sudden fluctuations in ICP when the feet are raised above the head. This is important during the first several days of life for IVH prevention, but should also be avoided throughout hospitalization to minimize GI reflux. · Avoid raising feet above head whenever possible · Slide new diaper under infant and lift slightly at hips to remove old diaper · To clean diaper area, lift knees to the chest while supporting the back and buttocks · Consider placing the infant on one side to clean buttocks and diaper area. NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 10 Miscellaneous strategies to prevent increased ICP include • Suction (ETT, deep nasal/oral) only when clinically indicated • Minimize pain and stress • Flush and draw from umbilical lines very slowly (1 ml over 30-45 seconds) For weights or bathing provide light swaddling. Swaddle bathing is similar to immersion bathing, but the infant is flexed and swaddled in a lightweight blanket prior to placement in the tub. The face is gently cleaned first with plain water. Each extremity is then individually unwrapped, cleansed and rinsed, and replaced in the swaddle. The stomach, back and genitals are cleaned and rinsed in a similar manner. The infant remains swaddled for shampoo and rinse, then removed from the swaddle, and the wet blanket left in the tub. The infant is placed in a warm blanket and dried as usual. Compared with routine bathing, infants who were swaddle bathed showed fewer stress cues, as well as decreased crying and agitation. Reminder: When done with bath, wet blankets should be thoroughly wrung out before placing in laundry. Wet linen is very heavy for our Environmental Services staff to lift, and more expensive since we are charged by weight for laundry service NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 11 Neuro-protective Best Practice Guidelines Part 3: Protecting Skin Goal is to protect newborn skin integrity and to provide opportunities for nurturing input through this vital sensory organ. Background: The skin is the largest organ of the body, and makes up about 13% of weight in a preterm, versus 6-10% of adult’s weight. Skin integrity is essential to survival and any break provides a portal of entry for infection. The skin is one of five sensory organs designed to help protect the body by relaying information about the environment via sensory neurons to the brain. Sensory receptors (nociceptors) embedded at the dermal layer detect and transmit messages about touch, pain, pressure, and temperature. Touch is the first of the senses to develop early in fetal life, with sensory neurons found around the mouth and face by week 7, and covering the entire body by week 20. The fetus (and preterm infant) has more sensory nerve endings than the adult, which are closer to the surface of the skin. The infant’s hands, feet, and mouth are especially sensitive to touch due to the density of sensory nerve fibers that send constant messages to the cerebral cortex. The skin is comprised of several distinct layers: A. The epidermis (outer layer) acts as a protective barrier against the environment and assists with temperature management. Term infants have 10-20 protective epidermal layers, but the epidermis becomes less keratinized and thinner as GA decreases. Preterms < 30 weeks GA may only have 2-3 layers, while those < 25 weeks have negligible epidermal barriers. Thus, they are vulnerable to absorption of toxins, and prone to insensible heat and transepidermal water loss (TEWL). B. The dermis (middle layer) is made up of collagen fibers that provide strength and elasticity, and contains both blood vessels and nerves. Thin fibrils connect the dermis and epidermis. Because preterm infants have fewer fibrils connecting the skin layers, they are susceptible to “epidermal stripping” with tape removal. Epidermal stripping occurs when the bond between tape and skin is stronger than the bond between epidermal and dermal layers, and the epidermal layer is accidentally removed with the tape. C. The bottom layer of skin is fatty connective tissue that provides shock absorption and insulation. Fat stores accumulate during the third trimester, so most preterm infants have minimal “padding” to maintain heat or protect from the discomfort of hard surfaces. NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 12 What can we do in the NICU? · Role model use of gentle but firm touch, which is tolerated better than stroking · Use care to minimize noxious touch to the hands, feet, and mouth. · Skin to skin care (KC) provides an excellent means of offering safe, nurturing touch · Apply and remove adhesives cautiously, as these are the primary source of skin breakdown in the NICU Protective skin strategies include: · Provide humidity for the first two weeks of life to reduce TEWL for ELBW infants (refer to SMC Humidification of Incubators) · Utilize SMC Skin Care: Premature infant < 26 Weeks to prevent and treat skin breakdown · Reduce unnecessary exposure to topical products, and rinse off with water if possible. · Avoid skin breakdown from common sources such as adhesive removal, thermal injury, abrasion/friction, diaper dermatitis, CPAP devices, pressure ulcers, and/or infection · Consider applying