NURSING CARE REPORT ON CLIENT Mrs.R’s BABY WITH MEDICAL DIAGNOSE LOW BIRTH WEIGHT AT TERATAI

WARD BANJARMASIN ULIN GENERAL HOSPITAL

By:HENGKI HANGGARA

SRN: 011016 D3 KI

BANJARMASIN MUHAMMADIYAH HEALTH COLLEGE

INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM

ACADEMIC YEAR 2014

• According to the World Health Organization (WHO) the baby born weighing less than 2500 grams, which is measured in the first 24 hours of birth. LBW is still a problem because it contributes to prenatal mortality, (76%) died in the first hour of birth and more than two-thirds died in the first week of life. LBW has a 40 times higher risk of neonatal death compared to babies born with normal weight, 5 times at risk of death during the post neonatal and risk trend will persist as delays in cognitive development, developmental problems and a tendency to experience pain in childhood. (Pantiawati, 2010).

• According to the (Riskesdas, 2013) Trends in low birth weight infants (LBW) in infants, in province South Kalimantan is at 5% and was lower than in 2010 (11.1%) the incidence in South Kalimantan is 15%. Data obtained from the General Hospital Ulin Banjarmasin dated 3 April 2013 that the incidence of most diseases in children in the Teratai ward is the LBW 364 cases.

Background

• According to the Proverawati and sulistyorini, (2010), infants of low birth weight (LBW) babies are born weighing less than 2,500 grams is regardless of pregnancy.

• infants of low birth weight (LBW) can be two (2) categories, infants with very low birth weight (BBLSR) with birth weight 1000 to 1500 grams birth weight and extremely low (BBLASR) with a birth weight less than 1,000 grams.

Definition

The causes of LBW is multi factorials, among other things sorely lacking maternal nutrition during pregnancy, impaired growth in the womb ( fetal growth is low), placenta factors, infections, mothers uterine abnormalities, trauma,(nanda 2012).

Etiology

According to (Surasmi and Handayani, 2013)Placenta previa, solucio placenta And premature rupture of membranes could result in placenta insufficiency so as not to transfer nutrient to the fetus and can causes premature birth or low birth weight. Volume maternal malnutrition can lead to decreased blood and lowers blood to the placenta this causing placenta insufficiency and reduced transfer of nutrient to the fetus causing the occurrence of LBW. In response to cold stimulations, the baby’s body will issue a stimulation norepenefrin metabolism of fat reserves to produce a calorie of fat which is then carried by the blood to the tissue.

Pathophysiology

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Low birth weight (LBW) are relatively less able to survive because of the structure of the immature anatomy and physiology and biochemical function has not worked as older infant. The shortage affect the infant’s ability to regulate and maintain body temperature within normal limits, because the temperature control center in the brain is not yet mature, the lack of subcutaneous fat and body surface relatively wide will cause the body to lose heart more. Shivering response in infant less or non-existent, so baby cannot increase body heart through activity. Beside skin reflex control is still lacking.

According to Maryunani ( 2013), low birth weight infant (LBW) highly variable and that is most evident in infant with gestational age shortened. As for the traits of characteristics of Low Birth Weight ( LBW) are:

General Proportions.• Preterm infants have large heads in proportion to body size. Head basic

the circumference equal to or less than 33 cm. lanugos air is still a lot. Body length generally equal to less than 40 cm, chest circumference equal to or less tan 30 cm, weight equal to less tan 2500 grams.

Activity• Weak muscle tone and the lower the gestational age, the less the child’s

activity.

Control Of Temperature• Preterm infant tend to have subnormal. This was caused by poor heat

production and increased heat loss.

Sings and symptom

ContinueRespiratory System• Infant respiratory muscles are week and under develop respiratory center

as well as the lack of production of surfactants to reduce surface tension of the lungs.

The Circulatory System.• Heart is relatively small at birth, in some preterm infant it works slow and

weak, especially in the blood vessels.Digestive System• The lower of gestational age, the more weak sucking and swallowing

reflex, the smallest infants are unable to swallow effectively. Urinary System• Renal function is less efficient because of a declining glomerular

filtration rate that results in a decreased ability to concentrate urine, and the become slightly

Nervous System• Development of the nervous system is largely dependent on the degree of

maturity. In premature infant more reflex and general tonic neck reflex and tendon reflex are generally less well.

Complication

According to Maryunani (2013) complications that can arise in low birth weight (LBW) is as follows:

• Takepnea in newborns.

• Fibroplasias retrolentral.

• Attacks Apnea

• Necrotizing enterocolitis (NEC).

• Hypothermia.

• Hypoglycemia

• Breating distress syndrome.

• Hyperbilirubinemia.

Nursing Care

• Client Identity Mrs.R’s baby with gender male was born on Tuesday 5th May 2014 at 23:01

pm at Ulin General Hospital in Vk ward attended by midwifes. Mrs R’s baby is the second child of the couple Mr.T (30 years old) and Mrs.R’s (28 years old). Mr.T family address in Jl. Kelayan A Rt. 22 Banjarmasin. Education: Mr.T is junior high school and was Mrs.R last education is junior high school. Mr.T occupation is a docker and Mrs.R is a housewife (IRT). Mr.T and Mrs.R are Muslim. Mrs.R gave birth Tuesday May 5th 2014 at 23:01 pm by Sectiocaesaria delivery breech presentation 32 weeks of gestation.

• General state of Mrs.R baby are born immediate with delivery method sectiocaesaria as because she mother had indication syndrome eklamsia in surgey ward Ulin General Hospital with afgar score 4-6-7 Afgar score 0-3 indicates that severe asphyxia, 4-6 indicates moderate aspyhyxia, and 7 showed mild asphyxia, and 8-10 normal / healthy body. Babies born with sex is male, weight 17.50 grams, hight 43cm heart rate 138x / minute, spontaneous respiratory 40x / minute, body temperature is 36.3oC (axillary) CRT is > 2 and no birth trauma in infant. At birth the action performed on Mrs.R’s baby is cry suction of the mouth and nasal, giving gentamcyin eyes drops in both eye, and trough IM injection of vitamin K by nurses after birth the baby immediately brought to teratai ward to get treatment because the baby have indication low birth weigh.

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Focus Data

Subjetive data:• mother said that her baby milk that come out just a little bit.• Mother said that her baby was weak in sucking reflex

Objective data :• Mrs.R’s baby placed in the box with a thick baby clothes, and baby

swaddled in a blanket. Baby being treated in hospital, the baby was placed in an incubator because Mrs.R’s baby some times temperature is down on 36.1oC.

• Cord circumstances seem not out and looked a little blackish.• At birth the baby was sucking mucus through the nasal and mouth.• Mrs.R’s baby gestational age 32 weeks• Baby aged 4 days.• Subcutaneous fat look thin• General state of compos mentis baby with AFGAR SCORE 4-6-7

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• Mrs.R.s baby positive more refex (extension or abduction movements in te extremities when startled), positive grasping reflex (moval time grasping fingers attached to the plam of the baby), rooting reflex

• (For the nipple) negative, sucking reflex (sucking) is still weak / swallowing reflex positive (swallow) but weak the swallowing reflex positive grabella (baby wink at the base nose or between the eyes being touched), startel negative reflex (baby do not look at his ears touched with a fingers).

• Anthropometric measurements in Mrs.R.s baby body weigth is 17,50 grams body length is 43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

• Respiratory rate when assessment 55x/ minute.• Mrs.R’s baby mucosa dry lips• Mrs.R’s baby is only able to sped a PASI 10 cc / 3 hours of the

recommended that 30 cc / 3hours.

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Palpation:• Baby body temperature is 36.1oC.measured use thermometer • At the time palpation pulse 120x / minute. Pecussion: -• Auscutation:• At the time of auscultation of bowel sounds in Mrs.R’s baby is 10x /

minute.

Data analysis

Data Problem Etiology

Thursday, May 8th 2014Subjective data:-Mother said that his baby milk thatcame out just a little bit.-mother said that his baby weak. sucking reflex.Objective data:-Sucking reflexes weak rootingreflex (to the nipple)negative,reflex swallowing(swallow) positive but still weak.

Imbalance nutrition lessthan bodyrequirement.

Weak sucking reflex, inadequate nutrition intake.

-Mrs.R’s baby mucosa lips looked dry.-bowel sounds are 10 x/ minute.-Mrs.R’s baby. Is only able to spend a PASI 10 cc / 3 hours from recomended is 30 cc / hours.-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oC-Anthropometric data:BW: 17,50 gBL : 43cmHC : 31cmCC : 25cmUC : 8cm

Thursday, May 8th 2014Subjective data: -Objective data:-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oCThursday, may 8th 2014-Mrs.R’s baby placed in the with a thick baby clothes, and baby swaddled in a blanket. Baby being treated in hospital, the baby was placed in an incubator because Mrs.R’s baby some times temperature is down on 36.1oC.-subcutaneous fat look thin.-baby body temperature at birth is 36.1oC.-baby aged is 2 days.--Anthropometric data:BW: 17,50 gBL : 43cmHC : 31cmCC : 25cmUC : 8cm

Ineffective thermoregulation

Imaturities

Thursday, May 8th 2014Risk factors:Subjective data :-Objective data :-General circumferences:afgar score 4-6-7.-Cord circumferences: seem not out and looked a little blackkish.-Baby age 2 days.-Mrs.R’s baby gestational age 32 weeks.- Hb. 15.5 g / dl- Leokosit 11.1-Vital signs: P : 110x / minute R : 55x / minute T : 36.1oC

Risk of infection

Priority Nursing Problem

1. Imbalance nutrition les tahn body requirement related to reflex weak sucking, inadequate nutrition intake.

2. Ineffective Thermoregulation related to immaturities subcutaneous fat tissue.

3. Risk of infection

1. Imbalance nutrition les tahn body requirement related to reflex weak sucking, inadequate nutrition intake.

Nursing Intervention

1. Assess the response of infants during feeding (sucking, swallowing

and coughing).

2. Observation addition of BW, about increase in the environmental.

3. Provide ASI / PASI (infant formula) with -+ 30 mil with slowly speed

of 1 mil /minute.

4. Fulfill needs to suck on Mrs.R’s baby using pipette when feeding

time (ASI /PASI).

5. Burp baby as soon as baby is given milk finished.

2. Ineffective Thermoregulation related to immaturities subcutaneous fat tissue.

1. Assess the baby's body temperature every 2 hours

2. Place baby in box warmers / incubators

3. Keep the incubator temperature (36,5oc – 37,5oc).

4. Wrap Mrs.R’s baby with a baby blanket and also cover baby head

5. Change clothes or bed linens when wet.

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3. Risk of Infection

1. Suggest parents of baby to wash hands and used gounds before

contact with baby.

2. Assess for signs of infection such as lack of temperature instability

3. Determine gestational age at Mrs.R’s baby.

4. Wipe baby using water and soap

5. Collaboration give antibiotics intravenously if need.

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3. Risk of Infection

1. Suggest parents of baby to wash hands and used gounds before

contact with baby.

2. Assess for signs of infection such as lack of temperature instability

3. Determine gestational age at Mrs.R’s baby.

4. Wipe baby using water and soap

5. Collaboration give antibiotics intravenously if need.

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Evaluation

Results of evaluation of nursing care Mrs.R’s baby, Diangnose 1 Imbalance nutrition less than body requirements related to a

weak sucking reflex inadequate nutritional intake, has been resolved during the 6th days of treatment.

With result:• Mother .said that his baby milk that come out full • Mrs.R.sbaby body weight is still in 17, 75g. body length is

43cm, head circumference 31cm, chest circumference 25cm and , upper circumference 8 cm.

• Mrs.R.s baby get asi 30.cc from she mother and can spend 30 cc according to recommended is 30 cc 1 / minute.

• Mrs.R.s baby had strong sucking reflex when giving asi via bras milk or pipette . and swallowing reflex is strong

• Ineffective thermoregulation related to immaturity subcutaneous fat tissue still happen after 6th days of treatment.

• risk of infection does not occur, in 6th of treatment

Diagnose 2 Ineffective thermoregulation related to immaturity

subcutaneous fat tissue. has been resolved during the 6th days of treatment.

With result• Mrs.R.s baby body temperature maintained in 36.5oC. after

laiding in incubator and no looked sings of hypothermia• Looked Mrs.R.s baby felt comfort and warm after Wrapping

with baby blanket and also cover baby head.• Clothes and bad Mrs.R.s baby dry and make Mrs.R.s baby felt

warm

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Diagnose 3 Risk of infection does not occur, in 6th of treatment with result:• No looked signs and symptoms of infection on part of body

Mrs.R’s baby and temperature maintained in the range 36. 5oC• Mrs.R’s baby gestational age is 32 weeks 9 days that still high

of risk infection.• Mrs.R’s baby felt comfort and skins Mrs.R’s baby looked

clean after get wiping from nurse,

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