Hind COLLEGE OF NURSING

SUBJECT-advance nursing practice

HEALTH ASSESSMENT
ON
RESPIRATORY DISTRESS SYNDROME

SUBMITTED TO SUBMITTED BY

MRS. ABHILASHA SAHA SAROJ TIGGA

ASSOCIATE PROFESSOR M.Sc .NURSING 1ST YEAR

HOD CHILD HEALTH NURSING HIND COLLEGE OG NURSING

 IDENTIFICATION DATA:
Baby of –Smuti parida
Registration no: 190941085
Father’s name: SALIL PARIDA
Bed no: 05
Name of the ward: NICU
Chronological age: 2 days
Developmental age: Neonate
Sex: Male child.
Religion: Hindu.

Address: Barabanki
Date of admission: 22/1/24

Diagnosis: Respiratory distress syndrome

CHIEF COMPLAIN:
 born by LSCS cried after positive pressure ventilation for 30 sec
 restlessness soon after birth
 dyspnoea since 1 hour after birth
 fever since 2 days

HISTORY OF PRESENT ILLNESS:

Present medical history:

Baby was born one month before having birth weight 1.39kg,single,preterm,34
week, SGA, Sborn in LSCS cried after positive pressure ventilation for 30sec.

Present surgical history:

Nothing significant
HISTORY OF PAST ILLNESS:

Past medical history: Nothing significant.

Past surgical history: Nothing

significant. BIRTH HISTORY:

 ANTENATAL HISTORY:
At the time of pregnancy mother was 33 years. The baby is first order child of the
mother. Mother attended all antenatal visits. She has been immunized by doses of inj.
TT. Mother has not taken any another vaccination. Mother has taken the require diet
like protein, carbohydrate, fat as per doctor’s order. She had taken iron folic acid
tablet during pregnancy. Mother had not taken any other drug without doctor’s
prescription. Mother had no history of exposure to radiation. The mother had attended
2 times ultrasonography during antenatal period & the ultrasound report showed
normal activity & position of the baby. Mother had history of hypothyroidism and
PIH she was taking tab labetalol(100)mg & tab calciguard retard 40mgduring
pregnancy.
 NATAL HISTORY:
Mother delivered a term baby in hospital by LSCS delivery. The history of no sever
oligohydramnios no meconium stained amniotic fluid. Birth weight is 1.39kg & baby
is not cried immediately after birth. Positive pressure ventilation has given for 30 sec.
 POST NATAL HISTORY:
Baby has not cried immediately after birth. Breast feeding start after birth.

DIETARY HISTORY:

Present history:

Pre operative time IV fluid- 120 ml/ kg/day. 10% dextrose.

Post operative after 15 days- baby get feeding 20 ml/ 2hours.

IMMUNIZATION HISTORY:
AGE NAME OF VACCINE TAKEN REMARKS
VACCINE
At birth BCG, OPV ‘0’ dose Yes Any complication is
not present at that
time.
 DEVELOPMENTAL MILESTONE:
BOOK PICTURE PATIENT’S PICTURE
PHYSICAL & BIOLOGICAL PHYSICAL & BIOLOGICAL
Weight: 2.5-3.5kg Weight: 1.39 kg
Height:48-50 cm Height:44cm
Head circumference: 35-37 cm. Head circumference:
Chest circumference:32-35cm 30cm. Chest
MUAC:11-12cm circumference: 28cm
VITAL SINGS: MUAC:10cm
Pulse – 110-160beats/ minute. VITAL SINGS:
Respiration- 35-45 breaths/ minute. Pulse – 152beats/ minute.
Blood pressure – 80/50-90/60 mm of Respiration- 64breaths/ minute.
Hg.
Blood pressure – 90/58 mm of Hg.
REFLEX
REFLEX
Well-developed sucking, rooting, swallowing,
Sucking, rooting, swallowing reflexes are not
extortion reflexes.
well-developed.
Well-developed motor reflex &tonic neck
reflexes.
Baby is very sick not understand properly.

DENTITION: Baby has no natal teeth.

PERSONAL HISTORY:

Hygiene: sponge baby daily with warm water & changed the baby clothes every day
morning.

Elimination: baby passing urine frequently & baby passing stool every day 4-5times.

Sleep & rest: baby sleeps 18-20 hours every day.

FAMILY HISTORY:
Family chart:

NAME AGE/ RELATI EDUCATION OCUPATION HEALTH

SEX ON
Smruti Parida 25 yrs./F Mother Matriculation House wife Good
Salil Parida 28 yrs/M Father Graduation Business Good
Baby 2daysM Self RDS

Family tree:
female

male

-diseased
GENERAL EXAMINATION:

General appearance: baby is lethargic.

Body built: lean & thin.

Nourishment: not well nourishment

Level of consciousness: baby is conscious.

Vital signs:
TPR& BP Normal value Patient value Remarks
Temperature 97 F 96.7 Vitals signs are
Pulse 120-160 beat/min 140 beat/min normal.
Respiration 30-50 breath/min 35 breaths/ min
Blood pressure 90/60 mm of hg 90/58 mm of Hg

REFLEXES:

Rooting, swallowing, sucking reflexes are present & other reflex is not present.

ANTHROPOMETRIC MEASUREMENT:

PARAMETER NORMAL VALUE PATIENT VALUE REMARKS

Weight 2.5-3.9 kg 1.39kg Baby’s biological
Height 48 cm 44cm growth is
head circumference 35cm 30cm inadequate
Chest 33cm 28cm
circumference
MUAC 12cm 10cm

HEAD TO TOE EXAMINATION:

HEAD:

 Shape of skull: shape of skull is round shape.

 Fontanel: anterior & posterior fontanels are not closed; wide gap is present between
two sutures.
 Hair colure & texture: black, silky & smooth hair.
 Presence of infection: no infection presence.
 Dandruff: dandruff is not present.
 Lice: lice are not present.
 Throat: there are no abnormalities.
  Neck: there are no abnormalities.

FACE:

 Face is round shape.

 Oedema is not present.
 Lesion is not present in face.

EAR:

 Both ears are symmetrical & size is same.

 Discharge or any lesion is not present.

EYES:

 Position: both eyes are symmetrical.

 Redness: redness is not present.
 Discharge: no discharge.
 Sclera: there is no abnormality.
 Other: nothing significant.

NOSE:

 Patency: two nostrils are patent.

 Nasolabial fold:nothing significant.
 Flaring: not present.
 Discharge: not present.

CHEST:

 Both sites are symmetrical, bilateral equal. Incision wound is present.

 Nodules are not present.
 S1 & S2 heart sound are present. No abnormal heart sound.

ABDOMEN:

 Round shape.
 No enlargement.
 Bowel sounds are present.

BACK & SPINE:

  Back is clean.
 Lesion is not present.
 Spinal deviation is not present.

GENITALIA:

Both the testes are descended. Rugae present. There is no anorectal malformation.

SKIN:

 Skin is not intact.

 Surgical wound is present.
 Small wound in left hand is present.

INVESTIGATION:

BLOOD TEST:

PARAMETER PATIENT VALUE

Complete blood count:
WBC 8.23 (10^ 3/UL)
RBC 4.77(10^ 6/UL)
HGB 17.3 mg/dl
PLT 88 (10^ 3/UL)
NEUTROPHYLE 82.4%
LYMPHOCYTE 13.3%
MONOCYTE 2.8%
EOSONOPHYLE 1.3%
BASOPHYLE 0.2%
BIOCHEMISTRY:
NA+ 135 MEQ/L
K+ 3.0 MEQ/L
CHLORIDE 100 MEQ/L
MICROBIOLOGY:

CPR- .2-5mg/lit CPR- 2.74mg/lit elevated

Titration = > 0.6 mg/ dl Titration = 0.6 mg/ dl normal

HHH-nonreactive HHH-nonreactive normal

Bilirubin direct-0-0.4mg/dl Bilirubin normal

Bilirubin direct-0.75mg/dl normal

total-0.3-1.0mg/dl TSH- Bilirubin normal

1.7-9.1mu/l total-12.52mg/dl TSH-

6.12mu/l