Altered Growth and Development

image

Neonates with Altered Gestational Age

• Term infant: Born between 38-42 weeks of pregnancy.

• Premature infant: Born before 38 weeks of gestation regardless of birth weight.

• Post mature infant: Infant born after the onset of 43 weeks of pregnancy regardless of birth weight.

• Normal birth weight for a term infant: 2500-4500gm.

• Appropriate for gestational age: An infant whose birth weight falls between 10th to 90th percentile on an intrauterine growth curve.

• Low birth weight infants (LBW): Infants with a birth weight less than 2500 g.

• Small for gestational age (SGA): Infants who fall below 10th percentile of weight on the intrauterine growth curve.

• Large for gestational age (LGA): Infants who fall above the 90th percentile in weight regardless of gestational age.

Pathophysiology

• Preterm: Pregnancy is ended prematurely while the fetus was growing normally inutero and have low birth weight.

• Small for gestational age: Growth was impaired inutero suggesting a pathologic process in the fetus or placenta – Intrauterine growth retardation (IUGR).

• Postmature: Growth has proceeded normally, but pregnancy has extended for unknown reasons. If this continues placenta can not support the fetus with adequate nutrients and oxygen and baby’s health is in danger.

 

SGA – Causes

• Placental anomalies

• Maternal malnutrition

• Adolescent pregnancy

• Placental damage, partial separation

• Maternal diseases – PIH, DM

• Maternal smoking

• Intrauterine infections – rubella, toxoplasmosis

• Chromosomal abnormalities of the fetus

 

Postmature infant

Features of Postmature infant

• Dry, cracked, leather like skin

• Absence of vernix

• Weight loss

• Finger nails long

• Alert

• Meconium staining at birth and less amniotic fluid.

Diagnosis of Postmature infant

• Ultrasound

• L/S ratio

• Serum estrogen levels in mat. Blood

Management for Postmature infant

• Induction of labor

• Cesarean if induction fails.

Assessment – post term

– Below average birth weight

– Overall wasted appearance

– Poor skin turgor

– Lack of lanugo

– Large head than the rest of the body

– Widely separated sutures

– Dull listless hair

– Sunken abdomen

– Dry, yellow stained cord

Differentiating from preterm

• Better neurological reflexes

• Better hair texture

• Better developed sole creases

• Firm ear cartilage

• Firm skull

• Alert and active

Lab Findings

• High hematocrit (Exchange transfusions needed if hct more than 65%)

• Polycythemia

• Hypoglycemia

 

Nursing management

Nursing diagnosis 1: High risk for altered respiratory function R/T aspiration of meconium during labour.

Goal: Newborn will initiate and maintain respirations at birth.

Interventions:

• Watch for meconium aspiration syndrome.

• Resuscitation at birth.

• Close monitoring of respiratory rate and characters.

Nursing diagnosis 2: High risk for ineffective thermoregulation R/T lack of subcutaneous fat.

Goal: Newborn will maintain body temperature within normal limits.

Interventions

• Dry the body well and wrap the baby well with warm clothes.

• Cover with blankets.

• Keep the baby in incubator until the temperature is stable.

Nursing diagnosis 3: High risk for altered parenting R/T possible cognitive impairment and high risk status.

Goal: Parents will demonstrate beginning bonding with infant while in hospital.

Interventions

• Discuss ways how the parents can promote the infant’s growth and development at home.

• Encourage parents to provide age appropriate toys.

 

Large for Gestational Age

Causes

• Maternal diabetes

• Multipara

• Associated congenital anomalies

Prenatal assessment

• Large size of uterus

• Ultrasound

Postnatal assessment

• Immature reflexes

• Low scores on gestational age estimation

• Birth injuries – clavicle fracture, Erb’s palsy

• Associated congenital abnormalities – TGA

• Hypoglycemia

 

Nursing management

• Nursing diagnosis 1: High risk for altered respiratory function R/T possible birth trauma and under developed body systems at birth.

• Goal: Newborn will initiate and maintain respirations at birth.

• Interventions:

• Watch for diaphragmatic paralysis.

• Resuscitation at birth.

• Close monitoring of respiratory rate and characters.

 

Premature infant

Features

– Weight : Less than 2500 g

– Length: Less than 47 cm

– Gestational age:  37 or less

Causes

• Low socioeconomic status

• Poor nutrition

• Lack of prenatal care

• Multiple pregnancy

• Previous history of preterm labor

• Race – Non-whites

• Maternal smoking

• Maternal age below 20

• Order of pregnancy – first or after fourth

• Closely spaced pregnancies

• Abnormalities of reproductive system

• Infections

• PROM

• Abruptio placenta

• Early induction of labor or cesarean birth

 

Complications – Prematurity

• Respiratory distress

• Hypothermia

• Infection

• Anemia

• Kernicterus

• PDA

• Intracranial hemorrhage

Post-term

Pre-term

Variable

Normal reflexes

Lies with hands and legs flexed, moves head from side to side. Active

Reflex activities not fully developed, Sucking may be present, swallowing, gag, cough reflexes may be weak

 Lies frog-legged with elbows, wrist, knees and ankles touching the bed. Inactive

Psychological

Reflexes

Behaviour


Post-term

Pre-term

Variable

Skin is thick and flaky, no superficial blood vessels and no lanugo.

Normal head circumference.

Distinct individual scalp hair.

Skin is transparent, gelatinous, shiny, superficial blood vessels visible and abundant lanugo,

Head circumference will be small.

 

Fine fuzzy hair.

Physiological

Skin

 

Head

Hair

Post-term

Pre-term

Variable

Ear lobe firm. Ears are set at the extension of a line joining the inner and outer canthi of the eyes.

 

Normal sucking

Thorax firm Breast tissues measure 10mm in diameter

Ear lobe very pliable with cartilage. May be pseudo lowset.

Swallowing, gag, cough reflexes are weak and neonate  prone to aspiration

Thorax less firm Little breast tissues and nipple barely visible

Ears and Eyes

Nutrition

Mouth

Chest Breast 

Post-term

Pre-term

Variable

Normal

Extremities kept flexed

Creases found over entire sole of feet

Normal

Protruding

Extremities are thin and muscles are small.

Plantar creases not present or covers only part of the sole

Soft

Elimination Abdomen

Activity Extremities

Plantar crease (feet)

Nails

Post-term

Pre-term

Variable

Pendulous, pigmented scrotum with rugated testicles well descended. 

Labia majora prominent covering structure

Testes high in the scrotum or down at the edges of inguinal canal

Labia majora widely separated by protruding labia minora and clitoris

Sexuality Genitalia

Male

Female

 

Nursing management

Nursing diagnosis 1: High risk for altered respiratory function R/T immaturity of the respiratory structures and function at birth.

Goal: Newborn will initiate and maintain respirations at birth.

Interventions:

• Give oxygen to the mother by face mask during delivery.

• Keep maternal anesthesia and analgesia to minimum.

• Resuscitation within 2 minutes of birth.

• Keep the baby warm during resuscitation.

• Gentle handling to prevent skin bruises.

• Close monitoring of respiratory rate and characters.

 

Nursing diagnosis 2: High risk for fluid volume deficit R/T insensible water loss at birth and small stomach capacity.

Goal: Newborn will take in adequate fluid and electrolytes to meet body needs.

Interventions:

• Adjust the daily intake to 160-200 ml/kg.

• Give IV fluid by an infusion pump to ensure a continuous infusion.

• Use # 27 gauge needle / cannula for IV or use umbilical catheter.

• Observe the IV site for any infiltration.

• Monitor weight, Urine output, specific gravity and serum electrolytes.

• Watch for signs of over hydration – weight gain, pulmonary edema, heartfailure.

• Observe for inadequate fluids – signs of dehydration, acidosis and weight loss.

• Monitor output by pamper weight method. Usualy 40-100 ml/Kg/ day.

 

Nursing diagnosis 3: High risk for altered nutrition, less than body requirements R/T feeding and sucking difficulties, small stomach and increased body requirements.

Goal: Newborn will receive adequate fluid and nutrients during hospitalization.

Interventions:

• Early administration of IV fluids.

• TPN if too premature to tolerate feeds.

• Plan 120-140 cal/Kg/day.

• NGT or bottle feeding as tolerated.

• Aspirate and measure stomach contents before gavage feeding. Should be less than 2 ml just before feeding.

• Start with plain water.

• Use EBM or a special formula with 24 cal/oz – 27 cal/oz.

• Supplement minerals – Ca, P, Na, K and Cl.

• Supplement vitamins – A,D,C,E. 0.5 mg Vit K is given at birth.

 

Nursing diagnosis 4: High risk for hypothermia R/T immaturity of the thermoregulatory center and low birth weight.

Goal: Newborn will maintain temperature within normal limits until term age.

Interventions:

• Keep the baby under radiant warmer or in an incubator.

• Check temperature. Axillary temperature should be 36.5OC.

• Avoid unnecessary exposure of body parts.

• Cover the head with a cap.

• No bath until temperature is stable.

 

Nursing diagnosis 5: High risk for infection R/T immaturity of the immune system at birth.

Goal: Newborn will remain free of infection during hospital stay.

Interventions:

• Use sterile items for the baby.

• Practice hand washing before touching the infant.

• Follow aseptic techniques while doing procedures.

• Care the baby in reverse isolation.

• Staff with an infection should not handle the baby.

 

Nursing diagnosis 6: High risk for altered parenting R/T impaired attachment secondary to hospitalization.

Goal: Parents demonstrate adequate bonding behaviors by the time of discharge.

Interventions:

• Encourage parental visits as per unit policy.

• Encourage breast feeding according to baby’s condition.

• Inform to the parents the progress of baby’s condition and when will be ready

 

Failure to thrive (Reactive attachment disorder)

• Failure to thrive (FTT) is a syndrome in which an infant falls below the 3rd percentile for weight and height in a standard growth chart or is falling in percentiles on the growth chart.

 

Failure to thrive – Causes

• Organic – Cardiac disease, inborn errors of metabolism, Cystic fibrosis, congenital defects, endocrine abnormalities.

• Nonorganic – Emotional (disturbed parent-child relationship)

• Mixed

Nonorganic and mixed types are due to parental neglects. In many cases parent feels little emotional attachment to the child and an associated lack of food or the child do not eat enough due to the lack of emotional attachment. The child is irritable, fussy, colicky or difficult temperament child. Sometimes child may have neurological dysfunction from birth injuries.

Severe failure to thrive in early months can lead to neurological damage or mental retardation because of protein deficiency and interference with brain metabolism.

 

Management

Assessment

• Weight measurement and use of growth chart

• Physical examination – Poor muscle tone, lethargic, do not resist examiners manipulation, infant rock on all fours excessively, reluctant to reach out for toys, stare hungrily on human faces, diminished crying.

• Detailed pregnancy history – Unplanned or unaccepted, loss of boy friend or husband during pregnancy, loss of job

• Delay in developmental milestones usually after the fourth month – sitting erect, pulling to stand, crawling, walking, delayed speech.

Therapeutic management

• Hospitalization

• Diet appropriate for their ideal weight

• Monitor weight gain

• Provide stimulation

Nursing diagnosis

Altered nutrition less than body requirement R/T inadequate intake secondary to emotional deprivation.

Goal

– Child will take in adequate nutrients for growth by 24 hours.

Outcome criteria

• Child shows interest in bottle feedings.

• Child is able to establish a regular eating pattern.

 

Nursing Interventions

• Ensure adequate nutrition

• Record intake and output.

• Assess stools for pH and reducing substances (glucose) to ensure absorption.

• Evaluate the infant’s ability to suck, take food from a spoon and swallow.

• Watch for signs of GI discomfort after feeding.

• Nurture the child

• Effective “mothering” by nurses.

• Follow a primary nursing care pattern of assignment.

• Spend time with the child rocking him, giving leisurely bath, talking to him and exposing to toys.

• Support and encourage the parents

• Encourage parental visits

• Give suggestions on how the baby is trying to communicate with them.

• Point out the infant’s ability to respond to parent.

• If the child is discharged with parents follow ups to see they maintain parenting at an acceptable level.

• Placement in foster homes if needed.

• Prevention

• Adequate follow-up to ensure physical and emotional needs of the child are met.

• Identify the women who are at risk of poor mothering during pregnancy.

• Close follow-up during postpartum visits.

•  Counseling for the woman as necessary.

 

Birth defects

• Congenital anomalies (birth defects) occur in 2-4% of live births.

Etiologic factors

• Heredity

• Chromosomal anomalies

• Exposure to teratogens – radiations, drugs

• Maternal infections

• Maternal diseases

• Advanced parental age

Parental reactions

• The more severe the defect, the greater the impact of the experience, especially to mother. Suddenly lost the psychological attachment formed during pregnancy to a normal child.

• Parents experience grief reaction. They may show shock, frustration and anger at what happened to them. They can have feelings of shame, embarrassment, personal failure and guilt.

• When the overwhelming shock is over the parents pass through the five stages of grief reaction

– Denial

– Anger

– Bargaining

– Depression

– Acceptance

 

Nursing responsibilities

• Initial contact

• Inform the parents with truthful statements about the child’s defect.

• Give brief explanations about the child’s condition.

• Talk about the baby as precious and emphasize the normal features.

• Encourage parents asking questions.

• Family support

• Allow parents time to grieve.

• Help parents to see the infant as a person and provide guidance in physical care.

• Accept the parental reactions and be nonjudgemental.

• Promote communication and understanding within the family.

• Care of the infant

• Teach the physical care of the infant to parents.

• Involve them in caring.

• Supplying information

• Accurate information on infant’s condition, care, treatment and community care facilities.

 

Down Syndrome

image

• Down syndrome (DS) is the common chromosome abnormality with trisomy of chromosome 21. Occur in 1 in 800-1000 live births.

• Etiology

– Radiation exposure

– Immunologic problems

– Infection

– Multiple causality

• Types

– Trisomy 21

– Translocation chromosome 21

– Mosaicism

 

Clinical manifestations of Down Syndrome

• Head

– Separated sagital suture

– Brachycephaly

– Small flat occiput

– Enlarged anterior fontanel

– Sparse hair

• Face

– Flat profile

• Eyes

– Oblique palpebral fissures

– Inner epicanthial folds

– Speckling of iris (Brushfield spots)

– Blepheritis

• Nose

– Small

– Depressed nasal bridge

• Ears

– Small, short pinna

– Overlapping upper helixes

– Narrow canals

• Mouth

– High arched, narrow palate

– Small osseous orbit

–  Protruding tongue

– Hypoplastic mandible

– Mouth kept open

• Teeth

– Delayed erruption

– Abnormal alignment

– Periodontal disease

• Chest

– Shortened rib cage

– 12th rib anomalies

– Pectus excavatum

• Neck

– Short and broad

– Skin excess and lax

• Abdomen

– Protruding

– Muscles lax and flabby – diastasis recti and umbilical hernia

• Genitalia

– Small penis, cryptorchidism

– Bulbous vulva

• Hands

– Broad, short, Stubby fingers

– Incurved little finger (Clinodactyly)

– Transverse palmar crease

• Feet

– Wide space between first and second toes

– Plantar crease between first and second toes

– Broad, stubby and short

• Musculoskeletal

– Hyper flexibility

– Muscle weakness

– Hypotonia

• Skin

– Dry, cracked and frequent fissuring

– Mottling

• Other

– Reduced birth weight

 

Development of the child

• Intelligence

– Varies from severely retarded to low average. Usually mild to moderate retardation. Initial development may be near normal.

• Social development

– 2-3 years beyond mental age.

– Easy child (friendly and lovable)

• Congenital anomalies

– CHD (septal defects)

– renal agenesis

– duodenal atresia

– Hirschprung’s disease

– tracheoesophageal fistula

– skeletal defects

• Sensory problems

– Ocular problems – strabismus, astigmatism, myopia, hyperopia, cataract

– Hearing loss, otitis media, narrow canals

• Other physical disorders

– Altered immune function, early aging

– Respiratory infections

– Leukemias

– Thyroid dysfunction

• Growth – Reduced

• Sexual development

– Delayed, incomplete or both

– Secondary sexual characters under developed

– Menstruation at average age, Can be fertile.

 

Therapeutic Management for Down Syndrome

• There is no cure

– Surgery may require to correct other serious congenital anomalies.

– Regular check and health care (to prevent sight, hearing, periodic test for thyroid function, growth chart to monitor nutrition, height and weight

– If diagnosed with lantoaxial instability (neck pain, weakness: prompt attention should be given—they are at risk for spinal cord compression

 

Nursing management for Down Syndrome

• Nursing diagnosis: Delayed growth and development R/T impaired cognitive functioning

• Goal 1 : Child will achieve optimum growth and development potential.

• Nursing interventions

– Involve child and family in an early infant stimulation program.

– Assess child’s developmental progress at regular intervals.

– Help family determine child’s readiness to learn specific tasks.

– Help family set realistic goals for the child.

– Employ positive reinforcement.

– Encourage learning of self care skills.

– Reinforce self care activities.

– Encourage family investigate special day care programs.

– Emphasize the child has the same needs as other children.

– Encourage optimum vocational training.

– Before adolescence counsel child and parents regarding physical maturation, sexual behavior marriage and child rearing.

 

Goal 2 : will achieve optimum socialization.

• Nursing interventions

– Emphasize child has the same needs for socialization as other children.

– Encourage family teach the child socially acceptable behaviors.

– Encourage grooming and age appropriate dress.

– Encourage peer relationships.

– Provide adolescent with sex information and a concrete code of conduct.

 

Nursing diagnosis 2: Risk for interrupted family process R/T having a child with MR.

• Goal 1: Child and family will receive adequate information and support.

• Nursing interventions

– Inform family of the defect at or as soon as possible after birth.

– Have both parents present while informing.

– Give written information about the condition.

– Discuss the pros and cons home care and other placement options.

– Encourage family meet other families with similar problems.

– Emphasize normal characteristics of the child.

– Encourage family members to express their feelings.

Goal 2: Child and family will be prepared for long term care of the child.

• Nursing interventions

– As child grows older, discuss parents with alternatives to home care.

– Encourage family include the child in planning for future care.

– Provide psychological and social support.

Related posts:

Posted in Nursing Care Plans, Nursing Intervention, Pediatrics Tagged with: , , ,

FaceBook Page

(function(i,s,o,g,r,a,m){i[\'GoogleAnalyticsObject\']=r;i[r]=i[r]||function(){ (i[r].q=i[r].q||[]).push(arguments)},i[r].l=1*new Date();a=s.createElement(o), m=s.getElementsByTagName(o)[0];a.async=1;a.src=g;m.parentNode.insertBefore(a,m) })(window,document,\'script\',\'https://www.google-analytics.com/analytics.js\',\'ga\'); ga(\'create\', \'UA-69237529-7\', \'auto\'); ga(\'send\', \'pageview\');