Newborn Clinical Pathways 4/15



[pic] DOCTOR’S ORDER SHEET

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PATIENT IDENTIFICATION ROOM NO.

NEWBORN CLINICAL PATHWAY ORDER – Page 1 of 5

|DATE |TIME | ORDERS FOR MEDICATION, DIET AND TREATMENTS |

| | |ADMISSION: |

| | | 1. Meconium stained amniotic fluid – See Newborn Special Orders – “Meconium staining”. |

| | | 2. V/S (pulse, respiratory rate, temperature) and assessments at birth and every 30 minutes until 2 hrs of age. |

| | | 3. Nasopharyngeal/oral suction and gastric decompression if needed at time of admission and x 1 as |

| | | needed during transitional care. |

| | | 4. After two hours of age, routine vitals every 8 hrs if infant stable and transition complete. |

| | | 5. Vitamin K 1 mg IM after the initial breastfeeding during the transition period. |

| | | 6. Erythromycin Ophthalmic ointment 1 ribbon in each eye after the initial breastfeeding during the transition period. |

| | | 7. Notify physician of admit via exchange. |

| | | 8. Notify pediatrician if maternal temperature greater than or equal to 101(F (38.3(C) or if mother placed |

| | | on antibiotics or rupture of membranes greater than 18 hours. |

| | | 9. If infant of diabetic mother (IDM), SGA, LGA, Late Preterm Infant (35 – 36 6/7 weeks) - See Newborn |

| | | Neonatal Hypoglycemia Orders “SGA, LGA, IDM, Late Preterm Infant - (35 – 36 6/7 weeks). |

| | |10. Infants placed in supine position. |

| | |11. Hearing screen prior to discharge. |

| | |12. Initial bath when axillary temperature greater than or equal to 98(F (36.7(C). |

| | |13. Triple dye to cord after initial bath. |

| | |14. Clean cord with alcohol swab daily and as needed after 24 hrs of age. |

| | |15. Infant may go to mother’s room when stable and admission assessment complete. |

| | |16. Hepatitis B vaccine IM by 12 hrs of age, after parental consent. |

| | |17. Hepatitis B Immune Globulin (HBIG) IM and Hepatitis B vaccine IM by 12 hrs of age to infants with |

| | | HBsAg positive mothers. |

| | |18. Hepatitis B vaccine IM by 12 hrs of age to infants of mothers with unknown HBsAg status. |

| | | If mother determined to be HBsAg positive, give HBIG IM as soon as possible within 7 days of birth. |

| | |19. Verify 3rd trimester maternal HIV status, if maternal HIV positive or HIV Rapid Antibody test reactive, initiate Administration of Zidovudine (AZT)|

| | |and/or Nevirapine (Viramune) for Newborn orders. |

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| | |TRANSITIONAL CARE: |

| | | 1. Transition nurse observation (first 2 hours of life) if: |

| | |respiratory symptoms (grunting respirations, tachypnea (rate ≥ 70), retractions, desaturations in |

| | |delivery). See Newborn Special Orders – “RESPIRATORY DISTRESS: Labor & Delivery” |

| | |gestational age less than 36 weeks – perform vital signs every 15 minutes X 2; then every 30 minutes |

| | |until stable. |

| | |birth weight less than 2250 grams |

| | | 2. Admit to Transition nursery if: |

| | |respiratory symptoms (grunting respirations, tachypnea (rate ≥ 70), retractions, desaturations) after 2 hrs of age – See Newborn Special Orders – |

| | |“RESPIRATORY DISTRESS: Transition Nursery” |

| | |LABORATORY: |

| | | 1. AccuChek for symptomatic infant and/or SGA, LGA, IDM, Late Preterm Infant (35 – 36 6/7 weeks),- |

| | | see Newborn Neonatal Hypoglycemia Orders. |

| | | 2. Cord blood workup on infants of O+ and Rh- mothers. |

| | | 3. Cord blood TSH. If abnormal, cord blood Free T4. |

| | | 4 If unable to obtain venous specimen for lab work, Respiratory Therapy may obtain arterial blood specimen. |

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6/2016 NEWBORN CLINICAL PATHWAY ORDERS

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[pic] DOCTOR’S ORDER SHEET

|DRUG ALLERGIES: |

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NEWBORN CLINICAL PATHWAY ORDERS PATIENT IDENTIFICATION ROOM NO.

Page 2 of 5

|DATE |TIME | ORDERS FOR MEDICATION, DIET AND TREATMENTS |

| | |CIRCUMCISION: |

| | | 1. Administer Tylenol liquid by mouth upon transport to nursery for circumcision. (Use birth weight to |

| | | determine dose – see below) |

| | | 30 mg for < 3 kg |

| | | 45 mg for 3-4 kg |

| | | 60 mg for > 4 kg |

| | | 2. If infant is still an inpatient, repeat the same Tylenol liquid dosage (based on weight range) by mouth |

| | | 4 to 6 hrs after initial dose prn discomfort X 1. |

| | | 3. Instruct parents to not continue the use of Tylenol upon discharge. |

| | | 4. Petroleum gauze to circumcision (except Plastibell) with each diaper change. |

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| | |BREASTFEEDING: |

| | |1. Infants may be put to breast immediately if stable and then breastfeed on demand baby-led (cue based) |

| | |2. If medically indicated, supplement with - |

| | |0-24 hours old: 2-10 ml per feeding |

| | |24-48 hours old: 5-15 ml per feeding |

| | |48-72 hours old: 15-30 ml per feeding |

| | |72-96 hours old: 30-60 ml per feeding |

| | | Enfamil Newborn |

| | | Similac Advance |

| | | Gentle Ease |

| | | 3. Lactation consult. |

| | |FORMULA FEEDING: |

| | |1. Infant may be fed when stable and on demand baby-led (cue-based). |

| | |2. Formula: Enfamil Newborn |

| | | Similac Advance |

| | | Gentle Ease |

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| | |TRANSCUTANEOUS BILIRUBIN (TcB) / JAUNDICE SCREENING: |

| | |1. Obtain TcB level on infants who appear jaundiced prior to 24 hrs of age. |

| | |2. Assess infants who are Direct Coombs positive for jaundice every 4 hrs until 24 hrs of age, then with |

| | | vital signs thereafter. Obtain TcB level if infant appears jaundiced. |

| | |3. Obtain Transcutaneous (TcB) level at 36 hrs of age or upon discharge if discharged before 36 hrs of age. |

| | | Date and Time TcB Due:_____________________ |

| | |4. Plot Bilirubin (TcB and TSB) results and risk factors on Bilirubin Nomogram. |

| | |5. If TcB in Zone 1: Repeat TcB in 6 hours. |

| | |6. Obtain Total Serum Bilirubin (TSB) if screening TcB in Zone 2 on Bilirubin Nomogram. |

| | |If TSB in Zone 2 and no risk factors present: Repeat TcB in 6 to 8 hrs. |

| | |If TSB in Zone 2 and risk factors present: Notify the physician. |

| | |7. Obtain Total Serum Bilirubin (TSB) if screening TcB in Zone 3 on Bilirubin Nomogram. |

| | |If TSB in Zone 3 and no risk factors present: Notify physician, begin single bank phototherapy, |

| | |and repeat TSB in 6 to 8 hrs. |

| | |If TSB in Zone 3 and risk factors present: Notify the physician. |

| | |8. Obtain Total Serum Bilirubin (TSB) if screening TcB in Zone 4 on Bilirubin Nomogram. |

| | |If TSB in Zone 4: Notify physician, begin double bank phototherapy, and obtain Neonatology consult |

| | |(ext. 4902). |

6/2016 NEWBORN CLINICAL PATHWAY ORDERS

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[pic] DOCTOR’S ORDER SHEET

|DRUG ALLERGIES: |

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PATIENT IDENTIFICATION ROOM NO.

NEWBORN CLINICAL PATHWAY ORDERS

Page 3 of 5

|DATE |TIME | ORDERS FOR MEDICATION, DIET AND TREATMENTS |

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| | |GROUP B STREPTOCOCCUS (GBS): |

| | | Initiate Newborn Clinical Pathway Guidelines for Group B Streptococcus if: |

| | |Maternal GBS positive and infant well-appearing (asymptomatic); |

| | |Maternal GBS status unknown and infant well-appearing (asymptomatic); or |

| | |Prior infant with GBS disease requiring antibiotic treatment. |

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| | |SYMPTOMATIC INFANT |

| | |Labor and Delivery or Transition Nursery settings: See Newborn Special Orders “SYMPTOMATIC |

| | | INFANT” |

| | |Couplet Care setting: Notify pediatrician if infant appears ill/symptomatic *: |

| | |* ill/symptomatic can include but is not limited to: |

| | |Sustained Tachycardia (HR 160-220); |

| | |Hypothermia and no previous maternal fever greater than 100.4°F; |

| | |If less than 24 hours of age: temperature less than 97.7° |

| | |If 24 hours of age or greater: temperature less than 97.0°  |

| | |Hyperthermia greater than 99.5°F (any age) and no previous maternal fever greater than 100.4°F |

| | |Respiratory symptoms (grunting respirations, tachypnea (rate greater than 70), retractions, |

| | | desaturations, apnea greater than 20 seconds, or |

| | |Decreased activity (lethargy, decreased tone, etc.). |

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| | |MATERNAL CHORIOAMNIONITIS present (defined by obstetrician) |

| | | 1. Obtain blood culture if not obtained already. |

| | | 2. Begin Ampicillin and Gentamicin per protocol. |

| | | 3. Obtain CBC at 6 hours of age. |

| | | 4. Notify Pediatrician on rounds unless: |

| | |WBC less than 3.5 thousand or greater than 30 thousand; |

| | |Platelets less than 125 thousand or greater than 800 thousand; |

| | |Hematocrit less than 40.4 or greater than 67. |

| | | 5. Admit for 48 hours minimum. |

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| | |PKU/NEWBORN METABOLIC SCREENING |

| | |After 36 hour TcB is obtained and plotted, obtain PKU/Newborn Metabolic screening specimen at 36 hrs of age or upon discharge if discharged prior|

| | |to 36 hrs of age. |

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6/2016 NEWBORN CLINICAL PATHWAY ORDERS

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[pic] DOCTOR’S ORDER SHEET

|DRUG ALLERGIES: |

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PATIENT IDENTIFICATION ROOM NO.

NEWBORN CLINICAL PATHWAY ORDERS

Page 4 of 5

|DATE |TIME | ORDERS FOR MEDICATION, DIET AND TREATMENTS |

| | |CAR SEAT TOLERANCE TESTING |

| | | If newborn is less than 37 weeks gestation (by obstetrical dates) and/or less than 2250 grams, perform: |

| | | car seat testing prior to day of discharge in infant’s own car seat for 90 minutes or the duration of travel, whichever is longer. |

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| | |If infant fails car seat testing: |

| | | 1. Repeat testing in supine position in open crib for 90 minutes or the duration of travel, whichever is longer. |

| | | Consult Neonatology (ext. 4902) if infant demonstrates bradycardia (heart rate ≤ 80 beats/minute), |

| | |desaturation (SpO2 ≤ 90%) or apnea (respiratory pause ≥ 20 seconds) while monitored in open crib. |

| | |If infant does not demonstrate bradycardia, desaturation, or apnea while monitored in open crib, |

| | |discharge in car bed. |

| | | 2. Inform pediatrician of failed car seat test. |

| | | 3. Notify Social Services for assistance to obtain car bed prior to day of discharge, if needed. |

| | | 4. If infant discharged in car bed: Notify pediatrician for follow-up. |

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| | |PULSE OXIMETRY SCREENING FOR CRITICAL CONGENITAL HEART DEFECTS: |

| | |Obtain pulse oximetry reading at 36 hours of age. If discharge is prior to 36 hours of age, screen should be done after 24 hours and as late as |

| | |possible. |

| | |* Preferably obtain reading using right hand and right foot. |

| | |If result is > 95% in right hand or foot and difference between hand and foot reading is 3%, repeat screen in one hour. |

| | |If result is 95% in right hand or foot and there is a < 3% difference between the hand and foot reading, the screen is negative (normal) and |

| | |complete. |

| | |If result is 90-94% in both hand and foot or the difference between hand and foot reading is >3%, repeat screen for third time in one hour. |

| | |If result is 95% in right hand or foot and difference between hand and foot reading is < 3%, the screen is negative (normal) and complete. |

| | |If result is 90-94% in both hand and foot or the difference between hand and foot reading is > 3%, the screen is positive (abnormal) and |

| | |complete. Notify pediatrician and consult pediatric cardiology. |

| | |If result is < 90% in either hand or foot, the screen is positive (abnormal) and complete. Consult neonatology(4902). |

6/2016 NEWBORN CLINICAL PATHWAY ORDERS

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[pic]

DOCTOR’S ORDER SHEET

|DRUG ALLERGIES: |

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PATIENT IDENTIFICATION ROOM NO.

NEWBORN CLINICAL PATHWAY ORDERS

Page 5 of 5

|DATE |TIME |ORDERS FOR MEDICATION, DIET AND TREATMENTS |

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| | |Maternal history of drug use and/or positive maternal drug screen |

| | |1. Obtain stool specimen for Meconium Drug screen for |

| | |documented or self-reported maternal substance use/abuse with newborn exposure in utero. |

| | |2. If history of drug use with (opiates, cocaine, benzodiazepines) during pregnancy |

| | |and/or positive maternal drug screen: |

| | |Except infants exposed only to marijuana or amphetamines. |

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| | |Begin Neonatal Withdrawal Inventory 2 hours after birth |

| | |and every 3 hours unless otherwise indicated |

| | |Obtain Neonatology consult, if score greater than or equal to 8 with 3 consecutive assessments |

| | |Obtain Neonatology consult, for two consecutive scores of 12 or above |

| | |Notify pediatrician upon physician rounds. |

| | |3.  Ad lib on demand feeds |

| | |4.  Similac Sensitive or Enfamil Gentlease for loose stools |

| | |5.  Diaper area protectant PRN |

| | |6.  Breastfeeding is allowed for methadone or buphenorphine exposed infants ONLY if mother |

| | |is in a treatment program and mother’s and infant’s drug screens not positive for other illicit drugs |

| | |7.  Monitor asymptomatic infants for 72 hours (does not include infants exposed only to marijuana or amphetamines). |

| | |8. Consult Social Services |

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