What should be included in a Neonatal Nursing Plan (NNP) for a neonate?

Neonatal Nursing Plan Components

A comprehensive neonatal nursing plan must be structured according to the infant's gestational age and clinical stability, with specific care elements determined by the appropriate level of care required—infants <32 weeks or <1500g require Level III NICU capabilities, while those ≥32 weeks with moderate illness can be managed at Level II facilities. 1

Level of Care Determination

The first critical decision is determining the appropriate care level based on gestational age and birth weight:

• Infants born <32 weeks gestation or weighing <1500g must receive care in a Level III facility with continuously available neonatologists, specialized nurses, respiratory therapists, and life support equipment for sustained duration 1

• Infants ≥32 weeks gestation and ≥1500g with moderate illness can be managed in Level II facilities if problems are expected to resolve rapidly and subspecialty services are not urgently needed 1

• Late preterm infants (34-36 weeks) who are physiologically stable may be cared for in Level I facilities, though they remain at increased risk for morbidity and mortality requiring close monitoring 1

Core Nursing Assessment Components

Physical Examination and Vital Signs

• Complete assessment of vital signs, weight, hydration status, and degree of jaundice must be performed and documented 2, 3

• Evaluation of feeding patterns including direct observation of breastfeeding technique or bottle-feeding coordination 2, 3

• Assessment of umbilical cord healing, skin condition, and genital health 3

• Monitoring for signs of jaundice with bilirubin measurement if clinically indicated, particularly watching for major risk factors including jaundice in first 24 hours, blood group incompatibility, gestational age 35-36 weeks, previous sibling requiring phototherapy, exclusive breastfeeding with poor intake, and East Asian race 3

• Documentation of adequate stool and urine patterns 3

Laboratory and Screening Verification

• Review maternal laboratory results including syphilis, hepatitis B surface antigen, and HIV status 3

• Verify newborn blood type and direct Coombs test if clinically indicated 3

• Confirm completion of newborn metabolic screening per state regulations, with repeat testing if initial screen was performed before 24 hours of milk feeding 3

• Verify hearing screening completion 3

• Confirm pulse oximetry screening for congenital heart disease 3

Respiratory Support Planning

The level of respiratory support capability must match the infant's needs:

• Level II facilities can provide CPAP and mechanical ventilation for brief duration (<24 hours) with equipment including portable x-ray, blood gas analyzer, and continuously available respiratory therapists 1

• Level III facilities must provide sustained ventilation ≥24 hours including conventional ventilation, high-frequency ventilation, and inhaled nitric oxide 1

• Infants requiring prolonged ventilation or complex respiratory management need immediate transfer to Level III or IV facilities 1

Nutritional Management

For Preterm Infants Requiring Parenteral Nutrition

• Early PN in the first days of life requires lower calcium, phosphorus, and magnesium intakes (Ca: 0.8-2.0 mmol/kg/d, P: 1.0-2.0 mmol/kg/d, Mg: 0.1-0.2 mmol/kg/d) compared to growing stable preterm infants 1

• Use molar Ca:P ratio below 1 (0.8-1.0) when calcium and phosphorus intakes are low to reduce incidence of early postnatal hypercalcemia and hypophosphatemia 1

• Growing premature infants require higher intakes (Ca: 1.6-3.5 mmol/kg/d, P: 1.6-3.5 mmol/kg/d, Mg: 0.2-0.3 mmol/kg/d) 1

• Careful monitoring of plasma phosphate concentration within first days of life is essential in preterm infants with intrauterine growth restriction to prevent severe hypophosphatemia that can result in muscle weakness, respiratory failure, cardiac dysfunction, and death 1

For Breastfeeding Infants

• Recommend nursing 8-12 times per day for the first several days 3

• Observe breastfeeding technique with assessment of position, latch, and swallowing 3

• Avoid routine supplementation with water or dextrose water for non-dehydrated breastfed infants 3

• Refer for lactation support if feeding evaluation is not reassuring 3

Developmental and Family-Centered Care

Skin-to-Skin Care and Positioning

• Discuss safe positioning during skin-to-skin care to prevent sudden unexpected postnatal collapse (SUPC), ensuring the infant's face is visible and not covered, positioning the head in "sniffing" position with straight neck, and covering the infant's back with blankets 2

• Provide continuous monitoring during skin-to-skin care, especially in the first 2 hours of life 2

• Attention to infant positioning and handling affects physiologic variables and joint mobility in preterm infants 4

Parental Involvement

• Encourage kangaroo care (parent/infant skin-to-skin contact) which improves preterm growth, decreases nosocomial infections, and may shorten hospital length of stay 4

• Evaluate mother-infant attachment and infant behavior 3

• Identify and prepare in-home caregivers for high-risk infants 2

Environmental Considerations

For Extremely Preterm Infants

• Establish adequate care environment to minimize iatrogenic injury given immature organ function 5

• Implement conservative skin care practices appropriate for extremely preterm infants 5

• Reduce sensory input to prevent overwhelming preterm infants while judiciously adding back soothing sensory input such as therapeutic touch and soft music 4

• Implement circadian light/dark cycles which improve preterm growth 4

Safety Education and Preventive Interventions

• Educate on safe sleep practices including supine positioning and avoidance of co-sleeping 3

• Provide instructions on appropriate car safety seat use 3

• Educate on recognizing signs of illness, particularly jaundice 3

• Provide instruction on temperature assessment and thermometer use 3

• Give guidance on umbilical cord care and skin care 3

• Educate on expected urination and stooling patterns 3

Social and Psychosocial Assessment

• Screen for maternal postpartum depression 3

• Assess family, environmental, and social risk factors 3

• Screen for risk factors requiring social services intervention including untreated parental substance use, history of child abuse or neglect, parental mental illness, lack of social support, housing instability, and domestic violence history 3

• Identify potential barriers to adequate follow-up care 3

Discharge Planning and Follow-up

• Establish a medical home for ongoing care 3

• For infants discharged before 48 hours after delivery, schedule follow-up within 48 hours of discharge 3

• Time follow-up based on discharge timing: discharge before 24 hours requires follow-up by 72 hours of age; discharge between 24-47.9 hours requires follow-up by 96 hours of age; discharge between 48-72 hours requires follow-up by 120 hours of age 3

• For high-risk infants, develop comprehensive discharge plan including nutritional care plan, equipment and supply sourcing, coordination with primary care physician, and assessment of home physical facilities 2

• Provide emergency contact information and instructions 3

Common Pitfalls to Avoid

• Do not delay transfer of infants <32 weeks or <1500g to Level III facilities—these infants require subspecialty care that cannot be adequately provided at lower levels 1

• Do not overlook hypophosphatemia risk in growth-restricted preterm infants on early PN, as this can lead to life-threatening complications 1

• Do not assume late preterm infants (34-36 weeks) are "near-term"—they remain at significantly increased risk for morbidity and require close monitoring even if physiologically stable 1

• Do not provide prolonged mechanical ventilation (>24 hours) in Level II facilities—transfer to Level III is required 1