Established in 1975

PROCEDURAL PRESENTATION

NICU/NSCU
Presented by:

AMBIDA, BERNARD JR. C. BANAYO, ARABETH C. KIAMCO, MARGELYN L. STA. MARIA, JOAN MARIE M.

TABLE OF CONTENTS

I. II.

Organizational Chart Different Areas of NICU Different Equipment in NICU Policies and Guidelines General Procedure A. Purpose B. Scope C. Process Flow A. Newborn Care i. ii. iii. iv. ..

Sta. Maria, Joan Marie Sta. Maria, Joan Marie

III. IV.

Banayo, Arabeth Banayo, Arabeth

Ambida, Bernard Jr.

Preparing for newborn deliveries Receiving of newborn babies Initial assessent of the newborn Performance of necessary recuscitation a. Algorithm v. Physical examination of the newborn vi. Providing routine newborn care vii. Provision of newborns identification viii. Carrying out the doctors order ix. Documentation of assessment, nursing intervention and patient information x. Charging, replacement and monitoring of medicines and supplies xi. Monitoring and close observation of the newborn B. Well Baby i. ii. iii. Rooming-in of the baby Breast feeding and daily newborn care Home discharge of the newborn Kiamco, Margelyn

C. Sick Baby i. ii. iii. iv. v. vi. vii. viii. ix. V. VI.

Ambida,Bernard Jr.

Admission to nicu Carrying out of therapeutic and diagnostic procedures Documentation of assessment and intervention Charging of supplies and equipments Continuous monitoring and provision of daily newborn care Referral to other consultants for specialized management Provision of safe therapeutic environment Endorsement of patient and unit as a whole Final disposition of the newborn Kiamco, Margelyn Kiamco, Margelyn

Breast Feeding Technique Newborn Sreening

NICU STAFF NURSE: Beverly B. Ilag, RN Jonah G. Aquino,RN Joan Mari D. Gavino,RN Anaryna Theresa C. Ondozo,Rn

NICU STAFF MIDWIFE Glenda S. Coria, RM Gishella A. Maghirang,RM Sharon V. Banzuela, RM

NICU NURSE TRAINEE Katherine S. Corninta, RN Kristine N. Capule,RN Hazel Marie S. Torres, Maureen L. Gabutero,RN Angela B. Pedraja,RN Danylyn Anne G. Edradan,RN Jayvee P. Bonila,RN

ON-CALL NICU STAFF NURSE Marvie M. Magtibay, RN Mirasol B. Ola, RN Carizza M. Laurel,RN Hilda G. Audije,RN

ROOMING-IN STAFF NURSE: Madeline C. Valerio,RN Monique A. Cabrera,RN Joan P. Emralino,RN Maria Veronica L. Ciar,RN

NICU MIDWIFE TRAINEE Arlene M. Dizon, RM Jacqueline M. Hernandez,RM

DIFFERENT AREAS OF NICU

POLICIES AND GUIDELINES IF NEONATAL INTENSIVE CARE UNIT

Doc. #: WI-NIU-006 Rev. #: 1 Rev. Date: 01-04-11
I. DRESS CODE a. Staffs shall wear fresh and clean scrub suits and slippers on their everyday duty. b. Staffs shall wear smack gowns and closed shoes when they will go to other areas of the hospital. c. Jewelries are removed and hair caps are worn during duty hours. d. Fingernails are kept short and free from nail polish. e. Pediatricians and other health personnel s shall wear gown and slippers before entering the NICU. II. VIEWING POLICY a. Viewing of babies shall be strictly observed as follows: 10:00am to 12:00 noon 4:00pm to 6:00 pm b. Viewing of newly delivered babies shall be facilitated immediately after providing routine newborn care. III. INFECTION CONTROL A. Strict compliance to WI-NIU-003 (Infection Prevention Guidelines) B. Baby s relatives except for breastfeeding mothers shall not be allowed to enter in the NICU except incases that an intubated for severely ill newborn is requested to be seen by his/her father and nearest relatives. But visiting inside the NICU will only be limited to five minutes. C. Breastfeeding mothers shall wear their own gown, slippers and hair cap before entering the NICU. Jewelries are removed and valuables such as wallet and cellphones are not allowed to be brought inside. D. Machines and equipment shall not be allowed to be used in the other areas of the hospital except for emergency cases. E. Picture and video taking of patients shall not be allowed inside the NICU. Such procedures may be done only on the viewing window. F. A portable X-ray and UTZ machine shall be used for newborns requiring x-ray and ultrasound procedures in the NICU after a request is forwarded to the radiology section. G. Eating, drinking and cigarette smoking shall be prohibited in the NICU.

H. A patient who requires CT-scanning and echoing procedures shall be brought to the respective department but shall not be brought back to NICU. A room transfer of a patient to NSCU shall be ordered by the AP. I. Newborns delivered outside the delivery/operating table of the hospital (those delivered on stretchers and mothers with no perineal preparations) shall be considered unsterile delivery and shall not be allowed to be brought inside NICU. NOTE: 1. Newborn care shall be done outside NICU. 2. Well newborns shall be immediately roomed-in after provisions of routine newborn care. 3. Sick babies shall be admitted to a private room upon doctor s order of AP. J. A sterile infant s layette pack shall be provided by the CSS to be used to newborns after delivery. K. Incubators shall undergo cleaning, disinfection and fumigation for 24hrs before it is used by a premature or sick baby. Reservation of incubator shall only be allowed of the expectant mother is already admitted in the hospital. IV. STATUTORY POLICIES A. Well babies shall be roomed in after 30 minutes to one hour for normal deliveries and after 4-6 hours for caesarean section. B. Breast feeding shall be strictly encouraged by NICU staff to all mothers before and after delivery in compliance to RA 7600 (The Rooming-in and Breastfeeding Act of 1992) C. Routine Newborn Screening test shall be facilitated to all newborn babies in compliance to RA 9288, an act promulgating a Comprehensive Policy and National System for ensuring Newborn Screening. D. Routine Hepatitis B vaccination shall be facilitated to all newborn babies in compliance to the DOH s Administrative Order 2006 0015. E. All fetal deaths weighing 500 grams and above shall have a fetal death certificate to be accomplished by the NICU Nurse and to be submitted to the Medical Records Office. V. A. B. C. D. E. STAFF WORK ETHICS Punctuality is expected to all NICU personnel. Professionalism and proper decorum shall always be observed. Use of personal cellphones are not allowed inside the NICU or during the tour of duty. Personal use of computer shall not be allowed. Internet access shall only be used for researches in relation to nursing care and other official businesses such as the use of bizbox system.

VI.

STAFFING Supervisor - 1 Charge Nurse 1 Staff Nurse -1 each shift Midwife 1 each shift (Note: one additional on-call nurse will be called each shift in presence of intubated patient or sick baby exceeds four newborns for close monitoring)

VII.

MONITORING a. VITAL SIGNS/ OXYGEN SATURATION i. Temperature, respiration and cardiac rate shall be monitored and recorded after birth as follows: 1. Every fifteen minutes for the first hour 2. Every thirty minutes for the next two hours 3. Every hour for four hours 4. Every two hours for eight hours 5. Every fours for the succeeding hours or as ordered by the physician. Note: Vital signs monitoring for sick babies will depend on the doctor s order ii. All pre-term babies on incubators shall be connected to continuous pulse oximeter monitoring. iii. Hooking to pulse oximeter for other sick babies will depend on doctor s order. b. INTRAVENOUS FLUID/ HEPLOCK DEVICE SITES. i. IVF and heplock device sites shall be monitored for patency and signs of complications hourly or more frequent and before giving IV medications. Monitoring shall be recorded in the NICU monitoring sheet. ii. Routine use of transparent dressing on all IV insertion shall be practiced to facilitate clear view of the insertion site. iii. Covering of insertion sites with cloth or disposable diapers shall not be practiced. c. CONTRAPTIONS i. IVF and heplock device sites shall be changed after every 72 hours (3 days) ii. OGT shall be changed after every 72 hours (3 days) NOTE: for intubated patients, changing of OGT will vary depending on doctor s order iii. IV tubings shall be labelled and changed after every 72 hours (3 days) iv. IV bottles and solu sets should have calibrations. v. All IV fluids shall be connected to an infusion pump to ensure accurate delivery of IV fluid to a patient. Urinary catheters shall be inserted by AP or ROD only. vi. NGT and OGT for lavage and gavage purposes shall be inserted by AP and ROD unless ordered by AP that a NICU nurse may insert.

vii.

All newborn patients requiring AP intubation shall be automatically hooked to a mechanical ventilator upon order of the AP. A waiver shall be signed by the parents in cases of their refusal to the said procedure.

VIII. a. b. c. d. e. f. g. h. i. j. k. l. m. n. IX.

ADMISSION CASES Prematurity Neonatal Pneumonia Sepsis Neonatorum AB Incompatibilities UTI Transient Tachypnea of the Newborn Respiratory Distress Syndrome Hyaline Membrane Disease Hyperbilirubinemia of the Newborn Macrosomia Persistent Pulmonary Hypertension Hypoglycemia Congenital Heart Disease Congenital Anomalies and Malformations

BED CAPACITY a. NICU has ten-bed capacity while the NSCU can accommodate up to four sick babies.

X.

CHARGING OF SUPPLIES AND EQUIPMENT a. Nurse on duty of the night shift shall be responsible to request medicines and supplies to the Pharmacy and CSS which will be needed by the patient for the next 24 hours. b. All remaining medicines and supplies of may go home patients shall be checked and returned areas before forwarding the chart to the Billing Section.

SPC MEDICAL CENTER EXCLUSIVE BREASTFEEDING AND ROOMING-IN POLICIES

1. Upon admission, all pregnant mothers are required to sign the consent regarding rules and regulations of the hospital and on breastfeeding and rooming-in policy. It is the duty of the admitting personnel and the security guard to remind mothers regarding the prohibition of bringing feeding bottles, formulas and other related products in the hospital. 2. Health personnel attending to the delivery should latch-on the baby immediately after the delivery. 3. Rooming-in policy should strictly be observed, for normal spontaneous delivery rooming-in is within 30minutes to one hour and for caesarean section 3-4 hours. For premature and sick babies, they should be placed at the NICU. And for those with poor sucking reflex, Expressed Breast Milk may be introduced by cup or dropper as determined by the pediatrician. 4. Mothers should be taught the advantages of breastfeeding and the proper breastfeeding techniques by the concerned nursing staff. 5. Exclusive breastfeeding as well as rooming-in and bedding in should be practiced. 6. Mothers and/or babies with medical and surgical problems will be temporarily separated, but as soon as possible the mother will breastfeed the baby continuously in the designated areas. 7. No hospital purchase of milk. 8. Confiscation of smuggled milk formula and bottle feeding paraphernalia should be implemented. 9. Formation of lactation management team: a. Give 15 hrs lactation training plus 3 hrs practicum for our training residents andparamedical personnel, in-service physicians, affiliated doctors, nurses and midwives. b. Monitor/ update breasfeeding strategies of the hospital. c. Handle problematic cases relevant to breasfeeding. 10. Set up a milk bank to NICU/NSCU babies for temporary storage of extracted breast milk. 11. Posting of instructional/demonstrative materials relevant to breasfeeding in the strategic places in the hospital.

12. Distribution of hospital breastfeeding policies to concerned units for ready reference. 13. Information dissemination- semi-annual lectures/ audiovisual aides/demonstration in the out-patient department and wards. 14. Orientation of the mothers to the breastfeeding policies of the hospital in the pre-natal clinic, admission, labor, delivery and operationg room. 15. All health personnel are required as routine policy to conduct mother s class during prenatal check up regarding nutrition, personnal hygiene, activities of daily living, care of the newborn, giving emphasis on breastfeeding. 16. Members of the breastfeeding committee as much as the Chairman has direct authority to reinforce and monitor the implementation of the above written policies on breastfeeding and rooming-in from admission to discharge.

GENERAL PROCEDURE: NEONATAL INTENSIVE CARE UNIT

Doc. #: QP-NIU-001 Rev #: 4 Rev. Date: 02-13-2010
I-PURPOSE 1. To establish a documented procedure in providing and maintaining optimum care to the new born after delivery. 2. Detect early signs and symptoms of abnormalities in new born infants for proper and immediate evaluation and management. 3. Provide legal documents/evidence concerning newborn s condition after delivery and their response to management. 4. Make sure that all equipment, medicine, and supplies are available and prepared before delivery of newborns. II-SCOPE 1. This covers the preparation before the delivery of the newborn, receiving a newborn and providing routine newborn care, rooming-in and admitting the newborn until discharge. III-PROCEDURE PROCESS FLOW START Preparing for newborn deliveries DETAILS >Includes interview of parents for birth certificates, preparing the equipment and supplies to be needed for the delivery and updating the paediatrician with regards the progress of labor of the mother for delivery. >The newly delivered baby is received in the operating/ delivery room. Initial resuscitation measures are done such as suctioning by bulb syringe, drying and stimulating to cry. Latching on is facilitated and a temporary identification wrist tag is applied on the newborn. >Performance of newborn APGAR scoring system.

Receiviving of newborn babies

Initial assessent of the newborn Performance of necessary recuscitation Physical examination of the newborn

>Application of the algorithm for resuscitation of the newly born infant. >Performance of maturity and classification of the newborn, visual and thorough examination for gross abnormalities and congenital anomalies.

PROCESS FLOW Providing routine newborn care

DETAILS >Includes oil bathing and weighing of the newborn. Anthroprometric measuring, cord dressing and giving routine medications and vaccine such as: Vitamin K, ophthalmic ointment and heap B vaccine. >Dressing the newborn and placing under droplights. >A risk tag with accurate name is applied on the baby. Crib tag is applied on the baby s crib and the baby s foot print, mother s thumb mark are secured in the baby s birth certificate card. >Complete and accurate execution of nursing and medical proceduresto the newborn baby. >Accomplishment of patient chart, Kardex, NICU log books and birth certificate of the baby.

Provision of newborns identification

Caring out the doctors order

Documentation of assessment, nursing intervention and patient information Charging, replacment and monitoring of medicines and supplies Monitoring and close observation of the newborn

>PH, CSS, and pulmo charge slips are accomplished, forwarded to respective department and replace to end-user.

>Monitoring for alterations in normal vital signs of the newborn, thermoregulation, observation for abnormal signs and symptoms and changes in the activity/behaviour of the newborn.

A Well baby? No b Yes Rooming-in of the baby

>Weather a newborn is well baby or sick.

>Bringing the baby to the mother s room, on her bed side or in a crib. Complete endorsement of patient and chart is done by NICU staff to the rooming-in and ward nurse. >The mother is assisted on proper breastfeeding techniques. Full bathing, vital signs monitoring, cord care and newborn screening procedure is done to the newborn.

Breast feeding and daily newborn care

Well baby? No C Yes Home discharge of the newborn End >Discharge order is done. Instructions of continuous breastfeeding and newborn care are given to the mother/parents. >Chart is billed accomplished and attached to the mother s chart.

PROCESS FLOW B Admission to NICU

DETAILS

>Parents are informed of the baby s condition and their consent is secured for the baby s admission. >Admitting section is informed and the baby is placed to sick baby room. >Includes placing oatient on NPO, inserting heplock, peripheral IV insertion or umbilical catheterization, giving IV medications and further needs are done (labs, x-ray,UTZ CT scan, 2DECHO). >Placed on/ placing equipents necessary for the newborn s condition (phototherapy, radiant warmer, pulse oximeter, incubator, O2 hood/cannula, CPAP or ventilators. >Placing orogastric tube for lavage and gavage purposes.

Carrying out of therapeutic and diagnostic procedures

Documentation of >Accomplishment of patient chart, kardex and logbooks. assessment and interventions Charging of supplies and equipment Continuous monitoring and provision of daily newborn care Referral to other consultants for specialized management Provision of safe therapeutic environment Endorsement of patient and unit as a whole >PH, CSS, Pulmo, Billing charge slips are accomplished, forwarded to respective department for charging and replacement. >vital signs are monitored, progression of untoward signs and symptoms of the newborn are observed. >newborn screening procedure done. >newborns are co-manage by other consultants depending on the newborns condition. >strict practice of infection prevention guidelines is observed.

>patient history, present condition and plans of care to the newborn are endorsed. Completeness and well functioning of supplies and equipment are endorsed. >newborn maybe discharged to home, transfer to other hospital, discharged to home against medical advice or discharged due to death.

Final disposition of the newborn

End C Admission to NSCU >the newborn is transferred to NSCU, medical and nursing care plans are explained to the parents and admission record is secured from the admitting section.

APGAR SCORING
Doc. #: WI-NIU-012 Rev. #: 0 Rev. Date: 06/12/2002

Apgar score quantifies the neonatal heart rate, respiratory effort, muscle tone, reflexes and color.

PURPOSE: to determine the status of an infant. EQUIPMENT:  Apgar score sheet  Stethoscope  Clock with second hand  Gloves PROCEDURE:  Assess the neonates respiratory response, begin neonatal rescusitation. Then, use the Apgar score the judge the progress and success of rescisitation efforts.  If the neonate exhibits normal responses, proceed to assign the Apgar scor at one minute after birth. Repeat the evaluation and record the score at 5 minutes after birth.  Using a stethoscope, listen to the heart beat for 30 seconds and record the rate. Assign a 0 for no heart rate, a 1 for a rate under 100 beats/min, a 2 for a rate over 100 beats/min.  Count unassisted respiration for 60 seconds, noting quality and regularity (a normal rate is 30-60 respiration/min). Assign a 0 for no respiration, a 1 for slow, irregular, shallow or gasping respirations, an d 2 for regular respirations and vigorous crying .  Observe the extremities for flexion and resistance to extension. This can be done by extending the limbs and observing their rapid retuned to flexion of elbows, knees and hips, with good resistance to extension.

 Observe the neonates response to nasal suctioning or to flickering the sole of his foot. Assign a 0 for no response, a 1 for grimace or weak cry, and a two for vigorous cry.  Observe for skin color , especially at the extremities. Assign a 0 for complete pallor, and cyanosis, a 1 for a pink body with blue extremities. And a 2 for a completely pink body. To assess color to a dark skinned neonate, inspect the oral mucous membranes and conjunctive, the lips, the palms and the soles.  Record the Apgar score at the Apgar score sheet or the neonate assessment sheet.

ALGORITHM FOR RESUSCITATION OF THE NEWLY BORN INFANT

Doc.#:WI-NIU-032 Rev.#: 0 Rev.Date: 02/05/2009 Appropriate Time
y y y y y

Birth
Clear of meconium? Breathing or crying? Good muscle tone? Color pink? Term gestation?

Routine Care y Provide warmth y Clear airway y Dry

NO 30 mins
y y y y Provide warmth Position, clear airway* (as necessary) Dry, stimulate, reposition Give O2 (as necessary)

Evaluate respiration, heart rate and color

Breathing
Supportive care

Apnea 30 mins
y

or HR < 100

HR>100 and pink Ventilating

Ongoing care

Provide positive pressure ventilation*

HR>100 and pink HR<60 30 mins

y y

HR>60

Provide positive-pressure ventilation* Administer chest compression

HR<60
y Administer epinephrine Recheck effectiveness of: y Ventilation y Chest compression y Epinephrine delivery Consider possibility of: y Hypovolemic y Severe Metabolic Acidosis

*Endotracheal intubation may be Considered at several steps

BREAST FEEDING TECHNIQUE

Doc. #: WI-NIU-002 Rev. #: 1 Rev. Date: 12-22-09
1. Assist the mother in wearing proper attire (gown, hair cap, mask, slippers) before entering the breastfeeding room and instruct the mother to do proper handwashing. 2. Instruct the mother to cleanse her nipple with cotton balls soaked in sterile water in circular moton. Direction must be inner to outer, from nipple to areola. NOTE: The mother should sitcomfortably, with her feet on a foot stool, and a pillow on her lap to support the infant.

3.Give the baby to the mother and assist her on proper positioning of the baby for breastfeeding (baby s body should be turned to mother, close in alignment supported by the mothers arm). 4. Instruct the mother to place forefingers posterior to mammary glands, while thumb is placed anteriorly for support and elicit the baby s rooting reflex by touching the baby s lips with the nipple. y y y y Wait until the baby has a wide-open mouth (almost as if he is going to yawn). Bring the baby to the breast, not the breast to the baby Move the baby;s whole body toward the breast; do not push his head to the breast Prevent the baby;s nose from being pressed against the breast Note: Baby s lips should be flunged; chin touching breast; more of areola below nipple in mouth; cheeks not drawn in; rhythmic burst-pause sucking and swallowing should be observed. 5. Assist the mother to: y Offer the second breast only after the baby has finished the first breast; some babies may wish to feed on only one breast per feed at early feeds. y Continue to offer each breast, one after the other, as long as the baby wants to continue the breastfeed. There is always milk in the breast. y Do not remove the baby from the breast if he is still suckling and swallowing. 6. To end a breastfeed, instruct the mother to feed until the baby releases the breast spontaneously. 7. Assist the mother in burping the baby after breastfeeding by holding the baby in upright position against shoulder using both hands to support baby, gently rubbing the baby s back until he burps. 8. Instruct the mother to cleanse her nipple with sterile cotton soaked in sterile water, wipe with soft dry cotton or cloth and wear a supportive brassiere.

NEWBORN SCREENING
WI-NIU-005 REV. NO. 1 REV. DATE 02-2-06

1.Explain the NBS procedure to parents/relatives. Note: NBS procedure is a mandatory procedure that should be done to all newborn babies in compliance with the RA 9288. 2. Informs parents/relatives that NBS fee of Php 600.00 will be included in the hospital bill. 3. Prepares filter card after each delivery of newborn by accomplishing the data legibly and accurately.

4. Scheduling of blood collection for NBS: y For babies born via NSD, blood collection will be done after 24th HOL. y For babies born via CS, blood collection will be done after 48 HOL. y No blood collection will be done to newborns on NPO. y Blood collection for newborns that had blood transfusions will be done after 4months post transfusion. 5. Informs the laboratory about the request for NBS on the scheduled date and time. 6. Perform blood collection from newborn using heel prick method and blot blood sample of filter chart. 7. Signs in the NBS logbook after blood collection to a newborn. 8. Completes the data in the filter card and on the NBS logbook. Note: Filter card with blood samples will be placed horizontally in the drying rack and dried for 4 hours. 9. Wrap the filter cards with blood sample in a clean paper and accomplish the transmittal form provided by the NBS laboratory. 10. Put the filter cards, transmittal form in the express flyer provided the assigned courier to pick up the blood samples and accomplished in the package to be picked up by the courier. 11. Received the package with the samples, signs in the NBS logbook and deliver the package to NBS laboratory. NOTE: Blood samples should be delivered to NBS laboratory within ten days from the data collection. Results available seven working days from the time blood samples were received at the NBS laboratory. 12. Sends NBS results to the hospital (NICU) through mail fax and internet. 13. Release results of NBS to parents/relatives 14. In case of positive results, instruct parents to bring baby to hospital or NBS laboratory for repeat sample collection or confirmatory test. 15. Refer newborn with confirmed positive results to specialist for further testing and management.