Case presentation

1

• Case presentation
• respiratory distress syndrome
• Prepared by arunima Ann
• (Nicu)

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• DEMOGRAPHIC DATA
• Case number 326
• Age newborn
• Date of birth 11-12-201
• Sex female
• A.O.G 28wks
• Weight 1.1kg
• Diagnosis preterm, respiratory distress
  syndrome

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PHYSICAL ASSESSMENT

• Vital signs
• Temperature is 36.2 0c. Baby is in incubator with
  humidity of 70
• Heart rate
• Heart rate is 164bpm
• Respiration
• Baby is on SIMV mode with PIP18, PEEP5, rate of
  40,Fio2 is 25.
• One dose of Survanta given. CXR shows mild RDS.
  Baby is tachypnic.

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GENERAL MEASUREMENT

• Head circumference 26cm.
• Chest circumference 24cm.
• Weight 1.1kg.
• Length 37cm.

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• SKIN
• Acrocyanosis at birth. Skin reddened and thin so
  blood vessels early seen. Lanugo is present
  all over the body. UVC is present on the
  umbilicus. Umbilicus is drying.
• HEAD Head appears large in proportion to the
  body.A.F is soft and flat
• EYES Eyes are symmetrical in position. No
  abnormal discharge.
• NOSE Nostrils are patent bilaterally. Nasal
  flaring are present. No nasal discharge. Obligate
  nose breathers
• MOUTH AND THROAT Uvula midline. Oral secretion
  is present Mucosa is moist. Tongue moves freely
  and does not protrude.

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• NECK Turns to side to side. clavicle intact.
  evident xiphoid process
• CHEST nipples symmetrical
• ABDOMEN dome shape, soft to palpate,UVC present,
  cord dry at base, bowel sound present on
  auscultation
• GENITALIA clitoris and labia minora slightly
  large voiding ad equating me conium passed with
  in 24 hrs
• BACK Intact spine without masses or opening.
• EXTRIMITERS Full range of motion. ten fingers
  and toes .creases are located only in front of
  the sole.

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PATIENT HISTORY

• Maternal medical history 36 old mother with
  G2P1A0 and LSCS was done due to PET and HELLP
  syndrome
• PATIENT HISTORY
• Present medical history Baby girl 28 weeks
  gestational age was delved in KING KAHLID
  HOSPITAL by LSCS due to severe PET and HELLP
  syndrome
• APGAR score was 5/1 and 7/5.baby was intubated
  immediately and given the first dose of Survanta
  and connected to mechanical ventilator with
  setting of PIP18,PEEP5 and RR 60/mt .

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INTRODUCTION OF RDS

• RDS also known as hyaline membrane disease. It
  occurs almost extremely premature infants
  .incidence and severity of RDS are related
  inversely to gestational age of the newborns
• ETIOLOGY
• Preterm babies
• LSCS
• Multiple pregnancy
• Maternal diabetics
• Delivery complications
• Me conium stained
• Infections
• Rapid labor

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ANATOMY AND PHYSIOLOGY
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ANATOMY AND PHYSIOLOGY
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DISEASE DISCUSSION

• The lungs are developmentally deficient in a
  material called surfactant, which allows the
  alveoli to remain open throughout the normal
  cycle of inhalation and exhalation
• Surfactant is a complex system of lipids,
  proteins and glycoproteins which are produced
  in specialized lung cells called Type II cells or
  Type II pneumocytes. The surfactant is packaged
  by the cell in structures called lamellar bodies,
  and extruded into the alveoli. The lamellar
  bodies then unfold into a complex lining of the
  alveoli. This layer reduces the surface tension
  of the fluid that lines the alveolar walls.

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• During exhalation the walls of the alveoli come
  in contact and surface tension tends to cause
  them to stick together, preventing re-inflation.
  By reducing surface tension, surfactant allows
  the alveoli to re-expand with inspiration.
  Without adequate amounts of surfactant, the
  alveoli collapse and are very difficult to
  expand.
• Microscopically, a surfactant deficient lung is
  characterized by collapsed alveoli alternating
  with hyper aerated alveoli, vascular congestion
  and, in time, hyaline membranes.

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• Hyaline membranes are composed of fibrin,
  cellular debries, red blood cells, rare
  neutrophils and macrophages. They appear as an
  eosinophilic, amorphous material, lining or
  filing the alveolar space and blocking gas
  exchange.
• As a result, blood passing through the lungs is
  unable to pick up oxygen and unload carbon
  dioxide from the alveolar spaces . Blood oxygen
  levels fall and carbon dioxide rises, resulting
  in rising blood acid levels and hypoxia .
  Structural immaturity , as manifest by low
  numbers of alveoli, also contributes to the
  disease process.

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PATHOPHYSIOLOGY
PREMATURITY
Decreased surfactant
Increased alveoli surface tension
Co2 retention
Hypoxemia
atelectasis
Respiratory Acidosis
Pulmonary vasoconstriction
Capillary damage
Fibrin exudate
respiratory distress syndrome/hyaline membrane
disease
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SIGNS AND SYMTOMS

• Bluish color of the skin and mucus membrane
• Apnea
• Decrees urine out put
• Grunting
• Nasal flaring
• Hypothermia
• Shallow breathing and rapid breathing

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DIAGNOSTIC EVALUVATION

•  
• ABG shows low O2 and excess acid in the body
  fluid
• Chest x-ray shows lungs have a characteristic
  ground glass appearance with often develops 6-12
  after birth
• Lab test at birth PH-7.40,PCO2-68,HCO3-25.4,BE1
•  

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NURSING INTERVENSTIONS

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• Promoting adequate gas exchange
• Maintain thermoregulation
• Promoting adequate nutrition and hydration
• Encouraging parental attachment

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TREATMENT

• Infant will be given warm, moist o2 intubated a
  breathing machine can be life saving especially
• High level of co2 in arteries
• Low blood o2 in arteries
• Low blood PH acidity
• A treatment with C-PAP delivers slightly
  pressurized air through nose and can help the
  airway open
• Antibiotics

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PROGNOSIS

• Condition worsens for 2-4 days some infants will
  die due to RDS during 2-7 days of life
• COMPLICATIONS OF RDS
• Pneumothorax
• Septicemia
• BPD
• PDA
• Pulmonary hemorrhage
• NEC
• Retinopathy of prematurity(ROP)

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MANAGEMENT OF NEONATAL

RESPIRATORY DISTRESS

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  INFANT WITH RDS
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Infant with RDS
Mild tache/grunting
Severe grunting
Observe for10-20mt
suggest
no
yes
Resolve spontaneously
resuscitate
Chest x-ray
Clinical improvement
no
o2
Nicu
Ventilation,nicu,lab test
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IMPAIRED GAS EXCHANGE RELATED TO DISEASE PROCESS
Assessment Planning implementation Rationale Evaluation
Vital signs Tem36.6 RR68/mts PR160/mts Spo280 ABG PH7.28 PCO268 PO270 HCO328 BE-2.5 nasal flaring Acrocyanosis T o maintain the normal parameters of respiration including saturation co2 and respiratory rate Cleaned the airway by proper suctioning when there is secretions Kept the head in sniffing position Properly monitored all vital signs and saturation Elevated the head end Checked the ABG level Administered Ventilator support To maintain patient airway ABG show pco2 PH level To prevent hypoxia RR-52/mnt O2 saturation 98 ABG PH-7.28 PCO2-39 HCO3-23 BE-1.1
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INEFFECTIVE THERMOREGULATION RELATED TO IMMATURETY
Assessment Planning implementation Rationale Evaluation
Subjective data Baby is crying continuously and seems to be irritable objective data Temperature 36.4c To maintain the temperature within the normal range Received baby in pre- warm radiant warmer Adjusted incubator or radiant warmer to obtain desired skin temperature Provided kangaroo care skin-skin contact Put the pre warmed gloves around the nest To prevent water loss potential for hypoglycemia To prevent hypothermia which may result in vasoconstriction acidosis After 1 hour of nursing intervention the goals were fully met as manifested by Temperature T 36.7 c Absence of bluish discoloration present in extremities Warm to touch
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NURSING HEALTH TEACHING

• Instruct the parents about,
• Kangaroo care,
• Breast Feeding
• Proper covering of the babywarm blanket
• Ensure that the family receives information on
  routine well baby care.
• Before discharge, parents should feel comfortable
  in their abilities to care for the infant.
• Educate them,importance of regular health care,
  periodic eye examinations, and developmental
  follow up with the parents

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CONCLUSION

• Presented a case of preterm new born baby
  with respiratory distress
• Baby relived from signs and symptoms of RDS
• Thermoregulation maintained
• Baby discharged after good care with Mixavit and
  iron drops

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BIBLIOGRAPHY  

• Maternal and Child Health Nursing by Adele
  Pillitteri 5th edition volume 1 page 426-
  433page 329-332
• Lippincott Manual of Nursing Practice 9th edition
• Lange clinical manual neonatology fifth
  edition-by Gomella,Douglas,Fabien
• Neonatal resuscitation 5th edition
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