General Care |
Nursing records (01) |
Correct and complete records. |
Hand hygiene (01) |
Before and after the procedures. |
Use of gloves (01) |
Before and after performing procedures. |
Vernix Caseosa (02) |
Vernix maintenance/removal. |
Polyethylene bag (03) |
Application/Removal time; mode of use. |
Use of antiseptic (05) |
Selection and mode of use. |
Exam collection (01) |
Time for hemostasis. |
Handling (10) |
Minimal handling; skin-to-skin contact; nesting; positive touch; weighing; noise reduction. |
Bath (11) |
Type; mode; time; interval; ideal moment. |
NSCS*
|
Safe, erythema, lesion (07) |
Skin evaluation interval; use of emollients. |
Neurological Regulation |
Alert and active (02) |
Repositioning in bed; use of special mattresses and protective dressings; evaluation of the skin and of areas at risk for lesion. |
Alert, but little active (03) |
Sleepy most of the time (06) |
Sedated/Comatose (06) |
Oxygenation* |
O2†/high flow catheter (05) |
Use of skin protective barrier (except Tracheal Tube); adequate device size; system fixation and stabilization; fixation exchange; way to remove adhesives; evaluation of at-risk areas. |
CPAP‡ (11) |
Ventilation: tracheal tube (05) |
Tracheostomy (06) |
Hydration |
Dehydrated (01) |
Repositioning; special mattresses; protective dressings; evaluation of the skin and of at-risk areas. |
Presence of edema (05) |
Nutrition |
Nasogastric/Jejunal catheter (05) |
Skin protective barrier; catheter/tube fixation and stabilization; way to remove adhesives; evaluation of at-risk areas; hygiene of peristomal skin. |
Orogastric/Jejunal catheter (05) |
Gastrostomy/Jejunostomy tube (06) |
Thermo-regulation |
Maintain axillary temperature between: 36.5 and 37.5ºC (04) |
Axillary temperature monitoring; measures for thermo-regulation (skin-to-skin contact, use of caps/socks/gloves, avoid air drafts and handling). |
Difficulty in maintaining axillary temperature between: 36.5 and 37.5ºC (05) |
Therapeutic hypothermia (04) |
Rigorous temperature monitoring; repositioning in bed; evaluation of the skin and of areas at risk for lesion; measures that must be avoided for temperature decrease/increase in the newborn. |
Ambience |
Two-walled incubator (08) |
Temperature for thermoneutral environment; humidification management (two-walled incubator); handling in the conduction of procedures; moment of transfer to the crib. |
Single-walled incubator (03) |
Radiant crib (02) |
Correct use of the crib. |
Lateral heating in crib (02) |
Adequate clothing; moment to turn heating on. |
Simple crib (01) |
Use of adequate clothing to maintain normothermia. |
Therapy |
Antibiotic: OR§, IM||, IV¶ (01) |
Care in infusion; adequate venous access; site evaluation during infusion; indications for interruption. |
Sympathomimetic Drugs; hyperosmolar; non-physiological pH (03) |
Blood/Blood products (04) |
Route for therapy |
Injection by SC** route (03) |
Site and way of administration; maximum volume; rotation and evaluation of the application sites. |
Injection by IM route (05) |
Peripheral venous access (17) |
Care in vessel selection; preparation of the puncture site; type of device; catheter fixation/stabilization; asepsis; exchange of dressing; site evaluation; way to remove adhesives; moment to remove vascular access. |
PICC††/Venous dissection (18) |
VUC‡‡/AUC§§ (19) |
|
Umbilical cord |
Umbilical cord present (10) |
Hygiene: antiseptic in alcohol-based solution: use of umbilical catheter; cleaning mode and interval; individualized dispensation of the product. |
Monitoring |
Temperature sensor (02) |
Sites, ways of fixation; sensor rotation; use of cutaneous barrier dressings under the sensor; evaluation of the contact areas; moment and method to remove the electrodes and the fixation adhesives. |
Pulse oxymetry (04) |
Cardiac monitor (04) |
Non-invasive pressure (03) |
Urinary Elimination |
Diuresis in diaper (07) |
Type of diaper; exchange interval; mode and material for hygiene of the diaper area; use of barrier-forming products; site evaluation. |
Bag to collect urine (04) |
Mode of use and removal; skin protection. |
Catheter: relief/delay (06) |
Catheter caliper; asepsis of the genitalia; fixation. |
Cystostomy (03) |
Hygiene; protection of the surrounding area; removal of adhesives. |
Vesicostomy (13) |
Selection of the collecting equipment; mode of use; local hygiene; protection of the peristomal area; evaluation of the effluent, of the stoma and of the peristomal skin; emptying of the collecting bag; exchange of the equipment. |
Bowel Elimination |
Normal evacuation/Increase in frequency/Change in feces' consistency (09) |
Type of diaper; exchange interval; mode and material for hygiene of the diaper area; use and selection of barrier-forming products; site evaluation. |
Colostomy/Ileostomy (13) |
Selection of the equipment; local hygiene; evaluation and protection of the peristomal area; evaluation of the effluent; emptying of the bag; exchange of the equipment. |
Others |
Phototerapy (03) |
Evaluation of the skin during the treatment. |
Thorax drain (03) |
Fixation; exchange of dressing; skin protection; removal of adhesives; evaluation of the areas at risk for lesion. |
Peritoneal dialysis catheter (03) |
Exudative wounds (04) |
Type and moment to exchange dressing; skin protection; removal of adhesives; evaluation of the perilesion area. |