Patient Information

Name of the patient: B/o Soniya

Hospital no:19/001155
Age: 2 days
Sex: Male
Ward: NICU
Bed no: L 2
Final diagnosis: Posterior Urethral Valve with Hydronephrosis
Date of admission: 1/02/2019
Unit: 1(Dr.Mamta)
1. Introduction:
 General condition –The child was arousable, irritable.
 Care taker of child- Father
2. Socioeconomic background

 Name of place: Bhiwini, Haryana

 Type of house: Concrete
 Ventilation: No. of doors/windows-2
 Water supply: Tap
 Drainage system: Closed
 Toilet facilities:Own latrine
 Recreational facilities: Television,radio,indoor games, outdoor games
 Medical facilities: Hospitals
 Religion: Muslim
 Occupation of parents: Father-Private job, Mother-Home-maker
 Total income of parents: 25,000/month

3. Family history;

Soniya Punam Kumar key: female

25 years 30years

male

Twinkle B/o Soniya

(3 years) (8 days)
Sl. Name Relationship Age/sex Education Occupation Health
No. with child status/
Treatment
given
1. Punam Kumar Father 30 years Graduate Private Job Healthy

2. Soniya Mother 25 years 12th Pass Homemaker Healthy

3. Twinkle Sibling 3 years Toddler ---- Healthy

4. B/O Soniya Self 2 days Infant ---- Sick

4. Personal history:

Nutrition: Breastmilk
Sleep: 8-10hours/day
Bowel and bladder: Normal
Hygiene: Bathing- Cleaning is done with warm water

5. Birth history (<five years of age)

Antenatal history;

 Order of pregnancy— G2 P2L2

 Antenatal clinic attended: yes
 Tetanus toxoid: yes
 No of doses: 2
 Consanguineous marriage: No
 No Exposure to drugs / radiation or any teratogens
 Illness during pregnancy-There was no history of any illness
 Diabetes/hypertension/epileptic/rubella/acute viral fever

Intra-Natal history:
 Mode of delivery: normal vaginal delivery
 Birth weight: 3kg
 Delivery conducted in an Institution
 Place of delivery-Hospital
 Birth injury:No
 Gestational age-Term

Postnatal history

 PPH- No
 Puerperal sepsis- no
 Breast engorgement-no
 Puerperal psychosis-no
Newborn:

 Color at birth-pink
 Cried and breathed at birth-yes
 Eye discharge-no
 Breast feeding initiated within one hour-yes
 Passed meconium within 24 hours- yes
 Passed urine within 24 hours- yes

6. IMMUNIZATION

AGE IMMUNIZATION REMARKS

At birth BCG, HEPB, OPV (ZERO Not immunized
DOSE) since birth.

7. DIET HISTORY

 Type of feed: Breastmilk

 Method of feeding: Syringe Feed
 Present diet pattern: 25ml/4hrly

MEDICAL- SURGICAL HISTORY

A. CHIEF COMPLAINTS-
As per father the infant passed 2-3 drops of urine in 24 hours.

B. PAST MEDICAL HISTORY-

Baby was identified with the abnormality during the antenatal period through
ultrasound.

C. PRESENT MEDICAL HISTORY-

Dibbling of urine since two days of birth. As per docter after ultrasound of the child
he was dignosed with type 1 and type 2 hydronephrosis.

D. PAST SURGICAL HISTORY-

No past surgical history.

E. PRESENT SURGICAL HISTORY- No history

 F. Duration- Day 2 of admission

G. Mode Of Admission: Through Casualty

8. HEALTH ASSESSMENT
PHYSICAL ASSESSMENT FROM HEAD TO FOOT
a) Growth measurement:

Parameters Normal range Findings

Length 48- 52cms 49 cm
Weight 2.35- 2.45kgs 2.5 kgs
Head circumference 30-33cms 30.5cm
Chest circumference 28- 31cms 32cms
Abdominal circumference 26- 28cms 27.5cms

b) Physiological measurement:
 Temperature-37.6 degrees celsius
 Pulse-150/min
 Respiration-42/min
 SpO2-98%

c) General appearance
 Consciousness-crying but arousable
 Orientation- cry well
 Activity-Intolerant
 Cleanliness-Hygiene maintained
 Body built-Ectomorphic
 Nourishment- Infant is well nourished.

d) Skin:

 Color-Pallor
 Texture-Smooth
 Temperature-36.6 degree Celsius
 Lesions- Absent

e) Head and scalp:

 Size – 35.5 cm
  Shape- anterior and posterior fontanalles present
 Hair-Fine
 Scalp-Clean

f) Eyes:

 Eye brows- Symmetric

 Eye lids-Normal
 Eye lash-Normal
 Sclera-white in color
 Conjunctiva-Normal
 Eye ball-Normal
 Eye muscle- Normal
 Pupil- NS NR
g) Ear:

 Hearing ability- Normal

 External canal-Normal
 Discharges-No discharge found
 Use of hearing aids- no

h) Nose:

 Septal deviation-Centrally located

 Epistaxis-no
 posteDischarges-no
 Nasal polyp- no

i) Mouth and throat:

 Lips-soft and pink

 Tongue- dry and pink
 Gums-no cleft lip and palate present
 Throat-No swelling(lymph nodes are normal) in size
j) Neck:

 Thyroid enlargement-Absent
 Lymph node-Normal
 Range of motion- Present

k) Chest:

 Shape-Side to side symmetric

 Movements-Use of accessory muscle is present
 Respiratory rate-50/min
 Respiratory sounds- normal
 Heart rate-148/min
  Heart sounds-S1S2 Present, no murmurs found

l) Abdomen:

 Inspection – Shape-Scaphoid, Umblicus-inverted, No herniation,dilated

veins,visible peristalisis found
 Palpation – no organomegaly found
 Auscultation – bowel sounds present
 Percussion – absence of gas, mass or fluid.
m) Back and spine:

 Posture-Normal
 Deformities-None

n) Genitalia:

 Urethral opening-present
 Lymph nodes- no lymphadenopathy found
 Testes- Descended testis
 Congenital defects- posterior urethral valve.

o) Anus:

 Sphincter control-present
 Lesions-Absent
 Inflammation-Absent

p) Extremities:

 Gait-cannot be observed
 Contour- normal
 Mobility- immobile
 Deformities- none
q) Integumentary system:

 Skin color-Pale
 Temperature-36.4 degree celsius
 Nails-Clubbing of nails not found
1. REFLEXES: -

I. Sucking: present.

II. Swallowing: normal swallowing reflex present.

III. Rooting: rooting reflex present in baby as when touching or stroking cheek
alongside of mouth causes.
 IV. Moro reflex: when assessing the Moro reflex, the baby extend his hands and
then flex and C shape curve formed between forefinger and thumb.

V. Gag: gag reflex present in the baby.

VI. Blinking reflex: baby blinks when cotton swabs moves near eyes.

VII. Tonic neck reflex: present in baby.

VIII. Babinski’s reflex: baby’s toe extends and fanning of fingers occurs when
opposite J formed in sole.

IX. Dolls eye: it is present in baby as when the head turns towards one side then
the eyes movement does not occur that side.

X. Stepping/ dancing reflex: this reflex present in baby.

9. DIAGNOSTIC AND LABORATORY DATA
SL.NO INVESTIGATIONS PATIENTS NORMAL
VALUE VALUES
1. HEMOGLOBIN 17.mg/dl 15-20g/dl

TLC 14.8 9-30000/cumm

DLC 74.7

PLATELET COUNT 271 1.5-4 lac/cumm

136-145 mEq/l
SODIUM 130
3.5-5.1 mEq/
POTASSIUM 6.2mEQ
110-200 mg/dl
CLORIDE 113
13-43 mg/dl
BUN 25

CREATININE 3.55mg/dl 0.72-1.18 mg/dl

BILIRUBIN(D,T) 0.16,0.63 0-0.2 mg/dl,0.1-1.2

mg/dl

SGPT 13 1-34 U/L

SGOT 40 1-31 U/L

3.5-5.2gm/dl
ALBUMIN 2.89
 10. MEDICATIONS

DRUG NAME DOSE ROUTE FREQUENCY ACTION SIDE EFFECTS

Inj. Amikacin 42.5mg I/V OD Antibiotic/ nausea,vomiting,loss of
aminogycoside appetite,increased thirst,
rash, or injection site reactions
(pain, irritation, redness).

injection site reactions

Inj. Cefotaxim 175mg I/V 12hrly antibiotic (swelling, redness, pain,
soreness, or a hard lump),
loss of appetite,stomach, pain,
nausea, vomiting,
diarrhea, headache, or.
vaginal itching or discharge.

allergic reaction, including:

Inj. 35mg I/V SOS anti-pyretic rash, itching/swelling
Paracetamol (especially of the
face/tongue/throat), severe
dizziness, trouble breathing.

Inj. Vit K 1mg I/V stat anticoagulant flushing, injection site pain or
discomfort, taste disturbances,
dizziness, rapid or weak
pulse, profuse sweating,
low blood pressure
(hypotension), shortness of
breath,

11. TREATMENTS: Folleys catheter in situ, continue monitering, oxgen flow @ 5 l/min.
urine output maintained, X ray and ultrasound was done found out as bilaterial
hydronephrosis. Advised for peritoneal dialysis and planned for uretheroscopic
fulguration.

12. I.V FLUID ON FLOW: N/2 in 5%. With Kcl(1:100)

 NURSING CARE PLAN

Fluid volume deficit related to disease process as evidenced by poor intake of feeds and
output.

Ineffective breathing pattern related to decrease oxygen in the body as evidenced by SpO2
monitoring.

Impaired urinary elimination due to congenital defects as evidenced by decreased urine

output.

Activity intolerance related to disease process as evidenced by weak cry and fatigue.

Knowledge deficient of parents related to disease process as evidenced by asking questions

regarding the treatment.

Risk for infection related to the presence of catheter.

 NURSING CARE PLAN

Assessment Nursing Goals Intervention Rationale Implementation Evaluation

Diagnosis
Subjective To Assess the Provides a Assessed the Intake output
Data: Fluid effectively general baseline data to general chart was
The mother volume maintain condition of plan care. condition, the maintained.
says infant deficient and child is restless.
the infant.
is irritable. related to control the
disease fluid
process as level. Assess for Assessed for the
To assess the
evidenced the weight of weight of the
the child. further baseline
Objective by poor data. infant that is
Data: intake of 3kgs.
The infant feeds and
looks output.
restless and Provide Feeds were
To maintain the
cry feeds as per provided every
doctors nutritional level
of the child. 2hrly @25ml.
advise.
To maintain Administered
Admister I/V intravenous fluid
fluids as per the hydration
N/2 5%. With
doctors level of the KCl.
advise. infant.

Assess for Assess the

Intake output
the intake difference chart was
and output between the maintained
level. intake and Intake-1200ml
output level. Output- 75ml in
24 hours.
Assessment Nursing Goals Intervention Rationale Implementation Evaluation
Diagnosis

Subjective Ineffective The infant The oxygen

Data: breathing will have Assess the Provides a Assessed the level of the
The infant pattern adequate breathing baseline to plan breathing pattern infant is
was having related to oxygen pattern of the care. of the child. maintained.
difficulty in decrease level and infant.
breathing oxygen in may
SPO2-80% the body as maintain Monitor the Monitoring the
evidenced by. O2 saturation Checks for the child with O2
by SpO2 level in the O2 level saturation 98%
monitoring. infant. content in the after
body. administering
oxygen 5 l/min.

Provide
comfortable Induces rest and Elevated the
position to sleep. head end of the
the child infant.
Assessment Diagnosis Goal Interventions Rationale Implementation Evaluation

Subjective Self-care Assess the To assess the Assessed the The child
Data: deficient The child general baseline data condition, child looks clean
Infant related to hygiene condition of of the child. looks weak and and tidy.
cannot disease will be the child. fatigue.
maintain process as maintained Maintains
hygiene due evidenced and the time.
to inability by cleanliness. Prepare the Gathered articles
to take care weakness child for for sponge bath
by himself. and sponge bath. such as water,
fatigue. clothes sheets and
gauzes etc.
Ensures the
Check the child Checked the
body whether the temperature of the
temperature of temperature child and water.
the child. is normal or
abnormal.

Restores
muscle Provided the
Provide range strength. infant with some
of motion leg movements
exercises to and stretching’s.
the infant. Reduces
infection Changed sheets
Change the after bathing.
sheets after
bathing.
Assessment Diagnosis Goal Interventions Rationale Implementation Evaluation

Subjective Impaired To Assess the Provides a Assessed the The parents

Data: urinary provide knowledge baseline data knowledge level looked less
The child’s elimination knowledge level of the to plan care. of the parents. stressed and
parents said due to about the parents. Knows something were
that after congenital disease about the disease. consoled to
birth the defects as process. some extent.
child did not evidenced Explain the Reduces Explained about
passed urine by reason of anxiety the disease
decreased disease level. process the
Objective urine process of the possible
Data: output. child to the occurrence.
The parents parents.
looks
worried and Answer the Clears the Answered the
confussed. questions queries. question asked by
asked by the the parents.
parents.

Provide Reduces Psychological

psychological anxiety. support was given
support to the to the parents.
parents.

Health education
Provide health given regarding
education Provides the hygiene and
regarding the information cleanliness of
cleanliness and to the child.
hygiene of the parents
infant.
Assessment Diagnosis Goal Interventions Rationale Implementation Evaluation

The child gets Risk for The Assess the Provides Assessed the The infection
irritated due to infection infant general a baseline general was
catheter and related to will be condition of data to condition of the prevented and
cries the free from the infant. plan care. infant, the the infant
continuously. presence infection. infant cries showed no
of continuously. signs of
catheter. infection.
Assess the Provides Assessed the
possible sites care for infant for the
for the signs further possible sites,
of infection. planning. the prescence
of urinary
catheter.

Clean the site Prevents Cleaned the site

with the with betadine
antiseptic growth of solution.
solution. infection.

Change the Prevent The urinary

urinary the catheter was
catheter if leakage. changed.
necessary.

Administer Prevents Administered

antibiotic as from Inj. Cefotaxime
per doctor’s infection as per doctor’s
order. order.
PROGRESS NOTES:
DAY 1

B/O Soniya is active, alert and has good cry. Periphery is warm. Temperature- 36.4ᵒC ,HR-
119beats/min, RR-28breaths/min
-Weight- 2500 gm, Head circumference:30.5cm,
-Total intake- 135ml, Total output- 195ml.
-Intravenous fluid 250 ml over 24 hours @5.5ml/hour. (100ml N/2+1 ml Kcl).
-Urinary catheter present.
-Draining clear urine.
-Surgical area is clean and healthy.

Nursing Care :

-Sponge bath
-Propped up position
-Monitoring vitals.
-Betadine dressing.

DAY 2

B/O Soniya is active, alert and has good cry. Periphery is warm.
Has passed stools and urine.
Feeds @25ml/kg/day. Total urine out put -50ml, Total -OG feed 200ml,
Intravenous fluid 27.5 ml.

Temp- 36.60 C, HR- 148b/min., R-28b/min., SPO2-96%.

Weight-2500gm.
Ryle’s tube feed 13 ml Expressed breast milk 2 hourly. @ 25ml/kg/day.
Urinary catheter present.
Draining clear urine.
Surgical wound is clean and healthy.

Nursing Care:

Sponge bath
Propped up position
Monitoring vitals.
Betadine dressing.
Feeding with NG tube
DAY 3

Patient is B/O Soniya is active, alert and has good cry.

Periphery is warm.
HR- 100beats/min,
RR-32breaths/min.,
Temperature- 36.4ᵒC,
Weight- 2500gm.
HC-34cm.
Ryle’s tube feed 29 ml Expressed breast milk 2 hourly.
Total intake- 204ml, Total output- 175ml.
Intravenous fluid 150 ml over 24 hours @5.5ml/hour. (100ml N/2 +1 ml KCl.)
Urinary catheter present.
Draining clear urine.

Nursing Care :

Sponge bath
Medications given
Monitoring vitals.
Betadine dressing.
Feeding with NG tube

DAY 4

B/O Soniya is active, alert and has good cry.

Periphery is warm.
Temperature- 36.4ᵒC,
HR- 119beats/min,
RR-28breaths/min., ,
Weight- 2515gm, 24hr.
weight gain-15 gm,
KC feed 33 ml Expressed breast milk 2 hourly. @ 120ml/kg/day.
Total intake- 340ml, Total output- 100ml.
Baby has passed urine and stool.
Surgical wound is clean and healthy.

Nursing Care :

Sponge bath
Medications given
Monitoring vitals.
Betadine dressing.
Feeding with katora feed.

DAY 5
Child is alert and active.
HR- 119beats/min, RR-28breaths/min., Temperature- 36.4ᵒC, Weight- 2515 gm.
Child hemodynamically stable.
Baby has passed urine and stool.
 HOLY FAMILY HOSPITAL,COLLEGE OF NURSING , OKHLA

CASE PRESENTATION
ON
B/O SONIYA
ON

POSTEIOR URETHRAL
VALVE.

SUBMITTED BY:
SUBMITTED TO:
MARY MENU EKKA
MADAM ASHLEY
M.SC 1ST YEAR
ASSISSTANT PROFESSOR
HFCON
HFCON
 Holy Family Hospital, Delhi

GROWTH
AND
DEVELOPMENT
OF
ADOLESCENT

SUBMITTED TO: SUBMITTED BY:

MADAM SHERLEY MARY EKKA
ASSISSTANT PROFESSOR M.Sc. 1ST YEAR.
HFCON HFCON