NPM : 22011180046
1. Personal Information
- Name : xxxx
- Age : 2,5 months
- Sex : Male
- DOA : 10 - 9 - 2006
- Diagnosis : Pertusis
- Nationality : K
2. Family History
Both parents are alive, they are middle class family.
Father is working in defence, living in Jahra.
Mother is a house wife.
Patient has 2 sisters and one brother. Parents are young. They have no known history of any cronic ilness like diabetics, heart disease, hypertension or blood disorder. Child has normal milestares up to the age. His birth weight was 3 kg. He was born in a full term normal delivery.
3. Past Medical History
Child was admitted in J hospital on 10 - 9 - 2006 at 2 am for fever and cough. No chronic ilness noted.
4. Immediate Care Given
A baby got admitted in IDH, pediatric ward on 10 - 9 - 2006 at 11 am with chief complaints of paroxysmal cough and fever since 2 weeks.
Provisionally diagnosed as ? pertussis.
Placed a child in a comfortable position to promote easier ventilation. Orientation given to parents about calling system bell, visiting time, ward set up etc.
Health teaching given about strict isolation to prevent cross infection. Instruction given to the mother not to go others room, wash the hands before and after giving feed.
Explained about vaccination schedule and how to take care of baby. Reassure the parents.
Vital sign monitor and recorded, temperature 38.5 degree celcius, pulse 140/minute, respiration rate 42/minute.
Adol drops one dropper given, cold compress applied. Oxygen by mask, suction machine, pulse oxymeter kept ready in the room. oxygen saturation 100% in room air. Child is taking artificial feeding S26 and breast feed. O2 by mask 4 litres/mnt given when the child become cyanosis.
CBC : WBC - 30.1/L
Lymph - 74.5%
Platelets - 783/L
Hb - 783/L
RFT : K - 5.57 mmol/ L
Na - 138.9 mmol/L
Glucose - 4.8mmol/L
Urea - 3.5 mmol/L
Creatine - 58mmol/L
Albumin - 42 g/L
5. On Going Treatment
Child had thick secretion, suction done to clear air way.
IV fluid of dextrose 5% with 0.225% normal saline started at the rate of 5 drops/ minute.
Injection Rocephin 500mg iv given after skin test negative as an antibiotic. Ventolin nebulization 0.2ml with atrovent 10 drops with normal saline 2 ml every 6 hourly, as prophylatic treatment.
Tuscalman suppository 1 x 2 administered per rectum to reduce secretion.
6.NURSING CARE RENDERED
1.Identification problem : Difficulty in breathing ( RR 50/mnt)
Objectives : The patient is relieved of dyspnoea and to maintain normal breathing.
Nursing intervensions :
- Asses vital signs 1 hourly
- O2 by mask 4 litre/ mnt as ordered.
- Keep the patient comfortable with semi sitting position
- Monitor O2 saturation 8 hourly as docter order.
- Observe the colour of lips, mucosa and nail beds for cyanosis.
2.Identification problem : Paroxysmal cough
Objectives : Patients is relieved from discomfort due to cough
Nursing intervension :
- Hold the baby in prone position with the head elevated.
- Do suction gently if needed.
- Maintain cough chart
- Observed the characteristic and duration of cough.
- Administer medicine as ordered.
- During nebulization hold the baby in sitting position.
3.Identification problem : Elevared temperature (temperature 38.5 C)
Objectives: The patient is relieved of hyperpyrexia and to maintain normal body temperature.
Nursing intervensions :
- Asses temperature, pulse, respiration regularly.
- Increased fluid intake.
- Apply cold compress or tepid sponging.
- Keep patient dry and comfortable.
- Berikan adol drops as order.
4.Identification problem: Knowledge deficit of parents.
Objectives: Parents will verbalise understanding of disease and homecare measure
- Asses readiness, level of understanding and current knowledge of illness
- Provide environtment, conducive to learning.
- Explain disease process as simply as possible.
- Inform parents treatment regimen.
7.Out come of care and present health status
Child was in the hospital 5 days. First day child was crying,irritable and noted 18 times cough. Child become dyspnoeic after cough, O2 by mask given 4 litre/mnt. Suction done, when there was thick secretion nebulization was getting every 6 hourly. Feeds taken and tolerated. Day by day condition of the child was improved.
8.Difficulties while rendering planned care
While giving adol drops child spitted out the medicine twice., the patient is infant, child is unable to expectorate the secretion. While giving nebulization child is irritable and moving too much.So proper positioning is not achieved.
catatan : pasien diambil dari rumah sakit Infectious Diseases ruang anak tempat penulis bekerja.