ATI Ob Chapter 26 Nursing Care and Discharge Teaching

Anesthesia for circumcision

Anesthesia is required for circumcision. Types of anesthesia include a ring block, dorsal‑penile nerve block, topical anesthetic (eutectic mixture of local anesthetics), and concentrated oral sucrose. Nonpharmacologic methods, such as swaddling and nonnutritive sucking can be used to enhance pain management.

Why should circumcision not be done immediately after birth?

B/c the newborn's level of vitamin K is at a low point, and the newborn would be at risk for hemorrhage.

Circumcision

Circumcision is the surgical removal of the foreskin of the penis. ● Circumcision is a personal choice made by the newborn's family for reasons of health and hygiene, religious conviction (Jewish male on eighth day after birth), tradition, culture, or social norms. Parents should make a well‑informed decision in consultation with the provider.

Complications related to newborn home care

Complications stemming from improper understanding of discharge instructions can include the following. ● An infected cord or circumcision from improper care or tub bathing too soon. ● Falls; suffocation; strangulation; burns resulting in injuries, fractures, aspiration; or even death due to improper safety precautions. ● Respiratory infections due to passive smoke or inhaled powders. ● Improper or no use of a car seat resulting in injuries or death. ● Serious infections due to lack of noncompliance with immunization schedule.

Cradle Hold

Cradle the newborn's head in the bend of the elbow. This permits eye‑to‑eye contact and is a good position for feeding.

Cardiopulmonary resuscitation

Encourage parents to seek CPR training.

How long do parents need to wait before bottle feeding or breastfeeding after a circumcision?

Explain to the parents that the newborn will not be able to be bottle feed for up to 2‑3 hr prior to the procedure to prevent vomiting and aspiration based on the preferences of the provider. Newborns who are breastfed can nurse up until the procedure.

Upright position

Hold the newborn upright, and face him toward the holder while supporting his head, upper back, and buttocks

When are vag delivery and CS births discharged home?

Mothersand newborns are normally discharged 48 hr following a vaginal delivery or 72 hr following CS birth.

How often should newborns be breastfed or formula fed in 24 hour period?

Newborns need to be breastfed at least 8 to 12 times in a 24‑hr period. Feeding for a newborn who is breastfeeding should be on demand or every 2 to 3 hr. Newborns who are formula‑fed should also be fed on demand or every 3 to 4 hr.

How long do newborns breast feed per breast and total?

Newborns who are breastfed will average 15 to 20 min per breast and 30 to 40 min for the total feeding.

How often should parents feed newborn at night and during day?

Newborns who are formula‑fed should also be fed on demand or every 3 to 4 hr. Parents should awaken the newborn to feed at least every 3 hr during the day and at least every 4 hr at night. Once the newborn is feeding well and gaining weight adequately, going to demand feeding is appropriate.

Swaddling

Parents should be shown how to swaddle their newborn. Swaddling the newborn snugly in a receiving blanket helps the newborn to feel more secure. Swaddling brings the newborn's extremities in closer to his trunk, which is similar to the intrauterine position.

Colic hold

Place the newborn face‑down along the holder's forearm with the hand firmly between the newborn's legs. The newborn's cheek should be by the holder's elbow on the outside. The newborn should be able to see the ground, and the holder's arm should be close to the body, using it to brace and steady the newborn. This is a good position for quieting a fussy newborn.

Football hold

Support half of the newborn's body in the holder's forearm with the newborn's head and neck resting in the palm of the hand. This is a good position forbreastfeeding and when shampooing the newborn's hair

Positioning and Holding of Newborn

Teach the parents that the newborn has minimal head control. The head should be supported when the newborn is lifted because the head is larger and heavier than the rest of the body.

Diapering

To avoid diaper rash, the newborn's diaper area should be kept clean and dry. Diapers should be changed frequently, and the perineal area cleaned with warm water or wipes and dried thoroughly to prevent skin breakdown.

Circumcision: Postprocedure Nursing actions

● Remove the newborn from the restraining board, and swaddle to provide comfort. ● Monitor for bleeding and voiding per facility protocol. Apply gauze lightly to penis if bleeding or oozing is observed. ● Fan‑fold diapers to prevent pressure on the circumcised area. ● Liquid acetaminophen 10 to 15 mg/kg can be administered orally after the procedure and repeated every 4 to 6 hr as prescribed for a maximum of 30 to 45 mg/kg/day.

Complications of circumcision: Other complications

● Report any frank bleeding, foul‑smelling drainage, or lack of voiding to the provider. ● Provide discharge instructions to the parents about manifestations of infection, comfort measures, medications, and when to notify the provider.

Assessment of Family Readiness for Home Care of Newborn

●● Previous newborn experience and knowledge ●● Parent‑newborn attachment ●● Adjustment to the parental role ●● Social support ●● Educational needs ●● Sibling rivalry issues ●● Readiness of the parents to have their home and lifestyle altered to accommodate their newborn ●● Parents' ability to verbalize and demonstrate newborn care following teaching

Quieting Techniques

●● Swaddling ●● Close skin contact ●● Nonnutritive sucking with pacifier ●● Rhythmic noises to simulate utero sounds ●● Movement (a car ride, vibrating chair, infant swing, rocking newborn) ●● Placing the newborn on his stomach across a holder's lap while gently bouncing legs ●● En face position for eye contact (when parents and newborns faces are about 30 cm (12 in) apart and on the same plane ●● Stimulation

When should newborn be seen in dr office after discharge?

Every newborn should be seen and examined at the doctor's office within 72 hr (2 to 3 days) after discharge from the hospital

Crying

Inform the parents that newborns cry when they are hungry, overstimulated, wet, cold, hot, tired, bored, or need to be burped. Assure the mother that, in time, she will learn what her newborn's cry means. Instruct the mother not to feed her newborn every time he cries. Overfeeding can lead to stomach aches and diarrhea. After checking the newborn, it is okay to let her cry for short periods of time

Signs of Illness to report

Instruct parents regarding the signs of illness and to report them immediately. ● A temperature greater than 38° C (100.4° F) or less than 36.6° C (97.9° F) ● Poor feeding or little interest in food ● Forceful vomiting or frequent vomiting ● Decreased urination ● Diarrhea or decreased bowel movements ● Labored breathing with flared nostrils or an absence of breathing for greater than 15 seconds ● Jaundice ● Cyanosis ● Lethargy ● Inconsolable crying ● Difficulty waking ● Bleeding or purulent drainage around umbilical cord or circumcision ● Drainage developing in eyes.

Clothing

Instruct the parents about how to properly clothe their newborn. ● The best clothing is soft and made of cotton. ● Clothes should be washed separately with mild detergent and hot water. ● Dress lightly for indoors and on hot days. Too many layers of clothing or blankets can make the newborn too hot. ● On cold days, cover the newborn's head when outdoors. ● A general rule is to dress the newborn as the parents would dress themselves

Asses newborn for these prior to circumcision:

The newborn should be assessed for the following. ● A history of bleeding tendencies in the family (hemophilia and clotting disorders) ● Hypospadias or epispadias ● Ambiguous genitalia (when the newborn has genitalia that can include both male and female characteristics). ● Illness or infection

Circumcision: Postprocedure Assessment

The newborn should be assessed for the following. ● Bleeding every 5 to 30 min for the first hour and then hourly for the next 4 to 6 hr ● The first voiding

Circumcision: Gomco (Yellen) or Mogen clam

The provider applies the Gomco (Yellen) or Mogen clamp to the penis, loosens the foreskin, and inserts the cone under the foreskin to provide a cutting surface for removal of the foreskin and to protect the penis. The wound is covered with sterile petroleum gauze to prevent infection and control bleeding.

Circumcision: Plastibell device

The provider slides the Plastibell device between the foreskin and the glans of the penis. The provider ties a suture tightly around the foreskin at the coronal edge of the glans. This applies pressure as the excess foreskin is removed from the penis. After 5 to 7 days, the Plastibell drops off, leaving a clean, healed excision. No petroleum is used for circumcision with the Plastibell.

Car sfaety

Use an approved rear‑facing car seat in the back seat, preferably in the middle (away from air bags and side impact), to transport the newborn. Keep infants in rear‑facing car seats until age 2 or until the child reaches the maximum height and weight for the seat

Bathing

● After the initial bath, the newborn's face, diaper area, and skin folds are cleansed daily. Complete bathing is performed two to three times per week using a mild soap that does not contain hexachlorophene. ● Bathing by immersion is not done until the newborn's umbilical cord has fallen off and the circumcision has healed, if applicable. Wash the area around the cord, taking care not to get the cord wet. Move from the cleanest to dirtiest part of the newborn's body, beginning with his eyes, face, and head; proceed to the chest, arms, and legs; and wash the groin area last. ● Teach the parents proper newborn bathing techniques by a demonstration. Have the parents return the demonstration. ● Bathing should take place at the convenience of the parents, (but not immediately after feeding to prevent spitting up and vomiting.) ● Organize all equipment so that the newborn is not left unattended. Never leave the newborn alone in the tub or sink. ● Make sure the hot water heater is set at 49° C (120.2° F) or less. The room should be warm, and the bath water should be 36.6° to 37.2° C (98° to 99° F). Test the water for comfort on inner wrist prior to bathing the newborn. ● Avoid drafts or chilling of the newborn. Expose only the body part being bathed, and dry the newborn thoroughly to prevent chilling and heat loss. ● The newborn's eyes should be cleaned using a clean portion of the wash cloth. Clear water should be used to clean each eye, moving from the inner to the outer canthus. ● Each area of the newborn's body should be washed, rinsed, and dried, with no soap left on the skin. ● Wrap the newborn in a towel, and swaddle him in a football hold to shampoo his head. Rinse shampoo from the newborn's head, and dry to avoid chilling. ● In male newborns, to cleanse an uncircumcised penis, wash with soap and water and rinse the penis. The foreskin should not be forced back or constriction can result. ● In female newborns, wash the vulva by wiping from front to back to prevent contamination of the vagina or urethra from rectal bacteria. ● Applying a fragrance‑free, hypoallergenic, moisturizing emollient immediately after bathing can help prevent dry skin.

Cord care

● Before discharge, the cord clamp is removed. ● Prevent cord infection by keeping the cord dry, and keep the top of the diaper folded underneath it. ● Sponge baths are given until the cord falls off, which occurs around 10 to 14 days after birth. Tub bathing and submersion can follow.

Cord infection

● Cord infection (a complication of improper cord care) can result if the cord is not kept clean and dry. ◯ Monitor for manifestations of a cord that is moist and red, has a foul odor, or has purulent drainage. ◯ Notify the provider immediately if findings of cord infection are present.

Health benefits of circumcision

● Easier hygiene ● Decreased risk of UTIs ● Decreased risk of STIs, including HIV ● Prevention of penile problems, such as phimosis ● Decreased risk of penile cancer and cervical cancer in female partners.

Newborn Wellness Checkups

● Every newborn should be seen and examined at the doctor's office within 72 hr (2 to 3 days) after discharge. The American Academy of Pediatrics recommends wellness checks at 2 to 5 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 2.5 years, 3 years, 4 years, and every year thereafter. ● Review the schedule for immunizations with the parents. Stress the importance of receiving these immunizations on a schedule for the newborn to be protected against diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae, polio, measles, mumps, rubella, influenza, rotavirus, pneumococcal, and varicella.

Complications of circumcision: Hemorrhage

● Monitor the newborn for bleeding. ● Provide gentle pressure on the penis using a small gauze square. Gelfoam powder or sponge can be applied to stop bleeding. If bleeding persists, notify the providerthat a blood vessel can need to be ligated. Have a nurse continue to hold pressure until the provider arrives while another nurse prepares the circumcision tray and suture material.

Complications of circumcision: Cold stress/hypoglycemia

● Monitor the newborn for excessive loss of heat resulting in increased respirations and lowered body temperature. ● Swaddle and feed the newborn as soon as the procedure is over.

Feeding/Elimination

● Mothers who are breastfeeding should be seen by the lactation consultant. ● Inform parents that adhering to specific timing of feedings is to be avoided. Parents should be instructed to recognize when the newborn has completed the feeding. No other fluids are offered to the newborn unless indicated by the provider. ● The mother's milk supply is equal to the demand of the newborn. Eventually, the newborn will empty a breast within 5 to 10 min, but can need to continue to suck to meet comfort needs. ● Frequent feedings (every 2 hr can be indicated), and manual expression of milk to initiate flow can be needed. ● Most newborns spit up a small amount after feedings. Keep the newborn upright and quiet for a few minutes after feedings. ● Breastfed newborns should have three or more bowel movements per day; formula (bottle) fed newborns are less frequent. Breastfed newborns should have six or more wet diapers per day; formula‑fed infants have a similar number of voids.

Home safety

● Never leave the newborn unattended with pets or other small children. ● Keep small objects (coins) out of the reach of newborns due to choking hazard. ● Never leave the newborn alone on a bed, couch, or table. Newborns move enough to reach the edge and fall off. ● Never place the newborn on his stomach to sleep during the first few months of life. The back‑lying position is the position of choice. The newborn can be placed on his abdomen when awake and being supervised. ● Never provide a newborn with a soft surface to sleep on (pillows or water bed). The newborn's mattress should be firm. Never put pillows, toys, bumper pads, or loose blankets in a crib. Crib linens should be tight‑fitting. ● Do not tie anything around the newborn's neck. ● Monitor the safety of the newborn's crib. The space between the mattress and sides of the crib should be less than 2 fingerbreadths. The slats on the crib should be no more than 5.7 cm (2.25 in) apart. ● The newborn's crib or playpen should be away from window blinds and drapery cords. Newborns can become strangled in them. ● The bassinet or crib should be placed on an inner wall, not next to a window, to prevent cold stress by radiation. ● If an infant carrier is placed on a high place, such as a table, an adult should always be within arm's reach. ● Smoke detectors should be on every floor of a home and should be checked monthly to ensure that they are working. Batteries should be changed twice a year. (Change batteries when daylight savings time occurs or on a child's birthday.) ● Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators, and heat vents. Linens could catch fire if they come into contact with heat sources. ● Control the temperature and humidity of the newborn's environment by providing adequate ventilation. ● Avoid exposing the newborn to cigarette smoke in a home or elsewhere. Secondhand exposure increases the newborn's risk of developing respiratory illnesses. ● All visitors should wash their hands before touching the newborn. Any individual who has an infection should be kept away from the newborn. ● Carefully handle the newborn. Do not toss the newborn up in the air or swing him by her extremities. ● Provide community resources to clients who can need additional and ongoing assessment and instruction on newborn care (adolescent parents).

Sleep Wake Cycle

● Reinforce to the parents that placing the newborn in the supine position for sleeping greatly decreases the risk of SIDS. ● Newborns sleep approximately 16 to 19 hr/day with periods of wakefulness gradually increasing. ● Many parents believe that adding solid food to the newborn's diet will help with sleep patterns. During the first 6 months of life, the American Academy of Pediatrics recommends only breastfeeding. *Most newborns will sleep through the night without a feeding by 4 to 5 months of age. The provider will instruct the parents when to add solid food to the newborn's diet. ● Keep the newborn's environment quiet and dark at night. ● Place the newborn in a crib or bassinet to sleep. The newborn should never sleep in the parents' bed due to the risk of suffocation. ● Most newborns get their days and nights mixed up. Provide basic suggestions for helping the parents develop a predictable routine. Bring the newborn out into the center of the action in the afternoon, and keep him there for the rest of the evening. Bathe him right before bedtime so that he feels soothed. Give him his last feeding around 2300, and then place him into a crib or bassinet. ● When awake, the newborn can be placed on his abdomen to promote muscle development for crawling. The infant should be supervised. ● For nighttime feedings and diaper changes, keep a small night‑light on to avoid having to turn on bright lights. Speak softly, and handle the newborn gently so that he goes back to sleep easily.

Circumcision: Preprocedure Nursing Actions

● Signed informed consent form from parents is needed. ● Gather and prepare supplies. ● Administer medication to newborn as RX'ed ● Assist with procedure. ◯ Place the newborn on the restraining board, and provide a radiant heat source to prevent cold stress. Do not leave the newborn unattended. Have bulb syringe readily available. ◯ Comfort the newborn as needed. ◯ Document time and type of circumcision, excessive bleeding, and newborn voiding following procedure.

Circumcision: Postprocedure Education

● Signed informed consent from parents is needed. ● Explain that the newborn is restrained on a special board during the procedure. ● Teach the parents to keep the area clean. Change the newborn's diaper at least every 4 hr, and clean the penis with warm water with each diaper change. With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr after the circumcision to keep the diaper from adhering to the penis. ● Avoid wrapping the penis in tight gauze, which can impair circulation to the glans. ● A tub bath should not be given until the circumcision is healed. Until then, warm water should be trickled gently over the penis. ● Notify the provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying from the newborn. ● Tell the parents that a film of yellowish mucus can form over the glans by day two, and it is important not to wash it off. ● Teach the parents to avoid using premoistened towelettes to clean the penis because they contain alcohol. ● Inform the parents that the newborn can be fussy or can sleep for several hours after the circumcision. Provide comfort measures for 24 to 48 hr, to include acetaminophen as prescribed. ● Inform the parents that the circumcision will heal completely within a couple of weeks.

Contraindications for circumcision

● Newborns born with hypospadias (abnormal positioning of urethra on ventral under‑surface of the penis) and epispadias (urethral canal terminates on dorsum of penis) because the prepuce skin can be needed for surgical repair of the defect ● Familiar history of bleeding disorders ● Newborns who are circumcised and whose parents decline vitamin K can be more likely to experience bleeding at the circumcision site, especially if they are breastfed.