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What is Respiratory Distress Syndrome and Its Assessment:Nursing Case Study

Friday, 28 March 2014


In respiratory distress syndrome (RDS) of the neonate, also known as hyaline membrane disease, the premature neonate develops widespread alveolar collapse due to surfactant deficiency. Surfactant, a lipoprotein present in alveoli and respiratory bronchioles, helps to lower surface tension, maintain alveolar patency, and prevent alveolar collapse, particularly at the end of expiration.

Mild cases of the syndrome subside after about 3 days, but severe deficiency commonly results in death or residual bronchopulmonary dysplasia. RDS occurs most exclusively in neonates born before 37 weeks' gestation, but may be seen in neonates of mothers who have diabetes, in those delivered by cesarean birth, suddenly to neonates born after antepartum hemorrhage, in sudden infant death syndrome, and occasionally in apparently healthy neonates.

Pathophysiology
Although the airways are developed by 27 weeks' gestation, the preterm neonate's intercostal muscles are weak, and alveoli and capillary blood supply are immature. Surfactant deficiency causes a higher surface tension in the alveoli and bronchioles; when severe, the alveoli can't maintain patency and begin to collapse. Ventilation is decreased and hypoxia develops. The resulting pulmonary injury and inflammatory reaction impede gas exchange between the capillaries and the functional alveoli. The inflammation also stimulates production of hyaline membranes composed of white fibrin accumulation in the alveoli. Because of immature lungs and the increased work of breathing, oxygen demand increases and contributes to cyanosis. The infant attempts to compensate with rapid shallow breathing, causing an initial respiratory alkalosis as carbon dioxide is expelled. The increased effort at lung expansion causes respirations to slow and respiratory acidosis to occur, leading to respiratory failure.

Complications
■ Respiratory failure
■ Cardiac failure
■ Bronchopulmonary dysplasia
■ Pneumothorax
■ Intracranial hemorrhage
■ Neurodevelopmental delay
■ Sepsis
■ Pulmonary hemorrhage
■ Patent ductus arteriosus

Assessment
Nutrition and metabolism
■ Poor eating pattern
■ Delayed development
■ Infection
■ Thermoregulation difficulties

Elimination
■ Difficulty breathing
■ Poor airway clearance

Activity and exercise
■ Decreased activity

Roles and relationships
■ Difficulty breast-feeding
■ Decreased infant attachment behaviors

Coping and stress management
■ Compromised parental coping due to fear

Physical findings
Integumentary
■ Pallor caused by peripheral vasoconstriction
■ Pitting edema in the hands and feet within 24 hours
■ Mottling

Respiratory
■ Tachypnea (more than 60 breaths/minute; may be as high as 100 breaths/minute)
■ Expiratory grunting or whining
■ Nasal flaring
■ Intercostal, suprasternal, or substernal retractions
■ Cyanosis (circumoral followed by central) related to percentage of desaturated hemoglobin
■ Decreased breath sounds, crackles, apneic episodes
■ Frothy sputum

Cardiovascular
■ Systolic murmur
■ Heart rate within normal limits
■ Bradycardia (less than 100 beats/minute) with severe hypoxemia
■ Peripheral edema due to cardiac failure

Gastrointestinal
■ Hypoactive bowel sounds

Neurologic
■ Immobility, motionlessness, flaccidity
■ Decreased body temperature

Renal and urinary
■ Oliguria

Hematologic and immune
■ Immature immune system

Diagnostic studies
Serial chest X‑rays reveal a clouded appearance with a grainy look, areas of density or atelectasis, and an elevated diaphragm with overdistended alveolar ducts.

Air bronchograms reveal ventilation of the airway, not the alveoli.

Automated fluorescence polarized assay (TDx instrument) is a fetal test done on amniotic fluid for rapid testing of lecithin-sphingomyelin (L/S) ratio. Normal L/S ratio is 2:1 or more, indicating pulmonary maturity; L/S ratio must be 3:1 if the mother is diabetic.

Amino-Stat-FLM is a fetal test done on amniotic fluid for determining phosphatidyglycerol (PG) levels to gauge lung maturity. PG should appear in amniotic fluid by 35 to 37 weeks' gestation.

Lamellar body count is a fetal test done on amniotic fluid to check the level of storage form of surfactant; it normally increases as gestation and lung maturity advance.

Arterial blood gas (ABG) analysis shows partial pressure of arterial oxygen (Pao2) less than 50 mm Hg while on 100% oxygen, partial pressure of arterial carbon dioxide (Paco2) less than 60 mm Hg, oxygen saturation of 92% to 94%, and pH of 7.31 to 7.45.

Potassium level increases as potassium is released from injured alveolar cells.

Serum glucose level decreases with excessive work of breathing.

Teaching checklist
■ Procedure for bottle or breast-feeding
■ Care of the high-risk neonate
■ Reasons to call the pediatrician
■ Cardiopulmonary resuscitation for infants
■ Signs and symptoms of respiratory distress
■ Immunization schedule
■ Home use of apnea monitor and CPAP device, if appropriate
■ Nutritional needs of the high-risk neonate
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