NCM 109: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS

(ACUTE & CHRONIC)

CASE PRESENTATION:
HIRSCHSPRUNG DISEASE AND FAILURE TO THRIVE

Instructions
The case analysis manuscript should be computer written and submit 3 hard copies of the completed
manuscript as well as soft copy for the clinical instructors.

After the submission, prepare a PPT presentation for your scheduled case presentation. Each member
of the group is expected to present during the case presentations.

Learning Outcomes
At the end of this module, you are expected to:
1. Utilize the nursing process in the care of clients with Hirschsprung disease.
2. Perform a comprehensive health history and assessment based on the case scenario
presented.
3. Utilize assessment information to formulate a patient-centered plan of care.
4. Discuss the therapeutics done for the simulated patient.
5. Explain appropriate nursing interventions per problems identified
6. Document the care rendered to assigned patient in the simulated health care record
accurately.

Case Scenario: Neonatal Patient with HD and failure to thrive.

Course in the Ward: Mother Merina brought her 8-month old baby girl Lovely to the Emergency room
of Davao Doctors College with a complaint of distended abdomen and poor feeding habits. Vital signs
revealed T= 38.1 degrees Celsius; pulse rate of 118BPM; respiratory rate of 25CPM; BP= 90/60mmHg;
Weight of 6kg (underweight); Height= 25cms; Abdominal girth=42cms. Patient appeared weak and the
mother verbalized continuous stimulation of feeding but the infant does not feed anymore.

Family Profile
Merina has been married to Amer for almost 10 years. She works at Jewelry Store as a manager and
she is a college graduate. She is a hardworking mother. They live in a low-cost housing subdivision,
and the husband’s source of income is working as foreman in housing constructions. chemical factory.
Her health history reveals nothing significant.

Natal History:
Baby Lovely was delivered at Maternity Clinic via NSVD at 39 th weeks age of gestation. Client
birth weight was 2.5 kilogram and Apgar score was 9.
Neonatal course:
Baby Lovely was exclusively breastfed by mother.

Immunization:

Patient was given immunization at a barangay health center near their residence. The following
were the vaccines given.

BCG: 1
Hepatitis B: 3
DPT: 3
OPV/IPV: 3
Measles: 1
HiB: 3

Pregnancy History
Merina's past obstetric history includes her first pregnancy with spontaneous vaginal delivery at 39
weeks 3 years ago. Her second pregnancy is Baby Lovely, with NSVD last July 12, 2020.

Past Medical History

● Nothing significant

Family History
● The mother stated that, the brother of her husband has similar type of history and he was
diagnosed as Hirschsprung Disease

History of Present Illness:

The nurse gathered more data about the infant’s illness and mother verbalized that the infant
started defecating on his 3rd day of life. Thereafter, infant defecates 1-2 times only per week with
occasional vomiting. With this at 2-months old, mother sought consultation of the infant and was given
Glycerin stick and manual evacuation as treatment. Mother verbalized alleviation of symptoms and no
follow-up check-up was done. At 5th month old, mother noted distention of the abdomen but will go
back to its normal size after defecation of ribbon-like or liquid stools. The infant was also feeding well
that time. Two weeks prior to admission, mother noted progression of abdominal distention with more
frequent vomiting. 1 week prior to admission, mother noted the onset of fever with Paracetamol given
when warm extremities were noted.The infant was also not feeding anymore and appeared weak.
Morning prior to admission, mother sought consultation with his attending physician for progression of
abdominal distention.
Physical Examination:
Vital Signs:
● BP: 60/90 mmHg
● Temp: 38.1°C
● PR: 118 bpm
● RR: 25 CPM
● Weight: 2.5 Kg
● Height: 25 cm
● Blood type: A (+)
● In general the patient is febrile, with active losses and weak-looking appearance but not
bradycardic and hypotensive. Evident mild dehydration noted but not in distress.
General Examination:

INSPECTION

● The patient has fair complexion no rashes, and no jaundice

● The anterior fontanelle can be felt with a soft spot. The posterior fontanelle is small and cannot
be palpated readily.
● Eyes: appear clear without any redness or purulent; slightly sunken eyeballs
● Ears: The level of the top part of the external ear is aligned from the inner canthus to the
outer canthus of the eye and back across the side of head.
● There were no eye, ear and nose discharges.
● Mouth: Intact palate. Dry lips
● Neck: Appears shorter and creased with skin fold. Head rotates freely on it. ● Chest: Looks
normal.
● Supine position with partial flexion of arms, legs and hand commonly turned a little to one
side. Hip joints are partially abducted.
● Back: Appears flat in the lumbar and sacral areas and base of the spine free of any
pinpoint openings, dimpling, or sinus tracts in the skin.
● Female Genitalia: labia majora fully covers labia minora
● Soles : sole crease mat partially cover the upper two-third of the sole
● Musculoskeletal: not flaccid; good muscle tone; can sit without support
● Neurologic: conscious; appropriate for age
PALPATION

● The anterior fontanelle can be felt with a soft spot. The posterior fontanelle is small and cannot be
palpated readily.
● Neck had no cervical lymphadenopathy
● Warm extremities; slightly delayed skin turgor; full pulses but only slightly palpable

AUSCULTATION

● Heart has a dynamic precordium, normal rate and regular rhythm

● Rales on lower lung fields

ABDOMINAL EXAMINATION
Inspection: Distended, visible peristalsis noted, flared ribs from abdominal distension causing a
wide subcostal angle.

Palpation: 42cms girth; globular; palpable fecal masses noted

Percussion: tympanitic;

Auscultation: Increased peristaltic sound in the right and left upper quadrant and right lower
quadrant of abdomen; no peristaltic sound in lower left quadrant of abdomen.

DER (Digital Rectal Examination): narrow, tight and empty anal canal with small amount of
meconium or explosive mixture flatus and feces following DRE.

ADMISSION IMPRESSION: Septic Ileus to consider Intestinal Obstruction

COURSE IN THE WARD

DOCTOR'S ORDERS Name: PT. Baby Lovely; Room number: PR 102

Diagnostic and Laboratory Results: HEMATOLOGY
Diagnostic and Laboratory Results: BLOOD CHEMISTRY

PT: BABY LOVELY

Age: 8mos
Physician: Dr.

Diagnostic and Laboratory Results: Plain X-ray Abdomen Erect Posture

Plain X-ray Abdomen Erect Posture:

There is no dilatation of the small
intestinal segments, with no associated
differential air-fluid level. No definite
unusual air collections noted. No unusual
soft tissue densities. Dilated large bowel
loops. Absence of air shadows in rectum.
The rest of the included structures are
unremarkable.

IMPRESSION:
>SEGMENTAL ILEUS, CONSIDERED.
>LARGE BOWEL OBSTRUCTION TO
CONSIDER HIRSCHSPRUNG DISEASE.
ADVISED BARIUM ENEMA
Barium enema demonstrates a
reduced caliber rectum and
sigmoid (the rectum is smaller
than the descending colon) with
a saw-tooth appearance. A
transition point is seen at the
junction between sigmoid and
descending colon.

Post evacuation film

demonstrates the transition
point more
obviously.
References:
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s fundamentals of nursing: Concepts,
process, and practice (10th ed.). Pearson Education, Inc.

Hinkle, J. & Cheever, K. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing (14th
ed.). Wolters Kluwer

Hockenberry, M., Wilson, D., & Rodgers, C. (2017). Wong’s essentials of pediatric nursing (10th ed.).
Elsevier. https://b-ok.asia/book/5010464/96923a

Silbert-Flagg, J. & Pillitteri, A. (2018). Maternal & child health nursing care of the childbearing &
childrearing family (8th ed.). Philadelphia: Wolters Kluwer. (618.20231/Si32). https://b-
ok.asia/book/5009747/63990c