Engineering Needs for Nursing of Preterm Infants

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Engineering Needs for Nursing of Preterm Infants

• Diane Holditch-Davis, PhD, RN, FAAN
• Duke University School of Nursing

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Who are Preterm Infants?

• Born 4 to 17 weeks early
• 70 4-6 weeks early
• Weight 350-4500 gm
• 12.8 of births
• 500,000 annually
• Costs 4 times a healthy fullterm--26 billion
  annually

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Medical Complications of Preterms

• Immunological
• Infections
• Respiratory
• Respiratory distress syndrome
• Chronic lung disease
• Apnea
• Gastrointestinal
• Feeding problems, poor growth
• Necrotizing enterocolitis
• Neurological, including visual and auditory

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Neurological Complications of Prematurity

• Developmental delay/learning disabilities
• Mental retardation
• Cerebral palsy
• Attention problems
• Visual problems
• Hearing problems

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Sources of Developmental Risk

• Intrauterine environment
• Neurological insults
• Chronic lung disease
• Intraventricular hemorrhage
• Periventricular leukomalacia
• Seizures
• Sepsis
• NICU environment
• Individual vulnerability

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Influences on CNS Maturation
Medical Problems
NICU Environment
Genetics
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Processes of Neurodevelopment

• Induction
• Proliferation
• Migration
• Organizationthird trimester and neonatal periods

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Organizational Processes

• Alignment and layering
• Elaboration
• Establishment of connections (including
  programmed cell death)
• Glial proliferation
• Myelination

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Elaborationa. 25 weeksb. 32 weeksc. term
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Elimination of Excess Connections
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Development of the Brain
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Goals of Nursing Preterm Infants

• Promote survival
• Minimize complications
• Promote normal development

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Focus on Three Nursing Issues

• Environmental protection
• Assessment of brain functioning
• Feeding

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Environmental Stimulation

• Lighting
• Noise
• Handling
• Positioning
• Painful Procedures

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Sequential Onset of Sensory Functioning
Tactile
Vestibular
Chemical
Auditory
Visual
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Womb

• Rhythmic low level sound
• Dark
• Warm37.5o
• Vestibular stimuli
• Much circadian patterning

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The NICU

• Loud
• Bright
• Cold
• Painful/unpleasant tactile stimuli
• Minimal circadian patterning

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Circadian Rhythm Effects

• Physical growth
• Heart rate and temperature regulation
• Sleep-wake state development
• Gastrointestinal enzymes
• Hormone secretion

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Nursery Re-Design
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Ongoing NICU Design Issues

• Space
• Noise and light dampening
• Storage
• Alarms
• Infection control

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Incubator

• Warmth and humidity
• Barrier to infection
• Bed space

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Issues with Incubators

• Limited visibility
• Difficult access
• Excess light
• Exposure to noise
• from air flow, motor,
• environment
• Water reservoir as source of infection

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Warmers as alternatives

• Good visibility
• Easy access
• Open to environment
• Excess light
• Excess noise
• No barrier to infection
• Convective heat loss to air currents

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Assessment of Brain Functioning

• Instrumented
• Electroencephalography (EEG)
• Ultrasound and imaging
• Near infrared spectroscopy (NIRS)
• Infant behaviors
• Infant sleep

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Issues with EEG, Ultrasound, and Imaging

• Somewhat invasive
• CT scan and MRI
• Structure, not function
• Require taking baby from NICU
• Require restraint or sedative
• Can not be done during care

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Issues with NIRS

• Non-invasive measure of cerebral oxygenation
• Can be used during NICU care
• Need for sensors for small heads
• Some versions only give trends

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Infant Behaviors

• Only way infant can express symptom distress or
  response to care
• Traditionally assessed by nurses during care
• Limited validation
• Affected by visibility
• Time intensive
• Needs instrumentation

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Infant Sleep

• Sleep is both consequence and cause
• Changes in sleep may reflect alterations in the
  brain

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Active Sleep

• Quiet Sleep

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Feeding

• Late developing skill
• Suck/swallow
• 28 weeks--mouthing only
• 33-36 weeks--immature
• Stomach
• 20 weeks--gastric motility and secretion
• Enzymes
• 10 weeks--lactase
• 26 weeks--enterokinase

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Feeding Progression

• Intravenous feedings
• Hyperalimentation
• Tube feeding
• Continuous by pump
• Gravity
• Bottle- and breast-feeding

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Issues with Tube Feedings

• Time to hold for gravity drainage
• Difficulty assessing placement in stomach
• Continuous tube feeding require very slow rates
• Feeding pumps not designed to give
• IV push pumps usually used,
• Not designed for viscous fluid
• Unknown pressure