INTRODUCTION:- The client B/o Anju Singh was apparently well after birth, parents noticed

increased rate of breathing since 3 days, fever since 2 days and refusal to feed since 1 day and hence
were brought to the hospital and was admitted in NICU ward on 01-02-2017 at 8:30 pm.

❖ BIODATA OF PATIENT:-

⮚ Name :- B/o Anju Singh

⮚ Age / Sex :- 10 days / male
⮚ Father’s Name :- Mr. Kundan Singh
⮚ Address :- Akash Nagar, jagdalpur
⮚ Registration No :- 12559
⮚ Date of Admission :- 01/02/2017
⮚ Ward/ Bed No :-NICU/3
⮚ Education of Parents :-
Father - B.Com
Mother – B.Sc. (Home Science)
⮚ Occupation of Parents :-
Father – Businessmen.
Mother – House Wife.
⮚ Family Monthly Income :- Rs 15,000-20,000
⮚ Nursing Alert :- No history of any sensitivity or allergy
⮚ Weight :- 2.56 kg
⮚ Height :- 53 cm
⮚ Diagnosis :- Acute lower respiratory infection
Provisional Diagnosis – LRTI
Final Diagnosis – Lower respiratory tract infection
⮚ Source of Information:- Through her mother

❖ CHIEF COMPLAINT WITH DURATION:-

The client B/o Anju Singh was apparently well after birth, parents noticed increased rate of
breathing since 3 days, fever since 2 days and refusal to feed since 1 day and hence were brought to the
hospital and was admitted in NICU ward on 01-02-2017 at 8:30 pm.

❖ HISTORY OF PRESENT ILLNESS:-

The client B/o Anju Singh was admitted in NICU ward on 01.02.2017 at 8:30 pm with a history of
increased rate of breathing since 3 days, fever since 2 days and refusal to feed since 1 day. There is
no other history of any loose motion, fever or vomiting.

❖ HISTORY OF PAST ILLNESS:-

● OBSTETRIC HISTORY:
Prenatal history
⮚ Was the pregnancy planned: yes.
⮚ Did you receive prenatal care: yes antenatal check up at private clinic.
Received 2 doses of TT
⮚ Any problem during pregnancy: Maternal Anemia.
⮚ Any accidents during pregnancy: No
⮚ Any medication during pregnancy: Not taken any medication during
pregnancy.
⮚ Any substance abuse during pregnancy: No
 Natal history:
⮚ Place of delivery: born in Maharani hospital
⮚ Type of delivery: LSCS.
⮚ Any problem encountered during delivery: no significant problem noticed.
⮚ Any vaginal infection: No significant vaginal infection.
⮚ Child’s apgar scoring: Not significant.
Post natal history:
⮚ Child’s birth weight: 2.12 kg
⮚ Child’s height: 50 cm
⮚ Head circumference: 34 cm
⮚ Did the child have any problem after birth: no significant problem
identified, baby cried immediately after birth.
⮚ Has the child ever been hospitalized: no, before admitting in hospital,
parents consulted local doctor but his symptoms didn’t subsided?
⮚ Has the child ever had any major illnesses: No
⮚ Has the child ever experienced any major injuries: No

❖ FAMILY HISTORY:-

⮚ Type: - Live in a pucca house.

⮚ No. of members:- 3 (including patients)
⮚ Family medical history: - Grandfather is having Type II Diabetes mellitus and there is no
history of any illness like Tuberculosis, Hypertension, hereditary illness etc. in the family member.
⮚ Any major diseased cause of death in family: - No significant history present.
⮚ Any member suffered with common disease: - no such significant history.

⮚ Family tree:-

Father Mother
Kundan Singh Anju Singh
28years 25years

B/o Anju Singh

10days Index:

Father

Mother

Patient

FAMILY COMPOSITION:

PATIENT AGE/ RELATIONSH EDUCATION OCCUPATIO HEALTH

RELATIVE’ SEX IP N
S NAME
KUNDAN 28YEARS/ FATHER B.com BUSINESSMAN HEALTHY
SINGH M
ANJU 25 YEARS/ MOTHER B.Sc HOUSEWIFE HEALTHY
SINGH F

❖ SOCIO-ECONOMIC STATUS:
HOUSING:-
⮚ Type: - Pucca House
⮚ No. of rooms: - 3 & separate kitchen
⮚ Toilet: - Indian
⮚ Electricity: - Yes
⮚ Drinking water: - Tap
⮚ Sanitation: - Maintained.
⮚ Health facility near home: - private clinic.
⮚ In any urgent need on whom can you depend on: - private clinic.
⮚ Family expenditure in treatment: - family can easily meet the expenditure of the treatment.
ENVIRONMENTAL CONDITIONS:
⮚ Factory or big market near home: - yes
⮚ Anyone in home smoke tobacco: - no
CHILD’S PERSONAL DATA
GROWTH AND DEVELOPMENT

⮚ DEVELOPMENTAL MILE STONE:-

S.N FEATURES IN BOOK PICTURES IN PATIENT

O

PHYSICAL ❖ Weight gain of 150-210 gm weekly ❖ 2.56 kg

1. GROWTH for first 6 months.
❖ Height gain of 2.5 cm monthly for ❖ 53 cm
first 6 months.
❖ Head circumference increases by 1.5 ❖ 34 cm
cm monthly for first 6 months.
❖ Chest circumference 3 cm less than ❖ 31 cm
head circumference.
❖ Pulse rate 140-160 beats/ min. ❖ 140 beats/ min
❖ Respiratory rate 40-60 breathes/ min. ❖ 54 breaths/ min
❖ Primitive reflex present and strong. ❖ Baby cries well and all
❖ Doll’s eye reflex and dance reflex primitive reflexes
fading. present.
❖ Obligatory nose breathing. ❖ Rooting & sucking
reflex poor.
❖ Assumes flexed position with pelvis ❖ Yes, lies flexed
GROSS MOTOR high but knees not under abdomen
2. DEVELOPMENT when prone. ❖ Yes, turns head when
❖ Turns head when prone but cannot prone.
support head. ❖ Head lags when pulled
❖ Head lags when pulled from supine from supine position.
position ❖ Yes when held in
❖ Assumes asymmetric tonic neck reflex standing position body
position when supine. is limp at knees and
 ❖ When held in standing position, body hips.
is limp at knees and hips.
❖ In sitting position, back is uniformly ❖ Absence of head
rounded, with absence of head control. control.

❖ Hands predominantly closed at 1 ❖ Yes, lies flexed

FINE MOTOR month and often open by age 2.
3. DEVELOPMENT ❖ Grasp reflex strong at 1st month and ❖ Yes
fades by 2nd month.
❖ Hand clenches on contact with rattle. ❖ normal

❖ Able to fixate on moving objects in ❖ Yes

4. SENSORY range of 45 degrees when held at a
DEVELOPMENT distance of 20-25 cm. ❖ Yes
❖ Visual acuity approaches 20/100.
❖ Follows light to midline. ❖ Yes
❖ Quiets when hears a voice.

VOCALIZATION
5. (SPEECH & ❖ Cries to express displeasure. ❖ Yes
LANGUAGE ❖ Make small, throaty sounds.
DEVELOPMENT ❖ Makes comfort sounds during feeding. ❖ Yes
)
❖ Yes

6. PSYCHOSOCIA ❖ Trust Vs mistrust ❖ Dependent on care

L ❖ The impostant event is feeding and the givers
DEVELOPMENT important relationship is with mother. ❖ No
❖ The infant must develop a loving
trustful relationship with the mother
care giver through feeding, teething
and comforting.
PSYCHOSEXUA Normal
7. L ❖ Oral stage:
DEVELOPMENT ❖ Derives pleasure from mouth by
suckling needs.
COGNITIVE Normal
8. DEVELOPMENT ❖ Sensory motor stage Yes
❖ Substage II (primary circular reaction)
❖ Reproduces reflex actions.
⮚ IMMUNIZATION HISTORY:-

Received all the vaccines as per age.

AGE VACCINES REMARKS

At birth BCG
HEPATITIS B 1 Received the vaccine as per
OPV-0 age

⮚ DIETARY PATTERN :-
Baby is only on breast milk

Breast milk is the best for a newborn because of its nutritional value, protection from the infection
against diseases and financial and social implication it has for a poor and over populated country like
India. Human milk is superior to all other milks. So exclusive breast feeding should be given for the
first 6 months and preferably it should continue. Average of 700ml milk is secreted by an Indian mother
and it is sufficient for the baby feeding.

Calories: 110-120 k.cal/kg/day

How much time baby takes feed: - baby is having feed in every two hourly, in one day 8-10 times.

Any problem in feeding: - no problem.

⮚ SLEEP PATTERN :-
● Timing: - sleep for 20-22 hrs/ day, sleep after fed for 2-3 hrs.
⮚ ELIMINATION:-
❖ Bowel per day: - 4-5 times a day.
❖ Urine frequency: - Every 2-3 hourly, 6-8 times, this shows that feeding is adequate.
❖ Color of urine: - colorless.

⮚ PLAY HABITS

S.NO PLAY STIMULATION IN BOOK IN PATIENT

1. Visual stimulation: Present
● Look at infant at close range.
● Hang bright, shiny object within 20-25 cm of
infants face and in midline.

2. Auditory stimulation: Baby attends talking to her and

● Talk to infant sing in soft voice. singing in soft voice.
● Play music box, tape or compact disc.
● Have tickling clock near by.
3. Tactile stimulation Baby enjoy holding, caring &
● Holds, caress, cuddles cuddling of the care givers
● Keep infant warm.
● May like to be swaddled.
4. Kinetic stimulation Normal
● Rock infant, place in cradle

⮚ OBSERVATION & ASSESSMENT:-

❖ General condition: - fair

❖ Sensorium: - conscious
❖ Emotional state: - Quite
❖ Foul body odor: - No
❖ Foul breath: - No

⮚ PHYSICAL EXAMINATION:-
❖ Temperature: -100.4 F
❖ Heart rate: - 140 beats/ min
❖ Respiration: - 54 breaths/ min
❖ Blood pressure:- 78/56mm of Hg
❖ SpO2:- 99%
❖ Skin color: - pale
❖ Posture: - Normal
❖ Gait: - Normal
❖ Bleeding: - Not present
❖ Discharge: - Not present

⮚ HEAD & BODY MEASUREMENT

❖ Head circumference:- 34 cm
❖ Chest circumference:- 31 cm

⮚ HEAD: -

❖ Status of fontanels:-
● Anterior fontanel – Open.
● Posterior fontanel - Open.
❖ Condition of scalp:- clean & silky hair
❖ Shape of the skull:- No caput or cephal hematoma is present

⮚ SKIN:-

❖ Color: - pale.
❖ Texture :- Dry
❖ Pallor:- Present
❖ Cyanosis:- Absent
❖ Generalized petechiae:- No
❖ Jaundice:- no
❖ Acrocyanosis :- no
❖ Lesion :- No
❖ Edema :- Present
❖ Skin turgor:- Dehydrated

⮚ FACE:-

❖ Symmetry of face:- Normal

❖ Flattened nose:-Not present
❖ Any folds below eyes:-Not seen
❖ Palsy:- Not present

⮚ EYES: -

❖ Symmetry:- Normal
❖ Eye lashes :- Normal
❖ Eye brow:-Normal
❖ Eye balls:-Normal
❖ Conjunctiva:-yellow
❖ Cornea & Iris:-Normal and no irregularities present
❖ Pupils :-Reactive to light
❖ Lens :-Transparent
❖ Fundus :-Normal
❖ Eye muscle:-Normal
❖ Discharge:- Present
❖ Squint:- Not seen
❖ Sclera :- yellow
❖ Vision:-Normal

⮚ NOSE:-

❖ Appearance:-Normal
❖ External nares:-Normal
❖ Nostrils:-No inflammation or septal deviation seen
❖ Profuse nasal discharge:-Present
❖ Depressed nasal bridge:- No

⮚ EARS:-

❖ External ears:- Normal

❖ Alignment of ears: - Normal.
❖ Hearing acuity:-Normal
❖ Wax:- Not present
❖ Foreign body:-No
❖ Shape:-Normal
❖ Lesion:-Not seen
❖ Pain:-No

⮚ MOUTH & PHARYNX:-

❖ Lips:- Normal
❖ Odor of the mouth:- No foul smelling
❖ Teeth:-Not present
❖ Mucus membrane:-Normal
❖ Gums:-Normal
❖ Tongue:-Normal
❖ Thrush:- Present
❖ Dryness :- Seen
❖ Cracked :- Yes
❖ Malocclusion: - Not seen.

⮚ NECK:-

❖ Head range of motion:- Yes

❖ Neck webbed on shoulder:- No
❖ Extended arms on one side:-No
❖ Tightness of muscle on one side:-No
❖ Lymph node:-Not palpable.
❖ Range of motion:-Possible

⮚ CHEST:-

❖ Shape & movement with breathing:- Diaphragmatic breathing with symmetrical movement of
chest
❖ Respiratory pattern: - breathing difficulty present.
❖ Cough & cold:- present
❖ Grunting sound on expiration:- yes
❖ Retraction on inspiration: - no.
❖ Breast nodule: - breast tissue more than 10mm diameter.
❖ Areola: - raised
❖ Heart rate:-140beats/minute
❖ Heart sound: - S1 & S2 sound heard, No murmur sound heard.
❖ Clavicle palpable on both side:- Yes
❖ Presence of breast engorgement & secretion of milk:-Absent
❖ Capillary refilling time: - less than 3 seconds.

⮚ ABDOMEN:-

❖ Shape:-Round abdomen seen

❖ Per abdomen:- soft
❖ Umbilical cord stump for presence of 3 vessels: - bluish white color.
❖ Congenital anomaly:-Not seen
❖ Discharge:-Not present
❖ Any mass:-Not present
❖ Bowel sound:-Normal bowel sound
❖ Umbilical Bleeding:-Not seen
❖ Distention :- Not seen

⮚ BACK:-

❖ Presence of any dimple in the coccygeal or sacrococcegyl:-Not present

❖ Sinus opening:-No
❖ Spina bifida:-Not present
❖ Tufts of hair:-Not present
❖ Tenderness:-No
❖ Kyphosis :-Not present
❖ Scoliosis:-Not present

⮚ UPPER EXTREMITIES:-

❖ Proportion to the rest of the body:-Arms is of equal length when extended

❖ Symmetry & spontaneous movements of arms & hands:- Present
❖ Check the baby hold hands in fists:-No
❖ Finger shows webbing, polydactyly or syndactyly:-Not present
❖ Skin tags:-Not present

⮚ LOWER EXTREMITIES:-

❖ Symmetry:-It is of equal length when extended

❖ Range of motion:-Normal
❖ Sole creases: - deep creases over anterior 1/3rd to ½ sole

⮚ FEET:-

❖ Presence of wrinkles in soles:- Yes

❖ Acrocyanosis:-Not present
❖ Talipes equinovarus:-No
❖ Talipes calcaneovalgus:-No
❖ Bow leg:-No
❖ Webbing:-No
❖ Polydactyl :-No
❖ Syndactyly :-No
❖ Toes & nails :- pale yellow

⮚ GENITALIA:-
Male:
● Urethral opening at lip of glans penis.
● Testes palpable in each scrotum.
● Scrotum usually large edematous pendulous usually deeply pigmented in dark skinned ethnic
groups.

⮚ CNS: -

❖ Activity- normal
❖ Cry – normal

REFLEXES

In book In patient
LOCALIZED:
Eyes:
✔ Blinking or corneal: infant blink at Good.
sudden appearance of a bright light or to
an approach to light.
✔ Pupillary: in infants pupils constricts Good.
when a bright light shines towards it.
✔ Doll’s eye: as head is moved slowly to Good.
right to left, eyes lag behind and do not
immediately adjust to new position of
head.

Noses:
✔ Sneeze: sneezing is a spontaneous Good.
response of nasal passages to irritation or
obstruction.
✔ Glabellar: tapping briskly to glabella Good.
causes eyes to close tightly.
Mouth and throat
✔ Sucking reflex: infant begins strong Poor.
sucking movement in response to
stimulation.
✔ Gag: stimulation of posterior pharynx by Good.
food, suction or passage of a tube cause
infant to gag persists throughout the life.
✔ Rooting: touching or stroking the cheek Fair.
along side of mouth causes infant to turn
head towards that side and begin to suck,
should disappear at about age 3-4 months
but may persists up to 12 months.
✔ Extrusion: when tongue is touched or Normal.
depressed infant respond by forcing it
outward, disappears by age 4 months.
 ✔ Yawn: yawning is a spontaneous Normal.
response to decrease oxygen by
increasing amount of inspired air.
✔ Cough: irritation of mucus membrane of Present.
larynx persists throughout life, usually
present after first day of birth.

Extremities:
✔ Grasp: touching palms of hands or soles Normal.
of feet base of digits causes flexion of
fingers and toes.
✔ Babinski: stroking outer sole of foot Normal.
upward from heel and across ball of foot
causes toes to hyperextend and hallux to
dorsiflex.

Mass:
Moro’s reflex: startling the neonate with a loud Normal.
voice or apparent loss of support due to change
in equilibrium. Sudden jarring or change in
equilibrium causes sudden extension and
abduction of extremities and fanning of fingers
with index finger and thumb forming a C shape,
followed by flexion and adduction of extremities,
legs may weakly flex infant may cry disappear
after age 3- 4 months usually strongest during 2
months.
Startle reflex: Normal.
A sudden loud noise cause’s abduction of the
arm with flexion of elbows, hands remains
clenched disappears by 4 months.
Tonic neck reflex: when infants head is turned Normal.
to one side arm and leg extend on that side and
opposite arm and leg flex disappears by age 3-4
months.
Stepping or dancing: hold neonate in a vertical Normal.
position with feet touching a flat and firm
surface. Rapid alternating flexion and extension
of the legs as in stepping, disappears with 3-4
months.

⮚ DEPENDENCY LEVEL OF PATIENT: - Dependent on care givers.

INVESTIGATION:-

S.NO INVESTIGATION PATIENT VALUE NORMAL VALUE INFERENCE

HEMOGRAM
1.
Haemoglobin 12.7 gm% 16.8gm% Normal
2.
Total leukocyte count 4,700/cumm 5000-20000/mm3 Normal
3.
 4. Neutrophil 40% 54-62% Normal
5. Lymphocyte 56% 25-33% Normal
6. Eosinophil .02% 1-3% Normal
7. Monocyte .02% 3-7% Normal
8. Basophil 00% 0-0.75% Normal
Platelet count 2,20,000/mm3 1.5-3.5lakh/m3 Normal
negative negative
Malarial parasite
MICROBIOLOGY Sterile No organisms Normal
1. Blood Culture

RADIOGRAPHY Right lung shows

1. Chest X-Ray hazy appearance in
upper & middle lobe - -

DIAGNOSIS: - On the basis of clinical sign, symptoms and investigation value patient was diagnosed
as a case of Lower Respiratory Tract Infection.

DEFINITION:
Essentially, it is inflammation of the airways/pulmonary tissue, due to viral or bacterial infection, below
the level of the larynx. Lower respiratory tract infection (LRTI) is infection below the level of the
larynx and may be taken to include:

● Bronchiolitis
● Bronchitis
● Pneumonia
● Laryngotracheobronchitis (croup)

The presentation of these conditions will depend on age, infecting organism and site of infection. The
main symptom of a lower respiratory tract infection is a cough, although it is usually more severe and
more productive (bringing up phlegm and mucus). Sometimes the mucus is blood-stained.

RISK FACTORS

IN BOOK IN PATIENT

● Infants of mothers who smoked during pregnancy Absent.

● Inuit infants were four times more likely to be admitted
Present.
for LRTI than mixed or non-Inuit infants
● Overcrowded living conditions
 ● Living in a rural community without a hospital Present.
Absent.
● Prematurity.
● Infants who were not breast-fed Present.
Present.
● Infants who were custom adopted
Present

CAUSES:

IN BOOK IN PATIENT
● Viral infections. About 45% of children
Not significant.
have a viral an etiology. These include:
o Influenza A.
o Respiratory syncytial virus (RSV)
o Human metapneumovirus (hMPV)
o Varicella-zoster virus (VZV) - chickenpox.
● Bacterial infection. These constitute about
60% cases:3
o Streptococcus pneumoniae (the majority of
Present.
bacterial pneumonias).
o H. influenzae.
o Staphylococcus aureus.
o Klebsiella pneumoniae.
o Enterobacteria, e.g. Escherichia coli.
o Anaerobes.
● Atypical organisms, i.e. Mycoplasma
pneumoniae (14% of all cases in
Absent.
children3),Legionella
pneumophila, Chlamydophila
pneumoniae(9% of hospitalised pneumonia
in children3), Coxiella burnetii.
● Secondary bacterial infection is relatively
common following viral lower respiratory Absent.
tract infection (LRTI).

General Host Factors

● Prematurity Present, LSCS was performed as baby passed

 the meconium
● Sex – infections more common in males, esp. Absent.
gram negative infections
● Birth asphyxia, meconium staining, stress Present, as baby passed the meconium in the
womb itself.
● Breaks in skin & mucous membrane integrity Absent.
(e.g. omphalocoele, meningomyelocoele)
● Environmental exposure Present as in the area they live are
overcrowded

PATHOPHYSIOLOGY:
Due to immature immune system and certain modifiable factors

Virulent microorganisms enter the nose and passes through larynx, pharynx & trachea

Activation of immune response i.e. by inflammation, vasodilation etc.

Bacteria multiplies in the alveoli and release of endotoxin and exotoxin from the

Bacteria take place.

Migrate into alveoli & fill with normal air containing spaces

Continuous mucus production and narrowing of airway passage

Lungs Consolidation

SIGNS AND SYMPTOMS

IN BOOK IN PATIENT
● Grunting. Present
● Poor feeding. Present
● Irritability or lethargy. Present
● Fever (but neonates may have Present, up to 101.2 F
unstable temperatures, with
hypothermia).
 ● Cyanosis (in severe infection). Not present
● Cough Present
● Tachypnoea (according to severity). Present 54 breaths/min
● Chest indrawing. Absent.
● Feeding difficulties. Present
● Irritability and poor sleep. Present
● Breathing, which may be described as
‘wheezy’ (but usually upper airway Present
noise)

DIAGNOSTIC EVALUATION:

IN BOOK IN PATIENT

● CBC:
Done, where WBC found to be increased.
o White cell count is often elevated. Although this
may be very noteworthy in certain infections
(like pneumococcal pneumonia), it is useful
only as a general guide to the presence of
infection.
o It is important in very ill children who may be
immunocompromised.

● Microbiological studies: Result was found to be sterile in patient

o Blood cultures are seldom positive in

pneumonia (fewer than 10% are bacteraemic in
pneumococcal disease). Sputum culture not done.
o Blood and sputum cultures should generally be
reserved for atypical or very ill patients
(particularly those who may be
immunocompromised).
● Imaging:
o Chest radiography (CXR) is not routinely Done in the patient and the result was
found to be hazy appearance in upper and
indicated in outpatient management.
middle lobe.
o CXR cannot differentiate reliably between
bacterial and viral infections.
● Other tests:
 o Tuberculin skin testing if tuberculosis is
Found to be negative in the patient
suspected.
o Cold agglutinins when mycoplasmal infection is
suspected (but only 50% sensitive and specific). Not done.
o Urine latex agglutination tests may ultimately
diagnose certain organisms but the tests take
time and are rarely of use acutely. Not done

● Diagnostic procedures:
o Drainage and culture of pleural effusions may
relieve symptoms and identify the infection.
Not done

MANAGEMENT
Decision to admit
Most children with lower respiratory tract infection (LRTI) and pneumonia can be treated as
outpatients, with oral antibiotics. Older children can be managed with close observation at home if they
are not distressed or significantly dyspnoeic and parents can cope with the illness. Viral bronchitis and
croup do not require antibiotics and mild cases can be treated at home.

Admission is advised for severe LRTI. This is indicated by:

● Oxygen saturation <92%.

● Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older child).
● Significant tachycardia for level of fever.
● Prolonged central capillary refill time >2 seconds.
● Difficulty in breathing as shown by intermittent apnoea, grunting and not feeding.

Presence of co morbidity, e.g. congenital heart disease, chronic lung disease of prematurity, chronic
respiratory conditions such as cystic fibrosis, bronchiectasis or immune deficiency should also prompt
consideration of admission.Admission should also be considered for:

● All children under the age of 6 months.

● Children in whom treatment with antibiotics has failed (most children improve after 48 hours of
oral, outpatient antibiotics).
 ● Patients with troublesome pleuritic pain.

Before admission

Be sure to offer the patient and parent’s general support, explanation and reassurance.

● Respiratory support as required, including oxygen.

● Pulse oximetry to guide management is helpful.
● Severe respiratory distress with a falling level of consciousness and failure to maintain
oxygenation indicates a need for intubation.

In hospital

● Resuscitation and respiratory support as required.

● Intravenous access and fluids in severe cases.
● CXR confirmation of the diagnosis and identification of effusions and empyema.

MEDICAL MANAGEMENT (in general)

● Antipyretics (avoid aspirin due to the danger of Reye's syndrome).

● Antibiotic treatment:
o It can be difficult to distinguish between viral and bacterial infection and young children can
deteriorate rapidly, so consider antibiotic therapy depending on presentation, and likelihood of
bacterial aetiology.
o Amoxicillin in a child-friendly formulation, should be used first-line, unless there is reason to
suspect a penicillin-insensitive organism (particularly pneumococcal disease). Evidence shows
that children with non-severe community-acquired pneumonia who receive amoxicillin for three
days, do as well as those who receive it for five days.7
o If a child is genuinely allergic to penicillin, consider using a cephalosporin, macrolide or
quinolone, depending on any local antibiotic prescription guidelines, patterns of resistance and
suspected organism.
o Vancomycin may be added to treatment of toxic-looking children when there is a high rate of
penicillin resistance.
o Acyclovir is used for herpes virus pneumonia.
● Bronchodilator treatment
● Despite unproved efficacy, bronchodilators are still often prescribed in patients with viral lower
respiratory tract infection.
MANAGEMENT:

IN BOOK IN PATIENT
 General support:

Oxygen was give to the patient at the

● Respiratory support as required, including oxygen.
rate of 2l/min as the spO2 of the patient
● Pulse oximetry to guide management is helpful.
was found to be 95 mm of hg.
● Resuscitation and respiratory support as required.
● Intravenous access and fluids in severe cases. Given.
● CXR confirmation of the diagnosis and
identification of hazy appearance in lungs.

Medical management:

● Antipyretics (avoid aspirin due to the danger Paracetamol syrup given as the patient
of Reye's syndrome). was having fever 101 f.
● Antibiotic treatment:
o Amoxicillin in a child-friendly formulation, should
be used first-line, unless there is reason to suspect a Antibiotics like vancomycin, amikacin
penicillin-insensitive organism . and amoxycilline was given to the
o If a child is genuinely allergic to penicillin, consider patient.
using a cephalosporin, macrolide or quinolone,
depending on any local antibiotic prescription
guidelines, patterns of resistance and suspected
organism. Given.
o Vancomycin may be added to treatment of toxic-
looking children when there is a high rate of
penicillin resistance.
o Acyclovir is used for herpes virus pneumonia. Not given.

NURSING CARE MANAGEMENT

Assessment:

Nursing care of the infant with LRTI involves observation and assessment as outlined for any
high risk infant. Another aspect of caring for infants with LRTI involves observation for signs of
complications, continuous monitoring of the child and to prevent from the life threatening condition of
child.

Nursing diagnosis:
After the nursing assessment a number of nursing diagnoses may be evident. Additional nursing
diagnoses that may apply include: -

⮚ Ineffective breathing pattern related to physiologic effects of LRTI as evidenced by dyspnoea.

⮚ Hyperthermia related to infection as evidenced by body temperature above normal.
⮚ Risk for fluid volume deficit related to diminished oral intake and increased insensible fluid
losses secondary to tachypnoea and distress.
⮚ Imbalanced nutrition less than body requirement related to decreased intake.
⮚ Interrupted family processes related to situational crisis. (Hospitalization of the child).

Goal /Outcome :

● Child maintains an improvement in respiratory status and respiration will be normal.

● Child will maintain stable body temperature i.e. 98.6 F.
● Child will exhibit signs of adequate hydration.
● Baby will maintain normal body weight.
● Family members will demonstrate ability to cope with child’s illness.

Evaluation:

The effectiveness of nursing interventions for the family and infant with neonatal sepsis is determined
by continual reassessment and evaluation of care based on the following guidelines:

● Check the airway, SpO2 level or CRT etc.

● Monitor the body temperature of baby timely.
● Evaluate the hydration status of baby.
● Assess the nutritional requirement as per the demand of the baby.
● Interview family members and observe parent infant interactions.

THEORY APPLICATION IN NURSING CARE PLAN

ROY’S ADAPTATION MODEL
INTRODUCTION
Roy’s Adaptation Model for Nursing was derived in 1946 from Harry Helson’s Adaptation Theory;
adaptive responses are a function of the incoming stimulus and the adaptive level.
The adaptive level is made up of the pooled effect of three classes of stimuli
● Focal
● Contextual stimuli, which are all other stimuli present
● Residual stimuli.

Roy’s adaptation model focuses on the concept of adaptation of person and she considered human being
as a open living system. This model consist of 5 essential elements
 ● Adaptation -- goal of nursing
● Person -- adaptive system
● Environment -- stimuli
● Health -- outcome of adaptation
● Nursing -- promoting adaptation and health

Systems, coping mechanisms and adaptive modes are used to address these elements.

Input Control processes Effectors Output

Adaptive
response.
Copingmechanis Physiologic
Stimuli
ms. factors Ineffective
Regulator. Self concept
Adaptation response.
Cognator Role function
Level
Interdependence

1. SYSTEM: it employs a feedback cycle of input, through put and output.

● Input: It is defined as stimuli (focal, contextual or residual) which come from the environment
or from the person.
● Through put: Makes use of person’s process and effectors.
● Output: It is the outcome of the system, i.e. a person’s behavior.

2. COPING MECHANISM: they are processes or behavior patterns that a person uses for self
control.
It is of two types:
● Regulator: it controls internal processes related to physiological needs.
● Cognator: it controls internal processes related to higher brain function.

3. ADAPTIVE MODES:
● Physiologic mode.
● Self concept mode.
● Role function mode.
● Interdependence mode.

APPLICATION OF ROY’S ADAPTATION MODEL IN NURSING CARE PLAN:

1. Using Roy’s six –step nursing process:

2. Assesses the behaviors.
3. The stimuli affecting those behaviors.
4. The nurse makes a statement or nursing diagnosis of the person’s adaptive state
5. Sets goals to promote adaptation.
6. Nursing interventions are aimed at managing the stimuli to promote adaptation.
7. The last step in the nursing process is evaluation.
 8. By manipulating the stimuli and not the patient, the nurse enhances the interaction of the person
with their environment, thereby promoting health.

HEALTH TEACHING

✔ Accompanied all instructions with reassurance necessary to prevent the parents becoming
anxious and fearful about assuming the care of the child.
✔ Explain the mother about the importance and techniques of breast feeding.
✔ Explain the mother about the importance & schedule of immunization.
✔ Explain the mother about care of the infant at home.
✔ Provide anticipatory guidance for developmental age of child.
✔ Encourage awareness of symptoms that require prompt medical attention among day care centers
and other child care providers.
✔ Explain the mother about the long term complication of LRTI if the baby is not cared properly
the baby may develop gross symptoms such as mental retardation, epilepsy and cerebral palsy.
Other may exhibit learning difficulties in later life. These are the most serious effect of hypoxia –
a sledge hammer to the brain.
 ✔ Help the parents understand the need for good nutrition and the need to follow the diet regimen.
✔ Encourage mutual support from others families who have a child with pneumonia.
✔ Encourage follow up care.

PROGNOSIS OF LRTI (in general)

The majority of children with lower respiratory tract infection will recover fully and without permanent
adverse effects.

● Complete resolution after treatment should be expected in the vast majority of cases.
● Bacterial invasion of the lung tissue can cause pneumonic consolidation, septicemia, empyema,
lung abscess (especially S. aureus) and pleural effusion.
● Respiratory failure, hypoxia and death are rare unless there is previous lung disease or the
patient is immunocompromised.

PROGNOSIS: (in patient)

DAY-1 01/02/2017
⮚ General condition – Poor
⮚ Irritable
⮚ CRT<3 sec
⮚ Cough & cold present
⮚ Breathing difficulty
⮚ Vital sign not stable, RR- 54/minute.
⮚ Crying excessively
⮚ Stool – 2times & Urine – 8times passed

DIET:-
⮚ Only breast milk was given
⮚ IV fluids given.
⮚ No top formulas, Water etc.

DAY-2 02/02/2017
⮚ General condition – fair
⮚ Cough & cold present
⮚ Decrease oral intake
⮚ Vitals are not stable.
⮚ T-101.2 F, P-108 beats/min, RR- 48 breaths/min
⮚ CRT<3 sec
⮚ CNS &CVS: - No abnormality detected.
⮚ Per abdomen soft
⮚ Stool-3 & Urine – 6 times passed

DIET:-
⮚ Only breast milk was given
⮚ IV fluids and antibiotics were administered.
⮚ No top formulas, water etc.
DAY-3 03/02/2017
⮚ General condition:- fair
⮚ Vitals are stable
⮚ T-98.8 F, P-108 beats/min, RR- 42 breaths/min
⮚ Urine- 8 times & Stool – 2 times passed
⮚ CVS & CNS- No abnormality detected
⮚ Cough and cold present
⮚ Breathing difficulty reduced.
⮚ Per abdomen soft
⮚ Normal bowel sound
DIET:-
⮚ Only breast milk was given
⮚ Antibiotics and IV fluids was administered.
⮚ No top formulas, water etc.

CONCLUSION:-

B/o Anju Singh came with complaints of cough and cold, breathing difficulty, fever, and
decrease oral intake and was admitted in NICU ward on 01.02.2017 at 8:30 pm, was kept under
observation with IV fluids and antibiotic administration, and later found that Vitals were stable and
baby’s breathing pattern was improved to some extent and was able to take feed also.

BIBLIOGRAPHY:-

❖ Adele pillitteri; textbook of care of child and family; 2nd edition; Page no - 587

❖ Dorothy R Marlow; Textbook of Pediatric Nursing; 6th edition; Page no-888-906

❖ Dutta Parul; Textbook of Pediatric Nursing; 1st edition; Jaypee Publication; Page no-179

❖ Ghai OP, Textbook of Essential Pediatrics; 6th edition; CBS publication; Page no- 3

❖ Hockenberry Wilson Wongs; Nursing care of infants & children; 7th edition;
Mosby Publication; Page no- 628-644

❖ Manoj yadav “a textbook of child health nursing” pee vee, pg-73-88

❖ A.Parthasarathy; et all; IAP Paediatrics; 3rd edition; Jaypee publication;
 ▪ Page no-743
❖ Dorothy R Marlow; Textbook of Pediatric Nursing; 6th edition; Page no-888-906

WEBSITES:-

www.google.com
www.med.umich.edu/1libr/pa/neonatal jaundice.htm
www.baby-health.net