I.

INTRODUCTION
Acute Gastroenteritis (AGE)
Gastroenteritis 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, although the
influenza virus is not associated with this illness. 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. Adults usually recover without
problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to
complications such as dehydration.
Gastroenteritis arises from ingestion of viruses, certain bacteria, or parasites. Food that has
spoiled may also cause illness. Certain medications and excessive alcohol can irritate the
digestive tract to the point of inducing gastroenteritis. Regardless of the cause, the symptoms of
gastroenteritis include diarrhea, nausea and vomiting, and abdominal pain and cramps. Sufferers
may also experience bloating, low fever, and overall tiredness. Typically, the symptoms last only
two to three days, but some viruses may last up to a week. A usual bout of gastroenteritis
shouldn't require a visit to the doctor. However, medical treatment is essential if symptoms
worsen or if there are complications. Infants, young children, the elderly, and persons with
underlying disease require special attention in this regard. The greatest danger presented by
gastroenteritis is dehydration. The loss of fluids through diarrhea and vomiting can upset the
body's electrolyte balance, leading to potentially life threatening problems such as heart beat
abnormalities (arrhythmia). The risk of dehydration increases as symptoms are prolonged.
Dehydration should be suspected if a dry mouth, increased or excessive thirst, or scanty urination
is experienced. If symptoms do not resolve within a week, an infection or disorder more serious
than gastroenteritis may be involved. Symptoms of great concern include a high fever (102 ° F
[38.9 °C] or above), blood or mucus in the diarrhea, blood in the vomit, and severe abdominal
pain or swelling. These symptoms require prompt medical attention.
Gastroenteritis is a self-limiting illness which will resolve by itself. However, for comfort and
convenience, a person may use over-the-counter medications such as Pepto Bismol to relieve the
symptoms. These medications work by altering the ability of the intestine to move or secrete
spontaneously, absorbing toxins and water, or altering intestinal microflora. Some over-the-
counter medicines use more than one element to treat symptoms.
II. Patient’s Profile
Patient N, is a female, 11/12 months old, residing at 218 Purok 2 Tuburan, Mahayag, Zamboanga
del sur. Her mother Mrs N., works part time in a shop and her father is a construction worker. She
has one sibling older than her, 3 years old. Patient N. was born on July 23, 2018, and born at
Tuburan, Mahayag, ZDS, Filipino in nationality. Their whole family is Born Again in religion.
She weighs 8.7 kg. She’s admitted on June 20, 2019 at pedia ward with chief complaint of high
fever for 2 days with emesis and has a diagnosis of Acute Gastroenteritis. And she was
discharged on June 26, 2010, Saturday at 1:30 pm. Her attending physicians was Wilson
Lumapas M.D.
III. Health History & Chief Complain
Chief Complaint
She was admitted for having high fever for 2 days with vomiting.
Present Illness
Patient N was only admitted to the hospital due to gastrointestinal problem now and was also
suspected of urinary tract infection by Dr. Lumapas. Aside from the diagnosis, no other disease
or complication was seen or diagnosed.
Past Health History
Mrs. N, the mother says “ mao ni first time nya ma-admit after nya ipanganak.” Pt N. gets
seasonal cough and colds at times but never serious because it usually last only for a few days.
They always consult their doctor once sick. She is complete in her vaccinations except those
which would be taken on her 1 year of age.
Family Health History
No one in the family had any respiratory illness or allergies. On her father’s side, almost all have
hypertension. One member of their family died on a heart attack.
IV. Gordon’s Pattern
Health Perception
As Mrs N. stated, “permi man ko mg pa check-up ani nya basta naa xa subaw or hilanat.
Ginabantayan gyod ni nako, lihok lang kaau ni bataa.”
Patient N has a mannerism of sticking anything on her mouth. Whatever she touches she directs it
toward her mouth. Although, she doesn’t practice hand washing every now and then. There are
some medications she takes easily but there are also those medications which is hard for her
because of the taste.
Nutritional-Metabolic
Patient N weighs 8.7 kg. She eats soft foods. She drinks 6-7 bottles of milk in a day. Mrs. N
provides her daughter milk and food in accordance to age and doctor’s advise. She drinks
formula milk. She stop being breastfed when she was 10 ½ moths. She has no allergy.
Elimination
She defecates once or twice a day in her usual days. She changes diaper 3-5 times in a day when
full or had defecated. She was advise to use Lactacid for her perennial wash and calmoseptin
ointment on her diaper rash.
Activity-Exercise
Patient N is a very playful and active girl. She has lots of energy but cries when she doesn’t like
something. She smiles and laughs a lot. Her coordination, gait, balance is not yet stable due to
age. Her daily living activities were provided by her parents. There is no musculoskeletal
impairment. She usually plays after she wakes up in the morning.
Sleep-Rest
She sleeps at 8 P.M. in the evening and usually gets up 7 A.M. – 8 A.M. in the morning. After
playing or eating she takes a nap. She has straight undisturbed sleep at night.
Cognitive Perceptual
Patient N has no sensory deficits. She response well to verbal stimulus by looking at you or
having facial expressions. “Bibo kaau na nga bata, lihok pero dali nimo makuha attention,” as
her mother stated.
Self-Perception
Patient N is not afraid of new people around her. She is friendly and is easy to accommodate.
Sexual-Reproduction
Prior to age, Patient N. is not yet oriented with any sexual matters.
Coping Stress
In her age, she usually cries when something is wrong about her. Simple smile or cry is a sign of
her comfort, distress or feelings. She is familiarized to her family members and long for them
when she doesn’t want the situation like giving of medications or other procedures.
Role-Relationship
She doesn’t know the concept of death yet due to age. Forms words like “dede” and “dada”. She
knows her family members and can easily familiarize the people around her.
Value-Belief
The family is Born Again. They regularly attend church together with all the members of the
family. They don’t usually believe in “hilot”. Once one is sick in the family, they go immediately
to the hospital or for check-up.
V. Head-to-Toe Assessment
General Assessment: Playful and active, neat
Initial Vital Sign: T=36.4°C RR=27 PR=118
Area Assessed Technique Normal Findings Actual Findings Evaluation
Skin Color Inspection Light brown, brown skin Normal
tanned skin
(vary according
to race
Lips, nail beds, Inspection Lighter colored Lighter colored Normal
soles and palms palms, soles, lips palms, soles, lips
and nail beds and nail beds
Normal
Normal
Normal
Normal
VI. Anatomy & Physiology
Digestion is the process by which food is broken down into smaller pieces so that the body can
use them to build and nourish cells and to provide energy. Digestion involves the mixing of food,
its movement through the digestive tract (also known as the alimentary canal), and the chemical
breakdown of larger molecules into smaller molecules. Every piece of food we eat has to be
broken down into smaller nutrients that the body can absorb, which is why it takes hours to fully
digest food. The digestive system is made up of the digestive tract. This consists of a long tube of
organs that runs from the mouth to the anus and includes the esophagus, stomach, small intestine,
and large intestine, together with the liver, gall bladder, and pancreas, which produce important
secretions for digestion that drain into the small intestine. The digestive tract in an adult is about
30 feet long.
Mouth and Salivary Glands Digestion - begins in the mouth, where chemical and mechanical
digestion occurs. Saliva or spit, produced by the salivary glands (located under the tongue and
near the lower jaw), is released into the mouth. Saliva begins to break down the food, moistening
it and making it easier to swallow. A digestive enzyme (called amylase) in the saliva begins to
break down the carbohydrates (starches and sugars). One of the most important functions of the
mouth is chewing. Chewing allows food to be mashed into a soft mass that is easier to swallow
and digest later. Esophagus - Once food is swallowed, it enters the esophagus, a muscular tube
that is about 10 inches long. The esophagus is located between the throat and the stomach.
Muscular wavelike contractions known as peristalsis push the food down through the esophagus
to the stomach. A muscular ring (called the cardiac sphincter) at the end of the esophagus allows
food to enter the stomach, and, then, it squeezes shut to prevent food and fluid from going back
up the esophagus. Stomach - a J-shaped organ that lies between the esophagus and the small
intestine in the upper abdomen. The stomach has 3 main functions: to store the swallowed food
and liquid;
to mix up the food, liquid, and digestive juices produced by the stomach; and to slowly empty its
contents into the small intestine. Small Intestine - Most digestion and absorption of food occurs
in the small intestine. The small intestine is a narrow, twisting tube that occupies most of the
lower abdomen between the stomach and the beginning of the large intestine. It extends about 20
feet in length. The small intestine consists of 3 parts: the duodenum (the C-shaped part), the
jejunum (the coiled midsection), and the ileum (the last section). The small intestine has 2
important functions. First, the digestive process is completed here by enzymes and other
substances made by intestinal cells, the pancreas, and the liver. Glands in the intestine walls
secrete enzymes that breakdown starches and sugars. The pancreas secretes enzymes into the
small intestine that help breakdown carbohydrates, fats, and proteins. The liver produces bile,
which is stored in the gallbladder. Bile helps to make fat molecules (which otherwise are not
soluble in water) soluble, so they can be absorbed by the body. Second, the small intestine
absorbs the nutrients from the digestive process. The inner wall of the small intestine is covered
by millions of tiny fingerlike projections called villi. The villi are covered with even tinier
projections called microvilli. The combination of villi and microvilli increase the surface area of
the small intestine greatly, allowing absorption of nutrients to occur. Undigested material travels
next to the large intestine.
Large intestine - forms an upside down U over the coiled small intestine. It begins at the lower
right-hand side of the body and ends on the lower left-hand side. The large intestine is about 5-6
feet long. It has 3 parts: the cecum, the colon, and the rectum. The cecum is a pouch at the
beginning of the large intestine. This area allows food to pass from the small intestine to the large
intestine. The colon is where fluids and salts are absorbed and extends from the cecum to the
rectum. The last part of the large intestine is the rectum, which is where feces (waste material) is
stored before leaving the body through the anus. The main job of the large intestine is to remove
water and salts (electrolytes) from the undigested material and to form solid waste that can be
excreted. Bacteria in the large intestine help to break down the undigested materials. The
remaining contents of the large intestine are moved toward the rectum, where feces are stored
until they leave the body through the anus as a vowel movement.
VII. Pathophysiology
VIII. Course in the Ward
On day 1, June 25, 2019, at 8:40 am Patient N. is for check up with her attending physician due
to high fever for 2 days associated with vomiting. She was seen and examined by Dr. Lumapas
and was advised to be admitted for further test and treatment due to suspected UTI. She was
diagnosed with Acute Gastroenteritis. An IVF D5 INM 500 ml x 10cc/hr is hooked and CBC was
done. She was brought to pedia ward at around 11:00 am and received by nurse on charge.
Monitoring of input and output was ordered by the doctor with increase fluid intake. Medications
were Paracetamol drops 1 ml every 4 hours for fever. 1 dose was given on admission and
following doses for every 4 hours was given.
On the second day, January 26, 2019, IVF was changed to #2 D5 INM 500 ml x 10cc/hr at 9:50
am. She was seen by Dr. Lumapas at 10:15 am and given an order of urinalysis and fecalysis. She
was prescribed with Omeprazole (Omepron) 5mg IV once a day, 1st dose is given at 8:00 am the
next morning. Also, Zinc Sulfate (E-Zinc) drops (0.6 ml) once daily was ordered. Her fever
decreases gradually unitl there administration of paracetamol every 4 hours for fever was
discontinued. She is being given Ceftriaxone (Xtenda) 750 mg IV once a day side drip every 12
noon. She was playful all through out the day. The laboratoty results was followed up.
On the third day, February 1, 2010, Monday, she was crying when received. She has fever of 37.9
°C and administration of Paracetamol drops 1 ml every 4 hours was resumed. She has been
irritable all day. 10:40 am Dra. Campos, examined S.Q. and was refered to Dr. Zablan due to
decreased results of urinalysis. All laboratory results were seen by Dra. Campos. During the
afternoon, her fever subsides to 37.2 °C . IVF #3 D5 INM 500 ml x 10 cc/hr was hooked at 1:00
pm. All medications were given.
On the fourth day, February 2, 2010, Tueasday, she has no fever, negative vomiting and playful.
Dra. Campos had her round at 4:50 pm and checked S.Q. she ondered continue all medications
and treatment and wait for Dr. Zablan’s assessment. IVF #4 D5 INM 500 ml x 10 cc/hr was
hooked at 11:30 am.
On the fifth day, February 3, 2010, Wednesday, Dr. Zablan had his round at 11:30 am. Findings
were with positive diaper rash, decrease laboratory results and afebrile, no vomiting. He ordered
repeat UA from AM (clear catch), urine culture and sensitivity, use of Lactacid pink for perennial
wash, and apply Calmoseptin ointment to diaper rash 3x a day. IVF #5 INM 500 ml x 10cc/hr
was hooked at 12:15 nn.
On the sixth day, February 4, 2010, Thursday, Dra. Campos ordered continue all medications and
follow order of Dr. Zablan. IVF #6 INM 500 ml x 10cc/hr was hooked at 11:00 am. S.Q. is
received active, playful but cries at times. All medications were given on time. Dr. Zablan saw
laboratory results and advise client to increase fluid intake and replace loses with PLRS. Follow
up urine culture and sensitivity. Repeat
urinalysis and notify him when WBC is 1-3. IVF #7 INM 500 ml x 10cc/hr was hooked at
1:00am.
On the seventh day, June 26, 2019, Friday, Dr Lumapas ordered continue all medications and
treatments. All 8:00 am medications were given. Pt N is taking a bath, playful and laughing when
received. IVF was regulated. IVF was ordered to shift to D5 IMB ½ L x 20 cc/hr. IVF #8 IMB ½
L x 20 cc/hr was hooked at 11:30 am. Dr. Lumapas had his round at 11:45, he checked Pt N. and
the laboratory test. He said all test were now stabilized and normal. He ordered follow up of urine
culture and sensitivity and advised periodic complete emptying of urinary bladder.
On the eighth day, June 27, 2019, Saturday, all findings were on normal range. Pt N is afebrile,
no vomiting, diminished diaper rash, and was active and playful. All morning medications were
given. IVF #9 imb ½ l X 20 cc/hr was hooked at 10:45 am. Dr. Lumapas, advised that they may
go home. Pt N. was discharge at 1:30 pm.