Stress responses. Autonomic, motoric, state, organizational behavior and attentional/interactive signs of stress combine to provide a baseline profile of an infant’s overall tolerance to various stimuli. Autonomic signs of stress include changes in color, heart rate, and respiratory patterns as well as visceral changes such as gagging, hiccupping, vomiting, and stooling. Motoric signs of stress include facial grimacing, gaping mouth, twitching, hyperextension of limbs, finger splaying, back arching, flailing, and generalized hypertonia or hypotonia. Jerky movements and tremors are associated with the preterm infant’s immature neuromotor system. State alterations suggesting stress include rapid state transitions, diffuse sleep states, irritability, and lethargy. Changes in attention or the interactional availability of preterm infants, exhibited by covering eyes/face, gaze aversion, frowning, and hyperalert or panicky facial presentation, represent signs of stress in premature infants.
Table 14.1 Neurobehavioral Organization and Facilitation
System
Signs of stress
Signs of stability
Interventions
Autonomic
Respiratory
Tachypnea, pauses, irregular breathing pattern, slow respirations, sighing, or gasping
Smooth, unlabored breathing; regular rate and pattern
Reduce light, noise, and activity at bedside (place pagers/phone on vibrate, lower conversation levels at bedside)
Color
Pale, mottled, red, dusky, or cyanotic
Stable, overall pink color
Use hand containment and pacifier during exams, procedures, or care
Slowly awaken with soft voice before touch including all procedures, exams, and care unless hearing impaired, use slow movement transitions
Visceral
Several coughs, sneezes, yawns, hiccups, gagging, grunting and straining associated with defecation, spitting up
Visceral stability, smooth digestion, tolerates feeding
Pace feedings by infant’s ability and cues in appropriately modified environment
Autonomic-related motor patterns
Tremors, startles, twitches of face and/or body, extremities
Tremors, startles, twitching not observed
Gently reposition while containing extremities close to body if premature
Avoid sleep disruption
Position appropriately for neuromotor development and comfort; use nesting/boundaries or swaddling as needed to reduce tremors, startles
Manage pain appropriately
Motor
Tone
Either hypertonia or hypotonia; limp/flaccid body, extremities and/or face; hyperflexion
Consistent, reliable tone for postmenstrual age (PMA); controlled or more control of movement, activity, and posture
Support rest periods/reduce sleep disruption, minimize stress, contain or swaddle
Posture
Unable to maintain flexed, aligned, comfortable posture
Improved or well-maintained posture; with maturation posture sustainable without supportive aids
Provide boundaries, positioning aids, or swaddling for flexion, containment, alignment, and comfort as appropriate
Level of activity
Frequent squirming, frantic flailing activity or little to no movement
Activity consistent with environment, situation, and PMA
Intervene as needed for pain management, environmental modification, less stimulation; encourage skin-to-skin holding; containment
State
Sleep
Restless, facial twitching, movement, irregular respirations, fussing, grimacing, whimpers or makes sounds; responsive to environment
Quiet, restful sleep periods; less body/facial movement; little response to environment
Comfortable and age appropriate positioning for sleep with a quiet, dim environment and no interruptions except medical necessity
Position with hands to face or mouth or so they can learn to achieve this on their own
Awake
Low level arousal with unfocused eyes; hyperalert expression of worry/panic; cry face or crying; actively avoids eye contact by averting gaze or closing eyes; irritability, prolonged awake periods; difficult to console or inconsolable
Alert, bright, shiny eyes with focused attention on an object or person; robust crying; calms quickly with intervention, consolable in 2-5 minutes
Encourage parent holding as desired either traditional or skin-to-skin
May be ready for brief eye contact around 30-32 weeks without displaying stress cues
Support awake moments with PMA appropriate activity based on stress and stability data for individual infant
Self-regulation
Motor
Little attempt to flex or tuck body, few attempts to push feet against boundaries, unable to maintain hands to face or mouth, sucking a pacifier may be more stressful than soothing
Strategies for self-regulation include: foot bracing against boundaries or own feet/leg; hands grasped together; hand to mouth or face, grasping blanket or tubes, tucking body/truck; sucking; position changes
Examine using blanket swaddle or nest to support infant regulation by removing only a small part of the body at a time while keeping most of body contained during
Ask a parent or nurse to provide support during exams, tests, or procedures; swaddle or contain as needed to keep limbs close to body during care or exams and to provide boundaries for grasping or foot bracing
Position for sleep with hands to face or mouth
Provide pacifier intermittently when awake and at times other than exams, care, or procedures
Give older infants something to hold (maybe a finger or blanket)
Encourage parenting to support parenting skill; teach parents communication cues and behaviors; model appropriate responses to cues
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Developmentally Supportive Care
Developmentally Supportive Care
Carol Spruill Turnage
Lu-Ann Papile
I. INTRODUCTION.
Individualized developmentally supportive care (IDSC) promotes a culture that respects the personhood of preterm and medically fragile term infants and optimizes the care and environment in which health care is delivered to this neurodevelopmentally vulnerable population. Implementing the principles of family-focused IDSC in a neonatal intensive care unit (NICU) environment promotes improved family adaptation and may improve neurodevelopmental outcomes.
Preterm infants have a substantially higher incidence of cognitive, neuromotor, neurosensory, and feeding problems than infants born at full term. Fluctuations in the cerebral circulation that occur in preterm infants even during routine care and smaller than expected brain volumes at 36 to 40 weeks’ postmenstrual age (PMA) may contribute to this increased morbidity. Changes in cerebral oxygenation and blood volume measured with near-infrared spectroscopy (NIRS) that occur during diaper changes with elevation of legs and buttocks, during endotracheal tube (ET) suctioning and repositioning, during routine physical assessment, and during standard gavage feedings have been associated with early parenchymal brain abnormalities. IDSC helps to minimize these disturbances.
II. ASSESSMENT.
Identification of an infant’s stress responses and self-regulating behaviors at rest, as well as during routine care and procedures, is essential in order to create plans of care that support and promote optimal neurodevelopment (Table 14.1). Ideally, an infant’s cues are continuously monitored and the care plan is modified as needed to lessen stress and promote stability. Acutely ill term infants have responses to stress and pain similar to those of preterm infants and may not respond as robustly as healthy infants. Their cues are often easier to read than the preterm infant because they have more mature autonomic, motor, and state behaviors.