Tegaderm to clean, dry skin at risk for abrasion/friction · Assess IV and PICC sites hourly for evidence of phlebitis and/or infiltration · Change diapers Q 2-4 hours during spontaneous awake periods to avoid diaper rash · Utilize SMC Perineal Skin Care/Diaper Dermatitis Management Guideline for Neonates · Handle preterms gently and provide soft bedding to compensate for lack of “padding”, but remind parents that soft bedding and ”nests” are safe only in hospital setting · Refer to Neonatal Skin Care: Evidence Based Clinical Practice Guideline, 3rd Edition. (2013, Association of Women’s Health, Obstetric and Neonatal Nurses) for further details Avoid epidermal stripping during tape removal: · Minimize the use of tape, adhesive products, and bonding agents such as Mastisol · Consider Duoderm “platforms” and “key holes” if frequent re-taping is required, apply tape directly to platform rather than to skin. Since Duoderm removal can damage skin in a manner similar to tape removal, leave in place until it begins to work itself off · Use blue silicone tape whenever possible, but not for securing critical lines · Tegaderm can be stretched to reduce adherence · Whenever possible, leave adhesives in place until adhesive bond starts to lessen · Remove tape using saline pledgets or water-soaked cotton balls · If re-taping is not needed, use Vaseline to loosen tape · To remove tape, hold surrounding skin in place and slowly pull tape at a very low angle, parallel to the skin surface rather than straight up at a 90⁰ angle · Continuously moisten adhesive-skin interface with either water, saline, or Vaseline · Use silicone-based, alcohol-free, adhesive removers when available, as they are the safest adhesive removers currently available for the neonatal population NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 13 Neuro-protective Best Practice Guidelines Part 4A: Minimizing Stress Goal is to reduce stress whenever possible, and to promote both self-regulation and neurodevelopmental organization Background: Much of brain development and growth is preprogrammed during the first two trimesters. During the third trimester, brain development is largely shaped by the fetal experience within the protected setting of the womb, or for preterm infants, within the stressful environment of the NICU. As observed by Peter Gorski, MD, “This is a time when every experience a child either enjoys or suffers is fed into their growth, and most importantly, the growth of their emotional, cognitive, social, and communicative brain.” The early life of most mammals is spent in close maternal contact, and animal studies have demonstrated that separation causes significant amounts of stress. Neonatal stress is greatly exacerbated by maternal separation, exposure to repetitive and uncomfortable caregiving interventions, painful procedures, and unfiltered noise and lighting. Short-term, stress may increase energy expenditure and cortisol levels, and cause cardiorespiratory instability. Long-term, there is evidence that repeated stress during this vulnerable period of brain development may result in permanent structural and functional changes. Minimizing stress may support the preterm’s capacity for neuroplasticity and decrease the likelihood of encoding abnormal stress responses. Strategies known to reduce infant stress and improve outcomes include skin to skin care (KC), “cue based caregiving” and safeguarding sleep. Much infant stress can be reduced by thoughtful use of parental nurturing touch, either with skin to skin care or containment (“hand hugs”). Parents should provide nurturing touch whenever possible, especially following caregiving or procedures until the infant has returned to baseline and/or fallen asleep. Procedural touch activates the sympathetic nervous system (“fight or flight response”), which increases stress and disrupts sleep. Nurturing touch activates the parasympathetic nervous system (“rest and digest response”). In animal studies, increased parental touching during infancy was associated with improvements in brain structure, reduced levels of stress hormones, and better ability to cope and survive in stressful surroundings. “Cue based caregiving” is based upon the concepts of neurobehavioral organization, which refers to a smooth balance between an infant's physiologic and behavioral systems. Individualized caregiving is dictated by different cues that tell caregivers to either continue with handling, or to pause temporarily to provide for recovery. Stress cues are physiologic signals that the infant is overwhelmed, and needs gentle containment and a break to avoid energy loss and decompensation. Stability cues indicate that it is safe to interact or proceed with caregiving. Self-help cues should be supported, since they indicate that an infant is trying to “organize” himself within the NICU environment. Help parents identify and respond to cues. NICU Brain Sensitive Care Committee/Terrie Lockridge/ 11-2015/Swedish Medical Center – used with permission 14 Stress (Disorganization) Cues Stability (Organization) Cues Physiologic/Autonomic System ◦Apnea, bradycardia ◦Respiratory pauses, tachypnea ◦Color changes (pallor or cyanosis) ◦Tremors, startles, twitches ◦Gagging, spitting up, straining ◦Sneezing, yawning, hiccoughing Behavioral/Motoric System ◦Flaccidity (trunk,