CHIEF COMPLAINTS: -

Baby have breathing problem, increaseheart rate after birth& poor breast feeding of baby.

PRESENT ILLNESS (MEDICAL/SURGICAL):-

 Heart rate increased

 Fetal distress
 Poor feeding
 Body skin bluish

Surgical: -No any present illness to the child.

PAST ILLNESS (MEDICAL/SURGICAL) :-

No any past medical and surgical history of the child

FAMILY HISTORY: -

Child is lived in nuclear family

Mr. Devinder Singh Mrs. Kamaljit Kaur

Patient (Father) (Mother)

Father

Mother
B/O Kamaljit Kaur
BIRTH HISTORY

 Prenatal history: Pregnancy was confirmed at 4th weeks of pregnancy. Pre-natal care initiated at 12 weeks of gestation and continued
throughout the pregnancy. Nothing uneventful was reported during pregnancy. Three antenatal visits were done by the mother. IFA
prophylaxis was taken by the mother, TT immunization was taken by the mother.
 Natal history: Delivery done at 30weeks& 05 days of gestation by LSCSin Civil Hospital Ludhiana. No any abnormalities during the intra-
natal period.
 Postnatal history: No complaints reported during the postnatal period by the mother. Lochia Rubra was present. Birth weight of baby
is700gm and length were 45cm, baby cried immediately after birth. APGAR score is 8 and 9.
IMMUNIZATION TAKEN: -

S.no Vaccine Dose Route

1. BCG 0.05ml ID
2. Hepatitis B 0.5ml IM
3. OPV 2 drops Oral

SOCIO ECONOMIC STATUS: -

Baby of Kamaljit Kaur belongs to a middle-class family. The monthly income of father is Rs. 20,000/-
Housing: Theparents lives in 5 rooms cemented house with separate bathroom and toilet. The ventilation and lighting is adequate in the
house and uses tube and bulb as the source of light in the night. Water supply from the municipal corporation taps. The disposal of waste is
done by burning method.
PHYSICAL EXAMINATION-

Head

Head circumference:23.3cm

Caput succedaneum Not present

Cephalohematoma Not present

Encephalic Not present

Microcephaly Not present

Encephalopathy Not present

Size of fontanel Normal not depressed

Forceps marks Not present

Eyes

Size: Appropriate for age

Shape: Normal

Symmetry: Symmetrical

Sclera Shiny and white in colour

Pupils Equal, round, reactive to light and accommodation

Discharge No any discharge

Vision: Not checked

Movement:Normal eye movement in all directions

Ears

Pinna: Normal in shape

Position: Equal alignment

Cartilage: Cartilage present

Auditory canal: Normal

Tympanic membrane: Not assessed

Hearing: Normal i.e. baby react toward loud voices

Nose

Shape of nose: Normal

Shape of bridge of nose:Normal

Potency of nostril: Adequate

Perforation: None

Septum: Normal, not deviated

Nasal mucosa: Pink and moist

Discharge: No discharge
Mouth

Size of oral cavitySmall cavity

Opening of oral cavity Normal

Tounge Normal no tie

Cleft lips Not present

Cleft palate Not present

Neck

GoiterNot present

ThyroglosalNot present

Bronchial arch Normal

Lymph nodes Not palpable

Range of motion Movement is adequate

Chest

Size Normal range

Shape Round

Symmetry Symmetrical

Nipples and breast Spacing normal and no discharge

Scapula symmetry Appears symmetrical

Inspection Round in shape

Auscultation Normal sound is heard

Heart rate 170p/m

Palpation No tenderness, tumor or growth

Breath sounds Normal breath sounds are heard

Apnea It was present at birth remain up to 10-15 sec

Respiration rate It was 66 breaths/min

Periodical breathing pause It was 5-10 sec show bradypnea

Abdomen

Inspection No scar present, normal healthy cord is present

Palpation Liver margin not palpable

Auscultation Dull bowel sounds

Percussion Normal, no fluid accumulation

Umbilicus Herniaabsent
Reproductive System

Urethral and anal patency are normal

Testis is normal

SYSTEMIC EXAMINATIONS

Integumentary system

Skin:Bluish discoloration of the skin was present skin turgor elasticity

Colour:Bluish

Skin cresses: Present

Texture:Dry and thin

Gastrointestinal system:

Inspection: No scare and lesion

Palpation: No tenderness

Auscultation: Bowel sound is normal

Percussion: Dull sound is hear

Liver function

Bilirubin level >5 mg/dl

Hypoglycemia was present blood glucose level was < 30mg p/dl (1.65mmol/l)in first 24 hours of life<then 45mg/dl(2.5mmol/l) indicate
metabolic problem in newborn normal range was 50 mg per /dl8.3gm p/dl but in this infant level was 4.0 so vitamin k 1mg i/m was given to
infant

Conjugate bilirubin:6mg/dl was normal range but, in this infant, it was >6mg indicate jaundice infant kept in phototherapy

Back:

Spine: c shape supine, flat and straight and fine

No lesion and not scar are present

Extremities:

Symmetry of extremities:Symmetrical

Joints:No pain, tenderness

Hip location: No hip dislocation

Range of motion:Less range of motion

Muscles: Less fat due to extreme low birth weight

Not presence of polydactyly and syndactyly

Palmer creases: Normal

VITAL SIGNS: -

Temp Pulse Respiration Heart Rate

100 ℉ 30 b/m 66p/min 170p/m

99℉ 36 b/m 70p/min 148p/m

99.6 ℉ 36 b/m 76p/min 148p/m

ANTHROPOMETRIC MEASUREMENTS: -

 Chest circumference 33cm

 Weight 700g
 Height 45cm
 Head circumference 23.3cm

REFLEXES: -

REFLEXES PRESENT OR NOT

Rooting reflex According to mother rooting reflexes is present baby is

sucking the breast milk

Globular Present the Globular reflex

Moro’s Poor the Moro’s reflex

Swallowing & sucking Present

 Doll’s eye Present

Tonic neck reflex Present

Palmer grasp reflex Present

GROWTH AND DEVELOPMENTAL: -

Physical Fine motor Social and Emotional Intellectual Development Language Development
Development Development

Lies in fetal Closes eye to bright light. Bonds with mother not Beginning to develop concepts Cries vigorously
position with yet developed. e.g. becomes aware of physical Respond to low-pitched
knees tucked up sensations such as hunger. tones by moving his limbs

Unable to raise Opens eye when held in an Explores using his senses
head. Head falls upright position.
backwards if
pulled to sit cry to indicate need.

Reacts to sudden
sound

INVESTIGATION: -
Name of investigation Patient Value Book value Remarks
Random blood sugar <35 mg p/dl 50 mg p/dl hypoglycemia
Spo2 88% 100% Respiratory distress/acidosis
CRT <25 sec 35sec Abnormal
Bilirubin >5mg p/dl <5mgp/dl Normal
Conjugate bilirubin 4mgp/dl 6mg p/dl Normal

HB 13.1mg/dl Mch11.17 Normal

Fch11.5-15.0
Neutrophil 48.8 % 40-80 % Normal

Lymphocytes 37.6% 20-40% Normal

Esonophil 2.5% 01-0.6% Raised

Monocyte 10.3 % 2-10% Raised
Basophli 0.8% 1-2 Normal
Platelet count 4.30thou/mm3 150-400thou/mm Raised

RBC count 3-90thou/mm3 3-6-5.thou/mm3 Normal

MEDICATION: -
NAME OF DRUG DOSE ROUTE TIME ACTION

Meropenam 40mg IV BD Antibiotic

Amikacine 20mg IV BD Antibiotic

Linsopam 25mg IV BD Antibiotic

NURSING DIAGNOSIS BASED ON NURSING THEORIES:

  Virginia Henderson’s Need Theory

1st Diagnose is based on Virginia Henderson’s Need Theory,aspect is breathe normally.

  Impaired Gases exchange related to lack of lung surfactant.

2nd Diagnose is based on Virginia Henderson’s Need Theory,aspect is eat and drink adequately.

 Fluid volume deficit related to insensible water loss and inadequate breast feed.

3rd Diagnose is based on Virginia Henderson’s Need Theory,aspect is select suitable clothes - dress and undress.

 Risk for cold stress related to in mature temperature regulating center mechanism.

4rth Diagnose is based on Virginia Henderson’s Need Theory,aspect iskeep the body clean and well groomed & protect the integument.

 Risk of infection related to hospital acquired infection.

5th Diagnose is based on Virginia Henderson’s Need Theory, aspect is Learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities.
 Deficit knowledge related to home care and disease condition of the baby.

NURSING CARE PLAN

Nursing assessment Nursing Goal Intervention Implementation Rational Evaluation
Diagnose
1.Subjective data: - Impaired To maintained Assess the general General condition of patient Help in maintained Balance is
Mother said that - I
Gases Balance condition of infant. was assessed it indicate of O2 and Co2. maintained
delivered in between
exchange respiratory distress. between the
o2/co2
Before 9th month
related to O2 and CO2.
-Baby not cries after
lack of Assess the level of level of cyanosis was Help in management
birth
lung cyanosis. assessed it was peripheral of acidosis.
Blueness of body was
surfactant cyanosis.
present.
based on
Objective data: -
Virginia Assess the Apgar score of The Apgar score was <the 6 Help in identified
I observed the condition
Henderson infants in 1 min after birth. p/min. respiratory distress.
of the baby, assessed the
’s Need
skin of the baby
Theory. Clear airway and Air passage was cleaned and Help in gases
administer O2 as per doctor O2 was given as pre doctor Maintains.
orders. order.

warmth was planned. warmth was provided by Help in prevent the

increased room temperature hypothermia.
34 c-.

Nursing Nursing Goal Intervention Implementation Rational Evaluation

assessment Diagnose
2.Subjective Fluid volume To maintain Assess the sucking Sucking reflex was checked it Help to know the There was no
data: -
deficit related fluid volume, reflex of newborn was poor so feed provided by condition of infant. hypoglycemia
Mother said
to insensible prevent orogastric feeding. and dehydration
that my baby
water loss and hypoglycemia feed taken by
passed more
inadequate and Assess fluid and Result of blood sugar was shown Help in prevention of orogastric and
urine. Not
breast dehydration electrolytes Hypoglycemia so 10% Dextrose hypoglycemia. spoon
take breast
feedbased on was given as pre doctor order 30
feed
Virginia ml for 8 hours.
remain in
Henderson’s
sleep
Need Theory. Assess the skin Skin turgor was checked by Help in assessment of
Objective
data:- turgor pinch of skin and see the dehydration.
I observed the
condition of fontanel there was
baby, Not take
no sign of dehydration.
breast feed,
passed more
urine. sleep all
Plan for daily weight Daily weight was taken it was Help to identified the
over the day
record. increased per day. health status of infant.
Nursing Nursing Goal Intervention Implementation Rational Evaluation
assessment Diagnose
3. Subjective Risk for cold To maintain Assess the gestational age Gestational age was To know the function Now the body
data
stress related body of neonate. assessed it was37weeks. regulating center which temperature was
Mother of
baby said that to in mature temperature in Control temperature. in normal range
my baby
temperature normal range it was 98℉ .
looks warm
Objective regulating Plan for maintains the warmer was switch on Help in prevention of
data:-
center environmental temperature and temperature was heat loss due to
I observed the Mechanismb of labor room/NICU now28±2℃ environment.
condition of
ased on 28±2℃ .
the child, I
checked the Virginia
temp. of the
Henderson’s Plan for prevention heat Newborn dry Help in prevention from
baby it was
100℉ Need loss. immediately after birth heat loss.
Theory. and cotton cloth was
Applied to newborn.

Assess the vital of Vital of new born in

newborn ½ hourly. normal range. Help to maintain the
body temperature of the
baby.
Nursing Nursing Goal Intervention Implementation Rational Evaluation
assessment Diagnose
4. Risk of To reduce the risk Assess the condition To provide the base line To prevent the further The risk of the
Subjective infection of infection. of the child. data to the child. risk of infection. infection is reduced.
data: related to
Mother said hospital
that she had acquired
concerned infectionbased Educate the mother Mother wash the hand To prevent from
for her baby on Virginia before and after before and after touch to infection.
related Henderson’s touching to the child the child.
infection. Need Theory. wash hand properly.
Objective
data:-
I observed
the Provide the education Provided the education to To prevent the further
condition of to the parents of the the child parents complications.
the baby child. regarding the nosocomial
and the infection.
hospital
environment
for the
baby. Provide the infection To isolate the child from To prevent the further
less environment to the infected children. infection.
the child.
Nursing Nursing Goal Intervention Implementation Rational Evaluation
assessment Diagnose
5.Subjective Deficit To provide Assess the ability of Parents knowledge was Help to known the Parents have enough
data: -
knowledge information to parents about assessed assistant and ability of parents in knowledge about care
Mother asked
related to parents premature care of counseling was provided home care of infant. of child and about the
question
home care regarding home newborn. regarding home care disease condition.
regarding
and disease care based on
home care.
condition of Florence Plan for Demonstration was To know the ability of
Lack of
the baby is Nightingale Demonstration provided and parents are mother in care of
experience
based on Environment preterm care. advised to participate in newborn
regarding
Virginia Theory. preterm infant care.
preterm care
Henderson’s
Objective
data: Need Theory Plan for provide Information was provided Help to identified the
Question
information regarding about the danger signs and symptoms of
about
signs and symptoms symptoms of respiratory respiratory distress.
how to feed
of respiratory distress. Distress.
baby.
How will
Plan to Provide Information provided Help in administration
maintain
information about related to the side-effects of medication.
body
medication. and the action of the
temperature
medicine.
Health Education:
Hypothermia and hygiene: -
Education was given that keep baby dry after birth put cloth and apply socks and cotton cap on head. Maintain room temperature and body
temperature by using warmer and room heater.
Switch on the warmer before received baby from labor room. Maintain Perineal hygiene and remove wet dipper immediately.
Nutrition: -
Assess the nutritional of the new born and feed was advice as per bodyweight.
I/V dextrose was given as per body weight.
Swallowing reflex was checked and advised to mother for kattori spoon feeding two hourly.
Advise to checked the baby body weight daily at same time and same machine.
Advise the mother to provide feed in frequent interval and demand feeding.
Cord care: -
Advise the mother to keep the cord dry and clean. Do not apply any things over the cord.
Advice to assess the condition of the cords. An educate the mother check for discharge and redness at the site of insertion of cord.
Eye care: -
Clean hand with water and soap before eye care. Educate the mother to clean eye with plain water and normal saline. Educate the mother Use
one swab at one time clean eye inner canter to outer canter in one stock. Educate the mother for any discharge redness in this condition inform to
physician.

Evidenced Based Study:

Background. This study was done to assess the maternal and sociodemographic factors associated with low birth weight (LBW)
babies. Methods. An unmatched case control study was done involving 159 cases (mothers having LBW singleton babies) and 159 controls
(mothers having normal birth weight singleton babies). Results. More than 50% of LBW babies were from the mothers with height ≤145 cm
while only 9.43% of NBW babies were from the mothers with that height. Finally, after multivariate logistic regression analysis, maternal
height, time of first antenatal care (ANC) visit, number of ANC visits, iron supplementation, calcium supplementation, maternal education, any
illness during pregnancy, and hypertension were found as the significant predictors of LBW. However, maternal blood group AB, normal
maternal Body Mass Index (BMI), mother’s age of 30 or more years, and starting ANC visit earlier were found to be protective for
LBW. Conclusion. Study findings suggest that selectively targeted interventions such as delay age at first pregnancy, improving maternal
education and nutrition, and iron and calcium supplementation can prevent LBW in Nepal.
BIBLIOGRAPHY

 Dutta Parul, “Pediatric Nursing”, published by Elsevier publication, New Delhi, edition 7th, page no 294- 305.
 www.rightdiagnosis.com/h/Low birth weight baby/intro.htm
 www.lpch.org/DiseaseHealthInfo/HealthLibrary/.../hyperb.
 www.ncbi.nlm.nih.govs

 pedsinreview.aappublications.org/content

 www.uptodate.com/.../premature -in-the-premature

 Bhaskar RK,Deo KK, Neupane U,Chaudhary Baskar S,Yadav BK, Pokharel HP,Pokharel PK.A Case control study on risk factors

associated with low birth weight babies in Eastern Nepal. International journal of pediatrics.2015 Dec10;2015