Admission Process for Premature Newborns <32 Weeks Gestation or <1500 Grams Birth Weight. Job Sequence Key Points Rationale

Transcription

1 1 Ntificatin f NICU f Impending Delivery f Premie < 32 weeks gestatin r <1500 grams BW Admissin Prcess fr Premature Newbrns <32 Weeks Gestatin r <1500 Grams Birth Weight Jb Sequence Key Pints Ratinale Ntify NICU charge RN re: impending delivery f a premature newbrn. OB attending will: Ntify the nenatlgist f impending delivery f premature newbrn, maternal histry, estimated fetal weight, ther cnditins that might affect resuscitatin, etc. Nenatlgist will: See mther and/r significant ther t: Intrduce himself/herself Explain management plan and all pssible utcmes Answer questins Care f the infant during delivery and expected NICU curse Mthers want t knw the pssible scenaris, what t expect and the management plan fr the premature newbrn. This relieves their anxiety. Majrity f mthers are cmfrted by the infrmatin presented prir t delivery. 2 Preparatin fr Premie delivery by L&D RN Make sure that all supplies and equipment needed fr resuscitatin are in the radiant warmer by using the Supply/Equipment Checklist fr Premie Delivery. (See attached Checklist) Supply/Equipment preparatin prevents related issues during resuscitatin.

2 3 Preparatin fr Premie admissin by NICU admitting RN and RCP (In the NICU) NICU admissin RN will: Prepare the admissin bed: Turn n radiant warmer. Prepare supplies at the bedside: electrdes, pulse ximeter prbe, temperature prbe, BP cuff, NGT, Nebar/ tape/ measuring tape, swab fr MRSA, UA and UV trays, IV pump, Admissin cart RCP will: Set up O2 (ventilatr, C-Pap, r Hi-flw) All supplies and equipment are available and ready fr use when admissin arrives. 4 NICU ntified that patient is ready t deliver 5 Arrival f nenatlgist and NICU RN in L&D Call NICU RN that patient is ready t deliver. Page nenatlgist n-call that patient is ready t deliver. NICU Admissin RN: Bring blue nenatal resuscitatin bag with her t L&D. NICU RN and nenatlgist will: Intrduce themselves t the mther and/r significant ther. Perfrm a pre-brief: Review risk factrs and management plan Check supplies/equipment that they are available and ready Team cmpsitin: Ne as team leader, NICU RN, L&D RN Assign rles: wh will d what during the resuscitatin Initiate the Glden Hur Checklist(See attachment) Nenatlgist will: Advise the OB t delay crd clamping fr at least secnds. Cnduct a pst-debriefing with NICU RN and L&D RN will after resuscitatin. Pst-briefing will answer the fllwing questins: What did we d well? A pre-briefing with team members befre resuscitatin ensures that all the required equipment is available and wrking, that the rles f individual team members are clear and planned sequence f activities is understd by everyne n the team. The Glden Hur checklist ensures that interventins during the first hur f the newbrns life are carried ut. Delayed crd clamping is

3 What did we d prly? What can we d better? assciated with less IVH f any grade, higher BP and bld vlume, and less need fr transfusin after birth, and less NEC. Pst-briefing gives the team t reflect n their perfrmance, identify errrs, cnditins fr crrectin, and imprvement f future perfrmance. 6 Baby is delivered. Newbrn resuscitatin initiated. Resuscitatin team (NICU RN, L&D RN, and Nenatlgist) will: Place the newbrn under the heated radiant warmer. Make sure there is a thermal mattress in the warmer cvered by a blanket. Perfrm newbrn resuscitatin fllwing NRP Flw Diagram. Apply temperature prbe ver newbrn s abdmen and set the radiant warmer at 36.5 C under Serv-cntrl mde. Wrap the newbrn (if <32 weeks gestatin) in plastic wrap frm neck dwn. Use a hat t cver the head. Maintain newbrn s temperature at 36.5 C t 37.5 C. Apply pulse ximeter prbe t right hand r wrist (pre-ductal) t mnitr SaPO2 and heart rate. Prvide supplemental xygen. Start xygen cncentratin at 21-30% and adjust xygen cncentratin t achieve SaPO2 target values fr the first 10 minutes after birth. Target SaPO2 Values after Birth 1 min 60%-65% 2 min 65%-70% 3 min 70%-75% 4 min 75%-80% 5 min 80%-85% 10 min 85%-95% Initiate CPAP If the newbrn is breathing spntaneusly but has labred Hypthermia in newbrns is assciated with adverse cnsequences, including an increased risk f mrbidity and mrtality. Preterm newbrns are especially vulnerable t hypthermia. The gal f using pulse ximetry t guide O2 cncentratin is t prevent hypxia withut using excess xygen and expsing the newbrn t the ptential risks f hyperxia. CPAP uses a cntinuus lw gas pressure t keep a spntaneusly breathing baby s lungs pen and is helpful if the baby has signs f labred breathing r persistently lw xygen saturatins. Several randmized cntrlled studies suggest that preterm infants treated with early CPAP reduce the need fr

4 breathing r xygen saturatin cannt be maintained within the target range despite 100% xygen. Prvide PPV if required and use the lwest inflatin pressure necessary t achieve and maintain a heart rate greater than 100/min. (20-25 cm H2O fr mst newbrns. Cnsider t administer prphylactic Surfactant after intubatin if newbrn is extremely premature (<26 weeks gestatin) Optinal in L&D intubatin, mechanical ventilatin, and incidence f BPD withut increasing mrbidity. 7 Preparing fr transprt t NICU NICU RN and nenatlgist will: Transprt the premature newbrn t the NICU using a pre-warmed transprt incubatr. Maintain the newbrn s temperature at 36.5 C t 37.5 C during transprt. Use thermal blanket inside transprt incubatr. Keep the newbrn wrapped in plastic bag with hat during transprt. If newbrn requires xygen supprt, page RCP t assist during transprt. Nenatlgist, NICU RN and RCP will accmpany newbrn during transprt; RCP will prvide xygenatin and ventilatin. Encurage significant ther t accmpany team during transprt. Mve the transprt incubatr slwly t the NICU. 8 Newbrn arrives in the NICU NICU Admissin RN will: Transfer newbrn frm transprt incubatr t pre-warmed radiant warmer. Remve plastic wrap. Place thermal mattress (frm transprt incubatr) t underneath the newbrn (place a blanket ver it). Place temperature prbe t abdmen. Ensure incubatr n ISC mde. Set desired skin temperature at 36.5 C. Place ximeter prbe. Place ECG electrdes. Turn mnitr n. Obtain weight, length, and head circumference. Check vital sighs including BP n all 4 limbs. Perfrm essential assessment nly. Secure newbrn fr umbilical line placement. Assist nenatlgist during umbilical line placement. Hang D10 W t UVL if newbrn needs fluids right away.

5 Attachments: Glden Hur Checklist Admissin Supply/Equipment Checklist fr Premie Delivery References: ILPQC Quality Imprvement Tlkit: Glden Hur. ILPQC. Nenatal Resuscitatin 7 th Editin. American Academy f Pediatrics The STABLE Instructr Prgram Manual, 6 th Editin Send bld wrks t lab as rdered. Prepare Starter fluids and UAC fluids (if with UAC line). Order CXR fr ET and line placement. Hang starter fluids and UAL fluids when crrect central line placement cnfirmed. Administer antibitics. Cmplete admissin assessment. Lwer tp f incubatr and start humidity per prtcl. Update family at bedside. Nenatlgist will: Cnsider Surfactant if intubated. Update family at bedside. RCP will: Prepare all xygen and ventilatin interventins including: Initiate lw flw and high flw xygen setups Assess pulse ximetry ready Apply patient interface Titrate liter flw and FIO2 per physician recmmendatin Initiate mechanical ventilatin Gather suctining supplies Assess securement and psitining f patient interface Validate patient settings Initiate ventilatin