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1、Maternal and Child Health Home Visiting Nursing Standards and Competencies Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching Developed by the following Healthy Babies Providers: Vermont Assembly of Home Health Agencies Vermont Department of Health Vermont Regional Peri
2、natal Program August, 1997 Division of Community Public Health Department of Health 108 Cherry Street, P. O. Box 70 Burlington, Vermont 05402-0070 Tel 802-863-7333 Purpose The purpose of the Guide for Newborn Physical Assessment, Anticipatory Guidance and Health Teaching is to describe in detail the
3、 competency demonstrates newborn physical assessment and compares data with norms as stated in Maternal and Child Health Home Visiting Nursing Standards and Competencies, Postpartum Maternal and Newborn Nursing Care Competency, Vermont Department of Health, January 1997. It is important to note that
4、 only when physical assessment of the newborn is combined with the psychosocial and environmental assessment of the newborn as well as the physical, psychosocial and environmental assessment of the postpartum woman and her family will effective nursing interventions and positive client outcomes take
5、 place. The competencies related to the psychosocial and environmental assessment of the newborn and postpartum woman are described in the Postpartum Maternal and the Newborn Nursing Care Competency, Maternal and Child Health Home Visiting Nursing Standards and Competencies, January 1997. A Guide fo
6、r Postpartum Maternal Physical Assessment, Anticipatory Guidance and Health Teaching is under development. Priority Areas for Home Visits to Newborns Less Than 48 Hours of Age Because important changes (e.g. jaundice) occur during the second and third days after birth, the following components of th
7、e physical assessment must be completed upon the first visit of all newborns less than 48 hours of age: parent(s) - infant interaction general health sleep feeding elimination cry alertness respiration temperature apical pulse newborn screening movement muscle tone symmetry jaundice hydration umbili
8、cus circumcision Communication with Medical Care Provider and Other Healthy Babies Providers It is expected that communication between the MCH Home Visiting nurse and the postpartum womans and newborns medical care provider and other Healthy Babies providers (e.g. nutritionist or lactation consultan
9、t) takes place on an ongoing basis and includes normal and abnormal findings, assessment items not addressed, nursing interventions and client outcomes. In the case of home visits to newborns less than 48 hours of age, it is expected that the MCH Home Visiting nurse will contact the newborns medical
10、 care provider immediately if any abnormalities are noted. The physical assessment of the newborn may be adapted to meet the needs of the postpartum woman and newborn. For example, if the newborn had a physical assessment by their medical care provider on the day of the home visit, then the complete
11、 physical assessment as outlined in this guide may not be necessary. Discussing the findings of the physical assessment by the medical care provider and its impact on nursing interventions is more appropriate. Applying this Guide Locally There may be variations in local medical practice regarding an
12、ticipatory guidance and health teaching. For example, some medical providers request parents to take a rectal rather than axillary temperature. It is important that MCH Home Visiting nurses know these local variations and incorporate, as appropriate, this information in their anticipatory guidance a
13、nd health teaching so that parents receive consistent health teaching. Methods of communication between MCH Home Visiting nurses, medical care providers and other Healthy Babies providers will also vary at the local level. The key component of any method of communication is that it is timely, ongoin
14、g and meets the needs of the client. Skills in Physical Assessment of the Newborn The acquisition and maintenance of physical assessment skills of the newborn, as outlined in this guide, are best accomplished in a setting which includes theory and practice under the guidance of a skilled preceptor(s
15、). It is the personal responsibility of the MCH Home Visiting nurse to maintain competency in newborn physical assessment as described in this guide. Contributors to the Guide for Physical Assessment, Anticipatory Guidance and Health Teaching This guide is based upon the work of Barbara Cardenas, au
16、thor of Community Health Nursing in Canada, Essential Skills: Physical and Developmental Assessment, Many thanks for her work and providing a model of nursing care that: 1. includes a health oriented approach, 2. intertwines physical assessment with anticipatory guidance and health teaching and 3. i
17、ncludes the client - postpartum woman, newborn and family as a partner in assessing and planning care. This guide articulates physical assessment of the newborn by MCH Home Visiting nurses within the context of maternal and child health nursing; community health nursing; home visiting of newborns le
18、ss than 48 hours of age as well as newborns over 48 hours of age; and nursing care that complements, rather than substitutes for the newborns primary medical care. The contributors to this guide are listed below; many thanks for your expertise and time. Clinical Review Team Nancy Kennedy, RN - VNA o
19、f Vermont and New Hampshire Lynn Metheny-Leib, RN, BSN, MPA - VNA of Chittenden, Grand Isle Dell McDonough, RN BSN, IBCLC - Barre District Office, Dept of Health Helen Woodard, RNC - Bennington Area Home Health MCH Home Visiting Nursing Competency Workgroup Betty Allen, RN, BSN - VNA Chittenden quie
20、t when held -continuous irritability or irritability on tactile stimulation DANCER(MEDs.BMOREAU.PHN) newbornassess.doc 4 REVISED 8/11/97 Assessment Items Norms Abnormalities Anticipatory Guidance and Health Teaching Priority Areas for Home Visits to Newborns 160 -irregular rhythm -refer to “Skin Col
21、or” section -Assess cardiovascular, refer to medical care provider if abnormality observed -respiratory -normal range for neonate 30-60 breaths per minute signs fold diapers so cord doesnt become soiled and apply alcohol at the base of the cord once a day -Assess umbilicus, refer to medical care pro
22、vider if abnormality observed H. Genitalia (male) -scrotum -2 testes felt in scrotum; hydrocele, a collection of fluid surrounding the scrotum, is common in newborns -genitalia may have edema due to maternal hormones which should decrease in a few days -undescended testes -hydrocele is common and us
23、ually resolves by 6 months of age -penis -foreskin normally adherent; cannot be completely retracted until 2 years and sometimes not until puberty -give guidance regarding bathing/cleansing the non- circumcised penis -circumcision -infection: purulent discharge, redness/induration, fetid odor -teach
24、 re circumcision care answer questions -instruct parents to apply bacitracin ointment liberally on the penis with each diaper change for at least 24-48 hrs to keep the diaper from adhering to the site. Note this is not indicated when a Plastibell is used -Assess circumcision, refer to medical care p
25、rovider if abnormality observe DANCER(MEDs.BMOREAU.PHN) newbornassess.doc 14 REVISED 8/11/97 Assessment Items Norms Abnormalities Anticipatory Guidance and Health Teaching Priority Areas for Home Visits to Newborns 48 Hrs of Age II. Head to Toe Examination and Discussion H. Genitalia -female -hymen
26、-discharge -hymenal tag is a common neonatal variation that usually disappears in a few weeks -during the 1st week of life the baby may have vaginal discharge composed of thick whitish mucus which can be tinged with blood -continuing vaginal discharge -ask re vaginal discharge, blood tinged; same ex
27、planation as enlarged breasts, i.e. is caused by maternal hormone; resolves by the 1st week of life -cleansing of all perineal folds should be done gently when bathing and at diaper change I. Moro Reflex -this reflex is a response to the sensation of loss of support and is present at birth and disap
28、pears 2-4 months -symmetric extension and abduction of arms w/ fingers extended; then return to normal relaxed flexion and closing of the fists; spine an audible cry may accompany this reflex -disappears 2-4 months -if no reflex or asymmetrical movements -if occurs after 6 months may indicate neurological disease -reassure mother before testing -parent(s) may feel they have a very nervous baby, explain that it is normal for baby to startle with noise or sudden movement, is a natural reflex and all babies do this at this stage