Table II

Results of Delphi Round 3

Round 3
Neonatal nursing standards of practice for CambodiaMdIR
A. Assessment
1. Physical assessment50
 Chief complaints: most serious symptoms/signs of illness causing neonate to hospital51
 Check temperature, airway, breathing and circulation (TABC)50
 Assess growth status50
  Weight in gram50
  Length50
  Head circumference50
 Evaluate general appearance50
  Level of consciousness: state of alertness50
  Skin color: integrity and perfusion50
  Activity: range of spontaneous movement50
  Postures: muscle tone50
 Obtains maternal history50
  Apgar score50
  Gestational age50
  Mode of delivery51
  Medications used and feeding provided50
 Assess skin integrity, muscle, and skeleton50
  Skin color50
  Skin condition: rashes, pustule, peeling, plethora, dry, erythema, infected, edema, and injury51
  Muscle tone: spontaneous movement50
  Jaundice50
 Check head, face, and neck41
  Head: shape, size, scalp51
  Fontaneles: sutures51
  Eyes: size, position structure41
  Nose: position structure41
  Mouth: palate, teeth, gums, tongue, frenulum, jaw size41
 Assess chest and respiratory system50
  Chest: size, shape, symmetry, movement, breast tissue, and nipples50
  Respiratory system: lung sounds, signs of respiratory distress, breathing pattern, oxygen needs, level of FiO2, and SpO2 and chest retraction50
 Assess cardiovascular system50
  Heart rate/sounds50
  Pulse/femoral pulse and rhythm50
  Shun syndrome41
  Blood vessels41
 Assess abdomen and gastrointestinal system51
  Abdomen: size, shape, symmetry, palpate live, spleen, and kidneys41
  Abdominal condition: soft, firm, redness, mass, and lobe visible51
  Umbilicus: bleeding, discharge, detached, and smell51
  Breastfeeding/feeding frequency: sucking51
  Bowel movement: meconium or stool condition/color, vomiting, nausea51
 Assess genitourinary51
  Abnormality: open passage for urine and stool, any discharge51
  Anal position/imperforate41
 Assess neurological status51
  Behavior50
  Irritable crying50
  Posture: muscle tone, spontaneous movement50
  Reflexes, primitive/five reflexes/red reflex, Erb’s palsy, and seizure51
 Other assessment51
  Neonatal status  
   IV site: redness, swelling, edema, clean, and duration of IV insertion50
   Fluid management: cc/kg/day, electrolyte management: mg /kg/day50
   Blood sugar level50
   Intake and output50
   Breastfeeding frequency and effectiveness50
   Vaccination status51
   Development51
   Incubator and room temperature50
  Maternal status  
   Body weight, and condition of the mother before and after delivery51
   Nutrition, breasts/express breast milk, and colostrum51
   Drug used, alcohol use, and coping post-partum50
2. Psychological assessment41
 Assess mood of mother/caregiver to identify anxiety/worries/scary/depress41
 Observe face expression of mother/caregiver to identify feeling41
 Assess perception and belief of neonatal sickness or issue at home41
3. Social-economic and family assessment41
 Recognizes role of parents in decision making about neonate’s health41
 Assess whether the family able to taking care financial issue40
 Assess neglecting issue of the young mothers from their family41
 Assess mother knowledge in taking care of baby51
B. Nursing diagnosis
1. Actual nursing diagnosis50
 Hypothermia50
 Hyperthermia50
 Ineffective thermoregulation50
 Airway obstruction50
 Impaired gas exchange50
 Ineffective breathing pattern50
 Asphyxia50
 Pain50
 Umbilical cord infection50
 Necrotizing Enterocolitis50
 Neonatal Jaundice50
 Premature/low birth weight infant50
 Ineffective feeding50
 Ineffective breastfeeding50
 Interrupt breastfeeding41
2. Risk for nursing diagnosis50
 Risk for aspiration50
 Risk for infection50
 Risk for body temperature alteration50
 Risk for alter nutrition50
 Risk for fluid volume deficit50
C. Planning
 Set safety goals for neonate to overcome actual and risk for nursing diagnosis from admission to discharge51
 Provide interventions to fit with actual and risk for nursing diagnosis50
D. Implementation
1. Nursing intervention for ineffective thermoregulation51
 Reduce or eliminate the sources of heat loss50
  Evaporation  
   When a shower, prepare a warm environment50
   Wash and dry each section to reduce evaporation51
   Limit the time of contact with clothing or a wet blanket50
  Convection  
   Avoid the flow of air41
  Conduction  
   Warm all goods for care such as stethoscope, scales, hand caregivers, clothes, and bed linen51
  Radiation  
   Reduce the objects that absorb heat41
 Monitor neonate’s body temperature51
  If temperature is below normal  
   Use two blankets41
   Wear headgear51
   Assess environmental sources for heat loss51
   If hypothermia settled >1 hour, refer to physician50
   Review the complications of cold stress, hypoxia, respiratory acidosis, hypoglycemia, fluid/electrolyte imbalance, and weight loss50
  If temperature is above normal  
   Remove blanket51
   Remove headgear, when worn41
   Assess environmental temperature again41
   If temperature not reduce to normal >1 hour, report to physician51
 Teach caregivers why neonates are vulnerable to temperature51
  Demonstrate how to save heat during bathing50
  Teach to measure temperature51
  Teach caregiver why neonates are vulnerable to heat and cold weather51
  Refer to hypothermia and hyperthermia for prevention50
2. Nursing Interventions for neonate with airway and respiratory problems50
 Place neonate in semi-follower/comfortable position50
 Maintain free airway50
 Provides oxygen per prescription50
 Monitor dyspnea, tachypnea, breath sounds, increased respiratory effort, lung expansion, and weakness50
 Evaluate changes of level of consciousness, cyanosis, skin color, mucous membranes, and nails50
3. Nursing interventions for neonate with infection51
 Keep neonate in isolation room51
 Monitor vital signs every 2 hours, notify the physician if vital signs are abnormal50
 Maintain a good temperature for an incubator and room51
 Wash hands before and after touching the neonate50
 Make sure that caregivers wash hands before touching/holding neonate50
 Let neonate rest, avoid holding if unnecessary41
 Administer antibiotics per prescription50
4. Nursing interventions for impaired skin integrity41
 Assess skin color every 8 hours41
 Monitor direct and indirect bilirubin51
 Change position every 2 hours41
 Massage the skin41
 Keep clean skin and moisture51
5. Fluid volume deficit50
 Monitor signs of dehydration such as skin turgor/fontanel/eyes50
 Monitor intake output50
 Record the frequency and amount of urine and stools50
 Monitor fluid and electrolytes balance51
 Explain the mother to breastfed often50
6. Nursing interventions for interrupted breastfeeding51
 Assess mother’s perception and knowledge about breastfeeding50
 Give emotional support to mother and accept decision regarding cessation/continuation of breastfeeding41
 Demonstrate use of manual breast pump41
 Explain techniques for storage of expressed breast milk51
 Provide privacy, calm surroundings when mother breast feeds41
 Recommend for infant sucking on a regular basis51
 Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake41
7. Nursing interventions: risk for altered nutrition51
 Weight neonate in gram daily50
 Assess maturity reflex, with regard to feeding such as sucking, swallowing and cough50
 Monitor input and output and calculate consumption of calories and electrolytes daily50
 Assess level of hydration, note fontanel, skin turgor, urine-specific gravity, condition of mucous membranes, and weight fluctuations50
 Assess signs of poor feeding, nervous, crying high tone, trembling, eyes upside down, and seizure activity50
8. Nursing interventions for pain41
 Encourage mother to provide breastfeeding51
 Repositioning, swaddling, and nesting51
 Facilitated tucking and containment holding41
 Decreasing environmental sensors41
 Change nappy as needed41
 Allowing neonate to grasp a finger41
 Kangaroo care50
E. Evaluation
 The neonate requiring intervention is promptly identified and is started early50
 The neonate’s metabolic and physiologic processes are stabilized, and recovery is proceeding without complications50
 Infant maintains temperature at 36.5°C to 37°C50
 Neonate maintains a respiratory rate of 30-60 breaths per minute50
 Neonate will exhibit no signs of infection50
 Fluid volume will be maintained: Oral mucosa moist and pink, skin turgor elastic, urine output at least 1-2 mL/kg/hr50
 Neonate will maintain adequate nutritional intake: Weight gain or maintenance occurs. Consumes adequate diet for age51
 Neonate will be in comfort and free from pain50
F. Ethics
 Advocate for equitable to healthcare consumer41
 Provide care follow guidelines/protocols so that the care nurse provides are safe for neonate50
G. Evidence-based practice and research
 Develop knowledge from routine jobs toward research work that would apply to nursing practice50
 Introduce important research finding and evidence-based practice to other nurses50
 Utilizes evidence-based practice and research finding to guide practice50
 Participate in nursing research according to educational level/role50
 Integrates research findings into the development of guidelines and standards of care50
H. Health teaching and health promotion
 Explain to family about treatment and procedures and follow-up51
 Tech parents about basic health information50
  Nutrition/breastfeeding50
  Reproductive health41
  Body hygiene50
  Hand hygiene correctly50
  Prevent hypothermia50
  Recognize signs of sick neonate50
  Schedule of vaccination and immunization50
I. Continuing education
 Participate in nursing education as appropriate to educational level and position51
 Participate in neonatal nursing training to update knowledge and competencies50
 Conduct self-directed learning, reading text books, and search internet50
J. Communication
 Make effective communication with families and members of healthcare team50

or Create an Account

Close Modal
Close Modal