Chapter 10 Nursing Care of the Newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier...

Chapter 10

Nursing Care

of the Newborn

Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Phases of Newborn Care


Objectives

Define key terms listed. Discuss the nursing responsibilities

concerning the care of the newborn infant. Describe a neutral thermal environment. Demonstrate three ways to hold a newborn. Demonstrate the proper way to suction the

newborn with a bulb syringe.


Three Phases of Newborn Care


Phases of Newborn Care

Phase 1: birth to 1 hour First period of reactivity; takes place in delivery

room Phase 2: 1 to 4 hours

Assessment is completed; may take place in newborn nursery or mother’s room

Phase 3: 4 hours to discharge Second period of reactivity; takes place in

mother’s room; involves nursing interventions and family teaching


Phase 1 Nursing Interventions


Clamping the Umbilical Cord

Initially white and gelatinous Two umbilical arteries and one vein (“AVA”)

Deviations should be reported immediately Begins drying within 1 to 2 hours after birth Once newborn is stabilized, disposable

umbilical clamp applied Bleeding/foul odor should be reported immediately

Cord cut shorter in length


Cord Care

May include Cotton swab with isopropyl alcohol Triple dye Saline or other solution ordered by health care

provider Clean around base of cord where it joins the

skin Do at every diaper change


Identification and Security

Matching ID bands placed on newborn and mother

Newborn has two: one on wrist, one on ankle

Electronic sensor may also be applied to infant’s band


Birth Certificates

Completed before discharge or within 48 hours of birth Health care provider should review data on

certificate, because it increases accuracy of information recorded

Need throughout life


Thermoregulation

Maintain a neutral thermal environment Allows for minimal oxygen consumption but is

adequate to maintain body temperature Room temperature should be maintained at 24° to

25° C (75.2° to 77° F)


Temperature Readings

Rectal or axillary Normal: 36.5°to 37.5°C (97.7°to 99.5°F) Hypothermia

Mild – 36° to 36.4° C (96.8° to 97.5°F) Moderate – 32.0°to 35.9°C (89.6°to 96.6°F) Severe – less than 32.6°C (90.7°F)


Hypothermia

Can cause Increased cell metabolism Increased oxygen consumption Hypoglycemia


Kangaroo Care

Newborn placed on naked chest of mother

Helps stabilize newborn’s body temperature


Administering IM Injection

Vitamin K (phytonadione [Aqua-MEPHYTON] 0.5 to 1 mg) Given to aid in blood clotting

Newborn cannot synthesize vitamin K without the presence of bacterial flora

Administer in mid-anterior thigh


Prophylactic Eye Care

Erythromycin ophthalmic ointment placed in both eyes

Prophylaxis against gonococcal ophthalmia neonatorum, which can cause blindness

Also destroys Chlamydia organisms


End of Phase 1 Care


Phase 2 Routine Nursing Interventions


Weight

Performed in birthing room or on admission to newborn nursery

Normal full-term newborn weighs approximately 3405 g (7 lbs, 8 oz) Scale zeroed with diaper in place; infant placed on

scale while nurse keeps hand above infant for safety

Initially loses weight but after 1 week gains about 200 g (7 oz) a week


Measurements

Measure Length Head circumference Chest circumference

Use disposable tape Document measurements in centimeters (cm)


Average Measurementsof Full-Term Infant

Weight: 3405 (7 lbs, 8 oz) Length: 48 to 53 cm (19 to 21 inches) Head circumference: 33 to 35.5 cm (13 to 14

inches) Chest circumference: 30.5 to 33 cm (12 to 13

inches)


Audience Response System Question 1

The nurse is bringing a newborn to her mother for breastfeeding. What should the mother and nurse do first?A. The mother should go to the bathroom and then

wash her hands.

B. Have the mother and nurse verify the ID bands between herself and the infant.

C. Observe the mother and infant interaction to see if the infant is ready to be fed.


Pain Assessment and Parent Teaching


Objectives

Describe newborn bathing and cord care to parents.

Interpret instructions for parents about newborn stools and voiding patterns.

Discuss care of the circumcised and uncircumcised penis.

Describe pain assessment and control in the newborn.


Objectives (cont.)

Explain the discharge care plan. Discuss five aspects of newborn care that the

mother should understand before discharge.


Protection from Infection

Cracks in skin increase vulnerability to infection

Hands, feet, and umbilical cord most common sites of infection Must perform hand hygiene before and after care Many institutions require 3 minute hand to elbow

scrub at the beginning of each shift


Signs of Newborn Infection

Poor feeding Lethargy Periods of apnea More obvious signs

Drainage Redness Possible odor


Hepatitis B Vaccination

All newborns should receive first vaccine within 12 hours of birth

Second injection at 1 month of age Third injection at 6 months of age


Assessing and Managing Pain in the Newborn

Untreated pain can have long-term effects Pain pathways and structures required for

long-term memory are well-developed by 24 weeks gestation

Several pain assessment tools are available


CRIES

10-point scale used postoperatively Newborn must be at least 32 weeks gestation Assesses

Facial expression Cry Movement of arms and legs Consolability Oxygen saturation


CRIES (cont.)

C: cry R: requires oxygen I: increased vital signs E: expression on face S: sleeplessness


PIPP

Premature infant pain profile Based on scales similar to CRIES


NIPS

Neonatal infant pain profile Based on scales similar to CRIES


N-PASS

Neonatal pain, agitation, and sedation scale Considers CRIES as well as behavior Very reliable and valid assessment tool

Especially of premature infants on a ventilator


FLACC

Face expression Leg movements Arousal and activity Cry high-pitched Consolability difficulty Rated on a 2-point scale

0 to 10 to rate newborn pain


Unrelieved Pain

Exhaustion Irritability Slow healing


Pain Treatments

Pharmacologic MSO4 or Fentanyl acetominophen

Nonpharmacologic, including Touching Stroking Swaddling Nonnutritive sucking (i.e., use of pacifiers)

• Avoid overstimulation


Promotion of Safety

Never leave infant unattended on table or scale

Hold infant while bottle-feeding Do not allow loss of body heat Place on side after feeding Placed on back for sleep Extra linen and diapers are not to be stored in

infant’s bassinet or crib


Facilitation of Parent-Newborn Attachment

Nurse teaches parents Newborn behaviors How to identify cues and how to respond

Newborns respond positively to stroking, massaging, and cuddling

Encourage mother to hold newborn en face


Phase 3 Parent Education


Call Health Care Provider

Instruct parents to call health care provider if infant shows any of the following signs and symptoms Fever Lethargy Irritability Poor feeding Dehydration Yellowing of skin


Bathing

Use to assess parent-infant interaction Teach techniques on how to wake a sleepy

newborn or calm an active one Important to maintain skin pH

Alkaline soaps, oils, powders, and lotion alter pH of skin

Provides medium for bacterial growth Avoid just after feeding


Positioning and Holding

Support head Firm mattress Supine


Ways to Hold an Infant


Nasal and Oral Suctioning

During the few days of life, the newborn has increased amounts of mucus

Teach parents the correct method of use Advise on how to clean the suction bulb Ask for return demonstration to ensure

parents can perform this task safely


Diapering

Fold diaper below umbilical stump to prevent urine or feces from contaminating the stump site

Clear water or premoistened wipes without chemicals or fragrances are best

Mild soap with water may be necessary to remove some stools


Diaper Rash

Results from ammonia irritation from the urine Vitamins A&D ointment or zinc oxide cream

can be applied after genitalia and buttocks have been cleaned

Some infants develop a rash where the plastic from the diaper comes in contact with the skin

Advise parents on what to observe for


Clothing

Dress infant according to weather Do not overdress or underdress infant,

because it may increase metabolic rate to try to keep warm or cause dehydration and heat stroke T-shirts, diaper, light- to medium-weight stretch

sleeper Hats in cool and hot weather

Wash clothing in mild soap, rinse thoroughly


Circumcision

Surgical removal of the foreskin of the penis Decision usually based on hygiene, religious

beliefs, culture, or social norms If phimosis present, infant should be

circumcised, since the foreskin cannot be retracted and can cause injury


Circumcision Techniques

Yellen or Gomco clamp or Plastibell Written consent from mother required Infant placed on circumcision board

Nerve block, topical analgesia is given for pain relief Pacifier with glucose for soothing infant

Sterile gauze with petroleum jelly or A&D ointment is applied to penis once procedure completed


Complications of Circumcision

Infection Hemorrhage Assess for pain, swelling, bleeding, voiding If bleeding occurs, apply gentle pressure with

a sterile gauze pad or apply powdered Gelfoam


Caring for the Uncircumcised Penis

Avoid forceful retraction of foreskin Wash penis with water only during infancy For toddler, gentle retraction during bathing

and drying prevent moisture from accumulating under foreskin

School-aged child is taught to retract foreskin at least once a week during bathing

Full retraction of foreskin may not be possible before puberty


Cardiopulmonary Resuscitation

Parents are advised to learn basic CPR and instructed on when to call 911 or emergency assistance


Cultural Beliefs and Practicesin Newborn Care

Influence type of care given to newborns Develop teaching plan around cultural beliefs

as much as possible Demonstrate a nonjudgmental attitude If practices are considered to be potentially

harmful, discuss concerns with family


Discharge and Follow-Up Care


Car Seats

Should not move more than 1 inch in any direction

Rear-facing position for infants less than 9 kg (20 lb) or less than 1 year of age

Newborns should be placed in seat that reclines 45 degrees


Follow-Up Care After Discharge

American Academy of Pediatrics recommends a follow-up office visit within 7 days of discharge from hospital or delivery


“Safety Net” Numbers

Provide telephone numbers for the Nursing unit Lactation consultant Health care provider


Discharge Teaching

Should include Breastfeeding or bottle-feeding Bowel and bladder patterns Cord care Skin care Signs of illness Car seat use Follow-up care


Questions for Review


Parent Education

Why is discharge planning integrated into all phases of newborn care?

How do shorter hospital stays influence discharge planning and its importance?

Why are support services important? What written information should be provided

to parents? Why should written as well as verbal information be provided?


Parent Education (cont.)

What findings should parents report to a health care provider after discharge?

How soon should a follow-up visit occur after discharge?

What pain control methods can be used during circumcision?

Is it recommended to use diaper wipes on a healing circumcised penis? Describe circumcision care. Describe care of the uncircumcised penis.


Parent Education (cont.)

Are car seats required for neonates? In what position should they be placed?

Where should an infant car seat be installed? Why?

How does infant CPR differ from adult CPR? Why are repeat demonstrations valuable in

parent education?


Review Key Points


Chapter 10 Nursing Care of the Newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier...

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Transcript of Chapter 10 Nursing Care of the Newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier...