CARE OF A NEWBORN WHO IS newborns at birth as well as stabilizing

them until the pediatric

PHYSICALLY OR team arrives to assume care or
DEVELOPMENTALLY transport of the newborn to a highrisk
CHALLENGED nursery.
 Consideration of the family’s resources,
ASSESSMENT both emotional andfinancial, is an
important aspect of planning care and
The following eight primary needs of newborns establishing expected outcomes (Nes,
should be assessed: Røysamb, Hauge, et al., 2014).
1. Adequate respiration  It’s important to consider both the
short- and long-term needs of the
2. Extrauterine circulation newborn and how these needs may
3. Body temperature stabilization affect the family.
 Supportive family members can be a
4. Blood sugar stabilization critical asset to parental adjustment
(Carmichael, Ma, Tinker, et al., 2014).
5. Prevention of infection
 Providing nursing support as part of an
6. An infant–parent bond interdisciplinary team, including social
workers, therapists, nutritionists,
7. Adequate stimulation medical specialists, and other
8. Ability to take in adequate nutrients community resources can also help with
parental adjustment.
9. Ability to achieve waste elimination

IMPLEMENTATION
NURSING DIAGNOSIS
• Nursing interventions for a newborn who is
Examples of possible diagnoses include: physically challenged include immediate life-
sustaining measures such as providing oxygen
1. Imbalanced nutrition, less than body
requirements, related to inability to take in or adequate intake of nutrients when a disorder
adequate nutrition secondary to a physical prevents the infant from establishing
challenge respirations or sucking.
• Encouraging skin-to-skin contact and
2. Impaired physical mobility related to
interacting with the newborn promotes infant–
congenital anomaly
parent bonding.
3. Risk for impaired parenting related to the
birth of child with a congenital anomaly • Educating the parents about procedures the
infant may undergo lessens the parental anxiety
4. Anticipatory grieving (parental) related to and enhances self-esteem.
loss of the idea of the “perfect” child
• Parents experience the same stages of grief as
those whose child has died at birth. :
OUTCOME IDENTIFICATION AND PLANNING 1) Denial
2) Anger
 Nurses play an important role in 3) Bargaining
providing immediate care to highrisk 4) Depression, and
5) Adjustment
• It is important for the nurse to provide • Normally closes at 9 – 12 wks. Of intrauterine
positive role modeling when caring for the life.
emotional and physical needs of the newborn;
• Causes:
 It helps the parents to adjust to parenting a
child born with a physical or developmental 1. Heredity
challenge. 2. Teratogenic factors
 Viral infections e.g. rubella
OUTCOME EVALUATION  Exposure to radiation
 Smoking during pregnancy
Outcome evaluation should focus on:
• Incidence:
 establishing expected outcomes for the
child’s physical and developmental health • Cleft lip
needs  More common in boys
 family’s coping ability for current and future
health of the child. • Cleft palate
• This includes addressing the family concerns  More common in girls
and providing resources to support the family
during and after discharge.
Nursing Diagnoses & interventions:
1. Risk for imbalanced nutrition less than body
CLEFT LIP and PALATE requirements r/t feeding problem caused by
cleft or palate.
Cleft Lip
• Preoperative Period:
• The maxillary and median nasal processes fails
1) Assess ability to suck & swallow.
to fuse.
2) Monitor weight daily.
• Normally fuse between 5 – 8 wks. of 3) Modify feeding techniques
intrauterine life (embryonic stage). -Support the baby in an upright position
-Direct the formula to the side and back
• May be unilateral or bilateral. of the mouth to prevent aspiration
-Feed the infant gently using a
commercial cleft lip nipple.

Cleft Palate
• Palatal structures fail to close.
• There is an opening at the palate, usually at
the midline.
• May involve the anterior hard palate ,
posterior soft palate, or both.

Nursing Diagnoses & interventions
1. Risk for imbalanced nutrition less than body
requirements r/t feeding problem caused by
cleft or palate.
• Preoperative Period:
➢Closure of cleft lip
• Performed usually between 6 wks. – 9
months.
➢Cleft palate repair
• Performed between 12 – 18 mos. of age
to allow for the palatal changes that take
place with normal growth.
• A prosthetic device may be used to
close the palate.
• Postoperative Period:
1) Keep infant NPO for 4 hrs.
2) Avoid tension on a lip suture line.
3) After palate surgery, liquids are generally
continued for 3 – 4 days followed by soft
diet until healing is complete
4) After a cleft palate repair, should not use
spoon because they will invariably push it
against the roof of the mouth and possibly
disrupt sutures.
5) Do not include milk in the first fluids
offered
• Milk curds tend to adhere to the suture
line.
6) After feeding, offer the child clear water
to rinse the suture line.
2. Modify feeding techniques (cont’d…)
• Feed small amounts gradually and burp
frequently.
• Keep suction equipment and bulb syringe
at bedside.
• Teach parents the ESSR method of
feeding:
❖Enlarge the nipple
❖Stimulate the suck reflex
❖Swallow
❖Rest to allow the child to finish
swallowing what has been placed in the
mouth
3. Risk for ineffective airway clearance r/t oral
surgery.
1) Observe for respiratory distress due to:
• local edema at the operative site.
• Before surgery, the infant breathe
through their mouth, after surgery, the
infant now has to learn to breathe
through their nose.
2) Suction secretions.
• Be gentle
• Do not touch suture line
3) After cleft lip surgery (cheiloplasty),
place infant on their side to drain
secretion.
4. Impaired tissue integrity at incision line r/t
cleft lip or cleft palate surgery.
1) After cleft lip surgery, the suture line is
held close by a Logan Bar, or an adhesive
bandage.
• Assess after each feeding to be
certain that it is secure.
2) If possible, prevent the infant from
crying.
• Provide pain relief.
• Anticipate the infant’s needs.
 • Help parents use whatever measures
such as rocking, carrying, or holding to
make infant feel secure and
comfortable.
3) Observe infant after palate repair not to
place toys with sharp edges into their
mouth.
4) Do not use straw to drink, nor brush their
own teeth.
5) Soft elbow or jacket restraints may be
used when no one is with them, to keep the
child from touching the repair site.
6) Instruct parents to monitor for signs of
infection at the surgical site:
• Redness
• Swelling
• Drainage
5. Risk for infection r/t surgical incision.
1) Clean the suture line with sterile
water, sterile saline or 50% hydrogen
peroxide used with sterile cotton-
tipped applicators every after feeding.
• Use a smooth, gentle rolling
motion to apply the solution.
• Dry the suture line with a
sterile cotton-tipped applicator.
6. Risk for impaired parenting r/t to the birth of
an infant who is physically challenged.
1) Promote bonding.
2) Caution them the incision line will
appear swollen in the immediate
postop period.
3) Caution the parents that time will be
needed for the infant to learn how to
suck.
Tracheoesophageal Atresia &
Fistula
• The esophagus terminates before it reaches
the stomach and/or a fistula is present that
forms an unnatural connection with the
trachea.
•The condition causes the oral intake to enter
the lungs or a large amount of air to enter the
stomach.
• Choking, coughing and severe abdominal
distention can occur.
•Aspiration pneumonia and severe respiratory
distress will develop, and death will occur
without surgical intervention.
Assessment
1. Frothy saliva in the mouth and nose,
and drooling.
2. Coughing and choking during feeding
3. Unexplained cyanosis
4. Regurgitation and vomiting
5. Abdominal distention
6. Inability to pass a small gauge (no. 5
French) orogastric feeding tube
Treatment includes:
1. Maintenance of a patent airway.
2. Prevention of pneumonia
3. Gastric or blind pouch
decompression
4. Supportive therapy
5. Surgical repair
Implementation
(Preoperative)
1. Intubation and mechanical
ventilation may be necessary if
respiratory distress occurs.
2. Maintain NPO status.
3. Monitor and regulate IV fluids as
prescribed.
4. Suction secretions.
5. A double-lumen catheter is placed
into the upper esophageal pouch and
attached to intermittent or continuous
low suction to keep the pouch empty.
6. Maintain in an upright position to
 facilitate drainage and to prevent
aspiration of gastric secretions.
7. A gastrostomy tube may be placed
and is left open so that air entering the
stomach through the fistula can escape,
minimizing the danger of regurgitation.
8. Adm. Broad spectrum antibiotics as
prescribed because of the high risk for
aspiration pneumonia.
Implementation
(Postoperative)
1. Monitor respiratory status
2. Maintain IVFs, antibiotics, and
parenteral nutrition as prescribed.
3. Monitor I & O and weigh daily.
4. Inspect surgical site.
5. Assess for signs of pain.
6. Assess for dehydration and possible
fluid overload.
7. Provide care to the chest tube if in
place.
8. Monitor for anastomotic leaks as
evidenced by purulent chest drainage,
increased temp.,and increased WBC
count.
9. If a gastrostomy tube is present, it is
attached to gravity drainage until the
infant can tolerate feedings (usually 5 –
7th day postop).
10. Before oral feedings and removal of
the chest tube, a barium swallow is
performed to verify the integrity of the
esophageal anastomosis.
11. Feedings through the gastrostomy
tube may be prescribed until the
anastomosis is healed.
12. Oral feedings are begun with sterile
water, followed by small frequent
feedings of formula.
13. Instruct parents to identify
behaviors that indicate the need for
suctioning, signs of respiratory distress,
and signs of constricted esophagus:
• Poor feeding, dysphagia, drooling, or
regurgitated undigested food.
HYPERTROPHIC PYLORIC
STENOSIS
• Hypertrophy of the circular muscles of
the pylorus causing narrowing of the
pyloric canal between the stomach and
the duodenum.
• Usually develops in the first few weeks
of life, causing projectile vomiting,
dehydration, metabolic alkalosis, and
failure to thrive.
Symptoms:
•Vomiting is the first symptom in most children:
➢Vomiting may occur after every
feeding or only after some feedings
➢Vomiting usually starts around 3
weeks of age, but may start any time
between 1 week and 5 months of age
➢Vomiting is forceful (projectile
vomiting)
➢The infant is hungry after vomiting
and wants to feed again
• Other symptoms generally appear several
weeks after birth and may include:
 Abdominal pain
 Belching
 Constant hunger
 Dehydration (gets worse with the
severity of the vomiting)
 Failure to gain weight or weight loss
 Wave-like motion of the abdomen
shortly after feeding and just before
vomiting occurs
 (Preoperative Care)
Signs and tests: 1. Monitor hydration status by daily
• The condition is usually diagnosed before the weights, I & O, and urine for specific
baby is 6 months old. gravity.
• A physical exam may reveal signs of 2. Correct fluid and electrolyte
dehydration. imbalances.
• The infant may have a swollen abdomen. • Adm. IVF as prescribed.
• The doctor may detect the abnormal pylorus, 3. Maintain NPO status
which feels like an olive-shaped mass, when 4. Monitor the number and character of
touching the stomach area. stools.
•An ultrasound of the abdomen may be the first 5. Maintain patency of NGT for stomach
imaging test performed. decompression.
•Other tests that may be done include:
➢Barium x-ray -- reveals a swollen stomach (Postop Care)
and narrowed pylorus 1. Feed the infant slowly, burping
➢Blood chemistry panel -- often reveals an frequently.
electrolyte imbalance 2. Monitor for abdominal distention.
3. Monitor the surgical wound and for
Treatment: signs of infection.
• Treatment for pyloric stenosis involves 4. Instruct the parents about wound
surgery to split the overdeveloped muscles. care and feeding.
➢Pyloromyotomy - pyloroplasty

• Pyloroplasty is a surgical procedure to widen

the opening in the lower part of the stomach
(pylorus) so that the stomach contents can
empty into the small intestine (duodenum).
•Balloon dilation does not work as well as
surgery, but may be considered for infants
when the risk of general anesthesia is high.
•The patient will be given fluids through a vein,
usually before surgery.