Sandra R. Jungers, RN, BSN, MEd McArtor Neonatal Symposium Friday, May 15, 2015

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(1)

      Sandra  R.  Jungers,  RN,  BSN,  MEd  

McArtor  Neonatal  Symposium   Friday,  May  15,  2015      

(2)

Disclosure:  

—  President  and  Clinical  Consultant  –The  Bimeco  

Group,  Inc.      Medical  Sales  and  Distribution  

—  Clinical  Consultant  for  DandleLION  Medical  

(3)

OBJECTIVES:  

—  Upon  completion  of  the  this  lecture/demonstration  

the  participant  will  be  able  to:  

—  Assess  the  positioning  needs  of  the  neonate  to  promote  

midline  orientation  and  proprioception  

—  Discuss  the  benefits  of  appropriate  developmental  

positioning:  self  calming;  decreasing  stress;  improve   oxygenation;  and  establish  sleep  patterns  

—  Position  infants  in  a  prone,  side-­‐lying  and  supine  

position  with  appropriate  supports  and  be  able  to  apply   the  principles  of  developmental  supportive  positioning    

(4)

 “My”  Famous  Quote…  

 

“  All  truth  passes  through  three  stages:        First,  it  is  ridiculed  

     Second,  it  is  violently  opposed  

     Third,  it  is  accepted  as  being  self  evident.”    

 

   Arthur  Schopenhauer  (1788-­‐1860)            

(5)

Core  Measures  for    

Trauma-­‐Informed  Age-­‐Appropriate  Care  

(6)

 

 

Age  Appropriate  AcFviFes  of  Daily  

Living  

—  Positioning  and  Handling  

—  Feedings  

—  Skin  Care  

(7)

IMPORTANCE  of  POSITIONING  

—  Provides  the  building  blocks  to  promote  physical  

development  

—  Self  organization  

—  Improves  sleep  quality  

—  Conserves  body  heat  and  reduces  energy  expenditure  

—  Encourages  midline  and  coordination  

—  Optimizes  respiratory  function  

(8)

PosiFoning  and  Handling  

—  Positioning  effects  

—  Musculoskeletal  development  

—  Neuromotor  development  

—  Physiologic  function  and  stability  

—  Thermal  regulation  

—  Skin  integrity  

—  Bone  density  

—  Energy  expenditure  and  growth  

—  Sleep  facilitation  

(9)

The  Womb…  

—  Physiologic  Flexion  

—  Head/neck  midline  

—  Shoulder  protraction  

—  Hands  Midline  and  to  

mouth  

—  Posterior  pelvic  tilt  

—  Flexed  upper  extremities  

as  well  as  lower  

—  Containment  

—  Foot  bracing  

(10)

The  Womb…  

—  Proprioceptive  input  

—  Tactile  input  

—  Muted  sensory    

—  Mom’s  rhythm  

—  Physiologic  flexion  –  will  

Increase  with  gestational   age  

(11)

Early  Musculoskeletal  Development  

—  Third  week  –  day  20  

—  Mesoderm  begins  to  form  somites  

—  Somites  differentiate  into:  

—   Sclertome  (vertebrae  /  ribs)  

—  Dermomyotome  (skin  /  muscle)    

—  Fourth  week  –  day  21  to  28  

—  Verterbral  column  developed  

(12)

Musculoskeletal  System  Development  

—  Five  to  Twenty  weeks  

—  Skeletal  muscles  emerge   —  Seven  weeks  

—  Early  Movements  of  the  embryo  at  7.5  weeks  slow  neck  

extension  present  

—  Nine  weeks  

—  General  movements  

(13)

Musculoskeletal  System  Development  

—  Thirteen  to  Fifteen  weeks  

—  Non-­‐nutritive  sucking  begins  

The  VLBW  and  LBW  infant  presents  us  with  an  immature   musculoskeletal  system.  

     

(14)

Musculoskeletal  System…  

—  Shaping  of  this  system  begins  on  admission  

—  System  process  continues  during  hospital  stay  

—  Observations  of  early  posture  and  movement  are  seen  

by  caregivers  

—  Enhance  appropriate  motor  development  

(15)

Inappropriate  Handling  

— 

Contributes  to  undue  stress  and  disorganization  

— 

Hypoxia  

— 

Increased  intracranial  pressure  

— 

Vestibular  over  stimulation  

— 

Average  NICU  Patient:  

—  130  care  givers  during  stay  

—  Handled  82  times  per  day  for  medical  reasons  

(16)

Developmental  Handling  

—  Slow  gentle  movements  

—  Provide  containment  

—  Provide  supports  

—  Eliminate  unnecessary  procedures  and  “routines”  that  

have  no  benefit  

—  Co-­‐Bedding  

(17)

Our  VLBW  and  LBW  infant…  

—  Gestational  age  from  23  to  32  weeks  

—  Unable  to  overcome  the  forces  of  gravity  

—  Up  to  28  weeks  –  completely  hopotonic  and  lacks  all  

physiologic  flexion  

—  At  32  weeks  –  hips  and  knees  begin  to  show  some  

flexion  while  arms  are  extended  

—  36  weeks  flexion  present    

(18)

Musculoskeletal  Development  

impacted  by…  

—  Handling  

—  Positioning  

(19)

Developmentally  Appropriate  

— 

Handling  and  Positioning  should  be  implemented  

during  the  following:  

—  Admissions   —  Assessments  /  Exams   —  Procedures   —  Transports   —  Weights   —  Feedings   —  Bath  Time  

(20)

Developmental  Handling  

—  Slow  gentle  movements  

—  Provide  containment  

—  Provide  supports  

—  Eliminate  unnecessary  procedures  and  “routines”  that  

have  no  benefit  

—  Co-­‐Bedding  

(21)
(22)

 

Principle  of  AcFvity-­‐Dependent  Development  

—  “Use  it  or  loose  it”  framework    

—  Intrauterine  environment  constantly  reinforces  

extremity  flexion  and  midline  orientation  of  the  normal   fetus  

—  The  premature  infant  in  the  NICU  that  has  no  

boundaries  has  active  extension  without  reinforcement   to  return  to  flexion  and  midline  

(23)

Impact  of  Gravity  

Undeveloped flexor tone Absence of musculoskeletal support

(24)

 

Goals  for  Developmentally    

SupporFve  PosiFoning…  

—  Maintenance  of  proper  body  alignment  (midline  

orientation,  flexion,  &  containment)  

—  Provide  musculoskeletal  support  for  ongoing    

growth  and  development.  

—  Provide  comfort  and  security  through  pressure  

support  from  containment  and  facilitating  hands   to  face  for  self-­‐soothing.  

(25)

Improper  PosiFoning…  

—  Hip  external  rotation  problems  

—  Negative  cranial  molding  

—  Shoulder  retraction  

—  Delay  in  motor  development  

—  Decreased  lung,  tidal  volume  affecting  oxygenation  

—  Negative  impact  on  parent-­‐infant  bonding  

(26)

Unsupported  posiFon  in  the  NICU  

—  Flattened,  abducted  

—  Externally  rotated  

—  Gravity  

—  Dominance  of  extensor  

tone  

(27)

ImplementaFon  of  Appropriate  PosiFoning…  

—  Initiate  on  admission  

—  Avoid  complacency  in  positioning  

—  Educate  staff  on  the  physiololgic  and  developmental  

benefits  to  the  infant  

—  Adopt  as  a  unit  based  standard  of  care  

—  Opportunity  to  enhance  your  personal  practice  and  

(28)

   ImplementaFon…    

—  “Nest”  that  offers  comfortable  and  secure  boundaries  –  

simulate  the  intrauterine  environment  and  its  benefits  

—  Swaddling  

—  Appropriate  sized  diapers  

—  Protocol  for  repositioning    

(29)

Common  PosiFoning  Problems…  

—  No  prone  support  

—  No  posterior  pelvic  tilt  

—  No  foot  support  

—  No  humeral  support  

—  Hands  out  -­‐    not  to  face  and  mouth  

—  Bundled  too  tight  –  no  ability  to  move  

(30)

PosiFonal  Development…  

—  Head  Position  

—  Infants  prefer  head  turning  to  the  right  

—  Torticollis  

—  Lateral  trunk  curvature  

—  Deformational  Plagiocephaly  

Abnormal  head  shape  from  prenatal  or  postnatal  external   molding  forces  

—  Dolichocephaly  

(31)
(32)

Developmental  Delays…  

—  Head  /  Neck  Alignment  affects:  

—  Head  shaping      

—  Brachycephaly  (posterior  head  flattening)  

—  Plagiocephaly  (bulge  in  posterior  quadrant  with  bulge  in  

opposite  anterior  quadrant)  

—  Scaphocephaly        

—  Head  centering  and  midline  activities  

—  Head  control  in  prone  and  sitting  positions  

—  Limited  downward  visual  gaze  

(33)

Improper  PosiFoning  –  

Developmental  Delays…  

—  Shoulder  girdle  alignment  affects:  

—  Midline  activities  

—  Weight  bearing  on  elbows  

—  Reaching  

—  Sitting  

—  Shoulder  rounding  

—  Rolling  

—  Arm  and  shoulder  instability  in  prone  

—  Weight  bearing  on  hands  –  later  issues  with  

(34)

Developmental  Delays…  

—  Pelvic  tilt  and  hip  alignment  affect:  

—  Weight  bearing   —  Rolling  over   —  Crawling   —  Sitting   —  Weight  bearing   —  Balance     —  Gait  

(35)

PosiFonal  DeformiFes…  

—  “Frog”  Leg  

—  Everted  feet    (turned  out)  

—  Hyper  extended  neck  and  retracted  shoulders  

(36)

Developmental  Delays…PosiFonal  

DeformiFes…  

—  “Frog  Leg”  

—  Ability  to  transtion  in/out  of  prone  and  sitting  

—  Hip  stability  in  4-­‐point  crawl  

—  Prolonged  wide-­‐based  gait  

—  Excessive  “out-­‐toeing”  gait  

—  Everted  Feet  

—  Increased  out-­‐toeing  

—  Immature  foot  flat  pattern  with  delay  in  heeltoe  pattern  

—  Hyper  extended  neck  and  retracted  shoulders  

(37)

Developmental  Delays…  

—  Foot  alignment  /  foot  bracing  affects:  

—  Tibilal  torsion  

—  Ankle  eversion  

—  Foot  pronation  

—  Proper  weight  bearing  

—  Gross  motor  activities  

—  Walking  

—  Running  

(38)

Developmental  Delays…  

—   Overall  extensor  pattern  

—  Toe  Walkers  

—  Insufficient  play  in  prone  

—  Restricted  mobility  at  the  pelvis,  scapulae,  hips,  feet  

and  elbows    

(39)

Supported  PosiFoning…  

—  Flexed  

—  Head  in  midline  –  neutral  neck  

—  Shoulder  protraction  

—  Hands  to  midline  /  mouth  

—  Posterior  pelvic  tilt  

—  Neutral  hips  and  feet  

—  Boundaries  with  freedom  of  movement  

—  Tactile  input  

(40)

WHY????  SupporFve  PosiFoning…  

—  Promotes  physiologic  stability  

—  Increases  O2  sats  and  decreases  HR  and  RR  

—  Promotes  deep  sleep  

—  Facilitates  different  levels  of  consciousness  and  stability  

—  Promotes  self-­‐regulation  

—  Reduces  stress  

—  Provides  proprioceptive,  tactile,  and  visual  stimuli  

—  ?  Decreased  need  for  analgesics    /    sedatives  

—  Promotes  ossification  and  bone  density  

—  Decreases  risk  for:  

—  skeletal  deformities  

—  muscle  shortening  

(41)

Midline  Head  PosiFon…  

—  Can  help  to  prevent  IVH    

—  Contributors  to  IVH  

—  Antenatal  steriod  use  

—  Resuscitation  methods  

—  Pharmacological  interventions  

—  Thermoregulation  

—  Positioning  of  head  

—  Prevention  

—  Midline  /  neutral  head  

—  30°  degree  HOB  elevation  for  first  72  hours  of  life  <32  

weeks  GA  in  addition  to  medical  practices  

(42)

SupporFve  PosiFoning  can  be  

implemented  with…  

—  Positioning  Aids:  

NEWEST  to  the  market…  

—  DandleLION  Roo’s  –  Roo  2  

—  DandleLION  Wraps  –  Regular  /  Lite   —  PALS  –  positioner    

 

Previous  and  current  generation…    

—  Snuggle-­‐Up  

—  Bendy  Bumper  (baby  /  regular)  

—  Bean  Bag  positioners  –  Fred  the  Frog   —  Gel  Pillows  

—  Z-­‐FLOW   —  ZAKY    

 

—  THE  STANDBY  -­‐  Blanket  Rolls  

(43)
(44)
(45)

Developmentally  Appropriate  PosiFoning…  

—  Provides  for  midline  orientation  

—  Hands  to  Mouth  

—  Proper  flexing  of  hips,  shoulders,  ankles,  head  and  neck  

—  Self  soothing  and  self  regulating  behavior  

—  Appropriate  development  

(46)

Medical  and  Developmental  ConsideraFons  in  

PosiFoning…  

—  Medical  Stability  a  top  priority  

—  Developmental  support  is  necessary  

—  Education  brings  awareness    

—  Positioning    

—  Improves  physiologic  stability’  

—  Increases  infant  comfort  

—  Minimizes  positional  deformities  

(47)

KANGAROO  CARE…  

—  Implementation  and  practice  needs  implementation  

in  all  NICU’s  

—  Improves  state  organization  

—  Reduces  oxygen  needs,  improves  respiratory  patterns  

—  Reduces  apnea  and  brady’s  

—  Improves  thermal  regulation  

—  Enhances  parent  infant  bonding,  parental  sense  of  

competence  

(48)
(49)

FLEXION  

 

THE  KEY  TO    

EARLY  MOTOR  DEVELOPMENT   IN  THE    

(50)

REMEMBER…  

— 

Do  not  leave  the  preterm  infant  immobilized  for  

long  periods  of  time  

 

— 

Prolonged  exposure  to  static  flattened  positions/

postures  lead  to  numerous  deformities    

— 

Influences  of  gravity  cannot  be  overcome  by  the  

infant  alone  

   

(51)

Summary  

—  Optimize  alignment  

—  Support  posture  and  movement  with  “containment  

boundaries”  

—  Individualize  positioning  and  handling  

—  Appropriate  positioning  and  handling  promotes  state  

regulation  as  well  as  sleep  states  so  as  to  promote   growth  

(52)

NICU  is  a  TraumaFc  Life  Event…  

—  What  do  we  need  to  do…  

—  Clinicians  have  got  to  be  better  prepared  clinically  and  

emotionally  

—   Evidence  Based  Practice  should  be  mandated  

—  This  incorporation  into  practice  will  minimize  and  mitigate  

the  associated  toxic  stress  and  will  favorably  impact  long   term  mental  health  outcomes.  

—  Muscular-­‐skeletal  issues  will  have  better  outcomes  which  will  

enhance  the  mental  health  issues  –  mobility  and   independence  

 

(53)
(54)

PosiFoning  Techniques  

—  Supine  

—  Avoid  neck  rolls  

—  Round  shoulders  forward  and  place  elbows  in  flexion  

—  Hips  partially  flexed  and  adducted  toward  midline  

—  Knees  partially  flexed  with  feet  inside  boundary  so  as  to  

promote  foot  bracing        

(55)

PosiFoning  Techniques  

—  Prone  

—  Neutral  alignment  of  head  and  trunk  

—  Use  of  a  prone  roll  to  promote  flexion  (top  of  the  head  to  

the  umbilicus)  

—  Stable  boundaries  to  assist  the  infant  to  maintain  a  secure  

balanced  position  

(56)

Sidelying    

— 

Facilitates    midline  orientation  

— 

Encourages  hand  to  hand  and  hand  to  face  and  

mouth  activity  

— 

Concerns  by  some  as  this  position  may  promote  

atelectasis  

— 

Provide  boundaries  and  do  not  trap  the  bottom  arm  

— 

Hugging  a  item  will  facilitate  forward  tucking  

(57)

Begin  the  movement  to  change…  

Make  a  difference…  

(58)

—  500,000  preterm  infants  are  born  annually  

—  Prematurity  and  survival    rates  continue  to  rise  

—  $26.2  billion  in  societal  cost  annually  for  prematurity    

—  Unfavorable  environment  in  the  NICU  can  negatively  

affect  brain  growth  and  development  

—  Follow  up  studies  are  consistently  finding  reduced  

cognitive  performance  and  increased  behavioral   problems  

 

(59)
(60)

THANK    YOU  

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