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CASE PRESENTATION RESPIRATORY DISTRESS SYNDROME PREPARED BY ARUNIMA ANN (NICU) 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 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. GENERAL MEASUREMENT Head circumference : 26cm. Chest circumference : 24cm. Weight : 1.1kg. Length : 37cm. 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. 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. 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 . 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 ANATOMY AND PHYSIOLOGY ANATOMY AND PHYSIOLOGY 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 glycoprotein’s 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. PATHOPHYSIOLOGY PREMATURITY Decreased surfactant Increased alveoli surface tension Hypoxemia atelectasis Respiratory Acidosis Pulmonary vasoconstriction Capillary damage Fibrin exudate respiratory distress syndrome/hya line membrane disease Co2 retention 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 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,BE—1 NURSING INTERVENSTIONS Promoting adequate gas exchange Maintain thermoregulation Promoting adequate nutrition and hydration Encouraging parental attachment 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 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) MANAGEMENT OF NEONATAL RESPIRATORY DISTRESS INFANT WITH RDS Infant with RDS Mild tache/grunting Severe grunting Observe for10-20mt suggest resuscitate Clinical improvement no Ventilation,nicu,lab test yes Resolve spontaneously Chest x-ray o2 Nicu no IMPAIRED GAS EXCHANGE RELATED TO DISEASE PROCESS Assessment Planning implementation Vital signs: Tem:36.6 RR:68/mts PR:160/mts Spo2:80% ABG: PH:7.28 PCO2:68 PO2:70 HCO3:28 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 Rationale To maintain patient airway ABG show pco2 &PH level To prevent hypoxia Evaluation RR-52/mnt O2 saturation 98% ABG: PH-7.28 PCO2-39 HCO3-23 BE-1.1 INEFFECTIVE THERMOREGULATION RELATED TO IMMATURETY Assessment Subjective data Baby is crying continuously and seems to be irritable objective data Temperature 36.4c Planning implementation To maintain the temperature within the normal range Rationale 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 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 NURSING HEALTH TEACHING Instruct the parents about, Kangaroo care, Breast Feeding Proper covering of the baby[warm 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 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 BIBLIOGRAPHY Maternal and Child Health Nursing by Adele Pillitteri 5th edition; volume 1 page 426- 433;page 329-332 Lippincott Manual of Nursing Practice 9th edition Lange clinical manual neonatology fifth edition-by Gomella,Douglas,Fabien Neonatal resuscitation 5th edition