PRACTICAL 2 ORGANIZATION OF

NEONATAL CARE
UNIT
Structure
2.0 Objectives
2.1 Introduction
2.2 Physical Layout
2.2.1 Space and Location
2.2.2 Floor Plan
2.2.3 Ventilation and Lighting
2.2.4 Environment Temperature and Humidity
2.2.5 Acoustic Characteristic and Communication System

2.3 Personnel
2.4 Equipment
2.4.1 Incubator
2.4.2 Radiant Warmer
2.4.3 Phototherapy Unit
2.4.4 Pulse Oximeter
2.4.5 Mechanical Ventilator
2.4.6 Infusion Pump

2.5 Disinfection of Equipment

2.6 Let Us Sum Up

2.0 OBJECTIVES
After completing this practical, you should be able to:

• describe the physical layout of neonatal care unit;

• indentity the personnel required for providing optimal care to high risk
neonate;

• operate various neonatal equipments efficiently; and

• provide nursing care to neonate being nursed with various devices.

2.1 INTRODUCTION
The organization of a good quality neonatal care unit is essential for reducing
the neonatal mortality and improving the quality of life amongst survivals. The
emphasis should be laid on developing a sound infrastructure to ensure
delivery of safe nursing care, promote asepsis. Adequate space, availability of
running water round the clock, centralized oxygen and suction facilities, .
maintenance of thermoneutral environment, ready availability of adequate linen
and disposal and sophisticated electronic gudget is mandatory to provide care
to high risk neonate. . 19
Nursing Techniques in
Paediatric Care-I 2.2 PHYSICAL LAYOUT
In this section we shall focus on location floor plan, ventilation, lighting
environmental tempereture and humidity, acoustic characteristic, communication
system.

2.2.1 Space and Location

Each neonate should be provided with a minimum area of 100 square feet.
Neonatal care unit should be located as close as possible to the labour room and
obsteric operation theatre to facilitate prompt transfer of sick and high risk
neonate.

2.2.2 Floor Plan

The neonatal care unit should be preferably in a square space so that abandoned
open unencumbered space: is available. The wall should be made of glazed tile
and windows should have two layers of glass panes to ensure heat and sound
insulations. Wash basins with elbow or foot operated tap having round the clock
water supply should be prcvided. The door should be provided with automatic
door closures. Built in well wooden cabinet with foldable cover should be used
for stocking purposes. There should be isolation room where effected neonate
with neonatal sepsis should Le nursed. There should be breast feeding room for
promoting practice of exclusive breast feeding and educating mothers.

2.2.3 Ventilation and Lighting

Effective air ventilation of nursery is essential to reduce nosocomial infection.
The most satisfactory ventilation is achieved oy laminated air flow system.
Simple methods to achie 'e satisfactory ventilation consist of provision of exhaust
fan in a reversed direction near the ceiling fer input of fresh uncontaminated air
and fixation of at.other exhaust fan in the conventional manner near the floor air
exit. Constant positive air pressure should be maintained in the nursery so that
contaminated air from the corridor does not gain access into the nursery.
The nursery must be well illuminated and painted with white or slight off-white to
permit prompt and early detection of jaundice and cyanosis. It is best achieved
by cool white fluorescent tubes to provide at least 100 foot candle, shadow free
illumination at the infant level. f/>,

2.2.4 Environment Temperature and Humidity

The temperature of the nursery complex must be maintained around 28 ± 2
degree centigrade indoor to minimize effects of thermal stress on the babies.
This is best achieved by centralized air conditioning having temperature control
knobs in the nursery. Portable radiant heater, infrared iamp or bulb can be used
tc provide additional source of heat to an individual infant. Humidity is maintained,
around 50 per cent Neonatal care unit should be equipped with room
thermometer and hygrometer.

2.2.5 Acoustic Characteristic and Communication S} .t\"1(

Sr-und intensity in the nursery should not exceeu 75db to pror: Cl !l' b o.

'\ :-sery personnel and infants. Telephone rings and equipn-cnr, ala.i.is should b·;
. Ylc,'r: uy blmking light. Decibel meter should be installed to monitor sound
k"L,1 .n it ' ..ursery. The beneficial and soothing cf~'~;t of mcan.nziul sound such
a·. gen.:e music or recon.mg of p'lren.' )i( S!-k' .1 ',;; ham I;:, se-i o provide
pL:' ')1.) .c stability :0 the bab.es.
"
Tr.: nun-ry coi.iplex should b. provided with ,u1 intercom system so that
'.ll! : i, ;.11 ~'i;rS(l,.can be called fo, help in ca.; of emergency. A direct line
 external telephone in mandatory so that parents have an easy access to enquire Organization of
about welfare of their infants. Mobile phone should not be used near the vicinity Neonatal Care Unit
of nursery because the electromagnetic waves are liable to interfere with the
functioning of the electronic equipment.

2.3 PERSONNEL
\
It is important that while allocating nursing, medical and paramedical staffs, the
needs of the neonatal unit should not be ignored. The highest priority in the
organization of neoriatal unit is the availability of sufficient number of adequate
trained personnel especially the nurse. The high power committee has
recommended one nurse is needed to offer special or intermediate nursing care /
to three babies or intensive care to one infant.

The National Neonatology Forum of India has recommended that at least one
- trained nurse should be allocated to provide coverage to four babies in the
special care neonatal unit. The allowance should be kept for additional 25 per
cent staffs to provide for the exigencies if day off and leave. The continuity of
the service can be maintained if at least 5 per cent of the nurse are rather
permanent and not transferred frequently as is the usual practice in general
hospital. I ,

Neonatologist should devote his full time to improve the existing standard of
neonatal special care service. The unit must also have an independent senior
resident doctor and one junior resident round the clock for every eightbabies
requiring special care.
A laboratory technician should be available to operate bilirubinometer, glucometer,
micro centrifugation, eRP kits and blood gas analyzer. A biomedical technician or
a link person is essential to maintain a liaison with supplies of equipment to ....-'\
j ensure their smooth functioning and prevent breakdown. When ventilatory facility
- are established respiratory therapist is a useful member of neonatal team to
monitor ventilatory settings.

2.4 EQUIPMENT
In neonatal care unit various equipments are used either for monitoring the
physiological status of neonate for example pulse oximeter and apnea monior or
for maintaining temperature and other therapeutic purposes for example
photothearapy unit, radiant warmer and incubator.

2.4.1 Incubator
The incubators are essential to provide an ideal microenvironment. The main
functions are: isolation, maintenance of thermo neutral ambient temperature,
desired humidity and administration of oxygen. It is essential that an incubator
should not interfere with observation of an infant, should offer easy access to the
baby and readity cleanable.
An incubator that can control tempertaure, humidity and oxygen concentration
while providing a high degree of isolation through the slight positive pressure
maintained by air circulation system.
These incubators are becoming less popular now days as increased risk of
nosocomial infection (humidity chamber is potential source of infection).
A) Indicator lights - Two white lights on the control panel. One white light
indicates that the power is on and the other indicates that the air circulation
system is operating. 21
Nursing Techniques in B) Temperature indicator meter - Provides continuous readings of the infant's
Paediatric Care-I
temperature when the probe is affixed to skin.

C) Thermo stat knob - To obtain thermostat control of incubator air

temperature turn this knob to the position that will maintain the incubator
termperature at the desired level.

D) Servo control probe - The probe is secured to the midline of the abdomen
half way between the umbilicus and the xiphoid.

E) Thermometer - The thermometer inside the incubator indicates the

temperature of the incubator.

F) Control point adjust button - The temperature control point of the infant
servo control unit is fixed at 97 F (36.1°C). A temperature control point of
9rF or 36.1°C. Skin temperature is correlated with a body temperature of
98.5°F or 36.9°C.

G) Red line adjust button - Provides a quick means of checking the

temperature meter for proper calibration. Press redline adjust button. The
meter needle should slowly swing up, stopping on the redline on the meter
face.

H) Oxygen inlet - The tube attached to the source of oxygen flow should be
connected at this oxygen inlet.

I) Humidity chamber ~ The humidity chamber should be filled with sterile

distilled water. The water should be drained and replenished daily to the
level indicated by ablack line. To drain the humidity reservoir, turn the' fill
pipe counter clockwise. High humidity aids in relieving respiratory difficulty.
Add 0.8 - 2.5 ml of 1:10,000 solution of silver nitrate per liter of water to
inhibit the growth of microorganism, Humidity tank incubators are potential
source of infection. In some places incubators are used without adding water
in the humidity chamber.

J) Port holes and plastic - For access to the infant the port hole is opened/
closed by turning the metal ring that surrounds the plastic sleeve counter
clockwise/clockwise.

The plexiglass port hole is a lined plexiglass door located at the foot end of
incubator through which contaminated linen and other articles may be
removed from incubator.

K) .Weighing facility - The vent at top portion of the plexiglass hood is used to
facilitate weighing of the infant.

L) Storage cabinet - The base of the incubator provides storage area for
individual linen and supplies.

M) Heater out put monitor - Built in heater out put monitor provides
information regarding the amount of heat generated by the incubator warmer
to keep the infant homeothermic.
, .~. '
N) The front panel can be opened an(t bassinet can be pulled out, for unhindered
access to infant for examination procedure.
22
 Organization of
Neonatal Care Unit
Access panel
latch releases

Oxygen input -----lllf!t""" ~.,_...

"'-_-: Hood hinge latch
connection ~];;~~=§;:~=::.::.~e (hidden)
Iris entry .f~'"fI.~~3~~
point
Access door
latch/releases
Tubing
access port
Hood lift handle

Humidity
fill pipe
Matteress
elevator levers

Caster lock

Fig. 2.1: Isolette incubator

Weaning the Infant from the Incubator

When heater output reading is minimal or nil it suggest that infant is capable of
generating enough metabolic heat to keep himself warm and can be nursed in an
open cot.

Dress and wrap the infant warmly, switch off the incubator, open all the
incubator port/holes, the incubator's temperature come downto room ~
temperature gradually, the infant may be removed and placed in a cot.

Specific instructions

Alcohol, ether or acetone should not be used to clean the plexiglass and
plastic parts of the incubator.

Nurse's Responsibilities

The incubator should be pre warmed to 34°-36.1°C for infants less than 1500
gms and 33.9° -35°C for infants more than 1500 gms.

After the infant is placed the incubator is set for maintenance of skin
temperature between 36.0° C-36.5°C.

. The infant need not be fully clothed, a diaper is only put.

23
Nursing Techniques in Ensure that servo control probe is in place and properly secured to prevent
Paediatric Care-I hyperthermia. Reposition the probe when infant is turned, never place a probe
under the infant.

The weaning of infant from incubator should be gradual process.

The unit should be thoroughly disinfected every day.

Record temperature and humidity of the incubator and the responses of infant.

Donot open the incubator during the routine care. Abrupt change in the
temperature can cause untoward metabolic responses in the new born that may
cause apnea.

Humidity chamber should be drained and replenished daily.

2.4.2 Radiant Warmer

A radiant warmer is a device used to maintain the body temperature of the
newborn and thus play an essential role in influencing oxygen- consumption, apnea
and acid base balance.

The infrared heat is preferable because it directly warms the subject without
affecting the temperature of intervening environment. Open care system is
equipped; with an overhead radiant warmer and skin thermister with servo-
control is becoming increasingly popular and preferred over an isolette incubator
because of easy access to infant and less chances of nosocomial infection.

1) Hood - Hood contains the radiant heat panel. The radiant heat panel will
automatically turn on and off to maintain the infants temperature as desired
by temperature control and thermister attached to the infant.

2) Panels - There are four panels, two sides panels, head and foot panel.

3) Bassinet procedure table - The bassinet may be placed in varying levels of

fowlers or trendelenburg position by squeezing the handle under the tabletop.

. 4) Storage area - Linen and equipment necessary for the individual care of
infant may be stored here.

5) Control panel

a) Off-on switch - Turn power on or off.

b) Power light- Amber light illuminated when power is on.

c) Set temperature - Set the temperature between 36° C- 36.5° C radiant

energy is maintained at a level that will maintain the desired skin
temperature.

Skin sensor probe - It is fixed to the abdominal skin midway between

umbilicus and xiphisternum. The skin sensor feeds the information
regarding temperature of the baby to thermostat, which automatically
regulates the output of the heat to maintain desired skin temperature.

Heater output - Provides information regarding the amount of heat

generated by the incubator\warmer to keep the infant normeothermic,
~
Visible/Audible alarm speaker - Red light flashes/Emits audible alarm
when temperature measured by thermister is ± 1° C set temperature i.e.
36.0° -36.S°C.
24
 Organization ot
Neonatal Care Unit

I.v. Pole

Monitor

Controller

Oxygen delivery
system

Instrument tray

Skin temperature
probe

Bassinet

Middle cart shelf

Fig. 2.2: Radiant warmer

2.4.3 Phototherapy Unit

Principle

Photo isomerisation and photo-oxidation changes indirect bilirubin into water

soluble substance.

Operational Instruction

• Adjust the angle and height of the lamp housing to the desired position. It is
recommended that the light be kept at 18" or 45 cm away from the infant to
minimize any heating effect of the lamp. Intensity of light is 425-475 nm.

• Turn on the power switch located on extension arm.

• Rotate the aperture control for maximum field size.

• Rotate the intensity as determined by radiometer.

25
Nursing Techniques in Nurse's Responsibility
Paediatric Care-I
• Remove clothing to maintain proper skin exposure.

• Turn frequently to expose all skin areas.

• Monitor temperature and level of hydration.

• Close infant's eylids and cover with a light opaque eyeshield secured/ held in
place by tape or bandage. It should be changed every eight hours and give
eye care.

• Cover genitalia.

• Observe common side effects of phototherapy - loose greenish stools

transient skin rash, bronze discolouration of the skin, hyper pigmentation,
dehydration as phototherapy increases insensible water loss.

Local hyperthermia under the electrode can cause redness of the skin.
Overheating of surface should be avoided. The nurse should be alert to the
development of blisters and should record and report her findings. Change
the site 2-3 hourly.

2.4.4 Pulse Oximeter

It is a non-invasive measure for continuously monitoring the blood oxygen
tension levels i.e. POzlevels so that minute to minute changes can be observed.

Principle •
Infra red rays are absorbed by oxygenated blood and deoxygenated blood
differently.

The arterial blood oxygen saturation can be determined transcutaneously by

measuring the absorption of two selected wave lengths of light. The light
generated in the sensor probe passes through the body and tissues and is
converted into electronic signals by a photodetector located in the sensor. The
oxyhemoglobin and reduced haemoglobin allow different amounts of light at
selected wavelengths to reach the photodetector. The monitor gives the digital
display of arterial oxygen saturation, pulse rate and audible pulse tone.

Indication

Hypoxemia i.e. inadequate ventilation plus poor perfusion of tissues combine to

cause low arterial oxygen tension.

Uses

To monitor pulse rate, oxygen saturation and apnea.

Types of probe

Flex probe/Multi sensor probe:

Precautions

Do not place probe of pulse oximeter on the limb on which J3.P. cuff is put for
recording blood pressure.

26 Do not put on the TV set as this can cause altered reading.

 Organization of
Neonatal Care Unit

Pulse Oximeter Pulse

Power
Wave Form High
Oxygen Saturation High

Pulse Volume Low

Alarm Volume . --1
Low

Fig. 2.3: Pulse oximeter

Nursing care of infant with pulseoximeter:

Placement of probe: The skin is cleaned with alcohol to remove oil and allowed
.to dry. The probe can be fixed on the dorsum of the foot of baby.

Check for proper contact between electrode and skin to maintain accurate
readings ..

Blood pressure cuff should not be applied to the same limb to which
transcutaneous probe is fixed.

Infants less than three days old have marked reduction of pa2 level during
vigorous crying. More accurate pa2 levels are obtained when the infant is at
rest. The rate of pa2 level should alert the nurse, to an imminent need for
resuscitative measures.

Record pa2 level every half hour.

The nurse should use pa2 level as a guide to modify nursing care. Handling,
special procedures, position and crying of an infant can significantly alter P02
level. Suctioning, diapering etc. should be done in a gentle, organized, well spaced
plan to maintain a constant pa2 level.
27
 Nursing Techniques in Do not use probe in neon ate having severe oedema, skin diseases, barbiturate
Paediatric Care-I intoxication (due to high skin sensitivity), receiving nitrous oxide because the
presence of 100 per cent Nitrous Oxide stimulates presence of approximately 2
per cent oxygen.

To safeguard the risk of hyperoxia and retrolental fibroplasia, upper limit of alarm
for oxygen saturation should be set at 95 per cent.

2.4.5 Mechanical Ventilator

Continuous positive pressure breathing (CPPB) and synonymous term continuous
positive pressure ventilation (CPPV); Positive end-expiratory pressure (PEEP)
continuous residual airway pressure (CRM) are designed to prevent atelectasis
and to allow for greater oxygen and carbon dioxide exchange at the alveolar -
capillary level.

Ventilators are sophisticated electronic mini air pumps. Assisted ventilation is

required in some babies with respiratory failure (hyaline membrane disease,
recurrent apneic attacks.)

Two types of ventilators (IPPV):

Pressure generator

Flow generator

On the basis of built in control principles for termination of inspiratory phase, the
ventilator may be pressure cycled, volume cycled or time cycled. A suitable
infant ventilator should be able to deliver adequate gas volume and compensate
for any loss of gas volume due to compression, leaks and dead space.

Clinical Parameters indicating ventilatory support are as follows.

Arterial blood gas:

Pa02< 50 mm Hg

Pc02> 60 mm Hg

Parts of ventilator are:

Oxygen blender: Provides precise control of oxygen concentration from 21 per

cent atmospheric air to 100 per cent.

Compressor: Centralised supply of oxygen and purified air alternatively air

compressor of 50 PSI is mandatory for assisted ventilation. Percentage of F102
is regulated as per the requirement compressor compresses the air and deliver at
50 PSI. (It should be washed daily).
Pressure manometer: Provides constant monitoring of the pressure of air/
oxygen mixture being delivered to the ventilator. A green wedge on the
manometer dial indicates mandatory operational pressure range between 45 and
55 PSI.

Humidifier module: Fill jar with distilled water to the full mark.

Thermometer: Indicates the temperature in the tube system near the patient
and so approximates the temperature of the inspired gas .
. 28
 Organization of
Endotracheal intubation may be needed in some infants.
Neonatal Care Unit
• When the ventilator is put into operation record all gauge settings i.e.
pressure, flow rate, oxygen concentration, temperature, tidal volume
settings.
• Auscultate and assess the ventilation of both lungs. Observer for hyper
expansion and degree and location of retractions. Detect early signs of
pneumothorax.
• Observe the inspiratory/expiratory ratio (normal is 1:1.5 to 1:2).
• Observe for abdominal distension, which can cause undue pressure on the
diaphragm preventing full lung expansion.
• Observe and record temperature of inspired gas, it should approximate body
temperature.
• Check water volume of humidifying system.
• Strict aseptic techniques must be observed to prevent infection - periodic
filter changes, culturing humidifying container for bacterial growth, use of
sterile suctioning equipment.
• Suctioning to remove accumulated tracheobronchial secretion.
• Chest physiotherapy.
• Monitor arterial blood gas. A sudden fall in Pa02 and rise in PaC02
indicates deterioration of the patient.
• Be sensitive to alarm.
• The position of the infant should be changed frequently. Vital signs, fluid
intake and output should be monitored.

Complications: Atelectasis, Pneumothorax, oxygen toxicity, infection,

psychological trauma.

2.4.6 Infusion Pump

As you have learnt earlier, the amount of fluid to be administered to neon ate
is based on the neonate's weight and physiological status. It is recommended
that in a neonate the fluid should be given through infusion pump, because this
devise allows for a more accurate setting of flow rates.

An infusion pump can be used to control the administration of small volumes

of fluid, blood, medication and total parenteral nutrition. It is important to be
familiar with the type of infusion pump, used at your institution. Be sure to
set controls for both the amount of fluid to be infused and rate of infusion.
Check the pump frequently to be certain it is programmed and working
accurately.

2.5 DISINFECTION OF EQUIPMENT

Prevention of infection is more cost effective than treating infections in neonate.
Thus every Hospital should establish its own detailed guidelines to prevent
infection in neonatal care unit. Basic requirement for asepsis are running water
supply, soap, elbow or foot operated taps, strict handwashing, adequate
disposables, good housekeeping and asepsis routine.
29
Nursing Techniques in
Paediatric Care-I Name of Equipment Disinfection method Frequency

Probes of radiant Clean with spirit swab Daily

Warmer/incubator/pulse
Oximeter

Laryngoscope Clean with spirit swab Daily and after each use
Wrap in autoclave cloth
Put date on cover

Infusion pumps Clean with wet clean Daily

cloth if blood stained
Use soap and water

Oxygen hood Wash with soap and Daily

water and dry

Face mask Clean with soap and Daily and after each use
water, immerse in cidex
for 20 minutes, rinse in
. distilled/running water
and then dry

Resuscitation bag, Clean with soap and Weekly

Reservior, oxygen water after dismantling,
tubing immerse in cidex for 4 -
6 hours, rinse in
distilled water, dry and
wrap in autoclave linen

Radiant warmer and Wet mop with clean Daily

incubator water daily if occupied.
If not occupied, clean
with 2 per cent bacillocid

Pulse oximeter and Wet mop with clean Daily

Phototherapy unit water

Guidelines

• Name of the Nursery visited

• Number of beds

Name of the equipment Functions of Disinfection Remarks

observed equipment Procedure

1.
2.
3.
4.
5.

2.6 LET US SUM UP

In this practical you have learnt about organization of neonatal care unit and nurses
role in maintenance of safe environment and promoting asepsis. You have also
learnt operation of various equipment used in nursery and nurses responsibilities.
30