Small for

Gestational
Age
(Case Presentation)

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

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 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 Management………………………………………….…14-16

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INTRODUCTION

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

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 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 problem
encountered in our patient during his stay in Neonatal Intensive Care Unit.
We identified proper nursing interventions for the client to prevent further
complications that may developed.

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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 develop appropriate nursing management for small gestational age
infant.
 To distinguish physical appearance of infant with small gestational age
to a normal 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

MEDICAL HISTORY

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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 - - + -
Mother + + - +

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ANATOMY AND PHYSIOLOGY

Placenta
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.
Organ formed temporarily in the uterus of pregnant women. 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.

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PATHOPHYSIOLOGY

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

Limit blood supply through the placenta and Lack of nutrients and oxygen supply

Decrease 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 White coating on Due to
texture, non- tongue accumulation of
coated tongue milk
Neck Inspection Symmetrical; no Symmetrical; no Normal
Palpation no presence of no 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

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 lanugo; before the time
poor skin turgor lanugo will
decrease (36-
40weeks); 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 Sunken abdomen Due to small liver
Palpation distended;
Cylindrical, round,
soft, bowel sound
presence 30-60
minutes after
birth, liver
plapable 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

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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

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 usually bacteriolytic.

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

Brand Name : Route: synthesis by binding irritation, a irritation

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 >Stoma >administer
Name : 1.8mg inhibitor of histamine ch pain medication with
Ranitidine H2-receptors. The >Nause food
Route: reversible inhibition a and
Brand Name : IV of H2-receptors in vomitin >Increase fluid
Zantac gastric parietal cells g intake if not
Frequency: results in a reduction >Diarrh contraindicated
Classification: Every 12 in both gastric acid ea or >Monitor signs of
Histamine H2 hours volume and constip hypersensitivity
Antagonists concentration. ation reactions, including
>Skin pulmonary
Rash symptoms
(tightness in the
throat or chest,
wheezing, cough) or
skin reactions (rash,

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 pruritus, urticaria).

NURSING CARE PLAN

Assessment Background Nursing Planning Nursing Rationale Evaluation
Knowledge Diagnosis Intervention
Subjective: SGA infant had Ineffective After 8hrs of INDEPENDENT: After 8hrs
N/A lower body fat Thermore- nursing 1. Monitor vitals -Serves as a of nursing
due to gulation r/t intervention signs. baseline intervention
inadequate to , information and , infant
nutrient supply decrease infant will any changes may maintained
Objective: during fetal stored maintain indicate normal
life. Exposure body fats body worsening of temperatur
Cold skin to cold leads as temperature infant’s condition. e
Pale to heat loss evidenced within appropriate
Shivering through by normal 2. Place infant in a -Maintain for age.
convection, shivering range. warmer, thermoneutral
Vital signs: radiation, and incubator, or open environment and T= 36.5 °C.
HR- 150 conduction temperatu Temp:36.5° bed with radiant helps prevent cold
bpm and re of 35°C. C. warmer. stress.
T-35°C evaporization -Goals Met
RR-26cpm makes the 3. Use heat lamps -Decreases heat
infant unable during certain loss to the cooler
to maintain procedures. environment of
normal body the room.
temperature. 4. Warm the -Decreases loss of
objects coming in heat by
contact with conduction.
infant’s body, such
as stethoscopes
and thermometer.
5.Change clothing -Decreases
or bed linens when evaporative heat
wet. Keep infant’s losses
head covered.

COLLABORATIVE:
1. Provide or -Helps prevent
administer meds seizures
as prescribed. associated with
hypothermia.
2. Monitor -Reveals &

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

Assessment Background Nursing Planning Nursing Rationale Evaluation

Knowledge Diagnosis Intervention
Subjective: Lack of Imbalanced After 1 week INDEPENDENT: After 1
N/A prenatal care Nutrition: of nursing 1. Monitor the -Identifying the week of
and poor Less Than intervention  weight by risk and the nursing
Objective: nutrition of Body the client measuring body degree of risk to intervention
*Poor skin the mother Require- will weight every day, growth patterns. the client
turgor during ments  experience p then document in SGA infants with was able to
pregnancy related lack rogressive infant growth excess extracellul experience 
*poor leads to of nutrients weight gain charts every day. ar fluid possibility progressive
muscle tone infant received as of losing 15% weight gain
received less from the evidenced of birth weight. as
*Weight - than required mother by: Weight evidenced
1.8kg nutrients. during of 2.2 kg. 2. Assess the level -Provide by: Weight
pregnancy of hydration, note information about of 2.2 kg.
*Low RBC as fontanelle, skin the actual input in
evidenced turgor, urine conjunction with -Goals met
V/S taken as by low birth specific gravity, an approximate
follows: weight and the condition of adjustment needs
PR:120bpm poor the mucous to be used in
RR:40cpm muscle membranes, the diet.
Temp:36.5O tone. weight
C fluctuations.
-Glucose is the
3. Monitor for main source of
signs of fuel for the brain,
hypoglycemia; deficiency can
tachypnea and cause permanent
irregular damage to the
breathing, apnea, CNS.
lethargy, Hypoglycemia
temperature significantly
fluctuations, and improve the
diaphoresis. mobility of
mortality and
severe effects of
time dependent o

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 n the duration of
each episode.

4. Place in semi- -To prevent back

fowler’s position flow of formula.
during feeding and
burp after.

5. Administer -To provide

feeding through feedings into
orogastric tube. stomach until
baby can take
food by mouth.

COLLABORATIVE:
1. Monitor -Hypoglycemia
laboratory tests as can occur in the
indicated: serum early 3 hours of
glucose, blood birth infants SGA
urea nitrogen, when glycogen
creatinine, stores quickly
osmolality, reduced and
serum / urine, gluconeogenesis
urine electrolyte. inadequate
because of a
decrease in
deposits of
protein drugs and
fat.

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