KGMU- INSTITUTE OF NURSING- LUCKNOW
SUB: - CHILD HEALTH NURSING
CASE STUDY ON- MALROTATION
1. Patient Bio-Data
● Name –Nishant Mishra
● Age – 8 Years
● Sex – male
● Religion- hindu
● Father’s name- Ram Pravesh Mishra
● Occupation - Farmer
● Education - 10th passed
● Mother’s Occupation - House wife
● Education – 8th standard
● Date of admission-31/04/2018
● Informant- Mother
● Diagnosis- Malrotation
● Surgery (if any) - Planned
● Treated by - Dr. prof. A. Wakhlu
2. Presenting complaints (complaints given by mother/father)-: Patient is admitted in the hospital with
the complaints of ;
1. Abdominal Pain.
2. Decreased Appetite.
3. Weight Loss.
4. Nausea and Vomiting.
3. History of present illness:
a. Mode of onset:
1. Abdominal pain with distention.
2. Refusal to take feed.
b. Sequential history of appearance of complaints:
1. Refusal to food.
2. Nausea and vomiting.
c. Therapy /treatment received so far:
name ency n
pipzo gm otic
Dynapar esic
Metronidazole otic/Antiprotozoal
Ranitidine id
acin g otic
4. Past history (medical/surgical or any other): there is no past medical or surgical history.
Birth history
a. Antenatal history
1. Mother taking adequate nutrition at the time of pregnancy: Yes
2. Registered in the health facility: Yes
3. Consuming iron and folic acid: Yes
4. Regular antenatal checkups: Yes
b. Natal history
1. Type of delivery: Normal vaginal delivery
2. Baby cried/ not cried at birth: Cried
3. Instrumental delivery (where): N/A
4. weight of the child:2.6 kg
[Link] history
1. Condition of the baby: Good
2. Condition of mother: Normal
3. History of any infections (PPH or any other problems): Nothing significant
5. Personal History
1. Personal hygiene of the child – Personal hygiene of the child is maintained by the parents,
and health care workers.
2. Response of child towards illness – He is lethargic.
3. Response of parents to child’s illness – Worried about their child’s disease condition.
6. Family history:
1. History of contact illness (TB/HIV): No
2. History of similar ailment in the family: Not present
3. History of consanguinity: No
4. Birth order: First
5. Number of siblings: One
6. Illness: Other family members are healthy
7. Any death in the family: No
7. Socio-economic history:
1. Nuclear/joint family: Nuclear family
2. Who looks after child: Mother work as a primary care giver for him during hospitalization
3. Housing condition: Pacca
4. Overcrowding: Yes
5. Rural/urban: Rural
6. Water source (drinking): Hand pump
7. Smoking among family members: Father
8. Schooling of the child: Yes
9. Interactive behavior /interest of the child: Yes
8. Nutritional history:
1. Breastfeed/top feeds/mixed mode of feeding: N/A
2. Vegetarian/non-vegetarian: Vegetarian
3. Dietary intake: Chapati, Milk, Fruits, Rice, Dal.
9. Immunization: Pt. has immunized at birth.
1. Any known allergies- no
2. Blood transfusion till date (if any): not
PHYSICAL EXAMINATION
1. General examination:
● General condition: general condition of the patient is good, but little discomfort due to pig
tail drainage and difficulty in breathing..
● Decubitus- not present
● Built & nutrition ((PEM Grade)calculated by degree of malnutrition formula= actual weight/
expected weight×100)-76%
● Pallor - Not present
● Icterus- Not present
● Cyanosis- Not present
● Edema- Hepatomegaly is present.
● Clubbing of nails- Not present
2. Vital signs:
● Temperature - 99.4 F
● Pulse- 90 beat/ min
● Respiratory rate -30 breath/ min
● Blood pressure -130/90 mmHg
● SPO2 - 93%
● Input - 1000 ml
● Output - 1000ml
● ABG pH - 7.47
3. Anthropometry measurement:
● Height /length: 135 cm
● Weight: 10 kg
● Head circumference: 50 cm
● Chest circumference : 65 cm
● Abdominal girth: 59 cm
● Mid arm circumference :12 cm
Condition of skin: Pink but dry skin.
Head: Normal
Condition of hairs:
● Color - Black
● Flag signs- absent
● Dryness- absent
● Pediculosis- absent
● Dandruff - absent
● Split ends- not present
Head shape: normal
● Fontanelles: Closed
● Cranial sutures: Normal
● Characteristic facies: Normal
Eyes: No any discharge
Ear: Cerumen is present and no other discharges.
Condition of lips- Dry lips
Neck: normal
Condition of nails:
● Color - Pink
● Shape- Normal
Head & face: Dullness
4. Systematic Assessment
a. Respiratory system
● Respiratory rate- 30 breath/ min
● Use of accessory muscles - Yes
● Type of breathing - Labored breathing
● Movement/ symmetry- Asymmetry
● Chest wall deformity - Not present
● Neck vein distension - Not present
● Trachea midline- Normal
● Air entry - Abnormal lung sounds
● Any other audible sounds - No
b. Cardiovascular system
● Apex beat - 90beat/min
● Any murmur - No
● Any other sounds- S3 and S4is present.
c. Abdomen
● Shape - Normal
● Prominent veins- Not present
● Visible peristalsis- Not present
● Bowel sounds audible- Not clear
● Distension- Present
● Abdominal wall rigidity/ guarding- Present
d. Musculoskeletal
● Joints: Normal
● Muscle tone: Present
e. Gastro nervous system:
● Stool color and character : Clay colored stool
● Diarrhea: Mild
● Constipation: Not Present
● Vomiting: Present
● Hematemesis: Not present
● Jaundice :Not Present
● Abdominal pain: Present
● Colic: Absent
● Appetite: Decreased
f. Central nervous system
● General appearance- Dull
● Posture- Good
● Gait - Normal
● State of sensorium- Good
● Meningeal irritation:( neck rigidity/ Kernings / Brudzinski’s sign / Photophobia): Not Present
● Abnormal movements : Not present
● Sensory : Sensation to touch and pain is present
Growth & development assessment (as per the patient’s age group)- Physical , Psychological, social and
moral development of the patient is according their age group is present.
Neuromuscular maturity
Flexion of extremities- Present
Extension of extremities- Present
Turn head from side to side –Yes
Head lag in all position- No
Reflexes:
Eyes- Blinking and pupillary reflex present.
Nose-Sneeze reflex present.
Mouth and throat- N/A
Palmar and plantar reflex- N/A
Stepping reflex- N/A
Nutritional assessment: BMI of patient is.
Investigations:
S. Investigation Patient value Normal values
No.
1. Complete blood count
Hemoglobin 11.0 g/dl 11.5-15.5 g/dl
Total leukocyte count(TLC) 15300 cells/mm3 4000-11000 cells/mm3
Total RBCs 3.65 Million/micro 4.5-5.5
L
1. Kidney panel
Serum urea 34.7 mg/dl 10-45
2. Serum creatinine 0.57 mg/dl 0.6-1.5
Electrolytes
Serum sodium(Na+) 137.1mmol/l 135-145
Serum potassium(k+) 3.59mmol/l 3.5-5.3
3. Liver function test
Serum bilirubin total 6.19 mg/dl 0.3-1.4
Serum bilirubin direct 0.13 mg/dl 0-0.4
DESCRIPTION OF DISEASE CONDITION:
Definition-
Intestinal malrotation is a congenitalanomaly of rotation of the midgut(embryologically, the gut undergoes
a complex rotation outside the abdomen).
Etiology- The exact causes are not known. It is not associated with a particular gene, but there is some
evidence of recurrence in families.
Signs and symptoms-
Patients (often infants) present acutely with midgut volvulus, manifested by biliousvomiting, crampy
abdominal pain, abdominal distention, and the passage of blood and mucus in their stools. Patients
with chronic, uncorrected malrotation can have recurrent abdominal pain and vomiting.
Malrotation can also be asymptomatic.
• The obstruction can be classified as:
• Pre-ampullary
• Post-ampullary = approximately 85%
• The pylorus is usually both distended and hypertrophic
• The bowel distal to the obstruction is collapsed
• Complete obstruction of the duodenum à the incidence of Polyhydramnios 32% to 81%.
• Growth retardation is also common
Diagnosis-
Book picture Patient picture
With acutely ill patients, consider emergency surgery laparotomy if there is a high
index of suspicion.
Plain radiography may demonstrate signs of duodenal obstruction with dilatation of Present
the proximal duodenum and stomach but it is often non-specific. Upper
gastrointestinal series is the modality of choice for the evaluation of malrotation as it
will show an abnormal position of the duodeno-jejunal flexure (ligament of Treitz).
In cases of malrotation complicated with volvulus, it demonstrates a corkscrew
appearance of the distal duodenum and jejunum. In cases of obstructing Ladd bands,
it will reveal a duodenal obstruction. Present
In equivocal cases, contrast enema, may be helpful by showing the caecum at an
abnormal location.
It is usually discovered near birth, but in some cases is not discovered until
adulthood.[2] In adults, the "whirlpool sign" of the superior mesenteric artery can be
useful in identifying malrotation.
Pre-operative care-
• Appropriate resuscitation
• Correction of fluid balance and electrolyte abnormalities
• Gastric decompression
• Parenteral nutrition via central catheter line
• Investigations:
• Complete metabolic profile,
• Complete blood cell count,
• Coagulation studies,
• An abdominal and spinal ultrasound evaluation,
• Two-dimensional echocardiography
Therapy / operation-
Treatment is possible and these are the steps taken: Resuscitate the patient with fluids to stabilize them
before surgically
● correcting the malrotation (counterclockwise rotation of the bowel),
● cutting the fibrous bands over the duodenum,
● widening the mesenteric pedicle by separation of the duodenum and cecum.
With this condition the appendix is often on the wrong side of the body and therefore removed as a
precautionary measure during the surgical procedure.
One surgical technique is known as "Ladd's procedure", after Dr. William Ladd.[4][5]Long term research on
the Ladd procedure shows that even after the procedure, patients are susceptible to have complaints and
might need further surgery.
POST-OPERATIVE CARE
• Total parenteral nutrition (tpn) is continued
• Nasogastric tube output is monitored
• Feedings may be started when the volume of the nasogastric output has diminished and its color has
lightened and it becomes clear à several days to a week
• Small feedings are then initiated with volume and concentration, Advanced as tolerated
• The majority may be discharged within one to several weeks
COMPLICATIONS
This can lead to a number of disease manifestations such as:
● Acute midgut volvulus
● Chronic midgut volvulus
● Acute duodenal obstruction
● Chronic duodenal obstruction
● Internal herniation
● Superior mesenteric artery syndrome
References-
● Wong’s, essentials of pediatric nursing, eight edition, Elsevier India private LTD, 2012.
● Gupta Suraj,’’ the short textbook of pediatric’’11th edition, published by JAYPEE
Brothers medical publisher Pvt. Ltd.
● Brunner’s and Suddharth’s 13th edition 2015 Publisher- Elseiver’s Serics medical surgical
nursing 3rd edition
● Murphy FL, Sparnon AL (2006-04-01). "Long-term complications following intestinal malrotation and
the Ladd's procedure: a 15 year review". Pediatric Surgery International. 22 (4):
326–329. doi:10.1007/s00383-006-1653-4
