ABHILASHI COLLEGE OF NURSING

CASE PRESENTATION
ON
RESPIRATORY DISTRESS SYNDROME

SUBMITTED TO SUBMITTED BY

MRS PALLAVI MEHRA MRS. SWATI SHARMA

ASSOCIATE PROFESSOR (CHN) M.Sc NURSING 1ST YEAR

ACON ACON

SUBMITTED ON-
History of the patient

Identification Data:-

Name :- B/O Anjana

Age :- 1/ 365 days

Sex: FCH

Date of admission :- 03/06/22

Ward and unit :- S.N.C.U

Cr no.:- 2751

Diagnosis:- RESPIRATORY DISTRESS SYNDROME (RDS)

Religion :- Hindu

Address:- Vill.Pundal P/O Padhar The- Padhar Distt. Mandi

History

Chief complaint :-

 Baby is having difficulty in breathing

 Flaring nostrils.
 Bluish discouration of body
 Increased respiratory rate i.e 66 b /min.
History of present illness :-
Baby is appearently well after birth, but suddenly his extremities turns blue and baby is having difficulty in breathing. Then baby is immediately
shifted To S.N.C.U. Zonal Hospital Mandi . There baby is under strict vigilance with treatment includes oxygen administration to maintain
oxygenation level with in the body , inj Cefotaxim and injection Amikacin .

History of past illness:-

Baby develops sudden respiratory distress immediately after the birth . no other significant past medical history.

Birth history :- The patient was born with full term lower segment caesarian section ( LSCS) due to breech presentation in last trimester of
pregnancy.

 Birth weight- 1.7kg

 SNCU admission at birth.
Antenatal :- G1 P1 A0 L1 . Mother attended anitnatal checkup 4 times during her pregnancy period. She was immunized against Tetanus
Toxoid. She was having good nutritional status during her pregnancy. There is history of malpresentation during last trimester of her pregnancy.

Natal :- She delivered a full term baby through LSCS at Zonal hospital mandi . Baby cried immediately after birth.

Postnatal: Baby cries immediately after the birth. The birth weight is 1.7 kg .

Immunization History : baby is immunized at birth.

AGE NAME OF VACCINE DOSE ROUTE CHILD HAS

RECEIVED

At birth BCG 0.1 ml I/D Yes

OPV-0 dose 2 drops Oral Yes

Hep. B-1st dose 0.5 ml I/M

 yes

Dietary /feeding habits :

a. Type of feeding :- Baby is on exclusive breast feeding.

b. Current Diet:- Orogastric feeding 20 cc at 2 hours interval.
c. Eating habits:- normal

Growth and developmental milestones:

 BOOK PICTURE PATIENT PICTURE
Physical growth

 Weight 1.7 kg
 Length 48cm
 Head circumference 32cm
 Chest circumference 30 cm
 Abdominal girth 26 cm

Vitals Temperature Pulse Respiration Blood Oxygen

pressure saturation

36.8℃ 140 56b/min 68/49 90%

b/min mmhg

37.1℃ 136b/min 48b/min 62/42mmhg 91%

Social and Emotional

 Social relationship is not develop yet as baby is too sma to achieve this
 Is shy or nervous with strangers 
milestone..
 Cries when mom or dad leaves 

 Patient shows painful and crying expression during injection or medication

administration
  No patient is small to hands book to other
 Shows fear in some situations   Not significant
 Hands you a book when he wants to hear a story   Not significant
 Repeats sounds or actions to get attention 

Language/Communication
 Patient response to toys sound
 Responds to simple spoken requests 
 Uses simple gestures, like shaking head “no” or
 Not significant as baby age is small
waving “bye-bye” 
 Makes sounds with changes in tone (sounds more
like speech) 
 Says “mama” and “dada” and exclamations like
“uh-oh!” 
 Tries to say words you say

Personal history:

a. Hygiene : Personal hygiene is maintained by nursing staff as well as child’s parents.

b. Sleep: good
c. Elimination:- normal elimination habits 4-5 times a day.
d. Social relationship : not yet developed as baby is too small to achieve such milestones.
e. Activities : baby is not too active ,mostly in sleepy state.
Family history :

Family tree :
KEYS:-

MALE

FEMALE

PATIENT
 Family composition :

Sr Name of the family Relation to child Age/ Sex Educational Occupational Income per Health status
no. members status status month
1. Mr. ram chander Grandfather 60yrs/M 5th pass Farmer ----- Healthy

2. Mrs.bimla devi Grandmother 58yrs/F 5th pass Housewife ----- Healthy

3. Mrs .Neena devi Aunty 35yrs +2 pass Housewife ----- Healthy

4. Mr. vinod Father 30 yrs/M B.A Working in 20,000 /- Healthy

company
5. Mrs. Anjana Mother 25 yrs/F +2 pass Private teacher 5,000/- Healthy

6. Baby of Anjana Patient 1/365day ------ ------ ---- Unhealthy

/ Fch
Socio economic status :

Occupation of parents :- Patient’s father work in a pvt. Company at Baddi (H.P).

Total income per month :- 25,000/-

History of any hereditary disease :- There is no significant history of any kind of hereditary diseases in the family

Traditional practices:- There is no significant history of traditional practices followed by the family.

Physical Assessment :-

1. Baseline Data
1. Weight : 1.7 kg

2. Length : 48 cm

3. Temperature : 36.8 oC

4. Pulse : 146 beats/ min

5. Respiration : 32 breaths/min

6. Chest circumference : 31cm

2. General appearance
1. Nourishment : Moderately nourished
2. Body fluid : Adequate
3. Health : Healthy
4. Activity : Active
3. Mental Status
1. Conciousness : Concious
 2. Look : Anxious
4. Posture
1. Movement : Normal range of motion
5. Skin condition
1. Color : Fair
2. Texture : Warm
3. Lesion and infection : No infection , lesions absent
4. Rash : Diaper rashes absent
5. Nails : Normal
6. Head
1. Hair color : Black
2. Scalp : healthy , posterior fontanel are closed.
3. Face : No abnormal faces like mongoloid faces
7. Eyes
1. Eyebrows : Equally distributed
2. Eyelashes : Normal
3. Eyelids : No infection
4. Eyeball : Normal size
5. Eye conjunctiva : Not pallor
6. Sclera : White
7. Pupils : Pupils are reacting to light
8. Ears
1. External ear : No discharge

9. Nose : No deviated nasal septum

Nostrils : No external discharge.

10. Mouth and pharynx

1. Lips : Pink
 2. Odor of mouth : No fowl odour
3. Presence of cleft lip and cleft palate : No presence of cleft lip and cleft Palate
4. Color of tongue : pinkish
5. Throat : no enlargement of lymph nodes
11. Neck
1. Shape : normal symmetry
2. lymph node : no enlargement of lymph nodes
3. Movements : normal range of motion

12. Chest
1. Expension : bilateral air entry
2. Mark of any injury : absent
3. Surgery mark : no mark of any surgery is present on chest
13. Abdomen
1. Inspection : no scar is present
2. Abdominal girth : 28 cm
3. Palpation : no abnormal mass is palpable
4. Auscultation : bowel sounds are present
5. Percussion : fluid is present
6. Presence of generalized edema : yes

14. Back : no abnormal curve is present

15. Extremities
1. Upper extremities : range of motion is present
2. Lower extremities : range of motion is present

16. Genitalia : There is no edema or abnormal discharge is present

17. Rectum : No imperforate anus is present
 18. Elimination pattern:
1. Bowel habits: Normal ( 3-4 times a day)
2. Bladder habits: normal

ANATOMY AND PHYSIOLOGY

Respiration

Respiration is the act of breathing in and out. When you breathe in, you take in oxygen. When you breathe out, you give off carbon dioxide
 The respiratory system

The respiratory system is made up of the organs involved in the interchanges of gases:

 Nose
 Mouth
 Throat (pharynx)
 Voice box (larynx)
 Windpipe (trachea)
 Airways (bronchi)
 Lungs

The upper respiratory tract includes the:

 Nose
 Air-filled space above and behind the nose (nasal cavity)
 Sinuses

The lower respiratory tract includes the:

 Voice box
 Windpipe
 Lungs
 Airways (bronchi and bronchioles)
 Air sacs (alveoli)

Function of lungs:
The lungs take in oxygen. The body's cells need oxygen to live and carry out their normal functions. They also get rid of carbon dioxide. This is
a waste product of the cells.

The lungs are 2 cone-shaped organs. They are made up of spongy, pinkish-gray tissue. They take up most of the space in the chest, or the thorax
(the part of the body between the base of the neck and diaphragm). They are inside a membrane called the pleura.

The lungs are separated by an area (called the mediastinum) that has the following:

 Heart and its large vessels

 Windpipe
 Food pipe (esophagus)
 Thymus gland
 Lymph nodes

The right lung has 3 lobes. The left lung has 2 lobes. When you breathe, the air:

 Enters the body through the nose or mouth

 Travels down the throat through the voice box and windpipe
 Goes into the lungs through tubes (mainstem bronchi):
o One of these tubes goes to the right lung and one goes to the left lung
o In the lungs, these tubes divide into smaller bronchi
o Then into even smaller tubes called bronchioles
o Bronchioles end in tiny air sacs called alveoli

Breathing in babies
An important part of a baby's lung development is the production of surfactant. This is a substance made by the cells in the small airways. By
about 35 weeks of pregnancy, most babies have developed enough surfactant. It is normally released into the lung tissues. There it helps to keep
the air sacs (lung alveoli) open. Premature babies may not have enough surfactant in their lungs. They may have trouble breathing.
 DISEASE CONDITION

RESPIRATORY DISTRESS SYNDROME

Definition:

Respiratory distress syndrome is defined as the persistence of arterial O2 tension (PaO2) < 50 mm Hg and central cyanosis in room air (oxford
network). Supplemental oxygen supply is required to maintain PaO2 > 50 mm Hg or pulse oximeter saturation > 85%.

Incidence:

It ranges from 75% at around 28 weeks to 52% at 30 weeks of gestation. Use of exogenous surfactant has significantly reduced the risk of
neonatal death by <10%.

Clinical Causes:

Present in book Present in patient

 Hyaline membrane disease (HMD) or RDS   Hyaline membrane disease.
 Meconium aspiration  Meconium aspiration
 Clear fluid aspiration  Asphyxia.
 Pulmonary hypoplasia
 Bronchopulmonary dysplasia 
 Bronchopneumonia 
 Airway obstruction 
 Transient tachypnea 
 Pneumothorax
 Pulmonary edema 
 Congenital heart disease Aortic stenosis Coarctation of aorta Cyanotic—
Transposition of great vessels – Tetralogy of Fallot – PDA – VSD 
 Heart failure
 Persistent pulmonary hypertension of newborn (PPHN)
  Metabolic acidosis 
 Hypo- or hyperthermia 
 Hypoglycemia 
 Asphyxia 
 Drugs (Pethidine) 
 Birth trauma 
 Intracranial injury

Pathogenesis:

 The primary cause is inadequate pulmonary surfactant. Deficiency of surfactant in the lung alveoli increases alveolar surface tension.
 It is seen within first 24 hours of birth. Surfactant is a surface active material. It is produced by alveolar epithelial cells called Type II
pneumocytes at 24–28 weeks gestation.
 Antenatal corticosteroids enhances but fetal hyperinsulinemia delays surfactant synthesis.
 Other factors that enhance maturity of type II cells are: chronic stress, PIH, FGR, twins and placental insufficiency.
 There is poor lung compliance, reduction in ventilation— perfusion ratio and progressive atelectasis.
 Hyaline membrane disease (HMD) is further complicated by the weak respiratory muscles of the newborn.

Clinical Features:

Present in book Present in patient

 Respiratory rate more than 60
  Respiratory rate more than 60 breaths/minute. breaths/minute.
 Nasal flaring.  Nasal flaring.
 Rib retraction  Rib retraction.
 Expiratory grunt and  Central cyanosis.
 Central cyanosis.
 The infant develops both metabolic and respiratory acidosis. PaO2
< 50 mm Hg and PCO2 may rise to even 80 mm Hg in a severe
case
 hypoxia.

Investigations:

Present in book Done in patient

 Sepsis workup: CBC, absolute neutrophil count (ANC), band cell,  Hb--- 11.8 gm
micro-ESR, CRP, blood culture are done to detect early onset of
sepsis (Gr. B Streptococcus).  TLC --- 13900 cu/mm
 Blood glucose, calcium levels.
 Serum electrolyte levels.  BUN--- 21.3 mg/dl
 Echocardiography to exclude PDA, congenital heart disease.
 Creatinine --- 2.31 mg/dl

 Uric acid—7.90

 Calcium--- 9.26 mg/dl

Prevention:
(1) Administration of betamethasone (12 mg) to the mother two doses IM 24 hours apart especially before 34 weeks. Cortisol acts on type II
pneumocytes to stimulate phospholipid synthesis. Benefits are obtained after 24 hours of therapy and continue for 7 days (see p. 367). Fetal
hyperinsulinism blocks cortisol action.

(2) Assessment of lung maturity before premature induction of labor and to delay the induction as much as possible without any risk to the fetus;

(3) Prevent fetal hypoxia in diabetic mothers.

Treatment:

Principles of management are:

(i) Prevent hypoxia and acidosis;

(ii) Maintain fluid and electrolyte balance;

(iii) Prevent atelectasis and pulmonary edema and

(iv) Avoid lung injury (barotrauma) and infection.

 The baby should be placed in neonatal intensive care unit and nursed in a warm incubator with high humidity (neutral thermal condition).
Air passage is cleaned periodically through endotracheal suction.

 Adequate warmed and humidified oxygen therapy in concentration of 35–40% under positive pressure is to be administered through
endotracheal tube to relieve hypoxia and acidosis. If the arterial oxygen tension (PO2) cannot be maintained above 50 mm Hg, application of
continuous positive airway pressure (CPAP) at 5–8 cm of water is indicated.

Correction of hypovolemia with albumin or other colloid solution.

 Correction of anemia, electrolyte imbalance if any and prevention of infection.

 Frequent monitoring of the arterial PO2, PCO2, pH and base excess are to be determined to diagnose metabolic and respiratory
acidosis .Higher than necessary FiO2 may cause lung injury and retinopathy of prematurity.
 Acidosis should be corrected by intravenous administration of sodium bicarbonate 4.2% (0.5 mEq/mL) in amount 1 mEq/kg or 2 mL/kg
body weight in 1 : 1 dilution with distilled water and in minimum dosage.

 Continuous positive airway pressure (CPAP): Nasal (NCPAP) or nasopharyngeal (NPCPAP) is used early to delay or prevent the need for
mechanical ventilation and tracheal intubation.

 Mechanical Ventilation—Ventilator therapy—indications are: Respiratory acidosis with a PaCO2 > 50 mm Hg, a PaO2 < 50 mm Hg or O2
saturation <90% or severe apnea. Synchronized intermittent mechanical ventilation is preferred.

 Hypocapnia is associated with increased risk of BPD and CLD and periventricular leukomalacia. It should be avoided.

 Fluid and nutrition—Intragastric feeding, if possible, is the preferred method. If there is risk of vomiting and aspiration, intravenous
administration of 10% glucose in amount of 60 mL/kg body weight per day may be given to a term baby on 1st day through a catheter inserted
into peripheral or umbilical vein.

 Antibiotic therapy against common neonatal infections should be started initially.

 Medication and Treatment

S. Drugs Dose Route/frq Action Side Effect Nursing Responsibilities

No name

1. Inj 325g IV/BD  Binds to  Fever,nausea,vomiting,anemia or  Assess for infection,

Amoxicla m bacterial cells skin rash. monitor vital signs
v causing cell  Allergic reaction including  Monitor periodically liver
death. anaphylaxis and serum sickness and kidney function.
 Bacterial  Diarrhoea, hepatic dysfunction  Determine history of
action against  Seizure hypersensitivity reactions to
susceptible other beta-lactans,
bacteria cepahlosporins, penicillins,
 Used for all or other drugs
systematic
infection
2. Inj 20M IV/BD  Useful to  Stomach upset  Culture and susceptibility
Gentamyc G preventor  Loss of appetite tests should be performed
in treat a wide  Pain, irritation initially and periodically at
variety of  Redness at the site of injection the time of any adverse
bacterial  Numbness,tingling, muscle reaction
infection. twitching or weakness
 It is
aminoglycosi
de antibiotic.

Complications:
Acute complications of RDS include—

(i) Infection;

(ii) Air leak (pneumothorax);

(iii) Pneumomediastinum;

(iv) Persistent patent ductus arteriosus.

Other complications are :

(a) intraventricular hemorrhage,

(b) chronic lung disease (CLD),

c) bronchopulmonary dysplasia (BPD),

(d) intracranial hemorrhage,

(e) retionpathy of prematurity,

(f) pulmonary hemorrhage,

(g) barotrauma—pneumothorax,

(h) retrolental fibroplasia and neurological abnormalities.

Prognosis:
About one-third of the babies die. In mild affection with good vigor, the baby may survive, if acidosis and biochemical abnormalities are
corrected effectively. The long-term sequelae of the infants in terms of respiratory and neurological development is dependent on the birth
weight and gestational age.

Nursing assessment

Central nervous system :-

Sucking reflex :- present

Gag reflex : present

Rooting reflex:- present

Extrusion reflex:- present

Cough reflex:- present

Moros reflex:- present

Dance/ step reflex:- absent

Nursing management :

Nursing diagnosis:-

 Ineffective breathing pattern related to impaired pulmonary perfusion as evidenced by difficulty in breathing and cyanosis.
 Impaired gas exchange related to decreased volumes and lung compliance, pulmonary perfusion as evidenced by decreased SPO2 level.
 Imbalanced nutritional status less than body requirements related to the inability to suck or decreased intestinal motility as evidenced by
poor intake output.
 Ineffective family coping related to anxiety, guilt and parting with the baby as evidenced by verbal and facial expression.
 Knowledge deficit related to care of the baby and disease condition as evidenced by frequently asking questions.

Nursing Care Plan:

  Ineffective To improve the  Assess the rate  To assess the  Rate and The condition of
Subjective data:- breathing tissue perfusion and rhythm of breathing rhythm has the patient is
pattern related breathing in pattern. been assessed. improved to
Patient’s mother to impaired patient. RR is 60 b/min. some extent as
told that the baby is pulmonary indicated by the
having difficulty in perfusion as  Provide  To improve  Fowler position RR- 50-52 b/min
breathing from 2-3 evidenced by appropriate the oxygen is provided to
days. difficulty in position to the requirement the patient.
breathing and patient. as indicated  Oxygen therapy
cyanosis. by the is administered
shortness of to the patient as
 Provide breath. indicated by the
Objective data:- oxygen therapy physician.
By observation : to improve  To improve Humidifying
baby is having chest breathing breathing oxygen at the
retractions and pattern pattern rate of 6 L/min.
SP02 value is
between 75-80%.  Provide  To relive the  Quite calm
adequate rest discomfort of environment is
to the patient the patient provided to the
patient fro
adequate rest.

Assessment Nursing Diagnosis Goal Planning Rationale Implementation Evaluation

ASSESSMENT NURSING GOAL PLANNING RATIONALE IMPLEMENTATIO EVALUATION
DIAGNOSIS N
 Imbalanced To improve  Assess the  To know the  General The nutritional
Subjective data:- nutritional nutritional general condition of condition of the status of child
status less status of the condition of the patient patient has been has been
Patient mother says than body patient. the patient assessed. improved to
that, the baby is not requiremen some extent.
able to take feed ts related to  Maintain  To know the  Intake output
properly. the intake output nutritional chart has
inability to chart daily status of the maintained
suck or patient
decreased  To maintain  Child has been
Objective data:-  Feed the child nutritional feed regularly
intestinal
frequently. status. after short time
motility as
evidenced of interval
By observation ,  Administer  To maintain
by poor
baby is taking less more IV fluids hydration or  IV fluids has
intake
amount of feed as as prescribed restore loss administered as
output.
compared to by the doctor. fluids or prescribed by
prescribed amount electrolytes. the doctor.
Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

Subjective data:-  Assess the  To know their  Anxiety level of The anxiety level
Parents says that Ineffective family To improve level of anxiety knowledge parents is of parents is
they have no idea coping related to family coping and lack of level assessed by reduced to same
regarding disease anxiety, guilt and strategies. knowledge regarding asking extent as they
and how they have parting with the reading their disease questions. also involved in
to handle or provide baby as baby’s disease condition.  Knowledge providing care to
care to the baby. evidenced by condition.  To increase regarding caring the child.
verbal and facial  Provide their and handling
expression knowledge to confidence the baby is
Objective data:- the parents level in provided to the
By observation , regarding handling and parents through
parents having fear, handling and providing care demonstration.
anxiety related to care of the to the babies.  Parents are
their baby’s care and baby .  To reduce taught about the
disease condition as  Teach about their anxiety disease
frequently asking the disease level and condition and
questions. condition and improve their treatment
effects of knowledge regimen.
treatment regarding  Parents are
 Make them disease. introduced with
familiar with  To remove the other child
other child guilt feeling suffering from
having same and anxiety. same disease
problems. condition.
HEALTH EDUCATION:-

 Parents are educated about the disease condition, effect on the child and about treatment regimen
 Educated regarding how to carefully handle child at home and about providing care to the child
 Educated about the major signs of respiratory distress if suddenly develops at home.
 Child head should be slightly lift up and there must a continuous watch over the child while at home
 Medications must be provided regularly at time according to prescribed by the doctor
 If any complication arise immediately return to hospital or inform the doctor.
 Return for follow up visits as advised by the doctor.
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