Pediatric Patient History for attachment 33ppt.pptx

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1. AMBO UNIVERSITY WOLISO CAMPUS DEPARTMENT OF NURSING 3rd year Nursing students Hospital Attachment of padaterics Name Id Afiram kassay .............................. . ........ Ugr / 51235/13 Abush Tibebe.................................. . ......Ugr/51162/13 Aderaw Alemie................................ . ......Ugr/35168/12 Alembirhan beyene........................ ........ Ugr/ 5 1 3 3 8 / 1 3 Aman u el Degefu.................................... Ugr/ 5 1 9 1 7 / 1 3 Addis T/mariam............................. . .......Ugr/35718/12 Amare Nigus..................................... . .....Ugr/53913//13 Shewafera Kassa.......................... . .........Ugr/35716/12 Banchiamlak Amare...................... . ........Ugr/ 5 9 7 8 / 1 3 Bayush Esubalew...................... . ........... Ugr/ 5 9 7 4 / 1 3 Aster Gezahign..................................... Ugr/ 5 1 1 9 / 1 3 Simale Bahiru........................................ Ugr/ 5 1 6 6 3 / 1 3

2. PATIENTS IDENTIFICATION Name : Nihala Feyisa Age : 9 months
Sex : female Date of birth : 28/8/2015 E.C
Place of birth: wolikite Address : gurage Ward : E PW Bed No : 3 Card No : 004081/16 Date of admission :30/3/2016 E.C
Source of information : from mother
Source of referral : health center

3. CHIEF COMPLAINTS Diarrhea and Vomiting of 2 Day duration

4. HISTORY OF PRESENTE IL L NESS- This is a 9 month old female patiant presented with complain of diarrhea and vomiting of 2 day duration. The diarrhea is non bloody watery with frequency of 4 -5 episodes per day and not have rice water character. ,The vomiting is non projectile with the frequency of 5-6 episodes per day for 2 day duration. and She was relatively health before 5 day duration the vomiting is not fecal matter,it is ingested matter and milk content.

5. The vomiting was decreased/relieved by not taking orally including berast milk.but not complately relieved associated to this she has high grade intermittent fever , sunkening of eye ball,weight loss and she is irritable , she also manifest loss of appitite to any food and also decresed need to suckling breast milk Otherwise -she has no edema ,no constipation she has no abdominal distension no cough

6. PAST MEDICAL HISTORY She has no history of past medical illness Like -TB,ASTHMA , DM, CHF, HYEPER TENTION She has no any history of Surgery Like -appendicitis , bowel obstruction ,no birth trauma She has also previous admission by CAP and treat dioper dermatitis

7. NUTRITIONAL HISTORY The duration of exclusive breast feeding was 6 month and the mother feeds breast milk to infant every 2 hours for 5-8 minutes duration for each feeding after 6 month his parents tried to feed complmentary feeding like gruel ,cow milk and the infant tastes only or takes this food very small amount ,not eating adequately..

8. Developmental history She was started head control at 4 month and she started lifts head 6-8 month.sits alone at 7 month ,she started crawl and creep at 9 month ,and at the present time

9. IMMUNIZATION She is vaccinated according to EPI She started vaccination at birth BCG 0.05 and OPVO 2 drops. she vaccinated OPV1,2 drops ,PCV1 0.5ml,pentavalent -0.5 ml and rota1 1.5ml.at 6 weeks she also taken measels1 vaccine at 9 months

10. PHYSICAL EXAMINATION General apperance –she is a cute sick looking VITAL SIGNS T=38.1 ⁰ C Axillary , PR=119 b/minute , RR =38 breath/ min SPO2=98%

11. Anthropometry Weight-7.4 kg WFA-[0,-2] Length -72cm WFL-[-1,-2] H/C -46 cm LFA- [0,-2] MUAC-13 cm

12. HEENT She has pink conjuctiva ,whitish sclera, She has sunken of eye ball . She has dry mucous membrane Genitourinary system She has no discharge She has no urine incontinence She has decreased urine output

13. RESPIRATORY SYSTEM – Clear chest with air entry Cardiovascular – system – s1 and s2 well heard ,no s3 and s4 No murmurs or gallop Integumentary system she has skin pinch goes to back very slow > 2 second ,dry skin and mucusal

14. Musculoskeletal System : – No edema / deformity Norvous system : - She is lethargy DIFFERENTIAL DIAGNOSIS 1 . Gastroenteritis 2 . D iabetic kitoacidosis 3 . I nfection 4 . Medication side effect

15. Laboratory result CBC STOOL EXAMINATION No ova and parasite seen WBC=15 . 7 3 x 1 ⁹ / L SERUM ELECTROLYTE Neu =59.6 % Na=144 m m o l / L Lym =28.4 % k=2.3 m m o l / L Mon =11.7 % Cl =98.8 m m o l / L HGB =15.4 g / dL HCT =50.5 % MCV=75.3 f L PLT= 6 4 5 x 1 ³

16. FINAL MEDICAL DIAGNOSIS SEVERE DEHYDRATION

17. Plan Give 30 ml/kg of RL fluid over 1 hour and then continue with 70ml/kg over 5 hour was adminsterd To give gentamicin 5mg/kg/days T o give Amoxacillin 50mg /kg/days Follow with rehydration chart ORS was stareted

18. Discharge summry She improved from the symptom ORS per loss Zn 10mg PO daily for 10 days Encourage to take rich foods and fluids Appointed after 6 weeks

19. Dehydration

20. CONTENT I ntroduction of dehydration D efination of dehydration List the cause of dehydration Identify c lassification of dehydration C omplications of dehydration C linical findings D iagnostic tests T reatment

21. Introduction Dehydration occurs when the body loses more fluids than it takes in ,leading to an imbalance in the body electrolytes and decrease in the bodys ability to function properly. This condition can range from mild to severe and can be caused by a variety of factors including excessive sweating , vomiting,diarrhea,fever and inadequate fluid intake.

22. WHAT IS DEHYDRATION Dehydration— excessive loss of fluid from the body— occurs when the loss of fluid exceeds the fluid intake.

23. CAUSES hemorrhage excessive perspiration acute renal failure with polyuria abdominal surgery vomiting or diarrhea nasogastric drainage excessive GI suctioning

24. CLASSIFICATION OF DEHYDRATION IN CHILDREN Severe dehydration the following signs: - Lethargic or unconscious Sunken eyes Not able to drink or drinking poorly Skin pinch goes back very slowly

25. Some dehydration the following signs:- R estl e ss, i rr i ta b l e Sunken eyes Drinks eagerly, thirsty Skin pinch goes back slowly

26. No dehydration Not enough signs to classify as some or severe dehydration

27. CLINICAL FINDINGS An assessment may reveal numerous symptoms affecting many body systems 1- orthostatic hypotension due to increased systemic vascular resistance and decreased cardiac output 2- .Tachycardia induced by the sympathetic nervous system to increase cardiac output

28. Cont… 3-Physical findings may include flattened neck veins related to decreased circulating fluid volume 4- sunken eyeballs related to decreased total fluid volume with consequent dehydration of connective tissue and aqueous humor

29. Cont… 5- Urine will be dark amber in color and decreased in volume 6- diminished skin turgor due to decreased fluid in the dermal layer 7- The patient may also exhibit weakness , irritability

30. DIAGNOSTIC TESTS Blood chemistries(to check electrolytes, especially sodium, potassium, and bicarbonate levels) Blood urea nitrogen(BUN) Complete blood count(CBC) Creatinine Urine specific gravity Other tests may be done to determine the cause of the dehydration (for example, blood sugar level to check for diabetes

31. COMPLICATIONS Complications include hypotension, risk of falls related to hypotension, and decreased cardiac output and perfusion to tissues and organs. Severe dehydration can progress to hypovolemic shock

32. Cont… Other complications include renal failure from decreased renal perfusion and, without intervention, death

33. TREATMENT For some dehydration oral fluid is the most effective to replenish fluid deficit. The patient with severe dehydration will require I.V. fluid replacement. I.V. fluids should be hypotonic, low-sodium solutions, such as dextrose 5% in water

34. Cont… Avoid rapid administration of the I.V. solutions, because this will cause fluid to move from the veins into the cells and result in edema. Fluids should be administered gradually, over a period of 48 hours

35. Cont… children with severe dehydration- Begin Ringer’s lactate: For < 12 months : Initial bolus: 30mL/kg over 1 hour Maintenance: 70mL/kg over 5 hours For > 12 months: Initial bolus: 30mL/kg over 30 min Maintenance: 70mL/kg over 2 1/2 hours

36. Cont… When the child can't drink use NGT The child can drink : Start ORS by mouth Give 20mL/kg/hour for 6 hours For vomiting or gastric distention, give fluid more slowly. Reassess every hour. If hydration status is not improving, send for IV therapy. After 6 hours, re-classify degree of dehydration and chose appropriate plan (A,B, or C) for continued therapy.

37. REFERENCE Harrison,T.R.,and Kasper,D.L .[2018].Harrison principles of internal medicine.McGraw -Hill education. Davison,A.,and Stricker,E.M .[2003].Journal of athletic training,38[3],220-225. Mayo clinic staff .[2020]. dehydration.Mayo clinic.

38. THANKS