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:
   6. Evaluation/outcome criteria:


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.
      3. Altered nutrition, less than body requirements, related to feeding problems secondary to respiratory distress and GI hypermotility.
      4. High risk for impaired skin integrity related to scratching, secondary to withdrawal symptoms.
   6. Nursing care plan/implementation:
      1. Goal: prevent/minimize respiratory distress.
         1. Position: side-lying, head dependent - to facilitate mucus drainage.
         2. Suction prn with bulb syringe for excess mucus - to maintain patent airway.
         3. Monitor respirations and apical pulse.
      2. Goal: minimize possibility of convulsions.
         1. Decrease environmental stimuli - quiet, touch only when necessary, offer pacifier.
         2. Keep warm, swaddle for comfort.
      3. Goal: maintain nutrition/hydration.
         1. Food/fluids - oral or IV, as ordered.
         2. I&O.
         3. Daily weight.
      4. Goal: assist in diagnosis of drug and drug level. Collect all urine and meconium during first 24 hr for toxicologic studies.
      5. Goal: maintain/promote skin integrity.
         1. Mitts over hands - to minimize scratching.
         2. Keep clean and dry.
         3. Medicated ointment/powder, as ordered, q2-4h, to excoriated areas.
         4. Expose excoriated areas to air.
      6. Goal: minimize withdrawal symptoms. Administer medications, as ordered.
         1. Paregoric elixir - to wean from drug.
         2. Phenobarbital - to reduce CNS hyperirritability, hyperbilirubinemia.
         3. Chlorpromazine , diazepam - to tranquilize, reduce hyperirritability. Note: Valium is contraindicated for jaundiced neonate because it predisposes to hyperbilirubinemia.
         4. Methadone.
      7. Goal: emotional support to mother.
         1. Encourage verbalization of feelings of guilt, anxiety, fear, concerns.
         2. Refer to social service.
   7. Evaluation/outcome criteria:
      1. Infant responds to medical/nursing regimen.
         1. Maintains adequate respirations.
         2. Feeds well, gains weight.
         3. No evidence of CNS hyperirritability, convulsions; demonstrates normal newborn reflexes.
      2. Infant evidences bonding with parent(s). Responsive to mother’s voice.