A CASE STUDY IN ACUTE GASTROENTERITIS WITH MILD DEHYDRATION

In Partial Fulfillment of the Requirement for Related Learning Experience Second Semester 2012 2013

Submitted By: Jarin, Mary Joy BSN 2A

Submitted to: Sir Paul John Carvajal R.N. Clinical Instructor

February 13, 2013

I. Introduction Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the stomach and intestine. It is frequently referred to as the stomach or intestinal flu, although the influenza virus is not associated with this illness. Major symptoms include nausea and vomiting, diarrhea, and abdominal cramps. These symptoms are sometimes also accompanied by fever and overall weakness. Gastroenteritis typically lasts about three days. Adults usually recover without problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to complications such as dehydration. Gastroenteritis arises from ingestion of viruses, certain bacteria, or parasites. Food that has spoiled may also cause illness. Certain medications and excessive alcohol can irritate the digestive tract to the point of inducing gastroenteritis. Regardless of the cause, the symptoms of gastroenteritis include diarrhea, nausea and vomiting, and abdominal pain and cramps. Sufferers may also experience bloating, low fever, and overall tiredness. Typically, the symptoms last only two to three days, but some viruses may last up to a week. A usual bout of gastroenteritis shouldn't require a visit to the doctor. However, medical treatment is essential if symptoms worsen or if there are complications. Infants, young children, the elderly, and persons with underlying disease require special attention in this regard. The greatest danger presented by gastroenteritis is dehydration. The loss of fluids through diarrhea and vomiting can upset the body's electrolyte balance, leading to potentially lifethreatening problems such as heart beat abnormalities (arrhythmia). The risk of dehydration increases as symptoms are prolonged. Dehydration should be suspected if a dry mouth, increased or excessive thirst, or scanty urination is experienced. If symptoms do not resolve within a week, an infection or disorder more serious than gastroenteritis may be involved. Symptoms of great concern include a high fever (102 F [38.9 C] or above), blood or mucus in the diarrhea, blood in the vomit, and severe abdominal pain or swelling. These symptoms require prompt medical attention. Gastroenteritis is a self-limiting illness which will resolve by itself. However, for comfort and convenience, a person may use over-the-counter medications such as Pepto Bismol to relieve the symptoms. These medications work by altering the ability of the intestine to move or secrete spontaneously, absorbing toxins and water, or altering intestinal micro flora. Some over-the-counter medicines use more than one element to treat symptoms.
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The researcher chose this study to help even the health care providers become aware of their condition that they ignore. Having stomach pain right after eating may not be just a simple side effect of not eating on time; it might already be a sign of a gastrointestinal disease like acute gastroenteritis. Patient M.E.A, 1yr and 7 months of age was admitted at St. Dominic Medical Center last January 21, 2013 with chief complaints of fever 39.2C, vomiting and diarrhea for 2 days already. I chose this case because I want to acquire knowledge and understanding of the development of Acute Gastroenteritis and the other complications that may arise with the disease. This case study will serve as an opportunity for me to learn more about the said case and to extend help to the patient and the family. This serves as a chance for me to provide information and assess him and his significant others to understand the disease process. Objectives

a) General Objectives: During the course of the study, the patient and specific others shall have: acquired knowledge on the risk factors that have contributed to the development of Acute Gastrioentertis; gain understanding and demonstrate compliance on the treatment and management rendered by the health care team to present reoccurrence of disease.

b) Specific Objectives: o To build a trusting and cooperative relationship with the nurse researchers as well as with the other members of the health care team o To gain knowledge on the definition of Gastroenteritis, its development, risk factors, medical and nursing management o To receive the best possible medical and nursing care, leading to a feeling of security, comfort and good progression of the disease condition o To demonstrate independence or self-care and home management upon discharge

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I.

HEALTH HISTORY A. Demographic (Biographical) Data o Clients Name or Initial: M.E.A o Gender (Sex) : Male o Age: 1yr/7mos. o Admission Date: 01/21/2013 o Time Admitted: 11:17 pm o Attending Physician: Dr. Christine S. Caringal o Admitting Diagnosis: Acute Gastroenteritis rule out UTI with some Dehydration o Final Diagnosis: Acute Gastroenteritis with mild Dehydration B. Source and Reliability of Information o The sources of information are the patients chart, the staff nurses, and the family. C. Reason for Seeking Care o Fever 39.2C, vomiting and diarrhea for 2 days already. o Tatlong araw na kasi siyang nilalagnat, tapos nagtatae siya. Yung dumi niya, kulay dilaw at matubig, pero wala namang dugo. Kaya isinugod na naming sa dito sa ospital as verbalized by the mother. D. History of Present Illness Patient M.E.A was well 2 days prior to admission when he started to develop diarrhea. It started at 2 am and it was a sudden onset and occurred about 4-5 times a day. The diarrhea was watery in nature, yellowish to brown in color with no blood stained. Since then, he had loss appetite and only ate a little amount of foods and drinks. There was no recent history of taking outside food and travelling. On Saturday morning which was 2 days after diarrhea occurred, his mother brought him to the medical center and the doctor prescribed him Oral Rehydration Salt (ORS). However, the problem was not resolved. His fever and vomiting started a few hours after he was brought to the clinic. His mother measured the temperature at home and it was 39.2C (high grade fever) with no rigor. His mother said that there was no rash or joint pain and no episode of fit since he had the fever. No cough or runny nose. The vomiting started on the same time with fever. It occurred once and is nonprojectile. His mother described the amount of vomitus was about half of cup, contained fluid but no blood or bilious with slight offensive smell. There was no history of changing formula milk. His mother said that M.E.A appeared lethargic and less active than usual during that period. She brought him back to the same medical center at night on the same day. The doctor gave M.E.A. per rectally and antiemetic drugs to reduce his fever and vomiting. He was then referred to SDMC and his parents brought him to ER around 9:30 pm and was admitted to ward 314-B1 at 11.07 pm.

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E. Past Medical History The patient was delivers NSD at one of the lying-in in Manila and was fully immunized. Vaccine BCG Hepa B Vitamin K DPT OPV AMV F. FAMILY HISTORY No significant family history. G. Socio-Economic o The clients mother is a pure housewife while his father call center agent in Alabang who earns more or less - P30, 000 /month. o The mother usually cooks food for her children. o They have enough resources for their needs and leisure. H. Developmental History (Based on Erick Ericksons Psychosocial Development Theory) o Stage: Infancy Birth to 18 months Ego Development Outcome: Trust vs. Mistrust Basic strength: Drive and Hope Gross Motor: Hes able to walk, run, skip and climb. Vision & fine motor: Hes able to draw straight line, circle and cross line without seeing how it is done. Speech & Language: He knows his age, can talk constantly in 2-3 words and understand command. Personal & Social: Plays with people around him. Impression : Development milestones is corresponding to his chronological age. I. Review of Systems 1. Regional Examination September 18, 2012 Normal Findings Actual Findings Vital Signs for infants: PR: 134 bpm Systolic BP: 50-70 RR: 26 cpm PR: 80-140 bpm T: 37.5 Wt: 21 lbs. RR: 20-30 cpm (+) Weight Loss T: 36-37.5C (+) Altered sleeping pattern Wt. (lbs.): 9-22 lbs.
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Age of Vaccination At birth At birth At birth 6 weeks 6 weeks 9 months

System

General

 Eyes Integumentary Mouth & Throat: Gastrointestinal Urinary Musculoskeletal 2. Laboratory Studies / Diagnostics Stool - Solid, Light Brown Light Yellow Urine

(+) Sunken and tearless (+) Reduced skin turgority (+) Dry lips (+) Loss of Appetite (+) Vomiting Non-projectile (+) Yellowish to brown in Color - dehydration (+) Weakness

Procedure Date

Indication

Normal Findings / Values

Actual Findings

Significance / Interpretation Explanations of the Findings (as too High or Low) iron deficiency due to menstruation

Hgb The oxygen-carrying pigment of red blood cells that gives them their red color and serves to convey oxygen to the tissues Hct A measure of the packed cell volume of red cells, express as a percentage of the total blood volume. WBC This is used to determine if there is infection present. FUNCTIONAL ASSESSMENT

12.0 - 15.0 (g/dL)

10.4 (g/dL)

January 21, 2013

0.36 0.43%

.32 %

iron deficiency due to menstruation

5.00 10.00

4.08

increase infection

* Health Perception and Health Management The mother considers the patient's health so important. She assures that the patient receives enough nutrition and is alert to any abnormal condition his son is experiencing. Whenever her son has cough, she gives home remedies in which if does not alleviate maker her decide to bring him on private clinics. She ensures that she is focused on the patient's health.
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* Nutritional and Metabolic Pattern Patient M.E.A is exclusively breastfed from birth up to six months old. When he is 6 months old, he started to east solid foods like rice and biscuits such as Marie and Bravo. His appetite is good according to the mother. He does not eat salty foods yet fond of eating fruits like orange and banana. Her mother then gave him formula mil and its brand is Pediasure. He drinks a lot of water. When he was hospitalized, this routine was changed since he's no longer fond of eating fruits and drinking water but is still given with formula milk. * Elimination pattern The mother changes his diaper three-four times a day. According to the mother, the patient defecates three times a date with yellow colored stool. The consistency of his stool is condensed, soft and slightly formed. When he was hospitalized, her mother then changes his diaper two times a day and his stool is watery. * Activities of daily living (ADL) According to the mother, he wants to walk but needs assistance. He plays many toys but he loses eagerness and gets easily tired and plays another toy. * Sleep rest pattern He sleeps in the morning up to lunch, two naps in the afternoon and sleeps in the whole night. When he was hospitalized, his sleep pattern changed. He sleeps on and off for about every two hours at night and just take naps if not disturbed. * Cognitive-Perception The patient is active and is oriented with the people around him. He could recognize his mother and father. * Role-Relationship Pattern (while confined) According to the mother, he is a very active child and does not cry easily. He recognizes the people around him and play with them. He can cope easily with other person. * Values Belief Pattern Their religion is Roman Catholic. The mother verbalized that they dont always attend worship sessions. They dont actively participate in the activities in their church. * Coping and Stress Tolerance Patient M.E.A. copes up to his condition very well. He is not easily irritated and is even a jolly kid. He is fond of playing with people around him. He reduces his stress by entertaining himself with the different things around him.

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PATHOPHYSIOLOGY (Book Base)

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Narrative Viral spread from person to person occurs by fecal-oral transmission of contaminated food and water. Some viruses, like noroviruses, may be transmitted by an airborne route. Clinical manifestations are related to intestinal infection, but the exact mechanism of the induction of diarrhea is not clear. The most extensive studies have been done with rotavirus. Rotaviruses attach and enter mature enterocytes at the tips of small intestinal villi. They cause structural changes to the small bowel mucosa, including villus shortening and mononuclear inflammatory infiltrate in the lamina propria. The current knowledge on the mechanisms leading to diarrheal disease by rotavirus is as follows: * Rotavirus infections induce maldigestion of carbohydrates, and their accumulation in the intestinal lumen, as well as a malabsorption of nutrients and a concomitant inhibition of water reabsorption, can lead to a malabsorption component of diarrhea. * Rotavirus secretes an enterotoxin, NSP4, which leads to a Ca2+ -dependent Cl- secretory mechanism. Mobilization of intracellular calcium associated with NSP4 expressed endogenously or added exogenously is known to induce transient chloride secretion. Morphologic abnormalities can be minimal, and studies demonstrate that rotavirus can be released from infected epithelial cells without destroying them. Viral attachment and entry into the epithelial cell without cell death may be enough to initiate diarrhea. The epithelial cell synthesizes and secretes numerous cytokines and chemokines, which can direct the host immune response and potentially regulate cell morphology and function. Studies also suggest that one of the nonstructural viral proteins may act as an enterotoxin, promoting active chloride secretion mediated through increases in intracellular calcium concentration. Toxin-mediated diarrhea would explain the observation that villus injury is not necessarily linked to diarrhea.

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CONCEPT MAPPING

Key Problem #1 Acute pain related to irritation due to of gastric acid.

Key Problem #2 Imbalanced nutrition due to loss of appetite

Key Demographic Data: Clients initial: P.P.P Age: 1 y/o 7 months Gender: Male Assessment of Patient: Increase of gastric acid, loss of appetite, Dehydration and alteration of body thermo regulation Key Assessments: RR: 25 PR: 96 Temp: 38.6

Key Problem #3
Deficient fluid volume related to dehydration as manifested by dark yellow urine

Key Problem #4

Alteration of body thermoregulation

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PROBLEM LIST a. ACTUAL or active Problem No. 1. Problem Acute pain related to irritation due to acid of gastric Remarks Client shows feelings of comfort and relief. The patient improves appetite and lessens the dryness of his lips. The patient partially maintains his fluid volume at a functional level The patient maintained core temperature within normal range, 37.

2.

Imbalanced nutrition due to loss of appetite or anorexia

3.

Deficient fluid volume related to dehydration as manifested by yellowish to brownish urine

4.

Alteration of body thermoregulation

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NURSING CARE PLANS

Acute pain Assessment VS: PR: 96 Diagnosis Acute pain related to Planning At the end of the shift the Intervention Evaluation At the end of Establish rapport Rationale: to facilitate cooperation as well as to gain patient's trust Express a feeling of comfort and relief from pain Assess for signs and symptoms of pain Rationale: To prevent possible complications Promote comfort for the client Rationale: To regain strength and to reduce anxiety Dependent: Administer Ranitidine Client shows feelings of comfort and relief the shift the goal was met as evidenced by:

inflammation of patient will be gastric mucosa Patient holding abdominal area face is grimace able to :

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Imbalanced nutrition less than body requirements Assessment VS: Weight: 52 kg50 kg Dry lips Poor skin turgor Loss of appetite Body weakness Diagnosis Imbalanced nutrition related to vomiting and irregularities to body perception Planning At the end of the shift the patient will be able to : Eat foods at least 50% of the meal Be free of signs of malnutrition The lips at least lessen it dryness Intervention Independent: Monitor tolerance of fluid and food intake when resumed, nothing abdominal distention, report of increase pain or cramping and vomiting Rationale: To evaluate changes as related to fluid status Provide oral hygiene on a regular frequent basis, including petroleum jelly for lips Rationale: To note presence of dehydration Evaluation At the end of the shift the patient was able to: Eat foods at least 50% of the meal Free of signs of malnutrition The lips at least lessen it dryness

The goal was met.

Dependent: Administer D5LR, 1L for 16 hours

Collaborative: Collaborate with nutritional team and dietician as indicated Monitor the laboratory results; hemoglobin / hematocrit, electrolytes and total protein and pre albumin

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Fluid Volume Deficit

Assessment Objective: Dry mucus membrane Pale, clammy skin Dry lips Vital signs taken: BP: 80/60 PR: 96

Diagnosis Deficient fluid volume may be related to active fluid loss vomiting.

Planning

Intervention

Evaluation At the end of our duty, the patient will demonstrate adequate hydration.

After 8 hours Independent: of nursing Monitor I & O intervention, Rationale: Accurately measuring intake the patient and output is vital for the client with fluid will be able to volume overload. (Ackley & Ladwig, replace the 2008, p. 377). fluid Monitor administration of IV Fluids by regulating it Laboratory studies specifically serum electrolytes Rationale: To assure that the body receives accurate amount of fluids and electrolyte Encourage the patient to have an adequate skin and oral care. Rationale: to maintain high-level of wellbeing Monitor vital signs. Note presence/degree of postural BP changes. Observe for temperature elevations/fever. Rationale: BP, PR, RR often increases when either fluid deficit or excess is present Collaboration: Monitoring Laboratory studies specifically serum electrolytes Rationale: IV flow rate monitoring and regulation seeks to infuse the proper dose and exact amount of fluids required by the patient. Following the pharmacological approach, the nurse plays an important role in the curative side as well as in the prevention of potential complications arising from IV fluid infusion

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Hyperthermia

Assessment Objective: Flushed skin Warm to touch Restlessness

Diagnosis Hyperthermia related to present condition

Planning After 4 hour of nursing interventions, the patient will maintain core temperature within normal range 36 37 C

Intervention Independent: Provide TSB Rationale: To relieve pain and provide comfort; The water has the initial effect of depressing body systems. Monitor vital sign Rationale: To prevent possible complications Promote surface cooling, loosen clothing and cool environment Rationale: Fever is usually reduced by the cool atmosphere of the mist tent Promote bed rest, encourage relaxation skill Rationale: To regain strength and to reduce anxiety Increase oral fluid intake Rationale: To facilitate hydration Dependent: Administer Paracetamol every 4 hours Rationale: To decrease the temperature within normal range, 36-37C If the symptom persist report to the charge nurse / doctor

Evaluation After 30 minutes of nursing interventions, after doing consecutive TSB, the temperature of the patient went back to core temperature within normal range, 37.2

Vital sign Temp.: 38.6

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II.

Pharmacotherapeutics /Medicines (IV-Fluids, Drugs) Side Effect Adverse Reactions - DERM Skin rashes -ENDO Liver Damage Nursing Responsibilities includes health teaching and implications (PRE, INTRA, POST) - Assess the patients fever or pain; type of location, intensity, duration, temperature - Assess allergic reactions: rash, urticaria: if these occur drug may have to discontinue - Inform the relatives of the patient that the urine may become dark brown as a result of phenacetin (metabolite of acetaminophen) - Obtain patient history, including drug history and any known allergies. - Notify physician if patient develops hypotension, nausea, vomiting, headache, dizziness, fatigue, fever, mouth sores. - Instruct the patient to maintain adequate fluid statusand avoid excess dehydration or overdehydration. - Inform patient that the drug can cause drowsiness and to use caution while performing tasks requiring mental alertness.

Indication GN (BN) (Client Specific) Classification Dosage & Stock Frequency Paracetamol Class: Analgesic / Antipyretics Relief of mild to moderate pain; treatment for fever Dosage: 7 mg Frequency: Every 4 hours

Mechanism of Action

* Decreases Fever * Inhibiting the effects of pyrogens on the hypothalamic heat regulating center * A hypothalamic action

Ranitidine Class: Histamine H2 antagonist

Prevention of upper gastrointestinal bleeding. Dosage: 150 mg BID

Reversibly and competitively blocks histamine at H2 receptors, particularly those in gastric parietal cells, leading to inhibition of gastric acid secretion.

- Dizziness

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D5LR Class: HypertonicNonpyrogenic, parenteral fluid, electrolyte and nutrient plenisher

- Treatment for persons needing extra calories who cannot tolerate fluid overload. Dosage: 20 drops/ minute

Hypertonic Solutions are those that have an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy Provides/replaces elemental iron essential component information on RBC development

-Increased serum osmolality -Hypernatremia -Hypokalemia -Altered thermoregulation

- Check vital signs frequently. Report adverse reactions.

Ferrous Sulfate Class: Dietary / Nutritional Preparations

Prevention and treatment of iron-deficiency anemia. Dosage: 15 mg OD

-Anorexia -Vomiting -Dark stool

- Obtain patient history, including drug history and any known allergies. - Evaluate Hgb and Hct count during therapy. - Monitor color of stool. - Tell the patient that drug may cause black stools, constipation or diarrhea and to report anorexia, nausea, vomiting. - Identify foods to include for iron-rich diet. - Tell the patient that the drug can cause stomach upset, instruct the patient to take the drug after meals.

III. DISCHARGE HEALTH-TEACHINGS Content Instruct the parents to administer the following medications as prescribed by the doctor: - Zinc Drop 1ml OD x 14 days - Probiotics + Prebiotics 1 sachet OD to be mixed with formula - Paracetamol 170 mg q4 for fever 37 - Ferrous Sulfate 2ml OD Strategy

Compliance M Medication

* Inform the parents on the side effects of the following drugs given * Instruct the mother to properly comply on the following medications * Give emphasis on the right time and right dose of every drug to be given

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E Exercise

* Encourage the mother to have some walk with her child especially early morning. * Play with the child * Encourage to have a stretching of the hands and feet * Advice the mother to visit their barangay health center for further observations * Teach the mother to keep an eye on the appearance of the clients stool

T Treatment

Continue the medications that have been prescribed by the doctor

H Health Teaching

- Teach family/significant others to foster independence, and to intervene if the patient is unable to perform task or becomess excessively frustrated. - Teach the mother the proper hand as well as the family and most especially the client - Instruct the family/significant others to observe proper hygiene such as taking a bath - The importance of a clean environment. - The significance of bed rest, eating healthy everyday - Encourage patient to comply with foods, and increased fluid intake. medications given. - The importance with complying with - Teach the proper food handling prescribed medications. - Teach the family the susceptible microorganism that can cause diseases to the GI tract including where, when and how to get these kinds of microorganisms - Teach the parents the best nutrition that fits to the clients needs at the same time the appropriate time and number of hours for time and rest Go to the outpatient department to associate and investigate, to know if are ok to discharge.

O OPD

Before you discharge, go to the OPD.

D Diet

Follow the BRAT diet

Instruct the mother to increase the fluid intake of the patient, avoid eating street foods and to start eating fruits and vegetables. If discomfort is felt and pain arises again, do not hesitate to go to the hospital immediately. Its better to be safe than sorry.

S Sign and symptoms

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Bibliography: Marilyn E. Doenges, Mary Frances Moorhouse, Alice C. Murr Nursing Care Plans 8th Edition Davi's Nursing Resource Center George R. Spratto, Adrienne L. Woods. PDR Nurses Drug Handbook, 2008 Edition. Thomson Delmar Learning

Online Sources Retrieve Date: February 11, 2013 www.virtualmedicalcentre.com http://www.gastro.com/Gastro/statistics.aspx http://www.nationmaster.com/graph/mor_gas_and_duo-mortality-gastritis-and-duodenitis http://www.virtualmedicalcentre.com/diseases/gastritis/622#Statistics http://www.thefilipinodoctor.com/search-drugdetails.php?keyword=lysmix&keybrand=Lysmix&id=20071208 http://www.peoples-health.com/gastritis.htm www.virtualmedicalcentre.com Lifespan, "Potential vaccine to prevent gastritis, ulcer disease, gastric cancer." www.sciencedaily.com, 2 Feb. 2011. Web

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