Section P Group 1E.C.S. Pediatric WardRLE (Period covered: July 27-Aug. 1,2009)Mr. Ralph P. Pilapil, R.N. Clinical Instructor

A. Nursing HistoryIdentifying Data

Name of Patient: Patient XSex:MaleAge:16 years oldCivil Status : SingleNationality: FilipinoReligion :R.C.Address :Sta. Cruz, Guizo Mandaue CityOccupation : StudentDate Admitted:July 27, 2009 Time: 8:10 p.m.

Informant: MotherAge: 30 years oldPhysician: Dr. PitogoRoom: Pediatric Ward

Admission Data

Source of Information: MotherMode of Admission: Ambulatory

Vital Signs on Admission Temperature: 36.6CHeart Rate : 60 bpmRespiratory Rate: 18 cpmBlood Pressure: 120/70 mm HgWeight: 56 kgHeight: 5 4Chief of Complaints: LBM, pain and vomiting

History of Present Illness

Two days PTA, The patient defecated watery stools more than 5 times with nausea and vomiting. The following day, Monday, client still defecated watery stool in succession and was partially relieved after taking Diatabs. After several hours LBM reoccur with occasional vomiting. Thus, patients mother saught medical advise resulting to his admission.

Past Medical History

The client experienced severe diarrhea last January 2004 and was hospitalized.

Injuries:No previous injuries

Operation:No minor and major operation were performed

Family Medical History:Negative in: Heart Disease Diabetes Mellitus Hypertension Cancer Congenital Anomalies Obesity Arthritis Seizure Tuberculosis

Physical Assessment EENTEye functioned well and responsive to light accommodation (3-4mm)tonsils are pink and in normal size

2. Central Nervous Systemable to speak the words clearly (responsive)irritability notednegative presence of seizure or tremorsweak hand grasping and movement

3. Cardio Vascular Systemweak capillary refillblood pressure of 100/60regular heart rhythm

Respiratory Systemsymmetric chest expansionclear breath sound

Gastrointestinal Systempresence of hyperactive bowel soundexcessive bowel elimination (five times/day)facial grimacing noted during defecationpalpated with soft abdomen/tenderpain sensation at anal area due to irritation from frequent defecationexcessive loose / watery stool with fecal particlesDry skin & poor skin turgor Sunken eye ball

Genito-Urinary Systemdisturbed sleeping pattern due to nocturnal urinationlow urine output (25ml/hour)reddish urine color

Integumentary Systempoor skin turgor rough / dry skinresponsive to pain

Musculoskeletal Systemcan stand and sit on his own with signs of weaknesspoor tendon reflex

Laboratories Performed

Date Ordered: July 27, 2009

FecalysisUrinalysisSpecimen Data Report

FECALYSIS

DiagnosticNormal ValueResultSignificanceColorYellowReddishPresence of components that indicates infectionConsistencySoftWaterySign of dehydrationCellular FindingsRBCNoneNot SeenNormalPus Cells0-20-1/HpfNormalBacteriaNoneManyInfection is presentYeast CellsRare Normal

URINALYSIS

DiagnosticNormal ValueResultSignificanceColorClearYellowTransparencyClearClearPh6-7.56.0NormalSpecific Gravity1.010-1.0251.025NormalProteinNegativeNegativeNormalSugarNegativeTracew/in normal rangeMicroscopic Exam:Pus Cells0-23-6Infection presentRBC0-10-1NormalEpithelial Cells-FewNormalA. Urates-FewNormalA. Phosphates---Bacteria-ModerateInfectionMucus Thread-FewNormalCa Oxalates-ModerateNormal

SPECIMEN DATA REPORT

DiagnosticNormal ValueResultSignificanceWBC5-10/109L14.0Increased WBC count indicates infection

B. Anatomy & PhysiologyOrgans affectedFunctionsGrowth and development according to the age of client

Digestive System

ESOPHAGUSApproximately 25 cm (10inches long) but its diameter depends on how much food it contains.When its full, it can hold about 4 liters of food; when empty, it collapses and its mucosa is thrown into large folds called rugae.Esophageal peristalsis propels the bolus of food into the stomach through the cardiac sphincter

A distendible pouch with a capacity of about 1500 mL4 anatomic regionsStores and mixes food with the enzyme- containing gastric juice.Produces protein digesting enzymes pepsinogen, mucus, intrinsic factor and hydrochloric acid.Food stays from a half hour to several hoursChyme, which is food mixed with secretions enters the small intestine through the pyloric sphincter

STOMACH

The small intestine is the longest and most convoluted portion of the digestive tractMeasuring 16 to 19 feet ( 5 to 6m) in length in an adult. Composed of three different regions: - duodenum,- jejunum, and - ileum. The inner surface of the small intestine has a velvety appearance because of numerous mucous membrane finger like projections called intestinal villi.Pancreatic secretions: trypsin, amylase and lipaseIntestinal glands secrete mucus, hormones and electrolytes that coats the

Function:Three main functions: movement (mixing and peristalsis)digestion absorption

LARGE INTESTINE

about 5 to 6 feet in length from the ileocecal valve to the anus lined with columnar epithelium that has absorptive and mucous cells. it begins with the cecum, a dilated pouchlike structure that is inferior to the ileocecal opening. the large intestine then extends upward from the cecum as the colon. the colon consist of four divisions:- ascending colon - transverse colon - descending colon- sigmoid colon.

Function:Three Main Functions:AbsorptionEliminationMovement

GASTROENTERITIS:Is an increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract.

Primarily affects the small bowel and can be either viral or bacterial origin. DIAGNOSIS AND DEFINITION

C. Pathophysiology Precipitating Factors:Poor sanitation during warm monthsCrowded living conditions Risk Factors:ChildrenOlder adultsFamilial tendency

DIAGNOSISAcute Gastroenteritis

Signs and SymptomsWatery stoolsIntestinal rumblingsAbdominal painDistentionVomitingFever

Diagnostic EvaluationFecalysisUrinalysisSpecimen Data Report

EtiologyBacteria

Release of enterotoxins and attachment of organism to mucosal epitheliumGI wall irritation and destruction of intestinal villiFluid secreted into lumenIncreased fluid in the GI lumen and reduction of absorption

OUTCOMEHYPOVOLEMIA

ComplicationsSHOCK - renal failure - irreversible acidosis

PROGNOSIS

DEATH

The pt. was responsive to the therapeutic mgt.

Signs and Symptoms:DiarrheaExplanation: The epithelium of the digestive tube is protected from insult by a number of mechanisms constituting the gastrointestinal barrier, but like many barriers, it can be breached. Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species. Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results.

Abdominal pain or crampExplanation:The pain associated with obstruction of a hollow viscus (as opposed to peritoneal and solid organ pain) is often intermittent or "colicky", coinciding with the peristaltic waves of the organ. Such cramps are exactly what is experienced with early acute appendicitis and gastroenteritis and are somewhat relieved by writhing and massage

VomitingExplanation:Vomiting in diarrhea can occur when the lining of the intestines or stomach is irritated by an infection. Usually the infection is caused by a virus or bacteria. Diarrhea and vomiting can drain water and salts from the patient.These need to be replaced to prevent the patient from becoming dehydrated (dry).

D. Medical ManagementsDIAGNOSTIC / LABORATORY PROCEDURES

Ideal:Complete Blood CountUrinalysisRoutine stool examinationStool CultureBarium enema

Actual:UrinalysisFecalysis

Complete Blood Cell CountImportance of CBCA complete blood count may be done as part of a regular physical examination. A blood count can give valuable information about the general state of your health. While there are many different types of cells in your blood, they can all be grouped into one of three categories: red blood cells, white blood cells, and platelets. White Blood Cells (WBC)A high white blood cell count likely indicates that an infection is present somewhere in the body, whereas a low number might indicate that an infection or disease has slowed the ability of the bone marrow to produce new WBCs.Red Blood Cells (RBC)A low red blood cell count can indicate anemia, which can lead to fatigue. If the count is too high (a condition called polycythemia), there is a chance that the red blood cells will clump together and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to carry oxygen.Hemoglobin (HGB) and HematocritFor men, the hematocrit should be between 40% and 52%; for women, it should be between 35% and 46%. A low hemoglobin number or hematocrit percentage are good indicators of anemia.PlateletsIf there are too few platelets, uncontrolled bleeding may be a problem. If there are too many platelets, there is a chance of a blood clot forming in a blood vessel. Also, platelets may be involved in hardening of the arteries.

How is it done?Your health professional drawing blood will:Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein.Clean the needle site with alcohol.Put the needle into the vein. More than one needle stick may be needed.Attach a tube to the needle to fill it with blood.Remove the band from your arm when enough blood is collected.Put a gauze pad or cotton ball over the needle site as the needle is removed.Put pressure to the site and then a bandage.

UrinalysisA urinalysis tests the urine for color, clarity (clear or cloudy), odor, concentration, and acidity (pH). It also checks for abnormal levels of protein, sugar, and blood cells or other substances that, if found in the urine, may indicate an illness or disease somewhere in the body. A regular urinalysis often includes the following tests:Color Clarity Odor Specific gravitypHProtein Glucose Nitrites Ketones

How It Is DoneClean-catch midstream one-time urine collectionWash your hands to make sure they are clean before collecting the urine.If the collection cup has a lid, remove it carefully and set it down with the inner surface up. Do not touch the inside of the cup with your fingers.Clean the area around your genitals.A man should retract the foreskin, if present, and clean the head of his penis with medicated towelettes or swabs.A woman should spread open the genital folds of skin with one hand. Then use her other hand to clean the area around the urethra with medicated towelettes or swabs. She should wipe the area from front to back so bacteria from the anus is not wiped across the urethra.

After the urine has flowed for several seconds, place the collection cup into the urine stream and collect about 2 fl oz of this midstream urine without stopping your flow of urine.Do not touch the rim of the cup to your genital area. Do not get toilet paper, pubic hair, stool (feces), menstrual blood, or anything else in the urine sample.Finish urinating into the toilet or urinal.Carefully replace and tighten the lid on the cup then return it to the lab. If you are collecting the urine at home and cannot get it to the lab in an hour, refrigerate it.

Stool CultureA stool culture is done to:Find the cause of symptoms, such as severe diarrhea, an increased amount of gas, nausea, vomiting, loss of appetite, bloating, abdominal pain and cramping, and fever.Find and identify certain types of bacteria, viruses, fungi, or parasites that are causing infections or diseasesIdentify a person who may not have any symptoms of disease but who carries bacteria that can spread infection to others. This person is called a carrier. A person who is a carrier and who handles food is likely to infect others.Find out if treatment for an infection has been effective

Collect the sample as follows:

Urinate before collecting the stool so that you do not get any urine in the stool sample. Do not urinate while passing the stool.Put on gloves before handling your stool. Stool can contain material that spreads infection. Wash your hands after you remove your gloves.Pass stool (but no urine) into a dry container. You may be given a plastic basin that can be placed under the toilet seat to catch the stool.Either solid or liquid stool can be collected.If you have diarrhea, a large plastic bag taped to the toilet seat may make the collection process easier; the bag is then placed in a plastic container.If you are constipated, you may be given a small enema.Do not collect the sample from the toilet bowl.Do not mix toilet paper, water, or soap with the sample. Place the lid on the container and label it with your name, your doctor's name, and the date the stool was collected. If you are collecting more than one sample, use one container for each sample, and collect a sample only once a day unless your doctor gives you other directions.Take the sealed container to your doctor's office or the laboratory as soon as possible. You may need to deliver your sample to the lab within a certain time. Tell your doctor if you think you may have trouble getting the sample to the lab on time.

Barium EnemaA barium enema, or lower gastrointestinal (GI) examination, is an X-ray examination of the large intestine (colon and rectum). The test is used to help diagnose diseases and other problems that affect the large intestine. To make the intestine visible on an X-ray picture, the colon is filled with a contrast material containing barium. This is done by pouring the contrast material through a tube inserted into the anus. The barium blocks X-rays, causing the barium-filled colon to show up clearly on the X-ray picture.

II. MEDICATIONSActual:

Ranitidine HCl (Zantac) 80mg slow IVTT q8h Antiulcer Agent Ciprofloxacin HCL 500mg 1tab BID PO PC - Anti Infective AgentAluminum Magnesium Hydroxide(Isopan) 20 ml 1pc 2 H.S. - Antacid Agent

Drug Name : Cefotaxime (Claforan) Classification : Third-generation parenteral antibiotic with wide coverage, including gram-negative bacilli.

Mechanism of Action : Arrests bacterial cell wall synthesis, which, in, turn inhibits bacterial growth

Drug Name : Rifaximin (Xifaxan, RedActiv, Flonorm) Classification : Nonabsorbed (

TREATMENT

Ideal:Oral rehydration therapy Antimicrobial therapyE coli: Antibiotic treatmentActual:D5LR 1 Liter @ 30 gtts/minMonitoring of urine and stoolV/S q shift

IV. EXERCISES AND ACTIVITIESAmbulate by himself w/o the assistance of S.O.

V. DIET Ideal:The bland dietIntroduce lean meats and clear fluids as soon as possible.Actual:DAT

MEDICATIONSMedications are substances used in the diagnosis, treatment, cure, relief, or prevention of health alterations. This is the primary treatment client associate with restoration of health.

Name of Drug Generic (Brand)DateOrderedClassificationDose FrequencyRouteRanitidine HCL(Zantac)7/27/09Anti ulcer drug 80 mg, slow IVTT q8 hrMechanism of ActionSpecific IndicationSide EffectsNursing ImplicationsCompetitively inhibits action of histamine on the H2 @ receptor sites , parietal cells decreasing gastric secretion.Gastro esophageal reflux disease

Contraindications:-patient with hypersensitive to drug & those with phorphyria.-Use cautiously in patient with hepatic dysfunction.-adjust dosage in patient with impaired renal functionCNS: vertigo, malaise, headache.EENT: blurred visionHepatic: jaundiceOther: burning and itching @ injection site anaphylaxis, angioedema.Before :Assess patient for abdominal pain, note for presence of blood & emesis & stool.During:Administer IVTT slowly.After:Monitor patient for adverse reaction.Store IV injection @ 30 degrees After dilution solution is stable for 48 hrs. @ room temperature.After taking the medication advise pt to report immediately any adverse reactions.

Name of Drug Generic (Brand)DateOrderedClassificationDose FrequencyRouteCiproflaxacin HCL7/27/09Anti -Infective500 mg/tab BID PO pcMechanism of ActionSpecific IndicationSide EffectsNursing ImplicationsInhibits bacterial DNA, an enzyme needed for bacterial replication. Complicated intra-abdominal infection.

Contraindications:Hypersensitive to a ciproflaxacin.-its unknown if drug appears in breast milk after application. EENT: local burning or discomfort, foreign body sensation, itching. GI: bad or better taste in mouth. Before:-Assess vital sign.-Assess lab. Results and the causative agent.During:-Stop drug @ first sign of any hypersensitivity.After:-Prolonged use may result in overgrowth of susceptible organisms.-Assess for adverse reaction.

Name of Drug Generic (Brand)DateOrderedClassificationDose FrequencyRouteAluminum Magnesium Hydroxide(Isopan)7/27/09antacidsSusp. 20 ml pc 2 H.S.Mechanism of ActionSpecific IndicationSide EffectsNursing ImplicationsReduces total acid load in GI tract, elevates gastric ph to reduce pepsin activity strengthens gastric mucosal barrier, and increases esophageal sphincter tone.Acid indigestion .Contraindications:Severe renal disease.Use cautiously in patients with mild renal impairment. GI: mild constipation, diarrhea.GU: increased urine ph.Metabolic: hypokalemiaBefore:-Assess patient with renal failure.-Instruct patient not to take suspension or liquid well and follow dose with water.During:-monitor magnesium level in patient with mild renal impairment.After :-Urge patient to notify prescriber about the signs or symptoms of GI bleeding, such as tarry stools & coffee ground vomiting.

Nursing Management

Deficient Fluid VolumeI. Goal of Care: To assess causative/precipitating factors:Determine effects of age.

II. Goal of Care: To correct/replace losses to reverse pathophysiological mechanisms.Establish 24 hour fluid replacement needs and routes to be used.

III.Goal of Care: To promote comfort and safety:Provide frequent oral care as well as eye care.Administer medications.

Acute PainGoal of Care: To evaluate clients response to pain:Perform pain assessment each time pain occurs.Accept clients description of pain.Assess for referred pain as appropriate..

II.Goal of Care: To assist client to explore methods for alleviation/control of pain:Review/expectations and tell client when treatment will hurt.Administer analgesics as indicated to maximal dosage as needed.Assist client to alter drug regimen, based on individual needs.

III.Goal of Care: To promote wellness (Teaching/Discharge Considerations):Encourage adequate rest periods.Provide for individualized physical therapy/ exercise program that can be continued by the client when discharged.

Risk for Imbalanced NutritionGoal of Care: To assess causative/contributing factors:Ascertain understanding of individual nutritional needs.Discuss eating habits, including food preferences, intolerance /aversions.Assess drug interactions, disease effects, allergies, use of laxative, diuretics.Determine psychological factors/perform psychological assessment as indicated.

II.Goal of Care: To establish a nutritional plan that meets individual needs:Assist in developing individualized regimen.Consult dietitian/nutritional team as indicated.Limit fiber/bulk if indicated.Prevent/minimize unpleasant odors/sights.Encourage client to choose foods that are appealing.

III.Goal of Care: To promote wellness (Teaching/Discharge Considerations):Weigh weekly and document resultsRefer to home health resources and so on Consult with dietitian/nutritional support team as necessary

Nursing Care Plan 1ASSESSMENT SUBJECTIVE:tubig gihapon ako gikalibang as verbalized by the pt.

OBJECTIVE: excessive loose / watery stoolDry skin & poor skin turgor Sunken eye ballexcessive bowel elimination (five times/day)

NSG DIAGNOSIS: Fluid volume deficit related to diarrhea secondary to acute gastroenteritis.

Scientific Basis:Decreased intravascular, interstitial and/ intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

NSG GOAL:After 2-4 hours nursing interventions, the patient will be able to maintain fluid volume at functional level as evidenced by stable vital signs, moist mucous membranes & good skin turgor.

OUTCOME CRITERIA:Independent:After 2-4 hours of nursing interventions, patient will experience adequate fluid volume and electrolyte balance as evidenced by: urine output greater than 30 ml/hr, normal blood pressure, heart rate of 60-100 beats/ min, respiratory rate of 12-20 cycles/min,normal skin turgor.Pt. will maintain afebrile state.Pt. will initiate rehydration.Pt. will increase fluid intake of more than 2 liters.Dependent:Patient will follow medication on time.Collaborative:Patient will eat food prepared for him as advised by dietician.

NSG INTERVENTION

INDEPENDENT: Obtain patient history to ascertain the probable cause of the fluid disturbance

Evaluate fluid status in relation to dietary intake.

Monitor temperature .

RATIONALE

This can help with making the various nursing interventions

Most fluids enter the body through drinking water in foods & water.

Febrile states decrease body fluids through perspiration.

Encourage oral hygiene

Encourage oral intake of small amounts of fluids and bland foods.

Provide oral fluids that are preferred by the patient and place it at bedside, within reach. Ensure that it is fresh.This promotes interest in drinking, leading to rehydration

Eating small amounts can be helpful because it is more easily absorbed. Be creative in providing oral fluids to promote and encourage intake.

Teach interventions to prevent future episodes of dehydration/inadequate intake.

DEPENDENT:

Administer medications and IV fluids as ordered.

Client needs to understand the importance of drinking extra fluid during bouts of diarrhea.

Nursing Care Plan 2ASSESSMENT

SUBJECTIVE: Sige ug sakit-sakit akong tiyan as verbalized by the pt.

OBJECTIVE: Hyperactive bowel sounds (6 sounds in 20 seconds) Abdominal distentionFacial grimacing and guarding.pain sensation at anal area due to irritation from frequent defecationPain scale of 7 out of 10.

NSG DIAGNOSES:Pain related to injuring agents (physical inflammation of GI tract) secondary to Acute GastroenteritisScientific Basis:Acute infectious diarrhea results to increase frequency and fluid content of stool. The patient usually has abdominal distention and hyperactive bowel sounds. Painful spasmodic contraction of the anus and ineffectual straining may occur with each defecation.

NSG GOAL:After 30 mins 1hour of nursing interventions, the patient will report relief of pain from a pain scale of 7/10 to a pain scale of 4/10.

OUTCOME CRITERIA:Independent:After 30 mins 1hour of nursing interventions, the patient will report relief of pain from scale 7 to 4.Pt. will verbalize lesser episodes of pain.Dependent:Patient will follow medication on time.Collaborative:Patient will eat food prepared for him as advised by dietician.

NSG INTERVENTION INDEPENDENT:Assess pain scale.

Encourage verbalization of feelings about pain.

Provide comfort measures (back rub, change of position) RATIONALE

Serves as part of baseline data.

Facilitates timely intervention.

Provides non-pharmacological pain management.

Encourage adequate rest period.Instruct patient to report intense pain as soon as it begins

DEPENDENT:Administer analgesics as ordered.

Prevents fatigue.

Timely intervention is more likely to be successful in alleviating pain.

Relieves pain

Nursing Care Plan 3ASSESSMENT

SUBJECTIVE: Dili ko ganahan mokaon as verbalized by the pt.

OBJECTIVE: Poor muscle toneHyperactive bowel soundsAversion to eatingFood served remained untouched

NSG DIAGNOSES:Risk for Imbalanced nutrition: less than body requirements related to inadequate intake with nutrients secondary to acute gastroenteritis.

Scientific Basis:Nutrition is imbalanced to a relative absolute deficiency of one or more essential nutrients. This may be manifested as undernutrition.

NSG GOAL:After 8 hrs of nursing intervention, patient will exhibit progressive signs of appetite as evidenced by increased food intake.

OUTCOME CRITERIA:Independent:After 8 hours of student nurse patient intervention , patient will brush teeth every after meals, pt will verbalize satiety of food by evidence of at least consumption one half cup of rice. Dependent:Patient will follow medication on time.Collaborative:Patient will eat food prepared for him as advised by dietician.Patient will cooperate with the S/O and nurse to determine proper way of selecting nutritional food

NSG INTERVENTION INDEPENDENT:Provide oral hygiene

Serve food in well-ventilated, pleasant surroundings.

Avoid/ limit foods that might cause/exacerbate abdominal cramping and flatulence RATIONALE

Clean mouth can enhance the taste of food

Pleasant environment aids in reducing stress and is more conducive to eating

Individual tolerance varies, depending on stage of disease and area of bowel affected.

Encourage bed rest and/ limit activity

DEPENDENT:Administer medication as specified by the doctor.

COLLABORATIVE:Coordinate with dieticianHealth teachings to pt and S.O. on proper nutrition and hygienic preparation of food.Decreased metabolic needs aids in preventing caloric depletion and conserve energy.

F. Progress and PrognosisThe actual progress and prognosis of the disease of the patient X can be referred to as Fair. The patient was discharged last July 30, 2009. The main s/sx or the course of illness had been relieved by medication therapy and treatment instituted. It was successful but it was considered as fair because generally, the prognosis is dependent upon compliance of the prescribed treatment regimen.

G. Discharge PlanningMEDICATIONS:Follow strictly medication regimen such as oral rehydration solution or as prescribed by the physician and report immediately of adverse reactions.

EXERCISE:Carry out daily activities as tolerated.Do activities of daily living as tolerated.

TREATMENT:Take medications as scheduled and as prescribed for fast recovery.

HEALTH TEACHING:Observe proper personal hygiene to avoid complication; frequent hand washing is advised.Observe proper food preparation and handling to avoid reinfection.

OUT-PATIENT:Advise patient to visit for check-up to the doctor for further follow-up of health status.

DIET:Follow religiously the prescribed diet to regain strength and improve health status; these include BRAT (banana, rice, apple, tea) diet.

SPIRITUAL:Advise family to ask assistance and guidance from the divine providence for speedy recovery.

*