NCM 102 - HIGH RISK NEWBORN Nursing Management: A.DETECT EARLY B.

KEEP NEWBORN WARM Rationale: the presence of a congenital defect, acquired injuries, & other metabolic disorders predispose the NB to hypothermia C. PROVIDE IMMEDIATE SUPPORTIVE CARE D. REPORT/REFER PROMPTLY DANGER SIGNS OF NEWBORN DISTRESS A.DIFFICULT RESPIRATION OR TACHYPNEA/INCREASED RATE (over 60/min) The earliest sign of various problems, often respiratory in origin; Asphyxia Respiratory distress sepsis B. LETHARGY, FAILURE TO SUCK May be due to: hypoglycemia, hypothermia, brain damage, sepsis & prematurity C. CYANOSIS (generalized or central) Central cyanosis that increases with crying, sucking or activity is likely b/c of CHD Central cyanosis that decreases w/ crying is likely b/c of a respiratory problem, often upper airway (nasal) obstruction RATIONALE: The NB is an obligate nose breather b/c his mouth is close & opens only when crying. So if he cries with no apparent cause, check the nares/nostrils for secretions or for congenital anomaly: CHOANAL ATRESIA

D. EXCESSIVE MUCUS/DROOLING A danger sign of congenital defect; esophageal atresia or tracheoesophageal atresia

SAFETY ALERT: In suspected esophageal atresia, NEVER place the NB in Trendelenburg position: instead, elevate his head slightly Placing him w/ his head down can drain gastric contents to the lungs via the fistula & can cause respiratory distress & aspiration pneumonia Maintain a slight head-up position, frequent suctioning & NPO & refer promptly E. SAC OR DIMPLING AT THE LOWER BACK OVER THE LUMBAR REGION SAFETY ALERT Position the NB on his abdomen or on his side, NEVER SUPINE; cover sac with sterile saline soak to keep it moist F. ABSENT OR SLUGGISH MORO REFLEX Brain damage Moro reflex is the BEST INDEX of CNS integrity in the NB Its absence can signify brain damage or injury G. TWITCHING, SEIZURES OR TREMORS Hypoglycemia, brain damage SAFETY ALERT; For any suspicion of head/brain injury, NEVER position the baby w/ the head DOWN, as this will increase ICP & cause further brain damage. Prevent episodes of convulsion by genlt handling & by decreasing environmental stimuli H. BILE-STAINED (GREENISH) VOMITUS Intestinal obstruction, intussusception SAFETY ALERT: If there is any suspicion of GI obstruction DO NOT FEED INFANT! And for any infant w/ vomiting of whatever type, PREVENT ASPIRATION!

YELLOWISH DISCOLORATION OF THE SCLERA, SKIN IN THE FIRST 24 HOURS Hemolytic disease or erythroblastosis fetalis SAFETY ALERT: The first thing to do when the NB is yellowish is to identify how old the NB is Jaundice in the first 24 hours is pathologic Jaundice between 2-7 days is physiologic, due to fetal polycythemia & liver immaturity

J. MECONIUM STAINING OF SKIN & NAILS If only the amniotic fluid is meconium-stained & the infants skin & nails are not greenish, it means recent hypoxia/fetal distress K. NO PASSAGE OF MECONIUM IN 1-2 DAYS OR MECONIUM FROM AN INAPPROPRIATE OPENING (FISTULA) Imperforate anus the most common congenital anomaly that is not compatible with life Infants at Risk for Resuscitation Nonreassuring fetal heart pattern Apneic episode unresponsive to tactile stimulation Inadequate ventilation Small for gestational age Cardiac disease diagnosed prenatally Other congenital abnormality diagnosed prenatally Premature birth Infant of multiple pregnancy Prolonged or difficult delivery Infants at Need for Resuscitation Weak cry at birth Poor respiratory effort at birth Retractions at birth Resuscitation methods Stimulation by rubbing newborn's back: Done initially to all infants Use of positive pressure to inflate lungs: Used if respirations are inadequate or have not been initiated Endotracheal intubation: Used immediately for severely premature infants, infants with known congenital anomalies, infants who do not respond to stimulation or positive pressure Medications: Nalaxone (Narcan) may be used to reverse effects of narcotics given to mother prior to birth