Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Age: [Baby’s Age in Days or Hours]
Gestational Age: [Weeks]
Birth Weight: [Grams]
Chief Complaint:
Respiratory distress (increased work of breathing)
History of Present Illness:
Onset of respiratory distress (immediately after birth or hours/days later).
Presenting symptoms (tachypnea – rapid breathing, retractions – chest wall pulling inward with each breath, grunting, nasal flaring).
Oxygen requirement (if any).
Maternal history (prenatal complications, infections, chorioamnionitis).
Physical Exam:
General examination: Assess for prematurity, cyanosis (bluish skin coloration), and signs of respiratory distress.
Vital signs: Heart rate, respiratory rate, oxygen saturation (measured by pulse oximetry).
Chest examination: Assess for breath sounds (rales – crackling sounds indicative of fluid in the lungs) and chest wall movement (symmetry, retractions).
Laboratory Tests:
Blood gas analysis: Measures blood pH, oxygen and carbon dioxide levels to assess respiratory function and acidosis (if present).
Complete blood count (CBC): May be done to rule out other causes of respiratory distress (e.g., sepsis).
Chest X-ray: May show a characteristic “grainy” appearance of the lungs in infants with NRDS.
Assessment:
Neonatal respiratory distress syndrome (NRDS): Based on clinical presentation (respiratory distress) and supportive findings on chest examination and chest X-ray (if obtained).
Severity of NRDS: Classified based on the level of oxygen support needed (room air, low-flow oxygen, mechanical ventilation).
Possible risk factors (if identified):
Prematurity (most common risk factor)
Maternal factors (diabetes, chorioamnionitis)
Meconium aspiration (inhalation of stool during birth)
Plan:
The plan will depend on the severity of NRDS and the infant’s overall condition. Possible elements include:
Supportive care: Maintaining warmth, ensuring adequate oxygenation and ventilation.
Oxygen therapy: May include nasal cannula, hood, or mechanical ventilation depending on the severity.
Surfactant replacement therapy: Administration of synthetic surfactant to improve lung function and decrease surface tension in the alveoli.
Monitoring: Close monitoring of vital signs, oxygen saturation, blood gases, and chest X-ray (if obtained).
Consultations: Consider referral to a neonatologist for complex cases or those not responding to initial treatment.
Disposition:
Admit to the neonatal intensive care unit (NICU) for close monitoring and treatment with oxygen therapy, surfactant, and possible mechanical ventilation.
Prognosis:
The prognosis for NRDS depends on the severity, gestational age, and presence of other complications. With prompt diagnosis and treatment, most infants with NRDS recover well.
Education:
Educate parents about NRDS, its causes, and the importance of monitoring their baby for signs of respiratory distress.
Discuss the treatment options and the course of care in the NICU.
Provide emotional support and address parental concerns.