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BIODATA:

Name- Master Sudeep Behera

Age – 1month 2days Sex - Male
Date of Birth – 06.07.2017, Time – 3 am
Address – Khurda, Odisha
Date of admission- 7/8/2017
Informant-mother and staff nurse
CHIEF COMPLAINTS- Baby has
fever,
running nose and cough.
PRESENT MEDICAL HISTORY- He was apparently alright 2 days back, then he has
fever and cough since 2 days back and suddenly developed breathing difficulty.
PAST MEDICALHISTORY- There is no evidence of past medical history.

MATERNAL & PERINATAL HISTORY:

Maternal History-

 Age: 30
 Para - 1
 Gravida - 1
 No of abortions – No
 No of still births – No
 Duration of Marriage – One year
 Pre-pregnant health status - Good
 Any systematic illness: Nothing significant.
 Any endocrine disorders: no
 Others: Nothing significant

Present Pregnancy:
 LMP: 1.11.2016
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 Expected date of delivery - 8.7.2017

 Present gestation in weeks – 39 weeks

Antenatal History:
 Antenatal checkup: Yes, her antenatal check-up was done in Kims medical
 Number:8
 Tetanus Toxoid: Two dose, Blood group: “AB” positive
 Any other investigation - Ultrasound
 Family history of mother – baby’s grandmother is having diabetes mellitus.
 Dietary intake – Adequate
 Maternal malnutrition / substance abuse /APH/ Accidental hemorrhage - Nothing
significant
 Placenta previa – Absent

Labor and Delivery History –

 Place of delivery – PBMH, KIMS
 Delivery mode: Normal vaginal
 Presentation: Vertex
 Duration:1st stage: 10 hours
2nd stage: 2 hours
 Amniotic fluid: Clear amniotic fluid
 Drugs used in labor: injection oxytocin
 Congenital malformation: no congenital malformation seen

Neonatal history / Postnatal History –

 Complication of mother if any: No

 Baby cried: Yes, cried immediately after birth
 Resuscitation required: No
 APGAR Score: 1 minute: 8; 5minutes: 8; 10 minutes: 9
 Vitamin-K: 1 mg per kg dose, location & time: gluteal aspect of the thigh,
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 Immunization: BCG, OPV-0 dose is given

Vital Signs

 Temperature: 98.4˚ F
 Pulse: 120 beats/min
 Respiration: 40 breaths/min
 B.P: 50/360 mmHg

General Behavior
 Posture: Relaxed posture
 General Condition: General condition is stable
 Crying: Normal crying present
 Sleeping pattern: Normal sleeping pattern

Feeding Behavior
 Sucking / Swallowing reflex: Present but not too strong
 Vomiting: Not present
 Regurgitation: Not present
 Chocking /frothiness: Not present

Pattern of elimination
 Meconium passed within: 6 hours after birth
 Urine passed within: 20 minutes after birth

Anthropometric measurement
 Weight: 2.9 kg
 Height: 51 cm
 Head circumference: 34cm
 Chest circumference: 31 cm
 Crown to heel length: 51 cm,
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Anthropometric Measurement (Table)

Parameter Normal Value Child’s Value Remark

1. Weight 2.5 kg to 3.5 kg 2.9 kg Normal

2. Height 50 – 52 cm 51 cm Normal

3. Head circumference 33 – 35 cm 34 cm Normal

4. Chest circumference 31 – 33 cm 31 cm Normal

5. Crown to heel length 50 - 52 cm 51 cm Normal

Physical Assessment (Head to toe)

Head:
 Shape: round shape, Molding: molding is present in parietal bone
 Fontanelles – Anterior: diamond shape, 2 cm (shape & diameter)
Posterior: triangular shape, 1 cm (shape & diameter)
 Birth Trauma: not present,
 Forceps marks: not present
 Caput succedaneum: not present

Hair:
 Color: brownish black, Texture: wooly fuzzy hair

Face:
 Symmetry: face is symmetrical, Swelling: no swelling is present
 Abnormal Movement: no abnormal movement is seen

Ears:
 Position : above the imaginary line from the outer canthras of eye,
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 Size & Shape: normal size and shape

 Cartilage formation: delayed recoil of the ear cartilage,
 any discharge: no discharge is present

Eyes:
 Position (slant, hypertelorism): normal
 Discharge: no discharge is present
 Color of sclera: white, no conjunctival hemorrhage is seen
 Papillary reflex to light: pupils are reactive to light

Nose:
 Patency: nasal passage is patent, Flaring: slight nasal flaring is present
 Nasolabial folds: they are normal
 Discharge: no discharge is present, Others: no congenital anomalies seen

Mouth:
 Lips: normal size and shape, color is pink,
 Palate: hard and soft palate are normal, no congenital anomalies seen
 Tongue: normal, Others: no mouth ulcer is seen
Skin:
 Colour: pink, Lanugo: lanugo hair is not present
 Vernix: body is clear, but in head there is vernix, Skin turgor: good skin turgor, Milia: milia
is present in nose
 Birth marks: not present, Dehydrations: not present
 Edema/Puffiness: not present
 Nails: normal shape and color, no spoon shaping is present
Neck:
 No webbing, no masses, no Dryness is present in the neck
Chest:
 Shape: shape of the chest is normal,
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 Chest movement: it is not bilaterally equal

 Respiratory rate: 66 breaths per min, Retraction/Grunting: grunting is present
 Apnea: not present, Breath sounds: normal breath sounds are present & ronchii
 Breast tissue: more than 5 cm in diameter, Capillary refill time: 3 seconds

Cardiovascular:
 Heart rate: 130bts/min, Unusual rhythm/murmurs: not present
 Cyanosis (acrocyanosis): not present,
Abdomen:
 Shape: normal size and shape, Distention: mild distension
 Liver, Spleen: not palpable
 Umbilicus: 2 cm cord present, 2 arteries and one vein present

Extremities & Back:

 Upper extremities(Digits, symmetry): normal size and shape, 10 digits present
 Lower extremities (Digits, symmetry): normal size and shape, 10 digits present
 Barlow maneuver: Absent, Club foot: not preent
 Erb sign: Absent Plantar creases: present

Genitalia:
Female: Labia majora &Labia minora: labia majora is not covering labia minora, and labia
minora is prominent
Clitoris: it is prominent,
Urethral meatus: normal
Vagina & Anus: normal. No anorectal malformation or vesico-vaginal fistula is present
Pseudo-menstruation: pseudo menstruation is present

Neurological Assessment:
Reflexes of neonate:
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Rooting: is present
Sucking/swallowing/gagging: all the reflexes are present
Glabellar tap: it is present
Sneezing & coughing: reflex present
Doll’s eye&blinking: both are present
Stepping or dancing: present
Moro: reflex is present
Tonic neck: reflex is not present
PalmarGrasping: it is present

Assessment of Gestational age:

Via date, via ultrasound, & via examination (using NBS) the baby is a term baby

DISEASE CONDITION

INTRODUCTION:
Infection is still one of the leading causes of neonatal death in the developing countries.
The neonates are more susceptible to infection as they are deficient in natural immunity
and acquired immunity. Neonates that survive from sepsis often suffer from severe
neurological as well as severe parenchymal lung disease.

DEFINITION:
It is a inflammatory disease characterized by inflammation of bronchiole causing severe
dyspnea.

RELATED ANATOMY AND PHYSIOLOGY:

Anatomy of the lung
POSITION- There is 2 lungs present in thoracic cavity. The space between the 2 lungs
is known as madiastinum.
STRUCTURE
Each lung is a conical shaped structure. It has an apex a medical surface and costal
1. APEX: - It projects into neck2.5cm above medial of clavicle. It is capped by cervical pleura.
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2. BASE:-The base is concave and rests on thoracic surface of the diaphragm which is
lined by diaphragmatic pleura.
3. MEDICAL SURFACE: - The medial surface is directly related to mediastinal pleura
extending like a partition from anterior to posterior between the mediastinal pleura of the
two sides, great vessels, trachea, esophagus, thoracic duct and nerves are present.
4. COSTAL SURFACE: - The costal surface is related to ribs and intercostals muscles.
The thoracic wall is lined inside by costal pleura.

BRONCHIOLES
It do not have any cartilage in their wall instead their wall contains smooth muscles. The
epithelial lining of wider tubes is pseudostratfied ciliated columnar which is gradually
replaced by cuboidal epithelium.Exchange of gases started at respiratory bronchioles

Functions of the Lungs

 1.Regulation of air entry
 2.Removal of particular matter
 3. Humidification of air
 4. Cough reflexes is generated.

ETIOLOGY
According to book According to patient
 Respiratory sycytial virus Maternal diabetes
 Adeno virus
 Influenza virus
 Hemophilus influenza
 Pneumococcus
 streptococcus

SIGN AND SYMPTOMS

ACCORDING TO BOOK ACCORDING TO PATIENT
 fever  fever
 dyspnea  dyspnea
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 cyanosis
 air hunger
 nasal flaring
INVESTIGATION:
According to book According to patient
History collection History collection
Physical examination Physical examination
-Blood investigation
-Blood culure
-x-ray Lab test –
 CBC
 CRP
 GRAM STAIN (CSF)
 SERUM UREA
 SERUM CREATININE

10. INVESTIGATION
SL. VALUE IN REMARKS
NO. DATE PARAMETER PATIENT NORMAL
VALUE
1. 9/8 CRP 1.18 LESS THAN 0.5
MG/DL
2.. GRAM STAIN NO
POLYMER ,NO
ORGANISM
FOUND
3. SERUM.SODIUM 138 136-145
MMOL/L
4. SERUM. UREA 4 12-42 mg/dl
5. SERUM.CREATININE 0.2 0.9-1.3 mg/dl
6. CBC
WBC 10.07 5-19 10˄3/UL
NEUTROPHIL 55 13-33 %
LYMPHOCYTE 37 41-71%
MONOCYTE 05 4-7%
EOSINOPHIL 03 0-3%
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BASOPHIL 0 0-1 %

HAEMOGLOBIN 16.02 11.5-16.5

gm/dl

PCV 50.06 33-53%

TOTAL PLATELET 271.5 200-500

COUNT 10˄3/UL

MANAGEMENT:

According to book
1. Antibiotic therapy
2. Supportive therapy

 Mechanical ventilation
 Dopamine for hypotension
 Anti-convulsant for seizures
 Sodium bicarbonate for metabolic acidosis

According to patient
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Medication:
DRUG Pharmacol DOSE ROUTE Action NURSING
NAME ogical RESPONSIB
name LITY
Inj . Pipzo Piperacilin 350 IV -Blocking the To observe
And mg bacterial cell wall for allergic
Tazobactum TDS growth reaction
Inj.Amikacin Amikacin 52 mg IV Binds to negatively To maintain
OD charged sites on 14 rights
bacterial outer cell during drug
wall, disrupting cell administration
integrity, inhibit
protein synthesis,
lead to cell death
Inj Lizolid linezolid 35 mg IV It inhibits bacterial To observe
BD protein synthesis by for any
interfering with adverse
translation of effects
ribonucleic acid

Syrup Levetiracetam 0.9 ml Orally It controls seizure Observe for

LEVERA BD by suppressing the any adverse
abnormal and reaction
excessive activity of
nerve cells in brain
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COMPLICATION:
According to book According to patient
a) Increasing respiratory distress resulting Nothing significant
in the need for mechanical ventilation
b) Secondary bacterial infection
c) Pneumothorax and pneumo-
mediastinum
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PROGNOSIS-
Patient with dyspnea, cough and fever was admitted in hospital. Then
nebulization was given and then suction was done to clear the airway. After
antibiotic administration the infection was controlled. Patient was also given anti-
seizure medication to prevent seizure.
After proper treatment he became alright and was discharged and sent home.

CONCLUSION:
Respiratory tract infection is a frequent cause of acute illness in infants and children.
The child response to the infection will vary based on the age of the child, existence of
chronic medical condition and degree of contact with other children.
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BIBLIOGRAPHY:
1. Dutta. P (2009) Pediatric Nursing (2 nd Ed.) New Delhi: Jaypee Brothers Medical
Publishes Pvt. Ltd.
2. Sharma. R (2013) Essentials of Pediatric Nursing (1 st Ed.) New Delhi: Jaypee
Brothers Medical Publishers Pvt. Ltd.
3. Ghai. OP (2016) Essential Pediatrics (8 th Ed) New Delhi: CBS publishers &
distributors Pvt. Ltd.
4. Parthasarathy. A (2016) IAP Textbook of Pediatrics (6 th Ed.) New Delhi: Jaypee
Brothers Medical Publishers Pvt. Ltd.
5. Kumar A.S. Manual of newborn care. 2 nd edition. New Delhi: Paras Medical
Publisher; 2011.p-56-60
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CASE PRESENTATION
ON
BRONCHIOLITIS

SUBMITTED TO SUBMITTED BY
MRS.PRAMILA BAXLA DIPTIMAYEE BHUJABALA
ASSISTANT PROFESSOR MSC NURSING 1 ST YEAR
KINS ROLL NO-1688005

SUBMITTED ON-16/08/2017