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- 1. Devlopmentally supportive care By Dr Sachin Verma Moderator- Dr Prashant Kumar S.
- 2. Current scenarios in NICU Preterm babies with immature organ system “Deprivation or over stimulation” Inappropriate pattern of stimulation Immature distnt receptors(eg. Hearing, visual)over stimulated Mature tactile and vestibular pathway understimulated Robotic care(TECHNOLOGY ORIENTED CARE) No maternal or paternal involvement
- 3. What is DSC ? A holistic module which incorporates care that supports: Brain architecture and development Motor development and normalizing movement patterns Sensory system and state system development Oral/feeding development along with family development
- 4. Why DSC Important? With increasing technology and the variety of medical treatment options, the infant become the patient/object we treat. DSC reminds us that the newborn has its own personality,his own path and can communicate his own needs. Based on observation of behavior cues ,we can ‘tailer’the treatment to the specific baby and his family. The DSC model “HUMANISED”the medical care that we are giving. Promoting DSC plays a big role in shapig the future of newborn. Due to advance in Hi tech, survival of preterm has improved but, quality of life has not significantly improved.
- 5. Humanised care: To create a baby friendly womb like ambience and ecology in the NICU to simulate in –utero envienment. Depanding on the degree of immaturity,graded rhythmic and soothing stimulation should be introduced when babty has achieved physiologic stability. Nurse trained to provide DSC to preterm babies by adopting flexible approach. All the healthcare proffesionals in theNICU should be gentle,considerate and companssionate in providing preterm care. Earlyand intensive participation by family members in care of newborn should be encouraged to promote bonding,facilitates growth and neuromotor development.
- 6. The Virtues of the womb Cushioned and comfortable aquatic abode Thermal comfort Zero insensible water losses Shielded from light Protected from sound. Effective and safe ECMO-like oxygenation Optimal excretion of waste of products Isolation and asepsis Parenteral nutrition
- 8. Core measures of DSC
- 9. Core 1- protected sleep Most important It involves a totally undisturbed sleep state/phase, in which the infant conserves energy, experiences weight gain and has optimal brain growth. All non-emergent care giving is provided during wakeful states. Facilitative tuck, swaddled bathing and skin-to- skin care Light and sound levels
- 10. Core2 - Pain and stress assessment and management Routine assessment and documentation of pain and stress Non-pharmacologic and / or pharmacologic measures are utilized prior to all stressful and/or painful procedures Each infant is assessed for pain and/or stress at a minimum of 4 to 6 hours interval
- 11. CORE 2-Assessment/observation of stress Stress behaviors I. Behavioral States (sleep states or states of arousal) II. Autonomic stress (signs) behaviors III. Motor Stress Behaviors IV. Attention/Interaction Stress Behaviors V. Self-Regulatory Behaviors
- 12. Behavioral States 1. Deep sleep 2. Light sleep 3. Drowsy (Dozing) 4. QuietAlert 5. Active awake 6. Crying Autonomic stress (signs) behaviors Changes in HR, RR, SaO2, BP Color change Gag Hiccup Stooling Sneeze Yawn
- 19. Caregiver responses to infant stress & self- regulatory cues 5 (non-pharmacologic) 1) Pain and stress management- supportive practices 2) Provide routine activities of daily living (i.e. feeding, nappy change) 3) Adjust environmental stimuli (sound, light, temperature, movement, smells) 4) Use developmentally supportive handling and positioning
- 20. DSC interventions for stress and pain (non- pharmacological) Facilitated tuck (also called containment) Facilitated Tuck: “Involves firmly containing the infant using a care-giver’s hands on both head and lower limbs to maintain a ’folded-in’ (flexion) position. Infant may or may not be wearing clothes”, can be done prior to and during care and procedures that are known or observed to be stressful to the baby
- 21. Swaddling is when an infant is securely wrapped in a blanket to prevent the child’s limbs from moving around excessively.” Effective for stable preterm infants for reactivity (stress responses) and immediate regulation of pain. Swaddle babies in a flexed and midline position, hips with a posterior tilt Have elbows flexed to allow hands to touch mouth and face Legs also flexed and tucked up close to the body Swaddle should be secure so that the swaddle stays in place, and the infant can have some movement into extension and back to flexion.
- 22. KMC NNS ORAL SUCROSE
- 23. Core measure 3: Developmental activities of daily living: positioning, feeding and skin care Positioning: Provide comfort, safety, physiologic stability and optimal neuromotor development Infant is positioned and handled in flexion, containment and alignment during all care giving activities. Feeding Skin integrity should be ascessed at least once per shift and documented
- 24. Core measure 4: Family-centered care Access to their infant Family is supported in parenting activities Access to resources and supports that assist them in their short and long term parenting needs
- 25. Core measure 5: The healing environment Continuous background sound and transient sound in the neonatal intensive care unit shall not exceed an hourly continuous noise level of 45 to 50 decibels (dB). Transient sounds or Lmax (the single highest sound level) shall not exceed 65 dB. Ambient light levels ranging between 10–600 lux and 1–60 foot candles shall be adjustable and measured at each infant bed space. Direct care providers demonstrate caring behaviors which include adherence to hand hygiene protocols sensitive relationship orientation Documentation of evidence-based policies, procedures and resources to sustain the healing environment over time
- 26. Baby friendly ecology in the NICUY: SOUND LIGHT POSITIONING AND HANDLING FEEDING AND HUMAN MILK PHYSIOLOGIC STABILITY RHYTHMIC GENTLE STIMULATION TACTILE AND VESTIBULAR DEVELOPMENT AUDITORY STIMULATION DEVELOPMENT OF VISUAL SYSTEM STIMULATION OF OLFACTORY SYSTEM
- 27. SOUND Uterus 40-60 decibles. NICU -70-80 db Main source- telephone rings, equipment alarms, paging bleeps, air compressor, carting of equipment, loud talking during the rounds etc.(90% human related) Consequences –startle response, apneic attacks, bradycardia or tachycardia and oxygen desaturation,? Bp inc l/t IVH, cochlear damage in long standing. Preterm *5times risk. Acoustic friendly nursery*** Decibel meters installedto moniter sound levels in NICU.
- 28. Light high intensity of day and night illumination ranging between 50-150 foot candles Procedure lights and phototherapy units may provide light intensity between 200-400 foot candles conseq- squint, "shutting out" behaviour with reduced socialization, REM is increased l/t bradycardia and apnea,?ROP, affect circadian rhythm l/t poor weight gain. The light should be dimmed at night to simulate day- night pattern to promote hormonal surge and physical growth. Eyes should be covered and protected against exposure to bright light when incubator lid is opened or baby is picked up The lux meter can be used to monitor light intensity in the NICU
- 29. Positioning and handling preterm babies maintain better oxygenation, temperature control and sleep pattern when they are nursed in a prone or lateral position. The infant should be positioned prone or on the side with flexed extremities by providing a "nest" with a rolled blanket. Swaddling simulates in-utero feeling of lack of space and it makes the baby less jittery or prone to startle midline orientation to facilitate hand-to-mouth activities which are self- soothing Putting on a small diaper- comfort. handled minimally and gently with clean and warm hands and warm heart procedures - "containment"
- 30. FEEDING WITH HUMAN MILK milk is not only species specific, it is indeed baby-specific Trophic feeds are credited to enhance maturation and growth of intestinal mucosa and gut musculature PHYSIOLOGIC STABILITY The major goal of reducing noise, bright light and rough handling is to ensure that babies in the NICU attain physiologic stability. RHYTHMIC GENTLE STIMULATION Simulation should be provided when "baby is physiologically stable and alert or receptive TACTILE AND VESTIBULAR DEVELOPMENT gently touching the head or back of the baby while speaking softly in a soothing voice encouraged to grasp the finger of the caretaker or edge of the blanket or a small rolled up cloth MOTHER- skin to skin contact,warmth,smell,feeding,against mother heart simulate inutero.
- 31. AUDITORY STIMULATION soft and soothing music- physiologic stability and weight gain velocity. Babies like and enjoy classical or gentle instrumental music,taped voice of parents on and off- enhances parent-infant bonding. DEVELOPMENT OF THE VISUAL SYSTEM Encouraged to develop an eye-to-eye contact, turn to the source of diffuse light. Stimulus- bright toys and pictures. A picture with distinct facial pattern can be placed on the incubator or crib wall in line with the gaze of the baby. Dim- light encourages babies to open their eyes and look around. STIMULATION OF OLFACTORY SYSTEM Alcohol, betadine, or other skin scrub bottles should be opened away from the baby. The medicated swabs should be removed from the incubator immediately after their use. Skin-to-skin contact provides pleasant and "special" smell of the mother to the baby. The gauze pads or cotton balls soaked in mother’s milk can be kept inside the incubator to stimulate olfactory system.
- 32. Conclusion : Humanised care is not an alternative to Hi-tech care but is complementary. NICU should have womb like ambience and ecology. The sound level should be low and light kept dimmed to have "quiet periods" during each shift and day night pattern Lightening should be kept dimmed with Comfortable "nest" (side or prone with flexion of limbs). Painful procedures- Cuddling and containment >> analgesics and sedatives Early and intensive family participation. Mother should be encouraged for skin-to-skin contact to her baby. She should be asked to touch talk, feed and take care of her baby and provide necessary tactile visual and auditory stimuli.
- 34. THE GENES ARE BRICKS AND MORTAR TO BUILD A BRAIN, THE ENVIRNMENT IS THE ARCHITECT. THANKYOU
- 35. Our NICU