ORIENTATION

ON

NICU ( NEONATAL INTENSIVE CARE UNIT )

INTRODUCTION

I m pooja from MSc 1st year student from pediatric nursing were posted in NICU

in SGT hospital, gurugram.

OBJECTIVES

 Students are able to :

 Gain proficiency in performing newborn assessment
 Provide safe, holistic and evidence based nursing care to the newborn withcritical needs.
 Maintain thermoneutral environment in NICU.
 Perform/ assist basic and advanced procedures in NICU.
 Participate in continuous monitoring and proactively manage emergencies.

INTRODUCTION

The Neonatal Intensive Care (NICU) aimed to provide comprehensive services to prematureinfant
and their families 24 hr a day.

GOAL OF THE DEPARTMENT:

 High quality patient care with an aim to maximise the longterm outcome of neonates.
 Family centered care and increased patient information /education
 A safe and secure environment for patients, family and staff.
 Consistent delivery of cost-effective but high quality care.

SCOPE OF SERVICES OF NICU

The neonatal ICU is for less than 28 days newborn who may benefit from the skills provided by
the ICU team and from the special resources available in the unit. Most NICU patient are
admitted directly from Labour and delivery, the newborn nursery, or from outside .

ADMISSION CRITERIA

 Need for intensive care or specialised diagnosis of treatment

 Less than 28 days , but upto 90 day

NICU procedures include:

 Endotracheal intubation
 Umbilical line placement
 Chest tube placement
 PICC
 Thermoregulation
 Iv access and maintenance
 Peritoneal Dialysis
 Exchange transfusion
 Hemodynamic monitoring

 Oxygen saturation monitoring

 Total parenteral nutrition
 Surfactant therapy
 Ventilator support including High frequency ventilation plus nitric oxide treatment.
 Promotion of breast feeding and lactation assistance.
 Gavage feeding or PO
 Developmental intervention
 Education of family and parents
Additional Services:
1. NICU provides services to other units or departments as defined:
 Attends high risk deliveries as required in labour.
 Provides physician and nursing consultation assistance in other departments.

2. Kangaroo mother care:

  The hospital promotes KMC in the NICU, for all the preterm and low birth wt babieswho
are hemodynamically stable.

PHYSICAL LAYOUT

Physical facilities: The unit was located in 2nd floor.

Physical set up: The NICU was in a single room with a capacity of 5 beds. There wasa gap of
about 5-6 feet between two radiant warmers/beds for adequate circulation.There were no
facilities of incubators. Each bed had central voltage stabilized electric outlets, oxygen outlets,
compressed air outlets, suction outlets. Additional power plug point were also available.

Temperature of the unit: There was adequate sunlight for illumination. The temperature inside
the unit could be maintained from within the ward only.

Ventilation: The unit had a fair degree of ventilation through central air conditioning.The unit
had laminar air flow system, however alternate air conditioned with multipore filters and fresh
air exchange of 12 per hour was not noted.

Colour: The walls of the whole unit were wash able and had light soothing colors.

Lighting: The lighting arrangement provided uniform, shadow illumination of light atthe baby's
level. In addition, spot illumination was not available for each baby for any procedure. The light
from the warmers were only used for the procedures.

Sounds : The Acoustic characteristics should be such that the intensity of noise kept well below
75 decibels. Though , a quiet environment was maintained , however therewas no facility to
monitor the noise level.

Communication: The parents were called via direct line for communication. Also,visiting hours
and doctors round were pre informed. However, there was no separate counselling room, where
the doctors and parents could coomunicate.
 POLICIES AND PROTOCOLS:

 Admission & Discharge criteria

 Standard Operating Procedures for interventions including but not exclusive of: fluid
management, medications, drug dilution, mechanical ventilation, sedation, nutrition
 Anti-microbial and infection control
 Death and Organ Donation
 Contingency plans regarding fire and unit evacuation.

Future Improvement Plans of the Unit:

o Update protocols and standards to provide a continuing high level of care.

o Improve developmental care of all the babies
o Decrease nosocomial infection rate
o Promote breast feeding and family /parental education

ADMISSION PROTOCOL

NICU admission are done on the basis of following criteria;

 Birth wt <1250 gm2.

 Gestation < 30 wk3.
 Requirement for PPV4.
 Require exchange transfusion5.
 Babies are below 28 days of life
Common reasons for neonatal admission are as follows:

1. Low Birth weight : less than 2500 gm

2. Preterm - less than 36 weeks gestation or Small for gestational age/ IUGR.

3.Infection

a) Meconium aspiration syndrome

b) Sepsis or Shock

4.Respiratory Problems:

a) Hyaline membrane disease/ respiratory distress syndrome

b) Birth asphyxia

5. GI Problems :

a)Jaundice unresponsive to phototherapy

6. Metabolic problems:

a) Metabolic disorders such as hypoglycaemia

7.CNS problems:

a) Seizures and toxins induced seizures

b) Intraventricular haemorrhage/ HIE

8.Malformations

9. Cardiovascular:

a)Polycythaemia

b).On occasions, preterm with congenital anomalies such as cardiac conditions.

10. Miscellaneous

a) Pathological or physiological hyperbilirubinemia/ ABO incompatibility.

 b) For umbilical venous catheterization (UVC)

c) Temperature instability

d) Birth related trauma

TRANSFER OUT IN NICU ARE DONE UNDER FOLLOWING CRITERIA:

• Patient is hemodynamically stable

• Baby can survive without any equipment’s help.

Procedure:

After the concerned physician assess the baby and confirms that the baby can be shifted to
lesser dependant areas and roomed in with mother, the staff transfer out baby to the step
down unit located besides the NICU.

Transportation of critically ill child

Purpose:

 To maintain safety and to prevent deterioration of baby’s condition duringtransport

 To maintain adequate oxygenation.
 To secure continuity of ongoing supportive treatment.

Essential Equipment:

Basic equipment’s are carried by the doctors while transporting the baby from one place to
other.

 Bag and mask, pulse oximeter, glucometer, transport monitor, intubation tray with
allessential articles such as ET tube, laryngoscope, tape etc.
 Oxygen cradle with O2 tubing.
 Emergency medication, fluids and infusionpumps

STAFFING PATTERN

 The head of Department, Critical care along with his team of consultanats and intensivist
isresponsible for implementing the policy of NICU.
 ICU intensivist
 Lecturers/ Associate Intensivist NICU Registrars
 Sister in charges
  Staff Nurse
 Studen Nurse
 Class 4 Workers
 Ratio of Staff nurse: Patient followed in this hospital is 2:1.The total number of Staff
including Incharge is 17.

DUTIES OF STAFF NURSES

 To take admission, screen the baby according to microbiological screening of patients on

admission (including MRSA guideline)
 To ensure that information regarding infection status of both mother and infant is
sought from referring hospital.
 To ensure that infection control precautions are put in place should there be concerns
regarding either the infection status of either mother or infant according to trust
guidelines.
 To complete nursing documentation, including weighchart.
 To nurse the baby in line with current guidelines
 To communicate the baby’s condition to colleagues including handover
 To ensure the parents are updated with the baby’s progress and visiting is documented
 To ensure that the mothers health needs are addressed
 Give advice regarding available midwifery care and contact for local GP
 If baby is receiving enteral feeds, to ensure that breastfeeding if possible is supported
and encouraged and if not, that parental choice regarding type of formula feed is sought.
 Check skin integrity and use neonatal mattresses for at-risk neonate

EQUIPMENTS

Necessary equipment in NICU are:

 Patient care articals:

 Cardiac monitors
 Ventilators
 Capnometers
 Portable X-Ray
 Pulse oximeter
 Sypgmanometer
 CPAP
  Rectal thermometer
 Fluids
 Emergency drugs and its diluents
 Infusion pump
 Laryngoscope with all size blades
 Bag and mask with different sizes of mask
 Radiant warmer / Incubator
 Suction apparatus
 Sterilizer
 Umbilical catheters/ PICC lines
 Transducers for arterial montoring
 GlucometerOther articles:
 Personal protective devices
 Dressing materials
 Oral Airway
 Nasal cannula
 Oxygen hood
 Syringes and needles
 Disinfectants and anti-septic solutions
 All accessories for proper segregation

INFECTION CONTROL PROTOCOLS FOLLOWED IN NICU

All the NICU staff were taught regarding Infection Control Policies. Routine review of policywas
also done.

General care:

• Strict use of cap , gown and mask was done.

• Strict handwashing after entering the ward , and also before and after touching each
patients with soap and water or handrub.

• Handrub solution used was sterillium.

• Restrict visitors only mother is allowed.

• Screening of the personals whenever there is an epidemic

• No sharing of equipments between the patients.

• Terminal cleaning with hypochloride solution

• Surface and floor cleaning with with 2% hypochloride solution once in a shift.
Incubator:

 Clean daily with hypochloride solution

 Terminal cleaning with 5% hypochloride solution

Newborn care:

 Daily bath in the morning.

 Cord care with normal saline once during sponge bath.
 Eye care was also done in every shift.

Universal precaution:

o Use of gloves when handling blood is mandatory.

o Prevention of needle stick injury by avoiding recapping of the needle, discarding
thesharps in puncture proof containers.
o Keeping the spillage kit handy.
o Isolating the septic babies into different NICU and separate staff to look after them.

Cleaning Procedure for Ventilator parts

1. 1st Box: Rinse for 15-20 min

Hot RO/ Distilled water+Mild detergent

2. 2nd Box: Rinse for 15-20 min

Plain RO/ Distilled water

3. 3rd Box: To dry in room

DISCHARGE CRITERIA:

1. The baby has to be gaining weight: it doesn’t have to reach a particular weight, as long as
there is weight gain.

2. The baby should have good sucking.

a. If breast feeding is established , it is not pre requisite that the baby has to be onfull breast
feeding prior to discharge.

3. The baby must be maintaining his//her temperature in a cot in normal room

temperature.
 4. Parents must be willing and happy to take baby home and be able to demonstrate that
they have adequate parenting skills.

5. Assessment of the home environment before discharge. Eg: A patient from remote area
would be less likely to get early discharge in case of low birth wt.

CONCLUSION :

Overall, it was avery fruitful experience from both speciality as well as managerial aspect.
Thestudents gained insight regarding management of diseases, as well as
organisationalmanagement of NICU department.The students are grateful to the teachers and
the college of nursing for guiding them throughoutthe posting and enabling them to learn and
enhance their knowledge and interest in neonatal nursing.