MUHIMBILI UNIVERSITY OFHEALTH AND ALLIED SCIENCES SCHOOL OF NURSING. PEDIATRIC NURSING CASE STUDY PRESENTATION PRESENTER: SONGOMA JOHN SUPERVISOR: MR .NDILE.
CASE PRESENTATION• PATIENT NAME:x.• AGE :8 Month• SEX :MALE• PLACE: kinyerezi• Registration No.A 673555.
HISTORY OF PATIENTThe patient is eight month old , male he is referral from Passada through Temeke with a diagnosis of PAID with severe malnutrition and anemiaCHIEF COMPLAINThe chief complain of child was weight faltering for three month and cough for two week.
HISTORY OF PRESENT ILLNESS• The mother reported the child to have been born with body weight of 3.5kg and attained weight and attained weight of 4.8kg in which the mother reported child have had episode of fever and recalls the maximum weight to have attained to have been 7kg for three month past where the child started deterating and recently the child weight 5kg
• The mother reported to have breastfeed exclusively only three month in which she introduced water , plain porridge with added salts in which the child fed four times a day Given ½ small cups and by 6 month age the child was introduced to stiff porridge mashed banana and potatoes , bean and meat occasionally fed 4-5 times a day . Recent child is being breastfed on demand
• The child started coughing 2 week prior to admission accompanied difficult in breathing but no fever . The cough was non productive and non postural rerated to related .• The cough has been progressive increasing more during the day time• In course of this illness the mother was counseled and tested for HIV tested and found to be positive.
PAST MEDICAL HISTORY .• Admission 2nd admission previous Temeke for fever , cough , difficult in breathing , malaria• Prenatal booked at 4th month of pregnancy . Attended at kisaki RCH• Checked for HIV non reactive• VRDL non reactive .• Given hematenics• Not given ant malaria• Deworm
• Natally delivery at term 3.5kg SVD at kisaki dispensary baby cried immediately after.• Postnatally stayed for one days and cord drops in three days.• Immunization : No BCG scar , No RCH card. Not received Measles and vitamin A .
Developmental historySocial smile achieved at in 2monthNeck control achieved in three monthSitting on support , crawling achieved in 5 month ,crasp .Now can not craw
FAMILY AND SOCIAL HISTORY• Single parent , mother was never living with her grand mother ,Not married , petty business women , std seven leaver and uses Tsh 4000/= for food per day• The child is the third child in family of three children.No history of TB contactNo history of inherited disease.
• REVIEW OF SYSTEM.• HEENT-hair was soft , there was no discharge.• GI : abdomen moves with respiration soft consistency palpation• RS : Symetrical chest moves with respiration• CVS:Normal• CNS: Recognize mother , follow the direction of objective , babinsk , normal
Medical diagnosis• PAID iv stage• Marasmus• Pneumonia• Severe anaemia
MEDICAL MANAGEMENT• At admission.5/6/2012Give 50ml dextrose 10% per oral start• Give 60ml of F75 2 hours• Administer IV ampicillin 350mg 6hourly for one week• IV Gentamycin• Tab folic acid
DIAGNOSTIC MEASURE DONE• HIV Serology DNA –PCR.• FBP• BS for malaria parasite.• Comprehensive chemistry panel• Urine test
Management which done by nurses and my self.• 7/6/2012• The patient weight was 5.3kg• The milk therapy given is F75- 90ml 3hourly• Vital sign monitored• Patient continued with antibiotics continued.
• 8/6/2012• The children given F75-90ml• Antibiotic was given as ordered• Vital sign monitored• The weight was 5.1kg.• 9/06/2012• The patients given F75-90ml• Antibiotics given as ordered• The weight of patient was 5.05kg.
• 11/06/2012.• The patient continued with F75-90ml• Continued with antibiotics• Tablet fluconazo 50mg o.d prescribed and given• Vital signs monitored• 12/06/2012.• The patient given F100-90ml• Guathrone cream prescribed
• 13/06/2012.• The child continued given F100-90ml 3hrs• The vital signs monitored• Weight was 5.2kg• The patient continued with antibiotics• 14/06/2012.• F100-90ml the volume increased each feed by 10%maximum was 145.• Continued with antibiotics
• 15/05/2012.• The child send to VCT and started ARVS• Continued with F100-145ml• 16/06/2012• The patient discharged after nutrition counselling.
Nursing diagnosis1.Potential to hypothermia related to low energy store• INTERVETION-• Cover the child to protect from heat loss• Keep the room temperature warm• Monitor vital signs
2.Potential to infection related to impaired body immunity• INTERVENTION• Aseptic technique adhered ,hand washing was observed, mother taught to wash hand and wash clothes of child every day.• Antibiotics was administered as prescribed.
3.Nutritional imbalance , less than body requirement related to disease condition and inadequate food intake as evidenced by severe wasting.Interventions.• The food F75 and F100 provided every 2 hour at fist and then every 3 hours• The mother taught on how to feed the child at home after discharge.• To educate the mother do not give other food to avoid interfere with milk therapy.
• 4.Dehydration related to impaired absorption as evidenced by dry mouth , decrease skin tag• Intervention.• Give oral rehydration therapy.
Etiology• HIV is a retrovirus that is transmitted by lymphocytes and monocytes.• It is found in the blood, semen, vaginal secretions, and breast milk. It has an incubation period of months to years . There are different strains of HIV. HIV-2 is prevalent in Africa, whereas HIV-1 is the dominant strain in the United States and elsewhere.• Horizontal transmission of HIV occurs through intimate sexual contact or parenteral exposure to blood or body fluids containing visible blood. Perinatal (vertical) transmission occurs when an HIV-infected pregnant woman passes the infection to her infant. There is no evidence that casual contact between infected and uninfected individuals can spread the virus.
Pathophysiology• The HIV virus primarily infects a specific subset of T lymphocytes, the CD4+ T cells. The virus takes over the machinery of the CD4+ lymphocyte, using it to replicate itself, rendering the CD4+ cell dysfunctional. The CD4+ lymphocyte count gradually decreases over time, leading to progressive immune deficiency. The count eventually reaches a critical level below which there is substantial risk of opportunistic illnesses followed by death.
Clinical Manifestations• Common clinical manifestations of HIV infection in children are varied .The diagnosis of AIDS is associated with certain illnesses or conditions.• The most common AIDS-defining conditions observed among American children Other problems in these children may include short stature, malnutrition, and cardiomyopathy. CNS abnormalities resulting from HIV infection may include neuropsychologic deficits; developmental disabilities; and deficits in motor skills, communication, and behavioral functioning.
Common Clinical Manifestations of HIV Infection in Children• Lymphadenopathy• Hepatosplenomegaly• Oral candidiasis• Chronic or recurrent diarrhea• Failure to thrive• Developmental delay• Parotitis
Common AIDS-Defining Conditions in Children• Pneumocystis carinii pneumonia (PCP)• Lymphoid interstitial pneumonitis (LIP)• Recurrent bacterial infections• Wasting syndrome• HIV encephalopathy Candidal esophagitis• Cytomegalovirus disease• Mycobacterium avium-intracellulare complex infection• Severe herpes simplex infection• Pulmonary candidiasis• Cryptosporidiosis
Diagnostic Evaluation• For children 18 months of age and older, the HIV enzyme- linked immunosorbent assay (ELISA) and Western blot immunoassay are performed to determine HIV infection. In infants born to HIV-infected mothers, these assays will be positive because of the presence of maternal antibodies derived transplacentally. Maternal antibodies may persist in the infant up to 18 months of age. Therefore other diagnostic tests are employed, most commonly the HIV polymerase chain reaction (PCR) for detection of proviral DNA. With this technique, more than 95% of infected infants can be diagnosed by 1 month of age (Ezekowitz and Stockman, 2003).• The Centers for Disease Control and Prevention (CDC) (1994
Therapeutic Management• The goals of therapy for HIV infection include slowing the growth of the virus, preventing and treating opportunistic infections, and providing nutritional support and symptomatic treatment. Antiretroviral drugs work at various stages of the HIV life cycle to prevent reproduction of functional new virus particles. Although not a cure, these drugs can suppress viral replication, preventing further deterioration of the immune system, and thus delay disease progression. Classes of antiretroviral agents include nucleoside reverse transcriptase inhibitors (e.g., zidovudine, didanosine, stavudine, lamivudine, abacavir), nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine, delavirdine, efavirenz), nucleotide
• reverse transcriptase inhibitors (e.g., adefovir), protease inhibitors (e.g., indinavir, saquinavir, ritonavir, nelfinavir, amprenavir), and adjunctive antiretrovirals (e.g., hydroxyurea). Combinations of these drugs are used to forestall the emergence of drug resistance. Antiretroviral therapy regimens and guidelines are continually evolving. Therapy is lifelong, making adherence difficult. Laboratory markers (CD4+ lymphocyte count, viral load) assist in monitoring both disease progression and response to therapy.
• Immunization against common childhood illnesses is recommended for all children exposed to and infected with HIV . Varicella (chickenpox) vaccine and measles-mumps- rubella (MMR) vaccine can be administered if there is no evidence of severe immunocompromise close contacts. The pneumococcal and influenza vaccines are recommended. Because antibody production to vaccines may be poor or decrease over time, immediate prophylaxis after exposure to several vaccine-preventable diseases (e.g., measles, varicella) is warranted.• It should be recognized that children receiving IV gamma globulin prophylaxis may not respond to the MMR vaccine
• HIV infection often leads to marked failure to thrive and multiple nutritional deficiencies.• Nutritional management may be difficult because of recurrent illness, diarrhea, and other physical problems.• Intensive nutritional interventions should be instituted when the childs growth begins to slow or weight begins to decrease Malnutrition continues to be a major health problem in the world today, particularly in children younger than 5 years of age. Lack of food, however, is not always the primary cause for malnutrition
MALNUTRITION• Malnutrition continues to be a major health problem in the world today, particularly in children younger than 5 years of age. Lack of food, however, is not always the primary cause for malnutrition. In many developing and underdeveloped nations, diarrhea is a major factor. Additional factors are bottle-feeding (in poor sanitary conditions), inadequate knowledge of proper child care practices, parental illiteracy, economic and political factors, and simply the lack of adequate food for children.. The most extreme forms of malnutrition, or protein and energy malnutrition (PEM), are kwashiorkor and marasmus.• In the United States milder forms of PEM are seen, although the classic
• In many developing and underdeveloped nations, diarrhea is a major factor. Additional factors are bottle-feeding (in poor sanitary conditions), inadequate knowledge of proper child care practices, parental illiteracy, economic and political factors, and simply the lack of adequate food for children.. The most extreme forms of malnutrition, or protein and energy malnutrition (PEM), are kwashiorkor and marasmus.• In the United States milder forms of PEM are seen, although the classic
• Marasmus results from general malnutrition of both calories and protein. It is a common occurrence in underdeveloped countries during times of drought, especially in cultures where adults eat first; the remaining food is often insufficient in quality and quantity for the children.• Marasmus is usually a syndrome of physical and emotional deprivation and is not confined to geographic areas where food supplies are inadequate. It may be seen in children with failure to thrive in whom the cause is not solely nutritional but primarily emotional
• . Marasmus may be seen in infants as young as 3 months of age if breast-feeding is not successful and there are no suitable alternatives. Marasmic-kwashiorkor is a form of PEM in which clinical findings of both kwashiorkor and marasmus are evident; the child has edema, severe wasting, and stunted growth. Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears to be very old, with flabby and wrinkled skin, unlike the child with kwashiorkor, who appears more rounded from the edema. Fat metabolism is less impaired than in kwashiorkor, so that deficiency of fat-soluble vitamins is usually minimal or absent.
• The child is fretful, apathetic, withdrawn, and so lethargic that prostration frequently occurs. Intercurrent infection with debilitating diseases such as tuberculosis, parasitosis, HIV, and dysentery is common
Therapeutic Management• The treatment of PEM includes providing a diet with high-quality proteins, carbohydrates, vitamins, and minerals. When PEM occurs as a result of diarrhea (see also Diarrhea, Chapter 24), three management goals are identified: (1) rehydration with an oral rehydration solution that also replaces electrolytes, (2) medications such as antibiotics and antidiarrheals, and (3) provision of adequate nutrition either by breast- feeding or a proper weaning diet. When the child is too ill to tolerate oral fluids, intravenous administration of fluids, electrolytes, minerals and vitamins will be required to prevent death. Additional management of PEM is aimed at restoring or replacing essential vitamins and minerals, namely vitamin E, vitamin A, selenium, and zinc which have been shown to have significant roles in infection and congestive heart failure related to PEM