Initial Newborn CareNeonatal Resuscitation Algorithm

On Observation of the Neonate:

In the case of infants, everything must depend upon the accurate observation of the nurse or mother…For it may safely be said, not that the habit of ready and correct observation will by itself make us useful, but that without it we shall be useless with all our devotion… If you cannot get the habit of observation one way or the other, you better give up…being a nurse, for it is not your calling, however kind and anxious you may be.

Florence Nightingale

Important factors to know going in to a delivery 5 things to investigate :

AAP Neonatal Resuscitation(NRP) All nurses working in L&D are required to

be biannually certified in NRP Involves online quizzes on theory R/T

neonatal physiology and nursing care Involves a practicum proficiency

covering a massive resuscitation effort. Ask your clinical instructor to review

equipment used for complete NRP.

Newborn Resuscitation Algorithm.

Kattwinkel J et al. Circulation 2010;122:S909-S919

Copyright © American Heart Association

Website for more information on NRP http://www2.aap.org/nrp/ --

This is from the American Academy of Pediatrics and has all the information about the process.

Nursing Assessment Thermoregulatio

n Dry infant  Remove wet

blankets Position to assess

ABC’s

ABC's of CPR Airway Breathing Crying Muscle tone Circulation—pulse Color

General Assessment for Gross Anomalies

Done simultaneously as you are doing the drying and the ABC, muscle tone assessment.

APGAR Scoring—which is most significant?

SIGN

SCORE 0

SCORE 1

SCORE 2

Heart Rate Absent Slow, Less than 100/min

More than 100/min

Respiratory Effort Absent Slow, Irregular, gasping

Strong cry, regular rate

Muscle Tone Flaccid Some flexion of extremities

Active motion of extremities

Reflex irritability (response to stimuli)

No Response Grimace Vigorous cry, cough, or sneeze

Color Blue, pale Body pink, extremities blue

Completely pink

(Source: Apgar,V. The newborn (apgar) scoring system, reflections and advice. Pediatric clinics of North America.13:645; 1966.)

A = Appearance (color)P = Pulse (heart rate)G = Grimace (reflex irritability)A = Activity (muscle tone)R = Respiration (respiratory rate) Apgar done at 1 & 5 minutes

*Apgar Score 8-10

Approximately 90% of newborns fall into this category.

The approach is drying, warmth, stimulation, positioning to drain secretions and open upper airways, and bulb suctioning of oronasal pharynx.

Invasive maneuvers should be avoided. Occasionally ambient oxygen by mask or ‘blow by’ may be provided briefly.

They should be observed and re-evaluated at 5 minutes after birth.

*Apgar Score 5-7

These newborns have usually undergone a period of intrauterine asphyxia prior to birth. The initial delivery room approach should be slightly more aggressive.

Drying, warmth, suctioning and opening upper airways is immediately indicated. They generally are apneic but may respond to tactile stimulation (e.g. rubbing of the back, gentle slapping of the feet).

Heated/humidified air or oxygen should be provided by mask. If the infant fails to respond to stimulation, positive pressure ventilation/manual bagging is indicated.

Bradycardia usually responds to ventilation and oxygen. Vigorous stimulation and deep suctioning should be avoided.

Repeat Apgar score at 10 minutes if still 5-7 at 5 minutes.

*Apgar Score 3-4

Newborns who are scored in this category at one minute or less are moderately depressed, acidotic, and have suffered more prolonged intrauterine asphyxia.

In addition to the approaches provided for newborns, as indicated above, chest compressions should be initiated in tandem with manual ventilation if bradycardia

<60 bpm persists beyond 60 seconds of bag/mask ventilation alone.

Apgar Score 0-3

These are the severely asphyxiated, depressed newborns.

In addition to immediate drying, warmth, positioning, suctioning, Bag and mask ventilation with 100%

oxygen (heated/humidified) Chest compression Drug administration Intubation may be necessary

Final Interventions  Identification—

ID bracelets and security bracelet Footprints DNA testing (at Advocate BroMenn only) Assess umbilical cord clamp

Weight and Length Vital signs—P, R X 3 q 30 min, Sao2 (at SJMC) X4 AB Prophylaxis

Hemorrhage Vitamin K—AquaMephyton—IM L leg ABMC

Infection Hepatitis vaccine—1st dose given IM during

admission assessment and bath—Needs signed permit. Document Lot number, manufacturer, and expiration date.

Erythromycin ophthalmic ointment in both eyes Eye ointment prophylaxis within 1 hour of delivery.

State Law. Hypoglycemia—follow hospital protocol to do Accucheck/heel stick within 1 hr

Gestational age <37 weeks Infant of a diabetic mother Macrosomia-- > ___ pounds Sx of jitteriness or hypothermia

  Thermoregulation: Double wrap with hat on; skin-to-skin with mom 1st

priority  Bonding Time!! Initiate breastfeeding ASAP with skin to skin contact!

Daily interventions

See p. 832 for list of pertinent Nsg Diagnoses Complete systems assessment q 8 hrs. Maintenance of a neutral thermal environment Careful monitoring of intake and output Promotion of adequate hydration and nutrition Maintenance of skin integrity and cord care At 24 hr of age, complete a Critical Congenital

Heart Dz (CHD) Screening on all babies (see next slide)

Preparation for discharge: TEACH, TEACH, TEACH on all topics. Refer to other Ppt.

The proposed pulse-oximetry monitoring protocol based on results from the right hand (RH) and either foot (F).

Kemper A R et al. Pediatrics 2011;128:e1259-e1267

©2011 by American Academy of Pediatrics

Nourishment

Breastfeeding—goal is always to attempt to breastfeed within 1 hour of delivery. Mom may nurse as long as she would like. Assess infant on mom’s chest q 30 min.

 Formula Feeding—start with sterile water to confirm patency and ability to swallow, then offer formula. Recommend not to exceed 30 mls at first feeding.

Daily Care Bath (see link in PowerPoint on adaptation to Extrauterine Life). Transcutaneous Bilirubin (TCB) assessment—q 24 hr till discharge

  Circumcision care

  Gomco—apply Vaseline to tip of penis

Plastibell—NO Vaseline is used because of risk of dislodging ring. Photo of Plastibell

Pain management—newest research strongly advocates use of some form of pain control. AAP mandates that meds should be given:

Sucrose on pacifier 2 min prior to procedure at ABMC, during at SJMC Acetaminophen 10mg/kg po 30minutes prior to procedure and q4h prn Local anesthetic in dorsum penile nerve—administered by practitioner doing

circumcision Topical anesthetic: EMLA cream applied to tip of penis 30-45 minutes before

procedure Encourage breastfeeding soon after procedure if allowed at institution Change diaper promptly when wet Pain assessment: NIPS

Reassess for bleeding and time of first void per hospital protocol at 15 minutes and 60 min or q 15 times 4 and then q shift.

Don’t you just love being a neonatal nurse?