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Bedside Education and a
Standardized Positioning Tool
to Improve Developmental Positioning of NICU Nurses
Arlene Spilker DNP, RN, CNE
Outcomes
The participants will describe the fundamental principles of developmental positioning.
The participants will discuss the current evidence regarding the actual and potential benefits of developmental positioning.
The participants will analyze the barriers to developmental positioning and propose potential solutions.
Preterm infants do
not have the typical
fetal position
because of their
decreased amount of
time in utero – “a lack
of physiologic flexion”
Fetal PositioningIntrauterine environment – free
floating & self-contained
NICU Positioning
Extrauterine environment -gravitational pull & no
boundaries
Long Term Outcomes In the U.S., preterm birth impacts about 500,000
infants every year, and it is the leading cause of long-term neurodevelopmental disability, with an estimated cost of $26 billion dollars per year ("Preterm Birth," n.d.).
Evidence Based Practice Questions
What do we know?
What remains unknown?
What resources are available?
What is feasible for our unit?
What Do We Know?
Developmental positioning:
promotes normal postural &
musculoskeletal development (Coughlin et al., 2010;
Jeanson, 2013; Madlinger-Lewis et al., 2014; Zarem et al., 2013)
maintains a patent airway (Gibbins, Hoath, Coughlin,
Gibbins, & Franck, 2008)
promotes thermal regulation (Gibbins, Hoath,
Coughlin, Gibbins, & Franck, 2008)
What Do We Know?
Infants who are developmentally
positioned:
cry less, have less flailing of their extremities,
and fewer behavioral indicators of pain (Gibbins,
Hoath, Coughlin, Gibbins, & Franck, 2008).
have improved physiologic outcomes and
sleep states (Picheansathian, Woragidpoonpol, & Baosoung,
2009).
What Remains Unknown?
The definition and standardization of developmental positioning has not been fully researched or implemented into practice (Coughlin, Lohman, & Gibbins, 2010).
Developmental positioning is inconsistently implemented (Gibbins,
Coughlin, & Hoath, 2010).
Poor Positioning Negatively Impacts:
Cerebral Blood Flow
Blood pressure
FiO2 needs
Pain scores
Sleep and rest
Need for PT
Motor development
Parental anxiety and satisfaction
Nursing satisfaction
Knees, Ankles, Feet
Knees extended, ankles and feet externally rotated
Knees, ankles, feet extended
Knees, ankles feet are alignedand softly flexed
HeadRotated laterally (L or R) greater than 45° from midline
Rotated laterally (L or R) 45°from midline
Positioned midline to less than 45° from midline (L or R)
Proper Positioning Components
Neutral head position
Rounded shoulders
Hips and knees flexed
Toes pointed straight
Hands to mouth
Boundaries provided appropriately
Mimic the fetal position
EYES, NIPPLES, KNEES & TOES ALL IN SAME DIRECTION = PROPER ALIGNMENT
Making a Nest - ProneEQUIPMENT PROCEDURE
Appropriate Size Bunting
Cloth diapers and/or T-shirts
Boundary rolls
Make an appropriate size linen support for the baby’s trunk
Place the linen support in the middle third of the bunting vertically!
Place the baby deep into the “pocket” of the bunting
Allow the shoulders to fall forward and the arms to “hang” somewhat
Place straps and use boundaries inside or outside the bunting
Making a Nest –Supine or Side Lying
Equipment Procedure
Appropriate size bunting
Cloth diapers and/or t-shirts to make supports for the shoulders
Boundary rolls/bumber
Position baby deep in the bunting pocket with the hips and knees flexed
Position the linen rolls to provide support behind the shoulders
Strap the baby in and use boundary rolls/bumpers as needed
Common Concerns IV site assessments
Skin temperature probe placement
Catheter toes monitoring
Temperature regulation
Phototherapy
“Safety” issues with hands to mouth positioning on ventilated patients
Current State of Our NICU Pros
Some developmental care products available
Incubators that facilitate developmental care
Developmental care committee and “experts” on staff
Interdisciplinary support
Cons
Not enough developmental care products
Wrong size products used on patients
Products used incorrectly much of the time
Lack of education/knowledge
Fear of the unknown
Hip abduction
Lack of circuit support
Practice Problem No standardization or exact definition for
developmental positioning in the literature
Minimal education on use of developmental positioning equipment at this facility
Musculoskeletal outcomes are adversely affected (preferential head turning, eversion of ankles, flattened skulls, scapular retractions, hip abduction)
Research Purpose Improve the developmental positioning
proficiency of neonatal intensive care unit (NICU) nurses
Determine the effectiveness of a standardized positioning assessment tool as a teaching and evaluation resource
Determine barriers to providing optimal developmental positioning
Standardized Positioning Tools Infant Position Assessment Tool (IPAT)
– developed 2007-2010
Validity and reliability established –2010
IPAT used in 2013 study
Two other standardized tools (China and Italy) – validity and reliability undetermined
MethodsA 46 bed Level 3 NICU Developmental positioning team recruitedPre-Post IPAT Score Collection – 54 and 55NICU Nurse Survey – 50% response rateEducation –IPAT at each bedside, voice
over slides on bedside computers, hard copy of materials in each room, bedside consultations with positioning team members available
LimitationsShort intervention time
Informal education – not all nurses participated
No post intervention nurses survey
Positioning equipment availability lacking
Acuity of infants may have differed
Unknown if improvement will be long term
Conclusions and Recommendations IPAT and bedside education was useful in
improving developmental positioning practice -increase in IPAT scores was statistically significant
Informal (bedside) education may be a viable alternative to formal (skills lab or other) education needs
IPAT measurements in the future at this facility would indicate whether change in practice continued and/or improved further
References• Chen, C. M., Lin, K. H., Su, H. Y., Lin, M. H., Hsu, C. L. Improving the
positioning and nesting for premature infants by nurses in neonatal intensive care units. Hu Li Za Zhi 2014: Supplement 61.
• Coughlin, M., Lohman, M. B., Gibbins, S. Reliability and effectiveness of an infant positioning assessment tool to standardize developmentally supportive positioning practices in the neonatal intensive care unit. Newborn and Infant Nursing Reviews 2010: 10(2): 104-06.
• Gibbins, S., Coughlin, M., Hoath, S. B. Quality indicators: Using the universe ofdevelopmental care model as an exemplar for change. In Kenner C, McGrath J,editors. Developmental care of newborns and infants: a guide for health professionals. Missouri, United States :Mosby Publishers; 2010. P. 43-59.
• Giometti, E., Baroni, L., Artese, C., Davidson, A. Postural care of newborns in the NICU: A study of nurses’ educational needs. ChildrensNurses: Italian Journal of Pediatric Nursing Science 2009: 1(3): 95-100.
References Hunter, J. Therapeutic positioning; Neuromotor, physiologic, and sleep
implications. In Kenner C, McGrath J,editors. Developmental care of newborns and infants: a guide for health professionals. Missouri, United States:Mosby Publishers; 2010.
Jeanson, E. One-to-one bedside nurse education as a means to improve positioning consistency. Newborn and Infant Nursing Reviews 2013: 13(1): 27-30.
Louw, R., & Maree, C. The effect of formal exposure to developmental care principles on the implementation of developmental care positioning and handling of preterm infants by neonatal nurses. Health SA Gesondheid 2005: 10(2): 24-32.
References Madlinger-Lewis, L., Reynolds, L., Zarem, C., Crapnell, T., Inder, T., &
Pineda, R. The effects of alternative positioning on preterm infants in the neonatal intensive care unit: A randomized control trial. Research in Developmental Disabilities 2014: 35: 490-97.
Picheansathian, W., Woragidpoonpol, P., & Baosoung, C. Positioning of preterm infants for optimal physiologic development: A systematic review. Joanna Briggs Institute Library of Systematic Reviews 2009: 7(7): 224-59.
Preterm birth. (2013). Retrieved May 4, 2014, from http://www.who.int/mediacentre/factsheets/fs363/en/
Preterm birth. (n.d.). Retrieved May 1, 2014, from http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PretermBirth.htm
References Symington, A. J., & Pinelli, J. Developmental care for promoting
development and preventing morbidity in preterm infants. Cochrane Database of Systematic Reviews 2006: 2
VandenBerg, K. A. Individualized developmental care for high risk newborns in the NICU: A practice guideline. Early Human Development 2007: 83(7): 443-42.
Zarem, C., Crapnell, T., Tiltges, L., Madlinger, L., Reynolds, L., Lukas, K., et al. Neonatal nurses’ and therapists’perceptions of positioning for preterm infants in the neonatal intensive care unit. Neonatal Network 2013: 32: 110-16.