History Taking

Bio-demographic Data

Name :- B/O Indira Khanal Ward :- SICU

Age :- 2nd Day of Life Bed no. :- 292
Sex :- Female I.P no. :- 174208
Address :- Sundarbajar-8, Lamjung Birth weight:- 2300gm
Date of admission :- 2080/04/16 at 7:30 pm Admission weight: 2300gm
Date of birth: 2080/4/15 8:05pm
Name of informant: Indira Khanal
Relation with child: Mother
Economic status :- Middle class
Religion :- Hindu
Date and time of History collection: 2080/04/24 @ 11am
Place :- Kanti Children Hospital
Provisional diagnosis :- ? Omphalocele
Final diagnosis :- Perforated Omphalocele
Consultant Doctor :- Dr. BMB

Chief Complain
Swelling in Umbilical Region since birth

History of Present illness

The neonate was delivered by normal vaginal delivery at 35+3 Weeks of Gestation in Pokhara
Academy of Health Sciences Western Regional Hospital with APGAR score of 7/10 and 9/10 at
1 minute and 5 minute respectively. On birth there was swelling in umbilical region for which
USG abdomen was done and referred to Kanti Children Hospital for further management with
diagnosis of ? Omphalocele.

1
Prenatal History
 Maternal medical disorder- No significant history of any medical disorder like malaria,
hypertension, diabetes, heart disease, anemia, pulmonary tuberculosis, seizures etc.
 Blood group/RH factor: Maternal blood group was A positive
 Dose of TT vaccine: 2 times at 20 weeks and 24 weeks of gestation in Western Regional
Hospital
 No. of ANC checkup and place: Regular ANC checkup was done in Western Regional
Hospital since 2nd month of pregnancy about 5-6 times till delivery.
 History of Drug taken during pregnancy: During pregnancy, mother has history of taking
Tab PCM for minor illness such as cold after prescription from doctor. No other drugs were
used during pregnancy.
 Gestation age at delivery: 35+3 Weeks of Gestation

Natal History
The child was delivered by Normal Vaginal delivery. No birth injuries was noted but presence of
swelling over umbilical region.

Neonatal History immediately after birth

APGAR score: 7/10and 9/10 at 1 minute and 5 minutes respectively. Baby had strong cry and
was active.

Growth and Developmental history

Immediately following birth, the neonate was referred to Kanti Children Hospital for
management of Omphalocele and admitted in SICU.

Family history
The family lives in a middle class family with 5 members in a joint family. There is no history of
illness among any family members. No history of medical illness like malaria, hypertension,
diabetes, heart disease, anemia, pulmonary tuberculosis, seizures, or surgical interventions and
blood transfusion among family members.

2
 Family tree:

6
2
62 yrs

32 yrs 32

9 DOL
10 yrs
yrs
Index:

: Male
: Female
: Deceased Male
: Patient
: Related by marriage
: Offspring

Fig : Family tree of patient

S.No Family Name Age Education Occupation Chronic Remark

Illness
2 Gand- Gun 62 Can read Agriculture Not any
Mother kumari years and write
Khanal
3 Father Shyam 36 Bachelor’s Police Not any
Khanal years degree arts officer
4 Mother Indira 34 SLC Housemaker Not any
Khanal years
4. Sister Satya 10 Grade 4 - Not any
Khanal years studying
5 Patient B/O Indira 9th day - - Admitted in History
Khanal of life SICU for taken on
Omphalocele 2080/04/24

3
Environmental History

Housing: The family lives in a cemented house with good system of drainage and water seal
latrine. The house is well ventilated with two windows in each room with well-developed
kitchen and there is regular supply of water and electricity.

Nutritional History

On admission the neonate was on Nil Per Oral status with Intravenous fluid 80mg per kg over 24
hours and gradually increased after evaluation on daily basis.

Immunization History:
The baby has not been immunized.

Review of System: the neonate was diagnosed with ?omphalocele immediately following birth
in health center and referred to Kanti Children hospital. No any specific symptoms of other
illness noted till admission.

4
Physical Examination

On 2080/04/25 systemic head to toe examination was done in bedside after morning care.

The findings are noted as follows.

S.No. Examination Findings

1. Anthropometric
Examination
Weight 2500gm
Length 45 cm
Head 32 cm
Circumference
Chest 30 cm
Circumference
Abdominal Girth 23 cm
2. Vital Signs
Body Temperature 980F
Heart Rate 150 beats/min
Respiratory Rate 56 breaths/min
SPO2 95% at room air.
3. General appearance  Low pitched cry with old man look.
 Small body size with relaxed attitude
 Limbs extended position and have little skiny muscle mass (low
sub-cutaneous fat )
 Good hygiene
4 Inspection Palpation

 Bright Pink colored skin  Warm temperature with

 Presence of small blood smooth texture
Skin vessels slightly visible  No signs of dehydration and
 No any signs of bruises, rashes, normal skin turgor
petechie, postules or blister.
 Presence of Mongolian spots
and lanugo at back
5 Lymphatic System No any palpable lymph nodes
detected

6 Head Inspection Palpation

 Body larger in size in  Widely separated with large
comparison to body Anterior fontanelle and soft
 Fine and feathery hair skull bone
 Hygiene well maintained  Posterior fontanelle palpable
 No any palpable nodules,
masses and injury

5
 S.No. Examination Findings

7 Eyes  On inspection, bilateral symmetrical eye brows, normal eye lids with
normal shape and size
 Closed most of the time
 No signs of infection and discharge
 No signs of anemia and jaundice
 Pupillary reflex, blinking reflex present
8. Ears  On inspection, normal position of ear (lies horizontally to outer
canthus of eye )
 Normal position, shape and size
 No any discharge, bleeding
9. Nose  On inspection, normal location, shape and size
 Presence of nasal flaring
 No discharge, bleeding or lesion
10. Mouth  On inspection Bluish colored lips, moist mucosa
 No signs of dehydration with normal sized tongue
 Highly arched palate and intact uvula centrally located
 Presence of gag reflex
11 Neck Inspection Palpation
 No any skin fold behind the  No lymph nodes palpable
neck and head lagging on
holding
 No any rashes
12. Chest Inspection  On superficial palpation, no
 Small and narrow chest any masses or nodules noted
 Normal abdominal breathing  On auscultation bilateral
 Presence of small sized breast equal air entry
bud about 3mm wide
13. Cardiovascular Inspection Auscultation
system  Normal color pinkish color of  Apical beat-150beats/min
extremities  Normal lubdub sound
 Capillary refill <3sec  Normal rate and rhythm of
 No clubbing and cyanosis pulse
14 Abdomen Inspection Auscultation
 Circular shape with visible  Normal bowel sound present
abdominal respiration (normal peristalsis
 Presence of few visible veins movement)
 Umbilical stump normal with no Palpation
signs of infection  Normal skin turgor, no signs
 Presence of incision wound at of dehydration
left side of umbilicus about 3-  Deep palpation for liver,
4cm long sutured with prolene spleen and kidneys were not
(6 sutures) (Transverse incision) performed due to incision for
repair of omphalocele.

6
 S.No. Examination Findings

15. Genito-urinary Inspection

system  Normal sized of vulva and
clitoris (pink and moist).
Prominent labia minora.
 Urethral meatus located posterior
to clitoris.
 Vaginal orifice located posterior
to urethral meatus.
 Redness and rashes around
inguinal region.
 Normal bladder habit
16. Anus and  Redness and rashes around anal areas.
rectum  No any anorectal malformation detected
 Normal bowel habit
17. Musculoskeletal Upper Extremities Lower Extremities
System  Bilaterally symmetrical size  Bilaterally symmetrical size
 Limbs are extended  No syndactyly, polydactyly
 No syndactyly, polydactyly  Soft and flat soles with little
 Some palmer crease present but creases
not prominant  Galaezze sign or Allis sign
 Presence of strong palmer grip not assessed due to post-
surgical condition.
 Ortolani test was also not
done.
18. Back Inspection Palpation
 Presence of fine lanugo and  Normal alignment of spine
Mongolian spots  No signs of missing vertebra,
 No sacral dimpling, tuff of hair spina-bifida or
and rashes meningomyocele
19. Neurological (Neonatal Reflexes were monitored in detail later in surgical ward)
system  Rooting reflexes- present (watched on bottle feeding)
 Sucking and swallowing reflexes: Present (on EBM feeding)
 Babinski Reflexes: presence (fanning of toes)
 Moro reflexes, Stepping Reflexes and Tonic neck Reflexes could not
be assessed due to his sickness on the day of Physical Examination but
assessed before the child was shifted was shifted to surgical ward.

7
Reflexes were again monitored in surgical ward on 2078/04/26.

S.No Reflexes Expected behavior Present Absent

1. Blinking Blink eye to light or loud sound 

2. Sneezing With irritation or obstruction. 

3. Glabellar Eyes close tightly when tapping briskly on 

glabella

4. Sucking Strong sucking while breast feeding 

5. Gagging When baby takes more milk than he/she can 

swallow, elicited to remove out of the milk.

6. Rooting Baby turns his mouth towards source that touches 

his cheek

7 Swallowing Able to swallow breast milk while feeding. 

8 Tonic neck Causes the baby to extend limb (arm and leg) on Not
that side and flex the opposite arm and leg. Assesse
d

9. Crawl Attempts to crawl forward using arms and legs 

when keep in prone position.
10. Grasp Touching palm of hand or sole of feet near base 
of digits causes flexion of fingers and toes.
11 More Extends and abduct all extremities when sudden 
change in equilibrium.
12 Dancing or Makes walking motion with both feet when keep 
stepping in standing position.
13 Babinski Hypertension of toes, dorsiflexes of great to and 
fans the toe upwards.

Summary of Physical Examination

 On 2080/04/24 head to examination was done after morning care. The vital signs were within
normal range.
 Presence of surgical wound of about 3cm sutured with prolene on left side of umbilicus
(Transverse incision).
 Presence of Redness and rashes around inguinal and anal areas
 Normal bowel and bladder habits. Has normal reflexes.
8
 No any specific abnormalities were detected on examination but since the child was born pre-
matured with omphalocele should be evaluated detailed on following days.

Growth and Developmental Milestone

On 2080/04/26 the child was transferred to surgical. The child’s developmental milestone and
developmental milestone was observed in surgical ward when the child was 10 days old
(2080/04/26).

1) Physical Growth/ Biologic Development

S.NO. Parameters Findings Expected

1. Weight 2600gm Weight gain of 150-210gm weekly for 1st
6months.
2. Height 45cm Length increased by 1.5cm monthly
3. Head circumference 32cm Head circumference increases than birth
4. Chest circumference 30cm Chest circumference increases than birth

2) Vital Signs

S.NO. Parameters Findings Expected

1. Temperature 36.80C 36.5-37.50C
2. Pulse rate 130beats/min 100-160 beats/min
3. Respiratory rate 50breaths/min 30-60breaths/min

3) Fontanelle

Fontanelle Closed Remark

Yes No
Anterior 
Posterior 

4) Developmental milestone of infant (1 months)

Developmental milestones are physical or behavioral signs of development or maturation of

infants and children. The milestones are different for each age range.

I. Motor development

a) Gross motor development

Milestones YES NO Remarks

9
 Flexed position with pelvis high but knees not 
under abdomen when prone All these mile stone
Can turn head from side to side  were monitored in
Has marked head lag, especially when pulled from  Surgical Unit on
lying to sitting position. 2080/04/26.
Asymmetric tonic neck flex position when supine. 
When held in standing position, body is limp at 
knees and hips

b) Fine motor development

Milestones YES NO Remarks

Hands predominantly closed  Closed most of the
time
Grasp reflex strong  Grasp reflex present
Hands clenches on contact with rattle  Could clenches pen.

II. Sensory Development

Milestones YES NO Remarks

Able to Fixate on moving object in range of 45  Could not be assessed
degrees when held at distance of TO-75 cm (8-10 since the child was
inches) sleeping
Visual Acuity approaches 20/100" 

Follows light to midline 

Quiets when hears a voice 

IV. Language Development

Milestones YES NO Remarks

Cries to explain displeasure 

Makes Small throaty Sounds 
Makes Comfort sound during feeding 
V. Socialization
Milestones YES NO Remarks

Is in sensorimotor phase,  Sensory motor phase

a) stage I, use of reflexes (birth—1 mo) stage I
b) stage II, primary circular reactions (1-4 mo)
Watches parent’s face intently as she or he talks to 

10
infant

DEVELOPMENTAL TASK

Theory Stages Yes No Remarks

Psycho Social Development: Trust Versus  Ongoing
Erikson's Phase I Mistrust
Psycho Sexual Development: Freud's Oral Stage  Ongoing
Theory State
Cognitive Development : Piaget's Use Of Reflexes  Ongoing
Sensorimotor Phase (birth -1 month)

• As the neonate is just 14 days of life on discharge, the child has not achieved much tasks
but on the process of achieving.
• She has adapted to various physiological equilibrium after birth.
• Other developmental tasks of child are ongoing.

11
Disease Portion

Introduction

An omphalocele is a midline abdominal wall defect (absent skin, fascia, and abdominal muscles)
of variable size at the base of the umbilical cord. The defect is covered by a three-layer
membranous sac consisting of amnion, Wharton's jelly, and peritoneum.

The cord/umbilical vessels insert at the apex of the sac, which typically contains herniated
abdominal contents.

Omphaloceles are categorized as either non-liver-containing (containing bowel loops) or liver-

containing. Small defects generally can be closed in the first 24 to 72 hours of life. The
remaining spectrum of defects usually involves some type of silo in the first 24 hours of life and
delayed closure.

Prevalence and epidemiology

The worldwide prevalence of omphalocele is 2.6 per 10,000 births. In the United States,
Omphalocele and gastroschisis are the most common fetal abdominal wall defects with
prevalences of approximately 2 and 4 per 10,000 live births, respectively (Stallings E.B. et.al,
2019)

The occurrence of omphalocele appears to be more common in offspring of mothers at the

extremes of reproductive age. In mothers <20 or >40 years of age, the odds of omphalocele in
offspring are more than doubled compared with the general obstetric population: odds ratio (OR)
2.45 (95% CI 1.22-4.86) and OR 8.76 (95% CI 4.02-19.32), respectively. The prevalence is
slightly higher in Black than White patients (1.91 versus 1.47 per 10,000 live births) ( Kirby R.S;
2017).

12
 • According to annual report of Kanti children hospital for the fiscal year 2079/80, a total
of 11 neonate were admitted in SICU with diagnosis of Omphalocele.

Causes
 Exact cause is unknown.
 Other factors that may contribute to omphalocele are:
o Genetic factors: Some infants have omphalocele because of a change in
their genes or chromosomes.
o Omphalocele has high incidence of associated chromosomal anomalies and
syndromes such as:
 Trisomy 13, 18, 21
 Turner syndrome
 Klinefelter syndrome
 Triploidy
 Beckwith-Wiedemann syndrome
 Pentology of Cantrell
 OEIS complex (Cloacal exstrophy )

Risk Factors
 Possible maternal risk factors associated with development of omphalocele consist of
 Maternal age < 20 or >35 years
 Afro-American ethnicity
 Maternal obesity (BMI > 30 kg/m2 )
 Alcohol and maternal smoking: Women who consumed alcohol or were heavy
smokers (more than 1 pack a day) were more likely to have a baby with omphalocele.
Possibly due to placental insufficiency and abnormal development of the vascular
system.
 Certain medications: Women who used selective serotonin-reuptake inhibitors
(SSRIs) during pregnancy were more likely to have a baby with an omphalocele.
 Maternal disorders of glycemic control and in turn fetal macrosomia (>4000 g birth
weight)
 High Gravida and multiple births
 Maternal history of repeated abortion

 Patient risk factors associated with omphalocele are primarily

 chromosomal anomalies
 Omphalocele is especially common in patients with trisomy 18 (80–90% of cases)
 Beckwith-Wiedemann syndrome (10–66% of cases)
 Consecutive children and family history
 Prematurity, low birth weight, Intra uterine Growth Retardation

Possible risk factor for the patient

13
  Maternal history of Repeated abortion
 High Gravida (G4)

Embroyology

Normal embryologic development of the abdominal wall – During the fourth to fifth week of
development, the flat embryonic disk folds in four directions and/or planes: cephalic, caudal, and
right and left lateral. Each fold converges at the site of the umbilicus, thus obliterating the
extraembryonic coelom. The lateral folds form the lateral portions of the abdominal wall, and the
cephalic and caudal folds make up the epigastrium and hypogastrium. Rapid growth of the
intestines and liver also occurs concurrently.

During the sixth week of development (or eight weeks from the last menstrual period), the
abdominal cavity temporarily becomes too small to accommodate its contents, resulting in
protrusion of the midgut into the residual extraembryonic coelom at the base of the umbilical
cord. This temporary herniation involves 90 degrees of counterclockwise rotation of the midgut
around the superior mesenteric pedicle and is called physiologic midgut herniation. It is
sonographically evident in the 9th to 11th postmenstrual weeks (up to crown rump length 45 mm).

Reduction of the hernia involves further rotation to 270 degrees in the abdominal cavity and
normally occurs by the 12th postmenstrual week; thus, midgut herniation is no longer physiologic
beyond the 12th week.

In contrast to the bowel, the liver does not undergo physiologic migration outside of the
abdominal cavity during development. Therefore, the liver is never present in physiologic midgut
herniation.

14
Pathogenesis

The exact cause of omphalocele is unknown. Fetal abdominal wall defects result from
disturbances in organogenesis during the embryonic period.

Two mechanisms have been proposed.

The main theory is failure of the normal intestinal migration back into the abdominal cavity,
and persistence of the physiological umbilical herniation. Here, the extraembryonic gut fails to
undergo the obligatory 270 degree counterclockwise rotation back into the abdomen, resulting in
a simple, small, and midline omphalocele.

Other theories include failure of central migration of the two lateral embryonic folds to fuse, or
persistence of the body stalk for more than 12 weeks gestation. Here, the left and right lateral
folds to fails to close normally create a large abdominal wall defect through which contents of
abdominal cavity (including the liver) can herniate. In addition, the rectus abdominis muscles
insert laterally into the costal margins instead of meeting in the midline at the xiphoid.
In general, omphaloceles are associated with advanced maternal age and are known to occur in
twins.

Clinical features
According to Book According to Patient
 Omphaloceles are 4-12 cm abdominal  Omphalocele of about 4cm located
wall defects, located centrally within centally within the umbilical cord
the umbilical cord. (Small <5cm and  Small sized with only intestine
large >8cm) remaining outside
 In small one only the intestines remain  Absence of liver
outside the body  Presence of sac surrounding the gut
 In larger ones, the liver or other contents (peritoneum, warton’s jelly
organs may be outside including liver and amnion) with healthy intestine
 Presence of protective  Umbilical cord inserted directly into
membranes surrounding the herniated the sac in an apical position
gut contents (peritoneum, warton’s
jelly and amnion), the intestines are
usually healthy at delivery
 Umbilical cord inserts directly into
the sac in an apical or lateral
position

Diagnostic Evaluation

Omphalocele is a mainly clinical diagnosis. It can be diagnosed by prenatal ultrasound or upon

birth through physical examination.

Prenatal Examination

15
Alpha-fetoprotein: On antenatal screening AFP is typically elevated in abdominal wall defects.
This may be as a result of direct protein loss from the intestine into the surrounding amniotic
fluid. Elevated alpha-fetoprotein indicates further assessment through high-definition ultrasound
in addition to routine scans.

Fetal Untrasound and invasive procedure: Omphalocele can be picked up on routine

antenatal ultrasounds in the second trimester (the anomaly scan), when masses outside the
abdominal cavity can be detected. If there is evidence of omphalocele, invasive procedures can
be performed to assess for associated chromosomal anomalies. This includes chorionic villus
sampling at 10-12 weeks or amniocentesis at 15-20 weeks.

Post-natal Examination

Physical Examination: After birth, a thorough search for associated anomalies should be done
along with echocardiography and abdominal ultrasound to check for cardiac and renal
anomalies.

According to book According to patient

Prenatal Fetal Ultrasound Although general fetal scan was done in antenatal
period as routine scan, anomaly scan was not
Alpha fetoprotein (AFP) performed in details

Physical examination after birth reveal AFP not done

central defect of abdominal wall with gut
contents outside covered with sac. Physical examination after delivery reveal
swelling around umbilical cord covered with sac.

History taking for possible presence of risk factors

USG abdomen: Midline umbilical swelling with

herniation of bowel loops. Cord inserted at apex.

Other evaluative procedures performed in patient

 Detail history from mother to access risk factors

 Physical examination
 ECHO cardiogram to rule out associated cardiopulmonary anomalies.
 Normal left ventricular size and systolic function (EF 60 %).
 Normal diastolic function
 Normal right ventricular size and systolic function
 Normal valve structure and function
 Pre-operative and post-operative investigations
 Blood analysis to rule out sepsis
 ABG analysis

16
 Investigation/ 4/16 4/20 4/23 4/26 Remarks
(normal value with
Date Units)
Hb 14.7 11.8 12.6 12.6 12-16 g/dl
Blood Grouping O positive
TLC 9000 12900 10550 4000-11000/cumm
N:L:E:B:M 42:50:02: 54:40:03 56:38 In %
06
Platelets 226000 1,53,000 3,38,000 150000-350000/
cumm
Urea/ 45/0.6 26/0.7 26.9/0.6 14.6/1.0 15-45mg/dl /
Creatinie 0.4-1.4 mg/dl
Na+/ 139/4.1 135/4.6 135/4.4 140/5.5 135-150mg/dl/
K+ 3.5-5.5mg/dl
RBS 100 90 100 70 60-140mg/dl
PT/INR 16sec/1.2
Control 14sec
TSB/DSB 17.94 9.3/10.8 2.1/0.3 0.4-1.0mg/dl
0.1-0.4mg/dl
SGOT 63.0 <45 IU/L
SGPT 10.0 <40 IU/L
Total protein 5.3 5.5-8.3gm/dl
fTSH 1.97 0.3-4.5uIU/ml
ABG
 PH:  7.30  7.345
 PCO2  40.0  36.o
 PO2/FiO2  90.0  91.0
 Std HCO2  26.5  22.7
 Lactate  3.4  1.33

Differential diagnosis

Gastroschisis – abdominal wall defect usually to the right of the umbilicus involving protruding
bowel loops without membranous covering. It has less association with chromosomal anomalies.

Cloacal Exstrophy – abdominal wall defect where a segment of large bowel and two halves of
the bladder are present outside the abdominal cavity.

Physiological gut herniation – herniation of bowel in early pregnancy at 6-8 weeks and
subsequent return back into abdominal cavity at 12-13 weeks in utero.

Hernia of the cord – where the abdominal wall defect is less than 1.5cm.

17
MANAGEMENT

BOOK PICTURE

Management following Prenatal Diagnosis

 Once omphalocele has been diagnosed on prenatal ultrasound, prenatal and perinatal
management is paramount. it is important to look for associated anomalies as a majority
of newborns with omphalocele (>70%) will have at least one additional congenital
anomaly.
 Associated anomalies include cardiac (32%), chromosomal (17%) and central nervous
system (8%) defects. Genitourinary anomalies and diaphragmatic hernias are less
commonly associated with omphalocele.
 In order to identify chromosomal anomalies, karyotyping via chorionic villous sampling
or amniocentesis can be performed as early as during the first trimester (concomitant risk
of early abortion: 0.2–0.3%.
 Prenatal fetal organ screening and echography are important tools to identify cardiac and
other associated anomalies. If a major chromosomal abnormality is diagnosed and/or
other anomalies are present, prenatal parental counselling by a team of specialist (eg,
pediatric surgeon, neonatologist, high-risk obstetrician) to counsel the family regarding
treatment and prognosis of patients with abdominal wall defects in a tertiary center is
crucial.

Prenatal care:

 Monitoring of Fetal Growth: The presence of anomalies in fetuses with omphalocele is

strongly associated with poor prognosis and complications leading to fetal demise and
neonatal death. Fetal growth and wellbeing should be monitored in a tertiary center with
serial sonographic controls every 4 weeks (depending on ultrasound findings) up to 32
WGA once diagnosis of omphalocele has been established, as growth restriction is
commonly observed and may be an early warning sign of fetal demise. To detect signs of
late fetal demise serial weekly scans are recommended from 32 WGA until delivery.

 Transfer of mother for prenatal care to obstetrician who handles high-risk pregnancies
and who can monitor and deliver at a tertiary care center—with neonatal ICU—supported
by a team experienced managing neonates with complex surgical issues is important.
 Goal for the mother is term vaginal delivery, unless fetal or maternal obstetric indications
dictate need for cesarean delivery Cesarean delivery may be elected for the patient with
large omphalocele, especially when it contains liver or in emergency situation.
 After birth a close clinical inspection and (repeated) echography are recommended as
further anomalies may be identified

18
Intrapartum Management

 Delivery Timing and Route: Once the decision has been made by the family to continue
the pregnancy, a multidisciplinary team involving obstetrics, pediatric surgeons and
neonatologists should determine the best timing and route of delivery together with the
parents. Against the background of the morbidity associated with prematurity there is no
recommendation for preterm delivery as long as fetal wellbeing is not impaired. Optimal
route of delivery is still controversially discussed. Factors to consider when determining
route of delivery are the defect size, organs exteriorized in the sac, the integrity of the sac
and any other associated abnormalities. In cases of minor omphalocele vaginal delivery
can be considered to be safe. In cases of larger defects or in cases where large parts of the
liver are herniated, caesarean section is generally the preferred route of delivery to
minimize the risk of significant bleeding, dystocia or sac disruption. Small tears in the sac
membrane may be primarily closed with a suture or tissue glue if the sac is robust and
sufficient to cover the viscera.

Delivery room Anticipation and Resuscitation

Pre-briefing:

 Team huddle with discussion of plan of care and clearly defined team member roles

 Advanced preparation of supplies including equipment for intubation, 8 fr (Preterm) and

10 fr (term) salem sump, bowel (lahey) bag, and potential normal saline fluid boluses and
resuscitative medications.

Delivery/Resuscitation:

 Placement of 8 fr (Preterm) and 10 fr (term) salem sump orogastric or nasogastric tube to

low intermittent suction

 Assess respiratory status, Small omphaloceles may not require additional support,
whereas large omphaloceles may require CPAP or intubation.

o Gaint omphaloceles more likely to have hypoplasia and often responds to low
volume and rapid rate ventilation

 Peripheral IV access and avoid umbilical lines

 Dextrose stick to assess blood glucose level

 Initiate IV fluids DW at 80ml/kg/day

19
 o Assess need for additional NS fluid boluses; most often needed in events of sac
rupture

Maintain integrity of omphalocele sac:

 Maintain infection prevention technique whwn handling

 Place neonate in bowel (lahey) bag lined with small amount of warm sterile saline
solution

 Position neonate sidelying while supporting the omphalocele with blanket rolls to
optimize perfusion and prevent compression of blood vessels

Antibiotics:

 Ampicillin and Gentamycin if needed for sepsis risk factors or in events of sac rupture

Postnatal management

Effective postnatal care and management may influence outcomes. The goals of management
include maintaining cardiorespiratory stability, protecting the herniated viscera, managing fluids,
maintaining vascular access, monitoring lab tests, maintaining normothermia, facilitating gastric
decompression, preventing infection, and performing diagnostics.

Immediate management

 Special care must be exercised immediately at delivery to avoid damage to the sac and its
fragile contents. Rupture of the sac increases the risk of infection and can lead to
intestinal or hepatic trauma, but worse, destroys options for delayed closure strategies.
The umbilicus should be divided with a generous stump since, especially in smaller
omphaloceles, abdominal contents may project into the cord more distally than
appreciated.

 Stabilization of the infant is the immediate concern upon delivery of a newborn with an
omphalocele. Depending on the type and defects, pulmonary or cardiac compromise may
require immediate intubation and ventilatory support.
 Peripheral intravenous (and, if required, arterial) access should be placed immediately,
but no attempt should be made to use the umbilical vessels for access.
 An oro- or nasogastric sump tube is placed to suction to keep the bowels decompressed
until stable.

 With large omphaloceles, fluid and heat loss are accelerated, and the omphalocele sac
should be covered and stabilized with gauze. Some practitioners have the mistaken idea
that the omphalocele should be kept very moist, and wrap the babies with saline-soaked

20
 guaze. This practice can lead to hypothermia. So loose coverage of the sac with Xeroform
or other moist, nonadherent dressing, followed by a mildly compressive gauze wrap that
travels around the omphalocele and also has some multiple wraps around the abdomen in
order to stabilize the sac and contents is helpful. A layer of plastic wrap (such as Saran-
Wrap) or SILO BAG can help to diminish evaporative fluid losses. However constructed,
the most important part is that the wrap does not distort the sac, be too tight at the base,
or restrict ventilation.

 Once stabilized, the baby can be transported to the neonatal intensive care unit (NICU)
for surgical evaluation and definitive care.

Care to be provided on NICU Arrival

Monitoring

Respiratory:
 Lung hypoplasia and decreased lung volumes often requires respiratory support
 Risk of pulmonary hypertension in patients with giant omphalocele
 Monitor pre and post ductal saturations

Cardiovascular
 Echocardiogram to evaluate for cardiac anomalies and assess for pulmonary
hypertension

IV Fluids and Assess:

 PICC for long term central venous access if early primary closure not possible
 If sac is intact: total fluid limit of 80ml/kg/day
 If sac is ruptured: may need up to 120ml/kg/day and NS boluses for replacement
fluids
 Hypoglycemia often seen in neonates with BECKWITH Wiedemann Syndrome

Antiobiotics: Clinical use of antibiotics is not empirical

 May consider 48 hr sepsis rule out antibiotics treatment in presence of re-natal risk
factors, symptomatic patients, or ruptured omphalocele

Gastrointestinal:
 NPO until hemodynamically stable
 Salem sump to low intermittent wall suction
 Consider replacement of high volume salem sump output (≥30ml/kg/day)
o 1/2ml replacement to 1 ml output of 0.45 NaCl.

Genetics:
 Genetics consult at admission
 Anticipate sending chromosomal microarray analysis

21
  Consider AFP level if suspicion of Beckwith Wiedermann syndrome

Skin:
 Wound care consult at admission

Surgical Management

The goals of omphalocele repair are

(1) Return of the viscera to the abdominal cavity and
(2) Closure of both fascia and skin.

Surgical closure techniques for omphalocele have proliferated since the Gross technique
reported in 1948. The surgeon chooses surgical procedure according to the size of the defect
relative to the child, the volume of viscera that must be reduced, and the physiologic context
produced by the child’s comorbidities. Surgeons have also devised a number of strategies to
avoid Abdominal Compartment Syndrome (ACS) to achieve a sound closure. Definitive
surgical methods employed for omphalocele are described as follows.

Direct closure

For small (<5 cm defect in a full term infant) omphaloceles (including ‘hernia of the cord’),
direct closure is the best method. While these defects are the easiest to manage surgically,
they can be the most difficult medical patients: risk and severity of comorbidities (especially
chromosomal defects) do not correlate with size of the defect.

Closure of these defects is straightforward. The sac is carefully excised, taking care to ligate
the umbilical vessels. Skin flaps are raised along the border, exposing the remaining fascia.
Although variably displaced, the usual fascial layers and rectus and oblique muscles are still
present. The fascia is usually closed vertically, reducing the viscera, and leaving the baby
with narrowing at the waist that loosens as the baby grows. Some surgeons prefer manually
stretch the oblique muscles and fascia before approximating the midline. During closure of
the fascia, communication between the anesthesiologist and surgeon is essential to ensure
that ACS is not created. If the pressure is too high, the surgeon temporizes, and may uses
various options like:

1) Temporary bridging of the fascia with Gore-tex or other mesh that can be removed and
the fascia closed after the child has grown.

2) Bridging of the fascia with Alloderm, Surgisys or similar ‘biocompatible’ product that
will incorporate into the fascia and are not removed.

22
3) Temporary closure of the skin only, with return to the operating room and repair of the
ventral hernia later. This method is essentially the Gross technique, and may be more
useful as a backup strategy than as a primary method.

4) Some form of transposition of the abdominal musculature, either by lateral division of the
external oblique, or by creating flaps from the internal fascia of rectus adominus that are
closed in the midline.

5) Conversion to a staged technique, such as placing a silo of polypropylene (with an inner,

nonadherent layer) or silastic mesh.

Various combinations and modifications of these basic strategies may be used depending
on the patient’s specific circumstances and the surgeon’s experience. During closure,
monitoring of bladder pressure may be useful, with one group advocating the keeping of
bladder pressure below 20 mmHg to avoid pressure related postoperative complications.

Staged reduction and closure

Larger omphaloceles that have either a very large abdominal defect or a large amount of
viscera protruding through a smaller defect cannot be closed primarily. In these cases, the
surgeon applies some type of temporary coverage that includes some form of pressure
(gravity and compression) that slowly and gradually drive the viscera back into the abdomen
as edema diminishes, the babies lose body water, and the abdominal wall stretches and
grows.

The oldest variation of this method that is still used today was described by Schuster (1967).
The Schuster repair consists of sewing sheets of Teflon or Silastic mesh to the rectus sheath
and gradually tightening the closure of the two sheets over around 7–10 days until the
midline fascia can be closed primarily. This mesh dwells beneath the abdominal skin, which
is reopened with each tightening procedure every 2–3 days. The sac is typically left intact.

Similarly, Silastic sheeting can be sewn to the fascia around the edges of the defect in such a
manner as to create a ‘silo’ containing the viscera. The silo is suspended above the baby
allowing gravity to pull the viscera back into the abdominal cavity. Many surgeons also place
ties or sutures every 48 h in order to compress the silo. Similarly, the silo may be compressed
with bandages. Once the viscera are nearly fully reduced, a primary repair can be completed.

(Delayed repair) Paint and wait

The strategy of is often chosen for infants with giant omphalocele and/or a high degree of
abdomino-visceral disproportion. Further patients qualifying for this treatment are children
with low or very low birth weight, with marked pulmonary hypoplasia and/or other
comorbidities. The safest course for these patients is ‘paint and wait’ in contrast to primary
and staged repair. The goal of the paint and wait technique is to achieve an escharization and
eventual skin coverage of the viscera.
23
 To prevent infectious complications and to promote escharization, topical combined
escharotic/anti-infective agents is applied. A number of agents have been used with this
method. Classically, the sac would be painted with Mercurochrome (Mebromine), a strong
antiseptic and sclerosant. Betadine solution can also be used which is effective, but there are
reported cases of induced hypothyroidism attributed to absorption of iodine. Silver
sulfadiazine (Silvadene) is currently the most widely used agent since it has broad spectrum
activity, little toxicity, and needs only daily application.

The hernia sac is daily painted with the escharotic agent and covered with dressings to
protect the membrane and to avoid rupture. Much later, the large ventral hernia can be closed
primarily or with a biocompatible membrane as describe above.Compared to staged repair
infants undergoing paint and wait have a shorter time to full enteral feeds and there is often
no need for mechanical ventilatory support or neuromuscular paralysis

Omphaloceles that have a ruptured membranous sac require immediate surgical

intervention, similar to the management of gastroschisis.

Surgical Management of Choice Procedure

Repair of hernias into the cord/small Primary repair

omphaloceles

Repair of larger (giant) omphaloceles without Staged repair (e.g., Schuster)

abdomino-visceral disproportion/pulmonary
hypertension

Repair of giant omphaloceles with abdomino- Paint and wait

visceral disproportion/pulmonary
hypertension

Surgical Preparation (Preoperative management)

 Preoperative lab investigation to be completed within 24 hours prior to surgery and

evaluated:

o CBC with differential count

o Basic Metabolic Pannel (BNP) at 12-24 hours of life

o Blood gas analysis

o Blood grouping and crossmatching (if not already completed)

24
  Preoperative echocardiogram

 Order desired blood products to be on hold for operation

o Packed red blood cells, platelets, FFP (20ml/kg of each) with large defect
closures

 Ensure adequate IV access (2 peripheral IV’s or 1 peripheral and 1 PICC) for

administration of blood products and medications

 Replace TPN with D10 1/2NaCl or D5 ½ NaCl to avoid electrolyte imbalances

 Anesthesia to administer pre-operative antibiotics within 1 hour of incision

 Make appropriate post-operative pain control plan and pre-order appropriate

medications

Postoperative management

 Monitoring

o Monitor for signs and symptoms of compartment syndrome: decreased distal

pulses, abdominal distension, decrease urine output, skin discolouration

 Gastric Decompression

o 8 fr or 10 fr salem sump tube to low intermittent suction

o NPO with salem sump until return of bowel function

 Diagnostic Studies/ Laboratory investigation:

o CXR immediately post-operative

o Temperature, blood gas and glucose level within 1 hour post-operative

o CBC/ BNP in the morning on 1st post-operative –earlier if clinically warranted

 Fluid management

o Continue pre-operative management of fluids

 Antibiotics: 24 hours postoperative prophylaxis in absence of any complications or

symptomatic patient

25
 o Omphalocele closure including bowel surgery: 2nd generation cephalosporin
(cefoxtin)

o Omphalocele closure not including bowel surgery: 1 st generation cephalosporin

(ancef)

 Pain management: as clinically indicated

o IV acetaminophen Q 6 hrs for 24 hours and reevaluate pain management plan

daily

o Utilize PRN dosing of narcotics prior to initiating infusion of narcotic

o Morphine or fentanyl infusion, versed PRN if indicated

 Skin care:

o Use of negative pressure wound vac in some cases

o Notify surgery of any signs of erythema, drainage, bleeding, or wound concerns

o If surtures are in place contact surgery for removal plan/date

PATIENT PICTURE (Management done in Patient)

Although there was regular antenatal visit of the mother in Hospital and antenatal fetal sac
performed, the diagnosis of omphalocele was made only after delivery of the neonate in health
center. Immediately following birth, the omphalocele sac was covered with moist gauze and usg
scan was performed for definitive diagnosis.

After confirmation the child was referred to tertiary level hospital for further management with a
10 fr NG tube free drain and NPO status.

The child was brought to Kanti Children Hospital Emergency Unit from where surgical team
admitted the child in SICU (Surgical Intensive Care Unit) for further management and was done
as follows.

Immediate management on Admission

Monitoring

Respiratory: The child was kept on room air with continue monitory support (Assessment of
respiration and saturation)

26
Cardiovascular: Planning was done for Echocardiogram to evaluate for cardiac anomalies and
assess for pulmonary hypertension

IV Fluids and Assess:

 Peripheral IV line was maintained and IV fluid started via an infusion pump.
 Fluid: Since sac was intact: total fluid was calculated at 80ml/kg/day initially

o For first 48hours of life 10% dextrose and then N/5 + 10% dextrose
o 10% dextrose 80ml/kg/day on 1st day of life then 100ml/kg/day on 2nd day of life.
o Then, progressively increase 10ml/kg/day to 150ml/kg/day on 7th day of life
 Hypoglycemia was monitored regularly (q 6 h)

Antiobiotics and other medicine

 Inj. Ampicillin 115mg BD for 1st 7 day of life
 Inj. Amikacin 18mg/kg (41mg) every 36 hours for 1st 7 days
 Inj. Vitamin K 1mg IV OD
 Inj. PCM 30mg IV SOS

Gastrointestinal:
 NPO until hemodynamically stable
 Gastric decompression using NG tube in free drain
 Consider replacement of high volume NG output (≥30ml/kg/day)
o 1/2ml replacement to 1 ml output of 0.45 NaCl.

Parental Counselling:
 On admission parental counselling was done for patient condition and probable need of
surgery after stabilization of the neonate.
 Planning done with parents for echo cardiogram to rule out associated anomalies.

Skin:
 Small omplalocele <5mm with bowel loop was covered with Vaseline gauze and
gauzed pad to prevent heat-loss, dryness and infection prevention.

SURGICAL MANAGEMENT

Preoperative Management:

Patient counselling on operative procedure, outcome and possible complication was done by
surgery team.

Preoperative lab investigation to be completed within 24 hours prior to surgery and evaluated:

27
  CBC with differential count, Blood gas analysis, Blood grouping and cross matching
and serology reports collected.

 One pint packed red blood cell (O positive) was arranged and kept on standby for
operative procedure.

Informed written consent was taken from father.

Pre-anesthesia checkup was done by anesthesia team prior to operation and discussed about
possible complication of anesthesia with parents. Need for resuscitation and ventilation was also
discussed.

Patient preparation was done using pre-operative checklist according to hospital protocol.

NPO Status with IV fluid, prophylaxis antibiotics, gastric decompression with NG free drain and
other routine care to neonate was provided in SICU.

Definitive management

Repair of perforated bowel and primary closure of omphalocele done on 2080/04/21.

Description of Operation: (Copied from Report of Operation)

Under all aseptic and antiseptic precautions, cleaning and draping was done. Sac of omphalocele
was incised and separated. Bowel adhesiolysis was done. Perforated part of ileum was identified
and repaired. Bowel was kept inside the abdominal cavity. Muscles and skin sutured in layers.
Hemostasis maintained. Wound dressing done.

Findings of procedure: Perforated Ileal segment about 3mm.

Postoperative management

 Monitoring

o Monitor Vital signs every 2 hourly. Observe patient for signs and symptoms of
compartment syndrome: decreased distal pulses, abdominal distension, decrease
urine output, skin discolouration

o GRBS 8 hourly

 Gastric Decompression

o 10 fr NG tube in free drain

o NPO until return of bowel function

28
  Diagnostic Studies/ Laboratory investigation:

o Temperature, blood gas and glucose level monitored within 1 hour post-operative

o CBC and RFT in the morning on 1st post-operative

o CXR on 1st post-operative day.

 Fluid management

o IVF N/5 + D10% dextrose 240ml IV over 24 hours via infusion pump

 Antibiotics
o Inj. Ampicillin 115mg BD for 1st 7 day of life
o Inj. Amikacin 18mg/kg (41mg) every 36 hours

o Inj. Metron 15mg IV TDS

 Pain management: as clinically indicated

o Inj. PCM 30mg IV TDS

o Inj. Pethidine 1.2mg IV TDS

 Skin care:

o Sterile dressing maintained at wound site

o Notify surgery team of any signs of erythema, drainage, bleeding, or wound

concerns

NURSING MANAGEMENT

BOOK PICTURE

Neonatal nurses can be instrumental in recognizing instability in infants with an omphalocele.

This is particularly important for patients born with associated anomalies such as congenital
heart defects and for infants with giant omphaloceles, who frequently present with respiratory
compromise. An understanding of signs of associated congenital anomalies helps the nurse
anticipate potential effects on cardiorespiratory and hemodynamic stability, thus allowing for
rapid identification and for initiation of early intervention.

Immediately after birth, follow healthcare provider protocol for maintaining the omphalocele
sac. Here neonatal nurses can help to minimize the risk of sac rupture by advocating for gentle

29
and infrequent handling of the defect and thereby promoting protection of the sac and underlying
viscera.

Overall, nursing goals in caring for an infant with an omphalocele should include recognizing
cardiovascular instability, maintaining fluid and electrolyte balance, maintaining normothermia,
preventing gastric distention, promoting comfort through the use of environmental and
pharmacologic measures, and promoting optimal nutrition, growth, and development. Neonatal
nurses can also advocate for the early initiation of secure central vascular access in infants whose
feedings will be delayed. This approach may promote patient comfort by reducing the number of
peripheral IV lines required and therefore the overall number of painful interventions.

1. Maintaining Cardiorespiratory Stability

The infant’s cardiorespiratory state should be assessed immediately upon birth and
ventilation and cardiovascular support provided as required. Infants with giant
omphaloceles are at risk for respiratory insufficiency and therefore frequently require
intubation and ventilatory support immediately at delivery. Those with chromosomal or
other structural anomalies may develop hemodynamic instability secondary to other
associated anomalies such as congenital heart disease.

2. Protecting the Herniated Viscera

After delivery of the infant, the defect should be handled gently and as little as possible to
avoid injury to the herniated viscera and the membranous sac covering the defect.
Although the sac can occasionally rupture antenatally or during delivery, most infants are
born with it intact.

To avoid accidental injury, the cord clamp should be placed away from the viscera (i.e.,
bowel, liver) at the distal aspect of the umbilical cord.

The infant should be positioned to avoid vascular compression from the weight of the
defect (usually side-lying). The defect should be wrapped with sterile, warm, saline-
soaked gauze and then covered with a water-tight dressing (i.e., clear plastic wrap).

Alternatively, a sterile, clear bowel bag can be used to enclose the abdominal defect, legs,
and torso. These interventions are to minimize insensible water losses by limiting heat
and evaporative losses and reduce the risk of infection.

3. Maintaining Fluids and Electrolyte balance

Water, electrolyte, and protein losses are increased in an infant with an omphalocele, with
the greatest losses occurring when the membranous sac covering it has ruptured.
Intravascular fluid deficits may lead to reduced tissue perfusion and the development of
metabolic acidosis.

30
 Maintaining intravascular fluid volume is important in continuing generalized tissue
perfusion, including preservation of bowel wall perfusion.

Assessment of the adequacy of intravascular volume involves ongoing evaluation of the

heart rate, blood pressure, urine output, blood gases, electrolytes, fluid balance, and
hematocrit. Measures to reduce insensible water loss include using humidified, warmed
incubators instead of radiant warmers; wrapping the defect as previously described; and
maintaining normothermia.

4. Maintaining Vascular Access

An intravenous (IV) line should be started immediately at birth, preferably in an upper

extremity. Upper extremities are preferred particularly in the postoperative period
because lower limb perfusion may be decreased due to increased intra-abdominal
pressure and venous compression that develops when the abdominal viscera are
surgically returned to within the abdominal cavity.

Enteral feedings, particularly in cases of giant omphaloceles, are frequently delayed due
to prolonged ileus; even when feedings are introduced, limited enteral tolerance may
restrict the advancement of feedings.

In these cases, adequate vascular access is important, and a peripherally inserted central
catheter (PICC) or central venous line (CVL) should be considered, preferably within the
first few days, for administration of fluids and total parenteral nutrition.

5. Monitoring Lab Tests

Assessing the adequacy of the intravascular volume and hemodynamic stability

frequently includes measuring blood gases, electrolytes and fluid balance, glucose, and
hematocrit levels. Frequency and specific laboratory analysis are guided primarily by
clinical assessments. If Beckwith-Wiedemann syndrome is suspected, glucose levels
must be monitored frequently because hypoglycemia often occurs with it.

6. Maintaining Normothermia

Increased evaporative heat losses, particularly in cases of a ruptured omphalocele,

increase the risk of hypothermia.

Hypothermia should be avoided because it may lead to vasoconstriction, decreased tissue

perfusion, and increased risk for the development of metabolic acidosis.

Overheating should also be avoided because insensible water losses increase with
hyperthermia.

Interventions to maintain normothermia include thoroughly drying the infant at birth to

reduce evaporative heat losses and caring for him in a warmed incubator. Humidified

31
 incubators are preferred over radiant warmers because insensible water losses are
significantly reduced in this environment.

7. Facilitating Gastric Decompression

A nasogastric tube of adequate caliber must be inserted promptly post-delivery and

connected to intermittent wall suction to facilitate gastric drainage decompression. This
reduces the risk of pulmonary aspiration of gastric secretions. In addition, gastric
decompression reduces the risk of intestinal distension and impairment of bowel wall
perfusion in crying infants who swallow large quantities of air.

An indwelling urinary catheter can be inserted to reduce pressure on the herniated

viscera from an overdistended bladder and to facilitate accurate assessment of urinary
output.

8. Preventing Infection

Broad-spectrum antibiotics are routinely started at birth because the risk of infection
increases with unavoidable exposure of the defect to environmental microorganisms.
Routine use of infection-control practices (sterile gloves and dressings) minimizes
infection risk. In anticipation of a surgical intervention and the risk of associated
bleeding, vitamin K must be administered routinely

9. Performing Diagnostics

After an infant has been stabilized, a thorough physical examination should be completed
and investigations arranged to evaluate for other associated anomalies. Postnatal
investigations may include an echocardiogram, chest x-ray, abdominal ultrasound, and
chromosome analysis. Antenatal investigations such as chromosome analysis and
echocardiograms are frequently repeated postnatally to confirm antenatal findings.

10. Parental Support

Nurses must incorporate goals to meet the psychosocial needs of the family. Even though
most infants with omphaloceles are antenatally diagnosed and most parents have been
informed of postnatal expectations, the postnatal experience is unique to that family.
From the time of prenatal diagnosis to discharge, parents require information, support,
and compassion. For many, the prolonged hospitalization can be difficult. Tertiary care
centers are generally located in large urban centers, and social workers can assist families
from distant communities with living accommodations, transportation, and ongoing
psychosocial support. Especially for families who live far away from the hospital and
whose infant requires prolonged hospitalization, pictures can help parents stay connected.

Nurses are in a position to address the ongoing fears and concerns of these parents using
a multidisciplinary and individualized approach. Throughout the infant’s hospitalization,
parents need clear, accurate explanations about the infant’s condition. To help the parents

32
 deal with the crisis of an acutely ill newborn, provide emotional support and encourage
parents to express their feelings.

Although the initial instability of the infant often temporarily precludes holding him, for
example, nurses can encourage parents to hold their infant as soon as stability is
achieved. The cyclic pattern of enteral feeding progression and regression, although
typical, can be discouraging for parents. Nurses can promote their inclusion in infant care
needs such as diapering. Parental bonding must be a priority. Regular family meetings
with members of the multidisciplinary team can provide parents an opportunity to ask
questions and have their fears and concerns addressed.

Expected outcomes of nursing care depend on the severity of the defect and its correction, but
may include:

 Fluid volume balance is maintained.

 The incision heals without signs of infection.

 Stable thermoregulatory function is maintained.

 Effective pain management is achieved.

 Parent–infant bonding and attachment are demonstrated.

PATIENT PICTURE (Nursing management in patient)

Nursing management provided to patient was similar to book picture which is described in
nursing care plan that follows.

Problems and Risk factors in Patient present during hospitalization

• SICU admission

• Surgical intervention

• Acute pain

• Fever; Temperature: 100.3F

• NPO status with NG free drain for gastric decompression

• Skin dryness, redness and rashes around inguinal and anal areas

• Continue use of diaper

• Impaired mother and child relationship

33
Nursing diagnosis of patient according to assessment and priority from 2080/04/22-
2080/04/26

1) Acute pain related to surgical incision as evidence by facial grimacing, restlessness,

irritability and crying.
2) Ineffective thermoregulation (More than body temperature) related to pain as evidenced
by Axillary temperature 100.3 degrees Fahrenheit and flushed and dry skin.
3) Risk for deficit fluid volume related to decrease oral intake (Nil Per Oral) as evidence by
skin dryness.
4) Impaired skin integrity related to contact with irritants (Urine) as evidence by rashes and
erythema.
5) Impaired parent infant attachment related to hospitalization of neonate in SICU.
6) Risk of infection related to invasive procedure secondary to disease condition.

34
Assessment (2080/04/22)

Objective data: During morning care the child was restless, irritable and crying with facial grimacing. NIPS Score i.e. Pain level > 5.
Vital signs shows increased body temperature and tachycardia.
Temperature: 100.30C, RR-44/min, P-160b/Min

Nursing Diagnosis: Acute pain related to surgical incision as evidence by facial grimacing, restlessness, irritability and crying.

Goal: The neonate will appear relaxed and able to sleep/rest appropriately (pain level< 3 on NIPS Score) within 2 hours of
intervention.
Planning Intervention Rationale Nursing implementation
Assess pain, noting location, Useful in monitoring effectiveness of Assessment of the client for pain was done
characteristics, severity (0–10 scale). medication, progression of healing. Changes using NIPS i.e. Pain level > 5.
Investigate and report changes in in characteristics of pain may indicate Vital signs monitored every 2 hourly
pain as appropriate. developing abscess or peritonitis, requiring recorded in TPR sheet.
prompt medical evaluation and intervention.
Keep patient at rest in semi-Fowler’s To lessen the pain. Gravity localizes The neonate was kept in comfortable
position. inflammatory exudate into lower abdomen position semi-fowler’s position in cot.
or pelvis, relieving abdominal tension,
which is accentuated by supine position. Bundle of care was provided like
medications, vitals monitoring and morning
care was provided to restrict excessive
movement of the child.
Encourage early ambulation. Promotes normalization of organ Since the child was a neonate early
function (stimulates peristalsis and passing ambulation was not possible but passive
of flatus, reducing abdominal discomfort). exercise of upper and lower limb along with
oil massage was provided to the neonate to
enhance comfort.
Provide diversional activities Refocuses attention, promotes relaxation, Gentle touch and swaddling of the neonate
and may enhance coping abilities. was done to comfort the neonate.
Keep Patient in NPO and maintain Decreases discomfort of early intestinal The patient was on NPO following surgical
NG suction initially. peristalsis, gastric irritation and vomiting procedure and NG free drain for abdominal
following surgical intervention. decompression.

35
 Administer analgesics as indicated. Relief of pain facilitates cooperation with Prescribed analgesic was provided as per
other therapeutic interventions. order.
Inj. PCM 30mg IV TDS
Inj. Pethidine 1.2mg IV TDS and SOS.
Watch closely for possible surgical Continuing pain and fever may signal Wound dressing was done under aseptic
complications. wound infection. technique and observed for signs of
infection i.e. redness, exudates, fever etc.
which was absent.

Evaluation:
After an hour of nursing implementation, the neonate was relaxed and slept comfortably. NIPS score of Pain Level was <3.
Vitals were also within normal range with temperature reduced to 990F at 10:00am.

36
Assessment (2080/04/22)

Objective data: During morning care the child was restless, irritable and crying with facial grimacing. Vital signs shows increased
body temperature and tachycardia. Temperature: 100.30C, RR-44/min, P-160b/Min. On palpation skin was warm and flushed with
dryness.

Nursing Diagnosis: Ineffective thermoregulation (More than body temperature) related to pain as evidenced by axillary temperature
100.3 degrees Fahrenheit and flushed and dry skin.

Goal: Neonate will maintain core temperature within normal range after nursing intervention in 2 hours.

Planning intervention Rationale Nursing implementation

Assess for signs of Flushed face with skin that is hot to touch, General inspection of skin was done to assess the
hyperthermia. weakness, fatigue, headache, and signs of hyperthermia during morning care.
abnormal vital signs are possible Skin was warm and flushed with dryness.
indicators of hyperthermia that provide Presence of irritability and restlessness.
baseline data.
Monitor Vital Signs. Hyperthermia results in a core Vital signs especially including temperature was
temperature of 104°F or higher. This will monitored every 2 hourly and recorded in TRP chart.
cause a rapid heart rate and breathing. During morning care there was increased body
Rectal or tympanic thermometers are most temperature and tachycardia.Temperature: 100.30C,
accurate for core temperature assessment. RR-28/min, P-120b/Min
Assess for underlying Various disorders including infection and Neonate was assessed for various underlying causes.
conditions. invasive procedure can cause She was on NPO status following Surgical procedure
hyperthermia in children. (Reduction of omphalocele) till next order.
Skin turgor within normal limit.
NIPS pain level> 5.
Monitor for dehydration Dehydration precipitate hyperthermia. During morning care the child was assessed for signs
of dehydration.
Presence of dry skin and normal skin turgor.
No sweating.
Implement surface cooling A tepid sponge enhance evaporation A tepid sponge bath was provided to the neonate
measures: Tepid sponge bath reducing body temperature rapidly. during morning care with warm water.

37
 can be given.
Cool the environment: Helps in decreasing body temperature Heavy clothing was removed and light cloth was
Remove blankets and heavy through evaporation. provided to the neonate.
clothing. Provide fans for Heavy blankets were removed from baby’s body.
ventilation. Temperature of radiant warmer was maintained at
360C.
Rehydrate. To prevent the occurrence Since the child was in NPO following surgical
Administer IV fluids to treat of dehydration precipitated by an increase procedure, IV fluid 1/5NS with dextrose was infused
dehydration. in temperature. To reduce metabolic continuously via an infusion pump at 14ml per hour.
demands/oxygen consumption that may
precipitate fever.
Administer antipyretics and Antipyretics such as acetaminophen will Analgesic and antipyretics was provided as per
analgesic if associated with quickly lower body temperature. prescription.
pain. Inj. PCM 30mg IV TDS and SOS.
Inj. Pethidine 1.2mg IV TDS and SOS.
Evaluate blood for sepsis. For early detection of infection. Blood investigation was done to rule out sepsis i.e
Total and differential blood count.

Evaluation: Normal body temperature was recorded i.e. T-990F, RR-36/min and P-136b/min after nursing intervention in 2 hours.
Thus the goal was met.

38
Assessment (2080/04/23)

Objective data: The child was on NPO following surgical intervention and NG free drain for abdominal decompression. The skin was
dry but urine output is in normal range (300ml over 24 hours).

Nursing Diagnosis: Risk for deficit fluid volume related to decreased oral intake (Nil Per Oral) as evidence by skin dryness.

Goals: The child will maintain adequate fluid balance as evidenced by moist mucous membranes, good skin turgor, stable vital signs,
and individually adequate urinary output in 24hours.

Planning intervention Rationale Nursing Implementation

Assess the child’s general condition  To determine need for intervention and the Assessment of general condition of baby was
including vital signs and weight. effectiveness of therapy. done- baby was irritable with dry skin (peeling
 To obtain baseline data for further of skin tissue).
intervention. Vital signs were monitored and recorded every 2
hourly in TPR chart.
Daily weight measurement was done and
recorded.
Inspect mucous membranes; assess Indicators of adequacy of peripheral circulation On assessment skin turgor was normal and
skin turgor and capillary refill. and cellular hydration. capillary refill time was <3 seconds. Although
skin was dry, mucous membrane was moist.
Monitor Intake & Output; note Intake and output chart was maintained daily and
urine color and concentration, Decreasing output and concentrated urine with recorded. I/O for last 24 hours was
specific gravity. increasing specific gravity suggests dehydration Intake: 340ml/24hours
and need for increased fluids. Output-300ml/24hours
Negative balance= 40ml
Auscultate and document bowel Bowel sound present on auscultation. Presence
Indicators of return of peristalsis, readiness to
sounds. Note passing of flatus, of abdominal distension so was on NG free
begin oral intake.
bowel movement. drain. Flatus passed but stool not passed.
Maintain gastric and intestinal
To decompress the bowel, promote intestinal NG tube was maintained in free drain for gastric
suction, as indicated.
rest, prevent vomiting. decompression both pre and post-operatively.
Provide clear liquids in small Reduces risk of gastric irritation and vomiting Neonate was in NPO till next order so oral fluid

39
 amounts when oral intake is
to minimize fluid loss. was not provided but IV fluid was provided as
resumed, and progress diet as
per order.
tolerated.
Administer IV fluids and The peritoneum reacts to irritation and infection IV fluid was provided as ordered.
electrolytes. by producing large amounts of intestinal fluid,  IVF 1/5NS + 10% dextrose with Inj KCl
possibly reducing the circulating blood volume, 5cc at 14ml/hour.
resulting in dehydration and relative electrolyte  Inj. Astgmin 10ml +100ml NS
imbalances.  Total fluid (340ml over 24hours)
Evaluate and treat factors causing The causative factors or risk factors for deficit
deficit fluid volume. To assess what factors contribute to fluid fluid volume were evaluated.
volume deficit that may be given prompt Nil per Oral and mild dehydration was most
intervention. probable cause so fluid supplied with electrolyte
as per order.
Promote skin hygiene. Oral and skin care were provided with tepid
To prevent dryness of the skin.
sponging during morning care.
Evaluation:
On evaluation of child on 2080/04/24 reveals that the child had normal skin turgor, stable vital signs with adequate urine output
(300ml/24hrs). The goal was met.

40
Assessment (2080/04/24)
Objective data: There was redness and rashes around inguinal and anal region. The neonate was continually on diaper.
Nursing Diagnosis: Impaired skin integrity related to contact with irritants (Urine) as evidence by rashes and erythema.
Nursing goal: Patient will maintains optimal skin integrity in 2 days following nursing intervention as evidenced by intact skin.

Planning intervention Rationale Nursing implementation

Perform complete skin assessment. A thorough head-to-toe skin assessment should Assessment of the client was done.
Assess skin noting color, moisture, be performed on admission, transfer between Skin around anal region and inguinal area
texture, temperature; note erythema, units, and once per shift to monitor and/or had rashes and erythema i.e. diaper rash
edema, tenderness. prevent skin breakdown. due to continual use of diaper in SICU.
Assess skin turgor, sensation, and Poor skin turgor, decreased sensations (nerve On assessment there was normal skin
circulation damage), and poor circulation (lack of blood turgor and no signs of dehydration on
flow assessed via palpation of pulse sites as well palpation around other areas of body.
as observed by purplish or ruddy discoloration of
lower legs) increase the risk of tissue damage.
Monitor ambulation status and bed Patients who cannot walk or cannot shift their Neonate was provided passive limb
mobility weight in a chair or bed are at a higher risk for exercise and oil massage regularly.
skin breakdown.
Keep the skin clean and dry. Patients who are unable to ask for assistance to The neonate was assessed for bodily
Consider incontinence or increased use the bathroom or are incontinent need secretions. Wet bed linens, clothing were
perspiration. frequent monitoring to keep skin dry and clean changed immediately after being soiled.
as urine, feces, and sweat are irritating to the Diapers were changed immediately after
skin. passage of urine and stool or at least every
2 hourly.
Repositioning and support of boney Patients who cannot reposition themselves The neonate was supported on soft linen
prominences should be turned in bed on a schedule at least and position was changed every 2 hourly.
every 2 hours to prevent pressure injury on bony Oil massage was provided frequently to
prominences. enhance skin perfusion before position
change.
Cleanse the area with plain water and Dry clothes and regular wipes can further Wet wipes and moist gauze was used to
soft clothes. irritates the skin. clean the inguinal and anal area before
changing diaper.
Clean warm water was used for morning

41
 care and the skin was allowed to air dry or
gently pat the skin dry.
Rubbing or brisk drying of skin was
strictly avoided.
Apply emollient or protective To maintain skin moisture and prevent irritation. Regular oil massage was provided to the
ointments after cleaning. Moisturizing is the cornerstone of treatment. neonate.
Nappy soft ointment was applied to
affected area.
Encourage nutrition and hydration Proper intake of fluids increases oxygen and Adequate intravenous fluid as prescription
nutrient delivery to the wound bed by increasing was provided during NPO status and
the blood volume. breast milk was initiated on 3rd post-
operative day after surgical intervention.
Provide information about skin care To prevent diaper rashes and maintain healthy Mother was informed about skin care and
to parents such as sin of child following discharge. encouraged them to adopt skin care
 Long bathing or showering in hot routines for patient to decrease skin
water causes drying of the skin irritation following discharge. Information
and can aggravate itching through on following was provided.
vasodilation.  Bathe or shower patient using
lukewarm water and mild soap or
 Rubbing the skin with a towel can non-soap cleansers.
irritate the skin and exacerbate
the itch-scratch cycle.  After bathing, allow the skin to air
dry or gently pat the skin dry.
 Lubrication with fragrance-free Avoid rubbing or brisk drying.
creams or ointments serves as a
barrier to prevent further drying  Apply topical lubricants
of the skin through evaporation. immediately after bathing.
Moisturizing is the cornerstone of
treatment.
Evaluation:
There was reduction of skin rashes and erythema around inguinal and anal area on inspection during morning care on the following
day.
Assessment (2080/04/25)

42
Subjective data: child’s mother were bothered about the child’s condition and anxious about care. She expresses, “सुन्नुस न मेरो बच्चा लाई
कस्तो छ? जन्मेदेखि अस्पतालमा भर्ना गरेको राम्ररी श्याहार नि गर्न पाको छैन| दूधनि खुवाउन पाको छैन , अब मेरो दूध खाने हो कि नाई| खाएन भने के गर्ने होला है | ”

Objective data: Mother was concerned about her child and expressing her anxiety about breast feeding. Mother was only allowed to
visit the child once in a day but was not allowed to care in SICU.
Nursing Diagnosis: Impaired parent infant attachment related hospitalization of neonate in SICU.
Goals: Mother will spend time and participate in care of the neonate during breastfeeding in 2 days.
Planning Intervention Rationale Nursing Implementation
Assess the parent’s Assessment of the parents for knowledge about neonate’s need for SICU
knowledge about the To obtain baseline data for admission was done during counseling session.
child’s need for ICU further intervention.  Although she was well aware about child’s disease condition and
admission. operative procedure performed, she was concerned and anxious about
breast feeding and the infant’s condition and prognosis.
Orient the parents about Parents were oriented about the need of NICU protocol (hand hygiene
institutional policy To reduce parental anxiety. before touching neonate, gowning and changing shoes) including visiting
including ICU protocol. hours.
Encourage the parents to This reduces parental concern
Parents were provided with opportunities to share their concerns and
share their feeling and and provide emotional support
frustration during counseling session.
concerns. to parents.
Assess for the parents’ To improve neonatal care and Parents’ readiness to care for neonate was assessed and information about
readiness to care for the prevent complication following neonatal care like eye care, umbilical care, exclusive breast feeding,
child. discharge. immunization was provided.
Involve the parents in  Neonate’s mother was encouraged to pump her breast and bring milk for
care of child. feeding the child postoperatively after initiation of oral intake following
To enhance coping with
surgical procedure.
separation and attachment.
 Mother was also taught about breast feeding and kangaroo mother care to
help child gain weight.
Evaluation: Mother was happy to bring her own breast milk to feed the child. After learning about neonatal care, she was eager to
keep the child for care before neonate was shifted on 2080/04/26 to surgical ward.
Assessment (2080/04/26)

43
Objective data: The child was active and alert but had thin body structure. Patient had invasive procedure (Reduction of
Omphalocele), multiple prick marks and IV cannula insitu.

Nursing Diagnosis: Risk of infection related to invasive procedure secondary to disease condition.

Goals: No signs of infection will be present during hospital stay as evidence by normal blood count and vitals within normal limit.

Planning Intervention Rationale Nursing Implementation

Assess the child for To determine need for intervention after Assessment of child was done for:
potential factors and signs obtaining baseline data.  Vital signs every 2-4 hourly especially temperature
of infection. and pulse rate and recorded.
For early intervention if any signs of infection  Wound site and cannula sites for signs of infection
present. (swelling, redness, tenderness) was assessed and
changed cannula site if any present changed.
 Monitored blood count before shifting the child to
surgical ward.
Orient the parents about Hand hygiene are maintained by every staff before
institutional policy This helps to prevent cross infection and touching the neonate either using soap water or sanitizer.
including ICU protocol. reduce parental anxiety. Parents were provided gown, shoes and encouraged to
perform hand hygiene prior to entry in SICU.
Maintain aseptic technique This reduces contamination and prevent Aseptic technique was maintained before IV cannulation
for invasive procedure. inoculation of infectious agents through with Spirit and sterile vein open set.
invasion. Aseptic technique was followed on wound dressing.
Administer antibiotics as IV antibiotics were given as per ordered.
per prescription.  Inj. Ampicillin 115mg BD for 1st 7 day of life
To reduce bacteremia if any present.
 Inj. Amikacin 18mg/kg (41mg) every 36 hours
 Inj. Metron 15mg IV TDS
Provide Breast milk to the Breast milk provides IgA that helps in Expressed breast milk was provided followed by breast
child as far as possible. prevention of infection. feeding to the neonate in SICU and surgical ward.
Evaluation: There was no signs of infection during discharge. Vitals were within normal limit before discharge on 2080/4/29.

44
Complications

Omphalocele complications can be categorized according to their time of occurrence.

Prenatally and during delivery, the omphalocele may rupture, and in the case of a giant
omphalocele, the liver can be injured.
The majority of infants with omphalocele have a small thorax with varying degrees of pulmonary
hypoplasia. Thus, mechanical ventilation is often required for weeks or even months until the
lungs mature.
Infants with omphaloceles often need parenteral nutrition, which can lead to cholestasis and
hepatomegaly. Thus, large omphaloceles need a staged repair. Tracheostomies are often needed
until the lung mature.
Postnatally and after surgical repair, the complications consist of
• Feeding difficulties
• Failure to thrive
• Inguinal hernias
• Gastroesophageal reflux
• Occasionally esophagitis.
• In children with giant omphalocele neurodevelopmental and motor delays occur more
often.

• Volvulus does occur after repair of omphalocele in up to 3% of cases.

• More commonly (13–15%) patients present with adhesive small bowel obstructions
following omphalocele repair.

Prognosis

A prognosis is the expected outcome of treatment for a specific condition. The prognosis is based
on research study data involving studies of others with the same condition who received
treatment. The prognosis of an omphalocele depends on many factors, including:

 The size of the omphalocele

 Any damage that may have occurred to the organs (from a loss of blood flow)

 Other congenital birth defects or health issues

Outcome and survival have drastically improved over the last decades in children born with
omphalocele. Overall survival for live born omphalocele infants is up to 80%. In cases of
isolated omphalocele one year survival rate has been reported as high as 90%. The prognosis
largely depends on the associated congenital anomalies. Giant omphaloceles are generally
associated with more long-term medical problems

45
Evidence

A 2019 study involving long-term follow-up evaluation in school-age children who were treated
as infants for omphalocele discovered some facts about the child’s cognition, health status,
quality of life and behavior, the study concluded:

 Those who were treated for an isolated (no defects other than an omphalocele), minor
omphalocele did not require any type of long-term follow-up treatment for behavioral,
cognitive or health problems.

 81% of those who were treated for a “giant omphalocele” (over 5 centimeters or 1.9
inches), were reportedly normal when they reached school age, with no behavioral,
cognitive or health problems.

 Those with multiple congenital defects and giant omphaloceles had the lowest scores for
risk for delayed cognitive function at school age; this group was recommended for long-
term follow-up care and intervention.

46
Drug Profile

1. AMIKACIN SULFATE

Classifications: ANTIINFECTIVE; AMINOGLYCOSID; ANTIBIOTIC

Prototype: Gentamicin
Pregnancy Category: C

Availability: 250 mg/mL, 50 mg/mL injection

Actions: Semisynthetic derivative of kanamycin with broad range of antimicrobial activity that
includes many strains resistant to other aminoglycosides. Pharmacologic properties are
essentially the same as those of gentamicin. Appears to inhibit protein synthesis in bacterial cell
and is usually bactericidal.

Therapeutic Effects

Effective against a wide variety of gram-negative bacteria including Escherichia coli,

Enterobacter, Klebsiella pneumoniae, most strains of Pseudomonas aeruginosa, and many
strains of Proteus species, Serratia, Providencia stuartii, Citrobacter freundii,
Acinetobacter. Also effective against penicillinase- and non-penicillinase-
producing Staphylococcus species, and against Mycobacterium tuberculosis and atypical
mycobacteria.

Uses: Primarily for short-term treatment of serious infections of respiratory tract, bones, joints,
skin, and soft tissue, CNS (including meningitis), peritonitis burns, recurrent urinary tract
infections (UTIs).

Unlabeled Uses: Intrathecal or intraventricular administration, in conjunction with IM or IV

dosage.

Contraindications

History of hypersensitivity or toxic reaction with an aminoglycoside antibiotic. Safety during

pregnancy (category C), lactation, neonates and infants, or use period exceeding 14 d is not
established.

Cautious Use

Impaired renal function; eighth cranial (auditory) nerve impairment; preexisting vertigo or
dizziness, tinnitus, or dehydration; fever; older adults, premature infants, neonates and infants;
myasthenia gravis; parkinsonism; hypocalcemia.

Route & Dosage

47
Moderate to Severe Infections
Adult: IV/IM 5–7.5 mg/kg loading dose, then 7.5 mg/kg q12h
Child: IV/IM 5–7.5 mg/kg loading dose, then 5 mg/kg q8h or 7.5 mg/kg q12h
Neonate: IV/IM 10 mg/kg loading dose, then 7.5 mg/kg q12–24h

Uncomplicated UTI
Adult: IV/IM 250 mg q12h

Administration

Intramuscular

 Use the 250 mg/mL vials for IM injection. Calculate the required dose and withdraw the
equivalent number of mLs from the vial.
 Give deep IM into a large muscle.

Intravenous: Verify correct IV concentration and rate of infusion with physician for neonates,
infants, and children.

PREPARE: Intermittent:
 Add contents of 500 mg vial to 100 or 200 mL D5W, NS injection, or other diluent
recommended by manufacturer.
 For pediatric patients, volume of diluent depends on patient's fluid tolerance.
Note: Color of solution may vary from colorless to light straw color or very pale yellow.
Discard solutions that appear discolored or that contain particulate matter.

ADMINISTER: Intermittent:

 Give a single adult dose (including loading dose) over at least 30–60 min by IV infusion.
 Increase infusion time to 1–2 h for infants.
 Monitor drip rate carefully. A rapid rise in serum amikacin level can cause respiratory
depression (neuromuscular blockade) and other signs of toxicity.

Store at 15°–30° C (59°–86° F) unless otherwise directed.

Adverse Effects ( 1%)

CNS: Neurotoxicity: drowsiness, unsteady gait, weakness, clumsiness, paresthesias, tremors,

convulsions, peripheral neuritis.
Senses: Auditory–ototoxicity, high-frequency hearing loss, complete hearing loss (occasionally
permanent); tinnitus; ringing or buzzing in ears; Vestibular: dizziness, ataxia.
GI: Nausea, vomiting, hepatotoxicity.
Metabolic: Hypokalemia, hypomagnesemia.
Skin: Skin rash, urticaria, pruritus, redness.
Urogenital: Oliguria, urinary frequency, hematuria, tubular necrosis, azotemia.
Other: Superinfections.

48
Interactions

Drug:
ANESTHETICS, SKELETAL MUSCLE RELAXANTS have additive neuromuscular blocking
effects; acyclovir, amphotericinB, bacitracin, capreomycin, cephalosporins, colistin, cisplatin, ca
rboplatin, methoxyflurane, polymyxin B, vancomycin, furosemide, ethacrynic acid increase risk
of ototoxicity and nephrotoxicity.

Pharmacokinetics

 Peak: 30 min IV; 45 min to 2 h IM.

 Distribution: Does not cross blood–brain barrier; crosses placenta; accumulates in renal
cortex.
 Elimination: 94–98% excreted renally in 24 h, remainder in 10–30 d.
 Half-Life: 2–3 h in adults, 4–8 h in neonates.

Nursing Implications

Assessment & Drug Effects

 Baseline tests: Before initial dose, C&S; renal function and vestibulocochlear nerve
function (and at regular intervals during therapy; closely monitor in the older adult,
patients with documented ear problems, renal impairment, or during high dose or
prolonged therapy).
 Monitor peak and trough amikacin blood levels: Draw blood 1 h after IM or immediately
after completion of IV infusion; draw trough levels immediately before the next IM or IV
dose.
 Lab tests: Periodic serum creatinine and BUN, complete urinalysis. With treatment over
10 d, daily tests of renal function, weekly audiograms, and vestibular tests are strongly
advised.
 Monitor serum creatinine or creatinine clearance (generally preferred) more often, in the
presence of impaired renal function, in neonates, and in the older adult; note that
prolonged high trough (>8 mcg/mL) or peak (>30–35 mcg/mL) levels are associated with
toxicity.
 Monitor S&S of ototoxicity [primarily involves the cochlear (auditory) branch; high-
frequency deafness usually appears first and can be detected only by audiometer];
indicators of declining renal function; respiratory tract infections and other symptoms
indicative of superinfections and notify physician should they occur.
 Monitor for and report auditory symptoms (tinnitus, roaring noises, sensation of fullness
in ears, hearing loss) and vestibular disturbances (dizziness or vertigo, nystagmus,
ataxia).
 Monitor & report any changes in I&O, oliguria, hematuria, or cloudy urine. Keeping
patient well hydrated reduces risk of nephrotoxicity; consult physician regarding
optimum fluid intake.

49
Patient & Family Education

 Report immediately any changes in hearing or unexplained ringing/roaring noises or

dizziness, and problems with balance or coordination.
 Do not breast feed while taking this drug without consulting physician.

2. AMPICILLIN SODIUM

Ampicin , Omnipen-N, Penbritin , Polycillin-N, SK-Ampicillin-N, Totacillin-N

Classifications: ANTIINFECTIVE; ANTIBIOTIC; AMINOPENICILLIN

Pregnancy Category: B

Availability: 250 mg, 500 mg capsules; 125 mg/5 mL, 250 mg/5 mL oral suspension; 125 mg,
250 mg, 500 mg, 1 gm, 2 gm vials

Mechanism of Actions

A broad-spectrum semisynthetic, aminopenicillin is highly bactericidal even at low

concentrations, but is inactivated by penicillinase (beta-lactamase).

Therapeutic Effects

Active against gram-positive microorganisms such as alpha- and beta-Hemolytic streptococci,

Diplococcus pneumoniae, non-penicillinase producing Staphylococci, and Listeria. Major
advantage over penicillin G is enhanced action against most strains of Enterococci and several
gram-negative strains including Escherichia coli, Neisseria gonorrhoeae, N. meningitidis,
Haemophilus influenzae, Proteus mirabilis, Salmonella (including typhosa),
and Shigella. Inactive against Mycoplasma, rickettsiae, fungi, and viruses.

Uses

Infections of GU, respiratory, and GI tracts and skin and soft tissues; also gonococcal infections,
bacterial meningitis, otitis media, sinusitis, and septicemia and for prophylaxis of bacterial
endocarditis. Used parenterally only for moderately severe to severe infections.

Contraindications

Hypersensitivity to penicillin derivatives; infectious mononucleosis.

Cautious Use

History of severe reactions to cephalosporins; pregnancy (category B) or lactation.

50
Route & Dosage
Systemic Infections
Adult: PO 250–500 mg q6h IV/IM 250 mg–2 g q6h
Child: PO 25–50 mg/kg/d divided q6h IV/IM 25–100 mg/kg/d divided q6h
Neonate: IV/IM 7 d & 2000 g, 50 mg/kg/d divided q12h; 7 d & >2000 g, 75 mg/kg/d
divided q8h; >7 d, 50–100 mg/kg/d divided q6–12h

Meningitis
Adult/Child: IV 150–200 mg/kg/d divided q4–6h
Neonate: IV/IM 7 d & 2000 g, 100 mg/kg/d divided q12h; 7 d & >2000 g, 150 mg/kg/d
divided q8h; >7 d, 100–200 mg/kg/d divided q6–12h

Gonorrhea
Adult: PO 3.5 g with 1 g probenecid times 1 IV/IM 500 mg q8–12

Administration
Oral:

 Give with a full glass of water on an empty stomach (at least 1 h before or 2 h after
meals) for maximum absorption. Food hampers rate and extent of oral absorption.

Intramuscular

 Reconstitute each vial by adding the indicated amount of sterile water for injection or
bacteriostatic water for injection (1.2 mL to 125 mg; 1 mL to 250 mg; 1.8 mL to 500 mg;
3.5 mL to 1 g; 6.8 mL to 2 g). All reconstituted vials yield 250 mg/mL except the 125 mg
vial which yields 125 mg/mL. Administer within 1 h of preparation.
 Withdraw the ordered dose and inject deep IM into a large muscle.

Intravenous

 Verify correct IV concentration and rate of infusion with physician for administration to
neonates, infants, and children.
 PREPARE: Direct/Intermittent:
o Reconstitute each 500 mg or less with at least 5 mL of sterile water for injection.
Final concentration must be 30 mg/mL; thus may be further diluted in 50 mL or
more of NS, D5W, D5/NS, D5W/0.45NS, or RL.
o Stability of solution varies with diluent and concentration of solution. Solutions in
NS are stable for up to 8 h at room temperature; other solutions should be infused
within 2–4 h of preparation. Give direct IV within 1 h of preparation.
o Wear disposable gloves when handling drug repeatedly; contact dermatitis occurs
frequently in sensitized individuals.
 ADMINISTER: Direct/ Intermittent:
o Slowly over at least 15 min.

51
 o With solutions of 100 mL or more, set rate according to amount of solution, but
no faster than direct IV rate.
o Convulsions may be induced by too rapid administration.
 INCOMPATIBILITIES Solution/additive: Do not add to a dextrose containing
solution unless entire dose is given within 1 h of preparation. Y-site: Amiodarone.

 Store capsules and unopened vials at 15°–30° C (59°–86° F) unless otherwise directed.
Keep oral preparations tightly covered.

Adverse Effects ( 1%)

 Body as a Whole: Similar to those for penicillin G. Hypersensitivity (pruritus, urticaria,
eosinophilia, hemolytic anemia, interstitial nephritis, anaphylactoid reaction);
superinfections.
 CNS: Convulsive seizures with high doses.
 GI: Diarrhea, nausea, vomiting, pseudomembranous colitis.
 Other: Severe pain (following IM); phlebitis (following IV).
 Skin: Rash.

Diagnostic Test Interference

Elevated CPK levels may result from local skeletal muscle injury following IM injection.

Urine glucose: high urine drug concentrations can result in false-positive test results
with Clinitest or Benedict's (enzymatic glucose oxidase methods, e.g., Clinistix, Diastix,
TesTape, are not affected).

AST may be elevated (significance not known).

Interactions
Drug:

 Allopurinol increases incidence of rash. Effectiveness of

the AMINOGLYCOSIDES may be impaired in patients with severe end-stage renal
disease.
 Chloramphenicol, erythromycin, and tetracycline may reduce bactericidal effects of
ampicillin; this interaction is primarily significant when low doses of ampicillin are used.
Ampicillin may interfere with the contraceptive action of oral contraceptives
 Estrogens. Female patients should be advised to consider nonhormonal contraception
while on antibiotics.
 Food: Food may decrease absorption of ampicillin, so it should be taken 1 h before or 2 h
after meals.

52
Pharmacokinetics
 Absorption: Oral dose is 50% absorbed. Peak effect: 5 min IV, 1 h IM, 2 h PO.
 Duration: 6–8 h.
 Distribution: Most body tissues; high CNS concentrations only with inflamed meninges;
crosses the placenta.
 Metabolism: Minimal hepatic metabolism.
 Elimination: 90% excreted in urine; excreted into breast milk.
 Half-Life: 1–1.8 h.

Nursing Implications

Assessment & Drug Effects

 Determine previous hypersensitivity reactions to penicillins, cephalosporins, and other

allergens prior to therapy.
 Lab tests: Baseline C&S tests prior to initiation of therapy; start drug pending results.
Baseline and periodic assessments of renal, hepatic, and hematologic functions,
particularly during prolonged or high-dose therapy.
 Note: Sodium content of drug must be considered in patients on sodium restriction.
 Inspect skin daily and instruct patient to do the same. The appearance of a rash should be
carefully evaluated to differentiate a nonallergenic ampicillin rash from a hypersensitivity
reaction. Report rash promptly to physician.
 Note: Incidence of ampicillin rash is higher in patients with infectious mononucleosis or
other viral infections, Salmonella infections, lymphocytic leukemia, or hyperuricemia or
in patients taking allopurinol.
 Take medication around the clock; continue taking medication until it is all gone (usually
10 d) unless otherwise directed by physician or pharmacist.

Patient & Family Education

 Note: Ampicillin rash is believed to be nonallergenic and therefore its appearance is not
an absolute contraindication to future therapy.
 Report diarrhea to physician; do not self-medicate. Give a detailed report to the physician
regarding onset, duration, character of stools, associated symptoms, temperature and
weight loss (if any) to help rule out the possibility of drug-induced, potentially fatal
pseudomembranous colitis (see Appendix F).
 Report S&S of superinfection (onset of black, hairy tongue; oral lesions or soreness;
rectal or vaginal itching; vaginal discharge; loose, foul-smelling stools; or unusual odor
to urine).
 Notify physician if no improvement is noted within a few days after therapy is started.
 Do not breast feed while taking this drug without consulting physician.

3. VITAMIN K (PHYTONADIONE)

AquaMEPHYTON, Konakion, Mephyton, Phylloquinone

53
Classifications: HORMONES AND SYNTHETIC SUBSTITUTES; VITAMIN; ANTIDOTE
Pregnancy Category: C

Availability: 5 mg tablets; 2 mg/mL, 10 mg/mL injection

Mechanism of Actions

Fat-soluble naphthoquinone derivative chemically identical to and with similar activity as

naturally occurring vitamin K. Vitamin K is essential for hepatic biosynthesis of blood clotting
Factors II, VII, IX, and X.

Therapeutic Effects

Promotes liver synthesis of clotting factors by unknown mechanism. Does not reverse
anticoagulant action of heparin. Reportedly demonstrates wide margin of safety when used in
newborns.

Uses

Drug of choice as antidote for overdosage of coumarin and indandione oral anticoagulants. Also
reverses hypoprothrombinemia secondary to administration of oral antibiotics, quinidine,
quinine, salicylates, sulfonamides, excessive vitamin A, and secondary to inadequate absorption
and synthesis of vitamin K (as in obstructive jaundice, biliary fistula, ulcerative colitis, intestinal
resection, prolonged hyperalimentation). Also prophylaxis of and therapy for neonatal
hemorrhagic disease.

Contraindications

Hypersensitivity to AquaMEPHYTON; severe liver disease.

Cautious Use

Pregnancy (category C); lactation. Effect on fertility and teratogenic potential is not known.

Route & Dosage

Anticoagulant Overdose
Adult: PO/SC/IM 2.5–10 mg; rarely up to 50 mg/d, may repeat parenteral dose after 6–8 h if
needed or PO dose after 12–24 h IV Emergency only: 10–15 mg at a rate of 1 mg/min, may be
repeated in 4 h if bleeding continues

Hemorrhagic Disease of Newborns

Infant: IM/SC 0.5–1 mg immediately after delivery, may repeat in 6–8 h if necessary

Other Prothrombin Deficiencies

54
Adult: IM/SC 2–25 mg
Child: IM/SC 5–10 mg
Infant: IM/SC 1 mg

Administration: Intramuscular

Note: Konakion, which contains a phenol preservative, is intended ONLY for IM use.
AquaMEPHYTON may be given SC, IM, or IV as prescribed.

 Give IM injection in adults and older children in upper outer quadrant of buttocks. For
infants and young children, anterolateral aspect of thigh or deltoid region is preferred.
 Aspirate carefully to avoid intravascular injection.
 Apply gentle pressure to site following injection. Swelling (internal bleeding) and pain
sometimes occur with SC or IM administration.

Intravenous

 Note: Reserve IV route only for emergencies.

PREPARE: Direct: Dilute a single dose in 10 mL D5W, NS, or D5/NS.

ADMINISTER: Direct: Give solution immediately after dilution at a rate not to exceed 1
mg/min.

INCOMPATIBILITIES Solution/additive: Ranitidine Y-site: Dobutamine.

 Protect infusion solution from light by wrapping container with aluminum foil or other
opaque material.
 Discard unused solution and contents in open ampul.

Adverse Effects ( 1%)

o Body as a Whole: Hypersensitivity or anaphylaxis-like reaction: facial flushing, cramp-
like pains, convulsive movements, chills, fever, diaphoresis, weakness, dizziness,
shock, cardiac arrest.
o CNS: Headache (after oral dose), brain damage, death.
o GI: Gastric upset.
o Hematologic: Paradoxic hypoprothrombinemia (patients with severe liver disease),
severe hemolytic anemia.
o Metabolic: Hyperbilirubinemia, kernicterus.
o Respiratory: Bronchospasm, dyspnea, sensation of chest constriction, respiratory arrest.
o Skin: Pain at injection site, hematoma, and nodule formation, erythematous skin
eruptions (with repeated injections).

55
 o Special Senses: Peculiar taste sensation.

Diagnostic Test Interference

Falsely elevated urine steroids (by modifications of Reddy, Jenkins, Thorn procedure).

Interactions
Drug: Antagonizes effects of warfarin, cholestyramine, colestipol, mineral oil decrease
absorption of oral phytonadione.

Pharmacokinetics
 Absorption: Readily absorbed from intestinal lymph only if bile is present.
 Onset: 6–12 h PO; 1–2 h IM/SC; 15 min IV.
 Peak: Hemorrhage usually controlled within 3–8 h; normal prothrombin time may be
obtained in 12–14 h after administration.
 Distribution: Concentrates briefly in liver after absorption; crosses placenta; distributed
into breast milk.
 Metabolism: Rapidly metabolized in liver.
 Elimination: Excreted in urine and bile.

Nursing Implications

Assessment & Drug Effects

 Monitor patient constantly. Severe reactions, including fatalities, have occurred during
and immediately after IV injection.
 Lab tests: Baseline and frequent PT/INR.
 Frequency, dose, and therapy duration are guided by PT/INR clinical response.
 Monitor therpeutic effectiveness which is indicated by shortened PT, INR, bleeding, and
clotting times, as well as decreased hemorrhagic tendencies.
 Be aware that patients on large doses may develop temporary resistance to coumarin-type
anticoagulants. If oral anticoagulant is reinstituted, larger than former doses may be
needed. Some patients may require change to heparin.

Patient & Family Education

 Maintain consistency in diet and avoid significant increases in daily intake of vitamin K–
rich foods when drug regimen is stabilized. Know sources rich in vitamin K: Asparagus,
broccoli, cabbage, lettuce, turnip greens, pork or beef liver, green tea, spinach,
watercress, and tomatoes.

4. METRONIDAZOLE

56
 Classifications: ANTIINFECTIVE; ANTITRICHOMONAL; AMEBICIDE; ANTIBIOT
IC
Pregnancy Category: B

Availability

250 mg, 500 mg tablets; 375 mg capsules; 750 mg sustained release tablets; 500 mg vials; 0.75%
lotion, emulsion; 0.75%, 1% cream; 0.75%, 1% gel

Mechanism of Actions

Synthetic compound with direct trichomonacidal and amebicidal activity as well as antibacterial
activity against anaerobic bacteria and some gram-negative bacteria.

Therapeutic Effects

Effective against Trichomonas vaginalis, Entamoeba histolytica, and Giardia lamblia. Exhibits
antibacterial activity against obligate anaerobic bacteria, gram-negative anaerobic bacilli,
and Clostridia. Microaerophilic Streptococci and most aerobic bacteria are resistant.

Uses

Asymptomatic and symptomatic trichomoniasis in females and males; acute intestinal amebiasis
and amebic liver abscess; preoperative prophylaxis in colorectal surgery, elective hysterectomy
or vaginal repair, and emergency appendectomy. IV metronidazole is used for the treatment of
serious infections caused by susceptible anaerobic bacteria in intraabdominal infections, skin
infections, gynecologic infections, septicemia, and for both pre- and postoperative prophylaxis,
bacterial vaginosis. Topical: Rosacea.

Unlabeled Uses

Treatment of pseudomembranous colitis, Crohn's disease, H. pylori eradication.

Contraindications

Blood dyscrasias; active CNS disease; first trimester of pregnancy (category B), lactation.

Cautious Use

Coexistent candidiasis; second and third trimesters of pregnancy (category B); alcoholism; liver
disease.

Route & Dosage

Trichomoniasis, Giardiasis, Gardnerella
Adult: PO 2 g once or 250 mg t.i.d.; 375 mg b.i.d. or 500 mg b.i.d. for 7 d Vaginal Apply once

57
or twice daily times 5 d
Child: PO 15 mg/kg/d in 3 divided doses for 7–10 d
Infant: PO 10–30 mg/kg/d for 5–8 d
Amebiasis
Adult: PO 500–750 mg t.i.d.
Child: PO 35–50 mg/kg/d in 3 divided doses

Anaerobic Infections
Adult: PO 7.5 mg/kg q6h (max: 4 g/d) IV Loading Dose 15 mg/kg IV Maintenance Dose 7.5
mg/kg q6h (max: 4 g/d)
Child: PO/IV 30 mg/kg/d divided q6h (max: 4 g/d)
Neonate: PO/IV 7.5–15 mg/kg/d divided q12–48h

Pseudomembranous Colitis
Adult: PO 250–500 mg t.i.d. IV 250–500 mg t.i.d. or q.i.d.
Child: PO 30 mg/kg/d divided q6h times 7 d

Bacterial Vaginosis
Adult: PO (Flagyl ER) 750 mg q.d. times 7 d

Rosacea
Adult: Topical Apply 0.75% gel as a thin film to affected area b.i.d.; apply 1% gel as a thin film
to affected area q.d.

Administration
Oral

 Crush tablets before ingestion if patient cannot swallow whole.

 Ensure that Flagyl ER (extend-release form) is not chewed or crushed. It must be
swallowed whole. Give on an empty stomach, 1 h before or 2 h after meals.
 Give immediately before, with, or immediately after meals or with food or milk to reduce
GI distress.
 Give lower than normal doses in presence of liver disease.

Topical

 Apply a thin film to affected area only.

Intravenous

 Note: Verify correct IV concentration and rate of infusion for administration to neonates,
infants, or children with physician.

58
PREPARE: Intermittent: Sequence for preparing solution (important) consists of (1)
reconstitution with 4.4 mL sterile water or NS, (2) dilution in IV solution to yield 8 mg/mL in
NS, D5W, or RL, (3) pH neutralization with approximately 5 mEq sodium bicarbonate injection
for each 500 mg of Flagyl I.V. used. Avoid use of aluminum-containing equipment when
manipulating IV product (including syringes equipped with aluminum needles or hubs). Note:
Flagyl IV RTU does not require mixing, diluting, or neutralizing. Each container contains 14
mEq of sodium.

ADMINISTER: Intermittent: Give IV solution slowly at a rate of one dose per hour.

INCOMPATIBILITIES Solution/additive: TPN, amoxicillin/clavulanate, aztreonam, dopam

ine, meropenem. Y-site: Amphotericin B cholesteryl
complex, aztreonam, filgrastim, meropenem, warfarin.

 Note: Precipitation occurs if neutralized solution is refrigerated. Use diluted and

neutralized solution within 24 h of preparation.

 Store at 15°–30° C (59°–86° F); protect from light. Reconstituted Flagyl I.V. is
chemically stable for 96 h when stored below 30° C (86° F) in room light. Diluted and
neutralized IV solutions containing Flagyl I.V. should be used within 24 h of mixing.

Adverse Effects ( 1%)

 Body as a Whole: Hypersensitivity (rash, urticaria, pruritus, flushing), fever, fleeting
joint pains, overgrowth of Candida.
 CNS: Vertigo, headache, ataxia, confusion, irritability, depression, restlessness,
weakness, fatigue, drowsiness, insomnia, paresthesias, sensory neuropathy (rare).
 GI: Nausea, vomiting, anorexia, epigastric distress, abdominal cramps, diarrhea,
constipation, dry mouth, metallic or bitter taste, proctitis.
 Urogenital: Polyuria, dysuria, pyuria, incontinence, cystitis, decreased libido,
dyspareunia, dryness of vagina and vulva, sense of pelvic pressure.
 Special Senses: Nasal congestion.
 CV: ECG changes (flattening of T wave).

Diagnostic Test Interference

Metronidazole may interfere with certain chemical analyses for AST, resulting in decreased
values.

Interactions
Drug: ORAL ANTICOAGULANTS potentiate hypoprothrombinemia; alcohol may elicit
disulfiram reaction; oral solutions of citalopram, ritonavir; lopinavir/ritonavir, and IV
formulations of sulfamethoxazole; trimethoprim, SMX-TMP, nitroglycerin may elicit
disulfiram reaction due to the alcohol content of the dosage form; disulfiram causes acute

59
psychosis; phenobarbital increases metronidazole metabolism; may
increase lithium levels; fluorouracil, azathioprine may cause transient neutropenia.

Pharmacokinetics
 Absorption: 80% of dose absorbed from GI tract.
 Peak: 1–3 h.
 Distribution: Widely distributed to most body tissues, including CSF, bone, cerebral and
hepatic abscesses; crosses placenta; distributed in breast milk.
 Metabolism: 30–60% metabolized in liver.
 Elimination: 77% excreted in urine; 14% excreted in feces within 24 h.
 Half-Life: 6–8 h.

Nursing Implications

Assessment & Drug Effects

 Discontinue therapy immediately if symptoms of CNS toxicity (see Appendix F) develop.

Monitor especially for seizures and peripheral neuropathy (e.g., numbness and
paresthesia of extremities).
 Lab tests: Obtain total and differential WBC counts before, during, and after therapy,
especially if a second course is necessary.
 Monitor for S&S of sodium retention, especially in patients on corticosteroid therapy or
with a history of CHF.
 Monitor patients on lithium for elevated lithium levels.
 Report appearance of candidiasis or its becoming more prominent with therapy to
physician promptly.
 Repeat feces examinations, usually up to 3 mo, to ensure that amebae have been
eliminated.

Patient & Family Education

 Adhere closely to the established regimen without schedule interruption or changing the
dose.
 Refrain from intercourse during therapy for trichomoniasis unless male partner wears a
condom to prevent reinfection.
 Have sexual partners receive concurrent treatment. Asymptomatic trichomoniasis in the
male is a frequent source of reinfection of the female.
 Do not drink alcohol during therapy; may induce a disulfiram-type reaction (see
Appendix F). Avoid alcohol or alcohol-containing medications for at least 48 h after
treatment is completed.
 Urine may appear dark or reddish brown (especially with higher than recommended
doses). This appears to have no clinical significance.
 Report symptoms of candidal overgrowth: Furry tongue, color changes of tongue,
glossitis, stomatitis; vaginitis, curd-like, milky vaginal discharge; proctitis. Treatment
with a candidacidal agent may be indicated.

60
  Do not breast feed while taking this drug.

5. PARACETAMOL (ACETAMINOPHEN)

Classifications: CENTRAL NERVOUS SYSTEM AGENT; NONNARCOTIC ANALGESIC,

ANTIPYRETIC
Pregnancy Category: B

Availability

80 mg, 120 mg, 125 mg, 300 mg, 325 mg, 650 mg suppositories; 80 mg, 160 mg, 325 mg, 500
mg tablets; 80 mg/0.8 mL, 80 mg/2.5 mL, 80 mg/5 mL, 120 mg/5 mL, 160 mg/5 mL, 500 mg/5
mL liquid

Actions

Produces analgesia by unknown mechanism, perhaps by action on peripheral nervous system.

Reduces fever by direct action on hypothalamus heat-regulating center with consequent
peripheral vasodilation, sweating, and dissipation of heat. Unlike aspirin, acetaminophen has
little effect on platelet aggregation, does not affect bleeding time, and generally produces no
gastric bleeding.

Therapeutic Effects

It provides temporary analgesia for mild to moderate pain. In addition, acetaminophen lowers
body temperature in individuals with a fever.

Uses

Fever reduction. Temporary relief of mild to moderate pain. Generally as substitute for aspirin
when the latter is not tolerated or is contraindicated.

Contraindications

Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Cautious Use

Children <3 y unless directed by a physician; repeated administration to patients with anemia or
hepatic disease; arthritic or rheumatoid conditions affecting children <12 y; alcoholism;
malnutrition; thrombocytopenia. Safety during pregnancy (category B) or lactation is not
established.

61
Route & Dosage
Mild to Moderate Pain, Fever
Adult: PO 325–650 mg q4–6h (max: 4 g/d) PR 650 mg q4–6h (max: 4 g/d)
Child: PO 10–15 mg/kg q4–6h PR 2–5 y, 120 mg q4–6h (max: 720 mg/d); 6–12 y, 325 mg q4–
6h (max: 2.6 g/d)
Neonate: PO 10–15 mg/kg q6–8h

Administration
Oral

 Administer tablets or caplets whole or crushed and give with fluid of patient's choice.
 Chewable tablets should be thoroughly chewed and wetted before they are swallowed.
 Do not coadminister with a high carbohydrate meal; absorption rate may be significantly
retarded.
 Store in light-resistant containers at room temperature, preferably between 15°–30° C
(59°–86° F).

Rectal

 Insert suppositories beyond the rectal sphincter.

Adverse Effects ( 1%)

 Body as a Whole: Negligible with recommended dosage; rash.
 Acute poisoning: Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills,
epigastric or abdominal pain, diarrhea; onset of hepatotoxicity—elevation of serum
transaminases (ALT, AST) and bilirubin; hypoglycemia, hepatic coma, acute renal
failure (rare).
 Chronic ingestion: Neutropenia, pancytopenia, leukopenia, thrombocytopenic
purpura, hepatotoxicity in alcoholics, renal damage.

Diagnostic Test Interference

False increases in urinary 5-HIAA (5-hydroxyindoleacetic acid) by-product of serotonin; false

decreases in blood glucose (by glucose oxidase–peroxidase procedure); false increases
in urinary glucose (with certain instruments in glucose analyses); and false increases in serum
uric acid (with phosphotungstate method). High doses or long-term therapy: hepatic, renal, and
hematopoietic function (periodically).

Interactions
Drug: Cholestyramine may decrease acetaminophen absorption. With chronic
coadministration, BARBITURATES, carbamazepine, phenytoin, and rifampin may increase
potential for chronic hepatotoxicity. Chronic, excessive ingestion of alcohol will increase risk of
hepatotoxicity.

62
Pharmacokinetics
 Absorption: Rapid and almost complete absorption from GI tract; less complete
absorption from rectal suppository.
 Peak: 0.5–2 h.
 Duration: 3–4 h.
 Distribution: Well distributed in all body fluids; crosses placenta.
 Metabolism: Extensively metabolized in liver.
 Elimination: 90–100% of drug excreted as metabolites in urine; excreted in breast milk.
 Half-Life: 1–3 h.

Nursing Implications

Assessment & Drug Effects

 Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially
in individuals with poor nutrition or who have ingested alcohol over prolonged periods;
poisoning, usually from accidental ingestion or suicide attempts; potential abuse from
psychological dependence (withdrawal has been associated with restless and excited
responses).

Patient & Family Education

 Do not take other medications (e.g., cold preparations) containing acetaminophen without
medical advice; overdosing and chronic use can cause liver damage and other toxic
effects.
 Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a
physician.
 Do not use this medication without medical direction for: fever persisting longer than 3 d,
fever over 39.5° C (103° F), or recurrent fever.
 Do not give children more than 5 doses in 24 h unless prescribed by physician.
 Do not breast feed while taking this drug without consulting physician.

6. PETHIDINE HYDROCLORIDE (MEPERIDINE HYDROCHLORIDE)

Classifications: CENTRAL NERVOUS SYSTEM AGENT; NARCOTIC (OPIATE) AGONIST

ANALGESIC
Prototype: Morphine
Pregnancy Category: B (D at term)
Controlled Substance: Schedule II

63
Availability

50 mg, 100 mg tablets; 50 mg/5 mL syrup; 10 mg/mL, 25 mg/mL, 50 mg/mL, 75 mg/mL, 100
mg/mL injection

Actions

Synthetic morphine-like compound. Chemically dissimilar to morphine, but in equianalgesic

doses it is qualitatively comparable. Usual doses produce either no pupillary change or slight
miosis, but overdosage results in marked miosis or mydriasis. Also, unlike morphine, has little or
no antidiarrheic or antitussive action. Produces CNS stimulation in toxic doses.

Therapeutic Effects

Control of moderate to severe pain.

Uses

Relief of moderate to severe pain, for preoperative medication, for support of anesthesia, and for
obstetric analgesia.

Contraindications

Hypersensitivity to meperidine; convulsive disorders; acute abdominal conditions prior to

diagnosis; pregnancy prior to labor [(category B), at term (category D)], lactation.

Cautious Use

Head injuries, increased intracranial pressure; asthma and other respiratory conditions;
supraventricular tachycardias; prostatic hypertrophy; urethral stricture; glaucoma; older adult or
debilitated patients; impaired kidney or liver function, hypothyroidism, Addison's disease.

Route & Dosage

Moderate to Severe Pain
Adult: PO/SC/IM/IV 50–150 mg q3–4h prn
Child: PO/SC/IM/IV 1–1.5 mg/kg q3–4h (max: 100 mg q4h) prn

Preoperative
Adult: IM/SC 50–150 mg 30–90 min before surgery
Child: IM/SC 1–2.2 mg/kg 30–90 min before surgery

Obstetric Analgesia
Adult: IM/SC 50–100 mg when pains become regular, may be repeated q1–3h

64
Administration
Oral

 Give syrup formulation in half a glass of water. Undiluted syrup may cause topical
anesthesia of mucous membranes.

Subcutaneous and Intramuscular Injections

 Be aware that SC route is painful and can cause local irritation. IM route is generally
preferred when repeated doses are required.
 Aspirate carefully before giving IM injection to avoid inadvertent IV administration. IV
injection of undiluted drug can cause a marked increase in heart rate and syncope.

Intravenous

 Note: Verify correct IV concentration and rate of infusion/injection for administration to

infants or children with physician.
 Store at 15°–30° C (59°–86° F) in tightly closed, light-resistant containers unless
otherwise directed by manufacturer.

PREPARE:

Direct: Dilute 50 mg in at least 5 mL of NS or sterile water to yield 10 mg/mL.

IV Infusion: Dilute to a concentration of 1–10 mg/mL in NS, D5W, or other compatible

solution.

ADMINISTER:

Direct: Give at a rate not to exceed 25 mg/min. Slower injection preferred.

IV Infusion: Usually given through a controlled infusion device at a rate not to exceed 25
mg/min.

INCOMPATIBILITIES

 Solution/additive: Aminophylline, BARBITURATES, floxacillin, furosemide, hepari

n, methicillin, morphine, phenytoin, sodium bi-carbonate.
 Y-site: Allopurinol, amphotericin B cholesteryl complex,
cefepime, cefoperazone, doxorubicin
liposome, furosemide, heparin, idarubicin, imipenemcilastatin, mezlocillin, minocycl
ine, tetracycline.

65
Adverse Effects ( 1%)
 Body as a Whole: Allergic (Pruritus, urticaria, skin rashes, wheal and flare over IV site),
profuse perspiration.
 CNS: Dizziness, weakness, euphoria, dysphoria, sedation, headache, uncoordinated
muscle movements, disorientation, decreased cough reflex, miosis, corneal
anesthesia, respiratory depression. Toxic doses: muscle twitching, tremors, hyperactive
reflexes, excitement, hypersensitivity to external stimuli, agitation, confusion,
hallucinations, dilated pupils, convulsions.
 CV: Facial flushing, light-headedness, hypotension, syncope, palpitation, bradycardia,
tachycardia, cardiovascular collapse, cardiac arrest (toxic doses).
 GI: Dry mouth, nausea, vomiting, constipation, biliary tract spasm.
 Urogenital: Oliguria, urinary retention.
 Respiratory: Respiratory depression in newborn, bronchoconstriction (large doses).
 Skin: Phlebitis (following IV use), pain, tissue irritation and induration, particularly
following subcutaneous injection.
 Metabolic: Increased levels of serum amylase, BSP retention, bilirubin, AST, ALT.

Diagnostic Test Interference

High doses of meperidine may interfere with gastric emptying studies by causing delay in gastric
emptying.

Interactions
Drug: Alcohol and other CNS DEPRESSANTS, cimetidine cause additive sedation and CNS
depression; AMPHETAMINES may potentiate CNS stimulation; MAO
INHIBITORS, selegiline, furazolidone may cause excessive and prolonged CNS depression,
convulsions, cardiovascular collapse; phenytoin may increase toxic meperidine
metabolites. Herbal: St. John's wort may increase sedation.

Pharmacokinetics
 Absorption: 50–60% absorbed from GI tract.
 Onset: 15 min PO; 10 min IM, SC; 5 min IV.
 Peak: 1 h PO, IM, SC.
 Duration: 2–4 h PO, IM, SC; 2 h IV.
 Distribution: Crosses placenta; distributed into breast milk.
 Metabolism: Metabolized in liver.
 Elimination: excreted in urine.
 Half-Life: 3–5 h.

Nursing Implications

Assessment & Drug Effects

66
  Give narcotic analgesics in the smallest effective dose and for the least period of time
compatible with patient's needs.
 Assess patient's need for prn medication. Record time of onset, duration, and quality of
pain.
 Note respiratory rate, depth, and rhythm and size of pupils in patients receiving repeated
doses. If respirations are 12/min or below and pupils are constricted or dilated
(see ACTIONS AND USES) or breathing is shallow, or if signs of CNS hyperactivity are
present, consult physician before administering drug.
 Monitor vital signs closely. Heart rate may increase markedly, and hypotension may
occur. Meperidine may cause severe hypotension in postoperative patients and those with
depleted blood volume.
 Schedule deep breathing, coughing (unless contraindicated), and changes in position at
intervals to help to overcome respiratory depressant effects.
 Chart patient's response to drug and evaluate continued need.
 Repeated use can lead to tolerance as well as psychic and physical dependence of the
morphine type.
 Be aware that abrupt discontinuation following repeated use results in morphine-like
withdrawal symptoms. Symptoms develop more rapidly (within 3 h, peaking in 8–12 h)
and are of shorter duration than with morphine. Nausea, vomiting, diarrhea, and pupillary
dilatation are less prominent, but muscle twitching, restlessness, and nervousness are
greater than produced by morphine.

Patient & Family Education

 Do not smoke and walk without assistance after receiving the drug. Bed side rails may be
advisable.
 Be aware nausea, vomiting, dizziness, and faintness associated with fall in BP are more
pronounced when walking than when lying down (these symptoms may also occur in
patients without pain who are given meperidine). Symptoms are aggravated by the head-
up position.
 Do not drive or engage in potentially hazardous activities until any drowsiness and
dizziness have passed.
 Do not take other CNS depressants or drink alcohol because of their additive effects.
 Do not breast feed while using this drug.

7. POTASSIUM CHLORIDE

Classifications: ELECTROLYTIC AND WATER BALANCE AGENT; REPLACEMENT

SOLUTION
Pregnancy Category: A

Availability

Chloride 6.7 mEq, 8 mEq, 10 mEq, 20 mEq sustained release tablets; 500 mg, 595 mg tablets;
20 mEq, 25 mEq, 50 mEq effervescent tablets; 20 mEq/15 mL, 40 mEq/15 mL, 45 mEq/15 mL

67
liquid; 15 mEq, 20 mEq, 25 mEq powder; 2 mEq/mL injection; 10 mEq, 20 mEq, 30 mEq, 40
mEq, 60 mEq, 90 mEq vials

Gluconate 20 mEq/15 mL liquid

Actions

Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission

of nerve impulses, contraction of cardiac, skeletal, and smooth muscles, maintenance of normal
kidney function, and for enzyme activity. Plays a prominent role in both formation and
correction of imbalances in acid–base metabolism.

Therapeutic Effects

Given special importance as therapeutic agents but are also dangerous if improperly prescribed
and administered. Utilized for treatment of hypokalemia.

Uses

To prevent and treat potassium deficit secondary to diuretic or corticosteroid therapy. Also
indicated when potassium is depleted by severe vomiting, diarrhea; intestinal drainage, fistulas,
or malabsorption; prolonged diuresis, diabetic acidosis. Effective in the treatment of
hypokalemic alkalosis (chloride, not the gluconate).

Contraindications

Severe renal impairment; severe hemolytic reactions; untreated Addison's disease; crush
syndrome; early postoperative oliguria (except during GI drainage); adynamic ileus; acute
dehydration; heat cramps, hyperkalemia, patients receiving potassium-sparing diuretics, digitalis
intoxication with AV conduction disturbance.

Cautious Use

Cardiac or kidney disease; systemic acidosis; slow-release potassium preparations in presence of

delayed GI transit or Meckel's diverticulum; extensive tissue breakdown (such as severe burns);
pregnancy (category A); lactation.

Route & Dosage

Hypokalemia
Adult: PO 10–100 mEq/d in divided doses IV 10–40 mEq/h diluted to at least 10–20 mEq/100
mL of solution (max: 200–400 mEq/d, monitor higher doses carefully)
Child: PO 1–3 mEq/kg/d in divided doses; sustained release tablets not recommended in
children IV Up to 3 mEq/kg/24 h at a rate <0.02 mEq/kg/min

68
Administration
Oral

 Give while patient is sitting up or standing (never in recumbent position) to prevent drug–
induced esophagitis. Some patients find it difficult to swallow the large sized KCl tablet.
 Do not crush or allow to chew any potassium salt tablets. Observe to make sure patient
does not suck tablet (oral ulcerations have been reported if tablet is allowed to dissolve in
mouth).
 Swallow whole tablet with a large glass of water or fruit juice (if allowed) to wash drug
down and to start esophageal peristalsis.
 Follow directions for diluting various liquid forms of KCl exactly. In general, dilute each
20 mEq potassium in at least 90 mL water or juice and allowed to completely before
administration.
 Dilute liquid forms as directed before giving it through nasogastric tube.

Intravenous

PREPARE: IV Infusion: Add desired amount to 100–1000 mL IV solution (compatible with all
standard solutions). Usual maximum is 80 mEq/1000 mL, however, 40 mEq/L is preferred to
lessen irritation to veins. Note: never add KCl to an IV bag/bottle which is hanging. After adding
KCl invert bag/bottle several times to ensure even distribution.

ADMINISTER: IV Infusion: KCl is never given IV push or in concentrated amounts by any

route. Infuse at rate not to exceed 10 mEq/h. Adult patients with severe potassium depletion may
be able to tolerate 20 mEq/h. Too rapid infusion may cause fatal hyperkalemia.

 Take extreme care to prevent extravasation and infiltration. At first sign, discontinue
infusion and select another site.

INCOMPATIBILITIES Solution/additive: Amphotericin B, dobutamine (potassium

phosphate only). Y-site: Amphotericin B cholesteryl
complex, diazepam, ergotamine, methylprednisolone, phenytoin, promethazine.

Adverse Effects ( 1%)

 GI: Nausea, vomiting, diarrhea, abdominal distension.
 Body as a Whole: Pain, mental confusion, irritability, listlessness, paresthesias of
extremities, muscle weakness and heaviness of limbs, difficulty in swallowing, flaccid
paralysis.
 Urogenital: Oliguria, anuria.
 Hematologic: Hyperkalemia.
 Respiratory: Respiratory distress.
 CV: Hypotension, bradycardia; cardiac depression, arrhythmias, or arrest; altered
sensitivity to digitalis glycosides. ECG changes in hyperkalemia: Tenting (peaking) of T
wave (especially in right precordial leads), lowering of R with deepening of S waves and

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 depression of RST; prolonged P-R interval, widened QRS complex, decreased amplitude
and disappearance of P waves, prolonged Q-T interval, signs of right and left bundle
block, deterioration of QRS contour and finally ventricular fibrillation and death.

Interactions
Drug: POTASSIUM-SPARING DIURETICS, ANGIOTENSIN-CONVERTING
ENZYME (ACE) INHIBITORS may cause hyperkalemia.

Pharmacokinetics
 Absorption: Readily absorbed from upper GI tract.
 Elimination: 90% excreted in urine, 10% in feces.

Nursing Implications

Assessment & Drug Effects

 Monitor I&O ratio and pattern in patients receiving the parenteral drug. If oliguria occurs,
stop infusion promptly and notify physician.
 Lab test: Frequent serum electrolytes are warranted.
 Monitor for and report signs of GI ulceration (esophageal or epigastric pain or
hematemesis).
 Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregular
heartbeat is usually the earliest clinical indication of hyperkalemia.
 Be alert for potassium intoxication (hyperkalemia, see S&S, Appendix F); may result
from any therapeutic dosage, and the patient may be asymptomatic.
 The risk of hyperkalemia with potassium supplement increases (1) in older adults because
of decremental changes in kidney function associated with aging, (2) when dietary intake
of potassium suddenly increases, and (3) when kidney function is significantly
compromised.

Patient & Family Education

 Do not be alarmed when the tablet carcass appears in your stool. The sustained release
tablet (e.g., Slow-K) utilizes a wax matrix as carrier for KCl crystals that passes through
the digestive system.
 Learn about sources of potassium with special reference to foods and OTC drugs.
 Avoid licorice; large amounts can cause both hypokalemia and sodium retention.
 Do not use any salt substitute unless it is specifically ordered by the physician. These
contain a substantial amount of potassium and electrolytes other than sodium.
 Do not self-prescribe laxatives. Chronic laxative use has been associated with diarrhea–
induced potassium loss.
 Notify physician of persistent vomiting because losses of potassium can occur.
 Report continuing signs of potassium deficit to physician: Weakness, fatigue, polyuria,
polydipsia.

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 Advise dentist or new physician that a potassium drug has been prescribed as long-term
maintenance therapy.
 Do not open foil-wrapped powders and tablets before use.
 Do not breast feed while taking this drug without consulting physician.

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 Daily Progress Note

The neonate was refered to KCH and admitted in SICU from Emergency on 2080/04/16. After
surgical intervention (Reduction of Omphalocele) shifted to surgical ward on 2080/04/26 on 5th
post-up day.

Date Vital signs Nursing note and care provided Medications and fluid ordered

04/16 T: 98.60F The neonate was admitted from ER for Medication

management of Omphalocele under Unit II.  Inj. Amica 34mg IV stat
P: 110beats/min
Patient was kept NPO and NG free drain.  Inj. Ampicillin 230mg IV
RR: stat
48breaths/min Anthropometric examination findings are: Fluids ordered
Weight: 2300gm
SPO2: 98% in Head circumference: 32cm IVF D10 80ml/kg/day (200ml at
room air Length: 44cm 8.3ml/hr) started
CRT<3sec
Blood investigations CBC, RFT, Blood
GRBS:
112mg/dl Grouping, USG abdomen done and reports
collected.

04/21 T: 98.60F Neonate was active and alert. NPO for Medication
surgical intervention for omphalocele under  Inj. Amica 41mg IV every
P: 136beats/min General anesthesia. GRBS 6 hourly to be 36 hours
monitored. NG free drain insitu. Normal  Inj.Ampicillin 115mg IV
RR:
bowel and bladder habit. BD
42breaths/min
 Inj VIT K 1mg IV OD *
SPO2: 93% in Informed written consent taken and pre- 3days
operative investigation reports collected.  Inj PCM 30mg IV TDS and
room air
Pre-op check list completed. I pint O SOS
GRBS: positive blood (PRBC) arranged.  Inj. Metron 15mg IV TDS
102mg/dl,  INJ. Pethidine 1.2mg IV
TDS
168mg/dl,136mg
Fluids ordered
/dl
IVF N/5+D10 with 10meq KCl
340ml over 24 hours at
14.0ml/hr)

04/22 T: 100.30F Anthropometric examination findings are: Medication

Weight: 2400gm  Inj. Amica 41mg IV every
P: 160beats/min Head circumference: 32.0cm 36 hours
Abdominal girth: 24 cm  Inj.Ampicillin 115mg IV
RR:
Urine output: 280ml/24 hrs BD
44breaths/min
1st post-op day following repair of

72
 SPO2: 95% in omphalocele. The child was irritable and  Inj VIT K 1mg IV OD *
room air. restless during morning care. Is in NPO till 3days
next order and is in Ng free drain. Vitals  Inj PCM 30mg IV TDS and
GRBS: SOS
136mg/dl, recorded every 2 hourly. Position and diaper
changed every 2 hourly. Investigation  Inj. Metron 15mg IV TDS
116mg/dl,106mg
 INJ. Pethidine 1.2mg IV
/dl reports collected. Foleys in-situ. I/O chart
TDS
maintained. NIPS score for pain level Fluids ordered
before administration of analgesic was >4
and after medication was <2. IVF continued IVF N/5+D10 with 10meq KCl
at 14ml/hour via infusion pump. Bowel 340ml over 24 hours at
sound absent. 14.0ml/hr)

04/23 T: 98.80F Anthropometric examination findings are: Medication

 Inj. Amica 41mg IV every
P: 132beats/min Weight: 2400gm
36 hours
RR: Head circumference: 32.0cm  Inj.Ampicillin 115mg IV
48breaths/min BD
Abdominal girth: 23 cm  Inj PCM 30mg IV TDS and
SPO2: 95%in SOS
room air Urine output: 300ml/24 hrs
 Inj. Metron 15mg IV TDS
GRBS: 2 post-op day. Active and alert. Is in NPO  INJ. Pethidine 1.2mg IV
nd

116mg/dl, and NG drain blocked. Bowel sound present SOS

126mg/dl,102mg Fluids ordered
and flatus passing. Normal bowel and
/dl bladder habit. Raised total bilirubin level so IVF N/5+D10 with 10meq KCl
medicine (NICU) consultation done and 340ml over 24 hours at
phototherapy not required. IVF continued 14.0ml/hr)
and vitals recorded. I/O chart maintained.
NG drain blocked.
 TSB, DSB,TSH and septic
evaluation done.
04/24 T: 98.80C Anthropometric examination findings are: Medication
 Inj. Amica 41mg IV every
P: 132beats/min Weight: 2430gm 36 hours
 Inj.Ampicillin 115mg IV
RR: Head circumference: 28.0cm
BD
40breaths/min
Abdominal girth: 22.5 cm  Inj PCM 30mg IV SOS
SPO2: 95% in  Inj. Metron 15mg IV TDS
Urine output: 260ml/24 hrs  INJ. Pethidine 1.2mg IV
room air.
SOS
GRBS: 83mg/dl, 3rd post-op day. Active and alert. NG 5- Fluids ordered
105mg/dl,140mg 10ml/2hrly with 10% dextrose and if
/dl tolerated then expressed breast milk after 6 IVF N/5+D10 with 10meq KCl
hours. IVF 150ml over 24 hours continued 340ml over 24 hours at

73
 till full feeding. Wound dressing done under 14.0ml/hr)
aseptic technique. Foley’s out. Morning
care and oil massage done with timely NG drain out.
position and diaper change. Vitals recorded Foley’s out.
and I/O chart maintained. Systematic head
to toe examination done.

04/25 T: 98.00C Anthropometric examination findings are: Medication

 Inj. Amica 41mg IV every
P: 132beats/min Weight: 2500gm 36 hours
 Inj.Ampicillin 115mg IV
RR: Head circumference: 32.0cm
BD
44breaths/min
Abdominal girth: 25.5 cm  Inj PCM 30mg IV TDS and
SPO2: 94% in SOS
Urine output: 250/24 hrs  Inj. Metron 15mg IV TDS
Room Air.
 INJ. Pethidine 1.2mg IV
GRBS: 4th post-op day. Active and alert. Breast SOS
111mg/dl, feeding started. IVF stopped. Bowel sound Fluids ordered
126mg/dl,116mg present. Normal bowel and bladder habit.
IVF Stopped.
/dl Counselling to mother about care of
newborn, importance of immunization, skin Breastfeeding on demand.
care, maintenance of hygiene of child etc
were provided. Planned for shifting the
child to surgical ward.

04/26 T: 98.60F Anthropometric examination findings are: Medication

 Inj. Amica 41mg IV every
P: 132beats/min Weight: 2500gm 36 hours
 Inj.Ampicillin 115mg IV
RR: Head circumference: 32.0cm
BD
38breaths/min
Abdominal girth: 22.5 cm  Inj PCM 30mg IV TDS and
SPO2: 94% in SOS
Urine output: 250/24 hrs  Inj. Metron 15mg IV TDS
Room Air.
 INJ. Pethidine 1.2mg IV
GRBS: 5th post-op day. Active and alert. Breast SOS
111mg/dl feeding on demand. Bowel sound present. Fluids ordered
Normal bowel and bladder habit. Discharge
Breastfeeding on demand.
planning done and shifted to surgical ward
after wound dressing under aseptic Shifted to surgical ward.
technique. GRBS within normal range so
monitoring stopped.

74
 Health Teaching Offered to Parents during Hospitalization

Health teaching plays a vital role in hospital situation in caring patient. It is most useful in
preventing disease, promoting and curing the disease condition. It is one of the essential aspects
in nursing management. The nurse is responsible to provide appropriate information about the
factors which are associated with the disease condition which will help the mother/ care provider
aware of the details about the health. The process involves identifying the patient need and
developing a detail plan to meet them. Communication and Co-operation of the family is
essential.

So, it is important to provide health education on following.

o To promote health.
o To prevent illness and infection.
o To recover from illness and achieve normal health.
o To prevent further complications.
o To maintain and fulfill the nutritional needs.

My patient was transferred to surgical unit from SICU on 2080/04/26 and was discharged from
ward on 2080/04/29. Throughout this period, I regularly followed up the patient in the ward and
assessed the progress in patient’s condition. I provided health teaching to the parents on
following during hospitalization:
Nutrition
• Exclusive breast feeding for 6 months and complimentary feeding to be initiated after 6
months of age with semi-solid food as tolerated with iron supplement.
• Strict aseptic measures for expressed breast milk feeding or artificial feeding.
• Demand feeding or at least 2 hourly
About Disease
• Information about the probable causes, symptoms, management of the illness and
complications were provided to the family members in order to help the family to feel
less alone and to feel more in control of what happens as well as to improve management
of symptoms.
KMC
• Counselling on Kangaroo mother care, its need to the child, benefits to mother, duration
of care, requisites of KMC and technique or procedure of KMC was done to help child
gain weight and maintain temperature.

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Infection Prevention
• Parents were encouraged for hand hygiene before care to child. Also maintaining
personal hygiene of child, nail cutting, oil massage.
• Exclusion of infected persons or carriers from the neonatal care areas
• Cord care and eye care
Wound care
• Parents were encouraged to maintain wound hygiene and nothing to be applied in and
around the wound site.
• Alternate day dressing should be done until suture is removed.
• Immediate follow up required if signs of infection like redness and swelling around
wound, fever, and fluid or pus drainage from wound.
Immunization
• Health teaching on need for immunization and national schedule was provided.
Maintenance of warmth
• Since the child was small and pre-term baby undergone surgical procedure, need for
maintaining normo-thermal temperature was provided. To avoid hypothermia, mother
was encouraged for KMC, providing appropriate clothing to the neonate.
Sleep and Activity
• Neonates sleep for about 20-22hours. Rest and sleep are essential for physical maturation
and development of various milestone.
Injury prevention
• Careful observation is required to prevent injury. Child should be wrapped with
appropriate clothing uncovering face and mouth. During rest, mother should be careful
not to press the child.
Care of mother
• Mother needs to eat and drink to satisfy hunger and thirst. Adequate balanced diet, rest
and sleep, activity, hygiene of mother are important aspects for good care of neonate by
mother.
Danger signs
• Seizure, high grade fever, vomiting, difficulty in breathing etc., signs of umbilical
infection (pus discharge, redness), pus discharge from eyes requires immediate medical
help.
Follow up care

76
• Necessity of regular follow up after discharge was discussed with the patient and his
family. Patient party was told to come for follow up visit after a week or if necessary.
They were also advised to attend family therapy and bring the patient for follow up visit
as doctor’s advice.

77
 Stress Reduction Therapy in my Case Study Patient And Patient’s Parents During
Hospitalization

The environment of the SICU, stressful procedures are significant source of toxic stress for
hospitalized neonates. Following recommendations are applied to care giving practices that could
significantly reduce toxic stress experienced by hospitalized neonates to promote health, prevent
disease and mitigate sources of early stress that have lifelong consequences for pediatric patient.

 Maintaining Normo-thermal temperature through radiant warmer

 Reduction of back ground noise of ventilators and monitors during night.
 Emphasis on less noxious products.
 Provision of maternal odors provided by breast milk.
 Use of two person techniques such as hand containment, facilitated tucking which lowers
physiological and behavioral response to stress during care giving.
 Sustained touch, talking with eye contact for social interaction after the patient stabilized.
 Tailoring of frequency of care giving to reduce neonate’s exposure to toxic stress.
 Scheduling care giving activities around sleep/wake cycles, arousal cues and unique
developmental needs.

New adjustment, new situation and different environment from usual always arise the stressful
situation. Stress is a state produced by the charge in the environment that is perceived threatening
or damaging to the persons dynamic equilibrium.

Stress reduction therapy is used in parallel with medicines for the treatment of sick person but
my patient is neonate so I used this therapy to her parents. Parents were very concerned about
their baby and illness. This concern may cause depression and mental or emotional upsets. Due
to limited visiting hours and no provision of child care by parents in SICU, parents were very
anxious. I collected all information with parents.

• Oriented parents about hospital rules, regulation and visiting hour in NICU.
• Gave clear information about disease condition, diagnosis, prognosis etc.
• Explained parents before doing procedures and investigations.
• Communicated with parent’s maintained therapeutic relationship with them.
• Explained about the disease prognosis.
• Provided health education regarding the care of the baby once baby was shifted to
surgical ward, where parents were allowed all time with the patient

78
 DISCHARGE PLANNING

• Since 2080/04/26 patient was planned for discharge. Before discharge, the client was
evaluated for any problems related to disease that has forced the client for admission.
Care giver was also assessed for ability of care to be provided to the client.
• Family members were provided information regarding disease condition, problems that
may arise due to disease condition, management option, drugs being used, complications
that may arise later in life due to surgical intervention, its prognosis and comorbidity.
• They were encouraged for KMC at home, exclusive breast feeding, maintain hygiene of
mother and child, prevent injury, immunize child according to national immunization
program and immediate follow up for danger signs.
• Parents were able to recognize need for child care and understand disease condition. They
had positive attitude and approach toward care of client at home.
• Since patient party showed support and cooperation for treatment plan, the child was
planned to discharged on 2080-04-29 and evaluate the progress of the client through
follow up on OPD basis observation.

DISCHARGE SUMMARY & FOLLOW UP

• On 2080/04/29 patient was planned to discharge after dressing under aseptic technique.
• Discharge teaching planning is an integral part of patient care. The duty nurse remains
main responsibilities in planning and providing discharge teaching. We involved the
parents and tried our best to involve other family in discharge teaching.
• Health teaching given at the time of discharge plays a vital role in preventing
complications promoting, restoring and maintenance of the health.
Objectives of Discharge Teaching Plan
• Maintain and promote health and prevent illness at home.
• To consider primary health care concept in health teaching plan.
• To provide relevant health teaching.
• We had given discharge teaching according to the need of the patient.
 Exclusive breast feeding
 Immunization
 Eye care and cord care

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  Kangaroo mother care
 Personal hygiene of child and mother
 Infection prevention
 Wound care
• Parents were encouraged to maintain wound hygiene and nothing to be
applied in and around the wound site.
• Alternate day dressing should be done until suture is removed.
• Immediate follow up required if signs of infection like redness and
swelling around wound, fever, and fluid or pus drainage from wound.
 Injury prevention
 Danger signs of neonate
 Growth assessment (weight and height measurement during vaccination)
 Follow up visit and medication

Discharge Medications:
• We advised to continue the prescribed medications according to doctor’s order. Advised
to take home medications following right drug, frequency, dosage and timing such as
follows:
• Medicine on discharge:
 Syrup cefexime 5ml PO BD for 3days
 Drop DV-400 1 ml PO OD
 Syp. Calvit 2.5ml PO BD
Follow Up visit:
• Patient party was told to come for follow up visit after a week or if necessary with
discharge paper in surgical OPD (TUES/FRI) for suture removal and further evaluation.

80
References

1. Bindler, R.C. & Ball, J.W.(2017). Pediatric nursing. (7th ed.). India: Pearson education.
2. Hinkle J.L. (2015). Brunner and Suddharth’s Textbook of medical surgical nursing. (Vol.
1). (13th ed.). India: Wolters Kluwer.
3. Hijkoop A, Rietman AB, Wijnen RMH, et al. Omphalocele at school age: What do
parents report? A call for long-term follow-up of complex omphalocele patients. Early
Hum Dev. 2019;137:104830. https://doi.org/10.1016/j.earlhumdev.2019.104830
(assessed august 2023).
4. https://www.uptodate.com/contents/omphalocele-prenatal-diagnosis-pregnancy-
management (accessed august 2023)
5. https://www.choc.org/wp/wp-content/uploads/careguidelines/Omphalocele-clinical-
guideline.pdf
6. https://pubmed.ncbi.nlm.nih.gov/16989131/
7. James SR, Ashwill JW. Nursing care of children. 3rd ed. India: Elsevier, 2009
8. Kleigman et. al. (2017). Nelson textbook of pediatrics.(Vol. 2). New Delhi: Replica Press,
Elsevier.
9. Leaphart, CL. Omphalocele and gastroschisis. https://bestpractice.bmj.com/topics/en-
gb/1158 (accessed March 2021).
10. The Department of Specialist Neonatal and Paediatric
Surgery. Exomphalos. https://www.gosh.nhs.uk/conditions-and-treatments/conditions-
we-treat/exomphalos/ (accessed august 2023).
11. Wong, DL & Hockenberry, MJ. Wong’s nursing care of infants and children. 7th ed.
New Delhi: Elsevier, 2006

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