OBSTETRICS & GYNAECOLOGYNURSING - II WRITTEN ASSIGNMENT ON ORGANIZATION OF NEONATAL INTENSIVE CARE UNIT Submitted To: Submitted By Mrs. Martha Raut Mrs. Monika Bagchi Asst Prof nd 2 year MSc N Submitted On: 17/02/2016 INTRODUCTION Newborn intensive care approach developed from the concept that a more intensive approach to neonates who require special care would result in a significant decrease in neonatal mortality and morbidity. A neonatal intensive care unit (NICU) is an intensive care unit specializing in the care of ill or premature newborn infants. The first official ICU for neonates was established in 1961 at Vanderbilt University Mildred Stahlman, officially termed a NICU when Stahlman used a ventilator off-label for a baby with breathing difficulties, for the first time ever in the world. DEFINITION OF NICU It is very specialized unit where critically ill neonates are cared to reduce the neonatal morbidity and mortality. INDICATIONS FOR ADMISSION IN NICU Low birth weight Large babies Birth asphyxia(APGAR score less than or equal to 6) Me conium aspiration syndrome Severe jaundice Infants of diabetic mother Neonatal sepsis/meningitis Neonatal convulsions Severe congenital malformation O2 therapy/parenteral nutrition Immediately after surgery Cardio respiratory monitoring Exchange blood transfusion PROM/foul smelling liquor Mother of Hepatitis B carrier Injured neonate. AIMS /GOALS OF NICU The goals of neonatal intensive care unit are To improve the condition of the critically ill neonates keeping in mind the survival of neonate so as to reduce the neonatal mortality and morbidity To provide continuing in-service training to medicine and nursing personnel in the care of newborn. To maintain the function of the pulmonary ,cardiovascular, renal and nervous system To monitor the heart rate, body temperature, blood pressure,central venous pressure and blood by non invasive techniques. To measure the oxygen concentration of the blood by oxygen analysers To check/observe alarms systems signal ,to find out the changes beyond certain fixed limits sets on the monitors. To administer precise amounts of fluids and minute quantities of drugs through I.V infusion pumps. CATAGORIES OF NICU:- LEVEL 1 . Evaluation and postnatal care of healthy newborn infants.. for infants with chronic lung disease needing long-term oxygen and monitoring Normal new born care LEVEL 2 .g. Phototherapy Care for infants with corrected gestational age greater than 34 weeks or weight greater than 1800 g who have mild illness expected to resolve quickly or who are convalescing after intensive care Ability to initiate and maintain intravenous access and medications Nasal oxygen with oxygen saturation monitoring (e. . Care of infants with a corrected gestational age of 32 weeks or greater or a weight of 1500 g or greater who are moderately ill with problems expected to resolve quickly or who are convalescing after intensive care Peripheral intravenous infusions and possibly parenteral nutrition for a limited duration Resuscitation and stabilization of ill infants before transfer to an appropriate care facility Mechanical ventilation for brief durations (less than 24 h) or continuous positive airway pressure. . Intravenous infusion. total parenteral nutrition. and possibly the use of umbilical central lines and percutaneous intravenous central lines Mild to moderate respiratory distress syndrome Suspected neonatal sepsis Hypoglycemia Infants of diabetic mother LEVEL 3 . and possibly inhaled nitric oxide. for as long as required immediate access to the full range of subspecialty consultation Comprehensive on-site access to subspecialty consultants. including computed tomography. Care of infants of all gestational ages and weights. hemofiltration and . Performance and interpretation of advanced imaging tests. magnetic resonance imaging and cardiac echocardiography on an urgent basis Performance of major surgery on site but not extracorporeal membrane oxygenation. Mechanical ventilation support. through both the areas there must have separate and adequate staff and single administrative control. or surgical repair of serious congenital cardiac malformations that require cardiopulmonary bypass. a) Clinical care areas b) Clinical support areas . For economising costs it would be preferably to have combined with level 2 facilities. The intensive area should be localised preferably next to labour ward and delivery rooms. the neonatal unit can be conceptualised in terms of four elements which exist in a concentric layering inside outwards with designed work traffic flow pattern. Severe respiratory distress syndrome Persistent pulmonary HTN Sepsis Prematurity at<32 weeks Major congenital malformations ORGANISATION OF NICU Physical Organization Personal Organization Equipment Organization PHYSICAL ORGANISATION The neonatologist and nurse incharge must be involved while planning the unit.haemodialysis. c) Administrative zones d) Family support area a) Clinical care areas . Scrubbing areas Storage spaces Hand washing scrub zones b)clinical support areas . . . Laboratory X ray machine Formula preparation TPN preparation Breast milk expression Equipment storage Clean and dirty utility areas c)Administrative and staff support areas Central reception area . and nursing staff Staff changing room On call duty doctor room Staff rest room Counselling room Seminar rooms Library 1. Separate unit office for ward master. resident doctor. Family support area Children play area Nourishment area A lounge Lockable storage Education area PHYSICAL ENVIRONMENT CHARACTERSTICS: . one intensive care bed is generally required for 100 deliveries provided the prematurity ratio is around 8 percent and hence for a population of one million. It would be uneconomical to have a NICU of less than 6-8bed.100 square feet is required for each baby as it is true for any adult bed ..1. Bed strength The NICU can be in a single area or it can be in multiple rooms with a capacity of 2-4 infants each. 2.30 intensive care beds would be required for our country. Space between the patient For the patient care. TEMPERATURE AND HUMIDITY CONTROL OF THE UNIT In case of controlling the environmental temperature. the NICU should not be located on the top floor. Each patient station should have 12-16 central voltage stabilised electrical outlets 2-3 oxygen out lets 2 compressed air outlets 2 compressed air outlets 2-3 suction outlets Additional power plug point would be required for the portable x-ray machine close to the patient care area 3. There should be a gap of about 6 feet between two incubators for adequate circulation and keep the essential life saving equipments. .space needed about 120 square feet. but there must be adequate sunlight for illumination The unit must have a fair degree or ventilation of fresh air through central air conditioning is must. The temperature inside the unit should be maintained at 28+_2deg c while the humidity must be above 50%. 6. In addition spot illumination should be available for each baby for any procedure. SOUNDS . Neat wash basin. WATER-HAND WASHING The unit must have an uninterrupted clean water supply and each patient care area must also have a wash basin with foot or elbow operated tapes. LIGHTING The lighting arrangement should provide uniform. 5.4. A generator back up is mandatory where there is frequent power fluctuations or power failures. shadow free illumination. COLOUR The walls of the whole unit should be washable and have a white or slightly off white colour for better colour appreciation of the neonates. 7. however alternatively air conditioned with multipore filters and fresh air exchange of 12 per hours should be provided. The unit should be equipped with laminar air flow system. placing paper towel and receptical. 2 air changes should be outside for filtering the inner air. adequate stores for keeping consumable and non-consumable articles A room for keeping x-ray and ultrasound machines One or two rooms each would be needed for doctors and nurses on day and night duties There is space available for a biomedical engineer to provide essential periodic preventive maintenance of costly equipments. The unit should also have an intercom and a direct outside telephone so that the parent of the patient can have an easy access to the medical personnels in case of an emergency 8.The acoustic characteristics should be such that the intensity of light kept below 75 decibels. like a room for scrubbing and gowning near the entrance. . VENTILATION Minimum of six air changes. a side laboratory mothers room. her e is need of space for certain essential functions. ROOMS Apart from the patient care area including rooms for isolation and procedures. Additional space will be required for educational activities and storing of data 9. COMMUNICATION: One emergency call bell in each room connected to doctors room .5H) to restrict passage of microbes 10. minimize microbial growth CEILINGS . ENVIRONMENTAL DESIGN: WALL SURFACES Easily cleaneable. noise reduction 11. protect at point with moveable equipment. Easily cleanable. made with sound absorbable material FLOORS Easily cleanable with out use of hazardous material. Effective air ventilation of nursery is essential to reduce nasocomial infections The air conditioning ducts must be provided with Millipore filters(0. DATABASE AND RESEARCH ENVIRONMENT: Computer ports with internet access should be readily available to maintain database and data analysis. 13. ECG. Toilets It is important to plan the number and position of water closets in the Neonatal Unit. teaching aids like X rays. medical on-call rooms. Transitional Care.12. Parents’ bedrooms. and the area dedicated to counselling (Parents’ Quiet Rooms) should all have separate toilet .SEPTIC NURSERY 14. and ABG reports must be maintained for future training and research. Database of all NICU information.SECURITY 15.HEAD WALL SYSTEM Refers to the array of the medical gas outlet+electrical+data outlet at each patient care station Electric environment Medical gases Data outlets 16. 17.facilities.Pneumatic tube system Careful thought should be put into how specimens can be transferred urgently to central laboratories in the Hospital. In a large Neonatal Unit there should be at least 3 further toilets for staff and the general public. Transport incubator store Transport incubators are bulky and should not be stored in public corridors. There should be a designated area for storing them within the Equipment Store 18. it . If a pneumatic tube system is chosen. and indeed any intensive care equipment required to service the infants in the incubator. Stationery Although some NNUs are striving towards becoming paperless. oxygen and air pipes and a vacuum facility for suction. Gantries . The clinician has the opportunity of specifying the number of electric sockets. Readily available personnel can then identify problems if the system were to fail to send an urgent specimen 19. monitors. The pendants contain intensive care facilities including electrical outlets. 20. gantries or cabinetry is a crucial early decision. CLINICAL Pendants. and the number of shelves which are fixed to the pendant arms. syringes drivers. There should therefore be a room of 12 sqm with extensive shelving for storage of all the paper sheets and forms necessary for the efficient running of the NNU. most will not achieve this in the next five years. robust and reliable. These shelves can hold ventilators. Pendants descend from the ceiling and are single-armed or double-armed.should be easily accessible. gantries. The outlet might be best positioned at the central station next to the Unit Office. cabinetry or head-rails? Choosing to equip the rooms with pendants. a mother and father with comfortable seating. vacuum and power points as well as the computer networks.Gantries have many of the advantages of pendants containing internally all the pipin and wiring required to provide the oxygen. so that staff can be familiar with the work area no matter which room or cots have been allocated to them. The size of the bays is critical. All intensive care and high dependency cots can be contained in spacious bays. Each must accommodate an incubator. air. computer and piped gas outlets can all be positioned so that there is no interference with the movement of staff caring for the infant. It is recommended that all such bays be identical in the Unit. monitors and syringe drivers can all be attached to the gantry. Many of the gantries allow movement laterally of the hangars and ventilators. Such bays should be at least 3. Electric sockets.g. cabinetry is fully consistent with the demands of intensive care.2m wide and the bay walls may extend 2-3 cm in room Head-rails . two members of nursing staff. for taking X-rays) within the allocated space. and it should be possible to manoeuvre all machinery (e. The clinicians again have the opportunity of specifying the number of sockets and the number of shelves. Cabinetry If designed carefully. These rails then carry most of the intensive care monitoring equipment WORK FLOW PATTERN AND ATMOSPHERE The NICU should be designed to allow efficient patient and staff movements within the unit. should be designed to maximise safety and convenience. push pad opening. • Ready access of the NNU to Labour Suite including Operating Theatres • All doors between Labour Suite and NNU. swipe-card access. and also those within NNU.It is possible to combine cabinetry systems with horizontal rails at the head of the incubator. Automatic opening. corridors and corners should be considered so that mothers have access to all clinical areas • Access to all cots in all clinical areas for X-ray. Widths of doors. punch-code access and manual opening may all be appropriate in individual circumstances • Positioning of Neonatal intensive care cots closest to the Labour Suite • Access for mothers on trolleys or in wheelchairs. The following should be included. An MRI scanner ideally should be available nearby on the same floor . ultrasound and other mobile equipment. and to the autopsy suite. and sufficiently distanced from busy corridors and extraneous noises to allow adequate rest opportunities • Consultant and research offices can be positioned further away from the clinical care area • Ideally there should be ready access to the mortuary. by arrangement. equipment storage. sound-proofed. support services (e. pharmacy. Atmosphere The NNU should be thought of as “baby’s first home”. to families • Attending consultant’s office should be in the NNU so that family interviews and staff interviews can take place readily • Doctors’ on call rooms should be in the NNU. clean and dirty linen store • Family access to the waiting area. milk storage.g. Such supports include near patient testing laboratory. This is achieved by thinking of the comforts of the . a viewing area for the bereaved. It must have a welcoming atmosphere. social work and community neonatal nursing) and recreational facilities • Positioning of the Clinical Manager’s office on the NNU floor. easily available to all staff and.• Clinical support areas should be as close as possible to clinical care areas. counselling rooms. research and teaching as well as co-ordinate with level 1 and level 2 hospital in the area . STAFF REQUIREMENTS . Natural lighting and where possible views of the surroundings outside are beneficial.infant and family. He should be responsible for maintenance of standard of patient care Development of operating budget Equipment evaluation and purchase Planning and development of education programme Evaluation of effectiveness of perinatal care in the area He should devote time to patient care services. Internal decoration can convert a clinical area into a room which is appealing to families. and encourages all members of staff to treat the care area as the infant bed room PERSONAL ORGANISATION MEDICAL STAFF-The unit should be headed by a director who is full time neonatologist with special qualification and training in neonatal medicine. radiologists cardiologists and should be available on call. He should be available for 24 hrs basis for consultation A ratio of one physician in training to every 4-5 patient who requires intensive care ideal round the clock Services of other specialists like micro biologists. four trained nurses per intensive care bed are needed Additional head nurse who is the overall incharge . hemtologists. Neonatal physician 6-12 in the continuing care. An anaesthetist capable of administering anaesthesia to neonate Paediatric surgeon and paediatric pathologists should be available NURSES RATIO Nurse patient ratio of 1:1 maintained throughout the day and night A ratio of one nurse for two sick babies not requiring ventilator support may be adequate For an ideal nurse patient ratio. intermediate care and intensive care areas. use of ventilators and the use of mask resuscitations and even endotracheal intubation. arterial sampling and so on EXPERIENCE The staff nurse must have a minimum of three 3yrs experience in special neonatal care unit in addition to having three months training in a intensive care unit. In addition to basic nursing training for level 2 carer. OTHER STAFF One sweeper should be available round the clock Laboratory technician Public health nurse/social workers Respiratory therapist Bio medical engineer . tertiary care requires dedicated committed and trained staff of the highest quality The training must include training in handling equipment. EQUIPMENT REQUIRED FOR ANY NEONATAL ICU 1. Incubator . Radiant warmer 2. Ward clerk can help in keeping track of the stores EQUIPMENT ORGANISATION Equipment and supports should include all that is necessary to resuscitation and intermediate areas Supply should be kept to the patient station so that nurse does not have to go away from the neonate unnecessarily and nurses time and skills are used efficiently There should be controlled incubators and open air system for providing adequate warmth Adequate number of infusion pumps for giving fluid and parenteral nutrition solutions and drugs should be available Infant ventilators capable of giving pressure ventilation and various cardiopulmonary monitor. Non invasive BP monitor 12. Infusion pumps 6. ECG monitor . Microdrips 15. Oxygen catheter 5. 14.3. Open care system 17. Suction apparatus 16. Intracranial pressure monitor. Oxygen analyser 8. Transcutaneous PO2 and PCO2 monitor 11. Invasive BP monitor 13. Electronic weighing machine 10. Positive pressure ventilator 7. Phototherapy 9. Radiography 4. Oxyhood Disposable articles 21. I.18. Three way stop cocks. ventilator tubes. umbilical arterial and venous catheter. IV set. Resuscitation set 20. 30. Nasogastric tubes 22. Bacterial filters. Pulse oxymeter 19. syringes. needles. Feeding bottles and cups. 27. 28. 31.V catheter 26. . 24. 23. Specimen bottles 25. 29. Diapers. demonstrations and group discussions. 33. steralisation to be maintained for critically ill babies. Catheters suction. DOCUMENTATION IN NICU The unit should have printed problem oriented stationary for maintaining records. Canula.32. There should be regular discussion with the obstetrician to discuss the perinatal care and condition Individual high risk cases Education and follow up is necessary ROLE OF A NURSE IN NICU . putting in arterial catheters. Educational programmes covering the nurses and physicians in the community should be developed. maintenance of ventilators. This should cover important issues like resuscitation. admission and discharge slips Record of all admission should be maintained in a register or on a computer The information should be analyzed and discussed at least once a month to improve the effectiveness of the nicu in providing the services EDUCATION PROGRAMME AT NICU There should be continuing medical education programmes for physicians and nurses in the form of lectures. urinary ET tube. conducting exchange transfusions. nasal catheters. have a caring attitude.A Neonatal nurse job role involves working in a specialist neonatal baby care unit (within maternity or children’s hospitals) or in the local community. As far as possible. very anxious and stressed or upset seeing baby coupled up to wires and monitors. Providing health education and counselling to patients. There are a vast number of conditions that can affect a new-born baby and require treatment from specialists within the healthcare team. Provides and/or manages the nursing plan of care for neonates with complex problems. As a neonatal nurse its important to be sensitive to the needs of others. and other members of the clinical team. As a neonatal nurse has an important role of supporting parents of the sick baby at a time when they themselves are frightened of losing their child. Performing other related duties as assigned/required. the parents and occasionally other family members are encouraged to take an active role in the care of the baby. Provides education. coordinates. information. ESSENTIAL DUTIES: Managing patient care of newborns and pediatrics. Maintaining medical records Participating in nursing and unit staff meetings and patient care conferences. registered nurses. methods and procedures for neonatal nursing in the Perinatal areas. training. Neonatal nurses care for new-born babies who are premature or are born sick. Keeps informed of current practices and trends and incorporates them into practice . Interprets. assisting with the admission assessment discharge of these patients. and consultation services to physicians. and implements new and existing policies. nurses will help parents to feel equipped in all aspects of meeting their little one's needs and will continue to serve as a basic support system during the hospitalization. these may also be administered during these times. If a baby is receiving any medications. need regular changes. At each care time. . the NICU will assign each baby "care times" throughout the day and night. General Care One of the main duties for a neonatal nurse is the general care of the infant. feedings and cuddles. Babies. take his temperature. a neonatal nurse will teach them how to perform these basic cares. Makes professional contacts with a variety of public. and often becomes the saving grace to worried parents who have plenty of questions and few answers about their situation. and feed him breast milk or formula. Performs other related duties as assigned/required. The duties for a neonatal nurse may vary slightly at each hospital. but overall their care tasks are the same. even tiny ones or those with physical ailments. the nurse will change the baby's diaper. A neonatal nurse is one of the primary caregivers of a baby in the intensive care unit. usually about 3 or 4 hours apart from each other. Works in cooperation with other members of the multidisciplinary health teams. private and professional institutions/organizations. If the parents of an infant are able to visit regularly. Customarily. With time. . Nurses will carefully place the correct amount of formula or dietary supplementation if a baby is not yet eating. and drawing blood for various testing.Special Needs Sometimes babies are too fragile or small to eat directly from breast or bottle. and monitors the baby for any positive or negative changes in the infant. Technical Duties for a Neonatal Nurse Regardless of their other responsibilities. Nurses are able to perform many other procedures as well. as well as the nurse's experience level and staff rating. The details logged into the online chart allow doctors. completed electronically via a special hospital computer system. and it fully depends upon each hospital's individual protocol. they are fed either intravenously. administering blood transfusions when necessary. all neonatal nurses do a fair bit of charting on each of their patients. and anyone else within the baby's medical care team to view a baby's updated health records. or through a gavage tube. other nurses. When this is the case. which is a small tube that goes from the nose or mouth into the stomach. This may be on a paper sheet. The duties for a neonatal nurse also include inserting and changing IVs. or more commonly every year. into either of these methods of nutrition. Neonatal nurses are often the unsung heroes to families and able to give the earliest of lives a fighting chance.A nurse may also be responsible for emailing the neonatologist (NICU doctor) or calling the parents with specific requests or information. This works well. . especially if they happen to have a primary baby they take care of. they often also spend a large portion of their shift charting and getting messages out to those who need to receive them. Their daily duties add up to countless miracles and a rewarding career at the same time. they can often provide emotional support and comfort during scary times. If a baby has to go through surgery or is exceptionally ill. In building relationships with these families. While a neonatal nurse's priorities are found in caring for the child assigned to them. Emotional Support A neonatal nurse often gets to know the families of infants very well. nurses are great for reassuring the parents and providing as concrete of answers as they are permitted to. A primary nurse will care for the same infant for the duration of his hospital stay. whenever he/she is on shift. as the nurses become very familiar with their babies and can in turn provide them with the best care possible. Neonatal intensive care unit ideally should be next to the obstetric suite. These cost increase with decreasing birth weight and gestational age.CONCLUSION A neonatal intensive-care unit (NICU). . Therefore neonatologists must include parents in any discussion about whether to continue the extreme measures being provided to their extremely low birth weight preterm infants. is an intensive-care unit specializing in the care of ill or premature newborn infants. resident physicians. nurse practitioners. physician assistants. nurses and architects. Neonatal intensive care is costly not only to the individual but also to the family. also known as an intensive care nursery (ICN). dietitians. pharmacists. Development of neonatal intensive care unit requires careful planning with the joint efforts of physicians. and respiratory therapists. A NICU is typically directed by one or more neonatologists and staffed by nurses. Many other ancillary disciplines and specialists are available at larger units. The plan should be based on functional efficiency. and quality care. The units are located in some remotest districts where the burden of neonatal deaths is high.5 per 100 deliveries in 2009. 2011 Oct. Correlation coefficients were estimated to understand the possible association of casefatality rate with factors. such as bed:doctor ratio. A cross-sectional survey was also conducted to assess the availability of human resources. The neonatal mortality rate in India is high and stagnant. The case-fatality rate reduced from 4% to 40% within one year of their functioning. The study was conducted to assess the functioning of SCNUs in eight rural districts of India. and the asepsis score was determined. equipment. Descriptive statistics were used for analyzing the inputs (resources) and outcomes (morbidity and mortality). and access to special newborn care is poor. and bed occupancy rate. bed:nurse ratio. average duration of stay. Chisquare test was used for analyzing the trend of case-fatality rate over a period of 3-5 years considering the first year of operationalization as the base.7 per 100 deliveries in 2008 to 19. The rates of admission increased from a median of 16. The rate of mortality among admitted neonates was taken as the key outcome variable to assess the performance of the units. Special Care Newborn Units (SCNUs) have been set up to provide quality level II newborn-care services in several district hospitals to meet this challenge.RESEARCH PUBLICATIONS: Journal of Health Population & Nutrition. Proportional mortality due to sepsis and low birth weight (LBW) declined significantly over two years (LBW <2. The evaluation was based on an analysis of secondary data from the eight units that had been functioning for at least one year.5 .29(5):500-509 (1) Assessment of special care newborn units in India. neonatal stabilization units (level I care) and newborn care corners can . The units are located in some of the remotest districts where the burden of neonatal deaths and accessibility to special care is a concern.kg). The major reasons for admission and the major causes of deaths were birth asphyxia.3). The units had a varying nurse:bed ratio (1:0. maintenance of equipment. and the average duration of stay ranged from two days to 15 days (median 4.48(12):931-935. Neonatal mortality rate in India is high and stagnant. However. although several challenges relating to human resources.75 days). The bed occupancy rate ranged from 28% to 155% (median 103%). Indian Journal of Pediatrics.5-1:1. A recently concluded evaluation of these units indicates that it is possible to provide quality level II newborn care in district hospitals. and maintenance of asepsis remain. It is not the SCNU alone but an active network of SCNU (level II care). (2) Challenges in scaling up of special care newborn units-lessons from India. sepsis. and LBW/prematurity. there are critical constraints such as availability and skills of human resources. 2011 Dec.By Malhotra S & Mohan P. It is possible to set up and manage quality SCNUs and improve the survival of newborns with LBW and sepsis in developing countries. Special Care Newborn Units (SCNUs) are being set up to provide quality level II newborn care services in district hospitals of several districts to meet this challenge. maintenance of equipment and bed occupancy. . Repair and maintenance of equipment were a major concern. Ahuja Publication.2000 Edition.Pune.Pediatric Nursing.First Edition. 2.B.14-16 3.2005 Edition. Marta Velasco. ”Manual Of NICU Protocol”.By Neogi S & Zodpey S REFERENCES: 1.12-14 .impact neonatal mortality rate reduction higher.Page No. .T Basavanthappa. Number of beds is also not sufficient to cater to the increasing demand of such services.Command Hospital.Page No. Scaling up these units would require squarely addressing these issues. Uma Raju.Mc Graw Publication . An effective and sustainable system to maintain and repair the equipment is essential.Pediatric Child Health Nursing.Surg Cdr SS Mathai. Available number of nurses is a problem in many such units. Dr. Col. M . National Institutes of Health. Boston: Council of International Neonatal Nurses.. Douglas Harper.20-22 6. Craig (July 2004). 2010. "neonatal". Beverly A.2002 Edition. "Frequently Asked Questions".4. "Neonatal Nurse". Shoemaker. Assuma Beevi. Peters. Retrieved October 26.12-18 7. Whitfield. 11.1st Edition. Douglas.Page No.T. 2010. 2009.. Wong’s. Achars Text Book Of Pediatrics. Jonathan M.Text Book Of Pediatric Nursing. Conceptualization and initiation of a neonatal intensive care nursery in 1960 (PDF). 8. 9. "Conference summary: a celebration of a century of neonatal care".Nursing Care Of Infants And Children. Neonatal intensive care: a history of excellence. Elsevier Publication.7th Edition.Page No.University Press Publication.Page No.Harper. . Nurses For A Healthier Tomorrow. Gluck.2002 Edition .Fourth Edition. 2010. Retrieved October 26. Online Etymology Dictionary. Retrieved October 26. Louis (7 October 1985).Mosby Publication. Nurses For A Healthier Tomorrow. 10.13-15 5. Global Unity for Neonatal Nurses. digitale-sammlungen.org/classics/cadogan. Nurses for a Healthier Tomorrow. http://www. Nurses for a Healthier Tomorrow. 2010.neonatology.html 15."Neonatal Nurse". http://www.12.de/bsb00027988/image_1 14.pdf . http://daten. 13. Retrieved October 26.neonatology.org/pdf/arrault.