Camryn is an 8-day-old infant who was born at 26 weeks' gestation. Her corrected age is 27 weeks, 1 day. Her birth weight was 985g (2#, 2 1/4oz) and weights have been deferred since that time. Using this same weight, she's at the 50th percentile. Today, Camryn was taken off of the ventilator and put on nasal CPAP (Constant Positive Airway Pressure) with a PEEP of 5 and 42% oxygen. On 3/3 her antibiotic was changed from Gentamycin to Ampicillen and she was given a sedative called Fentanyl. She was started on Aminophillen on 3/3, which is a medication to help prevent apnea and bradycardic spells. These are episodes where Camryn experiences breathing pauses and her heart rate slows. She had two of these episodes on 2/27 and on 2/28. She no longer has an umbilical artery catheter. She has a PICC line, a special type of IV in her L arm through which she receives nutrition and fluids. She started OG (the tiny tube that's inserted into her mouth and leads to her stomach) feedings on 1/27. Feedings have been off and on and were restarted yesterday. Today she's up to 2cc of breast milk or EPF with low iron every 3 hours. She's under phototherapy, which are special lights used to address the build up of a substance in her body called bilirubin. This causes her skin to appear yellow jaundice). She was under lights from 2/25 to 3/1and started again today. She had a blood transfusion on 3/2.

Camryn was observed for a total of 36 minutes on 3/4/99. She was observed for 7 minutes, 45 seconds before the caregiving. She was under phototherapy lights and wore a mask covering her eyes. She was positioned on her left side in a deep nest formed by side and foot rolls that effectively supported her to keep her legs tucked and her feet braced. She was sucking on her left thumb and making smacking noises the entire time before caregiving began. The loud clunking of the tube system could be heard six times. Camryn reacted to this by squirming or moving her right arm. She kept her hand closed, touching her head or her cheek. She seemed to be in a drowsy state as she reacted to the sounds in her environment. Her heart rate was steady between 153-160 beats/minute. Her oxygen saturation levels were 96-9711/o and her breathing was fairly regular and a little fast at 62-70 breaths/minute.

Camryn was observed for 10 minutes during the caregiving interaction. She wore her phototherapy mask the entire time. She continued to appear to be drowsy as she lay on her left side. She kept her legs tucked and feet braced at the rolls on the foot of her bed. As her nurse listened to her lungs with a stethoscope, Camryn started flailing her right arm and her nurse offered her hand to hold onto. She continued to make sucking sounds while her nurse listened to her abdomen. She extended her right arm and was able to bring it back in close to her head on her own while her nurse gave her a short break before measuring her for anew OG tube. She continued to move her right arm to explore different areas of her head and face. She settled briefly as her nurse held her hand while she took her temperature. She continued make sucking sounds as her nurse slowly inserted her OG tube. She stopped sucking while her nurse taped the OG in place and checked for residual food in her stomach. Camryn briefly held onto her CPAP tubing while her nurse measured her abdomen. Her nurse placed a diaper roll at her midline before starting Camryn's feeding of 2cc. This took under a minute to go in and then her nurse left the bedside to chart. Camryn's breathing was more irregular varying between 31-61 breaths/minute. Her heart rate and oxygen saturation levels remained steady.

Camryn was observed for 18 minutes, 15 seconds following the caregiving interaction. During this time she was restless and squirming a lot. The clunking of the tube system occurred six times, which made it difficult for Camryn to settle down to go to sleep. Each time she reacted by squirming or flailing her right arm. She finally settled with both arms tucked near her mouth. Saliva pooled outside her mouth. Her father arrived toward the end of the observation and she briefly held onto his hand. Her heart rate was steady between 139-146 beats/minute. Her oxygen saturation levels were between 96-9911/o. Her breathing pattern changed, as it slowed between 26 to 38 breaths/minute and became more irregular with frequent pauses.

INFANT'S CURRENT GOALS:

1. Camryn is working on developing a more even skin color and regular breathing pattern.

2. Camryn is working on conserving her energy in order to prevent exhaustion with caregiving interaction and in order to gain weight.

3. Camryn is working on using tucking of her arms and legs, holding on and keeping her hands by her face, bracing her feet, and sucking when she's given bedding or caregiver support. In this way she can be an active participant during caregiving and stay relaxed without becoming worn out.

4. Camryn is working on achieving long periods of relaxed sleep.

RECOMMENDATIONS:

• Please try covering Camryn's ears with "ear muffs" to see if this enables her to get more restful sleep without constant reacting to the clunking noise of the tube system. When possible, consider another location for her bed.

• Consider the noise level near her bed space and support her sleep by whispering at all times.

• If she's not under phototherapy and protected by her mask, consider keeping the lighting dim so that she doesn't become overwhelmed.

• Continue providing Camryn with a deep nest with side and foot rolls. The rolls need to be high enough so that she can brace her feet.

• Continue to time the caregiving interaction when Camryn is stirring and squirming in herbed and avoid unnecessary interruptions when she's sleeping.

• Please shut off her phototherapy lights and remove her mask during caregiving interactions so that you can look to her face to see how she's handling the interaction. This is especially important during stressful procedures. We want her to know that her sleep time is "safe".

• Consider ways to support her parents as they begin skin to skin holding.

• Consider Camryn as an active participant during caregiving interactions. Support her efforts to keep her hands by her face, stay tucked, hold on, brace her feet etc. She requires careful pacing with rest breaks provided in order to avoid exhaustion.

• Please position Camryn on her side as much as possible. This is especially important during care giving interactions as this is the position where she is best able to stay tucked and use her self regulatory strategies.

• Please consider staying with Camryn after caregiving to make she she's settled into a restful sleep. She may show a delayed response to the stress of caregiving and will need your support to settle herself.