Admission Assessment
R.G. is twin #1 born in a twin pregnancy.  At birth her APGAR scores were 8 for the first minute and 9 at ten minutes. 
R.G. was born weighing 945gm which places her in the extremely low birth weight (ELBW).  The mortality rate is 70- 100 times greater in infants born weighing less than 1,500 gms (Vandenbosche, 1998).  Her length was 36cm and her head circumference was 23.5 cm.
She is in an isolette which helps her body to maintain thermoregulation.  R.G. shares this isolette with her twin brother, otherwise known as co-bedding.  There is also a machine that monitors her heart rate and rhythm, respirations and oxygen (O2) saturation. She has a nasal gastric tube that has been placed to help supply her with needed nutrients.

Diagnosis
R.G. was diagnosed with Intrauterine Growth Retardation (IUGR).
IUGR is defined as a birth weight under the 10th percentile of predicted fetal weight for gestational age (Vandenbasche,1998).  the incidence of IUGR is approximately five percent in the general obstetric population (Hunter, 1998).
According to Catz, the major risk factors are small maternal size, low maternal weight gain but the major predictor is a low maternal body mass index.  There are two categories that divide the many different causes of IUGR; maternal and fetoplacental factors.  Some of the maternal factors include smoking, alcohol, cocaine, warfarin use and malnutrition.  The fetoplacental factors include chronic hypertension, diabetes mellitus, syphilis, Hepatitis B and HIV-1 (Vandenbosche, 1998).
If we can work on getting the parents involved in early prenatal care, this could help to lower the incidence of IUGR.  Stopping the use of drugs and getting the maternal diseases under control could eliminate nearly all of the cases that are a result of maternal factors and help to decrease the cost of the hospital stay in the long run.
Some of the signs and symptoms of IUGR before birth include:

• A fundal height that lags by more than 3 cm.
• A fundal height that is increasing in disparity with gestational age.
• An abdominal circumference below the 2.5th percentile.
• A decreased volume of amniotic fluid (fluid index value less than 5cm) (Hunter,1998).

• The face is shrunken.
• The umbilical cord is thinner.
• The head appears larger than the body.
• The extremities are scrawny with thin skin folds, decrease in subcutaneous fat and skeletal muscle.

Assessment 

R.G.'s gestational age was thirty-one weeks old at the time of my assessment.  She had a weight gain of 320 gms, making her current weight 1265 gms.  She is 40 cm in length and has a head circumference of 26 cm.
R.G. moves all extremities equally and has a delayed root reflex and a weak suck-swallow reflex.  Her fontenelles are soft and flat. 
R.G.'s heart rate is regular and ranges from 150-160's, with no murmur present.  Her capillary refill is less than 2 seconds.
R.G. is on room air and her breathing pattern was non-labored, irregular, periodic and abdominal.  Her respiratory rate ranges between 54-60's.  Her temperature ranged 36.5-36.8 C while in an isolette.
Eyes and ears are symmetrical with no discharge present.  In her right nostril is a feeding tube that requires aspiration for placement before feeding.  A white substance was noted during aspiration.
Bowel sounds were present and her abdomen was soft, round and symmetrical with no distention present.  Since she is twenty-eight weeks old, her umbilical cord has already healed and fallen off.
R.G.'s skin was pink, dry and intact.  She had good skin turgor with no tenting observed.  Light blonde lanugo was present on her shoulders, and there is little subcutaneous fat or muscle tissue.  Skin folds are only evident around her knees and buttocks. An expected newborn assessment.

Current abnormal laboratory values were:
                  Norms       why abnormal
WBC 4.7    (6-17)     immunosupressed due to prematurity
Segs  22     (50-60)    immunosupressed due to prematurity
bands 2      ( 3-8)       immunosupressed due to prematurity 
lymphs 72  (25-40)    immunosupressed due to prematurity
bilirubin 11.2 (.2-1.2) RBC breakdown from polycythemia

Medications 

Erythropoetin
Name: epoetin alfa (Epogen®, Procrit®) 
Use: treat anemia associated with chronic renal failure to elevate or maintain red 
blood cell level and to decrease the need for transfusions 
Usual dose:200-300units/kg/dose,2-3 times per week/ 
Ordered dose: 220 U every other day 
Side effects: hypertension, fatigue, headache, and fever 
Nursing implications: -hematocrit should be determined twice weekly until stabilization within the 
target range (30% - 36%), and twice weekly for at least 2 to 6 weeks after a dose increase 
     -careful monitoring of blood pressure is indicated 
     -iron, folic acid, and vitamin B12 deficiencies limit hemoglobin synthesis 
test                           initial phase frequency           maintenance phase frequency 
hematocrit/hemoglobin         2 x/week                                                 2-4 x/month 
blood pressure                       3 x/week                                                3 x/week 
serum ferritin                          monthly                                                quarterly 
transferrin saturation            monthly                                                quarterly 
serum chemistries including :  regularly per routine           regularly per routine 
CBC w/ differential, creatinine, 
BUN, potassium, phosphorous 
Patient education: -frequent blood tests are needed to determine the correct dose; notify physician 
if any severe headache develops.

This medicine was prescribed to deal with anemia, although her hemoglobin and hematocrit would within normal limits when I cared for her, they were not when she was admitted.

  Vitamin E 
Name: -free d-alpha tocopherol is most biologically active 
Use: -antioxidant 
     -treat vitamin E deficiency 
Usual dose: -premature infants <= 3 months 17 mg (25 U)/day 
     -infants <= 6 months 3 mg (4.5 U)/day 
     -neonates, premature, low birth weight 25-50 U/day results in normal levels within 1 week 
Ordered dose: 15 U every day 
Side effects: -hypervitaminosis E 
Nursing implications: -in growing premature infants, iron supplementation should not be started until adequate vitamin E is supplied in the diet;  otherwise iron may increase hemolysis 
Patient education: -none for this situation.

This medication was used as an antioxidant for her and to prevent a deficiency which can occur in premature infants.

Ferrous Sulfate
Name: Feosol 
Use:-treat iron deficiency and iron deficiency anemias 
     -dietary supplement for iron 
Usual dose: 5-10 mg/kg/day (6 mg-38 mg/day)
Ordered dose: 25 mg/day 
Side effects: -GI irritation, nausea, vomiting, constipation, diarrhea, darker stools 
-iron-containing liquids may temporarily stain teeth or membrane covering teeth 
with infants 
Nursing implications: -avoid use in premature infants until the vitamin E stores, deficient at birth, 
are replenished 
     -avoid using for longer than 6 months except in patients with conditions that require prolonged 
therapy 
     -food interactions:  milk, cereals, dietary fiber, tea, coffee, or eggs may decrease absorption of iron 
Patient education: -take on an empty stomach; if GI irritation occurs, take after meals or with food 
     -do not take within 2 hours of antacids, tetracyclines, or fluoroquinolones 
     -may cause black stools, constipation, or diarrhea.

This medication was given for her anemia and because sshe was premature, her nutritional intake may not supply her iron needs.

     Folvite
Name: folic acid, vitamin B9 
Use: -treatment of magaloblastic and macrocytic anemias due to folate deficiency 
     -dietary supplement to prevent neural tube defects 
Usual dose: .05-0.1 mg/day
Ordered dose:.05 mg/day
Side effects: -no major side effects 
Nursing implications: -falsely low serum concentrations may occur with the Lactobacillus caseiassay method in patients on anti-infectives (eg, tetracycline) 
Patient education: -take folic acid replacement only under recommendation of physician.

This medication, too, was used for her anemia.
(Neofax, 2000).

Nutrition Consultant 
Nutrition Screen 
Gender:            Female
Length:            40 in
Weight:            1265 gm 

Weight Change in Past 6 Mo: 
     945 gm at birth
Age:               30 weeks
Diagnosis:            Intrauterine growth retardation
Diet Order:            Nasal Gastric Tube 
                        Epf 24 kcal at 25cc every 3 hours
                        MCT oil at 1.6 cc
                        Iron Supplement at 25 mg
                        Vitamin E at 15 units
                        Folic Acid at 0.05 mg
Ideal Body Weight:  Patient is AGA (appropriate for gestational age)
Vital Signs:            Temp – 36.7
                        Heart Rate – 157 
                        Resp. Rate – 54
                        BP – 56/36
Labs:             WBC – 4.7
                        RBC – 9
                        Hgb – 19.1
                        Hct – 61.2
                        Na – 136
Drugs/Meds:            Epoetin – 220 units
                                    Fe Supplement – 25 mg
                                    Vitamin E – 15 units
                                    Folic Acid – 0.05 mg
Nutritional Risk Assessment: 
            Patient is at high nutritional risk due to diagnosis.
Recommendation:

            Fluids – begin at a rate of 133 mL/day (105mL/kg/day) and increase to 202 mL/day (160 mL/kg/day) by the second week.  (Fluid needs must be determined on an individual basis, but without actually assessing the patient this is what I would suggest)

            Energy – patient should be receiving 64kcal/day (50 kcal/kg/day) for maintenance and this amount should be gradually increased once the patient is stable to 133 – 164 kcal/day (105 kcal/kg/day – 130 kcal/kg/day), which will meet the energy requirements for growth.

            Glucose – an initial glucose load of 5.1 – 7.6 mg/min (4 – 6mg/kg/min) should be administered and then advanced by 1 – 2 mg/kg/min to reach a maximum rate of 13.9 – 15.2 mg/min (11 –12 mg/kg/min).

            Amino Acids – the patient should receive 0.6 – 1.3 g/day (0.5 – 1.0 g/kg/day) initially and increase by 0.5 g/kg/day to reach a maximum of 3.2 – 3.8 g/day (2.5 – 3 g/kg/day) as tolerated.

            Lipids – the patient should receive 0.6 g/day (0.5 g/kg/day) initially and increase by increments of 0.5 g/kg/day as tolerated to reach a rate of 3.8 g/day (3 g/kg/day).  To prevent a rise in triglycerides and free fatty acids the lipids should be administered over 24 hours at a rate less than 0.12 g/kg/h.

            Electrolytes – Na, Cl, and K should each be administered at a rate of 2.5 – 3.8 mEq/day (2 – 3 mEq/kg/day).  Urine electrolytes should be quantified when serum levels are abnormal to monitor for inappropriate electrolyte excretion.

            Vitamins and Minerals – extra supplementation is probably not necessary due to the concentrations found in the formula the patient is receiving. 
These recommendations are based on the patient information that was available.  To make an accurate assessment and recommendation it would be necessary to perform an actual nutrition assessment on the patient.

Nursing Diagnosis

For my first nursing diagnosis; I choose altered nutrition, less than body requirements related to decreased nutritional stores ( prematurity) as evidenced by extremely low birth weight at 10th   percentile at birth.

The second one that I choose for, R. G., was risk for caregiver strain related to demands of      child care at home ( 5 and 7 year olds) and the needs of twins in the neonatal intensive care     unit.

Nursing Interventions

R.G. has a nasogastric tube through which she is fed EPF 24 calories 25 cc's every three hours with MCT oil, she is also receiving folic acid, Vitamin E and Ferrous Sulfate to aid in her         nutritional needs. This regimine will continue until R.G. weight gain for 2 days and then we will  recalculate her caloric needs according to her new body weight.  She had not been having any bowel movements so she is now receiving suppositories as well. 
 Her isolette temperature is set at 29.1 C to ensure that her body temperature is appropriate.   Along with regulating the temperature, it is also important to make sure that the infant has     adequate nutrition and is well hydrated.  Understanding the infants ques can help make sure     that her needs are met and that she is cared for if she is distressed.  Monitoring for            hypoglycemia, hypocalcaemia and polycythemia are necessary to avoid further complications   and aid in the proper development of an infant with IUGR. 
Some interventions for the second nursing diagnosis, would include: teaching the mother some   of the skills to care for her new twins ( baths and CPR) and make sure that she can             demonstrate them back to you, another would be to provide some support group oppertunities that the mother could attend to deal with the stresses of caring for twins, planning to have the   mother room in with the twins for two nights before they are discharged and allow her to do all of the cares and that way if she needs help there are people are around that can help her.
 

Outcomes
Most infants with IUGR have normal rates of growth in infancy and childhood.  Unfortunately, about 1/3 of these chiMost infants with IUGR have normal rates of growth in infancy and childhood.  Unfortunately, about 1/3 of these children never achieve normal height (Hunter, 1998).  There can be a variety of long-term complications that can result from IUGR.  According to Robert Vandenbosche, some of these include, hyperactivity, clumsiness and poor concentration. Some studies have found that these infants are at a greater risk for hypertension, abdominal obesity and type two diabetes as adults (Vandenbosche, 1998). 

R.G. and her twin brother were both very fortunate because both of them have been            discharged and sent home. This means that both of them reached an appropriate body weight and showed no signs of any dangerous complications. At this point it is too early to fully          determine their outcome but as for now they are both healthy. 

Conclusion
It can be very traumatic to hear that your baby has intrauterine growth retardation but today, there is more technology available and some of the smallest babies are surviving.  Even though some infants born with IUGR will have cognitive and medical problems, there are the other infants born with this and they are surviving with little defects.

*RG has been used to protect the confidentiality of the pateint.

References

  Catz, C. S., Grave, G. D., Hay, W. W., & Yaffe, S. J. (1997). Fetal growth: its regulation

and disorders. Pediatrics,99(4), 585-592. [Online]. Available: Infotrac/Health-Reference

Center/A21253834[2001,Mar.5].

   Fleming, J. E., McNay, M.B., Smith, G. C., & Smith, M. F.(1998). First- trimester growth 

and the risk of low birth weight. The New England Journal of Medicine,339(25), 1817-1822.

   Grobman, M. A., & Parilla, B. V. (1999). Positive predictive value of suspected growth

aberration in twin gestations. American Journal of Obstetrics & Gynecology, 

181(5),1139-1141.

   Hunter, S. K., Kennedy, C. M., & Peleg, D. (1998). Intrauterine growth restriction: 

identification and management. American Family Physican,58(2), 453-563. Available; 

infortrac/ Health-Referenec Center/A21038656 [2001, Mar. 5].

   Vandenbosche, R. C. (1998). Intrauterine growth retardation. American Family Pysician,

58(6), 1384-1391. Available; Infortrac/ Health-Reference Center/ A21251949 [2001, Mar. 

5].