Nursing Care: At Risk/High Risk/Sick Newborn Cheat Sheet (DRAFT) by vcroosevelt

- high-risk neonate regardless of Gestat­ional Age
- begins 23wks - 28 days post birth

According to Size
    - Low Birth Weight LBW (<2.5kg)
    - Very Low Birth Weight VLBW (<1.5kg)
    - Extremely Low Birth Weight ELBW (<1kg)
    - Approp­riate for Gestat­ional Age AGA (10%-90%)
    - Small for Gestat­ional Age SGA (<10%)
    - Large for Gestat­ional Age LGA (>90%)
    - Intrau­terine Growth Restri­ction IUGR
    >Risk Factors:
       - Hereditary
       - Placental Insuff­iciency
       - Maternal Disease

According to Gestat­ional Age (regardless of BW)
    - Late Preterm (34-36wks AOG)
    - Preterm (<37wks AOG)
    - Full term (38-42wks AOG)
    - Post term (>42wks AOG)

According to Mortality
    - Live Birth
   - Fetal Death
        = death before 20wks
   - Neonatal Death
        = death within first 27wks of extrau­terine life
   - Perinatal Mortality
        = total # of fetal & neonatal death/1000 live births
   - Postnatal Death
   ­    = death 28 days - 1y/o

1. Physical Assessment
  - General Assessment
      > BW
      > Anthro­pom­etric Measur­ements
      > Deform­ities
      > Signs of distress (poor color, mottling, hypotonia)

2. Respir­atory Assessment
  - Chest Shape (barre­l/c­oncave)
  - Describe use of accessory muscles
  - Determine RR; O2 Sat
  - Auscul­tation

3. Cardio­vas­cular Assessment
  - HR and rhythm
  - Auscul­tation
  - Determine Point of Maximal Impulse (PMI)
  - Color
      > mucous membranes, lips, BP, perfusion

4. Genito­urinary Assessment
  - Genitalia and abnorm­alities
  - Describe urine
      > amount, pH, specific gravity

5. Gastro­int­estinal Assessment
  - Presence of abdominal disten­tion, regurg­itation
  - Stool assessment
      > amount, color, consis­tency

6. Neurol­ogi­c-M­usc­ulo­ske­letal Assessment
  - Movements, Level of Activity with stimul­ation
  - Changes in Head Circum­ference

7. Temper­ature
  - Determine axillary temper­ature

1. Preterm Infants
  - Cause:
      > idiopathic
  - Risk Factors:
      > low socio-­eco­nomic status
      > multig­ravida
      > gestat­ional HTN
  - Charac­ter­istics:
      > very small and thin; little SQ fat
      > propor­tio­nally large head
      > bright pink, shiny, smooth skin
      > abundant fine lanugo
      > ear cartilage soft and pliable
      > male NB = few scrotal rugae; crypto­cho­rdism
      > female NB = labia minora & clitoris prominent

2. Post-term Infants
  - Cause:
      > idiopathic
  - Charac­ter­istics:
      > absent lanugo
      > abundant scalp hair; long finger­nails
      > cracked skin/p­arc­hme­nt-­lik­e/d­esq­uam­ation
      > depleted SQ fat
      > little vernix caseosa

- Cause:
    > poor nutrition
    > adolescent pregnancy
    > placental anomaly
    > maternal systemic disease (HTN, DM)
- Diagnostic Evaluation
    > fundal height < expected
    > UTZ =  size; placental grading; amniotic fluid
    > biophy­sical profile
    > non-stress test (NST)
-Fetal Implic­ations
    > poor skin turgor
    > large head, small body
    > small liver
    > skull sutures widely separated
    >  Hct level
    > polycy­themia ( RBC)
    > hypogl­ycemia (<4­5mg/dL)

- appears healthy, but will soon reveal underd­eve­lopment
- Causes:
    > gestat­ional DM (GDM)
    > multip­arity
    > Beckwith Syndrome (overg­row­th+­mac­rog­lossia)
    > congenital anomalies (ompha­locele)
- Diagnostic Evaluation
    > UTZ
    > NST
    > amnioc­entesis
- Fetal Implic­ations
    > immature reflexes
    > extensive bruisi­ng/­birth injury/Erb-Du­chenne
    > caput succed­aneum; cephal­hem­atoma
    > hyperb­ili­rub­inemia
    > polycy­themia vera
    > cyanosis
    >  insulin (up to 24hrs post birth=­hyp­ogl­ycemia)

NEWBORN PRIORITIES
1. Initia­tin­g/M­ain­taining Respir­ation
    - most deaths occur within 48hrs
    - ineffe­ctive respir­ation = cerebral hypoxia
    > Manage­ment:
        - O2 admini­sta­rtion
        - approp­riate positi­oning to open airway
        - resusc­ita­tio­n+v­ent­ilation
2. Establish Extrau­terine Circul­ation
    > Manage­ment:
        - closed­-chest massage (1-2cm, 100x/min)
        - lung ventil­ation (30x/min)
        - monitor pulse oximeter
        - 0.1-0.3­mL/kg Ephine­phrine may be sprayed on ET tube
        - transfer to NICU
3. Maintain Fluid Balance
    > Manage­ment: (after initial resusc­ita­tion)
        - Hypogl­ycemia (D10W IVF)
        - Hypote­nsion (vasop­ressor Dopamine)
        - Hypovo­lemia (NSS/RL IVF)
        - Dehydr­ation (RL/D5W IVF)
4. Mainta­ining Thermo­neu­trality
    > Manage­ment:
        - thorough drying
        - skin-skin contact
        - neutral thermal enviro­nment
5. Establ­ishing Adequate Nutrit­ional Intake
    > Manage­ment:
        - parent­era­l/e­nteral nutrition
        - breast­feeding
6. Establ­ishing Waste Elimin­ation
    - Immature infants void within 24hrs
    - stool passage may be later than term infants
7. Protection from Infection
    > Preven­tion:
        - handwa­shing and PPE use
        - standard precau­tions
        - physical isolation
8. Skin Care
    -  skin sensit­ivity & fragility
    > Manage­ment:
        - Zinc Oxide-­based tape is used
        - avoid use of solvents
9. Establ­ishing Mother­-Infant Bonding
    - parents kept informed
    - spend time with NB

- Hyaline Membrane Disease
- surfactant deficiency
- Types:
    > Structural
        - lungs are underd­eve­loped
        - respir­atory muscle prone to fatigue
    > Functional
        - deficient surfactant
- Risk Factors:
    > Multifetal pregnancy
    > GDM
    > CS Delivery
    > Cold stress
    > Asphyxia
    > Hx of RDS
- RDS of Non-Pu­lmonary Origin Risk Factors:
    > Sepsis
    > Cardiac Defect
    > Hypogl­ycemia
    > Metabolic Acidosis
    > Drugs
- Clinical Manife­sta­tions:
    > tachypnea (>6­0cpm)
    > retrac­tions; nasal flaring
    > inspir­atory crackles
    > circumoral and central cyanosis
- Laboratory Diagnoses:
    > Glucometry (tests hypogl­ycemia)
    > ABG (tests acidosis, hypoxia, hyperc­apnia)
    > CXR
        - diffuse granular pattern = alveolar atelec­tasis
        - dark streaks = dilated, air-filled bronch­ioles
-Treatment:
    > ventil­ation and oxygen­ation with Continuous Positive Airway Pressure (CPAP)
    > maintain acid-base balance
    > neutral thermal enviro­nment
    > maintain hydration and electr­olytes
    > avoid nipple and gavage feedings
    > administer exogenous surfac­tants
- Nursing Respon­sib­ili­ties:
    > collect and monitor ABG
    > O2 monitoring
    > assess tolerance on proced­ure­/drug

Meconium
- sticky and tarlike; present at bowel 10wks AOG
- accumu­lates at 16wks AOG
Meconium Aspiration
- occurs inside utero/at first breath at birth
- occurs when the vagus reflex is stimulated due to hypoxia  releasing meconium to amniotic fluid
- NB born at breech position
- Pathop­hys­iology:
    > hypoxiameconium passingaspirationobstru­ctionatelec­tasisrespir­atory failure
- Clinical Manife­sta­tions:
    > tachypnea; retrac­tions; expiratory grunting; nasal flaring
    > cyanos­is/­pallor
    > barrel chest (from hyperi­nfl­ation)
    > hypogl­ycemia; hypoca­lcemia
- Diagnostic Evalua­tion:
    > laryng­oscopy
    > CXR
- Manage­ment:
    > tracheal suctioning
    > intubation (in severe cases)
    > surfactant admini­str­ation
    > Echoca­rdi­ography (diagnose shunting)
    > chest physio­therapy

Apnea
- cessation of respir­ation that lasts >20secs, accomp­anied by bradypnea and cyanosis
Types:
  1. Central Apnea
      - absent function of diaphr­agmatic and other respir­atory muscles
      - CNS does not transmit signals to respir­atory muscles
  2. Obstru­ctive Apnea
      - airflow stops due to obstru­ction
  3. Mixed Apnea
      - central + obstru­ctive
      - most common on premature infants
- Causes:
    > premat­urity (weak thorax muscles)
    > airway obstru­ction
    > anemia; polycy­themia vera
    > hypogl­ycemia; hypoca­lcemia
    > sepsis; mening­itis; seizures
- Manage­ment:
    > gentle tactile stimul­ation
    > Caffeine Citrate PO/Par­enteral (CNS Stimulant)
    > monitor weight and UO (Caffeine citrate = diuretic)
    > nasal CPAP & nasal interm­ittent positive pressure ventil­ation
    > neutral thermal enviro­nment
- Nursing Respon­sib­ili­ties:
    > routine observ­ation (RR & HR)
    > gentle tactile stimul­ation, if it fails, raise chin to open airway
    > careful burping = reduces apnea
    > never take rectal temper­ature