Transcript I. DEMOGRAPHIC DATA - Dr. Ahmad Abanamy Hospital
CASE PRESENTATION
PREPARED BY: BINDHYA XAVIER NURSERY
I. DEMOGRAPHIC DATA
CASE NO: AGE: 145*** NB DATE OF BIRTH: 24-10-12 SEX: MALE AOG: WEIGHT: 36+4 weeks 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 Hypoxemia Increased alveoli surface tension atelectasis Respiratory Acidosis Pulmonary vasoconstriction Capillary damage Fibrin exudate RESPIRATORY DISTRESS SYNDROME/HYALINE MEMBRANE DISEASE Co2 retention
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 BIRTH PATIENT VALUE AFETR 1 HOUR NORMAL VALUE PH-7.22
PH-7.37
PH[7.35-7.45] PAO2-70 PAO2-87 PA02[80-95%] PCO2- 50.4
HCO3-28 BE—[-2.5 ] PCO2-42 HCO3-23 BE[-4] PCO2[35-45mmHg] HCO3[22-26mEq/L] 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: Severe grunting,flaring,apnea Suggest RDS Rescucitation Supplemental O2 Chest Radiography Pulse Oximetry
CLINICAL IMPROVEMENT
NO VENTILATION LABORATIRY TEST NICU TRANSFER ANTIBIOTICS Management of Neonatal Respiratory Distress Infant with respiratory distress Mild tachypnea/grunting YES OBSERVE FOR 10-20 MINUTES RESOLVE SPONTANEOUSLY YES NO
•
CHEST RADIOGRAPHY
•
PULSE OXIMETRY
•
SUPPLEMENTAL O2
•
NICU TRANSFER
1.
2.
3.
4.
IMPAIRED GAS EXCHANGE RELATED TO DISEASE PROCESS INEFFECTIVE THERMOREGULATION RELATED TO IMMATURITY IMBALANCE NUTRITION, LESS THAN BODY REQUIREMENTS RELATED TO PREMATURITY AND INCREASE ENERGY EXPENDITURE ON BREATHING 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 liter per min.
To prevent hypoxemia 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
Receive baby in pre- warm radiant warmer
RATIONALE FOR ACTION
To prevent water loss& potential for hypoglycemia Adjust incubator or radiant warmer to obtain desired skin temperature To prevent hypothermia which may result in vasoconstriction & acidosis Provide neutral thermal environment to maintain the infants abdominal skin temperature between 97-98F To prevent heat loss &maintain thermoregulation Immediate drying & cover with warm blanket To prevent heat loss &maintain thermoregulation Provide kangaroo care [skin-skin contact] To prevent heat loss &maintain 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 9 th edition Lange clinical manual neonatology fifth edition-by Gomella,Douglas,Fabien Neonatal resuscitation 5 th edition