care of high risk newborn-low birth weight baby and IUGR

1. WelcomeWelcome
By: S.K MOHANA SUNDARIBy: S.K MOHANA SUNDARI
II. YEA M.SC (N)II. YEA M.SC (N)

2. NURSING CARE OF LOW BIRTHNURSING CARE OF LOW BIRTH
WEIGHT BABYWEIGHT BABY

3. INTRODUCTION:INTRODUCTION:
Previously, the birth weight of 2500gm or lessPreviously, the birth weight of 2500gm or less
was taken as index of prematurity with out takingwas taken as index of prematurity with out taking
any consideration of the gestational period orany consideration of the gestational period or
any other factor. But infants born at term or postany other factor. But infants born at term or post
term may weight less than 2500gm andterm may weight less than 2500gm and
occasional a baby of diabetic mother may weightoccasional a baby of diabetic mother may weight
much more than 2500gm even before 37 weeks.much more than 2500gm even before 37 weeks.
Thus, the inclusion of all the babies weighingThus, the inclusion of all the babies weighing
less than 2500gm without due consideration toless than 2500gm without due consideration to
the gestational period seems inappropriate.the gestational period seems inappropriate.

4. DEFINITION:DEFINITION:
low birth weight “low birth weight “ as one whose birth weight isas one whose birth weight is
less than 2500gm irrespective of the gestationalless than 2500gm irrespective of the gestational
age” .age” .
Very low birth infants weight 1500gm or less andVery low birth infants weight 1500gm or less and
extremely-low birth infant weight 1000gm orextremely-low birth infant weight 1000gm or
less.less.

5. INCIDENCE:INCIDENCE:
•In India aboutIn India about 30 to 40 percent30 to 40 percent neonates areneonates are
bornborn LBWLBW. Approximately. Approximately 80% of80% of all neonatalall neonatal
deaths anddeaths and 50% of infant’s death50% of infant’s death are related toare related to
LBW.LBW.
•High incidence of LBW babies in our country isHigh incidence of LBW babies in our country is
due todue to higher number of babies with IUGRhigher number of babies with IUGR
(SMALL FOR DATE)(SMALL FOR DATE) rather than preterm.rather than preterm.
•The baby with a birth weight of less thanThe baby with a birth weight of less than
2000gm is more vulnerable2000gm is more vulnerable and need specialand need special
care.care.
•AboutAbout 10% of all10% of all LBW babies require admissionLBW babies require admission
to the special care nursery.to the special care nursery.

6. TERMINOLOGY:TERMINOLOGY:
Very low birth weight babyVery low birth weight baby :: babies with ababies with a
birth weight of less than 1500mg.birth weight of less than 1500mg.
Extremely low birth eight babiesExtremely low birth eight babies :: babiesbabies
with a birth weigh of less than 1000gm.with a birth weigh of less than 1000gm.

7. TERMINOLOGY continu--TERMINOLOGY continu--
• Small for date’s babies:Small for date’s babies:
• Babies with a birth weight less than 10thBabies with a birth weight less than 10th
percentile for their gestational age.percentile for their gestational age.
• Appropriate for dates (AFD) babiesAppropriate for dates (AFD) babies ::
babies with a birth weight between 10th to 90thbabies with a birth weight between 10th to 90th
percentiles for the period of their gestationalpercentiles for the period of their gestational
age.age.

8. TERMINOLOGY continu--TERMINOLOGY continu--
Large for date babies (LFD):Large for date babies (LFD): babies with ababies with a
birth weight more than 90th percentile for thebirth weight more than 90th percentile for the
period of their gestational age at high risk andperiod of their gestational age at high risk and
should be monitored for hypoglycemia.should be monitored for hypoglycemia.
Preterm baby/ immature baby/ prematurePreterm baby/ immature baby/ premature
baby:baby: baby born with a gestational are of lessbaby born with a gestational are of less
than 37 completed week.than 37 completed week.

9. TERMINOLOGY continu--TERMINOLOGY continu--
• Term baby:Term baby: a baby born with aa baby born with a
gestational age of 37 to 41 weeks is calledgestational age of 37 to 41 weeks is called
as term baby.as term baby.
• Post term babyPost term baby:: a baby born with aa baby born with a
gestational age of 42 weeks or more isgestational age of 42 weeks or more is
called as term baby.called as term baby.

10. Classification of babies on the basisClassification of babies on the basis
weight alone and gestational age withweight alone and gestational age with
birth weight.birth weight.
Gestational ageGestational age Birth weightBirth weight
Pre termPre term
TermTerm
Post termPost term
-Small for date-Small for date
-Appropriate for date-Appropriate for date
-Large for date-Large for date
-small for date-small for date
-Appropriate for date-Appropriate for date
-Large for date-Large for date
-Small for date-Small for date
-Appropriate for date-Appropriate for date

11. TYPES OF LBW:TYPES OF LBW:
A low birth weight baby includes bothA low birth weight baby includes both
1. preterm1. preterm
2. Small for dates (SFD) babies.2. Small for dates (SFD) babies.

12. PRE TERM IUGRPRE TERM IUGR
DefinitionDefinition::
• Baby born with a gestationalBaby born with a gestational
are of less than 37are of less than 37
completed week.completed week.
INCIDENCE OF LBWINCIDENCE OF LBW
BABIESBABIES::
• It constitutes 2/3 of LBW.It constitutes 2/3 of LBW.
• 20 to 25% in the developing20 to 25% in the developing
countries.countries.
• 10% in the developed10% in the developed
countries.countries.
DefinitionDefinition
• Babies with a birth weightBabies with a birth weight
less than 10th percentile forless than 10th percentile for
their gestational age.their gestational age.
INCIDENCE OF SFD:INCIDENCE OF SFD:
• comprises about 1/3 ofcomprises about 1/3 of
LBW.LBW.
• 2 to 8% in developed2 to 8% in developed
countries.countries.
• 5% among term babies.5% among term babies.
• 15% among post term15% among post term
babies.babies.

13. PRE TERM IUGRPRE TERM IUGR
CAUSES FOR PRE TERMCAUSES FOR PRE TERM ::
Spontaneous causes:Spontaneous causes:
• Constitutional:Constitutional: acute emotionalacute emotional
stress, trauma.stress, trauma.
• Low maternal weight gain and poorLow maternal weight gain and poor
socioeconomic condition, Verysocioeconomic condition, Very
young and unmarried mothers, tooyoung and unmarried mothers, too
frequent child birth, history offrequent child birth, history of
previous preterm baby,previous preterm baby,
• Maternal nutrition:Maternal nutrition: anemia,anemia,
maternal malnutritionmaternal malnutrition
• Maternal diseases:Maternal diseases: Ante partumAnte partum
hemorrhage, cervicalhemorrhage, cervical
incompetence, threatenedincompetence, threatened
abortion, bicarnuate uterus,abortion, bicarnuate uterus,
chronic and systemic diseases,chronic and systemic diseases,
and infection,and infection,
CAUSES FOR SFD BABIES:CAUSES FOR SFD BABIES:
• Maternal causes:Maternal causes:
• ConstitutionalConstitutional: small women,: small women,
maternal genetic and radical backmaternal genetic and radical back
groundground
• Maternal nutritionMaternal nutrition: glucose, amino: glucose, amino
acid and oxygen deficiencyacid and oxygen deficiency
• Maternal diseasesMaternal diseases: anemia,: anemia,
hypertension, thromphillia, hearthypertension, thromphillia, heart
disease and chronic renal disease,disease and chronic renal disease,

14. PRE TERM IUGRPRE TERM IUGR
Spontaneous causesSpontaneous causes ::
• ToxinsToxins: cigarette: cigarette
smoking, and drugsmoking, and drug
abuse during pregnancy,abuse during pregnancy,
• Fetal causesFetal causes: multiple: multiple
pregnancypregnancy
• congenital malformation.congenital malformation.
Maternal causes:Maternal causes:
• ToxinsToxins: alcohol,: alcohol,
smoking, cocaine,smoking, cocaine,
heroine, drugs.heroine, drugs.
Fetal causes:Fetal causes:
• Structural anomaliesStructural anomalies
(renal or cardiovascular),(renal or cardiovascular),
chromosomalchromosomal
abnormalities,abnormalities,
• TORCH infection,TORCH infection,
• multiple pregnancymultiple pregnancy

15. PRE TERM IUGRPRE TERM IUGR
Induced causes:Induced causes:
• Maternal diabetes mellitusMaternal diabetes mellitus
and severe heart diseases.and severe heart diseases.
Placental dysfunction withPlacental dysfunction with
unsatisfactory fetal growth.unsatisfactory fetal growth.
• Eclampsia, severe preEclampsia, severe pre
eclampsia, and hypertension.eclampsia, and hypertension.
Fetal hypoxia and fetalFetal hypoxia and fetal
distress,distress,
• severe Rh incompatibility,severe Rh incompatibility,
• improper diagnosis ofimproper diagnosis of
maturity in elective deliveriesmaturity in elective deliveries
Placental causes:Placental causes:
• Chronic placentalChronic placental
insufficiency, placentainsufficiency, placenta
previa, abruption,previa, abruption,
circumvallates, infarction andcircumvallates, infarction and
mosaicism.mosaicism.

16. PRE TERM IUGRPRE TERM IUGR
• CLINICAL FEATURE OFCLINICAL FEATURE OF
PRETERM:PRETERM:
• Length- <44cmLength- <44cm
• weight-2500gm or <2500gm.weight-2500gm or <2500gm.
• Head circumferenceHead circumference
disproportionately exceedsdisproportionately exceeds
than that of the chest.than that of the chest.
• The skin is thin, red andThe skin is thin, red and
shiny, due to lack ofshiny, due to lack of
subcutaneous fat andsubcutaneous fat and
covered by plentiful lanugoscovered by plentiful lanugos
and vernix caseosa.and vernix caseosa.
• Pinnae of the ear are soft.Pinnae of the ear are soft.
• The eyes are kept closed.The eyes are kept closed.
• CLINICAL FEATURESCLINICAL FEATURES
OF SFD:OF SFD:
• Length is unaffected,Length is unaffected,
• wweight is about 600 gmeight is about 600 gm
below at birth.below at birth.
• dry and wrinkled skindry and wrinkled skin
because of lessbecause of less
subcutaneous fat.subcutaneous fat.
• thin meconium stained vernixthin meconium stained vernix
caseosacaseosa

17. PRE TERM IUGRPRE TERM IUGR
CLINICAL FEATURECLINICAL FEATURE
OF PRETERMOF PRETERM::
• Muscle tone is poor.Muscle tone is poor.
• Plantar creases are notPlantar creases are not
visible before 32 weeks.visible before 32 weeks.
• The testis isThe testis is
undescended,undescended,
• The labia minora isThe labia minora is
exposed, and there is aexposed, and there is a
tendency of herniation.tendency of herniation.
• The nail is not grown upThe nail is not grown up
to the finger tips.to the finger tips.
• Reflexes are poor.Reflexes are poor.
CLINICAL FEATURESCLINICAL FEATURES
OF SFD:OF SFD:
• Scapoid abdomen,Scapoid abdomen,
• Plantar crease are wellPlantar crease are well
defined.defined.
• Thin umbilical cord.Thin umbilical cord.
• All these give a babyAll these give a baby
“old man appearance”“old man appearance”
• The baby is alert, activeThe baby is alert, active
• has normal crying.has normal crying.
• Reflexes are normalReflexes are normal

18. NURSING CARE OF LOW BIRTHNURSING CARE OF LOW BIRTH
WEIGHT BABIESWEIGHT BABIES

19. NURSING CARE OF LOW BIRTH WEIGHTNURSING CARE OF LOW BIRTH WEIGHT
BABIES:BABIES:
Nursing care of low birth weight includes:Nursing care of low birth weight includes:
1.1. Care at neonatal intensive care unit,Care at neonatal intensive care unit,
2.2. Maintenance of breathing,Maintenance of breathing,
3.3. Maintenance of stable body temperature,Maintenance of stable body temperature,
4.4. Maintenance of nutrition and hydration,Maintenance of nutrition and hydration,
5.5. Gentle early stimulation,Gentle early stimulation,
6.6. Prevention, early detection and promptPrevention, early detection and prompt
management of complication,management of complication,
7.7. vaccinization of LBWvaccinization of LBW
8.8. Transport of sick LBW baby.Transport of sick LBW baby.
9.9. Family support discharge, follow- up and homeFamily support discharge, follow- up and home
care,care,

20. 1.1. Care at neonatal intensive care unit:Care at neonatal intensive care unit:
1.1. The NICU should be warm, free from excessiveThe NICU should be warm, free from excessive
sound smoothing light.sound smoothing light.
2.2. Protection from infection should be ensured byProtection from infection should be ensured by
aseptic measures and effective hand washing.aseptic measures and effective hand washing.
3.3. Rough handling and painfulRough handling and painful
procedure should be avoided.procedure should be avoided.
4. Baby should be placed4. Baby should be placed
on soft comfortable,on soft comfortable,
““nestled” and cushioned bed.nestled” and cushioned bed.

21. 4. Continuous monitoring of the baby’s clinical4. Continuous monitoring of the baby’s clinical
status are vital aspects of management whichstatus are vital aspects of management which
depends upon the gestational age of thedepends upon the gestational age of the
baby.baby.
5. Baby can be placed in prone5. Baby can be placed in prone
position during care.position during care.

22. 2.2. Maintenance of breathing:Maintenance of breathing:
1.1. Baby should be positioned with neck slightlyBaby should be positioned with neck slightly
extended and air passage to be cleared by gentleextended and air passage to be cleared by gentle
suctioning to remove the secretion, if needed.suctioning to remove the secretion, if needed.
Precaution should be taken to prevent aspirationPrecaution should be taken to prevent aspiration
of secretion and feeds.of secretion and feeds.
2.2. Concentration of oxygen to be maintained toConcentration of oxygen to be maintained to
have saO2 between 90 and 95% and paO2have saO2 between 90 and 95% and paO2
between 60 and 80 mm of Hg.between 60 and 80 mm of Hg.
3.3. Baby’s respiration rate, rhythm, signs of distress,Baby’s respiration rate, rhythm, signs of distress,
chest retraction, nasal flaring, apnea, cyanosis,chest retraction, nasal flaring, apnea, cyanosis,
oxygen, saturation, etc. to be monitored atoxygen, saturation, etc. to be monitored at
frequent interval.frequent interval.

23. 2. Maintenance of breathing conti---2. Maintenance of breathing conti---
4. Tackling stimulation by sole flaring can be4. Tackling stimulation by sole flaring can be
provided to stimulate respiratory effort.provided to stimulate respiratory effort.
5. Chest physiotherapy by percussion, vibration5. Chest physiotherapy by percussion, vibration
and postural drainage may be needed toand postural drainage may be needed to
loosen and remove respiratory secretion.loosen and remove respiratory secretion.
6. Desirable level of arterial blood gas values6. Desirable level of arterial blood gas values
should be I) Pao2 55-65 mm Hg .ii) PaCO2should be I) Pao2 55-65 mm Hg .ii) PaCO2
35-45 mmHg and iii) PH 7.35-7.45.35-45 mmHg and iii) PH 7.35-7.45.

24. 33. Maintenance of stable body temperature. Maintenance of stable body temperature ..
– Baby should be received in a prewarmed radiant warmerBaby should be received in a prewarmed radiant warmer
or incubator. Environmental temperature should beor incubator. Environmental temperature should be
maintained according to baby’s weight and age.maintained according to baby’s weight and age.
– Baby’s skin temperature should be maintained 36.5 toBaby’s skin temperature should be maintained 36.5 to
37.5 degree celcious.37.5 degree celcious.
– Baby birth weight of less than 1200gm should be caredBaby birth weight of less than 1200gm should be cared
in the NICU incubator with 60 to 70 % humidity, oxygenin the NICU incubator with 60 to 70 % humidity, oxygen
and thermonutral environment for better thermal controland thermonutral environment for better thermal control
and prevent heat loss.and prevent heat loss.
– Alternatively the baby should be managed under radiantAlternatively the baby should be managed under radiant
warmer with protective plastic cover.warmer with protective plastic cover.
– The baby as to be placed naked. If it I possible maintainThe baby as to be placed naked. If it I possible maintain
temperature of the entire room.temperature of the entire room.

25. 3.3. Maintenance of stable bodyMaintenance of stable body
temperature contin-temperature contin- --
– The baby cot should be kept warm. Rubber hotThe baby cot should be kept warm. Rubber hot
water bottle may be usable for the purpose. Thewater bottle may be usable for the purpose. The
bottle should be filled with hot but not boiled water.bottle should be filled with hot but not boiled water.
Those should be covered with cloths.Those should be covered with cloths.
– The temperature of the cot should be checked so asThe temperature of the cot should be checked so as
to maintain it up to 85’F.to maintain it up to 85’F.
– Kangaroo mother care can be provided when theKangaroo mother care can be provided when the
baby’s condition stabilized. Baby should be clothedbaby’s condition stabilized. Baby should be clothed
with frock, cap, socks, and mittens while givingwith frock, cap, socks, and mittens while giving
kangaroo care.kangaroo care.
– Bathing should be delayed.Bathing should be delayed.

26. 4.4. Maintenance of nutrition and hydrationMaintenance of nutrition and hydration ::
– caloric needs of non-growing LBW babies during firstcaloric needs of non-growing LBW babies during first
week of life are 60 kcal/ kg/ day on 7th is to be steppedweek of life are 60 kcal/ kg/ day on 7th is to be stepped
up gradually to 100 on 14th day and about 120-150 onup gradually to 100 on 14th day and about 120-150 on
21st day, to maintain satisfactory growth.21st day, to maintain satisfactory growth.
– Human milk is the first choice of nutrition for all LBWHuman milk is the first choice of nutrition for all LBW
babies. Colostrums, hind milk, foremilk, and preterm milkbabies. Colostrums, hind milk, foremilk, and preterm milk
help faster growth of baby.help faster growth of baby.
– if breast milk is not available cows milk in proportion ofif breast milk is not available cows milk in proportion of
1:1 (milk: water) for 1st month and 2:1 during second1:1 (milk: water) for 1st month and 2:1 during second
month is an alternative substitute. One teaspoon glucosemonth is an alternative substitute. One teaspoon glucose
should be added to 50ml of milk prepared for the first 10should be added to 50ml of milk prepared for the first 10
days and there after reduced to 1 teaspoon to 100ml milk.days and there after reduced to 1 teaspoon to 100ml milk.

27. 4. Maintenance of nutrition and hydration4. Maintenance of nutrition and hydration
continu--continu--
–Those babies who have good sucking andThose babies who have good sucking and
swallowing reflexes should start breastfeeding asswallowing reflexes should start breastfeeding as
early as possible.early as possible.
–Expressed breast milk can be given through spoonExpressed breast milk can be given through spoon
and bowl at 2 hour’s interval. Katoris-spoon orand bowl at 2 hour’s interval. Katoris-spoon or
palady can also be used for feeding the pretermpalady can also be used for feeding the preterm
babys.babys.

28. 4. Maintenance of nutrition4. Maintenance of nutrition
and hydration conti-and hydration conti-
– Gavages or nasogastric tube feeding can be givenGavages or nasogastric tube feeding can be given
with EBM to all babies with poor sucking reflex.with EBM to all babies with poor sucking reflex.
– Intravenous dextrose less than 1200 gm or sickIntravenous dextrose less than 1200 gm or sick
babies.babies.
– Starvation to be avoided and early enteral feedingStarvation to be avoided and early enteral feeding
should be started as soon as the baby is stable.should be started as soon as the baby is stable.

29. 4. Maintenance of nutrition4. Maintenance of nutrition
and hydration conti--and hydration conti--
• CommencementCommencement:: early feeding betweenearly feeding between
1-2 hours of birth is now widely1-2 hours of birth is now widely
recommended, the interval of feedingrecommended, the interval of feeding
ranges from hourly in extreme prematurityranges from hourly in extreme prematurity
to 3 hourly feeds in babies born after 36to 3 hourly feeds in babies born after 36
weeks. The baby when kept in the cot,weeks. The baby when kept in the cot,
should be placed on one side with theshould be placed on one side with the
head raised a little to preventhead raised a little to prevent
regurgitation.regurgitation.

30. Maintenance of nutrition and hydrationMaintenance of nutrition and hydration
contin--contin--
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)

31. Fluid requirement for LBW babies.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

32. • The first day the fluid requirement ranges fromThe first day the fluid requirement ranges from
60 to 100ml/kg ( the difference from each60 to 100ml/kg ( the difference from each
categories being 20ml/kg each)categories being 20ml/kg each)
• The daily increment in all group is around 10 toThe daily increment in all group is around 10 to
15 ml per kg till day 9.15 ml per kg till day 9.
•Need extra requirement in case of phototherapyNeed extra requirement in case of phototherapy
(20-40ml/kg/day) and radiant warmer (40-(20-40ml/kg/day) and radiant warmer (40-
80ml/kg/day)80ml/kg/day)

33. 6.6. Prevention, early detection andPrevention, early detection and
prompt management of complicationprompt management of complication ::
• The baby should be observed for respiration,The baby should be observed for respiration,
skin temperature, heart rate and skin color,skin temperature, heart rate and skin color,
activity feeding bahaviour, passage ofactivity feeding bahaviour, passage of
meconium or stool and urine, condition ofmeconium or stool and urine, condition of
umbilical cord, eyes and oral cavity and Anyumbilical cord, eyes and oral cavity and Any
abnormal signs like edema, bleeding,abnormal signs like edema, bleeding,
vomiting, etc. biochemical and electronicvomiting, etc. biochemical and electronic
monitoring should be done if needed.monitoring should be done if needed.

34. 6. Prevention, early detection and prompt6. Prevention, early detection and prompt
management of complication conti--management of complication conti--
• Weight recording should be done daily inWeight recording should be done daily in
sick babies or at alternative days. Positionsick babies or at alternative days. Position
should be checked at every 2 hours. Babyshould be checked at every 2 hours. Baby
should be placed in right side after feeding toshould be placed in right side after feeding to
prevent regurgitation and aspiration.prevent regurgitation and aspiration.
• Mother should be allowed to take care ofMother should be allowed to take care of
baby whenever condition permits.baby whenever condition permits.

35. 7.7. vaccinization of LBW:vaccinization of LBW:
• If the LBW baby is not sick, the vaccinationIf the LBW baby is not sick, the vaccination
schedule is the same as for the normalschedule is the same as for the normal
babies. BCG, OPV, and HBV vaccine shouldbabies. BCG, OPV, and HBV vaccine should
be given at the time of discharge.be given at the time of discharge.

36. 8.8. Transport o sick LBW babies:Transport o sick LBW babies:
• It is essential to provide warmth during transportIt is essential to provide warmth during transport
cold injury.cold injury.
• The baby should be clothed and placed in aThe baby should be clothed and placed in a
prewarmed basket or box. But a transport incubatorprewarmed basket or box. But a transport incubator
is ideal.is ideal.
• Hot water rubber bottle may be used as heatHot water rubber bottle may be used as heat
source. However make sure to cap them tightly andsource. However make sure to cap them tightly and
wrap 2 layers of towel to avoid direct contact withwrap 2 layers of towel to avoid direct contact with
the baby.the baby.
• Mother of the baby should also be transferred to theMother of the baby should also be transferred to the
hospital along with the baby as for as possible. Thishospital along with the baby as for as possible. This
will allay her anxiety and ensure breast milk feedingwill allay her anxiety and ensure breast milk feeding
of the baby.of the baby.

37. 8.8. Transport o sick LBW babiesTransport o sick LBW babies
continu--:continu--:
• Placing the baby next to mother’s body duringPlacing the baby next to mother’s body during
transport will provide the necessary warmth to thetransport will provide the necessary warmth to the
child during the journey.child during the journey.
• The infant should be stabilized as for as possibleThe infant should be stabilized as for as possible
before transporting. A baby or nurse shouldbefore transporting. A baby or nurse should
accompany the baby, if possible.accompany the baby, if possible.
• The referring doctors should send a written noteThe referring doctors should send a written note
covering the antenatal, intranatal, and neonatalcovering the antenatal, intranatal, and neonatal
details along with the baby.details along with the baby.

38. 9.9. Family support discharge, follow- up and homeFamily support discharge, follow- up and home
carecare::
• Baby’s condition and progress to be explained to theBaby’s condition and progress to be explained to the
parent’s to reduce their anxiety. Treatment plan should beparent’s to reduce their anxiety. Treatment plan should be
discussed.discussed.
• Parents should be informed about the care of baby, afterParents should be informed about the care of baby, after
discharge at home. Need for warmth, breast feeding,discharge at home. Need for warmth, breast feeding,
general cleanliness, infection prevention measures,general cleanliness, infection prevention measures,
environmental hygiene, and follow-up plan. Immunizationenvironmental hygiene, and follow-up plan. Immunization
etc. should be explained to the parents.etc. should be explained to the parents.
• Mostly healthy infant with a birth weight of 1800gm or moreMostly healthy infant with a birth weight of 1800gm or more
and gestational maturity of 3weeks or more can be managedand gestational maturity of 3weeks or more can be managed
at home. Mother should be prepared mentally and trained toat home. Mother should be prepared mentally and trained to
provide essential care to the preterm baby at home.provide essential care to the preterm baby at home.
• At the discharge the baby should have daily steady weightAt the discharge the baby should have daily steady weight
gain with good vigor and able to suck and maintain warmth.gain with good vigor and able to suck and maintain warmth.
• Ultimate survival of the baby depends upon continuity ofUltimate survival of the baby depends upon continuity of
care. The community health nurse should visit the familycare. The community health nurse should visit the family
every week for a month and provide necessary guidanceevery week for a month and provide necessary guidance
and support.and support.

39. PROGNOSIS:PROGNOSIS:
Prognosis for survival is directly related to thePrognosis for survival is directly related to the
birth weight and quality of neonatal care. Longbirth weight and quality of neonatal care. Long
term complications may be found asterm complications may be found as
neurological handicap in the form of cerebralneurological handicap in the form of cerebral
palsy, seizure, hydrocephalus, microcephaly,palsy, seizure, hydrocephalus, microcephaly,
blindness, deafness, and mental retardation.blindness, deafness, and mental retardation.
Minor neurological disabilities are found as,Minor neurological disabilities are found as,
behaviour problem, language problems, learningbehaviour problem, language problems, learning
disabilities, HDAD.disabilities, HDAD.

40. Nursing diagnosis;Nursing diagnosis;
1.1. Altered breathing dyspnea related to poor lung maturityAltered breathing dyspnea related to poor lung maturity
secondary to respiratory distresssecondary to respiratory distress
2.2. Altered body temperature hypothermia related to immatureAltered body temperature hypothermia related to immature
thermoregulation centre secondary to less subcutaneous fat.thermoregulation centre secondary to less subcutaneous fat.
3.3. Altered nutrition less than body requirement related to poorAltered nutrition less than body requirement related to poor
sucking reflex.sucking reflex.
4.4. Fluid volume deficit hypovolumia related to poor intake.Fluid volume deficit hypovolumia related to poor intake.
5.5. Parental fear and anxiety related to NICU procedures andParental fear and anxiety related to NICU procedures and
child conditionchild condition
6.6. High risk for complication like hypoglycemia related to poorHigh risk for complication like hypoglycemia related to poor
feeding.feeding.
7.7. High risk for infection related to poor immunity.High risk for infection related to poor immunity.
8.8. Parental knowledge deficit regarding care of low birth weightParental knowledge deficit regarding care of low birth weight
babies related to lack of exposure.babies related to lack of exposure.

41. 1.1. Altered breathing pattern dyspnea relatedAltered breathing pattern dyspnea related
to poor lung maturity secondary toto poor lung maturity secondary to
respiratory distress.respiratory distress.
– Baby should be positioned with neck slightly extended.Baby should be positioned with neck slightly extended.
– Tackling stimulation by sole flaring can be provided toTackling stimulation by sole flaring can be provided to
stimulate respiratory effortstimulate respiratory effort
– Do gentle suctioning to remove the secretion,Do gentle suctioning to remove the secretion,
– Concentration of oxygen to be maintained to have saO2Concentration of oxygen to be maintained to have saO2
between 90 and 95% and paO2 between 60 and 80 mmbetween 90 and 95% and paO2 between 60 and 80 mm
of Hg.of Hg.
– Baby’s respiration rate, rhythm, signs of distress, chestBaby’s respiration rate, rhythm, signs of distress, chest
retraction, nasal flaring, apnea, cyanosis, oxygen,retraction, nasal flaring, apnea, cyanosis, oxygen,
saturation, etc. to be monitored at frequent interval.saturation, etc. to be monitored at frequent interval.
– Chest physiotherapy by percussion, vibration andChest physiotherapy by percussion, vibration and
postural drainage may be needed to loosen and removepostural drainage may be needed to loosen and remove
respiratory secretion.respiratory secretion.

42. 2.2. Altered body temperature hypothermiaAltered body temperature hypothermia
related to immature thermoregulation centrerelated to immature thermoregulation centre
secondary to less subcutaneous fatsecondary to less subcutaneous fat ..
– Baby should be received in a pre warmed radiant warmerBaby should be received in a pre warmed radiant warmer
or incubator.or incubator.
– Environmental temperature should be maintainedEnvironmental temperature should be maintained
according to baby’s weight and age.according to baby’s weight and age.
– Alternatively the baby should be managed under radiantAlternatively the baby should be managed under radiant
warmer with protective plastic cover.warmer with protective plastic cover.
– The baby as to be placed naked in the warmerThe baby as to be placed naked in the warmer
– The baby cot should be kept warm.The baby cot should be kept warm.
– Kangaroo mother care can be provided when the baby’sKangaroo mother care can be provided when the baby’s
condition stabilized.condition stabilized.
– Baby should be clothed with frock, cap, socks, andBaby should be clothed with frock, cap, socks, and
mittens while giving kangaroo care.mittens while giving kangaroo care.

43. 3. Altered nutrition less than body3. Altered nutrition less than body
requirement related to poor suckingrequirement related to poor sucking
reflex.reflex.
• If baby is able to suck encourage breast milk.If baby is able to suck encourage breast milk.
• If baby is unable to suck provide expressed breast milkIf baby is unable to suck provide expressed breast milk
with help of paladai.with help of paladai.
• If aspiration is evident then give through NG tube.If aspiration is evident then give through NG tube.
• Early enteral feeding should be started as soon as theEarly enteral feeding should be started as soon as the
baby is stable.baby is stable.
• Monitor the weight of the child every day until babyMonitor the weight of the child every day until baby
become stable.become stable.
• Administer 10% glucose through IV.Administer 10% glucose through IV.

44. 4. Fluid volume deficit hypovolumia4. Fluid volume deficit hypovolumia
related to poor intake.related to poor intake.
• Administer IV fluids according to the weightAdminister IV fluids according to the weight
of the baby.of the baby.
• Monitor I/O chart.Monitor I/O chart.
• Check body temperature to note the way ofCheck body temperature to note the way of
insensible water loss.insensible water loss.
• Encourage breast feed and increase theEncourage breast feed and increase the
frequency of breast feeding.frequency of breast feeding.
• Administer injection vitamin k to preventAdminister injection vitamin k to prevent
blood loss due to hemorrhagic diseases.blood loss due to hemorrhagic diseases.
• Provide 15 to 20 ml extra fluids when theProvide 15 to 20 ml extra fluids when the
child under warmer and phototherapy.child under warmer and phototherapy.

45. 5. High risk for infection related to poor5. High risk for infection related to poor
immunity.immunity.
• The baby should be observed for respiration, skinThe baby should be observed for respiration, skin
temperature, heart rate and skin color, activity,temperature, heart rate and skin color, activity,
feeding bahaviour, passage of meconium or stoolfeeding bahaviour, passage of meconium or stool
and urine, condition of umbilical cord, eyes and oraland urine, condition of umbilical cord, eyes and oral
cavitycavity
• Any abnormal signs like edema, bleeding, vomitingAny abnormal signs like edema, bleeding, vomiting
should be noted,should be noted,
• Lab values (CRP), biochemical and electronicLab values (CRP), biochemical and electronic
monitoring should be done.monitoring should be done.
• One person as to handle the baby.One person as to handle the baby.
• Wash hand before touching each sick baby.Wash hand before touching each sick baby.
• Restrict number of visitors.Restrict number of visitors.
• If baby is not too sick vaccine can be given as likeIf baby is not too sick vaccine can be given as like
healthy baby.healthy baby.