Nursing Care of the High Risk Newborn to Maturity

NURSING DIAGNOSIS OUTCOME EVALUATION ASSESSMENT INTERVENTION

PRETERM INFANT
Nursing Diagnosis: Impaired gas exchange Outcome Evaluation: functioning Cesarean birth
related to immature pulmonary  irregular respiratory pattern (a few quick o although it has the advantage of reducing pressure on the
Newborn initiates breathing at birth after breaths, immature head,
resuscitation;  a period of 5 to 10 seconds without o may lead to additional respiratory complications
respiratory effort, a few quick breaths because of retained lung fluid.
maintains normal newborn respirations of 30 to again, and so on).
60 breaths per minute free of assisted  no bradycardia with this irregular pattern Giving the mother oxygen by mask during the birth can help provide a
ventilation;  (sometimes termed periodic preterm infant with optimal oxygen saturation at birth (85%–90%).
respirations) intensified by immaturity
exhibits oxygen saturation levels of at least 90%  true apnea Keeping maternal analgesia and anesthesia to a minimum also offers an
as evidenced by arterial blood gases  (pause in respirations is more than 20 infant the best chance of initiating effective respirations.
preterm babies seconds_
 have great difficulty initiating respirations at susceptible to irreversible acidosis
birth because pulmonary capillaries are still so o Birthing room teams need to be prepared with;
immature  preterm-size laryngoscopes,
 Lung surfactant does not form in adequate  endotracheal tubes,
amounts until about the 34th to 35th week of  suction catheters, and
pregnancy.  synthetic surfactant to be administered by the
o Inadequate lung surfactant leads to endotracheal tube so
alveolar collapse with each expiration
 forces an infant to use resuscitation can be accomplished within 2 minutes.
maximum strength to inflate  must be kept warm during resuscitation procedures (so they are
lung alveoli each time. not expending extra energy to increase metabolic rate to maintain
body temperature)
preterm infant may still be in a breech position at
birth=ASPIRATION Giving 100% oxygen to preterm infants during resuscitation or to
o apt to expel meconium into the amniotic maintain respirations presents two additional dangers:
fluid. If the fetus aspirates either
pulmonary edema and retinopathy of prematurity
vaginal secretions or meconium, the
 development of both of these conditions depends on saturation
respiratory problem can be aggravated by
of the blood with oxygen
inflammation or pneumonia.
 (PO2 of more than 100 mm Hg, which usually occurs when
oxygen is administered at a concentration over 70%).
blood from bruising is reabsorbed, this could lead to
soft rib cartilage of a preterm infant tends to create respiratory problems
hyperbilirubinemia
because it collapses on expiration.
 procedures must be carried out gently; a
preterm infant’s tissues are extremely sensitive to
trauma and can be damaged or bruised easily by
an oxygen mask.

Nursing Diagnosis: Risk for deficient fluid Outcome Evaluation: cannot concentrate urine well because of immature preterm baby to receive up to 160 to 200 mL of fluid per kilogram of
volume related to insensible water loss at birth kidney function. Because of this, a high proportion of body weight daily (higher than the term infant).
and small stomach capacity Plasma glucose is between 40 and 60 mg per 100 body fluid is excreted.
mL;
Intravenous fluid administration typically begins within hours after birth
 Nursing Care of the High Risk Newborn to Maturity

specific gravity of urine is maintained at 1.003 to

1.030; to fulfill this fluid requirement and provide glucose to prevent
hypoglycemia.
urine output is maintained at a minimum of 1 via a continuous infusion pump to ensure a constant infusion rate and
mL/kg/hr; electrolyte levels are within normal prevent accidental overload.
limits.  Intravenous sites must be checked conscientiously
 lack of subcutaneous tissue places a preterm newborn at
risk for damaged tissue(designed 27-gauge needles)

o Monitor the baby’s weight, urine output and specific gravity, and
serum electrolytes to ensure adequate fluid intake.
 Too little fluid and calories can lead to dehydration and
starvation, acidosis, and weight loss.
 Overhydration may lead to nonnutritional weight gain,
pulmonary edema, and heart failure.
Measure urine output by weighing diapers rather than using urine
collection bags, (urine collection bags=skin irritation and breakdown from
URINE OUTPUT OF PRETERM IS HIGH! frequent changing and leaking.)
COMPARE TO TERM

PRETERM (40 to 100 mL per kg per 24 hours),

TERM (compared with 10 to 20 mL per kg per 24
hours.)

specific gravity is low, rarely more than

PRETERM (1.012)
(normal term babies may concentrate urine up to 1.030).

Hyperglycemia caused by the glucose infusion may lead

to glucose spillage (test urine for glucose and ketones blood glucose determinations every 4 to 6 hours help to determine
ARE POSITIVE) into the urine and an accompanying hypoglycemia or hyperglycemia (increased serum glucose).
diuresis
 40 and 60 mg/Dl

CAUTION!!!!! blood drawn CAN MAKE INFANTS

Check for blood in stools
become hypovolemic
 determining the possible cause of
hypovolemia

Nursing Diagnosis: Risk for imbalanced Outcome Evaluation: preterm newborn requires a larger amount of nutrients than the
 Nursing Care of the High Risk Newborn to Maturity

nutrition, less than body requirements, related to mature infant.

additional nutrients needed for maintenance of Infant’s weight follows percentile growth curve;
rapid growth, possible sucking difficulty, and COMPLICATION IF NOT AVHIEVE
small stomach skin turgor is good;
If not supplied, an infant can develop
specific gravity of urine is maintained between  hypocalcemia (decreased serum calcium) or
1.003 and 1.030;  azotemia (low protein level in blood).
Delayed feeding and a resultant
infant has no more than 15% weight loss in first 3  decrease in intestinal motility may also
days of life and continues to gain weight after this  add to hyperbilirubinemia, a problem an infant
point. already is at high risk of developing when fetal
red blood cells begin to be destroyed.
NOT REFLEXES due to immature reflexes
 swallowing
 and sucking difficult
Increased activity = ineffective sucking =increase the
metabolic rate = increase oxygen requirements.=
increase caloric requirements

DO NOT OVERFEED PABOR!

full feeding =small stomach is distended = puts

pressure on the diaphragm= can lead to respiratory
distress. INTERVENTION:

full feeding =small stomach is distended = puts

pressure on the diaphragm= can lead to respiratory Set Feeding Schedule-
distress=IF TIENE immature cardiac sphincter allows o early administration of intravenous fluid(total parenteral
regurgitation to occur readily= lack of a cough reflex nutrition) to prevent hypoglycemia and supply fluid,
may= aspirate regurgitated formula. feedings may be safely delayed until an infant has
stabilized his or her respiratory effort from birth.

radiograph taken before a first feeding(presence of air in the stomach

shows that the route to the stomach is clear.)

be certain their filled stomach is not causing

respiratory distress. Breast, gavage, or bottle feedings are begun as soon as an infant is able
to tolerate them to prevent deterioration of the intestinal villi.

 preterm infant needs 115 to 140 calories per kilogram of body

weight per day

 Protein requirements are

Nursing Care of the High Risk Newborn to Maturity

 3 to 3.5 g per kilogram of body weight, compared with

 2.0 to 2.5 for a term newborn.

they cannot take large feedings and so must be fed more frequently with
smaller amounts.
small as 1 or 2 mL every 2 to 3 hours

Gavage Feeding(Forced feeding) . gag reflex is not intact until 32 weeks’

gestation.
o Inconsistent coordination between (swallowing and
sucking) until approximately 34 weeks’ gestation

o 32 to 34 weeks’ gestation and those who are ill or

experiencing respiratory distress are usually started on
gavage feedings

Bottle feeding or breastfeeding is gradually introduced as an infant

matures and begins to demonstrate feeding behaviors such as being
(awake, moving or fussing as if hungry)
o nipples that are softer than regular nipples are used.

Gavage feedings may be given

o intermittently every few hours(aspirate first)
o continuously via tubes (MOUTH OR NOSE VIA TUBE
1 mL/hr)
o intermittently (stomach secretions are usually
aspirated)
o stomach content of more than 2 mL just before
a feeding
o do not increase the mL and even cut back the
mL (reduces regurgitation and aspiration)
o Inability to digest this way is also a sign that
necrotizing enterocolitis, a destructive intestinal
disorder that often occurs in preterm babies, may
be developing

pacifier during gavage feeding can help strengthen the sucking reflex

 Formula
o caloric concentration preterm infants is usually 24
 Nursing Care of the High Risk Newborn to Maturity

DIMINISHED SUCKING cal/oz (term 20 cal/oz)

o Supplementing additional minerals such as iron, calcium,
and phosphorus and electrolytes such as sodium,
potassium, and chloride may be necessary,

vitamin K (0.5 mL) because body is small vs

term (1mL)

Vitamin A is important in improving healing and possibly reducing the

incidence of lung disease

Vitamin E seems to be important in preventing hemolytic anemia in

preterm infants.

Breast Milk.
o best milk for them, the same as with term infants, is
breast milk
o immunologic properties of breast milk apparently play a
major role in preventing neonatal necrotizing
enterocolitis, as well as increase immune defences
o breastfeed can manually express breast milk for her
infant’s gavage feedings
o This high level of sodium is necessary for fluid retention
o Breast milk is 20 cal/oz
 advised to add a human milk fortifier
 supply additional calories, protein, vitamins, and
minerals

Nursing Diagnosis: Ineffective thermoregulation Outcome Evaluation: difficulty maintaining body temperature because they INTERVENTION
related to immaturity have a relatively  provided to keep warm. In a birthing room, typically
Infant’s temperature is maintained at 97.6° F  large surface area per kilogram of body o kept at 62° to 68° F (16.6° to 20° C),
 . (36.5° C) axillary. weight.
 preterm infants should be kept under
 do not flex their body well but remain in an o radiant heat warmers or
extended position, rapid cooling from o warmed by skin-to-skin contact.
evaporation
 radiant heat warmer is warmed before the infant is born.
little subcutaneous fat insulation and
 For transportation purposes keeping the newborn warm during
 poor muscular development and so cannot transport is crucial.
move as actively

 limited amount of brown fat, the special tissue  warmed incubator is placed near a cold window or air
present in newborns to maintain body conditioner or in a cold transport ambulance,
 Nursing Care of the High Risk Newborn to Maturity

temperature o infant will lose heat to the distant source.

Intervention
 cannot shiver, a useful mechanism to increase  additional heat shield or plastic wrap may be placed over an
body infant on a radiant warmer to help conserve heat during transport.

 temperature; at the same time,

 they cannot sweat and thereby reduce body

temperature because of an immature central
nervous system and hypothalamic control

 dependent on the environmental temperature

 1500-g infant exposed to this low a

temperature loses 1° C of body heat every 3
minutes if left unprotected.

Nursing Diagnosis: Risk for infection related to Outcome Evaluation: of a preterm baby is easily traumatized and therefore INTERVENTION:
immature immune defenses in preterm infant offers less resistance to infection  prevent infection, linen and equipment used with preterm
Temperature is maintained at 97.6° F (36.5° infants must not be shared with other infants
difficulty producing phagocytes to localize infection  Staff members must be free of infection,
C) axillary;
and have a deficiency of IgM antibodies because of  and handwashing and
insufficient production. gowning regulations should be strictly enforced
further signs and symptoms of infection such
as poor growth

a reduced temperature are absent.

Nursing Diagnosis: Risk for impaired parenting Outcome Evaluation: purpose of a period of reactivity WHEN TO DISCHARGE THE BABY?
related to interference with parent–infant Parents visit frequently and hold infant; speak of him or  stimulate respiratory function, this places a  child reached a “magic” weight of 4.5 or 5.5 lb,
attachment resulting from hospitalization of her in positive terms. preterm infant at an even
infant at birth  greater threat of respiratory failure, because  Some nursery personnel offered to allow the mother to feed her
respiratory efforts may not be stimulated
infant once under supervision before the day of discharge.
NORMALLY
 first and second periods of reactivity normally INTERVENTION:
observed in newborns at 1 hour and 4 hours of extremely important to conserve a preterm infant’s strength
life may be delayed  reducing sensory stimulation as much as possible
 no period of increased activity or tachycardia  handling an infant gently
may appear until 12 to 18 hours of age

ABNORMAL
 recognized that preterm infants need as much loving attention
 A second consequence of a delayed period of as term newborns
reactivity is the loss of an opportunity for
interaction between parents and the newborn o Rocking,
in the early postpartum period.
o singing, and
o talking to them and gentle
 preterm infant was handled as little as possible
 Nursing Care of the High Risk Newborn to Maturity

by hospital staff to conserve the infant’s energy.  develop a sense of trust in people,

 Encourage parents to begin interacting with their infant in as

 Parents were strictly isolated from the nursery normal a manner as possible as soon as possible to strengthen
to prevent the introduction of infection bonding

 Holding an infant with skin-to-skin contact is an effective way

to begin this

Before effective bonding can be established

 come to terms with their feelings of disappointment
that the infant is so small or guilt
 A nurse can be instrumental in helping them air these
feelings and develop a more positive attitude toward their
preterm infant.

infant cannot be removed from an incubator or a radiant heat warmer

 Encourage a woman to express breast milk for her infant if the

child is too young to nurse.

 encourage her to come to the hospital and hold the baby before
and after gavage feedings or to give bottle feedings.

 Encourage them to visit the distant site as often as possible.

 parents can still stay in touch by telephone or nursery e-

mail.

Goal of this: parents should be able to feel they are taking home
“their” baby, one whom they know and have already begun to love.
On discharge assessment:

 Check to be certain that siblings do not have an upper

respiratory infection or fever.

 Their immunizations should be up to date and

 they should not have been recently exposed to a communicable

disease, such as chickenpox.

Small for gestational Age

Nursing Diagnosis: Ineffective breathing pattern Outcome Evaluation: Birth asphyxia INTERVENTION:
related to underdeveloped body systems at birth  require resuscitation at birth
Newborn maintains respirations at a rate of 30 to  (body is deprived of oxygen,  suction
60 breaths per minute after resuscitation at  causing unconsciousness or death; suffocation.) is a
 Closely observe both respiratory rate and character in the first
birth. common problem for SGA infants,
few hours of life
 underdeveloped chest muscles Underdeveloped chest muscles can make SGA infants unable to sustain
developing meconium aspiration syndrome the rapid respiratory rate of a normal newborn.
 Nursing Care of the High Risk Newborn to Maturity

 (result of anoxia= an absence of oxygen.)

Fetal hypoxia IN UTERO

 causes a reflex relaxation of the anal sphincter and

increased intestinal movement(CAUSES FOR
MECONIUM TO VACUATE IMMENDIATELY)
 gasping for breath in utero, the fetus draws
meconium
 amniotic fluid down into the trachea and bronchi
 Acting as a foreign substance, this blocks airflow into
the alveoli
o leading to hypoxemia (An abnormally low
concentration of oxygen in the blood.)
o , acidosis,
o and hypercapnia (excessive carbon dioxide
in the bloodstream, typically caused by
inadequate respiration.)

Nursing Diagnosis: Risk for ineffective Outcome Evaluation: Infant’s temperature is  less able to control body temperature than other INTERVENTION:
thermoregulation related to lack of subcutaneous fat maintained at 36.5° C (97.8° F) axillary. newborns carefully controlled environment is essential to keep the infant’s body
o they lack subcutaneous fat temperature in a neutral zone

LARGE FOR GESTATIONAL AGE

Nursing Diagnosis: Ineffective breathing pattern Outcome Evaluation:  difficulty establishing respirations at birth because intervention
related to possible birth trauma in LGA newborn of birth trauma  cesarean birth, transient fluid can remain in the lungs and interfere with
Newborn initiates breathing at birth;  Increased intracranial pressure = pressure on the effective gas exchange.
respiratory center.
maintains normal newborn respiratory rate of 30 to 60 o cause a decrease in respiratory function  Careful observation is needed to detect these conditions.
breaths per minute.  diaphragmatic paralysis
o cervical nerve trauma as the head is bent
sideways to allow for birth of the large
shoulders.
o prevents active lung motion on the affected
side

Nursing Diagnosis: Risk for imbalanced nutrition, less Outcome Evaluation: HYPOGLYCEMIA INTERVENTION:
than body requirements, related to additional POLYCYTHEMIA  LGA infant needs to be breastfed immediately to prevent
nutrients needed to maintain weight and prevent Infant’s weight follows percentile growth curve; hypoglycemia.
hypoglycemia skin turgor is good;  The infant may need supplemental formula feedings after
 specific gravity of urine is 1.003 to 1.030; s breastfeeding to supply enough fluid and glucose for the larger-
erum glucose is above 45 mg/dL. thannormal size for the first few days.

 BOTTLED FEED = difficulty than do others learning to breastfeed.

 Do not overestimate LGA infants’ ability to suck effectively at birth.
 should be able to suck well because they are already the size of a 2-
month-old.
 However, the infant is an inexperienced newborn, so sucking may not
be effective enough to obtain the larger-than-usual amount of milk
needed.

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