DHANWANTARI COLLEGE OF

NURSING
Vinayak Nagar, Chikkabhanavar, Bangalore

CHILD HEALTH NURSING

Care Plan on:

NEPHROTIC SYNDROME

SUBMITTED TO
Ms. Babitha K
Lecturer in Pediatric Nursing
Dhanwantari College of Nursing
Bangalore

SUBMITTED BY
Mr. Somashekhar.S,Akalad
I Yr M.Sc. Nursing
Dhanwantari College of Nursing
Bangalore

SUBMITTED ON: 18-02-2011

 NEPHROTIC SYNDROME
INTRODUCTION
As a part of our clinical experience in Pediatric nursing, we were posted to IGICH
(Sanjay Gandhi Institute of Child Health), Bangalore. When I was posted to medical ward, I
came across the patient by name Baby Chandana, diagnosed as Nephrotic Syndrome. I have
selected this case for my care plan and to apply theory on 08/02/11 in order to use this
knowledge in my day to day clinical practice.

I. BIOGRAPHICAL INFORMATION
Name : Baby Chandana
Age : 4 years
Sex : Female
Address : D/o Ganapathi
Kanakapura
Bangalore dist
Religion : Hindu
IP No. : 61837
Admission unit : B Unit
Date of admission : 6/02/2011
Date of history taking : 08/02/2011
Informant : Mother

II. DIAGNOSIS : Nephrotic Syndrome

III. PRESENT HISTORY

Chief Complaints with Duration
Baby Chandana was admitted with the complaint of
Puffiness of face since 20 days,
Abdominal distension since 2 weeks and
 Pedal edema since 10 days.
History of Present Illness
Baby Chandana was apparently normal till 1 month back when she starts to
develop puffiness of face and periorbital edema which was more in morning and
gradually reduced in evening followed by distension of abdomen since 2 weeks and
swelling of both feet since 10 days. The child has history of reduced urine output
since 15 days. Child used to pass urine 8 – 10 times/24 hours before one month. Now
child passes urine only 4 – 5 times / day, small quantity.

IV. PAST MEDICAL HISTORY

Past illness, hospitalizations : There is no history of past illness, surgeries or
major illness

Allergies : No allergies to any medications or food items

Medications : There is no history of previous medications.

V. BIRTH HISTORY
Antenatal : Uneventful

Natal – Place of Birth : Hospital

Mode of Delivery : Normal Vaginal Delivery
Gestational Age : Full term
Birth Weight : 2.3kg

Postnatal : No Injuries

VI. FAMILY HISTORY

29years 23years

4years
 Has no family history of hypertension, diabetes, communicable disease,
cardiovascular disease or congenital anomaly. All of her family members enjoy good
health.
VII. GROWTH AND DEVELOPMENT
The growth and development is appropriate to the age.

VIII. IMMUNIZATION
Baby Chandana received all the immunization vaccines as per schedule.

IX. ELIMINATION PATTERN

Bowel : Has regular bowel movement once a day
Bladder: Passing small quantity of urine. 4-5 times/day

X. NUTRITIONAL PATTERN
Recent Weight : 16 kg Expected Weight: 14kg
Appetite : Poor.

24 Hours Diet Recall:

Time Diet items
1. 7.30 AM 1Glass of milk
2. 9 AM 1 glass of juice
3. 1.30 PM 1 ½ cup of rice and sambar
4. 4.PM 1 Glass of milk.
5. 8 PM 1 ½ cup of ragi saru and sambar.

XI. SLEEPING PATTERN

Sleep pattern is normal.
 PHYSICAL EXAMINATION
1. General Observation
Baby Chandana is moderately built, nourished, 4years old female, conscious and oriented
to time, place and person.

2. Vital Signs
Temperature : 98.4 o F
Respiration : 30breaths/min.
Pulse rate : 108 bts/min
BP : 110/70 mmHg

3. Anthropometric Measurements
Height : 95 cms
Weight : 16 kg
Head Circumference : 44 cms
Chest Circumference : 52 cms
Mid Arm Circumference : 15cms

4. Skin And Mucus Membrane

Color : Wheatish
Edema : present on face, periorbital region and feet.
Moisture : Moist
Temperature : Warm to touch
Turgor : Good
Texture : Good
Any Abnormal Discharges : No

5. Hair
 Changes in Texture : No changes
Characteristics : Equally distributed, Black in color
Lice : Absent
6. Nails
Changes in Appearance : Nil
Cyanosis : Absent
Texture : Normal

7. Head
Skull/Cranium Size, Shape : Normal
Movements : Normal
Forehead : No scars

8. Face
Appearance : Puffiness of the face
Color : Fair
Symmetry : Symmetrical
Movements : Normal

9. Eyes
Expression : Appears dull and pale
Eye Lids : Periorbital edema present
Lacrimation : Clear fluid expressed no discharge present.
Eyebrows : Equal, evenly distributed hair
Conjunctiva : Pale
Sclera : White and moist
Cornea : Smooth, moist and round
Pupil : Pupils are equally reactive and accommodates light.

10. Ears
Appearance : No abnormal masses
Discharges : Nil
 Lesions : Nil
Any Abnormalities : No

11. Nose
Appearance : No septal deviation
Discharges : Nil
Patency : Good
Sense of Smell : Good

12. Mouth And Throat

Lips : Normal, moist
Tongue : Not coated, no atrophy
Teeth : Intact in upper and lower jaw.
Gums : Normal
Buccal Mucosa : No inflammation
Palate : Normal
Tonsils : No inflammation
Taste : Able to differentiate taste.

13. Neck
General Appearance : Normal range of movements
Trachea : Centrally located
Lymph Nodes : No enlargement
Thyroid Glands : Smooth, firm and non tender
Salivary Glands : No enlargement
Cysts and Tumors : Nil

14. Chest And Respiratory System

Inspection : Size & shape is normal and symmetrical. RR: 30 breath/ min
Palpation : No swelling and tenderness
 Percussion : No fluid collection
Auscultation : No abnormal breath sounds

15. Cardio Vascular System

Inspection : Size and shape of the chest is within normal limits
Palpation : No pericardial rub or palpable sounds
Percussion : Cardiac borders well within normal limits, no cardiac or
supracardiac dullness
Auscultation : S1 S2 heard well. No abnormalities, Pulse-108bts/min and
regular.

16. Abdomen
Inspection : Abdominal distention present
Palpation : Mild tenderness present
Percussion : Fluid presence felt.
Auscultation : Slow peristaltic sounds heard

17. Back
Spine, Curvature : Normal
Symmetry : Symmetrical
Tenderness : No tenderness

18. Genitalia
Normal female genitalia

19. Extremities
Deformities : Nil
Swelling/ Edema : Present on both the feet.
Muscles : Normal
Lymph Nodes : Not palpable
 Joints : Pain at ROM
Fingers and Toes : Normal
Nails : Pale
20. Central Nervous System
Birth Injuries : Absent
Seizures : Absent
Speech : Appropriate to the age
Sensory Motor Changes : Responds to touch
Gait Changes : Sluggish
Cognitive Changes : Well oriented and conscious
Reflexes : Normal

21. Urinary System

Urinary Tract Infections : Absent
Any Abnormalities : Nil

22. Gastro-Intestinal System

Diarrhea : Absent
Constipation : Absent
Bleeding : Absent
Worm Infestation : Absent

23. Psychosocial History

General Status of the Family:
The child’s father is a coolie worker with a monthly income Rs. 3000/- and her
mother is a housewife. Her father is the breadwinner of the family. They are staying at a
rented house which has a living room, 1 bed room, kitchen and attached bathroom and
toilet. They have a low socio economic status. Lavatory facilities are not available.

Relationship with the friends & family: Have good relationship with the friends & family

Activities of Daily Living : The child is accepting to perform his activity daily living.

Play Activities : Group and individual play with toys.

 School Performance : The child has not yet started to go to school.

Hobbies : Hide and seek, playing with toys.

24. Laboratory investigations

Sl. Investigation Results Normal values Remarks
No.

1. Hemoglobin 16.8gm/dL 12-16gm/dL Elevated

2. TC 20,500cells/cmm 4500-11000cells/cmm Elevated
3. DC:
Prothombin 40%
Lymphocyte 42%
Erythrocyte 15%
4. Glucose 74mg/dL 60-100 mg/dL Elevated
5. Creatinine 1.0mg/dL 0.6-1.4 mg/dL Normal
6. Sodium 138meq/L 135-148 meq/dL Normal
7. Potassium 5.7meq/L 3.5-5.2 meq/dL Elevated
8. Chloride 117meq/L 95-106 meq/dL Elevated
9. Urea 49.6mg/dL 10-50 mg/dL Elevated
10. Alkaline phosphate 79.5 IU/dl 85-400 units/L
11. SGOT 41.4 IU/dl
12. SGPT 30 IU/dl
13. Urinary:
Protein 2.3gm/dl
Volume: 200ml Elevated
Albumin: 1.6mg/dl
Globulin: 2.4mg/dl

25. Special investigations

Renal biopsy: MCNS-Negative.
Culture/sensitivity-specimen-ascitic fluid- Heals no growth.
 MEDICATIONS
Medication name Dosage Frequency Route Actions Side effects Nursing responsibilities
1. Inj. Lasix 40mg 6th hourly IV Diuretic Allergic reaction, Follow the safety principles of
nausea, vomiting, drug administration.
increased salivation, Maintain aseptic precautions
fever and chills. during drug administration.

Administer the IV injections as

20mg Od Oral Antimicrobial Nausea, vomiting,
2. Tab Wysolone slowly as prescribed.
diarrhea, indigestion,
Continuous monitoring of vital
rash and urtricaria
signs.
25mg Od Oral Corticosteroid Hypertenstion, Observe the baby continuously for
3. Tab Levanisale susceptible for side effects of drugs.
infection Inspect the site of injection
regularly.
80mg Bd Oral Antibiotic Nausea, vomiting,
4. Tab Septra diarrhea, indigestion,
rash and urtricaria
 ASSESSMENT OF BABY CHANDANA USING JOHNSON BEHAVIOURAL SYSTEM MODEL
The focus on assessment process is to obtain knowledge regarding the client through interviews and observation of the patient
and family. The purpose is to evaluate the present behavior in terms of past patterns to determine the impact of the present illness or
perceived health threat and /or hospitalization on behavioral patterns and to establish the maximum possible level of health towards
which an individual can strive. The behavioral system analysis approach provides a comprehensive framework in which various types
of data can be organized into a cohesive structure.
The assessment gathers specific knowledge regarding the structure and function of the eight subsystems (behavioral
assessment and those general and specific factors that supply the subsystem functional requirements/ sustenal imperatives
(environmental assessment)

FRAMEWORK ELEMENTS:

BEHAVIOURAL ASSESSMENT
ACHIEVEMENT : Baby Chandana is a 4 years old girl, who lives with parent and elder sister in a rented house.

AFFLIATIVE : Baby Chandana lives with her parents with love and guidance. She is loved and Cared by his
family members.

AGGRESSIVE/PROTECTIVE : Baby Chandana has puffiness of face, abdominal distension and pedal Edema. The mother is
not taking proper care of the child as she is not aware of the condition.

DEPENDENCY : Baby Chandana depend on others for all of her needs. The child’s father is former with a
monthly income Rs. 3000/- and his mother is a housewife.
ELIMINATIVE : She has regular bowel pattern and has decreased urine output. Passing 4 – 5 times a day with
small quantity

INGESTIVE : Has no problem in digesting.

RESTORATIVE : Baby Chandana admitted with the complaint of puffiness of face since 20 days, abdominal
distension since 2 weeks and pedal Edema since 10 days. Now she is experiencing fatigue and
weakness. She is also anxious and depressed due to disease and environment.

SEXUAL : Baby Chandana is very cooperative with other children.

ENVIRONMENTAL ASSESSMENT
FAMILIAL : Baby Chandana stays with her parents and sister. There were four members in the family.
Father is the breadwinner of her family. Mother looks after them with love and affection. Her
uncle gives financial support for his medication as father’s income is not affordable.

SOCIOCULTURAL : Baby Chandana is from Hindu middle class family. They believe in god and do prayers. They
maintain good social relationship with friends, relatives and neighbors. They celebrate all the
regional festivals regularly.

ECOLOGICAL : They lived in a rented house, which consist of 1 bed rooms and one kitchen and attached
bathroom and toilet. The drainage is open drainage. They have poor public transportation
facility.

DEVELOPMENTAL : Baby Chandana is 4 years old girl. She enjoy with his friends in neighbor
 NURSING CARE GIVEN:
According to NANDA’s format of nursing diagnosis the following diagnosis are formulated:

1. Fluid volume excess related to fluid accumulation in tissues.

2. Imbalanced nutrition, less than body requirements related to loss of appetite.
3. Disturbed family processes related to child with a serious disease and hospitalization.
4. Parental knowledge deficit regarding disease condition, treatment and follow up care related to lack of knowledge.
5. High risk for infection related to lowered body defenses, fluid overload.
6. High risk for impaired skin integrity related to edema, lowered body defenses.
NURSING CARE PLAN
NURSING NURSING PLANNING
ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
THEORY DIAGNOSIS
It is identified Subjective data: Fluid volume Baby will -Assess the child - Baby have facial Baby Chandana
that due to the The mother excess related maintain for signs of fluid puffiness, periorbital edema has
mode of complaint that to fluid fluid volume overload. and pedal edema reduced the
intervention, he my son is having accumulation in the body -Assess intake - Maintained the edema. The
is allowed to stay swelling of face in tissues as and to reduce relative to output. intake and output child’s
in bed and his since 1 month. evidence by the edema. -Measure and chart. abdominal girth
ADL has to be Objective data: puffiness of record intake and - Output is lesser than was 54 cms.
met in the bed. The child is face, output accurately. intake.
Nurses also having puffiness periorbital and - Measure
identifies of face, pedal edema, abdominal girth. - Abdominal girth is
potential periorbital and abdominal -Test urine for 58cms.
problems of her edema and distension. specific gravity - Albumin level is
condition and edema at feet. and albumin. . 1.6mg/dl
assesses her Temp: 98.4o F -Administer - Administered
everyday and Resp: 30/mt corticosteroid and Tab. Wysolone and
take action to Pulse: 108/mt diuretics to inj. Lasix as
prevent BP: 86/60mmHg decrease the fluid prescribed by the
complication overload. physician.

NURSING ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

 THEORY DIAGNOSIS OBJECTIVE INTERVENTIONS
Johnson’s Subjective data: Parental The parent -Assess the -Understanding level Parent got
Behavioral system The parents say knowledge will maintain knowledge level of the parents is poor. adequate
model. that they don’t deficit related the knowledge of parents. knowledge.
Nurses identifies know anything to disease level -Educate the -Educated mother They follow up
that the client’s about the child condition, regarding the parents regarding regarding the the ordered.
parent has lack of conditions. treatment and child’s the condition of condition of their
knowledge follow up care. condition. their child in child in Kannada.
regarding the Objective data: simple language.
child’s conditions, The client’s -Explain about the -Educated parents
treatment and parent looks causes, symptoms regarding the
follow up care. anxious and and the prevention measures to prevent
Nurses set mutual asked many of further the complications.
goals with client, doubts. complications.
identifies focus of - Educate the -Explained the
intervention, parent regarding importance of
technique of the importance of treatment and their
intervention treatment and its support.
evaluation is done side effects.
according to the -Clarify the doubts -Clarified the doubts.
established goal. of the parent. .

NURSING NURSING PLANNING

ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
THEORY DIAGNOSIS
Johnson’s Subjective data: High risk for Child will be -Assess the -Assessed the The child
behavioural The mother infection related free from condition of the condition of the exhibits no
system model. complaint that to potential child. child. evidence of
It is identified the child is hospitalization. infections. -Monitor vital infection.
that he has having itching. signs for any sign -Vital signs are stable. Family member
itching and Objective data: of infections. apply good
redness. Nurses Child is -Protect the child -Advised mother to health practices.
set mutual goals, hospitalized and from contact with keep the soiled things
identifies the having infected persons. away from the child.
focus of intravenous -Place in room -Child is placed in the
intervention, procedures.. with well ventilated and
identify noninfectious hygienic ward.
techniques of children. -Following the aseptic
treating during -Do proper hand precautions during
his planning. washing before procedures.
and after handling
the child. -Advised mother to
-Keep the child keep the child warm
warm and dry. and dry.

NURSING NURSING PLANNING

ASSESSMENT OBJECTIVE INTERVENTIONS IMPLEMENTATION EVALUATION
THEORY DIAGNOSIS
Johnson’s Subjective data: High risk for The child -Assess the risk -Facial puffiness, The child‘s skin
behavioural The mother impaired skin will maintain factors for the periorbital edema and display no
system model. complaint that integrity skin impairment of skin pedal edema present. evidence of
Nurse identifies my son is having related to bed integrity. integrity. redness and
that the client edema. ridden - Provide irritation. The
-Provided the skin
has high risk of condition, fluid meticulous skin mother is
care.
getting bed Objective data: overload. care. applying cream
sores. While Child having - Avoid tight -Advised mother to to the child.
planning facial puffiness clothing. avoid tight clothing.
intervention she and pedal edema. - Cleanse and
-Cleansed and
sets mutual goals powder opposing
powdered skin
with clients, skin surfaces
surfaces.
identifies focus several times a day
of intervention, - Change the
techniques of position frequently. -Advised mother to
intervention. change the position
- Use pressure frequently.
relieving
-Provided pressure
mattresses to
relieving mattresses
prevent ulcer.
and maintained good
body alignment.