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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
ANNEXURE – II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 Name of the candidate and address
{in block letters}
MISS. JISNET P.PAULOSE
SAHYADRI COLLEGE OF NURSING
SAHYADRI CAMPUS, NH-48, ADYAR,
MANGALORE- 575007
2 Name of the institution SAHYADRI COLLEGE OF NURSING,
SAHYADRI CAMPUS, NH-48,ADYAR,
MANGALORE – 575007
3 Course of study and subject M.Sc NURSING,
CHILD HEALTH NURSING
4 Date of admission to the course 03-12-2011
5 Title of the topic
“EFFECTIVENESS OF SUPINE V/S SELECTED POSITIONS ON SELECTED
PHYSIOLOGICAL PARAMETERS AMONG LOW BIRTH WEIGHT INFANTS
AT SELECTED HOSPITAL IN MANGALORE”
1
6 BRIEF RESUME OF THE INTENDED WORK:
INTRODUCTION :
New born period is the most crucial period in a child’s life. The most profound
physiologic change required of the neonate is transition from fetal or placental circulation
to independent respiration. The immediate adjustments includes respiratory system,
circulatory system ,thermoregulation, fluid and electrolyte balance, etc .All the systems
are trying to adjust to extra uterine life.
A low birth weight infant means an infant whose birth weight is less than 2500 g,
regardless of gestational age. Low birth weight infants are high risk newborns, who has a
greater-than-average chance of morbidity or mortality because of conditions or
circumstances associated with birth and the adjustment to extra uterine existence.1
Neonatal mortality in India accounts for 50% of all infant mortality, which has
declined to 84/1000 live births. The common causes of neonatal mortality in our country
are asphyxia, prematurity, low birth weight and infections. Improvement in neonatal care
in India is needed in order to fulfill the National health policy to reduce infant and
perinatal mortality and low birth weight babies. Low birth weight accounts for 50-60% of
perinatal and infant mortality.2
Three fourth of neonatal mortality in preurban setting in Bangladesh was
attributed to preterm neonates as compared to one third of low birth weight infants. Out
of 1322 neonatal deaths, 65.4% were contributed by prematurity as a single cause of
death over a three year period study in, India. In India ,26 million babies are born every
year ,out of which 1.2 million die before completing the first four weeks of life.3
2
Prolonged supine positioning for preterm infants is not desirable, since they
appear to lose their sense of equilibrium when supine and use vital energy in attempts to
recover balance by postural changes. In addition prolonged supine positioning is
associated with long-term problems such as decreased flexion of the limbs, pelvis and
trunk; widely abducted hips etc.
Early in hospitalization, the prone position is best for preterm infants and result
in improved oxygenation, better tolerated feedings, and more organized sleep-rest
patterns. Infants exhibit less physical activity and energy expenditure when placed in the
prone position. 1
6.1 NEED FOR STUDY
An infant whose birth weight less than 2500 g, regardless of their gestational age
is called low birth weight infants. Reduction in infant and child mortality is a major goal
of strategy to achieve health for all. The major contribution of infant death is by neonates
which is a serious concern, since nearly 5 million neonates die each year in the world of
which 96% are in the developing countries, effective reduction of such high neonatal
death rate remains a major global challenge in 21st century.4
Basic neonatal care is not available at majority of the centers where neonates
are delivered and admitted. Low birth weight infants require specialized care in NICU.
The national population policy of India aims at bringing down the infant mortality rate to
30 per 1000 live births by 2010.5
3
The simple positioning of low birth weight infants may prevent these dangers to
the neonatal life. Prone and head tilted up 450 positions are researched in improving the
efficacy of oxygenation. Positioning of neonates is a simple and safe therapeutic
maneuver with prompt and demonstrable benefit.6
The investigator, through self experience analyzed the need for implementing the
different positions that may be favorable to the low birth weight infants with low cost.
The findings of this experiment may also be adopted in settings with lesser facilities.
These viewpoints motivated the investigator to experiment to find the best position which
provides good heart rate, respiratory rate and oxygen saturation for low birth weight
infants.
4
6.2 REVIEW OF LITERATURE
A study was conducted on 11 spontaneously breathing healthy infants with a mean
birth weight of 1520+171 gm and gestational age of 31.7+1.5 weeks for the effect of
positioning on pulmonary mechanisms when placed in both supine and prone positions.
The respiratory rate, heart rate and oxygen saturation was monitored. Results revealed
unaffected respiratory rate and oxygen saturation by positioning ,but highlighted a
clinically significant heart rate in prone position .The study concluded that prone
positioning did not affect pulmonary mechanisms or oxygen saturation and facilitated the
developmental needs of these infants.7
A study was conducted to evaluate the effect of body position on energy
expenditure and behavior of 42 healthy low birth weight infants (920-1760 g). Each
infant was randomly assigned to supine or prone position for the first three hours and the
position was reversed in the 2nd and 3rd hours. The difference in energy expenditure and
the percentage of time in active sleep, quiet sleep and wakefulness between the two
positions was computed. When only periods of active sleep were analyzed, the median
difference in energy expenditure remained significant with the value being supine
position than prone by +2.6Kcal/Kg/d.(P<0.001). In the supine position, the time awake
was 5.7%higher (P<.001) than in prone position. Study found decreased energy
expenditure in low birth weight infants when changed from the supine to prone which
further provided a clue for an advantageous prone position with an increased time spent
in quiet sleep. The study concluded that consumption of calories are proportional to the
metabolism and thereby to the vital function. 8
5
A study was conducted on 44 full term infants with mean age 7.9 weeks during an
overnight sleep to identify risk factor for sudden infant death syndrome. Recordings were
made while the infants were horizontal and asleep in the supine and prone positions, and
repeated after a head up tilt to 60°, maintained for 30 minutes, while in both sleep
positions. Blood pressure, heart rate, anterior shin, and anterior abdominal wall skin
temperatures were measured. Systolic blood pressure was lower, but peripheral skin
temperature and heart rate were higher during sleep, while horizontal, in the prone rather
than the supine position. Prone sleeping has a measurable effect on circulatory control,
with a reduction in vasomotor tone resulting in peripheral vasodilatation, a higher
peripheral skin temperature, a lower blood pressure, and a higher resting heart rate. The
study concluded that prone sleeping has a measurable effect on circulatory control, with a
reduction in vasomotor tone resulting in peripheral vasodilatation, a higher peripheral
skin temperature, a lower blood pressure, and a higher resting heart rate.9
A study was conducted on effect of position on sleep, heart rate variability, and
QT interval in preterm infants at 1 and 3 months corrected age, on a sample of 16
premature infants longitudinally at 1 and 3 months' corrected age. The results showed
that there was a significant difference between supine and prone position either in total
sleep time or in percentage of quiet sleep. Percentage of active sleep was significantly
lower in the supine position. The incidence of short, spontaneous sleep transition was
significantly higher in supine also only at 1 month corrected age. The study concluded
that prone position did not substantially increase total sleep at these ages and supported
“back to sleep” as the position of choice for infants after discharge.
A study was conducted on eighteen stable very-low-birth-weight (VLBW) 6
mechanically ventilated infants with chronic lung disease were studied to examine the
effects of right and left lateral positioning in contrast to supine positioning on
transcutaneous (tc) oxygen (tcPO2) and carbon dioxide measurements (tcPCO2). The
neonates were studied at a median postnatal age of 31 days (range, 17 to 57 days) and
had median birth weights and gestational ages of 975 g (range, 570 to 1360 g) and 27.5
weeks (range, 24 to 30 weeks), respectively. Median fraction of inspiratory oxygen was
0.32 (range, 0.23 to 0.40). The sequence of study positions was randomly determined.
Sleep states as well as tcPO2 and tcPCO2 were recorded every 30 s for five minutes. A
significant difference in mean tcPO2 or tcPCO2 was not detected for any of the positions.
Lateral positioning may facilitate the development of midline behaviour in VLBW
infants. The study concluded that placing the stable VLBW mechanically ventilated
infant in a side-lying position has no deleterious effects on oxygenation and ventilation,
as measured by tcPO2 and tcPCO2, and therefore should be encouraged.11
A study was conducted on effect of posture on respiratory function and drive, in
20 prematurely born infants with gestational age between 25 to 32 weeks immediately
prior to discharge. They were placed both on supine and prone posture for three hours. At
the end of three hours, tidal volume (TV), inspiratory and expiratory time, respiratory
rate and minute ventilation were measured. Results revealed higher tidal volume with
lower respiratory rate Pimax in the prone compared to that of supine position. There was no
significant difference in inspiratory tidal volume (Ti) or expiratory tidal volume (Te)
between two postures. The study concluded that posture related differences in respiratory
function are predominantly present in prematurely born infants.12
A study was undertaken on the effect of body position before and after tube
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feeding was evaluated in six extremely immature infants who were being mechanically
ventilated due to chronic lung disease. Mean birth weight and gestational age were 766
gram (540-994gram) and 24.9 weeks (23.9-26.0weeks) respectively. The prone position
resulted in a significant hike in oxygen saturation before and after feeding, total tidal
volume increased before feeding and the heart rate decreased before and after feeding.
The study concluded an advantage of prone position over the supine position in
managing the extremely immature infants with chronic lung disease before and after
feeding.6
6. 3 PROBLEM STATEMENT
“EFFECTIVENESS OF SUPINE V/S SELECTED POSITIONS ON SELECTED
PHYSIOLOGICAL PARAMETERS AMONG LOW BIRTH WEIGHT INFANTS
AT SELECTED HOSPITAL IN MANGALORE’’
6.4 OBJECTIVES OF THE STUDY
The objectives of the study are to :
assess the physiological parameters of low birth weight infants in supine
position.
assess the physiological parameters of low birth weight infants in lateral position.
assess the physiological parameters of low birth weight infants in prone position.
compare the physiological parameters of low birth weight infants in supine,
lateral and prone positions.
8
Find the association between the physiological parameters and the selected
demographic variables.
6.5 OPERATIONAL DEFINITION
1. Effectiveness: In this study effectiveness refers to the extent in which the change of
body positions will produce an effect on the heart rate, respiratory rate and oxygen
saturation, measured in terms of physiological parameters by a stethescope, trunk
movement observation and pulse oxymeter.
2. Position: In this study position refers to the placement of a low birth weight infant in
supine, prone and lateral position.
Supine position: In this study supine position refers to placing a low birth weight
infant on his/her back on an even surface of a radiant warmer bed.
Prone position: In this study prone position refers to placement of a low birth
weight infant on his/her abdomen with head turned to one side on an even
surface.
Left lateral position: In this study left lateral position of a low birth weight
infant refers to the position in which the left arm and leg will be in contact with
the bed with an exposure of right arm and leg to the environment.
3. Physiological parameters: In this study physiological parameters refers to the
measurement of heart rate, respiratory rate and oxygenation of the low birth weight
infants.
9
Heart rate: In this study heart rate refers to the manual measurement of heart
beats of a low birth weight infant for one single minute through auscultation.
Respiratory rate: In this study respiratory rate refers to the manual assessment of
respiratory movements in low birth weight infants for a period of one minute.
Oxygen saturation: In this study oxygenation refers to the oxygen saturation in
the neonatal blood as revealed by the readings of the pulse oxymetry.
4. Low birth weight infant: In this study low birth weight infants refers to an infant
whose birth weight is less than 2500 g, regardless of their gestational age.
6.6 Assumptions:
The study assumes that:
Change of positions influence physiology of cardiovascular system and respiratory
system.
6.7 Delimitations
The study is delimited to,
The stable low birth weight infants admitted to the NICU of the selected
hospital.
6.8 Hypotheses (all the hypotheses will be tested at 0.05 level of significance)
H1: There will be significant relationship between physiological parameters in supine
and other selected positions among low birth weight infants.
H2: There will be significant difference in the physiological parameters with supine,
10
lateral and prone positions among low birth weight infants.
H3: There will be a significant association between physiological parameters and
selected demographic among low birth weight infants.
7. MATERIALS AND METHODS
7.1 Sources of data
The sources of data are low birth weight infants at selected hospital in Mangalore.
7.1.1 Research designs
The research design is pre-experimental one group pre-test post-test design
O1 O2 X1O3O4 X2O5O6
O1: Assessment of physiological parameters during 1st minute in supine position.
O2: Assessment of physiological parameters during 15th minute in supine position.
X1: Administration of lateral position.
O3: Assessment of physiological parameters during 1st minute after giving lateral
position.
O4: Assessment of physiological parameters during 15th minute after giving lateral
positions.
X2: Administration of prone position.
O5: Assessment of physiological parameters during 1st minute after giving prone position.
O6: Assessment of physiological parameters during 15th minute after giving prone
positions.
11
7.1.2 Setting
The study will be conducted in selected NICU of Mangalore.
7.1.3 Population
The population consists of low birth weight infants admitted to the selected hospitals in
Mangalore.
7.2 METHOD OF DATA COLLECTION
7.2.1 Sampling procedure
Non- probability purposive sampling will be used to select the samples
7.2.2 Sample size
Sample consists of 30 low birth weight infants of selected hospitals in Mangalore.
7.2.3 Inclusion criteria for sampling
An inclusion criteria for sampling refers to low birth weight infants whose weight is
less than 2500 g
7.2.4 Exclusion criteria for sampling
An exclusion criteria for sampling refers to low birth weight infants who are
having cardiovascular and respiratory diseases
on mechanical ventilation.
7.2.5 Instruments used
Baseline Performa
Clinical Performa
Stethoscope
Pulse oxymeter
7.2.6 Data collection method.
12
The investigator would get the permission prior to data collection from concerned
authority
The investigator will introduce herself to the parents and obtain consent from
them.
Different positions are given to check the effect on physiological parameters.
Biophysiological observation of the physiological parameters.
Comparison of the positions to identify best position for the low birth weight
infants.
7.2.7 Data Analysis Plan
Demographic data will be analyzed using frequency, percentage.
Effect of positions on the physiological parameters will be assessed using mean,
median, standard deviation and ANOVA.
Chi-square test will be used to find out association between positions and
selected demographic variables.
7.3 Does the study require any investigation or interventions to be conducted on
patient or other human or animals? If so please describe briefly.
Yes. The researcher has to administer three different positions to the low birth
weight infants.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes. Ethical clearance will be obtained from the concerned authority.
8. REFERENCES
1. Hockenberry MJ, Wilson D. Wong’s essentials of pediatric nursing. New delhi:
Mosby Elsevier; 2010. 250-259.13
2. Bhargava SK, Ramjee S, Sachedev HP. Current status of neonatal care and alternate
strategies for reduction of neonatal mortality in the decade of nineties. Indian
Pediatr.1991 dec; 28(12): 1429-1436.
3. Pity K. Teaching curriculum in neonatal nursing does it require change. Journal of
neonatology 2005; 19(3).
4. Shrivastava SP, Kumar A, Ojna AK. Perinatal determinants of neonatal mortality in
India, Sep 2011. Available from http :/// www.indian pediatrics.net
5. Nair MKC, Jana AK, Neswade AK. Neonatal survival and beyond. Indian paediatrics
2005; 42: 985-988.
6. Marynard V, Rignall S, Kitchen S. Effect of positioning on respiratory synchrony in
non ventilated preterm infants Physiother Res Int. 2000; 5(2) : 96-110.
7. Pandey A. Positioning premature babies. Which position is best? NNT Mar 5: 24-27.
8. Masterson J, Zucker C, Schulze K. Prone and supine positioning effects on energy
expenditures and behavior of low birth weight neonates. Paediatrics 1997; Nov 80(5):
689-692.
9. Chong A, Murphy N, Maeehews T. Effect of prone sleeping on circulatory control in
infants.
10. Ariagno RL, Mirmiran M, Adams MM, Saporito AG, Dubin AM, Baldwin RB.
Effect of position on sleep, heart rate variability, and QT interval in preterm infants at
1 and 3 months' corrected age. Available from http://www.ncbi.nlm.nih.gov/pubmed.
11. Bozynski ME, Naglie RA, Nicks JJ, Burpee B, Johnson RV. Lateral positioning of
the stable ventilated very-low-birth-weight infant. Effect on transcutaneous oxygen
14
and carbon dioxide. Am J Dis Child. 1988 Feb; 142(2):200-2.
12. Leipala JA, Bhat RY, Rafferty GF Hannams, Greenough A. Effect of posture on
respiratory function and drive in preterm infants prior to discharge. Paediatric
pulmonology 2003 Oct; 36(4): 295-300.
15