15. Risk for altered endocrine/metabolic processes related to hyperbilirubinemia and kernicterus.

5. Nursing care plan/implementation:
   1. Hypoglycemia—administer formula or IV glucose, as ordered (may cause rebound effect).
   2. Preterm/immature—institute preterm care prn.
   3. Hypocalcemia—administer oral or IV calcium gluconate, as ordered.
   4. Inform pediatrician immediately of signs of:
      1. Jaundice.
      2. Hyperirritability.
      3. Birth injury.
      4. Increased intracranial pressure/hemorrhage
6. Evaluation/outcome criteria:
   1. Infant makes successful transition to extrauterine life.
   2. Infant responds to medical/nursing regimen. Experiences minimal or no metabolic disturbances (hypoglycemia, hypocalcemia, hyperbilirubinemia).
   3. Infant exhibits normal respiratory function and gas exchange.

5. Hypoglycemia
   1. Pathophysiology—low serum-glucose level—» altered cellular metabolism —» cerebral irritability, cardiopulmonary problems.
   2. Etiology:
      1. Loss of maternal glucose supply.
      2. Normal physiologic activities of respiration, thermoregulation, muscular activity exceed carbohydrate reserve.
      3. Decreased hepatic ability to convert amino acids into glucose.
      4. More common in:
         1. Infants of diabetic mothers.
         2. Preterm, postterm infants.
         3. SGA infants.
         4. Smaller twin.
         5. Infant of mother with preeclampsia.
         6. Birth asphyxia.
   3. Assessment:
      1. Jitteriness, tremors, convulsions; lethargy and hypotonia.
      2. Sweating; unstable temperature.
      3. Tachypnea; apneic episodes; cyanosis.
      4. High-pitched, shrill cry.
      5. Difficulty feeding.
   4. Analysis/nursing diagnosis:
      1. Altered tissue perfusion (fetal) related to placental insufficiency associated with maternal diabetes, PIH, renal or cardiac disorders; erythroblastosis.
      2. Risk for altered endocrine metabolic processes related to high incidence of morbidity associated with birth asphyxia.
      3. Impaired gas exchange related to coexisting RDS.
      4. Altered nutrition, less than body requirements, related to hypoglycemia.
      5. High risk for injury related to coexisting infection, metabolic acidosis.
   5. Nursing care plan/implementation: see IV. Infant of the diabetic mother, p. 177.
   6. Evaluation/outcome criteria: see IV. Infant of the diabetic mother, p. 177.
6. Disorders affecting psychosocial-cultural functions: drug-dependent (heroin) neonate
   1. General aspects
      1. Maternal drug addiction has been associated with:
         1. Prenatal malnutrition and vitamin deficiencies.
         2. Increased risk of antepartal infections.
         3. Higher incidence of antepartal and intrapartal complications.
      2. Infant at risk for:
         1. Intrauterine growth retardation (IUGR).
         2. Prematurity.
         3. Fetal distress.
         4. Perinatal death.
         5. Child abuse.
         6. Sudden infant death syndrome (SIDS) (5-10 times higher than normal).
         7. Learning and behavior disorders.
         8. Poor social adjustment.
   2. Pathophysiology—withdrawal of accustomed drug levels —» physiological deprivation response.
   3. Etiology—repeated intrauterine absorption of heroin/cocaine/methadone from maternal bloodstream —» fetal drug dependency.
   4. Assessment—degree of withdrawal depends on type and duration of addiction and maternal drug levels at birth.
      1. Irritability, hyperactivity, hypertonicity, exaggerated reflexes, tremors, high-pitched cry, difficult to comfort:
         1. “Step" reflex—infant places both feet on surface; assumes rigid stance—does not “step” or dance.
         2. “Head-righting" reflex—holds head rigid; fails to demonstrate head-lag.
      2. Nasal stuffiness and sneezing; respiratory distress, tachypnea, cyanosis or apnea.
      3. Exaggerated acrocyanosis or mottling in the warm infant.
      4. Sweating.
      5. Hunger—sucks on fists; feeding problems— regurgitation, vomiting, poor feeding, diarrhea, and increased mucus production.
      6. Convulsions with abnormal eye-rolling and chewing motions.
      7. Developmental lags/mental retardation.
   5. Analysis/nursing diagnosis:
      1. High risk for injury related to convulsions secondary to physiological response to withdrawal, CNS hyperirritability.
      2. Impaired gas exchange related to respiratory distress secondary to inhibition of reflex clearing of fluid by the lungs.