Nursing Care Plan for Low Birth Weight
Nursing Diagnosis : Imbalanced Nutrition: Less Than Body Requirements related to
- decrease nutrient deposits,
- immaturity of enzyme production,
- weak abdominal muscles,
- weak reflexes.
Expected outcomes:
- Babies get the calories and essential nutrients are adequate.
- Maintain growth and weight gain in a normal curve with weight gain remains, at least 20-30 grams / day.
Interventions :
Independent:
- Assess maturity reflex, with regard to feeding (eg, sucking, swallowing, and cough).
- Auscultation presence of bowel sounds, assess physical status and respiratory status.
- Assess the weight by measuring body weight every day, then documented in infant growth charts.
- Monitor the input and output. Calculate the consumption of calories and electrolytes every day.
- Assess the level of hydration, note fontanelle, skin turgor, urine specific gravity, the condition of the mucous membranes, weight fluctuations.
- Assess for signs of hypoglycemia; tachypnea and irregular breathing, apnea, lethargy, temperature fluctuations, and diaphoresis. Poor feeding, nervous, crying, high tone, trembling, eyes upside down, and seizure activity.
- Monitor laboratory tests as indicated: serum glucose, blood urea nitrogen, creatinine, osmolality, serum / urine, urine electrolyte.
- Give electrolyte supplements as indicated for example calcium gluconate 10%.
Rationale :
Independent:
- Determine the appropriate method of feeding for infants.
- The first infant feeding stable has peristaltic can begin 6-12 hours after birth. If there is respiratory distress, parenteral fluids indicated, and oral fluid had to be postponed.
- Identifying the risk and the degree of risk to growth patterns. SGA infants with excess extracellular fluid possibility of losing 15% of birth weight. SGA infants may have lost weight in the uterus or decrease fat deposits / glycogen.
- Provide information about the actual input in conjunction with an approximate adjustment needs to be used in the diet.
- Increased metabolic needs of SGA infants may increase fluid requirements. Infant state of hyperglycemia can lead to diuresis in infants. Intravenous fluids may be needed to meet increased demand, but must be carefully handled to avoid fluid overload.
- Because glucose is the main source of fuel for the brain, deficiency can cause permanent damage to the CNS. Hypoglycemia significantly improve the mobility of mortality and severe effects of time dependent on the duration of each episode.
Collaboration:
- Hypoglycemia can occur in the early 3 hours of birth infants SGA when glycogen stores quickly reduced and gluconeogenesis inadequate because of a decrease in deposits of protein drugs and fat.
- Detecting changes in renal function associated with a decrease in deposits of nutrients and fluid levels due to malnutrition.
- Metabolic instability in SGA infants / LGA may require supplements to maintain homeostasis.
