RDS Latest

RESPIRATORY
DISTRESS
SYNDROME
MATRIX NO : PBPN 1020
COHORT
: COHORT 16 (1/2016)
COURSE
: POST BASIC PAEDIATRIC
NURSING
1
LEARNING OBJECTIVES
AT THE END OF THE CASE STUDY I WILL ABLE TO:
1)
EXPLAIN THE PATIENTS PROFILE, HISTORY, INCLUDING CHIEF

PRESENTING COMPLAINTS AND HISTORY OF PRESENT ILLNESS.
2)
STATE THE GROWTH AND DEVELOPMENT, MILESTONES INCLUDING

PHYSICAL MEASURES, GROSS MOTOR, FINE MOTOR AND SOCIALIZATION.
3)
STATE THE BIRTH HISTORY AND IMMUNIZATION HISTORY OF THE PATIENT.
4)
STATE THE DIET HISTORY INCLUDING NUTRITIONAL ASSESSMENT

(GROWTH CHART), FEEDING MILESTONE AND 24-HOUR RECALL.
5)
EXPLAIN FAMILY BACKGROUND INCLUDING FAMILY MEDICAL HISTORY

AND SOCIOECONOMIC BACKGROUND.
6)
DESCRIBE PHYSICAL ASSESSMENT FINDING ON THE SPECIFIC BODY

SYSTEMS
7)
DESCRIBE GROWTH AND DEVELOPMENT FINDING.
CONT..
5) EXPLAIN THE DISEASE CONDITION INCLUDING DEFINITION,
INCIDENCE, AETIOLOGY, PATHOPHYSIOLOGY, SIGN AND SYMPTOMS
6) DESCRIBE LABORATORY FINDING OF BABY FROM ADMISSION TILL
DISCHARGE.
7) DESCRIBE RADIOLOGY FINDING OF BABY FROM ADMISSION TILL
DISCHARGE.
8) EXPLAIN DRUG COMMENCE TO THE BABY DURING HOSPITALIZATION
INCLUDING NURSING RESPONSIBILITIES PRIOR TO THE
ADMINISTRATION.
9) DESCRIBE OTHER TREATMENT GIVEN TO THE BABY.
10) EXPLAIN APPROPRIATE NURSING CARE PLAN FOR THE PATIENT
DURING HOSPITALIZATION.
11) DESCRIBE DISCHARGE PLAN INCLUDING HEALTH EDUCATION GIVEN
TO FAMILY MEMBERS REGARDING CARE OF THE BABY IN HOME
AFTER DISCHARGE.
3
12) SUMMARIZE PATIENT FLOW OF HOSPITALIZATION TILL DISCHARGE.
MY
PATIE
NT
PATIENT'S PERSONAL DATA

NAME : Miss Y
MRN
AGE
: 40XXXX
: 10 hours of Life
SEX : FEMALE
DATE OF BIRTH
IC NUMBER
RACE
: 24 OCTOBER 2016 @ 1649H
: 75XXXX-XX-XXXX
: MALAY
RELIGION : MUSLIM
DATE OF ADMISSION
: 25 OCTOBER 2016
TIME OF ADMISSION
: 2345H
CONSULTANT
: DR.Q
ADMITTING DIAGNOSIS :SEVERE RESPIRATORY

SYNDROM
DISTRESS5
CONT..
DATE OF DISCHARGED : 5 NOVEMBER 2016@1340H
FOLLOW UP : 14 NOVEMBER 2016@1200H
CHIEFT COMPLAINTS
have an episode of Grunting &
chest recession soon after
delivery and was intubated
after desaturated while on
head box oxygen
HISTORY OF PRESENTING
ILLNESS
PRETERM BABY DELIVER AT 4.49PM TRANSFERRED
FROM KPJ SELANGOR AFTER HAVING DIFFICULT LSCS
DUE TO PREVIOUS SCAR IN THE LABOR.(APGAR
SCORE 7 AT 1 MINUTE AND 9 AT 5 MINUTE)
DEVELOP GRUNTING WITH CHEST RESECTION SOON
AFTER DELIVERY. PUT ON HEAD BOX
AT 8.45 PM DESATURATED AND INTUBATED WITH SIZE
3 ETT AND ANCHORED AT 9CM
7
MISS Y WAS AMBUBAGGED OXYGEN, SATURATION WAS 90
-100 FROM KPJ SELANGOR LETTER.
CONT
ON ARRIVAL MISS Y WAS DUSKY AND CYANOSED, FLAT WITH
NO SPONTANEOUS MOVEMENT, SATURATION 17 20% IN 100
%O2.
PUT ON VENTILATOR , LEAK >30%, NO BETTER, CONT.
BAGGED, STILL NO BETTER, REINTUBATED WITH ETT SIZE
3.5, FIXED AT 9 AND GIVEN CUROSORF 100MG/KG.
UAC & UVC INSERTED, DOING CXR( SEVERE RDS, LARGE
HEART AND NO PNEUMOTHORAX)
PUT ON SIPPV WITH PIP 30, PEEP 8, RATE 50, FIO2 0.9
BLOOD GASES SHOWS(MIX RESPIRATORY & METABOLIC
ACIDOSIS)
CONT. CLOSE MONITORING IN NICU
PAST HISTORY
PAST MEDICAL HISOTRY : PROLONG DELIVERY
PAST SURGICAL HISTORY : NIL
ALLERGIC
: UNKNOWN
BLOOD GROUP
: B+
MEDICATIONS
:INTRAMUSCULAR VITAMIN K
WERE GIVEN IN KPJ SELANGOR.
BIRTH HISTORY
BORN ON 24 OCTOBER 2016 @ 1649H IN HOSPITAL
KPJ SELANGOR, THROUGH LSCS PLUS VACUUM
FROM PREVIOUS SCAR IN LABOUR. IT TOOK ABOUT
20 MINUTE TO BRING HER OUT DUE TO ADHESION.
SHE IS PRETERM BABY AT 36 WEEKS OF
GESTATIONS WAS BORN WITH:
APGAR SCORE : 7 AT 1 MINUTE & 9 AT 5 MINUTE
BIRTH WEIGHT : 3.77 KG
HEAD CIRCUMFERENCE : 36 CM
BIRTH LENGTH : 56 CM
10
BIRTH HISTORY
ANTENATAL
MRS. E HAD REGULAR ANTENATAL VISIT , ALSO GAIN

WEIGHT, HAVE GESTATIONAL DIABETES ON DIET
CONTROL, IMMUNIZATION TAKEN.IM
DEXAMETHASONE GIVEN 2 TIMES BEFORE
DELIVERY.
INTRANATAL
DELIVERY WAS LSCS PLUS VACUUM AND TOOK ABOUT 20
MINUTE TO BRING NANY OUT. BIRTH. APGAR SCORE IS 9 AT
BIRTH, AFTER 5 MIN 9. MISS Y DEVELOP GRUNTING AND CHEST
RECESSION IMMEDIATELY AFTER BIRTH.
POSTNATAL
MISS Y HAD RESPIRATORY DISTRESS.
11
IMMUNIZATIONS
Figure: Immunization schedule in Malaysia for 2016
DR. IQ EXAMINED AND ASSESS MISS Y AND

DECIDED WILL ADMINISTER BCG AND HEP
B LATER BASE ON PATIENTS CONDITION.
FAMILY
HISTORY
13
FAMILY PEDIGREE
Mr. T
38 years old
Businessmen
NIL MEDICAL &
SURGICAL HISTORY
MISS A
3 Y/O
B.w:4.26
BORN AT 39 WEEK
HISTORY OF RDS
AFTERBIRTH
NIL SURGICAL HISTORY
Madam E
36 years old
Housewife
MEDICAL HISTORY :
GASTATIONAL DIABETIS
SURGICAL HISTORY OF LSCS
TIMES TWO
MASTER Z
2 Y/O
B.wt: 3.21
BORN AT 38 WEEK
NIL MEDICAL &
SURGICAL HISTORY
MISS Y 10 hour of
Life (patient)
BORN AT 36 WEEK
HISTORY OF
PROLONG LABOUR
FATHER:
BUSINESSM
EN
MOTHER
HOUSEW
IF
E
SOCIOECONOMIC
BACKGROUND
8000
per
month
Stay at
BANGLOW
15
PHYSICAL EXAMINATION
VITAL SIGN ON ADMISSION
TEMPERATURE : 37.4 C
PULSE
: 140BPM
BLOOD PRESSURE : 66/ 44
RESPIRATION RATE : 50BPM
SPO2 RATE
: 17% - 20%
16
Growth & DEVELOPMENT

AGE
10 hours of life
WEIGHT ON ADMISSION
3.77KG
HEIGHT
56 CM
HEAD CIRCUMFERENCE
36CM
CHEST CIRCUMFERENCE
34CM
Table: Anthropometric measurements of Miss Y during admission.

Reflexes- Miss Y have palmer grasp as her mother
put her finger into Miss Y hand, she respond by
NUTRITIONAL
MISS Y NIL BY MOUTH TILL 3 DAYS AND
STARTED TROPHIC FEEDING ON DAY 4
THROUGH NG TUBE FEEDING.
STARTED AMOUNT WAS 5 MLS OF EBM
(MOTHERS COLOSTRUM) FOR 3 HOURLY.
FEEDING TOLERATED WELL & ON DAY 5
FEEDING INCREASE TO10 MLS/3 HOURLY
DAY 6 INCREASE TO 30MLS/ 3 HOURLY
DAY 7 INCREASE TO 35 MLS/3 HOURLY AND
INCREASE 5 MLS FOR EVERY 2 CYCLE.
*MISS
Y TOLERATE FEEDING WELL, WAS

GIVEN FULLY EBM.
ANATOMY
&
PHYSIOLO
GY
19
RESPIRATORY DISTRESS
SYNDROME (RDS)
IO
T
I
IN
F
E
D
N
RDS OF THE NEWBORN, ALSO KNOWN AS HYALINE
MEMBRANE DISEASE
IS A BREATHING DISORDER OF NEWBORN BABIES.
THE ALVEOLI (THE SMALL, AIR EXCHANGING SACS OF
THE LUNGS) ARE COATED BY SURFACTANT, WHICH IS A
SOAP-LIKE MATERIAL PRODUCED IN THE LUNGS AS THE
FETUS MATURES IN PREPARATION FOR BIRTH.
IF PREMATURE NEWBORNS HAVE NOT YET PRODUCED
ENOUGH SURFACTANT, THEY ARE UNABLE TO OPEN
THEIR LUNGS FULLY TO BREATHE.
G
O
L
IO
M
E
EPID Y
SYNDROME
Rds affects about 1 percent of newborn

infants and is the leading cause of death in
babies who are born prematurely
About 10 percent of premature babies in
the united states develop rds each year.
The risk of rds rises with increasing
prematurity. Babies born before 29 weeks
of gestation have a 60 percent chance of
developing rds, but babies born at full term
rarely develop this condition.
Male is higher risk than female
ic
t
i
s
t
St a
SYNDROME
HOSPITAL
INCIDENCE
ic
t
i
s
t
St a
Bar chart on RDS incidence of Newborns in DSH

8
7
5
3
1
SYNDROME
prematurity
A brother or
sister who had
RDS
maternal
diabetes.
RISK FACTORS
Multiple
pregnancy
Prolong
labor
Perinatal
asphyxia
O
L
O
I
S
Y
H
P
SYNDROME
O
H
T
PA
GY
PREMATURITY & PRENATAL ASPHYXIA
REDUCED SURFACTANT SYNTHESIS, STORAGE, RELEASE
INCREASED ALVEOLAR SURFACE TENSION
PROGRESSIVE ATELECTASIS
HYPOVENTILATION
HYPOXEMIA CO2 RETENTION
RESPIRATORY ACIDOSIS
SIGNS & SYMPTOMS

TACHYPNOEA (RESPIRATORY RATE >60/MINUTE)
NASAL FLARING
STERNAL AND INTERCOSTAL RECESSION (DUE TO
COMPLIANT CHEST WALL AND NONCOMPLIANT
LUNGS)
EXPIRATORY GRUNT (CAUSED BY THE INFANT
EXHALING AGAINST A CLOSED GLOTTIS, WHICH
MAINTAINS A HIGH RESIDUAL AIR VOLUME IN THE
LUNGS PREVENTING ALVEOLAR COLLAPSE).
CENTRAL CYANOSIS
APNOEA
n
tio
a
c
l
i
SYNDROME
p
com
1.Pneumothorax
2.pulmonary interstitial emphysema
3.persistent pulmonary hypertension
4.necrotising enterocolitis
5.intraventricular haemorrhage
6.patent ductus arteriosis
(Johnston et al, 2003)
* Miss Y develop no complication during hospitalization.
N
SYNDROME
O
I
T
A
TIG
S
E
I NV
CHEST X- RAY
AN ARTERIAL BLOOD GAS
FULL BLOOD COUNT
SEPTIC SCREEN IS INDICATED IF INFECTION
IS SUSPECTED.
BUSE
y
a
r
X
t
s
e
Ch
CXR BEFORE & AFTER

REINTUBATION
ON ADMISSION:
25/10/16@ 0043H
POST REINTUBATED:
25/11/16@0820H
29
ay
r
X
t
s
e
h
C
CXR BEFORE AND

AFTER SURFACTANT
DATE: 25/10/16@ 0043H

BEFORE SURFACTANT THERAPY
DATE: 25/10/16@ 1955H

AFTER SURFACTANT
THERAPY
ray
X
O
D
B
A
UAC REPOSITION
DATE: 25/10/16@0802HPOST UAC & UVC INSERTION

(MARKING @ 20CM, 11CM)
DATE:
25/10/16@1900HPOST UAC
ADJUSTMENT.
MARKING AT 12CM.
T
S
E
T
D
O
B LO
Date
ABG
Normal
range
25/10
27/10
0149
1408
Implication and significant
PH
7.113
6.955
Mode: PTV
Pco2
69.6
114.3
Post curosuft 400mg
Po2
60
19
Bic
22.3
25.4
BE
-7
-7
rate, Increase PEEP and KIV
Glucose
10.4
7.3
HFO, maintain strict hand
Intepretation
Mix res. & met. Mix res. &

acidosis
met. acidosis
Monitor saturation, Doing

suction, increase Fio2, Increase
hygiene & minimal handling
T
S
E
T
D
O
B LO
Date
ABG
Normal
range
25/10
26/10
1728
0829
PH
7.138
7.154
Mode: HFOV
Pco2
65.4
66.3
Po2
24
15
suction, change IV Dextrose
Bic
22.2
23.3
12.5%, Kiv Curosurf., maintain
BE
-7
-5
strict hand hygiene & minimal
Glucose
7.7
4.0
handling
Intepretation
Mix res. & met. res. acidosis

acidosis
T
S
E
T
D
O
B LO
Date
ABG
Normal
range
26/10
27/10
2245
0546
PH
7.518
7.386
Mode: HFOV
Pco2
22.5
32.5
Post curosurf 200mg/kg
Po2
192
85
Bic
18.3
19.5
BE
-5
-6
hand hygiene & minimal
Glucose
7.4
6.5
handling
Intepretation
res. alkalosis
Normal

suction as needed. maintain strict
T
S
E
T
D
O
B LO
Date
Hb
PCV
White cells
Platelet
Neutrophils
Normal range
FBC
25/10
27/10
0240H
0806
10.0 13.1
18.5
16.5
35 45
5.3
5.5 15.5
5.2
150 509
36.4
17.1
15 55
23.3
26.3
*All lab value is within normal

range
T
S
E
T
D
O
B LO
Date
Normal
range
UBUSE & CRP
25/10
26/10
27/10
0240H
0903
0806
Sodium
139
139
145
Potassium
5.5
4.5
4.7
Urea
1.2
Chloride
CRP
115
0.35
17.80
2.48
TREATMENT
Treatment
1. IV drip
10%.
Rational for treatment

Dextrose To maintain patients hydration status
Day 1: 90/kg/day
Day 2: 110/kg/day
Day 3: 130/kg/day
-
2. Vital signs monitoring

- Temperature
- Pulse rate
- Respiration rate
- Blood pressure
- Pain level
To
monitor
patient
responding
to
the
treatment
and
early
detection of detoriation
Related nursing
responsibilities
Maintain IV drip till
patient rehydrate and had
increased oral intake back
to normal.
Assess for the signs of
water toxicity
-Monitor vital signs and pain

level hourly.
- Document the findings and
report any abnormalities to
doctor
INTRAVENOUS FLUID
THERAPY
TO MAINTAIN PATIENTS HYDRATION STATUS
DR Q. ORDER IV DRIP DEXTROSE 10% FOR MISS Y STARTING
FROM 25/10/16 DAY 1: 60MLS/KG/DAY
DEXTROSE 10%@ 8MLS/ HOUR +INFUSION MORPHINE @1MLS /
HOUR +UAC FLUSHING 0.5MLS/HOUR.
DAY 2: 110/KG/DAY
DAY 3: 130/KG/DAY
38
TREATMENT
Treatment
Rational for treatment
Related nursing
responsibilities
Monitor O2 saturation,
Fio2, ETT marking,
Assess for the Sign or
hypoperfussion, perform
suction.strictly
Hand
hygiene and minimal
hamdling.
1. Ventilator
To assist patients
ventilation
- Give Oxygen and remove CO2 without
cause trauma to the lung
2. Feeding
To prevent Nutritional -give feeding as order and

imbalance and loose monitor aspiration, I/O and
weight.
BO.
Medication
Curousorf
Date On
Date Off
Dosage
Frequency
Route
25/10/2016
15/10/2016 400mg
stat
ET
25/10/2016
31/10/2016 400mg
BD
IV
26/10/2016
31/10/2016 60 mg
daily
IV
11/10/2016
16/10/2016
STAT
IV
Cafutaxime
25/10/2016
31/10/2016 200mg
BD
IV
Dobutamine
25/10/2016
27/10/2016
2mls/ho
Hourly
ur
IV
Dopamine
25/10/2016
28/10/2016
0.2mls/h
hourly
our
IV
morphine
25/10/2016
25/10/2016
1mls/ho
Hourly/ PRN IV
ur
ampicilin
Amikacin
Recurronium
1 mg
stat
40
y
d
t
u
s
Dr ug
SYNDROME
Name of drug
Generic name
Action
Mode of action
Curosurf
Poractant alfa
Improve lung compliance
Absorb in the alveoli and reduce alveoli surface
tension.
Route
ETT
Dosage administered
Initial: 100mg/kg
Frequency: every 12 hour if needed
Rational for used
100- 200mg/kg
To replace surfactant deficiency and help lung in preventing
atelectatis .
Potential side effects -
No side effect
41
CONT..
Nursing
responsibilities in
serving the drug
1. Endotracheal suction is not recommended for several hours

after administration
2. Careful observation of the baby is essential, and changes in
ventilatory settings may be necessary
3. (High levels of ventilator support usually can be significantly
reduced as Results in rapid and dramatic improvement in lung
compliance and gas exchange)
4. Monitor saturation because High levels of
ventilator support usually can be significantly
reduced as Results in rapid and dramatic
improvement in lung compliance and gas
exchange.
42
y
d
t
u
s
Dr ug
SYNDROME
Name of drug
Generic name
Action
Cafutaxime
Mode of action
Route
Dosage administered
Rational for used
Inhibit the bacterial cell wall synthesis

IV
50mg/kg every 12 hour
CEFOTAXIME SODIUM
Broad spectrum cephalosporin antibiotic
in infants with suspected sepsis who have previously

received multiple courses of antibiotics.
Potential side effects - Vomiting, diarrhoea; pseudomembranous colitis, rarely

- Rash, pruritis, urticaria.
43
CONT..
Nursing
responsibilities in
serving the drug
1. Before starting therapy, determine if patient has had previous

hypersensitivity reactions to cafutaxime
2. Reconstitute drug with sterile water for injection, normal
saline solution, D5W
3. After initial reconstitution, further dilute to desired
concentration for intermittent I.V infusion
4. Know that solution color ranges from light yellow to amber,
depending on length of storage, concentration and diluent
used.
5. Thaw premixed drug at room temperature
6. Do not add other drugs to premixed containers. Discard
unused solution.
7. Observe patient for signs and symptoms of anaphylaxis (rash,
pruritus, laryngeal edema, wheezing).
44
re
a
c
g
i
n
Nu rs
p la n
SYNDROME
NURSING
DIAGNOSIS
IMPAIRED GAS EXCHANGE RELATED TO DECREASED

PRODUCTION OF SURFACTANT.
ALTERED IN NUTRITIONAL STATUS: LESS THAN BODY
REQUIREMENT RELATED TO RESPIRATORY DISTRESS.
INEFFECTIVE THERMOREGULATION (HYPOTHERMIA) RELATED
TO LARGE BODY SURFACE.
RISK OF INFECTION RELATED TO IMMUNE SYSTEM
DEFICIENCY AND INVASIVE PROCEDURES.
PARENTAL ANXIETY RELATED TO CHILDS CONDITION AND
PROGNOSIS.
NCP 1
Date: 25/10/2016 @ Time: 1800 pm
Nursing Diagnosis
Impaired gas exchange related to inadequate
surfactant levels
Supporting Data
-
Breathing patterns (Poor breathing Effort)
Objective Data:
46
as evidenced by respiratory acidosis and SPO2 level <92%
NCP 1:IMPAIRED GAS EXCHANGE RELATED

TO INADEQUATE SURFACTANT LEVELS
1) MONITOR
AND
DOCUMENT
HOURLY
FIO2
LEVELS. SA02 PER PULSE OXIMETER, AND

VITAL
SIGNS
(TEMPERATURE,
HEART
RATE/RHYTHM AND BP).

ASSESSMENT PROVIDES INFORMATION ABOUT
NEONATES ABILITY TO INITIATE AND SUSTAIN AN
EFFECTIVE BREATHING PATTERN.
I: I MONITOR CHILD PARAMETER EVERY HOURLY
INCLUDING HER SPO2, HR AND BP AND THE RESULT 47
WAS SPO2 LESS THAN 92%, HR:140- 150BPM. .
NCP 1: IMPAIRED GAS EXCHANGE

RELATED TO INADEQUATE SURFACTANT
LEVELS
2)
MONITOR
LABORATORY
STUDIES
(ABGS,
GLUCOSE, ELECTROLYTES)
LAB STUDY IS ESSENTIAL MONITORING FOR
BODY SYSTEMS BALANCE
I:I TOOK ABG AND RESULT WAS MIX RESPIRATORY AND
METABOLIC ACIDOSIS.
NCP IMPAIRED GAS EXCHANGE RELATED TO

INADEQUATE SURFACTANT LEVELS
3) ADMINISTERED WARMED AND

HUMIDIFIED OXYGEN AT RATE ORDER BY
DOCTOR.
TO PREVENT HYPOXIA AND INJURY TO
THE
CHILD
MUCOSA
MEMBRANE
OF
AIRWAY.
I: I ENSURE THE OXYGEN SUPPLY WAS
HUMIDIFIED AND TEMPERATURE MAINTAIN
NCP IMPAIRED GAS EXCHANGE RELATED

4)
POSITION
PATIENT
FOWLERS
TO
FACILITATE OPTIMUM BREATHING PATTERNS.

ALLOWS GRAVITY TO ASSIST IN LOWERING
THE DIAPHRAGM, AND PROVIDES GREATER
CHEST EXPANSION
I: I ADJUST THE INCUBATOR TO BE IN 15 DEGREE
AND MAINTAIN HEAD MILD EXTENDED WITH
BLANKED.
50
NCP IMPAIRED GAS EXCHANGE

RELATED TO INADEQUATE
SURFACTANT LEVELS
5) MAINTAIN AIRWAY CLEARANCE BY PERFORM
ETT AND ORONASAL SUCTIONING IF HAVE
EXCESSIVE MUCOSE AS ORDER BY DR.
MAINTAINS A PATENT AIRWAY FOR GAS
EXCHANGE
I: I DO ETT AND ORONASAL SUCTION AND RESULT
WAS MODERATE, YELLOWISH AND THICK.
51
NCP IMPAIRED GAS EXCHANGE RELATED

6) ADMINISTER MEDICATION , FOR EXAMPLE
CUROUSOF 100MG/KG AS ORDER BY DR Q
INCREASE SURFACTANT LEVEL AND
IMPROVE GAS EXCHANGE.
I: I ASSIST DR IQ SERVE CUROSURF THROUGH
ETT BY USING OGT FEEDING.
52
Impaired gas exchange related to inadequate

surfactant levels
EVALUATION:
Miss Y spo2 level maintain > 92 % regardless of
reduce FIO2 within 1 hour after nursing intervention
given.
Date:25/10/16
Time: 1900H
53
IMPAIRED GAS EXCHANGE RELATED

RE-EVALUATION:
MISS Y SPO2 LEVEL MAINTAIN > 92 %
REGARDLESS OF REDUCE FIO2 WITHIN 24
HOUR AFTER NURSING INTERVENTION
GIVEN.
DATE: 27/10/16
TIME:1800H
54
NCP 2
Date: 27/10/2016 @ Time: 2.00 pm
Nursing Diagnosis
Alteration in nutritional status less than body requirement
related respiratory distress and Nil By mouth status.
Supporting Data
Tacypnea > 60 breathe per min
Nil by mouth since birth 24/11/16 until 28nd October 2016
Orogastric feeding started on 28nd October 2016
55
NCP 2: Alteration in nutritional status less than

body requirement related respiratory distress and
Goal
Nil By mouth status.
Short Term: Patient will exhibit adequate nutrient

according her body requirement after 24 hours
nursing intervention given
Long Term: Child will not lose excessive body
weight more than 10% of birth weight throughout
hospitalization and before discharge.
56
NCP 2: ALTERATION IN NUTRITIONAL STATUS

LESS THAN BODY REQUIREMENT RELATED
RESPIRATORY DISTRESS AND NIL BY MOUTH
STATUS.
1) ASSESS CHILD CONDITION SUCH AS DIET HISTORY, GLUCOSE
STATUS AND CURRENT NUTRITIONAL INTAKE SUCH AS FREQUENCY,
AMOUNT, AND TYPE OF FEEDING PLANNED.
AS A BASELINE DATA AND GUIDELINE FOR FURTHER NURSING
INTERVENTION.
I: I ASSESS CHILD NUTRITIONAL STATUS INCLUDING HER CURRENT
DIET GIVEN, WEIGHT AND FEEDING REQUIREMENT .
57
NCP2: ALTERATION IN NUTRITIONAL STATUS LESS

THAN BODY REQUIREMENT RELATED RESPIRATORY
DISTRESS AND NIL BY MOUTH STATUS.
2)
ENCOURAGE MOTHER TO EXPRESS BREAST MILK AND
PASSING TO THE NURSE FOR CHILD FEEDING.

MOTHER EBM IS MOST HIGHER NUTRITION COMPARE TO
FORMULA MILK AND CONTAIN COLOSTRUM.
I: I TEACH AND ASSIST MADAM Q TO EXPRESS HER BREAST MILK
AND KEEP IN THE REFRIGERATOR TILL THE DR PLAN STARTED
HER FEEDING..
58

STATUS.
3. OBSERVE AND DOCUMENT AMOUNT OF INTAKE AND OUTPUT
OF CHILD.
TO PROVIDE DATA ON CHILD NUTRITIONAL AND HYDRATION
STATUS.
I: DURING MY SHIFT, I CALCULATE ALL INTAKE AND OUTPUT OF
MISS Y AND MAKE SURE URINE OUTPUT MORE THAN 1MLS/KG
/HOUR.
59

STATUS.
4) ADMINISTER IV THERAPY AS ORDER BY A DOCTOR
SUCH AS DEXTROSE 10%.
FOR FLUID REPLACEMENT , PREVENT DEHYDRATION
AND PREVENT HYPOGLACEMIA.
I: FOR MISS Y, DOCTOR Q ORDERED DEXTROSE 10%
BECAUSE SHES STILL NBM AND PLANNING FOR FEEDING
SOON.
60
NCP 2:ALTERATION IN NUTRITIONAL STATUS

STATUS.
START WITH SMALL AMOUNT OF FEEDING

AND FREQUENTLY AS ORDER BY DR.
5)
BY GIVING SMALL AND FREQUENT

FEEDING, WILL HELPS MAINTAIN THE INTAKE
AND HYDRATION STATUS OF
I: DURING FEEDING TIME, I GIVE SMALL
AMOUNT AS PATIENT CAN TOLERATE WITH IT
AND INFORM DR IF ASPIRATION MODERATE.
61
NCP 2: ALTERATION IN NUTRITIONAL

STATUS LESS THAN BODY
REQUIREMENT RELATED RESPIRATORY
DISTRESS AND NIL BY MOUTH STATUS.
PERFORM ETT AND ORONASAL SUCTION IF
VISIBLE AND AUDIBLE OF SECRETION BEFORE
STARTING THE FEEDING.
6)
SECRETION WILL CAUSE PATIENT POOR

TOLERATE WITH FEEDING GIVEN.
I:I DO ETT AND ORONASAL SUCTION BEFORE
GIVE PATIENT FEEDING AND RESULT WAS,
MODERATE YELLOWISH AND THICK SECRETION.
62

STATUS.
EVALUATION:
28/10/16@1600
- MISS Y ABLE TO TOLERATE OGT FEEDING GIVEN
3RD NOVEMBER 2016 @ 1000HOURS
- MISS Y NOT LOSE EXCESSIVE BODY WEIGHT MORE THAN 10% OF
BIRTH WEIGHT.
SUPPORTING DATA:
WEIGHT ON DISCHARGED WAS 3.51KG
BREAST FEEDING WAS SUCKING WELL
CUP FEEDING TOLERATED WELL
63
NCP 3
Date: 25/10/2016 @ Time: 1800 pm
Nursing Diagnosis
Ineffective thermoregulation (hypothermia) related to large body surface.
Supporting Data
-
Premature 36 weeks + 6 days
Temperature on admission 36c
Acrocyanosis
64
NCP 3: Ineffective thermoregulation (hypothermia)

related to large body surface.
Goal:
Childs axillary temperature will be maintained within
normal range 36.5c 37.5c after nursing intervention
given and during hospitalization.
65

1. ASSESSED CHILDS GENERAL CONDITION SUCH
AS:
- ACROCYANOSIS
- BODY COLD TO TOUCHED
AS A BASELINE DATA AND PLAN FOR FURTHER

NURSING INTERVENTIONS
I DO ASSESSED CHILDS GENERAL CONDITIONS BY
TOUCHING THE CHILDS BODY THAT IS COLD TO
66
TOUCH AND ACROCYANOSIS DUE TO JUST
DELIVERED.

2. MONITORED CHILD VITAL SIGN ESPECIALLY
AXILLARY TEMPERATURE EVERY HOURLY UNTIL
STABLE THEN EVERY 3 HOURLY.
TO OBTAINED A CONSTANT TEMPERATURE
READING.
I DO CHECKED CHILDS BODY TEMPERATURE ON
ADMISSION THAT IS WAS 36C THEN REPEATED 1
HOUR LATER IS 36.8C AND THEN CHECK FOR
EVERY 3 HOURLY.
67

3. KEPT THE INCUBATOR WINDOW CLOSED
AND AVOID FROM OPEN THE INCUBATOR
WINDOW FREQUENTLY.
TO PREVENT FROM HEAT LOSS THROUGH
CONVECTION
ALL THE STAFF INCLUDED ME DO NOT OPEN
THE INCUBATOR WINDOW FREQUENTLY, ONLY
DURING OBSERVATION OR ANY PROCEDURE.
68

4. CHANGED THE DIAPERS FREQUENTLY EG: EVERY
3HOURLY
TO PREVENT FROM HEAT LOSS THROUGH
EVAPORATION.
I DO CHANGE CHILDS DIAPER EVERY 3 HOURLY.
69

5. ADJUSTED THE INCUBATOR/RESUSCIATARE
TEMPERATURE BY INCREASE THE
INCUBATOR/RESUSCIATARE TEMPERATURE
ACCORDING TO CHILDS BODY TEMPERATURE.
TO INCREASED THE BODY TEMPERATURE AND
PREVENT FROM HYPOTHERMIA.
I DID NOT ADJUST THE INCUBATOR/RESUSCITARE
TEMPERATURE BY INCREASED THE INCUBATOR
TEMPERATURE BECAUSE CHILDS BODY TEMPERATURE
WAS MAINTAINED IN NORMAL RANGE (36.5 37.5C).
70

6. KEEPS CHILD AWAY FROM AIR
CONDITIONING VENTS OR DRAFTS.
TO PREVENT HEAT LOSS FROM
CONVECTION.
THE STAFFS ALWAYS KEEP THE BABIES IN
SPECIAL CARE NURSERY AWAY FROM AIR
CONDITIONING.
71

EVALUATION:
25TH NOVEMBER 2016@ 1800HOURS
CHILDS AXILLARY TEMPERATURE WAS MAINTAINED
WITHIN NORMAL RANGE 36.5C 37.5C.
RE- EVALUATION
5TH NOVEMBER 2016@ 1200HOURS
CHILDS AXILLARY TEMPERATURE WAS MAINTAINED
WITHIN NORMAL RANGE 36.5C 37.5C.
72
NCP 4: RISK OF INFECTION RELATED TO

IMMUNE SYSTEM DEFICIENCY AND INVASIVE
PROCEDURES.
SUPPORTING DATA
PERIPHERAL INTRAVENOUS SITE OF REDNESS,
SWELLING AND OTHER INFECTION SIGN
YELLOWISH OR GREENISH SECRETION THROUGH
ENDOTRACHEAL TUBE
SMELLY GASTRIC ASPIRATION
GOAL:
CHILDS WILL EXHIBIT NO EVIDENCE OF NOSOCOMIAL
INFECTION AFTER NURSING INTERVENTION GIVEN AND
DURING HOSPITALIZATION.
73

PROCEDURES.
1. OBSERVE AND REPORT SIGN OF INFECTION SUCH AS
WARMTH, REDNESS AND ANY DISCHARGE AT THE
AROUND INTRAVENOUS LINE
YELLOWISH OR GREENISH SECRETION THROUGH
ENDOTRACHEAL TUBE
SMELLY GASTRIC ASPIRATION
AS A BASELINE DATA AND FOR FURTHER TREATMENT.
I DO OBSERVE SIGN OF INFECTION TO THE CHILD MONITOR
FOR GASTRIC ASPIRATION, SECRETION THROUGH
ENDOTRACHEAL TUBE AND AROUND INTRAVENOUS LINE. 74

PROCEDURES.
2. MONITOR CHILDS VITAL SIGN ESPECIALLY
TEMPERATURE >37.5C
HEART RATE > 160 BEAT PER MIN
MAY INDICATE FOR INFECTION
I DO MONITOR CHILDS VITAL SIGNS EVERY 3
HOURLY FOR TEMPERATURE AND HEART RATE EVERY
HOURLY TO DETECT EARLY SIGN OF INFECTION.
75

PROCEDURES.
3. TAKE BLOOD AS PRESCRIBED BY DOCTOR

AND NOTE THE REPORT LABORATORY VALUES
(E.G: WHITE BLOOD CELL COUNT AND
DIFFERENTIAL)
TO PROVIDE VIEW OF THE CHILDS IMMUNE
FUNCTION AND TO DEVELOP AN APPROPRIATE
PLAN OF CARE.
THE STAFF NURSE TOOK THE BLOOD THROUGH
PERIPHERAL VEIN FOR FULL BLOOD COUNT AS
PRESCRIBED BY DOCTOR.
76

PROCEDURES.
4. ADMINISTERED IV ANTIBIOTIC AS PRESCRIBED
BY DOCTOR.
IV AMPICILIN 400MG BD
IV AMIKACIN 60MG DAILY
CEFUTAXIME 200MG BD
TO REDUCE ACTUAL AND POTENTIAL OF
INFECTION.
I DO ADMINISTER THE IV ANTIBIOTIC AS ABOVE
ACCORDING TO 7R.
77

PROCEDURES.
5. ENSURE THAT ALL CAREGIVER USE
APPROPRIATE HAND HYGIENE SUCH AS HAND
WASHING OR USE OF ALCOHOL-BASED HANDS
RUB
TO REDUCE TRANSMISSION OF ANY
ORGANISM TO THE CHILD.
I DO WASH HAND (MEDICALLY) BEFORE AND
AFTER TOUCHING THE CHILD WITH HIBISCRUB.
78

PROCEDURES.
7. ENSURE ALL EQUIPMENT IN CONTACT WITH CHILD IS CLEAN
OR STERILE SUCH AS
RESUSCITATION BAG, NASOGASTRIC TUBE, INCUBATOR
ET SUCTION TUBING, INTRAVENOUS MEDICATION
TO PREVENT FROM TRANSMISSION OF ORGANISM FROM
COMING INTO DIRECT CONTACT WITH THE CHILD
I DO USED CLEAN OR STERILE EQUIPMENT TO THE CHILD
ESPECIALLY CANNULA, ENDOTRACHEAL TUBE, ENDOTRACHEAL
SUCTION TUBING, SYRINGE, OROGASTRIC TUBING,
79
RESUSCITATION BAG AND ETC.

PROCEDURES.
8. ENSURE STRICT CLEAN OR STERILITY TECHNIQUE ARE
PERFORMED WITH INVASIVE PROCEDURE SUCH AS
PERIPHERAL IV INSERTION
ENDOTRACHEAL SUCTIONING (STERILITY)
OROGASTRIC FEEDING OR ASPIRATE
TO PREVENT FROM TRANSMISSION OF MICROORGANISM TO THE
CHILD
I DO USED STERILE TECHNIQUE DURING ENDOTRACEAL
SUCTIONED BY USING STERILE GLOVES ADMINISTER OROGASTRIC
FEEDING OR ASPIRATE. THE STAFF NURSE USED STERILE
TECHNIQUE DURING INSERTION OF IV LINE TO THE CHILD.
80

PROCEDURES.
EVALUATIONS:
27TH OCTOBER 2016 @ 1400HOURS
CHILD EXHIBITS NO EVIDENCE OF NOSOCOMIAL
INFECTION AFTER NURSING INTERVENTION
GIVEN AND DURING HOSPITALIZATION.
RE- EVALUATION:
5 NOVEMBER 2016 @ 1200H
CHILD IS FREE FROM NOSOCOMIAL INFECTION
AFTER NURSING INTERVENTION GIVEN AND
BEFORE DISCHARGE.
81
NCP5: PARENTAL ANXIETY

RELATED TO CHILDS
CONDITION AND PROGNOSIS.
SUPPORTING DATA
PARENT KEEP ASKING REGARDING CHILDS
CONDITION AND PROGRESS
MOTHER WAS CRIED AND EXPRESS HER FEELING
TO THE ME.
GOAL:
PARENTAL ANXIETY WILL BE REDUCING TO THE
MINIMUM LEVEL AFTER INTERVENTION GIVEN
AND DURING HOSPITALIZATION.
82

RELATED TO CHILDS
1. ASSESS PARENTAL LEVEL OF FEAR AND
ANXIETY.
TO KNOW LEVEL OF FEAR AND ANXIETY OF
PARENTS AND ABLE TO PLAN FOR FURTHER
INTERVENTION.
I ASSESS PARENT LEVEL OF ANXIETY BY
LOOKING AT THE PARENTS FACIAL
EXPRESSION AND MISS M MOTHER CRIED
DURING CAME TO SPECIAL CARE NURSERY.
83

RELATED TO CHILDS
2. REINFORCE THE DOCTORS EXPLANATION
REGARDING RESPIRATORY DISTRESS SYNDROME
AND CHILDS MANAGEMENT NEEDED TO RULE
OUT OF RDS.
TO ENHANCE PARENTS KNOWLEDGE AND
FACILITATE UNDERSTANDING
I DO REINFORCE TO PARENTS ABOUT THE
DIAGNOSIS, AND THE MANAGEMENT AS
PRESCRIBED BY DOCTOR TO MAKE PARENTS
MORE UNDERSTANDING.
84

RELATED TO CHILDS
3. USE A SIMPLE LANGUAGE AND TERMS
WHILE EXPLAIN TO THE PARENTS AND
AVOID FROM USING MEDICAL TERM.
FOR EASIER THE PARENTS TO
UNDERSTAND WHAT WILL EXPLAIN TO
THEM.
I EXPLAINED TO PARENTS IN BAHASA
MELAYU FOR EASIER PARENTS TO
UNDERSTAND AND USING A SIMPLE WORD.
85

RELATED TO CHILDS
4. EXPLAINED ALL PROCEDURE TO BE DONE TO
CHILD TO THE PARENTS.
TO REDUCE PARENTAL FEAR AND ANXIETY
ABOUT THE PROCEDURE TO THEIR CHILD.
I EXPLAINED TO PARENTS ALL PROCEDURE SUCH
AS THE PURPOSE OF TAKING VITAL SIGNS,
GIVING IV MEDICATION AND INVASIVE OXYGEN
THERAPY.
86

RELATED TO CHILDS
5. KEEP FAMILY INFORMED OF CHILDS
PROGRESS.
TO HELP REDUCE FAMILY ANXIETY ABOUT
CHILDS CONDITION AND PARENTS AWARE OR
PROGRESS OF THEIR DAUGHTER.
I DO INFORMED TO MISS M PARENTS
REGARDING MISS M PROGRESS EVERY TIME MISS
M MOTHER CAME TO SPECIAL CARE NURSERY.
87

RELATED TO CHILDS
6. ENCOURAGE THE PARENTS TO ASKING THE QUESTION
THAT THEY MAY NOT UNDERSTAND.
TO PROVIDE PARENTS MORE KNOWLEDGE AND
UNDERSTANDING ABOUT THE DISEASE CONDITION.
I ENCOURAGE THE PARENTS TO ASK ME OR OTHER STAFF
ALSO THE DOCTOR IN CHARGE IF THEY HAVE ANY QUERIES
ABOUT THEIR CHILD CONDITION.
88

RELATED TO CHILDS
EVALUATION:
26TH OCTOBER 2016@0800 HOUR
PARENTS KNOWLEDGE REGARDING DISEASE CONDITION
IMPROVED BY EVIDENCES OF THE PARENTS IS CALM AND
GIVES FULLY COOPERATION DURING TREATMENT IN THE
WARD AFTER 1 HOUR OF INTERVENTION.
RE-EVALUATION
5TH OCTOBER @1200 HOUR
PARENTS KNOWLEDGE REGARDING DISEASE CONDITION
IMPROVED BY EVIDENCES OF THE PARENTS IS CALM AND
GIVES FULLY COOPERATION DURING TREATMENT IN THE89
WARD AND READY FOR DISCHARGE .
Patient discharge on 21/11/2012 at 1400 Hour

Educate father and mother on:
Hand hygiene
Breast feeding
Care of cord
Sign and symptom of jaundice
Diet and fluid for mother
Immunization
Follow up
Summary
24/10/16 @ Miss y transfer in from KPJ Selangor,
look very ill with central cyanosis, Spo2 <20%,
Intubated , Fix on ventilator leaking >30% ,OGT
tube inserted, after 30 min. still not pick up
spo2,Do CXR and Reintubated, put on PTV mode.
25/10/16- morning: UAC & UVC

inserted, do ABG, mix respiratory &
metabolic acidosis, total fluid is
60mls/kg/day=9.5mls/hour
25/10/16@ early
morning Curousorf
400mg, Spo2 increase
to >95, turn to pinkish
in color, Sedated with
morphine infusion.
Started antibiotic.
Summary
25/10/16 @ afternoon- Desaturated, 40-60%, did
CXR, pull out ETT, increase Fio2 1.0%, MAP 4045mmhg, started infusion dobutamin, change
mode to HFOV, ABG show mix respiratory and
metabolic acidosis, ECHO done- normal
26/10/16- night shift, Ptn

NPU, bladder hard, urine
catheter inserted , good
urine pouring.reduce
dopamine and increase IV
fluid
26/10/16@afternoonspo2 drop again- repeat

CXR and serve surfactant
another 6 mls, Start IV
midazolam, Spo2 increase
to 92%, reduce dopamine.
Summary
27/10/16@ morning- more
stable, fio2 0.4, spo2 >95 %
mainatain. Started BO, large
amount, CBD removed
fluid requirement110mls/kg/day.dobutamine
off. K+:3.5mmol/L+added
3.6 mls of KCL.
28/10/16morning,stable, have
eye opening. Start
trophic feeding, 5mls
for 3 hourly. Change
IPPV setting to PTV
mode, no spotanues
breathing- reduce
midazolam to 0.5
mls/hour..
Total fluid 120mls/kg/day
29/10/16- PTV tolerated,

gradually reduce Fio2, ABG
Normal, increase feeding as
tolerated
Summary
1/11/16 @pt extubate. Put

on nasal prong 3 L/min
5/11/16@ SB
normal, -off
Photo, allow
discharge.
2/11/16. Reduce n/p 2L/min

UAC & UVC removed, off ivd,
transfer to CAN, commence
photo
4/11/16-still on photo, brestfeed well
CONCLUSION
THE VAST MAJORITY OF BABIES WHO DEVELOP
RDS DO SO BECAUSE THEY ARE PREMATURE.
ATTEMPTS TO PREVENT EARLY DELIVERY ARE
THEREFORE A MAJOR CONSIDERATION. A NUMBER
OF STRATEGIES CAN BE USED.
95

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RESPIRATORY

: POST BASIC PAEDIATRIC

EXPLAIN THE PATIENTS PROFILE, HISTORY, INCLUDING CHIEF

STATE THE GROWTH AND DEVELOPMENT, MILESTONES INCLUDING

STATE THE BIRTH HISTORY AND IMMUNIZATION HISTORY OF THE PATIENT.

STATE THE DIET HISTORY INCLUDING NUTRITIONAL ASSESSMENT

EXPLAIN FAMILY BACKGROUND INCLUDING FAMILY MEDICAL HISTORY

DESCRIBE PHYSICAL ASSESSMENT FINDING ON THE SPECIFIC BODY

DESCRIBE GROWTH AND DEVELOPMENT FINDING.

PATIENT'S PERSONAL DATA

: 24 OCTOBER 2016 @ 1649H

ADMITTING DIAGNOSIS :SEVERE RESPIRATORY

MRS. E HAD REGULAR ANTENATAL VISIT , ALSO GAIN

Figure: Immunization schedule in Malaysia for 2016

DR. IQ EXAMINED AND ASSESS MISS Y AND

Growth & DEVELOPMENT

Table: Anthropometric measurements of Miss Y during admission.

Y TOLERATE FEEDING WELL, WAS

Rds affects about 1 percent of newborn

Bar chart on RDS incidence of Newborns in DSH

SIGNS & SYMPTOMS

CXR BEFORE & AFTER

CXR BEFORE AND

DATE: 25/10/16@ 0043H

DATE: 25/10/16@ 1955H

DATE: 25/10/16@0802HPOST UAC & UVC INSERTION

Implication and significant

Post curosuft 400mg

rate, Increase PEEP and KIV

HFO, maintain strict hand

Mix res. & met. Mix res. &

Monitor saturation, Doing

hygiene & minimal handling

Implication and significant

Monitor saturation, Doing

suction, change IV Dextrose

12.5%, Kiv Curosurf., maintain

strict hand hygiene & minimal

Mix res. & met. res. acidosis

Implication and significant

Post curosurf 200mg/kg

hand hygiene & minimal

Monitor saturation, Doing

Implication and significant

*All lab value is within normal

UBUSE & CRP

Implication and significant

Rational for treatment

2. Vital signs monitoring

-Monitor vital signs and pain

Rational for treatment

To prevent Nutritional -give feeding as order and

Potential side effects -

1. Endotracheal suction is not recommended for several hours

Inhibit the bacterial cell wall synthesis

in infants with suspected sepsis who have previously

Potential side effects - Vomiting, diarrhoea; pseudomembranous colitis, rarely

1. Before starting therapy, determine if patient has had previous

IMPAIRED GAS EXCHANGE RELATED TO DECREASED

Breathing patterns (Poor breathing Effort)

as evidenced by respiratory acidosis and SPO2 level <92%

NCP 1:IMPAIRED GAS EXCHANGE RELATED

LEVELS. SA02 PER PULSE OXIMETER, AND

RATE/RHYTHM AND BP).