Saturday, March 24, 2012

Nursing Care of low birth weight babies, PRETERM, IUGR.

NURSING CARE OF LOW BIRTH
WEIGHT BABY
INTRODUCTION:
Previously, the birth weight of 2500gm or less was taken as index of prematurity with out taking any consideration of the gestational period or any other factor. But infants born at term or post term may weight less than 2500gm and occasional a baby of diabetic mother may weight much more than 2500gm even before 37 weeks. Thus, the inclusion of all the babies weighing less than 2500gm without due consideration to the gestational period seems inappropriate.
DEFINITION:
low birth weight  “ as one whose birth weight is less than 2500gm irrespective of the gestational age” .
Very low birth infants weight 1500gm or less and
 extremely-low birth  infant weight 1000gm or less.
INCIDENCE:
         In India about 30 to 40 percent neonates are born LBW. Approximately 80% of all neonatal deaths and 50% of infant’s death are related to LBW.
         High incidence of LBW babies in our country is due to higher number of babies with IUGR (SMALL FOR DATE) rather than preterm.
         The baby with a birth weight of less than 2000gm is more vulnerable and need special care.
         About 10% of all LBW babies require admission to the special care nursery.
TERMINOLOGY:
         LOW BIRTH WEIGHT : Weight of  2500gm
         Very low birth weight baby: babies with a birth weight of less than 1500mg.
         Extremely low birth eight babies: babies with a birth weigh of less than 1000gm.
         Preterm baby/ immature baby/ premature baby: baby born with a gestational age of less than 37 completed week
         Term baby: a baby born with a gestational age of 37 to 41 weeks is called as term baby.
         Post term baby: a baby born with a gestational age of 42 weeks or more is called as term baby.
TYPES OF LBW:
         A low birth weight baby includes both
         1. preterm 
         2. Small for dates (SFD) babies.
Classification of babies on the basis weight  alone and gestational age with birth weight.
Gestational age
Birth weight
Pre term



Term


Post term
-Small for date
-Appropriate for date
-Large for date
-small for date
-Appropriate for date
-Large for date
-Small for date
-Appropriate for date
-Large for date            
PRE TERM baby :
Definition:
          Baby born with a gestational are of less than 37 completed week.
INCIDENCE OF LBW BABIES:
         It constitutes 2/3 of LBW.
          20 to 25% in the developing countries.
         10% in the developed countries.
CAUSES FOR PRE TERM:
Spontaneous causes:
         Constitutional: acute emotional stress,  trauma.
         Low maternal weight gain and poor socioeconomic condition, Very young and unmarried mothers, too frequent child birth, history of previous preterm baby,
         Maternal nutrition: anemia, maternal malnutrition
         Maternal diseases: Ante partum hemorrhage, cervical incompetence, threatened abortion, bicarnuate uterus, chronic and systemic diseases, and infection,
Spontaneous causes:
         Toxins: cigarette smoking, and drug abuse during pregnancy,
         Fetal causes: multiple pregnancy
         congenital malformation.
Induced causes:
         Maternal diabetes mellitus and severe heart diseases. Placental dysfunction with unsatisfactory fetal growth.
         Eclampsia, severe pre eclampsia, and hypertension. Fetal hypoxia and fetal distress,
         severe Rh incompatibility,
         improper diagnosis of maturity in elective deliveries
CLINICAL FEATURE OF PRETERM:
         Length- <44cm
         weight-2500gm or <2500gm.
         Head circumference disproportionately exceeds than that of the chest.
         The skin is thin, red and shiny, due to lack of subcutaneous fat and covered by plentiful lanugos and vernix caseosa.
         Pinnae of the ear are soft.
         The eyes are kept closed.
         Muscle tone is poor.
         Plantar creases are not visible before 32 weeks.
         The testis is undescended,
         The labia minora is exposed, and there is a tendency of herniation.
         The nail is not grown up to the finger tips.
         Reflexes are poor.
IUGR
Definition
         Babies with a birth weight less than 10th percentile for their gestational age.
INCIDENCE OF SFD:
          comprises about 1/3 of LBW.
         2 to 8% in developed countries.
         5% among term babies.
         15% among post term babies.
CAUSES FOR SFD BABIES:
         Maternal causes:
         Constitutional: small women, maternal genetic and radical back ground
         Maternal nutrition: glucose, amino acid and oxygen deficiency
Maternal diseases: anemia, hypertension, thromphillia, heart disease and chronic renal disease
         Toxins:  alcohol, smoking, cocaine, heroine, drugs.
Fetal causes:
         Structural anomalies (renal or cardiovascular), chromosomal abnormalities,
          TORCH infection,
         multiple pregnancy
Placental causes:
         Chronic placental insufficiency, placenta previa, abruption, circumvallates, infarction and mosaicism
CLINICAL FEATURES OF SFD:
         Length is unaffected,
         weight is about 600 gm below at birth.
         dry and wrinkled skin because of less subcutaneous fat. 
         thin meconium stained vernix caseosa
         Scapoid abdomen,
         Plantar crease are well defined.
          Thin umbilical cord.
         All these give a baby “old man appearance”
         The baby is alert, active
          has normal crying.
          Reflexes are normal

      NURSING CARE OF LOW BIRTH     WEIGHT BABIES
Nursing care of low birth weight includes:
1.      Care at neonatal intensive care unit,
2.      Maintenance of breathing,
3.      Maintenance of stable body temperature,
4.      Maintenance of nutrition and hydration,
5.      Gentle early stimulation,
6.      Prevention, early detection and prompt management of complication,
7.      vaccinization of LBW
8.      Transport of sick LBW baby.
9.       Family support discharge, follow- up and home care,
Care at neonatal intensive care unit:
1.      The NICU should be warm, free from excessive sound smoothing light.
2.       Protection from infection should be ensured by aseptic measures and effective hand washing.
3.      Rough handling and painful
 procedure should be avoided.
4. Baby should be placed
on soft comfortable,
 “nestled” and cushioned bed.
4. Continuous monitoring of the baby’s clinical status are vital aspects of management which depends upon the gestational age of the baby.
5. Baby can be placed in prone
position during care.
2. Maintenance of breathing:
1.      Baby should be positioned with neck slightly extended and air passage to be cleared by gentle suctioning to remove the secretion, if needed. Precaution should be taken to prevent aspiration of secretion and feeds.
2.      Concentration of oxygen to be maintained to have saO2 between 90 and 95% and paO2 between 60 and 80 mm of Hg.
3.      Baby’s respiration rate, rhythm, signs of distress, chest retraction, nasal flaring, apnea, cyanosis, oxygen, saturation, etc. to be monitored at frequent interval.
2.      4. Tackling stimulation by sole flaring can be provided to stimulate respiratory effort.
3.      5. Chest physiotherapy by percussion, vibration and postural drainage may be needed to loosen and remove respiratory secretion.
4.      6. Desirable level of arterial blood gas values should be I) Pao2 55-65 mm Hg .ii) PaCO2 35-45 mmHg and iii) PH 7.35-7.45.
3. Maintenance of stable body temperature.
        Baby should be received in a prewarmed radiant warmer or incubator. Environmental temperature should be maintained according to baby’s weight and age.
        Baby’s skin temperature should be maintained 36.5 to 37.5 degree celcious.
         Baby birth weight of less than 1200gm should be cared in the NICU incubator with 60 to 70 % humidity, oxygen and thermonutral environment for better thermal control and prevent heat loss.
        Alternatively the baby should be managed under radiant warmer with protective plastic cover.
        The baby as to be placed naked. If it I possible maintain temperature of the entire room.
        The baby cot should be kept warm. Rubber hot water bottle may be usable for the purpose. The bottle should be filled with hot but not boiled water. Those should be covered with cloths.
        The temperature of the cot should be checked so as to maintain it up to 85’F.
        Kangaroo mother care can be provided when the baby’s condition stabilized. Baby should be clothed with frock, cap, socks, and mittens while giving kangaroo care.
        Bathing should be delayed.
4. Maintenance of nutrition and hydration:
        caloric needs of non-growing LBW babies during first week of life are 60 kcal/ kg/ day on 7th is to be stepped up gradually to 100 on 14th day and about 120-150 on 21st day,  to maintain satisfactory growth.
        Human milk is the first choice of nutrition for all LBW babies. Colostrums, hind milk, foremilk, and preterm milk help faster growth of baby.
        if breast milk is not available cows milk in proportion of 1:1 (milk: water) for 1st month and 2:1 during second month is an alternative substitute. One teaspoon glucose should be added to 50ml of milk prepared for the first 10 days and there after reduced to 1 teaspoon to 100ml milk. 
        Those babies who have good sucking and swallowing reflexes should start breastfeeding as early as possible.
        Expressed breast milk can be given through spoon and bowl at 2 hour’s interval. Katoris-spoon or palady can also be used for feeding the preterm babys.
        Gavages or nasogastric tube feeding can be given with EBM to all babies with poor sucking reflex.
        Intravenous dextrose less than 1200 gm or sick babies.
         Starvation to be avoided and early enteral feeding should be started as soon as the baby is stable.
        Commencement: early feeding between 1-2 hours of birth is now widely recommended, the interval of feeding ranges from hourly in extreme prematurity to 3 hourly feeds in babies born after 36 weeks. The baby when kept in the cot, should be placed on one side with the head raised a little to prevent regurgitation.
Additional suplimentation: supplement of minerals and vitamin after 2 weeks should be started.
1.      Vitamin-A-25000IU
2.      vitamin-D- 600IU
3.      vitamiv-C- 50mg.
4.      Vitamin-B1- 0.5mg.
5.      Folic acid- 65mg.
6.      Calcium and phosphorus supplementation also essential. a liquid preparation of iron 1-2mg/kg/day  should be given in the second or 3ed week.
7.      IV gamma globulin therapy (400mg/kg/dose) may be given to prevent infection in selected cases.
8.      Very LBW babies ( <1500gm, <32 weeks gestation) need vitamin-E.

Fluid requirement for LBW babies.
Days
<1000gm
1000 -1500gm
>1500gm                
1st and 2nd
100-120ml
80-100ml
60-80ml

3ed and 4th
130-140ml
120-130ml
90-100ml

5th and 6th
150-160ml
140-150ml
110-120ml

7th and 8th
170-180ml
10-170ml
130-140ml

9th day on wards
190-200ml
180-190ml
150-160ml

         The first day the fluid requirement ranges from 60 to 100ml/kg ( the difference from each categories being 20ml/kg each)
          The daily increment in all group is around 10 to 15 ml per kg till day 9.
         Need extra requirement in case of phototherapy (20-40ml/kg/day) and radiant warmer (40-80ml/kg/day)
5. gentle and early stimulation, Prevention, early detection and prompt management of complication:
         The baby should be observed for respiration, skin temperature, heart rate and skin color, activity feeding bahaviour, passage of meconium or stool and urine, condition of umbilical cord, eyes and oral cavity and Any abnormal signs like edema, bleeding, vomiting, etc. biochemical and electronic monitoring should be done if needed.
         Weight recording should be done daily in sick babies or at alternative days. Position should be checked at every 2 hours. Baby should be placed in right side after feeding to prevent regurgitation and aspiration.
         Mother should be allowed to take care of baby whenever condition permits.
6. vaccinization of LBW:
         If the LBW baby is not sick, the vaccination schedule is the same as for the normal babies. BCG, OPV, and HBV vaccine should be given at the time of discharge.
7. Transport o sick LBW babies:
         It is essential to provide warmth during transport cold injury.
         The baby should be clothed and placed in a pre warmed basket or box. But a transport incubator is ideal.
         Hot water rubber bottle may be used as heat source. However make sure to cap them tightly and wrap 2 layers of towel to avoid direct contact with the baby.
         Mother of the baby should also be transferred to the hospital along with the baby as for as possible. This will allay her anxiety and ensure breast milk feeding of the baby.
8. Family support discharge, follow- up and home care:
         Baby’s condition and progress to be explained to the parent’s to reduce their anxiety. Treatment plan should be discussed.
         Parents should be informed about the care of baby, after discharge at home. Need for warmth, breast feeding, general cleanliness, infection prevention measures, environmental hygiene, and follow-up plan. Immunization etc. should be explained to the parents.
         Mostly healthy infant with a birth weight of 1800gm or more and gestational maturity of 3weeks or more can be managed at home. Mother should be prepared mentally and trained to provide essential care to the preterm baby at home.
         At the discharge the baby should have daily steady weight gain with good vigor and able to suck and maintain warmth.
         Ultimate survival of the baby depends upon continuity of care. The community health nurse should visit the family every week for a month and provide necessary guidance and support.
PROGNOSIS:
         Prognosis for survival is directly related to the birth weight and quality of neonatal care. Long term complications may be found as neurological handicap in the form of cerebral palsy, seizure, hydrocephalus, microcephaly, blindness, deafness, and mental retardation. Minor neurological disabilities are found as, behaviour problem, language problems, learning disabilities, HDAD.
Nursing diagnosis;
1.      Altered breathing dyspnea related to poor lung maturity secondary to respiratory distress
2.      Altered body temperature hypothermia related to immature thermoregulation centre secondary to less subcutaneous fat.
3.      Altered nutrition less than body requirement related to poor sucking reflex.
4.      Fluid volume deficit hypovolumia related to poor  intake.
5.      Parental fear and anxiety related to NICU procedures and child condition
6.      High risk for complication like hypoglycemia related to poor feeding.
7.      High risk for infection related to poor immunity.
8.      Parental knowledge deficit regarding care of low birth weight babies related to lack of exposure.
1.  Altered breathing pattern dyspnea related to poor lung maturity secondary to respiratory distress.
·         Baby should be positioned with neck slightly extended.
·         Tackling stimulation by sole flaring can be provided to stimulate respiratory effort
·         Do gentle suctioning to remove the secretion,
·         Concentration of oxygen to be maintained to have saO2 between 90 and 95% and paO2 between 60 and 80 mm of Hg.
·         Baby’s respiration rate, rhythm, signs of distress, chest retraction, nasal flaring, apnea, cyanosis, oxygen, saturation, etc. to be monitored at frequent interval.
·         Chest physiotherapy by percussion, vibration and postural drainage may be needed to loosen and remove respiratory secretion.
2. Altered body temperature hypothermia related to immature thermoregulation centre secondary to less subcutaneous fat.
·         Baby should be received in a pre warmed radiant warmer or incubator.
·         Environmental temperature should be maintained according to baby’s weight and age.
·         Alternatively the baby should be managed under radiant warmer with protective plastic cover.
·         The baby as to be placed naked in the warmer
·         The baby cot should be kept warm.
·         Kangaroo mother care can be provided when the baby’s condition stabilized.
·         Baby should be clothed with frock, cap, socks, and mittens while giving kangaroo care.
   3. Altered nutrition less than body requirement related to poor sucking reflex.
         If baby is able to suck encourage breast milk.
         If baby is unable to suck provide expressed breast milk with help of paladai.
         If aspiration is evident then give through NG tube.
         Early enteral feeding should be started as soon as the baby is stable.
         Monitor the weight of the child every day until baby become stable.
         Administer 10% glucose through IV.
 4. Fluid volume deficit hypovolumia related to poor intake.
         Administer IV fluids according to the weight of the baby.
         Monitor I/O chart.
         Check body temperature to note the way of insensible water loss.
         Encourage breast feed and increase the frequency of breast feeding.
         Administer injection vitamin k to prevent blood loss due to hemorrhagic diseases.
         Provide 15 to 20 ml extra fluids when the child under warmer and phototherapy.
   5. High risk for infection related to poor immunity.
         The baby should be observed for respiration, skin temperature, heart rate and skin color, activity, feeding bahaviour, passage of meconium or stool and urine, condition of umbilical cord, eyes and oral cavity
         Any abnormal signs like edema, bleeding, vomiting should be noted,
          Lab values (CRP), biochemical and electronic monitoring should be done.
         One person as to handle the baby.
         Wash hand before touching each sick baby.
         Restrict number of visitors.
         If baby is not too sick vaccine can be given as like healthy baby.










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