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Acute Gastroenteritis
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Health History
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Demographic Data
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Demographic Data
Clients Name:
Gender:
Demographic Data
Race/ Nationality:
Religion:
Address:
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Hospitalization:
Immunizations:
No Known Allergy
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Family History
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Developmental History
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Developmental History
Sigmund Freuds Psychosexual Development
Oral (birth 1 year old) Anal (1-3 years old) Phallic (3 6 years old) Latency (6 puberty) Genital (puberty death)
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Developmental History
Stage Task Patients Description
Infant's mouth isBaby LC is taking the focusformula milk oflibidinal instead of gratification derivedbreastmilk. At the from the pleasuresame time, his of feeding at thecurrent condition mother's breast,(AGE) usually and from the oralderived from exploration of his orsucking dirty things her environment
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Review of Systems
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Review of Systems
Regional Examinations General/ Overall Health State
5 months old 7.5 kg in weight Vital signs of 36.2C (temperature),
Review of Systems
Regional Examinations Integument
Skin rashes are covering half of his
buttocks * Skin rashes pinkish to reddish in color and approximately 3-5 cm in circumference each circle
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Review of Systems
Laboratory Results: Normal Values Procedure
Hemoglobin Hematocrit WBC Lymphocytes 140-180 0.42-0.54 5-10 25-40%
Interpretation Low Iron intake Low Iron intake Infection Viral infection
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Functional Assessment
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Functional Assessment
Elimination Baby LC defecated 2 times from 6 oclock in the morning up to 12 oclock in the afternoon. The color of his stool is yellowish and semi-formed in consistency
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Pathophysiol ogy
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Concept mapping
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1
Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes
2
Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6 hours
Baby LC
Dx: Acute Gastroenteritis Signs & Symptoms: *defecated 2x *watery to semi-formed stool *skin rashes (pinkish to reddish)
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Problem list
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Problem List
Actual Number 1 Problem Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes
Potential Number 1 Problem Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6 hours
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S: No verbal Impaired skin At the end of Assessed site of At the end of skin impairment cues the entire shift, integrity r/t the entire shift, Advised the irritation of the the patient will patients mother to the patients lessen the O: skin irritation skin from lessen his skin positioning on the defecated 2x was lessened excessive irritation due toaffected area watery to semiAdvised the formed stool moist aeb skin excessive patients mother to rashes moist check most of the skin rashes time the affected (pinkish to area and report reddish, 3-5 cm immediately if the in condition worsen Advised the circumference patients mother to each circle) change located at the immediately the buttocks diaper especially
Nursing Intervention
Evaluation
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Medical-surgical management
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Drug Study
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Classification
Adverse effect
Indication
Contraindication
Nursing Responsibilities
Protexin Probiotic (Restore) Helps to improve the balance of microorganism in the intestinal tract Vitamin for growth and health. It helps the body use carbohydrates, fats and protein. It also strengthens blood vessel walls
Blood problems, Observe the 5 Glucose-6rights in giving phosphate medication dehydrogenase Advise the (G6PD) patients mother deficiency to: -Strictly follow the doctors advise on how much to take and how often -May be taken with or without food -Try not to miss any doses
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Classification
Adverse effect
Indication
Contraindication
Nursing Responsibilities
Zinc Sulfate Trace element Nausea and Acute diarrhea Immuno(E-Zinc) vomiting, compromised dizziness, patients Contributes to fever, stomach the recovery of pain, the intestinal incoordination, microbial flora restless and maintenance of skin hydration
Observe the 5 rights in giving medication Shake drug well before administra-tion Monitor patient for any unusual effect
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Classification
Adverse effect
Indication
Contraindication
Nursing Responsibilities
Antiseptic
Nappy rash & Hypersensitivit Store below Urinary rash y to 25C benzalkonium Tell the chloride, patients cetrimide or mother that it is lanolin for external use only Advise the patients mother to discontinue the topical cream if adverse reaction occur
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Classification
Adverse effect
Indication
Contraindication
Nursing Responsibilities
Antibiotic
Take the drug Treatment of Allergic to infection caused penicillin, around-the-clock by susceptible cephalosporins Take the full strains course of therapy It should not be used to self-treat other infections aside from what the doctor stated Advise to report N/V, diarrhea
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with the drugs as prescribed by the doctor and do not abruptly stop the drug without doctors consent
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and support Baby LC in playing and moving- around because it serves as his ADL
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feeding as tolerated)
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Thank You
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