CHILD HEALTH NURSING
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Nursing care plan
On
Diarrehea
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SUBMITTED TO SUBMITTED BY
Mrs. Rakhi Ghosh. Pritha Biswas
Senior Lecturer M.Sc (N) 1st yr
C.O.N., M.C.H C.O.N., M.C.H
Kolkata Kolkata
Identification Data:
Name of the baby : Pritam Ghosh
Sex : Male
Age : 4 years
Religion : Hindu
Address : Ghoshpara, kestopur, North 24 pargara
Ward : MC HUB
unit : I
Registration no. : MCHK/RG2400456360
Hospital : MCH, Kolkata
Date of admission : 3/2/24
Provisional diagnosis : Diarrhea
Chief Complaint : Baby has now abdominal pain and vomiting persists and waiting for further diagnosis.
History of present illness : Baby is admitted with chief complain of abdominal pain for 6 hours, periodic
episodes of diarrhea last 1 week and 4 episodes of vomiting.
History of Past illness : Nothing significant.
Antenatal history
1st trimester
Maternal age - 22 years
Years since marriage - 3 years
IFA - taken
Total No of ANC- 3 times
1st trimester USG - done
Hyperemesis - vomiting occur only morning
Any fever or rash - nil
H/o drug intake - nil
Blood group - A+ve
2nd trimester
TT doses - taken
When was quickening felt - 5 months
HTN/ GDM - nil
3rd trimester
APH - nil
Any drug intake - nil
Weight gain during pregnancy – 11 kg, pre pregnant weight – 55 kg
Foetal movement - present
Intrantal history
Mode of birth: LUCS
Birth order: Primigravida Mother
Birth weight: 2.7 Kg
Gestational week: 38 weeks
Postnatal History:
Cry: cried after birth
Initiation of breastfeeding: within 1 hr
Activity: normal
Jaundice: no history
Congenital malformation: nothing significant
Immunization history: completed up to date
Developmental history: no developmental delay present
Family history
Any hereditary or major illness - nil
Recurrent blood transfusion - nil
Developmental problem – nil
Type of Family - Nuclear
Number of family - 3
Head of family - Father
Earning member - One
Monthly income - 20,000/-
Significant family history - Not Significant family history
Dietary History: Home- cooked food
Socio-economic history
Types of house - Pakka
Electricity - Present
Water supply - Well
Sanitary history - Well
Physical Examination:
1.General appearance
Body built: Thin body built, moderately healthy.
Posture: normal
Gait: Gait is normal.
2. Vital Signs:
Pulse: 98 beats/min
Respiration: 28 breaths/min
Temperature: 98.2oF
3.Anthropometric Measurement:
Weight: 14 kg
Height: 96 cm
Head Circumference: 49 cm
Chest Circumference: 47cm
Mid upper arm circumference: 15 cm
4.Skin:
Colour: normal
Hydrate: some dehydration is present; skin pinch goes back slowly.
Rash: Rash is not present
Peripheral cyanosis: Peripheral cyanosis not present
Central cyanosis: not present
Petechial rashes: absent
Jaundice: Jaundice is not present.
Lesion: There is no lesion.
Ecchymosis: Ecchymosis is not present
Oedema: oedema is absent
Skin turgor: Skin pinch go back slowly.
Cleanliness: present
Texture: normal
Sensation: present
5.Head:
Size: Size of the head is normal
Shape: Shape of the head is symmetrical
Hydrocephaly: hydrocephaly is not present
Microcephaly: Microcephaly is not present
Scaphocephaly: Scaphocephaly is not present
Plagiocephaly: Plagiocephaly is not present
Oxycephaly: Oxycephaly is not present
Fontanelles: Anterior and posterior fontanelle is closed.
Abnormal mass: Abnormal mass is not present
6.Hair:
Texture: Hair texture is normal
Lice: absent
Dandruff: no dandruff is present
Colour: black
7.Eye:
Blinking reflex: blinking reflex is present
Corneal reflex: corneal reflex is normal
Discharge: discharge from eye is absent
Corneal opacities: Absent
Nystagmus: nystagmus is absent
Squint: squint is absent
Cataract: cataract is not present
Periorbital oedema: periorbital oedema is absent
Haemorrhagic spot: haemorrhagic spot is absent
8. Ear:
Ear recoil: Ear recoil is normal and instant.
Ear discharge: There is no discharge present
Hearing abilities: normal, bilateral equal.
Position: Position of the ear is normal
9.Nose:
Shape: Shape of the nose is normal
Discharge: Discharge is absent
Septum: Nasal septum is not deviated.
Nasal bridge: normal
Flaring of nose: flaring of nose is absent
Nasal polyp: nasal polyp is absent
10.Mouth:
Lips: dry, cracked lips.
Clef lip or palate: cleft lip or cleft palate is absent
Tongue: coated tongue, dry
Dental carries: absent.
Teeth: Normal eruption (all 20 primary teeth)
Agnosia or hypoglossal: absent
Gingivitis: absent
Stomatitis: angular stomatitis is present
Gum bleeding: absent
Central cyanosis: central cyanosis is absent
Supernumerary teeth: absent
Taste sensation: taste sensation is present
11. Neck
Enlargement of thyroid gland: no enlargement of thyroid gland.
Mass: any abnormal mass is not present
Swelling: not present
Tort coils: absent
Webbing of neck: webbing of neck is absent
12.Chest:
Pigeon chest: not present
Barrel chest: not present
Rockette Rosary: absent
Funnel chest: absent
Symmetry: chest shape is symmetrical.
Nipple discharge: No discharge from nipple.
Palpable mass: Palpable mass in breast is absent
Breath sound: Normal and audible.
Bilateral air entry: Bilateral air entry is equal
Heart sound (S₁& S2): audible, no abnormal heart sound is audible.
13. Abdomen:
Peristalsis movement: peristalsis movement is present and bowel sound audible.
Abdomen: abdomen is soft & palpable
Liver: not palpable
Inguinal hernia: absent
Umbilicus: umbilicus is normal
Bladder: Bladder is normal
Diarrhoea: Present
Constipation: Absent
14. Limbs:
Clubbing finger: clubbing finger is absent
Formation of nails: formation of nail is normal
CRT: Capillary refill time< 3 secs
Syndactyl: syndactyly is absent
Polydactyl: polydactyly is absent
Change in nails (Koilonychias): absent
Talipes: talipes is absent
Bowed legs: absent
Palpable mass: absent
15. Spine/back:
Kyphosis: kyphosis is absent.
Scoliosis: scoliosis is absent
Lordosis: lordosis is absent
Dislocation of hip: dislocation of hip absent
Spina bifida: absent
Meningocele: absent
Palpable mass: absent
16. Genital:
Urethral opening present at tip of penis: normal positioning
Foreskin: foreskin is normal
Pendulous scrotum: scrotum is pendulous
Presence of pigmentation: hyper pigmented and good rugae present.
Both testes Descended: Both testes are descended.
Anus: anal opening is present.
Abnormal palpable mass: absent
Reflexes: primitive reflexes are present
Growth and development:
Gross motor development:
Runs on tiptoes
Balances on one foot 3-5 seconds.
Jumps from greater heights
Pedals a tricycle quickly, turns sharp corners
Catches ball with extended arms and with hands
Hops on preferred foot
Climbs ladders, trees
Fine motor development
Copies a square Draws a simple face
Cuts around picture with scissors
Sensory development
Visual acquity20/20
Psychosocial development:
Sense of Initiative (3-5 years) Egocentric-unable to see others viewpoint why offers don't see child's
Tends to be impatient and selfish
Usually separates easily from parent
Physically and verbally aggressive
Still has fears
Dreams and nightmares continue
Demonstrates strong attachment for parent of opposite sex
Sexually curious
Jealousy of siblings may be evident More cooperative in play although reminds others of ownership
Psychosexual- phallic stage (3-6 years)
Receptive language: Understands directives (on, under, in back, in front).
Expressive language:
Names one or more colours correctly
Uses "I"
Counts to 5
Uses 3-to-7-word sentences
Had a vocabulary of 1500 words
Preoperational thought:
Substage II –
Not able to conserve matter Continues to believe thoughts cause events Obeys because parents set
limits, not because of understanding between right and wrong
Classifies objects according to one characterise
Concept of time improving especially in relation to sequence of daily routines
Highly imaginative
Lises alibis to excuse behaviour
Moral:
Preconventional Morality Stage 2 (4-7 Years)
Medical Management:
Blood for CBC, CRP, BUN, Cr. Albumin, Total protein, Na, Potassium AG ratio sent
USG whole abdomen done
Urine RE, M/E C/S sent
Chest X-Ray done
The child is on following treatment
IV isolyte P 25ml/hr
T. PCM, 75ml, oral, BD
Inj Ceftriaxone, 250mg, IV, BD
Srp Amoxyclave, 228 5/5, 5ml, TDS
multivitamin 20 drops OD
NURSING CARE PLAN:
Assessment Nursing Goal Planning Implementation Evaluation
Diagnosis
Subjective Imbalanced To - To assess baby’s -Body weight was Nutritional
Data: nutrition less maintained nutrition level checked status is
than body maintained to
Mother said, normal - To check skin -Skin turgor is
requirements some extent
checked
“My baby is related to nutritional turgor
Not taking feeding status - To assess intake -Intake out chart
difficulties is maintained
food and output chart
as evidenced
properly” by decreased -Health Education - Mother is given
health education
Objective body to be given
data: weight, and -Given multivitamin
regarding diet of
Child is signs of 20 drops OD as per
lethargic dehydration. child, hygiene order
- To provide
-Administered IV Iso
nutritional P 25 ml/hr as per
requirements of ordered
child
Assessment Nursing Goal Planning Implementation Evaluation
Diagnosis
Subjective Fluid To - To assess baby’ -Body weight was Fluid volume
Data: volume maintained fluid volume status checked status is
deficit maintained to
Mother said, normal - To check skin -Skin turgor is
related to some extent
checked
“My baby is dehydration fluid turgor
vomiting as volume - To assess intake -Intake out chart
evidenced is maintained
sometimes” status and output chart
by diarrhea
Objective and -Health Education - Mother is given
data: health education
vomiting to be given
Child is
lethergic regarding ORS -Administered IV Iso
P 25 ml/hr as per
making at home, ordered
hygiene
- To provide fluid
requirements of
child
Assessment Nursing Planning Implementation Evaluation Assessment
Diagnosis
Subjective Parenteral To -To assess knowledge of -Existing Anxiety was
data: anxiety reduce mother knowledge was reduced to
related to the - To provide information
Mother said Parent’s assessed some extent
malformatio regarding the cause of
“ I am very
n of lips and anxiety the disease, follow up - They knew
tensed
palate and care and the line of informed about
about my
the bonding, treatment of the baby. Disease, risk factor
baby”
- Family member
process as -To involve the family
is involved in child
Objective evidenced by member in child care care
data: the child is -To provide knowledge
Anxiety - knowledge is
derived from regarding the prognosis
present provided regarding
breast of the disease.
disease prognosis
feeding. -Parents should be made
aware of the surgical - Parent are
management and the involved in child
overall development of handeling
the child.
-Patient’s to be involved
in handling the child and
feeding the child.
Assessment Nursing Goal Planning Implementation Evaluation
Diagnosis
Objective Deficient To - To assess the - Assessed the Knowledge is
data: knowledge knowledge level of knowledge level of improved to
improve
Mother has related to mother mother some extent.
some knowledge - To discuss about - Discussed about the
disease
confusion the disease process disease process
prognosis as level
related to - To give advice - Gave advice about
disease evidenced about the child care the child care at
process by mother’s at home home
verbalization - To give health - Gave health talk
talk about diet, rest, about diet, rest,
hygiene, hygiene, medication
medication - Teach mother about
- To teach mother signs of infection
about signs of
infection
Assessment Nursing Goal Planning Implementation Evaluation
Diagnosis
Objective Interrupted To provide - To assess the - Assessed the Parents are
data: Baby family process emotional emotional emotional condition concerned
has surgery related to long support to condition of baby of baby about the baby
time the family - To advise parent - Advised parent
hospitalization about baby’s care about baby’s care at
and surgery of at home home
baby - To give all - Gave all possible
possible answers answers to questions
to questions - Parent is advised
- To advice the the for follow up
parent for follow - Advised to talk
up with the doctor
- To advise talk
with the doctor
Assessment Nursing Goal Planning Implementation Evaluation
Diagnosis
Objective Risk for To reduced - To check - Checked Risk for
data: infection risk for temperature of temperature of child infection
Child’s related to infection child - Mother is advised reduced to
immunity is hospital stay - To advice the to wash hand before some extent
compromised mother to wash giving food
due to hand before giving - Gave proper
hospital stay, food nutritional
Presence of - Give proper requirements of
IV channel nutritional baby
etc requirements of - Maintained aseptic
baby technique during IV
- Maintain aseptic medication
technique during - Gave antibiotic as
IV medication per Dr’s antibiotic
- Give antibiotic as
per Dr’s order
