8.2b Care Management - From 2 Hours until Discharge Flashcards
1
Q
Acute Pain for Neonate Manifestations
A
Physiologic
- Increased HR, BP, RR (shallow)
Oxygen
- Decrease transcutaneous and arterial oxygen saturation
Skin
- Pallor/Flushing/Diaphoresis/Palmar Sweating
Metabolic
- Hyperglycemia/Acidosis/Elevated Corticosteroids
Observations
- Increased muscle tone, dilated pupils, decreased vagal nerve tone, increased intracranial pressure
Behavior
- Crying, Grimace, Brow furrow, eyes closed tightly, open squarish mouth
Body movement
- Limb withdrawal, thrashing, rigidity, fist clenched
Sleep
- Changes in cycle, changes in feeding behavior, changes in activity level, irritable
2
Q
Birth Injuries
A
- Increased pressure during birth can cause retinal hemorrhage which disappear in 7-10 days
- Erythema, petechiae, abrasions, lacerations and edema in butt and extremities
- Discoloration can appear in areas where forceps/vacuum was used
3
Q
Thrombocytopenic Purpura
A
- Petechiae can happen over trunk and face and should disappear in 2-3 days
- If they do not disappear and are accompanied by lesions it can be thrombocytopenic purpura
- Petechiae and Ecchymosis do not blanch, rashes and discoloration do blanch
4
Q
Caput Succedaneum
A
- Common edema that crosses cranial suture lines and midline
5
Q
Cephalhematoma
A
- Small blood vessels that cross the periosteum rupture
- Blood and serosanguineous fluid collects between scalp and periosteum
6
Q
Forceps Injury
A
- Linear mark across both sides of face
7
Q
Breech Position
A
- Swelling and bruising can occur over butt and genitals
8
Q
Nuchal Cord
A
- Can cause ecchymotic and petechiae over the entire head
- Notify HCP if these areas do not disappear in 2 days
9
Q
Hyperbilirubinemia
A
Physiological Jaundice - Self limiting and do not require interventions
- Occurs after 24 hours and peaks at 3-5 days. Resolves in a week or two
- Phototherapy used to lower bilirubin
- Assess jaundice every 8-12 hours
- Assessed by applying pressure over bony prominences. If blanched area is yellow during capillary refill, jaundice is present. (Assess in natural light not artificial)
- Conjunctival sacks and buccal mucosa is easier to assess in dark skinned patients
10
Q
Total Serum Bilirubin (TSB) and Transcutaneous Bilirubin (TcB)
A
- If TcB is greater than 12-15 mg/dL TSB is checked as confirmation
- Repeat testing is based off risk
11
Q
Prevention of Hyperbilirubinemia
A
- Adequate feeding is essential to prevent hyperbilirubinemia
- Breastfeed within 1-2 hours of birth and 8-12 times a day (same for formula)
12
Q
Risk Factors for Hyperbilirubinemia
A
- Most common is gestational age less than 35-36 weeks
13
Q
Treatment for Hyperbilirubinemia
A
- Based on TSB levels, gestational age, and risk factors
- Phototherapy is the most common treatment
- Exchange blood transfusion is used when bilirubin continues to rise even with phototherapy
14
Q
Phototherapy
A
- Light changes structure of bilirubin and changes it to a conjugated form that can be excreted in stool and urine.
- Can be delivered via lamp, blanket, pad, or cover body device
- Takes 4-6 hours to start working
- Within 24 hours bilirubin should drop by 30-40%
- Temperature levels should be monitored during phototherapy because it can cause temp change
- Can also cause water loss in LBW babies so they should be monitored for hydration
- Baby should be repositioned every 2-3 hours
15
Q
Exchange Transfusion
A
- Used when phototherapy does not work, caused by hemolytic disease, or treatment of bilirubin encephalopathy
16
Q
Hypoglycemia
A
- 40-45 mg/dL is lower limit of glucose in the first 72 hours
- Less than 45 should be confirmed with stat serum glucose
- Healthy newborns can have transient decrease in glucose to 30 mg/dL during the first 1-2 hours of life
- High risk infants should be fed in the first hour of life
- Checked via heel stick
17
Q
Hypoglycemia Symptoms
A
- Jitteriness
- Lethargy
- Poor feeding
- Abnormal cry
- Hypotonia
- Hypothermia (temperature instability)
- Respiratory distress
- Apnea seizures
18
Q
Hypoglycemia Risk Factors
A
- SGA or LGA
- LBW
- Mothers with diabetes
- Babies who experienced asphyxia or perinatal stress
- Cold Stress and Respiratory Distress
19
Q
Other Baby Tests
A
- Sickle cell disease (hemoglobinopathies)
- Inborn errors of metabolism (phenylketonuria (PKU) galactosemia)
- Severe combined immunodeficiency
- Hearing loss
- Critical Congenital Heart Disease (CCHD)
20
Q
LAB VALUES
A
O2 - 92 - 94% WBC - 9,000 - 20,000 pH - 7.35 - 7.45 Bilirubin 24 hours - 2 - 6 Bilirubin 48 hours - 6 - 7 Bilirubin 3-5 days - 4 - 6 Glucose before 1 day - 40-60 Glucose after 1 day - 50-90 Hematocrit - 44-70% Hemoglobin - 15-24
21
Q
Newborn Hearing Test
A
- Evoked Otoacoustic Emissions Test (EOAE)
- Auditory Brainstem Response (ABR)
- These tests do not diagnose hearing loss but determine if further intervention is needed
- If the first test is failed, a follow up is done. If the second test is failed a comprehensive audiologic evaluation is done by 3 months of age
22
Q
Critical Congenital Heart Disease Screening
A
- Most serious heart defects requiring surgery
- Screening is done at 24-48 hours
- Done with pulse ox to determine hypoxemia (first sign of congenital heart defect)
- Oxygen sat checked at right hand and one foot
- Passing is greater than 95% in either extremity and less than 3% difference between 2 locations.
- Less than 90% oxygen requires immediate intervention
23
Q
Heel Stick
A
- Used if volume of blood needed is less than 1 mL
- Apply heat to heal for 5-10 minutes to help dilate vessels
- Necrotizing Osteochondritis - Penetration of bone with heel stick. Avoided by using heel stick on outer sides of foot.
24
Q
Venipuncture
A
- Used when more than 1 mL of blood is required
- Drawn from antecubital, saphenous, superficial wrist, and rarely scalp
- 23 - 25 gauge butterfly needle
- Pressure with dry gauze for 3-5 minutes to prevent bleeding after specimen is drawn
25
Urine Specimen
- Most commonly drawn to check exposure to utero drugs
- Specimen should be analyzed within 1 hour of it being drawn
- Ideally first urine after birth
26
Infection Control Nursery
- Bassinets should be 3 feet apart from each other
- Visitors should be limited
- Cohort infants with same pathogen
- Only specified personnel directly involved in care of mothers and infants are allowed
- Always use gloves before baby has had amniotic fluid and blood removed with bath, and when drawing blood or handling body fluids.
People with the below are not allowed in nursery
- Upper respiratory tract infection
- GI Infections
- Infectious skin conditions
27
Prevention of Infant Abduction
- Limited-Entry Systems
- Mothers should check ID of anyone removing babies from their rooms
- Families should question why their baby is being taken
- Personnel should all wear ID badges
- Computer monitoring systems
- Fingerprint Identification pads
- Infant bracelet security systems
28
Baby Fall Risk Factors and Prevention
RISKS
- Maternal Medication (Opioids)
- Exhaustion from Parents
- Lightheadedness
- Incoordination of Parents
PREVENTION
- Bed sharing while sleeping is not safe
- Frequent rounds to monitor fall risk
- Newborns are always transported in bassinets
29
Sudden Unexpected Postnatal Collapse (SUPC)
- Any condition resulting in permanent cessation of respirations or cardiorespiratory failure
- Occurs during first week of life
- Happens most often during first 2 hours of life and is related to suffocation or entrapment
- Happens when mothers do not pay attention while breastfeeding or holding infant prone during skin to skin contact
30
Intramuscular Injections
- Vitamin K, Hep B vaccine and immunoglobin
- 25 gauge 5/8 needle used
- Usually injected into thigh at 90 degrees slowly (vastus lateralis)
- Wear gloves during injection
- Oral sucrose given prior to injection or nonnutritive sucking to reduce baby discomfort
31
Hep B Vaccine
- Obtain HepB status and consent from parent
| - If mother is positive for HepB newborn should receive both vaccine and immunoglobins within 12 hours of life
32
Circumcision
- Done in first few days of life
- Prevents UTI in male infants under the age of 1
- Reduces risk of penile cancer
- Reduces risk of STI (particularly HIV) '
CONCERNS OF CIRCUMCISION
- Acute pain
- Hemorrhage
- Infection
- Penile injury
- Adverse effects of sexual function
33
Circumcision Procedure
- Not performed immediately after birth due to risk of cold stress and decreased clotting factors.
- No feeding 2-3 hours before to reduce risk of vomit and aspiration
- Preformed with Gomco (Yellen), Morgen Clamp, or Plastibell Device
- Gauze is applied to wound for 24 hours, and then petrolatum is applied with each diaper change for 7-10 days to prevent diaper from adhering to penis
- Petrolatum is not applied when using plastibell
34
Pain Management Circumcision
- Dorsal Penile Nerve Block (DPNB)
SubQ injection of lidocaine on dorsum of penis
- Ring Block
Lidocaine injection at base of penis (allow 5-8 minutes after injection for circumcision)
- Topical Anesthetic (Eutectic Mixture Local Anesthetic - EMLA)
NONPHARMACOLOGIC
- Oral Sucrose
- Swaddling
- NNS (Non-Nutrient Sucking)
Liquid acetaminophen every 6 hours for 24 hours after circumcision
35
Circumcision Care
- Bleeding assessment every 15-30 minutes for the first hour, then hourly for 4-6 hours
- Assess urinary output, if there is bleeding, apply pressure with sterile gauze
- Gelfoam powder or sponge can be used to control bleeding
- If bleeding persists, blood vessel may need to be ligated (closed)
- If this is the case, 1 nurse prepares equipment while second nurse maintains intermittent pressure on the bleeding
36
Discharge Information for Circumcision
Bleeding
- Check for bleeding after each diaper change, if there is bleeding, apply pressure with gauze
Urination
- Void 2-6 times in the first 1-2 days, then 6-8 times for 3-4 days
Cleaning
- First 3-4 days clean perineum with water only
- Next 3-7 days apply petrolatum after each diaper change (except with plastibell)
- If plastibell was used, it should fall off in a week, notify provider if ring moves to shaft of penis
- Diapers should be applied loosely
- Sponge bath should be used for the first week until wound is healed
Infection
- Dark red and covered with yellow exudate for 24-48 hours is normal. Do not remove exudate
- Redness swelling and discharge should be reported
Comfort
- Handle area gently
- Skin to skin, swaddling, rocking is best for comfort
37
PAIN RESPONSE NEONATE
Physiological
- Increased HR, BP, Shallow respirations
- Decreased transcutaneous and arterial oxygen saturation
- Pallor/Flushing/Diaphoresis/Palmar Sweating
LAB
- Hyperglycemia/Acidosis/Elevated Corticosteroids
OTHER
- Increase Muscle Tone/Dilated Pupils/Decreased Vagal Nerve Tone/Increased Intracranial Pressure
BEHAVIOR
- Crying/Whimpering/Groaning
FACIAL
- Grimace/Brow Furrowed/Chin Quivering/Eyes closed tightly/Mouth open and squarish
BODY MOVEMENT
- Limb withdrawal/Thrashing/Rigidity/Flaccidity/Fist Clenched
CHANGE IN STATE
- Change in Sleep cycle/Change in feeding/Change in activity level/Fussiness/Listlessness
38
Assessment of Neonatal Pain
- Health Status of Neonate
- Type/Duration of Painful stimulus
- Environmental Factors
- Infant state of Alertness
ASSESSMENT TOOLS
- Neonatal Infant Pain Scale (NIPS)
- Premature Infant Pain Profile (PIPP)
- Neonatal Pain Agitation and Sedative Scale (NPASS)
- CRIES
39
Nonpharmacological Pain Management
- Swaddling
- Containment/Positioning
- Breastfeeding
- NNS
- Skin to Skin (during painful event)
- Sucrose for procedural pain
- Distractions (imagery, auditory)
- Sensory Stimulation (touch, massage, rocking, holding)
- Environmental modifications (low noise and lighting)
40
Pharmacological Pain Management
- Topical Anesthesia for circ, punctures, heel sticks
- Non-opioids (acetaminophen) for mild to moderate inflammatory pain
- Morphine/Fentanyl for moderate to severe pain
41
Newborn Cues
- Engagement Cues (Relaxed Body, Bright Open Eyes) - Talk and play with baby
- Rooting/Sucking/Tongue Thrusts/Diving for Nipple (Baby is hungry. Crying is late cue)
- Babies who just ate will show "milk drunk face" (Satisfied, sleepy)
- Creaking noise, grimacing, squirming, pulling up legs means they are gassy
- Thoughtful expression, pursed lips, furrowed brow, grunting means they need to poop
-
42
Discharge Teaching
- Baby should always sleep on their back with firm mattress with no extra bedding and no bed sharing
- Prevent newborn falls by allowing mom to sleep, keeping side rails up, keeping a nightlight on
- Anyone with flu like symptoms should not be visiting the baby (hand hygiene)
- Do not release baby to someone without an ID badge
- Demonstrate use of bulb syringe
- Baby should be in upright position after feedings
- Always transport babies in their crib when in the hallway
43
Discharge Teachings
- Sponge bath should be used until cord stump falls off
- Cord Care - Nothing special, keep it dry and out of diaper
- Use mittens over fingernails
- Circumcision care (Put jelly on baby every time you change diaper
- Car seats - Must be proper size for baby, no more than 2 fingers between baby and strap.
44
Normal Things that may Look Weird (Discharge Teaching)
- Spitting up after feeding
- Mushy Poop
- Pseudomenstruation in girls
- Mucoid discharge in girls
- Yellow crystals in circumcision site
- Newborn rash (milia)
- Periodic breathing
- Hiccup/sneezing
- Startle reflex
- Dried up cord stump
- Molding, caput
- Mongolian Spots
45
What is Not Normal (Discharge Teaching)
- Baby turns blue or stops breathing
- Seizures
- Unresponsiveness to stimuli
- Crying inconsolably (high pitch cry)
- 100.3 Temperature (axillary)
- Projectile vomiting
- Refuses to feed
- Lethargic (poor tone, limp, sleep too long)
- Looks yellow
- Problems with circ sites
- Not urinating enough
46
Sleeping
- Supine position for first year to prevent SIDS
| - Placed on stomach when awake to practice crawling
47
Diaper Rash
- Contact dermatitis (skin inflammation with redness, scaling, blisters, papules)
- Caused by diarrhea, infrequent diaper change, change in diet
- Candida Albicans can grow due to warm environment
48
Bathing/Umbilical Cord Care
- Goal is to prevent hemorrhage and infection
- Can easily become infected
- Assess cord stump for edema, redness, purulent discharge with each diaper change
- Keep area clean, dry, and loosely covered with clothing
- Clean area with water and dry if soiled
- Normal for umbilical cord to dry, shrivel, and blacken by 2-3 days
- Cord separation usually takes 10-14 days
49
Signs of Illness
- Fever greater than 38/100.4
- Hypothermia lower than 36.5/97.7
- Refusal of 2 eating's in a row
- Frequent forceful vomiting over a 6 hour period
- Bilious (bright green) emesis (vomit) may indicate bowel obstruction
- Watery Stools (Diarrhea leaves water ring around stool, breastfed stools also watery but does not leave ring around stools)
- Less than 3 stools a day for breastfed, less than 1 stool a day for formula
- Less than 6-8 urinations a day
- Labored breathing
- Cyanosis
- Lethargy (periods of sleep longer than 6 hours)
- Inconsolable crying (continuous high pitched cry)
- Drainage from eyes
