HAND-OUT (READ AND REVIEW)

B. NURSING CARE OF THE HIGH RISK NEWBORN

ASSESSMENT:
1. APGAR score- provides immediate assessment for the need of resuscitation; done in
1 & 5 minutes of life. It has five parameters : Skin color, Respiration, Cardiac rate, Muscle
tone, reflex irritability
2. Ballatd’s Scoring – assesses the age of gestation of the newborn with 2 components:
PRIORITY NEEDS OF THE NEWBORN:
1. Initiation of Respiration- 40-60/min
- Most deaths occurring during the first 48 hours after birth result from the newborn’s
inability to maintain adequate respirations. If he survives, the child may experience
residual neurologic difficulties because of cerebral hypoxia. Prompt and thorough care
is necessary for effective intervention
- Sneezing, coughing are mechanism to clear the airway. A vigorous , strong cry is a proof
that lung expansion is good because vocal sounds are produced by a free flow of air
- Efforts to prevent hypothermia by wiping the baby dry will help the newborn initiate and
sustain respiratory effort and prevent acidosis
- An infant who breathes spontaneously but then cannot sustain effective respirations
may need oxygen by bag and mask to aid lung expansion at a rate of 40-60 compressions
per minute.
- An infant with difficulty maintaining respirations should be placed under a radiant warmer
and position on his back with the head of the bed elevated approximately 15 degrees.
This would allow the abdominal contents to fall away from the diaphragm and allow
additional breathing space
- If respiratory depression appears to be related to the administration of a narcotic such
as morphine sulfate, Demerol to the mother during labor, a narcotic antagonist may be
given, NALOXONE (Narcan) injected into an umbilical vessel or intramuscularly into the
thigh.

- Note: If with Meconium aspiration syndrome, do not give oxygen under pressure
because it will push the meconium further , may give oxygen by face mask.

- An increasing RR, is often a first sign of obstruction or or respiratory compromise. Check

for chest indrawing or retractions (inward sucking of the anterior chest wall on inspiration).
This reflects the difficulty of the newborn to draw in air.

- An adequate respiration will lead to the closure of the patent ductus arteriosus and
foramen ovale (open structures during fetal circulation)

2. Establish extrauterine circulation- 120-160 beats /minute

- If no audible heartbeat or 80 beats/min, do closed chest massage at a rate of 100x/min,

lung ventilation at arate of 30x/min
- Palpate femoral pulse to check return of pulse
- If heart sound does not resume above 80 beats/min after 30 secs of cardiac
compression, 0.3 ml/kg of Epinephrine may be given endotracheally to stimulate cardiac
function

3. Maintaining Fluid and Electrolyte Balance

- Note for Hypoglycemia- < 40 mg/dl. There is increase energy expenditure to initiate
breathing. Early breastfeeding would help maintain calorie needs.

- Dehydration may result from insensible fluid loss from rapid respiration. It may be
monitored by urine output and urine specific gravity measures. An output of < 2ml/kg/hr
or a Specific gravity of >1.015-1.020 suggests inadequate fluid intake.

4. Regulating temperature – maintained at 36.5 C or 97.8 F (97-99.5F)

(Process of Heat Loss: Evaporation, Conduction, Convection, Radiation)
- Keep the NB in a neutral temperature environment. Rationale: Cold temp increases
metabolism to warm body cells; Hot temp decrease metabolism to cool their body
- Wipe baby dry and cover head with bonnet.
- Do Kangaroo Mother Care- skin to skin contact
- Radiant heat sources are kept at 36.5 C
5. Establishing Adequate Nutritional Intake
- Infant should not lose > 10% of bodyweight
- All infants should be breastfed. Preterm infants with good sucking can be breastfeed
early.
- Intravenous feeding is given to infants who suffered from asphyxia
- Gavage feeding may be given : may use expressed breastmilk
6. Establishing waste elimination
- Voids 6-8 /day; defecates 2-3x/day
- Infants void within 24 hours of birth, but preterm infants may void later as a result of
procedures and resuscitation, their blood pressure are not adequate to optimally supply
their kidneys.
- Immature infants may pass stool later than term infants because their stool has not yet
reached the end of the intestine at birth
7. Preventing Infection
- Infection stresses the immature immune system of the newborn
- Review labor and delivery history; presence of prolonged labor and rupture of
membranes because this poses a risk to infection
-Common causes: TORCH infections, Group B streptococcus (Septicemia), Candidiasis
(NB oral thrush), Herpes infections, Gonorrhea & chlamydial infections (Opthalmia
Neonatorum)
- Prevent skin breakdown, care of cord stump: Handwashing, no binders, clean with clean
water
- Observe handwashing to reduce infection transmission
8. Establishing Parent–Infant Bonding
> Be certain that the parents of a high-risk newborn are kept informed of what is
happening during resuscitation at birth.

> They should be able to visit the special nursing unit to which the child is admitted as
often as they choose, and, after washing and gowning, hold and touch their child.

1. POOR APGAR SCORE

(REVIEW THE APGAR SCORING & ITS INTERPRETATION – 5 PARAMETERS:
COLOR,
CR, RR, REFLEX IRRITABILITY , MUSCLE TONE,
INTERPRETATION: 0-3 =SEVERE DISTRESS; 4-6 = MODERATE DISTRESS; 7-10
WELL ADJUSTED TO EXTRAUTERINE LIFE
CAUSES:
A. Hypothermia- contributes to sluggish circulation added to the immaturity of the
peripheral circulation , this leads to cyanosis or acrocyanosis altering the color of
the skin

B. Congenital Defects/ malformations - presence of congenital heart problem such

as Transposition of the great vessels leading to cyanosis altering the color of the
skin

C. Altered respiration/Poor gas exchange

REF. e- book- Pilliteri

/ecferrer