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The study discusses the pathophysiology, therapeutic management, and nursing interventions on a neonate with respiratory distress syndrome secondary to prematurity.
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A Case Study Presented to the Faculty of the College of Health Sciences, Department of Nursing, University of Southern Philippines Foundation Salinas Drive, Lahug, Cebu City In Partial Fulfillment of the Requirements for the Degree of Bachelor of Science in Nursing Mary En P. Cena June 2023
ii Approval Sheet This case study entitled “A CARE OF A NEONATE WITH RESPIRATORY DISTRESS SYNDROME”. Prepared and Submitted by: MARY EN P. CENA In partial fulfillment of the requirements for the degree of BACHELOR OF SCIENCE IN NURSING, had been examined through oral examination, hereby granted a grade of ___________ and is recommended for acceptance and approval. PETER ARNOLD T. TUBAYAN, R.N., M.A.N., Ph.D. Clinical Instructor, College of Health Sciences - Department of Nursing University of Southern Philippines Foundation Accepted and approved in partial fulfillment of the requirements for the degree in BACHELOR OF SCIENCE IN NURSING MERLYN A. OUANO, R.N., M.N. Dean, College of Health Sciences - Department of Nursing, Coordinator, Related Learning Experience University of Southern Philippines Foundation
iv Dedication This study is unfeignedly dedicated to my family. I live for you and with you. With this study I desire to give a lump of my knowledge from my nursing journey to the community and to my future patients, to reflect the kind of daughter and sister that my family has nurtured me to be. Further, this study is dedicated to the patients that I will care for in the future. May this be a medium to aid me in all the care that I will administer. May I learn to become non-maleficent and benevolent in every action that I do.
v Table of Contents Content Page Approval Sheet ii Acknowledgement iii Dedication iv Table of Contents v List of Tables vii List of Figures ix I. General Information and Patient’s Profile Introduction 1 Patient’s Profile 3 II. Pertinent Nursing Health History and Physical Assessment History of Present Illness 4 Family Health History 6 Environmental History 6 Genogram 7 Developmental Task 8 Health Assessment and Physical Examination 9 Laboratory and Diagnostic Studies 18 III. Summary of Significant Findings Summary of Significant Findings 22 IV. Anatomy and Physiology Anatomy and Physiology 24 V. Pathophysiology
vii List of Tables Table No. Title Page No. Health History and Physical Assessment 1 Family History 11 2 Newborn Reflexes 16 Laboratory and Diagnostic Studies 3 Complete Blood Count 18 4 Microbiology 19 5 Newborn Screening 19 6 Urinalysis 20 7 Stool Analysis 20 8 Chest X-Ray 21 Summary of Significant Findings 9 Summary of Significant Findings 22 Anatomy and Physiology 10 Pulmonary Embryology 26 Nursing Care Management 11 NCP 1: Imbalanced Nutrition: Less Than Body Requirements 31 12 NCP 2: Ineffective Breathing Pattern 34 13 NCP 3: Risk for Impaired Gas Exchange 37 14 NCP 4: Risk for Ineffective Breathing Pattern 40 15 NCP 5: Risk for Infection 42 Discharge Plan 16 Discharge Plan 45
viii Health Teaching Plan 17 Techniques in Breastfeeding 52 18 Environmental Practices Modification 54 19 Routine Immunization for Infants 57 Drug Study 20 Beractant 59 21 Ampicillin 60 22 Fluconazole 61 23 Dibencozide 62
Neonatal respiratory distress syndrome, or RDS, is a common cause of respiratory distress in a newborn, presenting within hours after birth, most often immediately after delivery. RDS primarily affects preterm neonates, and infrequently, term infants. The incidence of RDS is inversely proportional to the gestational age of the infant, with more severe disease in the smaller and more premature neonates. The most important risk factors are prematurity and low birth weight. Other risk factors include white race, male gender, late preterm delivery, maternal diabetes, perinatal hypoxia and ischemia, and delivery in the absence of labor (Kumar, 2021). Symptoms and signs of RDS include rapid, labored, grunting respirations appearing immediately or within a few hours after delivery, with suprasternal and substernal retractions and flaring of the nasal alae. As atelectasis and respiratory failure progress, symptoms worsen, with cyanosis, lethargy, irregular breathing, and apnea, and may ultimately lead to cardiac failure if adequate lung expansion, ventilation, and oxygenation are not established. While treatment modalities, including antenatal corticosteroids, surfactants, and advanced respiratory care of the neonate, have improved the outcomes for patients affected by RDS, it continues to be a leading cause of morbidity and mortality in the preterm infant (Lee, 2022). As the most common cause of respiratory distress in premature infants, RDS occurs in about 24,000 infants born in the United States annually (Lee, 2022). It is also the most common complication of prematurity leading to significant morbidity in late preterm neonates and even mortality in very low birth weight infants. The incidence of RDS increases with decreasing gestational age at birth. In one study of babies born between 2019 and 2021 at various National Institute of Child Health and Human Development
(NICHD) Neonatal Research Network centers, 98% of newborns born at 24 weeks had RDS, while at 34 weeks, the incidence was 5%, and at 37 weeks was less than 1%. The case fatality rate for RDS in Asia is 30-40%. In Southeast Asia, it ranges from 14.3% to 30.37%. In developing countries such as the Philippines, incidence soared to 14% to 30% (Kumar, 2021). For every 1,000 live births, about 13 infants die at age below 1 year old due to RDS. In a previous study in 2020, the country has an alarmingly high over-all mortality rate of 45% (Reñosa, 2020). It was studied that RDS incidence and subsequent infant mortality in the Philippines can be reduced by improved prenatal care, early detection and referral of high risk pregnancies, closer links between referral hospitals and health centers, close monitoring of labor to detect fetal distress, and early intervention when indicated (Pascual, 2020). Hence, neonatal respiratory distress syndrome is a frequent cause of increased morbidity and mortality in neonates. This study was aimed towards understanding the pathophysiology, clinical presentation, diagnosis, prevention, and management of this condition. Extensive research and study is vital to decreasing its morbidity and mortality. The researcher intended to explore therapeutic mediums of RDS to gear this study towards greater medical and societal significance.
History of Present Illness June 2022 The mother of the patient suspected pregnancy due to frequent bouts of nausea and vomiting in the morning. However, no professional attention was sought yet. July 2022 The mother of the patient sought for first prenatal consultation at barangay health center. A pregnancy test confirmed probable pregnancy. The mother was advised to consult for sonography, however the mother did not heed. September 2022 The mother of the patient consulted for first sonogram. The mother reported to have been informed that the fetus was thriving well, with normal estimated size, and normal quantity of amniotic fluid. October to December 2022 No medical consultations sought. The mother verbalized to have suffered from severe financial crisis during this time. Further, she verbalized to not have come across any reason to seek consultation. She believed that she went through a healthy pregnancy during this course. December 2022 The mother reported to have had a minor vehicular accident. The incident was narrated as follows: At 8 am the mother was riding backseat on a motorcyle on her way to the wet market, she was caught off guard when the driver suddenly hit the brakes to stop due to a stray dog crossing the road, both the driver and the mother fell off due to the impact, the driver helped her up while she inspected herself immediately, there was no
bleeding nor was there any injury apart from diffused abrasions on left upper leg and lower thigh, the mother insisted to not have experienced any troubling pain and therefore refused to see a professional. The mother went on her day as usual. There were no issues in the succeeding days as reported. January 6, 2023 (date of delivery) Before the patient had been delivered, the mother complained of onset of a non- radiating and non-persistent hypogastric pain at 6 AM on the same day of admission. The mother was nonchalant of her pain and continued her ADLs as usual. The mother reported performing household tasks such as cooking and doing the laundry. She recalled experiencing bouts of sudden pain which she thought of as normal stomach ache. The mother reported to consider herself as highly tolerant to pain. However, as hours progressed, the intensity, duration, and frequency of the pain also progressed. She decribed the pain as radiating towards the back, persistent, and extremely painful. She would rate the pain as 10 and she reported that she knew at that moment (1 PM) that she was going into labor. She contacted the father of the patient and he immediately rushed her to the hospital. The parents rode a single taxi (motorcycle) and the mother recalled to have passed upon bumpy roads and the vehicle was on full speed. She reported that the short ride has exacerbated the pain. Upon arrival at the emergency unit, the bag of water had broken with a gush of amniotic fluid and blood. The mother was immediately admitted to the delivery room and delivered the patient a few moments after via normal spontaneous vaginal delivery with cephalic presentation. Five minutes after delivery, patient’s APGAR score was 6 (moderately depressed), with a Ballard Score of 7, 8. Birth weight was 1,550 grams. Harsh breath sounds, shallow retractions, and cyanotic extremities were noted. Hypotonia and weak, irregular cry were noted. The patient was placed inside incubator for further assessments and management.
Figure 1 presents the patient genogram consisting of generations 1, 2, and 3. This shows the correlation between the patient’s condition and its hereditary dispositions.
The first stage of Erikson’s psychosocial development starts at birth and continues to approximately 18 months of age. The principal task is trust versus mistrust (Erikson, 1968). Newborns and infants must learn that adults can be trusted. This occurs when adults meet a newborn’s basic needs for survival. Newborns and infants are dependent upon their caregivers, so caregivers who are responsive and sensitive to their newborn’s needs help them to develop a sense of trust and thus the newborn will see the world as a safe, predictable place. Unresponsive caregivers who do not meet their newborn’s needs can engender feelings of anxiety, fear, and mistrust; thus the newborn may see the world as unpredictable. A sense of mistrust for people in the world results upon failure of this stage. The virtue developed at this stage is hope (Norton, 2018). The mother of the patient expressed her genuine concern for the welfare of her newborn. She constantly asked about the patient’s status and if there was anything more that she could do for her. She intended to have her newborn discharged the soonest possible because she would want her family to meet and bond with her newly-born daughter. She regularly breast-fed the patient and communicated as if they were bonding. The mother would often carry the patient and hum her songs everytime they were given the time alone. The mother was mostly present everytime the patient cried for attention. The patient appeared relaxed and well-rested upon assessments. The patient appeared calm and comfortable upon contact and interaction with mother. There were no episodes of agitation nor restlessness noted. Based on current assessments per se, the newborn attained the principal task of trust.
Illness incurred during course of pregnancy: none Medications taken during pregnancy (OTC or prescribed): none B. Obstetric History G 3 P 3 T 1 P 2 A 0 L 2 Use of tobacco: ocassionally during 2 nd^ trimester (1-2 sticks of Fortune cigarette every other week) Use of alcohol: ocassionally throughout pregnancy (1-2 cans of Red Horse Beer 330 mL every other week) Use of drugs: none C. Labor and Delivery AOG during labor: 30 wks 2 days Duration of Labor: 8 hrs Type of Delivery: NSVD Type of Anesthesia: local Place of Delivery: CCMC delivery room Complications: prematurity
D. Birth History Respiratory effort of newborn: __ unassisted __ assisted Character of cry: __ loud __ high pitched __weak Medications administered: Dibencozide, Fluconazole, Ampicillin, Beractant Presence of congenital anomalies: none Length of baby’s hospital stay: approximately 1 month E. Feeding History First feeding was started at how many minutes/hours after birth: 2 hrs
Amount and frequency: 400-600 mL/day every 4 hrs
F. Health History Previous illness, injuries, operations: none Medications taken:Dibencozide, Fluconazole, Ampicillin, Beractant as management for RDS I. Immunization Immunization Received: OPV 1 2 3 BCG 1 HepB 1 2 3 Approximate weight at birth: 1,550 g G. Family History (Focus only in the immediate family members) Table 1 Family History Name Relationship Age Health Status Education Occupation M.J.F. Mother 19 Normal Elementary level Housewife, hawker E.S. Father 21 Normal Elementary level Hawker J.C.F. Sibling 3 Normal N/A N/A Family History of: __ heart disease __ stroke __ cancer Other health conditions: premature labor and delivery, prematurity General Survey: Please encircle, check, or provide additional information as necessary. Integumentary: Are there any abrasions, lacerations, or birthmarks? none Head and Neck:
