CARE PLAN

PATIENT’ S BIODATA

 NAME: Baby of Mr.sureshbhai makawana

 AGE: 1st day

 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

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- Moro’s, Routine, sucking ,palmer grasp, babinski reflex is present
12. INVESTIGATION

SAMPLE PATIENT NORMAL INFERENCE

VALUE VALUE
Hemoglobin 19 mg/dl 12.3-15.3 mg/dl 3.7 more
RBC 5.3 million/cu 4.5-5.1 million/cu 0.2 more
Hematocrit 60.6% 35.9-44.6% 16% more
WBC 26500/cumm 4,400-11,000 15500 more
Differential
count
Neutrophil 40% 50-70% 10%less
Lymphocyte 55% 20-40% 15% more
monocytes 4% 2-6% Normal
Eosinophils 1% 1-6% 5%
Basophils 0% 0-2.5% 2.5%
Platelet count 2,78,000/cumm 1,50,000-4,50,000 Normal

Renal function
test
Blood urea 38 mg/dl 15-45mg/dl Normal
Serum creatinine 0.88 mg/dl 0.7-15 mg/dl Normal
Liver function test
Billirubin total 0.8 0.2-1.2 Normal
direct - 0.0-0.5 -
indirect - 0.0-0.2 -
Serum alkaline 184 <500 less
phosphate
S.G.P.T 39U/L 0-55U/L Normal
Prothrombin time 13sec 9.5-14.1 sec Normal
INR 1.13Sec - -
C-Reactive 2.4mg/dl <0.6mg/dl Positive
protein

OTHER INVESTIGATION:

- Chest x-ray: pneumothorax is present.

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 GOA INTERVENTION IMPLEMENTATIO EVALUATI

T DIAGNOSIS L N ON
Objective Impaired gas Neon - Administer -Administered The newborn
data: exchange ate oxygen. warmed and was weaned
Newborn is related to will humidified oxygen at to room air
in inadequate maint rate ordered . after 8 hours.
respiratory surfactant ain clear breath
distress, levels; as norm - Monitor and - Monitor and sounds,
bilateral evidenced by al document hourly. document hourly 99-100% per
advantageou grunting, respir FiO2 levels,pulse pulse
s breath flaring, ation oximeter, and vital oximeter.
sounds, with substernal by her signs while on
deep and own room air,
intercostal intercostal effort - Auscultate lung absence of
retractions retractions -Auscultate lung fields hourly and tachypnea,
and sound every hourly. assess respiratory grunting,
substernal effort hourly, flaring,
retractions. grunting, flaring or retracting
retracting and
activity.
- Maintained gastric
- Maintain gastric decompression per
decompression per oral gastric tube open
oral gastric tube to air, perform
open to air, perform oral/nasal suctioning
oral/nasal and chest
suctioning. physiotherapy as
ordered.
- Maintain - Maintain
temperature in temperature in normal
normal range. range and schedule
nursing interventions
to help newborn
minimize stress,
conserve energy, and
reduce oxygen
requirements.
ASESSMENT NURSING GOA INTERVENTION IMPLEMENTATIO EVALUATIO
DIAGNOSIS L N N
Objective data: Ineffective The - Provide neutral -Provide neutral The radiant
Newborn is on thermoregula new thermal thermal environment warmer was
radiant warmer tion related born environment per per radiant warmer required for 18
with to low birth will radiant warmer. with temperature hours and
temperature weight as maint probe secure and in thereafter an
evidenced by ain anterior position to incubator with
poor flexion therm newborn. neutral
and lack of al - Protect newborn - Protect newborn thermal
subcutaneous hemo from loss of body from loss of body environment
fat stores stasis. heat. heat from conduction, based on her
convection, radiation, age and
and evaporation. weight
- Cover warmer bed probided a
-Cover warmer bed over infant's chest warm, safe
over infant's chest and lower body with environment.
and lower body. saran wrap to prevent
insensible fluid loss
and drafts.
- Monitor axillary
- Monitor axillary temperature hourly
temperature hourly and adjust settings on
and adjust settings warmer as needed to
on warmer. maintain temperature
of 97.8 to 98.8 F.
-Warm and - Warm and
humidify oxygen humidify oxygen
being delivered to being delivered to
newborn newborn.
ASESSMENT NURSING GOA INTERVENTION IMPLEMENTATIO EVALUATIO
DIAGNOSIS L N N
Objective data: Altered The -Provide IV fluids, -Provided IV fluids, The newborn
nutrition newb D10W for D10W for hydration has increased
Newborn is less than orn hydration and and glucose while weight after
losing her body will glucose. newborn is under NPO status by
weight requireme maint oxyhood. proving
nt related ain -Assess need for - Assessed need for feedings
to adequ parenteral parenteral nutrition through a
respiratory ate nutrition. if oxygen therapy is nasogastric
distress; hydra longer than 12 hours. (NG) tube.
as tion, -provide formula - When respiratory
evidenced outpu feeding. status has stabilized
by t, begin feeding
respiratory gluco newborn D5W to
rate se assess tolerance to
greater levels oral feedings. Begin
than 60 formula feedings
per after two glucose
minute, water feedings.
and NPO - provide feedings - If newborn does
status. through a not have a strong
nasogastric (NG) sucking, gag, or
tube. swallow reflex or is
at risk for aspiration,
provided feedings
through a
nasogastric (NG)
tube.
- Monitored glucose
- Monitor levels hourly until
glucose levels stable, each four
hourly until hours times two,
stable then every eight
hours while on IV
fluids.
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 “Wong’s Nursing Care of Infants and Children”, 8th

edition, Mosby publication , USA, 2007 Pp 579-602

-Mcltosh Neil “Forfar & Arneils Textbook of Pediatrics” 7th 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: SUBMITTED BY :

Prof. U.Ramya mam Ms Himali prajapati

Principal F.Y.Msc.nursing

JG College of nursing JG College of nursing

SUBMITTED ON:17/12/2010 ROLL NO: 10