Nursing Care Plan for Low Birth Weight
Nursing Diagnosis : Risk for Ineffective Thermoregulation
- Low birth weight, birth weight 1500 - 2500 g.
- Very low birth weight, birth weight less than 1500 g.
- Extreme low birth weight, birth weight less than 1000 g.
Clinical Manifestations
1. Signs and symptoms of preterm infants according Surasmi (2003: 32), among others:
- Gestational age equal to or less than 37 weeks.
- Weight loss is equal to or shellfish than 2500 grams.
- Body length is equal to or less than 46 cm.
- Nails are not yet past the fingertip length.
- Limit the forehead and scalp hair ends are unclear.
- Head circumference is equal to or less than 33 cm.
- Chest circumference is equal to or less than 30 cm.
- Lanugo hair is still a lot.
- Thin subcutaneous fat tissue or less.
- The ear cartilage growth is not perfect, so it seems not palpable cartilage earlobe.
- Heel shiny, smooth soles.
- Genitals: the baby boy pigmentation and scrotal rugae; less, the testes do not descend into the scrotum, to baby girl protruding clitoris, labia minora covered by the labia majora.
- Weak muscle tone so that the baby is less active and weak movement.
- Nerve function yet or less mature, resulting in reflex suction, swallowing and cough is still weak or ineffective and weak cries.
- Mammary gland tissue is still lacking due to the growth of fat tissue is still lacking.
- Vernix no or less.
2. Signs and symptoms of infants according Surasmi dysmature (2003: 34), among others:
- Dysmature preterm infants: visible physical symptoms of preterm coupled with growth retardation symptoms.
- Dysmature term and postterm infants
- Symptoms of placental insufficiency and duration depending on the time of the baby suffering from a deficit, growth retardation would happen if the deficit lasting (chronic).
- Stadium baby dismature:
1. First
2. Second
- The baby looked thin and relatively longer.
- Loose skin, dry as a permanent stain is not yet meconium.
3) Third
- There are signs of the first stage.
- The green color of the skin of the placenta and umbilical (as meconium mixed), amniotic settles on the skin, umbilicus and placenta due to intrauterine anorexia.
- There is a sign of the third stage.
- The skin, nails, yellow cord.
- Found signs of anorexia intrauterine long.
Nursing Diagnosis for : Risk for Ineffective Thermoregulation related to immature CNS (central regulation of residues, reduced lean body mass to surface area, subcutaneous fat loss, inability to feel cold and clammy, poor metabolic reserves).
Goal: Thermoregulation becomes effective in accordance with the development.
Expected outcomes:
Maintaining the skin or axillary temperature (35 - 37,50C).
Nursing Interventions :
Independent:
- Assess the temperature with a rectal temperature check at first, then check the temperature of the axilla or use a thermostat with an open base and spreader warm.
- Place the baby in an incubator or in a warm state.
- Monitor the temperature control system, spreader warm (keep the upper limit of 98.6 ° F, depending on the size and age of the baby)
- Assess output and urine specific gravity.
- Monitor weight gain in a row. If weight gain is inadequate, increase the ambient temperature as indicated.
- Note the development of tachycardia, redness, diaphoresis, lethargy, apnea or seizure activity.
Collaboration:
- Monitor laboratory tests as indicated (serum glucose, electrolytes and bilirubin levels).
- Give medications in accordance with the indication.
Rationale :
- Hypothermia make babies tend to feel stressed because of the cold, the use of fatty deposits can not be updated if there is and decreased sensitivity to increasing CO2 levels or decreased levels of O2.
- Maintaining a thermoneutral environment, helps prevent stress due to the cold.
- Hyperthermia with an increased rate of oxygen and glucose metabolism as well as the need for water loss can occur when the ambient temperature is too high.
- The decline in output and an increase in specific gravity of urine associated with a reduction in renal perfusion during periods of stress because of the cold.
- The inadequate weight gain despite adequate caloric intake may indicate that the calories are used to maintain the ambient temperature of the body, thus requiring an increase in ambient temperature.
- Signs of hyperthermia can be continued in brain damage if not resolved.
- Cold stress increases the need for glucose and oxygen and can lead to problems when a baby has acid base anaerobic metabolism when oxygen levels are not enough available. Increased levels of indirect bilirubin may occur due to the release of fatty acids from brown fat metabolism by fatty acids compete with bilirubin in the bond part in albumin.
- Helps prevent seizures relating to changes in CNS function induced hyperthermia.
- Fixing acidosis can occur in hypothermia and hyperthermia.
