CRITICAL PATHWAY for Newborn Care

Category	First 4 Hours	4-8 Hours Past Birth	8-24 Hours Past Birth
Referral	Review labor/birth record Review transitional nursing record Check ID bands PRN consults: orthopedics, genetics, infectious disease	Check ID bands Transfer to mother/baby care at 4-6 hours of age if As parents desire, obtain circumcision permit after their discussion with physician Lactation consult PRN	Check ID bands every shift Expected Outcomes: Mother/baby ID bands correlate at time of discharge; consults completed PRN
Assessments	Continue assessments begun first hour after birth. Vital signs: TPR, BP PRN, qlh X 4 (skin temp 97.898.6°F, resp may be irregular but within 30-60 per	Assess newborn’s progress through periods of reactivity Vital signs: TPR q8h and PRN, BP PRN	VS q8h. Normal ranges: T, 97.5-99°F; P, 120-160; R, 30-60; BP, 60-80/40-45 mm Hg
	Newborn Assessments: Respiratory status with resp distress scale X 1 then pm. If resp distress, assess q5-15minutes Cord-bluish white color, clamp in place Color: skin, mucous membranes, extremities; trunk pink with slight acrocyanosis of hands and feet Wt (5 lb 8 oz-8 lb 13 oz), length (18-22 inches), HC (12.5-14.5 inches), CC (32.5 cm, 1-2 cm less than head) Extremity movement- may be jerky or brief Gestational age classification-term AGA Anomalies (cong. anomalies can interfere with normal extrauterine adap-	Newborn Assessments: Skin color q4h prn (circulatory system stabilizing, acrocyanosis decreased) Eyes for drainage, redness, hemorrhage Ausculate lungs q4h (noisy, wet resp normal) Increased mucus production (normal in second period of reactivity) Check apical pulse q4h Umbilical cord base for redness, drainage, foul odor, drying, clamp in place Extremity movement q4h Check for expected reflexes (suck, rooting, Moro, grasp, blink, yawn, sneeze, tonic neck, Babinski) Note common normal varia- Assess suck and swallow during feeding Note behavioral characteris- Temp before and after admission bath	Continue Newborn Assessments: Skin color q4h Signs of drying or infection in cord area Check cord clamp in place until removed before discharge Check circ for bleeding after procedure, then q30min X 2, then q4h and PRN Expected Outcomes: Vital signs medically acceptable, color pink, assessments WNL, circ site without s/s infection, cord site without s/s infection and clamp removed; newborn behavior WNL
Teaching/ psychosocial	Admission activities performed at mother’s bedside if possible, orient to nursery pm, hand washing, assess teaching needs Teach parents use of bulb syringe, signs of choking, positioning, and when to call for assistance Teach reasons for use of radiant warmer, infant hat, and warmed blankets when out of warmer Discuss/teach infant security, identification	Reinforce teaching about choking, bulb syringe use, positioning, temperature maintenance with clothing and blankets Teach infant positioning to facilitate breathing and diges- Teach new parents holding and feeding skills Teach parents soothing and calming techniques	Final discharge teaching: diapering, normal void and stool patterns, bathing, nail and cord care, circumcision/uncircumcised penis/genital care and normal characteristics, rashes, jaundice, sleep/wake cycles, soothing activities, taking temperatures, thermometer reading Explain s/s of illness and when to call health care provider Infant safety: car seats, immunizations, metabolic screening; on back for sleep Expected Outcomes: Mother/family verbalize comprehension of teaching; demonstrates care capabilities
Nursing care management and reports	Place under radiant warmer Place hat on newborn (decreases convection heat loss) Suction nares/mouth with bulb syringe pm Keep bulb syringe with infant Attach security sensor Obtain lab tests: blood glucose; as needed obtain blood type, Rh, Coombs on cord blood, HSV culture if parental hx Notify physician’s office for exchange of infant's birth and status Maintain standard precautions	Wean from radiant warmer (T 98°F axillary) Chemstrips pm; BP pm Oxygen saturation prn Bathe infant if temp >97.8°F 5 Position on side Suction nares prn (esp during second period of reactivity) Obtain peripheral Het per protocol Cord care per protocol (alcohol or triple dye prn) Fold diaper below cord (for plastic diapers, turn plastic layer away from skin)	Check for hearing test results Weigh before discharge Cord care every shift DC cord clamp before discharge Perform newborn metabolic screening blood tests before discharge Circumcision if indicated. Circumcision care: change diaper prn noting ability to void, follow policy for Gomco or Plastibell care Expected Outcomes: Newborn maintains temp, lab test WNL, cord dry without s/s infection and clamp removed, screening tests accomplished, circ site without s/s infection or bleeding
Activity and comfort	Place under radiant warmer or wrap in prewarmed blankets until stable Soothe baby as needed with voice, touch, cuddling, nesting in warmer	Leave in warmer until stable, then swaddle Position on side after each Bleeding	Place in open crib Swaddle to allow movement of extremities in blanket, including hands to free Expected Outcomes: Infant maintains temp WNL in open crib; infant attempts self-calming
Nutrition	Assist newborn to breastfeed as soon as mother/baby condition allows Supplement breast only when medically indicated or per agency policy Initiate bottle-feeding within first hour Gavage feed if necessary to prevent hypoglycemia	Breastfeed on demand, at least q3-4hours Teach positions, observe/assist with feeding, breast/nipple care, establishing milk supply, breaking suction, feeding cues, latching on techniques, nutritive suck, burping Bottlefeed on demand, at least q3-6hours Determine readiness to feed and feeding tolerance	Continue breast/bottlefeeding pattern Assess feeding tolerance q4h Discuss normal feeding requirements, signs of hunger and satiation, handling feeding problems, and when to seek help Expected Outcomes: Mother verbalizes knowledge of feeding information; breastfeeds on demand without supplement; bottle-tolerates formula feeding, nipples without problems
Elimination	Note first void and stool if not noted at birth	Note all voids, amount and color of stools q4h	Evaluate all voids and stools color q8h Expected Outcomes: Voids qs; stools qs without difficulty; stool character WNL; diaper area without s/s skin breakdown or rashes
Medication	Prophylactic ophthalmic ointment OU after baby makes eye contact with parents within 1 hour after birth Administer Aquamephyton IM, dosage according to infant weight per MD/NP	Hepatitis B injection as ordered by physician after consent signed by parents	Hepatitis B vaccine before discharge Expected Outcomes: Baby has received ophthalmic ointment and vitamin K injection; baby has received first hepatitis B vaccine if ordered and parental permission received
Discharge planning/ home care	Hepatitis B consent signed Hearing screen consent	Review/reinforce teaching with mother and significant other Review home preparedness	Initial newborn screening tests (hearing, blood tests, PKU) before discharge Bath and feeding classes, videos, or written information given