HIGH RISK NEWBORN
CARDIOPULMONARY SYSTEMS
For the high risk newborn the nurse needs to observe the respiratory rate, rhythm, and depth with the understanding that initially, the rate increases without a change in rhythm. Also, the flaring of the nares and expiratory grunting are early signs of respiratory deistrss.
There will also be an increase in the apical pulse rate and noticeable subcostal and xiphoid retractions.
the color of the newborn progresses from pink to circumoral pallor to circumoral cyanosis to generalized cyanosis. There is an increased intensity of acrocyanosis.
As respiratory distress progresses there is a proninent chin tug (the chin is pulled down and in with the mouth opening wider and the use os auxiliary muscles of respiration are used).There is an abdominal seesaw breathing pattern as well as an increase in apneic episodes.
Progressing anoxia leads to cardiac decompensation and failure. There is an increased in muscle flaccidity to where the newborn will eventually assume a frog like position.
The body temperature will also decrease. The infants temperature needs to be assessed frequently, in addition to checking the coolness or warmth of the body and extremities.
If the infant shows signs of increased physical activity and crying, respiratory rate increases, an increased acrocyanosis or generalized cyanosis along with mottling of the skin(cutis marmorata)than the MD and/or nurse needs to be informed.
The axillary temperature is preferred since a rectal temperature can be taken, however, it is discouraged as it irritates rectal mucosa, can stimulate bowel movement and may lead to possible tissue trauma.
DISORDERS RELATED TO GESTINATIONAL AGE
Hyline membrane disease (HMD), also refered to as respiratory distress syndrome (RDS). This occurs as a result of the deficiency of surfactant which lines the alveoli.
Meconium aspiration sybndrome occurs when the fetus passes meconium in utero and aspirates the meconium into the lings, which leads to 0obstruction in the small airway passages.
The high risk infant with RDS will exhibit tachypnea (>60/min), apneic spells, abnormal breath sounds, chest retraction, chin tug, flaring of the nares and an expiratory grunt.
Grunting is an ominous sign and indicates impending need for respiratory resuscitative efforts.
Complications of RDS include retrolental fibroplasia and brochopulmonary displasia.
DISORDERS OF DEVELOPMENT
CLEFT LIP AND CLEFT PALATE
Cleft lip is a fissure or split in the upper lip which may vary from a slight notch to a complete separaton extending into the nostril; it may be unilateral or bilateral
Cleft palate is a fissure or a split in the roof of the mouth (palate).
Both are visible at birth as an incompletely formed lip. With a cleft palate there is also scuking difficulties as well as breathing problems. There is an increased incidence of upper respiratory infection (URI) as well as otitis media. Later problems related to speech and hearing difficulties can occur with a cleft palate.
The treatment for both is surgical in nature. Closure of the lip defect usually precedes treatment for a cleft palate (which is done in stages). The patient will need extensive orthodontics to correct problems with teeth as well as speech therapy.
Hearing problems related to chronic, recurrent otitis media along with varying degrees of hearing loss may occur.
The "Rule of Tens" applies to the planning of surgical repair. The infant must be either 10 pounds, 10 weeks old or have a hemoglobin of at least 10gm/dL.
ESOPHAGEAL ATRESIA WITH TRACHEOESOPHAGEAL FISTULA
The porximal end of esophagus ends in a blind ouch and the lower segment connects to the trachea.
EATF is characterized by the classic 3 Cs: choking, coughing, and cyanosis. There is excessive mucous secretions and constant drooling. Aspiration is a complication expecially during feeding.
If there is ANY suspicion of possible esophageal problems, the infant should be placed NPO until further evaluation.
IMPERFORATE ANUS
The absence of an anal opening.
With this condition there is an absence of the anal opening. There will be an absence of meconium as well as a GRADUAL increase in abdominal distension. If the infant does NOT pass stool within 24 hours the staff needs to be informed.
SPINA BIFIDA
A congenital malformation leading to defects in closure of the spinal cord. Most common site is the lumbosacral area.
There are primarily two types of spina bibida. The first is spina bifida oculta in which there is a bony defect (the bone of the spine does not cover the spinal cord). The second one is spina bifida cystica. With this one there are two different types. The first one is the meningocele. This is a sac like cyst of meninges filled with spinal fluid that proturdes thorugh a defect in the bony part of the spine.
The second one is the myelomeningocele. This also involes a sac like cyst. However, it contains meninges, spinal fluid, and a porton of the spinal cord with its nerves that protrudes through a defect in the vertebral column. This is most frequently associated with hydrocephalus.
Closure of these defecs within 24 to 48 hours is desired to decrease infection, relieve pressure, repair the sac, and possibly insert a shunt.
Corect positioning of the infant is of PARAMOUNT importance in preventing damage to the sac, as well as in providing nursing care after surgery.
ISOIMMUNE HEMOLYTIC DISEASE OF THE NEWBORN
An antigen-antibody response causing destruction of fetal RBC. There are two different types. The ABO incompatibility (mild form) and Rh incompatibility (occurs when an Rh negative mother and an Rh positive father produce and Rh positive fetus).
This disease manifests itself within 24 hours after the infant is born. A pathological jaundice occurs which begins in the face and azdvances downward on the body to the trunk and extremities and finally to the palms and the soles of the feet. The infant will also be anemic.
Diagnosis is done with an Indrect Coombs's test of the mother's blood prenatally or witha Direct Coomb's test of the infant's blood post delivery.
Treatment is the administration of Rhogam prenatally or given within the furst 72 hours postpartum. After every pregnancy, abortion, or blood transfusion MicRhogam is administerd as a mini dose.
The goal is to identify and recognize jaundice from the physiologic type (which occurs within 48-72 hours) versus the pathologic type (occurs within 24 hours).
INFANT OF THE DIABETIC MOTHER
This infant is large for gestinational age (LGA) usually over 10 pounds. The appearance is puffy with round cheeks and a stocky neck. The heart, liver and spleen are enlarged. The infant will show rapid, irregular resiratons as well as being lethargic.
Common complicatons include hypoglycemia as manifested by lethargy, irritability, hypocalcemia, high pitched cry. Twitching, jitteriness, and seizures will also be evidenced.
In addition to the above, apneic spells and abdominal distention, hyperbilirubinemia, RDS, birth trauma due to excessive size and congenital defects, specifically, cardiac in nature can be evidenced.
Prolonged hypoglycemia can cause irreversible brain damage. This needs to be reported STAT.
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