HISTORY COLLECTION

(A) CHILD`S PROFILE

Name of the child: Hardik Parmar
Chronological age: 5 years
Developmental age: Preschooler
Gender: Male
Diagnosis: Malaria Fever
Ward unit: Pediatric Ward
IP no: 29002356
Date of admission: 09/02/2021
Date of care started: 16/02/2021
Date of care ended: 18/02/2021
Date of discharge: No any discharge
Source of information: Parents

(B) PRESENTING COMPLAINS

My patient`s name is Hardik Parmar is admitted on 09/02/2021 in Parul sevashram
hospital with the complaints of:
 Headache
 Fever from 10 days
 Vertigo
 Weakness
 Pallor skin
(C) HISTORY OF PRESENT ILLNESS
At present day, my patient is having complaints of
 Low grade fever
 Weakness
 Pallor skin
(D) PAST HISTORY
1. Medical history: Hardik Parmar is not having any past medical history.

2. Surgical history: Hardik Parmar is not having any past surgical history.
(E) FAMILY HISTORY
 38 year 32 year

PT

8 YEAR 5 YEAR

NAME AGE/ RELATIO OCCUPATIO MARITA HEALTH

SEX N N L STATUS
STATUS
Rameshbhai 38/M Father Farmer Married Healthy
Surekhaben 32/F Mother Housewife Married Healthy
Sohilbhai 08/M Brother Student - Healthy
Hardik bhai 05/M Self - - Unhealthy

(F) BIRTH HISTORY

1. Antenatal history:
Surekhaben is healthy during antenatal period. Her weight is 52 kg during the
pregnancy time period. There is no any health problem during pregnancy month
has taken iron tablets and folic acid. She took immunization.
2. Intra natal history:
Surekhaben is delivered her delivery through full term, normal delivery at nearest
hospital setting.
3. Post natal history:
The child is having good sucking reflex of breast milk. She was having a good
crying and initiates the breast feeding as soon as possible. There is no any type of
jaundice or any abnormalities. Child is healthy at the time of birth.
(G)Socio- Economical History
 Hardik Parmar`s family members are living in urban area. Their monthly income is
12000 per month. They have well house and all facilities are available. They are not
having a proper drainage system near to their house.
(H)Nutritional History
Hardik is taking only breast milk till 5 months only. The family members are non
vegetarian. They are mostly spending money on staple food.
(I) Elimination History
Hardik is having a normal bladder and bowel habit twice a day.
(J) Immunization Schedule

No AGE VACCINE DOSE ROUTE REMARKS

1. At birth  BCG 0.05 ml ID Received
 OPV 2 DROPS PO

 HEP B-0 0.5 ml IM

2. At 6 weeks  DPT-1 0.5 ml IM Received

 OPV-1 2 DROPS PO

 HEP B-1 0.5 ml IM

3. At 10 weeks  DPT-2 0.5 ml IM Received

 OPV-2 2 DROPS PO

 HEP B-2 0.5 ml IM

4. At 14 weeks  DPT-3 0.5 ml IM Received

 OPV-3 2 DROPS PO

 HEP B-3 0.5 ml IM

5. At 9 months  Measles 0.5 ml SC Received

6. At 16-24  DPT 0.5 ml IM Received
months  OPV 2 DROPS PO
7. At 5 years  DT 0.5 ml IM Received
(K)Physical Examination
 Height :4 feet
 Weight: 22 Kg

Vital signs
Date Temperature Pulse Respiration Blood pressure
17/02/202 103 F 94/min 72/min 90/60 mm of Hg
1

 GENERAL APPEARANCE
 Nourishment: Well nourished
 Body built: Thin
 Health: Unhealthy
 Activity: Dull
 MENTAL STATUS
 Consiousness: Conscious
 Look: Anxious
 Body curve: Not Present
 Movement: Not Present any limb movement
 SKIN CONDITION
 Colour: Pallor
 Texture: Normal
 Temperature: Warm
 Lesion: Not present
 HEAD AND FACE
 Scalp: Clean
 Face: Anxiety
 EYES
 Eye brow: Normal
 Eye lids: No any lesion present
 Eye lashes: No any infection present
 Eye ball: No any sunken present.
  Pupils: Reacted to light
 EAR
 External ear: No any discharge
 Tympanic membrane: No any lesion or bulging
 Hearing: Active hearing
 NOSE
 External nose: No any discharge
 Nostrils: No any deviation
 MOUTH AND PHARYNX
 Lips: Pinkish
 Odor of the mouth: No any foul smelling
 Mucous membrane: No any swelling, bleeding
 Tongue: Pale and dry
 Throat: No any redness and pus
 NECK
 Lymph nodes: Palpable
 Thyroid gland: Not enlarged
 Range of motion: Flexion, extension and rotation
 CHEST
 Thorax: Symmetry of expansion
 Breath sound: Normal breathing sound
 Heart: Located normally
 ABDOMEN
 Observation: No any scar
 Auscultation: Normal bowel sound and gas present.
 Palpation: Tenderness at area of abdomen.
 Percussion: No any presence of gas, fluid.
 EXTRIMITIES
Movements of joints are good.
 BACK
 Spinal cord: no any abnormality seen
 GENITALS AND RACTUM
  Bladder pattern: 6-8 times a day
 Bowel pattern: pass stool after each feeding

(L) Growth And Development

BOOK PICTURE PATIENT PICTURE

1) GROSS MOTOR  Skips and hops on
 Skips and hops on alternate alternate feet.
feet.  Throws and catches ball
 Throws and catches ball well.
well.  Jumps rope.
 Jumps rope.  Walks backward with
 Skates with good balance heel to toe.
 Walks backward with heel to  Balances on alternate
toe. feet with eyes closed.
 Jumps from height of 12
inches and lands on toes.
 Balances on alternate feet
with eyes closed.
2) FINE MOTOR  Ties shoelaces.
 Ties shoelaces.  Uses scissors, simple
 Uses scissors, simple tools, tools, or pencil very
or pencil very well. well.
 In drawing, copies a
diamond and triangle; adds
seven to nine parts to stick
figure; prints a few letters,
numbers or words, such as
first name.
3) LANGUAGE  Has a good vocabulary
 Has vocabulary of about  Uses sentences of six to
2100 words. eight words, with all
  Uses sentences of six to
eight words, with all parts of
speech.
 Names coins
 Names four or more colors.
 Describes drawing or
pictures with much comment
and enumeration.
 Knows names of days of
week, months and other
time- associated words.
 Can follow three commands
in succession.
4) SOCIALIZATION AND
COGNITION
 Less rebellious and
quarrelsome than at the age 4
years.
 More settled and eager to get
down to business.
 Not as open and accessible
in thoughts and behavior as
in earlier years.
 Eager to do things right and
to please; tries to live by the
rules.
 Has a better manner.
 Not ready for concentrated
close work or small print
because of slight
farsightedness and still
unrefined eye- hand
coordination.
parts of speech.
 Names coins.
 Names four or more
colors.
 Describes drawing or
pictures.
 Knows names of days of
week, months and other
time- associated words.
 Not as open and
accessible in thoughts
and behavior as in
earlier years.
 Eager to do things right
and to please; tries to
live by the rules.
 Has a better manner.
 Not ready for
concentrated close work
or small print because of
slight farsightedness and
still unrefined eye- hand
coordination.
 INVESTIGATION

INVESTIGATION NORMAL PATIENT REMARKS

VALUE VALUE
Hb 16-18 gm/dl 8.2 gm/dl Decrease
Total RBC 4000-5000 5.20 millicum Decrease
millicum
PCV 35.00- 45.00% 25.00% Decrease
MCV 97.00-95..fl 48.00fl Decrease
Total WBC 4000- 11000/cmm 21.8000/cmm Increase
MCH 25.00-33.00 pg 17.30pg Decrease
R.D.W 11.6-14% 13.80% Normal
Neutrophils 40.00- 70.00% 74% Decrease
Lymphocytes 30.00-50.00% 24% Decrease
M.C.H.C 31.00- 37.00% 31.70% Normal

OTHER INVESTIGATION
 Chest X-ray(A & P)
 CT SCAN- Brain
 Sputum culture
NURSING DIAGNOSIS

1. Ineffective thermoregulation related to infection as evidence by assessment of

baby temperature of patient.

2. Impaired nutrition pattern less than body requirement related to nausea and
vomiting as evidence by weight loss.

3. Anxiety related to hospitalization as evidence by insomnia.

4. Knowledge deficit related to lack of knowledge about disease as evidence by

patient`s verbalization.

5. Risk of infection related to malnutrition as evidence by laboratory valus

showing of infection.
 HEALTH EDUCATION
1) Personal hygiene
 Give advice to child`s parents about personal hygiene.
 Give advice about daily bathing and oral hygiene.
 Give advice for use of clean clothes.
 Apply talcum powder to whole body especially to skin folds because prevent
infection.

2) Nutrition
 Give advice for mother about breastfeeding and soft diet.
 Give advice for mother to provide proper weaning diet after 6 months of birth.
 Give advice for mother about breast feeding techniques.

3) Immunization
 Health education is given to the patient mother and family regarding
immunization schedule.
 Give advice for mother about an vaccine given to your baby.

4) Medication
 Give advice to mother to take medicine of his/her baby.
 Give advice for medicine and after assess the side effects of medicine.
 Regular check your baby weight every day.

5) Follow up
 Give advice to patient`s family members about regular checkup in hospital.
 Give advice for family weekly regular checkup for doctor order.
CONCLUSION
Hardik parmar is admitted in Parul sevashram hospital on 16/02/2021 with parent`s
complaints of fever, weakness, vertigo, weakness, etc. Today, he is a taking treatment
and proper nutrition care given. Now, my patient complaints are reduced to some
extent.
SR NAME OF DOSE/ ACTION INDICATION SIDE-EFFECTS CONTRA NURSING
DRUG ROUT INDICATION RESPONSIBILITY
E
1. Tab. 0.5 ml/ Decreases Inflammation, CNS: Depression, Hypersensitivity Assess:
chloroquine IV inflammation by allergies, headache, mood to Potassium, blood,
suppression of neoplasma, changes, euphoria corticosteroids, urine glucose while
migration of cerebral edema, CV: Hypertension sulfites, or receiving long-term
polymorph septic shock, EENT: Increased benzyl alcohol; therapy;
nuclear collagen intraocular fungal hypo/hyperglycemia,
leukocytes, disorders, pressure, cataracts infections, Weight daily; notify
fibroblasts, dexamethasone ENDO: HPA abrupt prescriber of weekly
reversal of suppression test suppression, discontinuation, gain >5 lb, B/P, pulse;
increased for Cushing hyperglycemia, coagulopathy, notify prescriber of
capillary syndrome, sodium, fluid ulcerative chest pain.
permeability and adrenal cortical retention. colitis, seizure I&O ratio; be alert for
lysosomal insufficiency, GI: Nausea, peptic disorders decreasing urinary
stabilization, TB, meningitis, ulceration, output, increasing
suppresses acute vomiting edema
normal immune exacerbations of INTEG: Acne, Cerebral edema: LOC,
response, no MS. poor wound and headache, baseline
mineral- healing, and periodically.
corticoid effects ecchymosis,
petechiae. Evaluate:
META: Therapeutic response:
Hypokalemia, fluid decreased
retention and inflammation.
alkalosis
MS: Fractures, Teach patient/family:
osteoporosis, To carry medical alert
weakness, ID as corticosteroid
arthralgia. user at all time.
SR NAME OF DOSE/ ACTION INDICATION SIDE-EFFECTS CONTRA NURSING
. DRUG ROUT INDICATION RESPONSIBILITY
E
2. Inj. 400 mg Inhibits cell wall Acute bacterial CNS: Dizziness, Cephalosporin Assess:
cefotaxime q8hr/ synthesis skin/skin seizures hypersensitivity Infection: vital signs,
IV through binding structure GI: Diarrhea, Precautions: sputum, WBC before,
to essential infections nausea, vomiting, Child/infant/neo during therapy, obtain
penicillin- (ABSSI), Clostridium nate, culture and sensitivity,
binding protein bacterial difficile-associated breastfeeding, should be done before
(PBP) community- diarrhea (CDAD) elderly patients, starting treatment, may
acquired HEMA: Aplastic antimicrobial start medication before
pneumonia anemia resistance, results are obtained.
INTEG: Rash, penicillin
anaphylaxis hypersensitivity, Evaluate:
GU: Renal failure coagulopathy, Therapeutic response:
META: colitis, dialysis, negative C&S,
Hypokalemia, diarrhea, GI resolution of
hyperkalemia, disease, symptoms of infection.
hyperglycemia hypoprothrombe
MISC: Injection mia, IBS, Teach patient/family:
site reactions pregnancy, About the reason for
pseudo- treatment and expected
membranous result.
colitis, renal To immediately report
disease, rash, itching, difficulty
ulcerative breathing, bloody
colitis, viral diarrhea, fever,
infection, vita K abdominal pain
deficiency Pregnancy/breastfeedi
ng.
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data: Impaired nutritional To increase the Assess the general Assessed the general Reduced the body
My patient`s status less than nutritional intake. condition of the condition of the patient temperature of the
parents are body requirements patient baby to some
complaining me related to nausea extent.
about weakness, and vomiting as Check the weight Checked the weight of
and poor eating. evidence by weight of the baby at the baby at every 2
loss. every 2 hourly. hourly.
Objective data:
Baby is having To send the lab Sent the lab
nausea and investigation as investigation as
vomiting from 2 prescribed by the prescribed by the
days. doctor. doctor.

Provide small Provided small

frequent eating frequent eating food to
food to the baby. the baby.

Give medication to Gave medication to the

the baby as baby as prescribe by
prescribe by the the doctor.
doctor.
Documented the
To document the nursing activities in the
nursing activities in patient`s file.
the patient`s file.

To educate the Educated the parents

parents about the about the home
home remedies for remedies for improving
improving diet of diet of the patient.
the patient.
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data: Anxiety related to To reduce the fear Assess the general Assessed the general Reduced the fear
Patient`s parents change in and Anxiety. condition of the condition of the patient. and Anxiety of the
are told me that the environment as patient. baby to some
baby`s behavior is evidence by facial extent.
change. expression of baby. Assess the anxiety Assessed the anxiety
level of the patient. level of the patient.
Objective data:
Facial expression. To teach the Teaches the relatives to
Anxious face. relatives to be with be with the patient.
Irritable behavior. the patient.
Excessive crying.
To make a good Made a good
interpersonal interpersonal
relationship with relationship with the
the patient and patient and family.
family.
Played with the baby.
To play with the
baby.

To provide some Provided some toys

toys and activity to and activity to the
the baby. baby.

To make the baby Made the baby busy in

busy in his/ her his/ her activity.
activity.
ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION EVALUATION
Subjective data: Anxiety related to To reduce the fear Assess the general Assessed the general Reduced the fear
Patient`s parents change in and Anxiety. condition of the condition of the patient. and Anxiety of the
are told me that the environment as patient. baby to some
baby`s behavior is evidence by facial extent.
change. expression of baby. Assess the anxiety Assessed the anxiety
level of the patient. level of the patient.
Objective data:
Facial expression. To teach the Teaches the relatives to
Anxious face. relatives to be with be with the patient.
Irritable behavior. the patient.
Excessive crying.
To make a good Made a good
interpersonal interpersonal
relationship with relationship with the
the patient and patient and family.
family.
Played with the baby.
To play with the
baby.

To provide some Provided some toys

toys and activity to and activity to the
the baby. baby.

To make the baby Made the baby busy in

busy in his/ her his/ her activity.
activity.