Sei sulla pagina 1di 48

Click to edit Master subtitle style

Acute Gastroenteritis

5/4/12

Health History

5/4/12

Demographic Data

5/4/12

Demographic Data
Clients Name:

Baby LC Male 5 February 25,

Gender:

Age/ Birth Date/ Birthplace:

months old/ 2011/ Manila


5/4/12

Demographic Data
Race/ Nationality:

Filipino Roman Catholic Kawit, Cavite Hospital Philhealth


5/4/12

Religion:

Address:

Usual Source of Medical Care:

Source & Reliability of Information


5/4/12

Source & Reliability of Information

Patients chart Patients mother Patient himself

5/4/12

Reason for Seeking Care

5/4/12

Reason for Seeking Care 10 episodes of diarrhea

5/4/12

History of Present Illness

5/4/12

History of Present Illness


Few days prior to Baby LCs admission, he defecated more than 10 times. His mother described his stool as watery in consistency and transparent to yellowish in color. His mother reported 1 episode of blood-streaked stool.
5/4/12

Past Medical History

5/4/12

Past Medical History


Injuries/ Accidents:

None None Hepa B Vaccine,

Hospitalization:

Immunizations:

DPT, OPV, BCG


Allergy

No Known Allergy
5/4/12

Family History

5/4/12

5/4/12

Developmental History

5/4/12

Developmental History
Sigmund Freuds Psychosexual Development
Oral (birth 1 year old) Anal (1-3 years old) Phallic (3 6 years old) Latency (6 puberty) Genital (puberty death)
5/4/12

Developmental History
Stage Task Patients Description

Oral (Birth 1 year)

Infant's mouth isBaby LC is taking the focusformula milk oflibidinal instead of gratification derivedbreastmilk. At the from the pleasuresame time, his of feeding at thecurrent condition mother's breast,(AGE) usually and from the oralderived from exploration of his orsucking dirty things her environment

5/4/12

Review of Systems

5/4/12

Review of Systems
Regional Examinations General/ Overall Health State
5 months old 7.5 kg in weight Vital signs of 36.2C (temperature),

33 bpm (respiratory rate), 110 bpm (pulse rate)


5/4/12

Review of Systems
Regional Examinations Integument
Skin rashes are covering half of his

buttocks * Skin rashes pinkish to reddish in color and approximately 3-5 cm in circumference each circle
5/4/12

Review of Systems
Laboratory Results: Normal Values Procedure
Hemoglobin Hematocrit WBC Lymphocytes 140-180 0.42-0.54 5-10 25-40%

Findings 116 0.35 10.36 51.8

Interpretation Low Iron intake Low Iron intake Infection Viral infection

5/4/12

Functional Assessment

5/4/12

Functional Assessment
Elimination Baby LC defecated 2 times from 6 oclock in the morning up to 12 oclock in the afternoon. The color of his stool is yellowish and semi-formed in consistency
5/4/12

Pathophysiol ogy

5/4/12

5/4/12

Concept mapping

5/4/12

1
Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes

2
Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6 hours
Baby LC

Dx: Acute Gastroenteritis Signs & Symptoms: *defecated 2x *watery to semi-formed stool *skin rashes (pinkish to reddish)
5/4/12

Problem list

5/4/12

Problem List
Actual Number 1 Problem Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes

Potential Number 1 Problem Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6 hours
5/4/12

Nursing care plan

5/4/12

Impaired Skin Integrity


Assessment Diagnosis Planning

S: No verbal Impaired skin At the end of Assessed site of At the end of skin impairment cues the entire shift, integrity r/t the entire shift, Advised the irritation of the the patient will patients mother to the patients lessen the O: skin irritation skin from lessen his skin positioning on the defecated 2x was lessened excessive irritation due toaffected area watery to semiAdvised the formed stool moist aeb skin excessive patients mother to rashes moist check most of the skin rashes time the affected (pinkish to area and report reddish, 3-5 cm immediately if the in condition worsen Advised the circumference patients mother to each circle) change located at the immediately the buttocks diaper especially

Nursing Intervention

Evaluation

when soaked Advised the patients mother to use topical cream

5/4/12

Risk for Fluid Volume Deficit


Assessment S: No verbal cues O: defecated 2x watery to semiformed stool Nursing Intervention Risk for fluid At the end of Monitored volume deficit the entire shift, intake and r/t diarrhea the patient will output Advised the aeb 2x be free from defecation in 6 fluid volume patients hours deficiency mother to increase oral fluid intake of Baby LC Hydrated the patient with water mixed with Protexin Administered IVF Diagnosis Planning Evaluation At the end of the entire shift, the patient has no signs of fluid volume deficiency or mild dehydration. No depressed fontanel and sunken eyeballs noted

5/4/12

Medical-surgical management

5/4/12

Drug Study

5/4/12

Name of Drug & Action

Classification

Adverse effect

Indication

Contraindication

Nursing Responsibilities

Protexin Probiotic (Restore) Helps to improve the balance of microorganism in the intestinal tract Vitamin for growth and health. It helps the body use carbohydrates, fats and protein. It also strengthens blood vessel walls

Nausea and vomiting, stomach pain, severe diarrhea, dehydration

Prolonged diarrhea, prolonged infection, prolonged fever, intestinal disease, stress

Blood problems, Observe the 5 Glucose-6rights in giving phosphate medication dehydrogenase Advise the (G6PD) patients mother deficiency to: -Strictly follow the doctors advise on how much to take and how often -May be taken with or without food -Try not to miss any doses

5/4/12

Name of Drug & Action

Classification

Adverse effect

Indication

Contraindication

Nursing Responsibilities

Zinc Sulfate Trace element Nausea and Acute diarrhea Immuno(E-Zinc) vomiting, compromised dizziness, patients Contributes to fever, stomach the recovery of pain, the intestinal incoordination, microbial flora restless and maintenance of skin hydration

Observe the 5 rights in giving medication Shake drug well before administra-tion Monitor patient for any unusual effect

5/4/12

Name of Drug & Action

Classification

Adverse effect

Indication

Contraindication

Nursing Responsibilities

Benzalkonium ( Drapolene) It cleans and disinfect skin or surrounding tissues

Antiseptic

Localized dermatitis, pruritus

Nappy rash & Hypersensitivit Store below Urinary rash y to 25C benzalkonium Tell the chloride, patients cetrimide or mother that it is lanolin for external use only Advise the patients mother to discontinue the topical cream if adverse reaction occur

5/4/12

Name of Drug & Action

Classification

Adverse effect

Indication

Contraindication

Nursing Responsibilities

Ampicillin (Liferzin) It stop microorganisms from multiplying

Antibiotic

Anemia, Restlessness, fever

Take the drug Treatment of Allergic to infection caused penicillin, around-the-clock by susceptible cephalosporins Take the full strains course of therapy It should not be used to self-treat other infections aside from what the doctor stated Advise to report N/V, diarrhea

5/4/12

Discharge health teaching

5/4/12

Discharge Health Teaching


Medication
Advise the patients mother to

continue his medication regimen especially the antibiotic/s


Instruct patients mother to comply

with the drugs as prescribed by the doctor and do not abruptly stop the drug without doctors consent
5/4/12

Discharge Health Teaching


Exercise
Advise the patients mother to allow

and support Baby LC in playing and moving- around because it serves as his ADL

5/4/12

Discharge Health Teaching


Treatment
Continue medication as prescribed by

the doctor and follow doctors advise

5/4/12

Discharge Health Teaching


Health Teaching
Advise the patients mother to perform

proper hygiene for Baby LC (bathing)

Emphasize to the patients mother the

importance of proper caring and cleaning of the mouth and genital


Before performing any cleaning or changing,

make sure to do hand washing


Ensure that the new diaper fits perfectly
5/4/12

Discharge Health Teaching


OPD
Advise the patients mother to seek

follow-up check-ups for Baby LC

5/4/12

Discharge Health Teaching


Diet
There are no dietary restrictions (milk

feeding as tolerated)

5/4/12

Discharge Health Teaching


Signs & Symptoms
Be sure to call the physician if these

signs & symptoms occur:


Fever Diarrhea or vomiting Swelling of the buttocks

5/4/12

Click to edit Master subtitle style

Thank You

Presented by: Arrian L.

5/4/12