NUR2I [GROUP 1] – MIDTERMS [FIRST SEMESTER]

A.Y.
107 RLE VIRTUAL DUTY - NICU 22-23
BATCH 2025 Nurse Estela Guzman

TOPIC OUTLINE EINC (UNANG YAKAP)

I. Neonatal Intensive Care Unit
A. Apgar Score Essential Intrapartum and Newborn Care
B. Pyramid of Newborn Resuscitation • Evidence-based practice is recommended by DOH,
II. EINC (Unang Yakap)
A. Steps on Essential Newborn Care PhilHealth, and WHO. Help save lives
B. Anthropometric Measurement • Practices for newborn care constitute a series of
C. Lubchenco Grow Chart timebound, chronologically ordered, a standard
D. Routine Newborn Care procedures that a baby receives at birth
E. Vital Signs Monitoring
F. Hyperthermia STEPS ON ESSENTIAL NEWBORN CARE
G. Danger Sign of Illness
H. Newborn Assessment
4 Time-Bound Interventions
III. Swaddling
A. Diamond Swaddle 1. Immediate and thorough drying
B. Sleep Sack Swaddle 2. Early skin-to-skin contact
IV. Medication 3. Properly timed cord clamping and cutting
A. 14 Rights of Medication 4. Non-separation of the newborn from the mother for
B. Behaviors to Avoid During Medication early breastfeeding
Administration
ANTHROPOMETRIC MEASUREMENT
NEONATAL INTENSIVE CARE UNIT
• It is very useful to assess growth and identify
Taking care of baby given birth before 38 weeks/sick babies. nutritional risks.
• It serves also as a baseline.
APGAR SCORE
• Cm is used as a measurement
• Condition of the baby immediately after birth
Head Circumference
• Fetal-to-neonatal transition
Wrap around the prominent occiput measure just above the
• Done at 1st minute and 5th minutes of life
eyes (eyebrows)
• The additional score should be assigned every 5
minutes for up to 20 minutes if when 5 minutes score Chest Circumference
is less than 7.
Nipple line
Apgar Scoring
Abdominal Circumference
• 0-3 severely depressed, needs resuscitation
Umbilicus
• 4-6 moderately depressed, needs airway clearance
• 7-10 excellent condition, vigorous Birth Length
Sign 2 1 0
Sole of the feet up to the head
A Appearance Normal over Normal Cyanotic
(skin color) entire body except or pale all Body Weight
extremities over Using a digital body scale
P Pulse > 100 bpm < 100 bpm Absent With lining to avoid cold surfaces touching the newborn
G Grimace Sneezes, Grimaces No
(reflex irritability) coughs, or response LUBCHENCO GROWTH CHART
vigorous cry
A Activity Active Arms and Absent
(muscle tone) legs flexed
R Respirations Good, crying Gasping, Absent
irregular

PYRAMID OF NEWBORN RESUSCITATION

ROUTINE NEWBORN CARE

Crede's prophylaxis

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 • Erythromycin 0.5% ophthalmic ointment • They have a larger body surface area that results in
• Eye care more heat loss are that results in more heat loss.

Medication Administration Effects Of Hypothermia

• Vitamin K – 1mg (term)
- 0.5mg (preterm)
• Site
Identification ID bond
Vital Signs Monitoring
• Every 15 minutes until the condition of the newborn is
stable for at least 2 hours
• Then every 30 minutes for another 2 hours
• Every 1 hour if the newborn is under closed
monitoring for preterm and with respiratory distress
• Every 4 hours if stable vital signs
• Should be monitored during the calm and quiet stage
1. Acidosis – increased metabolic rate results in
increased production of carbon dioxide and metabolic
waste products result in acidosis
2. Hypoxemia – oxygen is utilized to increase
metabolism to produce more heat instead of being
used for oxygenation of cells and tissues
3. Hypoglycemia – increased metabolic rate increases
glucose utilization resulting in depletion of glucose
stores and lowering blood glucose levels.
Important Immediate Interventions for Hypothermia
✓ Inform the doctor immediately
✓ Remove the wet cloth
✓ Place the baby under the heat source
✓ Start oxygen administration if the baby has respiratory
distress or cyanosis

Respiratory Rate HYPERTHERMIA

• Temperature is above 37.4
• Normal ranges 40-60 bpm
• Abdominal or diaphragmatic in nature, the chest and Common Causes of Hyperthermia
abdomen should rise at the same time. • Too hot external environment
• Newborns are obligate nose breathers. • Too many covers or clothes on baby
• Periodic respiration – with a short period of apnea, • Infection
should not be longer than 15 seconds
• Irregular and shallow DANGER SIGNS OF ILLNESS
• RR increases with sensory and tactile stimulation • Hyperthermia/hypothermia
• Poor feeding/lethargy
Heart Rate • Vomiting/vomiting of bile
• Convulsion
• Full-term newborn normal heart rate ranges from 120- • No urine and meconium output within 24 hours
160 bpm • Respiratory signs of distress (like tachypnea,
• It may go down as slow as 80 bpm when deep sleep respiratory rate)
• May go up as high as 160 when vigorously crying • Cyanosis (a single episode)
• Abdominal distension
Blood Pressure • Jaundice (1st 24 hours)

• It is not routinely measured unless there is a cardiac NEWBORN ASSESSMENT

anomaly is suspected or present • Detailed systematic and whole-body examination of
• At birth, BP is approximately 80/40 mmHg. the newborn
• Done as soon as possible after birth and subsequent
Temperature assessment postnatal
• Cephalocaudal – head to toe
• Heat regulation is the second most important task a o Head – capput and cephal capput
newborn must achieve after birth. o Face, eyes, mouth, and ears
• Normal ranges of 36.5-37.4 degrees Celsius. o Chest, heart
• It is taken axillary. o Abdomen
o Hips
o Genitals
Heat Loss In Newborns Occur In 4 Ways
o Limbs
1. Convection – the flow of heat from the body surface
to the cooler surroundings
SWADDLING
2. Radiation – transfer of heat to cooler objects or
surfaces not in contact with the body THE DIAMOND SWADDLE
3. Evaporation – loss of heat due to conversion of liquid
• Lay blanket down on a safe, flat place for baby in a
to vapor
diamond shape/position
4. Conduction – loss of heat by way of cooler surfaces
• Lay baby down on their back in the center of the
in contact with the body. (ex. After bathing the baby
blanket with their neck on the folded corner
Newborn Loss Heat Easily Because: • Pull the left side over and snugly tuck under baby,
making sure to keep baby’s hips loose
• They have an immature temperature regulating
• Pull the bottom corner up and over baby’s left
system. They are not capable of shivering
shoulder
• A very little amount of subcutaneous fat to provide
heat in their body

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 • Wrap the last corner around baby. Tuck into the little • To monitor if the medication is given or not.
blanket pocket you’ve created on their front. Serves as an endorsement to the next shift
nurse.
11. Right to Refuse
12. Right Principle of Care
• E.g., check for the patent IV line
13. Right Prescription
• Double check the prescription, some drugs
are the same color and name.
14. Right Nurse Clinician

Example 1:
Give 130mg of ampicillin thru intravenous push every 12 hours.
Stock is a form of powder 250mg.

Dilute in 2ml sterile water

SLEEP SACK SWADDLE Desired / stock x quantity =
• Put baby in sleep sack like you would a onesie or 130mg / 250mg x 2ml = 1ml (rounded off)
footie pajamas
• Zip sleep sack Example 2:
• Wrap and Velcro Give 150mg on the same case as example #1
• These steps will vary depending on which product you
purchase and prefer Desired / stock x quantity =
150mg / 250mg x 2ml = 1ml (rounded off)

Example 3:
Give 7.5mg Gentamicin thru IV for 30 mins every 36 hours

Desired / stock x quantity =

7.5mg / 40mg x 1ml

Note: Every 40mg there is a 1ml quantity.

BEHAVIORS TO AVOID DURING MEDICATION

ADMINISTRATION
MEDICATION
1. Do not be distracted when preparing medications
2. Do not give drugs poured by others.
Color Codes for Medication Cards
3. Do not pour drugs from containers with labels that are
White – OD, HS, q 1hr, q 2 hrs, q other day, once a week hard to read or whose labels are partially removed or
(every) have fallen off.
Yellow – twice a day (8am-6pm) 4. Do not transfer drugs from one container to another
Pink – Three times a day (8am-1pm-6pm) 5. Do not pour drugs into the hand
Green – Four times a day (8am-12nn-4pm-8pm 6. Do not give medications for which the expiration date
Orange – PRN (as necessary) has passed
7. Do not guess about drug doses. Ask when in doubt
14 RIGHTS OF MEDICATION 8. Do not use drugs that have sediment and discolored
or are cloudy.
1. Right Drug/Medication 9. Do not leave medications by the bedside or with
2. Right Client/Patient visitors
• Children – ID Band 10. Do not give drugs if the patient says he/she has an
• Adult – ask for name, birthday, and check for allergy to the drug/drug group
ID Band 11. Do not call the client’s name as the sole means of
3. Right Route identification
• Depends on the patient's condition. FOCUS 12. Do not give a drug if the client states that the drug is
4. Right Dose different from the drug, he/she has been receiving.
5. Right Frequency/Time Recheck the drug order.
6. Right Assessment 13. Do not recap needles.
• Assess the patient first. E.g., administer 14. Do not mix a large amount of food or beverages or
insulin after assessing its glucose level. foods that are contraindicated.
7. Right Approach
• Inform the patient that the procedure will
cause a little uncomfortable feeling.
8. Right Education
• Educate patients about the effects, and what
to expect before taking medicines.
9. Right Evaluation
10. Right Documentation

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