Documente Academic
Documente Profesional
Documente Cultură
Submitted by:
BAI SANDRA M. SINAGANDAL
BSN 4 STUDENT
Date:
TABLE OF CONTENTS
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
XII.
XIII.
XIV.
XV.
XVI.
XVII.
XVIII.
XIX.
XX.
XXI.
XXII.
Introduction
Objectives of the Study
Vital information
Family Background
History of Past Illness
History of Present Illness
Effects and Expectations
Genogram
Developmental Data
Physical Assessment
Textbook Discussion/ Anatomy & Physiology
Definition of Terms
Etiology/ Symptomatology
Pathophysiology
Doctors Order
Laboratory Results
List of Drugs
Drugs Study
List of Prioritized Problem
Nursing Care Plan
Prognosis
References
OBJECTIVES
General Objectives:
After 1 hour of reading the case, the readers will be able to gain
adequate knowledge on Acute Gastroenteritis (AGE) and enhance knowledge
and skills in dealing with patients having this kind of condition , hence
allowing listeners to apply their learning appropriately in clinical setting and
develop positive attitude in caring for patients with the same condition.
Specific Objectives:
After 1 hour of reading the case, the readers will be able to:
involved.
Enumerate completely the general and specific objectives.
Identify correctly with important information regarding patients data
by presenting the following:
Vital Information
History of present and past Illness
Family Background
Effects and Expectations of illness to self and family
Genogram
Growth and Development Data
on textbook discussion.
Relate the Anatomy and Physiology of the systems involved in AGE.
Enumerate the predisposing and precipitating factors involved with the
diagnosis clearly.
Enumerate the etiology of AGE.
Discuss the pathophysiology of AGE.
Identify the laboratory test undergone by the patient and interpret the
result accurately.
Discuss the doctors order for patient wellness and rationalize properly.
Rationalize the drugs that the physicians ordered and discuss the
mechanisms of action, side and adverse effects, contraindication,
Acute Gastroenteritis
INTRODUCTION
This is a case of baby J, a 4 years old male patient of South Cotabato
Provincial Hospital. He was admitted last January 18, 2015 at 7:45am with
admitting diagnosis of Acute Gastroenteritis with moderate dehydration,
under the service of Dr. San.
Acute 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. At least 50% of cases of gastroenteritis as
foodborne illness are due to norovirus. Another 20% of cases, and the
majority of severe cases in children, are due to rotavirus. Other significant
viral agents include adenovirus and astrovirus.
Different species of bacteria can cause gastroenteritis, including Salmonella,
Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli,
Yersinia, and others. Each organism causes slightly different symptoms but
all result in diarrhea. Colitis, inflammation of the large intestine, may also be
present. Some types of acute gastroenteritis will not resolve without
antibiotic treatment, especially when bacteria or exposure to parasites are
the cause. Physicians may want to diagnose the cause by analyzing a stool
sample, when stomach symptoms remain problematic.
five and means that more than 5000 children are dying every day
as a result of diarrheal diseases. Of all child deaths from diarrhea,
78% occur in the African and South-East Asian regions. Each child
under 5 years of age experiences an average of three annual
episodes of acute diarrhea. Globally in this age group, acute
diarrhea is the second leading cause of death (after pneumonia),
and both the incidence and the risk of mortality from diarrheal
diseases are greatest among children in this age group,
particularly during infancy thereafter, rates decline
incrementally. Other direct consequences of diarrhea in children
include growth faltering, malnutrition, and impaired cognitive
development in resource-limited countries.
In the Philippine Health Statistic, gastroenteritis range as number 10 in the
ten leading causes of infant mortality, with the rate of 0.5 and percentage of
4.1 cases in the Philippines by the year 2004 this was updated last February
12, 2008.
PATIENTS DATA
Vital Information
Patients Name:
Baby J
Age:
2 years old
Sex:
Male
Birth Date:
Birth Place:
Address:
Occupation:
none
Tribe:
Ilonggo
Citizenship:
Filipino
Religion:
Roman Catholic
Civil Status:
Single
Body weight:
25.5 kg
Name of Institution:
Attending Physician:
Dr. San
Parents Name:
1. Mrs. K
2. Mr. L
27
32
housewife
Tricycle Driver
Sibling:
1. Kaye
2. Pt. J
Source of Information:
1. Mrs. K
2. Pt.s Chart
5
2
Student
none
Family background
Pt. J was born on October 25, 2012 at Koronadal City, South Cotabato. He is
an affiliate of Roman Catholic. He lived in Sitio Mani, Topland Bo.7, koronadal
city South Cotabato. He is a Second son of the family. According to his
mother, only Mr. L is the one who worked for the family because no one will
take care of their kids except Mrs. K. Mrs. K stated that baby J completed his
immunizations such as BCG1, OPV3, DPT3, Hepa-b3, MMR1. He was
breastfeed until he is 1 year old, and now he is already bottle feed. Based on
their diet,Mrs. L cook food such as fish and vegetable, they rarely eat meat
because according to Mrs. L it is too expensive. She also stated that Pt. baby
J is so hard to make him eat his food that is why he is under weight for his
age.
According to Mrs. L they do not have any hereditary diseases. Baby Js
grandparents are both alive.
Their house was made of half cement and half kalakat, it has one room,
kitchen and a living room. The comfort room is outside their house. Their
water source is nawasa and poso. They have pets in the house, 1 dog and 2
cats.
Based on their finances, Mr. L has a 250 per day for his boundary because
the tricycle he drive is not owned by Mr. L. So, he gets 7,500 per month plus
1,400 pesos a month by the government subsidy which is the 4 Ps
(pantawid pamilyang Pilipino program).
According to Mrs.L, whenever they got sick they do not directly consult the
doctor, instead they just go to health center and ask for a medicine such as,
Paracetamol for fever, Biogesic for head ache, neozep for flu and lagundi
capsule for cough.
DEVELOPMENTAL DATA
Developmental task theory of Robert Havighurst
A developmental task is a task which arises at or about a certain period in the life
of an individual. Havighurst has identified six major age periods:
infancy and early childhood (0-5 years), middle childhood (6-12 years),
adolescence (13-18years), early adulthood (19-29 years), middle
adulthood (30-60 years), and later maturity (61+)
Based on Havighurst s Theory, The patient developmental theory is in Infancy and
early chidhood
Theory
Task
Justification
Remarks
Robert
Havighurs
t
(infancy
and early
childhood)
Learning to walk
Learning to take
solid foods
Learning to talk
Learn to control
the elimination
of body waste
Learning sex
differences and
sexual modesty
Forming
Achieved
Achieved
Achieved
Achieved
Achieved
Achieved
concepts and
learning
language to
describe
social and
physical
reality.
Getting ready to
read
Achieved
PSYCHOSOCIAL THEORY
Erik Erikson
He envisions life as a sequenceof level of achievement. Each stage
signals a task that must be achieved. The resolution of the task can be
complete, partial or unsuccessfully.
Erikson believes that the greater the task achievement, the healthier
the personality of the person failure to achieve the task influences the ability
of the person to achieve the next task. This developmental task can be
viewed as a series of crisis and unsuccessful resolution of this crisis is
damaging to the ego. After attaining ones stage, the person may fall back
and need to approach it again.
Theory
Task
Justification
Remarks
Erik Erikson
(will)
Achieved
PHYSICAL ASSESSMENT
Date and time:
January 11,2015
7:45 PM
General Appearance:
The patient is a young male, with IVF D5LR 160 gtts/hr hooked at right
basillic vein, patent and infusing well. Patient is conscious, hair is not wellfixed, The patient wears striped sando and wears diaper.
Vital signs:
T- 37 C
RR- 20 cpm
PR-72 bpm
Head/Hair/Scalp:
Inspection: Head is proportional to the body and skull is rounded and
symmetrical, no dandruff and lice noted, hair is evenly distributed, gray in
color with dry texture.
Palpation: No tenderness and masses noted.
Face:
The face is symmetrical; skin is brown in complexion and has poor skin
turgor.
Eyes:
Eyes are symmetrical, eyebrows are black in color. Yellowish discharges
noted. Pupils are equal in size and reacts to light. Eye opening is good.
Conjunctiva is pinkish in color and sclera is well lubricated.
Nose:
Inspection: The external nose is symmetrical, align at the midline,
nasogastric tube noted inserted through the right nostril, mucosa is moist,
nasal septum is intact, no lesions and nose deformities noted.
Palpation: There is no tenderness noted.
Ears:
Inspection:
external ear, earwax noted, auricle has no deformities, pinna recoils when
folded.
Palpation: No tenderness and nodules noted.
Mouth and Lips:
Inspection: Lips are pale in with dry and flaky texture, no presence of
stomatitis, no lesions noted, the tongue is pinkish in color with white spots.
Incomplete set of teeth and yellow-orange color of the teeth is noted. Gums
and mucosa is light pink and no lesion noted. Tonsils are not inflamed; uvula
is bell in shape, pinkish in color, and at the midline.
Neck:
Inspection: Jugular veins are not inflamed and no stiffness noted.
Palpation: Lymph nodes at the neck are not palpable.
Breast:
Inspection: Brown areola and nipple noted, areola are equal in size.
Palpation: No tenderness and masses noted.
Lungs:
Auscultation: Breathing pattern is normal and no irregular rhythm noted.
Heart:
Auscultation: No abnormal sound noted.
Abdomen:
Inspection: No scars noted upon inspection. No lesion noted.
Auscultation: Gurgling sound noted. 7 gurgling sound/min.
Palpation: No tenderness noted, no masses noted.
Extremities:
Inspection: Extremities are proportionate to the trunk; skin is brown in
complexion, symmetrical on both upper and lower extremities. Immobility
noted on the right leg and arms. No withdrawal even on evoked pain
stimulus.
Skin:
Inspection: Skin is dry and flaky, no lesions
turgor.
Palpation: No masses and tenderness noted. Cool to touch.
Nails Inspection: Nails are dirty, and pinkish in color. Capillary refills after 3
seconds.
Teeth. The teeth are 32 small, hard organs found along the anterior and lateral
edges of the mouth. Each tooth is made of a bone-like substance called dentin and
covered in a layer of enamelthe hardest substance in the body. Teeth are living
organs and contain blood vessels and nerves under the dentin in a soft region known as
the pulp. The teeth are designed for cutting and grinding food into smaller pieces.
Tongue. The tongue is located on the inferior portion of the mouth just posterior
and medial to the teeth. It is a small organ made up of several pairs
of muscles covered in a thin, bumpy, skin-like layer. The outside of the tongue contains
many rough papillae for gripping food as it is moved by the tongues muscles. The taste
buds on the surface of the tongue detect taste molecules in food and connect to nerves
in the tongue to send taste information to the brain. The tongue also helps to push food
toward the posterior part of the mouth for swallowing.
Salivary Glands. Surrounding the mouth are 3 sets of salivary glands. The
salivary glands are accessory organs that produce a watery secretion known as saliva.
Saliva helps to moisten food and begins the digestion of carbohydrates. The body also
uses saliva to lubricate food as it passes through the mouth, pharynx, and esophagus.
Pharynx
The pharynx, or throat, is a funnel-shaped tube connected to the posterior end of the
mouth. The pharynx is responsible for the passing of masses of chewed food from the
mouth to the esophagus. The pharynx also plays an important role in the respiratory
system, as air from the nasal cavity passes through the pharynx on its way to the
larynx and eventually the lungs. Because the pharynx serves two different functions, it
contains a flap of tissue known as the epiglottis that acts as a switch to route food to
the esophagus and air to the larynx.
Esophagus
The esophagus is a muscular tube connecting the pharynx to the stomach that is part
of the upper gastrointestinal tract. It carries swallowed masses of chewed food
along its length. At the inferior end of the esophagus is a muscular ring called the
loweresophageal sphincter or cardiac sphincter. The function of this sphincter is to close
of the end of the esophagus and trap food in the stomach.
Stomach
The stomach is a muscular sac that is located on the left side of the abdominal cavity,
just inferior to the diaphragm. In an average person, the stomach is about the size of
their two fists placed next to each other. This major organ acts as a storage tank for
food so that the body has time to digest large meals properly. The stomach also
contains hydrochloric acid and digestive enzymes that continue the digestion of food
that began in the mouth.
Small Intestine
The small intestine is a long, thin tube about 1 inch in diameter and about 10 feet
long that is part of the lower gastrointestinal tract. It is located just inferior to the
stomach and takes up most of the space in the abdominal cavity. The entire small
intestine is coiled like a hose and the inside surface is full of many ridges and folds.
These folds are used to maximize the digestion of food and absorption of nutrients. By
the time food leaves the small intestine, around 90% of all nutrients have been
extracted from the food that entered it.
Liver and Gallbladder
The liver is a roughly triangular accessory organ of the digestive system located to the
right of the stomach, just inferior to the diaphragm and superior to the small intestine.
The liver weighs about 3 pounds and is the second largest organ in the body. The liver
has many different functions in the body, but the main function of the liver in digestion
is the production of bile and its secretion into the small intestine. The gallbladder is a
small, pear-shaped organ located just posterior to the liver. The gallbladder is used to
store and recycle excess bile from the small intestine so that it can be reused for the
digestion of subsequent meals.
Pancreas
The pancreas is a large gland located just inferior and posterior to the stomach. It is
about 6 inches long and shaped like short, lumpy snake with its head connected to
the duodenum and its tail pointing to the left wall of the abdominal cavity. The
pancreas secretes digestive enzymes into the small intestine to complete the chemical
digestion of foods.
Large Intestine
The large intestine is a long, thick tube about 2 inches in diameter and about 5 feet
long. It is located just inferior to the stomach and wraps around the superior and lateral
border of the small intestine. The large intestine absorbs water and contains many
symbiotic bacteria that aid in the breaking down of wastes to extract some small
amounts of nutrients. Feces in the large intestine exit the body through the anal canal.
Ingestion of food
Secretion of fluids and digestive enzymes
Mixing and movement of food and wastes through the body
Digestion of food into smaller pieces
Absorption of nutrients
Excretion of wastes
Ingestion
The first function of the digestive system is ingestion, or the intake of food. The mouth
is responsible for this function, as it is the orifice through which all food enters the
body. The mouth and stomach are also responsible for the storage of food as it is
waiting to be digested. This storage capacity allows the body to eat only a few times
each day and to ingest more food than it can process at one time.
Secretion
In the course of a day, the digestive system secretes around 7 liters of fluids. These
fluids include saliva, mucus, hydrochloric acid, enzymes, and bile. Saliva moistens dry
food and contains salivary amylase, a digestive enzyme that begins the digestion of
carbohydrates. Mucus serves as a protective barrier and lubricant inside of the GI tract.
Hydrochloric acid helps to digest food chemically and protects the body by killing
bacteria present in our food. Enzymes are like tiny biochemical machines that
disassemble large macromolecules like proteins, carbohydrates, and lipids into their
smaller components. Finally, bile is used to emulsify large masses of lipids into tiny
globules for easy digestion.
Mixing and Movement
The digestive system uses 3 main processes to move and mix food:
Peristalsis. Peristalsis is a muscular wave that travels the length of the GI tract,
moving partially digested food a short distance down the tract. It takes many waves of
peristalsis for food to travel from the esophagus, through the stomach and intestines,
and reach the end of the GI tract.
http://www.innerbody.com/image/digeov.html
TEXTBOOK DISCCUSSION
Acute Gastroenteritis
Gastroenteritis or infectious diarrhea is a medical condition from inflammation ("-itis") of
the gastrointestinal tract that involves both the stomach ("gastro"-) and the small
intestine ("entero"-). It causes some combination of diarrhea, vomiting, and abdominal pain
and cramping.[1]Dehydration may occur as a result. Gastroenteritis has been referred to
as gastro, stomach bug, and stomach virus. Although unrelated toinfluenza, it has also
been called stomach flu and gastric flu.
http://en.wikipedia.org/wiki/Gastroenteritis
Acute gastroenteritis is a common cause of morbidity and mortality worldwide. Conservative estimates
put diarrhea in the top 5 causes of deaths worldwide, with most occurring in young children in
nonindustrialized countries. In industrialized countries, diarrheal diseases are a significant cause for
morbidity across all age groups. Etiologies include bacteria, viruses, parasites, toxins, and drugs.
Viruses are responsible for a significant percentage of cases affecting patients of all ages. Viral
gastroenteritis ranges from a self-limited watery diarrheal illness (usually < 1 wk) associated with
symptoms of nausea, vomiting, anorexia, malaise, or fever, to severe dehydration resulting in
hospitalization or even death.
The clinician encounters acute viral gastroenteritis in 3 settings. The first is sporadic gastroenteritis in
infants, which most frequently is caused by rotavirus.[1] The second is epidemic gastroenteritis, which
occurs either in semiclosed communities (eg, families, institutions, ships, vacation spots) or as a result
of classic food-borne or water-borne pathogens. [2] Most of these infections are caused by caliciviruses.
The third is sporadic acute gastroenteritis of adults, which most likely is caused by caliciviruses,
rotaviruses, astroviruses, or adenoviruses.
http://emedicine.medscape.com/article/176515-overview
ETIOLOGY
Precipitating factor
Factor
Rationale
Age
(2 y/o)
Gender
(male)
Remarks
Present
Predisposing factor
Factor
Rationale
Remarks
Environment
Hygiene
stress
Present
Albumin
Sugar
pH
Pus cells
RBC
Epithelial
Cells
Bacteria
Mucus
Threads
Amorphous
Materials
negative
negative
6.0
2-3/hpf
0-2/hpf
Few
negative
negative
7.35-7.45
2-3 hpf
2-4 hpf
few
normal
normal
decreased
normal
normal
normal
Occassional
Absent
abnormal
Few
Few
normal
Moderate
Few
abnormal
acidic
Normally absent,
if present it
indicates
infection.
Too much
crystals in the
urine is an
indication of
having kidney
stones.
Fecalysis
Date: 1/12/15
PARAMETER
S
Color
Consistency
Pus Cells
RBC
ACTUAL
FINDING
S
Yellowish
Soft
0-3/hpf
NORMAL
FINDING
S
Yellowish
Soft
0
INTERPRETATIO
N
0-1/hpf
0-5/hpf
normal
normal
normal
abnormal
ANALYSIS
Invasion of
microorganisms.
PROGNOSIS
Criteria
Good
Fair
Poor
Justification
Onset of
Illness
It is Pt. jays
first
hospitalization
due to Acute
gastroenteritis.
Duration of
Illness
The patients
hygiene is fair
Hygiene
because he can
take a bath and
do his activity
of daily living.
drink.
At this age
Age
Computation:
Good: 2/5x 100% = 40%
Fair: 3/5 x 100% = 60%
Bad: 0/5 x 100% = 0%
Total: 100%
The interpretation of the Prognosis is Fair, because the pt. still having a
diarrhea with moderate dehydration.
Bibliography:
https://www.google.com.ph/?gfe_rd=cr&ei=xo_aVP7MGaK8QeuzIHoCA#safe=off&q=predisposing+factors+of+gastroenteritis
+on+adolescents
2011 LIPPINCOTTS NURSING DRUG HANDBOOK
MEDICAL SURGICAL NURSING BY UDAN
WWW.GOOGLE.COM
WWW.MEDSCAPE.COM/ACUTEGASTROENTERITIS