CAGAYAN COLLEGES TUGUEGARAO
COLLEGE OF HEALTH
A CASE STUDY
Submitted by: Dennis Gallardo
Acute gastroenteritis (AGE) is an acute infectious process affecting gastrointestinal tract caused by virus, bacteria and parasites. The disease is transmitted by ingestion of contaminated food, water, or by contaminated hands, linens, equipments, and supplies. Most serious complication is dehydration and electrolyte losses which may lead to metabolic acidosis and death. The primary manifestation of gastroenteritis is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. The vomiting usually settles in a day or so. The diarrhea may last for up to 10 days, but usually lasts only to 2 or 3 days. If there is fever, or blood and mucus in the stools it is more likely to be contagious. Gastroenteritis is contagious as the organism lives in the gastrointestinal tract, so it is important to wash hands thoroughly after going to the toilet and before preparing food.
Acute gastroenteritis is associated with significant morbidity in developed countries and each year is the cause of death of several million children in developing countries. Estimates of the overall incidence of acute gastroenteritis range from 1.3 to 2.3 episodes of diarrhea per year in children under five years of age. Each year, more than 300 U.S. children die from this illness. In the United States alone, gastroenteritis accounts for more than 220,000 hospital admissions per year in children less than five years of age, or approximately 10 percent of hospitalizations in this age group.
Acute gastroenteritis is a common and costly clinical problem in children. It is a largely self-limited disease with many etiologies. The evaluation of the child with acute gastroenteritis requires a careful history and a complete physical examination to uncover other illness with similar presentations. Minimal laboratory testing is generally required. Treatment is primary supportive and is directed at preventing or treating dehydration. When positive, an age-supportive diet and fluids should be continued. Oral rehydration therapy using a commercial pediatric oral rehydration solution is preferred approach to mild or moderate dehydration. The traditional approach using “clear liquids” is inadequate. Severe dehydration requires the prompt restoration of intravascular volume through the intravenous administration of fluids followed by oral rehydration therapy. When rehydration is achieved, an aged-appropriate diet should be promptly resumed. Anti-emetic and anti-diarrheal medications are generally not indicated and may contribute to complications.
On its mortality and morbidity, AGE is a leading cause of infant mortality throughout the world. By age 3 years, virtually all children become infected with the most common agents. Severe cases are seen in the elderly, infant and immunosuppressed population including transplant patients.
Last July 05, 2007, we encountered a patient with such kind of infection. This patient has caught our attention and has given the opportunity to study his case. The objective of this study is to help us understand the disease process of gastroenteritis and to orient ourselves for appropriate nursing interventions that we could offer to the patient. This approach enables us to exercise our duties as student nurses which is to render care. I was given the chance to improve the quality of care I can offer and to pursue our chosen profession as future nurses.
Patient’s Name: Budong
Age: 4 years & 7 months
Address: Carig Sur, Tuguegarao City
Date of Birth: December 3, 2002
Civil Status: Single
Religion: Roman Catholic
Date of Admission: July 5, 2007
Time Admitted: 9:50 AM
Attending Physician: Dra. M. Velarde
Chief Complaint: LBM & vomiting
Admitting Diagnosis: AGE with Dehydration
Final Diagnosis: AGE with Dehydration
NURSING HISTORY OF ILLNESS
PRESENT HEALTH HISTORY
> Two days prior to admission (July 3, 2007 in the evening), the patient had vomiting for 3 times associated with abdominal pain and passage of watery stool due to his intake of ice-cold coke and water according to his mother. A day prior to admission (July 4, 2007), the patient still attended his classes but still with vomiting and passage of watery stool. And last July 5, 2007, he was rushed to St. Paul Hospital due to weakness and severe abdominal pain.
PAST HEALTH HISTORY
> According to the patient’s mother, the patient has his complete immunizations. He is taking his vitamin supplements but still he is very slim and never liked vegetables. The patient was first hospitalized due to asthma. His second hospitalization was due to bronchopneumonia and the latest was due to AGE.
FAMILY HEALTH HISTORY
> According to the patient’s mother, their family have history of Hypertension, Diabetes mellitus, Bronchial Asthma and Cancer. Hypertension is evident on the patient’s grandfather and uncle, while Cancer is evident on the patient’s aunt.
GORDON’S 11 FUNCTIONAL PATTERN
Health Perception-Health Management Pattern
> Before his hospitalization, the patient perceives health in a way that he is not suffering from any disease. He takes vitamins for him to improve his health and to protect him from acquiring any disease.
> During his hospitalization, the patient feels so unhealthy according to his mother because of his hospitalization. He is obedient in taking his medications and is participative in all the nurses’ interventions.
> Before his hospitalization, the patient takes his meal three times a day without any restrictions. According to his mother, he has food preferences on fatty and oily foods. Her mother even shared that when they eat adobo, he prefers to eat the fat rather than the muscle because he gets irritated with foods between his teeth. He has no difficulty in swallowing and he usually eat junk foods when its snack time. He drinks 4-5 glasses of water a day and takes Clusivol to improve his appetite.
> During his hospitalization, his appetite decreased. He was restricted from eating dairy products. His fluid intake increased for about 5-7 glasses of water a day.
> Before his hospitalization, the patient used to eliminate once a day every morning before going to school with a semi-solid consistency and is brownish in color. He usually urinates 2 times a day with the normal light yellow color and aromatic odor. He also perspires every time he plays.
> During is hospitalization, the patient’s stool is watery with a yellowish color. He urinates 2-3 times a day. He also perspires but it’s due to the hot environment not from any activity since he just stays on bed.
> Before his hospitalization, especially during the weekend, he used to play outside with his cousins. They usually play toy cars and the usual games of his age. He stops playing when he feels tired.
> During his hospitalization, he used his time playing the cell phone of his father. Most of his time was spent for resting and sleeping.
> Before his hospitalization, he usually sleeps 8-9 hours. He is fond of watching the TV series “Super Twins” before going to bed when it was still showing.
> During his hospitalization, the patient sleeps early but has sleep disturbances when the nurses take his vital signs, administer medicines and also due to the environment.
> Before his hospitalization, the patient is normal in terms of his cognitive abilities. He has no problems with his senses. His mother even shared to us that he is already capable of writing his name and is capable of reading the alphabet and numbers.
> During his hospitalization, he relates to us actively. He responded to our questions enthusiastically. He also related to us some of his school activities.
Self-Perception/ Self-Concept Pattern
> According to the patient’s mother, he’s a good son though sometimes he tends to disobey his parents. She said this is normal for his age. He is the eldest but according to her mother he acts as if he is the youngest.
> The patient has a close relationship with his family, but he is closer to his father. He has a 2 year old sister, but according to his mother, he does not play the role of an elder brother. His mother even added that his sister ie more obedient than he is. But during his confinement, he is more obedient because he wanted to get well immediately.
> Prior to his age, the patient is not yet oriented with any sexual matters. According to hid mother, he has not yet undergone circumcision.
Coping Stress- Tolerance Pattern
> According to his mother, when he has problems he always approach his parents. She even added that when he gets scolded, he just stays in his room. When he is bullied or when his cousins get his toys, he does not quarrel with them but instead he reports it to his parents. During his hospitalization, he feels unsafe with people when his mother is not with him. He cries without the sight of his mother.
> He is a Roman Catholic. They attend mass regularly. He afraid to do something bad because he believes that God will punish him. According to his mother, before they consult the doctors or the hospital, they first consult the quack doctors.
Date assessed: July 06, 2007
General assessment: neat, conscious and coherent
Initial vital signs: T=37.9, RR=20, BP=80/60, PR=95
Area Assessed Technique Normal Findings Actual Findings Evaluation Skin
Light brown, tanned skin (vary according to race)
Normal Lips, nail beds, soles and palms
Inspection Lighter colored palms, soles, lips and nail beds Lighter colored palms, soles, lips and nail beds
Normal Moisture Inspection/
Palpation Skin normally dry Skin normally dry Normal Temperature Palpation Normally warm 37.9 o C d/t hyperthermia
Palpation Smooth, soft and flexible palms and soles (thicker) Smooth, soft and flexible palms and soles (thicker)
Normal Turgor Palpation Skin snaps back immediately Skin snaps back immediately Normal Skin appendages
Transparent, smooth and convex
Transparent, smooth and convex
Normal Nail beds Inspection Pinkish Pinkish Normal Nail base Inspection Firm Firm Normal
Inspection/ Palpation White color of nail bed under pressure should return to pink within 2-3 seconds White color of nail bed under pressure returned to pink within 2-3 seconds
Normal b. Hair
Normal Color Inspection Black Black Normal Texture Inspection/ Palpation Smooth Smooth Normal Eyes
Parallel to each other
Parallel to each other but sunken
d/t dehydration Visual Acuity Inspection (penlight) PERRLA- Pupils equally round react to light and accommodation PERRLA- Pupils equally round react to light and accommodation Normal Eyebrows Inspection Symmetrical in size, extension, hair texture and movement Symmetrical in size, extension, hair texture and movement Normal Eyelashes Inspection Distributed evenly and curved outward Distributed evenly and curved outward Normal Eyelids Inspection Same color as the skin
Blinks involuntarily and bilaterally up to 20 times per minute
Do not cover the pupil and the sclera, lids normally close symmetrically Same color as the skin
Blinks involuntarily and bilaterally up to 16 times per minute
Do not cover the pupil and the sclera, lids normally close symmetrically Normal
Normal Conjunctiva Inspection Transparent with light pink color Transparent with light pink color Normal Sclera Inspection Color is white Color is white Normal Cornea Inspection Transparent, shiny Transparent, shiny Normal Pupils Inspection Black, constrict briskly Black, constrict briskly Normal Iris Inspection Clearly visible Clearly visible Normal Ears
Ear canal opening
Free of lesions, discharge of inflammation
Canal walls pink
Free of lesions, discharge of inflammation
Canal walls pink
Normal Hearing Acuity Inspection Client normally hears words when whispered Client normally hears words when whispered
Shape, size and skin color
Smooth, symmetric with same color as the face
Smooth, symmetric with same color as the face
Normal Nasal septum Inspection Close to midline, thicker anteriorly than posteriorly Close to midline, thicker anteriorly than posteriorly
Oval, symmetric and without discharge
Oval, symmetric and without discharge
Normal Mouth and Pharynx
Pink, moist symmetric
Pink, moist symmetric
Normal Buccal mucosa Inspection Glistening pink soft moist Glistening pink soft moist Normal Gums Inspection Slightly pink color, moist and tightly fit against each tooth Slightly pink color, moist and tightly fit against each tooth
Normal Tongue Inspection Moist, slightly rough on dorsal surface medium or dull red Moist, slightly rough on dorsal surface medium or dull red
Normal Teeth Inspection Firmly set, shiny Firmly set, shiny
No tooth decay Normal Hard and soft palate Inspection Hard palate- dome-shaped
Soft Palate- light pink Hard palate- dome-shaped
Soft Palate- light pink
Symmetry of neck muscles, alignment of trachea
Neck is slightly hyper extended, without masses or asymmetry
Neck is slightly hyper extended, without masses or asymmetry
Normal Neck Rom Inspection Neck moves freely, without discomfort Neck moves freely, without discomfort Normal Thyroid gland Palpation Rises freely with swallowing Rises freely with swallowing Normal Trachea Inspection Midline Midline Normal Thorax and Lungs Auscultation Clear breath sounds Clear breath sounds Normal Abdomen
Bowel sounds Inspection
Auscultation Skin same color with the rest of the body
Clicks or gurling sounds occur irregularly and range from 5-35 per minute Skin same color with the rest of the body
Clicks or gurling sounds occur irregularly and range from 5-35 per minute Normal
Normal Neurology system
Level of consciousness
Fully conscious, respond to questions quickly, perceptive of events
Fully conscious, respond to questions quickly perceptive of events
Normal Behavior and appearance Inspection Makes eye contact with examiner, hyperactive expresses feelings with response to the situation Makes eye contact with examiner, hyperactive expresses feelings with response to the situation
Normal Value Results Analysis WBC 5-10 x 10 g/L 7.8 Normal Hgb M 13-16 g/dl 11 Decreased F 12-16 g/dl Hct M 39%-54% 33% Decreased F 37%-48% Differential Count
Normal Segmenters 60%-70% 69% Normal
Method used: Direct Smear
Results Analysis Physical properties: Color Light brown Normal Consistency Watery d/t profuse secretion of water and electrolytes Remarks:
No oral intestinal parasite seen
Results Analysis Color Yellow Normal Transparency Slightly turbid d/t increased urine concentration Reaction 6.0 Normal Specific gravity -1.020 Decreased: d/t dehydration Sugar Negative Normal Protein Trace Normal
Result Analysis Round epithelial cells Occasional Normal Mucus thread Many Normal RBC 0-1 Normal Pus cells 1-2 Normal Amorp urates/phosphates Few Normal
ANATOMY AND PHYSIOLOGY
THE DIGESTIVE SYSTEM
Every morsel of food we eat has to be broken down into nutrients that can be absorbed by the body, which is why it takes hours to fully digest food. In humans, protein must be broken down into amino acids, starches into simple sugars, and fats into fatty acids and glycerol. The water in our food and drink is also absorbed into the bloodstream to provide the body with the fluid it needs.
The digestive system is made up of the alimentary canal and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal (also called the digestive tract) is the long tube of organs – including the esophagus, the stomach, and the intestines – that runs from the mouth to the anus. An adult’s digestive tract is about 30 feet long.
Digestion begins in the mouth, well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that’s triggered when we sense food or even think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal.
As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase, which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth.
Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx (pronounced: fair-inks), a passageway for food and air, is about 5 inches long. A flexible flap of tissue called the epiglottis reflexively closes over the windpipe when we swallow to prevent choking.
From the throat, food travels down a muscular tube in the chest called the esophagus. Waves of muscle contractions called peristalsis force food down through the esophagus to the stomach. A person normally isn’t aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract.
At the end of the esophagus, a muscular ring called a sphincter allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, more digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts of these digestive juices each day.
Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it’s empty, an adult’s stomach has a volume of one fifth of a cup, but it can expand to hold more than 8 cups of food after a large meal.
By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme. A walnut-sized muscular tube at the outlet of the stomach called the pylorus keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream.
The small intestine is made up of three parts:
1. the duodenum, the C-shaped first part
2. the jejunum, the coiled midsection
3. the ileum, the final section that leads into the large intestine
The inner wall of the small intestine is covered with millions of microscopic, finger-like projections called villi. The villi are the vehicles through which nutrients can be absorbed into the body.
The liver (located under the ribcage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are still important for healthy digestion.
The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food.
The liver also plays a major role in the handling and processing of nutrients. These nutrients are carried to the liver in the blood from the small intestine.
From the small intestine, food that has not been digested (and some water) travels to the large intestine through a valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished. The large intestine’s main function is to remove water from the undigested matter and form solid waste that can be excreted. The large intestine is made up of three parts:
1. The cecum is a pouch at the beginning of the large intestine that joins the small intestine to the large intestine. This transition area allows food to travel from the small intestine to the large intestine. The appendix, a small, hollow, finger-like pouch, hangs off the cecum. Doctors believe the appendix is left over from a previous time in human evolution. It no longer appears to be useful to the digestive process.
2. The colon extends from the cecum up the right side of the abdomen, across the upper abdomen, and then down the left side of the abdomen, finally connecting to the rectum. The colon has three parts: the ascending colon and transverse colon, which absorb water and salts, and the descending colon, which holds the resulting waste. Bacteria in the colon help to digest the remaining food products.
3. The rectum is where feces are stored until they leave the digestive system through the anus as a bowel movement.
Predisposing Factors Precipitating Factors
¤ Age ¤ Lifestyle
¤ Environment ¤ Poor Hygiene
Etiology: infants/young children: Haemophilus influenzae
Person to person (hands) Contaminated food/water Animal pets
Ingestion of Pathogens
Invasion of the GIT
Enterotoxin production Affects the vomit Destruction of epithelial reduced absorption Systemic Invasion
receptors cells of fluid &
Interacts with mucosal lining Vomiting center Superficial ulceration of Inflammation of
in the brain is mucosa layer of tissue
stimulated beneath epithelium
abdominal spasm to limit of mucosa
Alters permeability mucosal injury
d/t underlying injury
Profuse secretion of water Abdominal Blood, mucus to GI
cramps in stool
Diarrhea Excretion of Access to
General weakness Interstitial fluids Systemic circulation
Fluid and electrolytes loss
Infection in other
part of the body
Deterioration and collapse DEATH Septicemia Meningitis
NURSING CARE PLANS
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION Subjective data:
“Mainit po ang pakiramdam ko” as verbalize by the patient
> T= 37.9 o C
> Skin is warm to touch
> RR= 20
> Decreased immunity
Hyperthermia r/t exposure to hot environment
Risk for infection r/t IV therapy At the end of thirty minutes, the patient will maintain a core temperature within normal.
At the end of 30 minutes, the client will verbalize understanding of individual causative and risk factors. > Provide proper ventilation.
> Monitor heart rate and rhythm.
> Promote surface cooling by means of cool environment and/or fans.
> Promote client safety.
> Encourage patient’s participation in ways to protect oneself from excessive exposure to hot environment.
> Instruct client/SO to increase fluid intake.
> Review sings and symptoms of hyperthermia.
> Note risk factors for the occurrence of infection.
> Observe for localized sings for infection at insertion sites.
> Assess skin conditions around insertion sites of pins, wires, and tongs, noting inflammation and drainage.
> Stress proper hand washing techniques by all caregivers and SO’s of the patient.
> Instruct client/SO in techniques to protect the integrity of the skin.
> Proper ventilation may reduce the temperature of the patient.
> Dysrhythmias are common due to electrolyte imbalance, dehydration, and direct effects of hyperthermia on blood and cardiac tissue.
> Heat loss by convention.
> Ensuring patient’s safety prevents other problems.
> Self-care awareness help in the prevention and control of hyperthermia.
> Adequate fluid intake prevents dehydration.
> These may indicate prompt interventions.
> Identifying the possible causative factors helps prevent/control the occurrence of infection.
> Visible sings of infection enable the management of more severe infections.
> The skin is our primary defense against infectious diseases.
> Hand washing technique is a first-line defense against nosocomial infections.
> Care for the skin integrity prevents the occurrence of infection.
“Nagsuka siya at nagtae”, as verbalized by her mother
> Dry mucous membranes and lips
> Sunken eyeballs
Fluid volume deficit related to increase metabolic demand and insensible fluid loss through vomiting and increased body temperature At the end of the shift, the patient will be able to:
– Achieve adequate hydration as evidenced by good skin turgor, moist mucous membranes and lips, no alteration in mentation > Assessed vital signs and degree of hydration and level of consciousness
> Encouraged adequate fluid intake as tolerated by the patient. Instructed SO to provide fluids in the bedside
> Regulated IVF according to specified flow rates basing on the physician’s order
> Monitored frequency of urination and amount of excreted urine > Provides baseline data and information; this is also important in the evaluating clients condition an success of intervention
> Adequate fluids will replace fluid lost through insensible water loss due to hyper metabolic state and vomiting
> Regulation of fluid is critical in maintaining adequate circulating fluids to recover for the amount of water loss through fever and vomiting
> Urine output serves as an important parameter in assessing client’s ability to conserve fluids
Generic name: Metronidazole
Brand name: Flagyl
Classification: Trichomonacide, amebicide
Effective against anaerobic bacteria and protozoa. Specifically inhibits growth by binding to DNA, resulting in loss of helical structure, strand breakage, inhibition of nucleic acid synthesis and cell death.
GI: nausea, dry mouth, metallic taste, vomiting,
abdominal discomfort, andominal pain
CNS: headache, dizziness
> Monitor stool number and character.
> With IV therapy, assess for sodium retention.
Generic name: Metoclopramide
Brand name: Reglan
Classification: gastrointestinal stimulant
Dopamine antagonist that acts by increasing sensitivity to acetylcholine; results in increased motility of the upper GI tract and relaxation of the pyloric sphincter and duodenal bulb.
GI: nausea, bowel disturbances
CNS: restlessness, drowsiness, fatigue, headache, dizziness
> Inject slowly IV to prevent transient feelings of anxiety and restlessness.
> Assess abdomen for bowel sounds and distention.
Generic name: Ampicillin
Brand name: Unasyn
Classification: Antiboitic, penicillin
Synthetic, broad-spectrum antibiotic suitable for gram-negative bacteria.
GI: diarrhea, abdominal distention
CNS: fatigue, headache
GU: dysuria, urinary retention
At the site of infection: pain and thrombo-phlebities
> Note history of sensitivity/reactions to these or related drugs.
> Monitor CBC, liver, and renal function
> Monitor urinary output and serum potassium levels
Generic name: Ranitidine
Brand name: Zantac
Classification: histamine H2 receptor blocking drug
Competitively inhibits gastric acid secretion by blocking the effect of histamine on histamine H2 receptors.
GI: constipation, diarrhea, abdominal pain
CNS: dizziness, headache, insomnia, anxiety
> Assess patient GI condition before starting therapy and regularly thereafter to monitor the doing effectiveness.
> Be alert for adverse reaction and drug interaction.
> Assess patient’s and family knowledge of the drug therapy.