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NURSING - II
WRITTEN ASSIGNMENT
ON
ORGANIZATION OF
NEONATAL INTENSIVE
CARE UNIT
Submitted To:
Submitted
By
Mrs. Martha Raut
Mrs. Monika Bagchi
Asst Prof
nd
2 year MSc N
Submitted On: 17/02/2016
INTRODUCTION
Newborn intensive care approach developed from the concept that a more
intensive approach to neonates who require special care would result in a
significant decrease in neonatal mortality and morbidity. A neonatal intensive
care unit (NICU) is an intensive care unit specializing in the care of ill or
premature newborn infants. The first official ICU for neonates was established
in 1961 at Vanderbilt University Mildred Stahlman, officially termed a NICU
when Stahlman used a ventilator off-label for a baby with breathing difficulties,
for the first time ever in the world.
DEFINITION OF NICU
It is very specialized unit where critically ill neonates are cared to reduce the
neonatal morbidity and mortality.
INDICATIONS FOR ADMISSION IN NICU
Large babies
Severe jaundice
Neonatal sepsis/meningitis
Neonatal convulsions
O2 therapy/parenteral nutrition
Injured neonate.
To check/observe alarms systems signal ,to find out the changes beyond
certain fixed limits sets on the monitors.
CATAGORIES OF NICU:-
LEVEL 1
Nasal oxygen with oxygen saturation monitoring (e.g., for infants with
chronic lung disease needing long-term oxygen and monitoring
LEVEL 2
limited duration
Resuscitation and stabilization of ill infants before transfer to an
LEVEL 3
ORGANISATION OF NICU
Physical Organization
Personal Organization
Equipment Organization
PHYSICAL ORGANISATION
The neonatologist and nurse incharge must be involved while planning the unit.
The intensive area should be localised preferably next to labour ward and
delivery rooms. For economising costs it would be preferably to have combined
with level 2 facilities, through both the areas there must have separate and
adequate staff and single administrative control. the neonatal unit can be
conceptualised in terms of four elements which exist in a concentric layering
inside outwards with designed work traffic flow pattern.
a) Clinical care areas
b) Clinical support areas
c) Administrative zones
d) Family support area
a) Clinical care areas
Scrubbing areas
Storage spaces
Laboratory
X ray machine
Formula preparation
TPN preparation
Equipment storage
Counselling room
Seminar rooms
Library
Nourishment area
A lounge
Lockable storage
Education area
1. Bed strength
The NICU can be in a single area or it can be in multiple rooms with a capacity
of 2-4 infants each..one intensive care bed is generally required for 100
deliveries provided the prematurity ratio is around 8 percent and hence for a
population of one million,30 intensive care beds would be required for our
country. It would be uneconomical to have a NICU of less than 6-8bed.
2. Space between the patient
For the patient care,100 square feet is required for each baby as it is true
for any adult bed
Additional power plug point would be required for the portable x-ray
machine close to the patient care area
The unit must have a fair degree or ventilation of fresh air through
central air conditioning is must. The temperature inside the unit should
be maintained at 28+_2deg c while the humidity must be above 50%.
4. WATER-HAND WASHING
The unit must have an uninterrupted clean water supply and each patient
care area must also have a wash basin with foot or elbow operated
tapes. Neat wash basin, placing paper towel and receptical.
The unit should be equipped with laminar air flow system, however
alternatively air conditioned with multipore filters and fresh air
exchange of 12 per hours should be provided.
5. COLOUR
The walls of the whole unit should be washable and have a white or slightly off
white colour for better colour appreciation of the neonates.
6. LIGHTING
The lighting arrangement should provide uniform, shadow free illumination. In
addition spot illumination should be available for each baby for any procedure.
A generator back up is mandatory where there is frequent power fluctuations or
power failures.
7. SOUNDS
The acoustic characteristics should be such that the intensity of light kept below
75 decibels. The unit should also have an intercom and a direct outside
telephone so that the parent of the patient can have an easy access to the medical
personnels in case of an emergency
8. ROOMS
Apart from the patient care area including rooms for isolation and procedures,
her e is need of space for certain essential functions, like a room for scrubbing
and gowning near the entrance, a side laboratory mothers room, adequate stores
for keeping consumable and non-consumable articles
One or two rooms each would be needed for doctors and nurses on day
and night duties
9. VENTILATION
Minimum of six air changes,2 air changes should be outside for filtering the
inner air.
FLOORS
CEILINGS ;
11.COMMUNICATION:
Database of all NICU information, teaching aids like X rays, ECG, and
ABG reports must be maintained for future training and research.
13.SEPTIC NURSERY
14.SECURITY
15.HEAD WALL SYSTEM
Refers to the array of the medical gas outlet+electrical+data outlet at each
patient care station
Electric environment
Medical gases
Data outlets
16. Toilets
It is important to plan the number and position of water closets in the Neonatal
Unit. Parents bedrooms, Transitional Care, medical on-call rooms, and the area
dedicated to counselling (Parents Quiet Rooms) should all have separate toilet
facilities. In a large Neonatal Unit there should be at least 3 further toilets for
staff and the general public.
17. Transport incubator store
Transport incubators are bulky and should not be stored in public corridors.
There should be a designated area for storing them within the Equipment Store
18.Pneumatic tube system
Careful thought should be put into how specimens can be transferred urgently to
central laboratories in the Hospital. If a pneumatic tube system is chosen, it
should be easily accessible, robust and reliable. The outlet might be best
positioned at the central station next to the Unit Office. Readily available
personnel can then identify problems if the system were to fail to send an urgent
specimen
19. Stationery
Although some NNUs are striving towards becoming paperless, most will not
achieve this in the next five years. There should therefore be a room of 12 sqm
with extensive shelving for storage of all the paper sheets and forms necessary
for the efficient running of the NNU.
20. CLINICAL
Pendants, gantries, cabinetry or head-rails?
Choosing to equip the rooms with pendants, gantries or cabinetry is a crucial
early decision. Pendants descend from the ceiling and are single-armed or
double-armed. The pendants contain intensive care facilities including electrical
outlets, oxygen and air pipes and a vacuum facility for suction. The clinician has
the opportunity of specifying the number of electric sockets, and the number of
shelves which are fixed to the pendant arms. These shelves can hold ventilators,
monitors, syringes drivers, and indeed any intensive care equipment required to
service the infants in the incubator.
Gantries
Gantries have many of the advantages of pendants containing internally all the
pipin and wiring required to provide the oxygen, air, vacuum and power points
as well as the computer networks. The clinicians again have the opportunity of
specifying the number of sockets and the number of shelves. Many of the
gantries allow movement laterally of the hangars and ventilators, monitors and
syringe drivers can all be attached to the gantry.
Cabinetry
If designed carefully, cabinetry is fully consistent with the demands of intensive
care. All intensive care and high dependency cots can be contained in spacious
bays. Electric sockets, computer and piped gas outlets can all be positioned so
that there is no interference with the movement of staff caring for the infant. It
is recommended that all such bays be identical in the Unit, so that staff can be
familiar with the work area no matter which room or cots have been allocated to
them. The size of the bays is critical. Each must accommodate an incubator, a
mother and father with comfortable seating, two members of nursing staff, and
it should be possible to manoeuvre all machinery (e.g. for taking X-rays) within
the allocated space. Such bays should be at least 3.2m wide and the bay walls
may extend 2-3 cm in room
Head-rails
infant and family. Natural lighting and where possible views of the surroundings
outside are beneficial. Internal decoration can convert a clinical area into a room
which is appealing to families, and encourages all members of staff to treat the
care area as the infant bed room
PERSONAL ORGANISATION
MEDICAL STAFF-The unit should be headed by a director who is full time
neonatologist with special qualification and training in neonatal medicine.
STAFF REQUIREMENTS
NURSES RATIO
Nurse patient ratio of 1:1 maintained throughout the day and night
A ratio of one nurse for two sick babies not requiring ventilator support
may be adequate
For an ideal nurse patient ratio, four trained nurses per intensive care
bed are needed
EXPERIENCE
The staff nurse must have a minimum of three 3yrs experience in special
neonatal care unit in addition to having three months training in a intensive care
unit.
OTHER STAFF
Laboratory technician
Respiratory therapist
EQUIPMENT ORGANISATION
Supply should be kept to the patient station so that nurse does not have
to go away from the neonate unnecessarily and nurses time and skills are
used efficiently
There should be controlled incubators and open air system for providing
adequate warmth
3. Radiography
4. Oxygen catheter
5. Infusion pumps
6. Positive pressure ventilator
7. Oxygen analyser
8. Phototherapy
9. Electronic weighing machine
10. Transcutaneous PO2 and PCO2 monitor
11. Non invasive BP monitor
12. Invasive BP monitor
13. Intracranial pressure monitor.
14. Microdrips
15. Suction apparatus
16. Open care system
17. ECG monitor
32. Canula,
33. Catheters suction, urinary ET tube, nasal catheters.
DOCUMENTATION IN NICU
The unit should have printed problem oriented stationary for maintaining
records, admission and discharge slips
Record of all admission should be maintained in a register or on a computer
The information should be analyzed and discussed at least once a month to
improve the effectiveness of the nicu in providing the services
EDUCATION PROGRAMME AT NICU
There should be continuing medical education programmes for
physicians and nurses in the form of lectures, demonstrations and group
discussions.
This should cover important issues like resuscitation, steralisation to be
maintained for critically ill babies, putting in arterial catheters,
conducting exchange transfusions, maintenance of ventilators.
Educational programmes covering the nurses and physicians in the
community should be developed.
There should be regular discussion with the obstetrician to discuss the
perinatal care and condition Individual high risk cases
Education and follow up is necessary
A Neonatal nurse job role involves working in a specialist neonatal baby care
unit (within maternity or childrens hospitals) or in the local community.
Neonatal nurses care for new-born babies who are premature or are born sick.
There are a vast number of conditions that can affect a new-born baby and
require treatment from specialists within the healthcare team.
As a neonatal nurse its important to be sensitive to the needs of others, have a
caring attitude. As a neonatal nurse has an important role of supporting parents
of the sick baby at a time when they themselves are frightened of losing their
child, very anxious and stressed or upset seeing baby coupled up to wires and
monitors. As far as possible, the parents and occasionally other family members
are encouraged to take an active role in the care of the baby.
ESSENTIAL DUTIES:
Managing patient care of newborns and pediatrics, assisting with the
problems;
Provides education, training, information, and consultation services to
physicians, registered nurses, and other members of the clinical team;
Interprets, coordinates, and implements new and existing policies, methods
and procedures for neonatal nursing in the Perinatal areas;
Keeps informed of current practices and trends and incorporates them into
practice
Special Needs
Sometimes babies are too fragile or small to eat directly from breast or bottle.
When this is the case, they are fed either intravenously, or through a gavage
tube, which is a small tube that goes from the nose or mouth into the stomach.
Nurses will carefully place the correct amount of formula or dietary
supplementation if a baby is not yet eating, into either of these methods of
nutrition, and monitors the baby for any positive or negative changes in the
infant.
The duties for a neonatal nurse also include inserting and changing IVs,
administering blood transfusions when necessary, and drawing blood for various
testing. Nurses are able to perform many other procedures as well, and it fully
depends upon each hospital's individual protocol, as well as the nurse's
experience level and staff rating.
Technical Duties for a Neonatal Nurse
Regardless of their other responsibilities, all neonatal nurses do a fair bit of
charting on each of their patients. This may be on a paper sheet, or more
commonly every year, completed electronically via a special hospital computer
system. The details logged into the online chart allow doctors, other nurses, and
anyone else within the baby's medical care team to view a baby's updated health
records.
A nurse may also be responsible for emailing the neonatologist (NICU doctor)
or calling the parents with specific requests or information. While a neonatal
nurse's priorities are found in caring for the child assigned to them, they often
also spend a large portion of their shift charting and getting messages out to
those who need to receive them.
Emotional Support
A neonatal nurse often gets to know the families of infants very well, especially
if they happen to have a primary baby they take care of. A primary nurse will
care for the same infant for the duration of his hospital stay, whenever he/she is
on shift. This works well, as the nurses become very familiar with their babies
and can in turn provide them with the best care possible.
In building relationships with these families, they can often provide emotional
support and comfort during scary times. If a baby has to go through surgery or
is exceptionally ill, nurses are great for reassuring the parents and providing as
concrete of answers as they are permitted to.
Neonatal nurses are often the unsung heroes to families and able to give the
earliest of lives a fighting chance. Their daily duties add up to countless
miracles and a rewarding career at the same time.
CONCLUSION
A neonatal intensive-care unit (NICU), also known as an intensive care
nursery (ICN), is an intensive-care unit specializing in the care of ill or
premature newborn infants. A NICU is typically directed by one or more
neonatologists and staffed by nurses, nurse practitioners, pharmacists, physician
assistants, resident physicians, and respiratory therapists, dietitians. Many other
ancillary disciplines and specialists are available at larger units. Neonatal
intensive care is costly not only to the individual but also to the family. These
cost increase with decreasing birth weight and gestational age. Therefore
neonatologists must include parents in any discussion about whether to continue
the extreme measures being provided to their extremely low birth weight
preterm infants. Development of neonatal intensive care unit requires careful
planning with the joint efforts of physicians, nurses and architects. The plan
should be based on functional efficiency. Neonatal intensive care unit ideally
should be next to the obstetric suite.
RESEARCH PUBLICATIONS:
Journal of Health Population & Nutrition. 2011 Oct;29(5):500-509
kg). The major reasons for admission and the major causes of deaths were birth
asphyxia, sepsis, and LBW/prematurity. The units had a varying nurse:bed ratio
(1:0.5-1:1.3). The bed occupancy rate ranged from 28% to 155% (median
103%), and the average duration of stay ranged from two days to 15 days
(median 4.75 days). Repair and maintenance of equipment were a major
concern. It is possible to set up and manage quality SCNUs and improve the
survival of newborns with LBW and sepsis in developing countries, although
several challenges relating to human resources, maintenance of equipment, and
maintenance of asepsis remain.
- By Malhotra S & Mohan P.
impact neonatal mortality rate reduction higher. Number of beds is also not
sufficient to cater to the increasing demand of such services. Available number
of nurses is a problem in many such units. An effective and sustainable system
to maintain and repair the equipment is essential. Scaling up these units would
require squarely addressing these issues.
- By Neogi S & Zodpey S
REFERENCES:
1. Col. Uma Raju,Surg Cdr SS Mathai, Manual Of NICU
Protocol,Command Hospital,Pune.
2. Dr.B.T Basavanthappa,Pediatric Child Health Nursing,Ahuja
Publication,2005 Edition,Page No.14-16
3. Marta Velasco,Pediatric Nursing,Mc Graw Publication ,First
Edition,2000 Edition,Page No.12-14