Post on 16-Nov-2014
HIGH RISK NEWBORN & FAMILY
ASSESSMENT NURSING
HISTORY PHYSICAL ASSESSMENT DIAGNOSTIC
ASSESSMENTObvious
congenital anomalies Gestational age
IMMEDIATE NEEDS OF THE NEWBORN
AIRWAY 2. BREATHING 3. CIRCULATION 4. WARMTH1.
Immediate Assessment of the Newborn
The newborn infant should undergo a complete P.E within 24 hours of birth. NOTE
:
It
is easier to listen to the heart and lungs first when the infant is quiet the stethoscope before using to decrease the likehood of making the infant cry
Warmth
Newborn Priorities in first day of life1. 2. 3. 4. 5. 6. 7. 8.
Initiation and maintenance of respiration Establishment of extrauterine circulation Control of body temperature Intake of adequate nourishment Establishment of waste elimination Prevention of infection Establishment of an infant-parent relationship Developmental care or care that balances physiologic needs and stimulation for best development
DIAGNOSIS Ineffective
airway clearance Ineffective cardiovascular tissue perfusion Ineffective thermoregulation Risk for imbalance of nutrition Risk for parenting Deficit diversional activity (lack of stimulation)
Planning/Implementation
ALTERED GESTATIONAL AGE OR BIRTHWEIGHT Infant
is evaluated as soon as possible after birth to determine : Weight Gestational
age
Birthweight Colorado
is plotted on a Growth Chart
intrauterine Growth Chart ( LUBCHENCO CHART)
Pre
term born before the 38th week term born at 38 to 42 weeks term born after 42 weeks
Full
Post
BIRTHWEIGHT
Appropriate Gestational Age (AGA) BW within 10-90th percentile Small Gestational Age (SGA) BW is < 10th percentile Large Gestational Age (LGA) BW > 90th percentile
LBW BW < 2,500 grams VLBW BW 1000-1,500 grams Extremely-VLBW 500-1000g
GESTATIONAL AGE It
is determine in the first 4 hours after birth so that age related problems can be identified and appropriate care can be initiated. Second assessment is done within 24 hours. New ballard Score is the most commonly used tool
It has 2 elementExternal physical characteristics Neuromuscular maturity
GESTATIONAL ASSESSMENT (DUBOWITZ)FINDING 0 36TRANSVERSE CREASE ONLY
37 38OCCASIONAL CREASES IN ANTERIOR 2/3
39 & OVER SOLE COVERED W/ CREASES 7 COARSE & SILKYSTIFFENED BY THICK CARTILAGE
SOLE CREASES ANTERIOR
BREAST NODULE 2 DIAMETER (MM)
4 FINE & FUZZY SOME CARTILAGE
SCALP HAIR EAR LOBE TESTES & SCROTUM
FINE & FUZZY PLIABLE, NO CARTILAGETESTES IN LOWER CANAL, SCROTUM SMALL, RUGAE
SOME CARTILAGETESTES PENDULOUS, INTERMEDIATE
SCROTUM FALL, EXTENSIVE RUGAE
posture
Square window
Popliteal angle
Scarf sign
Heel to ear
creases
Breast
Causes of Small for-Gestational-Age Infant ( SGA)
SGA infant experienced intrauterine growth restriction (IUGR) Most common cause of IUGR is PLACENTAL ANOMALY Mothers nutrition during pregnancy play a major rule in fetal growth. severe DM mother PIH Mother who smokes heavily Use of narcotics Baby with Rubella & chromosomal abnormality
SGA PRENATAL Fundic
ASSESSMENT:
height ultrasound Biophysical profile NST Placental
grading Amniotic fluid amount
What do they look like??? SGA
appearancesuffer nutritional deprivationEARLY in pregnancy
Infant
Increase in number of body cells Below average Weight, length & head circumference
Late
in Pregnancy
Increase in cell size Below average weight
Most SGA APPEAR LIKE?? Wasted
appearance Small liver Poor skin turgor Large head Skull suture widely separated lack of normal bone growth Dull hair Sunken abdomen Cord dry & stained yellow
Common problem of SGA Birth
asphyxia common problemchest muscles
Underdeveloped Risk
of meconium aspiration syndrome due to anoxia during labor.
Lack
of subcutaneous fatable to control body temperature
Less
DIAGNOSTICS CBC High
hematocrit Increase RBC ( polycythemia) Blood
glucoseHMD( hyaline membrane disease)
Common:1. preterm infant 2.infant of diabetic mother 3.meconium aspiration
Pathologic feature:
hyaline-like membrane formed fr an exudate of infant blood line the terminal bronchioles, alveolar.duct,and alveoli this membrane prevent exchange of O2 and CO2 at alveolar-capillary membrane
RDS Causes:Low
level or absence of surfactant
Surfactant
phospholipid lines the alveoli that reduces surface tension on expiration keep the alveoli from collapsing on expiration Form @ 34 wks AOG
Assessment S/Sx:
initial 1.low body temperature 2.nasal flaring 3.sternal and subcostal retraction 4.tachypnea 5. cyanotic mucus membrane
Assessment S/Sx:
late 1. seesaw respiration 2. heart failure 3. pale gray skin 4. period of apnea 5. bradycardia 6. pneumothorax
Diagnosis:Clinical sign : grunting, cyanosis in room air, nasal flaring, retraction and shock Chest X-ray: reveal diffuse pattern of radio opaque areas
MANAGEMENT1. surfactant replacement 2. oxygen administration 3.Ventilation 4. Additional therapy: - Indomethacin or Ibuprofen to close PDA - muscle relaxant increase pulmonary blood flow
PILLITTERI pp 778 Vol 1
Prevention:
Steroid quicken the formation of lecithins given 12 and 24 hours prior to delivery most effective when given between weeks 24- 34 of pregnancy
Transient Tachypnea of the Newborn
Transient Tachypnea of the Newborn RR
@ birth up to 80/min when crying Normal RR 30-60/ min S/sx: Rapid
RR 80-120/min Mild retraction No marked cyanosis Mild hypoxia & hypercapnia
Causes: Transient tachypnea of the newbornresult from slow absorption of lungs fluid reflect slight decrease in production of mature surfactant limit the amount of alveolar surface area available to an infant for oxygenation exchange infant tend to increase RR and depth
TTN- Peak in intensity at approx. 36hrs in life @ 72hrs of life spontaneously fade as lung fluid is absorbed common: 1.infant born via CS 2.infants whose mother received extensive fluid administration during labor 3. preterm infants
TTN Management:
1. Close observation 2.O2 administration
MECONIUM ASPIRATION SYNDROME
MECONIUM ASPIRATION SYNDROME- Meconium present in fetal bowel as early as 10 wks gestation
Meconium aspiration- Infant
may aspirate meconium either in utero or in first breath after birth.
Cause severe respiratory distress in 3 ways: 1.causes inflammation of bronchioles because a foreign substance 2.block small bronchioles by mechanical its
plugging
3. cause a decrease in surfactant production through lung cell trauma
Meconium aspirationsign and symptoms: 1. tachypnea 2. Retraction 3. Cyanosis 4. Barrel chest due to air trapping DIAGNOSTICS: CXR: bilateral coarse infiltrates ( honey comb effect) ABG: dec. 02 & inc. Pc02
Meconium aspiration SyndromeManagement: 1.suctioning with bulb syringe or catheter while at the perineum 2.severe aspiration infant might intubate 3. dont administer O2 under pressure 4. antibiotic therapy 5. chest physiotherapy and chest clapping
APNEA
Apnea : >pause
in respiration longer than 20 secs. With accompanying bradycardia commonly seen in: 1.preterm infant 2.infection 3.hyperbilirubinemia 4.hypoglycemia
APNEAMANAGEMENT: 1. gently shaking an infant or flicking the sole of the feet 2. Closely observe all NB esp. Preterm 3. always suction the secretion gently to minimize nasopharyngeal irritation 4. Use gently handling to avoid excessive fatigue 5. never take rectal temperature in infant prone to apnea cause vagal stimulation w/c result to Apnea
APNEA Drug
use to stimulate respirationsodium benzoate
Theophylline Caffeine
They
help increase infant sensitivity to carbon dioxide ensuring better respiratory function.
Sudden Infant Death SyndromeSID is a sudden unexplained death in infancy Cause is unknown who are at risk: 1. infant of adolescent mother 2.infant of closely spaced pregnancies 3.underweight infant 4. preterm infant
SIDSContributory factors: 1. viral respiratory infection 2.botulism infection3. brain stem abnormalities 4.neurotransmitter deficiency 5. heart rate abnormality 6.decrease arousal responses 7. possible lack of surfactant in alveoli 8. sleeping prone
Nsg Care Support
parents view second child as an individual child not as a replacement for the one who died New baby born to a family in which a SIDS infant died is screened sleep study as precaution within the first 2 wks of life. New baby placed on continuous apnea monitoring
Hemolytic disease of the newborn ABO
incompatibility: set up is mothers type is O babys type is A, B, AB Sign and symptom- primarily jaundice Mgt: 1.phototherapy 2.if with severe jaundice can do exchange transfusion 3.initiation of early feeding
RH incompatibility:
mother is RH(-)( has D antigen) baby is RH (+) Sign and symptoms: kernicterus hydrops fetalis (edema) ( lethal state)
Therapeutic Initiation
management
of early feeding Phototherapy Continuously
exposed to specialized light cool white day light or blue fluorescent light Light placed 12-30 inches above the NB bassinet or incubator at 25-28 hours of age Bilirubin level : term 15 mg/dl
Preterm 10-12 mg/dl Exchange
transfusion-
Nursing Stool
care phototherapy
of infant bright green & loose Urine darked colored Assess skin turgor Assess I & O to ensure hydration Monitor temp When infant is feeding removed from phototherapy for interaction
Hemorrhagic disease of newborn
Hemorrhagic disease of newborndue to deficiency of vitamin K bleeding occurs on 2nd to 5th day of life complication: subdural hemorrhage - fatal Sign and symptoms: 1. petechiae 2.vomit fresh blood or pass black tarry stool
Hemorrhagic disease of newbornManagement:1. 2.
IM /IV administration of vitamin K if with severe bleeding transfusion of fresh whole blood can be done
NEWBORN AT RISK DUE TO MATERNAL INFECTION/ILLNESS1. 2. 3. 4. 5. 6. 7.
Beta-hemolytic, Group B Streptococcal Infection Hepatitis B Virus Infection Herpes Virus Infection HIV Mother Infant Of Diabetic Mother Infant Of Drug Dependent Mother Infant With Fetal Alcohol Syndrome
Beta-hemolytic, Group B Streptococcal Infection GBS
major cause of infection of NB Natural habitant female genital tract MOT : spread from baby to baby by contact Risk : prolonged rupture of membrane
Beta-hemolytic, Group B Streptococcal Infection S/sx Early
onsetday of life PneumoniaTachypnea Apnea Shock dec urine output, extreme paleness or hypotonia Can die within 24 hours of life
First
Beta-hemolytic, Group B Streptococcal Infection S/sx late
onset Occurs at 2-4 weeks of age- meningitisLethargy, fever , loss of appetite Bulging fontanelles increased ICP Mortality 15%
Beta-hemolytic, Group B Streptococcal Infection Diagnostics
mothers vaginal culture Blood culture of NB
Therapeutic Ampicillin
management
IV @ 28 wks AOG & during labor ( reduce NB exposure) Bld test positive : gentamicin, ampicillin & penicillin
Hepatitis B Virus Infection Transmitted
to the NB through contact with infected vaginal blood at birth mother is HBsAg+ Destructive illness 70-90% of infected infant can become chronic carrier Complication : liver cancer later in life
Hepatitis B Virus Infection Vaccinate Hepatitis
the NB
B vaccine + immune serum globulin (HBIG)within 12H decrease possibility of infection.
Bathed
infant as soon as possible after birth removed blood Gentle suctioning- avoid trauma Breastfed infant if HBIG is given
Herpes Virus Infection HSV-2 Common
Multiple sexual partner
MOT: Contracted
through the placenta if mother has primary infection during pregnancy . Vaginal secretion of mother.
Herpes Virus Infection S/sx: Herpes
vesicles clustered with reddened base covering the skin Severe neurologic damage If acquired at birth: ( D4 & D7 of life) Loss
of appetite Low grade fever & lethargy Dyspnea , jaundice, purpura , convulsion & shock Death occur within hours or days
Herpes Virus Infection Diagnosis: Culture
from vesicles Blood serum analyzed for IgM antibodies Therapeutic Acyclovir
Mgt:
( zovirax) Advised CS- minimize newborn exposure Isolate infant
Infant Of Diabetic Mother Macrosomia-
LGA Chance to have Congenital anomaly cardiac Limp / lethargic first day of life hypoglycemia Greater chance of birth injury hyperbilirubinemiaPp 791 pillitteri
Infant Of Diabetic Mother Diagnostics Serum
glucose