EFFECTIVENESS OF CLING WRAP UPON HYPOTHERMIA IN NEWBORNS By JANE AMIRTHA SANJEEVI A DISSERTATION SUBMITTED TO THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING APRIL 2013
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EFFECTIVENESS OF CLING WRAP UPON HYPOTHERMIA IN
NEWBORNS
By
JANE AMIRTHA SANJEEVI
A DISSERTATION SUBMITTED TO THE TAMILNADU DR.M.G.R MEDICAL
UNIVERSITY, CHENNAI, IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTER
OF SCIENCE IN NURSING
APRIL 2013
EFFECTIVENESS OF CLING WRAP UPON HYPOTHERMIA IN
NEWBORNS
Approved by the Dissertation Committee on : ________________________
Research Guide : ________________________
Dr. Latha Venkatesan
M.Sc (N)., M.Phil(N)., Ph.D (N).,
Principal cum Professor in Nursing,
Apollo College of Nursing,
Chennai- 600 095
Clinical Guide : ________________________
Mrs.CeciliaMary.S, M.Sc(N),
Lecturer,
Apollo College of Nursing,
Chennai-600 095.
Medical Guide : ________________________
Dr.Radha Lakshmi Senthil.
MBBS., MD, DNB., MRCPCH,
Consultant Neonatologist
Apollo Children’s Hospital,
Chennai- 600 006.
A DISSERTATION SUBMITTED TO THE TAMILNADU DR.M.G.R MEDICAL
UNIVERSITY, CHENNAI, IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTER
OF SCIENCE IN NURSING
APRIL 2013
DECLARATION
I hereby declare that the present dissertation entitled “Effectiveness of cling wrap
upon hypothermia in newborns” is the outcome of the original research work
undertaken and carried out by me under the guidance of Dr.Latha Venkatesan
M.Sc.,(N).,M.Phil(N).,Ph.D.(N)., Principal, Apollo College of Nursing and
Mrs.CeciliaMary.S., M.Sc., (N).,Lecturer, Apollo College of Nursing, Chennai. I
also declare that the material of this has not formed in any way, the basis for the
award of any degree or diploma in this University or any other Universities.
M.Sc., (N) II Year
i
ACKNOWLEDGEMENT
I thank God Almighty for being with me and guiding me throughout my
endeavour and showering His immense blessings in each and every step to complete
the dissertation.
I proudly express my sincere gratitude to Dr. Latha Venkatesan M.Sc (N),
M.Phil(N), Ph.D (N)., Principal, Apollo College of Nursing for her relentless efforts
in setting higher goals for us to achieve and her excellent guidance, caring spirit,
support and valuable suggestions during the course which paved way for our overall
development.
I extend my earnest gratitude to Prof. Lizy Sonia, A., M.Sc (N),Ph.D.
Vice-principal and Head of the Medical Surgical Nursing Department, Apollo
College of Nursing, for her direction, encouragement and timely help.
My heartfelt thanks to My Research Guide, Mrs.Cecilia Mary.S, M.Sc (N),
Lecturer, Child Health Nursing Department for her continued efforts, motivation and
remarkable suggestions towards the completion of this study.
My bouquet of thanks toDr.Radhalaksmi Senthil, MBBS,MD,DNB,
MRCPCH, Consultant Neonatologist, Apollo Children’s Hospital ,Chennai for her
valuable suggestions and guidance.
My sincere thanks to Prof. K. Vijayalakshmi, M.Sc (N), M.A. Psychology,
Research Co-ordinator, Apollo College of Nursing, for her increasing search,
valuable suggestions, efficient guidance, invaluable caring spirit and profound
support throughout the study.
My profound gratitude to Prof. Nesa Sathya Satchi, M.Sc (N)., Head Of
The Department of Pediatric Nursing, for her splendid encouragement and guidance
and the successful completion is credited to her.
ii
I would like to specially thank Mrs.JamunaRani,Msc(N),Reader,
Mrs.Jenifer.S., Msc(N), Lecturer, Department of Child Health Nursing, for their
guidance and profound support throughout the study.
My sincere thanks to, Dr.Satish Babu, Neonatologist, Fortis Malar Hospital
Chennai, for permitting me to utilize all the facilities in the research setting. Their
good nature, kind heartedness and contagious energy will always be remembered. I
also wish to thank all the participants of the study.
A note of thanks to the Librarians at Apollo College of Nursing and
Dr. Tamilnadu M.G.R.Medical University, and to Mr.Murugan, Biostatistician
for his constructive effort in clarification and guidance in statistical analysis.
I am grateful to the experts for validating the tools used in this study and I
would also like to extend my thankfulness to all the faculty of Apollo College of
Nursing for their suggestions and encouragement throughout the study.
I’m indebted to my Parents, Mr.Sanjeevi , Mrs.Jessie Sanjeevi and my
sister Jennie Sanjeevi for their sacrifices, prayers, love and blessings.
I thank my classmates for being available for their help whenever I needed
them. I thank all those who have supported me in prayer and those who have helped
me even in a small way to successfully complete this study.
iii
SYNOPSIS
An Experimental Study to Assess the Effectiveness of Cling Wrap upon
Hypothermia in Newborns in Neonatal Intensive Care Unit at Selected Hospitals,
Chennai.
The Objectives of the Study were,
1. To assess the level of hypothermia before and after use of cling wrap
in control and experimental group of newborns.
2. To determine the effectiveness of cling wrap, by comparing the level
of hypothermia, before and after the use of cling wrap in control and
experimental group of newborns.
3. To determine the care givers level of satisfaction, regarding use of
cling wrap in experimental group of newborns.
4. To find out the association between selected neonatal variables and
the level of hypothermia before and after the use of cling wrap in
control and experimental group of newborns.
The conceptual framework for this study was developed on the basis of
Roy’s Adaptation Model which was modified for the present study. The study
variables were hypothermia and cling wrap. An extensive review of literature and
guidance by experts formed the foundation to the development of neonatal variables
proforma, temperature observation record sheet and rating scale on the care giver’s
level of satisfaction about cling wrap.
An experimental design was adopted for this study. The present study was
conducted in Fortis Malar Hospital, Chennai. A sample size of 60 who met the
iv
inclusion criteria were chosen, in that 30 were assigned to control group and 30 to
experimental group through systematic random sampling.
The data collection tools were validated and the reliability was established
through test-retest and split half technique. The researcher used validated tool for
collecting data. After the pilot study, the data for the main study was collected using
neonatal variable proforma, temperature observation record sheet to assess the level
of hypothermia and caregiver’s satisfaction rating scale on the level of satisfaction
about Cling wrap. The main data collection was done after determining the
feasibility and practicability through pilot study.
Cling wrap is one of the physiological interventions that involve use of a thin
polyethylene sheet used to cover over the bassinet from below the neck till the foot
end of a neonate to prevent hypothermia and is changed over a period of six hours or
whenever the integrity of the cling wrap is lost. Effectiveness of using cling wrap
was measured based on the maintenance of temperature at 36.5-37.5 degree celsius
in neonates. Newborn’s temperature was measured by checking the axillary
temperature using mercury thermometer once in every four hours for three
consecutive days. Cling wrap was administered only to the experimental group. The
level of satisfaction on administration of cling wrap was assessed by using the
caregiver’s satisfaction rating scale for the experimental group of newborns. Then
the collected data was tabulated and analyzed using descriptive and inferential
statistics.
Major Findings of the Study were
Majority of newborns had gestational age of 34-40 weeks
(46.7%,53.3%), were males( 50, 56.7%) , with an APGAR between
8-10 (63.3%,80%), and birth weight of 2.5-3.5 kg (50%, 66.7%), in
control and experimental group respectively.
v
Majority of newborns in the experimental group had moderate
hypothermia (86.7%) before use of cling wrap whereas after the use
of cling wrap there was no hypothermia in the experimental group
(100%). Therefore it is attributed to the effectiveness of cling wrap.
The difference in mean and standard deviation of the level of
hypothermia before the use of cling wrap (M=33.84, 33.84 &
SD=1.97, 1.53) between the control and experimental groups is not
statistically significant (p<0.001), whereas after the use of cling
wrap, there is a difference in the mean and standard deviation of the
level of hypothermia (M=34.26, 36.59 & SD=1.63, 0.145) between
the control and experimental groups of newborns. So the null
hypothesis Ho1 was rejected.
Majority of the caregivers were highly satisfied (87%) with use of
cling wrap. This shows that the use of cling wrap was highly
effective in reducing hypothermia among newborns in NICU.
There was significant association between neonatal variables such as
gestational age (χ2=12.94,15.39, df=2) (p<0.05), APGAR
(χ2=17.74,23.07, df=2) ( p<0.01) and pretest level of hypothermia in
control and experimental group of newborns. So the null hypothesis
Ho2 is partially rejected with regard to gestational age and APGAR.
There was significant association between neonatal variables such as
gestational age (χ2=4.04, df=2) (p<0.05), APGAR (χ2=12.9, df=2)
(p<0.01) and posttest level of hypothermia in control group of
newborns. So the null hypothesis Ho2 is partially rejected with regard
to gestational age and APGAR. Whereas there was no association
between neonatal variables and posttest level of hypothermia in
experimental group of newborns.
vi
Recommendations
Future study with larger sample size and a matched control will help
in reducing the bias.
A similar study can be conducted in other settings such as community
centres and peripheral hospitals.
A study involving newborns less than 30 weeks will be useful to
standardise medical practice in developing countries.
A comparitive study can be conducted on effectiveness of cling wrap
with other thermoregulation therapies upon thermal balances.
A study can be conducted to assess the level of knowledge among
nurses regarding thermal balance.
vii
TABLE OF CONTENTS
Chapter CONTENTS Page No
I INTRODUCTION 1-12
Background of the Study 1
Need for the Study 4
Statement of the Problem 6
Objectives of the Study 6
Operational Definitions 7
Assumptions 8
Null Hypotheses 8
Delimitations 8
Conceptual Framework 9
Projected Outcome 12
Organization of the Report 12
II REVIEW OF LITERATURE 13-23
Literature related to Neonatal care 13
Literature related to Hypothermia in newborns 15
Literature related to Cling wrap 18
Literature related to Effectiveness of cling wrap upon
hypothermia in newborns
19
Summary 23
viii
Chapter CONTENTS Page No
III RESEARCH METHODOLOGY 24-32
Research Approach 24
Research Design 25
Variables 25
Research Setting 28
Population, Sample, Sampling technique 28-29
Sampling Criteria 29
Selection and Development of Study Instruments 29
Psychometric Properties 30
Pilot Study 31
Protection of Human Rights 31
Data Collection Procedure 31
Problems faced during Data Collection 32
Plan for Data Analysis 32
Summary 32
IV ANALYSIS & INTERPRETATION 33-45
V DISCUSSION 46-51
VI SUMMARY, CONCLUSION, IMPLICATIONS
RECOMMENDATIONS
52-58
REFERENCES 59-62
APPENDICES xii-xxxiv
ix
LIST OF TABLES
Table No. Description Page No.
1. Frequency and Percentage Distribution of Neonatal
variables in the control and experimental group of
newborns 35
2. Frequency and Percentage Distribution of Pre test and
Post test Level of Hypothermia in Control Group of
Newborns 37
3. Frequency and Percentage Distribution of Pre test and
Post test Level of Hypothermia in Experimental Group
of Newborns 38
4. Comparison of Mean And Standard Deviation of Pre
test and Post test Level of Hypothermia in Control and
Experimental Group of Newborns 39
5. Association between Neonatal variables and Pre test
level of Hypothermia in Control Group of Newborns. 41
6. Association between Neonatal variables and Post test
Level of Hypothermia in Control Group of Newborns. 42
7. Association between Neonatal variables and Pre test
Level of Hypothermia in Experimental Group of
Newborns. 43
8. Association between Neonatal variables and Post test
level Hypothermia in Experimental Group of
Newborns. 44
x
LIST OF FIGURES
Fig.No. Description Page No.
1. Conceptual Framework based on Roy’s Adaptation
Model
11
2. Schematic Representation of the Research Design 27
3. Percentage Distribution of Birth Weight in Control and
Experimental group of newborns
36
4. Level of Satisfaction of Caregivers, in use of Cling wrap
in Experimental group of newborns.
40
xi
LIST OF APPENDICES
Appendix Title Page No.
I Letter Seeking Permission to Conduct the Study xii
II Letter Permitting to Conduct the Study xiii
III Ethical Committee Permission to Conduct the Study xiv
IV Plagiarism Originality Report xvi
V Request for Content Validity xvii
VI Content Validity Certificate xix
VII List of Experts for Content Validity xx
VIII Research Participant Consent Form xxii
IX Certificate for English Editing xxiii
X Neonatal Variable Profoma xxiv
XI Temperature Observation Record Sheet xxvi
XII Caregivers Satisfaction Rating Scale xxviii
XIII Item wise Frequency and Percentage of Caregivers
Level of Satisfaction
xxx
XIV Data Code Sheet xxxi
XV Master Code Sheet xxxii
XVI Photos During Administration of Cling Wrap xxxiii
xii
APPENDIX – I
LETTER SEEKING PERMISSION TO CONDUCT STUDY
xiii
APPENDIX - II
LETTER PERMITTING TO CONDUCT STUDY
xiv
APPENDIX - III
ETHICAL COMMITTEE CLEARANCE LETTER
xv
xvi
APPENDIX - IV
PLAGIARISM ORIGINALITY REPORT
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xvii
APPENDIX – V
REQUEST FOR CONTENT VALIDITY
LETTER REQUESTING OPINIONS AND SUGGESTIONS OF EXPERTS
FOR ESTABLISHING CONTENT VALIDITY OF RESEARCH
From
Ms. Jane Amirtha Sanjeevi,
M.Sc., (Nursing) II Year,
Apollo College of Nursing,
Chennai-95.
To
Through Proper channel
Dr. Latha Venkatesan,
Principal,
Apollo College of Nursing.
Sub: Request for opinions and suggestions of experts for content validity of
Research tool.
xviii
Respected Sir/ Madam
Greetings! As a part of the Curriculum Requirement the following research
title is selected for the study.
“An Experimental Study to Assess the Effectiveness of Cling Wrap upon
Hypothermia in Newborns in Neonatal Intensive Care Unit at selected hospital,
Chennai”.
I will be highly privileged to have your valuable suggestions with regard to
the establishment of Content Validity of Research tool. So, I request you to validate
my Research tool and give suggestions about the tool.
Thanking You,
Yours Sincerely,
(Ms. Jane Amirtha Sanjeevi)
xix
APPENDIX – VI
CONTENT VALIDITY CERTIFICATE
I hereby certify that I have validated the research tool and interventional
programme of Ms.Jane Amirtha Sanjeevi, M.Sc (Nursing) II year student who is
undertaking research study on “An Experimental Study to Assess the
Effectiveness of Cling Wrap upon Hypothermia in Newborns in Neonatal
Intensive Care Unit at selected hospital, Chennai”.
Signature of Expert
Name and designation
xx
APPENDIX - VII
LIST OF EXPERTS FOR CONTENT VALIDITY
1. Dr. Latha Venkatesan, M.Sc (N)., M.Phil., Ph.D.,
Principal cum Professor,
Apollo college of Nursing,
Chennai-95.
2. Dr.Radhalakshmi Senthil, MBBS, MD, DNB, MRCPCH
Consultant Neonatologist,
Apollo Children’s Hospital,
Chennai.
3. Prof. Lizy Sonia, A., M.Sc. (N), Ph.D
Vice Principal & Professor in Nursing,
HOD of Medical Surgical Nursing,
Apollo College of Nursing,
Chennai-95.
4. Prof. K.Vijayalakshmi,M.Sc.(N), M.A.Psychology, Ph.D,
HOD Dept. of Mental Health Nursing,
Apollo College of Nursing,
Chennai-95.
5. Prof.Nesa Sathya Satchi,M.Sc(N)
HOD, Dept .of Child Health Nursing,
Apollo College of Nursing,
Chennai-95.
xxi
6. Prof.G. Shobana, M.Sc(N),Ph.D.,
HOD, Dept. of Community Health Nursing,
Apollo College of Nursing,
Chennai-95.
7. Mrs. Stella Mary,I.,M.Sc.(N),
Reader, Dept. of Mental Health Nursing,
Apollo College of Nursing,
Chennai-95.
xxii
APPENDIX - VIII
RESEARCH PARTICIPANT CONSENT FORM
Dear Participant,
I am a M.Sc., Nursing student of Apollo College of Nursing, Chennai. As a
part of my study, a research on “An Experimental Study to Assess the
Effectiveness of Cling Wrap upon Hypothermia in Newborns in Neonatal
Intensive Care Unit at selected hospital, Chennai”. is selected to be conducted.
The findings of the study will be helpful in controlling hypothermia in newborns.
I hereby seek your consent and co-operation to participate your child in the
study. Please be frank and honest in your responses. The information collected will
be kept confidential and anonymity will be maintained.
Signature of the researcher
I ………………………………………. hereby consent to participate my child in the
study.
Place:
Date: Signature of the Parent
xxiii
APPENDIX -IX
CERTIFICATE FOR ENGLISH EDITING
To whomsoever it may concern
This is to certify that the dissertation title "Effectiveness of Cling Wrap
upon hypothermia in newborns at a selected hospital, Chennai" by Ms. Jane
Amirtha Sanjeevi, II year M.Sc. Nursing student of Apollo College of Nursing,
Chennai was edited for English language appropriateness.
xxiv
APPENDIX - X
NEONATAL VARIABLES PROFORMA OF NEWBORNS IN
NICU
Purpose
This proforma is used to measure the demographic variables of neonate such
as gestational age in weeks at birth, birth weight, gender, APGAR, Birth order.
Instructions
The investigator will collect the information through referring the records.
The information gathered will be utilized thoroughly for the purpose of research and
will be held confidential.
Sample no:
1. Gestational age of neonate in weeks
1.1 30- 33
1.2 34- 37
1.3 37- 40
2. Birth weight of the neonate in Kg
2.1 1-2.5
2.2 2.5-3.5
2.3 >3.5
xxv
3. Gender
3.1 Male
3.2 Female
4. APGAR score at 10th
minute
4.1 <3
4.2 4-7
4.3 8-10
xxvi
APPENDIX XI
TEMPERATURE OBSERVATION RECORD SHEET
Purpose
This observation sheet is used to measure Temperature.
Instruction
The investigator will collect information by observing using an appropriate
apparatus.
Day Temperature readings
Pretest 8am 12 Noon 4pm 8pm 12am 4am
1
2
3
Temperature grading:
<32.2 or 32.2-34.2 degree C – Severe Hypothermia
34.3- 36.0 – Moderate hypothermia
36.1- 36.8- No Hypothermia
> 36.8- Hyperthermia
xxvii
BLUE PRINT FOR RATING SCALE TO ASSESS THE LEVEL
OF CAREGIVER’S SATISFACTION IN EXPERIMENTAL
GROUP
Sl.No Content Item no Total item Percentage
1 Characteristics of the researcher 1,2,3,4,5 5 50%
2 Effectiveness of cling wrap 6,7,8,9,10 5 50%
TOTAL 10 100
Scoring Interpretations
Score Percentage Interpretation
<15 30% Satisfied
15-35 >30-70% Moderately
satisfied
>35 >70% Highly satisfied
xxviii
APPENDIX-XII
RATING SCALE TO ASSESS THE CAREGIVER’S LEVEL OF
SATISFACTION
[
Purpose
This rating scale is designed to assess the caregiver’s level of satisfaction
regarding use of cling wrap in experimental group of newborns.
Instruction
There are 10 items given below. Kindly go through and give the response.
Feel free to answer. The answers will be kept confidential. Please put a tick () in
the following:
SI
no Statement
Strongly
disagree
(1)
Disagree
(2)
Uncertain
(3)
Agree
(4)
Strongly
agree
(5)
1 The researcher clearly explained
about the intervention
2 I am satisfied with the manner
of information disclosure
3 The researcher cleared all
doubts about the intervention
4 The researcher was present
throughout the intervention
5 I have trust in the personal
approach of the researcher
xxix
SI
no Statement
Strongly
disagree
(1)
Disagree
(2)
Uncertain
(3)
Agree
(4)
Strongly
agree
(5)
6
Cling wrap effectively
maintained temperature of the
pre term neonate
7 Cling wrap effectively maintains
bio physiological parameters of
preterm neonate
8 It does not affect any clinical
procedure on the pre term
neonate
9 It is cost effective
10 It is easy to practice
Scoring key
Strongly agree - 5
Agree - 4
Uncertain - 3
Disagree - 2
Strongly disagree - 1
Interpretations
Score Percentage Interpretation
<15 30% Satisfied
15-35 >30-70% Moderately satisfied
>35 >70% Highly satisfied
xxx
APPENDIX XIII
ITEM WISE FREQUENCY AND PERCENTAGE
DISTRIBUTION OF CARE GIVERS LEVEL OF
SATISFACTION REGARDING USE OF CLING
WRAP IN EXPERIMENTAL GROUP OF NEWBORNS
(N=30)
Items
Strongly
agree Agree Disagree
Strongly
disagree
n p n p n p n p
The researcher clearly explained about the
intervention
29 96.7 1 3.3 - - - -
I am satisfied with the manner of
information disclosure
28 93.3 2 6.7 - - - -
The researcher cleared all doubts about the
intervention
28 93.3 2 6.7 - - - -
The researcher was present throughout the
intervention
26 86.7 4 13.3 - - - -
I have trust in the personal approach of the
researcher
26 86.7 4 13.3 - - - -
Cling wrap effectively maintained
temperature of the pre term neonate
24 80 6 20 - - - -
Cling wrap effectively maintains bio
physiological parameters of preterm
neonate
21 70 9 30 - - - -
It does not affect any clinical procedure on
the pre term neonate
25 83.3 15 16.7 - - - -
It is cost effective 29 96.7 1 3.3 - - - -
It is easy to practice 28 93.3 2 6.7 - - - -
xxxi
APPENDIX - XIV
DATA CODE SHEET
NEONATAL VARIABLE PROFORMA
GA Gestational age of neonate in weeks
1.1 30-33
1.2 34-37
1.3 37-40
B.WT Birth weight of the neonate in Kg
2.1 1-2.5 kg
2.2 2.5-3.5kg
2.3 >3.5 kg
GEN Gender
3.1 Male
3.2 Female
APG APGAR score at birth
4.1 <3
4.2 4-7
4.3 8-10
MT Mean Temperature
xxxii
APPENDIX – XV
MASTER CODE SHEET SI NO CONTROL EXPERIMENT
GA B.WT GEN APG MT GA B.WT GEN APG MT
1 1.3 2.3 3.2 4.2 33.86 1.3 2.3 3.1 4.2 36.7
2 1.1 2.2 3.2 4.3 33.3 1.2 2.2 3.1 4.3 36.7
3 1.2 2.1 3.1 4.2 31.8 1.2 2.1 3.1 4.3 36.8
4 1.3 2.2 3.1 4.3 31.9 1.3 2.2 3.1 4.3 36.4
5 1.3 2.3 3.1 4.3 33.8 1.2 2.3 3.2 4.3 36.7
6 1.3 2.2 3.1 4.2 36.7 1.1 2.2 3.1 4.2 36.8
7 1.1 2.1 3.2 4.3 36.8 1.2 2.1 3.1 4.3 36.7
8 1.2 2.3 3.1 4.3 33.8 1.2 2.2 3.2 4.3 36.8
9 1.3 2.2 3.1 4.2 32.7 1.3 2.2 3.1 4.3 36.3
10 1.2 2.2 3.2 4.3 33.9 1.2 2.2 3.2 4.3 36.5
11 1.3 2.1 3.1 4.1 32.7 1.1 2.2 3.2 4.3 36.7
12 1.1 2.2 3.2 4.3 33.9 1.2 2.3 3.1 4.1 36.7
13 1.2 2.3 3.1 4.2 32.3 1.2 2.2 3.2 4.3 36.5
14 1.3 2.2 3.2 4.3 33.9 1.3 2.2 3.1 4.3 36.6
15 1.2 2.1 3.1 4.3 32.4 1.2 2.1 3.2 4.3 36.4
16 1.3 2.2 3.2 4.2 33.8 1.3 2.2 3.2 4.3 38.6
17 1.2 2.2 3.2 4.3 34.5 1.2 2.2 3.1 4.3 36.6
18 1.3 2.2 3.1 4.3 36.8 1.1 2.2 3.2 4.3 36.7
19 1.1 2.1 3.2 4.2 36.9 1.3 2.2 3.2 4.2 36.6
20 1.3 2.2 3.1 4.3 36.7 1.2 2.3 3.1 4.3 36.4
21 1.2 2.3 3.2 4.3 34.5 1.3 2.2 3.1 4.3 36.7
22 1.3 2.2 3.1 4.3 32.6 1.2 2.1 3.2 4.3 36.8
23 1.3 2.1 3.2 4.1 32.5 1.1 2.2 3.1 4.3 36.7
24 1.1 2.2 3.1 4.3 34.2 1.3 2.2 3.1 4.3 36.5
25 1.2 2.2 3.2 4.3 34.0 1.2 2.2 3.1 4.2 36.5
26 1.3 2.1 3.2 4.3 34.7 1.3 2.2 3.2 4.3 36.6
27 1.3 2.2 3.1 4.2 36.8 1.2 2.3 3.1 4.3 36.5
28 1.2 2.1 3.1 4.3 34.2 1.2 2.2 3.2 4.3 36.4
29 1.2 2.3 3.2 4.3 35.0 1.3 2.2 3.2 4.3 36.7
30 1.1 2.1 3.2 4.2 36.9 1.2 2.3 3.1 4.2 36.5
xxxiii
APPENDIX – XVI
PHOTOGRAPHS DURING CLING WRAP ADMINISTRATION
xxxiv
1
CHAPTER -I
INTRODUCTION
Background of the Study
“As a mother my job is to take care of what is possible and trust God with
the impossible.”
-Ruth Bell Graham
A new addition into a family has always been a joyous event in any
community across the globe. The long awaited experience of birthing adds
inexplicable joy to motherhood and in turn the entire family. Newborns become the
center of attraction at any given point of time. Today’s healthy newborn is
tomorrow’s healthy as well as wealthy citizen of the country. Hence neonatal health
and well being is a prudent factor to decide upon the future health status of the
nation. This rings the alarm to escalate neonatal care to greater standards.
According to the WHO report of 2011, nearly 99% of all neonatal deaths
occur in low- and middle-income countries. Neonatal mortality has been declining
worldwide. The number of deaths among babies 0-28 days of life decreased from 4.4
million in 1990 to 3.1 million in 2010. Deaths that occur among babies less than 28
days of life (neonatal period) account for about 40% of all under-five deaths. As
many as 70 percent of neonatal deaths could be prevented with known, simple, non-
intensive interventions: basic resuscitation, management of low birth weight and
treatment of sepsis.
Yet such low-cost, proven treatments remain difficult to implement in
resource-poor settings, a reality that speaks to the pressing need for professionals
with an interest in reducing global health disparities. Problems in newborns include
thermoregulation, adaptation issues to extra-uterine life, jaundice, feeding problems,
birth injuries and defects to minor issues like colic, rash, fever etc out of which
hypothermia constitutes as a major issue amongst all newborns. According to the
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WHO report of 2011, 27% of the causes of infant mortality due to preterm delivery
and hypothermia contribute about 18-42% of infant mortality worldwide, 20-35% in
India and about 8-15% in Tamil Nadu.
Thermoregulation is a critical component of neonatal care because it has
been well documented that hypothermia is a major contributor to infant mortality.
Maintaining a neutral thermal environment for premature and very low birth weight
infants can have a significant impact on health outcomes and has been recognized
behind size, as perhaps the earliest distinguishable characteristic when compared to
the full term neonate. Newly born infants undergo a series of biological adjustments
in order to adapt to their new environmental conditions. One of the physiological
issues is the failure of the neonate to accommodate to the surrounding thermal
environment resulting in hypothermia.
Adaptation to extrauterine life involves the newborn infant in a series of
biological adjustments to a totally new environment, particularly when the ambient
temperature is cold. The primary source of heat production for the neonate is
through non-shivering thermogenesis (oxidation of brown fat), which is the
production of heat by metabolism. The posterior hypothalamus responds to cold
stress with the release of norepinephrine, which triggers the production of glucose
needed for thermogenesis in brown fat.
Brown fat, a thermogenic organ unique to the neonate is deposited after 28
weeks gestation in adipose tissue around the scapula, kidneys, adrenals, neck and
axilla. Neonatal hypothermia on admission remains a major problem in our
population. There is need to increase awareness among nursing staff and mothers
about the serious consequences of hypothermia in newborns.
Thermoregulatory needs of the newborn play a vital role in neonatal care,
particularly in first several hours of life. The infants are at risk for hypothermia in
the first days to weeks of life, due to evaporative, convective and radiant heat losses
during resuscitation. Evaporative and convective heat loss depends on air speed and
3
humidity of the air. Newborns can become hypothermic (subnormal body
temperature) very soon after birth, even in the summer.
Neonatal hypothermia is associated with an increased mortality risk for 28
days. There are few hospital-based data on specific risk factors for neonatal
hypothermia and is well recognized as a factor influencing newborn health. The
newborn infant exhibits immature thermoregulation as compared with the older
child or adult and therefore needs to be protected from extremes of cold and heat.
World Health Organization (WHO) provided the following definitions of
normothermia 36.5–37.5 °C and hypothermia as 32.0–36.0°C
Preventive measures of hypothermia range from simple efforts of delaying
the first baby bath, mummification, co-bedding and initiating kangroo mother care in
case of premature infants etc. For newborns who are ill or under close monitoring in
NICU, hypothermia is combated through use of radiant warmers, mummification,
use of head caps, mittens and socks and also increasing the ambient room
temperature.
Cling wrap is an innovative newer technique employed to control
hypothermia of newborns in NICU. It is a simple and effective mode that is utilized
to maintain normothermia by principle of radiation and convection. It conserves the
body heat and retains the ambient external source of heat supplied, as well as
preventing the insensible water loss from the newborns. As it is readily available and
affordable, requiring minimal efforts in administration along with broad spectrum of
benefits in maintaining thermoregulation, it is therefore the most sought after
convenient modality for thermal balance in newborns even in primitive settings.
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Need for the Study
Newborn baby is a homeothermic but his ability to stay warm may easily be
overwhelmed by extremes of environmental temperatures. Neonatal hypothermia is
often due to lack of attention by health care providers and continues to be a very
important cause of neonatal deaths.
Of all early neonatal deaths (deaths within the first 7 days of life) that are not
related to congenital malformations, 28% are due to hypothermia. Hypothermia have
been reported to range from 5% to 7% of live births in some developed countries,
but are estimated to be substantially higher in developing countries. According to the
WHO report of 2011, 27% of the causes of infant mortality is due to preterm
delivery and hypothermia contributes about 18-42% of infant mortality worldwide.
Approximately 20-35% of neonatal mortality in India is due to hypothermia alone
and nearly 8-15% of neonatal deaths in Tamil Nadu is chiefly due to hypothermia
and poor neonatal care.
The adverse effect of hypothermia on the viability and survival in premature
and low birth weight neonates has been well reported. Low body temperature in
newborns can lead to an increased rate of basal metabolism, peripheral
vasoconstriction, decreased peripheral perfusion, tissue ischemia and finally
metabolic acidosis .Vascular changes in the lungs may result in decreased
ventilation, increased demand for oxygen and worsening of respiratory distress.
Meanwhile, acidosis and hypoxia can predispose to pulmonary hemorrhage and