CH. 26 Nursing Care and Discharge Teaching

home safety

-Eliminate potential fire hazards. Keep a crib & playpen away from heaters, radiators, & heat vents. Linens could catch fire if they come into contact w/ heat sources. -Control temperature & humidity of environment by providing adequate ventilation. -Avoid exposing 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. Any individual who has an infection should be kept away. -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

-placing newborn in supine position for sleeping decreases the risk of SIDS -Newborns sleep approximately 16 to 19 hr/day w/ periods of wakefulness gradually increasing. -Many parents believe that adding solid food to the newborn's diet will help w/ sleep patterns. During first 6 mths 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 diet -Keep the newborn's environment quiet & dark at night.

Circumcision

-surgical removal of foreskin of penis. -Circumcision is a personal choice made by newborn's family for reasons of health & hygiene, religious conviction (Jewish male on eighth day after birth), tradition, culture, or social norms. Parents should make a well-informed decision in consultation w/ provider. -Circumcision should not be done immediately following birth because newborn's level of vitamin K is at a low point, & newborn would be at risk for hemorrhage.

a nurse is caring for a newborn immediately following a circumcision using a gomco procedure. Which of the following actions should the nurse implement? a. apply gelfoam powder to the site. B. Place the newborn in the prone position. C. apply petroleum gauze to the site. d. avoid changing the diaper until the first voiding

a. gelfoam powder is used to control bleeding when there is a risk for hemorrhage. B. Newborns should not be placed in the prone position. C. CORRECT: Petroleum gauze is applied to the site for 24 hr to prevent the skin edges from sticking to the diaper. d. diapers are changed more frequently to inspect the site

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: ANESTHESIA

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 & nonnutritive sucking can be used to enhance pain management.

HEALTH BENEFITS OF CIRCUMCISION

-Easier hygiene -Decreased risk of urinary tract infections -Decreased risk of STIs, including HIV -Prevention of penile problems, such as phimosis -Decreased risk of penile cancer and cervical cancer in female partners.

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.

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 & newborns faces are about 30 cm (12 in) apart & on the same plane -Stimulation

CIRCUMCISION: preprocedure- NURSING ACTIONS

-Signed informed consent form -Gather & prepare supplies. -Admin med to newborn as prescribed. -Assist w/ procedure. -Place newborn on restraining board, & provide a radiant heat source to prevent cold stress. Do not leave newborn unattended. Have bulb syringe readily available. -Comfort newborn as needed. -Document time & type of circumcision, excessive bleeding, & newborn voiding following procedure

clothing

-best clothing is soft & made of cotton. -Clothes should be washed separately w/ mild detergent & hot water. -Dress lightly for indoors & on hot days. Too many layers of clothing or blankets can make too hot. -On cold days, cover head when outdoors. -A general rule is to dress as the parents would dress themselves.

elimination

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

Cradle hold:

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

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, 2months, 4 months, 6 months, 9 months, 12 months, 15months, 18 months, 2 years, 2.5 years, 3 years, 4 years, and every year thereafter.

Football hold:

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 for breastfeeding and when shampooing the newborn's hair.

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

CIRCUMCISION: preprocedure- NURSING ASSESSSMENT

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

EQUIPMENT FOR PERFORMING CIRCUMCISION: Gomco (Yellen) or Mogen clamp

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.

EQUIPMENT FOR PERFORMING 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.

Upright position:

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

a nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? a. Front seat, rear‑facing B. Front seat, forward‑facing C. Back seat, rear‑facing d. Back seat, forward‑facing

a. This is not an appropriate position for the car seat. B. This is not an appropriate position for the car seat. C. CORRECT: The newborn should be restrained in a car seat in a rear‑facing position in the back seat until 2 years of age. d. This is not an appropriate position for the car seat.

CIRCUMCISION: postprocedure- NURSING ASSESSSMENT

newborn should be assessed for the following. -Bleeding every 15 to 30 min for first hour and then hourly for the next 4 to 6 hr -The first voiding

manifestations of illness to report

-A temp 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 w/ 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.

Cord Care

-Before discharge, cord clamp is removed. -Prevent cord infection by keeping cord dry, & keep top of diaper folded underneath it. -Sponge baths until cord falls off, which occurs around 10 to 14 days after birth. Tub bathing & submersion can follow. -Cord infection (a complication of improper cord care) can result if the cord is not kept clean & dry. -Monitor for manifestations of a cord that is moist & red, has a foul odor, or has purulent drainage. -Notify provider immediately if findings of cord infection are present.

home safety

-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).

Complications and nursing management- Hemorrhage

-Monitor 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 provider that 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 & suture material.

Complications and nursing management- cold stress/hypoglycemia

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

CONTRAINDICATIONS FOR CIRCUMCISION

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

CIRCUMCISION: parent teaching

-Notify provider if there is any redness, discharge, swelling, strong odor, tenderness, decrease in urination, or excessive crying -a film of yellowish mucus can form over glans by day two, & it is important not to wash it off. -parents to avoid using premoistened towelettes to clean penis b/c they contain alcohol. -can be fussy or can sleep for several hours after circumcision. Provide comfort measures for 24 to 48 hr, to include acetaminophen as prescribed. -circumcision will heal completely w/in a couple of wks

ASSESSMENT OF FAMILY READINESS FOR HOME CARE OF THE 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 & lifestyle altered to accommodate their newborn -Parents' ability to verbalize and demonstrate newborn care following teaching

CIRCUMCISION: postprocedure- NURSING ACTIONS

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

Complications and nursing management- 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.

car seat safety

-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.

complications r/t newborn home care

-infected cord or circumcision from improper care or tub bathing too soon. -Falls; suffocation; strangulation; burns resulting in injuries, fractures, aspiration; or even death d/t 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 w/ immunization schedule.

bathing

-initial bath, newborn's face, diaper area, & skin folds are cleansed daily. Complete bathing is performed 2-3 x's/wk using a mild soap that does not contain hexachlorophene. -Bathing by immersion is not done until newborn's umbilical cord has fallen off & circumcision has healed, if applicable. Wash area around cord, taking care not to get cord wet. Move from cleanest to dirtiest part of newborn's body, beginning w/ his eyes, face, & head; proceed to chest, arms, & legs; & wash groin area last. -hot water heater is set at 49° C (120.2° F) or less. The room should be warm, & the bath water should be 36.6° to 37.2° C (98° to 99° F). Test water for comfort on inner wrist prior to bathing newborn -male newborns, to cleanse an uncircumcised penis, wash w/ soap & water & rinse penis. foreskin should not be forced back or constriction can result

home safety

-monitor safety of crib. space between mattress & sides of crib should be less than 2 finger breadths.slats on crib should be no more than 5.7 cm (2.25 in) apart. -crib or playpen should be away from window blinds and drapery cords. can become strangled in them. -bassinet or crib should be placed on an inner wall, not next to window, to prevent cold stress by radiation. -If an infant carrier is placed on a high place, such as a table, an adult should be w/in arm's reach. -Smoke detectors should be on every floor & checked monthly to ensure they are working. Batteries should be changed twice a year. (Change batteries when daylight savings time occurs or on a child's birthday.)

home safety

-never leave unattended w/ pets or other small children. -Keep small objects (coins) out of reach due to choking hazard. -Never leave alone on a bed, couch, or table. Newborns move enough to reach the edge & fall off. -Never place on stomach to sleep during first few months of life. back-lying position is position of choice. can be placed on abdomen when awake & supervised. -Never provide w/ a soft surface to sleep on (pillows or water bed). mattress should be firm. Never put pillows, toys, bumper pads, or loose blankets in a crib. Crib linens should be tight-fitting. -Don't tie anything around neck

Sleep-wake cycle

-newborn in a crib or bassinet to sleep.should never sleep in parents' bed due to risk of suffocation. -Most newborns get their days & nights mixed up. Provide basic suggestions for helping the parents develop a predictable routine. Bring out into center of the action in afternoon, & keep there for rest of evening. Bathe right before bedtime so that feels soothed. Give last feeding around 2300, & then into a crib or bassinet. -When awake, can be placed on abdomen to promote muscle development for crawling. infant should be supervised. -nighttime feedings & diaper changes, keep a small night-light on to avoid having to turn on bright lights. Speak softly, & handle gently so goes back to sleep easily.

CIRCUMCISION: parent teaching

-newborn will not be able to be bottle feed for 2-3 hr prior to the procedure to prevent vomiting & aspiration based on preferences of provider. Newborns who are breastfed can nurse up until procedure. -Teach to keep the area clean. Change diaper at least every 4 hr, & clean penis w/ warm water w/ each diaper change. W/ clamp procedures, apply petroleum jelly w/ each diaper change for at least 24 hr after circumcision to keep diaper from adhering to the penis. -Avoid wrapping in tight gauze, can impair circulation to glans. -tub bath shouldn't be given until circumcision is healed. trickle warm water over penis.

Feeding

-offered breast immediately after birth & frequently thereafter. need to be breastfed at least 8-12x's in a 24-hr period. will average 15-20 min/breast & 30 to 40 min for total feeding. Feeding for a newborn breastfeeding, on demand or every 2-3 hr. Newborns who are formula-fed should also be fed on demand or every 3-4hr. Parents should awaken the newborn to feed at least every 3 hr during day & at least every 4 hr at night. Once newborn is feeding well & gaining weight adequately, going to demand feeding is appropriate. -adhering to specific timing of feedings is avoided. No other fluids are offered to newborn unless indicated by provider.

Colic hold:

Colic hold: Place the newborn face-down along the holder's forearm w/ 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, & the holder's arm should be close to the body, using it to brace & steady the newborn. This is a good position for quieting a fussy newborn.

a nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (select all that apply.) a. hypospadias B. hydrocele C. Family history of hemophilia d. hyperbilirubinemia e. epispadias

a. CORRECT: hypospadias involves a defect in the location of the urethral opening and is a contraindication to circumcision. B. hydrocele, a collection of fluid in the scrotal sac, is not a contraindication to circumcision. C.CORRECT: a family history of hemophilia is a contraindication for circumcision. d. hyperbilirubinemia is not a contraindication for circumcision. e.CORRECT: epispadias involves a defect in the location of the urethral opening and is a contraindication to circumcision.

a nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? a. Cover the cord with a small gauze square. B. Trickle clean water over the cord with each diaper change. C. apply hydrogen peroxide to the cord twice a day. d. Keep the diaper folded below the cord

a. Covering the cord with a gauze square prevents the cord from drying and encourages infection. B. Water should not be applied to the cord. C. The cord should be kept clean and dry. hydrogen peroxide is not applied to the cord site. d. CORRECT: Folding the diaper below the cord prevents urine from the diaper penetrating the cord site

a nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? a. "his circumcision will heal within a couple of days." B. "i should remove the yellow mucus that will form." C. "i will clean his penis with each diaper change." d. "i will give him a tub bath within a couple of days."

a. The circumcision will heal within a couple of weeks B. The yellow mucus should remain in place as part of the healing process. C. CORRECT: The penis should be cleaned with warm water with each diaper change. d. a tub bath should not be given until the circumcision is healed.