SEMINAR

ON
HIGH RISK NEW BORN

SUBMITTED TO:
[Link], [Link](N),
ASSOCIATE PROFESSOR,
DEPT: CHILD HEALTH NURSING,
SREE BALAJI COLLEGE OF NURSING,
CHROMPET.

SUBMITTED BY:
[Link] DEVA GNANAM,
[Link] NURSING I YEAR,
SREE BALAJI COLLEGE OF NURSING,
CHROMPET.

SUBMITTED ON:

18.03.2022
 HIGH RISK NEW BORN
INTRODUCTION:

Newborns those are susceptible to illness or death due to dysmaturity, immaturity, physical
disorders, or complications at birth.

DEFINITION/IDENTIFICATION:

A high risk neonate can be defined as a newborn regardless of gestational age or birth weight that
has greater than average chance of morbidity or mortality because of conditions or circumstances
associated with birth and the adjustment to extrauterine existence.

FACTORS TO DEFINE HIGH RISK NEWBORN:

A) DEMOGRAPHIC SOCIAL FACTORS:

Maternal age <16 or >40, Unmarried, Physical stress, Socio economic status.

B) PAST MEDICAL HISTORY:

Diabetes Mellitus, Genetic disorders, Hypertension

C) PREVIOUS PREGNANCY:

Intrauterine death, neonatal death, IUGR, Congenital malformations.

D) PRESENT PREGNANCY:

Vaginal bleeding , PROM, Multiple gestation, Pre eclampsia, Abnormal USG findings.

E) LABOR AND DELIVERY:

Obstructed labor, fetal distress, forceps delivery, meconium stained liquor.

F) NEONATE:

Birth weight < 2000 or > 4000, gestation < 37 or > 42, SGA , respiratory distress, congenital
malformation.

CLASSIFICATION:

HIGH RISK NEW BORN

According to Size According to Gestational Age According to mortality

[Link] Birth Weight [Link] Term [Link] Birth

[Link] Low Birth Weight [Link] Term [Link] Death

[Link] Low Birth Weight [Link] Pre Term [Link] Death

[Link] to Gestational Age [Link] Term [Link] Death

[Link] for Gestational Age

[Link]

[Link] for Gestational Age

CLASSIFICATION ACCORDING TO SIZE:

❖ LOW BIRTH WEIGHT (LBW) NEWBORN:

A new born whose birth weight is less than 2500 g regardless of gestational age.

❖ VERY LOW BIRTH WEIGHT (VLBW) NEWBORN:

A new born whose birth weight is less than 1500 g.

❖ EXTREMELY LOW BIRTH WEIGHT (ELBW) NEWBORN:

A new born whose birth weight is less than 1000 g.

❖ APPROPRIATE FOR GESTATIONAL AGE (AGA) NEWBORN:

A new born whose weight falls between the 10th and 90th percentiles on intrauterine growth
curves.

❖ SMALL FOR DATE (SFD) OR SMALL FOR GESTATIONAL AGE (SGA) NEWBORN:

A new born whose rate of intrauterine growth was slowed and whose birth weight fall below
the 10th percentile on intrauterine growth curves.

❖ INTRAUTERINE GROWTH RESTRICTION (IUGR):

Found in neonates whose intrauterine growth is restricted

1. SYMMETRIC IUGR:

Growth restriction in which the weight, length and head circumference are all affected.

2. ASYMMETRIC IUGR:

Growth restriction in which the head circumference remains within normal parameters while
the birth weight falls below the 10th percentile.

❖ LARGE FOR GESTATIONAL AGE (LGA) NEWBORN:

A new born whose birth weight falls above the 90th percentile on intrauterine growth chart.
CLASSIFICATION ACCORDING TO GESTATIONAL AGE:

❖ PRE TERM (OR) PRE MATURE NEWBORN:

A neonate born before completion of 37 weeks of gestation regardless of birth weight.

❖ FULL TERM NEWBORN:

A neonate born between the beginning of the 38 weeks and the completion of the 42 weeks of
gestation regardless of birth weight.

❖ LATE PRE TERM NEWBORN:

A neonate born between 34 0/7 and 36 6/7 weeks of gestation regardless of birth weight.

❖ POST TERM (OR) POSTMATURE NEWBORN:

A neonate born after 42 weeks of gestational age regardless of birth weight.

CLASSIFICATION ACCORDING TO MORTALITY:

❖ LIVE BIRTH:

Birth in which the neonate manifests any heartbeat, breathes or displays voluntary movement
regardless of gestational age.

❖ FETAL DEATH:

Death of the fetus after 20 weeks of gestation and before delivery with absence of any signs
of life after birth.

❖ NEONATAL DEATH:

Death that occurs in the first 27 days of life, early neonatal death occurs in the first week of
life; late neonatal death occurs at 7 to 27 days.

❖ PERINATAL MORTALITY:

Total number of fetal and early neonatal deaths per 1000 live births.

HIGH RISK RELATED TO PHYSIOLOGICAL FACTORS:

❖ HYPOTHERMIA:
Definition:
It is a condition characterized by lowering of body temperature than 36 C.
This occurs due to factors other than those immediately associated with delivery.
Example: Acute infection especially Septicemia.
Based on Severity:
• Mild Hypothermia <36 C
• Moderate Hypothermia <35.5 C
• Severe Hypothermia <35 C
 Clinical Features:
✓ Decrease in body temperature
✓ Cold Skin on trunk and extremities
✓ Poor feeding
✓ Shallow respiration
✓ Cyanosis
✓ Decrease activity Example: Weak cry.
Prevention:
✓ Keep infants out of drafts.
✓ Infant should be wrapped in a warm towel.
✓ Use extra clothes and blankets.
✓ Avoid exposure to direct source of air drafts.
✓ Check body temperature frequently.
✓ Give antibiotic if infection is present.
❖ HYPERTHERMIA:
Definition:
It is a condition characterized by an elevation in body temperature more than 37.5 C.
Causes:
✓ Disturbance in Heat Regulating Centre.
✓ Incubator temperature is set too high.
Management:
✓ Undress the infant. If at home keep light cloths, or only diaper if the infant is inside an
incubator.
✓ Reduction of incubator temperature.
✓ Provide tepid sponge bath.
✓ Increase fluid intake in the form of 5cc of Glucose 5% to prevent dehydration.

❖ HYPOGLYCEMIA:
Definition:
Neonatal hypoglycemia is usually defined as a serum glucose value of < 40-45 mg/dl.

Clinical Manifestations:
✓ Hypotonia
✓ Poor Feeding
✓ Tremors
✓ Lethargy
✓ Seizures
✓ Hypothermia
✓ Irregular respiratory pattern (Apnea)
✓ Irritability
✓ Poor reflexes especially sucking reflex.
Management:
✓ Enteral feeding must be started (nipple or tube feeding).
✓ A continuous infusion of 10% dextrose at a rate of 8 mg/kg/min should be started.
✓ Frequent monitoring of blood glucose.
 ❖ HYPERBILIRUBINEMIA:
Definition:
It is an elevation in the neonatal serum bilirubin more than 12.9 mg/dl. Characterized by Jaundice
yellowish discoloration of the skin and mucus membranes.
Management:
Phototherapy:
[Link] the infant’s eyes and genital organs.
[Link] infant must be turned frequently to expose all body surface areas to the light.
[Link] Serum Bilirubin level
[Link] oily lubricants or lotion on the skin because this can act as a barrier that prevent the
penetration of light through the skin.
[Link] the baby at regular intervals.
[Link] Intake output.

❖ HEMOLYTIC DISEASE OF NEWBORN

❖ RESPIRATORY DISTRESS SYNDROME
❖ RESPIRATORY COMPLICATIONS
❖ CARDIOVASCULAR COMPLICATIONS
❖ CEREBRAL COMPLICATIONS
❖ NEONATAL SEIZURES

HIGH RISK RELATED TO INFECTIOUS PROCESSES:

❖ SEPSIS:
Definition:
Neonatal sepsis is a disease of neonates in which they are clinically ill and have a positive blood
culture.
Types:
Early onset sepsis: Present within 24 -72 hours
Late onset sepsis: Beyond first 72 hours of life and is acquired from the care giving environment.
Clinical features:
✓ Decreased activity
✓ Excessive crying
✓ Apnea
✓ Jaundice
✓ Hypothermia
✓ Bulging fontanel
✓ Seizures
✓ Hypotonia
Lab findings:
✓ Raised Total Leucocyte Count
✓ Raised C-reactive protein
✓ Increased ESR
✓ Cultures positive
Management:
✓ Infection Control Practices including Isolation Precautions
✓ Antibiotics
 ❖ NECROTIZING ENTEROCOLITIS(NEC):
NEC is an acute inflammatory disease of the bowel with increased incidence in pre term and other high
risk infants.

HIGH RISK RELATED TO MATERNAL CONDITIONS:

❖ Infants of diabetic mothers

❖ Drug exposed infants
❖ Cocaine exposed
❖ Infections acquired from mother
❖ HIV
❖ Varicella
❖ Chlamydia
❖ Coxsackievirus
❖ Cytomegalovirus
❖ Hepatitis B
❖ Rubella
❖ Syphillis
❖ Toxoplasmosis

ASSESSMENT:

❖ GENERAL ASSESSMENT:
• Weigh daily or more often if indicated.
• Measure length and head circumference at birth.
• Describe general body shape and size, posture at rest, ease of breathing, presence and
location of edema.
• Describe any apparent deformities.
• Describe any signs of distress-poor color, hypotonia, lethargy, apnea.

❖ RESPIRATORY ASSESSMENT:
• Shape of chest (barrel, concave), symmetry, presence of incisions, chest tubes or other
deviations.
• Use of accessory muscles-nasal flaring or substernal, intercostal or suprasternal
retractions.
• Respiratory rate and regularity.
• Auscultate breath sounds-crackles, wheezing, wet or diminished sounds, grunting,
diminished air movement, stridor, equality of breath sounds.
• Describe cry.
• Describe ambient oxygen and method of delivery; if intubated describe size and
position of tube, type of ventilator, and settings.
• Oxygen saturation, partial pressure of O2 and CO2.

❖ CARDIOVASCULAR ASSESSMENT:
• Heart rate and rhythm.
 • Heart sounds (any murmurs).
• Infant’s color (cyanosis, pallor, plethora, jaundice, mottling)
• Color of mucus membranes, lips.
• Check BP if indicated.
• Check peripheral pulses, capillary refill and peripheral perfusion.
• Check the monitors, their parameters and alarms are ON.

❖ GASTROINTESTINAL ASSESSMENT:
• Presence of abdominal distention-increase in circumference, shiny skin, erythema,
visible peristalsis, visible loops of bowel, status of umbilicus.
• Any signs of regurgitation and time of feeding.
• Describe amount, color, consistency, odor of any emesis.
• Palpate liver margin.
• Describe amount, color and consistency of stools.
• Presence or absence of bowel sounds.

❖ GENITOURINARY ASSESSMENT:
• Any abnormalities of gentalia.
• Describe amount, color, pH , specific gravity of urine.
• Check weight.

❖ NEUROLOGIC MUSCULOSKELETAL ASSESSMENT:

• Infant’s movements-random, purposeful, jittery, twitching, spontaneous, elicited.
• Infant’s position (flexed, extended).
• Reflexes observed (moro, sucking, babinski, plantar, etc)
• Level of response and consolability.
• Changes in head circumference, size, fontanels, suture lines.
• Pupillary responses

❖ TEMPERATURE:
• Axillary temperature.
• Environmental Temperature.

❖ SKIN ASSESSMENT:
• Skin lesions, rash or birth marks
• Discoloration, reddened area, signs of irritation, blisters, abrasions (especially
monitoring equipment, infusions or other apparatus come in contact with skin.
• Texture and turgor of skin (dry, smooth, flaky, peeling)
• Assess for Arterial, venous, peripheral, umbilical, central lines.
DIAGNOSTIC EVALUATION:

✓ History Collection
✓ Physical Examination
✓ Complete Blood Count
✓ ABG
✓ Blood sugar level
✓ Electrolyte level
✓ Blood smear test
✓ X-Ray
✓ Ultrasound
✓ CT

MANAGEMENT:

❖ THERMOREGULATION:
The most crucial need of LBW infants is application of external warmth. In healthy infants,
it is recommended that axillary temperatures be maintained at 36.5 -37.5 C (97.7-99.5 F). The
three primary methods for maintaining a neutral thermal environment are the use of an
Incubator, a radiant warming panel, and a open bassinet with cotton blankets.

❖ KANGAROO MOTHER CARE:

Skin to Skin contact between a stable pre term infant and parent is also a viable option for
interaction because of the maintenance of appropriate body temperature by the [Link] is
simple, easily applicable, cost effective.

Benefits of Kangroo Mother Care to the baby:

✓ Stabilizing your baby’s heart rate
✓ Improving your baby’s breathing pattern and making the breathing more regular
✓ Improving oxygen saturation levels
✓ Gaining in sleep time
✓ Better adaptation to the environment
✓ Promotes healthy weight gain
✓ Aids better mental development
✓ Makes breastfeeding convenient
✓ Decreasing crying
✓ Having more successful breastfeeding episodes
✓ Having an earlier discharge

Benefits of Kangroo Mother Care to the mother:

✓ Improving bonding with your baby and feeling of closeness
 ✓ Increasing your breast milk supply
✓ Helps the mother to fight postpartum depression
✓ Increasing your confidence in the ability to care for your baby
✓ Increasing your confidence that your baby is well cared for
✓ Increasing your sense of control
✓ Helps in bonding with the father.

Essential Components of KMC:

➢ Skin to Skin Contact
➢ Exclusive breastfeeding
➢ Support to the mother and the baby

❖ PROTECTION FROM INFECTION:

• The sources of infection rise in direct relationship to the number of persons and pieces of
equipment coming in contact with the infants.
• Equipment used in the care of infants is cleaned on a regular basis as per institution protocol.
• Cleaning of cribs , mattresses, incubators, radiant warmers, monitors, etc
• Standard Precautions ( PPE),Hand Hygiene, Umblical Cord Care.

❖ HYDRATION:
Adequate hydration is particularly important in infants because their extracellular water
content is larger and the capacity for handling fluid shifts is limited in pre term infants’
underdeveloped kidneys. Therefore, these infants are highly vulnerable to fluid depletion.

❖ NUTRITION:
The amount and method of feeding are determined by the infant’s size and condition.
Nutrition can be provided by either enteral or parenteral routes or by the combination of both.

BREAST FEEDING: Human milk is the best source of nutrition for term and pre term [Link]
offers the best balance of nutrients-proteins, carbohydrates, fat, minerals, vitamins and water
in the right quantity to meet the growth and development needs of babies.
✓ Perfect nutrition
✓ Protection
✓ Brain power
✓ Ready and portable
✓ Size does not matter
✓ Good for mothers too
✓ Builds a special bond
✓ Advantages continue as baby grows
✓ Good for the planet
✓ Easy on the budget

❖ ENERGY CONSERVATION:

• This is one of the major goals of care for the high risk infant.
 • Diminish environmental noice levels and shade the infant from bright light to promote
rest.
• Position the baby in prone.
• Avoid frequent handling.

❖ SKIN CARE:

High risk newborns are highly susceptible to skin impairment caused by invasive
procedures, radiant warmer, phototherapy, etc
• Nappy Care
• Eye Care
• Oral Care
• Bathing/Sponge Bathing
• Umblical Cord Care
• Adhesives

❖ ADMINISTRATION OF MEDICATIONS:

• Administration of therapeutic agents such as drugs, ointments, IV infusions and oxygen

requires judicious handling and meticulous attention. The preparation, administration of
drugs often requires collaboration among health care team to reduce the chance of error.
• Nurses should be aware of the hazards of medication administration in infants.

❖ FAMILY SUPPORT AND INVOLVEMENT:

• The birth of a pre term or high risk infant is an unexpected and stressful event for which
families are emotionally unprepared.
• The Treating Physician of the infant or the assigned nurse should explain the parents
regarding the current condition of the infant, ongoing treatment, improvements, procedures
planned, etc in simple terms.

❖ FAMILY CENTERED CARE:

• Facilitating Parent and Infant Relationship

• Siblings
• Support Groups

❖ DISCHARGE PLANNING AND HOME CARE:

• Parents become excited as the time for discharge approaches.

• Appropriate instruction must be provided.
• Nurses need to assist the parents in acquiring or increasing their skills in the care of their
infant.
 ❖ NEONATAL LOSS:

Nurses in NICU are the persons who must prepare the parents for an inevitable death,
provide end of life care for the infant and family, facilitate a family grieving process after an
expected or unexpected death.

FOLLOW UP:

Neuro developmental delay: Supervise & screen for developmental delay with
Neonatologist and team

✓ Pediatric Neurologist
✓ Geneticist
✓ Speech Therapist
✓ Endocrinologist
✓ Pediatric Surgeon
✓ Assessment of feeding and dietary counseling
✓ Growth monitoring
✓ Developmental assessment
✓ Immunization
✓ Ongoing problems
✓ Neurological assessment
✓ Eye evaluation
✓ Hearing evaluation

NURSING DIAGNOSIS:

❖ Ineffective breathing pattern related to pulmonary and neuromuscular immunity, decreased

energy, and fatigue.

❖ Ineffective thermoregulation related to immature temperature control and decreased

subcutaneous fat.

❖ Pain related to procedure, diagnosis and treatment.

❖ Altered nutrition less than body requirements related to inability to ingest nutrients because of
immaturity and/or illness.

❖ Altered growth and development related to pre term birth, separation from parents.
 ❖ Altered family process related to situational/maturational crisis, knowledge deficit, interruption
of parental attachment process.

❖ Anticipatory grieving related to unexpected birth of high risk newborn, death of neonate.

❖ Risk for infection related to deficient immunologic defences.

❖ Risk for fluid volume deficit related to immature physiologic characteristics of pre term
neonate.

❖ Risk for impaired skin integrity related to immature skin structure, immobility, decreased
nutritional state invasive procedures.

❖ Risk for injury related to immature central nervous system and physiologic stress response.

CONCLUSION:

The goal of providing high quality care to high risk infants can be achieved through
continuing efforts by all participating providers and institutions to develop and sustain
communications and understanding based on professional interaction and mutual respect
throughout the health care. system.

BIBLIOGRAPHY

BOOK REFERENCE:

❖ Wong’s Essential of Pediatric Nursing, Sixth Edition, Published by Harcourt (India) Private
Limited. Page No:252-315.
❖ Rimple Sharma, Essential’s of Pediatric Nursing, 2013 Edition, Jaypee Brothers Medical
Publishers. Page No:180-195.
❖ Parul Datta, Pediatric Nursing,4th Edition, Jaypee Publishers, Page No:97-107.
❖ Susamma Varghese, Anupama Susmitha , Textbook of Pediatric Nursing, 2015 Edition, Jaypee
Publishers, Page No:173-186.
❖ [Link], Essentials of Pediatric Nursing, 2017 Edition, Jaypee Publishers, Page No:85-96.
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[Link] › rcefac
[Link] › education
[Link] › wiki ›
[Link] risk neonate

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❖ Journal of Pediatric Nursing, Nurses in Action: A Response to cultural care challenges in

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❖ NB MATHUR, A GUPTA, [Link]. Indian Academy of Pediatrics. Pulse Oximetry

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❖ GANG YANG, YINGLI, XIAOPING JIANG. Indian Journal of Pediatrics. Diagnostic

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