SPEECH-LANGUAGE PATHOLOGY & THE NEONATAL INTENSIVE …

SPEECH-LANGUAGE PATHOLOGY & THE NEONATAL INTENSIVE CARE UNIT

A Research Report Submitted in

Partial Fulfillment of the

Requirements for the Degree

Masters of Arts

Brooke Langel &

Megan Coady

University of Northern Iowa

December 2012

APPROVAL SHEET

Title: SPEECH-LANGUAGE PATHOLOGY & THE NEONATAL INTENSIVE CARE UNIT

(NICU): AN OVERVIEW

Name of Candidates: Brooke Langel and Megan Coady

Research Project Approved: ___________________________________

Kenneth Bleile, Ph.D., CCC-SLP

Research Director

___________________________________

Angela Burda, Ph.D., CCC-SLP

Second Reader

___________________________________

Date

Introduction: The purpose of these modulars is to provide future speech-language pathologist with a general background of the neonatal intensive care unit (NICU). It was developed by Brooke Langel and Megan Coady. These modulars were created in partial fulfillment of our Master’s degree in speech-language pathology. This project was completed at the University of Northern Iowa in December of 2012 with the supervision of Dr. Ken Bleile.

Modular 1: Knowledge and Skills It is important to understand the knowledge and skills a speech-language pathologist (SLP) is responsible for in the neonatal intensive care unit (NICU). In order to obtain these knowledge and skills, refer to the Knowledge and skills needed by speech-language pathologists providing services to infants and families in the NICU environment article found on the American Speech-Language-Hearing Association’s (ASHA) website. Read and answer the following quiz questions over the assigned reading found below. Quiz Questions

1. What are the four services an SLP is required to provide in the NICU according to the ASHA Scope of Practice?

2. According to this document, how many roles does an SLP hold within the NICU environment?

3. For role number 5, provide 3 areas of knowledge an SLP should have when working in the NICU.

4. What do roles 1, 2, and 3 have in common? State 3 expected skills for the roles. 5. Provide an example of knowledge and a skill for role number 4. What does role

number 4 relate to? 6. Do SLP’s collaborate with other team members and family members within the

NICU? 7. State roles 8-12 that are required by an SLP in the NICU environment.

Resource American Speech-Language-Hearing Association. (2004). Knowledge and skills needed by

speech-language pathologists providing services to infants and families in the NICU environment. [Knowledge and Skills]. Available from www.asha.org/policy. doi: 10.1044/policy.KS2004-00080

http://www.asha.org/policy

Modular 2: Guidelines for an SLP in the NICU A speech-language pathologist is required to follow certain guidelines when practicing in the NICU. These guidelines are found on ASHA’s website at www.asha.org/policy. Read the guidelines and answer the questions provided below. Quiz Questions

1. What are the three key principles for providing care in the NICU as an SLP? 2. An SLP is expected to be responsible for multiple major roles in a NICU; list the four

major sections that encompass these expectations. 3. What is the first step in a developmental assessment by an SLP? 4. T/F Developmental expectations for the infant are based on chronological age. 5. List four multiple-intervention approaches used within the NICU. 6. Why might a unimodality approach be recommended? 7. List two instrumental methods for evaluating the swallowing function. 8. What initial developmental difficulties might one observe in preterm infants and/or

very-low-birth rate infants? List two longstanding problems. Reference American Speech-Language-Hearing Association. (2005). Roles and responsibilities of

speech-language pathologists in the neonatal intensive care unit: Guidelines [Guidelines]. Available from www.asha.org/policy. doi: 10.1044/policy.GL2005-00060



Modular 3: The neonate and the environment: Impact on development A newborn baby is shaped early on in life by both the caregiver and the environment in which it is placed. This chapter discusses the overall psychological, social, and emotional development of the infant in the NICU. As speech-language pathologists interacting with this population, it is important to understand the development of the term and preterm neonates to provide the most effective therapy possible. The chapter on neonatal development is found within the book written by Gardner, Carter, Enzman-Hines, and Hernandez (2011) tilted Neonatal Intensive Care. For this modular, read chapter 13 and answer the quiz questions below. Quiz Questions

1. What is the primary task of newborns? 2. T/F The interaction between the caregiver and the newborn either facilitates or

disturbs the internal biorhythmic balance. 3. The infant develops a sense of self early on in life; how is the self of the infant

formed? 4. Tactile contact and vestibular stimulation are essential for what six developmental

traits? 5. Why is the nature (amount and type) of kinesthetic interaction between the

caregiver and the infant important? 6. Infants acquire individuality, what is the endowment of the individual infant? 7. In relation to temperament, what are the three basic types of infants identified in

the NICU? 8. How many stages does it require for appropriate brain growth in the fetus and

newborn? When do these stages occur in their life? 9. Very-low-birth-weight (VLBW) infants are less able to do which three tasks when

presented with stimuli? What does the inability to complete these tasks result in? 10. In what order do a neonate’s senses develop? 11. (a) Which sense is the major method of communication for neonates and infants?

(b) Where is this sense most developed? 12. T/F The fetus has heard the voices of mother, father, and siblings and is familiar and

able to differentiate them with the voices of strangers. 13. What will the neonate demonstrate in response to a sound? 14. (a) What is an infant’s language to communicate its needs? (b) What are the four

different types? 15. T/F Multiple caregivers do not confuse the infant, increase distress with feeding,

cause irritability, and upset visual attention. 16. Why does a preterm infant lag behind a term infant in care eliciting and responsivity

to the care provider? Reference: Gardner, S. L., Carter, B. S., Enzman-Hines, M., & Hernandez, J.A. (2011) Neonatal Intensive

Care (7th ed.) Mosby Elsevier: St. Louis, MO.

Modular 4: Breast feeding the neonate with special needs Breast milk and breast feeding has significant benefits for premature infants and their mothers. Nutrition is just one example of an advantage breast milk provides for a premature infant. This modular focuses on breast feeding and the mother and her neonate. For this modular, read chapter 18 from the assigned textbook and answer the following quiz questions. Quiz Questions

1. List three rewards a mother receives from breast feeding her infant. 2. Name two theories about breast feeding that explain improved neurobehavioral

development in premature infants. 3. T/F Initiating breast feeding as early as possible is important in prevent problems. 4. Sucking is a primitive reflex appearing as early as 15-16 weeks’ gestation. When can

an infant coordinate suck and swallow while breast feeding? 5. There is a difference between nonnutritive sucking and nutritive sucking; state that

difference. 6. T/F Bottle feeding requires the same amount of energy than breast feeding for any

infant. 7. What is the difference between preterm and full-term infants in relation to sucking

patterns? 8. Name and define the five separate processes involved in human nutritive suckling. 9. T/F An infant who has learned to feed using an artificial nipple often may suck

incorrectly, inhibiting milk flow. 10. List six hallmarks of breast feeding the preterm infant. 11. Name an assessment mentioned in the assigned chapter that assesses a preterm

infant’s oral feeding readiness and oral feeding skills. 12. Describe three potential difficulties one might observe if a preterm infant is bottle

fed before breast fed. Reference: Gardner, S. L., Carter, B. S., Enzman-Hines, M., & Hernandez, J.A. (2011) Neonatal Intensive


Modular 5: Respiratory Diseases As a speech language pathologist it is important to understand the respiratory system and how respiratory diseases affect neonates. This modular will discuss in depth the physiology, etiology, and symptomology of specific respiratory diseases, as well as, treatment and outcomes of these diseases. Refer to chapter 23 of the assigned textbook when answering the quiz questions below.

Quiz Questions

1. Define respiratory disease. 2. What is the single most common factor in the occurrence of respiratory distress

syndrome (RDS)? 3. T/F An oxygen hood is used to deliver a constant concentration of oxygen to the

infant. 4. List and define the three characteristics of the cause of apnea. 5. When discharging an infant it is important to look at and evaluate the parent’s

readiness. List four tools used by the team in preparing families for discharge. (Parent Teaching box on pg. 662).

6. Which form of suctioning is associated with an artificial airway? 7. Name five physiological alterations and complications that are associated with the

use of endotracheal tube suctioning. (pg. 595) 8. T/F CPAP stands for continuous positive airway pressure. 9. Describe one of the following forms of ventilations: Patient-Triggered Ventilation,

Assist-Control Ventilation, Pressure-Support Ventilation, Pressure Regulated Volume Control, Proportional-Assist Ventilation, High-Frequency Ventilation

10. What is surfactant?

Reference: Gardner, S. L., Carter, B. S., Enzman-Hines, M., & Hernandez, J.A. (2011) Neonatal Intensive


Modular 6: Neurological Disorders Intensive care nurseries encounter neurological diseases and secondary neurological complications. Neurological disorders can manifest in an infant before, during, or after birth. This modular discusses topics in neonatal neurology such as, congenital malformations, trauma, seizures, hypoxic-ischemic encephalopathy, and intraventricular hemorrhage (IVH). Chapter 26 on neurological disorders is found on page 748 in the assigned textbook; read and answer the quiz questions below. Quiz Questions:

1. Brain development includes cellular proliferation, migration, organization, and myelination. If abnormalities occur during this stage of development two defects may result. What are the two defects found within the assigned chapter?

2. What are birth injuries? 3. Give an example of a type of injury found involving the cranial and peripheral

nerves. 4. Give an example of a type of injury found involving an injury in the intracranial

region of the brain. 5. T/F Seizures are a clinical sign of peripheral nervous system dysfunction in the

neonate. 6. What does hypoxemia refer to? What does ischemia refer to? 7. What does hypoxic-ischemic encephalopathy (HIE) result in? 8. Name a major sign or symptom of HIE. 9. What is the most common source of hemorrhage in a premature infant? 10. What is the classification system used for CT scans when observing the extent of

hemorrhage? Reference: Gardner, S. L., Carter, B. S., Enzman-Hines, M., & Hernandez, J.A. (2011) Neonatal Intensive


Modular 7: Genetic disorders, malformations, and inborn errors of metabolism A neonate may be born with a genetic disorder, malformations, or a metabolic disorder; if this occurs, the NICU staff must manage the neonate accordingly. This modular will discuss briefly the basic genetic principles and focus on defining and addressing disorders and abnormalities found within the NICU. Refer to chapter 27 of the assigned textbook when answering the quiz questions below. Quiz Questions

1. Define gene. 2. How many chromosomes are found within normal somatic cells? 3. Name five instances in which a chromosomal abnormality should be suspected. 4. Microdeletions, or loss of a chromosome, are seen within the NICU. Chapter 27

discusses syndromes resulting from microdeletions. Name two and define them. 5. Name five syndromes resulting from a chromosomal abnormality. 6. Which chromosome is involved in Down syndrome? 7. T/F Prognosis is good in infants diagnosed with Trisomy 18 or Trisomy 13. 8. If an infant is diagnosed with Turner syndrome, what problems in development

might arise? 9. What characteristic is most evident in Cri du Chat? 10. T/F A negative family history does not rule out the presence of an autosomal

dominant disorder. 11. Multifactorial disorders are the result of what? 12. T/F The AAP recommends that all infants be screened for hearing loss before they

turn one. Reference: Gardner, S. L., Carter, B. S., Enzman-Hines, M., & Hernandez, J.A. (2011) Neonatal Intensive


Modular 8: Families in Crisis: Theoretical and Practical Considerations The development of the sick neonate is, in part, determined by the psychological strain and emotional stress encountered by the family; essentially the long-term caregivers. In turn, the NICU focuses on the need for a family-centered care approach to maximize the best possible outcome for the neonate post-NICU. This modular will discuss the families’ needs during this stressful period and how to intervene effectively. Read chapter 29 and answer the following quiz questions. Quiz Questions

1. What do the terms attachment and bonding refer to during and after an infant’s birth?

2. Early skin-to-skin contact between the mother and the infant results in six significant benefits. List these six benefits.

3. List the nine steps of attachment. 4. T/F The behaviors and attitudes of the hospital staff might affect parental coping. 5. What is the vulnerable child syndrome? 6. T/F Using words such as “retarded,” “brain damage,” or “the baby will die,” are ideal

words and phrases to use when conversing with a neonate’s family. 7. T/F As a staff member, it is important to encourage the parent or caregiver to

discuss their feelings about their family’s NICU experience. 8. The postpartum period is a time in a parent’s life where development of mood

disturbances is common. Provide three examples of possible predictors of postpartum mood disorders.

9. Postpartum mood disorders are usually divided into three categories. Name these three categories.

10. Name three helpful interventions to deal with families in the NICU (Found under the “Adaptation to the Intensive Care Environment).

11. What are four influences on the transfer of care from the NICU staff to the parent? 12. T/F Social work intervention may be needed if there is a history of substance abuse,

domestic violence, if other children have physical or mental handicaps, attachment difficulties with the infant, and/or inadequate food and other essentials.

13. T/F Parents do not need to know the infant’s mannerisms and behaviors when the infant is discharged.



Modular 9: Ethics, Values, and Palliative Care in Neonatal Intensive Care It is important in medical professions to understand ethical principles when caring for patients and their families. This modular will discuss topics related to ethics, values, and palliative care in the NICU specific to decision making. Refer to chapter 32 of the assigned textbook when answering the quiz questions below. Quiz Questions

1. Define ethics. 2. There are many clinical dilemmas in the NICU, for example personhood. What is the

dilemma related to personhood? 3. In relation to professional-patient relationships what are the four ethical principles? 4. T/F Parents are involved in the overall determination of goals for treatment. 5. List the different steps of decision making when a dilemma exists. 6. T/F Decision making is done by a single caregiver of the premature or anomalous

infant. 7. Define morals. 8. Define palliative care. 9. Good communication with parents is essential when caring for patients in the NICU.

This includes listening and being empathetic. List five questions to facilitate empathic conversation.

10. T/F Enhancing the NICU environment involves routine ethics rounds or committee and palliative care consults along with family care conferences.



Modular 10: Where’s Waldo? As speech-language pathologists, it is important to understand the experiences that one may go through in the NICU. This modular is designed to provide the reader with additional information from various chapters within the assigned text. The chapters cover topics such as prenatal care which can affect the neonate post birth, nutrition, low-birth weight and other speech-related topics. The chapters reviewed for this modular include: chapter 2, 5, 17, and 28. Read and answer the following quiz questions over the assigned chapters. Quiz Questions: Chapter 2

1. T/F A baby may undergo withdrawal-like symptoms (e.g., jittery movements) if a mother smokes during pregnancy.

2. Fetal alcohol spectrum disorders (FASD) is an umbrella term that encompasses fetal alcohol syndrome and other alcohol related effects. What are long term consequences of maternal intake of alcohol in relation to an infant’s speech and language development?

3. Preterm birth is defined as any birth before ________ weeks’ gestation. Chapter 5

4. T/F Gestational age can be estimated effectively by measuring foot length. 5. Name the three newborn classifications according to gestation. 6. What is kangaroo-care (KC)? What does KC facilitate?

Chapter 17 7. Gavage feedings are indicated in infants requiring endotracheal intubation or those

with immature, weak, or absent suck, swallow, or gag or cough reflex. If an infant does not have a mature suck, swallow, gag, or cough reflex, what is the infant at risk for during feeding?

8. T/F Tube feedings should be ran in quickly and infants should be overfed to supply them with additional nutrients.

9. An infant who is successful in oral feeding should exhibit four skills; name the four feeding skills required for successful oral feeding.

10. T/F After an operative procedure, the neonate is often nothing per oral (NPO) for 3 to 14 days until the return of intestinal motility and function.

Chapter 28 11. Failure in the normal development of the esophagus and in complete separation of

the trachea from the esophagus may result in esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). If this occurs, name two signs or symptoms that may be present.

12. Congenital chest masses may cause various difficulties in relation to respiratory. Name four congenital chest masses.



Answer Sheet

Modular 1

8. What does the NICU stand for? Neonatal intensive care unit 9. What are the four services an SLP is required to provide in the NICU according to

the ASHA Scope of Practice? Communication, cognition, feeding, and swallowing 10. According to this document, how many roles does an SLP hold within the NICU

environment? Twelve 11. For role number 5, provide 3 areas of knowledge an SLP should have when working

in the NICU. a. Principles of instruction, b. counseling principles, c. prenatal to postnatal continuities relative to communication cognition feeding and swallowing, d. psychobiology of early learning in the fetus and neonate, e. cultural values and their impact on professional practice in the NICU, f. family systems family dynamics parent infant interactions and approaches to family empowerment, g. developmentally supportive care in family centered practice, h. ethical decision making processes.

12. What do roles 1, 2, and 3 have in common? State 3 expected skills for the roles. The three roles all include information about identification and evaluation of swallowing and feeding.

13. Provide an example of knowledge and a skill for role number 4. What does role number 4 relate to?

14. Do SLP’s collaborate with other team members and family members within the NICU? yes

15. State roles 8-12 that are required by an SLP in the NICU environment. 8. Maintain quality control/risk management program, 9. Provide discharge/transition planning and follow-up care, 10. Educate and supervise SLP’s, including clinical fellows and students-in-training, 11. Provide public education and advocacy for serving infants and families in the NICU, 12. Conduct basic and clinical research in fetal and neonatal development and function and effectiveness of treatments.

Modular 2 9. What are the three key principles for providing care in the NICU as an SLP? Family-

centered care, developmental care, culturally appropriate care. 10. An SLP is expected to be responsible for multiple major roles in a NICU; list the four

major sections that encompass these expectations. (1) Communication, evaluation, and intervention, (2) feeding and swallowing evaluation and intervention, (3) Parent/caregiver education and counseling, (4) other roles assume in the NICU including quality control/risk management, discharge/transition planning and follow-up care, professional education and supervision, public education and advocacy, and research.

11. What is the first step in a developmental assessment by an SLP? The first step in a developmental assessment by an SLP is a chart review of history and prior evaluations.

12. T/F Developmental expectations for the infant are based on chronological age. False, expectations are based on gestation or adjusted age.

13. List four multiple-intervention approaches used within the NICU. (1) vestibular, auditory, visual, and/or tactile intervention, (2) clustering of care activities to provide more prolonged periods for sleep, (3) positioning or swaddling for the preterm infant; and (4) nipple feeding.

14. Why might a unimodality approach be recommended? Unimodality approaches have been recommended to avoid overstimulation because preterm infants lack multimodality contingencies.

15. List two instrumental methods for evaluating the swallowing function. Videofluroscopic swallow study (VFSS), endoscopic assessment of swallowing function, and ultrasonography (US)

16. What initial developmental difficulties might one observe in preterm infants and/or VLBW infants? List two longstanding problems. (a) Initial difficulties include problems with autonomic control, state organization, and attention regulation. (b) auditory and visual deficits, abnormal reflexes, inferior grasping and hand use, lower IQ, language and reading difficulties, academic underachievement, and behavior problems.

Modular 3

17. What is the primary task of newborns? To establish independent biorhythmic balance by stabilizing the function of sleep-wake cycles, respiratory and heart rates, blood chemistry levels, metabolic processes, and eating patterns.

18. T/F The interaction between the caregiver and the newborn either facilitates or disturbs the internal biorhythmic balance. True

19. The infant develops a sense of self early on in life, how is the self of the infant formed? Through interaction with people and objects within the environment.

20. Tactile contact and vestibular stimulation are essential for what six developmental traits? (1) development of a physical identity, (2) organization and sorting of stimuli, (3) coordination of sensorimotor skills, (4) a psycho logic and social sense of self, (5) normal neurophysiologic development, and (6) emotional stability and temperament.

21. Why is the nature (amount and type) of kinesthetic interaction between the caregiver and the infant important? Because lack of stimulus results in impairment or retardation of, or deviancy in, skill development for productive living.

22. Infants acquire individuality, what is the endowment of the individual infant? Primitive reflex behaviors, higher cognitive abilities, temperament, and sensorimotor competencies.

23. In relation to temperament, what are the three basic types of infants identified in the NICU? The “easy” child who is seen as regular, pleasant, and easy to care for and love, the “difficult” child who is difficult to rear and reacts with protest and withdrawal to strange events or people, and the “slow to warm” child who reacts with withdrawal or passivity to new events.

24. How many stages does it require for appropriate brain growth in the fetus and newborn? When do these stages occur in their life? Two, stage one is from 10-18 weeks of pregnancy, stage two is from 20 weeks’ gestation to two years of age.

25. Very-low-birth-weight (VLBW) infants are less able to do which three tasks when presented with stimuli? What does the inability to complete these tasks result in? (1) Modulate attention, (2) take brief breaks from processing information, and (3) habituate to stimuli. Results in the preterm infant being easily overstimulated and less able to deal with multiple sources of stimuli.

26. In what order do a neonate’s senses develop? Tactile/vestibular, olfactory/gustatory, and auditory/visual.

27. (a) Which sense is the major method of communication for neonates and infants? (b) Where is the sense most developed? (a) Touch (b) in the face, around the lips, and in the hands.

28. T/F The fetus has heard the voices of mother, father, and siblings and is familiar and able to differentiate them with the voices of strangers. True

29. What will the neonate demonstrate in response to a sound? Change in motor activity, change in heart rate, smile, startle or grimace, alert or arouse, cry or cease to cry, stop sucking.

30. (a) What is an infant’s language to communicate its needs? (b) What are the four different types? (a) Crying (b) birth cry, hunger cry, pain cry, and pleasure cry.

31. T/F Multiple caregivers do not confuse the infant, increases distress with feeding, causes irritability, and upsets visual attention. False

32. Why does a preterm infant lag behind a term infant in care eliciting and responsivity to the care provider? Because of the immaturity of the preterm infant’s central nervous system (CNS).

Modular 4

13. List three rewards a mother receives from breast feeding her infant. 1.) Knowing that she is providing the healthiest nutrition, 2.) Enhancing closeness between her and her preterm infant, 3.) Perceiving her preterm infant’s contentment and tranquility during breast feeding, 4.) Convenience for the mother, 5.) Giving her a tangible claim to her preterm infant

14. Name two theories about breast feeding that explain improved neurobehavioral development in premature infants. 1.) Nutritional content of breast milk that improves neurologic growth and 2.) The effect of breast feeding on mother-infant relationship that indirectly supports cognitive development.

15. T/F Initiating breast feeding as early as possible is important in prevent problems. True

16. Sucking is a primitive reflex appearing as early as 15-16 weeks’ gestation. When can an infant coordinate suck and swallow while breast feeding? 28 weeks’ gestation

17. There is a difference between nonnutritive sucking and nutritive sucking, state that difference. Nonnutritive sucking is sucking when no fluid or nutrition is given to the infant; nutritive sucking is when fluid or nutrition is available and is described as organized and rhythmic. Nutritive sucking is about half the rate of nonnutritive sucking.

18. T/F Bottle feeding requires the same amount of energy than breast feeding for any infant. False, bottle feeding requires more energy than breast feeding.

19. What is the difference between preterm and full-term infants in relation to sucking patterns? In preterm infants, sucking-to-breathing ratio is 2:1 to 4:1 whereas in full-term infants, sucking-to-breathing ration is 1:1 and is well coordinated.

20. Name and define the five separate processes involved in human nutritive suckling. 1.) Rooting- tactile stimulating of the infant’s face and lips elicits the infant to turn towards the stimulus, 2.) Orienting- occurs when the tongue draws the nipple and areola into an elongated teat and compresses it against the hard palate. 3.) Suction- the application of negative pressure in the infant’s mouth holds the nipple and areola in place. 4.) Expression- the motion of the tongue stimulates the release of oxytocin which helps eject milk from the ducts, 5.) Swallowing- the reflexive swallow is triggered

21. T/F An infant who has learned to feed using an artificial nipple often may suck incorrectly, inhibiting milk flow. True

22. List six hallmarks of breast feeding the preterm infant. 1.) Proper positioning; 2.) Use of breast pump; 3.) Waking every 2-3 hours to feed; 4.) Use of skin-to-skin care; 5.) Pre- and post-breast feeding weights; and 6.) Use of alternative methods of enteral nutrition

23. Name an assessment mentioned in the assigned chapter that assesses a preterm infant’s oral feeding readiness and oral feeding skills. Early Feeding Skills (EFS) Assessment

24. Describe three potential difficulties one might observe if a preterm infant is bottle fed before breast fed. 1.) Choking as a result of a soft nipple; 2.) A fast flow that the infant cannot control; or 3.) A nipple that is too long for the preterm infant’s mouth.

Modular 5

11. Define respiratory disease. A progressive impairment of the lungs to exchange gas at the alveolar level.

12. What is the single most common factor in the occurrence of RDS. Prematurity 13. T/F An oxygen hood is used to deliver a constant concentration of oxygen to the

infant. True 14. List and define the three characteristics of the cause of apnea.

Central Apnea - Absence of breathing effort Obstructive Apnea - Breathing efforts occur but the airway is blocked Mixed Apnea - Initial central apnea followed by obstruction of the airway

15. When discharging an infant it is important to look at and evaluate the parent’s readiness. List four tools used by the team in preparing families for discharge. (Parent Teaching box on pg. 662). Individualize parent teaching and evaluate parental readiness to care for an

infant with ongoing respiratory care needs Involve and teach parents care of their infant throughout hospitalization Provide parents with written instructions for home care Provide parents with written instructions about all medications Teach parents how to feed their infant and encourage frequent feeding

opportunities; teach parents how to feed with alternative feeding methods such as gastrostomy tube

Teach parents and other care providers how to perform cardiopulmonary resuscitation

Instruct parents in use of apnea monitors and other equipment for home use Instruct parents to notify emergency personnel about their infant posting

emergency phone numbers Instruct parents about the importance of follow up care

16. Which form of suctioning is associated with an artificial airway? Endotracheal suctioning

17. Name five physiological alterations and complications that are associated with the use of endotracheal tube suctioning. (pg. 595) Hypoxia/Hypoxemia Alterations in heart rate Alterations in blood pressure Alterations in cerebral blood flow Increase in plasma epinephrine and norepinephrine levels Tissue damage Atelectasis Pneumothorax Infection Unplanned extubation

18. T/F CPAP stands for continuous positive airway pressure. True 19. Describe one of the following forms of ventilations: Patient-Triggered Ventilation,

Assist-Control Ventilation, Pressure-Support Ventilation, Pressure Regulated Volume Control, Proportional-Assist Ventilation, High-Frequency Ventilation Patient-Triggered Ventilation – the ventilator delivers a mechanical breath, timed to the onset of inspiration in response to the neonate’s signal representing spontaneous respiratory effort. Assist-Control Ventilation – delivers mechanical breaths at a fixed rate. (Enables synchronization of ventilation breaths by sensing the neonate’s initiation of respiration and then triggering a mechanical breath.) Pressure-Support Ventilation – ventilation that compliments the neonate’s respiratory effect. A specific pressure triggers a mechanical breath. Pressure Regulated Volume Control – four breaths are delivered and modifies ventilation pressure to attain the appropriate tidal volume Proportional-Assist Ventilation – the ventilator pressure increases in proportion to inspiratory volume. High-Frequency Ventilation – uses less tidal volume at high frequencies to reduce barotrauma early in the course of RDS or reduce the progression of injury in infants with pulmonary interstitial emphysema, recurrent pheumothorax, or bronchopleaural fistula.

20. What is surfactant? It is a protective layer around the lungs made of fat and proteins. It is important for breathing to occur because it allows the lungs to not stick to its self when inhalation and exhalation are occurring.

Modular 6

11. Congenital malformations: Brain development includes cellular proliferation, migration, organization, and myelination; if abnormalities occur during this stage of development two defects may result. What are the two defects found within the assigned chapter? Microcephaly and lissencephaly

12. Trauma: What are birth injuries? The direct result of difficulties encountered during the delivery process

13. Give an example of a type of injury found involving the cranial and peripheral nerves. Radial nerve palsy, medical nerve palsy, sciatic nerve palsy, laryngeal nerve palsy, diaphragmatic paralysis, facial nerve palsy

14. Give an example of a type of injury found involving an injury in the intracranial region of the brain. Epidural hematoma, subdural hematoma, subarachnoid hemorrhage, cerebral contusion, cerebellar contusion, intracerebellar hematoma

15. Seizures: T/F Seizures are a clinical sign of peripheral nervous system dysfunction in the neonate. False, central nervous system

16. Hypoxic-ischemic encephalopathy (HIE): What does hypoxemia refer to? Refers to a diminished amount of oxygen in the blood. What does ischemia refer to? Refers to a diminished amount of blood perfusing the brain.

17. What does HIE result in? Lack of a sufficient oxygen supply to the brain. 18. Name a major sign or symptom of HIE. Seizures 19. Intraventricular hemorrhage: What is the most common source of hemorrhage in a

premature infant? The subependymal germinal matrix 20. What is the classification system used for CT scans when observing the extent of

hemorrhage? 0- No bleeding, I- germinal matrix only, II- germinal matrix with blood in the ventricles, III- germinal matrix with blood in the ventricles and hydrocephalus, IV- intraventricular and parenchymal bleeding (other than germinal matrix).

Modular 7

13. Define gene. A segment of a deoxyribonucleic acid (DNA) molecule that codes for the synthesis of a single polypeptide and contains the hereditary information needed for development or function.

14. How many chromosomes are found within normal somatic cells? 46 15. Name five instances in which a chromosomal abnormality should be suspected. 1.)

Small for gestational age for weight, length, or head circumference, 2.) Presence of one or more congenital malformations, 3.) Presence of dysmorphic features, 4.) Neurologic or neuromuscular dysfunction, 5.) Family history of multiple miscarriages or siblings with mental retardation or birth defects along with one or more of the above.

16. Microdeletions, or loss of a chromosome, are seen within the NICU. Chapter 27 discusses syndromes resulting from microdeletions. Name two and define them. 1.) Prader-Willi syndrome: caused by an interstitial deletion of chromosome 15; usually manifests in a newborn as severe hypotonia, feeding difficulties, and micropenis or hypoplastic labia. 2.) Williams syndrome: caused by an interstitial deletion or mutation of the elastin gene on the long arm of chromosome 7; may be a congenital

heart defect, hypotonia, poor suck and swallow, and vomiting and irritability. 3.) Velocardiofacial syndrome (VCFS): characterized by cleft palate or velophryngeal insufficiency, hypernasal speech, learning disabilities, conotruncal heart defects, and characteristic facies, caused by deletion of chromosome 22 (VCFS can represent DiGeorge syndrome or conotruncal anomaly face syndrome (CTAF)).

17. Name five syndromes resulting from a chromosomal abnormality. Down Syndrome, Trisomy 18, Trisomy 13, Turner Syndrome, Cri du Chat, San Luis Valley Syndrome.

18. Which chromosome is involved in Down syndrome? 21 19. T/F Prognosis is good in infants diagnosed with Trisomy 18 or Trisomy 13. False,

prognosis is poor, most infants with Trisomy 18 die within the first few months of life. Prognosis is extremely poor in infants with Trisomy 13.

20. If an infant is diagnosed with Turner syndrome, what problems in development might arise? Females diagnosed with Turner syndrome may have difficulties with spatial perception or fine motor abilities.

21. What characteristic is most evident in Cri du Chat? An unusual catlike, weak cry. 22. T/F A negative family history does not rule out the presence of an autosomal

dominant disorder. True 23. Multifactorial disorders are the result of what? They are the result of both

environmental and genetic factors. 24. T/F The AAP recommends that all infants be screened for hearing loss before they

turn one. False, it is recommended that infants are screened before the age of 3 months.

Modular 8

14. What do the terms attachment and bonding refer to during and after an infant’s birth? The terms refer to the emotional investment between parents and their infant (e.g., care, responsibility, knowledge).

15. Early skin-to-skin contact between the mother and the infant results in six significant benefits. List these six benefits. 1.) Better breast feeding 2.) Maintenance of infant body temperature 3.) Higher blood glucose 4.) Lower respiratory rate 5.) More affectionate maternal behaviors 6.) Less infant crying

16. List the nine steps of attachment. 1.) Planning the pregnancy 2.) Confirming the pregnancy 3.) Accepting the pregnancy 4.) Fetal movement 5.) Accepting the fetus 6.) Labor and birth 7.) Seeing 8.) Touching 9.) Care giving.

17. T/F The behaviors and attitudes of the hospital staff might affect parental coping. True

18. What is the vulnerable child syndrome? A condition in which a child is overprotected by his or her parents and treated as if he or she had a medical problem or is in danger of death when neither is any longer the case.

19. T/F Using words such as “retarded”, “brain damage”, or “the baby will die” are ideal words and phrases to use when conversing with a neonate’s family. False, these words and phrases cause unwanted and unnecessary distress and should be substituted with less stressful descriptors.

20. T/F As a staff member, it is important to encourage the parent or caregiver to discuss their feelings about their family’s NICU experience. True

21. The postpartum period is a time in a parent’s life where development of mood disturbances is common. Provide three examples of possible predictors of postpartum mood disorders. History of previous depression, present depression and anxiety disorders, low self-esteem, negative and/or stressful life events, marital discord, poor social support, difficult infant temperament, child-care stress, history of endocrine dysfunction, maternity blues, single marital status, adolescent pregnancy, unplanned/unwanted pregnancy, low socioeconomic status

22. Postpartum mood disorders are usually divided into three categories. Name these three categories. 1.) Postpartum blues 2.) Nonpsychotic postpartum depression, and 3.) postpartum psychosis

23. Name three helpful interventions to deal with families in the NICU (Found under the “Adaptation to the Intensive Care Environment). 1.) Meeting individual family’s needs, 2.) Providing welcoming NICU environment, 3.) Personalizing the infant, 4.) Teaching parents to interpret their infant’s cues and behaviors, 5.) Fulfilling the continuing need for information, and 6.) Forming partnerships with families in all aspects of decision making and caregiving.

24. What are four influences on the transfer of care from the NICU staff to the parent? 1.) The stability of the infant’s condition, 2.) The physical health of the mother, 3.) The level of parental support and 4.) The staff expectations.

25. T/F Social work intervention may be needed if there is a history of substance abuse, domestic violence, if other children have physical or mental handicaps, attachment difficulties with the infant, and/or inadequate food and other essentials. True

26. T/F Parents do not need to know the infant’s mannerisms and behaviors when discharged. False, Parents need to know the infant and their behaviors, otherwise the parent may feel exhausted and resentful and then guilty.

Modular 9

1. Define ethics. “Ethics is the study of rational processes for determining the most morally desirable course of action in view of conflicting value choices. “

2. There are many clinical dilemmas in the NICU, for example personhood. What is the dilemma related to personhood? The dilemma is when is one considered a person, for example some believe personhood is present at conception while others believe that it is based on the presence of certain human qualities.

3. In relation to professional-patient relationships what are the four ethical principles? Autonomy, beneficence, nonmaleficence, and justice

4. T/F Parents are involved in the overall determination of goals for treatment. True 5. List the different steps of decision making when a dilemma exists. 1.) Consider who

is involved in making and implementing the decision, 2.) Decide who will make the final decision, 3.) Clarify all of the medical facts within the case; consider indications, alternatives, and consequences of each action or inaction, 4.) Understand significant human factors and values, 5.) Identify the ethical dilemma or conflict, 6.) Make a decision, list options as solutions to the problem, weigh and prioritize values, make a decision, 7.) Check for moral and rationale defensibility.

6. T/F Decision making is done by a single caregiver of the premature or anomalous infant. False, many caregivers are involved.

7. Define morals. The conduct and codes of conduct of individuals and groups (e.g. right vs. wrong)

8. Define palliative care. Care that improves the quality of life of a patient who is facing problems related to life threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems. Total care of mind body and spirit.

9. Good communication with parents is essential when caring for patients in the NICU. This includes listening and being empathetic. List five questions to facilitate empathic conversation. What do you understand is going on with your baby Who is your main doctor, what have they told you Do you have the medical information you need or do you want more What kind of information would help you the most right now What are you expecting for your baby What do you think your baby feels What do you see your baby doing Who is your very best support person right now Is he or she available What is your greatest concern about your baby What would give you a sense of peace or comfort in the midst of this What is happening at home Faith and beliefs can be very important in the grief and healing process. Is there

anything about your faith or beliefs that we should know to be able to take care of you and your baby

Who or what is helping you get though this This may be or is best condition your baby will ever be in. When this is the case

we usually focus on keeping him or her warm and comfortable until he or she dies rather than on curing. How do you feel able this for your baby.

Our goal in health care are to o Improve health o Maintain health o Help someone die

How can we ease this experience for you? 10. T/F Enhancing the NICU environment involves routine ethics rounds or committee

and palliative care consults along with family care conferences. True

Modular 10 Chapter 2

13. T/F A baby may undergo withdrawal-like symptoms (e.g., jittery movements) if a mother smokes during pregnancy. True

14. Fetal alcohol spectrum disorders (FASD) is an umbrella term that encompasses fetal alcohol syndrome and other alcohol related effects. What are long term consequences of maternal intake of alcohol in relation to an infant’s speech and language development? Some consequences include: neurodevelopmental deficits,

mental retardations, abnormalities of the heart, skeletal system, and ears, facial anomalies, and growth restriction. Other consequences exist.

15. Preterm birth is defined as any birth before ________ weeks’ gestation. 37 Chapter 5

16. T/F Gestational age can be estimated effectively by measuring foot length. True 17. Name the three newborn classifications according to gestation. (1) Preterm (PR)

through 37 completed weeks, Late Preterm (LP) 34-37 weeks, (2) Full-term (Ff) 38 through 41 completed weeks, (3) Postterm (PO) 42 weeks or more.

18. What is kangaroo-care (KC)? What does KC facilitate? (1) Skin-to-skin “kangaroo” care, (2) improves self-regulation, reduces stress and crying, facilitates breast feeding, reduces pain, facilitates neurodevelopment maturation, and later mental health outcomes.

Chapter 17 19. Gavage feedings are indicated in infants requiring endotracheal intubation or those

with immature, weak, or absent suck, swallow, or gag or cough reflex. If an infant does not have a mature suck, swallow, gag, or cough reflex, what is the infant at risk for during feeding? Aspiration

20. T/F Tube feedings should be ran in quickly and infants should be overfed to supply them with additional nutrients. False, feedings should run slowly and the infant should not be overfed.

21. An infant who is successful in oral feeding should exhibit four skills; name the four feeding skills required for successful oral feeding. Infant should exhibit an active suck, coordinated swallow, minimal fluid loss around the nipple, and completion of feeding within 15 to 30 minutes.

22. T/F After an operative procedure, the neonate is often nothing per oral (NPO) for 3 to 14 days until the return of intestinal motility and function. True

Chapter 28 23. Failure in the normal development of the esophagus and in complete separation of

the trachea from the esophagus may result in esophageal atresia (EA) and distal tracheoesophageal fistula (TEF). If this occurs, name two signs or symptoms that may be present. Excessive oropharyngeal secretions and inability to swallow saliva or feedings.

24. Congenital chest masses may cause various difficulties in relation to respiratory. Name four congenital chest masses. Congenital Pulmonary Airway Malformation (CPAM), Pulmonary Sequestration, Bronchogenic Cyst, and Congenital Lobar Emphysema

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SPEECH-LANGUAGE PATHOLOGY & THE NEONATAL INTENSIVE …