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Clinical Guidelines (Nursing)

Ward management of a neonate

  • Note: the guideline is currently under review. 

    Introduction

    Neonates are a specialized cohort of patients requiring an individualized approach in nursing care. The four major components of neonatal nursing care are keeping them warm, pink, sweet and calm. 
    Goals of care include the following:

    • minimizing stress
    • conserving energy and enhancing recovery
    • promotion of growth and well being
    • protecting sleep pattern

    Aim

    To provide safe care of a neonate on the ward, when there is no requirement for a Neonatal Intensive Care Unit (NICU) bed. 

    Definition of Terms 

    • Neonate: An infant, less than 28 days old
    • Term baby: 37- 41 weeks gestational age
    • Convection: Loss of heat to air currents
    • Conduction: Loss of heat to object in direct contact with infant
    • Evaporation: Loss of heat by evaporation of water from the skin or respiratory tract
    • Radiation: Loss of heat to nearby cold, solid surfaces
    • mPAT: Modified Pain Assessment Tool
    • FLACC: Face, Legs, Activity, Cry and Consolability
    • WAT: Withdrawal Assessment Tool
    • Neutral Thermal Environment: An environment in which the infant has a minimal metabolic rate, meaning oxygen consumption and energy expenditure are minimal.

    A Registrar or Consultant should assess the neonate and consider the neonate to be stable for ward care, and not requiring a Butterfly ward bed prior to the ward accepting care for the neonatal patient. A Registrar or Consultant should assess the neonate and consider the neonate to be stable for ward care, and not requiring a Butterfly ward bed.

    Observations and Monitoring

    Baseline and ongoing observations should occur as per the Clinical Guideline (Nursing) Observation and Continuous Monitoring and Clinical Guideline (Nursing): Nursing Assessment.

    The Neonate needs to be admitted onto the monitor profile so that alarm limits are specific to age and weight.

    For Neonatal patient’s particular attention should be placed on the following aspects of assessment:

    Temperature

    • The normal temperature of a neonate ranges from 36.5oC - 37.2oC
    • Temperatures measured per axilla every 4 hours, unless febrile or hypothermic.
    • A medical review and full septic work up should be considered for any neonate with a temperature > 38oC
      • A full septic work up includes: Lumbar Puncture, sterile urine culture (Suprapubic Aspirate (SPA) or by insertion of urinary catheter), Blood Cultures, Full Blood Examination, CRP and Chest X-ray.
      • Please refer: Clinical Practice Guideline: Suprapubic Aspirate
    • A temperature of ≤36.5oC is considered hypothermic and a medical review is required.
      • An extra layer (clothing/blanket) should be added and the temperature should be repeated hourly.  If the temperature remains at 36.5oC or below, the neonate should be considered for transfer to an incubator. Please refer to the Policy and Procedures : Isolette Use in Paediatric Wards
      • Hourly temperatures should be checked until there are two consecutive temperatures equal to or greater than 36.6o
    • For more information Please refer to the:

    Neutral Thermal Environment

    Neonates are particularly vulnerable to heat loss via convection, conduction, evaporation and radiation.

    Therefore ensure:

    • They are dressed appropriately with a singlet, jumpsuit, socks, wrap, blanket and hat.
    • Maintain bed 1 metre distance from window and avoid drafts.
    • Minimal handling and clustering of cares. Clinical Practice Guidelines: Minimal Handling
    • Consider the need to use an overhead radiant warmer to regulate temperature. 
      • There are two modes: manual and servo. The Manual control should only be used for bed warming and not when patient is in the cot. The servo control should be used to maintain patient’s temperature and prevent overheating. 
    • Clinical Guideline Nursing: /rchcpg/hospital_clinical_guideline_index/Temperature_Management/
    • Consider transfer to an incubator (Isolette) if neonate is hypothermic
    • Policy and Procedures: Isolette Use in Paediatric Wards  

    Transfers

    • If a neonate needs to be transferred between departments, appropriate measures to maintain their temperature need to be ensured.
    • As per RCH Policy and Procedures : Isolette Use in Paediatric Wards  consider using isolettes/ incubator for neonates, immediately post operatively for a stabilisation period as per criteria (4-24 hours)
    • Neonates returning from theatre to the wards need to have a temperature of ≥36.5, prior to leaving the department.
    • Prior to transfer, any potential or active risks for infectious diseases should be advised to the receiving unit to maintain appropriate precautions and use of personal protective equipment for infection control. 

    Pain

    Blood Sugar Level

    • A blood sugar level should be measured on admission for all sick neonates.
    • Further BSL frequency dependent on:
      • Severity of illness
      • Risks of hypoglycaemia 
      • Clinical signs of hypoglycaemia 
      • Changes made to glucose infusions

    Please refer: Clinical Guidelines (Nursing): Neonatal Hypoglycaemia

    Enteral Intake

    • Establish feeding routine and history: breast fed, EBM, formula fed, or on nasogastric tube feeds
    • Assess the most appropriate feeding method (oral/nasogastric)
    • Strict recording of enteral input including duration of breast feeds and pre and post weights and/or, formula volumes and/or EBM volumes should be recorded.
    • If the neonate is too unwell to feed, breast-feeding mothers should be supported to express and store their breast milk. For further information please see the Clinical Guideline (Nursing): Breast Feeding Support & Promotion.
    • If poor oral intake, the neonate needs to be assessed for insertion of a nasogastric tube or commencement of IV fluids.
    • The following table shows suggested feeding volumes by age, however this table is an approximate guide only and requirements will differ according to gestational age and disease process.

    Age

    ml/kg/day

    Day 1 - 4

    Commence at 30 to 60 ml/kg/day and increase over the next few days as tolerated

    Day 5 - 3 months

    150ml/kg/day; some infants especially preterm may require 180-200ml/kg/day as clinically indicated

    3 months - 6 months

    120 ml/kg/day

     6 months - 12 months  100 ml/kg/day; some infants may reduce to 90ml/kg/day as clinically indicated

    Source: National Health and Medical Research Council (2012) Infant Feeding Guidelines. Canberra: National Health and Medical Research Council

    Output

    The following should be assessed and documented:

    • Urine Output should be measured & nappies weighed 
      • Urine output should be ≥ 2ml/kg/hr, variances to this should be considered and signs of clinical dehydration be reported to the treating team.
    • Bowel actions - frequency, consistency and colour,
    • Vomiting - frequency and colour.
    • If NGT in situ, - colour, quality, amount of aspirate and regular pH testing

    General Considerations

    • Check the General Child Health Record
    • Immunisation Record 
    • Newborn Screening Test

    Management

    Intravenous Fluid Management

    All Intravenous Fluids require a current medical order as per usual protocol
    Intravenous Fluids (IV): 

     Age

     ml/hr

     ml/kg/day

     Recommended Fluid

     0 - 24 hours

     weight x 2.5

     60ml/kg/day

     10% Dextrose

     25 - 48 hours

     weight x 2.5

     60ml/kg/day

     10% Dextrose

     49 - 72 hours

     weight x 3

     72ml/kg/day

     *10%Dextose+NaCl+KCl 

     > 72 hours

     weight x 4

     96ml/kg/day

     *10%Dextose+NaCl+KCl

    Note* Ordered as 10 per cent dextrose 500 mL and 6.5 mL 20 per cent NaCl and 10 mL 7.5 per cent KCl (giving 22 mmol NaCl and 10 mmol KCl per 500 mL) Source: Neonatal eHandbook - IV Infusions for Special Care Nursery Admissions

    Considerations if oral or nasogastric feeds are not tolerated or suitable, and IV fluid therapy is initiated. When selecting an appropriate IV fluid the following should be taken into account:

    • Neonates require solutions with a minimum of 10% dextrose to meet their increased metabolic demand and decreased energy reserves.
    • A maximum fluid rate of 100mls/kg/day should not be exceeded without consultation/approval from treating medical team and Neonatal consultant.
    • Restriction of fluids is often required and needs to be considered in the sick neonate
    • Blood Gases, BSL and UEC’s prior to commencement and 24 hourly (sooner if clinically indicated) for neonates on maintenance IV fluids.
    • Baseline weights should be recorded then frequency as clinically indicated. At a minimum twice weekly but for a sick neonate on IV fluids more frequent weights will be necessary. 
    • Syringe driver and minimum volume tubing should be used for administration of IV fluids and medications (i.e. Intravenous antibiotics).
    • Please refer: https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/perinatal-reproductive/neonatal-ehandbook/procedures/iv-infusion-for-scn-admissions

    IV and CVAD access in Neonates 

    Skin Care

    • Assessment of skin integrity should occur on admission and at least once a shift (and at each nappy change as needed).
    • Assess neonate for risk factors of skin breakdown i.e. loose or frequent stools, drug withdrawal, medications that alter stool frequency or composition. 
    • Nappy Area:  maintain skin integrity; apply a thick barrier cream that contains zinc oxide at every nappy change when having frequent or loose bowel actions well as at the first sign of erythema or skin breakdown.
    • Report any rashes to medical staff for review.
    • For further information refer to Clinical Guidelines (Nursing) : Neonatal & Infant Skin Care

    Sleep Maximisation

    Parent Engagement

    Illness and separation causes increased stress and anxiety on the infant and their family, and this has been proven to affect brain development and subsequent neurodevelopmental progress in childhood. Therefore, it is essential that every effort is made to nurture the parent-infant bond by encouraging families to interact with their babies as much as possible, from as early as possible. For more information refer to COCOON.

    Encourage engagement through:

    • Participating in feeding
    • Attending to nappy cares
    • Facilitating bathing
    • Providing routine
    • Skin to Skin Care

    For more information refer to COCOON

    Companion Documents

    Links

    References

    Comprehensive Neonatal Nursing. A Physiologic Perspective. Carole Kenner, Judy Wright Lott, Ann Applewhite Flandermeyer. WB Saunders Company. 2nd Edition, 1998. 

    Evidence Table

    Click here to view the Evidence Table.


    Please remember to read the disclaimer.


    The development of this nursing guideline was coordinated by Di Sili, RN, Koala and Alanah Crowle, CNS, Butterfly, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2017.