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Acknowledgement

This case study report is prepared during The Child Health Nursing clinical practicum
in Kanti children hospital,Maharajgunj. The report is prepared as a practical fulfillment of
post basic PBN curriculum. I realized that the requirement to do complete case study in the
hospital area has been an important opportunity for me to gain new experience and
knowledge in this field.
I got myself complete involved in the care and management of the patient during this
period. However the work would not have been accomplished successfully with my effort
alone.
I would like to express my sincere gratitude to all teachers of my colleges ,hospital,
hospital members and the staffs for providing valuable guidance, supervision and
suggestions in the clinical field area.
I am also thankful to my colleagues and my patient and her family who gave me their
valuable time for providing necessary information and kind cooperation during this period.
Finally, I would like to thank all of them who gave me their precious, valuable time
and suggestions directly or indirectly while preparing this case study.

BACKGROUND
As a partial fulfillment of Post Basic Bachelor of Nursing curriculum of Purwanchal
University under practicum of Child Health Nursing, we were supposed to do 3
weeks practicum at Kanti Hospital where we, individually were supposed to do a
detailed case study of a patient.
During the practicum period, I did a case study in Jaundice. I found
interesting case of Jaundice at Kanti Hospital during my practicum period, so I took
this case so that I could learn and get to know more about this diseases condition.
Shishir Kunwar, 5month old male was admitted with the diagnosis of Prolonged
jaundice .I gave holistic nursing care to the client and tried to make him comfortable
in hospital and solve his problem. I got to learn many new things from this case
study.

OBJECTIVES:
GENERAL OBJECTIVES:
General objectives of this case study are to gain comprehensive knowledge about
the disease, to gain the practical knowledge about the health problem, to gain
practical experience working with a patient having illness and provide holistic care to
the patient.

SPECIFIC OBJECTIVES:
1. To gain knowledge about one specific disease and its management.
2. To provide holistic nursing care to the patient by using nursing process.
3. To identify normal developmental tasks of patient age group.
4. To apply knowledge from the basic science, nursing theories and other related
courses to plan and implement nursing care.
5. To provide health teaching according to the need of the patient.
6. To minimize the stress of the patient and her family by using appropriate diversional
therapy.
7. To communicate effectively while providing care to the patient.

Patient's
Profile

GENERAL INFORMATION
Name of the Child

Master Sushil

Gender

Female

Age

5 months

Religion

Hindu

Provisional Diagnosis

Jaundice

Final Diagnosis

Jaundice

The patient was alert, active ,well nourished baby with pallor(+), icterus (+ ), edema(+) and
dehydration (-)
Vital signs within normal ramge.
Local examination reveals
Icteric tongue and eye/skin
Umbilical hernia present
Cerebral vascular system S1S1M0
Per abdomen examination reveals
>tenderness of flank
> hepato-splenomegaly
> umbilical hernia

DEVELOPMENTAL TASK OF MY PATIENT:


As my client was 5 month old, he is an infant, developmental task is given below:

Erik Eriksons theory shows Trust Vs Mistrust(Oral -sensory) (Birth -2 years):

Existential Question: Can I Trust the world?


The first stage of Erik Eriksons theory centers around the infants basic needs being met by
the parents and this interaction leading to trust or mistrust. Trust as defined by Erikson is an
essential truthfulness of others as well as fundamental sense of ones own trustworthiness.
The infant depend on parents, especially the mother, for sustenance and comfort. The child
s relative understanding the world and society come from parents and their interaction with
the child.If the parents expose the child to the warmth ,regularity, and dependable affection.
The infants view of the world will be one of trust. Should the parents fail to provide a secure
environment and to meet the childs basic needs a sense of mistrust will result. Development
of mistrust can lead to feelings of frustration, suspicion, withdrawl and a lack of confidence.

According to Erik Erikson, the major development task in infancy is to learn whether or not
other people, primary caregivers, regularly satisfy basic needs. If caregivers are consistent
sources of food , comfort , and affection ,an infant learns trust other are dependable and
reliable .If they are neglectful or perhaps even abusive,the infant instead learn ,mistrust that
the world is in an undependable, unpredictable and possibly dangerous place. While
negative, having some experience with mistrust allows the infant to gain an understanding of
what constitutes dangerous situations later in life.

Developmental milestones
Motor skill development
a. Gross motor
-rolling over
b. Fine motor
-reaching out with both or one hand
,transfer objects

Seen in my patient
All these development task were present in my
client s case.

Language behaviors
-monosyllabus
Personal Social behaviors
-smiles at mirror image
Psychosocial development

Trust vs. Mistrust


-can tolerate a delay need gratification

S.N Developmental task according to book

Seen in my patient

1.

Achieve equilibrium of organs, systems functions


after birth

Establish self as a dependent person separate from


other

Become aware of the environment; familiar versus


unfamiliar and develop basic social interaction

Develop a feeling of desire for affection and response


from others

Adjust somehow to the expectation of others

Begin to learn new motor skills, develop equilibrium,


begin eye hand coordination

Begin to understand and master the immediate


environment through exploration

Learn to use symbol or language system

Direct emotional expression to indicate needs and


wishes.

All these
development task
were present in my
client s case.

DISEASE
PORTION

JAUNDICE
Definition:
An excessive level of accumulated bilirubin in blood and is characterised by hyper
bilirubinemia or Icterus.this may be as the result of increased unconjugated and
conjugated bilirubin level above normal.
Jaundice comes from the French word Jaune which means yellow.

Jaundice is the clinical term used for the yellowish discoloration of the mucus
membrane and skin due to increase serum bilirubin level more than 4-5 mg/dl in the
new born.

Prevalence
Signs of Neonatal Jaundice are seen within the first three days of birth in 80% of
preterm babies and 60% of full-term infants
Jaundice persisting beyond 14 days of age (prolonged jaundice) can (rarely) be a sign of serious
underlying liver disease (Hussein, 1991). Jaundice persists beyond 14 days in 15-40% of breastfed
infants, depending on the series studied (Hannam, 2000). A prospective study of all 7139 term
infants born at Kings College Hospital (London) between January 1997 and June 1998 (Hannam,
2000) found 154 with prolonged jaundice, one of which had conjugated hyperbilirubinaemia (0.14
per 1000 live births).
Another study of 3661 babies in Sheffield (Crofts, 1999) found 127 who were jaundiced at 28 days,
of which 125 were breastfed (9.2%).

Although preterm infants, whose livers are more immature, have prolonged jaundice
more commonly than term infants (Fenton, 1998) there appear to be no studies of
incidence in this group (Lucas, 1986).

Etiology
Signs of Neonatal jaundice are seen within the first three days of birth in 80% of preterm
babies and 60% of full term infants.The journal of Paediatrics reports a retrospective
study,which observed that the incidence of Jaundice is higher in breast feed babies than in
the formula feed ones.

Causes of jaundice:

Physiological jaundice
Pathological jaundice associated with liver disease
Rh and ABO incompatibilty

Inherited cause of hemolytic disease i.e.glucose 6 phospate dehydrogenase


deficiency
Erythroblastosis Fetalis
Breast milk jaundice
Jaundice due to sepsis
Hemolysis due to drugs (quinine),poison(snake venom)
Congenital biliary atresia and obstructive jaundice
Inborn errors of metabolism:Galactosemia,Hypothyroidism,glucuronyl
transferase deficiency
Types of jaundice:
I.Physiological jaundice:
It is common in newborn babies. It usually becomes noticeable during the baby's first three
to five days of life. It disappears as the baby's liver matures. This type of jaundice is not
harmful.
II.Hemolytic jaundice:
This type of jaundice develops when there is Rh incompatibility and ABO in compatibility
between the mother and the fetus.
Rh incompatibility occurs when the mother is Rh negative and the fetus is Rh
positive, having inherited gene for the Rhesus factor from his/her parents
ABO incompatibility may present if the mother has blood group O and baby has
type A or B .then the mother makes Anti A or Anti B type anti bodies of the IgG glass and
cross the placenta causing destruction of the babys red blood cells.
III.Pathological Jaundice:
In some situation however there is so much billirubin in babys blood that it can be harmful
.This condition is called Pathological Jaundice.If the level of bilirubin becomes very high ,it
may affect some of the baby s brain cells. This may cause a baby to be les active.In rare
cases ,a baby may have seizures (convulsions).Pathological jaundice may lead to deafness
,cerebral palsy and /or mental retardation. Pathologic jaundice can occur in children or
adults. It arises for many reasons ,including blood incompatibilities, blood diseases, genetics
syndromes ,hepatitis , cirrhosis ,bile duct blockage ,other liver diseases ,infections ,or
medications.
IV. Jaundice of prematurity:
This occurs frequently in premature babies since they take longer to adjust to excreting
bilirubin effectively.
V. Breast Milk Jaundice:
In 1% to 2% breast fed babies, jaundice can be caused by substances produced in their
others breast milk that can cause the billirubin level rise above 20 mg.These substances

can revent the excertion of bilirubin through the intestines.It starts at 4 to 7 days and
normally lasts from 3 to 10 weeks. The cause is thought to be inadequate milk intake
,leading to dehydration or low caloric intake.It is a type of physiologic or exaggerated
physiologic jaundice.
VI. Not enough breast milk Jaundice:
This may occur because the baby is not getting enough milk.This is because sometimes the
mothers milk takes a longer than average time to come in, or because the baby is poorly
latched on and thus not getting the milk which is available.
VII. Inadequate Liver Function:
Jaundice may be related to inadequate liver function due to infection like TOCH and sepsis
or other factors.

In other aspect of classification, according to the onset and


duration of the jaundice it can be classified into:
I.

Within 36 hours:
Usually pathological jaundice appears within 36 hours of life. This may involve
haemolytical jaundice usually due to Isoimmunisation, G6PD deficiency and other
congenital infections.

II.

After more than 36 hours:


Usually the jaundice appearing after more than 36 hours of life are physiological
jaundice or may be pathological jaundice due to drugs or sepsis.

III.

Prolonged jaundice(more than 2-3 weeks):


The jaundice appears for more than 3 weeks in pre term and more than 2 weeks
in term infant .It may be conjugated or unconjugated. About more than 15% of the
cases seems to be conjugated jaundice.
This type of jaundice might occur due to
Bile duct obstruction
Endocrine disorder(hypothyroidism)
Metabolic disorder(Galactesemia)
Breast milk
TORCH infection
Viral hepatitis -antitrypsin deficiency, cystic fibrosis.

In my patient, PROLONGED JAUNDICE is present leading


toinadequate liver function with the relevant cause
of TORCH positive, and Hypothyroidism

Pathophysiology:

Bilirubin is one of the breakdown product of haemoglobin result from Red Blood
Cell(RBC) destruction.When RBC is destroyed ,the breakdown product are release
into the blood circulation where haemoglobin splits into two fraction:hame and globin.
The globin (protein) portion is used by the body and the heme is converted to
conjugated bilirubin, an insoluble substance to albumin.
In liver ,the bilirubin is detached from the albumin molecule in presence of enzyme
glucornyl transferase is conjugated with glucuronic acid to produce a highly soluble
,conjugated bilirubin glucoronide ,whivh is then excreted into the bile.In the intestine
,bacterial action reduces the conjugated bilirubin to urobilirobinogen ,the pigment
that gives the stool its characteristics color.Most of reduce bilirubin is excreted
through feces.
Normally, the body is able to maintain a balance between the destruction of RBCs
and the use and excretion of the byproducts.However, when developmental
limitation or a pathologic process interferes with this balance; bilirubin accumulates
into tissue to produce jaundice.

Signs and symptoms of jaundice


The symptoms of jaundice are extreme weakness, headache , and fever ,loss of appetite
,severe constipation ,nausea ,and yellow discoloration of the eyes ,tongue ,skin and urine

The patient may also feel a dull pain in the liver region.Obstructive jaundice may be
associated with intense itching.
In my patient,the yellowish discoloration of the sclera,skin and tongue is present.

Diagnosis:

a. History Taking: Positive family history of jaundice and anaemia,Previous babies with
jaundice
b. Family history of neonatal or early infant deaths due to liver disease suggesting
Galactesemia.
c. Maternal drugs such as sulphonamides or antimalarial drugs causing haemolysis in baby
d. Physical examination findings: Presence of yellowish staining of sclera ,skin and mucus
membrane.
e. A blood test will confirm the raised bilirubin level and other tests such as those for hepatitis
and haemolysis are also done on the blood.
Blood serum bilirubin
Complete blood count
Liver function test and bilirubin
Prothombin time
Bleeding time
Clotting time
f. Urine and fecal test(urobilinogen)
g. Ultrasound scanning of the liver and bile ducts for signs of obstruction,which often can
give useful information on the pancreas gland.
h. Endoscpic retrograde cholangiopancreotography
i. Ct scanning also helps to diagnose obstructive jaundice accurately

Investigation done in my patient:


Investigation item
WBC
Polymorph
Lymphocytes
Hb
Total protein
Albumin
Bilirubin (Total)
Bilirubin (conjugate)
Alkaline phosphate
SGPT
Macroscopic

findings
2069/03/27
9800/cu mm
54
46
8.7gm%
6.5
3.2
16.6
11.2
1220
655
URINE EXAMINATION
Color light yellow

normal range
(4,000-11,000)

(13.5-17.5)
(6-8gm%)
(3.5-5.2 gm %)
(0.4-0.8mg%)
(0.4mg%)

pH
Sugar
Appearance
Albumin
Microscopic
Puscell
RBC
Cast
Crystal
Epithelial cells
Bacteria

Acidic
Nil
clear
Nil
NIl
Nil
Nil
Nil
Nil
Nil
2069/3/28

Thyroid function Test


T3
5.42
(4.2-8.1pmol/l)
T4
14.9
(10.0-28.2pmol/l)
TSH
6.76microunit/ml
(0.4-4.6mIU/ml)
Ultrasonography :
Liver :normal
Gall Bladder: Normal
Kidney: Bilateral mild hydronephrosis,loss of CMD(corticomedullary differentiation)
Impression :? Medico renal disease
069/3/29
Ultrasonography :
Liver :normal
Gall Bladder: Normal
Kidney: right lateral hydronephrosis with echogenicity of bilateral kidney
Impression : Right in thinned out Renal Parenchyma CMD layered
Hb electrophoresis
Hgb
6.4gm%
PCV
21.7%
RBC
27,900,00cmm
WBC
12800/cmm
Platelets
184000
Retics
4.0
MP corrected
2%
HbF
0.8%
HbA2
3.6%
Hb Electrophoresis: Normal banded Speen;Normal Hb Electroporesis

069/04/1
Ultrasonography :
Liver :7.8 mm with normal echotexture
Spleen: 7.2 mm with normal texture
Kidney: Mild dilatation at right kidney
Impression : spleenomegaly
Mild hydronephrosis

Hb

Cholesterol
Total Protein
Albumin
Bilirubin Total
Bilirubin Congugate
SGPT
SGOT
PT
APTT

069/04/03
4.8

069/04/04
174mg%
6.2
4.1
21.1
15.3
285
208
18 sec
26sec

Anti HCV test


NON REACTIVE
HbsAg
NON REACTIVE
TORCH IgM Antibody test result(Method ELISA)
Toxoplasma gondii
NEGATIVE
Rubella Virus
NEGATIVE
Cytomegalovirus
NEGATIVE
Herpes Simplex Virus I
NEGATIVE
Herpes Simples Virus II
NEGATIVE
TORCH IgG Antibody test result(Method ELISA)
Toxoplasma gondii
778
Rubella Virus
283
Cytomegalovirus
10.3
Herpes Simplex Virus I
148
Herpes Simples Virus II
1.6

150-250mg%
6-8g%
3.5-5.2
0.4-0.9mg%
0.4gm%

(12 sec)
(23sec)

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Preventions of Jaundice:

Although jaundice cannot be totally prevented but recognition and treatment are important in
preventing bilirubin levels from rising to dangerous levels.If your babys color id turning more
yellow , promptly call your babys physician.
Feed babies frequently and dont let them become dehydrated
With jaundice,the important thing to prevent kernicterus toxic levels of bilirubin
accumulating in the brain. Early identification and treatment of jaundice will usually prevent
kernicterus, whatever the cause.

Treatment of Jaundice:
Most jaundice needs no treatment,but when it does,the given below treatments are possible:
1. Encourage frequent nursing ,at least 8-10 times per day and avoid pacifiers.
2. Avoid supplementation of mothers milk with water or glucose water.If supplementation
needed due to some reason then give expressed breast milk of formula feeding
approximately 30ml/feeding for term and near term infants.
3. Halted breast feeding until bilirubin level drop in case of prlonged jaundice
4. Phototherapy (light therapy) is considered very safe and effective.Placing the baby under
blue bililights lights naked in a bassinet,with his eyes covered will often do the trick

because ultraviolet light changes the bilirubin to a form that your baby can more easily
dispose of in his urine.
5. Fibre optic blanket:another option involves wrapping the baby in a fibre optic blanket
called a bili-blanket or bili-pad
Phototherapy is usually effective,but if a baby develops a severe case of jaundice ,or his
bilirubin levels continue to rise despite phototherapy treatment ,he may need to be admitted
to the intensive care unit for a blood transfusion called an exchange transfusion.

If left untreated ,Hyperbilirubinemia due to Neonatal Jaundice can result in mental


retardation,cerebral palsy, behavioural problems,hearing loss or even loss of life.

Nursing consideration of child with jaundice:


1. Routine physical assessment of baby chould be done by observing the color of
the sclera and the skin
,including palms,soles and mucus membrane at
regular intervals under natural lights
2. Reorganization anf differentiation of type of jaundice and early refferal

3. Provide supportive care


Early breast feeding
Optimal thermal environment
Sterile saline soaked dreesing in umbilical cord for possible exchange transfusion
Maintain intake/output chart accurately
Fluid volume correction
Assist in medical therapies such as collection and sending of investigations
4. Monitor vital signs and record accurately
5. Emotional support:parents need constant reassurance,clear explanation about
infants condition in
understanding level

6. Prevent blood incompatibility:


Encourage pregnant women to seek early antenatal care
Determine blood group
Administer RHoGAM to Rh-negative mother at delivery or during abortion
7. Identify infants at risk for hyperbilirubinimia and kernicterus:
Observe color of amniotic fluid at time of rupture of membrane and delivery
Early detection and early referal to physician
Early detection of risk conditions(acidosis,hypoxia,and hypothermia) that decreased
the risk of kernicterus
8. Care of baby receiving phototherapy
Assure effectiveness irradiance by placing the babay to machine at distance of 45
cm change bulbs every 2000hours of used,periodic checks of spectrum of irradiance
produced by sifferent photo therapy units

Provide eye protection:ensure the closure of the lids before applying shield and
check eye fordischarge,irritation and pressure as well.Gently clean the infants eye
strile cotton or soft gauze moistened with sterile water or saline,starting with the
inner canthus of the eye on moving outward in a single,smooth stroke.A separate
cleaning pad should be used for each eye.
Change the position of the baby frequently(every three hourly)
Monitor vital signs every 4 hourly
Assess skin exposure :the largest area of the infants body,the trunk should be
positioned in the center of the light,where irradiance highest and change position as
per need.Remove diapers for intensive phototherapy when the serum bilirubin level
approaching high level.
Assess and adjust thermo regulation devices
Promoting elimination and skin integrity
9. Maintain hydration
Assess early sign of dehydration
Ensure that the baaby is fed
Encourage mother to breast fed at least every three hourly.If baby receiving
intravenous fluid or expressed breast milk ,increasethe volume of fluid by 10% of
total daily volume per day as long as the baby is under photo therapy
Maintain intake output chart
Promoting parent infant interaction:unless jaundice is severe,photo therapy can
safely to interrupt at feeding time,allow parental visits and encourage skin to skin
contact
Monitoing bilirubin levels:The most significant decline in bilirubin level occurs in the
first 4-6 hours after initiating photo therapy so assess bilirubin periodically
Proper recording of duration and type of therapy
10. Care of baby receiving exchange transfusion
Give infant nothing by mouth prior to procedure(usually for 3-4 hours)
Check donor prior transfusion
Assist physician during tranfusion
Monitor optimal body temperature during procedure
Observe signs of exchange transfusion reactions
Keep resustication equipment ready at bed side(baby size)
Apply aterile dressing to catheter site and check for bleeding
Keep nrecording accurately(amount of blood infused anf withdrawn)
Observe for complications
Observe for signs of central nervous system depression such as
lethargy,hypotonia,poor sucking,convulsions,high pitched cry
Observe for hypothermia,dehydration and diarrhoea and bronze-baby syndrome
Observe for cord bleeding and infections
11. Follow up care and visit:periodic assessment of babys
condition,breastfeeding,observe for signs of anaemia and provide ferrous sulphate
supplementation at 2-3 month period

12. Parent teaching on:disease,treatment,homecare,nutritional care,signs of


severity,infections etc.

Complications:
a.
b.
c.
d.
e.

Acute bilirubin encephalopathy


Kernicterus
Abnormal motor movement
Behavior disorder
Sensor neural hearing loss

NURSING MANAGEMENT:
Assessment:
During patient's assessment, I observed following things:
Patient's general condition.
Vital signs.
Nutritional status
Anxiety level of parents.

NURSING DIAGNOSIS:
Imbalanced Nutrition:Less than Body requirements related to inadequate intake
and
diarrhoea
Impaired skin integrity related to hyperbilirubinemia and diarrhoea
Anxiety related to change in health status(patients mother)

Fluid volume deficit r/t poor absorption

Potential for altered growth-due to liver disease

Altered Growth and Development r/t chronic illness

Health Maintenance Altered, need for family to monitor for symptoms of increased liver
dysfunction

NURSING
CARE PLAN

SN

Nursing
diagnosis

Nursing goal

Nursing intervention

1.

Imbalanced
Nutrition:Less
than
Body
requirements
related
to
inadequate intake
and
diarrhoea

The client will - Record the number


maintain
and quality of faecal
adequate
infantile body
-Monitor skin turgor
fluids

Rationale

Evaluation

-Variations help identify fluctuating My goal was met the


intravascular volumes or changes in risk for fluid deficit was
vital signs associated with immune minimized.
response to inflammation
-indicators of adequacy of peripheral
circulation and cellular hydration
-Monitor intake output
-Monitor intake and output (I &O);note
urine color and concerntration and
-Give water between specific gravity
breastfeeding or giving -Indicators of return of peristalsis and
readiness to begin oral intake
a bottle
-Reduces risk of gastric irritation and
vomiting to minimize fluid loss

2.

Impaired
skin
integrity related to
hyperbilirubinemia
and diarrhoea

The integrity
of the baby
skin can be - Assess skin
every 8 hours
maintained

-Monitor direct
indirect bilirubin

-Useful in monitoring effectiveness of


medication,progression
of
color healing.Changes in characteristics of
pain may indicate developing abcess
/peritonitis,requiring prompt medical
evaluation and intervention.
and

-Being informed about progress of

My goal was partially


met. The patient was
quiet relieved by the
therapy
but
not
controlled.

situation provides emotional support,


-Change position every helping to decrease anxiety
2 hours
-Relief of pain facilitates cooperation
-Massage the area that with other therapeutic interventions,
stands out
-Refocuses
attention,
promotes
relaxation, and may enhance coping
abilities.
-Keep your skin clean -Decreases
discomfort
of
early
and moisture
intestinal peristalsis and gastric
irritation/vomiting.

3.

4.

Anxiety related to -to


relieve -examine the level of
change in health anxiety
anxiety
status(patients
mother)
-Give information about
the disease process
and actions
-reassure the patient
party
-Enhance the patient
general activity
Fluid
deficit

Understanding promotes cooperation My goal was met the


with therapeutic regimen, enhancing patient party was less
anxious
and
well
healing and recovery process
oriented
about
his
disease condition.
-to gain trust from the patient party

volume maintain fluid -document and monitor - Useful in


r/t poor and
:intake and output, assess for signs of

My goal was fully met,


blood transfusion done,

absorption

electrolyte
balance

daily dehydration, assess for fluid overload, haemodynamically


stabilized.
daily
girth -regular vital sign helps to rule out any
deviation normal body functions as
well as presence of infection in body
-check vitals, monitor -to maintain haeomostatic equilibrium
for signs of tachycardia - to assess the proper liver function
specific gravity,
weights,
abdominal
measurements,

or new murmurs,

and kidney function

-to assess the peripheral circulation


-blood transfusion
-Check
laboratory
studies for electrolyte
imbalances,
-Capillary refill less than
3 seconds and urine
output.
5.

Potential
for Infant/ child
altered
growth- grow
due
to
liver following
disease
growth curve
while
maintaining
appropriate
nutritional

-Monitor growth curve- Chart above information, be able to


monitor
weight
on identify and report abnormalities and
regular basis.
reassess
-assess range of motion, gross and
-Assure that ADEK fine motor skills
vitamins
taken
on
regular basis, monitor
lab values.

My goal was partially


met. The patient party
was well instructed for
the continuous growth
monitoring.

status
-Instruct
regarding
methods to increase
calories: medium chain
triglyceride
formula,
additional
formula
supplementation.
6.

Knowledge deficit Parents


-Teach parents about
R/T
Homecare understand
medications including
Instructions
home
care purpose,
dose,
instructions.
administration,
side
effects and signs and
symptoms to report.
-Teach

Proper knowledge about the disease


helps to promote cooperation with
therapeutic
regimen,
enhancing
healing and recovery process as well
as coping abilities.
-regular follow up helps for regular
monitoring of the childs health status.

My goal was met. The


parents
were
well
conscious about the
patient and caring.

parents

importance
of
compliance relating to
testing,
medications
and follow-up visits.
Teach
parents
to
identify, verbalize and
report
changes
in
childs health status.
8.

Health

Family/

-Review with

parents Early

instruction

about

the My goal was met. The

Maintenance
Altered ,need for
family to monitor
for symptoms of
increased
liver
dysfunction

Parents
familiar with
symptoms of
worsening
liver function.

the
signs
and complications due to altered body
symptoms of worsening function helps in early identification
liver function including: and treatment if present
change in stool color,
ascites,
peripheral
edema,
hepato/spleenomegaly,
anorexia, urine color,
lethargy,
jaundice, -early management help to gain good
bleeding, and pruritus.
prognosis if any complication prevails.
-Educate
regarding -the early identification
complications of end effective management.
stage liver disease.
-Attempt to identify of
signs and symptoms of
bleeding with treatment
of vitamin K or perhaps
even a transfusion

helps

in

patient party was well


conscious about the
child and no any
complication
shows
up. Though,blood
transfusion was done.

APPLICATION OF NURSING THEORY


By applying nursing theory of Faye Glenn Abdellah's Theory,
holistic care was given to my patient from the day of my visit.
"Nursing is based on an art and science that mould the attitudes, intellectual
competencies, and technical skills of the individual nurse into the desire and
ability to help people , sick or well, cope with their health needs." Abdellah

Although Abdellah spoke of the patient-centered approaches, she wrote of nurses


identifying and solving specific problems. This identification and classification of problems
was called the typology of 21 nursing problems. Abdellahs typology was divided into three
areas:
(1) the physical, sociological, and emotional needs of the patient;
(2) the types of interpersonal relationships between the nurse and the patient; and
(3) the common elements of patient care.

Adbellah and her colleagues thought the typology would provide a method to evaluate a
students experiences and also a method to evaluate a nurses competency based on
outcome measures.
(Tomey & Alligood, Nursing theorists and their work 4th ed., p. 115).
Abdellahs Typology of 21 Nursing Problems are as follows:

1. To promote good hygiene and physical comfort


2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and through the
prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance

9. To recognize the physiologic responses of the body to disease conditions


10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and
developmental needs
19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness

HEALTH EDUCATION TO THE CLIENT AND FAMILY


REGARDING HEALTH MAINTAINANCE
Health teaching plays an important role to prevent disease, promote health
as well as to cure diseases more rapidly without any complications. One of the most
important roles of nurse is to provide health education. So, I provided health teaching
to family as well as patient objectives of health education are as follows:
-To promote health
-To motivate for early diagnosis and treatment
-To help limitation of disability
-To help in rehabilitation.
Keeping these objectives in mind, I gave informal teaching and information to
patient and family.
-Nutrition: The importance of nutritious food and balanced diet. He was advised to
take plenty of fluids and soft hygienic foods.
-Infection prevention: I gave teaching on importance of personal hygiene and the role
of hygiene in infection control
-Rest and exercise: Adequate sleep is necessary for the patient.
- breast feeding
-Supplementary foods

-immunization
-Personal hygiene
-About disease
-Medications
-Follow up.

CONCLUSION
Case study is one of the most important parts of nursing practice. It is the best
method of learning case study concerned with the individualized care which helps to
provide holistic nursing care including physiological, psychological, social and
cultural traditional beliefs.
According to our B.N. 1st year curriculum, I had taken a case of Jaundice,
named Shishir Kuwar for case study. During this period of case study, at first, I had
collected relevant health history from the patient as well as his family members.
Then I had done complete physical examination of my patient. I gathered lots of facts
and formulated nursing diagnosis. I applied knowledge from the basic sciences,
nursing theories and other related courses, to plan and implement nursing care. I
had studied the normal developmental task of infant and correlate it with my patient.
He meets these entire normal developmental tasks.
I had also studied about disease its type, epidemiology, etiological factors,
Pathophysiology, clinical manifestations, diagnostic test, therapeutic and nursing
management including Prognosis, Prevention and Possible Complications.
I had provided different diversion therapy to the patient for stress
management.
Finally patients general condition was improved day by day and I am satisfied
from this case study and the goals set were fully met.

References
1. AZ of Practical Paediatrics,Baral Manindra.R,HISI Offset
printers1st edition,2007,page 234-238
2. Nursing 2012 Drug Handbook,Kluwer Wolters,Lippincott Williams and wikins, 32
edition page 780,1169,273,1466.
3. http://www.whereincity.com
4. Child health Nursing,uprety kamala,pradipa printing and publishing 1st edition pg no:
200-208

5. http://www.medindia.net
6. http://www.drugs.com
7. Internet: www.google.com.np