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KEMPEGOWDA COLLEGE of Nursing , Bangalore-04

CASE STUDY ON BABY WITH PRE-MATURITY

SUBMITTED TO MRS.KAMALA.J ASSOT. PROFF, KCN Bangalore

SUBMITTED BY Mrs. PRATHIBHA.N.J 2nd Year M.Sc Nursing KCN Bangalore

BASELINE DATA / GENERAL INFORMATION: Name Age Sex I.P. No. Ward Address : B/O Mrs. KAVYA : 1 day : Male : 32217/12 : Neonatal Intensive Care Unit : NO 141, Chennaswamy layout ,Bandepalya, Hosur road. Fathers Name Mothers Name Religion Education Occupation Mothers Occupation Monthly Family Income Date of Admission Provisional/ Final Diagnosis : Mr. Swamy : Mrs. Kavya : Hindu : PUC : Business : Home maker : Rs. 10,000/ month : 01 04 2012 : pre-mature baby with 37 weeks for NICU care

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 Significant Surgical History FAMILY HISTORY a) Type of Family b) No of Members in the family c) Family Composition : Sl.N o. Name Age Sex Relation ship with the child Father Marital Status Educati on Occupatio n Healt h Status : Nuclear : 03 : Nil : No significant history in past.

1.

Mr. Swamy

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Married

Graduate

Business

healthy

2.

Mrs. Kavya

23

Fe

Mother

Married

PUC

Home maker

Healthy

4.

B/O Kavya

1st day

Self

healthy

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

-----

-----

59y

57y

60y

54y

30y

29y

29y

23y

-female -male -newborn

SOCIO ECONOMIC HISTORY: a) Housing b) Rooms c) Occupancy d) Ventilation e) Light f) Water Supply : Semi Pucca : No. of Living Rooms Adequate : Monthly rent : Adequate : Electricity : Tap

g) Relationship among the family members : good

PERSONAL HISTORY a) Birth History i). Antenatal History a) Normal b) Nutrition of the Mother c) Regular Antenatal Check up d) Consumption of FST/Folic Acid e) Deviation from normal (f) Any exposure to teratogens Drugs Infection Radiations :No : No : No : No :Yes : Nourished : Yes : Yes :No

Any Complications

Natal History Mode of Delivery : normal delivery with right medio lateral episiotomy at 37 weeks gestation Cry Apgar Score Place of Delivery : Immediate : 6/10, 8/10 : MSRMH, Bangalore
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Weight of the body (Preterm) Condition of Neonate Any congenital deformity

: 2.2 Kg : pre- mature needs oxygen : No.

Condition of Neonate Meconium passed within 24 hrs Passed urine Any infection Any congenital deformity Feeding Initiation of breast feeding : Breast feeding is not Initiated due to illness Sucking IMMUNIZATION HISTORY : : poor : Yes : yes : No : No

Age of the child

Name of the vaccine

Dose

Route

Immunization status

Birth (1-7 days)

BCG OPV (O- dose) Hep .B I dose

0.1 ml 2 drops

ID Oral IM

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

0.5 ml

DIETARY HISTORY a) Breast Feeding b) Other Modes of Feeding c) Present Diet SLEEPING i) Sleeps in ii) Duration iii) Problems related to sleep : Incubator : Interrupted : Nil : Nil : Nil : Nil

ELIMINATION i) No. of Urine Frequency ii) No. of bowel movements : diaper : Irregular

PHYSICAL ASSESSMENT: Vital signs :

SL NO. 1

VITAL SIGNS

FOUND IN CHILD

NORMAL VALUE 98.6 F

REMARKS

Temperature

98.20 F

Baby has no fever

Pulse

168 beats/min.

80-140 beats/min

Baby has Tachycardia


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Respiration

52 breaths/min

30 40 breaths/min

Baby has tachypnea.

ANTHROPOMETRIC MEASUREMENT : SL NO PARAMETERS FOUND IN CHILD 2.2 kg NORMAL VALUE 2.9 3 kg REMARKS

Weight

Baby has low body weight Baby has reduced length

Length

40 cm

50 cm

3 4 5

Head circumference Chest circumference Mid arm circumference

30 cm 30 cm 8 cm

33 - 35 cm 31 33 cm 12- 17.5 cm

Less Less Baby has Low mid arm circumference.

PHYSICAL EXAMINATION GENERAL ASSESSMENT Appearance Body Built Sensorium Emotional State : ill : Thin : Restless : Restless, Crying
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Posture Foul Body odour Foul Breath Skin Condition Skin Colour Temperature Texture Turgor and elasticity Edema/ Puffiness Hair Colour Distribution

: Supine, flexed position : No : No

: Pink : Warm : smooth : Normal : No

: Dark Brown : Equally distributed

NAILS Hygiene Condition Angle of nail beds Nail Bed Colour HEAD AND FACE Shape : Normal
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: Clean : Smooth : Curved : Pink

Facial Appearance Cyanosis Tenderness

: Normal : Yes : No

EYES Eye Brows Eye lashes Eye lids : Equally distributed : Present : Normal

Shape and appearance of eyes - Normal Sclera Conjunctive Cornea Pupils Visual Aids Vision EARS Position Shape and Size Pinna Tympanic membrane Hearing : Normal : Symmetrical :soft : Normal : Not distinguished
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: White : Pale : Clear : Reacting to light normally : None : Not able identify.

Hearing Aid NOSE External Nose Size Shape Internal nasal mucosa Grunting MOUTH Lips Colour Shape Condition Gums Tongue Oropharynx Lesions Tonsils Uvula Glands Submandibular Sublingual : Pale : Thin : Dry : Pink : Red

: Absent

: normal in size : Normal : Normal :present

: Colour Red :Absent : Normal : Normal : Normal : Normal : Normal


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NECK Range of motion Thyroid Lymph node THROX AND LUNGS Respiratory rate Rhythm Shape Chest Wall movement Lung auscultation Breast and Axilla Lymph node Breast Heart Heart rate Heart Sound ABDOMEN i) Inspection Scar Lesions Size :No :presence umbilical cord lesion :Normal
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: Full :No enlargement :No enlargement

: : : : :

Increased i.e. 52 breaths/min varies Normal ASymmetrical ,has retraction Asymmetrical air movement.

: Normal : not developed

: 170 beats/min : Normal

Umbilicus Abdominal circumference ii) Palpation Liver Spleen Tenderness iii) Percussion Ascities iv) Auscultation : :

: Normal, looks dry, black in colour. : 20 cm

:Normal :Normal : No

No

Peristaltic movement: increased GENITALIA i) Scrotum ii)rugae iii)colour BACK : Vertebral column Joints EXTREMITIES Upper extremities Range of motion Syndactyl : Symmetrical :less, flaccid movement of extremities. : No
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:testis undesended, : underdeveloped : light

: Straight : Normal

Polydactyl Webbing of fingers Clubbing of fingers

:No : No :No

ii) Lower extremities : Range of motion Barlows Sign Ortolanis Sign Plantar creases REFLEXES: BOOK PICTURE

Symmetrical : : : : dull movement of lower extremities. Absent Absent very less

PATIENT PICTURE

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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 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 Disappears by about 4 months after birth Premature babies may have weak or immature sucking ability. A finger or nipple placed in baby's mouth will elicit rhythmical sucking. Sucking reflex is poor in this baby due to pematurity elicited in this baby , may be due to prematurity.

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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 cant be When the baby's head is turned to one side, the arm on that side stretches out and the opposite arm bends up at the elbow Often called the fencing position PALMAR GRASP REFLEX: elicit in newborn babies.

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Present at birth Disappears by about 2-3 months Stroking the palm of a baby's hand causes the baby to close the fingers in a grasp Reflex is stronger in premature babies OR 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 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. OR 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: Baby's foot is stroked from heel toward the toes. The big toe should lift Babinski reflex is good. Baby's foot is stroked from heel toward the toes
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Palmar grasp can be elicited and it is very strong in this baby.

Baby grasps examiners fingers when pressure applies on babys hand with finger.

Stepping is not well developed due to acute illness.

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 DOLLS 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 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.

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

Dolls eye reflex is not well developed.

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

Absence may indicate spinal injury or depression of the CNS. PEREZ REFLEX: Firmly stroking baby's spine from tail to head, will make her cry out and head will rise.

left side.

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 PLANTERS GRASP: Pressing thumbs against the balls of baby's feet will make his toes flex. Absence of this reflex may indicate damage to the spinal chord
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Plantar reflex is good.

WITHDRAWAL REFLEX: A pinprick to the sole of baby's foot will make baby's knee and foot flex. Absence of this reflex could indicate a damaged sciatic nerve.

This withdrawal reflex is achieved when babys sole pricked with needle for blood glucose monitoring, babys knee and foot flex.

INVESTIGATION Sl. No. 1 Investigation Patient Value Normal Value Remarks

Blood: Hb% CRP 9.2 gm% 25.8 mg/dl 13-18 gm% < 5 mg/ dl Baby looks anaemic, cyanosed and has systemic infection

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Electrolytes Na K Cl 2 ABG analysis PH PCO2 PO2 HCO3 7.2 33.7 55 23.2 7.35 7.45 < 45 60 80 25.2 25.6 128 meq/ltr 3.5 meq/ ltr 99 meq / ltr 135 145 meq/ lr 3.9 5.1 meq / lr 98 106 meq / lr

Hyponatrmia Hypokalemia normal

Baby has respiratory acidosis

3 4. 5 6

Blood group Chest X- Ray ECHO Cardiogram Abdominal ultrasound.

O + Ve

CORELATION BETWEEN BOOK PICTURE AND PATIENT PICTURE: SL NO. 1 CAUSES: Exact cause is unknown The Exact cause is unknown Mother got contraction and she was admitted BOOK PICTURE PATIENT PICTURE

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RISK FACTORS: Previous delivery Illness of the mother Multiple pregnancy Poly hydramnios Family history Placental insufficiency history of pre-term No risk factors are noted

CLINICAL PICTURES Small size 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

Small size 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 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
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as does a full-term newborn) Sleeping for most of the time Infants will be given warm, moist oxygen. This Management a. NICU care b. Adequate oxygenation

is critically important, but needs to be given carefully to reduce the side effects associated with too much oxygen. 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


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patient.

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

Babys behaviour Non verbal response like baby having distress

Nurse action
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 individuals action. The components of Orlandos 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
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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.


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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

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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

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SYMPTOMS o Premature newborns usually weigh less than 5 pounds (2.5 kilograms) o Some weigh as little as 1 pound ( 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

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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.
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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

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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
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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

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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


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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.

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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.

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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

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ASSESS MENT

NURSIN G DIAGN OSIS Impaired breathing pattern related to atelactasi s secondar y to surfactant deficienc y.

OBJEC TIVES

NURSING INTERVENTIONS

IMPLEMENTATION

EVALUATI ON

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

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

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

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.

Baby is maintaining normal saturation And free dyspnoea.

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On observatio n Looks hypotherm ic, extremitie s are cool.

Ineffectiv Child will be e thermore gulation related immature of thermore gulation centre, less subcutan eous fat. able to maintain normal body temperat ure.

Assess infants body temperature. Place the child under radiant warmer and maintain temperature between 36.5 37.5 C

Assessed infants body temperature.

Baby

Placed the child under radiant warmer maintain and maintain temperature between 36.5 37.5 C normal body temperature under radiant warmer.

Mummify the baby to reduce heat loss. Avoid touching baby with cold hands to avoid hypothermia to baby. Monitor the temperature of the warmer and adjust if needed Warm both hands before touching the baby to avoid hypothermia to baby.

Mummified the baby with a warm blanket to reduce heat loss. Avoided touching baby with cold hands to avoid hypothermia to baby. Monitored the temperature of the warmer and adjust temperature to 36.7 C

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

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On observatio n child looks fatigue, restless And low body weight is 2.2 kg.

Imbalanc ed

The child will be

Assess the nutritional status of the child by nutritional assessment. Monitor child weight daily Administer fluids, electrolytes and nutrients as per order. Provide comfort to the baby by meeting the daily needs.

Assess the nutritional status of the child by nutritional assessment. Monitor child weight daily Administer fluids, electrolytes and nutrients as per order. Provide comfort to the baby by meeting the daily needs.

Baby increased weight from 2.2 kg to 2.8 kg. Baby taking

nutritiona able maintain l status less than body requirem ent related NPO status, inability to take breast milk. normal

nutritiona l status -

Give expressed breast milk or prepared lactose feed to baby through NG tube or with the help of palada.

Give expressed breast milk or prepared palada feedscomfort lactose feed to baby through NG tube or with the help of palada. ably.

Encourage mother to give exclusive breast feeding every 2 hourly or on demand of the baby. Encourage mother to give exclusive breast feeding every 2 hourly or on demand of the baby. Monitor intake output chart. Encourage diversional therapies while providing food to the child.

Monitor intake output chart. Encourage diversional therapies while providing food to the child.

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Mother express her feeling that she is having fear about her child illness.

Anxiety

Mother

Assess parents level of anxiety and determine how parents copes with anxiety.

to parents will be related to child health condition able to cope up with present condition

Assessed parents level of anxiety and determine how parents cope with anxiety. Acknowledged awareness of patients anxiety. Acknowledgment of the patients feelings validates the feelings and communicates acceptance of those feelings.

Mother verbalizes that she is

Acknowledge awareness of patients anxiety. Acknowledgment of the patients feelings validates the feelings and communicates acceptance of those feelings. Reassure patient that he or she is safe. Stay with patient if this appears necessary.

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.

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

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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 babys 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 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.

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

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

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