IDENTIFICATION DATA:

Name of the child : B/O Palak

Name of the mother : Mrs Palak Sharma

Sex : Female

Age : 1 day

Developmental Stage : Neonate

Religion : Hindu

Address : Barnai, Jammu

Birth weight : 1.3 kg

Date of Admission : 29-07-2024

Name of father : Mr. Anil Kumar

MRD NO : 459601

Diagnosis : Respiratory distress

CHIEF COMPLAINTS

Patient was admitted in SMGS with the following chief complaints of:

• Slow breathing x 3days

• Nasal flaring x 4days
• Grunting sound x4days
• Shortness of breath x3days
• Bluish colour of skin x 1 day

HISTORY OF ILLNESS

Present medical history:

Patient was admitted in SMGS hospital with chief complaints of Rapid breathing, Nasal
flaring, Grunting sound, Shortness of breath, Bluish colour of skin. After
diagnosticevaluation, Doctor diagnosed her with respiratory distress.

Present surgical history:

The patient has no present surgical history.

Past medical history:

The patient has no past medical history.

Past surgical history

The patient has no past surgical history.

BIRTH HISTORY

ANTENATAL HISTORY

Mother age: 33 years

Age of marriage: 25 years

Mother was immunized with TT doses.

 INTRANATAL HISTORY

Delivery was C- Section

Birth weight is 1.3 kg

Baby don’t cried immediately after birth.

POST-NATAL:

No sign of jaundice but sign of cyanosis at birth

No birth injuries during delivery.

FAMILY HISTORY

Type of family: Nuclear family

No of family members: 05

Family history of any illness: There is no family history of DM, HTN,

Communicable diseases and congenital anomalies in the family.

Family composition:

Name of family Age Relation Education Occupation Health

members /sex with status
patient

Mr Rajesh 59Yrs/M Grandfather 12th Ex serviceman Healthy

Mrs Sapna 53 Yrs/F Grandmother 12th Housewife Healthy

Mr. Anil 40Yrs/M Father Graduate Teacher Healthy

Mrs Palak 33 Yrs/F Mother Graduate Teacher Healthy

Baby 1day/F Patient Nil Nil Unhealthy

FAMILY TREE

Mr Rajesh 59yr/ M Mrs Sapna/F 53yr/F

Mr Anil 40yr/M Mrs Palak/F/33yrs

Female/ 1 day

Key words

Male

Female

Patient
Sibling History: Patient has no sibling history.

IMMUNIZATION HISTORY

Vaccine When to give Dose Route Given/not given

BCG At birth as early as 0.1 ml (0.05 intradermal Given
possible till 1 year ml until 1
month age)
Hepatitis B At birth or early as 0.5 ml intramuscular Given
birth dose possible within 24 hours

Play History

Not significant

Personal History

Not significant.

Dietary History

Onset of feeding:
 Type of feeding: Breastfeeding
 Bottle-feeding : No
 Supplement of iron and vitamin : No
 Current diet: Breastmilk
PHYSICAL EXAMINATION

GENERAL APPEARANCE

Colour Bluish

Nourishment under-nourished

Body built thin

Health unhealthy

Consciousness conscious

POSTURE

Body curves no appearance of kyphosis

Movement normal movement of feet and arms

Height 14 inches

Weight 1.3 kg

SKIN

Cyanosis Present at the time of birth

Jaundice absent

Petechial Not seen

Birth marks Not seen

Haemangioma Not present

Subcutaneous fat Not Present

HEAD

Fontanelle Not closed

Caput succedaneum Not present

Cephalhematoma Not present

Encephalic Not present

Microcephaly Not present

Encephalopathy Not present

Size of fontanel Normal, not depressed

Forceps marks Not present

EYES

Symmetry Symmetrical

Placement Aligned in the same plane Symmetry

Sclera Shiny.

Pupil Equal, round, reactive to light and accommodation.

Movement Normal eye movement in all directions

EARS

Pinna Normal in shape

Position equal alignment

Cartilage Cartilage present

Auditory canal not assessed

Hearing proper, no hearing loss and tinnitus

NOSE

Shape of nose Aligned properly

Potency of nostril Adequate

Septum No septal deviation

Nasal mucosa Pink and moist

Discharge No discharge, no wax

MOUTH

Size of oral cavity Small cavity

Opening of oral cavity symmetrical

Cleft lip Not present

Cleft palate Not present

NECK

Goitre Not present

Thyroglossal Not present

Lymph nodes Not palpable

Range of motion Movement is adequate

CHEST

Shape Round

Symmetry symmetrical

Nipples and breast Spacing normal and no discharge

Scapula symmetry Appear symmetrical

Inspection Presence of seesaw respiration

Auscultation presence of murmurs.

Palpation chest expansion asymmetrical or reduced

Respiratory rate 29 breath/minute

ABDOMEN

Inspection No distension

Palpation: non tender masses

Auscultation Bowel sounds present

Percussion dullness

Umbilicus hernia absent

EXTREMITIES

Symmetry of extremities: symmetrical Joints, no pain

Range of motion: full range of motion.

SPINE AND BACK

Spina bifida: No spina bifida

Kyphosis : No kyphosis

CVS

Inspection : No pulsations

Palpation: No thrills palpable.

Auscultation: No murmur, rubs or gallops.

FEMALE GENITALIA:

External genitalia: no lesions

Vulva: no signs of infection

RECTUM:

Haemorrhoids: absent
 REFLEXES

S. Reflex Remarks
no.
1. Rooting Infant turns his head towards any object that touches his cheeks. Present
2. Sucking Baby begins to suck in response to stimulation of circumoral area. Absent
Stimulation of posterior pharynx by food or suction causes infant to Absent
gag.
3. Gagging

Sneezing/coughing Response of nasal and larynx to any irritant.

4. Present
5. Blinking Infant blink at bright light. Present
When the head is turned to one side , the eyes move to the opposite Present
6. Doll’s eye
direction.
Touching palms of hand causes flexion of hands
7. Absent
Palmer grasp

Stroking outer sole of foot upward from heel across ball of foot causes Absent
8. Babinski toes to hyper extend.

If infant is held such that sole of foot touches a hard surface, there is Absent
Stepping or dancing
9. reciprocal flexion and extension of legs.

BASIC PHYSIOLOGICAL DATA

Vital Sign Normal Value (Child) Child Value Remarks

Heart Rate 120-160 beats per minute 165 bpm Tachycardia

Respiratory Rate 30-60 breaths per minute 29bpm Bradypnea

Blood Pressure 55/45mm hg 55/40 mm Hg Normal

Temperature 98.6°F 980F Normal

Oxygen Saturation >95% 92% Low

 Physical Growth/ Anthropometric measurement

Measurement Normal Value (Child) Child Remarks

Value

Height 45-48 cm 35 cm Not normal

Weight 2.8-3.8 kg 1.3kg Under weight

Head Circumference 28-34 cm 27 cm Not normal

Chest Circumference 28-32 cm 27cm Not normal

Abdomen Circumference 30-36 cm 29cm Not normal

SUMMARY OF THE PHYSICAL EXAMINATION

• B/O Palak ,1day old female admitted in the SMGS hospital with complaints of slow
breathing, Nasal flaring, Grunting sound, Shortness of breath, Bluish colour of skin.
After physical examination, I found that patient is having respiratory distress.

DEVELOPMENTAL MILESTONES ACHIEVED

Age Present in book Present in child Remarks

1 day SOCIAL/EMOTIONAL Absent Not Achieved

MILESTONES he know good
and bad very well .chooses
own friends. socially active.
have emotions (both positive
and negative)

COGNITIVE MILESTONES
can read and write stories. they Absent Not Achieved
are better to explain, describe,
sum-up and argue.
Absent Not Achieved
MOVEMENT/PHYSICAL
MILESTONES can run, play
various games like cricket,
football, physical maturation,
weight gain, facial hairs.
probability of acting sexual
desires.
 GROSS MOTOR takes an Absent Not Achieved
interest in outdoor activities
having certain hobbies

FINE MOTOR Absent Not Achieved

Able to manipulate small and

large objects using both hands;
writing is improving,
comfortably able to write
paragraphs

SOCIAL AND ADAPTIVE Absent Not Achieved

MILESTONE

Knows his relatives very well,

involved in socially activities,
show more independence and
engage in less conflicts with
parents

LAB INVESTIGATIONS
Lab investigation Normal value Patient value Comments

Arterial blood gas

PH 7.35 - 7.45 7.28 Acidosis

pCO₂(partial pressure 35 - 45 mmHg 55mmHg Elevated indicating

of CO₂) respiratory acidosis

pO₂ (partial pressure 60 – 80 mmHg 45mmHg Low, indicating

of O₂) hypoxemia

CompleteBlood
Count (CBC)

Platelets 1,50000 – 4,50000ml 1,80000microliter Normal

Electrolytes
 Sodium (Na⁺) 135 - 145 mEq/L 140 mEq/L Normal

Potassium (K⁺) 3.5 - 5.5 mEq/L 4.8 mEq/L Normal

Chloride (Cl⁻) 95 - 105 mEq/L 102mEq/L Normal

Chest X-ray Findings might

include infiltrates,
atelectasis, or other
signs of lung
pathology.

C-Reactive Protein < 10 mg/L 25 mg/L Elevated, indicating

(CRP) inflammation or
infection

Lactate 1 - 2 mmol/L 3.5 mmol/L Elevated, which may

indicate hypoxia or
distress.

MEDICATION
Drug Name Dose/ Action Indications Contra Side effects Nursing
Indication responsibilities
Route/

Frequency

Oxygen As per Increa- Respiratory Hyperoxia Dry skin, nasal Monitor oxygen
therapy require- sing distress irritation,
Hyper- saturation (SpO₂),
ment oxygen oxygen toxicity.
levels Tachypnea capnia adjust flow as
Continuous
Apnea of needed, assess for
prematurity signs of irritation or
toxicity.

IT Beractant 100 mg/kg Surfac- Respiratory Known Bradycardia Monitor vital signs,
(Survanta) (4 mL/kg) tant distress hypersen- hypoxemia, assess for signs of
replace- sitivity pneumothorax
OD ment adverse reactions,
 Therapy Severe ensure proper
pulmo-
endotracheal tube
nary
hemorr- placement.
hage
Monitor heart rate,
Inhalation 0.05 - 0.15 BD Acute Hypersens Tachycardia, respiratory rate, and
Albuterol mg/kg/dose broncho- itivity jitteriness,
spasm hypokalemia electrolytes, ensure
Severe proper nebulizer use
Maintain- cardiac
ance conditions
therapy

0.1- 0.5 BD Autoimmu

Inj mg/kg/day Monitor blood
Dexamethaso ne diseases Hyper- Autoimmune
thyroid- diseases glucose levels, blood
ne
Adrenal ism pressure, signs of
insuffi- Adrenal
ciency Fungal insufficiency infection..
infections

Peptic
ulcer
disease

ocular
herpes
simplex
NURSING DIAGNOSIS

1. Impaired Gas Exchange related to decreased lung volume and impaired oxygenation
as evidenced by decreased oxygen saturation, cyanosis, and abnormal breath sounds.
2. Ineffective Breathing Pattern related to respiratory muscle fatigue, as evidenced by
nasal flaring, and retractions.
3. Impaired Skin Integrity related to the use of continuous positive airway pressure
(CPAP) or mechanical ventilation and potential pressure on skin as evidenced by
redness or irritation at sites of contact with CPAP or mechanical ventilation equipment
4. Fluid Volume Overload related to intravenous fluid administration and impaired
respiratory function as evidenced by increased respiratory distress.
5. Ineffective Thermoregulation related to respiratory distress and environmental factors,
as evidenced by hypothermia or difficulty maintaining normal body temperature.
Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

Subjective Impaired Gas To Regularly Regularly Continuous Gas

data: Exchange related to improve monitor oxygen monitored monitoring exchange is
Patient has decreased lung gas saturation levels oxygen saturation provides real- improved
shortness ofvolume and exchange using a pulse levels and time upto some
impaired
breath, chest oximeter and performed ABG information extent
pain and oxygenation as perform arterial analysis. about the
discomfort. evidenced by blood gas patient's
decreased oxygen (ABG) analysis oxygenation
Objective saturation, cyanosis, as needed. status.
data: and abnormal
By Oxygen breath sounds.
Saturation Administer Supplemental
levels, supplemental Administered oxygen helps
respiration oxygen to oxygen to correct
rate. maintain oxygen maintain oxygen hypoxemia
saturation levels saturation levels. and ensures
above 92%. adequate
oxygen
delivery to
tissues.
Position the
patient in an Positioned the
Proper
upright or semi- patient in a semi positioning
Fowler's fowlers position.
helps
position to increase lung
facilitate lung volumes and
expansion and enhance
improve ventilation,
breathing. thereby
improving
gas
exchange.

Administered Medications
Administer can reduce
prescribed medications
Albuterol and inflammation,
medications,
such as dexamethasone as open airways,
prescribed by and improve
bronchodilators lung function,
or doctor
which
corticosteroids contributes to
better gas
exchange.
Assessment Diagnosis Goal Planning Implementation Rationale Evaluation

Subjective Ineffective To Continuously Monitored the Helps in Ineffective

data: Breathing Pattern improve monitor the patients evaluating breathing is
Shortness of related to breathing patient’s respiratory rate, the improved
breath, respiratory muscle pattern. respiratory rate, rhythm. effectiveness upto some
fatigue fatigue, as rhythm. of extent.
evidenced by nasal interventions
Objective flaring, and
data: retractions.
Nasal Flaring
Retractions

Administer Supplemental
Administered
supplemental supplemental oxygen helps
oxygen if to alleviate
oxygen.
oxygen hypoxemia
saturation levels
are below the
target range
(e.g., < 92%).

Provide non- Provided non Non-invasive

invasive invasive ventilation
ventilation (e.g., ventilation. supports
CPAP or BiPAP) breathing by
if indicated, or reducing the
prepare for work of
mechanical breathing and
ventilation improving
gas
exchange.

Educate the
patient’s family Educated the pt’s Helps in
about signs of family about early
respiratory signs. detection.
distress
 Implementation
Assessment Diagnosis Goal Planning Rationale Evaluation

Subjective Impaired Skin To Regularly Regularly inspect Inspection Impaired

data: Integrity related to improve inspect the skin the skin for any helps in the skin
Itching or the use of skin at sites of redness or early integrity is
Burning at continuous positive integrity contact with irritation. identification improved
the contact airway pressure CPAP or of skin upto some
site, (CPAP) or mechanical issues, extent.
discomfort or mechanical ventilation allowing for
pain ventilation and equipment, timely
potential pressure Assess for interventions
on skin as evidenced redness, to prevent
Objective by redness or irritation. further
data: irritation at sites of deterioration
Pressure contact with CPAP
Ulcers or or mechanical
ventilation Proper skin
Sores. Implement a
equipment. Implemented skin care and
skincare care regimen at protection
Skin Texture regimen that the site of contact can help
Changes includes gentle maintain
cleansing and skin integrity
Redness moisturizing at
the sites of
contact.
Ensure that Ensured that Properly
CPAP or CPAP or MV is adjusted
mechanical properly fitted equipment
ventilation and adjusted to reduces the
equipment is minimize risk of skin
properly fitted. pressure irritation and
pressure
ulcers.

Helps to
Use protective Used protective reduce skin
padding or padding at the
breakdown.
cushions at the contact points.
points of contact
HEALTH EDUCATION
[Link] and Management

Supportive Care:

 Oxygen Therapy: Inform parents that their baby might receive supplemental oxygen
to ensure adequate oxygen levels in the blood.

 CPAP (Continuous Positive Airway Pressure): Describe how CPAP helps keep the
alveoli open by providing continuous air pressure.

Monitoring:

 Continuous Monitoring: Assure parents that the baby will be closely monitored in the
neonatal intensive care unit (NICU) for heart rate, respiratory rate, oxygen levels, and
overall well-being.

 Regular Updates: Promise to provide regular updates on their baby’s condition and
progress.

2. Parental Involvement and Care

Visitation and Interaction:

 Encourage Bonding: Encourage parents to spend time with their baby through
activities like kangaroo care (skin-to-skin contact) if the baby's condition allows.

 Limitations: Discuss any limitations on visitation or interaction due to the baby’s

condition and the need for specialized care.

Feeding and Nutrition:

 Breastfeeding: Explain the importance of breastfeeding and how it can be beneficial

for the baby’s immune system. If breastfeeding isn’t possible, discuss alternatives
such as expressed milk or formula.

 Feeding Support: Provide information on how to support feeding if the baby is too
weak to feed directly.

Emotional Support:

 Emotional Impact: Acknowledge that having a baby with RDS can be stressful and
emotionally challenging. Offer resources for counseling or support groups.

 Family Support: Encourage parents to lean on family and friends for emotional and
practical support.
[Link] Planning

Home Care Instructions:

 Follow-Up Appointments: Explain the importance of follow-up visits with a

pediatrician or specialist to monitor the baby’s lung development and overall health.

 Signs of Complications: Educate parents on signs of potential complications to watch

for after discharge, such as difficulty breathing, unusual fussiness, or feeding
problems.

Safety and Health Practices:

 Safe Sleep Practices: Provide guidelines on safe sleep practices to reduce the risk of
Sudden Infant Death Syndrome (SIDS).

 Infection Prevention: Emphasize the importance of good hygiene to prevent

infections, especially since the baby’s immune system might be compromised.

4. Resources and Support

Educational Materials:

 Written Information: Provide pamphlets or written materials about RDS, treatment,

and care.

 Online Resources: Share reliable online resources or websites where parents can find
additional information.

Contact Information:

 NICU Contacts: Give parents contact information for the NICU team and how to
reach them with questions or concerns.

 Support Groups: Provide information on local or online support groups for parents of
preterm or ill neonates.
CONCLUSION
After going through the case as well as the case of the patient. I came to know about many
things regarding Respiratory Distress. Like causes risk factors clinical menifestations, basic
treatment and care of patient with Respiratory Distress.
Now I can care for a patient with Respiratory Distress, with my own
individual decision and follow the doctors order.
BIBLIOGRAPHY

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Limited
2. Singh, Meharban. (2004). Care of the newborn (6th ed.). Sagar Publications
3. Baswanthappa, B. T. (2006). Textbook of midwifery and reproductive health nursing
(1st ed.). Jaypee Publications
4. Ricci, Scott. Susan., & Kyle, Terri. (2009). Maternity and pediatric nursing (1st ed.).
Lippincott Williams and Wilkins
5. Gada, D. (2011). International Federation of Fertility Societies Global Standards of
Infertility Care