Premature Baby

KEMPEGOWDA COLLEGE of Nursing , Bangalore-04

CASE STUDY ON BABY WITH PRE-MATURITY

SUBMITTED TO

SUBMITTED BY

MRS.KAMALA.J

Mrs. PRATHIBHA.N.J

ASSOT. PROFF,

2nd Year M.Sc Nursing

KCN

KCN

Bangalore

Bangalore

1

BASELINE DATA / GENERAL INFORMATION: Name

: B/O Mrs. KAVYA

Age

: 1 day

Sex

: Male

I.P. No.

: 32217/12

Ward

: Neonatal Intensive Care Unit

Address

: NO 141, Chennaswamy layout ,Bandepalya, Hosur road.

Father’s Name

: Mr. Swamy

Mother’s Name

: Mrs. Kavya

Religion

: Hindu

Education

: PUC

Occupation

: Business

Mother’s Occupation

: Home maker

Monthly Family Income

: Rs. 10,000/ month

Date of Admission

: 01 – 04 – 2012

Provisional/ Final Diagnosis

: pre-mature baby with 37 weeks for NICU care

2

CHIEF COMPLAINTS WITH DURATION The child has born at 37 weeks of gestation. Active , cried immediately after birth. Apgar is 6/10,8/10.saturation is 88%. HISTORY OF PRESENT ILLNESS: Baby is pre-term and not maintaining the oxygen saturation. Shifted to NICU for evaluation. HISTORY OF PAST ILLNESS Significant Medical History

: Nil

Significant Surgical History

: No significant history in past.

FAMILY HISTORY a) Type of Family

: Nuclear

b) No of Members in the family

: 03

c) Family Composition : Sl.N o.

Name

Age

Sex

Relation ship with the child

Marital Status

Educati on

Occupatio n

Healt h Status

1.

Mr.

29

M

Father

Married

Graduate

Business

healthy

23

Fe

Mother

Married

PUC

Home maker

Healthy

B/O

1st

M

Self

Kavya

day

Swamy 2.

Mrs. Kavya

4.

healthy

3

------

-----

-----

e) Hereditary illness : no history of any hereditary illness. FAMILY GENOGRAM

59y

30y

57y

60y

29y

29y

54y

23y

-female -male -newborn

SOCIO – ECONOMIC HISTORY: a) Housing

: Semi Pucca

b) Rooms

: No. of Living Rooms – Adequate

c) Occupancy

: Monthly rent

d) Ventilation

: Adequate

e) Light

: Electricity

f) Water Supply

: Tap

g) Relationship among the family members : good

4

PERSONAL HISTORY a) Birth History i). Antenatal History a) Normal

:Yes

b) Nutrition of the Mother

: Nourished

c) Regular Antenatal Check up

: Yes

d) Consumption of FST/Folic Acid

: Yes

e) Deviation from normal

:No

(f) Any exposure to teratogens 

Drugs

:No



Infection

: No



Radiations

: No

Any Complications

: No

Natal History Mode of Delivery

: normal delivery with right medio lateral episiotomy at 37 weeks gestation

Cry

: Immediate

Apgar Score

: 6/10, 8/10

Place of Delivery

: MSRMH, Bangalore 5

Weight of the body (Preterm)

: 2.2 Kg

Condition of Neonate

: pre- mature needs oxygen

Any congenital deformity

: No.

Condition of Neonate Meconium passed within 24 hrs

: Yes

Passed urine

: yes

Any infection

: No

Any congenital deformity

: No

Feeding Initiation of breast feeding

: Breast feeding is not Initiated due to illness

Sucking

: poor

IMMUNIZATION HISTORY :

Age of the child

Name of the vaccine

Dose

Route

Immunization status

Birth (1-7 days)

BCG

0.1 ml

ID

Baby is not Immunized due to low body weight and poor musculature growth

OPV (O- dose) Hep .B – I dose

Oral 2 drops IM 0.5 ml

6

DIETARY HISTORY a) Breast Feeding

: Nil

b) Other Modes of Feeding

: Nil

c) Present Diet

: Nil

SLEEPING i) Sleeps in

: Incubator

ii) Duration

: Interrupted

iii) Problems related to sleep

: Nil

ELIMINATION i) No. of Urine Frequency

: diaper

ii) No. of bowel movements

: Irregular

PHYSICAL ASSESSMENT: Vital signs :

SL

VITAL SIGNS

NO.

FOUND IN

NORMAL

CHILD

VALUE

REMARKS

1

Temperature

98.20 F

98.6 F

Baby has no fever

2

Pulse

168 beats/min.

80-140 beats/min

Baby has Tachycardia 7

3

Respiration

52 breaths/min

30 – 40

Baby has

breaths/min

tachypnea.

ANTHROPOMETRIC MEASUREMENT : SL NO PARAMETERS

FOUND IN CHILD

NORMAL VALUE

REMARKS

1

Weight

2.2 kg

2.9 3 kg

Baby has low body weight

2

Length

40 cm

50 cm

Baby has reduced length

3

Head circumference

30 cm

33 - 35 cm

Less

4

Chest circumference

30 cm

31 – 33 cm

Less

5

Mid arm circumference

8 cm

12- 17.5 cm

Baby has Low mid arm circumference.

PHYSICAL EXAMINATION GENERAL ASSESSMENT Appearance

: ill

Body Built

: Thin

Sensorium

: Restless

Emotional State

: Restless, Crying 8

Posture

: Supine, flexed position

Foul Body odour

: No

Foul Breath

: No

Skin Condition Skin Colour

: Pink

Temperature

: Warm

Texture

: smooth

Turgor and elasticity

: Normal

Edema/ Puffiness

: No

Hair Colour

: Dark Brown

Distribution

: Equally distributed

NAILS Hygiene

: Clean

Condition

: Smooth

Angle of nail beds

: Curved

Nail Bed Colour

: Pink

HEAD AND FACE Shape

: Normal 9

Facial Appearance

: Normal

Cyanosis

: Yes

Tenderness

: No

EYES Eye Brows

: Equally distributed

Eye lashes

: Present

Eye lids

: Normal

Shape and appearance of eyes - Normal Sclera

: White

Conjunctive

: Pale

Cornea

: Clear

Pupils

: Reacting to light normally

Visual Aids

: None

Vision

: Not able identify.

EARS Position

: Normal

Shape and Size

: Symmetrical

Pinna

:soft

Tympanic membrane

: Normal

Hearing

: Not distinguished 10

Hearing Aid

: Absent

NOSE External Nose Size

: normal in size

Shape

: Normal

Internal nasal mucosa

: Normal

Grunting

:present

MOUTH Lips Colour

: Pale

Shape

: Thin

Condition

: Dry

Gums

: Pink

Tongue

: Red

Oropharynx

: Colour Red

Lesions

:Absent

Tonsils

: Normal

Uvula

: Normal

Glands

: Normal

Submandibular

: Normal

Sublingual

: Normal 11

NECK Range of motion

: Full

Thyroid

:No enlargement

Lymph node

:No enlargement

THROX AND LUNGS Respiratory rate

:

Increased i.e. 52 breaths/min

Rhythm

:

varies

Shape

:

Normal

Chest Wall movement

:

ASymmetrical ,has retraction

Lung auscultation

:

Asymmetrical air movement.

Breast and Axilla Lymph node

: Normal

Breast

: not developed

Heart rate

: 170 beats/min

Heart

Heart Sound

: Normal

ABDOMEN i) Inspection Scar

:No

Lesions

:presence umbilical cord lesion

Size

:Normal 12

Umbilicus

: Normal, looks dry, black in colour.

Abdominal circumference

: 20 cm

ii) Palpation Liver

:Normal

Spleen

:Normal

Tenderness

: No

iii) Percussion Ascities

:

iv) Auscultation

No

:

Peristaltic movement: increased GENITALIA i) Scrotum

:testis undesended,

ii)rugae

: underdeveloped

iii)colour

: light

BACK

: Vertebral column

: Straight

Joints

: Normal

EXTREMITIES Upper extremities

: Symmetrical

Range of motion

:less, flaccid movement of extremities.

Syndactyl

: No 13

Polydactyl

:No

Webbing of fingers

: No

Clubbing of fingers

:No

ii) Lower extremities :

Symmetrical

Range of motion

:

dull movement of lower extremities.

Barlow’s Sign

:

Absent

Ortolani’s Sign

:

Absent

Plantar creases

:

very less

REFLEXES: BOOK PICTURE

PATIENT PICTURE

14

REFLEXES: Reflexes are involuntary movements or actions that help to identify normal brain and nerve activity. Some reflexes occur only in specific periods of development. The following are some of the reflexes seen in newborns. ROOTING REFLEX: Rooting reflex is poorly Present at birth Disappears by about 4 months after birth

elicited in this baby , may be due to prematurity.

Begins when the corner of the baby's mouth is stroked or touched. The baby turns the head and opens the mouth to follow and "root" in the direction of the stroking. This helps the baby to find the breast or bottle to begin feeding. If this reflex doesn't vanish in 3-4 months, the CNS may be malfunctioning. SUCKING REFLEX Begins about the 32nd week of pregnancy Is not fully developed until about 36 weeks

Sucking reflex is poor in this baby due to

Disappears by about 4 months after birth

pematurity

Premature babies may have weak or immature sucking ability. A finger or nipple placed in baby's mouth will elicit rhythmical sucking.

15

Depressed sucking may be due to medication given during childbirth MORO REFLEX: Present at birth Disappears by about 4-5 months after birth Moro reflex is good Often called a startle reflex because it usually occurs when the baby is startled by a loud sound or movement In response to the sound, the baby throws back the head, extends the arms and legs, cries, and then pulls the arms and legs back in. or Baby is held horizontally, then swiftly lowered a few inches, or the head may be lowered a few inches, or a loud sudden noise will make baby's arms fling out and then come together as hands open then clutch. Absence or weakness of this reflex may suggest a severely disturbed CNS. TONIC NECK REFLEX: Appears about 2 months after birth Disappears by about 6-7 months after birth tonic neck reflex can’t be When the baby's head is turned to one side, the arm on that side

elicit in newborn babies.

stretches out and the opposite arm bends up at the elbow Often called the fencing position PALMAR GRASP REFLEX:

16

Present at birth Disappears by about 2-3 months Stroking the palm of a baby's hand causes the baby to close the fingers

Palmar grasp can be elicited and it is very

in a grasp

strong in this baby. Reflex is stronger in premature babies OR

Baby grasps examiners

By pressing just one of baby's palms, fingers should grasp the object. Absence or weakness of this reflex could reflect an injured spinal cord

fingers when pressure applies on baby’s hand with finger.

or depressed CNS. STEPPING, PLACING OR DANCING REFLEX: Present at birth Disappears by 2 months after birth When dorsum of foot is placed under a table edge, the infant will step, lifting and placing the foot onto the table surface.

Stepping is not well developed due to acute

OR

illness.

Holding baby upright with feet touching a solid surface and moving him forward should elicit stepping movements. After 3-4 months, this reflex should vanish. If it reappears, there may be an injury of the upper spinal chord. BABINSKI REFLEX:

Babinski reflex is good.

Baby's foot is stroked from heel toward the toes. The big toe should lift

Baby's foot is stroked from heel toward the toes 17

up, while the others fan out. Absence of reflex may suggest immaturity of the CNS, defective spinal cord, or other problems. Reflex may be seen up to age one, and then reaction will be reversed with the toes curling downward

with the help of knee hammer edge, the bif toe of the baby is lift up and other fingers are fan shaped.

DOLL’S EYE REFLEX: While manually turning baby's head, his eyes will stay fixed, instead of moving with the head. While normally vanishing around one month of age, if it reappears

Doll’s eye reflex is not well developed.

later, there may be damage to the CNS. GALANT REFLEX: While stroking baby's back to one side, her spine and trunk will arch toward that side.

Gallant reflex is achieved when a stroking baby's back to one side ( left) with finger, baby’s spine and trunk arch toward

Absence may indicate spinal injury or depression of the CNS.

left side.

PEREZ REFLEX: Firmly stroking baby's spine from tail to head, will make her cry out and head will rise.

Perez reflex is performed due to baby is acutely ill.

If this reflex does not vanish in 4-6 months, baby's CNS may be severely depressed PLANTER’S GRASP: Pressing thumbs against the balls of baby's feet will make his toes flex.

Plantar reflex is good.

Absence of this reflex may indicate damage to the spinal chord 18

This withdrawal reflex is

WITHDRAWAL REFLEX: A pinprick to the sole of baby's foot will make baby's knee and foot flex.

achieved when baby’s sole pricked with needle for blood glucose

Absence of this reflex could indicate a damaged sciatic nerve.

monitoring, baby’s knee and foot flex.

INVESTIGATION Sl. No. 1

Investigation

Patient Value

Normal Value

Remarks

Blood: Hb%

9.2 gm%

13-18 gm%

CRP

25.8 mg/dl

< 5 mg/ dl

Baby looks anaemic, cyanosed and has systemic infection

19

Electrolytes

Hyponatrmia

Na

128 meq/ltr

135 – 145 meq/ lr

Hypokalemia

K

3.5 meq/ ltr

3.9 – 5.1 meq / lr

normal

Cl

99 meq / ltr

98 – 106 meq / lr

PH

7.2

7.35 – 7.45

PCO2

33.7

< 45

PO2

55

60 – 80

HCO3

23.2

25.2 – 25.6

3

Blood group

O + Ve

4.

Chest X- Ray

5

ECHO Cardiogram

6

Abdominal ultrasound.

2

ABG analysis Baby has respiratory acidosis

-

-

CORELATION BETWEEN BOOK PICTURE AND PATIENT PICTURE: SL NO.

BOOK PICTURE

PATIENT PICTURE

1 CAUSES: 

Exact cause is unknown



The Exact cause is unknown



Mother got contraction and she was admitted

20

RISK FACTORS: -

Previous

history

of

pre-term

No risk factors are noted

delivery

2

-

Illness of the mother

-

Multiple pregnancy

-

Poly hydramnios

-

Family history

-

Placental insufficiency

CLINICAL PICTURES

Small size

Small size

Thin, shiny, pink skin

Large head relative to rest of the body Little fat under the skin Thin, shiny, pink skin Veins visible beneath the skin Few creases on soles of feet Scant hair Soft ears, with little cartilage Underdeveloped breast tissue

Veins visible beneath the skin Few creases on soles of feet Scant hair Soft ears, with little cartilage Underdeveloped breast tissue Boys: Small scrotum with few folds. Testes may be undescended in verypremature newborns Weak, poorly coordinated swallowing reflexes

sucking

and

Boys: Small scrotum with few folds. Reduced physical activity and muscle tone (a Testes may be undescended in premature newborn tends not to draw up the verypremature newborns arms and legs when at rest as does a full-term Rapid breathing with brief pauses newborn) (periodic breathing), apnea spells Sleeping for most of the time (pauses lasting longer than 20 seconds), or both Weak, poorly coordinated sucking and swallowing reflexes Reduced physical activity and muscle tone (a premature newborn tends not to draw up the arms and legs when at rest 21

as does a full-term newborn) Sleeping for most of the time Infants will be given warm, moist oxygen. This Management

is critically important, but needs to be given carefully to reduce the side effects associated

a. NICU care

with too much oxygen.

b. Adequate oxygenation 

Maintained ideal body temperature by Placing the baby in radiant warmer and maintaining baby temperature between 36.5 – 37.5 C.



Baby is handled Gently and minimal disturbance to baby.



Administered fluids and electrolytes intravenously



First 24 hours: 10 % glucose & water and subsequently add electrolytes



Monitored tissue oxygen saturation continuously by using pulse oxymeter.



Monitored of ABG analysis.



Administred antibiotics and other drugs as per order

c. Supportive care. 

Maintained aseptic precautions to prevent infections.

 -

Nutrition :

Prepared lactose Feed is given through NGtube and Palada

-

Surfactant therapy is not yet planned for this 22

patient.

23

THEORY APPLICATION : Ida Jean Orlando conceived her theory from her search for information about the practice of nursing and formulated the Orlando’s theory of Deliberative Nursing Process;

Nurse action

Baby’s behaviour 



Non verbal response like baby having distress

Perception of need of the baby and prioritise the need

Nurse activity Provided warmer care , oxygen administration, recorded vital signs

This theory is based on the individual’s action. The components of Orlando’s Nursing Process Theory are ; 

Patient behaviour



Nurse reaction



Nurse activity

CONCEPTS OF THEORY 1. Patient behaviour 

The baby becomes restless and has retraction



Saturation is less

2. Nurse action 24

The nurse with her experiences tries to identify the reason and checks the vital signs 3. Nurse reaction 

After interpreting the behaviour of the baby the nurse administers the oxygen to the baby



Provides the warmer



Starts the iv line



Administer antibiotics according to doctors orders.

APPLICATION OF NURSING THEORY IN NURSING PROCESS Assessment:  Assess the causes for RDS by collecting complete histoty of maternal and birth history. -

Estimated gestational age

-

Maternal contributing factors such as multiple pregnancy, diabetes, nutritional status etc.

-

Antenatal complications.

NURSING DIAGNOSIS: 1. Impaired breathing pattern related to Atelactasis secondary to surfactant deficiency. 2. Ineffective airway clearance related to fatigue. 3.

Ineffective thermoregulation related immature of thermoregulation centre, less subcutaneous fat.

4. Imbalanced nutritional status less than body requirement related NPO status, inability to take breast milk. Nursing measures: 

Administration of oxygen to reduce restlessness caused by respiratory distress. 25



Maintaining ideal body temperature: Placing the baby in radiant warmer and maintaining baby temperature between 36.5 – 37.5 C.



Gentle handling and minimal disturbance to baby.



Fluid management: Infants with RDS also need careful fluid management. Intravenous fluids are administered to stabilize the blood sugar, blood salts, and blood pressure



-

Maintain acid – base balance:

Administration of fluids and electrolytes intravenously First 24 hours: 10 % glucose & water and subsequently add electrolytes

26

PRETERM BABY INTRODUCTION Full-term pregnancy lasts 37 to 40 weeks. About 12% of newborns are born prematurely (preterm). Many of these newborns are born just a few weeks early and do not experience any problems related to their prematurity DEFINITION  A premature newborn is, by definition, delivered before 37 weeks of development in the uterus. A premature newborn has underdeveloped organs, which may not be ready to function outside of the uterus. CAUSES The reasons for premature birth are frequently unknown. The risk of premature birth is, 

Higher among adolescents and older women



Women of lower socioeconomic status



Women with inadequate prenatal care



Multiple fetuses (twins, triplets, quadruplets).



Poor nutrition



Untreated infections, such as  

urinary tract infections sexually transmitted diseases,



Previous premature birth



Life-threatening disorders,   

 

heart disease severe high blood pressure kidney disease,

Preeclampsia or eclampsia Placental insufficiency

27

SYMPTOMS o Premature newborns usually weigh less than 5½ pounds (2.5 kilograms) o Some weigh as little as 1 pound (½ kilogram). o Symptoms often depend on immaturity of various organs. For example, some organs, such as the lungs or brain, may not be fully developed. o Premature newborns may also have difficulty regulating their body temperature and the level of sugar in the blood. o The immune system is also underdeveloped. o Physical Features of a Premature Newborn are, 

Small size

o Large head relative to rest of the body o Little fat under the skin o Thin, shiny, pink skin o Veins visible beneath the skin o Few creases on soles of feet o Scant hair o Soft ears, with little cartilage o Underdeveloped breast tissue o Boys: Small scrotum with few folds. Testes may be undescended in verypremature newborns o Girls: Labia majora not yet covering labia minora o Rapid breathing with brief pauses (periodic breathing), apnea spells (pauses lasting longer than 20 seconds), or both o Weak, poorly coordinated sucking and swallowing reflexes o Reduced physical activity and muscle tone (a premature newborn tends not to draw up the arms and legs when at rest as does a full-term newborn) o Sleeping for most of the time

28

COMPLICATIONS Risk of complications increases with increasing prematurity and depends in part on the presence of certain causes of prematurity, such as infection, diabetes, high blood pressure, or preeclampsia in the mother. UNDERDEVELOPED BRAIN: These problems include 

Inconsistent breathing: The part of the brain that controls regular breathing may be so immature that newborns breathe inconsistently, with short pauses in breathing or periods during which breathing stops completely for 20 seconds or longer



Difficulty coordinating feeding and breathing: The parts of the brain that control reflexes involving the mouth and throat are immature, so premature newborns may not be able to suck and swallow normally, resulting in difficulty coordinating feeding with breathing.



Bleeding (hemorrhage) in the brain: Newborns born very prematurely are at increased risk of bleeding in the brain. Bleeding typically begins in an area of the brain called the germinal matrix and may extend into fluid-filled spaces within the brain called the ventricles. Newborns with very large hemorrhages are at higher risk of having developmental delay, cerebral palsy, or learning disorders, and a few may not survive. 29

UNDERDEVELOPED DIGESTIVE TRACT AND LIVER: An underdeveloped digestive tract and liver can cause several problems, including 

Frequent episodes of spitting-up: Initially, premature newborns may have difficulty with feedings. Not only do they have immature sucking and swallowing reflexes, but also their small stomach empties slowly, which can lead to frequent episodes of spitting up (reflux).



Intestinal damage: Very premature newborns may develop a serious complication in which part of the intestine becomes severely damaged called necrotizing enterocolitis



Jaundice: In premature newborns, the liver is slow in clearing bilirubin (the yellow bile pigment that results from the normal breakdown of red blood cells) from the blood. Rarely, very high levels of bilirubin accumulate and put newborns at risk of developing kernicterus. Kernicterus is a form of brain damage caused by deposits of bilirubin in the brain.

UNDERDEVELOPED IMMUNE SYSTEM: Infants born very prematurely have low levels of antibodies, substances in the bloodstream that help protect against infection. Antibodies cross the placenta. Therefore, the risk of developing infections, especially infection in the blood (sepsis), is higher in premature newborns. UNDERDEVELOPED KIDNEYS: Before delivery, waste products produced in the fetus are removed by the placenta and then excreted by the mother's kidneys. After delivery, the newborn's kidneys must take over these functions. Kidney function is diminished in very premature newborns but improves as the kidneys mature. Newborns with underdeveloped kidneys may have difficulty regulating the amount of salt and water in the body. UNDERDEVELOPED LUNGS: The lungs of premature newborns may not have had enough time to fully develop before birth. Such newborns are likely to have respiratory distress syndrome, causing visibly labored breathing, flaring of the nostrils while breathing in, a grunting sound while breathing out, and a bluish discoloration to the skin (cyanosis) if oxygen levels in the blood are low

30

DIFFICULTY REGULATING BLOOD SUGAR LEVELS: Because premature newborns have difficulty feeding and maintaining normal blood sugar (glucose) levels, Without regular feedings, newborns may develop low blood sugar levels (hypoglycemia). Others become listless with poor muscle tone, feed poorly, or become jittery. Rarely, seizures develop. Premature newborns are also prone to developing high blood sugar levels (hyperglycemia) if they receive too much sugar intravenously, but hyperglycemia rarely causes symptoms. DIFFICULTY REGULATING BODY TEMPERATURE: Because premature newborns have a large skin surface area relative to their weight compared to full-term newborns, they tend to lose heat rapidly and have difficulty maintaining normal body temperature, If they are exposed to a cool environment, premature newborns will generate extra body heat, markedly increasing their rate of metabolism and making it difficult for them to gain weight.

PROGNOSIS Over recent decades, the survival of premature newborns has improved dramatically. For most premature newborns, the long-term prognosis is very good, and they develop normally. However, risk of death and long-term problems begins to increase in infants born before 26 weeks of pregnancy and particularly in those born before 24 weeks. Risks include delayed development, cerebral palsy, and vision impairment.

PREVENTION The best way for premature birth to be prevented is, Ante-natal 

The expectant mother should take good care of her own health.



Eat a nutritious diet



Avoid alcohol, tobacco, and drugs



Treat a medical condition. Ideally 31



Early and regular prenatal care



Any complications of pregnancy should be recognized early and treated.

Intra-natal 

Obstetricians may give drugs to the pregnant woman to slow or stop contractions for a short time.



During

that

interval,

corticosteroids,

such

as

betamethasone

, may be given to the mother to speed the development of the fetus's lungs to reduce the risk of the newborn developing respiratory distress syndrome and also to reduce the risk of brain hemorrhage. TREATMENT Treatment involves managing the complications of prematurity, such as respiratory distress syndrome and high bilirubin levels (hyperbilirubinemia). Very premature newborns are given nutrition into their veins until they can tolerate feedings into their stomach through a feeding tube and eventually feedings by mouth. The mother's breast milk is the best food for premature infants. Use of breast milk decreases the risk of developing necrotizing enterocolitis. Premature newborns may need to be hospitalized for days, weeks, or months.

CARE OF THE PRE-TERM NEONATE 

Immediate care following the birth 

The cord to be clamped quickly



The cord length is kept long



The air passage should be cleaned



Adequate oxygen through the hood



Baby should be wrapped the whole body including the head

32







Intensive care protocol 

Maintain the body temperature –place in the incubator



Respiratory support- clear the air passage and oxygen administration



Infection-prevent infection by following aseptic techniques, do not take the baby out from the incubator on and off, minimum handling



Nutrition-can start 2 hous after birth, breast milk by NG feed, palida feed, then to direct breast feeding

Favorable signs of progress 

Colour becomes pink



Smoth breathing



Progressive weight gain

Time to discharge 

If the baby gains weight, sucking to breast sucessfully 33



Advice on discharge 

Monitoring by the health worker



Follow up schedule



Immunization



Prescribe the multivitamin drops



Kangaroo mother care

CONCLUSSION .

However, the more prematurely newborns are born, the more they are prone to serious

and even life-threatening complications. Extreme prematurity is the single most common cause of death in newborns. Also, newborns born very prematurely are at high risk of long-term problems, especially delayed development and learning disorders. Nonetheless, most infants who are born prematurely grow up with no long-term difficulties. The risk of premature birth is decreased with early prenatal care.

HEALTH EDUCATION: 1. Disease condition: Educated child mother about disease condition, its causes, available treatment, prognosis. 2. Exclusive breast feeding; Explained in detail about importance of exclusive breast feeding 3. Immunization: explained the importance of immunization in their level of understanding to parents. 4. Prevention of infection: Educated mother about importance of hygienic practices in preventing infection to child 5.

Follow up care.

34

RESEARCH ARTICLE A cohort study conducted to study the Low plasma folate concentrations in pregnancy are associated with preterm birth. 34,480 low-risk singleton pregnancies enrolled in a study of aneuploidy risk, preconceptional folate supplementation was prospectively recorded in the first trimester

of

pregnancy.

Comparing

to

no

supplementation,

preconceptional

folate

supplementation for 1 y or longer was associated with a 70% decrease in the risk of spontaneous preterm delivery between 20 and 28 wk versus 4 spontaneous preterm births, respectively; HR 0.22, 95% confidence interval and a 50% decrease in the risk of spontaneous preterm delivery between 28 and 32 wk versus 12 preterm birth, respectively. However, the risk of spontaneous preterm birth decreased with the duration of preconceptional folate supplementation and was the lowest in women who used folate supplementation for 1 y or longer. The study concluded that Preconceptional folate supplementation is associated with a 50%–70% reduction in the incidence of early spontaneous preterm birth. The risk of early spontaneous preterm birth is inversely proportional to the duration of preconceptional folate supplementation. Preconceptional folate supplementation was specifically related to early spontaneous preterm birth and not associated with other complications of pregnancy.

CONCLUSION: B/O Kavya was admitted to MSRMH (NICU) immediately after birth, due pre maturity. Baby is under observation and treated with all medical measures and nursing care provided, which promote baby to recover from illness and presently baby is taking feed normally with palada and breathing pattern is normal.

35

BIBLIOGRAPHY :

1. Ghai OP, Vinod KP, Arvind B. Ghai Essential Peadrics.7th edn. CBS Publishers. New Delhi:2009:Pg:295. 2. Wong DL,Whaley &wong.nursing care of infants and children.6th edn.Mosby.1999.Pg. 841. 3. Dutta DC. Text book of Obsterics. 6th ed. New central book agency: Kolkata;2004.p.458-62 4. CIMS (Current Index of medical specialities). Apr- Jul 2009. India. 5. Ruth VB, Linda KB. Myles text book for midwives. 12th ed. Churchill livingstone; New york :1999.p.432-35. 6. CIMS 7. Annamma J. A comprehensive textbook of midwifery. 2nd ed.Jaypee brothers; new delhi: 2009.p.473-77. 8. Radek B, Fergal D. Malone,Flint T. Porter,David A. Nyberg, Preconceptional Folate Supplementation and the Risk of Spontaneous Preterm Birth: A Cohort Study. http://www.nlm.nih.gobv/medlineplus/ency/article/001563.htm

36

ASSESS MENT

NURSIN G DIAGN OSIS

OBJEC TIVES

On observatio n child is having dyspnea, substernal retraction on breathing and saturation is not is not maintainin g and presence hurried breathing.

Impaired breathing pattern related to atelactasi s secondar y to surfactant deficienc y.

The child will be breath normally and saturation will maintain at normal level.

NURSING INTERVENTIONS



        

Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnoea, use of accessory muscles. Auscultate lungs for presence of decreased or absent breath sounds. Administer humidified oxygen as per order. Assess changes in vital signs and temperature Do suctioning if necessary Monitor arterial blood gases (ABGs). Maintain normal body temperature of baby. Change position of baby 2 hourly. Provide comfort to the baby Give chest physiotherapy if required

IMPLEMENTATION



  

 

 

Assessed respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnoea, use of accessory muscles. Auscultated lungs for presence of decreased or absent breath sounds. . Administered humidified oxygen at 4 litre /hr Assessed changes in vital signs continuously with the help of pulse oxymeter Monitored arterial blood gases (ABGs) as per order. Maintained normal body temperature of baby by placing the baby under radiant warmer and maintaining temperature between 36.5- 37.5 C Position of baby changed 2 hourly. Provided comfort to the baby by meeting the basic needs such as feeding, hygienic needs and love and affection.

EVALUATI ON

Baby is maintaining normal saturation And free dyspnoea.

37

On



Assess infant’s body temperature.



Assessed infant’s body temperature.



Place the child under radiant warmer



Placed the child under radiant warmer maintain

observatio

Ineffectiv Child will be e

n

thermore

able to

and maintain temperature between

and maintain temperature between

normal body

Looks

gulation

maintain

36.5 – 37.5 C

36.5 – 37.5 C

temperature

hypotherm

related

normal

Mummified the baby with a warm

under radiant

ic,

immature

body

blanket to reduce heat loss.

warmer.

extremitie

of

temperat

s are cool.

thermore

ure.

gulation



subcutan eous fat.



loss. 

Avoid touching baby with cold hands



to avoid hypothermia to baby. 

centre, less

Mummify the baby to reduce heat



Monitor the temperature of the

Avoided touching baby with cold hands to avoid hypothermia to baby.



Monitored the temperature of the

warmer and adjust if needed

warmer and adjust temperature to

Warm both hands before touching the

36.7 C

baby to avoid hypothermia to baby.

Baby



Hands are warmed and disinfected with germiclean before touching the baby.

38

-

-

On

Imbalanc

The child

observatio

ed

will be

n child looks

nutritiona able maintain l status

fatigue,

less than

normal

nutrients as per order.

restless

body

nutritiona -

Provide comfort to the baby by

And low

requirem

l status

meeting the daily needs.

body

ent

weight is

related

lactose feed to baby through NG tube

Give expressed breast milk or prepared palada feedscomfort lactose feed to baby through NG tube

2.2 kg.

NPO

or with the help of palada.

or with the help of palada.

status,

Assess the nutritional status of the child by nutritional assessment.

Assess the nutritional status of the

Baby

child by nutritional assessment.

increased

-

Monitor child weight daily

-

Monitor child weight daily

weight from

-

Administer fluids, electrolytes and

-

Administer fluids, electrolytes and

2.2 kg to 2.8

nutrients as per order.

kg.

-

-

Give expressed breast milk or prepared

-

Provide comfort to the baby by meeting the daily needs.

-

Baby taking

ably.

Encourage mother to give exclusive -

inability

breast feeding every 2 hourly or on

Encourage mother to give exclusive

to take

demand of the baby.

breast feeding every 2 hourly or on demand of the baby.

breast

-

Monitor intake output chart.

milk.

-

Encourage diversional therapies while

-

Monitor intake output chart.

providing food to the child.

-

Encourage diversional therapies while providing food to the child.

39

Assess parent’s level of anxiety and

Anxiety

express

to parents will be

determine how parents copes with

her feeling

related to

able to

anxiety.

that she is

child

cope up

having

health

with

anxiety. Acknowledgment of the

fear about

condition

present

patient’s feelings validates the feelings

condition

and communicates acceptance of those

her child

Mother



Mother



Acknowledge awareness of patient’s

feelings.

illness. 

Reassure patient that he or she is safe.



Assessed parent’s level of anxiety and determine how parents cope with anxiety.

Mother verbalizes that she is





Stay with patient if this appears

Acknowledged awareness of patient’s anxiety. Acknowledgment of the patient’s feelings validates the feelings and communicates acceptance of those feelings.

free from fear and she is able to cope with

current Explained about child health status, situation. cause for illness and outcome of health status.

necessary. 

Maintain a calm manner while interacting with patient.



Establish a working relationship with the patient through continuity of care.



Use simple language and Encourage parents to talk about anxious feelings.



Avoid false reassurances.

 

Involved parents in child care. Allowed child to see baby every day.

 

Used simple language Encouraged parents to seek assistance from the health care provider when anxious feelings comes

40

On observatio n baby is taken out from the incubator on and off.

Risk for infection related to immature immune system.

Baby will  be free from  infection.  



 





Assess conditions risk for development of infections Monitor vital signs hourly to know the signs of infections (fever) Keep baby environment clean, hygienic. Follow aseptic measures while performing any procedures ( hand washing, wearing gloves) Wash hands thoroughly with antiseptics before and after touching each baby. Use clean and sterile instruments for baby care. Improve baby’s immune system by providing high calorie feeds to the baby.



Do routine blood investigation ( CRP level, ESR, WBC count, blood culture etc.) Clean all tubings, IV canula site with antiseptic solution every day.



  



  



Assessed conditions risk for development of infections Monitored vital signs hourly to know the signs of infections (fever) Kept baby environment hygienically . Aseptic measures used during each nursing procedures

Baby is free from infection as evidenced by normal vital signs.

Hands are washed thoroughly with antiseptics before and after touching each baby. Used clean and sterile instruments for baby care. Administered fluids, electrolytes intravenously. Expressed milk given through palada every 2 hourly. Routine blood investigation done.

All tubings, IV canula site are cleaned with antiseptic solution every day.

41