PATIENT PROFILE

Name: Baby J
Age: 1 year old
Gender: Male
Birthday: June 10, 2016
Religion: Iglesia Ni Cristo
Address: Sta. Lourdes, Puerto Princesa City
Date and Time Admitted: 8:14 AM, Jan. 5, 2017
Attending Physician: Dr. Jesusa A. Lachama
Chief Complaint: Loose Watery Stools since yesterday (January 4, 2017)
and skin rashes.
Admitting Diagnosis: Acute Gastroenteritis
 PRESENT ILLNESS

A 1 year old boy was admitted with a chief

complaint of loose watery stools since the
day before he was rushed to the hospital. His
mother verbalized that the client had loose
stools due to eating lechon, intermittent
fever and loss of appetite.
 ACUTE GASTROENTERITIS
Acute Gastroenteritis (AGE) 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.
Major symptoms include nausea and vomiting, diarrhea, and
abdominal cramps. These symptoms are sometimes also
accompanied by fever and overall weakness. Gastroenteritis
typically lasts about three days. Gastroenteritis arises from ingestion
of viruses, certain bacteria, or parasites. Food that has spoiled may
also cause illness. Adults usually recover without problem, but
children, the elderly, and anyone with an underlying disease are
more vulnerable to complications such as dehydration.
 SIGNS AND SYMPTOMS
Signs and symptoms usually begin 1272 hours after
contracting the infectious agent.

Gastroenteritis typically involves both diarrhea and

vomiting .
Fever, fatigue, headache, and muscle pain
Bloating
Dry skin and oral mucosa
 Watery, usually non-bloody diarrhea- bloody
diarrhea usually means you have a different, more
severe infection.
Abdominal cramps and pain
Nausea, vomiting or both
Occasional muscle aches or headache
Low-grade fever
 TREATMENT
1. Oral rehydration therapy should be the initial
treatment because it is as effective as intravenous
therapy in rehydrating and replacing electrolytes in
children with mild to moderate dehydration.
2. An age-appropriate diet should be continued in
children with diarrhea who are not dehydrated, and
an age-appropriate diet should be resumed as soon as
rehydration is accomplished in children with mild to
moderate dehydration.
Things to avoid while recovering:
Alcohol
Caffeine
Dairy products
Citrus products
Fatty, greasy and/ or fried foods
Raw fruits and vegetables
 NURSING CARE PLAN
ASSESSMENT CUES: NURSING DIAGNOSIS OBJECTIVES AND INTERVENTION RATIONALE EVALUATION
OUTCOMES
Subjective: Acute Gastroenteritis; Diarrhea Short Term Goal: After INDEPENDENT NURSING For presence, location Short Term: After 8
Mabasa-basa ang 8 hours of nursing INTERVENTIONS: and characteristic of hours of nursing
dumi ng anak ko. intervention the Auscultate the BM. intervention the
patients s/o (mother abdomen For the education of patients s/o (mother
Matubig-tubig siya. or father) will gain Discuss the different the significant other or father) gained
As verbalized by the knowledge about causative factors and Prevention of gastric knowledge about
father. diarrhea. rationale for ulcer diarrhea.
treatment regimen To determine if the
Objective: Expected Outcome: Avoid Caffeinated client is dehydrated. Long Term: After 2-3
Loose bowel - Verbalize Products days of nursing
movement with Understanding of Observe skin and intervention the
causative factor mucosa membrane patient is free of
yellowish watery - Verbalize rationale diarrhea
stool minimum of for treatment DEPENDENT NURSING
three times a day. - Verbalize the INTERVENTIONS:
Increase in bowel importance of Collaboration of IVF
sounds. proper hygiene. and monitor IVF
Weak looking
patient Long Term Goal: After
2-3 days of nursing
Bloated intervention the
(+) Skin Rashes patient will be free of
Weight of 10.16kg diarrhea
(+) Presence of
Ascaris Expected Outcome:
Lumbricoides Ova - Re-establish and
maintain normal BM.
 NURSING CARE PLAN
ASSESSMENT CUES: NURSING DIAGNOSIS OBJECTIVES AND INTERVENTION RATIONALE EVALUATION
OUTCOMES
Subjective: Madalas Acute Gastroenteritis; Deficient Short Term Goal: After INDEPENDENT NURSING To determine what Short Term: After 8
siyang humingi ng fluid volume 8 hours of nursing INTERVENTIONS: causes the hours of nursing
tubig. As verbalized intervention the Assess causative dehydration intervention the
patients s/o (mother precipitating factors Infants and children patients s/o (mother
by the mother or father) will gain Determine effects of have a relatively high or father) gained
knowledge about age percentage of total knowledge about
Objective: dehydration. Assess vital signs body water, are diarrhea.
Increased pulse Note complaints and sensitive to loss, and
rate Expected Outcome: physical signs are less able to Long Term: After 2-3
Decreased skin - Verbalize Compare usual and control their fluid days of nursing
turgor Understanding of current weight intake.. intervention the
causative factor Review laboratory patient is free of
Dry skin - Verbalize rationale data diarrhea
Decreased urine for treatment Maintain accurate I/O
output - Verbalize the and weigh daily
importance of DEPENDENT NURSING
proper hygiene. INTERVENTIONS:
Administer IV fluids
Long Term Goal: After as indicated
2-3 days of nursing Administer
intervention the medications
patient will be free of
dehydration

Expected Outcome:
-maintain a normal
fluid volume
 DRUG STUDY
NAME OF CLASSIFICATION DOSE, FREQUENCY MECHANISMS OF INDICATIO CONTRAINDIC SIDE EFFECTS AND NURSING
DRUG AND ROUTE ACTION -NS -ATIONS ADVERSE REACTIONS RESPONSIBILITIES

Balanced - Hypertonic - 500 cc; - A high Slow - Phlebitis - Allergic Do not administer
Multiple solution 40 cc/hr concentration of administration (inflammation reactions unless solution is
Maintenance Intravenous solute relative to essential to of the vein), including clear and
Solution with another solution prevent overload peripheral anaphylactic container is
5% Dextrose (e.g. the cell's (100 mL/hr) - edema, cellular shock undamaged.
(Euro Ion) cytoplasm). Water dehydration
When a cell is intoxication - - Severe Discard unused
placed in a Severe sodium Asthmatic portion.
hypertonic depletion Episodes
solution, the Caution must be
water diffuses exercised in the
out of the cell, administration of
causing the cell parenteral fluids,
to shrive. especially those
containing
sodium ions to
patients receiving
corticosteroids or
corticotrophin.
 HEALTH TEACHING
Drink at least 8 glass of water a day to prevent
dehydration. Consider drinking a few glasses of
electrolyte replacement fluids a day.
Eat foods with sodium and potassium. Most food
contain sodium. Potassium is found in meats and
many vegetables and fruits, especially purple grape
juice, tomatoes, potatoes, bananas.
 Increase foods containing soluble fiber, such as
rice, oatmeal and skinless fruits and potatoes.
Avoid caffeine which can aggravate the problem.
Limit food containing insoluble fiber, such as high-
fiber whole-wheat and whole-grain breads and
cereals, raw fruits and vegetables. Limit fatty food.
Thoroughly clean and dry the perineal area after
passing stool to prevent skin irritation and
breakdown.