Data

S> Nagsuka na naman siya

kanikanina lang, ang konti na
nga ng nadedede niya eh as
verbalized by her mother.
O> decreased food intake
>weight: 7 kg
>moist skin
>with capillary refill of 1-2
seconds
>with good skin turgor
>afebrile
>appears restless as
manifested by frequent
crying.
>muscle strength:
RU- 4/5
RL- 4/5
LU- 5/5
LL- 5/5
>poor sucking noted during
breastfeeding
>has a bulky stool
Nursing Dx:
Imbalance nutrition:
less than body
requirements related
to decreased food
intake secondary to
vomiting.

Explanation of the problem

Imbalanced nutrition: less
than body requirements is the
state by which the intake of
nutrients is insufficient to
meet the metabolic needs.
Adequate nutrition plays an
important role in healing and
recovery. It refers to an intake
of nutrients insufficient to
meet daily requirements
because of inadequate food
intake or improper digestion
and absorption of food. As to
the case of our patient, she has
a hirschprungs disease, which
is a congenital absence of or
arrested development of
parasympathetic ganglion
cells in the intestinal wall.
One of the symptom of this
disease is vomiting. This
vomiting of the infants causes
her to have decrease in
appetite therefore leading to
decrease food intake then
imbalance nutrition less than
body requirement.

Goals and Objectives

LTO> after 72 hours of
nursing interventions the
infant will be able to manifest
decreased signs of imbalance
nutrition with no other
complications as manifested
by: good sucking reflex
shown during breastfeeding
and normal consistency of
stool. And weight gain for
atleast .5-1 kg.
STO> after 8 hours of nursing
interventions the infant will
be able to :
-have a good sucking reflex
-tolarate given foods such as
cerelac and breastmilk
-have a soft form stool
-have absent episode of
nausea and vomiting

Nursing interventions
1. Assess patients
weight
2. Noted age, body
build, strength and
rest level.
3. Evaluate total daily
food intake.

4. Monitor input and

output.

5. Promote high fluid

intake (breastmilk,
water)

6. Promote
breastfeeding.
7. Encourage small
frequent meals that is
high in calories and
protein.
8. Encourage mother to
use foods appropriate
for his age that can
stimulate appetite.
9. encourage to breast
the infant and
reiterate the
importance of
breastfeeding

Rationale
1. To establish baseline
parameter.
2. This helps in
determining
nutritional needs of
the patient.
3. To reveal possible
changes that could be
made in patients
intake.
4. To observe the
balance between the
ingested and
eliminated foods and
fluids of the infant.
5. To reduce possibility
of early satiety and
promoting soft form
stool to prevent
constipation.
6. This provides
nutrients that are
needed by the infant.
7. This will promote
weight gain and
nitrogen balance
8. To encourage food
intake and to enhance
food satisfaction.
9.

To increase the
compliance of the
mother in
breastfeeding the
infant for the mother
to gain knowledge

Evaluation
LTO:
Fully met if: the infant
manifest a good sucking
reflex observed during
breastfeeding, has a normal
stool consistency and will
attain increase in weight from
7 kg to 7.5 kg.
Partially met if: the infant
manifest a good sucking
reflex, and has a normal stool
consistency but no changes in
weight occur.
Not met if: no changes occur
after 72 hours of nursing
interventions
STO>
Fully met if: the infant
manifest good sucking reflex,
able to tolerate foods such as
cerelac & breastmilk and
other given foods, and has a
soft form stool with no
episode of n/v.
Partially met if: the infant
manifest good sucking reflex,
able to tolerate foods such as
cerelac, breastmilk and other
given foods, with no episode
of n/v but has a has a bulky
stool.
Not met if: no changes occur
after 8 hours of nursing
interventions.

with its importance.

Saint Louis University

School of Nursing

CASE PRESENTATION:
Hirschsprungs Disease

Members:
Dela Cruz, John Francis Kei
Adaoag, Lyle Aika
Dagdag, Sheila Mae
Latiff, Sofia Abdul
Piluden, Christine Aubrey
Untalan, Angelica

BSN IV- A4