IDENTIFICATION DATA

Name Of patient – Miss khushi kumori

Age 5 years

Sex female

Father’s Name – Mr. Manish kumar

Ward General word

DateOf Admission 14/3/21

Address Ranchi

Diagnosis – pneumonia

Chief complain : - Miss khushi kumor admitted in the complain of

✔ Pever RIME hospital with

✓vomiting

✓ cough and Breathing difficulty for 3 to 4 days.

MEDICAL HSSTORY –

Present History :

Miss Khushi admitted in hospital on 7/3/21 with complain of fever, coughing, Vomiting and Breathing
difficulty for 3 to 4 days.

Past history

miss khushi kumari is no any past medical history.

SURGICAL HISTORY -:

Present surgical History : Miss khushi kumari does not Undergone through any surgical procedure.

Past surgical History Miss khushi kumari is having history of any surgery.

BIRTH HISTORY

A Antenatal History

✓ Tetenus Toxoid Taken – Yes

✓ Exposure to drug / Radiation – No

Illness during pregnancy-yes.

Blood group -A j

opregnancy-yes
Intranatal History

✓ Mode of Delivary – vaginal place of Delivary – Hospital

Belivary conducting – skilled staff 37 weeks

Gestational age at birth yes

Cry APGAR score Yes

Birth weight 2.6kg

Birth injury – No

c) Post Natal History :

✓ PPH

✓ Breast engargement – No

✓ Sepsis

New Born :

Baby color at birth – Pink

Eye discharge – No

Blood group AB+

Breast feeding stablish – yes

Pass maconium – yes

Any congenital abnormality – No

Social economical status :

Monthly income – 20,000/

Education – Inter

Occupation Driver

Type of House – pucca.

Living Locality – Town.

Ventilation proper ventilation

Drainage system proper drainage

Type of Latering – proper indian system water supply – good water supply

play ground facility – Not available

Personal History :

Feeding Habit -No

Sleep-10 hrs.

Bowel frequency – good

Bladder -Frequency-good

Toilet Training Yes

Hygiene Practice – yes

Allergy-No

Mensturation cycle – No

Family History

~Type of family – Nuclear family.

Number of Family Member-5

General Appearance :

Nourishment-Under Nourishment

Body Build-Thin

Activity – Dull

Health- unhealthy.

Mental status – Conscious

. Look – AnxiConscious

Pasture

–Body curve- Lordosis

. Look movement – proper movement

Skin –

Color – Brown

Texture –Dryness

Temperature – warm

Lesions -No lesions

Head & Face :

Shape of scalp – Round shape

Hair Color-Brown

Eye :

Eyelids Normal

Eyebrows-Normal

Conjunctiva- Red

Selera – clear

Cornea and Iris- Normal

Lens – Normal/Transparent

Fundus- Normal

Eye musele – Normal

vision – Normal.

Ear
External Ear – Normal

Tympanic membrane- Normal

Hearing problem – No

Nose –

External Nares- Normal.

Nostrils Normal

Mouth and pharynx =

Lips -Normal

Iodour of mouth-Foul smell

Teeth- yellow

Mucous membrane – Normal

Torgue white cooded color

Throat and pharynx – Normal

Neck

Lymph node – Normal

Thyroid gland – Normal

Chest :

Thorax – Round opacity

Breath sound-wheezing sound

Breast – Normal

Genitalia –

Labla majora Normal

Labia Manora – Normal

Bowel and bladder Not Proper working.

Extremities –

All Extem extremities – Normal

NURSING DIAGNOSIS –

1. airway clearance related to Inflammation and accumulation of secreation. As

evidence by cough with sputum production.
1) Impaired gas exchange related to alveolar capillary membrane charges as evidence by
tachycardia and restlessness.
2) Risk for fluid volume defecit related. To inadequate oral intake, fever as evidence by poor skin
turgor.
3) Hyperthermia related to inflammatory. Process as evidenced by increased body Temperature.
4) Sleeping pattern disturbed related to hyperthermic and cough as verbalized by mothers concern
for rest and sleep.
Day to Day prognosis:

1st Day

Name of the patient – Miss khushi kumari

Age 5 years old

Sex – Female

Chief complain – Miss khushi kumari I was admitted in the hospital inin general wand 20/6/21 with the
complaints of cough fever, vomiting and breathing difficulty for 3 day,

Vital sign

Temperodure 100 f

Pulse-99b/m

Respiration20 breath /minute

He Blood pressure 110/80 mm Hg.

Doctor Advice
Injection Azithromycin 250mg

✓ oxgen therapy.

Broncho dilation.

,2ndDay :

Patient complain that I have disturbed breathing pattern and do not daily activity. Properly.

Chest x-ray

Blood Test.

To continue some medicine as per doctor advice.

3rd day

Respiration – 26 b/min.

Heart rate 60/120 b/min

4th Day

Doctor Advice !

- To be continue medicine poor prognosis explained in details. To the attendent

Temperature 102 F

Pulse-90

Respiration 20b/min

BP-102/63mmHg
HEALTH EDUCATION

- Teach Parent about sign and symptoms Of pneumonia.

- To teach about fluid intake.
- To give proper rest and sleep
- . To make child to sleep in head elevated. At 30° to easy Breathing.Not taking feeds properly.
- wash your hands with soap and wooder. Or use alcohol based hand.
- Cough or sneeze into a tissue. Or band
- Oxygen therapy. Used.
- Advice regular check up to the Doctor.
- Advice to follow the int ind interaction Of the doctor.
- Adviced the patient to take medicine.
- Regularly According to doctor advice.
CONCLUSION

After completing this case presentation come to learn about caring of the client with pneumonia disease
how to treat this type of patient I am also learned the most important thing with should kept in mimof
mild pneumonia Was good experience for Care of the patient.
BIBLIOGRAPHY

- Parul Dotta Pediatric Nursing 4th ediction.Published by Jaypee Brothers medtal publishers.
- Ghai D-p. essentials of pediatrics 6th Edition New Delhi Cas publishers,
- 3) Net reference – (https: || 10.10.20. Inter topics)“Development Assessment”