NICU Past Paper PDF

THE NICU Objectives At the end of today’s session, the student will be able to: Describe and understand the characteristics of a Neonatal intensive care unit Recognize the roles and responsibilities of the physical therapist in the specialized neonatal setting Have a gen...

THE NICU Objectives At the end of today’s session, the student will be able to: Describe and understand the characteristics of a Neonatal intensive care unit Recognize the roles and responsibilities of the physical therapist in the specialized neonatal setting Have a general understanding of the history of the NICU Differentiate between levels of care within the NICU Define and explain NIDCAP observation List common PT test and measures utilized in the NICU Critically appraise and discuss Neonatal Physical Therapy Clinical Competencies, Practice Frameworks and Evidence-Based Practice Guidelines (Sweeney et al. 2009) History Early 1900s to 1950 : Prevailing philosophy of care in the first neonatal care unit: Dogmatic hands off policy to protect the babies from unnecessary handling and to provide them with favorable conditions for survival (warmth, cleanliness, and nutrition). 1958 : Virginia Apgar, proposed that the newborn required his own medical caregiver (other than midwife or physician) – newborn became own patient with own rights 1970 : American Academy of Pediatrics (AAP) added neonatology as a subspecialty with broad certification 1973 : Brazelton’s Neonatal Behavioral Assessment Scale : Newborn competent partner in social interaction 1975 : Committee on Perinatal Health Published guidelines for regional perinatal centers History cont’d… During the 1960’and 70’ technological & medical advancements helped improved the survival rates of very young, small and/or sick infants including the development of the NICU a specialized care environment. Some studies suggest that although the NICU advances have improved survival the actual stay in the NICU may have detrimental effects on development Developmental care in the NICU helps to provide a supportive environment to foster development 20th century optimal NICU care is defined as on that is “developmentally supportive, family focused, culturally sensitive, and evidenced based.” Tecklin p. 104 Levels of Newborn Intensive Care I II III IV Role of PT in the NICU Addresses functional and structural integrity of body parts and systems Promotes the development of postural and motor activities Promotes appropriate interaction between the infant and the environment Promotes interaction with family, NICU staff, and consultants Theoretical Frameworks to Guide Therapy - Dynamic Systems Theory - Neuronal Group Selection Theory - International Classification of Functioning, Disability, and Health - Synactive Theory - Developmental Care - Family Centered Care Als H 1982 Synactive theory Organization of the Fetus Autonomic (physiologic functioning) Motor State (ranges of consciousness from sleep to wakefulness) Attention/interaction (attend and interact with caregivers) Self-regulatory (balanced, relaxed, and integrated functioning of all four subsystems) Developmental Care Strategies to Decrease noise and light levels Minimize handling of the infant Protect infant sleep states Promote understanding of infant behavioral cues Promote relationship-based caregiving Newborn Individualized Developmental Care and Assessment Program (NIDCAP) NIDCAP observations every 7 to 10 days At a baseline for 10 to 20 minutes before nursing care or procedure Throughout the care session or procedure After the session or procedure until the baby returns to baseline functioning Watch for signs of stability and stress from each subsystem Record environmental and tasking events Note the strategies for self-regulation Recommendations for environmental modification, care giving, and parental involvement Formal training and certification required Family-Centered Care Address the loss of the final stages of pregnancy and preparation for infant Foster hope Encourage the positive Facilitate bonding between parents and babies Developmental Foundations to Guide Therapy Competencies of a term baby Physiologic Include the functional maturity or Capability of all organ systems to allow breathing, feeding, and growing Sensorimotor Include rooting, sucking, grasping, clearing the airway in prone Horizontal and vertical tracking Affective/communication Include crying Self-consoling Eye contact Facial animation Eye aversion Complex Newborn’s auditory preferences (mother’s voice) Taste preferences (mother’s breast milk) Visual preferences (faces) Imitative capacities (sticking tongue out) Preterm Infant Age of viability is 23-24 weeks Perceived as small and unattractive Less responsive More difficult to calm Cry elicits negative emotions in the caregiver Mother/Child Relationship with Preterm Infants Experience less synchronous interactions Play fewer games Work harder to engage Derive less gratification from their infants Bonding process is at risk between preterm infant and his family The Preterm Infant vs. the Term Infant Newborn term infants vs. corrected age preterm infants Show better behavioral functioning Attention/interactional subsystems as well as higher amplitudes in EEG and photic evoked responses increased gray/white matter differentiation and myelination Could be attributed to developmentally inappropriate sensory stimulation of an NICU  The NICU Environment NICU was designed to decrease mortality and morbidity, and improve outcome, however this results in a highly different environment as compared to the intrauterine environment Problems Include Light-disrupts normal sleep wake cycles Sound-harsh sounds ↑ startle, speech sounds muffled, less ability to localize sound Medical Procedures-disrupts sleep, rest thus wt. Gain and infant learns to respond negatively to touch Environmental Changes to NICU Dimming lights, covering isolettes, day/night cycling of lights, not placing items on isolette Clustering medical care, having specific rest periods Nesting, kangaroo care, hammocks, put twins together Music, clocks, mothers' clothing/smells Environmental changes can produce changes in state, behavior, wt. Gain, days on vent and days in NICU High Risk and Low Birth Weight High risk infants are “at risk” for developmental delay as a result of medical factors Infants are classified according to birth weight, gestational age and pathology The Clinical Assessment of Gestational age by Dubowitz most often used to determine gestational age based on external signs  High Risk and Low Birth Weight SGA= infants that weigh below the 10th percentile of published norms-can be term and pre-term and are categorized: LBW= low birth weight = 1501-2500g. VLBW= very low birth weight=below 1501g. ELBW=extremely low birth weight= below 1000g. AGA, SGA, and LGA Are Acronyms for Birth Weight AGA = appropriate for gestational age AGA refers to an infant whose weight at birth falls within the 10th and 90th percentiles for his or her age SMA = small for gestational age LGA = large for gestational age  Medical Complications Seen in the NICU RDS=Respiratory Distress Syndrome BPD=Bronchopulmonary Displasia PVL= Periventricular Leukomalacia IVH or GMIVH=(Germinal Matrix) Intraventricular Hemorrhage HIE= Hypoxic-Ischemic Encephalopathy NEC= Necrotizing Enterocolitis ROP= Retinopathy of Prematurity Hyperbilirubinemia Neonatal Seizures Other Complicating Disorders Fetal Alcohol Syndrome Fetal Abstinence (Withdrawal) Syndrome HIV-AIDS Brachial Plexus Injuries Other congenital disorders Genetic Cardiac Orthopedic Neurological State Regulation States are the stages and degrees of consciousness. Six stages have been identified in babies Premature and high-risk infants have difficulty regulating their states due to their level of health and maturity and the NICU environment Babies need to gain control of their body systems to show and control all states and transitions between states State Regulation 1. Deep sleep or quiet sleep 2. Light sleep or active sleep 3. Drowsy or semi-dozing 4. Alert or quiet alert 5. Active or Active awake 6. Crying Which states would be best for PT intervention?? Evolution of State Differentiation True behavioral states are in terms of a set of characteristic variables linked together. They are not present in infants less than 36 to 37 weeks gestational age. Preterm infants younger than 36 weeks do not possess a full capacity for control over states of arousal. Brazelton States of Arousal Six states defined in his newborn assessment During an assessment observe Range of behavior Variety of behavior Duration of state Examination / Assessment Developmental assessment is performed to: Identify impairments, neuromotor and feeding that require intervention Identify needs for positioning and handling Determine how to adapt the environment to optimize development DEVELOPMENTAL ASSESSMENT MAY NEED TO BE DONE OVER SEVERAL VISITS DUE TO INCREASE IN STRESS LEVELS OF THE INFANT AND THERAPISTS MUST BE KNOWLEDGEABLE ABOUT SIGNS OF STRESS DEVELOPMENTAL ASSESSMENT INCLUDES AN ASSESSMENT OF THE PARENTS OR CAREGIVERS RESPONSES TO THE INFANT AND THEIR ABILITY TO PARTICIPATE IN CARE  Tests and Measures Tests and measures for the pre-term include: Dubowitz Neurological Assessment or the preterm NIDCAP by Als NAPI Neurobehavioral assessment for preterm infants TIMP Test of Infant Motor Performance Tests and measures for the full-term include: Dubowitz Neurological Assessment of the Full term NBAS Neonatal Behavioral Assessment Scale (Brazelton) Morgan Neonatal Assessment Scale Assessment of General Movements Oral-Motor assessment NOMAS Neonatal Oral-Motor Assessment Scale NCAFS Nursing Child Assessment Feeding Scale Intervention in the NICU There is support (evidence) that developmental intervention in the NICU can lead to improvement in function, weight gain and earlier discharge Goals / Objectives can include: To limit impairment in muscle tone, ROM, postural adaptation Improve control of extremity movements Improved regulation of motor behavior and states These should improve motor behavior and the ability to interact with caregivers and the environment. Intervention in the NICU Environmental Modification Positioning Handling / Massage Sensorimotor Stimulation / Intervention Extremity Taping / Splinting / Casting Hydrotherapy Oral Motor Therapy Parent Education and Support Therapy Assessment and Intervention: Issues of Prematurity History should include information from the medical chart, nursing and physician staff, and the family Prenatal history Birth history Frequency and severity of episodes of apnea, bradycardia, and oxygen desaturation, as well as interventions needed  Physical Therapy History Cont’d Important to understand the central nervous system (CNS), respiratory, and gastrointestinal systems The baby’s initial means of getting nutrition, how this has been tolerated, modified, regressed, and/or progressed should be understood Medications can affect baby’s functioning and ability to become alert and sustain a wakeful state Physical Therapy Examination (cont’d) Dialogue with nursing Assess: changes in status leading to changes in medical care, tolerance to nursing care, care procedures that lead to distress, and preferred comfort measures Observe the infant both at rest and during care activities with nursing or other health care professionals. Recommend strategies to minimize sounds Parent Education Explain the behaviors of a preterm baby Explain the course of typical development and what to expect in the future Teach them how to read their infants and respond supportively to them Assist parents as they parent their infants Kangaroo Care Skin-to-skin holding Supports infant physiologic and behavioral stability and maturation as well as parent-infant interaction and attachment Involves the parent holding the diaper-clad infant underneath his/her clothing, skin to skin, chest to chest Gained wider acceptance in the United States for use in the NICU over the past decade Positioning in Preterm Infants Avoid postures of extension that lead to discomfort and an imbalance of flexion and extension Promote neutral head and neck position Slight chin tuck, scapular protraction to promote upper extremity flexion, and hands midline Use blanket rolls or commercially available devices Prone Positioning The unsupported prone position promotes shoulder retraction, neck hyperextension, truncal flattening, and hip abduction/external rotation A thin roll under the chest raises the chest from the surface Allow shoulder protraction and a more neutral neck alignment Place a roll under the infant’s hips to promote LE flexion and a larger roll around the infant’s sides and feet to promote boundaries Side-lying Positioning Demonstrates decreased stress behaviors than supine positioning Symmetry and midline orientation of trunk and extremities, which promotes hands to mouth The respiratory diaphragm is placed in a gravity- eliminated plane, which lessens the work of breathing GERD is decreased in left side-lying, and gastric emptying is increased in right side-lying Supine Positioning Supine positioning allows maximal observation and access to the infant by caregivers Supine poses the most challenges for the infant Forces of gravity pull the baby into neck extension, trunk extension, scapular retraction, anterior pelvic tilt, external hip rotation, and abduction Does not promote calming and self-regulation Supported Supine Should be supported with rolls to promote midline symmetrical flexion with head and trunk in midline, hands near mouth or face, and legs tucked close to the body with neutral hip position Unique potential for weight bearing on the posterior skull Affects cranial molding and head shape Risk of cranial deformations as they have softer and thinner skulls than full-term infants Observation Therapist decides on the competence of the infant to withstand an assessment and when to terminate or proceed with handling an infant Collaborate with nursing to understand the baby’s current medical status, tolerance to handling, and events of the day before undertaking any direct interaction with the baby Infant should also be evaluated before, during, and after any assessment Observation (cont’d) In a sleep state, serial responses to repeated light (flashlight across the eyes) and sound (a soft rattle) are used to assess the baby’s ability to filter repetitive stimuli Provides information regarding the stability of the sleep state Gives the therapist a chance to determine the readiness for handling Collaboration Key to NICU care It is imperative that PT’s develop collaborative relationships with the nursing and medical staffs and the family Collaboration acknowledges the expertise, perspectives and opinions of colleagues as well as respects the personal values, beliefs and opinions of the family to maximize the functional abilities of the infant in the NICU Level of Expertise needed to work in NICU Due to the highly specialized environment therapists need a high level of skill to observe, examine and provide intervention to neonates Neonate in the NICU are likely to experience rapid changes in physiological and behavior states during routine care due to metabolic instability and incomplete development of neuromusculoskeletal, cardiopulmonary and integumentary systems and risks are associated when providing routine care Level of Expertise needed to work in NICU Risks of routine care can include Hemodynamic complications; increased intracranial pressure in infants < 34 weeks gestation Respiratory complications of apnea or hypoxemia or aspiration pneumonia Cardiac: tachycardia, bradycardia Metabolic: fatigue and hypothermia Orthopedic: fractures, joint effusion Integumentary: skin breakdown Risk of infection Level of Expertise needed to work in NICU Handling of infants requires ongoing assessment and interpretation and moment to moment adjustment of procedures to minimize stress and thus risk to these vulnerable infants Thus it is suggested that PT assistants and student PT’s should not handle infants in the NICU Preparation to work in NICU It is suggested that PT’s preparing to practice in the NICU should Observe healthy, term infants in nursery, home or day- care Provide direct service to hospitalized children on physiologic monitoring equipment, supplemental oxygen, vents or with augmentative feeding Participate in NICU follow-up clinics Complete precepted training with an experienced PT in NICU and intermediate care units (2-6 months)