Documente Academic
Documente Profesional
Documente Cultură
Acute Gastroenteritis
Submitted by:
Cabrera, Alexander
BSN 3D
Submitted to:
Ms. Mendoza
I. INTRODUCTION:
Acute Gastroenteritis
Acute gastroenteritis could be more simply called a long, and potentially
lethal bout of stomach flu. The most common symptoms are diarrhea, vomiting
and stomach pain, because whatever causes the condition inflames the
gastrointestinal tract. Acute gastroenteritis is quite common among children,
though it is certainly possible for adults to suffer from it as well. While most cases
of gastroenteritis last a few days, acute gastroenteritis can last for weeks and
months.
Numerous things may cause acute gastroenteritis. Bacterial infection is
frequently a factor, and infection by parasites like giardia can cause acute
gastroenteritis to last for several weeks. Viruses can also cause lengthy stomach
flu, particularly rotaviruses and noroviruses. Accidental poisoning or exposure to
toxins may also instigate acute gastroenteritis as well.
Acute gastroenteritis remains a serious health issue, and is responsible for over
50,000 hospitalizations of children. In developing countries, acute gastroenteritis
is the leading cause of death for infants. Acute gastroenteritis should thus be
taken seriously, and people should not hesitate to seek medical treatment for
especially seniors and children who have been ill for more than a day.
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.
The case is about 11months old baby who has been diagnosed with AGE with
some dehydration. He was admitted last March 13, 2010.
II. OBJECTIVES:
A. General Objectives:
According to the significant patients mother, the client was vomiting and
defecating thats why they rushed her to the hospital.
C. Admitting Diagnosis: AGE with Dehydration
D. Final Diagnosis: AGE with Dehydration
E. HEALTH HISTORY
A. History of Present Illness
Prior to admission, the client was vomiting and defecating. Her stool was
watery and its color is yellow.
B. Past History
The client had fever, cough and colds. She had completed all vaccinations
including BCG, DPT, Oral Polio Vaccine, MMR and Hepatitis B vaccine.
The patient had never been any of the childhood disease such as
measles, mumps and chicken pox. The patient had no history of accident
or any injury. He does not have allergy in any food or drug.
C. Family History
According to the mother of Pt. they have a familial disease of asthma, both on
her father and mother's side. And an incident of hypertension on his father's side.
F. PHYSICAL ASSESSMENT
BODY
PARTS
ASSESSED
1.Skin
a. Moisture
TECHNIQUES
Palpation
NORMAL
FINDINGS
ACTUAL
FINDINGS
INTERPRETATIO
N
Moisture in skin
folds and axillae
Smooth
Dry skin
Deviated due to
slight dehydration
Deviated due to
slight dehydration
Deviated due to
slight dehydration
B Texture
Palpation
c. Turgor
Inspection and
Palpation
Springs back
immediately to
previous state
Moves back
slowly
Inspection
Parallel to each
other
Parallel to each
other but sunken
d/t dehydration
Visual Acuity
Inspection
(penlight)
Inspection
Eyelashes
Inspection
PERRLA- Pupils
equally round
react to light and
accommodation
Symmetrical in
size, extension,
hair texture and
movement
Distributed evenly
and curved
outward
Normal
Eyebrows
PERRLA- Pupils
equally round
react to light and
accommodation
Symmetrical in
size, extension,
hair texture and
movement
Distributed evenly
and curved
outward
2. Eyes
Eyes
3. Mouth
a. Lips
Inspection
Rough
Dry lips
Normal
Normal
Deviated due to
slight dehydration
b. Mucosa
Inspection and
Palpation
c. Gums
Inspection and
Palpation
4.Thorax
and Lungs
Auscultation
Clear breath
sounds
Clear breath
sounds
5. Abdomen
Bowel
sounds
Auscultation
Audible bowel
sounds
Hyperactive
bowel sound
Deviated from
normal due to
slight dehydration
Deviated from
normal due to
slight dehydration
Normal
Deviated due to
diarrhea
Nutritional-Metabolic Pattern
Before his hospitalization, according to patients mother he drinks about 5-7
bottle of milk a day with meal. And vitamins.
During his hospitalization, his appetite decreased, he drinks about 3-4 bottle
of milk.
Elimination Pattern
Before his hospitalization, the patient used to eliminate 4 times a day with a
semi-solid consistency and is brownish in color. He usually urinates 2 times a
day with the normal light yellow color and aromatic odor.
During is hospitalization; the patients stool is watery with a yellowish color.
He urinates 2-3 times a day.
Activity-Exercise Pattern
Before his hospitalization, he used to play outside with his cousins. They
usually play toy cars and the usual games of his age. He stops playing when
he feels tired.
During his hospitalization, he used his time playing the cell phone of his
father. Most of his time was spent for resting and sleeping.
Sleep-Rest Pattern
Before his hospitalization, he usually sleeps 10-11 hours.
During his hospitalization, the patient sleeps early but has sleep disturbances
when the nurses take his vital signs, administer medicines and also due to the
environment.
Cognitive-Perception Pattern
Before his hospitalization, the patient is normal in terms of his cognitive
abilities. He has no problems with his senses.
Sexual-Reproductive Pattern
Prior to his age, the patient is not yet oriented with any sexual matters.
Value-Belief Pattern
He is a Roman Catholic. They attend mass regularly. According to his mother
The human digestive system is a complex series of organs and glands that
processes food. In order to use the food we eat, our body
has to break the
food down into smaller molecules that it can process; it also has to excrete
waste.
Most of the digestive organs (like the stomach and intestines) are tube-like and
contain the food as it makes its way through the body. The digestive system is
essentially a long, twisting tube that runs from the mouth to the anus, plus a few
other organs (like the liver and
pancreas) that produce or store digestive
chemicals.
The Digestive Process:
The start of the process - the mouth: The digestive process begins in the
mouth. Food is partly broken down by the process of chewing and by the
chemical action of salivary enzymes (these enzymes are produced by the
salivary glands and break down starches into smaller molecules).
On the way to the stomach: the esophagus - After being chewed and
swallowed, the food enters the esophagus. The esophagus is a long
tube
that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle
movements (called peristalsis) to force food from the throat into the stomach.
This muscle movement gives us the ability to eat or drink even when we're
upside-down.
In the stomach - The stomach is a large, sack-like organ that churns the food
and bathes it in a very strong acid (gastric acid). Food in the stomach that is
partly digested and mixed with stomach acids is called chyme.
In the small intestine - After being in the stomach, food enters the duodenum,
the first part of the small intestine. It then enters the jejunum and then the ileum
(the final part of the small intestine). In the small intestine, bile (produced in the
liver and stored in the gall bladder),
pancreatic enzymes, and other digestive
enzymes produced by the inner wall of the small intestine help in the breakdown
of food.
In the large intestine - After passing through the small intestine, food passes
into the large intestine. In the large intestine, some of the water
and
electrolytes (chemicals like sodium) are removed from the food. Many microbes
(bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and
Klebsiella) in the large intestine help in the digestion process. The first part of the
large intestine is called the cecum (the appendix is connected to the cecum).
Food then travels upward in the ascending colon. The food travels across the
abdomen in the
transverse colon, goes back down the other side of the body
in the descending colon, and then through the sigmoid colon.
The large intestine is made up of three parts:
1. The cecum is a pouch at the beginning of the large intestine that joins the
small intestine to the large intestine. This transition area allows food to
travel from the small intestine to the large intestine.
2. The appendix, a small, hollow, finger-like pouch, hangs off the cecum.
Doctors believe the appendix is left over from a previous time in human
evolution. It no longer appears to be useful to the digestive process.
3. The colon extends from the cecum up the right side of the abdomen,
across the upper abdomen, and then down the left side of the abdomen,
finally connecting to the rectum. The colon has three parts: the ascending
colon and transverse colon, which absorb water and salts, and the
descending colon, which holds the resulting waste. Bacteria in the colon
help to digest the remaining food products.
The rectum is where feces are stored until they leave the digestive system
through the anus as a bowel movement.
The end of the process - Solid waste is then stored in the rectum until it is
excreted via the anus.
X
. Discharge Plan
Medications:
Advised the patient to continue the medication prescribed by the doctor such as:
OMX 1Cap BID x 5amp
Zinc drop 1ml, OD
Vitamin A 100000 u, PO
The patient already stayed for 2 days in the hospital. Shell continue her
medications at home.
Exercise:
Advised the pt mother to let their children play like solving simple puzzle.
Treatment:
No further treatment was ordered by the doctor
Health Teaching:
Advised the pt.mother about proper and strict supervision of child until
balance, gait, and coordination is gained.
Proper hygiene of both child and parent are very important as defense
from infection.
Advise to restrict child from handling items or objects especially if
unfamiliar and not edible. Emphasize importance of hand washing and nail
care.
Out patient follow up:
Advise the mother that infant nutrition is an important topic and she should
always feel free to discuss at health care visits.
Diet:
Increased vitamin C intake, to provide antioxidants that will prevent
possible cell damage.
Encourage pt. Mother to prepare a balanced diet meal for his baby.
Spiritual:
Advised the mother to develop a closed relationship with their baby and
always attend mass regularly.
LABORATORY RESULTS
HEMATOLOGY RESULTS
WBC
Hgb
Hct
Differential Count
Segmenters
Lymphocytes
Normal Value
5-10 x 10 g/L
M 13-16 g/dl
F 12-16 g/dl
M 39%-54%
F 37%-48%
Results
4.5
10.3
Analysis
Decreased
Normal
33%
Decreased
.40-.60
.20-.40
.32
.68
Decreased
Increased
FECALYSIS
Results
Analysis
Yellow
Soft
Normal
d/t profuse secretion of
water and electrolytes
Color
Transparency
Results
Yellow
Slightly turbid
Reaction
Specific gravity
6.0
1.030
Sugar
Protein
Negative
Trace
Analysis
Normal
d/t increased urine
concentration
Normal
Decreased: d/t
dehydration
Normal
Normal
Physical properties:
Color
Consistency
URINALYSIS