Effectiveness Hospital. A structured questionnaire sheet included

Effectiveness of Prone versus Supine Position on Oxygen Saturation, Respiratory and Heart rate among Preterm with Respiratory Distress

Amina Mohamed Thabet* & Nora Abd-El Hamid Zaki**
*Assistant professor of Pediatric Nursing, Faculty of Nursing, Sohage University
** Assistant professor of Pediatric Nursing, Faculty of Nursing, Assiut University
Abstract: Optimal oxygenation and heart rate in preterm is very important. Different measures are recommended for improving oxygenation and heart rate (Zahra A et al., 2016). One of these measures is the position of these infants. Aim of this study was to determine the effectiveness of prone versus supine position on oxygen saturation, respiratory and heart rate among preterm with respiratory distress. Quasi-experimental research design was carried out. Subjects included 30 preterm in Neonatal Intensive Care Unit (NICU) at Assuit University Children Hospital. A structured questionnaire sheet included part one: Bio-demographic data, part two: Monitoring respiratory rate, heart rate and oxygen saturation. Results: The main results were the mean of respiratory rate was 53.63±11.38, and 59.42±11.3554 (c/min) in prone and supine position respectively. The mean of heart rate was 137.4±6.29 and 141.65±10.06 (beat/min) respectively. The mean of oxygen saturation was 93.38±2.4 and 91.46±2.26 (%) respectively and these differences was highly statistically significant (P=0.001, 0.001 and 0.003 respectively). Conclusion: Prone position can be made more desirable respiratory rate, heart rate, and effective in improving oxygen saturation in preterm with respiratory distress. Recommendations: Nurses could be advised to put the preterm with respiratory distress in prone position if there is no obstacle to changing the infant’s position.

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Keywords: Prone position, Supine Position, Preterm infants, Oxygen saturation, Heart rate, Respiratory rate and Respiratory distress.
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Introduction:
Preterm birth is defined as delivery before 37 completed weeks. The issue of preterm birth is still a major health problem in the world; 75% of neonatal mortalities are due to prematurity. A variety of morbidities are significantly increased in preterm neonates who survive. Morbidity in multiple organs such as respiratory tract, cardiovascular, gastrointestinal, metabolic, neurological and urinary system is much more common in premature neonates compared with those delivered at term. (Mohsenzadeh A, et al., 2011)
Soon after a premature infant is born, it’s a big challenge to maintain previous functional patterns against different stimuli. Today, prematurity is the most important cause of admission in Neonatal Intensive Care Units (NICUs). Symptoms of prematurity of lung tissue and respiratory distress syndrome are common problems in preterm infants, which show the need for special attention to respiratory cares. (Ghorbani F et al 2013)
The main cause of morbidity and mortality in the early neonatal period is respiratory distress syndrome (RDS). According to the degree of prematurity, it occurs in 7%- 50% of neonates, it is responsible for 30%- 40% of hospital admission for newborns. The main cause of respiratory distress syndrome is deficiency of alveolar surfactants due to immaturity of the second type of lung, resulting in decreased compliance with the lungs, alveolar surface tension, low exchange of gases and demand for high ventilator pressure.
Signs and symptoms of respiratory distress syndrome includes apnea, cyanosis, inspiratory stridor, grunting, poor feeding, tachypnea, nasal flaring, retractions in the intercostal, subcostal, or suprasternal spaces. These manifestations are occurring at birth and then getting worse over the first 48- 72 hours of infant’s life (Das H et al., 2011).

Cardio-respiratory interaction has been considered an important indicator of development in infants and as reported, heart rate fluctuations may present at the respiratory frequencies even in absence of respiration. Positioning of preterm infants is a basic neonatal nursing care that includes, prone, supine, side-lying and head up tilted position, a variety of outcomes affected by different body positioning of preterm infants Therapeutic positioning of preterm infants is considered as an important intervention that a nurse can carry out with immediate effect and it can be integrated effectively into family-centered care to positively impact the future development of the preterm infant (Ghorbani F et al 2013)

The behavior of oxygen saturation depends on the body’s position. Scientific records have shown that positioning intervene positively in preterm newborns, contributing to improvement in oxygenation, reducing gastro-esophageal reflux episodes, and reducing thoracoabdominal asynchrony (Brunherotti MAA., et al 2013). Positioning requires more assiduous care by the ICU nurse. A specific set of skills is needed to take care of preterm infants (Chadwick, 2010).
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The aim of the study:
The aim of this study was:
To determine the effectiveness of prone versus supine position on oxygen saturation, respiratory and heart rate among preterm with respiratory distress.
Hypothesis:
1. There will be a difference in on oxygen saturation respiratory and heart rate among preterm when put in prone or supine position.
2. Preterm who put in prone or supine position will have good oxygen saturation, respiratory and heart rate than those who in other position.
3. The prone position will have good effect on cardio-respiratory status compare to supine position among preterm.
Materials and Method
Research design:
Quasi-experimental research design was utilized to meet the aim of this study.
Setting:
The study was conducted in Neonatal Intensive Care Unit (NICU) at Assiut University Children Hospital.
Subjects:
Convenience sampling of thirty preterm infants with respiratory distress who had the following criteria:
? Preterm who born at 28 -37 weeks of gestation.
? Oxygen dependent preterm with respiratory distress (tachypnea, retractions or chest in drawing (subcostal, intercostal, sternal, suprasternal) and grunting).
Exclusion criteria: Parents who do not accept to participate in this study, preterm infants with invasive ventilator, who were not able to tolerate the position either due to secretions, presence of nasogastric tube, cephalhematoma, sudden drop in saturation when change the position, preterm with congenital abnormalities or clinical/surgical reasons which made positioning contraindicated, and whose treated with sedative or paralyzing drugs were excluded.

Tool for Data Collection:
One tool was used for collecting data in this study.
A structured questionnaire sheet to collect data and it included two parts:
Part one: Preterm neonate’s bio-demographic data such as (preterm’ postnatal age, gestational age, gender, birth weight, type of delivery) (recorded data).
Part two: An assessment sheet for monitoring respiratory rate, heart rate, and oxygen saturation level during each position and change of positioning.

– A pilot study was done on 3 neonates to test the applicability of the tool; these 3neonates were excluded from the sample
Method:
1. An official approval for conducting the study was obtained from the responsible administrative personnel (the directors of Assiut University Children Hospital and the head of Neonatal Intensive Care Unit to conduct the study after explaining the purpose of the study. Explanation the objective of the study methodology was done to them by the investigators.
2. Research was approved from ethical committee in the faculty of nursing
3. Written informed consent from parents of the studied preterm neonates’ was obtained
4. Confidential ability of the researchers was ascertained
5. The tool was developed by the researchers after the thorough review of literature.
6. Respiratory rate, heart rate, and oxygen saturation were measured 15 minutes after changing the position (time of watch out).
7. Respiratory rate, heart rate, and oxygen saturation were measured while the infant was receiving the nursing care; the observer didn’t interfere with the routine care of the infants.
8. Respiratory rate, heart rate, and oxygen saturation were (measured) for an hour (at15 minutes, 30 minutes and 45 minutes and 60 minutes).
9. Several normal physiological parameters were used to determine the relation to changing position, these were:
– Desaturation: the oxygen saturation was is less than 88%;
– High oxygen saturation: the oxygen saturation was is 95% or more;
– Bradycardia: the heart rate was is less than 100 b/m;
– Tachycardia: the heart rate was is more than 160 b/m.
– Bradypnea: respiratory rate is less than 30 breath/minute
– Tachypnea: respiratory rate is more than 50 breath/minute
10- Oxygen saturation and the heart rate were measured by the pulse oximeter. A tiny, lighted probe placed on the infant’s hand or foot projects a beam of light through the capillary beds in the tissue. The light beam is converted into an electric signal by a photodetector in the probe that is processed within the module and displayed as both a waveform and a digital value for both the oxygen saturation and the heart rate.
11- Respiratory rate was measured through observation of chest wall and abdomen movement for one minute.
12- The procedure was performed in the following manner:

Changing positioning:
The pediatric nurse picked up the preterm infant during a calm period one continuous motion.
• First, the supine position was performed by supporting the preterm’s head, feet and the body in the midline by using soft rolls around them. A roll under the shoulders was placed to support the newborn’s (preterm’s) airway and allowed slightly forward flexion of the head.
• Second, the prone position was performed by putting the newborn’s (preterm’s) body prone. The arms should be close to the body with the hands symmetrically close up to the mouth. Flexion of the legs can be encouraged with the knees brought up to the chest, raising the hips slightly. This position was maintained by using a rolled blanket to make a boundary; the small hip roll was used to assist in maintaining flexion. Use of a rolled cloth placed under the infant (from top of the head to umbilicus) to provide elevation of the body. Careful observation was made while the preterm neonates were in the prone position to avoid the sudden infant death syndrome.
13- The preterm neonates were studied when awake and about one hour after a feed. All the infants were on full enteral feeds.
14- The effectiveness of supine position or prone position on oxygen saturation, respiratory and heart rate among the preterm neonates were assessed.
15- The effectiveness of supine position and prone position on oxygen saturation, respiratory and heart rate among the preterm neonates were compared.
16- The obtained sequence position was donning on two days (the first day for supine position and the second day for the prone position).

Field of the study:
Data collection was done by the researchers during 3 months period from the beginning of from April 2017 to June 2017. It was done during the routine work of the hospital in the morning. The sheet required about 60 minutes for filling it; about one preterm was collected per day.

Statistical analysis
The data were tested for normality using the Anderson-Darling test and for homogeneity variances prior to further statistical analysis. Categorical variables were described by number and percent (N,%), where continuous variables described by mean and standard deviation (Mean, SD). where compare between continuous variables by Paired T-test. A two-tailed p

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