Patient Information

Name of the patient; Master Basavaraj

Hospital no; 10036

Age; 2 years

Sex; male

Classification; Toddler

Ward; PICU

Bed no; 4

Final diagnosis; Autism

Date of admission; 13-12-2010

Date of discharge; 20-12-2010

Date of surgery; nil

Surgery proposed; nil

Surgery done - nil

Student’s information

Name of the student;Ms.sneha mary samuel

Class; 2nd year msc

Date-study started;13-12-2010

Date-study ended;16-12-2010

No. Of care note;3

1. Introduction;
General condition – Master Basavaraj was having complaints such as not speaking two word
spontaneously , little or no eye contact. Prefers solitary play activities, does not smile at or touch
face of another child and delayed language development. Baby also had fever since 2 days
,vomiting and decreased feeds

Care taker of child- mother (BHAMA)

2.Socioeconomic background

 Name of place; Dandekkatte, Harihar

 Type of house; concrete
 Ventilation; 2 doors and 4 windows
 Water supply; tap
 Drainage system; closed
 Toilet facilities; own latrine
 Recreational facilities; television and radio
 Medical facilities; hospitals
 Religion; hindu
 Occupation of parents; carpenter- father
 Total income of parents; Rs 500/month

2. Family history;

Type of family; nuclear

Diseases; NO communicable, congenital. genetic, disorders
Sl Name Relationshi Age/sex Education Occupation Health status/
.n p with child treatment
o given
1. Master Basavaraj Patient 2yrs/m Nil Nil autism
2 Mr . Mohan Father 36yrs,/m 10th Coolie worker Healthy
3. Mrs.Bhama Mother 32yrs/f 5th House wife Healthy

3. Personal history;

Nutrition; child likes to have same as his parents having.

Sleep; 14hours/day
Bowel and bladder; not achieved toilet training
Hygiene; bathing- child gets bath daily .
Brushing-tooth paste
Schooling; not yet started

4. Birth history(<five years of age)

Antenatal history;

 Order of pregnancy -1st—antenatal clinic attended; yes

 Tetanus toxoid; yes
 No of doses;2
 Consanguineous marriage; no
 Exposure to; drugs / radiation-no
 Illness during pregnancy-no
 Diabetes/hypertension/epileptic/rubella/acute viral fever-yes

Natal history;

 Mode of delivery; LSCS

 Birth weight;2.7kg
 Delivery conducted by-Gyenecologist
 Place of delivery--hospital
 Birth injury; no
 Gestational age-term

Postnatal history

 PPH- no
 Puerperal sepsis- no
 Breast engorgement-no
 Puerperal psychosis-no

5. IMMUNIZATION

AGE IMMUNIZATION DOSAGE ROUTE REMARKS

At birth BCG 0.1ml ID Given

OPV-0th dose 2 drops PO Given

Hep B-1st dose 0.5ml IM Given

6 weeks DPT-1st dose 0.5ml IM NOT Given

OPV-1st dose 2drops PO Given

 Hep B- 2nd dose 0.5ml IM Given
10 weeks DPT-2nd dose 0.5ml IM Not Given

OPV-2nd dose 2drops PO Given

14 weeks DPT-3rd dose 0.5ml IM Not Given

OPV- 3rd dose 2drops PO Given

6-8 months Hep B- 3rd dose 0.5ml IM Given

9 months Measles 0.5ml SC Given

12-15 months MMR 0.5ml IM Given

2 year Typhoid 0.5ml IM Given

6.DIET HISTORY

 Type of feed; normal

 Method of feeding; nomal oral feeding
 Present diet pattern; same as family members following
 Weaning started at what age :6 months
 Dietary pattern (24 hours recall)

Degree of malnutrition= actual weight/expected weight X 100

Expected weight= age in yrs×2+8
2×2+8=12
10÷12×100 =83%
Child is well nourished.

MEDICAL SURGICAL HISTORY

A. PAST- No Communicable Disease/Viral/Minor Ailments

PRESENT- Master Basavaraj was having complaints such as not speaking two word
spontaneously , little or no eye contact. Prefers solitary play activities, does not smile at or touch
face of another child and delayed language development. Baby also had fever since 2 days
,vomiting and decreased feeds.Baby is on treatment with inj.Risperidone ,Inj.AUGPEN,
Inj.DEXONA, Inj.MIKACIN , Inj.ALTHROCIN ,And baby is getting nebulization 3rd hourly.

6. HEALTH ASSESSMENT
7. 1.PHYSICAL ASSESSMENT FROM HEAD TO FOOT
1.Growth measurement(13-12-10)

Parameters Normal Childs value

Weight 12kg 10Kg

Height 75-80cm 75cm

Mid- arm circumference. 8-10cm 10cm

Abdominal circumference 52-58cm 52cm

 TemPh
 Physiological measurement (13-12-10)

PARAMETRS NORMAL CHILDS VALUE

Temperature 98.60F 1020F
Pulse 90-100 beats/mt 92 beats/mt
Respiration 26-30/mt 26 breaths/mt

3.General appearance
 Consciousness -conscious
 Orientation -oriented
 Activity -anxious
  Cleanliness -clean appearance
 Body built - moderately built
 Nourishment -moderately nourished
4.Skin:
 Color -pale
 Texture -normal
 Temperature -1020F
 Lesions -absent
 Edema - absent
a) Hair:
 Color: black.
 Distribution: equal
 Dandruff: present
b) Eyes:
 Eye brows: present.
 Eye lashes: present.
 Follicle/ sty: absent
 Eyelids :normal
 Lesions: absent.
 Eyeballs: normal.
 Conjunctiva: pale
 Visual acuity: normal
 Eye movements: normal
 Vision: normal.
c) Ears:
 Discharges: absent.
 Hearing acuity: normal
d) Nose:
 Crust/ discharge:absent.
 Nasal septum: normal
  Polyps: absent.
 Rhinorrhoea: absent.
e) Mouth and pharynx:
 Membrane: red
 Breath: normal
 Throat: sore throat
 Gum: normal
 Teeth: poorly aligned
 Tongue: coated
 Oral hygiene (habits): brushing _1___ times/ day.
 Material used: brush
 Dentifrices: tooth paste
f) Neck:
 Lymph nodes: normal.
 Thyroid gland: normal
g) Chest:
 Shape: normal
 Chest movements: symmetrical
 Heart (position of the heart): left.
 Heart sounds: normal
h) Auxiliary Lymph:

Nodes: palpable
i) Abdomen:
 Skin: normal
 Umbilicus normal
 Peristalsis: not visible.
 Size: normal
 Bowel sounds: present.
 Abdominal sounds on percussion: dull
 j) Genitals:
 Scrotal swelling/ mass: absent.
 Lymph nodes: not palpable.
 Congenital defects:no
 Urinary flow - low
k) Lower Extremities:
 Gait: abnormal
 Contour: normal
 Mobility: range of motion: limited.
 Deformity: absent
8. ASSESSMENT OF GROWTH AND DEVELOPMENT

ASSESSMENT CRITERIA YES N REMARKS

O

BIOLOGICAL DEVELOPMENT:
closed
 Anterior fontanels not
 Control of sphincter acheived

GROSS MOTOR DEVELOPMENT: Master Basavaraj not

achieved gross motor
 Able to walk without help  development
 Able to creep upstairs 

 Able to kneel with support 

 Able to assume standing position


without support

 Can throw ball without feeling
 Able to run but often falls

 Able to walk upstairs with one hand
 held
 Able to pull and push toys 
 Able to jump up place with both feet
 Able to seat self on chair 

 Able to throw ball over head without
falling

 Able to go up and down stairs above
with two feet on each stair
 Able to run fairly well with guidance

 Able to pick up objects without
falling
 Able to jump with both feet

 Able to stand on one foot
momentarily 
 Able to take a few steps on tip toe.

FINE MOTOR DEVELOPMENT: Master Basavaraj not

achieved fine motor
 Scribbles spontaneously  development
 Constantly casting objects to floor
 Able to use cup well but rotates
spoon 

 Able to turns pages of the book one


at time
 In drawing makes stroke initiatively

 Able to manage spoon without
rotation

 Able to aligns two or more cubes
like a train

 Able to turns pages of the book one
 at time
 Has good hand- finger co-ordination
 Able to initiate vertical or circular
stroke
 Able to unscrew the lid
 Able to move the finger 

independently

SENSORY ASSESSMENT:  Master Basavaraj not

achieved sensory
 Able to identify geometric figures development
(eg.round) 
 Displays interest in pictures
 Accommodation well developed. 

VOCALIZATION: Master Basavaraj not

achieved vicalization.
 Uses expressive jargon 
 Asks for objects by painting
 Able to understand simple 

commands
 Able to point out body parts
 Able to understand directional
commands
 Refers self by name
 Verbalizes need for toileting food or
drink

 Uses plural

 Able to name one color.

SOCIALIZATION: Master Basavaraj not

  Tolerates separation from parents  achieved socialization
 Less likely to fear strangers
 Imitates parents 

 Able to feed self using a cup with


little spilling

 Kisses and hugs parents

 Kisses pictures in book
 Has temper tantrums
 Has awareness of ownerships

 Demonstrate dependency on
transitional objects 
 Has sustained attention span
 Uses parallel play 
 Able to dress self in simple clothing 
 Knows own sex
 Begins to notice sex differences 

5. DIAGNOSTIC AND LABORATORY DATA

SL.NO date INVESTIGATIONS PATIENTS NORMAL VALUES

VALUE

1 13 -12-10 Haemoglobin 10 gm/dl 10 – 13gm/dl

2 RBC 3.22 4 -5.3 mil/cumm
3 WBC 18500c/c 4000-11000cells/cum
4 ESR 3mm/hr 0-9mm/hr
5 Platelet 0.99laks/cm 1.5-4.5 lakhs/cumm
6 Neutrophils 68% 54-62%
7 Lymphocytes 23% 25-33%
8 Monocytes 07% 3-7%
9 RBS 98.0mgs 70-140mg
10 Serum calcium 8.4mgs 9-11.0mgs
11 Serum phosphatase 5.6mgs 2.5-5.0mgs

8.TREATMENT

Master Basavaraj is getting I V fluids.

CONCLUSION

 Patient evaluation
The child has good prognosis. The child has improved from his febrile status.
 Self evaluation
 As a part of the specialty posting, I took Master Basavaraj to give care and to study the
case. The child had Fever when the child was admitted to the PICU. I had given care to
the child for 3 days. I found child’s condition has improved.

BIBLIOGRAPHY

1.Lippincott, “Text book of Paediatric Nursing”, Mosby Publishers

2.Mary Ann Hogan, Judy E White, “ Child health Nursing”, Prentice hall, New Jersey
3.Gupte Suraj, “ The short text book of Pediatrics”, 10th edition, Jaypee brothers
medical publishers(P) LTD, New Delhi
4.Achar’s “text book of paediatrics”, 3rd edition(2000), orient longman limited

PEDIATRIC NURSING
 Clinical presentation on
AUTISM

SUBMITTED TO: SUBMITTED BY:

Mrs Julina lobo Ms Sneha Mary Samuel
Lecturer 2nd year Msc Nursing
C.C.O.N C.C.O.N