Chapter 10 Nursing Care of the Newborn Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Phases of Newborn Care Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 2

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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 3

Three Phases of Newborn Care Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 4

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 5

Phase 1 Nursing Interventions Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 6

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 7

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 8

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 9

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 10

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) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 11

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) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 12

Hypothermia  Can cause  Increased cell metabolism  Increased oxygen consumption  Hypoglycemia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 13

Kangaroo Care  Newborn placed on naked chest of mother  Helps stabilize newborn’s body temperature Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 14

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 15

Prophylactic Eye Care  Erythromycin ophthalmic ointment placed in both eyes  Prophylaxis against gonococcal ophthalmia neonatorum, which can cause blindness  Also destroys Chlamydia organisms Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 16

End of Phase 1 Care Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 17

Phase 2 Routine Nursing Interventions Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 18

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 19

Measurements  Measure  Length  Head circumference  Chest circumference  Use disposable tape  Document measurements in centimeters (cm) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 20

Average Measurements of 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) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 21

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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 22

Pain Assessment and Parent Teaching Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 23

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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 24

Objectives (cont.)  Explain the discharge care plan.  Discuss five aspects of newborn care that the mother should understand before discharge. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 25

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26

Signs of Newborn Infection  Poor feeding  Lethargy  Periods of apnea  More obvious signs  Drainage  Redness  Possible odor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 27

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 28

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 29

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 30

CRIES (cont.)  C: cry  R: requires oxygen  I: increased vital signs  E: expression on face  S: sleeplessness Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 31

PIPP  Premature infant pain profile  Based on scales similar to CRIES Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 32

NIPS  Neonatal infant pain profile  Based on scales similar to CRIES Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 33

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 34

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 35

Unrelieved Pain  Exhaustion  Irritability  Slow healing Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 36

Pain Treatments  Pharmacologic  MSO4 or Fentanyl  acetominophen  Nonpharmacologic, including  Touching  Stroking  Swaddling  Nonnutritive sucking (i.e., use of pacifiers) Avoid overstimulation Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 37

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 38

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 39

Phase 3 Parent Education Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 40

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 41

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 42

Positioning and Holding  Support head  Firm mattress  Supine Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 43

Ways to Hold an Infant Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 44

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 45

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 46

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 47

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 48

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 49

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 50

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 51

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 52

Cardiopulmonary Resuscitation  Parents are advised to learn basic CPR and instructed on when to call 911 or emergency assistance Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 53

Cultural Beliefs and Practices in 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 54

Discharge and Follow-Up Care Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 55

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 56

Follow-Up Care After Discharge  American Academy of Pediatrics recommends a follow-up office visit within 7 days of discharge from hospital or delivery Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 57

“Safety Net” Numbers  Provide telephone numbers for the  Nursing unit  Lactation consultant  Health care provider Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 58

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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 59

Questions for Review Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 60

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? Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 61

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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 62

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? Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 63

Review Key Points Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 64