PAEDIATRIC NURSING CARE PLAN. I. GENERAL INFORMATION
Name of the child
: Master . Nitesh
Gender
: male
Age
: 2.7years
Religion
: Hindu
Date of admission
: 18 – 01 – 2009
IP.No
: 540251
Provisional diagnosis
: Broncho Pneumonia.
Final diagnosis
: Broncho Pneumonia
II. INTRODUCTION
As a part of my clinical requirement when I had been posted to Vani Vilas Hospital, I selected a patient by name master Nitesh who is been diagnosed as gastroenteritis to provide complete nursing care by using a nursing Process. I provided her care from 19.01.09 to 21.01.09.
VI. SIGIFICANT FAMILY HISTORY There’s no history of any familial diseases or any congenital diseases in the family or siblings
and no history of hypertension and diabetes mellitus.
VII. PRENATAL HISTORY: There is not consangeous marriage. Antenatal period mother has all antenatal checkups
and had been immunized there was no history of any abnormal condition during pregnancy. During pregnancy there was no history of illness during the pregnancy. Intake of mother during pregnancy mother had only iron and folic acid tablets and didn’t have any other drugs that could affect the pregnancy. VIII.NATAL HISTORY
After the full term the baby was delivered by lower segment caesarean section and baby weighed around 2.3 kgs and cried immediately with the apgar scoring to 8 at 1 min and 10 at 5 min. POSTNATAL HISTORY :
The child was normal breast feed and there was no complication during the postnatal period. There were no signs of infection .the mother had normal involution of the uterus.
X.IMMUNISATION SECHDULE Sl. No
Name of the Scheduled time of Route of Given Not vaccine administration administration given 1 BCG At birth Intradermal Yes 2, Oral polio At birth, up to 5 oral Yes vaccine years 3. DPT 6wks,10 wks.14wks Intramuscular Yes 4. MMR 9 months subcutaneous Yes 5. Hepatitis 6wks,10 wks, intramuscular Yes IX.NUTRITIONAL HISTORY Till the 7 months of age of the child he was under breast feeding and additional feeding th
started from 8 month. At present the child has one chapatti in morning with 1 glass of mild and midmorning has 4 biscuits afternoon has 1 cup rise dal at 4 pm has 1 cup of mild with 2 biscuits and at 6pm has any one fruit and at 8 pm 1 chapatti and water intake is up to 1 liter. APPETITE- presently due to his disease condition is reduced and the child refuses for the feeds and feels very lethargic. Nutritional assessment
The child weighs 12kgs which is on average to his age his anthropometric measurements are nearly to the normal measures hence the child is not malnourished his nutritional status is to the moderate level.
3. Fine motor activity – builds town of 9 or 10 cubes, in drawing copies a circle .imitates a
cross names, what he has a drawn, but he cannot stick figures.
4. Sensory motor development: Child puts on clothes on his own. feet himself and wear shoes put son the shoe place ,takes both with assistance knows fire hurts him and his vision is improved he does not have steroposis and binocular vision.
5. Self care: Eats on his own washes hands after eating on and dresses himself ,tries to groom his hair on own.
6. Psychosocial development: According to Erick Ercikson the development task at this stage is Sense of initiative v/s guilt.4-5years has identifies with the same sex partners and peers able to judge right from wrong, good from bad. 7. Psychosexual development: According to Sigmund Freud – this is an age so Phallic stage (3-6) yrs were the child is more attached to the mother than to the father this is called Oedipus complex.
8. Intellectual development: Remember things, books and searches for the objects that have been lost for a long time knows many things and identifies colors around him.
VITAL SIGNS o
Temperature : 100 F Pulse
: 100 bt/m
Respiration : 24 breath /m
ANTHROPOMETERIC MEASUREMENTS .
Birth weight
: 2.3kgs
Present weight
: 10kgs
Length /height
: 92cm
Head circumference
: 46cm
Mid arm circumference
: 13cm
Chest circumference.
: 48cm
SKIN: child skin is in dark colour, turgor is normal. Pruritis is absent and even purpuric spots
are absent.
HEAD & HAIR: Anterior fontanel and posterior fontanels are closed. Sutures are normal and
there is no widening of the sutures. Scalp veins are not visible and crack-pot sign is absent. Hair is clean, black in colour and well distributed.
MOUTH: the child open and close the mouth normally and no difficulty or pain. Halitosis is
absent. Lips are in brown in colour, teeth are healthy. Plaque is moist and child’s palate doesn’t have any abnormality like cleft lip and cleft palate. Child has the gag reflex. 0
NECK: Neck movements are normal at 180 . Trachea located at center. There is no thyroid
enlargement and even neck veins are normal.
CHEST AND LUNGS: Chest movements are symmetrical with intercostals retractions since
one month. Respiratory rate is 24 breaths/ min with regular movements and long with wheezing sounds. CARDIO VASCULAR SYSTEM: Pulse rate is 124 beats/ min with regular pattern. There is
no palpitation. Blood pressure is 100/80 mm of Hg. The child doesn’t have any congenital abnormalities in his previous medical and surgical history.
ABDOMEN: the child doesn’t have any sign of abdominal distension, bowel sounds are present
with regular movements. Other organs like liver and spleen are not palpable. Ascots are absent. Umbilicus is normal and visible veins and palpable mass are absent.
Lower extremity: wasting of muscles and has no strength in walking on independently. Muscle tone: moderate Ankle edema : absent Congenital deformity - there is no signs of any of the congenital abnormality.
CENTRAL NERVOUS SYSTEM: Spine is normal with absence of spino bifida. Cranial
nerves are normal. Glasgow coma scale is conscious and oriented to place and time. Moro reflex – absent as the child is a toddler. Sucking reflex – absent Plantar reflex – present
DISCRIPTION OF DISEASE Bronchopneumonia is an acute or chronic inflammation of the lungs, in which the alveoli and / or interstitial are affected. Pneumonias are the most common cause of death among infectious diseases. They take the fifth place in the statistics of diseases causing death.
CAUSES OF BRONCHOPNEUMONIA In most cases it occurs because of descends (which is going down) infection of the bronchi in an acute bronchitis. Inflammatory foci in different sizes are formed in the lung parenchym, which contain purulent
• Brownish-red sputa on the second day with plenty of leucocytes. • Chest pain when breathing due to the accompany ing pleurisy. • Chest pain when breathing due to the accompanying pleurisy. • Laboratory data - acceleration of ESR, blood count -
leucocytosis (increased leucocytes),toxic granulations, eosinopenia (reduction of eosinophils), lymphopenia (reduction of lymphocytes). • X-ray examination – thick, comparatively sharply outlined large overshadowing
Symptoms in atypical pneumonia 1. Slow start 2. Headache 3. Muscle pain (myalgia) 4. Little temperature (without fever) 5. Dry irritating cough without expectoration (spitting) 6. Weak auscultatory findings (rales almost missing) Complications of the bronchopneumonia • Septic distribution to the pneumonia agents through the blood with the development of otitis, meningitis,
brain abscess, endocarditis. • Pleura damage – pleurisy, pleural effusion, pleural empyema. • Recurrent pneumonia, affecting other lung sections. • Chronic pneumonia • Cardiovascular disease • Respiratory deficiency • Thromboembolic complications due to bed rest
Differential count WBC Eosinophils Basophils ESR Lymphocytes
2.
Protein
6000 – 5000/cumm 2- 3% 0 – 0.5 % < 20 -30mm/ hr 51 % 1.6 – 7.4 mg/dl
3.
Urea
20-40 mg /dl
38.3mg /dl
Hyper uremia
4.
Creatinine
0.6 – 1.2mg/dl
0.9mg/dl
No deviation
12000 / cumm 5% 1% 35 mm / hour 48 %
No deviation Increased Increased Increased No deviation
1.67
Hypoproteemia
TREATMENT Antibiotics 1. After taking bronchial secretions (sputum), unintentional treatment should immediately start without awaiting the results of bacteriological examination. 2.Targeted treatment is started after receiving the results of microbiology, according the a ntibiograma. If necessary the antibiotic have to be changed. 3. In severe cases, “blind” treatment of bronchopneumonia is undertaken with a combination of 2 antibiotics.
IN MY PATIENT XIII. MEDICATIONS
3
Inj
Benzyl IV
penicillin
4
Inj Gentamycin
250m
BD
g
IV
12.5 mg
Bd
They act by interfering in with synthesis of bacterial peptidoglycen cell wal.pencillin diffuse well into tissue and body fluids ,but penetration into the CSF is poor excepts when the menninges are inflamed It binds to 30 s and 50 s ribosomal subunits of susceptible bacteria disrupting protein synthesis, thus rendering the bacterial cell membrane defective.
Fever,hypersens etivityand urticaria
Nephro toxicity and ototoxicity
XIV. IDENTIFICATION OF PROBLEMS ACCORDING TO PRIORITY
Altered body temperature and body discomfort related to the infection
Imbalanced nutrition: less than body requirement related to loss of appetite, lack of intake of food, and anxiety, loss of appetite as evidenced by considerable loss of weight and changes paleness of eye.
ASSESSMENT
SUBJECTIVE DATA: The mother complain that the child having high body temperature
NURSING DIAGNOSIS
Altered
body
temperature and body discomfort
related
the disease condition. OBJECTIVE DATA On observation the child had fever of 100 degree Fahrenheit and had body discomfort
to
OBJECTIVES
INTERVENTIONS
EVALUATION
To maintain the normal body temperature and reduction of fever
- Regularly monitor the temperature and vital signs of the child and record.
The child fever was decreased.
- assess the type of fever its intensity and frequency. - provide tepid sponging tot eh child to reduce the fever. - provide comfortable clothes and loosen the tight clothes. -Provide adequate ventilation to the child and fresh cool air. -provide some cool drinks to drink -Administer the antipyretic medication to the child as per doctors orders Paracetamal 150ms TID - Also check for the signs of convulsions and dehydration.
ASSESSMENT
NURSING DIAGNOSIS
OBJECTIVE
PLANNING
EVALUATION
SUBJECTIVE DATA:
Imbalanced nutritional status less than body requirement resulted to loss of appetite and refusal to the feeds which is evidenced by weight loss.
To maintain the nutritional status of the child by regular feeding practices,
Assess the dietary pattern to the child present and before the condition and calculate the calorie requirement for the child
The nutritional status of the child is improved.
The mother complaints that the child is refusing to take feeds.
- plan a diet which fulfills the needs of the child
OJECTIVE DATA : On observation the child is irritable and doesn’t take feeds and refuses to feeds.
- Collect the detailed history of the child’s likes and dislikes in food preparation. - explain the mother the importance of maintenance of diet and its modified preparations which she could prepare. - modify the look of the food into pleasant colour, taste and smell that would attract the child to have it. - check the weight of the child regularly -avoid food items that are harmful to the child health condition. - The food should be rich in green leafy vegetable and fruits. -advise to drink adequate amount of water so as to maintain fluid and electrolyte balance.
ASSESSMENT
NURSING DIANOSIS
OBJECTIVES
PLANNING
EVALUATION
SUBJECTIVE DATA:
Activity intolerance related to generalized weakness, fatigue, imbalance between oxygen supply and demand.
To improve the health status of the child and relive weakness
- assess the child ‘level of physical tolerance.
The activity intolerance of the child was reduced and the health status of the child was improved.
Mother complains that the child is very dull and inactive and feels very tired on doing slight activity.
- anticipate child’s need for rest as evidenced by irritability, short attention span and fretfulness: assist child in those activities of daily living that may be beyond tolerance.
OBJECTIVE DATA: On observation the child looked to be very dull and lethargic and had generalized weakness.
- provide divers ional activated appropriate to the child’s age and interest to conserve energy. Instruct child to rest when feeling tired. - provide quiet environment to promote sleep. - organize activities for maximum sleep time. - schedule visiting to allow for sufficient rest. - encourage parents to remain with child to decrease separation and anxiety,
ASSESSSMENT
NURSING DIAGNOSIS
OBJECTIVES
PLANNING
EVALUATION
SUBJECTIVE DATA;
Anxiety and fear related to distressing procedures ,events,
To reduce stress and fear.
-prepare child as needed to reduce fear of the unknown and to promote cooperation.
Anxiety and fear of the child was reduced.
The child complains that he has fear of injections.
OBJECTVIE DATA On observation the child started to cry when a nurse took the tray near him to perform a procedure he ahs hear of procedures and this Stressing events.
- involve parents to unable them to serve as effective resources for their child. - recognize developmental fears associated with illness and procedures to ensure appropriate intervention. - provide age appropriate explanations for procedures the child may see or hear performed on other patients to decrease child’s fear. - provide privacy for any procedures that exposes the body. - answer questions and explain purpose of activated Keep child and family informed of progress.
ASSESSMENT
NURSING DIAGNOSIS
OBJECTIVE
PLANNING
SUBJECTIVE DATA: Mother complains that the child doesn’t co operate in bathing and doesn’t maintain hygiene.
Bathing /hygiene and dressing /grooming self care deficit related to physical or cognitive disability, mechanical restrictions.
To improve personal hygiene
- allow child to help plan own daily routine and choose from alternative when appropriate to promote sense of control. Encourage participation in self care activities according to development level and capabilities to promote mastery and decrease regression.
OBJECTIVE DATA : On observation the child was found to have lack of personal hygiene.
EVALUATION
Child has improved personal hygiene.
- provide devices and equipment and methods to assist the child in self care. -bath the child daily and keep the skin dry. - advocate for child sized features that foster independence (eg.bathroom door handles low enough for children to reach) - assist with dressing, grooming, bathing as indicated.
XVI. CONCLUSION.
After providing care to the patient by using nursing theory, better changes can be seen in Mast. Nitesh’s both physically and mentally. Now client and his family understand his condition and better cope up with the situation.
