Newborn in distress - Nursing Case Study

Pathophysiology

• Primary mechanism: Respiratory distress - Newborns can experience distress due to transient tachypnea, a condition characterized by rapid breathing caused by retained fetal lung fluid. This is common in babies born by C-section. The inadequate clearance of lung fluid obstructs the airways, causing hypoxia.

• Secondary mechanism: Hypoglycemia - Newborns, especially preterm and small for gestational age babies, can suffer from low blood sugar. This is caused by the interruption of the glucose supply from the mother immediately after birth, and the newborn's liver may not yet efficiently produce glucose.

• Key complication: Hypothermia - Newborns, particularly preterm babies, are at risk of losing body heat rapidly due to their large surface area relative to weight. This can lead to hypothermia, which can induce metabolic acidosis and hypoglycemia, further escalating the distress.

Patient Profile

Demographics:

Newborn, Male, Not Applicable

History:

• Key past medical history: Born at 32 weeks, premature

• Current medications: None

• Allergies: None

Current Presentation:

• Chief complaint: Respiratory distress, lack of appetite

• Key symptoms: Grunting, nasal flaring, abnormal breathing pattern, cyanosis around the mouth, lethargy

• Vital signs: Heart rate 180 beats per minute, respiratory rate 80 breaths per minute, temperature 36.1°C, blood oxygen saturation level 88%

Section 1

Initial Assessment Findings:

On physical examination, the newborn presented with central cyanosis, a bluish discoloration of the skin, indicating low oxygen levels in the blood. The baby also showed signs of respiratory distress such as intercostal retractions and grunting. His fontanelles were normal, and there was no sign of jaundice. The baby’s skin was cool to touch, suggesting hypothermia. The initial capillary refill time was more than 3 seconds, indicating poor peripheral perfusion. The nurse also noted the baby’s lethargy and poor feeding, which could be indicative of hypoglycemia.

New Diagnostic Results:

The arterial blood gas analysis showed a pH of 7.28, PaO2 of 55 mmHg, and PaCO2 of 50 mmHg, confirming the diagnosis of respiratory acidosis. The blood sugar level was found to be 40 mg/dL, which is lower than the normal range, confirming hypoglycemia. The complete blood count (CBC) showed a slightly elevated white blood cell count of 20,000/mm3, suggesting a potential infection. Chest X-ray showed streaky opacities in both lung fields, suggestive of retained fetal lung fluid.

These findings indicate the need for immediate interventions to correct the respiratory distress and hypoglycemia while monitoring for potential infections. The newborn's condition requires critical decision-making and comprehensive nursing care to ensure optimal outcomes.

Section 2

Response to Interventions:

The newborn was immediately started on supplemental oxygen therapy and was placed under a radiant warmer to address the hypothermia. Additionally, intravenous dextrose was administered to correct the hypoglycemia. After 2 hours, the baby's skin color improved and his breathing became less labored, suggesting an improvement in oxygenation. However, on reassessment, the baby's capillary refill time remained at 3 seconds and his body temperature was still below the normal range at 35.5 degrees Celsius, indicating ongoing hypoperfusion and hypothermia.

Despite the initial interventions, the baby's blood sugar level only increased slightly to 45 mg/dL, which is still below the normal range. Moreover, the subsequent arterial blood gas analysis revealed a pH of 7.3, PaO2 of 60 mmHg, and PaCO2 of 48 mmHg. Hence, while there was some improvement, the baby was still in respiratory acidosis. Given these findings, the nurse recognized the need for further interventions to improve perfusion, temperature, and blood sugar levels, and to address the ongoing respiratory distress. The nurse also contemplated the possibility of antibiotic therapy, considering the elevated white blood cell count and the potential for infection.

Section 3

New Diagnostic Results:

The nurse requested further blood tests to rule out sepsis, given the baby's persistent hypothermia and elevated white blood cell count. The results revealed an elevated C-reactive protein (CRP) level of 40 mg/L, a clear indication of systemic inflammation. The blood culture was sent to the lab and the results were pending. Moreover, the baby's blood glucose remained low at 45 mg/dL despite the administration of intravenous dextrose, suggesting possible inadequate glucose production or excessive use.

To further investigate the cause of the hypoglycemia, a critical sample was taken. This showed a low insulin level, but a high level of ketones and free fatty acids. These findings indicated that the baby was breaking down fats as an alternative energy source due to the lack of glucose, a condition known as ketosis. The nurse knew this could lead to a potentially life-threatening complication - ketoacidosis. This could also explain the baby's respiratory distress, as the body tries to compensate for the metabolic acidosis by hyperventilating to expel more CO2. The nurse quickly relayed these findings to the physician, knowing that immediate action was required to prevent further deterioration of the baby's condition.

Section 4

New Complications:

As the nurse continued to monitor the infant, she noticed the baby's heart rate began to elevate, a tachycardia of 180 beats per minute, and the respiratory rate increased to 70 breaths per minute. The baby's skin became mottled, and capillary refill time was prolonged to 4 seconds. Moreover, the baby was increasingly lethargic and showed reduced responsiveness to stimuli, a significant change from the previous assessment. These were signs of poor perfusion and potential septic shock, which could be a complication of the underlying infection causing sepsis.

Response to Interventions:

In response to the deteriorating condition, the physician ordered an immediate fluid bolus of 10 mL/kg normal saline in an attempt to improve perfusion and ordered a stat dose of intravenous insulin to correct the metabolic imbalance. Meanwhile, the nurse ensured that the baby was receiving supplemental oxygen via a nasal cannula to aid in respiratory distress. The nurse also started the baby on broad-spectrum antibiotics, pending the results of the blood culture. The nurse knew that if the baby's condition did not improve soon, more aggressive interventions such as mechanical ventilation and inotropic support might be needed. She prepared herself and the team for this possibility while continuing to closely observe the baby's response to treatment.

Section 5

New Diagnostic Results:

Later that day, the blood culture results came back, indicating the presence of Group B Streptococcus (GBS), a common cause of neonatal sepsis. The blood gas analysis revealed a metabolic acidosis with a pH of 7.28, pCO2 of 40 mmHg, and HCO3 of 18 mEq/L, indicating ongoing systemic hypoperfusion. Additionally, the complete blood count (CBC) showed a leukocytosis of 20,000 cells/mm3 with a left shift, further confirming the presence of infection. The blood glucose level was still high at 180 mg/dL despite the insulin administration.

Change in Patient Status:

Despite the initial interventions, the baby's condition continued to deteriorate. The heart rate escalated to 200 beats per minute, and the respiratory rate was now at 80 breaths per minute. The mottling of the skin became more pronounced and capillary refill time extended to 5 seconds. The baby also became increasingly lethargic and unresponsive. The persistent signs of poor perfusion and respiratory distress coupled with the new lab findings suggested the baby was progressing from septic shock to multiple organ dysfunction syndrome (MODS). The nurse immediately alerted the physician and discussed the next steps in the plan of care.