DHANWANTARI COLLEGE OF

NURSING
Vinayak nagar,Chikkabhanavar, Bangalore

CHILD HEALTH NURSING

Neonatal Nursing Care Plan

on:Pneumonia.

SUBMITTED TO
Ms. Babitha k
Lecturer in Pediatrics
Dhanwantari College of Nursing
Bangalore

SUBMITTED BY
Mr. Somashekhar.S.Akalad
I Yr M.Sc. Nursing
Dhanwantari College of Nursing
Bangalore
 SUBMITTED ON:
INTRODUCTION;
As a part of the clinical experience posting in (Sanjay Gandhi Institute of Child
Health), Bangalore, took care of baby of Leela from 18- 01-11 to 22-01-11
. I selected this case in order to use this knowledge in my day to day clinical practice.

I. BIOGRAPHICAL INFORMATION :

Name :B/O Leela

Age :one month
Sex :male
Address :bhavani vilaya ,N.B road
No;248, sina taluk
Tumkur, district

Religion :hindu
I.P. No. :61550
Admission Unit :unit B
Date of Admission :12-02-11
Date of History taking :18-02-11
Informant :mother

II. DIAGNOSIS :accute lower respiratory tract infection with severe

pneumonia

III. PRESENT HISTORY:

Chief complaint with duration: baby was apparently allright at birth after 10
days child had a complaint of CHD on the 20th day of life balloon valvuloplasty done
,in jayadeva hospital. After discharge from the hospital suddently child developed
vomiting child vomited 3 times, hurried breathing, chest indrawing , nasal
regurgitation .parents brought her to Sanjay gandhi hospital on 12-01-11

History of present illness: now child is very irritable, coughing is present,

child is refusing to have milk. Child is not taking sleep properly.hurried breathing and
chest indrawing is present. Regurgitation is sometimes present. Child vomited 3 times.

IV. PAST MEDICAL HISTORY:

 Past illness :child was hospitalized during 20th day
of life and undergone cardiac repair, balloon valvuloplasty in jayadeva hospital.

Allergies: child has no allergic to any drug or any inhalants.

V. BIRTH HISTORY:

Antenatal – ;mother was booked in hospital. she immunized

adequately during the antenatal time . Her first child is 13yr old and this is her 2nd
consieve.

Natal- Place of birth : jayadeva hospital

Mode of delivery : LSCS because, previous delivery was LSCS
Gestational age :38 weaks
Birth weight : 3.1 kg

Postnatal – After 20th day of life child is hospitalised and

undergone the cardiac surgery (balloon valvuloplasty).

VI. FAMILY HISTORY ;

child belongs to middle class family.it is nuclear family.

Sr Name of the Relationship Age sex education occupatio Health

no family members With the n status
; child
1. Mr: umesh Father 45yr m BA Private healthy
service
2. Mrs;Leelavathy Mother 36yr F secondar House healthy
. y wife
3. Kum: bhavani Sister 13yr F 8th std sister healthy
4. b/o triveri Client 1m m Nill nill pneumonia

VII. GROWTHY AND DEVELOPMENT:

Growth and development according to her age group is normal. Social smile
is present . but child cant recognize her parents.
 VIII. IMMUNIZATION:

Name of the vaccines Times Given or Not

1. BCG & OPV At birth Received

2. DPT & OPV 1st dose Received

3. DPT & OPV - -

4. DPT & OPV

- -
5. MMR
- -

IX. ELIMINATION PATTERN:

Bowel :2-3 times in a day

Bladder : 6-7 times in aday

X. NUTRITIONAL PATTERN:

Recent weight : 3.5 kg

Expected weight :4-5 kg
Appetite : child is refused have milk

24 hours diet recall :

Mother is trying to give 2hrs interval exclusive breast
feeding. Child is on exclusive breast milk.

DEGREE OF MALNUTRITION :

Body mass index =actual weight / (height )2

=3.5/
 Degree of malnutrition = actual weight/ expected weight x100

= 3.5/ 5kg x100

=70%

XI. SLEEPING PATTERN :

Child was very irritable and allways crying so client is not taking
sleep properly.

PHYSICAL EXAMINATION:

1. GENERAL OBSERVATION:
Child is looking very irritable , and always crying. child is not
cooperative illness is present. Pallor and malnourished is present.

2. VITAL SIGNS:

Temperature :febrile, 99.9f

Pulse :154/min
Respiration :66/min
Blood Pressure :not checked.

3. ANTHROPOMETRIC MEASUREMENTS:

Height :65cms
Weight :3.5kg
HC :38.1cm
CC :39cm
M.AC :7cm.

4. SKIN AND MUCUS MEMBRANE :

Colour : normal
Edema :not present
Moisture, Temperature : febrile
Turgor : poor
Texture :soft
Any abnormal discharge : no discharge present
5. HAIR :

Changes in texture : normal

Characteristics : hair is scanty ,blackish in colour
Lice :not present

6. NAILS :

Changes to appearance : normal

Cyanosis : cappilary refilling is 2-3 seconds
Texture : normal

7. HEAD :

Skull / cranium, size, shape, fontanelles

: normal skull, no cranial nerve deformities, size is
normal, shape is round , anterior fontonelle not disappeared but posterior
fontoneellae is disappeared.
Suture : no suture marks present
Movements : no restriction of movement is present
Forehead :no scars or lesion present

8. FACE :

Appearance : chld is very irritable

Color : fair
Symmetry :equal
Movements :movements are normal

9. EYES :

Expression :child is conscious

Eye lids :normal , no edema is present.
Lacrimation :clear fluid is present
Eyebrows :symmetrical eye brows is present
Conjunctiva :pale in colour
Sclera :normal
Cornea :clear and moist
Pupil :pupil is equally reactive to light.

10. EARS :

Appearance : normal, position of the ear (it is staight when we

draw an imaginary line from outer canthus.)
Discharges :no discharges present
 Lesions :no lesions present
Any abnormalities :no abnormalities

11. NOSE :

Appearance : normal
Discharges :slight discharge is present
Potency :patency is normal
Sense of smell :sense of smell is present

12. MOUTH & THROAT :

Lips : normal no dryness is present

Tongue :normal , uncoated
Teeth : not erected
Gums :pink and moist
Buccal mucosa : no lesion
Palate :soft palate
Tonsils :normal
Taste : child have the sensation of taste .

13. NECK :

General appearance :normal , neck foldings are present

Trachea : normal in position
Lymphnodes :no enlargement
Thyroid glands :feel
Salivary glands :drooling is present
Cysts & tumors :no cyst and tumour is present

14. CHEST & RESPIRATORY SYSTEM :

Inspection : normal size and shape ,chest indrawing is present .

Palpation : tachypnoea is present, RR is 66/min
Percussion : bilateral air endry equal
Auscultation : bilateral creps present

15. CARDIO VASCULAR SYSTEM :

Inspection :pericardium appears normal

Palpation : sinus rhythm rate is 154/min.
Percussion ;normal limits, cardiac boarders are well within normal
limits
Auscultation : apex beat palpable in 4th inter costal space.
 16. ABDOMEN :

Inspection :abdomen is normal in shape,

Palpation :soft liver is present2,5cm .liver and spleen is just palpable
Percussion :no free fluid is present.
Auscultation :peristaltic movement is present

17. BACK :

Spine, curvature :no abnormalities noted,

movements :movement is present
Tenderness :no tenderness noted

18. GENITALIA :
Normal , no discharges is present.

19. EXTREMITIES :

Deformities : no abnormalities noted

Swelling / edema :no swelling or edema is present
Muscles :muscles strength are present
Lymph nodes : no lymph node enlargement
Joints : no deformities found
Fingers & Toes : no deformities like polydigitalis
Nails : no clubbing of nails found

20. CENTRAL NERVOUS SYSTEM :

Birth injuries : no birth injuries happened

Seizures : no seizure or febrile convulsion at birth
Speech : babbling sounds are present, not yet speech started
Sensory motor changes : motor sensory changes is normal
Gait changes : normal
Cognitive changes :normal
Reflexes :all the reflexes are present ,including sucking reflex but
mother is giving exclusive breast milk because child is having respiratory difficulty.
 21. URINARY SYSTEM :

Urinary Tract Infections : no urinary tract infection

Any abnormalities : no abnormalities noted

22. GASTRO INTESTINAL SYSTEM :

Diarrhea : not present

Constipation :not present
Bleeding, worm infestation :not present

23. PSYCHO SOCIAL HISTORY :

General status of the family : child belongs to middle class family.

There is no any medical illness for family members.
Relationship with the friends & family :family members having good
relationship with neighbours and friends.
Play activities : now child is very irritable ,so he is
not interested in play, otherwise child was playing with toys.
School performance : not yet started schooling

Hobbies : child is one and a half year old age.

So there is no specific hobies for child
 24. LAB INVESTIGATIONS:

S INVESTIGATIONS PATIENT’S NORMAL REMARKS

L NO. VALUE VALUE

1 Haemoglobin 11.2mg/dl 9-14mg/dl Normal

2 TLC 16,000cumm 6000-15000 Leucocytosis is

present
3 Platelet 5.01 lakhs 1.5-4.5 lakhs Thrompocytosis
is present.
4 Sodium 140meq/l 139-146meq/l normal

5 Potassium 4.2meq/l 4.1-5.3 meq/l normal

6 Chloride 101meq/l 95-106meq/l normal

7 Urea 16mg/dl 5-18mg/d normal

8 Creatine 0.8mg/dl .6-1.4mg/dl normal

9 Bilirubin 0.9mg/dl <2 normal

10 SGOT 45u/l 5-40 u/l Slightly

elevated.
11 SGPT 33u/l 5-28u/l Slightly
elevated.
12 Alkaline phosphatase 107u/l 20-150u/l Normal

25.SPECIAL INVESTIGATIONS:

Chest x ray
Sputam culture and sensitivity.
 25. MEDICATIONS :

Medications Dose, Frequency Action Side effects Nurses Responsibilities

& Route
Inj: augmentin 150mg,BD, IV
antimicrobial Severs renal -moniter the vital signs
impairement,nausea
, vomiting,urticaria, -maintain the intake out
put chart.

Inj: amikacin 35mg , OD, antibiotic Hepatic - moniter the vital signs
impairement ,
vomiting, peptic -maintain the intake out
ulcer. put chart.

Nebulisation 2ml /8ml NS Bronchodilators Dyspnoea, - moniter the vital signs

with ,QUID, by nasal with respules. dizziness
sulbacton mask ,headache,cardiac -maintain the intake out
arrhythmia. put chart.
NURSING ASSESSMENT;

Determine the severity of the respiratory distress that the child is experiencing
o Observe the respiratory rate and pattern
o Observe the respiratory rhythm and depth
o Auscultate breath sounds over all lung fields
o Observe the degree of respiratory effort , normal, difficult or labored.
o Note presence of additional signs of respiratory distress.
o Observe for head bobbling, usually noted in a sleeping or exhausted
infant.
o Obseve the childs colour , note the presence and location of cyanosis
o Observe the presence of cough , noting type and duration such as dry
barking , and paroxysmal or productive .
o Note the presence of sputam ,including colour , amount, consistency and
frequency.
o Observe the childs fingernails and toenails for cyanosis and the presence
and degree of clubbing , which indicate underlying chronic respiratory
disease.
o Assess for signs of infection , such as elevated temperature , enlarged
cervical lymph glands , purelent discharge from nose or ears.

NURSING DIAGONSIS:

 Ineffective airway clearance related to inflammation , obstruction , secreation or

pain .

 Ineffective breathing pattern related to inflammatory process secondary to

pneumonia.

 Fatigue related to increased work of breathing .

 Parentral anxiety related to respiratory distress and hospitalization.

 Parentral role conflict related to hospitalization of the child .

 Deficient fluid volume related to fever , decreased apetite secondary to disease

condition.
NURSING CARE PLAN

SL NURSING NURSING EXPECTED NURSING NURSING EVALUATION

NO ASSESMENT DIAGONOSIS OUTCOME INTERVENTION IMPLIMENTATION

-assess the child. Assessed the pulse rate,

1 Sub data : Child will respiratory pattern Expected
Ineffective able to ,rate ,observed the outcome is
Mother airway decrease the respiratory rhythm and partially met as
complained that clearance secretions depth . observed the evidenced by
child is cough and related to and have to degree of respiratory effective airway
secreation , inflammation , maintain effort . observed the pattern and
and secreations effective presence of cough and decresed
secondary to airway sputam colour. secreation.
pneumonia. pattern.
Obj data : -provide a humidified -provided a humidified
environment enriched environment enriched
Child is having with oxygen to liquefy with oxygen.
cough and secreations.
secretions , RR is
66/min.
-give nebulisation as per -given nebulisation with
doctors order. sulbacton QUID , with
nasal mask.

-keep the nasal passages -kept the nasal passages

free of secreations . free of secreations by
given nebulisation.
 Nursing Nursing Expected Nursing intervention Nursing Evaluation
Sl:no: assessment diagonosis outcome. implementation.

Child nutritional
2.. Sub data: Impaired Child will -assess the nutritional status is partially
Mother nutrition less have to get status of child -Assessed the improved as
complains about than body improved nutritional status by evidence by
poor feeding of requirements nutritional assessing the checking improved
child. related to poor status. BMI, and degree of feeding pattern.
feeding malnutrition.
secondary to
anemia.
Obj:data: -maintain the oral
hygiene, remove if -told the mother to
candidiasis present. maintain the oral
Child is on hygiene and if cadidiasis
exclusive breast is present , inform to
feeding. Childs doctor.
weight is less as
compared to
expected weight.
-give small and frequent -exclusive breast
feedings. feeding is giving 2 hrly
by mother.

-Encourage the child to -adviced the mother to

feeding. encourage the child in
feeding, if baby is
sleeping.
 Nursing Nursing Expected Nursing intervention Evaluation
assessment diagonosis outcome Nursing implementation
Sl:no
Obj data; Expected
High Risk for -asses the child. outcome is
Child is having infection related Child will -checked the lab partially met as
3. temperature and to progressive be free from investigation report , evidenced by
elevated WBC increased WBC infection WBC count is 16, 000 decreased
count. secondary to and Temperature is 99.8f. temperature.
respiratory increased
infection. immunity T is 98.8f.
Temp is 99.9f. power. -maintain aseptic
condition . -maintained aseptic
WBC count is techniques maintly in IV
infusion, closed
intracath after every
infusion with intracath
cap.

-encourage prompt -fever of 99.8f has

medical attention for reported and IV inj:
fever or signs of augmentin 75 mg started
infection. as a broad spectrum
antibiotics and tapid
sponge given.

-adviced the mother to -adviced the mother to

separate the child from take care of child
infected patients. because infant is having
very low immunity
Nursing intervention power. Evaluation.
 Nursing Nursing Expected Nursing
Sl:no: assessment. diagonosis. outcome implementations

Expected
4. Obj data ; Deficient fluid Child will -assess the condition of -assessed the condition outcome is
volume related have to the child. of the child ,noted the partially as
Childs fluid to fever maintain colour of the vomit , evidenced by
volume is ver y ,decreased fluid checked for any decreased
less because child apetite and volume abnormal distension , no vomiting and
is not taking vomiting deficit and abdominal distension is improved
adequate feeding secondary to improved present. feeding pattern.
and baby vomited disease apetite.
3 times and nasal condition.
regurgitation is
present.
-prevent aspiration -prevented the aspiration
by , adviced the mother
to maintain proper
position during feeding.

-tell the mother to donot -told the mother that

force the child to take the
milk.
donot force the child to
have the milk, because it
may induse vomiting
and abdominal
distension.

-assist in condrol of -tapid sponge was given

fever. to reduse the fever.