I.

INTRODUCTION
Acute Gastroenteritis (AGE) Gastroenteritis is a catchall term for infection or
irritation of the digestive tract, particularly the stomach and intestine. It is
frequently referred to as the stomach or intestinal flu, although the influenza
virus is not associated with this illness. Major symptoms include nausea and vo
miting, diarrhea, and abdominal cramps. These symptoms are sometimes also accomp
anied by fever and overall weakness. Gastroenteritis typically lasts about three
days. Adults usually recover without problem, but children, the elderly, and an
yone with an underlying disease are more vulnerable to complications such as deh
ydration. Gastroenteritis arises from ingestion of viruses, certain bacteria, or
parasites. Food that has spoiled may also cause illness. Certain medications an
d excessive alcohol can irritate the digestive tract to the point of inducing ga
stroenteritis. Regardless of the cause, the symptoms of gastroenteritis include
diarrhea, nausea and vomiting, and abdominal pain and cramps. Sufferers may also
experience bloating, low fever, and overall tiredness. Typically, the symptoms
last only two to three days, but some viruses may last up to a week. A usual bou
t of gastroenteritis shouldn't require a visit to the doctor. However, medical t
reatment is essential if symptoms worsen or if there are complications. Infants,
young children, the elderly, and persons with underlying disease require specia
l attention in this regard. The greatest danger presented by gastroenteritis is
dehydration. The loss of fluids through diarrhea and vomiting can upset the body
's electrolyte balance, leading to potentially lifethreatening problems such as
heart beat abnormalities (arrhythmia). The risk of dehydration increases as symp
toms are prolonged. Dehydration should be suspected if a dry mouth, increased or
excessive thirst, or scanty urination is experienced. If symptoms do not resolv
e within a week, an infection or disorder more serious than gastroenteritis may
be involved. Symptoms of great concern include a high fever (102 F [38.9 C] o
r above), blood or mucus in the diarrhea, blood in the vomit, and severe abdomin
al pain or swelling. These symptoms require prompt medical attention. Gastroente
ritis is a self-limiting illness which will resolve by itself. However, for comf
ort and convenience, a person may use over-the-counter medications such as Pepto
Bismol to relieve the symptoms. These medications work by altering the ability
of the intestine to move or secrete spontaneously, absorbing toxins and water, o
r altering intestinal microflora. Some over-the-counter medicines use more than
one element to treat symptoms.
II.
Patients Profile S.Q. is a female, 11/12 months old, residing at P2 Blk1 L38 Pa
bahay Nanadero, Calamba City, Laguna. Her mother is J.Q., works part time in a s
hop and her father is R.Q., factory worker. She has one sibling older than her,
K.Q., 3 years old. S.Q. was born on March 6, 2009, and born at Calamba, Laguna,
Filipino in nationality. Their whole family is Born Again in religion. She weigh
s 8.7 kg. Shes admitted on January 30, 2010 at room 103-C, pedia ward with chie
f complaint of high fever for 2 days with emesis and has a diagnosis of Acute Ga
stroenteritis. And she was discharged on January 6, 2010, Saturday at 1:30 pm. T
heir attending physicians were Campos, Angelie, M.D. and Bonagua, Aireen, M.D.
III.
Health History & Chief Complain
Chief Complaint She was admitted for having high fever for 2 days with vomiting.
Present Illness S.Q. was only admitted to the hospital due to gastrointestinal
problem now and was also suspected of urinary tract infection by Dra. Campos. As
ide from the diagnosis, no other disease or complication was seen or diagnosed.
Past Health History Mrs. Q says eto first time nya ma-admit after nya ipangana
k. S.Q. gets seasonal cough and colds at times but never serious because it usu
ally last only for a few days. They always consult their doctor once sick. She i
s complete in her vaccinations except those which would be taken on her 1 year o
f age. Family Health History No one in the family had any respiratory illness or
allergies. On her fathers side, almost all have hypertension. One member of th
eir family died on a heart attack. IV. Gordons Pattern Health Perception As Mrs
Q. stated, lagi naman kami nagpapacheck up ni stephani. Napunta talaga kami ka
y Dra. Campos. Malikot lang talaga yan pero inaalagaan yan sa bahay.
S.Q. has a mannerism of sticking anything on her mouth. Whatever she touches she
directs it toward her mouth. Although, she doesnt practice hand washing every
now and then. There are some medications she takes easily but there are also tho
se medications which is hard for her because of the taste. Nutritional-Metabolic
S.Q. weighs 8.7 kg. She eats soft foods. She drinks 6-7 bottles of milk in a da
y. Mrs. Q provides her daughter milk and food in accordance to age and doctors
advise. She drinks formula milk. She stop being breastfed when she was 10 moth
s. She has no allergy. Elimination She defecates once or twice a day in her usua
l days. She changes diaper 3-5 times in a day when full or had defecated. She wa
s advise to use Lactacid for her perennial wash and calmoseptin ointment on her
diaper rash. Activity-Exercise S.Q. is a very playful and active girl. She has l
ots of energy but cries when she doesnt like something. She smiles and laughs a
lot. Her coordination, gait, balance is not yet stable due to age. Her daily li
ving activities were provided by her parents. There is no musculoskeletal impair
ment. She usually plays after she wakes up in the morning. Sleep-Rest She sleeps
at 8 P.M. in the evening and usually gets up 7 A.M. 8 A.M. in the morning. Af
ter playing or eating she takes a nap. She has straight undisturbed sleep at nig
ht. Cognitive Perceptual S.Q. has no sensory deficits. She response well to verb
al stimulus by looking at you or having facial expressions. Bibo nga yan bata n
ay an, makulit pero mabilis mo naman makuha attention, as her mother stated. Se
lf-Perception S.Q. is not afraid of new people around her. She is friendly and i
s easy to accommodate. Sexual-Reproduction Prior to age, S.Q. is not yet oriente
d with any sexual matters.
Coping Stress In her age, she usually cries when something is wrong about her. S
imple smile or cry is a sign of her comfort, distress or feelings. She is famili
arized to her family members and long for them when she doesnt want the situati
on like giving of medications or other procedures. Role-Relationship She doesnt
know the concept of death yet due to age. Forms words like dede and dada. S
he knows her family members and can easily familiarize the people around her. Va
lue-Belief The family is Born Again. They regularly attend church together with
all the members of the family. They dont usually believe in hilot. Once one i
s sick in the family, they go immediately to the hospital or for check-up.
V.
Head-to-Toe Assessment General Assessment: Playful and active, neat Initial Vita
l Sign: T=36.4C RR=27 PR=118
Area Assessed Skin Color Lips, nail beds, soles and palms Moisture Temperature T
exture Turgor
Technique Inspection
Normal Findings Light brown, tanned skin (vary according to race) Lighter colore
d palms, soles, lips and nail beds Skin normally dry Warm to touch Smooth, soft
and flexible palms and soles (thicker) Skin snaps back
Actual Findings brown skin Lighter colored palms, soles, lips and nail beds Skin
normally dry 36.4 o C, warm to touch Smooth, soft and flexible palms and soles
(thicker) Skin snaps back
Evaluation Normal
Inspection Inspection/ Palpation Palpation Palpation Palpation
Normal Normal Normal Normal Normal
immediately Skin appendages a. Nails Inspection Transparent, smooth and convex c
ut and clean Pinkish Firm White color of nail bed under pressure should return t
o pink within 2-3 seconds Evenly distributed Black Smooth Parallel to each other
immediately 1-2 seconds Transparent, smooth and convex Uncut and dirty Pinkish F
irm White color of nail bed under pressure returned to pink within 2-3 seconds P
oor grooming Normal Normal Normal
Nail beds Nail base Capillary refill
Inspection Inspection Inspection/ Palpation
b. Hair Distribution Color Texture Eyes Eyes Visual Acuity
Inspection Inspection Inspection/ Palpation Inspection Inspection (penlight) Ins
pection
Evenly distributed Black Smooth and curly Parallel to each other but slightly su
nken
Normal Normal Normal May be a sign of dehydration Normal
Eyebrows
Eyelashes Eyelids
Inspection Inspection
PERRLA- Pupils PERRLA- Pupils equally round equally round react to react to ligh
t and light and accommodation accommodation Symmetrical in Symmetrical in size,
size, extension, extension, hair texture hair texture and and movement movement
Distributed evenly Distributed evenly and curved and long curved outward outward
Same color as the Same color as the skin skin Blinks involuntarily and bilatera
lly up to 20 times per minute Blinks involuntarily and bilaterally up to 16 time
s per minute Do not cover the
Normal
Normal Normal
Normal
Conjunctiva Sclera Cornea Pupils Iris Ears Ear canal opening
Inspection Inspection Inspection Inspection Inspection Inspection
Do not cover the pupil and the sclera, lids normally close symmetrically Transpa
rent with light pink color Color is white Transparent, shiny Black, constrict br
iskly Clearly visible Free of lesions, discharge of inflammation Canal walls pin
k Client normally hears words when whispered Smooth, symmetric with same color a
s the face Close to midline, thicker anteriorly than posteriorly Oval, symmetric
and without discharge
pupil and the sclera, lids normally close symmetrically
Normal
Transparent with light pink color Color is white Transparent, shiny Black, const
rict briskly Clearly visible Free of lesions, discharge of inflammation Canal wa
lls pink Client normally hears words when whispered Smooth, symmetric with same
color as the face Close to midline, thicker anteriorly than posteriorly Oval, sy
mmetric and without discharge
Normal Normal Normal Normal Normal Normal
Normal Normal
Hearing Acuity Nose Shape, size and skin color Nasal septum
Inspection
Inspection
Normal
Inspection
Normal
Nares
Inspection
Normal
Mouth and Pharynx Lips Buccal mucosa
Inspection Inspection
Pink, moist symmetric Glistening pink soft moist
Pink, moist symmetric Glistening pink soft moist
Normal Normal
Gums
Inspection
Tongue
Inspection
Teeth Hard and soft palate Neck Symmetry of neck muscles, alignment of trachea N
eck Rom Thyroid gland Trachea Thorax and Lungs Abdomen
Inspection Inspection
Slightly pink color, moist and tightly fit against each tooth Moist, slightly ro
ugh on dorsal surface medium or dull red Firmly set, shiny Hard palatedome-shape
d Soft Palate- light pink
Slightly pink color, moist and tightly fit against each tooth Moist, slightly ro
ugh on dorsal surface medium or dull red Firmly set, shiny No tooth decay, milk
tooth present Hard palate- domeshaped Soft Palate- light pink
Normal
Normal Normal
Normal
Inspection Inspection Palpation Inspection Auscultatio n Inspection
Bowel sounds
Auscultatio n
Neck is slightly Neck is slightly hyper hyper extended, extended, without withou
t masses or masses or asymmetry asymmetry Neck moves Neck moves freely, freely,
without without discomfort discomfort Rises freely with Rises freely with swallo
wing swallowing Midline Midline Clear breath Clear breath sounds sounds Skin sam
e color Skin same color with with the rest of the rest of the body the body Clic
ks or gurling Clicks or gurling sounds occur sounds occur irregularly and range
irregularly and from 5-35 per minute range from 5-35 per minute Fully conscious,
Fully conscious, respond to respond quickly to questions quickly, stimulus perc
eptive of events Unstable gait, balance
Normal Normal Normal Normal Normal Normal
Normal
Neurology system Level of consciousness
Inspection
Normal
and coordination Behavior and appearance Inspection Makes eye contact with exami
ner, hyperactive expresses feelings with response to the situation Makes eye con
tact with examiner, hyperactive expresses feelings with response to the situatio
n
Normal for age (11 months) Normal
VI.
Anatomy & Physiology
Digestion is the process by which food is broken down into smaller pieces so tha
t the body can use them to build and nourish cells and to provide energy. Digest
ion involves the mixing of food, its movement through the digestive tract (also
known as the alimentary canal), and the chemical breakdown of larger molecules i
nto smaller molecules. Every piece of food we eat has to be broken down into sma
ller nutrients that the body can absorb, which is why it takes hours to fully di
gest food. The digestive system is made up of the digestive tract. This consists
of a long tube of organs that runs from the mouth to the anus and includes the
esophagus, stomach, small intestine, and large intestine, together with the live
r, gall bladder, and pancreas, which produce important secretions for digestion
that drain into the small intestine. The digestive tract in an adult is about 30
feet long. Mouth and Salivary GlandsDigestion - begins in the mouth, where chem
ical and mechanical digestion occurs. Saliva or spit, produced by the salivary g
lands (located under the tongue and near the lower jaw), is released into the mo
uth. Saliva begins to break down the food, moistening it and making it easier to
swallow. A digestive enzyme (called amylase) in the saliva begins to break down
the carbohydrates (starches and sugars). One of the most important functions of
the mouth is chewing. Chewing allows food to be mashed into a soft mass that is
easier to swallow and digest later. Esophagus - Once food is swallowed, it ente
rs the esophagus, a muscular tube that is about 10 inches long. The esophagus is
located between the throat and the stomach. Muscular wavelike contractions know
n as peristalsis push the food down through the esophagus to the stomach. A musc
ular ring (called the cardiac sphincter) at the end of the esophagus allows food
to enter the stomach, and, then, it squeezes shut to prevent food and fluid fro
m going back up the esophagus. Stomach - a J-shaped organ that lies between the
esophagus and the small intestine in the upper abdomen. The stomach has 3 main f
unctions: to store the swallowed food and liquid;
to mix up the food, liquid, and digestive juices produced by the stomach; and to
slowly empty its contents into the small intestine. Small Intestine - Most dige
stion and absorption of food occurs in the small intestine. The small intestine
is a narrow, twisting tube that occupies most of the lower abdomen between the s
tomach and the beginning of the large intestine. It extends about 20 feet in len
gth. The small intestine consists of 3 parts: the duodenum (the C-shaped part),
the jejunum (the coiled midsection), and the ileum (the last section). The small
intestine has 2 important functions. First, the digestive process is completed
here by enzymes and other substances made by intestinal cells, the pancreas, and
the liver. Glands in the intestine walls secrete enzymes that breakdown starche
s and sugars. The pancreas secretes enzymes into the small intestine that help b
reakdown carbohydrates, fats, and proteins. The liver produces bile, which is st
ored in the gallbladder. Bile helps to make fat molecules (which otherwise are n
ot soluble in water) soluble, so they can be absorbed by the body. Second, the s
mall intestine absorbs the nutrients from the digestive process. The inner wall
of the small intestine is covered by millions of tiny fingerlike projections cal
led villi. The villi are covered with even tinier projections called microvilli.
The combination of villi and microvilli increase the surface area of the small
intestine greatly, allowing absorption of nutrients to occur. Undigested materia
l travels next to the large intestine. Large intestine - forms an upside down U
over the coiled small intestine. It begins at the lower right-hand side of the b
ody and ends on the lower left-hand side. The large intestine is about 5-6 feet
long. It has 3 parts: the cecum, the colon, and the rectum. The cecum is a pouch
at the beginning of the large intestine. This area allows food to pass from the
small intestine to the large intestine. The colon is where fluids and salts are
absorbed and extends from the cecum to the rectum. The last part of the large i
ntestine is the rectum, which is where feces (waste material) is stored before l
eaving the body through the anus. The main job of the large intestine is to remo
ve water and salts (electrolytes) from the undigested material and to form solid
waste that can be excreted. Bacteria in the large intestine help to break down
the undigested materials. The remaining contents of the large intestine are move
d toward the rectum, where feces are stored until they leave the body through th
e anus as a bowel movement.
VII.
Pathophysiology
VIII. Course in the Ward On day 1, January 30, 2010, at 8:40 am S.Q. is for chec
k up with her attending physician due to high fever for 2 days associated with v
omiting. She was seen and examined by Dra. Campos and was advised to be admitted
for further test and treatment due to suspected UTI. She was diagnosed with Acu
te Gastroenteritis. An IVF D5 INM 500 ml x 10cc/hr is hooked and CBC was done. S
he was brought to pedia ward at around 11:00 am and received by nurse on charge.
Monitoring of input and output was ordered by the doctor with increase fluid in
take. Medications were Paracetamol drops 1 ml every 4 hours for fever. 1 dose wa
s given on admission and following doses for every 4 hours was given. On the sec
ond day, January 31, 2010, IVF was changed to #2 D5 INM 500 ml x 10cc/hr at 9:50
am. She was seen by Dra. Campos at 10:15 am and given an order of urinalysis an
d fecalysis. She was prescribed with Omeprazole (Omepron) 5mg IV once a day, 1st
dose is given at 8:00 am the next morning. Also, Zinc Sulfate (E-Zinc) drops (0
.6 ml) once daily was ordered. Her fever decreases gradually unitl there adminis
tration of paracetamol every 4 hours for fever was discontinued. She is being gi
ven Ceftriaxone (Xtenda) 750 mg IV once a day side drip every 12 noon. She was p
layful all through out the day. The laboratoty results was followed up. On the t
hird day, February 1, 2010, Monday, she was crying when received. She has fever
of 37.9 C and administration of Paracetamol drops 1 ml every 4 hours was resume
d. She has been irritable all day. 10:40 am Dra. Campos, examined S.Q. and was r
efered to Dr. Zablan due to decreased results of urinalysis. All laboratory resu
lts were seen by Dra. Campos. During the afternoon, her fever subsides to 37.2
C . IVF #3 D5 INM 500 ml x 10 cc/hr was hooked at 1:00 pm. All medications were
given. On the fourth day, February 2, 2010, Tueasday, she has no fever, negative
vomiting and playful. Dra. Campos had her round at 4:50 pm and checked S.Q. she
ondered continue all medications and treatment and wait for Dr. Zablans assess
ment. IVF #4 D5 INM 500 ml x 10 cc/hr was hooked at 11:30 am. On the fifth day,
February 3, 2010, Wednesday, Dr. Zablan had his round at 11:30 am. Findings were
with positive diaper rash, decrease laboratory results and afebrile, no vomitin
g. He ordered repeat UA from AM (clear catch), urine culture and sensitivity, us
e of Lactacid pink for perennial wash, and apply Calmoseptin ointment to diaper
rash 3x a day. IVF #5 INM 500 ml x 10cc/hr was hooked at 12:15 nn. On the sixth
day, February 4, 2010, Thursday, Dra. Campos ordered continue all medications an
d follow order of Dr. Zablan. IVF #6 INM 500 ml x 10cc/hr was hooked at 11:00 am
. S.Q. is received active, playful but cries at times. All medications were give
n on time. Dr. Zablan saw laboratory results and advise client to increase fluid
intake and replace loses with PLRS. Follow up urine culture and sensitivity. Re
peat
urinalysis and notify him when WBC is 1-3. IVF #7 INM 500 ml x 10cc/hr was hooke
d at 1:00am. On the seventh day, February 5, 2010, Friday, Dra Campos ordered co
ntinue all medeications and treatments. Proceed to Dr. Zablans orders. All 8:00
am medications were given. S.Q. is taking a bath, playful and laughing when rec
eived. IVF was regulated. IVF was ordered to shift to D5 IMB L x 20 cc/hr. IVF
#8 IMB L x 20 cc/hr was hooked at 11:30 am. Dr. Zablan had his round at 11:45
, he checked S.Q. and the laboratory test. He said all test were now stabilized
and normal. He ordered follow up of urine culture and sensitivity and advised pe
riodic complete emptying of urinary bladder. On the eighth day, February 6, 2010
, Saturday, all findings were on normal range. S.Q. is afebrile, no vomiting, di
minished diaper rash, and was active and playful. All morning medications were g
iven. IVF #9 imb l X 20 cc/hr was hooked at 10:45 am. Dra. Campos, advised tha
t they may go home. S.Q. was discharge at 1:30 pm.
IX. Urinalysis
Laboratory Results
01/30 /10 Color Transparenc y Reaction Specific Gravity Albumin Sugar WBC
Yellow SI turbid 5.5 1.025 Traces (#) 7-10
Int.
Normal increased urine concentrati on Decreased Normal Normal Increase sugar Inf
ection
01/31/ Int. 10
Yellow SI turbid 6.0 1.010 Traces (-) 15-20 Normal increased urine concentrat io
n Normal Normal Normal Normal Infection
02/03/ 10
yellow Clear
Int.
Normal Normal
02/05 Int. /10
Light Yello w Clear Normal Normal
6.0 1.025 +1 (-) 28-30
Normal Normal UTI Normal Infection
8.0 1.010 (-) (-) 1-3
Normal Normal Normal Normal Normal
Fecalysis Color Consistency Parasites Hematology 01/30/10 Hemoglobin Hematocrit
RBC WBC Neutrophils Lymphocytes Platelets MCV MCH MCHC Blood Chemistry 01/30/10
BUN Creatinine Results 11 0.3 Normal Value 7-17 0.52-1.04 Interpretation Normal
Decrease,indirectly proportional to glomerular filtrate rate Results 123 0.38 4.
98 19.1 0.77 0.23 297 77.3 26.7 31.9 Normal Value 120-150 0.37-0.45 4.6-5.2 5-10
x 10/L 0.55-0.65 0.25-0.35 140-340 x 10/L 86-100 26-31 31-37 Interpretation Nor
mal Normal Normal Increase, infection Increase, acute bacterial infection Decrea
se, may cause severe malnutrition Normal Normal Normal Normal 01/31/10 Green Sof
t No OVA or parasites seen Interpretation Sign of diarrhea Sign of diarrhea Norm
al
X. Generic
Drug Study Brand E-Zinc Classification Indication Vitamins & Minerals Nsg. Respo
nsibilities To prevent Participate in > Explain need individual trace synthesis
& for zinc element stabilization administration deficiencies in of protein & to
patient & patient nucleic acids family receiving long- in term total subcellular
> Report signs parenteral & membrane of nutrition transport hypersensitivity sy
stem promptly Gastrointestinal Inhibits > Sodium disturbaces and activity of res
tricted diet irritations acid (proton) should be pumps & cautious binds to hydro
gen> take 30 potassium minutes before adenosine meals triphosphate at secretory
surface of gastric parietal cells to block formation of gastric acid Action
Zinc-Sulfate Drops (0.6 ml) OD
Omeprazole 5mg IV OD
Omepron
Proton Pump Inhibitor
XI.
Nursing Care Plan Nsg. Diagnosis Risk for Infection Planning The client will be
able to demonstrate no signs of infection (fever) until discharge Intervention >
Demonstrate & teach proper handwashing technique and stress its importance Ratio
nale > first-line of defense against infection/ crosscontamination (NANDA 10th E
d. Pg. 323) > first-line defense and eliminate rough edges or long nails, which
can harbor microorganism (Kozier 8th Ed. Vol I pg. 682) > to prevent exposure of
client (NANDA 10TH Ed. Pg. 323) > same > Advise to avoid opening of door or goi
ng out the room too much > Instruct mother to neglect her child from putting han
ds or objects on Evaluation Goal Met AEB afebrile until discharged
Assessment S > Oo, mahilig nga yan magsubo ng kahit anong mahawakan nya, as st
ated by mother > sa halos 1 week naming na stay ditto sa ospital, 3-4 times ko
sya pinaliguan ditto, as stated by mother O > very playful > does not wash ofte
n > age = 11/12 moths old > dirty nails
> Instruct in daily bath/ shower, regular cutting of nails
> Limit visitors
> One source of fecal-oral route mode of transmission of pathogens (Kozier 8th E
d) >To avoid
mouth > Suggest techniques for safe food preparation and presentation Assessment
S> Sadyang malikot nga yan, maliksi kumilos, as stated by mother O > Tantrums
at times > Age= 11/12 months old > Unstable gait, balance and coordination >Unf
amiliar environment > Active and playful Nsg. Diagnosis Risk for Fall Planning T
he client will be able to maintain safety measure with free from injury within h
ospitalization Intervention > Provide assistive device or safety device like sid
e rails
microbial growth (NANDA 10TH Ed.)
Rationale > Prevent from falling onto one side or the other, also helps stabiliz
e balance (Kozier 8th Ed) > Supervision helps one child to be safe as well as ga
in courage to be independent on activity (Kozier 8th Ed.) > helps mucle and bone
s to stabilize and gain balance on coordination (Kozier 8th Ed.)
Evaluation Goal Met AEB free from injury upon discharge
> Encourage family for proper supervision
> Practice walking with support / exercise of legs and extremities
> Discuss safety measures that should be in > To avoid precautions injury and
lessen the risk (Kozier 8th Ed) Assessment S> Hinuhugasan ko naman kamay nya pa
g nadudumiha n sya. Ganun sabi nung nurse, pero hindi ko na minamayat maya ang
hugas, pag madumi lang, as stated by mother O > client has a habit of putting e
verything to mouth > hands are always wet with saliva > nails uncut and dirty >
Unorganized bed & bed side table > No bed linens Nsg. Diagnosis Deficient Knowle
dge (Infection Control) R/T information misinterpretatio n AEB verbalized data P
lanning The client will be able to practice understandin g of teaching after 1-2
hours of teaching Intervention Evaluatio n > Describe > to prevent Goal Met way
s to possible cross- AEB manipulate the contamination mother bed, room & (Kozier
8th Ed. performed other facilities Vol I pg. 682) hygiene care for > Instruct t
o > to induce self and rinse soiled death of child and cloth in cold microorgani
s cleaning water, wash in m of place hot water if (Kozier 8th Ed. possible & add
Vol I pg. 682) a cup of bleach or phenolbased disinfectant > Perform & teach ha
nd hygiene (before & after handling/eatin g of foods, or toileting) > first-line
defense against infection/ crosscontamination (NANDA 10th Ed. Pg 323) Rationale
> Promote nail care > eliminate rough edges or long nails, which can harbor micr
oorganis m (Kozier 8th Ed. Vol I pg. > Instruct not 682) share personal
items
> Infections can be transmitted from shared personal items through fomites (Kozi
er 8th Ed. Vol I pg. 682)
XII.
Prognosis
Medications Upon discharge client was advised to continue intake of Zinc-Sulfa
te (Ezinc) drops 0.6 ml once a day. Economics Advised client to buy foods with
in the budget. The client, prior to admission present a health insurance card, (
+ ) HMO. They had discount on S.Q.s hospitalization and also to the doctors f
ee. Treatment S.Q. was still advised for increase fluid intake, periodic compl
ete emptying of urinary bladder, use of lactacid for perinial wash, and keep han
ds clean. She still have a follow up check up after 1 week after discharge. Heal
th Teaching Proper hygiene of both child and parent are very important as defe
nse from infection. Proper and strict supervision of child until balance, gait,
and coordination is gained. Advise to restrict child from handling items or obje
cts especially if unfamiliar and not edible. Emphasize importance of hand washin
g and nail care. Out Patient Client was discharge on January 6, 2010. Last adv
ises and follow up check ups were reminded. Other treatments were elaborated. Di
et Client was ordered with diet for age, with increase fluid intake.
Calamba Doctors College S.Y. 2009-2010
CASE STUDY (ACUTE GASTROENTERITIS)
KIRSTEN E. PAPERA BSN LEVEL 3 GROUP 6