Case Study Age With Signs Of Dehydration

Bulacan State University City of Malolos, Bulacan College of Nursing

Case Study of Patient with Acute Gastroenteritis Submitted by:

Calma, Therese Josephine Censon, Luwalhati BSN – 3D Submitted to: Maribel Valencia, R.N.

I. INTRODUCTION

Acute Gastroenteritis Acute Gastroenteritis is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and resulting in acute diarrhea. The inflammation is caused most often by infection with certain viruses, less often by bacteria or their toxins, parasites, or adverse reaction to something in the diet or medication. At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus. Different species of bacteria can cause gastroenteritis, including Salmonella, Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, and others. Each organism causes slightly different symptoms but all result in diarrhea. Colitis, inflammation of the large intestine, may also be present. Some types of acute gastroenteritis will not resolve without antibiotic treatment, especially when bacteria or exposure to parasites are the cause. Physicians may want to diagnose the cause by analyzing a stool sample, when stomach symptoms remain problematic. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year and is a leading cause of death among infants and children under 5. The most common symptoms are diarrhea, vomiting and stomach pain, because whatever causes the condition inflames the gastrointestinal tract. Another reason to seek medical treatment is that some forms of acute gastroenteritis mimic appendicitis, which may require emergency treatment. As well, young children run an especially high risk of becoming dehydrated during a long course of the stomach flu. One should receive directions regarding how to help affected kids or adults get more fluids. Sometimes children, those with compromised

immune systems, and the elderly may require hospitalization and intravenous fluids. Dehydration can actually cause greater nausea, and can begin to cause organ shut down if not properly addressed. Acute gastroenteritis is quite common among children, though it is certainly possible for adults to suffer from it as well. While most cases of gastroenteritis last a few days, acute gastroenteritis can last for weeks and months. Acute gastroenteritis remains a serious health issue, and is responsible for over 50,000 hospitalizations of children. In developing countries, acute gastroenteritis is the leading cause of death for infants. Acute gastroenteritis should thus be taken seriously, and people should not hesitate to seek medical treatment for especially seniors and children who have been ill for more than a day. In the Philippine Health Statistic, gastroenteritis range as number 10 in the ten leading causes of infant mortality, with the rate of 0.5 and percentage of 4.1 cases in the Philippines by the year 2004 this was updated last February 12, 2008. Significance of the study: his study will enable the students to understand better about acute gastroenteritis and will explain the different risk factors for developing the disease, including consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation Since we are client-centered, we really should consider our patient’s comfort and this study will give the students sufficient knowledge that will help them to plan and implement nursing care plans that will satisfy patient’s needs. II. OBJECTIVES: A. General Objectives

This study aims to convey familiarity and to provide an effective nursing care to a patient diagnosed with Acute Gastroenteritis through understanding the patient history, disease process and management. B. Specific Objectives 1. To present a thorough assessment, through Nursing Health History, Gordon’s Typology 11 Functional Pattern, Physical Assessment, and the interpretation of the laboratory examination done on the patient. 2. To discuss the anatomy and physiology, pathophysiology of the patient’s condition, usual clinical manifestations and possible complications of this condition. 3. To have knowledge to the client medication and be familiar to that medication. 4. To formulate a workable nursing care plan on the subjective and objective cues gathered through nurse-patient interaction to be able to help the patient recover. III. PATIENT'S PROFILE A. Biographical Data Date: July 16, 2009

Clinical Area : Pedia ward room 202

Name

:

Ms. BB

Address

:

San Isidro II, Paombong, Bulacan

Date of Birth

:

November 5, 2005

Age

:

3 ½ years old

Sex

:

Female

Civil Status

:

Single

Nationality

:

Filipino

Religious Preferences

:

Born Again Christian

Health care financing

:

Philhealth and Financial health assistance from baranggay health center

Date of Admission

:

July 15, 2009

Diagnosis

:

Acute Gastroenteritis with signs of dehydration

B. Chief Complaint According to the significant others, the client was vomiting and defecating that’s why they rushed her to the hospital. IV. HEALTH HISTORY A. History of Present Illness Prior to admission, the client was vomiting and defecating. Her stool was watery and its color is green. At first, they to the baranggay health center and the midwife gave them medication. According to the midwife, the medication is for LBM, but after drinking the medication, the client was still defecating and vomiting so the family decided to rush the client at Emilio G. Perez Memorial District Hospital the next day. B. Past History The client had fever, cough and colds. She had completed all vaccinations including BCG, DPT, Oral Polio Vaccine, MMR and Hepatitis B vaccine. The patient had never been any of the childhood disease such as measles, mumps and chicken pox. The patient had

no

history of accident or any injury. She does not have allergy in any food or drug. She was not hospitalized before and she does not take any medication or supplements to maintain her health.

C. Family History According to the significant others of BB they have a familial disease of asthma, both on her father and mother's side. And an incident of hypertension on his father's side. Genogram:

Legends

Paternal

Maternal LB

EB 56y/o HPN

EC

RC

54 y/o

55 y/o

57 y/o

HPN

VB 33 y/o

LO

LP 32 y/o ASTH

KM

MB

31 y/o

29 y/o

35 y/o ASTH

HE PC

JB

31 y/o

28 y/o

BB

CB

3 ½ y/o

1 y/o

23 y/o ASTH

AC

JC

22 y/o

20y/o

ACTIVITIES OF DAILY LIVING Functional Health Perception

Prior to Hospitalization

Nutritional Metabolic Pattern

During Hospitalization

Ø The client eats four times a day

> The client seldom eats at the hospital. She does

including breakfast, lunch, merienda and

not have appetite for eating. She seldom drinks

dinner. According to the significant others, water or other fluids. she always eats rice and soup. She can drink 4 glasses of water in a day. She has no eating discomforts. She does not have any dental problems because she has a

3 days food recall July 14

July 15

July 16

2 cups rice

1 glass of water 2 pieces

complete set of teeth. 3 days food recall July 11 3 cups rice

July 12 3 cups rice

July 13 3 cups rice

1 bowl of

ponkan

sinigang

½ glass of

soup

water

3 cups soup 1 piece of egg 3 cups soup

2 glasses of

4 glasses of ½ piece paksiw 2 pices of

water

water

na bangus

bread

3 glasses of

4 glasses of

water

water

Elimination Pattern

Ø The client defecates everyday and her stool is soft but formed and its color is brown and has a foul odor. She urinates five times a day and is yellowish in color. She has no discomfort in defecating and urinating.

Ø The client defecates three times a day.

Ø The client has sufficient energy for

in color.

Her stool is watery and its color is green. She urinates twice a day and it is yellowish

completing her desired required activities. Ø The client does not have sufficient Activity-exercise Pattern

0- feeding

energy for completing her desired required

0- clothing

activities.

II- bathing II- grooming

II- feeding II- clothing

Ø The client sleeps about 10 hours a day.

II- bathing

From 8pm to 6am. She has no problem

II- grooming

falling asleep and does not take sleep Sleep-rest Pattern

medications. Her sleep is always

Ø The client still sleeps 10 hours a day.

continuous especially when she is tired.

She only wakes up when her medications

She takes a nap during afternoon. From

are due. She has no problem falling asleep

12:30pm to 3pm.

and does not take any sleep medications. She does not take naps.

Ø The client does not have difficulty in hearing and has no hearing aid. According to the significant others, whenever the Cognitive-Perceptual Pattern

client feels pain or any discomfort, they

Ø The client takes medications to relieve

always give her medications.

any discomforts.

Ø

The client lives with her mother, father

and grandparents. The structure of her family is extended. And just like the typical family, their family has problems wherein Role-relationship Pattern

they have difficulty in handling, as stated by

Ø The Family of the patient especially her

the grandmother.

parents are supportive and more caring.

Ø The client is a born again Christian. According to the significant others, they attend mass every Sunday. Value-belief Pattern

V. DEVELOPMENTAL TASK

Erik Erikson-Psychosocial development The patient is currently in the early childhood stage (3-6 y/o) wherein the central task is Initiative vs. Guilt. During this stage, initiative adds to autonomy the quality of undertaking, planning, and attacking a task for the sake of being active and on the move. The child is learning to master the world around him or her, learning basic skills and principles of physics; things fall to the ground, not up; round things roll, how to zip and tie, count and speak with ease. Guilt is a new emotion and is confusing to the child; he or she may feel guilty over things which are not logically guilt producing, and he or she will feel guilt when his or her initiative does not produce the desired results. At this stage the client wants to begin and complete her own actions for a purpose.

Interpretation: Positive Resolution

Jean Piaget’s Cognitive Development The patient is under the Pre-operational stage. In this period intelligence is demonstrated through the use of symbols, language use matures, and memory and imagination are developed, but thinking is done in a nonlogical, nonreversible manner. Egocentric thinking predominates. The patient was able to do make believe play and able to imitate others, like her mother doing some household chores as verbalized by the "SO". Interpretation: Positive Resolution

VI. PHYSICAL ASSESSMENT

Date: July 16, 2009

BODY PARTS ASSESSED

Clinical Area : Pedia ward room 202

TECHNIQUES

NORMAL FINDINGS

ACTUAL FINDINGS

INTERPRETATION

Palpation

Moisture in skin folds and axillae

Dry skin

Deviated due to slight

1.Skin a. Moisture

dehydration b Texture

Palpation

Smooth

Rough

Deviated due to slight dehydration

c. Turgor

Inspection and

Springs back immediately to

Palpation

previous state

Inspection

Pink in color, soft moist, smooth

2. Mouth a. Lips

Moves back slowly

Deviated due to slight dehydration

Dry lips

texture, symmetrical no

Deviated due to slight dehydration

tenderness, no lesions b.Mucosa

Inspection and

Uniform pink color

Dry and slightly pink in color

Palpation c. Gums

Inspection and Palpation

3. Abdomen

Deviated from normal due to slight dehydration

Pink gums, moist, firm texture

Pink gums, dry, firm texture

Deviated from normal due to slight dehydration

Bowel sounds

Auscultation

Audible bowel sounds

Hyperactive bowel sound

Deviated due to diarrhea

VII. REVIEW IF SYSTEM Digestive System The primary function of the digestive system is to break down the food we eat into smaller parts so the body can use them to build and nourish cells and provide energy. There occurs propulsion which is the movement of food along the digestive tract. The major means of propulsion is peristalsis, a series of alternating contractions and relaxations of smooth muscle that lines the walls of the digestive organs and that forces food to move forward. It secretes digestive enzymes and other substances liquefies, adjusts the pH of, and chemically breaks down the food. Mechanical digestion is the process of physically breaking down food into smaller pieces. This process begins with the chewing of food and continues with the muscular churning of the stomach. Additional churning occurs in the small intestine through muscular constriction of the intestinal wall. This process, called segmentation, is similar to peristalsis, except that the rhythmic timing of the muscle constrictions forces the food backward and forward rather than forward only. Chemical digestion which is the process of chemically breaking down food into simpler molecules. The process is carried out by enzymes in the stomach and small intestines. Then absorption or the movement of molecules (by passive diffusion or active transport) from the digestive tract to adjacent blood and lymphatic vessels. Absorption is the entrance of the digested food into the body. And lastly, defecation which is the process of eliminating undigested material through the anus. But because of acute gastroenteritis the normal functions were altered. The infectious agents that cause acute gastroenteritis causes diarrhea

by

adherence,

mucosal

invasion,

enterotoxin

production,

and/or

cytotoxin

production.

These mechanisms result in increased fluid secretion and/or decreased absorption leading to diarrhea. This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients.

VIII. ANATOMY AND PHYSIOLOGY

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. 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.

IX. PATHOPHYSIOLOGY

Non-modifiable Factor: Age

Modifiable Factors: Lifestyle; Diet; Hygiene

Secretion of fluid & Increased secretion of Cl Increased peristaltic Inhibition of in Nathe electrolytes in the & HCO3 ions Stimulation and destruction of mucosal lining of the movement reabsorption Person to person (hands) Direct invasion of the bowel wall Endotoxins Contaminated are released food and/or water Ingestion of Pathogens Excessive gas formation intestinal lumen bowel bowel wall Digestive andDiarrhea absorptive malfunction GI Distention

Etiology: Salmonella, Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia,Norovirus, adenovirus

Nausea & vomiting

Fluid and electrolytes imbalance Dehydration Dry lips, dry mouth, flushed skin, fatigue, irritability

X. LABORATORY FINDINGS Complete Blood Count:

Blood Test

Standard Range

Actual Findings

Interpretation

WBC

5.10 x 109/L

22.3 x 109/L

The body is fighting against an infection

RBC

3.80-5.80 1012/L

5.53 x 1012/L

Normal

HGB

110-165 g/L

136 g/L

Normal

HCT

.350-.500 1/l

0.441 1/l

Normal

PLT

150-390x 109/liter

156 x 109/liter

Normal

.133 10-2/l

Normal

80 fL

Normal

24.6 L

An indication of microcytic, hypochromic anemia

308 Lg/l

An indication of iron deficiency anemia

15.1%

An indication of iron deficiency anemia

8.5 fL

Normal

15.7 L%

Normal

8.3 L %

Normal

81.0 H%

Indicates presence of infection

3.5 109/L

Indicates presence of infection

0.7 109/L

Normal

PCT MCV MCH MCHC RDW MPV % LYM %MON % GRA # LYM #MON

-2

.100-.500 10 /l 80 – 97 fL 26.5 - 33.5 L 315-350 Lg/l 10.0-15.0 % 6.5-11.0 fL 17-48 L % 4-10 L% 43-76 H% 1.2-3.2 109/L 0.3-0.8 109/L

#GRA

1.2-6.8 109/L

18.1 109/L

Indicates presence of infection

Blood type: O RH : + Fecalysis: Microscopic Findings Ova/ parasite RBC Mucus Bacteria Pus Cells

Normal Values NOPS 0-5/hpf 0Negative(-) 0

Actual Findings Entamoeba 3-5/hpf + ++++ 8-12/hpf

Analysis/Interpretation Invasion of microorganism Normal Invasion microorganisms Invasion microorganisms Invasion of microorganisms

XI. DRUG STUDY

DRUG NAME 1. Cefuroxime

DOSAGE, ROUTE, FREQUENCY

INDICATION / ACTION

250 mg

-

TIV

final step in the formation

(q 8 hrs.)

of the bacterial cell wall. -

It interferes with the

CONTRAINDICATIONS -

ADVERSE EFFECTS

Hypersensitivity to N and V, anorexia,

cephalosphorins

NURSING RESPONSIBILITIES -

Protect drug

abdominal cramps or

from sunlight

pain and headache.

-

Lower respiratory tract

Instruct the

client to take with

infection

food to enhance absorption

2. Ranitidine

12mg

-

Inhibits gastric acid

TIV

secretion by blocking the

liver

(q 6 hrs.)

effect of histamine on

-

histamine H2 receptors.

hepatic function

-

-

- nausea, dry mouth,

temperature Take with food

vomiting, diarrhea

or milk to reduce GI

GERD Inhibits growth of

-

Cirrhosis of the Impaired renal or

3.

125mg/ 3.5 ml

-

Metronidazole

PO

amoebae by binding to

disease of the CNS

(q 8 hrs.)

DNA, resulting in loss of

-

Active organic Blood dyscrasias

Abdominal pain,

-

Take as directed

headache, dizziness,

with immediately

malaise, N and V

following meals Store at room

upset

helical structure, strand

-

breakage, inhibition of

urine brown, don’t be

nucleic acid synthesis and

alarmed.

cell death. -

Amoebiasis

Drug may turn

XII. NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

BACKGROUND

PLANNING

INTERVENTION

RATIONALE

EVALUATION

STUDY Subjective:

Diarrhea related to

Objective: >Hyperactive

Introduction of bacteria into the GI tract

>BM (4x),

client will be able to

factors

reestablish and

(parasites)

Release of bacterial toxins

Disrupts the mucus lining of the stomach

greenish in Release of HCl cause gastric irritation

Independent: >Monitor I/O.

maintain normal

Goal met >These assessments

After 8 hours of

are used to monitor

Nursing Intervention,

volume status.

client will be able to reestablish and

pattern of bowel functioning.

watery and color

Nursing Intervention,

physiological

bowel sounds >vomiting

After 8 hours of

>Restrict solid food intake.

maintain normal >To allow for bowel

pattern of bowel

rest/ reduced

functioning.

intestinal workload > Increase oral

> To ensure

fluid intake and

adequate amt. of

return to normal

fluid is taken by the

diet as tolerated.

pt.

Dependent: Increase gastric motility/peristalsis

Increase gastric motility

Frequent defecation (DIARRHEA)

> Administer

> To decrease

antidiarrheal

gastrointestinal

medications as

motility and minimize

indicated.

fluid loses

ASSESSMENT

DIAGNOSIS

BACKGROUND

PLANNING

INTERVENTION

RATIONALE

STUDY Subjective:

Objective: >watery stool >vomiting

Risk for

Digestive and

OUTCOME After 2 hrs of nursing

deficient fluid

absorptive

intervention the ct with

volume r/t

malfunction

the help of the "SO"

excessive

will be able to

loss of fluids

demonstrate behaviors

and electrolytes.

Increased secretion of fluid and electrolytes in the lumen

to prevent

Independent

Goal Meet

>Monitor I/O

>To ensure accurate

After 2 hrs of nursing

balance, being

picture of fluid status.

intervention the ct

aware of altered

with the help of the

intake or output.

"SO" was able to

development of fluid

>Offer fluids

volume deficit.

between meals &

>To prevent

demonstrate

occurrence of deficit

behaviors to prevent development of fluid

regularly

volume deficit.

throughout the day. Increased water content of the stools acompanied by vomiting

> Promote intake of high-water content foods and/or

>To facilitate hydration

electrolyte replacement drinks. Dependent:

Imbalanced fluid and electrolytes

>Provide supplemental fluids as indicated.

> Fluids may be given if the ct. is unable to take oral

Risk for deficient fluid

fluid, or when rapid

volume

fluid resuscitation is required.

Reference: MSN, LeMone and Burke, pp 754, 757

EXPECTED

> To decrease >Administer

gastrointestinal

medications

motility and minimize