Welcome to Bolton Neonatal Intensive Care and Special Care baby unit

S.Christie Updated July 2016

Welcome to Bolton NeoNatal Unit

We would like to welcome you to NICU/SCBU. We hope you enjoy placement.

We are an intensive and special care cot unit providing medical care to premature and sick neonates. We are also a regional referral centre for the North West for extreme premature babies and neonates requiring cooling therapy and nitric therapy. We strive to encourage family centred care in our approach. We aim to support your own learning and development needs regular meetings of progress and on-going feedback.

Student induction

If you have not had a placement at Bolton before please let us know as soon as possible as you will need to attend Trust induction for your mandatory training requirements.

All students will be given an orientation to the unit on their 1st day and will be introduced to key people in the Team.

General information:

Shift times:

7.30- 2000 – Day shift

1930 - 0800 – night shift

½ hour break for lunch and tea

Students are expected to work 37/5 hours a week (apart from midwifery students who will have 30 hour week and 7.5 hours study time) working a mixture of days, nights and weekends following their mentor as much as possible. Students are not required to work bank holidays. If there is a problem with your off duty please either speak to your mentor or liaise with Education team who will inform the PEL for Neonates, Sarah Christie.

Mentors:- S.Christie Updated July 2016

You will be allocated 2 mentors upon commencement of your placement. However we do operate a team mentoring approach in that if your mentor swaps a shift or is off sick, another mentor will be sought for you who will then feed back to your main mentors.

You are required to work 40% of your time with your allocated mentors. If there are any issues with this please speak to a member of the education team in the first instance or Sarah Christie PEL for this placement who will investigate for you.

Midwifery students: - As your placements are often split, we will endeavour to give you the same mentors but there may be times when this is not possible for a variety of reasons.

Security:

We have lockers available please bring a padlock or £1 coin

Please adhere to trust policy by wearing your ID badge at all times.

Health and Safety:

It is the responsibility of all staff to read and adhere to trust health and safety policies regarding moving and handling, Fire, Uniform and Infection control. This will be covered on your induction. Please let us know if there is a health issue we may need to be aware of such as back injury, epilepsy or pregnancy so that the necessary risk assessments and adjustments can be put into place for you.

Uniform:

It is unit policy, for infection control purposes that you must travel in your own clothes and get changed into uniform on the unit.

Please note black full shoes must be worn, Crocs are against trust policy.

It is trust and unit policy that only a single plain wedding band can be worn to confirm to infection control policy. Hair must be tied back and off your collar.

Sickness and absence:

If you are ill and unable to attend placement, it is important that you telephone the unit to inform the team of your absence. You should also telephone the university to inform them too. Unreported sickness is marked as absence.

Accountability:

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As a pre-registration student you are never professionally accountable in the way in which you will be after you qualify and register with the NMC. It is the registered practitioner of whom you are working with that is responsible for your actions or omissions. This is why you must always work under the direct supervision of a registered practitioner.

Assessment documentation:

Students should ensure they meet with their mentor as soon as possible so that the initial meeting can take place and future dates for mid-point and final can be allocated on your off duty. Please ensure your paperwork is available at all times.

Medical Devices:

Please ensure you have received correct training before use of any equipment. Please speak to shift co-ordinator or education team if you require further training.

Emergency Procedure:

If you are asked to summon help in an emergency, pull the red emergency call button and /or phone 2222

State you require NEONATAL CRASH TEAM and give your location eg

“Neonatal emergency requiring crash team in BAY 2”

You may also be asked to fast bleep a consultant. Again this is 2222 asking for NEONATAL CONSULTANT eg

“Neonatal emergency – Please can Neonatal Consultant on call attend BAY 2”

What you can expect from us:

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You will receive an induction into your work area to ensure you are familiar with the environment and are able to practice safely

You will discuss your learning needs and outcomes at the beginning of the placement

During your placement you will be allocated a mentor and associate mentor to work alongside

Your mentor will assess your performance against course learning outcomes and provide feedback to help you develop your skills

You will be supernumerary and be supervised throughout your placement You will be actively encouraged to be a member of our team and can

expect full support from all members of our multidisciplinary team We will listen to feedback and respond to any issues raised sensitively and

confidentially

What we can expect from you:

We expect you to ensure your mentor is aware of your learning outcomes, your personal development plan and any specific learning requirements.

We expect you to arrive on time for shifts and/or any other activities organised by your mentor

We expect you to act in a professional manor at all times We expect you to dress in accordance with University uniform policy You must inform both the unit and the university if you are unwell and

cannot attend your shift. This will be covered in your induction We would like you to raise any concerns or issues with your mentor in the

1st instance, and either the PEL or Matron, of which contact details are within this booklet. If you feel this is not possible please contact your link lecturer or personal tutor

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Philosophy for the Neonatal Unit

The Neonatal Unit provides low birth weight and sick newborn babies with the specialised care appropriate to their needs and gives support to their families.

We recognise that each baby is an individual who has a right to be treated with empathy and dignity in all circumstances.

We believe that the care we provide for the babies and their families should be founded on research.

We believe communication of information is a vital element to enable parents to participate fully in discussions regarding care if their baby and in making informed choices.

We believe partnership in care is important and we encourage parents to participate in the care of their baby both physically and emotionally.

We recognise that learning is improved in an environment which is supportive to students and where there is a commitment to sharing knowledge.

We acknowledge that many people have a role in the work of the Neonatal Unit and value their individual skills and contributions.

We recognise the importance for individuals to be able to further their personal and professional development.

Orientation Checklist-

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Is familiar and can locate- signature and date

Staff locker room, Uniform policyStaff RoomBand 7 OfficeEducation officeStore roomClean utilityDirty utilityQuiet roomParent facilitiesParent accommodationPharmacyPath labE5 – paeds wardG96 - store

Is familiar with Fire Policy and can-

Can describe procedure for reporting a fireCan describe unit procedure on hearing fire alarmIs aware of different alarms and meaningsCan locate- fire alarm/extinguishers/blanketsCan locate fire exitsHas read the fire policyHas attended mandatory training day

Is familiar with Visiting/ Security policy and-

Demonstrates and awareness of NNU visiting S.Christie Updated July 2016

policyIs able to use the intercom systemHas an ID badgeIs aware of bleep/phone numbers for securityDemonstrates an awareness of patient confidentialityHas the relevant door code numbers

Is familiar with the disposal policy and demonstrates knowledge of the disposal of-

Sharps and IV FluidsDirty LinenInfected LinenUsed glass bottles/Milk bottlesItems for CSSDUnit baby ClothesBlood ProductsClinical waste

Is familiar with the Breastfeeding policy on NNU

Can locate relevant policy and protocol and parent information bookletsDemonstrates awareness of initiation and maintenance of lactationInformed of how to escalate concerns to senior staff as appropriate

Is familiar with principles of resuscitation

Can locate resuscitation equipment- neo/adultS.Christie Updated July 2016

Can locate emergency call systemCan summon help appropriately in and emergency

Is aware of

Their mentorsAnnual leaveOff duty and requestsSickness policyCar Parking

Training has been received/assessed -

NeopuffSuctionBottle/ Cup/ Breast feedingTemperature control- skin to skin, bathing, dressingIncubators, IndithermDevelopmental care, HandlingMonitors, apnoea alarmsInfusion DevicesBlood Sampling, Requesting samplesOpti flowCpap/bipapAdmission paperworkIs aware of care plansInfection control procedures

Useful information:-

There are some student workbooks in the student file. These are not compulsory but may assist your learning. There are also theory books available S.Christie Updated July 2016

in the education office. The education team also have electronic copies of presentations around various topics and condition’s so please do ask us.

Common Topics:-

Nutrition-

Calculating fluid requirements-

Term infant Preterm/IUGR infantDay 1- 60mls/kg/day Day 1- 90mls/kg/dayDay 2- 90mls/kg/day Day 2- 120mls/kg/dayDay 3- 120mls/kg/day Day 3- 150mls/kg/dayDay 4- 150mls/kg/day Day 4- 180mls/kg/day

Occasionally medical staff will request and increase/decrease in fluid intake- this must always be a medical decision.

Infants are usually commenced on 10% dextrose before changing to either dextrose with/without additives or TPN (Total Parenteral Nutrition).

Fluids are calculated and given on an hourly rate-

Total daily fluid requirement/ 24hrs

Fluids are calculated on the infant’s heaviest weight available, this may be the infant’s birth weight as infants can lose up to 20% of their initial birth weight, but should have regained this weight by day 14 .

Introducing enteral feeds (milk) is a slow process called seesawing in which the milk is slowly increased and the fluid infusion is decreased. The current policy, of when and how to begin enteral feeding is available on the unit.

Feeding Methods

It is important to know the preferred method of feeding from the infants parents.

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Breast- As a neonatal nurses and students you have an important role to play in the support of mothers whom wish to breastfeed, this may initially be commenced by expressing breast milk (EBM)

Expression and storage of Breast milk- Mothers should be encouraged to stimulate their milk supply as soon after delivery as she is able, woman are advised to express both breasts simultaneously (double pumping) as this has been demonstrated to increase the hormone Prolactin which will subsequently increase milk supply. Mothers should be advised to stimulate/express her milk at least 8 times a day including once overnight which will again aid in milk production (prolactin level is at its highest around 2-3am)

There are breast pumps available on the unit and also a limited amount of loan units. Once expressed EBM should be stored in the fridge (up to 48hrs) on removal from the fridge the EBM must be given within 4 hours. If the infant is not yet feeding EBM may be frozen (up to 3 months) and can be defrosted in the fridge and then can be kept for up to 24hours. If EBM is to be given it is important to remember to give the milk in the order it was expressed (in the first 14 days) as this will contain the Colostrum which is highly beneficial for the infant. Please see Breast feeding policy available on the unit.

Once infants begin to establish breastfeeding it is important to remember that both mum and baby may need practice and support in learning the cues and methods of breastfeeding.

Formula-

If infants are below 2kg they are commenced onto Nutriprem 1 which is a higher calorie milk which will aid in growth and weight gain they will then move onto Nutriprem 2 which they can continue after discharge (to be prescribed on discharge). If the infant is of good weight the preferred brand of formula milk can be given.

Please remember that some parents may not know how to bottle feed and may need support and guidance in this method of feeding also.

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Before 32-34 gestation sucking is not a reflex, and sucking/swallowing may not be well co-ordinated, practice is therefore essential, but it is important not to allow the infant to tire. Allow the baby to progress at it’s own rate.

Gastrointestinal tract

Preterm infants have an immature GI tract, this may cause difficulties in tolerating and digesting enteral feeds, it may also make infants more susceptible to conditions such as Necrotizing Enter colitis (NEC) it is therefore advisable to monitor infants for signs of milk intolerance these include;

Abdominal distension Assess by medic and observeLarge aspirates/bile stained aspirates

Assess by medic and observe

Vomiting Assess by medicAbnormal stools Assess and send sampleVisible peristalsis Assess by medicBlood in stool NEC/GI infectionGeneral signs of infection

Stools; change in appearance according to age and method of feeding and type of milk. Stools should not be excessively loose, watery or offensive. If these symptoms occur a sample should be sent to microbiology for MC+S (microbiology, culture and sensitivity)

Reflux; research indicates that preterm infants may be susceptible to gastric reflux which may cause apnoeic/bradycardic episodes with risk of aspiration. Infants are usually prescribed Gaviscon to thicken feeds and prevent reflux.

RespiratoryS.Christie Updated July 2016

Most babies admitted to the NNU will either have or be at risk of, respiratory illness. Management of the respiratory symptoms will depend on their severity; some infants may require full assisted ventilation whilst others may only need small amounts of oxygen.

The most common respiratory problem is Surfactant Deficient Lung Disease (SDLD) commonly seen in preterm infants, the lower the gestational age the more severe the disease. The problem arises because of a deficiency or lack of surfactant within the alveoli.

Other common forms of respiratory illness include Meconium aspiration syndrome (MAS), Transient Tachypnoea of the newborn (TTN) and chronic lung disease (CLD). You are advised to consult a relevant textbook for full description of these diseases.

It may be useful to make yourself aware of the treatments available on the unit, presently we offer:-

Oxygen Support- to babies that breathe spontaneously, but may be unable to maintain a normal SaO2 level

Cpap/Bipap/Sipap- This is a non-invasive treatment that aims to stop the lung alveoli from collapse, it aims to splint the lungs open using a mixture of air and oxygen delivered under pressure via nasal prong/mask to the babies lungs. This is an effective treatment used very frequently on NNU to help babies that may tire easily and the use of Bipap gives the opportunity for breaths to be given if needed.

Ventilation- This is an invasive treatment were air and oxygen is delivered via mechanical breaths via a endotracheal tube by the ventilator. This can be given in varying degrees either as full support were the ventilator either breathes completely for the baby (CMV) or allows the baby to breath with the ventilator and have each breath supported (SIMV/PSV)

Thermoregulation

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An infant’s ability to maintain their own body temperature is dependent on, gestational age, weight, clinical condition, infection and its environment.

A ‘normal temperature’ for and infant should be 36.5-37.2

It is important to remember that infants may have a fluctuating (labile) temperature as an indication of infection and their temperature must be carefully monitored.

Infection

Neonate’s especially premature neonates are at greater risk of infection due to skin being thin and easily damaged; they are also immunodefcient due to reduced amount of circulating immunoglobulin’s. Steps should be taken to reduce all areas of infection were possible.

Reducing Risk-

Hand washing before and after handling any babyIndividual pieces of equipment for babiesUse of aseptic (ANTT) techniqueMinimising the amount of times the skin is breached ie- canulationSigns and Symptoms-

Temperature fluctuationsPallor, mottled skin,Vomiting, Abdominal distension, Reduced feedingIrritability, Lethargy, HypotoniaBradycardia , Apnoea’s , Desaturations If you are caring for a baby that begins to show any of these signs and symptoms you should report it to a senior nurse and/or doctor.

Jaundice

Physiological Jaundice is a common condition in neonates, it occurs by the gut being too immature to excrete bilirubin which will lead to the infant having a S.Christie Updated July 2016

slight yellow tint to their skin and eyes. Bilirubin levels are monitored by regular blood tests and the result plotted on a gestational specific graph which shows at which level the bilirubin should be at to receive phototherapy.

Phototherapy is a treatment of bright UV lights which allows the breakdown of bilirubin into compounds that the baby can excrete easily. It is important to remember that these bright lights can be very harmful to the infants eyes and their eyes should remain covered at all times when under the lights.

Whilst receiving phototherapy care must be taken to observe the infant for any side effects of treatment such as rashes, lethargy, and diarrhoea. They will also be susceptible to overheating or burns if phototherapy is too near to the skin.

For the infant to receive adequate phototherapy minimal handling must be promoted.

In some cases an infant may suffer from pathological jaundice this is due to a rhesus or blood group incompatibility with mum. These infants may require higher levels of phototherapy i.e. more than one light unit or may even require an exchange transfusion.

Developmental Care

Neonates, especially preterm’s do not have the same postures or behaviour as full term well infants, in very premature infants a ‘froglike’ position is seen as joints are not yet fully developed care must be taken to support these joint and aid the infant in maintaining a ‘normal’ position for joints to develop correctly this is known as adaptive positioning, in which positioning aids such as boundaries and nests are used to support the neuromuscular development.

It is important to become aware of good developmental care can influence an infant’s overall wellbeing, good developmental care can be as simple as keeping volume levels down by not shouting over incubators and silencing alarms quickly, lowering light levels by covering incubators.

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It is also good practice to promote minimal handling, and allowing the infant time to settle them following any intervention. Parents may be shown how to hold their babies whilst in incubators to involve them in their care and to promote bonding this is referred to as containment holding.

Parents may also be able to hold their infants out of the incubators for ‘skin to skin’ or ‘kangaroo’ care this is not just useful in aiding mums that are expressing to increase milk supply but also is reassuring to both parents and their babies.

Family Centred Care

As a neonatal nurse you are essential in the care of both the baby and the family this is the philosophy of family centred care a principle in which the infant is an integral part of a family unit and cannot be cared for in isolation from each other.

Therefore it is very important that the family are given as much information as possible about the care of their baby, the information must be given at an appropriate level of understanding for each family. In addition to keeping them up to date with their babies care it is important to involve them were possible in caring for their baby, giving them support in doing things such as nappy changes and mouth care for sick infants, and supporting both parents and babies developing skills such as helping to breast/bottle feed when appropriate to giving bath demo’s when baby is moving towards being discharged.

Siblings are an important part of the family unit and should not be discouraged from visiting but should be given age appropriate information in helping to care from their new baby brother or sister.

Useful Resources

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Bliss Website

Unicef Website- Breastfeeding

Neonatal Intensive Care Nursing by Glenys Boxwell

Nursing the Neonate by Maggie Meeks, Maggie Hallsworth and Helen Yeo

Neonatology at a Glance (At a Glance (Blackwell)) by Tom Lissauer and Avroy A. FanaroffNeonatology at a Glance by Tom Lissauer and Avroy A. Fanaroff

Useful contacts

Unit number:- 01204 390748

Anne – Marie White (Matron) – ext. 3807 Anne-marie.white@boltonft.nhs.uk

Education office: ext. 4276

PEL- Sarah Christie – 01204 390748 – Sarah.christie@boltnft.nhs.uk

M4/M5 – postnatal wards ext. 4626

Link lecturer:- Rob Kennedy – 0161 295 2717 – R.Kennedy@salford.ac.uk

PEF Team: Ext: 5984

Kisma Anderson Kisma.anderson@boltonft.nhs.ukLisa Cavanaugh Lisa.Cavanaugh@boltonft.nhs.uk

S.Christie Updated July 2016