NURSING CARE OF THE HIGH RISK NEWBORN -at rest (30-60 cpm); average RR

 Vital Signs -rate, rhythm, & depth (irregular); w/ periods of apnea for 15secs (NORMAL)

Temperature -watch the abdomen when checking the RR

-99° F (36.5-37.2° C) at birth. -newborns are obligate nose-breathers RDS

-newborns lose heat by four separate mechanisms: convection, conduction, Blood Pressure
radiation, and evaporation
-at birth (80/46 mm Hg)
-Brown fat, a special tissue found in mature newborns, apparently helps to
-on the 10th day (100/50 mm Hg)
conserve or produce body heat by increasing metabolism.
HIGH RISK NEWBORN
Temperature
NEWBORN (neonate)

A baby borne-alive ages 0 up to the 28 days of life extra-utero, regardless of the

AOG, birth weight, and method of delivery.

Under the Newborn Screening Act (R.A. 9288), the newborn is a child from the
time of complete delivery to 30 days old (neonatal stage).

All newborns have eight priority needs in the first few days of life:
NEWBORN PROFILE
1. Initiation and maintenance of respirations
Pulse
2. Establishment of extrauterine circulation
-fetus in the utero (120-160 bpm)
3. Control of body temperature
-immediately after birth (as rapid as 180)
4. Intake of adequate nourishment
-1 hour after birth (120-140 bpm)
5. Establishment of waste elimination
-heart rate is slightly irregular; transcient murmur
6. Prevention of infection
-apical pulse is used to check the HR
7. Establishment of an infant–parent relationship
Respiration

-first few minutes after birth (80 cpm)

8. Developmental care, or care that balances physiologic needs and stimulation -Hypoglycemia may result from the effort the newborn expended to begin
for best development breathing. Dehydration may result from rapid respirations.

Priorities for the first days of life: -Mgt: fluids (lactated ringers & D5W); electrolytes (K, Na, glucose)

1.Initiation and maintenance of respirations. 3. Regulating temperature.

-Most deaths occurring during the first 48 hours after birth result from the -keep newborns in a neutral temperature environment (increased metabolism
newborn’s inability to establish or maintain adequate respirations. required cells for increased oxygen)

-results to neurologic difficulties because of cerebral hypoxia. -skin-to-skin care is originally referred to as kangaroo care, the use of skin-to-skin
contact to maintain body heat (encourages parent–child bonding).
 Resuscitation
4. Establishing adequate nutritional intake.
(a) Establish and maintain an airway
-Preterm infants should be breastfed if possible because of the immune
-usually bulb syringe suction, removes mucus and prevents aspiration of any protection.
mucus and amniotic fluid present in the mouth or nose with the first breath.
-if BF is not possible, expressed breast milk can be used in the infant’s gavage
(b) expand the lungs feeding.
-the baby’s crying is a proof that lung expansion is good because the vocal 5.Establishment of waste elimination.
sounds are produced by a free flow of air over the vocal cords.
-most immature infants void within 24 hours of birth, they may void later than
(c) initiate and maintain effective ventilation term newborns.
-To allow a newborn to adjust to and maintain cardiovascular changes, effective -immature infants also may pass stool later than the term infant.
ventilation must be maintained.
6.Preventing infection.
1st sign of obstruction or respiratory compromised
-infection stresses the immature immune system and already stressed defense
2.Establishment of extra-uterine circulations. mechanisms of a high-risk newborn.
-If an infant has no audible heartbeat, or if the cardiac rate is below 80 beats per -observe good handwashing technique and standard precautions to reduce the
minute, closed-chest massage should be started. risk of infection transmission.
-Newborns who have difficulty maintaining cardiac function need to be 7.Establishment of an infant-parent relationship.
transferred to high-risk nursery for continuous cardiac surveillance. NICU
-Mother should be able to visit the special nursing unit (NICU) (after washing and
Maintaining fluid and electrolyte balance. gowning, hold and touch their child).
-Urge parents to spend time with their infant in the intensive care nursery as the HIGH RISK NEWBORN
infant improves.
Assessment of the High Risk Newborn:
8. Developmental care, or care that balances physiologic needs and stimulation
for best development.  Interpretation of APGAR Score

-thorough education and referral to a home care agency may be necessary to 0-3: Poor (needs resuscitation)
help parents continue with the level of care that is required when their infant is 4-6: Fair; (need suctioning and O2; condition guarded)
discharged home.
7-10: Good; (no signs of immediate distress; needs only admission care; no
-preterm children are at high risk for abuse. special care)
HIGH RISK NEWBORN  Heart rate is the most important APGAR score
Assessment of the High Risk Newborn:  Color is the least important APGAR score; a color of means acrocyanosis
(sluggish peripheral circulation at 1st 24h); stimulate cry.
PERFORMING APGAR SCORING  Reflex irritability; cry or sneezing; demonstration of reflexes (Moro
reflex)
Gives a numerical expression of the newborn’s adaptation to extra uterine life at
 Good cry means breathing is well. No need to count the RR.
1 and 5 min. after birth; a 10-minute APGAR is performed (under 7)
POOR APGAR SCORE
1-minute scoring: detects the cardio-respiratory function of the newborn,
general condition, need for resuscitation (initiated immediately). The following points should be considered in obtaining the APGAR scoring:

5-minute scoring: detects the newborn’s adjustments to the new environment; Heart Rate: Auscultating the NB heart is the BEST way to determine heart rate.
detects prognosis (outcome); basis for NCP making.
Respiratory effort: a newborn usually cries spontaneously at about 30 seconds
10-min APGAR is perfomed when the 5-min score is under 7 after birth.

POOR APGAR SCORE Muscle tone: mature newborns hold the extremities tightly flexed, simulating
their intrauterine position. They should resist any effort to extend their
APGAR scoring involves 5 aspects:
extremities.
 Heart rate
Reflex Irritability: newborn’s response to a suction.
 Respiratory effort
 Muscle tone Color: ALL INFANTS appear cyanotic at the moment of birth. They grow pink with
 Reflex irritability or shortly after the first breath. The color of the newborns thus corresponds to
 Color how well they are breathing.
ACROCYANOSIS – cyanosis of the hands and feet; common in newborns that a ALTERED RESPIRATION
score of 1 in this category can be thought of as normal.
Causes of alteration in respiration or poor gas exchange:
ALTERED RESPIRATION
 Prematurity
Respiratory Evaluation  Congenital Anomalies
 Obstruction of airway due to:
An aspect in newborn assessment tool (APGAR) which has the highest priority in
newborn care. -Deviation in nasal septum
-Secretions
 Silverman-Andersen score can be used to determine respiratory status -Tumor
of newborns specifically the degree of RESPIRATORY DISTRESS. Interventions:
ALTERED RESPIRATION • Assess respiratory rate every 15 minutes for 1 hour. Report any increase in
rate, retractions, or development of nasal flaring or grunting.
In this assessment, the
newborn is observed and then Provides baseline for evaluating changes. Increases in RR and
scored on each of five criteria: retractions, accompanied by nasal flaring, and grunting indicates respiratory
distress.
 Chest movement
 Intercostal retraction • Position the newborn on his side with head slightly lower than the rest of the
 Xiphoid retraction body.
 Nares dilatation
 Expiratory grunt Positioning in this manner facilitates drainage of secretions from airway.

ALTERED RESPIRATION • Suction mouth and then nose with bulb syringe as indicated.

Each item is given a value of 0, Gentle suctioning removes secretions that may collect in these areas.
1, or 2, these values are then Suctioning the mouth before the nose prevents possible aspiration of oral
added. secretions.

Score indications: • Change position frequently.

0 – no respiratory distress Position changes facilitate drainage of secretions, thus enhancing lung
aeration and expansion.
4-6 – moderate distress
• Inform the parents that the rapid respiratory rate is common in some
7-10 – result severe distress newborns after birth because of unabsorbed lung fluid.
 Providing information helps to allay parents’ anxieties and fears. Abdomen is distended causing pressure on the diaphragm.

• Monitor newborn’s temperature and keep warm. Wrap the newborn loosely in Respiratory stimulation in the brain is immature.
a blanket and place warm clothing.
Gag and cough reflexes are weak because of immature nerve supply.
Newborns have difficulty conserving body heat. Exposure to cold
RESPIRATORY DISTRESS SYNDROME – most common problems of newborns
increases the metabolic rate, increasing the need for oxygen and further
with inadequate respiratory function.
increasing the respiratory rate. Metabolic acidosis-low 02, high CO2
APNEA – another respiratory function inadequacy which is not a common sign
PREMATURITY
among premature newborns and is believed to be related to immaturity of the
• Preterm Infants nervous system (CNS).

‣ Defined as a live-born infant born before the end of week 37 of Sepsis

gestation.
Is a generalized infection of the bloodstream.
‣Another criterion is a weight of less than 2, 500 grams (5 lbs 8 ounce)
Common among premature infants due to immaturity of body systems.
at birth.
PREMATURITY
Physical Characteristics:
 Liver of the infant is immature and forms antibodies poorly.
 Skin is transparent and loose.
 Body enzymes are inefficient.
 Superficial veins may be seen beneath the abdomen and scalp.
 Lack of subcutaneous fat, and fine hair (lanugo) covers the forehead,  There is no or little immunity received from the mother.
shoulders, and arms.  Stores of nutrients, vitamins, and iron is insufficient.
 Abundant vernix caseosa PREMATURITY
 Short extremities short stature
 Few sole creases and the abdomen protrudes Signs and symptoms:
 Short nails, small genitalia (in girls, labia majora may be open)
 Low temperature lack of subq fats
PREMATURITY  Lethargy or irritability-less nutrients
 Poor feeding-immaturity ( poor sucking reflex)
Related Problems:
 Respiratory distress-dec. surfactant
Inadequate Respiratory Function

Occurs before the previability period, which leads to many neonatal deaths.

Muscles that move the chest are not fully developed.

PREMATURITY
Poor control of body temperature ➤ Premature infants blood has deficient PROTHROMBIN, a factor of
the clotting mechanism.
Hypoglycemia=low glucose
Retinopathy of Prematurity (ROP) (Retrolental Fibroplasia)
The fetus have not remained in the uterus long enough to acquire
sufficient stores of glycogen and fat. ➤ A condition in which there is separation and fibrosis of the retina,
which can lead to blindness.
Hypocalcemia =low calcium
PREMATURITY
Calcium is transported across the placenta throughout the pregnancy,
but greater amounts during 3rd trimester. Poor Nutrition
Early Hypocalcemia – parathyroid gland fails to respond to preterm infant’s low ➤ The stomach capacity of the preterm is small. Esophageal
calcium levels. sphincter/cardiac sphincter
Late Hypocalcemia – occurs about age 1 week in newborn or preterm infants ➤ The sphincter muscles at both ends of the stomach are immature,
who are fed cow’s milk. Cow’s milk increases serum phosphate levels, which which contributes to regurgitation and vomiting.
cause calcium levels to fall.
➤ Sucking and swallowing reflexes are immature.
Signs and symptoms hypocalcemia:
Necrotizing Enterocolitis
Low calcium-increase neuromuscular excitability
➤Acute inflammation of the bowel that
 Tremors-spasms of the muscle
leads to bowel necrosis.
 Weak cry=weakness
 Lethargy=weakness ➤Caused by diminished blood supply to the
 Convulsions=seizure lining of the bowel (LI) and bacterial invasion of
 Plasma glucose lower than 40 mg/dl. delicate tissues from sepsis.
Treatment: hypocalcemia Immature Kidneys Effects
➤ Intravenous calcium gluconate – monitor newborn for ➤ Improper elimination of the body wastes
bradycardia/cardiac arrest. contributes to electrolyte imbalance and disturbed acid-base relationships.
➤ Calcium Lactate Powder added to formula milk – monitor newborn  Dehydration can occur easily.
for neonatal tetany-muscle spasms.  Limited tolerance to salt (Na retention).
 Susceptibility to edema.
Increased Tendency to Bleed
Jaundice
 ➤ The liver is unable to clear blood of bile pigments that result from In the premature male the testes are very high in the inguinal canal and
normal postnatal destruction of the blood cells. there are very few rugae on the scrotum. The full-term infant’s testes are lower
in the scrotum and many rugae have developed.
RESTING POSTURE
FEMALE GENITALIA.
The premature infant is characterized by very little, if any, flexion in the upper
extremities and only partial flexion of the lower extremities. A premature female has very prominent clitoris and the labia majora
are very small and widely separated.
The full-term infant exhibits flexion in all four extremities.
The full-term infant, the labia minora and the clitoris are covered by the labia
SCARF SIGN. majora.
Hold the baby supine, take the hand, and try to place it around the neck POSTTERM NEWBORN
and above the opposite shoulder as far posteriorly as possible. Assist this
maneuver by lifting the elbow across the body. See how far across the chest the Postterm infants are those who are born after the 42nd week of gestation.
elbow will go.
Some postterm fetuses grow to more than 4000g (8 lb, 13 oz), placing them at
HEEL TO EAR. risk for birth injuries or CS.

With the baby supine, draw the baby’s foot as near to the ear (no Placental functioning decreases when pregnancy is prolonged.
forcing). In the premature infant very little resistance will be met. In the full-term
Postmaturity syndrome – results from hypoxia and malnourishment of the fetus.
infant there will be marked resistance; it will be impossible to draw the baby’s
foot to the ear. Fetus may pass meconium as a result of hypoxia before or during labor, ↑ the
risk of meconium passage and possible aspiration at delivery.
SOLE (PLANTAR) CREASES.
The following problems associated with postmaturity:
The sole of the premature infant has very few or no creases. With the
increasing gestation age, the number and depth of sole creases multiply, so that Asphyxia – caused by chronic hypoxia because of deteriorated placenta.
the full-term baby has creases involving the heel.
Meconium aspiration – hypoxia and distress causes relaxation of the anal
BREAST TISSUE. sphincter.
In infants <34 weeks’ gestation the areola and nipple are barely visible. Poor nutritional status - depleted glycogen reserves cause hypoglycemia.
Also, an infant <36 weeks’ gestation has no breast tissue. An infant of 39–40
weeks will have 5–6 mm of breast tissue, and this amount will increase with age Difficult delivery, birth defects, seizures

MALE GENITALIA. Characteristics:

Long and thin and looks as though weight has been lost. Multidisciplinary approach (teamwork)

Skin is loose (thighs and buttocks) Permanent placement of infant in a foster home if no progress.

Little lanugo or vernix caseosa During hospitalization, 1 nurse per shift to ↑ nurturing and interaction.

Nails are long stained with meconium. Maternal attachment

Infant has thick head of hair and looks alert. Assist the mother in the daily care of the child.

NURSING CARE Parents anonymous and parent aides

Labor induction or caesarean deliveries – pregnancy is past 42 weeks/signs of

fetal distress or maternal risk.

Observe respiratory distress (MSA, hypoglycemia, hyperbilirubinemia)

Placed in the incubator – vulnerable to cold stress

FAILURE TO THRIVE

Infants and children without an obvious cause have fail to gain and often lose
weight.

Physical (organic) pathology (OFTT) – CHD or malabsorption syndromes.

Nonorganic failure to thrive (NFTT) – lack of parent-infant interaction: neglect

and lack of information concerning nutritional needs.

Characteristics

Symptoms of weight loss and failure to gain

 Irritability
 Disturbances of food intake (anorexia or pica)
 Vomiting, diarrhea, neuromuscular
spasticity
 (hypotonia)

Treatment and Nursing Care