NICU

Ministry Of Health, General Directorate Of Nursing
nd
Edition
NICU
anual
of
ursing
olicies and
rocedures
Prepared by:
Nursing Policies and Procedures Committee 2011
Supervised by:
Dr. Munira Al Oseimy
General Director of Nursing-MOH
Ministry of Health, General Nursing Administration

Functions and Duties Policies and Procedures
SPECIALIZED NURSING: NEONATAL INTENSIVE CARE
TABLE OF CONTENTS
SN
POLICY TITLE
INDEX NUMBER
.1 ADMISSION OF AN INFANT TO NICU
SNR-NICU-001
.2 ASSESSMENT OF NEWBORN
SNR-NICU-002
.3 BATHING AN INFANT INSIDE THE INCUBATOR
SNR-NICU-003
.4 EMPLOYEE SURVILLANCE IN NEONATAL UNIT
SNR-NICU-004
.5 EYE TREATMENT OF THE NEWBORN
SNR-NICU-005
.6 FEEDING THE NEWBORN
SNR-NICU-006
.7 INCUBATOR CARE
SNR-NICU-007
.8 INFANT WEIGHING
SNR-NICU-008
.9 SKIN AND CORD CARE OF A NEWBORN INFANT
SNR-NICU-009
.10 TRANFER OF AN INFANT TO OTHER FACILITY
SNR-NICU-010
.11 VISITORS - TRAFFIC CONTROL IN NEONATAL UNIT
SNR-NICU-011
.12 ABDOMINAL GIRTH MEASUREMENT
SNR-NICU-012
.13 ARTERIAL BLOOD ANALYSIS
SNR-NICU-013
.14
WEANING OF PATIENT FROM MECHANICAL

VENTILATOR
New
SNR-NICU-014
.15 CHEST TUBE INSERTION, ASSISTING WITH
SNR-NICU-015
.16 SURFUNCTANT ADMINISTRATION, ASSISTING WITH
SNR-NICU-016
.17 BLOOD EXCHANGE TRANSFUSION
SNR-NICU-017
.18 REMOVAL OF CENTRAL LINE
SNR-NICU-018
.19 BLOOD TYPING AND CROSS MATCHING
SNR-NICU-019
.20 UMBILICAL CATHETERIZATION
SNR-NICU-020
.21 PULSE OXIMETRY
SNR-NICU-021
.22 SUCTIONING
SNR-NICU-022
.23 PHOTOTHERAPY
SNR-NICU-023
.24 BLOOD TRANSFUSION THERAPY
SNR-NICU-024
.25 PNEUMOTHORAX, NURSING CARE OF INFANTS WITH
SNR-NICU-025
.26 INFANT ABDUCTION
SNR-NICU-026
.27 INCUBATOR CLEANING AND MAINATENANCE
SNR-NICU-027
.28 STERILIZATION PROCEDURE OF VENTILATOR TUBING
SNR-NICU-028

TABLE OF CONTENTS
SN
.29
INDEX
POLICY TITLE
BABYS IDENTIFICATION BEFORE DISCHARGE /
TRANSFER TO OTHER UNIT
NUMBER
NUMBER
New
SNR-NICU-029
.30
BLOOD DRAW FROM UMBILICAL CATHETER
New
SNR-NICU-030
.31
BLOOD GLUCOSE MONITORING BY HEEL STICK
New
SNR-NICU-031
.32
CAPILLARY BLOOD GAS (CBG)
New
SNR-NICU-032
.33
CARE OF PATIENTS ON MECHANICAL VENTILATION
New
SNR-NICU-033
.34
New
SNR-NICU-034
.35
CENTRAL LINE MONITORING AND DRESSING

ASSISTING INSERTION OF CENTR AL VENOUS LINE
/PERIPHERALLYINSERTED CENTRAL CATHETER (PICC)
New
SNR-NICU-035
.36
CHEST TUBE REMOVAL- ASSESSING
New
SNR-NICU-036
New
SNR-NICU-037
.37
EMERGENCY CRASH CART CHECKING AND RESTOCKING
.38
EQUIPMENT CHECK-UP AND TESTING
New
SNR-NICU-038
.39
GASTRIC ASPIRATION
New
SNR-NICU-039
.40
INTRAVENOUS THERAPY & CANNULATION
New
SNR-NICU-040
.41
ISOLATION OF THE NEWBORN
New
SNR-NICU-041
.42
NARCOTIC AND CONTROLLED DRUG ADMINISTRATION
New
SNR-NICU-042
New
SNR-NICU-043
.43
NARCOTIC AND CONTROLLED DRUG ENDORSEMENT

AND STORAGE
.44
NASOGASTRIC FEEDING
New
SNR-NICU-044
.45
NASOGASTRIC TUBE INSERTION
New
SNR-NICU-045
New
SNR-NICU-046
New
SNR-NICU-047
.46
.47
NURSES CERTIFIED IN BASIC LIFE SUPPORT (BLS) &

NEONATAL RESUSCITATION PROGRAM (NRP)
NURSING CARE OF INFANT WITH HYALINE MEMBRANE
DISEASE
.48
OXYGEN THERAPY
New
SNR-NICU-048
.49
TRACHEOSTOMY CARE
New
SNR-NICU-049
.50
BREASTFEEDING, ASSISTING THE MOTHER
New
SNR-NICU-050
.51
AVAILABILITY OF 24 HOUR ON CALL PHYSICIAN
New
SNR-NICU-051

INTERNAL POLICY AND PROCEDURE

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-001
APPLIES TO:
NURSING
Admission and Discharge Criteria for Neonatal Intensive Care Unit
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
To give appropriate monitoring and care for infants who requires continuous nursing care and
cardiopulmonary support.
To establish written guidelines for the process of triaging neonates when limited beds are available.
To establish guidelines for the assessment of neonates admitted to the Neonatal Intensive Care Unit
(NICU).
2.0 DEFINITION
None
3.0 RESPONSIBILITIES
Responsible to Head Nurse / Head of NICU Department.
4.0 POLICY
Infants requiring continuous monitoring and cardiopulmonary support are admitted in
NICU.
Admission to NICU requires a written order by the admitting physician.
Patients are prioritized by level of nursing care and acuity, need for intensive medical therapy and type of
illness.
Newborn up to 29 days old is categorized as Neonate to be admitted to NICU.
Strictly no watchers allowed in NICU.
Resuscitation equipments must be ready at all times.
Standard precaution is a must.
5.0 PROCEDURES
* ADMISSION CRITERIA:
Preterm infants with a birth weight < 1250 grams and/or < 28 weeks gestation.
Infants who have experienced difficult labor/or delivery.
Infants exhibiting moderate to severe respiratory distress or requiring assisted ventilator.
Infants with anomalies, severe congenital heart disease.
Infants who have undergone resuscitation or laryngoscopy.
NICU-1


POLICY NUMBER:
DPP
TITLE:
SNR-NICU-001
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 3
Infants requiring hemodynamic monitoring: arterial, umbilical or central lines.

Erythroblastic infants.
Infants of diabetic mothers.
Newborn with medical problems.
Infants with possible sepsis.
Asphyxia neonatorum.
Infants requiring major surgical procedures with the potential for compromised respiratory or hemodynamic
status post-operatively, such as diaphragmatic hernia, myelomeningocele, gastroschises, omphalocele.
Any infant with whom the physician has determined that very close monitoring is needed (e.g., NEC,
SEPSIS)
* DISCHARGE CRITERIA:
Discharge of an infant may coincide with gestational age of 35 weeks and a weight of
1,600 1,800 grams. Small for gestational age infants may be discharged at a lower weight. Large for
gestational age infants or infants with a prolonged course of chronic lung disease may require NICU care
until the infant weighs 3,000 grams or more.
NICU RNs will discharge infants only after the physician has written
discharge orders.
The infant must meet the following criteria to be discharged from NICU
to home:
Ability to maintain body temperature.
Consistent weight gain.
Ability of parents / legal guardian to care for the infant.
Parental education will be an ongoing process throughout the infants hospitalization.
Follow P & P on Patients Admission and Discharge.
6.0 ATTACHEMENTS
Nursing Assessment Sheet
Consent Form
NICU-2


POLICY NUMBER:
DPP
TITLE:
SNR-NICU-001
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
7.0 MATERIALS & EQUIPMENT

None
8.0 REFERENCES
Medical Consultants Network Inc. CD
Neonatal Nursing Handbook by Carole Kenner, Judy Wright Lott
NAME:
DATE
PREPARED BY:
Mrs. Mary Ann Peralta

Quality Nurse Coordinator (MCH-Jeddah)
2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:
Central Committee Of NPP 2010

General Directorate Of Nursing- MOH.KSA
2010
NICU-3

POLICY NUMBER:
DPP
SNR-NICU-002
TITLE:
APPLIES TO:
NURSING
Nursing Newborn Assessment
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
1 of 4
1.0 PURPOSE
To identify any newborn apparent problems that needs immediate attention.
To evaluate cardiopulmonary and neurological function.
To evaluate any obvious congenital anomalies or evidence of neonatal distress.
2.0 DEFINITION
None.
Responsible to Staff Nurse.
4.0 POLICY
Upon admission, newborn will be assessed for physical health, identification of any abnormalities
that may exist, while establishing and maintaining the health and well- being of the newborn.
A thorough systematic physical assessment is an essential component in the care of a high risk
infant.
The nurse should be aware and alert of the subtle changes and reacts promptly to implement
interventions that promote optimum functioning in the high- risk neonate.
Accurate documentation of the infant's status should be performed.
5.0 PROCEDURES
RATIONALE
5.1 Complete physical and gestational age
assessment as soon as possible after delivery.
5.2 Initial assessment should include, but is not
limited to:
Estimation of gestational age by evaluation of both
neuromuscular and physical maturity.
Determination of presence of anomalies of previously
NICU-4

POLICY NUMBER:
DPP
SNR-NICU-002
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
unsuspected disease, as well

as general status of the
infant.
5.3 Assess the infant of the following:
Skin and subcutaneous tissue
Head, neck and mouth
Chest and abdomen
Genitalia and anus
Extremities, spine and joints
Respiratory status
Breath sounds
Cardiovascular system
5.4 Evaluate neurological status:
Cry
Muscle tone
Symmetry of movement
Plantar grasp
Motor reflex
Sucking and rooting reflexes
5.5 Assess for the following:
Weight documented in grams and pounds.
Length documented in centimeters and inches.
Head circumferences in centimeters and inches.
Chest circumferences in centimeters and inches.
Abdominal girth in centimeters and inches.
5.5.6 Vital signs as well as blood
NICU-5
2 of 4

POLICY NUMBER:
DPP
SNR-NICU-002
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
pressures, if appropriate.
Oxygen saturation
ECG strip
Intravenous line in place
5.6 Document all findings and report any unusual
findings to the physician.
6.0 ATTACHEMENTS
6.1 Neonatal Assessment and Reassessment Form.
Cardiac monitor
Gloves
Measuring tape
Stethoscope
Thermometer
Oxygen and suction equipment
Newborn assessment form
Ophthalmic antibiotic ointment
Footprint ink set
Radiant warmer, isolette or other controlled-heating device.
8.0 REFERENCES
Neonatal Nursing Handbook by C. Kenner, J. W. Cott
Neonatology Management, Procedures on Call Problem, Diseases & Drugs 5th edition by T.
Gomella
NICU-6
3 of 4

POLICY NUMBER:
DPP
SNR-NICU-002
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
NAME:
4 of 4
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-7

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-003
APPLIES TO:
NURSING
Bathing an Infant Inside the Incubator
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1.0 PURPOSE
To prevent heat loss and maintain perfusion to a critically ill infant.
To prevent infection and promote hygiene to a premature infant.
2.0 DEFINITION
None.
4.0 POLICY
Infants with the following clinical conditions must be given bath inside the
incubator:
With cardiac monitoring.
With oxygen and Intravenous therapy.
Preterm infant with a weight of less than 1.800 kgs.
Post-operatively.
Intravenous sites, wound site must not be immersed or soaked in water.
It is performed by an experienced nurse.
5.0 PROCEDURES
5.1 Wash hands and prepare all equipment.
RATIONALE
5.2 Fill basin with warm water.

5.3 Check the temperature of the infant
prior to bath.
5.4 Wash eyes, ears, nose and face with
clean water and cotton balls and dry
thoroughly.
5.3 To prevent heat loss by evaporation.
5.5 Clean the body with soap & water.

Clean the skin fold, interdigital spaces
NICU-8
1 of 3

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-003
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 3
and the neck.

5.6 Dry thoroughly with towel.
5.7 Clean the umbilical cord with alcohol
70%.
5.8 Inspect for any discharge/ foul smell
from the umbilical cord.
5.9 Put on clean diaper and ensure it does
not cover the cord.
5.10 Wrap the infant with a blanket to
promote warmth.
5.11 Document the procedure and the
infants tolerance or response.
5.10 To provide extra heat when parents hold the

infant outside the incubator.
5.11 For the continuity of care.
6.0 ATTACHEMENTS
6.1 Nurses' notes
Basin or infant tub
Warm water
Mild shampoo or soap
Towel
Diaper, infant clothing
8.0 REFERENCES
Photo Guide of Nursing Skills 2004, by Smith, Duell, Martin
Lippincott Manual of Nursing Practice, 7th edition by Nettina
Neonatal Nursing Handbook by Kenner, Lott
NICU-9

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-003
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
3 of 3
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-10

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-004
APPLIES TO:
NURSING
Employee Surveillance in Neonatal Unit
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1.0 PURPOSE
To prevent transmission of infectious disease between personnel and patient.
To prevent risk of acquiring disease from highly infected patients.
To monitor the health status of the staff who's providing care to the patient.
2.0 DEFINITION
None
Responsible to Head Nurse/ Head of Department.
Y
All staff must be free from respiratory, gastrointestinal or skin infection, active herpes simplex and
herpes zoster.
All staff must be free from infectious disease such as hepatitis.
All staff must have immunization against hepatitis, meningitis, mumps, measles, and rubella and has
known immunity to chickenpox.
If epidemic or outbreaks are confirmed all personnel staff must have culture swab of
the following areas:
Throat
Nasal
Hand
Axilla
All staff must be aware that the following infectious disease of the infant can be
transmitted to personnel.
Rubella
Hepatitis B
Cytomegalovirus
NICU-11
1 of 3

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-004
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 3
All staff must have theoretical and clinical knowledge about infectious diseases and infection
control guidelines.
Any suspected or confirmed infectious disease must be reported to infection control nurses.
Pregnant staff must not work in NICU Isolation unit.
5.0 PROCEDURES
5.1 Restrict personnel from patient care who has
skin, respiratory, & gastrointestinal
infection.
5.2 Submit all staff for serology clearance.
5.3 Coordinate with the infection control and
staff clinic for the immunization of all staff
in the unit: i.e. hepatitis B vaccine,
meningitis.
5.4 Obtain multiple swabs from all staff and
personnel working in the unit once clusters
or pattern which indicates epidemic /
endemic are confirmed.
5.6 Educate the staff regarding the infectious
disease, its epidemiology, pathology, clinical
manifestation, treatment, prognosis and
prevention.
6.0
RATIONALE
5.1 To prevent cross infection to compromise infant.
5.2 Any staff found positive to any infectious disease
must not work in the unit.
5.2 Prevents cross infection.
ATTACHEMENTS
None

None
8.0 REFERENCES
8.1 Neonatal Nursing Handbook by Kenner & Lott
NICU-12

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-004
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
3 of 3
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-13

POLICY NUMBER:
DPP
SNR-NICU-005
TITLE:
APPLIES TO:
NURSING
Eye Treatment of the Newborn
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 2
1.0 PURPOSE
To provide prophylaxis in the treatment of infection to the eye as in opthalmia neonatorum.
To prevent further infection.
2.0 DEFINITION
None
4.0 POLICY
All newborn infants will receive prophylaxis against opthalmia neonatorum, unless
treatment is refused by infant's parents.
The procedure is performed by a registered experience nurse in the neonatal unit.
The hands should be washed thoroughly prior to the procedure.
6.0 PROCEDURES
5.1 Place the infants in a supine position and
support the head with one hand.
RATIONALE
5.2 Gently pull down the lower eyelid and apply

a row of ointment without touching the eyelid
with the tube.
5.3 Close the eyelid gently and allow the
ointment to coat the eye
5.3 To prevent spill of the medication.
5.4 Wipe off the excess ointment with a cotton

ball.
5.4 To prevent contamination to the contralateral eye.
5.5 Repeat the procedure with the other eye.

5.6 Observe for the following:
6.6.1Redness
6.6.2 Swelling
5.6 Report any findings to the pediatrician.
NICU-14

POLICY NUMBER:
DPP
SNR-NICU-005
TITLE:
APPLIES TO:
NURSING
Eye Treatment of the Newborn
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
6.6.3 Discharge
5.7 Use a new tube of ointment for each infant.
5.8 Label the tube with date and time of opening.
6.0
ATTACHEMENTS
None

Ophthalmic ointment or drops as ordered.
Cotton balls.
8.0 REFERENCES
Lippincott Manual of Nursing Practice, 7th editon by Nettina
Neonatal Nursing Handbook by Kenner, Lott.
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-15

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-006
APPLIES TO:
NURSING
Feeding the Newborn (Mothers Breast or Formula)
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1.0 DEFINITION
None
2.0 PURPOSE
To provide nourishment for the baby.
To prevent dehydration.
To assist the mother in feeding her baby.
4.0 POLICY
Infants will be fed in a timely and careful manner in accordance with the physician's order.
Infants with respiration over 60 per minute shall not be nipple fed.
None
6.0 PROCEDURES
Bottle Feeding
RATIONALE
Confirm the identity of the mother and the baby

by checking mother's ID with 3 names,
nationality, medical record number with the
baby's ID band.
Check the milk brought by the mother and the
amount.
Have the mother sit comfortably on a chair; place
the baby in the mother's arm. Assist the mother to
start feeding. Instruct when to burp and what to
do if the baby gags or chokes. Observes first
feeding.
Record the feeding and response to
NICU-16
1 of 3

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-006
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
feeding on the infant's chart as well as the

amount, if any, or regurgitation.
Feeding Baby in Nursery
Check the physician's order for the appropriate
formula to be given to the infant and obtain that
formula.
Prepare the infant for feeding by changing
diaper and wrap with blanket.
Sit in a chair holding the infant, then place the
nipple in the baby's mouth and start feeding.
Observe for sucking reflex.
Feed the baby until he/ she refuses and appears
contented. Do not overfeed and underfeed the
infant.
Burp the infant by placing a hand under the
infant's chin while in a sitting position tilting the
head forward and patting or rubbing the infants
back.
6.3 Breast feeding :
6.3.1 Confirm the identity of the mother and
the baby by checking mother's ID with
3 names, nationality, medical record number
with the baby's ID band.
Have the mother sit on a chair; place the baby
in the mother's arms.
Demonstrate cradle hold, football hold or side
lying position.
Assist the mother by placing the baby at
the breast and see that the baby is
latched on well and sucking before leaving
the bedside.
Instruct the mother to let the baby suck 10-15
minutes on each breast. Nursing
NICU-17
2 of 3

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-006
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
mothers should feed their infant's every 1

1/2 3 hours, even during the night.
6.3.6 Document the amount and tolerance to
feeding.
7.0
ATTACHEMENTS
None
8.0 REFERENCES
Neonatatology Management, Procedures on Call Problem, Diseases, and Drugs.
Neonatal Handbook by Kenner and Lott.
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-18

POLICY NUMBER:
DPP
SNR-NICU-007
APPLIES TO:
NURSING
Incubator Care of Infants
TITLE:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
To provide nourishment for the baby.
To prevent dehydration.
To assist the mother in feeding her baby.
2.0 DEFINITION
It is a method of providing reasonable warmth to maintain a neutral thermal environment for the
newborn, the ill and low birth weight infants.
ICY
Infants requiring heat-regulatory device are:
Preterm infants.
Low birth weight infants.
Post-operative infants.
Infants with oxygen therapy and parenteral nutrition.
Transport for high risk infants.
Birth asphyxia.
Incubators must be moved away from cold sources such as windows, air conditioning
outlet to prevent heat loss by radiation.
Newborn weighing 500 - 800 grams, range shall have the starting environmental
temperature setting of 36.5 degrees C. The neutral thermal environment for
newborn is 32.5 + 1.4 degrees C for large babies and 35.4 + 0.5 for smaller babies.
Continuous cardio-respiratory monitoring should be maintained.
All clean incubators must be pre-heated ready for use at anytime.
Temperature adjustment is according to the age and weight of the infant.
NICU-19

POLICY NUMBER:
DPP
SNR-NICU-007
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 3
5.0 PROCEDURES
RATIONALE
5.1 Wash hands and wear gloves before
receiving the infant.
5.2 Place the infant in a pre-heated incubator.
5.3
Dry the infant immediately
5.4
Check the temperature by rectum.
Regulate the
incubator
temperature according to the age and
5.6 Check temperature every two hourly for
newly admitted infant until stable.
5.7 Observe for thermal instability, apnea,
bradycardia, and respiratory distress.
5.8 Check the infant's temperature and wrap
with blanket.
5.3 To prevent heat loss by evaporation.
5.5
5.9 Check the infants behavioral changes that

reflect cold stress.
Poor sucking
Increased / decreased activity
Irritability
Lethargy
Hypotonic
Weak or inability to cry
5.10 Check serum bilirubin level.
5.8 To provide extra heat when parents

hold the infant outside the incubator.
5.10 Hypothermia can lead to increased

bilirubin level.
5.11 Inform the physician for any changes

noted in the infant.
5.12 Document the assessment of the infant prior 5.12 Serves as legal document and basis for
placement in the incubator and reassessment
the continuity of care.
after.
NICU-20

POLICY NUMBER:
DPP
6.0
TITLE:
SNR-NICU-007
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
ATTACHEMENTS
None

Incubator
Oxygen
Thermometer
Cardiac Monitor
Weighing scale
8.0 REFERENCES
Neonatal Nursing Handbook, by Carole Kenner and Judy Wright Lott.
Neonatology Management, Procedures on Call Problem, Diseases and Drugs 5th Edition
by Tricia Lacy Gomella.
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-21

POLICY NUMBER:
DPP
SNR-NICU-008
TITLE:
APPLIES TO:
NURSING
Weighing an Infant
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 2
1.0 PURPOSE
1.1 To have a baseline and basis for the dosage of treatment for the newborn.
2.0 DEFINITION
None
4.0 POLICY
4.1 Infant should be weighed as baseline, and body weight often provides a clue to dosage of
treatment to any disorders in the neonatal period.
5.0 PROCEDURES
RATIONALE
5.1 Perform hand hygiene.
5.2 Confirm the identity of the infant with the
identification band with 3 names, nationality,
sex and medical record number.
5.3 Removed the pampers before obtaining the
weight of the infant.
5.4 Document in grams and pounds.
5.5 Obtain daily weight at the same time each
day and using the same scale.
5.6 The scale pan should be clean and
completely covered for each infant.
5.7 Avoid chilling the infant during weighing.
5.8 Calibration of all scales should be
monitored and adjusted on a regular basis.
5.9 Monitor for changes on weight
reassessments. If the change is greater than 50
grams variance ask another Nurse recheck the
weight.
5.10 Notify the physician for 10% loss of birth
NICU-22

POLICY NUMBER:
DPP
SNR-NICU-008
TITLE:
APPLIES TO:
NURSING
Weighing an Infant
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
weight or weight change of 50 grams or more.

5.11 Record the weight and assessment taken.
6.0 ATTACHEMENTS
Physical assessment form
Vital signs sheet
7.1 Weighing Scale
8.0 REFERENCES
Lippincott Manual in Nursing Practice 7th Edition by Nettina.
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-23

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-009
APPLIES TO:
NURSING
Cord Care and Skin Care of a Newborn
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
1.1 To reduce the incidence of peri-umbilical and skin infection.
2.0 DEFINITION
Skin is the largest organ of the body consisting of three layers, epidermis, dermis
and subcutaneous tissues. The skin of premature infants is thin and delicate
and tense to be deep red in extremely premature infant. It also appears almost
gelatinous, and bleeds and bruises easily. Postmature infant may have a peeling
patchment - like skin. Term skin is soft - wrinkled covered with vernix caseosa
and function similarly like that of adults.
4.0 POLICY
The nurse must have knowledge of the proper care and methods of preventing skin
damage.
Thorough hand washing should be done before handling an infant.
Cord care should be done with alcohol 70% daily, or as needed.
Baby powder is contraindicated because of its potential of pulmonary
contaminant.
Nursery personnel should use chlorhexidine or antiseptic soap for routine hand
washing before caring for an infant.
5.0 PROCEDURES
5.1 Wash hands before receiving the infant.
5.2 Receive the infant immediately under
radiant heat source.
5.3 Establish temperature within normal range.
with lancet.
5.4 Clean the infant upon admission with sterile
cotton or gauze soaked in warm water or
RATIONALE
RATIONALE
5.1 To reduce the spread of microorganisms.
5.2 Placing the infant in an incubator provides heat.
5.4 To provide comfort and maintain temperature.
NICU-24

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-009
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 3
mild soap solution.).

5.5 In some instances, the infant is cleansed with 5.5 Premature infants are usually hypo-thermic and
oil to remove excessive blood or meconium.
cannot tolerate bathing.
5.6 Dress the cord with alcohol 70% daily.
Follow the methods of preventing skin
damage:
To stop bleeding.
Use sterile gauze with pressure over punctured
wound.
Their skin are very fragile.
Avoid perfumed lotion.
Use hypoallergenic tape for
premature babies.
Report to physician for any presence of
skin damage.
5.7.5 Exposing to air helps heal the skin.
Clean excoriated buttocks with
water and expose.
Turn the baby every 2-4 hours.
Change cardiac electrodes only
when necessary.
5.8 Document assessment and observation of the
skin and cord every shift.
6.0
ATTACHEMENTS
6.1 None

Gloves
Antiseptic Solution
Sterile Cotton or Gauze
Alcohol swab or Alcohol 70%
8.0 REFERENCES
Lippincott Manual in Nursing Practice 7th Edition by Nettina.
NICU-25

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-009
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
3 of 3
DATE
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Naaddaa Harun

2010
APPROVED BY:
Central CCommittee Of NPP 2010

2010
NICU-26

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-010
APPLIES TO:
NURSING
Transfer of Infant to Other Facility
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
1 of 4
1.0 PURPOSE
To ensure continuity of care for high risk infant.
To provide accurate and concise information to the receiving center.
2.0 DEFINITION
None
Responsible to Head nurse / Head of Neonatal Intensive Care Unit
ICY
All infants for transfer must have a written physician's order.
Parental consent must be secured prior to referral / transfer.
It is the responsibility of the Neonatologist to explain to the parents about the infant's status that needs
further intervention and specialized care.
If an infant will be transferred to other hospital, per referral by the physician in-charge, the nurse shall
confirm that:
The physician responsible to the patient has notified the receiving doctor.
Consultation referral was sent by fax and with acceptance by the receiving hospital.
Name of receiving physician with his bleep number or telephone number is written in the referral.
Medical report of patient including copies of laboratory investigations, Ultrasound / X-ray reports, MRI /
CAT scan reports, including slides to confirm the diagnosis of the patient.
Hospital Coordinator on duty will be notified to arrange ambulance diver.
The transferring nurse shall confirm the availability of emergency resuscitation equipment, medications
and oxygen needed by the patient during transport (Emergency bag for the
NICU-27

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-010
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
2 of 4
ambulance is available in Emergency Room).

A vigilant monitoring must be done during transport for the unexpected changes on infants status.
Stabilization of the infant must be done prior to transport, intubated if needed.
Should a medical emergency require transfer, the medical director or his deputy is empowered to organize
and complete an emergency transfer.
If an infant will transfer to private hospital as requested by the parents or family, availability of bed and
receiving doctor should be arranged by the family.
Clearance from the discharge office must be obtained by the family before transferring the patient.
All infants for transfer shall be accompanied by a physician and an experienced nurse.
5.0 PROCEDURES
5.1 Confirm the transfer order and consultation
referral with acceptance from the receiving
hospital to facilitate fast and easy transfer.
5.2 Confirm that the attending doctor explain
the reason for transfer to parents.
5.3 Transfer the infant with an ambulance
accompanied by a physician and an experienced
nurse.
5.4 Ensure portable ventilators/incubator is
working properly and Oxygen is available.
5.5 Prepare all necessary documents and
keep copies in the file.
Stabilize the infant prior to transfer:
Vital signs
Tubes, catheters must be properly secured.
Check Intravenous access and patency.
RATIONALE
NICU-28

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-010
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
Documentation:
Chart time, mode of transfer, location and reason
for transfer.
Chart observation and the patient's condition at the
time of transfer.
Document latest vital signs of the patient.
5.8 Confirm the correct patient and give complete
endorsement and report of the infant to the
receiving nurse including needed documents,
present treatment and medications.
6.0 ATTACHEMENTS
Medical report
Consultation referral
Transport ventilator / incubator
Emergency bag
Oxygen cylinder
Suction machine
Ambubag with mask
Laryngoscope with blade
Cardiac monitor.
8.0 REFERENCES
Neonatal Nursing Handbook by Carole Kenner, Judy Wright Cott
Lippincott Manual in Nursing Practice 7th Edition by Nettina
NICU-29
3 of 4

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-010
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGE:
NAME:
4 of 4
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-30

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-011
APPLIES TO:
NURSING
Visitors Control in Neonatal Unit
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1.0 PURPOSE
To prevent unnecessary exposure to infectious diseases.
To avoid overcrowding in the unit.
To prevent possible cross-infection.
2.0 DEFINITION
None
Responsible to Head Nurse/ Head of NICU Department.
4.0 POLICY
Visitors must be limited to immediate family or guardian to control access.
People entering the unit must be limited only to personnel of the unit.
Visitors must come only during visiting time.
5.0 PROCEDURES
5.1 Explain carefully to the infant's family the
importance of limiting visitors inside the
unit.
5.2 Teach the family proper hand washing
and wearing of gown.
5.3 Observe visiting hours. Inform security
guard for overstaying visitors.
5.4 Visitors coming after visiting time should get
approval from the hospital supervisor on duty
and should be accompanied by the security
guard.
5.5 Confirm the exact and correct address and
telephone number in the infant's file.
5.6 Inform the nursing supervisor on duty
for any event that occurred with the
visitors.
RATIONALE
5.1 To lessen apprehension.
5.2 To prevent transmission of
microorganisms.
5.3 To ensure compliance to hospital
policy.
5.5 To confirm the identity of the

visitors coming to see the infant.
NICU-31
1 of 2

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-011
APPLIES TO:
NURSING
Visitors Control in Neonatal Unit
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
6.0 ATTACHEMENTS
Vital signs sheet
Nurse's notes
Gown
Visitor's identification badge
8.0 REFERENCES
8.1 Medical Consultants Network Incorporated CD
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-32

POLICY NUMBER:
DPP
SNR-NICU-012
TITLE:
APPLIES TO:
NURSING
Abdominal Girth Measurement
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 2
1.0 PURPOSE
1.1 To detect significant changes in the patient's medical condition thus resulting in early
intervention.
2.0 DEFINITION
Abdominal girth measurement is a procedure to measure the abdominal circumference to
assess abdominal distention.
4.0 POLICY
Baseline measurement of abdomen should be taken to all patients observed to have abdominal distention.
Abdominal girth should be measured just above the umbilicus.
Initial site of measurement should be marked as a guide to succeeding measurement
5.0 PROCEDURES
5.1 Gather equipment and bring to bedside.
5.2 Identify patient by Identification band, by
asking her name and check the medical
record.
5.3 Explain procedure to the patient.
RATIONALE
5.1 To facilitate an organize procedure.
5.2 To ensure the identity of the patient to be
examined.
5.3 Knowledge of the procedure lessens anxiety and
promotes cooperation.
5.4 To ensure privacy.
5.5 To prevent spread of microorganism.
5.4 Screen patient, expose area to be measured.

5.5 Wash hands.
5.6 Place measuring tape under the patient's back
bringing tape around to lie directly just
above the umbilicus.
5.7 Mark skin on both sides of the measuring 5.7 To ensure consistency for succeeding
tape and instruct the patient not to remove
measurements.
the marks.
NICU-33

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-012
APPLIES TO:
NURSING
Abdominal Girth Measurement
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
5.8 Report to physician any significant changes.

5.8 To provide prompt intervention.
5.9 Document and record the date and time of 5.9 Serial measurement should be taken to
determine measuring
the
abdominal girth; the
daily
changes in girth.
measurement.
6.0
ATTACHEMENTS
6.1 Nurses notes
7.0
MATERIALS & EQUIPMENT
Patients' ID band.
Measuring Tape.
8.0 REFERENCES
Lippincott Manual of Nursing Practice, 7th Edition by Nettina
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-34

POLICY NUMBER:
DPP
SNR-NICU-013
TITLE:
APPLIES TO:
NURSING
Arterial Blood Gas Analysis
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 5
1.0 PURPOSE
To evaluate the efficiency of pulmonary gas exchange.
To assess the acid base status of the body whether alkalosis or acidosis, respiratory or metabolic in
origin and to what degree, compensated or uncompensated.
To provide important diagnostic information on:
Adequacy of gas exchange in the lungs.
Integrity of the ventilatory control system.
Blood pH and acid-base balance.
2.0 DEFINITION
Arterial blood gas analysis evaluates gas exchange in the lungs by measuring the Pa02 (partial
pressure of Oxygen) and the pH (Hydrogen ion concentration) of an arterial blood.
4.0 POLICY
A written physician's order is required.
The procedure must be explained to the patient or relative for small child.
The arterial blood gas sampling must be done by a physician, respiratory therapist or
competent nurse under aseptic technique.
Ensure the arterial blood gases (ABG) machine is functioning correctly before
obtaining sample.
Syringe used must always be flushed with heparin.
After extracting samples, air bubbles must be removed and specimen must be
placed in an iced container when transporting to laboratory.
Patient must be closely observed during and after the procedure to prevent any
complications that may arise.
NICU-35

POLICY NUMBER:
DPP
SNR-NICU-013
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 5
5.0 PROCEDURES
RATIONALE
5.1 Explain procedure to patient or to parents 5.1 To ease anxiety and encourage cooperation.
for small children
patient's
inspired
oxygen 5.2 Changes in inspired oxygen
5.2
Record
concentration
concentration alter the change in Pa02.
Degree of hypoxemia cannot be assessed
without knowing the inspired oxygen
concentration.
5.3 Take patient's temperature
5.3 Hyperthermia and hypothermia influence oxygen
release from hemoglobin.
5.4 Heparinized the 2 ml. or 1 ml. syringe if
5.4 To cast the interior of the syringe with heparin to
commercial blood gas kit is not available
prevent blood from clotting.
5.5 Expel excess heparin and air bubbles from
5.5 Air in the syringe may affect measurement of the
the syringe.
pH.
5.6 Wash hands thoroughly and wear gloves.
5.6 Prevents spread of infection. Gloving ensure
sterility as well as protection from exposure to blood
and body fluid.
5.7 Palpate the radial, brachial or femoral artery. 5.7 Arterial puncture is performed on areas where a
Radial artery is the preferred site of puncture for good pulse is palpable. Femoral artery should never be
ABG.
the puncture site of the nurses.
5.8 Prepare chosen site with germicide.
5.8 To ensure sterility thus preventing infection.
5.9 Once the artery is punctured arterial pressure 5.9 The arterial pressure will cause the syringe
will push up the hub of the syringe and
to be filled within few seconds.
pulsating blood flow will fill the syringe.
5.10 After blood is obtained, withdraw needle 5.10 Significant bleeding can occur because of
and apply firm pressure over the
pressure in the artery.
punctured site with a dry sponge.
5.11 Remove air bubbles from syringe and
5.11 Immediate capping of the needles
needle. Insert needle into rubber stopper.
prevents room air from mixing with
blood specimen.
5.12 Notify housekeeping department to clean
5.12 Icing the syringe will prevent a clinically
cot and room.
significant loss of 0xygen
5.13 In patient's requiring serial monitoring of
5.13 All connections must be tight to
NICU-36

POLICY NUMBER:
DPP
SNR-NICU-013
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
arterial blood an arterial catheter (connected

to a flush solution of heparinized saline) is
inserted into the radial or femoral artery.
5.14 Blood gas analysis should be done
immediately once sample is extracted.
5.15 Inspect the puncture site, and assess cold
hand, numbness, tingling or discoloration.
5.16 Change ventilation setting of the respiratory
therapy equipment indicated by the results and
as ordered by the doctor.
5.17 Record the time of sampling, the site of
puncture, the length of time pressure was applied
to control bleeding and the type and amount of
oxygen therapy the patient was receiving.
NORMAL RANGES: ARTERIAL BLOOD
3 of 5
avoid disconnection and rapid blood

loss. The arterial line allow for direct
blood pressure monitoring in the
critically ill patient.
5.14 `Pa02 and pH can change rapidly.
5.15
Hematoma and arterial thrombosis are

complication following this procedure
5.16
The Pa02 results will determine whether to
maintain, increase or decrease the F102. The
PaC02 and pH results will detect if any changes
are needed in the tidal volume and rate of patient's
ventilator.
5.17
Documentation serves as a means of
communication of the healthcare team for the
continuity of treatment.
1. pH
7.35 7.45
2. PCO2
35 45
3. PO2
80 100
4. HCO3
22 27 Meg/ L
5. Base Excess
+2
6. Hemoglobin content
12 15 gm%
7. Oxyhemoglobin saturation
> 95 %
VENOUS BLOOD
1. pH
7.35
2. PCO2
46 mm Hg
NICU-37

POLICY NUMBER:
DPP
SNR-NICU-013
TITLE:
APPLIES TO:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
PO2
40 mm Hg
HCO3
20 m Eq/L
CLINICAL RANGE: ARTERIAL BLOOD

pH
7.30 7.50
PCO2
30 50 mm Hg
The ranges for arterial blood values given above indicate the normal
variation in arterial pH and PCO2. Slight variations outside these normal
ranges may not indicate a clinically changes.
The clinical ranges above indicate an acceptable pH and PCO2 from a patient
management point of view. Results outside these ranges indicate situations
requiring clinical intervention.
FOR NEWBORN:
6.0
NURSING
pH
7.32 7.4
PCO2
33 40 mmHg
PO 2
60 80 mmHg
ATTACHEMENTS
6.1 Printed ABG Report.

Commercially available blood gas kit or:
2 or 3 ml syringe
23 or 25 gauge needle
1 ml syringe with gauge 25 or 24 needle (for children)
0.5 ml. of sodium heparin (1:1000) to heparanize the syringe
Stopper no cap
Lidocaine 1% (optional)
Sterile germicide (Povidone, isopropyl alcohol 70%)
NICU-38
4 of 5

POLICY NUMBER:
DPP
SNR-NICU-013
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5 of 5
Cup, plastic bag or kidney basin with crushed ice

Gloves
8.0 REFERENCES
Maternity & Children Hospital Al Musaedeiya Jeddah Policy and Procedure Manual.
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-39

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-014
APPLIES TO:
NURSING
Weaning of patient from Mechanical Ventilator
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
To provide patent airway.
To provide route for short term mechanical ventilation.
To facilitate removal of pulmonary secretions.
To relieve Carbon dioxide retention in clients with chronic pulmonary disease.
To treat acute respiratory failure.
2.0 DEFINITION
Endotracheal intubation is an insertion of flexible tube through the mouth or nose into the trachea
beyond the vocal cords that acts as an artificial airway.
4.0 POLICY
Qualified nursing personnel can assist during endotracheal intubation.
A physician written order is required.
Sterile technique must be observed throughout the procedure.
5.0 PROCEDURES
5.1 Wash hands
5.2 Explain the procedure and rationale to the
patient and parents.
5.3 Assemble all equipment. Ensure function
of resuscitation bag, with mask and suction
equipment.
5.4 Assess the patient's heart rate, level of
consciousness and respiratory status.
5.5 Assemble laryngoscope. Make sure the
light bulb is tightly attached and functional.
5.6 Check tracheal cuff for leaking by inflating
RATIONALE
5.1 Maintains standard precaution.
5.2 To reduce anxiety and promote cooperation.
5.3 Patient may require ventilatory assistance during
the procedure.
5.4 Provides a baseline to estimate patient tolerance of
procedure.
5.6 Malfunction of the cuff must be ascertained before
NICU-40

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-014
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
cuff.
5.7 Lubricate tube.
5.8 Place patient in supine position with head
and neck hyper-extended and a pillow
under the shoulder.
5.9 Offer anesthetic spray, if time allows.
5.10 Oxygenate and ventilate patient before
each intubation. Re-oxygenate if attempt fails.
5.11 Put mark on the tube at level of patient's
mouth and tape securely.
5.12 Inflate cuff with 5 10 cc of air after
intubation is completed.
5.13 Insert oral airway when tube is positioned
orally.
5.14 Assess for expansion of both sides of the
chest and presence of breath sounds.
2 of 3
tube placement.
5.7 Aids in insertion.
5.8 Proper positioning will facilitate intubation and
prevent complication such as necrosis of nasal septum.
5.9 This will decrease gagging.
5.10 Pre-oxygenation decreases the likelihood of
cardiac dysrhythmias or respiratory distress.
5.11 Secured taping prevents tube from slipping.
5.12 This will occlude the trachea.
5.13 This keeps patient from biting down the tube and
obstructing the airway.
5.14 Observation and auscultation help in
determining correct placement of tube
and that it has not slipped into the right
bronchus. Air entry should be equal.
5.15 Record distance from proximal end of tube 5.15 To detect any change in tube position later.
to the point where the tube reaches the right
place.
5.16 Secure tube to the patients face with tape
5.16 To fix the tube and prevent dislodgment of
or ETT stabilization device.
inflated cuff.
5.17 Assist in chest x-ray as ordered.
5.17 To verify tube placement.
5.18 Measure with manometer. Make 5.18 The tube maybe removed or advanced
adjustment in tube placement on the basis of
several centimeters for proper placement
chest X-ray results.
according to chest X-ray results.
5.19 Assess Arterial Blood Gases (ABG) if
5.19 ABG ensure adequacy of ventilation and
ordered.
oxygenation.
5.20 Document tube size and type, cuff 5.20 To maintain legal record and serves as a
pressure, and patient tolerance of the procedure.
communication tool to other health team
members.
NICU-41

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-014
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
6.0 ATTACHEMENTS
Doctor's order sheet
Nurse's notes
Vital signs sheet
7.7 Suction catheter
Laryngoscope with blade and light source.

Endotracheal tube with two pressure cuff and
adapter to connect tube to ventilator or
resuscitation bag.
Disposable syringe (5-10cc) for cuff inflation
Water- soluble lubricant
Plaster, Sterile gloves
McGill forceps
7.8 Suction machine

7.9 Stylet
Ventilator
Ambu bag and mask
Stethoscope
8.0 REFERENCES
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-42

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-015
APPLIES TO:
NURSING
Chest Tube Insertion, Assisting & Maintaining
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 6
1.0 PURPOSE
To re-establish negative intra pleural pressure necessary for lung re-expansion when a
pneumothorax has developed.
To provide drainage of a pleural effusion or to obtain fluid for diagnosis.
2.0 DEFINITION
Chest tube insertion - method of inserting tube in the pleural space to facilitate evacuation of air or
fluid from the pleural cavity.
4.0 POLICY
Insertion of the chest tube should be performed by the physician under aseptic
technique, assisted by a qualified nurse.
Chest tube should be monitored for air leak and pleurovac water chamber
will be monitored for fluctuation every hour.
Rubber-tipped clamps or Kelly clamp should be ready at bedside.
5.0 PROCEDURES
RATIONALE
5.1 Explain procedure to patients and parents of
5.1 Knowledge and understanding of the procedure
infants.
alleviates anxiety.
5.2 Secure consent from patients or parents.
5.2 For legal purposes.
5.3 Wash hands thoroughly.
5.3 To prevent spread of infection.
5.4 Position the child with head of bed elevated. 5.4 Restraining the child ensures stabilization during
Secure limbs with soft restrain if necessary.
the procedure.
5.5 Monitor vital signs closely. Note any
5.5 To provide a basis on which to compass the
change in skin color. Connect to cardiopatient's vital signs and evaluate status after the
respiratory monitor and oxygen source.
procedure.
5.6 Set up under-water-seal-bottle following Prepares equipment to ensure readiness of the
direction on package.
procedure.
5.6.1 Open saline or water container. Unwrap
Establishes proper amount of water-seal
NICU-43

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-015
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
drainage system. Fill chambers to appropriate

level:
Place funnel in tubing or port leading to
suction control chamber.
Pour fluid into suction control port until
designated amount is reached per doctors
orders, or to specific line marked on bottle,
usually indicating the 20-cm water pressure
level.
Fill water-seal chamber of drainage
system to the 2-cm level.
5.7 Put on sterile cap, mask and gown and
sterile gloves for both the doctor and the
nurse.
5.8 Open sterile equipment and place on
sterile surface.
The following procedure should be done by the
physician.
Select the site of insertion.
APPLIES TO:
2 of 6
pressure.
5.6.2 Prevents spillage of water.
5.7 To ensure sterility of the procedure.

5.8 To maintain sterility and prevent contamination.
5.9 Prevents air from being sucked into the
vein by the increasing intrathoracic
pressure.
5.9.1 The site of chest tube insertion should be
determined by chest x-ray films. Air collects in the
uppermost areas of the chest and fluid in the most
dependent area.
Infiltrate the area with 0.5- 1% lidocaine. Make a small

incision in the skin over rib just below the
intercostal space where the tube is inserted.
Using the tip of the hemostat, puncture the
pleura just below the rib and spread gently.
Intercostal nerves, arteries and veins lie below the ribs.
This maneuver helps create a subcutaneous tunnel that
aids in closing the tract when the tube is removed.
Insert the chest tube through the opened hemostat.
Be certain that the sites of the tube are within the pleural
cavity.
5.10 Following insertion of chest tube, attach to
5.10 The water-seal vacuum drainage
a water-seal vacuum drainage system. Five to ten
system prevents air from being drawn
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cm. of suction pressure is usually used.

Secure the tube with silk tape or sutures done by the
physician.
Don gloves and connects drainage system to chest tube
& suction source, if suction is indicated,
maintaining sterility of connector ends.
f changing drainage system, ask patient to take a deep
breath, hold it, and bear down slightly while
tubing is being changed quickly.
5.12 Adjust suction flow regulator until quiet

bubbling is noted in suction control chamber.
5.13 Call for chest x-ray as ordered by the
physician.
5.14 Monitor vital signs every hour or as per
physician's order, observing for signs of
dyspnea, restlessness, irritability and fever.
5.15 Do not elevate drainage set above level of
chest.
5.16 Discard gloves and disposable materials.
5.17 Position patient for comfort, with call
button within reach.
Maintaining a Chest Tube:
5.18 Observe water-seal chamber for
bubbling.
Suspect an air leak if bubbling is present and
patient has no known pneumothorax. Also
suspect an air leak if bubbling is noted and
chest tube is clamped or if bubbling is excessive.
3 of 6
back into the pleural space.

5.10
To maintain tube in proper position and
prevent manipulation.
5.11.2 Prevents air influx into chest

while water seal is broken
5.12 Regulates flow of suction, not
pressure; vigorous flow is unnecessary
unless large air leak is present.
5.13 To verify placement and check for
residual fluid on pnuemothorax.
Positioning of the tube must always be
verified by a chest x-ray film.
5.14 To evaluate patient's response
to the procedure
5.15 To prevent drained fluid from flowing
back into pleural cavity.
5.17 Promotes comfort and safety.
5.18 Bubbling indicates air entering system
(from patient or air leak); determines if
air is entering system through loose
tube connections.
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Check tube connections.

Every 1 to 2 hours (depending on amount of drainage
or orders):
Mark drainage in collection chamber.
4 of 6
Detects hemorrhage or increased or decreased

drainage.
Indicates that suction is intact.
Monitor drainage system for bubbling in suction

control chamber.
Indicates patent tubing (may not
Check for fluctuation in water-seal
fluctuate if lung reexpanded).
chamber with respirations.
5.20 If the drainage slows or stops, gently milk 5.20 "Milking" prevents the tubing from
the tubing in the direction of the drainage
becoming obstructed from clots and
chamber as needed.
fibrin. Maintaining patency of the tube
facilitates prompt expansion of the
lung and minimizes complication.
Every 2 hours:
Facilitates prompt detection of problem and early
intervention.
Monitor chest tube dressing for adequacy of tape seal
and
Determines air leak, hemorrhage, or tube
amount & type of soiling.
obstruction & leakage at tube insertion
Assess breath sounds.
site.
Indicates progress toward lung reinflation.
Monitor vital signs and temperature every

Facilitates prompt detection of complications
2 to 4 hours. Use the following trouble- such as hemorrhage, tension
shooting tips in maintaining chest tube
pneumothorax / hemothorax and
drainage.
infection.
if drainage system is turned over & water seal
Prevents
is additional air reflux & determines
disrupted, reestablish water seal & assess patient. presence of pneumothorax.
if drainage decreases suddenly, assess for tube
Determines if drainage has been
obstruction (i.e., clots or kinks), & milk tubing.
blocked & reestablishes tube
Check that gravity drainage systems & suction
patency.
systems are below of patients chest.
Ensures proper gravitational pull & negative water
Watch for Tension Pneumothorax &
seal.
Indicates air or blood is entering chest cavity,
increasing pressure on structures in chest cavity.
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Hemothorax
If drainage increases suddenly or becomes bright
red, take vital signs, observe respiratory status, & Retains original seal around chest tube.
notify doctor.
Prevents air from entering chest; establishes
If a dressing becomes saturated, reinforce with
temporary water seal.
gauze & tape securely.
If drainage system becomes broken, clamp tube
with Kelly clamp or hemostat & replace system
immediately or place end of tube in sterile bottle
of saline solution, place bottle below level of
chest, & replace drainage system immediately.
NOTE: Clamp chest tubes for no more than

a few minutes (such as during system
change).
Documentation:
Air can enter pleural cavity with inspiration; if it

cannot escape, it will cause Tension Pneumothorax.
5.23 To provide a comprehensive view of
the procedure and to evaluate the
effectiveness to patient's condition.
ystem function (type & amount of drainage).

Time suction was initiated or system
changed.
atient status (respiratory rate, breath sounds, pulse
oximetry, pulse, blood pressure, skin color,
temperature & mental status).
Chest dressing status & care done.
Drainage characteristics & care done.
Date & time Chest tube inserted
Name of doctor performing chest tube
insertion.
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ATTACHEMENTS
6.1 Consent Form

Pre-packed chest tube tray typically consists of:
7.1 Sterile towels
7.2 4 x 4 gauze pad
7.3 3-0 silk sutures
7.4 Curved hemostats
7.5A no.15 or 11 scalpel
7.6 Scissors
7.7 25-gauge needle and 3 ml syringe
7.8 Needle holder
7.9 Antiseptic solution
7.10 Antibiotic ointment
7.11 1% lidocaine
7.12 Chest tube 8F-12F catheter
7.13 Sterile gloves
7.14. Mask, cap and gown
7.15. Suction-drainage system
7.16. Adhesive tape
7.17. Under-water-seal bottles
7.18. Resuscitation equipments
7.19. Oxygen source
8.0 REFERENCES
Nurses Guide to Clinical Procedure, 5th edition by Temple & Johnson
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-48

POLICY NUMBER:
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Surfactant Administration, Assisting
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1 of 4
1.0 PURPOSE
To prevent colonization of infectious microorganisms.
To provide maximum safety to the patient using the ventilator tubing. 1.3To set
standard method of sterilization.
2.0 DEFINITION
Surfactant is a surface active agent. It is a mixture of phospholipids that
is secreted into the pulmonary alveoli and reduces the surface tension of
pulmonary fluids, thus contributing to elastic properties of pulmonary
tissues. It is administered via endotracheal tube into the infants trachea
as treatment of Respiratory Distress Syndrome (RDS) or Hyaline Membrane Disease (HMD).
4.0 POLICY
Surfactant therapy must be administered with written order of the physician.
The nurse should assist the physician during administration of surfactant.
Infant should be closely monitored throughout the procedure.
Strict aseptic technique should be observed during surfactant administration.
The nurse should be aware of the possible complications of the procedure.
Intubation's equipment and oxygen source must be ready for use.
Working condition of suctioning equipment must be ensured.
Crash cart must be ready in case cardiopulmonary resuscitation is needed.
5.0 PROCEDURES
5.1 Wash hands before handling the infant.
5.2 Admit patient without delay.
RATIONALE
5.1 Reduces transfer of microorganisms.
5.2 To initiate emergency measures according
to patients condition.
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5.3 Place infant in a radiant warmer and

regulate temperature control accordingly.
5.3 To maintain normal body temperature

and prevent hypothermia
5.4 Attach cardiac monitor, check and record

vital signs including blood pressure and
weight.
5.5 Assist the physician in Intravenous canula
insertion and administer Intravenous fluids
as ordered.
5.4 To provide a baseline assessment.
5.6 Attach the infant to pulse oximeter.
5.6 To provide continuous or intermittent non

invasive method of determining oxygen
saturation.
5.7 Ventilate the infant if hypoxia and
respiratory distress is severe.
5.7 Assess for increase respiratory distress and

assist the physician in endotracheal
intubation. Connect to mechanical ventilator
and adjust setting as ordered.
5.8 Monitor Arterial Blood Gases
5.9 Assist in chest x-ray procedure
5.10 Wear gloves
5.11 Assist the physician in the administration
of Survanta intratracheally using a 5
inch end- hole catheter (shortened
according to length of endotracheal tube
(ETT) attached to a syringe pre-filled
with the medicine.
5.12 In premature infants less than 1250 grams
birth weight, preferably within 15
minutes after birth.
5.13 To treat infants with Respiratory Distress
Syndrome confirmed by X-ray and
requiring mechanical ventilation. Survanta
5.5 To maintain hydration, prevent

hypoglycemia and provides access for
medication.
5.8 To determine oxygenation status and

adjust ventilator setting accordingly.
5.9 To determine the degree of respiratory
distress syndrome and the needs for
surfactant therapy.
5.10 To facilitate sterility of procedure
5.11 Survanta is a sterile non pyrogenic
pulmonary surfactant. It is indicated for
prevention and treatment of Respiratory
Distress Syndrome or Hyaline Membrane
Disease.
5.12 As preventive treatment.
5.13 As rescue dose.
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should be given preferably by 8 hours of

age.
5.14 Dosage and administration according to
weight of the patient.
5.15 Survanta should be inspected visually for
discoloration.
5.16 Survanta should be warmed before
administration.
5.17 Suction secretions prior to administration
of Survanta.
5.18 Position the infant accordingly during
administration of survanta.
5.19 Increase the ventilator setting according to
physicians order during procedure.
5.20 Survanta should be administered slowly in
divided doses. Ventilate the infant in
between the procedure.
5.21 Monitor oxygen saturation by pulse
oximeter during and after the procedure.
5.22 Adjust ventilator setting to the usual
parameters after the procedure as long as
vital signs are stable.
5.23 Check arterial blood gas at least one hour
after the procedure or as ordered.
5.24 Assist chest X-ray procedure at least 6 to 12
hours after administration of surfactant or
as ordered.
5.25 Suction secretions 2 to 4 hours after the
procedure.
5.26 Observe for deterioration of vital signs and
3 of 4
5.15 Survanta is off- white to light brown.

5.16 Warm the solution by standing at room
temperature for at least 20 minutes. Do
not use artificial warming method.
5.17 Secretions interfere with gas flow and
predispose infant to obstruction of the
passages including endotracheal tube.
5.19 To maintain appropriate oxygenation.
5.20 To prevent cyanosis and to provide
adequate air exchange and chest wall
expansion.
5.21 To provide an ongoing assessment of
oxygenation status.
5.22 Once surfactant is absorbed, there is usually
increase in respiratory compliance that requires
adjustment of ventilator setting to decrease Mean
Airway Pressure (MAP) and prevent over
inflation or Hyperoximia.
5.23 To determine oxygenation status and to
adjust ventilator settings accordingly.
5.24 To assess patients response to therapy.
Revising might be needed in severe
cases of Hyaline Membrane Disease.
5.25 Suctioning is delayed to allow maximum
effects of the medicine.
5.26 To be able to initiate immediate Intervention for
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possible complications and refer to the

physician.
5.27 Document the patients condition, his vital
signs, the amount of surfactant
administered, date and time of
administration, and the infants response to
therapy.
4 of 4
any signs of deterioration

5.27
or continuity of care and legal purposes.
6.0 ATTACHEMENTS
None
Gloves
Radiant Warmer
Cardiac Monitor
IV Cannula & IV Fluids
Oximeter
Mechanical Ventilator
8.0 REFERENCES
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-52

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-017
APPLIES TO:
NURSING
Blood Exchange Transfusion, Assisting
APPROVAL DATE:
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1 of 5
1.0 PURPOSE
To prevent accumulation of bilirubin in the blood above dangerous level.
To prevent kernicterus as well as to prevent accumulation of other by products of
hemolysis from hemolytic disease.
To replace red blood cells which have poor oxygen releasing capacity and poor
carbonic anhydrase activity as in premature infants.
To remove toxic metabolites and to correct anemia.
2
DEFINITION
Exchange Transfusion is a technique or procedure used most often to maintain
serum bilirubin at levels below neurotoxicity. It refers to giving whole blood
in exchange of an infant blood. The infant's blood is repeatedly drawn out in small amount
and replaced with equal amount of compatible donor blood.
3 POLICY
Exchange transfusion procedure should be done by a physician under aseptic technique assisted by a
nurse.
Patient should be connected to cardiac monitor and pulse oximeter for continuous vital signs
monitoring throughout the procedure.
Fresh whole blood that is properly typed and cross matched should be used for exchange transfusion.
Consent from parents must be obtained by the physician.
5.0 PROCEDURES
5.1 Explain the procedure to parents.
5.2 Confirmed that consent has been
obtained.
5.3 Assemble equipment making sure
sterility is maintained. Assist the
doctor in setting up blood and
RATIONALE
5.1 To lessen anxiety and promote understanding
to procedure.
5.2 To protect the medical team and the
institution for legal matters.
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exchange transfusion equipment.

5.4 Correct identification of the patient by
two identifiers.
5.5 Place infant under radiant warmer and
keep his temperature within
thermoneutral zone.
2 of 5
5.1 To confirm the identity.

5.5 Hypothermia increased oxygen and
glucose consumption causing metabolic
acidosis and also inhibit the binding
capacity of albumin and bilirubin and
hepatic enzymatic reaction thus, increase
risk of kernicterus. Hyperthermia
damages the donor erythrocytes elevating
the free potassium content thus predisposing the
infant to cardiac arrest.
5.6 For continuous monitoring of infant's
cardiorespiratory status.
5.6 Attach electronic cardiac monitoring

device and pulse oximeter to infant.
5.7 The clinical status of the patient is
monitored and recorded before, during and
after the Procedure.
5.8 Place infant on his back. Restrain the
5.8 Proper positioning facilitates easy access to
infant during insertion of umbilical venous
procedure.
line.
5.9 To evacuate the stomach and should be
5.9 Infant will be kept NPO (nothing by
left in place to prevent regurgitation and aspiration
mouth) for 3 - 4 hours before the procedure,
of gastric juices.
or the stomach contents will be aspirated
with a nasogastric tube (NGT) if not NPO.
Confirm the identity of the patient and the blood
5.10 The majority of fatal transfusion reactions
product by a staff nurse and a physician before
are caused by clerical errors. It is strongly
initiating the procedure:
recommended that two qualified individual
do the counter checking of the right patient
Name of patient
and the blood product. Do not proceed with
Chart number
the procedure if there is discrepancy.
Serial Number of blood
Contact blood bank immediately.
Expiration date
Check blood product for clots & hemolysis.
Blood Group compatibility. All
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3 of 5
information must match the medical

record and the patient.
Negative Serology report
Check donor blood for type and other identifying
data.
Blood must be as fresh as possible (never more than
3-4 days old) and must be warm as near to
body temperature as possible.
Once umbilical catheter is inserted in the umbilical
vein, a three-way or four-way stopcocks is
connected. Pre exchange laboratory
studies must be obtained for the following:
Electrolytes
Blood culture
Bilirubin
Hematocrit / CBC
Blood glucose
5.12. The physician will start exchange

transfusion under strict aseptic
technique.
Blood will be removed and replaced at aliqouts of 5
ml/kg.
The removal
/infusion rates will not exceed 5
ml/kg/min.
Documentation provides information as a basis for further
Note and record the date and time
exchange transfusion started stating exact management and continuity of care.
amount of successive bloodwithdrawn
with the same amount infused.
During the exchange, the blood bag must gently If blood is not agitated during the procedure, the patients
massaged periodically throughout the procedure hematocrit will be low at the end of the blood exchange.
to prevent settling of the red blood cells (RBC).
5.13 After each 100 ml. of blood is exchanged,
5.13 To prevent hypocalcemia since the donor blood
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0.5 ml1.0 ml Calcium Gluconate is

injected thru IV slowly.
5.14 Closely monitor and record vital signs
during and after the procedure.
At termination of the exchange transfusion, when the

final volume of blood is removed a portion is
placed in tubes for post exchange laboratory
studies:
Electrolytes
Calcium
Bilirubin
Hematocrit / CBC
Blood Glucose
5.16 Discard used syringes, catheters and
blood bag according to bio hazardous
waste disposal.
Documentation:
The time exchange transfusion started and
completed.
Vital signs.
Time, volume of blood withdrawn and infused & total
volume exchanged.
Medications given, if appropriate.
Patient's response to procedure.
4 of 5
has been collected Citrate Phosphate

Dextrose.
5.14 To determine possible signs of
complications as well as patient's
tolerance to procedure. If signs of
cardiac and respiratory problem is
observed, stop the procedure and
stabilized the patient.
5.17 Documentation provides information

as a basis for further management and
continuity of care.
6.0 ATTACHEMENTS
Blood Transfusion Consent
Blood Transfusion Request
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Radiant Warmer
Equipment for Respiratory Support and Resuscitation
Cardiac Monitoring Device
Umbilical catheter insertion tray
Povidone-iodine solution
Exchange Transfusion Tray
Calcium Gluconate in 5-ml. Syringe
Blood Component, as ordered
Two additional 5-cc syringes 7.10Two
lavender vacutainers 7.11Two
microtainers 7.12Chemstrips
8.0 REFERENCES
Neonatal Nursing Handbook 2004, by Kenner and Lott
Hematology of Infancy and Childhood, 6th edition by Nathan, Orkin, Girsburg and Look
Medical Consultant Incorporated, CD 2002
Pediatrics & Neonatal Tests & Procedures 1996, by Taeusch, Christiansen & Buescher, Saunders
Company
NAME:
DATE
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2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-57

POLICY NUMBER:
DPP
SNR-NICU-018
TITLE:
APPLIES TO:
NURSING
Central Line - Removal
APPROVAL DATE:
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1.0 PURPOSE
1.1 To wean patient from central venous line safely without further complications and bleeding.
2.0 DEFINITION
Central Line - Removal of central venous catheter aseptically after physician's order.
4.0 POLICY
Removal of central line should be ordered by a physician.
Central line catheter should be removed by a physician if surgically inserted and by a
trained, qualified nurse, if non-surgically inserted.
Removal of central line catheter must be done under sterile technique.
5.0 PROCEDURES
Prepare the equipment.
Clamp the infusion tubing
Loosen tape at the catheter site while holding the
catheter firmly and applying counter traction to
the skin.
5.3 Don gloves.
5.4 Withdraw the catheter from the vein by
pulling it out along the line of the vein.
5.5 Apply firm pressure to the site using sterile
gauze for 2-3 minutes.
5.6 Apply sterile dressing.
RATIONALE
Prevents mixing of medications.
Clamping the tubing prevents the fluid from
flowing out of the catheter into the patient's bed.
Movement of the catheter can injure the
vein and cause discomfort. Counter
traction prevents pulling the skin
causing discomfort.
5.3 To maintain sterility of the procedure.
Gloves also prevents direct contact with
the client's blood and body fluids.
5.4 To avoid injury to the vein.
5.5 Pressure helps stop the bleeding and prevents
hematoma formation.
5.6 The dressing provides additional
NICU-58

POLICY NUMBER:
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SNR-NICU-018
TITLE:
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Central Line - Removal
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5.7 Discard used supplies in appropriate

container.
5.8 Record all relevant details of the procedure,
date and time central line is removed and
patient's response.
NURSING
2 of 2
pressure and covers the area in the skin

thus, preventing infection.
5.7 To prevent spread of microorganisms.
5.8 To provide information and continuity of care.
6.0 ATTACHEMENTS
Doctor's Notes
Nurse's Notes
Dressing set
Povidone-Iodine
Alcohol swabs
Sterile cotton balls
Sterile gloves
Sterile gauze pads
Adhesive tapes
8.0 REFERENCES
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-59

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-019
APPLIES TO:
NURSING
Cross Matching and Blood Type
APPROVAL DATE:
EFFECTIVE DATE:
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1 of 3
1.0 PURPOSE
To prevent blood transfusion complications.
To know the patients blood group.
2.0 DEFINITION
Cross Matching of blood is done to establish the compatibility between the patients blood and
donor.
Responsible to Staff Nurse/ Laboratory Technician.
4.0 POLICY
Laboratory technicians in blood bank should be responsible to do blood typing and
cross matching.
Any qualified registered nurse is allowed to extract blood specimen.
Specimen should be properly labeled corresponding to request forms.
Specimen should be registered in the laboratory book for proper
endorsement.
Treating doctor should complete the forms for cross matching with stamp and
signature.
Extraction of blood must be done under aseptic technique.
Blood Samples can be withdrawn from UAC/ UVC or peripheries for infants.
Proper documentation and recording is important for any amount of blood withdrawn. A total of 10 ml
withdrawn in neonate requires blood replacement.
5.0 PROCEDURES
5.1 Observe standard precaution.
5.2 Assemble things needed prior to extraction:
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Meddab, or alcohol, sterile cotton balls.

laster,
Edta tube with label.
yringe with Gauge 21 needle or butterfly gauge 21.
Blood transfusion form and blood grouping form.
5.3 Locate site of extraction and disinfect the area.
Collect 3 ml of blood in Edta tube.(Follow P & P of Blood Specimen Collection)
Withdraw the needle gently.
Apply pressure on the site of extraction.
Disinfect site of extraction then plaster with sterile cotton ball.
5.5 If blood is withdrawn from umbilical arterial catheter (UAC) line, please refer Policy &
Procedure on how to draw blood from site.
5.6 Label the specimen with the complete data of the patient.
5.7 The treating doctor will fill up the blood transfusion form with stamp,
signature, diagnosis, amount of blood needed, date and time requested
and blood group.
5.8 Register in the laboratory book for proper endorsement.
5.9 Document the amount of blood withdrawn and record. A total of 10cc blood extracted from
infant, notify the treating doctor for replacement.
5.10 Document in the nurse's note and record the type of blood and cross match has been
performed.
6.0 ATTACHEMENTS
Cross match request
Blood group request
Meddab, or alcohol, sterile cotton balls.
Plaster,
Edta tube with label.
Syringe with Gauge 21 needle or butterfly gauge 21.
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8.0 REFERENCES
Ministry of Health Policy & Procedure (CD)
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-62

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-020
APPLIES TO:
NURSING
Umbilical Catheterization, Assisting
APPROVAL DATE:
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1.0 PURPOSE
To provide an easy access when frequent measurements of arterial blood gases are
required.
To continuously monitor arterial blood pressure.
To obtain reliable arterial access for blood sampling.
To perform exchange transfusion.
2.0 DEFINITION
Umbilical Cord contains 2 arteries and 1 vein, umbilical vein is single,
thin wall, large diameter lumen. Umbilical artery is paired with 2 thick walls,
small diameter lumen. The vessel can be catheterized in the first 4-5 days after
delivery. The catheter should be made flexible, non-toxic radiopaque material
that will not kink when advanced through a vessel and will not collapse during
blood withdrawal.
Umbilical artery catherization is a procedure wherein a catheter is inserted via
one of the umbilical artery to the premeasured desired position (usually above
the level of the diaphragm, and rest in the descending aorta).
4.0 POLICY
Procedure must be done by physician under aseptic technique assisted by a staff nurse.
The location and proper placement of the umbilical catheter must be confirmed by
X-ray.
The catheter should be filled with heparinized saline before insertion.
Patients vital signs should be monitored during the procedure.
5.0 PROCEDURES
5.1 Explain procedure to the parents or guardian.
5.2 Place infant in supine position. Wrap a
diaper around both legs to restrain the
RATIONALE
5.1 Knowledge of the procedure lessens anxiety.
5.2 This stabilized the patient for the
procedure and allows observation of
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POLICY NUMBER:
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NURSING
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patient.
5.3 Put on sterile gloves, mask, cap and
sterile gloves (for both nurse and
physician).
5.4 Assemble equipments, making sure
that sterility is observed.
Prepare
umbilical catheter tray by attaching the
stopcock to the blunt needle. Fill the 10ml syringe with heparinized saline
solution and inject through the catheter.
5.5 Clean the umbilical cord with antiseptic
solution. Place sterile drapes around the
umbilicus leaving the feet exposed.
Procedure must be done by the doctor:
Tie a piece of umbilical tape around the base of
the umbilical cord tight enough to minimize
blood loss but loosely enough so that the
catheter can be passed easily through the
vessel. Cut off the excess umbilical cord with
scissors or scalpel leaving 1 cm. stumps.
2 of 4
the feet for vasospasm.

5.3 To ensure sterility and prevents spread
of infection and to protect from
exposure to blood and body fluids.
5.4 To facilitate a well organized
procedure. Ensure sterility.
5.5 To prevent infection. Observe the patient closely

during the procedure for vasospasm in the legs or
signs of distress.
5.6.1 A scalpel usually makes a cleaner cut, so that
the vessels are more easily seen. There are
usually 2 umbilical arteries and one umbilical
vein.
Using a curve hemostat grasp the end of the

umbilicus to hold upright and steady. Use
the forceps to open and dilate umbilical
artery then insert the catheter. Aspirate to
confirm blood return.
5.7 Proper placement of the catheter should be
confirmed with abdominal x-ray.
5.8 Secure the catheter. Suture the silk tape to
the skin at the base of the umbilicus using
3-0 silk sutures. The umbilical stump with
the catheter in place is left open. No special
dressing is needed.
5.7 Position above the diaphragm is at T-6, T-9 and

below the diaphragm at the aortic bifurcation.
5.8 The catheter can be fixed in place with a purse
string suture using silk thread and it should be
taped for further stability. Make sure of bridge
tape.
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Observe for the following complications

Infection
NURSING
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Infection can be minimized by using strict sterile

technique. Do not attempt to advance a catheter
once it has been placed and sutured into position.
Vascular accident
Thrombosis or infarction may

occur. Vasospasm may lead to loss of
an extremity.
Hemorrhage
Hemorrhage may occur if the catheter or tubing

becomes disconnected. If hemorrhage occurs,
blood volume replacement may be considered.
5.10 Document the time procedure started and

completed, the doctor who did the
procedure, size of catheter inserted and
patients response to the procedure.
5.10 All facts related to the procedure

provides information and continuity
of care as well as for legal purposes.
6.0 ATTACHEMENTS
Vital signs sheet
Nurse's notes
Prepackaged umbilical artery catheterization trays include:
Sterile drapes
Tape measure
Needle holder
Suture scissors
Hemostat
Forceps
Scalpel
7.9 Three way stopcock
7 .10 Umbilical artery catheter (3.5 inch for infant weighing < 1.2 kg
(5 inch for an infant weighing > 1.2 kg)
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POLICY NUMBER:
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NURSING
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4 of 4
Umbilical tape
Silk tape
3.0 suture
Gauze pads
Antiseptic solution
Sterile gloves, mask, surgical cap and sterile gown
for physician
10 ml syringe with gauge 22 needle
Heparinized saline
8.0 REFERENCES
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-66

POLICY NUMBER:
DPP
SNR-NICU-021
TITLE:
APPLIES TO:
NURSING
Pulse Oximetry
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
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1.0 PURPOSE
To continuously monitor oxygen saturation of arterial blood.
To assess patient's response to oxygen therapy.
2.0 DEFINITION
Pulse oximetry is a non invasive saturation monitoring where light sensor is
taped to a limb or the ear. It is useful for monitoring patient on oxygen, those
at risk for hypoxia and post operative patients.
4.0 POLICY
Calibration must be done by the Bio-medical technician.
Pulse oximeter probe must be cleaned with alcohol before and after each patient's
use.
Site of attachment of neonatal probe are the lateral side of the palm, foot and ear and the
fingers for bigger children.
5.0 PROCEDURES
5.1 Explain procedure to bigger children and to
parents for neonates.
5.2 Wash hands.
5.3 Select adequate site for application of the
probe (lateral side of palm, foot and ear for
neonate and pediatric).
Use the proper equipment. Probe should be
appropriate to patient's size and age.
Pulse oximeter monitor
Oximeter cable
Oximeter connector
Oximeter probe
RATIONALE
5.1 As explanation relieves anxiety
and facilitates patient cooperation.
5.2 Hand washing deters the spread of microorganisms.
5.3 Inadequate circulation can interfere with the Sa02
reading.
5.4 Inaccurate readings can result if probe or sensor is
not correctly attached.
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POLICY NUMBER:
DPP
SNR-NICU-021
TITLE:
APPLIES TO:
NURSING
Pulse Oximetry
APPROVAL DATE:
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5.4.5 Alcohol swab

5.5 Prepare the monitoring site by cleaning the
selected area and allowing it to dry.
5.6 Apply the probe securely to the skin. Make
sure that the light-emitting sensor and the light
receiving sensor are aligned opposite each
other.
2 of 3
5.5 Skin oil, dirt & nail polish can interfere with pulse
oximetry readings.
5.6 Secure attachment and proper
alignment of the light-emitting
and light receiving sensor to
promote satisfactory operation
of the equipment and accurate
recording of Sa02.
5.7 Connect the sensor probe to the pulse
5.7 Audible beep represents the
oximeter and check operation of the equipment.
arterial pulse, and fluctuating
waveform indicate strength of
the pulse. A weak signal will
produce an inaccurate recording
of Sa02.
5.8 Always position the patient's hand at heart
5.8 To eliminate venous pulsation and to promote
level.
accurate reading.
5.9 Set alarm on the pulse oximeter.
5.9 Alarm provides additional safeguard for patient.
5.10 Check oxygen saturation at regular
5.10 Monitoring Sa02 provides ongoing
assessment of patient's condition.
intervals as ordered by physician. Monitor
A low hemoglobin level may be
patient's hemoglobin.
satisfactorily saturated yet not
adequate to meet a patient's
oxygen needs.
Remove sensor on a regular basis and check
Prolong pressure may lead to tissue necrosis and
for skin irritation or signs of pressure.
adhesive sensor may cause skin irritation.
Relocate finger sensor at least every 4 hours, & spring Prevents tissue necrosis.
tension sensor at least every 2 hours.
Check adhesive sensors at least every shift.
Reduces risk of irritation from adhesive.
Documentation:
Date, time, type & location of sensor
Presence of pulse proximal to
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POLICY NUMBER:
DPP
SNR-NICU-021
TITLE:
APPLIES TO:
NURSING
Pulse Oximetry
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
sensor & status of capillary

refill.
Rotation of sensor & status of site.
Percentage of oxygen patient is
receiving.
6.0
ATTACHEMENTS
6.1 Nursing Assessment Form

Oximeter cable
Oximeter connector
Oximeter probe
Alcohol swab
8.0 REFERENCES
Lippincott Manual of Nursing Practice, 7th Editon by Nettina
Nurses Guide to Clinical Procedures, 5th edition by Temple & Johnson
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-69

POLICY NUMBER:
DPP
SNR-NICU-022
TITLE:
APPLIES TO:
Suctioning
APPROVAL DATE:
EFFECTIVE DATE:
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1.0 PURPOSE
1.1 To facilitate respiratory ventilation by removing secretions that obstruct the
airway and to prevent infection that may result from accumulated secretions.
2.0 DEFINITION
Suctioning is the aspiration of secretions, often through a rubber or polyethylene
catheter connected to a suction machine or wall outlets. It involves the
removal of secretions from the trachea or bronchi by means of a catheter
inserted through the mouth, nose, trachea, stoma, and tracheostomy or
endotracheal tube.
4.0 POLICY
Suctioning must be performed by a staff nurse with or without written order of a
Physician under aseptic technique.
Frequency of suctioning should depend on the needs of the patient.
Suction must not be applied when introducing the catheter.
Lavage fluid used for suctioning should be sterile normal saline solution.
Suction pressure should be regulated at 60-80 mmHg for neonates and 95-110
mmHg for bigger children.
Patient must be observed during and after the procedure to prevent
complications.
For adult patients dentures must be removed before suctioning
5.0 PROCEDURES
5.1 Explain to the child or to the parents that
suctioning will relieve breathing difficulty and
RATIONALE
5.1 Knowing that the procedure will
relieve breathing problems is often
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NURSING
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POLICY NUMBER:
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SNR-NICU-022
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NURSING
Suctioning
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that the procedure is painless but may stimulate

reassuring and ensures the patients
cough, gag or sneeze reflex.
cooperation.
5.2 Monitor heart rate and auscultate breath Suctioning may cause:
Hypoxemia initially results in tachycardia and increase
sounds.
blood pressure progressing to bradycardia,
hypotension and cyanosis.
Vagal stimulations which may results in bradycardia.
Position the patient:
Position a conscious patient in the semiThese positions facilitate the insertion of the catheter and help
fowlers position with the head turned to one
prevent aspiration of secretions.
side for oral suctioning or with the neck hyper
extended for nasal suctioning.
Position the unconscious patient in the lateral
position facing the nurse.
This position allows the tongue to fall forward so that it will
not obstruct the catheter on insertion. Lateral position
also facilitates drainage of secretions from the pharynx
and prevents the possibility of aspiration.
Assemble equipments. Check function of
suction and oxygen source.

Make sure that all equipments are functioning
before sterile technique is instituted to
prevent interruption once the procedure
begins. Use of oxygen will help to prevent
hypoxia.
Set the desired pressure on the suction gauge
To ensure that machine is working well.
and turn on the suction.
Open the sterile suction package. Set up the
The sterile gloved hand maintains the sterility
cup or containers touching only its outside
of the suction catheter and the unsterile glove
then pour sterile saline solution.
prevents
the transmission of the microorganism to
Do a non-sterile glove on the non- dominant
the nurse.
hand and then a sterile glove on the other hand,
attach the catheter to
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POLICY NUMBER:
DPP
SNR-NICU-022
TITLE:
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NURSING
Suctioning
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suction unit.
5.6 Make an appropriate measurement of the
depth of the insertion of the catheter. Connect
the catheter directly to the suction tubing
making sure the catheter is kept in the gloved
hand.
5.7 Ventilate and oxygenate the patient
5.8 Lubricate and introduce the catheter. Do not
apply suction when introducing the catheter.
5.9 Apply suction and quickly rotate the
catheter while it is being withdrawn.
5.10 Limit suction time to 10-15 seconds,
discontinue if heart rate decrease by 20 beats
minute or increase by 40 beats/minute or if any
cardiac ectopy is observed.
5.11 Hyperventilate patient between suctioning
by bagging or providing oxygen.
5.12 Rinse catheter between suctioning.
Continue doing suction until the airway are
clean of accumulated secretions but no
more than 4 suctioning be made per
episode.
5.13 When secretions are removed, disconnect
suction catheter from machine tubing, turn
off suction source, and discard catheter.
5.14 Apply petroleum jelly to lips & mouth.
5.15 Dispose of or store equipment properly.
5.16 Position patient for comfort with head of
bed elevated 45 degrees.
5.17 Discard gloves & perform hand hygiene.
5.18 Documentation:
5.6 To maintain sterility.
5.7 Ventilation prior to suctioning helps prevent

hypoxia.
5.8 This reduces friction and easier insertion.
5.9 Failure to rotate catheter may result in damage to
tracheal mucosa. Release suction if a pulling
sensation is felt
5.10 Suctioning for too long may cause increased or
decreased oxygen supply.
5.11 The oxygen removed by suctioning, must be
replenished before suctioning is attempted again.
5.12 Repeated suctioning of patient in
a short time interval predisposed
to hypoxemia as well as being tiring
and traumatic to the patient.
5.14 Prevents cracking of lips.

5.15 Promotes clean environment.
5.16 Promotes lung expansion.
5.17 Prevents spread of microorganisms.
5.18 To evaluate the effectiveness of the procedure and
the patients response
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POLICY NUMBER:
DPP
SNR-NICU-022
TITLE:
APPLIES TO:
Suctioning
APPROVAL DATE:
EFFECTIVE DATE:
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Color, amount, & consistency of

secretions.
Changes in vital signs or patients tolerance to
procedure.
Character of respirations after suctioning.
Condition of mouth & oral mucous membranes.
6.0 ATTACHEMENTS
Vital signs sheet
Nurses notes
Portable or wall suction machine with tubing and collection receptacle.
Sterile container and Normal saline solution
Sterile gloves & Y-connector
Sterile suction catheter (# 8-10 French for children and # 5-8 French for infants)
Sputum trap, if specimen is to be collected
8.0 REFERENCES
Fundamentals of Nursing 7th Edition, by Kozier, Erb, Berman, Snyder
Nursing Care of Infants and Children by Whaley & Wong
Nurses Guide to Clinical Practice, 5th edition by Temple & Johnson
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POLICY NUMBER:
DPP
SNR-NICU-022
TITLE:
APPLIES TO:
NURSING
Suctioning
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
5 of 5
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-74

POLICY NUMBER:
DPP
SNR-NICU-023
TITLE:
APPLIES TO:
NURSING
Phototherapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
To lower bilirubin level to normal.
To prevent complications of untreated hyperbilirubinemia such as kernicterus that
leads to brain damage and even death.
To treat hyperbilirubinemia in order to prevent bilirubin encephalopathy and to reverse
the hemolytic process in any blood group incompatibility.
2.0 DEFINITION
Phototherapy- is a treatment for hyperbilirubinemia by exposing the neonate to high
intensity fluorescent light that breaks down bilirubin for transport to the GI
system and excretion in urine and feces.
4.0 POLICY
Neonates must be exposed to phototherapy with written order of physician and
according to bilirubin level.
Procedure must be explained to parents.
The infant should be exposed bare skin but eyes and genitalia are covered.
Phototherapy machine must be adjusted about 18 inches above the neonates crib or at
least 3 inches above the incubator.
Initial bilirubin level and temperature must be recorded as a baseline measurement.
Neonates must be repositioned at least every 2 hours to expose all body surfaces.
Bilirubin level should be monitored at least every 24 hours more often if levels
rise significantly.
Progress of phototherapy and infants response to treatment must be documented.
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POLICY NUMBER:
DPP
SNR-NICU-023
TITLE:
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Phototherapy
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5.0 PROCEDURES
5.1 Explain the procedure to parents.
5.2 Record the neonates initial bilirubin level
and axillary temperature
5.3 Cover the neonates eyes with the
opague eye mask securely enough to
stay in place, to prevent the neonate
from opening his eyes, but loosely
enough to ensure circulation and avoid
pressure on the eyeballs.
5.4 Clean the eyes periodically.
5.5 Undress the neonate to expose the skin to
light. Remember to cover the genitalia
with a surgical mask.
5.6 Take the neonates axillary temperature
at least every 2-4 hours.
5.7 Check the urine specific gravity.
5.8 Monitor elimination rate, urine and stool
amount and frequency. Weigh the neonate
twice daily and watch for signs of
dehydration
5.9 Clean the neonate carefully after each bowel
movement. Dont apply ointment on the
neonate skin.
5.10 Feed the neonate every 3-4 hours and offer
water between feeding. Make sure water
intake doesnt replace breast milk or
formula.
5.11 Take the neonate out of the crib, turn off the
phototherapy light and unmask his eyes at
least every 8 hours if possible.
5.12 Reposition the neonate every 2 hours.
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2 of 4
RATIONALE
5.1 To reduce their anxiety and guilt and
to ensure cooperation.
5.2 To establish baseline measurement.
5.3 To protect the eye from light-related
retinal damage and prevent reflex
bradycardia, head molding and corneal
abrasions.
5.4 To assess eye circulation.
5.5 Exposing the infants skin to
adequate light source to achieve the
effectiveness of phototherapy.
5.6 To make sure the neonate maintains
normal and stable body temperature.
5.7 To gauge the neonates hydration status.
5.8 Phototherapy increases fluid loss through stools
and evaporation.
5.9 The loose green stool that results
from phototherapy can excoriate the
skin. Ointment can caused burns
under phototherapy lights.
5.10 To ensure adequate hydration and
to boost gastric motility.
5.11 To provide visual stimulation and human contact
and to assess eyes for inflammation and injury
5.12 To expose all body surfaces to light
and prevent head molding and skin
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POLICY NUMBER:
DPP
SNR-NICU-023
TITLE:
NURSING
Phototherapy
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5.13 Check the bilirubin level at least every

24 hours, more often if levels rise
significantly. Turn off the phototherapy unit
before drawing venous blood for testing.
5.14 Notify the doctor if the bilirubin level nears
20 mg / dl in full term neonates or 15 mg/dl
in premature neonates.
5.15 Document the progress of phototherapy
describing changes in skin appearance and
character feeding patterns and level of
activity
6.0
APPLIES TO:
3 of 4
break down from pressure.

5.13 The light may degrade bilirubin in
the blood sample and thereby produce
inaccurate test result.
5.14 Bilirubin level that is too high may lead to
Kernicterus, brain damage or even death.
5.15 To evaluate effectiveness of care
rendered. Documentation serves as
guidelines for continuity of care.
ATTACHEMENTS
7.1 Arterial Blood Gas Result

Phototherapy Unit
Opaque eye mask
Urimeter
Prepackaged eye coverings if available
Photometer
Thermometer
Surgical face mask and small diaper
8.0 REFERENCES
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POLICY NUMBER:
DPP
SNR-NICU-023
TITLE:
APPLIES TO:
NURSING
Phototherapy
APPROVAL DATE:
EFFECTIVE DATE:
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NAME:
4 of 4
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-78

POLICY NUMBER:
DPP
SNR-NICU-024
TITLE:
APPLIES TO:
NURSING
Blood Transfusion Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 7
1.0 PURPOSE
To restore intravascular volume after hemorrhage.
To restore the oxygen-carrying capacity of blood by replacing red blood cells.
To replace clotting factor and correction of anemia.
2.0 DEFINITION
Blood transfusion therapy is the intravenous administration of whole or blood component for
therapeutic purposes.
ICY
Blood transfusion must have a written physicians orders for type, amount, and rate of
blood administration.
Consent for blood transfusion must be signed by patient or parents for children.
Standard precautions are to be followed when handling blood product.
Blood for transfusion must be cross matched to the recipients blood type, and two qualified
staff nurses should verify the patients identity prior to blood extraction for type and cross
match.
Blood must be counterchecked by the Doctor and the attending Nurse, once Blood is
obtained from the blood bank.
Before giving blood transfusion two nurses should identify the patient correctly using the
appropriate means of identification such as using medical record number, identification
bracelet, and patients name.
Blood transfusion must be checked at patients bedside by two registered nurses or a
registered nurse and a physician before infusion.
Name of patient
Chart number
Serial Number on the Blood bag level
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POLICY NUMBER:
DPP
SNR-NICU-024
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
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2 of 7
Expiration date
Blood Group compatibility
Serology free results or negative results
Baseline vital signs should be taken and recorded.
A standard blood filter must be used and to be changed after 8 hours.
Nurse should observe patient closely for the first 5 to 15 minutes after the blood transfusion
is initiated.
The blood transfusion is to begin slowly within 30 minutes after obtaining the blood from
the blood bank and should be infused within 2 to 3 hours but not more than 4 hours.
Blood transfusion should be stopped and physician should be notified immediately if
signs of blood transfusion reaction occur.
Medication should never be injected into an Intravenous line with the blood component
because of the risk of contaminating the blood product with bacteria.
5.0 PROCEDURES
5.1 Verify a written doctor's order for Blood
Transfusion.
RATIONALE
5.1 A written order requesting the blood
transfusion therapy must be made by a
physician prior to implementation of this
procedure.
Assess the patient for the following:
History of blood reaction
Check blood return for venous access.
Obtain vital signs and document.

5.3 Check that transfusion consent has been
properly signed and explain to the patient.
To determine patient's history of blood

reaction.
Verify patency of canula.
Vital signs is important to provide
baseline data for any transfusion
reaction
5.3 Patient consent must be obtained or parent
consent for children.
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POLICY NUMBER:
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SNR-NICU-024
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5.4 Explain procedure to patient and family if

present, particularly the need for frequent
vital sign checks.
5.5 Pre medicate the patient as per doctor' order,
15 to 30 minutes before transfusion.
(Optional)
Obtain blood product by registered nurse from
blood bank & check the following with a
doctor:
Expiration date
Blood Group
Negative Serology Reports
Check blood product for clots & hemolysis
Confirm the identity of the patient and the blood
product by two staff nurses, or a staff nurse and a
physician before initiating the blood
Name of patient.
Chart number.
Expiration date
Blood Group compatibility. All information must
match the medical record and the patient.
Negative Serology report
Check blood product for clots &
hemolysis
5.8 Wash hands and wear disposable gloves.
5.9 Prime the blood administration set with
Normal Saline, ensure that it flush through
the IV tubing to clear air bubbles (optional
for adult).
NURSING
3 of 7
5.4 To allay anxiety and obtain cooperation

from patient.
5.5 To prevent infusion reaction.
5.7 This is to make sure blood is given correctly to the

right patient.
5.8 Reduce transmission of microorganism.

Prevent the nurse from direct contact to
patients blood and body fluid.
5.9 Blood products are compatible only
with Normal Saline. Flushing prevents
infusion of air and potential air
embolism.
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POLICY NUMBER:
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5.10 Invert blood component bag gently 2 to 3

times
5.11 Spike the product bag using aseptic
technique with clamp close. Squeeze drip
chamber, allowing saline to cover the filter.
5.12 Close the clamp on the Normal Saline and
open the clamp on the blood. Allow the blood to
completely cover the filter.
5.13 Remain with patient during the first 5 to
15minutes after initiating the blood transfusion.
5.14 If no signs of reaction for the first 15
minutes, regulate the flow rate according to
Physicians order to run at least 2 to 4 hours
(drop factor of BT is 10 drops/ml).
5.15 Monitor vital signs according to blood
transfusion observation sheet.
5.16 Observe for chills, flushing, dyspnea, rash
or other signs of transfusion reaction.
Stop blood transfusion immediately for any adverse
hemolytic reaction.
Assess the patient
Prioritize your nursing intervention
according to your assessment.
Inform the doctor
Inform the CN/HN/Supervisor
Write an Incident report
5.18 Flush the IV tubing with Normal Saline
and discard the blood bag according to biohazardous waste disposal, when transfusion is
completed.
5.19 Document in the nurses notes:
5.19.1 Date & time blood started &
NURSING
4 of 7
5.10 Equally distribute cell throughout preservatives

solution.
5.11Opening of clamp will prime the tubing with
Normal Saline. Priming the tubing remove air from the
system.
5.12 Prevent back flow of blood into the
Normal Saline.
5.13 Signs and symptoms of adverse
reaction usually occur during the first
15 to 30 minutes.
5.14 Maintaining the prescribed rate of flow
decreases risk of fluid volume excess
while restoring vascular volume.
5.15 Frequent monitoring of vital signs will
help the nurse to alert quickly to any
transfusion reaction.
5.17 Prompt intervention may minimize
potential for serious complications
5.18 Infuse IV saline solution to keep IV

line patent for supportive measures in
case of a delayed transfusion reaction
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POLICY NUMBER:
DPP
SNR-NICU-024
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
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consume
Amount & Type of blood infused
nitial & subsequent vital signs & the response of the
patient.
IV canula size, location & condition of
Intravenous (IV) site.
nstructions given & pts understanding of
instructions.
BLOOD TRANSFUSION:
The transfusion of blood and blood products remains a highly effective and
potentially life saving treatment for many patients. However, blood transfusion
rom one individual to another is risky; significant among these risks is the
potential for human error and subsequent transfusion of the incorrect blood
component.
Blood Samples to be obtained for Acute Blood Reaction:
1. Blood sample to examine serum for hemoglobin and confirm RBC group
and type.
2. Anticoagulated blood sample for a direct Coombs test to determine the
presence of antibody on the RBCs.
3. The first voided urine sample to test for hemoglobinuria.
Blood Components:
A. Platelet consist of platelets suspended in Plasma.
Infused 20-60 mins; depending on total volume, 1 unit of platelet / 10 kgs.
of body weight.
Indications include prevention or resolution of hemorrhage in patients with
thrombocytopenia or platelet dysfunction.
B. Plasma (Fresh or Fresh Frozen)
Consist of water (91%), plasma proteins including essential clotting factors
(7%), and carbohydrates (2%).
Infusion can be completed within 15-30 mins., depending on the total volume.
NICU-83
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POLICY NUMBER:
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SNR-NICU-024
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
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NUMBER OF PAGES
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Indications include treatment of blood loss or blood clotting disorders related

to liver disease and failure. DIC ( Disseminated Intravascular Coagulation ),
over anticoagulation with warfarin, congenital or acquired clotting factor deficiencies
C. Cryoprecipitate consist of certain clotting factors suspended in 10-20 ml plasma. Each unit
contains 80-120 units of factor VIII (antihemophilic and von Willebrand factors), 250 mg
fibrinogen, and 20% -30% of the factor XIII present in a unit of whole blood.
Indications include correction of deficiencies of factor VIII
(ex. Hemophilia A and von Willebrand disease),factor VIII, and
fibrinogen ( ex. DIC).
Dosage : Adult dosage is 10 units, which may be repeated every 8-12 hours
until the deficiency is corrected.
6.0 ATTACHEMENTS
Consent for Blood Transfusion
Blood Transfusion request
Nurses' notes
Vital signs sheet
Gloves.
Syringes.
IV tube.
Cannula.
Blood transfusion tube.
Normal saline.
8.0 REFERENCES
Maternity & Children Hospital Al Musaedeiya Jeddah Policy and Procedure Manual.
NICU-84

POLICY NUMBER:
DPP
SNR-NICU-024
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
7 of 7
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-85

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-025
APPLIES TO:
NURSING
Nursing Care of Infants with Pneumothorax
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
To be able to evacuate / drain accumulated air or fluid in the pleural space by insertion of chest tube.
To provide effective breathing pattern and promote effective gas exchange.
2.0 DEFINITION
Pneumothorax is the presence of air in the pleural space occurring spontaneously or from trauma.
Pneumothorax is classified as follows:
Spontaneous pneumothorax sudden onset of air in the pleural space with deflation of the
affected lung in the absence of trauma.
Open pneumothorax an opening in the chest wall large enough to allow air
to pass freely in and out of thoracic cavity with each attempted
respiration.
Tension pneumothorax - build up of air under pressure in the pleural space resulting in
interference with filling of both the heart and lungs.
4.0 POLICY
The staff nurse must have knowledge about pneumothorax.
The nurse must be alert to assess for signs and symptoms of pneumothorax.
Equipments for needle aspiration and chest tube insertion should be ready in case needed.
Policy and procedure in the care of patient with chest tube should be followed.
Standard precaution should be observed.
Equipment for intubation and oxygen therapy should be ready at bedside.
Crash cart should always be ready in case cardiopulmonary resuscitation is needed.
NICU-86

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-025
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
6.0 PROCEDURES
5.1 Wash hands before and after handling the
infant.
5.2 Admit patient without delay.
5.3 Place infant in a radiant warmer and
regulate the temperature control as
needed.
5.4 Attach to cardiac monitor. Check and
record vital signs including blood pressure
and weight.
5.5 Insert cannula and administer Intravenous
fluid solutions as ordered.
5.6 Monitor pulse oximetry & Arterial blood
gas.
5.7 Provide oxygen as needed.
5.8 Assess for increase respiratory distress,
cyanosis and desaturation, apnea and nasal
flaring.
5.9 Assist the physician in endotracheal
intubation and attach to mechanical
ventilator as ordered.
5.10 Suction secretions as needed.
5.11 Auscultate chest for diminished breath
sound and percuss for hyper resonance.
Observe for chest asymmetry.
5.12 Note for abdominal distention.
5.13 Assist in chest x-ray procedure as
ordered by the physician.
5.14 Assist the physician in needle aspiration
to release air in the pleural space.
2 of 4
RATIONALE
5.1 To maintain standard precaution.
5.2 To initiate emergency measures according to
patient's condition.
5.3 To maintain body temperature within accepted
thermal range.
5.4 To provide a baseline assessment.
5.5 To maintain hydration and also to
provide access for medications.
5.6 To provide continuous or intermittent non invasive
method of determining oxygen saturation.
5.7 To resolve impaired gas exchange.
5.8 To determine the severity of respiratory distress is
severe.
5.9 Ventilate the infant if hypoxia and respiratory
distress is severe.
5.10 To maintain patency of airway. Frequent
suctioning may cause bronchospasm, hypoxia and
bradycardia due to vagal nerve stimulation.
5.11 Presence of air in the pleural space prevents the
lung from expanding, making it difficult for the
infant to inspire resulting to atelectasis.
5.12 The infant's abdomen will become distended
because of pressure on the diaphragm.
5.13 To confirm presence of air in the pleural space.
5.14 This serves as emergency measure until chest
tube can be inserted.
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POLICY NUMBER:
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TITLE:
SNR-NICU-025
APPROVAL DATE:
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5.21 Document complete information on

patient's condition and the patient's
response to interventions rendered.
NURSING
5.15 Prepare equipments for chest tube

insertion and assist the physician in the
procedure.
5.16 Implement care for patient with chest tube
(refer to chest tube policy and procedure).
5.17 Continuously monitor vital signs including
blood pressure and oxygen saturation.
5.18 Perform cardiopulmonary resuscitation if
needed.
5.19 After pneumothorax has been drained,
evaluate patient's condition, vital signs,
repeat chest x-ray as ordered.
5.20 Check ABG as ordered and regulate
oxygen therapy accordingly.
6.0
APPLIES TO:
3 of 4
5.15 Insertion of chest tube into the pleural space

through a small chest incision to evacuate trapped air
in order to achieve re-expansion of collapsed lung.
5.17 To provide assessment of progress or
complication.
5.18 To prevent cardio respiratory arrest.
5.19 To check for recurrence of pneumothorax.
5.20 Arterial blood gas (ABG) indicates changes in
respiratory status. It also provides information
regarding lung function, lung adequacy and
tissue perfusion.
5.21 The effectiveness of nursing intervention is
determined by continuous reassessment and evaluation
of care.
ATTACHEMENTS
6.1 Arterial Blood Gas Result

Radiant warmer
Oxygen source
Intubation equipment
Cardiac monitor
Equipment for Chest tube insertion
Gloves
Suction equipment
Mechanical ventilator
NICU-88

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-025
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
4 of 4
8.0 REFERENCES
Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman, Synder
Neonatology Management, Procedures on Call Problem, Diseases and Drugs 5th Edition by Tricia Lacy
Gomella
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-89

POLICY NUMBER:
DPP
SNR-NICU-026
TITLE:
APPLIES TO:
NURSING
Infant Abduction
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 2
1.0 PURPOSE
To provide safe and secure environment for babies who are unable to protect themselves.
To locate and reunite the infant safely with the family as quickly as possible.
2.0 DEFINITION
None
Responsible to Staff Nurse/ Security guard.
4.0 POLICY
Nurses should observed strict adherence to a newborn identification system.
Matched Identification band must be presented to Nursery staff, when mother goes to
Nursery for breastfeeding or other members of the family will visit the
infant, if any doubt, staff should accompany the baby to the mothers room to confirm.
Mothers should be instructed to release the baby after breastfeeding to staff wearing
appropriate identification.
Babies should only be transferred to other department per bassinet or crib. Anyone
CARRYING a baby in the hallway should be inspected. The staff should question any
visitor not wearing an Identification badge.
During visiting time Nursery door should be monitored and locked, an authorized
staff will always be present.
If an infant is missing and abduction has been confirmed, "CODE PINK" should be
announced and simultaneously staff and security shall respond to their responsibilities.
5.0 PROCEDURES
5.1 If the infant cannot be found in the mothers room or the Nursery, and the nurse has suspicion that
infant is missing, inform your Head nurse immediately.
5.1.1
Staff will check every room in the unit.
NICU-90

POLICY NUMBER:
DPP
SNR-NICU-026
TITLE:
APPLIES TO:
NURSING
Infant Abduction
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
Simultaneously the following actions will follow:

All available hospital personnel will respond to all exits.
Communication to the Head of Security and Head of the Department.
a. Security staff should stop the flow of traffic going out of the
hospital until proper authorities will arrive.
b. Security staff will search around the hospital.
5.3 Once the abduction has been confirmed, the attending physician should notify
the parents.
5.4 All staff on duty when the abduction occurred will remain in the unit until authorities completed
proper questioning.
5.5 Document the incident from the discovery of the abduction until infant is located. Incident
report/Occurrence Variance Report should be accomplished.
6.0 ATTACHEMENTS
6.1 Occurrence Variance Report Form
None
8.0 REFERENCES
Ministry of Health Policy and Procedure, (CD)
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-91

POLICY NUMBER:
DPP
SNR-NICU-027
TITLE:
APPLIES TO:
Incubator Cleaning and Maintenance
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1.0 PURPOSE
To prevent colonization of microorganisms.
To provide maximum safety to patient using the incubator.
2.0 DEFINITION
None
4.0 POLICY
Incubator must be changed every 7 days for terminal cleaning with soap and water
before disinfecting with final touch solution.
Terminal cleaning must be done when changing the incubator and upon patients
discharge.
Date when incubator was changed should be recorded.
Incubator hood should be cleaned daily with hexamide a concentration of 10 ml in 1
liter of water according to infection control protocol.
Spills must be removed as they occur.
5.0 PROCEDURES
5.1 Switch off incubator
5.2
5.3
Remove linen and other items inside

Incubator.
5.2.1 Remove all fittings.
Using cleaned cloth, wash both outside
and inside of the incubator thoroughly
with Final Touch Solution (QuadriAmmonia) as supplied by Infection
Control Department.
5.3.1 Empty excess water from water
NURSING
RATIONALE
5.1 To prevent electric hazard.
5.2.1 Must be cleaned separately.
5.3.1Contaminated water is a good
NICU-92
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POLICY NUMBER:
DPP
SNR-NICU-027
TITLE:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
receptacle (Humidifier).
Do not start cleaning until the incubator is
empty and disassembled. Remove all solid
waste and contaminants from disassembled
parts.
Do not use products that contain
alcohol.
Do not expose the hood assembly to
direct radiation from germicidal lamps.
The controller module should be removed to
prevent accidental wetting. Remove the power
cord from the wall outlet and all probes from the
side panel.
5.4
APPLIES TO:
2 of 3
breeding place for bacteria.
5.3.2 Alcohol can cause crazing of the clear hood and

other plastic parts.
Ultraviolet radiation from these sources can cause
cracking of gaskets and crazing of the hood.
The controller heater can be hot
enough to cause burn. Wait for 45
minutes after the power has been
turned off before removing the
controller from the incubator base.
Check the temperature by rectum.
5.5
Regulate the
incubator
temperature according to the age and
weight.temperature every two hourly for
5.6 Check
newly admitted infant until stable.
5.7 Observe for thermal instability, apnea,
bradycardia, and respiratory distress.
5.8 Check the infant's temperature and wrap 5.8 To provide extra heat when parents
with blanket.
hold the infant outside the incubator.
5.9 Check the infants behavioral changes that
reflect cold stress.
Poor sucking
Increased / decreased activity
Irritability
Lethargy
Hypotonic
Weak or inability to cry
NICU-93

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-027
APPLIES TO:
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.10 Check serum bilirubin level.
NURSING
3 of 3
5.10 Hypothermia can lead to increased

bilirubin level.
5.11 Inform the physician for any changes

noted in the infant.
5.12 Document the assessment of the infant prior 5.12 Serves as legal document and basis for
placement in the incubator and reassessment
the continuity of care.
after.
6.0
ATTACHEMENTS
None

Gloves
Disinfectant solution
Wash basin
Clean cloth
8.0 REFERENCES
Manufactures Guidelines
Infection Control Guidelines by Dr. Wafa Trazi.
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-94

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-028
APPLIES TO:
NURSING
Sterilization Procedure of Ventilator Tubing
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
To prevent colonization of infectious microorganisms.
To provide maximum safety to the patient using the ventilator tubing.
To set standard method of sterilization.
2.0 DEFINITION
Sterilization is the process of destruction of live microorganisms leaving no viable
forms including spores.
Responsible to Head Nurse/ Staff Nurse.
4.0 POLICY
Ventilator tubing must be changed twice weekly.
Ventilator tubing and humidifiers must be soaked with disinfectant solution hexamide 30 ml in 1 liter water
according to infection control protocol for 4-6 hours for non infected cases and 24 hours for infected cases.
Ventilator tubing must be rinsed and dried thoroughly before packing in the autoclave bag.
Packed tubing must be sent to CSSD for sterilization.
Flow sensor must be soaked in enzymatic cleaner solution 0.2 ml in 25 ml water according to
manufacturers recommendation.
5.0 PROCEDURES
5.1 Check tubing of ventilator
5.2 Separate tubing according to types of
ventilator.
5.3 Prepare soaking solution- Hexamide 30 ml
in 1 liter of water according to infection control
protocol.
RATIONALE
5.1 Ventilator have different types of
tubing.
5.2 Put label not to mix up together.
NICU-95

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-028
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.4 Wash tubing in running water before

soaking.
5.5 Soak for 4-6 hours for non infected
cases and 24 hours for infected cases.
Dont
mix
infected
and non
infected tubing.
Dont soak or rinse bacteria filters.
5.6 Rinse and dry thoroughly ventilator
5.6 To Moist tubing is a perfect breeding
tubing.
area for bacteria.
5.7 Pack ventilator tubing in autoclave bag.
5.7.1 Label the autoclave bag, write
the name of department and
the date of sending to CSSD.
5.8 Enter in the CSSD logbook and send for
sterilization.
6.0
ATTACHEMENTS
6.1 CSSD Logbook

Gloves
Container for soaking
Soaking solution
Enzymatic cleaner solution
Autoclave bag
Dryer
8.0 REFERENCES
Manufacturers Guidelines,
Infection Control Manual by Dr. Wafa Trazi
NICU-96
2 of 3

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-028
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
3 of 3
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-97

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-029
APPLIES TO:
NURSING
Babys Identification before Discharge / Transfer to Other Unit
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
To prepare safe discharge from the hospital with correct identity of the baby.
To provide appropriate Health education, counseling of parents, explanation of home medication,
importance of breastfeeding and out patient appointment.
2.0 DEFINITION
None
Responsible to Head Nurse/ Staff Nurse.
ICY
Baby can only be discharged or transferred after the Pediatrician has written order.
If the mother of the baby still in the hospital, the infant should be transferred or discharged to the mother
after discharge clearance is presented by the father. The nurse assigned to the baby and if available a
nurse fluent in Arabic or a Saudi staff
in Neonatal Intensive Care Unit (NICU) will transfer or discharge the baby to the
mother in the OB/Gyne ward. Transferring nurse and the receiving nurse must confirm
matching identity of the mother and infant by checking both identification band with mothers
3 full name, nationality, medical record number, and sex of the baby. Date and time of delivery
and other personal data including mother and babys blood group must coincide with both
medical records. Ask the mother to sign the neonatal discharge paper with the presence of the
nurse handling the babys mother. Both nurses will sign the discharge paper. Babys care must
be dual responsibility of the mother and the nurse assigned to the babys mother until both will
be discharged.
4.3. On the discharge of both mother and baby from the hospital, the nurse must check
the babys data on the bracelet compared to mothers medical record and bracelet
in front of the mother, with the presence of CN or HN, Resident on Duty (ROD)
and the father of the baby or a relative with the discharge clearance. ID band after
confirmation should be removed and attached to the file.
If the mother is not in the hospital, the infant is allowed to go home only after discharge clearance is
presented by parents, and two nurses must confirm the
NICU-98

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-029
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 4
identity of the infant with the correct family.

Health Education, home medication, babys care, including breastfeeding must be instructed to mother.
Parents and family should be instructed about the safe use of medical equipment if
the baby has any.
Confirmed if the baby received first dose of immunization before discharge, vaccination card should be
given to parents with instructions when to comeback
for the second dose.
Babys discharge date, time, condition and with whom must be documented in the nurses notes.
Name & signature of the assigned nurse & the nurse who witness the identification of the
patient must be legible on the discharge form, & the signature of the father.
The baby should be properly covered when attending to his/her physical needs.
5.0 PROCEDURES
RATIONALE
5.1 Confirmed discharge or transfer order by
Pediatrician written in the babys file and
discharge summary.
5.2 Inform the parents of the babys discharge, if
the mother is not admitted in the Hospital.
Prepare Neonatal discharge form and check for
completion of the following documents:
Discharge Summary
mmunization Card
Out Patient prescription and medication
Appointment card
Referral if needed.
5.4 Inform parents to obtain discharge clearance
from the discharge office.
5.5 Once discharge clearance is obtained, dressed
up the baby, assigned nurse will confirm with
another nurse the identity by checking babys
NICU-99

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-029
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
data (3 names, nationality, medical record number

and sex of the baby) on the bracelet compared to
mothers medical record and bracelet with the
presence of the father of the baby or a member of
the family.
5.6 Hand over the necessary documents to the
parents including medications and follow up
appointment.
5.7 Ask the father to sign the Neonatal discharge
form, countersigned by the assigned nurse & the
nurse who witnessed babys identification.
5.8 Provide Health Education to mother regarding
babys care and importance of breastfeeding.
5.9 Document in the nurses notes date, time,
condition and with whom the baby is
discharged.
the mother still in the ward, transfer or discharge the baby
to the mother:
Discharge clearance must be obtained by the father before
transferring the baby to the mother.
Confirm the location of the mother and inform the nurse of
the receiving ward that infant is for transfer or
discharge.
Transferring nurse will transport the baby in a crib or
bassinet.
The nurse will endorse the infant to the nurse in charge of
the mother at the bedside, both nurses will confirm
the correct identity of both mother & the baby (by
checking matching mother & infants Identification
band with mothers 3 names, nationality, medical
record number & sex).
Transferring nurse will endorse everything about the baby
(condition, medication,
NICU-100
3 of 4

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-029
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
4 of 4
immunization, feeding, etc.) to both mother

and the receiving nurse.
5.11 Once the baby left, note the discharge of the
baby in the logbook, including date & time.
5.12 Notify housekeeping department to clean cot
and room.
5.13 Disinfect and prepare cot for new patient.
6.0 ATTACHEMENTS
Discharge Summary
Vaccination Card
Out Patient prescription
Appointment Card
Neonatal Assessment Form
Cot.
ID Band.
8.0 REFERENCES
8.1 Medical Consultants Network Incorporated CD
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-101

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-030
APPLIES TO:
NURSING
Blood Draw from Umbilical Catheter
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
To facilitate easy access of blood extraction.
To provide important diagnostic information.
2.0 DEFINITION
Collection of blood specimen aseptically from the umbilical catheter.
4.0 POLICY
A written physicians order is required.
Aseptic technique must be observed.
Patency of the umbilical catheter must be maintained.
5.0 PROCEDURES
5.1 Wash hands thoroughly, put on gloves
5.2 Open heparinized saline. If not available,
heparinized a 3 ml syringe with 0.05 ml
of 1000 units per ml heparin. Eject
remaining heparin from syringe.
5.3 Place sterile gauze under stopcock of
umbilical catheter.
5.4 Insert non-heparinized 3ml syringe into
stopcock. Turn off the stopcock
connected to IV flow.
5.5 Withdraw 2 ml of blood to be placed on
sterile field and turn stopcock halfway to
keep the tubing clear.
5.6 Insert another syringe into the stopcock.
Withdraw desired amount of blood.
RATIONALE
5.1 To prevent spread of infection. Gloving ensure
sterility as well as protection from exposure to
blood and body fluids.
5.2 To prevent blood clotting.
5.3 To prevent spillage of blood.

5.1 To prevent mixing of blood with IV fluid and
to ensure good result of desired laboratory
investigations.
NICU-102

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-030
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.7 Remove syringe from stopcock, turn

stopcock halfway off to patient.
5.8 Put extracted blood into the desired
specimen container.
5.9 Return 2 ml blood through line, clearing
all air from syringe and stopcock and
return stopcock to upright position, flush
line, replace with new syringe.
5.10 Label sample with patients information.
Record the time and amount of blood
taken and patients response to the
procedure.
6.0
APPLIES TO:
2 of 3
5.10 All facts related to the procedure should be

documented accordingly, to provide
information about the patients tolerance to the
procedure.
ATTACHEMENTS
6.1 Laboratory request

Alcohol swabs
1 ml syringe
Heparinized saline
3 ml syringe
Sterile gauze
Heparin 1000 units per ml
Gloves
Specimen container
8.0 REFERENCES
Medical Consultant Network Inc. CD
Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman and Synder
Neonatal Nursing Handbook 2004, by Kenner and Lott
NICU-103

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-030
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
3 of 3
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-104

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-031
APPLIES TO:
NURSING
Blood Glucose Monitoring by Heel Stick
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
To evaluate episodes of hyperglycemia and hypoglycemia in order to determine appropriate treatment.
To evaluate effectiveness of medications.
2.0 DEFINITION
Measuring of blood sugar with the use of a blood glucose machine extracted from the medial
aspect of the heel of an infant.
3.0 POLICY
A written physicians order is required.
The procedures must be done by a qualified nurse.
Standard precaution must be applied. Blood contaminated items should be disposed according to infection
control policy.
Meter calibration of the glucometer must be validated and confirmed before use.
If alcohol is used to cleanse the site of puncture, the first drop of blood must be discarded.
5.0 PROCEDURES
5.1 Determine safe area to use for neonatal
heel stick
5.2 Place infant in supine position for foot to

hang lower than torso.
5.3 Wipe the heel to be lanced with alcohol
swab. Dry thoroughly.
5.4 Turn on the glucometer; validate proper
calibration with the strips to be used.
RATIONALE
5.1 This area is marked by a line extending
th
th
posterior from a point between the 4 and 5
toes and running parallel to the lateral aspect of
heel, and a line extending posterior from the
middle of great toe running parallel to medial
aspect of heel.
5.2 To improve blood flow.
5.3 To cleanse and remove microorganism that is
present in the site of puncture.
5.4 Errors in glucose reading can result in
miscallibrated of improperly coded meters.
NICU-105

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NURSING
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5.5 Check for the glucometer readiness for

testing blood glucose.
5.6 Prick the patients heel lateral avoiding
the plantar surface.
5.7 Apply the blood carefully to the strip test
area.
5.8 Cover the lance heel with gauze until
bleeding subsides.
Complete the test
The blood remains on the strips as the
glucometer process the result.
Meter with a wipe system require that the
blood be wiped off from the test ball at the
appropriate end time. The strip is inserted into
the meter final reading.
5.10 Document reading and patients
response to procedure.
6.0
APPLIES TO:
2 of 3
5.6 Avoid pricking the most sensitive area.
5.9.1 Blood contact time with the test strip

vary with each glucometer, precise
timing is crucial for accurate result.
ATTACHEMENTS
6.1 Diabetic sheet

Gluco meter
Test strip
Lancet/Lancing device
Alcohol swab
Disposable gloves
2 x 2 gauze
Cotton ball
8.0 REFERENCES
Neonatal Nursing Handbook by Kenner and Cott.
Fundamentals of Nursing 7th Edition by Kozier, Erb, Berman and Synder.
NICU-106

POLICY NUMBER:
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NAME:
3 of 3
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-107

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-032
APPLIES TO:
NURSING
Capillary Blood Gas (CBG)
APPROVAL DATE:
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1 of 2
1.0 PURPOSE
1.1 To check blood gas for patient's level of oxygenation.
2.0 DEFINITION
Capillary blood gasses will be obtained to assess adequacy of oxygenation and ventilation to infants who
do not have arterial line access, per physicians order.
3.0 POLICY
Physicians written order is a must.
Standard precaution must be observed.
5.0 PROCEDURES
5.1 Identify the patient using two (2) patient identifiers.
5.2 Warm heel of the infant for 10 to 15 minutes prior to
procedure.
5.3 Cleanse site (lateral and medial posterior surface
only) with alcohol and pierce with lancet.
5.4 Collect blood in capillary tube making sure that no
air bubbles present. Obtain a continuous flow to
avoid clotting. Cap ends and place in ice or do the
Blood gas analysis as soon as possible (ASAP).
5.5 Apply pressure and Band-Aid.
5.6 Obtain results and refer to physician.
5.7 Documentation:
5.1.1 Date and time test drawn, person
obtaining sample and site of obtained
specimen.
5.6.2 Infants response to procedure and
notification of results to physician.
RATIONALE
NICU-108

POLICY NUMBER:
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6.0
SNR-NICU-032
TITLE:
APPLIES TO:
NURSING
Capillary Blood Gas (CBG)
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ATTACHEMENTS
None

Alcohol swabs
Betadine swabs
Heparinized capillary tubes with caps, as needed
Band-Aid
Gloves
Lancet
8.0 REFERENCES
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-109

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-033
APPLIES TO:
NURSING
Care of Patients on Mechanical Ventilation
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 6
1.0 PURPOSE
To achieve and maintain normal gas exchange.
To prevent atelectasis.
To prevent complications from oxygen toxicity.
To maintain physiologic functioning in patient with:
Respiratory failure
Neurovascular disease
Muscular skeletal disorders like flair chest.
Pulmonary disorders like adult respiratory distress syndrome.
To maintain cardio pulmonary functioning in cardiopulmonary arrest.
To maintain acid-base balance.
2.0 DEFINITION
Mechanical ventilator functions as a substitute for the bellows action of the thoracic cage and diaphragm.
Mechanical ventilation is indicated to maintain safe levels of oxygen or carbon dioxide by spontaneous
breathing even with the assistance of other oxygen delivery systems.
4.0 POLICY
Before connecting patient to mechanical ventilator, there must be a written order from the physician.
Ventilator parameter must be written by the physician or an anesthetist
Ventilator alarm must be set within the limits and checked for correct function. Never turn off alarms.
Ventilator parameter must be set up by a respiratory therapist or a qualified nurse with minimum 1
years' experience in Intensive Care Unit (ICU).
Patient requiring mechanical ventilation must be admitted in ICU.
Ventilated patients must be cared by a qualified nurse.
NICU-110

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5.0 PROCEDURES
5.1 Wash hand.
5.2 Check for the written order of the doctor.
Arrange the equipment:
2 of 6
RATIONALE
5.1 Maintains standard precautions.
uction setup & suction catheters
Oxygen source
tethoscope
Ambu bag (bag-valve mask)
gloves
oximetry
5.4 Explain the procedure to the patient and/or
his family.
5.4 The patient or his family should be

aware of the importance of putting the
patient on mechanical ventilation, at the
same time prepare them psychologically
for weaning.
5.5 Secure airway. Make sure cuffed
5.5 A closed system between the ventilator
endotracheal or tracheostomy tube (depends on
and the patient lower airway is necessary
doctors preference) are in place.
for positive pressure ventilator.
Assess oxygenation status by doing the
Determines efficacy of ventilation; helps
following:
identify problems that may require quick
Auscultate breath sounds.
intervention or changes in ventilator settings.
Note rate & depth of respirations.
Assess level of consciousness (LOC).
Note any cardiac dysrhythmias.
Identifies problems due to decrease cardiac perfusion.
Indicates possible displacement of endotracheal tube
Note symmetrical chest wall movement.
(ETT).
5.7 Continuously monitor oxygen saturation with 5.7 Ensures that changes in oxygen saturation will be
pulse oximetry.
quickly identified.
Prepare the ventilator:
et up desired circuitry
Connect oxygen and compressed air
NICU-111

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source
Turn on power.
et tidal volume = usually 10-15 ml/kg body weight
(BW) or peak pressure.
Set oxygen concentration:

et ventilator sensitivity.
et rate at 12 to 14 breaths per min. (can change
according to patient condition and response and
the type of ventilator being used.)
5.8.5 This is adjusted according to pH (hydrogen ion

concentration of arterial blood) and PaC02
(partial pressure of carbon dioxide).
5.9.2 This setting approximates normal ventilation.
5.10 Connect the patient's airway to the

5.10 This will prevent tubing from dislodging the
ventilator tubing. Make sure all connections are
artificial airway.
secure.
5.11 Assess patient for adequate chest movement 5.11 This will ensure proper functioning of
& rate of respiration. Note peak airway pressure
equipment. Gas flow is adjusted to
and positive end expiratory pressure (PEEP).
provide safe I: E ratio.
Adjust gas flow if necessary
Appropriate interventions maybe necessary.
Set airway pressure alarms according to
patient's baseline:
An alarm sounds if airway pressure selected is
High air way is set at about 20 cm. H20 above
exceeded, indicating decreased lung
peak airway pressure.
compliance, decreased lung volume,
increased airway resistance or lose of
patency of airway.
Alarm activation indicates
inability to build up airway pressure
because of disconnection or leak, or
Low airway pressure is set at 5-10 cm. to
inability to build up airway pressure
H20 below peak airway pressure.
because of insufficient gas flow to
meet patient's inspiratory needs.
5.13 Assess frequently change in respiratory
status If change is noted, notify attending
NICU-112

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physician.
5.14 Ensure adequate ventilation at all times
monitor and trouble shoot alarm conditions.
However, if it cannot be corrected
immediately removed the patient from
mechanical ventilation and manually ventilate
with resuscitation bag.
5.15 Turn patient from side to side every
1&1/2 to 2 hours, or more frequently as
possible.
5.16 Do passive range of motion exercises of
all extremities.
5.17 Assess for need of suctioning every two
hours
5.18 Assess breath sounds and airway patency
every 2 hours.
5.19 Assess lips and tongue for pressure
ulcers and provide oral care.
5.20 Rotate tube placement from side to side
of the mouth.
5.21 Check water level in the humidification
reservoir. Empty the water that condenses in the
delivery and exhalation tubing into a separate
receptacle not into the humidifier. Always wash
hands after emptying fluid from ventilator
circuitry.
4 of 6
5.14 The patient ventilation & oxygenation is the

priority and should not be compromised.
5.15 This will increase lung compliance and improve

oxygenation.
5.16 This may improve circulation.
5.17 Patient on mechanical ventilation are
unable to clear secretions on their own.
Suctioning helps to clear secretions and
stimulate cough reflex.
5.18 It confirms ventilatory distribution and
proper placement of the Endotracheal or
tracheostomy tube.
5.19 Reduces risk of skin breakdown and allows for
early intervention.
5.20 Decreases pressure on lips and mouth Tissues &
reduces risk of ulceration.
5.21 Water condensing in the inspiratory
tubing may cause increased resistance
to gas flow this may result in increased
peak airway pressure. Warm, moist
tubing is a perfect breeding area for
bacteria. If this water is allowed to
enter the humidifier, bacteria maybe
aerosolized into the lungs. Emptying
the tubing also prevents introduction of
water into the patient's airways.
NICU-113

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5.22 Measure delivered tidal volume and

analyzes oxygen concentration every 4 hours
or more frequently if indicated.
5.23 Obtain accurate daily weight and precise
monitoring of intake and output.
5.24 Administer sedation as needed per

doctors order.
5.25 Monitor nutritional status &

gastrointestinal function.
5.26 Provide psychological support.
Communicate to patient even without
response and ensure that the patient has
adequate rest and sleep.
5.27 Change ventilator circuitry every 24
hours, assess ventilator function every 4
hours.
5.28 Maintain a flow sheet to record
ventilation patterns such as Arterial Blood
Gas result, blood investigation &
assessment of patient condition.
Document in the nurse's notes:
Type of ventilator used
Ventilator settings, alarms on
Date & time mechanical ventilator started.
Any problem with the ventilator and
actions taken.
Observation and patient's tolerance
5 of 6
5.23 Positive fluid balance resulting

increase in body weight and interstitial
pulmonary edema is a frequent problem.
Ventilation stimulates release of
antidiuretic hormone, resulting in
decreased urine output. Prevention
requires early recognition of fluid
accumulation.
5.24 Synchronizes respirations and reduce
workload of breathing. Reduces the risk
of patient fighting the ventilator.
5.25 Mechanically ventilated patients are at risk for
development of stress ulcers.
5.26 Mechanical ventilation may result in sleep
deprivation and loss of touch with surroundings
and reality.
5.27 Prevents contamination of lower airways.
5.28 Established means of assessing effectiveness and
progress of treatment
5.29 Provide legal record & communication to other
members of the heath team.
NICU-114

POLICY NUMBER:
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6.0
TITLE:
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6 of 6
ATTACHEMENTS
6.1 ABG result

Suction setup & suction catheters
Oxygen source
Stethoscope
Ambu bag (bag-valve mask)
Clean gloves
Pulse oximetry
8.0 REFERENCES
Photo Guide of Nursing Skills by Smith, Duell, Martin
Neonatal Nursing by Kenner and Lott.
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-115

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-034
APPLIES TO:
NURSING
Central Line Monitoring and Dressing
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
1.1 To provide an aseptic, systemic approach in changing a central line dressing to prevent infection at the
Intravenous (IV) site and the introduction of microorganisms into the blood stream.
2.0 DEFINITION
Central Line Dressing - care given by a qualified nurse on the site of the central venous line.
Responsible to Staff Nurse/ Physician.
4.0 POLICY
Registered nurse may change a central line dressing and monitor the patency of the
catheter.
Handling central line and change dressing must be under strict aseptic technique.
Central line dressing should be changed every 48 hours.
5.0 PROCEDURES
Monitoring & Performing Maintenance
5.2 Label each lumen of multilumen catheter
with name of fluid / medication infusing.
Flush lumens without continuous fluid
infusions and capped every 8 hours with
heparin solution (usually 1:100 dilution) or
normal solution.
Depending on length of tubing and size of
catheter, use 1 to 3 mL of flush solution.
Use 6 mL or ordered amount of flush for
Hickmann catheter & short small needle (25
gauge).
For PICC lines, use a 10-cc syringe or larger for
flushing.
RATIONALE
5.1 To prevent spread of microorganism.
5.2 Prevents mixing of medications.
5.3 Prevents obstruction of catheter lumen
with blood clot.
5.3.1 Minimize leakage via cap or damage
to catheter; prevents rupture of PICC
tubing due to excess syringe pressure.
NICU-116

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5.4 Flush tubing between infusion of

medications and drawing of blood, first
using saline and then Heparinized solution.
5.5 Always aspirate before infusing medications
or flushing.
5.6 Monitor for clot formation in lumen. If
resistance is met when flushing tubing, do
not force. Aspirate and remove clot if
possible; if not, notify physiccian.
5.7 Monitor respirations and breath sounds
every 4 hours.
5.8 Maintain IV fluids above heart level. Do not
allow fluid to run out, and air to enter tubing.
Tubing Change
5.9 Prepare fluid and tubing aseptically.
5.10 Don mask & sterile gloves.
5.11 Expose catheter hub or rubber port of
multilumen catheter.
For centrally inserted lines:
Ask patient to gently turn head to opposite side,
take a deep breath, andbear down (Valsavas
maneuver).
Disconnect old tubing and quickly connect new
one.
Open fluid and adjust to appropriate infusion rate.
5.13 Remove gloves, discard equipment, and
position patient comfortably.
Dressing Change
5.14 Explain procedure to patient.
5.15 Perform hand hygiene and gather
equipment.
5.16 Prepare equipment/supplies on sterile
field.
2 of 4
5.4 Prevents medication interaction or lumen

obstruction.
5.5 Ensures patency of line ad validates
presence in vessel.
5.6 Reduces risk of embolism; prevents
dislodging of clot.
5.7 Promotes early detection of fluid entering
chest cavity or pulmonary embolism.
5.8 Prevents blood reflux into tubing;
prevents infusion of air, which could result in air
embolism.
5.9 Minimizes exposure to microorganisms
5.10 Protects against contamination.
5.11 Precedes connection of tubing
5.12 Increases intrathoracic pressure; prevents
air from entering vein; reduces risk of air
entering lumen.
5.13 Reduces risk of infection transmission.

5.14 Gains cooperation.
5.15 Reduces microorganism transfer and
promotes efficiency.
5.16 To facilitate access of supplies and
prevents contamination of catheter site.
NICU-117

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5.17 Don clean gloves and mask.

5.18 Place a towel under the Intravenous site.
5.19 Assess IV site for presence of infiltration or
inflammation.
5.20 Remove previous dressing & discard the
used materials in the appropriate
container.
5.21 Remove the tape securing the catheter
by stabilizing catheter hub with one hand.
5.22 Don sterile gloves.
5.23 Beginning at catheter insertion site and
wiping outward to the surrounding skin,
clean insertion site with alcohol three
times, allow it to dry, then clean with
antiseptic agent.
5.24 Cover gauze with tape or transparent
dressing; wrap tubing on top and cover
tubing with tape.
5.25 Label and secure the dressing. Write date,
time and initials on top of the dressing.
5.26 Raise side rails & position patient for
comfort.
Documentation:
Date & time of catheter insertion.
Type & location of catheter, Including the number
of linens.
Appearance of insertion site.
Care & monitoring done, including
flushing & resistance if any.
NURSING
3 of 4
5.17 Decreases the risk of contact with blood

and secretions.
5.18 This prevents soiling of bed linens.
5.19 Inflammation and infiltration
necessitates removal of the catheter to
avoid further trauma to the tissues.
5.20 Reduces risk of infection transmission.
5.21 This prevents in advertent dislodgement
of the catheter.
5.22 Prevents site contamination.
5.23 Antiseptics reduce the number of
microorganisms present at the site thus,
reducing the risk of infection
5.24 Secures dressing; prevents pull on
catheter.
5.25 Determines time for next dressing
(usually dressing requires every 48-72
hours), and as needed.
5.26 Promotes patient safety & comfort.
5.27 To provide information pertaining to
procedure, patient's tolerance and
condition, and the nursing intervention
for the continuity of care.
NICU-118

POLICY NUMBER:
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TITLE:
SNR-NICU-034
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4 of 4
6.0 ATTACHEMENTS
Doctor's Order Sheet.
Nurses notes
Intravenous tag
Mask, Gown, Sterile Gloves
Dressing Set
Alcohol swabs
Povidone Iodine Solution
Sterile Gloves
Benzoin
Sterile Cotton Tipped Applicator
Sterile Gauze
Adhesive Tapes
8.0 REFERENCES
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-119

POLICY NUMBER:
TITLE: Assisting
DPP
SNR-NICU-035
APPLIES TO:
NURSING
Insertion of Central Venous Line / Peripherally

Inserted Central Catheter (PICC)
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 5
1.0 PURPOSE
1.1 To provide a better access to the central venous system for patients with chronic illness who require
long term Intravenous therapy, to prevent trauma and complication of multiple venipunctures.
2.0 DEFINITION
Central Venous Line - is a catheter surgically or non-surgically inserted through a major vein, such
as the subclavian vein or less commonly, the jugular vein.
4.0 POLICY
Only a physician competent in this procedure shall insert a central line assisted by a nurse.
Procedure must be done under strict aseptic technique.
Heart rate, blood pressure, respiration shall be monitored throughout the procedure.
Central line placement shall be verified by X-ray after insertion.
5.0 PROCEDURES
Assemble all equipments needed.
Central Line Catheter Set
Antiseptic Solutions
10-cc Syringes ( 3 pcs. ) 5 cc syringe (2pcs.) and
Needles
Lidocaine 1%
Sterile Gloves
Administration Set, Tubings,
Adaptors
3-0 Silk Suture, scalpel
RATIONALE
5.1 To prevent the spread of microorganisms.
5.2 To facilitate patient care by ensuring all the
equipment available.
NICU-120

POLICY NUMBER:
TITLE: Assisting
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Needle holder and Sterile scissors

3 way stopcock (3pcs.)
Gown, Mask, Cap for Personnel involved in the

procedure.
Normal Saline 10 ml
Heparin flush Solution
Sterile gauze
Transparent occlusive dressing
5.3 A full explanation of the procedure should
be given to the patient.
5.4 If the catheter is inserted through subclavian
or internal jugular vein, place patient in a head
down position (Tendelenburg). If patient has
respiratory distress, place in supine position
with feet elevated 45 to 60 degrees (modified
Trendelenburgs).
5.5 For PICC insertion, position the arm for ease
of access to the upper arm or antecubital vein
sites-basilic or cephalic-with arm extended at
45- to 60-degree angle from the body.
5.6 Hold patients hand; obtain assistant &
restrain both hands if patient is resistant or
confused.
5.7 Don face mask & apply mask to patient
(optional).
5.8 Inform patient of progression of the
procedure, particularly when needle stick is to
occur.
5.9 After the vein has been punctured and the
physician has removed the syringe from the
insertion needle and inserted a guide wire
through the needle (central line), instruct the
patient to take a deep breathe and to bear down
5.3 Obtain patients consent to ensure

cooperation and allay anxiety.
5.4 To increase venous filling and reduce risk
of air embolism.
5.5 Facilitates access to insertion site.
5.6 Prevents disruption of procedure or contamination

of sterile field.
5.7 Reduces risk of insertion site contamination.
5.8 Prepares patient for discomfort; helps to
decreases startle reaction.
5.9 Prevents air from being sucked into the
vein by the increasing intrathoracic
pressure.
NICU-121

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(Valsavas maneuver) while the guide wire is

inserted.
5.10 As the multilumen central catheter or a
PICC is inserted over the guidewire into the
vein is withdrawn, observe for blood backing
up into the catheter lumen. Aseptically aspirate
air from the lumen and then flush saline
through each catheter lumen.
5.11 Apply IV lock and cap to catheter lumen, if
needed.
5.12 Once the catheter is in place & sutured,
apply sterile gauze or transparent dressing and,
if needed tape dressing down securely.
5.13 Label dressing with time and date of
catheter insertion.
5.14 Assist portable Chest X-ray per physician's
order, then begin regular infusion rate after
catheter position has been confirmed.
Observe for complication:
NURSING
3 of 5
5.10 Indicates the presence of the catheter in

the vein and removes air from the
catheter tubing before infusion of fluid.
5.11 Maintains sterility of lumen and

establishes a close system to minimize
blood loss & air entry.
5.12 Protects IV site from air leak, debris, and
organism while allowing visualization of
catheter tubing & insertion site.
5.14 Verifies correct placement and position

of the catheter tip (vena cava or right
atrium) before large amount of fluid are
infused.
The potential risks of the procedure make it
important to closely monitor the patient
following insertion of CVP.
Potential risk of pneumothorax and

hemothorax.
Observe respiratory rate and pattern at least
Signs and symptoms of pneumothorax do not
every half-hour together with blood pressure
always appear suddenly. Progressive
and pulse.
dyspnea and deterioration of cardiovascular
status maybe a presenting symptoms.
Permits the diaphragm to drop & aids chest
Sit the patient upright in bed supporting with
expansion.
pillows.
Enable adequate arterial oxygen.
Give oxygen in high concentration.
5.16 Haematoma over insertion site.
NICU-122

POLICY NUMBER:
TITLE: Assisting
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Apply pressure dressing to insertion site.
Observe for signs of extending

haematoma.
Documentation:
ate & time performed
ame of the physician
ite of insertion
atients response to procedure.
NURSING
4 of 5
Prevent extension of haematoma and staunch

blood flow.
May indicate internal hemorrhage.
5.17 To provide information and continuity of care.
6.0 ATTACHEMENTS
Intravenous Fluid (IVF) Tag
IVF sheet
Central Line Catheter Set
Antiseptic Solutions
10-cc Syringes ( 3 pcs. ) 5 cc syringe (2pcs.) and Needles
Lidocaine 1%
Sterile Gloves
Administration Set, Tubings, Adaptors
3-0 Silk Suture, scalpel
Needle holder and Sterile scissors
3 way stopcock (3pcs.)
Gown, Mask, Cap for Personnel involved in the procedure.
Normal Saline 10 ml
Heparin flush Solution
Sterile gauze
Transparent occlusive dressing
8.0 REFERENCES
Nurses Guide to Clinical Procedure, 5th edition by Temple & Johnson
NICU-123

POLICY NUMBER:
TITLE: Assisting
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SNR-NICU-035
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NAME:
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DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-124

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-036
APPLIES TO:
NURSING
Chest Tube Removal- Assessing
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
1.1 To ensure safe and consistent practice in the removal of chest tube by a physician
assisted by staff nurse.
2.0 DEFINITION
Chest tube removal - is a procedure wherein tube inserted in the pleural space is being removed
after re-expansion of the lungs has been attained.
5.0
PROCEDURES
RATIONALE
4.0 POLICY
5.1
Explain
the
procedure
to
the
patient
or
to
Chest tube must be removed upon physician's order.5.1 Knowledge and understanding of the procedure
parents for small children.
lessens anxiety and promotes cooperation.
ThisAdminister
is a two person
procedure;
removal offor
tube must
by the
physician
and aby patient during the
5.2
prescribed
pre-medication
5.2beTodone
relieve
pain,
experienced
nurse.
pain
30 minutes before procedure.
procedure.
5.3
Assemble
all
equipment
at
bedside.
5.3
To
procedure.
If more than one tube is inserted, the appropriate tube to befacilitate
removedsystematic
must be identified
by the physician
5.4
Wash
hands
and
wear
gloves.
5.4
To
prevent
infection.
Gloves
protect
the nurse
according to chest x-ray film.
from contamination to blood and body fluids.
Chest
tube must
be clamped
several
hours
before removal.
5.5 To facilitate readiness of the procedure.
5.5
Prepare
dressing
to be placed
in the
chest
tube site after removal.
Strict aseptic technique must be observed.
5.6 Remove chest tube dressing. Leave sternal
incision dressing intact.
NICU-125

POLICY NUMBER:
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TITLE:
SNR-NICU-036
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5.7 The physician cuts the suture from the

skin and removes the remaining anchoring
suture.
5.8 The physician quickly pulls out the chest
tube.
5.7 To facilitate easy removal of the chest tube.
5.10 Observe patient for signs of respiratory

distress caused by loss of negative intrapleural
pressure or tension pneumothorax.
5.10 Notify the physician immediately for

any complication that may arise after
removal of the chest tube, for immediate
management.
5.8 This is done either during the patient's

expiration or at the end of a full
inspiration to prevent air from being
sucked back into the pleural space while
tube is being pulled out.
Place Vaseline gauze and 4 x 4 gauze pad into
To prevent adherence of the dry gauze to the
site.
wound site that may cause irritation.
Apply dressing to the wound site and secure To prevent wound from infections.
with adhesive tape.
Have chest x-ray done after removal of the chest tube.
To confirm that the whole tube was removed and to check
Discard all supplies including chest tube and
for any possible complications.
drainage bottle in a biohazardous garbage bag.
Proper disposal of
wastes
facilitates the
prevention of cross contamination.
5.11 Document all information about the

procedure, and patient's response.
6.0 ATTACHEMENTS
Nurse's notes
Sterile gauze 4 x 4
Vaseline gauze
Povidone-iodine solution
Scalpel
Adhesive tape
Chest tube clamps
Biohazard garbage bag
Gloves
NICU-126

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-036
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
8.0 REFERENCES
Fundamentals of Nursing 7th Edition, by Kozier, Erb, Berman, Snyder
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-127

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-037
APPLIES TO:
NURSING
Emergency Crash Cart Checking and Re-Stocking
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
Pharmaceutical care department with CPR (Cardiac pulmonary and resuscitation) committee are
responsible to determine the items containing mobile crash cart, the pharmacist maintaining the expiry
date and replacement to all unit in the hospital.
To provide easy checking and re-stocking of crash cart
2.0 DEFINITION
None
Supervisor of inpatient pharmacy is responsible to follow the Implementation of this policy.
Head Nurse
4.0 POLICY
This Hospital maintains mobile supplies of emergency equipment and medications (crash cart) in patient
care areas. The Pharmacy and (CPR) (Cardiac pulmonary resuscitation) Committee determines which
medications will be stocked in crash carts. The Pharmaceutical Care Department is responsible for the
integrity and security of medications contained in the crash cart.
Emergency drugs and supplies for use in medical emergencies only, shall be
immediately available at each patient care unit of service area. Emergency drugs for
resuscitation shall be located in the emergency crash carts.
The emergency drug supply will remain inside the cart, sealed, at all times when not in use. The seal will
be broken only when emergency situation arises. The contents shall be listed in a log on top of the cart and
shall include the earliest expiration date of any drugs within the tray.
Nurses on duty will refill the used emergency drugs.
The departments in which emergency carts are kept are as follows:
Intensive care unit departments
Emergency department
NICU-128

POLICY NUMBER:
TITLE:
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-
SNR-NICU-037
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In-Patient Departments
Operating Room
Delivery Room
Out-Patient Departments
X-ray department
5.0 PROCEDURES
Pharmacy Procedures:
The emergency drug supply shall be stored in each crash cart. The contents of the tray shall be listed in a log on
top of the cart and shall include the earliest expiration date of any drugs within the tray.
Crash cart medication through out the hospital is fixed, standard according to the table attached.
(Pediatric list)(Adult list) and distributed to all departments.
Crash cart list is updated according to Saudi Heart / American Heart Association recommendation.
The emergency drug supply is stored in a clearly marked portable container, is sealed which can not be broken
and have protection from loss or theft.
The contents are listed on the outside cover and include the earliest expiration date of the drugs within.
should be stored in a safe place under supervision of nurses and pharmacists monthly.
The emergency medication is monitored by replacing the expired or damaged drugs from it and records in the
pharmacy report.
5.1.8 The pharmacist will inspect the drug supply monthly as part of a monthly unit inspection.
Nursing Procedure:
The nurse will inspect the seals integrity once a day.
Immediately following an emergency, cardiac arrest sheet (CPR Sheet) should be accomplished. Original will be
attached in the patients chart and the copy will be forwarded to the cardio resuscitation (CPR) committee
through the CPR leader.
After the emergency crash cart has been used, nurses on duty is responsible for cleaning all used instruments on
the cart, cleared all of disposable items, with replacement of completely equipped and standardized
emergency crash cart.
Head nurse will recheck and document medication with pharmacist whenever emergency cart is used, and at the
end of the month (monthly).
Patient care units head nurses and nursing staff are responsible for checking the integrity of all equipments on top
of the crash cart every shift and must be documented.
NICU-129

POLICY NUMBER:
DPP
6.0
TITLE:
SNR-NICU-037
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a. Defibrillators will be discharged on battery to verify defibrillator battery charging.

b. Portable oxygen tank located beside the crash cart should be checked at the beginning of
the shift and after each used.
c. Portable suction machine should be checked for adequate function.
d. Check availability of Ambu bags and reservoirs, drug calculation charts, ET tube (for
neonates, pediatrics, and adults) box for sharps and needles.
5.2.6 Universal pediatrics, neonates and adult dosing guidelines will be kept on every emergency
crash cart in the units.
ATTACHEMENTS
6.1 Crash cart checklist.

Stethoscope
Electrodes for Adult/ Pediatric
Gel, Gloves
Torch, Time Clock
Suction Tube, Naso Gastric Tube
Blade & Scalpel Blade
Face mask
Oropharyngeal airway, Nasopharyngeal airway
Laryngeal mask
Laryngoscop set blades
Stylet, Magils forceps
ET Tube
Scissor, Syringes
Plaster, Batteries, Lidocaine gel
Tourniquet , Alcohol swab, Gauze
IV. Cannula all size, Butterfly
CVP set, Surgical set
IV set, Micro dropper, 3 ways AY stopcocks
8.0 REFERENCES
Policy of dispensing system (1021).
Policy of labeling system (1032).
Resource Manual KFSH and Research (CD) 2007.
Resource Manual JCAHO (CD).
NICU-130

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-037
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
4 of 4
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-131

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-038
APPLIES TO:
NURSING
Equipment Check-up and Testing
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
To maintain good condition of hospital equipment for the safety of the patients.
To maintain the skills of the staff in the use of equipment including trouble - shooting.
3.0 DEFINITION
None
Responsible to Head Nurse.
4.0 POLICY
It is the responsibility of all staff in the unit to assure good maintenance and functions of medical
equipment before it will be used to patients.
Any malfunction equipment must be reported immediately to Maintenance Department. Make a job order
and call maintenance in the extension 2689, 2696. Periodic preventive maintenance (PPM) must be done
regularly by the Biomedical Department
Out of order tag should be placed on top of a machine that is malfunction, and endorse to Charge Nurse
of the incoming shift in case Bio-medical technician was not able to repair and take the machine.
5.0 PROCEDURES
Switch on the equipment.
Check all the indicator if it is functioning.
In case of malfunction, call the Biomedical Technician Extension 2689 2696.
Put Out of Order tag on the equipment and remove from the patients room and endorse to
the incoming shift, till the equipment is fixed and ready for use.
Clean the equipment before and after patients used.
NICU-132

POLICY NUMBER:
SNR-NICU-038
TITLE:
DPP
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
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Ventilator
a. Check power supply, O2 and any leakages and damages on tubing or
humidifier container by checking test lung.
b. Should be checked by staff daily.
c. Should be checked by Bio-medical technician weekly.
d. PPM should be done twice a year by biomedical technician.
Defibrillator
a. Check the power supply and working condition of the machine in each shift by
assigned Nurse and record the observation.
b. PPM should be done by Biomedical department.
ABG Machine
a. Assigned nurse in each shift should check the functioning of the machine before
calibration.
b. Different kinds of solution gases must be replaced by bio-med technician
whenever needed.
c. PPM should be done by responsible company twice a year.
ECG Monitor
a. Check the power supply, confirm good working condition by switch on the
machine daily.
b. Monitor continuously if machine is used by the patient.
c. PPM should be done by the responsible company or Biomed twice a year.
NICU-133

POLICY NUMBER:
DPP
SNR-NICU-038
TITLE:
APPLIES TO:
NURSING
APPROVAL DATE:
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CTG Machine
a. Check the power supply, switch on the machine and confirm good working
condition before use.
b. Should be checked daily by the staff.
Infusion Pump
a. Check the power supply, proper connection and working condition before use.
b. Check any alarms when in use.
Syringe Pump
a. Check the power supply and working status of system before use.
b. Check the proper connection of tubings on the pump.
c. Periodic check-up by the company or Biomed every 6 months.
Pulse Oxymeter
a. Check the power supply, working status and proper connection before use.
b. Check for the proper placement of the probe by the staff.
c. Periodic check-up by the company or Biomed every 6 months.
ECG Machine
a. Check the power supply and working condition of the machine before use.
b. Check for the proper placement of ECG paper.
c. Check for the proper connection of chest leads and limb leads.
d. PPM should be done by the responsible company or Biomed twice a year.
NICU-134
3 of 4

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-038
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NURSING
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EFFECTIVE DATE:
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6.0 ATTACHEMENTS
6.1 Job Order request.
Gloves.
Ventilator.
Defibrillator.
ABG machine.
ECG monitors.
CTG machine.
Infusion Pump.
Syringe Pump.
Pulse Oxymeter.
ECG machine.
8.0 REFERENCES
8.1 Medical Consultants Network Inc. CD
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-135

POLICY NUMBER:
DPP
SNR-NICU-039
TITLE:
APPLIES TO:
NURSING
Gastric Aspiration
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 3
1.0 PURPOSE
1.1 To be able to obtain specimen for diagnostic purposes.
2.0 DEFINITION
Gastric aspiration is a procedure by which the stomach content is aspirated with an oral or
nasogastric tube.
4.0 POLICY
Gastric Aspiration must be done by a staff nurse upon written order of the
physician.
Aseptic technique for specimen collection must be instituted.
The size of the nasogastric tube inserted must depend on the size and age of the
patient .
5.0 PROCEDURES
5.1 Explain the nursing practice and procedure
to patient.
5.2 Keep patient on NPO for 8-10 hours prior to
procedure.
5.3 Perform hand hygiene and collect and
prepare the equipments.
5.3 Position and drape the patient.
5.4.1 Place bigger children in semi
fowlers position unless contraindicated.
For infant position on side with a diaper
roll placed under the shoulder.
5.4 Measures approximately the nasogastric
tube to be inserted. Measure distance from
RATIONALE
5.1 Knowledge of the procedure alleviate patients
anxiety & promotes cooperation
5.3 Availability of the equipment to be used facilitates
readiness of the procedure.
5.4 Draping the patient ensures privacy and also to
protect her gown from spills.
5.4.1 This position allows for easy
passage of the catheter, facilitates
observation and helps avoid
obstruction of the airway.
5.5 Pre- measuring the catheter provides
guidelines on how far to insert catheter.
NICU-136

POLICY NUMBER:
DPP
SNR-NICU-039
TITLE:
APPLIES TO:
NURSING
Gastric Aspiration
APPROVAL DATE:
EFFECTIVE DATE:
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NUMBER OF PAGES
2 of 3
tip of the nose to bottom of earlobe then to

the end of Xyphoid process.
5.6 Wear Gloves.
5.7 Lubricate the tube and insert it gently but
firmly inward and backward along the floor
of the nose to nasopharynx. Passage of the
catheter may be synchronized with the
swallowing of the patient.
5.8 When nasogastric tube has been inserted,
carry out test to confirm tube placement.
5.9 Secure the tube with the tape when tube
placement is confirmed.
5.10 Aspirate the stomach contents. Either
continuous or intermittent aspiration will
be ordered by the medical practitioner.
5.11 Collect specimen and place in sterile
specimen container, label and transfer to
laboratory accompanied by properly
filled laboratory request.
5.12 Dispose used equipment safely.
5.13 Document the size & type of tube inserted,
color & amount secretions aspirated, and
the patients tolerance to procedure.
6.0
5.6 To maintain sterility and also serves as

protection from exposure to body fluids.
5.7 Swallowing motion will cause esophageal
peristalsis, which opens the sphincter and facilitate
passage of the catheter.
5.8 When introducing air, gurgling sound over stomach
is audible with stethoscope.
5.9 This prevents movement of the catheter from the
pre-established correct position.
5.10 Observe the characteristic of the gastric
aspirate. Report to the physician for any
abnormal changes observed.
5.11 Collected specimen must be
transported immediately for diagnostic
purposes. Delay of sending specimen
for analysis may alter the result.
5.12 To prevent cross- contamination.
5.13 To provide information that is helpful in treating
the patient.
ATTACHEMENTS
6.1 Laboratory request form

Gloves.
Nasogastric Tube.
Specimen container.
NICU-137

POLICY NUMBER:
DPP
SNR-NICU-039
TITLE:
APPLIES TO:
NURSING
Gastric Aspiration
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
3 of 3
8.0 REFERENCES
Ministry of Health Policy and Procedure, (CD)
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-138

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-040
APPLIES TO:
NURSING
Intravenous Therapy & Cannulation
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 5
1.0 PURPOSE
To restore and maintain fluid and electrolyte balance and body homeostasis when oral intake
is not adequate.
To correct concurrent losses from the gastrointestinal tract as a result of vomiting, diarrhea, or drainage of
secretions.
2.0 DEFINITION
Intravenous Therapy refers to the infusion of fluids directly into the venous
system, including safe administration of blood / blood components and
intravenous medications ordered by the physician.
ICY
Intravenous insertion should be performed by a competent certified Intravenous therapy
nurses, or a physician.
Intravenous insertion should be performed under strict aseptic technique.
Standard precaution for blood and body fluids should be observed.
Site of canula insertion preferably the upper extremities starting from the distal to proximal.
Superficial veins are used more frequently because they are accessible and there are fewer
complications than when deep veins are used.
After two (2) unsuccessful attempts of Intravenous insertion, assistance must be obtained
from the expert certified IV nurse, if still unsuccessful inform the physician and document
it.
All Intravenous fluids must be administered by corresponding Intravenous sets and infusion
pump to ensure accuracy and safety.
Canula should be changed as needed, or every 72 hours for adult, or 120 hrs
(5 days) for Neonates, Pediatrics, and chronic patients that are very difficult to
NICU-139

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-040
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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be inserted. Date and time of insertion should be written with the nurse signature.
Intravenous set should be changed every 24 hours.
Intravenous Fluids started will be infused to the patient within 24 hours, remaining will be
discarded thereafter.
Normal Saline should be used to flush Intravenous line before and after IV medication
Infusion site must be checked at least every hour.
5.0 PROCEDURES
5.1 Check physicians order for type of
solution and rate to be infused.
5.2 Wash hands.
Gather and assemble equipment:
Intravenous tray
Intravenous canula of appropriate gauge depends on
the age and size of the patient.
3 way Intravenous connector
Alcohol swabs, Betadine or
antiseptic solution.
Plaster or micro pore
Syringe w/ Normal Saline
Solution
Ordered Intravenous Fluid
Intravenous set, stand,
Infusion pump
Sterile gauze
Splint as required
Sharps container
Sterile or clean gloves
(optional).
5.4 Check the expiry date, sediment, and
RATIONALE
5.1 To avoid medication error.
5.2 Maintain standard precaution.
5.4 To verify accuracy.
NICU-140

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-040
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NURSING
APPROVAL DATE:
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cracks, then calculate the rate to be infused.

5.5 Attached an Intravenous Fluid tag,
writing the name of the patient, amount,
name of medication added, number of
drops/minute, date and time started and to
be finished, with the signature of two nurses
who prepared.
5.6 Remove the cover of the Intravenous
Fluid bottle and insert Intravenous set
into the rubber top observing aseptic
technique.
5.7 Identify correct patient. Explain the
procedure to the patient, and parents for
children.
5.8 Flush 3 way connector with saline and
keep on sterile surface.
5.9 Select a suitable vein away fromthe joint
and bony prominence. Location: hands,
arms, feet and scalp. Look at the extremities
before the scalp.
5.10 Apply tourniquet, do not impair arterial
blood flow.
5.11 Disinfect the site with alcohol swab in
acircular motion starting from inside out and
allow to dry.
5.12 Hold the canula with the bevel up;
insert the needle into the vein. If there is a
blood return flow, removed the needle from
the catheter.
5.13
Release the tourniquet.
5.14 Attach 3 way connector with salinefilled syringe to canula.
5.15 While flushing the canula, advance it
slowly then observe for subcutaneous
5.6 Maintain sterility of the solution.
5.7 To confirm correct patients identity and to gain

the cooperation.
5.8 For flushing to maintain the patency of canula.
5.10 Improper application of tourniquet may cause

blood stasis.
5.11 To avoid bacterial contamination.
5. 12 Bevel up position allows for smallest and
sharpest point of the needle to enter the vein.
NICU-141

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-040
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
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infiltration.
5.16 Secure the canula with tape.
5.17 Apply transparent dressing to site.
5.18 Label Intravenous site with date, time
and signature of the staff
5.19 Attached the Intravenous set to hub of
the connector and adjust the infusion flow at
the prescribed rate.
5.20
Observe
local
and
systemic
complication during IV therapy.
5.21 Tidy the environment; dispose the
sharps in the sharps disposal container.
5.22 Documentation
Date, time and site of insertion
Size of canula and Intravenous solution.
Patients
response
to
procedure.
4 of 5
5.16 To immobilize canula and prevent phlebitis.

5.18 To indicate the changing of Intravenous set
every 24 hours and canula every 3-5 days.
5.19 To ensure correct amount of fluid is being
infused.
5.22 Legal record is maintain to communicate to other

members of the Healthcare team.
6.0 ATTACHEMENTS
Intravenous Fluid Tag
Doctor's Order Sheet
Intravenous tray
Intravenous canula of appropriate gauge depends on the age and size of the patient.
3 way Intravenous connector
Alcohol swabs, Betadine or antiseptic solution.
Plaster or micro pore
Syringe w/ Normal Saline Solution
Ordered Intravenous Fluid
Intravenous set, stand, Infusion pump
Sterile gauze 7.10Splint as
required 7.11Sharps container
7.12 Sterile or clean gloves (optional).
NICU-142

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-040
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5 of 5
8.0 REFERENCES
Nursing Procedures, 2nd Edition by Springhouse
Lippincott, Manual in Nursing Practices, 7th Edition by Nettina
Photo Guide of Nursing Skills, 2004 by Smith, Duell, Martin
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-143

POLICY NUMBER:
DPP
SNR-NICU-041
TITLE:
APPLIES TO:
Isolation of the Newborn
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1.0 PURPOSE
1.1 To control cross infection.
2.0 DEFINITION
None
Responsible to Head Nurse/ Head of NICU Department.
4.0 POLICY
Infants delivered by a mother suspected or proved of having communicable / infectious
diseases are placed in the isolation nursery as ordered by the physician.
Infants delivered outside the hospital with positive culture are admitted in the Isolation
Room, but if no evidence of infection will be admitted to out born Nursery.
4.2 Patients with positive culture to any infectious diseases must be cared in
Isolation Room as ordered by the physician.
4. Standard precaution and transmission based precaution must be observed, and
to follow Infection Control guidelines.
5.0 PROCEDURES
5.1 The nurse obtains supplies for the patient to
last for 2 days, including formula and
nipples for each shift.
NURSING
RATIONALE
5.2 Wash hands, use gloves or appropriate

personal protective equipment before
caring infant.
5.3 Place infants individual supplies into the
isolate cabinet.
5.4 Follow routine procedures for the disposal
of linen and trash.
NICU-144
1 of 2

POLICY NUMBER:
DPP
SNR-NICU-041
TITLE:
APPLIES TO:
NURSING
Isolation of the Newborn
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
5.5 Remove gown and gloves, wash hands

before leaving the room and wash
hands again in the anteroom.
5.6 Collect cultures, administer antibiotics and
carry out any other special procedures as
ordered by the physician.
5.7 Observe all infants for early symptoms of
infection.
6.0
ATTACHEMENTS
None

Gloves
Mask
Gown
Eye protection, face shield if procedures likely to generate splashes.
8.0 REFERENCES
Infection Control Guidelines by Wafa Abdullah Al-Trazi
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-145

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-042
APPLIES TO:
NURSING
Narcotic and Controlled Drug Administration
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
1.1 To standardize the procedure of administering Narcotics and Controlled
drugs in compliance with the Ministry of Health guidelines and Jeddah
Maternity and Childrens Hospital policy.
2.0 DEFINITION
Narcotic and Controlled Drug Administration - an introduction of substances
or compounds considered to have limited medical use or that are potential for
abuse or addiction.
4.0 POLICY
Narcotic storage cabinet is safe, made of steel and should be double lock at all times.
Narcotic key should always be with the Head Nurse or Charge Nurse.
Narcotics should be ordered and prescribed by Consultant Physician, and must be re
ordered if still needed by the patient after 24 hours.
Injectable Narcotic or controlled drugs prescribed by the Consultant should be administered to patients
inside the hospital not outside the hospital or at home.
Prescribed Narcotic should be documented in the patients file.
Telephone orders/verbal orders of Narcotics and controlled drugs should not be
accepted.
The Narcotic is issued and counter checked by the Head Nurse/Charge Nurse from the
Narcotic cabinet to administering Nurse.
Vital Signs should be taken and general assessment to patient must be considered
before administering Narcotics.
NICU-146

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-042
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
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Registered Nurses (RN) should observed 7 rights of drug administration before giving Narcotic
and Controlled drugs.
There should always be a witness, a qualified RN during Narcotic administration and during
disposing an extra portion. Any extra medication from an ampoule that is discarded should be
documented. Write the exact amount of Narcotic discarded in the prescription form and
Narcotic book, counter signed by the witness.
A Narcotic prescription form is completed by the medical practitioner with his signature and stamp.
5.0 PROCEDURES
5.1 Confirm doctor's order and observe seven
rights of drug administration
5.2 Wash hands
5.3 Vital signs should be taken and recorded.
Assessment:
Assess for respiratory dysfunction, including
respiratory depression, rate, rhythm, character;
notify the Physician if respiration is below
normal range.
RATIONALE
Assess for intake and output ratio; be alert for

urinary retention, frequency, dysuria; drug
should be discontinued if these occur.
Observe for Central Nervous System (CNS)
changes, dizziness, drowsiness, hallucination.
5.5 Prepare the Narcotic drug as ordered and

should be checked by both Registered Nurses.
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5.6 Approach the patient and check identity by

both Nurses prior to administration using at
least 2 identifiers.
5.7 After administration, both Nurses should
complete and sign the Narcotic Prescription.
5.8 The administering Nurse will sign the
medication sheet and document in the Nurses
notes.
5.9 Patient should be observed closely after
narcotic administration.
6.0 ATTACHEMENTS
Physician's Order Sheet
Medication Sheet
Narcotic & Controlled drug prescription
Narcotic Logbook
Dinamap Monitor.
Stethoscope.
Kidney basin.
Medication.
8.0 REFERENCES
Fundamentals of Nursing by B. Kozier, A. Berman, S. Snyder; 7th Edition, 2004
Mosbys Nursing Drug Reference by L. S. Roth
Jeddah Maternity & Children's Hospital Pharmacy Department on Narcotic and Controlled Drug Policy
and Procedure
NICU-148

POLICY NUMBER:
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NAME:
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2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-149

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-043
APPLIES TO:
NURSING
Narcotic and Controlled Drug Endorsement and Storage
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
To keep an accurate record of Narcotic and Controlled drug.
To detect if any Narcotic drug or empty ampoule is missing.
To establish a safe practice for the storage of Narcotic and Controlled Drug available in the nursing
unit for immediate use.
2.0 DEFINITION
Endorsement of Narcotic and Controlled drug refers to the hand over of
responsibility for Narcotic and other Controlled drug from outgoing nurse
to the in-coming nurse.
4.0 POLICY
Narcotic storage cabinet is safe, made of steel and should be double-locked at all times.
Narcotic key should always be with the Charge Nurse of each shift.
Always endorse the Narcotic key to a responsible RN, every time the Charge Nurse is
out of the unit.
Auditing of Narcotic and Controlled Drug should be done by in-coming and out going
charge nurses; both should be present during the counting and should sign in each others
presence.
Both outgoing and in-coming Charge Nurses will count the number of empty ampoules that
should be equal to the number of prescriptions with completed administered doses, the
number of full ampoules should be equal to the number of doses not given, and Narcotic
record book should be signed by both charge nurses.
Any lost Narcotic or broken ampoules should be reported immediately to the Head Nurse
or Nurse Supervisor, an incident report must be submitted to the Director of Nursing
through proper channel.
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When using only part of the dose or ampoule, remaining portion must be discarded with
the presence of a witness. Write the exact amount of Narcotic discarded in the
prescription form and Narcotic book, countersigned by the witness.
Replacement of stock should be done by the Head Nurse or authorized staff, empty
ampoules with completed drug prescription must be replaced by the Pharmacist incharge of Narcotic.
4.10 If Narcotic key is lost, staff on duty should not leave the unit unless the
Narcotic steel cabinet is open (by Maintenance Department), and the Charge
nurse must confirm the availability of the drugs. Incident report should be
written, lock should be changed immediately.
5.0 PROCEDURES
5.1 Count at the end of every shift all narcotics
and controlled drugs in the presence of a
witness and the head nurse or charge nurse.
Record and sign in the Narcotic
endorsement book.
5.2 Auditing of narcotic and controlled drug
should be done by in-coming and outgoing
Charge Nurses in the presence of a
witness.
5.3 Charge Nurses will count the number of
empty ampoules that should be equal to the
number of prescriptions with completed
administered doses.
5.4 The number of full ampoules should be
equal to the number of doses not given;
Narcotic record book should be signed by
both Nurses.
5.5 Inform the Head Nurse and Nurse
Supervisor if discrepancies were observed.
5.6 If the discrepancy is not solved, submit an
incident report to the Director of Nursing
through proper channel.
RATIONALE
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5.7 Replace wasted materials of drug lost

through breakage or spillage within 24 hours
with the corresponding report to the Director of
Nursing.
5.8 When using only part of the dose or
ampoule, the waste portion must be
documented and DISCARDED written in the
Narcotic record book, and Narcotic
prescription.
6.0 ATTACHEMENTS
Narcotic endorsement logbook
Narcotic record book with details of administration
Narcotic prescription
Dinamap Monitor.
Stethoscope.
Kidney basin.
Medication.
8.0 REFERENCES
Fundamentals of Nursing by B. Kozier, A. Berman, S. Snyder; 7th Edition, 2004
Mosbys Nursing Drug Reference by L. S. Roth
Jeddah Maternity & Children's Hospital Pharmacy Department on Narcotic and Controlled Drug Policy
and Procedure
NICU-152

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2010
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2010
NICU-153

POLICY NUMBER:
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TITLE:
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Nasogastric Feeding
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1.0 PURPOSE
1.1 To provide a means of alimentation and administration of medication when the oral route is
inaccessible.
2.0 DEFINITION
Nasogastric Tube for feeding is - a means of providing food by way of a catheter
passed through the nose or mouth, through the pharynx down the esophagus
and into the stomach, slightly beyond the cardiac sphincter.
4.0 POLICY
Nasogastric tube must be in correct position and properly fixed before
commencing gavage feeding.
The size of the nasogastric tube should be according to the age and size of the patient
and the viscosity of the solution being fed.
Nasogastric tube feeding should be given by gravity and should not be pushed by
force.
The nasogastric tube should be aspirated every 4 hours unless otherwise ordered by
a physician. The amount of aspirate will be recorded on the intake and output sheet
every 8 hours.
After giving feeding, the nasogastric tube should be rinsed with water and close after
rinsing.
A general statement of formula type, volume and feeding tolerance should be recorded
in the nurses' notes.
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5.0 PROCEDURES
5.1 Explain procedure to patient. Assess bowel
sound through the use of stethoscope.
Assemble equipment. Check the amount
concentration, type, and frequency of tube
feeding on patient's chart. Check expiration of
formula.
Nasogastric tube of appropriate size (# 5-12
French)
Clear calibrated reservoir for
feeding fluid
Syringe
Stethoscope
Feeding fluid at room temperature
Disposable gloves
Sterile water for irrigation
Asepto syringe for larger volume
of Feeding
Disposable pad or towel.
5.3 Wash hands and don gloves.
5.4 Position patient with head of bed elevated
at least 30 degrees.
5.5 Check proper positioning of the
nasogastric tube before commencing
feeding.
5.6Aspirate the stomach contents before
feeding started and measure the
amount prior to administering the
feeding.
5.7 The flow of feeding should be slow. Do
not apply pressure. Elevate reservoir 6-8
NURSING
2 of 4
RATIONALE
5.1 This facilitates cooperation and provides
reassurance for patient. Presence of bowel sounds
indicates functional gastrointestinal tract.
5.2 This provides organize approach to procedure.
Ensure that correct feeding will be administered.
Outdated formula may be contaminated.
5.3 Hand washing deters the spread of

microorganism. Gloves protects from exposure
to body fluids.
5.4 This position minimizes possibility of aspiration
into the trachea.
5.5 A nasogastric tube left in place can become
dislodged between feedings. Aspiration may
cause serious respiratory problem if gastric tube
is not in proper place.
5.6 This is done to monitor for appropriate fluid
intake, digestion time, and over feeding that can
cause distention. Note an increase in gastric
residual contents.
5.7 The rate of flow is controlled by the size of the
feeding catheter; the smaller the size, the slower
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inches above the patient's head.

5.8 Formula taken too rapidly will interfere
with peristalsis, causing abdominal
distention and regurgitation.
5.9 When feeding is completed, the catheter
may be irrigated with clear water. Before the
fluid reaches the end of the catheter, clamp it
off and keep in place for the next feeding.
5.10 Place the patient on right side for at
least one hour. Observe patient's
condition after feeding; bradycardia and
apnea may still occur.
5.11 Note for any vomiting or abdominal
distention.
5.12 Note patient's activity.
5.13 Accurately describe and record
procedure, including, type and amount of
formula, amount retained or vomited and how
the patient tolerated the procedure.
NURSING
3 of 4
the flow. If the reservoir is too high, the pressure

of the fluid itself increases the rate of flow.
5.8 The presence of food in the stomach stimulates
peristalsis and cause the digestive process to begin.
When tube is in place, incompetence of the
esophageal- cardiac sphincter may result in
regurgitation.
5.9 Clamp the catheter before air enters the
stomach and causes abdominal distention.
Clamping also prevents fluid from
dripping from the catheter into the
pharynx, causing the patient to gag and
aspirate.
5.10 To facilitate gastric emptying and
minimize regurgitation and aspiration.
Bradycardia and apnea may occur because
of vagal stimulation.
5.11 It may occur due to overfeeding or too rapid
feeding.
5.12 Peaceful sleep offers insight as to tolerance of
the feeding.
5.13 This provides accurate documentation of the
procedure and the care given to the patient.
6.0 ATTACHEMENTS
Intake & Output chart
Nurse's Notes
Nasogastric tube of appropriate size (# 5-12 French)
Clear calibrated reservoir for feeding fluid
Syringe
Stethoscope
NICU-156

POLICY NUMBER:
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Nasogastric Feeding
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Feeding fluid at room temperature

Disposable gloves
Sterile water for irrigation
Asepto syringe for larger volume of Feeding
Disposable pad or towel
8.0 REFERENCES
Nursing Procedures, 2nd Edition by Springhouse
Fundamentals of Nursing, 7th Edition by Kozier, Erb, Berman, Snyder
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-157

POLICY NUMBER:
DPP
SNR-NICU-045
TITLE:
APPLIES TO:
NURSING
Nasogastric Tube Insertion
APPROVAL DATE:
EFFECTIVE DATE:
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1.0 PURPOSE
To decompress the stomach thus gastric distention, nausea and vomiting.
To administer tube feeding and medication to patient unable to eat by mouth or swallow a
sufficient diet without aspirating food or fluids into the lungs.
To remove stomach contents for laboratory analysis.
To lavage the stomach in case of poisoning or overdose of medications.
2.0 DEFINITION
Nasogastric tube is a tube (rubber or plastic tube) with radiopaque marker or strip
at the distal end passed into the stomach via the nose to remove gas or stomach
contents or for decompression post operatively and for feeding purposes.
4.0 POLICY
Nasogastric tube may be inserted by the physician or by a qualified nurse with the order of
the physician.
Insertion of nasogastric tube requires close observation of the patient and verification
of proper placement by x-ray studies.
Nasogastric tube must be changed every seven days unless ordered by a physician.
The date of change must be recorded in the nursing care plan and nursing notes.
The length of the nasogastric tube must be measured from the tip of the nose to the bottom
of the earlobe to the end of xyphoid process.
5.0 PROCEDURES
5.1 Explain to the patient or parents of children
about the procedure.
5.2 Position the patient to a high fowlers
position if health permits and support the head
on a pillow.
RATIONALE
5.1 Knowledge of the procedure eases anxiety and
promotes cooperation.
5.2 It is often easier to swallow in this position and
gravity helps the passage of the tube.
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Prepare equipment at bedside:
Nasogastric tube # 5-10 french

If rubber tube is used, place it on ice.
f a plastic tube is being used, place it in warm water.
Non-allergenic adhesive tape
Gloves
Water soluble lubricant
tethoscope
yringe as irrigation set
uction equipment if required
Restraints
Gauze swabs
5.4 Determine how far to insert the tube.
Measure from the tip of the nose to
tip of the earlobe to the end of xyphoid
process.
5.5 Wash hands and don gloves.
NURSING
2 of 4
To ensure readiness of the procedure.
This stiffens the tube for easier insertion.

This makes the tube more flexible, facilitating
insertion.
5.4 This length approximates the distance from the

nares to the stomach but it varies among
individuals.
5.5 To protect the nurses from contact of body fluid
(secretions).
5.6 A water soluble lubricant dissolves if the tube
accidentally enters the lungs.
5.7 Hyper extension of the neck reduces
the curvature of the nasopharyngeal
junction.
5.6Lubricate the tip of the tube with water

soluble lubricant.
5.7 Insert the tube, with its natural curve toward
the patient into the selected nostril.
Hyperextend the neck and gently advance
the tube toward the nasopharynx.
Do not hyperextend or hyper flex an infants neck: Hyper extension and hyper-flexion of the neck could
If the patient swallows, passage of the
occlude the airway.
catheter may be synchronized with the
Swallowing motions will cause esophageal
swallowing. Do not push against resistance.
peristalsis, which opens the cardiac
Gently try rotating the tube if resistance is
sphincter and facilitates passage of the
met.
catheter.
If there is no swallowing, insert the
catheter smoothly and quickly.
Because of cardiac sphincter and spasm,
resistance may be met at this point. Pause a few
seconds then proceed.
NICU-159

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5.8.3 If infant especially, observe for vagal

stimulations.
Once catheter has been inserted to the pre

measured length, ascertain correct tube
placement by:
nject 0.5-1 ml. air for small infants and up to 5 ml. in
larger children into the catheter while
simultaneously listening with stethoscope the
typical gurgling or growling sound over the
hypogastrium.
Aspirate injected air from the stomach.
Aspirate small amount of stomach content and
test acidity by pH tape.
NURSING
3 of 4
5.8.3 Stimulation of the vagus nerve

branches with the catheter will
directly affect cardiac and
pulmonary plexus.
The gurgling or growling sound over the

hypogastrium indicates that the catheter is in proper
location.
To prevent abdominal distention.
Failure to obtain aspirate does not indicate improper
placement; there may not be any stomach content or
the catheter may not be in contact with fluid.
5.10 Secure the tube by taping to the bridge of

the patient's nose and bring split ends under
the tubing and back up over the nose.
5.10.2 For infants or small children, tape
the tube to the area between the end of the
nares and the upper lip as well as to the
cheek.
5.10 Taping in this manner prevent the tube from

pressing against and irritating the edge of the nostril.
5.11 Record the date & time the NGT inserted,

type and size of the tube and length of the
tube inserted and document patient's response
to the procedure.
5.11 Measurement of the tube provides a baseline for

future comparison.
6.0 ATTACHEMENTS
6.1 Laboratory request
NICU-160

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Nasogastric tube # 5-10 french If rubber tube is used, place it on ice. If a plastic tube is being used, place
it in warm water.
Non-allergenic adhesive tape
Gloves
Water soluble lubricant
Stethoscope
Syringe as irrigation set
Suction equipment if required
Restraints
Gauze swabs
8.0 REFERENCES
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-161

POLICY NUMBER:
TITLE:
DPP
SNR-NICU-046
APPLIES TO:
NURSING
Nurses Certified in Basic Life Support (BLS) & Neonatal

Resuscitation Program (NRP)
APPROVAL DATE:
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1.0 PURPOSE
1.1 To establish efficiency of NICU staff to respond during emergency situation
and related nursing situations requiring the practice of Cardio Pulmonary
Resuscitation (CPR) that is current and according to standard of patient care.
2.0 DEFINITION
BLS - Basic Life Support
NALS / NRP Neonatal Advance Life Support / Neonatal Resuscitation Program.
4.0 POLICY
All new NICU staff are required to present certification of a current BLS upon hired
otherwise they should be certified within 3-6 months, and will be scheduled for NRP.
All nursing staff assigned in Neonatal Intensive Care Unit must be (Neonatal
Resuscitation Program) NRP certified. They must maintain NRP skills as
evidenced by an annual update review or recertification class.
It is the responsibility of the NICU staff to maintain a current BLS / NRP Certification and
provide evidence of recertification. A copy of the BLS and NRP certificates will be kept in
the employees file and will be updated before the expiry date.
5.0 PROCEDURES
BLS Initial Certification:
All nursing staff having direct patient contact is
required to be BLS certified.
If the staff has never been certified, then Head nurse will
submit the name of the new staff to Nursing
Education Department to attend an 8-hour initial
certification class.
RATIONALE
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5.2 BLS Re-certification:

5.2.1 Each staff with direct patient contact
will recertify his/her BLS card every
2 years at least 30 days before expiry
date.
5.3 NALS/NRP Certification:
5.3.2 All nursing staff assigned in
Neonatal Intensive Care Unit are
required to have NRP certificate.
Nursing Education will schedule the
staff to take NRP training and pass the
examination in King Fahd Armed
Forces Hospital or in Soliman Fakeeh
Hospital.
5.4 List of Staff with BLS and NRP Certificate is
attached.
6.0 ATTACHEMENTS
Copy of Certificate for each staff attached to their file.
List of BLS / NRP certified in NICU.
None
8.0 REFERENCES
Saudi Heart Association BCLS-NRP Manual
American heart Association BCLS-NRP Manual
NICU-163
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2010
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2010
NICU-164

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-047
APPLIES TO:
NURSING
Nursing Care of Infant with Hyaline Membrane Disease
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1.0 PURPOSE
To maintain adequate ventilation and oxygenation.
To promote adequate hydration and electrolyte status. Hyaline membrane disease is a syndrome of
premature infants that is characterized
2.0 DEFINITION
by a progressive and frequent fatal respiratory failure resulting from atelectasis and immaturity of
the lungs.
4.0 POLICY
The staff nurse must have knowledge of the disease.
Maternal and birth history must be taken as a tool in assessing the infants condition.
Strict hand washing should be observed in handling neonates.
The nurse must be alert in case of emergency. Crash cart and intubation equipment must be ready in
case needed.
The nurse should always be ready to assist the physician in emergency procedures such as intubation,
umbilical cannulation and surfactant administration.
The infant should be placed in the radiant warmer upon admission until temperature is stable.
5.0 PROCEDURES
5.1 Strict hand washing before attending to
patient
5.2 Maternal history and birth should be taken
Assess the infants respiratory status:
Determine the severity of retractions.
RATIONALE
5.1 To maintain standard precaution and to prevent
nosocomial infection.
5.2 Determines gestational age of infant.
5.3.1 To determine the degree of respiratory
disease.
Identify any period of apnea, and the

duration.
NICU-165

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Note any cyanosis.

Auscultate chest for diminished breath sound and
presence of crackles.
5.4 Monitor and record vital signs including
blood pressure, oxygen saturation and
weight.
Promote adequate gas exchange.
Administer supplemental oxygen at prescribed To prevent hypoxia and increasing respiratory
concentration by hood, nasal prong or
distress.
adequate tube.
Observe infants response to oxygen
Note response by improvement in
therapy.
arterial and capillary blood gas.
Observe for apnea. Stimulate infant if
If unable to produce spontaneous respiration
apnea occurs.
with stimulation, initiate
resuscitation.
Assist with endotracheal intubation and maintain
To improve oxygenation by preventing alveolar
mechanical ventilation as indicated.
collapse and increasing diffusion time.
Place patient in prone position.
To allow maximum lung expansion. This
position provides for a larger lung
volume because of the position of
the diaphragm. Decreases energy
expenditure and increase time spent
in quiet sleep, but it may also
present several problems:
uction secretions based on the assessment of the infant.

Observe for complications of suctioning such as
bronchospasm, bradycardia, hypoxia, trauma to
airway infection and pneumothoraces.
a. the chest might be obstructed

b. retractions are difficult to detect.
c. abdominal distention is difficult
to recognize.
Suction as needed because the gag reflex is
weak and cough is ineffective. Report
to the physician for any sign of
complication. Hyper- ventilate
patient prior to suctioning to
NICU-166

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prevent hypoxia.
5.5.7 Assist physician in the administration of
surfactant.
Assist physician during diagnostic
evaluation:
To check for biochemical abnormal- lities and to
Blood collection for glucose and serum calcium, CBC
determine the intervention to be applied.
and blood C/S.
To correct acidosis and hypoxia and adjust
ventilator setting accordingly.
Arterial blood gas analysis.
To determine the degree of the
disease and to distinguish RDS from
Chest X-ray
pneumonia.
Promote adequate nutrition and hydration.
Administer IV fluids or enteral feeding as needed and
observe infusion rate closely.
Observe IV sites for infiltration or infection; use
aseptic technique.
Administer tube feeding or parenteral
nutrition as ordered.
Monitor intake and output closely and weight infant
daily.
To prevent fluid overload.

To prevent sepsis.
To provide adequate caloric intake.
To determine the degree of hydration.
Maintain thermoregulation:
Place infant in isolette or radiant warmer to provideToa prevent hypothermia which may result in
vasoconstriction and acidosis.
neutral thermal environment.
Adjust isolette or radiant warmer to obtain
Radiant warmer should be used with caution
desired skin temperature.
to infant less than1,250 grams,
because of increased water loss and
potential for hypoglycemia.
5.9 Encourage parental attachment:
5.9.1 To provide information concerning
5.9.1 Encourage the parents to ask questions
the disease process, expected
concerning patients condition &
outcome and usual course of the
participate in the plan of care.
NICU stay.
NICU-167

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Call parents to update them on the infants

condition until they will visit the child.
Advice to give breast milk to feed infant
when enteral feeding is ordered.
Record all information regarding illness and
interventions rendered; and the patients
tolerance to the treatment.
6.0
SNR-NICU-047
4 of 5
To alleviate their anxiety and prepare parents

what to expect on their visit.
To promote mother and infant
bonding.
To provide assessment, progress or
implication of the patients illness for the
continuity of care..
ATTACHEMENTS
None

7.1
Oxygen source
7.2
Intubation equipments
7.3
Suction equipments
7.4
Surfactant
7.5
Radiant warmer / isolette
7.6
Umbilical cannulation equipment if needed
7.7
Intravenous tray with equipments
7.8
Intravenous solution
7.9
Crash cart
7.10 Syringe pump
8.0 REFERENCES
Lippincott Manual in Nursing Practice 7th Edition by Nettina
Neonatology Management, Procedures on Call Problems Disease and Drugs 5th Edition by Tricia Lacy
Go
NICU-168

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-047
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
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NAME:
5 of 5
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-169

POLICY NUMBER:
DPP
SNR-NICU-048
TITLE:
APPLIES TO:
NURSING
Oxygen Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1.0 PURPOSE
To promote tissue oxygenation
Oxygen Therapy is administered in the following circumstances:
Respiratory diseases such as chronic obstructive airway diseases, pulmonary
infarction/embolus, asthma.
Chest injuries following trauma when the mechanism of respiration may be impaired.
Heart disease when the cardiac output is reduced e.g. Myocardial Infarction,
Congestive Heart Failure.
Hemorrhage when the oxygen carrying capacity of the blood is reduced.
Pre operatively and post-operatively when analgesic drugs may have an
effect on respiratory function e.g. narcotics.
In emergency situation e.g. cardiac or respiratory arrest, cardiogenic,
bacteraemic or hemorrhagic shock.
2.0 DEFINITION
Oxygen therapy is the introduction of increased oxygen to the air available for
respiration to prevent hypoxia, a condition where insufficient oxygen is available
for the cells of the body especially in the brain and vital organs.
Oxygen masks are designed to give an accurate percentage of oxygen by entering
on appropriate amount of air as a specific flow rate of oxygen.
Different Mask Used:
2.1 Edinburgh Mask
The percentage of oxygen is adjusted by the flow rate at the flow meter only.
3.0 Hudson Mask
With this mask there are various attachments which can be used to give a more
specific percentage if prescribed; otherwise the percentage of oxygen is adjusted
directly by the flow meter.
NICU-170
1 of 7

POLICY NUMBER:
DPP
SNR-NICU-048
TITLE:
APPLIES TO:
NURSING
Oxygen Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
4.0 Venturi Mask

Individual masks are available for specific percentage of oxygen and appropriate
flow rates given for each mask.
5.0 Nasal Canulae
These are light plastic tubes inserted into each nostril and shaped to fit over ears
to maintain the position. Patients find them less claustrophobic than a conventional
mask. They are not suitable for all patients as lower percentage of oxygen are not
accurately obtained and at higher percentage. Humidification is inadequate.
6.0 Oxygen Tents
For emergency resuscitation procedures, oxygen may be administered via an
Ambubag and resuscitation mask.
7.0 Humidifiers
It is important that the oxygen administered is adequately humidified to prevent
drying of the mucosa of the respiratory tract. There are various humidifiers
available when percentages of oxygen above 35% is prescribed.
4.0 POLICY
Effectiveness of the oxygen therapy must be monitored and recorded, Oxygen
concentration maybe adjusted according to assessment.
Except in emergency situations oxygen therapy will be prescribed by Medical
Practitioner who will specify oxygen concentration, the method of delivery, &
parameters for regulation (blood gas levels, pulse oximetry values).
The patient's general condition should be assessed to identify any deterioration or
improvement in the hypoxic state.
level of consciousness
respiratory status (rate, depth, signs of distress)
vital signs (blood pressure & pulse)
color and condition of the patients skin & mucus membrane, must be observed for
the presence of cyanosis, clamminess, or sweating.
NICU-171
2 of 7

POLICY NUMBER:
DPP
SNR-NICU-048
TITLE:
APPLIES TO:
NURSING
Oxygen Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
The patient should be aware of the risk of fire while Oxygen is going on, dangers of smoking
should be explained to patient and visitors. No Smoking signs can help reinforce this
precaution.
Alcohol based solutions, ointments, and grease should not be used in areas where
oxygen is administered. These volatile substances are readily flammable and the
presence of oxygen will increase the risk of fire.
The administration of oxygen does not require aseptic technique, however standard precaution
should be maintained to prevent cross infection.
The respiration rate should be taken and recorded as frequently as necessary rating the
type and depth of the respirations.
Patients who have Bronchospasm can be helped by medication which includes
Bronchodilation, either systematically or via a nebulizer as prescribed.
Patients who have Chronic Obstructive Airway Disease (COAD) should be prescribed and
administered with low percentage of oxygen (24%-28% oxygen). Do not use more than 2
to 3 liters of nasal oxygen (30% face mask) without a Doctors order.
Oxygen tent or canopy is the most suitable oxygen delivery method for infants and young
children. They should not be exposed to a high percentage of oxygen for extended periods
unless ordered.
The removal of face masks for eating and drinking should be supervised by the nurse
and will depend on the patients condition. It may be possible to change to nasal
cannulae at meal time to maintain the accuracy of the oxygen percentage as
necessary.
4.12 Oxygen even when adequately humidified causes the mouth and nasal passages
to become dry, frequent oral and nasal hygiene will be required for the patients
comfort to maintain a healthy oropharyngeal mucosa.
NICU-172
3 of 7

POLICY NUMBER:
DPP
SNR-NICU-048
TITLE:
APPLIES TO:
Oxygen Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.0 PROCEDURES
5.1 Identify and confirmed the order for oxygen
therapy.
5.2 Explain the procedure to the patient.
5.3 Explain the dangers of smoking to the
patient and visitors and display No Smoking
signs.
Collect and assemble the equipment:
Oxygen humidifier (distilled water if needed for
humidifier).
Oxygen source (wall or cylinder)
Oxygen flowmeter
Nasal cannula or face mask
Nonsterile gloves
No Smoking sign
Cotton balls
Washcloth
Petroleum jelly
5.5 Insert flow meter into outlet on wall, or
place oxygen cylinder near the patient.
5.6 Prepare humidifier with distilled water to
the correct level, if needed.
5.7 Connect humidifier to flow meter then
attached the tubing to cannula or mask.
5.8 Turn on oxygen flow meter until bubbling is
noted in humidifier. Adjust the flow rate of
oxygen as prescribed.
5.9 Observe the flow of oxygen and water
vapor through the mask or cannulae before
administering.
NURSING
4 of 7
RATIONALE
5.1 To ensure accuracy of doctors order.
5.2 To gain patient's cooperation.
5.5 Allows for control of oxygen flow.

5.6 Delivers moistened oxygen to mucous membranes
of airway.
5.8 Permits delivery of correct oxygen concentration.
5.9 To check that the equipment is working efficiently.
5.10 Apply face mask or nasal cannnula in the

correct position adjusted to fit firmly and
comfortably over the patients nose & mouth.
NICU-173

POLICY NUMBER:
DPP
SNR-NICU-048
TITLE:
APPLIES TO:
NURSING
Oxygen Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5 of 7
For Nasal Cannula:

Place cannula prongs into patients nares.
Slip attached tubing around patients
ears and under chin. Place cotton
between tubing and ear for comfort
Tighten tubing to secure cannula, but
make sure patient is comfortable.
5.10.2 Aids in securing cannula and provides comfort

to patient.
For Face Mask:

Place mask over nose, mouth & chin
Adjust metal strip at nose bridge of mask
to fit securely over bridge of
patients nose.
Pull elastic band around back of head
or neck.
Pull band at sides of mask to
tighten.
Place cotton or gauze pad under
bridge of face mask.
5.11 Assist the Medical Practitioner when the

estimation of arterial blood gases is
required.
5.12 Remove nasal cannula each shift or every
4 hours to assess skin, apply petroleum jelly
to nares, & clean accumulated secretions.
Remove mask every 2 to 4 hours, wipe
away accumulated mist, & assess
underlying skin.
5.13 Observe all precautions to minimize the
risk of fire throughout the procedure and
5.10.4 Ensures correct fit.
5.13 Safety purpose
NICU-174

POLICY NUMBER:
DPP
SNR-NICU-048
TITLE:
NURSING
Oxygen Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
while the therapy still in use.

5.14 Position the patient for comfort with head
of bed elevated.
5.15 Dispose of or store equipment
appropriately.
5.16 Discard gloves to medical waste bag and
perform hand hygiene.
5.17 Evaluate respirations.
6 of 7
5.14 Facilitates lung expansion for gas exchange.

5.15 Decreases spread of micro organisms.
5.16 Reduces transfer of micro-organisms.
5.17 Aids in determining effectiveness of oxygen
administration.
Documentation:
Date & time Oxygen therapy started
Amount of oxygen & delivery method
Respiratory status before, during and after initiation.
Color of skin and mucous membranes
Teaching performed regarding therapy
& patients understanding
Blood gas results
Pulse oximetry levels
Pulse rate, respiratory rate
6.0
APPLIES TO:
ATTACHEMENTS
6.1 No Smoking Signs.

Oximeter cable
Oximeter connector
Oximeter probe
Alcohol swab
NICU-175

POLICY NUMBER:
DPP
SNR-NICU-048
TITLE:
APPLIES TO:
NURSING
Oxygen Therapy
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
7 of 7
8.0 REFERENCES
Fundamentals of Nursing, 7th Edition by Kozier, Erb, Berman, Snyder
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-176

POLICY NUMBER:
DPP
SNR-NICU-049
TITLE:
APPLIES TO:
NURSING
Tracheostomy Care
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 5
1.0 PURPOSE
To prevent infection and maintain mucus membrane and skin integrity.
To prevent accumulation of secretions that can interfere with respiration.
To ensure airway patency by keeping the tube free of mucus build up.
2.0 DEFINITION
Tracheostomy care is - the care rendered to patient with an artificial hole through the
neck to the windpipe. The airway is kept open, humidity is provided and the
wound is kept sterile. Without such care patient could suffer injury to the
vocal cords, stomach problems, blockage of the windpipe and infection.
4.0 POLICY
Tracheostomy care should be performed using aseptic technique.
Gloves must be used for all manipulation at the tracheostomy site.
The nurse should focus on maintaining patency of airway, facilitating the removal of
pulmonary secretions and cleansing the stoma.
The nurse must closely monitor signs of complication such as hemorrhage, edema
around the stoma, accidental decannulation, tube obstruction and the entrance of free
air into the pleural cavity.
The physician should be notified for any complications.
5.0 PROCEDURES
5.1 Wash hand thoroughly.
5.2 Perform any procedure that loosens
secretions (e.g., postural drainage, percussion,
nebulization).
5.3 Assemble equipments and supplies. Check
expiration date on sterile package and inspect
RATIONALE
5.1 To reduce the transmission of microorganism.
5.2 Promotes removal of secretions from all lobes of
lungs.
5.3 To ensure sterility.
NICU-177

POLICY NUMBER:
DPP
SNR-NICU-049
TITLE:
APPLIES TO:
NURSING
Tracheostomy Care
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 5
for tears.
Tracheostomy care kit
Sterile towel
Sterile gauze
Sterile cotton swabs
Sterile gloves
Hydrogen peroxide
Sterile water
Antiseptic solution & ointment (optional)
Tracheostomy tie tapes
(commercially available)
Tracheostomy securing device
Face shield
5.4 Assess the patient's condition and condition
of stoma such as redness, swelling, character of
secretions presence of purulence or bleeding.
5.5 Explain the procedure to the patient.
Provide privacy.
5.6 Place the patient on side or semi-fowler's
position unless it is contraindicated.
5.7 Put on face shield and sterile gloves.
5.8 Increase oxygen concentration to

tracheostomy collar or Ambu bag to 100%.
5.9 Using sterile technique, suction the length
of the tracheostomy tube.
5.10 Clear the external end of the tracheostomy
tube with 2 gauze sponges with hydrogen
peroxide.
5.11 Clear the stoma area with 2 peroxidesoaked gauze sponges. Make only a single
sweep with each gauze sponge before
5.4 To determine need for care. The presence of skin

breakdown and infection must be monitored. Culture of
the site may be needed.
5.5 Knowledge of the procedure lessens the anxiety of
the patient and to ensure cooperation as well.
5.6 To decrease abdominal pressure on the diaphragm
thereby promoting lung expansion.
5.7 Face shield prevents secretions from getting into the
nurse's eyes. Sterile gloves prevent contamination of the
wound by nurse's hands and also protect the nurse's
hands from infection.
5.8 Provides hyper oxygenation before suctioning.
5.10 Designate one hand as contaminated

and reserve the other hand as sterile for handling
sterile equipment.
5.11 Hydrogen peroxide may help loosen
dry
crusted secretions. To prevent contamination of a clean
area with a soiled pad.
NICU-178

POLICY NUMBER:
DPP
SNR-NICU-049
TITLE:
APPLIES TO:
Tracheostomy Care
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
discarding.
5.12 Loosen and remove crust with sterile
cotton swabs then clear the stoma area with
sterile water-soaked gauze sponges.
5.13 Clean the stoma area using dry sponges.
5.14 Clean an infected wound with an antiseptic
solution. A thin layer of antibiotic
ointment
may be applied to the stoma with a cotton
swab.
5.15 Change a disposable inner cannula,
touching only the external position and lock it
securely into place. If inner cannula is reusable,
remove it with your contaminated hand and
clean with hydrogen peroxide solution using
brush or pipe cleaners with the sterile hand.
When cleaned, drop it into sterile saline
solution and agitate it to rinse thoroughly with
sterile hand. Tap gently to dry.
5.16 Change tracheostomy tie tapes. Cut soiled
tape while holding tube securely with other
hand, careful not to cut the pilot balloon tubing.
5.17 Remove old tapes carefully. Grasp slit end
of clear tape and pull it through opening on side
of tracheostomy tube. Pull other end of tape
securely through the slit end of the tape. Repeat
on the other side then tie the tapes at the end of
the neck in a square knot. Alternate knot from
side to side each time tapes are changed.
5.17.1 Ties should be tight enough to keep tube
securely in the stoma, but loose enough to
permit two fingers to fit between the tapes and
the neck.
NURSING
3 of 5
5.12 Ensures that all hydrogen peroxide is removed.

5.13 Ensures dryness of the area. Wet promotes
infection and irritation.
5.14 May help heal wound infection.
5.15 Because cannula is dirty when

removed, use contaminated hand.
It is considered sterile once cleaned,
so handle it with sterile hand.
5.16 Stabilization of the tube helps

prevent accidental dislodgement
and keeps irritation and coughing.
5.17 To prevent discomfort, pressure and tissue
irritation.
5.17.1 Excessive tightness of tapes will

compress jugular veins, decrease
blood circulation to the skin
under the tape, and result in
discomfort for the patient.
NICU-179

POLICY NUMBER:
DPP
SNR-NICU-049
TITLE:
NURSING
Tracheostomy Care
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.18 Place a gauze pad between the stoma site

and the tracheostomy tube. Always keep the
area dry.
5.19 Cleaning of the fresh stoma should be
performed every 8 hours or more frequently if
indicated by accumulation of secretions. Ties
should be changed frequently if soiled or wet.
5.20 Documentation:
atus of tracheostomy site.
Size of trach cannula
eaning provided & dressing change, including date
and time.
Color, amount, & consistency of
Secretions.
Tolerance to procedure.
6.0
APPLIES TO:
4 of 5
5.18 To absorb secretions and prevent irritation and

infection of the stoma.
5.19 The area must be kept clean and dry to prevent
infection.
ATTACHEMENTS
6.1 Nurses notes

Tracheostomy care kit
Sterile towel
Sterile gauze
Sterile cotton swabs
Sterile gloves
Hydrogen peroxide
Sterile water
Antiseptic solution & ointment (optional)
Tracheostomy tie tapes (commercially available)
Tracheostomy securing device
Face shield
8.0 REFERENCES
Lippincott Manual of Nursing Practice, 7th Edition by Nettin
NICU-180

POLICY NUMBER:
DPP
SNR-NICU-049
TITLE:
APPLIES TO:
NURSING
Tracheostomy Care
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
5 of 5
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-181

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-050
APPLIES TO:
NURSING
Breastfeeding, Assisting the Mother
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 4
1.0 PURPOSE
To aid new mothers in acquiring skills for successfully breastfeeding their infants.
To establish the nurses role for the promotion and support of breastfeeding
mothers and their infants who require specialized care in the NICU or Intensive Care Nursery.
To promote mother infant bonding.
2.0 DEFINITION
None
3.0 POLICY
Mothers should be encouraged to breastfeed their infant as soon as feeding is ordered by
the physician.
Proper collection and storage of breast milk must be initiated.
Breast milk must remain at room temperature when infant is receiving continuous
feeds.
Breast pump set up and usage must be demonstrated to mother. Printed information
regarding breastfeeding must be provided.
Always use fresh milk first before going to frozen milk supply. Amount in excess of a
48 hour supply should be frozen for future use.
Do not thaw or heat milk in microwave.
Length of actual breastfeeding time should be limited only by infants tolerance.
Infants with special problems or concerns should be referred to a member of breastfeeding coordinator
for further counseling.
Breastfeeding card must be given to mother so that she can come to breastfeed her infant
anytime of the day.
NICU-182

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-050
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
5.0 PROCEDURES
5.1 Teach the mother about care of breast
and nipples
5.2 Prepare mother to receive baby.
5.3 Wash hands.
Teach mother different techniques and position of
breastfeeding:
Breastfeeding should be established within the first
hour of life.
Breastfed babies may be fed on demand.
Instruct proper latch on, getting much of areola
into mouth and nipple to back of the infants
mouth with lips flanged.
Instruct mother to burp the infant after
feeds, holding the infant upright
with gentle pressure against
stomach and patting or rubbing
back.
2 of 4
RATIONALE
5.1 Proper health teachings and information
must be provided to maintain a healthy procedure.
5.2 To promote mother infant bonding.
5.3 To maintain cleanliness and prevent infection.
5.4 Errors in glucose reading can result in
miscallibrated of improperly coded meters.
5.4.4 To prevent aspiration.
5.5 Instruct mothers on proper diet, to

increase fluid intake and to continue
prenatal vitamins and iron as prescribed
by physician.
5.6 Document condition of the breast and
nipples, and the response of the baby
to breastfeeding.
5.5 Helps in establishing and maintaining an

adequate supply of breast milk & promote
health of the mother and baby.
5.6 To provide information on infants
tolerance to procedure.
COLLECTION & STORAGE OF BREAST MILK:
Instruct the mother to always wash hands

with soap and water before handling the
breast, the pump & attachments.
Instruct the mother how to set up the pump
equipment properly.
5.3 Instruct mother to begin milk expression
NICU-183

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-050
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
as soon as possible after birth, ideally in

the first few hours.
5.4 Instruct mother to collect milk in sterile
plastic containers provided in NICU.
3 of 4
5.4 To maintain sterility of the breast milk thus

preventing complications that may occur.
5.4.1 Each milk container should be

labeled with mothers full name,
date and time pumped.
5.4.2 Amount in excess of 48 hour
5.4.2. Always use fresh milk first before
supply should be frozen for future use.
going to frozen milk supply.
STORAGE GUIDELINES FOR BREAST MILK:
Fresh
2 5 days in refrigerator
Thawed
24 hours in refrigerator
Frozen (home freezer unit)
3 6 months
Frozen (deep freeze 0 F)
6 12 months
6.0
ATTACHEMENTS
6.1 None

Breast milk
Feeding Bottle
Breast pump kit
8.0 REFERENCES
Neonatal Nursing Handbook by C. Kenner, J. W. Cott
Neonatology Management, Procedures on Call Problem, Diseases & Drugs 5th edition
by T. Gomella
Ministry of Health Policy and Procedure (CD) 1425
NICU-184

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-050
APPLIES TO:
NURSING
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
NAME:
4 of 4
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-185

POLICY NUMBER:
DPP
TITLE:
APPLIES TO:
SNR-NICU-051
NURSING
Availability of 24 Hour On Call Physician
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
1 of 2
1.0 PURPOSE
2.1 To facilitate prompt availability of on call physician at all times to provide immediate intervention in
emergency situation.
2.0 DEFINITION
None.
4.0 POLICY
Daily Rota of 24 hour on call Physician with pager number and/or mobile number
should be posted in NICU bulletin board.
Doctors room is provided to on call physician in NICU for easy access when
needed.
On call Physician should be contacted through pager bleeping system, mobile
number or through operator in case he/she is out of the area.
5.0 PROCEDURES
5.1 Head of the Department will prepare a
monthly Rota for the on call Physician.
5.2 NICU Nursing staff will be provided a
copy of the Physicians Rota as a guide
for the 24 hour on call.
5.3 Head nurse / Charge nurse in NICU should
check the Physician's Rota daily then
write the on call physician including their
pager number and mobile number in the
bulletin board for easy access of the
nurses to contact when needed.
5.4 Nurses on duty will contact them through
the following:
5.4.1 Pager system by:
RATIONALE
NICU-186

POLICY NUMBER:
DPP
TITLE:
SNR-NICU-051
APPLIES TO:
NURSING
Availability of 24 Hour On Call Physician
APPROVAL DATE:
EFFECTIVE DATE:
DUE FOR REVIEW:
NUMBER OF PAGES
2 of 2
a. Press number 88 in the telephone.

b. Press the Physician's pager number.
c. Press the extension number of the
telephone you are using, then finally
press #, hang up the phone and wait for
the reply.
Operator by:
a. Dial extension number 2777, 0 or
2861.
b. Give Physicians name to the
operator.
c. Inform the operator your location.
5.5 Document the time of calling and response
of the Physician in Nurses notes, and note
the time of arrival.
6.0 ATTACHEMENTS
6.1 Doctor's Monthly Rota.
None
8.0 REFERENCES
Ministry of Health Policy and Procedure (CD) 1425
NAME:
DATE
PREPARED BY:

2010
REVIEWED BY:
Mrs. Nada Harun

2010
APPROVED BY:

2010
NICU-187

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Ministry Of Health, General Directorate Of Nursing

Ministry of Health, General Nursing Administration

.1 ADMISSION OF AN INFANT TO NICU

.3 BATHING AN INFANT INSIDE THE INCUBATOR

.4 EMPLOYEE SURVILLANCE IN NEONATAL UNIT

.5 EYE TREATMENT OF THE NEWBORN

.6 FEEDING THE NEWBORN

.9 SKIN AND CORD CARE OF A NEWBORN INFANT

.10 TRANFER OF AN INFANT TO OTHER FACILITY

.11 VISITORS - TRAFFIC CONTROL IN NEONATAL UNIT

.12 ABDOMINAL GIRTH MEASUREMENT

.13 ARTERIAL BLOOD ANALYSIS

WEANING OF PATIENT FROM MECHANICAL

.15 CHEST TUBE INSERTION, ASSISTING WITH

.16 SURFUNCTANT ADMINISTRATION, ASSISTING WITH

.17 BLOOD EXCHANGE TRANSFUSION

.18 REMOVAL OF CENTRAL LINE

.19 BLOOD TYPING AND CROSS MATCHING

.20 UMBILICAL CATHETERIZATION

.21 PULSE OXIMETRY

.24 BLOOD TRANSFUSION THERAPY

.25 PNEUMOTHORAX, NURSING CARE OF INFANTS WITH

.26 INFANT ABDUCTION

.27 INCUBATOR CLEANING AND MAINATENANCE

.28 STERILIZATION PROCEDURE OF VENTILATOR TUBING

Ministry of Health, General Nursing Administration

BLOOD DRAW FROM UMBILICAL CATHETER

BLOOD GLUCOSE MONITORING BY HEEL STICK

CAPILLARY BLOOD GAS (CBG)

CARE OF PATIENTS ON MECHANICAL VENTILATION

CENTRAL LINE MONITORING AND DRESSING

CHEST TUBE REMOVAL- ASSESSING

EMERGENCY CRASH CART CHECKING AND RESTOCKING

EQUIPMENT CHECK-UP AND TESTING

INTRAVENOUS THERAPY & CANNULATION

ISOLATION OF THE NEWBORN

NARCOTIC AND CONTROLLED DRUG ADMINISTRATION

NARCOTIC AND CONTROLLED DRUG ENDORSEMENT

NASOGASTRIC TUBE INSERTION

NURSES CERTIFIED IN BASIC LIFE SUPPORT (BLS) &

BREASTFEEDING, ASSISTING THE MOTHER

AVAILABILITY OF 24 HOUR ON CALL PHYSICIAN

Ministry of Health, General Nursing Administration

INTERNAL POLICY AND PROCEDURE

Admission and Discharge Criteria for Neonatal Intensive Care Unit

DUE FOR REVIEW:

Ministry of Health, General Nursing Administration

INTERNAL POLICY AND PROCEDURE

Admission and Discharge Criteria for Neonatal Intensive Care Unit

DUE FOR REVIEW:

Infants requiring hemodynamic monitoring: arterial, umbilical or central lines.

Ministry of Health, General Nursing Administration

INTERNAL POLICY AND PROCEDURE

Admission and Discharge Criteria for Neonatal Intensive Care Unit

DUE FOR REVIEW:

7.0 MATERIALS & EQUIPMENT

Mrs. Mary Ann Peralta

Mrs. Nada Harun

Central Committee Of NPP 2010

Ministry of Health, General Nursing Administration

Nursing Newborn Assessment

DUE FOR REVIEW:

Ministry of Health, General Nursing Administration