Anda di halaman 1dari 18

Liceo de Cagayan University College of Nursing NCM501205

As Partial Requirement for NCM501205 Case Study on

Acute Gastro-enteritis with moderate Dehydration


Submitted to: Ms. Marineth Zapanta Clinical Instructor Submitted by: Webster S. Abadiano

October 13,2011 (Bukidnon Provincial Malaybalay Center)


PAGES I. Introduction a. Overview of the case b. Objective of the study c. Scope and Limitation of the study II. Health History a. Patient Profile b. Family health history c. Past health history d. History of present illness III. Developmental Data IV. Medical Management a. b. Medical Orders and Rationale Drug Study 6 7-8 9-10 11-14 1518-20 21-22 23 4 4 4-5 3 3 1 2 2

V. Pathophysiology with Anatomy & Physiology VI. Nursing Assessment (System Review & Nursing. Assessment II VII. Nursing Management a. b. Ideal Nursing Management 17 Actual Nursing Management (SOAPIE) VIII. Referrals and Follow-up IX. Evaluation and Implications b. Organization/Grammar/Bibliography

I. INTRODUCTION
A. OVERVIEW OF THE CASE Acute Gastroenteritis (AGE) 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. Gastroenteritis arises from ingestion of viruses, certain bacteria, or parasites. Food that has spoiled may also cause illness. Certain medications and excessive alcohol can irritate the digestive tract to the point of inducing gastroenteritis. Regardless of the cause, the symptoms of gastroenteritis include diarrhea, nausea and vomiting, and abdominal pain and cramps. Sufferers may also experience bloating, low fever, and overall tiredness. Typically, the symptoms last only two to three days, but some viruses may last up to a week. A usual bout of gastroenteritis shouldn't require a visit to the doctor. However, medical Treatment is essential if symptoms worsen or if there are complications. Infants, young children, the elderly, and persons with underlying disease require special attention in this regard. The greatest danger presented by gastroenteritis is dehydration. The loss of fluids through diarrhea and vomiting can upset the body's electrolyte balance, leading to potentially life- threatening problems such as heart beat abnormalities (arrhythmia). The risk of dehydration increases as symptoms are prolonged. Dehydration should be suspected if a dry mouth, increased or excessive thirst, or scanty urination is experienced. If symptoms do not resolve within a week, an infection or disorder more serious than gastroenteritis may be involved. Symptoms of great concern include a high fever (102 F [38.9 C] or above), blood or mucus in the diarrhea, blood in the vomit, and severe abdominal pain or swelling. These symptoms require prompt medical attention

B. OBJECTIVES OF THE STUDY This study aims to: Conduct and evaluate an assessment for the client Determine the causes, predisposing and precipitating factors that constitute the onset of the disease process. Render series of nursing interventions for the clients care Provide and disseminate important information as teachings to the client and the significant others to boost the knowing and understanding of the nature of the said health condition. Improve skills and knowledge as health care providers in the clinical area C. SCOPE AND LIMITATIONS OF THE STUDY 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 BPMC hospital. c. 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 mother as a SO, patients chart and nurse on duty. b. The interaction, assessment and care were only limited to a total of 24 hours (3 days

clinical duty, assessment) with actual nursing intervention done.

II. HEALTH HISTORY


A. Patients Profile Name : Age : Sex : Address : Date of Birthday : Birthplace : Religion : Nationality : Civil Status : Weight : Occupation: Income : JLG 8 months male Taguican valley, canayan, Malaybalay city December 31, 2010 Malaybalay city Baptist Filipino Child 7.3kg n/a n/a

Educational Attainment : n/a Most supportive person : mother Date of Admission : Time of Admission: Ward/ Room : First Impression : Chief Complaints : Final diagnosis: (hypokalemia) 2 to Admitting Physician : September 18,2011 9:30 P.M. Pedia Ward/ Room 302 AGE with moderate Dehydration vomiting and fever AGE with moderate dehydration, electrolytes imbalance acute gastrointestinal loses Dr. Shane Tortola

B. Family and Present health History The patients mother has diabetes and her father has no serious disease diagnose yet. The patient is a non-diabetic, non-hypertensive and non-asthmatic and has no previous hospitalization until today. C. History of Present Illness: A case of JGL, 8 months old Male, Filipino, a resident of Canayan, Malaybalay city, admitted for the first time at BPMC hospital with a chief complaint of LBM. Two days prior to admission he had persistent vomiting and fever.

III. DEVELOPMENTAL DATA


Developmental Task Theory of Robert Havighurst A developmental task is a task which arises at or about a certain period in the life of an individual. Havighurst has identified six major age periods: Infancy and early childhood (0-5 years). Basing on Havighursts Theory, my patient belongs in the infancy and early childhood stage wherein he is learning to distinguish right from wrong and developing a conscience. Psychosexual Theory of Sigmund Freud The psychosexual stages of Sigmund Freud are five different developmental periods during which the individual seeks pleasure from different areas of the body associated with sexual feelings Basing on this theory, JLG belongs to the oral stage wherein an infants pleasure centers are in the mouth. This is also the infant's first relationship with its mother; it is a nutritive one. Psychosocial Theory of Erik Erickson

Erik Erickson envisioned life as a sequence of levels of achievement. Each stage signals a task that must be achieved. He believed that the greater that task achievement, the healthier the personality of the person. Failure to achieve a task influences the persons ability to achieve the next task. Basing on this theory, he is still belongs to Infancy based on Eriksons theory the child developmental task is the TRUST vs. MISTRUST Because an infant is utterly dependent; the development of trust is based on the dependability and quality of the childs caregivers. If a child successfully develops trust, he or she will feel safe and secure in the world. Caregivers who are inconsistent, emotionally unavailable, or rejecting contribute to feelings of mistrust in the children they care for. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. Cognitive Theory of Jean Piaget Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction and influence of genetic and learning factors. Basing on this theory, JLG belongs to the sensorimotor stage in which inventions of new means through mental combinations. The patient uses memory and imitation act, he can solve basic problems.

VI. MEDICAL MANAGEMENT


A. Medical Orders and Rationale

Date September 18,2011 9:30 pm

Doctors order - please admit to ward

LBM, Vomiting for 2 days

Rationale For further management and treatment of condition -Secure consent - For further management and treatment of condition -TPR q 4 To have baseline data and for comparison of future data / for monitoring of patients condition. -diet for age to provide easy digestion of food -IVF with D5 0.3percent NaCl For hypertonic dehydration, Na 500 cc at 35 cc/hour and chloride depletion and water replacement -Labs: CBC with Platelet count, To screen the patients blood, SE, U/A urine and stool exam component and to detect any abnormalities. This also serves as a baseline data to evaluate effectiveness of blood transfusions. -Meds: Zinc drops 1.0ml OD P.O Paracetamol 100 ml PO q 4 PRN for above 38 degree celcius -Refer For treatment and for specific indication

Sunken eyeballs, Sunken fontanels

Weight: 7.3 kg T-36 RR-34 PR-128

Refer for any progression of the condition

-Thanks By: Dr. ShaneTortola September 19,2011 Still with LBM September 20,2011 -continue meds For continuing of treatment -follow up labs To follow the result -IVFTF with D5IMB 500cc at This is the IV that has a bigger 30cc/hr(2 bottles) amount of K (20 mEq) -continue meds For continuing of treatment -IVFTF D5IMB 500cc at same This is the IV that has a bigger rate -Vit. A 100,000 Units S.D -Cefexime drops 1.8Ml BID P.O -give PNSS 150 cc with IV amount of K (20 mEq) For nutrient purposes For antibiotic purposes Treatment for diarrhea and

Bolus now vomiting -revise present IVF with D5LR Replacement therapy 1L at 30 mgtts/min x 6 hour then regulate at 12 gtts/min particularly in extracellular fluid deficit

C. Laboratory Results Clinical Chemistry

Potassium Sodium
CBC

2.14 143.6

3.6-5.5mEq/dl 135-155 mEq/dl

CBC wbc Hgb Hct Platelet count Differential count Segmenters Lymphocyte Monocytes Eosinophils Basophils Urine analysis Fecalysis Color Color Transparency Sugar Character SP Gravity Fat globules Reaction Albumin

Result 6.1 10.2 32.3 428,000 25.5 49.4 23.4 0.8 0.9

Value 5,000-10,000 11.7-14.5 34.1-44.3 vols 174,000-390,000 43.4-76.2 17.4-46.2 4.5-10.5 2-3 4.5-0.5

yellow Greenish cloudy negative Soft 1.016 Plenty 6.0 negative

V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

DIGESTIVE SYSTEM 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 salivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the alimentary canal.

STOMACH It 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 ardioesophageal 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. The parietal (oxyntic) cells produce hydrochloric acid, involved in conversion of pepsinogen to the active enzyme pepsin, and intrinsic factor, involved in the absorption of Vitamin B12 for the red blood cell production. Mucous cells secrete mucus. Secretions of the zymogenic, parietal and mucus cells are collectively called the gastric juice. Enter endocrine cells secrete stomach gastrin, a hormone that stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower esophageal sphincter, mildly increases motility of the GI tract, and relaxes the pyloric sphincter. Most digestive activity occurs in the pyloric region of the stomach. After food has been processed in the stomach, it resembles heavy cream and is called CHYME. The chime enters the small intestine through the pyloric sphincter

Pathophysiology
Name of the patient: JLG Diagnosis: AGE with moderate DHN Definition: Acute Gastritis is defined as diarrheal disease of rapid onset, often with nausea, vomiting, fever, abdominal pain and loose bowel movement. It is an inflammation of the mucous membranes of the stomach often caused by an infection. Predisposing Factors: Environment ~ Age(6 Months) Hygiene Stress Precipitating Factors: Gender(Male) Age(6 Months)

VII. NURSING MANAGEMENT


Ideal Nursing Management -Risk for fluid volume deficit related to excessive losses through normal routes (frequent diarrhea, vomiting) IDEAL NURSING MANAGEMENT

INTERVENTION

RATIONALE

INDEPENDENT Monitor Intake and Output. Note number, Provides information about overall fluid character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. balance,renal function, and bowel disease Measure urine specific gravity; observe for control, as well asguidelines for fluid oliguria. replacement. Assess vital signs (BP, pulse, temperature) Hypotension (including postural), tachycardia, fever can indicate response to Observe for excessively dry skin and and/or effect of fluid loss. Indicates excessive fluid loss/resultant mucous membranes. Slowed capillary refill. dehydration. Indicator of overall fluid and nutritional status. Colon is placed at rest for healing and to decreasedintestinal fluid losses. Inadequate diet and decreased absorption may leadto vitamin K deficiency and defects in coagulation,potentiating risk for hemorrhage. COLLABORATIVE Excessive intestinal loss may lead to electrolyteimbalance, e.g., potassium, which Administer parenteral fluids, blood is necessary for proper skeletal and cardiac transfusions as indicated. muscle function. Minor alterations in serum Monitor laboratory studies, e.g., levels can result in profoundand/or lifeelectrolytes (especially potassium, magnesium) and ABGs (acid-base balance). threatening symptoms. Maintenance of bowel rest requires Administer medications as indicated: alternative fluidreplacement to correct Antidiarrheal e.g., dipphenoxylate (Lomotil),loperamide (Imodium), anodyne losses/anemia. Note: fluidscontaining sodium may be restricted in presence of suppositories. regional enteritis. Antiemetic, e.g., trimethobenzamide Determines replacement needs and (Tigan),hydroxyzine (Vistaril), effectiveness of therapy. prochlorperazine(Comparazine); Reduces fluid losses from intestines. Antipyretics, e.g., acetaminophen Used to control nausea and vomiting in (Tylenol); acuteexacerbations. Electrolytes, e.g., potassium supplement Controls fever, reducing insensible losses. (KCl-IV;K-Lyte, Slow-K); Electrolytes are lost in large amounts, Vitamin K (Mephyton especially inbowel with denuded, ulcerated areas, and diarrheacan also lead to metabolic acidosis through loss of bicarbonate (HCO3). Stimulates hepatic formation of prothrombin,stabilizing coagulation and reducing risk of hemorrhage Weigh daily Maintain oral restrictions, bed rest. Observe for overt bleeding and test stool daily for occult blood. Note generalized muscle weakness or cardiac dysrhytmias.

2. Actual Nursing Management

S
O

sige raman siya gud og gasuka as verbalized by the mother Sunken eyes Dry skin Watery stool Persistent vomiting Fluid volume deficit related to excessive losses through GI tract secondary to diarrhea Long term: At the end of shift days, patient will maintain electrolytes balance. Short term: At the end of 8 hours, the patient will be able to restore fluid and electrolyte imbalances Independent: Encouraged the mother to give oral fluid intake. To increase fluid intake Monitored intake and output balance. To ensure accurate picture of fluid status Observed for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. Indicates excessive fluid loss/resultant dehydration Weighed daily Indicator of overall fluid and nutritional status Monitored vital signs To note the changes in heart rate and respiration Dependent: .Provided supplement fluids as indicated D5LR 500cc @ 28cc/hr Fluids may be given in this manner if patient is unable to takeoral fluid Goal has been met; at the end of 8 hours, the patient was able to restore fluid and electrolyte imbalances

A P

S O

init man gud kayo siya as vervalized by the mother Flushed skin, Warm to touch. Restlessness T-37.8 Hyperthermia related to dehydration. After 4 hrs. Of nursing interventions, the patient will maintain core temperature within normal range. Independent: Administer replacement fluids and electrolytes. To support circulating volume and tissue perfusion. Promote surface cooling by means of tepid sponge bath. To decrease temperature by means through evaporation and conduction. Maintain bed rest. To reduce metabolic demands and oxygen consumption Provide high calorie diet, tube feedings, or parenteral nutrition.

A P I

Administer antipyretics orally or rectally as prescribed by the physician. To facilitate fast recovery. After 4 hrs. Of nursing intervention s, the patient was able maintain core temperature within normal range.