LICEO DE CAGAYAN UNIVERSITY

R.N. PELAEZ BLVD. KAUSWAGAN, CDO

COLLEGE OF NURSING
NCM501202

A Case Study of:

Jhunienne Matias
Name of the Patient
As Partial Requirement for NCM501202
Submitted by:
Tan, Kevin John T.
NCM501202 student
Group A2

March 19, 2009

TABLE OF CONTENTS
I.

Introduction
a. Overview of the case
b. Objective of the study
c. Scope and Limitation of the study
II.
Profile of the patient
III. Developmental Data
IV. Health History
a. Family and Personal health history
b. History of Present Illness
V.
Nursing Assessment (System Review & Nursing
Assessment II)
VI. Pathophysiology with Anatomy & Physiology
VII. Medical Management
a. Medical Orders and Rationale
b. Drug study
VIII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
IX. Referrals and Follow-up
X.
Evaluation and Implications
XI. Bibliography

I. Introduction
a. Overview of the Study
Acute diarrhea 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 or semisolid, abdominal cramps and bloating.
Acute watery diarrhea 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.
Gastroenteritis means inflammation of the stomach and small and large
intestines. Viral gastroenteritis is an infection caused by a variety of viruses that
result in vomiting or diarrhea or both. It is often called the "stomach flu," although it is
not caused by the influenza viruses.
Persons can reduce their chance of getting infected by frequent
handwashing, prompt disinfection of contaminated surfaces with household chlorine
bleach-based cleaners, and prompt washing of soiled articles of clothing. If food or
water is thought to be contaminated, it should be avoided.
Since most cases of acute watery diarrhea are infectious, especially in
developing countries, the majority of such illnesses can be prevented by drinking
water or eating foods that are not contaminated with infectious agents. Washing
hands frequently with non-contaminated water, when caring for a patient with
diarrhea as also always before eating is important. Proper storage of food and water
is also important to prevent harmful bacteria from contaminating them.

Other symptoms include nausea, vomiting, loss of appetite, belching, and

bloating. Occasionally, acute abdominal pain can be a presenting symptom. This is
the case in phlegm nous gastritis (gangrene of the stomach) where severe

abdominal pain accompanied by nausea and vomiting of potentially purulent gastric

contents can be the presenting symptoms. Fever, chills, and hiccups also may be
present.
The diagnosis of acute gastritis may be suspected from the patient's history
and can be confirmed histologically by biopsy specimens taken at endoscopy.
b. Objective of the Study
This study aims to:

Conduct and evaluate an assessment for the client

Determine the causes, predisposing and precipitating factors that constitute

the onset of the disease process.

Render series of nursing interventions for the clients care

Provide and disseminate important information as teachings to the client and

the significant others to boost the knowing and understanding of the nature of
the said health condition.

Improve skills and knowledge as health care providers in the clinical area.
c. Scope and Limitation of the Study
This study includes the collection of information specifically to the patients

health condition. The study also includes the assessment of the physiological and
psychological status, adequacy of support systems and care given by the family as
well as other health care providers.
The scope of this study would include:
a. Data collected via assessment, interviews with the patient, family members
and clinical records.

b. Actual and ideal problems for 3 days including the initial assessment and its
appropriate nursing intervention that would be applied within his stay in the
hospital at PGH hospital
c. Developing a plan of care that will reduce identified predicaments and
complications.
d. Coordinating and delegating interventions within the plan of care to assist the
client to reach maximum functional health.
e. Further evaluating the effectiveness of nursing interventions that have been
rendered to the client.
An array of factors influencing the limitations of this study includes:
a. Data collected is limited only to assessment and interview to the patient,
patients chart and nurse on duty.
b. The interaction, assessment and care were only limited to a total of 16 hours
(2 days clinical duty, 1 day assessment) with actual nursing intervention done.
c. The lack of complete family history obtained was due to lack of laboratory
examinations or diagnostic examinations results like x-ray which data or
results obtained is in the chart of the client during the time of care.

II. Patients Profile

Clients Name: Matias, Jhunienne

Age: 6 months old
Birthday: September 17, 2008
Address: Mambuaya, Cagayan de Oro City
Civil Status: Single
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Weight: 6.5 Kg.
Informant: Inalen Matias (Mother)
Date of admission: Febuary 15, 2009
Time of admission: 4:00 PM
Chief complaint: LBM
Admitting diagnosis: AGE with mild dehydration
Attending physician: Dr. Bacal

III. Developmental Data

Developmental Task Theory of Robert Havighurst
A developmental task is a task which arises at or about a certain period in the
life of an individual. Havighurst has identified six major age periods: infancy and
early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18
years), early adulthood (19-29 years), middle adulthood (30-60 years), and later
maturity (61+).
Basing on Havighursts Theory, my patient belongs in the infancy and early
childhood stage wherein he is learning to distinguish right from wrong and
developing a conscience.
Psychosexual Theory of Sigmund Freud
The psychosexual stages of Sigmund Freud are five different developmental
periods during which the individual seeks pleasure from different areas of the body
associated

with

sexual

feelings.

These

stages

Oral

Birth to

to

1year

Anal

to

3years

Phallic

to

5years

Latency

to

12years

Genital

13

and

Up

are

as

follows:

Basing on this theory, Jhunienne Matias belongs to the oral stage wherein an
infants pleasure centers are in the mouth. This is also the infant's first relationship
with its mother; it is a nutritive one.

Psychosocial Theory of Erik Erickson

Erik Erickson envisioned life as a sequence of levels of achievement. Each
stage signals a task that must be achieved. He believed that the greater that task
achievement, the healthier the personality of the person. Failure to achieve a task
influences the persons ability to achieve the next task. Stages of Eriksons
Psychosocial Theory are as follows:
Infancy

Birth 18 months

Trust vs. Mistrust

Early Childhood

18 months 3 years

Autonomy vs. Shame

Late Childhood

3 5 years

Initiative vs. Guilt

School Age

6 12 years

Industry vs. Inferiority

Adolescence

12 20 years

Identity vs. Role Confusion

Young Adulthood

18 25 years

Intimacy vs. Isolation

Adulthood

25 65 years

Generativity vs. Stagnation

Maturity

65 years to death

Integrity vs. Despair

Basing on this theory, he is still belongs to Infancy based on Eriksons theory

the child developmental task is the TRUST vs. MISTRUST Because an infant is
utterly dependent; the development of trust is based on the dependability and quality
of the childs caregivers. If a child successfully develops trust, he or she will feel safe
and secure in the world. Caregivers who are inconsistent, emotionally unavailable,
or rejecting contribute to feelings of mistrust in the children they care for. Failure to
develop trust will result in fear and a belief that the world is inconsistent and
unpredictable.
As observed the child had already built trust to his mother and his
grandmother wherein he only allows his mother and grandmother to cuddled and
feed him.

Cognitive Theory of Jean Piaget

Cognitive development refers to how a person perceives, thinks, and gains
understanding of his or her world through the interaction and influence of genetic
and learning factors. This is divided into five major phases:
Sensorimotor Phase

Birth to 2 years

Pre-conceptual Phase

2 3 years

Intuitive Thought Phase

4 6 years

Concrete Operations Phase

7 11 years

Formal Operational Phase

12 adulthood

Basing on this theory, Jhunienne Matias belongs to the sensorimotor stage in

which inventions of new means through mental combinations. The patient uses
memory and imitation act, he can solve basic problems.

IV. HEALTH HISTORY

9

a. Family Health History

According to the father regarding the herido-familial history both her
mother and father side has a history of hypertension. On the father side
they had a history of cancer since the fathers aunt died last 2001 due to
cervical cancer.
b. Past Health History
The father claimed that his child past illnesses were a typical cough,
colds and fever that usually lasted for three days. Over the counter
medicines such as Paracetamol (Calpol) was used to treat for fever and
Dimetapp for colds. The father claimed that his child has not completed
the vaccination required and never experiencing major illness that
required hospitalization until this Febuary 15, 2008 wherein the patient has
been admitted at JRB Hospital having an acute diarrhea but the father
denied that his child does not have known allergies to drugs and foods nor
his child received a blood transfusion.
The patient was born in JRB Hospital through a normal spontaneous
vaginal delivery.
c. History of Present Illness
A case of Matias, Jhunienne, 6months old Male, Filipino, a resident of
Mambuaya Cagayan de Oro City, admitted for the first time at PGH
hospital with a chief complaint of LBM. Two days prior to admission he
had persistent LBM, vomiting, cough and fever.

V. Nursing Assessment (System Review & Nursing Assessment

II)
Name: Jhunienne Matias

Date: 02-15-09
10

Temp: 38.6C HR: 137bpm BP: N/A Height_____ Weight:6.5 kgsRR: 50cpm
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space
provided. Indicate the location of the problem in the figure using [X].
EENT:
[ ] impaired vision [ ] blind
[ ] pain reddened [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion teeth
Assess eyes, ears, nose throat
For abnormality [ ] no problem
RESPIRATION:
[ ] asymmetric [ ] tachypnea [ ] barrel chest
[ ] apnea [ ] rales [x] cough
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotic
Assess resp. rate, rhythm, pulse blood
breath sounds, comfort [ ] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing
bowel sounds, comfort [x] no problem
GENITO-URINARY AND GYNE:
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
assess urine frequency, control, color, odor, comfort
NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip
assess motor, function, sensation, LOC, strength
grip, gait, coordination, speech [x] no problem
MUSCULOSKELETAL AND SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [x] poor turgor [ ] cool [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic/moist
assess mobility, motion, gait, alignment, joint function
skin color, texture, turgor, integrity [ ] no problem

SUBJECTIVE
COMMUNICATION:
[ ] hearing difficulty

Comments: Wala man

Sunken eyes
Poor appetite
Colds
Cough
Poor skin turgor
Hyperactive
bowel sounds

Hyperthermia
=38.6C
hooked with
IVF of D5 0.3Nacl
500cc

Watery Stools

OBJECTIVE
[ ] glasses

[ ] languages

11

[ ] visual changes

siya problema sa pandu

ngug ug pagtanaw as
verbalized by the
mother

[x] denied

OXYGENATION:
[ ] dyspnea
[ ] smoking history
Non-smoker

Comments:Naa jud siya

ubo nabalaka na jud ko
ani niyaas verbalized
by the mother.

[x] cough
[ ] sputum
[ ] denied
CIRCULATION:
[ ] chest pain
[ ] leg pain
[ ] numbness of
extremities

Date of last BM
December 5, 2008
[ x ] diarrhea
[ ] constipation

Resp. [x] regular

[ ] irregular
Describe: RR is within normal range.
R: symmetrical to the left lung
L: symmetrical to the right lung

Comments: Wala may

sakit sa tiil ug dughan
akong anakas verbalized
by the mother.

Heart Rhythm
[x ] regular
[ ] irregular
Ankle Edema: No ankle edema is present on both
extremities
Pulse
Car
Rad.
DP
Fem*
R _______+______+_ __ +
__not assessed
L
_____+_____ +_ _____+
not assessed
Comments: Right and left pulses are equal; strong
and palpable.

Comments: Gina patutoy

Raman nako siya
as verbalized by the
mother.

[ ]dentures

[x ] denied
NUTRITION:
Diet: Exclusive B.F
since Birth.
Character
[ ] recent change in
weight
[ ] swallowing
Difficulty
[x] denied
ELIMINATION:
Usual bowel pattern
5 loose stools per day
[ ] constipation
remedy

[ ] contact lenses [ ] hearing difficulties due to age

[ ] speech difficulties
Pupil size:R:3 mm L:3mm
Reaction: PERRLA (Pupil Equally Round Reactive
to Light and Accommodation)

[x] urinary frequency

Diaper
[ ] urgency
[ ] dysuria
[ ] hematuria
[ ] incontinence
[ ] polyuria
[ ] foley in place
[x] denied

[x]none
Complete

Incomplete

Upper

[]

[x]

Lower

[]

[x]

Comments: magsunod
sunod jud siya ug
kalibangaas verbalize
by the mother.

Bowelsounds:
hyperactive
Abdominal Distention
Present [ ] yes [x] no
Urine* (color, consistency,
odor)
urine color is straw,
amber transparent and
faint aromatic odor.
*if they are in place

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [ x ] denied
(amount & frequency)
________________________________________.
[ ] SBE: N/A Last Pap Smear: N/A

Briefly describe the patients ability to follow

treatments (diet, meds, etc.) for chronic health
problems (if present).
N/A.

SUBJECTIVE

OBJECTIVE

SKIN
INTEGRITY:

Comments:

[x] dry

[ ] cold

[ ] pale

12

[x] dry
[ ] other

Mala jud iya panit kay cige ra

ug kalibang as verbalized by
the mother.

[ ] flushed
[ ] warm
[ ] moist
[ ] cyanotic
*rashes, ulcers, decubitus (describe size, location,
drainage: no rashes and ulcers found the the
patients body.

Comments:
kalooy sa ginoo wala jud nag
lipong-lipong akong anak ug
maka lihok rapud siya as
verbalized by the mother.

[x] LOC and orientation Patient is normalunconscious oriented

Gait: [ ] walker
[ ] cane [ ] other

Comments:
perminte ra siya ga mata mata
tungod ni sa iyang kainit as
verbalized by the mother.

[x] facial grimaces

[ ] guarding
[ ] other signs of pain :

[ ] denied
ACTIVITY/
SAFETY:
[ ] convulsion
[ ] dizziness
[ ] limited motion
of
Joints
Limitation in
Ability to
[ ] ambulate
[ ] bathe self
[ ] other
[x] denied
COMFORT/SLE
EP/
AWAKE:
[ ] pain

(location)
Frequency
Remedies
[ ] nocturia
[x]sleep
difficulties
[ x ] denied
COPING:
Occupation: N/A
Members of household: 2 members of household
Most supportive person: Karl William Matias(father)
and Inalen Matias(mother)
Not ordered _Daily weight
_every 2hr ___BP q shift
____N/A___ _ Neuro vs
____N/A_
_ CVP/SG Reading __N/A___

VI.

[x] steady
[ ] unsteady_________
[ ] sensory and motor losses in face or
extremities No sensory and motor losses on face or
extremities
[x] ROM limitations: no ROM limitations

Observed non-verbal behavior: the patient

restless
Phone number that can be reached anytime:
refused

SPECIAL PATIENT INFORMATION

____N/A___ PT/OT __ N/A __
____N/A___ Irradiation
__ done _Urine test ___________
__No Order__24 hour Urine Collection

ANATOMY AND PHYSIOLOGY:

13

is

DIGESTIVE SYSTEM
The digestive system consists of two linked parts: the alimentary canal and the
accessory digestive organs. The alimentary canal is essentially a tube, some 9
meters (30 feet) long, that extends from the mouth to anus, with its longest sectionthe intestines- packed into the abdominal cavity. The lining of the alimentary canal is
continuous with the skin, so technically its cavity lies outside the body. The
alimentary tube consist of linked organs that each play their own part in digestion:
mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The
accessory digestive organs consist of the teeth and tongue in the mouth; and the
salivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the
alimentary canal.
STOMACH

14

It is a J- shaped enlargement of the GI tract directly under the diaphragm in

the epigastric, umbilical and left hypochondriac regions of the abdomen.

When

empty, it is about the size of a large sausage; the mucosa lies in large folds, called
RUGAE. Approximately 10 inches long but the diameter depends on how much food
it contains. When full, it can hold about 4 L ( 1 galloon) of food. Parts of the
stomach includes cardiac region which is defined as a position near the heart
surrounds the cardioesophageal sphincter through which food enters the stomach
from the esophagus; fundus which is the expanded part of the stomach lateral to the
cardia region; body is the mid portion; and the pylorus a funnel shaped which is the
terminal part of the stomach. The pylorus is continuous with the small intestine
through the pyloric sphincter, or valve.
With the gastric glands lined with several secreting cells the zymogenic
(peptic) cells secrete the principal gastric enzyme precursor, pepsinogen.

The

parietal (oxyntic) cells produce hydrochloric acid, involved in conversion of

pepsinogen to the active enzyme pepsin, and intrinsic factor, involved in the
absorption of Vitamin B12 for the red blood cell production. Mucous cells secrete
mucus. Secretions of the zymogenic, parietal and mucus cells are collectively called
the gastric juice. Enteroendocrine cells secrete stomach gastrin, a hormone that
stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower
esophageal sphincter, mildly increases motility of the GI tract, and relaxes the
pyloricsphincter. Most digestive activity occurs in the pyloric region of the stomach.
After food has been processed in the stomach, it resembles heavy cream and is
called CHYME. The chyme enters the small intestine through the pyloric sphincter.

VI.

Pathophysiology with Anatomy & Physiology

15

Name of the patient: Jhunienne Matias

Diagnosis: AGE with mild DHN

Definition: Acute Gastritis is defined as diarrheal disease of rapid onset, often

with nausea, vomiting, fever, abdominal pain and loose bowel movement. It is
an inflammation of the mucous membranes of the stomach often caused by an
infection.

Predisposing Factors:
Environment
Hygiene
Stress

Precipitating Factors:
~ Age(6 Months)
~ Gender(Male)

Ingestion of E. Coli

Invasion of gastric
mucosa
Penetration of Gastric
mucosa
Toxins producing
pathogens cause watery,
large volume diarrhea

Signs & Symptoms:

Watery stool
Fever

16

Irritation of the Gastric

Lining

Signs & Symptoms:

Vomiting

Fluid and Electrolyte imbalance too much Na+

and H2O are expelled from the body

Increased fluid loss

Dehydration

Signs & Symptoms:

Decrease skin turgor
Sunken Eyes

17

VII.

MEDICAL MANAGEMENT

a. Medical Orders and Rationale

DOCTORS ORDER
02-15-09

RATIONALE

Please admit to pedia ward For further management and

under the service of Dr. Bacal
At par with age regular diet

treatment of condition
To provide easy digestion of food
without experiencing pain upon
digestion

Start D5 0.3NaCL 500ml @ To provide access for intravenous

100cc/hr

To screen the patients blood

Labs:

medications.

CBC

component and to detect any

abnormalities. This also serves as a
baseline data to evaluate
effectiveness of blood transfusions.

Urinalysis

To screen the patients urine

components and to detect any
abnormalities.

SE

To screen the patients feces & to

detect any abnormalities

I & O q shift
v/s q4H

To measure daily I & O of the client

To have baseline data and for
comparison of future data / for
monitoring of patients condition.

02-15-09
IVF with D5 0.3NaCl 500ml @

To provide access for intravenous

medications.
18

100cc/hr
02-016-09
Continue medications
For billing today
IVF with D5 0.3 NaCl500cc @ To help for fast recovery
Preparation for going home

SR

To provide access for intravenous

02-16-09
Continue medications

medications.

IVF D5 0.3 NaCl 500cc @ SR

To help for fast recovery
To provide access for intravenous
medications.

b. Laboratory Results
CBC
Hemoglobin
Hematocrit

17.3 gms %
49.6 vol %

White Cell Count

14,351/mm3

Fecalysis
Character: soft

WBC/hpf: 4-6

Color: yellow

RBC/hpf: 6-8

Parasite ascarasis: none seen

cysts: positive

Trichuris: none seen

trophosites: none seen

Hook worm: none seen

19

c. Drug study

DRUG NAME
Paracetamol
DOSE/FREQUENCY/ROUTE
500 mg 1 tab q4h PRN for fever
CLASSIFICATION
Analgesic; antipyretic
MECHANISM OF ACTION
May produce analgesic effect by blocking pain impulses, by
inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by actingon
hypothalamic heat-regulating center. Relieves fever.
SPECIFIC INDICATION
For fever.
CONTRAINDICATION
Contraindicated in patients hypersensitive to drug or its
components.
SIDE EFFECTS
Anemia, jaundice, rash, urticaria.
NURSING PRECAUTION
Do not administer for fever thats above 39.5 C, lasts longer than 3
days or recurs.
DRUG NAME
AMBROXOL
DOSE/FREQUENCY/ROUTE
0.75ml TID P.O
CLASSIFICATION
Cough and Cold Preparation
MECHANISM OF ACTION
Ambroxol is a mucolytic agent. It acts by increasing the respiratory
tract secretion of lower viscosity mucus and exerting a positive influence on the
alveolar surfactant system which leads to improved mucus flow and transport.
Expectoration of mucus is thus facilitated.
SPECIFIC INDICATION
Cough
CONTRAINDICATION
Hypersensitivity to ambroxol or any ingredient of Ambrolex.
SIDE EFFECTS
Mild GI side effects.
NURSING PRECAUTION
Should be taken with food.

20

DRUG NAME
GENTAMYCIN
DOSE/FREQUENCY/ROUTE
IVT q 8 ANST
CLASSIFICATION
Amino glycoside
MECHANISM OF ACTION
Broad-spectrum aminoglycoside antibiotic derived from
Micromonospora purpurea. Action is usually bacteriocidal.
SPECIFIC INDICATION
Parenteral use restricted to treatment of serious infections of GI
CONTRAINDICATION
History of hypersensitivity to or toxic reaction with any
aminoglycoside antibiotic. Safe use during pregnancy (category C) or lactation is
not established
SIDE EFFECTS
a. an allergic reaction (shortness of breath; closing of the throat; hives;
swelling of the lips, face, or tongue; rash; or fainting);
b. little or no urine;
c. decreased hearing or ringing in the ears;
d. dizziness, clumsiness, or unsteadiness;
e. numbness, skin tingling, muscle twitching, or seizures; or
f. severe watery diarrhea and abdominal cramps.
NURSING PRECAUTION
Draw blood specimens for peak serum gentamicin concentration
30 min1h after IM administration, and 30 min after completion of a 3060 min IV
infusion. Draw blood specimens for trough levels just before the next IM or IV dose.
Use nonheparinized tubes to collect blood.

21

DRUG NAME
Ampicillin
DOSE/FREQUENCY/ROUTE
250mg IVT q 8 ANST
CLASSIFICATION
Antibiotic penicillin
MECHANISM OF ACTION
Bacterial action against sensitive organism inhibits synthesis of
bacterial cell wall, causing cell death.
SPECIFIC INDICATION
Treatment of infections caused by susceptible strains of E.coli.
CONTRAINDICATION
Contraindicated with allergies to penicillin.
SIDE EFFECTS
CNS: lethargy seizures
CV: CHF
GI: stomatitis, sore mouth, furry tongue
Other: super infections
NURSING PRECAUTION
A.
B.
C.
D.

VIII.

Take this drug Round the Clock.

Allergies of penicillin
Culture Infected area
Take oral drug on empty stomach

NURSING MANAGEMENT

22

Ideal Nursing Manangement - Risk for fluid volume deficit related to excessive
losses through normal routes (frequent diarrhea, vomiting)

INTERVENTIONS
INDEPENDENT
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.
Assess vital signs (BP, pulse, temperature).

RATIONALE

Provides information about overall fluid balance,

renal function, and bowel disease control, as well as
guidelines for fluid replacement.

Hypotension (including postural), tachycardia, fever

can indicate response to and/or effect of fluid loss.
Indicates excessive fluid loss/resultant dehydration.

Observe for excessively dry skin and mucous

membranes, decreased skin turgor, slowed
capillary refill.

Indicator of overall fluid and nutritional status.

Colon is placed at rest for healing and to decreased
intestinal fluid losses.
Inadequate diet and decreased absorption may lead
to vitamin K deficiency and defects in coagulation,
potentiating risk for hemorrhage.
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.

Weigh daily

Maintain oral restrictions, bed rest.

Observe for overt bleeding and test stool daily for

occult blood.

Note generalized muscle weakness or cardiac

dysrhytmias.

COLLABORATIVE
Administer parenteral fluids, blood transfusions as
indicated.

Maintenance of bowel rest requires alternative fluid

replacement to correct losses/anemia. Note: fluids
containing sodium may be restricted in presence of
regional enteritis.
Determines replacement needs and effectiveness of
therapy.

Monitor laboratory studies, e.g., electrolytes

(especially potassium, magnesium) and ABGs
(acid-base balance).

Reduces fluid losses from intestines.

Administer medications as indicated:

Antidiarrheal e.g., dipphenoxylate (Lomotil),
loperamide (Imodium), anodyne suppositories.

Used to control nausea and vomiting in acute

exacerbations.

Controls fever, reducing insensible losses.

Antiemetics, e.g., trimethobenzamide (Tigan),

hydroxyzine (Vistaril), prochlorperazine
(Comparazine);

Electrolytes are lost in large amounts, especially in

bowel with denuded, ulcerated areas, and diarrhea

23

Antipyretics, e.g., acetaminophen (Tylenol);

Electrolytes, e.g., potassium supplement (KCl-IV;KLyte, Slow-K);

can also lead to metabolic acidosis through loss of

bicarbonate (HCO3).

Stimulates hepatic formation of prothrombin,

stabilizing coagulation and reducing risk of
hemorrhage.

Vitamin K (Mephyton)

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
INDEPENDENT
Determine the mothers perception
of disease process.
Review disease process,
cause/effect relationship of factors
that precipitate symptoms, and
identify ways to reduce contributing
factors. Encourage questions.

Review medications, purpose,

frequency, dosage, and possible
side effects.
Stress importance of good skin care,
e.g., proper handwashing
techniques and perineal skin care.

RATIONALE
Establishes knowledge base and
provides some insight into individual
learning needs.
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.
Promotes understanding and may
enhance cooperation with regimen.
Reduces spread of bacteria and risk
of skin irritation/breakdown, infection.

Emphasize need for long-term

follow-up and periodic reevaluation.
24

 Patients with IBD are at risk for

colon/rectal cancer, and regular
diagnostic evaluations may be
required..

IDEAL NURSING MANAGEMENT

Hyperthermia related to dehydration as evidenced by increase in body
temperature higher than normal range.
Desired outcomes/evaluation criteria- patient will:
Demonstrate temperature within normal range, be free of chills.
INTERVENTION
Independent
monitor
patient
temperature(degree
and
pattern);
note
shaking
chills/profuse diaphoresis.

Monitor
environmental
temperature;
limit/add
bed
linens as indicated.
Provide tepid sponge baths;
avoid use of alcohol.
Collaborative
Administer antipyretics, e.g.,
acetylsalicylic
acid
(ASA)
(aspirin),
acetaminophen
(Tylenol).

RATIONALE
Temperature of 102F-106F (38.9C- 41.1C)
suggests acute infectious disease process.
Fever pattern may aid in diagnosis; e.g.,
sustained or continuous fever curves lasting
more than 24 hour suggest pneumococcal
pneumonia, scarlet or typhoid fever; remittent
fever (varying only a few degrees in either
direction) reflects pulmonary infections;
intermittent curves or fever that returns to
normal once in 24-hour period suggests
septic episode, septic endocarditis, or
tuberculosis (TB). Chills often precede
temperature spikes.
Note: Use of antipyretics alters fever patterns
and may be restricted until diagnosis is made or
if fever remains higher that 102F (38.9C).
Room temperature/number of blankets
should be altered to maintain nearnormal body temperature.
May help reduce fever. Note: use of ice
water/alcohol may cause chills, actually
elevating temperature. In addition,
alcohol is very drying to skin.
Used to reduce fever by its central
action on the hypothalamus; fever
should be controlled in patients who are
neutropenic or asplenic. However, fever

25

 Provide cooling blanket.

may be benefial in limiting growth of

organisms
and
enhancing
autodestruction of infected cells.
Used to reduce fever, usually higher
than 104F-105F (39.5C-40C), when
brain damage/seizures can occur.

b. Actual Nursing Management

Priority number 1

S
O
A
P

Sa wala pa na admit akong anak, ge ubo na siya as verbalized by the

patients mother

Productive cough

Inability to expectorate secretions

Restlessness

Ineffective Airway Clearance related to productive cough

Short Term: At the end of 8 hours, the patient will be able to maintain airway
patency.

1. Elevated head of the bed by putting pillow under the head/changed

position frequently.

To enhance drainage and ventilation to different lung

segments

2. Monitored infant for feeding intolerance, abdominal distention and

emotional stress.

May compromise airway.

3. Encouraged mother to hydrate infant frequently.

To loosen the secretions

4. Positioned appropriately and discouraged use of oil-based products

around the nose.

To prevent vomiting with aspiration to lungs

Dependent:

26

5. Administered Ambroxol as prescribed.

To loosen the secretions

The goal has been met; the patient was able to maintain airway patency.

Priority number 2

O
A
P

Nangluspad naman gud akong anak tungod kai daghan na siya nasuka ug
gekalibang as verbalized by the patients mother

Cool extremities

Sunken eyes

Dry skin

Watery stool

Persistent vomiting

Weight (Before = 7 kgs; Now = 6.5 kgs)

Fluid volume deficit related to excessive losses through GI tract secondary to

diarrhea
Short term: At the end of 8 hours, the patient will be able to restore fluid and
electrolyte imbalances

Encouraged the mother to give oral fluid intake.

To increase fluid intake

2. Monitored intake and output balance.

To ensure accurate picture of fluid status

3. Observed for excessively dry skin and mucous membranes, decreased

skin turgor, slowed capillary refill.

Indicates excessive fluid loss/resultant dehydration

4. Weighed daily

Indicator of overall fluid and nutritional status

5. Monitored vital signs

To note the changes in heart rate and respiration

Dependent:
6. Provided supplement fluids as indicated D5LR 500cc @ 28cc/hr

Fluids may be given in this manner if patient is unable to take

oral fluid

27

Goal has been met; at the end of 8 hours, the patient was able to restore fluid
and electrolyte imbalances

Priority number 3

Sakit kayo ang tiyan sa bata sig era siya hilak sa kasakit. Basa pa gyud
iya tae ug sige na siya kalibang as verbalized by the patients mother

O
A
P

Hyperactive bowel sounds

3-5 loose liquid stools per day

Diarrhea related to irritation of the GI tract

Short Term: at the end of 8 hours, the patient will reestablish and
maintain normal pattern of bowel functioning.
1. Weighed infants diaper.

To

determine

the

amount

of

output

and

fluid

replacement needs
2. Encouraged oral fluid intake containing electrolytes.

To maintain fluid and electrolyte balance

3. Provided prompt diaper changes and gentle cleansing

Because, skin breakdown can occur quickly when

diarrhea is present

4. Did auscultation of abdomen.

To check for presence, location, and characteristics of

bowel sounds.

Dependent:
5. Administered antidiarrheal medications as prescribed.

To treat infectious process and decrease motility and

minimize fluid losses

Goals were not met

At the end of 8 hours, the patient was unable to manifest signs of

decrease fluid volume.

28

IX.

Referrals and Follow-up

Our further Inpatient care includes monitoring of changes in vital signs,

assessment of effectiveness of treatment regimen, reinforcement of dietary
advice(At par with age regular diet), and the advice regarding the importance of
adequate bed rest.
Our further Outpatient care includes instructions of Mr.& Mrs.Inalen Matias
dietary modification of their son, compliance with treatment regimen, and parents
participation through reporting of adverse effects of medications to his physician.
The parent was also instructed to have a regular check-up at PGH Hospital with their
son in order to monitor the current condition.

X.

Evaluation and Implications

Within the span of 2 day of rendering care to Jhunienne Matias. I was able to
identify potential problems and specific nursing interventions were provided. With the
help of health teachings and other interventions, Parents of Jhunienne Matias were
able to learn how to recognize signs and symptoms and other risk factors of the
condition of their son. The Parents of Jhunienne Matias was able to verbalized the
importance of giving medications to their son. They had also recognized the
importance of compliance to treatment regimen in order to manage the condition of
their son, Jhunienne Matias.

29

XI. BIBLIOGRAPHY:
o

Luckman and Sorensen, Medical-Surgical Nursing. 3 rd Edition W.B. Saunders

Company (1987)

o Kozier, B, et al Fundamentals of Nursing. 7 th Edition Pearson Education South

Asia PTE LTD Philippines 2004
o Smeltzer, Medical-Surgical Nursing. 11th edition, Lippincott William & Wilkins,
2007
o Mosby, Mosbys Nursing Drug Reference, Elesevier Mosby, 2005
o Doengoes, Nurses Pocket Guide. 9th edition, F.A. Davis, 2004
o www.wikipedia.org
o www.mims.com

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