The High Risk Infant - PT Management Flashcards
what are the 3 main frameworks that guide PT
ICF
family-centered care
theories of development
what are the 2 theories of development
dynamic systems
synactive model of neonatal behavioral organization
dynamic systems vs synactive model of neonatal behavioral organization
dynamic:
- interacting subsystems -> functional behavior
- NICU: bio, sociocultural, tasks of infant
synactive model:
- subsystem interaction & interdependence
what adds a layer of complexity to the dynamic systems theory of development
NICU
what is the synactive model of development
5 subsystems organized as hierarchal but interconnected, reacting and influencing one another
what are the 5 subsystems/tiers of the synactive model of neonatal behavioral organization
- physiological stability
- starting point - motor organization
- low level, tone, reflexes - behavioral state organization
- alertness - attention/interaction
- attend for short periods of time - self-regulation
- around different tasks while maintaining physiological homeostasis
how do the tiers of the synactive model work and how does this differ b/w FT and high risk newborns
need tier below to progress above
FT healthy newborns can maintain homeostasis at varying levels while high risk infants might not be able to
what is neurobehavioral organization state control (6)
quiet sleep
active sleep
drowsy
quiet alert
active alert
crying
how does state control differ b/w FT and PT babies
FT - can attain all states and transition smoothly b/w level of alertness functionally
- how babies can stay asleep in noisy settings after interaction (adaptive to recovery)
PT babies might not be able to regulate/transition as smoothly
at what state is the newborn most attentive to interact w environment
quiet alert state
why is there a difference b/w FT and PT babies in their regulation and transition b/w states of control
PT might not have level of behavioral state control d/t level of brain maturity (no cellular differentiated or myelination)
- no gyri or sulci (or very shallow) at 24wks
what does the synactive theory and neurobehavioral maturation state
infants tell you what they need all the time
- have ability to regulate their own functioning and the behavior f their caregivers which ensures input and feedback they need for development
what are signals in the neurobehavioral maturation
self-regulatory behaviors
- signs of approach
- signs of stress
what happens if you don’t respect signs of stress that the infant is presenting with
babies will go back to earlier levels on synactive model and will jeopardize physiologic and autonomic state
what are signals that the baby is “happy and ready”
soft, alert
face, arms, legs relaxed
look at objects and people
what are signals that the baby is “not happy and need a change”
physiologic status change
- pass gas, vomit
- sneeze, yawn, hiccup
salute
spreads fingers apart
frowns
grimace or grunt
arch back/neck and push away
looks away
what are the signals that the baby is coping or self-regulating
*sucking
hand to mouth/face
grasp/holding on
leg bracing
- push against surface for proprioceptive input
tucking/swaddling
*hand/foot clasp
- prevents them from waving around
*light sleep
*snuggle into corners of bed
what is developmentally appropriate care (3)
application of synactive model
acknowledge medical fragility of neonate
observe & respect neurobehavioral cues to guide PT actions
- exam, intervene, family ed
if you go to see an infant and they are stressed, what do you do
don’t come back later
part of intervention is to help when they are stressed to foster neuroplastic change
how do PT actions in developmentally appropriate care change depending on if the infant is presenting w signs of approach or stress
approach
- proceed but observe for tolerance / expense
stress
- intervene to facilitate coping behaviors
what is the main thing you observe in PT exam of an infant
behavioral states
what do you do as part of your exam before you even touch the pt
hx: chart review
medical status/stability
what are 3 parts of your chart review when getting the infant’s hx for your exam
med dx
med interventions
meds
what are 3 parts of checking their medical status/stability for your PT exam
recognize current med status
observe changes in physio status
cluster care
how do you cluster care in your PT exam of a high risk infant
coordinate w NICU team so can have clusters of periods of time that infant is being cared for which allows for periods of rest (so can gain weight, grow, develop)
ex: ask the nurse if they want you to come before or after they are doing something
- if come after, it is our job to calm the baby down again
what do PT goals look like for a high risk infant
have nothing to do w developmental milestones
- trying to help them to tolerate stress
ex: infant will tolerate up to 10min of stim without _______ stress change / HR changes
what are components to observe in the behavioral stats during your exam and how do you utilize this info
neonate behaviors as safety guide
not ability to transition b/w states
use to determine best time for interaction
what component do we consider when doing a systems review in our PT exam
expectations for gestational age (GA)
what are components of the clinical exam
mvmt patterns
- including quality & quantity
- reflexes, tone
what are 4 common tests and measures to use in the high risk infant population
pain assessment
assessment of PT infant behavior (APIB)
test of infant motor performance (TIMP)
alberta infant motor scales
(AIMS)
what is a common way to assess pain in the high risk infant population
FLACC
- face
- legs
- activity
- cry
- consolability
(doc before, during, and after procedure/exam/intervention)
who is appropriate for the APIB
medically stable PT or high risk FT
from birth - 1mo after due date
what does the APIB look at
subsystems of functioning (neurobehavioral maturation)
who is the TIMP appropriate for
34wks post GA and 4mo post term (44-46wks)
what does the TIMP look at
posture and mvmt for function
- observed & elicited
who is the AIMS appropriate for
birth - 18mo
what does the AIMS look at
observation of motor skills in supine, prone, sitting, and supine
how do you determine a premature infant’s corrected age
(actual/chronological age) - (# of wks premature)
why is it important to adjust the age of premature infants
provides more accurate sense of developmental course
- accounts for infant’s system being underdeveloped when born prematurely
at what age do we stop correcting the infant’s age and why
2-2.5yrs
- usually have caught up and any deficits seen aren’t because they were born early
if we continue to correct will miss opportunity to provide intervention if continue to “cut them slack” for what they can achieve at this point
what are the 3 prioritized desired outcomes of PT intervention in the high risk infant and which is the most important? after achieving those 3 outcomes, what is the next goal of interventions
- regulation**
- behavior and mvmt
- can they recover/attend w/o jeopardizing VS - interaction abilities
- attachment
motor skill acquisition
what are 4 strategies with PT interventions
modification - environment
modulation - sensory
positioning - multisystem needs
promoting efficient mvmt
what are environment modifications that can be made during non-cluster care times
dimming lights (safely) to allow infant to sleep
what about the environment should the PT consider in their interventions
make modifications to support developmental needs
- NICU much louder, brighter, and more people than in womb or even at home
what should you be looking at before starting any intervention
observe infant at rest & w nursing care
- physiologic homeostasis maintained?
- startle w every touch?
- smooth mvmt or jerky/tremulous?
what is an important timing consideration when planning when you do your intervention for the infant and why
not immediately after feeding
- priorities are for wt gain and growth
don’t want to jeopardize calories during a stress reaction
what are the 2 main types of PT interventions seen
- positioning & sensory strategies to improve neurobehavioral regulation
- facilitation of early head control, etc.
what are 4 examples of PT interventions for positioning and sensory strategies to improve neurobehavioral regulation
hands together, flexion
inc somatosensation
- pressure at feet in isolette
- swaddling
non-nutritive sucking
skin to skin care
why is skin-to-skin care a successful strategy to improve neurobehavioral regulation
entrapment phenomenon
- HR slows down to match person holding them, temp control (comes down)
what is the key to implementing PT interventions in this patient population
only do what they can handle and evaluate the expense
what do we typically want positioning to facilitate in the patient
mimic physiological flexion
