Friday, September 20, 2013

A CASE STUDY REPORT ON “JAUNDICE”


 purbhanchal university
Asian college for advance studies
Satdobato, Lalitpur




A CASE STUDY REPORT ON
“JAUNDICE”
                                                          IN
CHILD HEALTH NURSING PRACTICUM



                 SUBMITTED BY:
                    SMRITI MANANDHAR
                     PBN 1ST YEAR
 
Acknowledgement


This case study report is prepared during The Child Health Nursing clinical practicum in Kanti children hospital,Maharajgunj.  The report is prepared as a practical fulfillment of post basic PBN curriculum. I realized that the requirement to do complete case study in the hospital area has been an important opportunity for me to gain new experience and knowledge in this field.

I got myself complete involved in the care and management of the patient during this period. However the work would not have been accomplished successfully with my effort alone.

I would like to express my sincere gratitude to all teachers of my colleges ,hospital, hospital members and the staffs for providing valuable guidance, supervision and suggestions in the clinical field area.

I am also thankful to my colleagues and my patient and her family who gave me their valuable time for providing necessary information and kind cooperation during this period.

Finally, I would like to thank all of them who gave me their precious, valuable time and suggestions directly or indirectly while preparing this case study.




BACKGROUND

As a partial fulfillment of Post Basic Bachelor of Nursing curriculum of Purwanchal University under practicum of Child Health Nursing, we were supposed to do 3 weeks practicum at Kanti Hospital where we, individually were supposed to do a detailed case study of a patient.

            During the practicum period, I did a case study in Jaundice. I found interesting case of Jaundice at Kanti Hospital during my practicum period, so I took this case so that I could learn and get to know more about this diseases condition.

Shishir Kunwar, 5month old male was admitted with the diagnosis of Prolonged jaundice .I gave holistic nursing care to the client and tried to make him comfortable in hospital and solve his problem. I got to learn many new things from this case study.
   
           


OBJECTIVES:

GENERAL OBJECTIVES:
           
General objectives of this case study are to gain comprehensive knowledge about the disease, to gain the practical knowledge about the health problem, to gain practical experience working with a patient having illness and provide holistic care to the patient.



SPECIFIC OBJECTIVES:

1.      To gain knowledge about one specific disease and its management.

2.      To provide holistic nursing care to the patient by using nursing process.

3.      To identify normal developmental tasks of patient age group.

4.      To apply knowledge from the basic science, nursing theories and other related courses to plan and implement nursing care.

5.      To provide health teaching according to the need of the patient.

6.      To minimize the stress of the patient and her family by using appropriate diversional therapy.

7.      To communicate effectively while providing care to the patient.



Patient's Profile


Mr.Shishir Sunwar,5mth male child admitted to Kanti Child Hospital on 069/03/28 with the diagnosis of prolonged jaundice . The chief complain manifest by mother shows the child was apparently well 4 month back, then he gradually develops the ywllowisn discolouration of the eye,skin and tongue.there was even presence of protusion in his umbilical site while crying.
There isn’t any Perinatal complication. He was a normally vaginal delivered full term child weigh 2300 gram with normal reflexes. He has been immunized as per NIP.No any history of previous hospitalization or illness.
His family doesn’t have any family history of jaundice or any other chronic illness like tuberculosis, diabetes, asthma, cancer  in his family.He was from the nuclear family with is grand parents and parents. He was the only son of his parents.
On physical examination,
The patient was alert, active ,well nourished baby with pallor(+), icterus (+ ), edema(+) and dehydration (-)
Vital signs within normal ramge.
Local examination reveals
  Ø  Icteric tongue and eye/skin
  Ø  Umbilical hernia present
  Ø  Cerebral vascular system S1S1M0
  Per abdomen examination reveals
  >tenderness of flank
  > hepato-splenomegaly
 
  > umbilical hernia



DEVELOPMENTAL TASK OF MY PATIENT:
As my client was 5 month old, he is an infant, developmental task is given below:


Erik Erikson’s theory shows “Trust Vs Mistrust”(Oral -sensory) (Birth -2 years):
    
  ¯  Existential Question: Can I Trust the world?

The first stage of Erik Erikson’s theory centers around the infant’s basic needs being met by the parents and this interaction leading to trust or mistrust. Trust as defined by Erikson is “an essential truthfulness of others as well as fundamental sense of one’s own trustworthiness”. The infant depend on parents, especially the mother, for sustenance and comfort. The child ‘s relative understanding the world and society come from parents and their interaction with the child.If the parents expose the child to the warmth ,regularity, and dependable affection. The infant’s view of the world will be one of trust. Should the parents fail to provide a secure environment and to meet the child’s basic needs a sense of mistrust will result. Development of mistrust can lead to feelings of frustration, suspicion, withdrawl and a lack of confidence.

According to Erik Erikson, the major development task in infancy is to learn whether or not other people, primary caregivers, regularly satisfy basic needs. If caregivers are consistent sources of food , comfort , and affection ,an infant learns trust other  are dependable and reliable .If they are neglectful or perhaps even abusive,the infant instead learn ,mistrust –that the world is in an undependable, unpredictable and possibly dangerous place. While negative, having some experience with mistrust allows the infant to gain an understanding of what constitutes dangerous situations later in life.



Developmental milestones
Seen in my patient
Motor skill development
                  a.      Gross motor
               -rolling over
                 b.      Fine motor
               -reaching out with both or one hand ,transfer objects

Language behaviors
               -monosyllabus

Personal Social behaviors
           -smiles at mirror image

Psychosocial development
    
Trust vs. Mistrust
           -can tolerate a delay need gratification


All these development task were present in my client ‘s case.

S.N
Developmental task according to book
Seen in my patient

1.


2


3
    

4


5

6


7


8

9


Achieve equilibrium of organs, systems functions after birth

Establish self as a dependent person separate from other

Become aware of the environment; familiar versus unfamiliar and develop basic social interaction

Develop a feeling of desire for affection and response from others

Adjust somehow to the expectation of others

Begin to learn new motor skills, develop equilibrium, begin eye hand coordination

Begin to understand and master the immediate environment through exploration

Learn to use symbol or language system

Direct emotional expression to indicate needs and wishes.


All these development task were present in my client ‘s case.










DISEASE PORTION




JAUNDICE

Definition:
An excessive level of accumulated bilirubin in blood and is characterised by “hyper bilirubinemia” or “Icterus”.this may be as the result of increased unconjugated and conjugated bilirubin level above normal.

Jaundice comes from the French word “Jaune” which means yellow.


Jaundice is the clinical term used for the yellowish discoloration of the mucus membrane and skin due to increase serum bilirubin level more than 4-5 mg/dl in the new born.
Prevalence

Signs of Neonatal Jaundice are seen within the first three days of birth in 80% of preterm babies and 60% of full-term infants
 Jaundice persisting beyond 14 days of age (prolonged jaundice) can (rarely) be a sign of serious underlying liver disease (Hussein, 1991). Jaundice persists beyond 14 days in 15-40% of breastfed infants, depending on the series studied (Hannam, 2000). A prospective study of all 7139 term infants born at King’s College Hospital (London) between January 1997 and June 1998 (Hannam, 2000) found 154 with prolonged jaundice, one of which had conjugated hyperbilirubinaemia (0.14 per 1000 live births).
Another study of 3661 babies in Sheffield (Crofts, 1999) found 127 who were jaundiced at 28 days, of which 125 were breastfed (9.2%).
Although preterm infants, whose livers are more immature, have prolonged jaundice more commonly than term infants (Fenton, 1998) there appear to be no studies of incidence in this group (Lucas, 1986).
Etiology

Signs of Neonatal jaundice are seen within the first three days of birth in 80% of preterm babies and 60% of full term infants.The journal of Paediatrics reports a retrospective study,which observed that the incidence of Jaundice is higher in breast feed babies than in the formula feed ones.

Causes of jaundice:

      ·         Physiological jaundice
      ·         Pathological jaundice associated with liver disease
      ·         Rh and ABO incompatibilty
      ·         Inherited cause of hemolytic disease i.e.glucose 6 phospate dehydrogenase deficiency
      ·         Erythroblastosis Fetalis
      ·         Breast milk jaundice
      ·         Jaundice due to sepsis
      ·         Hemolysis due to drugs (quinine),poison(snake venom)
      ·         Congenital biliary atresia and obstructive jaundice
      ·         Inborn errors of metabolism:Galactosemia,Hypothyroidism,glucuronyl transferase deficiency

Types of jaundice:

I.Physiological jaundice:
It is common in newborn babies. It usually becomes noticeable during the baby's first three to five days of life. It disappears as the baby's liver matures. This type of jaundice is not harmful.

II.Hemolytic jaundice:
This type of jaundice develops when there is Rh incompatibility and ABO in compatibility between the mother and the fetus.

            Rh incompatibility occurs when the mother is Rh negative and the fetus is Rh positive, having inherited gene for the Rhesus factor from his/her parents

            ABO incompatibility may present if the mother has blood group “O” and baby has type “A “or “B” .then the mother makes Anti A or Anti B type anti bodies of the IgG glass and cross the placenta causing destruction of the baby’s red blood cells.

III.Pathological Jaundice:

In some situation however there is so much billirubin in baby’s blood that it can be harmful .This condition is called Pathological Jaundice.If the level of bilirubin becomes very high ,it may affect some of the baby ‘s brain cells. This may cause a baby to be les active.In rare cases ,a baby may have seizures (convulsions).Pathological jaundice may lead to deafness ,cerebral palsy and /or mental retardation. Pathologic jaundice can occur in children or adults. It arises for many reasons ,including blood incompatibilities, blood diseases, genetics syndromes ,hepatitis , cirrhosis ,bile duct blockage ,other liver diseases ,infections ,or medications.

IV. Jaundice of prematurity:
This occurs frequently in premature babies since they take longer to adjust to excreting bilirubin effectively.

V. Breast Milk Jaundice:
In 1% to 2% breast fed babies, jaundice can be caused by substances produced in their other’s breast milk that can cause the billirubin level rise above 20 mg.These substances can revent the excertion of bilirubin through the intestines.It starts at 4 to 7 days and normally lasts from 3 to 10 weeks. The cause is thought to be inadequate milk intake ,leading to dehydration or low caloric intake.It is a type of physiologic or exaggerated physiologic jaundice.

VI. Not enough breast milk Jaundice:
This may occur because the baby is not getting enough milk.This is because sometimes the mother’s milk takes a longer than average time to “come in”, or because the baby is poorly latched on and thus not getting the milk which is available.

VII. Inadequate Liver Function:

Jaundice may be related to inadequate liver function due to infection like TOCH and sepsis or other factors.


In other aspect of classification, according to the onset and duration of the jaundice it can be classified into:

I.         Within 36 hours:
Usually pathological jaundice appears within 36 hours of life. This may involve haemolytical jaundice usually due to Isoimmunisation, G6PD deficiency and other congenital infections.

II.         After more than 36 hours:
Usually the jaundice appearing after more than 36 hours of life are physiological jaundice or may be pathological jaundice due to drugs or sepsis.


III.         Prolonged jaundice(more than 2-3 weeks):
     The jaundice appears for more than 3 weeks in pre term and more than 2 weeks in term infant .It may be conjugated or unconjugated. About more than 15% of the cases seems to be conjugated jaundice.
This type of jaundice might occur due to
·         Bile duct obstruction
·         Endocrine disorder(hypothyroidism)
·         Metabolic disorder(Galactesemia)
·         Breast milk
·         TORCH infection
·         Viral hepatitis α-antitrypsin deficiency, cystic fibrosis.
In my patient, PROLONGED JAUNDICE is present leading to inadequate liver function with the relevant cause of TORCH positive, and Hypothyroidism

Pathophysiology:
Bilirubin is one of the breakdown product of haemoglobin result from Red Blood Cell(RBC) destruction.When RBC is destroyed ,the breakdown product are release into the blood circulation where haemoglobin splits into two fraction:hame and globin. The globin (protein) portion is used by the body and the heme is converted to conjugated bilirubin, an insoluble substance to albumin.
In liver ,the bilirubin is detached from the albumin molecule in presence of enzyme glucornyl transferase is conjugated with glucuronic acid to produce a highly soluble ,conjugated bilirubin glucoronide ,whivh is then excreted into the bile.In the intestine ,bacterial action reduces the conjugated bilirubin to urobilirobinogen ,the pigment that gives the stool its characteristics color.Most of reduce bilirubin is excreted through feces.
Normally, the body is able to maintain a balance between the destruction of RBCs and the use and excretion of the byproducts.However, when developmental limitation or a pathologic process interferes with this balance; bilirubin accumulates into tissue to produce jaundice.







                                   
                       


Signs and symptoms of jaundice

The symptoms of jaundice are extreme weakness, headache , and fever ,loss of appetite ,severe constipation ,nausea ,and yellow discoloration of the eyes ,tongue ,skin and urine
The patient may also feel a dull pain in the liver region.Obstructive jaundice may be associated with intense itching.

In my patient,the yellowish discoloration of the sclera,skin and tongue is present.


Diagnosis:

      a.    History Taking: Positive family history of jaundice and anaemia,Previous babies with                   jaundice
     b.    Family history of neonatal or early infant deaths due to liver disease suggesting                            Galactesemia.
     c.    Maternal drugs such as sulphonamides or antimalarial drugs causing haemolysis in baby
    d.    Physical examination findings: Presence of yellowish staining of sclera ,skin and mucus       membrane.
    e.    A blood test will confirm the raised bilirubin level and other tests such as those for hepatitis and haemolysis are also done on the blood.
Ø  Blood serum bilirubin
Ø  Complete blood count
Ø  Liver function test and bilirubin
Ø  Prothombin time
Ø  Bleeding time
Ø  Clotting time

      f.     Urine and fecal test(urobilinogen)
    g.    Ultrasound scanning of the liver and bile ducts for signs of obstruction,which often can give  useful information on the pancreas gland.
     h.    Endoscpic retrograde cholangiopancreotography
     i.      Ct scanning also helps to diagnose obstructive jaundice accurately


Investigation done in my patient:


Investigation item                                 findings                  normal range
                                            2069/03/27
WBC                                                   9800/cu mm              (4,000-11,000)
Polymorph                                           54   
Lymphocytes                                       46
Hb                                                        8.7gm%                          (13.5-17.5)
Total protein                                         6.5                            (6-8gm%)
Albumin                                                 3.2                           (3.5-5.2 gm %)
Bilirubin (Total)                                      16.6                         (0.4-0.8mg%)
Bilirubin (conjugate)                              11.2                          (0.4mg%)
Alkaline phosphate                               1220
SGPT                                                    655

                                     URINE EXAMINATION
Macroscopic                                       Color  light yellow
                                              
pH                                                      Acidic
Sugar                                                 Nil
Appearance                                       clear
Albumin                                              Nil
Microscopic
Puscell                                               NIl
RBC                                                   Nil
Cast                                                   Nil
Crystal                                                Nil
Epithelial cells                                    Nil
Bacteria                                              Nil

                                      2069/3/28
Thyroid function Test

T3                                                       5.42                              (4.2-8.1pmol/l)
T4                                                       14.9                              (10.0-28.2pmol/l)
TSH                                                    6.76microunit/ml           (0.4-4.6mIU/ml)
Ultrasonography :
Liver :normal
Gall Bladder: Normal
Kidney: Bilateral mild hydronephrosis,loss of CMD(corticomedullary differentiation)
Impression :? Medico renal disease

                                                069/3/29
Ultrasonography :
Liver :normal
Gall Bladder: Normal
Kidney: right lateral hydronephrosis with echogenicity of bilateral kidney
Impression : Right in thinned out Renal Parenchyma CMD layered
                Hb electrophoresis
Hgb                                        6.4gm%
PCV                                       21.7%
RBC                                      27,900,00cmm
WBC                                     12800/cmm
Platelets                                184000
Retics                                     4.0
MP corrected                          2%
HbF                                         0.8%
HbA2                                       3.6% 
 Hb Electrophoresis: Normal banded Speen;Normal Hb Electroporesis

                                     
                                         069/04/1
Ultrasonography :
Liver :7.8 mm with normal echotexture
Spleen: 7.2 mm with normal texture 
Kidney: Mild dilatation at right kidney
Impression : spleenomegaly
                      Mild hydronephrosis

                                    
                                   069/04/03
Hb                                      4.8

                                     
                                     069/04/04
Cholesterol                       174mg%                                150-250mg%
Total Protein                     6.2                                          6-8g%
Albumin                            4.1                                          3.5-5.2
Bilirubin Total                   21.1                                         0.4-0.9mg%
Bilirubin Congugate          15.3                                         0.4gm%
SGPT                                 285
SGOT                                  208
PT                                       18 sec                                     (12 sec)
APTT                                   26sec                                       (23sec)

Anti HCV test                       NON REACTIVE
HbsAg                                  NON REACTIVE

TORCH IgM Antibody test result(Method ELISA)
Toxoplasma gondii                                 NEGATIVE
Rubella Virus                                          NEGATIVE
Cytomegalovirus                                     NEGATIVE
Herpes Simplex Virus I                           NEGATIVE
Herpes Simples Virus II                          NEGATIVE

TORCH IgG Antibody test result(Method ELISA)
Toxoplasma gondii                                 778                       <50iu span="span">
Rubella Virus                                          283                       <10iu span="span">
Cytomegalovirus                                     10.3                       <0 .5iu=".5iu" span="span">
Herpes Simplex Virus I                           148                         <5 .0iu=".0iu" span="span">
Herpes Simples Virus II                          1.6                          <5 .0iu=".0iu" span="span">

Preventions of Jaundice:
Although jaundice cannot be totally prevented but recognition and treatment are important in preventing bilirubin levels from rising to dangerous levels.If your baby’s color id turning more yellow , promptly call your baby’s physician.
·         Feed babies frequently and don’t let them become dehydrated
·         With jaundice,the important thing to prevent kernicterus –toxic levels of bilirubin accumulating in the brain. Early identification and treatment of jaundice will usually prevent kernicterus, whatever the cause.
Treatment of Jaundice:

Most jaundice needs no treatment,but when it does,the given below treatments are possible:
      1.    Encourage frequent nursing ,at least 8-10 times per day and avoid pacifiers.
    2.    Avoid supplementation of mother’s milk with water  or glucose water.If supplementation needed due to some reason then give expressed breast milk of formula feeding approximately   30ml/feeding for term and near term infants.
      3.    Halted breast feeding until bilirubin level drop in case of prlonged jaundice
     4.    Phototherapy (light therapy) is  considered very safe and effective.Placing the baby under blue “bililights” lights – naked in a bassinet,with his eyes covered – will often do the trick because ultraviolet light changes the bilirubin to a form that your baby can more easily dispose of in his urine.
      5.    Fibre optic blanket:another option involves wrapping the baby in a fibre optic blanket called a bili-blanket or bili-pad
   Phototherapy is usually effective,but if a baby develops a severe case of jaundice ,or his bilirubin levels continue to rise despite phototherapy treatment ,he may need to be admitted to the intensive care unit for a blood transfusion called an “exchange transfusion”.


If left untreated ,Hyperbilirubinemia due to Neonatal Jaundice can result in mental retardation,cerebral palsy, behavioural problems,hearing loss or even loss of life.

Nursing consideration of child with jaundice:

     1.      Routine physical assessment of baby chould be done by observing the color of the sclera and the skin            ,including palms,soles and mucus membrane at regular intervals under natural lights

     2.      Reorganization anf differentiation of type of jaundice and early refferal

     3.      Provide supportive care
·         Early breast feeding
·         Optimal thermal environment
·         Sterile saline soaked dreesing in umbilical cord for possible exchange transfusion
·         Maintain intake/output chart accurately
·         Fluid volume correction
·         Assist in medical therapies such as collection and sending of investigations

     4.      Monitor vital signs and record accurately

    5.      Emotional support:parents need constant reassurance,clear explanation about infant’s condition in                  understanding level

    6.      Prevent blood incompatibility:
·         Encourage pregnant women to seek early antenatal care
·         Determine blood group
·         Administer RHoGAM to Rh-negative mother at delivery or during abortion

   7.      Identify infants at risk for hyperbilirubinimia and kernicterus:
·         Observe color of amniotic fluid at time of rupture of membrane and delivery
·         Early detection and early referal to physician
·         Early detection of risk conditions(acidosis,hypoxia,and hypothermia) that decreased the risk of kernicterus

    8.      Care of baby receiving phototherapy
·         Assure effectiveness irradiance by placing the babay to machine at distance of 45 cm change bulbs every 2000hours of used,periodic checks of spectrum of irradiance produced by sifferent photo therapy units
·         Provide eye protection:ensure the closure of the lids before applying shield and check eye fordischarge,irritation and pressure as well.Gently clean the infant’s eye strile cotton or soft gauze moistened with sterile water or saline,starting with the inner canthus of the eye on moving outward in a single,smooth stroke.A separate cleaning pad should be used for each eye.
·         Change the position of the baby frequently(every three hourly)
·         Monitor vital signs every 4 hourly
·         Assess skin exposure :the largest area of the infant’s body,the trunk should be positioned in the center of the light,where irradiance highest and change position as per need.Remove diapers for intensive phototherapy when the serum bilirubin level approaching high level.
·         Assess and adjust thermo regulation devices
·         Promoting elimination and skin integrity

     9.      Maintain hydration
·         Assess early sign of dehydration
·         Ensure that the baaby is fed
·         Encourage mother to breast fed at least every three hourly.If baby receiving intravenous fluid or expressed breast milk ,increasethe volume of fluid by 10% of total daily volume per day as long as the baby is under photo therapy
·         Maintain intake output chart
·         Promoting parent –infant interaction:unless jaundice is severe,photo therapy can safely to interrupt at feeding time,allow parental visits and encourage skin to skin contact
·         Monitoing bilirubin levels:The most significant decline in bilirubin level occurs in the first 4-6 hours after initiating photo therapy so assess bilirubin periodically
·         Proper recording of duration and type of therapy

     10.  Care of baby receiving exchange transfusion
·         Give infant nothing by mouth prior to procedure(usually for 3-4 hours)
·         Check donor prior transfusion
·         Assist physician during tranfusion
·         Monitor optimal body temperature during procedure
·         Observe signs of exchange transfusion reactions
·         Keep resustication equipment ready at bed side(baby size)
·         Apply aterile dressing to catheter site and check for bleeding
·         Keep nrecording accurately(amount of blood infused anf withdrawn)
·         Observe for complications
·         Observe for signs of central nervous system depression such as lethargy,hypotonia,poor sucking,convulsions,high pitched cry
·         Observe for hypothermia,dehydration and diarrhoea and bronze-baby syndrome
·         Observe for cord bleeding and infections

    11.  Follow up care and visit:periodic assessment of baby’s condition,breastfeeding,observe for signs of anaemia and provide ferrous sulphate supplementation at 2-3 month period

   12.  Parent teaching on:disease,treatment,homecare,nutritional care,signs of severity,infections etc.

Complications:
         a.      Acute bilirubin encephalopathy
         b.      Kernicterus
         c.       Abnormal motor movement
        d.      Behavior disorder
        e.      Sensor neural hearing loss

NURSING MANAGEMENT:

Assessment:

During patient's assessment, I observed following things:
Patient's general condition.
Vital signs.
Nutritional status
Anxiety level of parents.


NURSING DIAGNOSIS:
           ·         Imbalanced Nutrition:Less than Body requirements related to inadequate intake and                diarrhoea
           ·         Impaired skin integrity related to hyperbilirubinemia and diarrhoea
           ·         Anxiety related to change in health status(patient’s mother)
           ·          Fluid volume deficit r/t poor absorption
·          Potential for altered growth-due to liver disease
·          Altered Growth and Development r/t chronic illness
·          Health Maintenance Altered, need for family to monitor for symptoms of increased liver dysfunction






NURSING CARE PLAN


SN
Nursing diagnosis
Nursing goal
Nursing intervention
Rationale


Evaluation
1.
Imbalanced Nutrition:Less than Body requirements related to inadequate intake and                diarrhoea
The client will maintain adequate infantile body fluids
- Record the number and quality of faecal

-Monitor skin turgor

-Monitor intake output

-Give water between breastfeeding or giving a bottle


-Variations help identify fluctuating intravascular volumes or changes in vital signs associated with immune response to inflammation
-indicators of adequacy of peripheral circulation and cellular hydration
-Monitor intake and output (I &O);note urine color and concerntration and specific gravity
-Indicators of return of peristalsis and readiness to begin oral intake

-Reduces risk of gastric irritation and vomiting to minimize fluid loss
My goal was met the risk for fluid deficit was minimized.
2.
 Impaired skin integrity related to hyperbilirubinemia and diarrhoea
The integrity of the baby skin can be maintained

- Assess skin color every 8 hours


-Monitor direct and indirect bilirubin

-Change position every 2 hours
-Massage the area that stands out


-Keep your skin clean and moisture
-Useful in monitoring effectiveness of medication,progression of healing.Changes in characteristics of pain may indicate developing abcess /peritonitis,requiring prompt medical evaluation and intervention.
-Being informed about progress of situation provides emotional support, helping to decrease anxiety
-Relief of pain facilitates cooperation with other therapeutic interventions,
-Refocuses attention, promotes relaxation, and may enhance coping abilities. 
-Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting.


My goal was partially met. The patient was quiet relieved by the therapy but not controlled.
3.
Anxiety related to change in health status(patient’s mother)
-to relieve anxiety
-examine the level of anxiety

-Give information about the disease process and actions
-reassure the patient party
-Enhance the patient general activity
Understanding promotes cooperation with therapeutic regimen, enhancing healing and recovery process


-to gain trust from the patient party
My goal was met the patient party was less anxious and well oriented about his disease condition.
4.
Fluid volume deficit r/t poor absorption
maintain fluid and electrolyte balance
-document and monitor :intake and output,  specific gravity, daily weights, daily abdominal girth measurements,

-check vitals, monitor for signs of tachycardia or new murmurs,

 -blood transfusion
-Check laboratory studies for electrolyte imbalances,

-Capillary refill less than 3 seconds and urine output.
- Useful in
assess for signs of
dehydration, assess for fluid overload,

-regular vital sign helps to rule out any deviation normal body functions as well as presence of infection in body
-to maintain haeomostatic equilibrium
- to assess the proper liver function and kidney function

-to assess the peripheral circulation
My goal was fully met, blood transfusion done, haemodynamically stabilized.
5.
Potential for altered growth-due to liver disease
Infant/ child grow following growth curve while maintaining appropriate nutritional status


-Monitor growth curve- monitor weight on regular basis.

-Assure that ADEK vitamins taken on regular basis, monitor lab values.

-Instruct regarding methods to increase calories: medium chain triglyceride formula, additional formula supplementation.
Chart above information, be able to identify and   report abnormalities and reassess
-assess range of motion, gross and fine motor skills


My goal was partially met. The patient party was well instructed for the continuous growth monitoring.
6.
Knowledge deficit R/T Homecare Instructions
Parents understand home care instructions. 

-Teach parents about medications including purpose, dose, administration, side effects and signs and symptoms to report.

-Teach parents importance of compliance relating to testing, medications and follow-up visits. Teach parents to identify, verbalize and report changes in child’s health status.
Proper knowledge about the disease helps to promote cooperation with therapeutic regimen, enhancing healing and recovery process as well as coping abilities.
-regular follow up helps for regular monitoring of the child’s health status.


My goal was met. The parents were well conscious about the patient and caring.
8.
Health Maintenance Altered ,need for family to monitor for symptoms of increased liver dysfunction
Family/ Parents familiar with symptoms of worsening liver function.
-Review with parents the signs and symptoms of worsening liver function including: change in stool color, ascites, peripheral edema, hepato/spleenomegaly, anorexia, urine color, lethargy, jaundice, bleeding, and pruritus.

-Educate regarding complications of end stage liver disease.

-Attempt to identify of signs and symptoms of bleeding with treatment of vitamin K or perhaps even a transfusion
Early instruction about the complications due to   altered body function helps in early identification and treatment if present





-early management help to gain good prognosis if any complication prevails.

-the early identification helps in effective management.


My goal was met. The patient party was well conscious about the child and no any complication shows up. Though,blood transfusion was done.






APPLICATION OF NURSING THEORY
 
                       By applying nursing theory of  Faye Glenn Abdellah's Theory, holistic care was given to my patient from the day of my visit.

"Nursing is based on an art and science that mould the attitudes, intellectual competencies, and technical skills of the individual nurse into the desire and ability to help people , sick or well, cope with their health needs." - Abdellah                      




“Although Abdellah spoke of the patient-centered approaches, she wrote of nurses identifying and solving specific problems. This identification and classification of problems was called the typology of 21 nursing problems. Abdellah’s typology was divided into three areas:
(1) the physical, sociological, and emotional needs of the patient;
 (2) the types of interpersonal relationships between the nurse and the patient; and
(3) the common elements of patient care.


Adbellah and her colleagues thought the typology would provide a method to evaluate a student’s experiences and also a method to evaluate a nurse’s competency based on outcome measures.”

(Tomey & Alligood, Nursing theorists and their work 4th ed., p. 115).

Abdellah’s Typology of 21 Nursing Problems are as follows:


1. To promote good hygiene and physical comfort
2. To promote optimal activity, exercise, rest, and sleep
3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformities
5. To facilitate the maintenance of a supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition of all body cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions
10. To facilitate the maintenance of regulatory mechanisms and functions
11. To facilitate the maintenance of sensory function
12. To identify and accept positive and negative expressions, feelings, and reactions
13. To identify and accept the interrelatedness of emotions and organic illness
14. To facilitate the maintenance of effective verbal and nonverbal communication
15. To promote the development of productive interpersonal relationships
16. To facilitate progress toward achievement of personal spiritual goals
17. To create and maintain a therapeutic environment
18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs
19. To accept the optimum possible goals in light of physical and emotional limitations
20. To use community resources as an aid in resolving problems arising from illness
21. To understand the role of social problems as influencing factors in the cause of illness



Daily progress note:
069/03/28
A patient named   Shishir Kuwar    of  5 month  was admitted with diagnosis of prolonged jaundice. Orientation given to the patient ‘s visitor about rules and regulation of hospital and ward, visiting hour, doctor”s visiting hour, canteen, water supply, toilet etc. General condition of the patient is fair.
Local examination shows
·         Icteric tongue and eye/skin
·         Umbilical hernia present
·         Cerebral vascular system S1S2M0
MEDICATIONS
Inj.cefrantal 250 mg I/V 8 hrly
Syp Hepamerz 3ml p/o BD
Syp Lactulose 5ml p/o HS
Syp SB2 3.5ml p/o BD
Inj Vit.K I/V OD 5 days
Inj R-tin I/ 8 hrly

069/04/02
Third day of admission, General condition of the patient is fair.The investigations were done. The patient was kept under medications.Vital signs were within normal range
Temperature:98.6⁰F
Pulse:132/min
Respiration:44/min
Local examination shows
·         Icteric tongue and eye/skin
·         Umbilical hernia present
·         Cerebral vascular system S1S2M0
Per abdomen examination
·         Tenderness of flank
·         Hepatomegaly-5cm
·         Splenomegaly-3-4cm
Central nervous system
·         Grossly intact

2069/04/04
Fifth day of admission, the child seems to be cheerful and playing.
The general assessment reveals
·         No fresh complain
·         No fever
·         Oral intake improved
·         Regular urine and stool
On examination
Active,alert,pallor +,icterus +,edema+,dehydration-
Vital signs were within normal range
Temperature:98⁰F
Pulse:94/min
Respiration:36/min
Per abdomen examination
·         Tenderness of flank
·         Hepatomegaly
·         Splenomegaly
·         Umbilical hernia

2069/04/05
Sixth day of admission, the child seems to be cheerful and playing.
The general assessment reveals
·         No fresh complain
·         No fever
·         Regular urine and stool
On examination
Active,alert,pallor +,icterus +,edema+,dehydration-
The Intravenous cannula was changed and I pint blood transfusion was done within 6-8 hours.
Vital signs were within normal range
Temperature:98.8⁰F
Pulse:92/min
Respiration:46/min
Patient was kept under oral medication.
Syp Hepamerz 3ml p/o BD
Syp Lactulose 5ml p/o HS
Syp SB2 3.5ml p/o BD

2069/04/06
Seventh day of admission.The infant was discharged. While discharged ,the child was discharged on conservative treatment. The discharge teaching about the child care ,nutrition, and personal hygiene was given  and follow up after a week. The general examination was as before no any further changes identified.
The patient was discharged under medication:
Syp Hepamerz 3ml p/o BD
Syp Lactulose 5ml p/o HS
Syp SB2 3.5ml p/o BD
Tab. Active Bile 5mg ½ tab TDS



DRUGS USED IN MY PATIENT
        1.      Inj.cefrantal:
(cefotaxime + sulbactum)


Group:
Cefotaxime-Third Generation Cephalosporin
Sulbactum - semisynthetic β-lactam sulphone
Mechanism:
- cefotaxime inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs).
- sulbactam inhibits β-lactamases of the Richmond types II, III, IV and V (plasmid or chromosomally mediated. It acts as a suicide inhibitor by forming a reversible inactive enzyme-sulbactam complex. This reversible acyl-intermediate may then revert to a more stable complex, which irreversibly inhibits the β-lactamase. Sulbactam is able to protect the activity of various β-lactam antibiotics by rendering β-lactamases inactive.
Dose:- Adult: Mild to moderate infections: 1/0.5 g to 2/1 g of cefotaxime/sulbactam every 8-12 hrs. Moderate to severe infections: 1/0.5 g to 2/1 g of cefotaxime/sulbactam every 6-8 hrs.
Child: 100/50 mg to 150/75 mg of cefotaxime/sulbactam /kg/day in 3 divided doses. Life-threatening infections: Dose of cefotaxime may be increased up to 12 g/day.
       
 Indications:
-perioperative
-uncomplicated gonorrhea/rectal gonorrhea
-serious illness like lower respiratory tract or urinary tract,central nervous system,skin,joints,gynaecological,bactreamia,septicemia,meningitis,resistant hospital acquired infections.
  Side effect:
-fever ,headache, phlebitis, thrombophlebitis, diarrhea, nausea, agranulocytosis, thrombocytopenia, esinophilia, haemolytic  anemia, pain, hypersensitivity reaction
Contra-indication:
- Contraindications are any previous hyper sensitivity to any of the cephalosporins /penicillins and severe renal impairment.
Nursing management
-before giving drug,obtain culture and sensitivity test .Begin therapy after awaiting drug
-for direct injection, reconstitute the drug in 500mg,1gm or2gm vial with 10 ml of sterile water for injection and inject drug over 3 to 5 min into large vein or in the tubing of a free IV solution.
-if large dose are given ,the therapy is prolonged and patient at high risk, monitor the patient for high on super infection.
-client teaching on:
Adverse reaction
Sign and symptoms of super infection
Report if any discomfort in injection site, swelling and pain.

        2.      Syp Hepamerz:
Each 5ml contains:
L-Ornithine L-Aspartate Brookes specification. 300 mg
Nicotinamide USP 24 mg
Riboflavin sodium phosphate B.P 0.76 mg
-Hepa Merz infusion concentrate (10ml ampoule contain)
L-Ornithine L-Aspartate Brookes Specification 5g
Hepa Merz Granules (Each sachet contains)
L-Ornithine L-Aspartate Brookes Specification 3g
Group: stable combination of two important endogenous Amino Acids, L-Ornithine and L-Aspartate.
Mechanism:
- After administration it quickly breaks down into L-Ornithine and L-Aspartate. L-Ornithine being a substrate of urea cycle, converts toxic ammonia into non-toxic urea which is eliminated via kidneys, helping the diseased liver to carry out its normal function smoothly (detoxification). The process lowers the elevated level of ammonia in blood (hyperammonaemia) which is a common problem in most of the liver diseases.
-L-Aspartate is an essential component of citric acid cycle which liberates energy (ATP), and thus helps in regeneration of damaged liver cells.
Indications
- liver disorders like
·         Acute Hepatitis (Viral, non-viral, drug induced)
·         Chronic Hepatitis (with or without hyperammonaemia)
·         Cirrhosis of Liver
·         Fatty Liver with hyperammonaemia
·         Hepatic Encephalopathy
-As an adjuvant therapy with all hepatotoxic drugs
Dose:
PO- 1-2 tab 3 times daily or 5 ml once daily
         
           Side effect:
- Transient nausea and vomiting
            Contra-indication:
- patients with elevated level of liver enzymes.
            Nursing management
-assess the liver enzyme level before administration
-this medicine can be administered with or without food.
-Avoid excess dosage.
-Store it at room temperature

     3.      Syp.Lactulose:
Group: Hyperosmolar Laxatives
Mechanism:
-promote movement of intestinal content through the colon and rectum in several ways; bulk forming,emollient,hyperosmolar and stimulant
- colonic acidifier that works by decreasing the amount of ammonia in the blood
Uses:
-liver disease (hepatic encephalopathy).
-constipation
-irritable bowel syndrome
-diverticulitis
Dose:
-packet:10gm,20gm
-syp.10mg/15ml         
   Side effect:
-flatulence,diarrhea,and abdominal disturbance
-fluid and electrolyte imbalance
Contra-indication:
-GI obstruction or perforation,toxic colitis ,megacolan.nausea and vomiting
-mild hepatic impairment
Nursing management
-       Monitor the sodium level for hypernatreamia especially which giving in higher dose to treat hepatic encephalopathy
-       Replace the fluid loss
-       Client teaching on
Instruct the client to take it usually 3-4 times a day or as directed by doctor. To improve the taste, it can be mixed with fruit juice, water, milk, or a soft dessert.
            Inform about the adverse reaction and tell to notify the prescriber
Instruct not to take laxative if ,is on lactulose therapy

     4.      Syp SB2:
Group: Vitamin B complex with zinc
The eight vitamins have both names and corresponding numbers. They are B1 (thiamin), B2 (riboflavin), B3 (niacin), B5 (pantothenic acid), B6 (pyridoxine), B7 (biotin), B9 (folic acid), and B12 (cobalamin).
The four unnumbered components of B complex that can be synthesized by the body are choline, inositol, PABA, and lipoic acid
Zinc is also added.

Mechanism:
- many claims for usefulness of various B vitamins.
VitaminB1(thiamine)-essential coenzyme in carbohydrate metabolism by combining with ATP
Vitamin B2(riboflavin)-component of flavoprotein enzymes that works together, which is necessary for normal tissue respiration; also needed for activation of pyridoxine and conversion of tryptophan to niacin
Vitamin B3 (niacin)-component of two co enzyme(NAD and NADP) which is necessary for tissue respiration, lipid metabolism and glyconeogenesis
vitamin B5 (pantothenic acid)-converts to coenzyme A internally; which  is essential to normal fatty acid synthesis, amino acid synthesis acetlyation of choline in production of neuro transmitter, acetylcholine
 vitamin B6 (pyridoxine)-precuser to pyridoxal,which function in metabolism of protein,carbohydrates and fats,also aids in release of liver and muscle-stored glycogen and in the synthesis of GABA(within CNS) and heme
vitamin B7 (biotin)- coenzyme for carboxylase enzymes, involved in the synthesis of fatty acids, isoleucine, and valine, and in gluconeogenesis.
Vitamin B9 (folic acid)- The human body needs folate to synthesize DNA, repair DNA, and methylate DNA as well as to act as a cofactor in certain biological reactions.
Vitamin B12 (cobalamin)- This generally creates no problem, except perhaps in rare cases of eye nerve damage,
Uses:
- Vitamin B complex is most often used to treat deficiencies that are caused by poor vitamin intake, difficulties with vitamin absorption, or conditions causing increased metabolic rate such as hyperthyroidism that deplete vitamin levels at a higher than normal rate.
           
Dose:
-adult dose:1-3 teaspoon per day
Pediatric dose-1-2 teaspoonful per day                  
           Side effect:
- Constipation; dark or green stools; diarrhea; nausea; stomach pain; vomiting
- Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); black, tarry, or bloody stools; severe or persistent stomach pain.


            Contra-indication:
-allergic to any ingredient in vitamin b complex/zinc
-  patient with high levels of iron in the blood (e.g., hemochromatosis, hemosiderosis
            Nursing management
-administration of drug according to prescription
-watch for any allergy, zinc may cause nausea.
- administer with food to decrease stomach upset.
- Store vitamin b complex/vitamin c/folic acid/iron/zinc at room temperature, between 59 and 86 degrees F (15 and 30 degrees C). Store away from heat, moisture, and light. Do not store in the bathroom. Keep vitamin b complex/vitamin c/folic acid/iron/zinc out of the reach of children and away from pets

5.      Inj R-tin:
Group: H2 receptor antagonist

Mechanism:
-It inhibit the action of histamine on the H2 receptors of parietal cells reducing artric acid 
output and concerntration under basal condition and also when stimulated by food,insulin,
histamine and caffeine

Uses:
-prevent heartburn ,acidindigestion and stomach hyperacidity
Dose:
-Injection Aciloc 50 mg TDS I/V
-Tab.Aciloc 150 mg TDS

Side effect:
-Dizziness,headache,fatigue,confusion,skin rashes, rarely liver dysfunction and blood disorders
,bradycardia after rapid I/V Injection,hypersensitivity

Contraindication and precaution:
-Pregnancy.Lactation,renal and hepatic dysfunction,gastric cancer

Nursing management:
-Administer I/V push slowly
-instruct patient to take drug as directed

-Tell patient to swallow oral form whole with water ;don’t chew

     6.      Vitamin K
Group:
Mechanism:
- Vitamin K helps to treat and prevent unusual bleeding by increasing the body's production of blood clotting factors.These substances help your blood to thicken and stop bleeding normally (e.g., after an accidental cut or injury).
Uses:
-   after an accidental cut or injury
- Low levels of blood clotting factors
 -unusual bleeding.
 -certain medications (e.g., warfarin) or medical conditions (e.g., obstructive jaundice).
            Dose:
Injection: 2mg/ml,10mg/ml
Tablets:5mg  
        Side effect:
- Pain, swelling, or soreness at the injection site may occur.
-Temporary flushing, taste changes, dizziness, rapid heartbeat, sweating, shortness of breath, or bluish lips/skin/nails may also infrequently occur.
            Contra-indication:
-
            Nursing management
                        -watch for any symptoms of an allergic reaction such as rashes,swelling,dizziness or trouble breathing

HEALTH EDUCATION TO THE CLIENT AND FAMILY REGARDING HEALTH MAINTAINANCE
             
               Health teaching plays an important role to prevent disease, promote health as well as to cure diseases more rapidly without any complications. One of the most important roles of nurse is to provide health education. So, I provided health teaching to family as well as patient objectives of health education are as follows:
-To promote health
-To motivate for early diagnosis and treatment
-To help limitation of disability
-To help in rehabilitation.

         Keeping these objectives in mind, I gave informal teaching and information to patient and family.

-Nutrition: The importance of nutritious food and balanced diet. He was advised to take plenty of fluids and soft hygienic foods.

-Infection prevention: I gave teaching on importance of personal hygiene and the role of hygiene in infection control

-Rest and exercise: Adequate sleep is necessary for the patient.
- breast feeding
-Supplementary foods
-immunization
-Personal hygiene
-About disease
-Medications
-Follow up.

                                  
STRESS MANAGEMENT AND DIVERSIONAL THERAPY
          Stress is a part of our life. It can be defined as an internal and external event that has the potential to bring about activities leading to significant psychological reaction.
            Diversional therapy is kind of therapy which diverts the mind of a person and helps in reducing stress. It is used parallel with medication for treatment of sick person because during sickness a person or family has more concern about sickness, this way lead to mental or emotional upset.

Since my client is an infant, he doesn’t represent more stress. Despite his illness, he appears to be  well active and playful as his developmental task.
 In order to enhance the prognosis of the client and relieving stress of the patient party , I perform some activities such as:
Ø  Talked about patient with the family member.
Ø  Encourage for parent child bonding
Ø  Suggested and helped in fulfilling patient’s need like physical need, nutritional supply..
Ø  Encourage for the play.

The ways of approaching for stress management includes

Meeting basic needs of the client:
There is a close relationship between basic physiological needs and stress.
The infant’s basic need fulfillment is the prior need, so the mother was well instruction of nutritional supply, breastfeeding, warmth and affection.
The hospital environment was quite unfamiliar to the infant, though the patient party and the infant were encouraged to be familiar to the environment. The client was provided warmth and caring environment.

Verbalization
Encouraging clients’ family to express their feelings is especially valuable in stress reduction. Freud (1959) used the term catharsis to describe the process of talking out one’s feelings. People instinctively know the value of “getting things off their chest” through verbalization.  Verbalization promotes relaxation primarily in two ways.  First, when a feeling is described it becomes real. Once the problem is identified, the person can begin to deal effectively with it. Also, the actual activity of talking uses energy and, therefore, reduces anxiety.
I encouraged the family to verbalize their feelings about disease process, family background, economical status & the care provided to child. They explained their feelings to me & experienced that their stress was minimized.

Involvement of Family and Significant Others

The family of the client is the primary source for providing care to the client so, their involvement is the priority. So, the family members were involved in each and every management of the client.


STRESS MANAGEMENT TECHNIQUES:
There are a variety of stress management techniques that can easily be taught to clients, families, and significant others. Many of these techniques are considered to be complementary modalities
As they are used in conjunction with traditional medical treatment methods (i.e., medication, radiation therapy). Some of the most common approaches for managing stress are discussed below.
Despite many stress management techniques, since my patient is an infant the most used approach was play therapy for the

Play therapy:


Play therapy enhances the child’s physical and psychological development. The play therapy involves educational, recreational sensorimotor, social and emotional adjustment of the child.
Play therapy helps a child to adapt socially, enhance motor activities, physical development and enjoyment.


What I learned from case study?
            Case study is the effective method of learning about related disease in depth and practice. Case study gives the comprehensive study of one selected patient and comparison with book in a real situation. During my case study of jaundice, I collected information from different resources such as library, teacher, consulted with doctors and friends searched internet. I learned and experienced many things from my case study i.e. about Jaundice.
Ø  About patient
Ø  About family environment
Ø  About nursing care
Ø  About diversional therapy (and stress management)
Ø  About documentation
Ø  About hospital policy
Ø  About method of treatment technique of Jaundice.
Finally, I think the case study is one of the best ways to develop individual knowledge and attitude.
SUMMARIZATION
During our clinical practice of child health nursing, our posting was in Kanti children Hospital. There I have selected a case for detail study which is in high risk group in the paying ward. The briefing about the case study given below:

Shishir is 5months old infant. His diagnosis is prolonged jaundice. He was admitted to this hospital with the complain of yellowish discoloration of skin and sclera.

During the hospitalization of the baby, I had provided holistic care to them considering physical, mental, social, spiritual and economic aspect. I had provided care on the base of Abdellah typology of nursing.


Patient totally hospitalization was 9 days. At the time of discharge, condition was improved, looking happy and cheerful. I gave health teaching to the patient and her family about nutrition, immunization, personal hygiene, rest and exercise, care of baby, medicines; follow up visit, breast feeding and complications condition of baby.
CONCLUSION
         Case study is one of the most important parts of nursing practice. It is the best method of learning case study concerned with the individualized care which helps to provide holistic nursing care including physiological, psychological, social and cultural traditional beliefs.
         According to our B.N. 1st year curriculum, I had taken a case of Jaundice, named Shishir Kuwar for case study. During this period of case study, at first, I had collected relevant health history from the patient as well as his family members. Then I had done complete physical examination of my patient. I gathered lots of facts and formulated nursing diagnosis. I applied knowledge from the basic sciences, nursing theories and other related courses, to plan and implement nursing care. I had studied the normal developmental task of infant and correlate it with my patient. He meets these entire normal developmental tasks.
         I had also studied about disease its type, epidemiology, etiological factors, Pathophysiology, clinical manifestations, diagnostic test, therapeutic and nursing management including Prognosis, Prevention and Possible Complications.
         I had provided different diversion therapy to the patient for stress management.           
         Finally patient’s general condition was improved day by day and I am satisfied from this case study and the goals set were fully met.


References

      1.      AZ of Practical Paediatrics,Baral Manindra.R,HISI Offset printers1st edition,2007,page 234-238
      2.      Nursing 2012 Drug Handbook,Kluwer Wolters,Lippincott Williams and wikins, 32 edition page 780,1169,273,1466.
      3.      http://www.whereincity.com
      4.      Child health Nursing,uprety kamala,pradipa printing and publishing 1st edition pg no: 200-208
      5.       http://www.medindia.net
      6.       http://www.drugs.com
      7.  Internet: www.google.com.np


            

2 comments:

John Dudley said...
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Alecia Madonado said...

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