Essential procedures in the care of high

risk newborn

By: JESSA ANNE R.

BORRE

Identify high risk newborn danger signs

The high-risk neonate is defined as a
newborn, regardless
of gestational age or birth weight, who has
a greater than average chance of
morbidity or mortality, usually because of
conditions or circumstances
superimposed on the normal course of
events associated with birth and the
adjustment to extrauterine existence.

high-risk period begins at the time of

viability (the gestational age at which
survival outside the uterus is believed
to be possible, or as early as 23
weeks of gestation)up to 28 days after
birth and includes threats to life and
health that occur during the prenatal,
perinatal, and postnatal periods.

LATE-PRETERM INFANT ASSESSMENT AND INTERVENTIONS

RISK FACTORS

ASSESSMENT

INTERVENTION

Respiratory
distress

Assess for cardinal signs of

respiratory distress (nasal flaring,
grunting, tachypnea, central cyanosis,
retractions) and
presence of apnea, especially during
feedings.

Perform
gestational age
assessment.
Observe for signs
of respiratory
distress; monitor
oxygenation
by pulse oximetry;
provide
supplemental
oxygen
judiciously.

Hypoglycemia

Monitor for signs and symptoms of

hypoglycemia.
Assess feeding ability (latch-on,
nipple-feeding).
Assess thermal stability and signs and
symptoms of respiratory
distress.
Monitor bedside glucose in infants
with additional risk factors
(IDM, prolonged labor, respiratory
distress, poor feeding).

Initiate early
feedings of human
milk or formula.
Avoid dextrose
water or water
feedings.
Provide IV
dextrose as
necessary for
hypoglycemia.

RISK FACTORS ASSESSMENT

INTERVENTIONS

Thermal
instability

Provide skin-to-skin
care in immediate
postpartum period
for
stable infant.
Implement measures
to avoid excess heat
loss (adjust
environmental
temperature, avoid
drafts).
Bathe only after
thermal stability has
been maintained for
1 hr.

Monitor axillary
temperature every 30
min immediately
postpartum until
stable; thereafter every
1-4 hr depending on
gestational age and
ability to maintain
thermal stability.

LATE-PRETERM INFANT ASSESSMENT AND INTERVENTIONS

RISK FACTORS

ASSESSMENT

INTERVENTION

Jaundice

Observe for jaundice in first 24

hr.
Evaluate maternal-fetal history
for additional risk factors that
may cause increased hemolysis
and circulating levels of
unconjugated bilirubin (Rh,
ABO, spherocytosis, bruising).

Monitor transcutaneous
bilirubin and note risk
zone on
hour-specific nomogram

Feeding
problems

Assess suck-swallow and

breathing.
Assess for respiratory distress,
hypoglycemia, thermal stability.
Assess latch-on, maternal
comfort with feeding method.
Determine weight loss (should
be 10% of birth weight).

Initiate early feedings

(human milk or formula).
Ensure maternal
knowledge of feeding
method and signs of
inadequate feeding
(sleepiness, lethargy, color
changes
during feeding, apnea
during feeding, decreased
or absent
urine output).

LATE-PRETERM INFANT ASSESSMENT AND INTERVENTIONS

RISK FACTORS

ASSESSMENT

INTERVENTIONS

Neurodevelopmental
problems

Assess for
respiratory
distress,
neonatal
jaundice,
hypoglycemia,
and thermal
instability.
Assess
neurodevelopmental status.
Assess for
seizure activity

Perform newborn screening,

including hearing test.
Implement individualized
developmental care.
Encourage parents to keep
follow-up appointments with
primary care provider for
evaluation of growth and
development (including
cognitive function and
achievement
of appropriate milestones).

RISK
FACTORS

ASSESSMENT

INTERVENTIONS

Infection

Evaluate
maternal-fetal
history for risk
factors that may
contribute to
neonatal
septicemia.
Assess for signs
and symptoms
of neonatal
infection.

Use Standard Precautions,

especially hand washing between
infants and contact with surfaces
that may harbor bacteria
(e.g., keyboards, telephones).
Maintain thermal stability.
Administer hepatitis B vaccine.
Encourage breast-feeding and assist
mother-baby pair with
breast-feeding.
Encourage parents to decrease
infant exposure to respiratory
viruses post discharge and obtain
vaccines as appropriate to
prevent development of respiratory
viruses (e.g., influenza).

Classification According to Size

Low-birth-weight (LBW) infantAn infant whose birth weight is less

than

2500 g (5.5 lb), regardless of gestational age

Very lowbirth-weight (VLBW) infantAn infant whose birth weight is

less than 1500 g (3.3 lb)

Extremely lowbirth-weight (ELBW) infantAn infant whose birth

weight is less than 1000 g (2.2 lb)

Appropriate-for-gestational-age (AGA) infantAn infant whose

weight

falls between the 10th and 90th percentiles on intrauterine growth curves

Small-for-date (SFD) or small-for-gestational-age (SGA) infantAn

infant whose rate of intrauterine growth was slowed and whose birth
weight falls below the 10th percentile on intrauterine growth curves

Intrauterine growth restriction (IUGR)Found in infants whose

intrauterinegrowth is retarded (sometimes used as a more descriptive term
for the

SGA infant)

Large-for-gestational-age (LGA) infantAn infant whose birth weight

falls above the 90th percentile on intrauterine growth charts

Evaluating Respiratory Syndrome

MAJOR FACTORS IN RESPIRATORY DISTRESS SYNDROME

CAUSE

EFFECT

Increased pulmonary vascular

resistance

Alveolar collapse; atelectasis;

increased difficulty breathing

Impaired gas exchange

Hypoxemia and hypercapnia

with
respiratory acidosis

Increased transudation of fluid

into lungs

Hypoperfusion of pulmonary
circulation

Hypoperfusion (with
hypoxemia)

Tissue hypoxia and metabolic

acidosis

Hyaline membrane formation;

impaired gas exchange

Increased surface tension of

alveoli
(surfactant deficiency)

SYMPTOMS.
The symptoms usually appear within minutes of birth, although
they may not be seen for several hours. Symptoms may
include:

Bluish color of the skin and mucus membranes (cyanosis)

Brief stop in breathing (apnea)
Decreased urine output
Grunting
Nasal flaring
Rapid breathing
Shallow breathing
Shortness of breath and grunting sounds while breathing
Unusual breathing movement -- drawing back of the chest
muscles with breathing

Silver-man Anderson Index

Perform to observe for signs of respiratory

distress:
Chest lag
Retractions
nasal flaring
expiratory
grunting

Score 10 = Severe respiratory distress

Score 7 = Impending respiratory
failure
Score 0 = No respiratory distress

BAPTIZING AN INFANT

BAPTIZING AN INFANT
Who can baptize in the absence of priest?
A health care provider who is Catholic
In the absence of the health care giver who is
Catholic, anyone may baptize provided he/ she:
1.
has the use of reason;
2.
believes in the sacrament;
3.
has intention of doing what the Catholic Church
desires &
4.
uses the proper form

When can a nurse or midwife baptize an

infant?
A.
B.
C.
D.

Birth of an abortus
Delivery of an stillborn
whenever an infant/child is in immediate danger
of death
And in all these situations, it should be that the
abortus fetus/ infant is a member of a Catholic
family

Preparation for Baptism

Verify the religion
B. Prepare the necessary utensils: pitcher of
pure water
C. Ask the mother what name she would like
to give her baby, if feasable
A.

After baptism
Record the baptism in infants chart and
in the chaplains roster of baptism if there
is one in then hospital or health care
agency.
B. Inform the parents of the baptism if they
were not present during the emergency
baptismal rite
A.

SUPPORING THE FAMILY IN GRIEF

FACTORS AFFECTING GRIEF AND GRIEF RESPONSES

A.
1.
2.
3.
4.
5.

Personal resources and stressors:

age and coping skills
previous experiences
level of education, socio economic status
physical and mental health
individual and family developmental stage

B. Meaning of the loss to the mother/ parents

C. Circumstances of the loss

D. Sociocultural resources and stressors

Normal characteristics of stages of Grief (Davidson)

Shock and disbelief: 24hrs- 3 weeks

1. Resistance to stimuli and denial
2. Difficulty in making judgments
3. Emotional outburst
4. Stunned feelings
grieving person feels numb, which
is a defense mechanism that allows
them to survive emotionally.
A.

B. Searching and Yearning: 3weeks- 4months

with occasional recurrence
1. Anger and guilt
2. restlessness and impatience
3. Testing of reality

grieving person longing or yearning for

the deceased to return. Many emotions
are expressed during this time and may
include weeping, anger, anxiety, and
confusion.

C. Disorientation: Intensify lifts by 7 months

1. Disorganization
2. guilt
3. awareness of reality and increasing
acceptance of death

desired to withdraw and disengage from

others and activities they regularly
enjoyed. Feelings of pining and yearning
become less intense while periods of
apathy, meaning an absence of emotion,
and despair increase.

D. Reorganization : 18 months- 24months

1.
sense of release
2. better judgment
3. renewed energy and the ability to plan for the
future

final phase, the grieving person begins

to return to a new state of normal.
Weight loss experienced during intense
grieving may be regained, energy levels
increase, and an interest to return to
activities of enjoyment returns. Grief
never ends but thoughts of sadness and
despair are diminished while positive
memories of the deceased take over.

Engel (1954) Phases of Grief

I. Shock and Disbelief
Person refuses to accept the loss
Stunned and numb responses (Not me?,
No)
II. Developing awareness
Presence of physical and emotional
responses (anger, feeling empty, crying, Why
me?)

Engel (1954) Phases of Grief

V. Idealization
Exaggeration of the good qualities of the
person or object lost
Followed by the acceptance of the loss and
need to focus on the loss is lessened
VI. Outcome
Dealing with the loss a common life
occurrence

Phases of Death and Dying (Kobler

Ross, 1969)
1. Denial & Isolation
Client denies he will die
may repress that is discussed or isolate self
from reality
Nursing Implications
Support emotional needs without
supporting denial

Phases of Death and Dying (Kobler

Ross, 1969)
2. Anger
Express anger and retaliates to family
members, staff, physician or supreme being
Becomes demanding and accusing
Maybe precipitated by guilt which will lead to
anxiety and low self-esteem.

Phases of Death and Dying (Kobler

Ross, 1969)
A positive way to maintain hope
Nursing implications:
Nurses must provide information regarding the
need for decision making.

Phases of Death and Dying (Kobler

Ross, 1969)
3. Bargaining
Client is willing to do anything to avoid loss or
change the prognosis.
Bargaining is commonly addressed to the
Supreme Being in an attempt to postpone death
A positive way to maintain hope

Phases of Death and Dying (Kobler

Ross, 1969)
Nursing implications:
A. Provide support and empathy
B. Allow and encourage the couple to
grieve/show emotions freely
C. Assess risk of harm to self and refer
accordingly.
D. Recognize and accept initial grief
E. Response of disbelief, shock, confusion
F. - Do not leave the couple alone, stay
with them