Dear Sloan,
We leave you each night in the care of kind and gentle nurses. It is hard for us to go when you are awake, but we know you need time to sleep and grow. You have a good home for now in the Neonatal Intensive Care Unit at the Kaiser Permanente Santa Clara Medical Center. In addition to all the nurses and doctors, each preterm baby there has a case worker. Yours was kind enough to write us a progress report on June 23. I'm saving it here so our family and friends can learn more about how you're doing. They are so kind to us, but we can't always write or call them with updates about you. I want you to know that, next to your health and own happiness, keeping friends and family in your heart is more important than anything else in the world.
Developmental Care Plan
June 23, 2009
Competencies
During this behavioral observation Sloan was observed as the nurse took her vital signs, changed her diaper, repositioned her, and fed her. Sloan was able to maintain a steady heart rate, good oxygen saturation and pink color while she was quiet, as well as during the time she was handled. As she was handled, Sloan became very active, but kept herself calm by bringing her hands up to her face and by clasping her feet together. She made soft mouthing movements on her feeding tube to show that she was getting hungry, but she was tube fed at this time. Sloan transitions from light sleep to brief periods of robust crying, spending most of the observation in a drowsy to quiet alert state. When in alertness she raises her eyebrows to show her interest in social interaction, however, she only locked her gaze with her nurse very briefly.
Sensitivities
Sloan is sensitive to sudden changes in her environment, and to handling. As the observation began, she was hiccoughing and breathing at an irregular rate. Her hiccoughing stopped as she was handled, but she began breathing fast after she was handled. Although her color is pink, she has an underlying yellowish color to her skin. This is very normal for her and should diminish within a week or so. Sloan was very active, moving about with jerky, flailing movements. As she was turned to her back her arms spread wide apart (airplaning) with her fingers spread wide apart (finger splaying) as well. While the nurse handled her she frequently extended her arms out in front of her (saluting) with her fingers splayed. However, she calms easily with hand containment. Sloan fussed briefly with her diaper change, but generally stayed calm. As she tires of socializing, she averts or closes her eyes.
Recommendations
Continue to keep Sloan in the covered isolette until she is at least 32 weeks, adjusted age, and is closer to 1500 grams. Since she still requires having the nasal cannula in place we don't want to make her try to maintain her own temperature as well as try to regulate her breathing. handle Sloan very slowly and gently to help keep her well regulated. use frequent hand containment by placing one of your hands over her head and the other over her hips and legs. provide this containment prior to handling her to prepare her for a change; during handling to keep her calm and well regulated; and following handling to help her smoothly transition back into deep sleep. Position Sloan with her arms and legs flexed (bent) and tucked in close to the midline of her body. Bring her hands up to her face, and bring her legs together to allow her to self-calm herself. When on her tummy, bring her arms up under her chest to keep her shoulders rounded forward, rather than lying flat on the bed. When placing her on her side, bring her well over onto her side with a small roll in front of her to drape over and hold on to. Use a size appropriate snuggle-up, keeping her down in to the fold of the snuggle-up to give her close, firm boundaries to push against. use the straps of the snuggle-up to bring her boundaries in closer for a more secure feeling nest. Sloan is getting close to starting to breast/bottle feeding, but she has some requirements to be met to ensure a successful breast/bottle feeding session. She needs to be able to maintain alertness throughout most of the feeding, as well as to exhibit hunger cues. These cues include making mouthing movements, searching for something to suck on, and sucking eagerly on a pacifier. These requirements need to be in place whether offering the breast or the bottle. Allow mom to put Sloan to the breast when she visits, and if Sloan is acting hungry. When starting bottle feeding, use the green rimmed nipple for a slower flow of milk. Gently rub her lips with the nipple until she opens wide. Allow her to take 4-6 sucks on the bottle, then lower the bottle to encourage her to swallow and breathe. Do not push her, but allow Sloan to set the pace of the feeding. As she slows with the sucking, gently turn the nipple in her mouth to encourage her to start sucking once again. After long pauses in sucking, remove the nipple and sit her up to burp her. Watch her closely for subtle color changes around her eyes and nose, suck as pale or slightly dusky colored, or for sudden sleepiness. If this happen removes the nipple an sit her up to encourage her to take deep breaths. Encourage the parents to participate in Sloan's care as much as possible. Allow them to kangaroo hold (skin-to-skin) each day, as tolerated. It is important to know that Sloan may not be able to tolerate being talked to and touched at the same time, so try to just hold her quietly when kangarooing. As she averts her eyes from yours or closes her eyes, she is telling you she has had too much stimulation. Provide support and encouragement to the parents as they begin their journey with Sloan.
June 23, 2009
Competencies
During this behavioral observation Sloan was observed as the nurse took her vital signs, changed her diaper, repositioned her, and fed her. Sloan was able to maintain a steady heart rate, good oxygen saturation and pink color while she was quiet, as well as during the time she was handled. As she was handled, Sloan became very active, but kept herself calm by bringing her hands up to her face and by clasping her feet together. She made soft mouthing movements on her feeding tube to show that she was getting hungry, but she was tube fed at this time. Sloan transitions from light sleep to brief periods of robust crying, spending most of the observation in a drowsy to quiet alert state. When in alertness she raises her eyebrows to show her interest in social interaction, however, she only locked her gaze with her nurse very briefly.
Sensitivities
Sloan is sensitive to sudden changes in her environment, and to handling. As the observation began, she was hiccoughing and breathing at an irregular rate. Her hiccoughing stopped as she was handled, but she began breathing fast after she was handled. Although her color is pink, she has an underlying yellowish color to her skin. This is very normal for her and should diminish within a week or so. Sloan was very active, moving about with jerky, flailing movements. As she was turned to her back her arms spread wide apart (airplaning) with her fingers spread wide apart (finger splaying) as well. While the nurse handled her she frequently extended her arms out in front of her (saluting) with her fingers splayed. However, she calms easily with hand containment. Sloan fussed briefly with her diaper change, but generally stayed calm. As she tires of socializing, she averts or closes her eyes.
Recommendations
Continue to keep Sloan in the covered isolette until she is at least 32 weeks, adjusted age, and is closer to 1500 grams. Since she still requires having the nasal cannula in place we don't want to make her try to maintain her own temperature as well as try to regulate her breathing. handle Sloan very slowly and gently to help keep her well regulated. use frequent hand containment by placing one of your hands over her head and the other over her hips and legs. provide this containment prior to handling her to prepare her for a change; during handling to keep her calm and well regulated; and following handling to help her smoothly transition back into deep sleep. Position Sloan with her arms and legs flexed (bent) and tucked in close to the midline of her body. Bring her hands up to her face, and bring her legs together to allow her to self-calm herself. When on her tummy, bring her arms up under her chest to keep her shoulders rounded forward, rather than lying flat on the bed. When placing her on her side, bring her well over onto her side with a small roll in front of her to drape over and hold on to. Use a size appropriate snuggle-up, keeping her down in to the fold of the snuggle-up to give her close, firm boundaries to push against. use the straps of the snuggle-up to bring her boundaries in closer for a more secure feeling nest. Sloan is getting close to starting to breast/bottle feeding, but she has some requirements to be met to ensure a successful breast/bottle feeding session. She needs to be able to maintain alertness throughout most of the feeding, as well as to exhibit hunger cues. These cues include making mouthing movements, searching for something to suck on, and sucking eagerly on a pacifier. These requirements need to be in place whether offering the breast or the bottle. Allow mom to put Sloan to the breast when she visits, and if Sloan is acting hungry. When starting bottle feeding, use the green rimmed nipple for a slower flow of milk. Gently rub her lips with the nipple until she opens wide. Allow her to take 4-6 sucks on the bottle, then lower the bottle to encourage her to swallow and breathe. Do not push her, but allow Sloan to set the pace of the feeding. As she slows with the sucking, gently turn the nipple in her mouth to encourage her to start sucking once again. After long pauses in sucking, remove the nipple and sit her up to burp her. Watch her closely for subtle color changes around her eyes and nose, suck as pale or slightly dusky colored, or for sudden sleepiness. If this happen removes the nipple an sit her up to encourage her to take deep breaths. Encourage the parents to participate in Sloan's care as much as possible. Allow them to kangaroo hold (skin-to-skin) each day, as tolerated. It is important to know that Sloan may not be able to tolerate being talked to and touched at the same time, so try to just hold her quietly when kangarooing. As she averts her eyes from yours or closes her eyes, she is telling you she has had too much stimulation. Provide support and encouragement to the parents as they begin their journey with Sloan.
