ADVANCED NEONATAL PROCEDURES

Introduction:

Childbirth is a complex process. There are numerous physical changes that

occur in babies as they adjust to life outside of the womb. Leaving the womb
means they can no longer depend on the mother’s placenta for critical body
functions, such as breathing, eating, and eliminating waste. As soon as babies
enter the world, their body systems must change dramatically and work together
in a new way. When babies need special care after delivery, they’re often
admitted to an area of the hospital known as the neonatal intensive care unit
(NICU). The NICU has advanced technology and has teams of different
healthcare professionals to provide specialized care for struggling newborns.
Not all hospitals have a NICU and babies who need intensive care may need to
be transferred to another hospital.

1. PERFORMING NEONATAL RESUSCITATION

Definition:

Measures taken to receive newborns who have difficulty in establishing

respiration at birth and includes suctioning, positive pressure ventilation,
external cardiac massage, intubation and medications as necessitated by the
neonate’s condition at one minute of age.

Purposes

To estabilish and maintain a clear airway.

 To ensure effective circulation.

To correct any acidosis present.

To prevent hypothermia, hypoglycemia and haemorrhage.

Warning signs of cardio pulmonary arrest:-

 Early signs: loss of consciousness & convulsions

 Late signs: Apnea .Dilated pupils .Absence of heart sound

o Other signs

 Changes in respiratory rate

 A weak or irregular pulse

 Bradycardia

 Cyanosis

 Hypothermia

Articles

 Suctioning articles

Bulb syringe

De lee mucus trap with no. 10 Fr catheter or mechanical suction.

Suction catheters no. 6,8,10.

Feeding tube no. 8 Fr and 20ml syringe.

 Bag and mask articles.

 Infant resuscitation bag with pressure release valve or pressure gauge with
reservoir, capable of delivering 90-100% oxygen.

Face masks with cushioned rims (Newborn and premature sizes)

Oral airways ( Newborn and premature sizes)

Oxygen with flowmeter and tubing.

 Intubation articles.

Laryngoscope with straight blades No. “O” ( premature), No “1” ( Newborn)

Extra bulbs and batteries for laryngoscope.

Endotracheal tubes. Sizes- 2.5, 3.0, 3.5 and 4.0 mm internal diameter.

Styllet

Scissors

 Medications

Epinephrine 1:10, 000 ampoules (1ml ampoule of 1:1,000 available in India)

Nalaxone hydrochloride (Neonatal narcan 0.02mg/ml)

Volume expander

 5% albulum solution.

 Normal saline

 Ringer’s Lactate

Sodium bicarbonate 4.2% (1mEq/2ml, 7.5% strength available in India

approximately 0.9 mEq/ml)
 Dextrose 10% concentration 250ml.

Sterile water 30ml

Normaline saline 30ml.

 Miscellaneous

Radiant warmer

Stethoscope.

Adhesive tape and bandages scissors.

Syring 1ml, 2ml, 5ml and 20 ml sizes.

Needles Nos 21,22 and 26 G

Umbilical Cord clamp

Warm dry towels.

Resuscitation Algorithm

As soon as baby is delivered, assess for five signs while cord is being cut.

a. Clear the meconium

b. Breathing or crying

c. Good muscule tone (Flexed posture and active movement of baby denotes
good tone).

d. Colour pink (Look at tongue and lips).

e. Term gestation
 If answers to all the five questions are ‘Yes’ then baby does not require any
active resuscitation and routine care should be provided. The baby can be
placed on mother’s abdomen after drying and cleaning. If required, secretions
can be wiped off using a clean cloth. Providing skin- to- skin contact and
allowing breastfeeding will help in easy transition to extra uterine life.

Approximate Time BIRTH

Clear the meconium? Routine Care

Breathing or crying?
Good muscule tone? Provide warmth
Colour pink? Yes Clear airway
Term gestation? Dry

30
Sec

No

Provide Warmth
Position, clear airway* (as
necessary)
Dry, stimulate, reposition
Give oxygen (as necessary)
 Evaluate respirations, Supportive care
heart rate and color Breathing

HR > 100 and pink

Apnea or HR < 100

30 Provide positive Ongoing care

Sec pressure ventilation Ventilating
ppressurepressure
ventilation*

HR > 100 and pink

HR < 60 HR > 60

30
Sec

Provide positive pressure ventilation*

Administer chest Compressions

* Endotracheal intubation may be

HR < 60 considered at several steps.
RESUSCITATION ALGORITHM

Procedure

S.N. Nursing action Rationale

1. Assess the Apgar score. Helps to know if resuscitation

measures are to be instituted.

2. Place infant under warmer, quickly Prevents heat loss.

dry off amniotic fluid, replace wet
sheets with a dry one.

3. Place the baby on his back with Straightens the traches and opens the
slightly head down 15 degree tilt, airway. Hyperextension may cause
neck slightly extended. airway obstruction.

4. Suction the mouth first and then Clears the airway passage. Infants often
nose. gasp when the nose is suctioned and
may aspirate secretion from the mouth
into lungs.

5. Give tactile stimulation if infant does Tactile stimulation of drying may bring
not breathe. ( Flick or tap the sole of spontaneous respiration.
foot twice or rub the back). Do not
slap.

6. Check the vital signs, and the colour Helps in determining further need for
of the newborn. resuscitation.
Note: Evaluation should be done on respiration, heart rate and colour. If the
baby is apnoeic, heart rate is less than 100bpm and central cyanosis is present,
proceed for bag mask ventilation or positive pressure ventilation.

Bag and Mask Ventilation/ Positive Pressure Ventilation

Indications

Apnea

Heart rate less than 100 bpm.

Procedure

S.N. Nursing action Rationale

1. Place back with head slightly Helps in opening airway.

extended. The newborn on his Hyperextension may cause airway
obstruction.

2. A tight seal is to be formed over the Prevents leakage of air from the sides
infant’s mouth and nose with the of the mask.
face mask.

3. Ventilate at a rate of 40-50 per

minute.
 4. Ventilate for 15-30 seconds and Spontaneous respiration may be
evaluate initiated with initial attempts to
ventilate.

5. Have an assistant to evaluate, listen

to the heart rate for 6 seconds and
multiply by 10.

Evaluation

If heart rate is above 100bpm and spontaneous respirations are present,

discontinue bagging.

If heart rate is 60-100bpm and increasing, continue ventilation, check

whether chest is moving adequately.

If heart rate is below 80bpm, start chest compression.

If heart rate is below 60 bpm, in addition to bagging and chest compressions,

consider intubation and initiate medications.

Signs of improvement.

Increasing heart rate.

Spontaneous respirations.

Improving colour

Continue to provide free flow oxygen by face mask after respirations are
established. If the baby deteriorates, check the following:-
 Placement of face mask for tight seal.

Head position and presence of secretions.

Pressure being used.

Presence of air in the stomach preventing chest expansion.

Oxygen being delivered (100% or not).

For bagging lasting for more than two minutes insert an orogastric tube to vent
the stomach.

Chest Compressions

Chest compressions consist of rhythmic compressions of the sternum that

compresses the heart against the spine, increase the intrathoracic pressure and
circulates blood to the vital organs.

Chest compressions must always be accompanied by ventilation with 100%

oxygen to assure that the circulating blood is well oxygenated.

Indications

Heart rate less than 60bpm after bagging with 100% oxygen for 15-30
seconds.
 Heart rate 60-80bpm and not increasing after bagging with 100% oxygen for
15-30 seconds.

Procedure

S.N. Nursing action Rationale

1. Compress the chest by placing the hands around the Correct hand position
newborn’s chest with the fingers under the back to compresses the heart
provide support and the thumbs over the lower third of and avoids injury to the
the sternum (just above the xiphoid process) liver, spleen, fracture
of the ribs and
0r
pnemothorax.
Use two fingers of one hand to compress the chest and
place the other hand under the back to provide support.

2. Compress the sternum to a depth of approximately one The size of the

third of the anteroposterior diameter of the chest and newborn determine the
with sufficient force to cause a palpable pulse. The depth of compressions
fingers should remain in contact with the chest between to avoid injury.
compressions.

3. Use three compressions followed by one ventilation for Simultaneous

a combined rate of compressions and ventilation for a compression and
combined rate of compressions and ventilations of 120 ventilation may
each minute. Pause for ½ second after every third interfere with adequate
compression for ventilation. ventilation. The short
pause allows air to
enter the lungs.
4. Check the heart rate after 30 seconds. If it is 60 bpm or Periodic evaluation is
more, discontinue compressions but continue necessary to ensure
ventilation until the heart rate is more than 100bpm and that treatment is
spontaneous breathing begins. appropriate to the
infant’s status.

If cardiac compression fails, endotracheal intubation should be initiated.

Endotracheal Intubation

Indications

Heart rate below 60 per minute inspite of begging and chest

compressions.Presence of meconium in the amniotic fluid.

Procedure

S.N. Nursing action Rationale

1. Place infant with head slightly extended with a rolled towel Position makes
under the shoulder. the airway open.

2. Introduce laryngoscope over the baby’s tongue at the right To guide the
corner of the mouth. endotracheal
tube

3. Advance 2-3 cm while rotating it to midline, until the To find right

epiglottis is seen. Elevation of the epiglottis with the tip of route
the laryngoscope reveals the vocal cords.
 4. Suction secretions if needed. Clears the
airway.

5. Pass the endotracheal tube a distance of 1.5-2cm into the Ensures

trachea, hold it firmly but gently in place and withdraw the adequate air
laryngoscope slowly. entry into both
lungs.

6. Attach the endotracheal tube to the adapter on the bag. To facilitate

ventilation

7. Ventilate with oxygen by bag. An assistant should check for To know the
adequate ventilation of both lungs with stethoscope. improvement.

Medications

Medications should be administered if despite adequate ventilation with 100%

oxygen and chest compressions the heart rate remains at 80 bpm.

Recording

Record the procedure in nurses’ record. Document the baby’s condition before
and after procedure.

2. CARE OF BABY UNDERGOING PHOTOTHERAPY

Definition

Caring for a baby being exposed to light source for prescribed of time.
Purpose

 To bring down serum bilirubin level to normal.

Articles

 Fluorescent lamps and fiberoptic pads (if available).

 Eye pads or eye shields.

 Napkin to cover the genetalia of male babies.

 Baby blankets, sheets – 2 nos.

Indications

 Elevated serum bilirubin levels

 Healthy term babies > 17mg/dl.

 Pre-term babies (weighing more than 1500 gm>8mg/dl).

 Preterm babies (weighing less than 1500mg> 5mg/dl).

Phototherapy can be delivered in several ways. The most common

methods are:-

 Fluorescent lamps or “bililights” placed over the infant who is usually in an

incubator or under a radiant warmer.

 Halogen lamps.

 Fiberoptic phototherapy blankets or pads.

Procedure

S.N. Nursing action Rationale

1. Provide explanation to mother that her Allays anxiety and convinces her
baby will be kept in an isolate and exposed about the need for phototherapy.
to a blue – green light for bringing down
the bilirubin levels.

2. Instruct the mother to feed the baby. Prevents dehydration when exposed
to phototherapy.

3. Check machine for electrical safety and Prevents electrical hazards.

proper insulation of wires.

4. Check whether all bulbs are burning in

machine.

5. Transfer the baby to nursery where Heat loss is minimized and

phototherapy equipment is present and temperature is controlled when an
place the baby in the isolate over which incubator is used.
phototherapy lights are placed.

6. Adjust height between baby and lamp to Lights that are too close increases
45cm. the risk of burning the skin. Lights
too far away from the infant will not
be effective.

7. Place the baby naked under light in the Exposes the skin as much as
isolette. possible for maximum exposure to
light.
8. Cover the baby’s eyes with eyepads. Protects eyes from the effect of high
intensity lights on retina and avoids
abrasions to cornea.

9. Cover the genitals of male babies with the Protects testicles from the high
napkin. intensity lights.

10. a. If fiberoptic pad is used, place it under Maintains the position.

the baby in contact with the baby’s skin.

b. Keep the baby on his side with a rolled

baby sheet on the side.

11. Switch on bili lights and/or machine for

the fiberoptic pad.

12. Change position every 2 hours. Ensures that light reaches all areas
of the body.

13. Record in baby’s chart, all details about Acts as a communication between
starting the procedure, observations made staff members.
and precautions taken.

Care and Observation during Phototherapy

Provide feeding at regular intervals to maintain adequate hydration. If

breastfeeding, mother should be encouraged to give demand feeding.

If baby is hyperthermic, discontinue phototherapy and keep baby exposed

under fan. When temperature reaches normal, restart phototherapy.

Monitor bilirubin level and other hematologic assessments at regular

intervals.
Check baby at least every hour and see that the eyeshields remain in place.
The eyeshields should not press against the eyes.

The infant may be removed from the lights for feeding, diaper changes and
other general care but should receive phototherapy for 18 hours every day.

If fiberoptic blanket is used, it should kept next to baby’s skin at all times.
Be sure that the baby does not roll off the blanket. It is not necessary to
cover the eyes if blanket alone is used.

Monitor the body temperature at regular intervals.

Observe the skin for rashes, dryness and excoriation.

Feed the baby every 2-3 hours because phototherapy causes the baby to
loose fluid from the skin and have loose stools. This may cause dehydration.

Count your baby’s wet diapers and stools. Increase feeding if the baby has
less than six wet diapers a day or if urine appears dark.

Do not apply oil to the skin of the baby.

Observe for side effects like:-

Loose green stool resulting from increased bile flow and peristalisis. Stool
may damage the skin and cause fluid loss.

Tanning effect from the light.

Bronze baby syndrome- a grayish brown discoloration of skin and urine.

Skin rash.

Temporary lactose intolerance.

3. CARE OF NEWBORN IN INCUBATOR

Definition

Providing care to prematurely born or sick infants in a device called incubator

which keep them warm.

Purposes

To maintain a baby’s core temperature stable at 37 degree Celsius.

To provide humidified air.

To administer oxygen.

To observe the baby without disturbing him.

To conserve the energy of premature canopy.

Parts of Incubator

 Deck

 Mattress which is enclosed by a clear plastic canopy.

 Air intake pipe.

 Microfilter assembly.

 Oxygen inlet.

 Thermostat.

 Caliberated dial.

 Arm ports.

 Hood: Single walled rectangular hood. The hood has a large door to aid in
placing or removing baby from incubator. There are four elbow operated
parts for better access during small procedures, inlet for IV tubes, probes,
endotracheal tubes etc. Canopy can be lifted for cleaning and access.

 Control panel: Heater, blower and electronics.

 Lower unit: This consists of control box, touch sensor, front panel with
display, humidifier, airducts and filter. The following are displayed on the
front of the panel.

Air temperature

Patient temperature

Control temperature

 Cabinet: This provides support for hood, canopy and lower unit. It houses
main switch, fuse and power cord connector. The cabinet has three drawers
for storage space.

 Humidity percentage: Air is circulated by configural blower. Fresh air enters

through air filters located at the end of incubator. Fresh air is mixed with
circulating air from incubator conopy and passed over heater and humidifier.
Temperature inside incubator is maintained by sensor placed on hood.Thus,
heated air flow maintains surroundings of infant at desired temperature.
Procedure

S.N. Nursing action Rationale

1. Identify the premature, weak or ill baby who Promotes chances of survival
needs to be nursed in an isolette. for premature baby who needs
thermoregulation.

2. Verify physician’s orders for management of Facilitates adequacy of

baby in the incubator. required unit assembly for
care.

3. Explain procedure to mother/parents. Promotes understanding and

acceptance of parents.

4. Prepare the incubator for placing the baby by Use of clean disinfected
cleaning it with soap and water and incubator prevents growth of
disinfecting. microorganisms.

5. Switch on the incubator and adjust the 36 degrees centigrade set on

temperature at 36 degree centigrade on” servo servo- control mode maintains
control mode” the baby’s skin temperature at
36 degree centigrade.

6. Prewarm the incubator for 15 minutes. Prewarming facilitates flow of

warm air on body surface.

7. Transfer the baby to the prepared isolette. Facilitates provision of

required care to baby without
causing stress.
8. Undress the baby except for diapers. Facilitates observation of the
baby through the clear plastic
canopy.

9. Check temperature of newborn and the Prevents over exposure to

incubator every hour until the temperature of heat.
the baby is stabilized.

10. Maintain flow chart to record, temperature,

heart rate, respiration and oxygen saturation.

11. Change humidifier water every day.

12. Give care for baby by introducing hand

through arm ports.

13. Permit mothers/ parents to see and bond with Reduces the chances of
the baby according to hospital policy. sensory deprivation.

14. Weaning a baby is important and has to be

taken care of. This is done by gradually
decreasing the temperature of incubator and
monitoring the infant’s body temperature.
Keep port holes open for some time. Then
take baby out and keep warm by dressing and
wrapping.

15. Do not tap incubator. Avoids disturbance to the

baby.
4. ASSISTING IN EXCHANGE TRANSFUSION

Definition

Assisting in withdrawing a baby’s blood which has high bilirubin content and
replacing with fresh blood through umbilical vein.

Aims

To correct anaemia by replacing the Rh positive sensitized red cells.

To remove the circulatory antibodies.

To eliminate circulatory bilirubin.

Indications

 Non- obstructive jaundice with serum bilirubin level of 20mg/dl or more in

fullterm and 15mg/dl in preterm infants, e.g. Rh or ABO incompability.

 Kernicterus irrespective of serum bilirubin level.

 Haemolytic disease of the newborn under following situations:-

Cord Hb 10% or less.

Cord bilirubin 5mg/dl or more.

Rise of serum bilirubin of more than 1mg/dl/hour.

 Maternal antibody titer of 1:64 or more, positive direct Coombs’ test and
previous history of a severly affected baby.

Articles

a. Exchange transfusion set containing:-

 Kidney tray-1

 Bowl-2

 Metal scale-1

 Suture scissors-1 fine scissors-1

 Vein dilator-1

 Fine toothed forceps-1

 Fine non-toothed forceps-1

 Fine non-toothed forceps-1

 Curved mosquito forceps-1

 Straight mosquito forceps-1

 Dressing forceps -1

 Surgical towel-2

 20cc syringe 2,10 cc syringe 2

 Cross splint, pads and bandages

b. Injection tray with antiseptic.

c. Small dressing pack.

d. Sterile scalpel blade 3/11.

e. Sterile feeding tray with pacifier.

f. I.V. stand

g. Injection normal saline 500ml.

h. Injection heparin.

i. 3-way stopcock.

j. Resuscitation equipment and oxygen source.

k. Heat source.

l. Suction apparatus with mucus sucker.

m. Umbilical vein catheter.

n. NG tube no 5,6,8.

o. Sterile linen bundle with 2 sheets and 1 biopsy towel.

p. Mask and gloves.

q. Cord tie.

r. Specimen containers.

s. Specimen tubes.

t. Adhesive plaster, scissors and extra syringes.

u. Emergency drugs like:-

 Injection Adrenalin.

 Inj. Calcium gluconate.

 Injection Soda bicarbonate.

 Inj. Amniophylline

v. Blood giving set.

w. Cross splint.

Choice of Donor Blood

The donor blood should be fresh ( less than 3 days old).

The amount needed for an adequate exchange is about 160ml/kg (double the
blood volume of baby).

The blood should be crossmatched against mother’s blood.

It should be made sure that the blood is slowly warmed to infant’s

temperature.

Fresh heparinized blood or blood preserved with acid citrate dextrose is

used.

In Rh incompatability the transfusions are performed with group O, Rh

negative blood whereas in case of ABO incompatability and G-6 PD
deficiency the procedure has to be performed with the same ABO and RH
groups of the baby.

20-30 ml of blood is withdrawn and about 10-20 ml are replaced each time.

Procedure

S.N. Nursing action Rationale

1. Explain the procedures to the patients. Helps in reassuring the

parents.

2. Get informed consent from the parent. Prevents legalities.

3. The procedure is best carried out in an air conditioned
room.

4. Collect the blood from blood bank and place in tepid Prevents hemolytic
water and check the blood type and group against the reaction caused by
neonate’s blood before administering. mismatched donor
blood.

5. Procedure should be carried out in an incubator

maintaining the temperature at 27-30 degree
centigrade.

6. NPO should be maintained for 4 hours before Minimizes the risk of

procedure. vomiting and aspiration
into lungs.

7. Expose and immobilize baby on cross splint. Prevents movements

during procedure.

8. Open dressing pack and assist in cleaning of Removes

umbilical stump. microorganisms.

9. Assist in cleaning umbilical cord and draping with

sterile linen.

10. Pour 500ml of I.V. normal saline into a sterile bowl Before beginning the
and add 1ml inj. Heparin in it. exchange the whole
apparatus should be
primed with the saline
as it prevents syringes
becoming sticky.
11. Umbilical cord is cut to less than 2.5 cm from the Helps in location of
skin surface. vein.

12. Attach ligature loosely round the base of the cord.

Insert umbilical catheter into the vein.

13. The catheter should be filled with a flushing solution, Minimimises the risk of
or donor blood before insertion. air embolism.

14. When free flow of blood is obtained, ligature is

tightened and the catheter should be deep enough to
reach the inferior venacava.

15. Make sure that heat source is available throughout the Hypothermia may lead
procedure. to metabolic acidosis.

16. Measure CVP after insertion of catheter into the

umbilical vein.

17. Take sample of pre-exchanged blood as well as after Helps in estimation of

exchange for investigation. bilirubin and
haemoglobin.

18. Monitor heart rate, respiratory rate and condition of

baby hourly during procedure.

19. The physician removes 10ml of umbilical blood and

replaces with 10ml of fresh blood immediately, until
calculated volume has been exchanged.

20. Apply cord tie at umbilicus, seal umbilicus with Prevents risk
tincture benzoin apply small gauze and secure with haemorrhage and
adhesive. infection.

21. Replace equipments and start phototherapy.

 22. Document time of starting, duration, completion time, Gives information to
amount and type of blood exchanged, condition of the staff members.
baby during and after procedure, drugs given during
procedure and samples sent to lab.

Post Transfusion Care

Place the baby in a radiant warmer.

Inspect umbilicus for evidence of bleeding.

Repeat serum bilirubin as required.

Check infant’s blood glucose level hourly.

Complications

Bacterial sepsis.

Thrombocytopenia.

Portol vein thrombosis.

Umbilical vein perforation

Dysrhythmia

Cardiac arrest.

Hypocalcemia
 Hypoglycemia

Hypomagnesemia

Metabolic acidosis

Alkalosis

HIV, Hepatitis B infections.

Graft versus host disease.

Special considerations

If citrated or heparinized donor blood is used, one should be prepared for

hypocalcemia, hypoglycemia, hyperkalemia and metabolic acidosis. Further,
citrated blood leaves the infant with low Hb level. So as, a precaution
calcium gluconate at regular intervals should be given when using citrated
blood for exchange.

For every 100ml of blood transfused one milli equivalent of sodium

bicarbonate is given to combat metabolic acidosis.

VENTILATION

LIFE CRITICAL SYSTEM As the failure of a mechanical ventilator may

result in death, it is classed as a life-critical system, and precautions must be
taken to ensure that these systems are highly reliable, This includes their
power-supply provision. They may have manual backup mechanism to
enable hand – driven respiration in the absence of power. They may also
have safety valves which open to atmosphere during power-cut. Other
modification can be gas tanks, air compresssor, backup batteries, etc.
Need of Ventilator

In anaesthesia (as a component of an

anaesthesia machine).

Home care in hypoventilated patients.

Emergency medicine.

Intensive care medicine

Indications

1. Acute lung injury.

2. Acute severe asthma, requiring intubation.

3. Chronic Obstructive Pulmonary Disease.

4. Apnea with respiratory arrest.

5. Hypoxemia.

6. Acute respiratory acidosis.

7. Respiratory distress addressing increased work

of breathing.

8. Hypotension including sepsis, shock, CHF.

9. Neurological conditions such as Muscular

Dystrophy, Amyotropic Lateral Sclerosis, etc

TYPES OF VENTILATOR

1. TRANSPORT VENTILATOR :- These are

small and more rugged, and can be

 powered pneumatically or via AC or DC

power sources.

2. INTENSIVE CARE VENTILATOR :- These are larger and usually run on

AC power(though virtually all contain a battery to facilitate intra-facility
transport and as a back-up in the event of a power failure). It provides
greater control of a wide variety of parameters. Many ICU ventilators also
provide visual feedback of each breathe through graphics

3. NEONATAL VENTILATOR :- These are designed with the preterm

neonate in mind, and are a specialized subset of ICU ventilators that are
designed to deliver the smaller, more precise volumes and pressures required
to ventilate such patient

Indications for Neonatal Ventilator

Respiratory Distress Syndrome.

Sepsis.
Birth asphyxia.
Meningities
Pneumonia.
Meconium Aspiration Syndrome. s.

4. POSITIVE AIRWAY PRESSURE VENTILATOR :-These are specifically

designed for non-invasive ventilator, and can also be used at home, e.g, for
treating sleep apnea or COPD. • It works by increasing the patient’s airway
pressure through an endotracheal or tracheostomy tube. • The positive
pressure allows the air to flow into the airway until the ventilator breathe is
terminated. • Then the pressure drops to ‘0’ and the elastic
5. NEGATIVE AIRWAY PRESSURE VENTILATOR :- Here the air is
withdrawn mechanically to produce a vacuum inside the tank, thus creating
negative pressure; which in turn leads to expansion of the chest. •It leads to
decrease in intra-pulmonary pressure, and increases flow of ambient air into
the lungs. •As the vacuum is released, the pressure inside the tank equalises
the ambient air pressure. •The elastic coil of the chest and lungs thus leads to
passive exhalation. 6. HIGH FREQUENCY VENTILATOR :- Frequency is
from 60/min upto even 3000/min. It is of two typesa) Jets:- It uses natural
elastic recoil of the lungs, where expiration occurs passively. It consists of a
applying high pressure jet to the airways via a cannula or endotracheal tube.
b) Oscillators:- It uses a reciprocating piston which aid expiration on its
return stroke. Here expiration is active.

Differential Ventilation When a person has bilateral lung pathology, then

this type of ventilation is used where two synchronised ventilators are used
simultaneously. It prevents ventilation -to- perfusion mismatch. Treatment
cost is expensive as two ventilators are required in one set-up.

APPLICATION AND DURATION OF VENTILATION

It can be used as a short-term measure, for e.g, during an operation or critical

illness. Long-term ventilatory assistance are required in chronic illness, and
may be used at home, or in a nursing or rehabilitation center. In positive
pressure ventilator, additional measures can be required to secure airway.
The common employed method is intubation which provides clear route for
the air. In negative pressure or non-invasive ventilator, there is no need to
use any adjunct.

CRITERIA FOR CHOOSING A VENTILATOR It mainly depends upon the

clinical condition of the patient on presentation, diagnosis, patient’s
respiratory drive, the compliance of lungs and the chest wall, and the degree
of synchronization. Other factors can be familiarity of the staff with the
equipment and the availability of the equipment.

FACTORS TO BE OBSERVED IN CASE OF VENTILATION

Vital Signs.

Oxygen Saturation in the blood.

Consciousness of the Patient.

Checks alarm function of the ventilator.

Secretions should be removed periodically

SETTING- NEONATAL VENTILATOR

Protocol for initial respiratory settings for mechanical ventilation of

infants

1. Rate: 30-40/minute.

2. Peak inspiratory pressure (PIP) - determined by adequate chest wall

movement. ...

3. Positive end expiratory pressure (PEEP): 4 cm of H2O OR 5-6 cm if

FiO2 > 0.90.

4. FiO2: 0.4 to 1.0, depending on the clinical situation

MODES OF VENTILATOR

I. Control.

II. Assist/Trigger.

III. Intermittent Mandatory Ventilation.

 IV. Mandatory Minute Volume.

V. Continuous Positive Airways Pressure.

PHASES OF VENTILATOR

I. Inspiratory Phase.

II. Cycling, or changeover, to expiration.

III. Expiratory Phase.

IV. Cycling to inspiration.

FUNCTION OF A VENTILATOR: The air reservoir is pneumatically

compressed several times a minute to deliver room air, or an air/oxygen
mixture to the patient. A turbine pushes the air through ventilator, with a
flow valve adjusting pressure to meet patient-specific parameters. When
over-pressure is released, patient will exhale passively due to the lung’s
elasticity, through a one-way valve within the patient-circuit, called patient
manifold.

CRITERIA FOR WEANING A VENTILATOR

Obtain ABG (Arterial Blood Gas) analysis.

Obtain chest x-ray.

Ensure stable hemodynamic status.

The underlying disease is removed.

Ensure adequate neuromuscular control to perform adequate ventilation.

 Dead space to tidal volume ration <0.60.

Vital capacity >10ml/kg of body weight

ADVANTAGES OF VENTILATOR

Better gas distribution.

Lower mean airway pressure.

Less Hemodynamic disturbance.

Less sedation is required.

Weaning is easier (in most of the cases).

COMPLICATIONS OF VENTILATOR

Barotrauma, including pneumothorax,

pneumomediastinum, pneumoperitoneum and

subcutaneous emphysema.

Ventilator associated lung injury.

Motility of mucocilia in the airways.

Ventilator associated pneumonia.

Oxygen toxicity.

Atrophy of Diaphragm or all respiratory

muscles.

Decreased Cardiac Output.

Fluid retention.

Aspiration.

Laryngeal or tracheal stenosis.

 Cricoid abscess.

High or low PaO2.

GI bleeding.

Thick secretions.

Hepatic congestion.

Decreased renal perfusion.

Respiratory acidosis or alkalosis.

Vagal secretions.

Anxiety or fear.

Patient’s discomfort

CONCLUSION

Intensive care nurses endure intensive and clinical orientation, in addition to

their general nursing knowledge, to provide highly specialized care for critical
patients. Their competencies include the administration of high-rismedications,
management of high-acuity patients requiring ventilator support, surgical care,
resuscitation, advanced interventions such as extracorporeal membrane
oxygenation or hypothermia therapy for neonatal encephalopathy procedures, as
well as chronic-care management or lower acuity cares associated with
premature infants such as feeding intolerance, phototherapy, or administering
antibiotics. NICU RNs undergo annual skills tests and are subject to additional
training to maintain contemporary practice.

BIBLIOGRAPHY
1. Dorothy E. Marlow, text book of paediatric nursing,16 th edition,Elsevier
publications,page no.316,486.

2. D.C Dutta, text book of obstetrics,central publications,2004,page

no.473,339,341,480.

3. Myles,textbook for midwives,14th edition,Churchill livingstone

publications, 2003, London,page no.876-877.

4. Achars Textbook of pediatrics ,fourth edition;orient Longman pvt

ltd,India.

5. www.encyclopedia.com

6. www.ncbl.nch.com

7. www.answer.com

8. www.slideshare.com
 SEMINAR

ON

ADVANCED NEONATAL PROCEDURES

Submitted To Submitted by

Mrs.K.Prashanthi S.Krupajyothirmai

Assist Professor MSc N 2nd year

GCON GCON

General objective: - At the end of the seminar students are able to review
advanced neonatal procedures.

Specific objectives: - At the end of the seminar students are able to,

1. Define the procedures.

2. List the advanced neonatal procedures.

3. Explain rational for every step in the procedure.

4. Arrange the articles for the procedures in the NICU

 5. Demonstrate the procedures

6. Perform after care of the child

7. Discuss about normal and abnormal results with the parents

Name of the student : S.Krupa Jyothirmai.

Subject : Child Health Nursing

Topic : Advanced Neonatal Procedures :

No. of Students : 4

Place : Child Health Lab

Date : 11.2.2020

Time :

Duration : 1hour 30minutes

Method of Teaching : Lecture cum Discussion

Supervised by : Mrs.K.Prashanthi mam

Assit.Professor Govt College of Nursing.

RESEARCH STUDY

Neonatal resuscitation practices among pediatricians in Gujarat. This survey

was conducted amongst paediatricians within the state of Gujarat over a period
of 4 months from April to July 2012.

Data Collection was done by the questionnaire was based on revised 2010 NRP
guidelines as well as NSSK guidelines and was developed, Out of 126
paediatricians, 68 (54%) were associated with Neonatal Intensive Care Unit
(NICU) with mechanical ventilation facility, 84 (66.7%) performed more than 20
resuscitation, and 67 (53.2%) attended more than 100 deliveries in the last one
year. Only 73 (57.9%) reported to conduct resuscitation of high risk/unstable
infants in the new-born corner in the delivery room under radiant warmer.
Most of the participants 93 (73.8%) reported having saturation monitor in the
delivery room, but only 34 (27%) reported availability of oxygen blender.
Although recommended, only 23 (18.3%) reported using continuous positive
airway pressure (CPAP) in the delivery room. Forty-six (36.5%) of the
paediatricians had NSSK training, while 55 (43.7%) were trained in NRP in the
last three years. Practice of positive pressure ventilation in delivery room was
performed by self-inflating bag flow inflating bag and Neopuff (T piece
resuscitator) in 103 (81.7%), 2 (1.5%), and 18 (14.2%) respondents,
respectively.
Of 126 paediatricians, 88 (69.8%) reported correct knowledge and practice
regarding effective bag and mask ventilation and chest compressions. Only 46
(36.5%) of the paediatricians applied plastic/thermal wraps for extremely low
birth weight newborns, which is a recommended practice. Similarly, only 48
(38.1%) participants followed the recommended practice of cutting the
umbilical cord after a delay of one minute. Many participants 78 (61.9%),
adopted the current recommendations of endotracheal suctioning of
nonvigorous newborn in cases of meconium stained liquor. Thirty-five (27.8%)
followed oral cavity suctioning before delivery of shoulder. This survey has
identified areas of nonuniformity and lack of awareness amongst paediatricians
for practices followed for neonatal resuscitation. There are evident gaps in the
knowledge and compliance for the latest NRP and NSSK norms amongst the
paediatricians of Gujarat.