CRITICAL PATHWAY for Newborn Care - cont'd


Category First 4 Hours

4-8 Hours Past Birth

8-24 Hours Past Birth

Discharge planning/ home care - cont'd

Plan discharge call with parent or guardian in 24 hr to 2 days

Assess parents’ discharge plans, needs, and support systems

Obtain birth certificate information

Give written copy of discharge instructions Newborn photographs

Set up appointment for follow-up PKU test

Have car seat available before discharge

All discharge referrals made, follow-up appt scheduled

Expected Outcomes:

Infant discharged home with family; mother verbalizes follow up appt, time/date

Family involvement

Facilitate early investigation of baby’s physical characteristics (maintain temp during unwrapping), hold infant en face

Dim lights to help infant keep eyes open

Assess parents’ knowledge of newborn behaviors, such as alertness, suck and rooting, attention to human voice, response to calming techniques

Assess mother-baby bonding/interaction

Incorporate father and siblings in care

Enhance parent-infant interaction by sharing characteristics and behavioral assessment

Support positive parenting behaviors

Identify community referral needs and refer to community agencies

Expected Outcomes:

Demonstrates caring and family incorporation of infant

Complications During the Neonatal Period:

The High-Risk Newborn

  1. General overview - successful newborn adaptation to the demands of independent extrauterine life may be complicated by environmental insults during the prenatal period or those arising in the period immediately surrounding birth. The nursing role focuses on minimizing the effect of present and emerging health problems and on facilitating and supporting a successful transition to extrauterine life.
  2. General aspects - common neonatal risk factors:
    1. Gestational age profile:
      1. Prematurity.
      2. Dysmaturity.
      3. Postmaturity.
    2. Congenital disorders.
    3. Birth trauma.
    4. Infections.
  1. Disorders affecting protective functions: neonatal infections
    1. Assess for intrauterine infections.
    2. Oral thrush (mycotic stomatitis).
      1. Pathophysiology - local inflammation of oral mucosa due to fungal infection.
      2. Etiology:
        1. Organism - Candida albicans.
        2. More common in vulnerable newborn, i.e., sick, debilitated; those receiving antibiotic therapy.
      3. Mode of transmission - direct contact with:
        1. Maternal birth canal, hands, and linens.
        2. Contaminated feeding equipment, staff’s hands.
      4. Assessment
        1. White patches on oral mucosa, gums, and tongue that bleed when touched.
        2. Occasional difficulty swallowing.
      5. Analysis/nursing diagnosis:
        1. Pain related to irritation of oral mucous membrane secondary to oral moniliasis.
        2. Altered nutrition, less than body requirements related to irritability and poor feeding.
      6. Nursing care plan/implementation:

        Goal: prevent cross-contamination.
        1. Aseptic technique; good handwashing.
        2. Givemedications as ordered:
          1. Aqueous gentian violet, 1-2%: apply to infected area with swab.
          2. Nystatin (Mycostatin) - instill into mouth with medicine dropper, or apply to lesions with swab, after feedings. Note: Before medicating, feed sterile water to rinse out milk.
      7. Evaluation/outcome criteria:
        1. Oral mucosa intact, lesions healed, no evidence of infection.
        2. Feeds well; maintains weight or regains weight lost, if any.
    3. Neonatal sepsis
      1. Pathophysiology - generalized infection; may overwhelm infant’s immature immune system.
      2. Etiology:
        1. Prolonged rupture of membranes.
        2. Long, difficult labor.
        3. Resuscitation procedures.
        4. Maternal infection (e.g., beta-hemolytic streptococcus vaginosis).
        5. Aspiration - amniotic fluid, formula, mucus.
        6. Iatrogenic (nosocomial) - caused by infected health personnel or equipment.
      3. Assessment:
        1. Respirations - irregular, periods of apnea.
        2. Irritability or lethargy.
      4. Analysis/nursing diagnosis:
        1. Fatigue related to increased oxygen needs.
        2. High risk for infection related to septic condition.
      5. Nursing care plan/implementation:
        1. Cultures (spinal, urine, blood).
        2. Check vitals.
        3. Monitor respirations.
        4. Give medications, as ordered.
      6. Evaluation/outcome criteria:
        1. Responds to medical/nursing regimen (all assessment findings within normal limits).
        2. Parent(s) verbalize understanding of diagnosis, treatment; demonstrate appropriate techniques in participating in care (as possible).
        3. Parent(s) demonstrate effective coping with situation; express satisfaction with care.

Preterm Infant

Born at 37 weeks of gestation or less.

  1. Pathophysiology-anatomical and physiological immaturity of body systems compromises ability to adapt to extrauterine environment and independent life.
    1. Interference with protective functions
      1. Temperature regulation-unstable, due to:
        1. Lack of subcutaneous fat.
        2. Large body surface area in proportion to body weight.
        3. Small muscle mass.
        4. Absent sweat or shiver responses.
        5. Poor capillary response to changes in environmental temperature.
      2. Resistance to infection-low, due to:
        1. Lack of immune bodies from mother (these cross placenta late in pregnancy).
        2. Inability to produce own immune bodies (immature liver).
        3. Poor WBC response to infection.
      3. Immature liver
        1. Inability to conjugate bilirubin liberated by normal breakdown of RBCs-increased susceptibility to hyperbilirubinemia and kernicterus.
        2. Immature production of clotting factors and immune globulins.
        3. Inadequate glucose stores increased susceptibility to hypoglycemia.
    2. Interference with elimination: immature renal function-unable to concentrate urine-precarious fluid/electrolyte balance.
    3. Interference with sensory-perceptual functions: CNS-immature-weak or absent reflexes and fluctuating primitive control of vital functions.
  2. Etiology: often unknown; preterm labor.
    1. Iatrogenic-EDB miscalculated for repeat cesarean birth (rare).
    2. Placental factors
      1. Placenta previa.
      2. Abruptio placentae.
      3. Placental insufficiency.
    3. Uterine factors
      1. Incompetent cervix.
      2. Overdistention (multifetal gestation, polyhydramnios).
      3. Anomalies (myomas).
    4. Fetal factors
      1. Malformations.
      2. Infections (rubella, toxoplasmosis, HIVpositive status, AIDS, cytomegalic inclusion disease).
      3. Multifetal gestations (twins, triplets).
    5. Maternal factors
      1. Severe physical or emotional trauma.
      2. Coexisting disorders (PIH, hypertension, heart disease, diabetes, malnutrition).
      3. Infections (streptococcus, syphilis, bacterial vaginosis, pyelonephritis, pneumonia, influenza, leukemia, UTI).
    6. Miscellaneous factors
      1. Close frequency of pregnancies.
      2. Advanced maternal age.
      3. Heavy smoking.
      4. High-altitude environment.
      5. Cocaine use.
  3. Factors influencing survival:
    1. Gestational age.
    2. Lung maturity.
    3. Anomalies.
    4. Size.
  4. Causes of mortality (in order of frequency):
    1. Abnormal pulmonary ventilation.
    2. Infection.
      1. Pneumonia.
      2. Septicemia.
      3. Diarrhea.
      4. Meningitis.
    3. Intracranial hemorrhage.
    4. Congenital defects.