CASE ABSTRACT

This is the case of Ms. F.V.B, 7 yrs. Old, residing at Paraaque City. Admitted last Feb. 1, 2011 with the chief complaint of fever and vomiting. One day prior to admission, patient was noted having high grade fever (39C), slightly relieved by Paracetamol. Patient also experienced vomiting of previously ingested food which prompted consultation for further evaluation and management. Upon admission to the ER, vital signs taken and recorded, febrile with temperature of 38C, BP of 90/60 mmHg, HR of 132 bpm, and RR of 28 cycles per min. She was seen and examined by Resident on duty with initial impression of Acute Gastroenteritis with severe dehydration. Consent for confinement signed by her parents. Orders made by the resident on duty, laboratory results of CBC, urinalysis, fecalysis requested to confirm the diagnosis of Acute Gastroenteritis with severe dehydration. IV fluid of D5 .3NaCl to run for 10 hours inserted and regulated at 100 cc/hr. Medications given: Paracetamol 200mg/5ml IV, Metoclopramide 50mg IV, Ampicillin 500mg IV. Brought to room of choice after observation and interventions are done.

PATHOPHYSIOLOGY

Acute gastroenteritis is usually caused by bacteria and protozoan. One of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts with ingestion of fecally contaminated food and water. The organism affects the body through direct invasion and by endotoxin being released by the organism. Through these two processes the bowel mucosal lining is stimulated and destroyed that eventually lead to attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the stomach. The client with acute gastroenteritis may also report excessive gas formation that may lead to abdominal distention and passing of flatus due to digestive and absorptive malfunction in the system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress to nausea and vomiting and increasing frequency of defecation. Abdominal pain and feeling of fullness maybe relieved only when the patient is able to pass a flatus. As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct invasion of the organism and the action of the hydrochloric acid of the stomach. As the protective coating of the stomach erodes the digestive capabilities of the acid helps in destroying the stomach lining. Pain or tenderness of the abdomen is then felt by the patient. When the burrows or ulceration reaches the blood vessels in the stomach, bleeding will be induced. Dysentery may be characterized by melena or hematochezia depending on the site and quantity of bleeding that may ensue. Signs of bleeding may be observed also through hematemesis. As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes water and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride and bicarbonate ions in the bowel as the body try to get rid of the organism by increasing peristalsis and number of defecation. Sodium and water reabsorption in the bowel is inhibited with the lost of the two electrolytes. Mild diarrhea is characterized by 2-3 stool, borborygmi (hyperactive bowel sound),fluid and electrolyte imbalance and hypernatremia. When the condition continue to progress, protein in the body is excreted to the lumen that further decreases the reabsorption and the body become overwhelmed that leads to intense diarrhea with more than 10 watery stool. Serious fluid volume deficit may lead to hypovolemic shock and eventually death.

Ingestion of fecally contaminated food and water.

Direct invasion of the bowel wall.

Endotoxins are released.

Stimulation and destruction of mucosal lining of the bowel wall. Pain Ulceration Bleeding (hematochezia, melena) Excessive gas formation, G.I. distention, flatus, N&V Attempted defecation (Tenesmus) Digestive & absorptive malfunction

Secretion of F&E in the intestinal lumen

Increase secretion of Cl & HCO3 ions in the bowel

Increase peristaltic movement

Hyperactive bowel sounds (borborygmi)

Mild diarrhea (2-3 stools)

Inhibition of Na reabsorption

F&E Imbalance

hypernatremia Intense diarrhea (>10x, watery stool)

Serious fluid volume deficit Hypotension Hypovolemic shock

Death

NAME/ CLASSIFICATION Metoclopramide (Maxolon) Gastrointestinal Stimulant

DOSAGE/ROUTE/ FREQUENCY 5 mg IV q 8

MECHANISM OF ACTION Dopamine antagonist that acts by increasing sensitivity to acetylcholine; results in increase motility of the upper GI Tract and relaxation of the pyloric sphincter and duodenal bulb.

INDICATION

SIDE EFFECTS

NURSING CONSIDERATIONS - Inject slowly over 1-2 mins. to prevent transient freelings of anxiety and restlessness. - Assess abdomen for bowel sounds vand distention, note any N&V. - Do not operate a car or hazardous machinery until drug effects realized; drug has a sedative effect up to 2hrs after dosing. - Avoid alcohol and any other CNS depressants.

Acute and recurrent diabetic gastroparesis, GERD.

Restlessness, drowsiness, fatigue, lassitude, anxiety, headaches, nausea, bowel disturbances.

NAME/ CLASSIFICATION Acetaminophen (Paracetamol)

DOSAGE/ROUTE/ FREQUENCY 200 mg/5ml IV q 4

MECHANISM OF ACTION Decreases fever by a hypothalamic effect leading to sweating and vasodilation. Inhibits the effect of pyrogens on the hypothalamic heat-regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis.

INDICATION

SIDE EFFECTS

NURSING CONSIDERATIONS - Document presence of fever. Rate pain, noting type, onset, location, duration, and intensity. - Take only as directed and with food or milk to decrease GI upset. - Any unexplained pain or fever that persists for longer than 3-5 days requires evaluation. - Avoid alcohol as this may cause toxicity.

Control of pain due to headache, ear ache, dysmenorrhea, arthritis. To reduce fever in bacterial or viral infection substitute for aspirin in upper GI disease, aspirin allergy, bleeding disorders, clients on anticoagulant therapy.

Few when taken in usual therapeutic doses. Chronic and even acute toxicity can develop after long symptom-free usage. Skin eruptions, fever, and drowsiness.

NAME/ CLASSIFICATION Ampicillin Sodium Antibiotic, penicillin

DOSAGE/ROUTE/ FREQUENCY 500mg IV q 6

MECHANISM OF ACTION Synthetic , broadspectrum antibiotic suitable for gramnegative bacteria. Acid resistant, destroyed by penicillinase.

INDICATION

SIDE EFFECTS

NURSING CONSIDERATIONS - Note history of sensitivity/reactions to this or related drugs. - Consume plenty of fluids to ensure adequate hydration. - Take for prescribed number of days even if symptoms subside. - Report adverse effects.

Respiratory tract infections due to Haemophilus influenzae and streptococcus pneumoniae. GI infections , GU infections.

Diarrhea, N&V, Flatulence, Abdominal distention, Fatigue, headache, urinary retention, rashes.

ASSESSMENT
Objective: - passage of loose watery stool - Nausea ad vomiting - fatigue - dehydration - weakness - decreased urine output - dry skin and mucous membrane - increased body temperature

DIAGNOSIS
Deficient fluid volume related to active fluid volume loss (vomiting, loose watery stool).

PLANNING
After 48 of nursing intervention, fluid volume deficit will be eliminated as evidenced by Fluid balance, electrolyte and acidbase balance, adequate hydration and adequate nutritional status; food and fluid intake.

INTERVENTION
1. Monitor and record VS. 2. Assess patients condition. 3. Monitor input and output balance. 4. Maintain adequate hydration, increase fluid intake. 5. Administer intravenous fluids as prescribed.

RATIONALE
1. To obtain baseline data. 2. To be aware of the patients condition and feelings. 3. To ensure accurate fluid status. 4. To prevent dehydration and maintain hydration status. 5. To deliver fluids accurately and at desired rates.

EVALUATION
Goal Met. After 48 of nursing intervention, fluid volume deficit was eliminated as evidenced by Fluid balance, electrolyte and acid-base balance, adequate hydration and adequate nutritional status; food and fluid intake.

ASSESSMENT
Subjective: Masakt ang tiyan ko. As verbalized by the pt. Objective: - Abdominal pain - weakness - diaphoresis - restlessness - facial grimaces - irritability - pain scale of 6/10

DIAGNOSIS
Acute pain related to inflammatory process.

PLANNING
After 8 of nursing intervention, pt. will demonstrate individualized relaxation techniques; maintain pain level at 3 or less.

INTERVENTION
1. Monitor and record VS. 2. Review factor that aggravate or alleviate pain 3. Ask the pt. to rate the pain on scale 0-10. 4. Encourage pain reduction techniques. 5. Administer analgesics as prescribed. 6. Instruct pt. to do deep breathing exercises.

RATIONALE
1. To obtain baseline data. 2. Helpful in establishing diagnosis and treatment needs. 3. To monitor pt.s pain level. 4. To reduce pain and promote relief/comfort. 5. To decrease pain.

EVALUATION
Goal Met. After 8 of nursing intervention, pt. demonstrated individualized relaxation techniques; maintained pain level at 3 or less.

6. Deep breathing exercises may reduce pain sensation.

ASSESSMENT
Subjective: Wala akong gana kumain. As verbalized by the pt. Objective: - Diarrhea - lack of interest in food - pale conjunctiva and mucous membrane - weakness - malaise

DIAGNOSIS
Imbalanced nutrition less than body requirements related to insufficient intake and excessive output.

PLANNING
After 12 of nursing intervention, pt. will verbalize willingness to follow diet, tolerate prescribed diet and report adequate energy levels.

INTERVENTION
1. Monitor and record VS. 2. Discuss eating habits and encourage diet for age

RATIONALE
1. To obtain baseline data. 2. To achieve health needs of the pt. with the proper food diet for her disease. 3. To reveal change that should be made in the clients dietary intake. 4. To maximize intake of nutrition.

EVALUATION
Goal Met. After 12 of nursing intervention, pt. verbalized willingness to follow diet, tolerated prescribed diet and reported adequate energy levels.

3. Note total daily intake include patter and time of eating. 4. Offer largest meal during time of day when patients appetite is greatest. 5. Create a pleasant environment for meals.

5. To encourage patient to eat.

ANATOMY AND PHYSIOLOGY

Small Intestine Consists of the duodenum jejunum, and ileum, the longest section. Majority of food nutrients are absorbed in the small intestine because its surface area consists of villi and microvilli, small fingerlike projections. Once chyme enters the dudodenum, contraction called segmentation occurs allowing the chyme to be moved down. Fat digestion occurs in the small intestine. Large Intestine Contains no villi. Mainly responsible for absorption of water and electrolytes and in the elimination of wastes. Consists of the following: (a) Cecum, where the ileum empties its contents. (b) Appendix is attached to the cecum and it has no known use and must be removed if it gets infected. (c) Colon has three main parts: the ascending, traverse and the descending and the sigmoid colon (the portion that crosses from the left to the midline to become the rectum). Most of the absorption occurs in the ascending and traverse colons. (d) Rectum and Anus. The rectum has veins and arteries. If the veins get enlarged they form hemorrhoids.

CASE STUDY ACUTE GASTROENTERITIS

JOHN LAWRENCE G. BATACLAN BSN 4 NCM 104 EDWIN DELA CRUZ CLINICAL INSTRUCTOR OGH ER