Acute Gastroenteritis with Severe Dehydration

Case Study Presented to

Adventist University of the Philippines

College of Nursing

In Partial Fulfillment

For the Requirements in

Maternal and Child Health Nursing

Submitted By:

Dunwan, Princess Joy P.

Dela Cruz , Luis Miguel F.

Serrano, Herdell Ray F.

Hill, Natalie Ann

Babe, Oliver

December 29, 2019

 TABLE OF CONTENTS

I. INTRODUCTION…………………………………………………………….3-5

A. Objective……………………………………………………………….…3

B. Overview of Medical Diagnosis………….………………………………3

C. Prevalence and Incidence………….……………………………………..4

D. Prognosis………………………………………………………………….4

E. Overview of Care….……………………………………………………...5

II. PATIENT’S DATABASE…………………………………………………...5-18

A. Health History:

1. Client Information and Source…………………...……………….5

2. History of Present Illness………………………………………….6

3. Past Medical History…...…….……………………………………6

4. Family History…...………………………………………………7

5. Personal/Social History……...………………….………………..7

B. Review of Systems……………………………………………………….10

C. Prioritized Nursing Problems’ List………..……………………………..12

D. Physical Assessment………………………………………………….….12

1. Subjective…………..…………………………………………….12

2. Objective………..………………………………………….…….13

E. Diagnostic Tests and final Medical Diagnosis…………………...………14

F. Developmental Tasks………...………………………………..…………17

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III. UNDERLYING CONCEPTS………………………………………………18-24

A. Theoretical Background……………………………………………….....18-20

1. Anatomy

2. Physiology

B. The Disease Entity…………………………………………………….....19-24

1. Risk/Etiologic Factors…………………………………………....

2. Pathophysiology (Narrative)…………………………...………...

3. Pathophysiology (Diagram)……………………………………...

C. Standard of Care…………………………………………………………25-27

1. Diagnosis………………………………………………………...25

2. Treatment………………………………………………………...26-27

IV. NURSING PROCESS………………………………………………………

A. Prioritized Nursing Problems’ List………………………………………28-38

B. Assessment

C. Diagnosis

D. Planning

E. Interventions

F. Evaluation

V. SUMMARY………………………………………………………………….39

VI. RECOMMENDATIONS…………………………………………………...40-41

VII. BIBLIOGRAPHY…………………………………………………………...41-43

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 I. INTRODUCTION

A. Objectives of the Study

After reading this case study, readers will be able to:

B. Overview of the Medical Diagnoses

C. Prevalence and Incidence

D. Prognosis

E. Overview of Care

II. PATIENT’S DATABASE

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A. Health History

1. Client Information

Name: Mr. N Age: 58 years old

Date of Birth: March 16, 1961 Gender: Male
Weight: Height:
Race: Filipino
Address: 192-C SEN Neptali Gonzales, Hagdang Bato Itaas,
Mandaluyong City
Significant Others: N/A
Source of Information: Sister, Niece
Chief Complaint: Infected DM Foot

2. History of Present Illness

Prior to admission, Mr. N has a non-healing wound from continuous scratching of the

wound, it became infected and extends to his right leg and foot. Mr. N has undergone wound

debridement

3. Past Medical History

a. Hospitalizations/ Surgeries/ Accidents

b. Problems at Birth/ Major Childhood/ Adult Illness (Physical, Mental, Emotional)

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 c Immunization

BCG vaccine given (May 10, 2018)

Hepatitis B given (May 10, 2018)

Oral Polio Vaccine given ( Date Unrecalled)

Haemophilus influenzae type B vaccine given (Date Unrecalled)

Diphtheria-Tetanus- Pertussis (DPT) immunizations given (Date Unrecalled)

f. Allergies

The patient doesn’t have any allergy to any food or drug.

g. Transfusions

No transfusions done.

h. Diagnostic Tests

2. Family History:

Parents:

Mother (+) Diabetes Mellitus (Unrecalled date of

diagnosis)

Father (+) Hypertension (Unrecalled date of

diagnosis)

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5. Personal History & Social History

a. Description of Typical Day

b. Nutrition and Weight Management

c. Activity Level and Exercise

d. Sleep and Rest

e. Substance Abuse

Patient does not engage into any substance abuse.

f. Self-Concept and Self-Care Responsibilities

g. Social Activities

h. Relationships

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 i. Values and Belief System

The patient’s family is Roman Catholic, they don’t regularly attend church but

makes a sign of the cross when they pray. When one family member is sick they usually bring

them to the hospital or for check-up.

j. Education and Work

k. Stress Levels and Coping Styles

l. Environment

The patients place is warm since it is located in the city. They are away from the highway

but prone to flooding when it rains.

B. Review of Systems

(As stated by the sister)

General

Neurological

HEENT

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Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Endocrine

Muskuloskeletal

Skin

Psychological/behavior

C. Prioritized Nursing Problems List

Problem Onset Current treatment

Probiotics (Erceflora),

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D. Physical Assessment

1. Subjective

2. Objective

Test Result

Inspection Color: Skin is pale in color, pale palpebral

conjunctiva, sunken eyeballs

Hydration : lips and oral mucosa is dry and

slightly pink in color, absence of tears,

Abdominal Size and shape: abdomen shape

cylindrical, round soft, stool appears yellow,

loose, non-foul

Mental Status: Appears weak/lethargic,

PERRLA- pupils round react to light and

accommodation,

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 Lungs: subcostal retraction present, uses

accessory muscles in breathing

Percussion Abdomen: Tympanic sound

Palpation Skin : cool and dry skin

Hydration: Sunken anterior fontanelle,

capillary refill of <2 seconds, poor skin turgor

(2 -3 seconds) non tenting, full equal pulse

present

Abdomen: abdomen is soft and not distended

Auscultation Abdomen : 5 to 15 hyperactive bowel sound

per minute
Lungs: Clear breath sounds
E. Diagnostic tests and Final Medical Diagnosis

Test Value Reference

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 

Test Date Value Reference

Sodium

Test Value Reference

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Final Medical Diagnosis:

F. Developmental Task

Developmental Task Theory Status

Erik Erikson's stages of

psychosocial development

Freud's stages of

psychosexual development

Piaget's theory of cognitive

development

III. UNDERLYING CONCEPTS

A. Theoretical Background

1. Anatomy and Physiology of Gastrointestinal System / Normal Pathophysiology

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2. Pathophysiology (Narrative)

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3. Pathophysiology (Diagram)

14
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C. Standard of Care

Diagnosis

Medications

Allergies

Past Medical History

Social History

Other Diagnostics

Treatment

DM Diet

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 IV. NURSING PROCESS

Prioritization of Problems:

1. Non healing wound

2. Inability to ambulate

3. Poor hygiene

Problem No. 1:

Nursing Diagnosis: Impaired sin integrity r/t non healing wound

Rationale:

Subjective Data:

Objective Data:

 Presence of non- healing wound

Goal:

Short Term: After 3 days of nursing care patient’s wound will not have manifestations of

infection as evidenced by fewer purulent discharge.

Long Term:

Independent Nursing Intervention:

 Provide skin care periodically

Rationale:

 Maintain asepsis for dressing change and wound care.

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  Encourage intake of protein calorie rich foods to maintain optimal nutrition and promote

wound healing.

 Observe for signs of infection and inflammation (fever, flushed appearance, cloudy urine)

 Change wound dressing with Betadine under gauze dressing

Dependent Nursing Interventions:

Evaluation

Short Term:

Long Term:

Problem No 2: Inability to ambulate

Nursing Diagnosis: Impaired physical mobility r/t limited range of motion by pt. reporting

activity intolerance & limited strength.

Rationale:

Subjective Data:

Objective Data:

Goal:

Short Term: After 8 hours of nursing care pt. will perform in bed exercises and increase ROM.

Long Term:

Independent Nursing Interventions:

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  Patient will perform upper and lower body strengthening exercises.

Rationale:

 Assist patient in sitting

 Encourage patient to turn on side to side.

 ROMS*

Dependent Nursing Interventions:

Rationale:

Action:

Nursing Responsibilities:

Evaluation:

Short Term: Goal not met, patient was not able to perform in bed exercises.

Long Term:

Problem No. 3:

Nursing Diagnosis:

Rationale:

Subjective Data:

Objective Data:

Goal:

Short Term:

Long Term:

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Independent Nursing Interventions:

Dependent Nursing Interventions:

Evaluation:

Short Term

Long Term:

V. SUMMARY

VI. RECOMMENDATIONS

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VII. REFERENCES

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