CASE STUDY OF CRITICAL CARE NURSING

Submitted By: AYESHA AKRAM

Roll No:
Class: 4TH YEAR BSN

CASE REPORT

For the fulfillment of the BSN (4th year) Degree

Submitted to: Madam. Nargis Parveen

Madam. Tahira Sharif

COLLEGE OF NURSING ALLIED HOSPITAL FMU

FAISALABAD

Session (2021-2025)

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 AKNOWLEDGEMENT

This project would not have become a reality without the support, guidance and
encouragement of many people. We would like to extend our most sincere gratitude
to our respected principal Madam. NARGIS PARVEEN for her kind cooperation and
encouragement that helped us a lot in completing this work, who have sacrificed her
personal time and invaluable ideas to provide us with professional and moral support.
Millions of thanks to: Madam Tahira shareef our project Supervisor for helping us
navigatethrough the entire time of writing this work. We are grateful that we were
able to learn and grow under your guidance, knowledge, patience and tenacity.
Without this entire help and direction, I was unable to complete this work.

Student Signature:

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 DEDICATION
This work is dedicated to:
This work is dedicated to the sake of Allah, my creator and my teachers. My parents
who have never failed to give us financial and moral support, forgiving all our needs
during the time we developed our system and for teaching us that even the largest
task can be accomplished if it is done one step on a time. We dedicated his project to
all the people who have worked hard to help us in completing this project.

Student Signature:

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 STUDENT COVER LETTER

Name of Student: AYESHA AKRAM

Roll No:
Class: BSN Generic Nursing 4th year
Teachers: Madam Nargis Parveen
Mam Tahira Shareef
Respected Madam,
I would like to submit my case report for your kind expert guidelines. I
hope that the five days survey forms and other regarding objectives,
lesson plan are understandable.
I am looking for best regards, I will be thankful for your paying attention.
Yours sincerely,
AYESHA AKRAM
BSN 4th year

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 Table of content

Sr. No Heading Page No.

1 CHAPTER1: INTRODUCTION 8-9

2 Back ground 9-10

3 Objective of study 9-10

4 Case scenario 10-11

5 Reflective log 11-12

6 ANATOMY 11-12

7 PHYSIOLOGY 12-14

8 RISK FACTOR 13-14

9 NURSING ASSESSMENT 15-16

10 NURSNG MANAGEMENT 15-16

11 CASE STUDY 15-16

12 PHYSICAL EXAMINATION 15-16

13 GORDON HEALTH PERFORMA 15-16

14 LABORTARY FINDINGS 16-17

15 REFRENCES 17-20

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ACUTE RESPIRATORY DISTRESS SYNDROME

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 BACK GROUND:

Respiratory Distress Syndrome (RDS), also known as Hyaline

Membrane Disease, is a serious respiratory condition that primarily
affects neonates (newborns), particularly those born prematurely. It is
caused by a deficiency of surfactant, a substance produced in the lungs
that helps keep the alveoli (air sacs) open for gas exchange.

SIGNIFICANCE OF STUDY:

 The study of Respiratory Distress Syndrome (RDS) is highly

significant in both neonatal and critical care medicine due to its
impact on morbidity and mortality, particularly in premature
infants and critically ill patients.
 Understanding RDS helps improve early diagnosis,
management, and outcomes through the use of modern
interventions such as surfactant therapy, mechanical
ventilation, and prenatal corticosteroids.
 By studying the pathophysiology, risk factors, and treatment
strategies, healthcare professionals can reduce complications like
chronic lung disease, neurological impairment, and death.

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 OBJECTIVE OF THE STUDY:
 To understand the pathophysiology of Respiratory Distress
Syndrome, particularly the role of surfactant deficiency in
neonates and alveolar damage in adults.
 To identify the risk factors contributing to the development of
RDS in preterm infants and ARDS in critically ill patients.
 To examine the clinical signs and symptoms associated with
RDS for early recognition and diagnosis.
 To evaluate current treatment modalities, including surfactant
replacement therapy, oxygen support, mechanical ventilation, and
corticosteroid use.
 To assess the effectiveness of preventive strategies, such as
antenatal corticosteroids in pregnant women at risk of preterm
delivery.


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 INTRODUCTION TO RDS
Case scenario:
Patient Name: Mrs. Fatima
Age: 38 years
Gender: Female
Medical Record Number: 001245
Date of Admission: April 28, 2025
Diagnosis: Acute Respiratory Distress Syndrome (ARDS) secondary to
pneumonia
Presenting Complaint:
Mrs. Fatima A., a 38-year-old female, presented to the emergency
department with shortness of breath, high fever, productive cough,
and fatigue for the past 4 days. She has a history of poorly controlled
Type 2 Diabetes.

History:
 Fever, chills, and dry cough progressing to yellow sputum
 Increased shortness of breath, now even at rest
 Unable to lie flat due to breathlessness
 No known allergies

Vital Signs on Admission:

 Temperature: 39.0°C
 Respiratory Rate: 32 breaths/min
 Heart Rate: 112 bpm
 BP: 90/60 mmHg
 SpO₂: 82% on room air

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10
REFLECTIVE LOG

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Description

During my clinical placement in the neonatal intensive care unit

(NICU), I cared for a preterm baby born at 30 weeks gestation who
developed respiratory distress syndrome (RDS) shortly after birth. The
baby presented with rapid breathing, nasal flaring, chest retractions, and
cyanosis. I observed the team administer oxygen therapy, provide
surfactant treatment via endotracheal intubation, and initiate CPAP
(Continuous Positive Airway Pressure).

2. Feelings

Initially, I felt anxious and overwhelmed, as it was the first time I saw a
critically ill neonate struggling to breathe. However, I also felt curious
and eager to learn how to effectively support and care for such
vulnerable patients. As the baby's condition improved, I felt a sense of
relief and satisfaction that the interventions were successful.

3. Evaluation

The situation was both challenging and rewarding. A positive aspect

was the team’s coordinated and rapid response, which stabilized the
infant. I was able to assist in monitoring the baby’s vital signs and
learned a lot from observing the surfactant administration. However, I
realized that my limited knowledge of neonatal RDS at the time
hindered my confidence in participating more actively.

4. Analysis

This experience highlighted the importance of early recognition of RDS

symptoms, especially in preterm infants, and the value of evidence-
based interventions such as surfactant therapy and CPAP. I understood
that prematurity and surfactant deficiency are major risk factors for
RDS. The case also emphasized the need for interprofessional
collaboration in emergency neonatal care.
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 5. Conclusion

From this experience, I learned the critical importance of understanding

the pathophysiology of RDS and the rationale behind interventions. I
also realized the need to build confidence and competence in neonatal
assessments and emergency responses. Although I felt underprepared,
the support of the clinical staff helped me grow in my learning.

6. Action Plan

To prepare for similar future experiences:

 I will review neonatal respiratory conditions, especially RDS and its

management.

 I plan to attend more neonatal training sessions and simulations.

 I will seek feedback from senior staff to improve my skills in monitoring,

documentation, and clinical decision-making in neonatal care.

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ANATOMY AND PHYSIOLOGY

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 ANATOMY OF RDS

Lungs

 Location: Occupy most of the thoracic cavity, divided into lobes (3 on

the right, 2 on the left).

 Function: Gas exchange—oxygen enters the blood and carbon dioxide is

expelled.

2. Alveoli

 Definition: Tiny air sacs at the end of bronchioles where gas exchange
occurs.

 Relevance to RDS: In RDS, alveoli collapse due to lack of surfactant,

a substance that reduces surface tension to keep alveoli open.

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 PHYSIOLOGY OF RDS

Surfactant Deficiency:

 In premature infants, surfactant production is often insufficient.

 Without surfactant, alveoli collapse after each breath (atelectasis).

Impaired Gas Exchange:

 Collapsed alveoli reduce the surface area available for oxygen and carbon
dioxide exchange.

 Leads to hypoxemia (low oxygen) and hypercapnia (high CO₂ levels).

Increased Work of Breathing:

 The infant must work harder to reopen collapsed alveoli with each breath.

 Leads to respiratory fatigue and eventual respiratory failure if

untreated.

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PATHOPHYSIOLOGY OF RDS

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INTRODUCTION TO DISEASE

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 Definition of Respiratory Distress Syndrome (RDS)

Respiratory Distress Syndrome (RDS) is a serious lung condition

characterized by difficulty in breathing due to inadequate gas exchange,
primarily caused by a deficiency of pulmonary surfactant. It is most
commonly seen in premature newborns, whose lungs are not fully
developed.

Signs and Symptoms of Respiratory Distress Syndrome (RDS)

 Tachypnoea (rapid breathing >60 breaths/min)

 Grunting (expiratory noise due to partially closed glottis)

 Nasal flaring

 Intercostal and subcostal retractions

 Cyanosis (bluish skin, lips, or nails)

 Low oxygen saturation

 Lethargy or poor feeding

Causes of RDS

 Surfactant deficiency (most common)

o Surfactant reduces surface tension in alveoli and prevents collapse.

 Prematurity (especially <34 weeks gestation)

 Maternal diabetes (delays fetal lung maturation)

 Cesarean delivery without labor (no stress-induced steroid surge)

 Perinatal asphyxia (low oxygen during birth)

 Genetic surfactant protein disorders (rare)

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20
NURSING CARE

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 Airway and Breathing Support

 Ensure airway patency: Position the infant in a neutral or slightly

extended position.

 Administer oxygen as prescribed (e.g., via nasal cannula, CPAP, or

mechanical ventilation).

 Monitor respiratory rate and effort regularly.

 Assist with surfactant administration if indicated (usually via

endotracheal tube).

 Suction airway gently if secretions are present and only as needed.

Monitoring and Assessment

 Continuous pulse oximetry: Monitor oxygen saturation closely.

 Vital signs: Monitor temperature, heart rate, and respiratory rate every 1–
2 hours or as needed.

 Arterial blood gases (ABGs): Monitor for hypoxia, hypercapnia, or

acidosis.

 Assess for signs of respiratory fatigue, such as grunting, cyanosis, and

decreased activity.

Nutrition and Hydration

 Administer IV fluids or total parenteral nutrition (TPN) until oral

feeding is safe.

 Monitor intake and output strictly to prevent fluid overload or

dehydration.

 Gradually introduce feeding via nasogastric tube once respiratory

status stabilizes.

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 Infection Prevention

 Use strict hand hygiene and aseptic techniques to reduce risk of

infection.

 Monitor for signs of sepsis, such as temperature instability, lethargy, or

irritability.

 Supportive care if antibiotics are initiated (monitor labs and drug

levels).

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CASE STUDY

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 DEMOGRAPHIC DATA:

Demographic Data Details

Patient Name Mrs. Fatima

Age 38 years

Gender Female

Date of Birth April 28,2025

Hospital ID Number 5436729

Date of Admission 18-2-2025

Ward/Unit [e.g., MEDICSL UNIT ]

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 PATIENT HISTORY

Patient Details:

Patient Name: Mrs. Fatima

Age: 38 years
Gender: Female
Medical Record Number: 001245
Date of Admission: April 28, 2025
Diagnosis: Acute Respiratory Distress Syndrome (ARDS) secondary to
pneumonia
Presenting Complaint:

 Tachypnea (respiratory rate: 70 breaths/min)

 Nasal flaring

 Grunting

 Intercostal and subcostal retractions

 Central cyanosis

Medical History:

 Maternal history: No antenatal corticosteroids given before delivery.

No history of gestational diabetes.

 No congenital anomalies noted on prenatal ultrasound.

 No history of infections or PROM (premature rupture of membranes).

Investigations:

 Chest X-ray: Ground-glass appearance with air bronchograms –

classic of RDS

 ABG: pH 7.28, PaO₂ 52 mmHg, PaCO₂ 60 mmHg – indicating

respiratory acidosis

 CBC and Blood cultures: Sent to rule out neonatal sepsis

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 CRP: Normal

Treatment Plan:

 Admitted to Neonatal Intensive Care Unit (NICU)

 Started on nasal Continuous Positive Airway Pressure (nCPAP)

 Administered exogenous surfactant via endotracheal tube

 Provided with IV fluids and nutritional support via TPN initially

 Monitored for oxygen saturation, blood gases, and vital signs

continuously

 Started on broad-spectrum antibiotics prophylactically until sepsis

ruled out

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 NURSING ASSESSMENT:
(Gordon’s Functional Health Patterns)

This portion of the study will present normal and regressed health
functions of patient.
[Link] Description of Client
An ill looking old client lying on the bed in supine position, he is able
to speak, appeared to be cleaned and hyenine, patient is able to move.
1. Health Perception – Health Management Pattern:
o Rarely visits a doctor to have a check-up and seek for medical assistance.
o Uses herbal medicines.
o When sick, goes to the general practitioner or just waits for the sickness
to heal.
o Practices healthy lifestyles.
o Buy and takes over the counter drugs.
2. Nutritional – Metabolic Pattern:
o Eats more of fruits and vegetables.
o Eats his meals 3x a day with snacks in between. But there is loss of
appetite since his admission to hospital.
o Drink up to 1.5L of water or 4-5 glasses a day.
o Takes tea in the morning and in the afternoon.
3. Elimination Pattern:
o No pain or burning sensation during urination.
o Defecates once a day.
4. Activity - Exercise Patterns:
o Decreased strength; becomes weak in prolonged activities.
o After admission unable to perform activities of daily life.
o Dyspnea occurs during activity.
5. Sleep – Rest Pattern:
o Can sleep for 5-6 hours per night.
o Straight hours of sleep.
o Earliest time in going to sleep is at 11:00 PM.
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 o Last time in waking up is at 5:00 AM.
o Sometimes takes a nap at noon for about 1-2 hours.
o Doesn’t use any medication to promote sleep.
o Feels drowsy after hospital admission.
6. Cognitive – Perceptual pattern:
o Intact memory and cognition.
o Patient is conscious well oriented, GCS 15/15.
o Obey commands appropriately.
7. Self-perception – Self-concept Pattern:
o Manages to practice healthy lifestyle so as not to seek medical assistance.
o After admission depends on nursing care.
8. Role Relationship Pattern:
o Well-supports and loves by his family with close relationship.
o Patient is married.
o Satisfactory in his life.
o Unable to accept situation by cooperating with medical advices and
procedures.
9. Sexual reproductive Pattern:
o Patient is married.
10. Coping-stresstolerance pattern:
o Copes up with stress by taking a nap or sleep.
o Copes up with problems by talking about it with the family and finds
ways toresolve it.
11. Value – Belief Pattern:
o Patient is Muslim and goes to mosque to offers prayers most of the time.
Havestrong faith in Allah.

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LABORATORY FINDINGS:

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 LAB VALUES:

Arterial Blood Gas (ABG)

 Findings in RDS:

o Hypoxemia (low PaO₂): PaO₂ typically <60 mmHg due to impaired gas
exchange.

o Hypercapnia (elevated PaCO₂): PaCO₂ may increase due to inadequate

ventilation and alveolar collapse.

o Acidosis: pH may be low (acidosis) due to respiratory insufficiency.

o Increased A-a gradient (alveolar-arterial gradient): This indicates poor

oxygenation efficiency.

 Example of ABG in RDS:

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o pH: 7.28 (normal: 7.35-7.45)

o PaO₂: 55 mmHg (normal: 75-100 mmHg)

o PaCO₂: 60 mmHg (normal: 35-45 mmHg)

o HCO₃: 22 mEq/L (normal: 22-28 mEq/L)

Chest X-ray

 Findings in RDS:

o Ground-glass appearance: Diffuse haziness due to alveolar collapse

and fluid accumulation.

o Air bronchograms: Visible air-filled bronchi due to surrounding

alveolar collapse.

o Lung opacity: Reduced lung expansion and poor aeration.

 Classic RDS Appearance: The chest X-ray shows bilateral infiltrates

and decreased lung volume, indicating the severity of RDS.

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 NURSING CARE PLAN

Nursing Nursing
Goal/Outcome Rationale Evaluation
Diagnosis Interventions
- Monitor respiratory
rate, depth, and
effort.- Administer Early detection of distress
Patient will Respiratory
Ineffective oxygen as helps prevent
maintain adequate rate and
breathing pattern prescribed.- Position [Link]
respiratory rate oxygen
related to in semi-Fowler’s or improves
and pattern within saturation
alveolar collapse high Fowler’s.- [Link]
24 hours. improved.
Assist with promotes lung expansion.
mechanical
ventilation if needed.
- Monitor ABGs and
Impaired gas Patient will pulse oximetry.- ABGs determine ABG values
exchange related maintain adequate Suction as needed to effectiveness of gas and O2
to decreased oxygen saturation maintain airway [Link] saturation
surfactant (>92%) within 8 patency.- Administer improves lung compliance within normal
production hours. surfactant therapy as and gas exchange. range.
ordered.
- Use strict aseptic
Risk for Patient will technique.- Monitor
No fever,
infection related remain free from temperature, WBC
Infection control prevents normal WBC,
to invasive signs of infection count.- Inspect
complications and sepsis. no signs of
procedures (e.g., during insertion sites (e.g.,
infection.
intubation) hospitalization. IV, ET tube) for
signs of infection.
- Provide emotional
Patient and family support.- Explain
Anxiety related
will verbalize procedures and Patient/family
to difficulty Understanding reduces fear
reduced anxiety condition in simple report reduced
breathing (for and promotes cooperation.
after 24 hours of terms.- Encourage anxiety.
patient/family)
intervention. family involvement
in care.

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 MEDICAL MANAGMENT

Indication in Nursing
Medication Class Route/Dose
RDS Considerations
Replaces Intratracheal
Administer under strict
Surfactant (e.g., deficient (via
Pulmonary sterile technique;
Beractant, Poractant endogenous endotracheal
surfactant monitor oxygenation
alfa) surfactant in tube)Dose
and ventilation closely
neonates varies by brand
Via nasal Use lowest effective
Respiratory therapy Improves cannula, concentration; monitor
Oxygen
agent oxygenation CPAP, or for oxygen toxicity and
ventilator retinopathy in neonates
Treats apnea of
Oral or Monitor heart rate and
Respiratory prematurity often
Caffeine citrate IVUsually once respiratory rate; avoid
stimulant associated with
daily overdose
RDS
Obtain cultures before
Antibiotics (e.g., Used if infection
starting; monitor renal
Ampicillin, Antibacterial agents suspected or IV
function and hearing
Gentamicin) sepsis risk present
(aminoglycosides)
May reduce Use cautiously;
inflammation and monitor for
IV or oral,
Dexamethasone Corticosteroid aid lung hyperglycemia,
tapered dose
maturation hypertension, and
(controversial) infection
Reduces Monitor electrolytes,
Diuretics (e.g.,
Loop diuretic pulmonary edema IV or oral urine output, and signs
Furosemide)
in severe cases of dehydration
For ventilated
IV, dosage Monitor respiratory
Sedatives/analgesics patients to reduce
CNS based on rate, BP, and sedation
(e.g., Morphine, agitation and
depressant/analgesic weight and level; risk of
Midazolam) improve
response respiratory depression
synchrony

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