JSS COLLEGE OF NURSING 1st MAIN SARASWATHIPURAM, MYSORE

SYNOPSIS SUBMISSION
BY, Ms. NEETHU C JOSEPH 1ST YEAR M.Sc NURSING CHILD HEALTH NURSING JSS COLLEGE OF NURSING MYSORE

GUIDE, Mrs. AMBIKA K Asst. PROFESSOR CHILD HEALTH NURSING JSS COLLEGE OF NURSING MYSORE

BATCH : 2011 2013

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

NAME

OF

THE

CANDIDATE

AND Ms. NEETHU C JOSEPH 1st YEAR MSC NURSING JSS COLLEGE OF NURSING MYSORE

ADDRESS

NAME OF THE INSTITUTION

JSS COLLEGE OF NURSING SARASWATHIPURAM MYSORE

COURSE OF STUDY AND SUBJECT

M.Sc NURSING CHILD HEALTH NURSING

DATE OF ADMISSION OF THE COURSE

28.03.2011

TITLE OF THE TOPIC

STUDY

TO

ASSESS

THE

EFFECTIVENESS OF NESTING ON POSTURE AMONG SELECTED MYSORE AND MOVEMENTS IN AT

NEWBORNS HOSPITALS

BRIEF RESUME OF THE INTENDENT WORK

6.0 INTRODUCTION
Newborns are the most vulnerable group to get adjust to the new environment. Following birth, the first few months act as a transitory period during which the baby adjusts from the aquatic to the aerial environment. As a result, the way in which he is positioned throughout this time is very important, his posture dictates the level of his well being & how his motricityy will evolve1. Posture refers to the positioning or alignment of the various parts of the body in relation to one another. Good posture can help to improve circulation and digestion enhances sleep and prevents cramping of internal organs. Proper posture can improve quality of life. Danielle Salducci, a pediatric physiotherapist, started to design and make nest which would enable newborn to make movements similar to those made in their mothers womb. If the newborn lies flat on his back on a very firm mattress, without the safe & secure feeling he had in the womb, he could feel he were falling into space. This posture could also be the start of various physical ailments1. Developmental care, introduced in the mid 1980s in an approach designed to address environmental concerns. Strategies used to modify the extra uterine environment include control of external stimuli, clustering of care activities, positioning or nesting of the preterm infant to mimic the intrauterine environment & provide containment & the provision of longer rest periods. One or more of these elements may be utilized, according to need, when providing developmental care to individual infants2. Lying on a firm mattress in a batrachians posture with his arms folded back & upwards on

either side of his body, baby either stares at the ceiling or turns his head inevitably to the same side the one he adopted in his mothers womb. Ultimately this can result in a non symmetrical lateralization, potential delay in the childs psychomotor development and an increase in the risk of plagiocephaly (a flattened head) observed amongst a growing number of young children today. An article published in Neonatal units in Trent Perinatal Network on positioning of preterm and sick neonates. In that its states that Positioning aim to provide safe comfortable and appropriate care for preterm infant who need help in coping with the environment outside their mothers body2.
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The fetus in-utero has consistent, dynamic uterine boundaries that continually promote return to a flexed midline position following periods of activity. Conversely, infants in the neonatal intensive care unit are subjected to the effect of gravity and have a tendency to assume flattened postures especially when they are either preterm or sick. This places the infant at increased risk of developing a typical posture and movement patterns both in the short and long term. Careful supportive positioning can help promote the normal structural alignment and neuromotor control necessary for optimal development of an infant posture and motor skills. In addition, a contained midline flexed support position, using specially designed bumpers to surround the baby and keep the limbs close to the body, is said to promote sucking and other calming behaviors2. The correct positioning will help the baby to develop good posture and improve muscle control. Some hospital l actually have a little nest which is a toweling nest with cotton straps. The baby lies in the nest and the cotton straps are pulled across the baby so that they feel safe and secure. If the towel nesting is not available, nesting can be prepared by using sheets, preferably soft ones. Roll the sheets length way so that they are tubes. These are then placed round the baby so that he/she got sometime secure around them on both sides and under his/her feet. This will not only help them to feel safe but it will also encourage good posture and muscle movement and provide comfort positioning3

6.1 NEED FOR THE STUDY

Newborn have so many adjustment problems soon after the delivery. When they were in mothers womb, the temperature is maintained & the also the flexed position provide much comfort to the baby. After the delivery there is an alteration in the posture. The striking difference between the intrauterine environment & the neonatal intensive care unit is obvious. The sensory impact of the NICU has been postulated to adversely influence the neurodevelopment outcome of pre term infants4. The studies show that disturbance in the posture cause spontaneous motor behavior. Normal position prevents frozen postures of arms & legs. In supine position movement towards & the midline, elegant wrist movement, abrupt hand or limb movement, rolling to side & frozen postures of arm & legs were assessed. If the newborn in nest, flexed posture with shoulders, adduction of elbow & knee flexion & the head was frequently in midline5.

Good posture during growth and development keeps bone and joints in correct alignment and prevent abnormal wear and tear as well as keeping spine from becoming fixing in an abnormal position. Good posture is very important to health and well being. While many people are aware of the importance of good posture it is still one of the most neglected method of improving health and fitness. One of the major causes of the bad posture is a misalignment of the skeletal bones. There are three major deviations of normal posture, lardosis, kyphosis and scoliosis. In addition to stressing the babys spine it can also negatively influence the development of babys hip joints6. Observing the needs of the babies, Danielle Salducci, a pediatric physiotherapist, started to design and make nest which would enable newborns to make movements similar to those made inside their mothers womb. Initial stage was to medically research and to determine a posture for the premature baby which could be described as a follow up womb1. When the baby is in nest, head is tilted slightly forward and he can make easy eye contact with his mother and father as soon as they bend towards him, facilitating the relationship between child and parent. With his arms in front of him and no longer in the batrachians or position his hands rapidly find his face. This in turn leads to a better ability to touch, feel and grasp. Less stressed by his new environment, calmed by the fact he can touch his face and aware of the limits of his own body, baby feels comforted and falls asleep more easily1. A survey conducted by the FSLD & BLISS (2008) on positioning and posture of newborns. The study result shows that the consequences of unsupported positioning of newborns. i.e., asymmetrical skull deformation due to professional head turning to the right, Dolichocephalyprogressive lateral skull flattering that results in a narrow elongated head, increased active extension of the trunk and neck with subsequent motor asymmetries causing arching of the neck and back, shoulder external rotation and retraction with scapular adduction, lower extremity hip adduction, external rotation of the tibia and ankle eversion resulting in the frog leg position. This may delay motor skills such as crawling and walking in the first year of life and is associated with toe walking up to eighteen months7. Another article on Developmental care of newborns and infants is published in a guide for health professional. It suggests the positioning techniques. Therapeutic positioning will only be effective with ongoing care giver attention. In all positions aim for; head in midline, shoulders rounded, hands to mid-line or face, neural flexed position, boundaries to circle the whole infant. This must be balanced with the need to promote rest and handle minimally. Elevated head of bed to 30
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degree to promote cardiovascular, pulmonary and gastrointestinal function. Provide boundaries using rolled up sheets and blankets or use commercially available positioning products such as nests, bean bags and bendy bumpers to contain infant. Boundaries should touch the baby and provide support but should not be restrictive or limit movements. Use of positioning aids, such as nests, necessitates careful monitoring of the infants temperature to avoid overheating containment. Positioning maneuvers during procedures such as blood taking or even routine cares and position changes has been shown to reduce the physiological and behavioral responses to stressful procedures8. The extended position for long periods can lead to abnormal tone with consequent delay in the motor development. Sometimes, it is difficult to place the premature baby in a curled up, flexed position because of attachments of lines & sensors. Nesting is one of the key factor in maintaining beneficial position of a neonate & should be practiced routinely9. An article on the topic Developmental care of the newborn and infants in a journal A guide for health care Professionals. External supports compensate for the infants immature postural and motor control; a comfortable soft nest with secure and deep boundaries simulates the positioning benefits of the womb support head and trunk in neural alignment with extremities flexed and tucked towards midline. In supine, encourage head in midline boundaries that are shallow, dont touch the infant or allow flat posture are ineffective10. Several literature reviews revels that newborn care includes positioning and maintain posture and is an important aspects, it can play a major role in the development of newborns. Incidence of newborn death rate and developmental problems related to improper maintains of posture and movement is increased. As a nurse its our responsibility is to maintain the posture and movement as much as possible to provide maximum comfort to the baby to reduce further complication. And there is no much studies done on the nesting on posture and movement and the society is not aware of the term , only in selected NICU setup this technique nesting is practicing. So the researcher felt the need that to contribute newer practices in neonates and to improve their posture and movements as well as prevent further hidden consequences this study have to be done to find out the effectiveness of nesting on the posture and movement of newborns.

6.2 REVIEW OF LITERATURE

A study was conducted in the year 2007 Feb 22 to evaluate lying in a nest affects the posture and spontaneous movement of healthy preterm infants. For this study the researcher took 10 healthy preterm infants of 3 age group i.e., 30 33 week, 34-36 week, & 37 40 week. Infants underwent serial video recording in the supine position in & outside of nest. The posture was assessed both before & after general movements by scoring the predominant postural pattern & the study results shows that a nest promotes a flexed posture of the limbs with adduction of shoulders, facilitates elegant wrist movements towards & across the midline & reduces abrupt movements and frozen posture of the arms and legs5. The study also suggests that the neonatal intensive care unit exposes the preterm infant to a non optimal physiological environment & to invasive procedure & handling. These may induce pain & stress, along with the frequent manipulations by medical & nursing staff that disrupt rest activity cycles & sleep, which may lead to chronic & prolonged stress in the preterm infant. Acute stress may induce abrupt movements & startles. Nesting reduces the stress and provides comfort positioning5. An article A new way to understand your babys crying it states that providing comfortable position why nesting had seemed to be promising intervention to stop excessive crying and it gained popularity, however it is important to understand what the benefit, risk and consequences of nesting. About one fifth of the worlds babies are nested. It is really effective to reduce excessive crying and maintains of good posture and movement in newborns. A group of scientists done a need based assessment among Pediatrician, Psychotherapist and Biologist & also being scientists regarding the effect of nesting in newborns. They all are interested in this topic and had several reasons to investigate nesting of babies. First, because from public health studies into the risk factor of crib death or sudden infant death. They came to knew that about half of the parents who still placed infants on their front to sleep which is very important risk factor for SIDS. In such position baby was not settling down when falling asleep or was crying. Second reason to investigate nesting was encouraged by the involvement in the childrens hospital with parents of babies who had injuries caused by shaking. Third reason was the fact they noticed that in well baby clinics nesting was used more & more often by parents as a method to stop crying & restlessness & to maintain posture & movement of newborns. They evaluated the evidence based methods and

scientific studies was found that tested the effect of nesting on excessive crying and maintains of posture and movements in newborns11. A study conducted by Ria, Blom, a Dutch maternal & Child Health Care Nurse in 1994 & she tested the use of nesting as a method that seemed to be able to reduce restlessness & crying and improve sleep & maintains normal posture and movements in newborns. She developed a holistic approach were nesting only during sleep periods was used. She has closely observed babies with crying, positioning, their posture and sleeping problems & over the years has developed methods for supporting families when newborns cry excessively. She wrote several books for parents & was willing to make her theory and practical experience available for research. The rhythm & uniformity approach used by Blom was rather similar to the approach by others in other parts of the world who demonstrated a positive effect of a certain rhythm in daily care of the newborns on the reduction of crying and maintains of normal posture & movements in the newborns studying the effect of nesting on excessive newborn crying & maintains of posture and movements was new. The final goal of the study to reduce excessive crying & maintains of normal posture & movements in newborns12. A retrospective and descriptive study conducted in the US demonstrated fewer stress behavior in nested position. The provision of boundaries was also associated with more efficient self regulation, more physiologic control, better motor organization and improved the highest stress indicating behaviors13. A study was carried out on developmental care interventions which may help preterm infants cope better with the environment of NICU. An unfavorable event can negatively affect the infant growth with the brain being particularly vulnerable. Data were extracted by the 2 authors. Metaanalyses were conducted for each intervention where the same outcome measures and or instruments were used with in comparable time points. Developmental care is a broad category of interventions the stress of the NICU environment. A number of elements are included under the umbrella of development care; positioning is also one of the elements and the nesting helps to provide similar to the intrauterine experience to the newborns14. A study was conducted on the premature infant and painful procedures in the year 2000 June. Pain management for premature infants raises challenging questions for nurses. This group of infants is often physiologically fragile Painful procedures are harmful to the physiological stability and the ability to self regulate, which includes maintenance of motor control and stable sleep/ wake cycles. Assessment of pain in the premature infant is complex. Major indicators of pain include facial
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grimaces and physiological parameters such as heart rate and oxygen saturation. The Premature Infant Pain Profile is one tool designed specifically for preterm infant. Non pharmacological nursing measures such as swadding or nesting and offering a pacifier are useful strategies to help infant cope with pain procedures15. In a prospective study conducted on retinopathy of prematurity screening, stress related responses, the role of nesting. In this study the degree of distress caused by retinopathy of prematurity screening in a cohort of preterm infant was assessed and the modifying effect of nesting in reducing their discomfort was evaluated. 38 preterm infant were included in the study. 19 infants were placed in a nest with boundaries (experimental group) and 19 infants were placed on a cot blanket (control group). Observations were made 2 minute before, throughout and 2 minute after ROP examination. The factors observed were crying response, neurobehavioral activity and physiological changes. Recording were made using a video camera for crying and neurobehavioral activity and an oxypleth monitor for Heart rate and oxygen saturation. The distress caused by ROP screening was significantly less for the nested group compared with the non-nested group of both movement activity. The study shows that ROP screening is distressing for preterm infants. Nesting can significantly reduce this discomfort16. Head position preference was studied in 20 awake newborns who differed in terms of delivery and sex. They were placed supine on a custom-built platform to reduce the effect of gravity and asymmetries in trunk posture and skull shape. The maintenance of the head in midline was comparable in duration to that reported for infants at 2-3 months when using the global scoring method. This suggests that the neural mechanisms responsible for attaining and maintaining a midline position are present at birth, but are not functionally expressed due to a lack of adequate power in the antigravity muscle of the neck17.

6.3 STATEMENT OF THE PROBLEM

A study to assess the effectiveness of nesting on posture & movements among newborns in selected hospitals at Mysore.

6.4 OBJECTIVES
1) To assess the posture and movements of newborns among experimental group and control group. 2) To determine the effectiveness of nesting on posture and movement of newborns
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6.4.1 CONCEPTUAL FRAME WORK

System Theory by Von Bertlanffy Model

6.4.2 OPERATIONAL DEFINITIONS

Effectiveness: It refers to quality of being able to bring about an outcome. In this study it refers to how much nesting can improve comfortability to maintain the normal posture & movements of the newborns as measured by the structured observation check list. Nesting: In this study it refers to a comfortable position provided to the newborns, which is shell shaped made by putting two rolled blankets in a form of an oval in which the baby lies. Posture: In this study it refers to a position or alignment of various parts of the body in relation to one another for minimum of 10 seconds, it includes position of shoulder in terms of shoulder adduction and abduction, flexion and extension of elbows, hips, knee when they are lying in nest. Movements: In this study it refers to a particular manner or style of moving body parts by newborns such as head rotation from side to midline and back, head rotation from side to side, hand-mouth contact, hand-head contact, gently striking head with open hands, hand-hand contact, hands touching contralateral shoulder and trunk, hand-leg contact, foot-foot contact, elegant wrist movements, abrupt hand and limb movement and rolling to side when they are lying in nest. Newborn: In this study it refers to baby born at term (between 3842 weeks) should have an average birth weight more than or equal to 2500gm and delivered through normal or caesarian section. Selected personal variable: In this study it refers to age, sex, mode of delivery, weight of the baby.

6.5 HYPOTHESIS
H1: There will be significant difference in the mean post test score of posture and movements of newborns among experimental and control group. H2: There will be significant association between the posture and movement of newborns and their selected personal variables like age, sex, mode of delivery, weight of the baby.

6.6 ASSUMPTION
Assumption of the study is Nesting improves the posture and movements of newborns

6.7 DELIMITATION
The study is delimited to: Newborns in Post caesarian and postnatal wards in selected hospitals of Mysore

7.0 MATERIALS AND METHODS RESEARCH APPROACH/ DESIGN

The research design used in the study is quasi experimental design, non-equivalent control group pretest-posttest design.

E O1 X O2 X O3 X O4 C O1 KEYS: E Experimental group C Control group O Observation O1 Pre-test O2-O4 Post-test X Intervention O2 O3 O4

VARIABLES OF THE STUDY

The variables included in the study is Dependent variable Independent variable Selected personal variable : : : Posture & movements of newborns Nesting Age, sex, mode of delivery, weight of the baby

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7.1 SOURCE OF DATA SETTING

Post caesarian ward and postnatal ward of selected hospitals at Mysore

POPULATION
Newborns in selected hospital at Mysore

7.2 METHOD OF COLLECTION OF DATA SAMPLE AND SAMPLING CRITERIA

Inclusion criteria: Newborns in Post caesarian and Postnatal wards in selected hospitals at Mysore Exclusion criteria: Preterm newborns in selected hospitals at Mysore Term newborns with any diseases or anomalies.

SAMPLING TECHNIQE
Convenience sampling technique will be used.

SAMPLE SIZE
Total 60 newborns (30 newborns each will be included in both experimental and control group)

DATA COLLECTION TECHNIQUE

The data collection instruments used were the following: 1) A personal variable Proforma to assess the sample characteristics 2) A structured observation checklist to assess the posture and movements of newborns
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METHOD OF DATA COLLECTION PLAN OF DATA COLLECTION

Approval from authority. Select sample as per criteria. Collect data as per plan below.

Group

Pre test

Intervention

Post test (3 observations, in morning, afternoon and night) Assess the posture and movements of newborns by structured observation check list for 30 minutes Assess the posture and movement of newborns by structured observation check list for 30 minutes

Experimental Assess the posture and group movements of newborns by structured observation Keep the check list for 30 minutes baby in nest Control group Assess the posture and movement of newborns by structured observation check list for 30 minutes

PLAN OF DATA ANALYSIS

Descriptive statistics : Frequency & percentage will computed to analyze sample characteristics. Mean, Median, Standard deviation and range will be computed to compare the pretest and post-test score of posture and movement of newborns. Inferential statistics: The paired t test will be computed for comparing pre- test and post test mean scores of posture and movements of newborns. Independent t test will be computed to determine the significant difference of posture and movements among control and experimental group. Chi square will be employed to find the association between posture and movements of newborns and their selected personal variable

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7.3 Does the study required any investigation or intervention to be conducted on patients or other human or animal? If so please describe briefly.
Yes. Nesting will be done for the newborns.

7.4 Has ethical clearance been obtained from your institution?

Yes

8.0 BIBLIOGRAPHY
1. Oyen N Markestaad T Facilitation of Developmental care for High Risk neonates: An interventional study Unpublished PhD( Nursing Science) thesis [cited on 2011 oct 22 ] [available from : http://upetd.up.ac.za/thesis 2. Darmwneward. Positioning of preterm and sick neonate. Early Human Development. 2003; 48 (1-2) : 35 46 3. Col MNG Nair, Surg Cdr Girish Gupta, Lt Col SK Jatana. NICU Environment: Can we be Ignorant? MJAFI. 2003;59:93-95 4. Hunter J, Kenner C, McGrath JM. Developmental care of Newborn and Infant.A Guide for Health Professionals. 3rd ed. New Delhi. St. Louis Elevier Publishers (P) Ltd. 2004; 219 - 319 5. Ferrari F et.al. Posture and movement in healthy preterm infants in supine position in and outside the nest. Archives of disease in childhood: Fetal and Neonatal. 2007, sep; 92 (5) : 48 52 6. Slevin M, Farrington N, Duffy, Daly L, Mruphy J F. Altering the NICU and measuring infants responses. Acta Paediatr 2000: 89(5): 577-81 7. Perez- woods, Malloy, Tse AM . 24 Tips for parents. NAACOGS Clinical Issue in Perinatal and Womens Health Nursing.1992, Jan, 1; 3(1) : 37-113 8. BLISS.Handle me with care: supporting your premature babys development London Bliss, 2006 9. Foundation for the study of Infant Deaths produced in association with BLISS Time to get back to sleep: information for professionals on reducing the risk of cot death for premature babies London FSID/ BLISS 10. Symington A, Pinelli J.Developmental Care for promoting development and preventing morbidity in preterm infants. 2003; 4: 119-30
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11. Grenier I.R, Bigsby R, Vergara E.R, Lester B.M.Comparison of motor self regulatory and stress behaviours of preterm infants across body positions. The Ameerican Journal of occupational Therapy.2003;57(3):289-97 12. Konishi Y Mikawa, Suziki J. Asymmetrical head turning of preterm infants: Some effect on lateral postureal and functional; literalities. Developmental Medicine and Child Neurology, 1986; 28(4):450-57 13. Mitchell A, Brooks, Roane D. The premature infant and painful procedures. Advanced Neonatal Care: 2003 oct, 3(5):241-249 14. Ophthalmol J. Retinopathy of prematurity screening, stress related responses, the role of nesting. Cochrane Database,2006; July;19(3):110-16 15. Hemingway M, Oliver S. A New way to understand your babys crying. Neonatal Intensive Care 2002;13(6):18-22 16. Gilies D, Wells.Positioning for acute respiratory distress in hospitalized infants and children. Cochrane database of systematic reviews.2009 updated. Orginal 2005;2; Art No: CD003645 [cited on 2011 Nov 6];Available from: http://www.hospitalizedchild.com/2426 17. Rutter N Hinchcliffe, Cartlidge PHT. Do preterm infants always have flattened heads? Archives of Disease in Childhood 1993;68:606-7.

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9.0 SIGNATURE OF THE CANDIDATE:

10.0 REMARKS OF THE GUIDE

RECOMMENDED AND FORWARDED

11.0 NAME AND DESIGNATION OF GUIDE

Mrs. AMBIKA K Asst. PROFESSOR DEPT. OF CHILD HEALTH NURSING J.S.S COLLEGE OF NURSING,1st MAIN, SARASWATHIPURAM,MYSORE

11.1 SIGNATURE

11.2 HEAD OF THE CHILD HEALTH NURSING DEPARTMENT

Mrs. AMBIKA. K Asst. PROFESSOR J.S.S COLLEGE OF NURSING, 1st MAIN, SARASWATHIPURAM MYSORE- 570009

11.3 SIGNATURE

12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL:

RECOMMENDED AND FORWARDED Prof. SHEELA WILLIAMS PROFESSOR CUM PRINCIPAL DEPT. OF MEDICAL SURGICAL NURSING J.S.S COLLEGE OF NURSING ,1st MAIN, SARASWATHIPURAM,MYSORE

12.2 SIGNATURE:

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