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”

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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

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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

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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.

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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

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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.

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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.

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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,

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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.

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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.

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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

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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.

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