neonatal organization

1. ORGANIZATION OF NEONATAL CARE UNIT,
SERVICES,TRANSPORTATION,
MANAGEMENT OF NURSING SERVICES IN NICU

3. When a baby leaves the womb, its body systems
must change. For example:
• The lungs must breathe air.
• The cardiac and pulmonary circulation changes.
• The digestive system must begin to process food
and excrete waste.
• The kidneys must begin working to balance
fluids and chemicals in the body and excrete
waste.
• The liver and immune systems must begin
working on their own.
Preterm birth, a difficult birth, or birth
defects can make these changes more
challenging. But a lot of special care is
available to help newborn babies.

4. What is the neonatal intensive care unit (NICU)?
New-born babies who need intensive medical care are often
put in special area of the hospital called the neonatal
intensive care unit (NICU).
The NICU has advanced technology and trained healthcare
professionals to give special care. NICUs may also care areas
for babies who are not as sick but do need specialized nursing
care.

5. To improve
the
condition of
the
critically ill
neonates
keeping in
mind the
survival of
neonate, so
as to reduce
the neonatal
morbidity
& mortality.
To provide
continuing
in-service
training to
medicine &
nursing
personnel
in the care
of
newborn.
To maintain
the
function of
the
pulmonary,
cardio-
vascular,
renal &
nervous
system.
To
monitor
the heart
rate, body
temperatur
e, CVP &
blood
values by
non-
invasive
techniques
.
To measure the
oxygen
concentration of
the blood is by
oxygen
analyzers.
To
check/obser
ve alarm
system
signals to
find out the
changes
beyond
certain
fixed limits
set on the
monitors.
To
administer
precise
amount of
fluid &
minute
quantities
of drugs
through i.v
infusion
pumps.

6. 1. To save the life of sick newborn.
2. To improve the condition of critically ill neonate..
3. To prevent damage in infants with problems at birth and also reduce
morbidity in later life.
4. To monitor high risk newborns so as to reduce mortality and morbidity
in these babies.
5. To provide continuing in-service training to medical and nursing personnel
in care of the newborn.

7. Being younger than age 16 or older than age 40
Drug or alcohol use
Diabetes
High blood pressure (hypertension)
Bleeding
Sexually transmitted diseases
Multiple pregnancy (twins, triplets, or more)
Too little or too much amniotic fluid
Premature rupture of membranes (also called the amniotic sac or bag of waters)

8. Changes in a baby’s organ
systems due to lack of oxygen
(fetal distress or birth asphyxia)
Buttocks delivered first (breech
birth) or other abnormal
position
The baby's first stool
(meconium) passed during
pregnancy into the amniotic
fluid
Umbilical cord wrapped around
the baby's neck (nuchal cord)
Forceps or cesarean delivery

9. Baby born at gestational age of less than 37 weeks or more than 42 weeks
Birth weight less than 5 pounds, 8 ounces (2,500 grams) or over 8 pounds, 13 ounces (4,000 grams)
Small for gestational age
Medicine or resuscitation in the delivery room
Birth defects
Respiratory distress including rapid breathing, grunting, or stopping breathing (apnea)
Infection such as herpes, group B streptococcus, chlamydia
Seizures
Low blood sugar (hypoglycemia)
Need for extra oxygen or monitoring, IV (intravenous) therapy, or medicines
Need for special treatment or procedures such as a blood transfusion
BABY FACTOR

10. Neonatologist.
Neonatal
fellow.
Pediatric
resident.
Neonatal
nurse
practitioner.
Respiratory
therapist.
Physical,
occupational, and
speech therapists.
Lactation
consultant
s.
Dietitians.
Pharmacists.
Social
workers.
Hospital
chaplain.
NICU TEAM

11. India has 3-tier system of neonatal care based on weight and gestational age of neonate.
LEVEL I CARE:
• Basic Newborn Care
• For care of neonates more than 1800
gms in weight or G.A>=34 weeks.
• The care consists of basic care at
birth, provision of warmth,
maintaining asepsis and promotion of
breastfeeding.
LEVEL II CARE:
• Specialty Newborn Care
• For care of neonates weighing
1200 - 1800 grams gestation. Or
G.A between 30- 34 weeks.
• Level IIA: These nurseries do
not provide assisted ventilation.
• Level IIB: These nurseries can
provide assisted ventilation for
less than 24 hours, and can also
provide continuous positive
airway pressure (CPAP).
LEVEL OF CARE

12. Subspecialty Newborn Care: Level III
NICUs care for the sickest babies and
offer the greatest variety of support.
For care of neonates weighing less than
1200 grams or G.A of less than 30 weeks.
Level IIIA: These nurseries
care for babies born greater
than 28 weeks. They offer
mechanical ventilation and
minor surgical procedures
such as central line placement.
Level IIIB: Level IIIB NICUs can offer
different types of mechanical ventilation,
have access to a wide range of pediatric
specialists, can use imaging capabilities
beyond x-ray, and may provide some
surgeries requiring anesthesia.
Level IIIC: The most acute
care is provided in level IIIC

13. Very Low birth weight babies
Large babies; more than 4 kg
Birth asphyxia
Meconium aspiration syndrome
Severe jaundice
Infants of diabetic mother
Neonatal sepsis
Severe congenital malformation

14. Cyanotic Congenital heart disease
Neonatal convulsions
If heart rate and breathing are unstable
Exchange blood transfusion
Foul smelling liquor
Mothers of hepatitis carrier
Injured neonate

15. • Warm incubator (33-36 degrees Celsius).
• Adequate light source.
• Resuscitation and treatment trolly stocked.
• History, continuation sheet, treatment and diet
sheet, problem list, flow charts, etc.
• Suction apparatus.
• Maintenance of thermoneutral environment.
• Availability of linen and disposables.
BASIC
REQUIREMENTS

16. • Oxygen line connected to oxygen and air flow
meter.
• Ventilation bag and mask of appropriate sizes.
• Vital sign monitors.
• Specific equipment as indicated by diagnosis.
• Adequate space.
• Availability of running water.
• Centralized oxygen and suction facilities.
BASIC
REQUIREMENTS

17. Physical
facilities
Personn-
els
Laborato
-ry
facilities
Equipme-
nts
Documen
-tation
Educatio-
nal
program
me

18. PHYSICAL FACILITIES
The NICU can be in a single area or multiple rooms with a capacity of 2-4 infants each.
The physical facilities include:
Space
Acoustic
characteristics
Location
Floor plan Ventilation Lighting
Environmental
temperature and
humidity
Electrical outlet Staff room
Nurses station Baby care room Clean utility

19. SPACE
Serve as a referral unit for the infants born outside
the hospital.
 Each infant should be provided with a minimum
area of 100 sq. ft. or 10 m2.
 There should be separate space for breastfeeding
500-600 gross square feet /bed.
 6 feet gap between two incubators for
adequate circulation and keeping the essential
lifesaving equipments.
 There should be no compromise on space and
its adequacy is crucial for reduction of
nosocomial infections.
 Space should be allocated within the nursery
complex for promotion of breast feeding,
expression of breast milk and its storage.

20. LOCATION
Located as close possible to the labor rooms and obstetric operation theatre
The presence of an elevator in close proximity is desirable for transport of outborn infants.
In tropical countries, the nursery should not be located on the top floor of the hospital but
there should be feasibility for the sunlight to peep into the nursery to enhance brightness
and provide ultraviolet rays to augment asepsis
FLOOR PLAN:
 The unit facility should preferably be in a square space so that abundant open unencumbered
space is available, walls should be made of washable glazed tiles and windows should have
two layered glass panes.
 Wash basins with foot or elbow operated taps having round the clock water supply should be
provided.
 The doors should be provided with automatic door closure. There should be an isolation room.

21. A SINGLE-CORRIDOR TYPE LAYOUT PLAN

22. VENTILATION
 There should be effective air ventilation and central air conditioning.
 Provision of exhaust fan
 A constant positive air pressure should be maintained in the nursery
 Do not use chemical air disinfection and ultraviolet lamps
LIGHTING
 Well illuminated and painted while or slightly off white.
 Cool white fluorescent tubes
 The number and exact location of fixtures can be worked out taking into account size of the nursery, height of ceiling,
and availability or otherwise of sunlight.
 Spot illumination for various procedures can be provided by a portable angle-poise lamp having two 15 watt
fluorescent bulbs
 The nursery light should be dimmed at night to simulate day-night pattern to promote hormonal surge and growth of
babies. Bed side lights with dimmer switches should be provided to create specialized microenvironment for each
baby.

23. ACOUSTIC CHARACTERISTICS:
1. Sound intensity in the unit should not be exceeded 75 decibles.
2. Telephone rings, equipment alarms should be replaced by blinking lights.
3. It is desirable to have effective sound proofing of ceilings, walls, doors and floor when a new nursery is designed.
ENVIRONMENTAL TEMPERATURE AND HUMIDITY
1. 26-28◦C in order to minimize effect of thermal stress on the babies and humidity must be above 50%.
2. The external windows of nursery should be glazed to minimize heat gain and heat loss and baby beds should be located
at least 2 feet away from the wall and windows.
COMMUNICATION SYSTEM:
1. The unit should have an intercom and a direct outside telephone line.
2. No mobile phones should be allowed in the inborn and out born area.

24. ELECTRICAL OUTLETS:
 There should be adequate number (8-12 electrical points at the height of 4-5 feets) of light and power
electrical points attached to a common ground.
 Each infants must be provided with at least eight electrical outlets.
 The use of adapters and extension boards should be discouraged.
 The electrical equipment used in the nursery must be checked at least once a month for leakage of current
and adequacy of grounding.
 The voltage supply to the nursery should be stabilized with the help of a voltage servo-stabilizer.

25. NURSES STATIONS.
1. Central area
2. New-born charts, hospital forms, computer
terminals, telephone lines should be located in
this area
CLEAN UTILITY AND SOILED UTILITY HOLDING ROOMS
Stocking clean utility items and sterile disposables, and for disposal of dirty
linen and contaminated disposables.

26. STAFF ROOMS
A comfortable room with intercom, telephone, computer facility.
It is the space provided within the NICU.  Nurses staff room  Residents duty room  Nurses changing
room
MOTHER AREA
Comfortable seating and privacy to mother to express breast milk with the help of lactation nurse.

27. PERSONNEL
1. Availability of sufficient number of adequately trained personnel
2. Nurse patient ratio in special care
Medical personnel
 One independent senior resident doctor + 1 junior resident round the clock for 8 babies
requiring special care.
NURSING STAFF
 The NNFI (National Neonatology Forum of India ) has recommended that at least 1:4 ratio of
babies in the special care neonatal unit.
 According to AAP, 1:3 for special & inter mediate nursery care, 1:1 for intensive care .The
allowance should be kept for additional 25% staff to provide for exigencies of day off &
leave.
 The nurse must be imparted continuous in service training in the art of neonatal nursing.

28. Para medical personnel
 Respiratory therapist- -If ventilatory facilities are established, 1 respiratory therapist to
monitor ventilatory settings, do tracheal suction & CPT.
 One paediatric pathologist to conduct and interpret autopsies.
Other Staff
1. Maintenance staff: 1 sweeper should be there for 24hrs and 1 laundry boy
2. 1 Lab technician-One lab technician to operate glucometer, bilirubinometer, micro
centrifuge, CRP kits & blood gas analyser.
3. 1 Social worker attached to NICU care

29. Resuscitation set
6.
Open air system
4.
Incubators 2. Infusion pumps
12.
Positive pressure
ventilators 6.
Oxygen hoods,
oxygen analyzers
6.
Heart rate apnea
monitors 6.
Phototherapy
unit 6.
9. Electronic
weighing scale
EQUIPMENTS
Equipments required of NICU for 6 patients include:

30. Pulse oxymeters
6.
Transcutaneous
PO2and PCO, monitors
Non invasive B.P
monitors 4.
Invasive BP
monitors 4.
ECG monitor without
defibrillator 1.
Intracranial pressure
monitor

31. 1. IV catheters 2. IV sets
3. Bacterial
filters
4. Feeding
tubes
5.
Endotracheal
tubes
6. Suction
catheters

32. Three way
adapters
Umbilical
arterial and
venous
catheters
Syringes
Needles
Ventilator
tubings
Trocar and
cannula
Pressure
transducer for
invasive blood
pressure

33. Environmental
equipment
Monitor
Diagnostic
equipment
Treatment
equipment

34. ENVIRONMENTAL EQUIPMENT
Environmental equipment include the following:
1.Incubators
2.Radiant warmer

35. MONITORS
Monitors include:
1. Blood Pressure Monitor.
2. Cardipulmonary Monitor
3. Transcutaneous oxygen/carbondioxide monitor
4. EEG monitor
5. ECG monitor
6. Pulse oximeter

36. DIAGNOSTIC EQUIPMENT
Diagnostic equipment include:
1. X-ray
2. Ultrasound
4. MRI
3. CT scan
1. X-ray: X-rays use electromagnetic energy beams to create images of bones, tissues, and organs.
2. Ultrasound: Ultrasound machines use high fre quency sound waves to create images of organs, tissues, and
blood vessels.
3. CT scan: A CT scan is a diagnostic imaging proce dure that uses a combination of X-rays and com puter
technology to produce horizontal, or axial, images (often called slices) of the body..

37. TREATMENT EQUIPMENT
Treatment equipment include:
Bili lights/ Phototherapy lights
Intravenous line
Continuous Positive Airway Pressure (CPAP
Extracorporeal Membrane Oxygenation (ECMO

38.  Central line
 Umbilical catheter
 Endotracheal tube (ET
 Respirator or mechanical ventilator
 Oxygen Hood
 Nasal Cannula or Nasal Prongs
 Feeding tube
 Peripherally Inserted Central Catheter (PICC) or Percutaneous
Central Venous Catheter (PCVC

39. LABORATORY FOR NICU
A micro chemistry laboratory attached to the unit and providing round the clock
service should be available. This should be well equipped with necessary
equiments to provide quick and reliable test results.

40. DOCUMENTATION
The unit should have printed problem oriented stationary for maintaining records, admission and discharge slips, etc.
Records of all admission should be maintain in a register or on a computer. The information should analyzed and
discussed at least once a month to improve the effectiveness of NICU in providing the services

41. EDUCATIONAL PROGRAMME
There should be continuing medical education programmes for physicians and nursing personnel’s in t form of
lectures, demonstrations, group discussions and panel discussions. These programmes should cour important issues
like resuscitation, sterilization change transfusions, maintenance of equipment’s etc.

42. PROCEDURES THAT MAY BE NEEDED FOR THE CARE OF THE BABY.
 Warmth and Temperature Regulation
 Nutrition for babies in the NICU
 Electrolyte and blood levels
Some babies have too much or too little of certain electrolytes or other substances in the blood. As a result, some
common problems include:
 Hypernatremia. This is high amounts of sodium (salt) in the blood.
 Hyperkalemia. This is high amounts of potassium in the blood. It can be diagnosed by blood test. Or it can
be diagnosed by changes in the baby's heart rate pattern.
 Hyperglycemia. This is high amounts of glucose (sugar) in the blood. It is diagnosed by blood tests, often
done by heel stick. Some babies may need insulin to control high glucose levels.
 Hypoglycemia. This is low blood sugar. It is usually treated with IV fluids that have dextrose. This is a type
of sugar.
 Hypocalcemia. This is low calcium levels in the blood. It is usually treated with calcium in IV fluids.

43.  Feeding
These are some ways babies may be fed in the NICU:
 Gavage or tube feedings.
 Cup or spoon feedings.
 Nipple feedings.
 Testing and Lab Procedures for the New-born in Intensive
 Intravenous (IV) Line and Tubes
Because most babies in the NICU are too small or sick to take full milk feedings, medicines, and fluids are often
given through their veins or arteries. Babies may also need frequent lab tests and measurements of blood oxygen
levels. There are several ways a baby may get fluids and medicines and have blood drawn. These include the
following:
 Intravenous (IV) line.
 Umbilical catheter (UVC or UAC).
 Percutaneous line.

44. TRANSPORT OF SICK NEONATES
The short distance transport within the hospital can be accomplished in a transport incubator.  The baby can
be wrapped in tin foil or covered with several layers of cotton.  Themocele (polystyrene) box is an effective
insulator and can be used in community.  Skin to skin contact with mother or a care taker is a useful
modality of transport in rural areas or resource poor settings.
When fragile neonates need to be moved to another facility, that move becomes the most important journey
of the baby's life. For the smallest and most critically ill newborns, reduced transport time between facilities
leads to improved outcomes. In utero transfer has better clinical outcomes for mother and infant than transfer
after birth. However, in utero transfer is not always possible due to a number of reasons:
 Accelerated birth due to baby's clinical condition.
 Need for treatment at a specialized hospital- extracorporeal membrane oxygenation
 Risk that could not be detected before birth
 Problems right after birth (for example respiratory distress syndrome)

45. In these instances, the critically ill newborns then rely on the hospital team and technology
to provide the best possible environment for them during transportation. Depending on the
region, hospital and situation, transfers can be done by ambulance or aircraft (fixed wing or
helicopter).
The Baby needs to be protected from factors such as thermal change and vibrations, the
caregiver needs fast access to the baby and life-supporting devices, and the transport team
needs a transport system that is easy to move.
Transferring these infants at such a critical state poses many challenges to the clinicians and
potential risks to the infant due to external factors including

46. In order to optimize transport and minimize discomfort to the infant, the effects of these factors
have to be reduced as much as possible.
Transportation requires skilled personnel and specialized equipment that is designed to meet
the needs of neonates. The team set up varies from region to region and hospital to hospital.
Equipment requirements also vary according to each situation but generally speaking the device
needs the following:
 Incubator with good access to the neonate
 Vital signs monitor to observe oxygen saturation, ECG, respiration, C02 elimination,
etc.
 Ventilator to provide respiratory support Infusion pumps to administer medication.

47. GOAL
1. The goal of every transport is to bring a sick neonate to a specialized neonatal centre in a
stable condition.
2. To avoid complications during transport, the infant should be as stable as possible before
leaving the referring hospital and a warm chain should be maintained.
3. The transport service gives high—risk patients timely access to the appropriate services
without interrupting their care.

48. Level of care
Transfer patterns in regional system
1. Level I [Basic Care] — relatively minor problems
2. Level II [Speciality Care] — Low birth weight babies (1500 to 2500 gm., 32 to
36 weeks of gestation)
3. Level III [Subspecialty Care] — Maternal and Neonatal those at high risk (less
than 1500 gm. birth weight or less than 32 weeks gestation
Level I to Level II: Complicated cases not requiring intensive care.
Level II to Level III: Complicated cases requiring intensive care. Labor less than 34 weeks gestation.

49. INDICATIONS
Sepsis
Persistent respiratory distress
LBW
Blood loss
Congenital malformations need surgical
Hypoglycaemia
Seizures
Congenital malformations need surgical
correction

50. ORGANISATION OF A NEONATAL TRANSPORT
The doctor in the referring hospital should,
 Be aware of where to refer the sick baby
 Contact the referral hospital
 Provide clear history to the staff to enable early referral
 Stabilise the infant before referral
 Keep baby warm
 Provide oxygen if hypoxic

51.  IV glucose if hypoglycaemia
 Correct metabolic acidosis
 Assist ventilation with bag & mask
 Aspirate the gastric content & place b on CRTD
 If sepsis, start apt antibiotics Ensure patent venous access
 Explain the family the need for referral& get consent

52. Components of a Newborn & Pediatric
Critical Care Transport Program:
 Transport dispatch system
 Communication with neonatal intensivist
 Response time
 Critical care transport team

53.  Interpretation of x-rays
 Common lab investigations
 Pharmacotherapy
 Fluid therapy
 Equipment training
 Legal issues
 Documentation
 Transport physiology Infection control
 Vehicle safety
 Public relations
 Continuous quality improvement
TRAINING & SKILLS
FOR TRANSPORT
TEAMS:

54. TRANSPORT PROCESS
 Upon arrival at the referral
institution
 Consent
 Assessment & stabilization
 Call back to prepare the
NICU/PIC

55. STABILISATIONDURINGTRANSPORT
•Thermal care
•Glucose infusion
•Monitor color, respiration, and heart rate during the transport.
•Follow protocol during neonatal transport Monitor: HR, RR, RBS temperature
•Check for nasotracheal tube extubation
•Pneumothorax
•Any sudden change in status
•Contact to NICU to
•Report status of newborn
•State what is required for newborn
•During long-distance transport
•➡ Monitor oxygen with a transcutaneous monitor
•→ Consider the use of IPPV & CPAP

56. Larger equipment
• Transport incubator or stretcher
• ventilator
• pulse-oximeter
• portable suction unit
• Oxygen Hood
• temperature probe
• defibrillator
• infusion pumps
• portable oxygen cylinder
TRANSPORT
EQUIPMENT &
MEDICATIONS

57. Smaller Transport Equipment
Various sizes of:
 chest tubes
 cervical collar
 IV cannula
 central line sets
 heparinized saline
 Procedure manual
 Co-operation between the obstetrician & neonatologists
 Organisation of neonatal care services & its importance

58. 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.
 To function effectively and safely, the ICU nurse should demonstrate the following capabilities :
 Good physical and emotional health
 Understanding or pathophysiology underlying diseases.
 Knowledge and understanding of sophisticated monitoring equipment and special apparatus.
 Ability to reason objectively and to judge and be aware of rapidly changing situations.
 Ability to interpret data and to take rapid, decisive action.
 Ability to perform complex technical skills correctly and organized manner.
 Understanding of the impact of illness and hospitalization on the life of the child.
 Understanding of parental responses and ways of coping with the stress of a critically ill child.
 Ability to record data concisely, accurately and thoroughly.

59. PHYSICAL CARE OF THE CHILD
 Apply understanding of the pathogenesis of the disease.
 Perform complex technical skills to monitor and support the child.
 Apply general nursing measures for patient comfort and prevention of complications.
 Provide careful, continuous clinical observations of the child.

60. Management of nursing care
1. Assessment
2. Monitoring physiological data
3. Safety measures
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

61. TOWARDSA GENTLEANDFRIENDLYNICUENVIRONMENT
• Attempts should be made to reduce unnecessary noise and light.
•Avoid excess of light
•Handling should be gentle
• Neonates including pre terms feel pain and painful stimuli can cause deleterious
physiological responses. Analgesia should be provided during all procedure
including ventilation.
•Parents should be allowed unrestricted entry to the nursery
• They should be explained about various tubing and attachments to the baby and
should be involved in care of their baby.

62. JOURNAL
Impact of the design of neonatal intensive care units on neonates, staff, and
families: a systematic literature review
Abstract
Newborn intensive care is for critically ill newborns requiring constant and continuous
care and supervision. The survival rates of critically ill infants and hospitalization in
neonatal intensive care units (NICUs) have improved over the past 2 decades because of
technological advances in neonatology. The design of NICUs may also have implications
for the health of babies, parents, and staff. It is important therefore to articulate the design
features of NICU that are associated with improved outcomes. The aim of this study was
to explore the main features of the NICU design and to determine the advantages and
limitations of the designs in terms of outcomes for babies, parents, and staff,
predominately nurses. A systematic review of English-language, peer-reviewed articles
was conducted for a period of 10 years, up to January 2011. Four online library databases
and a number of relevant professional Web sites were searched using key words.

63. There were 2 main designs of NICUs: open bay and single-family room. The open-bay
environment develops communication and interaction with medical staff and nurses and has the
ability to monitor multiple infants simultaneously. The single-family rooms were deemed
superior for patient care and parent satisfaction.
Key factors associated with improved outcomes included increased privacy, increased
parental involvement in patient care, assistance with infection control, noise control,
improved sleep, decreased length of hospital stay, and reduced rehospitalization. The
design of NICUs has implications for babies, parents, and staff. An understanding of the
positive design features needs to be considered by health service planners, managers, and those
who design such specialized units.

65. REFERENCE
 Magon P. Textbook of child health nursing. Lotus Publishers: Pg 172- 181
 Kurian S. Textbook of Pediatric Nursing. 1st Edition. Emmess: Pg 188-194
 Pendita MH. A Textbook of child Health Nursing. Vit Med. Pg 317-325
 Singh M. Came off the Newborn Sagan Publications. Pg. 20 20-30.

66. Thank you