High Risk Newborn: Part II

Resuscitation Asphyxia leads to tissue damage

Oxygen saturation 93-97% Airway -- establish patent airway

Suction mouth and nose Prone in sniffing position

Breathing – Rate of 40-60 bpm Initiate breathing Tactile stimulation while drying Mask fits over nose and mouth 100% oxygen

Resuscitation Circulation

Assess pulse by palpating umbilical cord or auscultate apical pulse

If pulse < 60 bpm, begin compressions Drugs – administer medications

Initiate IV of 10% dextrose (D10W) Epinephrine for bradycardia Naloxone Hydrochloride (Narcan) to

reverse narcotic depression

Respiratory Distress Assessment

Tachypnea Retractions Expiratory grunt Nasal flaring Cyanosis Decreased

breath sounds

Breath sounds wet

Decreased pH, decreased pO2, increased pCO2

Causes Cold stress Sepsis Respiratory

distress syndrome

Respiratory Distress Interventions

Monitor color, rate, and effort of breathing

Monitor oxygenation Airway clearance Support respirations as prescribed

O2 at lowest concentration needed Nasal cannula or Oxyhood Positive pressure or High frequency

ventilator Liquid ventilation or Nitric oxide

Transient Tachypnea of the Newborn Begins after birth and lasts about 2 days Delayed absorption of fetal lung fluid

Common in babies from cesarean delivery

Smoking during pregnancy Neonates of diabetic mothers Small for gestational age Percipitous delivery – no thoracic

squeeze

Transient Tachypnea of the Newborn Assessment – respiratory distress Intervention

Oxygen administration Monitor oxygen level Neutral thermal environment Maintenance of acid-base balance Nutrition

Respiratory Distress Syndrome Deficiency in surfactant production

resulting in atelectasis, hypoxia, and acidosis With atelectasis, lungs are less compliant Leads to vasoconstriction and increased

pulmonary vascular resistance Decreases blood flow to lungs Leads to hypoxia and increased CO2 Leads to acidosis Leads to increased vasoconstriction Which further impairs surfactant production

Respiratory Distress Syndrome (cont)

Alveoli can become necrotic and capillaries are damaged

Ischemia allows fluid to leak into the interstitial and alveolar space

Forms a hyaline membrane Hyaline membrane hinders respiratory

function by decreasing lung compliance Poor lung compliance leads to right to left

shunting of blood through foramen ovale and ductus arteriosus

Associated with high risk of long-term respiratory and neurologic complications

Respiratory Distress Syndrome Assessment

Tachypnea Labored breathing Retractions and nasal flaring Crackles Cyanosis Expiratory grunting Hypoxemia, hypercapnia, aciodosis X-ray has diffuse granular pattern

Respiratory Distress Syndrome Intervention

Administer surfactant replacement Administer glucocorticosteroids Thermoregulation Oxygen and mechanical ventilation Monitor blood oxygen level Correct acidosis Parenteral feedings Decrease stresss

Persistent Pulmonary Hypertension (PPHN) High pulmonary vascular resistance

Unoxygenated blood shunting through ductus arterosa

Assessment Respiratory distress and tachycardia Murmur Fluctuating PO2 levels

Interventions Administer O2 and nitric oxide Decrease stress

Bronchopulmonary Displasia Chronic disease as complication of RDS

Ventilator - alveoli over inflate and rupture Inflammatory changes lead to scarring

Assessment Abnormal alveoli on x-ray Signs of respiratory distress

Interventions Low ventilator pressure to maintain O2 level Theophylline to increase lung compliance Diuretics to decrease interstitial fluid Long hospitalization and maybe home on O2

Meconium Aspiration Syndrome

Fetal hypoxia, relaxing anal sphincter, passes meconium in amniotic fluid

Meconium inhaled into lungs while in utero or with first breaths Adheres to airway and alveoli Meconium creates ball-valve effect Hyperinflation, hypoxemia, and acidosis

causes increased peripheral vascular resistance

Meconium Aspiration Syndrome

Assessment Dark green staining of amniotic fluid Green staining of vernix, skin, and nails Respiratory distress with course

crackles Interventions

Suction airway before shoulders are delivered and before first breath taken

Suction trachea until clear Administer oxygen and ventilation Extracorporeal membrane oxygenation

Thermoregulation:Cold stress

Maintain neutral thermal environment to ensure metabolic homeostasis Temperature at which the infant’s

metabolic rate and oxygen consumption is at a minimum

Influencing factors Characteristics of baby Environment: sources of heat loss Stimulation of non-shivering

thermogenisis

Thermoregulation:Cold stress

Signs of cold stress Decreased skin temperature Mottling, acrocyansis, and pallor Respiratory distress Lethargy, decreased muscle tone,

poor feeding Decreased oxygen to tissues Hypoglycemia Acidosis

Thermoregulation:Cold stress

Norepinephrine & Thyroxine

Metabolism of brown fat

Hypoxia Hypoglycemia

Respiratory distress

Respiratory Metabolic acidosis acidosis

Thermoregulation:Cold stress

Intervention Reduce heat loss -- Conduction,

convection, radiation, evaporation Gradually warm baby Monitor vital signs Monitor for and treat hypoglycemia Monitor for and treat hypoxemia Evaluate for underlying problems

Sepsis Assessment

Behavioral changes

Temperature instability

Changes in feeding

Apnea Mottling, pallor,

and cyanosis

Hyperbilirubinemia

Abdominal distention

Intervention Obtain cultures Antibiotics Neutral thermal

environment Supportive care

Hypoglycemia Factors

Decreased availability of glucose and fat

Increased utilization of glucose Signs

Jittery and twitching - Poor suck Unstable temperature - Seizures Apnea - Hypotonia Lethargy - Weak cry Hypoglycemia: < 40 mg/dl

Hypoglycemia Interventions

Monitor at-risk population Decrease glucose requirements Provide glucose

Entera: Oral and Gavage Parenteral: IV

Pain Relief Pain medications Sucrose elevates the pain threshold

through an opioid release in the CNS Use for heel sticks, suctioning,

venipuncture, circumcision 0.5 to 2 ml via syringe or nipple Monitor for hyperglycemia

Hyperbilirubinemia Bilirubin - red blood cells are broken

down Unconjugated cannot be excreted Liver enzymes transform into

conjugated Conjugated bilirubin excreted in stools

and kidneys Jaundice - yellow pigment in tissue Kernicterus - Serum level over 20 mg/dL

Unconjugated bilirubin is toxic and crosses blood-brain barrier

Results in permanent neurological damage

Hyperbilirubinemia Intervention

Phototherapy Florescent light alters structure of

bilirubin to water soluble for excretion Expose as much skin as possible Shield eyes Monitor temperature and increase

fluids Fiberoptic blanket Home phototherapy

Frequent feeding for hydration and excretion

Administer albumin and phenobarbital

Hyperbilirubinemia: Pathologic jaundice or hemolytic disease

Rh and ABO blood type incompatibility Antigens from baby’s blood enter mom’s

bloodstream Antibodies are formed by mom Future pregnancies the antibodies cross

the placenta Antibodies hemolize fetal RBCs

ABO more common but less threatening than Rh ABO - Type O mom with Type A or B fetus Rh – negative moms with positive baby

Hyperbilirubinemia: Pathologic jaundice or hemolytic disease

Assessment Hyperbilirubinemia rapidly after birth Edema and anemia

Intervention Exchange transfusion after birth or

intrauterine Indicated for positive direct Coombs’ and

elevated bilirubin levels Removes sensitized RBC and treats

anemia Rho(D) immune globulin (RhoGAM) within 72

hours of delivery or procedures

Neonatal Developmental Care Decrease noxious stimulation

Lights and noise Read the baby’s behavioral cues

Stress Self-comforting

Care techniques Containment Nesting Kangaroo care Co-bedding

Psychosocial Needs:Facilitate family coping

Explain equipment simply and slowly No technical jargon Focus on the baby not on the equipment

Don’t make promises you cannot keep Do not give unrealistic reassurance or

take away all their hope Allow parents to touch and talk to baby

Don’t insist that they touch if they are uncomfortable

Show how baby is responding to them

Psychosocial Needs:Facilitate family coping

Refer to child by name Parents need to understand and be

understood Allow to voice concerns and feelings Allow to help with THEIR child’s care Allow to voice concerns and feelings

Keep communication open. Telephone calls.

“You must be wondering what caused this” “Are you wondering how you are going to manage?”

Anticipatory Grief Attachment

Parents go home without baby (loneliness), bring in toys and pictures, marital problems

Loss of the perfect child Guilt (what did I do wrong?), may withdraw

physically or emotionally, be realistic and honest with child’s outcome, must grieve for loss of perfect child before attaching to this one, demands from abnormal child inhibit grief recovery

Neonatal death Pictures, lock of hair, foot prints, hold baby

ECMO Extra Corporeal Membrane Oxygenation

References Hogan, M.A., & Glazebrook, R.S. (2003).

Maternal-newborn nursing: Reviews & rationales. Upper Saddle River, NJ: Prentice Hall.

Ladewig, P.A, London, M.L., & Davidson, M.R. (2006). Contempary maternal-newborn nursing care (6th ed.). Upper Saddle River, NJ: Prentice Hall.

Littleton, L.Y., & Engebretson, J.C. (2005). Maternity nursing care. Clifton Park, NY: Thomson Delmar Learning.

Olds, S.B., London, M.L., Ladewig, P.A., & Davidson, M.R. ( 2004). Maternal-newborn nursing & women’s health care (7th ed.). Upper Saddle River, NJ: Prentice Hall.

Silvestri, L.A. (2002). Saunders comprehensive review for NCLEX-RN (2nd ed.). Philadelphia: W.B. Sanders.

Straight A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.