3/2/18
THE HIGH-RISK NEONATE
Geraldine Rowena S. Galang, MAN, RN
PRIORITIES
1. initiating and maintaining respirations
2. establishing extrauterine circulation
3. fluid and electrolyte balance
4. temperature regulation
5. establishing adequate nutritional intake
6. preventing infection
7. establishing parent-infant bonding
8. providing developmental care
ORGANIZED STEPS IN RESUSCITATION
• 1. establish an airway
• 2. expand the lungs
• 3. maintain effective ventilation
THE HIGH-RISK NEONATE
• 1. maternal age
• 2. concurrent maternal disease conditions
• 3. pregnancy complications
• 4. unhealthy maternal lifestyle
• 5. labor problems
• 6. altered gestational age or birth weight
• 7. congenital malformations
- The ultimate prognosis of the high risk
infant depends greatly on how the
first moments of life are managed.
- Most infants are born with some
degree of respiratory acidosis, but the
spontaneous onset of respirations
rapidly corrects this.
ORGANIZED STEPS IN RESUSCITATION
• 1. establishing an airway
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ORGANIZED STEPS IN RESUSCITATION ORGANIZED STEPS IN RESUSCITATION

• 1. establishing an airway • 1. establishing an airway
INTUBATION

ORGANIZED STEPS IN RESUSCITATION ORGANIZED STEPS IN RESUSCITATION

• 1. establishing an airway • 1. establishing an airway

ORGANIZED STEPS IN RESUSCITATION ORGANIZED STEPS IN RESUSCITATION

• 2. expanding the lungs • 3. maintaining effective ventilation
administer oxygen at a rate of 40 to 60 IMPORTANT PRINCIPLES:
compressions per minute - continued respirations must be maintained
- undress chest and look for retractions
- position head elevated 15 degrees
- keep the infant warm

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ORGANIZED STEPS IN RESUSCITATION ORGANIZED STEPS IN RESUSCITATION

• 3. maintaining effective ventilation • 3. maintaining effective ventilation
PEDIATRIC OXYGEN SUPPORTS
A. OXYGEN CANNULA
B. OXYGEN HOOD
C. NASAL OR ET CPAP
D. VENTILATOR

ORGANIZED STEPS IN RESUSCITATION ORGANIZED STEPS IN RESUSCITATION

• 3. maintaining effective ventilation • 3. maintaining effective ventilation

ORGANIZED STEPS IN RESUSCITATION ORGANIZED STEPS IN RESUSCITATION

• 3. maintaining effective ventilation • 3. maintaining effective ventilation

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RESPIRATORY PATTERNS
• 1. eupnea – normal rate and rhythm of breathing
• EVALUATING RESPIRATORY DISTRESS
• 2. tachypnea – fast breathing GRADE DESCRIPTION
• 3. bradypnea – slow breathing
0 no retractions, no nasal flaring, expiratory grunt
• 4. apnea – cessation of breathing heard with stethoscope
• 5. hyperpnea – increase in depth and rate of breathing
• 6. cheyne-stoke respirations – alternating periods of 1 retractions, nasal flaring, expiratory grunt heard
shallow and deep breathing with stethoscope

• 7. biots respiration – quick, shallow breathing followed

by apnea 2 expiratory grunt heard with the naked ear
• 8. kussmaul respiration – deep and labored breathing

MECHANICAL VENTILATION
— 1. controlled mechanical ventilation (CMV)
AIRWAY DIFFERENCE OF CHILDREN FROM ADULTS - delivers a preset tidal volume at a preset rate, ignoring the patient’s own ventilatory drive

• 1. large occiput - for those with CNS dysfunction, drug-induced paralysis or sedation, severe chest trauma
— 2. assist-control ventilation (ACV)
• 2. short neck - delivers a preset tidal volume when the patient initiates inspiration
— 3. synchronized intermittent mandatory ventilation (SIMV)
• 3. large tongue - delivers a preset tidal volume at a preset rate, in addition, patient can breathe spontaneously
between ventilator breaths from an oxygen reservoir attached to the machine
• 4. immature laryngeal reflex - prevents breath stacking

• 5. small nares — 4. positive end-expiratory pressure (PEEP)

- improve ventilatory function of the lungs, thereby increasing PaO2
• 6. high glottis - counteracts small airway collapse and keeps alveoli open
- effective for atelectatic alveoli and alveoli filled with fluid
• 7. slanted vocal cords — 5. high-frequency ventilation and oscillation (HFPPV, HFJV, HFO)
- small tidal volumes are delivered at high rates
• 8. narrow cricoid ring — 6. inverse ratio ventilation (IRV)
- I is prolonged and E is shortened to promote alveolar recruitment, which improves
oxygenation at lower levels of PEEP

Physical damage to body tissues caused by a difference in • Pneumothorax is a collection of air or

pressure between an air space inside or beside the body gas in the pleural cavity of the chest
and the surrounding fluid. between the lung and the chest wall.
• In a small proportion, the
Damage occurs in the tissues around the body's air spaces pneumothorax leads to severe oxygen
because gases are compressible and the tissues are not. shortage and low blood pressure,
progressing to cardiac arrest unless
A. During increases in ambient pressure, the internal air space treated; this situation is termed
provides the surrounding tissues with little support to resist tension pneumothorax.
the higher external pressure. • The high pressure of positive pressure
B. During decreases in ambient pressure, the higher pressure ventilation may blow a hole in
of the gas inside the air spaces causes damage to the diseased or fragile lung tissue, leading
to this life-threatening complication.
surrounding tissues if that gas becomes trapped.

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• Peptic ulcer with profound Develops as a result of decreased venous

hemorrhage may develop as a result return secondary to increased
of physiologic pressure. intrathoracic pressure.
• Gastric dilatation can result due to Generally, this phenomenon is transient
large amount of air swallowed in the and is seen immediately after the patient
presence of an artificial airway. has been placed on mechanical
ventilation.

Increased production of antidiuretic hormone

OCCURS AS A RESULT OF (ADH) occurs as a result of increased pressure
DECREASED VENOUS RETURN, on baroreceptors in the thoracic aorta, which
causes the system to react as if the body were
WHICH CAUSES POOLING OF volume depleted.
BLOOD IN THE HEAD. This ADH stimulates the system to retain water
in the body.

EXTUBATION cardiac function must be maintained through:

A. Assess good ventilatory status after CLOSED CHEST MASSAGE
weaning. hold the infant with fingers supporting
B. Prepare intubation set. the back and pressing the thumbs against
C. Prepare ordered oxygen therapy after the sternum or depressing the sternum
ventilator. with 2 fingers approximately 1 or 2 cm at
D. Prepare racemic epinephrine a rate of 120 times per minute
nebulization.

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cardiac function must be maintained through:

CLOSED CHEST MASSAGE
EQUIPMENTS
• PULSE OXIMETER
• PHYSIOLOGIC MONITOR

• PULSE OXIMETER • PHYSIOLOGIC MONITOR

IMPORTANTS CONSIDERATIONS MEDICATIONS

• 1. DOPAMINE (2-5 mg/kg/min)
• 1. assess apical heart rate, peripheral - increase heart rate, renal blood flow, and
pulses, and state of perfusion contraction for distributive shock
• 2. DOBUTAMINE (2-15 mg/kg/min)
• 2. ECG monitoring - increase heart rate and contraction for
• 3. blood pressure cardiogenic shock
• 3. EPINEPHRINE (0.1 cc/kg)
• 4. invasive pressures - increase heart rate, blood pressure, blood flow
to heart and brain

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PERCEPTION AND COORDINATION PERCEPTION AND COORDINATION

IMPORTANT CONSIDERATIONS • PEDIATRIC GLASGOW COMA SCALE
• 1. note LOC, tone and responsiveness to EYE VERBAL MOTOR

stimuli 4 – spontaneous 5 – coos, babbles 6 – moves

spontaneously
• 2. measure HC 3 - to words 4 – irritable, cries 5 – withdraws
touch
• 3. ICP monitors 2 – to pain 3 – cries 4 – withdraws pain
1 – none 2 – moans 3 – flexion to pain
• 4. record frequency and type of seizure 1 – none 2 – extension to
activity pain
1 - none

BLOOD TRANSFUSION BLOOD TRANSFUSION

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IMPORTANTS CONSIDERATIONS DEFICITS IN

• 1. weigh patient daily
• 2. assess symptoms of hypovolemia or
BODY FLUID AND ELECTROLYTE
hypervolemia —1. decrease intake and ongoing
• 3. record all intakes normal losses
• 4. record all outputs
• 5. measure Na, K, Cl, and Ca at least once —2. increased losses without intake
everyday if on IV fluid

ASSESSMENT MILD MODERATE SEVERE

TYPES OF DEHYDRATION
DEHYDRATION DEHYDRATION DEHYDRATION
• 1. isotonic dehydration
1. appearance thirsty restless semi-comatose
2. turgor normal poor very poor Na = 130 to 150
3. fontanel normal sunken very sunken
4. mucus moist dry cyanotic
• 2. hypotonic dehydration
membrane
Na = < 130
5. pulse normal rapid rapid
6. respiration normal deep deep and rapid • 3. hypertonic dehydration
7. blood pressure normal normal low
8. urine normal reduced oliguria
Na = > 150
9. blood gases normal mild acidosis severe acidosis

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REPLACEMENTS • 1. HEAT LAMP, DROP LIGHT

— 1. dextrose
- D10W for children
— 2. saline
- hypotonic to provide hydration and hypertonic for severe Na
deficits
— 3. ringers
- Na, K, Cl, and Ca volume depletion
— 4. lactated ringers
- similar to plasma and as a blood volume expander
— 5. dextran
- maintain blood volume and treat shock and hypovolemia
— 6. lipids
- provide calories

• 2. RADIANT WARMER • 3. INCUBATOR, ISOLETTE

• 4. KANGAROO CARE HEAT LOSS

• 1. convection
• 2. radiation
• 3. evaporation
• 4. conduction

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• 1. enteral feeding • 1. enteral feeding

~ short term (orogastric tube) ~ long term (gastrostomy tube, jejunostomy tube)

• 2. parenteral nutrition IMPORTANT CONSIDERATIONS

~ central line, peripheral line
• 1. compute caloric requirement for age and
weight
• 2. measure AG every 8 hours especially if
patient is less than 1 month of age
• 3. check stool specimen for blood
• 4. note quantity and characteristics of gastric
residuals

FLUID REQUIREMENTS
— PRETERM TOTAL PARENTERAL NUTRITION
80-100 ml/kg/day
— TERM 1. severe diarrhea
100-150 ml/kg/day
— CHILDREN 2. GI abnormalities
70-110 ml/kg/day
3. cystic fibrosis, cancer, other conditions
— MILK
CALORIC REQUIREMENTS
4. disorders preventing enteral nutrition
20-24 kcal/oz within 5 days
— IV FLUID
g/100 cc

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