Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies.

Promotes efficient time management and provides an organized approach to the procedure. Additionally decreases risk of over exposure of infant to cooler environment.

2 Ensure that the opposite side rail of a crib or bed is raised. If the infant is in an isolette, keep the isolette doors closed until equipment is ready for the bath.

Depending on the developmental level of the child, he or she could roll off the bed if side rails are left down.

3 For newborn bath or infant who is thermodynamically unstable, turn on warming lamp and ensure that it is at appropriate distance from the infant (see Chapter 124 ). Use clinical judgement to determine if child is physiologically stable enough to tolerate bathing.

Prepares environment to be thermally stable. Heat loss can occur by convection. An infant’s temperatureregulating mechanisms are immature, and the infant is at high risk for heat loss, especially premature or very low-birth-weight infants. Hypothermia can result in increased oxygen consumption and respiratory distress.

4 Place a dry bath blanket or waterproof pad on the bed surface of the crib, isolette, or bed.

A dry surface will reduce heat loss by conduction.

5 Prepare bathing equipment or supplies:

Fill disposable basin or small tub with warm water. Water temperature should be about 98.6-100.4°F (37.0-38.0°C).

Warm prepackaged bathing product per manufacturer’s instructions.

Prevents scalding of infant skin. If a thermometer is not available, test the temperature of the water with the sensitive skin on the inside of your wrist or elbow. Avoid use of unfiltered tap water. Use sterile or distilled water or filtered water from the faucet. Ensures washcloth is at a comfortable temperature for use on the infant/child. Do not use if excessively hot.

caREminder

If wearing gloves, remember that the gloves will diminish your sensitivity to heat and you may not recognize how hot the washcloths may actually be.

6 Perform hand hygiene and don gloves.

Standard precaution to reduce transmission of microorganisms, and if this is the first bath, protects the healthcare provider from exposure to maternal blood.

7 Position the infant/child in a supine position. Loosely cover the infant/child at all times with a dry towel or blanket.

Keeping the total body area from being exposed to the air helps reduce heat loss.

8 Begin bath by bathing the face using cotton balls, soft washcloth and water, or disposable bathing product.

Using plain water will prevent cleanser from irritating the eyes.

For prepackaged bathing products, follow instructions on package for the body surface area that can be used for one cloth. Select a new cloth for next body surface area.

Prepackaged products usually contain several cloths. Each cloth is to be used on a different body surface area to help reduce spread of germs and ensure maximum cleansing and moisturizing benefits. The cloths are premoistened with a cleansing solution that may also contain aloe and vitamin E.

9 When cleansing orbital area, wash from inner canthus to outer canthus, using a fresh cotton ball or clean corner of washcloth for each eye.

Following the natural tear flow will prevent the spread of microorganisms.

10 Pat bathed area dry with a clean, dry towel.

Rubbing can irritate the skin.

11a Cleanse nose with corner of cloth or cotton ball. Remove any incrustations from the nares by using a twisted moist cotton ball or washcloth.

Moisture loosens the incrustations in the nares for easy removal.

11b For infant, gentle suctioning of the nares with a bulb syringe may help clear the nares of nasal secretions.

Infants and small children cannot expel the secretions in the nose by blowing through the nasal passages.

12 Wash the external ears and behind the ear by winding a damp washcloth around the index finger.

Prevents possible packing of the discharge farther down the ear canal. Prevents damage to the eardrum.

caREminder

Never place cotton swabs or other small objects in the infant’s ear canal.

13a Using a mild liquid cleansing agent and washcloth or the prepackaged bathing products, work from the shoulders to the feet in a systematic manner to wash one section of the body at a time. Pay special attention to the folds of the neck, thighs, and underarms.

Ensures that all areas of the body are bathed as efficiently as possible. The younger the infant, the more sensitive the skin is to abrasive cleansers. Cleansing agents that have a neutral pH and minimal dyes and perfumes will reduce the risk of future allergy sensitization to topical agents. There are no studies to support the use of antimicrobial solutions or cleansers for the purpose of bathing the infant or premature child. Using mild liquid cleansers as opposed to water alone for the first newborn bath has demonstrated minimal effect on skin bacterial colonization.

caREminder

For extremely premature infants (less than 26 weeks’ gestational age), sterile water alone should be used for bathing.

13b Excess vernix can be removed from the newborn’s skin; however, removal of all vernix is not necessary.

Studies indicate that vernix may provide antibacterial protection and promote wound healing. It may also contribute to the development of the epidermal barrier function, regulating postnatal and surface adhesion properties, heat flux, and surface electrical activities.

14 Rinse and pat dry each area after washing with a towel. Do not rub the skin surfaces.

Residue from the cleansing agents can be irritating to the infant’s skin. Rubbing skin surfaces can cause chafing and irritation.

If the infant is being monitored, observe the heart rate and oxygen saturation level. Discontinue the bath procedures if the infant’s condition deteriorates.

15 For infant, clean the umbilical area with a cleansing agent and water. Observe umbilicus for redness or drainage. Lift cord and clean base; do not wet the umbilical cord. Rinse and dry the area. Leave site open to air; do not apply alcohol, antiseptics, or antibiotics to umbilical cord stump.

Promotes drying of the stump. Prevents infection (omphalitis) that can be life threatening. Studies have shown that natural drying of the umbilical cord does not result in increased incidence of infection and that treatment with antiseptics prolongs time to cord separation.

16 Place the infant/child on his or her stomach. Wash, rinse, and dry the back. Cover the infant/child with a dry towel.

Prevents loss of body heat.

17 Cleanse the genital area:

17a For females, gently wash the area from front to back, from vagina to rectum. Use a portion of the washcloth or a moistened cotton ball to cleanse the area. Use cotton ball only once to wipe the area. Discard after one use and change to new cotton ball for each subsequent wipe.

Cleaning from front to back reduces the risk for contamination of the urethra or vagina from the anus. Reduces transmission of microorganisms.

17b If a white substance is noted in the labial fold, do not attempt to wipe clean. Females may have blood present during diaper change.

Some mucus may be noted in the vaginal area of the neonate. Blood may be present because of maternal hormones.

17c For males, squeeze clean water over head of the penis. In the uncircumcised male, gently move the foreskin back as far as it will go, cleanse the head of the penis, and return the foreskin to the normal position. Do not force the foreskin back.

At birth, only 4% of boys have a retractile prepuce; by the age of 3, the foreskin is retractable in 90% of boys. Leaving the prepuce in a retracted position constricts the blood vessels supplying the glans penis, causing edema. Retracting the foreskin when bathing decreases the chances of having smegma accumulation, inflammation, phimosis, or adhesions.

17d In the circumcised infant, a petroleum-coated gauze bandage or petroleum jelly should be applied to the tip of the penis if the circumcision was the Gomco type. May apply an antibiotic ointment on Plastibell-type circumcision if ordered by physician (see Chapter 31 ).

The dressing helps prevent the circumcised area from rubbing against the diaper or sticking to the diaper as the healing process progresses.

18 Wash, rinse, and dry the infant’s buttocks.

Wash from front to back to reduce the transmission of microorganisms from the anus.

19a For infant, apply protective ointment on the buttock area and crease areas if indicated by redness and/or breakdown of skin in the area (see Chapter 34 ).

Cream barrier keeps ammonia away from the infant’s skin and prevents diaper rash.

Powders should not be used on the infant. Baby powders may be accidentally aspirated by the infant. Aspiration of the particles can lead to pneumonia and even death.

20 Apply a clean diaper on the infant or young child. If the umbilical cord is still in place, adjust the top of the diaper so that it is below the umbilical area.

The umbilical area should be uncovered to prevent irritation and infection.

21 Apply emollient to the infant’s skin as needed. Avoid the use of baby oil or baby powder.

Emollients can prevent excessive drying, skin cracking, and fissures. Avoid products with perfumes or dyes because these substances can be absorbed and are potential contact irritants. Baby oil clogs the skin pores, and baby powder may irritate dry skin. Emollients are safe to use with premature infants.

22 If washing hair, wrap the infant/child in a warm blanket, securing the arms close to the body. Place the infant in a football hold position (Figure 15-1).

A warm blanket will help stabilize body temperature during hair washing. With the football hold, the infant will be securely held in place, allowing the parent a free hand to wash the infant’s hair.

Figure 15-1 Hold the child securely in the “football hold” position, supporting the neck, when washing the infant’s hair.

23 Position the infant’s head over the wash basin, or position the back of the child’s head in a basin designed for hair washing. Lather the scalp with a mild liquid cleansing agent or shampoo. Or use a dry shampoo cleansing agent per manufacturer’s instructions.

Gentle washing helps reduce seborrhea, a scaly scalp condition commonly called “cradle cap.”

23a If using water and a basin, use a damp, soapy cloth, wash the infant’s hair and rinse thoroughly. Massage the entire scalp including the fontanels. Cup your hand across baby’s forehead.

Residue from the cleansing agent or shampoo may irritate the scalp if either is left at the site.

24 Dry hair and scalp with a towel.

Prevents soapsuds running into the eyes.

25 Comb the infant/child’s hair with a fine-toothed comb or a soft-bristle brush.

Aids in removing crusts from the infant’s scalp if cradle cap is present.

26 Remove blankets from infant/child after hair washing. Proceed to dress the infant/child in dry clothing and wrap him or her in a dry blanket. Cover the infant’s head with a cap or bonnet. Position for comfort and safety. Ensure the bedside rails are up or isolette doors closed.

Prevents loss of body heat. Promotes safe environment.

27 Dispose of used basin and/or opened and used disposable bathing products in trash receptacle. Return all equipments to their proper storage area. Dispose of waste in appropriate receptacle.

Reduces the transmission of microorganisms. Standard precautions.

Do not flush disposable products down the toilet.

28 Remove gloves and perform hand hygiene.

Reduces transmission of microorganisms.