SANDIPANI ACEDEMY

PENDRI (MASTURI) BILASPUR C.G.

M.Sc. NURSING 1ST YEAR

SUBJECT :- CHILD HEALTH NURSING

CASE STUDY ON :- PNEUMONIA

SUBMITTED TO :- SUBMITTED BY:-

MRS R. S. RAMYA RUBINA RASHMI MASIH

M.Sc. NURSING 1st YEAR

Name Of Student - Rubina Rashmi Masih

Year Of Study -Msc Nursing 1st Year

Hospital - District Hospital, Bilaspur

DEMOGRAPHIC DATA

Name Of The Patient - Master Arjun

Father’s Name - Mr.Ganshyam

Mother’s Name - Mrs.Seema

Age / Sex - 10yrs / Male

Opd / Ipd No. - 32675 / 24986

Date Of Admission - 15/1 /2023

Date Of Birth - 28/12/2001

Mode Of Delivery - Hospital Delivery

Chief Complaints - Fever, Cough, Chest Pain

Provisional Diagnosis – Pneumonia

Final Diagnosis - Pneumonia

Date Of Care Started - 15/1/2023

Date Of Care Ended -18/1/2023

PERSONAL HISTORY

Personal Hygiene - Good

Bowel & Bladder Pattern -Regular.Urine Frequency Is 4-6 Times Per Day.

Sleep & Rest Pattern - Restless

FAMILY HISTORY

S.N NAME OF AGE SEX RELATI OCCUPATI EDUCATI HEALTH

O FAMILY ON ON ON STATUS
MEMBER WITH
PATIEN
T
1 MASTER 10 MALE SELF - - UNHEALT
ARJUN YRS HY
2 MR.GANSHY 30Y MALE FATHER SALESMA 10TH HEALTHY
AM RS N CLASS
3 MRS.SEEMA 22Y FEMA MOTHE HOUSEWI 9TH HEALTHY
RS LE R FE CLASS

FAMILY MEDICAL HISTORY

My Patient’s FamilyHas No Specific Hereditory Diseases Like Hypertension, Diabetes

Mellitus, Cancer Etc. There Is No Family History Of Communicable Diseases Like
Tuberculosis, Aids Etc.

SOCIO ECONOMIC HISTORY

Type Of Family - Nuclear Family

Housing - Pacca Concrete House

Income - Rs.5000/- Per Month

Earning Person Of Family -Mr.Ganshyam (Patient’s Father)

Electricity - Available

PRENATAL HISTORY

Prenatal Visits - 3 Times

Gestational Age - Full Term

Immunization Of Mother - Tetanus Vaccination Taken At 7 th Month Of Pregnancy.

Mother Had No Other Diseases During Pregnancy.She Was Not Taking Any Type Of Drugs
Except Folic Acid And Iron Tablets During Pregnancy Period.

NATAL HISTORY

Type Of Delivery - Normal Delivery

Immediate Cry - Baby Cried Few Seconds After Delivery

Apgar Score - No Information

Birth Weight - 2.5kg

Initiation Of Breast Feeding - Baby Had First Breast Feeding Soon After Delivery.

POST NATAL HISTORY

After Delivery Both Mother And Baby Had No Complications.

PAST MEDICAL HISTORY

My Patient Had Past Medical History Of Recurrent Fever Since 1 Month.They Had Only
Symptomatic Treatment During Episodes.

PAST SURGICAL HISTORY

My Patient Has No Past Surgical History Due To Any Significant Diseases.

PRESENT MEDICAL HISTORY

My Patient Admitted To The Hospital With Complaints Of Fever, Cough And Chest Pain.

NUTRITIONAL HISTORY

My Patient Takes Meals 2 Times A Day.

IMMUNIZATION HISTORY

AGE VACCINE TKEN

AT BIRTH SINGLE DOSE OF BCG.
AT 6th,10th,&14th WEEK 3 DOSES OF DPT AND ORAL POLIO
VACCINE AT 1-2 MONTH
INTERVAL.
1 YEAR SINGLE DOSE OF MEASLES
VACCINATION.
1.8 YR BOOSTER DOSE OF DPT AND
ORAL POLIO VACCINE.
5 YEAR BOOSTER DOSE OF DIPHTHERIA
AND TETANUS TOXOID.2 DOSES
OF TYPHOID AT 1 MONTH
INTERVAL.
PHYSICAL EXAMINATION

ANTHROPOMETRIC MEASUREMENT

HEIGHT - 95cm

WEIGHT - 26kg
GENERAL APPEARANCE

Activity - Less Active

Complexion - Fair

Level Of Consciousness - Conscious

HEAD TO FOOT EXAMINATION

HEAD

Hair - Black

Scalp - Soft

Skull – Round Shape

Birth Injury - Absent

FACE

Eye

Sclera - White In Colour

Conjunctiva - Pinkish

Pupil – Black Colour

Eye Brow – Hair’s Equally Distributed

EAR

Pinna – Curved

Cartilage – Curved

Low Set Ear – Absent

NOSE

Mucous Secretion – Absent

Nasal Septumderication – Absent

Flat Nasal Bridge – Absent

MOUTH

Teeth - - Present All Are In Normal Condition

Lips -Moist,Cyanosis Present

Tongue – Light Pinkish

Cleft Lip / Palate - Absent

NECK

Enlargement Of Thyroid Gland - Absent

Enlargement Of Lymph Nodes - Absent

Movement Of Neck - Can Move In All Possible Direction

CHEST

Inspection - Normal

Percussion - No Evidence Of Fluid Collection

Palpation - No Palpable Mass Present

Auscultation - Wheezing Heard.Heart Sounds Are Also Heard Normal.

ABDOMEN

Inspection - Normal In Observation.

Percussion - No Evidence Of Fluid Collection.

Palpation - No Palpable Mass Present.Liver And Spleen Are Not Palpable.

Auscultation - Peristaltic Sounds Can Be Heard.

BACK

Spinal Deformities - No Abnormalities Present.

Spina Bifida – Absent

EXTREMITIES

Polydactyly - Absent

Syndactyly - Absent

Nail - Developed

Knocked Knee – Absent

VITAL SIGNS

Temperature – 100f
Pulse - 98 Beats / Minute

Respiration - 30breath / Minute

GROWTH AND DEVELOPMENT

Sense Of Industry – My Patient Have Good Socialization.

Sense Of Inferiority – Absent

Psychosexual Development - My Patient Is In Latency Period.He Have More Attachment

With His Mother.

Spiritual Development-

Religious Belief - Present

Intellectual / Cognitive Development-

Concrete Operational Stage - Present

Ordering – Present

Classification - Present

Thinking And Reasoning – Present

Language And Social Behaviour - My Patient Have Good Language And Social Relations.

INVESTIGATION

TEST IN PATIENT NORMAL

HAEMOGLOBIN 11gm % MALE-13-18gm %
FEMALE-11.5-16.5gm %
WBC 11300/CUMM 4000-11000/CUMM
LYMPHOCYTE 65% 20-45%
MONOCYTE 01% 1-10%
NEUTROPHIL 55% 40-60%
EOSINOPHIL 01% 1-6%
BASOPHIL 0% 0-1%

MEDICATIONS

S. NAME D R TI ACTION SIDE EFFECT NURSING

N OF O O M RESPONSIBILITY
O DRUG S UT E
E E
1 INJ.AMP 50 IV B INTERFERES CNS- -TO REPORT SORE
ICILLIN 0 D WITH LETHARGY,A THROAT,FEVER,FATI
E m CELLWALL NXIETY,DEPR GUE,DIARRHOEA
 g REPLICATIO ESSION -RENAL STUDIES
N OF GI- MUST BE DONE
SUSCEPTIBL NAUSEA,VOM ,URINALYSIS.PROTEI
E ITING,DIARR N,BUN
ORGANISMS. HOEA -TO ASSESS
THE HEMA- RESPIRATORY
CELLWALL ANEMIA,INCR STATUS,RATE,CHAR
RENDERED EASED ACTER,WHEEZING,H
OSMOTICALL BLEEDING IGHTNESS IN CHEST
Y UNSTABLE TIME
2 INJ.AMI 5 IV S RELAXES CNS- -ASSESS
NOPHYL C T SMOOTH ANXIETY, THEOPHYLLINE
LINE C A MUSCLE OF RESTLESSNES BLOOD
WITH T RESPIRATOR S, LEVEL,TOXICITY
DEXTRO Y SYSTEM INSOMNIA,DI MAY OCCUR WITH
SE 5 BY ZZINESS. SMALL INCREASE
PERCEN BLOCKING GI- -MONITOR
T PHOSPHDIES NAUSEA,VOM DIURESIS,DEHYDRA
TERASE. ITING,DIARR TION MAY OCCUR IN
INCREASE HOEA CHILDREN
CAMP THAT GU- -AVOID IM
PRODUCES INCREASED INJECTION
BRONCHODI URINARY -AVOID GIVING
LATION,INCR FREQUENCY WITH FEED
EASED
PULMONARY
BLOOD
FLOW

DISEASE CONDITION

INTRODUCTION

Pneumonia Is An Infection Of One Or Both Lungs Which Is Usually Caused By

Bacteria,Viruses,Or Fungi. Prior To The Discovery Of Antibiotics, One-Third Of All People
Who Developed Pneumonia Subsequently Died From The Infection. Currently, Over 3
Million People Develop Pneumonia Each Year In The United States. Over A Half A Million
Of These People Are Admitted To A Hospital For Treatment. Although Most Of These
People Recover, Approximately 5% Will Die From Pneumonia.Pneumonia Is The Sixth
Leading Cause Of Death In The United States.
DEFINITION

Pneumonia Is An Inflammatory Condition Of The Lung, Especially Inflammation Of The

Alveoli (Microscopic Air Sacs In The Lungs) Or When The Lungs Fill With Fluid (Called
Consolidation And Exudation

CAUSES

Pneumonia Can Be Due To Microorganisms, Irritants Or An Unknown Causes. When

Pneumonias Are Grouped This Way, Infectious Causes Are The Most Common.The
Symptoms Of Infectious Pneumonia Are Caused By The Invasion Of The Lungs By
Microorganisms And By The Immune System's Response To The Infection. Although More
Than One Hundred Strains Of Microorganism Can Cause Pneumonia, Only A Few Are
Responsible For Most Cases. The Most Common Causes Of Pneumonia Are Viruses And
Bacteria. Less Common Causes Of Infectious Pneumonia Are Fungi And Parasites.

VIRUSES

Viral Pneumonia Is Commonly Caused By Viruses Such As Influenza Virus, Respiratory

Syncytial Virus (Rsv), Adenovirus, And Parainfluenza. Herpes Simplex Virus Is A Rare
Cause Of Pneumonia Except In Newborns. People With Weakened Immune Systems Are
Also At Risk Of Pneumonia Caused By Cytomegalovirus (Cmv).

BACTERIA

Bacteria Are The Most Common Cause Of Community Acquired Pneumonia With
Streptococcus Pneumoniae The Most Commonly Isolated Bacteria. Another Important
Gram-Positive Cause Of Pneumonia Is Staphylococcus Aureus, With Streptococcus
Agalactiae Being An Important Cause Of Pneumonia In Newborn Babies. Gram-Negative
Bacteria Cause Pneumonia Less Frequently Than Gram-Positive Bacteria. Some Of The
Gram-Negative Bacteria That Cause Pneumonia Include HaemophilusInfluenzae,
KlebsiellaPneumoniae, Escherichia Coli, Pseudomonas Aeruginosa And Moraxella
Catarrhalis. These Bacteria Often Live In The Stomach Or Intestines And May Enter The
Lungs If Vomit Is Inhaled. "Atypical" Bacteria Which Cause Pneumonia Include
ChlamydophilaPneumoniae, Mycoplasma Pneumoniae, And Legionella Pneumophila.

FUNGI

Fungal Pneumonia Is Uncommon, But It May Occur In Individuals With Immune System
Problems Due To Aids, Immunosuppresive Drugs, Or Other Medical Problems. The
Pathophysiology Of Pneumonia Caused By Fungi Is Similar To That Of Bacterial
Pneumonia. Fungal Pneumonia Is Most Often Caused By HistoplasmaCapsulatum,
Blastomyces, Cryptococcus Neoformans, Pneumocystis Jiroveci, And CoccidioidesImmitis.
Histoplasmosis Is Most Common In TheMississippi River Basin, And Coccidioidomycosis
In The Southwestern United States

PARASITES

The Most Common Parasites Causing Pneumonia Are Toxoplasma Gondii,

StrongyloidesStercoralis, And Ascariasis.

IDIOPATHIC

Idiopathic Interstitial Pneumonias (Iip) Are A Class Of Diffuse Lung Diseases. In Some
Types OfIip, E.G. Some Types Of Usual Interstitial Pneumonia, The Cause, Indeed, Is
Unknown Or Idiopathic. In Some Types Of Iip The Cause Of The Pneumonia Is Known,
E.G. Desquamative Interstitial Pneumonia Is Caused By Smoking, And The Name Is A
Misnomer.

SIGNS AND SYMPTOMS` `

Symptoms Of Pneumonia Vary, Depending On The Age Of The Child And The Cause Of
The Pneumonia. Common Symptoms Include:

 Fever
 Chills
 Cough
 Unusually Rapid Breathing
 Breathing With Grunting Or Wheezing Sounds
 Labored Breathing That Makes A Child's Rib Muscles Retract (When Muscles Under
The Rib Cage Or Between Ribs Draw Inward With Each Breath)
 Vomiting
 Chest Pain
 Abdominal Pain
 Decreased Activity
 Loss Of Appetite (In Older Kids) Or Poor Feeding (In Infants)

In Extreme Cases, Bluish Or Gray Color Of The Lips And Fingernails

Sometimes A Child's Only Symptom Is Rapid Breathing. Sometimes When The Pneumonia
Is In The Lower Part Of The Lungs Near The Abdomen, There May Be No Breathing
Problems, But There May Be Fever And Abdominal Pain Or Vomiting.

When Pneumonia Is Caused By Bacteria, An Infected Child Usually Becomes Sick

Relatively Quickly And Experiences The Sudden Onset Of High Fever And Unusually
Rapid Breathing. When Pneumonia Is Caused By Viruses, Symptoms Tend To Appear More
Gradually And Are Often Less Severe Than In Bacterial Pneumonia. Wheezing May Be
More Common In Viral Pneumonia.

Some Types Of Pneumonia Cause Symptoms That Give Important Clues About Which
Germ Is Causing The Illness. For Example, In Older Kids And Adolescents, Pneumonia Due
To Mycoplasma (Also Called Walking Pneumonia) Is Notorious For Causing A Sore Throat
And Headache In Addition To The Usual Symptoms Of Pneumonia.

In Infants, Pneumonia Due To Chlamydia May Cause Conjunctivitis (Pinkeye) With Only
Mild Illness And No Fever. When Pneumonia Is Due To Whooping Cough (Pertussis), The
Child May Have Long Coughing Spells, Turn Blue From Lack Of Air, Or Make A Classic
"Whoop" Sound When Trying To Take A Breath.

DIAGNOSTIC EVALUATION

Pneumonia May Be Suspected When The Doctor Examines The Patient And Hears Coarse
Breathing Or Crackling Sounds When Listening To A Portion Of The Chest With A
Stethoscope. There May Be Wheezing, Or The Sounds Of Breathing May Be Faint In A
Particular Area Of The Chest.

 A Chest X-Ray Is Usually Ordered To Confirm The Diagnosis Of Pneumonia

 Sputum Samples Can Be Collected And Examined Under The Microscope
 A Blood Test That Measures White Bloo D Cell Count (Wbc) May Be Performed
 Bronchoscopy Is A Procedure In Which A Thin, Flexible,Lighted Viewing Tube Is
Inserted Into The Nose Or Mouth After A Local Anesthetic Is Administered.The
Breathing Passages Can Then Be Directly Examined By The Doctor, And Specimens
From The Infected Part Of The Lung Can Be Obtained.

PREVENTION

There Are Several Ways To Prevent Infectious Pneumonia. Appropriately Treating

Underlying Illnesses (Such As Aids) Can Decrease A Person's Risk Of Pneumonia. Smoking
Cessation Is Important Not Only Because It Helps To Limit Lung Damage, But Also
Because Cigarette Smoke Interferes With Many Of The Body's Natural Defenses Against
Pneumonia.

Research Shows That There Are Several Ways To Prevent Pneumonia In Newborn Infants.
Testing Pregnant Women For Group B Streptococcus And Chlamydia Trachomatis, And
Then Giving Antibiotic Treatment If Needed, Reduces Pneumonia In Infants. Suctioning The
Mouth And Throat Of Infants With Meconium-Stained Amniotic Fluid Decreases The Rate
Of Aspiration Pneumonia.

Vaccination Is Important For Preventing Pneumonia In Both Children And Adults.

Vaccinations Against HaemophilusInfluenzae And Streptococcus Pneumoniae In The First
Year Of Life Have Greatly Reduced The Role These Bacteria Play In Causing Pneumonia In
Children. Vaccinating Children Against Streptococcus Pneumoniae Has Also Led To A
Decreased Incidence Of These Infections In Adults Because Many Adults Acquire Infections
From Children. Hib Vaccine Is Now Widely Used Around The Globe. The Childhood
Pneumococcal Vaccine Is Still As Of 2009 Predominantly Used In High-Income Countries,
Though This Is Changing. In 2009, Rwanda Became The First Low-Income Country To
Introduce Pneumococcal Conjugate Vaccine Into Their National Immunization Program.

A Vaccine Against Streptococcus Pneumoniae Is Also Available For Adults. In The U.S., It
Is Currently Recommended For All Healthy Individuals Older Than 65 And Any Adults
With Emphysema, Congestive Heart Failure, Diabetes Mellitus, Cirrhosis Of The Liver,
Alcoholism, Cerebrospinal Fluid Leaks, Or Those Who Do Not Have A Spleen. A Repeat
Vaccination May Also Be Required After Five Or Ten Years.

Influenza Vaccines Should Be Given Yearly To The Same Individuals Who Receive
Vaccination Against Streptococcus Pneumoniae. In Addition, Health Care Workers, Nursing
Home Residents, And Pregnant Women Should Receive The Vaccine. When An Influenza
Outbreak Is Occurring, Medications Such As Amantadine, Rimantadine, Zanamivir,
AndOseltamivir Can Help Prevent Influenza

TREATMENT

In The United States More Than 80% Of Cases Of Community Acquired Pneumonia Are
Treated Without Hospitalization. Typically, Oral Antibiotics, Rest, Fluids, And Home Care
Are Sufficient For Complete Resolution. However, People Who Are Having Trouble
Breathing, With Other Medical Problems, And The Elderly May Need Greater Care. If The
Symptoms Get Worse, The Pneumonia Does Not Improve With Home Treatment, Or
Complications Occur, Then Hospitalization May Be Recommended. Over The Counter
Cough Medicine Has Not Been Found To Be Helpful In Pneumonia.

BACTERIAL

Antibiotics Improve Outcomes In Those With Bacterial Pneumonia. Initially Antibiotic

Choice Depends On The Characteristics Of The Person Affected Such As Age, Underlying
Health, And Location The Infection Was Acquired.In The UkEmpiric Treatment Is Usually
With Amoxicillin, Erythromycin, Or Azithromycin For Community-Acquired Pneumonia. In
North America, Where The "Atypical" Forms Of Community-Acquired Pneumonia Are
Becoming More Common, Macrolides (Such As Azithromycin), And Doxycycline Have
Displaced Amoxicillin As First-Line Outpatient Treatment For Community-Acquired
Pneumonia. The Use Of Fluoroquinolones In Uncomplicated Cases Is Discouraged Due To
Concerns Of Side Effects And Resistance. The Duration Of Treatment Has Traditionally
Been Seven To Ten Days, But There Is Increasing Evidence That Short Courses (Three To
Five Days) Are Equivalent. Antibiotics Recommended For Hospital-Acquired Pneumonia
Include Third- And Fourth-Generation Cephalosporins, Carbapenems, Fluoroquinolones,
Aminoglycosides, And Vancomycin. These Antibiotics Are Often Given Intravenously And
May Be Used In Combination.
VIRAL

No Specific Treatments Exist For Most Types Of Viral Pneumonia Including Sars
Coronavirus, Adenovirus, Hantavirus, And Parainfluenza Virus With The Exception Of
Influenza A And Influenza B. Influenza A May Be Treated With RimantadineOrAmantadine
While Influenza A Or B May Be Treated With Oseltamivir Or Zanamivir. These Are
Beneficial Only If They Are Started Within 48 Hours Of The Onset Of Symptoms. Many
Strains OfH5n1 Influenza A, Also Known As Avian Influenza Or "Bird Flu," Have Shown
Resistance To Rimantadine And Amantadine.

ASPIRATION

There Is No Evidence To Support The Use Of Antibiotics In Chemical Pneumonitis Without

Bacterial Superinfection. If Infection Is Present In Aspiration Pneumonia, The Choice Of
Antibiotic Will Depend On Several Factors, Including The Suspected Causative Organism
And Whether Pneumonia Was Acquired In The Community Or Developed In A Hospital
Setting. Common Options Include Clindamycin, A Combination Of A Beta-Lactam
Antibiotic And Metronidazole, Or An Aminoglycoside. Corticosteroids Are Commonly
Used In Aspiration Pneumonia, But There Is No Evidence To Support Their Use Either.

NURSING MANAGEMENT

NURSING DIAGNOSIS

 Knowledge Deficit Regarding Baby Care After Hospitalization Evidenced By Parents

Verbalizing Indicating Lack Of Knowledge On Care Of Sick New Born Baby At
Home .
 Alteration In Thermoregulation Related To Disease Condition
 Infective Breathing Pattern Related To Low Intake Of Oxygen Evidence By Cyanosis
Difficult In Breathing
 Risk Of Infections Related To Invasive Procedures And Immaturity Of Baby System
 Potential For Impaired Skin Integrity Related To Baby Inactivity

NURSING CARE PLAN

S. ASSESS NURSING GOAL IMPLEM RATION EVALU
N MENT DIAGNOSI PLANN ENTATIO AL ATION
O S ING N
1 SUBJE INEFFECTI BABY - - CLEARI - THE
CTIVE VE WILL CLEAR AIRWAY NG OF AIRWA
DATA:- BREATHIN BE AIRWA WAS AIRWA Y
MY G ABLE Y CLEARE YS REMAI
PATIEN PATTERN TO D HELPS NED
T RELATED BREAT -GIVE BY REMOV CLEAR
COMPL TO LOW H OXYGE WIPING E AND -
AINTS INTAKE OF WITH N BY NOSTRIL MUCUS PATENT
THAT OXYGEN EASE. MASK S AND SECRET OXYGE
HE IS EVIDENCE ATTAI MOUTH IONS N
HAVIN BY N - AND AND REMAI
G CYANOSIS NORM MONIT ALSO MAINT NED ON
BREAT DIFFICULT AL OR SUCKIN AIN TILL
HING IN RESPIR VITAL G PATENT 3.30 PM
DIFFIC BREATHIN ATORY SIGNS AIRWA WHEN
ULTY. G RATE ½ - Y IT WAS
AND OF 40- HOURL OXYGEN - WEANE
OBJEC WEAK 50 Y WAS SUPPLE D
TIVE CRY AT BEATS TEMPE GIVEN 8 MENTA OF
DATA:- BIRTH / RATUR LITRES L THE
ON MINUT E /MINUTE OXYGE FOLLO
OBSER E PULSE BY FACE N WING
VATIO AND MASK HELP NORMA
NI RESPIR TO L
FOUND ATION -VITAL MEET RESPIR
THAT - OBSERV ALL ATION
CYANO MONIT ATION METAB RATE
SIS IS OR TAKEN ½ OLISM AND
PRESE COLOU HOURLY DEMAN OTHER
NT IN R THEN 2 D IN VITAL
MY OF HOURLY. THE SIGNS
PATIEN BABY 8AM BODY TEMPE
T’S AND TEMP TISSUE RATUR
LIPS ACTIVI 35.80C -CLOSE E 36.5
AN TIES PULSE MONIT PULSE
DNAIL IE. 100 ORING 136/MIN
S. REFLE BEAT/MI OF UTE
XES NUTE VITAL RESPIR
RESPIRA SIGNS ATION
TION 24 HELP 38/MIN
/MINUTE TO UTE
S DETECT
8:30 AM ANY
TEMP ABNOR
36.10C MAL
PULSE CONDIT
120 ION
/MINUTE AND
RESPIRA ACT AS
TION A
30/MINU GUIDE
TE IF
9AM THERE
TEMPER IS
ATURE IMPRO
36.20C VEMEN
 PULSE T.
130/MIN
UTE
RESPIRA
TION
34
/MINUTE

2 SUBJ ALTERATI PATIEN - - -TO AFTER

DATA- ON IN T WILL MONIT MONITO KNOW THESE
MY THERMOR BE OR R VITAL THE INTERV
PATIEN EGULATIO ABLE VITAL SIGNS CONDIT ENTION
T N TO SIGNS ION OF S
COMPL RELATED MAINT -TO GIVE PATIEN PATIEN
AINED TO AIN -TO SPONGE T T’S
ABOUT DISEASE NORM GIVE BATH BODY
HAVIN CONDITIO AL SPONG -TO TEMPE
G N BODY E BATH -TO REDUC RATUR
FEVER TEMPE ADMINIS E E
OBJ RATUR -TO TER TEMPE MAINT
DATA- E ADMIN ANTIPYR RATUR AINED
BY ISTER ETIC E AND TO
TOUCH ANTIP DRUGS MAKE NORMA
ING I YRETI COMFO L.
FOUND C RTABL
THAT DRUGS E
HER
BODY -HELPS
TEMPE TO
RATUR REDUC
E IS E
INCRE FEVER
ASED
3 SUBJE RISK BABY -HAND -HARD -HAND BABY
CTIVE OF WILL WASHI WASHIN WASHI GENER
DATA:- INFECTION NOT NG G NG AL
PATIEN S SHOW AND MAINT CONDIT
T RELATED ANY -USE GLOVIN AINING ION
HAVE TO SIGN ANTISE G BY PERSON IMPROV
PAIN INVASIVE OF PTIC ALL AL ING
AND PROCEDU INFECT TECHN STUFF HYGIEN AS
FEVER. RES ION IQUES BEFORE E SIGN
AND BY - GIVE HANDLI AND OF
OBJEC IMPROPER END OF ANTIBI NG ASEPTI INFECTI
TIVE ASESPTIC HIS OTICS THE C ON
DATA:- TECHNIQU STAY BABY TECHNI NOTED
O ES. IN - QUES AS
 OBSER THE MAINT - PREVE VITAL
VATIO NEW AIN TREATM NT SIGNS
NI BORN PERSO ENT SECON REMAI
FOUND UNIT NAL GIVEN DARY NED
THAT -BABY HYGIE UNDER INFECTI WITH
ASEPTI WILL NE ASEPTIC ON NORMA
C NOT TECHNIQ L
TECDH ACQUI - UE. - RANGE
NIQUE RE OBSER ANTIBI TEMPE
S INFECT VE - OTIC RATUR
SHOUL IONS OR IV KILL E
D BE MONIT AMIKACI MICRO- 36.60C
MAINT OR N ORGAN HEART
AINED SIGNS 600MG ISM RATE
PROPE OF OD AND 142/
RLY. INFECT X 7/7 ENHAN MINUTE
IONS CE RESPIR
QUICK ATION
RECOV 40/MIN
ERY UTE

4 SUBJE POTENTIA SKIN CHANG BABY ALL NO

CTIVE L INTEG E LINEN THESE SKIN
DATA:- FOR RITY LINEN CHANGE ACTIVI EXCORI
PATIEN IMPAIRED WILL FREQU D TIES ATIONS
T SKIN BE ENCY WHENEV HELP NOTED
COMPL INTEGRIT MAINT TREAT ER PREVE AND
AINED Y AINED PRESS SOILED NT BABY
ABOUT RELATED URE 3 EXCORI SKIN
BODY TO AREA HOURLY ATION REMAI
PAIN BABY CHANG TURNIN WHICH NED
AN INACTIVIT E G CAN INTACT
DSKIN Y BABY WAS LEAD
DRYNE POSITI DONE TO
SS ON BY PRESSU
FREQU HUGS RE
OBJEC ENCY ALSO SORES
TIVE MOTHER
DATA:- SHOWN
ON HOW
OBSER TO DO IT
VATIO BY
NI MASSAG
FOUND ING
THAT
PATIEN
T’S
 SKIN
CHANG
ES DUE
TO
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VITY.
5 Subjecti KNOWLED BOTH ASSESS HEALTH HEALT PARENT
ve dat:- GE FATHE PAREN MESSAG H SHOWE
My DEFICIT R TS E EDUCA D
patient REGARDIN AND KNOW S TION APPREC
and his G BABY’S MOTHE LEDGE INCLUDE INCREA IAT
parents CARE R BY D. SES ION
complai AFTER WILL THE - KNOWL OF
nts HOSPITALI HAVE ASKIN KEEPING EDGE THE
about ZATION ADEQU G BABY AND KNOWL
that they CHARACT ATE WHAT WARM HELPS ED
are ERIZED KNOW THEY AND FAMILY GE
unaware BY LEDGE KNOW CLEAN TO GAINED
about PARENT ON ABOUT ALWAYS ADJUST AND
the VERBALIZI CHILD DISEAS - WITH THE
disease NG CARE E EXCLUSI THE HELP
conditio INDICATIN AFTER CONDI VES NEW RECEIV
n and G DISCH TION BREAST BORN ED
aftercare LACK ARGE AND FEEDING AT DURING
. OF CHILD ON HOME THE
KNOWLED CARE. DEMAND AND TIME
GE ON BEFORE PROVID OF
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NEW OF CARE OF
WHILE AT ANY AS THEIR
HOME SUPPLE IT ALSO BABY
MENTAR HELP AND
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OF WITH CONTIN
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N ON MS FOLLO
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GE TO UPS
PREVEN
T FROM
INFECTI
 OUS
DISEASE
S
WHICH
ARE
IMMUNI
SABLE
-
FOLLOW
UP
CHECK
UP
AT
CLINIC
AFTER 2
WEEKS

THEORY APPLICATION

As My Patient Is Only 9 Year Old, She Cannot Care For Herself.Considering Her Disease
Condition And Age I Am Choosing Orem’s Self Care Deficit Theory.

LYDIA HALL : CORE CARE CURE THEORY

LYDIA HALL :
Basic Nursing Education In 1927 Bachelors In Public Health Nursing In 1937 Masters In
Teaching Natural Sciences In 1942 First Director Of Loeb Center For Nursing Nursing
Experience In Clinical, Education, Research And Supervisor Role Nursing Philosophy Based
On Patient Care Lydia Hall.

THEORY OVERVIEW :
Theory Developed In Late 1960’s Nursing Care Can Be Delivered On Three Interlocking
Levels -:
Care = Hands On Bodily Care
Core = Using Self In Relationship To Patient
Cure = The Disease.
Patient Care Only From Trained Nurses Defines Nursing As Care Performed By A
Professional Care Focused On Individuals, Families And Communities Care Focused On
Maintaining Optimal Health And Quality Life From Birth To End Of Life Care Is Ongoing
Matrix Of Learning And Teaching Theory. Three Interlocking Circles Representing One
Aspect Of Nursing Only Nursing Is Defined As The Function Necessary To Carry Out Care,
Core And Cure Philosophical View Of Humans Having Energy And Motivation For Self-
Awareness And Growth Definitions Of Health And Society Must Be Inferred.
CARE :
Nurturing Component Of Care It Is Exclusive To Nursing “Mothering” Provides Teaching
And Learning Activities Nurses Goal Is To “Comfort” The Patient Patient May Explore And
Share Feelings With Nurse Care.

CORE :
Patient Care Is Based On Social Sciences Therapeutic Use Of Self Helps Patient Learn Their
Role Is In The Healing Process Patient Is Able To Maintain Who They Are Patient Able To
Develop A Maturity Level When Nurse Listens To Them And Acts As Sounding Board
Patient Able To Make Informed Decisions Core.

CURE :
Care Based On Pathological And Therapeutic Sciences Professional Nurse Helps Patient
Through The Rehabilitative Phase Of Care Nurse Is Patient Advocate In This Area Nurses
Role Changes From Positive Quality To Negative Quality Cure.

PROGRESS NOTES

1st Day -: Patient’s Condition Was Poor

Temp-100f,Pulse-160/Min,Resp-60/Min

2nd Day -: Patient’s Condition Had Some Improvements.Patient’s Fever Reduced.

Temp-99f,Pulse-130/Min,Resp-50/Min

3rd Day -:Patient’sBecomecondition More Better.

Temp-98f,Pulse-130/Min,Resp-40/Min

4th Day -: Patient’s Activity Level Improved Well.

Temp-98.6f,Pulse-120/Min,Resp-40/Min

HEALTH EDUCATION

• Maintenance Of General Hygiene To Promote Baby’s Health And Prevent Infection

• Follow Up Immunization For The Baby According To Keeping Schedule As Instructed.

• To Bring Back Baby For Follow Up In Pediatric Outpatient Clinic After 2 Weeks.

• To Take Well Nutritious Diet (Family) To Promote Health And It Will Assist Herget
Enough Milk For Baby.
 BIBLIOGRAPHY

1.Dorothy R Marlow & Barbara A Redding;

The Text Book Of Pediatric Nursing;6thEdition;Page No:348-352.

2.Achar’s; The Text Book Of Pediatrics;4 thEdition;Page No:112-116.

3.Jaypees;Nurse’s Dictionary;3rdEdition;Page No:54.