HIGH RISK NEWBORN & FAMILY

ASSESSMENT NURSING

HISTORY PHYSICAL ASSESSMENT DIAGNOSTIC

ASSESSMENTObvious

congenital anomalies Gestational age

IMMEDIATE NEEDS OF THE NEWBORN

AIRWAY 2. BREATHING 3. CIRCULATION 4. WARMTH1.

Immediate Assessment of the Newborn

The newborn infant should undergo a complete P.E within 24 hours of birth. NOTE

:

It

is easier to listen to the heart and lungs first when the infant is quiet the stethoscope before using to decrease the likehood of making the infant cry

Warmth

Newborn Priorities in first day of life1. 2. 3. 4. 5. 6. 7. 8.

Initiation and maintenance of respiration Establishment of extrauterine circulation Control of body temperature Intake of adequate nourishment Establishment of waste elimination Prevention of infection Establishment of an infant-parent relationship Developmental care or care that balances physiologic needs and stimulation for best development

DIAGNOSIS Ineffective

airway clearance Ineffective cardiovascular tissue perfusion Ineffective thermoregulation Risk for imbalance of nutrition Risk for parenting Deficit diversional activity (lack of stimulation)

Planning/Implementation

ALTERED GESTATIONAL AGE OR BIRTHWEIGHT Infant

is evaluated as soon as possible after birth to determine : Weight Gestational

age

Birthweight Colorado

is plotted on a Growth Chart

intrauterine Growth Chart ( LUBCHENCO CHART)

Pre

term born before the 38th week term born at 38 to 42 weeks term born after 42 weeks

Full

Post

BIRTHWEIGHT

Appropriate Gestational Age (AGA) BW within 10-90th percentile Small Gestational Age (SGA) BW is < 10th percentile Large Gestational Age (LGA) BW > 90th percentile

LBW BW < 2,500 grams VLBW BW 1000-1,500 grams Extremely-VLBW 500-1000g

GESTATIONAL AGE It

is determine in the first 4 hours after birth so that age related problems can be identified and appropriate care can be initiated. Second assessment is done within 24 hours. New ballard Score is the most commonly used tool

It has 2 elementExternal physical characteristics Neuromuscular maturity

GESTATIONAL ASSESSMENT (DUBOWITZ)FINDING 0 36TRANSVERSE CREASE ONLY

37 38OCCASIONAL CREASES IN ANTERIOR 2/3

39 & OVER SOLE COVERED W/ CREASES 7 COARSE & SILKYSTIFFENED BY THICK CARTILAGE

SOLE CREASES ANTERIOR

BREAST NODULE 2 DIAMETER (MM)

4 FINE & FUZZY SOME CARTILAGE

SCALP HAIR EAR LOBE TESTES & SCROTUM

FINE & FUZZY PLIABLE, NO CARTILAGETESTES IN LOWER CANAL, SCROTUM SMALL, RUGAE

SOME CARTILAGETESTES PENDULOUS, INTERMEDIATE

SCROTUM FALL, EXTENSIVE RUGAE

posture

Square window

Popliteal angle

Scarf sign

Heel to ear

creases

Breast

Causes of Small for-Gestational-Age Infant ( SGA)

SGA infant experienced intrauterine growth restriction (IUGR) Most common cause of IUGR is PLACENTAL ANOMALY Mothers nutrition during pregnancy play a major rule in fetal growth. severe DM mother PIH Mother who smokes heavily Use of narcotics Baby with Rubella & chromosomal abnormality

SGA PRENATAL Fundic

ASSESSMENT:

height ultrasound Biophysical profile NST Placental

grading Amniotic fluid amount

What do they look like??? SGA

appearancesuffer nutritional deprivationEARLY in pregnancy

Infant

Increase in number of body cells Below average Weight, length & head circumference

Late

in Pregnancy

Increase in cell size Below average weight

Most SGA APPEAR LIKE?? Wasted

appearance Small liver Poor skin turgor Large head Skull suture widely separated lack of normal bone growth Dull hair Sunken abdomen Cord dry & stained yellow

Common problem of SGA Birth

asphyxia common problemchest muscles

Underdeveloped Risk

of meconium aspiration syndrome due to anoxia during labor.

Lack

of subcutaneous fatable to control body temperature

Less

DIAGNOSTICS CBC High

hematocrit Increase RBC ( polycythemia) Blood

glucoseHMD( hyaline membrane disease)

Common:1. preterm infant 2.infant of diabetic mother 3.meconium aspiration

Pathologic feature:

hyaline-like membrane formed fr an exudate of infant blood line the terminal bronchioles, alveolar.duct,and alveoli this membrane prevent exchange of O2 and CO2 at alveolar-capillary membrane

RDS Causes:Low

level or absence of surfactant

Surfactant

phospholipid lines the alveoli that reduces surface tension on expiration keep the alveoli from collapsing on expiration Form @ 34 wks AOG

Assessment S/Sx:

initial 1.low body temperature 2.nasal flaring 3.sternal and subcostal retraction 4.tachypnea 5. cyanotic mucus membrane

Assessment S/Sx:

late 1. seesaw respiration 2. heart failure 3. pale gray skin 4. period of apnea 5. bradycardia 6. pneumothorax

Diagnosis:Clinical sign : grunting, cyanosis in room air, nasal flaring, retraction and shock Chest X-ray: reveal diffuse pattern of radio opaque areas

MANAGEMENT1. surfactant replacement 2. oxygen administration 3.Ventilation 4. Additional therapy: - Indomethacin or Ibuprofen to close PDA - muscle relaxant increase pulmonary blood flow

PILLITTERI pp 778 Vol 1

Prevention:

Steroid quicken the formation of lecithins given 12 and 24 hours prior to delivery most effective when given between weeks 24- 34 of pregnancy

Transient Tachypnea of the Newborn

Transient Tachypnea of the Newborn RR

@ birth up to 80/min when crying Normal RR 30-60/ min S/sx: Rapid

RR 80-120/min Mild retraction No marked cyanosis Mild hypoxia & hypercapnia

Causes: Transient tachypnea of the newbornresult from slow absorption of lungs fluid reflect slight decrease in production of mature surfactant limit the amount of alveolar surface area available to an infant for oxygenation exchange infant tend to increase RR and depth

TTN- Peak in intensity at approx. 36hrs in life @ 72hrs of life spontaneously fade as lung fluid is absorbed common: 1.infant born via CS 2.infants whose mother received extensive fluid administration during labor 3. preterm infants

TTN Management:

1. Close observation 2.O2 administration

MECONIUM ASPIRATION SYNDROME

MECONIUM ASPIRATION SYNDROME- Meconium present in fetal bowel as early as 10 wks gestation

Meconium aspiration- Infant

may aspirate meconium either in utero or in first breath after birth.

Cause severe respiratory distress in 3 ways: 1.causes inflammation of bronchioles because a foreign substance 2.block small bronchioles by mechanical its

plugging

3. cause a decrease in surfactant production through lung cell trauma

Meconium aspirationsign and symptoms: 1. tachypnea 2. Retraction 3. Cyanosis 4. Barrel chest due to air trapping DIAGNOSTICS: CXR: bilateral coarse infiltrates ( honey comb effect) ABG: dec. 02 & inc. Pc02

Meconium aspiration SyndromeManagement: 1.suctioning with bulb syringe or catheter while at the perineum 2.severe aspiration infant might intubate 3. dont administer O2 under pressure 4. antibiotic therapy 5. chest physiotherapy and chest clapping

APNEA

Apnea : >pause

in respiration longer than 20 secs. With accompanying bradycardia commonly seen in: 1.preterm infant 2.infection 3.hyperbilirubinemia 4.hypoglycemia

APNEAMANAGEMENT: 1. gently shaking an infant or flicking the sole of the feet 2. Closely observe all NB esp. Preterm 3. always suction the secretion gently to minimize nasopharyngeal irritation 4. Use gently handling to avoid excessive fatigue 5. never take rectal temperature in infant prone to apnea cause vagal stimulation w/c result to Apnea

APNEA Drug

use to stimulate respirationsodium benzoate

Theophylline Caffeine

They

help increase infant sensitivity to carbon dioxide ensuring better respiratory function.

Sudden Infant Death SyndromeSID is a sudden unexplained death in infancy Cause is unknown who are at risk: 1. infant of adolescent mother 2.infant of closely spaced pregnancies 3.underweight infant 4. preterm infant

SIDSContributory factors: 1. viral respiratory infection 2.botulism infection3. brain stem abnormalities 4.neurotransmitter deficiency 5. heart rate abnormality 6.decrease arousal responses 7. possible lack of surfactant in alveoli 8. sleeping prone

Nsg Care Support

parents view second child as an individual child not as a replacement for the one who died New baby born to a family in which a SIDS infant died is screened sleep study as precaution within the first 2 wks of life. New baby placed on continuous apnea monitoring

Hemolytic disease of the newborn ABO

incompatibility: set up is mothers type is O babys type is A, B, AB Sign and symptom- primarily jaundice Mgt: 1.phototherapy 2.if with severe jaundice can do exchange transfusion 3.initiation of early feeding

RH incompatibility:

mother is RH(-)( has D antigen) baby is RH (+) Sign and symptoms: kernicterus hydrops fetalis (edema) ( lethal state)

Therapeutic Initiation

management

of early feeding Phototherapy Continuously

exposed to specialized light cool white day light or blue fluorescent light Light placed 12-30 inches above the NB bassinet or incubator at 25-28 hours of age Bilirubin level : term 15 mg/dl

Preterm 10-12 mg/dl Exchange

transfusion-

Nursing Stool

care phototherapy

of infant bright green & loose Urine darked colored Assess skin turgor Assess I & O to ensure hydration Monitor temp When infant is feeding removed from phototherapy for interaction

Hemorrhagic disease of newborn

Hemorrhagic disease of newborndue to deficiency of vitamin K bleeding occurs on 2nd to 5th day of life complication: subdural hemorrhage - fatal Sign and symptoms: 1. petechiae 2.vomit fresh blood or pass black tarry stool

Hemorrhagic disease of newbornManagement:1. 2.

IM /IV administration of vitamin K if with severe bleeding transfusion of fresh whole blood can be done

NEWBORN AT RISK DUE TO MATERNAL INFECTION/ILLNESS1. 2. 3. 4. 5. 6. 7.

Beta-hemolytic, Group B Streptococcal Infection Hepatitis B Virus Infection Herpes Virus Infection HIV Mother Infant Of Diabetic Mother Infant Of Drug Dependent Mother Infant With Fetal Alcohol Syndrome

Beta-hemolytic, Group B Streptococcal Infection GBS

major cause of infection of NB Natural habitant female genital tract MOT : spread from baby to baby by contact Risk : prolonged rupture of membrane

Beta-hemolytic, Group B Streptococcal Infection S/sx Early

onsetday of life PneumoniaTachypnea Apnea Shock dec urine output, extreme paleness or hypotonia Can die within 24 hours of life

First

Beta-hemolytic, Group B Streptococcal Infection S/sx late

onset Occurs at 2-4 weeks of age- meningitisLethargy, fever , loss of appetite Bulging fontanelles increased ICP Mortality 15%

Beta-hemolytic, Group B Streptococcal Infection Diagnostics

mothers vaginal culture Blood culture of NB

Therapeutic Ampicillin

management

IV @ 28 wks AOG & during labor ( reduce NB exposure) Bld test positive : gentamicin, ampicillin & penicillin

Hepatitis B Virus Infection Transmitted

to the NB through contact with infected vaginal blood at birth mother is HBsAg+ Destructive illness 70-90% of infected infant can become chronic carrier Complication : liver cancer later in life

Hepatitis B Virus Infection Vaccinate Hepatitis

the NB

B vaccine + immune serum globulin (HBIG)within 12H decrease possibility of infection.

Bathed

infant as soon as possible after birth removed blood Gentle suctioning- avoid trauma Breastfed infant if HBIG is given

Herpes Virus Infection HSV-2 Common

Multiple sexual partner

MOT: Contracted

through the placenta if mother has primary infection during pregnancy . Vaginal secretion of mother.

Herpes Virus Infection S/sx: Herpes

vesicles clustered with reddened base covering the skin Severe neurologic damage If acquired at birth: ( D4 & D7 of life) Loss

of appetite Low grade fever & lethargy Dyspnea , jaundice, purpura , convulsion & shock Death occur within hours or days

Herpes Virus Infection Diagnosis: Culture

from vesicles Blood serum analyzed for IgM antibodies Therapeutic Acyclovir

Mgt:

( zovirax) Advised CS- minimize newborn exposure Isolate infant

Infant Of Diabetic Mother Macrosomia-

LGA Chance to have Congenital anomaly cardiac Limp / lethargic first day of life hypoglycemia Greater chance of birth injury hyperbilirubinemiaPp 791 pillitteri

Infant Of Diabetic Mother Diagnostics Serum

glucose