DR. YANGA’S COLLEGES, INC.

Wakas, Bocaue, Bulacan

‘GASTROENTERITIS’

Group-22 Section:IV

Alcantara, Raymond
Collano, Arnel
Corpuz, Ma. Cristina
Dantes, Liezel
Germar, Danica May
Gonzales, Angelo James
Gonzales, Rommel
Isidro, Cherry Ann
Malaya, Grace
Policarpio, Aileen
Salvador, Franz Gelanine
I. INTRODUCTION

Gastroenteritis also called stomach flu is defined as the inflammation of the stomach,
small and large intestines. Gastroenteritis is an infection caused by a variety of viruses
that result in vomiting, diarrhea or both. It is often called stomach flu, although it is not
caused by influenza virus. Gastroenteritis exhibits watery diarrhea, vomiting, headache,
fever and abdominal cramps (stomach ache) although one or the other symptoms may
prevail.

Gastroenteritis has many causes. Viruses and bacteria are the most common such as
rotavirus and Staphylococcus aureus. Viruses and bacteria are very contagious and can
spread through contaminated food or water. In up to 50% of diarrheal outbreaks, no
specific agent is found. Improper hand washing following a bowel movement or handling
a diaper can spread the disease from person to person. Anyone can acquire it. It occurs
in all people of different backgrounds and races.

Viral gastroenteritis is infectious. The virus that causes gastroenteritis is spread

through close contact with infected persons thru contamination with stool or
vomitus. Gastroenteritis is a serious illness because infants, young children, or
elderly who acquire this illness are at risk for dehydration from loss of fluids.
Compromised persons are at risk for dehydration because they may get more
serious illness with greater vomiting and diarrhea, they may need hospitalization
to prevent dehydration. This can be prevented by frequent hand washing and
disinfection of contaminated surfaces with household chlorine.

II. OBJECTIVES

A. General Objective

This case study aims to acknowledge the student nurse to gain the appropriate
knowledge, attitude and ability on the occurrence of gastroenteritis and the care of the
patient affected by gastroenteritis.

B. Specific Objective

• To be able to identify the symptoms of gastroenteritis and to identify the

measures to lessen its occurrence.
• To obtain complete nursing history.
 • To perform physical assessment.
• To identify the anatomy and physiology of the digestive system and
related organs.
• To identify and implement appropriate nursing interventions for patient
having gastroenteritis.

III. NURSING HISTORY

PERSONAL DATA:

This is the case of patient, J.M 1 year old, male, Filipino, Roman Catholic,
presently residing at,San Jose del Monte, Bulacan. He was admitted at OLSJDM last July
4, 2010 at 12:00 pm. This was his first hospital confinement.

CHIEF COMPLAINT: diarrhea and vomiting

ADMITTING DIAGNOSIS: Gastroenteritis

A. PRESENT HISTORY

One day prior to admission patient started complaining of stomach ache with an
elevated temperature (39◦C).

B. PAST MEDICAL HISTORY

Patient has had no confinement since birth.

C. FAMILY HISTORY

There is a history of hypertension on her father side.

D. SOCIAL HISTORY

J.M. doesn’t yet go to school and resides in San Jose Del Monte,Bulacan. His
mother works as a vendor and his father as a jeepney driver. Drinks 8 – 10
glasses of water. And seldom washes his hands. She also stated that his son
 spends time playing in his room and sleeps 8- 9 hrs at night and take a nap for 1 –
2 hrs each day.

IV. PHYSICAL ASSESSMENT

Area ofTechnique Findings Findings

Assessment of Assessment (July 6,2010) ( July 7,2010)

Vital Signs:
Temperature 38˚
38˚ C (axilla) 36.5º
36.5º C (axilla)
Respiratory Rate Inspection 24cpm
24cpm 22 cpm
Pulse Rate Palpation 104bpm
104bpm 94bpm
94bpm

Area of Assessment Technique of Findings Findings

Assessment
Head : Proportionate to Proportionate to
Skull Inspection body’s size body’s size

Skin :
Lesions Inspection None None
Hair Distribution Inspection Equally Distributed Equally Distributed

Nails :
Shape Inspection/Palpation Convex Convex
Condition Inspection Smooth Smooth
Bed Color Inspection Pale Pale
Capillary Refill Palpation Returns in 2 seconds Returns in 2 seconds

Technique of Findings Findings

Area of Assessment
Assessment
Hair Condition : Inspection Equally distributed Equally distributed

Face : Inspection Proportionate toProportionate to body;

body; symmetrical symmetrical

Eyes inspection Located symmetricalLocated symmetrical to

to midline midline
Pale conjuctiva Pale conjuctiva
Ears : Inspection no discharge no discharge

Hearing Acuity Inspection Responds to normalResponds to normal and

and whispered voice
whispered voice

Nose : Inspection No discharge No discharge

Bilaterally Bilaterally
Symmetrical Symmetrical
Mouth
Lips Inspection Slightly pale Pinkish color
Teeth Inspection No DenturesNo Dentures
(upper/lower)
Gums Inspection Slightly pale Slightly pale
Pale Slightly pale
Tongue Inspection Midline Midline
Without lesions Without lesions
Normal
Normal
Throat Inspection Pink without lesions Pink without lesions

Neck : Inspection Normal Normal

Palpation No Enlarged LymphNo Enlarged Lymph
Nodes Nodes

Chest and Lungs:

Breathing Pattern Inspection Regular Regular
Breathing Sound Auscultation Normal Normal

Heart auscultation No murmurs No murmurs

Breast:
Inspection No tenderness,No tenderness, masses,
Palpation masses, nodules ornodules or nipple
nipple

Abdomen:
Skin turgor Ins/Pal Decreased turgor Good skin turgor
Contour/ Symmetry Inspection Symmetric contour Symmetric contour
Muskulo/Skeletal

Upper extremities Palpation / Patient is able toPatient is able to move

Inspection move between bedsbetween beds and able to
and able to go to restgo to rest room with
room with assistance assistance

Lower extremities Inspection Non pitting edema

Non pitting edema
V. ANATOMY AND PHYSIOLOGY

Digestive System

Body cells require a continuous supply of nutrients in order to carry out their vital
functions. Nutrients include carbohydrates, proteins, lipids, vitamins and minerals, and
they come from the food we eat. However most food molecules are too large to pass
directly into the blood, so they must be digested to break them down into absorbable
molecules. Digestion of food and absorption of nutrients are the major functions of the
digestive system.
The digestive system consists of the alimentary canal, a long tube through which food
passes and accessory organs. The major parts of the alimentary canal are the mouth,
pharynx, esophagus, stomach, small intestine, large intestine and anus. The major
accessory organs are the teeth, salivary glands, gallbladder, liver and pancreas,
Digestion involves both chemical and mechanical processes. Mechanical digestion is the
physical breakdown of food into smaller pieces, which provides a greater surface area
for contact with digestive secretions. Chemical digestion is the splitting complex, non
absorbable food molecules into small, absorbable nutrient molecules by the addition of
water – a process known as hydrolysis. Because hydrolysis is normally very slow, it is
the action of digestive enzymes that speeds up digestion and enables the formation of
small, absorbable nutrients within the alimentary canal. A number of different types
VIII. NURSING CARE PLAN

Assessment Planning Intervention Rationale Evaluation

• Short term
Subjective: • Prevent straining by • Supporting the Patient’s condition
‘Masakit po ang aking having a comfortable bra weight of the breasts improved.
dibdib’ >Partially Compensatory • Divert attention from may relieve pain.
pain through activities such as • Diversion of focus on
Objective: • After 2 hours of listening to music and watching something lessens
nursing television. the discomfort.
 Swollen and tender intervention client
breasts will be able to say
 Nipple is dry that the discomfort
of her breast had
Nursing Diagnosis : reduced.

Acute pain related to

production and
accumulation of milk in
breasts.
X. HEALTH TEACHINGS

Medications/Environment/Treatment/Health Teaching/Out-Patient
consultation/Diet/Safety

M • Encourage the patient to drink the recommended amount of water for good
hydration.

E
T • Advise the patient to eat none constipating and gas forming food as they may cause
the abdomen to expand.

H • Advise the patient about the right dosage and right time to take the medicine and
remind her also about proper hygiene that includes proper hand washing. And to
monitor the blood pressure from time to time.

O • Advise the patient to restrain from strenuous activity for fast recovery.

D • Proper positioning to lessen the discomfort.

X. EVALUATION

• I was able to familiarize the various signs and symptoms of Severe Pre-Eclampsia.

• I was able to gather complete nursing history by means of personal interview with the parents

of the Patient and the patient herself.

• I was able to conduct complete physical assessment from head to toe using nursing techniques.

• I was able to identify the nursing procedures in caring for patient suffering from pre-eclampsia.