HYALINE MEMBRANE DISEASE

OF THE NEWBORNWenna May S. Ramojal

INTRODUCTIONHyaline membrane disease also known as

neonatal respiratory distress syndrome,lung disease of prematurity, or surfactant deficiency refers to lung pathology which results from insufficient production of surfactant.

RDS almost always occurs in newborns born before 37 weeks of gestation. The more premature the baby is, the greater is the chance of developing RDS. RDS is more likely to occur in newborns of diabetic mothers.

Surfactant, a mixture of phospholipids and lipoproteins, is secreted by lung cells. The air-fluid interface of the film of water lining the alveoli of the lung (where the exchange of oxygen and CO2 occurs) exerts large forces that cause the alveoli to close if surfactant is deficient. Lung compliance is decreased, and the work of inflating the stiff lungs is increased. The preterm newborn is further handicapped because his or her ribs are more easily deformed (compliant). Breathing efforts therefore result in deep sternal (breastbone) retractions but poor air entry if the ribs are compliant compared with the lungs. This results in diffuse atelectasis (collapse of the lungs).

Rapid, labored, grunting respirations usually develop immediately or within a few hours after delivery, with retractions above and below the breastbone and flaring of the nostrils. The extent of atelectasis (lung collapse) and the severity of respiratory failure progressively worsen.

Not all infants with RDS have signs of respiratory distress; extremely low birth weight newborns (i.e., < 1000 g) may be unable to initiate respirations at birth because their lungs are so stiff; they may fail to initiate breathing in the delivery room.

The incidence of RDS can be reduced by assessment of fetal lung maturity to determine the optimal time for delivery. When a fetus must be delivered prematurely, giving betamethasone systemically to the mother for at least 24 hours before delivery induces fetal surfactant production and usually reduces the risk of RDS or decreases its severity.

If untreated, severe RDS can result in multiple organ failure and death. However, if the newborn's ventilation is adequately supported, surfactant production will begin and RDS will resolve by 4 or 5 days. Recovery is hastened by treatment with pulmonary surfactant.

Baby Boy L was delivered prematurely via Normal Spontaneous Vaginal Delivery last December 10, 2014 with 30 weeks Age of Gestation, Birth weight of 1.5 kgs., Apgar Score of 8-9.

OBJECTIVE

General objective:To know more about Hyaline Membrane Disease of the Newborn.

Specific objective:To know the Health History of Baby Boy L.To identify the precipitating factors of his premature delivery.

To understand the anatomy and physiology of the Respiratory System of the Neborn.

To understand the pathophysiology of the said disease.

To determine the laboratory result of Baby Boy L.To study about the drugs given to the patient.To discuss different nursing Care plans in relation to the patient’s condition.

DEFINITION OF DIAGNOSIS

A respiratory disease of the newborn, especially the premature infant, in which a membrane composed of proteins and dead cells lines the alveoli (the tiny air sacs in the lung), making gas exchange difficult or impossible. The word "hyaline" comes from the Greek word "hyalos" meaning "glass or transparent stone such as crystal." The membrane in hyaline membrane disease looks glassy.

Hyaline membrane is now commonly called respiratory distress syndrome (RDS). It is caused by a deficiency of a molecule called surfactant.

 

HISTORY

  Baby Boy L’s mother used to have prenatal every month in their Rural health unit and shows good finding about the patient. According to his mother, she didn’t took any drugs during conception just to assure that the baby will be safe and will have no abnormalities. Her mother was a plain house wife and having light chores to do everyday such us cooking foods for the family, sweeps the floor and their backyard and washes clothes.

Maternal History:

Mother L is 19 years of age from Bukidnon. She is 5th among the 7 children. According to her, she was delivered via NSVD and doesn’t have any vaccination during their time for they live in the farthest part of the province.

She’s currently living with his boyfriend at Magpet where she have her conception with the patient. She eats well especially vegetables.

It was December 10, 2014, Wednesday dawn when she felt labor pain and noticed that there is spotting already and there is water coming out from her. She was then rushed to Cotabato Provincial Hospital for immediate treatment and later on, she delivered a premature baby boy.

Paternal History:

Father L is 24 years of age from Bukidnon also. He is 3rd among the 4 children. According to him, there was no incidence in their family that was delivered prematurely. And during his time, his mother used to go to “manghihilot” during conception.

He doesn’t have any vices and don’t used to drink liquors too. He is currently works as a farmer.

PHYSICAL ASSESSMENTGeneral Health Survey/ Anthropometric Measurements

Flexed head and extremities

Head, 30cm; chest, 27cm; abdomen 23cm

Length head to heel, 44cm

Weight, 1.5 kgs

Vital Signs

Axillary temperature: 36.8◦C

Pulse, 140bpm

Respirations, 62cpm, irregular

Apgars

2 and 5

Integumentary

Bluish color of the skin and mucus membranes (cyanosis)

Head/Face

Positive molding but skull appears symmetrical

Fontanels soft and flat

Head, Eyes, Ears, Nose and Throat (HEENT)

React to noise

Ears align with external canthus of eyes

Respiratory

Tachypnea (RR: 67)

Cardiovascular

Cyanotic

Apical pulse, 140 regular

Positive femoral pulses

Gastrointestinal

Positive Bowel sounds

Anus patent

Umbilical cord white with two arteries and 1 vein, intact with no discharges

Genitourinary

Voided

Genitalia

Pink and edematous

Musculoskeletal

10 fingers and 10 toes

No fractures or discolorations

ANATOMY AND PHYSIOLOGYThe Respiratory System in Babies

What is respiration?Respiration is the act of breathing in and out. When you inhale, you take in oxygen. When you exhale, you give off carbon dioxide.

What makes up the respiratory system?The respiratory system is made up of the organs involved in the interchanges of gases and consists of the:

NoseMouth (oral cavity)Throat (pharynx)Voice box (larynx)Windpipe (trachea)Airways (bronchi)Lungs

The upper respiratory tract includes the:NoseNasal cavitySinuses

 

The lower respiratory tract includes the:Voice box (larynx)Windpipe (trachea)LungsAirways (bronchi and bronchioles)Air sacs (alveoli)

What is the function of the lungs?The lungs take in oxygen, which the body's cells need to live and carry out their normal functions. They also get rid of carbon dioxide, a waste product of the cells.

The lungs are a pair of cone-shaped organs 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 enveloped in a membrane called the pleura.

The lungs are separated from each other by the mediastinum, an area that contains the following:Heart and its large vesselsWindpipe (trachea)EsophagusThymus glandLymph 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 the mouth

Travels down the throat through the voice box (larynx) and windpipe

Goes into the lungs through tubes called mainstem bronchi:

One main stem bronchus leads to the right lung and one to the left lung

In the lungs, the main stem bronchi divide into smaller bronchi

Then into even smaller tubes called bronchioles Bronchioles end in tiny air sacs called alveoli

Breathing in babiesAn important part of lung development in babies is the production of surfactant. This is a substance made by the cells in the small airways and consists of phospholipids and protein. By about 35 weeks gestation, most babies have developed enough surfactant. Surfactant is normally released into the lung tissues where it helps lower surface tension in the airways. This helps keep the lung alveoli (air sacs) open. Premature babies may not have enough surfactant in their lungs and may have difficulty breathing.

PATHOPHYSIOLOGY

DIAGNOSTIC TESTHgt 44mg/dl Neonatal hypoglycemia, defined as a plasma glucose

level of less than 30 mg/dL (1.65 mmol/L) in the first 24

hours of life and less than 45 mg/dL (2.5 mmol/L)

thereafter, is the most common metabolic problem in

newborns. 

Hct 2/3 (low) A low hematocrit means the percentage of red blood cells is

below the lower limits of normal.

Hmoglobi

n mass

203 Elevated result.A high quantity of haemoglobin molecules is important in two ways. On the one hand it directly increases oxygen transport (1g haemoglobin can transport 1.39ml of oxygen) and on the other hand it increases blood volume by facilitating venous return which is a prerequisite for a high maximal cardiac output. tHb-mass, therefore, is an important parameter to assess the aerobic aspect of physical performance.

DIAGNOSTIC TESTWBC 14.9 x

10/g

Indicates infection.

Platelet 162 Normal level.

Neutrophils 0.51 Lower that normal level. The

lower your neutrophil count,

the more vulnerable you are

to infectious diseases.

Lymphocyt

es

0.39 Higher than normal level

DRUG STUDY

NURSING CARE PLAN

PROGNOSISCRITERIA POOR FAIR GOOD JUSTIFICATION

1. Duration of illness

      He was then admitted two days immediately after his birth.

2. Onset of illness

      The onset of illness is poor because at his young age, he already suffers from the said disease.

3. Precipitating Factors and Predisposing Factor

      The precipitating factor and predisposing factor of the patient was rate as fair because most of factors that could contribute to the severity of his present illness are on precipitating factor which depends on how his body will survive to ongoing medication.

PROGNOSIS4. Age       According to the patient’s age (30

weeks AOG), his immune system is weak and needs more intensive care

5. Environment       The environment of the hospital is not that good for recovery because it is not that conducive.

6. Family support

      Baby Boy L’s family is cooperative enough about the patient’s treatment

7. Attitude and willingness to take medications/ compliance to treatment regimen

      The patient receives his medication through IVTT.

CRITERIA POOR FAIR GOOD JUSTIFICATION

Indications: Score:1 Poor 1x3=3

2 Fair 2x4=8

3 Good 3x0=0

Total: 11/7=1.57

Result = Poor

IDEAL:Poor = (1.0 - 1.6)

Fair = (1.7 – 2.3)

Good = (2.4 – 3.0)