Perinatal Services BC Newborn Guideline 13 Newborn Nursing Care Pathway
August 2013 (v2 March 2015) Table of Contents Introduction About the Newborn Nursing Care Pathway . 2 Who Updated the Newborn Nursing Care Pathway. 2 Statement of Family Centered Care . 2 Referring to a Primary Health Care Provider (PHCP)...... 3 Referrals to Other Resources . 3 Goals and Needs – Health Canada’s National Guidelines. 3 Needs – World Health Organization (WHO)...... 4 Timeframes...... 4 Newborn Physiological Stability. 4 Newborn Pain...... 5 Physiological Health Head . 7 Nares ...... 9 Eyes...... 10 Ears...... 12 Mouth...... 14 Chest ...... 15 Abdomen/Umbilicus. 16 Skeletal/Extremities...... 17 Skin...... 18 Perinatal Services BC Neuromuscular ...... 20 West Tower, #350 Genitalia...... 21 555 West 12th Avenue Elimination Vancouver, BC Canada V5Z 3X7 Urine...... 22 Tel: (604) 877-2121 Stool...... 23 www.perinatalservicesbc.ca Vital signs...... 25 Weight...... 27 Behavioral . 28 Crying...... 30 Infant Feeding Breastfeeding...... 32 Breast Milk Substitute – Formula Feeding ...... 36 Health Follow-Up While every attempt has been made to ensure that the information Health Follow-Up...... 38 contained herein is clinically accurate Immunization and Communicable Diseases ...... 39 and current, Perinatal Services BC Safety and Injury Prevention. 41 acknowledges that many issues remain controversial, and therefore may be Screening/Other subject to practice interpretation. Newborn Blood Spot Screening. 42 Hearing Screening . 43 Biliary Atresia...... 43 Glossary of Abbreviations...... 44 References & Endnotes ...... 44
Revision Committee...... 47
© Perinatal Services BC, 2013 Introduction About the Newborn Nursing Care Pathway
The Newborn Nursing Care Pathway identifies the needs for care of newborns and is the foundation for the British Columbia Newborn Clinical Path. To ensure all of the assessment criteria are captured, they have been organized into five main sections:
• Physiological health (organized from head to toe) • Behavioural • Infant feeding • Health follow-up • Screening/other While the newborn assessment criteria are presented as discrete topic entities it is not intended that they be viewed as separate from one another. For example, the newborn physiological changes affect her/his feeding and behaviour. To assist with this, cross referencing will be used throughout the document (will be seen as “Refer to…”). This will also be evident with the cross referencing to the Postpartum Nursing Care Pathway as the newborn and mother are considered to be an inseparable dyad with the care of one influencing the care of the other. An example of this is with breastfeeding as it affects the mother, her newborn and bonding and attachment.
In this document, assessments are entered into specific periods; from immediately after birth to 7 days postpartum and beyond. These are guidelines and are used to ensure that all assessment criteria have been captured. Once the newborn and her/his mother are in their own surroundings, details of physical assessments will be performed based on the individual nursing judgment in consultation with the mother.
Who Updated the Newborn Nursing Care Pathway
Perinatal Services BC (formerly BC Perinatal Health Program)1 coordinated the updating of this document. It represents a consensus opinion, based on best evidence, of an interdisciplinary team of health care professionals. The team included nurses form acute care and public health nursing representing each of the Health Authorities as well as rural and urban practice areas. Clinical consultation was provided by family physicians, obstetricians, pediatricians and other clinical experts as required.
Statement of Family Centered Care
In conjunction with Women Centred Care, which places the woman at the center of care, family-centered maternity care, is an attitude/philosophy rather than a policy, and is based on guiding principles2. Key principles have been adapted and are reflected in the Newborn Nursing Care Pathway.
• Women and families have diverse birthing experiences (philosophies, knowledge, experience, culture, social, spiritual, family backgrounds and beliefs) thus approaches to care need to be adapted to meet each family’s unique needs • Relationships between women, their families, and the variety of health care providers are based on mutual respect and trust • In order to make knowledgeable and responsible informed decisions in providing newborn care, women and their families require support and information • Parents need to and should be provided with information about newborn screening/treatments (E.g.-eye prophylaxis, vitamin K and newborn screening) including why the treatment is recommended, advantages, side effects and risks if not performed – if parents decline screening/treatment, a signed and witnessed informed refusal is required3 • The family (Using Women Centred Care principles and as defined by the woman) is encouraged to support and participate in all aspects of newborn care • While in hospital (whenever possible), assessments and procedures should be performed in the mother’s room (to ensure mother-infant togetherness and to provide anticipatory guidance and information)
2 Perinatal Services BC Introduction
• Prior to, during, and following procedures that may cause newborn discomfort/pain, mothers should be encouraged to comfort their newborns through breastfeeding or skin-to-skin contact
Referring to a Primary Health Care Provider (PHCP)
Prior to referring to a Primary Health Care Provider (PHCP) a specific or newborn global assessment4 (physical and feeding) including history of the pregnancy and labour and birth, will be performed by the nurse. Whenever possible, the woman/her family (supports) are present at the assessment and included in the planning, and implementation of the newborn’s care. In the intervention sections it will be referred to as Nursing Assessment.
Referrals to Other Resources
To support nursing practice the following resources are available. Links for many specific resources are included throughout the document. Key resources for parents are:
• Healthy Families BC Website – This website is filled with up-to-date and practical information, useful tools and resources for women, expectant parents, and families with babies and toddlers up to 3 years of age. www.healthyfamiliesbc.ca/parenting/ • HealthLink BC – www.healthlinkbc.ca/kbaltindex.asp • HealthLink BC – Telephone number accessed by dialing 8-1-1 (Services available – health services representatives, nurses pharmacists, dietitians, translation services and hearing impaired services)
Goals and Needs - Health Canada’s National Guidelines
As indicated by Health Canada’s National Guidelines5 the postpartum period is a significant time for the mother, baby, and family as there are vast maternal and newborn physiological adjustments and important psychosocial and emotional adaptations for all family members or support people. The following are the goals, fundamental needs, and basic services for postpartum women and their newborns, adapted from Health Canada’s National Guidelines which are to:
• Assess the physiological, psychosocial and emotional adaptations of the mother and baby • Promote the physical well-being of both mother and baby • Promote maternal rest and recovery from the physical demands of pregnancy and the birth experience • Support the developing relationship between the baby and his or her mother, and support(s)/family • Support the development of infant feeding skills • Support the development of parenting skills • Encourage support of the mother, baby, and family during the period of adjustment (support may be from other family members, social contacts, and/or the community) • Provide education resources and services to the mother and support(s) in aspects relative to personal and baby care • Support and strengthen the mother’s knowledge, as well as her confidence in herself and in her baby’s health and well-being, thus enabling her to fulfill her mothering role within her particular family and cultural beliefs • Support the completion of specific prophylactic or screening procedures organized through the different programs of maternal and newborn care, such as: Vitamin K administration and eye prophylaxis, immunization (Rh, Rubella, Hepatitis B), prevention of Rh isoimmunisation and newborn screening • Assess the safety and security of postpartum women and their newborns (families) (e.g. car seats, safe infant sleeping, potentially violent home situations, substance use)
Newborn Guideline 13: Newborn Nursing Care Pathway 3 Introduction
• Identify and participate in implementing appropriate interventions for newborn variances/problems • Assist the woman in the prevention of newborn variances/problems
Needs – World Health Organization (WHO)
The WHO6 stated that “postpartum care should respond to the special needs of the mother and baby during this special phase and should include: the prevention and early detection and treatment of complications and disease, and the provision of advice and services on breastfeeding, birth spacing, immunization and maternal nutrition.”7
The twelve specific WHO newborn needs continue to be:
• Easy access to the mother • Appropriate feeding • Adequate environmental temperature • A safe environment • Parental care • Cleanliness • Observation of body signs by someone who cares and can take action if necessary • Access to health care for suspected or manifest complications • Nurturing, cuddling, stimulation • Protection from disease, harmful practices, abuse/violence • Acceptance of sex, appearance, size • Recognition by the state (vital registration system)
Timeframes
The first 12 hours are considered to be the period of transition where the normal newborn adapts to extra-uterine life.8 Thus, the guidelines determined the first 12 hours following the third stage of birth as the Period of Stability (POS) followed by >12-24 hours, >24-72 hours, and >72 hours - 7 days and beyond.
NOTE: In order to capture key parent teaching/anticipatory guidance concepts, concepts will be located in the >12-24 hour timeframe. It is at the individual nurse’s discretion to provide this information/support earlier or later.
Newborn Physiological Stability
The Newborn Nursing Care Pathway has adapted Consensus Statement #11, in the BC Postpartum Consensus Symposium9 and recommended that the six following criteria define infant physiologic stability following term vaginal delivery:
• Respiratory rate between 40-60/ min • Axillary temperature of 36.5- to 37.4 C10 and stable heart rate (100-160 bpm)11 • Suckling/rooting efforts and evidence of readiness to feed • Physical examination reveals no significant congenital anomalies • No evidence of sepsis • No jaundice developing <24 hrs
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Newborn Pain
Newborn pain is generally alleviated by interventions such as holding the baby skin-to-skin, breastfeeding, cuddling, rocking and/or lightly swaddling.
Although the measurement of pain is not usually required for a healthy term infant, there may be times when newborn pain requires further assessment.
For information to increase knowledge of assessing newborn pain the “Behavioral Indicators of Infant Pain” (BIIP) is available. It is an evidence-based, standardized way of assessing pain and is designed for term and preterm infants. Currently, this assessment tool is being used in hospitals around the world and in several BC hospitals’ neonatal intensive care units (NICUs). Research on the development of the BIIP has been published in peer reviewed journals and the BIIP has been used to assess pain in a number of studies.12,13
If a pain assessment is required, it may be done before a routine handling session (such as during the diaper change) and measured a second time at a subsequent handling to see if a change has occurred. This type of assessment would be equivalent to taking a temperature to see if the baby is in more or less distress over a short period of time (e.g. 2 hours). This measurement then forms part of the nursing documentation to report in the event treatment is needed.
Newborn Guideline 13: Newborn Nursing Care Pathway 5
14 And promotes bonding And promotes Refer to >12 – 24 hr spots plagiocephaly (flat Prevent neck on head) and strengthen muscles by placing baby on abdomen when awake (tummy time) for several short periods each day Carrying infant in arms (vs. in infant seat) assists with of flat head prevention Refer to POS ~ 3 days Moulding resolves head circumference Average 33 – 35 cm once moulding consistent disappears (ensure way of measuring) ducation / Anticipatory Education / Anticipatory Parent Guidance • • • Norm and Normal Variations Norm and • • • >72 hours – 7 days and beyond >72 hours Refer to POS Refer to >12 – 24 hr Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • >24 – 72 hours Anterior fontanel: 2 – 4 cm long, Anterior fontanel: 2 at 12 – 28 diamond shape, closes months than Posterior fontanel: smaller triangular shape anterior, position Supine (back) sleep Carry baby and alternate head positions (to avoid flattened head) of SIDS Prevention Norm and Normal Variations Norm and Refer to POS Education / Anticipatory Parent Guidance • • • • • www.healthlinkbc.ca/healthfiles/ hfile46.stm >12 – 24 hours Care when handling infant’s handling infant’s when Care head Refer to >12 – 24 hr Discuss variances and when they should resolve (caput succedaneum, cephalohematoma etc.) – refer to variance >12 – 24 hr Place baby skin-to-skin May have moulding, some May have moulding, overlapping of sutures fontanelles Anterior & posterior flat and soft Neck short and thick Full range of motion Head round, symmetrical Head round, • 0 – 12 hours Stability (POS) Period of • ducation / Anticipatory Education / Anticipatory Parent Guidance • • • • • Norm and Normal Variations Norm and • Behavior Postpartum Nursing Care Pathway: Bonding & Attachment Shape Size Fontanelles prn Circumference Physiological Physiological Assessment Refer to: • • Head Assess: • • • • Assess mother’s/family/ of supports understanding newborn and physiology variances capacity to identify further that may require assessments Physiological Health:Physiological Head Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 7 19 Carrying and the use of an Carrying and the use upright ring type carrier time when Supervised tummy awake Remarkably enlarged fontanelles/splayed suture lines Head appears abnormally & looks ‘heavy’-signs of large hydrocephalus Nursing assessment Refer to PHCP prn Apply non-perfumed oil, use Apply non-perfumed shampoo mild non perfumed oil. to remove – Plagiocephaly Variance of the skull) (flattening of 1 side Intervention – Plagiocephaly • • – Enlarged Variance fontanelles • • Intervention – Enlarged fontanelles • • Variance – Cradle cap – Cradle Variance – Cradle Cap Intervention • >72 hours – 7 days and beyond >72 hours Refer to 0 – 24 hr Refer to 0 Refer to 0 – 24 hr Variance • Intervention • >24 – 72 hours 17 18 Infants who birth with Infants who birth with assistance of vacuum caput extraction may have and bruising – Cephalohematoma first 3 – 4 days, increases wks disappears in 2 – 3 the bilirubin and may affect screen Risk of jaundice if head trauma and/or bruising Refer to POS – Caput succedaneum disappears spontaneously within 3 – 4 days • • • Intervention Refer to POS Variance • • >12 – 24 hours 16 15 Refer to appropriate PHCP Refer to appropriate prn Nursing assessment Bruising, excoriation, Bruising, excoriation, lacerations Bulging or sunken fontanelles Neck webbing, limited range of motion Masses Hydrocephaly Microcephaly Cephalohematoma – Cephalohematoma collection of blood between skull bone & periosteum against caused by pressure – maternal or forceps pelvis lines suture does not cross Caput succedaneum crosses crosses Caput succedaneum caused by lines (edema suture of occiput sustained pressure against cervix) • Intervention • • • • • • • • 0 – 12 hours Stability (POS) Period of Variance • Physiological Physiological Assessment HEAD (Continued) Physiological Health:Physiological Head Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
8 Perinatal Services BC Refer to POS Refer to POS Refer to POS Refer to POS >72 hours – 7 days and beyond >72 hours Norm and Normal Variations Norm and • Education/ Anticipatory Parent Guidance • Variance • Intervention • Refer to POS Refer to POS Refer to POS Refer to POS >24 – 72 hours Norm and Normal Variations Norm and • Education/ Parent Anticipatory Guidance • Variance • Intervention • Refer to POS Refer to POS Refer to POS Refer to POS >12 – 24 hours Norm and Normal Variations Norm and • Education/ Anticipatory Parent Guidance • Variance • Intervention • Refer to PHCP prn Nursing assessment Nasal congestion Sneezing common Nose breathers flaring Symmetrical, no nasal Thin, clear nasal discharge, sneezing common After mucous and amniotic nasal from cleared fluids are passages, infant differentiates unpleasant pleasant from odors patent Nares on nose Milia present 0 – 12 hours 0 – 12 Stability (POS) Period of • Intervention • Variance • ducation/ Anticipatory E Parent Guidance • Norm and Normal Variations Norm and • • • • • • Symmetry Air entry both nares Assess mother’s/ family/supports understanding of newborn to physiology and capacity may identify variances that further assessments require Vital signs Physiological Assessment Nares Assess: • • • Refer to: • Physiological Health:Physiological Nares Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 9 Refer to POS and >24-72 hr strabismus May have transient – 4 months or nystagmus until 3 Education Parent Refer to >12 – 72 hr No tears- tear ducts patent ~ 5 – 7 months Norm and Normal Variations Norm and • • Education/ Anticipatory Parent Guidance • • • >72 hours – 7 days and beyond >72 hours Refer to POS Resolving or decreasing edema of eyelids and chemical conjunctivitis of May have slight jaundice sclera Refer to 12 – 24 hr Jaundice progression/ treatment Norm and Normal Variations Norm and • • • Education/ Anticipatory Parent Guidance • • >24 – 72 hours Clean from inner canthus to Clean from water outer edge with warm when bathing Nearsighted – see most clearly when objects 8-10 face inches from Show attention by looking, lifting upper eyelids, ‘brightening’ Attracted to human face Display visual abilities most consistently in quiet alert state Newborn’s vision Newborn’s Refer to POS Eye care • Norm and Normal Variations Norm and • Education/ Anticipatory Parent Guidance • >12 – 24 hours 20 promotes initiation of promotes feeding and maternal/infant eye contact Refer to >12-24 hr Eye prophylaxis – prevention – prevention Eye prophylaxis of ophthalmia neonatorum May see chemical conjunctivitis due to eye ointment Uncoordinated movement Uncoordinated Outer canthus aligned with Outer canthus aligned upper ear Dark or slate blue color present Blink reflex Edematous lids Sclera clear No tears Pupils equal and reactive to light May see subconjunctival hemorrhage Administer eye prophylaxis (after completion of initial feeding or by 1 hour after birth) • ducation/ Anticipatory E Parent Guidance • • • 0 – 12 hours Stability (POS) Period of Norm and Normal Variations Norm and • • • • • • • • • yes Skin Symmetry Placement Clarity Risks for eye/vision (family history) problems Physiological Physiological Assessment Refer to: • Eyes Assess: • • • • family/ Assess mother’s/ of supports understanding newborn and physiology variances capacity to identify further that may require assessments Physiological Health:Physiological E Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
10 Perinatal Services BC Refer to POS and Refer to POS >24 – 72 hr Refer to POS and >24 – 72 hr and wait Watch May want to use a warm compress is no infection there Ensure to PHCP refer If unsure may Refer to PHCP. to Pediatric need referral Ophthalmology >72 hours – 7 days and beyond >72 hours Variance • Intervention • - Variance Blocked tear duct Intervention - Blocked tear duct • • • • – Obvious strabismus Variance or nystagmus >3 – 4 months Intervention – Obvious strabismus or nystagmus >3 – 4 months • Refer to POS Conjunctivitis eye care Teach health Refer to appropriate prn provider care >24 – 72 hours Variance • • Intervention • • Refer to POS Refer to POS >12 – 24 hours Variance • Intervention • Refer to appropriate PHCP Refer to appropriate prn Nursing Assessment Pupils unequal, dilated Pupils unequal, constricted Hazy, dull cornea Hazy, 0 – 12 hours Stability (POS) Period of • Intervention • • Variance • yes Physiological Physiological Assessment Eyes (Continued) Physiological Health:Physiological E Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 11 21 Family history Low birth weight Jaundice – requiring transfusion Infections Refer to POS Refer to >12 – 24 hr and Able to distinguish mother 2 weeks voice within father’s with distinct and responds pattern to each reaction and Monitor for normal hearing speech patterns to second hand Exposure risk of ear smoke increases infection Review factors associated with risk of hearing loss increased such as >72 hours – 7 days and >72 hours beyond Norm and Normal Variations Norm and Normal • Education/ Anticipatory Parent Guidance • • • • • Refer to >12 – 24 hr >24 – 72 hours Variations Norm and Normal Refer to POS Education/ Anticipatory Parent Guidance • Refer to POS do not Cleaning of ears e.g. swab use a cotton tipped sounds Higher-pitched generally gain the infant’s lower attention rather than pitched sounds Hearing Screening Provincial Program www.healthlinkbc.ca/ healthfiles/hfile71b.stm >12 – 24 hours Variations Norm and Normal • Education/Anticipatory Parent Guidance • • • • Refer to >12-24 hr Well formed cartilage Well – top of Ears level with eyes plane with pinna on horizontal outer canthus of eye May have temporary unequal asymmetry from on the intrauterine pressure sides of the of head to loud noises Startles/reacts vernixEar canal may contain (short external auditory ear canal) ars 0 – 12 hours Stability (POS) Period of ducation/ Anticipatory E Parent Guidance • Norm and Normal Variations Norm and Normal • • • • • For well-formed cartilage For well-formed cartilage Ears level with the eyes Ears Assess: • • family/ Assess mother’s/ supports understanding of newborn physiology and capacity to identify require variances that may further assessments Physiological Assessment Physiological Health:Physiological E Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
12 Perinatal Services BC Gentamycin Kanamycin Neomycin Streptomycin Tobramycin Bacteria meningitis Nursing Assessment Refer to PHCP prn Refer to POS to ototoxic Exposure medications especially as: aminoglycosides, such • Intervention • • >72 hours – 7 days and >72 hours beyond Variance • • Refer to POS Refer to POS Variance • Intervention • >24 – 72 hours Refer to POS Refer to POS Variance • Intervention • >12 – 24 hours Refer to appropriate PHCP prn Refer to appropriate Nursing Assessment Ear tags, ear pits – could Ear tags, ear pits – duct or indicate a brachial cleft and may cyst (risk for infection intervention) need surgical Low set ears Drainage present Family history of childhood sensory hearing loss of Cranial facial anomalies pinna or ear canal Unresponsive to noise Unresponsive ars • Intervention • • • • • • 0 – 12 hours Stability (POS) Period of Variance • EARS (Continued) Physiological Assessment Physiological Health:Physiological E Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 13 22 Wipe gums with soft, clean damp cloth daily Wipe gums with soft, of the first teeth prior to the eruption of tooth decay Prevention Refer to Maternal Guidelines (Breasts) Refer to PHCP for antifungal treatment Healthy Term PSBC (2013) Breastfeeding Infants Refer to POS Refer to POS and >24 – 72 hr or White, cheesy patches on the tongue, gums rub off mucous membranes – won’t rash – red Diaper area Discuss signs, symptoms & treatment itchy, (red, nipples for thrush Assess mother’s nipples, burning, shooting pain) persistent sore Both mother and baby need treatment feeding baby’s May affect as If using soother – may want to discontinue of yeast may contribute overgrowth Refer to POS Refer to >12 – 24 hr Oral hygiene mouth regularly Look into baby’s www.cda-adc.ca/en/oral_health/cfyt/dental_ care_children/tooth_decay.asp • • • • Variance • Intervention • – Thrush Candida (fungus) Variance • • Intervention – Thrush Candida (fungus) • • • • • Norm and Normal Variations Norm and • Guidance Education/ Anticipatory Parent • • • >72 hours – 7 days and beyond >72 hours Refer to POS May have sucking blister on lips be may Tongue coated white from feeding Refer to >12 – 24 hr Refer to POS Refer to POS If latching difficulty persists due to tight or tongue frenulum to PHCP refer Norm and Normal Norm and Variations • • • Education/ Parent Anticipatory Guidance • Variance • Intervention • • >24 – 72 hours Refer to POS www.healthlinkbc. ca/healthfiles/ hfile19a.stm Refer to POS Refer to POS Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • >12 – 24 hours Rooting Sucking Feeding variations to cope with variances Dry mucosa, assess hydration status PHCP prn Refer to appropriate Assess baby’s ability to latch without ability to latch without Assess baby’s causing pain and damage to nipple Tight frenulum (tongue tie) or heart Tight frenulum shaped tongue Cleft lip/palate tongue-large Short or protruding tongue (macroglossia) chin (micrognathia) Small receding Dry mucosa (may be dry after crying) or opens Mouth drooping asymmetrically (may be facial palsy) Refer to >12 – 24 hr Mucosa moist smooth and pink Mucosa moist pearls May have epithelial and can extend out to midline Tongue edge of lower lip sublingual May have noticeable frenulum Intact lips Jaw symmetrical Intact palate (soft, hard) Reflexes • • • Intervention • Variance • • • • • • ducation/ Anticipatory E Parent Guidance • 0 – 12 hours 0 – 12 Stability (POS) Period of Normal Variations Norm and • • • • • • • • Feeding Lips for colour midline Tongue Frenulum Palate Reflexes Oral health and care Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to: Refer to: • Mouth Assess: • • • • • • family/ Assess mother’s/ supports understanding of newborn physiology and capacity to identify variances that further may require assessments Physiological Physiological Assessment Physiological Health:Physiological Mouth
14 Perinatal Services BC Refer to POS usually enlargement Breast of by the second week resolves life Refer to >12 – 24 hr Refer to POS Refer to POS >72 hours – 7 days and beyond >72 hours Norm and Normal Variations Norm and • • Education/ Anticipatory Parent Guidance • Variance • Intervention • Refer to POS Refer to >12 – 24 hr Refer to POS Refer to POS >24 – 72 hours Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • Refer to POS Normal newborn breathing on Hiccoughs resolve own is Occasional sneezing to mechanism infant’s clear nasal passages Do not squeeze swollen due to they are – breasts maternal hormones Refer to POS Refer to POS >12 – 24 hours Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • • • • Variance • Intervention • Nasal flaring Tachypnea More common in Cesarean births common in Cesarean More mucous – potential Dark brown swallowing of mucous/blood during birth Retractions Grunting Circumference about 1cm < head about 1cm < Circumference circumference xiphoid protruding Round, symmetrical; process Clavicle intact Chest sounds clear common Hiccoughs and sneezing clear/milky may be swollen with Breasts nipple discharge Mucous Refer to appropriate PHCP prn Refer to appropriate Nursing assessment Mucousy / noisy respirations distress Signs of respiratory Deviation in chest shape clavicle Fractured Asymmetrical movement inflamed Breasts Supernumerary nipples Coughing Refer to >12 – 24 hr 0 – 12 hours Stability (POS) Period of Norm and Normal Variations Norm and • • • • • • • • Intervention • Variance • • • • • • • • ducation/ Anticipatory Guidance E Parent • Symmetry Shape Respirations Heart rate Cardiovascular function Physiological Physiological Assessment t Chest Assess: • • • • • family/ Assess mother’s/ supports understanding of newborn physiology and capacity to identify variances that further may require assessments Physiological Health:Physiological Chest Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 15 Refer to 0 – 24 hr separates Cord within 1 – 3 weeks Slight bleeding may occur with separation Refer to >12 – 24 hr Normal cord separation Refer to 0 – 24 hr Refer to >0 – 24 hr >72 hours – 7 days >72 hours and beyond Norm and Normal Norm and Variations • • • Education/ Parent Anticipatory Guidance • • Variance • Intervention • Refer to >0 – 24 hr clamp, if Cord may be present, if cord removed is dry When infant with discharged clamp on, cord of cord removal clamp to be carried out as per agency policy/ procedures Refer to >12 – 24 hr Refer to >0 – 24 hr Refer to >0 – 24 hr >24 – 72 hours Norm and Normal Norm and Variations • • • ducation/ E Parent Anticipatory Guidance • Variance • Intervention • Clean cord with water & air dry Clean cord applicator or washcloth to clean on cotton tipped Water cord the base of the gently around bathing and at diaper after cord the base of the Clean around changes irritation and to keep it to prevent Fold diaper below the cord dry and exposed to air coins, bandages or binders over navel buttons, Avoid colonization promote – to mother with skin-to-skin Encourage skin flora mother’s with non pathogenic bacteria from Clean and dry or slightly moist Clean and if present clamp secure Cord Cord S & S infection – redness or swelling >5mm from umbilicus, or swelling >5mm from S & S infection – redness and/or poor feeding lethargy, fever, Refer to POS umbilicus or swelling >5 mm from redness odor, – Foul Cord and/or poor lethargy, S & S of systemic infection – fever, feeding) Refer to POS is moist or “mucky” clamp if cord cord Do not remove infection if S & S of systemic care Urgent Wash hands with soap & water before and after contact with soap & water before hands with Wash umbilical area during bath care cord Review/demonstrate >12 – 24 hours Norm and Normal Variations Norm and • • www.healthlinkbc.ca/kbase/topic/special/tp22060spec/sec1. htm Variance • • • Intervention • • • ducation/ Anticipatory Guidance Education/ Anticipatory Parent Education Parent • • mbilicus U ducation/Anticipatory Education/Anticipatory Cord clamp secure Cord Slightly rounded, soft and soft Slightly rounded, symmetric Bowel sounds present Skin: pink, smooth, opaque blood vessels A few large may be visible and one vein arteries Two Abdomen Abdomen Refer to PCHP prn Nursing assessment Umbilical hernia Masses Bleeding Drainage Absent bowel sounds Sensitive with palpation &/or feeding emesis Green intolerance Bright blood emesis One artery Refer to >12 – 24 hr Cord Cord Norm and Normal Variations Norm and • 0 – 12 hours Stability (POS) Period of • Intervention • • • • • • • • • Variance • Parent Parent Guidance • • Symmetry Bowel sounds Cord Umbilical area n/ Abdome us Umbilic Assess: • • • • Assess mother’s/ family/supports understanding of newborn physiology and capacity to identify variances that may require further assessments Physiological Assessment Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to: Physiological Health:Physiological Abdomen/
16 Perinatal Services BC Refer to POS Refer >12 – 24 hr Refer to POS Refer to POS >72 hours – 7 days and >72 hours beyond Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • Refer >12 – 24 hr Refer to POS Refer to POS >24- 72 hours Normal Norm and Variations Refer to POS Education/ Parent Anticipatory Guidance • Variance • Intervention • Refer to POS Refer to POS Norm and Normal Norm and Variations Refer to POS Education/ Parent Anticipatory Guidance hip check done by Ensure physician Variance • Intervention • >12-24hours xtremities E Refer to appropriate PHCP prn Refer to appropriate Nursing Assessment Asymmetrical extremities of spine Curvature Non-intact spine of hair along an intact spine – may require Tufts ultrasound to rule out spina bifida Coccygeal dimple Fractures Poor range of motion of extremities Hypertonia/ contractures Skeletal abnormalities equinovarus (club foot) Talipes Congenital hip dislocation Refer to >12 – 24 hr Refer to >12 – 24 hr Intact, straight spine Intact, straight Full range of motion Clavicles intact Bow-legged, flat-footed Equal gluteal folds Equal leg length Symmetrical in size, shape, movement & flexion in size, shape, movement Symmetrical • Intervention • Variance • • • • • • • • • • • ducation/ Anticipatory Guidance Education/ Anticipatory Parent • 0 – 12 hours Stability (POS) Period of • • • • • • Norm and Normal Variations Norm and • al/ Symmetry Intact and straight spine Full range of motion Physiological Physiological Assessment Assess: • • • family/ Assess mother’s/ supports understanding of newborn physiology and capacity to identify require variances that may further assessments ties Extremi Skelet Physiological Health: Skeletal/ Physiological Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 17 Jaundice usually peaks Jaundice by day 3 – 4, resolves in one – two weeks Refer to 0 – 72 hr Refer to 0 – 72 hr Norm and Normal Variations Norm and • • Education/ Parent Anticipatory Guidance • >72 hours – 7 days >72 hours and beyond
26 27 Refer to 0 – 24h Refer to 0 of all infants About 60 percent it generally have some jaundice, medical clears up without any treatment Bilirubin levels – refer to CPS Bilirubin levels – refer Guideline Refer to 0 – 24h Relationship between poor feeding, hydration & jaundice and the need to monitor Management of jaundice – feeding, waking sleepy baby, monitoring output Norm and Normal Variations Norm and • • • www.cps.ca/english/statements/ FN/FN07-02.pdf Education/ Anticipatory Parent Guidance • • • www.healthlinkbc.ca/kb/content/ mini/hw164159.html#hw164161 >24 – 72 hours 25
23,24 region, but can be found anywhere can be found anywhere but region, on the body > Most often found in the lumbosacral > Most often found in the lumbosacral Amount of water, lukewarm Amount of water, soap can be irritating, use temperature, unscented lotions/oils Milia Cracks Peeling Hemangiomas in darkly Mongolian spots – frequently pigmented infants such as Asian, First Nation, African-American stability Refer to vital signs re every day Not required to sponge bath Immersion preferable (less chance for heat loss) Skin care – avoidance of perfumed Skin care products Delay first bath until baby stable and completed transition period to do the first bath encouraged Parents with nursing support Bathing: Refer to POS resolved Acrocyanosis Refer to POS Skin variations • • • • >12 – 24 hours Norm and Normal Variations Norm and • • Guidance Education/ Anticipatory Parent • • milia, mongolian Need for tactile stimulation Skin-to-skin May have (acrocyanosis) peripheral cyanosis Skin intact – may be dry with some peeling; lanugo on back; vernix in the creases May have erythema toxicum (newborn rash) spots, capillary hemangiomas, harlequin sign Skin pinch immediately returns to original state Skin is sensitive to touch 0 – 12 hours Stability (POS) Period of • ducation/ E Parent Anticipatory Guidance • Norm and Normal Norm and Variations • • • • • Feeding Skin color Turgor Integrity Factors that newborn increase risk for jaundice to BCPHP (refer Guideline) Physiological Physiological Assessment Refer to: • Assess mother’s/ Assess mother’s/ family/supports understanding of newborn physiology and her capacity to identify variances that further may require assessments Assess in natural Assess in light: • • • • Skin Physiological Health:Physiological Skin Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
18 Perinatal Services BC Refer to POS Refer to POS or unresolved New, unexplained rashes Refer to POS level of or increasing Severe jaundice Refer to >24 – 72 hr Refer to >24 – 72 hr >72 hours – 7 days and >72 hours beyond Variance • • Intervention • – Jaundice Variance • • Intervention – Jaundice • Refer to POS Refer to POS of for evidence Risk factors present history of jaundice (such as family bruising) preterm, jaundice, LBW, rouse to Infant difficult Feeding poorly not demonstrate ability to does Parent monitor feeding, output, behavior and colour Nursing assessment Bilirubin level as per facility guide or PHCP orders to support and educate plan Care monitoring for newborn in parents jaundice Assess feeding effectiveness Refer to PHCP prn Variance • Intervention • – Jaundice Variance • • • • Intervention – Jaundice • • • • • >24 – 72 hours Refer to POS Refer to POS Refer to POS Assess level of jaundice including hydration skin color, Assess feeding effectiveness- including output & weight Contact PHCP Variance • Intervention • Variance-Jaundice • Intervention – Jaundice • • • >12 – 24 hours Nursing Assessment Refer to PHCP prn Any jaundice in first 24 hours Refer to PHCP prn Nursing Assessment Pallor (may be genetic) Pallor (may cyanosis or increased Generalized cyanosis with activity Unexplained skin rashes/ in skin lacerations/ breaks Hemangiomas Petechia Bruising (ecchymosis) Intervention – Jaundice • • Variance – Jaundice Variance • • Intervention • Variance • • • • • • • 0 – 12 hours Stability (POS) Period of Skin (Continued) Physiological Assessment Physiological Health:Physiological Skin Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 19 Refer to POS Refer to >12 – 24 hr Refer to POS Refer to POS >72 hours – 7 days >72 hours and beyond Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • / Refer to POS Refer to >12 24 hr If mom on SSRIs SNRIs, ensure a follow-up appointment is booked for 3 – 5 days post discharge Refer to POS Refer to POS >24 – 72 hours Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • • Variance • Intervention • Refer to POS Encourage skin- to-skin and – if breastfeeding concerned risk about for low blood sugar and alertness Baby’s to feed readiness Positioning, movement, reflexes, muscle tone Jitteriness vs seizure activity – jittery movements stop when infant is held Refer to POS Refer to POS >12 – 24 hours Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • • • • Variance • Intervention • f 28 Sucking Babinski Grasping Moro Palmar Planter Rooting Stepping Abnormal foot posture Facial palsy Brachial palsy Limbs not flexed (hypotonicity) Lack of muscle tone/resistance activity Seizure Jitteriness – rule out low blood sugar (<2.6mmol/L) Asymmetrical facial/limb movement Refer to >12 – 24 hr APGAR scores between 7 and 10 at 5 minutes between 7 and APGAR scores Jitteriness differentiated between hypoglycemia and seizure activity between hypoglycemia and seizure Jitteriness differentiated Refer to PHCP prn Nursing assessment (including maternal medication/drug use) Abnormal or absent reflexes Arching Extremities symmetrical, full range of motion (ROM), flexed, good good motion (ROM), flexed, full range of symmetrical, Extremities muscle tone present Infant reflexes • • • • • • • Variance • ducation/ Anticipatory Guidance E Parent • • • • Intervention • • • www.camh.net/Publications/Resources_for_Professionals/ Lactation/psychmed_preg_lact.pd Pregnancy_ 0 – 12 hours Stability (POS) Period of Norm and Normal Variations Norm and • • Muscle tone and movement present Reflexes are for and appropriate developmental/ Physiological Physiological Assessment Assess mother’s/ family/ Assess mother’s/ supports understanding of newborn physiology and capacity to identify variances that further may require assessments Assess: • • uscular Neurom Physiological Health:Physiological Neuromuscular Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
20 Perinatal Services BC Frequent diaper changing Frequent Keep clean and dry (Refer to Skin) to air Exposure prn Use of barrier cream Bleeding Infection Edema Refer to POS labia and scrotum Swelling of about day 3 – 4 resolves Whitish mucoid or by end pseudomenses subsides of first week Refer to >12 – 24 hr and teach care If circumcised S & S of complications Refer to POS Rash that does not clear after several days Nursing Assessment to PHCP May refer For diaper rash Norm and Normal Variations Norm and • • • Education/ Anticipatory Parent Guidance • • >72 hours – 7 days and beyond >72 hours Variance • • Intervention • • • Refer to POS Refer to POS Variance • Intervention • >24 – 72 hours Do not remove vernix Do not remove to back front Clean from foreskin Do not retract information to Provide support informed decision prn circumcision making re not covered Circumcision under Medical plan Males Refer to POS Refer to POS Refer to POS dry Keep baby clean & Females • www.healthlinkbc.ca/kbase/ topic/special/hw142449/sec1. htm Variance • Intervention • >12 – 24 hours Norm and Normal Variations Norm and • Education/ Anticipatory Parent Guidance • • Fusion of labia opening below/above tip of penis Urethral (hypospadius) size Unequal scrotal palpable in inguinal canal or not palpable Testes Hydrocele Scrotum swollen – rugae present Scrotum descended palpable bilaterally Testes opening Central urethral not retractable Foreskin on penile shaft Epithelial pearls may be present Smegma may be found on foreskin common Erections Labia swollen Labia majora to midline of vaginal – in front open behind clitoris Urethral opening Clitoris maybe enlarged present Hymenal tag is normally labia between caseosa present Vernix pseudomensus Whitish mucoid or Anus patent Females Female Refer to PCHP prn Undifferentiated Undifferentiated Male Nursing Assessment Refer to >12 – 24 hr Males 0 – 12 hours Stability (POS) Period of Norm and Normal Variations Norm and • • • • Variance • • Intervention • ducation/ Anticipatory Guidance E Parent • • alia Elimination Genitalia Physiological Assessment Refer to: • Assess: • Assess mother’s/ family/supports understanding of newborn physiology and capacity to identify variances that may further require assessments Genit Physiological Health: Genitalia Health: Physiological Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 21 34 32 33 Day 3 – 5: 3 – 5 wet, clear, pale 3 – 5 wet, clear, Day 3 – 5: yellow diapers/day Day 5 – 7: 4 – 6 wet, clear, pale clear, Day 5 – 7: 4 – 6 wet, yellow diapers/day diapers Day 7 – 28: many wet daily and pale yellow Refer to >12 – 24 hr Refer to >24 – 72 hr Uric acid crystals may indicate dehydration after 72 hours Urine concentrated < 5 wet diapers/day Refer to >12 – 24 hr Norm and Normal Variations Norm and • • • Education/ Anticipatory Parent Guidance • Variance • • • • Intervention • >72 hours – 7 days and beyond >72 hours 31 30 Refer to >12 – 24 hr diapers/ day Less than 1 – 2 wet Urine concentrated Inadequate hydration/elimination dry fontanelles, (poor skin turgor, mucous membranes, lethargy, irritability) of the skin Yellowing Refer to >12 – 24 hr 48 – 72 hr: 2 - 3 wet clear pale 48 – 72 hr: 2 - 3 wet yellow diapers /day 24 – 48 hr: 1 – 2 wet, clear, pale 1 – 2 wet, clear, 24 – 48 hr: day yellow diapers/ ducation/ Anticipatory Education/ Anticipatory Parent Guidance • Variance • • • • Intervention • • Norm and Normal Variations Norm and • >24 – 72 hours 29 Uric acid crystals in the first Uric acid crystals in 24 hr feeding Relationship between and output – elimination is a component of feeding voiding for assessment (normal the first 72 hours) Assessing for adequate hydration Encourage use of elimination prn record No voiding in 24 hrs Urine concentrated feeding effective Ensure Nursing Assessment Reassess within 24 hr Refer to PHCP prn Voids within 24 hr within 24 Voids yellow pale ≥ 1 wet, clear, diaper(s) • Education/ Anticipatory Parent Guidance • • • Variance • • Intervention • • • • >12 – 24 hours Norm and Normal Variations Norm and • • rine Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr One clear void with One clear possible uric acid crystals color) (orange/brownish Urine pale yellow and odorless U – limination 0 – 12 hours Stability (POS) Period of Intervention • Variance • Parent Education/ Parent Anticipatory Guidance • Norm and Normal Norm and Variations • • – tion – Feeding Weight Bladder output and Bladder output and color of urine is normal age. for baby’s Adequate hydration/ to elimination (refer breastfeeding) Physiological Physiological Assessment Refer to: • • Assess mother’s/ family/ Assess mother’s/ supports understanding of newborn physiology and capacity to identify variances that may require further assessments Elimina Assess: • • Urine Physiological Health: E Health: Physiological Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
22 Perinatal Services BC 37 Day 3 – 5: 3 – 4 loose, yellow transitional 3 – 4 loose, yellow Day 3 – 5: stools or golden Day 5 – 7: 3 – 6 yellow yellow Day 7 – 28: 5 – 10+ Stools colours vary – may be yellow/ Stools colours vary seed with mustard or brown mustard (may green consistency or occasionally mothers diet) reflect bowel 3 – 4 weeks of age individual Around patterngo several days without a soft/ (may loose bowel movement) Mild odour May pass stool with each feed Formed Pale yellow to light brown odour Strong fortified formula with iron May be dark green Often 1 – 2 daily for first weeks – 4 weeks baby may have a bowel 3 Around movement every 1 – 2 days Refer to >12 – 72 hr with BC Infant Stool Colour parents Provide with them; advise them to review and Card for the stool colour every day check baby’s BC first month after birth and contact the program Screening Infant Stool Colour Card stools if baby has abnormal coloured >72 hours – 7 days and beyond >72 hours Norm and Normal Variations Norm and Breastfed • • • • • color mustard Watery, • • Formula fed • • • • • • ducation/ Anticipatory Guidance E Parent • • 36 Meconium & transitional stools & transitional stools Meconium or >1 meconium Day 2 – 3 brown greenish Refer to >12 – 24 hr Changes in bowel pattern feeding effective Frequent >24 – 72 hours Norm and Normal Variations Norm and • • ducation/ Anticipatory Education/ Anticipatory Parent Guidance • • • 35 Breastfeeding Skin-to-skin of Hand expression colosturm Expected stool pattern – amount, consistency, colour, changes Encourage intake of colostrum – acts like a laxative As above except for to related information directly breastfeeding Assess feeding/oral intake Assess feeding/oral feeding Relationship between is and output-elimination a component of feeding assessment Encourage 1 meconium passed within >1 meconium 24 hours >12 – 24 hours • • Formula Fed • ducation/ Anticipatory Education/ Anticipatory Parent Guidance • • • Norm and Normal Variations Norm and • limination Stool – Refer to >12 – 72 hr Active bowel sounds Active bowel Parent Education/ Parent Anticipatory Guidance • Norm and Normal Norm and Variations • 0 – 12 hours Stability (POS) Period of – tion – Feeding Weight Normal stooling for age baby’s Refer to: • • Elimina Assess mother’s/ family/supports understanding of newborn physiology and capacity to identify variances that further may require assessments Stool Assess • Physiological Physiological Assessment Physiological Health: E Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 23 38 may be loose, greenish in colour and may be loose, greenish sometimes explosive Diarrhea (very loose, foul smelling) in exclusively breastfed Constipation – rare in difficulty hard infants (stools dry, passing) Bloody stool Refer to >24 – 72 hr 3 stools on day 4 in combination without < 3 stools on day 4 in filling obvious breast per day stools more Does not have 2 or after 4 – 5 days of age jaundice lasting longer Displaying signs of of the baby’s than two weeks (yellowing chalk white, yellow, skin or eyes), with pale stools or clay coloured to have increased A jaundiced baby tends of stools frequency • • • Intervention • >72 hours – 7 days and beyond >72 hours Variance • • • • ≤ 1 stools passed within 48 hr ≤ 1 stools passed within Diarrhea stool foul smelling, mucousy Green, Nursing Assessment assist family in Assess feeding and output, report developing plan to monitor ongoing variance Refer to PHCP prn >24 – 72 hours Variance • • • Intervention • • • Nursing Assessment hrs if Reassess within 24 no stool passed Refer to PHCP prn No stools passed within No stools passed within 24 hours Intervention • • • Variance • >12 – 24 hours limination – Stool Nursing Assessment Refer to PHCP prn Check if meconium Check if meconium passed at birth Absence of bowel sounds Abdominal distension • • 0 – 12 hours Stability Period of (POS) Intervention • • Variance • – tion – Physiological Physiological Assessment Elimina Stool (Continued) Physiological Health: E Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
24 Perinatal Services BC Refer to >12 – 24 hr Refer to >12 – 24 hr
Parent Parent Education/ Anticipatory Guidance • • >72 hours – >72 hours and 7 days beyond Norm and Norm and Normal Variations /
Refer to >12 – 24 hr Refer to >12 – 24 hr If mom on SSRIs SNRIs, a ensure follow-up appointment is booked for 3 – 5 days post discharge
>24 – 72 >24 – hours • Parent Education/ Anticipatory Guidance • • Norm and Norm and Normal Variations
42 40 with parent 43 S & S of disorganized infant, such as S & S of disorganized .41 Baby should be examined by PHCP if mother shows Baby should be examined by PHCP if mother symptoms of CNS depression See variances POS Fever Prone, head lowered, and stroke back and stroke head lowered, Prone, aids in nose the use of mechanical Avoiding & bulb aspirators E.g. cotton tipped applicators over infant and mother Skin-to-skin with blanket – avoid swaddling Loosely wrap baby with hands free is too warm Feeling back of neck to determine if baby bonding mouth care, Including information such as hygiene, behaviours and feeding cues and and engagement, reflexes, physiological changes (sight, hearing) weight, HR, RR, (T, Metabolic/ vasomotor/ respiratory sneezing) muscle tone, sucking, swallowing) tremors, CNS (cry, GI (feeding, vomiting, stooling, excoriation) – exhibited as not feeding well, not waking up CNS depression to be fed, not gaining weight gain, limpness When newborn ready for discharge perform global (physical and perform global (physical for discharge When newborn ready feeding) assessment PHCP When to seek help from How (including normal values) and when to assess temperature, values) and when to assess temperature, How (including normal respirations How to clear mucous in infants Heat control Bathing to exposure Identifying changes in newborn vital signs if utero (Opioids, benzodiazepines, SSRIs, drug exposure psychotropic SNRIs) to if exposure Although codeine no longer recommended, milk codeine in breast Presents with normal newborn with normal CNS and no major examination Presents to concerns the infant is ready criteria to indicate – is one of the by parent move to care Refer to POS
>12 – 24 hours >12 – • • • • • • • • • • Parent Education/ Anticipatory Guidance Education/ Anticipatory Parent Norm and Normal Variations Norm and Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website
C o >94% ≥88%
and skin-to-skin care and skin-to-skin care 39 > 1 h ≤ 1 h
: 2 Nursing – hands on physical in assessment with parent(s) attendance Initial bath after baby has completed a stable transition period (universal until bath) precautions Use of toque/head covering indoors after infant stabilization not required Refer to >12 – 24 hr Effortless 30 – 60/min Effortless Clear sounds May be irregular Some mucus when mouth closed Easy respirations Sneezing common (<3 – 4 times/ interval) May have slightly wet sounding lungs for the first 15 – 30 min and is is good colour, and there improving tone and normal heart rate Axilla 36.5 – 37.4 stabilization Use of toque until infant achieved Heart rate: 100 – 160 pulses palpated Femoral and brachial SpO
0 – 12 hours 0 – 12 Stability (POS) Period of Normal Variations Norm and General and good tone Centrally pink Temperature • • • • Respirations • • • • • • • Education/ Parent Anticipatory Guidance • • • • • Circulation
if required 2 Respiratory effort Heart rate Heart sounds Colour Tone Rate
Include: • • SpO • • • • Circulation Temperature Respirations Then as required by Then as required nursing judgement and hospital policy At hour 6 Once per shift until hospital discharge including At 1 and 2 hours following the first vital signs and if stable Within 15 minutes in Within 15 minutes in and the first hour of life Frequency of Frequency assessment following policy organization’s Vital signs and include Vital signs risks – history and
Physiological Health:Physiological Vital Signs • VITAL SIGNS VITAL Assess: • • • • • Suggested frequency for vital signs: • Physiological Physiological Assessment Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 25 Refer to POS Refer to POS Variance • Intervention • >72 hours – >72 hours 7 days and beyond Refer to POS Refer to POS Variance • Intervention • >24 – 72 hours Refer to POS to SSRI/ SNRIs Uterine exposure Refer to POS Variance • • Intervention • >12 – 24 hours : 2 SNRIs / at one hour of life every 4 hours x 24 hours at discharge Indrawing Grunting Nasal flaring Dusky Jaundice Persistent tachycardia >160 or >160 or Persistent tachycardia ≤ 100 bpm bradychardia femoral or brachial Weak/absent pulses Temperature instability Temperature Heart murmur Bradypnea <25 per minute >60 per minute Tachypnea Diaphoresis Mottling Poor colour activity Decreased For infants exposed to SSRIs monitor SpO during pregnancy, Nursing Assessment Refer to PHCP prn Apneic episodes >15 sec Poor feeding Mucousy/noisy respirations that are are that Mucousy/noisy respirations not improving distress Signs of respiratory Variance • • • • • • • • • Intervention • • • • • • 0 – 12 hours Stability (POS) Period of
46
45 44 Fever during labour Fever during labour & birth Group B Strep or B Strep Group ROM >18 hours – vital signs q4h Use of SSRIs / SNRIs in late pregnancy al Signs Maternal use of codeine postpartum Chest Skin (jaundice) Maternal pregnancy Maternal pregnancy and labour & birth history for • Physiological Physiological Assessment Refer to: • • Assess mother’s/ family/ Assess mother’s/ supports understanding of newborn physiology and capacity to identify variances that further may require assessments (Continued) Review: • Vit Physiological Health:Physiological Vital Signs Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
26 Perinatal Services BC
50 47 51,52 53
54 49 48 Refer to >24 – 72 hr loss that continues after day 3 – 4 warrants Weight close assessment of the feeding situation No weight gain by day 5 2 weeks to birth weight by about Has not returned Refer to >24 – 72 hr plan with mother Assess feeding and develop a feeding Have a follow-up plan to initiate Depending on the variance, may need pumping q 3 – 4 hours and/ or expression/ breast supplemental feedings followed by A combination of hand expression, while pumping compression pumping with breast of milk supports the production When milk is in about day 3 – 4 expect wt gain of 20 – When milk is in about an ounce) 30 gms/day (about of about 140 – 200 gm/wk Consistent weight gain per week for the first 4 months (about 4 – 7 ounces) Refer to >12 – 24 hr Signs of adequate hydration the newbornAfter stability is established, is weighed 7 – 10 days (this latter – 4 days and at around 3 around by the weighing may be done during the follow-up discharge) PHCP assessment within one week of Refer to appropriate PHCP prn Refer to appropriate Evidenced-base expected weight loss and when weight loss and when expected weight Evidenced-base not yet established are to be regained should start Consensus that return to birth weight by about 2 Consensus that return weeks >72 hours – 7 days and beyond >72 hours Variance • • • • Intervention • • • • • • • Guidance Education/ Anticipatory Parent • • • • Norm and Normal Variations Norm and • • poor feeding (inadequate milk transfer), poor latch, poor suck, feeds infrequent low maternal milk production illness Refer to >72 hr – 7 Refer to >72 days and beyond Refer to >12 – 24 hr Refer to >12 – 24 hr Excessive weight loss may be due to Refer to >12 – 24 hr Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • • >24 – 72 hours Intervention • Refer to >72 hr – 7 days and Refer to >72 beyond is only one component Weight wellbeing and of a newborn’s the feeding assessment that hydration & Mother aware weight (intake elimination affect and output) adequate Feeding indicators of hydration Normal expected weight loss to day 3 – 4 (especially with exclusive breastfeeding) Normal expected weight gain after day 3 – 4 (especially with exclusive breastfeeding) weight prn Discharge Newborn Conditions that may daily weight require Gestational age <37weeks SGA Receiving phototherapy Nursing assessment Ongoing feeding assessment and support Teaching Refer to PHCP prn Norm and Normal Variations Norm and • Education/ Anticipatory Parent Guidance • • • • • • Variance • • • • Intervention • • • • >12 – 24 hours Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Normal birth weight Normal birth weight for term infants is 2500 – 4000 gm of newborn Weighing after completion of initial feeding or skin- to to-skin (may be up 2 hours) Refer to >72 hours – Refer to >72 7 days and beyond Intervention • Variance • ducation/ E Parent Anticipatory Guidance • • • Norm and Normal Norm and Variations • 0 – 12 hours 0 – 12 Stability Period of (POS) Vital Signs Feeding Behavior Elimination Skin Postpartum Nursing Care Pathway: Breasts Weigh baby naked Weigh on tummy on a warm blanket (anecdotal reports indicate infants startle and cry less – giving a more accurate weight – and less stressful) gain/loss for Weight age appropriate Signs of adequate intake Refer to: • • • • • • Assess mother’s/ Assess mother’s/ family/supports understanding of newborn physiology and capacity to identify variances that further may require assessments Assess: • • • Weight Physiological Physiological Assessment Physiological Health:Physiological Weight Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 27 Refer to >24 – 72 hr Refer to >12 – 24 hr Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • >72 hours – 7 days >72 hours and beyond Refer to >12 – 24 hr 8 or Wakes times in more 24 hours for feeding Refer to >12 – 24 hr Norm and Norm and Normal Variations • • Parent Education/ Anticipatory Guidance • >24 – 72 hours 56 55 57 interactions Organized state movement from quiet alert to crying quiet alert to state movement from Organized occurs) (if robust and strong Minimal crying but is efforts Responds to consoling Behavior states will not feed • Deep sleep – if aroused • Quiet sleep • Drowsy infant-parent • Quiet alert: optimal state for feeding and • Active alert: time for feeding • Crying: late feeding cue Satiety Cues • Sucking ceases • Muscles relax breast self from • Infant sleeps/removes Early feeding cues: infant wiggling, moving arms and moving arms cues: infant wiggling, Early feeding or hands to mouth fingers legs, mouthing, rooting, fussing, squeaky noises, Later feeding cues: to soft intermittent crying progressing restlessness, Refer to POS Review/discuss to feed (refer Behavioral feeding cues indicating readiness above) >12 – 24 hr, to Norm and Normal Variations Review/discuss infant attachment behavior – any behavior Review/discuss infant attachment behavior with and elicit a infant uses to seek and maintain contact mother/caregiver from response Demonstrates ducation/ Anticipatory Guidance Education/ Anticipatory Parent • • • • >12 – 24 hours Normal Variations Norm and • Feeding cues-refer to Norm and Feeding cues-refer >12 – 24 hr Normal Variations “Back to Sleep” Responds to consoling Expect baby to become more more Expect baby to become wakeful after POS Alert for the 1st 1 – 2 hours after 1st 1 – 2 hours after Alert for the birth POS remaining Sleeps much of the life) (transition to extrauterine due to May be sleepy or unsettled delivery efforts Responds to consoling and robust Cry – strong 0 – 12 hours Stability (POS) Period of • • • ducation/ Anticipatory Education/ Anticipatory Parent Guidance • Norm and Normal Variations Norm and • • • • • Understanding of normal newborn behavior Response to newborn cues/ needs Capacity to identify variances that may further require assessments Vital Signs Crying Elimination Feeding Head Behavior states Behavior cues Response to consoling Behavioral Behavioral Assessment Assess mother’s/ family/supports • • • Refer to: • • • • • Assess Infant’s: • • • Behavior Behavioral Assessment Behavioral Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
28 Perinatal Services BC Refer to 0 - 24 hr Refer to 0 – 24 hr Variance • Intervention • >72 hours – 7 days >72 hours and beyond Refer to 0 - 24 hr Refer to 0 – 24 hr Variance • Intervention • >24 – 72 hours Environmental stimuli Environmental sleeping position Correct Gestational age Medicated labor substance use Pregnancy Refer to appropriate PHCP Refer to appropriate Refer to POS Arching Refer to POS Guidance Education/Anticipatory Refer to Parent may influence behaviors Assess factors which • >12 – 24 hours Variance • • Intervention • • • Refer to appropriate HCP prn Refer to appropriate education re Mother/caregiver on newborn follow-up and effect care Complete a full newborn assessment Weak or irritable high pitched cry or irritable Weak to consoling respond Does not efforts to SSRIs/SNRIs exposure In utero to codeine in breastmilk Exposure to substances Exposure 0 – 12 hours Stability (POS) Period of • • Intervention • Variance • • • • • Behavioral Behavioral Assessment Behavior (Continued) Behavioral Assessment Behavioral Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 29 61 Breaks Support system(s) Exercise Period of PURPLE Crying resource Begins at about 2 weeks 3-4 months Continues until about Web reference for parents on prevention of on prevention for parents reference Web infant crying: shaken baby syndrome/ www.purplecrying.info Refer to POS Refer to >12 – 24 hr infant from Crying is a late signal crying to respond Family strategies to of crying Review & discuss amount Discuss normal feeling of frustration and potential Discuss normal feeling anger when infant inconsolable If consoling techniques do not work and baby is in a safe frustrated ensure feel parents and leave the room environment efforts Infant may continue to cry despite soothing capability) to parenting (is not related in pain when Healthy infants can look like they are not crying – even when they are the caregivers for Care • >72 hours – 7 days and beyond >72 hours Norm and Normal Variations Norm and • Guidance Education/ Anticipatory Parent • • • • • • • • • Refer to POS Refer to >12 – 24 hr >24 – 72 hours Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • 60 Is a late feeding cue in developing Assist parents soothing techniques Skin-to-skin Feeding face Showing mother’s soft voice in a steady, Talking Holding arms close to body Holding/carrying Movement: swaying, rocking, walking That infants cry to infant Importance of responding crying, but that infant may continue to cry despite soothing efforts Refer to POS states Review infant behavior during Breastfeeding/skin-to-skin painful procedures Crying Soothing and consoling techniques to establish trust/bonding Discuss >12 – 24 hours Norm and Normal Variations Norm and • Education/ Anticipatory Parent Guidance • • • • • Refer to >12 – 24 hr Refer to >12 – 24 hr Minimal crying but is Minimal crying but is robust strong, Responds to consoling – includes feeding 0 – 12 hours Stability Period of (POS) Parent Education/ Parent Anticipatory Guidance • Norm and Normal Norm and Variations • • ying Use consoling techniques Identify variances further that require assessments Behavior Feeding Maternal Postpartum Nursing Care Pathway: Bonding & Attachment Crying patterns Quality Duration Fussy periods Parental Interpretation of crying Coping strategies Assess: mother’s, Assess: mother’s, supports family, understanding of normal newborn crying and her capacity to • • Refer to: • • • Assess: • • • • • • • Cr Behavioral Assessment Behavioral Assessment: Crying Assessment: Behavioral Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
30 Perinatal Services BC Inconsolable constant crying Inconsolable Refer to POS Refer to POS baby Rule out medical concerns – ensure due to hunger, is thriving, i.e. not crying medical concern to related Discuss potential scenarios in consoling infant difficulty support Discuss choosing appropriate people Shaking an infant Nursing Assessment PHCP prn Refer to appropriate for Encourage use of family/support network support Consider consulting social services/ child services protection >72 hours – 7 days and beyond >72 hours Variance • • Intervention • • • • – Baby at risk for harm Variance • Intervention – Baby at risk for harm • • • • Refer to POS Refer to POS >24 – 72 hours Variance • Intervention • Review The Period of PURPLE Period of PURPLE Review The Crying resource Fever Vomiting Infant states Refer to POS Refer to POS >12 – 24 hours ducation/ Anticipatory Education/ Parent (cont’d) Guidance • www.purplecrying.info indicate that Review signs that baby may be ill • • • Variance • Intervention • Not responding to infant crying Not responding Making negative comments behavior about infant’s Infant does not respond to not respond Infant does techniques consoling crying Unusual, high-pitched (neurological) irritable cry Weak No cry (along with other illness, symptoms may reflect e.g. sepsis) parental/caregiver Inappropriate crying to baby’s response Nursing Assessment Refer to appropriate PHCP prn Refer to Parent Education/ Refer to Parent Anticipatory Guidance >12 – 24 hr 0 – 12 hours Stability (POS) Period of Variance • • • • • • • Intervention • ying Behavioral Assessment Cr (Continued) Behavioral Assessment: Crying Assessment: Behavioral Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 31 Refer to > 24 – 72 Refer to > hours of feeds Frequency once may decrease milk supply established Baby gaining weight regularly Content after most feedings usage Pattern of breast may change (e.g. one per or both breasts feed) Changes in feeding infants patterns where frequently feeds more for several days (commonly called spurts) growth >72 hours – 7 days >72 hours and beyond Norm and Normal Norm and Variations • • • • • • 72 Returns to birthweight by about two weeks Evidence of milk transfer 8 or more feedings after the first 8 or more 24 hours Hear a “ca” sound during feeding suck and swallow Coordinated numbers Refer to elimination re of wet diapers and bowel movements Signs of effective feeding Signs of effective Feeds 8 or more times/24 hours times/24 more Feeds 8 or the night during and frequently initially Shows signs of adequate hydration after Contented and satiated feeding Refer to >12 – 24 hr individual Amount eaten at each as milk supply feeding increases increases feedings that frequent Aware assists in milk production night – throughout Breastfeeding relieves stimulates milk production, discomfort, helps fullness breast engorgement prevent >24 – 72 hours • Norm and Normal Variations Norm and • • • Education/ Anticipatory Parent Guidance • • • • 71 70
69 67 65 66 64 68 Wiggling arms and legs Wiggling arms and Hands to mouth Rooting Mouthing Stomach capacity and amount of each unknown individual feeding are Duration varies for each feeding and mother- infant dyad (may last ~20 – 50 min) Wakes to complete feeds to complete Wakes Refer to POS for feeding cues Assist mother to watch/look Crying is a late feeding cue deep sleep will not from Infants aroused feed feeding breast Support early & frequent antibodies) (provides Normal newborns eat 15±11gms over the first 24 hours Discuss that a satiated infant is relaxed, breast sleepy & disengages from Burping positions be Elimination and hydration status should components of the feeding assessment Variable frequency and duration – different for and duration – different frequency Variable dyad each mother-infant Feeds ≥ 5 feedings in first 24 hours and may feedings in first 24 Feeds ≥ 5 cluster feed >12 – 24 hours • Healthy Term PSBC (2013) Breastfeeding Infants www.healthlinkbc.ca/kbase/topic/special/ hw91687/sec1.htm • Guidance Education/ Anticipatory Parent • • • • • • • • • • Norm and Normal Variations Norm and • The benefits of skin- to-skin during the establishment of breastfeeding Offer breast when he/she breast Offer shows signs of readiness 1 – 2 (usually with in first hours) Baby latchs and begins to suck Actively feeds feeds Tolerates may After initial feed baby in further not be interested feeding during this period. May have small emesis of mucous or undigested milk following feeds (10 mls or less) Skin-to-skin immediately Skin-to-skin after birth 0 – 12 hours Stability (POS) Period of ducation/ E Parent Anticipatory Guidance • • • • • • • Norm and Normal Norm and Variations •
62,63 If < 48h old to have 2 successful feeds documented before discharge Feeding response Mother’s to feeding Active feeding Positioning Latch Hydration Frequency Duration Sucking Swallowing Observe Elimination Weight Skin Behavior Postpartum Nursing Pathway: Care and Infant Breasts Feeding Infant Feeding: Breastfeeding Feeding: Infant Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to: eeding Breastf Assess feeding effectiveness • • • • • • • • ability Assess mother’s to initiate & complete feeds • Infant Feeding Assessment Refer to: • • • • •
32 Perinatal Services BC east feeding for the first six east feeding for the oups 74 ces Intr six months at or around recommended for up to with continued breastfeeding two years and beyond Refer to >12 – 24 hr Refer to >12 Resour PHN Services Community Health Support Gr Exclusive br months
• solids oduction ofcomplementary www.healthlinkbc.ca/healthfiles/ hfile69c.stm Parent Education/ Anticipatory Education/ Parent Guidance • • • • • • >72 hours – 7 days >72 hours and beyond >12 – 24 hours >24 – 72 hours eastfeeding Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website (especially if newborn is ns who are breastfed or breastfed ns who are 73 ess – several bursts of sustained sucking at both breasts each feeding both breasts – several bursts of sustained sucking at Active Feeding – Breast positioning, latch and evidence of milk transfer including effective nose Positioning – chest to chest, skin-to-skin, nipple to open mouth, flanged lips, no dimpling of Latch – Chest to chest, nose to nipple, wide Effective no the breast, easily slide off baby doesn’t rhythmic sucking, cheeks, may hear audible swallow, nipple damage or distortion after feed skin turgor responsive Adequate hydration – moist mucous membranes, elastic and to adequate output (refer Evidence of milk transfer – audible swallowing, rhythmical sucking, to Weight) weight loss for age (refer Elimination) appropriate fective positioning fective latch equency and duration LGA, SGA or risk for hypoglycemia – infants of diabetic mothers) receiving breastmilk should receive should receive breastmilk receiving of a daily vitamin D supplement least birth to at 10 µg (400 IU) from 12 months of age. Hydration Show all mothers how to hand expr Refer to >12 – 24 hr Refer to >12 Importance of br Ef Active feeding Ef Positioning Fr Newbor
www.hc-sc.gc.ca/fn-an/nutrition/ infant-nourisson/index-eng.php • • • • • 0 – 12 hours Stability (POS) Period of Anticipatory Education/ Parent Guidance • • • • • s capacity to
eastfeeding Br Need for vitamin supplement
identify variances that may identify variances that further assessments and/ require or intervention • Assess mother’ Infant Feeding Assessment BREASTFEEDING (Continued) family/supports Assess mother’s/ understanding of • Infant Feeding: Breastfeeding Feeding: Infant Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 33 Refer to 0 – 72 hr Refer to 0 Refer to 0 – 72 hr the In individual practice, decision to discontinue the supplement beyond 12 months of age can be informed by a dietary assessment of other contributors of vitamin D, such as cow milk.
>72 hours – 7 days and >72 hours beyond Variance • Intervention • Education/ Parent Anticipatory Guidance • Refer to 0 – 24 hr deficiency still occur in Cases of Vitamin D who do no receive Canada among infants supplements nutrient Vitamin D is an essential that helps the body use calcium and to build and maintain strong phosphorous bones and teeth www.hc-sc.gc.ca/fn-an/nutrition/infant- nourisson/recom/index-eng.php For advice about vitamin D for infants not breastfed who are and young children see: In practice: breastmilk or receiving to families about infant nutrition. Talking www.hc-sc.gc.ca/fn-an/nutrition/infant- nourisson/recom/index-eng.php#a12 not given any Newborns who are commercial receiving and are breastmilk formula do not need a vitamin D supplement as the formula contains vitamin D. Refer to 0 – 24 hr Refer to 0
>24 – 72 hours • • • • • • Guidance Education/ Anticipatory Parent Vitamin D Supplement: Variations Norm and Normal Intervention Variance Not feeding effectively Newborns are who or receiving breastfed should breastmilk a daily receive vitamin D supplement from IU) (400 10 µg of birth until at least 12 months of age. Refer to POS cheeks Dimpling of Smacking sounds while feeding
Variance >12 – 24 hours • Education/ Parent Anticipatory Guidance • • • • Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Respiratory distress with feeding with feeding Respiratory distress feeds Does not settle following Congenital anomalies (e.g. tongue tie, cleft palate) Mother chooses to provide additional milk when no medical indications for supplementation Infant shows no signs of interest no signs of interest Infant shows in feeding Poor/absent latch to initial Does not latch: prior for or root latch may lick, nuzzle nipple Poor feeding position suck/swallow/ Uncoordinated pattern breathing Coughing, choking
• • • • 0 – 12 hours Stability (POS) Period of • • • • • • Variance
Infant Feeding Infant Feeding Assessment BREASTFEEDING (Continued) Infant Feeding: Breastfeeding Feeding: Infant Refer to:
34 Perinatal Services BC Refer to 0 – 72 hr Refer to 0 Refer to 0 – 72 hr >72 hours – 7 days – 7 >72 hours and beyond Variance • Intervention • Improve latch & position Improve of feeding frequency Increase Stimulate baby after feeding Hand express q 2 – 3 hr Express/pump and top up Express up with______Top Refer to appropriate PHCP Refer to appropriate clinical Baby not getting enough milk based on assessment Nursing Assessment Assist with latch compression with breast Hand expression Assess for jaundice for waking sleepy baby (stimulating Techniques baby – skin-to-skin, not over dressing) if infant unable to effectively EBM Provide transfer milk EBM, Medically indicated supplementation: use donor milk or formula (start with small amounts) Refer to PHCP prn Refer to 0 – 24 hr Refer to 0 Intervention Refer to 0 – 24 hr feeding alternatives (by mother’s May require that the is evidence there informed decision) if is getting milk than he/she baby needs more bottle) dropper, (e.g. by spoon, cup, such as Feeding plan in place, >24 – 72 hours • feeding – Ineffective Variance • feeding Intervention – Ineffective • • • • • • • • Variance • • • • • 80 Encourage skin-to-skin and Support the upper back the neck/base shoulders, cradling on baby's of the skull, no pressure head clothing – baby Skin-to-skin or light is not wrapped to tummy with baby's Tummy to mom bottom tucked close breast support large, If breast areola) (fingers well back from lips with nipple baby’s Touch until mouth open wide Wait of the roof Aim nipple towards mouth – the bottom lip infant’s the base of the is well back from nipple Refer to Postpartum Nursing Care Pathway Position and Latch Refer to POS/Parent Education/ Refer to POS/Parent 24 hr Guidance >12 – Anticipatory to include: Nursing Assessment Waking/latching techniques Waking/latching PHCP Refer to appropriate Breast stimulation Breast Intervention • • >12 – 24 hours • • • Assess reason for Assess reason variance to Assess feeding mother that reassure met by needs are infant’s breastfeeding that concerns Ensure about feeding are addressed sufficient Provide information to ensure that the mother is of the effects aware of unnecessary supplementation on mother and baby as teaching Provide needed. Follow-up in 24 – 24 hr Refer to appropriate HCP prn Intervention • • • • • • • 0 – 12 hours 0 – 12 Stability (POS) Period of eeding Breastf (Continued) Infant Feeding Feeding Infant Assessment Infant Feeding: Breastfeeding Feeding: Infant Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 35 6 – 10 feedings per 24hrs 60 – 90 ml per feed 6 – 8 feedings per 24 hrs 60 – 90 ml per feed 5 – 7 feedings per 24 hrs 120 – 150 ml per feed of Introduction complementary solids at about 6 months 1 – 2 weeks 3 weeks – 2 months Baby is content between Baby is content between feedings safely Formula prepared Formula feeding your baby Refer to >12 – 24 hrs Cue based feeding Signs of fullness 3 – 7 days • • Norm and Normal Norm and Variations • • Education/ Parent Anticipatory Guidance • www.healthlinkbc.ca/ for healthfiles search Healthfile #69a and 69b • • • • >72 hours – 7 days and >72 hours beyond Refer to >12 – 24 hr Refer to >12 – 24 hrs For lactation – suppression Refer to Postpartum Nursing Care Pathway: Breasts Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance * If no variances • • >24 – 72hours 84 83 our Baby: Safely Preparing and Storing our Baby: Safely Preparing our Baby: Getting Started 81, 82 Equipment needed Cleaning of equipment Hold baby close during feeding supporting baby's head head higher than body, Have baby’s mouth and is in baby’s Hold bottle so most of the artificial nipple formula fills the nipple the bottle Never prop Infant wriggling and moving arms and legs Fingers or hand to mouth Rooting Mouthing Preparation, storage and warming formula (refer to BC Health File) formula (refer storage and warming Preparation, temperature Safety at room Positioning: early feeding cues recognize Encourage mother to observe baby to Formula www.healthlinkbc.ca/healthfiles/hfile69b.stm Formula Feeding Y Formula Feeding Y www.healthlinkbc.ca/healthfiles/hfile69a.stm Burping positions fullness – closing mouth, Stop feeding when baby shows signs of falling asleep pushing away, turning away, Not to coax to finish bottle Crying is a late feeding cue deep sleep will not feed from Infants aroused amount to give – newborns may drink small cues re Follow baby’s at a feeding amounts at a feeding, as little as 30 ml Equipment Choice of formula (ready-to-feed and concentrated are sterile until and concentrated are Choice of formula (ready-to-feed not sterile) formula is opened; powdered Every 2 – 4 hr Every 2 – Cue based feeding Signs of fullness • • • • • Resources: BC Health Files Resources: • • • • • • • • ducation/ Anticipatory Guidance – Formula Fed Infants Education/ Anticipatory Parent • >12 – 24 hours Normal Variations Norm and • • • Address maternal Address specific concerns feeding regarding issues Refer to >12 – 24 hr Information about the importance and maternal and infant benefits of and milk breast breastfeeding Skin-to-skin for all babies regardless of feeding method feed Tolerates 0 – 12 hours Stability Period of (POS) • • Parent Education/ Parent Anticipatory Guidance • Norm and Normal Norm and Variations • •
Provide Provide information as necessary for informed decision making and understanding of the difficulty the reversing decision to formula feed feeding Explore options-address specific mother’s concerns about infant feeding Coordinated suck and swallow (active feeding) Hydration Frequency Duration Able to consume appropriate volume for age/ weight lk milk Breast Substitute Feeding (Formula) • • Assess • • • • • Infant Feeding Assessment Infant Feeding: Breast Milk Substitute Milk Breast Feeding: Infant
36 Perinatal Services BC Refer to 0 – 24 hr Refer to 0 formula Inappropriate and preparation Incorrect storage Overfeeding Refer to 0 – 24 hr Variance • • • • Intervention • >72 hours – 7 days and >72 hours beyond Refer to >0 – 24 hr Refer to >0 Refer to >0 – 24 hr Variance • Intervention • >24 – 72 hours Inappropriate formula preparation preparation formula Inappropriate or type Fussy Irritable, crying Arching Gassy Loose stools Nursing assessment Assessing feeding and burping techniques Assessing hunger cues vs satiated cues to avoid overfeeding in intolerance/allergies food Inquire family Follow-up assessment in 24 – 48 hr Refer to nutritionist/ PHCP/other prn resources Variance • www.healthlinkbc.ca/healthfiles/ hfile69b.stm large or frequent Vomiting regurgitation • • • • • Intervention • • • • • • >12 – 24 hours May use soy based formula Babies of vegan parents Correct hypo-allergenic hypo-allergenic Correct formula (e.g. protein hydrolysate) Babies at high risk for Babies at allergies Intervention • Variance • Intervention • Variance • 0 – 12 hours Stability (POS) Period of
Potential health concerns with formula Newborn feeding to feeding response Mother’s Appropriate formula Appropriate Safe formula preparation Safe formula storage Cost Ability to initiate & complete feeds Observe Elimination Weight Skin Behavior Postpartum Nursing Care Pathway: Infant Feeding Awareness of the importance of Awareness feeding milk and breast breast newbornUnderstanding of normal feeding Knowledge of • • Refer to: • • • • • Infant Feeding Assessment Assess mother’s/ family/supports Assess mother’s/ • • • milk Substitute Breast a) Feeding (Formul (Continued) Infant Feeding: Breast Milk Substitute Milk Breast Feeding: Infant Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 37 Refer to 0 – 24 hr Refer to 0 Refer to 0 – 72 hr Refer to 0 – 24 hr Refer to 0 – 24 hr >72 hours – 7 days >72 hours and beyond Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • 91,92, 93 Need for further follow-up appointment with PHCP within first 6 weeks of life newborn’s Refer to 0 – 24 hr Refer to 0 – 24 hr Refer to 0 – 24 hr Refer to 0 of need Aware for a hands on assessment at 3 – 4 days and within 7 – 10 days >24 – 72 hours • Variance • Intervention • Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • 90 87,88, 89 Newborn feedings are successfully initiated and completed successfully Newborn are feedings to newborn and needs cues response Parent/caregiver Support system in place Normal newborn exam of normal newborn changes and informs recognition Caregiver findings PHCP of abnormal Parents/caregiver aware when discharged <48 hr after birth: when discharged aware Parents/caregiver paths for for evaluation (as per clinical care arrangements made by a Health Care within 48 hours of discharge assessment and care) Professional Parents aware of the need for a newborn physical and feeding aware Parents 3 – 4 days of life assessment around development of newborn and Growth not have a PHCP or a plan for follow-up with PHCP do Parents in not have knowledge or capacity to identify variances do Parents newborn Nursing assessment solutions Identify barriers and support family with follow-up Alternative medical/ health care Consult social workers/services and Family Development Ministry of Children www.gov.bc.ca/mcf/ www.ccrr.bc.ca/ and referrals resources Childcare Parents/caregiver have a plan for follow-up with PHCP for follow-up with have a plan Parents/caregiver for by to move to be cared Newborn (caregiver) ready parent >12 – 24 hours ducation/Anticipatory Guidance Education/Anticipatory Parent • • • www.healthlinkbc.ca/kbase/topic/special/hw42229/sec1.htm Variance • • Intervention • • • • • • Norm and Normal Variations Norm and • • 85 while skin-to- 86 Vitamin K given IM Vitamin K based on birth weight Administer after completion of initial of feeding (within 6 hr birth) Refer to >12 – 24 hr Refer to >12 – 24 hr Oral dose Vitamin K is 2 mg at time of first at feeding, repeated 2 – 4 weeks and at 6 – 8 weeks Parents refuse IM refuse Parents injection Vitamin K administration Vitamin K administration of – prevention hemorrhagic disease of the newborn skin Norm and Normal Norm and Variations • 0 – 12 hours Stability (POS) Period of • Intervention • Variance • Intervention • Variance • Parent Education/ Parent Anticipatory Guidance • p Assessment p
Access Health Care Identify variances that may further require assessments Understanding of health appropriate follow-up care Capacity to Follow agency policy for identification of high risk clients E.g. Consider use of Nursing Priority Tool Screening (Parkyn, BC adaptation 2010) Up Health Follow- Assessment Assess mother’s/ Assess mother’s/ family/supports • • h Healt Baby to receive Vitamin K -up follow U Follow- Health
38 Perinatal Services BC Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to 0 – 24 hr Refer to 0 – 24 hr Does not plan to have baby immunized reasons Explore information Provide prn Refer to appropriate PHCP prn Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • – Variance No immunizations • Intervention – No immunizations • • • >72 hr – 7 days and >72 hr – 7 beyond Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to POS and >72 hr – 7 days and beyond Refer to POS and >72 hr – 7 days and beyond Norm and Norm and Normal Variations • Parent Education/ Anticipatory Guidance • Variance • Intervention • >24 – 72 hours iseases Benefits of immunization www.caringforkids.cps.ca/immunization/index. htm immunizations available Diseases for which Schedule Side effects to access immunizations Where Child Health Passport www.healthlinkbc.ca/kbase/topic/special/ immun/sec1.htm Disease transmission Aware of appropriate immunizations and schedules immunizations appropriate of Aware Review Hepatitis B • www.healthlinkbc.ca/kbase/topic/detail/drug/zb1228/ detail.htm www.bccdc.ca/NR/rdonlyres/328189F4-2840-44A1- 9D13-D5AB9775B644/0/Epid_GF_HepBControl_ June2004.pdf www.phac-aspc.gc.ca/hcai-iamss/bbp-pts/hepatitis/ hep_b-eng.php www.who.int/csr/disease/hepatitis/ whocdscsrlyo20022/en/index.html Norm and Normal Variations Norm and • Guidance Education / Anticipatory Parent • >12 – 24 hours Household member(s) from an area where where an area Household member(s) from Hepatitis is endemic Mother is HBsAg (Hepatitis B Surface Antigen) positive Mother has risk factors for Hepatitis sex worker/status infection (IV drug user, unknown) giver or household contact Primary care Hepatitis B infection acute or chronic giver has risk factors for Primary care Hepatitis B infection (such as IV drug men who have sex with sex worker, user, men) and infectious state unknown Administer Hep.B immunization and HBIG Administer Hep.B immunization and HBIG as per BCCDC protocol Fetal exposure Refer to >72 hr – 7 days and beyond Refer to >72 hr – 7 Refer to >72 hr – 7 days and beyond Refer to >72 hr – 7 Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 or B, Hepatitis C to Hepatitis No exposure HIV Intervention – Hep B Exposure • 0 – 12 hours Stability (POS) Period of Variance – Hep B Exposure Variance • Intervention • Variance • ducation/ Anticipatory Guidance Education/ Anticipatory Parent • Norm and Normal Variations Norm and • • p Assessment: ImmunizationUp D Communicable and
tion
Postpartum Nursing Care Pathway: Communicable Diseases Immunization (including informed consent) Child Health Passport Hepatitis B prn protocols Hepatitis C prn protocols prn HIV protocols fetal / Varicella infant exposure Up Health Follow- Assessment Refer to: • Assess mother’s/ Assess mother’s/ family/supports understanding of: • • • • • • Assess mother’s capacity to identify variances that may further require assessments le le Communicab Diseases a Immuniz and Health Follow- Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 39 >72 hr – 7 days and >72 hr – 7 beyond >24 – 72 hours 96 reeClinic/default.htm iseases BCPHP Guideline www.bcphp.ca//sites/bcrcp/files/Guidelines/ Obstetrics/HIVJuly2003Final.pdf Clinic Oak Tree www.bcwomens.ca/Services/HealthServices/ OakT BCCDC Guideline D- www.bccdc.ca/NR/rdonlyres/0065F4A pid_GF_ 0EEC-430F-B1B5-9634115528D4/0/E Zoster_July04.pdf Varicella Recommend: infant to have a blood test (for PCR/RNA) blood test (for PCR/RNA) infant to have a Recommend: initial test positive, antibody at 6 weeks and, unless test at 12 months. /id08-05.htmSOGC D/id08-05.htmSOGC www.cps.ca/english/statements/I Guideline E-CPG- www.sogc.org/guidelines/public/96 October2000.pdf HIV • • Varicella • ducation/ Anticipatory Guidance Anticipatory Guidance Education/ Parent C Hepatitis • >12 – 24 hours 94,95 Follow Varicella Protocol – refer to > 12 – 24 – refer Protocol Follow Varicella Education / Anticipatory Guidance hr Parent Newborn exposure to Varicella to Varicella Newborn exposure Fetal exposure to Varicella Fetal exposure Breastfeeding contraindicated Breastfeeding to refer Follow HIV Protocol: Education/ Anticipatory >12 – 24 hr Parent Guidance Fetal exposure to HIV Fetal exposure If nipples are cracked or bleeding - discard - discard cracked or bleeding If nipples are as HCV is milk during this time breast blood transmitted through HCV is a blood borne pathogen and is not or stools transmitted by urine Support breastfeeding (breastfeeding not not (breastfeeding Support breastfeeding contraindicated Fetal exposure to Hepatitis C to Hepatitis Fetal exposure Intervention • • Variance – Varicella Variance • Intervention - HIV Exposure • • Variance – HIV Exposure Variance • • • 0 – 12 hours Stability (POS) Period of Intervention – Hep C Exposure Intervention – Hep • Variance- Hep C Exposure Hep Variance- • p: ImmunizationD Communicable and Up:
tion
Up Health Follow- Assessment a Immuniz and le Communicab Diseases (Continued) HealthFollow- Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
40 Perinatal Services BC Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Need to reassess safety risks as development infant’s changes (e.g. change table) Encourage to read safety labels and warranties Refer to Best Chance Baby’s Steps First Toddler’s Safe Start Health Files Refer to >12 – 24 hr Refer to >12 – 24 hr Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • • • • Variance • Intervention • >72 hr – 7 days and >72 hr – 7 beyond Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Norm and Norm and Normal Variations • Parent Education/ Anticipatory Guidance • Variance • Intervention • >24 – 48 hours C o 99 97
98 Sleeping in close proximity in the same room (on a separate safe sleep same room in the Sleeping in close proximity surface) for the first six months: www.perinatalservicesbc.ca infant Keep hot adult beverages away from – below 49 scalds during bathing to prevent Adjust hot water temperature Supine (back lying) position for sleep Supine (back lying) bottom surfaces, well fitting, firm mattress, sleep Safe sleeping environment: soft toys, pillow, in, blanket tucked in at the bottom, avoid sheet firmly tucked in crib objects, bumper pads (parent/caregiver/other hand and third – second hand environment Smoke free smoking, smoke with smoke on clothing and skin after persons handling infant lingering in a car) Alternative medical/ health care follow-up Alternative medical/ health care Consult social workers/services and Family Development: www.gov.bc.ca/mcf/ Ministry of Children www.ccrr.bc.ca/ and referral: resource Childcare www.purplecrying.info Period of PURPLE Crying resources: wipes change table, soothers, powders, Car seat, crib, stroller, Identify barriers and support family with solutions Identify barriers and support family with Nursing assessment Pets, siblings such as Safety of baby products for newborn a safe environment to provide unable Parents Supporting head and neck Community resources Shaken Baby Syndrome Shaken Baby Syndrome Hot liquid burns SIDS prevention /Safe Sleep environment /Safe Sleep SIDS prevention Parents able to provide a safe environment for newborn environment a safe able to provide Parents • Intervention • • • Variance • • • • • >12 – 24 hours ducation/ Anticipatory Guidance Education/ Anticipatory Parent • Norm and Normal Variations Norm and • Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr 0 – 12 hours Period of Stability (POS) Intervention • Variance • Parent Parent Education/ Anticipatory Guidance • Norm and Norm and Normal Variations Newborn identified as per organization’s policy • p: Safetyp: and Injury Prevention U obacco y y Use Postpartum Nursing Care Pathway: Lifestyle – T Up Health Follow- Assessment Refer to: • Assess mother’s/ Assess mother’s/ family/ supports knowledge of common safety risks and ability to access support when needed ety Safety r and Inju Prevention Health Follow- Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 41 Refer to >12 – 24h Refer to >12 – 24h Refer to >12 – 24h Refer to >12 – 24h >72 hr – 7 days >72 hr – 7 and beyond Norm and Normal and Norm Variations • Parent Education/ Anticipatory Guidance • Variance • Intervention • Refer to >12 – 24h Refer to >12 – 24h Refer to >12 – 24h Refer to >12 – 24h >24 – 72 hours Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • 101 Deferral Deferral will help prevent life threatening events life threatening will help prevent optimizes detection of PKU, CF and Hcy The second screen detected until time sensitive and cannot be reliably which are ≥ 24 hours after birth Rationale: The first blood screen will identify over 80% of disorders and will identify over 80% of disorders Rationale: The first blood screen Specimen collected prior to discharge. The NB Screening Laboratory at BCCH The NB Screening Specimen collected prior to discharge. be sample to need for a repeat provider primary care via the baby’s will request, collected by 2 weeks (14 days) of age Discharge less than 24 hours or transfer to another health care facility before facility before care less than 24 hours or transfer to another health Discharge 24 hours of age PSBC Neonatal Guideline 9 Information Sheet PSBC Neonatal Guideline HCP and families for Newborn screening www.newbornscreeningbc.ca Test Healthlink Newborn Screening E46E4 www.healthlinkbc.ca/healthfiles/hfile67.stm# Parent adequately informed Parent Newborns screened between 24 and 48 or prior to hospital discharge. If not hospital discharge. and 48 or prior to between 24 Newborns screened than 7 days no later timeframe, collection should be done completed during this in place where have early home follow-up programs Some Health Authorities specimen in the home setting can collect blood spot staff will collect the specimens Midwives For home births Registered Parent(s) signs Informed Refusal or Informed Deferral Form also signed by PHCP Parent(s) (one copy on infant chart, one copy to PHCP) Discuss & address questions Discuss & address Parental informed refusal or request for deferral or request informed refusal Parental >12 – 24 hours ischarge before 24 hours of age Intervention – Discharge before • ischarge before 24 hours of age – Discharge before Variance • • • • ducation/ Anticipatory Guidance Education/ Anticipatory Parent • Norm and Normal Variations Norm and • • • • Intervention – Refusal / • • Variance – RefusalVariance / Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr 0 - 12 hours Stability Period of (POS) Intervention • Variance • Parent Education/ Parent Anticipatory Guidance • Norm and Normal Norm and Variations •
100 BC’s Newborn BC’s Program Screening for 22 screens disorders. Assess mother’s/ Assess mother’s/ family/supports understanding of normal newborn and screening capacity to follow- up on variances further that require assessments d Blood Newborn eening Spot Scr Screening Assessment Screening/Other: Newborn Blood Spot Screening Spot Blood Newborn Screening/Other: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
42 Perinatal Services BC Refer to >12 – 24 hr Refer to >12 Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to Elimination - Stool section Refer to Elimination - Stool section Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • Variance • Intervention • >72 hr – 7 days >72 hr – 7 and beyond Refer to >12 – 24 hr Refer to >12 Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Norm and Normal Norm and Variations • Education/ Parent Anticipatory Guidance • Variance • Intervention • >24 – 72 hours Discuss & address questions Discuss & address if Refer to public health unit for hearing screening missed in hospital sign Informed Refusal Have parent(s) Arrange follow-up at community level prn Newborn Hearing Screening completed by Hearing completed Newborn Hearing Screening of facilities screening (in smaller Program Screening infants done in the community) Completed by newbornPSBC Newborn Record staff screening Newborn Screen Hearing www.phsa.ca/AgenciesServices/ Services/BCEarlyHearingPrgs/ForFam/ NewbornHearingScreening/default.htm www.phsa.ca/AgenciesServices/Services/ BCEarlyHearingPrgs/ForFam/Resources/ Brochures.htm Passed with risk factors for delayed onset not completed Newborn Hearing Screening Refusal Parental by nursing No intervention required will: staff Newborn Hearing Screening >12 – 24 hours Norm and Normal Variations Norm and • • Guidance Education/ Anticipatory Parent • Brochures • Variance • • • Intervention • • Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 – 24 hr Refer to >12 0 – 12 hours Stability (POS) Period of Intervention • Variance • Parent Education/ Parent Anticipatory Guidance • Norm and Normal Norm and Variations • TRESIA Y A Screening Assessment Assess mother's/ family/ supports understanding of the and BC Infant Stool Colour card capacity to identify variances in stool colour BILIAR Screening Program staff will staff Program Screening family/ assess mother’s/ of supports understanding a normal newborn hearing assessment and screening variances capacity to follow-up further assessments requiring Newborn Hearing Screening is Newborn Screening Hearing Program carried out by Hearing staff Screening Hearing and Nursing assessment not required. follow-up Screening/Other: Hearing Screening Hearing Screening/Other: Healthy Families BC Website – www.healthyfamiliesbc.ca/parenting Healthy Families BC Website Refer to:
Newborn Guideline 13: Newborn Nursing Care Pathway 43 Glossary of Abbreviations
BCCH British Columbia Children’s Hospital Mm Millimetres Bpm Beats per minute NICU Neonatal Intensive Care Unit BIIP Behavioral Indicators of Infant Pain POS Period of Stability CF Cystic fibrosis PHCP Primary Health Care Provider Cm Centimetres PCR/RNA The best approach to confirm the CNS Central Nervous System diagnosis of hepatitis C is to test for HCV RNA E.g. For example (Ribonucleic acid) using a sensitive assay such as polymerase chain reaction (PCR) EBM Expressed Breast milk PKU Phenylketonuria GI Gastrointestinal Prn As needed Gm Gram(s) PSBC Perinatal Services BC > Greater than RR Respiratory Rate ≥ Greater than or equal to ROM Rupture of Membranes HBIG Hepatitis B Immune Globulin SGA Small for Gestational Age Hcy Homocystinuria SSRI Selective Serotonin Reuptake Inhibitors HR Heart Rate SNRI Selective Norepenephrine Reuptake Inhibitors Hr Hours SIDS Sudden Infant Death Syndrome i.e. That is S&S Signs and Symptoms IV Intravenous T Temperature LGA Large for Gestational Age Vs Versus < Less than or equal to WHO World Health Organization Min Minute Ml Millilitre(s)
References
ACoRN Neonatal Society. (2006). ACoRN – Acute Care of at Risk First Nations, Inuit & Metis Health Committee, Canadian Newborns (1st Ed) ACoRN Neonatal Society. Vancouver, Pediatric Society (2007). Vitamin D Supplementation: BC. Recommendations for Canadian Mothers and Infants www.cps.ca/english/statements/II/FNIM07-01.htm Bryanton, J., Walsh, D. Barrett, N., Gaudet. (2003). Tub bathing www.caringforkids.cps.ca/pregnancy&babies/VitaminD.htm. versus traditional sponge bathing for the newborn. JOGNN. 33: 704-712. Health Canada (2000) Family-Centred Maternity and Newborn Care: National Guidelines (4th Edition). Ottawa. Ontario. BC Centre for Disease Control (BCCDC). (2006). Hepatitis C Public Health Nurse Resource. BC Hepatitis Services. Health Canada (2004). Exclusive breastfeeding duration – 2004 BCCDC. Health Canada recommendation. www.hc-sc.gc.ca/fn-an/nutrition/child-enfant/infant- British Columbia (BC) Women’s (2002). Neonatal Observation nourisson/excl_bf_dur-dur_am_excl-eng.php. Sheet. Fetal Maternal Newborn and Family Health Policy & Procedure Manual. Author. Kenner, C. & McGrath, M (2004) Developmental Care of Newborns and Infants – A Guide for Health Professionals. Centre for Addiction and Mental Health (CAMH) ; Mother Risk Elsevier, Philadelphia. PA. (2007). Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation. A Handbook Lowdermilk, D. L. & Perry, S. E. (2007). Maternity & Women’s for Healthcare Professionals. Toronto: CAMH Health Care (9th ed.). St. Louis, MI: Mosby. www.camh.net/Publications/Resources_for_Professionals/ Parkyn JH. (1985). Identification of At-Risk Infants and Preschool Pregnancy_Lactation/psychmed_preg_lact.pdf Children Public Health Nurses using a weighted multifactor Canadian Paediatric Society (CPS); College of Family Physicians risk assessment form. Early Identification of Children at Risk Canada (2009). Routine administration of vitamin K to An International Perspective. Eds: Frankenburg WK, Sullivan newborns. Position Statement CPS. Ottawa: Ontario. JW. Plenum Press, New York. CPS (2005). Exclusive breastfeeding should continue to six Perinatal Services BC (PSBC). (2013). Breastfeeding Healthy Term months. Paediatr Child Health 10(3):148. Infants. Author. www.cps.ca/english/statements/N/BreastfeedingMar05.htm PSBC. (2002). Report on the Findings of the Postpartum CPS (2008). Pregnancy and Babies, Breast feeding. Caring for Consensus Symposium. Author. Kids. CPS Ottawa: Ontario. www.caringforkids.cps.ca/ PSBC. (2010). Newborn Screening (Updated) Guideline. PSBC. pregnancy&babies/Breastfeeding.htm.
44 Perinatal Services BC References, cont.
PSBC (BCRCP). (2003). Hepatitis C in the Perinatal Period. Sio, J., Minwalla, F., George, R., (1987). Oral Candida: Obstetrical Guideline No.18. Author. Is Dummy Carriage the Culprit? Arch Dis Child. 62(4):406-8. PSBC (2013). Antidepressant use during pregnancy: SOGC. (2000). The Reproductive Care of Women Living with Considerations for the newborn exposed to SSRI / SNRIs. Hepatitis C Infection. Clinical Practice Guideline. No. 96. Author. SPGC. SOGC www.sogc.org/guidelines/documents/. PSBC (2013). BC Infant Stool Colour Cards Screening Program World Health Organization (1998) Health Topics, Pregnancy, for Biliary Atresia. Author. Making Pregnancy Safer, All Publications, Postpartum Province of British Columbia. (2010). Baby’s Best Chance. care, Postpartum care of Mother and Newborn: A Practical Second revision sixth edition. Queen’s Printer of British Guide. www.who.int/en/. Columbia, Canada.
Endnotes
1. Perinatal Services BC (formerly BC Perinatal Health 22. Sio, J., Minwalla, F., George, R., (1987). Oral Candida: Is Program) is a program of the Provincial Health Services Dummy Carriage the Culprit? Arch Dis Child. 62(4):406-8. Authority. 23. Reece R, Ludwig S. Child Abuse – Medial Diagnosis and 2. Health Canada. (2000). Family-Centred Maternity and Management (2nd Edition). Lippincott, Williams & Wilkins, Newborn Care: National Guidelines (4th Edition) p. 1.8-1.10. Philadelphia, PA. 2001. 3. Perinatal Services BC (PSBC). (2010). Newborn Screening 24. Helfer M, Kempe R, Krugman R. The Battered Child (5th (Updated) Guideline. Edition). University of Chicago Press, Chicago. 2006. 4. BCRCP (BCPHP) Postpartum Consensus Symposium, 25. Bryanton, J., Walsh, D. Barrett, N., Gaudet. (2003). Tub (2002). bathing versus traditional sponge bathing for the newborn. 5. Health Canada (2000) Chapter 6, Early Postpartum Care JOGNN. 33: 704-712.; Lowdermilk, D. L. & Perry, S. E. of the Mother and Infant and Transition to the Community, (2007). Maternity & Women’s Health Care (9th ed.), St. Louis, Family-Centred Maternity and Newborn Care: National MI: Mosby, p. 746. Guidelines (4th Edition). 26. Agency for Healthcare Research and Quality (AHRQ) (2009). 6. World Health Organization (WHO) (1998). Postpartum Care www.ahrq.gov/clinic/uspstf/uspshyperb.htm. of Mother and Newborn: A Practical Guide. 27. Canadian Paediatric Society. (2007) Guidelines for detection, 7. Ibid. p. 2. management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ 8. BCPHP. Postpartum Consensus Symposium. (2002). gestation). Paediatrics and Child Health Vol 12 Suppl B May/ 9. Ibid. June 2007, p5B. Access from: 10. Province of British Columbia. (2010). Baby’s Best Chance. www.cps.ca/english/statements/FN/FN07-02.pdf. Second revision sixth edition. Queen’s Printer of British 28. BCW (2007). Policy CH0200-Hypogycemia: Newborn. Fetal Columbia, Canada. Maternal Newborn and Family Health Policy & Procedure 11. ACoRN Neonatal Society. (2006). ACoRN – Acute Care Manual. of at Risk Newborns (1st Ed) ACoRN Neonatal Society. 29. PSBC. (2011) Breastfeeding the Healthy Term Infant. Vancouver, BC. 30. Province of BC. (2010). Baby’s Best Chance. 12. Holsti L, Grunau RE. Initial valization of the Behavioral 31. PSBC. (2011). Breastfeeding the Healthy Term Infant. Indicators of Infant Pain (BIIP). Pain 2007;137:264-272. 32. Ibid. 13. Holsti L, Grunau RE, Oberlander TF, Osiovich L. Is it painful or not? Discriminant validity of the Behavioral Indicators of 33. Ibid. Infant Pain (BIIP) Scale. Clin J Pain 2008;24:83-88. 34. Ibid. 14. Lowdermilk, D. L. & Perry, S. E. (2007). Maternity & 35. Ibid. Women’s Health Care (9th ed.), St. Louis, MI: Mosby, p. 36. Ibid. 683. 37. Ibid. 15. Ibid. p. 646. 38. Province of BC. (2010). Baby’s Best Chance. 16. Ibid. p. 647. 39. Lang N, Bromiker R, Arad I. The effect of wool vs. cotton 17. Ibid. p. 646. head covering and length of stay with the mother following 18. Ibid. p. 647. delivery on infant temperature. Int J of Nursing Studies. 19. Province of BC. (2010). Baby’s Best Chance. 2004:41;843-846. 20. BCPHP (2001) Eye Care and Prevention of Opthalmia 40. BCPHP (2002) Postpartum Consensus Symposium. Neonatorum. BCPHP Newborn Guideline 11. Author. 41. Koren G, Finkelstein Y, Matsui D and Berkovich M. Diagnosis 21. Province of BC. (2010). Baby’s Best Chance. and Management of Poor Neonatal Adaptation Syndrome in Newborns Exposed In Utero to Selective Seretonin/ Norepinephrine Reuptake Inhibitors. JOGC 2009:4;348-350.
Newborn Guideline 13: Newborn Nursing Care Pathway 45 Endnotes, cont.
42. Madadi P, Moretti M, Djokanovic N, et al. Guidelines for 71. BCPHP (2002). Consensus Symposium. Consensus maternal codeine use during breastfeeding. Canadian Statement #13. Family Physician 2009:55;1077-1078. Motherisk Update 72. PSBC. (2011). Breastfeeding the Healthy Term Infant. available at www.cfp.ca and www.motherisk.org. 73. Ibid. 43. BCPHP. (2002). Postpartum Consensus Symposium. 74. Health Canada (2004). 44. Koren G, Finkelstein Y, Matsui D and Berkovich M. 75. PSBC. (2011). Breastfeeding the Healthy Term Infant. Diagnosis and Management of Poor Neonatal Adaptation Syndrome in Newborns Exposed In Utero to Selective 76. Canadian Pediatric Society (CPS); (2007) Vitamin D Seretonin/Norepinephrine Reuptake Inhibitors. JOGC supplementaton: Recommendatons for Canadian mothers 2009:4;348-350. and infants. Paediatr Child Health. 12(7):583-9. www.cps.ca/englis/statements/II/FNIM07-01.htm. 45. BCPHP Obstetrical Guideline #12. www.bcphp.ca//sites/ bcrcp/files/Guidelines/Obstetrics/GBSJuly2003Final.pdf. 77. Canadian Pediatric Society (CPS); (2007) Vitamin D supplementaton: Recommendatons for Canadian mothers 46. Madadi P, Moretti M, Djokanovic N, et al. Guidelines for and infants. Paediatr Child Health. 12(7):583-9. maternal codeine use during breastfeeding. Canadian www.cps.ca/englis/statements/II/FNIM07-01.htm. Family Physician 2009:55;1077-1078. Motherisk Update available at www.cfp.ca and www.motherisk.org 78. Canadian Pediatric Society (2007). Vitamin D Supplementation: Recommendations for Canadian Mothers 47. PSBC. (2011). Breastfeeding the Healthy Term Infant. and Infants. 48. Lowdermilk, D. L. & Perry, S. E. (2007). Maternity & www.cps.ca/english/statements/II/FNIM07-01.htm; Women’s Health Care (9th ed.), St. Louis, MI: Mosby, p. 719. www.caringforkids.cps.ca/pregnancy&babies/VitaminD.htm. 49. Ibid. p. 723. 79. Canadian Pediatric Society (CPS); (2007) Vitamin D 50. Ibid. p. 719. supplementaton: Recommendatons for Canadian mothers 51. BCPHP. (2002). Postpartum Consensus Symposium. and infants. Paediatr Child Health. 12(7):583-9. www.cps.ca/englis/statements/II/FNIM07-01.htm. 52. www.sogc.org/guidelines/documents/190E-PS-April2007. pdf. 80. Province of BC. (2010). Baby’s Best Chance. 53. PSBC. (2011). Breastfeeding the Healthy Term Infant. 81. PSBC. (2011). Breastfeeding the Healthy Term Infant. 54. Morton J, Hall JY, Wong RJ et al. (2009). Combining 82. Ibid. hand techniques with electric pumping increases milk 83. Ibid. production in mothers of preterm infants. J Perinatology. 84. Ibid. Nov:29(11):757-64. 85. Canadian Paediatric Society (CPS); College of Family 55. PSBC. (2011). Breastfeeding the Healthy Term Infant. Physicians Canada (2009). Routine administration of vitamin 56. Ibid. K to newborns. Position Statement. 57. Ibid. 86. Ibid. 58. Koren G, Finkelstein Y, Matsui D and Berkovich M. 87. BCPHP. (2002). Postpartum Consensus Symposium. Diagnosis and Management of Poor Neonatal Adaptation 88. SOGC www.sogc.org/guidelines/documents/190E-PS- Syndrome in Newborns Exposed In Utero to Selective April2007.pdf. Seretonin/Norepinephrine Reuptake Inhibitors. JOGC. 89. CPS www.cps.ca/english/statements/FN/fn96-02.htm. 2009:4;348-350. 90. BCPHP (2002) Consensus Symposium. Consensus 59. Madadi P, Moretti M, Djokanovic N, et al. Guidelines for Statement #12. maternal codeine use during breastfeeding. Canadian Family Physician. 2009:55;1077-1078. Motherisk Update 91. Ibid. available at www.cfp.ca and www.motherisk.org. 92. www.sogc.org/guidelines/documents/190E-PS-April2007. 60. Province of BC. (2010). Baby’s Best Chance. pdf. 61. www.purplecrying.info/sections/index.php?sct=1&. 93. www.cps.ca/english/statements/FN/fn96-02.htm. 62. SOGC Policy Statement No. 190, 2007. www.sogc.org/ 94. BCPHP (BCRCP). (2003). Hepatitis C in the Perinatal Period. guidelines/documents/190E-PS-April2007.pdf. Obstetrical Guideline No.18. Author. 63. CPS joint statement with the SOGC. www.cps.ca/ 95. SOGC. (2000). The Reproductive Care of Women Living with ENGLISH/statements/FN/fn96-02.htm. Hepatitis C Infection. Clinical Practice Guideline. No. 96. SPGC. SOGC www.sogc.org/guidelines/documents/. 64. PSBC. (2011). Breastfeeding the Healthy Term Infant. 96. BC Centre for Disease Control (BCCDC). (2006). Hepatitis 65. Ibid. C Public Health Nurse Resource. BC Hepatitis Services. 66. Ibid. BCCDC. 67. Ibid. 97. Perinatal Services BC (2011). Safe Sleep Environment 68. Ibid. Guideline for Infants 0 to 12 Months of Age. Health 69. Santoro W, Martinez FE & Jorge SM. 2010. Colostrum Promotion Guideline 1. ingested during the first day of life by exclusively breastfed healthy newborn infants. Journal of Pediatrics. 156(1):29-32. 70. PSBC. (2011). Breastfeeding the Healthy Term Infant.
46 Perinatal Services BC Endnotes, cont.
98. Sleiman M, Gujdel LA, Pankow JF, et al. Formation of 99. Perinatal Services BC (2011). Safe Sleep Environment carinogens indoors by surface-mediated reactions of Guideline for Infants 0 to 12 Months of Age. Health nicotine with nitrous acid, leading to potential thirdhand Promotion Guideline 1. www.perinatalservicesbc.ca. smoke hazards. Proceedings of the National Academy 100. Perinatal Services BC Neonatal S Guideline 9: Newborn of Sciences. 2010;Sptil 107(15); 6576 – 6581. accessed Screening (2010). www.perinatalservicesbc.ca. April 21, 2010 from www.pnas.org/cgi/doi/10.073/ 101. Ibid. pnas.0912820107.
Revision Commitee
Members of the Newborn Nursing Care Pathway Revision Commitee Perinatal Services BC would like to acknowledge the working committee who revised the BC Newborn Nursing Care Pathway. Committee members included:
Barbara Selwood Project Lead, Health Promotion and Prevention, PSBC Taslin Janmohamed-Velani Coordinator, Knowledge Translation, PSBC Laurie Seymour Project Consultant Jacqueline Koufie Clinical Nurse Educator, St. Paul’s Hospital Radhika Bhagat Clinical Nurse Specialist, 0-5 years, Vancouver Community Kathy Hydamaka Program Leader, Healthy Babies and Families, Richmond Joan Brown Clinical Educator for the Early Years Team, North Shore Health Yvonne Law Perinatal Clinical Educator – Postpartum, BC Women's Hospital Monica Carey Staff Nurse, BC Women's Hospital Marina Green Lactation Consultant, BC Women's Hospital Tammy MacDonald Educator, Surrey Memorial Hospital Kate McCulloch Regional Clinical Nurse Educator – Aboriginal Health, Fraser Health Public Health Tanya Jansen Clinical Nurse Educator Maternal Child Program, Ridge Meadows Hospital Pam Munro CNS Maternal, Infant, Child & Youth Program, Fraser Health Public Health Elaine Klassen Clinical Nurse Educator, Fraser Health Public Health Bev Grossler Patient Care Coordinator, Lillooet Hospital Anita Gauvin NICU Clinical Resource Coordinator, Kamloops Hospital Patty Hallam Public Health Nursing Program Consultant – ECD, Kamloops Jennifer Stubbings Team Leader, Thompson Cariboo Shuswap Public Health Christine Moffitt Clinical Practice Educator, Labour and Delivery, Royal Inland Hospital Lynn Popien Regional Perinatal Education Coordinator, Royal Inland Hospital Tamara Kropp Program Manager Medical & Maternity, Quesnel Hospital Sharron Sponton Community Health Nurse, Smithers Grace Dowker Maternity RN/Educator, Campbell River Hospital and Community Amber Thomas Public Health Nurse, Courtenay Grace Park Family Physician, White Rock Wilma Aruda Pediatrician, Nanaimo
Newborn Guideline 13: Newborn Nursing Care Pathway 47 Perinatal Services BC West Tower, #350 555 West 12th Avenue Vancouver, BC Canada V5Z 3X7 Tel: (604) 877-2121 www.perinatalservicesbc.ca
While every attempt has been made to ensure that the information contained herein is clinically accurate and current, Perinatal Services BC acknowledges that many issues remain controversial, and therefore may be subject to practice interpretation.
© Perinatal Services BC, 2013