Care of The High Risk Neonate

Lecture Fourteen: Care of The High Risk Neonate
NURS 2208
T. Dennis RNC, MSN
At Risk Newborns (pg. 805)

1. SGA newborn
2. LGA newborn
3. Infant of a diabetic mother
4. Postterm newborn
5. Preterm newborn
6. Newborn exposed to HIV/AIDS
7. Newborn with congenital anomalies
8. Newborn with congenital heart defect
9. Care of the family of at risk newborns and nurses caring for them

Legal and Ethical Considerations (pg. )

1. Increased levels of nursery care have evolved with increased knowledge about the newborn.
2. High-touch / High-tech environment.
3. When is enough, enough?
4. Caring for the caretaker.

Identification of the High Risk Newborn (pg. 805)

1. An at-risk infant is one who is susceptible to illness (morbidity) or even death (mortality) because of dysmaturity, immaturity, physical disorders, or complications during or after birth.
2. Predictable risk factors include: 1) Low socioeconomic level of the mother with limited access to health care, 2) Exposure to environmental dangers such as toxic chemicals or illicit drugs, 3) Preexisting maternal conditions,  4) Maternal age or parity, and medical complications related to the pregnancy.
3. Risks may be anticipated and the appropriate facility can be notified for transport or preparation.
4. Birth related risks may be evaluated by electronic fetal monitoring and Apgar score.

Identification of the High Risk Newborn (pg. 805)

1. Birth weight and gestational age together are the criteria used to assess neonatal maturity and mortality risk.
2. Preterm, Term, and Postterm.
3. LGA, AGA, and SGA are plotted on the newborn classification and mortality risk chart.
4. Neonatal mortality risk (chance of death within the first 28 days of life) decreases as both gestational age and birth weight increase.
5. Neonatal morbidity rating assists in determining the needs of particular infants for special observation and care.
6. Minute to minute observations may mean the difference between survival and non-survival.

Nursing Care Management (pg. 806)

1. Decreasing physiologically stressful situations.
2. Constantly observing for subtle signs of change in clinical condition.
3. Interpreting laboratory data and coordinating interventions.
4. Conserving the infant’s energy for healing and growth.
5. Providing for developmental stimulation and maintenance of sleep cycles.
6. Assisting the family in developing attachment behaviors.
7. Involving the family in the planning and providing care.

Small for Gestational Age (pg. 806-812)

1. SGA: any newborn who at birth is at or below the 10th percentile for weight on the newborn classification chart.
2. Newborn may be preterm, term, or postterm.
3. Intrauterine growth restriction (IUGR): Fetal undergrowth due to any etiology, such as intrauterine infection, deficient nutrient supply, or congenital anomalies (used interchangeably with SGA).
4. SGA infants have an increased risk for asphyxia, perinatal mortality, polycythemia, and hypoglycemia.

Small for Gestational Age (pg. 806-812)

1. Contributing factors: maternal factors, maternal disease, environmental factors, placental factors, and fetal factors.
2. Symmetric (proportional) IUGR.
3. Asymmetric (disproportional) IUGR.
4. Complications: perinatal asphyxia, aspiration syndrome, heat loss, hypoglycemia, and polycythemia.
5. Significant IUGR is associate with: congenital malformations, intrauterine infection, continued growth difficulties, and learning difficulties.

LGA Newborn  (pg. 812-813)

1. Large for Gestational Age: a neonate whose birth weight is at or above the 90th percentile on the intrauterine growth curve (at any week of gestation) is considered LGA.
2. Best known condition associated with excessive growth of the newborn is maternal diabetes.
3. Contributing factors: genetic polycythemia, and hyperviscosity.
4. predisposition, multiparous clients, male newborns, and newborns with erythroblastosis fetalis, Wiedemann syndrome, or transposition of the great vessels.
5. Complications: birth trauma due to CPD, increased incidence of cesarean births/labor inductions, and hypoglycemia,

Infant of a Diabetic Mother
(pg.813-814)

1. Excessive fetal growth is caused by:          1) exposure to high levels of maternal glucose, 2) fetal response of increased insulin production, and 3) insulin has a “growth hormone effect” that results in greater linear growth.
2. Complications include: hypoglycemia, hypocalcemia, hyperbilirubinemia, birth trauma, polycythemia, respiratory distress syndrome, and congenital anomalies.

Postterm Newborn (pg. 815)

1. Any newborn born after 42 weeks gestation.
2. Cause unknown but associated factors include: primiparity, high multiparity, and a history of prolonged pregnancies.
3. Complications of post maturity syndrome: hypoglycemia, meconium aspiration, polycythemia, congenital anomalies, seizures due to hypoxic insult, and cold stress.
4. Characteristics are caused primarily by a combination of an aging placenta, subsequent insufficiency and continued exposure to amniotic fluid.

Care of the Preterm (Premature) Newborn    (pg 817-832)

1. An infant born before the completion of 37 weeks gestation.
2. Cause of preterm labor are poorly understood.
3. Major problem is variable immaturity of all systems.
4. The degree of immaturity depends on the length of gestation.
5. Common complications of the cardiopulmonary system include: respiratory distress syndrome, patent ductus arteriosis, and pulmonary air leaks.
6. Heat loss is a major problem due to : high ratio of body surface to body weight, decreased subcutaneous fat, thinner, more permeable skin, extended posture, and decreased ability conserve heat in body core.

Care of the Preterm (Premature) Newborn
GI immaturity leads to:

1. an increased danger of aspiration
2.  inability to meet caloric needs due to small stomach
3. Limited ability to convert essential amino acids
4. Inability to handle the increased osmolarity of formula protein
5. Difficulty with lactose digestion
6. Deficiency of calcium and phosphorus
7. Increased basal metabolic rate and increased oxygen consumption due to fatigue of sucking.
8. Feeding intolerance and NEC due to ↓intestinal perfusion.

Care of the Preterm (Premature) Newborn

1. At risk due to decreased glycogen stores for hypoglycemia, low iron stores, and high bilirubin levels and any blood loss is highly significant.
2. Brain growth is most rapid in the third trimester, so the closer to term the better the neurological prognosis.
3. A common interruption of neurological development in the preterm infant is caused by intraventricular hemorrhage (IVH) and intracranial hemorrhage (ICH).
4. Periods of reactivity may not be observed at all, more disorganized in their sleep-wake cycles, unable to focus on human face and environmental objects as well as term infants, and their neurological responses (sucking, muscle tone) are weaker.

Care of the Preterm (Premature) Newborn
Nutrition:

1. Early feeding is helpful in maintaining metabolism and lowering the possibility of complications but increases risk for complications related to maturity of the digestive system.
2. Feeding regimens are based on the infant’s weight and estimated stomach capacity.
3. Total parenteral nutrition (TPN) is given to newborns who cannot tolerate any oral feedings.
4. Nutritional intake is considered adequate when there is weight gain of 20 to 30 grams per day.
5. Methods of feeding include: bottle feeding, breast feeding, gavage feeding, transpyloric feeding and TPN.

Care of the Preterm (Premature) Newborn
Complications:

1. Patent ductus arteriosis
2. Apnea
3. Intraventricular hemorrhage (IVH)
4. Respiratory distress syndrome (RDS)
5. Sepsis
6. Retinopathy of pre-maturity (ROP)
7. Bronchopulmonary dysplasia (BPD)
8. Pulmonary interstital emphysema (PIE)
9. Posthemorrhagic hydrocephalus

Nursing Assessment (pg. 826)

1. Color
2. Skin
3. Lanugo
4. Head size
5. Skull

1. Ears
2. Nails
3. Genitals
4. Resting position
5. Cry
6. Reflexes/Activity

Nursing Diagnosis (pg. 836)

1. Impaired Gas Exchange
2. Ineffective Breathing Pattern
3. Alteration In Cardiovascular Status
4. Ineffective Thermoregulation
5. Potential Hyperbilirubinemia

1. Altered Nutrition: Less Than Body Requirements
2. Fluid Volume Deficit
3. High Risk For Intraventricular Hemorrhage
4. Ineffective Family Coping
5. Dysfunctional Grieving

Nursing Plan and Implementation (pg. 827)

1. Maintenance of respiratory function
2. Maintenance of neutral thermal environment
3. Maintenance of fluid and electrolyte status
4. Provision of adequate nutrition and prevention of fatigue during feeding.
5. Prevention of infection
6. Promotion of Parent-infant attachment
7. Promotion of developmentally supportive care
8. Preparation for home care

Evaluation (pg. 827-832)

1. The preterm newborn is free of respiratory distress and establishes effective respiratory function.
2. The preterm newborn gains weight and shows no signs of fatigue or aspiration during feedings.
3. The parents are able to verbalize their anger, anxiety, and guilt feelings about birth of a preterm baby and show attachment behavior such as frequent visits and growing confidence in their participatory care activities.
4. The preterm newborn demonstrates a serial head circumference growth rate of 1 cm/week.

Newborn exposed to HIV/AIDS (pg. 840)

1. Transmission during the perinatal and newborn periods can occur across the placenta or through breast milk or contaminated blood.
2. The majority of infants born to infected mothers ultimately remain uninfected (Vertical transmission decreased by AZT during gestation).
3. May show signs and symptoms within days of birth (enlarged spleen and liver, swollen glands, recurrent respiratory infection, weight loss, urinary tract infections and candidiasis infection.
4. Routine newborn care, standard precautions.
5. Hand washing is crucial.
6. All infants born to HIV positive mothers require regular clinical, immunologic, and virologic monitoring.
7. Routine immunizations except for the live polio vaccine.

Newborn with Congenital Anomalies (pg.841)

1. Congenital hydrocephalus
2. Anencephaly
3. Choanal atresia
4. Cleft lip
5. Cleft palate
6. Tracheoesophageal fistula
7. Diaphragmatic hernia
8. Myelomeningocele
9. Omphalocele
10. Gastroschisis

Newborn with Congenital Heart Defect (pg. 844)

1. Classified as acyanotic (without cyanosis) or cyanotic (with cyanosis).
2. The common cardiac defects seen in the first 6 days of life are left ventricular outflow obstructions (mitral stenosis, aortic stenosis, or atresia), hypoplastic left heart, coarctation of the aorta, patent ductus arteriosis, transposition of the great vessels, tetrology of Fallot, and large ventricular septal defect or atrial septal defects.
3. Many cardiac defects will not clearly manifest themselves until after discharge from the birthing unit.
4. Three most common manifestations are: cyanosis, detectable heart murmur, and signs of congestive heart failure (tachycardia, tachypnea, diaphoresis).

Newborn with Inborn Errors of Metabolism

1. Inborn errors of metabolism are a group of hereditary disorders that are transmitted by mutant genes: Phenylketonuria (PKU), Maple syrup urine disease (MSUD), Homocystinuria, Galactosemia, and congenital hypothyroidism.
2. PKU is the most common.
3. Phenylalanine is the essential amino acid used by the body for growth and excess is converted to Tyrosine.
4. The newborn with PKU lacks the ability to convert resulting in high levels of phenylalanine which results in a progressive mental retardation.
5. PKU is required by law in most states. The PKU must be drawn 24 to 72 hours after initiation of breast milk or formula feeding.

Birth Related Stressors (pg 863-902)

1. Newborn at risk due to asphyxia
2. Newborn with respiratory distress/Transient Tachypnea
3. Newborn with meconium aspiration syndrome
4. Newborn with persistent pulmonary hypertension
5. Newborn with complications due to respiratory therapy
6. Newborn with cold stress
7. Newborn with hypoglycemia
8. Newborn with jaundice
9. Newborn with polycythemia
10. Newborn with infection

Asphyxia (pg. 863)
Pathophysiology:

1. Results from cardiopulmonary, respiratory and biochemical factors.
2. Due to failure of lung expansion and hypoxia, fetal circulation reoccurs.
3. Biochemical: hypoxia causes anaerobic metabolism, rapidly using glycogen supplies.

Asphyxia (pg. 863)
Protective mechanisms:

1. Relatively immature brain
2. Lower resting metabolic rate than adults
3. Use energy more efficiently

Complications:

1. Severe, prolonged hypoxia may result in brain damage or death of the newborn.

Asphyxia (pg. 863)
Risk factors:

1. Non-reassuring fetal heart rate patterns
2. Difficult birth
3. Fetal Blood Loss
4. Apneic episode that is unresponsive to tactile stimulation
5. Inadequate ventilation
6. Prematurity
7. Structural Lung abnormality
8. Cardiac arrest

Asphyxia (pg. 863)

1. Requires immediate resuscitation of the newborn.
2. The goal of clinical therapy is to identify the fetus at risk for asphyxia and prepare for resuscitative efforts immediately at birth.
3. Monitor fetal well being during the prenatal and intrapartal periods.
4. Deliver the fetus immediately before major damage occurs and treat the asphyxiated infant.

Asphyxia (pg. 863)
Treatment:

1. Suction is always performed before resuscitation to prevent mucous, blood, and/or meconium being aspirated into the lungs.
2. Dry the baby off
3. If no respirations or gasping, provide Positive Pressure ventilation with 100% O2.
4. Endotracheal Intubation may be required
5. Position on a firm surface
6. Compressions with two-finger method or both thumbs
7. Medications as indicated

Nursing Assessment and Diagnosis (pg. 866)

1. Observe for the infant at risk.
2. Ineffective Breathing Pattern related to lack of spontaneous respirations at birth secondary to intrauterine asphyxia.
3. Decreased Cardiac Output related to impaired oxygenation.
4. Ineffective Family Coping: Compromised related to baby’s lack of spontaneous respirations at birth and fear pf losing their newborn.

Nursing Plan and Implementation (pg. 866)

1. Assemble the necessary equipment and insure proper functioning (LDR, DR, OR, Nursery, NICU).
2. Restock immediately after use.
3. Call for additional support- resuscitation is at least a two person effort.
4. Document, document, document.
5. Parent teaching: keep parents informed.

Evaluation (pg. 867)

1. The risk of asphyxia is promptly identified and intervention is started.
2. The newborn’s metabolic and physiological processes are stabilized and recovery proceeds without complications.
3. The parents can describe the reason for resuscitation and what was done to resuscitate their newborn.
4. Parents can verbalize their fears about the resuscitation process and potential implications for their infant’s future.

Respiratory Distress Syndrome (RDS) (pg. 867)

1. An inappropriate respiratory adaptation to extrauterine life.
2. Also referred to as Hyaline membrane Disease (HMD).
3. The result of a primary absence, deficiency, or alteration in the production of pulmonary surfactant.
4. Occurs more frequently in infant 30 weeks gestation or less.
5. Occurs more frequently in premature Caucasian infants than in infants of African descent and almost twice as often in males than in females.

Respiratory Distress Syndrome (RDS) (pg. 867)
Contributing factors:

1. Prematurity
2. Surfactant deficiency disease

Complications:

1. Hypoxia
2. Respiratory acidosis
3. Metabolic acidosis

Clinical Therapy:

1. The primary goal of prenatal management is to prevent preterm birth through aggressive treatment of preterm labor and administration of corticosteroids to enhance fetal lung development. Postnatally: 1) maintain adequate oxygenation and ventilation, 2) correct acid base abnormalities, and 3) provide supportive care to maintain homeostasis

Respiratory Distress Syndrome (RDS)
Medical management:

1. Oxygenation: oxyhood, Nasal cannula
2. Ventilatory support: ventilator, ECMO, nitrous oxide
3. Transcutaneous O2 and CO2 monitoring, pulse oximetry
4. Blood gas monitoring
5. Correction of acid-base imbalance
6. Environmental temperature regulation
7. Adequate nutrition: oral, gavage, and TPN
8. Protection from infection

Nursing Assessment and Diagnosis (pg. 866)
Assessment:

1. Increasing cyanosis
2. Tachypnea (60 or > breaths per minute)
3. Grunting respirations
4. Nasal flaring
5. Significant retractions, labored respirations
6. Apnea (episode of nonbreathing for more than 20 seconds)
7. Flaccid, hypotonic, unresponsive to stimuli
8. Seizures (indicative of deterioration and possible CNS damage.

Diagnosis:

1. Impaired Gas exchange
2. Altered Nutrition: Less than Body Requirements
3. Risk for infection

Nursing Plan and Implementation (pg. 866)

1. Admit directly to the special care nursery
2. Lab as ordered: blood type, Rh, Coombs, CBC
3. Administer antibiotics as ordered.
4. IV access for meds, hydration and nutritional support.
5. Assist MD/NP with placement of arterial catheter lines.
6. Attach servo probe to infant’s skin, radiant warmer on servo control.
7. Attach 3 lead EKG for continuous cardiac and respiratory monitoring.
8. Attach pulse ox to infant extremity.
9. Monitor oxygen administration.

Evaluation (pg. 867)

1. Prompt identification and early intervention occurred.
2. Newborn is free of respiratory distress and metabolic alterations.
3. Parents verbalize concerns, survival factors and understanding of treatment rationales.

Transient Tachypnea of the Newborn (pg. 870)

1. Occurs more frequently in AGA and near term infants.
2. Incident during the birth process which results in failure to clear the airway of lung fluid and or mucous.
3. An excess of fluid in the lungs due to aspiration of amniotic fluid.
4. Occurs more frequently in c-section newborns
5. Onset occurs shortly after birth with signs of: expiratory grunting, nasal flaring, and mild cyanosis.
6. Respiratory rates may be as high as 100 to 140 breaths per minute.

Transient Tachypnea of the Newborn (pg. 870)
Clinical Therapy:

1. Initial x-ray resembles RDS with minor differences.
2. Chest x-ray is clear in 48 to 72 hours
3. O2 at 30% to 50% usually under oxyhood correct hypoxemia.
4. IVF’s for fluid and electrolyte imbalances
5. Oral feedings are contraindicated due to high respiratory rate.
6. Infant usually begins to improve by 8 to 24 hours.
7. Duration of clinical course is 72 hours.
8. R/O pneumonia and persistent pulmonary hypertension.

Meconium Aspiration Syndrome (pg. 873)

1. Respiratory disease of the term, postterm, and SGA newborns cause by inhalation of meconium or meconium stained amniotic fluid into the lungs.
2. Characterized by mild to severe respiratory distress, hyper-expansion of the chest, hyper-inflated alveoli, and secondary atelectasis.
3. Syndrome primarily affects term, SGA, postterm and newborns who have experienced a long labor.
4. The severity of the clinical symptoms correlates with the extent of the aspiration.
5. The extreme hypoxia caused by cardiopulmonary shunting can lead to PPHN (Persistent Pulmonary Hypertension).

Normal Arterial Blood Gas Values for the Newborn

1. pH : 7.31 - 7.45
2. Arterial oxygen pressure (Pao2) :

   50–70 mm Hg

1. Carbon dioxide pressure (Paco2) :

    33-48 mm Hg

1. Bicarbonate :  16-24 mEq/L
2. Oxygen saturation : > 90%

Meconium Aspiration Syndrome (pg. 873)
Clinical Therapy:

1. Suctioning the nasopharynx and oropharynx before the delivery of the body.
2. Endotracheal intubations to visualize the cords: vigorous infant with thick meconium intubate and suction, thin meconium do not intubate, depressed infant suction.
3. Delivery of high oxygen concentrations and controlled ventilation.
4. Surfactant replacement.
5. Maintenance of systemic blood pressure by dopamine.
6. Extracorporeal membrane oxygenation (ECMO), a form of hear/lung machine may be needed.
7. Chest physiotherapy (Chest percussion, vibration, and drainage to remove the debris).

Meconium Aspiration Syndrome (pg. 873)
Nursing assessment and diagnosis:

1. Observe for signs of fetal hypoxia and meconium staining. After delivery, observe for hypoxia, convulsions, hematuria, oliguria, or anuria.
2. Ineffective Gas Exchange, Altered Nutrition: Less than Body Requirements, and Ineffective Family Coping: Compromised.

Nursing Plan and Implementation:

1. Prevention of meconium aspiration
2. Maintaining adequate oxygenation and ventilation.
3. Regulating temperature.
4. Observing intravenous fluids.
5. Providing caloric requirements.
6. Monitoring antibiotic treatment.

Evaluation:

1. The newborn is free of respiratory distress and metabolic complications
2. Parents can verbalize concern, understanding of treatment.

Persistent Pulmonary Hypertension (pg. 878)

1. Respiratory disease resulting from right to left shunting of blood away from the lungs and through the ductus arteriosis and patent foramen ovale.
2. May also be called persistent fetal circulation because the syndrome includes a return to fetal circulation.
3. Typically born at term or postterm and presents with tachycardia and cyanosis.
4. ECMO has improved chance of survival in these infants.
5. High frequency ventilation is another mode of treatment.

Complications Due to Respiratory Therapy (pg. 880)

1. Pulmonary Interstitial Emphysema: the accumulation of air in the lung tissues. Overdistention and rupture of the alveoli occur related to high ventilator pressures.
2. Pneumothorax: the accumulation of air into the thoracic cavity between the parietal and visceral pleura when alveoli are overdistended, rupture and air leaks into the thoracic cavity (pg.881)
3. Bronchiopulmonary Dysplasia (BPD): most commonly occurs in very compromised low-birth-weight infants who require oxygen therapy and assisted  mechanical ventilation for treatment of RDS.

Cold Stress (pg. 882)
Pathophysiology:

1. Excessive heat loss resulting in the use of compensatory mechanisms (increased respirations and non-shivering thermogenesis) to maintain core body temperature.
2. Occurs thought the mechanisms of evaporation, convection, conduction and radiation.
3. Metabolic consequences of cold stress can be devastating and potentially fatal to the infant.

Care management:

1. Warm newborn slowly
2. Monitor skin temp
3. Initiate efforts to maintain neutral thermal environment

Hypoglycemia (pg. 884)

1. Occurs when the blood glucose level is less than 40 mg/dL.
2. Occurs more commonly in IDM, SGA, and preterm AGA newborns.

Clinical Therapy:  signs & symptoms

1. Lethargy, jitteriness   
2. Poor feeding
3. Vomiting
4. Pallor
5. Apnea, irregular respirations
6. Hypotonia
7. Tremors, jerkiness
8. High-pitched cry

Hypoglycemia (pg. 884)
Treatment:

1. Early breastfeeding or formula feeding is a major preventative approach.
2. Intravenous therapy with 10% dextrose may be indicated with rate based on weight.
3. Oral glucose may be used.
4. Repeat blood sugar in 30 minutes.
5. Use heelstick method to obtain blood sugar values.
6. Use left lateral heel site to avoid damage to the newborn’s heel (pg. 885- 886).

Hypoglycemia (pg. 884)
Nursing Assessment and Diagnosis

1. Identify the newborn at risk: jitteriness, tremors, periods of apnea.
2. Monitor blood glucose levels.
3. Altered Nutrition: Less than body Requirements
4. Ineffective Breathing pattern related to tachypnea and apnea.
5. Pain related to frequent heelsticks for glucose monitoring.

Nursing Plan and Implementation

1. Monitor blood glucose levels
2. Initiate early feedings.
3. Monitoring glucose intravenous infusions.
4. Maintaining a neutral thermal environment.
5. Encourage non-nutritive sucking to decrease crying behaviors.
6. Weigh daily

Jaundice (pg. 887)

1. The most common abnormal finding in the newborn is jaundice.
2. Physiologic jaundice is due to the newborn’s shorter red cell life span, slower uptake by the liver, lack of intestinal bacteria, and poorly established hydration.
3. Hypothermia, hypoglycemia, asphyxia and some neonatal medications increase the chances of a newborn becoming jaundiced.
4. Hyperbilirubinemia: Excessive amount of bilirubin in the blood; indicative of hemolytic processes due to blood incompatibility, intrauterine infection, septicemia, neonatal renal infection, and other disorders.

Jaundice (pg. 887)
Clinical Therapy:

1. Phototherapy: the treatment of jaundice by exposure to high intensity light.
2. Exposure to high intensity light decreases serum bilirubin levels in the skin by facilitating biliary excretion of unconjugated bilirubin.
3. Phototherapy does not alter the underlying cause of the jaundice.
4. Phototherapy can be provided through conventional banks of phototherapy lights, by a fiber optic blanket or a combination of both.
5. Exchange transfusion is the withdrawal and replacement  of the newborn’s blood with donor blood.

Jaundice (pg. 887)
Nursing Assessment and Diagnosis

1. Identify the newborn at risk: assess for jaundice.
2. Monitor bilirubin levels.
3. Risk for Altered Parenting related to parenting a newborn with jaundice.
4. Risk for Injury related to use of phototherapy.
5. Fluid Volume Deficit related to increased insensible water loss and frequent loose stools.

Nursing Plan and Implementation

1. Monitor temperature for hyperthermia or hypothermia.
2. Apply eye patches over newborns closed eyes.
3. Turn off lights when drawing blood for repeat bilirubin.
4. Maintaining a neutral thermal environment.
5. Observe for signs of dehydration and perineal excoriation.
6. Weigh daily

Polycythemia (pg. 895)

1. An abnormal increase in the number of total red blood cells in the newborn’s circulation.
2. Observed more commonly in SGA, full term newborns with delayed cord clamping, maternal-fetal and twin to twin transfusions, or chronic intrauterine hypoxia.
3. Hct levels of 65 to 70 are considered polycythemic.
4. Symptoms include: ruddy appearance, tachycardia, congestive heart failure, grunting, tachypnea, and cyanosis.
5. Partial exchange transfusions may be indicated in infants who are symptomatic but controversial in newborns who are asymptomatic.

Infection (pg. 896)

1. Most nosocomial infections in the NICU present as bacteremia/sepsis, urinary tract infections, meningitis, or pneumonia.
2. Maternal antepartal infections such as rubella, toxoplasmosis, cytomegalic inclusion disease, and herpes may cause congenital infection.
3. Prevention of infection is essential prenatally and intrapartally, Erythromycin ointment in the eyes post delivery for GC, antibiotic therapy for asymptomatic positive group B streptococcal  infection intrapartally.

Infection (pg. 896)
Clinical Therapy:

1. Two blood cultures from two peripheral sites.
2. Spinal fluid culture following spinal tap.
3. Urine specimen for culture typically done by supra-pubic bladder aspiration.
4. Skin cultures are taken if there are any lesions or drainage from lesions.
5. Nasopharyngeal, rectal, ear canal, and gastric aspirate cultures may be obtained.
6. CBC, chest x-ray, serology (WBC 30,000 normal first 24 hours.)
7. A low neutrophil count and high band (immature white cells) count indicate an infection is present.
8. Antibiotic therapy is initiated after cultures with Ampicillin and Gentamicin.
9. After cultures are evaluated, appropriate antibiotic therapy is instituted. Therapy may continue for 7 to 14 days or may be discontinued on the 3rd day.

Infection (pg. 896)
Nursing Assessment and Diagnosis

1. Identify the newborn at risk: assess for infection.
2. Assess for subtle behavioral changes, lethargy or irritability, color changes (pallor, duskiness, cyanosis).
3. Assess for feeding intolerance, temperature instability (hypothermia), and hyperbilirubinemia.
4. Risk for Infection related to immature immunologic system.
5. Fluid Volume Deficit related to feeding intolerance.

Nursing Plan and Implementation

1. Monitor temperature for hyperthermia or hypothermia.
2. Promote strict hand washing technique.
3. Scrupulous care of equipment (to include isolettes, warmers, soap dispensers stethoscopes).
4. Maintaining a neutral thermal environment.
5. Observe for signs of dehydration.
6. Provide respiratory support.
7. Provide adequate calories.
8. Weigh daily

TORCH (pg. 429)

1. Tests for : toxoplasmosis, rubella, cytomegalovirus, and herpes simplex virus.
2. Cytomegalovirus may be acquired transplacentally
3. Diagnosis is CMV in the urine of the pregnant client.
4. No treatment exist for the pregnant client or the newborn.
5. Infection in the fetus can result in extensive tissue damage and after birth microcephaly, hydrocephaly, cerebal palsy, and /or mental retardation.

Questions?