Liceo De Cagayan University College Of Nursing Ncm501202 Related Learning

LICEO DE CAGAYAN UNIVERSITY COLLEGE OF NURSING NCM501202 RELATED LEARNING EXPERIENCE

A Case Study of A 6 Month Old Client with Acute Gastroenteritis with some Dehydration

Submitted to: Mrs. Annaliza Arellano, R.N.

In Partial Fulfillment of NCM 501202 RLE

RLE GROUP CLUSTER II – B7

Submitted by: Sabsal, Marylee S.

I. INTRODUCTION A. Overview of the Case Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). An infection may be caused by bacteria or parasites in spoiled food or unclean water. Some foods may irritate your stomach and cause gastroenteritis. Lactose intolerance to dairy products is one example. Acute diarrhoea or gastroenteritis is the passage of loose stools more frequently than what is normal for that individual. This increased frequency is often associated with stools that are watery orsemisolid, abdominal cramps and bloating. Acute watery diarrhoea is an extremely common problem, and can be fatal due to severe dehydration, in both adults and children, especially in the very young and the old or in those who have poor immunity such as individuals with HIV infection or patients who are using certain medications that suppress the immune system.In healthy adults, however, it is often no more than a nuisance. Because it may interfere with ones ability to work, it can also adversely affect the individual’s income. B. Objectives and Purpose of the Study This study generally aims to investigate the condition of a client and further understand the extent of the case. Specifically the student nurse sought to: •

Perform Physical Assessment, Data Base and History Taking that solidifies the present diagnosis of the client.

•

Identify Signs and Symptoms associated with the disorder.

•

Identify priority nursing problems which will be the basis of the care plan.

•

Develop Plan of Care and Implement nursing interventions relevant and suitable to the case.

•

Evaluate the effectiveness of the interventions and detect any progress or regression of the client’s disease condition. The purpose of the study is to gather significant data to broaden my

knowledge of the disease process and to improve my abilities as future healthcare provider. This is done to be able to aid in the recovery process of the client. Moreover this case study will enable me to apply the acquired skills I have obtained in the classroom set-up. C. Scope and Limitation of the Study The scope of the study consists of one pedia ward client of the TalakagBukidnon Provincial Hospital. Significant others was interviewed specially her mother to know more about the client and her condition. The time period for which the study was conducted and completed, was constrained and limited to a span of 1 week. The first assessment done was last January 27, 2009, at around 5:00 pm. Then continuous assessment was done in the span of my duty in the said ward from January 28 and 29.The said assessment dates were maximized to gather of information including profile, data base, history of present illness, chart data and many others. II. HEALTH HISTORY A. Patients Profile Name of Patient:

John Dave Salungayan

Sex:

Male

Age:

6 month old

Birthday:

July 15, 2008

Birthplace:

Talakag, Bukidnon

Religion:

Roman Catholic

Civil Status:

Child

Mother:

Cecile Salungayan

Father:

Aaron Salungayan

Nationality:

Filipino

Date Admitted:

January 26, 2009

Time Admitted:

4:15 pm

Informant:

Mother

Temperature:

37.6 ̊C

Pulse Rate:

140 bpm

Respiration:

35 cpm

Attending Physician:

Dr. Joseph J. Borong, M.D.

B. Personal Health History My patient John Dave Salungayan was born through a normal vaginal delivery. He had completed all his immunization. He has not received any blood from the past. It was his first time to be admitted in the hospital. He has no known food and medicine allergies. The patient had no previous history of surgery. He had experienced cough, colds, and fever that don’t necessitate the patient to be admitted at the hospital. C. Chief Complains and History of Present Illness John Dave Salungayan, a 6 month old child from Talakag, Bukidnon was admitted for the first time due to diarrhea and vomiting, with the initial vital signs of: temperature- 36.5 ˚C, respiratory rate- 27 cpm, and a pulse rate of 140 bpm. The result of his physical assessment was that he has respiratory distress. Two days prior to admission the patient is already suffering from diarrhea. There was no skin lesions observed upon admission. The doctor’s admitting diagnosis is acute gastroenteritis with some dehydration. III. DEVELOPMENT DATA Sigmund Freud’s Theory (Psychosexual Theory) The 0-2 years of age is under the oral stage of Freud’s psychosexual theory. Early in your development, all of your desires were oriented towards your lips and your mouth, which accepted food, milk, and anything else you, could get your hands on (the oral phase). The first object of this stage was, of course, the mother's breast, which could be transferred to auto-erotic objects (thumbsucking). The mother thus logically became your first "love-object," already a

displacement from the earlier object of desire (the breast). When you first recognized the fact of your father, you dealt with him by identifying yourself with him; however, as the sexual wishes directed to your mother grew in intensity, you became possessive of your mother and secretly wished your father out of the picture (the Oedipus complex). This Oedipus complex plays out throughout the next two phases of development. Feeding, crying, teething, biting, thumbsucking, weaning - the mouth and the breast are the centre of all experience. The infant's actual experiences and attachments to mum (or maternal equivalent) through this stage have a fundamental effect on the unconscious mind and thereby on deeply rooted feelings, which along with the next two stages affect all sorts of behaviours and (sexually powered) drives and aims - Freud's 'libido' and preferences in later life. John Dave is under the oral stage of Freud’s psychosocial theory in which he find more pleasure in sucking his thumb every time he is going to bed. I had also observed that John Dave is a mama’s boy because he won’t go to sleep unless her mother would carry him. Erik Erikson’s Theory The infant will develop a healthy balance between trust and mistrust if fed and cared for and not over-indulged or over-protected. Abuse or neglect or cruelty will destroy trust and foster mistrust. Mistrust increases a person's resistance to risk-exposure and exploration. "Once bitten twice shy" is an apt analogy. On the other hand, if the infant is insulated from all and any feelings of surprise and normality, or unfailingly indulged, this will create a false sense of trust amounting to sensory distortion, in other words a failure to appreciate reality. Infants who grow up to trust are more able to hope and have faith that 'things will generally be okay'. This crisis stage incorporates Freud's psychosexual Oral stage, in which the infant's crucial relationships and experiences are defined by oral matters, notably feeding and relationship with mum. Erikson later shortened 'Basic Trust v Basic Mistrust' to simply Trust v Mistrust, especially in tables and headings.

Hope & Drive (faith, inner calm, grounding, basic feeling that everything will be okay - enabling exposure to risk, a trust in life and self and others, inner resolve and strength in the face of uncertainty and risk). My patients is irritable and crying when he cannot see her mom or when his mom is not around. But when her mother came and he recognized the voice, the touch, John Dave will stop from crying. Jean Piaget’s Theory (Cognitive Theory) Sensorimotor stage. In this period, intelligence is demonstrated through motor activity without the use of symbols. Knowledge of the world is limited (but developing) because it’s based on physical interactions / experiences. Children acquire object permanence at about 7 months of age (memory). Physical development (mobility) allows the child to begin developing new intellectual abilities. Some symbolic (language) abilities are developed at the end of this stage. My patient learns many things by what he saw. At this moment he is still developing his motor skills. He is aware only of their sensations, fascinated by all the strange new experiences his bodies is having. He like little scientists exploring the world by shouting at, listening to, banging and tasting everything. IV.MEDICAL MANAGEMENT a. Medical Orders and Rationale DOCTOR’S ORDER Date / time January 26, 2009

Order  Please admit under the care of Dr. Borong

Implication  For individualized care and monitoring

 Secure consent

 For

legal

and

documentation purposes 4:15 pm

and

 For closer monitoring of

respiration every q 30 min.

the patient’s vital signs

 Temperature, pulse

and also to know if there’s changes from the baseline vital signs  Start with D5O.3% NaCl 500cc, regulate at 40cc/hr

 For fluid and electrolyte imbalance

 Medicines: •

Cotrimoxazole 3-4 tsp  For infection control BID, P.O.

•

Chlorpromazine 3-4 tsp  Relieves BID, P.O.

nausea

and

vomiting

 Laboratory: •

Fecalysis

 To identify presence of microorganisms

in

the

feces •

Urinalysis

 To check presence of microorganisms

in

the

urine  DAT, increased fluid intake January 27, 2009

 To restore fluid loss

(ORESOL)  For x-ray

 X-Raydisease

 V/S q 4, I and O q shift

2009

 Moderate high back rest

signs.

 To follow D5O.3% NaCl



500cc, regulate at 40cc/hr  Same IVF to follow same rate

January 28,

 Refer for unusualities

monitor

activity

and

progression. 

January 28,

to

To

monitor

vital

To maintain airway

patency 

For

fluid

and

electrolyte replacement]  For fluid and electrolyte

2009

 To consumed IVF

replacement  For monitoring purposes

 MGH

Laboratory/ Diagnostic Examinations FECALYSIS: Date: January 26, 2009 Macroscopic appearance: Color: yellow

Consistency: Soft

Microscopic appearance: Pus cells: few RBC: none seen /hpf Fat globules: none seen / hpf URINALYSIS Date: January 26, 2009 Color: Yellow Appearance: Clear Specific gravity: 1.025 Protein (Albumin): Negative Glucose: Negative Bacteria: Few

V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY A. Anaphysiology Your digestive system started working even before you took the first bite of your pizza. And the digestive system will be busy at work on your chewed-up lunch for the next few hours — or sometimes days, depending upon what you've eaten. This process, called digestion, allows your body to get the nutrients and energy it needs from the food you eat. So let's find out what's happening to that pizza, orange, and milk. The Mouth Starts Everything Moving. Even before you eat, when you smell a tasty food, see it, or think about it, digestion begins. Saliva or spit, begins to form in your mouth. When you do eat, the saliva breaks down the chemicals in the food a bit, which helps make the food mushy and easy to swallow. Your tongue helps out, pushing the food around while you chew with your teeth. When you're ready to swallow, the tongue pushes a tiny bit of mushed-up food called a bolus toward the back of your throat and into the opening of your esophagus, the second part of the digestive tract. The esophagus is like a stretchy pipe that's about 10 inches (25 centimeters) long. It moves food from the back of your throat to your stomach. But also at the back of your throat is your windpipe, which allows air to come in and out of your body. When you swallow a small ball of mushed-up food or liquids, a special flap called the epiglottis flops down over the opening of your windpipe to make sure the food enters the esophagus and not the windpipe.If you've ever drunk something too fast, started to cough, and heard someone say that your drink "went down the wrong way," the person meant that it went down your windpipe by mistake. This happens when the epiglottis doesn't have enough time to flop down, and you cough involuntarily (without thinking about it) to clear your windpipe. Once food has entered the esophagus, it doesn't just drop right into your stomach. Instead, muscles in the walls of the esophagus move in a wavy way to

slowly squeeze the food through the esophagus. This takes about 2 or 3 seconds. B. Pathophysiology Definition: Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). Person to person

Contaminated food or H20

Animal Pets

Escherichia Coli, Shigella, Salmonela, Staphylococcus Aureus Invasion of Gastrointestinal tract Exterotoxin production

Destruction of epithelial cells

Interacts with mucosa

Superficial ulceration of Mucosa

Inflammation of layer

Blood, mucus in stool

of tissue beneath

Prufuse secretion of H20 and electrolytes

System invasion

epithelium of mucosa

Hyperemia and edema Diarrhea Dehydration/ Detorioration

Excretion of intestinal fluids

Access to systemic circulation

and collapse Infection in another part of body

Nursing Assessment II

SUBJECTIVE

OBJECTIVE

SKIN COMMUNICATION: INTEGRITY: [ ] hearing loss Comments: [X] dry Comments: [ ] visual changes applicable [ ] other applicable [X] denied [ ] denied

[X] dry [ ] cold [] [ ] glasses [ ] languages pale Not [ ] contact lenses [ ] hearing aide Not [ ] flushed [X] warm [ ] speech difficulties [ ] moist [ ] cyanotic Pupil size: 3-5 mm *rashes, ulcers, decubitus Reaction: PERRLA (describe size, location, drainage: No presence of rashes, ulcers, decubitus. Resp. [x] regular

OXYGENATION: [ ] dyspnea Comments: ACTIVITY/SAFET [ ] smoking history applicable Y: Comments: [x] cough [ ] convulsion applicable [ ] sputum [ ] dizziness [ ] denied [ ] limited motion of

Not Describe: _has a regular breathing [ ] LOC and orientation: pattern Not Conscious. R: Right lung is symmetric to the left Gait: [ ] walker [ ] cane [] lung other L: Left lung is symmetric to the right [X] steady [ ] unsteady lung.

Joints

sensory and motor losses

CIRCULATION: Limitation in [ ] chest pain Ability to [ ] leg pain [ ] ambulate [ ] numbness of [ ] bathe self extremities [ ] other [X] denied [X] denied

Comments: applicable

in face and Not Heart Rhythm [X] regular [ ] Extremities: Sensitivity in hands irregular & feet Ankle Edema: no presence of unkle edema [ ] ROM limitations: Normal ROM Pulse Car Rad. DP Fem* limitation R: 125 96 92 91 L:

112

Comments:

PAWAKE:

101

114

pulses

are

120 strongly

palpable. [ ] facial grimaces

COMFORT/SLEE Comments;

[ ] pain applicable NUTRITION: Comments: (location) Diet:DAT,(dry applicable Frequency foods,Increased Remedies fluid intake) [ ] nocturia []N[]V [ ]sleep Character difficulties [X] recent change in [X] denied weight appetite [x]

[ ] irregular

Not

[ ] guarding

[X] other signs of pain pain in Not [ ]dentures [X]none the infusion site(pt. is irritable) [ ] side rail release N/A Full Partial with patient Upper [ ]

[X]

[]

Lower [ ]

[]

[]

swallowing

difficulty COPING:

Observed

non-verbal

behavior:

VII. NURSING MANAGEMENT A. Ideal nursing Management NURSING DIAGNOSIS: Fluid volume deficient may related to excessive fluid loss, oral intake INTERVENTION and RATIONALE Independent: 

Assess vital sign changes.

(Elevated temperature/ prolonged fever increases metabolic rate and fluid loss thought evaporation) 

Asses skin turgor, moisture of mucous membranes (lips, tongue).

(Indirect indicators of adequacy of fluid volume, although oral mucous membranes may be dry because of mouth breathing and supplement oxygen) 

Monitor intake and output(I&O), nothing color, character of urine.

Calculate fluid balance. Be aware of insensible losses. Weigh as indicated. (Provide information about adequacy of fluid volume and replacement needs)

Dependent: 

Provide supplemental IV fluids as necessary.

(In presence of reduced intake/ excessive loss, use of parenteral route may correct/ prevent deficiency)

NURSING DIAGNOSIS: Risk for infection related to inadequate primary defenses, inadequate secondary defenses INTERVENTION and RATIONALE Independent: 

Monitor vital signs closely, especially during initiation of therapy.

(During this period of time, potentially fetal complications (hypotension/ shock) may develop) 

Instruct patient concerning the disposition of secretion and

reporting changes in color, amount, odor of secretion) 

Limit visitors as indicated

(Reduce likelihood of exposure to other infectious pathogens) 

Demonstrate/ encourage good handwashing technique.

(effective means of reducing spread or acquisition of infection) Dependent: 

Prepare for/ assist with diagnostic studies as indicated.

(Fiberoptic bronchoscopy (FOB) may be done in patients who do not respond rapidly (within 1-3 days) to antimicrobial therapy to clarify diagnosis and therapy needs.)

NURSING DIAGNOSIS: Knowledge deficient regarding condition, prognosis, treatment, self-care, and discharge needs as related to unfamiliarity with resources and information misinterpretation INTERVENTION and RATIONALE Independent:  Determine the mother’s perception of disease process. (Establishes knowledge base and provides some insight into individual learning needs)  Review disease process, cause/effect relationship of factors that precipitate symptoms, and identify ways to reduce contributing factors. Encourage questions. (Precipitating/aggravating factors are individual; therefore, the mother needs to be aware of what foods, fluids, and lifestyle factors can precipitate symptoms. Accurate knowledge base provides opportunity for the mother to make informed decisions/choices about future and control of chronic disease. Although most others know about

their own disease process, they may have outdated information or misconceptions)  Review medications, purpose, frequency, dosage, and possible side effects. (Promotes understanding and may enhance cooperation with regimen)  Stress importance of good skin care, e.g., proper handwashing techniques and perineal skin care. (Reduces spread of bacteria and risk of skin irritation/breakdown, infection)  Emphasize need for long-term follow-up and periodic reevaluation. (Patients with IBD are at risk for colon/rectal cancer, and regular diagnostic evaluations may be required) B. Actual Nursing Management S

Not applicable  Pale  Dry skin

O

 Appears weak

A

 Poor capillary refill (3 sec.) Fluid volume deficit related to dehydration Long term: At the end of 1 day, the patient’s mother will be able to

P

demonstrate understanding and follow treatment regimens for her daughter. Short term: At the end of 30 minutes, the patient’s mother will be able to demonstrate understanding and follow treatment regimens for her daughter. Independent:

I

 Encouraged adequate rest (To maximize rest)

 Increased fluid intake as tolerated. (For adequate hydration)  Give ORESOL (To restore fluid & electrolyte loss)  Monitor intake and output (I&O), noting color, character of urine. Calculate fluid balance. (indicators of adequacy of fluid volume) Dependent:  IV

administration

(D50.3%

NaCl

500cc,

regulated

at

35cc/min) E

( to correct fluid and electrolyte loss) At the end of 30 minutes, the patient’s was able to demonstrate understanding and follow treatment regimens

S

Not applicable  Loss of appetite  Present weight (5 kls)

O

 Appears weak

A

 Vomiting Nutritional imbalance nutrition, less than body requirements. Long term: At the end of 1 month, the pt. body weight will increased

P

at least 0.5 kilo. Short term: At the end of 30 min. pt. will be able to improve her appetite in eating. Independent:  Identify factors contributing to nausea and vomiting

I

 Assess with or encourage oral hygiene (Eliminate noxious sights, smell, and taste to prevent vomiting)  Provide small frequent meals including dry foods and that are

appealing to the patient (These measures may enhance intake even though appetite may be slow to return)  Evaluate general nutritional state, obtain baseline weight ( Presence of chronic conditions or financial limitations can contribute to malnutrition, lowered resistance to infection)  Encouraged snacks. (To increase total nutrient intake) E

At the end of 30 min. pt. was able to improve her appetite in eating.

VIII. REFERRALS and FOLLOW-UP Once the client will be discharged, I had instructed her mother encouraged my client to drink his home medications religiously to prevent further infection. I have also instructed her mother to let her son have a daily exercise like deep breathing pattern and I’d teach the mother some of the range of motion exercises in order to promote proper blood circulation and attain proper oxygenation. And I have also reminded her mother to stick with her son’s diet and to have adequate amount of it to meet nutritional needs and attain full wellness. IX. EVALUATION AND IMPLICATION At the end of my hospital duty, I was able to render care to my patient to help him resolve his health condition. Through observing the patient’s status, I was able to identify priority problems related to his health. The patient’s mother was willing to pursue the medical therapy just to promote health and wellness for the betterment of her son’s condition. I have also made the patient’s mother realize the importance of completing the course of therapy by taking the medicines prescribed or ordered for his son by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to his mother especially the benefits he will gain in eating those foods.

Moreover, this several interventions given to the patient made her body conditioning normal and I can say that our patient has somehow recovered from his illness.

X. BIBLIOGRAPHY BOOKS Doenges,

Marilynn,

et

al.

Nursing

Care

Plans,

Guidelines

for

Individualizing Patient Care (7th Edition) F.A. Davis Company. Copyright 2000. Kozier, Erb, Blais, Wilkinson. Fundamentals of Nursing (7th edition). Addison Esley Longman Inc. 1998. Smeltzer, Suzanne C. and Bare, Brenda G. Medical-Surgical Nursing. (10th Edition). Volume 2. Lippincott Williams and Wilkins.2004 Luckman and Sorensen, Medical-Surgical Nursing. 3rd Edition W.B. Saunders Company (1987) Jacob, S, et al Structure ad Function in Man. 5th Edition W.B. Saunders Company (1982) INTERNET http://www.medicinenet.com/pneumonia/page4.htm

http://www.merck.com/pubs/mmanual_ha/sec3/ch41/ch41d.html http://fog.ccsf.cc.ca.us/~jgrass/Content/Lessons/skeletal.html http://web.indstate.edu/thcme/mwking/nucleotide-metabolism.htm EENT:

� Impaired vision � blind � pain � reddened � drainage � gums � hard of hearing � deaf � burning � edema � lesion � teeth Asses eyes, ears, nose Throat for abnormality [x] no problem RESPIRATION �asymmetric � tachypnea � apnea � rales [x] cough � barrel chest � bradypnea � shallow � rhonchi � sputum � diminished � dyspnea Vomiting � orthopnea � labored � wheezing � pain � cyanotic Asses resp. rate, rhythm, depth, pattern breath sounds, comfort � no problem CARDIO VASCULARNURSING SYSTEM REVIEW CHART Poor skin turgor � arrhythmia � tachycardia � numbness �Name: diminished pulses � edema � fatigue (2-3 sec.) John Dave Salungayan Date: January 28, 2009 � irregular � bradycardia � murmur Signs: �Vital tingling � absent pulses � pain Pulse:heart 140 sounds, bpm Temp: 37.6 ̊Cpulse, Respi: Assess rate, rhythm, blood35 cpm pressure, etc., fluid retention, comfort [x] no problem GASTRO INTESTINAL TRACT � obese � distention � mass IV site (D50.3% NaCl � dysphagia � rigidity � pain 500cc regulated @ Asses abdomen, bowel habits, swallowing, bowel sounds, comfort [x] no problem 40gtts/min) GENITO-URINARY and GYNE � pain � urine color � vaginal bleeding � hematuria � discharge � nocturia Assess urine freq., control, color, odor, comfort/ Gyn-bleeding, discharge [x] no problem NEURO � paralysis � stuporous � unsteady � seizures � lethargic � comatose � vertigo � tremors � confused � vision � grip Assess motor function, sensation, LOC, strength, grip, galt, coordination, orientation, speech. Cough [x] no problem MUSCULOSKELETAL and SKIN � appliance � stiffness � itching � petechiae � hot � drainage � prosthesis � swelling Moist skin � lesion [x] poor turgor � cool � deformity � wound � rash � skin color � flushed � atrophy � pain � ecchymosis Poor capillary refill � diaphoretic [x] moist Asses mobility, motion, galt, alignment, joint function /skin color, texture, turgor, integrity � no problem Diarrhea Place an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure if appropriate, using (x)