Nursing Care Plan for Deviations in Growth Patterns

Deviations in intrauterine growth patterns not only increase the risk of morbidity and mortality in the early newborn period, but may also have long-term implications for altered growth and development and for altered CNS function and learning disabilities in childhood.

This general plan of care is designed to facilitate optimal nursing management of the infant with deviations in intrauterine growth and is to be used in conjunction with the CPs: The Neonate at Two Hours to Two Days of Age, and The Preterm Infant, as appropriate. Growth deviations are classified as SGA, intrauterine growth retardation/restriction (IUGR), and LGA.


SGA/IUGR: Any newborn whose birth weight falls at or below the 10th percentile on classification charts, considering local factors (e.g., ethnicity, altitude).

LGA/Macrosomic: Any newborn whose birth weight is at or above the 90th percentile on classification charts, considering local population at any week in gestation (with special attention to determining appropriate gestational age), or who at birth weighs more than 4000 g (8 lb 13 oz).

NURSING PRIORITIES
1. Maintain physiological homeostasis.
2. Prevent and/or treat complications.
3. Identify/minimize effects of birth trauma.
4. Provide family with appropriate information/strategies for meeting short- and long-term needs associated with
growth deviation.

Nursing diagnosis: Impaired gas exchange may be related to Alveolar capillary membrane changes (decreased surfactant levels, retained pulmonary fluid, meconium aspiration), altered oxygen supply (diaphragmatic paralysis/phrenic nerve paralysis, increased intracranial pressure) possibly evidenced by restlessness/irritability; inability to move secretions, tachypnea, cyanosis, hypoxia.

Desired Outcome
1. Display spontaneous, unassisted regular respiratory effort with rate of 30–50/min; and ABGs WNL.
2. Be free of apnea and complications of hypoxia/lung disease.

Nursing intervention with rationale:
1. Review history for abnormal prenatal growth patterns and/or reduced amounts of amniotic fluid, as detected by ultrasonography/fundal changes.
Rationale: Low-birth-weight infant or infant with IUGR suffers chronic intrauterine asphyxia, resulting in hypoxia/malnutrition. Fetal contribution to the amniotic pool is reduced in the stressed infant. Macrosomia can be related to maternal diabetes, prolonged pregnancy, heredity, and inappropriate nutrition. Macrosomia in IDM results from excess release of growth hormone (thyroid stimulation), increasing the number of cells and/or organ size throughout the body.

2. Note type of delivery and intrapartal events indicative of hypoxia.
Rationale: Infant with chronic hypoxia will be more susceptible to acidosis/respiratory depression/persistent fetal circulation (PFC) after delivery. Cesarean birth increases risk of excess mucus because thoracic compression by the birth canal does not occur as in a vaginal delivery.

3. Note time/onset of breathing and Apgar scores. Observe ensuing respiratory patterns.
Rationale: The infant with intrapartal asphyxia may present with a delayed onset of respirations and altered respiratory pattern. Apgar scores aid in evaluation of the degree of depression or asphyxia of the newborn at birth and are directly correlated with serum pH/degree of infant acidosis.

4. Assess respiratory rate, depth, effort. Observe and report signs and symptoms of respiratory distress, distinguishing from symptoms associated with polycythemia.
Rationale: Infant with altered growth is more susceptible to respiratory distress associated with chronic asphyxia in SGA infant, inadequate surfactant levels in IDM,

5. Auscultate breath sounds regularly.
Rationale: Presence of crackles/rhonchi reflect respiratory congestion and need for intervention.

6. Suction nasopharynx/endotracheal tube as needed, after first providing supplemental oxygen.
Rationale: Ensures patency of airway, removes excess mucus. Supplemental oxygen reduces hypoxic effect of procedure.

7. Auscultate apical pulse; note presence of cyanosis.
Rationale: Tachypnea, bradycardia, and cyanosis may occur in response to altered oxygen levels.

8. Prevent iatrogenic complications associated with cold stress, metabolic imbalance, and caloric insufficiency.
Rationale: Such complications increase metabolic demands and oxygen needs.

9. Ensure availability of resources in the event complications occur.
Equipment for oxygenation, suction, intubation, assisted ventilation, resuscitation, and chest tube placement must be readily available in the event of severe/prolonged respiratory distress.

10. Monitor transcutaneous oxygen/pulse oximeter readings.
Rationale: Identifies therapy needs/effectiveness.