Nursing Care of the Newborn and Family Chapter 24 Nursing Care of the Newborn and Family Copyright © 2016 by Elsevier Inc. All rights reserved.

Learning Objectives Explain the purpose and components of the Apgar score. Describe how to perform a physical assessment of a newborn. Describe how to perform a gestational age assessment of a newborn.

Learning Objectives (Cont.) Compare the characteristics of the preterm, late preterm, early term, and postterm neonate. Provide nursing care to assist the newborn to transition to extrauterine life. Explain the elements of a safe environment.

Learning Objectives (Cont.) Discuss phototherapy and the guidelines for teaching parents about this treatment. Explain the purposes and methods for circumcision, the postoperative care of the circumcised infant, and parent teaching regarding circumcision. Describe the procedures for administering an intramuscular injection, performing a heelstick, collecting urine specimens, and venipuncture.

Learning Objectives (Cont.) Evaluate pain in the newborn based on physiologic changes and behavioral observations. Discuss pharmacologic and nonpharmacologic interventions to reduce neonatal pain. Review anticipatory guidance nurses provide to parents before discharge.

Care Management: Birth Through the First 2 Hours Assessment Immediate care after birth Initial physical assessment Apgar scoring Heart rate Respiratory rate Muscle tone Reflex irritability Generalized skin color

Care Management: Birth Through the First 2 Hours (Cont.) Physical assessment General appearance Vital signs Baseline measurements of physical growth Weight Head circumference Body length

Care Management: Birth Through the First 2 Hours (Cont.) Neurologic assessment Newborn reflexes Gestational age assessment Dubowitz Scale New Ballard Scale

Gestational age assessment (Cont.)

Care Management: Birth Through the First 2 Hours (Cont.) Gestational age assessment (Cont.) Classification of newborns by gestational age and birth weight Appropriate for gestational age (AGA) Large for gestational age (LGA) Small for gestational age (SGA)

Gestational age assessment (Cont.)

Care Management: Birth Through the First 2 Hours (Cont.) Gestational age assessment (Cont.) Classification by gestation Preterm or premature—born before completion of 37 weeks of gestation, regardless of birth weight Late preterm—34 0/7 through 36 6/7 weeks Early term—37 0/7 through 38 6/7 weeks Full term—39 0/7 through 40 6/7 weeks Late term—41 0/7 through 41 6/7 weeks Postterm—42 0/7 weeks and beyond Postmature—born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency

Neonatal Interventions Airway maintenance Side-lying position Bulb syringe Use of nasopharyngeal catheter with mechanical suction apparatus Maintaining an adequate oxygen supply Maintaining body temperature

Neonatal Interventions (Cont.) Immediate interventions Eye prophylaxis To prevent ophthalmia neonatorum or neonatal conjunctivitis Vitamin K administration Promoting parent-infant interactions

Care Management: From 2 Hours After Birth Until Discharge Common problems in newborns Birth injuries Retinal and subconjunctival hemorrhages Soft-tissue injuries: erythema, ecchymoses, petechiae Trauma secondary to dystocia Accidental lacerations

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Common problems in newborns (Cont.) Physiologic problems Jaundice Assessment and screening Therapy for hyperbilirubinemia Phototherapy Types of phototherapy Precautions Exchange transfusion

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Common problems in newborns (Cont.) Hypoglycemia Usually defined as blood glucose levels less than 45 mg/dl Hypocalcemia Serum calcium levels of less than 7.8 to 8 mg/dl in term infants and slightly lower (7 mg/dl) in preterm infants

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Laboratory and diagnostic tests Universal newborn screening Mandated by U.S. law Early detection of genetic diseases that result in severe health problems if not treated early Newborn hearing screening Screening for critical congenital heart disease (CCHD)

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Collection of specimens Heelstick Venipuncture Urine specimen Interventions Protective environment Environmental factors Infection control factors

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Preventing infant abduction Preventing newborn falls

Care Management: From 2 Hours After Birth Until Discharge (Cont.)

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Therapeutic and surgical procedures Intramuscular injection Immunizations Circumcision Policies and recommendations Parental decision Procedure Yellen (Gomco) clamp Mogen clamp PlastiBell device

Care Management: From 2 Hours After Birth Until Discharge (Cont.)

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Therapeutic and surgical procedures Circumcision Procedural pain management Care of the newly circumcised infant

Neonatal Pain Neonatal responses to pain Behavioral responses Most common sign is vocalization or cry Physiologic/autonomic responses Changes in heart rate Blood pressure Intracranial pressure Vagal tone Respiratory rate Oxygen saturation

Neonatal Pain (Cont.) Assessment of neonatal pain Neonatal Infant Pain Scale (NIPS) Premature Infant Pain Profile (PIPP) Neonatal Pain Agitation and Sedation Scale (NPASS) CRIES—for use in the neonatal intensive care unit (NICU)

Neonatal Pain (Cont.) Management of neonatal pain Nonpharmacologic management Containment (swaddling) Nonnutritive sucking Oral glucose Skin-to-skin contact Breastfeeding

Neonatal Pain (Cont.) Management of neonatal pain Pharmacologic management Local and topical anesthesia Nonopioid analgesia Acetaminophen Opioid analgesia Morphine Fentanyl

Care Management: From 2 Hours After Birth Until Discharge (Cont.) Promoting parent-infant interactions Assess attachment behaviors Support and education for parents Cultural considerations

Discharge Planning and Teaching Temperature Respirations Use of bulb syringe Feeding patterns Elimination Positioning and holding Safe sleep positions Sudden infant death syndrome (SIDS)

Discharge Planning and Teaching (Cont.) Rashes Diaper Other (rash on the cheeks, erythema toxicum) Clothing Car seat safety Nonnutritive sucking Bathing Cord care Skin care

Discharge Planning and Teaching (Cont.)

Discharge Planning and Teaching (Cont.) Infant follow-up care Immunizations Cardiopulmonary resuscitation Practical suggestions for first week at home Interpretation of crying and use of quieting techniques Recognizing signs of illness

Key Points Assessment of the newborn requires data from the prenatal, intrapartal, and postnatal periods. The immediate assessment of the newborn includes Apgar scoring and a general evaluation of physical status. Knowledge of biologic and behavioral characteristics is essential for guiding assessment and interpreting data.

Key Points (Cont.) Gestational age assessment provides important information for predicting risks and guiding care management. Nursing care immediately after birth includes maintaining an open airway, preventing heat loss, and promoting parent-infant interaction.

Key Points (Cont.) Providing a protective environment is a key responsibility of the nurse and includes such measures as careful identification procedures, support of physiologic functions, and ways to prevent infection. The newborn has social and physical needs. Newborns require careful assessment for physiologic and behavioral manifestations of pain.

Key Points (Cont.) Nonpharmacologic and pharmacologic measures are used to reduce infant pain. Before hospital discharge, nurses provide anticipatory guidance for parents regarding feeding and elimination patterns; positioning and holding; comfort measures; car seat safety; bathing, skin care, cord care, and nail care; and signs of illness. All parents should have instruction in infant cardiopulmonary resuscitation (CPR).

Question Prior to discharging a male infant who has just been circumcised, the nurse must evaluate that the parents understand the instructions for care at home. The nurse is reassured when the parents report which of the following? They will check for bleeding with every diaper change. The baby is expected to void at least four times in 24 hours. Soap and water should be used to clean the penis. They will notify the provider if a yellow exudate develops and covers the head of the penis. ANS: A Feedback A Correct: Bleeding needs to be evaluated at every diaper change. If bleeding occurs, gentle pressure should be applied with a sterile gauze square. If the bleeding does not stop, the primary health care provider should be notified. B Incorrect: The baby should void after the circumcision prior to discharge. He is expected to void six to eight times within 24 hours. C Incorrect: The penis should be cleansed with plain water and petroleum applied. Soap should not be used until the circumcision is healed at 5 or 6 days after the procedure. D Incorrect: This is normal and will remain for 2 to 3 days. The parents should not attempt to remove this exudate. Redness, swelling, or discharge indicates infection, and the physician should be notified.