.

1. ADVANCED NEONATAL PROCEDURES
Introduction:
Childbirth is a complex process.There are numerous physical changes that
occurin 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 soonas babies
enter the world, their bodysystems 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 NEONATALRESUSCITATION
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 establish and maintain a clear airway.
To ensure effective circulation.
To correct any acidosis present.
To prevent hypothermia, hypoglycemia and hemorrhage.

2. Warning signs of cardio pulmonary arrest:-
 Early signs: loss of consciousness & convulsions
 Late signs: Apnea .Dilated pupils .Absenceof 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 pressuregauge 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.

3.  Intubation articles.
Laryngoscopewith straight blades No. “O”( premature), No “1” ( Newborn)
Extra bulbs a nd 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% album 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.

4. Syringe 1ml, 2ml, 5ml and 20 ml sizes.
Needles Nos 21,22 and 26 G
Umbilical Cord clamp
Warm dry towels.
ResuscitationAlgorithm
As soonas baby is delivered, assess forfive signs while cord is being cut.
a. Clear the meconium
b. Breathing or crying
c. Good muscle tone (Flexed posture and active movement of baby denotes
good tone).
d. Color 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
Yes
Clear the meconium?
Breathing or crying?
Good muscule tone?
Colour pink?
Term gestation?
Routine Care
Provide warmth
Clear airway
Dry

5. No
Breathing
HR > 100 and pink
Apnea or HR < 100
Ventilating
HR > 100 and pink
HR < 60 HR > 60
Supportive care
Provide Warmth
Position, clear airway* (as
necessary)
Dry, stimulate, reposition
Give oxygen (as necessary)
Evaluate respirations,
heart rate and color
Provide positive
pressure ventilation
ppressurepressure
ventilation*
Provide positive pressure ventilation*
Administer chest Compressions
Ongoingcare
30 Sec
30 Sec
30 Sec

6. HR < 60
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
dry off amniotic fluid, replace wet
sheets with a dry one.
Prevents heat loss.
3. Place the baby on his back with
slightly head down 15 degree tilt,
neck slightly extended.
Straightens the traches and opens the
airway. Hyperextension may cause
airway obstruction.
4. Suction the mouth first and then
nose.
Clears the airway passage. Infants often
gasp when the noseis suctioned and
may aspirate secretion from the mouth
into lungs.
5. Give tactile stimulation if infant does
not breathe. ( Flick or tap the sole of
foot twice or rub the back). Do not
slap.
Tactile stimulation of drying may bring
spontaneous respiration.
6. Check the vital signs, and the colour
of the newborn.
Helps in determining further need for
resuscitation.
* Endotracheal intubationmaybe
consideredatseveral steps.

7. Note: Evaluation should be doneon 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 pressureventilation.
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
extended. The newborn on his
Helps in opening airway.
Hyperextension may cause airway
obstruction.
2. A tight seal is to be formed over the
infant’s mouth and nose with the
face mask.
Prevents leakage of air from the sides
of the mask.
3. Ventilate at a rate of 40-50 per
minute.
4. Ventilate for 15-30 seconds and
evaluate
Spontaneous respiration may be
initiated with initial attempts to
ventilate.
5. Have an assistant to evaluate, listen
to the heart rate for 6 seconds and
multiply by 10.

8. 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 color
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.

9. ChestCompressions
Chest compressions consistof 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
newborn’s chest with the fingers under the back to
provide supportand the thumbs over the lower third of
the sternum (just above the xiphoid process)
0r
Use two fingers of one hand to compress the chest and
place the other hand under the back to provide support.
Correct hand position
compresses the heart
and avoids injury to the
liver, spleen, fracture
of the ribs and
pneumothorax.
2. Compress the sternum to a depth of approximately one
third of the anteroposterior diameter of the chest and
with sufficient force to cause a palpable pulse. The
fingers should remain in contactwith the chest between
The size of the
newborn determine the
depth of compressions
to avoid injury.

10. compressions.
3. Use three compressions followed by one ventilation for
a combined rate of compressions and ventilation for a
combined rate of compressions and ventilations of 120
each minute. Pause for ½ second after every third
compressionfor ventilation.
Simultaneous
compressionand
ventilation may
interfere with adequate
ventilation. The short
pause allows air to
enter the lungs.
4. Check the heart rate after 30 seconds. Ifit is 60 bpm or
more, discontinue compressions but continue
ventilation until the heart rate is more than 100bpm and
spontaneous breathing begins.
Periodic evaluation is
necessary to ensure
that treatment is
appropriate to the
infant’s status.
If cardiac compressionfails, endotracheal intubation should be initiated.
EndotrachealIntubation
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
under the shoulder.
Position makes
the airway open.
2. Introduce laryngoscope over the baby’s tongue at the right To guide the
endotracheal

11. corner of the mouth. tube
3. Advance 2-3 cm while rotating it to midline, until the
epiglottis is seen. Elevation of the epiglottis with the tip of
the laryngoscope reveals the vocal cords.
To find right
route
4. Suction secretions if needed. Clears the
airway.
5. Pass the endotracheal tube a distance of 1.5-2cm into the
trachea, hold it firmly but gently in place and withdraw the
laryngoscope slowly.
Ensures
adequate air
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
adequate ventilation of both lungs with stethoscope.
To know the
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 procedurein nurses’ record. Document the baby’s condition before
and after procedure.

12. 2. CARE OF BABY UNDERGOINGPHOTOTHERAPY
Definition
Caring for a baby being exposed to light sourcefor 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 canbe delivered in severalways. The most common
methods are:-

13.  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
baby will be kept in an isolate and exposed
to a blue – green light for bringing down
the bilirubin levels.
Allays anxiety and convinces her
about the need for phototherapy.
2. Instruct the mother to feed the baby. Prevents dehydration when exposed
to phototherapy.
3. Check machine for electrical safety and
properinsulation of wires.
Prevents electrical hazards.
4. Check whether all bulbs are burning in
machine.
5. Transfer the baby to nursery where
phototherapy equipment is present and
place the baby in the isolate over which
phototherapy lights are placed.
Heat loss is minimized and
temperature is controlled when an
incubator is used.
6. Adjust height between baby and lamp to
45cm.
Lights that are too close increases
the risk of burning the skin. Lights

14. too far away from the infant will not
be effective.
7. Place the baby naked under light in the
isolette.
Exposes the skin as much as
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
napkin.
Protects testicles from the high
intensity lights.
10. a. If fiberoptic pad is used, place it under
the baby in contactwith the baby’s skin.
b. Keep the baby on his side with a rolled
baby sheet on the side.
Maintains the position.
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
starting the procedure, observations made
and precautions taken.
Acts as a communication between
staff members.
Care and Observationduring Phototherapy

15. 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 bodytemperature 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:-
Loosegreen stoolresulting from increased bile flow and peristalisis. Stool
may damage the skin and cause fluid loss.
Tanning effect from the light.

16. 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.

17. 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 doorto 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

18.  Cabinet: This provides supportfor hood, canopyand 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 conopyand passed over heater and humidifier.
Temperature inside incubator is maintained by sensorplaced 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
needs to be nursed in an isolette.
Promotes chances of survival
for premature baby who needs
thermoregulation.
2. Verify physician’s orders for management of
baby in the incubator.
Facilitates adequacy of
required unit assembly for
care.
3. Explain procedureto mother/parents. Promotes understanding and
acceptance of parents.
4. Prepare the incubator for placing the baby by
cleaning it with soap and water and
disinfecting.
Use of clean disinfected
incubator prevents growth of
microorganisms.
5. Switch on the incubator and adjust the
temperature at 36 degree centigrade on” servo
36 degrees centigrade set on
servo- control mode maintains

19. 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 bodysurface.
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
incubator every hour until the temperature of
the baby is stabilized.
Prevents over exposure to
heat.
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
the baby according to hospital policy.
Reduces the chances of
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 bodytemperature.
Keep port holes open for some time. Then

20. 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

21.  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-1fine 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

22.  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 biopsytowel.
p. Mask and gloves.
q. Cord tie.
r. Specimen containers.
s. Specimen tubes.

23. t. Adhesive plaster, scissors and extra syringes.
u. Emergency drugs like:-
 Injection Adrenalin.
 Inj. Calcium gluconate.
 Injection Sodabicarbonate.
 Inj. Amniophylline
v. Blood giving set.
w. Cross splint.
Choice of DonorBlood
The donorblood 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 procedurehas 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.

24. Procedure
S.N. Nursing action Rationale
1. Explain the procedures to the patients. Helps in reassuring the
parents.
2. Get informed consentfrom the parent. Prevents legalities.
3. The procedureis best carried out in an air conditioned
room.
4. Collect the blood from blood bank and place in tepid
water and check the blood type and group against the
neonate’s blood before administering.
Prevents hemolytic
reaction caused by
mismatched donor
blood.
5. Procedureshould be carried out in an incubator
maintaining the temperature at 27-30 degree
centigrade.
6. NPO should be maintained for 4 hours before
procedure.
Minimizes the risk of
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
umbilical stump.
Removes
microorganisms.
9. Assist in cleaning umbilical cord and draping with
sterile linen.

25. 10.Pour 500ml of I.V. normal saline into a sterile bowl
and add 1ml inj. Heparin in it.
Before beginning the
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
skin surface.
Helps in location of
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,
or donorblood before insertion.
Minimimises the risk of
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
procedure.
Hypothermia may lead
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
exchange for investigation.
Helps in estimation of
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

26. replaces with 10ml of fresh blood immediately, until
calculated volume has been exchanged.
20.Apply cord tie at umbilicus, seal umbilicus with
tincture benzoin apply small gauze and secure with
adhesive.
Prevents risk
haemorrhage and
infection.
21.Replace equipments and start phototherapy.
22.Document time of starting, duration, completion time,
amount and type of blood exchanged, condition of
baby during and after procedure, drugs given during
procedureand samples sent to lab.
Gives information to
the staff members.
PostTransfusionCare
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.

27. Portolvein thrombosis.
Umbilical vein perforation
Dysrhythmia
Cardiac arrest.
Hypocalcemia
Hypoglycemia
Hypomagnesemia
Metabolic acidosis
Alkalosis
HIV, Hepatitis B infections.
Graft versus host disease.
Specialconsiderations
If citrated or heparinized donorblood 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

28. 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
anaesthesia machine).
icine
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.

29. 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 controlof 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.

30. 4. POSITIVEAIRWAYPRESSUREVENTILATOR:-Thesearespecifically designed
for non-invasiveventilator, and can also be used at home, e.g, for treating
sleep apnea or COPD. • Itworks 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 pressuredrops to ‘0’ and the elastic
5. NEGATIVE AIRWAY PRESSUREVENTILATOR :- Here the air is
withdrawn mechanically to producea 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 personhas bilateral lung pathology, then
this type of ventilation is used where two synchronised ventilators are used
simultaneously. It prevents ventilation -to- perfusion mismatch. Treatment
costis expensive as two ventilators are required in one set-up.
APPLICATION AND DURATION OF VENTILATION

31. 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
ventilator.
SETTING- NEONATAL VENTILATOR
Protocolfor initial respiratory settings for mechanical ventilation of
infants
1. Rate: 30-40/minute.
2. Peak inspiratory pressure(PIP) - determined by adequate chest wall
movement. ...

32. 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.

33. CRITERIA FOR WEANING A VENTILATOR
x-ray.
equate neuromuscular controlto perform adequate ventilation.
ADVANTAGES OF VENTILATOR
COMPLICATIONS OF VENTILATOR
pneumomediastinum, pneumoperitoneum and
subcutaneous emphysema.

34. muscles.
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,

35. 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 bookof paediatric nursing,16th edition,Elsevier
publications,page no.316,486.
2. D.C Dutta, text bookof 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 Textbookof 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

36. SEMINAR
ON
ADVANCED NEONATAL PROCEDURE
Submitted To Submitted by

37. Mrs.K.Prashanthi S.Krupajyothirmai
Assist Professor MSc N 2nd year
GCON GCON
Generalobjective:- 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

38. 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.ProfessorGovtCollege of Nursing.

39. 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,Outof 126
paediatricians, 68 (54%) wereassociated with Neonatal IntensiveCareUnit
(NICU) with mechanical ventilation facility, 84 (66.7%) performed morethan 20
resuscitation, and 67 (53.2%) attended morethan 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%) weretrained in NRP in the
last three years. Practice of positivepressureventilation in delivery roomwas

40. 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 correctknowledge and practice
regardingeffective 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.

41. Continuous Positive Airway Pressure (CPAP)
Introduction
Continuous Positive Airway Pressure (CPAP) is a means of providing
respiratory supportto neonates with either upper airway obstruction or
respiratory failure. Respiratory failure constitutes either failure of ventilation or
failure of lung function.
CPAP delivers oxygen concentrations and distending airway pressures via the
ventilator without the hazards associated with full endotracheal intubation and
mechanical ventilation. The delivery of constant positive pressure to the airway
of a spontaneously breathing neonate maintains adequate functional residual
capacity within the alveoli to prevent atelectasis and improves oxygen and
carbondioxide exchange within the pulmonary circulation.ontinuous Positive
Airway Pressure (CPAP) in Neonatal UnitsDefinition of Terms /
Abbreviations
 CPAP: Continuous Positive Airway Pressure
 Single nasal prong (SNP): An endotracheal tube that has been cut and
shortened at the connectorend and inserted via the nostril into the
nasopharynx.
 Bi-nasalprong: Specially designed nasal prongs which end at the nasal
level
Assessment
 Identify the patient group(s) to whom the guideline applies

42.  Physical Assessment
 initial acute
 ongoing assessment
Investigations – biochemistry, procedures
Social history/issues
Education needs (patient and parent/care-giver)
Nutrition
SpecialConsiderations
 Respiratory assessment
 Blood gases as required (determined by clinical condition and
previous blood gases)
 Respiratory rate
 Heart rate
 Chest rise and fall
 Work of breathing
 Oxygen requirements
 Pulse oximetry
 Capillary refill time
Maintain neutral thermal environment
Ensure cardio-respiratory and pulse oximetry monitoring, correct alarm
settings, and documentation

43. Ensure gastric decompressionwith naso/oro gastric tube in situ
Ensure hand hygiene at all times
Indications
 Increased work of breathing – tachypnoea, nasal flaring, grunting,
retractions, cyanosis, increasing oxygen requirements
 Respiratory acidosis on blood gas
 The following conditions when associated with the above signs may be
responsive to CPAP
 Respiratory Distress Syndrome (RDS)
 Pulmonary oedema
 Atelectasis
 Recent extubation
 Transient Tachypnoea of the newborn (TTN)
 Tracheomalacia or similar disorder of the lower airway
 Apnoea of prematurity
Contraindications
 Upper airway abnormalities that make CPAP ineffective or dangerous,
e.g. choanal atresia, cleft palate, unrepaired trachea-oesophageal fistula
 Congenital Diaphragmatic hernia pre surgical repair
Complications
Complications related to equipment:
 Obstruction of prong due to kinking of prong and/or delivery circuit

44.  Inefficient delivery due to malposition of bi-nasal prongs/mask
 Skin irritation from securing tapes to the face (SNP)
 Pressure necrosis around nostrils and distortion of the nasal septum due to
incorrect strapping and positioning
 Pressure necrosis around head/ears and head molding due to failure to
release hat and strapping regularly (bi-nasal prongs)
 High air leak around prongs due to mouth being open (SNP and bi-nasal
prongs) or air escaping from other nostril (SNP)
Complications related to infant's clinicalcondition:
 Obstruction of SNP or bi-nasal prongs from secretions
 Pneumothorax
 Pneumomediastinum
 Pulmonary interstitial emphysema
 Decreased cardiac output (due to decreased venous return) with excessive
CPAP levels
 Gastric distension and feed intolerance
 Increased work of breathing related to increased airway resistance
(related to diameter of SNP or bi-nasal prong)
 Inadequate ventilation
 Medical review will be required if the nurse is concerned about any of
these potential complications
Initial CPAP settings:

45. This should be undertaken in discussion with the NICU consultant. The usual
range of settings is
5-8cmH2O, however in some clinical conditions (e.g. bronchiolitis, severe
chronic lung disease and tracheal issues) higher CPAP up to 12-14cmH2O may
be ordered by the NICU consultant. An increase in CPAP may be required from
the initial setting if work of breathing, respiratory rate, oxygen requirement, and
underlying lung pathology deteriorate.
DeliveredCPAP:
Commonly the measured CPAP pressure will be lower than the set pressure
because of CPAP attenuation within the interface and leak. In general, both
should be documented in the EMR Flowsheets and the delivered pressure
should not be targeted beyond the usual care of the patient (e.g. repositioning
the patient or interface, and being aware of leak through the patient’s mouth). If
the clinical situation determines that a specific delivered CPAP pressure should
be targeted, the medical officer should document this in the CPAP order along
with the range for the maximum and minimum CPAP pressures that are
acceptable.
Weaning CPAP settings:
CPAP is usually weaned in increments of 1cmH2O every 12-24 hours. The
timing and rate of weaning will be decided by either the NICU consultant or
fellow, in discussion with the infant’s nurse. The factors to consider when
deciding to wean the CPAP include work of breathing, respiratory rate, oxygen
requirement, and underlying lung pathology.
Ceasing CPAP:
When the infant has demonstrated a stable respiratory pattern on CPAP of
5cmH2O in <30% FiO2 for 12-24 hours, the CPAP may be removed. In some
circumstances it may be appropriate to cease CPAP at a higher CPAP level (e.g.

46. older, larger infants). This decision should be discussed with the NICU medical
team before the CPAP is removed from the infant. At times, the NICU medical
staff, in discussionwith the nurse, may decide to electively change the infant
from CPAP to High or Low Flow Nasal Cannulae Oxygen, if deemed
appropriate (this requires a medical order).
Management
A medical order is required to initiate CPAP, to alter the amount of CPAP
delivered, and to discontinue CPAP. These should be documented by the
medical officer.
CPAP commencement and ongoing care is the responsibility of the infant's
nurse, with the assistance of a second nurse.