STUDENT NAME : MIZAB AKASHA SEEDAHMED ELNUR

1. Patient demographic data :

Name : Wojn Othman Taha

Date of birth : 29.2.2021 Age : 3 years and 7 months.

Adress :Al Kanag , Dongola, North state

Sex : femal ethnic :Mahass

Primary care physician : Doctor Diab.

2. Chief complaint:

- Fever

- Convulsions (3 episodes at home)

- Loss of appetite

- Vomiting after any oral intake

3. History of present illness :

3-year-old girl presented with symptoms that began on the morning of Tuesday, October 17th. The
mother reported that her daughter abruptly stopped eating her breakfast and refused to drink her usual
morning tea. Later in the day, after drinking even small sips of water or attempting to eat, the child
began vomiting, with symptoms worsening each time she tried to consume anything. By noon, the child
developed a fever, which marked the onset of febrile convulsions shortly after. The convulsions lasted
approximately one minute. Her mother attempted to manage the fever at home with Paracetamol,
which provided temporary relief, though the fever would return after the medication wore off..

Hospital Course/Progress Notes:

On the second day of hospitalization, the child developed new symptoms, including halitosis and throat
pain, which were indicative of tonsillitis. . These findings necessitated adjustments to her management
plan to address the new complications.

4.Past medica history

_ history of lactulose intolerance, identified during the neonatal period, one week after birth.

_Diagnosed with a congenital heart defect, an atrial septal defect (ASD), incidentally during evaluation
for lactose intolerance; the ASD remains unclosed.

_Additionally, she has a history of recurrent upper respiratory tract infections and episodes of the
common cold.

5.Hospitalization History

No history of previous hospitalization.

6. Drug History:

- No chronic medications.

- Not allergic to any specific drugs.

- Previous medications include antimalarials (for past malaria infection) and antibiotics (for upper
respiratory infections). Paracetamol used intermittently for fever management.

7.Immunization history :

- received all routine vaccinations according to the * Sudan national immunization schedule at
Obstetrics and Gynecology Hospital in Dongola. No known missed vaccines.

8.Nutrition :

- The child stopped breastfeeding after being diagnosed with lactose intolerance and transitioned to
lactose-free formula. She was weaned at 2 years of age.

Currently, she consumes three main meals , in addition to morning tea and an afternoon snack. She is
not allergic to any foods. Prior to illness, her diet was balanced and appropriate for her age.

9.Growth and Development History:

- Milestones:

achieved all developmental milestones appropriate for her age, including motor, language, social, and
cognitive skills.

demonstrated age-appropriate abilities such as climbs stairs alternative feet , running, speaking in short
sentences, and interacting socially with family and peers.

anthropometric information

Hight :90 cm

weig :10kg

MUAC : 16 cm

- Tooth Eruption:

Primary tooth eruption occurred within the normal age range.

full set of primary teeth.

- Toilet Training: Successfully toilet trained .

can communicate her needs effectively .

_Kindergarten History:

refuses to go to kindergarten.

1. Reason for Refusal: child refuses to go to kindergarten due to separation anxiety, preferring to stay at
home with parents.

2. Behavior Observed: crying, clinging to parents and temper tantrums .

3. Duration of Refusal: for one week.

4. Parental Response:Parents are concerned but have not forced the child to attend.

Family history

- Similar Conditions:maternal side, specifically in an aunt.

second-degree family members. .

- Chronic Diseases: Positive family history of diabetes mellitus (DM) and hypertension in first-degree
relatives .

- Other Health Conditions: No reported family history of ENT problems, cardiopulmonary,

gastrointestinal, genitourinary, or musculoskeletal diseases.

Family social history :

1. Family Composition:

- Family type: Nuclear family.

_Marital Status: Married.

- Degree of relation between the parents : Third-degree relatives.

- Number of siblings: no sibling

2. Parental/Guardian Information:

- Father :- Occupation: Farmer .

- Age: 30 years. - Level of Education: High school graduate.

- Mother:

- Occupation: Housewife.

- Age: 29 years.

- Level of Education: Bachelor's Degree in Economics .

3. Housing Conditions:

- Location: urban area.

_size :Adequate for the family.

Good ventilation, reliable access to water and electricity.

- Health Insurance: Not available.

4. Lifestyle:

- smoking :father ,

No alcohol, or drug use by parents.

GENERAL PHYSICAL EXAMINATION:

Vital Signs

- Temperature: 36.4°C

- Heart Rate: 110 bet per minute

- Respiratory Rate: 21 breath per minute

- Blood Pressure: Not measured

- Oxygen Saturation:Not measured

General Appearance

- Alertness: The child is alert but irritable and appears fatigued .

- Nutrition: Well-nourished with no signs of malnutrition.

- Hydration: Well-hydrated; skin turgor is normal, and mucous membranes are moist.

---

1. Skin and Lymphatic

- Skin:Mosquito bites present on the upper limbs and face. Skin is clear, without rashes, lesions, or
unusual pigmentation. Skin is warm, dry, and intact.

- Lymph Nodes:Enlarged, tender cervical lymph nodes, likely due to tonsillitis.

- Nails:Normal pink color with no clubbing or cyanosis.

- Capillary Refill: Less than 2 seconds, indicating good peripheral circulation.

---

2. Head and Neck

- Head:Symmetrical with no abnormal shape or deformities.

- Neck: Full range of motion. Enlarged, tender cervical lymph nodes.

---

3. Eyes

- Sclera:White, conjunctiva pink and glossy, no discharge.

- Pupils: Equal, round, and reactive to light.

---

4. Ears

- Pinna: No malformations.

- External Ears:No discharge, redness, or swelling.

- Hearing:No concerns noted .

---

5. Nose

- Nasal Passages: Clear, without discharge or congestion.

---

6. Mouth and Throat

- Mucous Membranes: Pink and moist.

- No lesions or swelling.

- Tonsils:Enlarged, erythematous tonsils, indicative of tonsillitis.

- Halitosis: Noted.

- Teeth:20 deciduous teeth, healthy with no dental decay.

---

7. Chest

- Shape:Chest shape is normal, without deformities.

- Breathing: Chest movements are symmetrical bilaterally.

- Heart: Systolic murmur heard at the left sternal border in the 3rd intercostal space, consistent with the
history of a congenital heart defect (VSD).

- Lungs: Clear to auscultation, no wheezes, rales, or rhonchi.

Diagnostic Test :

1. Blood Film for Malaria BFFM.

Result :positive

2. Complete Blood Count(in table 1)

3. Renal profile( in the table 1)

Table 1

Results Normal range

1. Serum Potassium (S. K) = 3.7 mmol/L 3.5–5.0 mmol/L

2.Serum Sodium (S. Na) (S. Na) = 134 mmol/L 135–145 mmol/L

3. Serum Calcium (S. Ca) (S. Ca)= 9.6 mg/dL 8.5–10.5 mg/dL

4.Hemoglobin (Hb) 11 g/dL 11–13 g/dL

5. Red Blood Cell Count (RBC) 5.2 million cells/µL 5–15 x 10³/µL

7. Neutrophils 78% 30–60%

8. Lymphocytes 19% 30–60%

9. Mean Corpuscular Volume 68 fL 70–86 fL

(MCV)

10. Mean Corpuscular 34 g/dL 32–36 g/dL

Hemoglobin Concentration
(MCHC)

11.White blood cells (WBC) 13,000 cells/mcL 6,000 to 17,000 cells/mcL

Summary:

The results suggest mild hyponatremia, a slightly low hemoglobin level, microcytic anemia, and an
elevated neutrophil and White blood cells (WBC) count, likely indicating a bacterial infection. The mild
anemia and low MCV could be consistent with iron deficiency.
Management :

Dosage/Instructions Purpose

Artesunate (IV) 30 mg Antimalarial treatment.

Diazepam (IV) 1.5 mg (as needed for To control febrile

convulsions) convulsions

Ondansetron 7.5 mg every 8 hours To manage nausea and

vomiting.

Paracetamol (IV) 100 mg every 6 hours To reduce fever and

manage pain.

Penicillin 100 units every 6 hours Antibiotic for bacterial

infection.

Monitor Vital Signs Every 4 hours To assess response and

stability
Nursing process

Nursing Assessment

- Abnormal Findings:

- Fever and a positive malaria blood film.

- febrile convulsions (3 at home, 2 in the hospital).

- Enlarged, erythematous tonsils and halitosis (indicative of tonsillitis).

- Enlarged, tender cervical lymph nodes.

- Mild anemia (Hb = 11 g/dL) with microcytic anemia (MCV = 68 fL).

- Slightly low serum sodium (134 mmol/L).

- The child refuses to attend kindergarten due to separation anxiety.

---

Nursing Diagnoses, Evidence, Goals, and Interventions

1. Risk for fluid volume deficit related to fever, vomiting, and inadequate oral intake, as evidenced by
dehydration signs (dry mucous membranes).

- Goal:The child will maintain adequate hydration, as evidenced by normal skin turgor, moist mucous
membranes, and stable vital signs.

- Interventions:

- monitor fluid intake and output.

- Encourage frequent sips of fluids when tolerated.

- Assess for ongoing dehydration symptoms (e.g., delayed capillary refill, dry mucosa).

- Monitor vital signs every 4 hours.

---
2. : Hyperthermia related to malaria infection as evidenced by fever and positive blood film for malaria.

- Goal:The child’s temperature will normalize within 24 hours of treatment.

- Interventions:

- Administer Artesunate 30 mg IV as prescribed for malaria.

- Administer Paracetamol 100 mg IV every 6 hours for fever.

- Use tepid sponging to manage fever.

- Monitor temperature every 4 hours and watch for convulsions.

---

3. Risk for injury related to febrile convulsions as evidenced by recurrent episodes at home and in the
hospital.

- Goal:The child will remain convulsions-free during hospitalization.

- Interventions:

- Administer Diazepam 1.5 mg IV during convulsion episodes as prescribed.

- Monitor for signs of seizure activity and ensure safety measures (., padded bedrails).

- Educate parents on febrile seizure first-aid measures, such as placing the child in a safe position
during convulsions.

- Record seizure duration and characteristics.

---

4. Acute pain related to throat inflammation as evidenced by halitosis, tonsillar enlargement, and throat
pain.
 - Goal:The child will report reduced pain and demonstrate improved eating and drinking behaviors
within 24 hours.

- Interventions:

- Administer Penicillin 100 units every 6 hours as prescribed.

- Offer warm fluids and soft foods to reduce throat irritation.

- Monitor for improvement in swallowing and pain relief.

---

5. Anxiety related to separation from parents, as evidenced by refusal to attend kindergarten and
clinging behavior.

- Goal:The child will show reduced anxiety and develop coping mechanisms for separation within one
week.

- Interventions:

- Encourage short visits to familiar settings with gradual exposure to new environments.

- Provide reassurance and emotional support to the child and parents.

- Offer age-appropriate activities to distract and engage the child.

- Educate parents on strategies to reduce separation anxiety, such as creating routines and using
comforting items (e.g., a favorite toy).

---

Parental Education
During my interaction with the parents, I provided education on the following topics:
1. Malaria Prevention

- I emphasized the importance of using insecticide-treated mosquito nets at night to protect the child
from mosquito bites.

- I advised eliminating stagnant water around the house to reduce mosquito breeding sites.

- I encouraged the family to use child-safe insect repellents and ensure the child wears long-sleeved
clothing in the evening and at night.

2. Prevention of Anemia

- I recommended increasing the intake of iron-rich foods, such as lean red meat, poultry, fish, eggs,
and legumes.

- I also suggested incorporating vitamin C-rich foods like oranges, tomatoes, and peppers to enhance
iron absorption.

3. Separation Anxiety

- I discussed strategies to reduce the child’s separation anxiety, including gradually exposing her to
short, positive experiences away from the parents.

- I advised creating a consistent drop-off routine for kindergarten and involving the child in preparing
for her day, which can provide a sense of control.

- I recommended giving the child a familiar object, like a toy or blanket, for comfort.

- I reassured the parents that separation anxiety is common at this age and highlighted the importance
of being patient and supportive during the adjustment period.

4. Managing Temper Tantrums

- I educated the parents on the developmental nature of temper tantrums and how to handle them
constructively.

- I recommended staying calm during tantrums, avoiding excessive attention to the behavior, and
maintaining consistent rules.

- I suggested offering simple choices to the child, such as "Do you want the blue cup or the red cup?"
to reduce frustration.

- I also encouraged using positive reinforcement to reward desired behaviors and redirecting the
child’s attention when a tantrum begins.