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PEDIATRIC NURSING HISTORY

Introduction:
 I was posted in General ward (B-ward) for seven days. There I took one case for my clinical teaching, firstly when I met with

my patient, he is restless, anxious because of strange environment. I introduced myself to patient and patient relatives.

1.Demographic data

Name of the child – Master Ayaz pasha

Age of the child - 4 years

Gender - Male

Unit/ Ward - 1st - ward

Diagnosis - Enteric fever

Address - S/o Mr. Fiaz Pasha, Rehamath Nagar, Kolar.

Date of admission -18/02/2018

2. Chief complaints

- Fever since 10days.

- Not eating well from 10 days.

 - Vomiting X 3 days.

- Headache X 3 days

3. Family history

a) Family tree

Patient is living in a nuclear family along with his parents. There is no history of Diabetes Mellitus, Bronchial Asthma, and

Hypertension etc. in patient’s family.

30 25 Male

Female

Patient

b) Family composition

Name of the Relationship Age Gender Marita Education Occupation Health

Family to the Head of (yrs) l Status Status

Member the family

Mr Fiaz pasha Father 34 Male Married 10th std. Businessman Good

Mrs. Salmataj Mother 32 Female Married 10th Housewife Good

Master. Ayaz Patient 4 Male - Nursery - Unhealthy

pasha

c) Family income in rupees per month - Rs.10,000/month.

d) Religion – Mohammad belongs to a Muslim family.

e) Housing facility – Three family members are living in a house containing two room which are well-ventilated and well-

illuminated. Bathroom and toilet is present in house. There is a separate kitchen for cooking. They use LPG for cooking. They

drink corporation water.

4. Birth History

a) Prenatal history – Mr. Fiaz pasha is a non-consanguineous child. Age of the mother during pregnancy was 20 years. There is

no history of infectious disease like TORCH during prenatal period. There was no exposure to radiations during prenatal
 period. Patient’s mother did not take any medicine during her prenatal period. It was her 1st pregnancy. Injection TT was

given during her prenatal period.

b) Natal history – Birth order is 1st Delivery was conducted in home. Birth weight of the child was about 3 kg. Mother reported

that child was pink in color at the time of birth.

c) Postnatal/Neonatal history – Child cried immediately after birth. There is no history of asphyxia/cyanosis/birth injury/eye

during post- natal period.

5. Immunization history

AGE NAME OF VACCINE DOSE ROUTE CHILD HAS

RECEIVED
At birth BCG 0.1 ml I/D 
OPV-0 dose 2 drops Oral 
Hep. B-1st dose 0.5 ml I/M X
1.5 months DPT- 1st dose 0.5 ml I/M 
HIB- 1st dose 0.5 ml I/M X
OPV- 1st dose 2 drops Oral 
Hep. B- 2nd dose 0.5 ml I/M X
2.5 month DPT- 2nd dose 0.5 ml I/M 
HIB- 2nd dose 0.5 ml I/M X
OPV- 2nd dose 2 drops Oral 
3.5 months DPT- 3rd dose 0.5 ml I/M 
HIB- 3rd dose 0.5 ml I/M X
OPV- 3rd dose 2 drops Oral 
6-9 OPV- 4th dose 2 drops Oral 
months Hep.B- 3rd dose 0.5 ml I/M X
th
9 month Measles 0.5 ml S/C 
Vitamin A 1 lac unit Oral 
At interval of 6 months 2 lacs units
1 year Varicella (Chickenpox) 0.25 ml I/M -
15-18 DPT- 1st booster dose 0.5 ml I/M 
months OPV- 1st booster dose 2 drops Oral 
HIB- booster dose 0.5 ml I/M X
MMR 0.5 ml I/M 
2 year Typhoid 0.5 ml I/M -
4.5 years DPT- 2nd booster dose 0.5 ml I/M 
OPV- 2nd booster dose 2 drops Oral 

6. Diet history- Exclusive breast-feeding was done till six months. Additional food was started after 6 months. Weaning food items

included mashed potatoes and mashed bananas, fruit juices, khichdi etc. he is non-vegetarian. Presently takes cereals, vegetables, daal,

pulses, fruits, meat etc. Usually, he takes three meals per day. Child is not having any food allergy.
7. Elimination pattern- Bowel movements are regular. Ayazpasha did not have problems of diarrhea and constipation. Bowel and

bladder control is fully attained.

8. Developmental history

Sl. No. Milestones Normal age of Child’s age of

attaining attaining

Milestones Milestones

1) Head holding 2 months 1.5 months

2) Social Smile 3 months 3 months

3) Sitting independently 6 months 6 months

4) Crawling 9 months 10 months

5) Standing 12 months 11 months

6) Speaks ma-ma 12 months 11 months

7) Walking starts with support 12 months 12-13 months

8) Teething 7 months 7 months

9) Walks independently without any 13-18 months 15 months

support

10) Drinking well from small glass 24 months 24 months

11) Toilet trained in day-time 24 months 2-3 years

12) Bowel and bladder control 3-5 years 4 years

9. Day history- Ayazpasha was looking dull and irritated because of disease condition. He was having fever and vomiting.

10. Past medical history- He did not have any disease in the past. He is admitted in the Shree Narasimharaja district Hospital, Kolar

for the complaints fever for the first time.

11. Present Medical history –

Client was admitted to indira Gandhi Hospital, Bangalore on 17th Nov 2009 with the chief complaints of fever, not eating well,

vomiting which was started 10 days before the admission.

He was diagnosed with Enteric fever.

12. Summary – Ayazpasha is an 4 years old male child who is suffering from Enteric fever. Presently his chief complains are fever,

not eating well, vomiting is reduced after taking treatment from indira Gandhi Hospital, Bangalore.

PHYSICAL EXAMINATION- HEAD TO TOE ASSESSMENT

General appearance – Ayazpasha is of moderate body built and well nourished. He is dull but well oriented to time, place and

person. The child is irritable and anxious because of complains like fever, not eating well and vomiting.

Anthropometric measurement

Sl.No. Measurements Child’s measurements Expected

measurements
1. Height in inches 100 cm. 95 - 109 cm.

2. Weight 15 kg. 13.5 – 19.5 kg.

3. Head circumference 51 cm 50-55 cm

4. Chest circumference Exceeds head Exceeds head

circumference circumference

Vital sign assessment

Sl.No. Vital Signs Child’s Values Normal Values

1. Temperature 99.5 0 F 98.6 0 F

2. Pulse 80/minute 80-90/minute

3. Respiration 18/minute 16-24/minute

 4. Blood pressure 120/80 mm of Hg 110/70 mm of Hg

ASSESSMENT OF HEAD TO TOE

Integument – No bad odor was there. Skin was pink in color. Skin texture is smooth and skin turger is good. Oedema and lesions

were not found over any body part. Skin is warm to touch.

Nails – Nails are pink in color. Shape is normal. Nails are hard, not brittle. Nails are clean and cut properly.

Hair – Hair are equally distributed. Color of hair is black and texture is good. Scalp is clean.

Head and Neck – Skull size is normal and it is symmetrical. Neck stiffness was not found. Lymph nodes are normal in size.

Ears – Position and placement of ears is normal. Hearing capacity is also normal.

Eyes - There is no ptosis or drooping of eyelids, eyebrows are also normal. No discoloration of sclera is found. Pupils are equal,

round, reacting to light and accommodating to light is normally. Visual equity is 20/20.

Nose – Size and shape is normal. Foul smell was absent. Nasal flaring and frost bite are not found. No abnormal nasal discharge was

found.

Mouth & lips – Lips are pink in color. Mouth and lips are symmetrical. Buccal mucosa and tongue are normal. Number of teeth is 24,

having no dental caries. Tonsils and voice are normal.

Thorax & lungs – Lungs and thorax are symmetrical. Depth and regularity of respiration is also normal. No abnormal sounds were

heard on percussion and auscultation.

Heart – Shape and size are normal. Heart is symmetrical. S1 and S2 sounds heard on auscultation, no abnormal sounds were heard.

Abdomen –Peristaltic waves are visible on inspection. Liver is palpable. No organomegaly. On palpation abdominal pain was present.

Bowel sounds are normal.

Umbilicus – Discharge and bad odor were not found from umbilicus.

Groin – Hernia was not present.

Genitalia –There was no abnormal discharge.

Anal region – Fissures/prolapse and anomalies are not found.

Breasts – Normal in shape and size.

Spine – Spine curvatures are normal. Abnormalities like discoloration, hair growth and dimple are not found.

Extremities – Gait is normal. Creases in palm and muscle strength are normal. Pitting edema was not found over extremities. Child

felt pain during movements.

REFLEXES

Deep tendon reflexes

Biceps - Normal

Triceps - Normal

Brachioradialis - Normal

Patellar - Normal
Kneejerk - Normal

Achilles - Normal

Superficial reflexes

Abdominal - Normal

Cromastric - Normal

Anal - Normal

MENTAL STATUS

Ability to respond and follow directions- Ayazpasha is responding properly and he is able to follow instructions on the day of physical

examination.

Active – He is active but irritated due to disease condition.

Articulation – Normal

PAIN ASSESSMENT

Pain is assessed by using Wong Bakers Faces Pain Rating Scale.

Child was asked to select faces closest to amount of pain felt. He has selected 3rd face. So pain rate is 2 that mean it hurts little more.

FINAL IMPRESSION

Ayazpasha is slightly irritable and anxious. Anthropometric measurements are within normal range. Mild fever is present on the day

of physical examination. Head, neck, ears, eyes, nose, mouth, lips and all other body parts are normal. Heart and lung sounds are also

normal. Child is fully conscious. Pain rate is 2.

DEVELOPMENTAL ASSESSMENT

BOOK PICTURE PATIENT PICTURE

Physical or biological Physical or biological

Weight – 13.5 – 19.5 kg Weight – 15 kg

Height – 95 - 109 cm Height – 100 cm

Pulse – 90 - 110/min Pulse – 88/minute

Respiration – 20 - 28 breaths/min Respiration – 24 breaths/min

Blood pressure – 110/70 mm of Hg Blood pressure – 110/70 mm of Hg

Motor and self care Motor and self care

- Rides bicycle with training wheels. -He knows to ride bicycle.

-Runs, jumps. -He likes to run.

-Grooming and dressing skills. -Usually he is well groomed and well

dressed.

Sensory Sensory

- Visual acuity- 20/20. - Visual acuity is 20/20.

Language & speech development Language & speech development

-Follows suggestions better than commands. -He listens very carefully whenever I told

him something.

Play stimulation

-Likes to compete. Play stimulation

-Enjoys dramatic play. -He enjoys making toys with clay.

 -Enjoys making things.

INVESTIGATIONS

Sl.No. Investigations Normal values Findings Remarks

1. Hb. 12-14 gm% 13.8 gm% Normal

2. TLC 4000-11000/cu mm 5,800 /cu mm Normal

3. DLC

4. N 40-75% 56% Normal

M 6-20% 06% Normal

 L 25-40% 35% Normal

E 1-2% 04% Increased

5. ESR 10-20 mm/hr 10 mm/hr Normal

6. Widal test Negative Positive

MEDICATION

Sl.no Medication Dose Rout Action Side-effects Nursing responsibilities

e
1. Inj. 100 ml I/V Antibiotic Nausea -Assess child for nausea,

Ciprofloxacin Vomiting vomiting and diarrhea.

Diarrhoea -Weigh child daily.

-Offer favorite food.

-Maintain I/O charts.

-Administer fluids cautiously to

 prevent fluid overload and edema

2. Tab. 200mg Oral Antibiotic Antibiotic- -Assess for possible signs and

Ofloxacin associated symptoms of drug reaction.

colitis( severe -Assess for anemia and renal

abdominal pain, dysfunction.

tenderness; -Assess moth for white patches

fever; watery, on mucus membranes, tongue.

severe diarrhea), - Monitor bowel activity/stool

other consistency carefully; mild GI

superinfections effects may be tolerable, but

increasing severity may indicate

onset of antibiotic- associated

colitis.

-Monitor I & O, renal function

reports for nephrotoxicity.

-Be alert for superinfection;

3. Tab. 500 mg Oral Antipyreti Allergic -Perform sensitivity reaction test

paracetamole c reactions, before starting the medication.

Nausea, -Be with the child for sometime

Dyspepsia after giving syrup to check for

Hepatic any side-effect.

necrosis. -Maintain oral hygiene after

giving syrup to the child to

prevent bad odor and bad taste.

NURSING DIAGNOSIS

Based on the above problems the diagnosis is set according to the priorities.

Nursing diagnosis:

1) Hyperthermia related to infection evidenced by high body temperature.

2) Fluid volume deficit related to vomiting evidenced by dull skin texture.

3) Imbalanced nutrition; less than body requirement related to disease condition evidenced by low body weight.

4) Disturbed sleeping pattern related to hyperthermia evidenced by dull face.

5) Activity intolerance related to fatigue.

 NURSING CARE PLAN

NURSING NURSING GOALS PLANNING IMPLEMENTATION RATIONALE EVALUATION

ASSESSMENT DIAGNOSIS
Subjective data: Hyperthermia To maintain - Assess the body -The patient had 99.5 0 F -To collect the Body

Mother related to the body temperature of client. temperature. baseline data for temperature is

complaints that infection temperature further planning. within normal

child is having within limits after 3-4

high body normal - Provide comfortable -Comfortable bed was -To promote hours.

temperature, limits. bed to the child. provided to patient. Head comfort during

restlessness and was supported with febrile conditions.

tiredness. pillow.

- Loosen the child’s -Loose, cotton clothes -To promote heat

clothes. were advised. regulation by

proper ventilation.

Objective data:

By checking -Increase the oral intake -Oral fluids have been -To prevent

body temperature of fluids. encouraged. complications such

I come to know as dehydration and

child is having febrile

fever. convulsions.

- Teach the parents about -Parents have been taught -To involve the

monitoring the body about monitoring child’s family members in

temperature. body temperature and simple

significance of increased interventions

oral fluids, cold bath, and regarding the care

 cool environment. of child during

hyperthermia.

Subjective data: Imbalanced To maintain --Assess height and - Height is measured, it -Provide Child takes food

The mother nutrition; less normal weight and compare with was 100cm anthropometric according to his

complains that than body nutritional the previous values and information about body

the child is not requirement status of the standard charts. body’s fat and requirement,

taking food related to child. protein content and which is

properly. disease general nutritional evidenced by

condition status. increase in food

Objective data: intake.

Child is very -Offer small and frequent - Child was provided with -Easy to digest and

weak and dull. feeding with increased small & frequent feeds, fulfill the

amount of protein. especially pulses, milk. additional

requirement for

protein.
 -Provide protein foods in Child is provided at least -Protein help in

each small meal. one item rich in protein normal growth and

during each feed. development of the

child.

-Request the family -The family members are -Favorite foods

members to bring foods requested to bring foods will be appealing

from home according to from home according to for the child, he

choice of child. choice of child. will eat it with

enjoyment.

Subjective data: Disturbed To maintain -Assess the child’s -Child’s condition is - Helps to collect Sleeping pattern

Child verbalized sleeping pattern normal condition. assessed. the baseline data is improved; now

that he was not related to sleeping for further child is able to

able to sleep at hyperthermia. pattern. planning. sleep for 7-8 hrs

night. after relieving

 -Provide comfortable -Comfortable position is -To promote fever.

position to the child. provided to the child. comfort.

Objective data:

On observation I -Provide hot fluids at bed -Child has been advised -Helps to promote

found that child time. to take a cup of hot milk good sleep.

looks very at bed-time.

tired ,his eyes

were red. -Administer antibiotics as -Antipyretics has been -Helps to relieve

prescribed by the administered according to fever because child

physician. doctor’s prescription. was not able to

sleep properly

because of fever.

Subjective Activity To promote -Provide bed rest. -Bed rest is provided to -Promote adequate Absence of

data: intolerance activity the client in a quite rest and reduce fatigue with

“I feel fatigue related to tolerance of environment. stimuli. return to baseline

very soon; weakness the child. activity.

even after characterized by -Avoid unnecessary -Child was disturbed only -Conserves energy

walking a few easy fatigue, disturbance. when necessary for care and prevent

steps” preference for and procedures. interruption in rest.

inactivity, de-

Objective conditioning -Provide play activities at -Child is provided with -Prevents energy

data: with bed rest. bed side. quite play as reading depletion caused

It is done by books, games while at by excessive

checking rest. activities.

child’s

response -Take measures to -Child has been provided -Preserves energy

during various preserve energy as far as with an access to needed which improves

procedures possible. articles within reach, aids endurance.

such as while to assist in performing

checking vital ADL

signs and

walking while -Increase the activity -Activity participation of -Promotes recovery

going to participation of child as the child is increased as without

bathroom etc. tolerated on daily basis. tolerated on a daily basis. compromising

energy or causing

fatigue.

Health education:

Health education was provided specially on Prevention of Enteric fever in children

 Vaccination: The best thing to avoid Enteric fever is get your child vaccine for typhoid. The vaccination saves a child from

Enteric fever and its dangerous complications. However, the success ratio does not show 100% protection from the disease, but

it is far better to get vaccinated rather than being more exposed to the infection.
  Food hygiene: For prevention, the strict rule is to stay in hygienic condition. Stop eating outside food as it can be

contaminated. Uncovered and stale food is the prime carrier for the microorganism causing typhoid.

 Boiled water: The water, which is not pure, should be avoided by all means. Your child should be given boiled and then

cooled water and nothing other than that. Supply the bodily fluid that is lost in diarrhea and vomiting and for that, you should

give plenty of liquid to meet the bodily requirement. If the child is suffering from severe vomiting, intravenous fluid should be

given. The food and water should be fresh and a child should remain in fresh air too.

 Avoid overcrowded areas: Dense area is dangerous in Enteric fever condition. Keep your home neat and clean. Kitchen,

floor, walls, toilets should be extra clean and are to be washed with powerful disinfectants.

Conclusion:

After implementing the nursing care and providing health education

 Body temperature comes within normal limits.

 Child has started to take food according to his body requirement, which is evidenced by increase in food intake.

 Sleeping pattern is improved; now child is able to sleep for 7-8 hrs after relieving fever.
  Fatigue subsides.

 Fluid volume is maintained as required for the normal body functions.

So, nursing care has the positive effects on child, his nursing needs are full-filled. He looks happy and active on the last day of my

posting in the ward.

Bibliography :

 Wong LD, Hockenberry-Earton M, Winkelstein LM, Wilson D, Ahmann E, Davito-Thomas AP et al. Whaley & Wong’s

nursing care of infants & children. 6th edition. Missouri: Mosby; 1999. P.

 Behrman ER, Kliegrman MR, Jenson BH, Adams GW, Adelman DR, Anderson M P et al. Nelson’s textbook of paediatrics.

16th ed. New Delhi: Harcourt India Pvt. Ltd. 2000. P.

 Wong LD, Hockenberry-Earton M, Winkelstein ML, Wilson D, Ahmann E, Davito-Thomas AP et al. Whaley & Wong’s

nursing care of infants & children. 7th ed. Missouri: Mosby; 2003. P.

 Viswanathan J., Desai BS. Achar’s textbook of paediatrics. 3rd ed. Madras: Orient Longman Ltd.; 1989. P.

 Dorothy R. Marlow, Redding AB, Abbot IM, Blackmore AC, Bonner K, Boos LM et al. Textbook of paediatric nursing. 6th

ed. New Delhi: Harcourt India Pvt. Ltd.; 2001. P