NICU Flashcards
Medical equipment in NICU
Radiant warmer = open bed with overhead open heat source
Incubator = clear, plastic heated box that encloses the mattress and infant
Open crib = bassinet style bed
Oxygen Assisted Ventilation
Bag and mask ventilation = bag attached to face mask is rhythmically squeezed to deliver positive pressure and oxygen
Continuous Positive Airway Pressure (Cpap) = steady stream of pressurized air given through endotracheal tube, nasopharyngeal tube, nasal prongs or small nasal
Mechanical Ventilation = machine controls or assists breathing by mechanically inflating the lungs, increasing alveolar ventilation, and improving gas exchange
(ECMO) Extracorporeal Membrane Oxygenation = life support system that uses modified heart-lung bypass to minimize lung damage
Oxygen therapy without assisted ventilation
Vapotherm = respiratory therapy device attached to a nasal cannula that allows very high nasal flows of warmed and moist air
Oxygen hood = plastic hood that provides a flow of warm, humidified oxygen placed over infant’s head
Nasal Cannula = humidified oxygen delivered by flexible NC with small prongs that fit into the nares
Intrauterine environment:
Tactile Vestibular Auditory Visual Thermal
Tactile = constant proprioceptive input, smooth, wet, comfortable, boundaries
Vestibular = maternal movements, dinural cycle, amniotic fluid creates gentle oscillating environment, flexed posture
Auditory = biological sounds, muffed environmental sounds
Visual = dark, occasional red dim spectrum light
Thermal = constant warmth, consistent temp
Extrauterine environment:
Tactile Vestibular Auditory Visual Thermal
Tactile = painful and invasive; dry cool air, medical touching, some social touching
Vestibular = flat postures, rapid position changes; influence of gravity; restraints due to equipment
Auditory = loud, non-contingent, mechanical frequent harsh intermittent impulse noise
Visual = bright lights, eyes unprotected; often no dinural rhythm
Thermal = environmental temp variations, high risk of neonatal heart loss from thin skin and lack of subcutaneous fat
Light exposure in NICU
Fluorescent light exposure can lead to:
chromosomal damage
disruption of dinural rhythms
over stem leading to physiological stress
Pre-30 wk infants unable to close eyelids tightly or filter light properly
Environmental Modification: dimmed especially during night only use moderate lighting shield infant eyes with bedside draping or phototherapy eye mask or isolette cover focused lighting for procedures
Sound exposure in NICU
constant environmental noise usually 50-90 dB
(same as street traffic with light machinery)
auditory processing development is most active in 3rd trimester
may lead to auditory sensitivity and processing problems
Environmental Modifications: sound proof materials pods or individual rooms strict noise level policies (pagers vibrate, phones flash not ring sound blocking isolette covers for cribs
Tactile exposure in NICU
frequent medical touching
pain receptors are more sensitive, increased pain response
sleep deprivation
decreased opportunities for infant/parent tactile interaction
uncomfortable bedding
Environmental Modifications:
let infant determine schedule
avoid unnecessary touching-bathing every other day
check vitals from monitors
suction PRN, not on a schedule
speak softly to infant prior to physical handling
swaddling during painful procedures and baths
Calming strategies for infant
Containment = the use of materials or humans to provide physical boundaries for the infant (Z-flo fluidized positions)
Kangaroo Care = involves skin to skin contact with parent (better for non-ventilated infants); yields increased feeding time, reduction of physiological stress and improved attachment
Swaddling = a type of containment that provides the infant deep pressure and simulation of womb positioning through the wrapping of a blanket around the baby
Infant massage = a technique in which parent provides gentle tactile stimulation or prolonged placement of the hands with the infant (best for children 32 wks PCA
Family Education
Vygotsky’s scaffolding method to train family
zone of proximal development
give cues but don’t do it for them
Neuromotor and Neurobehavioral evaluation and intervention in NICU
neuromotor = NICU positioning without positioning, infant presents with: W-posturing of arms frog like posturing of legs asymmetrical head position
neurobehavioral = Synactive Theory of Development: Neurobehavioral Subsystems, Signs of Stress and Stability
Autonomic = physiologic (respiratory, color, visceral, motor)
Motor = tone (flaccid, hypertonic, hyperflexions)
State = sleep/wake (diffused or disorganized)
Attention-Interaction = (autonomic or motor)
Self Regulation
NICU positioning
attempts to simulate:
flexed, contained, midline posture
side lying position supported with snuggle wraps and blanket rolls
watch for extensor tone in neck due to trach and vent tubing (work on neck flexion as these are removed)
Nesting = place infant in flexed position inside a concave space made by blankets and towel rolls with high, steep boundaries and soft secure gel mattress to relieve pressure
Change position every 2-4 hours or if infant gives cues
Avoid oversized diapers to avoid abnormal hip development
Without proper positioning infants can develop
Iatrogenic conditions affecting head shape
Plagiocephaly = prolonged position of head toward one direction
Brachycephaly = flattening of the back of the head due to prolonged supine position
Scaphocephaly = narrowing of the head along the sides due to prolonged head in one position in prone
Prematurity
Preterm = infant born before 38 wks of gestation or less Low birthweight = 2500 grams Very low birthweight = 1500 grams Postconceptual Age (PCA) survival rate = 23 wks PCA = 5-25% 27 wks PCA = >90%
Stages of Prematurity
Prematurity can be categorized by stages based on post-conceptual age (PCA)
Early preemie = less than 30 wks gestation
Developing preemie = 30-35 wks gestation
Older preemie = 35 wks + gestation
Early preemie
more or less in drowsy state
unstable physiologic signs
color changes, cardiorespiratory problems
flaccid Mm tone, few elicited responses, jitteriness
weak palmar grasp, weak suction reaction
little capacity to remain alert
Developing preemie
longer periods of alertness and some fuzziness
physiologically more stable
disorganized movements and some self comforting movements
flaccid Mm tone, beginning to flex knees, frog like
stronger suck and grasp
lifting of legs, swiping of arms, attempts to reach mouth or kick
attends briefly to caregiver
Older preemie
physiologically stable
well differentiated states with longer alert periods
movements smoother and more coordinated
greater Mm tone, better suck swallow reflex, palmar grasp, better motor control
begins to respond to social interaction
may push away a stimulus, more directed self comfort
much longer alert periods
FOR to use in NICU
Coping
Sensory integration
Sensory processing
Motor Skills Acquisition/Dynamic Systems
Pre-Natal Genetic Disorders
Autosomal Dominant = abnormal gene passed on from one of the non-sex chromosomes (neurofibromatosis)
Autosomal Recessive = gene must be carried by both parents (1/4 chance of getting disease - Cystic Fibrosis
Sex linked = sex linked abnormal gene is passed on sex-linked chromosome by the mother (hemophilia or duchenne muscular dystrophy)
Polygenetic or Multifactorial = many genes passed from both parents (cleft palate, midline shifts)
Pre-natal Concerns
Maternal Health ( STORCH Viruses )
Nutrition
Exposure to Toxins
Syphilis = caused by hepatitis, can lead to death, feeding problems and neurological deficits
Toxoplasmosis = fecal matter from cats can cause death, hydrocephaly, liver damage and chorioretinitus (blindness)
Rubella = measles can cause deafness, blindness, heart defects
Cytomeglovirus = (CMV) type of herpes passes through body fluids, affecting multiple systems, high association with creating deafness of hearing loss
HIV/AIDS = result in neurological deficits and motor impairments
Peri-Natal Complications
Diabetes Structural abnormalities of the pelvis Placenta Previa Present birth defects Multiple Births
Post Natal Complications
Prematurity
Accidents
Anoxia
Exposure to Lead
Shaken Baby Syndrome
Infection
Acquired childhood illness
Cancer
Juvenile diseasesRespiratory Issues related to Prematurity
Bronchopulmonary Disease (BPD) = acute respiratory problem that requires prolonged use of ventilator
ECMO
Marconium Aspiratin Syndrome (MAS) = aspiration of marconium into trachea and bronchi
Apnea = prolonged pause in respiration, accompanied by slowing of heart rate
Respiratory Distress Syndrome (RDS) = air sacs of term babies kept open by a chemical coating called surfactant for gas exchange to occur. In premature infant, doesn’t produce surfactant the lungs will collapse
Cardiovascular Problems related to Prematurity
Patent Ductus Arteriosis (PDA) = while in utero, fetal circulation by passes the lungs via ductus arteriosis and normally closes at birth. In some preterm infants it may remain open, leading to enlargement of heart and back-up of blood in lungs.
Neurological Problems related to Prematurity
Hypoxic-ischemic encephalopathy = lack of oxygen due to many factors (perinatal), seizures are associated
Interventricular or intracranial hemorrhage (IVH) = bleeding into cerebral ventricles and surrounding brain tissue. Another common reason for motor issues, could have CP
Brain bleeds:
Grade 1 and 2 can be reversible
Grade 3 can cause motor problems, can cause cerebral palsy. If half the tracts are affected it can cause spastic diplegia
Grade 4 most severe, involves bleeding into ventricles, can cause more severe cerebral palsy
Periventricular Leukomalacia (PVL) = necrosis of white matter below the cortex around the ventricles
Hydrocephalus = inflammation from blood in ventricles impedes circulation and re-absorption of CSF. Build-up of CSF in the ventricles of the brain.
Metabolic Problems related to Prematurity
Hyperbilirubemia = excess of bilirubin referred to as jaundice
Hypo and Hyperglycemia = blood sugar imbalance, can lead to problems with controlling temperature and regulation of breathing
GI and Nutritional Problems related to prematurity
Necrotizing Entercolitis (NEC) = necrosis of the mucosa of the small intestine and colon
Malnutrition = referred to as failure to thrive if not maintaining adequate calories or inadequate absorption of nutrients
Medical Problems Related to Prematurity
Temperature Regulation
incubator may be necessary
Sepsis
decreased immunity leads to increased susceptibility
of infectionOpthomalogical problems related to Prematurity
Retinopathy of Prematurity (ROP)
Grade 1 and 2 = minor, no long term effects (pretty good recovery)
Grade 3 = results in high levels of nearsightedness (coke bottle glasses)
Grade 4 = involves the retina being partly attached, causes significant vision problems
Grade 5 = completely detached retina, leads to blindness
Sensory and Behavioral problems related to prematurity
Visual perceptual problems myopia cortical visual impairment strabismus hearing loss 30% higher chance ADHD
NICU Discharge
Begin discharge planning with parents on admission day
Discharge criteria = breath independently or caregiver is independent with vent care
feed well by bottle/breast or caregiver is independent with tube placement and feedings
maintain adequate temperature and weight
referral to early intervention or medically-based pediatric services and follow-up NICU clinic
Therapeutic Positioning
Nesting
Nesting = place infant in flexed position inside a concave space made by blankets and towel rolls with high, steep boundaries
Therapeutic Positioning
Avoid extremities being unconfined - disorganizing for the infant
Provide opportunities for prone and sidling positions
Change position every 2-4 hours or when infant gives cues
Avoid oversized diapers to avoid abnormal hip development
Watch for extensor tone in neck due to trach and vent tubing eventually work on neck flexion as these are removed
Feeding in the NICU
Many feeding problems occur due to underdeveloped: oral motor skills respiratory skills endurance gastro-intestinal system
