PANPACIFIC UNIVERSITY NORTH PHILIPPINES

SAN VICENTE URDANETA CITY, PANGASINAN

COLLEGE OF NURSING

ACUTE GASTROENTERITIS

MARK JOSEPH ORDANZA APPLE JOY PERALTA

I.

PATIENT ASSESSMENT DATA BASE A. GENERAL DATA 1. Patients name: M.J.V 2. Address: Asingan 3. Age:4 4. Sex: Male 5. Birth Date: Sept. 7 2007 6. Rank in the family: 2nd Baby 7. Nationality: Filipino 8. Civil Status: Child 9. Date of Admission; Nov. 27 2011 10. Order of Admission: CBC, U/A D5LRS 1000mL/ mins. As ordered ampicillin 200mg every 6 hours ANST(-) Gentamicine 30mg every 8 hours. 11. Attending Physician: Dra. Tinaza B. CHIEF COMPLAINT: (+) Loose Watery stool and (+) several episode of vomiting C. HISTORY OF PRESENT ILLNESS: 4 days prior to admission the patient experience abdominal pain with a episode of watery stool. No consultation done according to the mother of the patient. And after 5 day the mother of the child decide to go in the community hospital for check up.

PAST HEALTH HISTORY/STATUS: 1. 2. 3. 4. 5. Childhood illness: According to the mother of the patient her child experience common cold and fever during their childhood life Immunization: The patient has complete immunization but her mother cannot recall the doses given. Major illness: The patient did not undergo any minor or major operations, and it was her first time admitted at Asingan community hospital Current medication: Antibiotics Allergies: The patient has a allergy to fish

D. FAMILY ASSESSMENT: Name M.L.V C.V M.J.V D.V E. SYSTEM REVIEW: 1. HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN N/A 2. NUTRITIONAL METABOLIC PATTERN Appetite: The patient has poor appetite but fried foods trigger her appetite. Usual Daily Menu: Food: According to the mother her child want to eat fried chicken and snacks and seldom eats vegetables. Water: The Patient drinks 3-4 glasses of water a day Beverages: The patient 4-5 glasses of juices and Milk. 3. ELIMINATION PATTERN: Bowel habits: The patient defecates 2 times a day Color: light brown and sometimes green Odor: Foul odor Consistency: Semi-Watery Stoll Laxatives use: The patient does not use any laxatives. Bladder: The patient usually urinates 3 to 4 times a day Color: yellowish Odor: Pungent Alterations: no alteration upon urination Relation Father Mother Son son Age 34 31 4 6 Sex Male Female Male Male Occupation Driver House wife N/A N/A Educational attainment High School Graduate College Under graduate N/A N/A

4. ACTIVITY-EXERCISE PATTERN Self-care ability:(Patient is child) II Feeding III Toileting II Dressing IV Cooking IVGrooming II Bed mobility II Bathing IV Home maintenance

LEGEND: 0 - full care I - requires use of equipment II - requires assistance or supervision from others III - requires assistance or supervision from another, and equipment and devise IV - dependent; doesnt participate 1. COGNITIVE-PERCEPTUAL PATTERN Hearing: Responds quickly every time she call her mother. She is not using any hearing aids. Vision-: The patient is not using any glasses/contact lens and during the interview he is crying at the bedside Sensory perception- There is no problem with sense of taste and smell. She can differentiate the taste of milk and juice Learning styles The patient learn by her mother Ex. Counting 1 to 10 SLEEP-REST PATTERN: Sleep Habits: Her mother stated that her child always takes a nap in the afternoon Special sleeping problems: the patient doesnt have sleeping problems. Hours of sleep: 9 hours (8pm 5am) Sleeping alterations: The mother stated that her child has no hard time to sleep when its bedtime. Sleeping Aids: The mother stated that when her child watching television he fall sleep her chid.

2. SELF-PERCEPTION AND SELF-CONCEPT PATTERN: N/A(Patient is child) 3. ROLE RELATIONSHIP PATTERN N/A (Patient is child)

4. SEXUALITY-REPRODUCTIVE PATTERN N/A (Patient is child) 5. COPING-STRESS TOLERANCE PATTERN N/A (Patient is child 6. VALUE BELIEF PATTERN The patients family is a roman catholic. According to the mother she is always visit in the church during Sunday together with her baby strongly believes that faith in God will help her during crises in life and believes that the Lord does miracle and nothing is impossible with God.

HEREDO-FAMILIAL ILLNESS: According to the mother of the patient there is history of hypertension on her maternal side and no known familial illness on paternal side Maternal:Hypertension Paternal:Diabetis mellitus A. DEVELOPMENTAL HISTORY:

H. DEVELOPMENTAL HISTORY THEORIST AGE SEX PATIENT DESCRIPTION

Erick Erickson

18 months to 3 years

Male

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. As observed the child had already built trust to his mother and father wherein he only allows his mother and fatherto cuddled and feed him.

Basing on this theory, Jimmy Mendaros Segmund Freud 1 month to 1 year Male 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.

James Fowler

0 to 3 years

Male

Interprets the environment by mental image

Male Jean Piaget 1 to 2 years

Infant unable to formulate concepts about self and the environment

B.

PHYSICAL ASSESSMENT A. General Survey 1. Overall appearance & grooming: Upon assessment, the patient is conscious and flat on bed 2. Actual weight and height: The patient stands 32 and weighs 18 kgs/167.2 lbs BMI = wt. in kg (height in m) BMI 18kg 2.56 = 7.031 BMI = 7.031 Guide for BMI Evaluation <16 severely underweight 17-18.4 Mild Underweight 18.5-24.9- Normal 25-30.9 overweight 31-40 Moderately to severely obese

3. Symptoms of distress: the patient is weak 4. Posture, gait: the patient can stand alone 5. Affect, mood: the patient response is not totally clear because during I ask question he is crying

B. Vital Signs Temperature: 37.1 degree Celsius Respiratory rate: 31 beats per minute Cardiac rate: 123 Cardiac per minute

Regional Examinations ( using IPPA technique) Hair Equally distributed, dry and thick with white and black hair and no parasite infestation noted. Head and face Normocephalic, spherical proportionate to body size and symmetrical, no evidence of masses or with slightly moist scalp, terminal hair and equal and evenly distributed.

Eyes . Upon inspection, the eyes are symmetrical and in level with each other. Terminal hairs of the eyebrows are equally and evenly distributed with no scaling or dryness. Pupils are equal round and reactive to light and accommodation. Ears Upon inspection the ears are proportionate with head and face. Same color with face, bilaterally symmetrical pinna is in level with the lateral cantus of eyes. The patients ear has no tenderness or pain felt; no lumps or lesions. Nose Upon inspection, the nose is symmetrical; no deformities, lesions nor deviations Pinkish nasal cavity, no inflammations, swellings or abnormal discharges. Mouth Upon inspection, lips close symmetrically; dry and symmetrical. Yellowish-white teeth and pinkish gum. Has dental caries. Neck Upon inspection, neck is symmetrical and no distention or bulging noted. Nails Upon assessment, normal angle between fingers and nail base is about 160 degrees. Nail base is firm when palpate; capillary refill time is 1-2 seconds. Thorax and lungs Upon observation, breathing or respiration is regular, clear breath sound. Pinkish in color, symmetrical and oval, no lumps, masses, bulges or visible pulsations. Abdomen Upon auscultation, there was normal bowel sounds. Upon palpation, there is pain verbalized. Extremities Upper extremities (ARMS) Upon inspection, hands and arms are symmetrical, absence of muscle wasting, and no tenderness and redness.

PERSONAL/ SOCIAL HISTORY A. Habits/vices: a. b. c. d. e. B. C. D. E. F.

Caffeine: None Smoking: None Alcohol: None Tea: None Drugs: According to the mother her child is taking vitamins.

Life style: It can play with out of her mother Social affiliation: The mother stated that during they have a birthday party they go their together with her child nd Rank in the family: 2 baby in the family Travel: N/A ( Patient is child) Educational attainment: N/a (Patient is child)

ENVIRONMENTAL HISTORY (LIVING/NEIGHBORHOOD/CIRCUMSTANCES) According to the mother of the patient her two sons and husband live in rural area. Their house is hallow block in the barrio along the farm which has 2 rooms, 1 bathroom. The source of water is Depwel

INTRODUCTION

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 the doctor. 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. Gastroenteritis is a self-limiting illness which will resolve by itself. However, for comfort and convenience, a person may use over-the-counter medications such as Pepto Bismol to relieve the symptoms. These medications work by altering the ability of the intestine to move or secrete spontaneously, absorbing toxins and water, or altering intestinal microflora. Some over-the-counter medicines use more than one element to treat symptoms.
VI. ANATOMY

PHYSIOLOGY

Alimentary Organs Mouth Food enters in the digestive tract through the mouth or oral cavity, a mucous membrane- lined cavity. Pharynx- From the mouth, food passes posteriorly into the oropharynx and laryngopharynx both of which are common passageways for food, fluid and air. Esophagus- The esophagus or gullet runs from the pharynx though the diagphram to the stomach. About 25 cm ( 10 inches ) long, it is essentially a passaageway to conducts food ( by peristalsis ) to the stomach. Stomach- The c-shaped stomach is on the left side of the abdominal cavity, nearly hidden by the liver and diagphram. The stomach acts as temporary storage tank for food as well as a site for food breakdown. Small Intestine- The bodys, major digestive organ. Within its twisted passageways usable food is finally prepared for its journey into the cells of the body. It is a muscular tube extending from the pyloric sphincter to the large intestine. Small intestine has three subdivisions: the duodenum, the jejenum, and the ileum. Large Intestine- It is much larger in diameter than the small intestine.About 1.5 m ( 5 feet long ) Its major function are to dry out the ingestible food residue by absorbing waterand to eliminate this residues from the body ass feces. There are three sides and has the following subdivisions: Appendix- is a potential travel spot because it is usually twisted, it is an ideal locatio for bacteria to accumulate and multiply.

Accessory Digestive Organs Teeth- the role of the teeth play in food proccessing needs little introduction. We masticate or chew by opening and closing our jaws and moving them fromside to side while continuesly using our tongue to mve the food between our teeth. In the process, the teeth tear and grind the food, breaking it down into the smaller fragments. Tongue- occupies the floor of the mouth. The tongue has several bony attachment two of this are to the hyoid bone and the steloid processes of the skull Liver- is the second lrgest gland in the body. Located under the diaphragm, more to the right side of the body, it overlies and almost completely covers the stomach. Gallblader- is a small, thin walled green sac that snuggles in a shallow fossa in the inferior surface of the liver. Salivary Glands Parotid glands- lie anterior to the ears

Vll. PATHOPHYSIOLOGY

VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS DATE: November 28, 2011 Hematology result
TEST Hemoglobin M (140-170 g/L) F (123-153 g/L) Hematocrit M (0.415-0.504 vol. %) F (0.359-0.446 vol. %) 12 RBC (3.5-4.7 x 10 /L) RESULT 124 SIGNIFICANCE There is normal hemoglobin aggregation.

.334 3.99

Normal.

There is normal red blood cell. WBC (4.5-11 x 10 g/L) 10.0 There is normal number of circulating white blood cell in the patient blood chemistry. LYMPO (0.23-0.35%) 20.7 Lymphocytes are increased due to bacterial infections. PLATELET (150,000-450,000/mm ) 496. Increased platelet due to inflammatory disease.

IX. DRUG STUDY

GENERIC NAME: BRAND NAME: DRUG CLASSIFICATION: DOSAGE: INDICATION: Mechanism of Action Antiinflammatory and analgesic activity; inhibits prostaglandins and leukotriene synthesis

KETOROLAC Acular LS, Acular PF Anti-Pyretic, Non- Opioid Analgesic, NSAID 50 mg IVP every 6 hours Short-term management of pain (up to 5 days) Adverse Reaction CNS: headache, dizziness, insomnia GI: Nausea, dyspepsia, GI pain, constipation Contraindications Contraindicated with significant renal impairment; bleeding patients wearing soft contact lenses (ophthalmic); aspirin allergy; concurrent use of NSAIDs; active peptic ulcer disease, recent GI bleed of perforation, history of peptic ulcer disease or GI bleeding; hypersensitivity to ketorolac; as prophylactic analgesic before major surgery; treatment of perioperative in CABG; suspected or confirmed cerobrovascular Side Effect Gastric or duodenal ulcers Renal impairment Nursing Consideration Do not use ophthalmic drops with contact lenses Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision; black tarry stool, easy bruising

GENERIC NAME: BRAND NAME: DRUG CLASSIFICATION: DOSAGE: INDICATION: Mechanism of Action Bactericidal: inhibits synthesis of bacterial cell wall causing cell death

Cefuroxime Sodium Zinacef Antibiotic 250 mg IVP every 8 hours Lower respiratory infections caused by Staphylococcus Pneumoniae, Staphylococcus Aureus, E. coli, Klebsiella Adverse Reaction GI: nausea, vomiting, diarrhea, anorexia, abdominal pain LOCAL: pain OTHER: superinfections Contraindications Contraindicated allergy cephalosporins penicillins with to or Side Effect Bone marrow depression Pseudomembranous colitis Nursing Consideration Take full course of therapy even if you are feeling better You may experience these side effects stomach upset or diarrhea Report severe diarrhea, difficulty in breathing, unusual tiredness or fatigue, pain at injection site

GENERIC NAME: BRAND NAME: DRUG CLASSIFICATION: DOSAGE: INDICATION: Mechanism of Action Unknown. Thought to produce analgesic by locking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of the other substances that are sensitive pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic hearregulating center.

Paracetamol Acephen Non- Opioid Analgesics and Antipyretics 325 P.O. 650 mg P.O. every 4 hours P.O. 6 hours, BRN Mild Pain or Fever Adverse Reaction Hematologic: Hemolytic Anemia Hepatic: Jaundice Skin: Rash, Urticaria Contraindications Contraindicated in patients hypersensitive to drug Side Effect Leukopenia Hypogylcemia Nursing Consideration ALERT: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose.

X. LIST OF IDENTIFIED PROBLEMS Acute Pain related to obstruction/ductal spasm Hyperthermia related to exposure to hot enviroment Imbalanced nutrition less than body requirements related to impaired fat digestion due to obstruction of bile flow.

XI. NURSING CARE PLAN Assessment Nursing Diagnosis Scientific Background Planning Nursing Intervention Rationale Evaluation

Subjective: Masakt ang tiyan ng aking anak with pain scale of 8/10

Acute pain related to obstruction/ ductal spasm

Objective: Facial grimace Guarding at incision site Restless and irritable Observed selffocusing or narrowed focus Self protective behaviour Limited movement noted Slightly diaphoretic

It is accompanied by acute localized pain because of potential tissue damage which cause inflammation, swelling and redness at the site.

Within 30 minutes of nursing intervention, the clients pain scale will decreases from 8/10 to 5/10

Assist patient in use of distraction techniques. Assist patient in comfortable position. Promote adequate rest and sleep. Encourage patient to do deep breathing exercise. Administer pain medication as prescribed.

To control pain

To facilitate comfort. To restore body strength To promote relaxation

Goal met: After 30 minutes of nursing intervention, the clients pain scale was decreased from 8/10 to 5/10.

To minimize pain.

Hyperthermia related to exposure to hot enviroment Scientific Background

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationales

Evaluation

Subjective: Ang init ng Pakiramdam ng aking anak Objective: Flushed skin Skin warm to touch Weak in appearance Dry lips Temperature: 38.1 c

Hyperthermia related to exposure to hot enviroment

Tissue destruction Release of pyrogenic substances

Changes in hypothalamic thermostat

After 2-3 hours of rendering nursing interventions, the patients body temperature will be reduce from 38.1 to 37.5 degrees Celsius

monitor vital signs Assess presence of sweating

Serves as baseline data The body attempts to increase heat loss by evaporation Promotes surface cooling. Heat is loss through radiation and conduction To decrease body temperature through evaporation and conduction Body heat is loss through the process of convection To decrease body temperature

Goal Met: After 2-3 hours of nursing interventions rendered, the patients body temperature went down from 38.1 to 37.5 degrees celsius as manifested by: a. Skin not warm to touch b. Moist lips and oral mucosa.

hyperthermia

Remove extra blank and clotting

Provides tepid sponge bath Promote cool environment by using electric fan Administer antipyretic as ordered Discuss the importance of adequate fluid intake

Assessment

Nursing Diagnosis

Scientific Background Due to insufficient intake of nutrients it causes the body not to meet metabolic demands because of biological, psychological or economic factors.

Planning

Nursing Intervention

Rationale

Evaluation

Subjective: Bigla na lang pumayat ang aking anak. Objective: Pale and weak in appearance Reduced body movement Reported dysfunctional eating patterns

Imbalanced nutrition less than body requirements related to impaired fat digestion due to obstruction of bile flow

Within 8 hours of proper nursing interventions, the client will demonstrate/behaviours/ lifestyle changes to regain and maintain appropriate weight.

Work with the client to develop a plan for increased activity and energy Teach strategies for energy conservation such as limiting of talking to others, increased number of rest periods. Provide companionship at meal time. Emphasize importance of adequate rest and sleep. Encourage patient to eat a well-balanced diet. Offer frequent and small quantitie of food.

To increase patients appetite.

To maximize patients strength

Goal Met: After 8 hours of nursing interventions, the client was able to demonstrate behaviours/ lifestyle changes to regain and maintain appropriate weight.

To encourage nutritional intake. For energy conservation.

To restore patients energy. It is important For client to maintain intake as much as possible.

XII. ONGOING APPRAISAL: The patient shows that it is progressive and responding well to both medical and nursing interventions.

XIII. DISCHARGE PLAN (HEALTH TEACHINGS)

Medication o The patient should take the medications that are prescribed (vitamins, anticholinergics and antispasmodics) Exercise o Encourage the mother of the patient to perform physical activities or walking, but avoid lifting objects exceeding 5 lbs. after surgery usually for one week Treatment o Instruct the mother of the patient to continue the medications of her child as needed Diet o Encourage the significant other of the patient to have a nutritious menu for her children. o Maintain a nutritious diet and continue drinking milk Danger Signs o Tell to the mother of patient to seek medical care/ advise if symptoms reoccurred/ persist.

Health Teachings as follows: Importaance of proper hygiene Proper handwashing Proper preparation of foods and boiling of water Eat nutrritious foods and fruits Increase oral intake should be conveyed