A NEW BORN CARE PLAN

ON

VESTIBULAR FISTULA
WITH
PSARP
INTRODUCTION
As a part of the clinical experience posting I took care of B/o Swathi from 4.02.17 to
06.02.17. I selected this case in order to use this knowledge in my day to day clinical practice.

I. BIOGRAPHICAL INFORMATION :

Name : B/o Swathi

Age : 4 days
Sex : Male
Address : S/o Mr.Bhasker
#36 ,1st cross,
T.T Nagar
BHOPAL

Religion : Hindu
I.P. No. : 61813
Admission Unit : SICU
Date of Admission : 1.01.17
Date of History taking : 4.01.17
Doctor in charge : Dr.Ramesh
Informant : Mother

DIAGNOSIS : Vestibular Fistula

SURGERY DONE : Posterior Saggital AnoRectoPlasty (PSARP)

PRESENT HISTORY:
Chief complaint with duration: Congenital absence of anal orifice.

History of present illness: B/o Swathi is referred to Kamla NehruHospital to correct vestibular
fistula and PSARP procedure done.

PAST MEDICAL HISTORY:

Past illness, hospitalizations, surgeries or major illness:

Nothing significant

Allergies: Nothing significant.

BIRTH HISTORY

Antenatal – The mother has normal antenatal history and she had regular antenatal checkup.
She has taken two doses of TT. She doesn’t have any history of GDM, Gestational hypertension
etc. She never had any complications during pregnancy. It was her second child.

Natal- Place of birth : Hospital

Mode of delivery : Normal Vaginal Delivery
Gestational age : 9months + 3days
Birth weight : 2.9 Kg

Postnatal – The baby cried soon after birth. Inj. Vitamin K given after birth. Delivery was
full term normal vaginal delivery. Baby cried immediately after birth. Baby established
satisfactory airway.

FAMILY HISTORY:

28 yrs
36yrs

5 days 2 ½ yrs.

No history of consanginous marriage. No history of same disease in their family.

II. GROWTH AND DEVELOPMENT:

Growth and development is appropriate to the age.

III. IMMUNIZATION:

Name of the vaccines Times Given or Not

1. BCG & OPV At birth Given

 IV. ELIMINATION PATTERN:

Bowel : Impaired.
Bladder : Normal

V. NUTRITIONAL PATTERN:

Recent weight : 2.7 Kg

Expected weight : 2.5-3.0 kg
Appetite : Normal

24 hours diet recall :

TIME DIET

2 hourly Breast milk

VI. SLEEPING PATTERN :

Sleep pattern is disturbed due to pain and discomfort.

PHYSICAL EXAMINATION ( NEWBORN ASSESSMENT )

1. GENERAL OBSERVATION:

Baby looks weak and irritable.

2. VITAL SIGNS:

Temperature : 96.4 0 F
Pulse : 80/mt
Respiration : 40/mt

3. ANTHROPOMETRIC MEASUREMENTS:

Height : 49 cm
Weight : 2.7 kg
HC : 30.5 cm
CC : 31.5 cm

4. SKIN AND MUCUS MEMBRANE :

 Colour : Normal, pink
Edema : No edema present.
Moisture, Temperature: The skin is generally moist and warm to touch.
Turgor : Good
Texture : Good, Normal
Any abnormal discharge : Nil

5. HAIR :

Changes in texture : Nil

Characteristics : Normal black distributed

6. NAILS :

Changes to appearance : Nil

Cyanosis : No cyanosis present.
Texture : Normal

7. HEAD :

Skull / cranium, size, shape, fontanelles : Small in size, fontanelles not closed.
Suture : Present
Movements : Normal within range
Forehead : Hairy, no lesions.

8. FACE :

Appearance : Weak
Color : Fair
Symmetry : Symmetrical
Movements : Normal

9. EYES :

Expression : partially closed

Eye lids : Not infected
Lacrimation : Clear fluid expressed
Eyebrows : Equal distribution
Conjunctiva : Pale
Sclera : Pale, Jaundice present
Cornea : Normal, moist and round
Pupil : PEARL

10. EARS :
 Appearance : Normal
Discharges : Nil
Lesions : Nil
Any abnormalities : Absent, No low set ears

11. NOSE :

Appearance : Normal, No DNS

Discharges : No abnormal discharges.
Patency : Patent.
Sense of smell : Developed, can identify smell of breast milk

12. MOUTH & THROAT :

Lips : Normal
Tongue : Coated
Teeth : Absent
Gums : Pinkish color
Buccal mucosa : Normal
Palate : Epstein pearl present
Tonsils : Not inflamed.
Taste : Not well developed.

13. NECK :

General appearance : Folds present

Trachea : Normal
Lymph nodes : Not palpable
Thyroid glands : Not palpable
Salivary glands : Normal in function
Cysts & tumors : Nil.

14. CHEST & RESPIRATORY SYSTEM :

Inspection : No scar or lesions, normal in size.

Palpation : No abnormal mass.
Percussion : No fluid collection and tenderness
Auscultation : No crepitus, RR-36/mt
NVBS heard.

15. CARDIO VASCULAR SYSTEM :

Inspection : Size and shape are normal.

Palpation : No abnormal mass
Percussion : No abnormal sounds
Auscultation : No cardiac murmurs, S1 S2 heard, HR-150/mt
16.ABDOMEN :

Inspection : No scar/lesions, normal umbilicus

Palpation : No tenderness and mass
Percussion : No gas/ fluid collection
Auscultation : Bowel sound heard

17. BACK :

Spine, curvature : No spinal abnormalities

Symmetry : Symmetrical
Tenderness : Nil

18.GENITALIA :

Anal orifice absent.

19.EXTREMITIES :

Deformities : Nil
Swelling / edema : Nil
Muscles : Normal development
Lymph nodes : Not palpable
Joints : No abnormalities, normal ROM
Fingers & Toes : No syndactility or polydactylity
Nails : Normal, no cyanosis

20.CENTRAL NERVOUS SYSTEM :

Birth injuries : Nil

Seizures : Present
Speech : Not developed
Sensory motor changes : Normal response to stimuli.
Gait changes : Not developed
Cognitive changes : Not developed

REFLEXES:

a. Grasp reflex : present.

b. Moro reflex : present.
c. Dancing reflex : present.
d. Trunk incurvation reflex : present.
e. Asymmetric tonic reflex : present.
 f. Extrusion reflex : present.
g. Dolls eye reflex : present.
h. Sucking reflex : present.
i. Rooting /swallowing reflex : present.
j. Blinking reflex : present.

21.URINARY SYSTEM :

Urinary Tract Infections : Nil

Any abnormalities : No abnormalities present.

22.GASTRO INTESTINAL SYSTEM :

Diarrhea : Nil
Constipation : Nil
Bleeding, worm infestation : Nil

23.PSYCHO SOCIAL HISTORY :

General status of the family : They belongs to a middle class and nuclear family where
the father is an earning member. They stays in their own house with one bedroom, kitchen and
maintaining good social contact with society.

Relationship with the friends & family: The parents maintaining good relationship with
friends and relatives. The baby has been loved by all.

Activities of daily living : Baby is hospitalized and ADLs are not developed.

Play activities : Nil

School performance : Nil

Hobbies : Nil
 15. LABORATORY INVESTIGATIONS :

INVESTIGATIONS RESULTS NORMAL VALUE REMARKS

1.Hemoglobin 9.8 gm/dl 12-16 gm/dl

2.TC 8700 4500-11000cells/cumm Normal

cells/cumm
3.DC:
Prothrombin 73%
Lymphocyte 27%
Erythrocyte 3%

4. Glucose 77 mg/dl 60-100 mg/dl Normal

5. Creatinine 0.8 mg/dl 0.6-1.4 mg/dl Normal

6. Sodium 142.0 135-148 mEq/dl Normal

mEq/dl
7.Potassium 4 mEq/dl 3.5-5.2 mEq/dl Normal
Normal
8.Chloride 101 mEq/dl 95-106 mEq/dl
Normal
9.Urea 16 mg/dl 10-50 mg/dl
 17.MEDICATIONS :

Medications Dose, Frequency & Action Side effects Nurses Responsibilities

Route

Inj.Ceftriaxone 250 mg, Q12H, IV Antibiotics Head ache, Monitor vital signs
lethargy, frequently.
drowsiness, Check for any adverse
urticaria,tachycardia reactions. Provide drug
by calculating drops.

Inj.Amikacin 37.5 mg, Q12H, IV Antibiotics Tachycardia, Monitor pulse during

itching, nausea, administration of drug.
lethargy, pruritis. Observe the baby for
any adverse reactions.
Monitor the effects of
drug.

Inj.Metrogyl 7.5ml,Q8H, IV Antibacterial Nausea, vomiting, Monitor vital signs

headache, urticaria. frequently.
Weakness, Check for any adverse
respiratory distress. reactions. Provide drug
by syringe pump for
accuracy of drops.

Isolyte P 20 ml/Hr, IV Electrolyte Monitor fluid

balance electrolyte balance
regularly. Check the
hydration status of the
baby. Maintain intake
& output chart.
NURSING DIAGNOSIS:

 Impaired comfort pain related to surgical procedure.

 Impaired bowel elimination pattern related to congenital vestibular fistula.

 Disturbed sleep pattern related to pain and discomfort secondary to surgical incision.

 Activity intolerance related to surgical pain and discomfort.

 Risk for infection related to the presence of colostomy.

 Parental anxiety related to prognosis and hospitalization.

 Deficient knowledge of parents related to follow up care.

 NURSING PLANNING
ASSESSMENT IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTIONS

Impaired comfort Baby gets free Assess the site and Assessed that the baby Severity of pain and
Subjective data:
pain, related to from pain. severity of pain. had PSARP surgery. discomfort reduced
Mother says that “ surgical procedure. as evidenced by –
baby is crying
baby is sleeping
continuously” Clean the area under Cleaned the area under quitly.
Objective data: strict aseptic techniques strict aseptic techniques
only. only.
Baby looks irritable
and weak. Administer antibiotics Administered
to avoid infection. antibiotics.

Check for any signs of No signs of infection

infection. evident.
Provide adequate
warmth to the child. Provided adequate
warmth to the child
Instruct to avoid
handling of the baby. Instructed to avoid
handling of the baby.
Advise the mother to
feed the baby as per his Advised to promote
demand. demand feeding.
 NURSING PLANNING
ASSESSMENT IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTIONS

Subjective data: Impaired bowel Baby maintains Assess the elimination Assessed that the baby Baby is improving
elimination pattern normal elimination pattern of the baby had congenital defect and elimination pattern .
Mother says that “ my related to pattern. colostomy present.
baby is not passed congenital
meconium” Ascertained the
vestibular fistula Ascertain the colostomy
colostomy functioning.
Objective data: functioning.
Congenital rectal
malformation evident. Assessed that the intake
Assess the intake and and output level is
output. satisfactory.

Ascertain the GI system

Ascertained the GI
is functioning properly.
system is functioning
properly.

Encourage the mother to Encouraged the mother

feed the baby. to feed the baby.

Provide aseptic Provided aseptic

colostomy care. colostomy care.

Assess the characteristics Assessed that which is

of colostomy wastes. normal in
consistency,color and
amount.
 NURSING PLANNING
ASSESSMENT IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTIONS

Objective data: Risk for infection Baby remains free Assess the colostomy and Assessed that colostomy Baby is free from
related to the from infection. its patency. is patent. infection.
Colostomy present.
presence of
colostoma. Maintain strict aseptic Maintained strict aseptic
techniques in all techniques in all
procedures. procedures.

Monitor vital signs Monitored vital signs

frequently. frequently.

Check for any signs of Checked for any signs of

infection. infection.

Instruct the parent to Instructed the parent to

minimize the handling of minimize the handling of
child. child.

Administer antibiotics Administered antibiotics

regularly as prescribed. regularly .

Feed the baby properly to Instructed the mother

improve the immune tofeed the baby properly.
status.
 NURSING PLANNING
ASSESSMENT IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE INTERVENTIONS

Subjective data Disturbed sleep Baby maintains Assess the sleep pattern Assessed that child’s Baby improved her
pattern related to normal sleep pattern. of the child. duration of sleep is sleep pattern.
Mother says that “baby
pain and discomfort reduced.
is not sleeping properly
secondary to Provide adequate warmth
and crying also”
operative procedure to the child. Provided adequate
warmth to the child.
Objective data:
Avoid handling of the Minimized handling of
Baby looks weak and baby. the baby.
disturbed.

Keep away stimuli like Kept away all stimuli.

excess noise and light.

Administer medications Administered medications

properly as prescribed. properly as prescribed

Restrict the visitors while Restricted visitors.

the child is sleeping.

Advice to maintain Advised the mother to

good nutritious status feed the baby
by frequent feeding. frequently.
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