Clinical Case Studies for the Family Nurse Practitioner, First Edition. Edited by Leslie Neal-Boylan.
© 2011 John Wiley & Sons, Inc. Published 2011 by John Wiley & Sons, Inc.
9
SUBJECTIVE
Caitlin, a 12 - hour - old female, was born at home via planned home birth. She was brought into the offi ce for an initial health maintenance visit. On initial examination, she was found to have rapid breathing when the offi ce nurse weighed her. Caitlin is accompanied by both parents. There are no parental concerns.
Birth h istory: Caitlin is the product of a 40 - week gestation. She was delivered vaginally at home by a certifi ed nurse midwife. During the pregnancy, Caitlin ’ s mother had no falls, infections, or known exposures to environmental hazards. She did not drink alcohol, take prescription medication (other than prenatal vitamins), use tobacco products, or use illicit drugs. The total labor duration was 2 hours. Caitlin ’ s birth weight was 3380 g and her Apgars were 9 at 1 minute and 9 at 5 minutes.
Social h istory: Caitlin was born to a 37 - year - old mother. Caitlin is the second child and has a 3 - year - old sibling. She lives at home with both parents and her older sibling. The family employs an au pair who also resides in the home. Both parents are college educated. The mother works as a research assistant, and the father works as an accountant. There are no pets or smokers in the home.
Diet: Breastfeeding ad lib, but mother feels that Caitlin is having problems latching on. Colostrum is present. Milk has not come in yet.
Elimination: Urinated at birth, and has had 3 wet diapers since that time. Passed meconium at 10 hours of age.
Sleep: Sleeps between feedings.
Family m edical h istory: PGF (age 67): sarcoidosis; PGM (age 63): healthy; MGF (age 64): Type 2 diabetes; MGM (age 64): history of MI at age 63; mother (age 37): healthy; father (age 42): healthy;
Sibling #1 (age 3): healthy; history of bronchiolitis.
Medications: Currently taking no prescription, herbal, or over - the - counter medications.
Allergies: No known allergies to food, medications, or environment.
By Mikki Meadows - Oliver , PhD, RN
10 The Neonate
OBJECTIVE
Vital s igns: Weight in the offi ce today is 3360 g; length: 48 cm; temperature: 37.2 ° C (rectal); pulse oximeter reading: 95% on room air.
General: Alert, active baby.
Skin: Clear with no lesions noted; no cyanosis of skin, lips, or nails; no diaphoresis noted; skin turgor intact.
Head: Molding present; anterior fontanel open and fl at (2 cm × 2 cm); posterior fontanel open and fl at (1 cm × 1 cm).
Eyes: Red refl ex present bilaterally; pupils equal, round, and reactive to light; no discharge noted.
Ears: Pinnae normal; Tympanic membranes gray bilaterally with positive light refl ex.
Nose: Both nostrils patent; no discharge; mild nasal fl aring.
Oropharynx: Mucous membranes moist; no teeth present; no lesions.
Neck: Supple; no nodes.
Respiratory: RR = 68; crackles present in lower lung fi elds bilaterally; mild intercostal retractions;
no grunting. No deformities of the thoracic cage noted.
Cardiac/Peripheral v ascular: HR = 120; regular rhythm; no murmur noted; brachial and femoral pulses present and 2 + bilaterally.
Abdomen/Gastrointestinal: Soft, nontender, nondistended, no evidence of hepatosplenomegaly.
Umbilical is cord in place with no signs and symptoms of infection.
Genitourinary: Normal female genitalia.
Back: Spine straight.
Extremities: Full range of motion of all extremities; warm and well - perfused; capillary refi ll < 2 seconds; negative hip click.
Neurologic: Good suck and cry; good tone in all extremities; positive Moro, rooting, gag, plantar, palmar, and Babinski refl exes.
CRITICAL THINKING
Which diagnostic or imaging studies should be considered to assist with or confi rm the diagnosis?
___Chest radiograph
___ Arterial blood gas ( ABG ) ___Pulmonary function tests
What is the most likely differential diagnosis and why?
___Transient tachypnea of the newborn ___Pneumonia
___Neonatal sepsis
What is your plan of treatment, referral, and follow - up care?
Are there any demographic characteristics that would affect this case?
What if the patient lived in a rural, isolated setting?
Are there any standardized guidelines that you should use to assess or treat this case?
Pulmonary Screening Exam 11
RESOLUTION
Diagnostic t ests: It is important to obtain an arterial blood gas (ABG) to determine the level of gas exchange and acid - base balance. The ABG results reveal mild respiratory and metabolic acidosis.
Chest radiography is the diagnostic standard for transient tachypnea of the newborn. The chest radiograph shows generalized overexpansion of the lung (hypoaeration of alveoli) and fl attened contours of the diaphragm which are consistent with transient tachypnea of the newborn.
What is the most likely differential diagnosis and why?
Transient tachypnea of the newborn (TTN):
Transient tachypnea of the newborn ( TTN ) is a self - limited disease. Approximately 1% of neonates have some form of respiratory distress that is not associated with infection such as transient tachy- pnea of the newborn. TTN results from a delay in clearance of fetal liquid from the lungs. Infants with TTN usually present with tachypnea within the fi rst few hours of life. It has been associated with precipitous deliveries and births by cesarean section. The use of medications in TTN is minimal, although empiric antibiotics are often used for 48 hours after birth until sepsis has been ruled out.
Medical care of TTN is supportive. As the retained lung fl uid is absorbed by the infant ’ s lymphatic system, the pulmonary status of the infant typically improves. TTN resolves over a 24 - hour to 72 - hour period.
What is your plan of treatment, referral, and follow - up care?
• Begin oxygen therapy in the offi ce.
• Refer the patient and family to the local emergency department for support of the respiratory system, a workup for possible sepsis (complete blood count, blood cultures, lumbar puncture for culture of cerebrospinal fl uid, and urine culture), and consultation with a neonatologist. An ambulance should be called to transport the baby from the offi ce to the emergency department so that the baby ’ s airway and respiratory status may be maintained.
• Provide emotional support to the parents. Allow the parents to verbalize their concerns about their baby ’ s health status. Facilitate mother - infant attachment.
Are there any demographic characteristics that would affect this case?
The risk for TTN is equal in males and females. There has been no association with race or ethnicity reported. TTN presents as respiratory distress in full - term or near - term infants.
What if the patient lived in a rural, isolated setting?
Health care providers practicing in rural, isolated settings should have emergency offi ce plans in place for patients experiencing respiratory distress.
Are there any standardized guidelines that you should use to assess or treat this case?
There were no standardized guidelines located in the literature for the assessment and/or treatment of transient tachypnea of the newborn.
REFERENCES AND RESOURCES
Kasap , B. , Duman , N. , Ozer , E. , Tatli , M. , Kumral , A. , & Ozkan , H. ( 2008 ). Transient tachypnea of the newborn:
Predictive factor for prolonged tachypnea . Pediatrics International , 50 , 81 – 84 .
Liem , J. , Huq , S. , Ekuma , O. , Becker , A. , & Kozyrskyj , A. ( 2007 ). Transient tachypnea of the newborn may be an early clinical manifestation of wheezing symptoms . The Journal of Pediatrics , 151 , 29 – 33 .
Takaya , A. , Igarashi , M. , Nakajima , M. , Miyake , H. , Shima , Y. , & Suzuki , S. ( 2008 ). Risk factors for transient tachypnea of the newborn in infants delivered vaginally at 37 weeks or later . Journal of Nippon Medical School , 75 , 269 – 273 .