Nursing Care of at Risk/High ● Intrauterine growth restriction (IUGR) Assessment:

Risk/Sick Client ○ intrauterine growth is ● APGAR scoring

restricted (sometimes used ● obvious congenital anomalies or
as a more descriptive term evidence of neonatal distress.
Classification According to Size:
for the SGA infant) ● feeding behaviour, activity, colour,
● Low-birth-weight (LBW) infant: oxygen saturation (Sp02), or vital signs
○ Less than 2500 g (5.5 lb), often indicate an underlying problem
● Large-for-gestational age (LGA)
regardless of gestational age
infant
○ falls above the 90th
Monitoring Physiologic data:
● Very low-birth-weight (VLBW) ● placed in a controlled thermal
percentile on intrauterine
○ less than 1500 g (3.3 lb) environment and monitored for heart
growth charts
rate, respiratory activity, and
● Extremely low-birth-weight (ELBW) temperature
Classification According to Gestational Age ● blood glucose, bilirubin, electrolytes,
○ less than 1000 g (2.2 lb)
● Pre-Term calcium, hematocrit, and blood gases.
○ Born before completion of 37 ● Samples may be obtained byheel stick;
● Appropriate-for-gestational age
weeks of gestation venipuncture; arterial puncture; or an
(AGA)
indwelling catheter in an umbilical vein,
○ weight falls between the 10th umbilical artery, or peripheral artery.
● Full Term
and 90th percentiles on
○ Between the beginning of 38
intrauterine growth curves
weeks and 42 weeks of Respiratory Support:
gestation ● supplemental oxygen and assisted
● Small-for-date. (SFD) or
ventilation
small-for-gestational-age (SGA)
● Post Term ● appropriate positioning to ensure an
infant
○ Born after 42 weeks of open airway and to maximise
○ rate of intrauterine growth
gestation oxygenation and ventilation.
has slowed and whose birth
● Oxygen therapy is provided on the
weight falls below the 10th
● Late Preterm basis of the infant's requirements
percentile on intrauterine
○ Born between 34 and 36 and illness
growth curves
weeks of gestation ●

Pante, Jeff Henry J. BSN 2

Thermoregulation:
● The most crucial need of the
low-birth-weight (LBW) infant is
external warmth.
● Prevention of heat loss in the
distressed infant is essential for
survival, and maintaining a neutral
thermal environment is a challenging
aspect of neonatal intensive nursing
care.
Pathophysiology
● produces heat mainly through
increasing her metabolic rate
● Norepinephrine, secreted by the
sympathetic nerve endings in
response to chilling, stimulates fat
metabolism in the richly vascularized
brown adipose tissue to produce
internal heat, which is then
conducted through the blood to
surface tissues.
● Increased metabolism in response to
chilling creates a compensatory
increase in oxygen and calorie
consumption
● Decreased oxygen intake reduces
the supply available for glucose
metabolism L glucose is broken
Pante, Jeff Henry J. BSN 2
down by an alternate, hypoxic
pathway (anaerobic glycolysis) that
generates increased lactic acid
Maintaining Thermoneutrality:
● use of an incubator
● a radiant warming panel
● an open bassinet with cotton
blankets.
● infant requiring close observation or
treatments such as phototherapy
may need to be cared for in an
incubator or under radiant heat
Protection from Infection:
● Thorough and frequent hand
washing is the foundation of a
preventive program.
● masks or gloves, to reduce the
likelihood of contamination.
Hydration:
● Pulmonary edema, congestive heart
failure, patent dúctus arteriosus
(PDA), and intraventricular
haemorrhage (IVH) may occur with
fluid overload.
● Dehydration may cause electrolyte
disturbances (particularly sodium),
with potentially serious central
nervous system (CNS) effects.
Nutrition:
● Preterm infants have poor muscle
tone in the area of the lower
oesophagus
● The stomach has a limited capacity
in preterm infants and is easily
overdistended, further compromising
respiration.
● secretion of lactase, a
late-developing enzyme, is low in
infants born before 34 weeks of
gestation; formulas containing
lactose may not be well tolerated
● Preterm infants are inefficient in
digesting and absorbing lipids
Nutritional Needs:
● Total parenteral nutritional support
of acutely ill infants may be
accomplished with commercially
available IV solutions specifically
designed to meet the infant's
nutritional needs, including protein,
amino acids, trace
minerals,vitamins, carbohydrates
(dextrose), and fat (lipid emulsion).
 ● Daily monitoring of weight,
electrolytes, renal function, calcium,
and hydration status is carried out to
ensure adequate therapy.
● Early feeding (provided that the
infant is medically stable) reduces
the incidence of complicating factors
such as hypoglycemia and
dehydration and reduces the degree
of hyperbilirubinemia
Breastfeeding:
● a nurse should carefully evaluate the
preterm infant for readiness to
breastfeed, including assessment of
behavioural state, ability to maintain
body temperature outside an
artificial heat source, respiratory
status, and readiness to suckle at the
mother's breast.
Skin Care:
● Alkaline-based soap that might
destroy the "acid mantle" of the skin
should be avoided.
● take care to avoid damage to the
delicate structure
● observe for rashes or excoriation,
keep skin clean with warm water,
Pante, Jeff Henry J. BSN 2
promptly clean perineum after
stooling, reposition every 2 hours,
carefully monitor cleanliness and
skin integrity, and avoid direct
contact of blanket with infant's skin.
Administration of Medications:
● nurses need particularly alert for
signs of adverse reaction.
Therapeutic Management :
● a neonatologist or a neonatal nurse
practitioner, a staff nurse, and a
respiratory therapist are present for
the delivery.
● a neonatologist or a neonatal nurse
practitioner, a staff nurse, and a
respiratory therapist are present for
the delivery.
● Infants who do not require
resuscitation are immediately
transferred in a heated incubator to
the NICU, where they are weighed
and where IV access, oxygen
therapy, and other therapeutic
interventions are initiated a s
needed.
● Resuscitation is conducted in the
delivery area until infants can be
safely transported to the NICU.
Post term infants:
● A common finding in post term
infants is a wasted physical
appearance that reflects intrauterine
nutritional deprivation
● The little vernix caseosa that
remains in the skin folds may be
stained a deep yellow or green
which is usually an indication of
meconium in the amniotic fluid
● Induction of labor is usually
recommended when infants are
significantly overdue.
High Risk related to disturbed
respiratory function
Apnea of Prematurity
● Preterm infants are characteristically
periodic breathers.
● Apnea of prematurity (AOP) is a
common phenomenon in the preterm
infant.
 ● Apnea usually resolves as the infant
approaches 37 weeks ○
○ those born very prematurely,
apnea can persist up to 43
weeks' postmenstrual age
AOP may be further classified according
to origin
● (1) Central apnea: CNS does not
transmit signals to the respiratory
muscles
● (2) Obstructive apnea: Upper airway
obstruction, yet chest or abdominal wall
movement
● (3) Mixed apnea: a combination of
central and obstructive apnea and the most
common form of apnea seen in preterm
Pathophysiology:
● neurons have fewer dendritic
associations than those of more
mature infants
● respiratory reflexes of these infants
are significantly less mature, which
may be a contributing factor in the
etiology
● Overall weakness of the muscles of
the thorax, diaphragm, and upper
Pante, Jeff Henry J. BSN 2
airway may also contribute to apneic
episodes in the preterm infant.
Therapeutic Management: Pathophysiology
● Caffeine is often effective in
reducing the frequency of primary
apnea-bradycardia spells in
newborns
● Caffeine acts as a CNS stimulant to
breathing.
● Neonates receiving caffeine must be
closely observed for symptoms of
toxicity.
● fewer side effects than previously
used aminophylline or theophylline,
requires dosing once daily, hasmore
predictable plasma concentrations,
has slower elimination, therapeutic
range (trough, 5 to 20 mcg/ml).
● It can be injected or administered
orally. Weight and urinary output
should be closely monitored because
caffeine acts as a mild diuretic.
Meconium Aspiration Syndrome Clinical Manifestation
● Meconium Aspiration Syndrome
At delivery of the chest and initiation
of the first breath, infants inhale fluid
and meconium into the
naso-oropharynx.
● Once the fetus ingests meconium,
any gasping activity occurring as a
result of intrauterine stress may
cause the sticky and tenacious
substance to be aspirated into the
lower airways ; partial airway
obstruction, air trapping,
hyperinflation distal to the
obstruction, and atelectasis caused
by surfactant deactivation.
● The air trapping of MAS causes
overdistention of the alveoli and
often air leaks.
● There is evidence that meconium
contributes to the destruction of
surfactant, increasing surface
tension and further predisposing the
alveoli to decreased functional
capacity.
● stained from green meconium stools
(those with more recent meconium
passage may not be stained),
 tachypneic, hypoxic, and often blood away from the pulmonary
depressed at birth system. Risk Factors
● expiratory grunting, nasal flaring, ● Prematurity
and retractions Therapeutic Management ● invasive procedures such as
● initially be cyanotic or pale as well as ● tracheal suctioning placement of IV lines and ET tubes,
tachypneic, and they may ● vigorous with strong, stable administration of total parenteral
demonstrate the classic barrel chest respiratory effort, good muscle tone, nutrition
from hyperinflation. and heart rate greater than 100 ● nosocomial exposure to pathogens
● stressed, hypothermic, beats/min SHOULD NOT undergo in the NICU.
hypoglycemic, and hypocalcemic tracheal suctioning but should be
● Severe meconium aspiration CLOSELY MONITORED IMPORTANT!!
progresses rapidly to respiratory ● poor respiratory effort, low heart ● Thorough hand washing is the single
failure if untreated rate, and poor tone SHOULD BE most important infection control
● profound respiratory distress with RAPIDLY INTUBATED, SUCTIONED, measure in the NICU.
gasping, ineffective ventilations, AND RESUSCITATED according to ● Proper Handling of formula and
marked cyanosis and pallor, and clinical status after suctioning. supplies such as syringes and
hypotonia.
gavage tubes is also vital to prevent
Neonatal Sepsis infection.
● Diagnostic Evaluation ● refers to a generalised bacterial ● Breastfeeding has a protective effect
meconium can often be visualised against infection and should be
infection in the bloodstream
via laryngoscopy in the respiratory promoted for all newborns
● Neonates are highly susceptible to
passages and vocal cords ● Colostrum contains agglutinins that
infection because of diminished
● Chest radiographs show uneven are effective against gram-negative
nonspecific (inflammatory) and
distribution of patchy infiltrates, air bacteria.
specific (humoral) immunity, such as
trapping, hyperexpansion, and ● Human milk contains large
impaired phagocytosis, delayed
atelectasis quantities of IgA and iron-binding
chemotactic response, minimum or
● Echocardiography assists in the protein that exert a bacteriostatic
absent igA and immunoglobulin M
diagnosis of right-to-left shunting of effect on Escherichia coli.
(IgM), and decreased complement
levels.

Pante, Jeff Henry J. BSN 2

 ● Human milk also contains
macrophages and lymphocytes that
promote a local inflammatory
reaction.
Pathophysiology
● premature withdrawal of the
placental barrier leaves infants
vulnerable to most common viral,
bacterial, fungal, and parasitic
infections
● Immune substances, primarily
immunoglobulin G (IgG), are normally
acquired from the maternal system
and stored in fetal tissues during the
final weeks of gestation to provide
newborns with passive immunity
● Early birth interrupts transplacental
transmission of IgG ; preterm infants
have a low level of circulating IgG
Sources of Infection
● Can be acquired prenatally across
the placenta from the maternal
bloodstream or during labor from
ingestion or aspiration of infected
amniotic fluid
● Prolonged rupture of the membranes
always presents a risk for
Pante, Jeff Henry J. BSN 2
maternal-fetal transfer of pathogenic confirmation and identification of the
organisms exact organism
● In utero transplacental transfer can ● circulatory support, respiratory
occur with a variety of organisms support, and aggressive
and viruses such as administration of antibiotics.
cytomegalovirus,toxoplasmosis, and ● Supportive therapy usually involves
Treponema pallidum (syphilis), which administration of oxygen (if
cross the placental barrier during the respiratory distress or hypoxia is
latter half of pregnancy evident)
● Careful regulation of fluids
Diagnostic Evaluation ● correction of electrolyte or acid-base
● Established by laboratory and imbalance
radiographic examination. ● temporary discontinuation of oral
● Isolation of the specific organism is feedings
always attempted through cultures of ● Blood transfusion may be needed to
blood, urine, and CSF correct anemia
● Blood studies may show signs of ● IV fluids for shock
leukocytosis or leukopenia ● electronic monitoring of vital signs
● regulation of the thermal
Therapeutic Management environment
● Antibiotic therapy is continued for 7
● good hand washing, early
to 10 days if cultures are positive,
recognition and diagnosis are
discontinued in 36 to 48 hours if
essential to increase the infant's
cultures are negative and the infant
chance for survival and reduce the
is asymptomatic, and most often
likelihood of permanent neurologic
administered via IV infusion.
damage
● Antifungal and antiviral therapies
● Antibiotic therapy is initiated before
are implemented as appropriate,
laboratory results are available for
depending on causative agents

Nursing Care management
● involves observation and
assessment for any high-risk infant .
● Awareness of the potential modes of
infection transmission also helps the
nurse identify those at risk for
developing sepsis.
● Knowledge of the side effects of the
specific antibiotic and proper
regulation and administration of the
drug are vital
● providing an optimum
thermoregulated environment and
anticipating potential problems such
as dehydration or hypoxia
● Proper hand washing, the use of
disposable equipment (e.g., linens,
catheters, feeding supplies, and IV
equipment), disposal of secretions
(e.g., vomit and stool), and adequate
housekeeping of the environment
and equipment are essential.
● observation for signs of
complications, including meningitis
and septic shock, a severe
complication caused by toxins in the
bloodstream.
Pante, Jeff Henry J. BSN 2
Prognosis
● Severe neurologic and respiratory
sequelae may occur in ELBW and
VLBW infants with early-onset
sepsis.
● Late-onset sepsis and meningitis
may also result in poor outcomes for
immunocompromised neonates.
HIGH RISK RELATED TO PHYSIOLOGIC
FACTORS
Hyperbilirubinemia
● excessive level of accumulated
bilirubin blood and is characterized
by JAUNDICE or icterus, a yellowish
discoloration of the skin, sclerae, and
nails.
● results from increased unconjugated
or conjugated bilirubin.
unconjugated form or indirect
bilirubin is the type most commonly
used.
Pathophysiology
BILIRUBIN is one of the breakdown products
of the hemoglobin that results from red blood
cell (RBC) destruction.
● When RBCS' are destroyed, the
breakdown products are released
Into the circulation, where the
hemoglobin splits Into two fractions:
heme and globin.
● The globin (protein) portion is used
by the body; and the heme portion is
converted to unconjugated bilirubin,
an insoluble substance bound to
albumin.
● In the liver, the bilirubin is detached
from the albumin molecule and in the
presence of the enzyme glucuronyl
transferase, is conjugated with
glucuronic acid to produce a highly
soluble substance, conjugated
bilirubin which is then excreted into
the bile.
The
Causes of Hyperbilirubinemia
1. Physiologic ( developmental) factors
(prematurity)
2. An association with breastfeeding or
breast milk
3. Excess production of bilirubin (e.g
hemolytic disease)
4. Disturbed capacity of the liver to
secrete conjugated bilirubin(e.g
enzyme deficiency)
 5. Combined overproduction and under Within several hours expiratory grunting
secretion (e.g sepsis) Acute Bilirubin Encephalopathy occurs caused by closure of the glottis as
6. Some disease states(infant of a ● Is the destruction of brain cells by it tries to increase the preterm newborn.
diabetic mother) invasion of indirect or unconjugated
7. Genetic predisposition to increased bilirubin. On AUSCULTATION,there may be fine rales
production. ● This invasion results from high and diminished breath sounds because of
concentration of indirect bilirubin POOR air entry
Breastfeeding is associated with an that forms in the bloodstream from Signs and symptoms:
Increased incidence of jaundice. an excessive breakdown of RBC at 1. seesaw respiration (on inspiration
Two types: birth. the anterior chest wall retracts and
1. EARLY ONSET OF JAUNDICE begins the abdomen protrudes on
at 2 to 4 days of age and occurs in ILLNESSES THAT OCCUR IN NEWBORNS expiration the sternum rises)
approximately 10% to 25% of breast ● RESPIRATORY MEMBRANE 2. Heart failure, evidenced by
fed newborns. DISTRESS SYNDROME formerly decreased urine output and edema
● The Jaundiced is related to the termed HYALINE MEMBRANE of the extremities
process of breastfeeding and DISEASE common in preterm 3. pale gray skin
probably results from decreased newborns. 4. periods of apnea
caloric and fluid Intake by breastfed 5. Bradycardia
infants before the milk supply is well Causes: 6. pneumothorax
established, because fasting is
1. meconium aspiration syndrome
associated with decreased hepatic Therapeutic Management
2. sepsis
clearance of bilirubin 1. SURFACTANT REPLACEMENT
3. pneumonia
● SURFACTANT restores naturally
2. Late onset jaundice begins at age 5 occurring lung surfactant to improve
ASSESSMENT
to 7 days and occurs in 2% to 3% of lung compliance.
1. Low body temperature
breast fed infants. Rising levels of ● dosage :4ml/kg intratracheally; four
2. nasal flaring
bilirubin peak during the second doses in first 48 hours of life
3. sternal and subcostal retractions
week and gradually diminish. ● possible adverse effects: transient
4. tachypnea ( more than 60 bpm) 5.
cyanotic bradycardia, rales

Pante, Jeff Henry J. BSN 2


NURSING RESPONSIBILITIES
1. Suction infant before administration
2. assess infants respiratory rate,
rhythm, oxygen saturation and color
before administration
3. ensure proper endotracheal tube
placement before closing
4. change infants position during
administration to encourage the
drug to flow to both lungs
5. assess infants respiratory rate, color,
and pulse oximetry or arterial blood
gasses after administration.
6. do not suction the endotracheal tube
for 1 hr after administration to avoid
removing the drug
TRANSIENT TACHYPNEA OF THE
NEWBORN
● At birth, a newborn may have a rapid
rate of respirations, up to 80 bpm
when crying caused by retained lung
fluid.
● Within 1 hr this rapid rate slows to
between 30 and 60 bpm.
● The infant does not appear to be in a
great deal of distress aside from the
tiring effort of breathing.
Pante, Jeff Henry J. BSN 2
● Transient tachypnea of the newborn
occurs more often in infants who are
born by CESAREAN birth, in infants
whose mothers received extensive
fluid administration during labor and
in preterm infants
● Infants born BY CESAREAN BIRTH
are probably more prone to develop
this form of respiratory distress
because the thoracic cavity is not
compressed as it is in vaginal birth,
and so less lung fluid is expelled.
SUDDEN INFANT DEATH
SYNDROME(SIDS)
● is a sudden unexplained death in
infancy.
Incidence
1. adolescents mothers
2. infants of closely spaced pregnancies 3.
underweight
causes of sudden infant death syndrome 1.
sleeping prone rather than supine
2. viral respiratory problem
3. exposure to secondary smoke
4. pulmonary edema
5. brainstem abnormalities
RETINOPATHY OF PREMATURITY
● An acquired ocular disease that
leads to partial or total blindness in
children is caused by
vasoconstriction of immature retinal
blood vessels.
● Immature retinal blood vessels
constrict when exposed to high
oxygen concentrations; endothelial
cells in the periphery of the retina
when proliferate, causing retinal
detachment and possible blindness
The Newborn at Risk because of a
Maternal Infection
HEMOLYTIC GROUP B STREPTOCOCCAL
INFECTION
● A serious cause of infection in
newborns is the gram positive B
hemolytic, group B streptococcal
organism, a natural inhabitant of the
female genital tract.
● AMPICILLIN ADMINISTERED IV
DURING PREGNANCY AND AGAIN
DURING LABOR HELPS TO REDUCE
THE POSSIBILITY OF NEWBORN
EXPOSURE
ASSESSMENT OPHTHALMIA NEONATORUM ● Hepatitis B is a destructive illness
● early onset signs and symptoms; ● Is an eye infection that occurs at with greater than 90% of infected
○ tachypnea birth or during the first month of life. infants becoming chronic carriers of
○ apnea the virus as well as the risk of
○ extreme paleness Causative agent: developing liver cancer later in life
○ Hypotension NEISSERIA GONORRHOEAE and CHLAMYDIA ● To reduce the possibility of hepatitis
○ decreased urine output TRACHOMATIS which are contracted from b being spread to the newborns in
Late onset type occurs at 2 to 4 weeks of vaginal secretions. the future, parents are asked if they
age, with this aside from pneumonia being would like their infants vaccinated
the infection focus, MENINGITIS TENDS TO extremely serious form of infection because against hepa b at birth
OCCUR if left untreated the infection progresses to
SIGNS AND SYMPTOMS CORNEAL ULCERATION and DESTRUCTION, GENERALIZED HERPESVIRUS INFECTION
1. Lethargy resulting in opacity of the cornea and severe ● most prevalent among women
2. Fever vision impairment. with multiple sexual partners can
3. loss of appetite be contracted by a fetus across the
4. bulging of fontanelles increased ASSESSMENT placenta if the mother has a primary
intracranial pressure infection during pregnancy.
● Fiery red conjunctiva
● Thick pus ● The virus is contracted from the
● Neurologic consequences can occur ● edematous eyelids vaginal secretions of a mother who
in up to 50% infants who survive. has active herpetic vulvovaginitis at
Prevention: the time of birth.
Therapeutic management ● Instillation of ERYTHROMYCIN
1. penicillin OPHTHALMIC OINTMENT ASSESSMENT
2. Cefazolin ● infant with vesicles covering the skin
3. clindamycin ● loss of appetite
HEPATITIS B VIRUS INFECTION
4. Vancomycin ● low grade fever
● can be transmitted to the newborn
through contact with infected vaginal ● Lethargy
blood at birth when the mother is ● stomatitis( ulcers of the mouth)
positive with the virus

Pante, Jeff Henry J. BSN 2

If the case progress and extremely ill ● the baby also has the greater chance FETAL ALCOHOL SPECTRUM
● Dyspnea of having a congenital anomaly such DISORDER.
● jaundice as cardiac anomaly because of ● The most serious long term effect is
● Purpura hypoglycemics teratogenic to a cognitive challenge. Behavior
● Convulsions rapidly growing fetus. problems such as hyperactivity may
● Hypotension ● Most such babies have a occur in SCHOOL AGE CHILDREN:
CUSHINGOID ( fat and fluffy )
THERAPEUTIC MANAGEMENT APPEARANCE 1. Apnea of Prematurity (AOP)
ACYCLOVIR (ZOVIRAX) antiviral drug that ● They tend to be lethargic or limp 2. Meconium Aspiration Syndrome
inhibits viral DNA SYNTHESIS is effective in in the first days of life as a result 3. Neonatal Sepsis
combating the infection. of hyperglycemia. 4. Hyperbilirubinemia
● women with active herpetic vulvar 5. Acute Bilirubin Encephalopathy
lesions are advised to have AN INFANT OF A DRUG DEPENDANT 6. Transient Tachypnea of Newborn
cesarean birth rather than vaginal MOTHER 7. Sudden Infant Death Syndrome
birth to minimize the newborns
● AN INFANT OF A DRUG DEPENDANT (SIDS)
exposure
MOTHER 8. Retinopathy of Prematurity
● infants with an infection should be
separated from other infants in a 9. Hemolytic Group B Streptococcal
Signs and symptoms
nursery. 10. Ophthalmia Neonatorum
irritability, disturbed sleep pattern, constant
11. Hepatitis B Virus Infection
movement, tremors, frequent sneezing, high
THE NEWBORN AT RISK BECAUSE OF A pitched cry, convulsions, tachypnea,vomiting
12. Generalized HerpesVirus
MATERNAL ILLNESSES and diarrhea, dehydration. Infection
● AN INFANT OF A WOMAN WHO HAS 13. Newborn at risk because of a
DIABETES MELLITUS AN INFANT WITH FETAL ALCOHOL maternal illness
● nfants of women who have diabetes EXPOSURE 14. Infant of a drug dependant
mellitus whose illness was poorly mother
● Alcohol crosses the placenta in the
controlled during pregnancy are 15. Infant with fetal alcohol exposure
same concentration as is present in
typically longer and weigh more than
the maternal bloodstream so may
other babies (MACROSOMIÃ)
result in fetal alcohol exposure or

Pante, Jeff Henry J. BSN 2