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Name: Jaicinth Blaire Alle Ebanio

Age: 10/12 months


Birthday: January 22, 2014
Address: apugan, Baguio City, Benguet
Chief Complaint: Loose bowel movement and Fever

Nationality: Filipino
Occupation: none
Civil Status: Single
Date of Confinement: December 16, 2014

HISTORY
History of Present Illness
1 week prior to admission, client had episodes of loose bowel movements characterized by watery stools, non blood tinge, no foul odor but
with associated vomiting and fever as claimed by the mother. Client has no abdominal pain, has good oral intake. No consult was done and no
medications were given.
3 days prior to admission, clients condition persisted with intermittent fever. The mother gave paracetamol 1.2ml which provided relief of
fever.
A few hours prior to admission, clients condition persisted still with intermittent fever and loose stools which made the mother admit her son
to SLUHSH.
History of Past Illness
Mother claimed that the infant had no past illness except for common colds and cough. Mother gave no medications for the illness and
claimed that this was the first hospitalization of the child.
a. Pedia History
natal: mother was 22 years at that time with an OB score of G1P0. Mother was cognizant of pregnancy after amenorrhea of 4 months and with
positive pregnancy test. Mother claims to have regular prenatal check up every month until birth.
Neonatal: client was born full term via NSD
Feeding History: client was fully breast feed for 6 months and until now. Mother claimed of giving the infant oats for breakfast which the
infant would eat. The mother avoided drugs, smoke, and alcohol during pregnancy. Foods served at home include rice and variety of viand for
breakfast, lunch and dinner. The family would serve vegetables every day and the client eats a little of it as claimed by the mother.

Social History
The client is active in their home, playing with their friends and family members as claimed by mother. The client lives together with his family
in his grandmothers house with 7 other family members which includes the client himself, the father, mother, two siblings of his father, the
grandmother, and the grandfather. Moreover, all are affiliated to Born Again.
The usual diet includes rice for all meals with meat and vegetables served. The grandmother claimed that they get their drinking water
from the faucet, boiling until it boils. They practice segregation of wastes which was collected once a week and claimed that no one smokes in
their house.
PATHOPHYSIOLOGY
Medical Diagnosis: Acute Gastroenteritis with moderate signs of Dehydration
Precipitating Factors:
Undeveloped immune
system
Improper Food
Handling

Predisposing Factors:
Youth
Contaminated Drinking Water

Ingestion of contaminated water or with allergenic


stimulus
Bacterial

The release of toxins that


bind to specific enterocyte
receptors and cause the
release of chloride ions into

Intestines become
irritated
Pus cells from
Urine analysis: 02/hpf

Damaged villous brush of


the border of intestine
Malabsorption of Intestinal
Contents
Osmotic Diarrhea

Poor Skin Turgor, Dry


oral mucous
Secretory
Diarrhea
membranes, sunken
eyes
Acute Stress
Risk for
disturbed skin
integrity

Dehydration

Increased Cardiac Rate =


159bpm
Temperature of 37 deg C

WBC of 24.31
Neutrophils of
24.31
Decreased weight from
7.9 to 7.4

Hyperthermia

Deficient fluid Volume


Reference: Prescilla, R. (September 9, 2014). Pediatric Gastroenteritis. Retrieved from http://emedicine.medscape.com/article/964131overview#a0104
NCP PROPER
Cues
S> mother claims
that infant
decreased in weight
from 7.9 to 7.4
kilograms, does not
eat nor drink other
than breastmilk and
claimed that infant
has episodes of
vomiting yesterday.
O> Client is irritable

Explanation of the Problem


Fluid volume deficit, or hypovolemia,
occurs from a loss of body fluid or
the shift of fluids into the third
space, or from a reduced fluid
intake. Common sources for fluid
loss are the gastrointestinal (GI)
tract, polyuria, and increased
perspiration. In the case of the
patient, fluid volume deficit results
from the chronic loose bowel
movement of the patient due to
either an infection, which promotes

Objectives
STO: After 8 hours of
nursing intervention,
the client will have a
urine output of 30 mL
per hour.

Interventions
Diagnostics:
Monitor vital signs
Check further

laboratory results

Monitor I & O

Rationale
An increase in the
temperature
suggests
dehydration and
the process of
infections.
This reflects
possible infection;
provides basis for
intervention

Evaluation

with cold clammy


active fluid loss from the intestinal
skin, temperature of lumen or from the disturbed villi of
36-37.5 degrees
the intestines causing malabsorption
centigrade has dry
of intestinal contents.
oral mucous
membranes, always References:
prefers to sleep,
Prescilla, R. (September 9, 2014).
refuses oral fluids
Pediatric Gastroenteritis.
given by mother.
Retrieved from
Diagnostic test
http://emedicine.medscape.com/
results increased
article/964131-overview#a01.
WBC specifically
Galanes, S.(2012). Fluid Volume
Neutrophils and pus
Deficit. Retrieved from
cells in urine. Has
http://www1.us.elsevierhealth.co
urine output of
m/MERLIN/Gulanick/archive/Const
190ml for 8 hours,
ructor/gulanick21.html
increased cardiac
rate to 159bpm
A> Deficient Fluid
Volume related to
active fluid lost.

quantitatively.
This provides a
baseline data for
fluid retention
and loss.

Therapeutics:
Give oral
rehydrating
solution every
after vomiting or
LBM

ORS replaces lost


fluids and
electrolytes
therefore
maintaining
equilibrium
Keeps hydration
status up.

Offer oral fluids as


tolerated.
Regulate IVF as
ordered

Educative:

IVF provides
hydration and
prevents the body
from dehydrating
and it provides
fluids and
electrolytes.

Encourage client
to wash hands
before eating

Encourage to drink
oral fluids as
tolerated

Teach the
importance of
hand hygiene

LTO: after 4 days of


nursing intervention,
the client will gain 2.2
pounds, increasing its
weight from 7.4
Diagnostics:
kilograms to 7.5
kilograms
Record initial
weight

Therapeutics

this limits the


mode of transfer
of pathogenic
organisms
causing
gastroenteritis.
Drinking water
restores the lost
waters from loose
bowel movement.
Hand hygiene
limits the transfer
of pathogenic
microorganisms.

This provides a
baseline data for
evaluation

Offer fluids and


foods rich in
protein

Protein helps in
building body
mass.

Regulate IVF as
ordered

IVF serve as a
substitute when
client refuses to
eat and drink

Give zinc
supplement as
ordered

Zinc supplements
help in the growth
of body tissues
and also promote
strengthening of
the
immune system.

Educative
Advise client to eat Eating all foods
served increases
all foods served.
the amount of
nutrients taken in
the body
therefore
facilitating
growth.
Encourage client
to eat foods rich in
vitamin C, protein, This nutrients
further enhance
iron and Zinc

the capability of
the body to
synthesize
protective
enzymes and
growth factors.