Neonatal clinical report


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Neonatal clinical report

  1. 1. 1 | P a g e Objectives of neonatal monitoring • Evaluate the status of neonate at birth - Prepared by: Najwa Subuh Student “PhD in Pediatric Nursing Program”
  2. 2. 2 | P a g e • Categorize degree of risk to the baby • Anticipate and detect early signs of illness • Assess the progress of illness • Monitor adequacy of nutritional intake and growth. PROCEDURE FOR ADMISSION TO THE NURSERY a. Carry out the hospital policy for gowning and the three-minute scrub. If you are already wearing scrubs, it is not necessary to gown. If the initial scrub has already been completed when coming on duty, a one-minute scrub is acceptable. b. Receive the newborn from the transporter. Take the newborn from the transporter or the transporter's arms. Verify the ID bracelet on the newborn's arm and leg with the delivery room personnel. Make sure the information is accurate (i.e., mother's name, sex of the newborn, date and time of birth). Take the report from the delivery room person. The report concerns pertinent information of the mother's labor and of the newborn's birth. c. Remove the delivery room blanket from the newborn d. Weigh the newborn. Place a protective paper cover over the scale first and make sure the scale is balanced. Place the newborn on the scale. Document the newborn 's weight on the: (1) Delivery room record. (2) Instant data card. e. Place the newborn in an open warmer for the remainder of the admission procedures to maintain adequate temperature. (1) Measure the newborn. (a) Length (from top of head to the heel with the leg fully extended). (b) Head circumference - repeat after molding and caput succedaneum are resolved. (c) Chest circumference (at the nipple line). (d) Abdominal circumference. (2) Record measurements in inches and centimeters. (3) Document the information in the appropriate areas on Nursing Notes, the delivery room record, and the instant data card. (4) Take newborn's vital signs and document on Nursing Notes and the delivery room record.
  3. 3. 3 | P a g e (a) Temperature-only the first one is done rectally, the remainders are axillary. (b) Heart rate and respirations-count a full minute because of the irregularities in rhythm. BONDING PROCESS- If newborn condition is permit a. Bonding should be initiated in the delivery room. b. The significant other should be allowed to participate in as much of the care as possible during the admission process to develop the bond between the mother and the baby. c. Transport the newborn back to the mother as soon as local policy allows to take advantage of the alert state newborns have during those first few hours after birth. (1) This is considered a critical time for both individuals to interact and get to know one another. (2) It is an excellent time to establish breast-feeding while the infant is awake. (3) Approximately the first four hours after delivery, the infant returns to a sleep state or less alert state The admission assessment: 1) Gestational Age Assessment- Assessment 1. Determine the neonate's gestational age: a. Review the prenatal record to determine whether ultrasonography was performed between 15 and 19 weeks of gestation. b. Perform postnatal gestational assessment within 12 hours of age using an appropriate scoring tool such as the New Ballard Score (NBS). 2. Obtain the neonate's length, weight, and head circumference and plot the results, ideally on a validated growth curve. 3. Classify the neonate as small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA), ideally using a growth curve with appropriate norms (e.g., one that accommodates normal variations in altitude). Incubator Care A closed incubator provides a baby with high ambient temperature while allowing attendants to work at a lower and comfortable temperature. Air mode is considered more satisfactory for nursing most newborn babies. Temperature settings depend
  4. 4. 4 | P a g e on whether the baby is clothed or naked, on the weight and the postnatal age of the baby. Following values are recommended (Hey, 1975). Provision of incubator humidity in premature babies  Evidence and current practice guidelines support the use of humidity in caring for extremely preterm infants. However, the infant‘s needs for humidity reduce substantially after 7-14 days.  Humidity should be commenced in all infants born at < 31 weeks gestation.  Humidity should start at 85% (>85% results in rainout and temperature instability).  Humidity should be reduced with respect to gestation and temperature stability. The gestation specific parameters are outlined below.  Humidity should be discontinued in all infants when a level of 40% has been demonstrated to be compatible with thermal stability. Incubator cleaning • The interior of the incubator should be wiped down daily when in use and kept free of visible particulate matter. • Incubators should be changed in all but the most unstable babies at weekly intervals. • All signs of physical contamination should be removed. • Incubators and parts should be dried thoroughly with hand towels after washing. They should not be switched on to run until dry as this will encourage colonization. • Incubator parts should not be soaked in detergent solutions but should be cleaned as above. Recommended Procedures for Cleaning and Disinfecting Incubators and Isolettes Incubators should be cleaned and disinfected according to established hospital protocols. This may include: A) After use of the incubator
  5. 5. 5 | P a g e B) When an infant has been discharged C) At least once a week if in continual use. 1. Gather all equipment, cleaning solutions and materials required to clean the room. 2. WASH hands and put gloves prior to entering room. Personal protective equipment should be changed if torn or soiled and between patient rooms. 3. Complete the disassembly of the incubator as instructed by the manufacturer guidelines for Cleaning and Maintenance. Ensure that the oxygen supply to the incubator is turned off and that power pack and motor are removed 4. Visible or gross soil present and/or blood or body fluid spills must be removed prior to cleaning. 5. To clean the incubator/isolette, apply disinfectant Solution to entire external surface of incubator or Isolette and parts by wiping with a cloth. 6. Wipe all surfaces ensuring that clean cloths and solutions do not become contaminated (NO DOUBLE DIPPING). Allow surfaces to remain wet for 30 seconds to achieve the 30-second Broad-Spectrum Sanitizing claim. 7. After the cleaning procedure, the incubator/Isolette then requires thorough disinfection. All large components of the incubator (i.e. incubator walls, mattress tray and mattress, main deck) may be wiped down. Smaller pieces of the incubator can be submersed 8. Wipe surfaces dry especially corners etc. to avoid pooling of liquid. A thorough periodic rinse of all items using potable water is recommended. Wipe all items dry with a clean cloth. 9. Reassemble incubator according to manufacturer‘s instructions. 10.Soiled rags should be placed in a regular plastic bag and then in regular soiled linen bin or the dirty utility room. 11.Take all garbage to the appropriate disposal area. 12.Remove and discard gloves, WASH hands prior to leaving room. Recommended Procedures for Cleaning & Disinfecting of Blood & Body Fluid Spills Appropriate personal protective equipment should be worn for cleaning up a body fluid spill. Gloves should be worn during the cleaning and disinfecting procedures. If the possibility of splashing exists, the worker should wear a face shield and
  6. 6. 6 | P a g e gown. For large spills, overalls, gowns or aprons as well as boots or protective shoe covers should be worn. Personal protective equipment should be changed if torn or soiled, and always removed before leaving the location of the spill, and then wash hands. 1. WASH hands and put on gloves. 2. If the possibility of splashing exists, the worker should wear a face shield and gown. If there is potential for large spills, overalls, gowns or aprons as well as boots or protective shoe covers should be worn. Personal protective equipment should be changed if torn or soiled and always removed before leaving the location of the spill. 3. Apply the AHP Solution to spill – wait 30 seconds. 4. Blot up the blood with disposable towels. Dispose of paper towel in plastic-lined waste receptacle. 5. Spray or wipe surface with the AHP Solution – wait 5 minutes. Wipe dry with disposable paper towel. Discard paper towel as above. 6. Remove gloves and dispose in plastic-lined waste receptacle. 7. WASH hands. What is the best way to manage the baby’s respiratory distress in order to maximize the chance of a good outcome for the baby given the resources available? 1) Thermoregulation Issues Immediate Assessment and Care (First 30 Minutes of Life) 1. Review perinatal and intrapartum history for factors that could increase risk for heat loss and cold stress, such as lower Apgar scores, gestational age, and need for resuscitation. 2. Immediately after birth, initiate actions to maintain and promote an a neutral thermal environment NTE, such as the following: a. Thoroughly dry the neonate and place a prewarmed blanket over the neonate's back and a dry cap on the head. b. Provide immediate and sustained skin-to-skin contact, or KC, between mother and infant whenever possible. c. The premature infant who requires assistance with transition should be dried completely with prewarmed towels and placed on a preheated radiant warmer bed with temperature controls in place.
  7. 7. 7 | P a g e 3. Assess axillary temperature within 30 minutes of life. In preterm infants, axillary temperature should be 97.7°–99.3° F (36.5°–37.4° C). Assess for cold stress symptoms, such as the following: a. Tachypnea b. Poor color: cyanosis or pallor c. Mottling d. Altered pulmonary vasomotor tone e. Metabolic acidosis f. Lethargy 4. Take measures to ensure an NTE by avoiding heat loss that can occur through the mechanisms of: 1. Conduction 2. Convection 3. Evaporation 4. Radiation 4. Initiate additional measures to maintain an NTE: a. Maintaining maternal–newborn contact. b. Encourage rooming in, breastfeeding and KC or swaddling. c. Twins may be placed simultaneously in KC. d. Keep a dry cap on the neonate's head as needed. e. Keep the neonate warm during weighing by using one or more of the following measures: Place a warm blanket on the scale. Stay away from air vents and drafts. Ensure that the neonate's body surface and hair stay dry. f. Postpone the bath until thermal and cardiorespiratory stability are ensured, typically 2–4 hours after birth, then bathe the infant, incorporating the following environmental controls: Keep the bath duration as short as possible. Use a sponge bath or swaddled bath. Ensure that the bath water temperature is 100° to <104° F (38° to <40° C). (Consider using a thermometer to test water temperature before bathing). Minimize or avoid drafts in the room.
  8. 8. 8 | P a g e Ensure that the room temperature is between 79° and 81° F (26° and 27° C). Use prewarmed towels for drying. Dry the newborn immediately after bathing, place a diaper and dry cap on the baby, and wrap her in warm blankets. g. Minimize interruptions of KC or swaddled holding by considering the following measures: Delaying temperature taking until after a KC or swaddling session is complete. Being flexible about feeding schedules to permit KC before or during feedings. 5. Monitor for signs of hypoglycemia that may be indicative of hypothermia following the bath, such as irritability, lethargy, jitteriness, apnea, tachypnea, pallor, and cyanosis (see also the section Hypoglycemia, below). 6. If the neonate becomes hypothermic: a. Place in KC in an incubator or under a radiant warmer b. Monitor temperature every 30 minutes until it is within normal limits c. Review risk factors and potential signs of illness. 2) Start Respiratory Assessment Immediate Assessment and Care (First 30 Minutes of Life) 1. Assess respiratory status immediately after birth: a. Observe the neonate's physiologic functional status in an undisturbed state and environment whenever possible. b. Count the respiratory rate for one full minute. Respiratory rate for neonates should be between 30 and 60 breaths per minute. Respirations may be irregular during the first 15 minutes of life, with respiratory rate reaching 60-80 breaths per minute, and may be up to 100 breaths per minute for a limited time. c. Note signs of increased work of breathing including chest retractions, grunting, nasal flaring, tachypnea, tachycardia, and asymmetrical chest movement. 2. Identify events from the maternal obstetrical history and labor and delivery record — such as low gestational age, male gender, presence of maternal
  9. 9. 9 | P a g e complications, Apgar score less than 7 at 5 minutes of age, cesarean birth, maternal fever, or infection — to evaluate the risk for the following: a. Apnea b. Transient tachypnea of the newborn (TTN) c. Respiratory distress syndrome (RDS) d. Hypoglycemia e. Hypothermia or cold stress f. Sepsis g. Anemia 3. If respiratory distress symptoms such as tachypnea, retractions, nasal flaring, grunting, and cyanosis are present, implement appropriate interventions such as the following: a. Seek evaluation of the infant by the primary neonatal health care provider b. Administer supplemental oxygen until respiratory distress resolves. Monitored, heated, and humidified oxygen is recommended. c. Apply a pulse oximetry monitor (ranges should be between 85% and 95%). d. Any sign of increased work of breathing or increasing oxygen requirement suggests the need for early institution of positive pressure support. Babies should not be allowed to become significantly acidotic (pH<7.25) without escalating support. e. Provide a supplemental heat source, such as a radiant warmer, an incubator, or chemical thermal mattress. f. Check blood serum glucose levels. 4. If the baby is stable, and the mother desires, implement kangaroo care (KC) (also known as skin-to-skin care). If KC is not feasible, provide an alternate heat source, such as a radiant warmer.
  10. 10. 10 | P a g e Algorithm for the management of respiratory distress in the moderately preterm infant in the newborn nperiod.CPAP; CXR, chest x-ray; RDS, respiratory distress syndrome. Hypoglycemia Assessment 1. Review the antepartum/intrapartum history for conditions that increase the risk of hypoglycemia: a. Maternal conditions: Gestational or diabetes mellitus Pregnancy-induced hypertension
  11. 11. 11 | P a g e Maternal obesity Tocolytic use for preterm labor Late antepartum/intrapartum administration of intravenous glucose Difficult/prolonged delivery Nonreassuring fetal heart rate pattern 2. Use information determined from the gestational age assessment (New Ballard Score), growth assessment, and physical examination to evaluate risks for hypoglycemia. Intervention 1. Immediately after birth, quickly dry and assess the neonate, then place the stable neonate in KC with the mother until the first feeding is completed. 2. Perform a screening plasma glucose test by heel or venous sampling within the first 2 hours of life if the baby is displaying symptoms of hypoglycemia. 3. Assess the neonate frequently and at regular intervals for signs of hypoglycemia: a. Poor feeding b. Hypothermia c. Abnormal cry, irritability, lethargy d. Tremors, jitteriness, hypotonia, seizures e. Change in level of consciousness f. Apnea, tachypnea, pallor, cyanosis g. Periodic breathing 4. Provide early, frequent feedings on demand, allowing no more than 2–3 hours between feedings if breastfeeding or 3–4 hours if formula-feeding. 5. If hypoglycemia is suspected, immediately assess glucose levels, either from a heel stick or venous glucose concentration, preferably by glucometer, and report and record the results. 6. Threshold glucose ranges for diagnosis and intervention vary according to facility protocol. However, in general, if the glucose value is less than 40–45 mg/dL, immediately send a blood specimen to the laboratory for confirmation. 7. Institute treatment without delay as indicated based on the plasma glucose value obtained by point-of-care (bedside) testing.
  12. 12. 12 | P a g e 8. If the neonate has a plasma glucose value of 40–45 mg/dL or more, frequent feedings should be established and the neonate followed clinically as warranted. 9. If the neonate has a plasma glucose value below 40–45 mg/dL, the baby should immediately be put to the breast or formula-fed, by mouth or gavage as appropriate. If the breastfed newborn requires supplementation, breast milk should be provided whenever possible. A repeat plasma glucose level should be obtained within 30 minutes after the completion of the feeding. 10.If the neonate exhibits clinical signs, has a plasma glucose value below 40– 45 mg/dL, and refuses or does not tolerate feedings, the nurse should request orders for the following interventions: a. An intravenous bolus of 2 mL/kg of dextrose 10% in water (D10W) should be given immediately, and an intravenous D10W infusion initiated at a rate of 4–6 mg/kg/minute (80 mL/kg/day). b. A repeat plasma glucose level should be obtained within 30 minutes of completion of the D10W bolus. c. A recheck of the plasma glucose value every 1–2 hours until a safe, steady-state glucose concentration has been achieved. 11.For persistent hypoglycemia, consider transferring the infant to a higher acuity unit or a high-risk facility. Sepsis Assessment 1. Identify maternal risk factors that may predispose to early-onset sepsis: a. Prolonged rupture of membranes (>18 hours) b. Less than 37 completed weeks of gestation c. Evidence of intra-amniotic infection d. Intrapartum fever (temperature >100.4º F [38º C]) e. Young maternal age f. Hispanic ethnicity g. Previous delivery of an infant with invasive group B beta hemolytic streptococcus (GBS) disease 3. Identify neonatal risk factors that may predispose to early-onset sepsis: a. Prematurity b. Male sex c. Multiple births d. Low birthweight (<2,500 grams)
  13. 13. 13 | P a g e e. Congenital anomalies f. Difficulties during delivery, such as meconium staining, resuscitation, or birth asphyxia 4. Recognize the presenting signs of infection in the newborn, including the following: a. Temperature instability b. Lethargy c. Jitteriness d. Irritability e. Hypotonia f. Respiratory distress g. Hypotension h. Poor perfusion i. Poor feeding j. Gastric distension k. Vomiting or diarrhea l. Glucose instability m. Rashes, pustules, or petechiae n. Jaundice Intervention 1. Communicate assessment data to the primary care provider, anticipate the need for a sepsis workup, and initiate antibiotic therapy as ordered for infants who present with clinical signs consistent with infection. 2. Anticipate that at least a limited diagnostic evaluation may be born to a mother whose group B beta hemolytic streptococcus status is unknown. This evaluation includes but may not be limited to obtaining a complete blood count analysis (CBC) and monitoring neonatal vital signs more frequently than every 4 hours for the first 24 hours as needed. 3. Infants (term, late preterm, and preterm) with clinical signs of infection should have a full diagnostic evaluation, including complete blood count, blood culture, chest x-ray, and lumbar puncture, if feasible; they should receive empiric antibiotic therapy. 4. Continue to monitor signs of infection for at least 48 hours before discharging the infant from hospital.
  14. 14. 14 | P a g e Feeding Challenges Assessment 1. Assess the baby's readiness to feed before initiating oral feeding and at regular intervals during hospitalization: a. Evaluate the coordination of sucking, swallowing, and breathing. Behaviors demonstrating success include smooth, regular respirations and hand activity near the face with good posture. Behaviors demonstrating stress include increased respiratory rate, coughing, and choking. b. Behavioral feeding cues may include: Rooting Hand-to-mouth movements Sucking movements/sounds Opening of mouth in response to tactile stimulation Transition between behavioral states from sleep to drowsy and quiet alert c. Evaluate infant's sleep-wake cycle prior to feedings. 2. Monitor the baby for physiologic stability during early feedings. 3. Evaluate the mother's position for breastfeeding, latch, and milk transfer at least twice per day after birth. 4. Evaluate the infant for potential complications associated with poor feeding, such as hypoglycemia, hyperbilirubinemia, and increased weight loss. Intervention 1. Facilitate early infant feeding as soon as possible after birth. 2. Observe, educate, and validate the mother's knowledge about feeding behaviors seen in baby, such as the following: a. Patterns of sucking, including coordination of sucking, swallowing, and breathing b. Need to wake before feedings c. Need for frequent feedings d. Importance of monitoring milk intake 3. Educate the mother who is breastfeeding and validate her knowledge about methods to facilitate milk transfer, such as proper latch, prepumping her breast prior to breastfeeding, milk expression, and other measures, such as the following a. Ensuring proper positioning and head support
  15. 15. 15 | P a g e b. Using a breast pump c. Using nipple shields d. Seeking support from a lactation consultant Fluid/nutrition: In the acute phase, intravenous fluids are required.Full volume enteral feeding is usually postponeduntil severe respiratory distress has settled, butminimal enteral nasogastric feeding can be continued. Risk Factors Assessment Interventions Respiratory Distress Assess for cardinal signs of respiratory distress (nasal flaring, grunting, tachypnea, central cyanosis, retractions) &presence of apnea, especially during feedings. Assess for hypothermia, hypoglycemia. Perform gestational age assessment. Observe for signs of respiratory distress; monitor oxygenation by pulse oximetry; provide supplemental oxygen judiciously Thermal instability Monitor axillary temperature every 30 min immediately postpartum until stable; thereafter every 1-4 hr depending on gestational age and ability to maintain thermal stability. Provide skin-to-skin care in immediate postpartum period for stable infant. Implement measures to avoid excess heat loss (adjust environmental temperature, avoid drafts). Bath only after thermal stability has been maintained for 1 hr. Hypoglycemia Monitor for signs and symptoms of hypoglycemia. Assess feeding ability (latch- on, nipple-feeding). Assess thermal stability and signs and symptoms of respiratory distress. Monitor bedside glucose in infants with additional risk Initiate early feedings of human milk or formula. Avoid dextrose water or water feedings. Provide IV dextrose as necessary for hypoglycemia.
  16. 16. 16 | P a g e factors (IDM, prolonged labor, respiratory distress, poor feeding). Jaundice Observe for jaundice in first 24 hr. Evaluate maternal-fetal history for additional risk factors that may cause increased hemolysis and circulating levels of unconjugated bilirubin (Rh, ABO, spherocytosis, bruising). Assess feeding method, voiding and stooling patterns. Monitor transcutaneous bilirubin and note risk zone on hour-specific nomogram Feeding problems Assess suck-swallow and breathing. Assess for respiratory distress, hypoglycemia, thermal stability. Assess latch-on, maternal comfort with feeding method. Determine weight loss (should be ≤10% of birth weight). Initiate early feedings (human milk or formula). Ensure maternal knowledge of feeding method and signs of inadequate feeding (sleepiness, lethargy, color changes during feeding, apnea during feeding, decreased or absent urine output). Neurodevelopmental problems Assess for respiratory distress, neonatal jaundice, thermal instability & hypoglycemia, Assess neurodevelopmental status. Assess for seizure activity. Perform newborn screening, including hearing test. Implement individualized developmental care. Encourage parents to keep follow-up appointments withprimary care provider for evaluation of growth anddevelopment (including cognitive function and achievement of appropriate
  17. 17. 17 | P a g e milestones). Infection Evaluate maternal-fetal history for risk factors that may contribute to neonatal septicemia. Assess for signs and symptoms of neonatal infection. Use Standard Precautions, especially hand washing between infants and contact with surfaces that may harbor bacteria (e.g., keyboards, telephones). Maintain thermal stability. Administer hepatitis B vaccine. Encourage breast-feeding and assist mother-baby pair with breast-feeding. Encourage parents to decrease infant exposure to respiratory viruses post- discharge and obtain vaccines as appropriate toprevent development of respiratory viruses Admission protocol for neonate: Monitoring Physiologic Data Monitor heart rate, respiratory activity, and temperature. The monitoring devices are equipped with an alarm system that indicates when the vital signs are above or below preset limits. However, a ―hands on‖ assessment, including auscultation of heart tones and breath sounds, is essential. The placement of electrodes may be challenging because of the lack of flat areas on the neonate‘s chest, the limited space for alternating sites, the size of the electrodes, and irritationfrom the adhesive. Hydrogel electrodes are gentler on the skin and are easily removed by lifting an edge from the skin and moistening it with plain water to release the adhesive In the NICU frequent laboratory examinations and their interpretation are integral parts of the ongoing assessment of infants‘ progress. So keeps accurate intake and output records on all acutely ill infants. An accurate output can be obtained by collecting urine in a plastic urine collection bag
  18. 18. 18 | P a g e specifically made for preterm infants or by weighing the diapers, which is the simplest and least traumatic means of measuring urinary output. The pre- weighed wet diaper is weighed on a gram scale, and the gram weight of the urine is converted directly to milliliters (e.g., 25 g = 25 ml). Urine obtained from cloth diapers and disposable diapers containing absorbent gel material may yield inaccurate results for urine specific gravity, pH, and protein. Urine samples obtained from 100%-cotton, cotton balls strategically placed in the diaper proved to be the most accurate. Blood examinations are a necessary part of the ongoing assessment and monitoring of the sick newborn‘s progress. The tests most often performed are blood glucose, bilirubin, electrolytes, calcium, hematocrit, and blood gases. Samples may be obtained by heel stick; venipuncture; arterial puncture; or an indwelling catheter in an umbilical vein, umbilical artery, or peripheral artery. Attach Oximeter lead to monitor, ECG leads to baby (away from chest x-ray area) attach leads to monitor, attach a temperature probe to the baby (probe next to skinunder the axilla to cover probe, then silver reflective disc. Admit and place lines in an open care radiant environment with baby on servo. Remove cling wrap (if it has been applied) after sterile plastic drapes have beenapplied for insertion of umbilical lines. Note: if the infant requires exogenous surfactant this should be the priority Apply respiratory support as required -CPAP or intubation/ventilation (Assisted ventilation in the Newborn) Insert oro-gastric tube and decompress stomach. Document- time of arrival, temperature, respiratory rate, heart rate, saturations, blood pressure, blood gas and blood sugar level. Set up and assist with line insertion (Aseptic Technique in NICU) Provide explanation of events to family member and give them pamphlets anddiscuss house rules etc. Provide crib covers to reduce excessive light and noise. Observations will be more frequent if they are not within the normal parameters. Admission criteria for high risk newborn: 3) Birth weight less than 1500 grams. 4) Gestation less than 35 weeks or weight less than 2.2 kg 5) Respiratory distress syndrome (RDS) requiring mechanical ventilation for two hours or more.
  19. 19. 19 | P a g e 6) Other forms of respiratory distress requiring mechanical ventilation for more than two hours. 7) CNS infection 8) Asphyxia neonatorum as indicated by a five-minute Apgar score below 7. 9) Hypoglycemia as proven by two consecutive blood glucose levels below 40 mg/dl&requiring tube feeds or IV fluids. 10) Neonatal seizures 11) Hypotonia on discharge examination. 12) Polycythemia: Venous hematocrit of 65 or higher or 60-64 with signs and partial exchange transfusion, with resolution of signs. 13) Maternal substance abuse during pregnancy. 14) Sepsis 15) SGA 16) Hyperbilirubinemia (requiring exchange transfusion) 17) Intraventricular hemorrhage 18) Sibling meets criteria 19) Intrauterine transfusion 20) Babies who required major resuscitation 21) Cyanosis 22) Apnea 23) Abnormal cardiac rhythm 24) Initiating antibiotic therapy for suspected sepsis 25) Inability to suck adequate volume of feeds 26) Bile stained or persistent vomiting 27) Major congenital anomalies 28) Need for surgery 29) Assumption of care 30) Boarder babies where mother or family are unable to care for the baby 31) Hypothermia (an axilla temperature of 36.3 or less despite attempts to rewarm) Assessment of Gestational Age: The Dubowitz/Ballard Examination Points are given for each area of assessment: • Skin textures (sticky, smooth, peeling) • Lanugo (the soft downy hair on a baby's body) - is absent in immature babies • Plantar creases - range from absent to covering the entire foot • Breast - the thickness and size of breast tissue and areola
  20. 20. 20 | P a g e • Eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue. • Genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled. • Genitals, female - appearance and size of the clitoris and the labia. SIGN SCORE -1 0 1 2 3 4 5 Skin Sticky, friable, transparent gelatinous, red, translucent smooth pink, visible veins superficial peeling &/or rash, few veins cracking, pale areas, rare veins parchment, deep cracking, no vessels leathery , cracked , wrinkle d Lanug o none sparse abundant thinning bald areas mostly bald Plantar Surface heel-toe 40-50mm: -1 <40mm: -2 >50 mm no crease faint red marks anterior transverse crease only creases ant. 2/3 creases over entire sole Breast impercepta ble barely perceptabl e flat areola no bud stippled areola 1-2 mm bud raised areola 3-4 mm bud full areola 5-10 mm bud Eye / Ear lids fused loosely: -1 lids open pinna flat sl. curved pinna; well-curved pinna; soft formed & firm thick cartilage
  21. 21. 21 | P a g e tightly: -2 stays folded soft; slow recoil but ready recoil instant recoil ear stiff Genital s (Male) scrotum flat, smooth scrotum empty, faint rugae testes in upper canal, rare rugae testes descending, few rugae testes down, good rugae testes pendulous, deep rugae Genital s (Femal e) clitoris prominent & labia flat prominent clitoris & small labia minora prominent clitoris & enlarging minora majora&mi nora equally prominent majora large, minora small majora cover clitoris &minora TOTAL PHYSICAL MATURITY SCORE TOTAL SCORE (NEUROMUSCULAR + PHYSICAL) WEEKS -10 20 -5 22 0 24 5 26 10 28 15 30 20 32 25 34 30 36 35 38 40 40 45 42 50
  22. 22. 22 | P a g e Incubator Care A closed incubator provides a baby with high ambient temperature while allowing attendants to work at a lower and comfortable temperature. Air mode is considered more satisfactory for nursing most newborn babies. Temperature settings depend on whether the baby is clothed or naked, on the weight and the postnatal age of the baby. Following values are recommended (Hey, 1975). Provision of incubator humidity in premature babies Evidence and current practice guidelines support the use of humidity in caring for extremely preterm infants (Marshall, 1997; Harpin and Rutter, 1985). However, the infant‘s needs for humidity reduce substantially after 7-14 days. • Humidity should be commenced in all infants born at < 31 weeks gestation. • Humidity should start at 85% (>85% results in rainout and temperature instability). • Humidity should be reduced with respect to gestation and temperature stability. The gestation specific parameters are outlined below. • Humidity should be discontinued in all infants when a level of 40% has been demonstrated to be compatible with thermal stability. Incubator cleaning • The interior of the incubator should be wiped down daily when in use and kept free of visible particulate matter. • Incubators should be changed in all but the most unstable babies at weekly intervals. • All signs of physical contamination should be removed. • Incubators and parts should be dried thoroughly with hand towels after washing. They should not be switched on to run until dry as this will encourage colonization. • Incubator parts should not be soaked in detergent solutions but should be cleaned as above. Care of Neonate with respiratory problem: An infant requires the measurement of arterial blood gases and pH as frequently asdemanded by the clinical status. When the condition is rapidly changing, measurements must be performed more frequently. When an infant is placed in an oxygen enriched environment, the FiO2 delivered to the infant must be measured by an oxygen analyzer at least once an hour.
  23. 23. 23 | P a g e Mixtures of oxygen and air delivered to an infant by endotracheal tube, nasal CPAP, hood, or incubator should be warmed and humidified. An infant recovering from Respiratory Distress Syndrome should have the FiO2 lowered in steps of no more than 0.10 at intervals of not less than 15- 20 minutes, or with the use of continuous pulse oximetry, the FiO2 can be decreased at a faster rate as long as the O2 saturation remains within acceptable limits. An infant with chronic lung disease, especially those requiring oxygen therapy for more than 5-6 days, may require lowering of the FiO2 in steps of 0.02 - 0.05. Exposure of the infant's eyes to bright light should be minimized. Detection and Management of Abnormal Body Temperature: The normal axillary temperature of a newborn infant, if correctly measured for 5 minutes, is from 36.5 to 37.4°C Careful attention to providing the best possible thermal environment increases the chance of survival and the quality of outcome, particularly in the small premature infant. The following guidelines apply to both the incubator and radiant warmer: a) Insert probe plug securely into hole in heater unit. b) Choose the desired abdominal skin temperature, usually 36.5°C. Some olderinfants will require a lower set point, e.g., 36.0°C to avoid overheating. c) Check the setting of the control panel. Adjust if necessary. d) Attach the probe to the exposed abdominal skin at mid-epigastrium, halfwaybetween the xiphoid and the umbilicus. If the infant is prone, attach the probe tothe skin over either flank (not between the scapulae). The probe should not beplaced in the axilla. e) Under the radiant warmer, protect the probe with a foil-backed shield. f) Read the skin temperature from the temperature gauge on the heater unit. If itregisters below the set point (36.5°C), the heater should be on. Check the heaterindicator light or dial. If the heater is not on, check all connections. g) If the skin temperature does not rise as quickly as you think it should, make surethe heater is on and WAIT. Increasing the set point will not cause faster warming. h) When the abdominal skin temperature reaches the chosen set point, check theaxillary or rectal temperature to be sure it is within the normal range (36.5 to 37.4°
  24. 24. 24 | P a g e i) Adjust the set point slightly if the axillary (or rectal) temperature is abnormal. Donot change the set point if the axillary (or rectal) temperature is normal. j) Check frequently to be sure the probe is in solid contact with the skin. Poorcontact will cause overheating. Entrapment of the probe under the arm or betweenthe infant and mattress will cause underheating k) Record incubator air temperatures along with infant skin and axillary (or rectal)temperatures. A clearly decreasing (or increasing) trend in incubator temperaturemay indicate the development of sepsis or a neurological problem. Care of baby under phototherapy: a. Infant receiving phototherapy should be left unclothed except for eye protection (mask) and a diaper. Care should be taken to ensure that the mask is not too loose such that it can slip over the nose and obstruct respiration. To increase the area of skin exposed to light the diaper may be omitted by a physician's order in cases where it is desirable to lower plasma bilirubin more quickly (required because diaper protects gonads from potentially harmful exposure to light). To keep control over the mess that loose phototherapy stools can cause, a surgeon‘s face mask may be used as an alternative to a diaper. b. To monitor the potential for increased insensible water loss occurring with the use ofoverhead phototherapy, daily weights and urine output should be monitored every shift. c. The output of the phototherapy units will be monitored by the nursing staff with a Bilimeter(photometer) d. Monitoring of the phototherapy lights will be performed every 48 hours. Care of Baby on mechanical ventilation: When placing a neonate on mechanical ventilation, an order is written indicating: A. Conventional Mechanical Ventilation A. Mode (IMV or conventional sigh breaths when using HFV) Monitor ventilator set up:  Rate (breaths per minute)  FiO2  Inspiratory time (seconds) or I:E ratio  Peak inspiratory pressure (cm H2O)  PEEP (cm H2O)
  25. 25. 25 | P a g e Surfactant Replacement Therapy o Correction of hypoxia with oxygen. Infants requiring increased ambient oxygenconcentration, and who are breathing spontaneously, can be placed on NPCPAP. Theconcentration of inspired oxygen should maintain the infant's arterial oxygen tension at 50-70mm Hg. If oxygen required is greater than 50%, consider endotracheal intubation with surfactant replacement. Always confirm diagnosis with a chest radiograph. o Nasal pharyngeal CPAP for RDS should start at 6 cm H2O. If the infant is having recurrentapnea, persistent respiratory acidosis (pH less than 7.20) or if the PaO2 is inadequate in 50% ormore oxygen with usage of nasal CPAP, the infant should be intubated and treated withsurfactant. o Once intubated, the neonate with RDS should be ventilated by a pressure respirator. To minimize both barotrauma and BPD, peakinspiratory pressures should be decreased as tolerated to keep the pCO2 between 40 and 60 mmHg as long as the pH > 7.25. If pCO2 remains above 60 mm Hg, consider increasing therespiratory rate first, then, if necessary, increase PIP. o If barotrauma occurs (PIE or pneumothorax), consider high frequency ventilation. o To maintain body temperature, the infant is placed in an incubator or on a radiant heater bed. o The skin probe is placed on the mid-epigastrium and covered with heat reflecting tape. Theservocontroller is set at 36.5°C. o Intravenous fluids (D10W or D5W) are given at an initial rate of 60-80 ml/kg body weightper 24 hours with fluid therapy reassessed every 8-12 hours. Infants with birth weights less than750g should be given fluids at an initial rate of 80-150 ml/kg per day due to their increasedinsensible losses and fluid therapy should be reassessed every 6-8 hours. Sodium received assodium bicarbonate will also have to be taken into consideration when calculating the dailysodium requirement. o Metabolic acidosis (pH< 7.20) is corrected by a slow infusion of sodium bicarbonate (0.5mEq/ml.; 4% solution) through a peripheral IV at the rate of 1 mEq/kg body weight per hour. o The formula for calculation of the base deficit is: mEq of NaHCO3 = base excess x 0.6 x bodyweight in kg. Give one-half of the calculated dose and then recheck pH and pCO2 within onehalfhour. o Shock is corrected by use of normal saline or Plasmanate R; the dose is 10 cc/kg infused over 15 to 30 minutes.
  26. 26. 26 | P a g e o Carefully evaluate the need forcorrection of low BP based on numbers alone in a premature infant who is otherwise welloxygenated, since acute changes in blood pressure may be an etiologic factor in intracranialhemorrhage. o Oral feedings may be initiated even if the infant is mechanically ventilated, or on nasalpharyngealCPAP, however, feedings should not be initiated until the infant's condition is stable.Ultimately, the oral intake should provide 100-120 calories/kg/day. o When the infant is on CPAP or mechanical ventilation, a chest film should be obtainedimmediately after initiating therapy and subsequently at least once every 24 hours until theinfant's condition is stable. Guidelines for Surfactant Administration (SurfactantReplacement Therapy) Dosing: The recommended doses are: Exosurf - 5 ml/kg every 12 hours; Survanta- 4 ml/kg every 6-12hours. Subsequent doses are generally withheld if the infant requires less than 30% oxygen. Surfactant is usually not continued beyond 3 days of life (72 hours). Surveillance after administration: The clinical response is unpredictable. Lung compliance usually improves, sometimes quiterapidly. Blood gases should be monitored frequently, and the ventilator should be adjusted tokeep the PCO2 above 40 if possible. Occasionally, gas exchange deteriorates after Surfactantadministration, requiring a temporary increase in PIP. In either case, close surveillance of chestwall movement and frequent monitoring of blood gases, especially during the first 3 hours afterdosing, will minimize the complications of barotrauma and atelectasis. Sampling Techniques for Arterial Blood Gas Samples  0.2 ml of blood is required for arterial blood gas sampling. If the syringe is heparinized, theheparin should be removed as completely as possible before drawing blood into the syringe;excess heparin left in the syringe decreases the pH value, dilutes the sample, and lowers thePaCO2. Before drawing a sample from an indwelling arterial line, the line should be cleared bywithdrawing 1 to 2 ml of blood which is returned immediately thereafter.  An infant without an arterial line who is not severely ill can have his oxygenation statusmonitored by continuous pulse oximetry or by transcutaneous PO2 monitoring. Any infant beingmonitored by capillary blood gas samples should have arterial sticks done periodically tovalidate the capillary sample results or should have continuous pulse oximetry or transcutaneousPO2 monitoring.
  27. 27. 27 | P a g e  Arterial sticks are sometimes performed in severely ill neonates who do not have anindwelling arterial line. A percutaneous arterial stick can be performed using the temporal orradial artery. The brachial artery may be use in emergency situations. A femoral arterial stickshould be avoided if at all possible, as there is an increased incidence of aseptic necrosis of thefemoral head when this site is used for sampling. Since many infants shunt through the ductusarteriosus, the arterial site from which the sample is obtained should be noted on the blood gassample requisition.  The frequency of sampling is dependent upon the patient's clinical condition. Any changes inventilator or CPAP setting must be monitored by a blood gas sample within 15-30 minutes. Anyacutely ill child in the NICU in an increased ambient oxygen concentration must have at leastdaily arterial or fingerstick blood gas sampling  Indwelling catheters should not be placed into the temporal or brachial artery. Pulse Oximetry- Considered as ―Fifth vital sign‖ • Normal range – 92+3% (room air) • Advantages : - Noninvasive - No patient preparation - Rapid response time - Useful on different patient population. • Limitations : - Decreased accuracy < 65% - Not sensitive for hyperoxemia - Affected by type of Hb (F/A) - Nor reliable with low pulse volume Pulse oximeters determine oxygen saturation noninvasively through absorptionspectrophotometry. Oxygen delivery to the tissues is a direct function of cardiac output, oxygencapacity (hemoglobin concentration) and the oxygen affinity of the patient's hemoglobin. In the presence of both normal cardiac output and normal Hgb, measurement ofoxygen saturation can be a guide to both oxygen exchange and delivery.
  28. 28. 28 | P a g e We tend to keep the oxygen saturation in premature infants between 88% - 95% (higher in terminfants). Pulse oximeters are accurate within ±4%, thus a reading of 95% could represent asaturation of 99% with a concomitant PO2 of 160. Thus, to avoid hyperoxia, wewould decrease the oxygen concentration for saturations greater than or equal to 95%. Causes for Inaccurate Readings: A. Jaundice - causes falsely decreased values. B. Direct high intensity light - i.e. phototherapy lights - increases inaccuracy, socover sensor site from lights, or use a phototherapy blanket. C. Impaired perfusion - need good pulsatile blood flow for accurate readings,manage by treating shock. D. Severe hypoxemia - at saturations less than 70% accuracy begins to fall offwith the pulse oximeters overestimating the measured value. Manage by directlychecking an arterial PaO2, or by using a transcutaneous oxygen monitor Developmental Care Interventions in the Neonatal Intensive Care Unit Modify all handling and touch so that it is supportive and calming. Consider sleep-wake states and behavioral cues to determine optimum times for handling and touch. Adjust handling and touch based on continual observation of the infant‘s autonomic and behavioral responses. Ensure appropriate touch opportunities for parents aside from routine caregiving. Encourage parents to be primary providers of social touch. Avoid using massage with vulnerable high-risk infants (e.g., medically unstable, low-birth-weight infants less than 32 weeks of gestation; easily disorganized, low-threshold infants; chronically ill infants with chronic lung disease or cardiac disorders known to display physiologic and behavioral disorganization). Assist parents in identifying the most appropriate type of touch and handling for their infant. Teach infant cues to parents for monitoring responses to handling and touch. Weigh the risks and benefits for any tactile intervention. Intake / Output Record • Record fluid intake ml to ml (including boluses & flushes) • Record feed volume & type accurately • Record accurately
  29. 29. 29 | P a g e - Stool – frequency, type - Vomiting – frequency, color, content - Gastric residuals – volume, color, content. • Urine – volume (accurately) or frequency (stable NB) • Stool- Normal pattern • Weight Monitoring • Most important parameter of growth • Monitoring intake-output balance • Record with a sensitive weighing scale • Check daily till weight gain stabilized • Plot daily weight on a chart • Monitor rate of weight gain / loss • In addition, record, length and head circumference weekly. Medications for Use in Neonatal Resuscitation Drug & Indication Dose Administration Bicarbonate "0.5mEq/ml" Metabolic acidosis 1-2mEq/Kg IV slowly Not routinely given for resuscitation Note: Use only 0.5mEq/ml solution for infants Epinephrine (1:10,000) Severe bradycardia& hypotension Heart rate should rise to >100 within 30 seconds after bolus infusion 0.1-0.3ml/Kg IV or intratracheal equal to 0.01-0.03 mg/Kg/dose of 1:10.000 concentration For continuous infusion- start at 0.05 mEq/Kg/min Warning: Never use undiluted 1:1.000 concentration And NEVER inject into an artery IV push or IT followed by 1ml normal saline Don't mix with bicarbonate If heart rate remain 100, may repair dose q 5 min as ordered Volume Expander Normal Saline (recommended) Acceptable: Ringer‘s lactate, O Rh negative PRBCs 10 ml/kg Drawestimated volume needed into large syringe(s) Give over 5-10 minutes Give by syringe or infusion pumpgiven slowly over five to ten minutes to avoid intraventricular hemorrhage. Naloxone 0.1 mg/kg 1 mg/ml IV route preferred IM route Avoid giving naloxone to an infant whose mother has a history of narcotic dependence as
  30. 30. 30 | P a g e Prepare 1 ml of 1 mg/ml solution in a 1 ml syringe acceptable, but delayed onset of action naloxone can cause withdrawal seizures in this situation. Give rapidly Care of the Infant with the Meconium Aspiration Syndrome Treatment in the nursery: a. The infant should be monitored and observed carefully for signs of respiratory distress, i.e., cyanosis, tachypnea, retractions, and grunting. b. Arterial blood gases and pH should be monitored for evidence of either metabolic or respiratory acidosis. c. Obtain a chest x-ray to rule out air leak (pneumothorax, pneumomediastinum, orpneumopericardium), secondary to air trapping from ball-valve obstruction. d. An infant with a history of meconium aspiration who develops respiratory distressshould be placed in a hood to maintain O2 saturations greater or equal to 99% to prevent episodes of hypoxia and shunting. e. Postural drainage should be done as clinically indicated. f. Consider intubation and suctioning below the cords in the nursery, since meconium can be removed from the upper airways even after the infant has initiated spontaneous respirations. g. If the infant experiences persistent respiratory distress after one-half hour of life, antibiotics should be started after first obtaining blood, tracheal aspirate, and CSF cultures. Urine, forGroup B Strep Latex, should also be obtained, but antibiotics should not be withheld while waiting for urine. h. Monitor the infant for pulmonary hypertension with evidence of right-to-left shunting Suctioning of Endotracheal Tubes Pre-assemble suction equipment. Recommended suction catheters are 5 or 6 French for 2.5 mm ET tube, 6 French for 3.0 ET tube and 8 French for 4.0 ET tube. The amount of suction applied to the catheter should be between 40-80 mmHg. Suction between feedings or discontinue feedings for period of treatment. Auscultate chest prior to suctioning. Oxygenation prior to suctioning will be done with anFiO2 no greater than 0.10 above that being used to ventilate the infant. Monitor heart rate continuously.
  31. 31. 31 | P a g e Suction should not be applied while the catheter is being inserted down the ETtube. The tip of the suction catheter will not be inserted beyond the end of the tube. Whenwithdrawing the catheter, continuous suction is applies. The procedure should not take longer than 10 seconds. Following suctioning, ventilate the infant with an FiO2 no greater than 0.10 above that used prior to suctioning. The PaO2 should be raised to a level comparable to that prior to suctioning. Do not add saline unless necessary. Saline may be used if the infant has thick tenacious secretions which cannot be extracted by using suctioning alone. Normal saline for secretions for Respiratory Therapy use is instilled into ET tube and 3-5 ventilated breaths performed prior to suctioning as above. Vibration and percussion (CPT) will not be performed routinely prior to suctioning. If the need for CPT is documented, it must be ordered by a physician describing the area to be treated and the frequency of treatments. Collection of Arterial Blood Gas Samples  Due to the persistent, continuing incidence of retinopathy of prematurity (ROP), any infant in an increased ambient oxygen concentration must have his arterial oxygen tension or saturation monitored. Retinal changes have been noted in children whose PaO2s have not been higher than 100 mm Hg.  An ill infant without an indwelling arterial catheter should have arterial O2 tension monitored by arterial puncture, or PO2 catheter, or transcutaneous PO2 monitor. An acceptable alternative would be continuous pulse oximetry with upper limits of saturation in the low 90's, but caution should be used to prevent exposure to high amounts of oxygen. If questions arise regarding the appropriate level of oxygen saturation, peripheral arterial puncture should be performed.  Frequency of sampling depends on the clinical situation and the reliability of the other monitoring devices. Generally, a change in respirator or CPAP setting should be followed by a capillary or arterial sample within 15 minutes to an hour. If performing a peripheral arterial puncture for blood gas purposes, note should be made of the location, as many infants have shunting through the ductusarteriosus that may effect the interpretation.  Blood gas sampling with peripheral arterial puncture or indwelling arterial catheter requires 0.1 ml of blood. If electrolytes, ionized calcium and hematocrit are also run in the NICU laboratory, 0.3 ml of blood are obtained. Generally, the tuberculin syringe should be heparinized by withdrawing 0.1-
  32. 32. 32 | P a g e 0.2 ml of 100 U/ml heparin solution, coating the surfaces and disposing of the remainder. Excessive heparin left in the syringe will dilute the sample, decrease the pH valueand lower the PaCO2. If using blood in the syringe for other labs, including spun hematocrit inthe NICU lab, heparin cannot be used and one must notify the blood gas technician to run the sample immediately.  Arterial puncture, although not as commonly used in NICU's as other methods of monitoring, can be performed with relative ease, using the radial temporal, posterior tibial, or dorsalispedisartery. The brachial and femoral artery should be used only in emergency situations, because of the risk of complications at those sites. Indwelling catheters may be placed in the radial, posteriortibial or dorsalispedis artery but should not be placed the temporal or brachial artery.  Prep the site with 3 alcohol swabs and wear appropriately fitting gloves. Goggles or eyeglasses are also recommended. The artery should be easily palpable or visible with transillumination. If using the radial artery, an Allen test should be performed prior to puncture.  An arm board may be useful to prevent extreme dorsiflexion of the wrist which makes the procedure more difficult. A 25 gauge butterfly needle, with TB or 3 ml syringe should be used.  The bevel up position should be used, except in the most superficial arteries. The angle of insertion should be 25o for a superficial and 45o for a deep artery, against the flow of the artery.  Blood should flow spontaneously or with gentle suction.  After the needle is removed, continuous pressure should be applied for 5 minutes, with care not to squeeze with the fingertips. If hematoma formation is prevented, the artery may be used multiple times. Observe the extremity for 15-20 minutes after the procedure for arterial spasm. Obtaining Blood Via Heel Stick I. Adequate quantities of serum may be obtained via heel stick in almost any neonate. If done properly, hemolysis should not be a significant problem. The skin's blood supply is located at the junction of the dermis and subcutaneous tissue, 0.35 to 1.6 mm from the skin surface. II. Prewarming with the commercially-available heel warmers or with a diaper which has beenwarmed under a warm faucet and taped around the heel often increases the blood supply and arterializes the sample. The area should be cleaned thoroughly with alcohol swab. The person performing the procedure should wear appropriately fitting gloves. III. The heel puncture should be done on the most medial or lateral portions of the plantar surface of the heel, not on the posterior curvature, to avoid the
  33. 33. 33 | P a g e calcaneous. The lancets are designed to enter no deeper than 2-3 mm. If using a scalpel blade, the blade should enter the skin no more than 2-3 mm. After the puncture, wipe the first small drop off to rid the skin of the tissue juices that may increase clotting at the site. IV. Hold the ankle area with the 3 fingers on your ulnar side while placing your thumb behind the heel and your second finger just below the ventral surface of the toes. By alternately pressing the lateral three fingers , followed by a milking motion of the second finger, blood can be expressed. The fingers should be relaxed for a few seconds periodically to allow refilling. To prevent bruising, caution should be used to limit squeezing with the finger tips. To prevent hemolysis, allow large droplets to form, collecting the drops as they form into the micro tube, not scraping the blood into the tube. V. Fingerstick sampling is used for capillary blood gas analysis in our NICU and may be used for additional laboratories as well. The technique is similar to heelstick in that only the medial and lateral aspects of the finger are stuck. The milking motion includes the whole finger and even portions of the hand. Fluid and Electrolyte Management in the Newborn 1. Initiate fluid therapy at 60-80 ml/kg/d with D10W, (80-150 ml/kg/d for infants>26 weeks). 2. Infants <1500 g should be covered with a saran blanket and strict I&O should be followed. For infants < 26 weeks the saran blanket should be applied directly upon the infant to minimize IWL. 3. Infants <1000 g should have electrolytes and weights recorded every 6-8 hours; every 12 hours for infants 1000-1500 grams. 4. For serum Na+ >145 mEq/L, increase infusate by ~10 mL/kg/d without Na+ in the infusate. 5. Increase fluids for urine output <0.5 mL/kg/hr by ~10 mL/kg or, in infant >26 weeks, calculate IWL and change fluids accordingly. 6. Infuse Na+ free fluids (including flushes) until serum Na+ <145 and good urine output is established (post diuretic phase). Then add 3-5 meq/kg/d Na+. 7. Add KCl (2-3 meq/kg/d) to IV fluids after urine output is well established and K+ <5 mEq/L (usually 48-72 hours). 8. Increase fluid administration gradually over the first week of life to 120-130 cc/kg/d by day 7, allowing for expected physiologic weight loss.
  34. 34. 34 | P a g e Guidelines for Use of Human Milk in the Nursery o Expressed human milk is to be fed only to the infant whose mother provided the milk. o Expressed milk is precious to the mother and the baby and should be treated as a valuable commodity. It should be discarded only for a good reason. o Containers for storage of expressed milk should be small in size (4 oz. or less). If milk is to be frozen it should be stored in airtight containers (plastic or glass containers, or disposable baby bottle bags) with as little head space as possible. o Milk that will be fed within 48 hours of expression should not be frozen but be kept refrigerated at all times, including while being transported to the hospital. It is preferable to collect such milk in plastic containers. Sterile urine containers are acceptable. o Milk that will be stored for 48 hours or more should be frozen immediately after expression and transported to the hospital in the frozen state. Transport (on ice or in a cooler) should occur at least once a week, preferably more often. Milk should be frozen in portions approximately equal to the amount needed for one or two feedings. o Once thawed, milk should not be kept at room temperature for more than 4 hours. If kept refrigerated, it may be kept for up to 24 hours. o Instructions given to the mother should be specific and complete, with emphasis on cleanliness. Washing of hands with soap and water and of the breasts with water alone should be stressed. Mothers should be instructed to empty breasts as completely as possible because incomplete emptying produces milk with low caloric content (low fat). o The mother should notify her ownand the baby's physician of any symptoms of mastitis, and milk from an infected breastshould not be fed. Guidelines to Enhance Successful Breast-feeding A. Advocating for breast-feeding of ill or preterm infants: o For inpatient mothers, the Labor and Delivery or Postpartum nurses will: o Give breast-feeding handouts and discuss feeding options with mother o lInstruct the mother on pumping and storage of breast milk o Assure that pumping is initiated within the first 24 hours after delivery o For mothers of transported infants, the transport nurses will: o Give breast-feeding handout to mother o Ask the local maternity nurse to assure that pumping begins with 24 hours o Reinforce decision to breast-feed at regular "call back" times
  35. 35. 35 | P a g e B. Initiating non-nutritive "time at the breast": o Baby meets these criteria: o Corrected gestational age about 32 weeks o Has ability to swallow own secretions o Stable outside incubator at least 10 minutes o Tolerates kangarocare Nursing interventions: 1. Discuss goals of non-nutritive "time at the breast" with mother 2. Help position the baby at the breast 3. Review pumping techniques with mother and assess her ability to pump 4. Arrange housing for the mother close to the nurseries C. Progress toward non-nutritive sucking Baby displays these signs: o Mouth is at breast, but may not latch on or suck o May swallow once or twice o May fall asleep at the breast Nursing interventions: 1. Avoid feeding with a bottle; continue with orogastric or nasogastric gavage 2. Time feedings with infant hunger cues if possible 3. Teach mother infant feeding cues 4. Review with mother the importance of pumping every 3 hours (8 times a day) or 100 minutes per day 5. Use finger feeding when the mother is unavailable to breastfeed 6. Teach mother to continue to pump between or after feedings if needed 7. Minimize pacifier use until breast-feeding proficiency is achieved E. Successful transition breast-feeding: Baby wakes up for feedings Mother identifies nutritive suck and swallow Baby shows adequate hydration and weight gain without supplementation Mother is confident in her ability to breast-feed baby at home Nursing interventions: When mother is not available for breast-feeding, provide milk or formula by finger feeding or, at mother's request, provide milk or formula by bottle
  36. 36. 36 | P a g e Neonatal Skin Care General Skin Care Assessment o Assess skin once each shift for redness, dryness, flaking, scaling, rashes,lesions, excoriation, or breakdown. o Identify those infants at increased risk for skin breakdown. o Evaluate and report abnormal skin findings& analyze for possible causation. o Intervene according to interpretation of findings or physician order. Bathing Initial bath Assess for stable temperature a minimum of 2 to 4 hours before first bath. Use cleansing agents with neutral pH or minimum dyes or perfume, in water. Do not completely remove vernixcaeosa. Bath preterm infant (>32 weeks of gestation) in sterile water alone. Routine  Decrease frequency of baths to every second or third day by daily cleansing of eye, oral and diaper areas, and pressure points.  Use cleanser or soaps no more than two or three times a week.  Avoid rubbing skin during bathing or drying.  Immerse stable infants fully (except head) in an appropriate-sized tub.  Use swaddled immersion bathing technique: slow unwrapping after gently lowering into water for sensitive, but stable, infants needing assistance with motor system reactivity. Adhesives  Decrease use as much as possible.  Use transparent semipermeable adhesive dressings to secure intravenous lines,catheters, and central lines.  Use hydrogel electrodes.  Consider using pectin or hydrocolloid barriers beneath adhesives to protect skin.  Secure pulse oximeter probe or electrodes with elasticized dressing material  (carefully avoid restricting blood flow).  Do not use adhesive remover, solvents, and bonding agents.  Avoid removing adhesives for at least 24 hours after application.  Adhesive removal can be facilitated using water, mineral oil, or petrolatum.
  37. 37. 37 | P a g e  Remove adhesives or skin barriers slowly, supporting the skin underneath with one hand and gently peeling away the product from the skin with the other hand. Antiseptic Agents Apply before invasive procedures. Evaluate the risks and benefits of any antiseptic agent. Chlorhexidinegluconateand 10% povidone-iodine have both been shown to reduce skin bacterial counts in newborns. Povidone-iodine may be absorbed systemically. Avoid use of alcohol. Skin Breakdown Prevention  Decrease pressure from externally applied forces using water, air, or gel mattresses; sheepskin; or cotton bedding.  Provide adequate nutrition, including protein, fat, and zinc.  Apply transparent adhesive dressings to protect arms, elbows, and knees from friction injury.  Use tracheostomy and gastrostomy dressings for drainage and relief of pressure from tracheostomy or gastrostomy tube (Hydrasorb or Lyofoam).  Use emollient in the diaper area (groin and thighs) to reduce urine irritation. Treating Skin Breakdown  Irrigate wound every 4 to 6 hours with warm half-strength normal saline using a 30 ml or larger syringe and 20-gauge Teflon catheter.  Culture wound and treat if signs of infection are present (excessive redness, swelling, pain on touch, heat, or resistance to healing).  Use petrolatum-based ointments for uninfected wounds.  Apply hydrogel with or without antibacterial or antifungal ointments (as ordered) for infected wounds (may need to moisten before removal).  Use hydrocolloid for deep, uninfected wounds (leave in place for 5 to 7 days) or as an ostomy barrier and to improve appliance adhesion; warm barrier in hand for several minutes to soften before applying to skin.  Avoid use of antiseptic solutions for wound cleansing (used for intact skin only). Treating Diaper Dermatitis a. Maintain clean, dry skin; use absorbent diapers and change often. b. If mild irritation occurs, use petrolatum barrier. c. For developing dermatitis, apply a generous quantity of zinc-oxide barrier.
  38. 38. 38 | P a g e d. For severe dermatitis, identify cause and treat (e.g., frequent stooling from spinabifida, severe opiate withdrawal, or malabsorption syndrome). e. Treat Candida albicanswith antifungal ointment or cream. f. Avoid talcum powders and antibiotic ointments Use of Thermal Devices Avoid heat lamps because of increased potential for burns. If needed, measure actual temperature of exposed skin every 15 minutes. When using heating pads C hangeinfant‘s position every 15 minutes initially and then every 1 to 2 hours. • Preset temperature of heating pads to less than 40° C (104° F). When using preheated transcutaneous electrodes:  Avoid use on infants weighing less than 1000 g (2.2 lb).  Set at lowest possible temperature (>44° C) and secure with plastic wrap.  Use pulse oximetry rather than transcutaneous monitoring whenever possible.  When prewarming heels before phlebotomy, avoid temperatures greater than 40° C.  Warm ambient humidity, and direct away from infant; use aerosolized sterile water and maintain ambient temperature so as not to exceed 40° C.  Document use of all heating devices. Use of Fluid Therapy and Hemodynamic Monitoring  Be certain fingers or toes are visible whenever extremity is used for intravenous or arterial line.  Secure catheter or needle with transparent dressing or tape to promote easy visualization of site.  Assess site hourly for signs of ischemia, infiltration, and inadequate perfusion  (check capillary refill).  Avoid use of restraints (e.g., arm boards); if used, check that they are secured safely and not restricting circulation or movement (check for pressure areas).  Use commercial intravenous protector (e.g., I.V. House) with minimum tape.
  39. 39. 39 | P a g e Role of Neonatologist nurse: Discharge planning: Discharge planning should ideally begin as soon as the baby isadmitted in the nursery. This gives adequate time for the caretakers to ask questionsand practice skills. The following criteria should be fulfilled before discharging a high riskinfant:  Hemodynamically stable; able to maintain body temperature in open crib  On full enteral feeds (either breast feeding or by paladai/spoon)  Parents confident enough to take care of the baby at home  Has crossed birth weight and showing a stable weight gain for at least threeconsecutive days; in case of very low birth weight infants, weight should be atleast 1400 grams before considering for discharge.  Not on any medications (except for vitamins and iron supplementation). Ideallypreterm babies on theophylline therapy for apnea of prematurity should be offtherapy for at least five days to make sure that there is no recurrence.  Received vaccination as per schedule (based on postnatal age). 1) Counseling prior to discharge: Counseling plays an important role in the care of these babies at home; regular counseling sessions should be done before discharge. Parents should be given advice regarding: a. Temperature regulation – proper clothing, cap, socks, Kangaroo mother care etc. b. Feeding – type and amount of milk, method of administration, and nutritionalsupplementation, if any. c. Prevention of infections – hand washing, avoidance of visitors, etc. d. Follow-up visits – where and when e. Danger signs – recognition and where to report if signs are present f. Vaccination – schedule, next visit, etc. g. Special needs – e.g. next visits for ROP screening. h. If possible the family should be provided with the telephone number of the health i. care provider e.g. on-duty doctor in case the family needs to consult for infant‘sillness. 2) Health Educator: Parent Teaching and Support 1. Teach parents and validate their understanding about the special health needs of their baby affecting their care at home. These include but may not be limited to the following: a. Maintain Natural Thermal Environment and dress the infant appropriately.
  40. 40. 40 | P a g e b. Help prevent the spread of infection by good handwashing, limiting contact with ill family members, limiting contact with visitors, and breastfeeding when possible. c. Maintain adequate nutritional and fluid intake to promote adequate growth and development. d. Ensure frequent monitoring by a pediatric health care provider & contact the primary pediatric care provider immediately if the following conditions arise: Temperature below (36.1° C) or above (38° C) Difficulty breathing or turning blue Jaundice Difficulty feeding Vomiting Failure to void for 12 hours Lack of stooling for 24 hours Lethargy Irritability Changes in the baby's typical behaviors e. Place the infant in supine position (e.g., on his back) for sleep and avoid soft mattresses or blankets under the infant. Avoid exposure to secondhand smoke. 2. Support the establishment of the parental role: a. Encourage rooming in whenever possible. b. Encourage KC (skin-to-skin care) and minimize hospital-associated constraints, such as staff interruptions and infant unavailability. Assess all vital signs, pulse oximetry, and pain score before KC and 15 minutes after transfer to KC. Assess parental readiness and teach them about skin-to-skin holding. To facilitate KC, the mother should wear a front-button blouse or patient gown and remove her bra. Assist the parent with transferring infant to KC. Position the infant chest-to-chest, upright, inclined about 30 degrees, with the infant‘s nose slightly above the mother's nipples.
  41. 41. 41 | P a g e Monitor the infant's vital signs, pulse oximetry, and pain scores as needed during skin-to skin holding. Vital signs should be monitored every 10–15 minutes during skin-to-skin holding for ventilated newborns. KC can be usually be maintained for 1 hour or more. c. Help parents identify infant behaviors, especially alertness, hunger, and satiety cues. d. Model appropriate responses to infant cues during routine caregiving, such as responding quickly to infant cries or fussiness and talking & maintaining eye contact when the infant is alert. 3. Assess the mother for emotional distress, especially depression & posttraumatic stress symptoms. 4. Encourage parents to spend time interacting with their infant at home. 5. Help parents identify a primary pediatric care provider and community follow-up resources before discharge. 6. Ensure that an appointment for a follow-up visit is made with the primary pediatric care provider within 24-48 hours of hospital discharge. If this post- discharge visit does not coincide with the time frame when the baby's bilirubin levels are likely to peak (day 5 to day 7), an additional follow-up visited should be planned for between day 5 and day 7 of life. Teaching The Level III neonatal nurse also helps parents of premature infants learn how to care for their baby. The neonatal nurse helps parents deal with the special needs of the baby and the proper care of a premature infant when they leave the hospital. Parents may require instruction on the use of home equipment for the care of a high-risk premature infant. Counselor: Growth monitoring: Growth (including weight, head circumference, mid- armcircumference and length) should be monitored and plotted on an appropriategrowth chart at each visit. The infant‘s growth pattern (slope of the curve) is comparedwith the standard curve; any deviation should be noted and appropriate remedialaction taken. Weight should be taken on an electronic weighing scale. Lengthshould be measured with an infant meter. The infant should be held supine andlegs fully extended. The feet
  42. 42. 42 | P a g e should be pressed against the movable foot piecewith the ankles fixed to 90˚. Head circumference should be measured withnonstretchable fiberglass tape. Developmental assessment: Assessment of developmental milestones shouldbe done according to the corrected age. The milestones should be assessed infour domains- gross motor, fine motor, language, and personal-social. The date ofassessment and the infants‘ corrected age should be mentioned against eachmilestone. Based on the date of achievement of milestones in a particulardomain and the expected age of achieving them, the developmental age can becalculated. Referral: Eye evaluation: The check-up for retinopathy of prematurity starts in the NICU andcontinues till 44 weeks post-conceptional age or till the retinal vessels have matured Hearing evaluation: High risk infants have higher incidence of moderate toprofound hearing loss (2.5-5% vs. 1%). Since clinical screening is oftenunreliable, brainstem auditory evoked responses should be performed between 40 weeks and 3 months postnatal age. Infants with unilateral abnormal resultsshould have follow-up testing within three months. Surveillance: The mission of a neonatal follow up program is to provide a continuum of specialized care to sick babies discharged from NICUs. The objective is to identify early deviation of growth, development or behavior from normal and provide support and interventions as indicated. The neonate ―at-risk‖ of neurodevelopmental disability must be identified before discharge from birth admission. A discharge summary must be provided to primary care provider and parents, the discharge summary should describe the prenatal and perinatal risk factors, neonate‘s hospital course and therapies that can increase the risk of neurodevelopmental disability Monitoring Nurses working in a Level III neonatal nursery are caring for premature infants with serious health concerns and illnesses. The nurse is responsible for monitoring equipment including incubators and ventilators. The nurse monitors newborns and their response to treatment. The babies in the neonatal nursery may also require surgical care. A Level III neonatal nurse provides patient care to newborns in the Neonatal Intensive Care Unit.
  43. 43. 43 | P a g e The newborns in a NICU require technology and cannot be treated in other neonatal level nurseries. The care of these high-risk newborns requires the specialized training of a Level III neonatal nurse who is skilled in the use of life- saving equipment in the Neonatal Intensive Care Unit. Each unit shall have a lead for All staff will undertake training to; Breastfeeding Support mothers to feed their infant appropriately promote the use of breast milk and breastfeeding Developmental needs and care of the baby Assess developmental needs Prepare babies and families for discharge, Emotional and psychological support to families Support families in acquiring the knowledge and skills they will need to care for their baby at home provide emotional and psychological support to families Bereavement support Supporting families during bereavement Education and training Communication and Interpersonal relationships • Including data processing and management, production and communication of information and knowledge, and the design and production of visual records. • The neonatal nurse will use a wide range of media to communicate effectively with babies, parents, carers and health care workers. • The neonatal nurse will demonstrate interpersonal behaviour and skills conducive to developing and maintaining therapeutic and professional relationships • Maintain effective and supportive communication within the neonatal nursing team and with other professionals. • Contribute to creating an environment that fosters open communication and trust with families and colleagues. • Liaise with health care professionals and individuals in other disciplines from within and outside the organisation to support quality patient care.
  44. 44. 44 | P a g e Core skills specifically relate to patient care (Responsibility for patient care). • Fluid, electrolyte, nutrition & elimination management • Neurological & pain management • Respiratory & cardiovascular management • Skin, hygiene & infection control management • Temperature management • Bereavement management • Investigations & procedures • Equipment Nursing Diagnosis: 1 Ineffective breathing pattern related to pulmonary and neuromuscular immaturity, decreased energy and fatigue. 2 Ineffective thermo-regulation related to immature temperature control and decreased subcutaneous body fat. 3 High risk for infection related to deficit immunologic defenses. 4 Altered nutrition: less than body requirement related to inability to ingest nutrients because of immaturity or illness. 5 High risk for fluid volume deficit or excess related to immature physiologic characteristics of Preterm infant. 6 High risk for impaired skin integrity related to immature skin structure. Immobility decreased nutrition state, invasive procedures. 7 High risk for injury from increased intra-cranial pressure related to immature central nervous system and physiologic stress response. 8 Pain related to procedure, diagnosis and treatment. 9 Altered growth and development related to Preterm birth, unnatural neonatal intensive care unit (NICU) environment, and separation from parents. 10 Altered family process related to situational crisis, knowledge deficit, and interruption of parental attachment process.
  45. 45. 45 | P a g e Planning The following are basic goals for care of all high-risk infants: 1- Exhibit adequate oxygenation. 2-Maintain stable body temperature. 3-Protect the infant from nosocomial infection. 4-Receive adequate hydration and nutrition. 5-Maintain skin integrity. 6-Experience no pain. 7-Receive appropriate development care. 8-Receive appropriate family support, including, preparation for home care. Implementation: 2. Thermoregulation: After the establishment of respiration, the most crucial need of high-risk infant is the application of external warmth, to delay or prevent the effects of cold stress; infants are placed in a heated environment immediately after birth. This is especially important for the pre-term infant, whose very high skin surface relative to body mass promotes heat loss. Nursing Intervention: 1 Place infant in incubator, radiant warmer or warmly clothed in open crib. 2 Regulate servocontrolled unit or air temperature control as needed. 3 Monitor for signs of hyperthermia- redness, flushing. 4 Check temperature of infant in relation to temperature of heating unit. 5 Avoid situation that might predispose infant to heat loss such as exposure to cool air, drafts, bathing or cold scales. 6 Monitor for signs of hypothermia- cold extremities, cyanosis (protocol of thermo-regulation). 3. Respiratory Support: Assess for deviations of respiratory function, observe for signs of distress, grunting, cyanosis, nasal flaring and apnea, many infants require supplemental oxygen and assisted ventilation.
  46. 46. 46 | P a g e Nursing Intervention: 1 Position for optimum air exchange (place prone when feasible or side lying) since this position results in improved oxygenation better tolerated. 2 Suction to remove accumulated mucus from nasopharynx, trachea. 3 Carry out regimen prescribed for oxygen therapy (appendix of O2 therapy). 4 Closely monitor blood gases measurement. 5 Maintain neutral thermal environment to conserve utilization of O2 6 Apply and manage monitoring equipment correctly. 7 Observe and assess infant‘s response to ventilation and oxygenation therapy. 8 Observe any deviation. 3. Protection from Infection: High-risk neonates are particularly susceptible to infection. The source of infection rise in direct relationship to the number of person and pieces of equipment coming in contact with the infant. Nursing Intervention: 1 Ensure that all care givers wash hands before and after handling the infant. 2 Ensure that all equipments in contact with infant are clean or sterile. 3 Ensure strict asepsis or sterility with invasive procedures. 4 Prevent persons with upper respiratory tract or communicable infections from coming into direct contact with infant. 5 Isolate infants who have infections. 6 Emphasize health care workers and parents to administer antibiotics as ordered. 7 Ensure that the incubator must be clean and sterilized to combat infections (protocol of infection control). 8 Assess for risk factors in maternal history that place the newborn at increased risk. 9 Monitor for changes in vital signs such as temperature instability, tachycardia, or tachypnea. 10 Assess oxygen saturation levels. 11 Assess feeding tolerance, typically an early sign of infection.
  47. 47. 47 | P a g e 12 Monitor laboratory test results for changes. 13 Avoid using tape on the newborn's skin to prevent tearing. 14 Use sterile gloves. 15 Use disposable equipment. 16 Avoid coming to work when ill, and screen all visitors for contagious infections. 4. Nutrition: Optimum nutrition is critical in the management of LBW Preterm infants, but there are difficulties in providing their nutritional needs. An infant‘s need for rapid growth and daily maintenance must be met in the presence of several anatomic and physiologic disabilities. Nursing Intervention: - Encourage breast-feeding if strong sucking, swallowing and gag reflexes. - Use gavage feeding if infant tires easily or has weak sucking, gag or swallowing reflexes. - Assist mothers with expressing, breast milk to establish and maintain lactation until infant can be breast-fed. - Assist parenteral fluid or total parenteral nutrition therapy as ordered. - Monitor for signs of intolerance to protein and glucose. - Follow until protocol for advancing volume and concentration of formula. 5. Hydration: Adequate hydration is important in Preterm infants because their extracellular water content is higher, their body surface is larger, and the capacity for osmotic diuresis is limited in preterm infants, underdevelopment kidneys. Therefore, these infants are highly vulnerable to water depletion. Nursing Intervention: - Monitor fluid and electrolytes closely with therapies that increase insensible water loss (IWL) e.g. phototherapy, radiant warmer. - Ensure adequate parenteral/oral fluid intake. - Assess state of hydration (e.g. skin turgor, edema, weight, mucous membrane, urine specific gravity, electrolytes, fontanel).
  48. 48. 48 | P a g e - Regulate parenteral fluid closely to avoid dehydration over hydration or extravasation. - Avoid administering hypertonic fluid (e.g. undiluted medication, concentrated glucose infusions) to prevent excess solute load on immature kidneys and fragile veins. - Monitor urinary output and laboratory values for evidence of dehydration or over hydration (adequate urinary output), strict measurement of urine output is indicated (forms of nursing care). 6. Skin Care: Assess skin for any discoloration, redness, sings of irritation and skin turgor because the skin of infant was very delicate. Nursing Intervention: - Clean skin with plain water (see appendix of sponge bath). - Provide daily cleaning of eye, oral, cord and diaper area, and any areas of skin breakdown (for infant who are not feeding, wipe the mouth and tongue with Nestatin daily using a cotton piece until they are advancing to feeds). - Use minimal tape / adhesive. - Use a protective skin barrier between skin and all tape/ adhesive especially premature babies (protocol of nursing care for infants in the NICU). 7. Minimal Stress: Preterm infants are subject to stress just as other human beings. They are biologically deficient in their capacity to cope with or adapt to environmental stresses. Stress affects hypothalamus function, causing adverse effects on growth, heat production and neurologic mechanisms. Nursing Intervention: - Decrease environmental stimulation because of stress responses, especially increased blood pressure, increase risk of elevated ICP. - Establish a routine that provides undisturbed sleep /rest periods. - Use minimal handling. - Organize care during waking hours. - Close and open draps and dim lights to allow for day/night schedule. - Remain calm, limit number of visitors and staff near infant at one time. - Keep equipment‘s noise to minimum.
  49. 49. 49 | P a g e - Maintain adequate oxygenation because hypoxia increases cerebral blood flow. 8. Neonatal Pain: Both preterm and full term perceives and react to pain in much the same manner as children and adult. The response of neonate to pain is evidenced by cardio respiratory changes, increase in heart rate and blood pressure, and decrease PO2 or oxygen saturation, sweating. Crying associated with pain is more intense. Facial features include eye squeeze, brow bulge, open mouth. Suspect pain if the newborn exhibits the following:  Sudden high-pitched cry.  Facial grimace with furrowing of brow & quivering chin .  Increased muscle tone.  Oxygen desaturation.  Body posturing, such as squirming, kicking, arching.  Limb withdrawal and thrashing movements.  Increase in HR, Bp, pulse, and respirations.  Fussiness and irritability. The goals of pain management are to minimize the amount, duration, and strength of pain and to assist the newborn in coping. Nonpharmacologic techniques to reduce pain may include: Nursing Intervention: - Recognize that infants, regardless of gestational age feel pain. - Use non-pharmacologic pain measure appropriate to infant‘s age and condition as touch, music, cuddling and roching. - Gentle handling , rocking, caressing, cuddling, and massaging - Rest periods before and after painful procedures - Swaddling and positioning to establish physical boundaries - Offering a pacifiers dipped in sucrose prior to procedure Use of minimal amount of tape, with gentle removal to avoid skin tears. - Use of warm blankets for wrapping to facilitate relaxation. - Reduction of environmental stimuli by removing or turning down noxious stimuli such as noise from alarms, beepers, loud conversations and bright lights - Encourage parents to provide comfort measures.
  50. 50. 50 | P a g e - Administer analgesics as ordered. - Monitor for side effects of opiods, especially respiratory depression. - Assess effectiveness of non-pharmacologic and pharamcologic pain measures. 9. Care to Promote Growth and Development: Much attention had been focused on the effects of early intervention or its lack on both normal and preterm infants. Findings indicate that infants are able to respond to a greater variety of stimuli. The atmosphere and activities of the NICU are over stimulating. Nursing Intervention: - Provide optimum nutrition to ensure steady weight gain and brain growth (see appendix of growth measurements). - Provide regular periods of undisturbed rest to decrease unnecessary O2 use and caloric expenditure. - Provide age – appropriate development intervention simulate all the sense of infant and observe their response e.g. visual, tactile, auditory, olfactory and taste. - Promote parent-infant interaction since it is essential for normal growth and development. - Clustering care to promote rest and conserve the infant's energy. - Flexed positioning to simulate the in utero positioning. - Environmental management to reduce noise and visual stimulation. - Kangaroo care to promote skin to skin sensation. - Placing twins in the same isolette or open crib to reduce stress. - Activities that promote self regulation& state regulation. 10.Family Support and Involvement: The birth of a preterm infant is an unexpected and stressful event for which families are emotionally unprepared. Nursing Intervention: - Give information to help parents understand most important aspects of care. - Encourage parents to ask questions about child‘s status. - Be honest; respond to questions with correct answer to establish trust.
  51. 51. 51 | P a g e - Encourage mother and father to visit the infant so that attachment process in initiated. - Help parents by demonstrating infant care and offer support. - Encourage siblings to visit infant. - Explain to family members the infant condition and why he cannot come home soon. Patient/Family Involvement in the Care Delivery of a Pre-term Infant Another example illustrates the extensive involvement of parents in the planning and delivery of care for their premature son. On October 30, 2012, a mother delivered premature twins at 24 weeks and two days gestation. The baby girl succumbed to pulmonary hemorrhage at 3 days of age, and the baby boy struggled to survive numerous complicating sequelae of extreme prematurity. His Apgar scores at birth were zero at one minute, one at five minutes, and seven at ten minutes; he was born with an undetectable heart rate, poor tone, poor color and no movement requiring intubation and neonatal cardiopulmonary resuscitation (CPR). Once stabilized, the infant endured a very long and complex course in neonatal intensive care unit (NICU). From the beginning, it was a priority of the nursing staff to engage his parents in his care as much as possible. Fostering the parent- child relationship was essential for bonding and a crucial part of relationship-based care. The parents were taught to hold their infant son inside the incubator by cupping a hand over his head and cradling his feet with the other. As he became stable enough to have his diaper changed, the nurses worked diligently to employ his parents to participate. They afforded them the autonomy to accomplish this task and taught them how to navigate around all of medical equipment, such as the endotracheal and orogastric tubes, suction apparatus, intravenous lines, heart monitor and temperature sensor leads, and blue lights used to treat hyperbilirubinemia. Nurses and lactation consultants worked closely with the mother so she could provide breast milk once the infant could tolerate enteral nutrition. The parents spent many hours at the bedside, and, with the nurses' encouragement and guidance, learned to participate to the maximum extent in his care. As the patient's course continued, he experienced numerous complications: multiple intubations, high frequency ventilation, several intravenous, central venous and arterial line insertions, barium swallow and enema studies, laryngoscopy, bronchoscopy, surgeries for ligation of a patent ductusarteriosus,
  52. 52. 52 | P a g e peritoneal drainage of abdomen for intestinal perforation, cricoid split, tracheostomy, repair of inguinal and umbilical hernias, and insertion of a gastrostomy tube. Through this tumultuous course, the parents and nurses were closely involved in his care decisions. Consistent with Relationship-Based Care, the nurse/family relationship played a vital role in the continuum of care. To facilitate this, the NICU utilized a primary nursing approach to offer continuity of care and strengthen these relationships. The nurses who most frequently cared optimized relationships among themselves, as they coordinated patient care, taking into consideration the unique needs of this baby and his family, and shared information to ensure everything was done to facilitate getting him home as soon as possible. Care planning for the patient began at birth and was consistently documented on the Family Teaching and Discharge form. To include the parents in this process, the parents participated in periodic interdisciplinary meetings and were updated daily by the nursing and medical staffs. As the discharge plan developed with parent input, and aspects of patient care were discussed with the family, this teaching form was initialed and dated by the nurse. The nurse also assessed and documented any barriers to learning and the level of learning achieved at this time. In this patient's case, the discharge process was considerably more complex than most. The family was involved in milk/formula preparation and fortification, with different directions for some feeds, care of the g-tube, feeding procedures, numerous medications and medication administration, tracheostomy care, tracheostomy changes, CPR including use of an ambu bag, and infant care coordination with home nursing One of the primary direct-care nurses, prepared a grid to assist the mother with the plethora of medications and feeding requirements. The medication times were listed so the mother was able to print out the sheet and check off when each was given/completed. The mother found the tool to be so useful, that she continued to update and modify the chart as her son's medication doses increased with his weight. The nurse also prepared a summary of nursing care for g-tube and tracheostomy maintenance, as well as helpful individualized care hints. The summary served as a reminder for the parents, and provided consistent guidelines for the patient's home nurses. In preparation for discharge the parents participated in learning "going home" skills and plans. As part of the discharge plan, the nurse also coordinated with Physical Medicine and Rehabilitation, physical, occupational and speech therapists to identify follow-up resources available to the family, and facilitate bedside therapy sessions with the family and therapists.
  53. 53. 53 | P a g e After the parents filled prescriptions for medications, the nurse and parents review the purpose, dosage, and administration method and time for each medication in order to ensure safe, therapeutic medication administration. The nurse coordinated with the medical staff to ensure follow-up appointments were scheduled and that the parents were aware of them. In addition to developing the discharge plan with the parents, the nurse coordinated with the case manager and social worker to ensure delivery and training on applicable home equipment, such a home monitor, oxygen delivery system, ventilator, and suction machine. Consistent with the Care Delivery Model, the nurse/family relationship played a vital role in the continuum of care for this child. The nurses formed an interactive and supportive relationship with the parents and integrated them into all aspects of the planning and delivery of care. As a result of this Relationship-Based Care, the patient was successfully discharged to home on May 3, 2013. Role of Neonatal Nurse: Educator: Actively participate in teaching programs and facilitate learning Provide parents with the information required for them to make informed decisions regarding their baby. Use health promotion strategies to support and advise parents and families Develop and maintain a sound knowledge base relevant to neonatal care. Advocator: Act as the neonate‘s advocate. Monitor safe work practices. Co-coordinator: 1. Liaise with health care professionals and individuals in other disciplines from within and outside the organization to support quality patient care. 2. Demonstrate a commitment to continuous professional development and actively participate in the appraisal process. 3. Identify and deliver strategies to ensure the provision of education and development program to meet the needs of the neonatal service. 4. Demonstrate the ability to access medical information efficiently, evaluate it critically, and apply it appropriately to the care of ill newborns
  54. 54. 54 | P a g e 5. Demonstrate effective strategies to access the information needed for effective patient care. 6. Demonstrate effective approaches to acquiring new information. 7. Assess one's own strengths and weaknesses with respect to professional knowledge and skills, and identify a process to remediate or make allowance for them in information gathering, decision-making, and professional development. 8. Identify one's knowledge gaps in the course of providing patient care, and cultivate the habit of continuous inquiry to expand one's knowledge of medical advances. 9. Seek and incorporate feedback and self-assessment into a plan for professional growth as well as provide constructive feedback to others. Public relations: Collect, collate, record, input and report routine and simple data and information. Maintain accurate and up to date records. Act as a resource of specialist knowledge and clinical practice. Foster an environment that encourages staff development, supporting and counseling staff as necessary. Develop, deliver and evaluate staff development programs that support the achievement of clinical skills, leadership and best practice in neonatal nursing. Demonstrate knowledge of public policies and participate in professional activities that relate to the advancement of neonatal nursing practice. Researcher:  Develop knowledge and skills to remain ‗current‘ in practice, disseminating new knowledge and skills for wider benefit.  Identify own limitations and/or knowledge and skill deficits, formulate a plan of action and organize development opportunities to enhance continuous professional development.  Recognize limitations of others, provide support, information and teaching to others to help their development.  Instigate and facilitate research and audit.  Proactively foster a culture of enquiry and facilitate change to integrate best evidence into neonatal care.