NURSING DIAGNOSIS

RESPIRATORYDISTRESS SYNDROME

Impaired Gas Exchange

May be Related to: Inadequate Surfactant

Level Altered oxygen supply Cold stressAs possibly evidenced by: tachypnea use of accessory

muscle pallor or cyanosis changes in ABGs

Impaired Spontaneous Ventilation

May be Related to: Respiratory muscle

fatigue Metabolic factorsPossibly evidenced by: Dyspnea Increased metabolic rate Restlessness Use of accessory muscles

and, Abnormal ABGs

NURSING RESPONSIBILITIES

RESPIRATORYDISTRESS SYNDROME

Nursing Responsibilities Airway stabilization Airway management Oxygen therapy Thermoregulation Blood gas monitoring Family involvement

therapy

Airway Stabilization and Comfort

Nursing the naked infant supine in an incubator will allow observation of chest movement, and arterial and venous lines. The head should ideally be slightly extended to stabilize the tube and prevent laryngeal trauma.

Side-lying postures tend to lessen hip and shoulder rotation and abduction. In any position the infant should be supported with flexible boundaries of, for example, rolled blankets.

Blood Gas Monitoring  Blood gases must be

monitored as a guide to ventilatory management and to minimize the risk of retinopathy of prematurity from inappropriate use of high levels of oxygen (McGurk, 2003).

Non-invasive methods such as pulse oximetry and carbon dioxide tension monitors are useful trend detectors but should not be used in isolation.

Thermoregulation Neonates have poorly

developed mechanisms for thermoregulation and maintenance of a neutral thermal environment is a perpetual challenge. Core temperature should be maintained at 37°C to minimize oxygen consumption and acidosis.

To minimize heat loss, it is recommended that sick infants are nursed in an incubator with a controlled temperature, or an open cot with an overhead heater controlled by a temperature probe on the skin.

Fluid and electrolyte balance RDS delays the onset of

normal postnatal diuresis, and edema often appears after 24-48 hours. Meticulous attention to fluid and electrolyte balance is crucial to avoid fluid overload, which contributes to complications such as patent ductus arteriosis and chronic lung disease.

To an extent, a humidified environment can help but insensible losses should be an essential part of the fluid balance equation.

Parent Health Education 

It is vital that the parents feel involved. Their anguish begins as soon as they know they are to deliver a preterm infant who may have RDS, and the moment of birth, which should be a happy time, is fraught with worry. The admission of their baby to the neonatal ICU, attached to a plethora of machinery, can be devastating (Strange, 2002).

Family-centred care is an appropriate framework for the neonatal ICU (Turrill, 1999).

CRITICAL CARE AREA EQUIPMENTS

RESPIRATORYDISTRESS SYNDROME

Infusion Pump An infusion

pump infuses fluids, medication or nutrients into a patient's circulatory system. It is generally used intravenously, although subcutaneous, arterial and epidural infusions are occasionally used.

Incubator Infants are cared for in

incubators or "open warmers." Some low birth weight infants need respiratory support ranging from extra oxygen (by head hood or nasal cannula) to continuous positive airway pressure (CPAP) or mechanical ventilation. Public access is limited, and staff and visitors are required to take precautions to reduce transmission of infection.

Continuous Positive Airway Pressure (CPAP) As a treatment or

therapy, CPAP uses mild air pressure to keep an airway open.

 In some preterm infants whose lungs haven't fully developed, CPAP improves survival and decreases the need for steroid treatment for their lungs.

Positive end expiratory pressure (PEEP) Positive end expiratory

pressure (PEEP) is routinely used when ventilating preterm infants, and high levels are recommended in those with severe respiratory distress syndrome (RDS). Elevation of PEEP increases lung volume, as does surfactant administration. 

Pulse Oximeter A pulse oximeter is

a medical device that indirectly monitors the oxygen saturation of a patient's blood (as opposed to measuring oxygen saturation directly through a blood sample) and changes in blood volume in the skin, producing a photoplethysmogram.

Food for Thought…

It is not how much you do but how much love you put in the doing. ---Mother Theresa

To do what nobody else will do, a way that nobody else can do, in spite of all we go through; is to be a nurse… ---Rawsi Williams

Short Quiz:1.  A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?

A. Hypotension and BradycardiaB. Tachypnea and retractionsC. Acrocyanosis and gruntingD. The presence of a barrel chest with grunting

2. A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:

A. Subcutaneous injectionB. Intravenous injectionC. Instillation of the preparation into the lungs through an endotracheal tubeD. Intramuscular injection

3. Which action best explains the main role of surfactant in the neonate?

A. Assists with ciliary body maturation in the upper airwaysB. Helps maintain a rhythmic breathing patternC. Promotes clearing mucus from the respiratory tractD. Helps the lungs remain expanded after the initiation of breathing

4. The highest-priority nursing diagnosis for a neonate experiencing RDS is:

A. Altered Nutrition: More Than Body RequirementsB. Alterations in ParentingC. Acute PainD. Impaired Gas Exchange, related to inadequate lung surfactant

5. Neonatal RDS can also be the result of the following conditions.

A. Mother with DMB. Caesarean Section DeliveryC. Both A & BD. None of the above

6. CPAP is a treatment or therapy for RDS. CPAP stands for?

A. Continuous Pressure- Airway PositiveB. Complementary Positive Airway PressureC. Continuous Positive Alveolar PressureD. Continuous Positive Airway Pressure

7. A medical device that indirectly monitors the oxygen saturation of a patient's blood (as opposed to measuring oxygen saturation directly through a blood sample) and changes in blood volume in the skin, producing a photoplethysmogram.

A. Pulse OximeterB. CPAPC. PEEPD. Arterial Blood Gas (ABG)

8. Surfactants are primarily made up of? (select all that apply)

A. LipidsB. ProteinsC. GlycoproteinsD. Carbohydrates

9. What is/are the primary diagnostic procedures to rule out RDS? (select all that apply)

A. Pulse OximetryB. Chest X-rayC. CBCD. Bacteriology

10. What is the most commonly used Surfactant?

Answers…1. A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?

A. Hypotension and BradycardiaB. Tachypnea and retractionsC. Acrocyanosis and gruntingD. The presence of a barrel chest with

grunting

The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

2. A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:

A. Subcutaneous injectionB. Intravenous injectionC. Instillation of the preparation into the

lungs through an endotracheal tubeD. Intramuscular injection

The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.

3. Which action best explains the main role of surfactant in the neonate?

A. Assists with ciliary body maturation in the upper airwaysB. Helps maintain a rhythmic breathing patternC. Promotes clearing mucus from the respiratory tractD. Helps the lungs remain expanded after the initiation of breathing

Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.

4. The highest-priority nursing diagnosis for a neonate experiencing RDS is:

A. Altered Nutrition: More Than Body RequirementsB. Alterations in ParentingC. Acute PainD. Impaired Gas Exchange, related to inadequate lung surfactant

The lungs of infants with respiratory distress syndrome are developmentally deficient in a material called surfactant, which helps prevent collapse of the terminal air-spaces (the future site of alveolar development)

throughout the normal cycle of inhalation and exhalation.

5. Risk for Neonatal RDS can be increased with the following conditions.

A. Mother with DMB. Caesarean Section DeliveryC. Both A & BD. None of the above

Risk for developing neonatal RDS:

-A brother or sister who had RDS

-Diabetes in the mother

-Cesarean delivery

-Delivery complications that reduce blood flow to the baby

-Multiple pregnancy (twins or more)

-Rapid labor

6. CPAP is a treatment or therapy for RDS. CPAP stands for?

A. Continuous Pressure- Airway PositiveB. Complementary Positive Airway PressureC. Continuous Positive Alveolar PressureD. Continuous Positive Airway Pressure

As a treatment or therapy, CPAP (Continuous Positive Airway Pressure )

uses mild air pressure to keep an airway open.

7. A medical device that indirectly monitors the oxygen saturation of a patient's blood (as opposed to measuring oxygen saturation directly through a blood sample) and changes in blood volume in the skin, producing a photoplethysmogram.

A. Pulse OximeterB. CPAPC. PEEPD. Arterial Blood Gas (ABG)

8. Surfactants are primarily made up of? (select all that apply)

A. LipidsB. ProteinsC. GlycoproteinsD. Carbohydrates

Surfactant is a complex system of lipids, proteins and glycoproteins which are produced in specialized lung cells called Type II cells or Type II pneumocytes.

9. What is/are the primary diagnostic procedures to rule out RDS? (select all that apply)

A. Pulse OximetryB. Chest X-rayC. CBCD. Bacteriology

-A blood gas analysis shows low oxygen and excess acid in the body fluids.-A chest x-ray shows the lungs have a characteristic "ground glass" appearance, which often develops 6 to 12 hours after birth.-Lab tests are done to rule out infection and sepsis as a cause of the respiratory distress.

10. What is the most commonly used Surfactant?

If the baby's condition worsens, an endotracheal tube (breathing tube) is inserted into the trachea and intermittent breaths are given by a mechanical device. > exogenous preparation of surfactant, either synthetic or extracted from animal lungs, is given through the breathing tube into the lungs. (commonly used surfactants is SURVANTA, derived from cow lungs, which can decrease the risk of death in hospitalized very-low-birth-weight infants by 30%.)

THANK YOU!

Group 6

Loraine ValleKaren TaopoCharmaine Del RosarioJett Arr Jun Plocios