This is the process where the nurse assesses and provides expert emergency care to the neonate who is unwell and needs prompt nursing care/intervention.
Aims
· Keep baby warm and well resuscitated
· Recognize existing or potential problem for appropriate treatment as soon as possible
· Prevent further deterioration of baby’s condition
· Decrease morbidity and mortality
Requirements
· Extra sheet/blanket
· Restoration tray with self-inflating bag, mask, suction tube
· Suction machine
· Vital signs tray
· Glucometer with strip
· Pain assessment tool
· Weighing scale 11. Cannula
· Tape measure
· Syringes and needles
· IV fluids (10% dextrose and normal saline)
· Tourniquet
· Cotton wool swab
· Receiver for used swab
· Adhesive plaster
· Drugs (Vitamin k, naloxone and adrenaline)
Steps
1. Establish rapport (refer steps) if mother is conscious
2. Explain procedure (refer steps) if mother is conscious
3. Show baby to mother to confirm sex of baby
4. Identify and articulate emergency mood
5. Call for help
6. Prevent overcrowding at the clinical area
7. Dry and stimulate the baby with clean cloth
8. Position the baby on his/her back on a firm surface
9. Provide warmth by covering baby with cloth or using radiant warmer
10. Assess for APGAR score within the 1st and 5th minute
11. Stimulate the baby by rubbing the back 2-3 times and reposition if APGAR score is below 5
12. Clear airway by suctioning and administer inj. vitamin k 1mg if it has not been given
13. Look for the rise and fall of the chest, listen to any audible breath sounds
14. Auscultate for lung sounds and feel for the breaths
15. Assess the capillary refill time, apex heart rate and RBS
16. Set up IV line and administer 10% dextrose (4ml/kg) as bolus if RBS is below 2.5mmol/L and continue with the fluid
17. Assess the colour of the skin, central and peripheral cyanosis and oxygen saturation
18. Start resuscitation if baby is not breathing by bag and mask connected to an oxygen source
19. Position mask over the mouth and nose and make a firm seal if breathing is not established and gently deliver 5 inflational breaths by squeezing the bag to produce rise and fall of the chest
20. Start chest compression if heart rate is below 60bpm
21. Give 30 gentle chest compression at the rate of 100-120/minute
22. Use 2 or 3 fingers in the center of the chest below the nipple, (Press down approximately 1/3 the depth of the chest (about 1 and half Inches). Allow time for chest to recoil 23. Deliver two (2) rescue breaths into the infant’s mouth and nose with the bag and mask connected to an oxygen source over one (1) second and observe for chest rise and fall/any gag or cough response, if unsuccessful, continue with chest compression
23. Look for rise and fall of the chest, listen to breath sounds and feel for airflow at the mouth and nose
24. Re-assess heart rate, skin colour and respiration if within normal ranges, give post resuscitation care
25. Administer IV adrenaline (1:10,000) 0.1-0.3ml/kg if the heart rate is still below 60bpm
26. Administer IV naloxone 0.1mg/kg to counteract effect of injection pethidine given to mother within 4 hours to delivery
27. Continue compressions and breaths in a ratio of 2 breaths per every 30 compressions
28. Re-assess heart rate, skin colour and respiration if within normal ranges, give post resuscitation care
29. Inform mother about progress of baby and the need to transport baby to NICU
30. Report findings detected to the Ward Manager and the Paediatrician
31. Consider endotracheal intubation with paediatrician if child is still unresponsive and transport to NICU
32. Appreciate mother’s cooperation if conscious
33. Dispose off, decontaminate and clean used items
34. Document findings and procedure
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