BIODATA OF THE PATIENT

Name: Sohan khan

Age: 18 Months
Sex: Mch
Address: Model town Ludhiana.
Religion: Hinduism
Ward: Pediatric Ward
CR No: 21698
Informant: Father
D.O.A:
Diagnosis: Hydrocephalus (Infection and Convulsions)

CHIEF COMPLAINTS

Patient has presented with the following complaints:

 Increasing head size X 10days
 Headache X 4days
 Irritable X 4days
 Excessive crying X 4days
 Refusal to feed X 4days
 Downward gaze X 4days
 Cough X 4days
 High Grade Fever X 1day
 Vomiting X 1day
 Convulsions X at time of admission

PRESENT HISTORY

Patient was all well 10days back when started developing increased head size which could be
apparantely noticed. Later, after 6days he was found to be irritable, had excessive and loud cry
and refused to feed. Mother noticed continous downward gazing of the patient. Cough was mild,
intermittent and non productive. Vomiting was small in quantity, non bilious and non projectile.
3-4 episodes of vomiting were reported. Patient had convulsion on the day of admission. There
was twitching of lips with tonus of upper and lower left limbs.

PAST HISTORY

PAST MEDICAL HISTORY

Patient is a known case of hydrocephalus. He had abnormally increasing head size since birth.
For this he was admitted to hospital within a month of his birth and was diagnosed as congenital
obstructive/non-communicating hydrocephalus with aqueduct stenosis.
PAST SURGICAL HISTORY

Patient is shunted twice with Ventriculo- Peritoneal Shunt. He was firstly shunted at the age of
2months with parietal burrhole operation on the left side. Later with the same procedure he was
shunted in January 2017on the right side.

PERINATAL HISTORY

Mother registered pregnancy in a private hospital. She had routine check ups. She was taking
iron and folic acid tablets and calcium supplements throughout her pregnancy.
No significant antenatal history found.
The baby was born full term through normal vaginal delivery. Baby was born with meconium
stained liqour. He was kept under observation for 2days in NICU. Birth weight was 3kgs.

DEVELOPMENTAL HISTORY

Developmental milestones are appropriate with age. Baby has developed neck holding. He is
bisyllable and sits without support. He recognizes his family members well.

FAMILY HISTORY

No significant family history of any genetic or hereditary disorder found.

32yrs 29yrs

18mnths

SOCIOECONOMIC STATUS

Patient belongs to a middle class family. His father is in Military Services and degree holder in
arts. Mother is a house lady and 12th pass. It is a nuclear type of family. Total family income is
Rs. 12000-15000.

FEEDING HISTORY

Patient was put on breast feed soon after birth. Initially he was given EBM with katori and
spoon. Later he was successfully put on breast. Weaning was started by the age of 6months.
Patient usually takes breast milk, cow’s milk, porridge, dal, curd, banana, egg etc.
IMMUNIZATION STATUS

Immunization is complete for age. BCG mark is present on the left upper shoulder. Special
vaccines like HepB and Hib are also given.

GENERAL PHYSICAL EXAMINATION

1. GROWTH MEASUREMENTS:

a) Height:75.5cm
b) Weight: 10kgs
c) Head circumference: 48cm

2. PHYSIOLOGICAL MEASUREMENTS:

a) Temperature: 100°F
b) Heart rate: 110beats/min
c) Respiration: 34breaths/min

3. APPEARANCE:

Patient appears to be acutely sick by face with a large head size. Body movements are less.
Hygiene is well maintained. Child appears to be undernourished and irritable. Child is less
responsive and is lazy.

4. SKIN:

Patient appears pale. no lesions, jaundice, cyanosis, scar, rash, petechiae seen. Condition of
mucous membrane is healthy. No specific birthmarks found. No tenderness & masses found.
Tissue texture & turgor are nomal. No enlargement of lymph nodes found on palpation.

5. HAIR:

Hair is black, fine, silky and clean without any infections, lesions, dandruff, lice etc.

6. HEAD AND NECK:

Increased head size, anterior fontanel tensed, hair colour and texture normal, absence of
infections or any other lesions, dandruff or lice, movement of head restricted due to increased
head size, head lagging due to large head size, no webbing of neck, torticollis, normal thyroid
and no neck swelling etc.
7. EYES:

Downward gaze, distance between the eyes normal, distribution of eyebrows normal & vision is
normal. No infection, periorbital edema, photophobia, Mongoloid slant, exophathalmos,
cataract, squint, nystagmus, xerophthalmia. Normal pupillary response to light

8. EARS:

Ears normal for shape, size, position, no low set ears, deformities, discharge, and tenderness
over mastoid bone, and hearing abilities.

9. NOSE:

Shape, size, position normal, no deformities, discharge

10. MOUTH AND THROAT:

Color of lips pink, no lesions at the corner of mouth, no cleft lift or cleft palate, no teeth, normal
buccal mucosa, tongue and pharynx, no infections, any spot, ulcer, swelling, tongue tie etc.

11. CHEST:

Normal shape, size and symmetry of chest, no chest retractions, no pigeon chest, funnel chest,
rachitic rosary; normal breath sounds & heart sounds etc.

12. ABDOMEN:

Abdomen distended, healthy umbilicus, absence of any congenital anomalies and developmental
defects like hernias.

13. LIMBS:

No deformity, asymmetry, bow legs, knock knees, edema, any swelling. There is normal
movement of joints, number of fingers or toes normal, creases on palms and soles normal,
general cleanliness maintained and no deformity of feet (talipes, flat foot), no infections, etc.

14. SPINE AND BACK:

Spinal curvature, no tuft of hair, spina bifida, meningocele, meningomylocele, dislocation of

hip, neck stiffness, any swelling etc.
15. GENITALIA:

No hypospadias, epispadias, phimosis, hydrocele, hernia, undescended testis, ambiguous

genitalia. General cleanliness maintained.

16. ANUS AND RECTUM:

Patent anus, no fissures or fistulas

17. NEUROLOGICAL EXAMINATION:

Excessive cry, irritability, normal motor coordination, muscle tone, sense of touch or pain,
absence of meningeal irritation, paresis or paralysis etc. Patient had convulsion on the day of
admission. There was twitching of lips with tonus of upper and lower left limbs

SYSTEM WISE EXAMINATION

1. CARIOVASCULAR SYSTEM:

Heart rate: 110beats/min, shape and size normal, no abnormal heart sounds (murmurs),
no cyanosis, no associated congenital heart defects noted, capilliary refill time normal

2. RESPIRATORY SYSTEM:

Respiratory rate: 34 breaths/min. Cough was mild, intermittent and non produtive.
Shape and size of chest normal and symmetric. No chest retractions found. No Flaring of
nose found.

3. GASTROINTESTINAL SYSTEM:

Vomiting was small in quantity, non bilious and non projectile. 3-4 episodes of vomiting
were reported. On inspection no lesions, marks found, on palpation, abdomen found
distended, umbilical stump found healthy and sterile.

4. INTEGUMENTARY SYSTEM:

Skin is pale, turgor is normal, no lesions or infections found. Other structures of skin like
nails & hairs are normal and free from infections, general cleanliness maintained.

5. GENITOURINARY SYSTEM:

Urine output, colour and appearance normal.

6. REPRODUCTIVE SYSTEM:
 No hypospadias, epispadias, phimosis, hydrocele, hernia, undescended testis, ambiguous
genitalia. General cleanliness maintained.

7. LYMPHATIC SYSTEM:

All the lymph nodes found nontender on palpation, no lymphadenopathy

8. CEREBROSPINAL SYSTEM:

Baby has excessive cry and irritable. No defects of spine found. Baby responds to pain
and has normal pupillary responses. Patient had convulsion on the day of admission.
There was twitching of lips with tonus of upper and lower left limb
 NURSING CARE PLAN

NURSING PROBLEMS:
1. Convulsion
2. Difficulty in breathing
3. Lack of knowledge of family
4. Risk of infection
5. Lack of nutrition

NURSING DIAGNOSIS:
1. Inability to maintain normal breathing related to disease condition
2. Lack of knowledge of family related to home based care of child
3. Risk of infection related to surgical incisions present on the body
4. Altered nutrition less than body requirement related to disease condition
5. Risk for injury related to convulsion and large head size

PRIORITY SETTING
1. Inability to maintain normal breathing pattern related to disease condition
2. Altered nutrition less than body requirement related to disease condition
3. Risk for injury related to convulsion and large head size
4. Risk of infection related to surgical incisions present on the body
5. Lack of knowledge of family related to home based care of child

SHORT TERM GOAL

1. To maintain normal breathing pattern
2. To maintain body nutritional status within normal requirements
3. To alleviate risk for injury
4. To alleviate the risk of infection
5. To impart knowledge to family

LONG TERM GOAL

1. To prevent the complications to occur
2. To make the family knowledgeable to care the child in home
SR. NURSING NURSING NURSING INTERVENTIONS RATIONALE NURSING
NO DIAGNOSIS OBJECTIVE OUTCOME
NURSING CARE PLANNED NURSING CARE
IMPLEMENTED
1. Inability to maintain To maintain normal -assess the rate and pattern of -respiratory rate 32breaths/min -keen assessment will Normal breathing
normal breathing breathing pattern breathing of child and related and difficulty in breathing help to plan the further pattern maintained
pattern related to physical examination. found. management.
disease condition - child is positioned with head -such position will
-position the child with head end end raised at 45° clear the airway
raised at 45° -child is oxygenated with -oxygen relieve
-oxyenate the child oxygen hood @ 6-8 l/min breathing difficulty
-child is suctioned at regular -suctioning the saliva
-suction the child intervals and secretions prevent
aspiration.
2. Altered nutrition less To maintain body -assess the nutrional status of the -child refused feeds, vomiting - keen assessment will Normal body
than body nutritional status child. present help to plan the further nutritional status
requirement related to within normal management. mantained
disease condition requirements -entral feeds may cause
-maintain NPO satus -NPO status maintained until aspiration
child tolerate feeds -IV fluids maintain
-administer IV fluids as prescribed -IV fluids administered as hydration and
prescribed electrolyte balance
-start RT feeding
-administer antiemetics as -child given RT feeding -it will relieve vomiting
prescribed -syp. emset 3ml TDS
3. Risk for injury To alleviate risk for -assess the risks for injury
related to convulsion injury
and large head size
-during convulsion:
a) support the head with pillows
b) keep the environment safe with
least obstacles of furniture
c) make the side rails of bed up
d) donot try to open the mouth of
baby forcefully
e) after the convulsion, turn the
head to one side
f) contact the doctor soon possible
g) administer antiepileptics as
prescribed
4. Risk of infection To alleviate the risk -assess the sites for signs of
related to surgical of infection infection
openings present on
the body
-The child’s diaper to kept off the
peritoneal dressing or suture line
-keep the sites dry and maintain
hygiene of the sites
-use aseptic techniques
-give meticulous skin care and
inspect skin for any signs of
pressure, irritation and infection.
-risks for injury are related to - Keen assessment will Risk for injury
convulsion to patient and large help to plan the further alleviated
head size management.
-such measures will
-during convulsion: prevent the injury
a) head supported with pillows during convulsion
b) environment kept safe with
least obstacles of furniture
c) side rails of bed are made up
d) no tries are made to open the
mouth of baby forcefully
e) after the convulsion, head
turned to one side
f) the doctor is contacted soon
possible
g) Inj phenytoin 20mg IV
-upper and lower end of VP - Keen assessment will Risk of infection
shunt are assessed regularly for help to plan the further alleviated
signs of infection like redness, management.
swelling, discharge etc
-diapers are kept below the -fecal matter may cause
suture line contamination of
wound
-wet sites harbour
-both the sites are kept dry and microorganisms
hygiene is maintain. -asepsis prevent
- aseptic techniques followed infection
like hand washing
- Meticulous skin care is given
& Skin is inspected for any
signs of pressure, irritation and
infection.
 -administer prophylactic antibiotics - Inj ceftrax 425mg IV BD
as prescribed. administerd.
5. Lack of knowledge of To impart knowledge -assess the level of knowledge of - level of knowledge of family - keen assessment will Family becomes
family related to to family family regarding care of child at assessed regarding care of child help to plan the further knowledgeable
home based care of home at home as reported by the management. regarding care of
child -give health teaching to the patient family -health talk imparts child at home
on various aspects of home care. -health teaching given to the knowledge
patient on the following area:
1) Parents instructed to
recognize signs of shunt
malfunction, infection and how
to pump the shunt if necessary
2) Safe transportation is
essential issue with enlarged
head
3) Life long problem; requires
regular evaluation
4) Active children may have
accidents (falls, blows) which
may damage or disconnect
shunt.
5) Avoid parents being
overprotective
6) Few restrictions required like
contact play with siblings.
7) Contact with doctor as per
follow up and as the need arise.