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Nursing care of ELBW and LBW babies

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This topic was presented by me in Neonatal Nursing Workshop in GUJNEOCON' 14. This presentation highlights some issues in the management of extremely low birth weight babies (<1000gm) from Nursing care point of view. Transport, Aseptic precautions, feeding issues are important aspects of cere which are not discussed here because were discussed by others. I had mainly focused on delivery room management, temperature and humidity maintenance, skin care and develpmental care because these are important aspects of ELBW care but often neglected.

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Nursing care of ELBW and LBW babies

  1. 1. Nursing Care of ELBW and VLBW Babies DR DILIP PATEL (BHARODIYA) Consultant Neonatologist Apple Hospital, Surat, Gujarat.
  2. 2. Success Brings New Challenges: • With More success in survival of extremely preterm infants, Now challenge is to give INTACT SURVIVAL. • Learning Objectives: • Delivery Room Management: -Hypothermia, -OPTIMAL Oxygenation. • Transport to NICU • NICU Management: – Temperature and Humidity maintenance, – Infection, – Skin Care, – Handling and general care of Small babies, – Feeding issues, – Developmental care, – KMC, NNS. – Transport, Aseptic precautions and Feeding methods are discussed separately.
  3. 3. Case Scenario: • A gynecologist called you to attend delivery and shift the baby who is about to be delivered by LSCS- due to sever maternal pregnancy induced hypertension. • Baby’s GA is- 26 weeks, • Expected weight is- 800gm. • Do you want to ask further Question or any other information is required or not?
  4. 4. • Million Dollar Question if you have received the phone: – Single Baby or Multiple Gestation (Twins, Triplets)? • To Decide How many persons are needed to attend call and • Which and How many instruments are needed. • For Simplicity we assume that in our case it’s single baby. • So, Next Questions- Which Instruments/ Equipments are needed? • Prepare Transport call Bag accordingly.
  5. 5. Delivery and Transport call Requirements Checklist: NAME OF EQUIPMENTS/ MATERIALS NUMBER Autoclaved baby towels 3-4 Ambubag- Term and preterm size (Check for functioning) 1-1 Mask- Term and preterm size 1-1 Laryngoscope (Check for functioning) 1 Laryngoscope Blades- Straight- size- 00, 0, 1. (with extra bulbs and batteries) 1-1-1. Oxygen tube 1 O2 Prongs- Neonatal and Child size 1-1 ET tubes- size- 2, 2.5, 3, 3.5 1-2-2-2. Tapes to fix ET tube & Scissor. 10- 1. Feeding tube- size- 6,8 5-5. Suction catheters- size- 6, 8 5-5. Mucus sucker and Rubber suction bulb 1-1
  6. 6. Cont… Cord clamp 1 Surgical Gloves 2 Microshield/ Sterilium 1 Small O2 cylinder. 1 Medicines:- Adrenaline(5), Sodabicarb(2), Calcium(2), NS-100ml(1), 10% Dextrose-500ml(1), Dobutamine(1), Lopez(3), Vit K(5), DW(5) Syringes- 1ml(5), 5ml(5), 10ml(5) I.V. Cannula- size-24 (3), tapes to fix cannula. Infusion pump, 50cc syringe, P.M.O. line s.o.s. Stethoscope 1 Pulse Oxymeter 1 Transport incubator 1 Glucometer 1 Sterile Plastic Bag or Wrap, Heated Mattress 1
  7. 7. Delivery Room Management: •More Hands on Deck: •Call for additional help- ideally 2 doctors, Pediatrician/Neonatologist expert in intubation and CPR with Nurse. •Increase the room temp >26 C •Switch on Radiant Warmer 100% Power •Plastic wrap or bag and Thermal mattress •Pulse Ox probe to RIGHT hand and adjust oxygen blender as per SPO2 •CPAP or PPV to be kept ready. •Good Documentation/Communication
  8. 8. Mechanisms of Heat Loss in Delivery Room:
  9. 9. Temperature Stabilization Strategies in Delivery Room: • Increase Temperature of the Delivery Room • Radiant warmer • Plastic wrap or Bag • Drying the Baby • Heated Mattresses with Embrace • Hats (Wool)
  10. 10. Importance of Plastic Wrap to Prevent Heat Loss in Very Preterm Infants: Intervention: At delivery infant placed in polyethylene bag (food grade) under radiant warmer and head dried Results: No benefit for ≥ 29 week GA but < 29 week GA subgroup have improved admission core temperature and survival.
  11. 11. Heated Mattresses with Embrace:
  12. 12. Use of Oxygen During Resuscitation in Preterm Infants: •Remember Universal Rule: Oxygen is also a drug and it also had side effects. •SPO2 should be in Normal range- Not low, Not High. •High Oxygen Causes Free radical injury. •Use pulse oximeter and O2 Blender during resuscitation. •Begin with O2 between room air and 100%. •Adjust O2 concentration up or down to achieve SPO2 between 90-93% -Decrease O2 as SPO2 rise over 95%.
  13. 13. NICU Management: Now Baby is Shifted to NICU and after Maintaining Vitals next most important thing is to maintain Temperature and Humidity. •Premature Infants and TEWL : •Skin of Preterm baby is immature, so loss of water is more severe than Term baby. •As GA and weight decrease- more water loss. •If Humidity level around baby is not maintained, baby may loss up to 20-30% of total body water in one day.
  14. 14. Strategies to Decrease water and Heat Loss in NICU: • Incubator rather than radiant heater • Humidity >70% • Plastic wrap or bags • Thermoneutral Environment • Transparent adhesive dressings • Emollients
  15. 15. Humidity Guidelines : • In Incubators: High humidity (>70%) for first 7 days: • 23-26 weeks--85% • 27-30 weeks--70-75% • Decrease to 50-70% after first week, • No added humidity after 32 PCA. • As most of NICU uses Radian warmer (open care system), maintaining this humidity level is not possible. • In that case- cover trolley with plastic wrap as much as possible. • Minimal opening of plastic wrap is advised.
  16. 16. Environmental Temperatures to Attain Neutral Thermal Environment in Neonates: Less than 1,200 grams 1,200 – 1,500 grams 1,500 – 2,500 grams Greater than 2,500 grams 0-12 hours 34.0º C – 35.4ºC 33.9º C – 34.4ºC 32.8º C – 33.8ºC 32.0º C – 33.8ºC 12-24 hours 34.0º C – 35.4ºC 33.3º C – 34.3ºC 31.8º C – 33.8ºC 31.0º C – 33.7ºC 24-48 hours 34.0º C – 35.0ºC 33.0º C – 34.2ºC 31.5º C – 33.5ºC 30.5º C – 33.3ºC 48-96 hours 34.0º C – 35.0ºC 33.0º C – 34.0ºC 31.2º C – 33.3ºC 30.5º C – 33.0ºC 4-14 days 33.0º C – 34.0ºC 33.0º C – 34.0ºC 31.0º C – 33.0ºC 2-3 weeks 32.2º C – 34.0ºC 32.2º C – 34.0ºC 3-4 weeks 31.5º C – 33.5ºC 31.5º C – 33.5ºC
  17. 17. SKIN CARE IN VLBW BABIES: • Skin of Preterm baby is very immature and Fragile, gets damaged easily. • Damaged skin becomes site for Infection and water loss. • Principles of skin care: • Maintain integrity of skin • Prevent risk of skin injury • Management of skin injury
  18. 18. Maintain integrity of skin: Provide appropriate soft, wrinkle free bedding
  19. 19. • Turn regularly if Stable • Sick infants with intact skin: Turn 3-4 hourly • Infants with skin breakdown: Turn 2 hourly • Initial & ongoing skin assessment: • Color of skin • Rash, breakdown, pressure sores • Monitor probe sites- it can cause burn injury - Avoid direct contact with Skin, keep gauge piece inbetween. -Change site frequently.
  20. 20. Prevent risk of skin injury: • Guideline for applying tape: Cavilon Tegaderm Tape. • Use cavilon on skin before tape application. • While fixing ET tube, apply tegaderm Tape on the skin before putting dynaplast. • Use transparent dressing/ tegaderm for fixation of IV cannula. • Apply tape in minimal possible area of skin. • Once tape is applied, remove it only after 24 hr. • Do not bandage after venepuncture for hemostasis.
  21. 21. Tips for Safer Adhesive Removal: •Peel adhesive back parallel to skin surface instead of straight up. •Apply distilled water to the skin adhesive interface. •Hold skin surface next to adhesive. •Transparent dressings: stretch to release adherence .
  22. 22. Extra care to prevent IVH: • Intaraventricular hemorrhage is the most serious neurological injury. • Can be reduced by Gentle handling and good monitoring. • Changes in blood pressure may occur as a result of handling, for example: – movement, – crying, – feeding, – intubation, – suctioning and – stimulation.
  23. 23. Infant Positioning and Handling: • Try to cluster cares. • Allow long rest periods between stressful interventions. • Handle gently. • When changing nappies- slide the nappy under baby. • Avoid raising legs as increase to intracranial pressure occurs especially if lifted above the head.
  24. 24. Wrong Method
  25. 25. • Position with the head midline and the head of the bed slightly elevated. • Intracranial pressure is lowest when the head of the bed is elevated. • Avoid Twisting of head. • Report fluctuations in BP, too low or too high BP to Doctor.
  26. 26. While giving IV FLUIDS and Medications: • To avoid fluid overload, use accurate checking of rate of infusion pumps. • Avoid Rapid Bolus. - Intermittent infusions , boluses or medications e.g. blood plasma, should be given via Infusion pump -Rate should be checked and signed by Doctor. - Infants <30 weeks are not to be weighed in the first 5 days unless requested by the Doctor.
  27. 27. Developmental supportive care: • Provide opportunities for undisturbed rest. • Cluster cares • If an infant indicates signs of stress during handling – stop. • Abrupt/fast changes in position are poorly tolerated. • Gently prepare infant for handling with a soft voice or gentle touch
  28. 28. Positioning: • Nesting: enhance flexion and promote comfort by Providing boundaries using a nest-with a napkin/ blanket roll. • Opportunities for movement should always be possible. • Always swaddle infant when transferred to and from incubator.
  29. 29. Nesting: Nesting with Swaddling
  30. 30. Light and Vision: • Minimise light levels where appropriate. • Protect infant’s eyes from bright light. • Provide eye protection for infants receiving phototherapy and • shield light from infants in adjacent incubators/cots. • Dim lights in room at night if safe to do so, to enhance development of circadian rhythms.
  31. 31. Sound and Hearing: • Minimise environmental noise. • Talk softly at the bedside. • Attend to alarms promptly and set alarm volume as low as is clinically safe. • Decrease volume/tone of telephone ring and no radios in rooms. • Close incubator doors quietly. • Do not tap or bang on incubator. • Ensure CPAP and ventilator tubing is regularly cleared of H2O.
  32. 32. Noise Levels in NICU: Event Loudness Telephone ringing 80 db Dash Alarms (set at 70%) 70 dB at 1 metre distance Closing incubators doors 100-135 dB Bubbling in ventilator circuit 62-87dB Tapping incubator with fingers 80 dB Talking around the bedside (normal level) 60 dB The American Academy of Pediatrics recommends that noise levels not exceed 40-45 dB in NICU. <35 dB is desired for sleep.
  33. 33. Non-Nutritive Sucking: • Promotes maturation of reflexes and early establishment of Oral Feeds. • Encourage hand to mouth contact. • Encourage non-nutritive sucking during NG/OG feeds and for comfort. • Oral suction only when clinically necessary.
  34. 34. Smell and Taste: • Familiarize infant with the smell of breast milk by using milk soaked gauze prior to and during a feed. • Protect from noxious odours. • Open alcohol wipes and antiseptic preparations away from the incubator and infant. • Avoid use of strongly scented perfume.
  35. 35. Parents involvement: • Promote early and continued parental involvement • Encourage parents to observe their infants behaviour. • Encourage parents to assist with cares in particular gentle touch, containment during and after handling, and Kangaroo care where appropriate. • Offer information and education on preterm developmental care.
  36. 36. Kangaroo Mother Care (KMC): Learning Objectives: •When and how to use. •The procedure and benefits. •How to assist and support mother.
  37. 37. Benefits of KMC to the baby:  Breast feeding ▪ Increased breast feeding rates ▪ Increased duration of breast feeding  Thermal control ▪ Equivalent to conventional incubator care in stable babies  Early discharge ▪ Better weight gain leads to early discharge  Lesser morbidity ▪ Regular breathing ▪ Less apnea ▪ Protection from nosocomial infections
  38. 38. Benefits of KMC to the mother: • Stronger bonding with the baby • Deep satisfaction • More confident parents • Eligibility criteria: • Birth weight >1800 gm: Start at birth • Birth weight 1200-1799 gm: When Hemodynamically stable – takes a few days • Birth weight <1200 gm: Need specialized care due to sickness – may take weeks to initiate. • Hemodynamic stability is MUST
  39. 39. Preparing for KMC: • Mother’s clothing • Front-open, light dress as per the local culture • Baby’s clothing • Cap, socks, nappy and front-open sleeveless shirt or ‘jhabala’ • KMC procedure: Kangaroo positioning • Place baby between the mother’s breasts in an upright position • Head turned to one side and slightly extended • Hips flexed and abducted in a “frog” position; arms flexed • Baby’s abdomen at mother’s epigastrium • Support baby’s bottom
  40. 40. Duration of KMC: • Start KMC sessions in the nursery • Practice at least one hour sessions initially • Transit from conventional care to longer KMC • Transfer baby to post-natal ward and continue KMC • Increase duration up to 24 hours a day • KMC during sleep and resting: • Reclining or semi-recumbent position • Adjustable bed • Several pillows on an ordinary bed • Easy reclining chair
  41. 41. Any family member can do it ! Father & other family members can also provide skin-to-skin care
  42. 42. Discontinuation of KMC: • Term gestation • Weight ~ 2500 gm • Baby uncomfortable  Wriggling out  Pulls limbs out  Cries and fusses
  43. 43. Discharge criteria: • Baby is well with no evidence of infection • Feeding well (predominant breast milk) • Gaining weight (15-20 gm/kg/day) • Maintaining body temperature • Mother confident of taking care of the baby • Follow-up visits ensured
  44. 44. Key Message: Handle with Care Thank You

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