A Case Study

On

ACUTE GASTROENTERITIS WITH MODERATE DEHYDRATION, CONGENITAL ICHTHYOSIS

In partial Fulfillment of the requirement in Related Learning Experience 30 Group 06

Presented by:

ABSTRACT
Acute gastroenteritis (AGE) in the pediatric population remains a significant cause of pediatric patient morbidity and mortality. For these patients, oral rehydration therapy is an intervention that should be initiated with the first signs and symptoms of Acute Gastroenteritis. Oral rehydration therapy should be based on the degree of clinical dehydration. Clinical findings, such as those used in the clinical dehydration score, should be utilized as a means to standardize the dehydration assessment. Recent evidence supports the use of ondansetron, both orally and intravenously, to facilitate oral rehydration when vomiting is a concern. Consideration should be given to a trial of ondansetron therapy in the management of children with AGE to potentially avoid intravenous rehydration and hospital admission. Norovirus, Sapovirus and Astrovirus are causative agents of viral gastroenteritis affecting all age groups, but most frequently the young, the elderly and persons in semiclosed communities such as hospitals, nursing homes, military bases and cruise ships. The sensitive and rapid detection of causative agents of viral gastroenteritis is key to the effective implementation of infection control systems. Traditional detection methods such as electron microscopy and antigen detection assays lack sensitivity. The detection of gastrointestinal viruses by molecular methods has resulted in increased levels of detection, and enables the epidemiological investigation of viral strains. The significant diversity of gastrointestinal viruses, in particular Norovirus and Sapovirus, are compounded by increasing reports of virus recombination, and pose an ongoing challenge to the development of sensitive and specific molecular detection assays.

Table of Contents

I.

Acknowledgement ------------------------------------------------------

6 7

II. Introduction ---------------------------------------------------------------

III. Significance of the Study to the:

a. Nursing Education -------------------------------------------------b. Nursing Practice ----------------------------------------------------c. Nursing Research --------------------------------------------------

8 8 8

IV. Objectives of the study:

a. General --------------------------------------------------------------b. Specific ---------------------------------------------------------------

9 9

V. Patients Profile
a. Nursing Health History -------------------------------------------b. Physical Assessment ---------------------------------------------c. Developmental Data ----------------------------------------------VI. Anatomy and Physiology --------------------------------------------VII. Pathophysiology --------------------------------------------------------- 27 VIII.

10 11-18 19 21

Diagnostic Tests ---------------------------------------------------------

28

IX. Medical and Surgical Management a. Drug Study -----------------------------------------------------------X. Nursing Management a. Nursing Care Plan --------------------------------------------------XI. Evaluation, Results & Discussion -----------------------------------XII. Bibliography ---------------------------------------------------------------

ACKNOWLEDGEMENT
First and for most, we would like to thank our Almighty Father for giving us the chance to live and experience lifes challenges. Second, we would like to thank our parents for supporting and providing us in our studies. Third, is our gorgeous and intelligent clinical instructor Ms. Fredelina Santiago for helping us and teaching us to be responsible and be more committed in our studies. Fourth are our ever supportive head nurses for helping us in making our case study. Without them we will not be able to make this case study. We might experience a lot of bumpy ride in making our case study, we still make it through. Thank you for all the people who helped and inspired us in making this. No word can express how thankful we are for everything. Thank you.

I INTRODUCTION
Acute Gastroenteritis is infection or irritation of the digestive tract, particularly the stomach and the intestines due to ingestion of contaminated food & H2O. Consist of mild to severe diarrhea that may be accompanied by loss of appetite, nausea, vomiting, cramps and discomfort in the abdomen. Not serious for healthy adults, it can cause lifethreatening dehydration and electrolyte imbalance in very ill, the very young and the every old. This risk is due to poor hygiene of a few people with the disease that may be encountered frequently in daily living (for example, infants, children, or some food handlers). NSO surveys, 572, 259 infants, young and old were affected by diarrheal diseases during 2006. In July 22, 2004, the Department of Health (DOH), Philippines declared an epidemic (outbreak) of a water/food-borne disease called acute gastroenteritis in 45 towns in Central Pangasinan.

SCOPE AND LIMITATION

This study includes the collection of information specifically to the patients health condition. The study also includes the assessment of the physiological and psychological status, adequacy of support systems and care given by the family as well as other health care providers. The scope of this study would include: a. Data collected via assessment, interviews with the patient, family members and clinical records. b. Actual and ideal problems for 3 days including the initial assessment and its appropriate nursing intervention that would be applied within his stay in the hospital at NMMC hospital. c. Developing a plan of care that will reduce identified predicaments and complications. d. Coordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health. e. Further evaluating the effectiveness of nursing interventions that have been rendered to the client. An array of factors influencing the limitations of this study includes: a. Data collected is limited only to assessment and interview to the patient, patients chart and nurse on duty. b. The interaction, assessment and care were only limited to a total of 16 hours (2 days clinical duty, 1 day assessment) with actual nursing intervention done. 5

c. The lack of complete family history obtained was due to lack of laboratory examinations or diagnostic examinations results.

SIGNIFICANCE OF THE STUDY

Nursing Education:
The significance of this study to nursing education is to further increase and expound knowledge of the students. It also helps to make a reliable and holistic care plans to improve the quality of life of the client. The study hastens the opportunity for the students to apply theoretical knowledge to actual health care settings.

Nursing Practice:
This study is significant to nursing practice to further improve the skills and ability of the nursing students and enhances students capability to make intelligent actions and decisions in the clinical area. This study also helps us to attain our goal which is to provide quality care to our client to improve their quality of life.

Nursing Research:
Through having this study, nursing students would be able to apply their skills in research. Be able to apply systematic and scientific way of solving problems and discover new ideas that would give answers to the patients situation. It also a means of revision the kind of therapy we have and a means of discovering a new technique or methods in dealing and caring of client with this kind of condition.

Objectives
A.

General Objectives
understand the underlying disease of the patient and identify the

1.

To

significant physiological, psychological and socioeconomic needs to provide appropriate care.

B.

Specific Objectives

1. To know the anatomy of the G.I. tract and pathophysiology of Acute Gastroenteritis. 2. To learn about the major etiologic agent of AGE. 3. To determine the previous and present medical history of the patient. 4. To perform physical assessment with special attention on the systems focus. 5. To show the laboratory examination results with the corresponding normal values, actual result from the patient, and its interpretation. 6. To learn the basic principle of medical management of AGE. 7. To gain information through Nurse-Patient interaction, identify problems from the client and provide the appropriate nursing care plan. 8. To understand the pharmacological management set on the client and provide nursing interventions. 9. To identify the discharge plan for the patients rehabilitation to conduct an evaluation of the clients condition from admission to present.

II CLIENT PROFILE
Socio-demographic Data Patient X a 1 year old, male, Filipino, was admitted at Northern Mindanao

Medical Center last Jan.19,2012,with medical diagnoses of Acute Gastroenteritis w/ Moderate Dehydration , Congenital icthyosis. HEALTH PERCEPTION AND HEALTH MANAGEMENT PATTERN Reason for hospitalization/Chief Complaint Patient was admitted due to Acute gastroenteritis w/moderate dehydration, congenital ichthyosis . History of present illness 4 days prior to admission, patient experienced LBM watery, yellowish, bubbly about 2 to 3 episodes per day. Vomited 2 to 4 tablespoon episode per day. No consultation and medicines given to the patient at home. At OPD patient was diagnosed with dehydration. Upon admission, the patient experienced 2 episodes of upward rolling of eyeballs with cycling motion of extremities at the ER with admitting vital signs of BP70/50 mmHg, CR- 140bpm, RR- 58cpm, Temp- 38.8C, with pulse oxymeter reading of 96% O2 saturation. Past Medical History (Previous Hospitalizations/surgeries) Patient X was hospitalized on Jan. 17, 2012 due to passage of watery stool. Things done to manage health Patient X significant other gives Hydrite when he experienced diarrhea and vomiting. Statement of the patients general appearance Patient X is conscious, restless and appears weak, protuberant abdomen, hypertympanitic abdomen with sunken periorbital area, skin and lips looks pallor.

NUTRITION AND METABOLIC PATTERN Pre-hospitalization Prior to admission patient was properly nourished. He eats 4 meals a day with snacks in between, with good appetite. Moreover, he has a supplement of vitamins C with zinc supplement. He is 78 cm in height and weighs 9 kilograms.

Hospitalization
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When he was admitted he was bottle-fed, eating rice and taking vitamin C with Zinc supplement. His pattern of daily food intake was 4 times a day. Prior to admission he experienced vomiting. He was not properly nourished during our first assessment. He is 78 cm in height and weighs 7 kilograms.

ELIMINATION PATTERN Pre-hospitalization Patient X was able to defecate at least once a day in no particular time. Hospitalization On the first day of assessment, Patient X has episodes of defecation 6 times a day with yellowish, bubbly, watery stool. Feeding Bathing Dressing Grooming ADL Status 4 Meal Preparation 4 Cleaning 4 4 Laundry Toileting 4 4 4 4 Mobility Status Bed Mobility 4 Chair/toilet transfer Ambulation R.O.M. 4 4 4

0 Total independence 1 Assist with device 2 Assist with person 3 Assist with person & device 4 Total dependence

SLEEP-REST PATTERN Prehospitalization Patient X sleeps more than 4 hours a day and absence of sleep disturbances. Hospitalization During admission, Patient X mother state that his sleeping pattern was abnormal because of his illness with a sleeping pattern of less than an hour.

Date 01/26 8am 10am 01/27 8am 10am 01/28 8am 10am

Temperature 37 37.4 36.1 36.8 36.5 36.2

VITAL SIGNS Blood Pulse Rate Pressure 134 139 120 115 123 118

Respiratory Rate 35 37 20 18 22 20

Oxygen Saturation -

INTEGUMENTARY SYSTEM January 26, 2012 January 27, 2012 January 28, 2012 Color Pinkish brown; Pinkish brown; Pinkish brown; uniform skin color with uniform skin color with uniform skin color with slightly darker areas slightly darker areas slightly darker areas noted noted noted Odor No unusual odor No unusual odor No unusual odor Lesions Fissures on skin Fissures on skin Fissures on skin noted noted noted Rashes on the gluteal Rashes on the gluteal Rashes on the gluteal and perineal area and perineal area and perineal area noted noted noted Temperature Skin was cool to Skin was cool to Skin was cool to touch touch touch Moisture Dry Dry Dry Texture Rough Rough Rough Turgor Firm Firm Firm Nails: Nail dystrophy noted Nail dystrophy noted Nail dystrophy noted Color Pinkish in color Pinkish in color Pinkish in color Texture Shiny but scaly due to Shiny but scaly due to Shiny but scaly due to skin desquamation. skin desquamation. skin desquamation. Hair Hair distribution Hair dysplasia noted. Hair dysplasia noted. Hair dysplasia noted. Body hair Absent Absent Absent Color Black Black Black
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Condition Lips Teeth Oral Mucosa Gums Tongue Ovula Tonsils Trachea Thyroids Neck Size Shape Facial movement Scalp Lids

Scaly scalp and some fissures noted. Pallor Pallor Pallor Midline

Scaly scalp and some fissures noted. Mouth: Pallor Pallor Pallor Midline

Scaly scalp and some fissures noted. Pallor Pallor Pallor Midline Midline Not inflamed Midline Not inflamed Limited ROM Normocephalic Symmetrical and round Symmetrical Scaly Keratosis of skin near the periorbital region pulls the lids outwards. Sunken Pale Clear & shiny; no lesion Anicteric Equal size; 3 mm R & L; Brisk Uniform contrition/convergenc e Grossly normal Intact/full Poorly developed ears. Auricle in ears are poorly developed. asymmetrical Poorly developed septum Pale Both patent No discharge
11

Pharynx: Midline Not inflamed Midline Not inflamed Limited ROM Normocephalic Symmetrical and round Symmetrical Scaly Keratosis of skin near the periorbital region pulls the lids outwards. Sunken Pale Clear & shiny; no lesion Anicteric Equal size; 3 mm R & L; Brisk Uniform contrition/convergenc e Grossly normal Intact/full Poorly developed ears. Auricle in ears are poorly developed. asymmetrical Poorly developed septum Pale Both patent No discharge Midline Not inflamed Neck: Midline Not inflamed Limited ROM Head: Normocephalic Symmetrical and round Symmetrical Scaly Eyes: Keratosis of skin near the periorbital region pulls the lids outwards. Sunken Pale Clear & shiny; no lesion Anicteric Equal size; 3 mm R & L; Brisk Uniform contrition/convergenc e Grossly normal Intact/full Ears: Poorly developed ears. Auricle in ears are poorly developed. asymmetrical Nose: Poorly developed septum Pale Both patent No discharge

Periorbital region Conjunctiva Cornea & Lens Sclera Pupils: Size Reaction to light Reaction to accommodatio n Visual acuity Peripheral Vision Size Symmetry Septum Mucosa Patency Discharge

Breathing Pattern Shape of the chest Lung expansion Cough

RESPIRATORY SYSTEM January 26, 2012 January 27, 2012 Irregular Irregular 49cpm 46cpm AP:L ratio 2:1 AP:L ratio 2:1 Symmetrical Non productive Symmetrical Non productive

January 28, 2012 Irregular 48cpm AP:L ratio 2:1 Symmetrical Non productive

Precordial area Point of maximal impulse Heart sounds Peripheral pulses

CARDIOVASCULAR SYSTEM January 26, 2012 January 27, 2012 Flat Flat 3rd or 4th intercostal 3rd or 4th intercostal space, just left of space, just left of midclavicular line midclavicular line Regular Regular 92 95 Regular Regular 130 132 ABDOMEN & DIGESTIVE SYSTEM January 26, 2012 January 27, 2012 Superficial veins not Superficial veins not visible visible Symmetrical Symmetrical Hyperactive Normoactive 40 clicks/min 15 clicks/min (-)tenderness (-)tenderness Midline midline None None

January 28, 2012 Flat 3rd or 4th intercostal space, just left of midclavicular line Regular 93 Regular 135

General Configuration Bowel Sounds Palpations Umbilicus Presence of hemorrhoids

January 28, 2012 Superficial veins not visible Symmetrical Normoactive 12 clicks/min (-)tenderness Midline None

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Fluid intake Urine color Urine amount Urine frequency

RENAL SYSTEM January 26, 2012 January 27, 2012 Oral 230cc/day; IV Breastfeed; IV 1180 cc/day 630cc/day Amber colored urine Amber colored urine 870cc/day 510cc/day 4 times a day 3 times a day Intake Oral Parenteral 100 500 130 320 BF BF BF BF BF 160 200 240 240 150

January 28, 2012 Breastfeed; IV 500cc/day Amber colored urine 520cc/day 3 times a day

Date 1.26.12 1.27.12

Time 8-10 7-3 3-11 11-7

Total 600 450 160 200 T=810 240 240 150 T=630

Urine 250 370 w/ stool 170 180 150 180 180

Output Drainage Others -

Total 250 370 170 180 T=620 150 180 180 T=510

1.28.12

7-3 3-11 11-7

GAIT SPINE ROM MUSCLE TONE

MUSCULOSKELETAL SYSTEM January 26, 2012 January 27, 2012 Non-ambulatory Non-ambulatory Lordosis Lordosis Limited ROM of Limited ROM of extremities extremities Muscle wasting Muscle wasting noted noted

January 28, 2012 Non-ambulatory Lordosis Limited ROM of extremities Muscle wasting noted

Level of consciousness Orientation

NERVOUS SYSTEM January 26, 2012 January 27, 2012 Conscious and alert Conscious and alert Patient recognizes significant other and unfamiliarity to hospital experience. Other factors such as orientation to time and place are not applicable. Irritable N/A Patient recognizes significant other and unfamiliarity to hospital experience. Other factors such as orientation to time and place are not applicable. Calm N/A

January 28, 2012 Conscious and alert Patient recognizes significant other a unfamiliarity to hospital experience. Other factors such as orientation to time and place are not applicable. Irritable and restless N/A

Emotional state Verbal communication

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Day 1 Date: January 26, 2012

Head, Eyes, Ears, Nose and Throat (HEENT): skull symmetrical, fontanels closed, eyes intact, positive red light reflex eyes (OU), reacts to noise, nares patent.
Keratosis of skin near the periorbital region pulls the lids

Cardiovascula r: HR 134bpm,

Respiratory: RR 35cpm, regular Integumenta ry : Temp: 37, Skin pink, warm and flaky with no jaundice.

Gastrointestin al: Globular, abdomen; anus is patent. 40

Genitourinary: Urinary meatus is midline and an uninterrupted stream is noted on voiding, no nodules and discharges.

Musculoskeletal: Muscle wasting noted. Poorly developed toes and fingers and with presence of

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Day 2 Date: January 27, 2012

Head, Eyes, Ears, Nose and Throat (HEENT): skull symmetrical, fontanels closed, eyes intact, positive red light reflex eyes (OU), reacts to noise, nares patent.
Keratosis of skin near the periorbital region pulls the

Cardiovascular: HR 120bpm, cyanosis, no

Respiratory: RR 20cpm, irregular Intergument ary: Temp: 36.5, Skin pink, warm and flaky with no

Gastrointestin al: Bowel sounds 15 clicks/min, anus patent Musculoskeletal: Muscle wasting noted. Poorly developed toes and fingers and with presence of nail dystrophy.

Genitourinary: Urinary meatus is midline and an uninterrupted stream is noted on voiding, no nodules and dischargers.

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Day 3 Date: January 28, 2012

Head, Eyes, Ears, Nose and Throat (HEENT): skull symmetrical, fontanels closed , eyes intact, positive red light reflex eyes (OU), reacts to noise, nares patent.
Keratosis of skin near the Respiratory: periorbital region pulls the

Cardiovascular: HR 120bpm, cyanosis no

RR 20cpm, irregular Intergumentar y:

Skin was cool to touch, Pinkish brown; uniform skin color with slightly darker

Gastrointestin al: Bowel sounds 20 clicks/min, anus patent

Genitourinary: Urinary meatus is midline and an uninterrupted stream is noted on voiding, no nodules and dischargers.

Musculoskeletal: Muscle wasting noted. Poorly developed toes and fingers and with presence of nail dystrophy.

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III DEVELOPMENTAL DATA

Stage: Birth A. Psychosocial Theory

Erik Erikson Basic Trust vs. Mistrust Hope (birth- 18 months old) Begins to trust caregiver. Develops drive and hope.

According to the theorist, this stage is the most important period in a persons life. Patient is entirely dependent upon his mother or caretaker; hence his personality becomes so relative to the quality of care that he receives while he still is at this stage of growth. During this level, he learns whether he can put trust on people around him or not. It gives him a virtue of HOPE. This is crucially established whenever he cries and that his mother or his caretaker, immediately attends to his needs. When these needs are consistently met, the patient will learn to trust the people who are caring for him if otherwise, he may begin to develop mistrust. Instead of feeling safe and secured, he may become overly sensitive, fearful of rejection and of whatever is unpredictable and inconsistent.

Erick Ericksons Psychosocial Theory Basic Trust mistrust

Goal

Tasks

Evaluation

vs. Begins to caregiver. and hope.

trust Drive

patient He cries The and that developed trust to his his mother caregivers. or his caretaker, immediatel y attends to his needs.

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B. Cognitive Development Theory Jean Piaget Understanding of the world is through overt physical actions. Moves from simple reflexes to organized set of schemes of permanent objects. Sensorimotor stage is the first of the four stages in cognitive development which extends from birth to the acquisition of language. In this stage, patient begins to understand the world by coordinating experiences with physical and motor actions. He gains knowledge from the physical actions he performs on it (i.e. hearing, smelling, tasting, grasping). The knowledge of the world is limited because its based on physical interactions and experiences. The development of Object Permanence is one of the most important accomplishments at the sensorimotor stage wherein the patients understanding that objects continue to exist even though they cannot be seen or heard. Beginning this stage, patient eventually learns to familiarize objects in his environment. Although there are cases wherein he encounters objects which are unfamiliar to his senses, and that he cannot identify what physical actions he should do, stranger anxiety begins to occur to the patient. However, these are but normal experiences on this stage. Once accomplished, patient may be prepared to proceed to the next cognitive developmental stage.

Jean Piaget Cognitive Development Theory Sensorimotor Stage

Goal

Task

Evaluation

The patient will be able to familiarize objects in his environment.

The patient will be Anxiety to the able to understand surrounding will and learn from his eventually diminish. environment.

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III ANATOMY AND PHYSIOLOGY

Anatomy of the Gastrointestinal System: The human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the structures from the mouth to the anus. (The "digestive system" is a broader term that includes other structures, including the accessory organs of digestion). In an adult male human, the gastrointestinal (GI) tract is 5 meters (20 ft) long in a live subject, or up to 9 meters (30 ft) without the effect of muscle tone, and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract.
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The GI tract always releases hormones to help regulate the digestion process. These hormones, including gastrin, secretin, cholecystokinin, and grehlin, are mediated through either intracrine or autocrine mechanisms, indicating that the cells releasing these hormones are conserved structures throughout evolution.

Functions of the Gastrointestinal System: The gastrointestinal tract is also a prominent part of the immune system. The surface area of the digestive tract is estimated to be the surface area of a football field. With such a large exposure, the immune system must work hard to prevent pathogens from entering into blood and lymph. The low pH (ranging from enter 1 it. to 4) of the stomach is fatal for

many microorganisms that

Similarly, mucus (containing IgA antibodies)

neutralizes many of these microorganisms. Other factors in the GI tract help with immune function as well, including enzymes in saliva and bile. Enzymes such as Cyp3A4, along with the antiporter activities, also are instrumental in the intestine's role of detoxification of antigens and xenobiotics, such as drugs, involved in first pass metabolism. Health-enhancing intestinal bacteria serve to prevent the overgrowth of

potentially harmful bacteria in the gut. These two types of bacteria compete for space and "food," as there are limited resources within the intestinal tract. A ratio of 80-85% beneficial to 15-20% potentially harmful bacteria generally is considered normal within the intestines. Microorganisms also are kept at bay by an extensive immune system comprising the gut-associated lymphoid tissue (GALT).

ESOPHAGUS

20

The esophagus (or oesophagus)

is

an organ in vertebrates which

consists

of

a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach. It is usually about 2530 cm long depending on individual height. Function of the Esophagus Anatomically and functionally, the esophagus is the least complex section of the digestive tube. Its role in digestion is simple: to convey boluses of food from the pharynx to the stomach.

STOMACH

The st a muscular, part an of canal which

omach is hollow, dilated the alimentary functions as

important organ of the digestive tract. The stomach is about 12 inches (30.5 cm) long and is 6 inches. (15.2 cm) wide at its widest point. The stomach's capacity is about 1 qt (0.94 liters) in an adult.

Function of the Stomach The stomach is the portion of the digestive system most responsible for breaking down food. The lower esophageal sphincter at the top of the stomach regulates food passing from the esophagus into the stomach, and prevents the contents of the stomach from reentering the esophagus. The pyloric sphincter at the bottom of the stomach governs the passage of food out of the stomach into the small intestine.

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INTESTINE

Intestine (or bowel) is the segment of the alimentary canal extending from the pyloric sphincter of the stomach to the anus and, in humans and other mammals, consists of two segments, the small intestine and the large intestine. In humans, the small intestine is further subdivided into the duodenum, jejunum and ileum while the large intestine is subdivided into the cecum and colon. Small Intestine The small intestine is about six meters long (20 feet) and 2.5 cm wide (1 inch). It extends from the stomach to the cecum of the large intestine. There are three parts to the small intestine.

The duodenum is the first 25 cm (10 inches). The common bile duct enters the duodenum at the ampulla of Vater (hepatopancreatic ampulla). The jejunum is about 2.4 meters long (8 feet). Some digestion and absorption takes place in the first part of the jejunum. The ileum is about 3.6 meters long (12 feet). It extends from the jejunum to the ileocecal valve, which prevents the reflux of contents from the cecum back into the ileum. The lining of the ileum contains numerous patches of lymphoid tissue called Peyer's patches, which diminish the bacterial content of the digestive system.

Functions of the small intestine:

secrete digestive enzymes (peptidases, sucrase, maltase, and lactase) secrete buffers absorb nutrients
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Large Intestine The large intestine is also known as the colon or bowel. It is about 6.3 cm in diameter (2.5 inches) and 1.5 meters (5 feet) in length, extending from the ileum of the small intestine, to the anus. The large intestine does not secrete digestive enzymes and does not have villi. Parts of the large intestine include:
o

The taenia coli are three longitudinal muscle bands visible on the outer surfaces of the colon just beneath the serosa. Muscle tone within these bands produces the haustrae. The haustrae are external pouches that permit the considerable distension and elongation required of the intestine. They also affect the mucosal lining, producing a series of internal creases. The cecum is the expanded pouch at the start of the large intestine and where chyme first enters. Chyme is a semifluid mixture of food and digestive secretions. Attached to the cecum is the appendix. The ileocecal valve is the muscular sphincter or junction between the ileum and the cecum. The ascending, transverse, and descending portions of the colon encircle the small intestine The ascending colon begins at the ileocecal valve and ascends along the right side of the peritoneal cavity until it reaches the inferior margin of the liver. The right colic flexure or hepatic flexure marks the transition to the transverse colon. The transverse colon continues toward the left side, passing below the stomach, following the curve of the body wall. Near the spleen, it turns at the left colic flexure or splenic flexure. The descending colon continues on the left side until it reaches the iliac fossa where it curves and recurves to form the sigmoid colon, which empties into the rectum. The rectum is about 15 cm or 6 inches long. It is the last part of the digestive tract and the last portion of the rectum is the anorectal canal. The anorectal canal is the last inch of the colon that surrounds the anus.

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RECTUM

o o

absorption of water and certain electrolytes synthesization of certain vitamins (especially vitamin K and certain B vitamins) by the "good" intestinal bacteria temporary storage of fecal waste elimination of waste from the body (defecation)

o o

Function of the Rectum The rectum is a muscular ring that is at the end of the large intestine. Its function is to keep the intestine sealed shut until the need to pass feces arises. When that need arises it assists in the moving of the feces out of the bod

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IV PATHOPHYSIOLOGY

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V LABORATORY RESULTS
LABORATORY RESULT: JANUARY 23, 2012 HEMATOLOGY REPORT TEST WHITE BLOOD CELLS RED BLOOD CELLS REFERENCE 5.0-10.0 4.2-5.4 RESULT 13.2 3.08 INTERPRETATION Indicates infection Decreased in erythrocytes indicated fluid loss. Within the normal range. Indicates decreased concentration of RBC and plasma volume Within normal range. Within normal range. Indicates infection Indicates infection Within normal range. Within normal range.

HEMOGLOBIN HEMATOCRIT MCV MCH MCHC RDW-C PDW MPV DIFFERENTIAL COUNT LYMPHOCYTE (%) NEUTROPHIL (%) MONOCYTE (%) EOSINOPHILS (%) BASOPHILS (%) BANDS/STABS (%) PLATELETS

12.0-16.0 37.0-47.0 82.0-98.0 27.0-31.0 31.5-35.0 12.0-17.0 9.6-16.0 8.0-12.0

9.5 26.7 86.7 30.8 35.6 11.2 13.7 10.1

17.4-48.2 43.4-76.2 4.5-10.5 1.0-3.0 0.0-2.0 1.0-2.0 150-400

37.4 45.6 13.0 3.7 0.3 116

Within normal range. Within normal range. Indicates presence of infection Indicates infection Within normal range. -Decreased clotting factor and may indicate decreased in plasma volume.

LABORATORY RESULT: JANUARY 26, 2012

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HEMATOLOGY REPORT TEST WHITE BLOOD CELLS RED BLOOD CELLS REFERENCE 5.0-10.0 4.2-5.4 RESULT 12.5 3.05 INTERPRETATION Indicates infection Decreased in erythrocytes indicated fluid loss. Within the normal range. Indicates decreased concentration of RBC and plasma volume Within normal range. Within normal range. Indicates infection Indicates infection Within normal range. Within normal range.

HEMOGLOBIN HEMATOCRIT MCV MCH MCHC RDW-C PDW MPV DIFFERENTIAL COUNT LYMPHOCYTE (%) NEUTROPHIL (%) MONOCYTE (%) EOSINOPHILS (%) BASOPHILS (%) BANDS/STABS (%) PLATELETS

12.0-16.0 37.0-47.0 82.0-98.0 27.0-31.0 31.5-35.0 12.0-17.0 9.6-16.0 8.0-12.0

9.5 22.5 86.7 30.8 38.2 10.7 13.7 10.1

17.4-48.2 43.4-76.2 4.5-10.5 1.0-3.0 0.0-2.0 1.0-2.0 150-400

37.4 45.6 14.6 4.2 0.3 120

Within normal range. Within normal range. Indicates presence of infection Indicates infection Within normal range. -Decreased clotting factor and may indicate decreased in plasma volume.

PLEASE PAKIDUGANG SA INYO Lab!!!!!

VI SUMMARY AND CONCLUSION

In summary, current recommendations for the management of mild-to-moderate dehydration in the pediatric population secondary to AGE advocate for the use of
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ORT together with supplements and IV with low osmolarity based on the degree of clinical dehydration. Prevention is towards proper food handling should be addressed to reduce incidence of gastroenteritis.

DISCHARGE PLAN

Clients with Acute Gastroenteritis are instructed to take the following plan for discharge:

M- Medications should be taken regularly as prescribed, on exact dosage, time, & frequency, making sure that the purpose of medications is fully disclosed by the health care provider. Among the take home medications were:
Zinc Sulfate (E-zinc), 1 ml every 8am once a day Domperidone, (Motillium), 2 ml, three times daily, 8am, 1 pm

and 6pm Mupirocin apply on buttocks twice daily, 8am and 6pm E- Exercise should be promoted in a way by passive stretching of hand and feet every morning to promote proper circulation in the body.

T- Treatment after discharge is expected for patients and watcher with Acute Gastroenteritis to fully participate in continuous treatment. SO was encouraged to comply with the medications and treatment appropriate to the patient.

H- Health teachings were given with emphasis on:

The importance of proper hygiene and hand washing. Food and water preparation, intake of adequate vitamins

especially vitamin C-rich foods to strengthen the immune response and increasing of oral fluid intake should be conveyed.

O- OPD such as regular follow-up check-ups should be greatly encouraged to clients with Acute Gastroenteritis as ordered by physician to ensure the continuing management and treatment.

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 SO was advised to have a follow-up check up two weeks after in the hospital clinic.

D- Diet which is prescribed should be followed. Laxative-containing food should be avoided. To include high fiber diet and fruits especially banana in the diet is significant. Increase in fluid intake is also encouraged.

VII DEFINITION OF TERMS

Ondasetron- A drug currently used to fight nausea in cancer patients which has been shown effective in helping the hardest-to-treat, early onset alcoholics reduce their drinking. Norovirus- Noroviruses are a group of related, single-stranded RNA (ribonucleic acid) viruses that cause acute gastroenteritis in humans. Sapovirus- A genus of the family CALICIVIRIDAE associated with worldwide sporadic outbreaks of GASTROENTERITIS in humans. Astrovirus- a genus in the family Astroviridae; small, nonenveloped, single-stranded RNA virus associated with enteric infections in several species including cattle, sheep and dogs. In negatively stained electron micrographs virions have a characterisitic starlike staining pattern that gives the name to the genus. AGE- Acute Gastroenteritis, Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the stomach and intestine. It is frequently referred to as the stomach or intestinal flu, although the influenza virus is not associated with this illness. Major symptoms include nausea and vomiting, diarrhea, and abdominal cramps. These symptoms are sometimes also accompanied by fever and overall weakness. Gastroenteritis typically lasts about three days. Adults usually recover without problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to complications such as dehydration.

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VIII REFERENCE BIBLIOGRAPHY:

http://www.enchantedlearning.com/subjects/anatomy/digestive/ http://www.merck.com/mmpe/sec02/ch016/ch016a.html#sec02-ch016ch016a-924 http://baby.about.com/od/growthanddevelopment/p/physical_development_n ewborns.htm Microsoft Student Encarta Premium 2009 Microsoft Encarta 2006 http://www.leeds.ac.uk/chb/lectures/anatomy8.html http://www.emc.maricopa.edu/faculty/farabee/BIOBK/BioBookDIGEST.html http://nosubject.com/Anna_Freud http://www.medicinenet.com/gastroenteritis/article.htm#tocb http://www.drreddy.com/gastro.html http://www.emedicinehealth.com/gastroenteritis/page2_em.htm#Gastroenter itis%20Causes http://emedicine.medscape.com/article/801948-overview http://www.merck.com/mmpe/sec02/ch016/ch016a.html http://www.scribd.com/doc/12445474/NCP-Risk-for-Impaired-skin-integrity-rtdryskin-and-behaviors-that-may-lead-to-skin-integrity-impairment-AEBscratchingof-scabs BOOKS: Pediatric Nursing Parul Datta Medical and Surgical Nursing (2nd Edition) Volume 2 Nursing Diagnosis Handbook (A Guide to Planning Care) 5th Edition sAckley Ladwig Urinalysis and Body fluids Edition 4 Copyright 2001 by F.A. Davis Company Medical-Surgical Nursing Volume 1 (8th edition)
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Joyce M. Black, Jane Hokanson Hawks; Copyright 2008 Wongs Clinical Manual of Pediatric Nursing (6th Edition) Marilyn J. Hockenberry; Copyright 2004 Nurses Pocket Guide (11th edition) Marilynn Doengens, Mary Frences Moorhouse, Alice Murr, Copyright 2008 Van De Graaffs Human Anatomy Fifth Edition 2009 Lippincotts Nursing Drug Guide http://www.medscape.com/viewarticle/703533_2 http://www.medscape.com/viewarticle/568619 Merck Manual www.medicinenet.com www.census.gov.ph

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