Professional Documents
Culture Documents
Acute Gastroenteritis
Acute Gastroenteritis
Submitted by:
Tan, Kevin John T.
NCM501202 student
Group A2
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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
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I. Introduction
a. Overview of the Study
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.
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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.
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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.
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II. Patients Profile
Sex: Male
Nationality: Filipino
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III. Developmental Data
Basing on this theory, Jhunienne Matias belongs to the oral stage wherein an
infant’s pleasure centers are in the mouth. This is also the infant's first relationship
with its mother; it is a nutritive one.
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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 person’s ability to achieve the next task. Stages of Erikson’s
Psychosocial Theory are as follows:
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.
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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:
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IV. HEALTH HISTORY
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V. Nursing Assessment (System Review & Nursing
Assessment II)
Name: Jhunienne Matias Date: 02-15-09
Temp: 38.6ºC 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 Sunken eyes
[ ] gums [ ] hard of hearing [ ] deaf Poor appetite
[ ] burning [ ] edema [ ] lesion teeth Colds
Assess eyes, ears, nose throat Cough
For abnormality [ ] no problem Poor skin turgor
RESPIRATION:
[ ] asymmetric [ ] tachypnea [ ] barrel chest Hyperactive
[ ] apnea [ ] rales [x] cough bowel sounds
[ ] 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 Hyperthermia
assess urine frequency, control, color, odor, comfort =38.6C
NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures hooked with
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors IVF of D5 0.3Nacl
[ ] confused [ ] vision [ ] grip 500cc
assess motor, function, sensation, LOC, strength
grip, gait, coordination, speech [x] no problem
MUSCULOSKELETAL AND SKIN: Watery Stools
[ ] 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
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SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] hearing difficulty Comments: “Wala man [ ] glasses [ ] languages
siya problema sa pandu [ ] contact lenses [ ] hearing difficulties due to age
[ ] visual changes
[ ] speech difficulties
[x] denied ngug ug pagtanaw” as Pupil size:R:3 mm L:3mm
verbalized by the Reaction: PERRLA (Pupil Equally Round Reactive
mother to Light and Accommodation)
OXYGENATION: Resp. [x] regular [ ] irregular
[ ] dyspnea Comments:”Naa jud siya Describe: RR is within normal range.
[ ] smoking history ubo nabalaka na jud ko
Non-smoker ani niya”as verbalized R: symmetrical to the left lung
L: symmetrical to the right lung
[x] cough by the mother.
[ ] sputum
[ ] denied
CIRCULATION:
[ ] chest pain Comments: ”Wala may Heart Rhythm [x ] regular [ ] irregular
sakit sa tiil ug dughan Ankle Edema: No ankle edema is present on both
[ ] leg pain
akong anak”as verbalized extremities
[ ] numbness of Pulse Car Rad. DP Fem*
by the mother.
R _______+______+_ __ + __not assessed
extremities
L _____+_____ +_ _____+ not assessed
[x ] denied Comments: Right and left pulses are equal; strong
and palpable.
NUTRITION:
Diet: Exclusive B.F Comments: ”Gina patutoy [ ]dentures [x]none
since Birth. Raman nako siya”
Character as verbalized by the Complete Incomplete
[ ] recent change in
mother.
weight Upper [] [x]
[ ] swallowing
Difficulty Lower [] [x]
[x] denied
ELIMINATION: Comments: ”magsunod Bowelsounds:
Usual bowel pattern [x] urinary frequency sunod jud siya ug hyperactive
5 loose stools per day Diaper kalibanga”as verbalize Abdominal Distention
[ ] constipation [ ] urgency by the mother. Present [ ] yes [x] no
remedy [ ] dysuria Urine* (color, consistency,
[ ] hematuria odor)
Date of last BM [ ] incontinence urine color is straw,
December 5, 2008 [ ] polyuria amber transparent and
[ ] foley in place faint aromatic odor.
[ x ] diarrhea [x] denied
[ ] constipation *if they are in place
MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to follow
[ ] alcohol [ x ] denied treatments (diet, meds, etc.) for chronic health
(amount & frequency) problems (if present).
________________________________________. N/A.
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[ ] SBE: N/A Last Pap Smear: N/A
SUBJECTIVE OBJECTIVE
SKIN
Comments: [x] dry [ ] cold [ ] pale
INTEGRITY:
”Mala jud iya panit kay cige ra [ ] flushed [ ] warm
[x] dry ug kalibang” as verbalized by [ ] moist [ ] cyanotic
the mother. *rashes, ulcers, decubitus (describe size, location,
[ ] other
drainage: no rashes and ulcers found the the
patients body.
[ ] denied
ACTIVITY/
SAFETY: Comments: [x] LOC and orientation Patient is normal-
[ ] convulsion ”kalooy sa ginoo wala jud nag unconscious oriented
[ ] dizziness lipong-lipong akong anak ug Gait: [ ] walker [ ] cane [ ] other
[ ] limited motion maka lihok rapud siya” as
of verbalized by the mother. [x] steady [ ] unsteady_________
Joints [ ] sensory and motor losses in face or
extremities No sensory and motor losses on face or
Limitation in extremities
Ability to [x] ROM limitations: no ROM limitations
[ ] ambulate
[ ] bathe self
[ ] other
[x] denied
COMFORT/SLE
EP/ Comments: [x] facial grimaces
AWAKE: perminte ra siya ga mata mata [ ] guarding
[ ] pain tungod ni sa iyang kainit” as [ ] other signs of pain :
verbalized by the mother.
(location)
Frequency
Remedies
[ ] nocturia
[x]sleep
difficulties
[ x ] denied
COPING:
Occupation: N/A Observed non-verbal behavior: the patient is
Members of household: 2 members of household restless
Most supportive person: Karl William Matias(father) Phone number that can be reached anytime:
and Inalen Matias(mother) refused
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VI. ANATOMY AND PHYSIOLOGY:
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 section-
the 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
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salivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the
alimentary canal.
STOMACH
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.
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VI. Pathophysiology with Anatomy & Physiology
Name of the patient: Jhunienne Matias Diagnosis: AGE with mild DHN
Ingestion of E. Coli
Invasion of gastric
mucosa
Penetration of Gastric
mucosa
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Irritation of the Gastric Signs & Symptoms:
Lining Vomiting
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VII. MEDICAL MANAGEMENT
a. Medical Orders and Rationale
DOCTOR’S ORDER RATIONALE
02-15-09
02-15-09
To provide access for intravenous
IVF with D5 0.3NaCl 500ml @
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100cc/hr
02-016-09
Continue medications medications.
For billing today
IVF with D5 0.3 NaCl500cc @ To help for fast recovery
SR Preparation for going home
02-16-09 To provide access for intravenous
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
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
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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 that’s 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.
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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
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
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VIII. NURSING MANAGEMENT
Ideal Nursing Manangement - Risk for fluid volume deficit related to excessive
losses through normal routes (frequent diarrhea, vomiting)
INTERVENTIONS RATIONALE
INDEPENDENT
Monitor Intake and Output. Note number, Provides information about overall fluid balance,
character, and amount of stools; estimate renal function, and bowel disease control, as well as
insensible fluid losses, e.g., diaphoresis. Measure guidelines for fluid replacement.
urine specific gravity; observe for oliguria.
Assess vital signs (BP, pulse, temperature). 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
Weigh daily intestinal fluid losses.
Maintain oral restrictions, bed rest. Inadequate diet and decreased absorption may lead
to vitamin K deficiency and defects in coagulation,
Observe for overt bleeding and test stool daily for potentiating risk for hemorrhage.
occult blood. Excessive intestinal loss may lead to electrolyte
imbalance, e.g., potassium, which is necessary for
proper skeletal and cardiac muscle function. Minor
Note generalized muscle weakness or cardiac alterations in serum levels can result in profound
dysrhytmias. and/or life-threatening symptoms.
Monitor laboratory studies, e.g., electrolytes Reduces fluid losses from intestines.
(especially potassium, magnesium) and ABGs
(acid-base balance).
Vitamin K (Mephyton)
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Knowledge deficient regarding condition, prognosis, treatment, self-care, and
discharge needs as related to unfamiliarity with resources and information
misinterpretation.
INTERVENTION RATIONALE
INDEPENDENT
Determine the mother’s perception Establishes knowledge base and
of disease process. provides some insight into individual
learning needs.
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Hyperthermia related to dehydration as evidenced by increase in body
temperature higher than normal range.
INTERVENTION RATIONALE
Independent
monitor patient Temperature of 102F-106F (38.9C- 41.1C)
temperature(degree and suggests acute infectious disease process.
pattern); note shaking Fever pattern may aid in diagnosis; e.g.,
chills/profuse diaphoresis. 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).
Monitor environmental Room temperature/number of blankets
temperature; limit/add bed should be altered to maintain near-
linens as indicated. normal body temperature.
Provide tepid sponge baths; May help reduce fever. Note: use of ice
avoid use of alcohol. water/alcohol may cause chills, actually
elevating temperature. In addition,
Collaborative alcohol is very drying to skin.
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b. Actual Nursing Management
Priority number 1
Short Term: At the end of 8 hours, the patient will be able to maintain airway
P patency.
E The goal has been met; the patient was able to maintain airway patency.
Priority number 2
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“Nangluspad naman gud akong anak tungod kai daghan na siya nasuka ug
S gekalibang” as verbalized by the patient’s mother
• Cool extremities
• Sunken eyes
• Dry skin
• Watery stool
• Persistent vomiting
O • Weight (Before = 7 kgs; Now = 6.5 kgs)
Fluid volume deficit related to excessive losses through GI tract secondary to
A diarrhea
Short term: At the end of 8 hours, the patient will be able to restore fluid and
P 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
I 4. Weighed daily
• Indicator of overall fluid and nutritional status
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
E
Goal has been met; at the end of 8 hours, the patient was able to restore fluid
and electrolyte imbalances
Priority number 3
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“Sakit kayo ang tiyan sa bata sig era siya hilak sa kasakit. Basa pa gyud
S iya tae ug sige na siya kalibang” as verbalized by the patient’s mother
P Short Term: at the end of 8 hours, the patient will reestablish and
maintain normal pattern of bowel functioning.
I 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
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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.
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.
XI. BIBLIOGRAPHY:
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o Luckman and Sorensen, Medical-Surgical Nursing. 3rd Edition W.B. Saunders
Company (1987)
o Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education South
Asia PTE LTD Philippines 2004
o Smeltzer, Medical-Surgical Nursing. 11th edition, Lippincott William & Wilkins,
2007
o Mosby, Mosby’s Nursing Drug Reference, Elesevier Mosby, 2005
o Doengoes, Nurse’s Pocket Guide. 9th edition, F.A. Davis, 2004
o www.wikipedia.org
o www.mims.com
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