NCM 30

High Risk Newborn – Study Guide

APGAR SCORING
(Management of poor Apgar score)

- Apgar scoring done at and minute after birth.

Nursing Management

______________ Apgar score

- Assist in resuscitation
- Prepare the equipment needed like endotracheal tube, suction machine, oxygen
- Perform cardiopulmonary resuscitation
- Administer medications as ordered

______________ Apgar score

- Stimulate the newborn to cry
- Keep the newborn warm
- Continuous suctioning of the newborn until the airway is clear from secretions
- Administer oxygen as ordered

_____________ Apgar score

- The newborn is in good condition
- Keep the newborn warm
- Promote maternal and child bonding

Altered Respiration/ Poor Gas Exchange

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• Disorders of the respiratory tract occur frequently in infancy and childhood.

• Anatomically, several factors influence the manner in which children, particularly infants,
respond to respiratory disturbances.

Structures of the Respiratory system

• Nose
• Pharynx
• Larynx
• Trachea
• Bronchi
• lungs

Effective pulmonary gas exchange requires:

• Clear airways
• Normal lungs
• Normal chest wall
• Adequate pulmonary circulation

Assessment
• Configuration of the chest

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• Pattern of respiratory movement
• Rate and regularity of respiration
• Symmetry of movements of the chest
• Depth and effort expended in respiration
• Use of accessory muscles

Alteration in Respiration
1. (rapid respirations)
- observed with anxiety, elevated temperature, severe anemia, and metabolic acidosis.
2. (too deep respirations)
- noted with fever, severe anemia, respiratory alkalosis associated with psychosis and CNS
distrubances, and respiratory acidosis that accompanies disorders such as DM or diarrhea.
3.
- less easily detected
- occurs with metabolic alkalosis in conditions such as pyloric stenosis and respiratory acidosis
that accompanies diaphragmatic paralysis or CNS depression

Associated Observations
• Retractions or sinking in of soft tissues
• Nasal flaring
• Head bobbing
• Snoring
• Stridor
• Grunting
• Color changes of the skin
• Chest pain
• Clubbing
• Cough

Diagnostic Procedure
1.
- noninvasive pulmonary mechanics are often measured at the bedside of infants and children
with the use of spirometry.
2. Radiology
- nurses should make sure that the infant or child receives proper protection from possible
hazards of radiation.
3.
- provide valuable information regarding lung function, lung adequacy and tissue perfusion.

Respiratory therapy
• Oxygen therapy
• Aerosol therapy
• Chest physical therapy
• Mechanical ventilation
- Endotracheal tube intubation
- tracheostomy

Respiratory Emergency
• Respiratory failure
- the inability of the respiratory apparatus to maintain adequate oxygenation of the blood, with
or without carbon dioxide retention.

Conditions that predispose to Respiratory failure

1. lung disease
- aspiration
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 - infection
- tumors
- anaphylaxis
- laryngospasm from local irritation
2. lung disease
- respiratory distress syndrome
- pneumonia
- cystic fibrosis
- pneumothorax
- pulmonary edema
- pleural effusion
- near drowning
- diaphragmatic hernia
- abdominal distention
- muscular dystrophy
- paralytic conditions
- severe structural conditions
3. Primary inefficient gas transfer
- cerebral trauma (birth injuries)
- intracranial tumors
- CNS infection
- overdose with barbiturates

Nursing care Management

• Observation and monitoring
• Family support
• Cardiopulmonary resuscitation

Hypothermia
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Hypothermia…
• Defined as the cooling of the body’s core temperature (pulmonary artery or esophageal
temperature) to injurious levels, usually identified as below °C.
• Occurs in environmental settings when heat production by exercise and metabolism is less than
heat lost by convection, conduction or radiation.

Therapeutic Management
• _________________ is the major objective of therapy
- for mild hypothermia (30-35°C), only external application of heat lamps or immersion in
water is necessary to restore core temperature with little risk of complications.
• Supportive therapy
-includes maintenance of ventilation, cardiac monitoring, monitoring of renal function and
correction of fluid and acid-base imbalances.

Nursing Management
• Monitoring vital functions and assisting with therapies
• Obtaining history from the family or other observers, environmental temperature and any care
given.
• Prevention – anticipation of cold conditions and knowledge of cold survival techniques are the
basis of prevention.

Prematurity
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Preterm Infants
• Accounts for the largest number of admissions to NICU.
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• Places infants at risks for neonatal complications like and
, and predispose the infant to problems that persist into adulthood (learning disabilities, growth
deficiency, asthma).

Etiology
• Low socioeconomic status
• Multiple pregnancies
• PIH
• Placental problems

Characteristics
• Very small
• Appear scrawny
• Bright pink, smooth and shiny skin
• Abundant fine
• Ear cartilage is soft and pliable
• Soles and palms have minimum creases
• Bones of the skull and ribs feel soft
• Male infants have scrotal rugae and undescended testes
• Female infants have labia minora and clitoris
• Inactive and listless (extremities maintain an attitude of extension and remain in any position
in which they are placed)

Therapeutic Management
• The intensive care nursery nurse is alerts and a team approach implemented.
• Infants who do not require resuscitation are transferred in a heated incubator to the NICU,
where they are weighed and where IV, oxygen therapy are initiated.
• Resuscitation is conducted in the delivery room until infants can be safely transported to the
NICU.

Postmaturity
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Postmature Infants
• Infants born of a gestation that extends beyond 42 weeks as calculated from the mother’s LMP.
• The cause of delayed birth is unknown.

Characteristics
• Display the characteristics of infants who are 1 to 3 weeks of age
- absence of lanugo
- Little vernix caseosa
- Abundant scalp hair
- Long fingernails
- The skin is cracked, parchmentlike and desquamating
- Depletion of subcutaneous fat (thin, elongated appearance)

Management

Alcohol and Drug intoxication

Fetal Alcohol Syndrome (FAS) or Alcohol-Related Birth Defects (ARBD)

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• Infant and children with FAS/ARBD were previously reported to have characteristic facial and
associated physical features attributed to excessive ingestion of alcohol by the mother during
pregnancy.

Effect of alcohol
• Alcohol (ethanol and ethyl alcohol) interferes with normal fetal development.
• The effects on the fetal brain are permanent, and even moderate use of alcohol during
pregnancy may cause long term postnatal difficulties, including impaired maternal-infant attachment.

Categories for diagnosis of FAS

• Growth restriction, both prenatal and postnatal
• Midfacial dysmorphic facial features
• CNS involvement (structural, neurologic or functional abnormality)

Major Features if Fetal Alcohol Syndrome

• ______________________
- short palpebral fissures
- hypoplastic or smooth philbrum
- thinned upper lip
- short, upturned nose
- hypoplastic maxilla
- micrognathia or prognathia in adolescence
- retrognathia in infancy

• _______________________
- mental retardation
- motor retardation
- microcephaly
- poor coordination
- hypotonia
- hearing disorders

• ________________________
- irritability (infancy)
- Hyperactivity (child)

• ________________________
- disproportionately low weight to height
- prenatal growth retardation
- persistent postnatal growth lag

Nursing management
• Provide proper nutrition
• Strategies to provide individualized developmental care are aimed at reducing noxious
environmental stimuli and helping the infant achieve self-regulation
• Early diagnosis and intervention, actively involve in identifying and referring children exposed
to alcohol prenatally.
• Emphasize to women of all ages that there is no known “safe” amount of alcohol intake during
pregnancy.

Low Birth Weight

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Small for Gestational Age (SGA) Infant

• If the birth weight is below the 10th percentile on an intrauterine growth curve for that age.

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• Small for their age because they have experienced intrauterine growth restriction (IUGR) or
failed to grow at the expected rate in utero.

Causes
• Maternal nutrition
• Pregnant adolescents
• Placental anomaly
• Placental damage
• Women with systemic diseases (DM, PIH)
• Mothers who smoke heavily or use narcotics

Assessment
• Prenatal Assessment
- fundal height becomes progressively less than expected
- sonogram
- biophysical profile, nonstress test, placental grading, amount of amniotic fluid

• Appearance
- early in pregnancy, below average weight, length and head circumference
- late in pregnancy, reduction in weight.
- wasted appearance
- may have small liver
- poor skin turgor
- appear to have large head
- skull suture may be widely separated
- hair is dull and lusterless
- abdomen may be sunken
- the cord often appears dry and may be stained yellow

• Laboratory Findings
- low _______________ level (amt of plasma < RBC because of lack of fluid in utero)
- increase in number of /polycythemia (due to anoxia during intrauterine
life)

Nursing diagnosis and Management

• Ineffective breathing pattern related to underdeveloped body systems at birth
- closely observe both respiratory rate and character in the first few hours of life.
Underdeveloped chest muscles can make them unable to sustain the rapid respiratory rate of a
normal newborn.
• Risk for ineffective thermoregulation related to lack of subcutaneous fat
- a carefully controlled environment is essential to keep an infant’s body temperature in a
neutral zone.
• Risk for impaired parenting related to child’s high risk status and possible cognitive or
neurologic impairment from lack of nutrients in utero.
- one way to promote maternal bonding with the child is to discuss ways parents can promote
an infant’s development once they are at home.
- encourage parents to provide toys suitable for their child’s chronologic age, not physical size.

Failure to Thrive
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• FTT or growth failure is a sign of growth resulting from inability to

obtain or use calories required for growth.

General categories of FTT

1.
- result of a physical cause, such as:
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 congenital heart defects,
 neurologic lesions,
 cerebral palsy,
 microcephaly,
 chronic renal failure,
 gastroesophageal reflux,
 malabsorption syndrome,
 endocrine dysfunction,
 cystic fibrosis
 AIDS

2.
- result of a definable cause that is unrelated to disease, most often psychosocial factors such
as:
 Inadequate parenteral knowledge of nutrition
 Deficiency in maternal care
 Disturbance in maternal child attachment
 Disturbance in child’s ability to separate from the parent leading to food refusal to maintain
attention

3.
- unexplained by the usual organic and environmental causes but may also be classified as
NFTT.

Classification according to Pathophysiology

• Inadequate caloric intake (incorrect formula preparation, neglect, poverty, food fads)
• Inadequate absorption (cystic fibrosis, celiac disease, hepatic disease, vitamins and minerals
deficiency)
• Increased metabolism (hyperthyroidism, congenital heart defects)
• Defective utilization (genetic anomaly, congenital infection)

Factors that can lead to inadequate Feeding

• Poverty
• Health beliefs
• Inadequate nutrition knowledge
• Family stress
• Psychosocial factors
• Feeding resistance
• Insufficient breast milk

Therapeutic Management
• The primary management of FTT is aimed at reversing the cause of the growth failure.
- if malnutrition is severe, the initial treatment is directed at reversing the malnutrition
• A multidisciplinary team is needed to deal with the multiple problems.
• Efforts are made to relieve any additional stresses on the family by offering referrals to welfare
agencies or supplemental food programs.
• Family therapy may be required
• Temporary placement in a foster home may relieve the family’s stress
• Behavior modification aimed at mealtime rituals
• Hospital admission if: evidence of severe malnutrition, child abuse or neglect, significant
dehydration, caretaker substance abuse or psychosis, and outpatient management that does not result in
weight gain.

Presence of Infection
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• Neonates are highly susceptible to infection as a result of diminished nonspecific
(inflammatory) and specific (humoral) immunity, such as impaired phagocytosis, delayed chemotactic
response, minimum or absent IgA and immunoglobulin M(IgM) and decreased complement levels.
• Because of the infant’s poor response to pathogenic agents, there is usually no local
inflammatory reaction at the portal of entry to signal an infection, and the resulting symptoms tend to
be vague and nonspecific. Thus, diagnosis and treatment may be delayed.

Predisposing Factors
• Gender - The frequency of infection is almost twice as great in
infants as in and also carries a higher mortality for males.
• prematurity
• congenital anomalies,
• acquired injuries that disrupt the skin or mucous membranes,
• invasive procedures such as placement of IV lines and ET tubes,
• administration of total parenteral nutrition,
• nosocomial exposure to a number of pathogens in the NICU.

Sources of Infection
• Prenatal
- across the placenta from the maternal bloodstream
- during labor from ingestion or aspiration of infected amniotic fluid
- prolonged rupture of the membranes
• Early-onset sepsis (less than 3 days after birth
- direct contact with organisms from the maternal GI and genitourinary tracts
- most common infecting organism is E. coli
• Late-onset sepsis (1-3 wks after birth)
- primarily
- offending organisms are usually staphylococci, klebsiella organisms, enterococci,
E.coli, and Pseudomonas or Candida species.

Manifestations of Neonatal Sepsis

GENERAL SIGNS
Infant generally “not doing well”
Poor temperature control –hypothermia, hyperthermia(rare)

CIRCULATORY SYSTEM
Pallor, cyanosis or mottling
Cold, clammy skin
Hypotension
Edema
Irregular heartbeat- bradycardia, tachycardia

RESPIRATORY SYSTEM
Irregular respiration, apnea, or tachypnea
Cyanosis
Grunting
Dyspnea
retractions

CENTRAL NERVOUS SYSTEM

Diminished activity-lethargy, hyporeflexia, coma
Increased activity- irritability, tremors, seizures
Full fontanel
Increased or decrease tone
Abnormal eye movement

GASTROINTESTINAL SYSTEM
Poor feeding
Vomiting
Diarrhea or decreased stooling
Abdominal distention
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Hepatomegaly
Hemoccult-positive stools

HEMATOPOIETIC SYSTEM
Jaundice
Pallor
Petechiae, ecchymosis
splenomegaly

Therapeutic Management
• Early recognition and diagnosis
• Supportive therapy – administration of Oxygen, careful regulation of fluids, correction of
electrolyte or acid-base imbalance, temporary NPO and Blood transfusion.
• Antibiotic therapy –continued for 7 to 10 days if culture are positive, discontinued in 3 days if
cultures are negative and the infant is asymptomatic and most often administered via IV infusion.

Nursing Care Management

• Observation and assessment
• Recognition of the existing problem
• Awareness of the potential modes of infection transmission
• Knowledge of the side effects of the specific antibiotic and proper regulation and
administration of the drug.
• Decrease any additional physiologic or environmental stress.
• Precautions to prevent spread of infection to other newborns.
• Proper handwashing, use of disposable equipment, disposal of excretions, and adequate
housekeeping of the environment and equipment.

Respiratory Distress Syndrome

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RDS
• Refers to a condition of surfactant deficiency and physiologic immaturity of the thorax.
• It is seen almost exclusively in infants but may also be associated with
multifetal pregnancies, infants of diabetic mothers, cesarean section delivery, delivery before 37
weeks’ gestation,precipitous delivery, cold stress, asphyxia and a history of previous RDS.
• Nonpulmonary origin may also be caused by sepsis, cardiac defects, exposure to cold, airway
obstruction,hypoglycemia, metabolic acidosis.

Clinical Manifestations
• Rapid respirations (tachypnea)
• Retractions
• Abnormally elastic rib cage (indrawing or retraction of the skin between the ribs)
• Fine inspiratory crackles can be heard over both lungs
• Audible expiratory grunt
• Flaring of the nares
• Central cyanosis

Therapeutic Management
Supportive measures
• Maintain adequate ventilation and oxygenation with either an oxygen hood or mechanical
ventilation
• Maintain acid-base balance
• Maintain a neutral thermal environment
• Maintain adequate tissue perfusion and oxygenation
• Prevent hypotension
• Maintain adequate hydration and electrolyte status

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- Administration of exogenous surfactant

Nursing care Management

• Responsible for maintenance and regulation of respiratory equipment
• Observe and assess the infant’s response to therapy
• Continuous monitoring of the vital signs and oxygen saturation
• Suctioning should be performed only when necessary and should be based on individual infant
assessment.
• Position the infant on the side with the head supported in alignment by small folded blanket to
maintain patent airway.
• Inspection of the skin is part of routine infant assessment.
• Mouth care is especially important when infants receiving nothing by mouth, and the problem
is often aggravated by the drying effect of oxygen therapy.

Prepared by:
Bergris M. Puerto, RN, MN

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