Nursing Care Plan on Malaria for a 3-year-old male patient, Study Guides, Projects, Research of Nursing

Download Nursing Care Plan on Malaria for a 3-year-old male patient and more Study Guides, Projects, Research Nursing in PDF only on Docsity! NURSING CARE PLAN ON MALARIA SUBJECT: CHILD HEALTH (PAEDIATRIC) NURSING IST IDENTIFICATION DATA OF PATIENT “ Name/Nick Name- Mohd Zaid * Age /Sex- 3 years / Male “ Weight- 8 Kg * Father's Name- Shah Nawaj “ Occupation of Father- Teacher “ Education of Child- N/A * Religion- Muslim * Address- 815 Shakti colony Amargarh Jaipur “ Language spoken- Hindi Informants relative/ parents- Mother & Father * Date of Admission- 7/10/20 “> Ward- MU-III * Registration No.- 26697 * Bed. No.- Bed No.7 Me “ Consultant’s name- Dr.Ashok Gupta “ Diagnosis- Malaria PRESENT COMPLAIN * Fever* 5 days * Diarrhoea *2 days * Shallow grunting respiration “* Feeding problem &Letharginess. “ seizure PRESENT MEDICAL HISTORY The child was free from symptoms 5 days ago, then he develops shivering .2days later he suffers from the fever. Firstly the child was taken to the near dispensary Amagarh jaipur city. Where he is diagnosed as the Maleria. After all the child is taken to the JK Loan hospital in pediatric medical unit 3". PAST MEDICAL/SURGICAL HISTORY No any surgical significant history found. Baby birth with normal vaginal delivery. OBESTETRICAL HISTORY Antenatel History “+ Mother was antenatally registered at clinic/Hospital/health center Yes, registered at sub centre. During pregnancy suffered from any infection/disease (HTN, DM etc.) specify? Mother suffered from mildanaemia. She was on any drug except Vitamin, Fe or Calcium. IFA tablets twice a day for 3 months. Received Tetanus Toxoid injection. (2 dose) Yes received two doses of T.T. If other vaccine is given place a tick mark- Yes/No yes Hepatitis B/MMR /HiB Vaccine / Typhoid / Varicella (chicken pox)/ Hepatitis A / Japanese encephalitis PHYSICAL EXAMINATION ¢ General condition of child- Comfortable / Anxious / Restless / Tonic posture “+ Patient is- Conscious / Drowsy / Stupors / Comatose Vital sign “ Temperature 100..8° F + Pulse- 124/Min “> Respiration- 35 b/Min “> BP- 70/88 mmhg Anthropometry of child “+ Weight - 8Kg “+ Height - 85cm “+ Head circumference - 42 cm Examination of head, Neck and Face “* Shape of head- Normal “+ Anterior fontanel - closed “+ Posterior fontanel - Fused * Other findings- Hair distribution-black and normal Face-symmetrical There is no abnormality in size and shape of head. Examination of eyes, ears, nose, and chin “+ Eyes slate gray in color. ** Corneal papillary & blink reflex present. “> Pinna flexible & cartilage present. “* Sneeze &Glabellar reflexes are present. “+ Flaring of nares. Examination of mouth and throat “+ Sucking, gag, rooting, yawning, and cough reflexes are present. “+ Intact, high-arched palate. > Uvula in midline. + All structures in oral cavity appear normal. Examination of neck- ¢ Short, thick, symmetric neck. “ Tonic-neck reflex present «+ Head movements are normal & full range of motion. Examination of skin and Nail- “ Nail beds bluish. ¢ Dry skin with poor turgor Examination of chest intercostals spaces during inspiration. + Round in shape Examination of abdomen- “+ Cylindrical in shape. “ Distended Examination of upper extremities “> Nail bed bluish. * Ten fingers. Symmetry of extremities Equal bilateral brachial pulse Full range of motion. % & % % Examination of lower extremities “+ No of toes-ten “+ Symmetry of extremities “+ Full range of motion Examination of genitalia “+ Urethral opening is present at tip of glans penis. * Testes palpable in each scrotum. «+ Scrotum covered with rugae, deeply pigmented no fluid in scrotum. “ No ambiguous genitalia. “+ No masses in scrotum. Systemic examination * Cardiovascular system Tachycardia (124/min), Flushed appearance. Pallor Respiratory system. Difficulty in breathing, Tachypnea (36/mi) Central nervous system Lethargic Digestive system breast feed. loose motion No H/O vomiting . Distended abdomen. * Musculoskeletal system Spine is straight Both shoulders are at same level No congenital dislocation of hips No H/O tenderness, heat over swelling over the joints Full range of motion present CLINICAL MANIFESTATIONS Book Picture Patient Picture Dyspnea Present Diarrhoea Present Fast Breathing More Than 36/Min | Present Fever Present Seizure Present Inability To Feed Present Shivering Present INVESTIGATION:- Test Name Value Normal Value HB 11.8 12 -18.0 TLC 9.57 4500-11000 DLC Neutrophil 36 % 40-75 Lymphocyte 51 % 20-45 Eosinophil 06 % 1-6 Monocyte 07 % 2-10 Basophil 00 % 0-0 RBC count 5.74 Million/cmm | 3.5-5.0 CRP negativ e MCV 69.7 Um3 44-72 MCH 22.6 Picogram 26.5-33.5 Urea 77 mg/dl 13-45 Platelet count 604 Lakh/cmm 1.50-4.00 Serum creatinine | 0.60 mg/dl 0.7-1.3 Sr Ca 10 mg/dl 8-10.5 Bilirubin Totle 0.29 mg/dl 0.3-1.2 Bilirubin Direct | 0.19 mg/dl 0-.3 SGOT 109 IU/L 0-37 SGPT 193 IU/L 0-42 MP QBC Positive  Assessment Nursing Diagnosis Desired Outcome Intervention Planned Implementation (Action) Rationale Evaluation Objective data Patient exhibits thin,weak, tachycardia (136/min) and (lethargic) and doarrhoea of causative factors when known and necessary intervention. Long term - After 1 week of nursing intervention the client will demonstrate progressive status 4.Prevent minimize over eating food. 5.serve food in attractive manner. in the appetite. necessary intervention. After 1 week of nursing intervention the child has demonstrated progressive weight gain towards goal. 3.Subjectiv e data Parents complains of fever Objective data Body temperatur e100°F Pulse 148/min Resp 54/min Altered body temperatu re hyperther mia related to infection evidenced by hyperther mia. To maintain temperat ure within normal limits. 1.Monitor vital sign 2.Reduce temperature 3.Maintain personal hygiene 1.monitor body temperature every hour for increase in temperature 2.Monitor heart rate 3.Provide tepid sponging. 4.Give antipyretic drugs as ordered 5.Give plenty of fluids 6.Light clothing 7.Ventilated room 8.Give skin care and mouth care 9.Change lines and feeding cover as necessary 1.Increased temp. will destroy cells and causes dehydration. 2.Resp. rate is increased due to increased O2 demand. 3.Heart rate is increased as the result of fever dehydration. 4.Basic measure to bring down temperature. These drugs down the temperature. 5.Fluids helps in elimination thus reducing temperature.  Assessment Nursing Diagnosis Desired Outcome Intervention Planned Implementation (Action) Rationale Evaluation 6.Makes the patient comfortable 7.Give clean feeling and promotes well being. 4.Subjectiv e data Parents complains of therapy feeding problem, difficulty breathing Objective data TLC -9.74 cu/mm Lymphocyte s45% ESR 12mm/hr Body temp- 100°F Pulse 136/min Resp 54/min Risk for infection related to presence of infective organism evidenced by increased WBC count To prevent secondar y infection. 1.Maintain aseptic environment 2.Administor medication 3.Maintain personal hygiene 4.Maintain aseptic environment 5.Administor medication 6.Health education 1.Washing the hands before providing care to patient 2.Use sterile equipments 3.Limit the number of visitors and screen for any recent illness in visitors 1.Give antibiotic as indicated 2.Monitor side-effects of antibiotic 1..Give skin and oral care 2..Change linens and bedding covers as necessary 1.Practise hand washing after touching the patient 2.Sterilize or disinfect equipments after use. 3.Limit the number of visitors 1.Give antibiotics as ordered 1.Educate the family members about hand washing technique and necessary precaution to be 1.Prevents cross infection 2.Prevents cross infection 3.Prevents cross infection 1.Antibiotic reduce existing infection and prevent new infections Helps to prevent complication. 1.Inhibts the growth of infective agents 2.Cleanliness and dryness inhibits the growth of infective agents 1.Prevent spread of infection 2.Prevent spread of infection 3.Prevent spread of infection 1.Antibiotics kill infective agents 1.Education gives knowledge and knowledge leads to Current infection is resolved without any complication  Assessment Nursing Diagnosis Desired Outcome Intervention Planned Implementation (Action) Rationale Evaluation taken for prevention of infection. practice 5.Subjectiv e data Requests for information Objective data Statement of misconcepti on failure to improve Knowledg e deficit regarding condition treatment, care related to lack of exposure evidenced by requests for informatio nand statement of misconcep tion To improve knowledg eof family members regarding condition treatmen t&care of baby etc. Teaching disease process 1.Review pathology of Malaria condition 2.Discuss debilitating aspects of disease, length of convalescence and recovery expectations 3.Provide information in written and verbal form. 4.Emphasize necessity for continuing antibiotic therapy for prescribed period. 5.Stress importance of continuing medical follow- up and obtaining medication on as appropriate 1.Promotes understanding of current situation 2.Information can enhance coping and help reduce anxiety excessive concern 3.Fatigue and depression can affect ability to follow medical regimen 4.Early discontinuation of antibiotic may result in failure to completely resolve infectious process. 5.May prevent recurrence of brain damage and/or related complications Parents verbalize understanding of condition. Disease process, therapeutic regimen and prognosis.