Case Presentation

BSN 2Y2 1 ( 1B )

Acute gastroenteritis

GASTROENTERITIS
is a term for infection or irritation for digestive tract, particularly the stomach and intestine. It is frequently referred as the stomach or intestinal flu.

 S/SX: - nausea and vomiting - diarrhea - abdominal cramps - fever - overall weakness

Patients profile
Name: J.M Age: 2 1/2 Gender: Male Birthday: May 21, 2009 Religion: Roman catholic

 Date and time of admission: November 30, 2011 1:36PM Attending physician: Dr. E. G. Chief complaint: Vomiting Diagnosis: Acute gastroenteritis with moderate dehydration Date and time of discharge: December 2, 2011 10:30 AM

HISTORY
JM was a 2 years old male, born on May 21, 2009, and Roman Catholic was diagnosed with Acute gastroenteritis with moderate dehydration.

 Date of Admission:
November 30, 2011 at 1:36 PM

Chief Complaint: Vomiting Date of Discharge:

December 2, 2011 at 10:30 AM

 Personal Medical History:

Second Day of PTA, patient had 5 episodes of vomiting associated with 3X LBM (Loose Bowel Movement), not associated with fever and abdominal pain.

Consultation:
done

No consultation was

Medication:

No medication taken

 First Day of PTA, patient had 2 bouts of

vomiting and 2 episodes of LBM associated with anorexia and abdominal pain prompting consult and was advised admission in Valenzuela Emergency Hospital and were transferred in the institution. (Fatima Medical Center)

Allergies:

No known allergies (-) Asthma

Past Medical History:

Physical assessment

Body Parts Skin

Normal Findings Light to dark brown and feels warm, no swelling, moisture must be relatively dry with minimal perspiration

Actual Findings Dry skin and poor skin turgor

Remarks Abnormal

Hair and scalp

Smooth and soft, color black, shiny and not dry Fine texture, pinkish nail beds, edged should be smooth and rounded, no masses and properly distributed

Smooth, black and soft hair

Normal

Nails

Fine texture, pinkish nail beds, edged should be smooth and rounded, no masses and properly distributed

Normal

Eyes, eyebrows, eyelids

Blinking symmetrical, evenly distributed, eyelid margins are moist and pink in color

Blinking symmetrical, evenly distributed, eyelid margins are moist and pink in color

Normal

Ears

Look symmetrical, similar appearance, no discharge and no odor

Look symmetrical, similar appearance, no discharge and no odor

Normal

Nose

Color is same as face, no redness in the nasal mucosa, no bleeding The lips should be symmetrical, pink, smooth and moist. There should be no growths, lumps or discoloration of the tissue. The dorsal side of the tongue should be symmetrical protrusion of the tongue. It should be pink, moist with a slightly rough surface from the papillae symmetrical, moist, pink/coral with tight well defined margins, no bleeding and no sore gums

Color is same as face, no redness in the nasal mucosa, no bleeding Dry lips

Normal

Lips

Abnormal

Tongue

Pink and moist

Normal

Gums

moist, pink, no bleeding and no sore gums

Normal

Head and neck

Face is symmetrical, position is smooth and controlled movements, centered

Face is symmetrical, position is smooth and controlled movements, centered

Normal

Upper Extremities

Bilateral pulses strong and equal, intact condition of the skin in arms, no lesion and no swelling

Bilateral pulses strong and equal, intact condition of the skin in arms, no lesion and no swelling

Normal

Abdomen

No rashes or lesions, umbilicus is centrally located, rounded, symmetrical, skin is smooth and uniform

Hyperactive bowel sound, abdominal tenderness,

Abnormal

Lower Extremities

Bilaterally symmetrical and equal, no lesion and no swelling, skin color is the same with the other parts of the body

Bilaterally symmetrical and equal, no lesion and no swelling, skin color is the same with the other parts of the body

Normal

Pulmonary system

Age 1-2 the normal range is 2440cpm, 2-5 is 2234cpm, 6-12 is 18-30cpm, >12 is 12-16

Respiratory rate was 32cpm

Normal

Cardiovascular system

Age 1-2 the normal range is 90150bpm, 2-5 is 80-140bpm, 6-12 is 70-120bpm, >12 is 60-100bpm

Cardiac rate was 122bpm

Normal

Related Treatments
IVF of PLR 1L; 100 ml as fast drip to be regulated at 10-11 gtts/min He is also advice to take Diagnostic Test such as Complete Blood Count at 8:45pm, Urinalysis and Fecalysis. Zinc Sulfate was given to take once a day.

Laboratory results
Remarks Laboratory Procedur e Complete blood count Actual Result 6.5 0.32 0.57 0.08 0.02 0.01 132 0.39 4.73 82 27.8 340 14.1 381 3.72 Normal Abnormal Abnormal Normal Normal Normal Abnormal Abnormal Abnormal Date 11-3011 Component WBC Differential Count Neutrophil Lympocytes Monocytes Eusonophil Basophil Hemoglobin Hematocrit RBC MCV MCH MCHC RDW Platelet MPV Normal Finding 5.0- 10.0 x 10 g/L 0.40-0.60 0.20-0.40 0.02-0.08 0.01-0.03 0-0.02 M: 140- 175 g/L M: 0.42-0.48 M: 5.5- 6.5 x 10g/L 88-96 27-33 pg 300-360 g/L 12.7- 22.7% 150-450 x 10 g/L 4.5- 7.5/L

Abnormal Normal Normal Abnormal Normal Abnormal

Remarks Laboratory Procedure Urinalysis Actual Result Yellow Turbid Normal Abnormal

Date 12-111

Component Color Transparency

Normal Finding Pale yellow to amber Clear to hazy

RBC Pus Cell Bacteria Epithelial Cell Mucus Thread

0-2 / HPF 5-10/HPF

0-1 0-2 Few Few

Few

Normal Abnormal Abnormal Abnormal Abnormal

Spec. Gravity pH Nitrite Protein Glucose Ketone

1.003- 1.029 4.5-7.8 Negative Negative Negative Negative

1.025 6.5 Negative Negative Negative Negative

Normal Normal Normal Normal Normal Normal

Urobilinogen Bilirubin Leukocytes Blood

1.EU/dl Negative Negative Negative

Normal Negative Negative Negative

Normal Normal Normal Normal

Drug study
DRUG NAME CLASSIFICATION DRUG ACTION DRUG INDICATIONS CONTRAINDICATIO N ADVERSE EFFECTS Zinc Sulfate Nutritional Supplement Promotes wound healing and help maintai n normal growth rate, normal skin hydratio n and taste and smell sensatio n  Replacement and Supplementati on. Therapy in patient who are at risk for zinc deficiency including patient on logterm parenteral nutrition.  Hypersensitivity or Allergy to any compounds in formulation. Use cautiously in renal failure GI- Nausea, Vomiting, Gastric irritation.

DRUG NAME

CLASSIFICA TION

DRUG ACTION

DRUG INDICATI ONS  Acute infection with susceptib le anaerobic bacteria. Acute intestinal amebiasis .

CONTRAINDICATIO N

ADVERSE EFFECTS

Metronidazole

Antibacterial Antibiotic

Bactericidal: Inhibits DNA synthesis in specific(obli gate) anaerobes, causing cell death; antiprotozo al Amebicidal: Biochemical mechanism of action is not known

 

Hypersensitivity to metronidazole. Use cautiously with CNS disease, hepatic disease, candidiasis, blood dyscrasias.

CNS: Headache, dizziness, ataxia vertig o, insomia,seiz ures, peripheral neuropathy, fatigue. GI: Unpleasant metallic taste, anorexia,nau sea, vomiting, diarrhea,GI upset,cramp s GU: Dysuria, Incontinence , darkening of the urine. Local:redness, burning,dryn ess, and skin irritation

DRUG NAME

CLASSIFICATI ON

DRUG ACTION

DRUG INDICATIO NS  Against susceptible bacteria causing infections of the middle ear, ear, throat infections, laryngitis, bronchitis, sinusitis, and pneumonia . It is also used in treating urinary tract infections, skin infections, and gonorrhea.

CONTRAINDICATION

ADVERSE EFFECTS

Coamoxic lav

Antibiotic Aminopeni cillin

Should be avoided by patients with an allergy to penicilli n and other related antibioti cs. Serious and occation ally fatal allergic reaction s (anaphyl axis) have been reported in sensitive individu als

Severe kidney disease that requires dialysis, history of liver problems (such as cholestatic jaundice) that occurred with previous use of amoxicillin/clavul anic acid. Before using this medication, tell your doctor or pharmacist your medical history, especially of: liver disease, kidney disease, a certain type of viral infection (infectious mononucleosis).Ki dney function declines as you grow older.

Diarrhea, nausea, vomiting, or stomach/abdom inal pain may occur during the first few days as your body adjusts to the medication. Take with food to minimize stomach upset.

Nursing Care Plan

ASSESSMENT Subjective: Madalas dumumi ang anak ko as verbalized by the patients mother. Objective:  Frequent watery stools  V/S: t: 36.6 p:80 r:18 bp:110/90 NURSING DIAGNOSIS Risk for deficient fluid volume r/t excessive losses through normal route. PLANNING Within 6 hours of nursing intervention the patient will report reduction in frequency of stool.  INTERVENTIONS Observe record stools frequency characteristics, amount and precipitating factors Promote bed rest Provide bedside commode. Identify foods and fluids hat precipitate diarrhea. Administer antidiarrheals as prescribed by physicians EVALUATION After 6 hours of nursing intervention the patient was able to report reduction in frequency of stool.

   

ASSESSMENT Subjective: Masakit ang tiyan anak ko. verbalized the mother the patient.

NURSING DIAGNOSIS Acute abdominal pain r/t increased intestinal peristalsis.

PLANNING Within 1 hour of nursing interventions, the patients pain will be lessening from 7 to 3/10.

INTERVENTIONS  Determine pain characteristics through clients description. Observe nonverbal cues. Collaborate in treatment of disease process causing pain. Provide comfort measures (e.g, nurses presence), quiet environment and calm activities. Instruct in use of relaxation techniques such as focused breathing. Evaluate pain everytime it occurs. Give analgesics as per doctors order.

EVALUATION After 1 hour of nursing interventions, patients pain was lessened from 7 to 3/10

din ng As by of

 

Objective:  Observed evidence of pain: irritability and crying  Pain scale of 7/10

 

Recommendation

A. Medications
Advice Patient to strictly follow prescriptions given by the doctor.
Medication  Zinc Sulfate - For Hydration Drug Class/es

Metronidaone

- Amebicide, Antibacterial, Antibiotic,

G- Amoxyclav

- Antibiotic

B. Exercise
Encourage parents of the patient to lessen activities for prevention of perspiration. Encourage parents of patient for frequent oral as well as eye care to prevent dryness.

C. Treatment
Increase Fluid intake Intake of oral rehydration salts. Institute personal and food hygiene

D. Health Teaching
Advice parents of patient to see the nearest doctor if dehydration might occur and go severe. Advice parents to increase water intake of patient. Advice parents to clean fresh fruits and vegetables, avoid eating raw shellfish and too much person to person contact.

E. Out-patient follow-up
Teach patient where could be nearest hospital could be for when the signs and symptoms occur.

F. Diet
Increase in water intake.

G. Spiritual
Advice the family to always be thankful even in the times of hardship, for the guidance, for the struggles that you succeeded, mainly we talk about health, for the continuing guidance for the future.