Nursing Care Plan for Low Birth Weight
Nursing Diagnosis : Risk for Fluid Volume Deficit age and extreme weight, excessive fluid loss (thin skin), less fat layer, immature kidney / failure to concentrate urine.
Goal: liquid fulfilled
Expected outcomes:
- Free of signs of dehydration.
- Shows the weight gain of 20-30 grams / day.
Interventions :
Independent:
- Compare the input and output of urine, every shift and balance each periodic cumulative 24 hours.
- Monitor the specific gravity of each finished urinating or every 2-4 hours to inspire urine from diapers when the baby can not stand the reservoir bag urine.
- Evaluation of skin turgor, mucous membranes, and the state of the anterior fontanelle.
- Monitor blood pressure, pulse, and mean arterial pressure (TAR).
- Monitor laboratory examination in accordance with the indications; Ht.
- Give parenteral infusion.
- Give a blood transfusion.
Rationale :
- Output should be 1-3 ml / kg / h, while the need for fluid therapy is approximately 80-100 ml / kg / day on the first day, increased to 120-140 ml / kg / day on the third day postpartum. Blood sampling for tests lead to decreased levels of hemoglobin / hematocrit.
- Although renal immaturity and inconvenience to concentrate urine, usually resulting in a low specific gravity in preterm infants (range normal1,006-1,013). Low levels indicates excessive fluid volume and content of greater than 1.013 indicates the inability of fluid intake and dehydration.
- Loss or minimal fluid shifts can quickly lead to dehydration, visible by poor skin turgor, dry mucous membranes, and sunken fontanelle.
- Losing 25% of blood volume resulting in shock, with TAR 25 mmHg indicates hypotension.
- Dehydration increases hematocrit levels 45-53% above normal serum potassium.
- Hypoglycemia can occur due to loss through diarrhea or vomiting nasogastric tube.
- The replacement of body fluids increase the volume of blood, helps restore vasoconstriction due to hypoxia, acidosis, and right-to-left shunt through the PDA, and has helped in reducing complications necrotizing enterocolitis, and bronchopulmonary dysplasia.
- It may be necessary to maintain the levels of hematocrit / hemoglobin optimal and replace blood loss.