Calamba Doctors’ College Parian Calamba City, Laguna SY 2010 – 2011

Case Presentation Of Infant Respiratory Distress Syndrome
Submitted by: Bajado, Christian Dave Bautista, Maria Cindy Corcelles, Jay Concepcion, Graziella Del Fuerte, Heidi Avediz Dena, Pauline Charmine Domino, Jonnavel Flores, Melson Gutierrez, Mary Grace Isturis, Shaddy Ili, Charie May Mariano, Resti

Introduction
Infant Respiratory Distress Syndrome (IRDS) or the Hyaline Membrane Disease. IRDS is a most often applied to severe lung disorder that carries the highest risk in terms of long-term respiratory and neurologic complications. It is seen almost exclusively in preterm infants. The disorder is rare in drug-exposed infants or infants who have been subjected to intrauterine stress, like pre-eclampsia or hypertension. The pathologic feature of IRDS is a hyaline-like membrane formed from exudates of an infant’s blood that begins to line the bronchioles, alveolar ducts, and alveoli. This membrane prevents exchange of oxygen and carbon dioxide at the alveolar-capillary membrane. The cause of RDS is a low level or absence of surfactant, the phospholipid that normally lines the alveoli and reduces surface tension on expiration to keep the alveoli from collapsing on expiration. Common clinical manifestations of IRDS are tachypnea, pronounced intercostals or substernal retractions, fine inspiratory crackles, audible expiratory grunt, flaring of the external nares, and cyanosis or pallor. The diagnosis of IRDS is made on the basis of clinical manifestations in radiographic studies. Radiographic findings characteristic of IRDS include 1) a diffuse granular pattern over both lung fields that closely resembles ground glass and represents alveolar atelectasis, and 2) dark streaks or bronchograms, within the ground glass areas that represent dilated, airfield bronchioles. Pulse oximetry and carbon dioxide monitoring, as well as pulmonary functions studies, assist in differentiating pulmonary and extra pulmonary illness and are used in the management of IRDS The treatment of IRDS involves immediate establishment of adequate oxygenation and ventilation and supportive care and measures required for any preterm infant, as well as those instituted to prevent further complications associated with preterm birth. The supportive measures most crucial to a favorable are to 1) maintain adequate ventilation and oxygenation, 2) maintain acid-base balance, 3) maintain a neutral thermal environment, 4) maintain adequate tissue perfusion and oxygenation, 5) prevent hypotension, and 6) maintain adequate hydration and electrolyte status. IRDS is a self-limiting disease. After a period of deterioration, and in the absence of complications, affected infants begin to improve by 72 hours. Often heralded by the onset of diuresis, this improvement has been attributed primarily to increase production and greater availability of surface active material

Nursing Theory
Roy’s Adaptation Model Background: The most well-known of the Californian theorist was Sister Calista Roy, a student of Dorothy Johnson’s who was also a teacher of Nursing at Mount Saint Mary’s College in Los Angeles. The major of Roy’s theory is on behavioral science concepts, with the individual described as a participant in bio-psychosocial adaptive systems. Patients are described as being under varying degrees of stress and their goal is to adapt to that stress. Major Concepts: 1. System A system is “a set of parts connected to function as a whole for some purpose and that does so by virtue of the interdependence of its parts”. In addition to having wholeness and related parts, “systems also have inputs, outputs, and control and feedback processes” 2. Adaptation Level “Adaptation level represents the condition of the life processes described on three levels as integrated, compensatory, and compromised”. A person’s adaptation level is “constantly changing point, made up of focal, contextual, and residual stimuli, which represent the person’s own standard of the range of stimuli to which one can respond with ordinary adaptive responses”. 3. Adaptation Problems Adaptation problems are “broad areas of concern related to adaptation. These describe the difficulties related to the indicators of positive adaptation. 4. Focal stimulus The focal stimulus is the “internal or external stimulus most immediately confronting the human system”. 5. Contextual Stimuli Contextual stimuli “ are all other stimuli present in the situation that contribute to the effect of the focal stimulus”. That is, “contextual stimuli all the environmental factors that are present to the person from within or without but which are not the center of the person’s attention and energy.

6. Residual stimuli Residual stimuli “are environmental factors within or without the human system with the effects in the current situation that are unclear”. 7. Coping Processes Coping processes “are innate or acquired ways of interrupting changing environment”. 8. Innate coping Mechanism Innate coping mechanism “are genetically determined or common to the species and are generally viewed as automatic processes; humans do not have to think about them”. 9. Acquired coping Mechanism Acquired coping mechanism “ are developed through strategies such as learning. The experience encountered throughout life contribute to the customary responses to particular stimuli”. 10. Regulator Subsystem Regulator is “a major coping process involving the neural, chemical, and endocrine system”. 11. Cognator Subsystem Cognator is a major coping process involving four-cognitive emotive channels: perceptual and information processing, learning, judgment, and emotion. 12. Adaptive Responses These are those “that promote integrity in terms of those human system”. 13. Ineffective Responses These are those “that do not contribute to integrity in terms of the goals of the human system”. 14. Integrated Life Processes It refers to the adaptation level at which the structure and functions of a life process are working as a whole to meet human needs. 4 Adaptive Models: I. Physiological-physical Mode The physiological mode is associated with the physical and chemical processes involve in the function and activities of living organisms. Five needs are identified in the physiological physical mode relative to the basic need of physiological integrity as follows: 1) oxygenation, 2) nutrition, 3) elimination, 4) activity and rest, and 5) protection. II. Self-concept Mode/ Group Identity Mode The self-concept-group identity mode is one of the three psycho-social modes and “it focuses specifically on the psychological and spiritual aspects of the human system. The basic need underlying the individual self-concept mode has been identified as psychic and spiritual integrity, or the need to know who one is so that one can be or exist with a sense of unity, meaning, and purposefulness in the universe”.

Self-concept is defined as the composite of beliefs and feelings about oneself at a given time and is formed from internal perceptions and perceptions of others’ reactions. Its components include the following: 1) the physical self which involves sensation and body image, 2) the personal self which is made up of self consistency, self ideal or expectancy, and the moralethical-spiritual self. III. Role Function Mode The role function mode “is one of two social modes and focuses on the roles the person occupies in society. A role, as the functioning unit of society is defined as a set of expectations about how a person occupying one position behaves toward a person occupying another position. The basic underlying the role function mode has been identified as social integrity—the need to know who one is in relation to others so that one can act”. These roles are carried out with both instrumental and expressive behaviors. Instrumental behavior is “the actual physical performance of a behavior”. Expressive behaviors are the feelings, attitudes, likes, or dislikes that a person is about a role or about the performance of a role. IV. Interdependence Mode The basic need of this mode is termed relational integrity. Two major areas of interdependence behaviors have been identified, receptive behavior and contributive behavior. These behaviors apply respectively to the receiving and giving of love, repect and value in interdependent relationships. Major Assumptions: Adaptation According to Roy, adaptation refers to “the process and outcome whereby thinking and feeling persons as individuals or in groups, use conscious awareness and choice to create human and environmental integration”. Nursing Roy defines nursing broadly as a “health care profession that focuses on human life processes and patterns and emphasizes promotion of health for individuals, families, groups, and society as a whole”. Specifically, Roy defines nursing according to her model as the science and practice that expands adaptive abilities and enhances person and environmental transformation. She identifies nursing activities as the assessment of behavior and the stimuli that influence adaptation. Nursing judegments are based on the assessment and interventions are planned to manage the stimuli. Nursing science is a “developing system of knowledge about persons that observes, classifies, and relates the processes by which persons positively affects their health status. “Nursing acts to enhance interaction of the person with the environment—to promote adaptation”.

Roy’s goal of nursing is “the promotion of adaptation for individuals and groups in each of the 4 adaptive modes thus contributing to health, quality of life and dying with dignity” Person According to Roy, humans are holistic, adaptive systems. “As an adaptive system, the human system is described as a whole with parts that function as unity for some purpose. Human system include people as individuals or in groups including families, organizations, communities, and society as a whole”. Health “Health is the state and the process of being and becoming integrated and a whole person. It is the reflection of adaptation that is, the interaction of the person and the environment. Roy derived this definition from the thought that adaptation is a process of promoting physiological, psychological, and social integrity and that integrity implies an impaired condition leading to completeness or unity. Health and illness are one inevitable, coexistent dimension of the person’s total life experience. Nursing is concerned with this dimension. When mechanism for coping are ineffective, illness results. Health ensues when human continually adapt. As people adapt to stimuli, they are free to respond to other stimuli. The freeing of energy from ineffective coping attempts can promote healing and enhance health. Environment Environment is “all the conditions, circumstances, and influences surrounding and affecting the development and behavior of persons or groups, with particular consideration of the mutuality of person and earth resources that includes focal, contextual, and residual stimuli”. “It is changing environment that stimulates the person to make adaptive responses”. Environment is the input into the person as an adaptive system involving both internal an external factors. These factors may be slight or large, negative or positive.

INPUT Stimuli Adaptation Level

CONTROL PROCESSES

EFFECTORS Physiological functions Self-concept Role function Interdependence

OUTPUT

Coping mechanisms Regulator Cognator

Adaptive and ineffective Responses

Feedback

Patient's Data Biographic Data Baby Girl E.S. is a newborn female. She was born last June 16, 2010 at Calamba Doctors' Hospital, Parian, Laguna. She lives at Phase 6, Mabuhay City, Cabuyao, Laguna. She is a Filipino citizen and a Roman Catholic. There were no financial assistance from any institutions noted. History of Present Illness A few hours prior to the delivery of the child, Mrs. E.S. experienced episodes of contractions. She immediately went to a nearby clinic for a check-up and ultrasound. The ultrasound was not performed since the clinic stated that the baby is ready to be delivered and that she is in a preterm labor. She was then transported to Calamba Doctor's Hospital for the delivery. Past Health History Mrs. E.S., 29 years old and the mother of the patient, stated that the pregnancy was not planned. Although it was not planned, she felt happy when she found out that she was pregnant. After using the pregnancy test kit, it turned positive for pregnancy and that's when she went to their local health center who confirmed that she was already 3-months pregnant. She stated that she was previously pregnant just a year a ago and also delivered through a normal spontaneous delivery. It was a baby boy and it was delivered in full term by a midwife at home. No complications were noted. Regarding her general health during pregnancy, she said that she felt fine and healthy. But the only problem was, she gets very tired easily doing household chores and the taking care of her one year old baby. She even complained of slight pain on her abdomen and stated, “Minsan, pagnapapagod ako, pakiramdam ko bumababa yung bata”. There were no accidents noted. In terms of medications, she only took Ferrous Sulfate for iron supplementation. Mrs. E.S. never took tobacco, alcohol or any drugs during the pregnancy. Before the Delivery of the Child:

Mrs. E.S. eats at least 3 times a day with one cup of rice each meal. And which usually consist of vegetables. Her water intake is usually 8 glasses (2000mL) and 2 glasses of powdered orange juice everyday. She stated that she did not take any milk for her pregnant state rather she drinks Milo, and Bearbrand milk. She’s not very fond of eating neither junkfoods nor any sweets. Every now and then, she eats fruits and vegetables whenever her budget permits it. With regards to her elimination pattern, Mrs. E.S. voids 8 times a day, light yellow in color, no pain during urination, and scanty in amount. She usually defecates once everyday, brown in color, semi-formed, and no pain during bowel movement. She has a happy and close relationship with her husband. Even during pregnancy, they were sexually active and it happened every month. Delivery of the Child: Baby Girl E.S. was born last June 16, 2010, 3:12pm at Calamba Doctors' Hospital. She was delivered through a Normal Spontaneous Delivery. There were no problems experienced during the delivery except that the baby was in premature condition because the Age of Gestation was 32 weeks. Baby Girl E.S.' Apgar Score was 8 and interpreted as normal. Her birth weight was 1.5KG., Length of 40cm, Head circumference of 30cm, chest circumference of 25cm, and abdominal circumference of 23cm. She was diagnosed of having Infant Respiratory Distress Syndrome (IRDS) due to prematurity. So far, Baby Girl E.S. was given Anti-Hepatitis B and BCG vaccines at birth. Family History: No known history of any diseases were noted like Diabetes Mellitus, Hypertension, Cancer, and others.

Gordon’s Pattern Nutritional-Metabolic Pattern Baby E.S. started receiving Express Breast Milk (EBM) on her 8th day of

confinement. The feeding started at 6cc per day. Then the physician ordered to increase feeding to 0.5cc everyday. On her 14th day, her feeding was increased to 30cc per day.

Elimination Pattern Bladder/Bowel Habits: Baby Girl E.S. changes diaper 1-2 times a day. Her urine is clear yellow in color. Her stool is greenish in color and watery in consistency.

Sleep/Rest Pattern Baby E.S. sleeps for almost the whole day. She would only wake up for atleast 5-10 seconds and then goes back to sleep after that.

Diagnostic Test

COMPLETE BLOOD COUNT JUNE 20 ,2010 HGB HCT RED BLOOD CELLS WHITE BLOOD CELLS NEUTROPHILS LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS PLATELET MCV MCH MCHC RESULT 12 0.34 3.35 11.35 0.390 .560 0 0.040 0 250 101.5 35.80 35.30 NORMAL VALUES 12-15 0.35-0.45 4.6-5.2 5-10 0.55-0.65 0.25-0.35 0.02-0.1 0.02-0.04 0-0.05 140-340 86-100 26-31 31-37

JUNE 26, 2010 HGB HCT RED BLOOD CELLS WHITE BLOOD CELLS NEUTROPHILS LYMPHOCYTES MONOCYTES EOSINOPHILS BASOPHILS PLATELET MCV MCH MCHC RESULT 14.30 0.41 4.07 14.61 0.390 0.560 0 0.050 0 422 100.20 35.10 35 NORMAL VALUES 12-15 0.35-0.45 4.6-5.2 5-10 0.55-0.65 0.25-0.35 0.02-0.1 0.02-0.04 0-0.05 140-340 86-100 26-31 31-37

BLOOD CHEMISTRY JUNE 18,2010 Sodium Potassium Calcium Result 133 6.3 7.7 JUNE 20, 2010) Sodium Potassium Calcium Result 145 4.6 9.9 JUNE 23, 2010 Sodium Potassium Calcium Result 134 6 8.3 ARTERIAL BLOOD GAS JUNE 17, 2010 (10:50 am) Ph PCO2 Result 7.209 46.4 Normal values 7.35-7.45 35-45 mmHg Normal values 137-145 mmol/L 3.5-5.1 mmol/L 8.4-10.2 mmol/L Normal values 137-145 mmol/L 3.5-5.1 mmol/L 8.4-10.2 mmol/L Normal values 137-145 mmol/L 3.5-5.1 mmol/L 8.4-10.2 mmol/L

PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

82 22.8 -4 95% 36.9 60% 23 JUNE 17,2010 (6:35pm)

80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

Ph PCO2 PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

Result 7.14 64.5 58 21.98 -7 79% 37.5 60% CPAP 56 JUNE 17, 2010(9:49pm)

Normal values 7.35-7.45 35-45 mmHg 80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

Ph PCO2 PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

Result 7.25 50.89 161 22.6 -4 99% 37.4 100% via mech. vent. 50 (JUNE 18,2010) (7:20am)

Normal values 7.35-7.45 35-45 mmHg 80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

Ph PCO2 PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

Result 7.225 54.2 153 22.6 -5 79% 36.6 95% 65 JUNE 18,2010 (3:50 pm) Result

Normal values 7.35-7.45 35-45 mmHg 80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

Normal values

Ph PCO2 PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

7.26 51.2 135 23.1 -4 99% 37.3 85% 65 JUNE 19,2010 (7:42pm)

7.35-7.45 35-45 mmHg 80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

Ph PCO2 PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

Result 7.34 34.6 206 18.7 -7 100% 37 80% via mech. Vent. 60 JUNE 19, 2010 (7:34pm)

Normal values 7.35-7.45 35-45 mmHg 80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

Ph PCO2 PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

Result 7.30 44.4 99 21.9 -5 97% 36.9 65% via mech. vent 50 JUNE 21, 2010

Normal values 7.35-7.45 35-45 mmHg 80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

Ph PCO2 PO2 HCO3 Be O2 Saturation Temperature F1O2 RR

Result 7.56 18.5 143 16.8 -5 100% 36.9 40% via mech. vent 43

Normal values 7.35-7.45 35-45 mmHg 80-100 mmHg 22-28 meq/L (+ -) 2 80-100%

X- Ray findings There are granular haziness of both lung field. The heart and the rest of the visualized chest structure are remarkable. Conclusion: Hyaline-membrane disease Ogt in place Blood Culture and Sensitivity (June 18,2010) Org= no growth after 24 hoursof incubation (June 20,2010) Org= no growth after 3 days of incubation (June 24,2010) Org= no growth after 7 days of incubation

Hemo-GlucoTest June 18,2010 CBG=172mg/dl June 24,2010 CBG=44 mg/dl

Journal The Philippine Journal of Pediatrics April- June 2001 Clinical Outcome of Preterm Infants with Maternal Pre-eclampsia Emalyn Joy g. Montero, MD Pre-eclampsia is a unique and often dangerous condition that occurs only during pregnancy. Severe pre-eclampsia may threaten the life of a mother seriously, enough to force her to deliver more than 10 weeks prematurely. Vaginal delivery of very low birth weight babies may increase the risk of intraventricular hemorrhage, but caesarian delivery may increase the risk of critically ill mother. Recently, studies conducted suggests that infamts born to pre-eclamptic mothers have accelerated lung maturation due to chronic intrauterine hypoxia which stimulates production of cortisol leading to increase production of pulmonary surfactant.

This study examines the clinical outcome of preterm infants born to mothers with and without maternal pre-eclampsia, to compare the incidence of RDS and sepsis and their mortality rate. This study looks at the clinical outcome of preterm infants with and without maternal preeclampsia, by describing the profile of these infants in terms of Ballard’s Score, APGAR Score, sex, birth weight, mode of delivery, etc. and to compare the incidence of sepsis and RDS these infants. Lesser incidence of RDS born to pre-eclamptic mothers has been shown in the study. However, the risk of complications of sepsis is greater, particularly in the lower age group and in the very low birth weight. Contributing factors are longer NICU stay and use of mechanical ventilators and other invasive devices.

Reflection After two weeks of caring and handling Baby Girl E.S., we are happy as she gradually improves with regards to her over-all health. It was honestly challenging for us because it is our first time to handle an infant confined in a NICU department. What more with the case which is IRDS? It is a complex case for us to manage and because she is premature, she needed an intensive care from us, as health care providers. Because of her condition, she is extremely fragile that a slight touch may injure her. We needed to give her the tenderest touch that we can offer. Assessment and data gathering were hard to get. The NICU limits the number of visitors allowed inside. And so, we assigned shifts every duty so as to observe and handle our baby girl. It was a great relief in all of us that she is currently in a great state. She is recently on a crib and without mechanical ventilation. At least, through the simple ways that we did, it added up to the reasons why she’s in a fine health right now. And maybe someday, if destiny permits it to happen, one of us will meet her as a young lady and that she would thank us for being a part of who she is by then.

With regards to the activity performed, it served as a bonding moment for us. We laughed, we cried, we fought for pillows and time, and of course, we panicked. It was a strange but unforgettable moment for all of us. The group became much closer and comfortable with each other. Yes, we can’t deny that it was very hard, sooooooo hard to do this activity. BUT! We learned. And that’s what made the experience memorable and satisfying. And so, with this, we would like to thank our dearest, and ever smiling, wonderful, bubbly, exciting, cool, loving, adorable, hot… Mrs. Czarlynn Goopio for the opportunity, the never-ending patience and trust in our group that we can do this. And of course for our advisers, Mr. Jun Manaloto and Mr. Jude Inandan for the effort in helping make this presentation presentable and possible.

Evaluation of Care Impaired Gas Exchange
Goal unmet. The patient was not able to attain an adequate oxygen supply. Nutrition Less Than Body Requirements Risk For Infection

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