Acute Gastroenteritis A Case Study

In Partial Fulfillment of the Requirements in Related Learning Experience 3

INTRODUCTION The mucosal surface of the gastrointestinal tract is composed of a highly dynamic population of epithelial cells that are specialized for transmembrane absorption and secretion. This secretory and absorptive ability facilitates digestion and nutrient uptake, which must b accomplished while keeping potentially harmful pathogens and mutagens in the lumen. The barrier function is accomplished through both the physical integrity of the mucosal surface and the extensive population of resident immune cells. (Harrisons 5th edition Principles of Internal Medicine) Diseases of the GI tract produce clinical consequences through physical disruption of the mucosal layer (eg blood loss, fluid loss, pathogenic invasion) or nutritional derangements caused by impaired digestion and nutrient absorption. Focal or localized disease processes are more likely to disrupt mucosa ; diffuse processes are more likely to alter absorption. (Harrisons 5th edition Principles of Internal Medicine) Acute Gastroenteritis Gastroenteritis is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and resulting in acute diarrhea. The inflammation is caused most often by infection with certain viruses, less often by bacteria or their toxins, parasites, or adverse reaction to something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year, and is a leading cause of death among infants and children under 5. Acute gastroenteritis accounts for millions of deaths each year in young children Harrison's Principles of Internal Medicine estimates the current total figure to be 2.4 to 2.9 million per year. The global death rate has now come down significantly to approximately 1.5 million deaths annually, mostly in developing communities. In developed countries is as high as 1-2.5 cases per child per year and a major cause of hospitalization in this age group. It is a common reason for presentation to general practice or emergency departments and for admission to hospital. The researchers of this case study have chosen to indulge in such illnesses like acute gastroentetitis for the reasons that they would like to increase the depth of their knowledge on this disease. As acute gastroenteritis is a common disease among children. The group have decided to take such topic for the case study because it focused in the care for children since they are the vulnerable persons, this would enable the student nurse to perform the comprehensive and precise care for the patient.

II. NURSING ASSESSMENT A. Personal History To secure confidentiality, the patient would be referred as Choy throughout the study. Tabatina , the mother of choy is the primary source of information. Choy is 9 months old baby boy and a naturally born Filipino citizen affiliated to the Roman Catholic religion who lives in a barrio in Arayat, Pampanga along with his parents and 1 sibling. He was born on June 28, 2008. He is the youngest among two siblings. Choy was admitted on February 22, 2009 at 4pm in a district hospital in Magalang with complaints of vomiting 5 -7 times upon admission and likewise the day before admission to the hospital. The admitting diagnosis is Acute Gastroenteritis (AGE) and was discharged on February 24, 2009 with a final diagnosis of AGE.

B. Pertinent Family History Choy a 9 month old baby, comes from a nuclear family composed of 4 members the father, mother and 2 children. His parents Mrs Tabatina And Mr. Arnee has no history of AGE his sister has likewise no history of AGE. Mrs. Tabatina has 2 children the first one is a girl who is 5 years old and Choy. She delivered both the first and second child through normal spontaneous delivery. Choy lives in a barrio which has limited accessibility to the hospital. His father Bitoy work as a precast maker to sustain the needs of their family. The family is affiliated to the Roman Catholic Church and they dont attend mass regularly. At present, they live in a house which has concrete walls, sawali for the roof and flooring which is still not cemented. Her mother describes their community as a peaceful one and her neighbours are hospitable. The family of Tabatina do not rely on cultural practices when it comes to their health, they readily consult for medical assistance. They have a Kapampangan culture which means most of their diet is mostly high in salt and fat since they are known for cooking food increasing the risk in acquiring disease of the heart and kidney problems.

B. Pertinent Family Health-Illness History

Popeye (+) (accident)

Wilma ( stigmatism)

Brutos

Lulu

Nowei (-)

Nina(-)

Neree (asthma)

Tabatina (measles, edema, fever ,c convulsions)

Bitoy (-)

Arnold (tonsillitis)

Legend: (+) deceased (-) - not specified by the mother of the pt, none

Chay (cough and colds, fever)

Choy (AGE & UTI)

There are no significant influences of the diseases/ illnesses of Choys grandparents and parents to his present condition which is AGE and UTI. Except for the diet of the family which most likely contributes to the said condition of baby Choy.

Theories of Growth and Development (Client-centered)

Erik Ericson Psychosocial Development Trust VS Mistrust (0-9 months) The major emphasis for the first months of life of the infant is positive and loving care for the child, with a big emphasis on visual contact and touch. The significant person in this stage is the mother that responds to the infants needs and provides a secure environment for the infant, in this stage the infant also learns to love and be loved. If he pass successfully through this period of life, he will learn to trust that life is basically okay and have basic confidence in the future. If he fail to experience trust and are constantly frustrated because her needs are not met, he may end up with a deep-seated feeling of worthlessness and a mistrust of the world in general he may view a very dangerous world. A 1-8 months old infant first year of life is vital to be able to gain trust sin order to fulfil this the mother the significant person should be a able to promptly respond to the infants need like feeding and sleep, he must also provide a predictable environment in which routines is establihed and provide a secure environment.

Jean Piaget Cognitive development Sensorimotor (1-12 months) Infants as soon as they are born, they begin learning to use their senses to explore the world around them and their behavior is entirely reflexive. Most newborns can focus on and follow moving objects, distinguish the pitch and volume of sound, see all colors and distinguish their hue and brightness, and start anticipating events such as sucking at the sight of a nipple. A three months old infants can recognize faces, imitate the facial expressions of others such as smiling and frowning and respond to familiar sounds. A six months of age babies are just beginning to understand how the world around them works. They imitate sounds, enjoy hearing their own voice, recognize parents, fear strangers and base distance on the size of an object. They also realize that if they drop an object they can pick it up again. A four to seven months infants can recognize their names.

A nine months, infants can imitate gestures and actions, experiment with the physical properties of objects, understand simple words such as "no" and understand that an object still exists even when they cannot see it. They also begin to test parental responses to their behaviour such as throwing food on the floor they remember the reaction and test the parents again to see if they get the same reaction. During this period it is important to develop the senses and motor skills of an infant this could be accomplihed through interacting and playing with the infant, its also important to provide good toys like colour plastic blocks and rings etc. for sesorimotor development

Sigmund Freud Psychosexual development Oral Phase (1-12 months) Oral phase occupies the 1-12 months of a child's life. The source of pleasure in this stage is the mouth, the infant seek the enjoyment or relief of tension as well as nourishment during this stage the child derives pleasure initially from breast-feeding and later from sucking things-a child in. If he is hungry it sucks, when food is not immediately available it will then cry until its needs are satisfied. During this stage the infant should be provided oral stimulation by giving a pacifier and do not discourage thumb sucking If a child were locked into or fixated at this stage, he would continue to engage in behavioral activities related to oral stimulation like thumb sucking, being talckative etc.

Anna Freud Ego Psychology Defense mechanisms are psychological strategies brought into play by various entities to cope with reality and to maintain self-image. Healthy persons normally use different defenses throughout life. ego defense mechanism becomes pathological only when its persistent use leads to maladaptive behavior such that the physical and/or mental health of the individual is adversely affected. The purpose of the Ego Defence Mechanisms is to protect the mind/self/ego from anxiety, social sanctions or to provide a refuge from a situation with which one cannot currently cope. A 1-9 month old infant show fear of strangers and usually cries when other hold them, also in this stage a increase of separateness infant experiences anxiety when the mothers leavesThey also begin to test parental responses to their behaviour such as throwing

food on the floor they remember the reaction and test the parents again to see if they get the same reaction. Immunization Baby Choy is already vaccinated with 1 BCG, 3 OPV, 3 DPT, 3 Hepa B and measles. His mother makes sure that Choy is vaccinated on schedule and goes to the health center to avoid the preventable diseases. 4. HISTORY OF PAST ILLNESS Baby Choy has been hospitalized for three times already with the same chief complaint which is vomiting. For the minor conditions such as fever, mild diarrhea, cough and colds which were managed at home by his mother such as having bed rest and increasing fluid intake and if necessary goes to the nearby Barangay health center for medical assistance and checkups. 5. HISTORY OF PRESENT ILLNESS

February 21, 2009 Baby Choy vomited 5 to 7 times and on the next day February 22, 2009 he started to have diarrhea, also which impelled her mother to confine her to the nearest Hospital in their place because of frequent vomiting and diarrhea that could not be manage. He was admitted at 4 pm on the same day and there was given the initial interventions in the hospital and further examination and diagnostic procedures like complete blood count and stool exam and urinalysis were done which led to the admitting medical diagnosis of acute gastroenteritis and UTI.

DIAGNOSTIC AND LABORATORY PROCEDURES The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood and includes the following:

White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant.

White blood cell differential looks at the types of white blood cells present. There are five different types of white blood cells, each with its own function in protecting us from infection. The differential classifies a person's white blood cells into each type: neutrophils (also known as segs, PMNs, grans), lymphocytes, monocytes, eosinophils, and basophils.

Red blood cell (RBC) count is a count of the actual number of red blood cells per volume of blood. Both increases and decreases can point to abnormal conditions.

Hemoglobin measures the amount of oxygen-carrying protein in the blood. Hematocrit measures the percentage of red blood cells in a given volume of whole blood. The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.

Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias.

Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.

Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the

red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.

Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such as pernicious anemia, the amount of variation (anisocytosis) in RBC size (along with variation in shape poikilocytosis) causes an increase in the RDW.

Diagnostic Laboratory Procedures ` Complete Blood Count Date ordered: Date results in: Indication or Purpose Results Normal Values

Analysis & Interpretation Of Results

Date ordered: Hemoglobin February 23. 3009

Date results in: February 23, 2009

This was used to evaluate the pt.s hemoglobin content (and thus the iron status and oxygencarrying capacity). Measures grams of hemoglobin found in deciliter of whole blood. Hemoglobin concentration correlates closely with RBC count

12.6 mg%

12-16 mg%

Clients hemoglobin level is within the normal range which indicates that there is an enough oxygenation on the blood.

This

blood

test Clients WBC is below normal. This indicates presence of infection.

evaluates a number of White blood cells Date ordered: February 23. 3009 conditions and

differentiates causes 5,700/cu.mm 10,000of alteration in total WBC including inflammation infection and since count 25,000/cu.mm

immune system of the Date results in: February 23, 2009 patient It is is

compromise. done to

evaluate of

presence infection.

 Measures the volume of RBCs in whole blood expressed in %. Value also tells whether the blood is too thick or too thin. Date ordered: February 23. 3009 Aid in diagnosis of abnormal hydration states of Clients Hematocrit level is within normal range which indicates there is enough RBC in patients body and there is no presence of Hematocrit Date results in: February 23, 2009 38 vol% 37-47 vol% dehydration

Diagnostic Laboratory Procedures Date ordered: Date results in: Indication or Purpose Results Normal Values

Analysis & Interpretation Of Results

Lymphocytes

Date Ordered: February 23, 2009

Used to determine viral infection which may be caused by opportunistic microorganisms due

33 %

25-40

The result shows that there is increase number of lymphocytes, thus increasing the number of antibodies to be use as body defenses. Viral infection is present.

Date results in: February 23, 2009

to decrease immunity of the patient. This test is also use to determine if the body is producing antibodies against the infection.

Diagnostic Laboratory Procedures Date ordered: Date results in: Indication or Purpose Results Normal Values

Analysis & Interpretation Of Results

Segmenters

Date Ordered: February 23, 2009

Measures percentage of neutrophils to the total number of leukocytes

20%

50-70%

Neutrophils, being the first line of defense of wbcs have already decreased from normal level which may indicate that infection is taking place.

Date results in: February 23, 2009

responsible for phagocitisizing foreign bodies.

Diagnostic Laboratory Procedures Eosinophils Date ordered: Date results in: Date Ordered: February 23, 2009 Indication or Purpose Eosinophils are used to test for allergic reactions and the bodys Date results in: February 23, 2009 response to parasitic diseases. 2% 1-4% Results Normal Values

Analysis & Interpretation Of Results The result is within normal range and indicates that there are enough eosinophils in the patients body.

NURSING RESPONSIBILITIES (Complete Blood Count)

Before the test: Check Doctors order Explain the purpose and procedure of CBC to the SO of the patient Tell the SO that the patient may feel discomfort from the needle puncture and blood is withdrawn into a capillary tube. Ensure the specimen/blood sample is not taken from the hand or arm that has an intravenous line in the vein because of the dilution effect on the red blood cells concentration. Plan to obtain the specimen when the patient is calm and physically still. Refer to the other member of the Health Care team During the test: Use aseptic technique when obtaining the sample Send the sample to the laboratory as soon as possible to avoid stasis and to allow early separation of the serum from the clotted blood. Send the sample to the laboratory as soon as possible to avoid stasis and to allow early separation of the serum from the clotted blood.

After the test: Apply pressure or a pressure dressing to the venipuncture site to prevent bleeding. Check the venipuncture site for bleeding Immediately label the specimen.

Diagnostic Laboratory Procedures Fecalysis Date ordered: Date results in: Date Ordered: February 23, 2009 Indication or Purpose Help to diagnose certain conditions affecting the digestive tract Date results in: February 23, 2009 Help find the cause of symptoms affecting the digestive tract To determine the presence of parasitic worm in the GI tract of the patient No OVA / Amoeba seen Color : Yellowish Consistency: Soft Fat Globulin: Few Results Normal Values Color: brown

Analysis & Interpretation Of Results

Fat Globulin: Consistency: formed Bacteria: none Bacteria: Normal

Normal

No OVA / Amoeba seen:

Normal

NURSING RESPONSIBILITIES (Fecalysis)

Before the test: Check doctors order Explain to the SO the purpose and the procedure of fecalysis Usual aseptic technique Try to collect the freshest stool possible Take a small piece of stool with the wooden applicator Provide clean specimen cup Refer to the other member of the Health Care team During the test: Collect the stool in a clean specimen cup Report the consistency of the stool sample: Formed, semi-formed, soft or watery. Report the visible presence of blood, mucus or parasites. Look for adult worms of Ascaris lumbricoides or Trichuris trichuria. After the test: Immediately label the specimen. Remove gloves and wash hands. Record the clients name, the test performed and disposition of the specimen collected criteria.

Diagnostic Laboratory Procedures Urinalysis Date ordered: Date results in: Date Ordered: February 23, 2009 Indication or Purpose This was order for the patient in order to screen for renal or urinary tract Date results in: February 23, 2009 diseases and to determine metabolic or systemic disease related to renal disorder. Trace pH: Acidic Specific Gravity: 1 Pus Cells: Negative Albumin: Clear Sugar: Color: yellowish Transparency: Results Normal Values Color: Pale yellow to deep amber Transparency: Clear Sugar: Negative Albumin: Negative pH: 5.5-6.5 Specific Gravity: 1.001-1.025 Pus Cells: 0-1/hpf Mucus Thread: few

Analysis & Interpretation Of Results Concentrated Transparency: Normal Sugar: Normal Albumin: Normal pH: Normal Pus Cells: Few Mucus thread:

2-5/hpf Mucus Thread: Few

Normal

NURSING RESPONSIBILITIES (Urinalysis)

PRIOR Check the doctors order. Determine the prescribed test and other restrictions prior to the test. Get the laboratory requisition slip. Explain to the patient what the procedure to be done is. Inform the patient that this requires a urine sample. Inform the patient how the procedure is performed, the equipment to be used.

DURING Explain to the patient what test should be done. Prepare all the equipments to be used. Encourage the patient to remain calm during the test. Assist the patient. Ensure a urine sample from the patient.

AFTER Send the urine sample to the laboratory immediately. Prevent contamination to the samples. Secure it properly and label it before giving to the laboratory. Proper documentation.

Physical Examination: February 22, 2009 (Day of admission) Vital Signs: T=37.1C PR=150bpm RR=46bpm

Physical Examination lifted from the chart: 2 days PTA (+) intractable vomiting 1 day PTA (-) vomiting persisted also with body malaise weight: 10.5 kg Skin: (-) pallor HE ENT: Dry lips and buccal mucousa C/L: Clear B.S Heart: (-) murmurs Abd: (-) organomegaly Full pulse February 24, 2009--First day of Nurse-Patient Interacion Vital Signs: T=36.9C PR=120bpm RR=38bpm

SKIN He has a white complexion with evenly distributed hair. He has a good skin turgor as evidenced by when the skin was lifted at the abdomen, the skin goes back to its previous state. HAIR He has short-hair, black in color, uncombed, dry, and equally distributed on scalp area, there is no infestation noted.

NAILS He has untrimmed dirty fingernails. His nails are quite rough and but have a good curvature. The nail base is firm and adhises to the bed capillary refill time of approximately 2 seconds upon performing Blanch test.

SKULL AND FACE His skull is round and normocephalic with no tenderness, lumps, nodules and masses noted upon palpation. He also has symmetrical facial features and movements as evidenced by his ability to raise eyebrow, smile. Anterior and posterior fontanels are already closed.

EYES AND VISION The eyebrows and eyelahes are evenly distributed and are symmetrically aligned with equal movements. Eyelids have intact skin with discharges (morning glory) and no discoloration noted. They also close symmetrically. The bulbar conjunctivas are transparent and capillaries are sometimes evident but no presence of nodules or lesions. The sclera also appears clear. His palpebral conjunctiva is slightly pale. No edema or lesions noted upon the inspection of lacrimal sac and nasolacrimal duct. Cornea is transparent, shiny and smooth and details of iris are visible. The client blinks when cornea is touched by cotton which means that he has an intact cranial nerve 5

(trigeminal). Iris is round, brown in color and equal in size. Illuminated and nonilluminated pupils are equally round and reactive to light accommodation (PERRLA).

EARS AND HEARING His tip of ears is aligned to the outer cantus of the eye. There is presence of wet cerumen which is dark brown in color inside the ear canal. No deformities or inflammation noted and auricles are smooth, firm and not tender upon palpation. The pinna recoils after it is folded and normal voice tone audible as evidenced by responding when called by his name.

NOSE Clients nasal septum is intact and at the midline with no tenderness and lesions noted upon inspection. Each nostril is not occluded by discharges and doesnt have difficulty of breathing.

MOUTH AND OROPHARYNX The lips are moist and slightly dark in color with no lesions noted. The client was able to purse his lips which indicate an intact cranial nerve 7 (facial) function. He has no gingivitis and no evidence of dehydration. His teeth have spaces in between and are not yet complete. The tongue is slightly pink in color and moist with thin whitish coating. Both the hard and soft palates are light pink on color and the uvula is positioned in midline of soft palate upon inspection. Tonsils are pink and smooth with no discharges noted and are normal in size. Gag reflex is present upon pressing the posterior tongue with tongue depressor.

NECK Head is on the center upon inspection and no swelling or enlargement of lymph nodes. The trachea is in the midline of neck and spaces are equal on both sides. The

thyroid gland is not visible on inspection and ascends during swallowing but not still visible. Lobes are small, smooth, centrally located, painless, and rise freely with swallowing upon palpation. He was able to flex, hyperextend, laterally flex and laterally rotate the head and can move side to side, up and down.

THORAX AND LUNGS The spine is vertically aligned and straight. Chest is uniform in color and has a warm temperature. It expands symmetrically and no tenderness or masses upon palpation. There is no presence of abnormal breath sounds and with regular rate and rhythm.

HEART He has normal heart rate, no murmurs noted upon auscultation.

ABDOMEN He has unblemihed skin, rounded abdomen. With normal bowel sounds.

UPPER AND LOWER EXTREMITIES The skin is uniform in color with no contractures or deformities. Muscles on both sides of the body are equal in size. There are no lesions, tenderness or swelling and no jaundice and cyanosis. He has dry skin and uniform temperature upon palpation.

III. ANATOMY AND PHYSIOLOGY

The Digestive System

The gastrointestinal system (GI) system is a long, hollow tube that passes through the body providing an isolated environment for digestion and absorption of the nutrients. Ingested contents pass sequentially through the mouth, esophagus, stomach, small intestine and large intestine before exiting the body at the anus.

A. The Oral Cavity

Plays a role in digestion, speech, and breathing. Digestion begins when food enters the mouth. Teeth break down food and the muscular tongue pushes food back toward the pharynx, or throat. Three salivary glands- sublingual, submandibular and parotid gland secrete enzymes that partially digest food into a soft, moist, round lump. Muscles in the pharynx swallow the food, pushing into the esophagus, a muscular tube that passes food into the stomach. The epiglottis prevents food from entering the trachea, or windpipe during swallowing.

B. The Esophagus

The presence of food in the pharynx stimulates swallowing, which squeezes the food into the esophagus. The esophagus, a muscular tube about 25 cm long, passes behind the trachea and heart and penetrates the diaphragm before reaching the stomach. Food advances through the alimentary canal by means of rhythmic muscle contractions known as peristalsis. The process begins when circular muscles in the esophagus wall contract and relax one after the other, squeezing food downward toward the stomach. Food travels the length of the esophagus in two or three seconds. C. The Stomach Anatomy of the Stomach

The stomach is an enlarged segment of the digestive tract in the left superior part of the abdomen. The opening from the esophagus into the stomach is called the cardiac opening because it is near the heart. The region of the stomach around the cardiac opening is called the cardiac region. The most superior part of the stomach is the fundus. The largest part of the stomach is the body, which turns to the right, forming a greater curvature on the left, and a lesser curvature on the right. The opening from the stomach into the small

intestine is the pyloric opening, which is surrounded by a relatively thick ring of smooth muscle called the pyloric sphincter. The region of the stomach near the pyloric opening is the pyloric region.

The muscular layer of the stomach is different from other regions of the digestive tract in that it consists of three layers: an outer longitudinal layer, a middle circular layer, and an inner oblique layer. These muscular layers produce a churning action in the stomach, important in the digestive process. The submucosa and mucosa of the stomach are thrown into large folds called rugae when the stomach is empty. These folds allow the mucosa and submucosa to stretch, and the folds disappear as the stomach is filled. The stomach is lined with simple columnar epithelium. The mucosal surface forms numerous tubelike gastric pits which are the openings for the gastric glands. The epithelial cells of the stomach can be divided into five groups. The first group consists of surface mucous cells on the inner surface of the stomach and lining the gastric pits. Those cells produce mucus, which coats and protects the stomach lining. The remaining four cell types are in the gastric glands. They are mucous neck cells, which produce mucus; parietal cells, which produce hydrochloric acid and intrinsic factor; endocrine cells, which produce regulatory hormones; and chief cells, which produce pepsinogen, a precursor of the protein-digesting enzyme pepsin. Secretions of the Stomach

The stomach functions primarily as storage and mixing chamber for ingested food. As food enters the stomach, it is mixed with stomach secretions to become a semi fluid mixture called chyme. Although some digestion and a small amount of absorption occur in the stomach, they are not its principal functions.

Stomach secretions from the gastric glands include mucus, HCl, pepsinogen, intrinsic factor, and gastrin. A thick layer of mucus lubricates and protects the epithelial cells of the stomach from the damaging effect of the acidic chyme and pepsin. Irritation of the stomach mucosa stimulates the secretion of a greater volume of mucus. Hydrochloric acid produces a pH of about 2.0 in the stomach. Pepsinogen is converted by HCl to the active enzyme pepsin. Pepsin breaks covalent bonds of protein to form

smaller peptide chains. Pepsin exhibits optimum enzymatic activity of a pH of about 2.0. The low pH kills microorganisms. Intrinsic factor binds with Vitamin B12 and makes it more readily absorbed in the small intestine. Vitamin B12 is important in DNA synthesis and is important in RBC production. Gastrin is a hormone that helps regulate stomach secretions.

D. The Small Intestine Anatomy of the Small Intestine The small intestine is about 6 meters long and consists of three parts: the duodenum, jejunum and ileum. The duodenum is about 25 cm long. The jejunum is about 2.5 m long and makes up two-fifths of the total length of the small intestine. The ileum is about 3.5 m long and makes up three-fifths of the small intestine.

The duodenum nearly completes a 180-degree arc as it curves within the abdominal cavity. Part of the pancreas lies within this arc. The common bile duct from the liver and the pancreatic duct from the pancreas join each other and empty into the duodenum.

The small intestine is the major site of digestion and absorption of food, which are accomplished by the presence of a large surface area. The surface of the small intestine has three modifications that increase surface area about 600-fold: the circular folds, villi and microvilli. The mucosa and submucosa form a series of circular folds that run perpendicular to the long axis of the digestive tract. Tiny fingerlike projections of the mucosa form numerous villi, which are 0.5-1.5 mm long. Most of the cells composing the surface of the villi have numerous cytoplasmic extensions called, microvilli. Each villus is covered by simple columnar epithelium. Within the loose connective tissue core of each villus is a blood capillary network and a lymphatic capillary called lacteal. The blood capillary network and the lacteal are very important in transporting absorbed nutrients.

The mucosa of the small intestine is simple columnar epithelium with four major cell types: (1) absorptive cells, which have microvilli, produce digestive enzymes and absorb digested food; (2) goblet cells, which produce a protective mucus; (3) granular cells, which may help protect the intestinal epithelium from bacteria; and (4) endocrine cells, which produce regulatory hormones.

The epithelial cells are produced within tubular glands of the mucosa, called intestinal glands, at the base of the villi. Granular and endocrine cells are located in the bottom of the glands. The submucosa of the duodenum contains mucous glands, called duodenal glands, which open into the base of the intestinal glands.

The duodenum, jejunum and ileum are similar in structure except that there is a gradual decrease in the diameter of the small intestine, in the thickness of the intestinal wall, in the number of the circular folds, and in the number of villi as one progresses through the small intestine. Lymph nodules are common along the entire length of the digestive tract. Clusters of lymph nodules, called Peyers patches, are numerous in the ileum. These lymphatic tissues in the intestine help protect the intestinal tract from harmful microorganisms.

The junction between the ileum and the large intestine is the ileocecal junction. It has a ring of smooth muscle, the ileocecal sphincter, and ileocecal valve, which allows material contained in the intestine to move from the ileum to the large intestine, but not in the opposite direction. Secretions and Absorption in the Small Intestine

Secretions from the mucosa of the small intestine mainly contain mucus, ions and water. Intestinal secretions lubricate and protect the intestinal wall from the acidic chime and the action of the digestive enzymes. They also keep the chime in the small intestine in the liquid form to facilitate the digestive process. Most of the secretions entering the small intestine are produced by the intestinal mucosa, but the secretions of the liver and the pancreas also enter the small intestine and play important roles in the digestive processes.

The epithelial cells in the walls of the small intestine have enzymes to their free surfaces that play a significant role in the final steps of digestion. Peptidases break the peptide bonds in proteins to form amino acids. Disaccharidases break down disaccharides into monosaccharides. The amino acids and monosaccharides can be absorbed by the intestinal epithelium.

Mucus is produced by duodenal glands and by goblet cells, which are dispersed throughout the epithelial lining of the entire small intestine and within intestinal glands. Hormones released from the intestinal mucosa stimulate liver and pancreatic secretions. Secretion by duodenal glands is stimulated by the vagus nerve, secretin release, and chemical or tactile irritation of the duodenal mucosa.

A major function of the small intestine is the absorption of nutrients. Most absorption occurs in the duodenum and jejunum, although some absorption also occurs in the ileum. E. The Large Intestine Anatomy of the Large Intestine

The

large

intestine

consist of cecum, colon, rectum and anal canal.

Cecum The proximal cecum of is the the large

end

intestine and is where the large and small intestines meet at the ileocecal junction. The cecum is located in the right lower

quadrant of the abdomen near the iliac fossa. The cecum is a sac that extends inferiorly about 6 cm past the ileocecal junction. Attached to the cecum is a tube about 9 cm long called the appendix.

Colon

The colon is about 1.5-1.8 m long and consists of four parts: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon. The ascending colon extends superiorly from the cecum to the right colic flexure, near the liver, where it turns to the left. The transverse colon extends from the right colic flexure to the left colic flexure near the spleen, where the colon turns inferiorly; and the descending colon extends from the left colic flexure to the pelvis, where it becomes the sigmoid colon. The sigmoid colon forms an S- shaped tube that extends medially and the inferiorly into the pelvic cavity and ends at the rectum. The mucosal lining of the colon contains numerous straight tubular glands called crypts, which contain many mucus-producing goblet cells. The longitudinal smooth muscle layer of the colon does not completely envelope the intestinal wall but forms three bands called teniae coli.

Rectum

The rectum is a straight, muscular tube that begins at the termination of the sigmoid colon and ends at the anal canal. The muscular tunic is smooth muscle and it is relatively thick in the rectum compared with the rest of the digestive tract.

Anal Canal

The last 2-3 cm of the digestive tract is the anal canal. It begins at the inferior end of the rectum and ends at the anus. The smooth muscle layer of the anal canal is even thicker than that of the rectum and forms the internal anal sphincter at the superior end of the anal canal. The external anal sphincter at the inferior end of the anal canal is formed by skeletal muscle. Functions of the Large Intestine

Normally 18-24 hours is required for material to pass through the large intestine in contrast to the 3-5 hours required for movement of chyme through the small intestine.

While in the colon the chyme is converted to feces. Absorption of water and salts, the secretion of the mucus, and extensive action of microorganisms are involved in the formation of feces. The colon stores the feces until they are eliminated by the process of defecation.

DEFENITION OF THE DISEASE Gastroenteritis Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). An infection may be caused by bacteria or parasites in spoiled food or unclean water. Some foods may irritate your stomach and cause gastroenteritis. Lactose intolerance to dairy products is one example. Many people who experience the vomiting and diarrhea that develop from these types of infections or irritations think they have food poisoning," which they may, or call it "stomach flu," although influenza has nothing to do with it. Travelers to foreign countries may experience traveler's diarrhea" from contaminated food and unclean water. The severity of infectious gastroenteritis depends on your immune systems ability to resist the infection. Electrolytes (these include essential elements of sodium and potassium) may be lost as you vomit and experience diarrhea. Most people recover easily from a short bout with vomiting and diarrhea by drinking fluids and easing back into a normal diet. But for others, such as babies and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration, which is a life-threatening illness unless the condition is treated and fluids restored. Gastroenteritis has many causes. Viruses and bacteria are the most common. The infectious agents can come from outside your body or internally from some abnormal condition. For example, both normal and disease-causing intestinal bacteria may grow when antacids or other medication alter the stomach acidity. Viruses and bacteria are very contagious and can spread through contaminated food or water. In up to 50% of diarrheal outbreaks, no specific agent is found. Improper handwashing following a bowel movement or handling a diaper can spread the disease from person to person. Gastroenteritis caused by viruses may last 1-2 days. On the other hand, bacterial cases can last a week or more.

Bacteria: These are the most common bacterial causes: Escherichia coli Travelers diarrhea, food poisoning, dysentery, colitis, or uremic syndrome, Salmonella - Typhoid fever; handling poultry or reptiles such as turtles that carry

the germs, Campylobacter - Undercooked meat, unpasteurized milk, Shigella Dysentery.

Viruses: Viral outbreaks (30-40% of cases in children) can spread rapidly through close contact among children in day care and schools. Poor handwashing habits can spread viruses. Common viral causes include the following: Adenoviruses, Rotaviruses, Caliciviruses, Astroviruses, Norovirus (formerly called Norwalk-like virus or NLV) and Norwalk virus, Norovirus. Parasites and protozoans: These tiny organisms are less frequently responsible for intestinal irritation. You may pick up one of these by drinking contaminated water. Swimming pools are common places to come in contact with these parasites. Common parasites include these: Giardia - The most frequent cause of waterborne diarrhea causing giardiasis, Cryptosporidium Affects mostly people with weakened immune systems, causes watery diarrhea Other common causes: Chemical toxins most often found in seafood, food allergies, heavy metals, antibiotics, and other medications also may be responsible for bouts of gastroenteritis that are not infectious to others. Medications

Aspirin Nonsteroidal anti-inflammatory medicines (such as Motrin or Advil) Antibiotics Caffeine Steroids - Excessive use or a sudden change in frequency or dosage Laxatives

Inability to tolerate the sugar lactose in milk and milk products such as cheese and ice cream Exposure to heavy metals sometimes present in drinking water

Arsenic Lead Mercury

IV.

PATHOPHYSIOLOGY (Book-Centered)

Non- Modifiable Age- children below 5y/o & elderly

Modifiable Environment Antibiotic Therapy Food Handling

Increase motility of intestines

Microorganisms attach and enter mature enterocytes at the tips of small intestinal villi

serotonin release

stimulates chemoreceptor PAIN & BORBORYGMIA Structural changes to the small bowel mucosa and inflammation of the lamina propria VOMITING trigger zone

BACTEREMIA

Bacteria invades blood stream across lamina propria

INCREASE WBC

Mucosal Cell Destruction hypothalamus

Bacteria releases endotoxin

Releases pyrogens that stimulates

BLOODY STOOLS

Increase amount of diarrheal Fluid

FEVER

Active Secretion of Chloride & Bicarbonate Ions

Inhibition of Na & water reabsorption

DIARRHEA

SCHEMATIC DIAGRAM (Client Centered)

Non- Modifiable > Age (5 years old)

Modifiable >Environment > Eating Habits

Stimulates trigger zone

Microorganisms attach and enter mature enterocytes at the tips of small intestinal villi

Vomiting (2/22/09)

Structural changes to the small bowel mucosa and inflammation of the lamina propria

M.O. invades blood stream across lamina propria

INCREASE LEUCOCYTES (02/23/09)

Bacteria releases endotoxin

Increase amount of diarrheal Fluid

Active Secretion of Chloride & Bicarbonate Ions

Inhibition of Na & water reabsorption

Soft, yellowish DIARRHEA (4 diapers a day) (2/22/09, 2/23/09)

PREDISPOSING & PRECIPITATING FACTORS PREDISPOSING FACTORS: a.) Age Different body systems mature as age increases. Infants and adults are more likely to develop such diseases since their body processes are either immature or degenerating. b.) Sex Male toddlers are more prone to have acquired gastroenteritis. Males usually play outside their house compare to girls who usually stay at home.

PRECIPITATING FACTORS:

a.) Poor Environmental Sanitation The environment plays a vital role in our health. An unhygienic or poor environmental condition is not conducive to live in because it may lead to acquiring such disease. b.) Eating Habits A person who frequently eats street foods and junk foods is at risk of having Gastroenteritis thus it can also be acquired by eating unwashed fruits and vegetables, raw eggs and those that are contaminated by the fecal oral route. c.) Lack of Education Due to lack of education, buyers are no longer thinking whether the food that they buy are nutritious or not and the no longer care whether the food they are eating are clean or not

SIGNS AND SYMPTOMS WITH RATIONALE a.) Diarrhea Pathogens cause gastric inflammation by releasing enterotoxins that stimulate the mucosal lining of the intestines, resulting in greater secretion of water and electrolytes in the intestinal lumen which may cause fluid and electrolyte imbalance. c.) Nausea or vomiting In intestinal disorders, nausea results from the distention of the duodenum. Vomiting occurs from changes in the integrity of the intestinal wall or from changes in the motility of the bowel (such as caused by an obstruction). Vomitus that contains fecal matter usually indicates a distal obstruction in the small intestines. g.) Dehydration

Dehydration happens when there is frequent vomiting, diarrhea and excessive sweating. h.) Dry skin and Buccal Mucosa Because of frequent vomiting and dehydration, the membranes and skin tends to be dry. Enterotoxin

MEDICAL MANAGEMENT

MEDICAL MANAGEMENT/ TREATMENT

DATE ORDERED DATE PERFORMED DATE CHANGED

GENERAL DESCRIPTION

INDICATION(s) PURPOSE(s)

CLIENTS RESPONSE TO TREATMENT

D5,0.3NaCl 500ml

DO: February 22, Intravenous Fluids are sterile. 2009 Introduced directly into the vein. The type of which and DP: February 22, regulation depends upon the 2009 fluid needs of the patients.

It is given to the patient to maintain the fluid status and serves as a route for administration of IV medications. Primarily it is given to replace lost fluids in the body.

The patient maintained a normal hydration status as evidence by good skin turgor and moist skin.

D5, 0.3 NaCl is a solution in 5% dextrose and 0.3 % NaCl in 500ml of water

NURSING RESPONSIBILITIES

BEFORE: When inserting an IV line to the patient, always prepare all the materials to be used. Wash hands thoroughly before performing the procedure. Identify the correct patient by checking the name on the chart or by asking directly the patient. Explain the procedure to the patient. Prepare the materials needed.

DURING: 1. Count drops per minute in drip chamber. 2. Adjust IV clamp as needed and recount drop per minute. 3. Inspect for any inflammation. 4. Provide comfort during insertion. AFTER: Monitor patients therapeutic response to treatment. Check the IV infusion site for signs of infiltration: bulging, heat, pain, and redness.

B. DRUGS

Name of drugs

Date ordered/ date stopped/ date given/ date change

Route of administration/ dosage and frequency of administration

General action/ classification/ mechanism of action

Indication/ initial reaction/ purpose

Cefuroxime

DO: February 22, 2009 DP: February 22, 2009

1gm IV q 8 ANST

Antibiotic Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins

For prophylaxis against the occurrence of secondary infections

Paracetamol

DO: February 22, 2009 DP: February 22, 2009 150mg IV if temp is >38.5

antipyretic/analgesic Inhibits the synthesis of prostaglandins in the central nervous system and peripherally blocks pain impulse generation; produces antipyresis from inhibition of hypothalamic

Indicated if pt temp reaches >38.5

heat-regulating center

Nursing Responsibilities for Medication: Preparing the client: Check the written order for completeness. It should include the drugs name, dosage, frequency and duration of the therapy. Check to see if there are any official circumstances surrounding Perform sensitivity teting Administration of the dose to the patient Know the expected action, safe dosage range, special instruction for administration and adverse effects associated with drug effect Prepare the need equipment like the medication card and water. Wash your hands Prepare the dosage as ordered Check the label on the medication three times before administering any drug Do not prepare a dosage of medication which is discarded precipitate is contaminated

Performing the procedure Administer slowly as the medication may cause burning sensation Check the proper dosage

After the procedure Watch out for side effects

Name of Drugs

Date Ordered

Route

Dosage

and General Action of

Frequency Administration

Indication(s) Purpose(s)

or Clients response to the medication with actual side effects

Generic Name: Metoclopramide

Date Ordered: February 22, 2009

150 mg IV q 6 hours (- Action: ) ANST Metoclopramide, dopamine

To stop the vomiting of The patient the pt effects such headache a and restlessness

side as:

antagonist,

stimulates motility of the Brand Name: Plasil DP: February 22, 2009 upper gastrointestinal Response patient: of the

tract without stimulating gastric, pancreatic biliary or

secretions.

Its mode of action is unclear. It seems to sensitize tissues to the action of acetylcholine. The effect of on

There was a change in the patients Gastrointestinal tone.

metoclopramide

motility is not dependent on intact vagal

innervation but it can be abolished by

anticholinergic Metoclopramide

drugs.

increases the tone and amplitude (especially contractions, the pyloric of gastric antral) relaxes sphincter

and the duodenum and jejunum, resulting in

accelerated

gastric

emptying and intestinal transit. It increases the resting tone of the lower esophageal sphincter

General Classification: Antiemetic Antivertigo and

Nursing Responsibilites: Plasil Prior: Check for the doctors order. Assess if the patient has hypersensitivity to drug. Tell the patient to avoid activities that require alertness for 2 hours after doses.

During: Urge patient to report persistent or serious adverse reactions promptly. Monitor the patients bowel sounds. Assess and monitor the patients heart rate.

After: Monitor if there is a decrease in the patients neutrophil and granulocyte count. Check if there is an increase in the aldosterone levels.

C. DIET Date Ordered Type of Diet Date Started Date Changed

General Description

Indication or Purpose

Specific Foods Taken

Clients Response

Pt. is allowed to To help the patient Breastfed DAT drink soups. taken. and is indicated with

and The client was able to

eat have a strong body bottle-feeding was have strong body while it trying to cope up with the current situation.

Essential while the disease.

nutrients may be compensating

During the Date of Admission, patient is for NPO temporarily.

NURSING RESPONSIBILITIES PRIOR:

Check doctors order to determine the kind of diet Identify patient, instruct S.O. or mother when diet is changed.

DURING:

Explain to S.O. the prescribed diet Educate the S.O. on the purpose of the diet and its implication

D. EXERCISE

DATE ORDERED TYPE OF EXERCISE DATE PERFORMED DATE CHANGED

GENERAL DESCRIPTION

INDICATION

CLIENTS RESPONSE TO ACTIVITY

Rest periods accompaniment SO

with DO: February 22, 2009 from

Pt. Should be with the To promote SO to prevent falls and and recovery help recover from illness

wellness Pt. SO complied with the order.

NURSING RESPONSIBILITIES:

1. Explain the reason to the SO, rationale and aims of the said exercise.

NURSING CARE PLANS Problem #1: Diarrhea ASSESSMENT NURSING DIAGNOSIS S: O:The patient manifested: -Passed loose stools 5-7 times -changes diapers about 4-5 times a day The patient may manifest: -Dehydration Diarrhea r/t infectious processes SCIENTIFIC EXPLANATION Diarrhea may result from a variety of factors, including intestinal absorption disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. Problems associated with diarrhea, which when acute includes fluid and electrolyte imbalance, and altered skin integrity. OBJECTIVES Short term: After 2-4 hours of nursing interventions the patient or the SO will verbalize understanding on ways to manage resolution of causative factors Long term: After 2-3 days of nursing interventions the patient will re-establish improvements in bowel functioning NURSING INTERVENTIONS -Assess for frequency and urgency of loose or liquid stools and hyperactive bowel sensations. RATIONALE -To ascertain onset and pattern of diarrhea noting whether acute or chronic. To be able to report pain associated with episode. -Diarrhea can lead to profound dehydration and electrolyte imbalance. EXPECTED OUTCOME Short term: After 2-4 hours of nursing interventions the patient or the SO shall have verbalized understanding on ways to manage resolution of causative factors Long term: - Diarrheal stool is extremely irritating to the skin. After 2-3 days of nursing interventions the patient shall have reestablished improvements in bowel functioning

- Assess hydration status, I&O, skin turgor and the moisture of mucous membrane.

-Change diapers immediately after the infant has defecated.

-Wash the skin of the diaper area well after each

- To prevent it from further irritation.

stool.

-increase the clients fluid intake

- To prevent dehydration. -Certain foods are difficult to digest. This inability results in digestive upsets and in some instances the passage of watery stool.

- Limit foods containing insoluble fiber, such as whole wheat and whole grain breads and cereals. Limit fatty and spicy foods.

- This allows - Restrict solid food bowel rest and reduces intestinal intake or eating small amounts can workload. be done. - To maintain electrolyte balance.

-Ingest foods with sodium and potassium. Most foods contain sodium. Potassium is found in meat and many vegetables and

fruits. -To asses if there is the presence of blood, infection and to determine the causative factors.

-Review results of laboratory listings on stool specimen.

- Explain importance of maintain proper nutrition and hydration. Teach importance of fluid replacement during diarrheal episodes. Explain rationale and intended effect of treatment program.

-Patients need to understand the importance of drinking extra fluid during hours of diarrhea, fever and other conditions causing fluid deficits. Fluid prevents dehydration.

Problem #2: Presence of infection ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S=

O = The patient manifested the following:

PRESENCE OF INFECTION related to the disease condition

SHORT TERM: After 2-3 hours of Nursing Interventions, the SO will verbalize understanding of the interventions to reduce risk of infection

-Assess patients condition

-to assess causative factors

SHORT TERM: After 2-3 hours of Nursing Interventions, the SO shall have verbalized understanding of the interventions to reduce risk of infection

-monitor and record VS

-to have a baseline data

-urinalysis results of: Albumin: trace Pus cells: 25/hpf

-note risk factors for the occurrence of infection

-to assess contributing factors

LONG TERM: After 1-2 days of Nursing Interventions, the So will demonstrate techniques and

-stress proper hand washing techniques

-to reduce existing causative factors

LONG TERM: After 1-2 days of Nursing Interventions, the So shall

-instructed to maintain adequate hydration

-to avoid

lifestyle changes to promote a safe environment for the patient -encourage to provide regular perineal care

dehydration

-to avoid irritation of the childs genitals and decrease the risk for secondary infection

have demonstrated techniques and lifestyle changes to promote a safe environment for the patient

-administer medications as ordered

-to counteract the presence of infection

Problem #3: Risk for bowel incontinence ASSESSMENT NURSING DIAGNOSIS S= As verbalized by the S.O. 6 times neng megbawas kanyan. O= The patient manifested the ff: - Reddened perineal area -Passed loosed and watery stool for 6 times -Fecal odor Risk for bowel incontinence related to chronic diarrhea SCIENTIFIC EXPLANATION Normal control of bowel movements depends on proper functioning of the colon and rectum, the muscles surrounding the anus (anal sphincter muscles), the brain and the body's nerves (the nervous system), plus the amount and consistency of waste products produced. OBJECTIVES Short term: After 4 hours of nursing interventions the SO will demonstrate ways to prevent bowel incontinence NURSING INTERVENTIONS -Note stool characteristics, color, odor, consistency, amount and frequency. - Encourage increase in fluids. RATIONALE -Provides comparative baseline. EXPECTED OUTCOME Short term: After 4 hours of nursing interventions the SO will demonstrate ways to prevent bowel incontinence

- To prevent dehydration.

Long term: After 3 days of nursing interventions the patient will maintain a regular pattern of bowel functioning.

- Palpate abdomen.

- To monitor abdominal distention, masses and tenderness.

Long term: After 3 days of nursing interventions the patient will maintain a regular pattern of bowel functioning.

Bowel or fecal incontinence is the loss of voluntary control of stool, or bowel movements. This condition can vary from being partial, in which a person loses only a

- Provide perineal care.

- To prevent excoriation of the area.

- Record times at which incontinence

- To note relationship to meals, activity

small amount of liquid waste, to complete, in which the entire solid bowel movement cannot be controlled.

occur.

and clients behavior.

-Inquire medications patient is taking.

-Laxatives and antibiotics may cause diarrhea.

- Inquire about tolerance to milk and other dairy products.

- Patients with lactose intolerance have insufficient lactase, the enzyme that digests lactose. The presence of lactose in the intestines increases osmotic pressure and draws water into the intestinal lumen.

- Give antidiarrheal drugs

- Most antidiarrheal

as prescribed.

drugs suppress GI motility thus allowing for more fluid absorption.

-Test stool for blood.

- To determine presence of bleeding.

- Culture stool

- Testing will identify causative organisms.

Problem #4: Risk for deficient fluid volume ASSESSMENT NURSING DIAGNOSIS S= Risk for deficient fluid volume related to active fluid loss SCIENTIFIC EXPLANATION The composition of body fluids remains relatively constant despite the many demands placed on the body each day. On occasion, these demands cannot be met, and electrolytes and fluids must be given in an attempt to restore equilibrium. If the body is becoming fluiddeficient, there will be an increase in the secretion of these hormones, causing fluid to be retained by the kidneys and urine output to be reduced. In illness, the situation is more complex. Fluid OBJECTIVES Short term: After 4 hours of nursing interventions the SO will verbalize understanding on ways to prevent deficient fluid volume NURSING INTERVENTIONS - Obtain patient history to ascertain the probable cause of the fluid disturbance. RATIONALE - This can help to guide interventions. EXPECTED OUTCOME Short term: After 4 hours of nursing interventions the SO shall have verbalized understanding on ways to prevent deficient fluid volume

O> The patient manifested the ff: -slightly pale palbebral conjunctiva -diarrhea with a frequency of 5-7 times a day -Vomited more than four times upon admission

- Assess and monitor weight daily and consistently, preferably at the same time of the day.

- Facilitates accurate measurement and follow trends.

Long term: After 3 days of nursing interventions the patient will demonstrate maintenance of hydration status thus - Evaluate fluid status in relation to dietary intake. - Most fluid enters the body through drinking, water in foods, and water formed by oxidation of foods. Long term: After 3 days of nursing interventions the patient shall have demonstrated maintenance of

may also be lost through vomiting and diarrhea. An individual is at an increased risk of dehydration in these instances, as the kidneys will find it more difficult to match fluid loss by reducing urine output (the kidneys must produce at least some urine in order to excrete metabolic waste.)

decreasing the risk for deficient fluid volume

- Assess skin turgor and mucous membrane.

- For signs of dehydration.

hydration status thus decreasing the risk for deficient fluid volume

- Assess color and amount of urine.

-Concentrated urine denotes fluid deficit.

- Monitor temperature.

- Febrile states decrease body fluids through perspiration and increased respiration.

- Teach interventions to prevent future episodes of inadequate intake.

- To understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

- Monitor serum electrolytes and urine osmolality.

- Elevated hemoglobin and elevated blood urea nitrogen suggest fluid deficit.

- For hypovolemia due to severe diarrhea or vomiting administer antidiarrheal or antiemetic medications as prescribed.

- This allows more effective fluid administration and monitoring.

- Administer parenteral fluid as ordered.

- Parenteral fluid replacement is indicated to prevent shock.

Problem #5: Risk for imbalanced nutrition: less than body requirements ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES Short term: S= O> The patient manifested the ff: -slightly pale palbebral conjunctiva -Passed loosed and watery stool for 6 times -decreased appetite -always cry Risk for imbalanced Nutrition: less than body requirements related to inability to digest food and absorb nutrients Poor nutrition includes both dietary excesses and imbalances. Imbalanced nutrition can result from eating less food, eating an unbalanced diet, or from a disease. Any illness or long term condition affect how often, how much, and what foods we eat. After 4 hours of nursing interventions the patient will have demonstrate changes in behavior to regain weight. NURSING INTERVENTIONS - Determine ability to chew, taste and swallow food. RATIONALE - To monitor factors that may affect ingestion or digestion of nutrients. - To evaluate degree of deficit. EXPECTED OUTCOME Short term: After 4 hours of nursing interventions the patient shall have demonstrated changes in behavior to regain weight.

-Assess weight, age, body build, strength, and activity.

Long term: After 3 days of nursing interventions the patient will have demonstrate progressive weight gain.

- Note total daily intake. Maintain diary of caloric intake, patterns and times of eating.

-To reveal changes that should be made in clients dietary intake.

Long term: After 3 days of nursing interventions the patient shall have demonstrated progressive weight gain.

-Promote adequately and timely fluid intake.

-Limiting fluids one hour prior to meal decrease possibility of early satiety.

-Avoid foods that cause intolerances and may increase gastric motility.

-To prevent occurrence of diarrhea.

Problem #6: Rediness for enhanced fluid volume ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTION S RATIONALE EXPECTED OUTCOME

S=

Readiness for enhanced fluid volume

O= Pt manifested: -Good skin turgor -Food and intake adequate for daily needs

Good skin turgor is one of the manifestation of improved fluid status of a patient and was able to increase fluid intake. Thus an improved fluid status is a manifestation for readiness for enhanced fluid volume.

SHORT TERM After 3 hours of NI, SO will be able to verbalize understanding on the health teachings given.

-Assessed Pt condition -Monitor I/O

-To gain baseline data

SHORT TERM After 3 hours of NI Pt SO shall have verbalized understanding on the health teachings given.

-To ensure accurate picture of fluid status

LONG TERM After 2 days of NI, SO will be able to demonstrate behavior to monitor childs fluid balance.

-Weigh Pt and compare with recent weight history -Encourage regular oral intake

-Provides baseline for future monitoring -To maximize intake and maintain fluid balance -Medication is indicated to prevent fluid imbalance if individual becomes sick.

LONG TERM After 2 days of NI Pt SO shall have demonstrated behavior to monitor fluid balance.

-Administered medication as ordered

CLIENTS DAILY PROGRESS CHART

DAYS NURSING PROBLEMS

2-22-09

2-23-09

2-24-09

Diarrhea Presence of infection Risk for deficient fluid volume Risk for imbalanced Nutrition: less than body requirements * Risk for bowel incontinence *

* *

* *

Readiness for enhanced fluid volume VITAL SIGNS Temperature Heart Rate Resp. Rate

37.1 C 150bpm 46bpm

36.9C 120bpm 38bpm

DIAGNOSTICS / LABORATORY PROCEDURES Complete Blood Count (CBC) Fecalysis Urinalysis

* *

MEDICAL MANAGEMENT IVFS

D5 0.3 NaCl DRUGS

* Cefuroxime Paracetamol * Metoclopramide

DIET NPO Temp. DAT ACTIVITY/EXERCISE (no precautions) * * *

DISCHARGE PLANNING a. General Condition of the Client upon Discharge Lifted from the physicians discharge notes were: MGH, he patient is active, playful, has normal body temperature; and the stool is soft and formed in appearance and no vomiting. Generally, he is afebrile and prepared for home management and maintenance. b. method

S- O received pt. lying on bed, conscious and awake, with an IVF of D5, 0.3NaCl, 500cc, at 100cc level, regulated at 23-24 ugtts/min, infusing well on the right foot, with vital signs taken and recorded as follows: T = 36.9 C, PR = 120, RR = 38 A Readiness for enhanced therapeutic regimen management P After 4 hours of NI, pt. SO will verbalize understanding of health teachings given and assume responsibility of managing treatment regimen I

M No medications prescribed E Encouraged pt. SO to provide adequate rest periods after play T No medications prescribed H Encouraged pt. SO to provide safe environment to prevent accidents O Instructed pt. SO for follow up checkup after a week D Instructed pt. SO to provide a well balanced diet

CONCLUSION The success of preventing and treating child with AGE depends largely with patients significant person, their mothers since they are the one who is taking care of their child, it is important to educated and equip them with basic knowledge to manage AGE. Thus it is essential for the nurses to provide knowledge and give health teachings on how to take care of the children and to perform procedures to manage. Moreover, the role of the mother facing an illness and disease is vital they are usually to provide the first treatment such as home remedies. Active participation of the patients significant others accompanied by adequate knowledge on the disease process and therapeutic management is a vital component in the effectiveness of the treatment regimen and assists the child to restoration of health. The nurses role in the maintenance of health can make a difference even if burdened and preventing illness and promotion of health. In this time where in health care is expensive that we sometimes could not be afford, a simple but effective solution is promotion of health and preventing disease. As student nurses, we are tasked to learn the different interventions that should be given in a client who has acute gastroenteritis in order for us to provide our clients with the necessary care that they need. Furthermore, we must raise the awareness of the public regarding this disorder in order to lessen the possible occurrence of such condition.

RECOMMENDATION We may be too young to do such extensive research, yet it does not follow that we are excused of the responsibility. We, as student nurses should take part in knowing what we ought to know, in teaching what we know and more in doing what we teach. The group would like to recommend this case study, to mothers to have a broaden understanding of the disease condition, update with the current information and help reflect upon the mothers daily habits and there children To all nurses, proper nursing management must be administered to help patient cope with his/her condition. Health teachings should be given in order for a patient to realize the effects of his/her disease/condition. Nurse, therefore, should also check and correct the lifestyle of the patient to lessen the occurrence of such disease. The student nurses also recommend that nurses should also master the use of effective communication skill in order to provide health teachings. We must always bear in mind that as nurses, the heart and soul of nursing is the promotion of health which can only be done through educating the people. But health education would be impossible without effective communication.

LEARNING DERIVED Prevention is better than cure. This quote shows that each of us should take the responsibility of taking care of the child health by adhering in the treatment regimen that is given and by directly consulting to the health care providers in times of the occurrence of disease. From this case study, we have learned that the practices and management of the parents mostly mothers affects the health of their children since they are the one to uncharged of taking care of the child. There must be proper health maintenance in order to alleviate or improve ones condition. It will not only rely on the care given by the health care providers but also the care given by mothers. As what we all know that the prevalence of acute gastroenteritis among chlidren. AGE being a cause of serious consequences, had a very complicated processing and

with that we should exert an extraordinary effort in order to fully understand it and at the same time, we are able to practice analytical thinking and reasoning as well. Upon doing this case study, we are able to develop a student nurse-patient relationship and be able to understand different life situations. Aside from that, this study helps us in entertaining a new perspectives regarding the disease condition and developing our nursing and managerial skills for the interventions. It also gave us the opportunity to widen our clinical skills that would contribute to the development of the quality of nursing rendered to patients and be globally competitive enough.

VI. BIBLIOGRAPHY Books: Diagnostic Tests. Lippincott Williams and Wilkins: Philadelpia, 2006 Pilliteri, Adel, Maternal and Child Health Nursing 5th Edition. Lippincott, 2007 Seeley, Stephens, Tate. Essential Anatomy and Physiology6th edition. New York: Mc Graw Hill. Brunner, L. and Suddarth, B. 2008Textbook of Medical-Surgical Nursing. (11th edition). J.B. Lippincott Company; Philadelphia. Meg Gunlanick, PhD,RN Judith L. Myers, MSN, RN Audrey KloppPhD, RN,CS, ET NHA, DeidraGradishar, RNC BS Nursing Care Plans Nursing Diagnosis and Interventions Mosby Company fifth edition Internet http://en.wikipedia.org/wiki/Antiemetic http://www.bmj.com/cgi/content/full/334/7583/35 http://en.wikipedia.org/wiki/Metoclopramide http://en.wikipedia.org/wiki/Ondansetron

http://www.businessballs.com/erik_erikson_psychosocial_theory.htm http://www.answers.com/topic/cognitive-development http://ourworld.compuserve.com/homepages/pete_wren/freud.htm#oral http://www.medscape.com/ anti-emetics for vomiting children and adolescent with acute gastroenteritis http://en.wikipedia.org/wiki/ Defence mechanism http://www.surgeryencyclopedia.com/Ce-Fi/Complete-Blood-Count.html http://www.drgecko.com/fecalexams.htm http://www.answers.com/topic/gastroenteritis http://www.answers.com/topic/gastroenteritis-causes-and-symptoms http://www.answers.com/topic/gastroenteritis-prevention http://health.allrefer.com/health/viral-gastroenteritis-info.html