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I.

Introduction

Respiratory Distress Syndrome of newborn, previously called hyaline


membrane disease. It is a syndrome caused in premature infants by
developmental insufficiency of surfactant production and structural
immaturity in the lungs. This syndrome is more frequent in infants of
diabetic mother or it can be genetically. It begins shortly after birth
and is manifested by tachypnea, tachycardia, chest retractions,
grunting. The lungs of infant with respiratory distress syndrome are
developmentally deficient in material called surfactant, which helps
prevent collapse of the terminal air-spaces (alveolar sac) throughout
the normal cycle of inhalation and exhalation.

Surfactant is a mixture of phospholipids, neutral lipids and proteins and


is spread as a film over the alveolar surface to lower surface tension
and to prevent alveolar collapse. This layer reduces the surface tension
of the fluid that lines the air- space. Surface tension is responsible for
approximately 2/3 of the elastic recoil forces. By reducing the surface
tension, surfactant prevents the air-spaces from completely collapsing
or exhalation. Therefore, without adequate amounts of surfactant, the
air spaces collapse and are difficult to expand. Blood passing through
the lungs is unable to pick up oxygen and unload carbon dioxide. Blood
oxygen levels fall and carbon dioxide rises, resulting in rising blood
acid levels and hypoxia. Structural immaturity, as manifest by
decrease number of gas-exchange and thicker walls, also contribute to
the disease process.

Respiratory Distress Syndrome (RDS) affects about 1% of newborn


infants and it is the leading cause of death in preterm infants. The
incidence decreases advancing gestational age, from about 50% in
babies born 26-28 weeks, to about 25% at 30-31 weeks.
Reasons for choosing the specific case

The group is already more or less familiar with Respiratory Distress


Syndrome; we’ve encountered only one so far in the hospital. Since
RDS is the leading cause in preterm infants, we are obliged to learn
more about the said disease so that we can know what are the causes
of it and the immediate action needed for it.

General Objective

The aim of this study is to present a case regarding Respiratory


Distress Syndrome in a simplified manner to give a clear picture about
the condition, thus, broadening the knowledge about the condition
process.

Nurse-centered
1. to gather reliable data, statistics and other related factors that
affect the health of the patient using observation and laboratory
records
2. to take an active part in the management and implementation of
nursing care
3. to analyze and interpret the data collected and be able to know
the factors that may lead to the patient’s present condition
4. to respond to the patient’s health needs by compliance to the
medical regimen and health teachings
Patient/Family-centered
1 Identify measures that could minimize the risk of occurrence of
the disease
2 Identify possible risk factors that may have contributed to the
development of the disease
3 Increase awareness on the risk factors of RDS
4 Develop the family’s support system and distinguish their
respective roles in improving the patient’s health status
5 Involve them in promoting the health care of the client

After the completion of the study, the student nurses shall be


able to:
• Perform a comprehensive assessment of Respiratory Distress
Syndrome
• Enumerate signs and symptoms of RDS
• Identify diagnostic procedures that would help in the diagnosis of
RDS
• Identify nursing problems utilizing the subjective/objective cues
gathered during the assessment
• Perform appropriate therapeutic interventions for each of the
formulated nursing diagnosis for RDS
• Evaluate effectiveness of care rendered to the client
• Formulate conclusions based on the findings and enumerate
recommendations concerning RDS
II. Nursing Assessment

A. Patient Profile
Patient Profile of Baby Boy Mendoza, Manalansan
Gender: Male
Nationality: Filipino
Birth date: February 06, 2010
Birth Place: Our Lady of Mt. Carmel Medical Center at San
Fernando, Pampanga
Address: 1145 San Antonio, Florida Blanca, Pampanga,
Philippines
Religion: Catholic
Father: Manalansan, Arley
Mother: Manalansan, Maria Genelyn
Admission Date and Time: February 06, 2010, 8:41 PM
Admitting Clerk: Mc Lat, Lea
Doctor: Dr. Alfonsa

B. History of Present Illness

Baby Boy Manalansan was admitted to Mt. Carmel Medical


Institute on February 06, 2010. He was delivered premature via
emergency cesarean section and was placed in the PCN unit of the
NICU. He was admitted due to prematurity, sepsis and transient
tachypnea or Hyaline Membrane Disease commonly known as
Respiratory Distress Syndrome.

C. Physical Examination

Date; February 06, 2010; as lifted from the chart (done by


Resident on Duty)

Chest AP and Lateral views:


>There are streaky changes in both lung fields
>The heart is normal in size and configuration
>Diaphragm is low lying with hyper-extended chest cage

Impression: Findings of transient tachypnea of the newborn or


Hyaline Membrane disease.

Vital Signs:
PR= 115 bpm
RR= 65 breaths per minute
Temp= 36.5 C

Vital Statistics
Weight= 1.7 kg
Length= 42 cm
Head= 30 cm
Chest= 27 cm
Abdomen=24 cm

Reflex: (+) Sucking, (+) Blink, (+) Rooting, (+)Palmar grasp, (+)Tonic
neck, (+)Moro Reflex, (+)Babinski Reflex

Appearance of the Newborn

Skin- normal skin turgor, pink, dry without lesions


Eyes- sclera is white, conjunctiva is clear, eyebrows thin, and
pupil equal in size
Ears- color is pink, the site is equal and symmetrical, the texture
is elastic, the pinna bend easily and recoil after bending
Nose- septum is midline, and both are patent. There is presence
of milia
Mouth- the lips is pink, mucosa is pink, tongue is midline, and
gum is pink
Neck- the neck is short with skin folds
Chest- the chest appears symmetric side to side, the breast is
slightly engorged, breathing pattern is normal
Abdomen- the contour of the abdomen is slightly protubesant
and cord is dry
Genitalia- testes is down and has rugae, the penis is small
Extremities- the arm and legs is short. The fingernails are
smooth and soft. The side of the foot is flat
D. Diagnostic and Laboratory Procedure

Diagnostic
and Analysis and
Normal
Laboratory Results Interpretation
Values
procedure( (book-based)
s)

Hemoglobi 256 140 -180 >RBC, hemoglobin,


n (Hgb) q/L and hematocrit are
elevated and may
indicate presence of
dehydration
Hematocrit 0.77
(Hct) 0.4 - 0.54 >The results indicate
the presence of
infection as
Red Blood 9.0 manifested by
Cells 5.5 – 6.5 X increased WBC count.
10 12/L
White 20.9 >Decreased
Blood Cells 5-10 X 10 lymphocyte may
9/L indicate sepsis
Lymphocyt 0.11
es >Segmenter within
0.20 - 0.40 normal range
0.80
Segmenter >Increased
0.50 – 0.70 monocytes may
0.09 indicate sepsis
Monocytes
0.01 – 0.06 >Platelet count
213 normal
Platelet
count 150 – 350 X
10 q/L
III. Anatomy and Physiology

The Respiratory System

The respiratory system's function is to allow gas exchange through all


parts of the body. The space between the alveoli and the capillaries,
the anatomy or structure of the exchange system, and the precise
physiological uses of the exchanged gases vary depending on
organism. In humans and other mammals, for example, the anatomical
features of the respiratory system include airways, lungs, and the
respiratory muscles. Molecules of oxygen and carbon dioxide are
passively exchanged, by diffusion, between the gaseous external
environment and the blood. This exchange process occurs in the
alveolar region of the lungs.

* The respiratory system consists of the nasal cavity, pharynx,


larynx, trachea, bronchi, and lungs.
* Upper respiratory tract refers to:
o Nasal cavity, pharynx, and associated structures.
* Lower respiratory tract refers to:
o Larynx, trachea, bronchi, and lungs
* Respiratory movements are accomplished by the diaphragm and
the muscles of the thoracic wall.

Nostrils/Nasal Cavities
During inhalation, air enters the nostrils and passes into the nasal
cavities where foreign bodies are removed, the air is heated and
moisturized before it is brought further into the body. It is this part of
the body that houses our sense of smell.

Sinuses
The sinuses are small cavities that are lined with mucous membrane
within the bones of the skull.

Pharynx
The pharynx, or throat carries foods and liquids into the digestive tract
and also carries air into the respiratory tract.

Larynx
The larynx or voice box is located between the pharynx and trachea. It
is the location of the Adam's apple, which in reality is the thyroid gland
and houses the vocal cords.

Trachea
The trachea or windpipe is a tube that extends from the lower edge of
the larynx to the upper part of the chest and conducts air between the
larynx and the lungs.

Lungs
The lungs are the organ in which the exchange of gasses takes place.
The lungs are made up of extremely thin and delicate tissues. At the
lungs, the bronchi subdivides, becoming progressively smaller as they
branch through the lung tissue, until they reach the tiny air sacks of
the lungs called the alveoli. It is at the alveoli that gasses enter and
leave the blood stream.

Bronchi
The trachea divides into two parts called the bronchi, which enter the
lungs.

Bronchioles
The bronchi subdivide creating a network of smaller branches, with the
smallest one being the bronchioles. There are more than one million
bronchioles in each lung.

Avleoli
The alveoli are tiny air sacks that are enveloped in a network of
capillaries. It is here that the air we breathe is diffused into the blood,
and waste gasses are returned for elimination.

IV. The Patient and His Illness

A. Pathophysiology: Book-Centered
Pathophysiology of Respiratory Distress Syndrome

Prematurity

Low level or absence of surfactant

Hypoinflation and pulmonary resistance occur

Blood shunts through the foramen ovale and the ductus
arteriosus


Poor perfusion of the lungs

Impaired gas exchange
V. PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT
1. INTRAVENOUS FLUIDS

DATE ORDERED/ CLIENT’S


MEDICAL DATE GENERAL INDICATIONS/ RESPONSE TO
MANAGEMENT PERFORMED DESCRIPTION PURPOSES THE TREATMENT

D10 W 500 cc via February 06, 2010 Isotonic It is used to supply Fluid balance was
solvent water and calories to maintained as
60 cc q 12 the body. It is also evidenced by stable
used as a mixing vital signs.
solution (diluents) for
other IV medications.

On going IVF February 07, 2010 Isotonic It is used to supply Fluid balance was
water and calories to maintained as
the body. It is also evidenced by stable
used as a mixing vital signs.
solution (diluents) for
other IV medications.

On going IVF February 08, 2010 Isotonic It is used to supply Fluid balance was
water and calories to maintained as
the body. It is also evidenced by stable
used as a mixing
vital signs.
solution (diluents) for
other IV medications.
Nursing Responsibilities
BEFORE DURING AFTER

- Check doctor’s order about - Practice aseptic technique - Monitor for the IV flow.
IVF therapy on the patient’s upon the procedure to - Regulate IVF based on the
chart prevent infection doctor’s order.
- Explain the procedure that - Check for the IVF level and - Monitor patient for evidence
is to be done to the the IVF kind of local IV complications.
significant others - Check for the patency of the - Always check for the
- Prepare the necessary tubing presence of air to prevent
materials - Select for a site appropriate air embolism.
for the insertion of the IVF.
2.
Medical Date Ordered Description Indication/
Management Purpose

Oral gastric Tube February 06, An Oral gastric tube Drainage for
2010 is a tube that is secretions and
inserted to the serves as a route for
client’s oral food intake
pathway towards
the stomach. The
purpose of this
procedure is to
provide nutrition
and aspiration of
gastric contents.

Medical Date Ordered Description Indication/


Management Purpose

Hooked to NCPAP at February 06, Oxygenation The client was


60% Fi O2, CA – 3, PA 2010 provides clients to having difficulty of
–3 have sufficient breathing that is
oxygen inhaled why oxygenation
towards their body. was given to ensure
that adequate
oxygen would be
taken by the client.
B. Drugs

NAME OF DATE ROUTE, GENERAL SIDE EFFECTS NURSING


DRUG ORDERED DOSAGE, ACTION, RESPONSIBILITES
FREQUENC INDICATION,
Y PURPOSE
GENERIC
NAME: February 06, 50 mg/kg IV • Third Generation CNS: fever • Obtain specimen for
2010 q 12 hours cephalosporin CV: phlebitis, culture and
Cefotaxime that inhibit cell- thrombophlebitis sensitivity test
sodium wall synthesis, GI: diarrhea, before giving.
BRAND promoting nausea • If large doses are
NAME: osmotic Hematologic: given, therapy is
instability; agranulocytosis, prolonged or patient
Claforan usually thrombocytopenia, is at high risk,
bactericidal transient monitor patient for
• Septicimea neutropenia, superinfection
caused by hemolytic anemia
susceptible Skin:
microorganisms, maculopapular and
such as erythematous
streptococci rashes, urticaria,
pain, temperature
elevation
Other: anaphylaxis
DATE ROUTE, GENERAL SIDE EFFECTS NURSING RESPONSIBILITES
NAME OF ORDERE DOSAGE, ACTION,
DRUG D FREQUENCY INDICATION,
PURPOSE
GENERIC
NAME: February 50 mg/kg IM • Inhibits cell-wall CNS: seizures, • Obtain specimen for culture
06, 2010 or IV within synthesis during lethargy and sensitivity tests before
ampicillin 30 minutes bacterial CV: vein irritation, giving
before multiplication thrombophlebitis
BRAND procedure • Bacterial GI: diarrhea, • Give IM or IV only if infection
NAME: meningitis or nausea, vomiting is severe or if patient cant
septicimea GU: nephropathy take oral dose
Apo-Ampi†, Hematologic:
Novo leucopenia, • Monitor sodium level
Ampicillin†, thrombocytopenia because each gram of
Nu-Ampi † , anemia ampicillin contains 2.9 mEq
Skin: pain at the of sodium
infection site
Other: • If large dose are given or if
hypersensitivity therapy is prolonged,
reactions, bacterial or fungal
overgrowth of non superinfection may occur
susceptible
organism • Watch for signs of
hypersensitivity
C. Diet
Date ordered
Type of Date taken General Description Indication/ Purpose Specific foods
Diet Date taken
Discontinued
or change

NPO February 06, is a medical instruction prevention of None


( nothing 2010 meaning to withhold aspiration pneumonia
per Orem) oral food and fluids
from a patient for
various reasons
VI. Nursing Management

List of Priority Identified Nursing Care Plans

1. Impaired Gas Exchange


2. Risk for infection (septicemia)
3. Risk for impaired Parent/infant attachment
Problem Number 1: Impaired Gas Exchange

ASSESSMEN NURSING INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATI


T DIAGNOS NS ON
IS
Prematurity
S: Ø Impaired ↓ After 1-2 >Assess, >to have a
gas Low level or hours of monitor and baseline data
O: exchange absence of nursing record vital
(+)Tachycardi related to surfactant intervention signs
a immaturit ↓ s, the >Developmenta
RR=65 y of Hypoinflation patient will >Consult with l care or trying
(+)Grunting newborn’s and demonstrat developmental to reduce infant
(+)Retractions lungs and pulmonary e improved care stress can
(+)Cyanosis lack of resistance ventilation coordinator as improve infant’s
(+)Nasal surfactant occur and vital to specific outcome
Flaring ↓ signs kept developmental
Poor to normal care measures
perfusion of for infant.
the lungs >to assess for
↓ >Evaluate respiratory
Impaired gas pulse oximetry insufficiency
exchange to determine
oxygenation >to reduce
irritation effect
>Keep of dust and
environment chemicals on
allergen or airways
pollutant free >Neutral
>Maintain a thermal
neutral thermal environment
environment minimizes risk
so infant’s of cold stress,
temperature which increases
remains stable metabolic
demands for
oxygen
>Maintain ET >ET tube
tube, protects patent
mechanical airway,
ventilation, Mechanical
and ventilation
supplemental assists with
warm delivery of
humidified oxygen to the
oxygen lungs. Using
warm,
humidified
oxygen
prevents cold
stress and
drying of
mucous
>Teach membranes.
parents that
the cause of >Parents will
preterm birth need to work
can’t be together to
identified arrange for best
care for preterm
infant
Problem Number 2: Risk for infection (septicemia)

NURSING EVALUATI
ASSESSMEN
DIAGNOSI INFERENCE PLANNING INTERVENTION RATIONALE ON
T
S

S: Ø Risk for Premature After 1-2 >Monitor neonate’s >To determine the
infection newborn hours of condition need for
O: related to ↓ nursing interventions and the
>Lethargy vulnerabilit Microorganis intervention effectiveness of
> y of infant, m enter body s, the >Monitor vital signs therapy
irritability lack of via IV client’s vital >To have baseline
>Hyperthe normal catheter, signs are >Practice Aseptic date
rmia flora, umbilicus kept to technique whenever >To minimize further
(TEMP= environme ↓ normal handling the infant risk of infection
37.5 C) ntal Weak immune range and
>Hypoxia hazards response due control the >Maintain ideal
> High and open to prematurity infection environment >To keep the body
pitch cry wounds ↓ temperature temperature at
>(+)cyano Sepsis normal range
tic (spells) Interdependent
>(+)Pallor >Ensure that all
>(+)Petec equipment used for >This will prevent the
hiae infant is sterile, spread of pathogens
scrupulously clean. to the infant
Do not share equipment
equipment with other
infants.

Dependent:
>Administer anti- >Aids in lowering
pyretics and anti- down the
biotics as ordered temperature and to
control the infection
Problem Number 3: Risk for impaired Parent/infant attachment
EXPECTED
ASSESSMEN NURSING INTERVENTI
INFERENCE PLANNING RATIONALE OUTCOME
T DIAGNOSIS ON

S=Ø Risk for Due to the Short Term: >interview >to know what The parent shall
impaired newborn’s parents, the parents be able to have
O= parent/neonat physical After 3 hours noting their feelings about mutually
e attachment illness and of nursing perception of the situation satisfying
>The
related to hospitalization intervention the situation interactions with
newborn is neonate’s , the parents and health and individual their new born
physical may have fear teachings, concerns
diagnosed
illness and on how to the mother
with a certain hospitalization handle their will identify >Educate >Helps clarify
baby since the and parents realistic
disease (RDS,
baby is on a demonstrate regarding expectations
sepsis) fragile state techniques child growth
and needed to enhance and
>The
extra care. behavioral development,
newborn is organization addressing
of the perception
hospitalized
neonate
>The >Involve >Enhances
parents in self concept
newborn is
activities with
separated the newborn
that they can
from his
accomplish
parents successfully

>Recognize >Reinforce
and provide continuation of
positive desired
feedback for behaviors
nurturant and
protective
parenting
behaviors
VII. DISCHARGE GOALS

1. Maintaining physiological and behavioral homeostasis with minimal


external support.
2. Weight 41/2 lb or greater appropriate to age/condition.
3. Complications prevented/resolving or independently managed.
4. Family identifying and using resources appropriately.
5. Family demonstrates ability to manage infant care.
6. Plan in place to meet needs after discharge
VIII. SUMMARY OF FINDINGS

Infant respiratory distress syndrome also called neonatal respiratory


distress syndrome or respiratory distress syndrome of newborn,
previously called hyaline membrane disease, is a syndrome caused in
premature infants by developmental insufficiency of surfactant
production and structural immaturity in the lungs. It can also result
from a genetic problem with the production of surfactant associated
proteins. RDS affects about 1% of newborn infants and is the leading
cause of death in preterm infants
Diagnostics includes: Chest X-ray, CBC, Echocardiogram, ABG.
Treatment includes oxygen given with a small amount of continuous
positive airway pressure ("CPAP"), and intravenous fluids are
administered to stabilize the blood sugar, blood salts, and blood
pressure. If the baby's condition worsens, an endotracheal tube
(breathing tube) is inserted into the trachea and intermittent breaths
are given by a mechanical device. An exogenous preparation of
surfactant, either synthetic or extracted from animal lungs, is given
through the breathing tube into the lungs.

IX. CONCLUSION

Based from everything we’ve found out about Respiratory Distress


Syndrome, it is a very crucial case because it is the leading cause of
infant death. Prompt treatment and adequate knowledge about the
disease process is needed so that complications won’t arise. Care is
not only given to the patient, but also to Parents of the patient.
Knowledge and appropriate skills are part of the tools of the nurse in
order to be effective in handling the patient.
X. RECOMMENDATION

We, the group 1, strongly recommend for every premature infants to


require prompt attention by a neonatal resuscitation team. Infants
should be given warm, moist oxygen. This is critically important, but
needs to be given carefully to reduce the side effects associated with
too much oxygen. Breathing machines can be lifesaving, and is useful
for infants with repeated breathing pauses. However, devices like
these can damage fragile lung tissues. In order to avoid some more
complications, there is a treatment called continuous positive airway
pressure or CPAP, this delivers slightly pressurized air through the nose
that can help keep the airways open.
If a breathing machine is unavailable, extracorporeal membrane
oxygenation is another option in treating a premature infant. This
provides oxygenation through an apparatus that imitates the gas
exchange process of the lungs. Unfortunately, if a newborn infant is
actually 2 kg below he/she is not to be placed on ECMO because they
have extremely small vessels for cannulation.
In preventing respiratory distress syndrome, mothers who are about to
deliver prematurely should be given glucocorticoids. Glucocorticoids
speed up the production of surfactant that can help the lungs inflate
with air and keeps the air sacs from falling. It is also important that all
babies with RDS receive excellent supportive care. Infants should not
be disturbed, handling them with gentle manner, and ideal body
temperature should be maintained.

XI. BIBLIOGRAPHY
BOOKS
Maternal and Child Nursing: Care of the Childbearing and Childbearing
Family. 5th Edition. By Adele Pillitteri
Essentials of Anatomy and Physiology. 6th Edition. Seeley, Stephens,
Tate.

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