LICEO DE CAGAYAN UNIVERSITYR.N. PELAEZ BLVD. KAUSWAGAN, CDO

COLLEGE OF NURSINGNCM501202

A Case Study of:Jhunienne MatiasName of the Patient

As Partial Requirement for NCM501202

Submitted by:Tan, Kevin John T.NCM501202 student

Group A2

March 19, 2009

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TABLE OF CONTENTS

I. Introductiona. Overview of the caseb. Objective of the studyc. Scope and Limitation of the study

II. Profile of the patientIII. Developmental DataIV. Health History

a. Family and Personal health historyb. History of Present Illness

V. Nursing Assessment (System Review & Nursing Assessment II)

VI. Pathophysiology with Anatomy & PhysiologyVII. Medical Management

a. Medical Orders and Rationaleb. Drug study

VIII. Nursing Managementa. Ideal Nursing Management (NCP)b. Actual Nursing Management (SOAPIE)

IX. Referrals and Follow-upX. Evaluation and ImplicationsXI. Bibliography

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I. Introduction

a. Overview of the Study

Acute diarrhea or gastroenteritis is the passage of loose stools more

frequently than what is normal for that individual. This increased frequency is often

associated with stools that are watery or semisolid, abdominal cramps and bloating.

Acute watery diarrhea is an extremely common problem, and can be fatal due to

severe dehydration, in both adults and children, especially in the very young and the

old or in those who have poor immunity such as individuals with HIV infection or

patients who are using certain medications that suppress the immune system.

Gastroenteritis means inflammation of the stomach and small and large

intestines. Viral gastroenteritis is an infection caused by a variety of viruses that

result in vomiting or diarrhea or both. It is often called the "stomach flu," although it is

not caused by the influenza viruses.

Persons can reduce their chance of getting infected by frequent

handwashing, prompt disinfection of contaminated surfaces with household chlorine

bleach-based cleaners, and prompt washing of soiled articles of clothing. If food or

water is thought to be contaminated, it should be avoided.

Since most cases of acute watery diarrhea are infectious, especially in

developing countries, the majority of such illnesses can be prevented by drinking

water or eating foods that are not contaminated with infectious agents. Washing

hands frequently with non-contaminated water, when caring for a patient with

diarrhea as also always before eating is important. Proper storage of food and water

is also important to prevent harmful bacteria from contaminating them.

Other symptoms include nausea, vomiting, loss of appetite, belching, and

bloating. Occasionally, acute abdominal pain can be a presenting symptom. This is

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the case in phlegm nous gastritis (gangrene of the stomach) where severe

abdominal pain accompanied by nausea and vomiting of potentially purulent gastric

contents can be the presenting symptoms. Fever, chills, and hiccups also may be

present.

The diagnosis of acute gastritis may be suspected from the patient's history

and can be confirmed histologically by biopsy specimens taken at endoscopy.

b. Objective of the Study

This study aims to:

Conduct and evaluate an assessment for the client

Determine the causes, predisposing and precipitating factors that constitute

the onset of the disease process.

Render series of nursing interventions for the client’s care

Provide and disseminate important information as teachings to the client and

the significant others to boost the knowing and understanding of the nature of

the said health condition.

Improve skills and knowledge as health care providers in the clinical area.

c. Scope and Limitation of the Study

This study includes the collection of information specifically to the patient’s

health condition. The study also includes the assessment of the physiological and

psychological status, adequacy of support systems and care given by the family as

well as other health care providers.

The scope of this study would include:

a. Data collected via assessment, interviews with the patient, family members

and clinical records.

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b. Actual and ideal problems for 3 days including the initial assessment and its

appropriate nursing intervention that would be applied within his stay in the

hospital at PGH hospital

c. Developing a plan of care that will reduce identified predicaments and

complications.

d. Coordinating and delegating interventions within the plan of care to assist the

client to reach maximum functional health.

e. Further evaluating the effectiveness of nursing interventions that have been

rendered to the client.

An array of factors influencing the limitations of this study includes:

a. Data collected is limited only to assessment and interview to the patient,

patient’s chart and nurse on duty.

b. The interaction, assessment and care were only limited to a total of 16 hours

(2 days clinical duty, 1 day assessment) with actual nursing intervention done.

c. The lack of complete family history obtained was due to lack of laboratory

examinations or diagnostic examinations results like x-ray which data or

results obtained is in the chart of the client during the time of care.

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II. Patients Profile

Client’s Name: Matias, Jhunienne

Age: 6 months old

Birthday: September 17, 2008

Address: Mambuaya, Cagayan de Oro City

Civil Status: Single

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Weight: 6.5 Kg.

Informant: Inalen Matias (Mother)

Date of admission: Febuary 15, 2009

Time of admission: 4:00 PM

Chief complaint: LBM

Admitting diagnosis: AGE with mild dehydration

Attending physician: Dr. Bacal

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III. Developmental Data

Developmental Task Theory of Robert Havighurst

A developmental task is a task which arises at or about a certain period in the

life of an individual. Havighurst has identified six major age periods: infancy and

early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18

years), early adulthood (19-29 years), middle adulthood (30-60 years), and later

maturity (61+).

Basing on Havighurst’s Theory, my patient belongs in the infancy and early

childhood stage wherein he is learning to distinguish right from wrong and

developing a conscience.

Psychosexual Theory of Sigmund Freud

The psychosexual stages of Sigmund Freud are five different developmental

periods during which the individual seeks pleasure from different areas of the body

associated with sexual feelings. These stages are as follows:

Oral Birth to to 1year

Anal 2 to 3years

Phallic 4 to 5years

Latency 6 to 12years

Genital 13 and Up

Basing on this theory, Jhunienne Matias belongs to the oral stage wherein an

infant’s pleasure centers are in the mouth. This is also the infant's first relationship

with its mother; it is a nutritive one.

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Psychosocial Theory of Erik Erickson

Erik Erickson envisioned life as a sequence of levels of achievement. Each

stage signals a task that must be achieved. He believed that the greater that task

achievement, the healthier the personality of the person. Failure to achieve a task

influences the person’s ability to achieve the next task. Stages of Erikson’s

Psychosocial Theory are as follows:

 Infancy Birth – 18 months Trust vs. Mistrust

 Early Childhood 18 months – 3 years Autonomy vs. Shame

 Late Childhood 3 – 5 years Initiative vs. Guilt

 School Age 6 – 12 years Industry vs. Inferiority

 Adolescence 12 – 20 years Identity vs. Role Confusion

 Young Adulthood 18 – 25 years Intimacy vs. Isolation

 Adulthood 25 – 65 years Generativity vs. Stagnation

 Maturity 65 years to death Integrity vs. Despair

Basing on this theory, he is still belongs to Infancy based on Erikson’s theory

the child developmental task is the “TRUST vs. MISTRUST” Because an infant is

utterly dependent; the development of trust is based on the dependability and quality

of the child’s caregivers. If a child successfully develops trust, he or she will feel safe

and secure in the world. Caregivers who are inconsistent, emotionally unavailable,

or rejecting contribute to feelings of mistrust in the children they care for. Failure to

develop trust will result in fear and a belief that the world is inconsistent and

unpredictable.

As observed the child had already built trust to his mother and his

grandmother wherein he only allows his mother and grandmother to cuddled and

feed him.

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Cognitive Theory of Jean Piaget

Cognitive development refers to how a person perceives, thinks, and gains

understanding of his or her world through the interaction and influence of genetic

and learning factors. This is divided into five major phases:

Sensorimotor Phase Birth to 2 years

Pre-conceptual Phase 2 – 3 years

Intuitive Thought Phase 4 – 6 years

Concrete Operations Phase 7 – 11 years

Formal Operational Phase 12 – adulthood

 

Basing on this theory, Jhunienne Matias belongs to the sensorimotor stage in

which inventions of new means through mental combinations. The patient uses

memory and imitation act, he can solve basic problems.

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IV. HEALTH HISTORY

a. Family Health History

According to the father regarding the herido-familial history both her

mother and father side has a history of hypertension. On the father side

they had a history of cancer since the father’s aunt died last 2001 due to

cervical cancer.

b. Past Health History

The father claimed that his child past illnesses were a typical cough,

colds and fever that usually lasted for three days. Over the counter

medicines such as Paracetamol (Calpol) was used to treat for fever and

Dimetapp for colds. The father claimed that his child has not completed

the vaccination required and never experiencing major illness that

required hospitalization until this Febuary 15, 2008 wherein the patient has

been admitted at JRB Hospital having an acute diarrhea but the father

denied that his child does not have known allergies to drugs and foods nor

his child received a blood transfusion.

The patient was born in JRB Hospital through a normal spontaneous

vaginal delivery.

c. History of Present Illness

A case of Matias, Jhunienne, 6months old Male, Filipino, a resident of

Mambuaya Cagayan de Oro City, admitted for the first time at PGH

hospital with a chief complaint of LBM. Two days prior to admission he

had persistent LBM, vomiting, cough and fever.

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V. Nursing Assessment (System Review & Nursing Assessment II)

Name: Jhunienne Matias Date: 02-15-09Temp: 38.6ºC HR: 137bpm BP: N/A Height_____ Weight:6.5 kgsRR: 50cpmINSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X].

EENT:[ ] impaired vision [ ] blind [ ] pain reddened [ ] drainage Sunken eyes [ ] gums [ ] hard of hearing [ ] deaf Poor appetite[ ] burning [ ] edema [ ] lesion teeth ColdsAssess eyes, ears, nose throat CoughFor abnormality [ ] no problem Poor skin turgorRESPIRATION: [ ] asymmetric [ ] tachypnea [ ] barrel chest Hyperactive[ ] apnea [ ] rales [x] cough bowel sounds[ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood breath sounds, comfort [ ] no problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain Assess abdomen, bowel habits, swallowing bowel sounds, comfort [x] no problem GENITO-URINARY AND GYNE: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia Hyperthermiaassess urine frequency, control, color, odor, comfort =38.6CNEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures hooked with [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors IVF of D5 0.3Nacl[ ] confused [ ] vision [ ] grip 500cc assess motor, function, sensation, LOC, strength grip, gait, coordination, speech [x] no problem MUSCULOSKELETAL AND SKIN: Watery Stools[ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [x] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic/moist assess mobility, motion, gait, alignment, joint function skin color, texture, turgor, integrity [ ] no problem

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SUBJECTIVE OBJECTIVE

COMMUNICATION:[ ] hearing difficulty

[ ] visual changes

[x] denied

Comments: “Wala man

siya problema sa pandungug ug pagtanaw” asverbalized by the mother

[ ] glasses [ ] languages[ ] contact lenses [ ] hearing difficulties due to age[ ] speech difficultiesPupil size:R:3 mm L:3mm Reaction: PERRLA (Pupil Equally Round Reactive to Light and Accommodation)

OXYGENATION:[ ] dyspnea[ ] smoking history Non-smoker

[x] cough[ ] sputum[ ] denied

Comments:”Naa jud siya

ubo nabalaka na jud ko

ani niya”as verbalized

by the mother.

Resp. [x] regular [ ] irregularDescribe: RR is within normal range. R: symmetrical to the left lungL: symmetrical to the right lung

CIRCULATION:[ ] chest pain

[ ] leg pain

[ ] numbness of

extremities

[x ] denied

Comments: ”Wala may

sakit sa tiil ug dughan

akong anak”as verbalized

by the mother.

Heart Rhythm [x ] regular [ ] irregularAnkle Edema: No ankle edema is present on both extremitiesPulse Car Rad. DP Fem*R _______+______+_ __ + __not assessed L _____+_____ +_ _____+ not assessed Comments: Right and left pulses are equal; strong and palpable.

NUTRITION:Diet: Exclusive B.F since Birth.Character[ ] recent change in weight [ ] swallowing Difficulty[x] denied

Comments: ”Gina patutoy

Raman nako siya”

as verbalized by the

mother.

[ ]dentures [x]none

Complete Incomplete

Upper [ ] [x]

Lower [ ] [x]

ELIMINATION:Usual bowel pattern5 loose stools per day [ ] constipation remedy

Date of last BM December 5, 2008 [ x ] diarrhea[ ] constipation

[x] urinary frequencyDiaper [ ] urgency[ ] dysuria[ ] hematuria[ ] incontinence[ ] polyuria[ ] foley in place[x] denied

Comments: ”magsunod

sunod jud siya ug

kalibanga”as verbalizeby the mother.

Bowelsounds: hyperactive Abdominal DistentionPresent [ ] yes [x] noUrine* (color, consistency, odor)urine color is straw, amber transparent and faint aromatic odor.

*if they are in place

MGT. OF HEALTH & ILLNESS:[ ] alcohol [ x ] denied(amount & frequency) ________________________________________.[ ] SBE: N/A Last Pap Smear: N/A

Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).N/A.

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SUBJECTIVE OBJECTIVESKIN

INTEGRITY:

[x] dry

[ ] other

[ ] denied

Comments: ”Mala jud iya panit kay cige ra ug kalibang” as verbalized by the mother.

[x] dry [ ] cold [ ] pale[ ] flushed [ ] warm [ ] moist [ ] cyanotic*rashes, ulcers, decubitus (describe size, location, drainage: no rashes and ulcers found the the patients body.

ACTIVITY/ SAFETY:[ ] convulsion[ ] dizziness[ ] limited motion of Joints

Limitation in Ability to[ ] ambulate[ ] bathe self[ ] other[x] denied

Comments:”kalooy sa ginoo wala jud nag lipong-lipong akong anak ug maka lihok rapud siya” as verbalized by the mother.

[x] LOC and orientation Patient is normal- unconscious orientedGait: [ ] walker [ ] cane [ ] other

[x] steady [ ] unsteady_________[ ] sensory and motor losses in face orextremities No sensory and motor losses on face or extremities[x] ROM limitations: no ROM limitations

COMFORT/SLEEP/AWAKE:[ ] pain

(location) Frequency Remedies[ ] nocturia[x]sleep difficulties[ x ] denied

Comments: perminte ra siya ga mata mata tungod ni sa iyang kainit” as verbalized by the mother.

[x] facial grimaces[ ] guarding[ ] other signs of pain :

COPING:Occupation: N/AMembers of household: 2 members of householdMost supportive person: Karl William Matias(father) and Inalen Matias(mother)

Observed non-verbal behavior: the patient is restlessPhone number that can be reached anytime: refused

SPECIAL PATIENT INFORMATION Not ordered _Daily weight ____N/A___ PT/OT __ N/A ___ every 2hr _ __BP q shift ____N/A___ Irradiation____N/A___ _ Neuro vs __ done _Urine test _______________N/A_ _ CVP/SG Reading __N/A___ __No Order__24 hour Urine Collection

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VI.ANATOMY AND PHYSIOLOGY:

DIGESTIVE SYSTEM

The digestive system consists of two linked parts: the alimentary canal and the

accessory digestive organs. The alimentary canal is essentially a tube, some 9

meters (30 feet) long, that extends from the mouth to anus, with its longest section-

the intestines- packed into the abdominal cavity. The lining of the alimentary canal is

continuous with the skin, so technically its cavity lies outside the body. The

alimentary ‘tube’ consist of linked organs that each play their own part in digestion:

mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The

accessory digestive organs consist of the teeth and tongue in the mouth; and the

salivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the

alimentary canal.

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STOMACH

It is a J- shaped enlargement of the GI tract directly under the diaphragm in

the epigastric, umbilical and left hypochondriac regions of the abdomen. When

empty, it is about the size of a large sausage; the mucosa lies in large folds, called

RUGAE. Approximately 10 inches long but the diameter depends on how much food

it contains. When full, it can hold about 4 L ( 1 galloon) of food. Parts of the

stomach includes cardiac region which is defined as a position near the heart

surrounds the cardioesophageal sphincter through which food enters the stomach

from the esophagus; fundus which is the expanded part of the stomach lateral to the

cardia region; body is the mid portion; and the pylorus a funnel shaped which is the

terminal part of the stomach. The pylorus is continuous with the small intestine

through the pyloric sphincter, or valve.

With the gastric glands lined with several secreting cells the zymogenic

(peptic) cells secrete the principal gastric enzyme precursor, pepsinogen. The

parietal (oxyntic) cells produce hydrochloric acid, involved in conversion of

pepsinogen to the active enzyme pepsin, and intrinsic factor, involved in the

absorption of Vitamin B12 for the red blood cell production. Mucous cells secrete

mucus. Secretions of the zymogenic, parietal and mucus cells are collectively called

the gastric juice. Enteroendocrine cells secrete stomach gastrin, a hormone that

stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower

esophageal sphincter, mildly increases motility of the GI tract, and relaxes the

pyloricsphincter. Most digestive activity occurs in the pyloric region of the stomach.

After food has been processed in the stomach, it resembles heavy cream and is

called CHYME. The chyme enters the small intestine through the pyloric sphincter.

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VI. Pathophysiology with Anatomy & Physiology

Name of the patient: Jhunienne Matias Diagnosis: AGE with mild DHN

Definition: Acute Gastritis is defined as diarrheal disease of rapid onset, often with nausea, vomiting, fever, abdominal pain and loose bowel movement. It is an inflammation of the mucous membranes of the stomach often caused by an infection.

Predisposing Factors: Precipitating Factors:

Environment ~ Age(6 Months) Hygiene ~ Gender(Male) Stress

Ingestion of E. Coli

Invasion of gastric mucosa

Penetration of Gastric mucosa

Signs & Symptoms:Watery stoolFever

Toxins producing pathogens cause watery,

large volume diarrhea

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Irritation of the Gastric Lining

Signs & Symptoms:Vomiting

Fluid and Electrolyte imbalance too much Na+ and H2O are expelled from the body

Increased fluid lossSigns & Symptoms:

Decrease skin turgorSunken Eyes

Dehydration

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VII. MEDICAL MANAGEMENT

a. Medical Orders and RationaleDOCTOR’S ORDER RATIONALE

02-15-09

Please admit to pedia ward

under the service of Dr. Bacal

At par with age regular diet

Start D5 0.3NaCL 500ml @

100cc/hr

Labs:

CBC

Urinalysis

SE

I & O q shift

v/s q4H

02-15-09

IVF with D5 0.3NaCl 500ml @

For further management and

treatment of condition

To provide easy digestion of food

without experiencing pain upon

digestion

To provide access for intravenous

medications.

To screen the patient’s blood

component and to detect any

abnormalities. This also serves as a

baseline data to evaluate

effectiveness of blood transfusions.

To screen the patient’s urine

components and to detect any

abnormalities.

To screen the patients feces & to

detect any abnormalities

To measure daily I & O of the client

To have baseline data and for

comparison of future data / for

monitoring of patient’s condition.

To provide access for intravenous

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100cc/hr

02-016-09

Continue medications

For billing today

IVF with D5 0.3 NaCl500cc @

SR

02-16-09

Continue medications

IVF D5 0.3 NaCl 500cc @ SR

medications.

To help for fast recovery

Preparation for going home

To provide access for intravenous

medications.

To help for fast recovery

To provide access for intravenous

medications.

b. Laboratory Results

CBC

Hemoglobin 17.3 gms %

Hematocrit 49.6 vol %

White Cell Count 14,351/mm3

Fecalysis

Character: soft WBC/hpf: 4-6

Color: yellow RBC/hpf: 6-8

Parasite ascarasis: none seen cysts: positive

Trichuris: none seen trophosites: none seen

Hook worm: none seen

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c. Drug study

DRUG NAME Paracetamol DOSE/FREQUENCY/ROUTE 500 mg 1 tab q4h PRN for feverCLASSIFICATION Analgesic; antipyretic MECHANISM OF ACTION May produce analgesic effect by blocking pain impulses, by inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by actingon hypothalamic heat-regulating center. Relieves fever. SPECIFIC INDICATION For fever.CONTRAINDICATION Contraindicated in patients hypersensitive to drug or its components. SIDE EFFECTS Anemia, jaundice, rash, urticaria.NURSING PRECAUTION Do not administer for fever that’s above 39.5 C, lasts longer than 3 days or recurs.

DRUG NAME AMBROXOLDOSE/FREQUENCY/ROUTE 0.75ml TID P.OCLASSIFICATION Cough and Cold PreparationMECHANISM OF ACTION Ambroxol is a mucolytic agent. It acts by increasing the respiratory tract secretion of lower viscosity mucus and exerting a positive influence on the alveolar surfactant system which leads to improved mucus flow and transport. Expectoration of mucus is thus facilitated.SPECIFIC INDICATION Cough CONTRAINDICATION Hypersensitivity to ambroxol or any ingredient of Ambrolex.SIDE EFFECTS Mild GI side effects.NURSING PRECAUTION Should be taken with food.

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DRUG NAME GENTAMYCINDOSE/FREQUENCY/ROUTE IVT q 8 ANSTCLASSIFICATION Amino glycoside MECHANISM OF ACTION Broad-spectrum aminoglycoside antibiotic derived from Micromonospora purpurea. Action is usually bacteriocidal.

SPECIFIC INDICATION Parenteral use restricted to treatment of serious infections of GICONTRAINDICATION

History of hypersensitivity to or toxic reaction with any

aminoglycoside antibiotic. Safe use during pregnancy (category C) or lactation is

not established

SIDE EFFECTSa. an allergic reaction (shortness of breath; closing of the throat; hives;

swelling of the lips, face, or tongue; rash; or fainting);

b. little or no urine;

c. decreased hearing or ringing in the ears;

d. dizziness, clumsiness, or unsteadiness;

e. numbness, skin tingling, muscle twitching, or seizures; or

f. severe watery diarrhea and abdominal cramps.

NURSING PRECAUTION Draw blood specimens for peak serum gentamicin concentration 30 min–1h after IM administration, and 30 min after completion of a 30–60 min IV infusion. Draw blood specimens for trough levels just before the next IM or IV dose. Use nonheparinized tubes to collect blood.

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DRUG NAME Ampicillin DOSE/FREQUENCY/ROUTE 250mg IVT q 8 ANSTCLASSIFICATION Antibiotic penicillinMECHANISM OF ACTION Bacterial action against sensitive organism inhibits synthesis of bacterial cell wall, causing cell death.

SPECIFIC INDICATION Treatment of infections caused by susceptible strains of E.coli.CONTRAINDICATION Contraindicated with allergies to penicillin.SIDE EFFECTS CNS: lethargy seizures

CV: CHF

GI: stomatitis, sore mouth, furry tongue

Other: super infections

NURSING PRECAUTION

A. Take this drug Round the Clock.B. Allergies of penicillinC. Culture Infected areaD. Take oral drug on empty stomach

VIII. NURSING MANAGEMENT

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Ideal Nursing Manangement - Risk for fluid volume deficit related to excessive losses through normal routes (frequent diarrhea, vomiting)

INTERVENTIONS RATIONALEINDEPENDENT

Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria.

Assess vital signs (BP, pulse, temperature).

Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill.

Weigh daily

Maintain oral restrictions, bed rest.

Observe for overt bleeding and test stool daily for occult blood.

Note generalized muscle weakness or cardiac dysrhytmias.

COLLABORATIVE Administer parenteral fluids, blood transfusions

as indicated.

Monitor laboratory studies, e.g., electrolytes (especially potassium, magnesium) and ABGs (acid-base balance).

Administer medications as indicated: Antidiarrheal e.g., dipphenoxylate (Lomotil),

loperamide (Imodium), anodyne suppositories.

Antiemetics, e.g., trimethobenzamide (Tigan), hydroxyzine (Vistaril), prochlorperazine (Comparazine);

Antipyretics, e.g., acetaminophen (Tylenol);

Electrolytes, e.g., potassium supplement (KCl-IV;K-Lyte, Slow-K);

Vitamin K (Mephyton)

Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

Hypotension (including postural), tachycardia, fever can indicate response to and/or effect of fluid loss.

Indicates excessive fluid loss/resultant dehydration.

Indicator of overall fluid and nutritional status. Colon is placed at rest for healing and to

decreased intestinal fluid losses.

Inadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating risk for hemorrhage.

Excessive intestinal loss may lead to electrolyte imbalance, e.g., potassium, which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound and/or life-threatening symptoms.

Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: fluids containing sodium may be restricted in presence of regional enteritis.

Determines replacement needs and effectiveness of therapy.

Reduces fluid losses from intestines.

Used to control nausea and vomiting in acute exacerbations.

Controls fever, reducing insensible losses.

Electrolytes are lost in large amounts, especially in bowel with denuded, ulcerated areas, and diarrhea can also lead to metabolic acidosis through loss of bicarbonate (HCO3).

Stimulates hepatic formation of prothrombin, stabilizing coagulation and reducing risk of hemorrhage.

IDEAL NURSING MANAGEMENT

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Knowledge deficient regarding condition, prognosis, treatment, self-care, and discharge needs as related to unfamiliarity with resources and information misinterpretation.

Desire outcomes/evaluation criteria- the significant others will:

Verbalize understanding of disease processes, possible complications.

INTERVENTION RATIONALEINDEPENDENT

Determine the mother’s perception of disease process.

Review disease process, cause/effect relationship of factors that precipitate symptoms, and identify ways to reduce contributing factors. Encourage questions.

Review medications, purpose, frequency, dosage, and possible side effects.

Stress importance of good skin care, e.g., proper handwashing techniques and perineal skin care.

Emphasize need for long-term follow-up and periodic reevaluation.

Establishes knowledge base and provides some insight into individual learning needs.

Precipitating/aggravating factors are individual; therefore, the mother needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. Accurate knowledge base provides opportunity for the mother to make informed decisions/choices about future and control of chronic disease. Although most others know about their own disease process, they may have outdated information or misconceptions.

Promotes understanding and may enhance cooperation with regimen.

Reduces spread of bacteria and risk of skin irritation/breakdown, infection.

Patients with IBD are at risk for colon/rectal cancer, and regular diagnostic evaluations may be required..

IDEAL NURSING MANAGEMENT

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Hyperthermia related to dehydration as evidenced by increase in body temperature higher than normal range.

Desired outcomes/evaluation criteria- patient will:Demonstrate temperature within normal range, be free of chills.

INTERVENTION RATIONALEIndependent

monitor patient temperature(degree and pattern); note shaking chills/profuse diaphoresis.

Monitor environmental temperature; limit/add bed linens as indicated.

Provide tepid sponge baths; avoid use of alcohol.

Collaborative

Administer antipyretics, e.g., acetylsalicylic acid (ASA) (aspirin), acetaminophen (Tylenol).

Provide cooling blanket.

Temperature of 102F-106F (38.9C- 41.1C) suggests acute infectious disease process. Fever pattern may aid in diagnosis; e.g., sustained or continuous fever curves lasting more than 24 hour suggest pneumococcal pneumonia, scarlet or typhoid fever; remittent fever (varying only a few degrees in either direction) reflects pulmonary infections; intermittent curves or fever that returns to normal once in 24-hour period suggests septic episode, septic endocarditis, or tuberculosis (TB). Chills often precede temperature spikes.

Note: Use of antipyretics alters fever patterns and may be restricted until diagnosis is made or if fever remains higher that 102F (38.9C).

Room temperature/number of blankets should be altered to maintain near-normal body temperature.

May help reduce fever. Note: use of ice water/alcohol may cause chills, actually elevating temperature. In addition, alcohol is very drying to skin.

Used to reduce fever by its central action on the hypothalamus; fever should be controlled in patients who are neutropenic or asplenic. However, fever may be benefial in limiting growth of organisms and enhancing autodestruction of infected cells.

Used to reduce fever, usually higher than 104F-105F (39.5C-40C), when brain damage/seizures can occur.

b. Actual Nursing Management

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Priority number 1

S “Sa wala pa na admit akong anak, ge ubo na siya” as verbalized by the

patient’s mother

O Productive cough

Inability to expectorate secretions

Restlessness

A Ineffective Airway Clearance related to productive cough

P Short Term: At the end of 8 hours, the patient will be able to maintain airway

patency.

I

1. Elevated head of the bed by putting pillow under the head/changed

position frequently.

To enhance drainage and ventilation to different lung

segments

2. Monitored infant for feeding intolerance, abdominal distention and

emotional stress.

May compromise airway.

3. Encouraged mother to hydrate infant frequently.

To loosen the secretions

4. Positioned appropriately and discouraged use of oil-based products

around the nose.

To prevent vomiting with aspiration to lungs

Dependent:

5. Administered Ambroxol as prescribed.

To loosen the secretions

E The goal has been met; the patient was able to maintain airway patency.

Priority number 2

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S “Nangluspad naman gud akong anak tungod kai daghan na siya nasuka ug

gekalibang” as verbalized by the patient’s mother

O

Cool extremities

Sunken eyes

Dry skin

Watery stool

Persistent vomiting

Weight (Before = 7 kgs; Now = 6.5 kgs)

A Fluid volume deficit related to excessive losses through GI tract secondary to

diarrhea

P Short term: At the end of 8 hours, the patient will be able to restore fluid and

electrolyte imbalances

I

Encouraged the mother to give oral fluid intake.

To increase fluid intake

2. Monitored intake and output balance.

To ensure accurate picture of fluid status

3. Observed for excessively dry skin and mucous membranes, decreased

skin turgor, slowed capillary refill.

Indicates excessive fluid loss/resultant dehydration

4. Weighed daily

Indicator of overall fluid and nutritional status

5. Monitored vital signs

To note the changes in heart rate and respiration

Dependent:

6. Provided supplement fluids as indicated D5LR 500cc @ 28cc/hr

Fluids may be given in this manner if patient is unable to take

oral fluid

E Goal has been met; at the end of 8 hours, the patient was able to restore fluid

and electrolyte imbalances

Priority number 3

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S“Sakit kayo ang tiyan sa bata sig era siya hilak sa kasakit. Basa pa gyud

iya tae ug sige na siya kalibang” as verbalized by the patient’s mother

O Hyperactive bowel sounds

3-5 loose liquid stools per day

A Diarrhea related to irritation of the GI tract

P Short Term: at the end of 8 hours, the patient will reestablish and

maintain normal pattern of bowel functioning.

I

1. Weighed infant’s diaper.

To determine the amount of output and fluid

replacement needs

2. Encouraged oral fluid intake containing electrolytes.

To maintain fluid and electrolyte balance

3. Provided prompt diaper changes and gentle cleansing

Because, skin breakdown can occur quickly when

diarrhea is present

4. Did auscultation of abdomen.

To check for presence, location, and characteristics of

bowel sounds.

Dependent:

5. Administered antidiarrheal medications as prescribed.

To treat infectious process and decrease motility and

minimize fluid losses

EGoals were not met

At the end of 8 hours, the patient was unable to manifest signs of

decrease fluid volume.

IX. Referrals and Follow-up

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Our further Inpatient care includes monitoring of changes in vital signs,

assessment of effectiveness of treatment regimen, reinforcement of dietary

advice(At par with age regular diet), and the advice regarding the importance of

adequate bed rest.

Our further Outpatient care includes instructions of Mr.& Mrs.Inalen Matias

dietary modification of their son, compliance with treatment regimen, and parents’

participation through reporting of adverse effects of medications to his physician.

The parent was also instructed to have a regular check-up at PGH Hospital with their

son in order to monitor the current condition.

X. Evaluation and Implications

Within the span of 2 day of rendering care to Jhunienne Matias. I was able to

identify potential problems and specific nursing interventions were provided. With the

help of health teachings and other interventions, Parents of Jhunienne Matias were

able to learn how to recognize signs and symptoms and other risk factors of the

condition of their son. The Parents of Jhunienne Matias was able to verbalized the

importance of giving medications to their son. They had also recognized the

importance of compliance to treatment regimen in order to manage the condition of

their son, Jhunienne Matias.

XI. BIBLIOGRAPHY:

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o Luckman and Sorensen, Medical-Surgical Nursing. 3rd Edition W.B. Saunders

Company (1987)

o Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education

South Asia PTE LTD Philippines 2004

o Smeltzer, Medical-Surgical Nursing. 11th edition, Lippincott William & Wilkins,

2007

o Mosby, Mosby’s Nursing Drug Reference, Elesevier Mosby, 2005

o Doengoes, Nurse’s Pocket Guide. 9th edition, F.A. Davis, 2004

o www.wikipedia.org

o www.mims.com

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