The case presentation is for a 5 day old male infant born prematurely at 34 weeks gestation with a very low birth weight of 1.89kg who was admitted to the NICU for respiratory distress and two episodes of apnea. Physical examination and laboratory tests were performed and showed the infant had normal vital signs and laboratory values. The infant was being treated with antibiotics, vitamins, and receiving breastmilk and KMC for episodes of apnea due to prematurity.

1. CASE PRESENTATION
ON
b/o Aarti with
Episodes of Apnea
Presented by:- neha malik

2. DEMOGRAPHIC PROFILE:
• Name : b/o aarti
• Age : 5 days of life
• Sex : male child
• Date of birth : 6th feb 2020
• Date of admission :11th February, 2020
• Ip number : 1004760
• Diagnosis :Prematurity
(34wks)VLBW(1.89kg)respiratory
distress with episodes of apnea on
5th day of life
• Educational status of mother : illiterate
• Father name : Mr. Harender
• Address : Goan barishwan , barsavan, bhojpur,
Bihar

3. HISTORY OF THE CHILD
Chief complaint:
• Prematurity (34 weeks)
• Very low birth weight – 1.89kg
• 2 episodes of apnea with respiratory distress on 5th day of life
Present medical history:
• The child got delivered at govt hospital and got admitted in lady Harding NICU
on 6th feb 2020, for KMC care, child was maintaining saturation of 99% on room
air and accepting breastfeeding well. But on 11th feb, mother suddenly complaint
that the child is not breathing, nursing staff immediately took the child in the
chronic side of NICU where the child kept on CIPAP for respiratory support. On
CIPAP child is maintaining saturation of 98%

4. CONT…
Past medical history:
• no significant past medical history
Present surgical history:
• no history of any surgical procedure
Past surgical history:
• no history of any surgical procedure in past
On admission the findings are
• Temp: -370C, pulse rate: - 60b/min respiration 12b/min…child SPO2 IS
80% on oxygen by mask 4L/min.
• Per abdomen: soft and no tenderness is present
• Investigation done on admission are: CBC, CXR, ABG analysis done.

5. BIRTH HISTORY; -
Antenatal history: -
mother received folic acid and iron calcium supplements during her pregnancy.
Mother received one doses of TT. Attended ante natal clinic. Mother undergone all
the investigations, including ultrasounds, no abnormalities are ruled out.
Intra natal history; -
• place of delivery : government hospital
• type of delivery : NVD
• condition of the baby at birth : Good, had cried immediately after birth
• birth weight : 1.89kg
Neonatal history; -
Child delivered prematurely at 34wks and the child was VLBW (1.89kg). cried
immediately after birth. No eyes discharge /infection was there. Breastfeeding was
initiated within first 24 hour of life, passed meconium and urine within first 24
hour of life. Child was kept in KMC room for KMC care.

6. FAMILY HISTORY:
Type of family: - joint family
Family medical history; - no significant history of any congenital or hereditary disease in the family
s.no Name Relation with
child
Age/sex education Health status
1 Mr. mahatv shah grandparent 44yrs/male Illiterate healthy
2 Mrs. Bindu devi Grand parent 40yrs /female Illiterate healthy
3 Mr. Harender father 24yrs/male illiterate healthy
4 Mrs. aarti mother 20yrs / male 11th pass healthy
5 Master ankesh brother 2yrs /male - healthy
6 b/o aarti self 6th day /male - NICU
.

7. PERSONAL HISTORY;
• Sleeps at least 17 to 18 hours a day
• Accepting / tolerate breastfeed well, taking breastfeed every 2 hours
• 8hours of KMC given by the family members on daily basis
• Mother is keeping the baby clean

8. SOCIOECONOMIC HISTORY:
• Type of house : concrete
• Ventilation : adequate
• Water supply : tap water
• Drainage system : covered
• Toilet facility : go for open defecation
• Medical facility : primary health centre, in motinagar
• Religion ; Hindu
• Occupation of parents ; private job of father, mother is
housewife
• Total income of the parents ; 8 thousand in a month
• IMMUNIZATION HISTORY ; immunized till date

9. PHYSICAL ASSESSMENT:
Growth measurement
• Present Weight : 1.78kgs
• Length : 46cms
Patient value Normal range REMARKS
Head circumference: 46cm 44-46cms Baby
anthropometric
measurements are
normal
Chest circumference: 27cm 28-30cms
Abdominal circumference: 28.2cms 28cm
Patient value Normal range REMARKS
Temperature: 37.1 degree C 36.5- 37.5 degree C Vital signs are
normal
Pulse: 146 beats/MIN 140-160beats/min
Respiration: 53breaths/min 40-60 breaths/min

10. Cont….
Neurological assessment;
• Child is opening eyes spontaneously
• Tone and movements are normal
General appearance:
• Consciousness : conscious
• Activity : dull
• Cleanliness : hygiene maintained
• Body built : very low birth weight
• Nourishment :NG feed provided to the child every 2 hr

11. Cont….
SKIN
• Colour : pink
• Texture : smooth
• Turgor : normal
• Capillary refill ; 3sec
• Temperature :37.1 degree Celsius
• Lesions : absent
HEAD & SCALP:
• Size : normal (H.C.=46cms)
• Shape : round and symmetrical in shape
• Hair : black hair
• Scalp : clean
: reactive

12. Cont….
EYES:
• Eye brows : symmetrical and evenly distributed
• Eye lids : normal
• Eye lash : normal distribution and black in colour
• Sclera : white in colour
• Conjunctiva : appear pink in colour
• Eye muscle : normal
EARS:
• Hearing ability : present
• External canal : normal
• Discharges : no discharge

13. Cont….
NOSE:
• Septal deviation : centrally located, no deviation
• Epistaxis : not present
• Discharges : no discharge
• Nasal polyp : no
MOUTH & THROAT:
• Lips : pink and no cleft lip is present
• Tongue : pink
• Gums : normal and healthy
• Throat : no swelling present
NECK:
• Lymph node : not palpable
• Range of motion : neck rigidity not present in the child

14. Cont…
CHEST:
• Shape : symmetric
• Movements : normal
• Respiratory rate : 56 breaths/min
• Respiratory sound : B/L clear
• Heart rate : 146b/min
• Heart sound : S1 and S2 heard
• Nasal flaring : not present
• Chest retraction : present

15. Cont…..
ABDOMEN:
Inspection:
• Abdomen distention is present
• Scar or lesion is not present
• Umbilicus is centrally located
Palpation:
• Abdomen of the child is soft and slight tenderness is present
• No mass is palpable
Auscultation: not heard
Percussion:
• sign of ascites and peritonitis seen
BACK AND SPINE:
• Posture : normal
• Deformities : none

16. Cont…
GENETALIA:
• Lymph nodes : no lymphadenopathy found
• Urethral opening : normal, child is passing urine in
diaper 4 to 5 times a day
• Testes : no abnormalities found
• Congenital defects : not any
ANUS:
• Sphincter control : not present
• Lesions : absent
• Inflammation : absent

17. Cont….
EXTREMITIES:
• Gait : can’t be observed, child is just 5d old
• Contour : normal
• Mortality : immobile
• Deformities : none
INTEGUMENTRY SYSTEM:
• Skin colour : pale
• Temperature :37.1degree Celsius
• Nails : normal

18. GROWTH AND DEVELOPMENT
HISTORY;
Child is very low birth weight and having episode of
apnea with respiratory distress

19. DAIGNOSTIC AND LABORATORY TEST:
Sl.no Investigation Patients values Normal values
1
2
3
4
5
6
7
8
9
10
11
12
Haemoglobin
WBC
Platelet count
Sodium
Potassium
Creatinine
SGPT
SGOT
Total protein
Calcium
CRP
Blood group
16.2g/dl
7.8*10000/cum
2.8*10000/cumm
143meq/l
5.1meq/l
0.62mg/dl
30U/L
29U/L
6.4g/dl
8.6mg/dl
0.4mh/l
B+
12-15g/dl
450O-11000/cumm
1.5-4lac/cumm
136-145mEq/l
3.5-5.1mEq/l
0.72-1.18 mg/dl
1-34U/L
1-31U/L
6.9-8.3g/dl
8.6 – 10.2mg/dl
0.0 – 6.0 mg/l

20. MEDICATION
Drug name Dose Route Frequency Action
Inj. PIPTAZ
Inj. Amikacin
Drops of vit D3
EBM
KMC-8hour/day-
10 hours/day
230mg
34mg
1ml
24ml
I/V
I/V
NG
NG
12hourly
12hourly
OD
2 hourly
Antibiotic
Antibiotic
Vitamin
supplement

21. ANATOMY AND PHYSIOLOGY OF
LUNGS

22. ANATOMY AND PHYSIOLOGY OF LUNGS
The lungs are pyramid-shaped, paired organs that
are connected to the trachea by the right and left
bronchi; on the inferior surface, the lungs are
bordered by the diaphragm. The diaphragm is the
flat, dome-shaped muscle located at the base of the
lungs and thoracic cavity.
The lungs are enclosed by the pleurae, which are
attached to the mediastinum. The right lung is
shorter and wider than the left lung, and the left lung
occupies a smaller volume than the right.
The cardiac notch is an indentation on the surface
of the left lung, and it allows space for the heart.

24. GROSS ANATOMY OF THE LUNGS.
Each lung is composed of smaller units called lobes.
Fissures separate these lobes from each other. The right
lung consists of three lobes: the superior, middle, and
inferior lobes. The left lung consists of two lobes: the
superior and inferior lobes. A bronchopulmonary
segment is a division of a lobe, and each lobe houses
multiple bronchopulmonary segments. Each segment
receives air from its own tertiary bronchus and is
supplied with blood by its own artery

25. PLEURA OF THE LUNGS
Each lung is enclosed within a cavity that is surrounded by the
pleura. The pleura (plural = pleurae) is a serous membrane that
surrounds the lung. The right and left pleurae, which enclose the
right and left lungs, respectively, are separated by the mediastinum.
The pleurae consist of two layers. The visceral pleura is the layer
that is superficial to the lungs, and extends into and lines the lung
fissures. In contrast, the parietal pleura is the outer layer that
connects to the thoracic wall, the mediastinum, and the diaphragm.
The visceral and parietal pleurae connect to each other at the hilum.
The pleural cavity is the space between the visceral and parietal
layers.

27. APNEA OF PREMATURITY

28. APNEA OF PREMATURITY
• Apnea is breathing that slows down or stops from any cause.
Apnea of prematurity refers to short episodes of stopped
breathing in babies who were born before 37 weeks of
pregnancy (premature birth).
• In most cases, AOP likely reflects a “physiological” rather than
a “pathological” immature state of respiratory control.
ALTERNATIVE NAMES
• Apnea - newborns; AOP;
• Blue spell - newborns;
• Dusky spell - newborns;
• Spell - newborns;
• Apnea – neonatal

29. Onset usually on third day of life
•Most premature babies have some degree of
apnea.it is inversely proportional to gestational
age: -
•7 % of neonates with GA of 34-35weeks
•15% of neonates with GA of 32-33weeks
•54% of neonates with GA of 30-31 weeks
•Nearly 100% neonates with GA of < 29 weeks or
weight < 1000gm

30. PATHOPHYSIOLOGY

31. RISK FACTORS

32. Apnea is classified into three categories
based on the presence or absence of upper
airway obstruction:
Central Apnea :-a pause in alveolar ventilation due to lack of diaphragmatic activity.
• -there is no signal to breathe being transmitted from the CNS to the respiratory muscles.
• -this is due to immaturity of brainstem control of central respiratory drive.
• -the premature infant also manifests an immature response to peripheral vagal stimulation.
Obstructive Apnea :- a pause in alveolar ventilation due to obstruction of airflow
• within the upper airway, particularly at the level of the pharynx.
• -once collapsed, mucosal adhesive forces tend to prevent the reopening of the airway
during expiration.
• -neck flexion will worsen this form of apnea.
• - excessive secretion in the nasopharynx and hypopharynx may also cause obstructive
apnea.

33. CONT…
Mixed Apnea :- a combination of both type of apnea
representing as much as 50% of all episodes.
• -mixed apnea consists of obstructed respiratory efforts
usually following central pauses.
• -central apnea is either preceded or followed by airway
obstruction

34. APNEA MONITOR

35. CAUSES
In book picture In child
There are several reasons why new-borns, in particular
those who were born early, may have apnea, including:
 If their brain is not fully developed
 If the muscles that keep the airway open are weak
present
Other stresses in a sick or premature baby may worsen
apnea, including:
 Anemia
 Feeding problems
 Heart or lung problems
 Infection
 Low oxygen levels
 Temperature problems
Not present
Present
Present
Present
Present
Not present

36. SYMPTOMS
In book picture In child
The breathing pattern of new-borns is not always regular and may
be called "periodic breathing." This pattern is even more likely in
new-borns born early (preemies).
This irregular pattern is felt to be normal, but also thought of as
immature.
It consists of short episodes (about 3 seconds) of either shallow
breathing or stopped breathing (apnea). These episodes are
followed by periods of regular breathing lasting 10 to 18 seconds.
Normal for first two days
Apnea episodes that last longer than 20 seconds are considered
serious. The baby may also have a:
 Drop-in heart rate. This heart rate drop is called bradycardia or,
sometimes, a "brady."
 Drop in oxygen level (oxygen saturation). This is called
desaturation or, sometimes a "desat."
Present in child

37. EXAMINATION AND TESTS
In book picture In child
 These babies will be placed on monitors in the hospital.
(The monitors keep track of their breathing, heart rate, and
oxygen levels.
Drops in heart rate and oxygen levels may occur for other
reasons than apnea (such as passing stool or moving around),
so the monitor tracings are most often reviewed by the health
care team.)
 Physical Exam
 Blood tests that check blood counts, electrolyte levels, and
infection
 Measurement of the levels of oxygen in the baby’s blood
 X-rays
 Apnea study, which monitors breathing effort, heart rate, and
oxygenation
Done
Done
Done
Done
Not done
Not done

38. TREATMENT
How apnea is treated depends on:
• The cause
• How often it occurs
• Severity of episodes
Babies who are otherwise healthy and sometimes have few minor episodes
are simply watched. In these cases, the episodes go away when the babies
are gently touched or "stimulated" during periods when breathing stops.
Babies who are well, but who are very premature and/or have many apnea
episodes, may be given caffeine. This will help make their breathing pattern
more regular. Sometimes, the nurse will change a baby's position, use
suction to remove fluid or mucus from the mouth or nose, or use a bag and
mask to help with breathing

39. CONT…..
In book picture In child
Breathing can be assisted by:
 Proper positioning
 Slower feeding time
 Oxygen
 Continuous positive airway pressure (CPAP)
 Breathing machine (ventilator) in extreme cases
Some infants who continue to have apnea but are
otherwise mature and healthy will be discharged from
the hospital on a home apnea monitor, with or without
caffeine, until they have outgrown their immature
breathing pattern.
Done
Not done
Done
Placed the child on
CPAP- 5/21%
Not done

40. PROGNOSIS
In book picture In child
Apnea is common in premature babies. Most babies
have normal outcomes. Mild apnea does not appear to
have long-term effects. However, preventing multiple
or severe episodes is better for the baby over the long-
term.
Apnea of prematurity most often goes away as the baby
approaches their "due date." In some cases, this may
last as long as the 44th week, such as in infants who
were born very prematurely.
Child is now stable

41. PROGESS NOTE:
Day 1- (11th feb, 2020)
• The child is conscious and under incubator. Child is on CPAP – 5/21%, Umbilical vein catheter is
inserted to the child and first line of antibiotics are started. Child is afebrile. Child had passed stool one
time during morning hours. Urine catheter is not present, child is passing urine in the diaper 4 5 times
a day.
All the required and needed Nursing care are given.
Vitals signs checked
• Temp :37.2’C
• Pulse :142b/min
• Respiration :42b/min
• SPO2 :98% on CPAP
• Medication provided as per physician order
• General assessment of the child is carried out
• Personal hygiene of the child maintained.
• Intake output is maintained.
• OG feed given to the child every 2 hourly
• Colostrum applied to the oral mucosal membrane of the child

42. Day 2 -12th feb,2020
The condition of the child is still same. Child is on CPAP – 5/21.day 2 of antibiotics. Child
is afebrile. Child had passed stool one time during morning hours. Urine catheter is not
present, child is passing urine in the diaper 4 5 times a day.
• All the required and needed Nursing care are given.
• Vitals signs checked
• Temp :37.1’C
• Pulse :144b/min
• Respiration :44b/min
• SPO2 :98% on CPAP
• Medication provided as per physician order
• Personal hygiene of the child maintained.
• Intake output is maintained.
• OG feed given to the child every 2 hourly
• Colostrum applied to the oral mucosal membrane of the child

43. Day 3 -13th feb,2020
The condition of the child is improving. CPAP is removed and child is maintaining
saturation on room air. Child is afebrile. Child had passed stool one time during morning
hours., child is passing urine in the diaper 4 5 times a day. Child is afebrile.
• All the required and needed Nursing care are given.
• Vitals signs checked
• Temp :36.8’C
• Pulse :146b/min
• Respiration :42b/min
• SPO2 :99% on room air
• Medication provided as per physician order
• Personal hygiene of the child maintained.
• Intake output is maintained.
• OG feed given to the child every 2 hourly
• Colostrum applied to the oral mucosal membrane of the child

44. Day 4 -14th feb,2020
Childs general condition is stable. personal hygiene of the child is maintained. child had a
spike of fever in the night since morning the child’s temperature is maintained to normal
range.
• All the required and needed Nursing care are given.
• Vitals signs checked
• Temp :36.7’C
• Pulse :142b/min
• Respiration :42b/min
• SPO2 :98% on room air
• Medication provided as per physician order
• Personal hygiene of the child maintained.
• Intake output is maintained.
• OG feed given to the child every 2 hourly
• Colostrum applied to the oral mucosal membrane of the child

45. HEALTH EDUCATION
• Taught parents about the importance of maintaining
personal hygiene and environmental hygiene of the
child of the child.
• Taught the parents about how to give kmc care to the
child
• Parents are taught about hoe to give NG feed to the
child properly.

46. NURSING DIAGNOSIS:
• Impaired gas exchange related to immature pulmonary functions.
• Risk of Ineffective thermoregulation related to prematurity as
evidence by lack of subcutaneous fat
• Risk of infection related to immunological defence ineffective.
• Risk of fluid volume deficit related to less fat layer
• Risk for impaired growth and development related to premature
birth
• Ineffective family coping related to the disease condition of the
child.

47. SUMMARY
b/o aarti, male child, 5days old came with the complaint
of episodes of apnea . Child put on CPAP on 5/21% to
maintain saturation and first line of antibiotics were
started. Pulse 144b/min, spo2-99% on CPAP. Child is
now stable

48. THANKYOU!!!!