Calamba Doctors’ College

Parian Calamba City, Laguna

SY 2010 – 2011

Case Presentation
Of
Infant Respiratory Distress Syndrome

Submitted by:

Bajado, Christian Dave

Bautista, Maria Cindy
Corcelles, Jay
Concepcion, Graziella
Del Fuerte, Heidi Avediz
Dena, Pauline Charmine
Domino, Jonnavel
Flores, Melson
Gutierrez, Mary Grace
Isturis, Shaddy
Ili, Charie May
Mariano, Resti
 Introduction

Infant Respiratory Distress Syndrome (IRDS) or the Hyaline Membrane Disease.

IRDS is a most often applied to severe lung disorder that carries the highest risk in terms of long-term
respiratory and neurologic complications. It is seen almost exclusively in preterm infants. The disorder is rare in
drug-exposed infants or infants who have been subjected to intrauterine stress, like pre-eclampsia or
hypertension.
The pathologic feature of IRDS is a hyaline-like membrane formed from exudates of an infant’s blood
that begins to line the bronchioles, alveolar ducts, and alveoli. This membrane prevents exchange of oxygen and
carbon dioxide at the alveolar-capillary membrane. The cause of RDS is a low level or absence of surfactant,
the phospholipid that normally lines the alveoli and reduces surface tension on expiration to keep the alveoli
from collapsing on expiration.
Common clinical manifestations of IRDS are tachypnea, pronounced intercostals or substernal
retractions, fine inspiratory crackles, audible expiratory grunt, flaring of the external nares, and cyanosis or
pallor.
The diagnosis of IRDS is made on the basis of clinical manifestations in radiographic studies.
Radiographic findings characteristic of IRDS include 1) a diffuse granular pattern over both lung fields that
closely resembles ground glass and represents alveolar atelectasis, and 2) dark streaks or bronchograms, within
the ground glass areas that represent dilated, airfield bronchioles. Pulse oximetry and carbon dioxide
monitoring, as well as pulmonary functions studies, assist in differentiating pulmonary and extra pulmonary
illness and are used in the management of IRDS
The treatment of IRDS involves immediate establishment of adequate oxygenation and ventilation and
supportive care and measures required for any preterm infant, as well as those instituted to prevent further
complications associated with preterm birth. The supportive measures most crucial to a favorable are to 1)
maintain adequate ventilation and oxygenation, 2) maintain acid-base balance, 3) maintain a neutral thermal
environment, 4) maintain adequate tissue perfusion and oxygenation, 5) prevent hypotension, and 6) maintain
adequate hydration and electrolyte status.
IRDS is a self-limiting disease. After a period of deterioration, and in the absence of complications,
affected infants begin to improve by 72 hours. Often heralded by the onset of diuresis, this improvement has
been attributed primarily to increase production and greater availability of surface active material
 Nursing Theory

Roy’s Adaptation Model

Background:
The most well-known of the Californian theorist was Sister Calista Roy, a student of Dorothy
Johnson’s who was also a teacher of Nursing at Mount Saint Mary’s College in Los Angeles. The major of
Roy’s theory is on behavioral science concepts, with the individual described as a participant in bio-psycho-
social adaptive systems. Patients are described as being under varying degrees of stress and their goal is to adapt
to that stress.

Major Concepts:
1. System
A system is “a set of parts connected to function as a whole for some purpose and that does so by
virtue of the interdependence of its parts”. In addition to having wholeness and related parts,
“systems also have inputs, outputs, and control and feedback processes”
2. Adaptation Level
“Adaptation level represents the condition of the life processes described on three levels as
integrated, compensatory, and compromised”. A person’s adaptation level is “constantly
changing point, made up of focal, contextual, and residual stimuli, which represent the person’s
own standard of the range of stimuli to which one can respond with ordinary adaptive
responses”.
3. Adaptation Problems
Adaptation problems are “broad areas of concern related to adaptation. These describe the
difficulties related to the indicators of positive adaptation.
4. Focal stimulus
The focal stimulus is the “internal or external stimulus most immediately confronting the human
system”.
5. Contextual Stimuli
Contextual stimuli “ are all other stimuli present in the situation that contribute to the effect of
the focal stimulus”. That is, “contextual stimuli all the environmental factors that are present to
the person from within or without but which are not the center of the person’s attention and
energy.
 6. Residual stimuli
Residual stimuli “are environmental factors within or without the human system with the effects
in the current situation that are unclear”.
7. Coping Processes
Coping processes “are innate or acquired ways of interrupting changing environment”.
8. Innate coping Mechanism
Innate coping mechanism “are genetically determined or common to the species and are
generally viewed as automatic processes; humans do not have to think about them”.
9. Acquired coping Mechanism
Acquired coping mechanism “ are developed through strategies such as learning. The experience
encountered throughout life contribute to the customary responses to particular stimuli”.
10. Regulator Subsystem
Regulator is “a major coping process involving the neural, chemical, and endocrine system”.
11. Cognator Subsystem
Cognator is a major coping process involving four-cognitive emotive channels: perceptual and
information processing, learning, judgment, and emotion.
12. Adaptive Responses
These are those “that promote integrity in terms of those human system”.
13. Ineffective Responses
These are those “that do not contribute to integrity in terms of the goals of the human system”.
14. Integrated Life Processes
It refers to the adaptation level at which the structure and functions of a life process are working
as a whole to meet human needs.

4 Adaptive Models:
I. Physiological-physical Mode
The physiological mode is associated with the physical and chemical processes involve in
the function and activities of living organisms. Five needs are identified in the physiological physical mode
relative to the basic need of physiological integrity as follows: 1) oxygenation, 2) nutrition, 3) elimination, 4)
activity and rest, and 5) protection.
II. Self-concept Mode/ Group Identity Mode
The self-concept-group identity mode is one of the three psycho-social modes and “it
focuses specifically on the psychological and spiritual aspects of the human system. The basic need underlying
the individual self-concept mode has been identified as psychic and spiritual integrity, or the need to know who
one is so that one can be or exist with a sense of unity, meaning, and purposefulness in the universe”.
 Self-concept is defined as the composite of beliefs and feelings about oneself at a given
time and is formed from internal perceptions and perceptions of others’ reactions.
Its components include the following: 1) the physical self which involves sensation and
body image, 2) the personal self which is made up of self consistency, self ideal or expectancy, and the moral-
ethical-spiritual self.
III. Role Function Mode
The role function mode “is one of two social modes and focuses on the roles the person
occupies in society. A role, as the functioning unit of society is defined as a set of expectations about how a
person occupying one position behaves toward a person occupying another position. The basic underlying the
role function mode has been identified as social integrity—the need to know who one is in relation to others so
that one can act”. These roles are carried out with both instrumental and expressive behaviors. Instrumental
behavior is “the actual physical performance of a behavior”. Expressive behaviors are the feelings, attitudes,
likes, or dislikes that a person is about a role or about the performance of a role.
IV. Interdependence Mode
The basic need of this mode is termed relational integrity.
Two major areas of interdependence behaviors have been identified, receptive behavior
and contributive behavior. These behaviors apply respectively to the receiving and giving of love, repect and
value in interdependent relationships.

Major Assumptions:
Adaptation
According to Roy, adaptation refers to “the process and outcome whereby thinking and
feeling persons as individuals or in groups, use conscious awareness and choice to create human and
environmental integration”.
Nursing
Roy defines nursing broadly as a “health care profession that focuses on human life
processes and patterns and emphasizes promotion of health for individuals, families, groups, and society as a
whole”. Specifically, Roy defines nursing according to her model as the science and practice that expands
adaptive abilities and enhances person and environmental transformation. She identifies nursing activities as the
assessment of behavior and the stimuli that influence adaptation. Nursing judegments are based on the
assessment and interventions are planned to manage the stimuli.
Nursing science is a “developing system of knowledge about persons that observes,
classifies, and relates the processes by which persons positively affects their health status. “Nursing acts to
enhance interaction of the person with the environment—to promote adaptation”.
 Roy’s goal of nursing is “the promotion of adaptation for individuals and groups in each
of the 4 adaptive modes thus contributing to health, quality of life and dying with dignity”
Person
According to Roy, humans are holistic, adaptive systems. “As an adaptive system, the
human system is described as a whole with parts that function as unity for some purpose. Human system
include people as individuals or in groups including families, organizations, communities, and society as a
whole”.
Health
“Health is the state and the process of being and becoming integrated and a whole person.
It is the reflection of adaptation that is, the interaction of the person and the environment. Roy derived this
definition from the thought that adaptation is a process of promoting physiological, psychological, and social
integrity and that integrity implies an impaired condition leading to completeness or unity.
Health and illness are one inevitable, coexistent dimension of the person’s total life
experience. Nursing is concerned with this dimension. When mechanism for coping are ineffective, illness
results. Health ensues when human continually adapt. As people adapt to stimuli, they are free to respond to
other stimuli. The freeing of energy from ineffective coping attempts can promote healing and enhance health.
Environment
Environment is “all the conditions, circumstances, and influences surrounding and
affecting the development and behavior of persons or groups, with particular consideration of the mutuality of
person and earth resources that includes focal, contextual, and residual stimuli”. “It is changing environment
that stimulates the person to make adaptive responses”. Environment is the input into the person as an adaptive
system involving both internal an external factors. These factors may be slight or large, negative or positive.

CONTROL
INPUT PROCESSES EFFECTORS OUTPUT

Stimuli Coping Physiological functions

Adaptation Adaptive and
mechanisms Self-concept
Level ineffective
Regulator Role function
Responses
Cognator Interdependence

Feedback
 Patient's Data

Biographic Data

Baby Girl E.S. is a newborn female. She was born last June 16, 2010 at Calamba
Doctors' Hospital, Parian, Laguna. She lives at Phase 6, Mabuhay City, Cabuyao, Laguna.
She is a Filipino citizen and a Roman Catholic. There were no financial assistance from
any institutions noted.

History of Present Illness

A few hours prior to the delivery of the child, Mrs. E.S. experienced episodes of
contractions. She immediately went to a nearby clinic for a check-up and ultrasound. The
ultrasound was not performed since the clinic stated that the baby is ready to be
delivered and that she is in a preterm labor. She was then transported to Calamba
Doctor's Hospital for the delivery.

Past Health History

Mrs. E.S., 29 years old and the mother of the patient, stated that the pregnancy
was not planned. Although it was not planned, she felt happy when she found out that
she was pregnant. After using the pregnancy test kit, it turned positive for pregnancy
and that's when she went to their local health center who confirmed that she was
already 3-months pregnant.

She stated that she was previously pregnant just a year a ago and also delivered
through a normal spontaneous delivery. It was a baby boy and it was delivered in full
term by a midwife at home. No complications were noted.

Regarding her general health during pregnancy, she said that she felt fine and
healthy. But the only problem was, she gets very tired easily doing household chores and
the taking care of her one year old baby. She even complained of slight pain on her
abdomen and stated, “Minsan, pagnapapagod ako, pakiramdam ko bumababa yung
bata”. There were no accidents noted. In terms of medications, she only took Ferrous
Sulfate for iron supplementation. Mrs. E.S. never took tobacco, alcohol or any drugs
during the pregnancy.

Before the Delivery of the Child:

 Mrs. E.S. eats at least 3 times a day with one cup of rice each meal. And which
usually consist of vegetables. Her water intake is usually 8 glasses (2000mL) and 2
glasses of powdered orange juice everyday. She stated that she did not take any milk for
her pregnant state rather she drinks Milo, and Bearbrand milk. She’s not very fond of
eating neither junkfoods nor any sweets. Every now and then, she eats fruits and
vegetables whenever her budget permits it.

With regards to her elimination pattern, Mrs. E.S. voids 8 times a day, light yellow
in color, no pain during urination, and scanty in amount. She usually defecates once
everyday, brown in color, semi-formed, and no pain during bowel movement.

She has a happy and close relationship with her husband. Even during pregnancy,
they were sexually active and it happened every month.

Delivery of the Child:

Baby Girl E.S. was born last June 16, 2010, 3:12pm at Calamba Doctors' Hospital.
She was delivered through a Normal Spontaneous Delivery. There were no problems
experienced during the delivery except that the baby was in premature condition
because the Age of Gestation was 32 weeks.

Baby Girl E.S.' Apgar Score was 8 and interpreted as normal. Her birth weight was
1.5KG., Length of 40cm, Head circumference of 30cm, chest circumference of 25cm, and
abdominal circumference of 23cm. She was diagnosed of having Infant Respiratory
Distress Syndrome (IRDS) due to prematurity.

So far, Baby Girl E.S. was given Anti-Hepatitis B and BCG vaccines at birth.

Family History:

No known history of any diseases were noted like Diabetes Mellitus, Hypertension,
Cancer, and others.

Gordon’s Pattern

Nutritional-Metabolic Pattern

Baby E.S. started receiving Express Breast Milk (EBM) on her 8th day of
confinement. The feeding started at 6cc per day. Then the physician ordered to increase
feeding to 0.5cc everyday. On her 14th day, her feeding was increased to 30cc per day.

Elimination Pattern

Bladder/Bowel Habits: Baby Girl E.S. changes diaper 1-2 times a day. Her urine is
clear yellow in color. Her stool is greenish in color and watery in consistency.

Sleep/Rest Pattern

Baby E.S. sleeps for almost the whole day. She would only wake up for atleast 5-10
seconds and then goes back to sleep after that.

Diagnostic Test

COMPLETE BLOOD COUNT

JUNE 20 ,2010
RESULT NORMAL VALUES
HGB 12 12-15
HCT 0.34 0.35-0.45
RED BLOOD CELLS 3.35 4.6-5.2
WHITE BLOOD CELLS 11.35 5-10
NEUTROPHILS 0.390 0.55-0.65
LYMPHOCYTES .560 0.25-0.35
MONOCYTES 0 0.02-0.1
EOSINOPHILS 0.040 0.02-0.04
BASOPHILS 0 0-0.05
PLATELET 250 140-340
MCV 101.5 86-100
MCH 35.80 26-31
MCHC 35.30 31-37
 JUNE 26, 2010
RESULT NORMAL VALUES
HGB 14.30 12-15
HCT 0.41 0.35-0.45
RED BLOOD CELLS 4.07 4.6-5.2
WHITE BLOOD CELLS 14.61 5-10
NEUTROPHILS 0.390 0.55-0.65
LYMPHOCYTES 0.560 0.25-0.35
MONOCYTES 0 0.02-0.1
EOSINOPHILS 0.050 0.02-0.04
BASOPHILS 0 0-0.05
PLATELET 422 140-340
MCV 100.20 86-100
MCH 35.10 26-31
MCHC 35 31-37

BLOOD CHEMISTRY
JUNE 18,2010
Result Normal values
Sodium 133 137-145 mmol/L
Potassium 6.3 3.5-5.1 mmol/L
Calcium 7.7 8.4-10.2 mmol/L

JUNE 20, 2010)

Result Normal values
Sodium 145 137-145 mmol/L
Potassium 4.6 3.5-5.1 mmol/L
Calcium 9.9 8.4-10.2 mmol/L

JUNE 23, 2010

Result Normal values
Sodium 134 137-145 mmol/L
Potassium 6 3.5-5.1 mmol/L
Calcium 8.3 8.4-10.2 mmol/L

ARTERIAL BLOOD GAS

JUNE 17, 2010 (10:50 am)
Result Normal values
Ph 7.209 7.35-7.45
PCO2 46.4 35-45 mmHg
 PO2 82 80-100 mmHg
HCO3 22.8 22-28 meq/L
Be -4 (+ -) 2
O2 Saturation 95% 80-100%
Temperature 36.9
F1O2 60%
RR 23

JUNE 17,2010 (6:35pm)

Result Normal values
Ph 7.14 7.35-7.45
PCO2 64.5 35-45 mmHg
PO2 58 80-100 mmHg
HCO3 21.98 22-28 meq/L
Be -7 (+ -) 2
O2 Saturation 79% 80-100%
Temperature 37.5
F1O2 60% CPAP
RR 56

JUNE 17, 2010(9:49pm)

Result Normal values
Ph 7.25 7.35-7.45
PCO2 50.89 35-45 mmHg
PO2 161 80-100 mmHg
HCO3 22.6 22-28 meq/L
Be -4 (+ -) 2
O2 Saturation 99% 80-100%
Temperature 37.4
F1O2 100% via mech. vent.
RR 50

(JUNE 18,2010) (7:20am)

Result Normal values
Ph 7.225 7.35-7.45
PCO2 54.2 35-45 mmHg
PO2 153 80-100 mmHg
HCO3 22.6 22-28 meq/L
Be -5 (+ -) 2
O2 Saturation 79% 80-100%
Temperature 36.6
F1O2 95%
RR 65

JUNE 18,2010 (3:50 pm)

Result Normal values
 Ph 7.26 7.35-7.45
PCO2 51.2 35-45 mmHg
PO2 135 80-100 mmHg
HCO3 23.1 22-28 meq/L
Be -4 (+ -) 2
O2 Saturation 99% 80-100%
Temperature 37.3
F1O2 85%
RR 65

JUNE 19,2010 (7:42pm)

Result Normal values
Ph 7.34 7.35-7.45
PCO2 34.6 35-45 mmHg
PO2 206 80-100 mmHg
HCO3 18.7 22-28 meq/L
Be -7 (+ -) 2
O2 Saturation 100% 80-100%
Temperature 37
F1O2 80% via mech. Vent.
RR 60

JUNE 19, 2010 (7:34pm)

Result Normal values
Ph 7.30 7.35-7.45
PCO2 44.4 35-45 mmHg
PO2 99 80-100 mmHg
HCO3 21.9 22-28 meq/L
Be -5 (+ -) 2
O2 Saturation 97% 80-100%
Temperature 36.9
F1O2 65% via mech. vent
RR 50

JUNE 21, 2010

Result Normal values
Ph 7.56 7.35-7.45
PCO2 18.5 35-45 mmHg
PO2 143 80-100 mmHg
HCO3 16.8 22-28 meq/L
Be -5 (+ -) 2
O2 Saturation 100% 80-100%
Temperature 36.9
F1O2 40% via mech. vent
RR 43
 X- Ray findings
There are granular haziness of both lung field. The heart and the rest of the visualized chest structure are
remarkable.
Conclusion:
Hyaline-membrane disease
Ogt in place

Blood Culture and Sensitivity

(June 18,2010)
Org= no growth after 24 hoursof incubation
(June 20,2010)
Org= no growth after 3 days of incubation
(June 24,2010)
Org= no growth after 7 days of incubation

Hemo-GlucoTest
June 18,2010
CBG=172mg/dl
June 24,2010
CBG=44 mg/dl
 Journal

The Philippine Journal of Pediatrics

April- June 2001

Clinical Outcome of Preterm Infants with Maternal Pre-eclampsia

Emalyn Joy g. Montero, MD

Pre-eclampsia is a unique and often dangerous condition that occurs only during
pregnancy. Severe pre-eclampsia may threaten the life of a mother seriously, enough to force
her to deliver more than 10 weeks prematurely. Vaginal delivery of very low birth weight
babies may increase the risk of intraventricular hemorrhage, but caesarian delivery may
increase the risk of critically ill mother.
Recently, studies conducted suggests that infamts born to pre-eclamptic mothers have
accelerated lung maturation due to chronic intrauterine hypoxia which stimulates production of
cortisol leading to increase production of pulmonary surfactant.
 This study examines the clinical outcome of preterm infants born to mothers with and without
maternal pre-eclampsia, to compare the incidence of RDS and sepsis and their mortality rate.
This study looks at the clinical outcome of preterm infants with and without maternal pre-
eclampsia, by describing the profile of these infants in terms of Ballard’s Score, APGAR Score,
sex, birth weight, mode of delivery, etc. and to compare the incidence of sepsis and RDS these
infants.
Lesser incidence of RDS born to pre-eclamptic mothers has been shown in the study.
However, the risk of complications of sepsis is greater, particularly in the lower age group and
in the very low birth weight. Contributing factors are longer NICU stay and use of mechanical
ventilators and other invasive devices.

Reflection

After two weeks of caring and handling Baby Girl E.S., we are happy as she gradually
improves with regards to her over-all health. It was honestly challenging for us because it is our
first time to handle an infant confined in a NICU department. What more with the case which is
IRDS? It is a complex case for us to manage and because she is premature, she needed an
intensive care from us, as health care providers.
Because of her condition, she is extremely fragile that a slight touch may injure her. We
needed to give her the tenderest touch that we can offer.
Assessment and data gathering were hard to get. The NICU limits the number of visitors
allowed inside. And so, we assigned shifts every duty so as to observe and handle our baby girl.
It was a great relief in all of us that she is currently in a great state. She is recently on a
crib and without mechanical ventilation. At least, through the simple ways that we did, it added
up to the reasons why she’s in a fine health right now. And maybe someday, if destiny permits
it to happen, one of us will meet her as a young lady and that she would thank us for being a
part of who she is by then.
 With regards to the activity performed, it served as a bonding moment for us. We
laughed, we cried, we fought for pillows and time, and of course, we panicked. It was a strange
but unforgettable moment for all of us. The group became much closer and comfortable with
each other.
Yes, we can’t deny that it was very hard, sooooooo hard to do this activity. BUT! We
learned. And that’s what made the experience memorable and satisfying.
And so, with this, we would like to thank our dearest, and ever smiling, wonderful,
bubbly, exciting, cool, loving, adorable, hot… Mrs. Czarlynn Goopio for the opportunity, the
never-ending patience and trust in our group that we can do this. And of course for our advisers,
Mr. Jun Manaloto and Mr. Jude Inandan for the effort in helping make this presentation
presentable and possible.

Evaluation of Care

Impaired Gas Exchange

Goal unmet. The patient was not able to attain an adequate oxygen supply.
Nutrition Less Than Body Requirements

Risk For Infection