COLLEGE OF NURSING, MADRAS MEDICAL COLLEGE, CHENNAI-03

ON

SUBMITTED To
MRS.V.JAYANTHI,M.SC.(N)
LECTURER,

SUBMITTED BY
S.PALANIAMMAL,

OBSTETRICS AND

M.SC NURSING I YEAR,

GYNAECOLOGICALNURSING ,

COLLEGE OF NURSING

COLLEGE OF NURSING,

,MADRAS MEDICAL COLLEGE,

MADRAS MEDICAL COLLEGE,

CHENNAI-03.

CHENNAI-03

SIGNATURE OF FACULTY

ORGANIZATION, LEVELS (SERVICE), TRANSPORT, MANAGEMENT OF

NURSING SERVICE IN NICU
INTRODUCTION
Some babies need special care If a child is premature or has health problems at birth, such as an
infection, he may need to spend some time in a special area with facilities for special
care.THE NICU .Neonatal mortality accounts for most infant mortality in India.Neonatal
mortality is closely associated with low birth weight (<1400gms,30 weeks) and VLBW
(<500gms,26 weeks) premature babies.Premature delivery accounts for most LBW/VLBW
Social disadvantage is associated with pre term delivery
THE NEED FOR NICU CARE:

NICU plays a critical role in reducing infant mortality rate (IMR) in poor urban
populations
Even in a metro city like Bangalore only some private hospitals have NICU and are
expensive
An NICU at a nominal cost will benefit many and save the babies.

AIMS AND OBJECTIVES OF SERVICE :

To improve babies chances of survival and minimise the morbidity associated with
being born either premature or term and sick. It is a high cost, low throughput service
in which clinical expertise is a key determinant of the quality of the outcomes for the
baby.
To provide a family-centred approach to care, defined as involving families in the
care of their own children, and helping parents understand their babys needs.
To improve quality of care by working in partnership with other provider units and
service commissioners within Operational Delivery Networks (ODNs) as part of the
broader Maternity and Childrens Strategic Network. This will ensure integration
across the whole maternity and childrens pathway of care.

The service will deliver the aim to improve both life expectancy and quality of life for
newborn babies by:

Ensuring neonatal outcomes are in line with the type of unit where babies are cared for.
Ensuring neonatal outcomes across an ODN are in line with other ODNs across England
& Wales.
Delivering care in a family-centred way that seeks to minimise the physical and
psychological impact of neonatal care on the baby and their family, for example by
improving psychological outcomes and breastfeeding rates.
Providing an environment where parents are enabled to make informed decisions about
treatment and become involved in the care of their baby / babies, thereby minimising the
psychological trauma of premature or sick term babies.

Ensuring robust arrangements for clinical governance are in place.

Ensuring that robust links to clinical governance in co-located maternity units are in
place.
Working in partnership with other network neonatal services to promote delivery of
neonatal care in the most appropriate setting.
Ensuring robust monitoring and reporting arrangements in accordance with performance
requirements and evidence of continuing improvement of quality and responsiveness,
year on year is demonstrated through evaluation and audit.
Ensuring that parents whose babies are unlikely to survive or have life limiting conditions
receive sensitive support and care which follows a recognised Palliative Care Pathway.

LEVELS OR (SERVICE) OF NEONATAL CARE:The concept of levels of care requires:

defi nition of relevant areas of responsibility for individual hospitals within a
comprehensive health care system
establishment of referral practices and transport services enabling transfer to different
levels of care when appropriate
establishment of necessary professional and technical infrastructure within hospitals.
Three levels of neonatal care are described. These levels are differentiated by the service
capability required to provide a designated level of care for newborn infants. Variations in
services may be warranted based on the needs of individual patients, resources and limitations
unique to the hospital or type of practice. When present, variations in service provision require
documentation and, where relevant, development of an appropriate risk management strategy.
Neonatal services are designated by the highest level of care they provide, even though they may
also provide less complex care.

First Level (Mild)

Second Level (Moderate)
Third Level (Critical)

Level 1:Hospitals with a birthing service that:

provide services to women with uncomplicated pregnancies and newborn infants without
complications
undertake appropriate management, including consultation with, or transfer to a higher
level of care (if required)
undertake immediate management of unanticipated complications arising in a newborn
baby.
Level 2:Larger hospitals that, while providing for all Level 1 services, also:
provide services for the diagnosis and management of selected at-risk pregnancies and
neonatal conditions (excluding intensive care)

participate as a local hub in the network established to provide consultative services and
perinatal education.
Level 3
Large tertiary maternity and childrens hospitals that provide neonatal intensive care as
well as a broad range of sub-specialty consultative and paramedical services.
They may also provide Level 1 and Level 2 neonatal care.
PRINCIPLES OF SAFE AND STABLE TRANSPORT TO NICU :neonatal transport:-Ideally all infant from high risk preganancies should be delivered in
maternity units attached to a level III NICU. Some babies may be born prematurely or term
babies may become sick after birth and hence need to be transferred
In-utero transfer:-If problem is known or arises in early labour, the preganant women is
transferred before delivery to a high risk prenatal center.
Ex-utero transfer:-Inter hospital transport of the baby is considered if the medical resources or
personnel needed for high risk baby are not available at the hospital
CRITERIA FOR ADMISSION OR TRANSPORT TO NICU:

(Low birth weight (2000gm.)

gestational age<32 weeks
respiratory distress problem
need ventilator support
seizure
Large babies (more than or equal to 4kg.)
Birth asphyxia (Apgar score less than or equal to 6)
Meconium aspiration syndrome. If symptomatic/ thick meconium seen in larynx.
Severe jaundice
Infants of a diabetic mother.
Neonatal sepsis/meningitis.
Neonatal convulsions.
Severe congenital malformation/cyanotic congenital heart disease.
O2 therapy/parentral nutrition.
Immediately after surgery / cardiological investigation.
Cardio respiratory monitoring, if heart rate and respiratory rate are unstable.
Exchange blood transfusion.
PROM/Foul smelling liquor.
Mother of hepatitis B carrier.
Injurred neonate.

LIFE THREATENING CONDITIONS WHICH REQUIRE:-The following are the life

threatening conditions in neonates
Apnea, Baby with respiratory distress, Birth asphyxia.,Convulsions, Low birth weight babies
(less than 1500 gm requiring intensive care.),Neonatal jaundice requiring exchange blood
transfusion.Sepsis and meningitis.
PREPARATION OF UNIT

Warm (33-36C) incubator

Adequate light source
Resuscitation and treatment trolly stocked.
History, continuation sheet, treatment and diet sheet, problem list and flow charts.
Oxygen air and suction apparatus (as available in the unit).
Oxygen line connected to oxygen and air flow meter.
Suction - complete suction unit tubing and various sizes of suction catheters.
Ventilation bag and mask of appropriate sizes.
Vital signs monitors.
Specific equipment as indicated by diagnosis.

INSTRUMENTS AND FACILITIES IN NICU:

Centralized O2 supply, suction facilities, incubators/open care system, vital signs and
transcutaneous ventilators and infusion pumps.
Physical facilities
Temperature of the unit-The temperature inside the unit should be maintained at 28o
29oC while the humidity must be above 50%
Shifting facilities
Physical Set up (Size)-The NICU can be in a single area or it can be in multiple
rooms with a capacity of 2-4 infants each.
Bed Strength of NICU-30 Intensive care beds would be reapured for our country.

ASPECTS OF NICU:Two main important aspects in NICU -Physical Set up, Administrative set up
PHYSICAL SET UP -SPACE BETWEEN THE PATIENT:

100 Square feet is required for each baby

Each patient station should have 12-16 central voltage stablized electrical outlets.
2 to 3 oxygen outlets
2 compressed air outlets
2 to suction outlets.
Uninterrupted clean water supply and each patient.

Room, Colour ,Lighting , Sounds, Ventilator Air, Ventilation, Exaster

The lighting arrangement should provide uniform, shadow free illumination of 100
foot candles.
The Acoustic characteristics should be such that the intensify of noise is kept well
below 75 decibles.
Like a room for scrubbing and gowning
A room for keeping the X-ray and ultra sound machines
One or two rooms each would be neded for doctors
There is a space available for a biomedical Engineer
Required for education activities and storing of data
Minimum of six air changes, 2 air changes should be outside for filtering the inner
air.
Keep away from baby
A simple method to achieve satisfactory ventilation consists of provision of exhaust
fan in a reverse direction.
Infection Control Measures
Hand Washing facilities
Each room should have a separate basin facilities, it can be used for children. Sinks
are regularly cleaned by disinfection

ADMINISTRATIVE OFFICE:-Medical Staff ( senior and junior medical staff , anesthesia),

Staff Requirements , Nurses Ratio(1:1 ), Experience, Other Staff (Physiotherapy, social workers,
dieticians, radiology services, respiratory therapists)
REQUIREMENTS FOR NICU:-Equipment required for any neonatal ICU and the quantity
required for 6 patient beds

Resuscitation set - 6
OPEN care system
- 4
Incubators
- 2
Infusion pumps - 12
Positive pressure ventilators - 6
O2 Hoods, O2 Analyzers - 6
Heart rate apnea monitors without scope-6
Phototherapy Unit-6
Electronic Weighing Scale-12
Pulse Oxymetres -6
Trans cutaneous PO2 and PCO2 monitors 2-3.
Non invasive B.P. monitors -1-2.
Invasive B.P. monitors 1-2
ECG Monitor without Defibrillator-1
Intracranial Pressure Monitor -1.

Layout map for a single corridor special neonatal intensive care unit for 24 infants

NEONATAL CONDITIONS MANAGED ACCORDING TO LEVEL OF CARE:Three levels of care are described.
Variations in services may be warranted based on the needs of individual patients, resources and
limitations unique to the hospital or type of practice. When present, variations in service
provision require documentation.

Level 1:- Uncomplicated- gestation 37 weeks or greater, birthweight 2,500 grams or greater

Emergency resuscitation and stabilisation.

Minor conditions not requiring additional nursing or specialist medical treatment.
Phototherapy (in consultation with a specialist paediatrician).
Simple convalescent babies (for example, infants establishing feeding)

Level 2: low dependency :Uncomplicated -gestation 34 weeks or greater

The majority of preterm infants born at 35 or 36 weeks gestation are suff ciently mature
to maintain their body temperature and feed normally enabling observation to occur in
the birthing unit and/or postnatal ward. birthweight 2,000 grams or greater, including
growing preterm and convalescing infants.
Infants requiring incubator care for,short-term transition problems , mild complications:
oxygen requirement (not exceeding 40 per cent), apnoea monitoring, blood glucose
monitoring, short-term intravenous therapy, phototherapy, gavage feeding.

Level 3 high dependency: Uncomplicated -gestation 32 weeks or greater, birth weight 1,300
grams or greater.
Note: The more immature the infant, the greater the complexity of care required and the higher
the risk for assisted ventilation.

PARENTING PROCESS;
Parenting is a process that begins in pregnancy and flowers when parental responsibilities
begins.
The degree of ease and satisfaction with which people make the transition to parenthood
depends mostly on how successfully they have defined and accepted their relationship with each
other.

Vital areas in transition to parenthood;

The needs of each person in the system as an individual.
The needs of the parents as a couple.
The influence of parents child interaction overtime.
The nurse must be aware of and respect this areas when working with families
undergoing the transition to parenthood.

ROLE SUPPLEMENTATION AND ROLE MASTERY;

Conceptual framework of preventive role supplementation leading to Role mastery;

By using this frame work health providers can help the parents and their significant others gain
the necessary information or experience to bring them to a full awareness of the anticipated
behavior patterns sensations and goals involved in the complementary role s of mother and
father.
This approach assist the parents to be in moving to role mastery of parenthood. The
impending role must be atleast partly rehearsed ,modeled and clarified through a process of
communication with significant others. In so doing the role expectations become clearer and the
partners begin to put themselves into the role of parents .as this is done ,there is a better fit
to the impending role ,with increased confidence leading to role mastery.
Lifespan cycles and role transition inpregnancy;
Family researchers have outlined four broad stages in a role cycle that have implications for
pregnancy and parenthood.
Anticipatory stage;

Formal or informal training for the role. Socializes the incumbent to-be; may take place years
before; no role modeling for the pregnant role.
Couples in the anticipatory stage experience many intense feelings ,challenges and
responsibilities. If used correctly this can be an opportune time to test skills in preparing to
accept integrate the new family member into the system.
Honey moon stage;
Immediately follow the assumption of the role ;exploration and adjustment to the fit of the
role to the incumbent ;reality testing.
The honeymoon stage refers to the postpartum period during which an attachment between the
parents and infant is achieved through prolonged contact and intimacy(Rossi 1968).
It is an intense period when the mother and their new family member and their relationships to
the infant ,who, in turn ,is working out a complicated communication system with the parents so
that his or her survival is assured. The couples personal relationship is no less important ,but
most of their energies at this time are focused on developing the new relationship with the infant.
Plateau stage;
Role is fully exercised; validation of role adequacy.
Disengagement stage or termination stage;
Immediately proceeds and includes role termination ;sometimes tangible (pregnancy); sometimes
less distinct (parenthood)
Laboring for relevance;
In a study using grounded theory, Jordan (1990) used the term laboring for relevance to describe
the essence of the experience of expectant and new fatherhood . This concept encompasses
intrapersonal and interpersonal aspects. The man labors to incorporate the parental role into his
self identity as a salient and integrated component of his personhood and to be seen as relevant to
child bearing and child rearing by others.
Laboring for relevance is the three-part process that consists of the following;

Grappling with the reality of the pregnancy and newborn.

Struggling for recognition as a parent from mate coworkers, friends,family,newborn and

society.

plugging away at the role of involved fatherhood.

Bonding and attachment;

Factors associated with attachment;

Parents emotional health including ability to trust.

Adequate social support system,including partner family and friends.

A competent level of communication and ability to give care.

Atleast partial parents and infant proximity; continuous proximity optimal.

Parent infant fit including satisfaction with sex of infant compatibility of infant state
with parents and compatibility of temperament of all parties.

Attachment process;
Positive reciprocal feedback; it includes verbal non verbal an social real or perceived responses
of infant to parent and parent to parent, which make the interactions mutually satisfying.
Claiming behavior; leading to identification of the newborns as theirs and identify with him or
her gradually expands the new borns identity; seeing infants as like them in some respects and
different from them in others.
Mutuality in interaction; the newborn has and develops a repertoire of behaviors that calls forth
corresponding behaviors in the parents, particularly the mother ;these behaviors initiate and
maintain contacts with their parents. Signaling behaviors (crying,cooing,smiling) executing
behaviors(rooting,suckling,grasping) are crucial in bringing the parents near and maintaining
contact.
CONCLUSION;
We have discussed about the organization of neonatal intensive care unit, transportation, levels
of services, administration and parenting process.

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