Case Presentation On Gbs

 

SISTER NIVEDITA GOVERNMENT NURSING COLLEGE I.G.M.C, SHIMLA

SUBJECT: CHILD HEALTH NURSING CASE PRESENTATION ON GUILLIAN BARRE SYNDROME SUBMITTED TO: DR. SEEMA CHAUHAN

SUBMITTED BY: RUCHI SHARMA

LECTURER SNGNC, IGMC SHIMLA

MSC NSG 1ST YEAR  SNGNC, IGMC SHIMLA SUBMITTED ON 27-02-2020

 

CASE PRESENTATION IDENTIFICATION DATA

1. Na Name me 2. Ag Agee 3. Sex 4. Birt Birth h we weig ight ht 5. Pres Presen entt we weig ight ht 6. Date Date of admiss admission ion 7. I.P.D. number 8. Registration nu n umber 9. Father’s name 10. Mother’s name 11. Address 12. Diagnosis Diagnosis 13. Doctor in charge

K Kaaran 6 ye year arss Ma Male 2. 2.5 5 kg 14 kg 27-0127-01-2020 2020 IP20202507 202001227424 Mr. Raghubir   Mrs. Kanta Village Baldun Tehsil Nurpur District Kangra, H.P. Guillian Guillian Barre Barre Syndrome Syndrome Dr. Ashwani Sood

CHIEF COMPLAINTS

Patient is admitted with the chief complaint of:  

Inability to stand * 2 days Pain * 2 days

MEDICAL HISTORY Present Medical History: According to parents, patient was apparently well few days ago and he started complaining of pain in lower  Present extremities and refused to go to school. But his father thought he’s just making excuses and he dropped him school. After some time they got a call from teacher that he has fell down and isn’t well. They rushed him to nearby hospital and was referred to IGMC Shimla.

medical cal history in past. Past Medical History:  No any medi

 

SURGICAL HISTORY Present Surgical History: Patient had not undergone any surgery. Past surgical History: Patient had not undergone any surgery in past. BIRTH HISTORY Antenatal History: Age of Mother-20 years  

Antenatal checkup- Regular antenatal checkup



Ante partum hemorrhage- Absent



 No History of Oligohydraminos or Polyhydraminos

Intranatal History: Type of delivery: Full term normal vaginal delivery  

Birth Weight: 2.5 Kg

Post Natal History: Child soon started crying after delivery. Immunization: The patient is immunized as per national immunization schedule. DIETARY HABITS/FEEDING HABITS:  

Type of feeding: The child started taking food such as roti, dal, sbji etc. Age of weaning: At the age age of 6 months

 

Current diet: Child takes pulses, rice, vegetables, and chapatti.

 

GROWTH AND DEVELOPMENT MILESTONE:

 

 

Activity

Milestone in children

Gross motor

 

   

Fine motor

 

   

Language/speech

 

   

Social development

    

 Not able to run, jump and hop  Not able to stand Sits upright with the help of support Catches a ball Using Knows right from left hand. Draws a person with 12-16 pass. Prints words, learns cursive writing. Has improved eye-hand coordination. Response dependent on mood. Response to praise. Repeat 10-12 words. Has a vocabulary of 2500 words. Knows date, month, and season. Attention span increasing. Jealous of sibling. Return to temper tantrums. Has better manners.

SOCIO-ECONOMIC STATUS: Patient belongs to middle class family. His father is a laborer & mother is a housewife. PERSONAL HISTORY: Hygiene: Patient hygiene is good and patient is well groomed 



Sleep Pattern: Sleep pattern is normal



Diet Pattern: Patient’s Diet pattern is inadequate



Elimination: Patient elimination pattern is inadequate

FAMILY HISTORY:

 



Type of family: Nuclear Family.

 

Family Tree:

 

Mr. Raghubir (32 years)

Mrs. Kanta (27 years)

Key Terms:

 

Male

  Karan (6 years)

Naina (9 years)

Female

  Patient  

Family composition:

Sr.N Sr.No. o. Name Name of fa fami mily ly members

Relation with patient

Age/sex

Education status

Occupation status

Income per month

Health status

1.

Mr. Raghubir

Father

32 years/ Male

10th 

Private

10,000

Healthy

2.

Mrs. Kanta

Mother

27 years/ Female

8th 

Housewife

Nil

Healthy

3.

Karan

Patient

6 years/ Male

1st c  cllass

Nil

Nil

4.

Naina

Sister

4 years/ Male

Nursery class

Nil

Nil

Unhealthy(Guillian Barre Syndrome) Healthy

Family Illness History:

 

 

 No family history of any illness.

SOCIOECONOMIC STATUS OF FATHER AND MOTHER:  

Occupation of father: Laborer  Total income: 10,000

 

Per capita income: 1,20,000

 

PHYSICAL ASSESSMENT 1. BASE BASE LINE LINE DA DATA TA  

General appearance:

Undernourished



Body build

Thin



Health

Unhealthy

 

Vital Signs

Temperature: 98.50F Pulse: 114b/min Respiration: 32breaths/min Blood pressure: 136/90 mm Hg SPO2: 98% on room air 

2. PHYSIC PHYSICAL AL EXA EXAMIN MINATI ATION ON

Sr. No.

Characteristics

Patient value

Normal value

Remarks

1.

Weight

14kg

17.5-25.5kg

Decreased

2.

Height

116cm

110-124cm

Normal

3.

Head circumference

52cm

51-54cm

Normal

4.

Chest circumference

56cm

54-58cm

Normal

5.

Mid arm circumference

16cm

16-17cm

Normal

3. SK SKIN IN CO COND NDIT ITIO ION N 

Color:

 Normal

 



Texture: 

Nourished



Rashes: 

Absent



Birth mark: 

Absent

Hair color & distribution:  Nails: 

Black and equally distributed Pale yellow

 

4. HEA HEAD & FA FACE 

Shape: 

Normal



Facial appearance: 

Normal



Cyanosis: 

Not present



Birth trauma: 

Not present

Scalp:  Hairs: 

Clear  Equal distribution

 

5. EYES 

Eyebrows: 

Normal



Eye lashes: 

Normal



Eye lids: 

Normal



Sclera: 

Normal



Conjunctiva:  Cornea: 

There is no swelling in the patient eye (Conjunctivitis) Normal



Pupils: 

Reactive towards light



Vision: 

Normal



6. EARS 

Position: 

Normal



Shape & Size: 

Normal

 



Tympanic membrane: 

Normal



Hearing: 

Normal



Cartilage formation: 

Ear recoil present

Any discharge:    7. NOSE 

No discharge



Size: 

Normal



Shape: 

Normal



Internal nasal mucosa: 

Intact

8. MOUTH 

Lips color:  Gums: 

Pink  Normal



Tongue: 

Pink moist



Tonsils: 

Normal



9. NECK   

Thyroid: 

There is no enlargement of thyroid gland (Hypothyroidism and hyperthyroidism)



Lymph nodes: 

There is no swelling or enlargement of lymph nodes.

10. CHEST CHEST 

Respiratory rate: 

Increased



Rhythm: 

Normal



Shape: 

Normal



Breath sounds: 

Noisy breathing



Heart rate: 

Increased

 

11. ABDOME ABDOMEN N  

Inspection: 

Scar: No scar present

Umbilicus: Normal Palpation:

 





Liver: Normal



Spleen: Normal

Percussion: 



Ascites /Any mass: There is no fluid accumulation or mass.

Auscultation: 

Peristaltic movements: Normal

12. GENITALIA GENITALIA  

Rectum: 

There are no congenital anomalies is present i.e. hemorrhoids, polyps etc.

 

Male genitalia: 

In patient there is no any congenital anomalies i.e. undescended testis, hypospadias, epispadiasis

13. BACK: BACK:

Patient spine is straight and no kyphosis, lordosis and scoliosis is present.

14. EXTREMITIE EXTREMITIES S  

Upper extremities: Range of motion:



 

Normal



Syndactyly:

No present



Polydactyl:

Not present

Lower extremities:

SYSTEMIC EXAMINATION

There is no any deformity i.e. hip dislocation, clubbed foot or any bone deformities is present. Paralysis in lower extremities and inability to stand and walk. No sensation is felt by patient in foot and legs.

 

 

 

 

 

 

Nervous System: Sensory and Motor nervous system: Normal Patient is conscious, follows some of commands and well oriented to time, place and person. Cardiovascular system:  Normal heart sounds Gastrointestinal system: Bowel pattern: Normal, have passed stools Genitourinary system: Urinary retention Musculoskeletal system: Good range of motion in upper extremities.

Poor range of motion in lower extremities due to paralysis. Inability to stand and walk.

 

LAB INVESTIGATIONS Sr. No 1.

Investigations

Patient’s value

Normal value

Blood test Haemoglobin WBC ESR BUN

11.8 10.20 12 11

12-14 g/dl 4,000-11,000 5-13 mm 5-18 mg/dl

Platelet count Creatinine PT INR APTT Sodium Potassium Chloride Calcium

322 0.26 13.8 1.05 33.8 139 4.68 105 96

1.5-4 lakhs 0.16-0.39 mg/dl 10-14 sec