6.1 High Risk New Born assessment and management.ppt

High risk new born

1. High Risk Newborn
Nasreen Asghar
Nursing Instructor
BTSON

2. Objectives
•At the end of session students will be able to learn :
••Preterm – before 38 weeks gestation
••Post mature babies
••Infants of Diabetic mothers
••Neonatal asphyxia
••TTN,RDS.Meconuim aspiration
••Neonatal septicemia
•PPHN
•IVH
•Birth trauma
 
•hyperbilirubinemia
 
••Medical and nursing management
•

3. High Risk Newborn
•Preterm – before 38 weeks gestation
•IUGR – full term but failed to grow normally
•SGA -
•LGA
•Infants of Diabetic mothers
•Post mature babies
•Drug exposed

4. Birth Weight Variations
•Appropriate for gestational age (AGA)
•Small for gestational age (SGA)
•Large for gestational age (LGA)

5. SGA
•SGA weight- less than 5lb 8 oz.
•IUGR- High risk growth does not meet
the expected growth pattern and is
pathologic

6. SGA
Characteristics
•Scaphoid
abdomen
(sunken)
•Wide sutures
•Thin umbilical
cord
•Head larger than
body
•Wasted
appearance to
extremities
•Reduced fat
stores

7. SGA
Common Problems
•Perinatal asphyxia
•Hypothermia- lack of brown fat
•Hypoglycemia- lack of glycogen stores
•Polycythemia- increase rate of
production due to hypoxia
•Meconium Aspiration

8. Nursing Management
•Initiate early and frequent oral feedings
•Monitor for hypoglycemia
•IV infusion of 10% dextrose if unable to
maintain glucose level.
•Weight daily
•Monitor for Polycythemia.

9. LGA
•Weight- Larger than 9 lbs.
•Infant can be preterm, term, or post-
term

10. LGA
Characteristics
•Large body size
•Poor motor skills
•Difficulty in regulating behavioral state.

11. LGA
Common Problems
•Birth Trauma
•Hypoglycemia
•Polycythemia
•Hyperbilirubinemia
•Shoulder dystocia

12. LGA
Nursing Management
Hypoglycemia
•Screen newborn for hypoglycemia
•Encourage feedings
•IV glucose
Hyperbilirubinemia
•Hydration
•Phototherapy

13. Gestational Age Variations
•Preterm newborn
•Post-term newborn
•Term newborn

14. Post Term Newborn
•Gestation > 42 weeks
•After 42 weeks placenta loses ability
to nourish the fetus.

15. Post term Newborn
Characteristics
•Meconium
stained
•Hair and nails
long
•Dry peeling skin
•Creases cover
soles
•Limited vernix
and lanugo

16. Nursing Management
•Monitor blood glucose levels and treat as
required
•Initiate feedings as soon as possible
•Monitor temperature and respiratory
characteristics
•Assess for polycythemia and
hyperbilirubinemia

17. Neonatal Asphyxia
•Failure to establish adequate,
sustained respirations after birth
•Insufficient oxygen delivery to meet
metabolic demands

18. Incidence
•It is usually related to gestational age and
birth weight.
•Higher in premature births.
•Incidence in developed countries is 1.0-
1.5%
•And in Pakistan is 3.3%

19. Risk factors
•Maternal
Hypertension,DM,hypotension.infections,maternal
hypoxia
•Placental
Abruptio placenta, placental insufficiency
•Fetal
Cord prolapse
Anemia,infections,hypoxia,postmaturiety

20. Diagnosis
•Depression of APGAR score
•APGAR score of 3 or less prolonged for
more than 5 mints is evidenced of
asphyxia.

21. Management
•Optimal management is prevention
•It depends on early detection and
management of high risk pregnancies .
•Regular follow up
•Good obstetrical care
•Prompt resuscitation

22. Nursing Assessment
•Asses for risk factors
•newborn’s color
•work of breathing
•heart rate
•Temperature
•Apgar scores

23. Nursing Management
•Immediate resuscitation
•Continued observation
•Neutral thermal environment
•Blood glucose levels
•Parental support and education

24. Transient Tachypnea Newborn
TTN
•Mild respiratory condition
•Result of delayed or incomplete
absorption of fluid from the lungs
•Occurs within a few hours of birth
•Resolves over 24-72 hour period

25. Incidence
•The incidence of TTN is 1-2% of all
newborns.

26. Risk factors
•Elective cesarean section
•Excessive maternal sedation
•Birth asphyxia
•Breech delivery
•Prolonged labor
•Infant of diabetic mother
•Fluid overload to mother

27. Transient Tachypnea of Newborn
TTN
Symptoms
•Respiratory rate as high as 100-140/m
•Labored breathing
•Grunting nasal flaring
•Retractions
•Chest x-ray ( retained lung fluid)

28. Diagnosis
•Chest X-rays
•CBC
•ABGs
•Pulse oximetry

29. Management
•Provide adequate oxygenation
•Don’t give oral feeding if respiration rate
>60 breaths /min.
•If rate is 60-80 breaths /min Give NG
feeding
•If >80 breaths /min than give intravenous
nutrition.
•Antibiotics

30. Transient Tachypnea Newborn
Nursing Care
•Mainly supportive
•Monitory VS & O2 Saturation
•Provide supplemental O2
•IV fluids
•NG feedings

31. Respiratory Distress Syndrome
•RDS result of lung immaturity and
surfactant deficiency
•Poor gas exchange & ventilation
•Seen in preterm newborns
•Cesarean births without labor
•Infants of diabetic mothers

32. Incidence
•It occurs in 25% infants born at 30 weeks
gestation.
•RDS accounts for 20% of all neonatal
deaths.

33. Clinical features
•Tachypnea >60/minute
•Nasal flaring
•Sternal and inter-costal retractions
•Cyanosis in room air persist for first 48-96
hours of life.
•Delayed onset of respirations in premature
babies.

34. Diagnosis
•Chest X-rays
•ABGs
•Pulse oximetry

35. Management
•If it is suspected to be at risk of giving birth
before week 34 of pregnancy, treatment
for RDS can begin before birth.
• Steroid injection given before baby is
delivered.
•A second dose is usually given 24 hours
after the first.

36. Conti…
•Oxygen administered
•Ventilator may be necessary if breathing
becomes too difficult for the newborn.
•Synthetic surfactant given.

37. Nursing Management
Supportive care
•Monitor VS & O2
•Thermoregulation- prevent cold stress
•O2 administration
•Fluid management
•Nutritional support
•Surfactant replacement therapy

38. Persistent Pulmonary
Hypertension in Neonate(PPHN)
•PPHN is a serious breathing condition in a
newborn in which lung vessels are not open
wide enough meaning that oxygen and blood
flow is restricted
•Cause occur idiopathic ally or as a
complication of perinatal asphyxia, meconium
aspiration syndrome, congenital heart
defects.

39. Clinical features
•Tachypnea within 12 hours after birth
•Marked cyanosis, grunting, and
retractions
•Changes in Blood pressure
•Low Oxygen saturation

40. Diagnosis
•Blood tests
•Pulse oximetry
•Chest X-ray
•Echocardiogram

41. Management
•Use of oxygen
•Use of nitric oxide
•Use of a special ventilator that breathes
for the baby at a very fast rate
•Temporary heart-lung bypass

42. Nursing Management
•Monitoring of oxygenation, perfusion,
and blood pressure
•Immediate resuscitation; oxygen therapy
•Medications
•Administer medicines
•Parental support and education

43. Intraventricular
Haemorrhage(IVH)
•Bleeding in the brain due to fragility of
cerebral vessels; most common in the
first 72 hours after birth.

44. Risk factors
•Extreme prematurity
•Prolonged labor
•Birth asphyxia
•Seizures
•Sudden elevation in ABGs

45. Clinical Features
•Possibly No Symptoms
•Unexplained Drop In Hematocrit, pallor,
•Poor Perfusion,
•Seizures,
•Lethargy,
•Weak Sucking reflex,
•High-pitched Cry,
•Hypotonia

46. Diagnosis
•Cranial Ultrasonography
•CBC
•Septic screen
•Bleeding profile

47. Management of IVH
•General supportive care
•Ventilation
•Blood transfusion
•Anti-convulsant drugs
•Serial USG or CT scanning to detect and
then manage hydrocephalus.

48. Nursing Management
•v/s monitoring
•Proper positioning
•Daily head circumferences
•Clustering of care; limiting of stimulation
•Medicine administration
•Parental support

49. Infant of Diabetic Mother
•Large amounts of glucose are transferred to
fetus
•Causes fetus to become hyperglycemic
•Fetal pancreas produces large amount of fetal
insulin
•Leads to hyperinsulinism, along with excess
production of protein and fatty acids, often
results in an LGA newborn weighing 9 pounds
(4082 g) or more (macrosomia)

50. Infant of Diabetic Mother
After delivery, infant may have low blood
glucose levels and Cushingoid appearance or
look healthy
•May have developmental deficits and suffer
complications of RDS
•Suffers from
–Hypoglycemia
–Hypocalcemia
–Hyperbilirubinemia

51. Infant of Diabetic Mother
Common Problems
•Congenital
Abnormalities
•Macrosomia
•Birth Trauma
•Perinatal
Asphyxia
•RDS
•Hypoglycemia
•Hyperbilirubinemia
•Polycythemia
•Birth trauma

52. Sign & Symptoms
Infant Characteristics
•Rosy cheeks
•Short neck
•Wide shoulders
•Excessive subcutaneous fat
•Distended abdomen

53. Medical management
•Monitor
–Glucose levels
–Vital signs
–Signs of irritability
–Tremors
–Respiratory distress
•Glucose levels below 40 mg/dL can result
in rapid and permanent brain damage

54. Nursing Management
•Monitor glucose level q. 3-4 h keep level
above 40 mg/dl until stable
•Feed q. 2-3 h to create a constant level
•IV glucose
•Monitor serum bilirubin levels
•Maintain neutral thermal environment to
prevent cold stress

55. Risk factors
•Cephalo-pelvic disproportion,
•the quick and rapid delivery,
•delayed and prolonged delivery,
•the abnormal birth position,
•breech presentation,
•forceps and vacuum extraction

56. Sign &Symptoms
•Lethargy 
or an appearance of 
unconsciousness.
•Seizures.
•Back 
arching while crying.
•Difficulty breathing.
•Drooling.
•Excessive crying.
•High
 
pitched 
crying or 
grunting 
sounds.
•Vomiting.

57. Diagnosis
•Electronic Fetal Monitoring (EFM) or
Continuous monitoring
•Intermittent monitoring
•Fetal scalp electrode
•APGAR score

58. Medical Management
•The type of medication will depend the type
and severity of the
 
birth injury.
•The most common types of medication
include:
• Pain
 
management 
and anti-inflammatory
medications, such as aspirin and
corticosteroids.
• Anti-spastic medication, such as baclofen,
tazidine, and dantrolene.

59. Nursing Management
•Supportive care
•Assessment for resolution or
complications
•Support and education
•Realistic appraisal of situation
•Community referral for ongoing follow-
up and care

60. Hyperbilirubinemia
•Excess of bilirubin in the blood-
elevated bilirubin level > 5mg/dl
•Heme from erythrocytes break down
forms unconjugated bilirubin
•Physiologic
•Pathologic

61. Hyperbilirubinemia Causes
•Drugs/Medical conditions disrupt
conjugation and albumin binding sites
•Decreased hepatic function
•Increased erythrocyte production
•Enzymes in breast milk

62. Hyperbilirubinemia Physiologic
•Develops in 3-4 days after term birth
•Develops3-5 days after preterm birth
•Term birth resolves 7 days
•Preterm birth resolves 9-10 days
•Unconjugated bilirubin level < 12.9
mg/100 ml

63. Hyperbilirubinemia Pathologic
•Present at birth or develops within 24
hrs.
•Persists beyond 7 days
•Bilirubin > 12.9mg/100 term
•Bilirubin > 15mg/100 preterm
•Increases > 5mg/100ml in 24hrs

64. Diagnosis
•Physical Examination
•Laboratory Evaluation

65. Medical Management
•Phototherapy
•Exchange Transfusion

66. Nursing care
•Phototherapy- eye shield, turn q2hrs.
monitor temperature 3-4 hrs.
•Increase feeding to q 2-3 hrs.
•Bili level q 6 hrs.

67. Neonatal septicemia
Sepsis
Bacterial, viral, fungal, Group B Strip
Patterns
•Early onset or congenital
•Nosocomial infection—late onset

68. Neonatal Infection
Septicemia
•Pneumonia
•Bacterial meningitis
•Gastroenteritis is sporadic

69. Neonatal Infections
TORCH infections
•Toxoplasmosis
•Gonorrhea
•Syphilis
•Varicella-zoster
•Hepatitis B virus (HBV)
•Human immunodeficiency virus (HIV)
and acquired immunodeficiency
syndrome (AIDS)

70. Sign &Symptoms
•Diminished spontaneous activity
•Less vigorous sucking
•Anorexia
•Apnea
•Bradycardia
•Temperature instability (hypothermia or
hyperthermia)

71. Diagnosis
•Blood,
•CSF
•Urine culture

72. Medical management
•Antibiotic therapy
•Supportive therapy

73. Nursing management
•Monitor respiratory status, oxygen support,
mechanical ventilation.
•Watch for worsening apnea/bradycardia.
•Suctioning PRN
•Volume replacements PRN with isotonic
solutions

74. Conti…
•Blood products
•Minimal handling to avoid extra stress
•Watch for seizures

75. Referneces
•Wong's Essentials of Pediatric Nursing - 1
0th Edition - Elsevier

76. Thank you