1. Retinopathy of Prematurity: Oxygen Weaning in the NICU
Jacqueline Gonzalez
University of Central Florida

2. Abstract
Retinopathy of prematurity is a leading cause of blindness in babies born prematurely. A major contributor to retinopathy of prematurity is prolonged exposure to high levels of oxygen. Ineffective weaning of oxygen has caused an increase in the amount of patients diagnosed with retinopathy of prematurity. Guidelines have been established to prevent, screen, and treat retinopathy of prematurity. Two types of treatment are cryosurgery and retinal laser ablation. It is important that units where premature neonates are taken care of incorporate an oxygen-weaning plan to prevent retinopathy of prematurity. Deborah Johnson’s behavioral system model can be applied to NICU nursing. Nursing behaviors can be planned and implemented for these neonates to have the best outcomes. Nurses play a vital role in the prevention of this disease.

3. Background/Problem Statement
Retinopathy of prematurity (ROP) is a potentially blinding disease in the newborn infant.
ROP occurs because a premature infant’s retina is not sufficiently vascularized, and if the extra uterine environment is not the same as that of the in utero environment, the retinal vessels will grow abnormally (Smith, Hard, & Hellstrom, 2013).
Risk factors for ROP include gestational age and weight. The most at risk population are premature infants and infants born with very low birth weight (VLBW).
ROP is caused by high levels of oxygen.
Ineffective weaning of oxygen has lead to an increased incidence of retinopathy of prematurity in the NICU.

4. Significance/Specific Aims
“Retinopathy of prematurity is a potentially blinding condition; at the current birth rate in the United States, 400 to 600 children born per year will have visual acuity 20/200 or less secondary to ROP” (Tlucek et al., 2010).
It is the third leading cause of blindness in children born preterm (Jordan, 2014).
According to an article written by Jordan (2014), in 2010 it was predicted that 184,700 premature neonates would be diagnosed with ROP, and 20,000 of those diagnosed would become fully blind or have severe visual impairment.
According to Tlucek et al. (2010), prolonged and excessive exposure to oxygen is a major contributor to the pathogenesis of ROP.
The goal is to create an oxygen weaning protocol.
The oxygen will be adjusted as needed for each patient to saturate within a specified oxygen saturation target range.
We will effectively wean oxygen and have a lower incidence of patients with ROP.
The oxygen weaning protocol will guide nursing care and behaviors.

5. Johnson’s Behavioral System Model
The goal Jonson was trying to achieve was to conceptualize nursing to teach nurses at all levels (McEwen & Wills, 2014).
Johnson was inspired by Florence Nightingale’s philosophical mindset to regard the patient, rather than the disease experienced by the patient (McEwen & Wills, 2014).
McEwen and Wills (2014) recognize Johnson’s theory as useful for application to nursing.
It can be used to create a plan of nursing care and to implement effective nursing care.
Johnson described four assumptions in her behavioral system model:
the belief that motivates acts as focal points around which behaviors are arranged to accomplish specific goals
behavior is characterized and coordinated within the usual capacity of set and choice
particular parts or subsystems of the behavioral system are measured by the importance of goal, set, choice, and actions
interactive and complimentary subsystems normally result in achieving and maintaining harmony between and among subsystems through control and regulatory processes
(McEwen and Wills, 2014)

6. Johnson’s Behavioral System Model
Several concepts have been identified in this theory. These concepts can be applied respectively to nursing circumstances.
The major concepts of the behavioral system model:
human, health, and environment
Other concepts identified in Johnson’s theory include:
behavioral system, boundaries, function, functional requirements, homeostasis, instability, stability, stressor, structure, system, subsystem, tension, and variables
Within the concept of subsystems are seven subsystems:
attachment, dependency, ingestive, eliminative, sexual, aggressive, and achievement
Within the concept of functional requirements are three requirements:
to be sheltered from harmful influences with which the person is unable to handle
to be nurtured through the help of rations from the environment
to be stimulated to boost growth and avoid inactivity
(McEwen and Wills, 2014)

7. Application
Johnson’s behavioral system model can be applied to the NICU by creating an oxygen weaning protocol to prevent ROP.
By creating an oxygen weaning protocol, nursing care and interventions can be planned according to each patient’s specific needs.
In an article written by Poster, Dee, and Randell (1997), the behavioral system model was used to determine patient outcomes from nursing behaviors such as assessment, plan of care, and implementation of nursing care.
Fruehwirth (1989) was also able to apply this model in her case study of nursing behaviors in assessment of and interventions of the nurses providing care.
In the NICU we will create an oxygen weaning protocol, as well as a screening and treatment program, for patients at risk for ROP.
This protocol and plan will engage everyone involved in the care of these patients, as this is the most effective way to come up with a plan structure, according to Darlow, Gilbert, and Quiroga (2013).
Those involved include the nurses, neonatologists, respiratory therapists, ophthalmologists, and parents.
With an oxygen weaning protocol, nurses will be able to effectively wean oxygen for the patient to saturate within the appropriate specified range.

8. Application
The neonatologist will order a target range of oxygen saturations.
Alarms will ring if the oxygen saturations are not within the ordered range.
With the alarms alerting us whether the patient has oxygen saturation within the target range, we will be able to adjust the oxygen according to the patients’ needs.
As the patients’ condition and gestational age changes, target saturations will be updated with a new order.
The goal will be to prevent ROP using the oxygen weaning protocol.
We will choose when it is appropriate to wean or increase the oxygen and this will affect the patients’ outcomes.

9. Summary and Conclusions
According to Smith et al. (2013), although oxygen monitoring has improved, ROP persists as a major problem because of improved practices resulting in the neonates’ survival at earlier gestational ages, when there is extreme retinal immaturity.
“When oxygen targeting is used, nurses are the caregivers primarily responsible for adjusting oxygen administration to keep pulse oximeter saturations in a specified range” (Coe, 2007).
It is important that we nurses take oxygen weaning seriously to prevent this terrible disease that leads to blindness and provide a better outcome for these babies.
The goal would be for the NICU to put in place an oxygen weaning protocol in order to prevent ROP from inflicting the neonates.
Johnson’s behavioral system model will be used to measure patient outcomes by assessing nursing behaviors while using the oxygen weaning protocol.
Prevention and early screening will decrease the incidence of ROP.

10. References
Coe, K. (2007). Nursing update on retinopathy of prematurity. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 36(3),
Darlow, B. A., Gilbert, C. E., & Quiroga, A. M. (2013). Setting up and improving retinopathy of prematurity programs. Clinics in Perinatology, 40(2),
Fruehwirth, S. (1989). An application of Johnson's behavioral model: A case study. Journal of Community Health Nursing, 6(2),
Jordan, C. (2014). Retinopathy of prematurity. The Pediatric Clinics of North America, 61(3),
McEwen, M., & Wills, E. (2014). Grand nursing theories based on human needs. In Theoretical basis for nursing (Fourth ed., pp ). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Poster, E., Dee, V., & Randell, B. (1997). The Johnson behavioral systems model as a framework for patient outcome evaluation. Journal of the American Psychiatric Nurses Association, 3(3),
Smith, L. E., Hard, A., & Hellstrom, A. (2013). The biology of retinopathy of prematurity. Clinics in Perinatology, 40(2),
Tlucek, P. S., Corff, K. E., Bright, B. C., Bedwell, S. M., Sekar, K. C., & Siatkowski, R. M. (2010). Effect of decreasing target oxygen saturation on retinopathy of prematurity. Journal of American Association for Pediatric Ophthalmology and Strabismus , 14(5),
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