nursing care plan Jaundice

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 Erikson’s theory shows “Trust Vs Mistrust”(Oral -sensory) (Birth -2 years):  Existential Question: Can I Trust the world?

The first stage of Erik Erikson’s theory centers around the infant’s 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 one’s 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 infant’s view of the world will be one of trust. Should the parents fail to provide a secure environment and to meet the child’s 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 Seen in my patientMotor skill development

                a.      Gross motor               -rolling over

               b.      Fine motor               -reaching out with both or one hand ,transfer objects

Language behaviors               -monosyllabus

Personal Social behaviors           -smiles at mirror image

Psychosocial development    Trust vs. Mistrust           -can tolerate a delay need gratification

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

S.N Developmental task according to book Seen in my patient

1.

2

3    

4

5

6

7

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

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

8

9

Learn to use symbol or language system

Direct emotional expression to indicate needs and wishes.

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 King’s 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 baby’s red blood cells.

III.Pathological Jaundice:

In some situation however there is so much billirubin in baby’s 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 other’s 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 mother’s 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 α-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 urineThe 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                                 findings                  normal range                                            2069/03/27WBC                                                   9800/cu mm              (4,000-11,000)Polymorph                                           54   Lymphocytes                                       46Hb                                                        8.7gm%                          (13.5-17.5)Total protein                                         6.5                            (6-8gm%)Albumin                                                 3.2                           (3.5-5.2 gm %)Bilirubin (Total)                                      16.6                         (0.4-0.8mg%)Bilirubin (conjugate)                              11.2                          (0.4mg%)Alkaline phosphate                               1220SGPT                                                    655                                     URINE EXAMINATIONMacroscopic                                       Color  light yellow                                              pH                                                      AcidicSugar                                                 NilAppearance                                       clearAlbumin                                              NilMicroscopicPuscell                                               NIlRBC                                                   NilCast                                                   NilCrystal                                                NilEpithelial cells                                    NilBacteria                                              Nil

                                      2069/3/28Thyroid 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: NormalKidney: Bilateral mild hydronephrosis,loss of CMD(corticomedullary differentiation)Impression :? Medico renal disease                                                069/3/29Ultrasonography :Liver :normalGall Bladder: NormalKidney: right lateral hydronephrosis with echogenicity of bilateral kidneyImpression : Right in thinned out Renal Parenchyma CMD layered                Hb electrophoresisHgb                                        6.4gm%PCV                                       21.7%RBC                                      27,900,00cmmWBC                                     12800/cmmPlatelets                                184000Retics                                     4.0MP corrected                          2%HbF                                         0.8%HbA2                                       3.6%  Hb Electrophoresis: Normal banded Speen;Normal Hb Electroporesis

                                                                              069/04/1Ultrasonography :Liver :7.8 mm with normal echotextureSpleen: 7.2 mm with normal texture Kidney: Mild dilatation at right kidneyImpression : spleenomegaly                      Mild hydronephrosis

                                                                       069/04/03Hb                                      4.8

                                                                          069/04/04Cholesterol                       174mg%                                150-250mg%Total Protein                     6.2                                          6-8g%Albumin                            4.1                                          3.5-5.2Bilirubin Total                   21.1                                         0.4-0.9mg%Bilirubin Congugate          15.3                                         0.4gm%SGPT                                 285SGOT                                  208PT                                       18 sec                                     (12 sec)APTT                                   26sec                                       (23sec)

Anti HCV test                       NON REACTIVEHbsAg                                  NON REACTIVETORCH IgM Antibody test result(Method ELISA)Toxoplasma gondii                                 NEGATIVE

Rubella Virus                                          NEGATIVECytomegalovirus                                     NEGATIVEHerpes Simplex Virus I                           NEGATIVEHerpes Simples Virus II                          NEGATIVETORCH IgG Antibody test result(Method ELISA)Toxoplasma gondii                                 778                       <50iu span="span">Rubella Virus                                          283                       <10iu span="span">Cytomegalovirus                                     10.3                       <0 .5iu=".5iu" span="span">Herpes Simplex Virus I                           148                         <5 .0iu=".0iu" span="span">Herpes Simples Virus II                          1.6                          <5 .0iu=".0iu" span="span">

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 baby’s color id turning more yellow , promptly call your baby’s physician.

         Feed babies frequently and don’t 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 mother’s 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 infant’s 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 infant’s 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 infant’s 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 baby’s 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.      Acute bilirubin encephalopathy         b.      Kernicterus         c.       Abnormal motor movement        d.      Behavior disorder        e.      Sensor neural hearing loss

NURSING MANAGEMENT:

Assessment:

During patient's assessment, I observed following things:Patient's general condition.Vital signs.Nutritional statusAnxiety 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(patient’s 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 Rationale Evaluation

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

The client will maintain adequate infantile body fluids

- Record the number

and quality of faecal

-Monitor skin turgor

-Monitor intake output

-Give water between

breastfeeding or giving

a bottle

-Variations help identify fluctuating intravascular volumes or changes in vital signs associated with immune response to inflammation-indicators of adequacy of peripheral circulation and cellular hydration-Monitor intake and output (I &O);note urine color and concerntration and specific gravity-Indicators of return of peristalsis and readiness to begin oral intake

-Reduces risk of gastric irritation and vomiting to minimize fluid loss

My goal was met the risk for fluid deficit was minimized.

2.  Impaired skin integrity related to hyperbilirubinemia and diarrhoea

The integrity of the baby skin can be maintained

- Assess skin color

every 8 hours

-Monitor direct and

indirect bilirubin

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

-Being informed about progress of

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

-Change position every

2 hours

-Massage the area that

stands out

-Keep your skin clean

and moisture

situation provides emotional support,

helping to decrease anxiety

-Relief of pain facilitates cooperation

with other therapeutic interventions,

-Refocuses attention, promotes

relaxation, and may enhance coping

abilities. 

-Decreases discomfort of early

intestinal peristalsis and gastric

irritation/vomiting.

3. Anxiety related to change in health status(patient’s mother)

-to relieve anxiety

-examine the level of

anxiety

-Give information about

the disease process

and actions-reassure the patient party-Enhance the patient general activity

Understanding promotes cooperation

with therapeutic regimen, enhancing

healing and recovery process

-to gain trust from the patient party

My goal was met the patient party was less anxious and well oriented about his disease condition.

4. Fluid volume deficit r/t poor

maintain fluid and

-document and

monitor :intake and

- Useful in

assess for signs of

My goal was fully met, blood transfusion done,

absorption electrolyte balance

output,  specific gravity,

daily weights, daily

abdominal girth

measurements,

-check vitals, monitor

for signs of tachycardia

or new murmurs,

 -blood transfusion

-Check laboratory

studies for electrolyte

imbalances,

-Capillary refill less than

3 seconds and urine

output.

dehydration, assess for fluid overload,

-regular vital sign helps to rule out any

deviation normal body functions as

well as presence of infection in body

-to maintain haeomostatic equilibrium

- to assess the proper liver function

and kidney function

-to assess the peripheral circulation

haemodynamically stabilized.

5. Potential for altered growth-due to liver disease

Infant/ child grow following growth curve while maintaining appropriate nutritional

-Monitor growth curve-

monitor weight on

regular basis.

-Assure that ADEK

vitamins taken on

regular basis, monitor

lab values.

Chart above information, be able to

identify and   report abnormalities and

reassess

-assess range of motion, gross and

fine motor skills

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 R/T Homecare Instructions

Parents understand home care instructions. 

-Teach parents about

medications including

purpose, dose,

administration, side

effects and signs and

symptoms to report.

-Teach parents

importance of

compliance relating to

testing, medications

and follow-up visits.

Teach parents to

identify, verbalize and

report changes in

child’s health status.

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 child’s health status.

My goal was met. The parents were well conscious about the patient and caring.

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

symptoms of worsening

liver function including:

change in stool color,

ascites, peripheral

edema,

hepato/spleenomegaly,

anorexia, urine color,

lethargy, jaundice,

bleeding, and pruritus.

-Educate regarding

complications of end

stage liver disease.

-Attempt to identify of signs and symptoms of bleeding with treatment of vitamin K or perhaps even a transfusion

complications due to   altered body

function helps in early identification

and treatment if present

-early management help to gain good

prognosis if any complication prevails.

-the early identification helps in

effective management.

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. Abdellah’s 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

student’s experiences and also a method to evaluate a nurse’s competency based on

outcome measures.”

(Tomey & Alligood, Nursing theorists and their work 4th ed., p. 115).

Abdellah’s 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 patient’s 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