Anda di halaman 1dari 62

Section P Group 1 E.C.S.

Pediatric Ward
RLE (Period covered: July 27-Aug. 1,2009)

Mr. Ralph P. Pilapil, R.N. Clinical Instructor

A. Nursing History
Identifying Data
Name of Patient Sex Age Civil Status Nationality Religion Address Occupation Date Admitted Time
Informant Age Physician Room

: : : : : : : : : :
: : : :

Patient X Male 16 years old Single Filipino R.C. Sta. Cruz, Guizo Mandaue City Student July 27, 2009 8:10 p.m.
Mother 30 years old Dr. Pitogo Pediatric Ward

Admission Data
Source of Information Mode of Admission : Mother : Ambulatory

Vital Signs on Admission Temperature : 36.6C Heart Rate : 60 bpm Respiratory Rate : 18 cpm Blood Pressure : 120/70 mm Hg Weight : 56 kg Height : 5 4 Chief of Complaints: LBM, pain and vomiting

History of Present Illness

Two days PTA, The patient defecated watery stools more than 5 times with nausea and vomiting. The following day, Monday, client still defecated watery stool in succession and was partially relieved after taking Diatabs. After several hours LBM reoccur with occasional vomiting. Thus, patients mother saught medical advise resulting to his admission.

Past Medical History

The client experienced severe diarrhea last January 2004 and was hospitalized.

No previous injuries

No minor and major operation were performed

Family Medical History:

Negative in: Heart Disease Diabetes Mellitus Hypertension Cancer Congenital Anomalies Obesity Arthritis Seizure Tuberculosis

Physical Assessment
Eye functioned well and responsive to light accommodation (3-4mm) tonsils are pink and in normal size


Central Nervous System

able to speak the words clearly (responsive) irritability noted negative presence of seizure or tremors weak hand grasping and movement


Cardio Vascular System

weak capillary refill blood pressure of 100/60 regular heart rhythm


Respiratory System
symmetric chest expansion clear breath sound


Gastrointestinal System
presence of hyperactive bowel sound excessive bowel elimination (five times/day) facial grimacing noted during defecation palpated with soft abdomen/tender pain sensation at anal area due to irritation from frequent defecation excessive loose / watery stool with fecal particles Dry skin & poor skin turgor Sunken eye ball


Genito-Urinary System
disturbed sleeping pattern due to nocturnal urination low urine output (25ml/hour) reddish urine color


Integumentary System
poor skin turgor rough / dry skin responsive to pain


Musculoskeletal System
can stand and sit on his own with signs of weakness poor tendon reflex

Laboratories Performed
Date Ordered: July 27, 2009

Fecalysis Urinalysis Specimen Data Report

Diagnostic Color Normal Value Yellow Result Reddish Significance Presence of components that indicates infection

Cellular Findings RBC Pus Cells Bacteria Yeast Cells



Sign of dehydration
Normal Normal Infection is present Normal

None 0-2 None

Not Seen 0-1/Hpf Many Rare

Color Transparency Ph Specific Gravity Protein Sugar Microscopic Exam: Pus Cells RBC Epithelial Cells A. Urates 0-2 0-1 3-6 0-1 Few Few Infection present Normal Normal Normal

Normal Value
Clear Clear 6-7.5 1.010-1.025 Negative Negative

Yellow Clear 6.0 1.025 Negative Trace


Normal Normal Normal w/in normal range

A. Phosphates Bacteria
Mucus Thread Ca Oxalates

Few Moderate

Normal Normal


Diagnostic WBC Normal Value 5-10/109L Result 14.0 Significance Increased WBC count indicates infection

B. Anatomy & Physiology

Organs affected Functions Growth and development according to the age of client

Digestive System

ESOPHAGUS Approximately 25 cm (10inches long) but its diameter depends on how much food it contains. When its full, it can hold about 4 liters of food; when empty, it collapses and its mucosa is thrown into large folds called rugae. Esophageal peristalsis propels the bolus of food into the stomach through the cardiac sphincter

A distendible pouch with a capacity of about 1500 mL 4 anatomic regions Stores and mixes food with the enzymecontaining gastric juice. Produces protein digesting enzymes pepsinogen, mucus, intrinsic factor and hydrochloric acid. Food stays from a half hour to several hours Chyme, which is food mixed with secretions enters the small intestine through the pyloric sphincter

The small intestine is the longest and most convoluted portion of the digestive tract Measuring 16 to 19 feet ( 5 to 6m) in length in an adult. Composed of three different regions: - duodenum, - jejunum, and - ileum. The inner surface of the small intestine has a velvety appearance because of numerous mucous membrane finger like projections called intestinal villi. Pancreatic secretions: trypsin, amylase and lipase Intestinal glands secrete mucus, hormones and electrolytes that coats the

Three main functions:
movement (mixing and peristalsis) digestion absorption

about 5 to 6 feet in length from the ileocecal valve to the anus lined with columnar epithelium that has absorptive and mucous cells. it begins with the cecum, a dilated pouchlike structure that is inferior to the ileocecal opening. the large intestine then extends upward from the cecum as the colon. the colon consist of four divisions: - ascending colon - transverse colon - descending colon - sigmoid colon.

Three Main Functions:
Absorption Elimination Movement


Is an increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract. Primarily affects the small bowel and can be either viral or bacterial origin.

C. Pathophysiology
Precipitating Factors: Poor sanitation during warm months Crowded living conditions Risk Factors: Children Older adults Familial tendency


Signs and Symptoms Watery stools Intestinal rumblings Abdominal pain Distention Vomiting Fever Diagnostic Evaluation Fecalysis Urinalysis Specimen Data Report

DIAGNOSIS Acute Gastroenteritis

Release of enterotoxins and attachment of organism to mucosal epithelium

GI wall irritation and destruction of intestinal villi

Fluid secreted into lumen

Increased fluid in the GI lumen and reduction of absorption




Complications SHOCK - renal failure - irreversible acidosis

The pt. was responsive to the therapeutic mgt.

Signs and Symptoms: Diarrhea


The epithelium of the digestive tube is protected from insult by a number of mechanisms constituting the gastrointestinal barrier, but like many barriers, it can be breached. Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species. Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results.

Abdominal pain or cramp Explanation:

The pain associated with obstruction of a hollow viscus (as opposed to peritoneal and solid organ pain) is often intermittent or "colicky", coinciding with the peristaltic waves of the organ. Such cramps are exactly what is experienced with early acute appendicitis and gastroenteritis and are somewhat relieved by writhing and massage

Vomiting in diarrhea can occur when the lining of the intestines or stomach is irritated by an infection. Usually the infection is caused by a virus or bacteria. Diarrhea and vomiting can drain water and salts from the patient. These need to be replaced to prevent the patient from becoming dehydrated (dry).

D. Medical Managements
Complete Blood Count Urinalysis Routine stool examination Stool Culture Barium enema

Urinalysis Fecalysis


Ranitidine HCl (Zantac) 80mg slow IVTT q8h Antiulcer Agent Ciprofloxacin HCL 500mg 1tab BID PO PC - Anti Infective Agent Aluminum Magnesium Hydroxide(Isopan) 20 ml 1pc 2 H.S. - Antacid Agent

Ideal: Oral rehydration therapy Antimicrobial therapy E coli: Antibiotic treatment Actual: D5LR 1 Liter @ 30 gtts/min Monitoring of urine and stool V/S q shift

IV. EXERCISES AND ACTIVITIES Ambulate by himself w/o the assistance of S.O.
V. DIET Ideal: The bland diet Introduce lean meats and clear fluids as soon as possible. Actual: DAT

Medications are substances used in the diagnosis, treatment, cure, relief, or prevention of health alterations. This is the primary treatment client associate with restoration of health.

Name of Drug Generic (Brand) Ranitidine HCL (Zantac) Mechanism of Action

Competitively inhibits action of histamine on the H2 @ receptor sites , parietal cells decreasing gastric secretion.

Date Ordered


Dose Frequency Route


Anti ulcer drug

80 mg, slow IVTT q8 hr

Specific Indication

Side Effects

Nursing Implications
Before : Assess patient for abdominal pain, note for presence of blood & emesis & stool. During: Administer IVTT slowly. After: Monitor patient for adverse reaction. Store IV injection @ 30 degrees After dilution solution is stable for 48 hrs. @ room temperature. After taking the medication advise pt to report immediately any adverse reactions.

Gastro esophageal CNS: vertigo, reflux disease malaise, headache. EENT: blurred vision Contraindications: -patient with Hepatic: jaundice hypersensitive to Other: burning and drug & those with itching @ injection phorphyria. site anaphylaxis, -Use cautiously in patient with hepatic angioedema.
dysfunction. -adjust dosage in patient with impaired renal function

Name of Drug Generic (Brand) Ciproflaxacin HCL

Date Ordered 7/27/09


Dose Frequency Route 500 mg/tab BID PO pc

Anti -Infective

Mechanism of Action
Inhibits bacterial DNA, an enzyme needed for bacterial replication.

Specific Indication
Complicated intraabdominal infection.

Side Effects
EENT: local burning or discomfort, foreign body sensation, itching. GI: bad or better taste in mouth.

Nursing Implications
Before: -Assess vital sign. -Assess lab. Results and the causative agent. During: -Stop drug @ first sign of any hypersensitivity. After: -Prolonged use may result in overgrowth of susceptible organisms. -Assess for adverse reaction.

Contraindications: -Hypersensitive to a ciproflaxacin. --its unknown if drug appears in breast milk after application.

Name of Drug Generic (Brand) Aluminum Magnesium Hydroxide (Isopan) Mechanism of Action
Reduces total acid load in GI tract, elevates gastric ph to reduce pepsin activity strengthens gastric mucosal barrier, and increases esophageal sphincter tone.

Date Ordered 7/27/09


Dose Frequency Route Susp. 20 ml pc 2 H.S.


Specific Indication
Acid indigestion . Contraindications: Severe renal disease. Use cautiously in patients with mild renal impairment.

Side Effects
GI: mild constipation, diarrhea. GU: increased urine ph. Metabolic: hypokalemia

Nursing Implications
Before: -Assess patient with renal failure. -Instruct patient not to take suspension or liquid well and follow dose with water. During: -monitor magnesium level in patient with mild renal impairment. After : -Urge patient to notify prescriber about the signs or symptoms of GI bleeding, such as tarry stools & coffee ground vomiting.

Nursing Management

Deficient Fluid Volume

I. Goal of Care: To assess causative/precipitating factors:
Determine effects of age.

II. Goal of Care: To correct/replace losses to reverse pathophysiological mechanisms.

Establish 24 hour fluid replacement needs and routes to be used.

III.Goal of Care: To promote comfort and safety:

Provide frequent oral care as well as eye care. Administer medications.

Acute Pain

Goal of Care: To evaluate clients response to pain:

Perform pain assessment each time pain occurs. Accept clients description of pain. Assess for referred pain as appropriate..


Goal of Care: To assist client to explore methods for alleviation/control of pain:

Review/expectations and tell client when treatment will hurt. Administer analgesics as indicated to maximal dosage as needed. Assist client to alter drug regimen, based on individual needs.


Goal of Care: To promote wellness (Teaching/Discharge Considerations):

Encourage adequate rest periods. Provide for individualized physical therapy/ exercise program that can be continued by the client when discharged.

Risk for Imbalanced Nutrition


Goal of Care: To assess causative/contributing factors:

Ascertain understanding of individual nutritional needs. Discuss eating habits, including food preferences, intolerance /aversions. Assess drug interactions, disease effects, allergies, use of laxative, diuretics. Determine psychological factors/perform psychological assessment as indicated.


Goal of Care: To establish a nutritional plan that meets individual needs:

Assist in developing individualized regimen. Consult dietitian/nutritional team as indicated. Limit fiber/bulk if indicated. Prevent/minimize unpleasant odors/sights. Encourage client to choose foods that are appealing.


Goal of Care: To promote wellness (Teaching/Discharge Considerations):

Weigh weekly and document results Refer to home health resources and so on Consult with dietitian/nutritional support team as necessary

Nursing Care Plan 1

tubig gihapon ako gikalibang as verbalized by the pt.

excessive loose / watery stool Dry skin & poor skin turgor Sunken eye ball excessive bowel elimination (five times/day)

Fluid volume deficit related to diarrhea secondary to acute gastroenteritis.

Scientific Basis:
Decreased intravascular, interstitial and/ intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

After 2-4 hours nursing interventions, the patient will be able to maintain fluid volume at functional level as evidenced by stable vital signs, moist mucous membranes & good skin turgor.

Independent: After 2-4 hours of nursing interventions, patient will experience adequate fluid volume and electrolyte balance as evidenced by: urine output greater than 30 ml/hr, normal blood pressure, heart rate of 60-100 beats/ min, respiratory rate of 12-20 cycles/min,normal skin turgor. Pt. will maintain afebrile state. Pt. will initiate rehydration. Pt. will increase fluid intake of more than 2 liters. Dependent: Patient will follow medication on time. Collaborative: Patient will eat food prepared for him as advised by dietician.


RATIONALE This can help with making the various nursing interventions Most fluids enter the body through drinking water in foods & water.

Obtain patient history to ascertain the probable cause of the fluid disturbance Evaluate fluid status in relation to dietary intake.

Monitor temperature .

Febrile states decrease body fluids through perspiration.

Encourage oral hygiene

This promotes interest in drinking, leading to rehydration

Encourage oral intake of small amounts of fluids and bland foods.

Eating small amounts can be helpful because it is more easily absorbed.

Be creative in providing oral fluids to promote and encourage intake.

Provide oral fluids that are preferred by the patient and place it at bedside, within reach. Ensure that it is fresh.

Teach interventions to prevent future episodes of dehydration/inadequate intake.

Client needs to understand the importance of drinking extra fluid during bouts of diarrhea.


Administer medications and IV fluids as ordered.

Nursing Care Plan 2

Sige ug sakit-sakit akong tiyan as verbalized by the pt.

Hyperactive bowel sounds (6 sounds in 20 seconds) Abdominal distention Facial grimacing and guarding. pain sensation at anal area due to irritation from frequent defecation Pain scale of 7 out of 10.

NSG DIAGNOSES: Pain related to injuring agents (physical inflammation of GI tract) secondary to Acute Gastroenteritis Scientific Basis:
Acute infectious diarrhea results to increase frequency and fluid content of stool. The patient usually has abdominal distention and hyperactive bowel sounds. Painful spasmodic contraction of the anus and ineffectual straining may occur with each defecation.

After 30 mins 1hour of nursing interventions, the patient will report relief of pain from a pain scale of 7/10 to a pain scale of 4/10.

Independent: After 30 mins 1hour of nursing interventions, the patient will report relief of pain from scale 7 to 4. Pt. will verbalize lesser episodes of pain. Dependent: Patient will follow medication on time. Collaborative: Patient will eat food prepared for him as advised by dietician.


Serves as part of baseline data. Facilitates timely intervention. Provides nonpharmacological pain management.

Assess pain scale.

Encourage verbalization of feelings about pain.

Provide comfort measures (back rub, change of position)

Encourage adequate rest period. Instruct patient to report intense pain as soon as it begins

Prevents fatigue. Timely intervention is more likely to be successful in alleviating pain. Relieves pain

Administer analgesics as ordered.

Nursing Care Plan 3

Dili ko ganahan mokaon as verbalized by the pt.

Poor muscle tone Hyperactive bowel sounds Aversion to eating Food served remained untouched

NSG DIAGNOSES: Risk for Imbalanced nutrition: less than body

requirements related to inadequate intake with nutrients secondary to acute gastroenteritis.

Scientific Basis:
Nutrition is imbalanced to a relative absolute deficiency of one or more essential nutrients. This may be manifested as undernutrition.

After 8 hrs of nursing intervention, patient will exhibit progressive signs of appetite as evidenced by increased food intake.


After 8 hours of student nurse patient intervention , patient will brush teeth every after meals, pt will verbalize satiety of food by evidence of at least consumption one half cup of rice.

Patient will follow medication on time.


Patient will eat food prepared for him as advised by dietician. Patient will cooperate with the S/O and nurse to determine proper way of selecting nutritional food


Clean mouth can enhance the taste of food Pleasant environment aids in reducing stress and is more conducive to eating Individual tolerance varies, depending on stage of disease and area of bowel affected.

Provide oral hygiene

Serve food in wellventilated, pleasant surroundings.

Avoid/ limit foods that might cause/exacerbate abdominal cramping and flatulence

Encourage bed rest and/ limit activity

Decreased metabolic needs aids in preventing caloric depletion and conserve energy.


Administer medication as specified by the doctor.


Coordinate with dietician Health teachings to pt and S.O. on proper nutrition and hygienic preparation of food.

F. Progress and Prognosis

The actual progress and prognosis of the disease of the patient X can be referred to as Fair. The patient was discharged last July 30, 2009. The main s/sx or the course of illness had been relieved by medication therapy and treatment instituted. It was successful but it was considered as fair because generally, the prognosis is dependent upon compliance of the prescribed treatment regimen.

G. Discharge Planning
Follow strictly medication regimen such as oral rehydration solution or as prescribed by the physician and report immediately of adverse reactions.

Carry out daily activities as tolerated. Do activities of daily living as tolerated.

Take medications as scheduled and as prescribed for fast recovery.

Observe proper personal hygiene to avoid complication; frequent hand washing is advised. Observe proper food preparation and handling to avoid reinfection.

Advise patient to visit for check-up to the doctor for further follow-up of health status.

Follow religiously the prescribed diet to regain strength and improve health status; these include BRAT (banana, rice, apple, tea) diet.

Advise family to ask assistance and guidance from the divine providence for speedy recovery.