2. Introduction
The infant mortality rate and neonatal mortality rate is
very high in India. The organization of a good quality
special care unit and paediatric ward is essential for reducing
the high mortality and improving the quality of care being
given to children.
During the past three decades, improvements in
diagnostic and therapeutic approaches in the care of high
risk infants have influenced their prognosis favourably.
Unfortunately, many neonatal care centres in developing
countries are unplanned and merely improvised.
3. Planning the paediatric ward
During planning of paediatric wards,
The paediatrician, and the nurse – in – charge of paediatric services
should be taken into confidence, so that the special care neonatal units
and paediatric wards are based on their opinions for meeting the
needs of infants during hospitalization
Emphasis should be laid on the following factors :
Asepsis
Warmth or thermo neutral environment
Adequate nutrition with human milk
Non – stimulating, noise free ward
Safety from all biological, physical and chemical hazards
The establishment of an ideal paediatric ward requires professional
expertise and sound infrastructure.
The philosophy of specialized conservative management of high
risk new born babies should be fully exploiting to bring down the
mortality rate in children
4. An ideal paediatric ward
should have facilities like :
Adequate space
Centralized oxygen and
suction facilities
Maintenance of thermo neutral
environment
Running water round the clock
Linens and disposables like
gloves, mask etc.,
Equipment's and articles of
general and special use like IV
stands, various procedure
trays, stethoscopes, torch,
syringes, bowels, kidney tray,
feeding cups, jugs, basin etc.,
Machines like incubator,
phototherapy unit, ventilator,
monitors, etc.,
Stationary as per need.
Toilets and bathrooms.
6. Physical
Facilities :
The neonatologist and nurse in-charge
must be involved while planning the unit
Location :
Neonatal unit should be located as close
as possible to the labour room and
obstetrics theatre
Adequate sunlight for illumination
Fair degree of ventilation of fresh air
7. Space:
۞500 to 600 gross square feet per bed
۞Space includes patient care area, storage
area, space for doctors, nurses, other
staff, office room area, seminar room
area, laboratory area, and space for
families
۞6 feet gap between two incubators for
adequate circulation and keeping the life
saving equipment
Ventilation:
& effective air ventilation
& central air conditioning
8. Floor plan :
Open encumbered space
The walls should be made of
washable glazed tiles and
windows should have two layers
of glass panes
Wash basin with elbow or floor
operated taps facility having
constant round the clock water
supply should be provided
The doors should be provided
with automatic door closers
Isolation room should be present
Lighting :
The whole unit must be well
illuminated and painted white
The lighting arrangements
should be provided uniform
shadow free, illumination of 100
foot candles at the baby’s level
9. Environmental
temperature &
humidity :
• The temperature inside the unit
should be maintained at 28’c +/-
2’c, while the humidity must be
above 50 %
• Portable radiant heater, infra red
lamps can be used
Communication system :
• The unit should have an
intercom facility & a direct
outside telephone facility
10. Acoustic
characteristics :
The ventilation system, incubators, air
compressors, suction apparatus and
many other devices used in the nursery
produce noise
Sound intensity in the unit should be
not exceed 75 decibels
Telephone rings and equipment alarms
should be replaced by blinking lights
Electrical outlets :
Each patient station should have 12 to
16 central voltage – stabilized
electrical outlets sufficient to handle
all pieces of equipment
An additional power plug point should
be preserved
There should be round the clock power
back up including provision of ups
11. Staff
pattern :
A direct who is a full time neonatologist
One neonatal physician is required for every 6 – 10 patients
One resident doctor should be present in the unit round the
clock
Anaesthetist – paediatric surgeon and paediatric pathologist are
essential persons in establishment of a good quality NICU
Other staff :
Respiratory therapist
Laboratory technician
Public health nurse
Social worker
Biomedical engineer
Clark
12. Nurses staffing
pattern :
A nurse : patient ratio of 1:1 maintained through out the
day time and night time is absolutely essential for babies
on multi system support including ventilator support.
For special care neonatal unit and intermediate care nurse
to patient ratio of 1:3 is ideal but 1:5 per shift is
manageable
Head nurse is the over all in-charge
In addition to basic nursing training for level-II care,
tertiary care requires, staff nurse need to be trained in
handling equipment, use of ventilators and initiation of
life support like use of bag and mask resuscitation,
endotracheal intubations, arterial sampling and so – on.
The staff must have a minimum 3 years work experience
in special care neonatal unit in addition to having 3
months hand on training in an intensive care neonatal
unit
13. Equipment :
Equipment and supplies should including all that is
necessary for resuscitation and intermediate care
areas.
Supplies should be kept close to the patient station
so that nurses do not have to go away from the
neonate unnecessarily and nurses time & skill are
used efficiently
There should be servo – controlled incubators and
open care systems for providing adequate warmth
Equipment's required as per the census of the unit
and the level of care providing facility
18. Laboratory facilities :
Micro chemistry laboratory
Well equipped to provide quick and reliable
Facilities for creative protein, total leukocyte counts
and microscopic examination of peripheral blood
Indications for the administration to NICU :
Babies less than 30 weeks
Very low birth weight baby of less than 1500 grams
Cardiopulmonary monitoring
Surfactant therapy
19. Contnd.,
• Convulsions
• Severe birth asphyxia
• Assisted ventilation
• Total parenteral nutrition
• Major surgery
• Babies need to be on special
vigilance care
• Opthalmia neonatrum babies
• Congenital syphilis babies
• Congenital malformation
babies
• Jaundice affected babies
20. BABY CARE AREA:
• BABY CARE AREA:
• • Areas and rooms for inborn or intramural
babies Examination area
• • Mother’s area for breast feeding and
expression of breast milk
• • Nurses’ station and charting area
• HAND-WASHING AND GOWNING ROOM:
• • Should be located at the entrance
• • Self-closing doors.
21. TRANSPORT OF
SICK INFANTS
• TRANSPORT OF SICK
INFANTS:
• • The goal of every
transport is to bring a
sick neonate to
specialized neonatal
center in a stable
condition.
• • To avoid
complications during
transport, the infant
should be as stable as
possible before
leaving the referring
hospital and warm
chain should be
maintained.
22. NURSES’ ROLE AND
REPONSIBILITY:
• NURSES’ ROLE AND REPONSIBILITY:
• To provide-
• • continuing, comprehensive
physical care and supportive
treatment
• • emotionally supportive care to
acutely ill children
• • empathetic support to parents and
families of children in the NICU
23. PHYSICAL
CARE OF
THE CHILD:
• PHYSICAL CARE OF THE CHILD:
• • Apply understanding of the
pathogenesis of the disease.
Perform complex technical skills to
monitor and support the child.
• • Perform nursing activities
related to life support of child.
• • Apply general nursing measures
for patient comfort and
prevention of complications.
• • Provide careful, continuous
clinical observations of the child.
24. MANAGEMENT OF NURSING CARE
• 1. Assessment
• 2. Monitoring physiological data
• 3. Safety
• 4. Respiratory support
• 5. Thermoregulation
• 6. Protection from infection
• 7. Hydration
• 8. Nutrition
• 9. Feeding resistance
• 10. Skin care
• 11. Administration of medication
• 12. Developmental outcome
• 13. Facilitating parent-infant relationship
• 14. Discharge planning and home care
• 15. Neonatal loss
25. Level – I (or)
primary care of
new born
Primary care is simple care of new
born who is normal (or) mild sick
This can be provided by mother, care
taker (or) I level health workers,
Trained Birth Attendant, Multi
Purpose Health Workers, Auxiliary
Nurse Midwives
Such care can be provided at home,
Primary Health Centre, Sub Centre,
Community Health Centre, Nursing
Homes, Taluk Hospitals
The aim is to provided optimal care
based on physiological needs of new
born
26. Component of primary care of new born
Preparation during Antenatal Period
Preparation of delivery & intra natal care
Resuscitation at birth
Physical examination & categorization of risk neonates
Maintenance of warmth to neonates
Breast feeding
Prevention of infection
Routine monitoring and management of minor ailments
Identification of danger signal indications of referral case during
transport
Follow up, growth monitoring, immunization
27. 1.Basic neonatal care
Good nutrition includes iron & folic acid for pregnant mother in
order to prevent malnutrition and to improve the growth of fetus
Immunization and adequate rest
2.Care of newborn at birth :
All deliveries should be at institution (or) attended by Trained Birth
Attendant
Sterile disposable kit can be used
Trained Birth Attendant can assess the new born at birth: cry,
breathing, color
Mouth to mouth resuscitation can be done when required
O2 cylinder must be available at centre
Weighing the baby to be done
If any emergency immediate referral service
28. 3.Warmth to neonates
• The hospital worker must be taught to dry the baby
immediately after birth
• Remove wet cloth wrap the baby in pre warmed cloth
• Head should be covered with cap
• Mother and hospital should be taught to keep the babies warm
by touching the trunk and extremities with the back of their
palm
• No bath should be given soon after birth
• At home room can be warmed by vacuum method
• At Centre over head lamp electrical bulbs can be very effective
in keeping the baby warm
• The best method of warmth is skin to skin, kangaroo method
29. 4.Promotion of breast
feeding
• Mother must be educated about the importance
of the breast feeding
• The baby must be put on to breast feeding after ½
hour of delivery if normal & there is no
complication in LSCS :4-6 hours
• Mother are encouraged to drink extra fluids and
addition 50% in order to maintain health
• 5. prevention of Infection
• Inj.TT 2 doses during AN period
• Using aseptic precaution during delivery to
prevent infection
• Keep delivery room clean, periodically cleaning
and fumigation of room is necessary
30. 6.Home care of LBW neonates
• Neonates below 1800 grams (or) more than 34 weeks of
gestation should be taken care at home
• If there is no sucking reflex feed with spoon
• Strict asepsis should be followed at home itself
• No self medication is encouraged at home
• 7.Identification and referral of high risk neonates:
• Hospital worker to be taught to identify high risk babies so that
timely referral can save life of the neonate
• Neonate at high risk are less than 1800 grams, less than 34
weeks of gestation, pale, cyanosed, rapid breathing more than
60/minute, persistent vomiting/diarrhoea, seizures, who fails to
pass urine / meconium with in 24 hours
31. level II care (or) Secondary of
new born
• The concept of participating mother in the case of new born under
the supervision of doctor, nurse are relevant the case they learnt at
hospital can be practiced at home confidentially
• The main care taken in level – II care needs physical space, trained
manpower
• Location :
• The level – II care should be close to the labor and delivery room
• There should be facility for new born unit so that sick babies can be
transferred quickly
• Nursery should not be located in first floor
• There should be adequate sunlight and illumination at nursery
32. Facilities for neonatal
resuscitation in labor
room
• A wall clock with seconds
• Warmer with radiant heat source
• Mucus extractor, suction apparatus
• Infant laryngoscope with neonatal size blade
• Proper neonatal size E.T. tubes
• Facility for bag and mask ventilation
• Mechanical ventilators
• O2 supply with flow meter
• Umbilical vein canulation set
• Thermometer
• Essential drugs needed for resuscitation such : adrenaline. I.V.Fluids, epinephrine,
Hco3
33. Function at level – II nursery :
• Pre term babies less than 33 to
36 weeks of gestation
• Babies with 1500 to 2000
grams and less than 4000
grams
• Babies with birth asphyxia
• Meconium aspirated
Respiratory Distress Syndrome
• Infant with abnormal behavior
(or) weight pattern
• Infant with metabolic,
hematologic problems
• Neonatal hyperbilirubinemia
needs phototherapy (or)
exchange transfusion
• High risk babies
34. Administrative aspects
• Well developed written protocol
• Admission discharge advice
• Orientation to new health
personnel
• Patient care routine and
proceeds
• In service training and education
• Written instruction about
handling of vacuum equipment
in the unit
• Instruction about the filling of
preformats discharge summary
and follow up
• Ongoing collection of monthly
and annual statistical data
35. Level – III (or)
Tertiary care of
the new born
• New born less than 1500 grams less than 32 weeks, critically ill
babies
• Level III care requires neonatal care experts, maternal – fetal
medicine experts
• Any children who needs intensive care such : hydrofetalis,
congenital heart disease, diaphragmatic hernia, abdominal wall
defects, neural tube defects, should be delivered level – III care
• Approximately 3-5% requires this type of care
36. Functions of level – III
nursing care :
• Resuscitation facilities ( all equipment's )
• Diagnosis and interventional therapy, fetal imaging and prenatal diagnosis of fetal
distress
• Development of fetal medicine to diagnose fetal disorders
• Continuous medical education for doctors, nurses in the form of lecture, seminar,
group discussion
• Documentation, records of all babies should be maintained
• Well equipped lab facilities for 24 hours
• Equipment facilities: open care system, infusion pumps, ventilators, monitors, ECG,
invasive monitors, pulse oxymeter
• Pediatrics under graduate and post graduate education
• Transport facilities – ambulance
• Follow up care
