Download Survey of Recommended Routines

Survey of Recommended Routines
Hospital: ____________________________________________
Discipline:
Date: _________
___
Obstetrician _____, Pediatrician _____, Family Physician _____, Nurse Practitioner or Nurse Midwife _____,
Staff Nurse(s) _____, other (please specify)
Nursing Staff, please indicate the time of day this survey was completed: Day ____
Instructions:
Examples:
Night ____
Please review each recommended routine in the survey and indicate the status of each routine in your hospital:
YES = The routine is established and in use.
NEED TO DO = The staff needs to establish the routine.
DO NOT NEED TO DO BECAUSE ..... = The routine is not needed in our hospital because:
• Routine is unworkable in our hospital
• Such patients are transferred
• Staff disagrees with routine
• Other reason
_YES_
A. Are guidelines established for the postpartum assessment for every woman whose
pregnancy was complicated by hypertension?...................................................................... __X__
B. Is there immediate 24 hour/day availability of a resuscitation team, consisting of at least
2 people, including someone skilled in endotracheal intubation?....................................... _____
C. Is continuous electronic cardiorespiratory monitoring provided for all babies at-risk for
apnea?................................................................................................................................... _____
2012 - revised
Evening ____
NEED
TO DO
DO NOT NEED TO
DO BECAUSE.......
______
__________________
___X__
__________________
_______
__patients transferred_
Survey of Recommended Routines
BOOK I
YES
Is the Mother Sick? Is the Fetus Sick?
1. Establish a record-keeping system that includes: ................................................................. ____
• Use of a single, standard prenatal record form by all obstetric practitioners
• Identification of risk status
• Reliable availability to labor and delivery staff of all prenatal records for all patients
NEED
DO NOT NEED TO
TO DO DO BECAUSE......._
______
__________________________
2. Develop a system that allows outpatient evaluation, in an obstetrical care area, of
women who may or may not be in labor, until it is determined that discharge home or
hospitalization is appropriate. .............................................................................................. ____
______
__________________________
3. Establish a system for notification of nursery personnel regarding any risk factor as soon
as a pregnant woman is admitted to the hospital. ................................................................. ____
______
__________________________
4. Establish a system of prenatal consultation and/or referral for high risk patients. .............. ____
______
__________________________
5. Provide fetal heart rate and uterine contraction monitoring for all patients during labor. .. ____
______
__________________________
6. Establish a system whereby an emergency cesarean delivery can be started within 30
minutes from the time the decision to operate is made, at any time of the day or night. ..... ____
NOTE: This routine is listed in 4 units in the books, but is listed only here for this survey.
______
__________________________
7. Establish a system whereby personnel and equipment are available to provide
resuscitation to a pregnant or postpartum woman, at any time of the day or night. ............ ____
______
__________________________
8. Establish a system whereby equipment and personnel for resuscitation of a newborn are
available for every delivery. ................................................................................................ ____
______
__________________________
9. Establish a protocol for documentation of telephone contact with patients, including
history to be obtained, standard advice, and communication with the obstetrical care
provider. ………………………………………………………………………………….. ____
______
__________________________
Fetal Age, Growth, and Maturity
YES
1. Develop a system for ensuring frequent and appropriate evaluation of each high risk
pregnancy throughout gestation. .......................................................................................... ____
NEED
DO NOT NEED TO
TO DO DO BECAUSE......._
______
__________________________
2. Ensure each high risk pregnancy has access to each of the following, as needed:
amniocentesis, comprehensive ultrasonography, laboratory evaluation for fetal lung
maturity, and maternal-fetal medicine subspecialist. ........................................................... ____
______
__________________________
3. Establish a routine for consistent measuring and recording of fundal height at each
prenatal visit. ........................................................................................................................ ____
______
__________________________
4. Use a system to ensure documentation of fetal maturity prior to a planned delivery. ......... ____
______
__________________________
Fetal Well-being
1. Establish a system so that each high risk pregnancy has access to:
• Continuous electronic fetal monitoring for non-stress and contraction stress testing..... ____
• Ultrasound evaluation for biophysical profile................................................................. ____
• Prompt consultation with maternal-fetal medicine specialists ....................................... ____
______
______
______
__________________________
__________________________
__________________________
2. Establish a system to ensure the availability of continuous electronic fetal monitoring
for:
• All high-risk pregnancies during labor.............................................................................____
• All low-risk pregnancies that develop problems during labor ..................................... ____
______
______
__________________________
__________________________
3. Develop a system for obtaining fetal scalp or acoustic stimulation tests whenever
indicated for assessment of fetal well-being. ....................................................................... ____
______
__________________________
4. Develop training sessions and adjust staffing patterns to ensure that at least one
individual skilled in recognizing abnormal fetal heart rate patterns is in attendance
during all electronically monitored labors. .......................................................................... ____
______
__________________________
______
__________________________
5. Establish a protocol and/or develop a checklist to ensure that each woman with an
electronically monitored labor has the following evaluated systematically and
frequently: ……………………………………………………………………………….. ____
• Uterine activity (including contraction strength, contraction frequency, contraction
duration, and baseline uterine tone [internal monitoring] or relative increase or
decrease in tone [external monitoring]),
• Fetal heart rate pattern (baseline fetal heart rate, fetal heart rate variability, periodic
or episodic rate changes)
• Catergorizarion of electronic fetal monitoring tracing
Is the Baby Sick?
1. Establish a system for classifying all babies as well, at-risk, or sick, with periodic
reassessment and reclassification as indicated by the baby's condition. ..............................
2. Provide continuous electronic cardiorespiratory monitoring for all sick babies and for all
babies at-risk for developing apnea. .....................................................................................
3. Provide continuous pulse oximetry monitoring for all babies receiving supplemental
oxygen or positive-pressure ventilation, and have oximetry immediately available for all
babies thought to be at risk for requiring supplemental oxygen. …………………………
4. Obtain preductal oximetry screening for all newborns, whether sick, at-risk, or well, to
rule out cyanotic congenital heart disease. ……………………………………………..…
YES
____
NEED
DO NOT NEED TO
TO DO DO BECAUSE......._
______ __________________________
____
______
__________________________
____
______
__________________________
____
______
__________________________
Resuscitating the Newborn
1. Utilize a system of prenatal identification of high risk pregnant women to recognize
high risk situations immediately upon admission to the hospital and
• Allow for elective transfer of a pregnant woman and her fetus for delivery at a
regional center, as appropriate.......................................................................................................................
____ ______ __________________________
• Mobilize extra personnel, skilled in newborn resuscitation, to the delivery room .......... ____ ______ __________________________
2. Establish a routine when meconium is present, and a baby is not vigorous, of direct
endotracheal suctioning. ...................................................................................................... ____ ______ __________________________
3. Ensure the immediate 24 hour/day availability of a resuscitation team, consisting of
at least 2 people, including someone skilled in endotracheal intubation. ........................ ____ ______ __________________________
4. Conduct resuscitation practice sessions periodically to be sure team members work
together effectively and efficiently. ..................................................................................... ____ ______ __________________________
5. Develop a system for periodically checking the presence and the operation of all
resuscitation equipment in each delivery room, in the nursery, and in postpartum rooms.....................................
____ ______ __________________________
6. Identify an independent person at each delivery to assign the Apgar score, and to record
the points (0, 1 or 2) for each of the 5 components of the score. .................................... ____ ______ __________________________
7. Establish the capability for immediate availability of equipment for mixing oxygen and ____
compressed air and for pulse oximetry monitoring in every delivery area. ……………..
8. Ensure continuous availability of equipment for transferring a resuscitated baby from
the delivery room to the nursery (e.g., warmed incubator, portable oxygen, etc.). ............. ____
9. Develop a checklist of things to observe and record in all babies who required
resuscitation. ........................................................................................................................ ____
10. Establish a protocol with obstetric providers to delay umbilical cord clamping for at least
1 minute, following complete delivery of the baby, for vigorous babies who do not
require resuscitation. …………………………………………………………………….. ____
______
__________________________
______
__________________________
______
__________________________
______
__________________________
Gestational Age and Size and Associated Risk Factors
NEED DO NOT NEED TO
YES_ TO DO DO BECAUSE......._
1. Establish a policy of performing a gestational aging and sizing examination of all
newborns within 2 hours of birth.............................................................................................____ ______ __________________________
2. Establish a policy of classifying each baby as small for gestational age (SGA),
appropriate for gestational age (AGA), or large for gestational age (LGA) and preterm, ____ ______ __________________________
term, or post-term and recording the findings in each baby’s medical record.......................................................................................................................
3. Develop standing orders to implement appropriate actions for each gestational age
____
and size category. .................................................................................................................
______
__________________________
4. Develop special procedures for identifying and caring for babies born late preterm or
extremely preterm. ………………………………………………………………………
5. Establish a policy of evaluating the status and assessing risk (including history,
gestational age and size, and clinical tests [as appropriate]) of each newborn, within
2 hours after birth. ................................................................................................................
6. Establish a policy to discourage elective cesarean section prior to 39 weeks gestation,
without specific medical indication. …………………………………………………......
Thermal Environment
1. Establish a routine of measuring body temperature frequently in sick and at-risk babies...
2. Establish a policy of withholding baths from all sick babies. ..............................................
3. Establish a policy of withholding baths from any baby until the baby's temperature has
been measured and has remained normal for several hours. ................................................
____
______
__________________________
____
______
__________________________
____
______
__________________________
____
____
______
______
__________________________
__________________________
____
______
__________________________
4. Establish a policy which will ensure the continuous availability of a radiant warmer or
pre-warmed incubator for any unexpected admission to the nursery. .................................. ____ ______
5. Post the neutral thermal environment graphs and establish a policy of adjusting the
environmental temperature of any occupied incubator to the appropriate neutral thermal ____
______
environment (NTE) temperature.........................................................................................................................
______
6. Use equipment to monitor and adjust the temperature of supplemental oxygen. ............... ____
Hypoglycemia
1. Establish standing orders which will ensure blood glucose screening for all babies at-risk
for hypoglycemia. ................................................................................................................. ____
______
2. Establish a policy of
• Starting early feedings in well babies………………………………………………… ____
______
• Starting feedings withi 1 hour of age for babies at risk for hypglycemia……………... ____
______
• Establishing intravenous glucose within 1 hour of age for the very low birth weight
or sick baby………………………………………………............................................ ____
______
3. Establish a policy of regular calibration and quality control measures for the beside
glucose screening instrument(s) used in your hospital. This procedure should follow
manufacturers' instructions and be in accordance with your hospital's policy regarding
______
point-of-care tests. .............................................................................................................. ____
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
BOOK II
NEED DO NOT NEED TO
Hypertension in Pregnancy
YES TO DO DO BECAUSE......._
1. Establish guidelines for the consistent classification, and reclassification if condition
changes during pregnancy, of pregnant women with hypertension as having either ......... ____
______ _________________________
• Chronic hypertension, or chronic hypertension with superimposed preeclampsia, or
• Pregnancy-related hypertension, including gestational hypertension, preeclampsia,
severe preeclampsia, eclampsia, or HELLP syndrome
2. Establish written instructions for the home care of women who develop hypertension
______ __________________________
during pregnancy, including a list of findings to report to their health care provider. ........ ____
3. Establish guidelines for assessment of women admitted for evaluation of preeclampia. .... ____
______ __________________________
4. Establish guidelines for the immediate stabilization of a woman who has rapidly
worsening preeclampsia or eclampsia. ................................................................................. ____
______ __________________________
5. Establish a protocol for response to maternal seizure(s) due to eclampsia. ......................... ____
______ __________________________
6. Establish guidelines for intravenous infusion of:
(a) magnesium sulfate and (b) antihypertensive medication............................................................................................
____
______ __________________________
7. Establish guidelines for the postpartum assessment of every woman whose pregnancy
was complicated by hypertension. ....................................................................................... ____
______ __________________________
Obstetric Hemorrhage
1. Develop a system whereby an emergency cesarean delivery can be started within 30
minutes from the time the decision to operate is made, at any time of the day or night,
any day of the week. NOTE: see Book I, Unit 1.
2. Develop a system whereby an emergency hyterectomy can be carried out urgently at
____
any time of day or night, any day of the week. ......................................................................................................
______ __________________________
3. Establish guidelines for the emergency treatment and stabilization of women with:
• Obstetric hemorrhage of unknown origin........................................................................ ____
______ __________________________
• Bleeding placenta previa................................................................................................. ____
______ _________________________
• Abruptio placentae........................................................................................................... ____
______ _________________________
• Disseminated intravascular coagulation (DIC)................................................................ ____ ______ _________________________
• Postpartum hemorrhage................................................................................................... ____ ______ _________________________
4. Establish a routine to ensure prevention and/or early detection of postpartum
hemorrhage for every woman, including administration of uterotonic medication
following placental delivery, visual inspection of the placenta, visual inspection of the
____ ______ _________________________
birth canal, and intensive monitoring during first hour postpartum. .............................................................................................
5. Establish written instructions for obtaining blood components quickly, at all times. ....... ____ ______ _________________________
6. Develop flow diagram(s) for quick and clear recording during crisis management of:
______ _________________________
• Severe antepartum obstetric hemorrhage.........................................................................____
____
_________________________
• Disseminated intravascular coagulation (DIC)................................................................ ____ ______
______ _________________________
• Severe postpartum hemorrhage,...........................................................................................
NEED
Perinatal Infections
YES_ TO DO
1. Establish a system to ensure use of standard precautions by all staff members. …............. ____ ______
DO NOT NEED TO
DO BECAUSE......._
__________________________
2. Establish a written protocol to obtain lower vagina and rectal cultures for group B betahemolytic streptococci (GBS) from all women at 35 to 37 weeks’ gestation (unless a
woman had an earlier baby with group B beta-hemolytic streptococci infection or had
____ ______
group B beta-hemolytic streptococci bacteriuria in current pregnancy)....................................................
__________________________
3. Establish a written protocol for prenatal and intrapartum management for the prevention
of neonatal GBS infection. ................................................................................................. ____
______
__________________________
4. Establish a policy to screen all women with culture, serology, and/or other test, as early
in pregnancy as possible, for:
• Bacteriuria ..................................................................................................................... ____
• Gonorrhea ....................................................................................................................... ____
• Hepatitis B virus (HBV) ................................................................................................ ____
• Human immunodeficiency virus (HIV) ........................................................................ ____
• Syphilis
______
______
______
______
__________________________
__________________________
__________________________
__________________________
5. Establish a protocol for treatment of bacteriuria, whether symptomatic or
asymptomatic. .................................................................................................................... ____
______
__________________________
6. Establish a system for timely transfer of information about possible or proven maternal
infections to neonatal providers. ........................................................................................ ____
______
__________________________
7. Establish written guidelines for isolation of:
• Women with active genital herpes and their babies ...................................................... ____
• Babies with congenital rubella ...................................................................................... ____
• Women with active tuberculosis and their babies .............................................................____
• Women with varicella-zoster infection, or recent exposure, and their babies ............... ____
______
______
______
______
__________________________
__________________________
__________________________
__________________________
8. Establish written guidelines for
• Prophylactic eye care of all newborns .......................................................................... ____
• Newborns at-risk for chlamydia conjunctivitis ............................................................. ____
______
______
__________________________
__________________________
______
__________________________
______
__________________________
______
__________________________
9. Establish a system to ensure administration of
• Hepatitis B virus vaccine to all babies, with first of 3-dose series given soon after
birth (Book III: Neonatal Care, Unit 8, Infections)………………………………….. ____
• Hepatitis B virus vaccine (first dose) and hepatitis B immune globulin to preterm
and term babies born to women positive for hepatitis B surface antigen, given
within 12 hours of birth …………………………………………………………………… ____
10. Establish a system to ensure maternal serologic status for syphilis is known for every
newborn before discharge. ................................................................................................. ____
Various High-Risk Conditions
YES
1. Establish a system of prenatal consultation and referral, as appropriate, for the:
• Evaluation and care of high-risk pregnant women ....................................................... ____
• Evaluation and care of at-risk or sick fetuses................................................................ ____
• Anticipated care of at-risk or sick newborns................................................................... ____
NEED
TO DO
DO NOT NEED TO
DO BECAUSE......._
______
______
______
__________________________
__________________________
__________________________
2. Attempt Vaginal Birth After Cesarean (VBAC) labor only when physician(s),
anesthesia staff, and neonatal staff are immediately available to provide emergency
care, possible hysterectomy, and neonatal resuscitation. ........................................................................................................................
____ ______ __________________________
Abnormal Glucose Tolerance
1. Establish a protocol to screen all women for abnormal glucose tolerance through
history and identification of risk factors and/or laboratory determination of blood
glucose levels, as early in pregnancy as possible. ...........................................................................
____ ______
__________________________
2. Establish a protocol of laboratory screening of women at high risk for abnormal glucose
tolerance early in pregnancy, and again at 24 to 28 weeks, even if their earlier results
were within normal limits. ..........................................................................................................
____
______
__________________________
3. Establish a protocol for estimation of fetal weight on admission to the labor unit for
women with gestational diabetes mellitus. ......................................................................... ____
______
__________________________
4. Establish a protocol for management of gestational diabetes mellitus during labor. ......... ____
______
__________________________
Premature Rupture and/or Infection of the Amniotic Membranes
1. Establish a system for consultation and referral for women with preterm, premature
rupture of membranes. ....................................................................................................... ____
______
__________________________
______
__________________________
______
__________________________
2. Establish a system to notify nursery personnel of women whose babies are at-risk for
infection, including women .............................................................................................. ____
• With evidence of intraamniotic infection (chorioamnionitis)
• Who received antibiotics during labor, and the indication for their treatment
• With premature rupture of membranes
• With prolonged rupture of membranes
3. Establish a protocol for the care of all women with premature rupture of membranes .... ____
• Evaluation for umbilical cord prolapse and compression
• Evaluation for infection
• Minimization of digital cervical examinations
--- None for women not in labor or not expected to have immediate induction of
labor
--- As few as necessary for women in labor and, as appropriate, administration of
antibiotics and/or corticosteriods
Preterm Labor
1. Develop a system that allows outpatient evaluation, in an obstetrical care area, of
YES
women with questionable preterm labor, until it is determined that discharge home or
hospitalization for continued treatment of preterm labor (or delivery) is appropriate. ........ ____
NEED
TO DO
DO NOT NEED TO
DO BECAUSE......._
______
__________________________
2. Establish a protocol for prompt evaluation of preterm labor and, if appropriate, prompt
intervention to stop labor. ......................................................................................................____
______
__________________________
3. Develop a system for appropriate consultation and referral of women at-risk for preterm
delivery. ................................................................................................................................. ____
______
__________________________
4. Establish a system to ensure that all pregnant women with fetuses between 24 and 34
weeks’ gestation are evaluated for treatment with corticosteroids, if preterm delivery
becomes a threat. .................................................................................................................. ____
______
__________________________
5. Establish a system to notify nursery personnel whenever a preterm delivery is expected... ____
______
__________________________
Inducing and Augmenting Labor
1. Establish a protocol for patient care and monitoring when prostaglandins are used for
cervical ripening. ................................................................................................................... ____
______
__________________________
______
__________________________
4. Establish a flowsheet for the administration of oxytocin that shows the dosage rate of
oxytocin (milliunit [mU]/minute), and every change in the rate, with the corresponding
time, maternal vital signs, fetal heart rate and pattern, contraction frequency, duration,
and strength, uterine tonus. ........................................................................................................
____
______
__________________________
5. Establish guidelines for staffing and personnel availability whenever oxytocin is given,
including nurse:patient ratio, attending physician or certified nurse midwife, surgical and
anesthesia staff, and continuous electronic fetal heart rate and uterine contraction
monitoring. ........................................................................................................................... ____
______
__________________________
6. Establish guidelines for the response to uterine tachysystole. ............................................ ____
______
__________________________
2. Establish a system to identify and record the reasons for the use of oxytocin, and the
evaluation done to rule out contraindications, whenever labor is induced or augmented.
3. Establish protocols for the use of oxytocin that include: ..................................................... ____
• Uniform dilution of oxytocin for IV administration
• Standard interval for the rate of IV oxytocin infusion change (both increase and
decrease)
• Administration of oxytocin only by the IV route for labor induction or augmentation
7. Develop a system whereby an emergency cesarean delivery can be started within 30
minutes of the decision to operate, at any time of the day or night. SEE Book I, Unit 1.
Abnormal Labor Progress and Difficult Deliveries
1. Establish a protocol for the assessment of women in questionable labor, including
YES
documentation of cervical dilatation, fetal presentation, contraction characteristics,
care provided, and response to therapy. .............................................................................. ____
NEED
TO DO
DO NOT NEED TO
DO BECAUSE......._
______
__________________________
______
__________________________
3. Establish guidelines for the use and application of forceps and vacuum extractor. For
midforceps or mid-VE, establish guidelines for personnel and readiness for immediate
cesarean delivery if the trial fails. ........................................................................................ ____
______
__________________________
4. Establish guidelines for response to precipitate labor. ......................................................... ____
______
__________________________
5. Establish guidelines for response to emergent, or potentially emergent, fetal situations:
• Meconium-stained amniotic fluid...................................................................................
• Fetal heart rate abnormalities.........................................................................................
• Complications of maternal anesthesia or narcotic analgesia..........................................
• Prolapsed umbilical cord ................................................................................................
• Shoulder dystocia...........................................................................................................
____
____
____
____
____
______
______
______
______
______
__________________________
__________________________
__________________________
__________________________
__________________________
Imminent Delivery and Preparation for Maternal/Fetal Transport
1. Establish guidelines for a kit for imminent delivery: standard contents, designated
storage locations (immediately accessible to, or in, each labor room), and maintenance
of sterility of contents and replacement of kits. .................................................................. ____
______
__________________________
2. Establish a protocol for response to imminent deliveries, including a system for
notifying obstetric, pediatric, anesthesia, and/or other personnel, as needed. ..................... ____
______
__________________________
3. Ensure that information about how to make an obstetrical referral is available at all
times. .................................................................................................................................... ____
______
__________________________
______
__________________________
2. Establish guidelines for the augmentation of labor (see also Unit 8, Inducing and
Augmenting Labor, in this book), including documentation of…………………………… ____
• Factors that indicate the need for oxytocin
• Evaluation done to rule out contraindications to the use of oxytocin
• Uniform dilution for oxytocin
• Standard interval for the rate of infusion change
6. Develop a system whereby an emergency cesarean delivery can be started within 30
minutes of the decision to operate, at any time of the day or night. SEE Book I, Unit 1.
4. Establish guidelines for: ....................................................................................................... ____
• Maternal condition prior to transport
• Equipment and supplies to be available during transport
BOOK III
Oxygen
YES
1. Periodically check oxygen delivery equipment to ensure: .................................................... ____
• a precise and adjustable concentration from 22% to100% can be achieved
• oxygen can be humidified and warmed to a precise and adjustable temperature
• blended oxygen and pulse oximetry are available in the delivery room
2. Establish a routine for monitoring the inspired oxygen concentration FiO2 continuously
____
or at least every hour for every baby receiving supplemental oxygen. .........................................
3. Establish a routine for pulse oximetry use, including: ......................................................... ____
• Assessment for initiation of oxygen therapy
• Continuous oximetry monitoring for any baby receiving oxygen therapy
• Adjusting inspired oxygen concentration based on oximeter readings
• Obtaining arterial blood gas sample intermittently, after oximeter readings have
stabilized, following a significant change in inspired oxygen concentration or
worsening of the baby's clinical condition
4. Establish a policy that will allow sufficient oxygen to be given to keep a cyanotic baby
pink until appropriate blood gas determinations are made. ................................................. ____
NEED
TO DO
______
DO NOT NEED TO
DO BECAUSE......._
__________________________
______
__________________________
______
__________________________
______
__________________________
______
__________________________
______
______
______
______
______
______
______
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
_________________________
5. Establish a system that ensures an ophthalmologist with experience with retinopathy of
prematurity performs a dilated funduscopic examination for
• Babies born at 32 weeks’ gestation or less or with birth weight less than 1,500 g OR
• Babies with birth weight of 1,500 g to 2,000 g or gestational age of more than
32 weeks with an unstable clinical course and believed to be at high risk for
retinopathy of prematurity
Examinations should begin at
• 31 weeks’ postmenstrual age for babies born at 22 to 27 weeks’ gestation AND
• 4 weeks’ chronologic age for babies born at 28 to 32 weeks’ gestation (see Book IV:
Specialized Newborn Care, Unit 6, Continuing Care for At-Risk Babies)
Respiratory Distress (Routines 3 through 9 on next page)
1. Establish a routine of using a pulse oximeter to monitor oxygenation of any baby with
respiratory distress, starting when the distress is first noted. ............................................... ____
2. Establish a routine for obtaining the following for any baby with respiratory distress,
within 30 minutes of the onset of distress:
• Vital signs (T, P, R, and BP)............................................................................................ ____
• Physical exam ................................................................................................................. ____
• Portable chest X-ray........................................................................................................ ____
• Arterial blood gas............................................................................................................. ____
• Hematocrit from venous or arterial (not capillary) blood................................................ ____
• Blood glucose screening test or laboratory test............................................................... ____
• Blood culture and/or white blood count with differential............................................... ____
Respiratory Distress (Continued)
3. Establish a policy to allow sufficient oxygen to be given to keep a cyanotic baby pink
until appropriate blood gas determinations are made. Routine also in Unit 1: Oxygen,
in this book.
NEED
_YES TO DO
DO NOT NEED TO
DO BECAUSE......._
4. Establish a policy of withholding baths and oral feedings from any acutely ill baby who ____ ______ __________________________
has respiratory distress or receives supplemental oxygen. ....................................................
____ ______ __________________________
5. Provide continuous cardiorespiratory monitoring for all babies at-risk for apnea...................................................................................................................
____ ______ __________________________
6. Be prepared to provide immediate transillumination for any baby in your nursery. ...........
7. Establish a system for obtaining a chest x-ray and an arterial blood gas within 30
____
minutes of the time a pneumothorax is suspected. ................................................................
____
8. Be prepared to provide immediate needle aspiration of a pneumothorax. ............................
______
__________________________
______
__________________________
9. Establish a policy that will ensure the presence of a sterile chest tube insertion tray and ____ ______ __________________________
suction drainage system in the nursery at all times. .........................................................................................................
Umbilical Catheters
1. Establish a policy to ensure the presence of a sterile umbilical catheter tray in each
____
delivery room and in the nursery at all times. ......................................................................
______
__________________________
2. Establish a policy of inserting an umbilical venous catheter (UVC) during delivery room ____ ______ __________________________
resuscitation when emergency medications are required....................................................................................
3. Establish a routine to consider insertion of an umbilical arterial catheter in any newborn
anticipated to require significant amounts of supplemental oxygen for longer than a
____
short period. ..........................................................................................................................
Low Blood Pressure
1. Consider establishing a policy to include blood pressure as a part of the initial
____
assessment for all newborns. ................................................................................................ ____
2. Require repeated blood pressure measurements for babies at-risk for hypotension. ............
____
3. Be sure sterile normal saline (0.9% NaCl) for intravenous use is always immediately
available in each delivery room and each nursery. ..............................................................
4. Check all blood pressure cuffs to ensure availability of appropriate-sized blood pressure ____
cuffs for newborns of all sizes. .............................................................................................
______
__________________________
______
__________________________
______
__________________________
______
__________________________
______
__________________________
NEED
TO DO
DO NOT NEED TO
DO BECAUSE......._
______
__________________________
______
__________________________
______
__________________________
______
______
______
______
______
______
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
____
______
__________________________
3. Establish a policy for preterm babies of using only breast milk (from a baby's own
____
mother) or isosmolar formulas designed specifically for preterm babies. ...........................
______
__________________________
______
__________________________
______
__________________________
______
__________________________
Intravenous Therapy
YES
1. Arrange staffing patterns to ensure constant availability of personnel with capability of
starting and monitoring a peripheral intravenous line in a baby. ......................................... ____
2. Establish a policy of delivering IV fluids to all babies: ........................................................ ____
• Who are sick
• Weighing less than 1800 g (4 lbs)
• With inadequate intake from nipple or tube feedings
3. Establish a routine of measuring urine volume and obtaining daily weights in all babies
receiving intravenous fluids. ................................................................................................ ____
Feeding
1. Establish a policy of withholding feedings and administering intravenous fluids to all
babies who:
• Have a history of maternal hydramnios, until a diagnosis is established........................ ____
• Have excessive mucus, until a diagnosis is established................................................... ____
• Have depressed, rapid, or labored respirations................................................................ ____
• Are vomiting, have distended abdomens and/or have not stooled by 48 hours of age.... ____
• Required prolonged resuscitation.................................................................................... ____
• Are acutely unstable for any other reason........................................................................ ____
2. Establish a policy of withholding nipple feedings and using tube feedings for all babies
below 32 to 34 weeks gestational age, unless a specific order is written to do otherwise
for a breastfeeding baby.
............................................................................................................
4. Establish a routine for determining the amount and frequency of feedings for babies,
according to their gestational age and weight, or expected weight for small-for____
gestational-age babies. ..........................................................................................................
5. Establish a policy of weighing every baby daily and plotting the weight on a growth
____
curve. ....................................................................................................................................
6. Establish a policy of providing vitamin and iron supplementation to preterm babies,
____
either through use of a formula designed specifically for preterm babies or with
supplements added to formula or breast milk. ......................................................................
Hyperbilirubinemia
1. Establish a policy of defining each case of jaundice as either physiologic or nonYES
physiologic. ............................................................................................................................____
2. Establish a policy of always investigating the cause of hyperbilirubinemia whenever
phototherapy is started. ......................................................................................................... ____
3. Establish a policy that allows nurses to obtain a transcutaneous bilirubim (TcB) level or
to order a total serum bilirubin (TSB) measurement any time jaundice is noted in a term
or preterm newborn or to obtain follow-up levels at defined intervals. ................................ ____
4. For all babies receiving phototherapy, establish a policy of covering the eyes, checking
vital signs frequently, and monitoring intake and output and assessing hydration. .............. ____
5. Establish a policy of obtaining a TcB or TSB level within 48 hours after birth for term
and near term babies and of using Figure 7.3 to predict the course of bilirubin and
likelihood of a subsequent value being in the high risk zone. ...............................................____
6. Establish a protocol so all newborns discharged 48 or fewer hours after birth, are
evaluated by a health care professional within 48 hours after discharge. ............................. ____
Infections
1. Establish a system to review periodically the use of infection control measures and to
ensure that good handwashing or a waterless antiseptic agent and standard precautions
are used at all times. ............................................................................................................. ____
2. Establish a mechanism to invoke additional transmission-based precautions, as
appropriate, for individual patients. ..................................................................................... ____
3. Establish a system for ensuring that maternal risk factors for infection are reliably
transferred to a baby's chart and that the baby's health care providers are notified.............. ____
4. Establish a policy of obtaining a blood culture before starting antibiotic therapy. .............. ____
NEED
TO DO
______
DO NOT NEED TO
DO BECAUSE......._
__________________________
______
__________________________
______
__________________________
______
__________________________
______
__________________________
______
__________________________
______
_________________________
______
__________________________
______
______
__________________________
__________________________
5. Establish a routine of withholding feedings, starting an intravenous line, and attaching
an electronic cardiorespiratory monitor for all babies in whom sepsis is suspected. .......................
____ ______
__________________________
6. Establish written protocols for management of babies and pregnant or postpartum
women with suspected or proven contagious diseases. ....................................................... ____
______
__________________________
______
__________________________
______
__________________________
7. Establish a system to provide hepatitis B immunization for all babies, according to the
recommendations for baby's birthweight, and maternal hepatitis B surface antigen status. ____
8. Consider establishing a policy to provide antimicrobial cleansing of scalp electrode site
for all babies who received internal fetal heart rate (FHR) monitoring. ............................. ____
There are no Recommended Routines for:
• Review: Is the Baby Sick? Identifying and Caring for Sick and At-Risk Babies
• Preparation for Neonatal Transport
YES
NEED
TO DO
DO NOT NEED TO
DO BECAUSE......._
Excahange, Reduction, and Direct Transfusions
1. Establish a policy of obtaining an x-ray for umbilical catheter placement before an
exchange transfusion. ............................................................................................................ ____
______
__________________________
2. Establish a policy of providing continuous electronic cardiac monitoring for all babies
undergoing an exchange transfusion. .................................................................................... ____
______
__________________________
3. Establish a policy of monitoring blood pressure at least every 15 minutes during an
exchange transfusion. .............................................................................................................____
______
__________________________
4. Establish a routine of determining hematocrit, serum glucose, calcium, potassium,
sodium, and bilirubin after every exchange transfusion. ..................................................... ____
______
__________________________
5. Establish a routine of warming blood before an exchange transfusion, using a
commercial blood warmer with appropriate temperature control and alarm features. ......... ____
______
__________________________
6. Establish a policy of using phototherapy after any exchange transfusion for
hyperbilirubinemia. .............................................................................................................. ____
______
__________________________
7. Establish a policy of checking the hematocrits of all babies at-risk for polycythemia. ....... ____
______
__________________________
BOOK IV
8. Establish a policy of using only venous or arterial (not capillary) blood to determine the
hematocrit of a newborn at-risk for polycythemia. ...........................................................................................................
____ ______ __________________________
9. Establish a policy of monitoring all babies with hematocrits greater than 65% for signs
of polycythemia. ................................................................................................................... ____
______
__________________________
10. Establish a policy for the hematocrit below with a baby who is critically ill (ventilated,
unstable) will be transfused. …………………………………………………………........ ____
______
__________________________
11. Establish a policy for monitoring the hematocrits of sick babies and stable, growing,
preterm babies. …................................................................................................................ ____
______
__________________________
12. Establish a policy of monitoring babies with low hematocrits for signs of anemia. ............ ____
______
__________________________
YES
Continuing Care for At-Risk Babies
1. Establish the following policies for continuing care babies:
• Maintain in an incubator until the baby weighs approximately 1,600 g (3 lb 8½ oz)
to 1,700 g (3 lb 12 oz). ................................................................................................. ____
NEED
TO DO
DO NOT NEED TO
DO BECAUSE......._
______
__________________________
•
Feed by tube feedings until the baby reaches 32 to 34 weeks’ postmenstrual age,
demonstrates a gag reflex, and can coordinate sucking, swallowing, and breathing.... ____
______
__________________________
•
Weigh daily. ................................................................................................................... ____
______
__________________________
•
Measure head circumference and length weekly. .......................................................... ____
______
__________________________
•
Monitor for apnea until the baby................................................................................... ____
• Weighs 1800 g (4 lb)
• Reaches a postmenstrhal age of 35 weeks
• Has been apnea-free for 7 to 8 consecutive days (off medication).
______
__________________________
•
Periodically measure the baby's hematocrit. Discharge the baby on iron-fortified
formula and/or supplemental iron, unless there are contradictions.............................
____
______
__________________________
•
Start assessment of the home environment and begin to teach caregiving skills as
soon as a baby is admitted. ........................................................................................... ____
______
__________________________
____
______
__________________________
____
______
__________________________
____
______
__________________________
• Record family visiting patterns and performance of caregiving skills.........................
2. Develop a pre-discharge checklist to review for all continuing care babies. ....................
3. Develop a system for periodically communicating with the regional center staff
regarding the progress of any continuing care baby who has a special problem. ..............
There are no Recommended Routines for:
• Direct Blood Pressure Measurement
• Continuous Positive Airway Pressure
• Assisted Ventilation With Mechanical Ventilators
• Surfactant Therapy