CASE PRESENTATIONonAcute G

CASE PRESENTATION
on
Acute Gastroenteritis with
Moderate – Severe Dehydration

Group 5
Somoray, Jude Edmund
Sosing, Melissa
Sumpingan, SIttie Ainah
Tan, Ruel
Tenedero, Daina Rose
Tome, Liezel
Zaspa, Kenneth

LEARNING OBJECTIVES
General Objective:
This case presentation aims to identify and determine the general health problem and needs of the patient with Acute Gastroenteritis with Moderate – Severe Dehydration. This presentation also intends to help promote health and medical understanding of such condition through the application of the nursing skills and for the students to gain needed knowledge, skills and attitude in dealing with clients with pneumonia.
Specific Objectives:
The group presenters will be able to:
KNOWLEDGE:
* Present a pediatric comprehensive health history of the patient: patient’s personal profile, chief complaints, present illness, past medical history, feeding history, and growth and development history through visual presentation.
* Know the latest facts and keep ourselves updated with the new information about Acute Gastroenteritis with Moderate – Severe Dehydration.
* Present a case for sequential changes in the normal anatomy and physiology of the systems involved in the disease process stating it’s implication on the laboratory findings.
* Describe the disease process and identify medical management through presenting the pathophysiology, medical and nursing interventions.
* Discuss the scientific action, indication, side effects, contraindication most especially the nursing responsibilities of the different drugs used in treating patient’s disease.
SKILLS:
* Demonstrate a thorough physical assessment and review of system for the comparison of patient’s condition from the normal anatomy and physiology.
* Implement medical and nursing interventions appropriately indicated to clients with Acute Gastroenteritis with Moderate – Severe Dehydration.
* Master the pharmacologic and therapeutic regimen for the patients with Acute Gastroenteritis with Moderate – Severe Dehydration.
* Formulate nursing diagnosis and care plan through obtaining comprehensive health history of the patient.
* Evaluate SO and patient’s responses to the care rendered and revise care as necessary to give appropriate and quality nursing care.

ATTITUDE:
* Establish a collective sense of teamwork through proper communication within the group to promote a harmonious relationship.
* Show confidence while presenting our part in the case presentation in order for us to catch their attention and for them to listen and actively participate during the presentation.
* Be open to the suggestions, questions and comments from the students and clinical instructors for the improvement of the case presentation.
* Motivate students to present their cases in a creative way of presentation after observing our case presentation.
* Observe confidentiality whatever been discussed during the case presentation for the right of the patients.

INTRODUCTION
Our group is assigned to have a case study on a patient admitted in the Pediatrics Ward of Northern Samar Provincial Hospital. Due to confidentiality purposes, we chose to address our patient as Patient G5.
Patient G5 is a 1 year and 4 months old female infant, a resident of Brgy. Sampaguita, Catarman, Northern Samar. She was admitted on February 2, 2013 at 02:10 pm with a medical diagnosis of Acute Gastroenteritis with Moderate – Severe Dehydration.
Gastroenteritis is a medical condition characterized by inflammation (“-itis”) of the gastrointestinal tract that involves both the stomach (“gastro”-) and the small intestine (“entero”-), resulting in some combination of diarrhea, vomiting, and abdominal pain and cramping. Gastroenteritis has also been referred to as gastro, stomach bug, and stomach virus. Although unrelated to influenza, it has also been called stomach flu and gastric flu.
Globally, most cases in children are caused by rotavirus. In adults, norovirus and Campylobacter are more common. Less common causes include other bacteria (or their toxins) and parasites. Transmission may occur due to consumption of improperly prepared foods or contaminated water or via close contact with individuals who are infectious.
The foundation of management is adequate hydration. For mild or moderate cases, this can typically be achieved via oral rehydration solution. For more severe cases, intravenous fluids may be needed. Gastroenteritis primarily affects children and those in the developing world.
Signs and symptoms
Gastroenteritis typically involves both diarrhea and vomiting, or less commonly, presents with only one or the other. Abdominal cramping may also be present. Signs and symptoms usually begin 12-72 hours after contracting the infectious agent. If due to a viral agent, the condition usually resolves within one week. Some viral causes may also be associated with fever, fatigue, headache, and muscle pain. If the stool is bloody, the cause is less likely to be viral and more likely to be bacterial. Some bacterial infections may be associated with severe abdominal pain and may persist for several weeks.
Children infected with rotavirus usually make a full recovery within three to eight days. However, in poor countries treatment for severe infections is often out of reach and persistent diarrhea is common. Dehydration is a common complication of diarrhea, and a child with a significant degree of dehydration may have a prolonged capillary refill, poor skin turgor, and abnormal breathing. Repeat infections are typically seen in areas with poor sanitation, and malnutrition, stunted growth, and long-term cognitive delays can result.
Reactive arthritis occurs in 1% of people following infections with Campylobacter species, and Guillain-Barre syndrome occurs in 0.1%. Hemolytic uremic syndrome (HUS) may occur due to infection with Shiga toxin-producing Escherichia coli or Shigella species, causing low platelet counts, poor kidney function, and low red blood cell count (due to their breakdown). Children are more predisposed to getting HUS than adults.[12] Some viral infections may produce benign infantile seizures.
Cause
Viruses (particularly rotavirus) and the bacteria Escherichia coli and Campylobacter species are the primary causes of gastroenteritis. There are, however, many other infectious agents that can cause this syndrome. Non-infectious causes are seen on occasion, but they are less likely than a viral or bacterial cause. Risk of infection is higher in children due to their lack of immunity and relatively poor hygiene.
Viral
Rotavirus, norovirus, adenovirus, and astrovirus are known to cause viral gastroenteritis. Rotavirus is the most common cause of gastroenteritis in children, and produces similar incidence rates in both the developed and developing world. Viruses cause about 70% of episodes of infectious diarrhea in the pediatric age group. Rotavirus is a less common cause in adults due to acquired immunity.
Norovirus is the leading cause of gastroenteritis among adults in America, causing greater than 90% of outbreaks. These localized epidemics typically occur when groups of people spend time in close physical proximity to each other, such as on cruise ships, in hospitals, or in restaurants. People may remain infectious even after their diarrhea has ended. Norovirus is the cause of about 10% of cases in children.
Bacterial
In the developed world Campylobacter jejuni is the primary cause of bacterial gastroenteritis, with half of these cases associated with exposure to poultry. In children, bacteria are the cause in about 15% of cases, with the most common types being Escherichia coli, Salmonella, Shigella, and Campylobacter species. If food becomes contaminated with bacteria and remains at room temperature for a period of several hours, the bacteria multiply and increase the risk of infection in those who consume the food. Some foods commonly associated with illness include raw or undercooked meat, poultry, seafood, and eggs; raw sprouts; unpasteurized milk and soft cheeses; and fruit and vegetable juices. In the developing world, especially sub-Saharan Africa and Asia, cholera is a common cause of gastroenteritis. This infection is usually transmitted by contaminated water or food.
Toxigenic Clostridium difficile is an important cause of diarrhea that occurs more often in the elderly. Infants can carry these bacteria without developing symptoms. It is a common cause of diarrhea in those who are hospitalized and is frequently associated with antibiotic use. Staphylococcus aureus infectious diarrhea may also occur in those who have used antibiotics. “Traveler’s diarrhea” is usually a type of bacterial gastroenteritis. Acid-suppressing medication appears to increase the risk of significant infection after exposure to a number of organisms, including Clostridium difficile, Salmonella, and Campylobacter species. The risk is greater in those taking proton pump inhibitors than with H2 antagonists.
Parasitic
A number of protozoans can cause gastroenteritis – most commonly Giardia lamblia – but Entamoeba histolytica and Cryptosporidium species have also been implicated. As a group, these agents comprise about 10% of cases in children. Giardia occurs more commonly in the developing world, but this etiologic agent causes this type of illness to some degree nearly everywhere. It occurs more commonly in persons who have traveled to areas with high prevalence, children who attend day care, men who have sex with men, and following disasters.
Transmission
Transmission may occur via consumption of contaminated water, or when people share personal objects. In places with wet and dry seasons, water quality typically worsens during the wet season, and this correlates with the time of outbreaks. In areas of the world with seasons, infections are more common in the winter. Bottle-feeding of babies with improperly sanitized bottles is a significant cause on a global scale. Transmission rates are also related to poor hygiene, especially among children, in crowded households, and in those with pre-existing poor nutritional status. After developing tolerance, adults may carry certain organisms without exhibiting signs or symptoms, and thus act as natural reservoirs of contagion. While some agents (such as Shigella) only occur in primates, others may occur in a wide variety of animals (such as Giardia).
Non-infectious
There are a number of non-infectious causes of inflammation of the gastrointestinal tract. Some of the more common include medications (like NSAIDs), certain foods such as lactose (in those who are intolerant), and gluten (in those with celiac disease). Crohn’s disease is also a non-infection source of (often severe) gastroenteritis. Disease secondary to toxins may also occur. Some food related conditions associated with nausea, vomiting, and diarrhea include: ciguatera poisoning due to consumption of contaminated predatory fish, scombroid associated with the consumption of certain types of spoiled fish, tetrodotoxin poisoning from the consumption of puffer fish among others, and botulism typically due to improperly preserved food.
Prevention
Lifestyle
A supply of easily accessible uncontaminated water and good sanitation practices are important for reducing rates of infection and clinically significant gastroenteritis. Personal measures (such as hand washing) have been found to decrease incidence and prevalence rates of gastroenteritis in both the developing and developed world by as much as 30%. Alcohol-based gels may also be effective. Breastfeeding is important, especially in places with poor hygiene, as is improvement of hygiene generally. Breast milk reduces both the frequency of infections and their duration. Avoiding contaminated food or drink should also be effective.
Vaccination
Due to both its effectiveness and safety, in 2009 the World Health Organization recommended that the rotavirus vaccine be offered to all children globally. Two commercial rotavirus vaccines exist and several more are in development. In Africa and Asia these vaccines reduced severe disease among infants and countries that have put in place national immunization programs have seen a decline in the rates and severity of disease. This vaccine may also prevent illness in non-vaccinated children by reducing the number of circulating infections. Since 2000, the implementation of a rotavirus vaccination program in the United States has substantially decreased the number of cases of diarrhea by as much as 80 percent. The first dose of vaccine should be given to infants between 6 and 15 weeks of age. The oral cholera vaccine has been found to be 50-60% effective over 2 years.
Management
Gastroenteritis is usually an acute and self-limiting disease that does not require medication. The preferred treatment in those with mild to moderate dehydration is oral rehydration therapy (ORT). Metoclopramide and/or ondansetron, however, may be helpful in some children, and butylscopolamine is useful in treating abdominal pain.
Rehydration
The primary treatment of gastroenteritis in both children and adults is rehydration. This is preferably achieved by oral rehydration therapy, although intravenous delivery may be required if a there is a decreased level of consciousness or if dehydration is severe. Oral replacement therapy products made with complex carbohydrates (i.e. those made from wheat or rice) may be superior to those based on simple sugars. Drinks especially high in simple sugars, such as soft drinks and fruit juices, are not recommended in children under 5 years of age as they may increase diarrhea. Plain water may be used if more specific and effective ORT preparations are unavailable or are not palatable. A nasogastric tube can be used in young children to administer fluids if warranted.
Dietary
It is recommended that breast-fed infants continue to be nursed in the usual fashion, and that formula-fed infants continue their formula immediately after rehydration with ORT. Lactose-free or lactose-reduced formulas usually are not necessary. Children should continue their usual diet during episodes of diarrhea with the exception that foods high in simple sugars should be avoided. The BRAT diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over normal feeding. Some probiotics have been shown to be beneficial in reducing both the duration of illness and the frequency of stools. They may also be useful in preventing and treating antibiotic associated diarrhea. Fermented milk products (such as yogurt) are similarly beneficial. Zinc supplementation appears to be effective in both treating and preventing diarrhea among children in the developing world.
Antiemetics
Antiemetic medications may be helpful for treating vomiting in children. Ondansetron has some utility, with a single dose being associated with less need for intravenous fluids, fewer hospitalizations, and decreased vomiting. Metoclopramide might also be helpful. However, the use of ondansetron might possibly be linked to an increased rate of return to hospital in children. The intravenous preparation of ondansetron may be given orally if clinical judgment warrants. Dimenhydrinate, while reducing vomiting, does not appear to have a significant clinical benefit.
Antibiotics
Antibiotics are not usually used for gastroenteritis, although they are sometimes recommended if symptoms are particularly severe or if a susceptible bacterial cause is isolated or suspected. If antibiotics are to be employed, a macrolide (such as azithromycin) is preferred over a fluoroquinolone due to higher rates of resistance to the latter. Pseudomembranous colitis, usually caused by antibiotic use, is managed by discontinuing the causative agent and treating it with either metronidazole or vancomycin. Bacteria and protozoans that are amenable to treatment include Shigella Salmonella typhi, and Giardia species. In those with Giardia species or Entamoeba histolytica, tinidazole treatment is recommended and superior to metronidazole. The World Health Organization (WHO) recommends the use of antibiotics in young children who have both bloody diarrhea and fever.
Antimotility agents
Antimotility medication has a theoretical risk of causing complications, and although clinical experience has shown this to be unlikely, these drugs are discouraged in people with bloody diarrhea or diarrhea that is complicated by fever. Loperamide, an opioid analogue, is commonly used for the symptomatic treatment of diarrhea. Loperamide is not recommended in children, however, as it may cross the immature blood-brain barrier and cause toxicity. Bismuth subsalicylate, an insoluble complex of trivalent bismuth and salicylate, can be used in mild to moderate cases, but salicylate toxicity is theoretically possible.
Epidemiology
It is estimated that three to five billion cases of gastroenteritis occur globally on an annual basis, primarily affecting children and those in the developing world. It resulted in about 1.3 million deaths in children less than five as of 2008, with most of these occurring in the world’s poorest nations. More than 450,000 of these fatalities are due to rotavirus in children under 5 years of age. Cholera causes about three to five million cases of disease and kills approximately 100,000 people yearly. In the developing world children less than two years of age frequently get six or more infections a year that result in clinically significant gastroenteritis. It is less common in adults, partly due to the development of acquired immunity.
In 1980, gastroenteritis from all causes caused 4.6 million deaths in children, with the majority occurring in the developing world. Death rates were reduced significantly (to approximately 1.5 million deaths annually) by the year 2000, largely due to the introduction and widespread use of oral rehydration therapy. In the US, infections causing gastroenteritis are the second most common infection (after the common cold), and they result in between 200 and 375 million cases of acute diarrhea and approximately ten thousand deaths annually, with 150 to 300 of these deaths in children less than five years of age.

PATIENT’S PROFILE
NAME: Patient G5
AGE: 1 yr. and 4 mos.
GENDER: Female
BIRTHDATE: September 25, 2011
BIRTHPLACE: Brgy. Sampaguita, Catarman, Northern Samar
ADDRESS: Brgy. Sampaguita, Catarman, Northern Samar
RELIGION: Iglesia ni Cristo
DATE OF ADMISSION: February 2, 2013
TIME OF ADMISSION: 02:10 pm
ADMITTING DIAGNOSIS: Acute Gastroentiritis with Moderate – Severe Dehydration
ATTENDING PHYSICIAN: Dr. J. Nochete
DIET: Breastfeeding with Strict Aspiration Precaution
CHIEF COMPLAINT: Low Bowel Movement
MOTHER’S NAME: Vivian Cornico
FATHER’S NAME: Sandy Cornico
SOURCE OF INFORMATION: Mother
DATE OF INTERVIEW: February 5, 2013
CASE NUMBER: 160127
PEDIATRIC COMPREHENSIVE HEALTH HISTORY
CHIEF COMPLAINT:
LBM
PRESENT ILLNESS:
Prior to admission, according to mother the patient suffers from LBM for 3 times a day with yellow, watery stool. According also to the mother, the patient always cries whenever she feels pain in her stomach. They don’t know what to do so they decided to go to the hospital and was admitted last February 2, 2013 and diagnosed with Acute Gastroenteritis with Moderate – Severe Dehydration.
PAST MEDICAL HISTORY:
Prenatal:
The patient’s mother states that she had her skin infection when she was 9 months pregnant and did not consult a doctor. She didn’t take any medication and just treated it with coconut oil. She also states that she don’t experience any illness during her pregnancy except for her skin infection. She doesn’t have any prenatal checkup during her pregnancy.
Birth History:
At birth, the patient hasn’t suffered from any illness or disease.
Natal:
She states that she didn’t feel any difficulty during her delivery. She delivered her child in their home with a trained hilot.
Neonatal:
She doesn’t have any experiences of illness during her postpartum period.
FEEDING HISTORY:
Infancy:
She said that she breastfed her baby up to 8 months old. She started feeding her baby with semi-solid food when her baby was 6 months old. She fed her baby with soft biscuits, porridge, and meat. She didn’t give any vitamin supplement because of lack of income.
Childhood:
Client’s mother states that when her baby got 1 year old, herbaby didn’t want to eat soft food anymore like porridge, breads, etc. Her child started to like toasted bread.
GROWTH AND DEVELOPMENT HISTORY:
Physical Growth:
First tooth eruption when her baby was 6 months old. Her baby was still starting to walk.

Developmental Milestones:
States that her baby started to sit with support when her baby was 4 months old and started to stand with support at 4 months old. Her baby can speak now, “mama”, “tata” and “bebe”.
SOCIAL DEVELOPMENT:
The mother stated that her baby usually sleeps at night at around 8 o’clock and waking up at 6am. Her child doesn’t want to sleep during siesta time. She said that her baby just want to play with them.
CHILDHOOD ILLNESS:
Patient did not experience any childhood illness as stated by the mother except for the usual cough and common colds.
IMMUNIZATION:
Her baby did not get immunized since birth.
SCREENING PROCEDURE:
No screening done.
OPERATIONS/INJURIES/HOSPITALIZATIONS:
According to mother, her child had first hospitalized last February, 2012, when her baby was 5 months old with the same chief complaint.
ALLERGIES:
There are no known allergies discovered by her mother, either in any food, environment or medication.
FAMILY HISTORY:
The mother of the patient is 19 years old, and stopped at an elementary level of education, while her father is 26 years old and stopped at a high school level of education. The mother is a housewife, while the father is a farmer. According to the mother, they don’t have any history of allergies and illnesses or diseases.

REVIEW OF SYSTEM
GENERAL APPEARANCE:
Patient is lying on bed wearing pink dress and diapers with white shorts. She appears restless. She has an ongoing IVF of D5 0.3 NaCl at 36 mcgtts/min at Left cephalic vein.
Vital Signs: Temperature – 37.6 oC
Respiratory Rate – 56 breaths per minute
Apical Pulse – 140 bpm
INTEGUMENTARY:
> Brown Complexion
> Warm to Touch
> Soft, Smooth Skin
> (+) Scars
> (-) Skin Lesions
HAIR:
> Thin, Black, Soft, Shiny Hair
> Evenly Distributed on Scalp
> Absence of Lice
NAILS:
> No Clubbing Noted
> Dirty, Untrimmed Nails
> Pink Nail Beds
> Intacked Cuticle
HEENT:
Head
> Sunken Fontanelles
> Absence of Nodules, Masses or Tenderness
> Symmetric
Eyes
> Sunken Eyeballs
> PERRLA
> Symmetric
Ears
> Symmetric
> Auricle Aligned with Outer Canthus of Eye
> Able to Hear
> Proportional to the size of head
> Absence of Discharge, Nodules, Lesions, Masses
Nose and Sinuses
> Nasal Mucosa is pink and moist
> (+) Nasal Flaring
Tongue
> Even Pink Color
> Symmetric
MOUTH and PHARYNX
> Slightly Pale
> Dry Lips
> Without Lesions
> Incomplete Teeth
NECK
> Symmetric
> Absence of Nodules and Masses
> Non – Palpable Lymph Nodes
BREAST
> Symmetric
> Absence of Masses or Tenderness
RESPIRATORY
> RR: 56 breaths per min
> (+) Crackles, Wheezes
CARDIOVASCULAR
> AP: 140 bpm
> Absence of Adventitious Sounds
> Normal Heart Beat
MUSCOSKELETAL
> Body Weakness
> Irritable
> Restless
> Can Sit Alone
> Can Stand Up with Help of SO
> Firm and Non Tender
> Extremities Symmetric
> No Deformities
GASTROINTESTINAL
> Round and Distended Abdomen
> No Reactive Bowel Sounds
> (-) Flatus
> (+) Bowel Movement
> Stool: Yellowish and Watery
COURSE IN THE WARD
Date Medical Management Indication Patient’s Response February 2, 2013 > Patient was admitted at the Emergency Room to the Pediatrics Ward.

> Secure consent.

> TPR q8h
> DFA

> Diagnostics: CBC/PLT, U/A, F/A

> Start with Plain LR 120 cc FD, then IVF of 1 L D5 0.3 NaCl at 36 mcgtts, V/V replacement of PLR.
> Paracetamol 60 mg IVTT q4h.
> Cefuroxime 200 mg IVTT q8h.
> V/S q2h > Patient was admitted due to LBM. Patient was assesses by the Doctor. Past medical history and present health history was taken. Patient with significant others were oriented to the unit.
> Consent care signed. Informed attending physician and SO about the admission.
> To determine any abnormalities in the patients vital signs.
> To determine any discomforts or other complications.

> Need to be facilitated immediately to serve for base line data and for treatment management.
> For IV Homeostasis
> Analgesic to decrease pain.
> Antibiotic, Bactericidal inhibits synthesis of bacterial cell wall.
> To determine any abnormalities in the patients vital signs. > Patient was brought to Pediatrics Ward still in LBM.
> Comfortably lying on bed.
> Significant others provided the needed treatment and laboratory exams.
> Consent secured.

> V/S monitored for any abnormalities.

> Patient and SO instructed that she can eat any meal as she tolerates.
> Diagnostics done.
> To replace fluid loss due to LBM.

> Pain decreases.

> Still having LBM.

> V/S monitored for any abnormalities. February 3, 2013 > Continue prescribed management.
> Monitor V/S q4h.

> For continuous management.
> To determine any abnormalities in the patients vital signs. > Still having LBM.

> V/S monitored for any abnormalities. February 4, 2013 > Start with Salbutamol Nebulization q15 x 3 doses, then Salbutmol + Ipratropium nebulization q4h.
> Continue meds.

> Serve O2 Inhalation via nasal cannula 1-2 LPM.
> Close watch. > Salbutamol was given as treatment for bronchospasm which improve ventilation.

> For continuous management.
> To improve ventilation. > Patient suffers from cough due to environment in the hospital and to be followed up by Dr. Nochete for further evaluation.
> Still having LBM.

> Ventilation provided. February 5, 2013 > Refer PCOD.

> See for CXR as ordered.
> Start Gentamicin 18 mg IVTT q12h ( ).
> Salbutamol + Ipratropium nebulization q6h. > For further examination.
> To serve as a patient’s baseline data and as a guide for the pt’s management as well.
> Antibiotic that treats serious infections.
> An anticholinergic agent that inhibits vagally-mediated reflexes by antagonizing the action of acetylcholine > Having DOB.

> Results to be followed up.
February 6, 2013
09:30 am > Continue present IV meds.
> Continue 02.

> Monitor V/S q1h.
> Start Hydrocortisone 24 mg IVTT q6h.
> Budesonide Respule 1 Respule q12h.
> Continue meds. > For continuous management.
> For continuous management.
> To determine any abnormalities in the patients vital signs.
> Initiates many complex reactions that are responsible for its anti-inflammatory, immunosuppressive and salt-retaining actions.
> Inhalation suspension: maintenance treatment and prophylaxis therapy of asthma in children 12 mos. – 18 years.
> For continuous management. > Patient decreases LBM and starting to have normal stools but she still experience DOB. February 7, 2013 > Continue meds.

> O2 inhalation at
2 LPM.
> Monitor V/S q4h.
> Repeat CBC q4h.
> Monitor O2 at 1-2 LPM via nasal cannula. > For continuous management.
> To improve ventilation.
> To determine any abnormalities in the patients vital signs.
> Make sure to report AP for any abnormalities for further evaluation and treatment.
> To improve ventilation.
> Patient does not experience LBM but experiences DOB. February 8, 2013

12 NN > Continue meds.

> Continue O2 inhalation.
> Prepare 55 cc type specific packed WBC for 4 then after blood typing, close watch.
> Hold IVF when BT.
> Furosemide 2.5 mg IVTT post BT.

> Repeat Hgb Hct q6h post BT.
> Continue meds. > For continuous management.
> To improve ventilation.
> Make sure to report to AP any abnormalities for further evaluation and treatment.

> Inhibits the absorption of Na and Cl from the proximide and distal tubules and ascending limb of the loop of Henle leading to a Na rich diuresis.
> For continuous management. > Patient is having DOB and secured with WBC after BT. February 9, 2013 > Still for BT.
> Continue meds.

> Refer Hgb Hct q6h for PCOD med.
> For continuous management.
> Patient is still for BT but the SO is well informed as ordered. February 10, 2013 > Continue meds. > For continuous management. > Patient and SO follows doctor’s orders. February 11, 2013
08:00 pm > Continue meds.

> Ferlin 1.0 mL OD PO.

> Vit. C 1.0 mL OD PO.
> Refused IVF follow up. > For continuous management.
> Prevention & treatment of Fe deficiency anemia in infants & child.
> Vitamin which is fundamental in the synthesis of collagen and intercellular materials. > Patient is already feeling better. February 12, 2013 > MGH
> Amoxicillin q8h x 7 days
> Continue oral meds at home. > Patient does not suffer from LBM and already have normal stools. She doesn’t experience DOB anymore. Instructed SO to comply with home meds given and for follow up checkup after 4 days. > Patient does not have the disease anymore and may go home with good prognosis with home meds given and ordered by the AP. LABORATORY TESTS
February 2, 2013
COMPLETE BLOOD COUNT
Parameters Normal Values Result Interpretation Hematocrit 0.30 – 0.32 0.34 Increased White Cell Count 5- 10 x 109 L 3.7 Decreased Neutrophils 0.55 – 0.75 0.56 Normal Lymphocytes 0.35 – 0.55 0.44 Normal February 6, 2013
URINALYSIS
Parameters Result Color Yellow Transparency Turbid Reaction ^.5 Specific Gravity 1.015 Protein + Sugar – Pus Cells 2.4 Epithelial Cells ++ Mucus Threas + Bacteria ++++ FECALYSIS
Parameters Result Color Yellow Consistency Soft Others: Y Cells Rare Bacteria ++ February 7, 2013
COMPLETE BLOOD COUNT
Parameters Normal Values Result Interpretation Hematocrit 0.30 – 0.32 0.26 Decreased White Cell Count 5- 10 x 109 L 9.9 Normal Neutrophils 0.55 – 0.75 0.64 Normal Lymphocytes 0.35 – 0.55 0.36 Normal February 8, 2013
CROSS MATCHING FORM PACKED WBC
Parameters Result Blood Type “B” Serial Number NVBSP 2013 – 2014 Volume 200 cc Screening NVSBSP Screened Cross Matching Compatible February 9, 2013
HEMATOLOGY
Parameters Normal Values Result Interpretation Hemoglobin 120 – 150 g/L 121.18 Normal
ANATOMY AND PHYSIOLOGY
Introduction to the gastrointestinal system
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of feces).
In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of nausea, vomiting, diarrhea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.

Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The contents of the tube are considered external to the body and are in continuity with the outside world at the mouth and the anus. Although each section of the tract has specialized functions, the entire tract has a similar basic structure with regional variations.
The wall is divided into four layers as follows:
Mucosa
The innermost layer of the digestive tract has specialized epithelial cells supported by an underlying connective tissue layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple layers).
Areas such as the mouth and esophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of smooth muscle which can contract to change the shape of the lumen.
Submucosa
The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and submucosa.
Muscularis externa
This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibers separated by the myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen.
Serosa/mesentery
The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium.
Individual components of the gastrointestinal system
Oral cavity
The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping actions of the teeth. The tongue, a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialized sensors known as papillae.
Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays a limited role in the digestion of carbohydrates. The enzyme serum amylase, a component of saliva, starts the process of digestion of complex carbohydrates. The final function of the oral cavity is absorption of small molecules such as glucose and water, across the mucosa. From the mouth, food passes through the pharynx and esophagus via the action of swallowing.
Salivary glands
Three pairs of salivary glands communicate with the oral cavity. Each is a complex gland with numerous acini lined by secretory epithelium. The acini secrete their contents into specialized ducts. Each gland is divided into smaller segments called lobes. Salivation occurs in response to the taste, smell or even appearance of food. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each pair of salivary glands secretes saliva with slightly different compositions.
* Parotids
The parotid glands are large, irregular shaped glands located under the skin on the side of the face. They secrete 25% of saliva. They are situated below the zygomatic arch (cheekbone) and cover part of the mandible (lower jaw bone). An enlarged parotid gland can be easier felt when one clenches their teeth. The parotids produce a watery secretion which is also rich in proteins. Immunoglobins are secreted help to fight microorganisms and a-amylase proteins start to break down complex carbohydrates.
* Submandibular
The submandibular glands secrete 70% of the saliva in the mouth. They are found in the floor of the mouth, in a groove along the inner surface of the mandible. These glands produce a more viscid (thick) secretion, rich in mucin and with a smaller amount of protein. Mucin is a glycoprotein that acts as a lubricant.
* Sublingual
The sublinguals are the smallest salivary glands, covered by a thin layer of tissue at the floor of the mouth. They produce approximately 5% of the saliva and their secretions are very sticky due to the large concentration of mucin. The main functions are to provide buffers and lubrication.
Esophagus
The esophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It extends from the pharynx to the stomach after passing through an opening in the diaphragm. The wall of the esophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by the esophageal nerve plexus. This nerve plexus surrounds the lower portion of the esophagus. The esophagus functions primarily as a transport medium between compartments.
Stomach
The stomach is a J shaped expanded bag, located just left of the midline between the esophagus and small intestine. It is divided into four main regions and has two borders called the greater and lesser curvatures. The first section is the cardia which surrounds the cardial orifice where the esophagus enters the stomach. The fundus is the superior, dilated portion of the stomach that has contact with the left dome of the diaphragm. The body is the largest section between the fundus and the curved portion of the J.
This is where most gastric glands are located and where most mixing of the food occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted into numerous longitudinal folds called rugae. These allow the stomach to stretch and expand when food enters. The stomach can hold up to 1.5 liters of material. The functions of the stomach include:
1. The short-term storage of ingested food.
2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some absorption of substances such as alcohol.
Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and fundus. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins.
Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the cecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity.
The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines digestive secretions from the pancreas and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and empties into the cecum at the ileocecal junction.
The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body’s blood stream.
The lining of the small intestine is made up of numerous permanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialized cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions.
Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, cecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm.
The cecum is the expanded pouch that receives material from the ileum and starts to compress food products into fecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters, control the passage of feces.
The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete mucous to lubricate fecal matter as it solidifies. The functions of the large intestine can be summarized as:
1. The accumulation of unabsorbed material to form feces.
2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas.
3. Reabsorption of water, salts, sugar and vitamins.
Liver
The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen. It is surrounded by a strong capsule and divided into four lobes namely the right, left, caudate and quadrate lobes. The liver has several important functions. It acts as a mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several metabolites including the breakdown of bilirubin and estrogen. In addition, the liver has synthetic functions, producing albumin and blood clotting factors. However, its main roles in digestion are in the production of bile and metabolism of nutrients. All nutrients absorbed by the intestines pass through the liver and are processed before traveling to the rest of the body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here, bile salts break down lipids into smaller particles so there is a greater surface area for digestive enzymes to act.
Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the liver’s right lobe. It consists of a fundus, body and neck. It empties via the cystic duct into the biliary duct system. The main functions of the gall bladder are storage and concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored in the gallbladder until it is needed. Bile is released from the gall bladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the spleen. The organ is approximately 15cm in length with a long, slender body connecting the head and tail segments. The pancreas has both exocrine and endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin, glucagon and other substances and these are the areas damaged in diabetes mellitus. The exocrine (secretrory) portion makes up 80-85% of the pancreas and is the area relevant to the gastrointestinal tract.
It is made up of numerous acini (small glands) that secrete contents into ducts which eventually lead to the duodenum. The pancreas secretes fluid rich in carbohydrates and inactive enzymes. Secretion is triggered by the hormones released by the duodenum in the presence of food. Pancreatic enzymes include carbohydrases, lipases, nucleases and proteolytic enzymes that can break down different components of food. These are secreted in an inactive form to prevent digestion of the pancreas itself. The enzymes become active once they reach the duodenum.

PATHOPHYSIOLOGY
Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts with ingestion of fecally contaminated food and water. The organism affects the body through direct invasion and by endotoxin being released by the organism. Through these two processes the bowel mucosal lining is stimulated and destroyed the eventually lead to attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the stomach.
The client with acute gastroenteritis may also report excessive gas formation that may leads to abdominal distention and passing of flatus due to digestive and absorptive malfunction in the system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress to nausea and vomiting and increasing frequency of defecation. Abdominal pain and feeling of fullness maybe relieved only when the patient is able to pass a flatus.
As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct invasion of the organism and the action of the hydrochloric acid of the stomach. As the protective coating of the stomach erodesthe digestive capabilities of the acid helps in destroying the stomach lining. Pain or tenderness of the abdomenis then felt by the patient. When the burrows or ulceration reaches the blood vessels in the stomach bleeding will be induced. Dysentery may be characterized by melena or hematochezia depending on the site and quantity of bleeding that may ensue. Signs of bleeding may be observed also through hematemesis.
As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes water and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride and bicarbonate ions in the bowel as the body try to get rid of the organism by increasing peristalsis and number of defecation. Sodium and water reabsorption in the bowel is inhibited with the loss of the two electrolytes.
Mild diarrhea is characterized by 2-3 stool, borborygmi (hyperactive bowel sound), fluid and electrolyte imbalance and hypernatremia. When the condition continue to progress, protein in the body is excreted to the lumen that further decreases the reabsorption and the body become overwhelmed that leads to intense diarrhea with more than 10 watery stool. Serious fluid volume deficit may lead to hypovolemic shock and eventually death.

PROGNOSIS
In most cases, gastroenteritis is a self-limited condition with an excellent prognosis. Symptoms of gastroenteritis usually subside within 3 to 5 days. Failure to improve within 2 weeks should bring the diagnosis into question. The duration of traveler’s diarrhea caused by E. coli or Shigella infection can be significantly shortened with antibiotic therapy.

Although infectious gastroenteritis is usually acute (rapid onset with a short duration), certain parasites such as Giardia can cause chronic diarrhea. For more severe or prolonged cases, the prognosis depends on the organism causing the gastroenteritis and the effectiveness of treatment. Recovery can be delayed by an extensive infection, unusual reactions to medicines, or infection from bacteria that produce a more powerful toxin. Without replacement, extreme loss of body fluid and electrolytes can lead to shock, coma, or death.
The prognosis for prolonged (more than 2 weeks) noninfectious gastroenteritis depends upon accurate identification and treatment of the underlying cause and ranges from good (food intolerances, allergies, medication side effects) to fair or poor (heavy metal toxicity, cytomegalovirus infection in HIV-compromised individuals).
The international mortality rate for gastroenteritis is estimated to be 3 to 10 million individuals each year, primarily from dehydration secondary to diarrhea.

HEALTH TEACHINGS
1. Good hand washing technique after defecation and before handling food.
2. Obtaining available vaccinations against bacterial and viral gastroenteritis
3. Encourage cleanliness and sanitation as well as proper food handling, preparation and storage techniques.
4. Not allowing food to sit at room temperature for long periods.
5. Warn client not to eat food containing raw eggs and to refrain from buying cans, boxes or jars that are damaged.
6. Advise clients to avoid the use of antibiotics over a long time.
7. Avoid dirty waters, raw meats or unsafe sea foods, and foods that cannot be cooked or peeled.
8. Increase fluid intake, breastfeeding for babies to promote hydration.
9. Emphasized proper hygiene to prevent invasion of microorganisms.
10. Instruct to eat nutritious foods, like green leafy vegetables, protein rich foods, vitamins supplements to boost immune system and prevention of occurrence of disease.