Assessment - Nursing Care Plan for Low Birth Weight (LBW)
Nursing Care Plan for Low Birth Weight (LBW)
Assessment
Subjective Data
Subjective data is the client's perception and sensation of health problems. Subjective data consists of:
1. Biography or the identity of the patient: includes name, date of birth, gender.
2. Parents include: name (father and mother, age, religion, ethnicity or nationality, education, employment income, and address.
3. Health history
4. The pattern of nutrients
Which needs to be studied in infants with low birth weight; gastrointentinal absorption disorders, vomiting aspiration, sucking weakness that needs to be given parenteral fluids or per-sonde according to the baby's condition to meet the needs of electrolytes, fluids, calories and also to correct dehydration, metabolic acidosis, hypoglycemia in addition to intravenous drug administration.
5. The pattern of elimination
Which needs to be studied in neonates is defecation: frequency, amount, consistency. Urination: frequency, amount.
6. The socio-cultural background
Cultural influence on LBW, maternal smoking habits, the dependence of certain drugs, especially the type of psychotropic drugs. The habit of consuming alcoholic beverages, mother habits on a strict diet or abstain from certain foods.
7. The relationship of psychological
Preferably as soon as the newborn be rooming with the mother if the baby's condition allows. This is useful where the baby will get the love and attention as well as to strengthen the psychological relationship between the mother and the baby. As with LBW because it requires intensive care.
Objective Data
Objective data is data obtained through a measurement and inspection using recognized standards or applicable.
1. General condition
In neonates with low birth weight, became very weak and just moaning. The situation will be improved when the show active movement and crying loudly. Awareness of neonates can be seen from the response to stimuli. The existence of a stable body weight, body length according to age there is no enlargement of the head circumference can indicate a good condition of the neonate.
2. Vital Signs
Neonatal with post severe asphyxia, conditions will be good when handling asphyxia with true, accurate and fast. For preterm infants at risk of hypothermia when the body temperature less than 36 ° C and the risk of hyperthermia occurs when the body temperature less than 37 ° C. While the normal body temperature of 36.5 ° C - 37.5 ° C, the normal pulse between 120-140 times per minute normal respiration between 40-60 times per minute, often in neonatal with post severe asphyxia, breathing is not regular.
3. Skin
Body skin color; red, while the colored extremities; blue, in preterm infants are lanugo and vernix.
4. Head
Chances are found caput succedaneum or cephal hematoma, large fontanel concave or convex possibility of increased intracranial pressure.
5. Eyes
Color conjunctiva anemic or not anemic, no bleeding conjunctiva, sclera no yellow color, pupils show a reflection of the light.
6. Nose
There nostril breathing and there is a buildup of mucus.
7. Mouth
Pale or red lips, there is mucus or not.
8. Ear
Pay attention to cleanliness and abnormalities.
9. Neck
Pay attention to cleanliness because nenoatus neck short.
10. Thorax
Symmetrical shape, there is a pull intercostal, consider the sound of wheezing and Ronchi, frequency heart sounds more than 100 times per minute.
11. Abdomen: The shape is cylindrical, hepatic baby is 1-2 cm below the arch costaae, on the lines of the mammary papilla, spleen not palpable, potbelly means the presence of ascites or tumor, sunken abdomen signs of diaphragmatic hernia, bowel sounds arise from 1 to 2 hours after the birth of a baby, often there is a retention due to GI Tract yet perfect.
12. Umbilicus
Withered umbilical cord, note there is bleeding or not, signs of infection in the umbilical cord.
13. Genitalia
In neonates at term testicular must come down, see the location of the urethral opening is there any abnormalities in male neonates, neonates of women see the labia majora and labia minora, the presence of whitish mucus secretion, sometimes bleeding.
14. Anus
Perhatiakan presence of blood in the stool, stool frequency, and color of the stool.
15. Extremities
The blue color, weak movement, acral cold, note the presence of a fracture or nerve paralysis or state their fingers as well as the amount.
16. Reflex
In preterm neonates post severe asphyxia and sucking reflex moro weak. Moro reflex can provide information on the state of the central nervous system or the presence of fractures.
Supporting Data
Supporting Data; laboratory tests are important in diagnosis or causal right so that we can provide the right medicine anyway.
Assessment
Subjective data is the client's perception and sensation of health problems. Subjective data consists of:
1. Biography or the identity of the patient: includes name, date of birth, gender.
2. Parents include: name (father and mother, age, religion, ethnicity or nationality, education, employment income, and address.
3. Health history
a. Antenatal history that needs to be studied or known of antenatal history in the LBW cases are:
- State of the mother during pregnancy with anemia, hypertension, poor nutrition, smoking dependence on drugs or with diseases such as diabetes mellitus, cardiovascular and pulmonary.
- Pregnancy at risk of preterm labor, for example; multiple births, congenital abnormalities, history of preterm labor.
- Pregnancy tests are not continuous, or irregular examination and check the pregnancy is not the health workers.
- The first day, the last day is not appropriate for gestational age (gestational Postdate or preterm).
- History natal complications of childbirth also has a strong link with the problems in the newborn.
b. Postnatal history
Which needs to be studied include:
- Newborn Apgar scores of 1 minute first, second and 5 min Apgar scores (0-3); severe asphyxia, Apgar score (4-6); moderate asphyxia, Apgar scores (7-10); mild asphyxia.
- Birth weight: preterm / low birth weight less than 2500 grams, 2500 grams at term, head circumference less or more than normal (34-36 cm).
- Congenital abnormalities: Anencephal, hirocephalus, esophageal atresia.
4. The pattern of nutrients
Which needs to be studied in infants with low birth weight; gastrointentinal absorption disorders, vomiting aspiration, sucking weakness that needs to be given parenteral fluids or per-sonde according to the baby's condition to meet the needs of electrolytes, fluids, calories and also to correct dehydration, metabolic acidosis, hypoglycemia in addition to intravenous drug administration.
5. The pattern of elimination
Which needs to be studied in neonates is defecation: frequency, amount, consistency. Urination: frequency, amount.
6. The socio-cultural background
Cultural influence on LBW, maternal smoking habits, the dependence of certain drugs, especially the type of psychotropic drugs. The habit of consuming alcoholic beverages, mother habits on a strict diet or abstain from certain foods.
7. The relationship of psychological
Preferably as soon as the newborn be rooming with the mother if the baby's condition allows. This is useful where the baby will get the love and attention as well as to strengthen the psychological relationship between the mother and the baby. As with LBW because it requires intensive care.
Objective Data
Objective data is data obtained through a measurement and inspection using recognized standards or applicable.
1. General condition
In neonates with low birth weight, became very weak and just moaning. The situation will be improved when the show active movement and crying loudly. Awareness of neonates can be seen from the response to stimuli. The existence of a stable body weight, body length according to age there is no enlargement of the head circumference can indicate a good condition of the neonate.
2. Vital Signs
Neonatal with post severe asphyxia, conditions will be good when handling asphyxia with true, accurate and fast. For preterm infants at risk of hypothermia when the body temperature less than 36 ° C and the risk of hyperthermia occurs when the body temperature less than 37 ° C. While the normal body temperature of 36.5 ° C - 37.5 ° C, the normal pulse between 120-140 times per minute normal respiration between 40-60 times per minute, often in neonatal with post severe asphyxia, breathing is not regular.
3. Skin
Body skin color; red, while the colored extremities; blue, in preterm infants are lanugo and vernix.
4. Head
Chances are found caput succedaneum or cephal hematoma, large fontanel concave or convex possibility of increased intracranial pressure.
5. Eyes
Color conjunctiva anemic or not anemic, no bleeding conjunctiva, sclera no yellow color, pupils show a reflection of the light.
6. Nose
There nostril breathing and there is a buildup of mucus.
7. Mouth
Pale or red lips, there is mucus or not.
8. Ear
Pay attention to cleanliness and abnormalities.
9. Neck
Pay attention to cleanliness because nenoatus neck short.
10. Thorax
Symmetrical shape, there is a pull intercostal, consider the sound of wheezing and Ronchi, frequency heart sounds more than 100 times per minute.
11. Abdomen: The shape is cylindrical, hepatic baby is 1-2 cm below the arch costaae, on the lines of the mammary papilla, spleen not palpable, potbelly means the presence of ascites or tumor, sunken abdomen signs of diaphragmatic hernia, bowel sounds arise from 1 to 2 hours after the birth of a baby, often there is a retention due to GI Tract yet perfect.
12. Umbilicus
Withered umbilical cord, note there is bleeding or not, signs of infection in the umbilical cord.
13. Genitalia
In neonates at term testicular must come down, see the location of the urethral opening is there any abnormalities in male neonates, neonates of women see the labia majora and labia minora, the presence of whitish mucus secretion, sometimes bleeding.
14. Anus
Perhatiakan presence of blood in the stool, stool frequency, and color of the stool.
15. Extremities
The blue color, weak movement, acral cold, note the presence of a fracture or nerve paralysis or state their fingers as well as the amount.
16. Reflex
In preterm neonates post severe asphyxia and sucking reflex moro weak. Moro reflex can provide information on the state of the central nervous system or the presence of fractures.
Supporting Data
Supporting Data; laboratory tests are important in diagnosis or causal right so that we can provide the right medicine anyway.
