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Bronchopneumonia Case Presentation

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    SUBMITTE TO: SUBMITTED BY: Mrs. INDHRANI Lecturer Mrs.SUJATHA Pediatric Nursing 1 ST  YEAR M. Sc Nursing Varalakshmi College of Nursing Varalakshmi College of Nursing Bangalore Bangalore    PAEDIATRIC NURSING CARE PLAN. I. GENERAL INFORMATION  Name of the child : Master . Nitesh Gender : male Age : 2.7years Religion : Hindu Date of admission : 18  –   01  –   2009 IP.No : 540251 Provisional diagnosis : Broncho Pneumonia. Final diagnosis : Broncho Pneumonia II. INTRODUCTION As a part of my clinical requirement when I had been posted to Vani Vilas Hospital, I selected a  patient by name master Nitesh who is been diagnosed as gastroenteritis to provide complete nursing care by using a nursing Process. I provided her care from 19.01.09 to 21.01.09. III. REASON FOR HOSPITALISATION The child has difficulty in breathing some wheezing sounds during breathing. IV.PAST SIGNIFICANT MEDICAL AND SURGICAL HISTORY The child has no history of any past medical or surgical history. V. PRESENT MEDICAL AND SURGICAL HISTORY Mother of the child complained that the child had cold and cough since 3 days after which he developed a serious condition and was unable to breathe adequately due to which he was having difficulty and wheezing type of breath sounds could be heard he also has fever since 3 days of intermittent type .the child is feeling very lethargic and refusal to diet.  VI. SIGIFICANT FAMILY HISTORY   There’s no history of any familial diseases or any congenital diseases in the family or siblings and no history of hypertension and diabetes mellitus. VII. PRENATAL HISTORY: There is not consangeous marriage. Antenatal period mother has all antenatal checkups and had been immunized there was no history of any abnormal condition during pregnancy. During pregnancy there was no history of illness during the pregnancy. Intake of mother during  pregnancy m other had only iron and folic acid tablets and didn’t have any other drugs that could affect the pregnancy. VIII.NATAL HISTORY After the full term the baby was delivered by lower segment caesarean section and baby weighed around 2.3 kgs and cried immediately with the apgar scoring to 8 at 1 min and 10 at 5 min. POSTNATAL HISTORY : The child was normal breast feed and there was no complication during the postnatal  period. There were no signs of infection .the mother had normal involution of the uterus. IX. NEONATAL HISTORY Condition of child at birth-  The child was normal during the birth and did not show any congenital abnormality or signs of distress Birth weight - 2.3kgs History of illness up to 1 month  - child had fever of intermittent type for 2 days which was relived on administering medicine and latter was apparently alright and had no complaints and was healthy.  X.IMMUNISATION SECHDULE Sl. No Name of the vaccine Scheduled time of administration Route of administration Given Not given 1 BCG At birth Intradermal Yes 2, Oral polio vaccine At birth, up to 5 years oral Yes 3. DPT 6wks,10 wks.14wks Intramuscular Yes 4. MMR 9 months subcutaneous Yes 5. Hepatitis 6wks,10 wks, intramuscular Yes IX.NUTRITIONAL HISTORY Till the 7 months of age of the child he was under breast feeding and additional feeding started from 8 th  month. At present the child has one chapatti in morning with 1 glass of mild and midmorning has 4 biscuits afternoon has 1 cup rise dal at 4 pm has 1 cup of mild with 2 biscuits and at 6pm has any one fruit and at 8 pm 1 chapatti and water intake is up to 1 liter. APPETITE- presently due to his disease condition is reduced and the child refuses for the feeds and feels very lethargic. Nutritional assessment The child weighs 12kgs which is on average to his age his anthropometric measurements are nearly to the normal measures hence the child is not malnourished his nutritional status is to the moderate level. X. GROTH DEVELOPMENT ASSESSMENT 1.   Developmental history:  The child has attained all milestones. He has attained control over his head during his 4 the month and sitting during 7 th  month crawling at 9 months and walks without support since 13 months he has almost got control over the bladder and bowel both during night and day since on 2months back. 2.   Motor development: Gross motor activity  –   the child rides tricycle .He jumped off bottom step and stands on one foot for few seconds ,goes upstairs using alternate feet ,may till come down using both feet on step child may try to dance ,but balance is not adequate for complex activities .  
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