Case presentation

On
Infective endocarditis

Submitted to- Submitted by-

Madam Rakhi Ghosh Payel Das
Sr. Faculty Teacher Msc (N) 1st year
College of nursing College of nursing
Medical college & hospital Medical college & hospital

Introduction:
Inflammation of valvular or mural endocardial lining of the great vessels is called infective endocarditis.it is
very common complication of congenital heart defects.it can be caused by bacteria staphylococcus aureus,
S.Pneumonie, staphylococcus viridians, enterococci, P. aeruginosa etc.

Definition:
It is an infection of endocardial surface of the heart. The endocardium is the innermost layer of the heart, is
contagious with the valves of the heart, therefore inflammation from infective endocarditis affects the
cardiac valves.

Anatomy & physiology of endocardium layer of heart:

The heart wall is mainly composed of a muscular layer, the epicardium and the pericardium cover the the
external surface. Internally endocardium covers the surface. The endocardium is composed of a layer of
endothelial cells and a few layers of collagen and elastic fibres. The endocardium is in continuation with
tunica intima of the blood vessles.the endocardium covers the both atriums, both of the ventricles, and all of
the valves of the heart. This very thin & delicate lining is made up of 3 layers:
 The first layer contains the connective tissue and purkinjee fibres. The connective tissue helps the
endocardium attach to the myocardium and the purkinjee fibre help to conduct electricity through the
heart muscle.
 The second layer contains a thin muscle layer & more connective tissue
 The third layer contains vascular endothelium which is made up of special cells that line the inside of
the circulatory system.

 Location of endocardium:
From the outside in, the heart is enveloped by the fibrous and serous pericardium. The myocardium
separates the serous pericardium from the epicardium. the endocardium then separates the myocardium from
the internal cavity of the heart. all the internal surface of the heart is composed of endocardial tissue.

 Parts of endocardium:
the endocardium lines all internal surfaces of the heart, including the valves separates the various chambers.
The endocardium itself is composed of three layers.
 Endothelium
 Elastic tissue layer
 Subendocardial layer

 Functions of endocardium:
Even the innermost & thin layer is endocardium but it serves three huge functions for the cardiovascular
system.
The endocardium which is primarily made up of endothelial cells, controls myocardial functions. the
endothelium of the myocardial capillaries, which is closely appositioned to the cardiomyocytes is involved
in the modulatory role. thus the cardiac endothelium controls the development of the heart in the embrayo as
well as in adult, for example during hypertrophy. additionally the contractility and electrophysiological
environment of the cardiomyocytes are regulated by cardiac endothelium.
The endocardial endothelium may also act as a kind of blood heart barrier, thus controlling the iconic
composition of the extracellular fluid in which the cardiomyocytes.

Types of endocarditis:
Two forms of infective endocarditis, subacute and acute, have been described. subacute form typically affect
those who have preeixting valve disease and has clinical course that may extended over months.in contrast
form acute phase typically affects those with healthy valves and presents as a rapidly progressive illness.
 Native valve endocarditis:
It is seen in patient’s those have valvular or heart disease that predispose to infective endocarditis.

 Prosthetic valve endocarditis:

It occurs in 1-6% in all prosthetic heart valve patient’s. the rate of infection of mechanical and tissue
valve are similar

 Nosocomial endocarditis:
It is usually occur due to the complications of bacteremia introduced through invasive procedures or a
vascular device and accounts for nearly 10% of infective endocarditis in some areas. It can occur after a
pacemaker implantation and has mortality rate as high as 24%

Etiology:( as per book) ( As per patient)

 Bacteria 1.Previous VSD device closure done.

 Bartonella quintana
 Chlamydiae
 Enterococci
 Staphylococcus aureus
 Staphylococcus bovis
 Streptococcus group A, B, C
 Rickettsiae
  Methicillin resistant staphylococcus aureus

 Fungi:

 Candida albicans
 Candida parapsilosis

 Viruses:

 Coxackie B virus

Predisposing factors of infective endocarditis:

 Cardiac conditions

 Prior endocarditis
 Prosthetic valve
 Acquired valve disease ( mitral valve prolapse, aortic stenosis)
 Cardiac lesions like VSD.
 Rheumatic heart disease
 Congenital heart disease
 Pacemakers
 Cardiomyopathy
 Marfan syndrome
 Asymmetrical septal hypertrophy

 Non cardiac conditions

 Intravenous drug use

 Nosocomial bacteremia

Pathophysiology:
Damage to endothelial surface may be due to turbulent blood flow that erodes the normal
Infection resistance of the endocardium, mitral valve prolapse, mitral regurgitation, RHD
Patients are more prone to have bacterial invasion.

Causative organism adhering to the endothelial surfaces of the heart.

Multiplication of the organisms

 Leukocytes, fibrins, platelets covers the multiplying organisms and forms
Vegetative lesion on valve surface

Local valve damage (mitral or aortic commonly affected)

As blood flows through the heart, these vegetations may break off and become emboli

Embolization of spleen, liver, brain, kidney, resulting from left sided endocarditis,
Pulmonary emboli may occur in right sided endocarditis.

Clinical Manifestations:
According to book According to patient
Fever Fever
Dyspnea Breathing difficulty
Petechiae Splenomegaly
Changing murmur Congestive heart failure
Dental carries Failure to thrieve
Hepatosplenomegaly Linear haemorrhagic streaks beneath the nails.
Congestive heart failure Decreased weight.
splenomegaly
Painless haemorrhagic lesions appeared on palm
and soles. ( Janway lesions)
Linear haemorrhagic streaks beneath the nails
Arthritis
Tender pea shaped intradermal nodes visible in
pads of fingers & toes.
Roth’s spot: splinter haemorrhage with pale
centers on sclerae, palate, buccal mucosa, chest,
fingers & toes.
Osler’s node: small tender nodules on the palms of
the toes or fingers.

Investigation:
According to book According to patient
 History taking: patient’s past and present  History taking: patient have VSD device
medical & surgical history should be taken closure history in last 6 months ago.
from the parents of the patient. If there is
any cardiac problems or any renal disease,
or any other type of past surgical history
like cardiac catheterization, valve
replacement etc
 Physical examination: murmur sound may  Physical examination: murmur sound is
present at the time of auscultation at the heard during auscultation. fever is present.
apex of the heart. Fever may present.
 Blood culture: blood culture report is  Blood culture: blood culture is positive for
positive.3 or more positive culture taken achromobactor xylosoxidons.
over more than 1 hour.
 Echo cardiography: positive  Echo cardiography: mild cardiomyopathy
echocardiography showing vegetation, is present. Mitral valve regurgitation
paravalvular abscess or valve dehiscence present, vegetation seen in the endocardium.
after surgery.
 Chest X ray: it is done to detect any  Chest Xray: boot shaped heart with
cardiomyopathy is present or not. cardiomyopathy is seen.
 Ecg: it may show 1st or 2nd degree AV  Ecg: Ecg shows 2nd degree AV block.
block because the cardiac valves lies in
proximity to cardiac conductive tissues,
specially the AV node.
 Cardiac catheterization: it is done to  Cardiac catheterization: Pulmonary
detect valve functioning and to assess the atresia, large aorta overriding VSD.
status of coronary arteries when surgical
intervention is being considered for
patient’s with infective endocarditis.
 Complete blood count: a mild leucocytosis  Complete blood count: WBC-
occur in acute endocarditis with average 20,000/mmm3. ESR- 30mm/hr.
WBC counts ranging from -10,000- CRP-25mg/lit. TC- 12000/mm3,
20,000/mm3. elevation of ESR a
normocytic, normochromic anaemia is
common, thrombocytopenia is present .
proteinuria may occur with microscopic
haematuria. CRP is more relevant than ESR
test.
 Urine test: proteinuria may present &  Urine test for routine examination: occult
microscopic haematuria is usually present. blood is positive in urine.

Medical management:
According to book According to patient
  Antibiotics: penicillin or ampicillin or
vancomycin plus gentamycin for 4-6 weeks
 Antibiotic-Inj. Meropenem (600 mg) iv Tds.
Inj. Vancomycin (200mg) BD.
 Proton pump inhibitor: Inj. Pan 40mg OD.
 ACE Inhibitor: tablet enalapril 2.5mg OD.
 Anti epileptic: syrup levera 3ml/oral BD.
Syrup phenytoin (30/5) 5ml/oral BD.

Surgical management:
According to book According to patient
Surgery is indicated if there is continued bacteremia There is no surgery is performed for endocarditis
after 2 weeks of appropriate therapy, fungal till now.
vegetations, abscess formation, worsening heart
failure or systemic emboli. Surgery may include:
 Debridement to remove infected tissues,
valve repair like mitral chordae repair, re
attaching cord like structure that connects
muscle to valve flaps.

Nutritional Management:
According to book According to patient
Low fat and low cholesterol rich food should be Breakfast: 1 egg, 1 glass milk, 2 bread
given to the patient. More vegetables & fruits Lunch: rice, 1 piece fish, dal, vegetables
should be given. Dinner: rice, dal, vegetables.

Prophylaxis by American Heart Association:

The new guidelines of American Heart Association (AHA) (2007) suggest that prophylaxis should be
targeted at conditions that are associated with the increased risk of adverse outcomes from IE. Those
conditions are:
 Prosthetic cardiac valve or prosthetic material used for valve repair.
 Previous IE.
 Congenital heart disease (CHD): Unrepaired cyanotic CHD, including palliative shunts and
conduits, during initial six months following the repair of congenital heart defect with prosthetic
material or device, whether placed by surgery or by catheter intervention, repaired CHD with
residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.
 Cardiac transplant recipients with cardiac valvulopathy.

All dental procedures involving the manipulation of gingival tissue, the peri-apical region of teeth or
the perforation of the oral mucosa need antibiotic prophylaxis. This is also required in case of individuals
who undergo an invasive procedure of the respiratory tract that involves incision or biopsy of the respiratory
mucosa, such as tonsillectomy and adenoidectomy. Prophylaxis is not recommended for GI or GU tract
procedures. Procedures on infected skin, skin structure or musculoskeletal tissue require coverage against
staphylococci and group A streptococcus.
Antibiotic regimens for dental procedures: Single dose move after IV/IM of Amoxicillin oral 50
mg/kg or Ampicillin/ Cefazolin/Ceftriaxone 50 mg/kg IV/IM. If allergic to penicillin, cephalexin or
clindamycin may be given.
Nursing Management:
Maintaining adequate cardiac output
 Auscultate heart to detect new murmur or change in existing murmur, presence of gallop
 Monitor BP, Pulse
 Evaluate jugular vein distention
 Record intake & output
 Record daily weight
 Auscultate lungs field for evidence of crackles.

Maintaining Tissue Perfusion

 Observe patient for altered mental status, haemoptysis, haematuria, aphasia, loss of muscle strength,
complaint pain
 Observe for splinter haemorrhages of nail beds, Osler's nodes, and Janeway's lesions
 Reposition patient frequently to prevent skin breakdown and pulmonary complications associated
with bedrest.

Maintaining Normal Temperature

 Observe basic principles of asepsis, good handwashing technique.

 Employ meticulous IV care for long-term antibiotic therapy.

o Note the date of needle or cannula insertion on nursing care plan.

o If a peripheral site is used, rotate the site every 72 hours or if site becomes tender,
reddened, infiltrated, or has purulent drainage.
o Change gauze or transparent dressing every 24 hours to prevent infection.
o If a continuous venous access device is used, follow facility policy for site care and
dressing changes and flushing procedures.

 Administer parenteral antibiotic therapy as directed.

o Develop chart for rotation of sites for IM administration of antibiotic therapy.

o Observe for adverse reactions to antibiotic therapy (severe respiratory distress, rash,
itching, and fever).
o Observe for adverse effects of long-term antibiotic therapy ototoxicity, renal failure.

 Monitor temperature every 2 to 4 hours.

 Observe patient for a general sense of well-being within 5 to 7 days after initiation of therapy.
 Monitor laboratory values HCT, BUN, creatinine, WBC, antibiotic levels, blood cultures.
 Promote adequate hydration, because diaphoresis and increased metabolic rate may cause
dehydration.

Improving Nutritional Status

o Assess patient's daily caloric intake
 o Discuss food preferences with patient
o Consult with a dietitian about nutritional needs of patient and food preferences
o Encourage small meals and snacks throughout the day
o Record daily caloric intake and weight
o Educate family about the patient's caloric needs
o Encourage family to assist the patient with meals and bring in patient's favourite foods.

Procedures for which infective endocarditis prophylaxis is recommended:

These are following:
Dental procedures
 Tooth extractions
 Periodontal procedure
 Dental implant placement
 Replacement of avulsed tooth
 Root canal or surgery
 Intra ligamentary local anaesthetic injections
 Any prophylactic dental procedure during which bleeding is anticipated.

Respiratory tract procedures

 Tonsillectomy, adenoidectomy
 Rigid bronchoscopy
 Surgery involving the respiratory mucosa.

Gastrointestinal tract procedures

 Esophageal varices sclerotherapy
 Dilation of esophageal stricture
 Endoscopic retrograde cholangiography for biliary obstruction
 Other biliary tract surgery
 Surgery involving the gastrointestinal mucosa

Genitourinary tract procedures

 Cystoscopy
 Urethral dilation
 Surgery involving the prostate

Nursing diagnosis:
  Risk for infection related to bacterial vegetation in the endocardium layer of heart as evidenced by
positive blood culture report, occurrence of recurrent fever.

 Decreased cardiac output related to structural defect, congenital anomaly or ineffective heart
pumping as evidenced by murmur, abnormal heart rate or abnormal heart sound

 Excess fluid volume related to ineffective cardiac muscle function as evidenced by shortness of
breath, dyspnea.

 Imbalance nutrition less than body requirement related to increase energy expenditure and fatigue as
evidenced by weight loss or height and weight below accepted standard.

 Ineffective tissue perfusion related to inadequate cardiac function or cardiac surgery as evidenced by
cyanosis, prolong capillary refill.

 Risk for delayed growth & development related to effects of cardiac disease and necessary
treatments, inadequate nutrition as evidenced by weight loss or weight below accepted standard.

Complications:
  Heart failure
 Heart valve damage
 Pocket of collected pus that develops in the heart, brain, lungs and other organs
 Pulmonary embolism
 Kidney damage
 Enlarged spleen

Prognosis:
The prognosis of bacterial endocarditis varies with the etiologic agent. infection by a penicillin sensitive
streptococcus, if diagnosed early, has a cure rate of 100%. Because many infections are diagnosed late or are
due to resistant organisms, the average mortality rate is approx. 16-25%.

Conclusions:
Infective endocarditis is an infection of the lining of the heart chambers and heart valves that is caused by
bacteria, fungi or other infectious substances. Most people who develop infectious endocarditis have
underlying heart disease or valve problem.it usually a result of blood infection. Bacteria or other infectious
substances are enter the blood stream during the any medical or surgical procedures including dental
procedure, and travel to the heart, where it can settled on damage heart valves. the bacteria can grow and
form infected clots that break off or may travel in the brain, kidney, lungs, spleen.

Assessment Nursing Goal Planning implementation evaluation

 diagnosis

Subjective Decreased Child will  Vital signs of  vital signs

data: cardiac demonstrate the child is to be are checked child
child’s output adequate checked closely & recorded improved
mother says related to cardiac and recorded  cardiac with elastic
that my structural output  Cardiac monitoring is skin turgor,
child’s defect or monitoring is to recorded to regular
respiration ineffective be recorded to detect any heart
is frequent heart detect arrythmia arrythmia rhythm,
& abnormal pumping as quickly  signs of pulse and
breathing evidenced  The signs of hypoxia, BP is
sound is by murmur, hypoxia, cyanosis is within
present. abnormal cyanosis is to be assessed normal
heart rate, assessed  oxygen is range.
Objective abnormal  Oxygen is to be administered
data: in heart administered as as per child’s
auscultation sounds. per condition of condition
murmur the child  adequate
sound is  Adequate hydration is
present and hydrartion is to provided
heart rate is be provided to  anti
also high. the child to arrythmic
HR-130 prevent clot drugs, ACE
bpm. formation inhibitors are
 anti arrythmics, given as per
ACE inhibitors doctor’s
is to be advice.
administer to
the child as per
doctor’s advice

Assessment Nursing Goal Intervention

Planning
 Diagnosis Evaluation

Subjective Excess fluid Child will  weight is to be  weight is

data: volume be able to checked daily & checked
child’s related to attain recorded  lung sound is Child’s
parent says ineffective appropriate  lung sound is to auscultate lung sound
that my cardiac fluid be ausculted regularly to is clear &
child has muscle balance regularly to assess heart sound
breathing functioning assess crackles crackles is normal.
problem as evidenced sound  signs of
and his by shortness  signs of hypoxia such
breath of breath, hypoxemia is to as peripheral
sound is abnormal be checked cynosis is
abnormal breathing  vital signs is to checked
sound be checked &  vital signs
Objective (murmur) or recorded are checked
data: pulmonary  oxygenation is  oxygenation
auscultate congestion to be given as is given as
the breath per need of the per need of
sound and patient. the child
assess the
breathing
pattern of
the child

Assessment Nursing Goal Evaluation

Planning Implementation
 Diagnosis

Subjective Imbalanced Child will  Body weight is

Data: nutrition be improved to be checked  body weight Child will
mother says less than nutritional regularly is checked be able to
that my body intake  food regularly & increase
child is requirement preferences of recorded nutritional
fatigue and Related to the child is to be  food intake.
his weight fatigue as assessed and preferences
is evidenced give food which of the child
decreased. by weight the child like is assessed
loss below  high calorie diet and give
Objective accepted is to be given child’s likely
Data: standards.  small frequent foods.
checking feeding is to be  High calorie
the weight given foods are
of the child.  vitamin and given
weight is 15 mineral  Vitamin and
kg. supplementation mineral
Are given to
the child.
Assessment Nursing Goal Planning Implementation Evaluation
Diagnosis

Subjective Ineffective Child will  Vital signs is to  Vital signs

Data: tissue be able to be checked & are checked Child will
Mother perfusion demonstrate recorded and recorded be able to
says that related to adequate  Pulse oximetry  Pulse demonstrate
my child is inadequate tissue and ABG oximetry and adequate
sometimes cardiac perfusion. analysis is to be ABG tissue
bluish function or done analysis is perfusion.
coloured cardiac  Vesodilators are checked
surgery as to be  Vesodilator’s
Objective evidenced administered as Is given as
Data: by cyanosis, per doctor’s per doctor’s
capillary Prolonged advice to advice
refill is capillary increase cardiac Hb level is
checked refill. output monitored to
and that is  Hb is to detect any
prolonged. monitored to blood loss
detect blood  Oxygen is
loss given as per
 Oxygen is to be doctor’s
given as per advice
doctor’s advice  Propped up
 Propped up position is
position is to be given.
given.
Assessment Nursing Goal Planning Implementation Evaluation
Diagnosis

Subjective To reduce  Vital signs is to  Vital signs

Data: Risk for the infection be checked & are checked Chances of
child’s infection recorded and recorded infection is
mother says related to  Cold sponging  Cold reduced to
my child is bacterial is to be given sponging is some
suffering vegetation  Cool and calmy given extent.
from high in the endo environment is  Antipyretics
grade fever Cardiam to be provided are given as
for last 10- layer of the  Antipyretics is per doctor’s
15 days. heart as to be given as advice
evidenced per doctor’s  Antibiotics is
Objective by history of advice given as per
data: high grade  Antibiotics is to doctor’s
checking fever be given as per advice
the doctor’s advice  Cool and
temperature calmy
of the child. environment
is provided.

Nursing
Assessment Diagnosis Goal Planning Implementation Evaluation
 Risk for
Subjective delayed Child will  Adequate  Adequate
Data: growth and be calorie diet is to calorie diet is Evidence of
My child’s development appropriate be given given cognitive &
weight is Related to for  Age appropriate  Age motor
decresed effect of development developmental appropriate function
from cardiac appropriate activity is to be is provided within
previous. disease and for age. provided  Time is normal
Necessary  Time is to be scheduled limits.
Objective treatment, scheduled for for regular
Data: inadequate regular activities of
checking nutrition and activities of the the child
the body separation child  Weight is
weight of from  Weight is to be checked &
the child caregivers. checked recorded.

Identification Data :
Name- Baby sk. Alamin
Age-5 yrs.
Sex-male
Developmental age- pre- school children.
Id No-20190002
ward- MC HUB 2nd floor.
DOA – 26/11/23
Address – karimpur, murshidabad.
Diagnosis – infective endocarditis
Name of Surgery – not done yet
Date of surgery – not done yet
Under Doctor – unit C doctor
Chief Complain
on Admission – high grade fever for 10-15 days.

At present – fever is sometimes come, loss of apetite, failure to thrieve.

History of present illness- High grade fever is comes frequent times in a day and relieved by taking
antipyretics.

Past medical History – congenital cardiac lesions VSD present, convulsion present from 6 months of age.

Past surgical History- VSD closure done on august 2023.

Family History -
Type of family- joint family
Any illness presents in family – nothing significant.
Family genogram:
Socioeconomic History:
Drinking Water- tap water
Housing Condition- pacca
Household water-tap water.
Ventilation -cross ventilation present.
Total monthly income-20.000/- ( approx.)
Personal History -
Allergy- not significant (food, drug)
Addiction-nothing significant.
Drug- nothing significant.
Occupation – pre-school children.
Education – pre school.
Elimination-normal
Hygiene-maintained
Sleep and rest-adequate.

Birth history –
Mother:
 Antenatal period:-
Age of pregnancy-5 yrs.
Birth order-1st
No of antenatal visit-4
TT taken or not- taken 2 dose
 Iron folic acid tablet taken or not- taken
No of USG- 2 times.
 Intranatal period-
Mode of delivery- normal vaginal delievery.
 Postnatal period-
Any abnormalities- no abnormalities.
Baby:
 Date of birth -02/03/18
 Time of delivery – 10.30 am
 Mode of delivery – normal vaginal delievery.
 Birth injury – not identified
 Congenital anomalies – not present
 Birth weight –2.5 kg
 Breast feeding-yes

Dietary history: child not take adequate diet because of disease.

Immunization history:
Age vaccine dose route remarks
5yrs DPT Booster 2 0.5ml I/M Fever comes after
giving vaccine

Developmental history:

Growth:
Anthropometric measurement -
o Head circumference – 50cm
o Chest circumference – 63cm
o Mid arm circumference -19 cm.
o Height / Length -112 cm
o Weight-5 kg.
o BMI –12.8
o Dentition-20 number of teeth present.

Developmental milestone:
Book picture
Gross motor: standing on 1 foot for upto 5 secs,
climbing up & down with alternating feet.
Fine motor: Drawing is more accurate, using
preferred hand for more activities, tie shoes, use
scissors & simple tools.
Sensory development: speaks in sentences of 5 or
more words,knows telephone number, has
improved math skill, has group of friends.
Patient picture
Gross motor: climbing up stairs with alternative
feet. Walk backward heel to toe, throws and cathes
ball
Fine motor: copies a squre, triangle & diamond
shape, ties shoes laces.
Sensory development: accurately describes events,
speak sentences of 5 or more words.
 Language development: can speak longer
sentences, and will start asking lots of WHO,
WHAT& WHY.
Play stimulation: associative play
Social development: play is associative, try to
follow rules but may cheat to avoid losing, very
industrious. look for parenteral support &
encouragement.
Cognitive development: accurately describes
events, classify objects according to relationship
that are similar, time orientation present.
Language development: can speak sentences. And
frequent questioning done
Play stimulation: play with group of friends
Social development: try to follow rules of parents.
Looks for parenteral support.
Cognitive development: Accurately describes
events. Time orientation present.

Physical Examination-
 General appearance:

Body Build -
Nutrition-not adequate
Emotional state – normal
Level of consciousness- alert
Activity- less active.
Vital signs:
Temperature- 101 degree celcius
Pulse- 130 b/min
Respiration-25 breaths/ min
Blood pressure- 110/60 mm of hg.
Reflexes:
Head to foot examination:
Head:
scalp- clean
hair-normal
face: shape- round shape
Ear:
Discharge- no discharge
Hearing acuity- normal
Position- symetrical
Eyes:
Eye brow-symmetrical
Eye lashes-normal
Eye lids-normal
sclera-normal
conjunctiva- normal
pupil-dilated
Nose:
Patency-patent
Flaring-not flaring
Polyp-no
Septum-deviated
Discharge-no discharge

 Central Nervous system:

Level of Conscious -alert
Oriented to -time, place, person
Time - yes
Place-yes
Person-yes
Speech -normal
 Respiratory system:
Respiration rate- 25brreaths/ min
Respiration rhythm- regular
Chest movement -rapidly
Air entry -bilateral
Breath sound -murmur & crackles present
Cough -present
Chest pain -not present

 Cardiovascular System:
Pulse-130beats/min
BP-110/60 mm of hg
Chest pain-not present
pace maker-not present
Heart Sound-murmur present
Peripheral pulse-present
  Gastrointestinal System:
Mouth - clean
Teeth -20 teeth present, delayed dentition
Tongue- white patches present
Oral ulcer-not present
Constipation -yes
Abdominal distension -not present
Peristalsis -present
Nausea -not present
Vomiting-not present
Bowel opened on – 30/11/23
Diarrhoea -not present
Melena – not present

 Genito-urinary system:
Testes- normal
Anus-normal
Any other abnormality- not present
Voids freely catheter – voids freely
Urine Colour -straw
Haematuria –occult blood is present in urine routine examination
 Skin:
Intact-yes
Rashes-not present
Hydration status-dehydrated
Braden score-normal range

 Musculoskeletal -system:
Ambulant bed to chair /Bedridden- ambulant
Muscle strength-normal
Continuity of spine-normal
Any deviation-not present.