CASE STUDY

1. Patient Bio-Data

 Name - Komal
 Age - 12 Years
 Sex - Female
 Religion - Hindu
 Father’s name - Mr. Ravi Singh
 Occupation - Farmer
 Education - 10th
 Mother’s name - Mrs. Savita
 Occupation - House wife
 Education - None
 Date of admission - 12/10/2019
 Informant - Father
 Diagnosis -Multiple Scleroisis
 Surgery (if any) - none
 Consultant - Dr R Kumar (pediatrician)

2. Presenting complaints (complaints given by mother)-: patient is admitted in the hospital with the complain of;

1. Weakness of both limbs since 2 months, weakness started initially with slipping of slippers, then
clumsiness while walking and eventually patient is not able to walk at all.
2. Presence of loss of sensation below umbilical region since 1 month
3. Not able to say about bladder, bowel motion since 1 month

2. History of present illness:

The patient was admitted in the medical ward on 27/12/18 with the complaints of Weakness of both limbs, Presence of loss of
sensation below umbilical region and not able to say about bladder, bowel motion. After history taking, physical assessment and
investigations, the patient is diagnosed as multiple sclerosis.

a) Approximately time of onset:

1. Weakness of both limbs since 2 months, weakness started initially with slipping of slippers, then
clumsiness while walking and eventually patient is not able to walk at all.
2. Presence of loss of sensation below umbilical region since 1 month
3. Not able to say about bladder, bowel motion since 1 month

b) Mode of onset:
1. Weakness of both limbs since 2 months, weakness started initially with slipping of slippers, then
clumsiness while walking and eventually patient is not able to walk at all.
2. Presence of loss of sensation below umbilical region since 1 month
3. Not able to say about bladder, bowel motion since 1 month

c) Sequential history of appearance of complaints:

1. Weakness of both limbs since 2 months, weakness started initially with slipping of slippers, then
clumsiness while walking and eventually patient is not able to walk at all.
2. Presence of loss of sensation below umbilical region since 1 month
3. Not able to say about bladder, bowel motion since 1 month

d) Therapy /treatment received so far:

S.no Drug name Dose Route Frequency Action

.
1. Inj. Piptaz 2.7 ml IV TDS Antibiotic
2. Inj. Gentamycin 0.3ml IV OD Antibiotic
3. Inj. Levofloxacin 8 ml IV BD Antibiotic
4. Inj . Dexamethosone 0.15 ml IV QID Corticosteroid
4. Past history: there is no any past history of headache, seizure, loss of consciousness, vomiting, trauma, fever or pain. There is no
history of difficulty in vision, any deviation of angle of mouth, drooling of saliva or difficulty of speech or regurgitation of food.

Birth history

a. Antenatal history
-mother taking adequate nutrition at the time of pregnancy: yes
-registered in the health facility: yes
-consuming iron and folic acid: yes
-regular antenatal checkups: yes (total 4 antenatal visits has been attended by mother)
- T.T vaccination: 2 doses has been taken
- Any complication to the mother: none

b. Natal history

 Type of delivery- Full term normal vaginal delivery at district hospital Raibarelli
 Baby cried/ not cried at birth- yes baby cried soon after birth
 Instrumental delivery (where)- None
 Place of delivery- district hospital
 weight of the child at birth– 2.6 kg

c. Postnatal history

-Condition of the baby: Normal

-history of any infections (PPH or any other problems): nothing significant

 5. Personal History

A) Personal hygiene of the child – Personal hygiene of the child is maintained by mother and health care worker.
B) Response of child towards illness – The patient is lethargic.
C) Response of parents to child’s illness – worried about the patient’s condition.

6. Family history:

- History of contact illness (TB/HIV): No

- History of similar ailment in the family: Not present
- History of consanguinity: no
- Birth order: second
- Number of siblings: none
- Illness: Other family members are healthy
- Any death in the family: no

7. Socio-economic history:

-nuclear/joint family: Nuclear family

-Who look after child – the mother and health workers looks after the child

-Housing condition: pucca

-Overcrowding: Not present

-rural/urban: urban

-Water source (drinking): tap water

-smoking among family members: Father

 -Schooling of the child: Not yet

8. Nutritional history:

- Breastfeed/top feeds/mixed mode of feeding: The patient is taking normal balance diet.

9. Immunization: Baby has immunized at proper time.

Any known allergies- no

Blood transfusion till date (if any): no

PHYSICAL EXAMINATION

1. General examination:

 General condition: poor

 Decubitus- not present
 Pallor - present
 Icterus- Not present
 Cynosis- Abesent
 Edema- absent
 Clubbing of nails- Not present

VITAL SIGNS

Temperature - 37.5° C
Pulse - 156 beats/ min
Respiratory rate – 64 breaths/min
Blood pressure - 89/76 mm of Hg
Oxygen saturation – 92 %

Anthropometric measurement:
 Parameters Patient value Normal value
Length 50 45-50cm
Weight 4.1 kg 2.5-3.5 kg
Head circumference 35 33-35 cm
Chest circumference 33 31-33 cm
Mid arm circumference 11 11-12 cm

Condition of skin: petechiae, redness, bruises (special areas), scratches, blunt injury, open wound are absent in the baby.

Head: normal head circumference

Condition of hairs:

a. Color - Black
b. Flag signs- absent
c. Dryness- absent
d. Pediculosis - absent
e. Dandruff - absent
f. Split ends- not present

Head shape: round

Fontanelles: not closed

Cranial sutures: Normal

Characteristics of faces:

Eyes: redness and discharge present

Ear: normal in position

Neck: trachea is in midline.

 Condition of nails: color is pinkish

Head & face: normal

2. Systematic circumference

a. Respiratory system
Respiratory rate - 40breaths/ min
Use of accessory muscles- Yes
Type of breathing - breath with the help of ventilator support
Movement/ symmetry -symmetry
Chest wall deformity - absent
Neck vein distension - absent
Trachea midline - normal
Air entry - clear
Chest indrawing - present

b. Cardiovascular system
Apex beat -150beats/min
Any murmur - present
Any other sounds - S1, S2 present

c. Abdomen
 Shape - cylindrical
 Prominent veins - absent
 Visible peristalsis - Not present
 Bowel sounds audible - clear
 Distension - present
 Abdominal wall rigidity/ guarding – Present
d. Musculoskeletal
 Joints: range of motion of joints is limited due to loss of sensation

e. Gastro nervous system:

Stool color and character: Normal
Diarrhea : absent
Constipation : Not present
Vomiting : Not present
Hematemesis : Not present
Jaundice : Not present
Abdominal pain: absent
Colic : Absent
Appetite : Absent

f. Central nervous system

Appearance - the baby looks disoriented
Posture - extended arms
Gait - unable to walk
State of sensorium – baby is not orient
Meningeal irritation -Not present
Abnormal movements - present
Sensory -sensation to touch and pain is present
GROWTH & DEVELOPMENT ASSESSMENT

Neuromascular system

Cry – cry absent in the baby

Flexion of extremities- absent

Extension of extremities – absent

Heads lags while sitting- absent

Turn head from side to side- absent

Signs of paralysis _ absent

Head lags in all position- absent

Myoclomic jerks_ absent

Reflexes :

Eyes- Blinking and papillary reflex present

Nose – sneeze reflex present

Mouth and throat –sucking reflex present, weak gag and rooting reflexes present

Extremities – weak palmar and plantar reflex present

Mass reflexes- moro and startle reflex present, stepping or dancing reflex is absent, weak asymmetric tonic neck reflex present
INVESTIGATIONS

Routine investigation:

s. Investigations Patient value Normal value Remarks

no.

1. HAEMATOLOGY
Complete blood count
Haemoglobin 18.6 g/dl 13.5-21.5
Total lecocyte count(TLC) 21000 cells/mm3 5000-19000 Increased
Differential./. leucocyte count
Neutrophils
Lymphocytes 40% 55-65
Esinophills 56% 28-38
Monocyte 03% 1-6
Basophills 02% 1.0-5.0
Platelet counts 00% 0.0-2.0
MPV 1.20 lac cells/mm3 1.5-4.5
Total RBCs 4.03 fl. 7.4-10.4
MCV (mean cell volume) 4.23 million cells/ml 3.0-5.4
MCH(mean corpus. Haemoglobin) 90.6 fl. 92-116
MCHC(mean corpus. Hb. Conc.) 30.2 pg 30-36
RDW 33.3 g/dl 29-37
HCT(hematocrit) 16.4% 11.5-14.5
2. BIOCHEMISTRY 38.3% 33-53
KIDNEY PANEL
Serum urea
Serum creatinine 48.3 mg/dl 10-45
ELECTROLYTE 0.55 mg/dl 0.6-1.5
Serum sodium
Serum potassium 143.0 mg/dl 135-145
Serum ionic calcium 4.23 mmol/l 3.5-5.3
4.24 mg/dl 4.5-5.5 Decreased
 C-Reactive Protein 21.05mg/L 0-6
Increased
3. COAGULATIION
P-TIME (PROTHROMBIN TIME) 13-9 sec
(PROTHROMBIN TIME) test 1.4 sec
(PROTHROMBIN TIME) INR 13.5 sec
(PROTHROMBIN TIME) ref. time
APTT
APTT-test 37.1 sec
APTT-control 30.0 sec
APTT-ratio 1.24

4. CSF EXAMINATION
PHYSICAL EXAMINATION
Color Clear
Ph Alkaline
Coagulam Absent
CHEMICAL EXAMINATION 98..3 mg/dl 15-45
Protein 38.1mg/dl 45-80 Increased
Glucose Decreased
MICROSCOPIC EXAMINATION 16 cells/mm3
Total nucleated cell count
Differential count 20%
Neutrophils 80%
Lymphocytes

Special investigations: MRI/ CT Scan/Biopsy/FNAC/CSF/Histo pathological has not done. In echocardiography acynotic CHD with
PDA is present.
ANATOMY OF BRAIN

DISEASE CONDITION

INTRODUCTION

DEFINITION

INCIDENCE

ETIOLOGY

PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS

s.no Book ’s picture Patient’s picture Inference

.
1.
2.

3.
4.
5.
6.

7. Absent
8. Present
9. Present Present
10. Present
11. Absent

DIAGNOSTIC EVALUATION

S. Patient picture Book picture Inference

no
.
1. History taking Done History of breathing difficulty
since birth
2. Physical examination – Done Systolic murmur present
Auscultation of heart sound reveals
continuous murmur (machinery
murmur) heard at second left
intercostal space or below the left
 clavicle or lower down, i.e a left
sternal border.

3. Chest X-ray Done Shows increased pulmonary

vascularity with increased size
heart
4. 2D echocardiogram with Doppler Done PDA is present
study

5. Cardiac catheterization can also be Not done

done to detect the extent of problems.

6. ECG reveals left arterial dilation and Not done

left ventricular hypertrophy.

7. Laboratory Studies Done Incressed TLC counts

 CBC count 21000cells/mm3
• Serum electrolyte levels
• Venous gas concentrations
• BUN and serum creatinine
levels
• Blood glucose level Done 72 g/dl
• ABG concentrations as
necessary

5 .MANAGEMENT

IN THE BOOK: -

MEDICAL MANAGEMENT
 • In symptomatic patient with PDA, Indomethacin,0.1 to 0.25 mg/kg/dose/I/V - over 30 minutes very slowly administered,
every 12 to 24 hours for 3 doses, for pharmacological closure of ductus arteriosus. Antiprostaglandin agents, aspirin,
ibuprofen and mefanaic acid can also be used.

• Supportive care is provided with rest, adequate intake of calorie for weight gain and promotion of normal growth and
development with routine care. Emotional support to the parents essential.

• Conservative management of CCF and other associated complications should be done with appropriate treatment

SURGICAL MANAGEMENT

• Transection or ligation of patent ductus arteriosus via lateral thoracotomy, a closed heart intervention is performed.

• It is done preferably between 3 and 10 years of age in asymptomatic patients and in symptomatic patients, it should be done
irrespective of age and in the presence of pulmonary hypertension.

• The result of surgery is excellent. Preoperative and post operative care for thoracic surgery to be provided with all precautions.

IN PATIENT

MEDICAL MANAGEMENT

 The antibiotics given to the patient are Inj. Dexamethosone, piptaz, levoflox.

 head up position given to the baby

 Vit K is given to the baby (Inj . Kaplin )

 Maintained provide thermal care

 Mechanical ventilation provided to the baby.

 Frequent suctioning of the baby done.

 Nebulisation is given to the baby.

 COMPLICATION

 Infective endocarditis,
 Pulmonary hypertension and pulmonary vascular occlusive disease.
 Rarely, calcification of ductus,
 Thromboembolism,
 Rheumatic heart disease
 Eisenmenger syndrome

C.NURSING DIAGNOSIS

 Decreased cardiac output related to alterations in heart rate and rhythm as evidenced by tachycardia.

 Ineffective breathing pattern related to inadequate respiratory effort as evidenced by changes in respiratory rate and continuous
mechanical ventilator support.

 Impaired gas exchange related to altered oxygen carrying capacity of blood as evidenced by tachycardia.

 Risk for infection related to long term hospital stay as evidenced by lab reports of the baby.

 Imbalanced nutrition less than body requirements related to staying on the mechanical ventilator as evidenced by weight loss
of baby.
 Risk for fluid volume deficit related to excessive fluid loss ( hyperventilation) as evidenced by skin turgor of baby.

 Fear & anxiety of parents related to baby’s disease conditions as evidenced by facial expression of parents.

 Knowledge deficit related to disease condition as evidenced by asking questions of parents of the baby.

s. Assessment Nursing Goal Implementation Rationale Evaluation

n Diagnosis
o.
5. Subjective data: Imbalanced To maintain Assessed the feeding pattern Determine the After 24 hours
nutrition less the of the baby appropriate method of of the nursing
Patient’s mother says than body nutritional feeding for infants. intervention
that her baby is not requirements status of the the patient was
feed properly related to baby To know the able to meet
staying on Assess the weight of the baby fluctuations in weight the goal
the every day and documented in of the baby partially.
mechanical file.
ventilator as Provide information
evidenced by Monitor the intake and output about the bowel
weight loss every day. pattern
of baby.
Objective data:
 The baby is enable to To check the state of
breast feed due to Monitored laboratory tests as hypoglycemia
placed on mechanical indicated: blood glucose level
ventilator To know the
Measured the abdominal girth abdominal distension
of the baby everyday
To fulfill the
Provided top feeding to the nutritional
baby (lactogen) requirement of baby

To check peristaltic
movement of the baby
Auscultated for presence of
bowel sounds. To maintain hydration
status of the baby
Administered IV fluid to the
baby

s. Assessment Nursing Goal Implementation Rationale Evaluation

n diagnosis
o
2. Subjective data: Ineffective After the 24 Help in distinguishing The Neonate
Assess the rate, depth of
The mother of the breathing hours of normal breathing and partially meet
respirations & chest
baby complaints that pattern nursing apnea the goal but
movement
the baby is not related to intervention Eliminate mucus that still on the
Suction the airway as per
breathing properly inadequate , the normal clogs the airways ventilator
need of the baby
respiratory breathing support on low
effort as pattern of pressure
evidenced by the baby Place the baby in the supine This position
changes in will position with a head and facilitates breathing
respiratory establish shoulder roll under the and decrease
rate and shoulder to produce episodes of apnea
 continuous hyperextension.
Objective data: mechanical To know the
The baby looks ventilator Checked the vital signs of the fluctuations in vital
restless and support. baby i.e. temp-36°c. HR-140 parameters
respiratory rate is 32 beats/min, R-46 breaths/min,
breaths/min Spo2-92%
Review the history of the Magnesium sulfate
mother to drugs and narcotics suppress
the respiratory center
and CNS activity.

Provided oxygen as indicated. Improvement of

oxygen and carbon
dioxide levels can
improve respiratory
function.
To helps in the lungs
Provided medications as
maturity
indicated

s. Assessment Nursing Goal Implementation Rationale Evaluation

n diagnosis
o.
4. Subjective data- Risk for To prevent Assess for signs of infection To find early signs of Partially meet
baby’s mother says infection infection infection the goal
that the baby is having related to into the Done hand washing before The leucocyte
some rashes on the long term baby and after handling the baby Actions taken to count
body hospital minimize the occurrence decreased.
stay as of infection wider.
evidenced
Objective data- by lab Make sure all equipment is To prevent infection.
I observed that ; the reports of in contact with the baby
 baby has developing the baby.
some rashes on the clean and sterile
body (TLC 21000 To prevent infection
cells/mm3) Educated the mother about from the mother
importance of hand washing
and maintenance of personal
hygiene
Helps to know presence
Checked the lab report of of infection by alteration
the baby. in leucocytes count

Changed the soiled bed
sheet and diaper of the baby
Administered antibiotic
drug as per as doctor’s order
To prevent further
infection and rashes
To reduced the sign of
infection

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
1. Subjective data- Decreased After the Assess the level of To determine the need of The baby
cardiac nursing consciousness of the baby the baby maintains
Patient’s mother output intervention adequate
complaint that the related to Checked the vital signs of To know the fluctuations cardiac output
the baby
baby ‘ s is not alterations in vital signs after the 6-8
will the baby.
responding in heart hours of
rate and maintain nursing
rhythm as adequate Assess the baby’s ECG to To know the cardiac intervention
evidenced cardiac functioning
 by output
tachycardi check dysrhythmias Capillary refill slow and
a. sometimes absent in
Assessed the baby for the these patient
Objective data- capillary refill To prevent
After checking the complications which can
vital signs there is cause harm to the baby
Assessed the respiratory
decreased cardiac
output i.e. temp- rate, rhythm and auscultate
36.5°c, HR-58 breath sounds Helps to know progress
beats/min, RR-30 of the baby & prevent
breaths/ min, BP- Monitored oxygen further damage
76/40 mm.hg saturation of the baby
To protect from the
Assessed the skin color and further complication
temperature of the baby
Helps to maintain the
circulatory volume
Administered IV fluid to the
baby

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
3. Subjective data: Impaired To maintain Monitored vital signs and To know the base line The patient
gas optimal gas documented frequently data about the parameters maintains
Patient’s mother exchange exchange Temp- 36.5°C, HR- normal vital
complaint that the related to 146bts/min, RR- signs after the
baby is having altered 44breaths/min, SPO2-90% intervention
dryness on the skin oxygen
carrying Administered oxygen to the To fulfill the oxygen
capacity baby demand of the baby
of blood
 as Tapped on the back of the To maintain normal
evidenced baby pattern of breathing
Objective data: by
tachycardi Suctioning done as the To maintain normal
I observed that there a. saturation level of the baby oxygen saturation level
is decreased level of decreased of baby
Spo2 i.e. 59%
Changed the position of the It helps to clear the lungs
baby of the baby

Observed the baby for To determine hypoxic

cyanosis on the skin state of the baby

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
6. Subjective data: Fear & To reduced Recognized the parent’s To identify the needs of The parents
anxiety of the anxiety level of fear and anxiety the parents anxiety level is
Baby’s mother asks parents level of the reduced
that what happened related to baby Orient the mother about the Helps to decrease the partially
to her baby. baby’s anxiety level of parents
environment and
disease
conditions equipments using on the
as baby
Objective data: evidenced Helps to prioritize their
Identified the needs of the
 I observed that the by facial need
mother looks expressio parents of the baby
anxious about her n of Helps to understand
baby parents Clarified their doubts about parents about the
their baby’s condition problems of the baby

To decrease the anxiety

Provided psychological level
support to the mother
Helps to understand the
Educated the mother about condition of the baby
the surgical procedure and
its complication

HEALTH EDUCATION

Breastfeeding & Weaning

 Educated the mother about the advantages of breastfeeding, importance and its effect on the baby’s weight gain.
 Educated the mother about the various techniques of breastfeeding and latching of the baby’s mouth.
 Asked the mother to take healthy and nutritious diet to fulfill the feeding requirement of the baby.
 Educated the mother about the expressed breast milk and its storage and methods of feeding the baby by katori and spoon.
 Educated the mother about importance of colostrums and burping of the baby after feed the baby to prevent backflow of milk.
  Educated the mother about the weaning and the variety of foods such as fruits, vegetables, wholegrain bread, low fat dairy
product, beans, meat and fish

Respiratory Care

 Educated the mother to protect the baby from the droplet infection such as cold because its produces cough into the baby.
 Educated the parents about use of humidifier to moisten the air because moisten air helps to cough up any mucus from the
lungs.
 Asked the parents do not smoke in the surroundings of the baby because its cause irritation to the baby.

Kangaroo mother care

 Educated the mother about the benefits of KMC for the baby such as weight gain of baby, maintenance of temperature and
adequate growth and development of baby.
 Educated the mother about the initiation and procedure of kangaroo mother care.

Immunization

 Educated the mother about the importance of vaccination to prevent the child from diseases.
 Asked the mother to vaccinate the baby according to the immunization schedule card of the baby.

Personal hygiene

 Asked the mother to maintain the personal hygiene of the baby as well as her.
 Educated the mother about maintenance of cleanliness of breast to prevent the baby from infection.
 Educated the mother about baby bath, changing the diaper, eye care, skin care etc.

Medication and follow-up

 Educated the mother about the importance of medication for the early recovery of the baby.
  Educated the mother about the importance of further surgical procedure after the weight gain of the baby.
 Educated the mother if the baby is developing fever, chills or cough, then immediately contact with the doctor.
 Asked them about the positioning of the baby which helps to facilitate adequate respiratory rate.
 Asked her to weight the baby periodically to know the progress of the baby even after discharge.
 Educated the mother about signs of complication to the baby occur, immediately go for the doctor.

PROGRESS NOTE

DAY- 1ST – The baby admitted in the NICU with the complaints of respiratory distress since 3 hours of life. The baby was kept
oxygen support & NG tube also inserted. IV fluids started immediately. After that the baby has kept on the mechanical ventilator.
Cardiac monitor attached with baby. The positive pressure ventilation is given to the baby immediately by the help of AMBU bag.
The vital signs of the baby were:-

Pulse rate- 100beats/ min

Temperature - 97.2° F

Respiration - 22breaths/min

Spo2- 60 %

To relieve patient we provide medication as prescribed by the doctor. After 5 hours of medication and nursing intervention patient’s
vital signs become normal

DAY-2nd - On the day second, the baby was still on the ventilator support. The NG tube feeding is given to the baby by the artificial
prepared milk (lactogen). The IV fluid had also given to the baby.. The bowel and bladder pattern of the baby was normal. The
shoulder roll and head roll put under the shoulder and head of the baby to decrease the risk of apnea. The inake and output chart has
been maintained. The vital signs also checked

Vital signs:

Pulse 140beats/min

Temperature 96.5 F

Respiration 46breath/min

SPO2 90%

DAY-3rd – On the third day the baby looks better from the previous days; the baby looks conscious. The baby’s intake and output is
normal. The medication is given to the baby such as inj. Kaplin and antibiotics injections vancomycin,meropeneum etc. Daily weight
recording has been done. The artificial milk lactogen (20 ml) was given to the baby by NG tube feeding. The vital signs have been
checked. The IV fluid was also given to the baby to prevent dehydration.

Vital signs:

Pulse 156beats/min
Temperature 96.2 F

Respiration 42breaths/min

Spo2 94%

BIBLIOGRAPHY

 “Sharma Rimple, Essentials of Pediatric Nursing, First Edition, Jaypee Brothers Medical Publishers LTD, 2013,Page
No. 350-355”

 “TM Beevi Assuma, Pediatric Nursing care Plans, First Edition, Jaypee Brothers Medical Publishers LTD, 2012,Page
No. 212-236”
 “Dutta Parul, Pediatric Nursing, Third Edition, Jaypee Brothers Medical Publishers LTD,2014, Page No. 361-366”

 “Wongs, Essentials of Pediatric Nursing, Eighth Edition, Reed Elsevier India Private LTD,2012,Page NO.846-848”

 “Ghai OP, Essentials of Pediatric Nursing, Eighth Edition, CBS Publishers Private LTD, 2012, Page NO. 289-292”

 “Gupta Suraj, The Short Textbook Of Pediatric Nursing, Eleventh Edition, Jaypee Brothers Medical Publishers LTD,
2013,Page No. 695-698”

 “Nelson, text book of pediatrics, 19th edition, volume 2, Reed Elsevier India Private LTD, 2013, page no. 1262-1263”