Term newborn - Nursing Case Study

Pathophysiology

• Primary mechanism: Transition from fetal to neonatal circulation - At birth, when a newborn takes their first breath, the increase in oxygen levels causes the ductus arteriosus and foramen ovale to close, transitioning the baby from fetal to neonatal circulation. This change can cause issues if not properly transitioned, leading to conditions like persistent pulmonary hypertension.

• Secondary mechanism: Thermoregulation - Newborns are susceptible to heat loss due to a larger body surface area relative to their weight, thin skin, and lack of subcutaneous fat. Difficulty in maintaining body temperature can lead to hypothermia, affecting metabolic processes and oxygen consumption.

• Key complication: Immature immune system - Term newborns have an underdeveloped immune system, making them vulnerable to infections. Their immune response is primarily humoral with limited memory cells, leading to a greater risk of sepsis and other severe infections.

Patient Profile

Demographics:

Newborn, Male, Not Applicable

History:

• No past medical history (Term newborn)

• No current medications

• No known allergies

Current Presentation:

• Chief complaint: Poor feeding, lethargy

• Key symptoms: Poor feeding, decreased activity, low urine output, fever

• Vital signs: Temperature 38.5°C (101.3°F), Heart rate 175 beats per minute, Respiratory rate 60 breaths per minute, Blood pressure 60/30 mmHg, Oxygen saturation 89% on room air

Section 1

Initial Assessment Findings:

Upon further examination, the newborn male exhibits a mottled skin appearance and a weak cry. His fontanelles are slightly sunken, indicating potential dehydration. His weight is marked at 2.9 kg, which is a little under the average for term newborns. The newborn's capillary refill time is slightly delayed, recorded at 3 seconds which may indicate poor perfusion. His Moro reflex is weak, which can be indicative of a neurological abnormality or significant fatigue.

Auscultation of the chest reveals tachycardia with a regular rhythm but a murmur is detected, raising concerns for a potential congenital heart defect. The newborn’s respiratory rate remains elevated at 62 breaths per minute, and his breath sounds are shallow with faint crackles noted bilaterally. His oxygen saturation fluctuates between 88% and 90% on room air, signaling potential respiratory distress.

These findings suggest that the newborn’s condition is worsening, and he may be experiencing complications related to his transition from fetal to neonatal circulation and his ability to thermoregulate. His poor feeding and lethargy could be signs of sepsis or another severe infection, given his immature immune system. Immediate medical intervention and further diagnostic tests are required to evaluate his hemodynamic status, confirm any suspected diagnoses, and implement appropriate therapeutic strategies.

Section 2

New Diagnostic Results:

Following the initial assessment, the newborn was sent for additional tests to further investigate the observed anomalies. An echocardiogram revealed a small ventricular septal defect (VSD), explaining the murmur and the tachycardia. Blood cultures were also drawn to rule out sepsis, given his signs of potential infection and respiratory distress. The results showed no bacterial growth, ruling out sepsis as the cause of the observed symptoms. However, a complete blood count (CBC) demonstrated a low number of white blood cells (3.2 x 103/uL) and a decreased platelet count (120,000/uL), indicating a possible viral infection or another non-bacterial illness.

Change in Patient Status:

Despite initial efforts to stabilize the newborn, his condition continued to deteriorate. His oxygen saturation dropped to 85% and his respiratory rate increased to 68 breaths per minute, indicating worsening respiratory distress. His heart rate remained tachycardic at 190 beats per minute, and he was increasingly lethargic, showing decreased responsiveness. The mottling of his skin worsened, suggesting an ongoing issue with perfusion. He was also unable to maintain his body temperature, with a recorded temperature of 35.5 degrees Celsius, indicating hypothermia. These changes in the newborn’s status show an increased need for aggressive medical intervention to address his deteriorating condition.

Section 3

Response to Interventions:

In response to the newborn's deteriorating status, a multidisciplinary team was quickly engaged. The neonatologist decided to place the baby on supplemental oxygen via nasal cannula, which improved his oxygen saturation levels to 92%. However, his respiratory rate remained high, suggesting the need for further respiratory support. It was decided to initiate non-invasive positive pressure ventilation (NIPPV) to reduce the work of breathing. In addition, Intravenous fluid therapy was started to combat dehydration and provide nutritional support. Despite these interventions, the newborn's heart rate remained elevated and his temperature continued to decline.

New Complications:

As the team continued to monitor the newborn, new complications began to emerge. He developed jaundice, with a total bilirubin level of 15 mg/dL, and an abdominal ultrasound revealed an enlarged liver. This could indicate a liver dysfunction, possibly due to a viral infection, which would also explain the low white blood cell and platelet counts. Meanwhile, his blood glucose dropped to 40 mg/dL, indicating neonatal hypoglycemia, a common complication in sick newborns. The team now faced the challenge of managing these new complications while continuing to stabilize the baby's respiratory and cardiac conditions. These developments require a comprehensive approach to care that connects the newborn's symptoms and responses to interventions, to effectively manage his complex health status.

Section 4

Change in Patient Status:

Over the next 48 hours, the baby's condition continued to deteriorate. His bilirubin levels rose to 22 mg/dL, and despite phototherapy, his jaundice worsened. His heart rate remained elevated at 180 beats per minute, and his temperature dropped to 96.6°F. His blood glucose levels persistently hovered around 30-35 mg/dL, despite continuous glucose infusion. Additionally, his respiratory distress seemed to be worsening, with grunting and nasal flaring noted, and oxygen saturation levels fluctuating between 88-92% even with continuous NIPPV support.

The team also noted that the newborn was increasingly lethargic, showing little interest in feeding and had decreased bowel movements. His abdomen appeared distended, and a repeat ultrasound showed increased liver size and signs of ascites. His blood reports showed a further decrease in white blood cells and platelets, with a rise in liver enzymes, suggesting worsening of the suspected liver infection. The team was now facing a critical situation, with the newborn's multiple organ systems affected and his condition becoming increasingly unstable. This situation demanded a swift reassessment of the current management plan and possibly more aggressive interventions.

Section 5

New Diagnostic Results:

Given the worsening condition of the newborn, the medical team decided to conduct further diagnostics. A blood culture revealed the presence of Escherichia coli (E. coli), confirming a sepsis diagnosis. An MRI scan also indicated the presence of a small intraventricular hemorrhage, which could explain the newborn's lethargy and poor feeding. The liver biopsy results supported the suspicion of an infected liver as it showed signs of cholangitis and steatosis.

These new findings were a cause for concern as they indicated a severe bacterial infection and possible brain injury. The team needed to quickly determine the best course of action to manage these new complications and reassess their current treatment plan. The presence of E. coli in the blood indicated that the infection was systemic, and the newborn might require a change from the current antibiotic regimen to a more broad-spectrum one. The intraventricular hemorrhage also suggested potential neurological complications, which might require neurology consultation and further monitoring. The liver results indicated that more aggressive management of the jaundice and infection might be necessary. The team needed to weigh the risks and benefits of each possible intervention, considering the newborn's fragile state.