Data sheet

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Data sheet

  1. 1. Bethlehem University.. Faculty of nursing and health science.. PEDIATRIC /333 . DATA SHEET BRONCHITIS ST.NAME: MAHMOUD BASSEM ALZGHARI..
  2. 2. Demographic Data: Patient initials :T.Z.SH Sex: Female. Date Of Admission: 22.11.2012. Gestational Age: (Full Term). Age:1.2 ((one year's & two month)). Diagnosis: Bronchitis CHIEF COMPLAIN: TALA , an 1.2 years old female patient admitted to AL-AHLI hospital complaining of sever cough , fever and running nose duration since two day ago . PREGNANCY HISTORY: LMP: 22.12.2010 AND EDD: 29.9.2011 TALA mother has 7 children (3 boys& 4 girls),all her pregnancies was NSVD ,with no any complications they were full term ,when she was pregnant in TALA her pregnancy period was 39 weeks. The mother said that she didn’t have any complications and she had taken all vitamins required and prescribed to her such as Folic acid and Calcium supplements, she used to visit a local clinic to do all prenatal procedures such as US, glucose level …etc. She didn’t have any problems during her pregnancy period. At the end of the 39 weeks of pregnancy on 29.9.2011 at 2:30 am TALA was born by NSVD weighing 3100 gram, TALA CC was 32 and HC was 34. She was breastfed since first day of birth and had no difficulties with sucking. History of present illness: A1.2 year's old female infant was healthy till 2 day who she started with fever relived by antipyretic. Then she developed to running nose. Pt seek OSD and seen by the Dr who ordered CBC that shows WBC 21000 & IYM 68. The recophin 0.5 mg give. Then the pt developed cough dry in nature and pt vomiting twice time after dry cough.
  3. 3. Past History: the past medical and surgical history is free Immunizations: (Since birth till now) Type: DATE: BCG vaccine 29.9.2011 Hepatitis B vaccine 29.9.2011/22.10.2011/27.3.2012 IPV 22.10.2011/3.12.2011 OPV 3.12.2011/21.1.2012/27.3.2012 HIB 3.12.2011/21.1.2012/27.3.2012 MUR 3.10.2012 PCV13 3.12.2012/21.1.2012/3.10.2012 Developmental Assessment Identify norms and relate to patient. DDST (<6 yrs) or school performance (>6 yrs). - Developmental assessment by interview: Age: 1.2 months . Hand together Grasp rattle ok Laughs ok Chest up arm support Good wt Sit- head steady Head up 90 The pt hold pencil ,knows to say mama dada love to parallel play points to body parts and smaile to the people her mother sent her to nursery school because mother was work . Gross motor: The patient can not roll over ,he can not sit without support ,he can not crawl or pull himself to stand or rise chest up by arm support.
  4. 4. Fine motor: The patient can follows to midline ,he also can put hands together and grasp a rattle but he can not reach for object or throw a ball. Language: The patient responds to bell and turns to voice ,he can say mama and dada and another wards . Social: The patient smiles responsively ,initially shy with strangers ,he can not work for toy out of reach. But she love the people so much. Cognitive development The pt under stand when mother play with her for example smaile ,clumped her hand to gather. Psychosocial (Erikson, Piaget, Freud) Erikson(psychosocial) Piaget(cognitive) Freud(psychosexual) Birth _ 1 year(trust versus mistrust) 0_2year(sensorimotor) Oral stage :at birth_2yesr Reflexive behavior lead to intentional behavior Major source of pleasure seeking is centered on oral activities such as sucking Sense of trust is rooted in the quality of an infants *egocentric view of world care and the relationship with the primary care givers *cognitive parallels motor development *if meet trust = happy Unmet =crying ,anxiety Favorite toys and games: Tala love to play in games involving girls like to play in the doll and the phone and habits which is holding Tala watching TV to watch paragraphs kids Any specific habits or routines : no specific habits or routines the more things that she do is watching T.V and playing with towels
  5. 5. Food preference: In terms of food considered normal to deal with food from 4 to 5 meals a day. Breastfeeding 4 times a day and night for 10.Minutes in each feed and take artificial feeding 800 cc within 24 hours Family Assessment 1. The family has good live style, finical statement is good , normal culture, live in clean and good environment. They live in Hebron city . Tala's father and mother were still alive the age of father is Father 42 and maternal age 30 housewife mother and father worked in construction workers in Israel. The relation between family and neighbor good . the baby live with his parents with father's family in good beautiful house. 2. PT/Family strengths and weaknesses: Strength relationship between family’s member . and good relationship between the family and the husband’s family. as you seem to you tow family in one family Nutritional needs: Diet: breast feeding +hospital formula. Like Tala food all dairy products, and all kinds of homemade desserts Prefer not to eat bananas and melons this what the mother said Dietary habits & mealtimes :3—5 meals /day at 8am & 11am & 3pm &7pm And artificial feeding when needed General appearance: Pt Looks well ,active ,.not cyanotic skin color pink . good appearance ,round face, pt in good hygiene and nutrition. Pt in good growth and development wt is 8800g cannula put on the head , Ht + Percentile: 63 cm Wt + Percentile: 8800 g Skin: uniform color of skin (pink), smooth, unbroken, warm and resilient, wet not dry. No cyanosis no skin rashes or lesions, clean skin, no sweat. Turgor skin was done and the result is normal (capillary refill less than 3 seconds). No Mongolian spots. Head: Round and symmetrical face head one fourth of body size head circumference 37 cm , normal skull no cephai hematomas,no caput succedaneum fontanels anterior is still open ,posterior triangle shaped is closed no sunken or bluging scalp is free abrasion or laceration ,hair texture is soft normal distribution Face: pink in color, symmetrical no lesions and scars, no voluntary movement of the face muscle, no edema. Sunken or bulging in his face.
  6. 6. Neck: the neck supports the head in midline backward, and to either side. Carotid pulses felt the neck is short and covered with folds of tissues There is no bulges or fullness in the neck, no any deviation, masses, or nodules when palpating neck structures palpate good rotation Eyes: The eyes are open normally. Symmetrical, normal space between them .no edema or bruising, tears present,no cataracts no nystagmus normal alignment and range of movement sclera is white , eyelids are normal pupils it constrict when it exposure to light, dilate when light fades Ears: Extends slight forward from the skull, symmetrical depressions and prominences. Good hygiene of ears, soft yellow cerumen. No abnormal opening or discharge, pink external canal, Normal hearing in both ears. Nose: normal shape and size, with each side symmetric. Both nostrils equal in size. Septum in midline and mucosal lining is pink, wet , and with obvious drainage ( running nose) because bronchitis. And wheezing sound because of partial stenosis in nasal canal Mouth & throat: the mouth surrounding by the lips .pink, smooth, and no cleft and lips palate no lesions of lips, mucous membrane is pink, intact and moist. Tongue in midline, freely movable, no lesions or masses under the tongue good sucking and the growth of teeth is normal. Chest & Lungs: skin intact Have symmetrical chest circumference 39 cm no rash or swelling around nipple no milk or abnormal discharge from them respiratory rate is 41b/m and irregular. Lung sound have wheezing because stenosis of bronchial tube. Heart & circulatory system: RHR(regular heart rate ), and rhythm no murmur normal heart sounds No heart problems(PDA,ASD,VSD,…) Blood pressure within normal 85/62 pulse 140b/min ,pulse in extremities can felt capillary refill on the nails refill in 2 second. good peripheral perfusion no cyanosis. Femoral, carotid, and brachial pulse is palpated Abdomen: soft, intact skin, no lesion. Umbilicus is flat, round, and without discharge, normal bowel sound. Pink in color, dry, concave, and flat, round in shape, normal bowel movement. Bowel movements: the frequency is 5—6 time / day. And it depends on amount and quality of food that she takes. When she needs to void she need partial helping to do
  7. 7. Renal: Yellow and slight urine. able to urinate, Normal urinate and no oliguria or noctoria of enuresis, and no infections no UTI. The frequency of urination is 4—6 times / day and the amount of urination about 850cc/ day. Skeletal system: good posture spine vertebral is normal no malformation range of motion is good , no fracture, no bone abnormalities no sclerosis or kiphosis. Neurological system :Alert, conscious, normal tone power, no focal neurological deficit. Pt angry and crying sometimes due to distress and hospitalization . equal muscle tone, no nervosa, he has acceptable and cooperative behavior. No convulsive or seizure. Alertness, reflexes :Normal reflexes at all sides, good vision & hearing and good sensory of skin. (Moro Reflex- Rooting-sucking reflex -palmer grasp reflex-stepping – babinski- tonic neck- Papillary reflex -Blinking reflex -Crawl) is good . Emotional, Intellectual : Most of the time to be quiet and cooperative, but in the absence of her mother begins to cry and scream and be too polite with nurses and the medical team Response to illness: Acceptor is the atmosphere of the hospital and sometimes start screaming in the absence of the mother in the case of severe coughing and high temperature Sleep (nap, bedtime, rituals and pears): good sleeping pattern in prone position, sleep 2—3 hours/day and at night about 8 o'clock until 7 o'clock.
  8. 8. pathphysiology bronchitis is a chronic inflammation of the bronchi (medium-size airways) in thelungs. It is generally considered one of the two forms of chronic obstructive pulmonary disease (COPD), the other being emphysema. It is defined clinically as a persistentcough that produces sputum (phlegm) and mucus, for at least three months per year in two consecutive years. Signs and symptoms Bronchitis may be indicated by a cough (also known as a productive cough, i.e. one that produces sputum), shortness of breath (dyspnea) and wheezing. Occasionally chest pains, fever, and fatigue or malaise may also occur. Mucus is often green or yellowish green and also may be orange or pink, depending on the pathogen causing the inflammation. Causes Tobacco smoking is the most common cause. Pneumoconiosis and long-term fume inhalation are other causes. Allergies can also cause mucus hypersecretion, thus leading to symptoms similar to asthma or bronchitis. Diagnosis A physical examination will often reveal diminished breath sounds, wheezing and prolonged exhalation. Most doctors rely on the presence of a persistent dry or wet cough as evidence of bronchitis. A variety of tests may be performed in patients presenting with cough and shortness of breath:       Pulmonary Function Tests (PFT) (or spirometry) must be performed in all patients presenting with chronic cough. An FEV1/FVC ratio below 0.7 that is not fully reversible after bronchodilator therapy indicates the presence of COPD, that requires more aggressive therapy and carries a more severe prognosis than simple chronic bronchitis. A chest X-ray that reveals hyperinflation; collapse and consolidation of lung areas would support a diagnosis of pneumonia. Some conditions that predispose to bronchitis may be indicated by chest radiography. A sputum sample showing neutrophil granulocytes (inflammatory white blood cells) and culture showing that has pathogenic microorganisms such as Streptococcus spp. A blood test would indicate inflammation (as indicated by a raised white blood cell count and elevated C-reactive protein). Neutrophils infiltrate the lung tissue, aided by damage to the airways caused by irritation. Damage caused by irritation of the airways leads to inflammation and leads to neutrophils being present
  9. 9.     Mucosal hypersecretion is promoted by a substance released by neutrophils Further obstruction to the airways is caused by more goblet cells in the small airways. This is typical of chronic bronchitis Although infection is not the reason or cause of chronic bronchitis it is seen to aid in sustaining the bronchitis. High Resolution Computed Tomography (HRCT) — This is a special type of CT scan that provides your doctor with high-resolution images of your lungs. Having a HRCT is no different than having a regular CT scan; they both are performed on an open-air table and take only a few minutes. Treatment Smoking cessation is of benefit as nicotine paralyzes the cilia comprising the Mucociliary Escalator. Antibiotics Only about 5-10% of bronchitis cases are caused by a bacterial infection. Most cases of bronchitis are caused by a viral infection and are "self-limited" and resolve themselves in a few weeks. For acute exacerbations of chronic bronchitis, if antibiotics are used, amoxicillin ordoxycycline is recommended. Bronchodilators Ipratropium is an example of a bronchodilator that may be useful for people suffering from chronic obstructive pulmonary disease, such as chronic bronchitis. Albuterol is also a common drug for this disease. Acute exacerbations Acute exacerbations of chronic bronchitis Acute exacerbations of chronic bronchitis (AECB) are episodes of difficulty in breathing in a person with chronic bronchitis.
  10. 10. During AECB, breathing becomes much more difficult because of further narrowing of the airways, in addition to increased secretion of mucus, which often is thicker than usual. Treatment of AECB may include:       Cough suppressants. Inhaled bronchodilators. Antibiotics are used if a bacterial infection is the suspected cause. However, antibiotics will not treat exacerbations caused by viruses. Corticosteroids. Theophylline. Oxygen therapy. Diagnostic procedure URINE ANALYSIS ((23.11.2012)) Test Result Color straw PH Acidic appearance clear Specific Gravity 1.01 Sugar nill Ketone nill Bilirubin +2 Urobilinoyen normal Blood nill Nitrate _ve negative
  11. 11. SERUM ELECTROLYTE((22.11.2012)) Test Clorid Result 99mmol/l Normal Values 99—111mmol/l Na 141mmol/l 132-150 mmol/l K 4.74mmol/l 3.5-5.5 mmol/L Chemistry:((22.11.2012)) Test RBC Result BUN 10.6 Creatintion 0.31 88 Normal Values 4.7—23.7 MG/DL 0.2—10mg/dl 60—200 mg/dl CBC: Test Result Normal Values Wbc 18.12 5—10*10^3 RBC HB 4.77 11.4 4.2—5.4*10^6 12—18 % PLT Neutrophils Lymph 530 20% 73% 150—400*10^3 45—65% 25--45 Chest x-ray (22.11.2012) The x-ray shows an inflammation of bronchial tubes. Urine culture (22.11.2012) The results show no growth. Meaning of abnormal Inflammation of the bronchial tube normal R/T poor feeding and disease normal normal Because of bronchitis
  12. 12. Medication Name& dose ZINACEF (cefuroxime) 250mg I.V q 8 hrs Uses to treat or prevent infections that are proven or strongly suspected to be caused by bacteria Rational Help to prevent infection. contraindication Hypersensitivity to cephalosporins or penicillins. Side effects Large doses can cause cerebral irritation and convulsions, nausea, vomiting, diarrhea, GI disturbances; erythema , Anaphylaxis, nephrotoxicity, pseudomembra nous colitis. Ventolin is a powerful To smooth you should avoid tremor, dry albuterol) B-adrenergic bronchial taking this drug mouth, muscle 0.5cc neb q6 hrs receptor agonist, muscles and during pregnancy and cramps, having a direct stops lactation anxiety, effect on smooth spasms headache and bronchial palpitation. muscles. It Rare makes the disturbances muscles relax of sleep and and stops behavior, spasms. caused by Maximum effect albuterol are of the individual. medication Allergic shows between 5 reactions are to 20 minutes rare after using it directly in a form of spray and slightly later in case of oral administration. Atrovent Ipratropium is Bronchio There are no dry mouth and 0.5 cc neb q 8 administered by dilator to contraindications for sedation have hrs inhalation for facilitate inhaled ipratropium, been reported. the treatment breathing apart Also, effects of chronic from hypersensitivity t such as skin obstructive oatropine and related flushing, pulmonary substances. For oral tachycardia, disease (COPD) administration, acute angle-
  13. 13. . For that purpose it is supplied in a canister for use in an inhaler or in single dose vials for use in a nebulizer. Ipratropium as a .03% nasal solution sprayed into the nostrils can reduce rhinorr hea contraindications are similar to other anticholinergics; they include narrow angle glaucoma and obstructions in thegastrointestinal tract and urinary system closure glaucoma, nausea, palpitations and headache have been observed What I learned from this case?? I heard the girl coughing severe coughing so I decided to study their causes and what led them to this case Benefited greatly from this case study ((inflammatory airways)) I've learned a lot about her and what roads caused by method of detection and treatment method and Prevention. I managed without reference to the many references left her health care after leaving the hospital and avoid non-hit by the disease in the coming days, and how we can alleviate the symptoms associated with pain In the other got many new information that I did not know before about the disease itself and the method of treatment. References: 1.THE CHILD FILE . 2.FROM HIS DOCTOR. 3.FROM FAMILY (MOTHER). 4.FROM INTERNET ( GOOGLE AND OTHER WEB-SITES . 5.DRUG INFORMATION AND SIDE EFFECTS ONLINE. AVAILABLE AT: WWW.DRUGS.COM . 6.TEXTBOOK OF MEDICAL SURGICAL NURSING . 7. SELECTED NORMAL PEDIATRIC LABORATORY VALUES.

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