BSN-2A (PEDIA 2) - Prelims LEVEL OF MATURATION

CHAPTER 26 NURSING CARE OF A FAMILY  How well-developed the infant is at birth

WITH HIGH-RISK  Ability of organs to function outside of uterus
NEWBORN  Identify maturity of the newborn by assessing
he physical findings as:
PRIORITY NEEDS OF NEWBORN IN THE - sole creases
FIRST FEW DAYS OF LIFE - skull firmness
1. Initiating and maintain respirations - ear cartilage
2. Establishment of extrauterine circulation - Neurologic findings that reveals
3. Body temperature control gestational age
 LMP and estimated gestational age thru
4. Maintenance of fluid and electrolyte balance
5. Intake of adequate nourishment ultrasound
6. Establishment waste elimination Common Classifications of High-Risk Infants #1
7. Prevention of infection
8. Establishment of an infant-parent relationship  Altered gestational age/weight
9. Developmental care or care that balances  Illnesses that occur in newborn
physiologic need and establishment for best  Newborns at risk from maternal
development infection/condition

Gestational age – actual time, from conception to Common Classifications of High-Risk Infants #2
birth that fetus remains in the uterus
 Altered gestational age
 Preterm - <38 weeks a. Preterm infant: live-born infant born prior to
 Term – 38-42 weeks 37 weeks gestation
 Postterm – 42 weeks  Late preterm – born between 34 to 37
 Late preterm - near term (24-36 weeks’ gestation
weeks)  Early preterm – born prior to 34 weeks
and after 24 weeks
Ballard scoring – used to estimate gestational age
based on the infant’s external characteristics and PRETERM INFANT
neurological development
 At birth,a weight of <2,500g (5lb 8 oz)
 Immature and small but well proportioned for
age.
 Assess for presence of:
 RDS (lack of lung surfactant causing
vulnerability to RDS)
 Hypoglycemia
 Intracranial damage

Preterm Infant

CAUSES:

- Low socioeconomic
- Poor nutritional status
- Lack of prenatal care
- Multiple pregnancy; closely birth spacing
- Previous early birth
- Order of birth
- Race
- Cigarette smoking
- Maternal age
 - Maternal illness; infection; gestational g) Observe the infant carefully and record
- Early induction of labor observations
- Elective cesarian birth h) Support and encourage the parents
- Pregnancy complications; (PROM or
premature separation of the placenta) Nursing care of premature infant

Possible Physical Characteristics of a Preterm 1. Incubator care

Infant 2. Prevention of infections
3. Oxygen administration
 Appears small and underdeveloped 4. Feeding and Nutritions
 Head appears disproportionately large (> 3 cm 5. Handling
greater than chest size) 6. Weighing
 Skin transparent or loose or unusually ruddy 7. Administration of Medication
 Lack of subcutaneous fat 8. Charting intake and output
 Superficial veins visible on abdomen and scalp 9. Bathing
 Lanugo is usually scant but covering forehead, 10. Care of the eyes
shoulders, and arms in late preterm babies 11. Care of the cord
 Vernix caseosa abundant 12. Kangaroo care
 Extremities appear short
 Soles of feet have few or no creases Special Needs
 Abdomen protrudes a) Thermoregulation
 Nails are short b) Kangaroo care; skin to skin contact
 Most preterm infant’s eyes appear small; eyes c) Nutrition
appear large in relation to the head
 Genitalia are small Inadequate Respiratory Function
 Respirations are irregular with periods of
apnea  During second half of pregnancy, structural
 Body temperature is below normal changes occur in the fetal lungs
 NB has poor sucks and swallow reflex  Alveoli (air sacs) enlarge
 Bowel sounds are diminised  Closer to capillaries in the lungs
 UO is increased or decreased  If born prematurely, the muscles that move the
chest are not fully developed
Common Classifications of High-Risk Infants #3  Abdomen is distended, increasing pressureon
diaphragm
 Common complications seen in preterm
 Stimulation of the respiratory center in the
infants:
brain is immature
 Anemia or prematurity
 Gag and cough reflexes are weak due to
 Acute bilirubin encephalopathy immature nerve supply
 Persistent patent ductus arteriosus
 Periventricular /Intraventricular Common Classifications of High-Risk Infants #4
haemorrhage
 Altered gestational age
 Others:
o RDS  Postterm infant: live born after the
o Apnea 42nd week of gestation
o Retinopathy of prematurity  Common complications : ‘’postterm
syndrome’’ high haematocrit and
Nursing Goals for the Preterm Newborn polycythemia (potentially leading to
hyperbilirubinemia) difficulty
a) Improve respiration establishing respiration
b) Maintain body heat
c) Conserve energy
d) Prevent infection
e) Provide proper nutrition and hydration
f) Give good skin care
POSTTERM NEWBORN  Infants contracted an intrauterine infection (e.g
rubella, toxoplasmosis and chromosomal
Physical characteristics: abnormality)
a. Looks long and thin body Assessment
b. Skin is loose
c. Little lanugo or vernix  Below average weight, length and head
d. Skin cracks and peels circumference
e. Nails are long and may be stained with  Overall wasted appearance
meconium  Small liver
f. Thick hair and infant is alert  Poor skin turgor
 Large head
Problems  Dull and lustreless hair
a. Asphyxia  Abdomen may be sunken
b. Mecomium aspiration  Umbilical cord often appears dry and tained
c. Poor nutritional status yellow
 Better-developed neurologic response, sole
d. Polycythemia
e. Difficult delivery creases, ear cartilage
f. Birth defects  Unusually alert and active
g. Seizures Laboratory findings:
Interventions  Blood studies:
a. Provide newborn care  Usually high haematocrit level (due to
b. Monitor for hypogylcemia anoxia)
c. Maintain newborn’s temperature  Increased in total number of RBCs
d. Monitor for meconium aspiration (polycythemia)

Common Classifications of High-Risk Infants #5 Common Classifications of High-Risk Infants #6

 Gestational weight  Gestational weight

 Small-for-gestational-age (SGA)  Large-for-gestational-age (LGA)
infants: infants whose birth weight is infants whose birth weight is above
below the 10th percentile on the the 90th percentile on the intrauterine
intrauterine growth chart for their growth chart for their gestational age
gestational age  Common complications:
 Common complications: high polycythemia (potentially leading to
haematocrit and polycythemia hyperbilirubinemia), prolonged
(potentially leading to acrocyanosis, hypoglycaemia
hyperbilirubinemia), prolonged
Assessment
acrocyanosis, hypoglycaemia
 If a woman’s uterus is unusally large for the
Small-for-Gestational-Age Infant
fate of pregnancy
 Etiology: Inadeqaute nutrition maybe a major  Immature reflexes
contributor of IUGR  Low scores on gestational age
 Placental anomaly: Most common cause of  May have extensive bruising or birth injury
IUGR (e.g.broken clavicle, Erb-Duchene paralysis
 Due to insufficient nutrients because of trauma in cervical nerves when
 Placental damage delivered vaginally
 Pregnant adolescents have a high incidence of  Large head with prominent caput
succedaneum, cephalhematoma or molding
SGA Infants
 Cyanosis (sign of transposition of great vessels
which is associatedwith macrosomia)
 Hyperbilirubinemia
  Polycythemia  Apparent life-threatening event
 Diaphragmatic paralysis due to cervical nerve  Periventricular leukomalacia
trauma
 Hypoglycemia Illnesses in the Newborn

Appropriate for Gestational Age (AGA) Respiratory Distress Syndrome

 Small gestational age: infants who belong  Hyaline membrane disease

below the 10th percentile weight for their age  Result of immature lungs, leads to decreased
 Large Gestation Age: infants who fall above gas exchange
the 90th percentile in weight  Predisposing factors:
 Low birth weight infants: infants weighing - Preterm infants
under 2500g - Infants of diabetic mothers
 Very-low-birth weight infants: infants - Infants born by CS
weighing 1000-1500g  Cause: low level or absence of surfactant
 Extremely-very-low-birth-weight infants: - Surfactant is a fatty protein that is high in
infants weighing 500-1000g lecithin its presence is necessary for the
lungs to absorb oxygen
- Begins to form at 24 weeks gestation and
by 34 weeks, if fetus is delivered, should
be able to breathe adequately
- If infant is premature, the surfactant level
is insufficient

Manifestations of RDS

 Respirations increase to 60 breaths/min or

higher (tachypnea)
 The tachypnea may be accompanied by grunt
like sounds nasal flaring, cyanosis, as well as
sternal and subcostal retractions low body
temperature
 As condition worsen:
 Seesaw respirations
 Heart failure (decreased urine
output & edema on extremities)
 Pale gray skin
 Apnea
 Bradychardia
 Pneumothorax occur as the
condition worsens

(Mechanical ventilation may be necessary)

Common Classifications of High-Risk Infants #7

Illneses that occur in newborns

 Respiratory distress syndrome

 Transient tachypnea of the newborn (TTN)
 Meconium aspiration syndrome
 Apnea
 Sudden infant death syndrome (SIDS)
Treatment for RDS  Aspiration of meconium can cause severe
respiratory distress: inflammation of
 If amniocentesis of mother while fetus is still bronchioles because it is a foreign substance,
in utero shows low L/S ratio, the mother may mechanical plugging due to blocking small
be given corticosteroids to stimulate lung bronchioles and can cause a decrease in
maturity 1 to 2 days before delivery surfactant production through lung trauma.
 In preterm infants, surfactant can be Assessment:
administered via ET tube at birth or when  Difficulty establishing respirations at birth
symptoms of RDS occur (Tachypnea)
 Oxygen administration: maintains correct PO2  Retractions
and ph levels; possible complication of O2  Cyanosis
therapy is retinopathy or prematurity  Coarse bronchial sounds
 Place infant in a warm incubator  Enlargement of A-P diameter of the chest (barrel
chest)
Surfactant Production
Interventions:
 Can be altered  To avoid meconium aspiration, suction using
- During cold stress bulb syringe or catheter while infant is at the
- Hypoxia perineum, (before delivery of the shoulders)
- Poor tissue perfusion  Intubation, if with severe staining of meconium
then suction.
Nursing Care of Infant with RDS  Maintain a temperature- neutral environment
 Monitor vital signs  Antibiotic therapy
 Minimal handling of infant to help conserve  Surfactant administration
energy  Chest physiotherapy
 Intravenous fluids are prescribed
- Observe for signs of under or overhydration Apnea in the Preterm Infant
 Oxygen therapy  Pause in breathing for 20 seconds or longer
- Monitor pulse oximetry  Not uncommon in preterm
- Infant on supplemental oxygen is at high risk  Believed related to immaturity of nervous system
for oxygen toxicity  May be accompanied by
- Bradycardia (heart rate <100 beats/min)
Transient Tachypnea of the Newborn (TTN) - Cyanosis
 Peaks in intensity at 36 hours of life Interventions:
approximately and then begins to fade  Maintain neutral thermal environment
 At 72 hours of life, it spontaneously fades  Handling gently to avoid exessive fatigue
since absorption of lung fluid occurs and  Suction gently to minimize nasopharyngeal
respiratory activity becomes effective. irritation
Assessment:  Never take rectal temperature; vagal stimulation
 Rapid breathing can reduce heart rate
 Mild retractions  Administer Theophylline or caffeine sodium
 Mild hypoxia benzone as ordered to stimulate respirations
 Hypercapnia
 Difficulty feeding Sudden Infant Death Syndrome (SIDS)
 Sudden unexplained death in infancy
Meconium Aspiration Syndrome a. Peak age of incidence is 2-4 months of age
 As early as 10 weeks gestation, meconium is  Higher incidence in:
present in fetal bowel  Infants of adolescent mothers
 Hypoxia may occur causing stimulation of  Infants of closely spaced pregnancies
vagal reflex, then relaxation of rectal  Underweight and preterm infants
sphincter.  Infants with BPD, twins, Native African and
 Meconium appears green to greenish black Alaskan Native infants, economically
disadvantaged black infants and infants pf
narcotic-dependent mothers.
Contributory factors:  Increased tendency to bleed
 Sleeping prone; room without moving currents  Signs and symptoms:
 Viral respiratory or botulism infection a. Petechiae from superficial bleeding into
 Exposure to secondary smoke the skin
 Pulmonary edema b. Conjuctival, mucous membrane and
 Brainstem abnormalities retinal hemorrhage
 Neurotransmitter deficiencies c. May vomit freshblood or pass black,
 HR abnormalities tarry stools
 Distorted familial breathing patterns
 Decreased arousal responses Interventions
 Possible lack of surfactant in alveoli
a. Administer 1 mg of Vitamin K IM
Prevention: immediately after birth
 Put newborns to sleep on their back b. Blood transfusion of fresh whole blood (for
 Use of firm sleep surface and avoid soft severe cases)
bedding
c. Handle gently
 Breastfeeding d. Monitor neurologic status
 Room sharing without bed sharing e. Monitor the newborn’s condition
 Routine immunizations
 Consider using pacifier
Twin-to-Twin Transfusion
 Avoid overheating
 Avoid overexposure to tobacco smoke, alcohol
and Illicit drugs
 Having a fan in the room while infant is
sleeping (SIDS risk reduction strategy)

Common Classifications of High- Risk Infants #8

Illnesses that occur in newborns - (cont.)

 Hemolytic disease (hyperbilirubinemia)

 Rh and ABO incompatibility
 Hemorrhagic disease of the newborn
 Twin to twin transfusion
 Necrotizing enterocolitis
 Retinopathy of prematurity
Retinopathy of Prematurity (ROP)
 This occur if twins are monozygotic or there is
 Separation and fibrosis of the retina, can lead
abnormal arteriovenous shunts occur that
to blindness
direct more blood to one twin than the other
 Damage to immature retinal blood vessels
 Anemia occurs in the donor twin (SGA, prone
thought to be caused by high oxygen levels in
to hypoglycemia, pale in appearance);
arterial blood
polycythemia in the hyperbilirubinemia)
 Leading cause of blindness in infants weighing
 Diagnostic procedure: Ultrasound
<1500 grams (3.3 lbs)
 Interventions:
Retroiental fibroplasia
a. Determine hemoglobin level at birth
Interventions:
(difference of 5.0g/100ml suggests
a. O2 therapy
blood transfusion)
b. Maintain vitamin A
c. Cryosurgery Hyperbilirubinemia

Hemorrhagic Disorder of Newborn  Hemolytic disease of the newborn is presence

 Results from a deficiency of Vitamin K of excessive destruction of RBCs leading to
(essential for the formation of prothrombin by elevated bilirubin level
the liver)
Causes:  Early onset: tachypnea, apnea,
extreme paleness, hypotension
 RH incompatibility (decreased urine output), hypotonia
 ABO incompatibility  Late onset: meningitis (lethargy,
Jaundice: iceterus fever, loss of appertite, bulging
fontanelles (ICP)
Kernicterus: serious neurological complication that  Intervention:
causes brain damage ‘’bilirubin encephalopathy’’  Administer antibiotics as prescribed
(e.g. penicillin. Cefazolin,
Interventions clindamycin or vancomycin)
b. Initiate early feeding  Support in the care of the child
c. Phototherapy  Immunization of women
d. Exchange transfusion (childbearing age) against
streptococcal B organisms
Necrotizing Enterocolitis
Opthalmia neonatorum
 Is an acute inflammation of the bowel that
leads to bowel necrosis  Eye infection that occurs at birth or during
 Sign & symptoms: the first month of life
a) Abdominal distention  Assessment
b) Bloody stools  Fiery-red conjunctiva with thick pus
c) Diarrhea  Edematous eyelids
d) Bilious vomitus  Interventions
 Instill erythromycin ointment
Interventions  Use of sterile saline solution to clear
the copious eye discharge
a. Monitor v/s
 Use standard and contact infection
b. Maintain infection control techniques
c. Oral fluids as ordered precautions
d. Antimicrobials and parenteral nutrition  Ceftriaxone (rocephin) and
penicillin
Common Classifications of High-Risk Infants #9
Generalized herpesvirus infection
Newborns at risk from maternal
infections/conditions  Assessment:
 Vesicles on the skin
 B-hemolytic, group B streptococcal infection  Loss of appetite
 Opthalma neonatorum  Low-grade fever
 Hepatitis B virus infection  Lethargy
 Generalized herpesvirus infection  Stomatitis
 HIV infection  Dyspnea
 Diabetes mellitus  Juandice
 Maternal drug or alcohol dependency  Purpura
 Convulsions
B-Hemolytic, Group B Streptococcal infection
 Hypotension
 Screening of pregnant woman for 35-37 of  Interventions
weeks of gestation (to determine presence of  Administer medications as
GBS organism) prescribed acyclovir (Zorivax)
 Risk factors
An Infant of Woman Who Has DM
 Prolonged ruptures of membranes
 A woman’s vaginal culture is  Assessment :
positive  Macrosomia (Alsoknown fragile
 Assessment: giant)
  Cushingoid (e.g fat, puffy)  Reduce the rate of deaths from sudden infant
 Lethargic or limp for the first days death syndrome (SIDS) to 0.55 per 1,000 live
 Complications births from a baseline of 0.55 per 1,000 live
 Risk for congenital anomaly (e.g births.
cardiac anomaly)
Examples of Nursing Diagnosis for a Family With a
 Birth injury
High-Risk Newborn
 Interventions
 Feed early  Ineffective tissue oxygenation related to
 Glucose infusions as prescribed breathing
 Monitor any vomiting and normal  Ineffective thermoregulation related to
bowel movements immature status
 Risk for imbalance nutrition, less than body
Drug-dependent mother and an infant requirements, related to the lack strength for
 Infant is SGA effective sucking
 Signs and Symptoms  Risk for impaired parenting related to illness
in new born at birth
a) Irritability
b) Sleep pattern disturbance Newborn Assessment of Transition to Extrauterine
c) Constant movement may lead to Life #1
abrasions
d) Tremors  Immediate assessment
e) Frequent sneezing  Initiation and maintenance of
f) Shrill respiration
g) Possible hyperflexia and clonus  Establishment of extra uterine
h) Convulsions circulation
i) Tachypnea  Thermoregulation
j) Vomiting and diarrhea  Fluid and electrolyte
An Infant with fetal alcohol exposure Interventions for a Family With a High-Risk
Newborn
 Asseement:
 Growth restriction Nursing Diagnosis Possible Nursing and
 CNS involvement Therapeutic
 Cognitive challenge (e.g Interventions
hyperactive-schoolage
 Microcephaly Risk for imbalanced Gavage feedings: Monitor
 CP nutrition, less than body for signs of aspiration,
 Distinct facial feature (short palpebral requirements, related to provide oral stimulation
fissure, thin upper lip) the lack of strength for through non-nutritive
 Tremulous, fidgety, irritable effective sucking sucking as appropriate for
 Weak sucking reflex infant's strength, and
 Sleep disturbance assure that breast milk is
 Interventions: stored appropriately and
labeled correctly.
 Monitor infant
Risk for impaired Offer parents/caregivers
2020 National Health Goals Related to a Family
parenting related to illness tour of unit and any
With a High-Risk Newborn
in newborn at birth equipment that they may
 Reduce the rate of fetal and infant deaths see being used; if infant's
during the perinatal period (28 weeks of condition permits, allow
gestation to 7 days or more after birth) to 5.9 parents to place their
per 1,000 live births from a baseline of 6.6 per palms on the infant lightly
1,000 live births. to establish contact; and
encourage frequent
 visiting and telephone
calls

Examples of Nurisng Diagnoses and Related

Outcomes from a Family With a High Risk
Newborn

Nursing diagnosis Outcome

Ineffective tissue Vital signs and oxygen

oxygenation related to saturation will remain
breathing difficulty within normal limits

Ineffective Infant’s temperature will

thermoregulation related remain within normal
to immature status range

Risk for imbalanced Infant will tolerate

nutrition, less than body feedings and develop
requirement, related to the normal sucking pattern
lack of strength for
effective scuking

Risk for impaired Parents/caregivers visit

parenting related to infant prior to mothers
illness in newborn at birth discharge and call neonata
unit on a regular basis/

Quality and Safety Education for Nurses

 Patient- centered care

 Teamwork and Collaboration
 Evidence-Based Practice
 Quality Improvement
 Safety
 Informatics