Upper Respiratory Tract Infection

Liceo de Cagayan University College of Nursing

Individual Care Study Name of Client

Submitted to:

CLINICAL INSTRUCTOR

In Partial Requirement for NCM501___ RLE Submitted by: Group B7 – Cluster 2

I. INTRODUCTION Upper respiratory tract infection (URI) is a nonspecific term used to describe acute infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and bronchi. The prototype is the illness known as the common cold, which will be discussed here, in addition to pharyngitis, sinusitis, and tracheobronchitis. Influenza is a systemic illness that involves the upper respiratory tract and should be differentiated from other URIs. Viruses

cause

most

URIs,

with

rhinovirus,

parainfluenza

virus,

coronavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenza virus accounting for most cases. Human metapneumovirus is a newly discovered agent causing URIs. Group A beta-hemolytic streptococci (GABHS) cause 5% to 10% of cases of pharyngitis in adults. Other less common causes of bacterial pharyngitis include group C beta-hemolytic streptococci, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia pneumoniae,

Mycoplasma

pneumoniae,

and

herpes

simplex

virus.

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms that cause the bacterial superinfection of viral acute sinusitis. Less than 10% of cases of acute tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae, or C. pneumoniae. Most URIs occurs more frequently during the cold winter months, because of overcrowding. Adults develop an average of two to four colds annually. Antigenic variation of hundreds of respiratory viruses results in repeated circulation in the community. A coryza syndrome is by far the most common cause of physician visits in the United States. Acute pharyngitis accounts for 1% to 2% of all visits to outpatient and emergency departments, resulting in 7 million annual visits by adults alone. Acute bacterial sinusitis develops in 0.5% to 2% of cases of viral URIs. Approximately 20 million cases of acute sinusitis occur annually in the United States. About 12 million individuals are diagnosed with acute tracheobronchitis annually, accounting for one third of patients presenting

with acute cough. The estimated economic impact of non–influenza-related URIs is $40 billion annually. Influenza epidemics occur every year between November and March in the Northern Hemisphere. Approximately two thirds of those infected with influenza virus exhibit clinical illness, 25 million seek health care, 100,000 to 200,000 require hospitalization, and 40,000 to 60,000 die each year as a result of related complications. The average cost of each influenza epidemic is $12 million, including the direct cost of medical care and indirect cost resulting from lost work days. Pandemics in the 20th century claimed the lives of more than 21 million people. A widespread H5N1 pandemic in birds is ongoing, with threats of a human pandemic. It is projected that such a pandemic would cost the United States $70 to $160 billion.

B. OBJECTIVES OF THE STUDY This individual case study provides goals or objectives which can be used as an instrument in assessing the patient’s health status and in his present conditions: 1. Use to obtain a complete heath data and can be used in follow up care. 2. Impart knowledge by conducting health teaching about the necessary information pertaining in the disease condition. 3. Understands the course and essence of the chosen care study.

C. SCOPE AND LIMITATION OF THE STUDY The study includes all the data gathered during the interview and the observation claimed by the patient as well as the significant others. It also deals with the several factors observed and gathered during the interview. That information gathered was the exact answer and the problems of the people in the community and not just basing in the opinions of the students conducting the interview of the students. The limitation of this study is limited in the place of interaction itself which is in the hospital. This study was completed in 2 days by the interaction of the student and the patient.

II. HEALTH HISTORY: A. Profile of the Patient

NAME: AGE: SEX: RELIGION: BIRTH DATE: CIVIL STATUS: Single NATIONALITY: Filipino ADDRESS: tagloan DATE OF ADMISSION: November 18, 2008 TIME OF ADMISSION: 9:05pm

VITAL SIGNS ASSESMENT

TEMPERATURE: 36.6 PULSE RATE: 86 bpm RESPIRATORY RATE: 100 bpm HEIGHT: 94 cm WEIGTH: 12.7 kg ALLERGY: No allergy

B. FAMILY AND PERSONAL HEALTH HISTORY Jurey was born on November 18, 2007. He was delivered NSVD in the Polymedic General Hospital. He was a healthy and a lovable boy. One month after birth Jurey experienced diarrhea lasting for two days, her mother panic and admitted him into the Polymedic General hospital. He was then diagnosed of having a diarrhea having a watery stool, Jurey stayed in the hospital for almost a day. A week after, Jurey had a fever due to infection. Her mother gave him paracetamol and she had performed a tepid sponge both on him. After giving the medications and performing tipid sponge bath the temperature of Jurey drop from 38° c to 36.8° c.

C. HISTORY OF PRESENT ILLNESS: The case of 2 years old male, Roman Catholic lived in Taguluan,came in Sabal Hospital CDOC at 12:50 pm on November 18 , 2008 with a chief complains of Loss bowel movement (LBM) and vomiting. Jurey had a cough lasting for 6 days. On that day, Jurey had LBM three consecutive defecation within an interval of 30minutes with watery, nonblood seen associated with vomiting at least two times after such intake of foods/fluids as stated by the mother where prompt to admission. There was no associated symptom like fever during that day. Jurey was diagnosed to have an acute gastroenteritis with mild dehydration (AGE). D. CHIEF COMPLAINS The chief complain of the patient is loss bowel movement and vomiting last November 18, 2008 at 12:05 pm.

III. DEVELOPMENTAL DATA: Sigmund Freud’s Psychosocial Development: According to Freud, the source of bodily pleasure is concentrated in zones around the musculocutaneous junctions. These erotogenic zones displace one another in sequence as the child matures. Initially, the infants erotogenic zone is the mouth, thus gratification of the id is derived through oral satisfaction. During the first 6 months of life, the infant is in the oral dependent or oral passive stage, as evidenced by sucking. After the first teeth erupt at about 5 to 7 months of age, the infant enters the oral aggressive stage with biting and sucking as the means of gratification. Infants enjoy sucking and later biting anything that touches the erogenous zone of the lips and mouth. Some infants enjoy this oral activity more than the others. While some may be satisfied by sucking at the breast or bottle, others require pacifiers, toys or other objects that can be orally manipulated. The young infant operates on the basis of primary narssism or self-love, wanting what is wanted immediately and unable to tolerate a delay in gratification. This process, the pleasure principle, later becomes a part of the ego structure that operates on the reality principle, giving up what is wanted now for something better in the future. If the mother or her substitute always sees to it that the infant’s need before there is evidence of these needs, the infant will feel no control over the environment. On the other hand, if required to wait too long after expressing a need, the infant will feel unable to control the environment and thus learns to mistrust the caregiver.

IV. MEDICAL MANAGEMENT MEDICAL ORDERS/RATIONALE/MEDICINE/LABORATORY: MEDICINE ORDERED DATE ORDERED o Cotrimoxazole 125mg/5ml November 18,2008 suspension 4.0ml BID (86)

o Metronidazole 125mg/5ml November 18, 2008 suspension 4.0ml TID(81-6) o Prozinc drops 1.3ml OD (once daily)

RATIONALE Antibacterial – for Shigellosis or UTIs caused by susceptible strains of Escherichia coli, Proteus (in dole positive or negative),Klebsiella, or Enterobacter species. Amoebicides & Antiprotozoals – intestinal Amebiasis Food supplement contains zinc an essential mineral that stimulates the activities of many enzymes promoting normal biochemical reaction in the body. Strengthen the immune system, support normal growth and drugs and help prevent retardation.

o Fecalysis

November 18, 2008

To check abnormalities.

for

o Urinalysis

November 18, 2008

for

o Hemochrome

November 18, 2008

To check abnormalities. To check abnormalities.

for

DRUG STUDY GENERIC NAME OF THE DRUG: CETTRIAXONE DATE ORDERED: November 18, 2008 CLASSIFICATION: Cephalosporin DOSE AND FREQUENCY: MECHANISM OF ACTION: SFECIFIC INDICATION: Lower respiratory tract infection, skin and skin structure infection due to s.aureus SIDE EFFECTS: Increases in the serum creatine presence of cast in the urine, alternation of PFs. NURSING PRECAUTION: 1. IM injection should be deep in the body of the large muscle. 2. IV infusion should contain concentrations of 40 mg/mL of sterile water. 3. Do not mix the drug with other antibiotics

V. ANATOMY AND PHYSIOLOGY: Acute gastroenteritis Viruses and bacteria from the contaminated food

It produces toxins that react with the small intestine mucosa

Dysentery caused by bacteria which affects the colon

Abdominal cramping, diarrhea and vomiting

Fluid electrolytes imbalance

Parasites invade the circulation and localize in the Gastrointestinal tract

Inflammation

Watery stools and vomiting occur

THE DIGESTIVE SYSTEM Consists of (1) an alimentary canal- a long muscular tube beginning at the lips and ending at the anus, including the mouth, pharynx (oral and laryngeal portions), esophagus, stomach, and small and large intestine, and (2) accessory glands that empty secretions into the tube- salivary glands, pancreas, liver, and gallbladder.

1. Teeth a. Crown projects above the gum, root below. Dentin (bulk of tooth) surrounds pulp cavity. Enamel covers dentin of crown; cementum covers dentin of root and anchors tooth to periodontal ligament. b. Each quadrant of mouth has eight teeth-two incisors, one canine, two premolars, and three molars.

2. Esophagus a. Mucous membrane lined with stratified squamous epithelium rather than simple columnar epithelium, as in stomach and intestine, b. Muscular layer of upper third, striated; lower third, smooth; middle, both striated and smooth. c. Segment above stomach (indistinguishable anatomically from remainder of esophagus) functions as sphincter, remaining closed until reflexively relaxed as peristaltic wave approaches,

3. Stomach a. Consists of upper fundus, central body, and constricted lower pyloric portion (antrum). b. Musculature contains an oblique inner layer of smooth muscle in addition to external longitudinal and underlying circular smooth muscle layers found elsewhere in digestive tract. c. Thick circular muscle in pyloric portion forms pyloric sphincter. d. Openings: cardia, between esophagus and stomach; pylorus, between stomach and duodenum. 4. Small Intestine a. Divided into duodenum, jejunum, and ileum. b. Surface area, serving absorptive function, increased by: 1. Circular folds (plicae circulares)- permanent, transverse folds. 2. Villi – fingerlike projections 3. Microvilli- processes on free surface of epithelial cells that form the brush order. c. Invagination of ileum into cecum – the first part of the large intestine – forms ileocecal valve, which opens rhymthmically during digestion, permitting gradual emptying of ileum and preventing regurgitation. 5. Large Intestine a. Extends from the end of the ileum to the anus and is divisible into the cecum, colon, rectum, and anal canal. The major part is the colon, which consists of ascending, transverse, descending, and sigmoid portions. b.

The longitudinal muscle of the cecum and colon forms three

conspicuous bands(taeniae coli). c.

Thickene circular smooth muscle of anal canal forms the internal

anal sphincter. Surrounding skeletal muscle forms the external sphincter.

6.Salivary Glands a. Three pairs (parotid, submaxillary, and sublingual), with ducts opening into the mouth. b. Two types of secretions: 1. Serous containing ptyalin –enzyme initiating digestion of the starch. 2. Mucous – viscous, containing mucus, which facilitates mastication. 7. Pancreas a. Two types of secretory cells in exocrine pancreas: 1. Enzyme- secreting acinar cells. 2. Bicarbonate-and-water-secreting –intralobular duct cells. b. Pancreatic duct empties pancreatic juice into duodenum. 8. Liver and Gallbladder a. Bile secreted by liver is essential for normal absorption of digested lipids. Bile salts combine with products of lipid digestion to form water-soluble complexes (micelles) which are absorbed by intestinal cells. b. Gallbladder concentrates and stores bile. c. Hepatic duct, formed from the bile duct system of liver, joins cystic duct of gallbladder to form common bile duct, which empties into duodenum. Motility of Digestive Tract 1. Swallowing a. In buccal stage (voluntary) bolus pushed toward pharynx. b. In pharyngeal and esophageal stages (involuntary) bolus passes through pharynx into esophagus and through esophagus into stomach. c. Reflexes raise soft palate, raise larynx, adduct aryepiglottic folds and true and false vocal cords, and inhibit respiration. When food enters the pharynx, reflex contraction of the superior constrictor

muscle initiates peristalsis, propelling the food, and relaxation of the upper and lower esophageal sphincters allows food to pass first into the esophagus and then into the stomach. 2. Peristalsis in Stomach a. Mixes contents and forces chime through pylorus. b. Three waves each beginning every 20 seconds near midpoint of stomach, lasting about one minute, and ending with contraction of pyloric sphincter travel down stomach at one time. c. Rate of emptying determined largely by strength of contractions. d. Feedback from duodenum regulates gastric emptying. Two control mechanisms, one neuronal (enterogastric reflex), the other hormonal (mediated mainly by enterogastrone), inhibit gastric motility. 3. Contractions of the Small Intestine a. Segmenting: rhythmic contractions along a section dividing it into segments: primarily mixing action. b. Peristaltic waves superimposed upon segmenting contractions. c. Ingestion of food increases ileal peristalsis and frequency of opening of ileocecal valve (gastroileal reflex). 4. Contractions of Large Intestine a. Simultaneous contraction of circular and longitudinal muscle, forming haustra, b. Infrequent usually two or three times daily of most mass movements transferring contents from proximal to distal colon and into rectum. Most commonly occur shortly after a meal (gastrocolic reflex). 5. Defecation reflex a. Distention of rectum triggers intense peristaltic contractions of colon and rectum and relaxation of internal anal sphincter. b. Reflex preceded by voluntary relaxation of external sphincter and compression of abdominal contents.

Digestion 1. Mouth a. Enzymatic action: initiation of the digestion of carbohydrate by ptyalin, which splits starch into the disaccharide maltose. Action in mouth slight, but continues in stomach until acid medium inactivates ptyalin. b. Regulation: exclusively nervous- impulses transmitted from center in medulla activated principally by taste, smell, or sight of food to salivary glands by parasymphatetic nerve fibers. 2. Stomach a. Enzymatic action: initiation of protein digestion by pepsin, producing proteoses, peptones, and polypeptides. Pepsinogen secreted by chief cells converted to pepsin by autoactivation process in presence of acid secreted by parietal cells. b. Regulation 1. Cephalic phase- initiated by taste, sight, or smell of food; secretion stimulated directly or indirectly by the hormone gastrin. Gastrin, released from so called G cells in the pyloric region of the stomach, stimulates the secretion of an acid-rich gastric juice. 2. Gastric phase- initiated by food in stomach; secretion triggered directly or indirectly, as in cephalic phase. 3. Intestinal phase- initiated by digestive products in upper small intestine; mediated by hormone released by duodenum acting on stomach. 4. Inhibition- strong acid in antrum inhibits gastrin release. Fat, acid, or hypertonic salt solutions in duodenum stimulate release of hormones which inhibit gastric secretion.

3. Intestine a. Enzymatic action- fat digestion

and continuation of carbohydrate and

protein digestion. 1. Pancreatic lipase splits fat into monoglycerides, fatty acids, and glycerol. 2. Pancreatic amylase converts starch and glycogen into maltose. Intestinal disaccharidases split maltose, sucrose, and lactose into their constituent monosaccharides, 3. Pancreatic enzymes trypsin and chymotrypsin both endopeptidases split proteins and the products of pepsin digestion into peptides. Peptidases split peptides into amino acids. b.. Regulation of pancreatic secretion: by vagus nerve during cephalic and gastric phase of gastric secretion and by two duodenal hormonescholecystokinin-pancreozymin cholecystokinin-pancreaozymin

and

sectetin.

stimulate

Vagus

enzyme

stimulation

secretion;

and

secretin

stimulates bicarbonate secretion.

Absorption 1. Occurs almost exclusively in the small intestine. 2. Simple sugars, amino acids, short-chain fatty acids, and glycerol are absorbed into blood stream via capillary network of villi. Products of lipid digestion are absorbed as chylomicrons into intestinal lymphatics via central lacteal of villi. Digestion process- the digestive system prepares food for consumption by the cells through five basic activities: 1. Ingestion- is an active, voluntary process of taking in food. Food must be placed in the mouth before it can be acted on.

2. Propulsion is movement of food along the digestive tract. Swallowing is one example of food movement that depends largely on the propulsive process called peristalsis. Peristalsis is involuntary and involves alternating waves of contraction and relaxation of the muscles in the organ wall to squeeze food along the tract. 3. Digestion- the breakdown of food by both chemical and mechanical processes. 4. Absorption- the passage of digested food from the digestive tract into the cardiovascular and lymphatic systems for distribution to cells. For absorption to occur, the digested foods must first enter the mucosal cells by active or passive transport processes. The small intestine is the major absorptive site. Defecation- the elimination of indigestible substances from the body

VI. NURSING ASSESMENT NameTumacas ,Jurey Date: _November 18, 2008 Vital Signs: Pulse: EENT: _100 bpm BP: ______Height___94 cm____ Temp: _38_°c_ Impaired vision blind pain reddened drainage gums hard of hearing deaf burning edema lesion teeth Asses eyes, ears, nose Sunken eyeballs Throat for abnormality no problem RESPIRATION asymmetric tachypnea apnea rales cough barrel chest P Dry , cracked bradypnea shallow rhonchi lips sputum diminished dyspnea orthopnea labored wheezing Abdominal pain pain cyanotic Asses resp. rate, rhythm, depth, pattern Dry skin breath sounds, comfort no problem Febrile T: 38˚C CARDIO VASCULAR arrhythmia tachycardia numbness Appeared weak diminished pulses edema fatigue irregular bradycardia murmur Dry skin and tingling absent pulses pain Afebrile T: 36.6˚C Assess heart sounds, rate, rhythm, pulse, blood pressure, etc., fluid retention, comfort no problem GASTRO INTESTINAL TRACT obese distention mass dysphagia rigidity pain Asses abdomen, bowel habits, swallowing, bowel sounds, comfort no problem GENITO-URINARY and GYNE pain urine color vaginal bleeding hematuria discharge nocturia Assess urine freq., control, color, odor, comfort/ Gyn-bleeding, discharge 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. no problem MUSCULOSKELETAL and SKIN appliance stiffness itching petechiae hot drainage prosthesis swelling lesion poor turgor cool deformity wound rash skin color flushed atrophy pain ecchymosis diaphoretic moist Asses mobility, motion, galt,NURSING alignment, ASSESSMENT joint function II /skin color, texture, turgor, integrity no problem

SUBJECTIVE COMMUNICATION: ( ) Hearing Loss Comments: “wla may ( ) visual changes problima sa pan(x)denied dungog ug panLantao” as verbaLized by the mother. OXYGENATION: ( ) dyspnea Comments: “ Dili man siya () smoking history galisud ug ginha___none____ hawa.” As ( ) cough verbalized by the ( ) sputum mother. (x ) denied CIRCULATION: ( ) chest pain Comments: “gasakit lang ( ) leg pain ang iyang tiyan”.as ( ) numbness of verbalized by the Extremities mother. (x) denied NUTRITION: Diet:full diet Comments: ” la na siya ( ) N ( x) V gana mokaon” as Character vaerbalized by (x) recent change in the mother. weight, appetite ( ) swallowing difficulty ( ) denied

ELIMINATION: Usual bowel pattern ( ) urinary frequency Loss bowel movement _ 5-7 times a day ( ) urgency Constipation remedy ( ) dysuria ( ) hematuria Date of last LBM ( ) Incontinence November 18, 2008 ( ) polyuria (x ) diarrhea ( ) foly in place character ( ) denied __not present__

OBJECTIVE ( ) glasses ( ) languages ( ) contact lense ( ) hearing aide Pupil size 3-5 mm_ ( ) speech difficulties Reaction _Pupils are equally rounded and reactant to _light accommodation._

Resp. (x ) regular () irregular Description _ R: right lung is clear in secretions and have a equal size to left lung_ L: left lung is clear in secretions and equal size to right lung

Heart Rhythm (x) regular ( ) irregular Ankle edema There was no presence of ankle edema Pulse Car Rad AP Fem R ______ + + L ________ + + Comments: _. Not all pulses is present ( ) dentures

(x) none

Complete Upper Lower

() ()

Partial () ()

Comments: “ sahay nlng Man gasakit akko tiyan. Bowel sounds: hyper active bowel sound Present ( ) yes (x) no Urine*(color,consistency, Odor) If foley is in place?

SUBJECTIVE SKIN INTEGRITY: (x) dry Comments: “Uga kayo iyang ( ) itching panit”.as verbalized ( ) denied by her mother. ACTIVITY/SAFETY: ( ) convulsion Comments:” Luya kayo ang () dizziness lawas ni Juey, dili kaa( ) limited motion yo siya galihok”. As of joints verbalized by the Limitation in mother. ability to () ambulate () bathe self ( ) other (x ) denied

OBJECTIVE (x) dry () cold () pale (x ) flushed (x ) warm ( ) moist ( ) cyanotic * rashes, ulcers, decubitus (describe size, location, drainage) .The patient has a flushed, warm and dry skin.

( ) LOC and orientation Gait: ( X) steady ( ) unsteady ________________ ( ) sensory and motor losses in face or extremities: No sensory and motor loss ( ) ROM limitations : patient has the ability to do ROM

COMFORT/SLEEP/AWAKE: () pain Comments: “gasakitaay ako (location, iyang tiyan” as verbalized by frequency her mother. remedies) ( ) nocturia ( ) sleep difficulties ( ) denied COPING: 3 members of the family___ Members of household

(x) facial grimaces () guarding () other signs of pain . Pain due to abdominal cramping.

Observed non-verbal behavior : The patient is rubbing his abdomen portion and has a facial grimace due to pain

_His father Mr. Tumacas Most supportive person

The person and his phone number that can be Reached any time _Was not given by the significant others.__________ MEDICAL ORDERS/RATIONALE/MEDICINE/LABORATORY:

MEDICINE ORDERED DATE ORDERED o Cotrimoxazole 125mg/5ml November 19,2008 suspension 4.0ml BID (86)

o Metronidazole 125mg/5ml suspension 4.0ml TID(81-6) o Prozinc drops 1.3ml OD (once daily)

RATIONALE Antibacterial – for Shigellosis or UTIs caused by susceptible strains of Escherichia coli, Proteus (in dole positive or negative),Klebsiella, or Enterobacter species. Amoebicides & Antiprotozoals – intestinal Amebiasis Food supplement contains zinc an essential mineral that stimulates the activities of many enzymes promoting normal biochemical reaction in the body.

Strengthen the immune system, support normal growth and drugs and help prevent retardation. o Fecalysis

November 19,2008

To check abnormalities.

for

o Urinalysis

November 19, 2008

for

o Hemochrome

November 19, 2008

To check abnormalities. To check abnormalities.

Diagnostic Examination: FECALYSIS: Date: November 19,2008 Macroscopic appearance: Color: yellow

Consistency: Soft

Microscopic appearance: Pus cells: none seen /hpf RBC:

none seen /hpf

Fat globules: none seen / hpf Amoeba: Cyst: 0-2 /hpf Result: Positive amoeba

URINALYSIS

for

Date: November 18, 2008 Color: Yellow Appearance: Clear Specific gravity: 1.025 Protein (Albumin): Negative Glucose: Negative Bacteria: Few Result: No findings Hemochrome Date: November 19,2008 WBC- 13.4

normal range (5-10x103ml3)

VII. IDEAL NURSING MANAGEMENT Acute pain related to abdominal cramping and irritation. Desired outcomes/evaluation criteria – the patient relieves Abdominal pain

INDEPENDENT  Encourage the mother to increase the oral intake of fluids containing electrolytes, such as juices and etc.  Monitor Intake and Output. Note number, character, and amount of stools; estimate insensible fluid losses, e.g., diaphoresis. Measure urine specific gravity; observe for oliguria.  Auscultate the abdomen of the patient.

 To maintain the skin integrity of the patient, because skin breakdown can occur quickly when LBM occur.  Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.  To determine for presence, location and characteristic of the bowel sound.

 Restrict the solid intake as indicated by the physician.

 To allow bowel rest5 or to reduce intestinal workload.

 Provide prompt diaper change and cleansing gently.

 To avoid skin breakdown and diaper rash.

 Place the bedpan in the bed of the patient or a commode chair near the bed.

 To provide easy access and to reduce the need to wait.

 Observe for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill.

 Indicates excessive loss/resultant dehydration.  Indicator of overall nutritional status.

 Weigh daily

 Maintain oral restrictions, bed rest.

 Note generalized muscle weakness or cardiac dysrhytmias.

DEPENDENT  Administer parenteral fluids, blood transfusions as indicated.

 Monitor

laboratory

studies,

e.g.,

fluid

fluid

and

 Colon is placed at rest for healing and to decreased intestinal fluid losses.

 Excessive intestinal loss may lead to electrolyte imbalance, e.g., potassium, which is necessary for proper skeletal and cardiac muscle function. Minor alterations in serum levels can result in profound and/or life-threatening symptoms.  Maintenance of bowel rest requires alternative fluid replacement to correct losses/anemia. Note: fluids containing sodium may be restricted in presence of regional enteritis.

IDEAL NURSING MANAGEMENT Knowledge deficient regarding condition, prognosis, treatment, self-care, and discharge needs as related to unfamiliarity with resources and information misinterpretation. Desire outcomes/evaluation criteria- the significant others will: Verbalize understanding of disease processes, possible complications. INTERVENTION RATIONALE INDEPENDENT  Determine the mother’s perception  Establishing knowledge regarding of disease process. the disease condition of her child .  Giving of information’s about the factors that causes the disease condition of the client. Encouraging the mother to ask question about it.

 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.

 Giving of information’s about the medication as well as it’s side effects and action.

 Promotes understanding and may enhance cooperation with regimen.

 Stressing the importance of the following :good skin care, e.g., proper hand washing 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..

IDEAL NURSING MANAGEMENT Impaired skin integrity related to effects of excretions on delicate tissue. Desired outcomes/evaluation criteria- patient will: The patient will be able to maintain his skin integrity as well as to maintain fluid volume. INTERVENTION RATIONALE Independent  Provide the patient with  This is to prevent from injury because oral mouth care. of dryness.  Maintain accurate intake and output and calculate also the 24 urine collection.

 To determine the fluids taken by the patient and also to calculate the output of the patient.

 Instruct the mother to use less frequently mild cleanser or soaps and to provide optimal skin care.

 This is to maintain skin integrity of the patient and to prevent excessive dryness.

Dependent:  Administer medication to prevent the skin and mucous membrane from cracking as indicated by the physician.

 To prevent injury and also to prevent the cracking of the mucous membrane of the patient.

VIII. Actual Nursing Management “Nagsakit man the tiyan ni Jurey tapos cige siya ug kalibang”. S >hyper active bowel sound. O

>Facial Grimace >Dry skin Acute pain related to abdominal cramping

A Long term: At the end of 2o minutes the patient will be able to reestablish and maintain the normal pattern of Bowel functioning. P

Short Term: At the end of 15 minutes the patient will be able to maintain the normal patter of normal bowel functioning. 1. Auscultate the abdomen of the patient. 2. Restrict solid foods intake as indicated by the physician. 3. Encourage the mother to increase the fluid intake

I

of her son containing electrolytes. such as juices to prevent dehydration. 4. place the bedpan near the bed top have a easy access. 5. Administer medications that can relieve abdominal

E

pain as indicated by the physician. 6. After the nursing intervention given the patient abdominal pain will be reduce.

Actual Nursing Management S O

“Init kayo si Jurey ug ga chill siya”. >Temperature:40°c >Pulse rate: 160 bpm >Respiratory Rate :72 cpm

A

>Flushed skin Fever related to infection Long term: At the end of 20 minutes the temperature of Jurey will drop into a normal range..

P

Short Term: At the end of 10 minutes the temperature of Jurey will drop slowly into the normal range.. 1. Perform tepid sponge bath. 2. Change the clothing of the patient into a more comfortable one. 3. Change the clothing of the patient as often as possible.

I

4. Apply hot water bag in the lower extremities of the patient. To lower his temperature. 5. Open the doors and windows in the patient room so that the fresh air will come in. 6. Administer

medications

prescribed

by

the

physician. To lower the temperature of the patient. After the nursing Intervention gentle patients body temperature E

will drops slowly into the normal range.

IX. HEALTH TEACHING MEDICATIONS

For

the

medications,

Instruct

the

mother of the patient to continue the

medication prescribed by the physician and to give the medication on the proper

time

and

route.

The

paracetamol which can lower the body temperature and should be given every EXERCISE

4 hours. For the exercise, Instruct the mother to teach her son to do the relaxation exercise.

TREATMENT

This

is

to

abdominal pain. Instruct the mother

to

relieve

his

follow the

treatment given by the physician, which includes the proper administration of the

medications,

the

time

the

medication be given and the diet that the patient must have. That treatment is necessary for the complete recovery OUT PATIENT

of the patient. Instruct the mother to be back in the hospital

after

1

of

the

discharge

week

after

patient. This

the to

determine if the condition of the patient is already stable and if there is another DIET

treatment be given. Instruct the mother to give her child foods rich in fibers such as vegetables and also to increase the fluid intake of the patient.

X. Evaluation: In the case of Jurey, Immediate intervention was given because Jurey was admitted to the Sabal Hospital after experiencing loss bowel movement and vomiting. History was taken to document the onset and frequency of diarrhea.

Exposure to contaminated food or water is initiated with the patient where drinking water might be contaminated. Physical examination helps the physician to identify underlying systemic disease. The doctor ordered for some diagnostic tests to find the cause of diarrhea which include the fecalysis where positively amoebiasis was detected. Urinalysis and hemochrome was also ordered to provide more specific data. Treatment for acute gastroenteritis includes restoration of fluid and electrolyte balance, management of signs and symptoms and treatment of causative factors. XI. REFERRALS: No one can escape from having this kind of disease Children are very susceptible to illness that is why I imparted knowledge to Mrs. Tumacas to continue giving nutritious foods, and vitamins. As much as possible report to the physician immediately if there are any unusualities may observe because diarrhea can be dangerous in newborns and infants. Children, especially those younger than 6 months of age and those with other health risks, need special attention when they have diarrhea because they can become dehydrated. Because a child can die from dehydration within a few days, the main treatment for diarrhea in children is dehydration. Quickly Careful observation of the child's appearance and how much fluid he or she is drinking can help prevent problems. And lastly I told her to follow-up the rural health center for his complete immunization.

XII. BIBLIOGRAPHY:

>://www.google.com/search?hl=en&q=case+study+acute+gastroenteritis&btnG= Search >Smeltzer, S, et al Medical-Surgical Nursing. 10th Edition Lippincott Williams and Wilkins (2004) >Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education South Asia PTE LTD Philippines 2004