ch. 24 nursing care of the newborn family Flashcards
care mgmt: birth through the first 2 hours
1) assessment
- immediate care after birth
- initial physical assessment
- apgar scoring: HR, RR, muscle tone, reflex irritability, generalized skin color
2) physical assessment:
- general appearance
- vital signs
3) vaseline measurements of physical growth
- weight
- head circumference
- body length
4) neurologic assessment:
- newborn reflexes
- gestational age assessment
- new ballard scale: subjective assessment of whether babies behavior aligns with gestational age
classification of newborns at gestational age and birth weight
1) appropriate for gestational age (AGA)
2) large for gestational age (LGA)
3) small for gestational age (SGA)
gestational age assessment (classification by gestation)
1) preterm or premature: born before completion of 37 weeks of gestation, regardless of birth weight
2) late preterm: 34 through 36 6/7 weeks
3) early term: 37 through 38 6/7 weeks
4) full term: 39 through 40 6/7 weeks
5) late term: 41 through 41 6/7 weeks
6) post term: 42 weeks and beyond
7) postmature: born after completion of week 42 of gestation and showing the effects of progressive placental insufficiency
immediate interventions
1) airway maintenance
2) maintaining an adequate oxygen supply
3) maintaining body temperature
4) eye prophylaxis
- to prevent ophthalmia neonatorum or neonatal conjunctivitis (prevent infection)
- erythromycin in eyes, offers protection
5) vitamin K prophylaxis (injection, thigh, mid level, luteal maximus, 25 5/8 gauge needle at 90 degree angle)
6) promoting parent infant interaction
care mgmt: from 2 hours after birth until discharge - common newborn problems
1) birth injuries:
- retinal and subconjunctival hemorrhages
- soft tissue injuries: erythema, ecchymoses, petechiae
- trauma to the presenting fetal part can occur during labor and birth
- accidental lacerations
care mgmt: from 2 hours after birth until discharge - common newborn problems (physiological problems) - hyperbilirubinemia
(a) assessment and screening:
- every newborn should be assessed for jaundice at least every 8-12 hours
- total serum bilirubin level (TSB)
- transcutaneous bilirubin levels (TcB)
- adequate feeding is essential in preventing hyperbilirubinemia
(b) therapy for hyperbilirubinemia:
- phototherapy: UV light, breakdown bilirubin
- types: crib by window, lamp, blanket
- precautions: shield eyes/genitals, prolonged UV can do harm, stay hydrated/fed, similar to tanning on beach, Q3-4H feeding
- exchange transfusions: if phototherapy isn’t enough
care mgmt: from 2 hours after birth until discharge - common newborn problems (physiological problems) - hypoglycemia
1) usually defined as BG levels less than 40-45 mg/dL
2) infants at risk for hypoglycemia:
- preterm/late preterm
- SGA/LGA
- low birth weight
- infants of mothers with diabetes
- infants who experienced perinatal stress such as asphyxia, cold stress, or respiratory distress (no temp. regulating)
- nurses should observe all newborns for signs of hypoglycemia (jittery, lethargy, hard to arouse)
care mgmt: from 2 hours after birth until discharge - common newborn problems (physiological problems) - laboratory and diagnostic tests
1) universal newborn screening
- mandated by US law
- early detection of genetic diseases that result in severe health problems if not treated early (CF, taysachs, thyroid)
2) newborn hearing screening (headset to test hearing)
3) screening for critical congenital heart disease (CCHD)
- 24H pulse ox
- bracelet on risk
- pulse rate LE
- O2 couple % points of each other
4) collection of specimens:
- heelstick: lateral
- venipuncture
- urine specimen
- meconium stool (tests for drugs)
5) interventions:
- protective environment (wrapped)
- environmental factors: hand hygiene
- infection control factors
- preventing infant abduction
- preventing newborn injury
6) therapeutic and surgical procedures
(a) intramuscular injection (vitamin K, first hep B (first 12H)
- immunizations
(b) circumcision:
-policies and recommendations
- parental decision (not medically indicated)
- procedure: yellen (gomco)/mogen clamp, plastibell device
- procedural pain mgmt: load of sucrose)
- care of the newly circumcised infant: parents advised to call nurse for first diaper change, vasoline gauze first (24-48H), yellow granulation
TIP: heel prick, 5 circles of blood -> state
neonatal pain: responses to pain
1) behavioral responses:
- most common sign: vocalization or cry
2) physiologic/autonomic responses to pain
- changes in HR
- BP
- intracranial pressure
- vagal tone
- RR
- O2 sat
neonatal pain: assessment of neonatal pain
1) neonatal infant pain scale (NIPS)
2) premature infant pain profile (PIPP)
3) neonatal pain agitation and sedation scale (NPASS)
4) CRIES: for use in the NICU
neonatal painL mgmt of neonatal pain
goals of pain mgmt:
1) minimize the intensity, duration, and physiologic cost of the pain
2) maximize the neonate’s ability to cope with and recover from the pain
nonpharmacologic mgmt:
- containment (swaddling)
- nonnutritive sucking on a pacifier
- oral glucose
- skin-to-skin contact (SSC) or kangaroo care
- breastfeeding
pharmacologic mgmt:
- local/topical anesthetic
- nonopioid analgesia
- acetaminophen
- opioid analgesia
- morphine
- fentanyl
care mgmt: promoting parent-infant interaction
1) promoting parent-infant interaction
- assess attachment behaviors: family dynamics, hows mom respond to baby
2) support and education for parents
3) cultural considerations
discharge planning and parent education
1) to set priorities for teaching, the nurse follows parental cues
- knowledge deficits or gaps should be identified before beginning to teach
- temperature
- respirations (normal rate): use of bulb syringe
- feeding (Q3H initially)
- elimination (x1 void/stool x24-48H)
- sleeping, positioning, holding (safe sleep positions - sac, on back, no toys, bumper) (sudden infant death syndrome (SIDS) - prematurity, smoking
2) rashes:
- diaper rash (front -> back)
- other rashes (under scrotum, inguinal creases)
3) clothing: dress as parents would be dressed
4) car seat safety: pulse ox car seat
5) pacifiers
6) bathing: until umbilical cord falls off, wash on surface and dry off, DONT submerge into tub until umbilical cord falls off
7) umbilical cord care:
- redness
- ecchymosis
- foul smell
- discharge
- pus: go to ER -> infection -> sepsis
- will fall off on own, bathe around it
8) infant follow up care
9) cardiopulmonary resuscitation (suction, newborn CPR, take it easy at home)
- signs of distress: respiratory distress, foul discharge, not eating, temperature
10) practical suggestions for first week at home:
- interpretation of crying and use of quieting techniques
- recognizing signs of illness
