Advice to nurses: Use a light touch with preemies
Simple tasks can affect growth, so take it easy
A body of research has grown around the importance of little things in neonatology, says nurse educator Diane Holditch-Davis, RN, PhD. By little things, she means the patients themselves of course, but also the common, everyday nursing procedures followed in keeping them alive.
A decade ago, almost nothing was known about the physiological responses of pre-term infants to simple things such as overhead lighting or a sponge bath. Holditch-Davis, a professor of nursing at the University of North Carolina at Chapel Hill, has followed the growing research into the environmental effects on preemies and says it’s still an imperfect science.
"We do know that environmental factors have a great effect on pre-term infants," she says. Some studies indicate they have long-term developmental effects on infants, including cognitive defects and learning disabilities later as early as age 3. "What we don’t know is how much this is affecting babies, which babies are most affected, and what’s the best environment for them in the neonatal intensive care unit."
Fortunately, nurse managers don’t have to establish rigid, formal protocols or elaborate pathways to improve conditions in the NICU. It’s the little things that count, she points out. Still, designing an optimum ICU for neonates will take some time. There are money factors to consider, and using research-based arguments in support of redesigning patient care workspaces is an extremely slow process, Holditch-Davis says.
But through enlightened nursing based on simple, common-sense approaches, individual nurses can have an enormous effect on the patient’s daily progress, says researcher Kathrine L. Peters, RN, PhD, an assistant professor at the Perinatal Research Center of the University of Alberta, Canada, in Edmonton. There’s also evidence that outcomes in the NICU can improve through the cumulative effects of these seemingly minor procedures, she adds. But no one is certain. "This is the big area for research right now."
As a result of such questions, a whole scientific discipline is emerging around environmental neonatology. In practice, it’s important for nurses to keep certain principles in mind, Peters and Holditch-Davis say, including these:
• Think small.
"Anything we do to them wakes them up," Holditch-Davis says about preemies, "and whatever we do can have a long-term impact on their development." With this in mind, nurses are advised to reduce their focus in the ICU. When working with preemies, taking small, well-timed steps in any action is important.
But any passive change in the baby’s environment also can result in dramatic responses, includ ing changes in normal body temperature and neurological reactions, says Peters. Anything that comes in contact with that infant, no matter how seemingly unimportant, can have a proportional effect. "And in preemies, we don’t often see these changes with the naked eye. Worse yet, we don’t exactly know how long-lasting those reactions can be," she adds.
"Just think how a cold stethoscope feels against your skin. Now imagine what a warm preemie feels when the metal touches its belly," Peters says. And nurses have routinely placed preemies on foreign surfaces or in rough swaddling materials without considering the immediate or long-term effects.
• Question routines.
Hospitals routinely bathe patients at fixed, or regular, time intervals. After years of working in hospitals, Peters says the only reason for this consistency is tradition. "This is how it’s always been done" is the guiding principle. The question she now asks at nursing seminars is "Why?" she remarks. "Nurses are so focused on what they’re doing, they often fail to see the effects they’re having on patients just by following convention."
Peters advises nurses to evaluate their routines. Assess the benefits against the cost of bathing the infant. "Do we really need to bathe the patient every 24 hours? Should you take the patient away from that warm ventilator and place [the infant] on a cold scale under blinding lights?" The same advice applies to routine blood-pressure checks and simply picking up preemies from their accustomed place.
• Look for responses.
Neonate survival rates have improved dras tically, thanks to technological advances. But patients who are less than 33 weeks old (which means they were born at least three weeks early) and weigh 1,500 g or less are still critical and therefore should be approached with a vastly different set of procedures compared with older ICU cases.
In her research, Peters gathered data on patient responses to conventional nurse-patient interactions in the NICU. She measured changes in functioning signs in relation to those occurring in the neonate’s immediate environment, such as changes in vital signs. She documented distinct changes in blood and cranial pressure, heart rate, oxygen consumption (transcutaneous saturation), and carbon dioxide levels. She developed a correlation between simple tasks such as infant bathing with these measured physiological changes.
In the bath study, Peters noted that "physiological and behavioral disruptions occurred throughout the bath phase, and in many cases beyond that phase."1 In the comparison study, the oxygen saturation levels taken at pre-bath, bath, and post-bath stages varied markedly by a mean index of 92.5 to 87.0 and 93.3 respectively. (For other comparisons, see charts, above and on p. 137.)
• Single out certain procedures.
Certain procedures can be identified easily as potentially disruptive to the patient by simple observation. If the patient squirms in response to touch or temperature change, nurses should account for those responses and note them, Peters says. "Don’t just let it go," she advises.
Lower lights, fewer movements involving the patient, and less surrounding noise are easy but far-reaching in effect, Holditch-Davis says. "Radios and laughter can work miracles in helping nurses with stress. But they may not be so great for their patients."
• Tailor approaches to individuals.
"Good nursing by definition means tailoring your medical care to patients individually," she says. There is a marginal difference in tolerance between a seven-weeker (a preemie who is seven weeks early) and a 16-weeker, she says. There is an obvious proportional change. A seven-weeker can tolerate some environmental change. A 16-weeker can’t tolerate any stimulation. Its survival outlook is quite poor. Similarly, she asks, why apply a one-standard-fits-all approach to routines?
It takes pre-terms about one-and-a-half hours to reach restful sleep. But nurses move throughout the unit taking vital signs on the hour, regardless of their patients’ rest states. "Tailor your actions to the individual situation," she advises.
• Imitate nature.
The best strategy is to try to imitate nature if possible, both experts say. In a setting surrounded by glass, metal, and constant noise, it’s difficult to emulate a mother’s womb. But by turning down some lights, especially at night, and minimizing disturbances to the infant, nurses also can lighten their work. "You’ll find fewer upset patients and possibly less unnecessary work on your hands," Holditch-Davis concludes.
Reference
1. Peters KL. Bathing premature infants: physiological and behavioral consequences. Am J Crit Car 1998; 7:90-100.
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