When performing nursing care for a neonate immediately after birth which intervention has the highest nursing priority?
Note: This guideline is currently under review. Show
Introduction Aim Definition of Terms Assessment Managment Potiential Complications Discharge Planning Family Centered Care Special Considerations Companion Documents Links Evidence Table References IntroductionThis guideline applies to neonates within the first two weeks of life. Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. Approximately 60% of term babies and 85% preterm babies will develop clinically apparent jaundice, which classically becomes visible on day 3, peaks days 5-7 and resolves by 14 days of age in a term infant and by 21 days in the preterm infant. Treatment with phototherapy is implemented in order to prevent the neurotoxic effects of high serum unconjugated bilirubin. Phototherapy is a safe, effective method for decreasing or preventing the rise of serum unconjugated bilirubin levels and reduces the need for exchange transfusion in neonates. AimThis guideline provides health care providers with information to understand the causes of neonatal jaundice, the rationale for the use of phototherapy and outlines the care of neonates receiving
phototherapy in order to enhance effective phototherapy delivery and minimise complications of phototherapy. Definition of Terms
**All phototherapy units are to be set on high intensity at all times, regardless of the amount of units in use. This ensures delivery of adequate amounts of blue light via light emitting diodes (LEDs). Therefore, a single unit is classified as a
single light and single, double or triple lights refers to the amount of units not the intensity setting. AssessmentPlease
note that when charting the TSB level onto the Phototherapy or Exchange Transfusion charts, in the presence of risk factors (sepsis, haemolysis, acidosis, asphyxia, hypoalbuminaemia) TSB values should be plotted on the range 1 lower than the neonate’s gestational age/weight. This is because the risk of developing kernicterus increases in the presence of the above risk factors.
During phototherapy neonates require ongoing monitoring of:
Investigations
Risk Factors
Management(link to phototherapy management document) NutritionBreastfed babies who require phototherapy should continue to breastfeed unless clinically contra-indicated due to other
pathology; the neonate’s sucking, attachment and mother’s milk supply should be monitored. In the case of infants nearing exchange transfusion level, the infant should not come out of phototherapy to feed as this is a medical emergency. All feeds should be given via a bottle or NGT if feeding is deemed safe Neonates who are receiving enteral feeds of EBM or infant formula should continue to do so. The total fluid intake (TFI) for a 24 hour period may need to be increased
by at least 10% to account for insensible fluid loss when a neonate is receiving phototherapy however this should be guided by hydration status and electrolyte monitoring. Phototherapy
Potential Complications
Discharge planning and community-based managementDocumentation in the neonates discharge letter and Child Health Booklet
should include details about TSB/SBR levels and duration of phototherapy treatment. Family Centered CareExplain to parents the need for and actions of phototherapy, particularly in relation to the need for skin surface to be exposed to the phototherapy light, and hence the need to care for neonates receiving phototherapy to be nursed in a neutral thermal environment. Potential complications of phototherapy and the need for protective eye coverings during phototherapy treatment should be explained. The need for measuring the TSB and need for blood sampling should also be explained. Neonates receiving phototherapy (where there are no other contraindications) can have brief periods where the phototherapy is ceased so that they can be cuddled/breastfed and have their eye covers removed for parent-baby interaction to occur. Special ConsiderationsNormal hand hygiene measures should be attended to during care of a neonate receiving phototherapy. More details on the neoBLUE LED lights can be found in the definition of terms. Companion Documents
Links
Evidence TableClick here to view the evidence table for this guideline. References
Please remember to read the disclaimer. The development of this nursing guideline was coordinated by Jessica Smith, Clinical Nurse Educator, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2018. Which intervention has the highest nursing priority when caring for a newborn at birth?With every newborn contact, respiratory evaluation is necessary because this is the highest priority in newborn care.
What is the immediate nursing management of the neonate?Components of essential new born care are ensuring warmth, immediate skin to skin care, initiation of early breast feeding, umbilical cord care, eye care, vitamin K administration and immunization.
What is the highest priority in the newborn assessment quizlet?The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
When performing an assessment on a neonate which assessment finding is most suggestive?When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? 1. Bradycardia. Hypothermic neonates become bradycardic proportional to the degree of core temperature.
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