ت ؼ ا ساد در تخؼ هزاقثت ا ض ر ؽ ا م تزل آى

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Gary Austin
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1 ت ؼ ا ساد در تخؼ هزاقثت ا ض ر ؽ ا م تزل آى 8 دا شگا عل م پششکی ت زاى دا شکد پزستاری هاهایی Fatemeh Ghelichkhani دا طج ی کبسض بسی هبهبیی تشم - Instructor : Ezzat jafarjalal یوسبل ا ل 90-91

2 Background: Brain development and stress The brain triples in size over the first 5 years of life Much of this growth is in the myelination of neurons and their synaptic interconnections Genetics determine the basic architecture of the brain, but its final form is dictated by experiences in the environment If an experiences are abnormal, non- nurturing, traumatic, and/or chronically stressful during a time of immense change in the development of the brain, then this impact may leave a permanent imprint on the structure and mechanisms of the functioning brain throughout life.

3 Background: Brain development and stress The stress response system is activated by a centrally located area in the right hemisphere of the brain In the early development of the brain (postnatally), the right hemisphere is also more deeply interconnected (than the left hemisphere) with the limbic, autonomic, and arousal systems, all areas of the brain that are important in the modulation of stress When an infant encounters stress, these areas of the brain are primary in telling the body how to respond, that is, when and what hormones to release (corticosteroids, vasopressin, oxytocin, etc.), when to increase the heart rate, how to mobilize energy, etc.

4 Background: Brain development and stress As the brain is developing structurally and mapping its neuropathways, these pathways are frequently compelled to take abnormal directions in order to deal with constant stress and/or trauma (such as those in the NICU and/or after discharge), which in turn can cause brain function to become abnormally integrated. if a premature infant s brain is programmed to respond to constant stress, subsequently as he grows older, he may have a difficult time sorting out how to respond normally to everyday circumstances

5 Background: Brain development and stress Caregivers should educate themselves as to the physiologic stress indicators that premature infants demonstrate such as increased heart rate, blood pressure, and respiratory rates, hiccups, mottling of skin color, staring with glossed over eyes, and even apnea or bradycardia

6 تنش در درون خانه رحن هادر خغت ي خا ج ي اعت. در رحن ج ي در هؼزض ػ اهل ت ؼ سا تغ ار اعت. تخؼ هزاقثت ا ض د ه ي خا ساد ارط ت وار اعت. در تخؼ ش ساد در هؼزض ػ اهل ت ؼ سا تغ ار اعت. حفظ تاه ي اه ت رفا جغو ر ح در ا ي د خا تزا ج ي ساد اس ظا ف هادر خا اد هزاقث ي ت ذاؽت جاهؼ اعت.

7 ت ؼ ا ساد : اقذامات مراقبتي اقذاهات ت ؼ سا ر سهز تؾخ ص درها : ( عامؾي خ گ ز اس دعت ا پاؽ پا تزقزار خط غ داخل ر ذ تص زتزدار ) تاست ثثت ؾا ا ح ات ػ ض مزدى پ ؽل ؽ زدادى

8 راهكار ها : ػذم هذاخل هگز در ه ارد ظز ر ارس ات عالهت ساد مارا تخؼ تا ا ي ؾا ا : ثثات ظزتاى قلة تؼذاد ت فظ ر ذ ه ظن ت فظ ثثات ر گ تحول ؽ ز ج د ت ى ػعال آع د ا ظؼ ت تذ خو ذ جوغ ؽذ گذاؽتي دعت ر ص رت ا در د اى هن ذى خ اب آرام ت ا ا ساد تزا وا ؼ ػنظ الؼول ا ه اعة

9 NICU environment Noise Studies have shown that loud noise is a concern because it can be stressful to the baby and may affect his/her heart rate or breathing patterns. It also affects the length and quality of sleep. Excessive noise levels may be a factor for hearing problems later in life. LIght Bright light has been shown to have an effect on the baby as it interferes with normal body rhythms and may also cause damage to the eye. Babies are unable to open their eyes for a long period, and this can prevent them from interacting with their families and carers. Bright light also affects the quality of sleep.

10 Positioning We also recognise the importance of ensuring that the baby is nursed in a comfortable, flexed position, which not only makes him/her feel secure, but also helps physiological stability (heart rate and oxygenation), and prevents him/her wasting energy. The pre-term infant does not always have the muscle strength to control arm, leg and head movements, which means that he or she may have to lie in an "extended position" for long periods. This can lead to stiffness and delay in motor development.

11 Handling Research has shown that pre-term infants do not cope well with excessive handling. They can show this by "stress signs", such as changes in their heart rate, colour and breathing patterns. Sometimes they show other signs such as yawning, hiccoughing, grimacing or squirming. Not all handling is negative, and we encourage parents to use positive touch, such as "kangaroo care", as one of the ways in which we can achieve this.

12 ت ؼ ا ساد : صذا صذا ا اؽ اس ػ اهل ا غا صذا ه ت ر ا ن تات ر ت هنا ن عا ز تج شات صذا ا تل ذ افذ : - تغ زات ف ش ل ص ل ت ذ ت فظ ت ذ ظزتاى قلة قف ت فغ ما ؼ درج اؽثاع امغ ضى افشا ؼ اگ ا ه ا گ ي فؾار خ ى ؽز ا خ اب آؽفت ت قزار ساد - آع ة ت اخت ا گ ػ ساد ( در افت آه گل ن س ذ ا( - احتوال ما ؼ ا اس دعت رفتي ؽ ا ساد - خ ز ش داخل هغش

13 THE ACOUSTIC ENVIRONMENT: HEARING Exposures to sound cause abrupt changes in the flow velocity of brain blood, in behavioral state, and in gross motor activity. A number of studies show that the human fetus detects subtle characteristics of the mother's speech. An active fetal learner and acute listener who can discriminate and show preferences for quite specific aspects of the mother's speech. On or near the birth day, however, term newborns do not discriminate the father's voice from that of another male, although recognition of this voice develops rapidly with exposure. Studies suggest that continual distraction, sensory overload, and the accompanying behavioral disorganization, together with the absence of the salient, responsive mother's voice, may be associated with long-term effects on attention and auditory processing

14 راهكار ها : تؾ ق هادر ت حع ر در تخؼ عخي گفتي تا ساد گفت گ آرام آ غت مارم اى تخؼ هال وت در تاس تغت مزدى در ا پ جز ا تخؼ ا ن تات ر ما ؼ صذا ؾذار د ذ دعتگا ا س گ تلفي ا ما ؼ صذا تج شات تا ت عاس آ ا Skin-to-skin holding by a parent or other close relative provides the infant access to the speech patterns and language that the brain first registers and on which the infant will pattern further language development

15 ت ؼ ا ساد : نور نور قوي و مذاوم در بخش : تغت ت دى چؾن ا اختالل ظزتا گ طث ؼ جغو ر ا ساد ما ؼ ؽتاب رؽذ ساد در خ اب ت ذار اختالل در "سهاى آراهؼ" تزا ساد اختالل در ظن تز اه خ اب ؽثا ر س ساد اختالل در تؼذ ل تغ زات هت ا ب ره ا اختالل در ت ظ ن ه شاى گزها تذى ساد

16 THE ENVIRONMENT OF LIGHT: CIRCADIAN RHYTHMICITY The typical NICU environment provides a paucity of circadian cues to the preterm infant. Circadian rhythm: longer sleep cycles and improvements in weight gain. These benefits appear to persist for at least several months.

17 راهكارها : ما ؼ ر ػو ه تخؼ رػا ت ت ا ب ؽثا ر س ر در تخؼ رػا ت سهاى آراهؼ ساد تا ر هال ن ؽثا در تخؼ حفاظت ساد اس ر تا پ ؽؼ عط ح خارج ا ن تات ر تغتي چؾو ا ساد در ح ي ردرها

18 ت ؼ ا ساد : وضعيت استقرار ػذم ت اى ػعال ماف تزا ه ار حزمات تذى ػذم ت اى تزا خن مزدى دعت ا پا ا خ ات ذى تا دعت پا مؾ ذ تاس اتصال ساد ت حغگز ا خط غ ت فغ - تغذ ا ت ى غ ز طث ؼ ػعال در اعتقزار ط ال در ا ي ظؼ ات اختالل تاخ ز در تناهل حزمت اختالل در ه شاى امغ ضى گ ز اختالل در تؼذ ل دها تذى اختالل در خ اب

19 راهكارها : هزاقثت اس ساد ارط م چل در ظؼ ت ا خ ات ذ ت ؽنن ا پ ل تا ا ذم تاال ت دى ؽا ا ظؼ ت دادى ت ساد ارط ت ؽنل ال مزدى KMC

20 ت ؼ ا ساد : دستكاري و جابجايي افشا ؼ ه ا گ ي پا غلظت م رت ش ل در خالل تؼ ط پ ؽل ت ؼ ا رفتار ف ش ل ص ل : - ت ذ ا م ذ ظزتاى قلة - ت ذ ت فظ قف ت فغ - ما ؼ درج اؽثاع امغ ضى - تغ ز ر گ ساد ت ت زگ ا تزافز ختگ - عنغن خو اس - خ ز ش داخل هغش

21 راهكارها : ما ؼ دعتنار ا جاتجا ساداى ارط ت موتز ي حذ هوني هال وت در ا جام و اقذاهات هزاقثت تؾخ ص درها KMC :Not all handling is negative, and we encourage parents to use positive touch, such as "kangaroo care", as one of the ways in which we can achieve this.

22 ت ؼ ا ساد : تماس پوستي ج د احغاط تواط تا پ عت اس ا ائل س ذگ ج ج د پ عت تغ ار ظز ف ؽن ذ در ساداى ارط ػنظ الؼول هتفا ت ساداى ارط تغ ار م چل غثت ت ع تواط پ عت ت ؾشا ت دى هالؼ پ عت در ساداى م چنتز اس ٣٠ فت ت جا آراهؼ تخؾ ذى

23 ENVIRONMENTAL CONTACT WITH THE SKIN: TOUCH Touching another person is a form of physical intimacy with an important role in maternal-infant bonding, human play. Touch can quiet a crying infant, quell an apneic episode, or elicit a period of instability and desaturation. Touch forms a natural bridge between neurobehavioral states that can assist the infant to transition smoothly from deep sleep to wakefulness and vice versa. Unfortunately, the built environment of most existing NICUs, the traditions of caregiving, and the technical demands of care result in the preterm infant being touched by a large number of individuals, whereas close contact with the parents is quite limited.

24 Effect of touching: researches Preterm infants often show adverse responses to procedural touch; they include hypoxia, bradycardia, sleep disruptions, or increased intracranial pressure The results of numerous animal studies suggest that providing appropriate tactile stimulation during the early days of life is critical for promoting optimal growth and development the practice of skin to skin holding (Kangaroo Care [KC]) also includes a form of tactile stimulation (in addition to vestibular stimulation and oral stimulation related to breast feeding) Gentle touch improve longer term outcomes such as weight gain, morbidity status, or length of hospital stay. Touch is a vital component in the social and neurobehavioral development of primates.

25 Stress of separation The hormonal and behavioral sequelae of brief periods of separation from the mother have been extensively investigated in both altricial species such as neonatal rats and in precocial species such as the squirrel monkey. The stress of separation from the mother leads to activation of the pituitary-adrenal axis, with increases in plasma cortisol levels in both infant and mother. These responses can be ameliorated by reunion and contact (and therefore touch) with the mother. The complex interaction between touch and breastfeeding deserves particular attention.

26 Effect of tactile stimulation Using a similar tactile stimulation model, Alasmi and coworkers showed that brushing the dorsal surface increased levels of circulating lactate in newborn rats, whereas the same stimulus had no effect at 1 week of age. Lactate is an important and preferred metabolic substrate for the developing neonatal brain. Recent work has implicated the protein kinase C (PKC)- alpha system as an important molecular mediator of maternal touch in regulating growth hormone gene expression in infant rats

27 Appropriate and inappropriate touch? The distinction between appropriate and inappropriate touch is nowhere more clearly seen than in the newborn intensive care unit. Infant massage has been touted as a means of promoting growth and development of the preterm infant with varying degrees of success. Skin-to-skin contact (kangaroo care) has been evaluated in a number of contexts with generally favorable outcomes. Areas such as therapeutic touch that do not involve actual physical contact with the patient are more controversial.

28 راهكارها : تؾ ق هادر پذر ت اسػ ساد خ ؼ در تخؼ هالؼ هال ن پ عت ساداى ارط تا ر غي غ ز ػطز اعتز ل احت اغ هزاقثت ماهل تزا هالؼ پ عت ساداى ارط تغ ار م چل رػا ت سهاى ت ا ب لوظ تز اعاط اس پاعخ ا ساد تؼو ن هزاقثت هادرا ما گز در تخؼ

29 تفکش Crawl) BC (Breast اص کجب آهذ ا لیي ثبس ایي هسئل ت سط دکتش ANNE MARIC وکبسا ص دس سبل 1987 دس SWEDEN هطشح گشدیذ اص سبل 1990 دس کط س بی هختلف تذمیمبت ثسیبسی دس ایي صهی ص ست گشفت. دس سبل 2005 کبسگب بی ثسیبسی ج ت ت صی آه صش ایي س ش دس کط س بی پیطشفت اص طشیك وبیص فیلن ثشگضاس گشدیذ. دس سبل 2007 سبصهبى ث ذاضت ج ب ی ی یسف ایي س ش سا ثع اى س ضی ه بست دس ضش ع ص د تغزی ثب ضیش هبدس اعالم و د.

30 دس طی فشای ذ BC سا پیذاهی ک ذ چگ صاد پستبى ساد تا ت ا ایی ای غزیشی تسیاری هت لد هی ش د ک در ایي اهز ت ا کوک هی واید : -1-2 ح اص تزشحات آ د کزیي 3- شزایط هحیطی رفلکس ا 4-

31 ث یبیی ت ئیدى ق یتزیي فاکت ر کوک ک د در اجزای ایي فزای د هی تاشد. سال 1998 یي تزگ وکاراى طی تحقیقی ت ایي تیج رسید د ک ت ی یپل ک هشات هایع آه ی تیک است ساد را در رسیدى ت پستاى دایت هی ک د.

32 ثی بیی صاد ثالفبصل ثعذ اص ت لذ چطو بیص سا کبهال ثبص هی ک ذ لبدس ث دیذى تصب یش ضدیک خص صب تصب یش تیش دس صهی س ضي هی ثبضذ)هب ذ یپل (. ص ست هبدس سا دیذ لبدس ث ضجط آى دس ر ص هی ثبضذ ث ط سی ک اگش 4 سبعت ثعذ هبدس ضخص دیگشی دس دیذ ا لشاس گیش ذ لبدس ث تطخیص ص ست هبدسش هی ثبضذ دس ه سد تص یش پذس دس %85 ه اسد ایي لضی صبدق است

33 ض یذى لتی دس توبط پ ست ث پ ست ثب هبدس است صذای للت هبدس سا هی ض د.)هب ذ صهبى ج ی ی ( ث ایي هذشک ث دلیل آساهص یبفتي ثب کب ص تعذاد ضشثبى للت پبسخ هی د ذ. صذای للت هبدس ت ب آساهص ثخص است اص گشی صاد جل گیشی هی ک ذ ثلک اص کب ص صى صاد جل گیشی هی ک ذ صذای هبدس سا هی ض د ث خبطش هی آ سد دس % 85 ه اسد صذای پذس سا ثخبطش هی آ سد صذای هبدس سجت و سبیک ل ژیک صاد ث ج د سضذ ی هی ض د دس ضوي س ی سضذ هغض اثش هی گزاسد صذای للت هبدس ط ل ضیشخ سدى صاد سا ثیطتش هی ک ذ

34 اکسی ت سیي تشضخ اکسی ت سیي دس توبط پ ستی هبدس ثب صاد دس هغض صاد یض تشضخ ضذ سجت تذشیک تشضخ 19 سه ى گ اسضی اص جول ا س لیي گبستشیي کلسی ت یي... ک دس سضذ یلی بی س د دس تیج جزة ث تش ضیش ه ثش است اکسی ت سیي سجت تس یل ث تش ثب ذی گ هبدس صاد هی ض د اکسی ت سیي سجت ایجبد آساهص ادسبط خ اة دس صاد هبدس هی ض د تشضخ ثضاق دس صاد طبى د ذ آى است ک غزا ضدیک است.

35 سفلکس ب 1- استپی گ سثة حزکت ت سوت پستاى تا استفاد اس حزکت دست پا ا هی گزدد. -2 دست تاعث هاساژ یپل تزشح شیز هی ش د 3 -ت علت و خ ب عضالت شا راى گزدى ساد در تد ت لد قادر است سز گزدى را تاال گ داشت ت کوک حزکت پا ا تاس ا ت پستاى شدیک ش د.

36 ف ایذ BC سادی : 1- کا ش %16 در هزگ ساد در ص رت شز ع تغذی تا شیز هادر در 24 ساعت ا ل کا ش %22 در هزگ ساد در ص رت شز ع تغذی تا شیز هادر در ین ساعت ا ل تعد اس ت لد. 2- حفظ گزهای ساد اس طزیق تواص پ ستی تا هادر ک هحزک تسیار ق ی رشد عصثی ساد هی تاشد. 3- آراهش ساد کا ش هیشاى گزی ی 4- ساسگاری هتات لیکی :ت ث دی سطح گل کشخ ى سایز پاراهتز ای تی شیوی تعادل اسید تاسدر ساعت ا ل تعد اس ت لد هی ش د

37 خطز عف ت ساد را کا ش هی د د رشد اجتواعی ر ا ی ساد تا دی گ ت تز تا هادر ش د کا ش شدت سردی فیشی ل ژیک ساد هی 9- تدا م اداه شیزد ی تعد اس تزخیص

38 ف ایذ هبدسی خز ج سزیعتز جفت کا ش خ زیشی رحن کا ش آ وی تعد اس سایواى تا دی گ ت تز هادر افشایش آستا درد هادر ایجاد احساص عالق عشق ت ساد ایجاد آراهش احساص خ اتیدى افشایش سطح جذب کالزی غذا تا ز تغذی کوک ت تزشح افشایش ت لید شیز

39 ت ؼ ا ساد : درد ج د احغاط درد در ساد تؾذ ذ احغاط درد تا ت ثثات ارعا ف ش ل ص ل ساداى تؾذ ذ احغاط درد تا پا ي ت دى آعتا تحز ل لوغ ساد درد اك ت دى ا جام غالة هزاقثت ا در تخؼ تزا ساد اثزات اخ ؽا ذ هخزب درد در هذاخالت ت اجو لش م ؽ اعا تفا ت درد تا ت ؼ

40 راهكارها : ما ؼ ا جام هذاخالت درد اك ت حذاقل هوني در ل هذاخل غ ز قاتل اجت اب اعتفاد اس : هغني ا آرام تخؾ ا ها ذ : ع مز س ؽ زهادر عزع هادر گ ل س گ هغني ا ه ظؼ هغني ا ػو ه هزف ي دار غ ز هزف ي دار آه سػ ح ارس ات درهاى درد ت مارم اى تخؼ

41 THE CHEMOSENSORY ENVIRONMENT: TASTE AND SMELL The chemosensory experience of preterm infants in the NICU is markedly unlike that in the uterine environment or on the mother's body surface. Instead of attenuated, progressive, temporally patterned, and species-specific taste and odor cues from the mother, preterm infants are overexposed to the scents of different staff caregivers and to alien tastants and odorants. These alien stimuli are on pacifiers and in cosmetic, detergent, disinfectant, or adhesive agents applied on the infant (lotions, alcohol), on caregivers (soaped or alcohol-cleaned hands, rubber gloves), or on the incubator (cleaning agents). Preterm infants are clearly reactive to these exposures. Additionally, their feeding ecology is impoverished by chemically monotonous formulas administered by means that bypass oronasal stimulation.

42 Long-term Effects Research suggests that odors and tastes may have lasting consequences on affective and behavioral development, and that their incorporation into care routines in the NICU is not innocuous. Infants detect, react to, and learn odors and tastes that can then modulate arousal states, provide directional cues, elicit emotional behavior, mediate recognition of significant individuals and settings, activate digestive physiology, regulate ingestive behavior, and contribute to durable alimentary and social preferences.

43 Family and Caregiver Considerations Close physical contact of the type provided by skinto-skin holding exposes the infant to the soothing potency of the mother's odors, as well as eventually to her milk. Familiar odor stimuli may help promote pain control in the infant, but care should be taken not to create negative conditioning of odors. Nonfamiliar and aversive strong scents should be removed from the infant's space (e.g., alcohol or strongly scented lotions on caregivers' skin; be sure alcohol has evaporated before touching the infant or the pacifier).

44 KMC Some 20 million low-birth-weight (LBW) babies are born each year, Of the estimated 4 million neonatal deaths, preterm and LBW babies represent more than a fifth )KMC( is an effective way to meet baby s needs for warmth, breastfeeding, protection from infection, stimulation, safety and love.

45 KMC Mothers report being significantly less stressed during kangaroo care than when the baby is receiving conventional care. Mothers prefer skin-to-skin contact to conventional care Mothers report an increased confidence, selfesteem, and feeling of fulfilment, also in highincome countries

46 KMC They describe a sense of empowerment, confidence and a feeling that they can do something positive for their preterm infants in different settings and cultures. Fathers too said that they felt relaxed, comfortable and contented while providing kangaroo care. KMC is acceptable to health-care staff, and the presence of mothers in the ward does not seem to be a problem.

47 KMC Nurses may think that conventional incubator care allows better monitoring of sick LBW and preterm infants, but they recognize that it increases the risk of hospital infections and it separates infants from their mothers Health workers would prefer KMC for their own preterm/lbw infant.

48 maternal experience of kangaroo holding premature infants in the NICU environment kangaroo care helped mothers feel needed in the NICU environment allaying feelings of frustration and helplessness and reducing stress learn how to be a mother and build their maternal confidence.

الگ بی طراحی ز را فبد ست غسال حبئری

الگ بی طراحی ز را فبد ست غسال حبئری تؼریف الگ تبریخچ اجسای الگ لبلت هست ذ سبزی هسایب هؼبیت دست ث ذی تؼریف الگ تؼریف الگ تبریخچ اجسای الگ لبلت هست ذ سبزی هسایب هؼبیت دست ث ذی را حل تىرار ضذ ثرای یه هطىل