Case Presentation (age) Ng Grp. A2 Final

Case Presentation of Patient with Acute Gastroenteritis Presented by: BSN 103-A/ Group A2 Flores, Ma. Fe Gabriel, Ivy Garcia, Kesselyn Garingo, Jeovina Gumasing, Mary Janine Gutierrez, Sunshine Hernandez, Baby Jane Lamurena, Jacquelyn Lopez, Christine Anne Lualhati, Richard Mapiscay, Ma. Richel Mendoza, Rosa Mia Nicolas, Jean Therese

ASSESSMENT

I. Patient’s Biographical Data NAME ADDRESS DATE OF BIRTH BIRTHPLACE BIRTH HISTORY AGE SEX HEIGHT WEIGHT FATHER’S NAME MOTHER’S NAME NO. of SIBLINGS ORDINAL POSITION IN THE FAMILY CIVIL STATUS NATIONALITY MEDICAL DIAGNOSIS CHIEF COMPLAINT

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Mrs. Green NHV, Tigbe, Norzagaray, Bulacan November 26, 1946 Leyte Home Birth 62 years old Female 5’1” 42 kgs. Deceased Deceased Six (6) Eldest Widowed Filipino Acute Gastroenteritis Loose watery stool and vomiting

HISTORY OF PRESENT ILLNESS Prior to admission, the patient complains of loose watery stool and vomiting. HISTORY OF PAST ILLNESS The patient reported that she had been hospitalized before with the same medical diagnosis of Acute Gastroenteritis.

II. General Physical Assessment V/S: temp=36.5˚C, P=62bpm, R=19cpm, BP=120/80

SKIN: The patient’s skin’s moisture is dry due to dehydration. The texture is rough due to aging and signs of dehydration. HEAD: The patient’s head was round and in proportion w/ the body. Hair color is white and has no dandruff and lice. The patient’s general appearance of face indicates a feeling of weakness. NECK and SHOULDERS: The veins and clavicle are visible. The shoulders are asymmetrical. The neck muscles are weak. EYES: The patient’s eyes are symmetrical to the ears. She manifested a blurred vision due to aging. Pale conjunctivae was noted. Sunken eyes was observed. The eyes appeared dry due to dehydration.

EARS: The client’s ear manifested a good hearing balance. There were no discharges noted. NOSE: The client’s nasal septum is intact and in the midline. There were no discharges noted. Airs move freely as the client breathes through the nose. MOUTH and THROAT: The client’s mouth has presence of lesions due to frequent vomiting. The lips were dry due to dehydration. The throat was functioning well. No dentures. (+) tartar. There is a black discoloration in the enamel. (+) breath odor. CHEST: The chest is symmetric. The skin was sagged. The thorax is elliptical. ABDOMEN: The skin of the abdomen is unblemished and uniform in color. Symmetric abdominal contour flattened and rounded. Audible bowel sounds. Symmetric movements cause by respiration. No tenderness noted.

EXTREMITIES: The fingers in both hands and feet are complete. The shape of the nails is spoon-shape, the consistency is smooth and the color is pinkish white. SPINE: The spine of the patient is slightly curved. No presence of defects.

III. Significant Health Patterns A. SLEEP Prior to Hospitalization: Her sleeping pattern before was normal. She was able to consume normal 8-hour sleeping time. During Hospitalization: During her stay at the hospital she said that she was experiencing difficulty of sleeping.

B. ACTIVITY AND EXERCISE Prior to Hospitalization: Mrs. Green was a street sweeper and a hog-raiser. During Hospitalization: During her stay at the hospital, she was not able to perform activities because of restlessness due to her illness.

C. NUTRITION Prior to Hospitalization: She has good appetite. During Hospitalization: During her stay at the hospital, she loses her appetite because of her illness.

IV. Work-ups and Interpretations A. LABORATORY EXAMINATIONS

URINALYSIS Color Base on the result the color of the urine is yellow. The normal color of the urine must be transparent yellow or amber. Since the color of the urine is yellow it may indicate, food pigments or highsolute concentration.

pH The pH of the patient’s urine is 8.0. Urinary pH is measured to determine the relative acidity or alkalinity of urine and assess the client’s acid- base status. Urine is normally slightly acidic. Less than 7 (acidic), greater than 7 (alkaline), 7 (neutral).

Specific Gravity The specific gravity of the patient’s urine is 1.010. The specific gravity of urine normally ranges from 1.010 to 1.025. If the specific gravity increase urine becomes more concentrated.

BLOOD CHEMISTRY Blood Urea Nitrogen The BUN of the patient is 48.3 mg/dl, the normal findings is 8-25 mg/dl. There is an increase in BUN that may cause dehydration, BUN measures amount of urea in blood. Directly related to metabolic function of the liver. Creatinine The creatinine of the patient is 0.6 mg/dl, the normal finding of the creatinine is 0.5-1.7 mg/dl. Creatinine is exerted entirely in kidney and therefore directly proportional to glomerular filtration rate.

HEMATOLOGY Hemoglobin The hemoglobin of the patient is 90g/L. The normal findings of hemoglobin is 115 to 155g/L. There is a decrease in hemoglobin that may possibly cause hemolytic anemia and bone marrow suppression. Hematocrit The hematocrit of the patient is 26%, the normal finding is 36 to 46%. Hematocrit measures the percentage of red blood cells in the total blood volume. It reported as percentage because it is the proportion of RBC’s to the plasma. There is also a decrease in hematocrit that may possibly cause diet deficiency anemia.

WBC Count The WBC count of the patient is 5.0 x 10g/L, the normal findings of WBC is 4 to 11x10g/L. High WBC count are often seen in the presence of bacterial infection; by contrast, WBC count may be low if a viral infection is present. RBC Count The RBC count of patient is 3.11 x 10 g/L, the normal finding of RBC is 4-7 x 10 g/L. Her RBC count decreases and the possible cause of this is Iron Deficiency Anemia. Differential Count The result of the patient lymphocyte is 19%, the normal value is 25-35%. There is a decrease in lymphocyte that may cause severe malnutrition. The result of patient monocytes is 4%, the normal value is 2-5%.

ANATOMY AND PHYSIOLOGY

DIGESTIVE SYSTEM The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals.

The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus – After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down.

In the stomach – The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme.

In the small intestine – After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food.

In the large intestine – After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon.

The end of the process – Solid waste is then stored in the rectum until it is excreted via the anus.

Digestive System Glossary: anus - the opening at the end of the digestive system from which feces (waste) exits the body. appendix - a small sac located on the cecum. ascending colon - the part of the large intestine that run upwards; it is located after the cecum. bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine. cecum - the first part of the large intestine; the appendix is connected to the cecum. chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion. descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon. duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum. epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe. esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach. gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine.

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ileum - the last part of the small intestine before the large intestine begins. jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum. liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins. mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food). pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine. peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside- down. rectum - the lower part of the large intestine, where feces are stored before they are excreted. salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules. sigmoid colon - the part of the large intestine between the descending colon and the rectum. stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and enzymes. transverse colon - the part of the large intestine that runs horizontally across the abdomen.

PATHOPHYSIOLOGY

Non-modifiable Factor: Age

Modifiable Factors: Lifestyle; Diet; Hygiene

Etiology: E. Hystolytica, Salmonella, Shigella, Campylobacter jejuni, E. Coli, Norovirus, Adenovirus

Person to person (hands)

Contaminated food and/or water

Ingestion of Pathogens

Direct invasion of the bowel wall

Endotoxins are released Nausea and Vomiting

Stimulation and destruction of mucosal lining of the bowel wall

F & E Imbalance Digestive and absorptive malfunction

GI Distention Dehydration

Secretion of fluid & electrolytes in the intestinal lumen

Excessive Gas Formation Dry lips, dry mouth, fatigue, irritability Increased Peristaltic Movement

Diarrhea

DRUG STUDY

Drugs Generic name; NIFEDIPINE Brand name; Nifediac cc Classification; Calcium channel Blocker Dosage; 5mg PRN

Mechanism of action Variables effects on AV Node effective and Functional Refractory period.

Indication Chronic stable angina with out Vasospasm including angina due to increases effort, especially in client, who cannot take beta blockers or nitrates who Remain Symptomatic following clinical doses of this drugs. Essential to hypertension

Contraindication Hypersensitivity, lactation

Adverse effect

Nursing consideration

CV; Peripheral And Pulmonary edema, Hypotensio , palpitation, And tachycardia.

Do not confuse nifedipine with Nicardipine (they also a calcium channel blocker)

Drugs Generic name; Ceftriaxone Brand name; Rocephin Classification; Cephalosporin Dosage; 1ampule= 50 ml TIV q12

Mechanism of action One-third to two-thirds excreted unchanged in the urine

Indication Lower respiratory tract infection due to streptococcus pneumonia, staphylococcus aureus. Skin and skin structure infections

Contraindication

Adverse effect Increase in serum creatinine presence of casts in the urine.

Nursing Consideration . IM injection should be deep into the body of a large muscles. . do not mixed drug with other antibiotics. .stability of solutions for IM or IV use varies depending on the diluents used. Check package insert carefully.

Drugs

Mechanism of action

Indications

Competitively inhibits gastric acid secretion Brand name; zantac blocking the effect of Classifications; histamine on histamine H2 histamine H2 receptor blocking receptors. drug. Food increases the Dosage; bioavailability. 1 ampule TIV q8

Short-term and maintenance treatment of duodenal ulcer. Short term of treatment of active benign gastric ulcer.

Generic name; Ranitidine

Contraindications Cirrhosis of the liver, impaired renal or hepatic function.

Adverse effect GI; Constipation , nausea and vomiting, diarrhea, abdominal pain,pancrea titis

Nursing consideration . do not confuse zantac with xanax or zyrtex.

Drugs Generic name; Paracetamol Brand name; Acetaminophen Classification non-narcotic analgesicDos age; adults; 325-650mg every 4 hour(per orem)Caplets , capsules, oral liquid, or syrup

Mechanism of action Decrease fever by Hypothalamic effect leading to sweating and vasodilation.

Indications

Contraindica tions

Renal Control of insufficiency pain due to anemia, headache, clients with Dysmenorrh cardiac or ea, pulmonary muscular disease are pain and more Arthritis To susceptible to reduce acetaminophen fever in toxicity. bacterial or viral infections.

Adverse Effect Few when taken in usual therapeutic doses. Chronic and even acute toxicity can develop after long syptomfree usage

Nursing Considerations . do not exceed dose of 4g/24hour in adults and 75mg/kg/day in children. .do not take for more than 5 days for pain in children, 10days for pain in adults, or more than 3 days for fever in adults or children without consulting provider. .take extended relief product with water; do not crush, chew or dissolve before swallowing.

Drugs Generic name; Metoclopramide Brand name; reglan Classifications; gastrointestinal stimulant Dosage; 10mg IV q8

Mechanism of action Dopamine antagonist that acts by increasing sensitivity to Acetylchol ine results in increased motility of the upper GI tract and relaxation of the pyloric sphincter and duodenal bulb. Gastric emptying time and GI transit time are shortened.

Indications Parenteral; facilitates small bowel intubation, Stim gastric emptying, and Increase intestinal Transit of barium to aid in radiologic Examinatio n of stomach.

Contraindications Gastrointestinal hemorrhage, obstruction or perforation; epilepsy.

Adverse effect CNS; restlessness, drowsiness, fatigue, anxiety, insomnia, headache, dizziness

Nursing considerations . inject slowly IV order 12mins to prevent transient feelings of anxiety and restlessness. Check packaged insert if drugs is to be admixed.

Drugs Generic name; Ferrous sulfate Brand name; feosol Classification; anti anemic iron Dosage; adults, 150-250mg (1-2 time per day) Per orem

Mechanism of action Iron is absorbed from the duodenum and upper jejunum by active mechanism through the mucosal cells where it combines with the protein Transferrin.

Indications .prophylaxis and treatment of iron deficiency and iron deficiency anemias. .dietary supplement for iron.

Contraindications Hemosiderosis, peptic ulcer,

Adverse effect Constipation, gastric irritation, nausea, abdominal cramps, anorexia, vomiting, diarrhea, dark colored stools.

Nursing consideration . For infants and young children, administer liquid preparation with a dropper. Deposit liquid well back against the cheek. . Eggs and milk and coffee and tea consumed with a meal or 1hour after may significantly inhibit absorption of dietary iron. . Do not crash or chew sustained release products.

NURSING CARE PLAN

ASSESSMENT

Subj. data: “ Madalas akong dumumi at nasusuka ako”. As verbalized by the patient. Obj. data: -dry skin, lips -body malaise -sunken eyes -paleness -poor skin turgor -restlessness V/S: T- 36.6˚C P- 63 bpm R- 19 cpm BP- 120/80 mmHg

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

LTG: Deficient Fluid After 72 hrs. Volume related of nsg. to frequent Intervention, elimination of the patient will loose watery be able to stool and maintain the vomiting fluid volume at functional level by:

Goal was met. After 72 hrs. of nsg. Intervention the patient was able to maintain her fluid volume in functional level as evidenced by:

1.)Health teaching on patient on how -Giving advice on the to attain normal patient to increase hydration fluid intake. status.

2.)Maintain normal fluid volume and replace fluid loss.

EVALUATION

-Encourage increase oral fluid intake

-To promote understanding and avoid rercurrence of Illness

-To reduce risk of skin breakdown

-The patient demonstrated proper understanding on the health teaching

-Fluid volume was normalized

STG: After 8 hrs. of nsg. Intervention, the patient will be able to improve her body fluid Volume at functional level: 1.)Note the cause of fluid volume deficit.

STG: After 8hrs. of nsg. Intervertion the patient improved her body fluid volume, evidenced by:

-Determine the effects of age.

2.)Note physical signs associated -Compare usual with dehydration. and current weight

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-Elderly

individuals are at high risk because of decreasing response/ effectiveness of compensatory Mechanism -Indicator of overall fluid nutritional status

The cause of fluid volume deficit was determined -

-Physical signs associated with dehydration is noted and Examined

3.)Establish 24 hrs. fluid replacement, needs, and routes, as ordered.

-Advice intake of foods with high fluid content

-To provide hydration

-Establish 24 hrs. fluid replacement, needs, as ordered

4.)Evaluate the degree of fluid deficit

-Measure client’s output

-To ensure accurate data of fluid status

-The degree of fluid is evaluated

5.)Promote comfort and safety of the patient

-Encourage change in position frequently

-To prevent stasis and reduce risk of tissue injury

-Comfort and safety of the patient was Promoted

6.)Promote wellness

-Provide optimal skin care

-To prevent injury from Dryness

-Wellness promoted

-Provide frequent oral and eye care

-To prevent injury from dryness

-Discuss factors and ways to prevent dehydration

-To educate the patient

-Assist client to measure her own intake and output

-Help determine baseline symptoms

-Recommend restriction of caffeine and Alcohol

-To prevent frequent Urination

DEPENDENT -Administer IV fluids as Indicated

-Fluids may be given in this manner, if client is unable to take oral fluid, or when rapid fluid resuscitation is required.

-Administer medications as ordered

Antiemetics or antidiarrheals limit gastric/intestinal losses

-Review laboratory data

-To evaluate degree of fluid and electrolyte imbalance and response to therapist

DISCHARGE PLAN

Patients with Acute Gastroenteritis, watchers 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. - Home medication : Ranitidine tablet (Zantac) E- Exercise should be promoted in a way by stretching hand and feet every morning and exercise burping every after meal. T- Treatment after discharge is expected for patients and watcher with Acute Gastroenteritis to fully participate in continuous treatment. - Usually supportive, treatment consists of nutritional support and increase fluid intake. H- Hygiene must be maintained for patients with Acute Gastroenteritis. Promotion of personal hygiene should be encouraged such as, daily bathing and always wash hands w/ warm water and soap handling foods, esp. after using the bathroom

O- OPD such as regular follow-up check-ups should be greatly encouraged to clients watcher with Acute Gastroenteritis as ordered by physician to ensure the continuing management and treatment. D- Diet should be promoted, such as soft and bland diet that cannot irritate the GI tract. S- Signs and Symptoms. -Clinical manifestations vary depending on the pathologic organism and the level of GI tract involved. AGE produces symptoms such as: diarrhea, abdominal discomfort, nausea and vomiting, fever, body malaise -In children and elderly and debilitated people, AGE produces the same symptoms, but the inability of the patient to tolerate electrolyte losses leads to a higher mortality.

-THE END-