RESPIRATORY

DISTRESS
in
NEWBORN
CASE PRESENTATION
PREPARED BY: BINDHYA XAVIER
NURSERY
I. DEMOGRAPHIC DATA

CASE NO: 145***

AGE: NB
DATE OF BIRTH: 24-10-12
SEX: MALE
AOG: 36+4 weeks
WEIGHT: 2.56 kgs.
DIAGNOSIS: RESPIRATORY DISTRESS
II. PHYSICAL
ASSESSMENT
 
GENERAL APPEARANCE
• Well flexed,full range of motion,spontaneous movement

• Vital Signs:
Temperature
• T-35.6C
• stabilizes in 1-2hrs after delivery T-36.7C
Heart Rate
• HR-150/mnt
• Heart rate may be irregular with crying
Respiration
• Bilateral bronchial breath sound
• Asymmetrical chest movements
• (+) Grunting
• (+)Nasal flaring
• (+)Retractions
Blood pressure-not done routinely
varies with change in activity level
BP-97/75
General measurements
• Head circumference-35cm
• Chest circumference-33cm
• Weight-2.56kgm
• Length 49cm
SKIN

• (+)Acrocyanosis at birth
• At 24hrs of age,skin dry and pink in colour
• cord with one vein and two arteries
• cord clamp tight &cord drying
• Hair silky& soft with individual strands
• Nipples present & in expected locations
• Nails to end of fingers & often extend slightly
beyond
• Vernix caseosa- present only in the skin folds
• Lanugo-Present only in sacral area
Nose
• Nostrills patent bilaterally
• No nasal discharge
• Obligate nose breathers
• Nasal flaring beyond first
few moments after birth
Mouth &Throat
• Uvula midline
• Minimal salivation
•Tongue moves freely& doesn’t protrude
• Well developed fat pads bilateral cheeks
• Mucosa moist
• Palate high arched
• Sucking reflex present
•Rooting reflex present
•Gag Reflex present
 NECK
•Short& thick
•Turns easily side to side
•Clavicles intact
•Tonic neck reflex present
•Evident Xiphoid process
•Equal anteroposterior& lateral diameter
•Bilateral synchronous chest movement
•Marked retractions[+]
•Symmetrical nipples
ABDOMEN
•Dome shaped abdomen
•soft to palpation
•Well formed umbilical cord
•Three vessels in cord
•Cord dry at base
•Bilaterally equal femoral pulses
•Bowel sounds auscultated within 2hrs of
birth
•Voiding within 24hrs of birth
•Meconium with in 24-48hrs of birth
GENITALIA
•Urinary meatus at tip of glans
penis
•Palpable testes in scrotum
•Large, edematous, pendulous
scrotum
•Smegma beneath prepuce
•Stream adequate on voiding
BACK
•Intact spine without
masses or openings
•Patent anal opening
EXTREMITIES
•Maintains posture of flexion
•Equal & bilateral movement &tone
•Full range of motion all joints
•Ten fingers&ten toes
•Negative Hip click
•Grasp reflex present
•Legs appear bowed
•Palmar creases present
•Sole creases present
NEUROMUSCULAR SYSTEM

•Maintains position of
flexion
•When prone, turns head
side to side
III. PATIENT HISTORY
 
MATERNAL MEDICAL HISTORY:
•Mother presented with 36 4/7 weeks of
gestation

•(+) Diabetes Mellitus

•(-) Hypertension

 
PATIENT HISTORY
 
PRESENT MEDICAL HISTORY
 
•Baby delivered normally, cried
immediately soon after birth Apgar 8/9 at 1-
5 mins.
• After few minutes baby started with
grunting, nasal flaring and tachypnea
•After O2 inhalation @ 2-3 liter per min.
Apgar Score becomes 10/10.
 
IV. INTRODUCTION
 
Respiratory distress syndrome [RDS]
•formely known as Hyaline Membrane
Disease
•Syndrome of premature neonates that
is characterized by progressive and
usually fatal respiratory failure
resulting from atelectasis & Immaturity
of lungs
.
 
V. ETIOLOGY
•Preterm baby
•Maternal diabetics
•Meconium stained
•Infection
VI. ANATOMY AND PHYSIOLOGY
VII. 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.
 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.
 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.
VII. PATHOPHYSIOLOGY
PREMATURITY

Decresed surfactant

Increased alveoli
surface tension

atelectasis

Hypoxemia Co2
Respiratory Acidosis retention

Pulmonary
vasoconstriction

Capillary damage

Fibrin exudate

RESPIRATORY
DISTRESS
SYNDROME/HYALINE
MEMBRANE DISEASE
VIII. Sign& symptoms
•Grunting[+]
•intercostal retractions[+]
•Inspiratory nasal flaring[+]
•Tachypnea more than 60 breaths per
minute[+]
•Hypothermia[+]
•Cyanosis when child is in room air,
increasing need for oxygen
 LABORATORY TEST
PATIENT VALUE AT PATIENT VALUE NORMAL VALUE
BIRTH AFETR 1 HOUR

PH-7.22 PH-7.37 PH[7.35-7.45]

PAO2-70 PAO2-87 PA02[80-95%]

PCO2- 50.4 PCO2-42 PCO2[35-45mmHg]

HCO3-28 HCO3-23 HCO3[22-26mEq/L]

BE—[-2.5 ] BE[-4] BE-[+/-3]

 IX. NURSING INTERVENTION
 
•Promoting adequate gas exchange
•Maintaining thermoregulation

• Promoting adequate nutrition and hydration

•Encouraging parental attachment
.
.

X. TREATMENT
•Oxygen therapy
•Positive pressure
ventilation
• Antibiotics
 
XI. COMPLICATIONS OF
RESPIRATORY DISTRESS
•HYPOTENSION
•DIC
•RETINOPATHY OF
PREMATURITY
•PDA OR HEART FAILURE
•NECROTIZING ENTEROCOLITIS
•INTRAVENTRICULAR
HAEMORRAHGE
ILLUSTRATION: Management of Neonatal
Respiratory Distress

Infant with
respiratory
Severe grunting,flaring,apnea distress Mild
tachypnea/grunting

Suggest RDS
OBSERVE FOR 10-20
MINUTES
Rescucitation
Rescucitation
Supplemental
Supplemental O2
O2
Chest Radiography
Chest Radiography RESOLVE SPONTANEOUSLY
Pulse
Pulse Oximetry
Oximetry

CLINICAL
YES YES NO
IMPROVEMENT

NO
•CHEST RADIOGRAPHY
•PULSE OXIMETRY
VENTILATION
LABORATIRY TEST •SUPPLEMENTAL O2
NICU TRANSFER •NICU TRANSFER
ANTIBIOTICS
 XII. PRIORITIZATION OF NURSING
PROBLEMS
1. IMPAIRED GAS EXCHANGE RELATED TO DISEASE
PROCESS
2. INEFFECTIVE THERMOREGULATION RELATED TO
IMMATURITY
3. IMBALANCE NUTRITION, LESS THAN BODY
REQUIREMENTS RELATED TO PREMATURITY AND
INCREASE ENERGY EXPENDITURE ON BREATHING
4. IMPAIRED PARENTING RELATED TO SEPERATION
FROM THE NEONATE DUE TO HOSPITALIZATION
 XII. NURSING CARE PLAN
ASSESSMENT
CUES/
EVIDENCE
OBJECTIVE CUES:
VITAL SIGNS:
T-35.6C
RR-72 mnt
PR-158 mnt
SPO2-85%
ABG:
Ph-7.22
PO2- 70
PCO2-5O.4
HCO3-28
BE-[-2.5]
(+) Nasal flaring
(+) Acrocyanosis
 NURSING DIAGNOSIS

Impaired gas exchange

related to disease process.
 PLANNING

GOALS & DESIRED OUTCOME

Within 30 minutes of nursing intervention the newborn will be able to

achieve or maintain adequate gas exchange as manifested by:
•Respiratory rate between 40-60 bpm

•ABG within normal limits

•O2 saturation between 95%-99%

•Absence of nasal flaring

•Absence of acrocyanosis
 IMPLEMENTATION
NURSING ORDER/ACTION RATIONALE FOR ACTION

Clear the airway by suctioning PRN To maintain patent airway

 

Checking ABG levels as soon as possible ABG Shows Pco2&pH levels.

Administer supplemental oxygen 2-3 To prevent hypoxemia

liter per min.
 

Provide Sniffing position. Sniffing position helps tomaximal lung

Volume
 
 EVALUATION
After 30 minutes of nursing intervention the
goals were fully met as manifested by:
•Respiratory rate 48 bpm
•O2 saturation 97 %
•ABG
Ph-7.37
PO2-87
PCO2-42
HCO3-23
BE-[-4]
•Absence of nasal flaring
•Absence of acrocyanosis
 ASSESSMENT
CUES/
EVIDENCE

OBJECTIVE CUES:
•Gestational age-36+4 weeks
T-35.6
 
•Bluish discoloration present on both
extremities
 
•Cold to touch
 
NURSING DIAGNOSIS

Ineffective thermoregulation
related to immaturity
 PLANNING
GOALS & DESIRED OUTCOME:

Within 1 hour of nursing intervention the newborn

will be able to maintain
temperature as manifested by:
 
•Temperature between 36.5-37 c

•Absence of bluish discoloration present in

extremities

•Warm to touch
 IMPLEMENTATION
NURSING ORDER/ACTION RATIONALE FOR ACTION
Receive baby in pre- warm radiant To prevent water loss& potential
warmer
for hypoglycemia

Adjust incubator or radiant warmer to To prevent hypothermia which may

obtain desired skin temperature result in vasoconstriction & acidosis

Provide neutral thermal environment To prevent heat loss &maintain

to maintain the infants abdominal skin thermoregulation
temperature between 97-98F

Immediate drying & cover with warm To prevent heat loss &maintain
blanket thermoregulation

Provide kangaroo care To prevent heat loss &maintain

[skin-skin contact] thermoregulation
 EVALUATION
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
XIII. NURSING HEALTH TEACHING.
1.Instruct the parents about,
kangaroo care,
Breast Feeding
proper covering of the baby[warm
blanket]
2.Ensure that the family receives
information on routine well baby care.
3.Before discharge ,parents should feel
comfortable in their abilities to care for
the infant.
4.Educate them,importance of regulare
health care,periodic eye examinations,and
developmental follow up with the parents
XIV. CONCLUSION:

-Presented a case of preterm

new born baby with respiratory
distress,T-35.6,RR-72/mnt,PR-
150/mnt,SPO2-87%
-Baby relived from signs and
symptoms after 2hrs
-Thermoregulation maintained
-vaccinated with BCG&HBV
-Baby discharged after24hrs with
vitamin A&D drops 1ml once daily
XV. BIBLIOGRAPHY
Maternal and Child Health Nursing by
Adele Pillitteri 5th edition; volume 1
page 426- 433;page 329-332
Lippincot Manual of Nursing Practice
9th edition
 
Lange clinical manual neonatology fifth
edition-by Gomella,Douglas,Fabien
 
Neonatal resuscitation 5th edition
 
THANK
YOU!!!