Latest RDS Ye

PROGRAMME
CERTIFICATE IN PAEDIATRIC NURSING
COHORT
COHORT 16
BLOCK
BLOCK 1
FULL NAME
WAN KHADIJAH BINTI WAN YUSOFF
I/C NUMBER
850109-03-6260
MATRIX NUMBER
TITLE
RESPIRATORY DISTRESS SYNDROME
PROGRAMME COORDINATOR
MADAM ANNAMAH
CLINICAL PRECEPTOR
3062161020
MARK OBTAINED
CONTENTS
No
Contents
Page Numbers
1.
Learning Objective
2.
Personal Data
4-5
3.
Patient history
6- 14
4.
Assessment and patient condition
15-22
Review of the System
23-27
Anatomy & Physiology
28-35
Disease Condition
35-68
Progress Report
69-104
6.
Nursing Care Plan
105- 122
7.
Discharge plan
123-125
12.
Conclusion
126
13.
Reference
127
14.
Appendix
128
5.
LEARNING OBJECTIVE
At the end of this case study I will able to:

1. Explain the patients profile, history, including chief presenting complaints and
history of present illness.
2
2. State the growth and development, milestones including physical measures, gross
motor, fine motor and socialization.
3. State the birth history and immunization history of the patient.
4. State the diet history including nutritional assessment (growth chart), feeding
milestone and 24-hour recall.
5. Explain family background including family medical history and socioeconomic
background.
6. Describe physical assessment finding on the specific body systems
7. Describe growth and development finding.
8. Explain the disease condition including definition, incidence,
etiology,
pathophysiology, sign and symptoms

9. Describe laboratory finding of baby from admission till discharge.
10. Describe radiology finding of baby from admission till discharge.
11. Explain drug commence to the baby during hospitalization including nursing
responsibilities prior to the administration.
12. Describe other treatment given to the baby.
13. Explain appropriate nursing care plan for the patient during hospitalization.
14. Describe discharge plan including health education given to family members
regarding care of the baby in home after discharge.
15. Summarize patient flow of hospitalization till discharge.
PATIENT PROFILE
Name
: Miss Y
MRN
: 407xxx
Age
: 10 hours of life
Date of birth
: 24/10/2016@0449H
Nationally
: Malaysian
Sex
: Female
Race
: Malay
Primary Language
: Nil
Religion
: Muslim
Address
: No 3,Jln Aman perdana, subang jaya, Selangor D.E.
Fathers occupation
: Businessman
Mothers occupation : Housewife

Allergy
: unknown
Date of admission
: 24 October 2016@2345H
Date of discharged
: 5 November 2016@1340H
Follow up
: 12 November 2016@0830H
Diagnosis
: Respiratory distress syndrome
Consultant
: Doctor Q
PATIENT HISTORY
2.1
Chief presenting complaints
Miss Y transfer in from KPJ Selangor, she has an episode of Grunting, nasal flaring with
chest recession soon after delivery and was intubated after desaturated while on head box
oxygen and due to insufficient equipment she has been transfer to Kpj Damasara Hospital.
2.2
History of presenting illness
Miss Y is a preterm baby deliver at 4.49pm transferred from kpj Selangor after having
difficult Lower Segment Caesarian Section due to previous scar in the labor. The Apgar score
was 7 at 1 minute and 9 at 5 minute. Miss Y developed grunting with nasal flaring and chest
resection soon after delivery. Put on head box and CXR done in kpj Selangor. At 8.45 Miss Y
desaturated and intubated with size 3 Endotracheal tube (ETT) and anchored at 9cm. She was
ambubagged oxygen, saturation was 90 -100 from kpj Selangor. On arrival Miss Y was dusky
and central cyanosed, flat with no spontaneous movement, saturation 17 20% in 100 %
oxygen, manually ventilation by Consultant KPJ Selangor , blood noted from ETT tube. Fix
on ventilator, leaking >30%, no better, continue bagged, still no better, Spo2 <30% with fio2
1.0, Rate 50 bpm, PEEP 8, PIP 30. Review by Dr I and taking history from kpj Selangor
consultant. At 0020H spo2 23% on high ventilation setting, NIBP 66/44mmhg, manually
ventilation done by Dr I but still the same, orogastric tube size 6 inserted, noted air ++ but no
bleeding seen, CXR done and noted the tube displace, serve iv morphine 400mcg and
reintubated with endotracheal Tube (ETT) size 3.5, fixed at 9 and given curosorf 100mg/kg.
Spo2 increase > 95% and noted pinkish color. Umbilical artery catheter (UAC) & Umbilical
Venous catheter (UVC) inserted and doing CXR showed Severe Respiratory distress
syndrome (RDS) with Large Heart and no pneumothorax seen. Put on Synchronize invasive
5
positive pressure ventilation (SIPPV) with PIP: 30, PEEP: 8, Rate 50, FiO2: 0.9. Blood gases
PH:7.11, Po2 60, PCo2 69.6, BE, -7 (Mix respiratory and metabolic acidosis) Glucose
10.4mmol on admission. Miss Y brought to NICU and admitted in NICU under Dr. Q.
2.3
PAST HISTORY
2.3.1 HISTORY OF PAST ILLNESS:

Miss Y develop grunting immediately after birth. She has respiratory distress after birth
2.3.2 BIRTH HISTORY
Miss Y was born on 24 October 2016 @ 1649H in hospital KPJ Selangor, through Lower
Segment cesarean section (LSCS) from previous scar in labor. It took about 20 minute to
bring her out due to adhesion. she is preterm baby at 36 weeks gestations was born with:
Apgar score
: 7 at 1 minute & 9 at 5 minute
Birth weight
: 3.77 kg
Head circumference
: 36 cm
Birth length
: 56 cm
According to referral letter, immediate after birth Miss Y developed sign of respiratory
distress.
2.3.3 ANTENATAL HISTORY
Madam. E had regular antenatal visit, also gain weight, have gestational diabetes on Diet
control, immunization taken.IM dexamethasone given 2 times before delivery.
2.3.4 INTRANATAL:
Delivery was Lower segment cesarean section plus vacuum and took about 20 minute to
bring Miss Y out. Birth Apgar score is 7 at birth, after 5 min 9. Miss Y develop grunting,
nasal flaring and chest recession immediately after birth.
2.3.5 POSTNATAL
Miss Y had respiratory distress Syndrome.
2.3.6 Illness & Surgeries
Miss Y got no history of surgical procedure since birth till now also unknown of having
allergic reaction to any foods or drugs or dust.
2.3.7 Medications
Intramuscular Vitamin K were given in KPJ Selangor.
2.3.8 Immunization history
Immunization is the process whereby a person is made immune or resistant to an infectious
disease, typically by the administration of a vaccine. Vaccines stimulate the body's own
immune system to protect the person against subsequent infection or disease. (CDC, 2016)
Meanwhile Vaccine is a special preparation of antigenic material that can be used to stimulate
the development of antibodies and thus confer active immunity against a specific disease or
number of diseases. It is usually given by injection but may be introduced into the skin
through light scratches; for some diseases (e.g. polio), oral vaccine is available. Many
vaccines are produced by culturing bacteria or viruses under conditions that lead to a loss of
their virulence but not of their antigenic nature. Other vaccines consist of specially treated
toxins (toxoids) or of dead bacteria that are still antigenic.
Immunization (2004), Elizabeth A.M, Dictionary of Nursing (pg 505, Malaysian ed)
Malaysia, Penerbit Fajar Bakti Sdn.Bhd.
Immunity can be divided into Active and Passive.
Active immunity
Naturally acquired active immunity occurs when the person is exposed to a live
pathogen, develops the disease, and becomes immune as a result of the primary
immune response.
Artificially acquired active immunity can be induced by a vaccine, a substance that
contains the antigen. A vaccine stimulates a primary response against the antigen
without causing symptoms of the disease.
Passive immunity
Artificially acquired passive immunity is a short-term immunization by the injection
of antibodies, such as gamma globulin, that are not produced by the recipient's cells.
Naturally acquired passive immunity occurs during pregnancy, in which certain
antibodies are passed from the maternal into the fetal bloodstream. Immunologic
tolerance for foreign antigens can be induced experimentally by creating conditions of
high-zone tolerance for example by injecting large amounts of a foreign antigen into
the host organism, or low-zone tolerance, by injecting small amounts of foreign
antigen over long periods of time.
Types of vaccine
Live Attenuated vaccine
Attenuated vaccine uses pathogen that are active but have reduced virulence so they
dont cause disease.

It Is the process of reducing the virulence of the virus.
It contains replicating microbes that can stimulate a strong immune response due to
the large number of antigen molecules.
Inactivated vaccine
Can be either whole agent vaccine produced with deactivated but whole microbes, or
subunit vaccines safer than live vaccines.

Several doses usually required because there is no multiplication in the body.
Reaction do not resemble those of the natural disease and usually follow soon after
inoculation.
Toxoid vaccine
Chemically or thermally modified toxins used to stimulate active immunity.

Useful for some bacterial disease e.g. Tetanus, Diphtheria.
Require multiple doses because they possess few antigenic determinants.
LIVE ATTENUATED
KILLED VACCINE
TOXOID VACCINE
VACCINE
Alive suspension of
microorganisms which
They are purified extracts
from live microorganisms.
have
They
been rendered
virtually non virulent.

Induce Long-lasting
are
replication
incapable
and
of
immunity that can be

reinforced with later
required because there is no
booster doses
and thus maintain its ability
therefore
non-infectious.
Several doses (usually 3)
They are toxins

But they retain antigencity
to provoke an immune
response.
multiplication in the body.

Later booster doses are also
necessary.
Reactions do not resemble
increased by absorption to a
those of the natural disease
mineral
and usually follow soon after
aluminum salts)
Antigenicity of toxoids cab be
carrier
(such
inoculation.
They induce relatively short
periods
of
protective
immunity.
Table : types of vaccines.

10
as
Figure: Immunization schedule in Malaysia for 2016
11
AGE
VACCINE
DATE GIVEN
AT BIRTH
BCG ,Hepatitis B (1st dose)

nd
5/11/16@1145H
1 MONTHS
Hepatitis B (2 dose)
Not yet taken
2 MONTHS
DPT , IPV, HIB ( 1st dose )
Not yet taken
3 MONTHS
DPT , IPV , HIB ( 2nd dose )
Not yet taken
rd
5 MONTHS
DPT, IPV, HIB ( 3 dose )
Not yet taken
6 MONTHS
Hepatitis B
Not yet takezn
9 MONTHS
MMR
Not yet taken
12 MONTHS
MMR
Not yet taken
18 MONTHS
DPT , IPV , HIB ( Booster )
Not yet taken
7 YEARS
MR,DT (Booster)
Not yet taken
13 YEARS
HPV
Not yet taken
15 YEARS
Tetanus (Booster)
Not yet taken
Dr Q examined and assess Miss Y and decided will administer BCG and Hepatitis B vaccine
later base on patients condition and before Miss Y discharge Dr Q has order to give BCG and
Hepatitis B vaccine (1st dose). BCG has been given 0.1ml intradermal at deltoid muscle.
Meanwhile, Hepatitis B vaccine was given intramuscular at rectus femoralis muscle, both
vaccine gave at 1145 on 5/11/16.
2.3.9 Diet history
Dr Q examined miss Y and according to the doctor she need to Nil by mouth till stable and
since birth till day 4 she was not given any feeding. Dr Q started trophic feeding on 28/10/16
2.3.10 Family pedigree
12
MADAM E
Mr. T
MISS
MASTER
MISS
Figure 1: Family data of Miss Y

INTERPRETATION:
According to MADAM E, all her kids was deliver through Lower segment caesarian section
(LSCS) and she had gestational diabetes during pregnancy for all her baby. Her first daughter
has mild respiratory distress syndrome soon after delivery but her second child was normal
and no other medical history. Both child have no surgical history. Furthermore, none of them
has any allergies to any medication, food or environment.
2.3.11 Family medical history

FATHER
Father of Miss Y Mr. T is 38 years old and healthy man. No history of medical illness also
has no history of allergic to dust, drugs or foods. His parental background also did not have
any history of congenital illness. His maternal background was well. There is no history of
any congenital anomalies among his sibling but he is a smoker.
13
MOTHER
Mother of Miss Y, Madam E para 3 have diabetic during pregnant of her 2 kids and Miss Y as
well. not taking any insulin during pregnancy only diet control. No history of other medical
illness and no history of allergic to any drugs, food or environment, congenital anomalies and
chronic illnesses. Madam E have surgical history of LSCS for her both kid previously and
first kid is a girl who was born on 39 week of gestation and has history of RDS after birth Her
mother has diabetes and father have hypertension but both have no surgical history or other
congenital illness.
2.3.12 Socioeconomic background
Mr. T is a businessman and earn about 8000 per month while madam E is a housewife. They
live in the bungalow house in taman USJ subang.
14
2.4 Assessment
2.4.1 Growth and development review
GROWTH
Deviation in growth patterns may be nonspecific or may be important indicators of
serious and chronic medical disorders. An accurate measurement of length/height, weight and
head circumference should be obtained at every health supervision. Growth is an increase in
number and size of cells as they divide and synthesize new proteins; result in increased size
and weight of the whole or any of its parts. Growth should be measured and compared with
statistical norms in a standard fashion growth chart. Serial measurements are much more
useful than single measurements to detect deviation from a particular childs growth pattern
even if the values remains within statistically defined normal limits ( percentile). Following
the trends help define whether growth within acceptable limits or warrants further evaluation.
FIGURE 3: GROWTH AND DEVELOPMENT
15
AGE
10 hours of life
WEIGHT DURING ADMISSION
3.77KG
HEIGHT
56 CM
HEAD CIRCUMFERENCE
36CM
CHEST CIRCUMFERENCE
34CM
Table 4: Anthropometric measurements of Y during admission.

INTERPRETATION:
Miss Y is preterm 36 weeks plus 4 days, she has well growth development. His weight
large for the age due to mother of gestational diabetes. Her Length was 56 cm is in average.
Head circumference was 36 cm, meanwhile chest circumference was 34cm. The table above
shows the anthropometric measurements during admission:
CHILD DEVELOPMENT
Child development refers to how a child becomes able to do more complex things as they get
older. Development is different than growth. Growth only refers to the child getting bigger in
size. When we talk about normal development, we are talking about developing skills like:
-
Gross motor: maturation in posture , head control , sitting , creeping , standing ,
walking.
Fine motor: using hands and finger grasp an object.
Language: crying , syllables dada , can say 3-5 words.
Cognitive: ability to know , learn to separate from other objects in the environment.
Social: Interacting and play with others, attachment to the parent.
DEVELOPMENT MILESTONE.
Developmental milestones are a set of functional skills or age-specific tasks that most
children can do at a certain age range. Although each milestone has an age level, the actual
age when a normally developing child reaches that milestone can very quiet a bit.
16
17
Table 5: Development milestones in normal children.

AGE
GROSS MOTOR
FINE MOTOR
SPEECH
SOCIAL
LANGUAGE
3 MONTHS
Pull to sit: Slight Hand
regard. Squeals
with Laughs.
head lag. Head Follows object from delight. Turns

occasionally bobs side to side (180). head to sound.
forward.
Hands held loosely.

Grasp object placed
Ventral
suspension: Head
above plane of
in
hand.
Not
reaching out.
the body.
Prone: Pelvis flat.
Lifts head up 45
- 90
5 MONTHS
Pull to sit: No Reaches for objects.
Mouthing.
head lag and sits Plays with toes.

with
straight
back.
Lying
supine:
Feet to mouth.
6 MONTHS
Pulls to sit. Lifts Palmar

head
in cube,
anticipation. Sits approach.

with
grasp
of
ulnar
Moves
support. head, eyes in all

18
Bears weight on directions. No squint

legs.
Prone: (after 4 months)
support
the
weight
hands,
chest,
upper
abdomen
couch.
off
Rolls
prone to supine.
18MONTHS
Gets up and down Tower of 3 cubes. Points to 2- 3 Intiates

stairs holding on Scribbles
body
parts. housework.
a rail or with one spontaneously.
Picture cards- Toilet training.
hand held. Pulls Visual test. Picture identify one.
Use
toy or carries doll. charts. Handedness.
well.
Throws
ball
stops.
without
falling.
spoon
Casting
Sits on a chair.
INTERPRETATION:
Miss Y has shown no development milestone in the first 1 day of admission, no sucking
reflex because she was intubated, no rooting reflex. On her second day of life she was visited
by her mother and during the time she was grasp her mothers finger as her mother put finger
on her palm which showed that Miss y have palmer grasp reflex.
19
2.4.2
Nutritional assessment
Nutritional assessment is the evaluation of an individuals nutritional status and requirement,
to identify undernourished and over-nourished child. Elements of assessment include:
A structured way to establish nutritional status and energy requirement by objective
measurements and whereby, completed with objective parameters and in relation to specific
disease-indications, an adequate nutritional treatment can be developed for the patient. All
this happen preferably in a multidisciplinary setting. When judging the need for nutritional
support, an assessment must be made both of underlying reason for any feeding difficulties
and also current nutritional status.
Anthropometric data including height, weight and calculation of body mass index
(BMI). Data should be plotted on age-appropriated and gender appropriate growth
chart and assessed for weight gain trends and upward crossing of percentiles.
Dietary and physical activity history. Assess patterns and potential targets for
behavioural change.
Physical examination. Assess blood pressure, adiposity distribution (central versus
generalised) markers or comorbidities (acanthosis nigricans, hirsutism, hepatomegaly,
orthopaedic abnormalities) and physical stigmata of genetic syndrome (Prader-Willi
syndrome).
Laboratory studies. These are generally reserved for children who are obese (BMI 95 th
percentile), who have evidence of comorbidities or both. Useful laboratory test may
include fasting lipid profile, fasting glucose level, liver functions tests and thyroid
function tests. Other studies should be guided by findings in the history and physical
examination.
The importance of nutritional balance includes:

20
To ensure that the children receive the nutrients that are vital for his growth and
development.
Different food provides different nutrient and different amount.
No single food can meet all the nutritional needs of the child.
A wide variety of food is required to ensure that child get the nutrient he need daily
Breast milk is most beneficial ready-made nutrition food available for the new-born baby:
The important of breastfeeding:
To baby
1.
2.
3.
4.
5.
6.
7.
8.
It supplies all the necessary nutrients in the proper proportions.

It protects against allergies, sickness, and obesity.
As a defence mechanism
Increase immunity for the child
It protects against infections, like ear infections.
It is easily digested no constipation, diarrhea or upset stomach.
Babies have healthier weights as they grow.
Breastfed babies score higher on IQ tests.
To mother
1.
2.
3.
4.
Have a reduced risk of Type 2 Diabetes and certain cancers such as breast cancer
May find it easier to return to what they weighed before they got pregnant
Strengthen the bond with their children
Reduce mothers stress level and risk of postpartum depression.
Based on Dr Q, Miss Y Need Nil by mouth till 3 days and Trophic feeding started on Day 4
through NG tube feeding.
-
Started amount was 5 mls of EBM (Mothers Colostrum) for 3 hourly.

Feeding tolerated well & on Day 5 feeding increase to10 mls/3 hourly
Day 6 increase to 30mls/ 3 hourly
Day 7 increase to 35 mls/3 hourly and increase 5 mls for every 2 cycle.
*Miss Y tolerate feeding well and she was given fully EBM.
21
2.4.3 Physical examination

During admission, Miss Y brought in via ambulance accompanied by pediatrician and nurse
to the emergency she was also accompanied by his father to NICU. Assessment, orientation
to the ward and observation has been taken and charted in the report.
The parameter as below:
Temperature
Pulse
Blood pressure
Respiration rate
SPO2 rate
Weight
Height
2.5
: 37.4 C
: 140bpm
: 66 / 44
: 50/min
: 17% - 20%
: 3.77KG
: 60cm
Review of the systems
2.5.1 General health and appearance:

Level of consciousness
Emotional status
Hygiene
: unconscious
: NA
: vernix and blood on the hair and body
2.5.2 Neurological:
Paediatric eye responds
Paediatric verbal response
Paediatric motor response
: no respond
: Nil
: Nil
2.5.3 Heent
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.
22
2.5.4
Eye
: Eyebrows and eye lashes present. Eye-ear at same level. Conjunctiva
Ear
is cyanosed, No eyes discharge

: pinna is parallel to the outer and inner canthus of eyes. Both ear is
Nose
Throat
Lips
symmetric. Not responds to voice and sound, no discharge seen.

: Nostrils equal in size.
: ON Endotrachial tube
: Cyanosed
Skin/hair/nails
Integumentary system
Skin colour
: cyanosed
Turgor
: Poor
Temperature
: Cold to touch
Rashes
: NIL
Hair
: black and have vernix
Nail
: cyanosed
2.5.5
Neck and lymph nodes

Neck: No palpable nodule present
2.5.6
Chest/lung
Structure: 2 nipples symmetric. Breast tissue diameter is normal like 5 cm in diameter.
Symmetrical expansion of chest. transient breath sound is heard symmetrically as
patient is on Endotracheal tube. Sometimes brief apnea is present. heart sound
auscultates normal rate and rhythm without murmur.
Pulmonary
Respiration rate
: 50/min on SIPPV
Rhythm
: Regular
Chest movement
: Symmetry
2.5.7
CVS
Cardiovascular
Rate
Rhythm
Any murmur
: 140 bpm
: Regular
: NIL
23
Pulse
Capillary refill
Skin color
Edema
2.5.8
: Radial
: >2 sec
: Dusky and cyanosed
: NIL
Peripheral vascular
Capillaries refill time > 2 second
Weak pulsation (radial)
Blue nail bed- Poor perfusion
2.5.9
GIT
Gastrointestinal
Diet
Appetite
Oral intake
Abdomen
: NBM
: NA
: NBM
: Soft, Appears large in relation to pelvis. two arteries and one
vein is present in umbilical.

Bowel sound
: NA
Bowel pattern
: NA
Stool characteristics : NA
2.5.10 Genitourinary system
Genitourinary
Urine output
: NIL
Characteristics
: NIL
Any urinary catheter : NIL
2.5.11 Musculoskeletal system
Musculoskeletal
Activity level
Range of motion
Mobility
Posture
Back
Lower extremities
: Flat and flaccid

: No movement
: Assistanted
: flaccid and neck appear short because cheek rest on chest
: NA
: Equal both legs
24
2.5.12 Genitalia
Genitalia: Female Buttocks are symmetric.
2.5.13 Extremities
Cold extremities, cyanosed and dusky in color.
2.5.14 Discussion on physical examination finding
Miss Y was flat, no respond with general cyanosis, perfusion poor showed that she has
severe respiratory distress.
25
2.6
Physical examination
I.
Vernix on
Hair
General
cyanosed
Umbilical
cord
IVB AT RT
HAND
II.
Figure 4: Physical examination of Miss Y
26
2.7
Anatomy and physiology
RESPIRATORY SYSTEM
RESPIRATORY SYSTEM IN CHILDREN
RESPIRATION
Respiration is the act of breathing:
Inhaling (inspiration) - taking in oxygen.
Exhaling (expiration) - giving off carbon dioxide.
27
RESPIRATORY SYSTEM
The respiratory system is made up of the organs involved in the interchanges of gases, and
consists of the:
Nose - The nose is the passageway into and out of the respiratory system. Oxygen is inhaled
in to the nose and when it comes out it is warm and moist surfaces. Air can also leave and
enter in the body by mouth.
Pharynx - Pharynx is also called throat. When a person breathes through nose or mouth, the
air flows into the Pharynx. The pharynx has two tubes. One leads to the stomach and is called
the esophagus and the other leads to the lungs and is called the larynx.
Larynx - If you put your head up a little bit, and rub your finger up and down on the front of
your throat, you can feel a bump. That is your Larynx. It has elastic bands, which stretches
across the Larynx, which is called the vocal cords. When air flows between the vocal chords,
they vibrate and make a sound.
Trachea - The Trachea is divided into two parts of your lungs. The Trachea also is a windpipe
that travels air to the lungs. It branches into your Bronchi.
Bronchi - Bronchi are two tubes. Each bronchus goes into each of the lungs and spreads out
into tiny tubes called
Bronchiole. The bronchiole connects to the alveoli and it is where oxygen exchanges occurs
Lung - Each bronchiole in the lungs has tiny sacs called alveoli. Capillaries surround each of
them.
28
UPPER RESPIRATORY TRACT
nose
nasal cavity
sinuses
o
ethmoid
frontal
maxillary
sphenoid
larynx
trachea
LOWER RESPIRATORY TRACT

29
lungs
airways (bronchi and bronchioles)
air sacs (alveoli)
FUNCTION OF THE LUNG

The lungs take in oxygen, which cells need to live and carry out their normal functions. The
lungs also get rid of carbon dioxide, a waste product of the body's 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).
The lungs 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 vessels
trachea (windpipe)
esophagus
thymus
lymph nodes
The right lung has three sections, called lobes. The left lung has two lobes. When a person
breathes, the air:
30
Enters the body through the nose or the mouth.
Travels down the throat through the larynx (voice box) and trachea (windpipe).
Goes into the lungs through tubes called main-stem bronchi.

o
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
and then into even smaller tubes called bronchioles
bronchioles end in tiny air sacs called alveoli
The bronchi progressively subdivide into:
Bronchioles
Terminal bronchioles
Respiratory bronchioles
Alveolar duct
Alveoli
31
BRANCHING OF THE BRONCHIOL TREE.

Trachea - main stem bronchi bronchi bronchioles terminal bronchioles
At birth the distal (peripheral) bronchioles that extend to the alveoli are narrow and fewer
in numbers than in an adult.
The childs overall growth can be correlated to the increased branching of the peripherals
bronchioles as the alveoli continue to multiply.
The taller the childthe grater the lung surface area.
The bronchi and bronchioles are lined with smooth muscles.
The newborn does not have enough smooth muscles bundles to help rap airway invaders.
The chest wall is so flexible that the negative pressure created by the downwards
movement of the diaphragm draws in air, but in cases wall to be drawn inwards, causing
retraction.
By 6 years of age , the child begins to use the intercostals muscle more effectively for
breathing.
32
TRANSPORT OF OXYGEN
NORMAL ALVEOLI
PULMONARY BLOOD SUPPLY
The pulmonary artery divides into 2, one branch conveying deoxygenated blood to each lung.
Within the lungs each pulmonary artery divides into many branches which eventually end in
a dense capillary network around the walls of the alveoli.
The walls of the alveoli and those capillaries each consist of only one layer of flattened
epithelial cells. The exchange of gases between air in the alveoli and blood in the capillaries
take place across these 2 very fine membranes. The pulmonary capillaries join up, becoming
2 pulmonary veins in each lung.
They leave the lungs at the hilum and convey oxygenated blood to the left atrium of the heart.
33
34
4
4.1
DISEASE CONDITION
INTRODUCTION & DEFINITION
Respiratory distress syndrome (RDS) is a breathing disorder of premature babies. It also

known as hyaline membrane disease, it caused by surfactant deficiency which is describe not
only in preterm baby but also in near term babies after caesarean section (CS) as can be seen
in Miss Y ( Rotb- kleiner et. al. 2003), Basically, in healthy infants, the alveoli are the small,
air-exchanging sacs of the lungs which are coated by surfactant which make the alveoli open
and close nicely without ruptured, surfactant is a soap-like material produced in the lungs as
the fetus matures in preparation for birth. If premature newborns they have not yet produced
enough surfactant because they not reach the certain age of fully surfactant develop, not
necessary the age make the surfactant less but also other factor which can make the surfactant
production affected for example in Miss Y case her mother has gestational diabetic and Birth
asphyxia which make her higher to develop surfactant deficiency.
FIG. 2. Relationship of the factors resulting in respiratory distress syndrome (RDS). Hyaline
membrane formation at the alveolar-capillary membrane in RDS.
35
1.
2.
3.
4.
5.
6.
7.
8.
Surfactant deficiency causes atelectasis and reduced lung compliance.

Gas exchange is impaired, resulting in hypoxemia, hypercapnia, and acidemia.
Work of breathing increases, and the neonate begins to fatigue and hypoventilate.
Pulmonary vasoconstriction and increased PVR lead to hypoperfusion of the lung.
PPHN with shunting through the ductus arteriosus (right-to-left shunt).
Hypoxia causes damage to alveolar epithelium.
Pulmonary capillary permeability increases, and plasma leaks from the capillaries.
Fibrin present in plasma forms a hyaline membrane that lines the alveoli and
bronchioles.
9. Alveolar ventilation decreases, and diffusion gradient increases.
10. High FIO2 and airway pressures needed during mechanical ventilation which actually
cause further tissue damage as can be seen in diagram below
Figure 2: graft of pressure needed to produce certain Vt in stiff lung.

4.2
Etiology
RDS is a disease resulting from immature lung anatomy and physiology. The primary
abnormality is surfactant deficiency. Without enough surfactant, alveoli collapse with each
breath, and the lungs cannot maintain expansion. Underdeveloped alveoli and pulmonary
capillary beds further compromise gas exchange.
36
Factors that increase the risk of developing RDS

1. Prematurity
2. Low birth weight (<1200 g)
3. Gestational age <30 weeks
4. Male infants have twice the risk of female infants.
5. Maternal hemorrhage during delivery
6. Maternal diabetes
7. Birth asphyxia
8. Multiple births (e.g., second twin)
9. Possible association with delivery by cesarean section
Among premature babies, the risk of developing RDS increases with Caucasian race, male
sex, an older sibling with RDS, cesarean delivery, perinatal asphyxia, and maternal diabetes.
4.3
Epidemiology
Internationally respiratory distress syndrome (RDS) affects about 1 percent of newborn

infants and is the leading cause of death in babies who are born prematurely. About 12
percent of babies born in the United States are preterm, which is higher than in other
developed countries. About 10 percent of premature babies in the United States develop RDS
each year. The risk of RDS rises with increasing prematurity. Babies born before 29 weeks of
gestation have a 60 percent chance of developing RDS, but babies born at full term rarely
develop this condition. Statistic in Damansara Specialist hospital also shows selari with other
in which there was 9 cases for year 2014, and 23 cases on 2015, Generally incident of boy
higher compare to the girl for the both year and premise baby is higher rate compare to full
term baby as can be seen in the bar chart below.
37
Bar Chart: Statistic of RDS cases in Damansara specialist Hospital.

4.4
Signs & symptoms
Symptoms of respiratory distress present at birth or develop 6 to 8 hours after birth.

-
Tachypnea
Retractions
Grunting
Nasal flaring
Cyanosis
CXR- ground Glass appearence
38
FIG. 2 Chest radiograph of a premature infant with respiratory distress syndrome (RDS).
Note the characteristic pattern of ground glass infiltrates with air bronchograms
Classic appearance in the untreated newborn is reticulogranular infiltrates described as
having a ground glass appearance. Severe RDS may progress to a total whiteout, in
which the heart border and diaphragm are indistinct because of severe atelectasis.
4.5
Laboratory data
Successful treatment of RDS requires careful monitoring and attention to the details of the
intensive care needed by preterm babies. This includes frequent blood gases, urea,
electrolytes, full blood count, and glucose estimation. Continuous monitoring of heart rate,
respiration, temperature, and blood pressure are the minimum requirements for a ventilated
baby. Visual observation should be recorded hourly. The chest should be auscultated regularly
to check for bilateral breath sounds and endotracheal tube positioning. All intravenous and
arterial lines should be checked at least hourly for patency.
Date
Normal range
15.0 23.5 g/dL
25/10
@
0240
18.5
26/10
@
0903
16.1
Hb
PCV
44 70- %
5.3
48
White cells
9.0 22 10/uL
5.2
29.2
Platelet
150450 10/uL
36.4
207
Neutrophils
Sodium
Potassium
30 60 %
139-155
3.4-5.8mmol/l
23.3
139
5.5
73.2
139
4.5
69.2
145
4.7
Urea
1.4-5.7mmol/l
4.0
1.2
CRP also was higher than normal
Chloride
95-115mmol/l
105
115
shows
ALT
< 57 U/L
14
30/10
@
0806
16.5
Implication and significant
D3 in NICU Miss Y show some

bacterial infection but already
17.1
covered with antibiotic so on the

30th the infectious rate is coming
down as WBC back to normal and
there
was
some
inflammation reaction inside ,miss

39
Protein
Albumin
CRP
48-76 g/L
28 44 g/L
<4.1mg/L
35
0.35
40
28
17.80
Y body.
2.48
SERUM BILIRUBIN
Date
Normal range
Serum
3/11 4/11 5/11 Implication and significant

@
@
@
0743 0732 0736
Newborn < 1 Day (1.4D 10 of life Miss Y develop
Bilirubin
6.0)
jaundice, the bilirubin is more
1-2 day (3.4- 8.7)
than normal, DR Q start on
2-5 day (1.5- 12.0)
15.4
12.9
9.8
phothotherapy (single photo
5-14 day (0.1- 10)
only) I care Miss Y under
2-4week (0.1-2.0)
photo therapy.
Care of Miss Y Under Phototherapy

-
exposed Miss Y skin fully (uncovered)

cover her eyes with eye pad
monitor Miss Y temp
allow the distance of light source and the baby (35cm)
maintain infant in flexed position with rolled blankets surrounding the infant.
ensure adequate fluid intake
monitor serum bilirubin level
allow parental - infant interaction
Blood Gases
40
Blood gases must be monitored (Table 2) as a guide to ventilator management and to

minimize the risk of retinopathy of prematurity from inappropriate use of high levels of
oxygen (McGurk, 2003). Frequent monitoring is essential in the acute stages of RDS. The
usual and most reliable method of achieving this is through umbilical artery catheterization or
indwelling arterial cannula.
Date
Normal
range
Mode
25/10
@
0149
PTV
25/10
@
1408
PTV
25/10
@
1758
HFOV
Fio2
0.9
0.8
1.0
PIP
30
30
PEEP
MAP
20
Rate/ Freq
40
TV(mls/Kg)
60
1.31
60
9.2
PH
7.35 7.45
7.113
6.955
7.138
Pco2
35- 45
mmhg
75 - 100
mmHg
2226mmol/l
-2-+2
2.5 mmol/L
69.6
114.3
65.4
60
19
24
22.3
25.4
22.2
-7
10.4
-7
7.3
-7
7.7
Interpretation
Mix. Respiratory
& metabolic
acidosis
Action
Suction
Mix.
Respiratory and
metabolic
acidosis
Initiation of
HFOV
Implication
and
significant
Important of
doing suction
to keep airway
clear and
improve
ventilation
Mix.
Respiratory and
metabolic
acidosis
Suction
Increase Fio2
&rate, increase
PEEP
When the
adjustment
reaching
maximum level
there is another
way of
Po2
Bic
BE
Glucose
recruiting the
lung and at the
same time
maintain CO2
within normal
value.
41
process
recruiting the
lung without
injured the lung
it self
42
Date
Normal
Mode
26/10
@
2245
HFOV
Fio2
0.45
0.4
0.3
24
70
20
55
17
9
12.9
10.4
10.7
7.518
7.39
7.373
22.5
30.3
37.3
192
123
98
18.3
18.4
21.7
-5
7.4
-4
11.1
-4
6.3
range
MAP
Rate/ Freq
TV(mls/Kg)
PH
Pco2
Po2
Bic
BE
Glucose
Interpretation
Action
Implication
and
significant
7.35
7.45
3545
mmhg
75 - 100
mmHg
2226mmol/l
-2-+2
2.5
mmol/L
Respiratory
alkalosis with
partial metabolic
compensate
Serve another
dose of
curousorf
200mg/kg.
Monitor O2
saturation and
prompt
adjustment
required to
prevent
hyperoxia
27/10
@
0138
HFOV
27/10
@
1219
HFOV
Respiratory
alkalosis with
fully metabolic
compensate
.
Normal ABG
Monitor O2
saturation and
prompt
adjustment
required to
prevent hyperoxia
Prolong
ventilation can
cause a lot of
complication,
thinking of the
weaning is
important to
minimize
complication
Planning
for
wean the mode
43
4.6
Radiology data
The EET tube from KPJ Selangor was located higher from region of carina, after reintubate
the location shows in the region of carina.
44
Before serve surfactant the CXR appearance of ground Glass and after surfactant there
some functional alveoli appear.
45
UAC and UVC looks like in Abdominal XRAY. The straight one was UVC with
46
4.7
Drug study
As the radiological appearance of RDS is similar to that of congenital pneumonia, all infants
should be given prophylactic antibiotics until an infection screen proves negative. First-line
antibiotics should be administered until a positive culture dictates specific medication.
Sedation with or without medical paralysis is usually recommended for ventilated infants to
avoid discomfort. The use of paralysing agents can cause tissue oedema and necessitate fluid
restriction. Sedation given by continuous infusion will also aid synchronous ventilation, and
should therefore be avoided in babies on CPAP and synchronised intermittent mandatory
ventilation.
Hypotension is common in sick infants with RDS who may require volume expansion or
inotropic support to improve cardiac function, and thus organ perfusion.
Calculations of medications must be carefully individualised. The infants weight must be
taken into account in association with consideration of the immature renal and hepatic
systems incapacity to metabolise and excrete drugs. Serum levels of drugs should be closely
monitored to avoid toxicity
47
IV AMIKACIN 60mg daily

Group: Broad spectrum antibiotic
Route: Intravenous injection
Indications:
Amikacin is indicated for the treatment of infections of: central nervous system,
urogenital system, biliary and intestinal tracts, skin and subcutaneous tissues, intraabdominal
infections, pneumonia, caused by Gram-negative microorganisms, secondary infections after
combustion, bacterial septicemia, infections of the bones and joints (caused by sensitive to
Amikacin microorganisms).
Dose:
In adults and children with normal renal function, Amikacin is administered
intramuscularly as an intravenous bolus or by slow intravenous infusion in a dose of 5 mg/kg

body weight given every 8 hours or 7.5 mg/kg body weight every 12 hours for a period of 7
to 10 days.
Before the infusion 500 mg Amikacin is dissolved in 200 mg saline or other suitable
solution. The infusion duration is 30 to 60 minutes.
The maximum daily dose should not exceed 15 mg/kg body weight, and the total dose
for one treatment course should be below 15 g.
In newborn and prematurely born infants, the single initial dose of Amikacin is 10
mg/kg body weight. After this dose the treatment continues with a dose of 7.5 mg/kg body
weight given every 12 hours during the following 7 to 10 days.
48
Amikacin can be used in a single daily dose of 1 g intramuscularly or 15 mg/kg body
weight intravenously.
Contraindication:
Hypersensitivity to aminoglycoside antibiotics, pregnancy and breast-feeding.
Special precaution:
In high plasma concentrations of the drug there is an increased risk of ototoxicity and kidney
toxicity, because of which a monitoring of the pick plasma concentration is advised Amikacin
should be prescribed with increased caution in patients suffering from parkinsonism, diseases
of the auditory nerve, myasthenia gravis, severe renal and hepatic insufficiency. In cases of
prolonged treatment, regular checks of the state of hearing and creatinine clearance are
advised. The treatment should be discontinued in cases of loss of hearing of high frequency
sounds.
Adverse reaction:
After prolonged treatment with Amikacin the most common adverse effects are the
nephrotoxicity and the ototoxicity. The manifestations of ototoxicity are vestibular toxic
changes (in balance) and cochlear toxic changes (loss of hearing associated with a sensation
for pressure and noise in ears and decreased perception of high frequency sounds). After
concurrent administration of Amikacin and other nephrotoxic drugs renal failure can be
developed. Relatively rare the following adverse effects can be seen: allergic reaction,
nausea, vomiting, stomatitis, blood changes, depression of respiration, and muscle pareses.
Date on:
26th October 2016
49
Date off:
31th October 2016
50
CEFOTAXIME 200mg BD
Generic Name:
CEFOTAXIME SODIUM
Brand Name:
Cefotaxime, Claforan
Route:
Intravenous
Indication:
Neonatal meningitis and Empirical therapy in infants with suspected sepsis who have
previously received multiple courses of antibiotics.
Dose:
50mg/kg every 12 hour.
Contraindications
History of hypersensitivity to cephalosporins or major allergic response to a penicillin.
Precautions
Renal impairment: cefotaxime has a high renal clearance, therefore reduce dose in moderate
to severe renal impairment. This is particularly important for lower birth weight infants, as
the pharmacokinetics of cefotaxime are influenced by birth weight.1, 2
Possible Adverse Effects
Vomiting, diarrhoea; pseudomembranous colitis, rarely
51
Rash, pruritis, urticaria.
Transient disturbance of hepatic enzymes.
Thrombocytopenia, eosinophilia, leucopenia.
False positive Coombs test.
Superinfection with non-susceptible organisms including fungi.
Encephalopathy, especially with high doses in renal insufficiency.
Special Considerations
Monitor renal and hepatic function.
Date on:
25th October 2016
Date off:
31th October 2016
52
Curosurf 100mg/kg stat

Route: Intratracheal
Indications:
Curosurf is indicated for prevention and treatment ("rescue") of Respiratory Distress
Syndrome (RDS) (hyaline membrane disease) in premature infants. Curosurf significantly
reduces the incidence of RDS, mortality due to RDS and air leak complications.
Dose:
100mg/kg birth weight intratracheally up to 200mg/kg in between 12 hours. Doses should not
be given more frequently than 6 hrly. To be administered as soon as possible. Prevention in
premature infant <1250 g birth wt or without evidence of surfactant deficiency preferably
within 15 mins of birth. Rescue preferably by 8 hr of age. Miss Y was already 10 hours of life
and CXR shows Ground glass looks, it is an evidence for RDS.
Contraindication:
None known.
Special precaution:
If an infant experiences bradycardia or oxygen desaturation during the dosing procedure, stop
the dosing procedure and initiate appropriate measures to alleviate the condition. After the
infant has stabilized, resume the dosing procedure. Rales and moist breath sounds can occur
transiently after administration of Curosurf. Endotracheal suctioning or other remedial action
is unnecessary unless clear-cut signs of airway obstruction are present.
53
Adverse reaction:
Transient bradycardia. O2 desaturation
Date on:
25th October 2016
Date off:
25th October 2016
54
DOPAMINE 0.2 mls/hour = 10mcg/kg/min infusion

Generic name: DOPAMINE HYDROCHLORIDE
Brand Name: Dopamine
Route:
Intravenous Continuous Infusion
Should be administered via a central line (UVC, Longline, or Surgical CVL).
If no central access available, use a cannula in a large vein.
-
Administered by a nurse with Neonatal IV Drug Certification.
Discoloration of solution (yellow, brown, pink, purple) indicates decomposition and

should be discarded.
Dilute 30 mg/kg (0.75 ml/kg) dopamine to make 50ml with NS or D5W - 1 ml/hour =
10 micrograms/kg/minute.
Compatible with sodium chloride 0.9%, glucose 5% and glucose 10%
Compatible at Y injection site with dobutamine, morphine, heparin, PGE1.
Incompatible with acyclovir, indomethacin, insulin, frusemide,, sodium bicarbonate

and other alkaline solutions including phenytoin. No information available on IVN,
therefore avoid co-infusion if possible.
Do NOT mix with any other drug, blood, or blood products. Do NOT flush line.
Administer via a syringe pump.
Change fluid and tubing every 48 hours or earlier if solution is discoloured.
55
Indication:
To improve cardiac output, blood pressure and urine output in critically ill infants with
hypotension.
Dose and Administration
-
2-20 micrograms/kg/minute by continuous IV infusion1.
Begin at a low dose and titrate by monitoring clinical response.
Maximum recommended dose 20 micrograms/kg/minute..
Administer via a central line (UVC, Longline, or Surgical CVL). If no central access
available, use a large vein.
Usual dilution 30 mg/kg (0.75 ml/kg) dopamine to make 50 ml with Normal Saline or
D5W
1 ml/hour = 10 micrograms/kg/minute.
Dopamine (mg) in 50ml IV solution =
3 x weight (kg) x dose (micrograms/kg/min)

IV Rate (ml/hr)
Contraindications
-
Hypersensitivity to sympathomimetic amines and sulfites.
Uncorrected tachyarrhythmias.
56
Venous irritation, soft tissue injury at the site of IV injection.
Vomiting, tachycardia, vasoconstriction, hypotension.
Infusions > 20 micrograms/kg/minute are associated with an increased risk of

dysrhythmias eg. tachycardia and, bradycardia, and vasoconstriction1
Less common: bradycardia, hypertension.
-
Dosage range is determined by type of desired clinical effect. Start at the lower end of
the desired range and titrate according to clinical response.
Volume loading is considered before commencing dopamine infusion.
Use with caution in patients with persistent pulmonary hypertension of the newborn.
Suggested treatment for tissue sloughing following IV infiltration: inject a 1 mg/ml

solution of phentolamine into the affected area. The usual amount needed is 1-5 ml,
depending on the size of the infiltrate.
General anaesthetic: increased risk of arrhythmias or hypertension.
Phenytoin may lower blood pressure.
Acidosis decreases effectiveness of dopamine.
Administration via the UAC is not recommended
Nursing Considerations
Monitor for adverse reactions.
-
Observe closely for IV filtration; discontinue immediately and notify doctor/NS-ANP.

Avoid extravasation of drug as may cause necrosis and tissue sloughing.
57
Assess colour and temperature of extremities & Monitor urinary output.

-
Continuous blood pressure monitoring. If a disproportionate rise in diastolic pressure

(decreased pulse pressure) notify doctor/NS-ANP immediately.
Continuous cardiorespiratory monitoring & Document vital signs hourly and PRN.
Date on:
25th October 2016
Date off:
28th October 2016
58
DOBUTAMINE 2 mls/hour = 10mcg/kg/min infusion

Generic name: DOPAMINE HYDROCHLORIDE
Brand Name: Dopamine
Route:
Intravenous Continuous Infusion
Should be administered via a central line (UVC, Longline, or Surgical CVL).
If no central access available, use a cannula in a large vein.
-
Administered by a nurse with Neonatal IV Drug Certification.

Discoloration of solution (yellow, brown, pink, purple) indicates decomposition and
should be discarded.
Dilute 30 mg/kg (0.75 ml/kg) dopamine to make 50ml with NS or D5W - 1 ml/hour =
10 micrograms/kg/minute.
Compatible with sodium chloride 0.9%, glucose 5% and glucose 10%
Compatible at Y injection site with dobutamine, morphine, heparin, PGE1.
Incompatible with acyclovir, indomethacin, insulin, frusemide,, sodium bicarbonate
and other alkaline solutions including phenytoin. No information available on IVN,
therefore avoid co-infusion if possible.

Do NOT mix with any other drug, blood, or blood products. Do NOT flush line.
Administer via a syringe pump.
Change fluid and tubing every 48 hours or earlier if solution is discoloured.
Indication:
Inotropic agent used to increase cardiac output. Cardiovascular shock
Dose and Administration
59
1. 2-25 micrograms/kg/minute by continuous IV infusion.

2. Begin at a low dose and titrate by monitoring effects.
3. Administer via a central line (UVC, Longline, or Surgical CVL). If no central access
available, use a large vein.
4. Usual dilution 30 mg/kg (2.4 ml/kg) dobutamine to make 50 ml with NS or D5W
1 ml/hour = 10 micrograms/kg/minute.
3 x weight (kg) x dose (micrograms/kg/min)
Dobutamine (mg) in 50ml IV solution =
IV rate (ml/hr)
Maximum concentration = 5 mg/mL
Contraindications
-
Hypersensitivity to sympathomimetic amines and sulfites.

Uncorrected tachyarrhythmias.

-
Venous irritation, soft tissue injury at the site of IV injection.

Vomiting, tachycardia, vasoconstriction, hypotension.
Infusions > 20 micrograms/kg/minute are associated with an increased risk of
dysrhythmias eg. tachycardia and, bradycardia, and vasoconstriction1

Less common: bradycardia, hypertension.
-
Volume loading is recommended before commencing dobutamine infusion.
Renal dysfunction: no dosage adjustment necessary.
Clinical experience with dobutamine in neonates is limited. Whether dobutamine has
any consistent advantages over dopamine in the treatment of a neonate with
60
myocardial dysfunction remains to be established.
Beta blockers may antagonise dobutamine effect.
General anaesthetics: greater incidence of ventricular arrhythmias.
Dobutamine should not be used with agents containing sodium bisulfite.
Date on:
25th October 2016
Date off:
27th October 2016
61
ROCURONIUM 1mg STAT and PRN if Baby agitated

DESCRIPTION
A non-depolarizing neuromuscular blocking agent that produces skeletal muscle paralysis
mainly by competitively attaching itself to the cholinergic receptors on the end-plates
responsible for transmitting signals to the bodys voluntary muscles. USE Skeletal muscle
paralysis in infants requiring mechanical ventilation paralysed infants should always be
sedated.
DOSE AVAILABLE:
50mg/5ml ampoule
PHARMACOKINETICS
Onset of action is 1-10 min and recovery may take up to an hour. The mean half life is 1.3
hours in infancy and is not greatly affected by renal dysfunction. Mostly eliminated by the
liver and biliary system, but up to a quarter is eliminated unchanged in the urine.
DOSE IV BOLUS
Initial 600mcg/kg/dose Maintenance 300mcg/kg/dose 2-4 hourly as needed.
ROUTE IV
infusion, IV injection, IM injection
RECONSTITUTION
Add 1ml of Rocuronium (10mg) to 4ml of 0.9%sodium chloride or 5% dextrose to make
2mg/ml solution.
62
NURSING CONSIDERATION
MONITORING Continuous cardio-respiratory and arterial blood pressure monitoring. Infant
must be on mechanical ventilation.
ADVERSE EFFECTS
-
Hypoxemia from inadequate mechanical ventilation and altered pulmonary
mechanics.
Tachycardia and blood pressure changes both hypotension and hypertension.
Increased salivation and nausea. 4. Arrhythmias.
Date given:
-
25th October 2016@1600H

63
64
Morphine infusion
4.8
Other treatment
Care procedures and treatments should coincide and be kept to a minimum - known as
minimal handling or cluster care - (Turrill, 2002), as sick infants can react to any disturbance
by becoming hypoxic. Crying (or silent crying in the case of an unsedated ventilated infant)
causes irregular respiration and compromises ventilation, increases pulmonary artery pressure
and shunting, lowering oxygen levels (Sparshott, 1994).
Endotracheal suction
Endotracheal suctioning to maintain airway patency is a necessary component of care for the
intubated baby. It removes secretions, while preventing obstruction that can lead to atelectasis
and decreased lung compliance. As suctioning is traumatic (infants may become bradycardic
or hypoxaemic, and it can damage the trachea), it should be instituted with great care and
only when absolutely necessary, based on clinical findings. It is a sterile procedure. Debate
surrounds the use of instilled normal saline prior to suction (McCormack, 2003).
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 37C to minimise oxygen consumption and acidosis. Peripheral temperature should be
maintained above 36C - a fall below 34C is indicative of underperfusion, which may be due
to hypovolaemia or infection. To minimise 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.
65
Fluid and electrolyte balance

Fluids should be administered intravenously during the acute stages of RDS either through an
umbilical line or a peripheral long line if the infant is small and sick. For bigger babies who
require only short-term ventilation, a peripheral cannula may suffice. Dextrose 10 per cent is
used for the first 24 hours, usually followed by total parenteral nutrition, to which electrolytes
can be added according to blood tests. Although full enteral feeding will probably be
withheld, gut-priming with 1mL or so of breast milk every four hours is usually
recommended. This is slowly increased as the babys condition improves.
Complications
Complications of RDS are pneumothorax, pulmonary interstitial emphysema, persistent
pulmonary hypertension, necrotising enterocolitis, intraventricular haemorrhage, and patent
ductus arteriosis (Johnston et al, 2003).
The most common sequela of RDS is chronic lung disease or bronchopulmonary dysplasia.
This has been defined as the requirement of supplementary oxygen after 28 days from birth,
or additional oxygen in a prematurely born infant after 36 weeks postmenstrual age (time
since the mothers last menstruation). Steroids reduce the duration of mechanical ventilation
and improve lung function (Speidal et al, 1998).
Oxygen is essential in managing bronchopulmonary dysplasia to reduce apnoea and
bronchospasm; inadequate oxygenation can cause heart failure. When infants are discharged
while still receiving low-flow oxygen, an apnoea monitor should accompany them, and their
66
parents should be taught how to use it. The parents should also be taught how to perform
cardiopulmonary resuscitation (Jevon and Henley, 2002).
67
Poor growth and poor weight gain are often related to persistent hypoxaemia, so vigorous
attention should be paid to optimal nutritional care. Cerebral palsy and learning difficulties
are also long-term complications.PATIENT PROGRESS
On 24th July @ 2345H
Transfer in case from KPJ Selangor, new born female 10 hours of life.
On arrival baby looks very ill. Central cyanosis. Spo2 <20%. Intubated with size 3 marking at
9 cm, manually ventilation by consultant KPJ Selangor, Fix on ventilator leaking >30% With
fio2 1.0, Rate 50 bpm, PEE 8, PIP 30. SB Dr. Q, took history from KPJ Selangor Consultant.
CXR from KPJ Selangor reviewed by Dr Q.
On 25/10/16@ 0020H
Parameter as charted. NIBP 66/44 mmhg. Spo2 23% on high ventilator setting. Plan for
reintubated. Spo2 dosents pick up event manually bagging by Dr Q.OGT size 6 inserted. A
lot of Air coming out. No bleeding seen. IV Morphine 400mcg given as ordered. CXR done
and result noted Dr Q. Reintubated with size 3.5 marking at 9 cm. no bleeding noted.
On 25/10/16@ 0010H
Another CXR taken. Plan for UAC and UVC insertion. Sedated baby with morphine infusion
3.8mg/50 cc D5% at 1 mls/ hour= 20 mcg/kg/hour. IVD started D10% at 9.5 mls/hour. fluid
resus 50mls N/saline given as ordered. Curousorf 400mg given through ETT by DR Q. Spo2
increasing till >95%, noted pinkish in color, Parameter more stable. UVC inserted with size5
marking at 11cm and UAC inserted with size 3.5 marking at 20cm. Blood C&S, ABG and
Blood test taken as order. All the infusion changes to UVC. Total fluid requirement was
60mls/kg/day=9.5 mls/hour. IVD Dextrose 10% at 8 mls/hour, Infusion Morphine at
68
1mls/hour, UAC flushing at 0.5mls/h. For Blood test, CXR and ABD X ray this morning.
Order to gradually reduce fio2 till spo2 remaining around 92%.
-
Keep body temperature at 33- 34

keep mean ABP more than 45 mmhg, to reduce morphine infusion to 10 mcg/kg/hour.
If mean ABP less than 45 mmhg then start dobutamin infusion as order
On 25/10/16@ 0200H
Spo2 96%, ABP 57/ 42 mmhg with mean bp 49mmhg. Reduce fio2 0.92, Moving limbs on
and off, body warm but extremities cold to touch, cont. treatment.
On 25/10/16@ 0300H
Fio2 reduce to 0.85, spo2 maintain more than 95% heart Rate reduce till 100 -110 per minute,
mean ABP maintain more than 45 mmhg, Reduce morphine infusion at 0.5 ml as per hour=
10 mcg/kg/h. Cont. treatment.
On 25/10/16@ 0400H
Reduce fio2 0.5, spo2 maintain 100% HR: 108/minute moving limbs on and off. Parameter
stable. Cont. treatment.
69
On 25/10/16@ 0700H
Day 2 in NICU
Day 1 of life
Diagnosis: Birth Asphyxia
Consultant DR. Q
Birth weight:3.77kg- girl
Fluid requirement 60mls/kg/day
Ventilation support mode PTV, fio2 0.3, rate 60 bpm, PEEP 8, PIP 30, Ti 0.5
Taken over report, check on baby on IPPV support, mode and setting same as above,
presented:
-
UAC size 3 marking at 20 cm- intact with flushing at 0.5 mls per hour
UVC size 5.5 marking at 11 cm,IVB times 1 at left hand- spigot
IVD- dextrose 10% at 8.5 mls per hour- progress well via uvc, infusion morphine (3.6
mg/ 50cc dextrose 5%) at 0.5 mls /hours. Ogt size insitu- spigot
Parameter as charted ABP 66/40 mmhg, MABP >45mmhg, HR:100-110 bpm, spo2
98-100%
Air entry equal bilaterally with good chest expension, intermittently with good breathing
effort, upper and lower limb bluish- poor perfusion- bluish spot seen at forehead-? birth
mark,otherwise strictly hand hygiene with minimal handling.cont. incubator nursing care
On 25/10/16@ 0830H
Review by Dr IQ update baby condition, explanation given, examine baby, noted blood
result. Noted CXR n ABDO XRAY, plan readjust UAC to 18 cm marking, readjust ogt about
6 cm-pull out, Reduce PIP to 18, Reduce PEEP to 6, For CXR and ABDO XRY post
procedure. While doing procedure baby desaturated till 40%, increase fio2 till 0.7, slowly
70
pick up. Upper and lower limb bluish till- poor perfusion, otherwise observe for bleeding,
cont. current treatment
On 25/10/16@ 0900H
Visited by father. Update baby condition, explanation given, look anxious talking and
touching the baby.
On 25/10/16@ 1230H
Attended baby, all care rendered. Parameter as charted, MAP >45 mmhg, HR: 100-110bpm,
spo2: 100%, temperature 35. Air entry equal bilaterally with good chest expansion. Vte 1416mls, no sign and symptom of bleeding from umbilical site. Suction done, moderate amount
of secretion from ETT and oral nasal., Diapers change noted NPU still and BNO. Rang up Dr.
Q update baby condition, plan: For IV NACL bolus 50 mls over hour. Otherwise cont.
current treatment
On 25/10/16@ 1330H
Check on baby. Desaturate ,80%, vte:7-8 mls, all air entry equal bilaterally with good chest
expansion, Suction performed. Thick, whitish with old blood stain. ABG done- result as
charted, increase PIP to 30, increase PEEP to 8, spo2 still not pick up: 40- 60%, range up D
Q, update baby condition, for urgent CXR.
On 25/10/16@ 1430H
Attended by Dr Q, noted CXR, decided to pulled out ETT to 8.5cm marking at lips, suction
done by dr Q, secretion in thick, moderate amount. Planned Increase fio2 to 0.95%, Increase
rate to 70 bpm, Reduce PEEP to 6, spo2 pick up >90%, vte:14-16mls, Kiv HFOV.
On 25/10/16@ 1530H
Baby condition not sustained, desaturated <80%, increase fio2 to 1.0%, MAP= 40-45mmhg
71
Range up Dr IQ, noted baby condition, for infusion dobutamine (60 mg/50cc Dextrose5%)
run at 2mls/hour=10mcg/kg/min, will review patient soon
On 25/10/16@ 1600H
Review by Dr. Q, examine baby. Planned for infusion dopamine started at
0.2mls/hour=10mcg/hour. Put baby on HFOV: fio2 1.0%, Iv Esmeron 500mcg if baby awake
and fighting ventilation, repeat ABG 1 hour, otherwise cont. same
On 25/10/16@ 1700H
Review by Prof zulkifli, ECHO done- normal CVS, no special order
On 25/10/16@ 1730H
ABG done- result as charted, Range up Dr noted ABG, parameter as charted, baby still
desaturated till 50%, IV esmaron 500mcg given as ordered
On 25/10/16@ 1900H
Review by dr Q, update baby codition, explanation given, examine baby, adjust ventilator
setting, readjust UAC marking, for portable cxr and abdo Xray, increase infusion dopamine to
0.4mls/hour since MAP: 40-43mmhg. Kiv another curosuf tonight, otherwise will review
soon. Parameter as charted MAP:43mmhg, HR 180=188bpm, spo2 80-85%. Ventilator setting
remain same.
72
Night shift
On 25/10/16@ 2115H
Took over case, baby critically ill. Still on IPPV support, HFO mode: fio2 1.0%, rate Delta P:
mean. Chest wiggle seen due to HFOV mode, ETT size 3.5 marking at 8.5cm, UVC size 5
marking at 11cm.
-
IVD- dextrose 10% at 10.6 mls/ hour,

Infusion morphine (3.8mg in 50cc Dextrose 5%) at 0.5 mls/hour=10 mcg/kg/hour.
Inf Dobutamine (60mg in 50 mls dextrose 5%) at 2 mls/ hour=10mcg/kg/hour
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.4 mls/hour= 20 mcg/kg/h
UAC size 3.5 marking at 12cm- Heparine saline 5 mls plus 45 mls Nacl at 0.5mls/hour
Ogt size 6 marking at 33cm-keep free flow, baby keep NBM, on and off moving limb but
baby not fighting, ABP 68/34mmhg (48) HR:170-173bpm, spo2 83-92%, Dco2 1777, father
around, update baby condition.
On 25/10/16@ 2300H
Temperature:38.0. Condition baby same, PU done, BNO, asp Nil, UAC and UVC intact
Urine output:4mls= 0.2mls/kg/hour
*fluid resus given at 2100hour 50mls Nacl to observe
On 25/10/16@ 2330H
ABG noted to Dr via phone, PH:7.327, Pco2:37.3, PO2:34:BE :-6, Glucose :4.0mmol/L
-
Change IV drip dextrose 12.5%

Maintain total fluid 90mls/kg/day
May suction baby if DCO2 reduce until 700
If baby struggle to give IV esmaron as prescribe
On 25/10/16@ 2400H
ABP: 68/32mmhg (47) HR: 170-173bpm, spo2 83-92%, DCO2:1572
73
All infusion on progress, cont. care

On 26/10/16@ 0130H
Spo2 82%, baby awake. IV esmaron given 500mcg, to observe baby closely,
ABP:70/34mmhg(50) HR:163bpm, Spo2 87%, Dco2: 11455
On 26/10/16@ 0250H
Noted Dr Q via phone regarding urine output nil since 2330H, ABP:72/33mmhg(49), no
futher order just monitor baby condition remain same on and off moving limb, spo2 82-85%.
On 26/10/16@ 0400H
Sudden spo2 drop until 70%, baby dusky, suction done, thick at ETT light yellowish
moderate amount, thick, whitish oronasal small amount. Slowly spo2 pick up until 83% , PU70 mls BNO.
On 26/10/16@ 0515H
Spo2 still low. 72-85%, ABP: 70/38mmhg (51) HR 166 bpm, all infusion on pregress, baby
resting, condition remain same.
74
Morning Shift
On 26/10/16@ 0700H
Day 3 in NICU
Day 2 of life
Diagnosis: Birth asphysia, RDS
Consultant: Dr. Q
B.Wt: 3.77kg- girl
Took over case, baby critical ill, still on IPPV support, HFO mode, Fio2:1.0, Rate :9, Delta
P:58, mean :20, chest wiggle seen due to HFOV mode, ETT size 3.5 marking at 8.5cm, UVC
size 5 marking at 11cm on progress:
IVD dextrose 10% at 10.6 mls/h
-
Infusion morphine (3.8mg in 50cc Dextr 5%)at 0.5ml/hour=10mcg/kg/hr

Infusion Dobutamine (60mg in 50 mls Dextrose 5%) at 2 mls /hour=10mcg/kg/h
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.4 mls /h=20mcg/kg/h
UAC size 3.5 marking at 12cm:

-
Heparine saline 5mls plus 45mls Nacl at 0.5ml/h.
OGT size 6 marking at 33cm- keep free flow, baby still NBM. On and off moving limb and
open both eyes, not fighting, ABP:72/33mmhg (53) HR:174bpm, spo2: 90-95%, DCo2:1777.
Dr Q around, assess on baby, change ventilator to PTV mode, baby desaturated, change back
to HFO again.
On 26/10/16@ 0810H
75
-S/B Dr Q, Took blood for LFT, BUSE, LACTATE, FBC, CRP and order CXR, If baby
vigorous fight to give iv esmaron as per cardex, to trace culture, wean infusion dopamine to
10 mcg if MAP persistently more than 55mmhg, kiv repeat surfactant after CXR.
On 26/10/16@ 0900H
Awaiting for CXR, ABP:71/36mmhg(50)HR:175bpm, RR:9(60)
On 26/10/16@ 1030H
Noted to Dr.Q blood result, Ask to review CXR and noted SPo2 60%, DCO2:>1200.
On 26/10/16@ 1040H
Called Dr Q, noted spo2 dropping to 50%, Dr Q called back noted no pneumothorax on CXR,
Its RDS still, meaning, the lung getting stiff, order to give surfactant 200mg/kg, to get ready.
Increase pressure to 22, ABP: 81/39mmhg (57), HR:140bpm
On 26/10/16@ 1130H
Still awaiting Dr. Q, Spo2 probe adjust to both hand and legs, Spo2 still 50-68% range.
On 26/10/16@ 1200H
Seen by Dr IQ, examine baby
-
To tilt down dopamine to 10mcg/ kg/hour if MAP>55mmhg (persistently)

If baby vigorous to give iv esmaron as per cardex
To trace blood C&S
Dr Q give curosof 1.5 mls x 4 bottle, to observe gradually
To start IV midazolam @ 1mls/hour (120 mcg/kg/h)
If MAP drop to off IV morphine
Start iv Amikacin as per cardex (monitor urine output daily, if urine output 24hour<
1mls. /kg/hour- omit)
On 26/10/16@ 1230H
Both upper and lower limb looks pink, Spo2 increase gradually to 92%. Visited by parent,
condition updated, suggest to see Dr Q for more detail.
76
On 26/10/16@ 1345H
Baby remain stable, spo2 94%, ABP: 92/50mmhg (66), reduce IV dopamine to 0.3 mls/h.
Afternoon shift
On 26/10/16@ 1430H
Took over case, baby critically ill, still on IPPV support HFOV mode, FIo2:1.0, Rate:9, Delta
P:60-70, mean:24. Chest wiggle seen due to HFO mode
-
ETT size 3.5 marking at 8.5cm, UVC sz 5 marking at 11cm

IVD dextrose 10% at 10.6 mls/hour
Infusion morphine (3.8mg in 50cc Dextr 5%)at 0.5ml/hour=10mcg/kg/hour
Infusion Dobutamine (60mg in 50 mls Dextrose 5%) at 2 mls /hour=10mcg/kg/hour
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.4 mls /hour=20mcg/kg/hour
Infusion midazolam (25mg in 50cc dextrose 55) at 1 mls/hour- just started @
1230hour
UAC size 3.5 marking at 12cm- Heparine saline 5mls plus 45mls Nacl at 0.5ml/h.
OGT size 6 marking at 33cm- keep free flow, baby keep NBM
On and off moving limb and open both eyes, not fighting, ABP:82/45mmhg (60)
HR:137bpm, spo2: 90-95%, DCo2:1426. Dr Q around assess on baby, ordered to reduce
fio2 gradually as spo2 >95%. Parent around, talk and touch the baby.
On 26/10/16@ 1600H
Attended to baby, pink and warm to touch, temp 38.0 gradually reduce fio2. All infusion in
progress, baby look sedated, Pu minimal-0.2 mls/kg/h. to observe. Mean bp started to drop
50-55mmhg, observe aspiration nil.
On 26/10/16@ 1730H
Noted Dr Iq regarding the MAP < 50mmhg. Spo2> 95% with fio2 75%, cont. same just obese
mean pressure ventilator. Still the same @ 24, others cont, same
77
On 26/10/16@ 2000H
Parameter stable. Otherwise DCO2> 1200. Baby pink, warm. Temp: 37.5, no sign of having
secretion, no suctioning done. Iv line intact flushed, all medication infusion in progress
(morphine already off @ 5pm). Still sedated but move hand and leg once touch the baby.
Aspiration nil. Abdomen looks slightly distended but soft still NPU, bladder hard, try to
stimulate but still no urine came out, baby looks uncomfortable once palpated, urine catheter
inserted with feeding tube size 5, urine pouring good, otherwise baby still on IPPV support
with
same
setting
and
mode.
Fio2:0.60.
parameter:
SABP:65/40
(50)mmhg.
HR:129bpm.97%.
78
Night shift
On 26/10/16@ 2130H
Taking over report, baby critically ill but pinkish in color, keep HFO with same setting,
sedated with Dormicum infusion (25mg/50cc D5%) @ 1mls/ h= 120 mcg/kg/hour. Parameter
as charted, body temperature around 37.7- 38. Mean BP > 50mmhg :
-
dopamine infusion (14mg/50 cc d5%)@0.4mls/h=20mcg/kg/min

Dobutamin infusion (60mg/50cc D5%)@ 2 mls/ h=10mcg/kg/min
Uac and uvc intact, IVF 12.5% Dextrose @10.1mls/h
Good urine output 2-6mls/kg/h after CBD insertion, Continue treatment2330H
Received call from Dr. Q update baby condition, reduce dopamine infusion at 10mcg/kg/min.
keep Mean BP>46mmhg. Increase IVF to 10.3mls/hour.
On 26/10/16@ 2245H
ABG taken as orderd. Result: PH: 7.518, Pco2:22.5, Po2:192, BE:-5, HCO3: 18.3.
On 26/10/16@ 2250H
Called up Dr Q. Noted ABG result. Order to reduce Delta P to 60, Reduce Mean to 22, Aim
Dco2 around 1100, Repeat ABG after 1 hour.
On 26/10/16@2245H
SB parents, looks sad but understand baby condition., updated baby condition, continue same
treatment.
On 26/10/16@ 2330H
Baby stable. Touching by mother, parameter as charted, cont. same treatment
On 27/10/16@ 0005H
ABG taken as order. Result: PH: 7.454, PCo2:25.4,Po2:184, BE:-6, Hco3:17.9
79
Call up Dr IQ, Update baby condition. Noted ABG result. Ordered: To reduce Delta P to 55
Mean reduce to 20, Repeat ABG after 1 hour. Action taken. Baby still accompanied by
parents. Updated current status to parents, cont same.
On 27/10/16@ 0120H
Parameter stable. Noted Mean Bp level increase 55-60mmhg, already reduce dopamine
infusion to 5 mcg/kg/min, Brought in EBM by father, good production. ABG result taken as
order. Result: PH: 7.390, Pco2: 30.3, Po2: 123, BE: -7, HCO3:18.4. Called up Dr Q, Noted
ABG result, planned to reduce Delta P to 50, remain mean 20, Remain dopamine infusion
5mcg/kg/min, Reduce Dobutamine infusion to 5mcg/kg/ min=1mls/hour. Action taken:
increase IVF to 11.4 mls/hour
On 27/10/16@ 0200H
Attended baby, Body temperature 36.7 degree, whole body cold to touch, perfusion at upper
and Lower extremities bluish and mottling. Noted ABP increase 60-70mmhg, HR: 110120/min. Spo2 69-93%. DCO2 around 650-1000. Increase Fio2 to 0.5 for the time being.
Checked pampers, BNO, urine output 0.9mls/kg/hour. Iv branular checked. Intact, IV
antibiotic given as prescribed, Cont. Treatment.
On 27/10/16@ 0230H
Now much better and more stable, Spo2 increase to 100%, Reduce Fio2 to 0.4, HR: 130140/min, mean BP 50-55mmhg, Dco2 increasing around 800- 1000, cont. same.
On 27/10/16@ 0250H
80
Noted baby agitated, HR: 140-160/min. Mean BP 60-70 mmhg, Spo2 80- 90%, DCo2 700900., Esmaron 500mcg given as ordered, to observe.
On 27/10/16@ 0320H
Spo2 around 89-90%, Dco2 around 500-600. Noted secretion in ETT seen. Attended baby,
Oral tracheal suction done with large amount light yellowish thick secretion from ETT and
large amount thick mucoid secretion from orally, Noted Dco2 increasing 900-1000 and spo2
increase 90-100% during procedure, baby more calm and looks comfortable after suction,
parameter stable.
On 27/10/16@ 0445H
Sleep on and off spo2 >92%, Dco2 900-1000, mean BP 60-70mmhg. HR:138/min. cont.
same.
On 27/10/16@ 0530H
S/B father. Updated baby condition, brought EBM, Good production.
On 27/10/16@ 0630H
Attended baby, awake, DCo2 900-1000, SPo2 89-95%, Change pampers again, BO large
amount meconium. Noted CBD out, Removed CBD, baby more comfortable after taken out
CBD, con. Same.
81
27th Oct 2016

Day 3 in NICU
Day 2 of life
Diagnosis: Birth asphysia, RDS
Consultant: Dr. Q
B.Wt: 3.77kg- girl
Fluid requirement- 110mls/kg/day
Ventilation mode HFOV, fio2 0.4, Rate:9, Delta P:50
On 27/10/16@ 0700H
Taken over report, checked baby on IPPV support, Mode and setting same as above,
presented:
-
UAC sz 3.5 marking at 12cm- intact with Heparine saline flushing 5mls plus 45mls
Nacl at 0.5ml/h.
Uvc sz 5.5 marking at 11cm
IvB x1 at lt hand- spigot
IVD dextrose 10% at 11.4 mls/h- progress well via UVC
Infusion Dobutamine (60mg in 50 mls Dextrose 5%) at 1 mls /hour
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.1 mls /h
Infusion Midazolam at 1.0 mls/ h
OGT sz 6 marking at 33cm- spigot
Parameter as charted
ABP:66/40, MABP>50 mmhg, HR:110-120bpm, Spo2> 92%, air entry equal bilaterally with
good chest expansion, Chest vibration symmetry. Upper and Lower limbs looked bluish- poor
82
perfusion, bluish spot seen at forehead ? birth mark, noted baby looks jaundice,
otherwisestrictly hand hygiene with minimal handling, cont. incubator nursing.
On 27/10/16@ 0830H
Reviewed by Dr. Q updates baby condition, explanation given, noted ABG result with
potassium 3.5 mmol/L, planned:
-
Reduce fio2 to 0.3%

Reduce Delta P to 40
Reduce Mean to 17
Off infusion Dobutamine
Increase total fluid to 110 mls/kg/day:17 mls/hour
Change IVD to saline 10% Dextrose + 3.6 mls of KCL
ABG at 1100hour
For phototherpy
On 27/10/16@ 0900H
Visited by parent, Explanation given, bring along EBM about 20 mls, looked anxious,
reassurance given, talking and touch the baby
83
On 27/10/16@ 1200H
Attended baby, all care rendered, ABG done- result as charted, parameter as charted
MAP:45-50 mmhg, HR:110-120bpm, Spo2:100% Suctioning done, secretion thick, large
amount and whitish from ETT tube and moderate whitish, thick from aral nasally.,
diaperse change, urinate well, Box 1 in large amount, IVD maintain at 15.4mls/h.
Infusion dopamine at 0.1mls/h, comfort the baby and cont. care.
On 27/10/16@ 1330H
Rang up Dr. Q, updates baby condition, Noted ABG result, no special order, cont. care.
On 27/10/16@ 1400H
Visited by mother. Bring along EBM, updates baby condition. Explanation given, talking
and touch the baby. Review by Dr. Q at the same time explained to the parent treatment
plan of their baby.
-
Wean Delta P and MAP

Try to reduce MAP to 15, baby desaturated till 80%
Maintain SPO2>92%, otherwise cont care
On 27/10/16@ 1730H
Attended to baby, all care rendered, parameter as charted, MAP>45mmhg, HR:120-130bpm,
SPO2 88-95%. Chest vibration symmetrically, suction done, secretion large amount, thick
and whitish from ETT, moderate whitish from oral nasally, diapers change- urinate well, BO
x1 in moderate amount, SPO2 78-81% post suction, DCO2 700-800, increase Mean pressure
to 16, observe baby condition.
On 27/10/16@ 1830H
84
Attend another suction, secretion remain same, Spo2 gradually picked up more than 85%,
DCO2: 900-1000, parameter as charted MAP: 45-50mmhg, HR: 130-140bpm, chest vibration
symmetry, cont care
On 27/10/16@ 2000H
Checked on baby, condition same, parameter as charted, MAP: 48mmhg, HR: 130 bpm,
Spo2:94%, mode and ventilator setting as charted, HFOV mode, Fio2:0.3%, Rate:9, Delta
P:40, Mean:15, ivd progress well at 15.4/h, infusion dopamine at 0.1mls/ hour, Infusion
midazolam at 1 mls/hour. Visited by mother, bring along EBM and updated baby progress,
touch and talking to the baby.
85
27th Oct 2016

Day 4 in NICU
Day 3 of life
Diagnosis:Birth asphysia, RDS
Consultant:DR Iq
B.Wt: 3.77kg- girl
On 27/10/16@ 2115H
Took over case, baby ill but stable, still on IPPV support, HFO mode, Fio2:0.3, Rate :9, Delta
P:40, mean :16, chest weegle seen due to HFOV mode,
-
ETT size 3.5 marking at 8.5cm

UVC sz 5 marking at 11cm
IVD saline dextrose 10% at 15.4 mls/h
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.1 mls /h=5mcg/kg/h
Infusion midazolam (25mg in 50cc Dext 5%) at 0.1 mls/ h= 5mcg/kg/h
UAC sz 3.5 marking at 12cm- intact with Heparine saline 5mls plus 45mls Nacl at
0.5ml/h.
OGT sz 6 marking at 33cm- keep free flow, baby keep NBM
On and off moving limb but not fighting, on phototherapy started at 1000hrs.
ABP:68/34mmhg (45) HR:130-140bpm, spo2: 88-92%, DCo2:782, mother still around,
updated condition satisfied
On 27/10/16@ 2330H
Temp: 37.2. condition remain same, Pu- urine output good, BNO, Aspiration Nil
86
UAC and UVC intact, suction done, ETT whitish large amount, oronasal whitish moderate
amount, desaturated until 70% during suction, increase fio2 :40%, ABP:62/32mmhg (44) HR:
230-140bpm, spo2: 92-94%, DCo2:954. All infusion on progress, cont care
On 27/10/16@ 0130H
ABP:68/34mmhg(48) HR: 136bpm, spo2:94%, DCo2 759, sleeping and looks comfortable,
cont phototherapy.
On 28/10/16@ 0730H
Day 5 in NICU
Day 4 of life
Consultant:DR Iq
B.Wt: 3.77kg- girl
Took over case, baby critical ill but stable, still on IPPV support, HFO mode, Fio2:0.3, Rate :
9, Delta P:40, mean :16, chest wiggle seen due to HFOV mode
-

Total fluid: 110mls/kg/day
IVD saline Dextrose 10% at 15.4 mls/h
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.41mls /h=5mcg/kg/h
0.5ml/h.
OGT sz 6 marking at 33cm- keep free flow, baby keep NBM
On and off moving limb, not fighting, on phototherapy started at 1000H yesterday,
ABP:70/38mmhg (50) HR:130-140bpm, spo2: 90-100%, DCo2:> 750
87
S/B Dr. M, noted baby condition and parameter and ABG, planned
-
To increase total volume to 120mls/kg/day

To start trophic feeding 5mls of EBM 3 hourly, off photolight, others cont. same
On 28/10/16@ 0800H
S/B Dr. Q. noted baby condition, parameters and changes done by Dr. M as planned:
-
Change IPPV setting to PTV mode, Rate 60, PEEP:5, Fio2:0.30, PIP:24, TI:0.38,
spo2> 90%, no spontaneous breathing
reduce midazolam to 0.5mls/h (60mcg/kg/h)
off infusion dopamine
On 28/10/16@ 0915H
Parameter stable, spo2 90-95%, resting, already visited by father, afebrile, had eye
opening and move passively once handling, aspiration minimal, change OGT to size 8.
Intact, aspiration 3.5mls saliva, PU and BO, perineal care done, feeding OGT given as
order, 5mls. Noted had minimal nasal flaring after change the mode
On 28/10/16@1000H
ABG done after 2 hour changing the mode. PH: 7.333, Po2:51, Pco2: 38.4, HCo3:20.5, cont
treatment
On 28/10/16@ 1100H
Visited by parent, updated baby condition and parameter, satisfied, talk and touch the baby
On 28/10/16@ 1230H
Attended to baby, looks stable but still had nasal flaring, to and tail clean done, suctioning
done, thick, yellowish moderate amount of ETT suction, oral whistis moderate. Lower spo2
88
during suctioning drop till 87%, slowly pickup to >95%, fio2 maintain@ 0.35, aspiration
3mls saliva + +. PU, BNO, feeding given as tolerated, other cont. same
On 28/10/16@ 1420H
Rang up Dr. Q, noted baby condition and parameter, VTE:14-18, Spo290-95% with fio2 0.35,
on and off looks tachypnic 70-85bpm, and need cont. dormicum or want to off it. (near to
empty)- to off if infusion dormicum once completed. Cont same. No futher ordered.
On 28/10/16@ 1515H
Attended to baby, parameter stable, Spo2 90-95%. Resting, aspiration minimal mucous.
Intact. Aspiration 3.5 mls saliva, PU bo done, perineal care done. Feeding OGT given as
tolerated at 5 mls. Noted had mild nasal flaring after change the mode.
On 28/10/16@ 0005H
Attended baby, looks stable, still have nasal flaring, looks slightly jaundice, warm to touch,
tem 37.8, suctioning done, thick yellowish, moderate amount, oral whitis, moderate. Lower
spo2 during suctioning drop till 70%, slowly pick up to > 90%, fio2 maintain @ 0.35,
aspiration 3mls saliva plus air ++, pu and bo, feeding given as order, other cot same.
On 28/10/16@ 1830H
Received call from father, updated baby condition and treatment via phone, satisfied, still at
home saw the other kids.
On 28/10/16@ 2030H
S/B dr iq, noted baby condition and parameters, order to increase the PEEP to 6, ABG done,
noted planned to increase fio2 as Spo2< 95% rate 60 bpm. PIP 26. Other cont. same.
89
28th Oct 2016

Day 5 in NICU
Day 4 of life
Consultant:DR Iq
B.Wt: 3.77kg- girl
Fluid requirement 120 mls/kg/day
Ventilation- mode PTV, fio2: 0.5%, Rate 60 bpm, PEEP:6, PIP:26, Ti:0.38
On 28/10/16@ 2100H
Took over case, baby critical ill but stable, still on IPPV support, mode and setting as above,
presented:
-

0.5ml/h.
- IVD saline Dextrose 10% + 3.6 mls of KCL progress well at 18.5mls/hat 15.4 mls/h
- Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.41mls /hour=5mcg/kg/hour
- OGT size 6 marking at 33cm insitu for feeding purpose.
- IVD intact at Rt hand- Spgot
Parameter as charted, MAP:45mmhg, HR:110- 120bpm, Spo2> 95%, good breathing
effort seen, air entry equal bilaterally with good chest expension, vte: 14-16mls, baby
looks pink, moving all upper and lower limbs
On 28/10/16@ 2200H
Visited by parents, updates baby condition, satisfied, talking and touch the baby
90
On 28/10/16@ 2300H
Attended to baby, all care rendered, Suctioning done. Secretion in moderate amount, light
yellowish secretion from ETT, minimal amount whitish from oral nasally, no bradycardia
during the procedure, desaturated with fast pick up, diapers change- urinate well, BNO,
abdominal soft to palpation, feeding attempted at 5 mls ofEBM- asp: 2mls of mucose,
otherwise gradually reduce fio2 to 0.45%, cont same.
91
29th Oct 2016

Day 5 in NICU
Day 4 of life
Consultant:DR Iq
B.Wt: 3.77kg- girl
On 29/10/16@ 0300H
attended to baby- all care rendered, look comfortable, parameter as charted, MAP: 45mmhg,
HR:110-120bpm, spo2 > 95%, feeding attempt at 5 mls of EBM- asp: 2 mls of mucos, IvB
flushed- noted redness at IVB site, keep the line rest cont. care.
On 27/10/16@ 0530H
Attended to the baby, all care rendered, clean don, skin intact, ABG done- result as charted,
parameter as charted MAP: 45-55mmhg, HR: 120-130bpm, spo2>95%, VTE: 15-17mls,
Temp: 37.0. Air entry equal bilaterally with good chest expansion, suctioning done, secretion
in moderate amount seen from ETT in light yellowish color, minimal amount in whitish color
seen oral nasally, diapers change, feeding attempt at 5 mls of EBM, aspiration: 2 mls of
mucus, rest cont. care.
92
On 29/10/16@ 0730H
Taking over report baby more stable, keep ippv with same mode setting. Parameter as
charted. HR: 10-120/min. Mean BP around 50-60mmhg. No inotrops, more active. UAC and
UVC insitu, IVF saline 10% dextrose + 3.6 mls of KCL run at 18.5 mls /hour, UAC
flushing in progress run at 0.5mls/h. Tolerated OGT feed EBm 3 hourly 5mls. Total aspiration
yesterday 17.5mls mucous, good urine output 4.1 mls/kg/h, other cont same.
On 27/10/16@ 0830H
Seen by father updated current status, brought EBM, Good production, talking and touch the
baby, baby looks active, parameter stable.
On 29/10/16@ 0900H
Attended baby, stable, and active, pampers change, BNO, PU good urine output 4.5 mls/kg/h.
turn to rt lateral position, aspiration 1.5 mls undigest milk, feeding given 10mls of EBM.
Medication serve as order, rest cont. same.
On 29/10/16@ 1015H
S/B dr Iq, with parent, updated baby condition, review ABG result- PH:7.292, PCo2:42.6,
PO2 :62, BE:-6, HCo3: 20.6, Glucose: 3.6. Increase total fluid requirement to 150mls/kg/h,
order to change IVF to 1/5 saline 10% Dextrose + 6.7mls KCl if glucose stilllow, rest con.
Same.
On 29/10/16@ 1200H
Attended baby, pampers change, BO moderate meconium, parameter stable. Ral tracheal
suctiondone, smll amount and loose secretion, feeding given as order, rest cont same.
On 29/10/16@ 1300H
S/B parent update status, talking and touching the baby
93
On 29/10/16@ 1345H
Attended baby, medication serve as charted, ABG taken. Glucose still 3.2 mmol, called up dr
Iq, noted ABG result planned; Change IVD to 1/5 saline 10% Dextrose + 6.7 mls KCL.
Reduce total fluid requirement to 130mls/h, rest cont same.
29th Oct 2016

Day 5 in NICU
Day 4 of life
Diagnosis: Birth asphyxia, RDS
Consultant:Dr. Q
B.Wt: 3.77kg- girl
UAC insitu with IVD 1/5 saline 10% dextrose plus 6.7 mls KCL@ 16.6 mls/ h
UAC flushing Nacl @ 0.5 mls/h
Ventilation- mode PTV, fio2: 0.3- 0.4%, Rate 40 bpm, PEEP:6, PIP:26, Ti:0.38
On 29/10/16@ 1500H
Took over report baby still on ippv support as per setting, ETT size 3.5@ 8.5 cm marking
intact, air entry equall bilaterally, attended to baby, looks pink jaundice, warm to touch, look
comfortable, parameter as charted, temp 37, MAP: 50 mmhg, HR: 100-120bpm, Spo2 > 95%,
94
Pu, BO done, all care rendered., Feeding attempt at 10 mls of EBM- aspiration: 2mls of
mucose. IVB insitu- noted redness at IVB. Keep rest cont care.
On 29/10/16@ 1815H
Noted baby start Brady till 100bpm, SABP: 90/40 (68), attended to baby, parameter stable,
afebrile, active once handling. Suctioning done, thick light, yellowish with plug moderate
amount from ETT, oronasal whitish loose scanty, Better, aspiration minimal mucos. PU bno.
All care rendered, feeding given as tolerated. Repeat HGT: 4.7mmol/l HR: 115 bpm,
Map:54mmhg, Spo2, 98%, breathing 40-50bpm
On 29/10/16@ 2045H
Attended to baby, suctioning done, thick light and yellowish moderate amount from ETT.
Oronasal whitish loose scanty, aspiration minimal mucose, PU,Bo done. All care rendered.
Feeding given as tolerated, Fio2:0.28. Spo2:99%. MAP: 50 mmhg, HR:115bpm, breathing
40=50bpm.
On 29/10/16@ 2100H
Taken over report check baby on ippv support mode and setting same as above. Presented:
-

UAC sz 3.5 marking at 12cm- intact with flushing at 0.5ml/h.
IVD saline Dextrose 10% + 3.6 mls of KCL progress well at 16.6mls/h
OGT sz 6 marking at 33cm insitu for feeding purpose.
IVD intact at Rt hand- Spigot
Parameter as charted, MAP: 55mmhg, HR: 110-120bpm, Spo2> 95%, good breathing effort
seen, air entry equal bilaterally with good chest expansion, Vte: 14-16mls, baby looks pink,
moving all upper and lower limbs.
On 29/10/16@ 2200H
95
Visited by parents, updating baby conditionsatisfied, touch and talk to the baby as usual.
On 29/10/16@ 2330H
Attended to baby. All care rendered, suction done, secretion in moderate amount, light
yellowish secretion seen from ETT, minimal amount, whitish secretion seen oral nasally, no
bradycardia during procedure, diapers change, urinate well- BNO, abdomen soft on
palpation, feeding attempt at 10mls of EBM- asp:1.5mls of mucus, rest cot. Same.
review by Dr IQ at the same time, updates baby condition, noted ventilator keep alarming:
low pressure, neopuff the baby, check on ventilator, after satisfied attached bat to the ETT
and ventilate well, reduce PEEP to 5, PIP 24 for phototherapy.
-

0.5ml/h.
IVD saline Dextrose 10% + 3.6 mls of KCL progress well at 18.5mls/hat 15.4 mls/h
Infusion dopamine (14mg in 50 mls Dextrose 5%) at 0.41mls /h=5mcg/kg/h
OGT sz 6 marking at 33cm insitu for feeding purpose.
IVD intact at Rt hand- Spgot
30/10/16
Day 6 in NICU
Day 5 of life

Consultant:Dr. Q
B.Wt: 3.77kg- girl
96

OGT feeding 3 hourly- 10 mls of EBM
0730H
Took over report patient still on IPPV as per settting
ETT size 3.5 marking at 8.5 cm intact. Air entry equall bilaterally, attended baby
look pink, warm to touch, blood taken for ABG, trchial aspiration taken C&S,
feeding attempt, at 10 mls of EBM- aspiration 2.5 mls of undigest milk.
31/10/16
Consultant:Dr. Q
B.Wt: 3.77kg- girl
OGT feeding 3 hourly- 20 mls of EBM

0730H
Took over patient still on IPPV support as per setting, attended baby look pink and warm to
touch. Asleep, S?B Dr Q. examined baby, planned
-
Change setting to SIMV (PSV)

Reduce PIP to 20
Reduce rate to 20
Increase feeding 25 mls, after 2 cycle increase by 5 mls each.
Total fluid 150mls/kg/day
Kiv Extubate Cm
97
To reduce PIP to 18 by 0400 and ABG at 6 am

Kiv remove UAC after extubate
2100
Fluid requirement 150/kg/day
UAC insitu flushing NACL 0.5 mls
UVC insitu with IV drip 1/5 saline 10% dextrose + 6.7 mls KCL@ 11.4 mls/ hour.
OGT feeding 3 hourly 35 mls of EBM- to increase 5 mls every cycle.
Baby still on IPPV, looks pink and warm to touch. Asleep.
1st Nov 2016
Day 8 in NICU
Day 7 of life
Consultant:Dr. Q
B.Wt: 3.77kg- girl
0400H
PIP reduce to 18, Spo2 96% with fio2 of 0.25
Feeding at 40 mls/ 3 hourly, reduce IVD to 9.7mls/h.
98
0530h
Attended baby, suction done, desaturated till 80% increase Fio2 to 0.29%, comfort the baby,
all dressing change, rechecked IVB no redness noted,pu and BO done , feeding given as
regeim, aspirate 4 mls.
0800
S/B dr Q. noted ABG, normal, planned extubate, put pt on nasal prong oxygen at 3l/min.
Spo2 more than 95%, no bradycardia seen, Good breathing Effort.
1100
Parameter as charted. HR: 100-110bpm, Resp 20-30, Spo2:100%, reduce oxygen to 2 L/min.
2nd Nov 2016
Day 9 in NICU
Day 8 of life
Consultant:Dr. Q
B.Wt: 3.77kg- girl
0730h
99
Took over report baby asslep, keep on nasal prong 2L/min, in incubator stable overnight, S/B
dr Q. remove UAC and UVC, to full feed baby 60 mls EBM 3 hourly to transfer to SCN.
1030H
Transfer baby to SCN via incubator on room air, parameter stable.
1400
S/B dr Q. noted serum bilirubin result, planned to commence photo light (single photo)
Repeat SB cm, maintain Spo2 > 92%.
3rd Nov 2016
Day 9 in NICU
Day 8 of life
Consultant:Dr. Q
B.Wt: 3.77kg- girl
0700H
Attend baby, PU and BO, pampers change, baby active on handling, feeding 60 mls given by
cup, tolerated well, baby sleep well in prone position.
1200H
Visited by mother, breast feeding with mother, sucking well, active no tachypnea seen.
100
4th Nov 2016

Day 11 of life
Consultant:Dr. Q
B.Wt: 3.77kg C.Wt: 3.51kg
0700H
cup, tolerated well, baby sleep well in prone position.
1200H
Visited by mother, breast feeding with mother, sucking well, active no tachypnea seen.
5th Nov 2016
Day 12 of life
Consultant:Dr. Q
B.Wt: 3.77kg C.Wt: 3.51kg
0700H
101
cup, tolerated well, baby sleep well in prone position.SB taken.
1000H
S/B Dr. Q. examine baby, noted SB result, planned off photo light, give hepatitis B and BCG
vaccine, allow discharge with aperton and TCA 1 week.
BCG and HEP B given, Advice mother regarding home care of the baby. Paper work
prepared.
1300H
Bill settle, parent took the baby, health education given on Brest feeding, medication, and
knowledge on respiratory distress symptom.medication to take home given with instruction,
TCA emphasize on 12 november at 0830 in Dr Q clinic.
102
NURSING CARE PLAN

1. impaired gas exchange related to decreased production of surfactant.
2. Altered in nutritional status: Less than body requirement related to respiratory
distress.
3. Ineffective thermoregulation (hypothermia) related to large body surface.
4. Risk of infection related to immune system deficiency and invasive procedures.
5. Parental anxiety related to childs condition and Prognosis.
103
Date: 25/10/2016 @ Time: 1800 pm

Nursing Diagnosis
Impaired gas exchange related to inadequate surfactant levels
Supporting Data
Breathing patterns (Poor breathing Effort)
Objective Data:
as evidenced by respiratory acidosis and SPO2 level <92%
1.
Monitor and document hourly FiO2 levels. Sa02 per pulse oximeter,
and vital signs (temperature, heart rate/rhythm and BP).
Assessment provides information about neonates ability to initiate and sustain an effective
breathing pattern.
I: I monitor child parameter every hourly including her SPO2, HR and BP and the result was
spo2 less than 92%, HR:140- 150bpm.
2.
Monitor laboratory studies (ABGs, glucose, electrolytes)
Lab study is Essential monitoring for body systems balance

I:I took ABG and result was mix respiratory and metabolic acidosis.
3.
Administered warmed and humidified oxygen at rate order by doctor.

To prevent hypoxia and injury to the child mucosa membrane of airway.
I: I ensure the oxygen supply was humidified and Temperature maintain warm 36 37
oxygen temperature.
4.
Position patient fowlers to facilitate optimum breathing patterns.
Allows gravity to assist in lowering the diaphragm, and provides greater chest expansion
I: I adjust the incubator to be in 15 degree and maintain head mild extended with blanked.
5.
6.
Maintain airway clearance by perform ETT and ORONASAl suctioning if
have excessive mucose as order by Dr.

Maintains a patent airway for gas exchange
I: I do ETT and oronasal suction and result was moderate, yellowish and thick
Administer medication , for example Curousof 100mg/kg as order by DR Q
increase surfactant level and improve gas exchange.
I: I assist Dr IQ serve curosurf through ETT by using OGT feeding.
104
EVALUATION:
Miss Y spo2 level maintain > 92 % regardless of reduce FIO2 within 1 hour after nursing
intervention given.
Date:25/10/16
Time: 1900H
Re-evaluation:
Miss Y spo2 level maintain > 92 % regardless of reduce FIO2 within 24 hours after nursing
intervention given.
Date: 27/10/16
Time:1800h
Date: 28/10/2016 @ Time: 0700 pm

Nursing Diagnosis
Altered in nutritional status: Less than body requirement related to respiratory distress and
NBM status.
Supporting Data
Tacypnea > 60 breathe per min
Nil by mouth since birth 24/11/16 until 28nd October 2016
Orogastric feeding started on 28nd October 2016
Goal
: Child will not lose excessive body weight more than 10% of birth weight.
Nursing intervention
1. Assessed child general condition such as:
Fontanel
Skin turgor
Mucous membrane
To plan appropriate nursing intervention and as a baseline data.
I do assess child general condition by looking at the child skin, mucosa and Glucose level in
ABG.
2. Administer intravenous fluid as prescribed by doctor according to body weight.
To maintained child hydration status
I do administer and regulated intravenous fluid as prescribed by doctor and used infusion
pump.
3. Monitor intake and output by weighing the diapers and record to the chart
Diaper weight 1 gm = 1mls
Adequate urinary output 1ml/kg/hour

For evidence of dehydration or overhydration.
105
I do monitor the intake by looking at the infusion pump that was setting of drop/hour of
intravenous fluid and monitor the output by weighing the diaper (1gm=1ml) and record to
the chart.
4. Served feeding via orogastric tube every 3 hourly and increase the feeding gradually as
prescribed by doctor.
To ensure tolerance in oral intake before starting bottle feeding.
I do served feeding through orogastric tube every 3 hourly as prescribed by doctor and
increase gradually as tolerated from the child. The child milk digestion was very well.
5. Encourage the mother to express breast milk that can give through orogastric tube.
To maintain lactation until infant can breast feed and breast milk is high in protein that is
good and needed for the child for growth.
I do encourage the child mother to express breast milk, the mother had done express breast
milk and sent the milk to nursery and kept in the fridge that was given to the child according
to feeding time.
7. Assessed child readiness to bottle feeding and breast feeding, especially ability to
coordinate swallowing and breathing.
To minimize risk of aspiration.
The child was showed rooting reflex that I was placed my finger at one corner of the childs
mouth and the child was turn the head toward the side stroked. Other than that I put my
cleaned finger on the childs lip and the child was showed the sucking reflex.
8. Served feeding through cup feeding every 3 hourly as prescribed by doctor.
To see child progress in oral intake.
The staff nurse served the milk through cup feeding every 3 hourly as prescribed by doctor
and the child was sucking very well.
9. Encouraged and assisted the mother for breast feeding.
Breast milk is the best supplement for the child and to provide support for breast feeding.
I do encourage the mother for breast feeding and the mother always came to the hospital for
breast feeding and assisted the mother by positioning and proper latch on.
10. Informed the doctor if child oral intake is poor.
To plan for further management.
Child oral intake was good and I did not inform the doctor.
Evaluation:
106
3rd November 2016 @ 1000hours

Childs not lose excessive body weight more than 10% of birth weight.
Supporting data:
Weight on discharged was 3.51kg
Breast feeding was sucking well
cup feeding tolerated well
107
Date: 25/10/2016 @ Time: 1800 pm

Nursing Diagnosis
Ineffective thermoregulation (hypothermia) related to large body surface.
Supporting Data
-
Premature 36 weeks + 6 days

Temperature on admission 36c
Acrocyanosis
Goal:
Childs axillary temperature will be maintained within normal range 36.5c 37.5c after
nursing intervention given and during hospitalization.
1. Assessed childs general condition such as:
- Acrocyanosis
- Body cold to touched
As a baseline data and plan for further nursing interventions
I do assessed childs general conditions by touching the childs body that is cold to touch and
acrocyanosis due to just delivered.
2. Monitored child vital sign especially axillary temperature every hourly until stable then
every 3 hourly.
To obtained a constant temperature reading.
I do checked childs body temperature on admission that is was 36c then repeated 1 hour
later is 36.8c and then check for every 3 hourly.
3. Kept the incubator window closed and avoid from open the incubator window frequently.
To prevent from heat loss through convection
All the staff included me do not open the incubator window frequently, only during
observation or any procedure.
4. Changed the diapers frequently eg: every 3hourly
To prevent from heat loss through evaporation.
I do change childs diaper every 3 hourly.
5. Adjusted the incubator/resusciatare temperature by increase the incubator/resusciatare
temperature according to childs body temperature.
To increased the body temperature and prevent from hypothermia.
I did not adjust the incubator/resuscitare temperature by increased the incubator temperature
because childs body temperature was maintained in normal range (36.5 37.5c).
108
6. Avoid from adjusted the incubator/resusciatare temperature more than 1c.

To prevent from drastic changes in body temperature (hypothermia/hyperthermia)
I did not adjust the incubator/resuscitare temperature more than 1C. I adjusted within 0.1
0.9c.
7. Used warm water when bathing or top to tail, wrap her in a towel and dry her quickly. Dry
her head thoroughly.
To prevent from heat loss through evaporation.
The staff nurse in special care nursery had done top to tail by using warm water and dry the
child quickly by using dry towel.
8. Keep child adequately clothed and cover
To maintained her body temperature.
After bathed the child, I straight away wear the child with clothed and wrapped the child
with wrapper.
9. Keeps child away from air conditioning vents or drafts.
To prevent heat loss from convection.
The staffs always keep the babies in special care nursery away from air conditioning.
Evaluation:
25th November 2016@ 1800hours
Childs axillary temperature was maintained within normal range 36.5c 37.5c.
5th November 2016@ 1200hours
Childs axillary temperature was maintained within normal range 36.5c 37.5c.
109
Date: 27/10/2016 @ Time: 1200H

Nursing Diagnosis
Risk of infection related to immune system deficiency and invasive procedures.
Supporting Data
-
Peripheral intravenous site of redness, swelling and other infection sign

yellowish or greenish secretion through endotracheal tube
smelly gastric aspiration
Goal:
Childs will exhibit no evidence of nosocomial infection after nursing intervention given and
during hospitalization.
1. Observe and report sign of infection such as
warmth, redness and any discharge at the around intravenous line
yellowish or greenish secretion through endotracheal tube
smelly gastric aspiration

As a baseline data and for further treatment.
I do observe sign of infection to the child monitor for gastric aspiration, secretion through
endotracheal tube and around intravenous line.
2. Monitor childs vital sign especially
Temperature >37.5c
Heart rate > 160 beat per min

May indicate for infection
I do monitor childs vital signs every 3 hourly for temperature and heart rate every hourly to
detect early sign of infection.
3. Take blood as prescribed by doctor and note the report laboratory values (e.g: White blood
cell count and differential)
To provide view of the childs immune function and to develop an appropriate plan of care.
The staff nurse took the blood through peripheral vein for full blood count as prescribed by
doctor.
4. Administered IV antibiotic as prescribed by doctor.
-
IV Ampicilin 400mg BD
IV Amikacin 60mg daily
Cefutaxime 200mg BD
To reduce actual and potential of infection.

110
I do administer the IV antibiotic as above according to 7R.

5. Ensure that all caregiver use appropriate hand hygiene such as hand washing or use of
alcohol-based hands rub
To reduce transmission of any organism to the child.
I do wash hand (medically) before and after touching the child with hibiscrub.
6. Follow standard precaution and wear gloves during any contact with blood, mucous
membranes, or other body fluid.
To avoid from transmission of microorganism from patient to the staff or from staff to the
patient.
I do wear gloves during contact with child body fluid such as changing dressing of
intravenous line, suctioning.
7. Ensure all equipment in contact with child is clean or sterile such as
Resuscitation bag, nasogastric tube, incubator
ET Suction tubing, intravenous medication

To prevent from transmission of organism from coming into direct contact with the child
I do used clean or sterile equipment to the child especially cannula, endotracheal tube,
endotracheal suction tubing, syringe, orogastric tubing, resuscitation bag and etc.
8. Ensure strict clean or sterility technique are performed with invasive procedure such as
Peripheral IV insertion
Endotracheal suctioning (sterility)
Orogastric feeding or aspirate

To prevent from transmission of microorganism to the child
I do used sterile technique during endotraceal suctioned by using sterile gloves administer
orogastric feeding or aspirate. The staff nurse used sterile technique during insertion of IV
line to the child.
9. Inform the doctor if sign and symptom of infection is occurring.
To plan further treatment and management.
The staff nurse did not inform the doctor because there is no sign and symptom was occurred.
Evaluations:
27th October 2016 @ 1400hours
Child exhibits no evidence of nosocomial infection after nursing intervention given and
during hospitalization.
Re- evaluation:
5 November 2016 @ 1200H
Child is free from nosocomial infection after nursing intervention given and before discharge.
111
112
Date: 26/10/2016 @ Time: 0700H

Nursing Diagnosis
Parental anxiety related to childs condition and Prognosis.
Supporting Data
-
Parent keep asking regarding childs condition and progress

Mother was cried and express her feeling to the me.
Goal:
Parental anxiety will be reducing to the minimum level after intervention given and during
hospitalization.
1. Assess parental level of fear and anxiety.
To know level of fear and anxiety of parents and able to plan for further intervention.
I assess parent level of anxiety by looking at the parents facial expression and Miss M
mother cried during came to special care nursery.
2. Reinforce the doctors explanation regarding respiratory distress syndrome and childs
management needed to rule out of RDS.
To enhance parents knowledge and facilitate understanding
I do reinforce to parents about the diagnosis, and the management as prescribed by doctor to
make parents more understanding.
3. Use a simple language and terms while explain to the parents and avoid from using
medical term.
For easier the parents to understand what will explain to them.
I explained to parents in Bahasa Melayu for easier parents to understand and using a simple
word.
4. Explained all procedure to be done to child to the parents.
To reduce parental fear and anxiety about the procedure to their child.
I explained to parents all procedure such as the purpose of taking vital signs, giving IV
medication and invasive oxygen therapy.
5. Keep family informed of childs progress.
To help reduce family anxiety about childs condition and parents aware or progress of
their daughter.
113
I do informed to Miss M parents regarding Miss M progress every time Miss M mother came
to special care nursery.
6. Encourage the parents to asking the question that they may not understand.
To provide parents more knowledge and understanding about the disease condition.
I encourage the parents to ask me or other staff also the doctor in charge if they have any
queries about their child condition.
Evaluation:
26th October 2016@0800 hour
Parents knowledge regarding disease condition improved by evidences of the parents is calm
and gives fully cooperation during treatment in the ward after 1 hour of intervention.
Re-evaluation
5th October @1200 hour
Parents knowledge regarding disease condition improved by evidences of the parents is calm
and gives fully cooperation during treatment in the ward and ready for discharge.
114
HEALTH EDUCATION
FEEDING
-
Breastfeeding
Baby will on demand when breastfeeding.
Position during breastfeeding eg: footballs position
Each breast atleast 10-15minutes.
Formula milk
-
Give formula milk after breast feeding if the child is not enough around 1ounc
Preparation of formula milk
1 scoop for 30mls of warm water
Feed the child every 3hourly
CLEANLINESS
-
Boil the bottle and teat before prepare the milk

Wash hand before prepare the milk
Use boiled water but warm when added to the milk
Changed the diaper frequently if the child wet or pass motion to avoid from nappy
rashes, eg: change every 3hourly
CORD CARE
-
I did not teach the mother regarding cleanliness of the cord because the child cord
already dropped.
IMMUNIZATION
-
Inform the mother that the next immunization on 2 months old.

Explained to the mother that Hepatitis B and BCG vaccine was given. Explained to
the mother that BCG was given at left arm. Informed the mother that local reaction of
BCG is a papule at site of vaccination occurs within 2 to 6 weeks.
115
TREATMENT
-
Explained to mother regarding treatment and medication was given to her child.
Teaches the mother about sign and symptom of respiratory distress eg: respiration
rapid, nasal flaring.
FOLLOW UP
-
Give the appointment card to the mother that was given the date for follow up and
explained to the mother that the doctor want to see the child progress.
If any sign and symptom of respiratory distress, fever, or other abnormalities present
just come to see the doctor early and no need to wait until appointment date.
MEDICATION
-
I explain on how to give apperton, the frequency and the indication of the medication
to the mother, I also emphasize on the side effect of the medication and if she noted
any reaction like rashes in the body stop to take the medicine and come to clinic.
FOLLOW UP CALL
-
I called madam E on the 12 November 2016, she said the doctor already examine
Miss Y and found Miss y is very well. There is no sign and symptom of respiratory
distress. No medication on the follow up day. The next follow up when Miss Y 2
months old or when necessary.
116
CONCLUSION
Antenatal maternal steroids and neonatal surfactant therapy have significantly reduced the
incidence, severity, and mortality associated with RDS. However, despite enormous advances
in the management of RDS, respiratory morbidity in the form of bronchopulmonary dysplasia
remains a major problem (Rodriguez, 2003). Excellent neonatal care and subsequent followup can maximise the occurrence of optimal outcomes for these potentially sick and fragile
infants.
117
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hypoglycemia: Suggested operational thresholds. Pediatrics, 105(5), 1141-1145.
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diagnosis,evaluation and treatment of hypoglycemia. Neonatal Network, 21(4), 9-19,
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Gardner (Eds.) Handbook of Neonatal Care (pp. 358-375).
T.L Gomela,1999, Neonatology, 4th edition, Appleton & Lange, United States of America,
pg503
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Zukowsky, K. (2004). Respiratory Distress. In M. T. Verklan & M. Walden (Eds.) Core
Curriculum for Neonatal Intensive Care Nursing (pp. 487-523).
118
8APPENDIX
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PROGRAMME

CERTIFICATE IN PAEDIATRIC NURSING

WAN KHADIJAH BINTI WAN YUSOFF

RESPIRATORY DISTRESS SYNDROME

Assessment and patient condition

Review of the System

Anatomy & Physiology

Nursing Care Plan

At the end of this case study I will able to:

pathophysiology, sign and symptoms

: No 3,Jln Aman perdana, subang jaya, Selangor D.E.

Mothers occupation : Housewife

: Respiratory distress syndrome

Chief presenting complaints

History of presenting illness

2.3.1 HISTORY OF PAST ILLNESS:

: 7 at 1 minute & 9 at 5 minute

Artificially acquired passive immunity is a short-term immunization by the injection

dont cause disease.

subunit vaccines safer than live vaccines.

Chemically or thermally modified toxins used to stimulate active immunity.

They are purified extracts

from live microorganisms.

virtually non virulent.

immunity that can be

required because there is no

and thus maintain its ability

They are toxins

multiplication in the body.

those of the natural disease

and usually follow soon after

Antigenicity of toxoids cab be

Table : types of vaccines.

Figure: Immunization schedule in Malaysia for 2016

BCG ,Hepatitis B (1st dose)

Not yet taken

DPT , IPV, HIB ( 1st dose )

Not yet taken

DPT , IPV , HIB ( 2nd dose )

Not yet taken

DPT, IPV, HIB ( 3 dose )

Not yet taken

Not yet takezn

Not yet taken

Not yet taken

DPT , IPV , HIB ( Booster )

Not yet taken

Not yet taken

Not yet taken

Not yet taken

Figure 1: Family data of Miss Y

2.3.11 Family medical history

FIGURE 3: GROWTH AND DEVELOPMENT

WEIGHT DURING ADMISSION

Table 4: Anthropometric measurements of Y during admission.

Gross motor: maturation in posture , head control , sitting , creeping , standing ,

Table 5: Development milestones in normal children.

Pull to sit: Slight Hand

head lag. Head Follows object from delight. Turns

Hands held loosely.

Pull to sit: No Reaches for objects.

head lag and sits Plays with toes.

Pulls to sit. Lifts Palmar

anticipation. Sits approach.