Holy Angel University College of Nursing Angeles City

A Case Study of a patient with ACUTE GASTROENTERITIS (AGE) with Dehydration

In partial fulfilment of the course requirements in NCM RLE

Prepared by: Group 3 CON II-202

Bayudan, Donnalyn Bie, Maica David, Robert Go, Sheila Gutierrez, Jan Mikeal Ledda, Ruia Karl Mesina, Joebil Pradilla, Angelica Sicat, Kathleen Waje, Celine Yumul, Ma. Lourdes Submitted to: Ms. Myra Ingrid C. Santos RN, MAN Clinical Instructor

17 January 2011 1

I.

INTRODUCTION Gastroenteritis (also known as gastro, gastric flu, tummy bug in some countries, and

stomach flu, although unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine (see also gastritis and enteritis) and resulting in acute diarrhea. The inflammation is caused most often by an infection from certain viruses or less often by bacteria, their toxins, parasites, or an adverse reaction to something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year, and is a leading cause of death among infants and children under 5. At least 50% of cases of gastroenteritis due to foodborne illness are caused by norovirus..Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus. In the Philippines, 527,000 children aged <5 years die from rotavirus diarrhea each year, while 2,235 others remain hospitalized due to an outbreak of acute gastroenteritis (AGE) in at least four villages in the province of Misamis Oriental last 2008 and the number of cases of acute gastroenteritis in Pangasinan has gone up to 6,350, reports from a joint surveillance team of regional Department of Health and the Provincial Health Office showed. (Source: Inquirer.net 20 November 2008). Currently, theres a study about a drug that reduces vomiting in Children with Gastroenteritis, study finds from Science Daily dated September 3, 2008 University of North Carolina at Chapel Hill researchers have demonstrated that a drug called ondansetron helps reduce vomiting, the need for intravenous fluids and hospital admissions in children with acute gastroenteritis. Persistent vomiting from acute gastroenteritis can be very frightening to children and their families and also poses a risk of dehydration. Current practice guidelines do not recommend

that doctors give medications to children with gastroenteritis, but several recent studies suggest that ondansetron might be helpful. In addition, Steiner said, many doctors are already prescribing ondansetron off-label for children with gastroenteritis. It has not been approved by the Food and Drug Administration for that indication, although it is approved for treating nausea caused by chemotherapy in cancer patients. To find out if there was valid scientific support for giving antiemetics to children with gastroenteritis, DeCamp, Steiner and two UNC colleagues -- Dr. Julie S. Byerly, assistant professor of pediatrics, and medical student Nipa Doshi -- conducted a systematic review of all the medical literature studying the use of antiemetics for gastroenteritis. The authors found that antiemetics other than ondansetron should not be used in children with gastroenteritis. The group believes that rendering quality nursing care is very vital to the wellness of our client. And as a health care provider we need to focus on the care of our patients. We choose this case study for the following reasons; first, is the availability of the case on our four weeks rotation in Bulaon District Hospital. Second, this will help the group to broaden their knowledge in the said disease. As well as to be able to provide health teachings that is appropriate in the said disease. The group also wants to know the process of this disease as well as the signs and symptoms that will manifest in the patient. To know as well what are the appropriate nursing intervention needed by the patient. With our skills and knowledge the group will be able to give health teachings about the factors that contribute to the disease, as well as on how to avoid acquiring the disease.

II. OBJECTIVES Short Term: Student Nurse-centered; General Objective: After the completion of the case study, the student nurse-researchers shall have: A deeper understanding of the development of Acute Gastroenteritis with some Dehydration ruled out Pneumonia in relation to the signs and symptoms presented by the patient and are able to discuss the proper management, treatment to provide better nursing care and preventive health teachings through the utilization of the nursing process. Specific Objectives: After the completion of the case study, the student Nurse- researchers shall: Define the disease process Identify the modifiable and non-modifiable risk factors presented by the patient that have contributed to the development of Acute Gastroenteritis with some Dehydration ruled out Pneumonia Identify the clinical signs and symptoms presented by the patient which resulted from the disease process. Discuss the disease process treatment and management. 4

 Analyze and understood the results of each diagnostic test performed and relate these findings on the developmental process of Acute Gastroenteritis with some Dehydration ruled out Pneumonia Develop critical thinking skills for providing safe and effective nursing care in the management of the disease. Familiarize ourselves with effective inter-personal skills to emphasize help promotion and illness prevention. Short term: Patient-centered General Objective: To enable the significant other of the patient to be cooperative in every intervention that may help in the improvement of the health of the patient, and for the significant other to be knowledgeable about the present condition. Specific Objectives: At the end of the study, the significant other of the patient should: Establish a trusting relationship with the student nurse. Widen their knowledge about the disease to correct misconceptions. Demonstrate strict compliance on the treatment regimen.

II. NURSING HISTORY A. DEMOGRAPHIC DATA Marilou, daughter of Mommy Roberta and Daddy Karlo, is a 8 years old female, Roman Catholic and currently living in a certain barangay in San Fernando, Pampanga. She was born on July 9, 2002 in San Fernando, Pampanga via Normal spontaneous delivery and is a full-blooded Filipino. She is the 2nd eldest in 5 siblings.

Their housing structure is made up of light wood and concrete and is in fair condition as verbalized by Mommy Roberta. The house has two rooms and their source of water (including drinking water) is through pitcher pump. They get their food from the market or nearby store and their method of excreta disposal is through pail system. In terms of health seeking behaviors, they would rather prefer going to herbolarios then to doctors, or at public hospitals due to their socio-economic status.

She was admitted in a secondary hospital in Bulaon on Janunary 3, 2011 at 9:30 a.m. with the chief complaint of vomiting. The information that was provided regarding Marilous personal history was stated by Mommy Roberta. B. SOCIO-ECONOMIC AND CULTURAL FACTORS Daddy Karlo is a Garbage Truck Driver and earning 1500php a week; and he works 5 days in a week. The head of the familys income is not enough for their food allowances and some other important expenses Both parents are high school graduates. The eldest is 10 years old, an elementary student while the two are not yet studying. And Marilou is a Grade 2 elementary student. Marilou is a Roman Catholic but Mommy Roberto verbalized that they are not a fully devoted Catholic. They seldom go to the mass every Sunday but they still never forget to pray. Her mother verbalized that Marilou is fond of eating junk foods/chips and softdrinks. . According to Mommy Roberta, whenever Marilou has money he always tend to buy junkfoods. Her mother always prepares baon for Marilou everytime she goes to school and she also gives her 10php money Mommy Roberta, as the decision maker in the family in terms of health, believes in herbolarios and in superstitious beliefs like the concept of usog, nuno and the like. She verbalized that in seeking health advice, she first consults in herbolarios and hilots then second to it is the public hospital when someone in their family is sick. 3. HISTORY OF PAST ILLNESS According to Mommy Roberta, Marilou also had chickenpox and measles during his childhood years but she doesnt remember anymore the age when her daughter had it and the treatment done to resolve it. Mommy Roberta stated also that Marilou had a cyst when she was 5 years old and it was operated last July 2009 in a hospital in Magalang. She also has no known allergy to any food or drug and there is no history of hospitalization.

4. HISTORY OF PRESENT ILLNESS Two (2) days prior to admission, she experienced decrease in appetite, vomiting and passage of loose watery stool. These continued until one (1) day prior to admission. Because of this, Mommy Roberta decided to bring Marilou in the hospital for appropriate treatment. Hence, admitted in a secondary hospital in on January 03, 2011 at 9:30 am with the chief complaint of vomiting. He was confined for 2 days and was discharged on January 05, 2011.

III.PHYSICAL ASSESSMENT ( CEPHALOCAUDAL AND FOCUSED ASSESSMENT) Nurse and Patient Interaction (January 3, 2011) General Survey: On the first day of interaction, the student nurse received the patient lying on bed, conscious and unresponsive during the assessment and with short attention. She is complaining of pain in the abdomen located at the right lower quadrant. Upon interaction,the patient was uncooperative and has blank look on face.

Vital signs are as follows: 8

RR: 27 PR: 75 T: 37.1 CEPHALOCAUDAL ASSESSMENT Skin: pallor, no jaundice, poor skin turgor Head: normal shape and contour, with no lumps, no tenderness noted upon palpation Hair: brittle, with lice Eyes: (not checked due to clients disposal) Ears: symmetrical, yellow discharges noted Nose: no discharges noted, no lumps nor lesion noted Mouth: (not checked due to clients disposal) Neck: normal symmetry, no palpable lymph nodes Chest and Lungs: symmetrical chest expansion, with rales and heard upon auscultation. Heart: regular pulse rate and rhythm Upper Extremities: no tenderness or swelling, joints move smoothly Lower Extremities: dry fissures on the soles of the feet. FOCUSED ASSESSMENT (abdomen) Focus assessment: Abdomen Skin Color: normally paler Integrity: No rashes or lesions Umbilicus Position: sunken, centrally located Umbilicus Color: Pinkish Abdomen Contour: generalized distention with seen air Abdomen symmetry: symmetrical

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IV. DIAGNOSTIC AND LABORATORY PROCEDURES CBC Diagnostic / Laboratory Procedure CBC Hemoglobin Date Ordered / Date Result January 04, 2011 To determine the presence or absence of anemia. To determine the percentage of red blood cells to the total blood volume. To check for bodys defense for infection 130 120-140 g/L (12-14) .38-.48 (37-47) Normal Indication (s) or Purpose (s) Results Normal Values (units used in the hospital) Analysis and Interpretation of Results

Hematocrit

.42

Normal

WBC count

5.2 5-10 X ^ 3 (5-10 thousand/mn ^3) Normal

Differential Crutial Count Segmenters Lymphocytes To measure the ability of the body to respond and eliminate infection. 11 0.60 0.40 0.40-0.60 0.20-0.40 Normal Normal

CBC Nursing Responsibilities: Before 1. Explain to the patient the purpose of the procedure for obtaining the specimen. 2. Secure patient consent for procedure. 3. Provide patient comfort, privacy and safety.. During 1. Provide patient comfort. 2. Maintain sterile technique. 3. Use the correct procedure for obtaining a specimen or ensure that the patient and the staff followed the correct procedure. 4. Instruct the patient to relax and avoid opening and closing the hand after the tourniquet is applied. 5. Note relevant information on the laboratory requisition slip; ensure the medication taking by the patient will not affect the laboratory results. 6. If the patient receiving IV infusion obtains the blood from the opposite hand or site. After 1. Provide patient comfort. 2. Label and transport the specimen to the laboratory promptly. 3. Report any abnormal in timely manner consistent with the severity of the abnormal result.

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Urinalysis Diagnostic / Laboratory Procedure Urinalysis Date Ordered / Date Result January 04, 2011 Indication (s) or Purpose (s) To diagnose metabolic or systemic disease or disorder (kidney function or urinary tract) Results Color: Yellow Transparency : Clear Reaction: 6.0 Normal Values (units used in the hospital) Yellow or amber Clear 4.0-6.5 Acidic 7-8.5 Alkaline Analysis and Interpretation of Results Normal Normal The result is within the range of the acidic value which indicates digestion and absorption problem. The result is below the normal value which indicates Dehydration. Normal Normal Normal Normal Normal

Sp. Gravity: 1.010

1.015-1.025

Sugar : Negative Albumin: (-) Pus cells: 1-2 Epithelial cells: Few Amorphous Urates: Few

Negative Negative 1-2 Few Few

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Urinalysis Nursing Responsibilities: Before 1. Explain to the patient the procedure and the methods to use to collect the urine. 2. Secure the patient consent for the procedure. 3. Informed the patient to get the midstream of the urine as the specimen. 4. Advice the patient to wash hands and observe other infection control procedure During 1. Provide privacy to the patient. 2. Tell the patient to collect at least 5-15ml of urine, freshly voided into a clean and dry container. 3. Observe sterility upon the collection of sample. After 1. Collect the patients specimen and labelled it properly. 2. Immediately transport it to the laboratory for the test. 3. Document any pertinent data.

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V. THE PATIENT AND HER HEALTH CONDITION 1. ANATOMY AND PHYSIOLOGY The Digestive system is a group of organs functioning in digestion and assimilation of food and elimination of wastes. The system begins with mouth and ends with the anus. It is a muscular tube stretching from the mouth to the anus. Several specialized compartments occur along this length: mouth, pharynx, esophagus, stomach, small intestine, large intestine, and anus. Accessory digestive organs are connected to the main system by series of ducts: salivary glands, parts of the pancreas, and the liver and gall bladder. Digestion takes substances in one form and breaks them down into molecules that are small enough to pass through the intestinal wall to the blood and lymphatic system. This activity requires chemical secretion and mechanical movements, all working together in a coordinated manner. The molecules may be moved by simple diffusion, active transport, or facilitated diffusion. Motility, secretion and absorption work together to make the process of digestion work.

Food enters the body through the mouth and exits through the anus. In between, it undergoes digestion (from the mouth to the stomach), absorption (from the stomach to the small intestines), and elimination (from the large intestine, or colon, to the anus). In most cases, these three stages of food processing take place in a total of about twenty-four hours in a relatively healthy individual. This journey takes place in what is on the average over fifteen feet of a single connected tube from the mouth to the anus. These fifteen feet of elasticized tubing (which includes the esophagus, stomach and intestines) is said to be continuous with the outside environment. That is, there is one entrance from the outside world to the food tube (the mouth) and one exit (the anus) with no other outlet inside the body proper.

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Food in this tube (usually called the gastrointestinal tract) is technically considered to be outside the body. As food passes through this tube, it may be partially absorbed by the body. At any time, the food itself may be rushed back out through the mouth (vomiting) or quickly expelled through the anus (diarrhea). This is the reason that man can seemingly eat anything. His digestive-absorptiveeliminative tract, or tube, actually holds the ingested food outside of the body proper. If a healthy person should eat harmful foods, they may be carried through the body to the nearest exit without actually being absorbed or entering into the body from this tube. However, many individuals, through years of improper eating, have degraded the natural power of the body to expel unsuitable foods. Consequently, the body gradually starts to absorb noxious substances from foods which a healthy organism would reject outright. Consider this example: If a young infant is given a swallow of strong coffee, he or she will probably vomit it back up or experience immediate diarrhea. This is because the gastrointestinal tract of a young child is still sensitive and strong enough to actively inhibit such substances from entering the body. People who have been vegetarians for several months will often experience this reaction if they, should attempt to eat meat again. A healthy body will try to protect itself from harmful non-food items. stinal tube is the pathway all food must follow in its process of digestion and assimilation. What occurs along this path is discussed in the next sections of this lesson. The Appropriation of Food Appropriation is the making of something into one's own. Appropriating foods, then, is the act of taking food into the body. The first step toward digestion and assimilation of food is the physical selection of food. This selection is guided primarily by visual and olfactory cues. Visual appearance of food is an important part of the digestive process. People start to salivate at colorful pictures of food dishes. If the food is pretty and served in a visually pleasing 16

manner the amount of digestive juices secreted is greater than if the food appears distasteful or if it is served in unpleasant surroundings. The visual appeal of an apple hanging on a tree in an orchard is evident; that same apple stuck in the mouth of a roasted pig, however, does not raise the same expectations in the eater. Food that is simply unfamiliar is often automatically rejected. Some people refuse to eat yellow tomatoes because they "look funny." Thereby they may miss a wonderful taste sensation. All of this may seem obvious, but it is often overlooked in the physiology of nutrition. The body begins to respond immediately when food is placed within the visual field. If the food itself or the surroundings within which it is presented are unappealing, then actual digestion and assimilation of the blood will be impaired. If, on the other Hand, food is artfully presented in a visually pleasing manner, digestion is enhanced. This does not mean that a lot of artifice should be used in preparing food. On the contrary, if food is naturally attractive, such as fruits or vegetables, then a minimum of 'stage dressing' is required. Notice that advertisements for steaks and hamburgers prominently feature salad with vegetables, their attractive colors of red, green and yellow to contrast with the distastefully brown or black meat. Digestion, or lack of it, begins with the eyes. Olfactory Cues The nose is the next organ involved in the physiology of digestion. The fragrance of food stimulates the olfactory nerves, which in turn starts the salivation process. This does not mean, however, that food must be overwhelmingly 'fragrant,' as is the usual case with cooked foods and spices and onions. Smelling food is actually a subtle experience that may require re-educating the sense of smell if it is jaded by over-seasoned cooked food. An apple gives a subtle bouquet of odors to whet the appetite. The smell of ripening bananas or a bowl of strawberries is more enjoyably overwhelming to the healthy individual than is the stench of onions and garlic piled upon burnt meat. 17

The eyes and the nose, then, are the first organs used in the process of digesting and assimilating food. It is important, therefore, that time be taken to appreciate and select food according to its appearance and smell. Alimentation: From the Mouth to the Stomach After food is chosen according to sight and smell, it is brought towards the mouth and saliva starts to secrete. The mouth is the first step in the digestion of food proper. The digestion of food can be viewed as two concurrent processes: 1) Mechanical, or the actual movement of food as it is broken down into smaller particles; and 2) Chemical, or the splitting of food into its simple nutritive components. In the mouth, mechanical digestion is performed by the actions of the teeth and tongue, while the saliva furnishes the first step of chemical digestion. The Mouth The teeth perform the first mechanical operation of digestion. Food is first bitten by the incisor teeth at the front of the mouth. Then the canine teeth (next to the front teeth) shred the food into smaller parts as it is passed back to the bicuspids, which continue tearing it into smaller portions. Finally, the molar teeth (in the back of the mouth) finish the grinding and crushing of the food. Chewing by the teeth increases the surface area of the food so that it may be more easily penetrated by the digestive enzymes. Chewing the food is a very important part of digestion. Not only does it break {he food down into more easily digestible...particles, but it also stimulates nervous impulses that cause the secretion of gastric juices, and thus prepare the digestive system for the food to be swallowed. The salivary glands help perform chemical digestion in the mouth. There are three pairs of salivary glands in the mouth. They continuously secrete saliva to keep the mouth from drying out. During the day, these glands produce from 1 to 1 1/2 quarts of saliva.

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The saliva prepares the food for swallowing by lubricating it with mucin, which gives saliva its slippery characteristic. Imagine how hard it would be to swallow food "dry" without this natural lubrication. The first digestive enzyme is also contained in the saliva. It is called ptyalin or amylase. This enzyme starts the digestion of starches in foods, Ptyalin helps convert starch to a sugar called maltose. Since this enzyme is the major factor in starch digestion, all starchy foods should be chewed thoroughly and mixed well with saliva. Human beings, however, are not well adapted to eating starches, so the amount of starches in the diet should be restricted. In addition to ptyalin, saliva has an enzyme called lysozyme that digests bacterial cell walls, thus killing certain microorganisms. Saliva also has a cleansing action as its constant flow helps to dissolve and remove food particles from the teeth. After mechanical and chemical digestion has progressed to a certain point in the mouth, the tongue gathers the food together into a small ball and then elevates the mass of food back into the pharynx of the throat. This is the first stage of swallowing and the beginning of the food's journey down to the stomach. From Mouth to Stomach After food rolls off the tongue, it is no longer under voluntary control. It is now moved through the system under the control of the involuntary nervous system. Short of self-induced vomiting, it is now up to the wisdom of the body to move the food as it sees fit. After leaving the tongue, it will take about 8 seconds for the swallowed food to reach the stomach. Most of this time is spent traveling down a tube called the esophagus. The food passes down this tube in a peristaltic (wave-like) motion. These peristaltic waves are strong enough so that even if suspended upside down, a person can swallow about a half-ounce of food and it will work its way against gravity into the stomach. This is why

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astronauts can eat in "free fall" or zero-gravity. This is also why they must eat in small sips or swallows, being careful not to take in over a half ounce of food per swallow.

The Stomach The food passes from the esophagus into the stomach through an opening called the cardiac orifice. As soon as food enters the stomach, a hormone called gastrin is released into the bloodstream. This hormone is carried to the gastric glands in the stomach which causes them to secrete digestive juices. These gastric juices help in the chemical digestion of the food, while the rhythmic contractions of the stomach contribute to the mechanical process of digestion. Three primary enzymes are also present in the gastric juices. The first is pepsin, which aids in the hydrolysis of proteins. The pepsin enzyme begins breaking down complex proteins into their simpler forms. It does not actually split the proteins into amino acids (the end-product of protein digestion), but it prepares them for that process which occurs in the intestines. The pepsin enzyme works best in a fairly acid environment. An acid environment is also conducive to protein digestion. The second enzyme is called lipase. This aids in the hydrolysis of fats. Lipase starts the digestion of fats by aiding their breakdown into glycerol and fatty acids. The lipase enzyme works best in a more neutral pH environment than does the pepsin enzyme. The third enzyme, found only in the gastric juices of infants, is called rennin. Its primary function is the hydrolysis of milk proteins. Adults do not have the rennin enzyme in sufficient quantity to digest milk products. Consequently, the only time milk should be used in the diet is during infancy and young childhood. Even at these times, the only suitable milk is that from the lactating mother. Milk from cows, goats, etc. is not of the same composition as is mother's milk and should not be consumed by humans of any age. 20

These three enzymes, along with the gastric juices, are mixed into the food by the mechanical actions of the stomach. The stomach contracts in waves at the rate of three per minute. The stomach has a capacity for holding up to two quarts of food in volume. When a person is fasting, the actual volume of his or her stomach may be less than two ounces. The gastric juices mixed in by the contracting and relaxing stomach are initially stimulated by the thought, sight, smell and taste of the food. This occurs before any food has actually entered the stomach. These juices are sometimes called the "appetite juices", and they may be suppressed if the food appears unappetizing, smells bad, or is eaten in an unpleasant environment. In the presence of intense pain, fear, or depression, gastric juices may be almost completely suppressed for up to twenty-four hours. This fact alone is reason enough not to eat when upset or feeling out of sorts. The stomach empties at the slow rate of about 3/100 ounce for each peristaltic wave. At three waves per minute, it can take up to five hours for two pounds of food to leave the stomach. The emptying time of the stomach also varies with the type of food present. Water and liquids leave the stomach most rapidly. Carbohydrates empty more quickly than proteins; proteins, in turn, leave the stomach more quickly than fats. Within five minutes after fat enters the stomach, a hormone called enterogastrone enters the bloodstream and travels to the stomach, "this hormone inhibits the motion of the stomach and causes it to empty at a much slower rate. Not all foods undergo the same digestive processes in the stomach, and not all foods leave the stomach at the same rate. Proteins digest in an acid environment, while fats need a neutral environment. Carbohydrates leave the stomach at a faster rate than proteins, and so on. Even among the carbohydrates (fresh fruits and vegetables), digestion time may vary a great deal. Below is a chart listing the time that various foods remain in the stomach:

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Food Parsley Lemon Grapes Tomato Carrot Almond Apple Banana Peanut Eggplant Persimmon Turnip

Minutes Held In Stomach 75 90 105 120 135 150 165 180 195 210 225 240

Since different foods require different sets of environments in the stomach to digest properly, it is reasonable to assume that if these foods are put into the stomach at the same time, difficulties could occur. That is exactly what happens. Consider the all-American cheeseburger. A bite of it might contain a starch (bread) a protein (meat), a fat (cheese), and an acid (tomato), what happens when a single bite of this hits the stomach? The starchy bread was probably not chewed very thoroughly in the mouth and the starchdigesting enzyme had little chance to do its work. So, the bread reaches the stomach in an unprepared state. The meat will require a very acid environment to digest. This makes it difficult for the starch to digest, since acids are inimical to starch digestion. The fat in the cheese requires a more neutral environment than the meat protein to digest, and its fat content causes the stomach to slow its digestion. At the same time, the acids in the tomatoes interfere with the starch digestion of the bread. In this single bite, there are over seven different types of food requiring four different sets of enzymes and digestive conditions, and all digest at different rates!

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At best, such a conglomeration of food in the stomach will slow digestion down to the point of fermentation. This will lead to autointoxication. At worst, the food simply becomes halfdigested and is pushed sluggishly through the system, releasing its poisons and gases throughout the body. The same people who would never mix water, kerosene, or oil with their gasoline for their car will sit down to a meal and give their stomachs a mixture of mashed potatoes, steak, butter, and beer. Fortunately, the stomach does not break down as fast as an abused automobile. But the stomach's resilient quality causes people to think they are getting away with their dietary indiscretions. If different foods are to be put into the stomach at the same meal, they should at least be of the same type that requires the same set of digestive conditions. Ideally, of course, only one food should be eaten at a meal to insure optimum digestion. Since food combining is such an important area, it is covered in a separate lesson in this course. The Small Intestine The small intestine consists of about 9 feet of inch tubing coiled in the abdomen. This tubing leads from the stomach to the large intestine. It is in the small intestine that most of the digestion and absorption of food occurs. Food passes into the small intestine from the stomach by entering the duodenum. The duodenum is the smallest segment of the intestine, being only 8 inches long. Food travels through the small intestine by weak contracting waves of motion that propel the food toward the large intestine. The other two segments of the small intestine are the jejunum, which is 3 feet long and connects the duodenum to the ileum, the final 3 feet of the small intestine. The small intestine interior has many folds. Along the surfaces of these folds are tiny finger-like projections called villi. 23

The villi of the intestine move back and forth, like thousands of tiny tentacles, passing through the food as it is moved along the intestinal tract. The villi play an important role in the absorption of food from the small intestine. Through the center of each villi is one or more fine white vessels called lacteals. The lacteals are part of the lymphatic system. Their principal function is probably the absorption of fat. As food passes through the small intestine, it is taken up, or absorbed, by structures in the wall of the intestines, especially the villi, and is then secreted into the lacteals. Some of the digested food is absorbed by the numerous blood vessels that line the villi. This digested food directly enters the bloodstream. As digestion progresses in the small intestine, portions of food are moving in large quantities into the capillaries of the intestinal villi. Blood from the intestines containing these products of digestion is collected in the portal vein, which is connected to the liver. The liver removes the excess glucose from the blood (glucose being one of the end-products of digestion) and stores it as glycogen, to be used later in normalizing the blood-sugar level and for supplying energy. It also attempts to detoxify harmful elements in the food (such as pesticides), and regulates the level of nutrients available to the body. The liver is one of the master organs in the body. It receives all the end-products of digestion. The bulk that remains behind after the vital elements are extracted by the villi in the intestine and sent to the liver is then pushed down toward the large intestine. Normally, most of the contents of the intestines have been absorbed by the time the food reaches the middle of the jejunum segment of the intestine, or about 3 feet along the 9 feet of tubing that makes up the small intestine. The tone and motility of the small intestine is increased by foods served at room temperature, fibrous foods, and high-carbohydrate, low-fat foods. Movement is slowed by cold, dry, and high-fat foods. The Large Intestine or Colon The small intestine joins the colon in the region of the right groin. At this juncture is the ileo-cecal valve whose purpose is to control the speed of passage of substances from the small intestine and to prevent any wastes from returning to it from the large intestine. The ileo-cecal 24

valve opens into the colon into a pouch known as the cecum, the first receptacle for waste residue. At the tip of the cecum is the appendix. Due to the appendix's position near the waste receptacle, toxins from a diet high in meat, heavy starches, etc. can contribute to its inflammation which may result in a condition known as appendicitis. If a person suffering from appendicitis simply abstains from all food (fasting), then the\body can conduct its housecleaning and clear up the inflammation without removal of the appendix. From the cecum, the large intestine ascends on the right side to the middle of the abdomen, then crosses to the left side and descends again. These three sections are called the ascending, transverse and descending colons. One of the chief functions of the colon is the reabsorption of much of the water used in the digestive process. If all the water in which the digestive enzymes were secreted was lost in the feces, man would have to drink liquids continually. If too much water is expelled with the feces, then a condition known as diarrhea exists. Diarrhea happens because of an irritation in the stomach and small intestine due to unsuitable food or inflammation. In this case, the colon expels all of its waste residue upon entry without holding it for water reabsorption. On the other hand, if the waste material moves too slowly through the colon, then excessive water is reabsorbed and the feces become hardened. This is called constipation. Waste material may move too slowly through the colon for a number of reasons. Perhaps the most usual reason is that peristaltic nerves are paralyzed by toxicity from decaying foodstuffs. Another reason for the slow movement of waste through the colon is that the passageway has become very small due to poor tone or to hardened feces clogging the intestinal walls. After several years on a conventional low-fiber diet, the average adult continually carries around about ten to twenty pounds of fecal material on the colon walls. In many instances, the distended abdomens in overweight individuals are not due so much to fat as they are to accumulation of feces over a period of years. Autopsies on much individuals have sometimes revealed over fifty pounds of fecal material in the body! 25

When the body is abused by the modern diet, the colon often suffers the most. Fortunately, a diet high in natural fiber (that is, raw fruits and vegetables) can greatly aid the body in restoring the health of the intestines. The last portion of the large intestine is the rectum. This segment serves as a storage chamber for the feces until defecation. The feces are eliminated from the rectum through an opening called the anus. And so the journey of food through the body is completed. Many healthy individuals process the food from the mouth to the anus in about sixteen to twenty-four hours. Most adults eating a conventional diet, however, generally take from forty-eight to seventy-two hours for their food to complete its journey. Much of this added delay is due to incompatible food combinations and lack of colon vitality. Now that we've followed the bodily journey of food from its beginning to end through the gastro-intestinal tract and learned about some of the physiological processes that accompany this journey, we will proceed to determine an optimum diet, one that promotes digestive efficiency and general well-being. 2. PATHOPHYSIOLOGY (Client-centered) A. SYNTHESIS OF THE DISEASE a.1 DEFINITION Acute Gastroenteritis is an inflammation of the stomach and intestines. It is usually caused by a bacterial or viral infection associated with food poisoning. Symptoms include nausea, vomiting, and diarrhoea. Gastroenteritis may cause dehydration, which precludes vigorous physical activity. Victims of gastroenteritis should drink plenty of fluids and maintain a good salt balance. Infants are at particular risk of dehydration and may require intravenous fluid replacement. All of the viruses produce watery diarrhea often accompanied by vomiting and fever, usually not associated with blood or leukocytes in the stool or with prominent cramping. 26

Rotavirus is the predominant viral cause of dehydrating diarrhea. Rotaviral infections tend to produce severe diarrhea, causing up to 70% of episodes in children under 2 years of age who require hospitalization. Rotavirus infection tends to occur in the fall in the southwest of the US, then sweeping progressively eastward, reaching the northeast by late winter and spring.

The bacterial diarrheas work through the elaboration of toxin (enterotoxigenic pathogens) or through invasion and inflammation of the mucosa (invasive pathogens). Secretory diarrheas are modulated through an enterotoxin, and the patient does not have systemic symptoms (fever, myalgias) or signs of local irritation of the bowel (tenesmus), or evidence of gut inflammation in the stool (white or red blood cells). The diarrhea is watery, often is large in volume, and often associated with nausea and vomiting. Invasive diarrhea is caused by bacterial enteropathogens, and is accompanied by systemic signs, such as fever, myalgias, arthralgias, irritability, and loss of appetite. Cramps and abdominal pain are prominent. The diarrhea consists of the frequent passing of small amounts of "mucousy" stool. Stool examination reveals leukocytes, red blood cells, and often gross blood. The symptoms of gastroenteritis are usually enough to identify the illness. Unless there is an outbreak affecting several people or complications are encountered in a particular case, identifying the specific cause of the illness is not a priority. However, if identification of the 27 Enteric adenovirus is the third most common organism isolated in infantile diarrhea. Norwalk viruses are the major cause of large epidemics of acute nonbacterial gastroenteritis. In schools, camps, nursing homes, cruise ships, and restaurants.

infectious agent is required, a stool sample will be collected and analyzed for the presence of viruses, disease-causing (pathogenic) bacteria, or parasites. a.2 PREDISPOSING AND PRECIPITATING FACTORS Precipitating factors: Age This factor pertains to those who are young and old. Children are fond of playing and in some instances they usually put into their mouth anything and their immune system is not yet fully developed same as with the adults whose immune system becomes less efficient later in life. Predisposing factors: Eating contaminated and unhealthy foods Activities of daily living Poor hygiene Lack of safe drinking water

a.3 SIGNS AND SYMPTOMS Diarrhea-frequent and copious discharge of abnormally liquid feces and increased chloride permeability leads to leakage into the lumen followed by sodium and water movement. Hyperthermia- due to infection Dehydration- a severe lose of hydrogen atoms and oxygen atoms in the proportions in which they occur in water, as in a chemical reaction Nausea and vomiting- patient feels disgust and revulsion and cause sensation of that precedes vomiting or cause to feel sick.

28

B. SCHEMATIC DIAGRAM (FLOW CHART)

Non modifiable: Age : 8 years old Modifiable: Eating contaminated foods Activities of daily living Poor hygiene Lack of drinking water

Ingestion of pathogens

Settles in the gastric and intestinal region Inflammatory response (endotoxins are released) Stimulation & destruction of Mucosal lining of the bowel wall ulceration

Direct invasion of the bowel wall Nausea and vomiting *January 1 & 2, 2011

Excessive gas formation

Digestive and absorptive malfunction

Increase peristaltic movement Secretion of fluid and electrolyte into the intestinal lumen Diarrhea *January 1 & 2, 2011

Pain *January 1 & 2, 2011

Inhibition of Na reabsorption Fluid and electrolyte imbalance dehydration

29

VI. THE PATIENT AND HER CARE A. MEDICAL MANAGEMENT a. INTRAVENOUS FLUID DATE MEDICAL MANAGEMENT AND TREATMENT Plain Lactated Ringers Solution (15=20 gtts/min.) A sterile, isotonic To supply and nonpyrogenic solution for parenteral replacement of extracellular losses of fluid and electrolytes. Marilous body adequate water and electrolytes that her body needs to maintain cellular equilibrium to achieve normal body functioning 5% Dextrose in 0.3% Sodium Chloride Hypertonic solution w/c increases the extra cellular fluid, drawing water from the cells that will lead to swelling. To provide Marilous hydration and electrolyte. -To increase Marilous ECF volume and decrease cellular swelling. A.1 NURSING RESPONSIBILTIES FOR IVF 30 DO: 01/03/11 DP: 01/03/11 01/04/11 DC: 01/04/11 Marilou did not experience dehydration and pain on the venipuncture site. GENERAL DESCRIPTION INDICATION/S ORDERED, DATE/S DATE CHANGED DO: 01/03/11 DP: 01/03/11 01/03/11 DC: 01/03/11 Marilou did not experience dehydration and pain on the venipuncture site. OR PURPOSE/S PERFORMED, CLIENTS RESPONSE TO THE TREATMENT

a. Verify the doctors order. b. Identify the client. c. Check if the IVF is infusing well. d. Adjust rate of flow of fluids appropriate to the needs of patient as prescribed. e. Monitor IVF flow and patients response. f. Check the level of the IVF g. Monitor pt. frequently for: Signs of infiltration / sluggish flow Signs of phlebitis / infection

Dwell time of catheter and need to be replaced Condition of catheter dressing h. . Check for the presence of air in tubing. If there is, remove immediately. i. Isotonic solution expands the intravascular compartment, monitor patients fluid overload. j. Record all procedures done.

31

B. DRUGS

Name of drug Name of drug

Dosage, General Action Indication Side effects Nsg responsibilities Dosage, Route, General Action Indication Side effects Nsg responsibilities Route, Frequency Frequency Generic name: 250mg Bactericidal: Infection of the *GI:pseudomembranous -culture infection site Generic name: 0.5cc q IV IVq8 -completes with Non CNS:drowsiness, Stop drug four days before diagnostic skin Cefuroxime ANST(-) histamine for H1 synthesis of Inhibits urinary, respiratory colitis, nausea, and arrange for Diphenhydramine for vomiting productive confusion, insomnia, testing because antihistamines can prevent, bacterial cell wall tract, and skin and anorexia,vomiting, positivesensitivityresponse. hydrochloride receptor sites on cough headache, reduce, or mask skin test tests Brand name: causing cell death skin structure diarrhea before and during effector cells. vertigo,sedation, Cefuroxime axetil infections. Brand name: Prevents but doesnt rhinitis sleepiness,dizziness, Warn patient not to taketherapy if expected this drug with any ceftin response is not seen. benadryl reverse, histamineincoordination, other products that contain dipenhydramine Serious lower mediated responses, allergy fatigue, restlessness (including topical therapy) because of Cefuroxime sodium -give particular those of symptoms respiratory tract nervousness, tremor, increase adverse reactions. oral drug w/ zinocef infections UTIs food to decrease the GI tract seizures GIupset and Before diphenhydramine motion CV:hypotension, Instruct patient to take drug 30 mins.enhance Bone and joint provides local sickness palpitation, travel to prevent motionabsorption sickness. infections anesthesia and tachycardia -give oral tablets suppression of cough parkinsons GI: nausea, vomiting, Tell patient to take dipenhydramine with to Septicemia children who disease diarrhea,drymouth, food or milk to reduce GI distress. can swallow tablets constipation,Epigastric Meningitisanorexia Have and available distress, Warn patient to avoid alcohol vit.Khazardous in case GU:dysuria, urine activities that require alertness until CNS Gonorrhea hypoprobinemia retention,urinary effects of drug unknown. occurs frequency Otitis media Tell patient that coffee or tea may reduce drowsiness urge caution-discontinue if if palpitations Pharyngitis hypersensitivity develop. reaction occurs Tonsillitis Inform patient that sugarless gum, hard Early lymes disease candy, or ice chips may relieve dry mouth. Tell patient to notify prescriber if tolerance develops because different anti-histamine may lead to be prescribed.

Warn patient of possible photosensitivity reaction and advise use of sunblock.

C. DIET Type of Diet NPO Date Ordered, Date Started, Date Change Jan. 03 2011 to Jan. 04 2011 General Description Indication/ Purpose Specific Food Taken Banana Lugaw Client Purpose to Therapy

It means nothing by mouth. When you labeled NPO by your doctor you cannot have anything that would go in your mouth including food, beverage and oftentimes medications. It is designed to rest the digestive tract.

To reduce gastric secretion related to abdominal pain to prevent aspiration during surgery, to eliminate nausea and vomiting. When you have nausea, vomiting and diarrhea that cannot be controlled you may have to be NPO to allow your GI tract and bowels to rest. Patient with bowel obstructions are often NPO for the same reason. This makes sense because food cannot continue to go in if it cannot come back out. The benefits of these diets are two fold; the soft food is digested easily and the bland food does not have the potential to aggravate the intestine.

SOFT DIET

Jan. 04 2011

The soft diet is prescribed for patients unable to tolerate a regular diet. It is part of the progressive stage of diet therapy after surgery or during recovery from an acute illness. It does not contain whole grain or salads with raw, fresh fruits and vegetables

None

Nursing Responsibilities NPO Check the doctors order Check the right client Be sure that the diet is properly instructed Monitor if the client complies with the given diet. Instruct the SO not to give any food to the client. If the client is thirsty, wet the lips of the client using a cotton ball and water. Assess for the patients condition; how he responds to the diet Document accordingly SOFT DIET Check the doctors order Check the right client Be sure that the diet is properly instructed Monitor if the client complies with the given diet. Be sure patient is taking only soft food. Assess for the patients condition; how he responds to the diet Document accordingly D. ACTIVITY / EXERCISE Since the client is experiencing vomiting and diarrhea, the client needs to have a complete bed rest. The patient needs to conserve more energy to fight for the pain shes experiencing. For this reason, the client need to change her position every 2 hours from lying flat on bed to side lying to promote venous return and prevent breakdown of skin over a bony surface caused by a prolonged lying on the same position. Upon discharge, the client needs to have enough exercise to have a strong and healthy body by exercising every day. Exercise helps in better blood circulation of our body. Exercise should be promoted in a way by stretching hand and feet every morning. Encourage the SO to help her daughter make a habit of drinking water frequently to maintain her normal functioning.

VII.

NURSING CARE PLAN

RISK FOR IMBALANCED NUTRITION

CUES S: ala, eman matako mangan. Neng kayi ne mung karitak kanan nasi, neng kayi pagbakalan ku neman pamangan amp opera, it apache atin ya pera pane chichiriya,softdrinks ampong candy ing kakanan na jang abak a maranun as evidenced by the SO O: T: 37.1 C RR: 27 Bpm PR: 75 bpm

NURSING DIAGNOSIS Risk for Imbalanced Nutrition: Less than body requirements r/t lack of interest to food

SCIENTIFIC EXPLANATION Adequate nutrition is necessary to meet the bodys demand. Nutritional status can be affected by the presence of disease. During times of illness, adequate nutrition plays an important role in healing and recovery. Usually sick patients would have an altered sense of taste and smell which cause lack of interest in eating thus the patient could not meet the metabolic needs of the body which makes her at risk for imbalanced nutrition.

OBJECTIVE Short term: After 1-2 hours of nursing interventions, the clients SO will be able to identify different foods that are nutritious and are very much needed for ones nutrition.

NURSING RATIONALE EVALUATION INTERVENTIONS 1. Monitor and record VS. 2. Assess patients condition. To obtain baseline data. To ascertain status and note progress of the disease. To obtain some information regarding the likes and dislikes of the client towards food To identify factors that affect the clients ability to eat To stimulate appetite. Short term: After 1-2 hours of nursing interventions, the clients SO shall have verbalized understanding of the importance of individual nutritional needs and necessary interventions to improve nutrition Long term: After 2 days of nursing interventions the patient shall have demonstrated interest in eating nutritious foods.

3. Encourage the client/SO to discuss eating ahbits, including fod preferences.

4. Note occurrence of sores and tooth aches. Long term: After 2-3 days of nursing interventions the patient will be able to demonstrate interest in eating nutritious foods.

5.. Advise SO to give patient foods that are appealing and nutritious . 5. Encourage SO to give foods in variety and in moderation.

. To decrease boredom and will also allow patient to choose foods she likes.

6. Advise SO to give It stimulates patients with appetite and

DEFICIENT FLUID VOLUME

Nursing Diagnosis S: Deficient fluid volume O: RT excessive losses The patient manifested: through normal routes Passage of loose AEB frequent passage of watery stool loose watery Vomiting stool Abdominal cramping Dehydration Nausea Fatigue Weakness The patient may manifest: Nervousness Confusion Weight loss Decreased skin turgor Decreased urine output Dry mucous membrane fever

Cues

Scientific Explanation AGE is an inflammation of the stomach and intestinal tract that primarily affects the small bowel. The universal manifestation of gastroenteritis is diarrhea which occurs in varying intensity depending on the organism involved and the health status of the client. Diarrhea is defined as an increase in the frequency, volume and fluid content stool. Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit.

Objectives Short term: After 2 hours of nursing interventions, the pt. will report understanding of causative factors for fluid volume deficit. Long term: After 2 days of nursing interventions, the pt. will maintain fluid volume of functional level AEB well dehydrated, intake is equal as output and normal skin turgor

Interventions 1. Establish rapport 2. Monitor and record VS 3. Assess patients condition 4. Monitor input and output balance 5. Maintain adequate hydration, increase fluid intake 6. Restrict solid food intake as indicated 7. Discuss individual risk factors/ potential problems and specific intervention s

Rationale 1. To gain pts trust 2. To obtain base line data 3. To be aware of the pts conditio n and feeling 4. To ensure accurate picture of fluid status 5. To prevent dehydra tion and maintai n hydratio n status 6. To allow for bowel rest & to reduced intestina l work load 7. To prevent or limit occurre

Evaluation Short term: After 2 hours of nursing interventions, the pt. shall have reported understanding of causative factors for fluid volume deficit. Long term: After 2 days of nursing interventions, the pt. shall have maintained fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.

ACTIVITY INTOLERANCE

Cues S: O: The patient may manifest: Weakness Restlessness Physical inactivity Increase respiratory rate Fatigue Low hgb count Low hct count

Nursing Diagnosis Activity intolerance RT generalized weakness AEB limited physical activity

Scientific Explanation Activity Intolerance is insufficient physiological or psychological energy poor endure or complete required or desired daily activities. Because of law hgb and hct level there will be decrease oxygen being delivered to the tissues of the body since the hgb is responsible for the oxygenation of tissue. As a compensatory mechanism, the body will increase its demand of oxygen by increasing respiratory rate of the pt. which results then to fatigue. Because of this, there will be fast

Objectives Short term: After 2 hours of nursing interventions, the pt. will identify negative factors affecting activity intolerance and eliminate or reduce their effects. Long term: After 2 days of nursing interventions, the pt. will report activity intolerance with enhance energy and the patient will participate willingly in necessary or desired activities.

Interventions 1. Monitor and record VS 2. Provide enough air coming from the electric fan or from the window 3. Develop and adjust simple activity like brushing his teeth 4. Assist client with activity 5. Promote comfort measures in the activity 6. Cluster Nursing care 7. Ascertain ability to stand and move about degree of assistance 8. Encourage complete bed rest

Rationale 1. To obtain the base line data 2. To enhance pt. ability to participa te in activity 3. To monitor pts respond to activitie s 4. To prevent overexer tion 5. To protect pt. from injury 6. To prevent over exhausti on 7. To determi ne current status and needs 8. For patient recupera

Evaluation Short term: After 2 hours of nursing interventions, the pt. shall have identified negative factors affecting activity intolerance and eliminate or reduce their effects. Long term: After 2 days of nursing interventions, the pt. shall reported activity intolerance with enhance energy and the patient will participate willingly in necessary or desired activities.

PAIN

Cues S: Masakit ya ing atyan na As verbalized by the SO O: The patient manifested: Abdominal pain Appears weak Restlessness Limited range of motion Verbalization of pan with a pain scale of 7/10

Nursing Diagnosis Acute pain RT Inflammator y Process

The patient may manifest: Facial grimace Irritability Sleep disturbances Reduced interaction with people Diaphoresis

Scientific Explanation Gastroenterit is is the inflammation of the stomach and intestinal tract that primarily affects the small bowel. One of the manifestatio n of gastroenteriti s is abdominal pain. During the course of inflammation , the bodys immune response causing release of cytokine and prostaglandi n causing an increase in vascular permeability and causes pain, which felt by the pt. in the abdomen.

Objectives Short term: After 2 hours of nursing interventions , the pt. will report relieved from pain from a pain scale of 7/10 to 5/10 Long term: After 2 days of nursing interventions , the pt. will be free from pain AEB demonstratio n of relaxation skills and diversional activities with the help of SO

Interventions 1. Establish rapport 2. Monitor and record VS

Rationale 1. To gain the trust of the patient 2. To provide baseline data and note deviatio ns 3. To lesser or alleviate pain caused by various factors 4. To reduce pain and promote relief/co mfort

Evaluation Short term: After 2 hours of nursing interventions , the pt. shall have reported relieved from pain from a pain scale of 7/10 to 5/10 Long term: After 2 days of nursing interventions , the pt. shall be free from pain AEB demonstratio n of relaxation skills and diversional activities with the help of SO

3. Review factor that aggravate or alleviate the pain

4. Instructed the SO to massage the area where pain is elicited if not contraindica ted 5. Encourage pain reduction techniques 6. Provide adequate rest

5. To promote healing 6. For clients comfort and relief fro m pain 7. To decrease pain 8. Deep breathin g exercise s may reduce pain sensatio n 9. To promote timely

7. Provide diversional activities like playing 8. Instructed the client to perform deep breathing exercises 9. Monitor effectivenes s of pain

VIII. TEACHING PLAN RELATED TO THE PROBLEMS IDENTIFIED

Content 1. Provide health teachings to the SO about proper diet like eating food that is nutritious. 2. Provide health teaching about food sanitation. 3. Encourage SO to increase the fluid intake of her daughter and explain its importance. 4. Encourage the SO to help her daughter have a strong and healthy body by exercising everyday and explain its importance. 5. Promote socialization to other people by encouraging her daughter to play with other children.

Time Allotment 30 min.

Teaching Strategies Discussion

Evaluation

30 min.

Discussion

30 min.

Discussion

30 min.

Discussion

30 min.

Discussion

IX. REFERENCES Internet http://www.rawfoodexplained.com/the-physiology-of-digestion/the-journey-of-food.html http://www.ehow.com/facts_5521949_definition-acute-gastroenteritis.html http://www.mims.com/Page.aspx?menuid=mng&name=Lactated+Ringers+Injection %2C+Solution&brief=true&CTRY=US http://en.wikipedia.org/wiki/Lactated_Ringer%27s_solution http://www.scribd.com/doc/8358289/Acute-Gastroenteritis#open_download http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=443 http://www.allivet.com/Lactated-Ringers-p/25211.htm http://nursingreference.blogspot.com/ http://www.drugs.com/pro/lactated-ringers.html http://en.wikipedia.org/wiki/Intravenous_therapy http://www.ehow.com/video_4997547_benefit-ringers-vs_-normal-saline.html http://www.scribd.com/doc/18151646/Drug-Silver-Sulfadiazine-FlamazineVI. http://www.answers.com http://www.scribd.com/doc/doc/8358297/discharge-plan-gastroenteritis Books Essentials of Anatomy and Physiology Sixth Edition Lippincotts Nursing Drug Guide 2011