Nicu seminar ppt

Concepts related to Neonatal intensive care unit ( NICU)

1. KAHER INSTITUTE OF NURSING SCIENCES BELAGAVI WELCOME TO SEMINAR Presenting by : Miss Shrutika.S.Navilyale

2. Neonatal Intensive Care Unit (NICU)

3. Objectives of Seminar At the end of this section participants will be able to : Define NICU. Organization of NICU. Admission and discharge procedure in NICU . Levels of NICU. Transport of sick neonate . Organization and management of nursing care.

4. Introduction NICU stands for neonatal intensive care unit, sometimes called a special care nursery . The nurseries care for babies who are born early , who have problems during , or who developed problems while still in the hospital. 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.

5. Definition of NICU A neonatal intensive care unit (NICU) , also known as an intensive care nursery (ICN) , is an intensive care unit (ICU) specializing in the care of ill or premature new-born infants . Neonatal refers to the first 28 days of life . Neonatal care as known as specialized nurseries or intensive care, has been around 1960’s .

6. Aims or Goals of NICU To improve the condition of the critically ill neonates keeping in mind the survival of neonates so as to reduce the neonatal morbidity and mortality. To provide continuing Inservice training to medicine and nursing personnel in the care of new-born. To moniter the heart rate , body temperature , blood pressure , central venous pressure and blood by non – invasive techniques. To measure the oxygen concentration of blood is by oxygen analysers.

7. Conti… To check / observe alarms systems signals , to find out the changes beyond certain fixed limits set on the monitors. To administer precise amounts of fluids and minute quantities of drugs through I.V. infusion pumps .

8. Objectives of NICU To save the life of the sick new-born . To prevent damage in infants with problems at birth and also reduce morbidity in later life . To monitor high risk new-borns so as to reduce morbidity and mortality in these babies.

9. Trends in NICU 1. Advanced technology There are many kinds of technology in the NICU, including different types of infant ventilators, monitors, and supportive devices, such as infusion pumps, oxygen hoods, and incubators. More than any other phenomenon, technological developments seem to have become the most transforming force in the advancement of neonatal care. It was the development of the first infant ventilator that many medical professionals believe actually "birthed" the NICU. Prior to that time, incubators kept infants warm but only the strongest survived in the small isolated special care nurseries.

10. Conti… 2. NICU professionals: The professionals who work in the NICU are highly trained in the care of preterm babies. There are neonatologists, neonatal nurse practitioners, staff nurses, respiratory therapists, developmental specialists, occupational therapists, and physical therapists. This team of professionals works together with the family to provide a holistic approach to the management of the child's needs.

11. Conti… 3. Philosophy of care: Neonatal intensive care has become a leader in the provision of family-centered care, which recognizes the unique and individual needs of each infant and family. Family-centered care is a philosophy of care in which the pivotal role of the family is acknowledged and respected in the lives of children. Within this philosophy, families are supported in their natural care giving and decision-making roles, and medical professionals respect their unique strengths as people and families. Family-centered care strengthens the family unit through advocacy, empowerment, and enabling the family to nurture and support their child's development.

12. Babies who need NICU admission Some factors that can place a baby a high risk and increased the chances of being admitted to NICU . But each baby must be assessed to see if he or she needs the NICU . High risk factors include the below. Maternal factors : Being younger that age 16 or older than 40 years . Drug or alcohol Diabetes Multiple pregnancy Too much or too little amniotic fluid. Premature rupture of membrane .

13. Conti… Delivery factors : Fetal distress or birth asphyxia. Breech birth or any other abnormal position. Meconium aspiration syndrome ( MAS) . Nuchal cord . Forceps or caesarean delivery.

14. Conti… Baby factors : Baby born at gestational age less than 37 weeks or more than 42 weeks . Birth weight less than 5 pounds , 8 ounces ( 2500 gms ) or over 8 pounds , 13 ounces ( 4000gms ). Small for gestational age . Medicine or resuscitation in the delivery. Birth defects . Respiratory distress including rapid breathing , grunting or apnea . Infections. Hypoglycaemia. Special treatment.

15. Equipments in NICU Resuscitation equipment The equipment needed for resuscitation are present in the emergency tray which contains Ambu bag and mask, Infant laryngoscope , tracheal tubes of different sizes , sterile suction catheters , oral mucus suction traps and emergency drugs .

16. Conti… Oxygen and suction facilities A centralized source of oxygen , compressed air and suction outlet consoles affixed on the walls is ideal .

17. Conti… Catheters , syringes and needles Nasogastric polyethylene feeding tubes , umbilical vein catheters , small vein infusion sets , medicaths are prepacked sterile by process of gamma – irradiation . Only single use syringes and needles should be used .

18. Conti… Cardiac monitor: It refers to the continuous or intermittent monitoring of heart activity . It is attached to sensors on the baby and provides a constant read-out of the baby's heart rate and rhythm, breathing rate, arterial or central venous pressure, and other useful information. Alarms can be configured to provide an alert when any of the vital signs being monitored goes above or below a certain limit.

19. Conti… Pulse oximeter: Pulse oximeter provides a simple , convenient and non- invasive method for continuous monitoring of haemoglobin saturated with oxygen .The arterial blood oxygen saturation can be determined transcutaneously by measuring the absorption. of two selected wavelength of light . The light generated in the probe passes through the blood and tissues and is converted into electronic signals .

20. Conti… Neonatal ventilators: Neonatal ventilators provide ventilatory support to preterm and critically ill infants who suffer from respiratory failure and who generally have low compliance lungs , small tidal volume , high airway resistance , and high respiratory rates. These mechanical ventilators promote alveolar gas exchange by generating positive pressure to inflate the lungs of infant.

21. Conti… Intracranial pressure monitor:

22. Conti… Infusion pump: Most sick babies have one or more intravenous (IV) or arterial lines, and the fluid that is delivered through those lines must be very carefully regulated, all the way down to the amount of 0.1 cc per hour (about 1/30 of a teaspoon per hour). There are many brands, sizes, and shapes of IV pumps; the pump shown here is called an IVAC.

23. Conti… Drainage pump : It may be hooked up to a naso -gastric (NG) tube or to other tubes in order to keep secretions from accumulating in the stomach or to drain other areas when the infant is very sick. These pumps can be adjusted to provide constant or intermittent suction.

24. Conti… Blood gas analyser :

25. Conti… Bassinets : A variety of bassinets are available for routine use in the nursery. It is desirable to use because it can be cleaned and are equipped with lockers and head tilting mechanism .They are placed at convenient height are desirable for observation and examination.

26. Conti… Incubator: The incubators are essential to provide and ideal micro environment for high risk newborns . About one – third of nursery beds should comprise of incubator. The main functions of an incubator are isolation , maintenance of thermoneutral ambient temperature, desired humidity and administer the oxygen.

27. Conti… Radiant warmer: The radiant warmer is body warming device to provide heat to the body . This device helps to maintain the body temperature of baby and limit the metabolism.

28. Conti… Phototherapy : Phototherapy is now generally accepted as safe and effective method for treatment of neonatal bilirubinaemia. A light source designed to give an irradiance or flux of 10 -30 µW / cm2 / nm between 400 – 520 nm wavelength range at the mattress is ideal.

29. Conti… Oxygen head box : A square shaped or circle shaped box made of transparent plastic or perspex which can enclose the head of infant is useful for administration of higher concentration oxygen.

30. Conti… Weighing machine :

31. Conti… Defibrillator : It is used to "shock" the heart from an abnormal rhythm pattern back into a normal rhythm. Every neonatal ICU has one of these devices, but they are rarely used there. Abnormal heart rhythms are quite unusual in babies, even those babies with several cardiac abnormalities -- arrhythmias are more typical of aged patients with damaged heart muscle or conduction pathways.

32. Staffing in NICU:

33. Conti… Neonatologist: Neonatologists are pediatricians with additional training in the care of newborn babies. Neonatal nurse practitioners, or advanced practice nurses who specialize in care of newborns, and doctors in training to be pediatricians (residents) or neonatologists (fellows) may also help care for your baby under the supervision of an attending neonatologist.

34. Conti… Neonatal clinical nurse specialist: A neonatal nurse with advanced training who works under the supervision of the neonatologist and who cares for sick and premature babies.

35. Conti… Registered nurse: A health professional who has passed a written examination after graduating from a college or hospital nursing program. Registered nurses in NICUs have experience in caring for sick newborns. The nurse to patients ratio should be 1:4-5 per shift in SCNU. While in more intensive care area providing mechanical ventilation support, nurse: baby ratio should be 1:1-2 per shift. The nurses should have necessary skills like: (a) maintaining nursery routines. (b) keeping cleanliness and disinfection (c) feeding by bottle, gavage etc ,

36. Conti… ( d) monitoring sick babies. (e) giving I.V. fluids and injection (f) providing oxygen and other respiratory support therapy. (g) Using various equipment and so on. Good nursing care is the backbone of any NICU and therefore experienced and skilled incharge & other nurses are essential for quality service.

37. Conti… Respiratory therapist: Respiratory therapists manage respiratory equipment, such as ventilators and CPAP machines to make sure they are functioning according to doctors’ orders. They may also provide breathing treatments. Physical therapist (PT):   A health professional who helps evaluate how a baby moves and how any movement problems may affect milestones like sitting, rolling over or walking. The physical therapist aims to improve muscle strength and co ordination.

38. Conti… Technicians: Staff members who perform specific procedures such as drawing blood or taking x-rays.

39. Organization and physical setup of NICU

40. Conti… Space : The size of the unit is related to the expected population intended to be served .In India 15-20 % new-born babies need the special care . In maternity unit having 2000 deliveries per year , facilities for special care of 6-8 high risk infants should be available . Each infant should be provide with minimum of 100sq .ft. Additional space should be provided for special facilities . There should be no compromise on space and its adequacy is crucial for reduction of nosocomial infection.

41. Conti… Location: The neonatal unit should be located as close as possible to labor rooms and obstetric operation theatre to facilitate prompt transfer of sick and high risk infants. Nursery design : The unit design may be in square space or a single corridor – based rectangular unit. A unit design occupying one side of corridor with a nurses control room in the centre , from where all the babies can be viewed. Apart from constant surveillance of all the babies , the design should ensure minimal walking distance for the staff.

42. Conti… Baby care area : The unit should be provided with areas and rooms for inborn or intramural babies , stepdown nursery, out born or extramural babies , examination area , mother’s area for breastfeeding and expression of breast milk , nurses station and charting area. The floors and the walls should be washable and the windows should have 2 layers of glass panes to ensure some measure of heat and sound insulation. Hand washing and gowning room : Handwashing and gowning facility should be located at entrance . Pictorial handwashing instruction should be provided on the walls near sink. The sink should be of stainless steel . The unit should have 24 hours uninterrupted water supply.

43. Conti… Examination area: A small comfortable room with examination table , comfortable seating , sufficient light, and warmth is needed for assessment of baby before admission . The baby is cleaned and provided with nursery garments in this room. Handwashing stations : Handwashing sinks should be provided within 20ft of every new-born bed. The sink should be large an deep and made of procelain or stainless steel. Single use cotton or disposable paper napkins should be available for drying the hands . Alternatively ,antiseptic solution can be used for disinfection of hands .

44. Conti… Preparation of intravenous fluids : A separate area should be earmarked and provided with laminar flow system for preparation of intravenous fluids , parenteral nutritional formation , entral feeds and medication. Nurses station: Nursing station and charting area for nurses and residents should be located in a central from where all the babies can be observed. New-born charts , hospital forms , computer terminals , telephone lines should be located in this area.

45. Conti… Staff rooms: Space should be provided within the unit to meet the professional, personal and administrative needs of resident staff on duty. Ventilation : The most satisfactory ventilation is achieved with laminar air flow system which is rather expensive. When centralized air conditioning is used minimum of 12 changes of room air per hour are recommended. The air conditioning ducts must be provided with Millipore filters (0.5u) to restrict the passage of microbes. A constant positive air pressure should be maintained in the nursery so that contaminated air from the corridors does not gain access into the nursery.

46. Conti… Lighting : It is best achieved by cool white fluorescent tubes to provide at least 100 foot candle, shadow free illumination at the infant’s level. Spot illumination for various procedures can be provided by a portable angle poise lamp having two 15 watt fluorescent bulbs which when held at a distance of about one foot from the infant, produce about 100 foot candle intensity of light. 

47. Conti… Environmental temperature and humidity: The temperature of the nursery complex must be maintained around 28+_2 o C in order to minimize effects of thermal stress on the babies. Room temperature can be reasonably well maintained in winter by use of radiant heaters and hot air blowers. Portable radiant heater, infrared lamp or bakery bulb can be used to provide additional source of heat to an individual infant

48. Conti… Electrical outlet : There should be adequate number of light and power electrical points attached to a common ground. Each infant must be provided with at least eight electrical outlets. The electrical equipment used in the nursery must be checked at least once a month for leakage of current and adequacy of grounding .  

49. ADMISSION PROCESS

50. Definition; Admission is defined as allowing a patient to stay in hospital for observation, investigation, treatment and care . OR Admission is the entry of a patient into a hospital/ward for therapeutic /diagnostic purposes. Purposes; To undergo evaluation & treatment To know what is really happening in his/her body To provide emotional security to the newly admitted patient and his family

51. Preparation before Admission   whenever arrival of a sick newborn. Prepare the following: Warm incubator to 33-36*C, or switch on radiant warmer. Check whether resuscitation trolley is well socked. Arrange oxygen, air and suction apparatus. Keep vital signs monitor ready. Keep ready specific equipment, as indicated by diagnosis.

52. 2.Admission Routine:   Check the following carefully during every admission. Carry out procedures on the baby in an incubator or under a warm heat source. Record time of admission of the baby. Enter the correct postal address in nursery register. Check the identification tag of the baby. Verify baby details like sex, name of mother and time and date of birth. Assess gestation using the simple physical criteria. Measure temperature by the axillary route. If there is hypothermia cross check with rectal temperature.

53. Weigh as soon as possible. Put a new sterile sheet or autoclaved paper under every baby to prevent cross infection. Record reason for admission after obtaining a brief history of birth and maternal details. Do not give bath. Babies can be given a scrub in their incubators when their condition permits. Check vital signs like heart rate, respiratory rate and blood pressure. Note major malformations like cleft palate, myelomeningocele and anal defects and then record.

54. For sick babies admitted to the intensive care unit do the following in addition; Attach chest leads and connect to monitor. Attach skin temperature probe. Nurse on servo-control mode at 36.5 C Apply pulse oximeter as ordered. Check blood glucose and record. Prepare for fluid administration. Assist with collection of blood and procedures. After documentation, ensure that parents are informed of the condition as soon as possible.

55. DISCHARGE   During the NICU stay, most parents are continually thinking about when their baby will be discharged so that they can go home and resume a normal life. Leaving the hospital is an exciting time, but it can also be worrisome to leave behind the continual medical support that the NICU offers.  

56. Discharge Orders : Discharge requirements vary from hospital to hospital. Most agree, however, that babies must be able to properly maintain their own temperature, to consume nutrition either through breastfeeding or bottle-feeding and to maintain steady weight gain. In addition, most hospitals require that babies are free of apnea spells for a week or more. Sometimes hospitals prefer to care for babies until they reach their actual due date, but other hospitals allow babies to go home much earlier once they have reached a healthy weight of 4 or 5 pounds. Prior to being completely discharged from the hospital, most babies will be moved to a regular nursery for a time to see how well they do without all the extra support offered in the NICU setting

57. Baby Safety Issues : Before babies are discharged from the hospital, caregivers will be instructed on baby safety issues. The caregivers will usually be asked to bring in their car seat to insure safe travel . Also, caregivers will be instructed about proper sleep safety, which involves putting a baby on his or her back always to prevent suffocation. Also, caregivers will be required to attend an infant CPR class so that they will be prepared to handle any emergencies. Some babies may be discharged while still they are in need of monitors or other equipment. Caregivers will be trained on this equipment prior to discharge.  

58. Resources : Most hospitals will provide parents a list of services that are available to them. Such services may include early intervention programs, physical therapy, speech therapy, support groups and various social services. The parents will also be advised to schedule an appointment with a pediatrician of their choice within a few days of arriving at their home. Also, other appointments may be scheduled with specialists if any health problems require further care

59. Discharge Routines:   The following should be noted while planning for discharge of a baby from the nursery: Ensure baby is feeding well, preferably at the breast, and gaining weight. Check discharge weight, head circumference and length and record. Check whether the doctor has prepared the discharge summary and given appointments for follow up. Confirm whether mother is clear about baby bath, feeding, immunization, medication schedules. Clarify whether mother knows proper wrapping methods and use of caps and booties, especially when discharging LBW babies. Check whether home conditions are appropriate to receive the baby. Record date and time of discharge in the ward log book .

60. LEVELS OF NICU CARE: Although all NICUs care for babies who need extra help, different NICUs offer different levels of care. Level I: Basic Newborn Care: Level 1 nurseries care for healthy, full-term babies. They are able to stabilize babies born near term to get them ready to transfer to facilities that offer special care.

61. Well-newborn nursery: has the capabilities to Provide neonatal resuscitation at every delivery. Evaluate and provide postnatal care to healthy newborn infants. Stabilize and provide care for infants born at 35 to 37weeks’ gestation who remain physiologically stable Stabilize newborn infants who are ill and those born at _35 weeks of gestation until transfer to a facility that can provide the appropriate level of neonatal care.  

62. Level II: Specialty Newborn Care: These nurseries can care for babies born at greater than 32 weeks gestation or who are recovering from more serious conditions. Special care nursery: level II units are subdivided into 2 categories on the basis of their ability to provide assisted ventilation including continuous positive airway pressure Level IIA: These nurseries do not provide assisted ventilation . Level IIB: These nurseries can provide assisted ventilation for less than 24 hours, and can also provide continuous positive airway pressure (CPAP) .

63. Level IIA: has the capabilities to Resuscitate and stabilize preterm and/or ill infants before transfer to a facility at which newborn intensive care is provided Provide care for infants born at _32 weeks’ gestation and weighing _1500 g (1) who have physiologic immaturity such as apnea of prematurity, inability to maintain body temperature, or inability to take oral feedings or (2) who are moderately ill with problems that are anticipated to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis Provide care for infants who are convalescing after intensive care

64. Level IIB: has the capabilities of a level IIA nursery and   The additional capability to provide mechanical ventilation For brief durations (_24 hours) or continuous positive airway pressure

65. Level III: Subspecialty Newborn Care: Level III NICUs care for the sickest babies and offer the greatest variety of support. Level III NICUs are subdivided into 3 categories

66. Level IIIA : These nurseries care for babies born greater than 28 weeks. They offer mechanical ventilation and minor surgical procedures such as central line placement. Level IIIB : Level IIIB NICUs can offer different types of mechanical ventilation, have access to a wide range of pediatric specialists, can use imaging capabilities beyond x-ray, and may provide some surgeries requiring anesthesia. Level IIIC : The most acute care is provided in level IIIC NICUs. These nurseries can provide advanced ventilation, including ECMO , and can provide advanced surgeries including “open-heart” surgeries to correct congenital heart defects .

67. TRANSPORT OF THE SICK NEONATE PRINCIPLES OF TRANSPORT OF THE SICK NEONATE : • Transport of neonates involves pre-transport intensive care level resuscitation and stabilization and continuing intra-transport care to ensure that the child arrives in a stable state. • Organized neonatal transport teams bring the intensive care environment to critically ill infants before and during inter-hospital or intra-hospital transport. • The basis of a safe and timely transport is good communication and coordination between the referring and receiving hospital to ensure adequate stabilization pre-transport and continuing intra-transport care. • There is a rare need for haste. • There must be a balance between anticipated clinical complications that may arise due to delay in definitive care and the benefits of further stabilization .

68. A)Pre-transport Stabilization: Transport of the neonate is a significant stress on the child and they can easily deteriorate during the journey. The presence of hypothermia, hypotension and metabolic acidosis has a significant negative impact on the eventual patient outcome . It is also almost impossible to do any significant procedures well during the actual transport. Therefore, stabilization pre-transport is critical to ensure a good patient outcome.   The principles of initial stabilization of the neonate follow the widely recognized ABC’s of

69. 1 Airway Management Establish a patent airway Evaluate the need for oxygen, frequent suction (Oesophageal atresia) or an artificial airway (potential splinting of diaphragm). Security of the airway – The endotracheal tubes (ETT) must be secure to prevent intra-transport dislodgement Chest X-ray – to check position of the ETT

70. 2 Breathing The need for intra-transport ventilation has to be assessed: Requires FiO2 60% to maintain adequate oxygenation ABG – PaCO2 >60mmHg Tachypnoea and expected respiratory fatigue Recurrent apnoeic episodes Expected increased abdominal/bowel distension during air transport If there is a possibility that the child may require to be ventilated during the transfer, it is safer to electively intubate and ventilate before setting off. If in doubt, the receiving surgeon should be consulted. If manual ventilation is to be performed throughout the journey, due consideration must be taken about fatigue and possible erratic nature of ventilation. 

71. 3 Circulations Heart rate and perfusion (Capillary refill) are good indicators of the hydration status of the baby. The blood pressure in a neonate drops just before the baby decompensate. The urine output should be a minimum of 1-2 mL /kg /hr. The baby can be catheterized or the nappies weighed (1g = 1 ml urine) A reliable intravenous access (at least 2 cannula) must be ensured before setting off. If the child is dehydrated, the child must be rehydrated before leaving

72. B) Immediately Before Departure Check vital signs and condition of the baby Check and secure all tubes Check the completeness and function of equipment Recommunicate with receiving doctor about the current status and the expected time of Arrival   C)Intra-transport Care   • Staff –Ideally, there should be a specialized neonatal transport team. If not, the medical escort should be a neonatal trained doctor with/without a neonatal trained staff nurse. A minimum of 2 escorts will be required for the ventilated/critically ill baby. The team should be familiar with resuscitation and care of a neonate. They should also be able to handle critical incidents. The team members should preferably not be prone to travel sickness

73. Safety of the team must be a priority. Insurance, life jackets and survival equipment should be made available for the escort team and parents.   • Monitoring – Regular monitoring of the vital signs, oxygenation and perfusion of the should be performed   • Fluids – Intravenous fluids must be given to the ill child to prevent dehydration and acidosis during the transport. Boluses need to be given as necessary depending on the assessment of the perfusion and heart rate of the child. If catheterized, the urine output can be monitored. The orogastric tube should be aspirated as required.  

74. • Temperature Regulation – A check on the baby’s temperature should be made. Wet clothes should be changed if required especially in the child with abdominal wall defects. Disposable diapers and one way nappy liners can be very useful here.   • Critical Incidents – Preoperative preparation is to minimize the critical incidents as these can cause loss of life and stress to the transport team. Edge et al (Critical Care Medicine, 1994) showed that the number of critical incidents that occurred during the transport by a nonspecialized team was 10 times the occurrence when transported by a specialized team.  

75. D)Arrival at the Receiving Hospital Reassessment of the baby Handover to the resident team   E ) Intrahospital Transport   Use transport incubator if available • Ensure all parties concerned are ready before transfer • Send team member ahead to commandeer lifts, clear corridors • Ensure patient is stable before transport • Skilled medical and nursing staff should accompany patient • Ensure adequate supply of oxygen • Prepare essential equipment and monitors for transport • Ensure venous lines are patent, well secured Infusion pumps should have charged batteries. To decrease bulk of equipment, infusions like insulin, relaxants maybe ceased temporarily.

76. PREVENTION OF NOSOCOMIAL INFECTIONS:   ICUs are notorious for spread of nosocomial infections by multi-drug resistant hospital-acquired pathogens because critically sick children are immunocompromised. Therefore, the following guidelines are followed for asepsis:   Entry to the NICU: Remove house shoes and wear NICU sleepers before entering. The nails should be kept short and trimmed. Scrub thoroughly both hands and forearms upto elbows with soap and water for at least 2 minutes after removing the watch, rings, bangles, etc. Dry with single use sterile napkin and rinse the hands with sterilium. Thereafter, before touching any child, rinse the hands with sterilium in-between patients. If sterilium is not available, rewash the hands with soap and water for at least 30 seconds. Mask should be worn if the person working in the NICU is suffering from an acute respiratory tract infection.

77. Aims of neonatal care Establish respiration Maintain normal body temperature Prevent contact with infection Provide adequate nutrition Identify sick babies & manage them promptly

78. To provide continuing, comprehensive physical care and supportive treatment required to maintain life and to aid recovery of acutely ill children. To provide emotionally supportive care to acutely ill children. To provide empathetic support to parents and families of children in the intensive care unit (ICU). To function effectively and safely, the ICU nurse should demonstrate the following capabilities:

79. Good physical and emotional health required to withstand the strain of continually nursing critically ill patients, Understanding or pathophysiology underlying diseases. Knowledge and understanding of sophisticated monitoring equipment and special apparatus. Ability to reason objectively and to judge and be aware of rapidly changing situations. Ability to interpret data and to take rapid, decisive action. Ability to perform complex technical skills correctly and in an organized manner. Understanding of the impact of illness and hospitalization on the life of the child. Understanding of parental responses and ways of coping with the stress of a critically ill child. Ability to record data concisely, accurately, and thoroughly.

80. PHYSICAL CARE OF THE CHILD Apply understanding of the pathogenesis of the disease in assessing patient needs and in planning care. Perform complex technical skills to monitor and support the child. These may include: Cardiac, respiratory, and blood pressure monitoring. Basic interpretation of electrocardiogram (ECG) tracing. Endotracheal suctioning. Oxygen administration and monitoring.

81. Tracheostomy care. Ventilator management. Monitoring central venous pressure. Monitoring intracranial pressure. Measuring arterial pressure. Hyperalimentation. Collection of specimens.

82. Perform nursing activities related to life support of child. These activities include the following: Cardiopulmonary support Respiratory management Observation of neurologic signs Fluid and nutritional assessment and management. Observations for complications and changing status. Apply general nursing measures for patient comfort and prevention of complications. Positioning-to prevent contractures, to drain secretions from the lungs, and to minimize pressure effects on skin.

83. Monitoring and regulation of body temperature. Skin care-to prevent breakdown. Eye care-to prevent conjunctivitis and injury to the cornea in unconscious children. Fluid balance-record daily fluid intake by all routes and losses of urine, stool, vomit, blood and other drainage; be sensitive to weight loss and gain. Mouth care-to cleanse mouth of secretions, vomitus, especially in unconscious patient or patient with endotracheal tube. Control of infection. Provide careful, continuous clinical observations of the child.

84. CONCLUSION: This section will help in clinicals that how to care high risk babies ,monitor and operate ventilator & also you can set the priorities for admission of patients& can give care according to the need. NICU services has got the major scope not only in the India but also in Abroad. This newer approach/concept will help us to manage the critical cases .