Ineffective Breathing Pattern related to Low Birth Weight

Nursing Care Plan for Low Birth Weight

Nursing Diagnosis :  Ineffective Breathing Pattern

According Manuaba (2002) since 1961 WHO replace the term premature with low birth weight (LBW) as they realized that not all babies born weighing less than 2500 grams at birth is not premature baby, then according Pantiawati (2009), LBW is a baby with birth weight less than 2500 grams. Meanwhile, according Proverawati (2010) LBW is babies born weighing less than 2500 grams regardless of pregnancy, in line with the opinions Prawiroharjo (2011) LBW is newborn birth weight less than 2500 (up to 2499 grams).

According Proverawati (2010), Clinical / LBW Infants characteristics:

• Weight less than 2500 grams.
• Length of less than 45 cm.
• Chest circumference less than 30 cm.
• Head circumference less than 33 cm.
• Thin subcutaneous fat tissue or less.
• Gestational age less than 37 weeks.
• Larger heads.
• Transparent thin skin, lanugo hair a lot, less fat.
• Cartilage earlobe, rudimentary growth.
• Weak hypotonic muscle is a muscle that is no active movement of the arms and elbows.
• Irregular breathing can occur apnea.
• Extremities: abduction of the thigh, the knee / leg flexion-straight, heel shiny, smooth soles.
• Head is not able to erect, yet nerve function or ineffective and weak tears.
• Breathing 40-50 times / min and pulse 100-140 beats / min.

Nursing Diagnosis for Low Birth Weight : Ineffective breathing pattern related to the immaturity of the respiratory center, the limitations of muscle growth or decline in muscle weakness and metabolic imbalance.

Goal: Patterns breath back effectively.

Expected outcomes:
Neonates will maintain periodic breathing patterns.
Pink mucous membranes.

Nursing Interventions :

Independent:
Assess the frequency and pattern of breathing, note the presence of apnea and cardiac frequency changes.
Suction the airway as needed.
Place the baby in the abdomen or supine position with a rolled diaper under the shoulder to produce hyperextension.
Review the history of the mother to drugs that would aggravate respiratory depression in infants.

Collaboration:
Monitor laboratory tests as indicated.
Give oxygen as indicated.
Give medications as indicated.

Rationale :

Help in distinguishing normal breathing rotation period of true apnea attacks, especially common in the 30th week of gestation.
Eliminate mucus that clogs the airways.
This position facilitates breathing and decrease episodes of apnea, especially if found any hypoxia, metabolic acidosis or hypercapnia.
Magnesium sulfate and narcotics suppress the respiratory center and CNS activity.
Hypoxia, metabolic acidosis, hypercapnia, hypoglycemia, hypocalcemia and sepsis aggravate apnea attacks.
Improvement of oxygen and carbon dioxide levels can improve respiratory function.

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Risk for Hypovolemic Shock, Risk for Metabolic Acidosis and Self-care Deficit

Nursing Diagnosis : Risk for Hypovolemic Shock related to continuous bleeding.

Goal :

• Shock does not occur during the treatment period.

Expected Outcomes:

• Not decreased consciousness.
• Vital signs within normal limits.
• Good skin turgor.
• Good peripheral perfusion (acral warm, dry and red).
• Fluid balance in the body.

Nursing Interventions :
1. Encourage the patient to drink more.
R /: Increased fluid intake, may increase intravascular volume, which can increase tissue perfusion.

2. Observation of vital signs every 4 hours.
R /: Changes in vital signs can be an early indicator of dehydration.

3. Observation of the signs of dehydration.
R /: Dehydration is the beginning of the syock if dehydration is not in good hands.

4. Observation of fluid intake and output.
R /: adequate fluid intake can compensate for excessive discharge.

5. Collaboration in:

• Intravenous fluids or transfusion.
• Giving coagulant and uterotonic.
• CVP custom installation.
• Examination of the plasma density.

Nursing Diagnosis : Risk for Metabolic Acidosis related to a decrease in the amount of blood in the capillaries.

Goal :
Metabolic acidosis did not occur during the treatment period,

Expected Outcomes:

• The results of blood gas analysis within normal limits.
• Vital signs within normal limits.

Nursing Interventions :
1. Observation vital signs within normal limits.
R /: Changes in vital signs is an early sign of detection of acidosis.

2. Encourage and motivate patients to drink sweet.
R /: Reducing protein breakdown and excessive fat to meet metabolic needs.

3. Collaboration in:

• BGA inspection.
• Intravenous fluids.

Nursing Diagnosis : Self-care Deficit related to physical weakness

Goal :
During the treatment period of daily activity needs are met.

Nursing Interventions :
1. Explain to the patient about the importance of maintaining personal hygiene.
R /: Adequate knowledge enables clients cooperatively towards the maintenance action performed.

2. Assist the client in meeting the nutritional needs (food and drink).
R /: Weakness of the body requires that the client needs with the help of others.

3. Assist the client in meeting the needs of personal hygiene.
R /: Weakness of the body that occur can lead to inability to meet the needs of personal hygiene.

4. Observation fulfillment daily activities.
R / Increased ability fulfillment of daily needs may reflect reduced body weakness.

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Anxiety related to Pleural Effusion

Pleural effusion is an abnormal amount of fluid around the lung. Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs.

Some of the more common causes are:

• Congestive heart failure
• Pneumonia
• Liver disease (cirrhosis)
• End-stage renal disease
• Nephrotic syndrome
• Cancer
• Pulmonary embolism
• Lupus and other autoimmune conditions

Symptoms of pleural effusions

• Shortness of breath
• Chest pain, especially on breathing in deeply (pleurisy, or pleuritic pain)
• Fever
• Cough

Nursing Diagnosis for Pleural Effusion : Anxiety or fear in relation to the threat of death imaginable (inability to breathe).

Goal : Patient is able to understand and accept the situation so there is no anxiety .

Outcomes:

• Able to breathe normally, able to adapt to the situation.
• Client's non-verbal response seemed more relaxed and at ease , the breath regularly with a frequency of 16-24 times per minute , pulse 80-90 times per minute.

Interventions :

1. Provide a pleasant position for the patient . Usually with a semi -Fowler.

2. Explain about the disease and diagnosis.
Rationale: The patient is able to receive and understand the circumstances that might be used in the treatment of co-operation.

3. Teach relaxation techniques.
Rationale : Reduce muscle tension and anxiety.

4. Aids in finding the source of the existing coping.
Rational Utilization of existing resources constructively coping very useful in overcoming stress.

5. Maintain a trusting relationship between nurse and patient.
Rationale : The relationship of mutual trust help the therapeutic process.

6. Assess the factors that cause anxiety.
Rationale : Appropriate action is necessary to address the problems faced by clients and build trust in reducing anxiety.

7. Aids patients recognize and acknowledge a sense of anxiety.
Rationale : Anxiety is an emotion that effect when they are well identified, disturbing feelings be known.

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