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TABLE OF CONTENTS I. Introduction a.Overview of the case b.Objective of the study c.Sco e and Li!

itation of the study

II. "rofi#e of the atient III. $ea#th $istory a.Fa!i#y and "ersona# hea#th history b.$istory of "resent I##ness I%. "atho hysio#o&y with Anato!y ' "hysio#o&y %. (edica# (ana&e!ent a.)ru& study %I. Nursin& (ana&e!ent a.Idea# Nursin& (ana&e!ent *NC"+


a. Overview of the Study

Acute diarrhea or gastroenteritis is the passage of loose stools more frequently than what is normal for that individual. This increased frequency is often associated with stools that are watery or semisolid, abdominal cramps and bloating.

Acute watery diarrhea is an extremely common problem, and can be fatal due to severe dehydration, in both adults and children, especially in the very young and the old or in those who have poor immunity such as individuals with $I% infection or patients who are using certain medications that suppress the immune system. Gastroenteritis means inflammation of the stomach and small and large intestines. Viral gastroenteritis is an infection caused by a variety of viruses that result in vomiting or diarrhea or both. It is often called the stomach flu, although it is not caused by the influen!a viruses. "ersons can reduce their chance of getting infected by frequent handwashing, prompt disinfection of contaminated surfaces with household chlorine bleach#based cleaners, and prompt washing of soiled articles of clothing. If food or water is thought to be contaminated, it should be avoided. $ince most cases of acute watery diarrhea are infectious, especially in developing countries, the ma%ority of such illnesses can be prevented by drin&ing water or eating foods that are not contaminated with infectious agents. 'ashing hands frequently with non#contaminated water, when caring for a patient with diarrhea as also always before eating is important. "roper storage of food and water is also important to prevent harmful bacteria from contaminating them.

(ther symptoms include nausea, vomiting, loss of appetite, belching, and bloating. (ccasionally, acute abdominal pain can be a presenting symptom. This is

the case in phlegm nous gastritis )gangrene of the stomach* where severe abdominal pain accompanied by nausea and vomiting of potentially purulent gastric contents can be the presenting symptoms. +ever, chills, and hiccups also may be present. The diagnosis of acute gastritis may be suspected from the patient,s history and can be confirmed histologically by biopsy specimens ta&en at endoscopy. b. Objective of the Study This study aims to .onduct and evaluate an assessment for the client /etermine the causes, predisposing and precipitating factors that constitute the onset of the disease process. 0ender series of nursing interventions for the client1s care "rovide and disseminate important information as teachings to the client and the significant others to boost the &nowing and understanding of the nature of the said health condition. Improve s&ills and &nowledge as health care providers in the clinical area. c. Sco e and Li!itation of the Study This study includes the collection of information specifically to the patient1s health condition. The study also includes the assessment of the physiological and psychological status, adequacy of support systems and care given by the family as well as other health care providers. The scope of this study would includea. /ata collected via assessment, interviews with the patient, family members and clinical records.

b. Actual and ideal problems for 2 days including the initial assessment and its appropriate nursing intervention that would be applied within his stay in the hospital at "G3 hospital c. /eveloping a plan of care that will reduce identified predicaments and complications. d. .oordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health. e. +urther evaluating the effectiveness of nursing interventions that have been rendered to the client. An array of factors influencing the limitations of this study includesa. /ata collected is limited only to assessment and interview to the patient, patient1s chart and nurse on duty. b. The interaction, assessment and care were only limited to a total of 45 hours )6 days clinical duty, 4 day assessment* with actual nursing intervention done. c. The lac& of complete family history obtained was due to lac& of laboratory examinations or diagnostic examinations results li&e x#ray which data or results obtained is in the chart of the client during the time of care.


"atients "rofi#e

C#ient,s Na!e- 7atias, 8hunienne A&e- 5 months old Birthday- $eptember 49, 6::; Address- 6; st. santol <ue!on .ity Civi# Status- $ingle Se.- 7ale Nationa#ity- +ilipino /e#i&ion- 0oman .atholic 0ei&ht- 5.= >g. Infor!ant- Inalen 7atias )7other* Chief co! #aint- ?@7 Ad!ittin& dia&nosis- AGA with mild dehydration


a. Fa!i#y $ea#th $istory According to the father regarding the herido#familial history both her mother and father side has a history of hypertension. (n the father side they had a history of cancer since the father1s aunt died last 6::4 due to cervical cancer. b. "ast $ea#th $istory The father claimed that his child past illnesses were a typical cough, colds and fever that usually lasted for three days. (ver the counter medicines such as "aracetamol ).alpol* was used to treat for fever and /imetapp for colds. The father claimed that his child has not completed the vaccination required and never experiencing ma%or illness that required hospitali!ation until this +ebuary 4=, 6::; wherein the patient has been admitted at 80@ 3ospital having an acute diarrhea but the father denied that his child does not have &nown allergies to drugs and foods nor his child received a blood transfusion. The patient was born in 80@ 3ospital through a normal spontaneous vaginal delivery. c. $istory of "resent I##ness A case of 7atias, 8hunienne, 5months old 7ale, +ilipino, a resident of 7ambuaya .agayan de (ro .ity, admitted for the first time at "G3 hospital with a chief complaint of ?@7. Two days prior to admission he had persistent ?@7, vomiting, cough and fever.



)I2ESTI%E S1STE( The digestive system consists of two lin&ed parts- the alimentary canal and the accessory digestive organs. The alimentary canal is essentially a tube, some B meters )2: feet* long, that extends from the mouth to anus, with its longest section# the intestines# pac&ed into the abdominal cavity. The lining of the alimentary canal is continuous with the s&in, so technically its cavity lies outside the body. The alimentary Ctube1 consist of lin&ed organs that each play their own part in digestionmouth, pharynx, esophagus, stomach, small intestine, and large intestine. The accessory digestive organs consist of the teeth and tongue in the mouthD and the salivary glands, liver, gallbladder, and pancreas, which are all lin&ed by ducts to the alimentary canal.

STO(AC$ It is a 8# shaped enlargement of the GI tract directly under the diaphragm in the epigastric, umbilical and left hypochondriac regions of the abdomen. 'hen empty, it is about the si!e of a large sausageD the mucosa lies in large folds, called 0EGAA. Approximately 4: inches long but the diameter depends on how much food it contains. 'hen full, it can hold about F ? ) 4 galloon* of food. "arts of the stomach includes cardiac re&ion which is defined as a position near the heart surrounds the cardioesophageal sphincter through which food enters the stomach from the esophagusD fundus which is the expanded part of the stomach lateral to the cardia regionD body is the mid portionD and the y#orus a funnel shaped which is the terminal part of the stomach. The pylorus is continuous with the small intestine through the pyloric sphincter, or valve. 'ith the gastric glands lined with several secreting cells the !ymogenic )peptic* cells secrete the principal gastric en!yme precursor, pepsinogen. The parietal )oxyntic* cells produce hydrochloric acid, involved in conversion of pepsinogen to the active en!yme pepsin, and intrinsic factor, involved in the absorption of Vitamin @46 for the red blood cell production. 7ucous cells secrete mucus. $ecretions of the !ymogenic, parietal and mucus cells are collectively called the gastric %uice. Anteroendocrine cells secrete stomach gastrin, a hormone that stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower esophageal sphincter, mildly increases motility of the GI tract, and relaxes the pyloricsphincter. 7ost digestive activity occurs in the pyloric region of the stomach. After food has been processed in the stomach, it resembles heavy cream and is called .3G7A. The chyme enters the small intestine through the pyloric sphincter.


"atho hysio#o&y with Anato!y ' "hysio#o&y

)efinition- Acute 2astroenteritis is defined as diarrhea# disease of ra id onset3 often with nausea3 vo!itin&3 fever3 abdo!ina# ain and #oose bowe# !ove!ent. It is an inf#a!!ation of the !ucous !e!branes of the sto!ach and intestines often caused by an infection.

"redis osin& Factors Environ!ent $y&iene Stress

"reci itatin& Factors4 A&e*5 (onths+ 4 2ender*(a#e+

Ingestion of A. .oli

Invasion of gastric mucosa "enetration of Gastric mucosa Toxins producing pathogens cause watery, large volume diarrhea $igns H $ymptoms'atery stool +ever

Irritation of the Gastric ?ining

$igns H $ymptomsVomiting

+luid and Alectrolyte imbalance too much IaJ and 36( are expelled from the body

Increased fluid loss $igns H $ymptoms/ecrease s&in turgor $un&en Ayes



a. )ru& study

DRUG NAME "aracetamol DOSE/FREQUENCY/ROUTE =:: mg 4 tab qFh "0I for fever CLASSIFICATION AnalgesicD antipyretic MECHANISM OF ACTION 7ay produce analgesic effect by bloc&ing pain impulses, by inhibiting prostaglandin or pain receptor sensiti!ers. 7ay relieve fever by actingon hypothalamic heat#regulating center. 0elieves fever. SPECIFIC INDICATION +or fever. CONTRAINDICATION .ontraindicated in patients hypersensitive to drug or its components. SIDE EFFECTS Anemia, %aundice, rash, urticaria. NURSING PRECAUTION /o not administer for fever that1s above 2B.= ., lasts longer than 2 days or recurs. DRUG NAME A7@0(K(? DOSE/FREQUENCY/ROUTE :.9=ml TI/ ".( CLASSIFICATION .ough and .old "reparation MECHANISM OF ACTION Ambroxol is a mucolytic agent. It acts by increasing the respiratory tract secretion of lower viscosity mucus and exerting a positive influence on the alveolar surfactant system which leads to improved mucus flow and transport. Axpectoration of mucus is thus facilitated. SPECIFIC INDICATION .ough CONTRAINDICATION 3ypersensitivity to ambroxol or any ingredient of Ambrolex. SIDE EFFECTS 7ild GI side effects. NURSING PRECAUTION $hould be ta&en with food.


DRUG NAME GAITA7G.II DOSE/FREQUENCY/ROUTE IVT q ; AI$T CLASSIFICATION Amino glycoside MECHANISM OF ACTION @road#spectrum aminoglycoside antibiotic derived from Micromonospora purpurea. Action is usually bacteriocidal. SPECIFIC INDICATION "arenteral use restricted to treatment of serious infections of GI CONTRAINDICATION 3istory of hypersensitivity to or toxic reaction with any aminoglycoside antibiotic. $afe use during pregnancy )category .* or lactation is not established SIDE EFFECTS b. an allergic reaction )shortness of breathD closing of the throatD hivesD swelling of the lips, face, or tongueD rashD or fainting*D c. little or no urineD d. decreased hearing or ringing in the earsD e. di!!iness, clumsiness, or unsteadinessD f. numbness, s&in tingling, muscle twitching, or sei!uresD or g. severe watery diarrhea and abdominal cramps. NURSING PRECAUTION /raw blood specimens for pea& serum gentamicin concentration 2: minL4h after I7 administration, and 2: min after completion of a 2:L5: min IV infusion. /raw blood specimens for trough levels %ust before the next I7 or IV dose. Ese nonheparini!ed tubes to collect blood.


DRUG NAME Ampicillin DOSE/FREQUENCY/ROUTE 6=:mg IVT q ; AI$T CLASSIFICATION Antibiotic penicillin MECHANISM OF ACTION @acterial action against sensitive organism inhibits synthesis of bacterial cell wall, causing cell death. SPECIFIC INDICATION Treatment of infections caused by susceptible strains of A.coli. CONTRAINDICATION .ontraindicated with allergies to penicillin. SIDE EFFECTS .I$- lethargy sei!ures .V- .3+ GI- stomatitis, sore mouth, furry tongue (ther- super infections NURSING PRECAUTION A. @. .. /. Ta&e this drug 0ound the .loc&. Allergies of penicillin .ulture Infected area Ta&e oral drug on empty stomach


Submitted by: Calubayan, Aran Patrick G. Casipit, Rommel Caramoan, Aileen Castro, Jean Clazzer Corong, Da e Angelo Dadi as, Donald Jack Submitted to: !rs. "lma Segador R.#. !A#