Infant Respiratory Distress Syndrome - Essay Example

Introduction Children need to be well taken care of, even when they are born at full term. This is because any carelessness on the part of caregivers can expose the child to any number of elements that can compromise the health of the infant. For preterm infants, this is even more so because they do not have a robust enough system to withstand too many shocks to their system. Vigilance, therefore, is essential if preterm infants are to enjoy good health and grow to maturity. This paper is a review and reflection on the care of a preterm infant within four hours of birth. Mother and infant remained in the hospital for observation and care in the intensive ward. The baby was diagnosed as having respiratory distress syndrome and this paper presents nursing care over the course of one shift, including reflections of this nurse on what was done for the baby and its mother and what might have been done better. The reflection also includes points about the working relationship among nursing staff and the doctor in charge of the mother and the baby. . Background The mother had rushed to the hospital in a taxi the previous night and was found to be in labour. She was asked to remain overnight for observation. She was not due to give birth until the next five weeks or so but her description of the pains she had had earlier on gave the doctor in charge the view that she might have been having the kind of contractions that could result in premature delivery. Not surprisingly, in the morning, around 8:40 a.m., she gave birth to a baby boy. The baby appeared healthy at first and for the first couple of hours, all seemed well. In about three hours, however, while on a routine observation of the ward in which this mother and her infant were, this nurse heard some distressing sounds coming from the mother. She said that from time to time the baby looked bluish and that it appeared as though the child could not breathe properly. The mother was clearly agitated, believing that she was going to lose her baby. Since a medical intervention cannot be made merely on speculation or on a whim it was important to gather as much information as possible. Even though the mother was agitated that the nursing staff was wasting time by not doing something, the proper approach was to gather as much information as possible within the shortest time possible and to combine that with observation in order to deliver the kind of care that would address the specific needs of the infant. Knowing that the baby had been born preterm was important but it was also important to get a fuller picture of the mother by consulting her chart, which gave no indication that she had been susceptible in the past to diabetes or asthma. These two health conditions were particularly important because if the mother had had asthma before it could very well be that the child had susceptibility as well. The other information, regarding diabetes, was in connection with the possibility of respiratory distress syndrome, which is not uncommon among babies whose mothers were diabetic and that had been delivered preterm. Diagnosis Since the child had been born only a few hours earlier and the hospital did not have any known triggers for asthma such as dust or smoke, it looked more and more like respiratory distress syndrome, especially when it was observed that indeed, the child appeared to have tachypnea, with more than 60 breathes per minute and that there were intercostals and subcostal retractions, along with nasal flaring and grunting. “Tachypnea is due to an attempt to increase minute ventilation to compensate for a decreased tidal volume and increased dead space. Retractions occur as the infant is forced to generate a high intrathoracic pressure to expand the poorly compliant lungs. Grunting results from the partial closure of the glottis during forced expiration in an effort to maintain [functional residual capacity] FRC” (Respiratory Distress Syndrome ). The infant in question was exhibiting the combination of factors that helped to support the view that the child might be suffering from respiratory distress syndrome. Background Infant respiratory distress syndrome, or hyaline membrane disease, is considered to be one of the most life threatening conditions for newly born babies. It has been found that “Surfactant deficiency at birth is the main precipitating factor for RDS. Pulmonary surfactant is synthesized and stored in type II alveolar epithelial cells as laemallar bodies, which re released by exocytosis into the alveolar space, where they are transformed into tubular myelin, a lattice-like structure that give rise to the surfactant monolyer that lines the alveolus” (Kazumasa et al. 2003 p25). In order to be sure about the diagnosis, information about the mother’s medical history was elicited, in particular, if she had had caesarean section without labor or if she had diabetes. Though I recognized the seriousness of the condition, knowing that “RDS affects 40,000 infants each year in the US and accounts for approximately 20% of neonatal deaths” (Respiratory Distress Syndrome ), it was important not to alarm the mother. Rather, it was important to give her the assurance that since the hospital was aware of what the baby was suffering from, that we were on the road to providing the necessary care to make him better. The mother was given the assurance that all would be well. This helped to calm her down and to make her less visibly excited and worried. The mother was informed that she and the baby would have to remain in the hospital for some time yet. Since it was a very busy time, the doctor in charge was able to spend only a few minutes with the baby and the mother. This made the mother worried that her baby was not getting the best attention possible. The mother was given the assurance that nurses were very experienced and that she was in good hands and did not need to worry. Though the baby was the one in distress it was important not to ignore the mother because emotional distress in mothers of preterm infants could be hurtful to the overall pattern of care. It does not help to make a child well only to see its mother sick. A holistic approach is therefore needed to ensure that both mother and baby are well. Knowing from studies by Miles et al. (1991) that sighs and sounds in the environment could be major stressors for such mothers, the mother was asked about her comfort level with the lighting in the room. In addition, “Issues related to parental role alteration (separation and powerlessness) and infant appearance (illness and vulnerability) were also rated as stressful” (Reid and Bramwell 2003 p280). While there was not much that could be done about the appearance of the baby at that very moment, it was possible to maintain the connection between the mother and the child and so no attempt was made to separate the two. Reflection Considering that the child was only a few hours old, the doctor decided against having radiography even though this would have provided a more definitive diagnosis. In fact, “The typical chest radiography whose low lung volumes and a bilateral, reticular granular pattern (ground glass appearance) with superimposed air bronchograms. In more severe cases, there is complete “white out” of the lung fields” (Respiratory Distress Syndrome ). Application of positive airway pressure appeared to minimize the baby’s condition but did not completely eliminate the irregular and belaboured breathing of the baby. The mother was encouraged to provide breast feeding for the baby; this was important since one of the key elements for the management of respiratory distress syndrome is to ensure that nutrition is maximized and that there is a reduction on the child of metabolic demands. The temperature of the room was also raised in keeping with the knowledge that hypothermia is a risk factor for babies with respiratory distress syndrome. Reflective practice Having the chance to reflect upon one’s behaviour and actions can be very useful in helping to eliminate unproductive or wrong-headed approaches. The benefit for nurses’ having to reflect on their work can be the nurses themselves who can have the opportunity to operate in the future at a more optimal capacity in terms of their ability and also to ensure more positive outcomes for the patients in their care if such reflection leads to fewer errors and more on-target application of the nurses’ knowledge. Not surprisingly, it has been suggested in some quarters that “reflection is the hallmark of professional nursing practice (Mantzoukas and Jasper 2004 926). In fact, reflection has reached the point of dogma in professional nursing care. As important as reflection is, one has to consider how it is that a nurse that is running around all day or night has the chance to properly reflect. A nurse that has no breathing or thinking time may be able to reflect later on, perhaps in the comfort of his or her home, but it is unlikely that the patients that are being cared for at the moment will have the benefit of the nurses’ reflections, unless they come back at another time! Reflection, as individual as it is, need not always be done by oneself. A person who reflects on mistakes and has no way of knowing what the proper procedures are does not benefit from improved practice and might end up repeating some of those same old ways, to the detriment of patients. A hospital that recognizes the importance of reflection might provide ways by which nurses can share their ideas and get the views of more experienced mentors so that their reflection and any areas that need to be improved can be improved through up-to-date knowledge. In an environment where managers simply talk down to nurses, there is not much opportunity or indeed willingness on the part of nurses to take their concerns up the chain of command. It has been found, in some research, that nurses’ always having to defer to doctors, sometimes undermines the care for the patients. This is because even though doctors are supposed to be more knowledgeable than nurses, they are human and sometimes make mistakes, in some cases, very obvious ones. In such a case, a nurse that is afraid to speak up might be hurting a patient. As Mantsoukas and Jasper (2004) write: Although no longer controlled by…doctors, the nurses are still perceived to maintain an unequal power relationship. This notion of inferiority is related to the value attributed to specific types of knowledge that imbue the beholder with power. Thus, much of nursing knowledge goes unrecognized and under-valued as it does not emerge from the dominant scientific paradigm. Hence, although nurses may have knowledge of alternative actions to be more effective in specific cases than those prescribed by the dormant paradigm, rather than implementing this knowledge, nurses are subjugated to the dominant power structure. (Mantsoukas and Jasper 2004 929). Even though the doctor with whom I have to work is considered one of the most knowledgeable she is also one of the most considerate when it comes to recognizing nurses’ knowledge. Rather than “bossing” nurses around, the doctor sometimes asks nurses what they think; this has helped boost morale for nurses and in this particular case, because the doctor knows of my previous experience with preterm babies, she discussed the case at length with me, thinking aloud and asking for my input regarding what would be in the best interest of the mother and her baby. As one nurse noted with regards to the issue of reflection, “there is not any formal reflection, not on the ward. It will have to be on my own time. If I wanted to look something up, yeah, they would not give it to you” (Mantzoukas and Jasper 2004 930). Hospitals are very busy and the management come to consider the making of time at the hospital’s expense for reflection a waste. While dedicated nurses such as myself are not unwilling to reflect on our practice outside of the work setting, I must admit that there are times when this leaves a lingering feeling of anger of being robbed of one’s free time. It is only the commitment and the love of the nursing profession that helps to keep me balanced but certainly with no thanks to management policies that provide room for the benefits of reflective practice rooted in the culture of the hospital as a whole. Even though reflective practice is widely touted in nursing circles the truth of the matter is that when it comes to doctors and hospital management it is something that must be kept private. While my hospital does not prohibit reflective practice there is no strong support of it either, a reality that leaves nurses groping at times to find out how they can fit in better with the other professionals without always feeling that they are inferior. It certainly helps, to find within the confining environment of my hospital a few doctors who are not so tethered to conventional notions that they are not willing to give other paradigms of practice an opportunity to be used in the hospital setting for the good of patients. The baby fell asleep soundly after a couple of hours following the mother’s distress call and during that period, this nurse went over to have a chat with the mother. This was an attempt to connect with the mother not just in the context of her sick child but to let her see that we could see her for the person she was, someone with connections in the community and a history. As it turned out, the two of us had a lot in common in terms of our mutual interest in reading. The thirty minutes or so we spent chatting really buoyed the mother’s spirits even though our conversation were generally on the more mundane aspects of life rather than the health of her child. Also, every hour or so within my shift, I went back to check on the mother and to ask about the child’s condition. Also, the mother’s own assessment of how the child was doing was important because it helped to reinforce the mother’s connection to the child and helped to obviate the notion that doctors and nurses felt that they knew so much more than the mother. Asking the mother herself how she was doing on a periodic basis also helped the mother to realize that her welfare was no less important to the hospital staff. The mother also took an interest in me and asked me questions about my family and background. Differential diagnosis While the doctor was satisfied that the problem was respiratory distress syndrome, she felt that the mother and the baby should remain under our care for some time so that various other tests could be taken. While the doctor appeared set against radiography, she wanted to ensure that there were no such other problems as diaphragmatic hernia, pulmonary sequestration, or chlothorax, or congenital heart anomalies. Other issues that she wanted to check out were haematological problems such as anaemia and polycythaemia. In this regard, the doctor hoped that over the next few days or so she could have full blood count, and perhaps have a pulse oximetry done to monitor the baby’s oxygen saturation level. Meanwhile, on the basis of the diagnosis of respiratory distress syndrome, the doctor suggested surfactant replacement therapy to be given via an endotracheal tube. The child was not at the point where it was necessary to give it oxygen but the doctor was adamant that we maintain a continual positive airway pressure in order to keep the alveoli open. Once the child woke up the problems began again and so the period of sleep had been an important respite for both the mother and the baby. Information to mother Having become somewhat bonded to the mother, it became easy to relay to her advice that could help her take care of the child. This included asking her to be gentle in handling the child. Also, she was asked to note how we kept the temperature of the room relatively high so as to avoid hypothermia. The mother was also told about the importance of maintaining fluids and monitoring blood glucose. All of this information was presented in a way that would not alarm the mother and make her feel that the child was on the verge of death. The doctor was considering the use of antibiotics but wanted to wait for a while. It seemed that if any such antibiotics would be administered it would be outside my shift because the target time for possibly administering antibiotics fell outside of my shift period. One thing that could not escape my notice was that for the most part I have had to work by myself, with the occasional assistance from another nurse and minimal contact with any mentor or supervisor. Because of this, I have had to become a leader of sorts, and to take my learning and growth into my own hands. Knowing the continued importance of practice with evidence in mind, I have tried to keep up with the literature and to read as widely as possible regarding some of the more common ailments and conditions that appear in my hospital setting. My condition is not all that surprising. Nursing supervisors are spread thin and simply do not have the time to ensure that those under them are doing everything in the best way possible. As a nurse who is committed to my profession I accept the challenge of extending the boundaries of my knowledge. Regarding the lack of supervision, Dame Jill Macleod Clark writes in the article “learning for Reality,” that, “It is widely acknowledged that ‘clinical placement overload’ is currently endemic as a result of the exponential rise in the numbers of nursing students in the UK. There are also ever-increasing pressures on clinical nurses throughout the healthcare system. As a result, nursing students have to be exposed to a wider and wider range of practice learning experiences in diverse settings which, although valuable in their own right, do not always provide appropriate opportunities for the development, practice and consolidation of nursing skills” (Clark 2006). Conclusion At the time of the discharge of the mother and the baby I was not in the hospital. Later on, however, she called to thank me for taking good care of her. I assured her that I was doing my best as I had always done and expressed my happiness for the positive outcome. It seems that more than the positive outcome for the child’s case, the mother was happy that I had taken the time to get to know her and not treated her as just a number or an appendage to her child. By recognizing her individuality I gave her a good impression about the nursing profession in general and about my practice in particular. It was fortunate that the interventions we put in place for her son worked out well. If there are any future complications, I am sure that the mother would think of our hospital first, knowing that she will be given the care that she deserves. For me, going the extra mile for the patient is a matter of course because I do not see individuals as means to an end but as ends in themselves, as people who matter and deserve the very best that our health care system can offer. 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