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Liceo De Cagayan University

College of Nursing

NCM501202

A Care Study

Kenno Balahay

Submitted to:

Ms. Lota Ortigoza

As Partial Requirement for NCM501202

Submitted by:

James Adrian Gali


I. Introduction

a. Overview of the Case

The digestive system is one of the most important systems of


the human body. It is in this system that absorption of essential
nutrients for the use of other organ systems is performed. The Foods
eaten are converted into their simplest forms by mechanical and
chemical process undergone in the digestive tract to be readily
absorbed by the circulation and, in turn, distributed to the whole body.

When the digestive system is disrupted by pathologic conditions,


its function is greatly affected, thus, the patient is unable to absorb
the required nutrients for the proper maintenance of the other organs.

One of the leading disorders of the digestive tract is Diarrhea,


the frequent passing of loose watery stools. This condition may have
different causes, either by Hyperactivity of the GIT, by invasion of
virulent pathogens, inflammation in the GIT, malabsorption or by
irritation of such chemicals as alcohol. The patient suffers heavy loss
of fluid because it is not absorbed in the bowel; Nutrients are also
unabsorbed because of the shorter stay of the digested food in the
stomach, shorter than it is needed for the bowel to absorb the
nutrients. If this condition is not promptly dealt with, complications will
follow and the patient will be at greater risk.

In the case of the patient of this study, 1 year old Kenno Balahay
is admitted due to repeated episodes of loose, watery stools,
diagnosed as Acute Infectious Diarrhea. In his case, the digestive tract
is infected by a pathogen that alters the activities of his intestine. The
presence of the bacteria caused inflammation in his bowel altering its
movement.
His nutritional status is also at risk because the nutrients are not
properly absorbed by the bowels.

b. Objective of the Study

The study was conducted so that the student in charge will be


able to know the underlying cause of the disease, the nature and the
severity so that he will be able to identify the interventions needed to
promote the well being of the patient.

Since the patient is too young, proper and well planned


interventions should be provided because young children are more
susceptible to complications.

The study also serves to provide information to other students


who are having patients that have related disease conditions to serve
as reference for an improved nursing care.

c. Scope and Limitation of the Study

The study was conducted at the Medical Ward of Polymedic


General Hospital, specifically at the pediatric ward of the station. All
relevant data regarding the patient’s condition and history are
gathered. These data includes the Health History, Profile of Patient,
Physical Assessment, and some basic personal information that may
help in proper identification of the patient.

Only those data considered relevant and in line with the


condition of the patient are taken and noted, other private information
were kept confidential and were not noted as due respect for the
patient. And also, only one patient was assessed for the study.
II. Health History

a. Profile of the Patient

Name of Patient: Kenno Balahay

Sex: Male

Age: 1 year old

Religion: Roman Catholic

Civil Status: N/A

Income: N/A

Nationality: Filipino

Date Admitted: November 22, 2009

Time: 1:00 p.m.

Hospital: Polymedic General Hospital

Area: Pediatric Ward, Station 7, Room 703,

Chief Complains: Loose watery stools, Fever

Admitting Diagnosis: Acute Infectious Diarrhea


Attending Physician: Dr. Nelia Lim, M.D

Informant: Mr. Danny and Mrs. Arlyn Balahay

Temperature: 37.3OC

Pulse Rate: 119 BPM

Respiratory Rate: 31 CPM

b. History of Present Illness

c. Chief Complaint
III. Developmental Data
IV. Medical Management
a. Medical Orders with Rationale
b. Drug Study
V. Pathophysiology with Anatomy and Physiology
a. Anatomy and Physiology
b. Pathophysiology
VI. Nursing Management
a. Ideal Nursing Management
b. Actual Nursing Management
VII. Referrals and Follow up
VIII. Evaluation and Implication
IX. Documentation
a. Documentation of Evidence of Care Study for 1 Week Rotation
b. Bibliography