ON
ACUTE
GASTROENTERITIS
SUBMITTED BY:
MELISSA D. DAVID
I. Introduction
a. Overview of the Study
Acute diarrhea or gastroenteritis is the passage of loose stools more frequently
than what is normal for that individual. This increased frequency is often associated with
stools that are watery or semisolid, abdominal cramps and bloating.
Acute watery diarrhea is an extremely common problem, and can be fatal due to
severe dehydration, in both adults and children, especially in the very young and the old
or in those who have poor immunity such as individuals with HIV infection or patients
who are using certain medications that suppress the immune system.
Gastroenteritis means inflammation of the stomach and small and large
intestines. Viral gastroenteritis is an infection caused by a variety of viruses that result
in vomiting or diarrhea or both. It is often called the "stomach flu," although it is not
caused by the influenza viruses.
Persons can reduce their chance of getting infected by frequent hand washing,
prompt disinfection of contaminated surfaces with household chlorine bleach-based
cleaners, and prompt washing of soiled articles of clothing. If food or water is thought to
be contaminated, it should be avoided.
Since most cases of acute watery diarrhea are infectious, especially in
developing countries, the majority of such illnesses can be prevented by drinking water
or eating foods that are not contaminated with infectious agents. Washing hands
frequently with non-contaminated water, when caring for a patient with diarrhea as also
always before eating is important. Proper storage of food and water is also important to
prevent harmful bacteria from contaminating them.
Other symptoms include nausea, vomiting, loss of appetite, belching, and
bloating. Occasionally, acute abdominal pain can be a presenting symptom. This is the
case in phlegm nous gastritis (gangrene of the stomach) where severe abdominal pain
accompanied by nausea and vomiting of potentially purulent gastric contents can be the
presenting symptoms. Fever, chills, and hiccups also may be present. The diagnosis of
acute gastritis may be suspected from the patient's history and can be confirmed
histological by biopsy specimens taken at endoscopy.
Data collected via assessment, interviews with the patient, family members and
clinical records.
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 SLH hospital.
Developing a plan of care that will reduce identified predicaments and
complications.
Coordinating and delegating interventions within the plan of care to assist the
client to reach maximum functional health.
Further evaluating the effectiveness of nursing interventions that have been
rendered to the client.
Clients Name: J. V. G.
Age: 18 y/o
Birthday: November 18, 1996
Weight: 59.5 kg
Address: Sta. Cruz, Manila
Civil Status: Single
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: December 15, 2014
Chief complaint: Vomiting
Admitting diagnosis: AGE with moderate dehydration
Technique
Normal Findings
Actual Findings
Evaluation
Inspection
brown skin
Normal
Lighter colored
palms, soles, lips and
nail beds
Skin
Color
Moisture
Inspection
Inspection/
Palpation
Lips Cracked
Normal
Palpation
Warm to touch
Texture
Palpation
Turgor
Palpation
Normal
Inspection
Transparent, smooth
and convex cut and
clean
Normal
Nail beds
Inspection
Pinkish
Pinkish
Normal
Nail base
Inspection
Firm
Firm
Normal
Temperature
Normal
Normal
Skin appendages
a. Nails
Capillary refill
Inspection/
Palpation
Normal
b. Hair
Distribution
Inspection
Evenly distributed
Evenly distributed
Normal
Color
Inspection
Black
Black
Normal
Texture
Inspection/
Palpation
Smooth
Normal
Eyes
Inspection
May be a sign
of dehydration
Visual Acuity
Inspection
(penlight)
PERRLA- Pupils
equally round react to
light and
accommodation
Normal
Eyebrows
Inspection
Symmetrical in size,
extension, hair
texture and
movement
Symmetrical in size,
extension, hair texture
and movement
Normal
Eyelashes
Inspection
Distributed evenly
Normal
Eyes
Eyelids
Inspection
Blinks involuntarily
and bilaterally up to
20 times per minute
Normal
Conjunctiva
Inspection
Normal
Sclera
Inspection
Color is white
Color is white
Normal
Cornea
Inspection
Transparent, shiny
Transparent, shiny
Normal
Pupils
Inspection
Black, constrict
briskly
Normal
Iris
Inspection
Clearly visible
Clearly visible
Normal
Inspection
Free of lesions,
discharge of
inflammation
Normal
Ears
Inspection
Smooth, symmetric
with same color as
the face
Close to midline,
Normal
Nose
Shape, size and skin
color
Inspection
Nasal septum
Inspection
Normal
Inspection
Pink, moist
symmetric
Normal
Buccal mucosa
Inspection
Normal
Gums
Inspection
Normal
Normal
Normal
Nares
Inspection
Normal
Normal
Tongue
Teeth
Inspection
Inspection
Inspection
Normal
Neck
Symmetry of neck
muscles, alignment
of trachea
Inspection
Neck Rom
Inspection
Normal
Thyroid gland
Palpation
Normal
Normal
Trachea
Inspection
Midline
Midline
Normal
Auscultation
Normal
Abdomen
Inspection
Normal
Clicks or gurling
sounds occur
irregularly and range
from 5-35 per minute
Bowel sounds
Auscultation
Normal
Neurology system
Level of
consciousness
Behavior and
appearance
Inspection
Inspection
Fully conscious,
respond to questions
quickly, perceptive of
events
Normal
Normal
The digestive system consists of two linked parts: the alimentary canal and the
accessory digestive organs. The alimentary canal is essentially a tube, some 9meters
(30 feet) long that extends from the mouth to anus, with its longest section-the
intestines- packed into the abdominal cavity. The lining of the alimentary canal is
continuous with the skin, so technically its cavity lies outside the body. The alimentary
tube consists of linked organs that each play their own part in digestion: mouth,
pharynx, esophagus, stomach, small intestine, and large intestine. The accessory
digestive organs consist of the teeth and tongue in the mouth; and the 14 salivary
glands, liver, gallbladder, and pancreas, which are all linked by ducts to the alimentary
canal.
Stomach is a J- shaped enlargement of the GI tract directly under the diaphragm
in the epigastric, umbilical and left hypochondriac regions of the abdomen. When empty,
it is about the size of a large sausage; the mucosa lies in large folds, called RUGAE.
Approximately 10 inches long but the diameter depends on how much food it contains.
When full, it can hold about 4 L (1 galloon) of food. Parts of the stomach includes
cardiac region which is defined as a position near the heart surrounds the cardio
esophageal sphincter through which food enters the stomach from the esophagus;
fundus which is the expanded part of the stomach lateral to the cardiac region; body is
the mid portion; and the pylorus a funnel shaped which is the terminal part of the
stomach. The pylorus is continuous with the small intestine through the pyloric
sphincter, or valve. With the gastric glands lined with several secreting cells the
zymogenic (peptic) cells secrete the principal gastric enzyme precursor, pepsinogen.
VI. Pathophysiology
Interpretation
Yellow
Normal
SI turbid
5.5
Decreased
Specific Gravity
1.025
Normal
Albumin
Traces
Normal
Sugar
(-)
Normal
WBC
7-10
Infection
Color
Transparency
Reaction
Fecalysis
Results
Interpretation
Green
Sign of diarrhea
Soft
Sign of diarrhea
Normal
Color
Consistency
Parasites
Hematology
Results
Normal Value
Interpretation
Hemoglobin
123
120-150
Normal
Hematocrit
0.47
0.37-0.45
Increase
RBC
5.42
4.6-5.2
Increase
WBC
15.3
5-10 x 10/L
Increase, infection
Neutrophils
0.58
0.55-0.65
Normal
Lymphocytes
0.27
0.25-0.35
Normal
Platelets
297
140-340 x 10/L
Normal
MCV
77.3
86-100
Normal
MCH
26.7
26-31
Normal
MCHC
31.9
31-37
Normal
Results
Normal Value
Interpretation
11
7-17
Normal
0.64
0.52-1.04
Normal
Blood Chemistry
BUN
Creatinine
Brand
Classification
Indication
Nsg. Responsibilities
Biogesic
Analgesic;
antipyretic
For fever.
Flagyl
Trichomonacide,
amebicide
Gastrointestinal
disturbances and
irritations
Effective against
anaerobic bacteria and
protozoa. Specifically
inhibits growth by binding
to DNA, resulting in loss of
helical structure, strand
breakage, inhibition of
nucleic acid synthesis and
cell death
500 mg 1 tab
q4h PRN for
fever
Metronidazole
Action
Nsg.
Diagnosis
Fluid volume
deficit related
to increase
metabolic
demand and
insensible fluid
loss through
vomiting and
increased
body
temperature
Planning
At the end of
the shift, the
patient will be
able to:
- Achieve
adequate
hydration as
evidenced by
good skin
turgor, moist
mucous
membranes
and lips, no
alteration in
mentation
Intervention
>Assessed vital signs
and degree of
hydration and level of
consciousness
Rationale
>Provides baseline data
and information; this is
also important in the
evaluating clients
condition an success of
intervention
>Encouraged
adequate fluid intake
as tolerated by the
patient. Instructed
mother to provide
fluids in the bedside
>Regulated IVF
according to specified
flow rates basing on
the physicians order
>Regulation of fluid is
critical in maintaining
adequate circulating
fluids to recover for the
amount of water loss
through fever and
vomiting
>Monitored frequency
of urination and
amount of excreted
urine
Evaluation
At the end of the shift
the patient was able
to show signs of
improvement such
as:
- Achieved adequate
hydration as
evidenced by good
skin turgor, moist
mucous membranes
and lips, no alteration
in mentation
Assessment
Subjective data:
Mainit po ang
pakiramdam ko
as verbalize by
the patient
Objective data:
>T= 37.9
>Skin is warm to
touch
>RR = 20
Nsg.
Diagnosis
Hyperthermia
r/t exposure to
hot
environment as
evidenced by
temperature of
37.9
Planning
After 30 mins
of nursing
interventions,
the patient
will maintain
a core
temperature
within normal
Intervention
Rationale
>Provide proper
ventilation.
>Dysrhythmias are
common due to
electrolyte imbalance,
dehydration, and direct
effects of hyperthermia
on blood and cardiac
tissue.
>Heat loss by
convention.
>Promote surface
cooling by means of
cool environment
and/or fans
>Promote client safety
.
>Encourage patients
participation in ways to
protect oneself from
excessive exposure to
hot environment.
>Instruct client/relative
to increase fluid intake.
>Ensuring patients
safety prevents other
problems.
>Self-care awareness
helps in the prevention
and control of
hyperthermia.
>Adequate fluid intake
prevents dehydration.
These may indicate
prompt interventions.
Evaluation
After 30 minutes of
nursing interventions
the patient was able
to maintain core
temperature within
normal, 37.5
X. Discharge Planning
Medications instructed client to continue medications as ordered by the physician
Economics Advised client to buy foods within the budget.
Treatment Pt. was still advised for increase fluid intake, periodic complete emptying of
urinary bladder and keep hands clean. He still have a follow up check up after 1 week
after discharge.
Health Teaching Proper hygiene of both child and parent are very important as
defense from infection. Proper and strict supervision of child until balance, gait, and
coordination is gained. Advise to restrict child from handling items or objects especially
if unfamiliar and not edible. Emphasize importance of hand washing.
Out Patient Client was advised to have follow-up check up one week after discharge.
Diet Client was ordered with diet for age, with increase fluid intake.