Angeles University Foundation Angeles City College of Nursing

A Case Study of Acute Gastroenteritis at Diosdado P. Macapagal Memorial Hospital

Presented to: Alvin D. Maninang, R.N.

Presented by: Biag, Kayla G. Dizon, Denice T. Gorospe, Eli Gold G. Yumul, Mary Clare C.

BSN II- 2, Group 07

Date Presented: February 12, 2010

I. Introduction Acute gastroenteritis remains a common illness among infants and children throughout the world. It could be more simply called as long, potential lethal stomach flu. The most common symptoms are diarrhea, abdominal pain, vomiting, headache, fever and chills. It 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. Some types of acute gastroenteritis will not resolve without antibiotic treatment, especially when bacteria or exposure to parasites are the cause. In the Philippines, one of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts with ingestion of fecally contaminated food and water. The organism affects the body through direct invasion and by endotoxin being released by the organism. Through these two processes the bowel mucosal lining is stimulated and destroyed then eventually lead to attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the stomach Gastroenteritis). Some forms of acute gastroenteritis mimic appendicitis, which may require emergency treatment. As well, young children run an especially high risk of becoming dehydrated during a long course of the stomach flu. Sometimes children, those with compromised immune systems, and the elderly may require (http://www.scribd.com/doc/12259822/Pa-Tho-Physiology-of-Acute-

hospitalization and intravenous fluids. Dehydration can actually cause greater nausea, and can begin to cause organ shut down if not properly addressed. Even though causes for acute gastroenteritis vary, methods of transmission from one person to another usually remain the same. Generally, contact with the fecal matter of a person with the condition and improper washing or not washing the hands causes acute gastroenteritis to be quite contagious. Proper hand washing for both the ill person and well people in the family is always encouraged. Other methods of transmission of acute gastroenteritis can include eating food or drinking liquids contaminated with bacteria or parasites. Drinking improperly treated water, or drinking from streams and lakes can expose one to giardia, which can leave one ill for many weeks, without treatment (http://www.wisegeek.com/whatis-acute-gastroenteritis.htm). In an article written by David M. Burkhart, M.D, study results suggest that some physicians do not know the current standards for oral rehydration therapy. Even physicians who are familiar with these standards do not necessarily use oral rehydration therapy in their dehydrated pediatric patients. Common management errors include using oral rehydration solutions in children with little or no dehydration, administering intravenous rehydration therapy to children with only moderate dehydration and inappropriately withholding oral rehydration solutions or other feeding in children with vomiting (http://www.aafp.org/afp/991201ap/2555.html). With this statement, oral rehydration fluids must be administered

appropriately depending on what specific kind of fluid to what disease the patient has. These are highly needed in order to maintain hydration and as a route of medications. But giving the wrong one can lead to more complications. Acute gastroenteritis has been the subject of considerable worldwide attention and effort. It becomes one of the most common illnesses that can be seen in the ward these days, particularly in the Pediatric ward. Dehydration is responsible for the morbidity and mortality in children that is why emphasis has been given to the development and promotion of inexpensive, easy-to-use oral rehydration solutions for the

treatment of dehydration, such as home-made oresol. This can be a big help on how parents with little amount of money be able to prove nourishment to their sick child. The group chose the case of Baby Big Tummy, who was admitted with a diagnosis of Acute Gastroenteritis (AGE). She was admitted Last February 06, 2010 with chief complaints of persistent vomiting and LBM. Prior to admission, patient defecated 4 times and vomited 3 times. AGE is one of the most prevalent diseases among children that is why the group want to explore and understand the diseases occurrence, its contributing risk factors, and how it will be prevented. They want to impart their knowledge on how they can help Baby Big Tummy overcome her condition with the use of proper assessment and carrying out the most appropriate interventions for her to achieve a sound overall well-being. In choosing this case, the group will have a chance to be more aware of the cause and effect of the said disease and to educate not just the group themselves, but also other people in order to promote healthy living and lifestyle. A common disease once taken for granted can lead to severe complications. The goal of the group is not just to present what they have learned from lectures, but to put these acquired knowledge into practice in order to be of service to others, to increase awareness, to educate, to prevent, to promote and restore health - a health everyone has a right of achieving. Education and awareness of this disease condition could greatly help prevent the occurrence of the disease or other possible complications, especially to those who are uneducated. Simple health teachings can lead a long way, especially if great precaution is maintained. Preventing what can be prevented means preventing what can lead to be unpreventable. reverse it might turn out to be too late. II. Nursing Assessment It is wise to practice a healthy lifestyle every day. Once disease already happens, trying to

1. Personal Data The group named the patient Baby Big Tummy to protect her identity. She is a 3 years old, naturally born Filipino. She is the first child of Father Big Tummy and Mother Big Tummy. Big Tummy family currently resides at Dila-Dila Sta. Rita, Pampanga. She was born at DPMMH (Diosdado P. Macapagal Memorial Hospital) last February 3, 2007. She is a Roman Catholic. She stands 107cm and weighs 12kg. According to Mother Big Tummy, she was brought to DPMMH last February 6, 2010 at exactly 3:50 pm due to her doctors referral that Baby Big Tummy is already dehydrated and prior to that, she experienced persistent vomiting and LBM. 2. Pertinent Family History Big Tummy Family is a nuclear family, consisting of Father Big Tummy, Mother Big Tummy, and Baby Big Tummy. Baby Big Tummy is the first child. Mother Big Tummys obstetrical history is G1P1 (T1P0A0L1) and delivered via NSD (normal spontaneous delivery). Baby Big Tummys father is working abroad with an occupation of being a contractor while her mother is a full time housewife. Her father is the one who sustains their daily needs. According to Mother Big Tummy, her husband earns around P13, 000-P15, 000 per month.

Expenses Food Rent Allowance Electricity Bill Water Bill Total

Amount P 4,000 P 3,400 P 1 000 P 400 P 300 P9, 100

The Table below shows the breakdown of the familys income in a monthly basis.

According to National Economic Development Authority (NEDA), a family to be considered not poor should have P2768.60 or more to be allotted for each member. With the amount stated above, the family is considered not poor since the familys income, when divided into each member, would be P4, 333.

Genogram

Legend: = Baby Big Tummy = Mother (Sister) = Grandmother = Grandfather

= Father (Brother)

The genogram shows the history of illness in the patients family. It starts from the patient up to the third generation family members. On the paternal side of Big Tummys Family, her grandmother is still alive with an age of 88 but had a stroke. Her grandfather died of an unknown cause at an age of 75 y/o. They have 8 children (5 boys, 3 girls), wherein, Father Big Tummy is the 3rd to last child. On the maternal side, her grandfather is still alive with an age of 61. Her grandmother died of stroke at the age of 78. They have 3 children and all of them are girls. Mother Big Tummy is the middle child among the 3 siblings. When it comes to health, her mother believes in albularyos. In fact, she brought Baby Big Tummy to an albularyo before going to the doctor. It was only when Baby Big Tummy experienced continuous vomiting and LBM that mother decided to bring her to Dr. Bacani.
3. Personal History

As mentioned above, her mothers obstetrical history is G1P1 (T1P0A0L1) via NSD (normal spontaneous delivery) and was born at DPMMH. There were no complications during and after the delivery. She stated that during her first 3 to 5 months of pregnancy, she was going out of the house to visit her sick mother at the hospital. Those times were stressful for her but she made sure that she is still looking out for her baby. She did not experience any complication during her pregnancy. It was around three weeks before her actual delivery that she had a false labor. Despite twhat happened, she still delivered Baby Big Tummy normally and without any complication or abnormalities. Baby Big Tummys Growth and Development

Erikson's stages of psychosocial development as articulated by Erik Erikson explain eight stages through which a healthy developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future _development). (http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial

According to Erik Eriksons Psychosocial Development, Baby Big Tummy is considered to be in Autonomy vs. Shame & Doubt Stage (Toddlers, 2 to 3 years). This was evident when her mom was dressing her up but she wants but she wants to dress up herself. Another instance was when the student nurse is feeding her, she does not like to be fed. She keeps on getting the spoon because she wants to feed herself. She wants her own autonomy or will. The Theory of Cognitive Development is a comprehensive theory about the nature and development of human intelligence first developed by Jean Piaget. It is primarily known as a developmental stage theory, but in fact, it deals with the nature of knowledge itself and how humans come gradually to acquire it, construct it, and use it. Thus, below, there is first a short description of Piaget's views about the nature of intelligence and then a description of the stages through which it develops until maturity (http://en.wikipedia.org/wiki/Theory_of_cognitive_development). According to Jean Piagets Theory of Cognitive Development, Baby Big Tummy is considered to be under Preoperational Stage (3-7 y/o). During the preoperational stage, children become increasingly adept at using symbols, as evidenced by the increase in playing and pretending. This was evident when she told her mom to get her comb and then started playing the role of being a fairy. The concept of psychosexual development, as envisioned by Sigmund Freud at the end of the nineteenth and the beginning of the twentieth century, is a central element in his sexual drive theory, which posits that, from birth, humans have

instinctual sexual appetites (libido) which unfold in a series of stages. Each stage is characterized by the erogenous zone that is the source of the libidinal drive during that stage. These stages are, in order: oral, anal, phallic, latency, and genital (http://en.wikipedia.org/wiki/ Psychosexual_development). According to S. Freuds Theory, Baby Big Tummy is considered to be under anal phase (2-4 y/o). In this phase children needs to be toilet trained. In the case of Baby Big Tummy, she is still using her diaper. When the student nurse asked the mother if she knows how to urinate on the toilet, her mothers response is oo, pero pag gabi dinadiaper ko parin siya. Baby Big Tummy still needs further training. Baby Big Tummys immunization status is complete (1 BCG, 3DPT, 3OPV, 3 HepB, and 1measles) and had them injected at the Barangay Health Center near them. Baby Big Tummy can be classified as a FIC, which means Fully Immunized Child. 4. History Of Past Illness Baby Big Tummy did not have any hospitalizations before, according to her mother. She sometimes only has cough, colds and fever that usually does not require hospitalization. 5. History of Present Illness One day prior to admission, Baby Big Tummy has been continuously vomiting and having LBM. Mother Big Tummy does not recall anything Baby Big Tummy ate that can be the source of her condition. At first, she brought her at an albularyo, but her condition still persisted which made her decide to have her daughter checked up to Dr. Bacani. Dr. Bacani then adviced Mother Big Tummy to have her child be confined due to perceived dehydration. 6. Physical Examination February 8, 2010

Vital Signs: TemperaturePulse RateRespiratory Rate36.9C 99 cpm 28 bpm

Skin
Has a light complexion and has a generally warm skin; presence of rashes

on her perineum was noted; scars were noted on her legs; absence of pallor, cyanosis and jaundice; She has a good skin turgor and with uniform skin temperature. Hair
With long and thin hair, evenly distributed, black in color, with lice infestation.

With no dandruff or lesions. Nails

With untrimmed fingernails and toe nails, epidermis is intact, (+) Blanch

test (<3sec.). Has a normal capillary refill of less than 3 seconds and there is absence of clubbing. Skull and face
Head is normocephalic and symmetrical in shape, her skull is smooth and

uniform in consistency. Her facial features are symmetrical and have a well distributed hair and symmetrical facial movements. There is absence of nodules and masses. Eyes and Vision
Her eyebrows are evenly distributed with intact skin. Eyebrows are

symmetrically aligned with equal movement. Her eyelashes are equally

distributed and curled slightly outward and her eyelids skin is intact with no discharge or discoloration. Her lids close symmetrically. There were absence of tearing and edema. Her cornea is shiny and transparent with details of the iris visible. Pupils are equally round and reactive to light and accommodation. When looking straight ahead, she sees objects in the periphery both eyes, coordinated, move in unison, with parallel alignment. Ears and Hearing
Ears have color same as facial skin with his auricle aligned with the outer

canthus of the eyes. Her ears are mobile, firm and not tender and her pinna recoils after it is folded. There is absence of cerumen. She was able to hear phrase that the student nurses whispered in her both ears. Nose and Sinuses
Nose is symmetrical in shape with nasal septum intact and in midline position.

There is absence of nasal flaring and secretions. Her nose is not tender and air moves freely as she breathes through the nostrils. Mouth and Oropharynx
She has 20 teeth present with presence of dental carries.

Neck
Neck has muscles equal in size with coordinated smooth movement and

absence of discomfort. Her thyroid gland ascends during swallowing. She has non-palpable lymph nodes on her neck. Thorax and Lungs
Her chest skin is intact with symmetrical chest expansion. Chest is

symmetrical in shape with spine vertically aligned and straight spinal column. Heart

Absence of murmurs noted and normal rate and rhythm upon

auscultation. Abdomen
Her abdomen has an unblemished skin with uniform color. She has a bloated

abdominal contour. There is no evident rise and fall of her abdomen during inspiration and expiration. No abnormal findings found palpation. Tymphany was heard during percussion; No pain and tenderness upon auscultation. Extremities
Lower extremities have scars. She was able to perform full range of motion.

Motor function: Gross motor and balance test: good posture, regular gait, free arm movements, walks unaided, negative Rombergs test, can maintain balance on toes and heels Fine Motor Test: can repeatedly touch the nose, performs with coordination rapidly during finger to nose and nurses fingers test, can repeatedly touch each finger by the thumb of the same hand in finger to thumb test Bones and Joints: no deformities, tenderness, swelling noted Mental Status: Language: respond very well and has good speech for her age Orientation: well oriented to person, time, date, and place Memory: can recall information and can concentrate

CRANIAL NERVE

TYPE AND

ASSESSMENT

EXPECTED

ACTUAL

FUNCTION I. Olfactory Sensor y Sense of smell

PROCEDURE Asked Baby Big Tummy to close eyes and to identify different mild aromas such as alcohol and vinegar. Instructed Baby Big Tummy to identify the picture shown to her Assessed six ocular movements and pupil reaction by instructing the patient to follow the pen not using her head. Used penlight to see the reaction of the pupil. Assessed six ocular movements, like what is done at cranial nerve number three.

RESULT She will identify different mild aromas correctly by means of smelling of it. She will identify the picture shown to her

RESULT She identified the mild aromas correctly

II. Optic

Sensor y Vision and visual fields

She was able to identify the picture shown to her She followed the pen easily and correctly. Her pupil performed constrictio n and dilation.

III. Oculomotor

Motor Extraocular eye movement Movement of the sphincter of pupil Movement of ciliarys muscle of lens

She will follow the pen correctly and easily. For pupil, it will perform constriction upon light and dilation when light removed.

IV. Trochlear

Motor Moves downward and laterally

She will be able to do the six ocular movements.

She perfectly performed the six ocular movement s. She blinked after

V. Trigeminal

Sensor While the clients looked Sensat upward, we

We will expect Baby Big Tummy

ion of cornea and skin of face and nasal mucosa

lightly touch the lateral sclera of eye to elicit blink reflex. To test deep sensation, we used alternating blunt and sharp ends of a safety pin over the same area. To test light sensation, we had the client close her eyes and wipe a wisp of cotton over the clients forehead and para-nasal sinuses. Assessed direction of gaze by looking at the side without using head. We instructed the client to smile, raise the eyebrows, frown, puff cheeks and close eyes tightly. Asked client to identify various taste place on tip

to blink her eyes when the cotton is being touched. For skin, she will identify the presence of cotton in her face and also identify if it is sharp or blunt.

cotton touched to her eyes; she felt the cotton; and she also identified if the object is sharp or blunt.

VI. Abducens

Motor Moves eyeball laterally

She will be able to move her eyes symmetrically. She will be able to perform all easily and symmetrically.

She moved her eyes symmetrically. She definitely did all activities

VII. Facial

Motor and sensory

She will identify what is the

She identified all tasted

side of tongue, salt, sour, chocolate candy(sweet) VIII. Auditory Sense of hearing Sensor y Assessed auditory by means of whispering to her. We instructed the client to move her tongue from side to side and up and down.

appropriate food taste for the appropriat specific food. e or correctly. She will identify the whisper words. She correctly repeated the whispered words. She actually did all movement easily.

IX. Glossopharyngeal

Motor and sensory Swallo -wing ability Tongu e movement Motor and sensory Sensation of pharynx and larynx Swallowing vocal cord movement motor head movement shrugg ing of shoulder

She will be able to perform side to side movement and also up and down movement. She will speak clearer and louder and will easily swallow.

X. Vagus

We assessed by instructing the client to open her mouth, speak and swallow.

She spoke clearly and did not have a difficulty in swallowing . She was able to shrugs her shoulder. She turned her head in all movement .

XI. Accessory

We instructed client to shrug against resistance from our hand. And turn head to side against resistance from our hands and instructed the patient to move her head side

She will be able to shrug her shoulder against the resistance given and she will turn her head to all movements

to side and up and down. XII. Hypoglossal motor protrus ion of tongue Asked the client to protrude tongue at midline then move it side to side and up and down. She will do all movements given. She did all movement instructed.

February 9, 2010 Vital Signs: TemperaturePulse RateRespiratory RateSkin

Has a light complexion and has a generally warm skin; presence of rashes

36.7C 100 cpm 24 bpm

on her perineum was noted; scars were noted on her legs; absence of pallor, cyanosis and jaundice; She has a good skin turgor and with uniform skin temperature.

Hair
With long and thin hair, evenly distributed, black in color, with lice infestation.

With no dandruff or lesions. Nails

 With untrimmed fingernails and toe nails, epidermis is intact, (+) Blanch

test (<3sec.). Has a normal capillary refill of less than 3 seconds and there is absence of clubbing. Skull and face Head is normocephalic and symmetrical in shape, her skull is smooth and uniform in consistency. Her facial features are symmetrical and have a well distributed hair and symmetrical facial movements. There is absence of nodules and masses. Eyes and Vision Her eyebrows are evenly distributed with intact skin. Eyebrows are symmetrically aligned with equal movement. Her eyelashes are equally distributed and curled slightly outward and her eyelids skin is intact with no discharge or discoloration. Her lids close symmetrically. There were absence of tearing and edema. Her cornea is shiny and transparent with details of the iris visible. Pupils are equally round and reactive to light and accommodation. When looking straight ahead, she sees objects in the periphery both eyes, coordinated, move in unison, with parallel alignment. Ears and Hearing Ears have color same as facial skin with his auricle aligned with the outer canthus of the eyes. Her ears are mobile, firm and not tender and her pinna recoils after it is folded. There is absence of cerumen. She was able to hear phrase that the student nurses whispered in her both ears. Nose and Sinuses Nose is symmetrical in shape with nasal septum intact and in midline position. There is absence of nasal flaring and secretions. Her nose is not tender and air moves freely as she breathes through the nostrils.

Mouth and Oropharynx

She has 20 teeth present with presence of dental carries.

Neck Neck has muscles equal in size with coordinated smooth movement and absence of discomfort. Her thyroid gland ascends during swallowing. She has non-palpable lymph nodes on her neck. Thorax and Lungs Her chest skin is intact with symmetrical chest expansion. Chest is symmetrical in shape with spine vertically aligned and straight spinal column. Heart Absence of murmurs noted and normal rate and rhythm upon auscultation. Abdomen
Her abdomen has an unblemished skin with uniform color. She has a bloated

abdominal contour. There is no evident rise and fall of her abdomen during inspiration and expiration. No abnormal findings found palpation. Tymphany was heard during percussion; No pain and tenderness upon auscultation. Extremities
Lower extremities have scars. She was able to perform full range of motion.

Motor function: Gross motor and balance test: good posture, regular gait, free arm movements, walks unaided, negative Rombergs test, can maintain balance on toes and heels

Fine Motor Test: can repeatedly touch the nose, performs with coordination rapidly during finger to nose and nurses fingers test, can repeatedly touch each finger by the thumb of the same hand in finger to thumb test Bones and Joints: no deformities, tenderness, swelling noted Mental Status: Language: respond very well and has good speech for her age Orientation: well oriented to person, time, date, and place Memory: can recall information and can concentrate

CRANIAL NERVE I. Olfactory

TYPE AND FUNCTION Sensor y Sense of smell

ASSESSMENT PROCEDURE Asked Baby Big Tummy to close eyes and to identify different mild aromas such as alcohol and vinegar. Instructed Baby Big Tummy to identify the picture shown to her Assessed six ocular movements and pupil reaction by instructing the patient to follow

EXPECTED RESULT She will identify different mild aromas correctly by means of smelling of it. She will identify the picture shown to her

ACTUAL RESULT She identified the mild aromas correctly

II. Optic

Sensor y Vision and visual fields

She was able to identify the picture shown to her She followed the pen easily and correctly. Her pupil performed

III. Oculomotor

Motor Extraocular eye movement Movement of the sphincter

She will follow the pen correctly and easily. For pupil, it will perform constriction

of pupil Movement of ciliarys muscle of lens

the pen not using her head. Used penlight to see the reaction of the pupil. Assessed six ocular movements, like what is done at cranial nerve number three. While the clients looked upward, we lightly touch the lateral sclera of eye to elicit blink reflex. To test deep sensation, we used alternating blunt and sharp ends of a safety pin over the same area. To test light sensation, we had the client close her eyes and wipe a wisp of cotton over the clients forehead and para-nasal sinuses. Assessed

upon light and dilation when light removed.

constrictio n and dilation.

IV. Trochlear

Motor Moves downward and laterally

She will be able to do the six ocular movements.

She perfectly performed the six ocular movement s. She blinked after cotton touched to her eyes; she felt the cotton; and she also identified if the object is sharp or blunt.

V. Trigeminal

Sensor y Sensat ion of cornea and skin of face and nasal mucosa

We will expect Baby Big Tummy to blink her eyes when the cotton is being touched. For skin, she will identify the presence of cotton in her face and also identify if it is sharp or blunt.

VI. Abducens

Motor

She will be

She

 Moves eyeball laterally

direction of gaze by looking at the side without using head. We instructed the client to smile, raise the eyebrows, frown, puff cheeks and close eyes tightly. Asked client to identify various taste place on tip side of tongue, salt, sour, chocolate candy(sweet) Assessed auditory by means of whispering to her. We instructed the client to move her tongue from side to side and up and down.

able to move her eyes symmetrically. She will be able to perform all easily and symmetrically.

moved her eyes symmetrically. She definitely did all activities

VII. Facial

Motor and sensory

She will identify what is the appropriate taste for the specific food. She will identify the whisper words.

She identified all tasted food appropriat e or correctly. She correctly repeated the whispered words. She actually did all movement easily.

VIII. Auditory

Sense of hearing Sensor y

IX. Glossopharyngeal

Motor and sensory Swallo -wing ability Tongu e movement Motor and sensory Sensation of pharynx and larynx

She will be able to perform side to side movement and also up and down movement. She will speak clearer and louder and

X. Vagus

We assessed by instructing the client to open her

She spoke clearly and did not

 Swallowing vocal cord movement XI. Accessory motor head movement shrugg ing of shoulder

mouth, speak and swallow.

will easily swallow.

have a difficulty in swallowing . She was able to shrugs her shoulder. She turned her head in all movement .

We instructed client to shrug against resistance from our hand. And turn head to side against resistance from our hands and instructed the patient to move her head side to side and up and down. Asked the client to protrude tongue at midline then move it side to side and up and down.

She will be able to shrug her shoulder against the resistance given and she will turn her head to all movements

XII. Hypoglossal

motor protrus ion of tongue

She will do all movements given.

She did all movement instructed.

7. Diagnostic and Laboratory Procedures Diagnostic/ Laboratory Procedures Urinalysis Date Ordered / Date Results 1st : DO: 02-06-10 DR: 02-07-10 It is used to Color for 1st : light tract yellow Light amber Indication(s) or Purpose(s) Results (1st and/or 2nd) Normal Values Analysis and Interpretation of Results The color of Big Tummys urine

screen urinary

yellow to Baby

infections, renal 2nd : 2nd : DO: 02-08-10 DR: 02-08-10 (kidney) diseases, organs result in appearance abnormal metabolites (break-down products) in the urine and to determine electrolyte imbalances. Possible connections Baby Tummys condition warrants analysis of urine to detect the of she can This extent infection has. in Big yellow and Transparency that turbid the 2nd : clear of clear

is normal for both tests. In the 1st its slightly result, was

diseases of other 1st : slightly

transparency turbid. It may be caused by precipitation of crystals, mucus, vaginal discharge the or presence and or

of blood cells, yeast, bacteria. While in the 2nd test, its transparency became clear as a result of adherence the medications given to Baby Big Tummy to lessen infection. her to different

also detect what has been altered in Baby Big body Tummys functioning.

Sugar 1st : negative 2nd:negative

negative

A (which

normal is

result of sugar negative) was found on both tests. In the first test, a protein detected, test, albumin minimal of was but no was amount

Albumin 1st : trace 2nd: negative

negative

on the second

detected as a result of Baby Big the medications being given to her to remove pH 1st : 6.5 2nd: 6.0 4.5-8 infection. Baby Big Tummys to adherence

Tummys urine pH is in the normal range for both tests. This indicates normal results for both tests.

Specific Gravity 1st : 1.005 2nd: 1.003

1.0031.030

RBC 1st : 0-1/hpf 2nd : 0-1/hpf Pus cells 1st : 15-20 2nd: 0-1

0-2/hpf

This indicates normal results for both tests. In the first test, the revealed increase result an in

Up to 10

number of pus cells as a sign of After medications to treat Baby Big Tummys condition were, evident decrease cells in was number of pus noted on the Epithelial cells 1st : few 2nd: none few second test. The results are within the normal which indicates normally slough into the urine in small numbers that epithelial cells limits an infection.

Fecalysis

1st : DO: 02-06-10 DR: 02-07-10 2nd : DO: 02-08-10 DR: 02-08-10

It is a diagnostic Color procedure to Big know of analyze done 1st : yellow the on fecal samples 2nd : brown condition of Baby Tummys digestive tract to Consistency presence 1 : semiany formed
st

Golden brown brown

Baby

Big

Tummys color of feces is still within the normal range.

soft, due to the water content formed, it should have a definite shape

On test,

the

first the semi-

consistency was formed. It has been the third day loose to alteration the flora of she is experiencing bowel the of her normal movement due

complication and 2nd: soft bacteria that is causing acute gastroenteritis. her

Bacteria 2nd: +1

Negative (none are found)

stomach. On the first test, moderate amount of bacteria were detected. After medications were administered to remove or treat these, +1

1st: moderate results

bacteria 2nd test. Complete Blood Count DO: 02-06-10 DR: 02-07-10 It information about the cells in a pts blood. It was ordered to Baby Big Tummy to find the cause of symptoms such as fatigue, weakness, fever, bruising, or weight loss ; find an infection; and see if there are too many or too few types This find conditions can of of may certain cells. help other that possibly gives

was

found on the

arise out of the Hemoglobin pts diagnosis. Hgb count is a 126 g/L usual test done as an index of the oxygen carrying capacity of the blood. It is 120-170 g/L The are normal results within limits.

This indicates circulation and oxygen

used to evaluate the hemoglobin of by the content erythrocytes measuring of per

transport normal Baby at risk

are and Big for and

Tummy is not anemia

number of grams hemoglobin deciliter of

polycythemia.

blood. Hematocrit This test is a fast way to determine the percentage of RBC in the plasma. The test is useful in the diagnosis anemia, polycythemia and Leukocyte count abnormal 13.6g/L 5-10x10 g/L hydration states. It is done to determine presence infection. the of of 0.38% 0.370.54% The are normal results within limits.

This indicates a proportional blood volume occupied to by RBC and also assess of hydration

the patient There is an increase Baby Tummys WBC which indicates there presence infection that is of and level in Big

inflammation and

inflammation.

Segmenters

It is used to help diagnose conditions associated acute chronic inflammation, including infections. with and

0.83

0.50-0.70

The result is above normal which with increase leukocyte count sign as a of is the range in the in

conjunction

Lymphocyte

It

produces that

0.17

0.20-0.40

infection. The result is below normal Baby fails produce the limits. Big to

antibodies

bind to pathogen of foreign bodies. It indicates tissue destruction whether inflammatory degenerative. or

Tummys body

enough lymphocytes to bind with leave immune foreign bodies which her system

Platelet count

This is required 686 thous/uL in the number the of determination of platelets present and/or their

150-450

compromised. Baby Big platelet is above normal count the range.

thous/uL Tummys

She is at risk of

ability to function X-Ray the abdomen) DO: 02-09-10 follow correctly. An means producing picture internal structures of the body. This was ordered to Baby Big Tummy to verify collections of fluid in the intestines waist circumference distension (51cm). NURSING RESPONSIBILITIES: 1. Urinalysis BEFORE: Check the doctors order. Explain the purpose of the procedures to the SO. Prepare all the materials needed for the urine collection. since there is evident of X-ray result to of a the

having thrombocytosis Absence of result to follow radiopaque sites normal contour of bones and absence of enlargement organs of and

(flat plate of DR: result to

examination is a follow

Provide a description of test in language the patient can understand. Wash hands prior to urine collection to avoid contamination. Wear gloves.

DURING:

Provide pts privacy and modesty. Collect a fresh urine specimen in a sterile urine container. Clean-catch on midstream will be needed in the procedure. Have the pt begin

to urinate in the bedpan, correctly position a sterile urine container and have the patient to void 1 oz of urine, cover the container and let the patient finish voiding. AFTER: Label the specimen. The collected urine should be delivered to the laboratory at once. Wash hands to prevent contamination and transfer of microorganism. If the collected urine cannot be delivered to the laboratory immediately, Record the procedure done.

refrigerate it.

2. Fecalysis BEFORE: Check the doctors order. Explain the purpose of the procedures to the SO. Prepare all the materials needed for the stool collection. Provide a description fecalysis in language the patient can understand. Wash hands prior to stool collection to avoid contamination. Wear gloves. Provide pts privacy and modesty. Once pt defecated, obtain stool with a scraper or depressor and place it in the specimen bottle. AFTER: Label the specimen. The collected stool should be delivered to the laboratory at once. Wash hands to prevent contamination and transfer of microorganism. Record the procedure done.

DURING:

3. Complete Blood Count BEFORE:

Check the doctors order. Explain the purpose of the procedures to the SO. Tell the SO that the test requires blood sample Tell Baby Big Tummy that she might feel pain and discomfort from the needle Prepare the needed materials. Maintain sterile technique. Handle the sample gently to prevent hemolysis. Be aware that hemolysis is caused by rough handling of the sample and may influence result. Send the sample to the laboratory as soon as possible to avoid stasis and to allow early separation of the serum from the clotted blood.

puncture and in the presence of tourniquet. DURING:

AFTER: Apply pressure to the puncture site to prevent bleeding. Properly dispose the needle in the sharps container (do not break/ recap needles). Immediately label the specimen. Remove gloves and wash hands. Record what has been done.

4. X-ray BEFORE: Check the doctors order. Send a request form to the x-ray section. Explain the purpose and risks of the procedures to the SO. Ready Baby Big Tummy for the procedure.

DURING:

Assist Baby Big Tummy in the x-ray bed. Position her to lie on her back. Ensure she will stay still and not get off the bed during the procedure. Assist pt. out of the bed. Attend to the needs of the pt. while waiting for the result. Document the procedure done.

AFTER:

III. Anatomy and Physiology Gastrointestinal System If a human adults digestive tract were stretched out, it would be 6 to 9 m (20 to 30 ft) long. In humans, digestion begins in the mouth, where both mechanical and chemical digestions occur. The mouth quickly converts food into a soft, moist ass. The muscular tongue pushes the food against the teeth, which cut, chop, and grind the food. Glands in the cheek linings secrete mucus, which lubricates the food, making it easier to chew and swallow. Three pairs of glands empty saliva into the mouth through ducts to moisten the food. Saliva contains the enzyme ptyalin, which begins to hydrolyze (break down) starcha carbohydrate manufactured by green plants. Once food has been reduced to a soft mass, it is ready to be swallowed. The tongue pushes this masscalled a bolusto the back of the mouth and into the pharynx. This cavity between the mouth and windpipe serves as a passageway both for food on its way down the alimentary canal and for air passing into the windpipe. The epiglottis, a flap of cartilage, covers the trachea (windpipe) when a person swallows. This action of the epiglottis prevents choking by directing food from the windpipe and toward the stomach.

The Digestive system http://www.nlm.nih.gov/medlineplus/ency/imagepages/1090.htm

a. Mouth The mouth plays a role in digestion, speech, and breathing. Digestion begins when food enters the mouth. Teeth break down food and the muscular tongue pushes food back toward the pharynx, or throat. Three salivary glandsthe sublingual gland, the submandibular gland, and the parotid glandsecrete enzymes that partially digest food into a soft, moist, round lump. Muscles in the pharynx swallow the food, pushing it into the esophagus, a muscular tube that passes food into the stomach. The epiglottis prevents food from entering the trachea, or windpipe, during swallowing. b. Esophagus It is about 10 inches long and connects the oral cavity with the stomach. It is really a muscular tube which passes by the lungs, heart, and through the diaphragm. Once food has been chewed and mixed with saliva in the mouth, it is

swallowed and passes down the oesophagus. The oesophagus has a stratified squamous epithelial lining (SE) which protects the oesophagus from trauma; the submucosa (SM) secretes mucus from mucous glands (MG) which aid the passage of food down the oesophagus. The lumen of the oesophagus is surrounded by layers of muscle (M)- voluntary in the top third, progressing to involuntary in the bottom third- and food is propelled into the stomach by waves of peristalisis. c. Stomach It is a 'j'-shaped organ, with two openings- the oesophageal and the duodenal- and four regions- the cardia, fundus, body and pylorus. Each region performs different functions; the fundus collects digestive gases, the body secretes pepsinogen and hydrochloric acid, and the pylorus is responsible for mucus, gastrin and pepsinogen secretion.The stomach has five major functions;

Temporary food storage Control the rate at which food enters the duodenum Acid secretion and antibacterial action Fluidisation of stomach contents Preliminary digestion with pepsin, lipases etc.

Small Intestine It is the site where most of the chemical and mechanical digestion is carried out, and where virtually all of the absorption of useful materials is carried out. The whole of the small intestine is lined with an absorptive mucosal type, with certain modifications for each section. The intestine also has a smooth muscle wall with two layers of muscle; rhythmical contractions force products of digestion through the intestine (peristalisis). There are three main sections to the small intestine;

The duodenum forms a 'C' shape around the head of the pancreas. Its

main function is to neutralise the acidic gastric contents (called 'chyme') and to initiate further digestion; Brunner's glands in the submucosa secrete an alkaline mucus which neutralises the chyme and protects the surface of the duodenum.

The jejunum and ileum are the greatly coiled parts of the small

intestine, and together are about 4-6 metres long; the junction between the two sections is not well-defined. The mucosa of these sections is highly folded (the folds are called plicae), increasing the surface area available for absorption dramatically. Pancreas It consists mainly of exocrine glands that secrete enzymes to aid in the digestion of food in the small intestine. The main enzymes produced are lipases, peptidases and amylases for fats, proteins and carbohydrates respectively. These are released into the duodenum via the duodenal ampulla, the same place that bile from the liver drains into. Pancreatic exocrine secretion is hormonally regulated, and the same hormone that encourages secretion (cholesystokinin) also encourages discharge of the gall bladder's store of bile. As bile is essentially an emulsifying agent, it makes fats water soluble and gives the pancreatic enzymes lots of surface area to work on. Structurally, the pancreas has four sections; head, neck, body and tail; the tail stretches back to just in front of the spleen. Large Intestine It removes water from the remainder, passing semi-solid faeces into the rectum to be expelled from the body through the anus. The mucosa (M) is arranged into tightly-packed straight tubular glands (G) which consist of cells specialised for water absorption and mucus-secreting goblet cells to aid the passage of faeces. The large intestine also contains areas of lymphoid tissue (L); these can be found in the ileum too (called Peyer's patches), and they provide local immunological protection of potential weak-spots in the body's defences. As the gut is teeming with bacteria, reinforcement of the standard surface defences seems only sensible. The Digestive Process

The digestive tract -- also called the gastrointestinal tract or alimentary canal -- provides the pathway through which foods move through the body. During this process, foods are broken down into their component nutrients to be available for absorption. Digestion actually begins in the mouth, as the enzymes in saliva begin to break down carbohydrate (starch). As food is chewed, it becomes lubricated, warmer, and easier to swallow and digest. The teeth and mouth works together to convert each bite of food into a bolus that can readily move into the esophagus ("the food pipe"). In the meantime, taste buds located in the mouth help you to enjoy each mouthful -- or to find the food distasteful, as is sometimes the case. After the bolus is swallowed, it enters the esophagus where it continues to be warmed and lubricated as it moves toward the stomach. The acidic environment of the stomach and the action of gastric enzymes convert the bolus into chyme, a liquefied mass that is squirted from the stomach into the small intestine. Carbohydrates tend to leave the stomach rapidly and enter the small intestine; proteins leave the stomach less rapidly; and fats linger there the longest. The small intestine is the principal site of digestion and absorption. There, enzymes and secretions from the pancreas, liver, gallbladder, and the small intestine itself combine to break down nutrients so that they can be absorbed. The pancreas is a veritable enzyme factory, supplying enzymes to digest proteins, fats, and carbohydrates. Intestinal cells also supply some enzymes. The liver produces the bile required for the emulsification of fat, and the gallbladder stores the bile until it is needed. The absorption of nutrients in the small intestine is facilitated by tiny projections called villi, which provide more surface area for absorption. The nutrients pass through the intestinal membranes into the circulatory system, which transports them to body tissues. Nutrients are then absorbed into the cells, where they are used for growth, repair, and the release or storage of energy. The overall process -called metabolism -- is highly complex.

Undigested chyme proceeds from the small intestine into the large intestine (colon), where it becomes concentrated, as liquid is absorbed in preparation for excretion. Bacteria cause fermentation, which facilitates further breakdown, but absorption of nutrients from the large intestine is minimal. The key points to remember about digestion are:

Foods must be broken down into their component nutrients before they can be absorbed. The body does not care whether nutrients it absorbs through the digestive tract come from "natural" or synthetic sources. The body's reaction to absorbed nutrients depends on their chemical structure not the source from which they were obtained.

So-called "health foods" do not contain any nutrients that cannot also be found in a varied and balanced diet of "ordinary" foods. Therefore the concept of "health foods" is meaningless.

IV. The Patients Illness A. Schematic Diagram (Pathophysiology)

(Book Centered)
Non-modifiable Factor: Age Modifiable Factors: Lifestyle; Diet; Hygiene

Etiology: E. Hystolytica, Salmonella, Shigella, Campylobacter jejuni, E. coli, Norovirus, Adenovirus

Person to person (hands)

contaminated food and/or water

Ingestion of Pathogens

Direct invasion of the bowel wall

Endotoxins are released

Stimulation and destruction of mucosal lining of the bowel wall Digestive and absorptive malfunction Secretion of fluid & electrolytes in the intestinal lumen Increased Peristaltic Movement Diarrhea Excessive Gas Formation GI Distention Nausea and Vomiting Fluid & Electrolyte Imbalance Dehydration Dry lips, dry mouth, fatigue, irritability

(Patient Centered)

Non-modifiable Factor: Age

Modifiable Factors: Lifestyle; Diet; Hygiene

Etiology: E. Hystolytica, Salmonella, Shigella, Campylobacter jejuni, E. coli, Norovirus, Adenovirus

Person to person (hands)

contaminated food and/or water

Ingestion of Pathogens

Direct invasion of the bowel wall

Endotoxins are released

Stimulation and destruction of mucosal lining of the bowel wall Digestive and absorptive malfunction Secretion of fluid & electrolytes in the intestinal lumen

irritation of GIT

Abdominal Pain

Excessive Gas Formation GI Distention (increased abdominal circumference of up to 51 cm) Increased Peristaltic Movement

Nausea and Vomiting (manifested by the patient Before admission 02-06-10 and during stay in hospital)

Diarrhea (manifested by the patient Before admission 02-06-10 and during stay in hospital)

Fluid & Electrolyte Imbalance

Dehydration Inflammation of the intestinal mucosa Dry lips, dry mouth, fatigue, irritability inflammatory response

release of chemical mediators formation of mouth sores (Seen upon assessment of the buccal cavity last 02-09-10) fever or hyperthermia (experienced low grade

fever of 38 degrees Last 02-07-10)

B.

Synthesis of the Disease

Definition of the Disease Acute gastroenteritis remains a common illness among infants and children throughout the world. It could be more simply called as long, potential lethal stomach flu. It 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. Some types of acute gastroenteritis will not resolve without antibiotic treatment, especially when bacteria or exposure to parasites are the cause. Gastroenteritis is a nonspecific term for various pathologic states of the gastrointestinal tract. The primary manifestation is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. A universal definition of diarrhea does not exist, although patients seem to have no difficulty defining their own situation. Although most definitions center on the frequency, consistency, and water content of stools, the author prefers defining diarrhea as stools that take the shape of their container. The severity of illness may vary from mild and inconvenient to severe and life threatening. Appropriate management requires extensive history and assessment and appropriate, general supportive treatment that is often etiology specific. Diarrhea associated with nausea and vomiting is referred to as gastroenteritis. Infectious agents usually cause acute gastroenteritis. These agents cause diarrhea by adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production.

These mechanisms result in increased fluid secretion and/or decreased absorption. This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients. Predisposing/ Precipitating Factors The list of risk factors for Acute Gastroenteritis in various sources includes:
Overcrowding Poverty Poor

sanitation International travel

Main Causes of Acute Gastroenteritis are: Viral (50-70%)

o

Norovirus this is the leading cause of viral gastroenteritis. Noroviruses (formerly known as Norwalk virus in the United States and as small round structured virus [SRSV] in the United Kingdom), along with the sapoviruses (formerly known as Sapporo-like viruses), are members of the Caliciviridae family of viruses. The norovirus is a small, nonenveloped, single-stranded RNA virus classified as a Calicivirus. Sapoviruses, a cause of gastroenteritis, predominantly in children, are also in the Caliciviridae family. It is a highly infectious viruswith as few as 10-100 particles necessary for transmissionand is quite resistant to quaternary ammonia compounds, alcohol, detergent-based compounds, freezing, and heat (to 60o C). Rotavirus (This is the leading cause of gastroenteritis in children, but rotavirus can also be found in adults. Rotavirus may cause severe dehydration.) Adenovirus, Parvovirus, Astrovirus, Coronavirus, Pestivirus, Torovirus

 Bacterial (15-20%)
o

Shigella, Salmonella, C jejuni, Yersinia enterocolitica, E coli Enterohemorrhagic enteroinvasive, Clostridium V O157:H7, cholera, enterotoxigenic, B M enteroadherent, C difficile, Aeromonas, cereus,

perfringens,

Listeria,

avium-intracellulare (MAI),

immunocompromised, Providencia, V parahaemolyticus, V vulnificus Parasitic (10-15%)

o

Giardia, Amebiasis, Cryptosporidium, Cyclospora

Food-borne toxigenic diarrhea

o o

Preformed toxin -S aureus, B cereus Postcolonization -V cholera, C perfringens, enterotoxigenic E coli, Aeromonas

Shellfish poisoning and poisoning from other marine animals

o o o o o o

Paralytic shellfish poisoning (PSP) - Saxitoxin Neurologic shellfish poisoning (NSP) - Brevetoxin Diarrheal shellfish poisoning (DSP) - Okadaic acid Amnesic shellfish poisoning - Domoic acid Ciguatera (ciguatoxins) Scombroid (conversion of histidine to histamine)

Drug-associated diarrhea
o o o

Antibiotics, due to alteration of normal flora Laxatives, including magnesium-containing antacids Colchicine, Quinidine, Cholinergics, Sorbitol

Pseudomembranous colitis
o o

Overgrowth of C difficile Positive C difficile assay findings

 Other causes
o o o o o o o

Unknown agents, especially in developing countries Ischemic colitis and Ulcerative colitis Crohn disease Carcinoid tumor or vasoactive intestinal peptide tumor (VIPoma) AIDS Dumping or short bowel syndrome Radiation or chemotherapy

Signs and Symptoms Acute gastroenteritis can be mild to severe. Symptoms of viral gastroenteritis generally resolve within 24-48 hours, but other causes of gastroenteritis can last longer. Gastroenteritis may be experiences and described in a variety of ways that often include the sensation of nausea prior to the onset of vomiting and diarrhea gastroenteritis. Nausea may be described as feelings of wooziness, queasiness, retching, sea-sickness, car-sickness, an upset stomach, and feeling green around the gills. Vomiting can recur multiple times and the may be many bouts of diarrhea. Stool may be very soft to very watery. There may also be abdominal pain, abdominal cramps, fever and weakness. Other symptoms that may accompany gastroenteritis can include bloating, gas and belching, flu-like symptoms, fatigue and bloody stools. Complications of gastroenteritis include dehydration. If untreated, severe dehydration can lead to an electrolyte imbalance and shock. A critical complication of gastroenteritis can also occur if the contents of the stomach flow into the lungs (aspiration) during vomiting. A tear in the esophagus can also occur (Mallory-Weiss tear) due to multiple violent episodes of retching during vomiting.

Bloody stool and vomiting blood can be symptoms of serious, even lifethreatening, conditions. Chronic diarrheal disease is characterized by dysenteric symptoms: foul-smelling, mucus-containing, diarrheic stool with flatulence and abdominal distention. The chronic disease may continue for months and require antibiotic treatment.

V. The Patient and Her Care A. Medical Management A. IVFs Medical Management/ Treatment Date Ordered Date Performed Date Changed/ D/C D5LRS 1L with DO: 02-06-10 1 amp DP: 02-06-10 Benotrex C D5 LRS is a This is given to Hydrated hypertonic solution has osmotic pressure that blood has of replace that loss due to good turgor as skin and General Description Indication(s) or Purpose(s) Clients Response to the Treatment

fluid manifested by

higher persistent vomiting

and moist mucous

than LBM; it is given membranes the to help meet

causing caloric higher and means as a for

cell to shrink. It requirements concentration

of solutes. The administering incorporation of medications; Benotrex C is incorporation

for deficiencies of Benotrex C of components is to replenish especially of Vit the impaired absorption, inadequate nutrition increased utilization during pregnancy, lactation, growth, stress, trauma, alcoholism, infections & convalescence. inadequate nutrition for or presence Baby and the of Big lost B & C due to vitamins due to

infection which Tummy has as detected in her urinalysis.

NURSING RESPONSIBILITY PRIOR:

Check for doctors order for IV therapy. Explain to SO the importance of having an IV fluid line Obtain the necessary materials including the correct type of IV fluid.

DURING:

Sterilize the site to be injected (right hand) with alcohol before administering Select suitable vein for the peripheral venipuncture. Perform peripheral venipuncture. Ensure the patency of the line

the IV fluid

Regulate the IV fluid 30-31gtts/min as ordered Check for redness and inflammation on the intravenous site.

AFTER:

Monitor IV flow and pts response. Monitor pt for evidence of local intravenous complications. Check for the presence of air in the tubing. Label the IV bottle with the following: - Patients name - Date and time started - Time to be consumed - Number of IV

Ensure pts comfort

B. Drugs Baby Big Tummy of Drug Generic Baby Big Tummy Brand Baby Big Tummy bisacodyl rectal suppository (Dulcolax suppository) Date Ordered Date Performed Date Changed DO: 02-06-10 DP: 02-06-10 suppository; A Stat (now) bisacodyl Milk Route of Admin. Dosage & Frequency of Admin. Indication(s) or Purposes Specific Foods Taken Clients Response to the Medication with Actual Side Effect Baby Tummy defacated three thirty after suppository was administered. times minutes the stimulant by the Big

order rectal suppository is a acts irritating laxative which

digestive tract and stimulates

intestinal activity. It is used to treat constipation or to clean out the tract bowel examinations or surgery. The pt has a distended waist circumference (51cm) hard Tymphany was palpated as a sign of air-filled stomach. This can help the pt. the waist circumference and provide eliminate normal thus restoring and time was having a eliminating. bowel intestinal before

Characteristics of the stool watery were

and green.

the pt a feeling ampicillin DO: 02-06-10 DT: 02-06-10 02-07-10 02-08-10 02-09-10 DC: 02-09-10 IV q8 of relief. 500mg Ampicillin is a Adminispenicillin antibiotic. works killing sensitive bacteria formation by of interfering with the bacteria's cell wall while it is growing. This weakens the cell wall and ruptures, resulting in the death of the bacteria. Baby Big has of pus Tummy an cells of turbid based it tered Slight irritation

on was observed administration

It an empty during by stomach

increase level (15-20/hpf), a trace slightly urine albumin, and a

on the result

of her

her

first

U/A. To treat infection, ampicillin was metronidazole Oral (Flagyl) DO: 02-07-10 DT: 02-07-10 02-08-10 DC: 02-08-10 IV DO: 02-08-10 DT: 02-08-10 02-09-10 IV q8 Oral q8 prescribed. 1tsp Metronidazole is amebicide, antibacterial, antibiotic, and an 500mg antiprotozoal DNA synthesis in specific obligate anaerobes, causing cell death. On her first fecalysis, moderate amount bacteria detected. her fecalysis, bacteria+1 and globules+1 were detected. Metronidazole flat of was On Not taken Pt. responsive and alert while administering the drug. No side effects were noted. was drug. It inhibits with food Milk and Pt. failed to

an rice porridge

finish her food and defecated after a while.

second

kills thus

these

bacteria found promoting healing the flora Bacillus clausii DO: 02-07-10 (Erceflora ) DT: 02-07-10 02-08-10 02-09-10 Oral TID and normal of the Baby Tummy cooperated with nurses No and drank the Erceflora. side were noted. effects of Big the return of

body. 1vial Erceflora is an milk antidiarrheal drug used in treatment acute diarrhea w/ duration of 14 days due to infections, or or w/ of drugs chronic persistent diarrhea duration

poisons or for

>14 days. It is a preparation consisting of suspension of Bacillus clausii spores, normal inhabitants of

the with

intestine, no

pathogenic powers. Baby Big had loose day Upon admission, several diagnostic procedures were undergone and revealed paracetamol (Naprex) DO: 02-07-10 DT: 02-07-10 Oral infections. 1tsp Naprex is an Milk alcohol-free Paracetamol preparation. It is safe and in of effective lowering and biscuit and Pt. responded well to Naprex AEB reduction of temperature from 38C to 37C after 2 hours. they Tummy been bowel a before

experiencing movement admission.

q4 x fever

pain relief and fever in infants children.

Paracetamol produces analgesia elevating and body temperature in patients fever increasing heat dissipation. At around 4:00pm, Baby Big Tummys temperature rose to 38C that is why was Baby Big Naprex ranitidine hydrochloride DO: 02-07-10 DT: 02-07-10 02-08-10 02-09-10 IV q8 with by by the

pain threshold lowers

administered. 20mg Ranitidine is in Rice a group of porridge drugs called It by the

Tummy usually cooperatively participates in giving side of effects medication. No were noted.

histamine-2 blockers. works reducing

amount of acid your stomach produces. It

was prescribed Baby Tummy decrease gastric acidity since pt. is and vomiting to Big to

was also put to NPO for 4. This drug was given prevent ulceration the cefuroxime DO: 02-09-10 DT: 02-09-10 IV of gastric Baby negative reaction to the skin test done and was given cefuroxime in of of around 12:00nn. Baby Big Tummy cooperatively participated with treatment. the at Big to

mucosa. 250mg Cefuroxime is Milk drugs called It by

q8 ANST(-) in a group of cephalosporin antibiotics. works fighting bacteria capable kinds bacterial infections, including your body. It is treating many

Tummy had a

severe or lifethreatening forms. Bacani orddered ampicillin to be changed to cefuroxime as a better drug in fighting the infections found in Baby Big Tummys and flat Baby Tummy the was Big cried enema being recent F/A (+1 bacteria +1 Fleet enema DO: 02-09-10 DT: 02-09-10 Dra.

globules). Fleet Enema Adminisis a saline tered without food drawing which bowel laxative. Saline laxatives work by colon a water into the helps produce movement. This provides a soft stool and mass

the whole time

administered. About 20mins later, defecated she a

lot. Her waist circumference also decreased from 51cm to

increased bowel A should action. bowel be

48cm.

movement stimulated in 1 to 5 minutes, without pain or spasm. Big had prominent waist circumference distension her the of 51cm. To help evacuate toxic in was Baby Tummy a

substance enema

her body, fleet prescribed. NURSING RESPONSIBILITIES: 1. bisacodyl rectal suppository (Dulcolax suppository) PRIOR: Check the doctors order Explain the action of the drug Prepare the drug and the materials needed

DURING: After: Inspect the anus once in a while for any signs of inflammation Provide privacy Unwrap suppository and moisten it slightly in warm water Assist Baby Big Tummy lie on her left side with the right knee slightly bent Insert the suppository into the rectum with the pinkie finger Guide pt to lie still for about 10 min for the drug to take effect properly

2. ampicillin PRIOR: Check the doctors order Perform negative skin test before administering it Explain the action of the drug Before initiating therapy, obtain a history to determine previous use of and reactions to penicillin or cephalosporin. Person with (+) history sensitivity may still have an allergic response. Recompute the drug formula

DURING: Clean the IV port with an alcohol before injecting the medication Inspect for the patency of the needle Check for any resistance Push the IV medications slowly as possible.

AFTER: Observe for any discomfort in the IV insertion site

Observe for any signs of adverse effect Advise the SO to report any signs of super infection and allergy noted on pt

3. metronidazole (Flagyl) PRIOR: Check and determine the prescribed the drug Prepare the drug

Inform the SO about the prescribed the drug Explain the procedure, purpose, indication and side effects of the drug Give food when administering oral metronidazole to increase bioavailability of the drug

DURING: AFTER: Observe for any discomfort Tell the SO to immediately report any signs of adverse effect Document all the findings that observed from the pt Sterilize the IV port with alcohol before administration Inspect for the patency of the needle Regulate it fast drip to run for 30 mins

4. Bacillus clausii (Erceflora )

PRIOR: Check and determine the prescribed the drug Inform the SO about the prescribed the drug Explain the procedure, purpose, indication and side effects of the drug

DURING:

Open the vial carefully Assist Baby Big Tummy in drinking the medicine

AFTER: Observe for any adverse reaction to the drug Allow pt to drink water to mask out the taste of the medicine Document any findings

5. paracetamol (Naprex) PRIOR: DURING: Assist Baby Big Tummy in drinking the medication Check and confirm the order, dosage, frequently and route for the said drug. Check the drug indication and computation Inform the patient of the drug and its purpose and action Obtain vital signs especially temperature to check for fever Prepare the drug

AFTER: Allow pt to drink water to mask out the taste of the medicine Observe for any adverse reaction to the drug Document any findings

Monitor the vital signs especially the temperature to note progress

6. ranitidine hydrochloride BEFORE: Check the doctors order Explain the action of the drug Recompute the drug formula Educate SO of the possible side effects and complications that can arise

DURING: Clean the IV port with an alcohol before injecting the medication Inspect for the patency of the needle Check for any resistance Push the IV medications slowly as possible.

AFTER: Observe for any discomfort Tell the SO to immediately report any signs of adverse effect Document all the findings that observed from the pt

7. cefuroxime BEFORE: Check and determine the prescribed the drug Perform negative skin test before administering it Prepare the drug and the materials

Inform the patient about the prescribed the drug Explain the procedure, purpose, indication and side effects of the drug

DURING: Clean the IV port with an alcohol before injecting the medication Inspect for the patency of the needle Check for any resistance Push the IV medications slowly as possible.

AFTER: Observe for any adverse reaction to the drug as this can cause severe diarrhea, difficulty of breathing, and unusual tiredness or fatigue Document any findings Ensure Baby Big Tummys comfort

8. Fleet Enema BEFORE: Check the doctors order Explain the action of the enema Prepare the drug and the materials needed Educate SO of its indications and effect Obtain waist circumference as a baseline data Ensure privacy Apply KY Jelly as a lubricant Insert enema on Baby Big Tummys anus Squeeze the bottle thoroughly Keep the buttocks tight for at least 5 min to ensure the effect of the drug

DURING:

AFTER: Inspect the anus once in a while for any signs of inflammation Note for pts bowel movement Observe for any adverse effects Obtain the waist circumference after pt successfully passed out stools to monitor progress d. Diet Type Of Diet Date Ordered Date Started Date NPO 4 Changed for DO:02-06-10 DS:02-06-10 DC:02-06-10 NPO for Per which nothing mouth. Doctors stands A Nothing stomach, Orem could lead means to vomiting, by especially if Baby use Tummys Big full No taken food Baby Tummy complied with the diet. She did not vomit as was admitted. frequent as before she Big General Description Indications or Purposes Specific Foods Taken Clients Response to the Diet

this on orders condition is when they do considered. not want the She might patient to take be at risk of in any type of aspirating food or liquid her vomitus by mouth and directly if lead to her Also especially

taking in food lungs. can aggravate another

the condition.

pts factor is that since stomach not functioning well, that everything she intakes, she will just vomit it. patient Tolerated take food by ingested the tendency is her is

DAT

DO:02-06-10 DS:02-06-10

The can

Cookies, rice, vegetables, fruits, etc

Baby able tolerate diet. rose diet. as

Big to the No an

bread, milk, Tummy was

anything

mouth as long provides as foods taken nutritional can tolerated the patient. NURSING RESPONSIBILITIES BEFORE: Check and determined the prescribed diet.

be value to the by patient according to body needs.

complications effect of this

Explain the reason to the SO why such diet is needed Explain to the SO to position pt properly to a semi-fowler position during feeding to prevent aspiration Observe any signs of intolerance and difficulty of feeding Instruct the parents to limit liquid foods before meals

 DURING: AFTER:

Explain to parents the regularity of meal times of patient must be done on her age Assist pt in eating Observe for initial response.

Inform SO if diet would be changed Observe and monitor for any adverse effects

D. Activity/Exercise Type of Exercise Date Ordered Date Started Date Normal ADLs, regular exercise with Changed n/a Patient perform normal activities daily and exercise can Help General Description Indications or Purposes Clients Response to the Activity/ Exercise patient Baby / Tummy able tone perform Big was to

her maintain increase of muscle

living and strength regular regular and enhance morning is sense of well- exercises being. Encourage more without undue fatigue. without undue She

encouraged.

patient to be fatigue.

active was also able to play with SO well. every time she feels

NURSING RESPONSIBILITIES: BEFORE:

Instructed SO about the different activities and how she can help Baby Big Explain importance of activity to enhance compliance. Emphasized to SO the importance of each activity and how they can improve

Tummy perform them.

pts condition

DURING:

Assist patient in doing the activity. Provide an environment conducive for rest Provide comfort measures such as touch therapy and arrangement of bed Provide safety measures such as placing a pillow beside the patient to Provide a calm and quiet environment

linens

prevent fall accidents

AFTER:

Assess clients response to activity / exercise

B. NURSING MANAGEMENT 1. Nursing Care Plans

2. Actual SOAPIERs

February 06, 2010 I= Admitted 3y/o, F, child accompanied by her mother with chief complaint of LBM & Vomiting Referred by Dr. Bacani with orders made & carried out Consent for admission signed Inserted a clysis CBS with APC requested U/A & S/E instructed Admission care rendered Endorse to ward -------------------------------------------------------------------------Christine Joy Valencia--------4:30 pm I= is from ER with D5LRS 1l @ 950 cc level Notified Dr. Bacani

 (-) vomiting, (+) soft BM VS taken Meds prescribed Endorse

6:15 pm I= see and examined by Dr. Bacani with no orders made CBC result referred to Dr. Bacani with no orders made ---------------------------------------------------------------------------Mary Joyce Pangilnan--------

>amino acid 1 amp incorporated to present IVF after (-) ANST --------------------------------------------------------------------------------------Camille Peng--------

February 06-07, 2010 11-7 I= received pt. on bed with ongoing IVF of D5 LRS 1L + 1amp amino acid @700 cc level no signs of dyspnea no episode of vomiting no episode of LBM no compliant of abdominal pain

 afebrile V/S taken & recorded Attended -------------------------------------------------------------------------------------Carreon, Juliet-------February 07, 2010 7-3 I= received pt o bed with ongoing IVF of D5 LRS 1L + 1amp amino acid @400 cc level with watery stool no episodes of vomit afebrile still for U/A & Fecalysis-instructed VS taken and recorded Attended ------------------------------------------------------------------------------------lic # 0525753---------2:20 pm I= Fecalysis result reffered to Dr. Bacani thru text with no reply yet

3-11 I= on bed with an IVF of D5 LRS 1L + 1amp amino acid @300cc level

 with soft stool no episode of vomit VS taken U/A instructed TSB instructed, febrile Attended --------------------------------------------------------------------------------- Danica Rose Yap------7pm I= U/A result referred to Dr. Bacani thru text, no reply yet --------------------------------------------------------------------------------- Danica Rose Yap------7:45pm I= positive abdominal distention referred to Dr. Bacani thru txt with new orders and carried out ----------------------------------------------------------------------------------Danica Rose Yap------9:45pm I= Seen and examined by Dr. Bacani with orders made and carried out ------------------------------------------------------------------------------------Loving Almario-------February 08, 2010 11-17 I= on bed with ongoing IVF of D5LRS1L + 1 amp of amino acid @ 90cc level

 (-) vomiting Negative abdominal distention noted Diet instructed VS taken Attended ------------------------------------------------------------------------------------------------Ryan--------1:15am I= above IVF consumed D5LRS 1L on Follow up

2:20am I=
incorporated to present IVF ANST (-)

7-3 I= seen pt lying on bed conscious with ongoing IVF of D5LRS1L + benotex C 1amp infusing well on right hand currently @900cc level no abdominal distention noted(abdominal girth) no vomiting episodes noted with soft greenish stool afebrile fecalysis for follow up result U/A instructed

 VS taken & recorded Needs attended -------------------------------------------------------------------------------------Pasinag, Direk-------7-3 S=nagsimula yan nung lang nagtae siya O= received pt. lying on bed, awake, conscious & coherent, with an IVF of #2 D5LRS1L + 1amp of benotrex C @ 950 cc level X 30-31 ugtts/min, infusing well over the right hand, with VS taken & recorded as follows: T:36C, PR: 86 bpm, RR: 23 cpm: with good skin turgor, generally warm skin, defecated twice during the shift(greenish mucoid stool), with rashes on the perineum, waist circumference of 51cm initially, tymphany noted on the stomach upon palpation. A= impaired skin integrity r/t moisture from feces in diapers AEB rashes on perineum P=after 30 mins. of NI, the SO will participate in prevention measure & treatment program such as ointment I= established rapport VS taken & recorded Regulated IVF Provided AM care Helped mother bathe the pt. Encouraged BRAT diet Helped SO changed diapers Obtained specimen for fecalysis Measured waist circumference Encouraged frequent diaper change to prevent further rashes Enhanced the importance of proper cleansing of the perineum

8:00am seen & examined by Dr. Bacani, with orders made and carried out start metronidazole 500mg IV q8 ANST/ give as side drip as ordered for U/A /done /follow-up result for fecalysis /done /follow-up result hold triconex/done for fleet enema/ prescribe administered metronidazole IV 500 mg through micro set fast drip
administered ampicillin 500 mg IV as ordered

E= Goal met AEB SO participated in prevention measure & treatment program such as ointment ------------------------------------------------------------------Mary Clare C. Yumul-------------3-11 S=ayoko na eh, tapus na eh as verbalized by the pt when feeding O= received pt.on sitting position, conscious & coherent with an IVF of # 2 D5LRS1L +1amp benotex C X 30-31ugtts/min, observed with lack of interest with food: aversion to eating, 12 kg, with semi-solid stool, with VS taken & recorded as follow: T: 36.9C,PR:99bpm,RR:28cpm A= imbalanced nutrition less than body requirement r/t aversion to eating P= after 4 of NI, the SO will verbalize understanding of necessary intervention for adequate nutrition I=
established rapport

monitored VS determined ability to swallow

 discussed eating habit assessed weight noted characteristic of stool evaluated food intake encouraged SO to provide several small feeding meals encouraged use of sugar beverages encouraged pt to choose food emphasize importance of well balanced diet E=goal met AEB SO will verbalization understanding of necessary intervention for adequate nutrition --------------------------------------------------------------------------------------Yestin Recces------02/09/10 11-7 I= with D5LRS + BC @600cc level (-) abdominal pain (-) fever, (+) LBM (-) vomiting

7-3 S=nagsimula yan nung lang nagtae siya O= received pt. lying on bed sleeping, with an IVF of #2 D5LRS1L + 1amp of benotrex C @ 400 cc level X 30-31 ugtts/min, infusing well over the right hand, with VS taken & recorded as follows: T:36.5C, PR: 68 bpm, RR: 24cpm: with good skin turgor, generally warm skin, defecated 4x during the shift(yellow loose stool), with

rashes on the perineum, waist circumference of 51cm initially, tymphany noted on the stomach upon palpation. A= impaired skin integrity r/t moisture from feces in diapers AEB rashes on perineum P=after 30 mins. of NI, the SO will participate in prevention measure & treatment program such as ointment I= VS taken & recorded Regulated IVF Provided AM care 8:00am : seen & examined by Dr. Bacani, with orders made and carried out
change ampicillin to cefuroxime 250mg q8 IV ANST/ done as ordered

flat plate of abdomen/done/result to follow fleet enema done administered 11:00 am> iv set infiltrated: in canulla 24 removed completely 12:00noon> reinserted IVF on left hand Endorsed to staff nurse E= Goal met AEB SO participated in prevention measure & treatment program such as ointment -----------------------------------------------------------------------------Mary Clare Yumul-----------

VI. Clients Daily Progress in the Hospital

1. Clients Daily Progress Chart

DAYS NURSING PROBLEMS 1. 2. 3. 4. Diarrhea Impaired Skin Integrity Hyperthermia Impaired Dentition

ADMISSION

Feb. 7

Feb. 8

Feb. 9

X X

X X X

X X

X X

1. Risk For Imbalanced Nutrition: Less Than Body Requirements VITAL SIGNS Temperature Pulse Rate Respiratory Rate DIAGNOSTICS/ LAB PROCEDURES Urinalysis Fecalysis CBC (complete blood count) X-Ray (Flat Plate) MEDICAL MANAGEMENT D5LRS 1L with 1 amp Benotrex C D5LRS DRUGS bisacodyl rectal suppository (Dulcolax suppository) ampicillin metronidazole (Flagyl) Bacillus clausii (Erceflora ) paracetamol (Naprex) ranitidine hydrochloride cefuroxime Fleet enema DIET X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 3:50 pm 37C 121 bpm 32 cpm X 12:00 nn 38C 106 bpm 30 cpm X 4:00 pm 36.9C 99 bpm 28 cpm X 12:00 nn 36.7C 100 bpm 24 cpm

2. Discharge Planning Baby Big Tummy does not yet have any orders for discharge from the doctor during the last day of nurse-patient interaction. (Discharge planning aims to ensure the continuity of care of the patient and it involves patients` relatives and family members.)

VII. Conclusion and Recommendation Conclusion While it is true that acute gastroenteritis remain a common illness among infants and children, this does not mean that we will be reluctant in treating and managing this disease. Acute gastroenteritis can be fatal if not given much attention due to its complication, especially dehydration. The article by DR. Barkhart suggests that even physicians tend to treat their patient inappropriately especially those with degree of dehydration. And these issues must be taken in serious consideration. And so by this Case study, our group was able to understand AGE in a broader perspective. All its process, manifestation, complication and management were understood. Preventive measures are still the best option in dealing with AGE. Proper sanitation, along with good proper hygiene must be carried out properly in order to decrease the incidence of AGE. Prevention is better than cure. The group as a future nurses, realizes that great responsibility regarding health, illnesses and disease. It is very important to know what interventions could be applied to appropriate situations in order to aid our patient. We should carry out the right plan of care while avoiding mistakes that will harm our clients. Being a nurse is being just and careful to all her patients and actions. We are dealing with lives and not object so we should take care of our patients. Recommendations The student nurses recommend this case study to the following:

 To the Government, especially to the DOH, that they may perform their duty appropriately by promoting the health and well-being of the people. They should implement programs such as mothers class and health teachings from responsible and knowledgeable DOH personnel that would educate the people regarding the preventive measures they may do and the signs and symptoms they must take note in order to decrease the prevalence of the disease and to address acute gastroenteritis;

To the parents and children, that they may be informed about this disease of childhood and that they may cooperate with the, government, the DOH and other health care providers in solving the problem regarding the increasing rate of acute gastroenteritis in the country;

To the health care providers, that they may render quality care appropriate to the prevention, treatment and cure of diseases, rehabilitation and recovery of those inflicted with diseases and most especially the promotion of health despite challenges and difficulties they may encounter.

To the valued university, whom the student nurses dedicate this study, that they may protect those who are under their care and that they may do measures for the casualties not to increase;

To the respected clinical instructors, that they may effectively instill the knowledge that is important, the skills that are necessary, and the attitude that must be developed in order to carry out appropriate care and alleviate those who are ill; and

 To other student nurses, that they may give proper care for their patients

wholeheartedly and sincerely, regardless of the monetary value that they may experience.

VII. BIBLIOGRAPHY Book Sources: Berman, A. Erb, G. Kozier, B. Berman, A. (2007). Koziers and Erbs Fundamentals of Nursing 8th Edition, Volume 1. Philippine: Pearson Education Southeast Asia Pte. Ltd. (Philippine Representative Office). Doenges, M. Moorhouse, M. Murr, A. (2008). Nurses Pocket Guide Edition 11. Philadelphia, Pennsylvania: F.A. Davis Company. Pagana, K. D. Pagana, T. J. (2007). Mosbys Diagnostic and Laboratory Test Reference 8th Edition. Singapore: Elsevier Pte. Ltd. Pillitteri, A. (2007). Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family 5th Edition, Volume 1. New York: Lippincott Williams and Wilkins. Seeley, R. Stephens, S. Tate, P. (2007). Essentials of Anatomy and Physiology Sixth Edition. New York: McGraw-Hill Company, Inc. Weber, J. (2008). Nurses Handbook of Health Assessment Sixth Edition. New York: Lippincott Williams and Wilkins. Internet Sources: http://co-ph.com/~Pediatrica/products.html http://emedicine.medscape.com/article/775277-overview http://emedicine.medscape.com/article/801012-overview http://emedicine.medscape.com/article/801948-overview

http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development http://en.wikipedia.org/wiki/Psychosexual_development http://en.wikipedia.org/wiki/Theory_of_cognitive_development http://mims.com/Page.aspx? menuid=mng&name=Erceflora+oral+soln&h=erceflora&CTRY=PH&searchstring=erc eflora http://mims.com/Page.aspx? menuid=mng&name=Erceflora+oral+soln&CTRY=PH&brief=false#SideEffects http://pathcuric1.swmed.edu/PathDemo/nrrt.htm http://www.aafp.org/afp/991201ap/2555.html http://www.drugs.com/mtm/cefuroxime.html http://www.drugs.com/ranitidine.html http://www.fleetlabs.com/fleet_enema_products.php?panel=0 http://www.labtestsonline.org/understanding/analytes/platelet/test.html http://www.medicinenet.com/bisacodyl-rectal_suppository/article.htm http://www.nlm.nih.gov/medlineplus/ency/imagepages/1090.htm http://www.nutriwatch.org/01Basics/digestion.html http://www.scribd.com/doc/12259822/Pa-Tho-Physiology-of-Acute-Gastroenteritis http://www.webmd.com/a-to-z-guides/complete-blood-count-cbc?page=2 http://www.wisegeek.com/what-is-acute-gastroenteritis.htm http://www.wrongdiagnosis.com/g/gastroenteritis/symptoms.htm http://www.uk-sh.co.uk/download/1/RADIOLOGY_Xrayexamination_leaflet.pdf