2014

NICU REPORT

Submitted to,
Prof. Mrs. Sonavane M. B.
Principal & HOD child health dept.
INE. Mumbai.
Submitted by, Kedar Vimal

Submitted by
Nagargoje Anita
M.Sc Nursing II year
I.N.E. mumbai
 INDEX
1. GENERAL POLICY OF NICU

2. ADMISSION CRITERIA

3. DISCHARGE CRITERIA

4. ALGORITHIM FOR RESUSCITTATION

5. FLUID MANAGEMENT

6. FEEDING POLICY

7. HYPOGLYCIMEA

8. MANAGEMENT OF NEONATAL SEIZURES

9. MECONIUM ASPIRATION SYNDROME

10. RESPIRATORY DISTRESS SYNDROME

11. NEONATAL HYPERBILIRUBENIMIA

12. NUTRITIONAL SUPPLEMENTS

13. TRANSFUSSION PROTOCLS

14. GUIDELINES FOR ROP SCREENING

15. DOSES OF INOTROPES

16. PROTOCOL FOR VENTILATION AND CPAP

17. RADIANT WARMER PROTOCOLS

18. DEATH GUDELINESS

19. INFECTION CONTROL POLICY IN NICU

20. ANTI-BIOTICS PROTOCOL

21. SYRINGE PUMP PROTOCOL

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NICU PHYSICAL LAY OUT

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 KEYS OF PHYSICAL LAYOUT
1. Toilet

2. Nurses preparation table

3. Nursing station

4. Neonate cubic‟s

5. Isolation cubic

6. Store room

7. Sterilization unit

8. Wash basin

9. Mothers rest bed

10. Mothers room

11. Passage

12. Doors

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 RECORDS MAINTAINED IN NICU
1. Weekly indent book
2. Special indent book
3. Surgical indent book
4. Petty supply book
5. Iv fluid book
6. Gauze cotton book
7. Surgical condemn book
8. Stationary book
9. Empty gas cylinder book
10. Biomedical complaint book
11. PWD book
12. Electrician complaint book
13. Servant complaint book
14. X-ray dispatch book
15. Sprit indent book
16. Lab indent book
17. Special indent book
18. Weekly indent book
19. Weekly injection checking book.
20. Admission book
21. Transfer out book
22. Death book
23. Remaining book
24. Night report book
25. Special report book
26. Staff duty register book
27. Drug record book

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 GENERAL POLICY OF NICU
1. INDUCTION

New residents who will join NICU should receive induction from JR III or lecturer

personally as well as by audio- visual means.

2. DRESSING CODE

a. No jwellery or rings are allowed in NICU.

b. Wearing a gown is compulsory before entering cubicles.

c. If an invasive procedure is being performed the doctor should be wearing a gown,

mask and cap.

3. RECORDS

Need to be dated and timed. The person who makes the entry needs to be signand write

his name and designation at the end of the entry.

4. HAND WASHING

Hand washing protocol should be followed strictly.

5. AIR / WATER SAMPLING

Air and water sampling should be done only in the case of epidemic.

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6. EMERGENCY DRUGS AND INSTRUMEENTS

Need to be checked and signed by the senior resident on call and lecturer every morning.

7. OXYGEN CYLINDERS

Full oxygen cylinders are tagged green and empty oxygen cylinders are tagged red

8. ALL EMERGENCY DUGS TRAYS

Need to be prepared daily.

9. REGISTERS

All registers should be coded with green blue or yellow colour and the list of same is

attached here with.

10. FOLLOW UP CLINIC AND EARLY INTERVENTION CLINIC

Shown to the care taker by resident doctor/intern before or at the time of discharge

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 ADMISSION CRITERIA TO NICU
1. All baby with weight less than 2kg

2. All baby with gestational age less than 34 weeks

3. All baby with history of PROM more than 18 hours in mother

4. All baby with RD persistence even after 2 hours of birth

5. All baby with RD with MSAF

6. All baby requiring intervention in form of bag and mask or bag and tube ventilation

7. Infants of diabetic mothers

8. All baby with birth weight more than 3.750 kg

9. Severe congenital anomalies which may require regular monitoring of vitals

10. PNC baby with RD, Hypoglycemia, convulsion, persistent lethargy,

hyperbilirubenimia, requiring exchange transfusion or who are being to require any

special care or investigation.

11. The same criteria applied to baby not burned at J.J. hospitalexcept that they must

arrive within 24 hours of birth.

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Guidelines for Admission to 1. Birth weight less than 1250g.

Level 3 2. Gestation less than 30 weeks. Some infants born at 30-

32 weeks may be admitted to Level 3 because of

staffing acuity.

3. Requirement for intermittent positive pressure

ventilation.

4. Requirement for an exchange transfusion.

5. Any other baby whose clinical condition is such that

they cannot be appropriately cared for in Level 2.

Guidelines for Admission to 1. Low Birth weight - under 2500g.

Level 2 Some babies between 2000 and 2500g may be able to

go directly to the postnatal ward.

This will depend upon the clinical assessment of the

baby and whether the postnatal ward is deemed likely

to provide an appropriate level of care or not.

2. Prematurity - 36 weeks gestation or less.

For babies between 35 and 36 weeks gestation, criteria

as in (1) apply.

3. Infection - suspicion of infection together with clinical

concern.

4. Respiratory problems

(a) Apnea or cyanotic episodes.

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 (b) Any respiratory distress causing concern.

(c) Persisting signs of respiratory distress for more than

one hour.

5. Gastrointestinal problems

(a) Feeding problems severe enough to cause clinical

concern.

(b) Bile stained vomiting, or other signs suggesting

bowel obstruction.

6. Metabolic problems

Inability to maintain a serum glucose concentration

greater than or equal to 2.6mmol/L despite adequate

feeding.

7. CNS problems

(a) Convulsion.

(b) Moderate birth asphyxia, which may require

monitoring for an initial period to ensure problems do

not ensue.

8. Malformations

Congenital anomalies that may require intervention

unavailable on the postnatal wards, or an initial period

of observation, eg Pierre Robin Syndrome.

9. Cardiovascular

Problems requiring monitoring or intervention

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 unavailable on the postnatal wards.

10. Miscellaneous

Any baby that is causing concern to such a degree that

the attending doctor or NS-ANP feels that the baby

requires observation or treatment in Level 2. It is better

for a baby to be admitted unnecessarily than for a baby

requiring admission to be left on the ward.

11. Social issues/terminal care

Such babies ideally be nursed on the ward with

parents, or at home. On occasions (after

multidisciplinary consultation) circumstances dictate

that these babies require a period of care on Level 2.

Discharge of Low Birthweight Infants

Infants that have been born at very low birthweight or low birthweight, represent an at risk group

of children. Increasingly they are being discharged home at a weight less than 2.5kg. The

following guidelines are suggested when considering discharge of such infants.

1. The baby has to be gaining weight – it doesn't have to have reached any particular

weight, however, as long as there is weight gain.

2. The baby has to be sucking all feeds.

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 If breast feeding is being established, it is not a prerequisite that the baby is on full breast

feeding prior to discharge, provided we are happy that the baby is able to suck strongly.

However we must be sure that the mothers are aware of the need to continue to monitor

progress once further feeding changes are made at home, i.e. a switch from

complementing to fully breast feeding etc.

3. The baby must be able to maintain his or her temperature in a cot in a normal household

environmental temperature.

This is particularly important when discharging low birth weight babies home in the

winter.

4. Parents must be willing and happy to take the baby home and to have demonstrated

that they have adequate parenting skills.This may be self-evident, particularly when there

have been other children in the family, although not always.

5. Some basic information should be known about the home environment and the

community to which the infant is going, i.e. if they are living in a remote area in a

caravan, then one would be less likely to effect a discharge home at a low birthweight.

6. There should be adequate community follow up services available.

It may be appropriate to contact the general practitioner by telephone to discuss follow

up. In remote areas details should be known about the availability of a Well Child Service

visiting. The neonatal home care nurses will be able to provide some initial support and

follow up and to provide liaison for ongoing community follow up.

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Transfers & Discharges from NICU and PIN

Transfers from Level 3

1. For transfers from Level 3 to Level 2 or PIN a formal transfer should occur between

Level 3 Registrar or NS-ANP and the appropriate registrar or NS-ANP.

2. Ideally the parents would have been told a few days in advance to accustom to the

transfer and possibly have looked around Level 2 or PIN.

3. A transfer letter should be in the notes (and should also be sent to the LMC/GP).

4. The problem list should be up-to-date (as should happen when a discharge/transfer

summary is prepared)

For infants discharged from Level 2

1. Babies transferred to PIN need a formal letter if they have had a complicated course

whilst in Level

2. If they have had a recent transfer summary from Level 3 to Level 2, this may not be

necessary.

1. Babies who are transferred to PIN should have an up-to-date problem summary in

the notes

2. Babies transferred to other hospitals must not go without a registrar or NS-ANP

letter.

3. Babies being transferred to towns outside the Auckland area should have a formal

letter prior to discharge.

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Discharge Documentation

All patients discharged from hospital must have:

1. A full examination record on the appropriate form (include age in days, weight, length,

head circumference).

2. A plan for follow up clearly documented in the case notes.

3. A record of any prescribed therapy.

Discharge Letters

1. No baby is to be discharged from Level 3, Level 2, or PIN without a letter.

2. For babies who are being discharged to the postnatal wards and where there are going to

be delays in generating a discharge letter, the baby can be discharged with out a letter

being available. However, it is the responsibility of the resident team (registrar or NS-

ANP) to ensure that a letter is completed as soon as possible and is filed in the notes of

the baby.

3. PLEASE ENSURE that the discharge letter contains the correct information.

1. The database can only use the information available within it.

2. It provides a structure for the letter, and makes an attempt at providing a letter

that is nearly complete.

3. You need to check the letter you have produced and edit it in Word.

4. The quality of the letters you sign your name to reflects on your abilities as well

as the quality of the care that the baby has received in NICU.

5. Please check and edit the letters before you sign them and send them off.

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ALGORITHM FOR RESUSCITATION OF NEWLY
BORN INFANT
Clear of meconium ?
Breathing or crying? Routine care
YES
Good muscle tone? Provide warmth
Colour pink? Dry the baby
Term gestation? Clear

NO
Provide warmth
Position Clear airway as necessary
Dry stimulate reposition.
Give O2 as necessary

Evaluate respiration heart rate BREATHING

Supportive care
and colour. HR>100 & PINK

APNEA or HR<100
Provide positive pressure HR > 100
ventilation. Ongoing care
And PINK

HR <60 HR>60

Provide positive pressure

ventilation.
Administer chest compression

HR<60
Endotracheal intubation may
Administer epinephrine be considered

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 INFECTION CONTROL POLICY IN NICU
Infection prevention is an important component of care of newbornbaby .babies are more

susceptible to infection because of their poor immune status.

GENERAL PRINCIPLES IF INFECTION PREVENTION

Observing the infection prevention practices below will protect the baby, mother, and health care

provider from infections. This will also help to prevent spread of infection.

1. Provide routine care of the new borne baby

2. Consider every person including baby , mother and staff as as potential source of

infection.

3. Through hand washing with soap or alcohol based hand scrub must before and after

touching each baby.

4. Wear protective clothing such as gown whenever necessary.

5. Use barrier nursing practice whenever indicated such as use of gown , mask and gloves

etc…

6. Use aseptic precaution whenever necessary.

7. Handle sharps carefully, clean, sterile or disinfect instruments and equipment‟s.

8. Routinely clean the newborn special care unit, and dispose of waste immediately.

9. Isolate babies with infection to prevent spread of infection to other babies.

10. Special precaution while dealing with babies with infection, strict use of barrier nursing.

11. Strict restriction of visitors and health team members with upper respiratory tract

infections

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 BIOMEDICAL WASTE MANAGEMENT AND
HANDLING GUIDELINES
 BMW rules were formed under environment protection act, 1986 by the Ministry of

Environment and forest, Government of India.

 BMW management and handling rules were implemented in 20thjuly 1998.

 The guideline have been prepared to enable each hospital to implement the said rules.

 Further amendments of the Bio medical waste (management and handling) rules 1998

were done by by the government of india in the year of 2000 and 2003.

 These rules apply to all person who generate , collect, receive, store , transport,treat,

dispose or handle biomedical waste in any form. Whosoever found breaching these rules

is liable to punishment in the form of 6 months imprisonment and penalty of up to Rs

25,000/-.

Why do we need proper Hospital waste management?

Poor hospital waste management is associated with health hazards like :

1. Injuries from sharps to all categories of hospital personnel.

2. Noscomial infection in patient due to poor infection control and poor Hospital waste

management.

3. Risk of infection outside hospital to waste handlers, scavengers and eventually the

general public.

4. Risk associated with hazardous chemicals, drugs being handled by persons handling

waste at all level.

5. Disposals- recycled-repacked and sold without treated.

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Biomedical Waste means any waste , which is generated during the diagnosis, treatment or

immunization of human beings or animals or in research activity.

Categories of Bio-medical Waste:

Categories Type of waste

Category 1 Human anatomical waste

Category 2 Animal waste

Category 3 Microbiology and biotechnology waste

Category 4 Sharp waste

Category 5 Discarded medicines and cytotoxic drugs

Category 6 Soiled waste

Category 7 Solid waste

Category 8 Liquid waste

Category 9 Incineration ash

Category 10 Chemical waste.

SEGRATION OF WASTE:

1. Segregation of waste should be done at the site of generation.

2. The responsibility of segregation should be with the generator of biomedical waste.

3. Bio medical waste should be segregated as per categories applicable.

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Why is it necessary to segregate waste?

By segregation of waste a hospital can:

1. Reduce the total treatment cost of waste disposal.

2. Reduce the impact of the this waste on the community.

3. Reduce the chance of infection to health care workers.

Collection of Bio-medical Waste

Color coded bags Type of waste

Yellow Bags Human anatomical waste, e.g. human tissues, organs, amputed

limbs, placenta, animal carcass etc.

Red Bag Soiled dressing & infected plastic tubing‟s, cut syringes, blood

bags.

Red and yellow bags to be taken to designated room near oxygen cylinder between 11:30am -

12:30 pm

Black Bag ( Dry waste) General office waste e.g. papers wrappers etc.

Black bag (Wet waste) Left over food, peels of fruits &vegetables

Black bag to be taken to dumping ground –between 8 Am to 8 PM

Puncture proof Container Sharps: needles, scalpel blades, glass etc.

Used needles tip should be burned in needle burner & tips of syringes should be cut with the

needle cutter.

Use of 1 % hypochlorite for disinfection of needles, syringes, gloves & I.V. Tubing‟s

Card board box Used glass bottles, saline bottles, Packing materials

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LOCATION OF CONTAINER:

All containers with different color coded bags should be located at the point of generation of

waste, i.e. wards, near OT tables, in injection rooms, diagnostic services areas, dressing trolleys

, injection trolleys, etc.

LABELLING:

All the bags/ containers must be labeled with bio-hazard symbols, according to the rules

(schedule III of Bio-medical waste rules 1998)

Labeling on Bag should include:

Ward number, name of hospital,

Name & sign of sister incharge

Date of transportation.

BAG:

It should be ensured that the waste bags are filled only up to three, fourth capacity, tied securely

and removed from the site of generation to the storage area regularly and thriley.

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THE QUANTITY OF COLLECTION SHOULD BE DOCUMENTED IN A REGISTER:

Date Time No of No of red No of Puncture Sign of Sign of

yellow bags black proof staff receiver
bags bags containers nurse

STORAGE OF WASTE:

No untreated biomedical waste shall be kept stored beyond 48 hrs.

SAFETY MEASURES:

Personal protective equipments like:

1. Gloves:- disposal gloves, heavy duty rubber gloves, till elbows 9 for cleaners)

2. Masks:- to prevent against aerosols, splashes and dust

3. Protective glasses/ eye shield

4. Plastic aprons

5. Gum boots

6. Any worker reporting with an accident/ injury due to handling of BMW shall be given

prompt aid.

7. All accidental injury should be reported to in charge, should be recorded and should

mention the nature of accident , when & where it occurred, emergency measures taken

following the accident.

8. Person should be immediately referred to ART centre / Ward 12 for PPE.

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 HYPOGLYCEMIA
Blood glucose to be routinely estimated in following conditions-

1. SGA babies and smaller of discontent twins

2. Pre term babies less than 34 weeks

3. Rhesus hemolytic disease of newborn

4. Symptoms suggestive of hypoglycemia

5. Prolonged hypoxia, hypothermia, polycythemia, septecimiea, cardiac failure and

suspected metabolic disease.

6. Infant born to mothers receiving therapy with terbutaline, propranolol and oral

hypoglycemia agents.

7. Infants on IV fluids

8. LGA babies and IDM – sugar to done at 0, 1,2,3,6,12,24, 36, 48 , hours of life.

ALOGORYTHM FOR MANAGEMENT OF NEONATAL HYPOGLYCEMIA

HIGH RISK NEONATES

ASYMPTOMATIC SYMPTOMATIC

Levels > 45- 50 with Levels low with feeds Give bolous 2ml /kg
feeds or doesn’t take feeds of 10 % dextrose
followed by iv
glucose 8 mg /kg/min

Continue feeds and Start iv glucose at the

monitoring rate 6mg/kg/min.

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  After nursing IV Glucose sugar to be monitored every 30 minutes. If sugar levels are still

low glucose drip Rate ( GDR) TO BE INCREASED BY 2 mg/kg/min.

 If despite receving GDR> 12 mg/kg /minute baby is hypoglycemic considered adding

hydrocortisone 10 mg/kg/d iv in two divided doses .

 Glucagon 0.025- 0.3mg/kg im (max 1 mg) can be given to hyogycemic infant with good

glycogen stores

 DIAZOXIDE ( 2-5mg/kg/do) orally after 8 hours for infants with persistent

hyperinsulemia.

FEEDING POLICY:
1. The optimal care is for all babies to receive breast milk only. This policy addresses those

infants who do not need IV fluids and whose mothers have not established a breast milk

supply.

2. In general, IV infusions should not be started if there are no medical indications for IV

fluids (such as respiratory distress, hypoglycaemia etc.)

3. Babies who need feeding should be given what mother‟s breast milk is available and

always receive mother‟s breast milk in preference to formula. Be sure to check that no

breast milk is available before considering infant formula.

4. If they require additional feeds, infants should then be started on term infant formula,

after discussion with their mother/father. In such discussions, parents should be informed

that there are few - if any - adverse effects of formula used short term in this way in a

neonatal unit. Click here to review the evidence supporting this policy.

5. For a baby who is already on an IV infusion, it is reasonable to continue the infusion for a

short time if mother‟s milk supply is being established and there is a reasonable

23
 expectation that she will be producing enough breast milk with in a day or so. This time

period needs to be judged against the ease of IV access and the condition of the baby.

Babies should not have IVs re-inserted solely because no breast milk is available.

6. Smaller preterm infants will often have a medical indication for ongoing IV fluids and in

them it is desirable to increase the oral fluids slowly. The pace of increase of oral fluids

can usually be matched to the increase in the availability of expressed breast milk.

7. Mothers should be advised and helped with expressing. NICU staff should discuss

expressing as soon as possible. It is accepted that the role of initially helping with

expressing lies with postnatal ward staff. NICU staff should support mothers‟ expression

of breast milk.

8. Nasogastric feeding rather than bottle or cup feeding is advantageous for ex-premature

babies. Term babies who do not have problems with hypoglycaemia can usually

transition directly from IV fluids to breast feeds. Alternatively, bottle or tube feeds may

be used for larger infants.

9. NICU does not provide hydrolysed formula unless there is a clinical indication (other

than a history of allergy). If there is a very strong family history of allergy, hydrolysed

formula may be supplied on an individual basis. Parents may supply

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 EXPRESSION OF THE BREAST MILK
1. Take all aseptic precautions possible.

2. Massaging the breast before expression of milk.

a. Take a sterile wati, with a warm towel ,wrap the breast for at least 5 minutes.

b. With two finger, using their pulp in circular motions massage breast.

Alternatively knuckles are used.

c. Massage breast towards the nipples as if kneading dough, continue without

hurting the mother.

d. Provide massage for atleast 5-10 minutes on each breast before expression of the

milk.

3. Teach mother to express the breast milk.

a. Wash hands thouroughly.

b. Sit comfortably, and hold the sterile container near the breast.

c. Make her put her thumb on her breast above the nipple and areola, and put her

first finger on the breast bellow nipple and areola, opposite to the thumb. And ask

her to support her breast by her own hand.

d. Press the thumb and the first finger slightly inward towards the chest wall.

e. Press the breast area behind the nipple and areola ,and than release.

f. Expression of breast atleast for 3-5 minutes until flow slows, then express the

other side.

g. Express 6-8 times a day.

h. To sustain the milk flow in a mother who has her baby sick , should express every

3 hourly.

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4. Breast pump can be also used to express the breast milk.

EXPRESSION OF BREAST MILK WITH PUMP

EXPRESSION OF BREAST MILK MANUALLY

26
 WEIGHT RECORDING

1. Carbonize the weighing machine daily with 2 % hypochlorite solution.

2. Assemble all needed supplies and equipment before starting to weigh the baby.

3. Place the weight scale on flat surface.

4. Hand wash should be done.

5. Put a clean cloth on the scale pan.

6. Deduct the towel‟s weight to ensure accuracy.

7. Tare and zero the scale

8. Keep the baby naked on the weighing scale.

9. Weigh the baby as quickly as possible.

10. Recording of the weight should be done prior to the feeding.

11. Be alert , and care full in order to prevent fall of neonate..

12. Do not leave the baby unattended for even a moment.

13. Record the weight .

14. Dress the newborn. Use a clean diaper.

15. Place the newborn back in the crib.

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28
 OXYGEN THERAPY BY HOOD

Oxygen is a gas that the cells in your body need to work properly. The air we breathe normally

has 21% oxygen. A maximum of 100% oxygen can be given.

WHY IS OXYGEN USED?

Babies with heart or lung problems may need increased amounts of oxygen.

HOW IS OXYGEN DELIVERED?

There are several different ways to deliver oxygen to a baby. It depends on how much oxygen is

needed and whether the baby requires a breathing machine.

An oxygen hood is used for babies who can breathe on their own but still need extra oxygen. A

hood is a plastic dome or box with warm, moist oxygen inside. The hood is placed over the

baby's head.

A thin, soft, plastic tube called a nasal cannula may be used instead. This tube has soft prongs

that gently fit into your baby‟s nose. Oxygen flows through the tube. The baby must be able to

breathe without assistance in order to use this type of oxygen therapy.

Another alternative is a nasal CPAP system. CPAP stands for continuous positive airway

pressure. A CPAP machine delivers oxygen through tubes with soft nasal prongs, but the air is

under higher pressure, which helps the lungs better expand (inflate).

Finally, a breathing machine or ventilator may be needed to deliver increased oxygen to the

baby. The oxygen flows through a tube placed down the baby's windpipe.

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WHAT ARE THE RISKS OF OXYGEN?

Too much or too little oxygen can be harmful. If the cells in the body receive too little oxygen,

energy production is decreased. With too little energy, cells may not work properly and may die.

Your baby may not grow properly. There is risk for injury to many of the developing organs,

including the brain and heart.

However, too much oxygen can also cause injury. Breathing too much oxygen can cause injury

to the lung. Under certain conditions, too much oxygen in the blood may also lead to problems in

the brain and eye. Babies with certain heart conditions may also require lower levels of oxygen

in the blood. Your baby‟s doctors and nurses try to balance how much oxygen is needed to

minimize the risks of too little or too much oxygen. If you have other questions regarding the

risks and benefits of oxygen in your baby, you should discuss these with your doctor.

WHAT ARE THE RISKS OF OXYGEN DELIVERY SYSTEMS?

Infants receiving oxygen by hood may get cold if the temperature of the oxygen is not warm

enough.

Most (but not all) nasal cannulas use cool, dry oxygen. At higher flow rates, this can lead to

irritation of the inner nose, such as cracked skin, bleeding, or mucous plugs in the nose. This can

increase the risk for infection.

Similar problems can occur with nasal CPAP devices. Also, some CPAP devices use wide nasal

prongs that can distort the nose.

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INSTRUCTION FOR NURSES:

1. Initiate the required flow as confirmed with confirmed using flow meter.

2. Minimum water levels to be kept in the humidifier.

3. Always a sterile set of humidifier and tubing set to be used.

4. Monitor baby for the respiratory rate, saturation, colour and distress.

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 FIXATION OF INTRAVENOUS CANNULA

1. Wash hands and take all aseptic precaution.

2. Prior prepare all the required materials like jelco, three way- attached flush, cleaning

material, sterile cotton swabs, sticking plaster, splint etc…

3. Suitable vein is identified.

4. Skin is prepared with betadine and spirit.

5. Assist the physicaian, by holding the extremity proximally and making the vein more

prominent.

6. Once canula is in, help in securing and immobilization of the joint proximal to it with

adhesive and splints.

7. Attach the intravenous line and adjust the required rate.

8. Document the time and date of insertion of the cannula.

9. Monitor for extravasation ( swelling and redness), leaking from the canula site, blockage

(non passage of the fluids)

10. While administering drugs:

a. Check and ensure the patency of the cannula with 0.4 ml of normal saline.

b. Remove the cap of jelco on sterile surface .

c. Administer the drug and reflushnthe cannula to clear the drug from the line.

d. Replace the cap.

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 TEMPERATURE MAINTENANCE:

1. Temperature of the baby is maintained as per the season.

2. Routinely temperature is documented every 2 hourly. But if baby is having hypothermia

or hyperthermia check after every 15 mins. Till temp. is normal.

3. Rectal temperature is taken for more accurate reading.

4. Thermometer is cleaned with soap and water, wiped and then used .recatl thermometer

are lubricated with paraffin before use. Insert thermometer 2-3 cm deep it is than

removed after 1 min. and take the reading.

5. Overhead warmers are used to maintain the desaired body temperature.

6. In case baby is having HYPERTHERMIA:

a. Expose the baby.

b. Switch on the selling fan.

c. In between check the body temperature to prevent hypothermia.

7. In case baby is having HYPOTHERMIA:

a. Room heaters and over head warmers are used to maintain the desired body

temperature.

b. Cover the baby with warm clothes.

c. Actively warm the baby- warm clothes should always be checked for the warmth

on dorsum of the hands and then put to the babies surface.

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OVER HEAD WARMER USED IN NICU.

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ROLE OF NURSE

HEAD NURSE:

1. The Charge Nurse (CN) has shift responsibility within the clinical setting to

ensure the safety and well-being of all patients' on the assigned unit.

2. Facilitates the placement of patients based on acuity and staffing within

assigned departments.

3. Acts as a clinical resource to assist with admissions and discharges.

4. Acts as a liaison and resource to nursing staff , troubleshoots and facilitates.

5. Collaborates with Administrative Supervisor and manager regarding daily

staffing.

6. Takes direct patient care assignment as needed and is held accountable for

patient safety, quality and financial implications of the unit.

7. Assures continuity of care and flow on assigned unit.

8. The CN is clinically involved in daily care activities on the unit and will be

assigned administrative days as deemed appropriate by the Manager/Director.

9. Establishes appropriate contacts with attending physicians/consults and other

involved healthcare professionals as necessary to ensure timely admissions and

discharges.

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 10. Delegates tasks and duties to appropriate team members in accordance with the

patient's appropriate information re: patient condition or concerns to other

healthcare team members to provide the necessary care for the patients.

11. Is proficient in communication skills and interpersonal relationships

12. Practices effective problem identification and resolution.

13. The CN is responsible for human resource management to achieve quality

services and positive employee relations.

14. Performs all other duties as assigned

STAFF NURSE:

Under general nursing and medical direction, utilizing standard procedures, the Nurse Practitioner or

Physician Assistant functions within an organized system for the delivery of health care in

association with other members of the health care team and performs specialized nurse practitioner

duties in clinical settings.

In collaboration with the physician, the essential job functions include:

1. Managing patient care of newborns and pediatrics, assisting with the admission assessment

and discharge of these patients;

2. Providing health education and counseling to patients;

3. Maintaining medical records;

4. Participating in nursing and unit staff meetings and patient care conferences;

5. Performing other related duties as assigned/required.

36
6. Under general supervision of the Director of Perinatal Nursing, the NICU/Pediatric Nurse

Practitioner or Physician Assistant performs specialized clinical nursing duties and serves as

the clinical expert for the neonatal inpatient population. The essential job functions include

the following:

a. Functions as part of the NICU clinical team;

b. Provides and/or manages the nursing plan of care for neonates with complex

problems;

c. Provides education, training, information, and consultation services to physicians,

registered nurses, and other members of the clinical team;

d. Interprets, coordinates, and implements new and existing policies, methods and

procedures for neonatal nursing in the Perinatal areas;

e. Keeps informed of current practices and trends and incorporates them into practice;

f. Works in cooperation with other members of the multidisciplinary health teams;

g. Makes professional contacts with a variety of public, private and professional

institutions/organizations;

h. Performs other related duties as assigned/required.

37
PEOPLE AS SOURCES OF INFECTION

Sepsis is the most common cause of mortality and morbidity in the nursery. Every hospital

should establish special policy to prevent infection of newborn in baby care area.

Newborn is usually free from harmfull organisms for initial few hours of life. It‟s the hospital

staff or relatives or even the mother tend to spread infection to baby and colonization of

pathogenic organisms.

Prevention of infection is the very cost effective than treatment of neonatal sepsis.

BASIC REQUIREMENTS FOR ASEPSIS IN NEWBORN CARE AREA:

1. Locate the newborn special care unit in a low-traffic area with restricted access.

2. Have a separate room (cubicles) for newborn babies, if possible.

3. 24 hours running water supply.

4. Soap

5. Elbow or foot operated taps.

6. Strict hand washing.

7. Promotion of breast feeding

8. Do not allow staff or visitors to enter the newborn special care unit if they have an acute

infection (e.g. respiratory virus)

9. Limit the number of individuals handling the baby.

10. Plenty of disposables.

11. Rational antibiotic policy.

12. Ggodhouse keeping and waste disposal.

38
GUIDELINES FOR ENTRY INTO BABY CARE AREA:

1. Remove shoes , socks, chapels, watch, rings, bangles, dupatas, apron.

2. Nails should be cut short.

3. Tie up the hairs if long.

4. Roll up the full sleeves up to the elbow.

5. Put on new sleepers, do not go bare foot.

6. Wash the hands with soap and water for 2 minutes following the six steps of hand

washing before entering baby care area.

7. Put on sterile grown.

POLICY REGARDING VISITORS:

1. Person with active infection should not be allowed to enter in NICU

2. Avoid over crowding.

3. Mothers are always welcome, attached mother room to baby care area is very convenient.

4. Father should be allowed to enter at the time of admission.

5. Mothers should be taught , guided and supervised about proper hand washing, good

hygiene.

39
 FEEDING POLICY

1. All babies are feed every 2 Hourly either by breast feed, or orogastric tube or by wati

spoon.

2. ONLY human milk is given.

3. Sero positive mothers are given option of breast feeding or top feeding and their babies

are accordingly fed.

4. Milk bank support is taken in particular cases like preterm, and cesarian section.

5. Wati-spoon, bondla, trays used is autocalved each time post feed.

6. Organize feeding: measured length (from nose to ear pinna and to xipoid process) of a

sterile got tube is inserted through the mouth.

7. Position of tube is checked by aspirate or by auscultation.

8. Look for any change in colour , chocking in the tube.

9. Feed the child and let the milk flow with the gravity.

10. Post feeds the ogt is kept closed and the baby put prone with head end at the higher level

than the legs.

11. Wati-spoon feeding: wash hands and collect milk in a sterile wati. Get the baby wrapped

in prewarmed clothing. Hold the baby in semi upright position in lap and feed slowly

with a spoon. Do not pour the feeds in the mouth but let baby suck from the spoon.

40
 INITIATION OF KANGAROO MOTHER CARE:

1. Counseling: tell all the benefits of KMC to the mother sand relatives.

2. Ask mother to wear light clothes.

3. Provide warm place for her.

4. Respect her privacy while providing KMC.

5. Baby should be kept naked except cap, socks and nappy.

6. Baby should be kept naked on the mothers chest in between her breast in a upright

position.

7. Head should be kept turned to one side and in slightly extended position. This allows

keeping the air way open and maintaining eye contact.

8. Avoid forward flexion or hyperextension of the head.

9. Babys hip should be flexed and abducted, elbows flexed, with in abdomen lying on the

mother epigastrium. This provides enough room for the babys breathing.

10. KMC actually makes breast feeding easier and holding baby near the breast stimulates

milk production.

11. KMC started earlist as soon as baby is stable. Short KMC is initiated while baby is on

recovery.

12. Each session should be lest be of half an hour or frequent handling may be stressful for

the baby.

13. Session are latter gradually increased only interrupted for the change of diapers.

14. Mother is to relax on easy chairs at an angle 15 degree from the horizontal.

41
IDEAL POSITION OF BABY DURING KMC

42
THE TWO COMPONENTS OF KMC ARE:

i. Skin-to-skin contact

Early, continuous and prolonged skin-to-skin contact between the mother and her baby is

the basic component of KMC. The infant is placed on her mother's chest between the

breasts.

ii. Exclusive breastfeeding

The baby on KMC is breastfed exclusively. Skinto- skin contact promotes lactation and

facilitates the feeding interaction.

THE TWO PRE-REQUISITES OF KMC ARE:

i. Support to the mother in hospital and at home

A mother cannot successfully provide KMC all alone. She would require counseling

along withsupervision from care-providers, and assistance and cooperation from her

family members.

ii. Post-discharge follow up

KMC is continued at home after early discharge from the hospital. A regular follow up

and access to health providers for solving problem are crucial to ensure safe and

successfulKMC at home.

BENEFITS OF KMC:

Breastfeeding: Studies have revealed that KMC results in increased breastfeeding rates as well

as increased duration of breastfeeding. Even when initiated late and for a limited time during day

and night, KMC has been shown to exert a beneficial effect on breastfeeding.

43
Thermal control: Prolonged skin-to-skin contact between the mother and her preterm/

LBW infant provides effective thermal control with a reduced risk of hypothermia. For

stable babies, KMC is at least equivalent to conventional care with incubators in terms of

safety and thermal protection.

Early discharge:: Studies have shown that KMC cared LBW infants could be discharged

from the hospital earlier than the conventionally managed babies. The babies gained

more weight on KMC than on conventional care.

Less morbidity: Babies receiving KMC have more regular breathing and less

predisposition to apnea. KMC protects against nosocomial infections. Even after

discharge from the hospital, the morbidity amongst babies managed by KMC is less.

44
 KMC is associated with reduced incidence of severe illness including pneumonia during

infancy.

Other effects: KMC helps both infants and parents. Mothers are less stressed during

kangaroo care as compared with a baby kept in incubator. Mothers prefer skin-to-skin

contact to conventional care. They report a stronger bonding with the baby, increased

confidence, and a deep satisfaction that they were able to do something special for their

babies. Fathers felt more relaxed, comfortable and better bonded while providing

kangaroo care.

PEOPLE AS A SOURCE OF INFECTION

Sepsis is the most common cause of mortality and morbidity in the nursery. Every

hospital should establish special policy to prevent infection of newborn in baby care

area.

New born is usually free from harmfull organisms for initial few hours of life. It‟s the

hospital staff or relatives or even the mother tend to spread infection to baby and

colonization of pathogenic organisms.

Prevention of infection is the very cost effective than the treatment of neonatal sepsis.

BASIC REQUIREMENT FOR ASEPSIS IN NEWBORN CARE AREA:

1. Locate the newborn special care unit in low-traffic area with restricted access.

2. Have a sepraterrom (cubicles) for newborn babies, if possible.

3. 24 hours running water supply

4. Soap

45
 5. Elbow or foot operated taps

6. Strict hand wahing.

7. Promotion of breast feeding.

8. Do not allow staff or visitors to enter the new born special care unit if they

have fan acute infection.

9. Limit the number of individuals handling the baby.

10. Plenty of disposables.

11. Rational antibiotic policy.

12. Good house keeping and waste disposal.

GUIDELINES FOR ENTERING INTO BABY CARE UNIT:

1. Remove shoes, socks, chappals, watch, rings bangles, duptas, apron.

2. Nail should be cut short.

3. Tie up the hair if long.

4. Roll up the full sleves up to the elbow.

5. Put on sleepers of NICU before entering.

6. Wash hands with water for 2 minutes following 6 steps of hand washing.

7. Put on sterile gown.

46
HAND WASHING
Hand washing is the simplest and most effective way to of preventing the transmission of

infection and thus reducing the incidence of health care associated infections.

Two minutes hand washing with six steps to be done before entering the unit. 20 seconds

hand washing is to be done before and after touching each baby.

Wash hands with soap and water if they are visibly claen. Disinfect them with using

alcohol based scrub.

Instruct the mother and the family members to wash their hands before and after handling

the baby.

INSTRUCTION TO WASH HANDS:

1. Thouroughly wet the hands.

2. Wash hands for 10-15 seconds with plain soap and running water.

47
 3. Allow hands to air dry or dry them with sterile paper or towel.

4. An alcohol based hand scrub is more effective in cleaning hands than hand

washing unless the hands are visibily soiled.

SKIN PREPRATION:

It is the most important step to avoid the entry of pathogenic organisms during any

invasive procedures e.g. intravenous cannulisation, pricks, procedure. Always were

sterile gloves after 2 minutes f hand washing.

 Wash and dry hand.

 Wear sterile gloves

 Prepare skin site confined to smallest possible area.

 Swab with the spirit, allow to dry

 Apply betadine and allow to dry

 Again clean it with spirit to wipe of the betadine and let it air dry.

48
 Skin is now ready for prick.

49
50
 HOUSE KEEPING AND DISINFECTION

EQUIPMENT DISINFECTION ROUTINE

Rooms Hypochlorite 2% Once in every shift mopping

Walls Hypochlorite 2% Once in every shift mopping

Fans Wet clean clothes Once in week

Windows With soap and water Once in week

Refrigerator Defrost and clean with soap Once in week

and water

Buckets Soap and water Once in week

Sinks/washbasin Detergent and water Daily in morning shifts and as

and when required

Basinets/ platforms/ Hypochlorite 2% Use daily as and when

radiant warmer required

Baby linen Wash, dry, autoclave Use autoclave linen each time

Cotton / gauze Autoclave As required

Feeding utensils Wash with soap and water, Before each use

dry, autoclave

Injection trays, medicine Wash with soap and water, Daily morning shift

trays, swab containers dry, autoclave

Set of procedure Wash with soap and water, After each use/ every 72 hrs

51
 dry, autoclave

Steel drum Wash with soap and water, After use and every 48 hrs.

dry, autoclave

Stethoscope, measuring Clean with spirit swab Daily

tape, probes of radiant

warmer, pulse oximetry,

skin thermometer

Rectal thermometer Clean with soap and water After and before each use

and dry

Laryngoscope Blade and handle are after each use remove bulbs

cleaned with spirit swab and cells. Wash with soap and

after dismantling, bulbs are water, dry, wrap in autoclaved

removed and cleaned with linen put date and time if not

spirit. used every 72 hrs.

52
 AUTOCLAVING
PRECAUTIONS FOR AUTOCLAVING:

Before Use

 Attempting to operate an autoclave without proper training from someone familiar with the unit

can cause serious injury or insufficient sterilization of its contents. If training is not an option,

reading the instruction manual and following the manufacturer's directions helps to avoid

accidental injury and promote proper operation of the autoclave.

Loading

 To achieve adequate sterilization, avoid overloading the autoclave, autoclave bags, or containers.

Prevent glass containers from exploding by loosening their caps before placing them in the

autoclave. When loading is complete, securely lock the door to enable a tight seal and avoid

burns from the release of steam.

Protective Gear

 Protective gear includes insulated gloves, safety goggles, lab coats, rubber aprons, and rubber

boots. Wear insulated gloves when unloading the hot contents of the autoclave or allow the items

to remain inside until cooled. When you open the autoclave door at the end of the sterilization

cycle, wearing rubber boots prevents burns on your feet due to an accumulation of condensed

steam pouring out of the unit. When sterilization is finished, open the autoclave slowly, using the

door as a shield to protect your body from injury due to the sudden release of trapped steam.

53
 Glass Precautions

 Liquids continue to boil after the sterilization cycle is completed. To avoid fracturing, glass

containers filled with liquid must remain in the autoclave for cooling prior to removal. Carefully

remove glass containers from the sterilization unit to prevent shattering by accidentally hitting

the containers against the autoclave walls.

Unloading

 Opening the autoclave and the actual physical process of extracting the enclosed materials

presents you with maximum exposure to injury. Your face, hands and arms are more susceptible

to injury from escaping steam and accidental contact with the autoclave walls during this phase

of the sterilization procedure. After the pressure level inside the autoclave registers zero, wait a

few minutes before opening the unit to reduce the potential for burns.

Maintenance

 Adherence to proper maintenance of the autoclave is required to insure the safety of you and the

efficiency of the sterilization process. Follow the manufacturer's recommended maintenance

schedule and use technicians qualified to provide this service. Check the efficiency of the

autoclave with sterilization indicator strips that contain live Bacillus spores. By changing color

during the sterilization process, the chemically treated strips verify the death of the spores and

the successful completion of sterilization.

54
STEAM PRESSURE DURING AUTOCLAVING:

A medical autoclave is a device that uses steam to sterilize equipment and other

objects. This means that all bacteria, viruses, fungi, and spores are inactivated.

However, prions, like those associated with Creutzfeldt-Jakob disease, may not be

destroyed by autoclaving at the typical 134 °C for 3 minutes or 121 °C for 15 minutes.

Also, some recently-discovered organisms, such as Strain 121, can survive at

temperatures above 121 °C.

55
OPERATING PROCEDURE:

1. Check the chamber pressure (GAUGE #2 in the Figure) if the autoclave door is already

closed and locked, because a locked door usually indicates that autoclaving is in progress.

Do not attempt to open the door unless the chamber pressure is at ambient. Opening a

chamber filled with pressurized steam can be suicidal. Although some newer models of

autoclaves have built-in safety features to guard against this possibility, never subject

one's own well being to such a shaky assumption. Check the jacket pressure (GAUGE

#1). If the gauge indicates a pressure of between 15-17 psig, proceed to Step 4; otherwise,

continue onto Step 2.

2. Open the condensate valve (VALVE #1 in the Figure).

3. Slowly open the steam supply valve (VALVE #2). Allow condensate to drain. When the

condensate is completely drained, as evidenced by the flow of steam from the outlet of

VALVE #1, close the condensate valve (VALVE #1). (If pipes start to "bang" hard

during condensate drainage, close VALVE #2 slightly.) Wait for the jacket pressure to

build up to the required 15-17 psig.

4. Open the door on the autoclave slowly and cautiously. Take out all the items from the

previous autoclaving runs if they are found inside the chamber. Place items to be

autoclaved inside the chamber. Make sure that all the components of each item can

withstand the heat of autoclaving; many plastic materials will melt or deform. Leaving a

few drops of water inside a closed container where the steam in the chamber cannot

easily penetrate will enhance the sterilization effect. If liquid is to be autoclaved, place all

such containers in a stainless steel pan so that any spill can be readily caught. Many

liquids will boil over in the autoclave. The boiling is especially violent when the pressure

56
 is released at the end of the autoclave cycle. The use of a pan will also facilitate handling

if more than one container is to be autoclaved. Vent all containers to avoid explosion. If

bottles are capped, make sure that the caps are screwed on lightly so that any excess

pressure can escape. The caps can be screwed tightly later as they are taken out from the

autoclave. At the same time, make sure that everything is closed so that contaminants

cannot enter after autoclaving. Note that the need for pressure relief and prevention of

contaminant entry are not contradictory. For example, shaker flasks can be vented with

cotton seals; fermentor jars, and nutrient jars can be vented with in-line filter units. On

the other hand, some items to be autoclaved cannot be conveniently vented; they must be

placed in a protective steel casing. The glass pH electrodes are such examples.

5. Near the center of the door locking wheel, there is a pin that, when in the inserted

position, prevents the door locking wheel from turning freely. The pin is released from its

hole by pushing the small (approx. 2 inches) lever parallel to the face of the door locking

wheel. To engage the pin, set the lever perpendicular to the face of the door locking

wheel, then turn the wheel slightly to allow the pin to drop into one of the holes intended

for it. Close the autoclave door. Engage the pin, and turn the wheel clockwise by about

1/8 of a turn to insert all the locking bars in the respective slots on the rim of the

autoclave. These bars do not always all slide into the slots at the first attempt. If so,

wiggle the bars as the wheel is turned. After make sure that all the the locking bars extend

securely through the slots, release the pin so that the door locking wheel is now free to

spin. Rotate the wheel clockwise until it is hand-tight; this applies pressure to the door to

seal it air tight so that steam pressure can be built up inside the chamber. Do not over

57
 tighten the wheel. Engage the pin to lock the wheel and prevent it from turning back. The

door is now securely locked.

6. Turn the four-position selection valve (VALVE #3) on top of the autoclave to the sterilize

position (STER) by lining up the STER mark with the arrow on the valve. This position

allows the steam to enter the autoclave chamber from the jacket.

7. Wait for the chamber pressure, as indicated by GAUGE #2, to reach the maximum,

where the pressure is to remain stationary during the entire autoclave cycle. The

pressurization of the chamber will take approximately 5 minutes. This marks the start of

the autoclave. The temperature in the chamber can be read with GAUGE #3 at the lower

front of the autoclave.

8. After autoclaving for 20-30 minutes, terminate the autoclaving cycle by shutting off

steam to the chamber and venting it slowly to the ambient pressure. This can be

accomplished by turning VALVE #3 from the sterilization position (STER) to the

exhaust position (EXH). It takes about 3-5 minutes to vent the excess steam. It is safe to

open the door only when the needle of the chamber pressure indicator, GAUGE #2, falls

within the narrow white area marked around 0 psig. When the chamber reaches ambient

pressure, release the pin that locks the door locking wheel. Slowly turn the wheel

counterclockwise to relieve pressure on the door. When the door locking wheel is fully

released, engage the pin and turn the wheel 1/8 turn further to disengage the locking bars

from the slots. Open the door slowly. Watch out for a small puff of residual hot steam

being released as the door is first opened. Note that a slight vacuum may be created in the

chamber as the hot air is cooled further while the door is left locked. In this case, a

screwdriver may be used to pry open the autoclave door with care; however this is not

58
 recommended for beginning students. Alternatively, introduce steam into the chamber for

a few seconds after securely locking and pressurizing the door will bring back a positive

pressure in the chamber.

9. Again, remember to wear gloves. Watch out for the boiling liquid and handle the hot

autoclaved items with great care so as not to burn oneself. Do not touch the hot chamber

wall. Now is the time to make sure that the sterile side of all the sterilized items are not

open to invasion by contaminants. For example, plug the mouth of shaker flasks if the

plugs have come off during autoclaving. Check all connections on a fermentor jar to

make sure that they all remain sealed and that no tubings have been broken. Reconnect

them quickly whenever possible. Remove all autoclaved items from the chamber.

10. Clean up any spills and close the autoclave door when done. Do not pressurize the door.

SUMMARY OF PROCEDURES

1. Check the jacket pressure.

2. Place items in the chamber.

3. Close and lock the autoclave door.

4. Introduce steam into the chamber.

5. Autoclave for 20-30 minutes.

6. Unlock and open the autoclave door.

7. Remove autoclaved items from the chamber.

8. Clean up.

59
60
 NICU ENVIRONMENT:

Optimal physical, psychological, social and ethical NICU environment is

crucial for the best neonatal outcome. Frequent NICU management procedures like s

u c t i o n i n g , h e e l s t i c k s f o r blood test s , IV l i n e placements,

imaging are stressful for the baby and also disrupt their sleep [1]. For the very small

preemies, just being handled for daily care, like diaper changing, feeding, vital

parameter‟s recording etc. can be stressful. Therefore, the physical environment

should include attention to sound, light, position, touch and other variables. Slevin et

al had shown that significant alteration of the NICU environment for light, noise,

infant handling and staff activity for a specified time period, resulted in reduced

median diastolic blood pressure, mean arterial pressure, neonatal movements and thus

reduction in neonatal stress .

Sound Environment

Loud sound besides being stressful, may lead to loss of hearing. The noise of the incubator

motor is 55-60 decibels (db) and warmer bed, 62 db. The use of mechanical ventilation or CPAP

makes it noisier. Chang e t a l [3] showed tha t during the 48 hour

observation period, 4994 peak noises were recorded. About 90% of these were due to human-

related factors. Loud, sharp sounds can raise noise levels to 100-200 db, which may damage cells

in the ear. This is more likely to happen in sick babies on ototoxic drugs like aminoglycosides.

Loud or sharp sounds can cause physiological changes like tachycardia, tachypnoea, apnoea,

oxygen desaturation and sudden increase in mean arterial blood pressure, disturb sleep, startle

61
the baby and may even produce intracranial haemorrhage in a micropremiee. Sound levels

must be reduced by talking quietly, closing doors and portholes gently, not dropping things on

top of the incubator, turning down machine alarms and phone ring and by modifying staff

b e h a v i o u r , c a r e p r o c e d u r e s , a n d e q u i pme n t [ 4 ] . Mother‟s voice and

soft music transfer love, emotions and wisdom and thus augur long term developmental

benefits, which allows their babies to approach their full potential.

Light Environment

Constant light may disturb body rhythm; bright light may not permit baby to open eyes and look

around. Preemies in nurseries with dimmed nightlight, progress more quickly in their sleep-wake

patterns. The amount of light should be reduced by covering the isolettes by laying a blanket

over the top with baby hooked to multisystem monitor. While using phototherapy lights, eyes

must be covered. “Quiet time” must be maintained during the day, when lights are dimmed for

several hours and the baby is not disturbed unless a procedure is really needed. This will help in

62
starting a day/night s l e ep schedul e and suppor t diurna l va r i a t ions in hormone and

temperature levels. Positioning The preemies lack the muscle strength to control movements of

body. They tend to lie with arms and legs straight, or extended, rather than flexed. The

extended position for long periods can lead to abnormal tone with consequent delay in the motor

development. S m a l l p r e e m i e s m a i n t a i n b e t t e r o x y g e n a t i o n ,

temperature, and sleep when they are nursed in prone or lateral positions with mild shoulder

elevation. Sometimes, it is difficult to place the preemie in a curled up, flexed position because

of attachments of lines and sensors. Nesting is one of the key factors in maintaining beneficial

position of a neonate and should be practiced routinely.

Handling

Handling of preterms may lead to physiologic and behavioural stress, which is shown as

tachycardia, bradycardia, tachypnoea, apnoea, desaturation, colour changes to dusky or flushed,

63
and responses like hiccups or yawning. Therefore, minimal handling is the most important

theme in managing a small preterm.

Touch

The sense of touch develops very early in fetal life. In very small preemies, the skin is so fragile

that touching has to be done with great care. For preemies <30 weeks gestational age, studies

show that touch may be stressful rather than soothing. For older preemies, gentle touching can

be helpful. Preemies react in different ways to different kinds of touch. How and how often the

preemie is touched, needs to be based on his responses. A gentle application of bland, sterile oil

is recommended for small preterm neonate. Kangaroo Mother care (KMC) which facilitates

intimate touch of the baby with mother‟s chest and provides various benefits to both mother and

the baby has become popular.

Analgesia

Neonates feel pain as older children and adults. Experiencing pain is stressful with

accompanying harmful effects. Therefore, it is essential to avoid or minimize painful events; if

inevitable, then analgesics like oral sucrose, breast milk, mother‟s nipple, soother, l o c a l a n a

l g e s i c , o p i o i d a n d n o n o p i o i d s y s t emicanalgesics, should be used judiciously.

Parental Stress

Having a premature baby is one of the most stressful experiences of a parent. Many aspects of

neonatal intensive care units are stressful to parents, including prolonged hospitalization,

alterations in parenting, exposure to a technical environment, and the appearance of their small,

64
fragile infant [6,7]. Frank, in-depthcommunication with parents is essential, to make them

participate in decision making and babycare. This will remarkably alleviate the parental anxiety

and confusion. Therefore, neonatal care providers should be trained in the art of communication,

in a structured curriculum. Its importance will progressively increase with the enactment of

consumer protection act.

Effects on Healthcare Workers

Effects of light and electromagnetic fields on pineal function could have implications for long-

term risk of breast cancer, reproductive irregularities, or depression in healthcare providers [8].

Therefore, there is need to monitor these variables and develop permissible standards.

Family Involvement

The quality and frequency of family participation in their neonate‟s care in the NICU can play a

significant role in their effectiveness after discharge. Their presence and involvement in the

NICU offer a unique way to humanize the healthcare experience for infants, the i r families

and their caregivers .The salient guidelines for parental involvement are, to teach parents signs of

stress and stability, provide a „parent friendly‟ area to be with their infant, provide privacy for

breast feeding and kparents to use their hands to provide support to the infant and provide

grasping opportunities, support parents in the transition of caring for their preterm infant.angaroo

care , delegate as much responsibility as they are comfortable with, encourage

65
Ethical Environment

NICU is a place where ethical issues are faced very often especially when a neonate suffers from

a nearly fatal condition. It is very difficult to decide to withhold life support or withdraw it. One

has to be very careful in newborn care because consent is given by a surrogate and not by the

patient. It is imperative that NICU should have standard ethical guidelines with full back up of

hospital ethical committee to avoid any ethical catastrophe and shouldpractise detailed

informed consent.

66