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.
|
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
|
|
|
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)
|
|
-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 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.
4.
Child health Nursing,uprety kamala,pradipa
printing and publishing 1st edition pg no: 200-208
6.
http://www.drugs.com
7. Internet: www.google.com.np
