According to the World Health Organization (WHO) the baby born

weighing less than 2500 grams, which is measured in the first 24 hours of
birth. LBW is still a problem because it contributes to prenatal mortality,
(76%) died in the first hour of birth and more than two-thirds died in the
first week of life. LBW has a 40 times higher risk of neonatal death
compared to babies born with normal weight, 5 times at risk of death
during the post neonatal and risk trend will persist as delays in cognitive
development, developmental problems and a tendency to experience pain
in childhood. (Pantiawati, 2010).

According to the (Riskesdas, 2013) Trends in low birth weight infants
(LBW) in infants, in province South Kalimantan is at 5% and was lower
than in 2010 (11.1%) the incidence in South Kalimantan is 15%. Data
obtained from the General Hospital Ulin Banjarmasin dated 3 April 2013
that the incidence of most diseases in children in the Teratai ward is the
LBW 364 cases.




According to the Proverawati and sulistyorini, (2010), infants of low birth
weight (LBW) babies are born weighing less than 2,500 grams is regardless
of pregnancy.

infants of low birth weight (LBW) can be two (2) categories, infants with
very low birth weight (BBLSR) with birth weight 1000 to 1500 grams birth
weight and extremely low (BBLASR) with a birth weight less than 1,000
grams.

The causes of LBW is multi factorials, among other things sorely lacking
maternal nutrition during pregnancy, impaired growth in the womb ( fetal
growth is low), placenta factors, infections, mothers uterine abnormalities,
trauma,(nanda 2012).











According to (Surasmi and Handayani, 2013)Placenta previa, solucio placenta
And premature rupture of membranes could result in placenta insufficiency so
as not to transfer nutrient to the fetus and can causes premature birth or low
birth weight. Volume maternal malnutrition can lead to decreased blood and
lowers blood to the placenta this causing placenta insufficiency and reduced
transfer of nutrient to the fetus causing the occurrence of LBW. In response to
cold stimulations, the babys body will issue a stimulation norepenefrin
metabolism of fat reserves to produce a calorie of fat which is then carried by
the blood to the tissue.





Low birth weight (LBW) are relatively less able to survive because of the
structure of the immature anatomy and physiology and biochemical function
has not worked as older infant. The shortage affect the infants ability to
regulate and maintain body temperature within normal limits, because the
temperature control center in the brain is not yet mature, the lack of
subcutaneous fat and body surface relatively wide will cause the body to lose
heart more. Shivering response in infant less or non-existent, so baby cannot
increase body heart through activity. Beside skin reflex control is still lacking.
According to Maryunani ( 2013), low birth weight infant (LBW) highly
variable and that is most evident in infant with gestational age shortened. As
for the traits
of characteristics of Low Birth Weight ( LBW) are:


General Proportions.
Preterm infants have large heads in proportion to body size. Head basic the
circumference equal to or less than 33 cm. lanugos air is still a lot. Body
length generally equal to less than 40 cm, chest circumference equal to or
less tan 30 cm, weight equal to less tan 2500 grams.

Activity
Weak muscle tone and the lower the gestational age, the less the childs
activity.

Control Of Temperature
Preterm infant tend to have subnormal. This was caused by poor heat
production and increased heat loss.




Respiratory System
Infant respiratory muscles are week and under develop respiratory center as
well as the lack of production of surfactants to reduce surface tension of the
lungs.
The Circulatory System.
Heart is relatively small at birth, in some preterm infant it works slow and
weak, especially in the blood vessels.
Digestive System
The lower of gestational age, the more weak sucking and swallowing
reflex, the smallest infants are unable to swallow effectively.
Urinary System
Renal function is less efficient because of a declining glomerular
filtration rate that results in a decreased ability to concentrate urine, and the
become slightly
Nervous System
Development of the nervous system is largely dependent on the degree of
maturity. In premature infant more reflex and general tonic neck reflex and
tendon reflex are generally less well.

















According to Maryunani (2013) complications that can arise in low birth
weight (LBW) is as follows:

Takepnea in newborns.
Fibroplasias retrolentral.
Attacks Apnea
Necrotizing enterocolitis (NEC).
Hypothermia.
Hypoglycemia
Breating distress syndrome.
Hyperbilirubinemia.

Client Identity
Mrs.Rs baby with gender male was born on Tuesday 5
th
May 2014 at 23:01
pm at Ulin General Hospital in Vk ward attended by midwifes. Mrs Rs
baby is the second child of the couple Mr.T (30 years old) and Mrs.Rs (28
years old). Mr.T family address in Jl. Kelayan A Rt. 22 Banjarmasin.
Education: Mr.T is junior high school and was Mrs.R last education is
junior high school. Mr.T occupation is a docker and Mrs.R is a housewife
(IRT). Mr.T and Mrs.R are Muslim. Mrs.R gave birth Tuesday May 5
th

2014 at 23:01 pm by Sectiocaesaria delivery breech presentation 32 weeks
of gestation.

General state of Mrs.R baby are born immediate with delivery method
sectiocaesaria as because she mother had indication syndrome eklamsia in
surgey ward Ulin General Hospital with afgar score 4-6-7 Afgar score 0-3
indicates that severe asphyxia, 4-6 indicates moderate aspyhyxia, and 7
showed mild asphyxia, and 8-10 normal / healthy body. Babies born with
sex is male, weight 17.50 grams, hight 43cm heart rate 138x / minute,
spontaneous respiratory 40x / minute, body temperature is 36.3
o
C

(axillary)
CRT is > 2 and no birth trauma in infant. At birth the action performed on
Mrs.Rs baby is cry suction of the mouth and nasal, giving gentamcyin
eyes drops in both eye, and trough IM injection of vitamin K by nurses
after birth the baby immediately brought to teratai ward to get treatment
because the baby have indication low birth weigh.



Subjetive data:
mother said that her baby milk that come out just a little bit.
Mother said that her baby was weak in sucking reflex

Objective data :
Mrs.Rs baby placed in the box with a thick baby clothes, and baby
swaddled in a blanket. Baby being treated in hospital, the baby was placed
in an incubator because Mrs.Rs baby some times temperature is down on
36.1
o
C.
Cord circumstances seem not out and looked a little blackish.
At birth the baby was sucking mucus through the nasal and mouth.
Mrs.Rs baby gestational age 32 weeks
Baby aged 4 days.
Subcutaneous fat look thin
General state of compos mentis baby with AFGAR SCORE 4-6-7



Mrs.R.s baby positive more refex (extension or abduction movements in te
extremities when startled), positive grasping reflex (moval time grasping
fingers attached to the plam of the baby), rooting reflex
(For the nipple) negative, sucking reflex (sucking) is still weak /
swallowing reflex positive (swallow) but weak the swallowing reflex
positive grabella (baby wink at the base nose or between the eyes being
touched), startel negative reflex (baby do not look at his ears touched with a
fingers).
Anthropometric measurements in Mrs.R.s baby body weigth is 17,50 grams
body length is 43cm, head circumference 31cm, chest circumference 25cm
and , upper circumference 8 cm.
Respiratory rate when assessment 55x/ minute.
Mrs.Rs baby mucosa dry lips
Mrs.Rs baby is only able to sped a PASI 10 cc / 3 hours of the
recommended that 30 cc / 3hours.
















Palpation:
Baby body temperature is 36.1
o
C.measured use thermometer
At the time palpation pulse 120x / minute.
Pecussion: -
Auscutation:
At the time of auscultation of bowel sounds in Mrs.Rs baby is 10x /
minute.


Data Problem Etiology
Thursday, May 8
th
2014
Subjective data:
-Mother said that his baby
milk that
came out just a little bit.
-mother said that his baby
weak.
sucking reflex.
Objective data:
-Sucking reflexes weak
rooting
reflex (to the nipple)
negative,reflex
swallowing
(swallow) positive but
still weak.
Imbalance nutrition less
than body
requirement.
Weak sucking
reflex, inadequate
nutrition intake.
-Mrs.Rs baby mucosa lips looked
dry.
-bowel sounds are 10 x/ minute.
-Mrs.Rs baby. Is only able to
spend a PASI 10 cc / 3 hours
from
recomended is 30 cc / hours.
-Vital signs:
P : 110x / minute
R : 55x / minute
T : 36.1
o
C
-Anthropometric data:
BW: 17,50 g
BL : 43cm
HC : 31cm
CC : 25cm
UC : 8cm
Thursday, May 8
th
2014
Subjective data: -
Objective data:
-Vital signs:
P : 110x / minute
R : 55x / minute
T : 36.1
o
C
Thursday, may 8
th
2014
-Mrs.Rs baby placed in the with a
thick baby clothes, and baby
swaddled in a blanket. Baby being
treated in hospital, the baby was
placed in an incubator because
Mrs.Rs baby some times
temperature is down on 36.1
o
C.
-subcutaneous fat look thin.
-baby body temperature at birth is
36.1
o
C.
-baby aged is 2 days.
--Anthropometric data:
BW: 17,50 g
BL : 43cm
HC : 31cm
CC : 25cm
UC : 8cm
Ineffective
thermoregulation
Imaturities
Thursday, May 8
th
2014
Risk factors:
Subjective data :-
Objective data :
-General circumferences:
afgar score 4-6-7.
-Cord circumferences: seem not out
and looked a little blackkish.
-Baby age 2 days.
-Mrs.Rs baby gestational age 32
weeks.
- Hb. 15.5 g / dl
- Leokosit 11.1
-Vital signs:
P : 110x / minute
R : 55x / minute
T : 36.1
o
C
Risk of infection
Priority Nursing Problem
1. Imbalance nutrition les tahn body requirement related to reflex weak
sucking, inadequate nutrition intake.

2. Ineffective Thermoregulation related to immaturities subcutaneous fat
tissue.

3. Risk of infection

1. Imbalance nutrition les tahn body requirement related to reflex weak
sucking, inadequate nutrition intake.
Nursing Intervention
1. Assess the response of infants during feeding (sucking, swallowing
and coughing).
2. Observation addition of BW, about increase in the environmental.
3. Provide ASI / PASI (infant formula) with -+ 30 mil with slowly speed
of 1 mil /minute.
4. Fulfill needs to suck on Mrs.Rs baby using pipette when feeding time
(ASI /PASI).
5. Burp baby as soon as baby is given milk finished.

2. Ineffective Thermoregulation related to immaturities
subcutaneous fat tissue.
1. Assess the baby's body temperature every 2 hours
2. Place baby in box warmers / incubators
3. Keep the incubator temperature (36,5
o
c 37,5
o
c).
4. Wrap Mrs.Rs baby with a baby blanket and also cover baby head
5. Change clothes or bed linens when wet.

Continue
3. Risk of Infection
1. Suggest parents of baby to wash hands and used gounds before
contact with baby.
2. Assess for signs of infection such as lack of temperature instability
3. Determine gestational age at Mrs.Rs baby.
4. Wipe baby using water and soap
5. Collaboration give antibiotics intravenously if need.

Continue
3. Risk of Infection
1. Suggest parents of baby to wash hands and used gounds before
contact with baby.
2. Assess for signs of infection such as lack of temperature instability
3. Determine gestational age at Mrs.Rs baby.
4. Wipe baby using water and soap
5. Collaboration give antibiotics intravenously if need.

Continue
Results of evaluation of nursing care Mrs.Rs baby,
Diangnose 1
Imbalance nutrition less than body requirements related to a
weak sucking reflex inadequate nutritional intake, has been
resolved during the 6
th
days of treatment.
With result:
Mother .said that his baby milk that come out full
Mrs.R.sbaby body weight is still in 17, 75g. body length is
43cm, head circumference 31cm, chest circumference 25cm
and , upper circumference 8 cm.
Mrs.R.s baby get asi 30.cc from she mother and can spend 30
cc according to recommended is 30 cc 1 / minute.
Mrs.R.s baby had strong sucking reflex when giving asi via
bras milk or pipette . and swallowing reflex is strong


Ineffective thermoregulation related to immaturity
subcutaneous fat tissue still happen after 6
th
days of treatment.
risk of infection does not occur, in 6
th
of treatment
Diagnose 2
Ineffective thermoregulation related to immaturity
subcutaneous fat tissue. has been resolved during the 6
th
days
of treatment.
With result
Mrs.R.s baby body temperature maintained in 36.5
o
C. after
laiding in incubator and no looked sings of hypothermia
Looked Mrs.R.s baby felt comfort and warm after Wrapping
with baby blanket and also cover baby head.
Clothes and bad Mrs.R.s baby dry and make Mrs.R.s baby felt
warm

Diagnose 3
Risk of infection does not occur, in 6
th
of treatment
with result:
No looked signs and symptoms of infection on part of body
Mrs.Rs baby and temperature maintained in the range 36. 5
o
C
Mrs.Rs baby gestational age is 32 weeks 9 days that still high
of risk infection.
Mrs.Rs baby felt comfort and skins Mrs.Rs baby looked
clean after get wiping from nurse,