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Case study

  1. 1. sd CASE STUDY ON SECONDARY CLEFT PALATE SUBMITTED TO: MRS .NISHA MANE , ASSISSTANTPROFESSOR,D.Y.P.C.O.N Submitted by : MS.JAYSGEORGE 7/10/17 1ST YEAR MSC (N), D.Y.P.C.O.N
  2. 2. TYPEPERSONALNAME INTRODUCTION As a part my clinical posting , I was posted in pediatric surgery unit. I took a 9 year old child (ms.Harshitha) with the diagnosisof secondary cleft palate repair for my casestudy. I collected history of the patient ,I had done a thorough physical assessment and find out the needs of the child, I had dealt with disease condition and given five days care and health education to the parent as well as to th child. Recording and reporting done.
  3. 3. TYPEPERSONALNAME DEMOGRAPHIC DATA Name: Harshitha janaskar Age : 9 years Sex : female Age group: schooler Address: nerul Religion: Hindu Mrd.no : 1603245 Admission unit: pediatric unit Date of admission : 9/1/17 Informant: mother Diagnosis: secondary cleft palate CHIEF COMPLAINTS: Harshidha janaskar brought to the Dr. d .y patil hospital on 9/1/17 with the chief complaints of difficulty in speaking as a result of cleft palate. FAMILY HISTORY Sr. No Name of the family members Age Sex Relation with patient occupation Health status 1. Dashratha janaskar 47 M Father House keeping Healthy 2. Darshana 35 F Mother House wife Healthy pedie3. Sudharshan 15 M Son 10th std Healthy 4. Harshidha 9 F Daughter Nil Cleft palate
  4. 4. TYPEPERSONALNAME FAMILY TREE : Keywords male SOCIOECONOMIC AND CULTURAL HISTORY : Patient belongs to a middle-class family. Patient is from rathnagiri, patient lives in nerul. she belongs to a nuclear family, they live in rented house with all the facilities like municipality water supply, electricity and attached bathroom facilities. Proper hygiene maintained around surroundings, father is the breadwinner of the family. They are following Indian culture and tradition. BIRTH HISTORY 1) Antenatal history Patient mother is a registered antenatal case during her pregnancy period. She has taken folic acid and iron tablets and two dose of TT injection during pregnancy period 3-4 ultrasonography was done in the antenatal period. Mother has no infections like TORCH and diseases like HTN, diabetes mellites, AIDS etc. 2) Intranatal history Type of delivery is normal full term delivery. There were no complaints during the delivery period. Baby cried after birth, at birth vaccines are given to the child. Birth weight of the baby is 2.5kg. 3) Postnatal history After the delivery, the child was had congenital anomaly like cleft palate. Mother has breast fed the baby till 1 year but the patient had difficulty in breast feeding after 6 months along with the breast milk complimentary food also been given into the child. 4) Newborn history Birth weight: 2.5 kg m fe m
  5. 5. TYPEPERSONALNAME Breast feeding: breast feeding till 1 year Meconium passage: the child had passage meconium within 48 hours of birth. Urine passage: the child had passed urine within 24 hours of birth. Color of the baby: color of the baby is slightly dark IMMUNIZATION HISTORY vaccine Time Dose Route Remark Bcg Opv 0 Hep -B At birth 0.1ml 2 drops 0.5ml Intradermal Oral IM Given DPT 1 Hep -B 1 Opv 1 6 weeks 0.5ml 0.5ml IM IM Given DPT 2 Hep -B2 Opv 2 10 weeks 0.5ml 2 drops IM Oral Given DPT 3 Hep-B3 Opv 3 14 weeks 0.5ml 2 drops IM Oral Given Measles 9 months 0.5ml Subcutaneous Given DPT booster 5- 6 years 0.5ml IM Given PRESENT MEDICAL/ SURGICAL HISTORY : when I took this patient for my case study. patient had complaints of cold, difficulty in speaking and bifida uvula. Patient underwent secondary cleft palate repair.
  6. 6. TYPEPERSONALNAME PAST MEDICAL HISTORY: patient has no past medical history of diseases like jaundice , malaria , typhoid ,etc. patient has a history of common cold. PAST SURGICAL HISTORY : patient had a history of cleft palate repair at the age of 4 years in Nair hospital. PHYSICAL EXAMINATION GENERAL APPEARANCE: the appearance of the child is abnormal. the patient is having cleft palate, so there is an opening between the roof of the mouth and nose. Posture: normal posture Gait: the gait of the child is balanced Nourishment: the child is nourished Activity: the child is dull in her activity VITAL SIGNS Temperature: 98.6 f Pulse rate: 98 bts/min Respiration :26 brths/min Blood pressure :110/70mmhg ANTHROPOMETRIC MEASUREMENTS: Height: 120 cm Weight: 28 kg Head circumference: 54 cm Chest circumference: 56 cm Skin and mucus membrane: Color: color of the child is brown. Edema: there is no edema present on the skin. Moisture: the temperature of the skin is normal. Texture: the texture is normal and slightly dry.
  7. 7. TYPEPERSONALNAME HEAD: Skull/cranium size: the skull size is 54 cm. there is no enlargement in the shape of the skull. Normal range of motion. Fontanelles : both the fontanelles are closed. Sutures: all the sutures are intact . FACE: Appearance: the appearance of the face is normal Color: the color of the face is brown Symmetry: the face is symmetric at both sides. EYES: Expression: the coordination of the eyes is similar in both sides. Eyelids: the eyelids are not edematous and no infection. Eyebrows: eyebrows equally distributed and no infection. Conjunctiva: there is no conjunctivitis Sclera: the sclera is white in color Pupils: the pupil get constricted when exposed to light. EARS: Appearance: both the ears lie in the straight line of outer canthus of eye to the pinna of the ear. Discharge: there is no discharge from the ear Abnormalities: no abnormalities seen in ear. Hearing activity is normal. NOSE: Appearance: the nose is short and the nasal deviation present . Discharge: there is no discharge from the nose.
  8. 8. TYPEPERSONALNAME MOUTH AND THROAT: Lips: the lips are normal, complaints of cleft palate Tongue: the tongue is light pink in color, the patient is having difficulty in speaking. Teeth’s: normal number of teeth’s according to age are present there is no dental carrier or other infections. NECK : Appearance: the neck is short There is enlargement of lymph nodes and thyroid gland Movements: Normal range of motion. CHEST AND RESPIRATORY SYSTEM: Inspection: on inspecting the chest is expanding and relaxing, bilaterally symmetrical in shape. Palpation: the movements of the chest is normal. Percussion: there is no abnormal fluid collection. Auscultation: on auscultating no abnormal sounds heard. CARDIOVASCULAR SYSTEM : Inspection: on inspecting the cardiovascular system no abnormalities are there. Palpation: there is no abnormal enlargement Percussion: there is no abnormal fluid collection Auscultation: on auscultation there is no cardiac murmers . s1 and s2 heard. ABDOMEN: Inspection: on inspecting the counter of abdomen is cylindrical Palpation: the liver is palpable, no tenderness observed, no hepatomegaly or splenomegaly. Auscultation: bowel sounds is normal. Percussion: there is no fluid or gas.
  9. 9. TYPEPERSONALNAME BACK: Spine; intact normal Curvature: there is no abnormalities like scoliosis, kyphosis, lordosis. Genito urinary system: child does not have urinary tract infection. Child is not having congenital anomalies like hypospadias is and epispadiasis. EXTREMITIES: Deformities: there is no deformities . Swelling / edema: not present Muscles : muscle tone is normal, reflexes normal. Fingers and toes : no polydactyly and syndactyly. CENTRAL NERVOUS SYSTEM: Birth injuries : no history of birth injuries. Seizures : no history of seizures Speech : delay in speech DRUG STUDY NAME OF DRUG DOSE/ROUTE MECHANISM OF ACTION SIDE EFFECT NURSES RESPONSIBILITY Inj.ceftrixone(1g m)BD 1gm(100mg/kg /day)2600mg/d ay1vial+500m g+15cc NS IV Antibiotics ,Semisynthetic Third generation cephalosporin Hypersentiv ity Nausea Vomiting Rash Monitor patient carefully during the first dose of the infusion for signs of hypersensitivity. Inj . pan 20 1 vial+10CC NS 5.5CC+10CC NS IV OD Proton pump inhibitor Diarrhea Abdominal pain Flatulence Nausea Dry mouth Prior to drug administration check lab tests Monitor for immediate report of signs and symptoms
  10. 10. TYPEPERSONALNAME Vomiting Syp.crocin ds 4ml sos if temperature >100℉ Antipyrectic Sleeping or irritable Rash Cough convulsion Check for the expiry date of the medication before administration. SCHOOLER ASSESSMENT SL.NO PARAMETER BOOK PICTURE PATIENT BOOK REMARK Anthropometric measurement ✓ Height ✓ Weight 106-162cm 16-58kg 128cm 24 kg Moderately built 2. Vital signs ✓ Temperature ✓ Pulse ✓ Respiration ✓ Blood pressure 98.6o f 80-100b/min 20-30b/min 120/80mmhg 98℉ 84bts/min 28br/min 120/80mm Of hg Normal range 3. Physical and motor development ✓ Central mandibular incisor erupt ✓ Active age, constant activity 6years 6yrs 6yrs 6yrs Appropriate to age
  11. 11. TYPEPERSONALNAME ✓ Finger feeding ✓ More aware of hand as tool for drawing and painting ✓ Maxillary central incision and mandibular incision erupt. ✓ More cautions in approach to new performances. ✓ Repeat performance to master them ✓ Lateral incisors erupt ✓ Always on the go, jumps, chases ,skips. ✓ Increased speed in fine motor control. ✓ Use cursive writing ✓ Dresses self completely 6yrs 6yrs 6yrs 7yrs 7yrs 8-9yrs 8-9yrs 8-9yrs 8-9yrs 8-9yrs 6yrs 6yrs 6yrs 6yrs 5yrs 7yrs 7yrs 8yrs 7yrs 7yrs Appropriate To age 4. Mental development ✓ Develops concept of numbers, Can count 13 pennies ✓ Knows whether it is morning or afternoon ✓ Defines common objects such as spoon and chair in terms of their use ✓ Obeys 3 commands in succession. 6yrs 6yrs 6yrs 6yrs 6yrs 6yrs 6yrs 6yrs Appropriate to age Appropriate to age
  12. 12. TYPEPERSONALNAME ✓ Knows right and left hand ✓ Notices that certain items are missing from pictures ✓ Can copy a diamond ✓ Repeats 3 number backward ✓ Develop concept of time; reads ordinary clock ✓ Give similarities and differences between two things from memory ✓ Counts backward from 20-1 ✓ Repeats days of week and months in order ✓ Describes common objects in details ✓ Reads classic books also enjoy comics ✓ More aware of time, can be relied on to get to school on time. ✓ Produces simple painting or drawing ✓ Write brief stories ✓ Write occasional short letters to friends or relatives ✓ Rises telephone for practical purposes 6yrs 7yrs 7yrs 7yrs 7yrs 8-9yrs 8-9yrs 8-9yrs 8-9yrs 8-9yrs 8-9yrs 8-9yrs 10-12yrs 10-12yrs 10- 12yrs 6yrs 7yrs 7yrs 7yrs 7yrs 8yrs 8yrs 8yrs 8yrs 8yrs - 8yrs - - - Appropriate to age Appropriate to age
  13. 13. TYPEPERSONALNAME ✓ Responds to magazines, radio ✓ Reads for practical information or own enjoyment, stories or library book of adventure or romance. 10-12yrs 10-12yrs - - 5. Adaptive development ✓ Uses knife to spread butter or jam on bread ✓ Cuts, folds, pastes, paper, sews crudely if needle is threaded ✓ Takes bath without supervision ✓ Performs bedtime activities alone ✓ Likes table games, checkers simple card games ✓ Sometimes steals money or attractive items ✓ Uses table knife for cutting meat; may need help with tough or difficult pieces. ✓ Brushes and combs hair acceptably without help ✓ Make use of common tools such as hammer, saw, screw driver ✓ Helps with routine household task such as dusting, sweeping. ✓ Assumes responsibility of sharing. ✓ Likes schools, wants to answer all the questions ✓ Is ashamed of bad grades ✓ Make useful tools or does easy repair works 6yrs 6yrs 6yrs 6yrs 6yrs 6yrs 6yrs 7yrs 7yrs 8-9yrs 8-9yrs 8-9yrs 10-12yrs - 6yrs 6yrs 6yrs 6yrs 6yrs 6yrs 7yrs 8yrs 8yrs - Appropriate to age Appropriate to age Appropriate to age
  14. 14. TYPEPERSONALNAME ✓ Raises pet ✓ Cooks or sews in small way. ✓ Washes and dries own hairs ✓ May stay alone at home for an hour or more. ✓ Is successful in looking after own need or take care of another child 10-12yrs 10-12yrs 10-12yrs 10-12yrs 10-12yrs - - - 6. Psychosexual theory ✓ Stage of latency ✓ Child masters the skills which is learnt previously by them. ✓ Spend their time in play and gain knowledge. 6-12yrs Developed Appropriate to age 7. Psychosocial theory Industry /inferiority ✓ They want to work and want achievement. the aim is to develop a feeling of competence rather than inability 6-12yrs Developed Appropriate to age 8. Pleasure motives; Concrete on pleasure motive Level 2: conventional morality Stage 3(7-9yr) 6yrs 7-9yrs Concrete on pleasure activity like play Developed Appropriate to age
  15. 15. TYPEPERSONALNAME ✓ Becomes socially sensitive, justice means equality between individuals they believe. Stages 4 ✓ Maintain social order and perform or carryout fixed rule and authority 10-12yrs - Appropriate to age - 9. Spiritual development Stage 2- mythical / literal ✓ Child develop strong believe on god. They feel thinking good behavior is acquired by god. 6-12yrs Child has developed belief on god and thinks god is good. Appropriate to age 10. 6-12yrs Has develop some level of imagination Appropriate to age 11. Play; ✓ Imaginative play ✓ Associative play ✓ Formal play ✓ Competitive play ✓ Quiet play 6-12yrs Associative play Formal play Quite play Appropriate to age 12. Accident ✓ Motor vehicle accident ✓ Drowning ✓ Burns ✓ Poisoning ✓ Sports injury 6-12yrs Injury from fall Appropriate to age
  16. 16. TYPEPERSONALNAME ANATOMY AND PHYSIOLOGY
  17. 17. TYPEPERSONALNAME ORAL CAVITY Extends from the lips to the oropharyngeal isthmus. The oropharyngeal isthmus Is the junction of mouth and pharynx. Is bounded Above by the soft palate and the palatoglossal folds Below by the dorsum of the tongue Subdivided into Vestibule & Oral cavity proper VESTIBULE Slit like space between the cheeks and the gums Communicates with the exterior through the oral fissure When the jaws are closed, communicates with the oral cavity proper behind the 3rd molar tooth on each side Superiorly and inferiorly limited by the reflection of mucous membrane from lips and cheek onto the gums. The lateral wall of the vestibule is formed by the cheek The cheek is composed of Buccinator muscle, covered laterally by the skin & medially by the mucous membrane A small papilla on the mucosa opposite the upper 2nd molar tooth marks the opening of the duct of the parotid gland. It is the cavity within the alveolar margins of the maxillae and the mandible Its Roof is formed by the hard palate anteriorly and the soft palate posteriorly Its Floor is formed by the mylohyoid muscle. The anterior 2/3rd of the tongue lies on the floor. FLOOR OF THE MOUTH Covered with mucous membrane in the midline, a mucosal fold, the frenulum, connects the tongue to the floor of the mouth on each side of frenulum a small papilla has the opening of the duct of the
  18. 18. TYPEPERSONALNAME submandibular gland a rounded ridge extending backward & laterally from the papilla is produced by the sublingual gland TONGUE Mass of striated muscles covered with the mucous membrane divided into right and left halves by a median septum. Three parts: Oral (anterior ⅔) Pharyngeal (posterior ⅓) Root (base) Two surfaces: Dorsal Ventral
  19. 19. TYPEPERSONALNAME DISEASE CONDITION DEFINITION It results from failure of masses of lateral palatine processes to meet and fuse together. It may be unilateral or bilateral or may occur in isolation or with cleft lip. Cleft palate in isolation may found in the midline involving only uvula or reaches the incisive foramen through soft palate.cleft palate is found as an opening or elongated opening or fissure in the roof of the mouth which should be detected during routine neonatal examination. Causes • Genetic or due to unfavourable maternal factors. • Viral infections during 5th to 12th weeks of gestation. • Ingestion of drugs. • Exposure to x-ray. • Anemia and hypoproteinemia. Types of cleft lip and cleft palate ➢ Group 1(prealveolar) ➢ Group 2(postalveolar) ➢ Group 3(combined) Complication 1. Feeding problems due to ineffective sucking resulting in undernutrition. 2. Aspiration of feeds resulting respiratory infections. 3. Parental anxiety due to defective appearance of the infant. Long term problems 1. Recurrent infections especially otitis media. 2. Disturbed parent child relationship and maladjustment with nonacceptance of the infant. 3. Impairement of speech.
  20. 20. TYPEPERSONALNAME 4. Malocclusion and malplacement of teeth. 5. Hearing problems due to oral malformation especially in cleft palate. 6. Impaired body image. Surgical management Palatoplasty, the surgical reconstruction of the palate is done with repair of the cleft, at about age of 1 to 2 years of age. It should be done before the child develops defective speech. Nursing management ✓ Demonstration to be given to the mother and family members regarding feeding of the baby to prevent aspiration. ✓ Cleft palate baby may require palatal obturator which can make feeding easier. ✓ Precautions to be taken to prevent chocking. ✓ The infant to be placed in upright position during feeding. ✓ Burping to be done in between feeds. ✓ Monitoring of vital signs , bleeding from site of oeration, oral secretions, vomiting and crying. ✓ The infant should be kept dry , well fed and comfortable to prevent crying. ✓ Care of suture line to prevent infection is very important. ✓ mouth care and cleaning of suture line after each feed with normal saline or antiseptic mouth wash. ✓ Antibiotics ,analgesics and other prescribed medications to be administered with specific precautions. Nursing diagnosis 1. Risk for aspiration related to anatomic correction. 2. Altered nutrition less than body requirement related to the surgical management. 3. Disturbed body Image related to anatomical defect of palate. 4. Impaired verbal communication related to congenital defect. 5. Parental anxiety related to post operative period of child . 6. Disturbed family coping pattern related to hospitalization of the child 7. Impaired skin intergirity related to surgical management 8. Risk for infection related to hospitaliztion 9. Knowledge deficit related to post operative period . 10. .Altered play related to hospitalization
  21. 21. TYPEPERSONALNAME HEALTH EDUCATION MEDICINES : Antibiotics is given to fight an infection caused by bacteria. Give your child this medicines as exactly ordered by pediatrician.Tell him /her if the child is allergic to any medicines. FEEDING TECHNIQUES: Feeding your child can be difficult. Try to be calm the patient. this will help your child relax as she eats. Provide colourful and attractive foods. Parents should give attention to childrens likes and dislikes. SPEECH AND NUTRITION THERAPY: I adviced parents about childs need of speech therapy and you may also need to meet with dietician to know the best foods for your child. PERSONAL HYGIENE: I educated the parents and the child about importance of personal as well as the dental hygiene. Because of inadequate dental hygiene child can cause inflammation in palate region. I encouraged the child to maintain person hygiene such daiy bath and changing the dress and doing daily brushing the teeths it will reduce the chances of infecton. FOLLOW UP : Child may need to return to check this stitches and to measure weight. Immediately take the child to hospital if the child is not taking food well, reducing weight, sunken eyes, bleeding or gap in the repaired site.
  22. 22. TYPEPERSONALNAME RESEARCH STUDY : A study to Incidence of cleft Lip and palate in the state of Andhra Pradesh, South India. Srinivas Gosla Reddy, Rajgopal R. Reddy, Ewald M. Bronkhorst,1 Rajendra Prasad,2 Anke M. Ettema,3 Hermann F. Sailer,4 and Stefaan J. Bergé3 ABSTRACT Objective: To assess the incidence of cleft lip and palate defects in the state of Andhra Pradesh, India. Design Setting: The study was conducted in 2001 in the state of Andhra Pradesh, India. The state has a population of 76 million. Three districts, Cuddapah, Medak and Krishna, were identified for this study owing to their diversity. They were urban, semi-urban and rural, respectively. Literacy rates and consanguinity of the parents was elicited and was compared to national averages to find correlations to cleft births. Type and side of cleft were recorded to compare with other studies around the world and other parts of India. Results: The birth rate of clefts was found to be 1.09 for every 1000 live births. This study found that 65% of the children born with clefts were males. The distribution of the type of cleft showed 33% had CL, 64% had CLP, 2% had CP and 1% had rare craniofacial clefts. Unilateral cleft lips were found in 79% of the patients. Of the unilateral cleft lips 64% were left sided. There was a significant correlation of children with clefts being born to parents who shared a consanguineous relationship and those who were illiterate with the odds ratio between 5.25 and 7.21 for consanguinity and between 1.55 and 5.85 for illiteracy, respectively. Conclusion: The birth rate of clefts was found to be comparable with other Asian studies, but lower than found in other studies in Caucasian populations and higher than in African populations. The incidence was found to be similar to other studies done in other parts of India. The distribution over the various types of cleft was comparable to that found in other studies.
  23. 23. TYPEPERSONALNAME CONCLUSION : I had taken this case for casestudy and given 5 days care to the child. Ihave dealt with history collection ,physical examination,investigation ,drug study , assessment and nursing careplan and application of theory. I have given care for 5 daysto the child and given health education to the child as well as to the parents. The child and his parents were very cooperative during care.
  24. 24. TYPEPERSONALNAME BIBLIOGRAPHY • Parul data,text book of pediatric nursing , 3rd edition, jaypee brothers publication, page ;no: 420-422. • Wongs , essentials of pediatric nursing , 1st south asia edition, Hockenberry Wilson and judie, elseviers publications , page no: 687-690. • Gulanic / myes nursing care plan , nursing diagnosis and intervention 5 th edition , mosby publications , page no :761-762. • Ghai paul bagga , essential pediatrics , 7 th edition , cbs publications , page no:152,337 • www.Google.com
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