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The Newborn at Risk: Birth Related Stressors

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Title: The Newborn at Risk: Birth Related Stressors


1
The Newborn at Risk Birth Related Stressors
  • Chapter 29
  • 1) Newborn at Risk for Asphyxia
  • 2) Care of the Newborn with Respiratory Distress
  • 3) Transient Tachypnea of the Newborn (TTN)
  • 4) Meconium Stained Amniotic Fluid
  • 5) Newborn at Risk Cold Stress
  • 6) Hypoglycemia
  • 7a) Hyperbilirubinemia
  • 7b) Hemolytic Disease of the Newborn
  • 8) Newborn at Risk for Anemia
  • 9) Newborn at Risk Polycythemia
  • 10) Antibiotic Therapy

2
All Infants- Nursing Care
  • -A, B, Cs
  • -NTE
  • -Early detection/treatment of hypoglycemia
  • -Support the family

3
  • Nursing care
  • Should always include these
  • How do you maintain a NTE?
  • - cap on head
  • - radiant heat source
  • - keep infant dry
  • - warm objects prior to contact with infant
  • - positioning of the infant (flexed posture)
  • Early detection/treatment of hypoglycemia

4
1) Newborn at Risk for Asphyxia
  • Asphyxia is severe, prolonged hypoxia
  • Can occur during antepartum, intrapartum, or
    postpartum
  • Causes respiratory, circulatory, and biochemical
    changes

5
Risk Factors for Asphyxia
  • Before and during labor
  • Biophysical profile
  • Fetal heart rate nonreassuring
  • Due to complications causing low O2
  • Low fetal scalp pH
  • Meconium stained fluid
  • Prematurity
  • Multiple gestation

6
  • Biophysical profile
  • - fetal breathing movement
  • - fetal movement of body/limbs
  • - fetal tone
  • - amniotic fluid volume
  • - reactive FHR with activity
  • FHR
  • - decreased variability
  • - normal FHR 110-160 baseline
  • - decelerations
  • Scalp pH
  • - 7.25 or gt considered normal

7
Risk Factors for Asphyxia
  • At birth
  • Diffcult birth
  • Low cord pH - acidosis
  • APGAR
  • Male
  • SGA
  • Sepsis
  • Congenital heart/lung defects

8
Asphyxia
0305
  • Newborn may be unable to make the transition to
    extrauterine circulation
  • Reverts to fetal circulatory patterns
  • pulmonary hypertension
  • increasing hypoxia
  • acidemia
  • Requires intensive supportive care to reverse

9
Newborn at Risk Asphyxia(Rlt60, start chest
compressions)
  • Nursing care
  • Oxygen
  • IV fluids
  • May need newborn resuscitation (NRP)
  • Relate appropriate information to parents

10
2) Care of the Newborn with Respiratory Distress
535
  • Respiratory Distress Syndrome
  • Prematurity
  • Surfactant deficiency disease
  • Transient Tachypnea of the Newborn
  • Meconium Aspiration Syndrome

11
605
12
  • How would we know that the infant has high CO2,
    or is acidotic?
  • ABG or Capillary Blood Gas (CBG)
  • Normal PH 7.30-7.40 after birth.
  • Co2 arterial 35-45 capillary 35-50
  • Po2 on room air arterial 50-80 capillary
    35-45
  • Bicarbonate 19-22 arterial or capillary l
  • Sao2 per pulse ox probe gt90
  • What would be normal for a cord pH?
  • Look it up!

13
Newborn at Risk Respiratory Distress
  • Respiratory distress syndrome (RDS) aka. Hyaline
    membrane disease (HMD)
  • ? surfactant
  • Hypoxia
  • Respiratory acidosis which can develop
  • Into Metabolic acidosis
  • RDS- indicates a failure to synthesize surfactant
  • So who is at risk?
  • more frequent in caucasian
  • more frequent in males than females
  • prematurity

14
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15
Newborn at Risk Respiratory Distress
  • Nursing assessment, youre going to see
  • Respiratory tachypnea, apnea (Normal is 30-60)
  • Chest retractions, grunting, nasal flaring
  • Skin color pallor, mottling, cyanosis

16
  • Nursing Care Plan, page 744, Care of the Newborn
    with Respiratory Distress
  • Turn to
  • Table 28-1, page 742 Clinical Assessment
    Associated with Respiratory Distress
  • Respiratory
  • - tachypnea (RR gt 60) is the most frequent
  • and easily detected sign of respiratory
    distress
  • - apnea (bad sign)
  • sign of
  • -metabolic alterations
  • - CNS disease
  • -IVH
  • -sepsis
  • -prematurity
  • Chest
  • work of breathing
  • -retractions -grunting -nasal flaring

17
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18
Newborn at Risk Respiratory Distress
1010
  • Nursing Care
  • Surfactant replacement
  • Oxygen ventilation (ex oxy hood/tent)
  • ABGs monitored
  • IV fluids/TPN (ex Central lines)
  • Cluster care
  • Supportive care

19
3) Transient Tachypnea of the Newborn (TTN)
1218
  • Failure to clear airways of lung fluid (in utero
    fluid is produced, if this fluid isnt cleared
    from the pressures on chest from birth, then TTN.
    C-Section dont get this squeeze.)
  • Mild intrauterine asphyxia
  • Maternal over sedation, bleeding, IDM
  • Difficult birth
  • Breech birth, prolapsed cord
  • C/Section birthInfant may have tachypnea with
    shallow rapid respirations or grunting
    respirations. Retractions and increased effort
    with breathing nasal flaring.
  • REVIEW
  • Normal Respiratory Rate 30-60 per minute

20
TTN Nursing Assessment
  • Little or no difficulty breathing at birth
  • Shortly after
  • Grunting
  • Flaring
  • Mild cyanosis
  • Tachypnea- usually by 6 hours of age
  • RR as high as 100-140/min.

21
TTN Nursing Care
  • Supplemental O2
  • IV Fluids

22
4) Meconium Stained Amniotic Fluid As the baby
stays in the fluid, this fluid will stain the baby
1505 WTF 1635
  • MAS
  • - 13 of births have meconium stained fluid
  • - of those 4-11 develop MAS
  • Represents a fetal asphyxial insult
  • before/during labor
  • Risk factors
  • Term SGAs
  • Postterm
  • Long labors

23
Meconium Aspiration Syndrome (MAS) Meconium fluid
has aspirated into the babys lungs
  • Air trapping, if not released can
    rupture/pneumothorax
  • Alveoli overdistention
  • Possible pneumothorax
  • Chemical pneumonitis

24
Nursing Care of the Newborn with Meconium
Aspiration Syndrome
1940
  • Prevention of aspiration (Prevent!!)
  • Detect meconium stained amniotic fluid
  • Suction ASAP
  • Mechanical ventilation
  • Surfactant
  • Antibiotics
  • Supportive care

25
5) Newborn at Risk Cold Stress
2035
  • Cold stress- excessive heat loss resulting in the
    use of compensatory mechanisms (increased
    respirations, nonshivering thermogenesis)
  • Infant heat production is by nonshivering
    thermogenesis
  • Burning of brown fat
  • Requires energy utilizes O2 and glucose
  • Leading to Hypoxemia ( lt 40mg/dL )
  • Which Produces acids
  • Decreases surfactant production

26
Cold Stress Chain of Events
27
  • Ladewig et al, P. 697
  • Figure 268 Cold stress chain of events. The
    hypothermic, or cold-stressed, newborn attempts
    to compensate by conserving heat and increasing
    heat production. These physiologic compensatory
    mechanisms initiate a series of metabolic events
    that result in hypoxemia and altered surfactant
    production, metabolic acidosis, hypoglycemia, and
    hyperbilirubinemia.
  • Cold stress is excessive heat loss resulting in
    the use of compensatory mechanisms to maintain
    core body temperature
  • Heat loss occurs in the newborn through
    evaporation, convection, conduction, and
    radiation.

28
Methods of Heat Loss
2155
  • Evaporation loss of heat incurred when water is
    converted to a vapor. Drying the newborn and
    etc.
  • Convection-the loss of hear from the warm body
    surface to the cooler air currents (ie. air
    conditioned rooms, air currents, O2 by mask,
    removal from incubator into cooler air)
  • Conduction-the loss of heat to a coolder surface
    by direct skin contact (cold hands, cool scales,
    cold stethoscope etc)
  • Radiation heat transfers from heated body
    surface to cooler surfaces and objects NOT in
    direct contact with the body (wall of a room or
    incubator, objects near the infant

29
Newborn at Risk Cold Stress
  • Signs/Symptoms
  • ? movement
  • ? respirations
  • ? skin temperature
  • ? peripheral perfusion (cyanotic looking)
  • Hypoglycemia- producing heat uses up stores
  • Metabolic acidosis

30
Newborn at Risk Cold Stress
  • Nursing care
  • Dont let it happen!!
  • Assess skin temperature q 15-30 minutes
  • Warm slowly rapid temperature elevation may
    produce apnea
  • Remove plastic wrap, caps, or heat shields while
    re-warming
  • Warm intravenous fluids prior to infusion
  • Block heat loss by evaporation, radiation,
    convection, and conduction
  • Asses for hypoglycemia

31
  • Dont let it happen!!
  • - the amount of heat loss of an infant
  • depends a great deal on the nurses actions
  • What are some ways we can decrease heat loss?
  • - NTE
  • - prewarm surfaces
  • - avoid drafts
  • - ..
  • Warm slowly
  • - rapid temperature elevation may cause
  • HYPOTENSION
  • APNEA

32
6) Hypoglycemia
2520
  • Why treat?
  • To prevent CNS damage or death

33
Hypoglycemic Neonate
  • At Risk
  • Sick and stressed neonates
  • Infants of diabetic mothers
  • SGA infants
  • Smaller twin will have less stores
  • Male infant
  • Preterm AGA
  • Mother with preeclampsia

34
Signs of hypoglycemia
  • Lethargy or jitteriness/tremor
  • Poor feeding
  • Vomiting
  • Pallor, cyanosis
  • Apnea, Irregular Respirations, Respiratory
    Distress
  • Tremors, jerkiness, seizure activity
  • High pitched cry (meaning neurological origin)

35
Glucose level
  • Hypoglycemic newborns plasma glucose
    concentration is 40 mg/dl or lower.
  • Signs of hypoglycemia may occur before 40 mg/dl
    and require intervention

36
Capillary blood specimen site
2755
  • To check blood glucose, capillary blood is
    usually drawn from newborns heel. Avoid the
    shaded areas to prevent injury to arteries or
    nerves in the foot.

37
Care of the Hypoglycemic Neonate
  • Early formula feeding or breastfeeding
  • If too ill, gavage feeding or IV infusion of D5W
  • Continue to monitor adequacy of treatment
  • Conserve energy stores
  • Maintain a neutral thermal environment

38
7a) Hyperbilirubinemia
3040
  • Bilirubin (Normal bilirubin level is 10-14)
  • potential toxin collects in fatty tissue and
    brain - kernicterus
  • Jaundice skin yellow due to deposit of
    bilirubin in tissues
  • Up to 60 of term newborns will have clinical
    jaundice ? for premature infants
  • Unconjugated bilirubin is a breakdown product
    derived from hemoglobin released from destroyed
    RBCsindirect bilirubin
  • To be eliminated from the body, conjugation of
    bilirubin occurs. Conjugation is the conversion
    of yellow lipid soluble pigment into
    water-soluble pigmentdirect bilirubin

39
Newborn at Risk Hyperbilirubinemia
3155
  • Risk factors
  • Fetal-maternal ABO/Rh incompatibilities
  • Prematurity
  • Cephalohematomas- from birth trauma
  • Bruising
  • Birth trauma
  • Polycythemia
  • Delayed meconium passage, which are normally
    excreted thru stool

40
Newborn at Risk Hyperbilirubinemia
  • Classification
  • Physiologic jaundice
  • Breastfeeding / Breast milk jaundice
  • Pathologic jaundice

41
  • Physiologic jaundice in the term newborn
  • - typically peaks at 3-4 days
  • then declines over the first week of life
  • usually the total bili will be lt 12 mg/dL- bili
    can go as high as 17 with multiple risk factors

42
  • Breastfeeding jaundice (early onset)
  • compared to formula fed infants--- breast fed
    infants
  • are 3-6X more likely to develop moderate to
    severe
  • jaundice (moderate biligt 12, severe bili
    gt15 mg/dL)
  • due to mild dehydration (decreased volume of
    breast milk)
  • - dehydration may cause a delay in meconium
    passage

43
  • Breastmilk jaundice (late onset)
  • - occurs laterbili usually peaks at day 6-14
    can develop in up to 1/3 of healthy breast fed
    infants bili can vary from 12-20, at this age it
    would not be considered pathologic- bili level
    usually continually falls after 2 wks of age,
    however, it may remain elevated for 1-3 months.
    if the cause of the jaundice is in question, the
    mom may be asked to stop breastfeeding, but
    continue to express breastmilk, with formula
    substitution, if the bili drops rapidly over 48
    hours, this confirms breastmilk jaundice and
    breastfeeding may be resumed.

44
Hyperbilirubinemia - Physiologic
3252
  • RBCs shorter life span
  • Immature liver
  • Lack of intestinal bacteria to conjugate
    bilirubin
  • Poor hydration hinders urine bowel elimination

45
Newborn at Risk Hyperbilirubinemia
  • Nursing Care
  • IO
  • Hydration
  • Observe for jaundice
  • Phototherapy
  • Transfusions
  • Nursing care plan, page 779-780

46
  • IO
  • - monitor for first stool WHY?
  • Hydration
  • - early frequent feeds
  • - more severe IVF
  • Jaundice
  • - note when it occurs
  • - monitor progression
  • - transcutaneous bili check before discharge
  • Phototherapy
  • - use of visible light to convert bilirubin into
  • water soluble isomers that can be eliminated
  • without being conjugated in the liver
  • Transfusions
  • - for severe anemia
  • - exchange transfusions
  • to replace the babys damaged blood
  • ? RBC count and ? bili level

47
Hyperbilirubinemia Pathologic Jaundice
3530
  • Hemolytic disease of the newborn (HDN) due to a
  • Rh incompatibility
  • ABO incompatibility
  • Jaundice at birth or in the first 24 hours of
    life
  • Physiologic jaundice occurs after 24hrs
  • Hydrops fetalis- massive edema in the fetus or
    newborn, usually in association with RBC
    destruction. (blood incompatibility) Rhogam to
    prevent.
  • Kernicterus- toxic accumulation of bilirubin in
    tissues caused by hyperbilirubinemia.

48
  • Rh incompatibility
  • - Rh negative Mom/Rh positive Dad
  • have an Rh positive baby
  • - babys blood cells cross over to the Rh
    negative Mom
  • - Mom develops antibodies (Rh sensitization)
  • - subsequent pregnancies are at risk for HDN
  • - How do we avoid this? RhoGAM
  • Signs/Symptoms
  • During pregnancy
  • - placenta helps rid some bili, but not all
  • mild anemia/hyperbilirubinemia/jaundice
  • - liver/spleen and bone marrow cant keep
  • up with RBC destruction
  • severe anemia liver/spleen enlargement
  • - babys organs cant handle the severe anemia
  • leading to heart failure with fluid buildup
    in tissues
  • and organs hydrops fetalis
  • After birth
  • - babys liver cant conjugate the large amount
    of bili

49
7b) Hemolytic Disease of the Newborn
  • Rh incompatibility
  • Rh neg mother with Rh positive newborn
  • Jaundice, anemia, hemolysis of RBCs, increased
    immature RBCs
  • Most severe form of hemolytic disease of newborn
    Hydrops Fetalis
  • Multi-organ system failure due to severe anemia
  • Rhogam for the block

50
  • Hemolytic disease of the newborn secondary to Rh
    incompatibility
  • Isoimmune
  • Rh neg mother with Rh positive newborn passes
    maternal antibodies to fetal circulation that
    destroy the fetal RBC
  • Jaundice, anemia, increased immature RBCs
    (erythroblasts) r/t hemolysis of RBCs,
  • Most severe form is hydrops fetalis occurs when
    maternal antibodies attach to the Rh site on the
    fetal RBC, making them susceptible to destruction
    by phagocytes multi-organ system failure
    frequently fatal

51
Hemolytic Disease of the Newborn Same thing, but
not as severe
3820
  • ABO incompatibility
  • Mother blood type O infant A or B can result in
    jaundice but rarely hemolytic disease
  • Jaundice, hyperbilirubinemia, hepatosplenomegaly
    r/t hemolysis of RBCs
  • Rh is not a factor

52
Care of Newborn at Risk for Hyperbilirubinemia
  • Identifying the Cause of Hemolytic Disease
  • Blood type
  • Coombs test
  • Indirect- amount of Rh antibodies in mothers
    blood
  • Direct- presence of antibody coated Rh RBCs in
    newborn
  • Serum bilirubin
  • CBC
  • Reticulocyte count

53
Care of Newborn at Risk for Hyperbilirubinemia
3935
  • Alleviate anemia
  • Exchange transfusion
  • Withdraw replace all newborns blood with donor
    blood
  • Increase serum albumin levels
  • Reduce serum bilirubin
  • Phototherapy
  • Drug therapy- Phenobarbital (Bilirubin binds to
    Phenobarbital, so when it goes the bilirubin
    does too)

54
8) Newborn at Risk for Anemia
  • Normal Hgb
  • Term 15-20 g/dL, less 14 anemia
  • Preterm 14-18 g/dL, less 13 anemia
  • Hemoglobin levels lt 14g/dl in term infant or 13
    g/dl in preterm

55
Common Causes of Anemia
  • Blood Losses
  • Placental bleeding
  • Intrapartal blood loss
  • Umbilical cord bleeding
  • Birth trauma
  • Cerebral bleeding
  • Hemolysis
  • Impaired red blood cell production

56
Physiologic anemia
4210
  • Decreased hgb first 6-12 weeks
  • Production of RBCs stopped in response to
    elevated O2
  • Hgb levels decrease, bone marrow production
    resumes

57
Care of the Newborn with Anemia
  • Early Detection and correction of pathological
    anemia
  • Pale infant, poor weight gain, tachycardia,
    tachypnea, apneic episodes
  • Ensure newborn well-being. Follow checklist
    airway, breathing, circulation, neutral thermal
    environment, early detection and intervention of
    hypoglycemia, promote comfort bonding
  • Monitor total blood out

58
Anemia
  • Signs Symptoms
  • ? Hgb
  • Pallor
  • ? BP
  • Tachycardia
  • Tachypnea
  • Apneic episodes

59
Nursing Care - Anemia
  • Mild anemia
  • Iron supplement
  • More severe
  • Hydration
  • Blood Transfusion

60
9) Newborn at Risk Polycythemia
  • ? blood volume
  • ?Hct gt 65-70
  • Hgb gt 22 g/dl
  • More common in
  • IDM
  • SGA
  • Postmature
  • Term infants with delayed cord clamping
  • Maternal-fetal transfusion
  • Twin-to-twin transfusion

61
Newborn at Risk Polycythemia
  • Often asymptomatic
  • S/S
  • CHF - Tachycardic, Respiratory distress (30-60
    is normal)
  • ? bili
  • ? peripheral pulses

62
Nursing Care
  • Exchange transfusion with FFP or albumin
  • Monitor VS during transfusion
  • /- phototherapy
  • Treatment goal
  • Reduce hematocrit to a range of 55-60, this is
    a success

63
Newborn at Risk Infection
4838
  • Sepsis Neonatorum
  • Newborns up to 1 month of age are particularly
    susceptible
  • Prematurity increases risk
  • Caused by organisms that do not cause infection
    in older children

64
Predisposing Factors
  • Maternal antepartal infections
  • TORCH - Toxoplasmosis, Rubella, Cytomegalic
    Inclusion Disease, Herpes (all deadly to
    newborns)
  • Intrapartal
  • Amnionitis, passage through the birth canal,
    Group B hemolytic Strep, Herpes, Gonococci,
    Listeria
  • Nosocomial
  • Pseudomonas, Staphylococcus aureas and epi

65
Diagnosis
5043
  • Usual Lab work
  • CBC, Blood Cultures (best) and Sensitivity with
    Gram Stain, Urine for antibody screen, C-Reactive
    Protein level, other cultures as recommended or
    ordered
  • Chest x-ray
  • If viral infection is suspected TORCH
    (toxoplasmosis, other, rubella, cytomegalovirus,
    herpes virus) titers are drawn. Skull and bone
    x-rays to check for any damage.

66
Nursing care
5142
  • Infants with sepsis can rapidly deteriorate!
  • Supportive care
  • Administer medications as ordered
  • Recognition of the signs of sepsis- hypotonia,
    color changes pallor, dusky, cyanosis, grey,
    temperature instability, feeding intolerance,
    hyperbilirubinemia, tachycardia, apnea,
    behavioral changes, RDS-type symptoms
  • Respiratory Distress symptoms
  • Incr respirations, nasal flaring, retractions,
    grunting, peripheral edema
  • A sub normal temperature, is a cardinal sign of
    sepsis.

67
10) Antibiotic Therapy
5342
  • Review proper dose/kg
  • Therapeutic peak/trough values
  • Method of administration (thru IV, Central line
    is better)
  • Incompatibilities
  • Side effects

68
Duration of Antibiotic Therapy
5423
  • Therapy initiated before test results are final
  • Treatment of infection with 2 broad spectrum
    antibiotics per intravenous route
  • When the pathogen and its sensitivities are
    determined appropriate specific antibiotic
    therapy is implemented for 7-14 days.
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