nov 2007 acorn © 2005-07 support baby, family and health care team

Nov 2007Nov 2007 ACoRN © 2005-07ACoRN © 2005-07

SupportSupport

Baby, Family and Baby, Family and Health Care TeamHealth Care Team


Problem List Respiratory Cardiovascular Neurology Surgical conditions Fluid & glucose Thermoregulation Infection

Support

Respiratory Laboured respiration* Respiratory rate > 60/min* Receiving respiratory support*

Surgical Conditions Anterior abdominal wall defect Vomiting or inability to swallow Abdominal distension Delayed passage of meconium or imperforate anus

Thermoregulation T < 36.3 or > 37.2ºC axillary* Increased risk for temperature instability

Fluid & Glucose Management Blood glucose < 2.6 mmol/L At risk for hypoglycemia Not feeding or should not be fed

Neurology Abnormal tone* Jitteriness Seizures*

Cardiovascular Pale, mottled, or grey* Weak pulses or low BP* Cyanosis unresponsive to O2 Heart rate > 220 bpm

Baby at risk Unwell Risk factors Post-resuscitation requiring stabilization

Sequences

Resuscitation Ineffective breathing Heart rate < 100 bpm Central cyanosis

Infection Risk factor for infection ACoRN alerting sign with * Clinical deterioration

Consider transport


Support is integral to all aspects of Support is integral to all aspects of ACoRNACoRN

• Provision of Provision of resuscitation, resuscitation, stabilization and stabilization and care tasks.care tasks.

• Provision of Provision of supportive care for supportive care for the baby, family, and the baby, family, and health care team.health care team.


Problem List Respiratory Cardiovascular Neurology Surgical conditions Fluid & glucose Thermoregulation Infection

Support

Respiratory Laboured respiration* Respiratory rate > 60/min* Receiving respiratory support*

Surgical Conditions Anterior abdominal wall defect Vomiting or inability to swallow Abdominal distension Delayed passage of meconium or imperforate anus

Thermoregulation T < 36.3 or > 37.2ºC axillary* Increased risk for temperature instability

Fluid & Glucose Management Blood glucose < 2.6 mmol/L At risk for hypoglycemia Not feeding or should not be fed

Neurology Abnormal tone* Jitteriness Seizures*

Cardiovascular Pale, mottled, or grey* Weak pulses or low BP* Cyanosis unresponsive to O2 Heart rate > 220 bpm

Baby at risk Unwell Risk factors Post-resuscitation requiring stabilization

Sequences

Resuscitation Ineffective breathing Heart rate < 100 bpm Central cyanosis

Infection Risk factor for infection ACoRN alerting sign with * Clinical deterioration

Consider transport


Alerting signsAlerting signs

Support of the baby involves monitoring and Support of the baby involves monitoring and managing:managing:

• Presence of distress or pain cuesPresence of distress or pain cues

• Uncontrolled environmental inputsUncontrolled environmental inputs– inadequate containment / positional supportinadequate containment / positional support– excessive light or noiseexcessive light or noise– excessive handlingexcessive handling


Pain and distress cuesPain and distress cues

• All newborns experience discomfort All newborns experience discomfort and painand pain– these may have detrimental these may have detrimental

physiological consequences and may physiological consequences and may affect long term outcomeaffect long term outcome

• Babies can communicate their Babies can communicate their tolerance of caregiving activities and tolerance of caregiving activities and their environment through non-verbal their environment through non-verbal cuescues


Behavioral signsBehavioral signs– state changestate change– facial expressionfacial expression– muscle tonemuscle tone– body movementbody movement– skin colourskin colour

• Even babies who are extremely preterm perceive Even babies who are extremely preterm perceive pain.pain.

• Signs of pain can vary depending on the baby’s Signs of pain can vary depending on the baby’s gestational age and status.gestational age and status.

Physiological signsPhysiological signs– increased: heart rate, increased: heart rate,

respiratory rate, blood respiratory rate, blood pressure, palmar sweating pressure, palmar sweating

– decreased: oxygen saturation, decreased: oxygen saturation, heart rate variability, irregular heart rate variability, irregular respiratory rate, skin respiratory rate, skin temperaturetemperature



Environmental inputsEnvironmental inputs

• Uncontrolled, excessive environmental Uncontrolled, excessive environmental light, noise, and other stimuli are not light, noise, and other stimuli are not tolerated by newborns. tolerated by newborns. – these may have detrimental physiological these may have detrimental physiological

consequences and may affect long term consequences and may affect long term outcomeoutcome

• Minimizing extraneous stimulation and Minimizing extraneous stimulation and attending to distress cues reduces attending to distress cues reduces morbidity and length of hospital stay.morbidity and length of hospital stay.


Core StepsCore Steps

• Minimize noise levelsMinimize noise levels

• Pace care interventions as much as possible, Pace care interventions as much as possible, allowing for recovery timeallowing for recovery time

• Minimize light levels as soon as possible, as Minimize light levels as soon as possible, as allowed by monitoring availableallowed by monitoring available

• Contain babies arms and legs by building a Contain babies arms and legs by building a “nest” with soft cloth material“nest” with soft cloth material

• Provide a sootherProvide a soother

• Observe for cues of distress or painObserve for cues of distress or pain


Organization of CareOrganization of Care

TasksTasksSupportive Supportive EnvironmentEnvironment

`̀

BabyBaby


ResponseResponse

• Consider the use of pharmacologic Consider the use of pharmacologic sedation and analgesia :sedation and analgesia :– after using non-pharmacologic strategies after using non-pharmacologic strategies

to minimize a baby’s discomfort, to minimize a baby’s discomfort, and and – the baby continues to show signs of the baby continues to show signs of

distress or pain, distress or pain, or or – unpaced care is needed to stabilize the unpaced care is needed to stabilize the

clinical conditionclinical condition

• Morphine is the most commonly used Morphine is the most commonly used analgesic in neonatal care. analgesic in neonatal care.


• The baby is lying on a radiant warmer in the The baby is lying on a radiant warmer in the brightly-lit nursery. There are loud voices in the brightly-lit nursery. There are loud voices in the background and the overbed heater alarm is background and the overbed heater alarm is ringing. ringing.

• The baby startles while vitamin K and The baby startles while vitamin K and erythromycin ointment are administered. A erythromycin ointment are administered. A capillary blood gas and glucose are drawn via capillary blood gas and glucose are drawn via heel poke. He cries throughout the procedure. heel poke. He cries throughout the procedure. An IV is started after four attempts. An IV is started after four attempts.

Case studyCase study


• The physician returns for an update and you The physician returns for an update and you exchange information across the warmer.exchange information across the warmer.

• The baby now looks exhausted. His The baby now looks exhausted. His respiratory distress is worsening and oxygen respiratory distress is worsening and oxygen requirements have increased to 55%. His requirements have increased to 55%. His eyes are closed but he startles, flails his arms eyes are closed but he startles, flails his arms and legs, grimaces, and cries each time he is and legs, grimaces, and cries each time he is handled or hears loud noises. handled or hears loud noises.

• While he is being positioned for a chest film, While he is being positioned for a chest film, he stops breathing and becomes he stops breathing and becomes bradycardic……..bradycardic……..

Case studyCase study


• The baby is lying on a radiant warmer in the The baby is lying on a radiant warmer in the brightly lit nursery. There are quiet voices in brightly lit nursery. There are quiet voices in the background and the overhead heater alarm the background and the overhead heater alarm is silenced promptly. is silenced promptly.

• You gently flex the baby’s limbs and position a You gently flex the baby’s limbs and position a U-shaped nest around him to help contain his U-shaped nest around him to help contain his arms and legs. He squirms slightly, splays his arms and legs. He squirms slightly, splays his fingers, and pushes against the sides of the fingers, and pushes against the sides of the nest with his feet. The boundaries of the nest nest with his feet. The boundaries of the nest contain the baby’s arms and legs. contain the baby’s arms and legs.

Case study – A different approachCase study – A different approach


• You place your hands on the baby to settle You place your hands on the baby to settle him and help him maintain a quiet state him and help him maintain a quiet state before beginning your assessment. You talk before beginning your assessment. You talk softly as you pace your care according to the softly as you pace your care according to the baby’s behavioural cues, giving him time to baby’s behavioural cues, giving him time to recover when necessary. You prefer to do recover when necessary. You prefer to do one intervention at a time to avoid one intervention at a time to avoid overwhelming him. overwhelming him.

• On arrival of the physician, the two of you On arrival of the physician, the two of you move away from the radiant warmer and move away from the radiant warmer and engage in quiet discussionengage in quiet discussion..

Case study – A different approachCase study – A different approach


• Supporting the Supporting the familyfamily is is an integral part of caring an integral part of caring for the baby.for the baby.

• A baby who requires A baby who requires transport to another transport to another facility represents an facility represents an additional source of additional source of stress over and above stress over and above the stress of an ill baby.the stress of an ill baby.

Next StepsNext Steps



• Supporting the family includes:Supporting the family includes:– allowing the parents to be present during resuscitation allowing the parents to be present during resuscitation

and stabilizationand stabilization

– be realistic when explaining the course of care and be realistic when explaining the course of care and possible outcomes possible outcomes

– as soon and as much as possible, bring them in to see, as soon and as much as possible, bring them in to see, touch and talk to their babytouch and talk to their baby

– help them understand the level of care their baby needs help them understand the level of care their baby needs by explaining it as they visitby explaining it as they visit

– focus on their baby rather than the technologyfocus on their baby rather than the technology

– provide parents with a photograph of their babyprovide parents with a photograph of their baby

– ask the parents what they need or want to help cope ask the parents what they need or want to help cope with this eventwith this event


Next StepsNext StepsSupporting the Team Supporting the Team • resuscitation and stabilization resuscitation and stabilization

are a team effortare a team effort• high intensity interventions and high intensity interventions and

critical illness in a baby can critical illness in a baby can result in feelings of distress result in feelings of distress amongst team members amongst team members

• important to recognize signs of important to recognize signs of distress amongst team distress amongst team members in order to:members in order to:

– prevent burnoutprevent burnout

– improve/maintain a high level of improve/maintain a high level of performanceperformance



• Every clinical experience should be Every clinical experience should be recognized as an opportunity to reflect.recognized as an opportunity to reflect.

• Routine case reviews build confidence, Routine case reviews build confidence, improve team functioning, and generate ideas improve team functioning, and generate ideas to improve policies, procedures, and training. to improve policies, procedures, and training.

• The use of the ACoRN Process and The use of the ACoRN Process and Sequences to review the clinical experience Sequences to review the clinical experience provides a structure for case reviews.provides a structure for case reviews.


Template for case reviewTemplate for case reviewAA nticipation/preparation nticipation/preparationPersonnel Personnel Supplies and equipmentSupplies and equipment

CC ommunication ommunicationBetween team membersBetween team membersBetween teamsBetween teamsWith family membersWith family members

OO bjective assessment of care bjective assessment of care As per ACoRN framework and sequencesAs per ACoRN framework and sequences

RR ecommendations ecommendationsEquipment and suppliesEquipment and suppliesCurrent policies and proceduresCurrent policies and proceduresCommunicationCommunicationStaff education/skill maintenanceStaff education/skill maintenance

NN ext: check completion of tasks ext: check completion of tasks


Palliative CarePalliative CarePalliative care is when you: Palliative care is when you: • move from active care to move from active care to save save

a baby’s lifea baby’s life, to , to • active care to provide active care to provide comfort comfort

carecare to the baby, family and to the baby, family and health care team as the baby health care team as the baby dies.dies.

During the difficult time During the difficult time surrounding the death of a surrounding the death of a baby, the family’s and health baby, the family’s and health care team’s needs should be care team’s needs should be supported. supported.


Questions??Questions??

nov 2007 acorn © 2005-07 support baby, family and health care team

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