Comprehensive Guide to Neonatal Equipment
Nursing Notes
Introduction to Neonatal Equipment
Neonatal equipment encompasses specialized tools and devices designed to support and monitor newborns, particularly those requiring intensive care. Understanding these tools is fundamental for nurses providing care in neonatal units. This comprehensive guide will explore the various equipment categories, their clinical applications, and important nursing considerations.
Clinical Pearl
Neonatal equipment must be specifically designed for the unique needs of newborns. Adult equipment should never be adapted for neonatal use as this can lead to serious complications including trauma, incorrect dosing, and inadequate support.
Key Principles of Neonatal Equipment
- Size-appropriate: Equipment must be appropriately sized for the neonate’s small and delicate anatomy.
- Precision: High precision is required due to the small margins of error in neonatal care.
- Temperature regulation: Many devices incorporate features to maintain optimal thermal environment.
- Gentle delivery: Equipment must deliver therapies with minimal trauma to delicate tissues.
- Monitoring capability: Continuous monitoring is essential for early detection of changes in status.
Neonatal Equipment Overview
Thermoregulation Equipment
Thermoregulation is critical for neonates, especially premature infants, who have limited ability to regulate their own body temperature. Hypothermia can lead to increased oxygen consumption, metabolic acidosis, and increased mortality, while hyperthermia can cause neurological damage.
Incubator
Purpose: Provides a controlled environmental temperature, humidity, and oxygen concentration while allowing visualization and access to the infant.
Key Components:
- Double-walled enclosure to minimize heat loss
- Servo-control mechanism with skin temperature probe
- Air temperature control system
- Humidity control system
- Oxygen concentration control
- Access ports/doors for procedures
- Adjustable mattress position
Temperature Modes:
- Air mode (manual): Set desired air temperature
- Servo-control mode: Set desired patient temperature
Radiant Warmer
Purpose: Provides heat via radiant energy, offering open access to the infant for procedures while maintaining thermal stability.
Key Components:
- Overhead heating element
- Servo-control mechanism with skin temperature probe
- Open bed with mattress
- Adjustable height
- Control panel
- Procedural lights
- Storage drawers/shelves
Temperature Modes:
- Manual mode: Set heater output
- Servo-control mode: Set desired patient temperature
Clinical Pearl
When using a radiant warmer, insensible water loss increases by 50-80% compared to an incubator. This requires increased fluid administration to prevent dehydration in these infants.
Nursing Considerations
- Properly secure the temperature probe with a reflective cover to prevent direct exposure to radiant heat
- Minimize opening incubator doors to maintain temperature stability
- Use plastic wrap or bags for extremely premature infants to reduce evaporative heat loss
- Monitor the infant’s temperature every 30 minutes until stable, then every 2-4 hours
- Ensure humidity levels of 50-70% for extremely premature infants to reduce insensible water loss
- Position equipment away from external heat sources and drafts
Comparison: Incubator vs. Radiant Warmer
| Feature | Incubator | Radiant Warmer |
|---|---|---|
| Heat Transfer Method | Convection (warmed air) | Radiation (infrared) |
| Access to Infant | Limited (through porthole doors) | Excellent (open access) |
| Insensible Water Loss | Lower | Higher (50-80% increase) |
| Humidity Control | Good | Poor |
| Noise Level | Higher (fans and motors) | Lower |
| Primary Use | Stable infants requiring thermal support | Infants requiring procedures or frequent interventions |
| Oxygen Control | Can create controlled oxygen environment | Cannot control environmental oxygen |
Mnemonic: “WARMER”
Key points to remember when using thermoregulation equipment:
W – Watch for water loss (insensible losses)
A – Assess temperature regularly
R – Regulate humidity appropriately
M – Monitor oxygen levels if controlling FiO₂
E – Ensure probe is properly placed
R – Reduce heat stress by proper setting selection
Case Scenario: Preterm Infant with Temperature Instability
Patient: A 28-week gestational age male infant, birth weight 1100g, 2 hours old
Situation: The infant is in a radiant warmer with servo-control set at 36.5°C. Current axillary temperature is 35.8°C despite the heater running at maximum output. The infant appears slightly jittery with mild retractions.
Assessment:
- Hypothermia (temperature < 36.5°C)
- Increased work of breathing
- Potential increased metabolic demands due to cold stress
Nursing Interventions:
- Check positioning of temperature probe and ensure it has a reflective cover
- Place a plastic wrap or heat-reflective blanket over the infant, leaving the chest exposed for visualization
- Use warm, humidified oxygen if respiratory support is required
- Place a hat on the infant to reduce heat loss from the head
- Consider transitioning to an incubator for better humidity control
- Monitor glucose levels as hypothermia increases risk of hypoglycemia
- Reassess temperature every 15-30 minutes until stable
Outcome: After implementing these interventions, the infant’s temperature stabilized at 36.6°C within one hour.
Troubleshooting Guide: Thermoregulation Equipment
| Problem | Possible Causes | Solutions |
|---|---|---|
| Infant temperature below target despite high heater output |
|
|
| Infant temperature above target |
|
|
| Humidity alarm on incubator |
|
|
| Wide temperature fluctuations |
|
|
Respiratory Support Equipment
Respiratory support is one of the most common interventions in neonatal care. Equipment ranges from simple oxygen delivery devices to sophisticated ventilators that provide full respiratory support for neonates with respiratory distress or failure.
Mechanical Ventilator
Purpose: Provides mechanical breathing support when an infant cannot maintain adequate ventilation independently.
Key Components:
- Control unit with display and alarms
- Oxygen/air blender
- Humidification system
- Breathing circuit
- Flow sensors
- Pressure monitors
- Endotracheal tube connection
Common Ventilation Modes:
- Pressure-controlled ventilation: Delivers set pressure with variable flow
- Volume-controlled ventilation: Delivers set volume with variable pressure
- High-frequency ventilation: Delivers small tidal volumes at rapid rates
- Pressure support ventilation: Augments spontaneous breathing
- SIMV: Synchronized intermittent mandatory ventilation
Continuous Positive Airway Pressure (CPAP)
Purpose: Provides continuous distending pressure to the airways to prevent alveolar collapse, reduce work of breathing, and improve oxygenation.
Key Components:
- Patient interface (nasal prongs, mask, or nasopharyngeal tube)
- Pressure generator
- Humidification system
- Pressure monitoring system
- Flow generator
- Oxygen/air blender
Types of CPAP:
- Bubble CPAP: Uses underwater seal to generate pressure
- Ventilator CPAP: Uses ventilator to generate pressure
- Variable flow CPAP: Adjusts flow to maintain pressure
- BiPAP: Provides two levels of positive airway pressure
High Flow Nasal Cannula (HFNC)
Purpose: Delivers heated, humidified oxygen or air at flow rates higher than standard nasal cannula, providing mild respiratory support.
Key Components:
- Nasal prongs (sized appropriately)
- Flow generator
- Heated humidification system
- Oxygen/air blender
- Temperature monitoring
- Tubing with water trap
Key Parameters:
- Flow rate: Usually 1-8 L/min for neonates
- FiO₂: Adjustable oxygen concentration (21-100%)
- Temperature: Usually 34-37°C
- Humidity: Near 100% relative humidity
Standard Nasal Cannula
Purpose: Delivers low-flow oxygen or air directly to the nasal passages.
Key Components:
- Small-bore nasal prongs
- Oxygen tubing
- Flow meter
- Optional humidification system
- Oxygen source
Flow Rates:
- Preterm: 0.25-0.5 L/min
- Term neonates: 0.5-1 L/min
Note: At these low flow rates, the delivered FiO₂ is unpredictable and depends on the infant’s respiratory pattern.
Clinical Pearl
When transitioning from mechanical ventilation to CPAP, maintain the same mean airway pressure initially to prevent atelectasis. For example, if the ventilator settings were PIP 20 and PEEP 5 with a rate of 30, the mean airway pressure would be approximately 8-9 cmH₂O, so start CPAP at 8 cmH₂O.
Nursing Considerations
- Assess for proper size and fit of nasal prongs to prevent pressure injuries
- Apply barrier protection (hydrocolloid or similar) to areas at risk for skin breakdown
- Ensure proper positioning of the infant to maintain airway patency
- Regularly assess for abdominal distension due to gas accumulation
- Provide regular oral and nasal care to prevent complications
- Monitor for signs of respiratory distress despite respiratory support
- Ensure tubing is free of condensation that could be inadvertently delivered to the infant
- Check that alarms are appropriately set and functional
Ventilator Parameters and Normal Ranges for Neonates
| Parameter | Description | Typical Range for Neonates |
|---|---|---|
| PIP (Peak Inspiratory Pressure) | Maximum pressure delivered during inspiration | 15-25 cmH₂O |
| PEEP (Positive End-Expiratory Pressure) | Pressure maintained at end of expiration | 4-8 cmH₂O |
| Respiratory Rate | Number of mechanical breaths per minute | 30-60 breaths/min |
| I:E Ratio | Ratio of inspiratory to expiratory time | 1:2 to 1:3 |
| FiO₂ | Fraction of inspired oxygen | 0.21-1.0 (target 0.21-0.40 when possible) |
| Tidal Volume | Volume of air moved in a single breath | 4-6 mL/kg |
| Flow Rate | Rate of gas flow through circuit | 6-10 L/min |
| MAP (Mean Airway Pressure) | Average pressure during respiratory cycle | 7-12 cmH₂O |
Mnemonic: “BREATHE”
Key assessments for infants on respiratory support:
B – Bilateral chest movement (equal?)
R – Rate of breathing (spontaneous efforts)
E – Effort (retractions, grunting, nasal flaring)
A – Air entry (auscultate lung fields)
T – Tidal volume (appropriate for weight)
H – Humidification (adequate moisture)
E – Equipment (properly functioning)
Case Scenario: Transition from Ventilator to CPAP
Patient: A 32-week gestational age female infant, day 3 of life, current weight 1650g
Situation: The infant has been on mechanical ventilation for respiratory distress syndrome since birth. Current ventilator settings: PIP 18, PEEP 5, rate 25, FiO₂ 0.28. Blood gases show pH 7.34, pCO₂ 45, pO₂ 65. The medical team has decided to extubate to CPAP.
Nursing Interventions:
- Gather equipment: Appropriately sized CPAP prongs, CPAP circuit, fixation device
- Apply hydrocolloid to nasal bridge and cheeks where prongs and fixation device will contact skin
- Set up CPAP system at 6 cmH₂O and FiO₂ 0.30 (slightly higher than current needs)
- Ensure proper positioning for extubation (slight neck extension)
- After extubation, quickly secure CPAP prongs and fixation device
- Assess respiratory status: work of breathing, chest movement, air entry
- Monitor oxygen saturation continuously and adjust FiO₂ as needed
- Check blood gas 1 hour post-extubation
- Monitor for signs of CPAP failure: increased work of breathing, apnea, oxygen requirement >0.40
Outcome: The infant tolerated extubation well with initial tachypnea that resolved after 2 hours. CPAP pressure was weaned to 5 cmH₂O and FiO₂ to 0.25 within 12 hours.
Troubleshooting Guide: Respiratory Equipment
| Problem | Possible Causes | Solutions |
|---|---|---|
| Low oxygen saturations despite high FiO₂ |
|
|
| High-pressure alarm on ventilator |
|
|
| CPAP pressure loss |
|
|
| Nasal injury with CPAP |
|
|
Monitoring Equipment
Continuous monitoring is essential in neonatal care to detect subtle changes in an infant’s condition, allowing for prompt intervention. Various monitoring devices track vital signs and physiological parameters.
Cardiorespiratory Monitor
Purpose: Continuously monitors heart rate, respiratory rate, and displays ECG waveform.
Key Components:
- Display screen
- ECG leads and cables
- Impedance respiratory leads
- Alarm system
- Recording capabilities
Parameters Monitored:
- Heart rate: Normal range 120-160 bpm
- Respiratory rate: Normal range 40-60 breaths/min
- ECG waveform: For rhythm assessment
Common Alarm Settings:
- HR low: 90-100 bpm
- HR high: 180-200 bpm
- RR low: 20-30 breaths/min
- RR high: 60-80 breaths/min
- Apnea: 15-20 seconds
Pulse Oximeter
Purpose: Non-invasively measures oxygen saturation of hemoglobin in arterial blood (SpO₂).
Key Components:
- Display monitor
- Neonatal-specific sensor
- Connecting cable
- Alarm system
Sensor Placement:
- Preductal: Right hand/wrist (represents brain oxygenation)
- Postductal: Foot (detects right-to-left shunting across ductus arteriosus)
Target SpO₂ Ranges:
- Preterm infants: 90-95%
- Term infants: 95-100%
- Infants with pulmonary hypertension: >95%
Blood Pressure Monitor
Purpose: Measures systolic, diastolic, and mean arterial pressure.
Monitoring Methods:
- Non-invasive (NIBP): Oscillometric measurement using inflatable cuff
- Invasive: Direct measurement via arterial catheter
Components (NIBP):
- Neonatal-sized cuffs (various sizes)
- Monitor display
- Connecting tubing
- Alarm system
Components (Invasive):
- Arterial catheter
- Pressure transducer
- Flush system
- Monitor display
- Waveform display
Temperature Monitor
Purpose: Continuously measures skin or core temperature.
Types:
- Skin probe: Measures surface temperature (servo-control for incubators/warmers)
- Rectal probe: Measures core temperature (limited use in neonates)
- Axillary probe: Intermittent measurement
- Infrared thermometer: Non-contact measurement
Normal Temperature Ranges:
- Skin temperature: 36.0-36.5°C
- Core/axillary temperature: 36.5-37.5°C
Alarm Settings:
- Low: 36.0°C (skin), 36.5°C (core)
- High: 37.0°C (skin), 37.5°C (core)
Clinical Pearl
When monitoring both preductal (right hand) and postductal (foot) oxygen saturations, a difference of >3% may indicate right-to-left shunting across the ductus arteriosus, which can be seen in persistent pulmonary hypertension of the newborn (PPHN).
Nursing Considerations
- Rotate the placement of pulse oximeter sensors every 3-4 hours to prevent skin breakdown
- Use appropriate size blood pressure cuff (width should be approximately 40% of limb circumference)
- Ensure ECG leads are securely attached and replace when adhesive degrades
- Set alarm limits appropriately based on the infant’s clinical condition
- Verify monitor readings with manual measurements periodically
- Minimize false alarms by ensuring proper placement of sensors
- Document all monitoring parameters according to unit protocol
- Consider developmental care by minimizing noise from alarms
Normal Vital Sign Ranges for Neonates
| Parameter | Preterm Infant | Term Infant | Abnormal Findings |
|---|---|---|---|
| Heart Rate | 120-170 bpm | 100-160 bpm | Bradycardia: <100 bpm Tachycardia: >180 bpm |
| Respiratory Rate | 40-70 breaths/min | 30-60 breaths/min | Bradypnea: <30 breaths/min Tachypnea: >60 breaths/min |
| Blood Pressure (Mean) | Approximately GA in weeks | 45-60 mmHg | Hypotension: MAP < GA in weeks |
| Oxygen Saturation | 90-95% | 95-100% | Hypoxemia: <90% Hyperoxemia: >95% in preterm with supplemental O₂ |
| Temperature (Axillary) | 36.5-37.2°C | 36.5-37.5°C | Hypothermia: <36.5°C Hyperthermia: >37.5°C |
| Glucose (Bedside) | 40-80 mg/dL | 40-90 mg/dL | Hypoglycemia: <40 mg/dL Hyperglycemia: >150 mg/dL |
GA = Gestational Age
Mnemonic: “VITALS”
Key points to remember when monitoring neonatal vital signs:
V – Verify placement of all sensors
I – Individualize alarm limits
T – Trends are more important than single readings
A – Assess all parameters together, not in isolation
L – Look for patterns in vital sign changes
S – Skin integrity at sensor sites needs monitoring
Case Scenario: Monitoring a Neonate with Apnea of Prematurity
Patient: A 30-week gestational age male infant, day 5 of life, current weight 1420g
Situation: The infant has had several episodes of apnea with bradycardia and desaturation over the past 24 hours. He is currently on caffeine therapy and nasal CPAP at 5 cmH₂O with FiO₂ 0.25.
Nursing Interventions:
- Set up comprehensive monitoring:
- Cardiorespiratory monitor with leads placed on upper chest and abdomen
- Pulse oximeter with sensor on right hand (preductal)
- Set apnea alarm at 15 seconds
- Set heart rate alarms at 90 (low) and 180 (high)
- Set SpO₂ alarms at 88% (low) and 95% (high)
- Position infant to optimize airway patency (slight neck extension, avoid flexion)
- Document frequency, duration, and characteristics of apneic episodes
- During apneic episodes:
- Provide gentle tactile stimulation
- Increase FiO₂ temporarily if needed
- Position airway with jaw thrust if required
- Begin bag-mask ventilation if not responsive to stimulation
- Monitor effectiveness of caffeine therapy:
- Track frequency and severity of episodes
- Check caffeine levels as ordered
Outcome: With proper monitoring, prompt intervention, and caffeine therapy, the frequency of apneic episodes decreased by 80% within 48 hours.
Troubleshooting Guide: Monitoring Equipment
| Problem | Possible Causes | Solutions |
|---|---|---|
| Frequent false alarms on cardiorespiratory monitor |
|
|
| Erratic SpO₂ readings |
|
|
| Inaccurate blood pressure readings |
|
|
| Temperature probe detachment |
|
|
Vascular Access Equipment
Vascular access is essential in neonatal care for medication administration, fluid management, nutrition, and blood sampling. Various devices are available based on the infant’s needs and expected duration of therapy.
Umbilical Catheters
Purpose: Provide central venous or arterial access through the umbilical vessels during the immediate neonatal period.
Types:
- Umbilical Venous Catheter (UVC): Placed in the umbilical vein for central venous access
- Umbilical Arterial Catheter (UAC): Placed in one of the umbilical arteries for arterial access
Components:
- Single or double-lumen catheter (3.5Fr or 5Fr)
- Sterile insertion tray
- Umbilical tape
- Sterile drapes and barriers
- Flush solution
- Suture material
Typical Uses:
- UVC: Medication administration, TPN, blood products, emergency access
- UAC: Continuous blood pressure monitoring, frequent blood sampling, arterial blood gases
Duration:
- Generally used for 5-7 days
- Some institutions allow up to 14 days for UVC
Peripheral Intravenous (PIV) Access
Purpose: Provides short-term venous access for fluid, medication administration, and blood sampling.
Components:
- Neonatal IV catheters (24G, 26G)
- Transilluminator or vein finder
- Extension tubing
- Sterile dressing materials
- Arm board or limb restraint if needed
Common Sites:
- Hands
- Feet
- Forearm
- Scalp (less common now)
Limitations:
- Short dwell time (typically 2-4 days)
- Limited to isotonic or mildly hypertonic solutions
- Risk of infiltration and extravasation
- Not suitable for continuous blood pressure monitoring
Peripherally Inserted Central Catheter (PICC)
Purpose: Provides medium to long-term central venous access when peripheral access is inadequate or central access is required.
Components:
- PICC insertion kit
- 1.9Fr or 2.8Fr silicone or polyurethane catheter
- Measuring tape
- Sterile barrier supplies
- Ultrasound device (sometimes used for guidance)
- Securement device
Common Insertion Sites:
- Basilic vein
- Cephalic vein
- Saphenous vein
- Axillary vein
Advantages:
- Longer dwell time (weeks to months)
- Suitable for hyperosmolar solutions (TPN, dextrose >12.5%)
- Reduced risk of infiltration
- Can be inserted at bedside
Non-Tunneled Central Venous Catheter
Purpose: Provides short to medium-term central venous access when immediate central access is required.
Components:
- Single, double, or triple-lumen catheter
- Insertion tray with Seldinger technique supplies
- Sterile barriers and drapes
- Ultrasound guidance
- Suture or securement device
Common Insertion Sites:
- Internal jugular vein
- Subclavian vein
- Femoral vein (less preferred due to infection risk)
Considerations:
- Usually inserted by physician in operating room or NICU
- Higher risk of complications than PICC lines
- Requires radiographic confirmation of placement
- Typically used for 7-14 days
Clinical Pearl
When calculating the insertion depth for an umbilical venous catheter, the “shoulder-umbilicus length” formula provides a good estimate: (shoulder to umbilicus distance in cm × 0.6) + 0.5 cm. For UACs, two positions are commonly used: “high” position (T6-T9 vertebral level) or “low” position (L3-L4 vertebral level).
Nursing Considerations
- Monitor insertion sites for signs of infection, infiltration, or extravasation
- Maintain aseptic technique during all catheter manipulations
- Ensure proper catheter stabilization to prevent dislodgement
- Assess blood return from catheters before medication administration
- Follow institutional guidelines for dressing changes and site care
- Document appearance of the site and catheter function each shift
- Maintain patency through appropriate flushing protocols
- For UACs, monitor perfusion to extremities distal to the insertion site
- Be vigilant for complications: thrombosis, catheter migration, infection
Comparison of Vascular Access Devices
| Feature | PIV | UVC | UAC | PICC |
|---|---|---|---|---|
| Typical Duration | 2-4 days | 5-7 days | 5-7 days | Weeks to months |
| Insertion Difficulty | Low to moderate | Moderate | Moderate to high | Moderate to high |
| TPN Administration | Limited (D10W max) | Yes | No | Yes |
| Blood Sampling | Limited | Yes | Yes (preferred for ABGs) | Limited |
| Blood Pressure Monitoring | No | No | Yes | No |
| Common Complications | Infiltration, phlebitis | Infection, thrombosis, migration | Vasospasm, thrombosis, embolization | Infection, thrombosis, migration |
| Time Limitation | None | First 3-7 days of life | First 3-7 days of life | None |
Mnemonic: “ACCESS”
Key points for vascular access care:
A – Aseptic technique for all manipulations
C – Check site appearance and function regularly
C – Compatibility of infusions (check for precipitation)
E – Ensure proper securement to prevent dislodgement
S – Scrub the hub before accessing
S – Signs of complications need prompt attention
Case Scenario: Management of Umbilical Catheters
Patient: A term newborn with meconium aspiration syndrome, 12 hours old
Situation: The infant has an umbilical venous catheter (UVC) and umbilical arterial catheter (UAC) placed in the delivery room. You are assuming care for this infant.
Nursing Interventions:
- Verify catheter position on X-ray:
- UVC tip should be at the junction of the inferior vena cava and right atrium
- UAC tip should be either above the diaphragm (T6-T9) or below the renal arteries (L3-L4)
- Assess catheter insertion sites:
- Inspect for bleeding, drainage, or signs of infection
- Verify secure anchoring with sutures
- Ensure transparent dressing is intact
- Maintain UAC:
- Connect to continuous pressure transducer
- Ensure system is properly calibrated and leveled
- Maintain continuous infusion at 0.5-1 mL/hr with heparinized solution
- Assess perfusion of lower extremities every hour
- Maintain UVC:
- Verify compatibility of all infusions
- Use dedicated lumens for TPN/lipids if multiple lumens are available
- Change tubing and caps according to protocol
- Monitor for complications:
- UAC: Blanching or cyanosis of lower extremities, hemorrhage, thrombosis
- UVC: Air embolism, hepatic necrosis if malpositioned, infection, thrombosis
Outcome: With proper maintenance, the catheters remained functional for 5 days until the infant’s condition improved and they were removed.
Troubleshooting Guide: Vascular Access
| Problem | Possible Causes | Solutions |
|---|---|---|
| Inability to flush catheter |
|
|
| Blood backing up in catheter |
|
|
| Dampened arterial waveform |
|
|
| Infiltration/extravasation |
|
|
Phototherapy Equipment
Phototherapy uses light energy to reduce bilirubin levels in neonates with jaundice. The light converts unconjugated bilirubin in the skin to water-soluble isomers that can be excreted without liver conjugation.
Conventional Phototherapy Light
Purpose: Delivers therapeutic light to reduce bilirubin levels in jaundiced neonates.
Key Components:
- Light source (fluorescent, halogen, or LED bulbs)
- Adjustable stand or overhead fixture
- Light meter for measuring irradiance
- Timer to track usage hours
Light Spectrum:
- Most effective wavelength: 450-475 nm (blue-green spectrum)
- Intensity typically 8-10 μW/cm²/nm for standard phototherapy
- Intensity ≥30 μW/cm²/nm for intensive phototherapy
Types:
- Fluorescent: Traditional but being replaced by LED
- LED: Efficient, doesn’t produce significant heat, longer bulb life
- Halogen: High intensity but produces heat
Fiberoptic Phototherapy Blanket/Pad
Purpose: Delivers phototherapy via a fiberoptic pad that can be placed directly against the infant’s skin.
Key Components:
- Light source (high-intensity halogen or LED)
- Fiberoptic cable
- Fiberoptic pad or blanket
- Disposable cover
Advantages:
- No heat generation at the pad surface
- No UV light exposure
- Can be used during holding and feeding
- No need for eye protection
- Can be used in combination with overhead lights for double phototherapy
Limitations:
- Lower irradiance than overhead systems
- Limited surface area coverage
- May not be sufficient for rapidly rising bilirubin levels
Clinical Pearl
The effectiveness of phototherapy depends on four key factors: light spectrum (blue-green is optimal), light intensity (higher is more effective), surface area exposure (maximize skin exposure), and proximity of light to the infant (closer is better). By optimizing these factors, you can achieve maximum bilirubin reduction.
Nursing Considerations
- Ensure proper eye protection that completely covers the eyes but doesn’t occlude nares
- Check eyes at least every 2-4 hours for discharge, corneal irritation, or improper placement of eye shields
- Expose maximum skin surface by keeping infant in only a diaper
- Verify appropriate distance between light source and infant (typically 30-50 cm for overhead lights)
- Reposition infant every 2 hours to maximize exposure
- Monitor hydration status closely as phototherapy increases insensible water loss
- Monitor skin temperature to avoid hyperthermia or hypothermia
- Remove eye protection during feeding and parental visits to promote bonding
- Maintain normal day-night cycles when possible by dimming room lights at night
Phototherapy Equipment Comparison
| Feature | Conventional Fluorescent | LED Phototherapy | Fiberoptic Blanket | Double Phototherapy |
|---|---|---|---|---|
| Light Source | Blue fluorescent tubes | Blue LED array | Halogen or LED with fiberoptic cables | Combination of overhead and mattress |
| Typical Irradiance | 8-12 μW/cm²/nm | 15-40 μW/cm²/nm | 5-10 μW/cm²/nm | ≥30 μW/cm²/nm |
| Heat Generation | Moderate | Minimal | None at pad | Varies with combination |
| Eye Protection | Required | Required | Not required if used alone | Required |
| Parent Holding | Interrupts therapy | Interrupts therapy | Can continue therapy | Partially interrupts therapy |
| Best Use | Moderate hyperbilirubinemia | Moderate to severe hyperbilirubinemia | Mild hyperbilirubinemia | Severe hyperbilirubinemia |
Mnemonic: “LIGHT”
Key points to remember for effective phototherapy:
L – Level (intensity) matters, check regularly
I – Irradiance should be measured and documented
G – Greater skin exposure equals better results
H – Hydration needs increase during treatment
T – Temperature monitoring is essential
Case Scenario: Managing Phototherapy
Patient: A 3-day-old full-term female infant with a total serum bilirubin of 18 mg/dL (high-intermediate risk zone)
Situation: The infant is admitted for intensive phototherapy. The medical order is to maintain intensive phototherapy until bilirubin levels decrease to < 13 mg/dL.
Nursing Interventions:
- Set up intensive phototherapy:
- Overhead LED phototherapy unit positioned 30 cm from infant
- Fiberoptic blanket placed under the infant
- Verify irradiance with light meter (target > 30 μW/cm²/nm)
- Prepare infant:
- Undress to diaper only
- Apply properly sized eye shields
- Position to maximize skin exposure
- Monitor during therapy:
- Vital signs every 4 hours
- Temperature every 2-3 hours
- Input and output monitoring
- Remove eye shields and check eyes every 4 hours
- Reposition infant every 2 hours
- Manage feeding and hydration:
- Continue breastfeeding every 2-3 hours
- Temporarily remove from phototherapy for feeding
- Consider supplementation if weight loss >10%
- Monitor for signs of dehydration
- Parent education:
- Explain purpose of phototherapy
- Teach parents about jaundice
- Encourage parental involvement
- Explain expected duration of treatment
Outcome: After 24 hours of intensive phototherapy, the bilirubin level decreased to 12.4 mg/dL, and phototherapy was discontinued. The infant was discharged home with follow-up arranged for the next day.
Troubleshooting Guide: Phototherapy Equipment
| Problem | Possible Causes | Solutions |
|---|---|---|
| Inadequate bilirubin reduction |
|
|
| Eye shield complications |
|
|
| Temperature instability |
|
|
| Skin rash or irritation |
|
|
Infusion Pumps & Feeding Apparatus
Accurate fluid delivery and nutritional support are critical in neonatal care. Various devices are used to safely administer enteral and parenteral nutrition, medications, and fluids to neonates.
Syringe Infusion Pumps
Purpose: Provides precise, controlled delivery of small volumes of fluids, medications, and nutrition.
Key Components:
- Pump mechanism with drive system
- Syringe holder
- Control panel with display
- Alarm system
- Battery backup
Features:
- Flow rates typically 0.1-60 mL/hr
- Accuracy of ±2-3%
- Multiple syringe size compatibility (3 mL to 60 mL)
- Occlusion pressure detection
- Anti-free flow mechanism
- “Smart pump” technology with drug libraries
Common Uses:
- Continuous medication infusions
- Total parenteral nutrition
- Lipid emulsions
- Inotropes and vasoactive medications
- Controlled fluid administration
Enteral Feeding Pumps
Purpose: Delivers breast milk or formula at controlled rates through feeding tubes.
Key Components:
- Peristaltic or syringe mechanism
- Control panel with display
- Feeding set holder
- Alarm system
- Battery backup
- Pole clamp
Features:
- Flow rates typically 0.1-20 mL/hr for neonates
- Compatible with various feeding sets
- Programmable for continuous or bolus feeding
- Occlusion detection
- Anti-free flow protection
Advantages:
- More precise than gravity feeding
- Allows for slow continuous feeding
- Reduces feeding intolerance
- Decreases energy expenditure during feeding
Enteral Feeding Tubes
Purpose: Provides direct access to the gastrointestinal tract for feeding when oral feeding is not possible.
Types:
- Orogastric (OG): Inserted through the mouth into the stomach
- Nasogastric (NG): Inserted through the nose into the stomach
- Nasoduodenal/Nasojejunal: Inserted through the nose into the duodenum/jejunum (less common in neonates)
Sizes:
- Preterm infants: 5-6 Fr
- Term infants: 6-8 Fr
Materials:
- Polyurethane: Softer, longer duration use
- Silicone: Soft, flexible, longer duration use
- PVC: Stiffer, shorter duration use
Verification of Placement:
- Measure pH of aspirate (gastric: 1-4)
- X-ray verification (gold standard)
- Length measurement (NEX method)
- Auscultation (not reliable alone)
Volumetric Infusion Pumps
Purpose: Delivers larger volumes of IV fluids and medications when precise control is required.
Key Components:
- Pump mechanism
- Administration set loading area
- Control panel with display
- Air-in-line detector
- Drip chamber sensor
- Alarm system
Features:
- Flow rates typically 0.1-999 mL/hr
- Multiple channel capability
- Programmable bolus function
- Drug dose calculation capabilities
- Anti-free flow protection
- Pressure monitoring
Common Uses:
- Maintenance fluid therapy
- Blood product administration
- Medication infusions
- Parenteral nutrition
Clinical Pearl
When administering medication through enteral feeding tubes, never add medication directly to formula or breast milk. This can affect drug bioavailability and stability. Instead, temporarily stop the feeding, flush the tube with water, administer the medication, flush again, and then resume feeding. This “separate, flush, administer, flush, resume” approach ensures proper drug delivery.
Nursing Considerations
- Use ENFit or other specialized enteral-only connectors to prevent misconnections between enteral and parenteral systems
- Label all tubing and pumps clearly to identify route (enteral vs. parenteral)
- Use proper size syringes for medication administration (oral syringes for enteral, parenteral syringes for IV)
- Verify feeding tube placement before each use
- Check compatibility when multiple medications are administered through the same line
- Maintain hydration status during gavage feeding
- Monitor for abdominal distension, residual volumes, and signs of feeding intolerance
- Secure feeding tubes appropriately to prevent dislodgement
- Reposition infant and feeding tube to prevent pressure injuries
- Always use “smart” features like drug libraries when available on pumps