COLLEGE OF NURSING

Case study

Acute Gastroenteritis
Cacayorin, Ria Jean Caido, Caren Camacho, Hannah Cardinez, Hazel Khaira Submitted by: Cardinez, Kathrina Kathlene Ceraos, Kimberly Collado, April Cuna, Sheena Dolly Delfin, John Paul
Submitted to: Mr. Eduard Castillo Clinical Instructor

I. PATIENT ASSESSMENT DATA BASE A. DEVELOPMENTAL HISTORY:

1. Patients Name: C.S 2. Address: Pangasinan 3. Age: 2 years old 4. Sex: Male 5. Birth Date: April 20, 2008 6. Rank in the family: 1st 7. Nationality: Filipino 8. Civil Status: Single 9. Date of Admission: February 16, 2011 10. Order of Admission: CBC, F/A, D5LRS 500mL/min as ordered, Zinc Sulfate syrup 5mL OD, Paracetamol 110mg every 4 hours, Ampicillin sodium( Liferzin) 200mg IVP every 6 hours ANST (-) 11. Attending Physician: Dra. Tolete

B. CHIEF COMPLAINT: LBM, Vomiting and fever C. HISTORY OF PRESENT ILLNESS: 3 days prior to admission, the patient is experienced Diarrhea , vomiting and fever.

D. PAST HEALTH HISTORY/STATUS: 1. Childhood Illnesses: According to the mother the patient had Fever, cough, colds and Stage 1 Dengue. 2. Immunization: The patient has complete immunization as verbalized by the mother but cannot recall the doses given. The mother stated that he brought the
patient in the center in every scheduled immunization for children.

3. Major Illnesses: The patient does not undergo any minor or major operations and injuries as stated by the mother. 4. Current Medication: The patient takes paracetamol, Proboitics, Ampicillin sodium, and Zinc sulfate as stated by the mother. 5. Allergies: No known allergy. E. FAMILY ASSESSMENT: NAME J.S G.S C.S RELATION Husband Wife Son AGE 26 25 2 SEX Male Female Male OCCUPATION OFW Housewife None
EDUCATIONAL ATTAINMENT

College Graduate Under College Graduate None

F.SYSTEM REVIEW: N/A G. HEREDO-FAMILIAL ILLNESS Maternal: Diabetes, UTI, and Hypertension Paternal: Hypertension, Rheumatic heart disease

H. DEVELOPMENTAL HISTORY

THEORIST Erick Erickson

AGE Early childhood (18 mos 3 y/o)

SEX Both male and female

PATIENT DESCRIPTION Autonomy versus shame and doubt The child has ability to cooperate and express one self.

Both male and female Sigmund Freud (1 1/2 3 y/o)

Anal The child can control and expelling feces to provide pleasures and sense of control.

(0-3 y/o) Fowler

Both male and female

Undifferentiated The child was unable to formulate concepts about self or the environment.

Jean Piaget

(2 4 y/o)

Both male and female

Preconceptual stage The child was able to use words to represent objects that are even beyond his senses.

Westerhoff

(Infancy/early adolescence)

Both male and female

Experience faith The child experiences faith through interaction with others who are living a particular tradition.

I.PHYSICAL ASSESSMENT A. GENERAL SURVEY 1. Overall appearance and grooming: the patient has medium body build with proportionate height and weight. He appears weak, conscious, and irritable. The patient is well groom, clean and no fool body smell. 2. Actual height and weight vs. Ideal body weight: The patient weighs 11 kgs. Height is 35 inches. BMI= wt. In kg (Height in ) 35 inch 0.889m BMI= 11kg 0.889 = 11kg 0.790321m= 13.9 or 14 (under weight) 3. Symptoms of distress: The patient is weak and irritated because of his fever and the IVF infused at his right hand 4. Posture gait: The patient can stand and ambulate on his own 5. Affect, mood: The patient responds every time we asked questions and despite his condition he still smiles. 6. Relevance and Organization of thought: The patient can organize and comprehend ideas within his age level.

B. VITAL SIGNS-ON THE DAY OF PHYSICAL EXAMINATION

VITAL SIGNS Temperature Respiratory rate Pulse rate

Day 1 38. 7 35 123

Day 2 37. 2 32 125

A. REGIONAL EXAMINATIONS (using IPPA technique) 1. Hair: no flakes, shiny and soft and with normal hair distribution upon inspection. Head: normocephalic and no lesions noted upon inspection. Face: pale cheeks and dry lips, no rashes and lesions noted upon inspection. 2. Eyes: pale pulp conjunctiva, sunken eyeballs 3. Nose: no discharges noted upon inspection 4. Ears: symmetrical and no discharges noted upon inspection 5. Mouth and throat: pink mucosal membranes, without lesions, incomplete set of teeth and with dental carries noted upon inspection 6. Neck and lymph nodes: no thyroid enlargement upon palpation and inspection 7. Skin: dry, and poor skin turgor 8. Nails: cut and clean nails and with pale nail beds upon inspection 9. Thorax and lungs: clear breath sounds upon auscultation 10. Cardiovascular: with regular rate and normal rhythm upon auscultation. 11. Breast and axilla: no lesions, no discharges, and no lumps noted upon palpation and inspection 12. Abdomen: flat, soft, abnormal abdominal bowel sound upon IPPA 13. Extremities: with active flexion and extension of extremities 14. Genitals: not performed 15. Rectum and anus: not performed 16. Neurological/cranial nerves: not performed

II. PERSONAL/ SOCIAL HISTORY A. Habits/ Vices: N/A B. Lifestyle: the patient cannot perform activity of daily living independently C. Social Affiliation: The patients socialize or mingle D. Rank in the family: first child E. Educational Attainment: None

III. ENVIRONMENTAL HISTORY The patient is living together with his parents. They live in a semi concrete,away from the highway. They are living in barrio wherein it is free from air pollution. They have garden in their backyard.

IV. PEDIATRIC HISTORY: (for neonates / infants and mother) a. Maternal and birth history

Date of Birth: April 20, 2008 Birth Weight: 6 lbs. Type of delivery: Normal spontaneous delivery Condition after birth: none Hospital: Pangasinan Provincial Hospital b. Mother Complications of delivery: None Anesthesia: Lidocaine Exposure to teratogens: None c. Neonates Neonatal history: No complications Feeding history: Breast feeding and bottle feeding/formula Type of feeding: Mixed

V. INTRODUCTION (RELATED TO THE DISEASE/CASE OF THE PATIENT)

Gastroenteritis is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and resulting in acute diarrhea. It can be transferred by contact with contaminated food and water. The inflammation is caused most often by an infection from certain viruses or less often by bacteria, their toxins, parasites or an adverse reaction to something in the diet or medication. Bacterial gastroenteritis is frequently a result of poor sanitation, the lack of safe drinking water, or contaminated food conditions common in developing nations. Natural or man-made disasters can make underlying problems in sanitation and food safety worse. In developed nations, the modern food production system potentially exposes millions of people to disease-causing bacteria through its intensive production and distribution methods. Common types of bacterial gastroenteritis can be linked toSalmonella and C am pylobact e r bacteria; however, Escherichia coli 0157 and Listeria monocytogenes are creating increased concern in developed nations. Cholera and Shigella remain two diseases of great concern in developing countries, and research to develop long-term vaccines against them is underw ay. The symptoms of gastroenteritis include diarrhea, nausea and vomiting, and abdominal 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. The greatest danger presented by gastroenteritis is dehydration. The loss of fluids through diarrhea and vomiting can upset t he bodys electrolyte balance, leading to potentially life threatening problems such as heart beat abnormalities (arrhythmia). The risk of dehydration increases as symptoms prolonged. Dehydration should be suspected if increased or excessive thirst, or scanty urination is experienced.

VI. ANATOMY AND PHYSIOLOGY A. SMALL INTESTINE

SMALL INTESTINE The small intestine is about 6m long (20-22ft). It extends from the pyloric sphincter to the ileocecal valve. It is divided into three parts: duodenum, jejunum and ileum. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. a. Duodenum The first portion of the small intestine extending for about 35 cm from the pyloric valve of the stomach to a sharp bend called the duodenojejunal flexure; receives cyhme from the stomach and secretions from the liver and pancreas. b. Jejunum The first 40 percent of the small intestine beyond the duodenum. The jejunum begins in the upper last quadrant of the abdomen but lies mostly within the umbilical and region. Most digestion and nutrients absorption occur here. c. Ileum Form the last 60 percent of the post duodenal small intestine. The ileum occupies mainly the hypogastric region and part of the pelvic. Compared with the jejunum, its wall is thinner less muscular and less vascular and it has a paler pink color. STOMACH The stomach is a muscular sac located on the left side of the upper abdomen. The stomach receives food from the esophagus. As food reaches the end of the esophagus, it enters the stomach through a muscular valve called the lower esophageal sphincter.

The stomach secretes acid and enzymes that digest food. Ridges of muscle tissue called rugae line the stomach. The stomach muscles contract periodically, churning food to enhance digestion. The pyloric sphincter is a muscular valve that opens to allow food to pass from the stomach to the small intestine.
a. Esophagus Is a tube that connects the opropharynx with the stomach. It lies posterior to the trachea of larynx and extends through the mediastinum, intersecting the daiphragm at level of the 11th thoracic vertebra. The esophagus functions primarily as a conduction for passage of food from the pharynx to the stomach. b. Fundic region (fundus) Is the dome-shaped portion superior to the esophageal attachment. c. Diaphragm
The sheetlike skeletal muscle separating the thoracic and abdominopelvic cavities.

d. Body (corpus) Makes up the greatest part of the stomach inferior to the cardiac orifice. e. Rugae An internal fold or wrinkle in the mucosa of the stomach; typically present when the organ is empty and relaxed but not when thenorgan is full and stretched.

VII. PATHOPHYSIOLOGY Ingestion of contaminated water

(E-coli) Causative agent

Increased number of bodies natural line of defense 1st line of defense (neutrophils)
2 line of defense (monocyte)
nd

Binding to the bacterial wall and releases enzyme called opsonin

Increased production of HCl by the parietal cells

Hyperacidity and sudden contraction of antrum of the stomach

Irritation or inflammation

Fever, nausea and vomiting, diarrhea

Dehydration

VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS: Date: February 16, 2011 Type of examination: CBC/Complete Blood Count

Results Leukocytes Monocytes Hematocrit Hemoglobin Thrombocytes 13 0.09 38 137 253

Normal Values 5 10 x 10 9/1 .02 - .08 40 50 vo 1% 140 - 170 150 300 x 10 3/1

Date: February 16, 2011 Type of examination: F/A (Fecal Analysis) Color: greenish yellow Consistency: watery Microscopic: Ascaris: no ova in the intestine Trichuris: parasite seen Others: bacteria: many Yeast: few

X. DRUG STUDY:

Generic Name: Ampicillin Sodium Brand Name: Liferzin Drug Classification: Anti-infectives/ Aminopenicillins Dosage: 200mg IVP every 6 hours ANST (-) Indication: Soft-tissue infections
Mechanism of Action Side Effects Contraindications Adverse Reactions Nursing considerations

Binds to bacterial cell wall, resulting in cell death.

SKIN: Rashes and urticaria

Hypersensitivity to penicillins

GI: Nausea and vomiting

Assees patient for infection (vital signs, urine, stool and WBC) at beginning of and throughout therapy. Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving results. Assess skin for ampicillin rash a nonallergic, dull red, macular or maculopapular, mildy pruritic rash.

Generic Name: Paracetamol Brand Name: Sinomol Drug Classification: Analgesic/Antipyretic Dosage: 110 mg every 4 hours Indication: Mild pain and fever Mechanism of Action Side Effects Contraindications Adverse Reactions Nursing considerations

Produces analgesia by blocking generation of pain impulses, probably by inhibition of prostaglandin synthesis/action of other substances that sensitize pain receptors to mechanical/chemical stimulations. It relieves fever by central action in the hypothalamic regulating center.

Skin: rashes, urticaria

Contraindicated for repeated use in anemia, renal or hepatic disease

Hepatic: severe liver damage with toxic doses

Assess overall status before administering paracetamol. Patients who are malnourished are at higher risk of developing hepatototxicity with chronic use of usual dose of this drug. Assess amount, frequency and type of drugs taken in patients self- medicating especially with OTC drugs. Prolonged use of paracetamol increases the raisk of adverse renal effects.

Generic Name: zinc sulfate Brand Name: Verazinc Drug Classification: Mineral Dosage: 1 tsp daily Indication: Dietary supplement to treat or prevent zinc deficiencies Mechanism of Action Side Effects Contraindications Adverse Reactions Nursing considerations Natural element that is essential for growth and tissue repair, acts as an integral part of essential enzymes in protein and carbohydrate metabolism Contraindicated with pregnancy and lactation (recommended dietary allowance is needed, but not supplemental replacement GI: vomiting, nausea Explain briefly the action of medication before administering Monitor progression of zinc deficiency symptoms (decrease sense of taste, decreased sense of smell) during therapy

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY 1. 2. 3. 4. 5. Acute pain related to hyperistalsis Hyperthermia related to illness High risk for fluid volume deficit related to diarrhea Impaired Skin/ Tissue Integrity related to stasis of secretions or drainage Risk for Imbalanced Nutrition: Less than body Requirements related to nausea and vomiting

XI. NURSING CARE PLAN

Assessment O-Skin warm to touch -Restlessness -Weak appearance -Dry lips -Flush skin V/S: Temp:38.7C RR: 35 cpm PR:123bpm

Nursing Diagnosis Hyperthermia r/t illness

Scientific Background The hypothalamic thermostat changes suddenly from normal level to a higher level as a result of the effects of tissue destruction, pyrogenic substances or dehydration on the hypothalamus

Planning After 30 minutes - 1 hour of rendering proper nursing interventions the body temperature of 38.7 will subside to 37.5C

Nursing interventions Monitor V/S

Rationales Monitor changes & to serve as baseline data Heat loss by evaporation

Evaluation Goal met. After an hour of rendering proper nursing interventions patients body temperature of 38.7C subsided to 37.4C

Provide TSB.

Change clothing and remove excess blankets when the client feel warm Provide adequate fluid

For clients comfort

To prevent dehydration

Promote rest

To reduce metabolic demands/oxygen consumption

Heat loss by convection Promote cool environment( by using fan/AC) Administer antipyretic as ordered by the physician Relieve fever by central action in the hypothalmic heat regulating center

Assessment O-

Nursing Diagnosis Fluid volume deficit r/t diarrhea and vomiting

Scientific Background A change in normal bowel habits characterized by the frequent passage of loose fluid/unformed stool due to a certain substance that irritates the intestinal mucosa. In response the mucosa secretes mucus to serve as a protective barrier. Also the cells secrete water and electrolytes, washing the irritating substance toward the anus.

Planning After 8 hours of proper rendering nursing interventions, the patient will reestablish normal pattern of bowel functioning and lessen the episodes of vomiting.

Nursing interventions Monitor V/S and weight Emphasized importance of hand washing to the mother

Rationales Monitor changes & serves as a baseline data To improve hygiene thus, minimizing the reoccurrence of diarrhea Low fiber foods help stools become firmer. To prevent aggravation of diarrhea To regain strength To prevent dehydration

Evaluation Goal partially met after 8 hours of rendering proper nursing intervention the patient demonstrated a minimal episode of abnormal bowel function and vomiting.

- pale in appearance -nausea -restlessness - sunken eyeballs -increased fecal frequeny 4 6 times (watery moderate in amount, greenish yellow in color) - vomiting 1 2 times (fluid, moderate in amount) - Hematocrit level:38
> V/S taken as follow: Temp: 38.7 RR: 35cpm PR: 123bpm

BRAT diet advised Limit intake of caffeine and high fiber foods/fruits Promote rest Replace fluid electrolyte loss (ORS)

Administer drug such as antibiotic and anemitic as ordered by the physician

To decrease GI motility

Assessment S> Abdominal pain rated 9/10

Nursing Diagnosis >Acute pain related to hyperperistalsis

Scientific Bakground Contaminated water

O > Facial grimace > Pale and weak in appearance >Dry skin > Sunken eye balls > Skin warm to touch V/S taken as follow:
Temp:38.7C RR: 35 cpm PR:123bpm

Entry of pathogens

Planning >After 8 hours of nursing interventions, the patient will verbalize abdominal pain rated 5/10 and will able to sleep and rest apptopriately

Nursing interventions > Assess vital signs >Encourage client to report pain >Assess reports with abdominal cramping or pain noting location, duration and intensity (pain scale) >Encourage client to assume position of comfort, such as knees flexed >Provide comfort measures such as back and reposition and provide diversional activities >Administer analgesics and anti cholinergic

Rationales >For base line data >May try tolerate pain rather than request analgesic >To determine the level of pain. >Reduces abdominal tension and promotes sense of control >Promotes relaxation, refocuses attention and may enhance coping activities >To relieve pain an relieve spasm of GI tract

Evaluation Goal met >After 8 hours the patient was verbalized abdominal pain rated 4/10 and able to sleep rest appropriately

Introduction of microorganisms to sterile stomach of the neonate

Invasion of microorganisms
Microorganisms out numbered good bacteria

Hyper peristalsis movement

Acute Pain

XII. ONGOING APPRAISAL The patient shows progressive recovery and responding well to both medical and nursing interventions.

XIII. DISCHARGE PLAN (Health Teachings) Medications: Instruct the patient to shift to cefaclor 250mg / 1 tsp three times a day for 1 week. Exercise: Encourage the patient to perform physical activities, which will help in calcium absorption. Treatment: Instruct the patient to continue his medications like Probiotics capsule 1 cap daily. Clinical: Advise for follow up check up/consultation after 5 days. Diet: Increase CHO, and CHON make up for the losses during the illness. Also advise the patient to take Vit. C supplements to boost his immune system. Danger signs: Tell the patients mother to seek medical care/advise if symptoms reoccurred.