OBJECTIVES

GENERAL OBJECTIVES;

At the end of the four weeks in College of Medical Sciences, I will be able
to take one comprehensive case study, apply nursing process in giving
holistic nursing care to my patient within the hospital setting.

SPECIFIC OBJECTIVES

 To select a case for case study.

 To follow up the case in hospital \ home.
 To gather previous record of previous treatment if they had.
 To anticipate the problem during hospitalization.
 To provide holistic nursing by using nursing process and nursing
theory.
 To compare the patient’s developmental task to normal state.
 To take measures for emergency management.
 To give informal teaching to the client (if understand) and families
about the promotion and maintenance of health.
 To apply knowledge from basic science and nursing theories in
planning the comprehensive care of patient.
 To collaborate with patient family and health team members in the
discharge planning of the patient.
 ACKNOWLEDGEMENT

This case study report on ‘NEPHROTIC SYNDROME’ is prepared on the

basis of the case study performed on that disease during my clinical
assignment in Paediatric Ward of Bharatpur Hospital. The report is prepared
as the partial fulfillment of Bachelor of Nursing Curriculum in Hospital
Practicum.

I found my words inadequate to express my sense of gratitude and reverence

to Madam Shrisha Rai and Madam Devi Sapkota, for their continuous
supervision, guidance, encouragement and sedulous leadership throughout
the study.

A very special thanks to the Ward In-charge and all staffs of Paediatric Ward,
concerned with the care of my patient for granting me permission to conduct
case study and for their kind co-operation and help.

I would also like to thank the Librarian for providing me necessary books. I
am also grateful to my colleagues and all those who have contributed with
their valuable suggestions.

Finally, I would like to express a sincere gratitude to my patient Mrs.

Ashmita Devkoata and her parents for providing valuable information, time
and co-operation that resulted in successful study of the case.

Yojana rimal
 BACKGROUND

The case study on “NEPHROTIC SYNDROME” is prepared in the hospital

practicum of Bachelor of Nursing 1st year curriculum.

The post basic nursing curriculum demands a case study on disease related
by fluid and electrolyte imbalances and during three weeks posting on
Paediatric Ward of Bharatpur Hospital.

Its aim is to enable the BN students to get through knowledge about the
disease. Its management in hospital setting and providing nursing care to the
client by applying nursing process and nursing theory to achieve optimum
benefit.
 BIODATA OF THE PATIENT

NAME ASHMITA DEVKOTA

AGE/SEX 7 YEARS/FEMALE
WARD PAEDIATRIC WARD
BED NO. 50
DATE OF ADMISSION 2071-03-31
DATE OF DISCHARGE 2071-04-05
DIAGNOISIS NEPHROTIC SYNDROME
ADDRESS BASANTAPUR-6, CHITWAN
RELIGION HINDU
LANGUAGE NEPALI

MOTHER’S NAME SARDA DEVKOTA.

AGE 37 YEARS
EDUCATION ILLITERATE
OCCUPATION HOUSEWIFE

FATHER’S NAME JEEVAN RAJ DEVKOTA

AGE 40YEARS
EDUCATION INTERMEDIATE LEVEL
OCCUPATION MARKETING

INFORMANT FATHER
ATTENDING DOCTOR DR. AMOD BDR THAPA
HEALTH HISTORY OF THE PATIENT

CHIEF COMPLAINTS.

On 2071-03-31 she was brought to emergency with the complains of ;

- Swelling of the whole body, starting from the face; 10-15days back.
- Occasional cough, running nose for 5days.
- No h \ o skin infection or URTI
- Decreased urine output 2-4 days
- Bowel – normal
- No h \ o pain abdomen

O\E
- comfortable
- pallor –
- Icterus –
- cyanosis –
- facial puffiness +
- pitting edema of legs +
- anemia –
- no significant lymphadenophathy
- no resp. distress

Vitals;
Temp. – 98 F
Pulse – 100 \min
Resp. – 24 \ min
B.P - 100 \ 80 mm hg
Wt. - 20 kg

PA – distension +
Fluid thrill +
 No organomegaly, flank dullness +

Chest – B\ L equal air entry

HISTORY OF PRESENT ILLNESS

According to the father, the child was alright 15 days back. Then she
developed swelling of the eyes 15 days back especially in the morning and
subsided in the daytime, 10 days back. She developed swelling of the face,
hands, and limbs. Developed running nose and cough which was dry in
nature. For all these symptoms she was taken to some local clinic where she
was given – Amoxy with investigations 5 days back. Had also h \ o passing
decreased amount of urine for about 4 days. No h \ o fever, skin infection or
sore throat.

PAST ILLNESS
Not eventful

Malnutrition Polio
Tuberculosis Rheumatic fever
Whooping cough Others
Diphtheria
Measles
Mumps

INJURIES \ACCIDENTS
Not known

HOSPITALIZATION
Never

OPERATIONS OR SPECIAL TREATMENTS (e.g. blood transfusion)

Not significant.

BIRTH HISTORY
- FT home delivery
 - No prenatal, natal, or postnatal complications.

IMMUNIZATION
- As per EPI
- BCG scar present in right hand.

ALLERGIC HISTORY
Not known.
FAMILY HISTORY
- 3 siblings
- She is the middle one.
- All are healthy.
- There is no history of any significant disease in her father and
mother’s family.

DEVELOPMENTAL HISTORY
Developmental milestone is within normal limits when compared to other
peer groups. Studying in class 2 and is regular average student.

SOCIO-ECONOMIC HISTORY
She is from middle class family consisting of 6 members.
Mother is not educated.
Father works in marketing department
They use gas and kerosene oil to cook food.
They use tap water for drinking.
They use water-sealed latrine.

NUTRITIONAL HISTORY
She takes normal Nepali diet, milk everyday. Takes meat, eggs once a week

FINDINGS OF PHYSICAL EXAMINATION

VITAL SIGNS
Temp. = 98.4 F
Pulse = 90 \ min
Resp. = 24 \ min
B.P = 100 \ 70 mm hg
Height = 117 cm
Weight = 20 kg
# General appearance;
-Fair.
-Weak appearance.
# Skin
-oedema
-no excessive moisture or dryness
-uniform color all over the body.
-Warm skin

# Head and face

-Color and texture of hair – black
-No swelling, injury, tenderness and depression.
-Uniform movement of both sides of face.

# Eyes
-Black in color.
-Bright and clear
-No discharge from eyes
-Pupils react to the light.
-Vision acuity- normal

# Ears
-Looks normal and clean
-No discharge and bleeding
-Hearing test result - normal

# Nose
-Centrally located
-No polyp or deviation
-No discharge

# Mouth
-Tongue and lips are pink
-No cyanosis
-White , presence of caries
-No missing teeth
-Pink throat, small tonsils.
-No difficulty in swallowing
#Neck
-No rigidity, moves freely
-Thyroid gland not visible.
-Lymph nodes are not palpable.

# Chest and lungs

-Breath sounds normal
-Even expansion of chest while breathing
-Breath sounds heard in all areas of the lungs.

# Breast
-normal shape and size
-soft, non-tender
-no discharge from the breasts

# Heart
-Normal and regular heart sound
-Heart rate – 90 \ min

#Abdomen
-Normal shape and size
-Slight edema present
-Bowel sounds present
-No abdominal mass and tenderness

# Genitalias
-No abnormality detected

# Back and spine

-The spine has no defects

# Extremities and trunks

-Symmetrical in size and shape
-Pitting edema of arms and legs.

# Musculo-skeletal
-No bone or joint deformity
-Able to move joints freely.
-Spine is in the midline.
# Nervous system
-Conscious and oriented to time and place.
-Walks straight.
DEVELOPMENTAL TASKS

The segment of the life span that extends from age 6-12 years is called
school years. It is also called middle childhood. This period begins with
entrance into the wider sphere of influence represented by the school
environment, which has a significant impact on development and
relationships. This age is also called gang age because children establish
close relation with pair groups.

PHYSICAL CHARACTERISTICS
The child between 6 to 12 years old exhibits considerable change in physical
appearance. The growth rate is slow and steady, characterized by periods of
accelerations in the spring and fall and by rapid growth during
preadolescence.

WEIGHT, HEIGHT AND GIRTH

These measurements vary considerably among children and depend on
genetic, environmental, and cultural influences. The average schoolchild
grows 2 to 2.5 inches (5-6cm) per year to gain 1 to 2 ft (30-60 cm) in height
by age 12. A weight gain of 4 to 7 pounds (2-3.5 kg) occurs per year. By age
12, the child has usually attained 90% of adult height. Muscle growth is
occurring at a rapid rate. During the juvenile or middle childhood period
girls and boys may differ little in size.

VITAL SIGNS
Vital signs of the schoolchild are affected by size, sex, and activity.
Temperature, pulse and respiration gradually approach adult norms with an
average temperature of 98 o 98.6 F, pulse rate of 70 to 80 per min, and
respiratory rate of 18 to 21 per min. The average systolic blood pressure is
94 to 112, and average diastolic blood pressure is 56 to 60 mm Hg.

CARDIOVASCULAR SYSTEM
The heart grows slowly during this age period; the left ventricle of the heart
enlarges. After 7 years of age, the apex of the heart lies at the interspace of
the fifth rib at the midclavicle line. By the age 9, the heart weighs 6 times its
birth weight. By puberty, it weighs 10 times its birth weight. Even though
cardiac growth does occur, the heart remains small in relation to the rest of
the body.

HEAD
The growth of the head is nearly complete; head circumference measures
approximately 21 inches and attains 95% of its adult size by the age of 8 or
9. The sinuses strengthen the structured formation of the face, reduce the
weight of the head, and add resonance to the voice. Jaw bones grow longer
and more prominent as the mandible extends forward, providing more chin
and a place into which permanent teeth can erupt.

GASTROINTESTINAL SYSTEM
Secretion, digestion, absorption, and excretion become more efficient. The
stomach shape changes and its capacity increases; capacity at a age 10 is 750
to 900 ml. Maturity of the gastrointestinal system is reflected in fewer
stomach upsets, better maintenance of blood sugar levels, and an increased
stomach capacity.

URINARY SYSTEM
The urinary system becomes functionally mature during the school years.
Between the ages of 5 to10, the kidneys double in size to accommodate
increased metabolic functions. Fluid and electrolyte balance becomes
stabilized, and bladder capacity is increased, especially in girls.

VISION
The shape of the eye changes during growth, and the normal farsightedness
of the preschool child is gradually converted to 20/20 vision by age 8. By
age 10 the eyes have acquired adult size and shape. Binocular vision is well
developed in most children at 6 years of age; peripheral vision fully
developed. Girls tend to have poorer vision acuity than boys, their color
discrimination is superior.

IMMUNE SYSTEM
Lymphoid tissues reach the height of development by age 7, exceeding the
amount found in adults. Enlargement of adenoidal and tonsillar lymphoid
tissue is normal, as are sore throats, upper respiratory infections, and ear
infections, which are caused by the excessive tissue growth and increased
vulnerability of the mucous membranes to congestion and inflammation.
Immunoglobulins G and A reach adult levels by age 9, and the child’s
immunologic system becomes functionally mature by preadolescence.

NEUROMUSCULAR DEVELOPMENT
By age 7 the brain has reached 90% of adult size. The growth rate of the
brain is greatly slowed after age 7, but by age 12 the brain has virtually
reached adult size. Memory has improved. Neuromuscular changes are
occurring along with skeletal development. Children of 7 have a lower
activity level and enjoy active and quiet games. The preadolescent, aged 10-
12, has energetic, active, restless movements with tension releases through
finger drumming or foot tapping.

PREPUBERTAL SEXUAL DEVELOPMENT

During the preadolescent or prepuberty period, both males and females
develop preliminary characteristics of sexual maturity. This period is
characterized by the growth of body hair, a spurt of physical growth,
changes in body proportion, and the beginning of primary and secondary sex
characteristics. As sebaceous glands of the face, back, and chest become
active, acne (pimples) may develop. These skin blemishes are caused by the
trapping of collected sebaceous material under the skin in small pores.
DEVELOPMENTAL TASKS OF SCHOOL AGED CHILDREN

ACCORDING TO BOOK ACCORDING TO PATIENT

-Decreasing dependency on family -She is totally depended on her
and gaining some satisfaction from parents due to disease condition.
pair and other adults.

-Increasing neuromuscular skills so -She used to participate in games

that she can participate in games and when she was alright.
work with others.

-Learning basic adult concept and -Not fulfilled.

knowledge to be able to reason and
engage in task of everyday living.

-Learning ways of communication -Talks with everybody politely.

with others realistically.

-Becoming more active and co- -She was active and used to help her
operative family participants. mother in household activities.

-Giving and receiving affection -She loves and cares her siblings and
among family and friends without her parents.
immediately seeking something in
return.

-Learning socially acceptable ways -She saves the money according to

of getting money and saving it for her mother.
later satisfaction.

-Learning how to handle strong -She lacks this task as she is very
feeling and impulses appropriately. soft-hearted.

-Developing a positive attitude -Respects her religion.

towards his \ her own and other
social, racial, economic and religious
groups.

-Beginning to develop appropriate -She has a strong feeling that she

masculine or feminine social roles. belongs to the feminine gender.
 INTRODUCTION TO DISEASE

NEPHROTIC SYMDROME

INTRODUCTION

Nephrotic syndrome is a set of signs or symptoms that may point to kidney

problems. The kidneys are two bean-shaped organs found in the lower back.
Each is about the size of a fist. They clean the blood by filtering out excess
water and salt and waste products from food. Healthy kidneys keep protein
in the blood, which helps the blood soak up water from tissues. But kidneys
with damaged filters may leak protein into the urine. As a result, not enough
protein is left in the blood to soak up the water. The water then moves from
the blood into body tissues and causes swelling.

Both children and adults can have Nephrotic syndrome. The causes of and
treatments for nephrotic syndrome in children are sometimes different from
the causes and treatments in adults.

Childhood nephrotic syndrome can occur at any age but is most common
between the ages of 1½ and 5 years. It seems to affect boys more often than
girls.

A child with nephrotic syndrome has these signs:

 high levels of protein in the urine, a condition called proteinuria

 low levels of protein in the blood
 swelling resulting from buildup of salt and water
 less frequent urination
 weight gain from excess water

Nephrotic syndrome is not itself a disease. But it can be the first sign of a
disease that damages the kidney’s tiny blood-filtering units, called
glomeruli, where urine is made.
DEFINITION

It is the name given to a condition when large amounts of protein leak out
into the urine. Normal urine should contain almost no protein. In nephrotic
syndrome the leak is large enough so that the levels of protein in the blood
fall.

PATHOPHYSIOLOGY

The initial physiology change in nephrotic syndrome is a derangement of

cells in the glomerular basement membrane (GBM) resulting in increased
membrane porosity and significant proteinuria. As protein continues to be
excreted, serum albumin is decreased (hypoalbuminiemia), thus decreasing
the serum oncotic pressure. The resultant fall in the plasma oncotic pressure
leads to interstitial edema and hypovolemia. The capillary hydrostatic fluid
pressure in all body tissues becomes greater than the capillary osmotic
pressure in all body tissues and generalized edema results. As fluid is lost
into the tissues, the plasma volume decreases stimulating secretion of the
renin-angiotensin-aldosterone axis and antidiuretic hormone secretion to
retain more sodium and water, which decreases the glomerular filtration rate
to retain water. This additional fluid also passes out of the capillaries into the
tissue leading to even greater edema.
 HEAVY PROTIENURIA

HYPOALBUMINEMIA

REDUCED PLASMA ONCOTIC PRESSURE

EXTRAVASATION OF INTRAVASCULAR FLUID

HYPOVOLEMIA

Rennin-angiotensin axis volume

receptors

ALDOSTERONE ANTIDIURETIC
HORMONE

DISTAL SODIUM AND WATER RETENTION

EDEMA
AETIOLOGY

Some of the more common causes of nephritic syndrome are:

1. Primary Glomerular disease
 Membranous proliferative glomerulonephritis
 Primary nephritic syndrome
 Focal glomerulonephritis
 Inherited nephrotic disease.

2. External causes

# Multisystem disease.
 Systemic lupus erythematous
 Diabetes Mellitus
 Sickle cell disease
 Amyloidosis

# Infections
 Bacterial (Streptococcal, syphyllis)
 Viral ( herpes zoster, HIV, and hepatitis)
 Protozoal (Malaria)

# Neoplasms
 Hodgkin’s disease
 Solid tumours of lungs, colon, stomach and breast.
 Leukemia

# Circulatory problems
 Severe congestive heart failure
 Chronic constrictive pericarditis

# Allergic reaction
 Insect bites, bee sting and pollen.
 Drugs (Penicillamine, NSAIDs, Captopril and Heroin)
SIGNS AND SYMPTOMS

ACCORDING TO BOOK ACCORDING TO PATIENT

-The onset is insidious with edema -Swelling of the eyes and face at
first noticed around the eyes and first, facial puffiness, edema present.
subsequently on legs.

-It is soft and pits easily on pressure. -Gradually swelling became

generalized, pitting edema on legs.

-Gradually edema may become -Abdomen distension and fluid thrill

generalized, with ascitis, hydrothorax +
and hydrocele.

-With increasing edema, urine output -Decreased amount of urine output.

decreases.

-The blood pressure is usually -Blood pressure was normal.

normal; sustained elevation suggests
the possibility of significant
glomerular lesions.

-After the loss of edema, severe -Presence of urine infection.

muscle wasting is revealed.

-Infections may be present at the

onset and during relapses.

DIAGNOSTIC TESTS

Lots of blood tests are useful. The most important test however is a renal
biopsy. This test is designed to take a small piece of kidney to look at under
the microscope. It is done with local anaesthetic and involves putting a
needle into the kidney through the back; a scanner is used to find the kidney
so the test is done in the X-ray department.
How is childhood nephrotic syndrome diagnosed?

To diagnose childhood nephrotic syndrome, the doctor may ask for a urine
sample to check for protein. The doctor will dip a strip of chemically treated
paper into the urine sample. Too much protein in the urine will make the
paper change color. Or the doctor may ask for a 24-hour collection of urine
for a more precise measurement of the protein and other substances in the
urine.

The doctor may take a blood sample to see how well the kidneys are
removing wastes. Healthy kidneys remove creatinine and urea nitrogen from
the blood. If the blood contains high levels of these waste products, some
kidney damage may have already occurred. But most children with
nephrotic syndrome not have permanent kidney damage.

A strip of chemically treated paper will change color when dipped in urine
with too much protein.

In some cases, the doctor may want to examine a small piece of kidney
tissue with a microscope to see if something specific is causing the
nephrotic syndrome. The procedure of collecting a small tissue sample
from the kidney is called a biopsy, and it is usually performed with a long
needle passed through the skin. The child will be awake during the
procedure and receive calming drugs and a local painkiller at the site of the
needle entry. A child who is prone to bleeding problems may require open
surgery for the biopsy. General anesthesia will be used if surgery is required.
For any biopsy procedure, the child will stay overnight in the hospital to rest
and allow the health care team to address quickly any problems that might
occur.

There are a few exceptions. In children the nephrotic syndrome is nearly

always caused by a condition that responds easily to treatment, treatment is
usually started first, and the biopsy only done if the protein leak is not cured.
In diabetes, a biopsy may not be essential if there is strong evidence that it is
likely to be related to diabetes. In adults, however many causes are possible,
making a renal biopsy important .

DIAGNOSTIC TESTS DONE IN MY PATIENT

DIAGNOSTIC TESTS FINDINGS NORMAL VALUE

UREA 35 13-45 mg\dl
CREATININE 1.0 0.7-1.4 mg \ 100 ml
ESR 76 1-20 mm / hr

HG 13%

WBC 14.5 4.25 – 14.0

NEUTRO 80 32 -62%
EOSINO 1 2.2%
LYMPHS 17 31%
MONOS 3 0-4%
CHOLESTEROL 415 140-250 mg\dl
SODIUM 146 135-148 m.Mol \ L
POTASSIUM 4.2 3.8-5.5 m.Mol \ L

URINE
WBC 0-2 Nil
RBC 1-3 2-3/ hpf
PUS CELLS 3-6 Nil
ALBUMIN 2 Nil
BACTERIA FEW Nil
EPITHELIAL CELLS 2-4 Nil
CREATININE 15 mg
PROTEIN 50 mg

URINE C \ S ASO < 200IU \ ML No growth

NEGATIVE
30,000 col \ ml of
E.Coli
What trouble does it cause?

The most obvious symptom is usually swelling of the ankles and legs. Extra
fluid may also accumulate in the abdomen and around the face, especially
overnight. In children and young adults the ankles may be less affected and
the abdomen and face more affected. Most ankle swelling is caused by other
diseases ; nephrotic syndrome is a rare cause of ankle swelling. Urine tests
and blood samples are required to prove that nephrotic syndrome is the
cause. The protein leak can sometimes make the urine frothy. Some people
feel tired.

Other problems can occur in nephrotic syndrome, probably as a result of

some particular proteins that are missing because of the leak.

Patients are unusually susceptible to some

Infections
infections.
In people who have nephrotic syndrome
for a long time, cholesterol is often very
Cholesterol
high. This may increase the risk of
narrowing of the arteries unless it is treated.
Blood is more likely to clot in the veins,
which may cause thrombosis in the leg
Blood
veins and occasionally elsewhere.
clotting
Some of these may require extra treatments
to prevent them
Severe swelling of the ankles in nephrotic syndrome ... and after
treatment.

TREATMENT

The treatments of fluid retention are managed by diuretics that force the
kidney to put out more salt and water in the urine. This is helped by
restricting the amount of salt in the diet and by avoiding excessive fluid
intake. If a lot of fluid has been retained, it is important that diuretic
therapy is carefully controlled by regular blood tests and weighing.
Some patients may require to be admitted to hospital.
PAEDIATRIC MANAGEMENT

Objectives of management are to preserve renal function and prevent

complications.
 Bed rest for a few days to promote diuresis and reduce edema.
 Dietary restrictions of protein and cholesterol to lower lipidemia.
 Low sodium, low saturated fat, liberal potassium.

PHARMACOLOGIC THERAPY

 Diuretics for severe edema, in combination with angiotension-

converting enzyme (ACE) inhibitors.
 Adenocorticosteriods to reduce proteinuria.
 Antineoplastic agents (Cytoxan) or immunosuppressive agents
(Imuran, Leukeran, or cyclosporine)

MEDICATIONS USED TO MY PATIENT

# Crystalline penicillin 10L IV

# Gentamycin 100mg IV

NURSING MANAGEMENT
 In the early stages, nursing management is similar to that of acute
glomerulonephritis.
 As the disease worsens, management is similar to that of chronic renal
failure.
 Intake and output are carefully measured and recorded; note signs of
low plasma volume and impaired circulation with prerenal acute renal
failure.
 Fluids are given according to the patient’s fluid losses and daily body
weight.
 Instruct patient receiving steroids or cyclosporine regarding
medications and signs and symptoms that must be reported to
physician.
  When indications of an acute infection, such as acute respiratory tract
infection, are first apparent, increased maintainance doses of
corticosteroids have been found to decrease the risk of relapse.
 Carbohydrates are given liberally to provide energy and reduce the
catabolism of protein.
 Provide bed rest with adequate support (abdomen, legs).
 Provide frequent change of position and care of pressure area with
antiseptic powder.
 Prevent contact with contaminated room-mates, visitors and
personnel; because they are vulnerable to infection due to
corticosteroid therapy.
 Vitals signs are monitored to detect any early signs of an infective
process.
 Daily weight record.
 Periodic health follow-up is essential.
 Reassurance to the parents and child.
 Instruct patient in selecting a therapeutic diet.

COMPLICATIONS

Complications of nephritic syndrome include infection (due to a deficient

immune response), thromboembolism (especially of the renal vein),
pulmonary emboli, ARF (due to hyperlipidemia)

PROGNOSIS

Almost 90 to 95 % of patients with minimal change nephritic syndrome

respond to treatment.
DRUG PROFILE

CRYSTALLINE PENICILLIN

ACTION
A natural penicillin that inhibits cell wall synthesis during active
multiplication; bacteria resist penicillins by producing penicillinases –
enzymes that convert penicillins to inactive penicillic acid.

INDICATIONS
Moderate to severe systemic infection.

ADVERSE REACTION
- Neuropathy, seizures, lethargy, anxiety, fatigue, agitation.
- Heart failure (with high doses)
- Nausea, vomiting, enterocolitis
- Interstitial colitis, nephrophathy
- Hemolytic anemia, leucopenia, agranulocytosis, eosinophilia.
- Arthralgia, urticaria, vein irritation, thrombophlebitis.

CONTRAINDICATIONS
In patients with hypersensitivity to drug or other penicillins and in patients
on sodium-restricted diets.

NURSING CONSIDERATIONS
- Use cautiously in patients with other drug allergies, especially to
cephalosporins.
- Obtain specimen for culture and sensitivity tests before giving first dose.
Therapy may begin pending results.
- I.V use: Reconstitute vials with sterile water for injection. Check
manufacture’s instructions for volume of diluent necessary to produce
desired drug concentration.
- Give penicillin G at least 1 hour before bacteriostatic antibiotics.
- Observe closely. With large doses and prolonged therapy, bacterial or
fungal superinfection may occur, especially in elderly, debilitated, or
immunosuppressed patients.
- Tell the patient to report adverse reactions promptly.
 GENTAMYCIN SULPHATE

ACTION
Inhibits protein synthesis by binding directly to the 30S ribosomal subunit.
Usually bactericidal.

INDICATIONS

- Serious infections caused by sensitive strains of Pseudomonas

aeruginosa, Escherichia coli, Proteus, Klebsiella, Serratia, Enterobacter,
Citrobacter, Staphylococcus.
- Meningitis
- After hemodialysis to maintain therapeutic blood levels.

ADVERSE REACTION
- Headache, lethargy, encephalopathy, confusion, seizures, numbness
peripheral neuropathy.
- Hypotension.
- Ototoxicity, blurred vision.
- Nausea, vomiting.
- Nephrotoxicity.
- Anemia, eosinophilia, leucopenia.
- Apnea.
- Rash, pruritis, tingling.
- Fever, muscle twitching, anaphylaxis, pain at injection site.

CONTRAINDICATIONS
In patients with hypersensitivity to drug or other aminoglycosides.

NURSING CONSIDERATIONS

- Use cautiously in neonates, infants, elderly patients, and patients with

impaired renal function or neuromuscular disorders.

- Obtain specimen for culture and sensitivity tests before giving first dose.
- Evaluate hearing before and during therapy. Notify doctor if patient
complains tinnitus, vertigo, or hearing loss.

- Weigh patients and review renal function studies before therapy begins.

- Monitor urine output, specific gravity, urinalysis, BUN and creatinine

levels, and creatinine clearance. Notify doctor of signs of decreasing
renal function.

- Watch for superinfection (continued fever and other signs of new

infection, especially of upper respiratory tract).

- Know that therapy uaually continues for 7 to 10 days. If no response

occurs in 3 to 5 days, therapy may be stopped and new specimens
obtained for culture and sensitivity testing.

- Encourage patient to take adequate fluid intake.

- Caution patient not to perform hazardous activities if adverse CNS

reactions occur.

DISCHARGE TEACHING

 Instructed the parents about the importance of following all

medications and dietary regimens so that their condition can remain
stable as long as possible.

 Advised them to visit physician if an acute infection, such as an acute

respiratory tract infection develops.

 Advised them to provide low salt diet to the patient.

 The skin may be dry or susceptible to breakdown as a result of edema;

so, taught them about meticulous skin care.
  Encouraged the parents to maintain the personal hygiene of the patient
and avoid contacts with infectious process.

 Informed them about follow-up care.

NURSING PROCESS

The nursing process is often defined as the application of critical thinking to

client care activities. The nursing process is a method of organizing and
delivering nursing care. To understand its functions, components and
interactions, the nurse should have a working knowledge of the nature of the
process. A process is a series of steps or components leading to a goal, which
includes the following;

Assessment
Diagnosis
Planning
Implementation
Evaluation
NURSING CARE PLANS

NURSING NURSING INTERVENTION RATIONAL EVALUAT

DIAGNOSIS GOAL ION
1. Activity Progressive -Assessed degree -Provides information Goal was
intolerance return to of weakness, about fatigue and achieved as
related to activities fatigue, extent of tendency of lying in patient
fatigue. within edema and prone position. return to
tolerance. difficulty in -Promotes activity play
movement. and exercise within activities as
-Encouraged limits and adequate edema
alternating activity rest. subsided.
with rest. -Provides stimulation
and activity within
endurance level.
-Provided selected -Helps to assess
play activities as degree of fatigue.
tolerated. -Promotes
independence and
-Observe for control of situations.
behavior changes -Reduces fatigue and
after activity. conserves energy.
-Encouraged the -Promotes return to
child to set own active life for child.
limits.

-Informed child to
rest when feeling
tired.

-Informed parents
to allow the child
for full
participation in
activities as the
disease is resolved.
 NURSING NURSING INTERVENTION RATIONAL EVALUATION
DIAGNOSIS GOAL
2.Excess Edema will -Assessed the -Decreased Goal was
fluid volume be presence of retention of achieved as
related to decreased. edema on sodium and edema subsided
edema. extremities. water result in at the time of
increased discharge.
systemic
vascular
pressure and
fluid overload,
which lead to
edema.

-Weighed daily -Weight gain is

with same an early sign of
clothing. fluid retention.

-Assessed for -Indicates

oliguria. decreased renal
perfusion
resulting in
sodium,
potassium and
water retention.

-Monitored -Provides
intake and output information
strictly. about the
changes and
treat
accordingly.

-Limited sodium -To decrease

intake by edema.
avoiding food
high in salt.
 -Limit fluid -Fluid
intake to restriction will
prescribed be determined
volume. on the basis of
weight, urine
output, and
response to
therapy.

NURSING NURSING INTERVENTION RATIONAL EVALUATIO

DIAGNOSIS GOAL N
3.Ineffective Parents -Assessed the Provides Goal was
coping knowledge knowledge about information achieved as
associated will be the disease. about teaching parents
with increased. needs for follow- knowledge
condition up care. was increased
and -Assessed the level and anxiety
treatment. of anxiety and Anxiety will was also
need for support in interfere with reduced.
care of the ill child. learning process.

-Instructed in
medications
administration Helps in accurate
including side- medication
effects. administration.

-Instructed parents
to monitor foe
edema, take daily Allows for
weight and to monitoring of
report changes of possible relapse
increased weight of disease and to
and presence of have prompt
albumin in urine to treatment.
physician.
 -Provided Promotes
information about understanding of
disease, its causes disease process
and need for and to prevent
frequent exacerbation.
hospitalizations.

NURSING NURSIN INTERVENTI RATIONAL EVALUATIO

DIAGNOS G GOAL ON N
IS
4.Potential Patient -Assessed Indicates
for will not temperature presence of Goal was
infection develop elevation, infectious achieved as
(URTI) any signs respiratory process. patient did
related to of changes. not develop
disease infection. any signs of
condition. -Prevented to To protect the infection
visit those with child from during
infectious infected persons hospitalizatio
diseases. that may n.
transmit
pathogens to
immunosuppress
ed child.
-Maintained Promotes
paediatric measures to
aseptic prevent
techniques and infection.
hand wash
when giving
care.

-Maintained Prevents chilling

warmth for and
child. predisposition to
URTI.

-Administered Prevents or
antibiotics treats infection
therapy as based on C\S.
ordered.
NURSING THEORY APPLICATION.

FLORENCE NIGHTINGALE’S ENVIRONMENTAL MODEL

Nightingale’s grand theory focused on the environment. Environment is the

surrounding matters that influence or modify a course of development; the
system must interact and adjust to its environment.

The environment is viewed as all the external conditions and influences that
affect the life and death and development of organisms. Environment is
capable of preventing, suppressing or contributing to disease, accidents or
death. She identified ventilation and warmth, light, noise, variety, bed and
bedding, cleanliness of rooms and walls, and nutrition as major areas of the
environment the nurse can control. When one or more aspects of the
environment are out of balance, the clients must use increased energy to
canter the environmental stress. These stresses drawn the client of energy
needed for healing. These aspects of the physical environment as also
influenced by the social and psychological environment of the individual.

My patient Miss. ASHMITA DEVKOTA is 7 years old and is the case of

Nephrotic Syndrome. As there is high risk for infection due to
immunosuppression, the environmental theory of Florence Nightingale
seems more applicable for me to care my patient.

a. Physical environment:

 Cleanliness – From the day I started to care my patient, I kept her

clean and encourage her parents to maintain hygiene. All
equipments and utensils were kept clean.
  Bed and bedding – Bedding is an important part of the
environment. Dirty and soiled linen contains large quantities of
organic matter and provided ready source of infection. This
organic matter enters the sheets and stays there unless the bedding
is changed and aired frequently. I kept the bedding neat and clean
and dry by managing the soiled linen properly. I reminded the
visitor not to sit upon the bed of the patient.

 Ventilation and warming – A steady supply of fresh air was the

most important principles of nursing. The person who repeatedly
breathed his or her own air would become sick or remain sick. The
temperature of the room should be also maintained. The patient
should not be too warm and too cold. I controlled the temperature
by maintaining appropriate ventilation from the windows and
monitored patient’s body temperature by palpating the extremities.

 Noise – Noise is another environmental element. I kept the patient

from noise by limiting the number of visitors in the room. I didn’t
wake her while she is sleeping.

 Nutrition and taking food – The variety of food presented to the

patient is also very important. I encouraged her and the visitors to
serve her nutritious diet which contains low salt and to give in
small frequent amounts because the frequent small services may
be more beneficial to the patient than a large meal.

b. Psychological environment:

The effect of mind and body is inter-related. I engaged her on talking and
expressing ideas, feelings. Helped the patient and her parents to assess
about her disease condition.

c. Social environment:
 Another important factor is the person’s social environment in which he
or she lived. The hospital should be well managed, i.e. organized, clean
and with appropriate supplies show client and environment in balance
and expending unnecessary energy being stressed by environment. The
patient’s total environment includes his family and community where she
comes from. So, I recognized her as a socially valuable person. I allowed
parents to be with her to make her feel safe and comfortable.

CONCLUSION.

In one week posting in Paediatric Ward, I selected a case of Nephrotic

Syndrome. I tried my best to provide good nursing care to my patient
during hospitalization. I maintained good relationship with the patient and
her family and they also co-operate me as well. I got an opportunity for
comprehensive study and provide holistically quality care.

I am fully satisfied with my case study because I got an opportunity to learn

about the patient’s disease condition, NEPHROTIC SYNDROME, its
causes, signs and symptoms, management also and fluid and electrolyte
imbalances in this disease. .

While caring my patient, I applied Florence Nightingale’s Environmental

theory. I cared him for 3 days. Then she was discharged. At the time of
discharge, I encouraged her parents to give nutritious, and low salt diet, to
maintain her personal hygiene, and to avoid contacts with infectious process.

I also visited home and studied other directly and indirectly related aspect of
the disease. I found her progressed much.

And lastly, I felt very satisfied with my case study as I got the chance to
study in detail about the disease applying the fluid and electrolyte concept.
BIBLIOGRAPHY

* Brunner and Suddarth’s, Textbook of Paediatric-Surgical Nursing, 11th

edition, 2008.

* Ghai Piyush Paul, Essentials of Paediatrics, 6th edition.

* Dr. Laxmi Shrestha Thakur, Advanced Child Health Nursing, Common

Health Throughout The Lifespan, 2006.
* Nursing 99 Drug Handbooks, Springhouse Corporation
Springhouse, Pennsylvania

* Ruth Beckmann Murray, Judith Proctor Zentner, Health Assessment

Promotion Strategies Throughout The Lifespan, 6th edition
*Nursing Care for Children, Health Learning Materials Center,
Institute of Medicine, Kathmandu, Nepal, 2000

* Marie Jaffe R.N., M.S. , Paediateic Nursing Care Plans.

BIRTH NO. 6773
NAME MRS. SUNITA SHRESTHA
AGE 22 YEARS
HUSBAND’S NAME MR. KRISHNA SHRESTHA
ADDRESS BHAKTAPUR
ANC OUTSIDE
LMP 2064-03-28
EDD 2064-12-05
GESTATION 39 +2
GRAVIDA 1
PARA 0
LIVING 0
ABORTION 0
DATE OF DELIVERY 2064-12-11 / 24 TH MARCH,
2008
BLOOD GROUP B +VE
VDRL N/R
DATE OF ADMISSION 2064- 12-11
BABY FEMALE
WEIGHT 3300GM
BIRTH TIME 9:34 AM
TYPE OF DELIVERY SVD with EPISIOTOMY
APGAR SCORE 8/10, 9/10
FIRST STAGE 4hrs 45 mins
SECOND STAGE 49 mins
THIRD STAGE 6 mins
TOTAL LABOUR 5 hrs 40 mins
DELIVERY CONDUCTED BY MAAM PURNA SHRESTHA
JYOTI MAHARJAN