Nursing Care Plan for Low Birth Weight
Low birth weight (LBW) is a newborn with a weight at birth of less than 2500 g or lower (WHO, 1961).
1. Obstetric complications
- Multiple gestation.
- Incompetence.
- Premature rupture of membranes.
- Pregnancy induced hypertention (PIH).
- Placenta previa.
- There is a history of preterm birth.
2. Medical Complications
- Maternal diabetes.
- Chronic hypertension.
- Disease : associated with pregnancy such as toxemia gravidarum, antepartum haemorrhage, physical and psychological trauma, acute infection, and cardiovascular disorders.
- Maternal age : prematurnitas highest incidence is in the mother's age under 20 years old and multi gravida that birth spacing is too close.
- Socioeconomic circumstances : the situation is very influential on the incidence of prematurity, a high incidence found in lower socioeconomic groups. This is due to unfavorable circumstances and lack of antenatal surveillance.
- The condition of the mother during pregnancy : an increase in weight bdan inadequate and a mother who smoked. (Mitayani, 2009)
Clinical manifestations include:
- Weighing less than 2,500 grams.
- Skin thin, transparent, lanugo much, crown and wide sutures.
- Immature genitalia, fine thin hair woven, elastic earlobe less.
- Tears weak, weak neck muscle tone.
- Moro reflex (+), reflex sucking, swallowing, coughing, not perfect.
- When hungry crying, restlessness, increased activity.
- Nothing seemed baby infection / intracranial hemorrhage.
- Breath is not regular.
- The blood vessels in the belly skin looks much.
- Rudimentary mammary tissue.
Nursing Diagnosis for Low Birth Weight
1. Ineffective breathing pattern
related to:
immaturity of the respiratory center,
limitations of muscle growth or decline in muscle weakness,
metabolic imbalance.
2. 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).
3. Imbalanced Nutrition Less than Body Requirements
related to :
decrease nutrient deposits,
immaturity of enzyme production,
weak abdominal muscles,
weak reflexes.
4. Risk for infection
related to
immunological defense ineffective.
5. Risk for fluid volume deficit
related to
age and weight extremes, excessive fluid loss (thin skin),
less fat layer,
immature kidney / failure to concentrate urine.
6. Risk for injury due to the variation of cerebral blood flow, systemic hypertension or hypotension, and reduced cellular nutrients (glucose and oxygen)
related to :
central nervous system and physiological stress responses immature.
7. Pain
related to :
procedures, diagnosis and action.
8. Risk for impaired growth and development
related to :
premature birth,
NICU environment unnatural, parting with parents.
9. Risk for impaired skin integrity
related to :
immobility,
skin moisture.
10. Anxiety : parents
related to :
baby disease conditions.