Small for

Gestational
Age
(Case Presentation)

By:
Akemi Hoshitani
Kathleen Dimacali
Ma. Patricia Dy
Cyra Mae Cuevo
Jerwina San Pedro
Bryan Joseph Tiongson
 TABLE OF CONTENTS

Introduction……………………………………………………….…………..……1
Objectives……………………….…………………………..……….……..………2
Overview…………………………………………………………………………..3-4
Patient’s Profile………………………..………………………………………….5
Patient’s Medical History……………………………………………………..6
Anatomy and Physiology………………………………………………………7
Pathophysiology…………………………………………………………………..8
Physical Assessment……………………………………………………..…9-10
Diagnostic tests…………………………………………………………………..11
Medical Management…………………………………………………….12-13
Nursing Care Plan 1………………………………………….………….…14-15
Nursing Care Plan 2………………………………………………….……….…16
INTRODUCTION

We are 4th year BS Nursing students; we were assigned to the

Pediatric Ward at Dr. Paulino J. Garcia Memorial Research and Medical
Center last March 5, 2021 for our clinical exposure this 2nd semester year
2020-2021. Under the supervision of our clinical instructor Mrs. Advincula
Fe Agulan we handled many cases and were able to conduct different case
studies. We chose to present the case of Small for Gestational Age to other
students who are unfamiliar with this case of an infant, that may help them
to obtain more knowledge. We have gathered information about the infant
and how he was small for gestational age when his mother delivered him.

As part of our RLE, we the 4th year students acquired the skills to be
competent enough to do the tasks given to us. There were some problems
encountered in our patient during his stay in the Neonatal Intensive Care
Unit. We identified proper nursing interventions for the client to prevent
further complications that may develop.

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OBJECTIVES

General objective
 This study aims to acquire knowledge on how to improve health,
development and quality of life of infant with low birth weight.

Specific objectives
 To gain understanding about the etiology of small gestational age.
 To distinguish physical appearance of infant with small gestational age
to a normal infant.
 To develop appropriate nursing management for small gestational age
infant.
 To determine ways on how to prevent development of complications.

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OVERVIEW

An infant is Small for Gestational Age if the birth weight is below the 10th
percentile on an intrauterine growth curve for the age. Such infants may be born:
 Preterm: before week of 38 of gestation
 Term: between weeks 38 and 42
 Postterm: past 42 weeks
SGA infants are small for their age because they have experienced intrauterine
growth restriction or failed to grow at the expected rate in the utero. This
characteristic makes them distinctly different from the infants who are born with
a less weight than the usual but their low weight is consistent for their
gestational age.

The most common cause of intrauterine growth restriction is placental issue; either the
placenta did not obtain sufficient nutrients from the uterine arteries or it was inefficient
at transporting nutrients to the fetus. Placental underdevelopment or damage, such as
partial placental separation with the bleeding is an example of a situation that would
limit placental function because the area of the placenta that separated infarcted and
fibrosed, reducing the placental surface available for nutrient exchange. Women with
systemic diseases that decrease blood flow to the placenta.

Things that can cause babies to be small for gestational age are listed below.
Problems with the mother
 High blood pressure
 Chronic kidney disease
 Diabetes
 Heart disease or respiratory disease
 Malnutrition or anemia
 Infection
 Alcohol or drug use
 Cigarette smoking
 Weighing less than 100 pounds

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Problems with the uterus and placenta
 Decreased blood flow in the uterus and placenta
 Placenta detaches from the uterus
 Placenta attaches low in the uterus
 Infection in the tissues around the baby

Problems with the developing baby

 Multiple pregnancy, such as twins or triplets
 Infection
 Birth defects
 Chromosome problems

Babies who are small for gestational age or who have IUGR may have problems at birth.
These can include:
 Lower oxygen levels than normal
 Low Apgar scores
 Breathing in the first stools (meconium) passed in the womb. This can
cause breathing problems.
 Low blood sugar
 Trouble keeping a normal body temperature

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PATIENT’S PROFILE

Name: Baby Boy M

Age: New born
Gender: Male
Religion: Catholic
Nationality: Filipino
Address: Cabanatuan City
Admission Date: March 5,2021
Admitting Diagnosis: Pre-mature 35weeks, Small for Gestational Age
Attending Physician: Dr. Dela Cruz

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MEDICAL HISTORY
Present medical history
A male infant was born on march 5,2021 at 35 weeks of gestation he is small for
gestational age with a birth weight of 1.8kg. The issue encountered during his stay at
neonatal intensive care unit were respiratory distress syndrome, low birth weight,
inability to maintain a constant body temperature, difficulty in feeding and slightly
jaundice in appearance. His respiratory distress problem was given oxygen via nasal
cannula at 1-2L/min. Prophylactic aminophylline was given to decrease the risk of
apnea.
According to the hospital guidelines, premature babies are given 5 days of
prophylactic ampicillin and cefotaxime. The infant had an umbilical catheter inserted
using aseptic technique which provided good intravenous access for the first 10 days of
life.
He was kept NPO for the first 48 hours and was maintained on intravenous
fluids. On the third day of life the infant, orogastric tube was inserted to start on 1mL
expressed breast milk every 2 hours.The feeds were increased by 1mL every other feed
provided that aspirates were minimal. The neonate’s observations were monitored,
with stool and urine output recorded on a chart. On his third day infant manifested
jaundice in appearance and physician order to have photo-therapy.

Socio-economic
His mother, a 20 year old woman, lives in a semi concrete house with her
parents and other family members. His mother is a out of school youth, and usually goes
to meet her friend. She and her friends have vices and often drink alcohol without
permission of her parents.
During interview, she admitted that she has poor nutrition, often smokes and
does not have prenatal checkup.

Family History
Parent DM HPN Kidney Disease SGA

Father - - + -

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 Mother + + - +

ANATOMY AND PHYSIOLOGY

Placenta
Organ formed temporarily in the uterus of pregnant women. It Grows from a few
identifiable trophoblastic cells at the beginning of pregnancy to an organ 15-20cm in
diameter and 2-3cm in depth, covering about half the surface area of the internal uterus
at term. Its roles are respiratory, excretory, and nutrition-delivery system for the fetus.
Nutrient and gas exchange: Terminal villi are the functional unit at which
maternal-fetal exchange of nutrients and gases occur. Mother's blood provides oxygen,
water with electrolytes, hormones, and other nutrients. In exchange, the fetus excretes
carbon dioxide, water, urea, hormones, and other waste products. The maternal and
fetal circulation do not mix. Instead, blood flow moderates the passive or active
transport of nutrients and gases between vasculature.

The umbilical cord is a helical and tubular blood conduit connecting the foetus to the
placenta. The umbilical cord achieves its final form by the 12th week of gestation and
normally contains two arteries and a single vein, all embedded in Wharton's jelly. 
The cord is sometimes called the baby's “supply line” because it carries the baby's blood
back and forth, between the baby and the placenta. It delivers nutrients and oxygen to the
baby and removes the baby's waste products.

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PATHOPHYSIOLOGY

PRECIPITATING FACTORS:
Lack of prenatal check-up
PREDISPOSING FACTORS Poor nutritional intake
Family history (SGA) Socio-economic
Smoking

Vasoconstriction of blood vessels

decrease blood supply to the placenta

Lack of nutrients and oxygen supply

Lack of necessary oxygen and nutrients receive by the fetus.

Failure to grow at expected rate

Low birth weight

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PHYSICAL ASSESSMENT
Asessment Examination Normal findings Actual findings Interpretation
Scalp Inspection Presence of Both anterior and Not fully develop
anterior and posterior fontanelles due to
posterior fontanelles are prematurity
fontanelles small

No lesion
Hair Inspection Soft, downy hair Dull and lusterless Due to lack of
nutrients

Face Inspection Normal Normal

configuration
>Eyes Inspection Bright and clear Appears small Due to early
Symmetrical delivery
eyelids
>Nose Inspection Presence of milia Presence of milia Normal; usually
disappears without
treatment
>Ears Inspection Well curved pinna Pinna less curve; Due to early
with firm cartilage; Properly aligned; delivery
Properly aligned; No presence of
No presence of skin tag, redness
skin tag, redness and lesion
and lesion
>mouth Inspection Pinkish smooth lips Dry pale lips and Due to poor
and symmetrical symmetrical nutrition
Smooth gums Smooth gums
pink color, smooth
to roughed
texture, non-
coated tongue
Neck Inspection Symmetrical; no Symmetrical; no Normal
Palpation no presence of presence of mass
mass
Skin Inspection Pink cover with Thin, red, shiny Infant has not fully
Palpation vernix caseosa skin; develop;
presence of Infant was born
lanugo; before the time
lanugo will
decrease (36-
40weeks);

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 poor skin turgor due poor
nutritional balance
Chest Inspection Presence of breast No breast edema;
Auscultation edema; unlabored
Palpation chest movement;
clear lung sounds
Abdomen Inspection Scaphoid, normal depressed Due to small liver
Palpation distended; abdomen
Cylindrical, round,
soft, bowel sound
presence 30-60
minutes after
birth, liver
palpable 1-2cm
below postal
marking;
Upper inspection Symmetrical, equal Thin extremities, Due to lack of
extremities in length, no Symmetrical, nutrients received
lesion, no equal in length, no from the mother
deformities. lesion, no during pregnancy
deformities
genital Inspection Descended testes Undescended Due to early
testes delivery
Lower Inspection sole creases over absent of sole Due to early
extremities Palpation the entire plantar creases to faint delivery
surface red markings
plantar
surface of
foot

APGAR SCORE
Indicator 1 minute after birth 5 minutes after birth 10 minutes after birth
Activity Some flexion (1) Some flexion (1) Some flexion (1)
Pulse >100bpm(2) >100bpm(2) >100bpm(2)
Grimace Good cry(2) Good cry(2) Good cry(2)
Appearance Acrocyanosis(1) Pinkish (2) Pinkish (2)
Respiration Strong and vigorous Strong and vigorous Strong and vigorous
cry(2) cry(2) cry(2)
Total 8 9 9

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DIAGNOSTIC PROCEDURE

Laboratory Test Norma values Results Clinical Significance

CBC
 RBC 5.00-7.00 x 10^12/L 4.70 x 10^12/L --Low RCBC due to
poor nutritional status
of the mother.
--Iron deposit at 36
weeks

 Lymphocyte 0.30-0.35 0.48 --High; Indication that

there is already an
infection and
inflammation.

RBS 30-125 78 --Within normal limits

Chest x-ray No demonstrate lung No demonstrate lung --Normal

parenchymal parenchymal
infiltrates infiltrates

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 DRUG STUDY
Name of Drug Dosage/ Action Side Effects Nursing Consideration
Route/
Frequency
Generic Name: Dosage : Is a complex of >Increased or >Monitor & record vital
Aminophylline 4 mg theophylline and ethyl rapid heart rate signs and I&O
enediamine and is >Irregular
Brand Name: Route:
Corophyllin IV given for its heartbeat
theophylline activity to >Seizures  >Monitor serum
Classification: Frequency:
relax smooth muscle theophylline levels.
Bronchodilator Every 6
hours and to relieve >Skin rash >Monitor for S&S of
bronchial spasm. toxicity
Theophylline is a >Notify physician or
smooth muscle nursing staff immediately
relaxant and it relaxes if these reactions occur.
the smooth muscle of
the bronchial airways.

Name of Drug Dosage/ Action Side Effects Nursing Consideration

Route/
Frequency
Generic Dosage: Acts as an irreversible >acute >Assess the client allergic
Name : 90 mg inhibitor of the inflammatory reaction
Ampicillin Route:
enzyme trans skin eruption >Assess for signs and
IV
Brand Name: peptidase, which is >redness and symptoms of infection
Omnipen needed by bacteria to peeling of the >Monitor blood studies
Frequency :
make the cell wall. It skin >Assess the bowel
Classification: Every 12
Antibiotic hours inhibits the third and >rash pattern daily
final stage of bacterial >hives
cell wall synthesis in >fever
binary fission, which >seizure
ultimately leads to cell >diarrhea
lysis, ampicillin is
usually bacteriolytic.

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Name of Drug Dosage/ Action Side Effects Nursing Consideration
Route/
Frequency
Generic Name: Dosage : It inhibits the >Injection site >Monitor injection site for
Cefotaxime 90 mg bacterial cell wall reaction(pain) pain, swelling, and
synthesis by binding irritation, a irritation
Brand Name : Route:
Claforan IV to one or more of the hard lump, or
penicillin binding’s inflammation) >perform skin test before
Frequency:
protein. This inhibits initial administration
Classification: Every 12
Antibiotics – hours the final >rash >Monitor signs of allergic
Cephalosporin transpeptidation step >itching reactions and anaphylaxis,
third of peptidoglycan >hives including pulmonary
generation
synthesis in bacterial >fever symptoms.
cell walls ,thus >Notify physician or
inhibiting cell wall nursing staff immediately if
biosynthesis these reactions occur.

Name of Drug Dosage/ Action Side Effects Nursing Consideration

Route/
Frequency
Generic Dosage : Is a competitive >Stomach pain >administer medication
Name : 1.8mg inhibitor of histamine >Nausea and with food
Ranitidine H2-receptors. The vomiting
Route: reversible inhibition >Diarrhea or >Increase fluid intake if not
Brand Name : IV of H2-receptors in constipation contraindicated
Zantac gastric parietal cells >Skin Rash >Monitor signs of
Frequency: results in a reduction hypersensitivity reactions,
Classification: Every 12 in both gastric acid including pulmonary
Histamine H2 hours volume and symptoms (tightness in the
Antagonists concentration. throat or chest, wheezing,
cough) or skin reactions
(rash, pruritus, urticaria).

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 NURSING CARE PLAN 1

Assessment Background Nursing Planning Nursing Rationale Evaluation

Knowledge Diagnosis Intervention
Subjective: SGA infant had Ineffective After 8hrs of INDEPENDENT: After 8hrs of
lower body fat Thermore- nursing 1. Mummify the -These measures nursing
due to gulation r/t intervention, baby and cloth raise the core intervention,
Objective: inadequate to low infant body appropriately temperature and infant body
nutrient supply stored temperature improve temperature
Cold skin during fetal body fats will increase circulation. Core increased
Pale life. Exposure as from 35°C- warming is from 35°C-
Shivering to cold leads evidenced 36.5°C indicated when 36.5°C
to heat loss by body temperature
Vital signs: through shivering is below 30 °C (86 -Goals Met
HR- 180 convection, and °F)
bpm conduction temperatu
T-35°C and re of 35°C. 2. Manipulate the -Decreases heat
RR-68cpm evaporization environment loss by convection
makes the (warm room
infant unable temperature)
to maintain
normal body
temperature. 3. Warm the -Decreases loss of
objects coming in heat by
contact with conduction.
infant’s body,
such as
stethoscopes and
thermometer.

4. Change clothing -Decreases

or bed linens evaporative heat
when wet. Keep losses
infant’s head
covered.

COLLABORATIVE:

5. Place infant in a -Maintain

warmer, thermoneutral
incubator, or environment and

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open bed with helps prevent cold
radiant warmer. stress.

6. Use heat lamps -Decreases heat

during certain loss to the cooler
procedures. environment of
the room.

7. Monitor -Reveals &

lab/diagnostic prevents any
studies as further
appropriate. complications.

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 NURSING CARE PLAN 2

Assessment Background Nursing Planning Nursing Rationale Evaluation

Knowledge Diagnosis Intervention
Subjective: Poor nutrition Imbalanced After 1 week INDEPENDENT: After 1
of the mother Nutrition: of nursing week
Objective: during Less Than intervention  of nursing
*Poor skin pregnancy Body the client 1. Place in semi- -To prevent back intervention 
turgor leads to fetus Require- will gain fowler’s position flow of formula. the client
*weak cry received less ments  weight from during feeding and gained
*Weight - than required related lack 1.8kg- 2kg burp after. weight from
1.8kg nutrients. of nutrients 1.8kg- 2kg
*Low RBC received 2. Administer -To provide
*pale from the feeding through feedings into -Goals met
mother orogastric tube. stomach until
during baby can take
pregnancy food by mouth.
as
evidenced COLLABORATIVE:
by low birth 3. Feeding as -To
weight, ordered prevent
poor skin the
turgor, hypoglyce
weak cry, mia and
low RBC 4.Administer TPN meet the
and pale in as ordered nutritional
appearance needs.

5.Administer -To meet

Calcium gluconate the
as ordered nutritional
need of
the infant

-to treat acute

hypocalcemia.

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