THE OXFORD COLLEGE OF NURSING

Begur road, Hongasandra, Bangalore

CHILD HEALTH NURSING

Case Presentation on:

SUBMITTED TO
Ms. Marilakshmi
Lecturer in Pediatrics Nursing.
The Oxford College of Nursing
Bangalore

SUBMITTED BY
Miss Soumya Jose.
I Yr M.Sc. Nursing
The Oxford College of Nursing
Bangalore

SUBMITTED ON:
INTRODUCTION
As a part of our clinical experience posting in IGICH (Indira Gandhi Institute of Child Health),
Bangalore took care of from to I selected this case in order to use this
knowledge in my day to day clinical practice.

I. BIOGRAPHICAL INFORMATION
Name :
Age :
Sex :
Address :

Religion :
IP No. :
Admission unit :
Date of admission :
Date of history taking :
Doctor in charge :
Informant :

II. DIAGNOSIS :

III. PRESENT HISTORY

Chief Complaints with Duration

History of Present Illness

IV. PAST MEDICAL HISTORY
Past illness, hospitalizations :

Allergies :

Medications :

V. BIRTH HISTORY
Antenatal

Natal – Place of Birth :

Mode of Delivery :
Gestational Age :
Birth Weight :

Postnatal

VI. FAMILY HISTORY

VII. GROWTH AND DEVELOPMENT

VIII. IMMUNIZATION
Name of the Vaccines Time Remarks
1. OPV 0 & BCG At Birth
2. OPV 1 & DPT 2 6 weeks
3. OPV 2 & DPT 2 10 weeks
4. OPV 3 & DPT 3 14 weeks
 5. MMR 9 months

IX. ELIMINATION PATTERN

Bowel :
Bladder :

X. NUTRITIONAL PATTERN
Recent Weight : Expected Weight:
Appetite :

24 Hours Diet Recall:

Time Diet items

Degree of Malnutrition :

XI. SLEEPING PATTERN

 PHYSICAL EXAMINATION
1. General Observation

2. Vital Signs

3. Anthropometric Measurements
Height :
Weight :
Head Circumference :
Chest Circumference :
Mid Arm Circumference :

4. Skin And Mucus Membrane

Color :
Edema :
Moisture :
Temperature :
Turgor :
Texture :
Any Abnormal Discharges :

5. Hair
Changes in Texture :
Characteristics :
Lice :
6. Nails
Changes in Appearance :
Cyanosis :
Texture :

7. Head
Skull/Cranium Size, Shape :
Fontanelles :
Suture :
Movements :
Forehead :

8. Face
Appearance :
Color :
Symmetry :
Movements :

9. Eyes
Expression :
Eye Lids :
Lacrimation :
Eyebrows :
Conjunctiva :
Sclera :
Cornea :
Pupil :
10. Ears
Appearance :
Discharges :
Lesions :
Any Abnormalities :

11. Nose
Appearance :
Discharges :
Patency :
Sense of Smell :

12. Mouth And Throat

Lips :
Tongue :
Teeth :
Gums :
Buccal Mucosa :
Palate :
Tonsils :
Taste :

13. Neck
General Appearance :
Trachea :
Lymph Nodes :
Thyroid Glands :
 Salivary Glands :
Cysts and Tumors :

14. Chest And Respiratory System

Inspection :
Palpation :
Percussion :
Auscultation :

15. Cardio Vascular System

Inspection :
Percussion :
Auscultation :

16. Abdomen
Inspection :
Palpation :
Percussion :
Auscultation :

17. Back
Spine, Curvature :
Symmetry :
Tenderness :
18. Genitalia

19. Extremities
Deformities :
Swelling/ Edema :
Muscles :
Lymph Nodes :
Joints :
Fingers and Toes :
Nails :

20. Central Nervous System

Birth Injuries :
Seizures :
Speech :
Sensory Motor Changes :
Gait Changes :
Cognitive Changes :
Reflexes :

21. Urinary System

Urinary Tract Infections :
Any Abnormalities :

22. Gastro-Intestinal System

Diarrhea :
 Constipation :
Bleeding :
Worm Infestation :

23. Psychosocial History

General Status of the Family:

Activities of Daily Living :

Play Activities :

School Performance :

Hobbies :

24. Laboratory investigations

Sl. Investigation Results Normal values Remarks
No.
1. Hemoglobin
2. TC
3. DC
Prothrombin
Lymphocyte
Erythrocyte
 4. Glucose
5. Creatinine
6. Sodium
7. Potassium
8. Chloride
9. Urea
10. Alkaline phosphate
11. SGOT
12. SGPT
13. ESR
14. Platelet
15. CRP

16. Urinary
Protein :
Volume :
Albumin :
Globulin :

25. Special investigations

 MEDICATIONS
Medication name Dosage Frequency Route Actions Side effects Nursing responsibilities
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
NURSING CARE PLAN

ASSESSMENT NURSING IMPLEMENTATION EVALUATION

DIAGNOSIS
OBJECTIVE INTERVENTION
S
ASSESSMENT NURSING IMPLEMENTATION EVALUATION
DIAGNOSIS
OBJECTIVE INTERVENTION
S
ASSESSMENT NURSING IMPLEMENTATION EVALUATION
DIAGNOSIS
OBJECTIVE INTERVENTION
S
ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS
OBJECTIVE INTERVENTION
S
ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS
OBJECTIVE INTERVENTION
S
BIBLIOGRAPHY