I.

ACKNOWLEDGEMENT

We, the students of UNCIANO MEDICAL COLLEGES, Antipolo city, BSN 4th yr
student, NCM 104, section C group C3 would like to give our deepest thanks to
following people of institutions. The completion of this case study was made possible
through the remarkable contribution of the people to whom we give our warmth
gratitude. To Binangonan Medical Hospital, general ward for sincerely welcoming us and
for giving us the Opportunity to gather the necessary information regarding our chosen
patent. To the doctors and staff nurses of Binangonan Medical Hospital, in general ward
who treats us and gave us the feeling of becoming part of the health care team. To our
Clinical Instructress, Ms. Etheldreda Santos RN MAN for guiding us and for opening our
minds to a deeper knowledge of understanding. To each member of our group who gave
their time and support in order for our case to be done. To our beloved family who is
always there to support us. And lastly, we heartedly thank our Almighty God who gave
us the knowledge in giving care to our clients. He continuous to guide us to the journey
of our success.
II. INTRODUCTION

In Partial Fulfillment of the NCM 104 requirements, we student of Unciano

Colleges Inc., Antipolo, BSN, level IV students of section C group C3 are assigned in
Binangonan Medical Hospital, general ward which gave us the opportunity to handle the
case of our patient which is Acute Gastroenthritis.

We chose this study precisely because it would give us relevant experience such
as enhancing our skills and our attitudes in dealing with the patient’s family and the
ability to understand thoroughly about his underlying condition. Furthermore, as students
we should be familiar with the hospital setting and ability to make informed critically
analyzed judgments to the practices.

We want to have a broader understanding and clearer view of this health

condition. The willingness showed by the family of our patient is very important because
it will give us full control of the assessment activity thus making our work facile.
V. Background of The Study

Acute Gastroenteritis is inflammation of the gastrointestinal tract, involving both

the stomach and the small intestine and resulting in acute diarrhea. The inflammation is
caused most often by infection with certain viruses, less often by bacteria or their toxins,
parasites, or adverse reaction to something in the diet or medication. At least 50% of
cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases,
and the majority of severe cases in children, are due to rotavirus. Other significant viral
agents include adenovirus and astrovirus. Different species of bacteria can cause
gastroenteritis, including Salmonella, Shigella, Staphylococcus, Campylobacter jejuni,
Clostridium, Escherichia coli, Yersinia, and others. Each organism causes slightly
different symptoms but all result in diarrhea. Colitis, inflammation of the large intestine,
may also be present. Some types of acute gastroenteritis will not resolve without
antibiotic treatment, especially when bacteria or exposure to parasites are the cause.
Physicians may want to diagnose the cause by analyzing a stool sample, when stomach
symptoms remain problematic. Worldwide, inadequate treatment of gastroenteritis kills 5
to 8 million people per year and is a leading cause of death among infants and children
under 5. The most common symptoms are diarrhea, vomiting and stomach pain, because
whatever causes the condition inflames the gastrointestinal tract. Another reason to seek
medical treatment is that some forms of acute gastroenteritis mimic appendicitis, which
may require emergency treatment. As well, young children run an especially high risk of
becoming dehydrated during a long course of the stomach flu. One should receive
directions regarding how to help affected kids or adults get more fluids. Sometimes
children, those with compromised immune systems, and the elderly may require
hospitalization and intravenous fluids. Dehydration can actually cause greater nausea, and
can begin to cause organ shut down if not properly addressed. Acute gastroenteritis is
quite common among children, though it is certainly possible for adults to suffer from it
as well. While most cases of gastroenteritis last a few days, acute gastroenteritis can last
for weeks and months. Acute gastroenteritis remains a serious health issue, and is
responsible for over 50,000 hospitalizations of children. In developing countries, acute
gastroenteritis is the leading cause of death for infants. Acute gastroenteritis should thus
be taken seriously, and people should not hesitate to seek medical treatment for especially
seniors and children who have been ill for more than a day.
IV. Objectives

General Objectives:

This study aims to convey familiarity and to provide an effective nursing care to a
patient diagnosed with Acute Gastroenteritis through understanding the patient history,
disease process and management.

Specific Objectives:

To be able to:

-Establish rapport with the client and his significant others.

-Apply and improve our assessment skills using the 13 areas of assessments

-Review the anatomy and physiology of digestive system.

-Identify the actual potential and health problem of the client.

-Study the pathophysiology of Typhoid fever.

-Formulate appropriate nursing interventions.

-Review medications prescribed to our client and know the nursing considerations when
administering them.

- Evaluate the effectiveness of the Nursing Care Plan’s and impart appropriate health
teachings on promoting client’s health recovery.
VI. PATIENT’S PROFILE

Case no. : 000858

Ward : Female Ward

Patient’s name : Mrs. MR

Age : 80 years old

Sex : female

Date of birth : August 25, 1930

Address : Binangonan, Rizal

Nationality : Filipino

Religion : Roman Catholic

Civil status : Widow

Chief complaint : Soft Stool

Initial diagnosis : Acute Gastroenthritis

Date of admission : June 23, 2010

Time of admission : 10:00 pm

Attending Physician : Dr. Dela Crus

Date of assessment : June 26, 2010

 Time of assessment : 5:30 pm

VII. NURSING HISTORY

Chief Complaint: “Nagtatae ako” verbalized by the patient.

History of Present Illness:

Prior to admission, the client was defecating. Her stool was watery and its color
is green. According to the patient after her son look that he is experience diarrhea, he
decided to bring her mother in the Hospital. In the emergency room she admitted their
with a chief complaint of soft stool, seen and examined by Dr. Dela Cruz. She sign the
consent for admission. She was inserted D5LR 1L X 10 hour regulated @ depend rate
aseptically. The doctor orders a medicines for her (metronidazole 500mg) and
( ampicillin 500mg TIV).

History of Past Illness:

The client had fever, cough and colds. The patient had never been any disease
such as measles, mumps and chicken pox. The patient had no history of accident or any
injury. She does not have allergy in any food or drug. She was not hospitalized before
and she does not take any medication or supplements to maintain her health.

Hereditary Illness:

There is no history of any diseases in the family of Mrs. M.R. However, in the paternal
line, a history of Hypertension is present. His father and her mother did not acquire any
from the two diseases nor have any disease.

Socio-Economic:
 According to the patient she is the one who shouldered the bill in the hospital. She has
keep a money when she is working. She is a vendor and her income is 100 a day.

13 AREAS OF ASSESSMENT

I.SOCIAL STATUS

The patient is 80 years old. He was baptized as a Roman Catholic but he is not an active
participant to any religious or social organization. She is works as a vendor in
Binangonan Market. She is a widow and she lives her own home. She has born on August
25, 1930.

II.MENTAL STATUS

We asked our patient if she is aware where he is, he replied to us that she is in
Hospital. We asked her if she is still working, she replied “Yes”. We asked what her full
name is, she answered correctly. She speaks and answers our questions but when she
answers our questions, she uses ‘Tagalog’ dialect fluently but she told us that she cant
knows how to speak in English. Also during the interview, she doesn’t maintain eye
contact and seems to be shy. When we assessed her memory, we asked her whether she
remembers what she ate for lunch; she thought for it for a while and answered, “Kanin”.

III.EMOTIONAL DEVELOPMENT

Our client was calm but she is a shy, when we are talking to her there is a time that we
need to repeat our question twice before she answer this. He felt sad because of her
condition, because she wants to work in the market.

IV.SENSORY PERCEPTION

a. VISION

The eyes were bilaterally assessed, there were no discharges seen. Upon
illumination of the penlight, starting from the outer canthus going to the inner canthus,
her pupil constricts. When illuminated, the pupil constricts as a direct response and the
client’s pupil dilates when non-illuminated, as a consensual response.

Upon the assessment of the visual acuity, we gave the client a flashcards, the
English alphabets, to be read, the client was able to read the words and letters at the
distance of 36 cm (14in) and font size of 48 with pictures of each words. Her pupils are
color black.

Assessment in peripheral vision includes the following procedures, we asked the

client to cover each eye one at a time, same as the examiner, and when the penlight was
moved into the visual field from various points in the periphery, she was able to see the
penlight in her periphery. We also assess the 6 ocular movement with the used of
penlight, his eyes is followed the penlight accurately.

Upon the assessment of the alignment and the coordination of the eye,
we asked the client to look at the penlight moving in an upright, downward and
sideward movement. Both eyes are coordinated and aligned. Although she is an 80 years
old woman, she told that she can see clearly and she never used eyeglass.

b. AUDITORY

We inspect the clients both auricles, the color is light brown the same as
the facial skin. It is symmetrical and auricle is aligned with outer cantus of the eye. The
auricles were palpated: the texture is smooth, areas were firm and there was no
tenderness seen; both the left and right auricle recoils after it was folded. There was no
discharge seen in both ear of the client.
We explained then performed the Weber’s test and Rinse’s test to the client.
With the used of tuning fork, Weber’s test was perform for
lateralization. The client was instructed to cover his left ear, the
examiner tap the tuning fork and place it above the clients head and
then the clients was ask if he hears the sound, the test was perform
bilaterally. The sound was accurately heard by the client at the
distance of 3inches and at 5second. After the Weber’s test, we perform
the Rinne’s test to compare air conduction to bone conduction, the
examiner taps the tuning fork and places it at the back of the left ear,
and the procedure was done bilaterally. The client was not really able
to distinguished air conducted hearing.

c. OLFACTORY

The client’s nose were assessed, it is symmetrically aligned, has

uniform color, and there is no discharge or nasal flaring. The external
nose was palpated and there was neither tender nor lesions present
during our assessment. The client was blindfolded during olfactory
test. We first test her sense of smell for pleasant smells by passing a
cotton ball soaked in liquid hand sanitizer flavored melon through her
nose with approximately 1 in. space. She was able to distinguish the
smell as a pleasant one and correctly identified it as scent of melon.
The next test was performed by passing a cotton ball soaked in alcohol
through her nose with approximately 1 inch space to test her sense of
smell for unpleasant odor. The client was able to identify the smell as
alcohol. The third is white flower by passing a bottle of white flower
through her nose and she distinguishes that is white flower the last
specimen that we used is coffee at the same procedure and she
distinguished that it is coffee. This four olfactory test performed
indicates that the clients Cranial Nerve I is properly functioning.

d. GUSTATORY

The tongue was in pinkish in color without lesions. She is also blind folded, we let him
taste and identify the different samples namely: sugar, a pinch of salt, vinegar and coffee
granules. We put sugar on the tip of her tongue using the tongue depressor and she was
able to determine the sweet taste, then we let her sip water between tests to lean the
residue on her tongue. We gave her a pinch of salt and put it in the middle of her tongue
and she was able to determine the salty taste. We also gave her vinegar by squeezing the
juice to the side of his tongue and let her taste it and she was able to determine the sour
taste. Lastly we gave her a coffee and she also distinguished this correctly.

e. TACTILE

Upon assessment of the sharp and dull sensations, we let the patient touch the bandage
scissor with a blunt and pointed ends. The client was able to distinguish sharp and dull
sensations.

Upon assessment of the hard and soft sensations, we let the client hold a
cotton ball and then a tuning fork. The client was able to distinguish hard and soft
sensations.

Upon assessment of smooth and rough sensations, we let the patient

brush her fingers on sandpaper and a plain paper. The client was able to distinguish
smooth and rough sensations.

Upon assessment of the warm sensation, we rubbed on hands the tuning

fork to produce friction that causes heat. The client was able to distinguish warm
sensations.

IV.BODY TEMPERATURE STATUS

The body temperature was 36.3°C, afebrile, taken via right axilla for 3minutes at around
4PM.

V.MOTOR ABILITY

Our client can ambulate even without any assistance. She can stand and walk but not in
properly. She can’t properly perform flexion; our client can also perform extension. And
also during our assessment, for abduction we asked our client to move each arm laterally
at the sides to a side position above her head and she was able to perform it but she is
slow to do it. We can’t assess the other way of assessment in motor ability because we
see that she feel weakness.

VI.NUTRITIONAL STATUS

Lips are cracked and dry without presence of bleeding lesions. Mucosa and gums are pale
in color and tongue is at midline and intact speech. Cavities are not present on molars and
premolars on both upper and lower gums. She has no teeth.

VII.ELIMINATION STATUS

We asked our client about her normal defecation pattern and she said once a day but
because of her present illness her stool is soft and she feels pain when she is defecating.
We also asked her if she defecated during our shift and he said not yet. The characteristic
of stool according to her was yellow unlike a past few days that the color of her stool is
yello green. According to her the shape is oblong and has unpleasant smell according to
her. In voiding the client voids more than five times a day with the total of 230cc , the
color is yellow, the odor is aromatic he uses the comfort room whenever he feels the
urge of voiding and defecating.

VIII.REPRODUCTIVE SYSRTEM

The reproductive organ was not visually assessed because the client doesn’t want us to
see his reproductive organ. We asked the patient when her first menstruation is and she
can’t remember but she told that her menopausal is on her ages of 50. We did not ask
more question about her genital.

IX.RESPIRATORY STATUS
 Our client obtained a respiratory rate of 22 cycles per minute. We asked our client
to inhale deeply and exhale slowly listening to her breath sound using stethoscope in the
back portion of the body. Her breath sound is normal in rhythm and there is no
adventitious breath sounds were heard.

X.CIRCULATORY

We took her pulse in her left radial pulse, which was easily palpable with a
regular rhythm and the rate was 88 beats per minute. Before starting the assessment, her
blood pressure was 110/80 mmHg, which was taken on the left brachial artery while he
was sitting on the bed side. The difference between systolic value and diastolic value
resulted to pulse pressure of 30 mmHg. We also test his capillary refill time which results
to 2 seconds which is within normal range of 1-2 seconds.

XI.STATE OF PHYSICAL REST & COMFORT

According to the client she sleeps 8 hours at day time and 9PM to
5AM at night time. According to the client she doesn’t feel any pain during the
assessment. She did not sleep in daytime because she is stay in market in this time.

XII.STATE OF SKIN & APPENDAGES

Our client’s hair was short, curly and black in color it was free from lice and nits. She
also has a fair skin color but it is like the skin of other older man it is not smooth. Her
nails are cut short and clean in both hands and feet. She has a negative sign of digital
clubbing and in the skin turgor we test it in about 1 second. She did not experiencing
edema.
ANATOMY AND PHYSIOLOGY

Human Digestive System

The human digestive system is a complex series of organs and glands that processes food.
In order to use the food we eat, our body has to break the food down into smaller
molecules that it can process; it also has to excrete waste.

Most of the digestive organs (like the stomach and intestines) are tube-like and contain
the food as it makes its way through the body. The digestive system is essentially a long,
twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver
and pancreas) that produce or store digestive chemicals.

The Digestive Process:

The start of the process - the mouth: The digestive process begins in the mouth. Food is
partly broken down by the process of chewing and by the chemical action of salivary
enzymes (these enzymes are produced by the salivary glands and break down starches
into smaller molecules).
On the way to the stomach: the esophagus - After being chewed and swallowed, the food
enters the esophagus. The esophagus is a long tube that runs from the mouth to the
stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food
from the throat into the stomach. This muscle movement gives us the ability to eat or
drink even when we're upside-down.

In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it
in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed
with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the duodenum, the first
part of the small intestine. It then enters the jejunum and then the ileum (the final part of
the small intestine). In the small intestine, bile (produced in the liver and stored in the gall
bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of
the small intestine help in the breakdown of food.

In the large intestine - After passing through the small intestine, food passes into the large
intestine. In the large intestine, some of the water and electrolytes (chemicals like
sodium) are removed from the food. Many microbes (bacteria
like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large
intestine help in the digestion process. The first part of the large intestine is called the
cecum (the appendix is connected to the cecum). Food then travels upward in the

ascending colon. The food travels across the abdomen in the transverse colon, goes back
down the other side of the body in the descending colon, and then through the sigmoid
colon.

The end of the process - Solid waste is then stored in the rectum until it is excreted via
the anus.
 TEXTUAL

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 life-threatening 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.

XIV. Evaluation
 After 32 hours of exposure in Queen Mary Hospital, ward, we, the 3rd year
students of Bachelor of Science in Nursing, section E, group 2 of Unciano Colleges -
Antipolo, City acquired proper attitude in communicating with the patients and the staffs
in the hospital, we gained much knowledge and competencies in our clinical area, and we
applied our classroom acquired skills in actual hospital setting.

We established rapport with the client and its significant others. We learn more about
the anatomy and physiology of the patient’s digestive system and we were able to gain more
knowledge about the medications given to our patient. We were able to enhance our assessment
skills using the 13 Areas of Assessment. We were able to formulate an effective nursing care plan
about the patient’s condition.

• We were able to establish rapport with our client as well as his family and helped them
recognize and gave importance on their health and personal development.
• We were able to identify and analyze present health problems of our client that might
place him at risk and we were able to use our nursing skills to help him.
• We were able to review our knowledge about anatomy and physiology of the Digestive
system as well as the pathophysiology of Typhoid Fever.
• We were able to formulate and plan appropriate nursing interventions that lessen the
health problems of our client, by involving him as well as the members of our group.
• We were able to impart necessary knowledge regarding health maintenance to our client
that guided him to achieve a healthy life.
• We were able to evaluate the effectiveness of our nursing care plan.

XV. PROGNOSIS, DISCHARGE PLANNING & HEALTH TEACHING

PROGNOSIS
 The infant shows good prognosis towards full recovery and resumption of
activities of daily living, as manifested by being able to eat and sleep better, as well as in
resuming his play and his attempt to walk around. Our client's family, especially the
mother, was open-minded and accepted our health teachings and nursing interventions.

Hygiene

*S.typhi is shed in human feces. Advise the patient to maintain proper

hygiene, especially after voiding to avoid spreading the disease.

*Advise the patient not to handle food or participate in food preparation.

*Educate significant others on importance of sanitary food preparation.

Outpatient

1. Water must be properly filtered and boiled before drinking if it is from an

unreliable source.
2. Food must be properly washed and then cooked
3. One must not eat or drink in suspected unhygienic or unreliable places.
4. Express importance of compliance to prescribed mediations.

Diet

Diet: Rich in Carbohydrates, proteins and fats

1. Food must be simple and easy to digest, avoid all kinds of spices on food.
2. Food should be cooked well, but not overcooked as that would make it difficult
to digest.

If diarrheas develop in typhoid increase fluid intake such as soups, curries, gravies and
fruit juice. Vitamin B and C foods must be consumed in order to compensate for the

3. hose vitamins.
4. Eggs and milks are suitable proteins that can be consumed during typhoid fever.
5. Vegetables oils and milk products such as butter, cheese, cream and emulsified
fats can be consumed. Wheat, rice, potatoes and other foods that are high in
carbohydrates are advised:

HEALTH TEACHING:

1. Wash your hands. Frequent hand washing is the best way to control infection.
Wash your hands thoroughly with hot, soapy water, especially before eating or preparing
food and after using the toilet. Carry an alcohol-based hand rub for times when water isn't
available.

2. Avoid untreated water. Contaminated drinking water is a particular problem in

areas where typhoid is endemic. For that reason, drink only bottled water or canned or
bottled carbonated beverages, wine and beer. Carbonated bottled water is safer than still
water is. Wipe the outside of all bottles and cans before you open them. Ask for drinks
without ice. Use bottled water to brush your teeth, and try not to swallow water in the
shower.

3. Avoid raw fruits and vegetables. Because raw produce may have been washed in
unsafe water, avoid fruits and vegetables that you can't peel, especially lettuce. To be
absolutely safe, you may want to avoid raw foods entirely.

4. Choose hot foods. Avoid food that's stored or served at room temperature.
Steaming hot foods are best. And although there's no guarantee that meals served at the
finest restaurants are safe, it's best to avoid food from street vendors — it's more likely to
be contaminated.

5. Get Vaccinated- Typhoid fever vaccine. one is injected in a single dose, and the
other is administered orally over a period of days. Neither is 100 percent effective, and
both require repeat vaccinations.

6. Appropriate systems for human waste disposal must be available. S.typhi can
only be shed through human feces. It is therefore of utmost importance that human
7. Waste be disposed in a most appropriate manner to avoid spread of bacteria.

BIBLIOGRAPHY

BIBLIOGRAPHY
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Marilyn E. Doenges, Mary Frances Moorhouse and Alice C. Geissier-Murr, 2006. Nurse’s
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FIFTH EDITION. Basic Nutrition for Filipinos. PA: Virginia Serraon-Claudio, Ofelia V.
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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLAN OF INTERVENTION EVALUATION

GOAL
Subjective: Activity Within 30 After 30 mins of nursing care
Establish
intolerance mins of plan the patient was able to
guidelines and
“hirap pa kong
related to nursing reduce the effects of inactivity.
goals of activity
maglakad” as
Generalized care plan
with the patient.
verbalized by the Goals partially met.
weakness as the patient
patient
evidenced by: will be R: Motivation is
able to enhanced if the
Objective:
>fatigue
reduce the patient participates
>fatigue effects of in goal setting
>slow
inactivity.
movement
>slow movement ∙Encourage
adequate rest
> need to
>need to assist
periods, especially
assist when
when she walk
before meals, other
she walk
ADLs, exercise
sessions, and
ambulation.

R: Rest between
activities provides
time for energy
conservation and
recovery.

Assist patient
to plan activities for
times when he or
she has the most
energy.
 R: Not all self-care
and hygiene
activities need to
be completed in the
morning.

Encourage
verbalization of
feelings regarding
limitations.

R:
Acknowledgment
that living with
activity intolerance
is both physically
and emotionally
difficult aids
coping.

ASSESSMENT DIAGNOSIS PLAN OF INTERVENTION EVALUATION

GOAL
Subjestive: Risk for Within 30 >Provide physical After 30 mins of nursing care
deficient fluid mins of and emotional plan the patient maintain
“Tae ako ng tae
volume nursing support. normal fluid volume.
ng malambot” s
care plan
verbalized by the >Provide e
the patient
patient antiemetics and
maintain
replace I.V. fluids
normal
Objective:
as ordered. Monitor
fluid
fluid intake and
>excess fluid volume.
output and
output
electrolyte levels.
> less weight
>  Monitor the
patient for
returning symptoms
as food is
reintroduced after
he has received
nothing by mouth.
At this time,
provide a bland diet
that takes into
account his food
preferences.

>Small, frequent
meals to reduce the
amount of irritating
gastric secretions.A
ASSESSMENT DIAGNOSIS PLAN OF INTERVENTION EVALUATION
GOAL

Subjestive: Within 30
mins of
Objective: nursing
care plan
the patien
wiil be
able to