High Risk Newborn
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Transcript of High Risk Newborn
HIGH RISK NEWBORN AND FAMILYPresented by:
Princess P. BarnuevoStudent, Master of Arts in Nursing
OVERVIEW
Key facts about neonatal mortality
Every year nearly 41% of all under-five child deaths are among newborn infants, i.e. the neonatal period.
75%of all newborn deaths occur in the first week of life.
In developing countries nearly half of all mothers and newborns do not receive skilled care during and immediately after birth.
Where are child deaths occurring?
Only 2 WHO regions account for more than 70% of all under-five deaths:
42% in the African region 29% in South-east Asia region
Only 6 countries account for 50% of all child deaths (2002 data):
India (Sear)Nigeria (Afr)China (Wpr)Pakistan (Emr)Ethiopia (Afr)DR Congo (Afr)
Source: Special analysis detailed in The Lancet Every Newborn Series - forthcomingThe lives of more than 3 million babies and women could be saved each year with high coverage of quality care around birth and care for small and sick babies
Care around birth gives a triple return on investments by reducing maternal and newborn deaths and stillbirths
Major Causes of Under 5 Child Mortality
Bryce et al. WHO estimates of the causes of death in children. Lancet 2005
Neonatal mortality :-
Birth process was the antecedent cause of 2/3 of deaths due to infections
Birth asphyxia in developing countries
Hypothermia and newborn deaths
Ophthalmia neonatorum is a common cause of blindness
6 Cleans for baby.
Neonatal mortality: Low birth weight
Place of childbirth◦ At least 2 out 3 childbirths in developing
countries occur at home◦ Only half are attended by skilled birth
attendants
Locally The Philippines is one of the 42 nations
that account for 90% under-five mortality rate
An estimated 82, 00 Filipino children die annually before their fifth birthday
37% of these children are newborns less than 28 days old
MDG 4: Reduce Child Mortality
Target : Reduce by two thirds, between 1990 and 2015, the child mortality rate:
- Reduce Under 5-mortality rate from 80.0 to 26.7 (per 1,000 LB)
- Reduce Infant mortality rate
from 57.0 to 19.0 (per 1,000 LB)
Solutions exist ….
Skilled care: skilled care during pregnancy, childbirth and in the post-natal period
Infant feeding: exclusive breastfeeding, complementary feeding and micronutrients
Vital vaccines: measles and tetanus immunization and other conventional and new vaccines
Combating diarrhoea: low osmolarity ORS and zinc in case management of diarrhoea, antibiotics for dysentery
Treating pneumonia and newborn sepsis: prompt treatment with appropriate antibiotics
Where appropriate: Combating malaria Preventing and caring for HIV (mother and child)
Newborn Priorities in First Days of Life
High Risk Newborn Nursing Care
The
1st 24 hours of Life
The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from
intrauterine to extrauterine life
Immediate Care of the Newborn• Airway and
Breathing
• Circulation
• Temperature
• Fluid and
Electrolyte Balance
Newborns undergo profound physiologic
changes at the moment of birth.
Within minutes after birth, a newborn has to initiate
respirations, and adapt a circulatory system to
extrauterine oxygenation. Within 24 hours, neurologic,
renal, endocrine, and gastrointestinal functions
must be operating competently for life to be
sustained.
Initiating and Maintaining Respirations
Breathing is initiated by the second stage of labor.
Most neonatal deaths within the first 24-48 hours are primarily caused by inability to initiate breathing.
Lung functions only begins after birth.
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Airway & Breathing Suction gently & quickly
using bulb syringe or suction catheter
Starts in the mouth then, the nose to prevent aspiration
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Airway & Breathing Stimulate crying by rubbing Position properly- side lying /
modified t-berg Provide oxygen when necessary
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Circulation It is initiated by lung expansion or
pulmonary ventilation and is completed by the cutting of the umbilical cord.
Gas exchange function is transferred from placenta to the lungs.
Increased metabolism to maintain body temperature and hence increased cardiac output.
Three shunts in the fetal circulation
1. Ductus arteriosus -from pulmonary artery to aorta -protects lungs against circulatory overload -allows the right ventricle to strengthen 2. Ductus venosus -fetal blood vessel connecting the umbilical vein to the IVC3. Foramen ovale - shunts highly oxygenated blood from right atrium to left atrium
Flow Chart of Fetal Circulation
At birth With the first breaths of life, the lungs begin to
expand. As the lungs expand, the alveoli in the lungs are cleared of fluid.
An increase in the baby's blood pressure and a significant reduction in the pulmonary pressures promotes the closure of ductus arteriosus.
These changes increase the pressure in the left atrium of the heart, which decrease the pressure in the right atrium. The shift in pressure stimulates the foramen ovale to close.
The closure of the ductus arteriosus and foramen ovale completes the transition of fetal circulation to newborn circulation.
Table 1.1 Structures at Birth and the Remnants After its Obliteration
STRUCTURE
APPROPRIATE TIME OF CLOSURE
STRUCTURE
REMAINING
FAILURE TO CLOSE
Foramen Ovale
1 year Fossa Ovales Atrial Septal Defect (ASD)
Ductus Arteriosus
1 month Ligamentum Arteriosum
Patent Ductus Arteriosus
Ductus Venosus
2 months Ligamentum Venosum
Umblical Arteries
2-3 months Lateral Umbilical
Artery (Inferior Iliac Artery)
Umbilical Vein 2-3 months Ligamentum Teres (Round Ligament of
Liver)
Fluid and Electrolyte Balance Principles of Fluid Balance: TBW = ICF + ECF
ECF = Intravascular + Interstitial
http://akramania.byethost11.com/OHCM/16%20%20Clinical%20Chemistry.htm
TOTAL BODY WATER COMPOSITION:
Adult TBW = 60% (40% ICF + 20% ECF) Full-term TBW = 75% (35% ICF + 40% ECF) Pre-term TBW = 90% (30% ICF + 60% ECF)
http://www.revivenaturally.com/dr-yoshitaka-ohno-md-phd/maintaining-intracellular-hydration-water.html
Why is FE management important? Many babies in NICU need IV fluids
If wrong fluids are given, NB kidneys are not well equipped to handle them
Serious morbidity can result from fluid and electrolyte imbalance
SENSIBLE VS. INSENSIBLE WATER LOSS
Sensible water loss (SWL): Easily measured
Insensible water loss (IWL): Not readily measured Evaporation from skin (66%) or respiratory tract (33%) IWL greater in lower GA Factors that increase: Immature skin, fever, radiant
warmers, phototherapy, skin defects/breakdown Factors that decrease: Mature skin, humidity, heat shields
FLUID RESTRICTIONS
Bronchopulmonary Dysplasia Respiratory Distress Syndrome
Patent Ductus Arteriosus Hypoxic-Ischemic
Encephalopathy
VOLUME OVERLOAD
and/or EDEMA
RESTR
ICTE
D
Management of F&E Goal: Allow initial loss of ECF over first
week (as reflected by weight loss), while maintaining normal intravascular volume and tonicity (as reflected by HR, UO, electrolytes, pH). Subsequently, maintain water and electrolyte balance, including requirements for body growth.
Individualize approach (no “cook book” is good enough!)
Common Electrolyte Problems
Sodium: Hypo (<130 mEq/L; worry if <125) Hyper (>150 mEq/L; worry if >150)
Potassium: Hypo (<3.5 mEq/L; worry if <3.0) Hyper > 6 mEq/L (non-hemolyzed)
(worry if >6.5 or if ECG changes )Calcium:
Hypo (total<7 mg/dL; ion<4) Hyper (total>11; ion>5)
Sodium Abnormalities:
Hyponatremia: Na < 130 mEq/L Causes: Usually due to excess free water but can
be increased Na losses/inadequate Na intake Signs/sx: lethargy, seizures, coma Tx: Restrict fluids and/or Na supplements
Hypernatremia: Na > 150 mEq/L Causes: Usually due to high water losses, rarely
excess intake Signs/sx: lethargy, seizures, coma Tx: Increase fluids and/or restrict Na
Potassium Abnormalities:
Hypokalemia: K < 3.5 mEq/L Causes: Diuretics, NG losses Signs/sx: EKG changes (flat T waves, prolonged QT,
U waves), arrhythmias, ileus, lethargy Tx: Slowly correct IV or orally
Hyperkalemia: K > 6 mEq/L Causes: Iatrogenic, severe acidosis, ARF, RBC
breakdown s/p transfusion, CAH Signs/sx: EKG changes (peaked T waves, wide QRS,
brady/tachycardia, SVT, V Tach, V fib), arrhythmias, death
Tx: D/C all K, Ca gluconate, sodium bicarbonate, albuterol, insulin + glucose, lasix, kayexalate, dialysis/exchange
* Most K is intracellular, thus serum levels might not accurately depict total body stores
** pH affects K levels: Acidosis drives K out of cell vs. Alkalosis pushes K into cell
Calcium Abnormalities:
Hypocalcemia: Ca < 7 mg/dL (iCa < 1) Causes: Prematurity, IUGR, IDM, HIE,
hypoparathyroidism, Vitamin D deficiency Signs/sx: Asymptomatic, jitteriness, irritability,
seizures Tx: Observation, repletion (Ca gluconate), or
supplementation
Hypercalcemia: Ca > 11mg/dL (iCa > 5) Rare in neonates Usually associated with preterm fortifiers (HMF)
* Important to follow Ca levels as well as Phos and Alk Phos levels
~every 2 weeks once on full feeds to screen for osteopenia
Temperature Regulation
Goal:Maintain correct body temperature range in order to:
maximize metabolic efficiencyreduce oxygen useprotect enzyme functionreduce calorie expenditure
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Challenges of thermoregulation in Neonatal care
Prior to delivery infants do not maintain temperature independently
Infant’s in-utero temp is generally 0.5˚C higher than mother’s temp
Rapid cooling occurs after delivery
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Neurologic adaptation: Thermoregulation
Maintenance of body temp is a major task
Skin is thin & blood vessels are close to the surface
Term Infants have 3x the surface to body mass of an adult
Preterm infants and SGA infants have 4x the surface mass to body mass of an adult
Preterm infants are especially susceptible to heat loss due to poor tone
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Healthy Vs. Sick Neonate
Healthy Newborn Brown adipose tissue Produces heat and
loses heat as needed
Sick or Low birth wt infants Increased energy
demand Decreased energy
store Vulnerable to heat
stress
Heat Loss Mechanisms Convection – the
flow of heat from the body surface to cooler surrounding air Eliminating drafts such
as windows or air con, reduces convection
Conduction – the transfer of body heat to a cooler solid object in contact with the baby Covering surfaces with
a warmed blanket or towel helps minimize conduction heat loss
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Radiation – the transfer of heat to a cooler object not in contact with the baby Cold window surface or
air con; moving as far from the cold surface, reduces heat loss
Evaporation – loss of heat through conversion of a liquid to a vapor From amniotic fluid; NB
should be dried immediately
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Nursing Considerations Keep dry and well-wrapped Keep away from cold objects or outside
walls Perform procedures in warm, padded
surface Keep room temperature warm
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Key Points to Know in Preventing Hypothermiao Infant most vulnerable
Premature and SGA infants Neonates requiring prolonged resuscitation Acutely ill Open skin defects (abdomen, spine)
Remember the basics Warm, humidified oxygen ASAP Warm objects before contact with infant Pre warmed Radiant warmer/incubator – utilize servo
control Rewarm cautiously- Be prepared to resuscitate