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Liceo de

Cagayan

University

College of

Nursing

NCM501205

As Partial

Requirement for NCM501205

Case Study on

Acute Gastro-enteritis with moderate

Dehydration

Submitted to:

Ms. Marineth Zapanta

Clinical Instructor

Submitted by:

Webster S. Abadiano

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October 13,2011

(Bukidnon Provincial Malaybalay Center)PAGES

I. Introduction

a. Overview of the case 1

b. Objective of the study 2

c. Scope and Limitation of the study 2

II. Health History

a. Patient Profile 3

b. Family health history 3

c. Past health history 4

d. History of present illness 4

III. Developmental Data 4-5

IV. Medical Management

a. Medical Orders and Rationale 6

b. Drug Study 7-8

V. Pathophysiology with Anatomy & Physiology 9-10

VI. Nursing Assessment (System Review & Nursing. Assessment II 11-14

VII. Nursing Management

a. Ideal Nursing Management 15-

17

b. Actual Nursing Management (SOAPIE) 18-20

VIII. Referrals and Follow-up 21-22

IX. Evaluation and Implications 23

b. Organization/Grammar/Bibliography

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I. INTRODUCTION

A. OVERVIEW OF THE CASE

Acute Gastroenteritis (AGE)

Gastroenteritis is a catchall term for infection or irritation of the digestive tract,

particularly the stomach and intestine. It is frequently referred to as the stomach or

intestinal flu, although the influenza virus is not associated with this illness. Major

symptoms include nausea and vomiting, diarrhea, and abdominal cramps. These

symptoms are sometimes also accompanied by fever and overall weakness.

Gastroenteritis typically lasts about three days. Adults usually recover without problem,

but children, the elderly, and anyone with an underlying disease are more vulnerable to

complications such as dehydration.

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 thedoctor. 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

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B. OBJECTIVES 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 clients 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 LIMITATIONS OF THE STUDY

This study includes the collection of information specifically to the patients 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 andclinical records.

b. Actual and ideal problems for 3 days including the initial assessment and itsappropriate nursing intervention that would be applied within his stay in thehospital at BPMC hospital.

c. Coordinating and delegating interventions within the plan of care to assist theclient 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 mother as a SO,

patients chart and nurse on duty.

b. The interaction, assessment and care were only limited to a total of 24 hours (3 days

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clinical duty, assessment) with actual nursing intervention done.

II. HEALTH HISTORY

A. Patients Profile

Name : JLG

Age : 8 months

Sex : male

Address : Taguican valley, canayan, Malaybalay city

Date of Birthday : December 31, 2010

Birthplace : Malaybalay city

Religion : Baptist

Nationality : Filipino

Civil Status : Child

Weight : 7.3kg

Occupation: n/a

Income : n/aEducational Attainment : n/a

Most supportive person : mother

Date of Admission : September 18,2011

Time of Admission: 9:30 P.M.

Ward/ Room : Pedia Ward/ Room 302

First Impression : AGE with moderate Dehydration

Chief Complaints : vomiting and fever

Final diagnosis: AGE with moderate dehydration, electrolytes imbalance

(hypokalemia) 2 to acute gastrointestinal loses

Admitting Physician : Dr. Shane Tortola

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B. Family and Present health History

The patients mother has diabetes and her father has no serious disease diagnose

yet. The patient is a non-diabetic, non-hypertensive and non-asthmatic and has no

previous hospitalization until today.

C. History of Present Illness:

A case of JGL, 8 months old Male, Filipino, a resident of Canayan, Malaybalay

city, admitted for the first time at BPMC hospital with a chief complaint of LBM. Two

days prior to admission he had persistent vomiting and fever.

III. DEVELOPMENTAL DATADevelopmental 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).Basing on Havighursts 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

Basing on this theory, JLG belongs to the oral stage wherein an infants pleasure

centers are in the mouth. This is also the infant's first relationship with its mother; it is a

nutritive one.

Psychosocial Theory of Erik Erickson

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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 persons ability to achieve the next task.

Basing on this theory, he is still belongs to Infancy based on Eriksons 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

childs 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.

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.

Basing on this theory, JLG 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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VI. MEDICAL MANAGEMENT

A. Medical Orders and Rationale

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Date Doctors order Rationale

September 18,2011 - please admit to ward For further management and

treatment of condition

9:30 pm -Secure consent - For further management and

treatment of condition

-TPR q 4 To have baseline data and for comparison of future data / for

monitoring of patients

condition.

-diet for age to provide easy digestion of

food-IVF with D5 0.3percent NaCl500 cc at 35 cc/hour

For hypertonic dehydration, Naand chloride depletion and

water replacement

LBM, Vomiting for 2 days -Labs: CBC with Platelet count,

SE, U/A

To screen the patients blood,

urine and stool examcomponent and to detect any

abnormalities. This also serves

as a baseline data to evaluateeffectiveness of blood

transfusions.

Sunken eyeballs,

Sunken fontanels

-Meds:

Zinc drops 1.0ml OD P.OParacetamol 100 ml PO q 4

PRN for above 38 degree

celcius

For treatment and for specific

indication

Weight: 7.3 kgT-36

RR-34

PR-128

-Refer Refer for any progression of thecondition

-Thanks

By: Dr. ShaneTortola

September 19,2011 -continue meds For continuing of treatment

-follow up labs To follow the result

Still with LBM -IVFTF with D5IMB 500cc at

30cc/hr(2 bottles)

This is the IV that has a bigger

amount of K (20 mEq)

September 20,2011 -continue meds For continuing of treatment

-IVFTF D5IMB 500cc at same

rate

This is the IV that has a bigger

amount of K (20 mEq)

-Vit. A 100,000 Units S.D For nutrient purposes

-Cefexime drops 1.8Ml BID

P.O

For antibiotic purposes

-give PNSS 150 cc with IV

Bolus now

Treatment for diarrhea and

vomiting

-revise present IVF with D5LR

1L at 30 mgtts/min x 6 hour

then regulate at 12 gtts/min

Replacement therapy

particularly in extracellular

fluid deficit

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C. Laboratory Results

Clinical Chemistry

CBC

Urine analysis

Fecalysis

Potassium 2.14 3.6-5.5mEq/dl

Sodium 143.6 135-155 mEq/dl

Color Greenish

Character Soft

Fat globules Plenty

CBC Result Valuewbc 6.1 5,000-10,000

Hgb 10.2 11.7-14.5

Hct 32.3 34.1-44.3 vols

Platelet count 428,000 174,000-390,000

Differential count

Segmenters 25.5 43.4-76.2

Lymphocyte 49.4 17.4-46.2

Monocytes 23.4 4.5-10.5

Eosinophils 0.8 2-3Basophils 0.9 4.5-0.5

Color yellow

Transparency cloudy

Sugar negative

SP Gravity 1.016

Reaction 6.0

Albumin negative

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V. PATHOPHYSIOLOGY WITH 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 9meters

(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 consists 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

ardioesophageal sphincter through which food enters the stomach from the esophagus;

fundus which is the expanded part of the stomach lateral to the cardiac 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. Enter endocrine cells secrete stomach gastrin, a hormone that stimulatessecretion of hydrochloric acid and pepsinogen, contracts the lower esophageal

sphincter, mildly increases motility of the GI tract, and relaxes the pyloric sphincter. 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 chime

enters the small intestine through the pyloric sphincter

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Pathophysiology

Name of the patient: JLG Diagnosis: AGE with moderate 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) Gender(Male)

Hygiene Age(6 Months)

Stress

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VII. NURSING MANAGEMENT

Ideal Nursing Management -Risk for fluid volume deficit related to excessive losses

through normal routes (frequent diarrhea, vomiting)

IDEAL NURSING MANAGEMENT

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INTERVENTION RATIONALE

INDEPENDENT

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 andmucous membranes.

Slowed capillary refill.

Weigh daily

Maintain oral restrictions, bed rest.Observe for overt bleeding and test stooldaily for occult blood.

Note generalized muscle weakness orcardiac dysrhytmias.

COLLABORATIVE

Administer parenteral fluids, bloodtransfusions 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.

Antiemetic, 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 diseasecontrol, as well asguidelines for fluid

replacement.

Hypotension (including postural),tachycardia, fever can indicate response to

and/or effect of fluid loss.

Indicates excessive fluid loss/resultantdehydration.

Indicator of overall fluid and nutritional

status.Colon is placed at rest for healing and todecreasedintestinal fluid losses.

Inadequate diet and decreased absorptionmay leadto vitamin K deficiency and defects

in coagulation,potentiating risk for

hemorrhage.

Excessive intestinal loss may lead toelectrolyteimbalance, e.g., potassium, which

is necessary for proper skeletal and cardiac

muscle function. Minor alterations in serumlevels can result in profoundand/or life-

threatening symptoms.

Maintenance of bowel rest requiresalternative fluidreplacement to correct

losses/anemia. Note: fluidscontaining

sodium may be restricted in presence of

regional enteritis.

Determines replacement needs andeffectiveness of therapy.

Reduces fluid losses from intestines.Used to control nausea and vomiting inacuteexacerbations.

Controls fever, reducing insensible losses.Electrolytes are lost in large amounts,especially inbowel with denuded, ulcerated

areas, and diarrheacan also lead to metabolic

acidosis through loss of bicarbonate

(HCO3).

Stimulates hepatic formation ofprothrombin,stabilizing coagulation and

reducing risk of hemorrhage

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2. Actual Nursing Management

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S sige raman siya gud og gasuka as verbalized by the mother

O Sunken eyesDry skinWatery stoolPersistent vomiting

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

to diarrhea

P Long term: At the end of shift days, patient will maintain electrolytes

balance.

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

I Independent:

Encouraged the mother to give oral fluid intake.To increase fluid intake

Monitored intake and output balance.To ensure accurate picture of fluid status

Observed for excessively dry skin and mucous membranes, decreased skinturgor, slowed capillary refill.

Indicates excessive fluid loss/resultant dehydration

Weighed dailyIndicator of overall fluid and nutritional status

Monitored vital signsTo note the changes in heart rate and respiration

Dependent:

.Provided supplement fluids as indicated D5LR 500cc @ 28cc/hrFluids may be given in this manner if patient is unable to takeoral fluid

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

and electrolyte imbalances

S init man gud kayo siya as vervalized by the mother

O Flushed skin,Warm to touch.RestlessnessT-37.8

A Hyperthermia related to dehydration.P After 4 hrs. Of nursing interventions, the patient will maintain core

temperature

within normal range.

I Independent:

Administer replacement fluids and electrolytes.To support circulating volume and tissue perfusion.

Promote surface cooling by means of tepid sponge bath.To decrease temperature by means through evaporation and conduction.

Maintain bed rest.

To reduce metabolic demands and oxygen consumptionProvide high calorie diet, tube feedings, or parenteral nutrition.

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m n s er an pyre cs ora y or rec a y as prescr e y e p ys c an.To facilitate fast recovery.

E After 4 hrs. Of nursing intervention s, the patient was able maintain coretemperature within normal range.