Bathing the Newborn Infant

Prévia do material em texto

NURSING
PRACTICE &
SKILL
Authors
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Maureen Jill Jordan, RNC,
MSN(Ed.),CNL
Cinahl Information Systems, Glendale, CA
Reviewers
Carita Caple, RN, BSN, MSHS
Cinahl Information Systems, Glendale, CA
Lee Allen, RN, MS
Glendale Adventist Medical Center,
Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
April 21, 2017
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Bathing the Newborn Infant
What is Involved in Bathing the Newborn Infant?
› Bathing, which is typically defined as cleansing the skin, is a basic component of
care for the newborn, but one that has potential risks. During the bathing procedure,
considerations must be made to promote the newborn's comfort and protect his/her safety.
The information that follows focuses on providing a sponge bath to the healthy, term
newborn prior to detachment of the umbilical cord stump. (For information about bathing
premature infants, see Nursing Practice & Skill ... Bathing the Premature Infant and for
general information about bathing infants, see Nursing Practice & Skill ... Bathing the
Infant )
• What: The first bath for a healthy newborn is typically provided a few hours after
birth when body temperature has remained within normal limits for at least 2 hours.
Subsequent baths are provided no sooner than every other day and as needed, and are
preferably scheduled to occur before the newborn receives a feeding in order to reduce
risk of regurgitation and aspiration of gastric contents. Prior to skin contact, the water
temperature is carefully checked because hot water can cause scalding and water that is
too cool can result in discomfort and hypothermia. The newborn's body is gently washed
one section at a time, the skin is gently but thoroughly patted dry to prevent evaporative
heat loss, and the newborn is dressed appropriately to prevent a potentially dangerous
drop in body temperature following the bath. A clinician, parent, or other caregiver
remains present with the newborn infant during the bath
• How: Although facility protocols vary, newborn infants are typically given a sponge bath
until the umbilical cord stump falls off by using a small cloth or sponge that is dipped
in water and mild skin cleanser. Sponge baths can be provided in the newborn's crib or
on another safe surface in a warm area. The procedure requires adherence to standard
precautions and facility infection control policies. Immersion bathing of the newborn has
replaced the traditional sponge bath in some facilities. (For more information, see Facts
and Figures, below)
• Where: Bathing a term newborn may be performed in any setting in which newborn
infants receive care, including the newborn nursery, postpartum maternal-newborn unit,
birthing center, and home setting
• Who: Any caregiver who is properly trained may bathe a healthy newborn infant. The
nurse is responsible for following or verifying that assistive personnel are following
the facility protocol for newborn bathing and using good judgment for safe completion
of the sponge bath. It is appropriate for parents to be present during the bath and is
especially desirable for demonstration of this skill to new parents. In some facilities, the
mother, father, or both are encouraged to perform the first bath under supervision of the
nurse
What is the Desired Outcome of Bathing the Newborn Infant?
› The desired outcomes of bathing the newborn infant are to gently and effectively clean the
skin of secretions, stool, urine, and potentially harmful bacteria, and to avoid hypothermia
and injury to the newborn
Why is Bathing the Newborn Infant Important?
› Bathing maintains skin integrity and reduces risk for infection
› Baths can be relaxing to the newborn infant and provide an opportunity for bonding between the newborn infant and the
parent/person who is giving the bath
› A newborn's first bath, which includes washing the hair/scalp, removes potentially infectious blood and body fluids from the
skin and reduces the risk for transmission of communicable disease
Facts and Figures
› Bath basins used for sponge baths are frequently contaminated with bacteria and are a source for transmission of
healthcare-associated infection (Johnson et al., 2009)
› Immersion bathing, which involves placing the newborn infant in a tub of warm water such that the entire body except
the head is immersed, was found to be an appropriate alternative to the traditional sponge bath even before the umbilical
cord stump has fallen off. In a study of 102 term newborns, investigators found that immersion bathing resulted in less
temperature loss, less newborn irritability during the bath, and better parental satisfaction with no difference in cord stump
healing compared with sponge bathing (Lavendar, et al 2013)
› Investigators in a randomized controlled trial showed that tub bathing was superior to sponge bathing in the areas of
decreasing mother’s anxiety, calming babies, maintaining better temperatures, and being consistent with the principles of
family-centered care (Lavender et al., 2013)
›
› Covering the head immediately after bathing and drying is an effective strategy to correct bath-related body temperature
decline and to stabilize physiologic status in newborns
• In a study of 58 newborns, investigators found that covering the infant head with a cotton hat after bathing significantly
decreased the time necessary for heart rate, body temperature, and oxygen saturation to return to baseline compared with a
control group of infants whose heads were not covered (Kimet al., 2012)
› Researchers who examined the literature during the period 1970–2010 found the following evidence with regard to skin care
of newborns and infants (Blume-Peytavi et al., 2012):
• It is typically acceptable for a newborn to be bathed within hours of birth if cardiopulmonary status and body temperature
are stable
• Use of mild skin cleansing agents is at least comparable, and possibly superior to, use of water alone for bathing
–In a randomized controlled trial involving approximately 300 healthy term newborns, investigators found no difference in
skin integrity and barrier function between infants washed using water alone and those washed with water combined with
a mild cleansing agent (Lavender et al., 2013)
What You Need to Know Before Bathing a Newborn Infant
› Prior to bathing a newborn infant, the nurse clinician should be knowledgeable about the following:
• The basic anatomy and physiology of the skin in newborns. The skin is comprised of three layers: the epidermis (i.e.,
outermost layer), dermis (i.e., middle layer), and hypodermis (i.e., inner layer) (Figure 2)
Figure 2: The skin is comprised of three layers: the epidermis (i.e., outermost layer),
dermis (i.e.,middle layer), and hypodermis (i.e., inner layer). Copyright© Madhero88.
Licensed under Creative Commons Attribution-Share Alike 3.0 Unported License
–The skin functions as a barrier to the external environment and serves a protective function against water loss, heat loss,
infection, and injury
- The stratum corneum, which is the outermost layer of the epidermis that regulates transepidermal water loss (TEWL)
and evaporative heat loss, is thinner in newborns than in adultsand contains fewer lipids and natural moisturizing
factors
- The pH of the skin surface at birth is neutral (e.g., ~ 6.5). During the next few weeks, changes in skin pH occur due to
sweat production, contact with microorganisms, and other internal and environmental processes. The acid mantle, which
has a pH of ~ 5.5, develops approximately four days after birth and serves a protective function against pathogens
–At birth, vernix caseosa (i.e., a white, soft, creamy substance comprised of water, sebum from the sebaceous glands of the
fetus, desquamated cells from the amnion, and other substances) may thickly cover the skin or be present only in body
crevices
–
- The necessity of removing vernix from the newborn's skin is an area of debate. Some experts recommend that vernix
not be completely removed from the baby’s skin because it provides antibacterial protection and contributes to epithelial
development, and others encourage clinicians to remove the substance during bathing, at least from the head and neck
area, because it is often mixed with blood, meconium, and other debris (Sarkar et al., 2010)
–For more information about skin assessment and skin care for the newborn, including normal variations in neonatal
skin (e.g., milia, miliaria, Mongolian spots)that may be noted during bathing, see Nursing Practice & Skill ... Physical
Assessment of the Newborn -- Performing and Evidence-Based Care Sheet: Skin Care in the Newborn
• Normal body temperature in healthy term newborns and strategies to minimize heat loss during the bathing procedure
–Neonates must be physiologically stable prior to their first bath because bathing can cause hypothermia and respiratory
distress (for details, see Red Flags , below). A baby’s first bath should be delayed until body temperature remains
within normal range for at least 2 hours
- In general, an axillary temperature of 97.7–99.5°F[36.5–37.5 °C] is considered normal for a term newborn
–To prevent heat loss, the newborn must be adequately covered during the bath, and the clinician should only expose the
area being cleaned at the moment. Newborns may be placed under a heat lamp or radiant warmer to prevent heat loss
during bathing . (For more information on the use of radiant warmers, see Nursing Practice & Skill … Newborn Care:
Radiant Warmer )
–
–The skin should be gently but thoroughly patted dry with a towel to prevent evaporative heat loss
–The infant should be dressed warmly following the bath to reduce further heat loss
• Proper water temperature to avoid scalding
–The bath basin should be filled with water that is comfortably warm, but not hot (e.g., 98.6−99.5 °F [37−37.5 °C])
–Sterile water may be used for a newborn’s first bath. Refer to the facility/unit protocol to clarify if sterile water is required
for the first bath
• Appropriate cleansing and moisturizing agents and the recommended frequency of bathing for newborns
–Bathing with alkaline soap can disrupt acid mantle formation
- Traditional soaps composed of lye and animal fats have an alkaline pH of > 7.0 and can be irritating to the newborn's
sensitive skin
- It is recommended that cleansing agents with a neutral pH (~ 5.5–7.0) be used when bathing newborns. The cleansing
agent should be free of dyes or artificial fragrances, which can cause skin irritation and may be absorbed systemically
–Newborns do not require complete baths every day but the diaper area should be thoroughly cleansed with each diaper
change. It is generally recommended that newborns be bathed no more than every other day; daily bathing can worsen
skin dryness
- When washing and drying the newborn, do not scrub or rub the skin, as doing so can cause skin irritation and
breakdown. Throughout the bath, gently wash the skin and pat dry with a soft towel
–To protect skin integrity in newborns, hydration of the stratum corneum is important. If using a skin moisturizer is
necessary, the American Academy of Pediatrics (AAP) recommends use of a fragrance-free, hypoallergenic product
› Preliminary steps that should be performed before bathing the newborn infant include the following:
• Review the facility/unit protocol for bathing the newborn infant, if one is available
• Review the treating clinician’s orders for bathing, if available. Note orders for specific skin cleansers and/or moisturizers
that should be used
• Verify parental completion of facility informed consent documents
–The general consent for treatment that is executed at admission to a healthcare facility generally includes provisions that
encompass basic care of the infant
• Review the patient's medical history/medical record for information about
–the most current documented body temperature; verify that body temperature has stabilized within normal limits for a
newborn
–substances that are known to cause skin irritation (e.g., a previously used cleansing agent); use alternative materials, as
appropriate
–existing skin conditions (e.g., a rash) with which new skin assessment findings can be compared
• Prepare the area in which the newborn will be bathed (e.g., his/her crib) by
–checking room temperature, which should be warm at about 75 °F [23.9 °C])
–closing doors and windows to prevent drafts
–using a heat lamp or radiant warmer, if available, if the area in which the baby will be bathed is cool. If using a heat
lamp, place the lamp a safe distance from the newborn (e.g., 18 in/0.5 m) to avoid burns and limit use of the lamp to ~ 15
minutes to avoid hyperthermia
› Gather supplies for sponge bathing the newborn, which typically include the following:
›
• Nonsterile gloves
• Facility-approved pain assessment tool appropriate for use with newborns, analgesic medication if prescribed, and means
for its administration
• Bath thermometer
• 2 cotton balls
• Sterile water or warm tap water according to facility protocol
• 4 bath towels
• 4 small washcloths
• 2 bath basins
• Mild, nonalkaline skin cleanser (e.g., commercial baby soap)
• Moisturizer/emollient and/or protective ointment for the diaper area if prescribed or as indicated in facility/unit protocol
• Petrolatum gauze if prescribed for a circumcised male during healing
• Soft-bristled baby hairbrush or fine-toothed comb
• Diaper, clean clothes, booties/socks, and infant cap
• Baby blankets
• Heat lamp or radiant warmer, if ordered/indicated
How to Bathe a Newborn Infant
› Perform hand hygiene and don nonsterile gloves
› Identify the newborn according to facility protocol
› Establish privacy as appropriate to the setting
› If the sponge bath will be performed in the mother’s room or the mother and/or father are present in another area where the
bath is being performed, introduce yourself and explain your clinical role in care of the infant. Assess the coping ability of
the parent(s) and for knowledge deficits and anxiety regarding bathing the newborn
• Determine if the parents require special considerations regarding communication (e.g., due to illiteracy, language barriers,
or deafness); make arrangements to meet these needs if they are present
–Follow facility protocols for using professional certified medical interpreters, either in person or by telephone, when
language barriers exist
• Explain details of the bathing procedure; answer questions and provide emotional support as needed
› Observe standard precautions during the procedure
› Fill 2 small basins with warm water. Add a small amount of skin cleanser to one of the basins
›
› Check the water temperature to verify that it is appropriately warm (e.g., 98.6−99.5 °F [37−37.5 °C]); if a bath thermometer
is not available, verify that the water is comfortably warm to the skin on the inside of your wrist or elbow
› Place supplies on a bedside table or other stable surface
› Lower the crib rail closest to where you are standing; be sure to raise the crib rail when you step away from the crib
› Put a bath towel on the surface to be used, and place the newborn infant supine on the towel
› Assess the newborn's general healthstatus, including his/her pain level using a facility-approved pain assessment tool
appropriate for use with newborns
• If indicated, administer analgesic medication as prescribed and allow sufficient time for a therapeutic level to be reached
before proceeding with the bath
› If ordered/indicated, set up heat lamp or place the infant under a radiant warmer to maintain normothermia during bathing
› Undress the newborn infant; set aside clothes and discard the diaper
› Loosely cover the infant's body with a bath towel; when giving the sponge bath, expose only the area being cleaned to avoid
hypothermia
› Throughout the bath, perform skin assessment for each area of exposed skin. Observe for abnormalities such as
• rash
• discoloration (e.g., redness, bruising)
• skin breakdown
› Gently wipe the eyes with a cotton ball dampened with sterile or tap water
• Wipe each eye with a separate cotton ball to avoid transferring potentially infectious microorganisms from one eye to the
other
• Wipe from the inner canthus to the outer canthus
• Discard the soiled cotton balls
› Using a dampened washcloth without soap, gently wash the face, including external portion of the ears and behind the ears.
Support the newborn's head and neck at all times
• Dry the face with the dry towel
• Put the soiled washcloth aside
› Dampen a soapy washcloth and wash the remainder of the body in the following order:
• Wash the upper extremities and trunk
• Carefully wash around the umbilical area, noting if there is redness or drainage from the stump that might indicate infection
• Take care to keep the umbilical cord stump dry
–If the cord gets wet, pat it dry thoroughly
–Do not apply antiseptics or alcohol to the stump, as doing so can increase time to stump detachment
• Rinse the upper extremities and trunk with nonsoapy water
• Pat dry and cover the upper extremities and trunk
• Dampen the soapy washcloth
• Wash the lower extremities
• Rinse the lower extremities
• Pat dry and cover the lower extremities
• Wash the feet and hands with soapy water
• Rinse the feet and hands with nonsoapy water
• Pat dry and cover the feet and hands
• Put the soiled washcloth aside
› Dampen a clean washcloth and wash the diaper area
• Wipe female newborns from the front to the back to avoid contamination of the genital area. Note that
–it is normal for mucous to be present in the labial fold; this mucous appears as a white substance and does not require
removal
–mild vaginal bleeding may occur during the first few days or weeks after birth; this finding is normal and is related to
maternal hormones
• Clean the penis of an uncircumcised male newborn by gently retracting the foreskin while avoiding use of force, gently
cleaning the head of the penis, and returning the foreskin to its original position
–Failure to return the foreskin to its original position can restrict blood flow and cause edema
• Clean the penis of a circumcised male by rinsing gently with water; apply petrolatum gauze to the tip of the penis, if
prescribed (usually within the first 24 hours after circumcision), to improve comfort and avoid irritation during healing
• Rinse the diaper area with nonsoapy water
• Dry and cover the diaper area
› During the newborn's first bath and then once or twice a week, wash the hair by dampening a clean washcloth in the soapy
water and gently lathering the scalp. Confirm that the infant’s head and neck are supported at all times, and be especially
gentle when touching the area over the fontanelles
• Rinse the hair with a small amount of the nonsoapy water, using caution to avoid spilling water and soap/shampoo in the
eyes
• Dry the head, hair, and any other area that got wet
• Gently brush or comb the newborn's hair
› Pat the newborn infant with a dry towel to make sure his/her whole body is dry
› Check the diaper area to make sure it is clean
• If there is any remaining stool or residue, wash with a fresh washcloth
› Replace the damp/wet towel beneath the infant with a dry towel, as necessary, and place the infant on it
› Apply moisturizer/emollient to the skin, as appropriate
› Apply protective ointment to the diaper area, as prescribed or as indicated in facility/unit protocol
› Diaper and dress the newborn infant
• Fold the top of the diaper down to avoid contact with the healing umbilical cord stump
• Place a cap on the newborn's head and booties/socks on the feet
• Wrap/swaddle the newborn in a blanket to maintain warmth
› Raise the crib rail
› Place soiled laundry in an appropriate location and discard used procedure materials
› Clean/disinfect and store the bath basins according to facility protocol
› Discard used gloves and perform hand hygiene
› Update the patient's plan of care, as necessary, and document the following information in the patient’s medical record:
• Date and time the bath was provided
• If the mother, father, or both participated in giving the bath and if so, assessment of their performance and response to
participating in the procedure
• Description of the bathing procedure, including use of skin cleansers, moisturizers/emollients, and protective skin ointment
for the diaper area
• Patient assessment findings such as
–pain/comfort level, if analgesic medication was administered, and efficacy of analgesic medication
–condition of skin (e.g., signs of skin irritation; comparison of existing skin abnormality with previously documented skin
condition)
–patient’s level of activity and response (e.g., calm, crying) during the bath
• Any unexpected patient events, interventions that were performed, whether or not the treating clinician was notified, and
patient outcome
• All parent education that was provided, including topics presented, response to education, plan for follow-up education,
barriers to communication and learning, and techniques that promoted successful communication and learning
Other Tests, Treatments, or Procedures That May Be Necessary Before or After
Bathing a Newborn Infant
› If new or worsening skin abnormalities are present, the treating clinician will evaluate and treat, as appropriate
› Monitor for signs of hypothermia following the bath (e.g., abnormally low body temperature, which can manifest as inability
of the clinician to obtain a temperature reading on a digital thermometer, respiratory distress); follow facility protocol to
keep the infant warm and check body temperature at regular intervals
What to Expect After Bathing a Newborn Infant
› The newborn infant’s skin will be clean and moisturized
› The newborn’s umbilical cord stump will remain dry and slowly fall off through the process of dry necrosis
Red Flags
› The immature temperature regulating system in newborns places them at risk for hypothermia when being bathed; heat
loss during the bath can result in a drop in body temperature and subsequent cyanosis, pallor, apnea, bradycardia, and
respiratory distress
› Head trauma or other injuries can occur if the newborn infant falls during the bath. If a fall occurs, assess for injuries,
provide emergency aid, and immediately notify the treating clinician of the fall and whether or not injuries have occurred or
are suspected
What Do I Need to Tell the Newborn Infant’s Parents?
› Explain the steps of bathing a newborn infant to the parents, if present, while you are performing the bath. If appropriate,
assist them in performing the bath to confirm their understanding of the procedure and necessary safety measures
› Provide written information that the parents can refer to later when bathing the newborn infant at home. Emphasize that
• sponge baths are commonly recommended until the umbilical cord stump falls off
• the baby should never be unattended during bathing
• unless specifically told to use these products by the treating clinician, baby powders should be avoided in infants because
of the risk for inhalation and asphyxiation
• the water should be comfortably warm to the touch
• the water heater at home may need to be adjusted to prevent accidentalscalding during baths; tap water should get no hotter
than 120–125 °F (48.9–51.7 °C)
› Provide information about how the family can contact the treating pediatrician if questions or problems arise
Note
› Recent review of the literature has found no updated research evidence on this topic since previous publication on June 24,
2016
References
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