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Assessment and Management of High Risk Neonates

Out line:
Definition. Predisposing factors. Methods used in determination of gestational age. Classification of newborns. Problems associated with Preterm, SGA, and Posterm infants. Assessment: 1. 2. 3. 4. 1. 2. 3. 4. 5. The initial assessment using the Apgar scoring system. (Refer to Transitional assessment during the periods of reactivity. (Refer Assessment of clinical gestational age and birth weight. Systematic assessment. Assessment. Nursing Diagnosis. Planning. Implementation. Evaluation. the module of assessment of normal newborn). to the module of assessment of normal newborn).

1Nursing management.

The high risk neonate can be defined as a newborn, regardless of gestational age or birth weight, who has a greater than average chance of morbidity or mortality because of threats to life and health that occur during prenatal, perinatal and postnatal period. It can also be defined as a neonate exposed to any condition that makes his life in danger.

Factors Predisposing to High-Risk Neonate:

Maternal Factors:
High-risk pregnancies as in lack of antenatal care, poor socioeconomic condition, previous history of obstetric complications as abortion, toxemias, placental insufficiency, stillbirth. Medical illness of mother as diabetes mellitus, heart and kidney diseases and severe infection. Complications of labor and delivery as prolonged rupture of membranes, cesarean section and stillbirth.

Neonatal Factors:
As neonatal asphyxia, neonatal infection, congenital anomalies, prematurity, post-maturity, low Apgar score, hypoglycemia and others. At birth, all infants should have a complete gestational age assessment. The purpose of this assessment is to compare a given infant against standardize norms of neonatal growth based on gestational age. It also includes evaluation of physical characteristics of the infant for the degree of maturity. This assessment helps to identify infants that are Preterm, post-term, small or large for gestational age. Then observe, report, help in medical treatment and intervene in nursing management.

Definition of Gestational Age:

The course of time from day one of menstrual cycle in which conception occurred till birth.

Methods used in Determination of Gestational Age:

1. 2. 3. 4. 5. Physical and neurological examinations. L.M.P. Obstetric history. Lab tests. Fetal ultrasonic scanning.

Classification of Newborn:
Classification of newborn at birth by both gestational age and weight provides a more satisfactory method for predicting mortality risk and providing guidelines for management of neonates. In using gestational age neonates can be classified as: Preterm: The neonate is born before term i.e. is less than 38 weeks of gestation. Term: The neonate is born between 38-42 weeks of gestation. Post term: The neonate is born is born after 42 weeks of gestation. (Fig.1)

When using gestational age and birth weight, newborn can be classified as:
1Small for gestational age (SGA): when plotted on intrauterine growth chart, they lie below 10th percentile. 1Appropriate for gestational age (AGA): When plotted on intrauterine growth chart, they lie between 10th and 90th percentile. 1Large for gestational age (LGA): When plotted on intrauterine growth chart, they lie above 90th percentile. (Fig.1)

Classification of High-risk Infants:

According to size:
1. age. Very-Low-Birth weight (VLBW): An infant whose birth weight is less than 1500 gm. 3. Very-Very-Low-Birth-Weight (VVLBW) or extremely low (ELBW): An infant whose birth weight is less than 1000 gm. 4. Moderately-Low Birth Weight (MLBW): An infant whose birth weight is 1500- 2500 kg. 5. Appropriate for Gestational Age (AGA) infant: An infant whose weight falls between the 10th 90th percentiles. 6. Small- for-Date (SFD) or Small for- Gestational Age (SGA) Infant: An infant whose intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intra-uterine growth curves. 7. Intrauterine Growth Retardation (IUGR): Found in infants whose intrauterine growth is retarded (sometimes used as a more descriptive term for the SGA infant). 8. Large for Gestational Age (LGA) infant: An infant whose birth weight falls above the 90th percentile on intrauterine growth charts. 2. Low- birth-weight (LBW) infant: An infant whose birth weight is less than 2500 gm regardless of gestational

Problems Associated with Preterm, SGA and Post term infants:

Preterm Problems:
These are related to: 1. Size: As temperature instability- hypothermia. 2. Immaturity: Such as; i- Respiratory Problems: - Apnea. - Respiratory Distress Syndrome.(RDS) ii- Metabolic Problems: - Hyperbilirubinemia. - Hypoglycemia. iii- Hematological Problems: - intracranial Hemorrhage. iv- Other problems: - Infections. - Congenital Abnormalities.

SAG Problems:
iiiiiiiiiCongenital Congenital abnormalities, intrauterine infection. Metabolic Hypoglycemia. Hematological Pulmonary Hemorrhage. Intrauterine Asphyxia. Meconium Aspiration.

Post Term Problems:

1. Assessment of Clinical Gestational Age:
The frequently used method of determining gestational age is the simplified assessment of gestation age by Ballard, Novack and Driver (1979, Fig. 2). It assesses six external physical and six neuromuscular signs. Physical signs as, skin, lanugo, planter surface, breast, eye/ear and genitals (male), genitals (female). Neuromuscular signs as posture, square window (wrist), arm recoil, popliteal angle, scarf sign and heal to ear sign. Each sign has a number score, and the cumulative score correlates with a maturity rating for 26-44 (Fig. 2). The new Ballard and Scale, a revision of the original scale, can be used with newborns as young as 20 weeks of gestation. The tool has the same physical and neuromuscular sections but includes 1 and 2 scores that reflect signs of extremely premature infants such as fused eye lids, imperceptible breast tissue, sticky friable transparent skin, no lanugo and square window (flexion of wrist) angle of greater than 90 degrees (see Fig. 2). The total numerical, score for both external physical and neuromuscular criteria is plotted on maturity rating graph in Fig 2 and the estimated gestational age obtained.

Estimation of Gestational Age by Maturity Rating:

Neuromuscular Maturity:

Physical Maturity:

2. Systemic Assessment of High-Risk Neonates:

General assessment: 1Weigh daily, measure length and head circumference. 1Describe general body shape and size, posture at rest, presence and location of edema. 1Describe any apparent deformities. 1Describe any signs of distress: Poor color, mouth open, grimacefurrowed brow. ii- Respiratory assessment: 1Describe shape of chest (barrel, concave), system, presence of incisions, chest tubes or other deviation. 1Describe use of accessory muscle: nasal flaring or substantial, intercostal or subclavicular retractions. 1Determine respiratory rate and regularity. 1Describe breath sounds: stridor, crackles, wheezing, and grunting, equality of breath sounds. 1Determine whether suctioning is needed. 1Describe cry if not incubated. 1If incubated, describe size of tube, type of ventilator and setting, and method of securing tube. 1Determine oxygen saturation by pulse oximetry. iii- Cardiovascular assessment: 1Determine heart rate, heart sounds, including any murmurs. 1Describe infants color: cyanosis, pallor, plethora, jaundice- assess the color of the lips, nail beds, mucous membranes. 1Determine blood pressure and cuff size. 1Describe monitors, their parameters and whether alarms are in on position. iv- Gastrointestinal assessment: 1Determine presence of abdominal distention, increase in circumference, shiny skin and state of umbilicus. 1Determine any signs of regurgitation; time related to feeding, character and amount of residual if gavage- fed. If Nasogastric tube in place, describe type of suction, drainage (color, consistency). 1Describe amount, color, consistency and odor of any emesis. 1Palpate liver margin. 1Describe amount, color and consistency of stools, check for occult blood. 1Describe bowel sound: presence or absence. v- Genitourinary assessment: 1Describe any abnormalities of genitalia. 1Describe amount, color, PH, lab stick finding, and specific gravity of urine. 1Check weight (the most accurate measure of hydration). vi- Neurologic- Musculoskeletal assessment: i-

1Describe infants movement: random, purposeful, jittery, twitching, level of activity with stimulation, evaluation based on gestational age. 1Describe infants position or attitude: flexed, extended. 1Describe reflexes: Moro, sucking, Babiniski, plantar reflex and other expected reflexes. 1Determine level of response. 1Determine changes in head circumference: size and tension of fontanels, suture lines. vii- Temperature: 1Determine skin and axillary temperature. 1Determine relationship to environmental temperature. viii- Skin assessment: 1Describe any discoloration, reddened area, signs of irritation, abrasions. Observe for monitoring equipment, infusions, or other apparatus coming in contact with skin. 1Determine texture and turgor of skin; dry, smooth. 1Describe any rash, skin lesion or birthmarks. 1Determine whether intravenous infusion device is in place and observe for sign of infiltration. ix- Monitoring physiological data: 1Vital signs: -2 Temp: 36.5-37.3C. -3 Pulse: 120-150 beat /min. -4 Respiration: 40-60 cycle/ Min. 1Blood examination is a necessary part of the ongoing assessment and monitoring of risk newborns progress. The tests most often performed are blood glucose, Bilirubin, calcium, and hematocrit and blood gases. 1Blood glucose (protocol of hypoglycemia).

General Nursing Management:

It is important for the nurse to assess the condition of high-risk newborn as previously discussed to reach one or more nursing diagnosis.

Nursing Diagnosis:
Ineffective breathing pattern related to pulmonary and neuromuscular immaturity, decreased energy and fatigue. Ineffective thermo-regulation related to immature temperature control and decreased subcutaneous body fat. High risk for infection related to deficit immunologic defenses. Altered nutrition: less than body requirement related to inability to ingest nutrients because of immaturity or illness. High risk for fluid volume deficit or excess related to immature physiologic characteristics of Preterm infant. High risk for impaired skin integrity related to immature skin structure. Immobility decreased nutrition state, invasive procedures.

High risk for injury from increased intra-cranial pressure related to immature central nervous system and physiologic stress response. Pain related to procedure, diagnosis and treatment. Altered growth and development related to Preterm birth, unnatural neonatal intensive care unit (NICU) environment, and separation from parents. Altered family process related to situational crisis, knowledge deficit, and interruption of parental attachment process.

The following are basic goals for care of all high-risk infants: 1. Exhibit adequate oxygenation. 2. Maintain stable body temperature. 3. Protect the infant from nosocomial infection. 4. Receive adequate hydration and nutrition. 5. Maintain skin integrity. 6. Experience no pain. 7. Receive appropriate development care. 8. Receive appropriate family support, including, preparation for home care.

1. Respiratory Support:
Assess for deviations of respiratory function, observe for signs of distress, grunting, cyanosis, nasal flaring and apnea, many infants require supplemental oxygen and assisted ventilation.

Nursing Intervention:
Position for optimum air exchange (place prone when feasible or side lying) since this position results in improved oxygenation better tolerated. Suction to remove accumulated mucus from nasopharynx, trachea. Carry out regimen prescribed for oxygen therapy (appendix of O2 therapy). Closely monitor blood gases measurement. Maintain neutral thermal environment to conserve utilization of O2 . Apply and manage monitoring equipment correctly. Observe and assess infants response to ventilation and oxygenation therapy. Observe any deviation.



After the establishment of respiration, the most crucial need of high-risk infant is the application of external warmth, to delay or prevent the effects of cold stress; infants are placed in a heated environment immediately after birth. This is especially important for the pre-term infant, whose very high skin surface relative to body mass promotes heat loss.

Nursing Intervention:

Place infant in incubator, radiant warmer or warmly clothed in open crib. Regulate servocontrolled unit or air temperature control as needed. Monitor for signs of hyperthermia- redness, flushing. Check temperature of infant in relation to temperature of heating unit. Avoid situation that might predispose infant to heat loss such as exposure to cool air, drafts, bathing or cold scales. Monitor for signs of hypothermia- cold extremities, cyanosis (protocol of thermo-regulation).


Protection from Infection:

High-risk neonates are particularly susceptible to infection. The source of infection rise in direct relationship to the number of person and pieces of equipment coming in contact with the infant.

Nursing Intervention:
Ensure that all care givers wash hands before and after handling the infant. Ensure that all equipments in contact with infant are clean or sterile. Ensure strict asepsis or sterility with invasive procedures. Prevent persons with upper respiratory tract or communicable infections from coming into direct contact with infant. Isolate infants who have infections. Emphasize health care workers and parents to administer antibiotics as ordered. Ensure that the incubator must be clean and sterilized to combat infections (protocol of infection control).



Optimum nutrition is critical in the management of LBW Preterm infants, but there are difficulties in providing their nutritional needs. An infants need for rapid growth and daily maintenance must be met in the presence of several anatomic and physiologic disabilities.

Nursing Intervention:
Encourage breast-feeding if strong sucking, swallowing and gag reflexes. Use gavage feeding if infant tires easily or has weak sucking, gag or swallowing reflexes. Assist mothers with expressing, breast milk to establish and maintain lactation until infant can be breast-fed. Assist parenteral fluid or total parenteral nutrition therapy as ordered. Monitor for signs of intolerance to protein and glucose. Follow until protocol for advancing volume and concentration of formula.



Adequate hydration is important in Preterm infants because their extracellular water content is higher, their body surface is larger, and the capacity for


osmotic diuresis is limited in preterm infants, underdevelopment kidneys. Therefore, these infants are highly vulnerable to water depletion.

Nursing Intervention:
1Monitor fluid and electrolytes closely with therapies that increase insensible water loss (IWL) e.g. phototherapy, radiant warmer. 1Ensure adequate parenteral/oral fluid intake. 1Assess state of hydration (e.g. skin turgor, edema, weight, mucous membrane, urine specific gravity, electrolytes, fontanel). 1Regulate parenteral fluid closely to avoid dehydration over hydration or extravasation. 1Avoid administering hypertonic fluid (e.g. undiluted medication, concentrated glucose infusions) to prevent excess solute load on immature kidneys and fragile veins. 1Monitor urinary output and laboratory values for evidence of dehydration or over hydration (adequate urinary output), strict measurement of urine output is indicated (forms of nursing care).


Skin Care:

Assess skin for any discoloration, redness, sings of irritation and skin turgor because the skin of infant was very delicate.

Nursing Intervention:
1Clean skin with plain water (see appendix of sponge bath). 1Provide daily cleaning of eye, oral, cord and diaper area, and any areas of skin breakdown (for infant who are not feeding, wipe the mouth and tongue with Nestatin daily using a cotton piece until they are advancing to feeds). 1Use minimal tape / adhesive. 1Use a protective skin barrier between skin and all tape/ adhesive especially premature babies (protocol of nursing care for infants in the NICU).


Minimal Stress:

Preterm infants are subject to stress just as other human beings. They are biologically deficient in their capacity to cope with or adapt to environmental stresses. Stress affects hypothalamus function, causing adverse effects on growth, heat production and neurologic mechanisms.

Nursing Intervention:
1Decrease environmental stimulation because of stress responses, especially increased blood pressure, increase risk of elevated ICP. 1Establish a routine that provides undisturbed sleep /rest periods. 1Use minimal handling. 1Organize care during waking hours. 1Close and open draps and dim lights to allow for day/night schedule. 1Remain calm, limit number of visitors and staff near infant at one time. 1Keep equipments noise to minimum. 1Maintain adequate oxygenation because hypoxia increases cerebral blood flow.


Neonatal Pain:


Both preterm and full term perceives and react to pain in much the same manner as children and adult. The response of neonate to pain is evidenced by cardio respiratory changes, increase in heart rate and blood pressure, and decrease PO2 or oxygen saturation, sweating. Crying associated with pain is more intense. Facial features include eye squeeze, brow bulge, open mouth.

Nursing Intervention:
1Recognize that infants, regardless of gestational age feel pain. 1Use non-pharmacologic pain measure appropriate to infants age and condition as touch, music, cuddling and roching. 1Encourage parents to provide comfort measures. 1Administer analgesics as ordered. 1Monitor for side effects of opiods, especially respiratory depression. 1Assess effectiveness of non-pharmacologic and pharamcologic pain measures.


Care to Promote Growth and Development:

Much attention had been focused on the effects of early intervention or its lack on both normal and preterm infants. Findings indicate that infants are able to respond to a greater variety of stimuli. The atmosphere and activities of the NICU are over stimulating.

Nursing Intervention:
Provide optimum nutrition to ensure steady weight gain and brain growth (see appendix of growth measurements). Provide regular periods of undisturbed rest to decrease unnecessary O2 use and caloric expenditure. Provide age appropriate development intervention simulate all the sense of infant and observe their response e.g. visual, tactile, auditory, olfactory and taste. Promote parent-infant interaction since it is essential for normal growth and development.

10.Family Support and Involvement:

The birth of a preterm infant is an unexpected and stressful event for which families are emotionally unprepared.

Nursing Intervention:
Give information to help parents understand most important aspects of care. Encourage parents to ask questions about childs status. Be honest; respond to questions with correct answer to establish trust. Encourage mother and father to visit the infant so that attachment process in initiated. Help parents by demonstrating infant care and offer support. Encourage siblings to visit infant. Explain to family members the infant condition and why he cannot come home soon.

Discharge Planning and Home Care:

Assess readiness of family to care for infant in home setting to facilities parents transition to home with infant.


Teach necessary infant care techniques and observation. Reinforce medical follow up. Refer to appropriate agencies or services so that needed assistances are provided.

The effectiveness of nursing intervention is determined by continuous reassessment and evaluation of care based on the following observational guidelines and expected outcomes: Take vital sings and perform respiratory assessments at time intervals based on infants condition and needs. Observe infants respiratory efforts and response to therapy. Measure abdominal skin and axillary temperature at specified intervals. Observe infants behavior and appearance for evidence of sepsis. Assess for hydration: assess and measure fluid intake, observe infant during feeding, measure amount of formula or parental intake, weight daily. Observe infants response to pain and pain relief interventions. Observe infants response to developmental care. Observe parental interaction with infant, interview family regarding their feelings and readiness for home care.

Admission Criteria for High Risk Unit:

Preterm. Post term. Hyperbilirubinemia. Respiratory disorders. Hemolytic disorders. Neonatal seizures. Sepsis. Hypoglycemia.