BETHLEHEM UNIVERSITY

FACULTY OF NURSING & HEALTH SCIENCES

Pediatrics of Nursing NURS 333 / Fall Semester

Data Sheet

Pt. initials: A.R.A Student name: Muna heehAge: 4 days Date of admission: 19/9/2014 Sex: male Diagnosis: URTI r/o bronchiolitis

Information:From patient’s mother ,and from patient's file and from my observation. health team members(nurses and doctors).my instructorDr (Hanan hasboun).

Chiefcomplaint: Short of breath ,cough ,fever ,running nose.

Pregnancy history: mother 26years old ,G5.P5.A0. she has 3 girls(10,8,3) years old,and 2 males (5years,4mounths) old. All of them N.V. D,nocomplication during previous pregnancy.my case, with N.V.D .and birth weight 3.100kg. full term as the mother said that she complained from viscous vein during her pregnancy and disappear after delivery .

History of present illness :A 4 month old male was admitted to CaritasHospital as case of bronchiolitis after c/o S.O.B , cough ,fever ,running nose,sleepness . the doctor during examination found the pt. complains from otitis media .

Past history: no past operation , pt. was at the same hospital before 10 days as a case of sepsis and then again readmitted as bronchiolitis . No past Diseases history or heredity diseases from his family.

Immunizations: (Since birth till now)

Type : Age BCG vaccine 1 day(take it )Hepatitis B vaccine 1 day , 1 month (both doses taken) IPV 1 month , 2 months (both doses taken)DPT 4 months (didn’t take it yet )OPV 4 months , 6 months ((didn’t take yet )

Developmental Assessment Identify norms and relate to patient).1. DDST (<6 yrs) or school performance (>6 yrs). Done (attached to the paper).

2. Psychosocial (Erikson, Freud ,Piaget)Erikson: trust versus mistrust ,the child seems trusting his mother and feel comfortable and relax with his mother. Also infant is entirely dependent upon his mother, trust the people that are caring for him(as it happened with me) and smile to strangers.

Freud: the oral phase, the child focused on the pleasures that he receive from sucking and biting with his mouth.

Piaget : The infant knows the world through his movements and sensations. only aware of what is immediately in front of him. he focus on what he see, what he doing, and physical interactions with his immediate environment.

Favorite toys, games, hobbies, interests, pets : he likes often to hold his toy (car) he like to play in hospital playing room (by giving him cards and telling him what the picture look like) .no favorite pets or interest .

Hobbies and routines and food preference : he used to at hospital routine he wake up in the morning then take a bath then breast feeding after a while he return to sleep .no food preference (only milk). No specific habits.

2.Family Assessment1. Organization (life style, environment, cultural implication).

The family has good live style, live in clean and good environment. They live in (Beit omer) . the relation between the pt.’s family very good the brothers don’t fight with each other they like to play with him . the baby live with his parents and 4brothers and sisters in good house. His father is 37 years old and he is (RN),his mother 29 years old stays at home to take care of her suns .As the mother said that she live in a quiet area and the place where she live has good ventilation, sanitation, and hygiene, no financial problems.

2-Relationships, (primary care givers, parent/child relationships, siblings relationships, recent family crisis or changes).

1. . The baby was taken all his vaccine in health care center with his mother , the mother and the father give primary care for their children , The patient attached to his mother since she is the primary caregiver during his Residence in the hospital , the relationship between family members is strong, they don’t have any problems or crisis the relation between the pt.’s family very good the brothers don’t fight with each other they like to play with him. Not very strong relationships with siplings,

PT/Family strengths and weaknesses:

1. .the relationship between husbands and family members is strong, the father work as a nurse are the mother graduated from college in Elementary Education , the financial stat is stable.Strong relationship between all family member . and not very good relationship between the husband’s family end mother`s family so the sipping relationships not very good.

4. Family tree (Genogram) with pertinent medical history.

85 yearsdiabetic 94year 69 60

not related

The father 38years the mother 29 years(RN) house keeper Healthy healthy No heredity disease in the family .

Female female 5 years10 years 8years 3years 4 months

Bronchiolitis All children born healthy

f Female female, deceased male

Good relationships

Nutritional needs:Diet: breast feeding every3 hr .Dietary habits and mealtimes: no special habits, every 3-4 hours .No IV fluid.Pt. in good growth and development R/to hir age .in good hygiene.

Physical Assessment/Review of systems:

Finding :

General appearance

he looks active, pale, child’s height 59cm, weight 6.905kg and it’s appropriate to his age, he breaths well, no abnormalities in his shape

Height: 59cm percentile: 75% Weight: 6.905 percentile: 50%

Skin:Clean and clear without lesion , the texture of his skin is smooth, no spots ,pink, smooth, unbroken, warm temp. 36.4 ,hydrated not dry . no sweat. Turgor skin was done and the result is normal (capillary refill less than 3 seconds ).

Head:H.C=41the size of skull is in proportion with the body. smooth texture, normal distribution, anterior and posterior fontanel are palpable, they are flat and soft, no tenderness.. Head in midline, the pt. moves her head up to down and from side to side (full range of motion). Anterior fontanel and posterior fontanel were open. Scalp in good hygiene, no lesions and trauma. Black color and good distribution of hair.Round and symmetrical face andcheeks,no lesions or scars ,little pale face.

Neck: normal shape, smooth, short, thick, pink color, surrounded by skin folds, no masses or tenderness, there is a presence of tonic nick reflex, supports the head in midline he is able to bend the head forward, backward, and to either side. Equal bilaterally pulses. There is no bulges or fullness in the neck, no any deviation, masses, or nodules when palpating neck structures. Thyroid gland not palpated.

Eyes:Both symmetrical, brown color ,sclera is white while conjunctiva is pink, pupils equal and clearreactive to light (it constrict when put light on , dilate when shut light), normal tears when he cry and normal eyelashes(the eyelashes are present along the margins of each eye) and brow hair. clear corneas ,. the eyes are open normally.

Ears:Both symmetrical, normal shape and location without any deformed or lumps pink external canal, intact . good hygiene, soft. no abnormal opening or discharge, normal hearing in both ears. Auricle pink in color , no discharge present. Pt has good hearing acuity and he can respond to sounds. He have acute otitis media at Rt ear .

Nose:symmetricalin midline, with each side, there is no Septal deviation ,nostrils are patent ,no tenderness ,sinusitis or lesions are present ,dry mucus membranes (mucosal lining is pink, moist ,intact , and free of obvious drainage or discharge).. Both nostrils equal in size. Septum in midline.

Mouth & throat:lips pink, smooth ,intact , and no lesions of lips, the gum is pink and intact,mucous membrane is pink, intact and moist. Tongue in midline, freely movable, no lesions or masses under the tongue and he has no teeth , no bleedingThe uvula is in midline. His hard and soft palate are pink, intact , and no lesions. The sucking reflex is good.no tonsillitis.

Chest & Lungs:The chest is symmetrical,no enlargement ,Patient has symmetrical lung expansion and normal lungs sound(no wheezes ,no crackles),good air entry to the lungs, and symmetrical nipples ,normal movement of chest up and down during breathing ,Respiratory rate is 41 Resp/min, anteroposterior and lateral diameters equal, normal nipples, symmetrical, no discharge. Clear breath sounds, normal movement of abdomen during breathing.. Good bilateral air entry.

Heart & circulatory system:Patient has regularheart rate141/min , normal heart sounds (S1& S2), No heart problems, Normal in size & shape. Blood pressure within normal. no murmurs evident ,has good peripheral circulation.

Abdomen:Soft, symmetric(cylindrical in shape), abdomen intactno rashes or masses,no lesionsor organomegaly. Clean umbilical. Normal bowel movements (frequent, hyperactive, clicks like sounds)., , soft, no bleeding or discharge, femoral pulses palpated bilateral.normal movement of abdomen during breathing.

RenalSystem: straw color urine, no history of UTI, normal urination with no burning ,no oliguria, and no infections. patient wears diapers, her mother change it for her 5-7 times per day.

Muscular/ Skeletal system:symmetrical extremities , he can crawl , can control his head or back to sit alone ,he can hold things put in her both hands, good muscle toughen .Full (ROM), no fracture, shoulders, scapula, and iliac crests symmetric. normal shape, no deformities, there is ten fingers and ten toes, good color and warmth, nails are pink.

Neurological system and reflexes: Alert, conscious, active, he can control his movement, flexion and extension of the extremities, he able to turn his head to the right and left side, with a good sensory feeling and response( the baby respond to sound and light and follow them, no tremors, good sucking. normal tone power, equal muscle tone, no neurological deficit. Pt crying sometimes due to distress or hungry, he has acceptable and cooperative behavior. Normal reflexes at all sides, good vision & hearing and good sensory of skin(blinking reflex, papillary, doll’s eyes, and corneal reflex. Nose reflexes such as Glabellar. Mouth and throat reflex such as sucking, gag, rooting, and yawn. Extremities reflex grasp, babinski).

Emotional, Intellectual: my patient is quiet child and attract the others by his smile to them. she is oriented, She alert to other ,can differentiate between stranger and his caregiver and doctor .very cooperative with other don’t seem afraid or distressed from hospitalization.

Response to illness: He seems response to treatment very well ,not distressed, cooperative when given medication, eat well, active , playing with his play most of the time .

Sleep (nap, bedtime, rituals and pears): he takes(3) naps during the day, and has good sleeping pattern, usually he sleep from 9pm to 6am , when he gets up in the morning he take his shower and BF then return to sleep .

Spiritual: relaxant music to relax her (she sing to him sometime to calmdown). he need to feel safety and love from his mother ,he need to play with and spend more time with .

PathophysiologyBronchiolitis

Bronchiolitis is a common lung infection in young children and infants. It causes congestion in the small airways (bronchioles) of the lung. Bronchiolitis is almost always caused by a virus. Typically, the peak time for bronchiolitis is during the winter months. Bronchiolitis starts out with symptoms similar to those of a common cold but then progresses to coughing, wheezing and sometimes difficulty breathing. Symptoms of bronchiolitis can last for several days to weeks, even a month. Most children get better with supportive care at home. A very small percentage of children require hospitalization.

Diagnosis procedure Laboratory results

Lab investigation(CBC)

Date19/9/2014

Pt’s value Normal value Comments

leukocytes 19.0 mm*3 5000-10000 Normal

Erythrocyte 4.29 ml/ul 4.2-6.3 10

Normal

HGB (Hemoglobin)

11.5g/dl 11-16 g/dlNormal

HCT (Hematocrit). 40% 40-50 Normal

Plt. 410 Higher than 265

Normal

CRB 3.0 mg/L Less than 5 Normal

Lab investigation Date20/9/2014

Pt’s value Normal value Comments

Glucose 103mg/dl 70-115 normal

Na 134 mmol/l 135-145 normal

K 5.0 mmol/l 3.5-5.5 normal

Pharmacology

*Name: AmpicillinTrade name: Principen, Totacillin, Omnipen, Omnipen-N, Totacillin-N.Dosage :IV350mg ,Q8hrAction : stop bacteria from multiplying by preventing bacteria from forming the walls that surround them. The walls are necessary to protect bacteria from their environment and to keep the contents of the bacterial cell together. Bacteria cannot survive without a cell wall. Penicillins are most effective when bacteria are actively multiplying and forming cell walls.Rational : for treating bacterial infections (bronchiolitis).Side effect : nausea, vomiting, loss of appetite, diarrhea, abdominal pain, rash, itching, headache, confusion and dizziness.Nursing consideration : Persons who are allergic to the cephalosporin class of antibiotics, which are related to the penicillins, for example, cefaclor (Ceclor), cephalexin (Keflex), and cefprozil (Cefzil), may or may not be allergic to penicillins. Serious but rare reactions include seizures, severe allergic reactions (anaphylaxis), and low platelet or red blood cell count. Ampicillin can alter the normal bacteria in the colon and encourage overgrowth of some bacteria such as Clostridium difficile which causes inflammation of the colon (pseudomembranous colitis). Patients who develop signs of pseudomembranous colitis after starting ampicillin (diarrhea, fever, abdominal pain, and possibly shock) should contact their physician immediately.

Evaluation : pt was for 10 days under treatment and from lab test it was effective.

*Name : AcamolTrade name : Paracetamol or Tylenol

Dosage : 3.5cc po

Action: Paracetamol is a clinically-proven non-salicylate analgesic and antipyretic with rapid absorption and action. It produces analgesia by elevation of the pain threshold, and antipyresis through action on the hypothalamic heat-regulating center.

Rational: antipyretic ,to reduce fever .

Side effect : it could cause serious damage to the liver, or bleeding in the stomach.

Nursing consideration: If a sensitivity reaction occurs, discontinue use. Paracetamol should be given with care to patients with impaired kidney or liver function. Risk-benefit ratio should be taken into consideration in the presence of viral hepatitis and alcoholism, since there is an increased risk of hepatotoxicity.

Evaluation : pt no more complain from fever.

Dx1. Ineffective Breathing Pattern related to increased work of breathing and decreased energy (fatigue).Goal: 1-The child will return to respiratory baseline. The child will not experience respiratory failure

2-The child’s oxygenation status will return to baseline

Nursing action :

1-Assess respiratory status a minimum of every 2–4 hours or more often as indicated for a decreasing respiratory rate and episodes of apnea. Cardio respiratorymonitor and pulse oximeter attached with alarms set.Record and report changes promptlyto physician.

Rational : Assessment and monitoring baseline reveal rate and quality of air exchange. Frequent assessment and monitoring provides objective evidence of changes in the quality of respiratory effort, enabling prompt and effective intervention

2-Administer humidified oxygen via mask, hood, or tent.

Rational :Humidified oxygen loosens secretions and helps maintain oxygenation status and ease respiratory distress

3-Position head of bed up or place child in position of comfort on parent’s lap, if crying or struggling in crib or bed.

Rational :Position facilitates improved aeration and promotes decrease in anxiety

Outcomes:1-The child returns to respiratory baseline within 48–72 hours.

2-The child’s respiratory effort eases. Pulse oximetry reading remains less 94%oxygen saturation during treatment

3-The child rests quietly in position of comfort.

Dx2- imbalanced nutrition, less than body requirements, related to illness.Goalsafter 30min the pt. should be able to breast fed

Nursing Action: - weigh daily.- give milk formula.- monitor daily laboratory data.- treated the illness. Rationale:- to prevent dehydration.- to prevent losing weight.- to maintain skin integrity.Evaluation: The goal is met.

DX3. Risk for Fluid Volume Deficit related to inability to meet body requirements

and increased metabolic demand.

Goal: 1-Child’s immediate fluid deficit is corrected.

2-Child will be adequately hydrated, be able to tolerate oral fluids, and progress to normal diet (BF)

Nursing action :

1-Evaluate need for intravenous fluids. Maintain IV, if ordered.Rational: Previous fluid loss may require immediate replacement.

2-Perform daily weight measurement on the same scale at the same time of day. Evaluate skin turgor.

Rational: Further evidence of improvement of hydration status

3-Assess mucous membranes and presence of tears. Report changes promptly to physician.

Rational Moist mucous membranes and tears provide observable evidenceof hydration.

Outcomes:

1-Child’s hydration status is maintainedduring acute phase of illness.

2-Child’s weight stabilizes after 24–48hours; skin turgor is supple

3-Child shows evidence of improved hydration

DX4. Anxiety (Child and Parent) related to acute illness, hospitalization, uncertain course of illness and treatment, and home care needs.

Goal: 1-Child and parents will demonstrate behaviors that indicate decrease in anxiety.

2-Parents will verbalize knowledge of symptoms of bronchiolitis and use of home care methods before the child’s discharge from the hospital.

Nursing action :1-Encourage parents to express fears and ask questions; provide direct answers and discuss care, procedures, and condition changes.

Rational: Provides opportunity to vent feelings and receive timely, relevant information. Helps reduce parents’ anxiety and increase trust in nursing staff.

2-Incorporate parents in the child’s care. Encourage parents to bring familiar objects from home. Ask about and incorporate in care plan the home routines for feeding and sleeping

Rational: Familiar people, routines, and objects decrease the child’s anxiety and increase parents’ sense of control over unexpected, uncertain situation

3-Explain symptoms, treatment, and home care of bronchiolitis. Anticipate potential for recurrence. Rational: Assist family to be prepared should respiratory symptoms recur afterdischarge

4-Provide written instructions for follow-up care arrangements as neededRational: written and oral instructions reinforce knowledge. Parents maynot “hear” and remember the particulars of home care if presented only orally

Outcomes:

1-Parents and child show decreasing anxiety and decreasing fear as symptoms improve and as child and parents feel more secure in hospital environment.

2-Parent freely asks questions and participates in the child’s care Thechild cries less and allows staff to hold and/or touch him

3-Parent accurately describes respiratory symptoms and initial home careactions.

STUDENT SELF EVALUATION:-

What I learned?:

I learned from my case about the physical, emotional, and social development of the child Also I learn and understand that children are not simply small adults They often present different symptoms from adults. They need different prescriptions or treatments than adults. And it was an apprutunity to know more about one of upper respiratory diseases (bronchiolitis) in related to pathophisiology,S&S,complication and how to take care of a child with this disease .

What I need to work on?:I need to improve my knowledge about pediatric disease in order to be able to manage and caring the child and to have the confidence in my knowledge to advice parents how to take care their children and avoid complication .

What I liked the best?I was having difficulty in learning reflexes but after I took this case it was very easy to me to know them, also loved working with children in over all , it was A very useful opportunity to work with the best in this field .

*References

From my observation.

Patient chart.

Health team members (nurses and doctor).

From patient.

Previous data sheets

Internet references :

http://emedicine.medscape.com/article/961963

http://kidshealth.org/parent/system/medical/newborn_screening_test

http://www.peds.arizona.edu/medstudents/Physicalexamination

Book References

Lenin (1995) pharmacology, Philadelphia, Lippincoot Company, fourth edition. Pillitter, Adel, maternal and child health nursing, fourth edition. Gil Bert and human, manual of high risk pregnancy and delivery, third edition 2003