• This document has been designed to assist nursing staff to ensure they provide and receive full information about the infant / family under their care. This list is not exclusive and there may be further issues that need to be included for a particular infant.

• This document also outlines the equipment check that must be performed at the beginning of every duty to ensure that prompt resuscitation can be completed if required.
   

Nursing Handover

• Baby’s name, days old, gestation at birth and currently (taken from gestational flow sheet)
• Current weight and recent increase/loss of weight
• Active problems with progress over 24hours
• Respiratory

• breathing assistance required: Vent settings, HCPAP (cmH2O), HHF (L), LF (ml)
• oxygen requirement, saturation targets
• secretions
• apnoeas
• destaturations (self-corrected vs. stimulation/oxygen)
• respirations: rate, indraw, nasal flare, grunting

• Observations

• temperature (if unstable ?environmental effects)
• heart rate, BP

• Feeding

• ml/kg/day, EBM or formula, fortified or not
• rate of increase, tolerance
• number of breast feeds and coding
• ? Haberman bottle and abilities

• IV therapy

• access: peripheral vs. longline
• D10 or D10+adds or P100+D10+lipids

• Output
  • Urine (?need nappy weighs)
  • Bowels
     
• Current medication
  • antibiotics: number of days, dosing
  • vitamins, diuretics, dexamethasone, other meds
     
• Blood results/due
  • glucose, SBR, blood gas, electrolytes
     
• Any other issues e.g. skin rash, mucky eyes
• How often/when mum/family in, any parental issues
• Potential to removed levels of care or movement to PIN or PNW
• How ready infant is for discharge
• Any special concerns
   

Receiving Handover

Take a full handover at the bedside for all infants in your care.
Before the previous duty nurse leaves check:

• IV/LL Fluids

• type of fluid is as per order i.e. correct additives
• correct rate infusing
• correct volume infused
• check all clamps and attachments
• IV site
• Double sign IV chart

• Respiratory therapy

• appropriate oxygen is being administer via CPAP, Humidified High-flow or Low-flow (check meter)

• Medication Chart
  • check all drugs given and signed for
  • note times medications due

• Check 2 correct name bands in place (1 in Level 3)
• Consider your workload
  • Are you responsible for any infants in the parent rooms
  • Is it appropriate? Does there need to be discussion with fellow workmates/CCN
  • Do you have the admission space? Is it set up?

Full Bedside Checks

• Resuscitation checks
  • check that the laerdal bag or neopuff in each bedspace, or in the PIN resuscitaire, is attached to gas supply and functioning appropriately (Neopuff set at 20/5 unless ventilator setting above)
  • check that appropriate masks are available
  • check cone is available at all spaces
  • Level 3: check resuscitation trolley in pod once per shift
  • Resource: check Level 2 trolley and adult resus trolley/defib once per shift

• CPAP

• critique CPAP application and remedy deficits ASAP especially if baby has an oxygen requirement or is unstable
• Ask for Resource Nurse or other nursing staff to help you if this is required immediately and you have feeds due

• Suction
  • Check suction system is functioning and appropriate size suction catheters are available in ponta drawer (sizes 6,7,8 available)
  • The suction pressure should be set around  100-150mmHg when occluded
     
• Monitors
  • Consider if monitoring is appropriate for infants status
  • Check cardiac, respiratory SaO2 and apnoea alarm limits are appropriate for each infant
  • Check audible alarm volume is set to 30%
  • Check the current configuration is correct
  • Check that ‘view other beds on alarm’ is set to auto
  • Check that ‘alert tone’ is set to repeat
     
• Temperature
  • Check temperature controls on incubators and heat tables
  • Check humidity temperatures on incubators and humidifiers
     
• Feeding plans
  • Check timing of next feed and recalculate feeds
  • Note when parents are due in
  • Defrost small amounts of EBM when required
  • Consider potential plans for the day: ?stop IV, increase feeds, commence fortifier, encourage demand BF
     
• Daily Plans
  • Sign the observation chart as taking over for the shift (covers responsibility for filling in Care Map as well)
  • Check Careplan
    • any equipment changes due
    • any screening due
    • maternal milk supply
    • parent education required
  • Check for any feeding issues highlighted
     
• Assessment Tool
  • Fill in assessment tool within the first 2 hours of the shift
  • Replace name bands if required

Nurse responsibilities

• Cleaning (PIN and Level 2 & 3)
  
  All cleaning fluids are kept in a basket by the sink in each clinical room for TWICE DAILY
  CLEANING (i.e. at the beginning of each 12 hour shift).
   
  • Using 0.1% Sodium hypochlorite solution wipe down the following at each cot space:
     
    • Individual trolley
    • PONTA or Gemina systems
    • Parent locker
    • Computer desk
    • Lazy boy chairs
      
       
  • Using Mediwipes:
    • Wipe down leads and equipment i.e. humidifier, Dash monitor

  The cleaners will come through and wash the floor, carry out high dusting and wipe the surfaces
  of shared areas – bench tops and cupboards. Assist the cleaners by pulling incubators away from
  the wall and supervise/direct them to clean any spills or obvious dirt that you have observed.
  
   

• Restocking (PIN and Level 2 & 3)

• Nursing staff re-stock:
  • All items in the large cupboards
  • All items in the drawers (common bench)
  • Linen, stationery
  • Medications

• The Health Care Assistants will stock
  • Individual trolleys twice a day, you can help by directing them to what is needed.
  • Oral syringes on common bench top.

Nursing Handover for Ward Round

New admissions to NICU should be presented with a complete medical history by the Registrar or
NS-ANP. There should then be a nursing handover emphasising current condition in terms of
observations, handling and any issues missed in the medical handover.

• Registrar/NS-ANP perform the bulk of the handover in Level 3 on Tuesdays and Thursday, all other days the nurse presents the infant
• In Level 2 the nurse will present the infant for wards rounds on every day
• Remember that we are trying to preserve the infant/family privacy so aim not to institute kangaroo cuddles around ward round time as parents will need to leave the room when other infants are being discussed

This should include a brief summary of:

• Baby’s gestation at birth and corrected, also days old
• Birth weight and current weight
  • gain or loss
• Active problems with progress over 24hours
• Respiratory
  • breathing assistance required: Vent settings, HCPAP, HHF, LF
  • oxygen requirement, saturations
  • secretions
  • apnoeas
  • destaturations (self-corrected vs. stimulation/oxygen)
  • respirations: rate, indraw, nasal flare, grunting
• Observations
  • temperature (if unstable ?environmental effects)
  • heart rate, BP
• Feeding
  • ml/kg/day, method, type, rate of increase, tolerance
• IV therapy
  • access: peripheral vs. longline
  • D10 or D10+adds or P100+D10+lipids
• Output
  • Urine
  • Bowels
• Drugs
  • antibiotics: number of days, dosing
  • vitamins, diuretics, dexamethasone
• Blood results
  • glucose, SBR, blood gas, electrolytes
• Potential to removed levels of care or movement to PIN or PNW
• Any other issues e.g. skin rash, mucky eyes
• Parental issues