NICU AND ENVIRONMENT

Submitted by,
Ms.Dipali.S.Dhayagude,
First Year Msc.Nursing,
INE,Mumbai.
Introduction:
• The organization of good quality NICU is
essential for reducing neonatal mortality and
improving the quality of life.
• Emphasis should be laid on developing a sound
infrastructure to ensure delivery of safe nursing
care,promote asepsis.
GOALS OF NICU

• The goals of neonatal intensive care unit are

1. To improve the condition of the critically ill neonates
keeping in mind the survival of neonate so as to
reduce the neonatal mortality and morbidity.
2. To provide continuing in-service training to
medicine and nursing personnel in the care of
newborn.
3. To maintain the function of the
pulmonary ,cardiovascular, renal and nervous
system.
Contd...
• To monitor the heart rate, body temperature, blood
pressure, central venous pressure and blood by non
invasive techniques.
• To measure the oxygen concentration of the blood
by oxygen analyzers.
• To check/observe alarms systems signal ,to find out
the changes beyond certain fixed limits sets on the
monitors.
• To administer precise amounts of fluids and minute
quantities of drugs through I.V infusion pumps.
A.PHYSICAL LAYOUT:

1.Space and
2.Floor plan
location

4.Environment
3.Ventilation and
temperature and
lighting
humidity
1.Space and location:
1. Each neonate should be provide with a
minimum area of 100sq.ft.
2. 6 feet gap between 2 incubators for adequate
circulation and keeping the essential lifesaving
equipment.
3. Located as close as to labour room and obstetric
OT.
2.Floor plan:
1. Preferably in square space.
2. The wall should be made of glazed tile.
3. Windows should have 2 layers of glass panes to
ensure heat and sound insulations.
4. Wash basins with elbow or foot operated tap
having round clock water supply.
5. Automatic door closures.
6. Isolation room.
7. Breastfeeding and KMC room.
3.Ventilation and lighting:
• Effective air ventilation.
• Laminated air flow system.
• Provision of exhaust fans.
• Constant positive air pressure should be
maintained.
• Nursery must be well illuminated and painted with
white or slight off white.
• It is best achieved by cool white flurescent tubes to
provide atleast 100 ft candle, shadow free
illumination at infant level.
4.Temperature and humidity:
1. Must be maintained 28(+/-2) degree celsius, indoor
to minimize the effects of thermal stress on babies.
2. Centralized air conditioning having temp. control
knobs in nursery.
3. Portable radiant heater,infrared lamp can be used
as additional source of heat to an individual infant.
4. Humidity- 50%
5. NICU should be equipped with room thermometer
and hygrometer.
5.Acoustic characteristics and
communication system:
1. Sound intensity- not exceed 75 db.
2. Telephone rings and equipments alarms should
be replaced by blinking light.
3. Decibel meter to be installed to monitor sound
level in nursery.
4. Soothing effect of meaningful sound such as
gentle music or recording of parent voice
should be harnessed.
Contd..
5. Should be provided with an intercom system so
that additional person can be called for help.
6. A direct line external telephone is mandatory.
7. Mobile phones should not be used near the
nursery.
Contd...
• Electrical outlet:
1. Each patient station should have 12-16 central
voltage.
2. Additional power plug point.
3. Should be round-the-clock power back up
including provison of UPS system.
Personnel management:
• Highest priority in the organization of NICU is
the;
1. Availability of sufficient number of adequate
trained personnel especially “NURSE.”
a) One nurse is for intermediate nursing care to 3
babies.
b) One nurse is for intensive care to 1 infant.
c) Head nurse is the overall in-charge.
Contd...
• National neonatalogy forum of india has
recommended that,
At least one trained nurse allocated to provide
coverage to 4 babies in the special care neonatal
unit.
Contd...
• Neonatalogist:
 Full time to improve the standard of special care
services.
• The unit must have an independent senior resident
doctor and one junior resident doctor round the clock
for every eight babies.
• Respiratory therapist:
 To monitor ventilator settings.
• Anesthetist:pediatric surgeon and pediatric
pathologist are essential persons in establishment of a
good quality NICU.
Contd..
• Laboratory technician:
Available to operate bilirubinometer , glucometer,
micro centrifugation, CRP kits and blood gas
analyser.
• Biomedical technician:
To maintain liasion with supplies of equipment to
ensure their smooth functioning and prevent
breakdown.
• PHN or social worker
• clark
Equipment:
• Equipments are used for
1. Monitoring the physiologic status of neonate.
2. Maintaining temperature,
3. Providing artificial breathing.
Equipment for level-III FOR 6 BED
SR.NO ITEM NOS
1 RESUSCITATION SET 6
2 OPEN CARE SYSTEM 4
3 INCUBATORS 2
4 INFUSION PUMPS 12-18
5 POSITIVE PRESSURE 6
VENTILATORS
6 OXYGEN HOODS,O2 6
ANALYSER
7 APNOEA MONITORS 6
WITH SCOPE
8 PHOTHOTHERAPY 6
UNIT
9 ELECTRONIC 1
WEIGHING SCALE
CONTD..
SR.NO ITEM QTY
10 PULSE OXYMETERS 6
11 CO2 MONITOR 6
12 TRANSCUTANEOUS PO2 AND PCO2 2-3

13 NIBP MONITORS 1-2

14 INVASIVE BP MONITORS 1-2

15 ECG WITH DEFIBRILLATOR 1

16 ICP MONITOR 1
17 PORTABLE RADIOGRAPHIC MACHINE 1

18 PORTABLE ULTRASOUND MACHINE 1

19 BLOOD GAS ANALYSER 1

DISPOSABLE ARTICLES REQUIRED FOR
NICU:
1. IV catheters,IV sets
2. Micro burette sets
3. Bacterial filters
4. Feeding tubes
5. ET tubes
6. Suction catheters
7. 3 way stopcocks
8. Extension tubing
9. Umbilical arterial and venous catheters
10. Syringes, needles
11. canula
Equipment
1. Incubator:
• Essential to provide micro-environment.
• Main functions are: isolation, maintenance of
thermo neutral ambient temperature, desired
humidity and administration of oxygen.
Nurse’s responsibilities:
1. Incubator should be pre warmed to 34-36.1 celsius
for infants less than 1500 gms and 33.9-35 celsius
for infants more than 1500 gms.
2. Maintenance of skin temp. Between 36-36.5 celsius.
3. Infant need not be fully clothed, a diaper is only put.
4. Ensure that servo control probe is in place and
properly secured to prevent hyperthermia, never
place a probe under the infant.
5. Unit should be thoroughly disinfected every day.
Contd...
6. Record temperature and humidity of the
incubator and the responses of the infant.
7. Don’t open the incubator during the routine
care.
8. Humidity chamber should be drained and
replenished daily.
2.Radiant warmer:
1. A device is used to maintain the body
temperature of the newborn.
2. Plays essential role in influencing oxygen
consumption, apnoea and acid base
balance.
3. Phototherapy unit:
• Principle:
Photoisomerization and photo-oxidation
changes indirect bilirubin into water soluble
substances.
Nurses responsibilities:
1. Remove clothing to maintain proper skin
exposure.
2. Turn frequently to expose all skin areas.
3. Monitor temperature and level of hydration.
4. Close infants eyelids with a light apaque
eyeshield secured in place by tape or bandage.
5. Should be changed every shift and give eye care.
6. Cover genitalia.
7. Observe common side effects of phototherapy.
4. Pulse oximeter:
• Non invasive measure for continously monitoring
the blood oxygen levels i.e PO2 levels so that min
to min changes can be observed.
Principles:
• Infra red rays are absorbed by oxygenated blood
and deoxygenated blood differently.
Contd...
• Indication:
Hypoxemia.
• Uses:
To monitor PR, Oxygen saturation and apnoea.
• Types of probe:
Flex probe/multisensor probe.
Nursing care:
1. Placement of probe: the probe can be fixed on
the dorsum of the foot of baby.
2. Check for proper contact between electrode and
skin to maintain accurate readings.
3. BP cuff should not be applied to the same limb
to which transcutaneous probe is fixed.
4. Record PO2 level hourly.
5. Suctioning, diapering should be done in a
gentle, to maintain constant oxygen level.
Mechanical ventilator:
Infusion pump:
• Amount of fluid to be administered to neonate is
based on the neonate’s weight and physiological
status.
• Used to control the administration of small
volumes of fluid, blood,medication, and TPN.
Infusion pump Syringe pump
Indications for the admission to NICU
• Babies less than 30 weeks.
• VLBW baby less than 1500 gms.
• Cardiopulmonary monitoring
• Surfactant therapy
• Convulsions
• Severe birth asphyxia
• Assisted ventilation
• TPN
• Major surgery.
LEVELS OF NEONATAL CARE
UNITS:

LEVEL-I LEVEL-II
LEVE
L-III
LEVEL-I
1. About 80-90 % of neonates require minimal care.
2. Can be provided by their mothers under supervision
of basic health professionals.
3. Neonates weighing >2000 gm or having GA of 37
weeks.
4. Basic care at birth, provision of warmth , maintenance
of asepsis and promotion breast feeding.
5. This care can be given at home, subcentre and primary
health centres.
LEVEL-II
1. Neonates weighing between 1500 to 2000 gms or having GA
of 32-36 weeks need specialized neonatal care.
2. Supervised by trained nursing staff and pediatricians.
3. Intermediate neonatal care should be provided by the equipped
DH, teaching institutions, and nursing homes.
4. Should be arrangement of resuscitation procedures,
maintenance of thermoneutral env, IV infusions, gavage
feeding, phototherapy and exchange BT.
5. ONLY 10-15% of all neonate require this care.
6. Available at all hospitals where 1000-1500 deliveries takes
place a year.
LEVEL-III
• Neonates weighing less than 1500gm or born before
32 weeks of gestation require intensive neonatal
care.
• Only 3-5 percent of all newborn babies need this care
by skilled nurses and neonatologists.
• Regional perinatal centres equipped with centralized
oxygen and suction facilities, incubators, ventilators,
monitors and infusion pump etc.
 NICU
ENVIRONMENT
TRANSPORT OF SICK NEONATES:
TRANSPORT OF SICK NEONATES:
• Neonates are transported from labor room to
nursery with level-II OR level-III OR NICU.
• Transport may be required from home to level-I,
level-I to LEVEL-II CENTRE OR Level-II to
level-III Centres.
• If the birth of an ‘at-risk’ neonate is anticipated,
then mother is transported to the facility with
optimum maternal and neonatal care.
Principles for transporting neonates:
1. Correct assessment of baby should be done.
2. Explain the condition of the baby and reasons for referral.
3. Baby’s condition to be stabilized and hypothermia should
be corrected before transporting.
4. Record case history, need for referral and treatment given
in the referral sheet.
5. Mother should accompany the baby at the time of
transport.
6. Nurse or health care worker should accompany the
neonate to provide necessary care on the way to referral
center.
Contd...
• Provide instructions and guidelines to the health care
worker/attendants for care during transport.
• Ensure warmth of the baby to maintain warm chain;baby should
be fully covered with cloths including head and extremities.
• Transport incubator can be used if available.
• Mother should be instructed to give breastfeeding; if not
possible then with vati-spoon.
• Nearest referral should be availed by the shortest route and
using fastest, and available mode of transport.
• Reverse transport also communicated with feedback
information.
• Follow-up should be done to evaluate the outcome.
Common types of infections in the NICU:
1. Blood stream infections:
• Central venous catheter/PIIC
• Umbilical catheter associated blood stream
infections
2. Ventilator associated pneumonia
3. Device associated infections
4. Most frequent infective agents
Gram negative pathogens, coagulase-negative
staphylococci.
Preventive strategies in the NICU:
1. REGULAR SURVEILLANCE OF INFECTIONS
2. VACCINATION OF HEALTH CARE
WORKERS
3. APPROPRIATE VISITATION POLICIES
4. ADEQUATE STAFFING
5. DISINFECTION OF EQUIPMENTS
PREVENTION OF CLABSI:
• CORE hand hygiene
• Ensuring easy access to soap and water and alcohol
based hand rubs in NICU.
• BARRIER precautions during CL insertion.
• Avoiding femoral site.
• Antiseptic Non Touch Technique (ANTT)
1. Always wash hands effectively
2. Never contaminate Key parts
3. Touch non- key parts with confidence
4. Take appropriate infective precautions
Preventive strategies:
• Hand hygiene
• Environmental hygiene
• Use of personal protective equipment
• Safe use and disposal of sharps
• Prevention of a central line-associated bloodstream
infection (CLABSI)
• Prevention of Ventilator Associated Pneumonia (VAP)
• Judicious Antibiotic use and prevention of misuse
• Use of breast milk and early enteral feeding
• Reduce duration of Total Parenteral Nutrition
• Avoid use of topical emollients
Hand hygiene:
• Adequate handwashing with water and soap
requires 40– 60 seconds
• Average time usually adopted by health-care
workers: < 10 seconds.
• Alcohol-based hand rubbing: 20–30 seconds
Five movements of hand hygiene:
Policy regarding visitors:
1. Person with active infection should not be
allowed to enter in NICU.
2. Avoid overcrowding.
3. Mother is always welcome, attached mother
room to baby care area.
4. Mother should be taught, guided and
supervised about proper hand washing and
good personal hygiene.
Summary:
• We have learned about:
1. NICU and its management,
2. Indications for NICU admission
3. Levels of NICU.
4. Transporting of sick babies.
5. NICU environment
6. Infection control policies in NICU
7. Role of nurse in NICU.
bibliography
1. Parul Datta,Pediatric Nursing, fourth edition,jaypee brother
publication,page no.106-107.
2. World Health Organization recommendations on
newborn health guidelines approved by the WHO
guidelines review committee updated may 2017
http://apps.who.int/iris/bitstream/handle/10665/259
269/WHO-MCA-17.07-eng.pdf?sequence=1
3. World Health Organization: Core components for IPC-
Implementation tools and resources. Available at:
http://www.who.int/infection-prevention/tools/core-compon
ents/en/