Case Pres-janjan Age

8/8/2019 Case Pres-janjan Age

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Universidad De Manila

A. Villegas St. Mehan Garden

Manila City

College of Nursing

A Case Study about

Acute Gastroenteritis

In

Partial fulfillmentfor the Requirement in

Related Learning Experience

In the

Pedia Ward

Submitted to:

Ms. Isabel Demillo, RN

Clinical instructor

Submitted by:

Pimentel, Jan Marienne G.

NR-42, Group IV

July 5, 2010


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ACKNOWLEDGEMENT

On every accomplishment there is always a hidden personality that stands as an

inspiration to those who work to achieve their goals. And for that, I would like to humbly

express my appreciation and deepest gratitude to the following persons who have been

supporting me to accomplish this requirement. This work will not be possible without

your help.

First of all, to my beloved family, especially my brother, uncles and my loving

mother for their kind understanding, unconditional love, encouragement, guidance and

endless support.

To all my friends who believed and supported me at all times. I will always

cherish our memories together and I hope someday our dreams will become reality.

To my respected clinical instructor Ms. Isabel Demillo, RN for giving me an

opportunity on developing my skills, and for the support, concerns and criticism

To Above all, to the God Almighty, that stands as my eternal source of strength

and for giving me definite knowledge and perseverance on accomplishing my work.


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TABLEOFCONTENTS

I. Title page

II. Acknowledgement

III. Table of contents

1. Objectives

2. General

3. Specific

IV. Introduction

V. Biographical data

VI. Patients Health history

1. Chief complain

2. Presence health history

3. Past medical history

4. Family medical history

5. Environmental Health History

VII. Physical assessment

VIII. Review of System (Growth and Development)

IX. Anatomy and physiology

X. Pathophysiology


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XI. Laboratory and diagnostics study

XII. Drugs study

XIII. Nursing care plan

XIV. Discharge plan

XV. Summary and conclusion


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INTRODUCTION

Acute gastroenteritis is a common cause of morbidity and mortality worldwide.

Each year, more than 3.5 million infants develop acute viral gastroenteritis, resulting in

more than 500,000 office visits, 55,000 hospitalizations, and 30 deaths. The most

common symptoms are diarrhea, vomiting and stomach pain, because whatever causes

the condition inflames the gastrointestinal tract. 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.

Numerous things may cause acute gastroenteritis. Bacterial infection is

frequently a factor, and infection by parasites like giardia can cause acute

gastroenteritis to last for several weeks. Viruses can also cause lengthy stomach flu,

particularly rotaviruses and noroviruses. Accidental poisoning or exposure to toxins may

also instigate acute gastroenteritis as well.

When a person does not recover from stomach flu symptoms within a day or so,

it is usually a good idea to see a doctor. Some types of acute gastroenteritis will not

resolve without antibiotic treatment, especially when bacteria or exposure to parasitesare the cause. Physicians may want to diagnose the cause by analyzing a stool sample,

when stomach symptoms remain problematic.

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.


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Even through causes for acute gastroenteritis vary, methods of transmission from

one person to another usually remain the same. Generally, contact with the fecal matter

of a person with the condition and then improperly washing or not washing the hands

cause acute gastroenteritis to be quite contagious. Proper hand washing for both the ill

person and well people in the family is always encouraged.

Other methods of transmission of acute gastroenteritis can include eating food or

drinking liquids contaminated with bacteria or parasites. For example, poorly cooked

hamburger might result in a very severe case of acute gastroenteritis due to exposure to

E. coli, a sometimes lethal bacterial infection in young children. Drinking improperly

treated water, or drinking from streams and lakes can expose one to giardia, which can

leave one ill for many weeks, without treatment.

Acute gastroenteritis remains a serious health issue, and is responsible for over

50,000 hospitalizations of children in the US each year. 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.


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OBJECTIVES

General Objectives:

To be able to conduct a thorough research about Acute Gastroenteritis in order

to apply the valuable knowledge in utilizing nursing process as the basis for

providing effective nursing care for a client which contributes to promotion of

wellness and restoration of health or relief of pain or discomfort.

Specific Objectives:

To gain information and knowledge that may improve the health status in relation

to the disease

To observe the signs and symptoms that triggers the wellness of an individual

To determine the specific causes of having such illness


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BIOGRAPHICALDATA

Name: Capati,Edmay

Address: 2770 G. Santos St. Tondo Manila

Age: 1 month

Sex: Female

Date ofBirth: May 18, 2010

Nationality: Filipino

Religion: Roman Catholic

Civil Status: Single

Name of the Mother: Cecille May Capati occupation: House wife

Name ofFather: Eddie Capati occupation: Vendor


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NURSINGHEALTHHISTORY

PERSONALDATA

Patient C.E. is a 1 month old baby girl. She was born on May 18, 2010 at

Marinduque which is her familys province. She is a Filipino and her religion is Roman

Catholic. She is living at Tondo Manila with her Mother who is a house wife and with his

father who works as a vendor. She is the second daughter of the family. Her family

migrated from province to Manila aspiring for better life.

CHIEFCOMPLAINT

The mother verbalized Nagtatae at nagsusuka ang anak ko, kadalasan madali

siya mairita at madalas umiiyak

HISTORYOFPRESENTILLNESS

The mother of patient C.E. stated that they were alarmed 3 days before her

admission to the hospital. For the reason that she was having frequent watery stool and

vomiting, she was also observed to be irritable.

PASTMEDICALHISTORY

The mother states that her daughter doesnt show any symptoms of illness

except watery stools and vomiting before her first week of admission.

FAMILYHEALTHHISTORY

According to the mother she has asthma since she was a child and her mother

as well has hypertension. On patients father side, his brother developed Diabetes

Mellitus type 2 because of his lifestyle.

ENVIRONMENTALHISTORY

Patient C.E lived at Tondo Manila which is according to the mother the place is

populated with small houses and small living space. There is only one small room for

the whole family members. She also added that their usual sleeping area was a set


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mattress on the floor. And, they were present vectors that might cause disease to the

family members include roaches, mosquitoes, flies, rats and termites. They dont have a

kitchen inside their house instead their cooking area was placed outside their house

where food can harbor microorganisms that could cause disease. The family source of

drinking water and hygienic usage is the local water system.


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PHYSICALASSESSMENT

Date Conducted: June 23, 2010

VITAL SIGNS:

Temperature: 37.2 o C

Pulse Rate: 141Beats per minute

Respiration Rate: 48 cpm

Body Part Technique Findings Analysis/

Interpretation

Skin Inspection

Palpation

Dry Skin,

Presence of rash on

inguinal area

Warm to touch; elastic

and mobile as to turgor;

No lesions, edema or

tenderness

Deviation from

normal

Normal findings

Head and Skull Inspection

Palpation

Head is proportion to

the size of the body

Round with

prominences in the

frontal area and

occipital area,

symmetrical in all

planes;

No presence of nodules

or masses

Normal Findings

Normal Findings

Scalp and Hair Inspection Dry scalp,

The color of the hair is

black,

Deviation from

normal


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Palpation

no presence of

dandruff;

Evenly distributed and

thick; no presence of

infestations;

Body hair is variable;

No areas of tenderness

Nails Inspection Smooth texture;

Prompt return of usual

color of the nails

(capillary refill)

Normal findings

Face Inspection Round shape;

prominent cheekbones;

symmetrical facial

features and facial

movements;

These are normal

findings;

Eyes Inspection Hair evenly distributed;

Eyebrow symmetrically

aligned; no discharge;Pale sclera and

conjunctiva

Cornea is transparent;

iris are visible;

pupils are black in

color, equal in size;

Normal Findings

Ears Inspection Color same as the facial

skin

Symmetrical;

Responsive as

evidenced by crying on

unfamiliar stimuli

Normal findings


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Nose Inspection Symmetric; no

discharge; uniform in

color;

Normal Findings

Mouth Inspection Pale oral mucosa and

dry lips

Deviation from

normal which may

be caused by

dehydration

Neck Inspection

Palpation

Muscles equal in size;

head centered with

coordinated smooth

movements and equal

strength;

No palpable lumps,

areas of tenderness;

Normal findings

Normal Findings

Thorax/ Lungs Inspection

Auscultation

Symmetrical chest;

Clear breath sounds

Normal Findings

Normal Findings

Heart Auscultation The two heart soundsare available in all areas

Normal Findings

Abdomen Inspection symmetrical movements

caused by respiration;

Normal Findings

Lower

Extremities

Inspection Smooth skin with fair

complexion;

symmetrical fine hair

evenly distributed;

Normal Findings


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REVIEWOF SYSTEM (GROWTHANDDEVELOPMENT)

Freuds five Stages ofPsychosocial Development

Oral Stage- 0-1y/o

According to Freud's theory of psychosexual development, the oral stage the

infant feels attached and unable to differentiate self from mother figure (anxiety of the

mother may be passed into the infant) a sense of self is only developed in consequence

of ego development.Interaction with the Environment: To the infant, the mother's breast

not only is the source of food and drink, but also represents her love. Because the

child's personality is controlled by the idand therefore demands immediate gratification,

responsive nurturing. Both insufficient and forceful feeding can result in fixation in this

stage.

Patient C.E. was observed to be attached to her mother. She shows emotion by

crying to express feelings of thirst. In this matter, feeding produces pleasure and sense

of comfort and safety on the patient. The mother of Patient C.E. believes that when

feeding it should be pleasurable and provided when required.

Eriksons Eight Psychosocial Developments

Trust vs. mistrust (Infancy) 0-18months

In Eriksons Psychosocial Developments he explains that when the parents

present consistent, adequate, and nurturing care, the child develops basic trust and

realizes that people are dependable and the world can be a safe place. The child

develops a sense of hope and confidence; this is a belief that things will work out well in

the end. While on the other hand, when the parents fail to provide these things, the child

develops basic mistrust, resulting in depression, withdrawal, and maybe even paranoia.

Patient C.E was observed to develop feeling of safeness and security on the

arms of her mother. She shows calmness by not crying when seeing the image of her

mom while she was being treated on the hospital.


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Piagets Cognitive development

Sensory Motor Stage

In this theory Piaget implies that sensorimotor stage is the first of the four stages

of cognitive development. "In this stage, infants construct an understanding of the world

by coordinating sensory experiences (such as seeing and hearing) with physical, motor

actions. Infants gain knowledge of the world from the physical actions they perform on

it. An infant progresses from reflexive, instinctual action at birth to the beginning of

symbolic thought toward the end of the stage

Patient C.E. showed Coordination of sensation and action through reflexive like

the sucking of objects in the mouth, following moving or interesting objects with the

eyes, and closing of the hand when an object makes contact with the palm (palmar

grasp).


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ANATOMYANDPHYSIOLOGY

PARTS OF DIGESTIVETRACT

DIGESTIVE TRACT- Consists of oral cavity (mouth), pharynx, esophagus,

stomach, large intestine, small intestine and anus.

Function: to take in food, breakdown food, absorb, provide nutrients and

eliminate.

Accessory organs:

Salivary glands

Liver

Gall bladder

Pancreas

MOUTH contains lips, cheeks, palate, tongue, teeth, salivary glands, masticatory /facial

muscles and bones

anteriorly bounded by lips

posteriorly bounded by oropharynx

important for mechanical digestion of food


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SALIVA

Contains salivary amylase or ptyalin that starts the initial digestion of

carbohydrates.

ESOPHAGUS

Hollow collapsible tube

Length of 10 inches

Made up of stratified squamous epithelium

Functions to carry or propel foods from the oropharynx to stomach

Involved in the process of swallowing or deglutition.

STOMACH

J-shaped organ in the epigastric

Contains 4 parts: fundus, cardiac region, body and pylorus

Cardiac sphincter prevents the reflux of the contents into the esophagus

Pyloric sphincter regulates the rate of gastric emulsifying into small intestine

Functions to digest the food and propel the digested material into the small

intestine for final digestion

Glands and cells in the stomach secrete digestive enzymes.

1. Parietal cells- hydrochloric acid and Intrinsic factor

2. Chief cells-pepsin

3. Antral G-cells- Gastrin

4. Argentaffin cells-serotonin

5. Mucus neck cells- mucus

SMALLINTESTINE

Grossly divided into duodenum, jejunum, ileum

Ileum is the longest part (12ft.)

Duodenum contains 2 openings for bile and pancreatic ducts

Intestinal glands secrete digestive enzymes that finalize the digestion of all food

stuff

ENZYMES

Enzymes digest carbohydrates to

-dissacharides


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Enzymes digest proteins to

-dipeptidase

-aminopeptidase

Enzymes for lipids

-intestinal lipase

LARGEINTESTINE

5FT. Long

Cecum has widest diameter and is the proximal end of large and small intestine

meet at the ileocecal junction

Colon which consists of ascending colon, transverse colon and sigmoid colon

Sigmoid colon is most mobile and prone to twisting

DIGESTIONPROCESS

The large, hollow organs of the digestive tract contain a layer of muscle that

enables their walls to move. The movement of organ walls can propel food and liquid

through the system and also can mix the contents within each organ. Food moves from

one organ to the next through muscle action called peristalsis. Peristalsis looks like an

ocean wave travelling through the muscle. The muscle of the organ contracts to create

a narrowing and then propels the narrowed portion slowly down the length of the organ.

These waves of narrowing push the food and fluid in front of them through each hollow

organ.

The first major muscle movement occurs when food or liquid is swallowed.

Although you are able to start swallowing by choice, once the swallow begins, it

becomes involuntary and proceeds under the control of the nerves.

Swallowed food is pushed into the esophagus, which connects the throat above

with the stomach below. At the junction of the esophagus and stomach, there is a

ringlike muscle, called the lower esophageal sphincter, closing the passage between

the two organs. As food approaches the closed sphincter, the sphincter relaxes and

allows the food to pass through to the stomach.


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The stomach has three mechanical tasks. First, it stores the swallowed food and

liquid. To do this, the muscle of the upper part of the stomach relaxes to accept large

volumes of swallowed material. The second job is to mix up the food, liquid, and

digestive juice produced by the stomach. The lower part of the stomach mixes these

materials by its muscle action. The third task of the stomach is to empty its contents

slowly into the small intestine.

Several factors affect emptying of the stomach, including the kind of food and the

degree of muscle action of the emptying stomach and the small intestine.

Carbohydrates, for example, spend the least amount of time in the stomach, while

protein stays in the stomach longer, and fats the longest. As the food dissolves into the

juices from the pancreas, liver, and intestine, the contents of the intestine are mixed andpushed forward to allow further digestion.

Finally, the digested nutrients are absorbed through the intestinal walls and

transported throughout the body. The waste products of this process include undigested

parts of the food, known as fiber, and older cells that have been shed from the mucosa.

These materials are pushed into the colon, where they remain until the feces are

expelled by a bowel movement.

RECTUM

Straight muscular tube that begins at the termination of the sigmoid colon and

ends at the anal canal

ANALCANAL

Last 2-3 cm of digestive tract

Begins at the inferior end of the rectum and ends at the anus.


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LABORATORYANDDIAGNOSTIC STUDY

Fecalysis

Fecalysis is also known as stool analysis.It refers to a series of laboratory tests

done on fecal samples to analyze the condition of a person's digestive tract in general.

Among other things, a fecalysis is performed to check for the presence of any reducing

substances such as white blood cells (WBCs), sugars, or bile and signs of poor

absorption as well as screen for colon cancer.

Urinalysis

` Urinalysis is the examination of urine for certain physical properties, solutes,cells, casts, crystals, organisms, or particulate matter. Because urinalysis is easy,

cheap, and productive, it is recommended as part of the initial examination of all

patients and should be repeated as clinically warranted. This chapter focuses on what

the physician may do in a few minutes with a urine sample, reagent strips, a

microscope, and an inquiring mind. Such analysis may lead to more sophisticated

chemical, immunologic, or bacteriologic studies.


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DISCHARGEPLAN

MEDICATIONS

Emphasize compliance and strict adherence to dosage and the time of intake of

the medicines to attain the desired therapeutic effects.

Explain the consequences of not strictly adhering to the drug regimen.

Instruct the patient not to alter doses of medications and emphasize the

importance of continuous medication.

EXERCISE

Encourage the mother to perform Passive ROM to promote blood circulation.

TREATMENT

Encourage the family members promote quite environment to facilitate relax and

have adequate rest to prevent stress and promote healing.

Give emphasis on compliance on further treatment for the proper maintenance

and gain of optimal health.

Remind clients relative on close monitoring of clients activities as some may

interfere with ongoing treatment and procedures.

HEALTHTEACHINGS

Emphasize the importance of hand washing

Encourage the family to promote a clean drinking water for the prevention of

ingestion of pathogens

Conduct a health teaching regarding diseases that may be acquired through

improper food and environment sanitation.

OUT-PATIENTDEPARTMENT

Ordered to have a follow-up check up 3 days after discharge and have a

diagnostic examination if there is reoccurrence of AGE.

DIET

Maintain the diet that was ordered by the physician.


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SUMMARYANDCONCLUSION

This case study deals with the Acute Gastroenteritis prior to the diagnosis

condition of Patient C.E. who was a 1 month old female. She developed the disease

due to improper environmental and water sanitation. In this study the student assess the

patient, to know the necessary information that will contribute in doing the case study.

That includes the biographical data; chief complain; present health history; lifestyle;

social data and psychological data. The researchers also perform the physical

assessment, and construct the Review of the systems (Growth and development),

Pathophysiology of the given disease. The student also analyze the laboratory and

diagnostic reports of the patient; medication and drug study; nursing care plan and the

discharge plan.

In doing the study the student knew the important facts about the disease Acute

Gastroenteritis which will help for future reference as nurse. Also, she learned the

concept of the case presentation.

Successful management of Acute Gastroenteritis benefits not only the patient but

society as well. Alleviating factors that contribute to the prognosis of the disease can be

easily noticed, prevented and managed as part of health awareness and concern more

specifically by doing primary prevention.

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