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at risk, high risk, and sick newborn Cheat Sheet by

Contents includes nursing assessment, planning and interventions for newborn at risk for complications

APGAR chart

Poor Apgar Score

1st minute (9)
general condition (neuro­/re­spi­/ci­rcu­latory)
5th minute (10)
Determine if neonate can adjust to extrau­terine life
0-3
poor: severely depressed, needs CPR
4-6
fair: guarded, moderately depressed
7-10
good: healthy
Note: Pulse is the most important and Color is the least (acr­ocy­ano­sis due to extrau­terine adapta­tion)

Respir­atory Evalua­tions

0 : Normal | 1-3 : Poor | 4-6 : Moderate | 7-10 : Severe

Normal Respir­atory Adaptation

RR
30-60 bpm (80 bpm in 1st min)
Breathing
Use of abdominal muscles & diaphragm. Newborns are nose breathers
Reflex
Coughing & sneezing to clear airway
Init­iation of repira­tio­ns:
Chemical
surfactant reduces surface tension
Thermal
sudden chilling of moist infant
Mechanical
compre­ssion of fetal chest at delivery

Nursing Interv­entions

Assess
for Respir­atory distress
Plan
To maintain a patent airway
Inte­rve­nti­ons
Position
Head lower
Suction
Bulb near the head, mouth first, avoid trauma to membranes
Eval­uat­ion
RR
30-60 bpm with no signs of distress
In order for the respir­atory system to function the infant must have:
- adequate pulmonary blood flow
- adequate amount of surfactant
- strong respir­atory muscul­ature

Sepsis (blood infection)

Early onset
birth to 7 days after delivery
Late onset
8-28 days after birth
Nosocomial
1st week until discharge
Symp­toms
• fever, breathing problems, lethargy
• poor feeding, bloated abdomen. vomiting (yello­wish)
• Diarrhea, sleepi­ness, jaundiced, irregular HR
• low blood sugar and seizures
Trea­tment
• Sepsis is confirmed with culture test for 7-21 days
• Antibi­otics to be given IV
• IV fluids to support the infant till infection clears
• Oxygen or ventil­ation to support breathing
Prev­ent­ion
• Antibi­otics to control dangerous bacteria
• Breast­feeding may help prevent sepsis
• Providing a clean place
• Delivery within 24 hrs after water breaks

Hyperb­ili­rub­inemia

Phys­iologic Jaundice
• Increase in bilirubin by 2nd day of life, declines in 5th
• Onset and resolution delayed in premature (5-14days)
Path­ologic Jaundice
• Persistent jaundice may indicate hepatitis, biliar atresia, down syndrome, hypoth­yro­idism, breast milk inhibitors
• Total bilirubin increasing by >5mg/dl per day
Brea­stf­eeding Jaundice
• appear on breastfed babies after 7 days of life
• peak during weeks 2-3 but may last for a month
Trea­tment
• Monitor how fast it has been rising
• Needs to be kept hydrated with breastmilk
• Feed baby often up to 12 times a day
• Photot­herapy: blue light
• Blood transf­usion, IV immuno­glo­bulin
 

Premat­urity (before 37 wks)

Physical Findings
<2500g (5lb 8 oz)
Sole creases, skull firmness, ear cartilage
mother's report of last menstrual period
sonogr­aphic estimation of gestat­ional age
Risk factors
multiple gest., history of preterm, single teen mother
Physical assess­ment
AOG
less than 37 weeks
Respir­atory
Irregular
Digestive
bowel sounds diminished
Thermo­reg­ulatory
hypoth­ermia = hypogl­ycemia
Reflex
Poor suck, swallow, flexion
Nursing Care
Prevention
Prevention of acquiring infection
Promote oxygen­ation
maintain and monitor body temp, apical pulse, respir­atory rate
Provision
tactile stimul­ation for apnea
 
safe and effective enviro­nment
Nutrition (readi­ness)
respir­ation is <60/m | rooting, sucking and gag reflex
Educ­ation of parents
Handle carefully when reposi­tioning
Psycho­logical support : sharing info, reinforce positives
Share caretaking respon­sib­ilities with parents

Postma­turity (old man looking)

Prob­lems
Aspiration
Meconium, hypoxia
Polycy­themia
Increase number of RBC
Seizure activity
severe hypoxia
Cold stress
loss of subcut­aneous fat
Hypogl­ycemia
use of glucose stores, glycogen
Nursing Care
- may require prolonged monitoring
- support well being due to wasting effect
- Early detection of polycy­themia & hyperb­ili­rub­inemia
- Focus on prevention : due date
- Attention to thermo­reg­ulation & feeding
Common compli­cat­ions
• 2-3 times higher morbidity than term infants
• Hypogl­ycemia
used depleted glycogen stores
• Aspiration
of meconium in response to hypoxia
• Polycy­themia
Increase RBC response to hypoxia
• Seizure activity
from severe hypoxia
•Cold stress
start to lose weight in the utero

Large for Gestat­ional Age

Appe­ara­nce
• Possible fracture of the clavicles
• Facial head bruising and palsy
• Caput succed­aneum (normal: disappear 12 018 mons)
• Cephal­hem­atoma
Comp­lic­ati­ons
• Birth trauma due to cephal­opelvic dispro­portion
• Increased ceasarian sections
• Hypogl­ycemia , hyperb­ili­runemia
• Polycy­themia, hyperv­isc­osity
• irregular HR, cyanosis
Nursing Care
- Monitor for hypogl­ycemia
- Screening for polycy­themia (cbc, h&h)
- Careful assessment for injuries & address prenatal concerns about injuries like fractured clavicle
- Monitor temp, and minimize heat loss
- Initiate early feedings, touch and cuddling
- Support parents and teach

Meconium Aspiration Syndrome

Symp­toms
• Bluish skin color of the infant
• Difficult breathing (none or rapid)
• Limpness in infant at birth
Trea­tment
• ET tube placement and suctioning
• Using a face mask with oxygen mixture
• Antibiotic to treat infection
• Radiant warmer to maintain body temp

Respir­atory Distress Syndrome (copy)

Causes
Not enough of substance called surfac­tants that consists of phosph­olipids and protein. begins to be produced at 24-28 wks. by 35 wks most have develop adequate surfac­tant.
Symp­toms
• Difficulty of breathing (tachy­pnea, grunting)
• Cyanosis (blue coloring)
• Flaring of the nostrils
• Chest retrac­tions (pulling in ribs & sternum)
• symptoms peak at 3rd day, diuresis dec. need of O2
Trea­tme­nts
• Placing an ET tube, mechanical ventil­ation
• Supple­mental oxygen
• Continuous positive airway pressure (CPAP)
 

Hypoth­ermia

Methods of Heatloss
Evapor­ation
wet surface exposed to air
Conduction
Direct contact with cool objects
Convection
surrou­nding cool air. Drafts
Radiation
Transfer of heat to cooler objects
Mani­fes­tat­ions
CC
cold skin on trunk & extrem­ities. cyanosis
DD
decrease in temper­ature & activity
P
poor feeding in form of suckling
S
Shallow respir­ations
Nursing Care
Prevention
radiant warmer. careful not to burn
Provision
quick dry, head cap & dry warm blankets
Cold Stress
R
respir­atory distress
I
increased oxygen need
D
decreased surfactant production
H
hypogy­lcemia (<30 mg/dl)
M
metabolic acidocis

Small Gestation Age (<10%)

Causes
- may be born preterm, term, post term
- may have experi­enced (IUGR) or failed to grow
- Placental anomaly, poor nutrition
- Smoking, cocaine, teratogen exposure
- Severe DM, decreased blood flow to placenta
Common compli­cat­ions
Perinatal asyphaxia
deficient oxygen­ation
Hypoth­ermia
Inadequate surfactant
Hypogl­ycemia
Use of glycogen stores
Meconium aspiration
Hypoxia | RDS
Still birth
loss from death
Nursing Care
• Maintain airway and temper­ature
• Monitor for signs of respir­atory distress
• Monitor glucose level, or signs of hypogl­ycemia
• Minimize heat loss to prevent hypoth­ermia
• Provide feeding, touch, support, teaching
• Evaluate Hct level : hypoxia & polycy­themia
• Monitor signs of sepsis, infection, malfor­mations
• Fluids and frequent feedings
Lab findin­gs: low plasma levels and high levels of RBC makes blood thick and heart to pump harder. Increases the chance of thrombosis and prolonged cyanosis

Low birth weight

LBW
less than or equal to 2500g (5lbs 8 oz)
VLBW
less than or equal to 1500g (3lbs 5oz)
ELBW
less than or equal to 1000g (2lbs 3oz)
Prev­ent­ion
• Early & regular prenatal care
• Seek medical check uo
• Quit smoking and other terato­genic factors
• Take multiv­itamin containing 400 micg of folic acid

Failure to Thrive

Symp­toms
• height­,we­ight, and head do not match growth charts
• Weight is lower than 3rd percentile (20% below ideal)
• growth may have slowed or stop
• Delayed or slow to develop physical, mental, social
Trea­tment
Nutrit­ional
provide a well balanced diet
Supple­ments
talk to HCP first, correct deficiency

ABO | Rh Incomp­ati­bility

Symp­toms
• Back pain, blood in urine
• Chills, fever, jaundice, impending doom
Trea­tment
• Antihi­sta­mines to treat allergic reactions
• Steroids to treat swelling and allergies
• Fluids given intrav­enously
• Medicines to raise blood pressure if drops too low
• Rh immune globulins (Rhlg) for rh incomp­ati­bility
Exams and tests
• Coombs' test to llok for cell destroying antibodies
• Bilitubin test shows high. CBC: damage to RBC
• Urine test shows presence of hemoglobin

SIDS (crib death)

Factors causing SIDS
Brain Ab.
portion that controls sleep & breathing doesn't work properly
LBW
baby's brain has not matured completely
infection
contri­butes to breathing problems
Sleeping
on side, on soft surface, with parents
Prev­ent­ion
• Sleeping on the back
• Keep the crib as bare as possible. use firm mattress
• Don't overheat baby. blanket should be lightw­eight.
Baby should sleep alone. baby can be rolled over by parents
• Breast feed for six months lowers risk of SIDS.
                           
 

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