Clinical Scenario

iDevice icon Tommy's story
  • Tommy was born at 24 weeks of gestation, with a birth weight of 525 g.
  • Pregnancy History
    • Mother is 25 years old
    • Complication – severe pre-eclampsia and excessive weight gain during the last month
      of pregnancy
  • Birth History
    • Tommy was blue and limp at birth
    • APGAR scores of 2 @ 1 minute; 4 @ 5 minutes
    • Received bag/mask ventilation and was intubated in the delivery room
    • Ventilatory support x 9 weeks; several attempts at non-successful weaning
    • Remained on supplemental oxygen via nasal cannula after extubation
  • Perinatal History
    • Severe BPD Grade II IVH, evident on US performed on day 7 of life
    • Patent ductus arteriosus, which was treated with indomethacin
    • Hyperbilirubinemia
  • Referral to physiotherapy at 6 weeks
    • Chart review and discussion with Tommy’s nurse
    • Tommy is irritable and feels very stiff when moving his limbs
  • Observation of routine care (using the Neonatal Individualized Developmental Care and Assessment Program)
    • Demonstrated a low tolerance to handling and position changes
    • Frequently overstimulated
    • Signs stress included irregular respiration, increased heart rate, startling, grunting, and
      straightening extremities with tension
  • Chart review and discussion with Tommy’s nurse
    • Tommy is irritable and feels very stiff when moving his limbs
    • Displays few approach and calming behaviours; he can eventually calm with a pacifier and swaddling
    • Not able to transition to or maintain an awake alert state
  • Physiotherapy Assessment (using the Test of Infant Motor Performance, TIMP)
    evaluated at 34 weeks postconceptional age, and 1 week following extubation
    • Measured outcomes
    • Poor midline orientation & trunk extension
    • Limited antigravity movement
    • Increased tone in extremities, with postures and movements predominantly into
      extension, tremulous & disorganized
    • UEs in scapular retraction, with shoulder abduction and external rotation, and elbow
      flexion
    • Head preference to the right, with tightness in left neck rotation
    • Asymmetries between the right and left sides also when rolling
    • Impaired visual tracking, and showing increased signs of stress with presentation of visual
      stimuli
    • Poor response to auditory stimuli
    • Not able to maintain an alert state
    • With handling quickly transitioned to a cry state
      Total score of 40, which is below average for an infant @ 34 weeks

  • Family situation
    • Mother does not visit NICU very often, as she lives 3 hours away and must rely on others for
      transportation
    • She has 2 other young children at home under her care; the father is not involved
    • She has had to return to work to support her family; again, the father is not involved
    • Very interested in learning about Tommy and she is very engaged in his care, despite limited time

In class, you will participate in a 'think-pair-share' activity to develop a family-centred plan of care for Tommy. Students will be expected to share their plan of care with the class for discussion. 



« Previous