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NICU-Developmentally Supportive Care

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NICU-Developmentally Supportive Care

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  1. Developmentally Supportive Care in NICU Dr.C.S.N.Vittal

  2. Developmentally Supportive Care Agenda: • Introduction: Developmentally Supportive Care • Difference in environment Term Vs Preterm • NICU Environment –Effects of Sound • NICU Environment –Effects of Light • Handling & Positions • Feeding • Stimulation • Summary & Quiz

  3. NICU QUIZQ1 Select the correct statement: A. Preterm baby should be exposed bright red light to improve the vision B. Preterm baby should listen to music always C. REM sleep is important for preterm baby’s brain growth D. Preterm baby feels pain but does not remember it

  4. Developmentally supportive care • Developmentally supportive care is defined as care of an infant to support positive growth and development, while allowing stabilization of physiologic and behavioral functioning • Providing similar environment to mother’s WOMB National Association of Neonatal Nurses, 2000

  5. Normal fetal development • Musculoskeletal system develops • In a gravity-free buoyant environment • With freedom to move and receive developmentally appropriate stimulation, (tactile=sense of touch, vestibular=sense of balance, auditory and visual sensory stimulation) • Provides positive sensory input for brain development

  6. Preterm infant Early neurosensory development impacted • NOT a gravity-free & buoyant environment • NOT a positive intrauterine environment, (position, touch, sound, comfort and light) Incomplete development of muscle tissue, joint structures, bone density Difficult to maintain flexed position, cannot alter Can Impact Developing Brain Difficult to maintain flexed position, cannot alter position for pain & discomfort LIE FLAT IN A FROG LEG POSITION

  7. Preterm infant Additonal problems Illness Energy depletion Gravity & weight of IV lines

  8. NICU Care Past Present

  9. NICU Environment –Present Scenario • Preterm babies with immature organ systems • “Deprivation” or “Over-stimulation” • Inappropriate patterns of stimulation • Immature distance receptors (e.g. hearing & vision) over stimulated • Mature tactile and vestibular pathways under-stimulated • “Robatic” care • No parental / maternal involvement

  10. The BENEFITS of the Womb • Cushioned with comfortable aquatic abode • Thermal comfort • Zero water losses • Shielded from light • Protected from sound • Effective and safe oxygenation • Optimal excretion of waste products

  11. NICU QUIZQ2 All are signs of pain and stress, except: • Mid Line position of hands • Saluting position of hand • Sitting in Air posture • Limbs flaying • Drop in O2 Saturation

  12. NICU Environment Signs of neonatal stress • Color changes, alterations in HR & RR, alterations in O2 Saturation, Hiccoughs • Reduced movements, increased movements, open mouth • State : Hyperalert, fussing, uneven sleep states (Gupta G,2001) HR=Heart Rate, RR=Respiratory Rate

  13. NICU QUIZQ3 The following measures are taken to minimize pain, except: • Avoid bright light and loud noise • Limit the number of invasive procedures • Swaddling • Facilitated Tucking • Tactile stimulation

  14. NICU Environment – Sound Adverse effects of loud sound (> 60 db) Interferes with sleep Increase in Heart Rate Peripheral vasoconstriction (Hypothermia, Increased Heart Rate) Sudden loud noise may iO2 Saturation, h Intra Cranial Pressure Hearing loss Lefrak L, 2001

  15. What is Noise for a preterm newborn?NICU Environment –Sound

  16. NICU Environment –Sound Interventions to reduce noise Decrease noise in NICU Decrease monitor noise Respond quickly to alarms Rounds & reports away from bedside Speak softly Decrease telephone & intercom noise Move equipment quietly, repair noisy ones Decrease staff generated noises Prepare medications & feedings away from bedside Gently open doors and drawers

  17. NICU SoundHelpful Effects Sound of mother’s voice (calming effect) Light music may be beneficial Greet & talk to the baby • Better weight gain • Decreased hospital stay Lullabies, womb sound, Better behavioural organization

  18. NICU Environment- Light Present scenario Slevin M, 2000

  19. NICU Environment- Effects of Light Slevin M, 2000

  20. NICU Environment - Light Reduction Recommended Range: 10 -600 lux (approximately 1 to 60 foot candles), at bedside. Sunlight 107,527 Full Daylight 10,752 overcast Day 1,075 Very Dark Day 107 Twilight 10.8 Luxmeter (for light intensity measurement)  Brandon HD et al,2002. http://www.engineeringtoolbox.com/light-level-rooms-d_708.

  21. NICU Environment - Cycling of Light Cycled light exposure  – Rotating Light and Darkness  12 hours 12 hours Brandon HD et al,2002

  22. NICU Environment - LIGHT & Sound

  23. NICU QUIZQ4 Massage to be done by: A. With light feathery touch B. With at least 20 ml of coconut oil C. With 2 fingers flat on baby and firm gentle strokes  D. From limbs to head with a electronic massager

  24. NICU QUIZQ5 For preterm and extremely low birth weight, the following can be done: • Gentle Massage • Apply coconut Oil instead of Massage • Do Massage using coconut Oil • Just light feathery touch

  25. Handling Flexion Extension

  26. NICU Environment –PositioningGuidelines

  27. Reduce Physical and behavioral stress NICU Environment –Handling Pace the care according to baby Time the care around Sleep / wake cycles No routine procedures Provide 2-3 hrs of Uninterrupted sleep Watch for stress

  28. Promote development & enhance comfort (self-regulation) • REMEMBER:  • Preemie flip, extremely stressful • Supportive turning and lifting • Facilitate smooth movement against gravity • Avoid tension from medical lines

  29. If this was a uterus, the legs would have pushed  through the wall! These pictures show inadequate positioning. Importance of rolls and supports in order to recreate the womb. This allows the baby to feel secure and continue to develop

  30. Should not be constrained but lie in a flexible nest that encourages a return to postural flexion, as in the uterus Boundaries should promote development, i.e. shoulders forward, not in extension 

  31. NICU Environment  - Handling Allow for normal, not stressed movement.  Should not be constrained but occurs in a flexible nest that encourages a return to postural flexion, as in the uterus

  32. Avoid “frog-legged” position

  33. Back to sleep, prone for play Position for play Position for Sleep

  34. Facilitated Tuck (Containment) Firmly containing the infant using hands on both head and lower limbs to maintain a ’folded-in’ (flexion) position.  Infant may or may not be wearing clothes. Tucking can be done prior to procedures that can be stressful to the baby.

  35. Swaddling (Bundling) Secure wrapping of the baby in a blanket to prevent the limbs from moving around excessively. Swaddling helps for attaining “folded in” or flexion posture . Effective for stable preterm infants for stress and immediate control of pain.

  36. Nesting (Boundary) Creating a nest like oval boundary around the infant using sterilized sheets. Nesting holds and contains the infant in the position, mimicking the “womb”. Nesting helps in stabilizing the infants and promotes sleep.

  37. Nesting (Boundary)

  38. NICU QUIZQ6 The non-pharmacological measures to minimize pain, except: • Using Sucrose/Glucose droplets • Skin to Skin care • Breast Feeding • IV Analgesics  • Non-Nutritive sucking

  39. NICU QUIZQ7 • The analgesic effect of sucrose lasts for how long? • Up to 30 mins • Up to 15 mins • 1-2 mins • 5-8 mins  • More than 10 mins 

  40. NICU QUIZQ8 Which of the following is not a physiological response to pain? A. Blood Pressure Changes B. Heart rate Changes C. Miosis  D. Drop in Saturation  E. Tremors

  41. Signs of Pain NICU Interventions

  42. Neonatal Pain – Misconceptions NICUInterventions • Newborns lack anatomical &  physiological structures to transmit pain  sensation. • Can not express pain sensation • Have no memory of pain • Would not tolerate analgesia /  anesthesia No routine procedures Watch for stress

  43. How to pick up the signs of Pain/Stress

  44. NICU Environment-Feeding

  45. NICU QUIZQ9 Which of the following is not suitable for trophic feeding to prepare the gut? • Mother’s Milk • Pasteurized Donor Human Milk  • Formula Feeds • TPN • Saline Drops through mouth

  46. NICU QUIZQ10 Advantages of Fortification with human milk-based fortifier are:  • Made of Human Milk • Can be initiated as early as 40 mL/kg/day • More feed intolerance as compared to bovine based fortifiers • Available to be used with 12.5 ml of mother’s milk • Human Milk based fortifier is not available in our centre

  47. NICU Interventions - Stimulation Stimulation through special  senses (Visual/Auditory/Sensory) during neonatal life  is beneficial. Fetuses known to respond to  mother’s heart beats and voice. Should begin in the womb SinghM,2003

  48. NICU QUIZQ11 The best form of multimodal stimulation for providing optimal DSC care would be by: • Swaddling • KMC • Massage • Facilitated Tuck

  49. Summary

  50. Thank you

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