Alphabet Soup of Preemie Problems… Developmental Care, IVH, PVL Tanya Hatfield, MSN, RNC-NIC 2 Objectives Upon completion of this presentation the participant will be able to: ▪ Identify developmental and physiological differences between the term and premature infant ▪ Identify various stressors experienced by the preemie in the ICN and discuss evidence based methods to reduce them ▪ Describe evidence based nursing interventions designed to enhance the normal development of the preterm and term ill neonate 3 Brain Development (Giedd, 1999) Brain Development ▪ Brain development is activity-dependent • experiences and stimuli "shape" the way the connections are made. • different beginnings foster different end points • Interventions can increase cell maturation, such as environmental enrichment So why is developmental care crucial? 6 This is what we are working with… 7 Developmental care Goal is to optimize -Early life exposure development by providing predicts future outcomes an environment and later in life experiences that support -Neurons that fire physiologic stability and together wire together allow for brain -THRIVE not just survive development and growth of the extremely low birth reduce morbidities as weight infant much as possible 8 “Everything Matters” Dr. Heidelise Als Normal newborn behavior and development ▪ Regulation/State Cycling ▪ Posture ▪ Movement Patterns ▪ Attention 10 Premature Infants‐ Developmental Consequences Evolution of developmental delay is evident by term equivalent • Compared to full term infants: • Poor orientation (p<.001) • Poor tolerance of handling (p<.001) • Poor self regulation (p<.001) • More sub-optimal reflexes (p<.001) • More stress (p<.001) • More hypertonicity (p<.001) • More hypotonia (p<.001) • More excitability (p=.007) Pineda, Bobbi. "Neurobehavioral Assessment Of High-Risk Infants In The NICU". (2016): n. pag. Web. 11 Five Subsystems of Behavioral Organization 1. Autonomic or Physiologic 2. Motor 3. State a. Attention or Interactional b. Self-regulation 12 13 Neurobehavioral Organization and Facilitation- Autonomic Signs of stress- tachypnea, irregular breathing, gasping, pallor, cyanosis, sneezing, yawns, hiccups, straining with defecation, tremors, twitches of extremities Signs of stability- smooth, regular breathing, stable pink color, no twitching or tremors Interventions- Reduce light, noise and activity, hand containment, slowly awaken, pace feeds, minimize sleep disruptions, position appropriately, manage pain 14 (Verklan and Walden, 2015) Neurobehavioral Organization and Facilitation- Motor Signs of stress- hyper or hypotonia, unable to maintain flexed, aligned posture, stiff extension of extremities, frequent squirming or flailing movement to little to no movement Signs of stability- consistent reliable tone for PMA, improving or well-maintained posture, less self-stimulating motor arousals, hands to mouth, activity consistent with environment Interventions- support rest/sleep, minimize stress, provide boundaries/positioning aids/containment, encourage skin-to- skin 15 (Verklan and Walden, 2015) Neurobehavioral Organization and Facilitation- Sleep State Signs of stress- Restlessness, movement, responsive to environment Signs of stability- quiet restful sleep, less movement, less responsive to environment Interventions- ▪ Age appropriate positioning that promotes comfort ▪ Quiet dim environment without interruption ▪ Position with hands to face/mouth 16 (Verklan and Walden, 2015) Neurobehavioral Organization and Facilitation- Awake State (attention/interaction) Signs of stress- low level arousal, hyperalert, prolonged awake periods, difficult to console Signs of stability- alert, eyes that can focus on object/person. Robust crying, but able to be consoled with intervention Interventions- ▪ Encourage parent holding, STS ▪ May be ready for eye contact at 30-32 weeks ▪ Support awake moments with age appropriate activity 17 (Verklan and Walden, 2015) Neurobehavioral Organization and Facilitation- Self-Regulation Without self-regulation- Little attempt to flex or tuck body, few attempts to push against boundaries, sucking a pacifier may be stressful Strategies for self-regulation- foot boundaries, hands grasped together, hand to mouth/face, grasping blanket, position changes Interventions- ▪ Swaddle exams, have another person for support ▪ Swaddle & provide boundaries, hands to mouth ▪ Provide pacifier when awake and at times other than exams/procedures 18 (Verklan and Walden, 2015) Neurobehavioral Organization and Facilitation- State Transitions Signs of stress- Rapid state transitions, unable to move to drowsy when stressed Signs of stability- Transitions smoothly from high arousal to quiet alert or sleep, focused attention, maintains quiet alert without stress Interventions- ▪ Encourage parenting to support skill, cue recognition ▪ Avoid rapid disruption of state behavior ▪ Assist return to sleep ▪ Provide auditory and visual stimulation* 19 (Verklan and Walden, 2015) In what state is it most appropriate to interact with an infant? 1. Active alert 2. Quiet Alert 3. Drowsy transitional 4. Light sleep 20 Watson, R. (2007). Core review for neonatal intensive care nursing. Philadelphia, Pa.: Elsevier Saunders. Developmental Assessment & Response Cues Clues Physical & behavioral Reasons for response? stability vs stress Stress cues? Consider Response Nursing Intervention or facilitation Connect Patterns of Behavior Cues that happen every exam & weight Communicate Developmental Plan 1. Containment during exams and weights 21 (Verklan and Walden, 2015) Core Measures of Developmental Care Protected Sleep Assessment and Management of Stress and Pain Developmentally Supportive Daily Living Activities Family-Centered Care Healing Environment 22 (Verklan and Walden, 2015) Impact of NICU Environment - Physical ▪ Healthy environments for NICU design • Single-patient rooms • Social Impact ▪ Skin and development • First sense to develop • Interface for development 23 (Verklan and Walden, 2015) Impact of NICU Environment - Sound ▪ Sound vs NOISE ▪ AAP recommends ambient noise to be less that 45-dB ▪ Ototoxic meds and noisy environment may both contribute to hearing loss ▪ Potential for atypical development of auditory pathways 24 (Verklan and Walden, 2015) Source Sound Level (dB) Potential Effects Sound in the ICN Airplane engine 130 Pain/ hearing loss RockFindings music show that many high120 amplitude levels (70 dB or above) are related to staff activities Heavy traffic 80-90 ▪ Closing drawers Snapping isolette portholes 110!!! shut▪ Trash can lids Placing▪ Incubator hard objects ports andon top drawers 77-84 Prolonged exposure at this of isolette level can cause hearing ▪ Laughter and conversation loss MedAAP pump has alarms recommended NICU77-84 noise should not exceed 45 dB Overhead pages 79 3 people talking at the 73-84 Interrupts sleep patterns same time Water in vent tubing 62 25 Impact of NICU Environment - Light ▪ Vision is the last sense to develop ▪ Early light leads to • Interference with auditory discrimination pathways • Problems with peripheral vision, motor coordination, disconjugate gaze & visual processing disorders ▪ Mismatch in sensory input may alter neuronal connections and organization ▪ Negatively influence later development Developmental Care Practices ▪ Care necessitates a collaborative team with family participation ▪ Positioning interventions depend on infant’s needs • Flexion, containment midline alignment regardless of position • Use of aids to support ▪ Utilize slow transfer with flexion and containment ▪ Utilize infant feeding cues to determine feeding readiness Positioning ▪ Therapeutic positioning can influence normal alignment & neuromotor control ▪ Limited intrauterine space promotes “physiologic flexion” ▪ Correct and incorrect positioning affects the neurobehavioral organization, musculoskeletal development and neuromotor functioning Positioning Goals ▪ Decrease the effects of gravity ▪ Prevent musculoskeletal deformity ▪ Promote sensory motor development ▪ Provide boundaries & postural support ▪ Enhance self-regulatory behavior through good positioning ▪ Promote skin integrity ▪ Nurturing to promote long-term development ▪ Neutral or ▪ Elbow flexion slightly flexed neck ▪ Hands to face or midline ▪ Gently rounded shoulders ▪ Hips partially flexed and ▪ Trunk slightly adducted and rounded with knee flexion pelvic tilt ▪ Secure boundaries for foot bracing 30 Outcomes of Poor Positioning ▪ Skull flattening on sides of the head ▪ Decreased depth of rib cage ▪ Hip external rotation and abduction (frog legs) ▪ Retraction and abduction of shoulders (W) ▪ External tibial torsion ▪ Increased neck extension with head preference Prone ▪ Facilitates flexion and head control ▪ Improves oxygenation ▪ Keep hips and knees flexed ▪ Knees under hips • Flexed and close to the body ▪ Hands near mouth ▪ Head to side Prone Yes! No! Prone Supine ▪ Time on back will decrease severity of head molding ▪ Keep shoulders flexed with hands on chest or abdomen ▪ Hips and knees flexed ▪ Symmetry throughout • No hip rotation Supine Do’s Supine “Don’ts” Side Lying ▪ Chin tucked with head to midline, arms forward with hands to face or mouth, hips and knees flexed Side Lying 41 (Morris, 2016) Anatomy!! ▪ Ventricles ▪ Intraventricular Foramen ▪ Cerebral aqueduct ▪ Choroid plexus ▪ Germinal matrix Introductory sentence Arial – 21pt font 42 Anatomy!! Introductory sentence Arial – 21pt font 43 Germinal Matrix ▪ Highly vascularized and poorly supported • Involutes over time ‒ 23-24