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 NEONATAL, INTENSIVE CARE UNIT (NICU)
Introduction - NICU is a very specialized
unit where critically ill neonates are
cared to reduce the neonatal
morbidity and mortality.
The admission to neonatal
special care unit
intensive care unit has some criteria.
or
lf the child is neonate in the critical
condition, the neonate needs the care of intensive
unit. Mostly from the labour wards, operation theatre and hospital or any other reterral,
they will be sent to Intensive Care Unit
(ICU).
15.1 CRITERIA FOR ADMISSION IN NICU
Indications for admission to the neonatal intensive care unit are as follows.
Low birth weight
(2000gm.)
-

Large babies (more than or equal

4kg.) to
-

Birth
asphyxia (Apgar score less than or equal to 6)
Meconium aspiration syndrome. If symptomatic/thick meconium in
seen larynx.
Severe jaundice
Infants of a diabetic mother.
Neonatal sepsis/meningitis.
- Neonatal convulsions.

Severe congenital malformation/cyanotic congenital heart disease.

O, therapy/parentral nutrition.
 364
Neonatal and Paediatric Intensive Care Unit

Immediately after surgery/cardiological investigation.

rate and unstable.
Cardio respiratory monitoring, if heart respiratory rate are

Exchange blood transtusion.

PROM/Foul smelling liquor.

Mother of hepatitis "B' carrier.
Injurred neonate.
intensive care specialist,
Intensive care needs highly trained personnel including the
the monitoring and
trained nurses and techniques. Sophisticated equipments for are
and the availability of continuous laboratory support
maintenance of vital functions
essential in the intensive care.

15.2 AIMS/GOALS OF NEONATAL INTENSIVE CARE UNIT

The goals of a neonatal intensive care unit are the
ill neonates keeping in mind
To improve the condition of the critically
survival of neonate so as to reduce
the neonatal morbidity and mortality.
in
inservice training to medicine and nursing personnel
To provide continuing
the care of the new born.
cardio-vascular, renal and
nervous

To maintain the function of the pulmonary,

system. central venous
body temperature, blood pressure,
To monitor the heart rate,
blood by non-invasive techniques.
pressure and analyzers.
the oxygen concentration of the blood is by oxygen
To measure
certain
to find out the changes beyond
To check/observe alarms systems signal,
the monitors.
fixed limits set on
amounts of fluids
and minute quantities of drugs through
To administer precise
I.V. infusion pumps.
OF NICUU
15.3 PREPARATION
Warm (33-36°C) incubator
Adequate light source
stocked.
Resuscitation and treatment trolly and tlow
treatment and diet sheet, probiem list
History, continuation sheet,
charts.
(as available in the unit).
Oxygen air and suction apparatus
meter.
connected to oxygen and air flow
Oxygen line catheters.
various sizes of suction
Suction-complete suction unit tubing and
and mask of appropriate sizes.
Ventilation bag
Vital signs monitors.
Specific equipment as indicated by diagnosis.
 PUA Text Book of Child Health Nursing
365
ADMISSION PROCEDURE IN NICU
data recorded
All babies admitted to the neonatal unit should have the following
carefully within 24 hours of admission (if possible much sooner).

History and examination

Maternal history
Paternal history
Previous obstetric history
Details of present pregnancy
Labour
Delivery
Apgar score

On admission

Notify the doctor and the nurse incharge.

Resuscitate infant as necessary and maintain warmth.

Check infant identification label.

Quickly examine the infant from head to toe for obvious abnormalities if the
condition permits.
Record weight, length and head circumference as soon as possible.
Transfer to warm environment as soon as possible.
Commonest ubservations are-
(a) Temperature - Infant normal temperature range 36°C to 37°C
- Environment See natural thermal environment charts.

(b) Heart rate. (c) Respiration (d) Colour (e) Activity.

Explain to parents
- Hand over from transferring unit staff.

Record keeping
Birth history- Done in labour ward.
History
(a) Ward history contains
Apgar score and examination of new born infant sheet.
- Neonatal weight and feed sheet, progress chart.
(b) Compiled history contains
-

Iatient registration form.

- Progress sheet.
 Neonatal and Paediatric Intensive Care Unit 366
Intra uterine growth chart.
O, flow sheets, fluid balance sheet etc.

15.4 LIBE THREATENING CONDITIONS WHICH REQUIRENCU

The following are the life threatening conditions in neonates
Apnea
Baby with respiratory distress
Birth asphyxia.
Convulsions.
intensive care.)
Low birth weight babies (less than 1500 gm requiring
transfusion.
Neonatal jaundice requiring exchange blood
Sepsis and meningitis.
NICU
15.5 HOW TO MAKE ROUND WITH THE CONSULTANT IN
and reporting while round with
The nurse should have the following recording
consultant.
and evaluate assigned patients (neonate) each day.
A. Examine

B. Record Keeping8 ongoing

status of infants and
n e w or
notes It should reflect present
(1) Progress
-

problemns. at the front of the progress

notes.

(2) Problem list A complete

-
problem list is kept also noted.
n e w problems listed and resolved problem
This must be kept current, be consistent with the
in the progress chart should
The number of the problems
problem list. be collected from
needs to be discussed. The problems should
Only active problem
the following areas

(a) Generalstatus
Better? Worse ? No change?
Pertinent physical findings.
-
(b) Nutrition
appropriate?, inappropriate
Weight, change
Caloric status, source.

nutrition (feeding)
Plan of
(c) Respiratory problems
physical findings, laboratory findings.
-
Present status, pertinent

(d) Infection
findings.
If suspected or present, pertinent
 367 PUA Text Book of Child Health Nursing
cultural results.
Plan of therapy e.g., how long antibiotic treatment is planned ?

(e) Apnea
Number and severity of apneas/bradycardia.
Treatment (ventilation).
Caffeine or theophyline levels.
(f) Cardio-vascular :-
Physical findings
Blood pressure
Results of test such as echo,
Treatment plans.
(g) Fluids and electrolytes-
Intake and output, electrolytes
Problems and plan.
(h) Metabolic
-

Glucose, calcium, phosphorusim balance or any problems

Assessment and plan.

i) Neurological
Problems, changes, medication, plans.
Seizures, medications, blood levels, ECG results
j) Hematological
- Anemia/coagulopathy, neutropenia etc.

Transfusions and plans.

(k) Hepatic
(1) Renal problems
(m) Eyes when examined and results
(3) Discharge - Summaries/transfer summaries must be done prior to discharge of

patient.
15.6 INSTRUMENTS AND FACILITIES IN NICU
Apex institution or regional perinatal centre must be equipped with centralized O,
supply, suction facilities, incubators/open care system, vital signs and transcutaneous
ventilators and infusion pumps, which are mandatory to provide intensive neonatal
Care
Physical facilities-The neonatologist and the nurse incharge must be involved
while planning the unit. The intensive care area should be localised preferably next to
Neonatal and Paediateie Intensive Care Un 368

the labour ward and delivery For economising the costs it would be preferably to
rooms.
have il combined with level l tacilities, through both the areas there must have separate
and adequate stalf and a single administrative control.

Temperature of the unlt

In the case of controlling the environmental temperature, the NICU should not
illumination.
be located the top floor, but there must be adequate sunlight for
on

central air
The unit must have a fair degree or ventilation of fresh air through
should be maintained
conditioning is a must. The temperature inside the unit
at 28 + 2C while the humidity must be above 50%.

Shifting
*In case the unit is responsible for picking up babies, referred from the regional
it should be within easy access for the ambulance entrance and should
hospitals,
have a separate elevator.

Physical set up (Size) :- for

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
One intensive care bed is generally required for 100 deliveries provided the
30
prematurity ratio is around 8% and hence for a population of one million,
intensive care beds would be required for our country. These figures would
require modification based on the growth rate, number of premature deliveries
and the load of high risk population drains since the supportive services to be
provided for it would be uneconomical to have a of less than 6-8 bed.
NICU
15.7 ASPECTS OF NICU
Two main important aspects in NICU
(1) Physical set up (2) Administrative set up
Categories of NICU-There are three categories
(1) First level (mild) (2) Second level (moderate) (3) Third level (critical).
(1) PHYSICAL SET UP
Space between the patient
For the patient care, 100 square feet is required for each baby as it is true tor
any adult bed.
There should be a gap of about 6 feet between two incubators for adequate
circulation and keep the essential life saving equipments, space needed about
120 square feet.
369 PUA Text Book of Child Health Nursing
Each patient station should have 12-16 central voltage stabilised electrical
outlets.
2 to 3 oxygen outlets.
2 compressed air outlets.
2 to 3 suction outlets.
Additional power plug point would be required for the portable x-ray machine
close to the patient care area.

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.
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.
Lighting-The lighting arrangement should provide uniform, shadow free
illumination of 100 foot candles at the baby's level. In addition, spot illumination should
be available for each baby for any procedure.
A generator back up is mandatory where there are frequent power fluctuations or
power failures.
Sounds The Acoustic characteristics should be such that the intensity of noise is
kept well below 75 decibles.
The unit should also have an intercom and a direct out side telephone line so that
parent of the patient can have an easy acess to the medical personnels in case of an
emergency.
Rooms-Apart from patient care area including rooms for isolation and procedures,
there is need of spacefor 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.
room for the x-ray and ultra sound machines.
keeping
One or two rooms each would be needed for doctors and nurses on day and
night duties.
There is a space available for a biomedical engineer to provide essential periodic
preventive maintenance of the costly equipments.
Additional space will be required for educational activities and storing of data.
Ventilation : Minimum of six air changes, 2 air changes should be outside rOr
filtering the inner air.
Effective air ventilation of nursery is essential to reduce nosocomial infections.
 370
Neonatal and Paediatric
intensive Care Unit
The air conditioning ducts must be provided with millipore filters (0.5H) to

restrict the passage of microbes.

Exaster
Keep away from the baby.
Ventilated air-A simple method to achieve satisfactory ventilation consists of
in direction near the ceiling for input of fresh
provision of exhaust fan a reverse
the
uncontaminated air fixation of other exhaust fan in the conventional manner near

floor for air exit.

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.

(2) ADMINISTRATIVE SET UP

director who is full time

Medical staff -
The unit should be headed by a

with special qualification and training in neonatal medicine.

neonatologist
He should be responsible for maintenance of standard of patient care.
Development of the operating budget.
Equipment evaluation and purchase.
Planning and development of education programme.
Evaluation of effectiveness of perinatal care in the area.
He should devote time to patient care services, research and teaching as well
o-ordinate with level I and level II hospital in the area.

Staff Requirements

Neonatal physician 6-12 patient in the continuing care, inter mediate care and
intensive care areas.
He should be available on 24 hours bases for consultation.
A ratio of one physician in training to every 4-5 patient who requires intensive
care ideal round the clock.
Services of other specialists like microbiologist, hematologist, radiologist,
cardiologist and should be available on call.
An anesthetist capable of administering anaesthesia to neonate.
Paediatric surgeon and paediatric pathologists should be available.
Nurses Ratio

1 Nurse patient ratio of 1:1 maintained throughout day and night.

4 A ratio of one nurse for two sick babies not requiring ventilatory supPport may
be adequate.
For an ideal nurse patient ratio, four trained nurses per intensive care bed are
needed.
 372
and Paediatric Intensive Care Unit
Neonatal
quantity required for 6 patient
Equipment required for any neonatal ICU and the
beds:-
Resuscitation set -6
-Open care system-4
Incubators -2
Infusion pumps -12

+ve pressure ventilators -6

-6
O, hoods, O, analyzers
Heart rate apnea monitors without scope-6
Phototherapy unit-6
Electronic weighing scale-12

Pulse oxygmetres -6
and PCO, monitors 2-3.
Transcutaneous PO,
Non invasive B.P. monitors -1-2.
Invasive B.P. monitors 1-2
ECG monitor without defibrillator -1
Intracranial pressure monitor -1.

Disposable Articies Required for the NICU

endotracheal tubes, suction
I.V. catheter, I.V. sets, bacterial filters, feeding tubes,
v e n o u s catheters, syringes, needles,
catheters, three way adoptors, umbilical arterial and
ventilator tubings, trocar and canula, pressure transducers for invasive blood pressure.

15.9 LABORATORY FOR NICU

round the
A micro chemistry laboratory attached to the unit and providing
not be
clock service, in preferable through under indian conditions, this may
mandatory.
This should be well-equipped to provide quick and reliable hematocrit, blood

glucose and total serum bilirubin.

Facilities for total leukocytes counts and microscopic examination of peripheral
blood films for evidence of infection.
Equipment for measure of specific gravity of urine and calcium should be
available
House X-ray machine and an ultrasound machine should be mandatory for
modern day neonatal care units.
 PUA Text Book of Child Health Nursing
373

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 374
Neonatal and Paediatric Intensive Care Unit

15.10 DOCCUMENTATIONS IN NICU

for maintaining
The unit should have printed problem oriented stationary
records, admission and discharge slips etc.
a register or on a computer.
Records of all admission should be maintained in
at least once a month to
The information should be analyzed and discussed
the services.
improve the effectiveness of the NICU in providing
15.11 EDUCATION PROGRAMME AT NICU
for physiciarns and
There should be continuing medical education programmes
nurses in the form of lecturers,
demonstrations and group discussions.
sterilisation to be
This should c o v e r important issues like resuscitation,
maintained for critically ill babies, putting in arterial catheters, conducting
maintenance of ventilators etc.
exchange transfusion,
Educational programmes covering the nurses and physician in the community
should be developed.
There should be regular meetings with the obstetrician to discuss the perinatal
condition and care.
Individual high risk cases.
Education and follow up is necessary.

15.12 PAEDIATRIC INTENSIVE CARE UNIT (PICU)

Introduction:-Paediatric intensive care unit where critically ill children are cared
to reduce the child mortality.
Advances in the understanding of pathophysiology and management of complex
life threatening processes, such as respiratory failure, shock, trauma, and increased
intracranial pressure and availability of electronic monitoring and life sustaininng
procedures such as mechanical ventilators have dramatically improved the level of care
that can be offered to seriously ill children. Efforts to deliver this highly sophisticated
health care in an organized manner have led to evolution of a new sub speciality intensive
care unit.
Paediatric intensive care units for the critically ill are found in many children hospitals
and the large paediatric departments in general hospitals. In some states, care of the
high risk children takes place in regional centers equipped for this purpose. Children
who are critically ill are transported from local hospitals to these centers for care.
Development of separate paediatric intensive care units is only logical in this process,
as physiological need and disease patterns of young and infants and children are distinct
from adults.