CASE PRESENTATION ON RHEUMATIC HEART DISEASE

1. Patient Bio-Data

 Name - Roshani
 Age - 10 years
 Sex - Female
 Religion - Hindu
 Father’s name - Mr. Ramesh Kumar
 Occupation - shopkeeper
 Education - 12th
 Mother’s name - Mrs. Jyoti
 Occupation - House wife
 Education - none
 Date of admission - 11/07/2018
 Informant - mother
 Diagnosis - Rheumatic heart disease
 Surgery (if any) - none
 Consultant - Dr. M. Kumar

2. Presenting complaints (complaints given by mother)-: patient is admitted in the hospital with the complain of;

1. Abdominal distension since 1 months which gradually involve lower limb and whole body pain in 2-3
days
2. Dry cough since 1 month (cough increase on sleeping)
3. Breathlessness since 15 days

2. History of present illness:

The baby was admitted in the pediatric medicine ward on 7/10/19 with the complaints of abdominal distension gradually involve
lower limb and whole body pain, dry cough and breathlessness. After history taking, physical assessment and investigations, the child
is diagnosed as rheumatic heart disease.

a) Approximately time of onset:

1. Abdominal distension since 1 months which gradually involve lower limb and whole body pain in 2-3
days
2. Dry cough since 1 month (cough increase on sleeping)
3. Breathlessness since 15 days

b) Mode of onset:
1. Abdominal distension since 1 months which gradually involve lower limb and whole body pain in 2-3
days
2. Dry cough since 1 month (cough increase on sleeping)
3. Breathlessness since 15 days
c) Sequential history of appearance of complaints:
1. Abdominal distension since 1 months which gradually involve lower limb and whole body pain in 2-3
days
2. Dry cough since 1 month (cough increase on sleeping)
3. Breathlessness since 15 days

d) Therapy /treatment received so far:

S.no Drug name Dose Route Frequency Action

.
1. Inj. Ceftriaxone 12 ml IV BD Antibiotic
2. Inj. Dobutamine in IV fluid 10 ml IV BD Inotropic agent
3. Tab. Digoxin 0.25mg PO BD Cardiac agent (increase
contractility of heart muscles)
4. Inj . Metrogyl 85 ml IV TDS Antibiotic
5. Tab. Lasix 20 mg PO BD Diuretics
 6. Tab. Omnacortil 60 mg PO TDS Corticosteroid

4. Past history: The child has no any significant past medical or surgical history.

Birth history

a. Antenatal history
-mother taking adequate nutrition at the time of pregnancy: yes
-registered in the health facility: yes
-consuming iron and folic acid: yes
-regular antenatal checkups: yes (total 3 antenatal visits has been attended by mother)
- T.T vaccination: 2 doses has been taken
- Any complication to the mother: none

b. Natal history

 Type of delivery: full term vaginal delivery

 Baby cried/ not cried at birth- yes baby cried soon after birth
 Instrumental delivery (where)- nil
 Place of delivery- District Hospital, Faizabad
 weight of the child at birth– 2.7 kg

c. Postnatal history

-Condition of the baby: Normal

-history of any infections (PPH or any other problems): nothing significant

5. Personal History
 A) Personal hygiene of the child – Personal hygiene of the child is maintained by mother and health care worker.
B) Response of child towards illness – The child was irritated
C) Response of parents to child’s illness – worried about their daughter’s condition.

6. Family history:

- History of contact illness (TB/HIV): No

- History of similar ailment in the family: Not present
- History of consanguinity: no
- Birth order: Third
- Number of siblings: two
- Illness: Other family members are healthy
- Any death in the family: no

7. Socio-economic history:

-nuclear/joint family: Nuclear family

-Who look after child – the mother and health workers looks after the child

-Housing condition: pucca

-Overcrowding: Not present

-rural/urban: Rural

-Water source (drinking): Hand pump

-smoking among family members: Father

-Schooling of the child: yes she was going to the school before illness.

8. Nutritional history:
-Breastfeed/top feeds/mixed mode of feeding: The child is getting normal diet.

9. Immunization: the child has immunized at proper time. She got all the vaccines as per immunization per schedule till now.

Any known allergies- no

Blood transfusion till date (if any): no

PHYSICAL EXAMINATION

1. General examination:
 General condition: poor
 Decubitus- not present
 Pallor - Not present
 Icterus- Not present
 Cynosis- present
 Edema- pitting edema present
 Clubbing of nails- Not present

VITAL SIGNS

Temperature - 36.5° C
Pulse - 90 beats/ min
Respiratory rate – 20 breaths/ min
Blood pressure - 90/70 mm.Hg

Anthropometric measurement:

Height /length : 130 cm

Weight : 25kg

Head circumference : 52cm

 Chest circumference: 63cm

Abdominal circumference : 60cm

Mid upper arm circumference: 13.5cm

Condition of skin: petechiae, redness, bruises (special areas), scratches, blunt injury, open wound are absent in the patient.

Head: normal head circumference

Condition of hairs:

a. Color - Black
b. Flag signs- absent
c. Dryness- absent
d. Pediculosis - absent
e. Dandruff - absent
f. Split ends- not present

Head shape: round

Fontanelles: closed

Cranial sutures: Normal

Characteristics of faces:

Eyes: no redness or discharge present

Ear: normal in position

Neck: trachea is in midline.

Condition of nails: color is pinkish

 Head & face: normal

2. Systematic circumference

a. Respiratory system
Respiratory rate - 18breaths/ min
Use of accessory muscles- yes
Type of breathing - abnormal
Movement/ symmetry -symmetry
Chest wall deformity - absent
Neck vein distension - absent
Trachea midline - present
Air entry - clear
Chest indrawing - absent

b. Cardiovascular system
Apex beat -98beats/min
Any murmur - present
Any other sounds - S1, S2 present

c. Abdomen
 Shape - cylindrical
 Prominent veins - absent
 Visible peristalsis - Not present
 Bowel sounds audible - clear
 Distension - present
 Abdominal wall rigidity/ guarding – absent
d. Musculoskeletal
 Joints: range of motion of joints is limited due to pain
 e. Gastro nervous system:
Stool color and character: Normal
Diarrhea : absent
Constipation : Not present
Vomiting : Not present
Hematemesis : Not present
Jaundice : Not present
Abdominal pain: present
Colic : Absent
Appetite : present

f. Central nervous system

Appearance - the patient looks oriented
Posture - normal
Gait - walk with support
State of sensorium – patient is oriented
Meningeal irritation -Not present
Abnormal movements - absent
Sensory -sensation to touch and pain is present

GROWTH & DEVELOPMENT ASSESSMENT

Growth & development assessment (as per the patient’s age group)-physical , psychological, social and moral development of the
patient is according their age group is not present due to the disease condition.

Neuromascular system

Cry – cry prsent in the patient

 Flexion of extremities- present

Extension of extremities – present

Myoclomic jerks_ absent

Nutritional assessment: -

BMI of the patient =weight in kg/(height in cm)2

=25/130*130=0.0014792 the patient is mild malnourished
INVESTIGATIONS

Routine investigation:

s. Investigations Patient value Normal value Remarks

no.

1. HAEMATOLOGY
Complete blood count
Haemoglobin 10.4 g/dl 11.5-15.5 Decreased
Total lecocyte count(TLC) 13700 cells/mm3 4000-11000 Increased
Differential./. leucocyte count
Neutrophils 70% 40-80
Lymphocytes 25% 20-40
Esinophills 02% 1-6
Monocyte 03% 1.0-5.0
Basophills 00% 0.0-2.0
Platelet counts 4.37 mill.cells/mm3 1.5-4.5
MPV 9.41 fl. 7.4-10.4
Total RBCs 4.37 million cells/ml 4.5-5.5
MCV (mean cell volume) 86.7 fl. 80-100
MCH(mean corpus. Haemoglobin) 23.7 pg 27-32
MCHC(mean corpus. Hb. Conc.) 27.4 g/dl 32-35
RDW 22.1% 11.5-14.5
HCT(hematocrit) 37.9% 40-50
PCT 0.115 % 0.10-0.28
PDW 22.5 % 10-17

2. BIOCHEMISTRY
KIDNEY PANEL
Serum urea 58.1 mg/dl 10-45
Serum creatinine 0.85mg/dl 0.5-1.4
ELECTROLYTE
Serum sodium 140.0 mg/dl 135-145
 Serum potassium 4.50 mmol/l 3.5-5.3
Serum ionic calcium 5.09 m 4.5-5.5

3. COAGULATIION
P-TIME (PROTHROMBIN TIME)
(PROTHROMBIN TIME) test 11-9 sec
(PROTHROMBIN TIME) INR 1.4 sec
APTT
APTT-test 37.9 sec

4. LIVER FUNCTION TEST

Bilirubin, total 3.58mg/dl 0.3-1.4 Increased
Bilirubin, direct 2.27 mg/dl 0-0.4
81.3 IU/L 0-40
74.5 IU/L 0-40
Alkaline phosphatase 281.3 IU/L 50-270 Increased
5. URINE EXAMINATION ROUTINE
Physical Examination
Color Yellow
Appearance SL Cloudy
Specific gravity 1.015
Ph 5.0
Proteins +-10 mg/dl
Glucose -neg
Ketones -neg
Nitrate -neg
Bilirubin -neg
Urobilinogen + 1.0 mg/dl
Microscopic Examination
R.B.C. 4-5RBC/hpf
Pus cells 2-3/HPF
Epithelial cells 1-2/HPF
6. CRP 89.4 mg/L 0-6
Special investigations: MRI/ CT Scan/Biopsy/FNAC/CSF/Histo pathological have not done. The ECG suggest that is prolonged PR
interval present. The ECHO suggest that there is mild mitral regurgitation present

ANATOMY OF HEART

The heart is the organ that helps supply blood and oxygen to all parts of the body. It is divided by a partition or septum into two
halves, and the halves are in turn divided into four chambers. The heart is situated within the chest cavity and surrounded by a fluid
filled sac called the pericardium. This amazing muscle produces electrical impulses that cause the heart to contract, pumping blood
throughout the body. The heart and the circulatory system together form the cardiovascular system.
Chambers

 Atria - upper two chambers of the heart i.e. right atrium and left atrium
 Ventricles - lower two chambers of the heart i.e. right ventricle and left ventricle.

Heart Wall

The heart wall consists of three layers:

 Epicardium - the outer layer of the wall of the heart.

 Myocardium - the muscular middle layer of the wall of the heart.
 Endocardium - the inner layer of the heart.

Cardiac Conduction

Cardiac Conduction is the rate at which the heart conducts electrical impulses. Heart nodesand nerve fibers play an important role in
causing the heart to contract.

 Atrioventricular Bundle - bundle of fibers that carry cardiac impulses.

 Atrioventricular Node - a section of nodal tissue that delays and relays cardiac impulses.
 Purkinje Fibers - fiber branches that extend from the atrioventricular bundle.
 Sinoatrial Node - a section of nodal tissue that sets the rate of contraction for the heart.

Cardiac Cycle

The Cardiac Cycle is the sequence of events that occurs when the heart beats. Below are the two phases of the cardiac cycle:

 Diastole Phase - the heart ventricles are relaxed and the heart fills with blood.
 Systole Phase - the ventricles contract and pump blood to the arteries.

Heart Anatomy: Valves

Heart valves are flap-like structures that allow blood to flow in one direction. Below are the four valves of the heart:

 Aortic Valve - prevents the back flow of blood as it is pumped from the left ventricle to the aorta.
 Mitral Valve - prevents the back flow of blood as it is pumped from the left atrium to the left ventricle.
 Pulmonary Valve - prevents the back flow of blood as it is pumped from the right ventricle to the pulmonary artery.
 Tricuspid Valve - prevents the back flow of blood as it is pumped from the right atrium to the right ventricle.

Arteries:

 Aorta - the largest artery in the body of which most major arteries branch off from.
 Brachiocephalic Artery - carries oxygenated blood from the aorta to the head, neck and arm regions of the body.
 Carotid Arteries - supply oxygenated blood to the head and neck regions of the body.
 Common iliac Arteries - carry oxygenated blood from the abdominal aorta to the legs and feet.
 Coronary Arteries - carry oxygenated and nutrient filled blood to the heart muscle.
 Pulmonary Artery - carries de-oxygenated blood from the right ventricle to the lungs.
 Subclavian Arteries - supply oxygenated blood to the arms.

Veins:

 Brachiocephalic Veins - two large veins that join to form the superior vena cava.
 Common iliac Veins - veins that join to form the inferior vena cava.
 Pulmonary Veins - transport oxygenated blood from the lungs to the heart.
 Venae Cavae - transport de-oxygenated blood from various regions of the body to the heart

DISEASE CONDITION

INTRODUCTION

Rheumatic fever is a diffuse inflammatory disease characterized by a delayed response to an infection by group A beta-hemolytic
streptococci (GAS) in the tonsilopharyngeal area, affecting the heart, joints, central nervous system, skin and subcutaneous tissues.
DEFINITION

 Rheumatic heart disease is a chronic condition resulting from rheumatic fever which involves all the layers of the heart and is
characterized by scarring and deformity of the heart valves.
 The commonest valves affecting are the mitral, aortic and tricuspid valves are affected.

INCIDENCE

 Rheumatic fever is principally a disease of childhood, with a median age of 10 years, although it also occurs in adults (20% of
cases).

 Rheumatic fever occurs in equal numbers in males and females, but the prognosis is worse for females than for males.

 The disease is seen more commonly in poor socio-economic strata of the society living in damp and overcrowded place.

ETIOLOGY

 Group A beta-hemolytic streptococcus.

 Rheumatic fever

RISK FACTORS

 Poor socio-economic status

 Over-crowding
 Age (5 to 15 years)
 Climate and season ( rainy season and in the cold climate)
  Upper respiratory tract infection ( group A beta- hemolytic streptococcus)
PATHOPHYSIOLOGY

Causative agent (Group A Beta-hemolytic streptococci)

Untreated Sore throat

Rheumatic fever

All layers of the heart and the mitral valve become inflamed

Vegetation forms

Valvular regurgitations and stenosis

Heart failure

CLINICAL MANIFESTATIONS

s.no Book ’s picture Patient’s picture Inference

.
I.  Polyarthritis Absent Present since 1 month
 Carditis Present
 Subcutaneous nodules Absent
 Erythema marginatum Absent
 Sydenham’s chorea Absent
 II.  Chest pain Present Present since 15 days
 Heart palpitations Absent
 Breathlessness on exertion Present
 Breathing problems when lying Absent
down (orthopnoea)
 Waking from sleep with the Absent
need to sit or stand up
(paroxysmal nocturnal
dyspnoea)
 Swelling (oedema)
Present
 Fainting (syncope)
Absent
 Stroke
Absent
 Fever associated with infection Absent
of damaged heart

DIAGNOSTIC EVALUATION

S. Patient picture Book picture Inference

no
.
Diagnosis may include:
1. Physical examination – while a Done Murmur sound resent
heart murmur may suggest
RHD, many patients with RHD do
not have a murmur
2. Medical history – including Done Present
evidence of past ARF or strep
infection
3. Chest x-ray – to check for Done Swelling present
enlargement of the heart or fluid on
the lungs
4. Electrocardiogram (ECG) – to Done Prolonged PR interval present
 check if the chambers of the heart
have enlarged or if there is an
abnormal heart rhythm (arrhythmia)
5. Echocardiogram – to check the Done
heart valves for any damage or It suggest that right atrium and
infection and assessing if there is ventricle dilated and mild mitral
heart failure. This is the most useful regurgitation present
test for finding out if RHD is present.
6. Other test
• High ESR Done Increased
• Anemia, leucocytosis
• Elevated C-reactive protien

CARDIAC PROBLEMS AND ITS MANAGEMENT

IN BOOK

1.Mitral regurgitation

It results in systolic leak of blood to left atrium, which passes back into the ventricles on diastole. The blood flowing out of the
ventricles becomes insufficient duing exertion. This reduction in systemic output results in fatigue.

Treatment

 The medical management consist of using digitalis, diuretics and vasodilators besides prophylactic penicillin for preventing
recurrence of rheumatic fever.
 In severe MR, mitral valve repair is indicated.

2.Mitral stenosis
It is less common than mitral regurgitation. It results in obstruction to the flow of blood across mitral valve, during left ventricular
diastole. The left atrium compensates for this obstruction by increasing its pressure. This increase in pressure results in hypertrophy of
left atrial wall.

Treatment

Medical management is digitalis and diuretics. Surgical management is closed mitral vavotomy. Also done mitral vavoplasty in few
patients, using a balloon catheter.

3.Aortic regurgitation

In this, the semi lunar cups of aortic valve are deformed and shortened, due to which aortic ring gets dilated. The defect leads to back
flow of blood aorta to left ventricles. Due to back flow, volume overload occurs in left ventricle leading to left ventricular
hypertrophy.

Treatment

Digitalis and vasodilators are commonly used.

4.Tricuspid regurgitation

It is associated with mitral stenosis and mitral regurgitation. There are no specific symptoms of tricuspid regurgitation. Specific
features of tricuspid regurgitation are:

 Prominent V waves in jugular venous pulse

 Systolic pulsation of liver
 Systolic murmur at lower left sterna border, increasing in intensity with inspiration

Treatment

The common drug used are digoxin and diuretics.

IN PATIENT
The patient was having condition of mitral regurgitation and she is getting the medical treatment such as tab. Digitalis, inj. Lasix. Tab.
Omnacortil etc

NURSING DIAGNOSIS

 Decreased cardiac output related to disturbance on the closure of the mitral valve as evidenced by altered hear rate.

 Ineffective tissue perfusion related to decrease in peripheral blood circulation as evidenced by impaired vital signs.

 Ineffective breathing pattern related to musculoskeletal fatigue as evidenced by irregular breathing patterns.

 Impaired body comfort related to pain as evidenced by verbalization of the patient.

 Activity intolerance related to pain in joints as evidenced limited activity of the patient.

 Fear & anxiety of parents related to baby’s disease conditions as evidenced by facial expression of parents.

 Knowledge deficit related to disease condition as evidenced by asking questions of parents of the baby.
s. Assessment Nursing Goal Implementation Rationale Evaluation
n Diagnosis
o.
1. Subjective data: Decreased To maintain Assess pulse, To obtain baseline After 24 hours
cardiac the normal respiration, blood pressure data of the nursing
Patient’s says that she output related cardiac regularly every 4 hours. intervention
is having to output  To assess the the patient was
breathlessness disturbance  Monitor the heart abnormal heart sounds able to meet
on the sounds. the goal
closure of the  To identify further partially.
mitral valve  complications
as evidenced  Assess changes in
by low blood skin color towards cyanosis
pressure. and pallor. To know the
 nutritional status of
Objective data: the patient

By checking the vital
signs it was found that  Monitor intake and
To prevent discomfort
blood pressure is output every 24 hours.
of the child
80/50 mm.hg 
 Limit activities of the To decrease the
patient adequately. anxiety of the patient

 Give psychological To make comfortable
support to the patient to the patient

  Provide calm and
quiet environment to the To facilitate blood
patient circulation in the body

Change the position of the

patient (semi fowler position)

s. Assessment Nursing Goal Implementation Rationale Evaluation

n diagnosis
o
3. Subjective data: Ineffective After the 24 Help in distinguishing The patient
Assess the rate, depth of
The patient breathing hours of normal breathing and partially meet
respirations & chest
complaints that she is pattern nursing apnea the goal
movement
having breathing related to intervention
difficulty musculoskele , the normal
tal fatigue as breathing
evidenced by pattern of Checked the vital signs of the To know the
irregular the patient baby i.e. temp-37.6°c. HR- fluctuations in vital
breathing will 96beats/min, R- parameters
patterns. establish 20breaths/min, Spo2-88%,
BP. 90/60 mm.Hg
Observe for cyanosis,
Objective data: dyspnea, hypoxia and To prevent worsening
The baby looks confusion of condition
restless and
respiratory rate is 16 Place patient in upright To obtain greater lung
breaths/min position expansion

Avoid high concentration of To prevent

oxygen to the patient at a complications of the
time patient
 To facilitate normal
Provided oxygen as indicated. breathing pattern

s. Assessment Nursing Goal Implementation Rationale Evaluation

n diagnosis
o.
4. Subjective data- Impaired To provide Assess the duration, site and To know the severity of The patient’s
The patient says that body comfort to intensity of pain of the pain pain is
she is having pain in comfort the patient patient partially
the body especially related to To decrease the pain of decreased.
joints pain as Provide range of motion the patient
evidenced exercise to the patient
by
Objective data- verbalizati Observe the patient for
I observed that ; there on of the complications such as To prevent further
is tenderness present patient. swelling on the joints and damage of the patient
on the joints erythema marginatum and
subcutaneous nodules

Provide complete bed rest to To prevent further

the patient complications of the
patient
Provide calm and quite
environment to the patient To provide rest to the
when she is sleeping patient
 To make comfortable to
the patient
Changed the position of the
patient frequently To decrease pain of the
patient
Administered analgesic drug
as per as doctor’s order

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
5. Subjective data- Activity To patient  Assess the patient's To determine the The patient is
Patient’s complaints intoleranc can work tolerance for activity using problems occurring able to perform
that she is having e related within the the following parameters: during performing some activities
difficulty during to pain in noted an increase in blood activities
limit of
performing activities joints as pressure, dyspnoea, chest
evidenced activities pain, severe fatigue,
limited with weakness, sweating,
activity of tolerance dizziness or fainting.
the  To prevent further
patient.  Increase breaks, complication of the
limit activity on the basis of patient
pain
Objective data-  To make comfortable to
I observed that the  Provide leisure the patient
patient is having activities that are not heavy.
fainting during  To prevent discomfort of
perform the the patient
 Limit visitors or
activities
visits by patients.
Helps to know the

  Assess readiness to problems during
increase activities eg performing activities
decrease weakness / fatigue,
stable blood pressure / pulse
rate, increased attention on
the activities and self-care. To increase the self
 esteem of the patient
 Promote activities of
self care to the patient To fulfill the need of
 selfcare
 Provide assistance as
needed (eating, bathing,
dressing, elimination)

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
2. Subjective data: Ineffective To maintain Monitor changes To know the effect on The patient
tissue normal suddenly or continuous the mental status of the maintains
Patient complaint perfusion circulation mental disorders (anxiety, patient optimum
that the she is related to confusion, lethargy, circulation
of the
having breathing decrease fainting). after 24 hours
difficulty in patient To know the changes in
 Observation of pale,
peripheral cyanosis and cold skin of skin of the patient
blood patient
circulation 
as  Assess Homan's sign To know the severity of
evidenced (pain in the calf with the disease in patient
Objective data: by dorsiflexion), erythema,
impaired edema.
I observed that the vital signs. 
patient looks restless  Encourage leg To maintain normal
exercises active / passive. circulation of the patient
 
 Monitor breathing To protect the child from
pattern of the patient dyspnea

 Assess GI function, To assess the nutritional
record anorexia, decreased status of the patient
bowel sounds, nausea / because adequate
vomiting, abdominal nutrition is essential for
distension, constipation. increase o2 concentration

 Monitor input and To prevent fluid overload
changes in urine output in the patient

s. Assessment Nursing Goal Implementation Rationale Evaluation

no. diagnosis
6. Subjective data: Fear & To reduced Recognized the parent’s To identify the needs of The parents
anxiety of the anxiety level of fear and anxiety the parents anxiety level is
The parents ask that parents level of the reduced
what happened to related to baby Orient the parents about the partially
her daughter. baby’s Helps to decrease the
environment and
disease anxiety level of parents
conditions equipments using on the
as child
Objective data: evidenced
I observed that the by facial Identified the needs of the Helps to prioritize their
parents looks expressio parents of the baby need
anxious about her n of
daughter parents Clarified their doubts about Helps to understand
their child’s condition parents about the
problems of the child
Provided psychological
To decrease the anxiety
 level
support to the patient and
family members
Helps to understand the
Educated the mother about condition of the child
the pattern of disease and
its complication To create some
awareness into the
Educated the mode of parents regarding the
transmission and spread of disease
the disease and its
prevention

HEALTH EDUCATION

Diet

 Asked the mother to provide healthy and nutritious diet to fulfill the feeding requirement of the baby.
 Educated the parents to provide balanced diet to the child which is rich in protein vitamins and minerals
 Educated the mother to avoid oily and spicy food which are harmful for the baby
 Educated her to use clean water for preparation of food and use clean utensils for making food.
 Educated the mother to do hand wash and also her child before and after eating food.

Exercise

 Educated the parents to provide range of motion exercise to the child frequently to prevent swelling on the joints.
 Educated the parents do not force the child to do strenuous activities eg. Heavy bucket lifting, running etc.

Personal hygiene
  Educated the parents about hand washing techniques and hand wash after going to the toilet.
 Educated the parents about importance of bathing, eye care, skin care etc.

Medication and follow-up

 Educated the parents about the importance of medication for the early recovery of the child.
 Asked her to weight the baby periodically to know the progress of the baby even after discharge.
 Educated the mother about signs of complication to the child occur, immediately go for the doctor.
 Educated the parents if the child is having fever again then immediately go for the doctor.

PROGRESS NOTE

DAY- 1ST – The patient admitted in the pediatric medicine ward with the complaints of whole body pain, breathlessness, abdominal
distension and dry cough . The child condition was poor at that time. The oxygen therapy and IV fluids was started immediately.
Blood sample had taken for the investigations. The vital signs also checked.

Pulse rate- 64beats/ min

Temperature - 100.2° F

Respiration - 18breaths/min

Spo2- 87%

To relieve patient we provide medication as prescribed by the doctor. After 5 hours of medication and nursing intervention patient’s
vital signs become normal
DAY-2nd - On the day second, the condition of the baby was better than the previous one. The IV fluid and medication had also given
to the child. The bowel and bladder pattern of the patient was normal. Blood samples collected for the further investigations. Weight
of the patient checked. ECG of the patient was also done. The intake and output chart has been maintained. The vital signs also
checked

Vital signs:

Pulse 82beats/min

Temperature 99.5 F

Respiration 20breath/min

SPO2 92%

DAY-3rd – On the third day the baby looks better from the previous days; the child looks conscious. The patient’s intake and output is
normal. The medication is given to the baby such as tab. Digitalis, omnacartil, inj. Ceftriaxone, metrogyl etc. The vital signs have been
checked. The IV fluid was also given to the baby to prevent dehydration.

Vital signs:

Pulse 156beats/min

Temperature 96.2 F

Respiration 42breaths/min

Spo2 94%
 BIBLIOGRAPHY

 “Sharma Rimple, Essentials of Pediatric Nursing, First Edition, Jaypee Brothers Medical Publishers LTD, 2013,Page
No. 481-485”

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