CARE PLAN

PATIENT S BIODATA

NAME: Baby of Mr.sureshbhai makawana

AGE:

SEX: female

WARD: N.I.C.U

I.P.NO: 10110338

DATE OF ADMISSION:7/12/10

DIAGNOSIS: Respiratory distress with non vigorous me conium aspiration

NAME OF FATHER: sureshbhai makwana

NAME OF MOTHER: Induben makawana

INCOME: 5,000/-Rs

ADDRESS: Gam,bhat man ta, dholka district, Ahmedabad

CARE STARTED: 7/12/10

CARE ENDED: 9/12/10

1st day

CHIEF COMPLAINTS:
Baby not cried immediately after birth. She is having apnea at birth and non
vigorous aspiration of meconium stain liquor. Apgar score is 8/9. Resuscitation per positive
pressure ventilation for 2 minutes and transferred to nursery under free oxygen per face
mask. Admitted to nursery with special care nursery orders, medical diagnosis RDS and non
vigorous mecomium aspiration ; weight is 2.130 kg. Mother is 23 years old, primi gravid
and experiencing complicated delivery requiring admission to surgical unit STAT.
HISTORY OF PRESENT ILLNESS:
Newborn is in respiratory distress, bilateral advantageous breath sounds (crackles),
with deep intercostal retractions and substernal retractions. Acrocyanosis is noted,
but newborn is centrally pink and active.
Ventilator initiated at 40% FiO2, on SIMV mode,RR-75, SPO2-100%, with should
roll to maintain open airway position. Newborn is on radiatn warmer with

temperature probe to abdomen, incubator set at 37.0C. Axillary temp 97.2F. Warmed
and humidified oxygen being administered. Glucose per chemstrip is 65-80 mg/dl.
Peripheral IV started in right hand with 24 guage insyte catheter, D10W infusing per
IV at 6 ml/hr. Cardiac/apnea monitor and pulse oximeter monitoring began with
regular sinus rhythm of 162, respiratory rate 75, and SPO2 96% while under oxygen
support. Blood pressure 55/35. Capillary refill <2 sec, pulses strong and regular all
extremities, newborn reflexes present and appropriate.
Oral gastric 5 french tube placed and checked by auscultation. Obtain 5cc clear
mucous and 7cc air by aspiration and tube left open to air.

HISTORY OF PAST ILLNESS:

baby not cried immediately after birth. She has respiratory distress after birth
BIRTH HISTORY:
ANTENATAL: Mrs. Induben makawana had regular antenatal visit , also gain weight, no any
problem encountered, immunization 2 T.T injection taken.
INTRANATAL: Delivery was vaginal. Birth weight is 2.310 kg. baby not cried immediately
after birth. Apgar score is 8 at birth, after 5 min 9.
POSTNATAL: child had respiratory distress.

FAMILY HISTORY
FAMILY TREE:

Mr.sureshbhai

Mrs. Induben

Patient

Male
Female

FAMILY HISTORY OF ILLNESS: no other family members have no any major diseases like
tuberculosis, ischemic heart diseases ,cancer ,asthma ,allergy ,etc.
SIBLING HISTORY: she is first child of her parents.
IMMUNISATION HISTORY: no any vaccine given to her.
PHYSICAL EXAMINATION:
1.General health
Vital signs: Temperature -96 F
Respiration by ventilator 20 breaths/min
Apical Pulse- 138 beats/min
Weight : 2.310 kg
Height : 48 cm
Head circumference : 32 cm
Chest circumference: 30cm
Posture : body flexed, hands tightly clenched,neck appear short because cheek rest on chest.
2 . Skin color and sign of jaundice is to be noted. dehydration is present. milia is present
across the bridge of nose.
3. Head : round , symmetry ,easily move left to right and down to up, greater than chest
circumference. Anterior fontanel is 4-5 cm in diamond shape. 1-2 cm at birth triangle shape.
slight pulsation and bulging is also present. Hair is smooth with fine texture. Hair distribution is
also normal.
4. Face : symmetric movement of all facial features. Eyebrows and eye lashes present. Eye-ear
at same level. Nostrils equal size.Facial skin Smooth pink.
5. Ears pinna is parallel to the outer and inner can thus of eyes. Both ear is symmetric.
Responds to voice and sound
6. Eyes Bruised and puffy eyelids. Blinking to be observed. Focusing on the line of vision to
be noted.
7. Nose Shape. Breathing normally through both nostrils with lips closed. Sneezing is noted.
8. Mouth hard palate in domed shape. Uvulva midline with symmetric movement of soft
palate. Tongue freely moving in all direction.

9. Neck short , straight, creased with skin folds. Contraction of the shoulder and arm muscles
11. Chest 2 nipples symmetric.breast tissue diameter is normal like 5 cm in diameter. Breast
may have some enlargement. Symmetrical expansion of chest. transient breath sound is heard
because of secretion present in respiratory track. Sometimes brief apnea is present . heart sound
auscultate normal rate and rhythm without murmur.
12. Abdomen: cylindrical with some protrusion. Appears large in relation to pelvis. No
protrison of umbilicus . two arteries and one vein is present.
13. Genitalia Female clitoris is covered with labia majora . Normal skin color. No vaginal
tag. Vaginal discharge is not present. Buttocks are symmetric.
Me conium pass 4 hrs after
birth.
14. extremities and trunk- short and generally flexed, extremities moves symmetrically through
range of motion but lack of extention. Arms and legs also equal in length. Palmer crease is also
present. Legs shorter than arms.
C- shaped spine.
15. Sleep 12 to 16 hours in a day
16. Urine passing 12 hours after birth. One wet diaper every 8 hours on day 2. This will
gradually increase to 6-8 wet diapers in 24 hours on day 5.
17. Stool First stool within 4 hours
18. Reflexes- Moros, Routine, sucking ,palmer grasp, babinski reflex is present

12. INVESTIGATION
SAMPLE
Hemoglobin
RBC
Hematocrit
WBC
Differential
count
Neutrophil
Lymphocyte
monocytes
Eosinophils
Basophils
Platelet count
Renal function
test
Blood urea
Serum creatinine
Liver function test
Billirubin total
direct
indirect
Serum alkaline
phosphate
S.G.P.T
Prothrombin time
INR
C-Reactive
protein

PATIENT
VALUE
19 mg/dl
5.3 million/cu
60.6%
26500/cumm

NORMAL
VALUE
12.3-15.3 mg/dl
4.5-5.1 million/cu
35.9-44.6%
4,400-11,000

INFERENCE

40%
55%
4%
1%
0%
2,78,000/cumm

50-70%
20-40%
2-6%
1-6%
0-2.5%
1,50,000-4,50,000

10%less
15% more
Normal
5%
2.5%
Normal

38 mg/dl
0.88 mg/dl

15-45mg/dl
0.7-15 mg/dl

Normal
Normal

0.8
184

0.2-1.2
0.0-0.5
0.0-0.2
<500

Normal
Less

39U/L
13sec
1.13Sec
2.4mg/dl

0-55U/L
9.5-14.1 sec
<0.6mg/dl

Normal
Normal
Positive

OTHER INVESTIGATION:
-

Chest x-ray: pneumothorax is present.

3.7 more
0.2 more
16% more
15500 more

13. MEDICATION:

Inj sulbacin 400kg I.V

Inj Amikasin 30 mg i.v
Inj Gardinal 40 mg i.v
Inj meropenum 40 mg i.v
Inj levoflox 2.0 mg I.V
Inj fentanyl 2 mg i.v

15. NURSING DIAGNOSIS AND PROCESS:

ASESSMEN NURSING
T
DIAGNOSIS
Objective
Impaired gas
data:
exchange
Newborn is
related to
in
inadequate
respiratory
surfactant
distress,
levels; as
bilateral
evidenced by
advantageou grunting,
s breath
flaring,
sounds, with substernal
deep
and
intercostal
intercostal
retractions
retractions
and
substernal
retractions.

ASESSMENT

NURSING
DIAGNOSIS

GOA
L
Neon
ate
will
maint
ain
norm
al
respir
ation
by her
own
effort

INTERVENTION

GOA
L

INTERVENTION

- Administer
oxygen.
- Monitor and
document hourly.

-Auscultate lung
sound every hourly.

- Maintain gastric
decompression per
oral gastric tube
open to air, perform
oral/nasal
suctioning.
- Maintain
temperature in
normal range.

IMPLEMENTATIO EVALUATIO
N
N
-Administered
The newborn
warmed and
was weaned
humidified oxygen at
to room air
rate ordered .
after 8 hours.
- Monitor and
clear breath
document hourly
sounds,
FiO2 levels,pulse
99-100% per
oximeter, and vital
pulse
signs
oximeter.
- Auscultate lung
while on
fields hourly and
room air,
assess respiratory
absence of
effort hourly,
tachypnea,
grunting, flaring or
grunting,
retracting and
flaring,
activity.
retracting
- Maintained gastric
decompression per
oral gastric tube open
to air, perform
oral/nasal suctioning
and chest
physiotherapy as
ordered.
- Maintain
temperature in normal
range and schedule
nursing interventions
to help newborn
minimize stress,
conserve energy, and
reduce oxygen
requirements.

IMPLEMENTATIO
N

EVALUATIO
N

Objective data:
Newborn is on
radiant warmer
with
temperature

Ineffective
thermoregula
tion related
to low birth
weight as
evidenced by
poor flexion
and lack of
subcutaneous
fat stores

The
new
born
will
maint
ain
therm
al
hemo
stasis.

- Provide neutral
thermal
environment per
radiant warmer.
- Protect newborn
from loss of body
heat.
-Cover warmer bed
over infant's chest
and lower body.
- Monitor axillary
temperature hourly
and adjust settings
on warmer.
-Warm and
humidify oxygen
being delivered to
newborn

ASESSMENT

NURSING
DIAGNOSIS
Objective data:
Altered
Newborn is
nutrition
losing her
less than
weight
body
requireme
nt related
to

GOA
L
The
newb
orn
will
maint
ain
adequ

INTERVENTION
-Provide IV fluids,
D10W for
hydration and
glucose.
-Assess need for
parenteral
nutrition.

-Provide neutral
thermal environment
per radiant warmer
with temperature
probe secure and in
anterior position to
newborn.
- Protect newborn
from loss of body
heat from conduction,
convection, radiation,
and evaporation.
- Cover warmer bed
over infant's chest
and lower body with
saran wrap to prevent
insensible fluid loss
and drafts.
- Monitor axillary
temperature hourly
and adjust settings on
warmer as needed to
maintain temperature
of 97.8 to 98.8 F.
- Warm and humidify
oxygen being
delivered to newborn.

IMPLEMENTATIO
N
-Provided IV fluids,
D10W for hydration
and glucose while
newborn is under
oxyhood.
- Assessed need for
parenteral nutrition

The radiant
warmer was
required for
18 hours and
thereafter an
incubator with
neutral
thermal
environment
based on her
age and
weight
probided a
warm, safe
environment.

EVALUATIO
N
The newborn
has increased
weight after
NPO status by
proving
feedings
through a

respirator
y distress;
as
evidenced
by
respirator
y rate
greater
than 60
per
minute,
and NPO
status.

ate
hydra
tion,
outpu
t,
gluco
se
levels

-provide formula
feeding.

- provide feedings
through a
nasogastric (NG)
tube.

- Monitor
glucose levels
hourly until
stable

if oxygen therapy is
longer than 12 hours.
- When respiratory
status has stabilized
begin feeding
newborn D5W to
assess tolerance to
oral feedings. Begin
formula feedings
after two glucose
water feedings.
- If newborn does
not have a strong
sucking, gag, or
swallow reflex or is
at risk for aspiration,
provided feedings
through a
nasogastric (NG)
tube.
- Monitored glucose
levels hourly until
stable, each four
hours times two,
then every eight
hours while on IV
fluids.

nasogastric
(NG) tube.

BIBLIOGRAPHY:

-Behrman, Killegman Jenson Nelson Textbook of Pediatrics,

11th
edition, Saunclers Publication, Philadelphia, 2008,
Pp271-278

-Dorthy R. Marlow, et. at Textbook of Pediatric Nursing, 6th

edition,
New Delhi Saunders Publication, 2006, Pp722-756
-Ghai O. P et al Essential Pediatric, 6th CBC Publisher and
distributors, New Delhi Pp 124-130
-Hocken Bery Wongs Nursing Care of Infants and Children, 8th
edition, Mosby publication , USA, 2007 Pp 579-602
-Mcltosh Neil Forfar & Arneils Textbook of Pediatrics 7 th edition,
Churchill livingstone Elsevier publication, Pp 645-652
-Niraja

K.P.[2006]Text book of growth and development first

edition,Jaypee Brothers.New delhi, Pp 125-140

-Tambulwadker R.S.[2005],Paediatric nursing second

editon,vora medical publication,Mumbai, Pp 122-128

J G COLLEGE OF NURSING

SUBJECT: CHILD HEALTH NURSING

TOPIC

: CARE PLAN ON RESPIRATORY

DISTRESS

SUBMITTED TO:
BY :

SUBMITTED

Prof. U.Ramya mam

Ms Himali prajapati

Principal
JG College of nursing

F.Y.Msc.nursing
JG College of nursing

SUBMITTED ON:17/12/2010

ROLL NO: 10