5 years child as deficiency of protein with an in adequate of calories, he has a

symptoms of thin, wasted extremities, prominent abdominal edema with severe

muscular atrophy, impaired immune response and susceptibility to infections,
night blindness, changes in behavior, defective wound healing and impaired
growth. Identify the condition of the child, enumerate the clinical, diagnostic
and therapeutic features and what are the steps taken to avoid the risk factors.
Ans)
Kwashiorkor
It is a type of Malnutrition characterized by severe protein deficiency.
Risk factors
 Low intake of caloric diet.
 Lack of cognitive and moral development
 Reduced absorption of macro and micro nutrients.
 Absence of exclusive breast feeding
 Low BMI of mothers.
 Cultural, psychological factors
 Environmental stresses.
 Infectious outbreak of measles and dysentery.
Signs and symptoms
 Thin, wasted extremities
 Prominent abdominal edema called as ascites
 Severe muscular atrophy
 The skin is scaly and dry and has areas of dyspigmentation
 Permanent blindness results from severe lack of vitamin A
 Skin rashes
 Hair is Thin, dry, coarse, and dull
 Impaired immune response
 Changes in affective behavior
 Defective wound healing
 Impaired growth
 Loss of hair
 Falg sign
 Muscle wasting
 Hypoalbuminemia
 Fatty liver
 Apathy irritability.
  Moon face
 Nail plates are thin and soft and may be fissured and ridged.
Diagnostic findings
 Physical examination
 History collection
 Anthropometric measurement reveals reduced weight for age, weight for
height and height for age.
 Peripheral blood film shows microcytic or macrocytic RBC’S
 Stool examination for presence of ova and parasites.
 Blood hematology and biochemistry include
a. Blood glucose estimation
b. Serum albumin estimation
c. Blood hemoglobin
d. Serum electrolytes estimation it reveals hypokalemia,
hypomagnesemia, hypocalcemia and hypernatremia
 Blood PH
 Urine examination shows decreased urinary excretion of hydroxy proline
it impaired wound healing.
Management
It can be divided into two phases
1. Initial phase
2. Rehabilitation phase
Initial phase (1-2 weeks)
 Treatment of complications such as hypoglycemia, hypothermia,
infections, electrolyte imbalances, dehydration.
 Correction of nutritional deficiencies should be administered 50000 IU of
vitamin A, 1 lakh to 2 lakh IU for infants below 6months, 6-12 months
and children above 1 year of age.
 Vitamin k must be given at intramuscularly in a single dose of 2.5 mg.
 Reversal of metabolic abnormalities such as return of appetite,
disappearance of hepatosplenomegaly, gain in body weight, absence of
edema, rising serum albumin levels.
 Administered Inj. Amoxycillin150 mg TID, Inj. Gentamycin 80mg/24
hours/ IV, Zinc 20 mg OD, Multivitamin without Ferum 1 tea spoon /day.
Paracetamol syrup 3 teaspoon, Resomal 50 cc when child has dairrhoea.
  For moderate to severe dehydration and shock, intravenous fluids are
given. Initially Ringer lactate or NS/ 2 saline is given in dose of 30 ml/ kg
body weight in 2 hours, followed by NS/ 6 saline in dextrose in a dose of
100 ml/ kg body weight, in next 10 hours.
Rehabilitative phase (2-6 weeks)
 Recovery of lost weight
 Emotional and physical stimulation to the child
 Training the mother for domiciliary care
 Preparation for discharge.
 Give therapeutic diet must be at 175- 200 kcal/kg/ day, 4-5 gm protein /
kg/ day and 150 ml fluid/ kg/ day.
 Adequacy of diet intake is determined if the rate of weight gain is 10- 20
mg/ kg/ day.
 Human contact, emotional support, and tender loving care are important
during this phase.

2) A 66 years old asthmatic man, had a 3-day history of worsening cough,

wheeze and shortness of breath that was not relived by his salbutamol inhaler.
He had purulent sputum but neither fever, chest pain nor haemoptysis. but had
never required admission to intensive care. His other comorbidities were atrial
fibrillation and a deep vein thrombosis many years earlier. He had never
smoked. He was a retired accountant. He took warfarin in addition to his
salbutamol. On examination, he was able to complete sentences, but was using
accessory muscles to aid respiration. He had a respiratory rate of 23 breaths/
min and required 2L/ min of oxygen by nasal cannula to saturate at 94%. His
heart rate is 104 bpm and he was normotensive. Auscultation of the chest
revealed a bilateral polyphonic wheeze. The remainer of the examination was
normal. Identify the disease condition based upon the signs and symptoms he
had, what are the further investigations and steps has to be taken to prevent his
Risk factors.
Ans) Acute exacerbation of asthma
Acute exacerbation as episodes of progressive increase in shortness of breath,
cough, wheezing, or chest tightness, or some combination of these symptoms,
accompanied by decrease in expiratory airflow that can be quantified by
measurement of lung function.
Risk factors
 Bacterial infections
 Allergies
 Defective antiviral immunity
 Allergen exposure
 Pollutants, such as tobacco smoke and particular matter.
 Occupational exposures.
Signs and symptoms
 Breathlessness
 Coughing
 Wheezing
 Chest tightness
 Agitation
 Increased respiratory rate
 Increased pulse rate
 Decreased lung function
Measurement of lung function
1. Forced expiratory volume
2. Peak respiratory flow
3. Partial pressure of oxygen
4. Partial pressure of carbon dioxide
5. Arterial oxygen saturation
Diagnosis
1) History collection ;- including allergic disorders in the family, presenting
complaints, precipitating factors, duration of signs and symptoms
persists.
2) Physical examination ;-
respiratory rate > 2SD for age.
Too breathless to talk or take feed
Use of accessory muscles for respiration
Pulsus paradoxus >15 mm Hg
Heart rate > 140 beats / min
3) Chest X- Ray ;- Identifying lung volume and edema in the lung
parenchyma. Shows bilateral and symmetrical air tapping in the lungs.
4) Spirometry ;- measures how fast the he can breath out and how much we
can hold.
 5) Peak how test ;- breath out after how much air can hold it is hand held
device that measures how fast.
6) Pulmonary function test ;- check peak expiratory flow rate ( PEFR),
FEVand FVC. These all parameters are decreased.
7) Allergy test
8) Skin test or RAST ( radio allegro sorbent allergen specific IgE) help in
identify the causative agent.
Nurse’s responsibility;
Pharmacological aspects
 Magnesium sulfate , intravenous treatment has to provide
bronchodilation effect in addition to other treatments in severe acute
asthmatic attacks.
 Short acting beta adrenoceptor agonists such as salbutamol are
administer as a metered dose inhaler.
 Anticholinergics such as ipratropium bromide can administered in
case of if the person has severe symptoms, cannot tolerate with SABA.
 Bronchodilators such as theophylline BD to soothing of secretions.
Non pharmacological aspects
1) Evaluate the respiratory status and facilitate breathing
Monitor the child respiratory function. Observe the child for cyanosis.
Administer oxygen, to alleviate hypoxia if saturation is falls below 92%
Heliox, a mixture of helium and oxygen, may also be considered in severe
unresponsive cases can be placed in oxygen hood or in nasal cannula.
2) Administer adequate fluids and maintain intake and out put chart,
child have fluid and electrolyte imbalance due to decrease intake of
fluids, increased respiratory effort and insensible loss due to
hyperventilation and perspiration.
3) Provide rest and comfort by the child head should be raised with pillows
as this position helps in breathing. If the child feels more comfortable in leaning
forward, provide cardiac table and pillow to the child.
4) Providing the emotional support and education by addressing the child
calmly, quietly.
5) Teach the child and his parents about the use of metered inhalers and
spacers.
12-year-old boy, was admitted to the emergency department of Chittoor
government Hospital, with acute colicky periumbilical abdominal pain not
referred to other sites, vomiting and constipation for 3 days.
On physical examination
He had pallor and appeared poorly nourished.
His oral temperature was 37.5 °C, and blood pressure was 100/60 mmHg. Pulse
was regular with a rate of 120 beats per minute, and respiratory rate was 35
breaths per minute.
Respiratory examination
Bilateral air entry with no added sounds but slight respiratory effort.
Cardiovascular examination
normal S1 and S2 with no murmur,
central nervous system examination
No neurological deficits.
Abdominal examination
abdominal tenderness and rigidity in the central and mid-abdomen. There was
no organomegaly. Auscultation revealed a silent abdomen or minimal
peristalsis.
At the time of admission, laboratory investigations were done. The red blood
cell count was 3.4 to 3.8 × 106/µL, and haemoglobin level was 10 g/100 mL.
They usually ate vegetables from the field without washing. The boy had a
history of pica. As the patient’s mother gave a history of expulsion of one very
big worm from the ear shortly before coming to the hospital. Moreover, there
were repeated attacks of vague abdominal pain, colic and some attacks of
diarrhoea. Let brief discuss about the condition of the boy, signs and symptoms,
risk factors and management of the symptoms and role of nurse’s
responsibilities.
A) Ascaris lumbricoides is the largest nematode round worm parasitizing the
human intestines .It is most common helminthic infection.
Causative agent, Mode of transmission
Common name : Intestinal round worm
Disease :Ascariasis
 Route of Entry :Through direct contact, contaminated drinking
water ,Vegetables grown in fields of manured with human feces (Night soil )
Host : Human intestine
Infective stage :Infective rhabditiform larva
Morphology :
It is a elongated ,cylindrical and tapering at both ends
Genders are separate they have a digestive tract and reproductive
organs .

Risk factors :

 Poor socio economic conditions

 Use of human feces as fertilizer
 Lack of hand washing
 Eating unwashed Fruits and vegetable
 Environmental contamination with feces
 History of pica in children’s
Who is at Risk :
 Pre school and School age children’s
 Women of child bearing age including 2nd and 3rd trimesters and Lactating
mothers
 Adults in occupation’s where there is a high risk of infection .
Signs and Symptoms :
1. Abdominal pain , tenderness ,bloating ,abdominal mass rigidity ,
jaundice, crackles , wheezes.
2. Diarrhoea ,vomiting presence of worms .
3. Slight raise in temperature, cough and Bloody sputum and wheezing .
4. It blocks intestines and Appendix .
5. They may enter into bile or Pancreatic duct and interferes with digestion .
6. Loss of appetite ,weight loss ,small bowel obstruction .
 7. Malabsorption of nutrition ,growth retardation .
8. Heavy worms in children leads to intussusception and total obstruction .
Complications :
 Intestinal obstruction
 Appendicitis
 Biliary ascariasis
 Obstructive jaundices
 Perforation of intestines
 Cholecystitis
 Pancreatitis
 Peritonitis
Diagnostic findings :
 History collection revealed that Socio economic status, Personal history,
Dietary pattern and hygienic needs of the child
 Physical examination revealed that pallor skin and poorly nourished
 On Abdominal examination tenderness and rigidity in the central and
mid-abdomen , Auscultation revealed a silent abdomen or minimal
peristalsis.
 Microscopic examination of sputum , stool for detection of presence of
eggs.
 Blood investigations like CBC,WBC ,RBC and Platelet count.
 Ultra sound Abdomen reveals that Tubular structure with well defined
echogenic walls with curling movements called ‘railway track sign’
 X-Rays shows air fluid levels and shadow of round worms with a
‘whirlpool’ image .
 CT Scan can be visualized that bowel lumen and soft tissues .
 Skin biopsy
 Endoscopic retrograde cholangio pancreatography (ERCP) can be used
for diagnosis and treatment.
 Serological testis helpful in extra intestinal ascarisis like loeffler’s
syndrome such as indirect hemagglutination (IHA),immuno fluorescence
anti body (IFA), enzyme linked immunosorbent assay (ELISA).
Management :
Medical Management :
It is treated with Tab. Albendazole 400 mg orally once in a week or yearly
once . It should be taken with food .
Tab .Mebendazole 100 mg orally twice in a day for 3 days or 500 mg orally
once
Tab. Ivermectin 150 -200 mcg /kg orally once in a day ,it should be taken on
empty stomach .
Surgical management
 Laparotomy for enterotomy for the extraction of worms.
 If necrosis is found, they may need resection and re anastomosis.
 Illeal perforation peritonitis associated with Ascaris lumbricoides
infestation.
Nurse’s Responsibilities :
 Explain about child condition and treatment regimen to the family
members .
 Monitor vital signs such as Tachy cardia ,skin changes and Temperature.
 Assessment of the child include history ,physical examination and general
symptoms include fever, jaundice, urticaria.
 Pulmonary symptoms include Wheezing ,rales , diminished breath
sounds.
 GI symptoms include nausea and Vomiting.
 Maintain fluid and electrolyte balance related to fluid loss secondary to
diarrohea.
 Monitor intake and out put and observe the signs of dehydration . To give
oral Rehydration solution to assist in adequate hydration levels.
 Assess the level of pain and impaired sense of comfort related to smooth
muscle spasm secondary to migration of parasites in the stomach.
 Provide adequate nutritional diet to the child by measuring the body
weight every day explain the importance of adequate nutrition and
maintain good personal hygiene.
 Perioperative teaching given to the family members if the child is plan for
surgical theraphy.
Prevention :
 Mass media education on improved sanitation and avoidance of human
feces as fertilizer are critical.
 A programme of mass treatment in highly endemic areas has been
suggested .
 Improved personal hygiene among people who handle food is an
important aspects of control.
 Educate the child to avoid contact with soil that may contaminated with
human feces .
 Wash the hands with soap and warm water before handling food.
 Teach children the importance of handwashing to prevent infection .
 Wash ,peel ,or cook all raw vegetables and fruits before eating .
 Not defecating out doors and by effective sewage disposal system.