Case Study On Age

CAGAYAN COLLEGES TUGUEGARAO COLLEGE OF HEALTH

A CASE STUDY ON

ACUTE GASTROENTERITIS (AGE) Submitted by: Dennis Gallardo

INTRODUCTION Acute gastroenteritis (AGE) is an acute infectious process affecting gastrointestinal tract caused by virus, bacteria and parasites. The disease is transmitted by ingestion of contaminated food, water, or by contaminated hands, linens, equipments, and supplies. Most serious complication is dehydration and electrolyte losses which may lead to metabolic acidosis and death. The primary manifestation of gastroenteritis is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. The vomiting usually settles in a day or so. The diarrhea may last for up to 10 days, but usually lasts only to 2 or 3 days. If there is fever, or blood and mucus in the stools it is more likely to be contagious. Gastroenteritis is contagious as the organism lives in the gastrointestinal tract, so it is important to wash hands thoroughly after going to the toilet and before preparing food. Acute gastroenteritis is associated with significant morbidity in developed countries and each year is the cause of death of several million children in developing countries. Estimates of the overall incidence of acute gastroenteritis range from 1.3 to 2.3 episodes of diarrhea per year in children under five years of age. Each year, more than 300 U.S. children die from this illness. In the United States alone, gastroenteritis accounts for more than 220,000 hospital admissions per year in children less than five years of age, or approximately 10 percent of hospitalizations in this age group. Acute gastroenteritis is a common and costly clinical problem in children. It is a largely self-limited disease with many etiologies. The evaluation of the child with acute gastroenteritis requires a careful history and a complete physical examination to uncover other illness with similar presentations. Minimal laboratory testing is generally required. Treatment is primary supportive and is directed at preventing or treating dehydration. When positive, an age-supportive diet and fluids should be continued. Oral rehydration therapy using a commercial pediatric oral rehydration solution is preferred approach to mild or moderate dehydration. The traditional approach using “clear liquids” is inadequate. Severe dehydration requires the prompt restoration of intravascular volume through the intravenous administration of fluids followed by oral rehydration therapy. When rehydration is achieved, an aged-appropriate diet should be promptly resumed. Anti-emetic and anti-diarrheal medications are generally not indicated and may contribute to complications. On its mortality and morbidity, AGE is a leading cause of infant mortality throughout the world. By age 3 years, virtually all children become infected with the most common agents. Severe cases are seen in the elderly, infant and immunosuppressed population including transplant patients. Last July 05, 2007, we encountered a patient with such kind of infection. This patient has caught our attention and has given the opportunity to study his case. The objective of this study is to help us understand the disease process of gastroenteritis and to orient ourselves for appropriate nursing interventions that we could offer to the patient.

This approach enables us to exercise our duties as student nurses which is to render care. I was given the chance to improve the quality of care I can offer and to pursue our chosen profession as future nurses.

PATIENT’S PROFILE Patient’s Name: Budong Age: 4 years & 7 months Gender: Male Address: Carig Sur, Tuguegarao City Date of Birth: December 3, 2002 Civil Status: Single Religion: Roman Catholic Nationality: Filipino Dialect: Ilocano

Date of Admission: July 5, 2007 Time Admitted: 9:50 AM Attending Physician: Dra. M. Velarde Chief Complaint: LBM & vomiting Admitting Diagnosis: AGE with Dehydration Final Diagnosis: AGE with Dehydration

NURSING HISTORY OF ILLNESS PRESENT HEALTH HISTORY  Two days prior to admission (July 3, 2007 in the evening), the patient had vomiting for 3 times associated with abdominal pain and passage of watery stool due to his intake of ice-cold coke and water according to his mother. A day prior to admission (July 4, 2007), the patient still attended his classes but still with vomiting and passage of watery stool. And last July 5, 2007, he was rushed to St. Paul Hospital due to weakness and severe abdominal pain.

PAST HEALTH HISTORY  According to the patient’s mother, the patient has his complete immunizations. He is taking his vitamin supplements but still he is very slim and never liked vegetables. The patient was first hospitalized due to asthma. His second hospitalization was due to bronchopneumonia and the latest was due to AGE.

FAMILY HEALTH HISTORY  According to the patient’s mother, their family have history of Hypertension, Diabetes mellitus, Bronchial Asthma and Cancer. Hypertension is evident on the patient’s grandfather and uncle, while Cancer is evident on the patient’s aunt.

GORDON’S 11 FUNCTIONAL PATTERN Health Perception-Health Management Pattern  Before his hospitalization, the patient perceives health in a way that he is not suffering from any disease. He takes vitamins for him to improve his health and to protect him from acquiring any disease.  During his hospitalization, the patient feels so unhealthy according to his mother because of his hospitalization. He is obedient in taking his medications and is participative in all the nurses’ interventions.

Nutritional-Metabolic Pattern  Before his hospitalization, the patient takes his meal three times a day without any restrictions. According to his mother, he has food preferences on fatty and oily foods. Her mother even shared that when they eat adobo, he prefers to eat the fat rather than the muscle because he gets irritated with foods between his teeth. He has no difficulty in swallowing and he usually eat junk foods when its snack time. He drinks 4-5 glasses of water a day and takes Clusivol to improve his appetite.  During his hospitalization, his appetite decreased. He was restricted from eating dairy products. His fluid intake increased for about 5-7 glasses of water a day.

Elimination Pattern  Before his hospitalization, the patient used to eliminate once a day every morning before going to school with a semi-solid consistency and is brownish in color. He usually urinates 2 times a day with the normal light yellow color and aromatic odor. He also perspires every time he plays.  During is hospitalization, the patient’s stool is watery with a yellowish color. He urinates 2-3 times a day. He also perspires but it’s due to the hot environment not from any activity since he just stays on bed.

Activity-Exercise Pattern  Before his hospitalization, especially during the weekend, he used to play outside with his cousins. They usually play toy cars and the usual games of his age. He stops playing when he feels tired.

 During his hospitalization, he used his time playing the cell phone of his father. Most of his time was spent for resting and sleeping.

Sleep-Rest Pattern  Before his hospitalization, he usually sleeps 8-9 hours. He is fond of watching the TV series “Super Twins” before going to bed when it was still showing.  During his hospitalization, the patient sleeps early but has sleep disturbances when the nurses take his vital signs, administer medicines and also due to the environment.

Cognitive-Perception Pattern  Before his hospitalization, the patient is normal in terms of his cognitive abilities. He has no problems with his senses. His mother even shared to us that he is already capable of writing his name and is capable of reading the alphabet and numbers.  During his hospitalization, he relates to us actively. He responded to our questions enthusiastically. He also related to us some of his school activities.

Self-Perception/ Self-Concept Pattern  According to the patient’s mother, he’s a good son though sometimes he tends to disobey his parents. She said this is normal for his age. He is the eldest but according to her mother he acts as if he is the youngest.

Role-Relationship Pattern  The patient has a close relationship with his family, but he is closer to his father. He has a 2 year old sister, but according to his mother, he does not play the role of an elder brother. His mother even added that his sister ie more obedient than he is. But during his confinement, he is more obedient because he wanted to get well immediately.

Sexual-Reproductive Pattern  Prior to his age, the patient is not yet oriented with any sexual matters. According to hid mother, he has not yet undergone circumcision.

Coping Stress- Tolerance Pattern  According to his mother, when he has problems he always approach his parents. She even added that when he gets scolded, he just stays in his room. When he is bullied or when his cousins get his toys, he does not quarrel with them but instead he reports it to his parents. During his hospitalization, he feels unsafe with people when his mother is not with him. He cries without the sight of his mother.

Value-Belief Pattern  He is a Roman Catholic. They attend mass regularly. He afraid to do something bad because he believes that God will punish him. According to his mother, before they consult the doctors or the hospital, they first consult the quack doctors.

PHYSICAL ASSESSMENT Date assessed: July 06, 2007 General assessment: neat, conscious and coherent Initial vital signs: T=37.9, RR=20, BP=80/60, PR=95 Area Assessed Skin Color

Lips, nail beds, soles and palms Moisture

Technique

Normal Findings

Actual Findings

Evaluation

Inspection

Light brown, tanned skin (vary according to race) Lighter colored palms, soles, lips and nail beds Skin normally dry

Tanned skin

Normal

Lighter colored palms, soles, lips and nail beds Skin normally dry

Normally warm

37.9 o C

Smooth, soft and flexible palms and soles (thicker)

Smooth, soft and flexible palms and soles (thicker)

Inspection

Normal

Temperature

Inspection/ Palpation Palpation

Texture

Palpation

Turgor

Palpation

Skin snaps back immediately

Skin snaps back immediately

Normal

Skin appendages a. Nails

Inspection Inspection Inspection

Capillary refill

Inspection/ Palpation

Transparent, smooth and convex Pinkish Firm White color of nail bed under pressure returned to pink within 2-3 seconds

Normal

Nail beds Nail base

Transparent, smooth and convex Pinkish Firm White color of nail bed under pressure should return to pink within 2-3 seconds

Inspection Inspection Inspection/ Palpation

Evenly distributed Black Smooth

Evenly distributed Black Smooth

Normal Normal Normal

Eyes

Inspection

Visual Acuity

Inspection (penlight)

Parallel to each other PERRLA- Pupils equally round react

Parallel to each other but sunken PERRLA- Pupils equally round react

d/t dehydration Normal

b. Hair Distribution Color Texture

Normal d/t hyperthermia Normal

Normal Normal Normal

Eyes

Eyebrows

Inspection

Eyelashes

Inspection

Eyelids

Inspection

to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Same color as the skin

to light and accommodation Symmetrical in size, extension, hair texture and movement Distributed evenly and curved outward Same color as the skin

Blinks involuntarily Blinks involuntarily and bilaterally up to and bilaterally up to 20 times per minute 16 times per minute

Conjunctiva

Inspection

Sclera Cornea Pupils

Inspection Inspection Inspection

Iris

Inspection

Ears Ear canal opening

Hearing Acuity

Inspection

Inspection

Nose Shape, size and skin color

Inspection

Nasal septum

Inspection

Nares

Inspection

Normal

Normal Normal

Normal

Do not cover the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible

Do not cover the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible

Normal

Free of lesions, discharge of inflammation

Free of lesions, discharge of inflammation

Normal

Canal walls pink Client normally hears words when whispered

Canal walls pink Client normally hears words when whispered

Normal

Smooth, symmetric with same color as the face Close to midline, thicker anteriorly than posteriorly

Smooth, symmetric with same color as the face Close to midline, thicker anteriorly than posteriorly

Oval, symmetric and without

Oval, symmetric and without

Normal

Normal Normal Normal Normal

Normal

Normal Normal

Normal

discharge

discharge

Inspection

Pink, moist symmetric

Pink, moist symmetric

Normal

Buccal mucosa

Inspection Inspection

Hard palate- domeshaped Soft Palate- light pink

Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny No tooth decay Hard palate- domeshaped Soft Palate- light pink

Normal

Gums

Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny

Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Midline Clear breath sounds

Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Midline Clear breath sounds

Skin same color with the rest of the body

Skin same color with the rest of the body

Mouth and Pharynx Lips

Tongue

Inspection

Teeth

Inspection

Hard and soft palate

Inspection

Neck Symmetry of neck muscles, alignment of trachea Neck Rom

Inspection Inspection

Thyroid gland

Palpation

Trachea Thorax and Lungs Abdomen

Inspection Auscultation

Bowel sounds

Auscultation

Neurology system

Inspection

Clicks or gurling Clicks or gurling sounds occur sounds occur irregularly and irregularly and range from 5-35 per range from 5-35 per minute minute

Normal Normal Normal Normal

Normal Normal Normal Normal Normal Normal

Normal

Level of consciousness

Inspection

Behavior and appearance

Inspection

Fully conscious, respond to questions quickly, perceptive of events

Fully conscious, respond to questions quickly perceptive of events

Makes eye contact Makes eye contact with examiner, with examiner, hyperactive hyperactive expresses feelings expresses feelings with response to the with response to the situation situation

Normal

Normal

LABORATORY RESULTS HEMATOLOGY RESULTS WBC Hgb Hct Differential Count Lymphocytes Segmenters

Normal Value 5-10 x 10 g/L M 13-16 g/dl F 12-16 g/dl M 39%-54% F 37%-48%

Results 7.8 11

Analysis Normal Decreased

33%

Decreased

20%-40% 60%-70%

31% 69%

Normal Normal

FECALYSIS Method used: Direct Smear Physical properties: Color Consistency

Results

Analysis

Light brown Watery

Normal d/t profuse secretion of water and electrolytes

Remarks: No oral intestinal parasite seen

URINALYSIS Color Transparency

Results Yellow Slightly turbid

Reaction Specific gravity

6.0 -1.020

Sugar Protein

Negative Trace

Analysis Normal d/t increased urine concentration Normal Decreased: d/t dehydration Normal Normal

MICROSCOPIC EXAM Round epithelial cells Mucus thread RBC Pus cells Amorp urates/phosphates

Result Occasional Many 0-1 1-2 Few

Analysis Normal Normal Normal Normal Normal

ANATOMY AND PHYSIOLOGY THE DIGESTIVE SYSTEM

Every morsel of food we eat has to be broken down into nutrients that can be absorbed by the body, which is why it takes hours to fully digest food. In humans, protein must be broken down into amino acids, starches into simple sugars, and fats into fatty acids and glycerol. The water in our food and drink is also absorbed into the bloodstream to provide the body with the fluid it needs. The digestive system is made up of the alimentary canal and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal (also called the digestive tract) is the long tube of organs — including the esophagus, the stomach, and the intestines — that runs from the mouth to the anus. An adult's digestive tract is about 30 feet long. Digestion begins in the mouth, well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or even think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal. As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase, which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth. Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx (pronounced: fair-inks), a passageway for food and air, is about 5 inches long. A flexible flap of tissue called the epiglottis reflexively closes over the windpipe when we swallow to prevent choking. From the throat, food travels down a muscular tube in the chest called the esophagus. Waves of muscle contractions called peristalsis force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract. At the end of the esophagus, a muscular ring called a sphincter allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, more digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts of these digestive juices each day. Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an adult's stomach has a volume of one fifth of a cup, but it can expand to hold more than 8 cups of food after a large meal.

By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme. A walnut-sized muscular tube at the outlet of the stomach called the pylorus keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream. The small intestine is made up of three parts: 1. the duodenum, the C-shaped first part 2. the jejunum, the coiled midsection 3. the ileum, the final section that leads into the large intestine The inner wall of the small intestine is covered with millions of microscopic, fingerlike projections called villi. The villi are the vehicles through which nutrients can be absorbed into the body. The liver (located under the ribcage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are still important for healthy digestion. The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food. The liver also plays a major role in the handling and processing of nutrients. These nutrients are carried to the liver in the blood from the small intestine. From the small intestine, food that has not been digested (and some water) travels to the large intestine through a valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished. The large intestine's main function is to remove water from the undigested matter and form solid waste that can be excreted. The large intestine is made up of three parts: 1. The cecum is a pouch at the beginning of the large intestine that joins the small intestine to the large intestine. This transition area allows food to travel from the small intestine to the large intestine. The appendix, a small, hollow, finger-like pouch, hangs off the cecum. Doctors believe the appendix is left over from a previous time in human evolution. It no longer appears to be useful to the digestive process. 2. The colon extends from the cecum up the right side of the abdomen, across the upper abdomen, and then down the left side of the abdomen, finally connecting to the rectum. The colon has three parts: the ascending colon and transverse colon,

which absorb water and salts, and the descending colon, which holds the resulting waste. Bacteria in the colon help to digest the remaining food products. 3. The rectum is where feces are stored until they leave the digestive system through the anus as a bowel movement.

PATHOPHYSIOLOGY (GASTROENTERITIS)

Precipitating Factors

Predisposing Factors ¤ Age

¤ Lifestyle

¤ Environment

¤ Poor Hygiene ¤ Diet

Etiology: infants/young children: Haemophilus influenzae

Person to person (hands)

Contaminated food/water

Ingestion of Pathogens

Invasion of the GIT

Animal pets

Enterotoxin production

Affects the vomit receptors

Interacts with mucosal lining

Alters permeability

Destruction of epithelial cells

Vomiting center in the brain is stimulated

Superficial ulceration of mucosa

Abdominal cramps

Cellular metabolism d/t underlying injury to GI

Blood, mucus in stool

Abdominal abdominalpain pain

Systemic Invasion

Inflammation of layer of tissue beneath epithelium of mucosa

abdominal spasm to limit mucosal injury

Vomiting Vomiting

Profusesecretion secretionof offluids water Profuse and electrolytes

reduced absorption of fluid & electrolytes

Hyperthermia and edema

Abdominal cramps Diarrhea General weakness

Excretion of Interstitial fluids

Access to Systemic circulation

Fluid and electrolytes loss Infection in other part of the body

Dehydration Deterioration and collapse

DEATH

Septicemia Meningitis

NURSING CARE PLANS ASSESSMENT Subjective data: “Mainit po ang pakiramdam ko” as verbalize by the patient Objective data:  T= 37.9 o C  Skin is warm to touch  RR= 20

NURSING DIAGNOSIS Hyperthermia r/t exposure to hot environment

PLANNING At the end of thirty minutes, the patient will maintain a core temperature within normal.

NURSING INTERVENTIONS  Provide proper ventilation.

RATIONALE  Proper ventilation may reduce the temperature of the patient.

 Monitor heart rate and rhythm.

 Dysrhythmias are common due to electrolyte imbalance, dehydration, and direct effects of hyperthermia on blood and cardiac tissue.

 Promote surface cooling by means of cool environment and/or fans.

 Heat loss by convention.

EVALUATION

 Promote client safety.  Encourage patient’s participation in ways to protect oneself from excessive exposure to hot environment.

Objective data:  Decreased immunity

Risk for infection r/t IV therapy

At the end of 30 minutes, the client will verbalize understanding of individual causative and risk

 Ensuring patient’s safety prevents other problems.  Self-care awareness help in the prevention and control of hyperthermia.

 Instruct client/SO to increase fluid intake.

 Adequate fluid intake prevents dehydration.

 Review sings and symptoms of hyperthermia.

 These may indicate prompt interventions.

 Note risk factors for the occurrence of infection.

 Identifying the possible causative factors helps prevent/control the occurrence of infection.

factors.  Observe for localized sings for infection at insertion sites.  Assess skin conditions around insertion sites of pins, wires, and tongs, noting inflammation and drainage.

 Visible sings of infection enable the management of more severe infections.  The skin is our primary defense against infectious diseases.

 Stress proper hand washing techniques by all caregivers and SO’s of the patient.

 Hand washing technique is a firstline defense against nosocomial infections.

 Instruct client/SO in techniques to protect the integrity of the skin.

 Care for the skin integrity prevents the occurrence of infection.

Subjective data: “Nagsuka siya at nagtae”, as verbalized by her mother Objective data:  Dry mucous membranes and lips  Sunken eyeballs

Fluid volume deficit related to increase metabolic demand and insensible fluid loss through vomiting and increased body temperature

At the end of the shift, the patient will be able to: - Achieve adequate hydration as evidenced by good skin turgor, moist mucous membranes and lips, no alteration in mentation

 Assessed vital signs and degree of hydration and level of consciousness

 Provides baseline data and information; this is also important in the evaluating clients condition an success of intervention

 Encouraged adequate fluid intake as tolerated by the patient. Instructed SO to provide fluids in the bedside

 Adequate fluids will replace fluid lost through insensible water loss due to hyper metabolic state and vomiting

 Regulated IVF according to specified flow rates basing on the physician’s order

 Regulation of fluid is critical in maintaining adequate circulating fluids to recover for the amount of water loss through fever and vomiting

 Monitored frequency of urination and amount of excreted urine

 Urine output serves as an important parameter in assessing client’s ability to conserve fluids

DRUG STUDY METRONIDAZOLE Generic name: Metronidazole Brand name: Flagyl Classification: Trichomonacide, amebicide Action: Effective against anaerobic bacteria and protozoa. Specifically inhibits growth by binding to DNA, resulting in loss of helical structure, strand breakage, inhibition of nucleic acid synthesis and cell death. Side Effects: GI: nausea, dry mouth, metallic taste, vomiting, abdominal discomfort, andominal pain CNS: headache, dizziness Nursing Responsibilities:  Monitor stool number and character.  With IV therapy, assess for sodium retention.

METOCLOPRAMIDE Generic name: Metoclopramide Brand name: Reglan Classification: gastrointestinal stimulant Action: Dopamine antagonist that acts by increasing sensitivity to acetylcholine; results in increased motility of the upper GI tract and relaxation of the pyloric sphincter and duodenal bulb. Side Effects: GI: nausea, bowel disturbances CNS: restlessness, drowsiness, fatigue, headache, dizziness Nursing Responsibilities:  Inject slowly IV to prevent transient feelings of anxiety and restlessness.  Assess abdomen for bowel sounds and distention.

AMPICILLIN Generic name: Ampicillin Brand name: Unasyn Classification: Antiboitic, penicillin Action: Synthetic, broad-spectrum antibiotic suitable for gram-negative bacteria. Side Effects: GI: diarrhea, abdominal distention CNS: fatigue, headache GU: dysuria, urinary retention At the site of infection: pain and thrombo-phlebities Nursing Responsibilities:  Note history of sensitivity/reactions to these or related drugs.  Monitor CBC, liver, and renal function  Monitor urinary output and serum potassium levels RANITIDINE Generic name: Ranitidine Brand name: Zantac Classification: histamine H2 receptor blocking drug Action: Competitively inhibits gastric acid secretion by blocking the effect of histamine on histamine H2 receptors. Side Effects: GI: constipation, diarrhea, abdominal pain CNS: dizziness, headache, insomnia, anxiety Nursing Responsibilities:  Assess patient GI condition before starting therapy and regularly thereafter to monitor the doing effectiveness.  Be alert for adverse reaction and drug interaction.  Assess patient’s and family knowledge of the drug therapy.