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CASE STUDY

ON
ACUTE
GASTROENTERITIS
SUBMITTED BY:
MELISSA D. DAVID

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 hand washing,
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
histological 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 constitutethe
onset of the disease process.
Render series of nursing interventions for the clients care
Provide and disseminate important information as teachings to the client andthe
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:

Data collected via assessment, interviews with the patient, family members and
clinical records.
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 SLH hospital.
Developing a plan of care that will reduce identified predicaments and
complications.
Coordinating and delegating interventions within the plan of care to assist the
client to reach maximum functional health.
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:


Data collected is limited only to assessment and interview to the patient, patients
chart and nurse on duty.
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.
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: J. V. G.
Age: 18 y/o
Birthday: November 18, 1996
Weight: 59.5 kg
Address: Sta. Cruz, Manila
Civil Status: Single
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: December 15, 2014
Chief complaint: Vomiting
Admitting diagnosis: AGE with moderate dehydration

III. History of Present Illness


(-) cough and cold
(-) bleeding
(+) headache
(+) fever, on and off for 2 days
(+) throat pain
(+) vomiting 4x PIF
IV. Physical Assessment
Date assessed: December 15, 2014
General assessment: neat, conscious and coherent, weak looking
Initial vital signs: T=36.5, RR=24, BP=110/80, PR=83
Area Assessed

Technique

Normal Findings

Actual Findings

Evaluation

Inspection

Light brown, tanned


skin (vary according
to race)

brown skin

Normal

Lighter colored
palms, soles, lips and
nail beds

Lighter colored palms,


soles, and nail beds

Skin normally dry

Skin normally dry

Skin
Color

Lips, nail beds, soles


and palms

Moisture

Inspection
Inspection/
Palpation

Lips are dry

Lips Cracked
Normal

Palpation

Warm to touch

36.5 o C, warm to touch

Texture

Palpation

Smooth, soft and


flexible palms and
soles (thicker)

Smooth, soft and flexible


palms and soles (thicker)

Turgor

Palpation

Skin snaps back


immediately

Skin snaps back


immediately 1-2 seconds

Normal

Inspection

Transparent, smooth
and convex cut and
clean

Transparent, smooth and


convex cut and clean

Normal

Nail beds

Inspection

Pinkish

Pinkish

Normal

Nail base

Inspection

Firm

Firm

Normal

White color of nail


bed under pressure
should return to pink
within 2-3 seconds

White color of nail bed


under pressure returned
to pink within 2-3 seconds

Temperature

Normal

Normal

Skin appendages
a. Nails

Capillary refill

Inspection/
Palpation

Normal

b. Hair
Distribution

Inspection

Evenly distributed

Evenly distributed

Normal

Color

Inspection

Black

Black

Normal

Texture

Inspection/
Palpation

Smooth

Smooth and straight

Normal

Eyes

Inspection

Parallel to each other

Parallel to each other but


slightly sunken

May be a sign
of dehydration

Visual Acuity

Inspection
(penlight)

PERRLA- Pupils
equally round react to
light and
accommodation

PERRLA- Pupils equally


round react to light and
accommodation

Normal

Eyebrows

Inspection

Symmetrical in size,
extension, hair
texture and
movement

Symmetrical in size,
extension, hair texture
and movement

Normal

Eyelashes

Inspection

Distributed evenly

Distributed evenly and

Normal

Eyes

Eyelids

Inspection

and curved outward

long curved outward

Same color as the


skin

Same color as the skin

Blinks involuntarily
and bilaterally up to
20 times per minute

Do not cover the


pupil and the sclera,
lids normally close
symmetrically

Normal

Blinks involuntarily and


bilaterally up to 16 times
per minute
Normal
Do not cover the pupil
and the sclera, lids
normally close
symmetrically
Normal

Conjunctiva

Inspection

Transparent with light


pink color

Transparent with light


pink color

Normal

Sclera

Inspection

Color is white

Color is white

Normal

Cornea

Inspection

Transparent, shiny

Transparent, shiny

Normal

Pupils

Inspection

Black, constrict
briskly

Black, constrict briskly

Normal

Iris

Inspection

Clearly visible

Clearly visible

Normal

Ear canal opening

Inspection

Free of lesions,
discharge of
inflammation

Free of lesions, discharge


of inflammation

Normal

Ears

Canal walls pink


Canal walls pink
Normal
Hearing Acuity

Inspection

Client normally hears


words when
whispered

Client normally hears


words when whispered

Smooth, symmetric
with same color as
the face

Smooth, symmetric with


same color as the face

Close to midline,

Close to midline, thicker

Normal

Nose
Shape, size and skin
color

Inspection

Nasal septum

Inspection

Normal

thicker anteriorly than


posteriorly

anteriorly than posteriorly

Oval, symmetric and


without discharge

Oval, symmetric and


without discharge

Inspection

Pink, moist
symmetric

Pink, moist symmetric

Normal

Buccal mucosa

Inspection

Glistening pink soft


moist

Glistening pink soft moist

Normal

Gums

Inspection

Slightly pink color,


moist and tightly fit
against each tooth

Slightly pink color, moist


and tightly fit against each
tooth

Normal

Moist, slightly rough


on dorsal surface
medium or dull red

Moist, slightly rough on


dorsal surface medium or
dull red

Normal

Firmly set, shiny

Firmly set, shiny

Normal

Nares

Inspection

Normal

Normal

Mouth and Pharynx


Lips

Tongue

Teeth

Inspection

Inspection

No tooth decay, milk tooth


present
Hard and soft palate

Inspection

Hard palate- domeshaped

Hard palate- domeshaped

Soft Palate- light pink

Soft Palate- light pink

Neck is slightly hyper


extended, without
masses or
asymmetry

Neck is slightly hyper


extended, without masses
or asymmetry

Normal

Neck
Symmetry of neck
muscles, alignment
of trachea

Inspection

Neck Rom

Inspection

Neck moves freely,


without discomfort

Neck moves freely,


without discomfort

Normal

Thyroid gland

Palpation

Rises freely with


swallowing

Rises freely with


swallowing

Normal

Normal

Trachea

Inspection

Midline

Midline

Normal

Thorax and Lungs

Auscultation

Clear breath sounds

Clear breath sounds

Normal

Abdomen

Inspection

Skin same color with


the rest of the body

Skin same color with the


rest of the body

Normal

Clicks or gurling
sounds occur
irregularly and range
from 5-35 per minute

Clicks or gurling sounds


occur irregularly and
range from 5-35 per
minute

Bowel sounds

Auscultation

Normal
Neurology system
Level of
consciousness

Behavior and
appearance

Inspection

Inspection

V. Anatomy and Physiology

Fully conscious,
respond to questions
quickly, perceptive of
events

Fully conscious, respond


quickly to stimulus

Makes eye contact


with examiner,
hyperactive
expresses feelings
with response to the
situation

Makes eye contact with


examiner, hyperactive
expresses feelings with
response to the situation

Normal

Normal

The digestive system consists of two linked parts: the alimentary canal and the
accessory digestive organs. The alimentary canal is essentially a tube, some 9meters
(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 consists 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 14 salivary
glands, liver, gallbladder, and pancreas, which are all linked by ducts to the alimentary
canal.
Stomach 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 cardio
esophageal sphincter through which food enters the stomach from the esophagus;
fundus which is the expanded part of the stomach lateral to the cardiac 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 secretemucus. 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 pyloric sphincter. 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

VII. Diagnostic Exams


Urinalysis
Results

Interpretation

Yellow

Normal

SI turbid

increased urine concentration

5.5

Decreased

Specific Gravity

1.025

Normal

Albumin

Traces

Normal

Sugar

(-)

Normal

WBC

7-10

Infection

Color
Transparency
Reaction

Fecalysis
Results

Interpretation

Green

Sign of diarrhea

Soft

Sign of diarrhea

No OVA or parasites seen

Normal

Color
Consistency
Parasites

Hematology
Results

Normal Value

Interpretation

Hemoglobin

123

120-150

Normal

Hematocrit

0.47

0.37-0.45

Increase

RBC

5.42

4.6-5.2

Increase

WBC

15.3

5-10 x 10/L

Increase, infection

Neutrophils

0.58

0.55-0.65

Normal

Lymphocytes

0.27

0.25-0.35

Normal

Platelets

297

140-340 x 10/L

Normal

MCV

77.3

86-100

Normal

MCH

26.7

26-31

Normal

MCHC

31.9

31-37

Normal

Results

Normal Value

Interpretation

11

7-17

Normal

0.64

0.52-1.04

Normal

Blood Chemistry

BUN
Creatinine

VIII. Drug Study


Generic
Paracetamol

Brand

Classification

Indication

Nsg. Responsibilities

Biogesic

Analgesic;
antipyretic

For fever.

May produce analgesic


effect by blocking pain
impulses, by inhibiting
prostaglandin or pain
receptor sensitizers. May
relieve fever by acting on
hypothalamic heatregulating center. Relieves
fever.

Do not administer for fever thats above


39.5C, lasts longer than 3days or recurs.

Flagyl

Trichomonacide,
amebicide

Gastrointestinal
disturbances and
irritations

Effective against
anaerobic bacteria and
protozoa. Specifically
inhibits growth by binding
to DNA, resulting in loss of
helical structure, strand
breakage, inhibition of
nucleic acid synthesis and
cell death

>Monitor stool number and character.

500 mg 1 tab
q4h PRN for
fever

Metronidazole

Action

>With IV therapy, assess for sodium retention

IX. Nursing Care Plan


Assessment
Subjective data:
Nagsuka siya at
nagtae, as
verbalized by the
mother
Objective data:
>Dry mucous
membranes and
Cracked lips
>Sunken eyeballs
Temp: 37.9

Nsg.
Diagnosis
Fluid volume
deficit related
to increase
metabolic
demand and
insensible fluid
loss through
vomiting and
increased
body
temperature

Planning
At the end of
the shift, the
patient will be
able to:
- Achieve
adequate
hydration as
evidenced by
good skin
turgor, moist
mucous
membranes
and lips, no
alteration in
mentation

Intervention
>Assessed vital signs
and degree of
hydration and level of
consciousness

Rationale
>Provides baseline data
and information; this is
also important in the
evaluating clients
condition an success of
intervention

>Encouraged
adequate fluid intake
as tolerated by the
patient. Instructed
mother to provide
fluids in the bedside

>Adequate fluids will


replace fluid lost through
insensible water loss due
to hyper metabolic state
and vomiting

>Regulated IVF
according to specified
flow rates basing on
the physicians order

>Regulation of fluid is
critical in maintaining
adequate circulating
fluids to recover for the
amount of water loss
through fever and
vomiting

>Monitored frequency
of urination and
amount of excreted
urine

>Urine output serves as


an important parameter
in assessing clients
ability to conserve fluid

Evaluation
At the end of the shift
the patient was able
to show signs of
improvement such
as:
- Achieved adequate
hydration as
evidenced by good
skin turgor, moist
mucous membranes
and lips, no alteration
in mentation

Assessment
Subjective data:
Mainit po ang
pakiramdam ko
as verbalize by
the patient
Objective data:
>T= 37.9
>Skin is warm to
touch
>RR = 20

Nsg.
Diagnosis
Hyperthermia
r/t exposure to
hot
environment as
evidenced by
temperature of
37.9

Planning
After 30 mins
of nursing
interventions,
the patient
will maintain
a core
temperature
within normal

Intervention

Rationale

>Provide proper
ventilation.

>Proper ventilation may


reduce the temperature
of the patient.

>Monitor heart rate


and rhythm.

>Dysrhythmias are
common due to
electrolyte imbalance,
dehydration, and direct
effects of hyperthermia
on blood and cardiac
tissue.
>Heat loss by
convention.

>Promote surface
cooling by means of
cool environment
and/or fans
>Promote client safety
.
>Encourage patients
participation in ways to
protect oneself from
excessive exposure to
hot environment.
>Instruct client/relative
to increase fluid intake.

>Ensuring patients
safety prevents other
problems.
>Self-care awareness
helps in the prevention
and control of
hyperthermia.
>Adequate fluid intake
prevents dehydration.
These may indicate
prompt interventions.

Evaluation
After 30 minutes of
nursing interventions
the patient was able
to maintain core
temperature within
normal, 37.5

X. Discharge Planning
Medications instructed client to continue medications as ordered by the physician
Economics Advised client to buy foods within the budget.
Treatment Pt. was still advised for increase fluid intake, periodic complete emptying of
urinary bladder and keep hands clean. He still have a follow up check up after 1 week
after discharge.
Health Teaching Proper hygiene of both child and parent are very important as
defense from infection. Proper and strict supervision of child until balance, gait, and
coordination is gained. Advise to restrict child from handling items or objects especially
if unfamiliar and not edible. Emphasize importance of hand washing.
Out Patient Client was advised to have follow-up check up one week after discharge.
Diet Client was ordered with diet for age, with increase fluid intake.