committee of Fetus
and Newborn of American Academy of Pediatrics):
Perinatal depression
placental membrane
A higher risk of fetal inrapartum or neonatal
death
The newborn is at increased risk for developing
complications related to compromised uteroplacental
perfusion and hypoxia (e.g., meconium aspiration
syndrome MAS)
Hypertension
Cardiac, pulmonary, or renal disease
Diabetes mellitus
Poor nutrition
Use of alcohol, tobacco, or drugs
Maternal conditions associated with SGA
babies include:
Age
Multiple gestation
Placental insufficiency
Placental fetal abnormalities
Pregnancy occurred at high altitudes
Fetal conditions associated with SGA infants
include:
1. Clinical manifestations
Soft tissue wasting and dysmaturity
Loose, dry, and scaling skin
Perinatal asphyxia (due to a small placenta that is
less efficient in gas exchange)
Plethora, respiratory distress, and central nervous
system (CNS) aberrations (if the infant has
polycythemia)
Congenital anomalies (occurring in as many as 35%
of SGA infants who suffered insults early in gestation)
2. Laboratory and diagnostic study findings
Cyanosis
Jaundice
breast feeding.
Explain the importance of follow-up with a
Genetic predisposition
Excessive maternal weight gain during
pregnancy.
Poorly controlled maternal diabetes
secondary to high levels of maternal glucose
that cross the placenta during pregnancy.
Pathophysiology
Infants who are large for gestational age have been
subjected to an overproduction of growth hormone in
utero. This most frequently happens with infants of
diabetic mothers who are poorly controlled. It may also
occur in multiparous pregnancies because with each
pregnancy babies tend to grow larger.
Hypotension.
Edema of the hands and feet.
Absent bowel sounds early in the illness.
Decreased urine output.
Diagnostic Evaluation
Prenatal diagnosis: Evaluation of amniotic fluids to
assess fetal lung maturity.
Lecithin/sphingomyelin ratio tests of surfactant
phospholipids in amniotic fluid.
Phosphatidylcholine and phosphatidylglycerol (PG)
phospholipids that stabilize surfactant.
TDX fetal maturity assay determines PG levels in
amniotic fluid or neonatal tracheal aspirates.
Lamellar bodies test measures a storage form of
surfactant in amniotic fluids.
Diagnostic Evaluation
Laboratory tests:
Elevated Partial pressure of arterial carbon dioxide
PaCO2.
Low Partial pressure of arterial oxygen (PaO2) low.
Low Blood Ph due to metabolic acidosis.
Low Calcium
Low Serum glucose
Pulmonary function studies - stiff lung with a
reduced effective pulmonary blood flow.
Diagnostic Evaluation
Laboratory tests:
Chest X-ray - diffuse, fine granularity; whiteout,
very heavy, uniform granularity reflecting fluid-
filled alveoli and atelectasis of some alveoli,
surrounded by hyperdistended bronchioles; ground
glass appearance with prominent air bronchogram
extending into periphery of lung fields. Pulmonary
interstitial emphysema (PIE) is observed in
premature neonates with RDS due to
overdistention of distal airways.
Management
Maintenance of oxygenation
Maintaining Thermoregulation
Provide a neutral thermal environment to maintain
the infant's abdominal skin temperature between
(36.1 and 36.7 C) to prevent hypothermia, which
may result in vasoconstriction and acidosis.
Adjust Isolette or radiant warmer to obtain
desired skin temperature. For the infant
weighing less than 1,250 g., the radiant
warmer should be used with caution
because of increased water loss and
potential for hypoglycemia.
Prevent frequent opening of Isolette.
Ensure that oxygen is warmed to a
temperature between (30.9 and 34 C) with
60% to 80% humidity
4. Impaired Parenting related to separation from
the neonate due to hospitalization
Encouraging Parental Attachment
Neonatal Sepsis
SEPTICEMIA
NEONATORUM
Neonatal sepsis is a bacterial
infection in the blood. It is found
in infants during the first month
of life. This may become a
serious condition
Causes
Neonatal sepsis is caused by bacteria.
The infant may come in contact with
bacteria during pregnancy, birth, or from
the environment after birth.
EARLY ONSET SEPSIS
Early onset sepsis develops in the first 2-3 days after
birth.
Early onset sepsis is caused by an infection from the
mother. It may pass to the infant from the placenta or
birth canal during birth.
Antibiotics may be given to high risk mothers, during
labor. They have been able to prevent early onset
bacterial sepsis in some infants.
LATE ONSET SEPSIS
Late onset sepsis develops within 3-7 days
after birth.
UNKNOWN
RISK FACTORS
Exposure to tobacco, smoke
Alcohol use by the parent [mother]
especially in the first trimester
Use of certain illegal drugs
Improper care during pregnancy
Improper growth of the fetus
Sleeping with parents
RISK FACTORS
Short interval between pregnancies
Lack of use of pacifier at bed time
Prone or side sleeping position
Thermal stress or over heating or over
wrapping
Lack of breastfeeding
Soft sleeping surface or bedding
OTHER RISK FACTORS
Low socioeconomic status of the parents
Lower level of education
Young age
and single marital status
Signs and Symptoms
Infant may present with certain common signs
difficulty in breathing
and change in color (pallor, purple, blue).
Edema
Cataracts.
OTHER: Hepatitis B
Transmission Treatment
Ifmother + HbSAG
Placental
Birth
administer to
newborn
Breast milk Hepitisis B vaccine
HBIG
Rubella
S/S of Newborn
Congenital cataracts
Deafness
Congenital heart defects
Sometimes fatal
Hydrocephaly
Cerebral palsy
Mental delays
Herpes Simplex II
Transmission: S/S of Newborn
Direct contact at Microcephaly
birth Mental delays
Seizures
Retinal
dysplasia
Apnea
Coma
HIV/AIDS
Transmission: < 2% Nursing Interventions
Transplacentally Protect self from
Exposure at birth body fluids
Breast milk Labs - + antibody
titer
Administer AZT,
Retrovir
Provide care like that
of any other newborn
GASTROESOPHAGEAL
REFLEX
GER is a malfunction of the distal end of the
esophagus, which acts as an antireflux barrier,
permitting return of stomach contents into the
esophagus.
1. Positioning
Infants:
Supine position while sleeping
Prone positioning is acceptable while the
infant is awake
1. Positioning
Infants:
Avoid slumped position, use of infant seat,
car seat (expect while driving), swings, and
bouncers this increases intra-abdominal
pressure, thereby increasing reflux
Thirty-degree elevation is acceptable,
while maintaining straight plane of
alignment.
Older children
Prevent obesity.
Avoid tight or constrictive clothing.
Avoid nonsteroidal anti-inflammatory
drugs, especially at bedtime.
4. Drug Therapy
TRACHEOSOPHAGEAL
FISTULA
Esophageal atresia (EA) is failure of the
esophagus to form a continuous passage from
the pharynx to the stomach during embryonic
development.
SUCCESS ALL
DEPENDS ON THE
SECOND LETTER