I.

BIOGRAPHICAL INFORMATION
Name

: B/o Lavanya Sharma

Age

: 1 month 2 days

Sex

: Male

Address

: S/o Mr. Suresh

Bhind

Religion

: Hindu

IP No.

Admission unit

: Pediatric ICU

Date of admission

: 11/01/10

Date of history taking

: 13/01/10

Informant

: Mother

II.

DIAGNOSIS

: Acute Gastro Enteritis with Moderate Dehydration

III.

PRESENT HISTORY
Chief Complaints with Duration
Baby of Lavanya came with the complains of
Loose stools since 2 days
Refusal of feeds since 1 day
Fever since 1 day
History of Present Illness
The child B/o Lavanya is first born male baby to a second degree consanguineously
married parentage came to the hospital with the complains of loose stools since 2
days. On day 1, about 5-6 episodes, yellowish in color and watery in nature. On day
2, about 6 episodes, yellowish, sometimes associated with mucoid secretions, not
blood stained.
H/o of vomiting of 2 episodes contained ingested milk, non projectile.

H/o fever since one day mild to moderate degree does not decrease with medication,
associated with refusal of feeds and decreased activity.
Had history of one episode of excessive cry lasting for one hour.

IV.

PAST MEDICAL HISTORY

Past illness, hospitalizations

V.

Allergies

: Nil

Medications

: NS

BIRTH HISTORY
Antenatal

Natal

: Premature rupture of membrane

Place of Birth

: Hospital

Mode of Delivery

: LSCS

Gestational Age

: 8 months 22 days

Birth Weight

: 2.75 kg

Postnatal

VI.

: Has history of abdominal distention and reason is

unknown.

FAMILY HISTORY

: Admitted and kept baby in NICU for 3 da

50 yrs

42 yrs

38 yrs

21 yrs

36 yrs

28 yrs

1 month

VII.

GROWTH AND DEVELOPMENT

Appropriate to the age of 1 month.

VIII. IMMUNIZATION
Name of the Vaccines
1. OPV 0 & BCG
2. OPV 1 & DPT 2

IX.

Time
At Birth
6 weeks

Remarks
Given
------

ELIMINATION PATTERN
Bowel
: Altered bowel pattern. Baby has a history of loose stools 5-6 episodes
per day since 3 days.
Bladder

X.

: Passing urine adequately

NUTRITIONAL PATTERN
Recent Weight

: 3kg

Appetite

: Normal

Expected Weight: 3.5kg

24 Hours Diet Recall:

Baby of Lavanya is in NPO since last 24 hours.

Baby received IVF Isolyte P 10% 288 ml at the rate of 12 ml/hr.

Also received O +ve packed cells and replaced by RL.

At 2 am baby received Fresh Frozen Plasma 25 ml.

Degree of Malnutrition :
Degree of malnutrition

= actual weight/expected weight X 100

= 3kg/3.5kg X 100
= 85.7 %

I Degree malnutrition

XI.

SLEEPING PATTERN
Baby sleep decreased due to dehydration.

PHYSICAL EXAMINATION
1. General Observation
Moderately built, nourished and conscious, sick looking

2. Vital Signs
Temperature

: 102o F

Pulse rate

: 164 bts/min

Respiration

: 54 breaths/min

3. Anthropometric Measurements
Height

: 53cms

Weight

: 3 kg

Head Circumference

: 37cms

Chest Circumference

: 35cms

4. Skin And Mucus Membrane

Color

: Normal brown

Edema

: Absent

Moisture

: Mild dryness

Temperature

: Increased

Turgor

: Impaired. Has skin pinch greater than 2 sec.

Any Abnormal Discharges : Nil

5. Hair
Changes in Texture

: Nil

Characteristics

: Equally distributed and black in color.

Lice

: Absent

6. Nails
Changes in Appearance

: Nil

Cyanosis

: No

Texture

: Normal

7. Head
Skull/Cranium Size, Shape : Normal and round in shape
Fontanelles

: Normal

Suture

: Normal

Movements

: Decreased

Forehead

: No scars

8. Face
Appearance

: Dull

Color

: Normal

Symmetry

: Symmetrical

Movements

: Normal

9. Eyes
Expression

: Dull

Lacrimation

: Normal

Conjunctiva

: Clear

Sclera

: White

Cornea

: Moist and round

Pupil

: Reactive to light

10. Ears
Appearance

: Normal and symmetrical

Discharges

: Nil

Lesions

: Nil

Any Abnormalities

: Nil

11. Nose
Appearance

: Normal

Discharges

: No

Patency

: Good

12. Mouth And Throat

Lips

: Dry

Tongue

: Moist, not coated

Teeth

: Absent

Gums

: Normal

Buccal Mucosa

: No inflammation

Palate

: Normal

Tonsils

: Normal

13. Neck
General Appearance

: Normal

Trachea

: Centrally located

Lymph Nodes

: No enlargement

Thyroid Glands

: Non tender, firm

Salivary Glands

: Not palpable

14. Chest And Respiratory System

Inspection

: Barrel chest

Palpation

: No swelling

Percussion

: Dull

Auscultation

: No abnormal sounds

15. Cardio Vascular System

Inspection

: Normal

Percussion

: No murmurs

Auscultation

: Normal cardiac sounds S1 and S2 heard

16. Abdomen
Inspection

: Distended veins present over the abdominal wall.

Palpation

: Liver palpable

Percussion

: No fluid collection

Auscultation

: bowel sounds are dull.

17. Back
Spine, Curvature

: Normal

Symmetry

: Symmetrical

Tenderness

: No tenderness

18. Genitalia
Normal male genitalia
19. Extremities
Deformities

: No

Swelling/ Edema

: Absent

Muscles

: Strengthening

Lymph Nodes

: No enlargement

Joints

: Normal movements

Fingers and Toes

: No abnormalities

20. Central Nervous System

Birth Injuries

: Nil

Seizures

: Absent

Sensory Motor Changes

: Respond to shout and painful stimuli

Gait Changes

: Appropriate to age

Cognitive Changes

: Appropriate to age

Reflexes

: Normal

21. Urinary System

Urinary Tract Infections

: Nil

Any Abnormalities

: Nil

22. Gastro-Intestinal System

Diarrhea

: 5 -6 episodes of loose stools per day

Constipation

: No

Bleeding

: NO

Worm Infestation

: No

23. Psychosocial History

General Status of the Family:
The baby belongs to a middle class family, whose father is doing business and
mother is primary school teacher, with the income above Rs 10000/ month. They are
living in their own house with proper light and ventilation.

Relationship with the friends and family:

Baby is the first born male and loved & taken care by family members.

24. Laboratory investigations

Sl.
No
.
1.
2.
3.
4.
5.
6.

Investigation

Results

Normal values

Remarks

Blood test
Group and Rh
Hemoglobin
Sodium
Potassium
Platelet
CRP

O + ve
9.6%
120 meq/dl
3.1 meq/dl
2,29,000 cells/mm3
Positive

------12-16gm/dl
135-145meq/l
4-6.2meq/l
150,000 - 350,000/ml
Negative

-----Anemia
Hyponatremia
Hypokalemia
Normal
Infection present

MEDICATIONS
Medication name
1. IVF Isolyte P
2. Inj. Ceftraxone

Dosage Frequency Route Actions

12ml/hr
Every
IV Replacement of fluid
hourly
electrolytes
150mg

Bd

IV

Antibiotic

25mg

Bd

IV

Antibiotic

15mg

Tid

IV

Antimicrobial

Tid

IV

3. Inj Amikacin
4. Inj. Metrogyl
5. Inj. Adenosine

6. Inj. Vit K
7. FFP
8. Packed Cell
transfusion
9. Inj. Rantac

1 mg

IV

Coagulant

30 ml

----

IV

Replacement

60 ml

-----

IV

Replacement

3 mg

Bd

IV

Antacid

Side effects
Fluid overload
Nausea and vomiting

Nursing responsibilities
Calculate the fluid requirement
and administer at required rate.
Swelling, redness, pain, Follow the safety principles of
drug administration.
or soreness, loss of
Maintain aseptic precautions
appetite, nausea,
during drug administration.
vomiting, diarrhea,
Administer the IV injections as
weakness
slowly as prescribed.
Continuous monitoring of vital
Dizziness, headache,
signs.
diarrhea, nausea,
Observe the baby continuously for
stomach pain,
side effects of drugs.
Allergic reaction:
Inspect the site of injection
Itching or hives,
regularly.
swelling in your face or
hands, swelling or
tingling in mouth or
throat, chest tightness.
Pain, swelling and
tenderness at the site.
Allergic reactions,

Nausea, vomiting

ACUTE GASTROENTERITIS WITH DEHYDRATION

INTRODUCTION
In developing countries of the world, infectious diarrhea kills about 4 million people per
year. In the United States, it is estimated that children younger than 5 years of age experience
more than 20 million episodes of diarrheal diseases each year, with about 400 deaths per year
attributed to such episodes. Dehydration is the most important factor for the morbidity and
mortality associated with diarrheal disease in India also. Dehydration is largely controllable by
using rehydration therapy (Guerrant & Steiner, 2000).

DEFINITION OF GASTROENTERITIS
An infection or irritation of the stomach and intestines, caused by bacteria or parasites
from spoiled food or unclean water
A short painful illness affecting your stomach and intestines that is caused by bacteria in
food or a virus and that makes you go to the toilet frequently
Diarrhea: Frequent, loose, and watery bowel movements. Common causes include
gastrointestinal infections, irritable bowel syndrome, medicines, and malabsorption.

CAUSES OF GASTROENTERITIS
In many cases, the cause of diarrhea cannot be found. The major infection causing agents are

Bacteria
o Escherichia coli.
o Salmonella.
o Shigella.

Viruses
o Norwalk virus.
o Rotavirus.

Parasites
o Cryptosporidia.
o Entamoeba histolytica.
o Giardia lamblia.

RISK FACTORS

Eating food that irritates the stomach lining

Food intolerances. Some people are unable to digest a component of food, such as
lactose, the sugar found in milk.

Emotional upsets such as anger, fear, or stress.

Reaction to medicines, such as antibiotics, blood pressure medications, and antacids

containing magnesium.

Intestinal diseases, like inflammatory bowel disease or celiac disease.

Functional bowel disorders, such as irritable bowel syndrome, in which the intestines do
not work normally.

Some people develop diarrhea after stomach surgery or removal of the gallbladder.

The reason may be a change in how quickly food moves through the digestive system
after stomach surgery or an increase in bile in the colon that can occur after gallbladder
surgery.

As long as diarrhea goes away on its own, an extensive search for the cause is not usually
necessary.

SIGNS AND SYMPTOMS OF GASTROENTERITIS

Book picture
Fever

Patient picture
Present. Temperature 102oF

Nausea, vomiting,
Abdominal cramping
Diarrhea may be accompanied by cramping abdominal pain, Acute diarrhea
bloating, nausea, or an urgent need to use the bathroom.
Diarrhea can be either acute or chronic.
The acute form, which lasts less than 3 weeks, is usually
related to a bacterial, viral, or parasitic infection.
Chronic diarrhea lasts more than 3 weeks and is usually
related to functional disorders like irritable bowel syndrome
or diseases like celiac disease or inflammatory bowel

Bacterial infection

disease.
Depending on the cause, a person may have bloody stools.

One episode of bloody stool.

No improvement even after 24 hours.

No improvement.

Diarrhea in infants
Diarrhea can be dangerous in newborns and infants. In Moderate Dehydration present
small children, severe diarrhea lasting just a day or two
can lead to dehydration. Because a child can die from
dehydration within a few days.
Signs of dehydration in children include:

Dry mouth and tongue.

No tears when crying.

No wet diapers for 3 hours or more.

Sunken abdomen, eyes, or cheeks.

High fever.

Listlessness or irritability.

Skin that does not flatten when pinched and released.

Dry Mouth and Lips.

No tears when crying
No wet diapers since 3-4 hour
Sunken eyes
High fever 102oF
Poor turgor

Severe dehydration may require hospitalization.

INVESTIGATIONS
Book picture
Patient picture
History collection about food pattern, eating habits and Baby is exclusive breast
medication use.

feeding.

Physical examination to determine degree of dehydration. Moderate dehydration

Rectal exam for fecal consistency and for microscopy.

-------

Stool for culture and sensitivity (C & S), ova and ------parasites (O & P), and electron microscopy for viruses.
Routine blood test, blood and urine cultures. Blood tests Hypokalemia and
hyponatremia
can be helpful in ruling out certain diseases.
------ Fasting tests to find out food intolerance or allergy is

causing the diarrhea.

Sigmoidoscopy and Colonoscopy.
COMPLICATIONS

------

Dehydration.
Electrolyte disturbances.
Hyper or hyponatremia, hypokalemia, metabolic acidosis.
Transient, due to villous damage.

TREATMENT
Assessment of dehydration
Mild dehydration (35%): normal or increased pulse, decreased urine output,
thirsty, normal physical examination.
Moderate dehydration (710%): tachycardia, little or no urine output, irritable/
lethargic, sunken eyes and fontanel, decreased tears, dry mucous membranes,
mild tenting of the skin, delayed capillary refill, cool and pale.
Severe dehydration (1015%): rapid and weak pulse, decreased blood pressure,
no urine output, very sunken eyes and fontanel, no tears, parched mucous
membranes, tenting of the skin, very delayed capillary refill, cold and mottled

Prevention and treatment of dehydration

In most cases, replacing lost fluid to prevent dehydration is the only treatment
necessary.
Dehydration occurs when the body has lost too much fluid and electrolytes (the
salts potassium and sodium). The fluid and electrolytes lost during diarrhea need
to be replaced promptly. Dehydration is particularly dangerous for children, who
can die from it within a matter of days.
Although water is extremely important in preventing dehydration, it does not
contain electrolytes. To maintain electrolyte levels, you should also have chicken
or beef broth, which contains sodium, and fruit and cola drinks, which contain
potassium.
For children, special oral rehydration solution that contains the nutrients they
need. Examples include Pedialyte, Ceralyte, and Infalyte.

 Guidelines for Fluid Management of Dehydration

Restore intravascular volume
Normal saline: 20ml/kg over 20min (Repeat until intravascular volume
restored).

Calculate 24-hr water needs

Calculate maintenance water
Calculate deficit water = Percent dehydration weight

Calculate 24-hr electrolyte needs

Calculate maintenance sodium and potassium
Calculate deficit sodium and potassium
Sodium deficit
= water deficit 80 meq/l
Potassium deficit = Water deficit 30 meq/l

Select an appropriate fluid (based on total water and electrolyte needs)

Administer half the calculated fluid during the first 8?hr, first subtracting any
boluses from this amount
Administer the remainder over the next 16?hr

Replace ongoing losses as they occur

Early re-feeding advisable

Administration of antibiotics in case of bacterial infection.
In case of viral infection either treated with medication or left to run their course,
depending on the severity and type of the virus.

For Children with severe dehydration

Fluid needs
Firstly administer an Initial bolus of fluid to correct hypovolaemia ;
Then Maintenance plus, Deficit plus based on Ongoing losses

Hypovolaemia

Give boluses of 10-20ml/kg of normal (0.9%) saline, which may be repeated.

Do not include this fluid volume in any subsequent calculations.

Children with severe dehydration require maintenance fluids. They may also need extra
to replace fluid deficit due to dehydration, and possibly more fluid to replace abnormal ongoing
losses (eg from drain sites).

Maintenance

Less if in a basal state (ie very inactive lying in bed). -25%

Less in children on mechanical ventilation with humidified gases. -25%

More in children with fever. +10 to 20%

Less in children with excessive secretion of Antidiuretic Hormone (ADH)eg pneumonia,

meningitis Varies (-20 to 40%)

More if unable to concentrate urine (eg some renal diseases, Diabetes insipidus) Varies

Children with moderate to mild dehydration

Fluid needs
Well children with normal hydration but no oral intake require an amount of fluid that is
often termed "maintenance".
Maintenance fluid is that volume of daily fluid intake which replaces the insensible losses
(from breathing, through the skin, and in the stool), and at the same time allows excretion of the
daily production of excess solute load (Urea, Creatinine, electrolytes etc) in a volume of urine
that is of an osmolarity similar to plasma.
A childs maintenance fluid requirement decreases proportionately with increasing age
(and weight). The following calculations approximate the maintenance fluid requirement of well
children according to weight in kg.

Pt weight

mls/day

mls/hour

3 to 10kg

100 x wt

4 x wt

10 - 20kg

1000 + 50 x (wt-10)

40 + 2 x (wt-10)

>20kg

1500 + 20 x (wt-20)

60 + 1 x (wt-20)

The following table may be used to estimate maintenance fluid requirements.

Wt (kg)

10

12

14

16

20

30

40

50

ml/hr

16

24

32

40

44

48

52

60

70

80

90

mls/day

400

600

800

1000

1100

1200

1300

1500

1700

1900

2100

100mls/hour (2500mls/day) is the normal maximum amount

Dietary Advice
Until diarrhea subsides, try to avoid milk products and foods that are greasy, high-fiber,
or very sweet. These foods tend to aggravate diarrhea.
As condition improves, patient can add soft, bland foods to their diet, including bananas,
plain rice, boiled potatoes, toast, crackers, cooked carrots, and baked chicken without the skin or
fat.
For children, the pediatrician may recommend what is called the BRAT diet: bananas,
rice, applesauce, and toast.

Points To Remember About Diarrhea

Diarrhea is a common problem that usually resolves on its own.

Diarrhea is dangerous if a person becomes dehydrated.

Causes include viral, bacterial, or parasitic infections; food intolerance; reactions to

medicine; intestinal diseases; and functional bowel disorders.

Treatment involves replacing lost fluids and electrolytes. Depending on the cause of the
problem, a person might also need medication to stop the diarrhea or treat an infection.
Children may need an oral rehydration solution to replace lost fluids and electrolytes.

Call the doctor if a person with diarrhea has severe pain in the abdomen or rectum, a
fever of 102 degrees Fahrenheit or higher, blood in the stool, signs of dehydration, or
diarrhea for more than 3 days.

NURSING DIAGNOSIS:
Dehydration related to excessive loss of fluid.
Hyperthermia related to infectious process.
Disturbed bowel elimination pattern related to gastrointestinal infection.
Impaired parental bonding related to isolation of baby.
Parental anxiety related to childs condition and its prognosis.
Risk for impaired skin integrity related to dry and scaly skin.
High risk for further infection related to immature immune mechanism.

 NURSING CARE PLAN

ASSESS
MENT
Objective
data
Poor skin
turgor.
Increased
pulse 162
bts/min.
Decreased
electrolyte
level
i.e.
sodium
120meq/d
l
potassium
3.1 meq/
dl

NURSIN
G
DIAGNO
SIS
Dehydrati
on related
to loss of
fluid.

PLANNING
OBJEC
INTERVE
TIVE
NTIONS
Baby
will
achieve
and
maintain
normal
hydration
status.

IMPLEMEN
TATION

EVALUA
TION

Assess the
Assessed that
hydration status and child has moderate
degree of dehydration. dehydration.

Calculate
the total water and

Baby had 6-10

electrolyte loss in the
% of water loss.
baby.

Monitor
Baby is
blood electrolyte level.

Restrict the electrolyte level is low.

enteral feeding.

Restricted

Administer enteral feeding

normal saline as a

bolus to meet the

Administered
immediate fluid and
electrolyte need of the 60 ml of NS in 20
minutes.
baby.

Administer

the IV fluids to
maintain the normal
Administered
hydration status.
IVF Isolyte P 10% at the

Baby
achieved
normal
hydration
status as
evidenced
by
improved
skin
turgor and
normal
electrolyte
level.
Sodium
133meq/dl
Potassium
5.1meq/dl

rate of 12ml/hr.

ASSESS
MENT

Objective
data
Increased
body
temperatu
re.
Temp
102o F

NURSIN
G
DIAGN
OSIS

Hyperthe
rmia
related to
infectious
process.

PLANNING
OBJEC
TIVE

Baby will
achieve
normal
body
temperat
ure.

IMPLEMEN
TATION

EVALUA
TION

Assess the
vital signs.

Assessed that
Temp-102 F

Set the low

temperatur
e in the
radiant
warmer.

Radiant
warmer is set
to the
temperature
of 98o F

Baby
temperatu
re reduced
to 98.6o F.

INTERVE
NTIONS

Maintain
proper
ventilation.
Maintain
the
hydration
status.
Provide
cold
compress.

Maintained
the normal
room
temperature.
Maintained
normal
hydration
status.
----
Administered


Administer
anti
-pyretic
and
antibiotics
as
prescribed.

Inj.
Ceftraxone
Administered.

NURSIN
ASSESSME
NT
Objective

PLANNING
OBJECTI

DIAGN
OSIS
Impaired

INTERVEN

VE

TIONS

Mother

Assess the

IMPLEMEN
TATION
The baby is

EVALUA
TION
Mother

data

parental

will

bonding

one month

understoo

Baby is

bonding

achieve

level of

old, so it is

d the

admitted in

related to

proper

mother and

the important

condition

NICU and

isolation

bonding

baby.

period in

of the

separated

of the

with the

developing

baby and

from the

baby

baby.

the bonding

need of

Allow the

with the

maternal

mother.

bonding.

mother.
Also

mother to see

restricted the

the baby as

breast

frequently as

the baby once

feeding.

possible.

in 2-3 hours.

Explain the
mother about

Mother saw

Educated the

the

mother

importance

regarding the

of bonding

importance of

between

maternal

them.

bonding.

Explain the

Explained

mother

mother

regarding the

regarding the

need for

need for

isolation in

isolation.

the present

condition of

Explained the

the baby.

reason behind

Explain the

restriction of

reason for

breast

restricting

feeding.

the breast

feeding.

NURSIN
ASSESSME

NT
Subjective

PLANNING
OBJECTI

DIAGN
OSIS
Parental

data

IMPLEMEN

INTERVEN

VE

TATION

TIONS

Parents will

Assess the

Assessed that,

anxiety

be free

anxiety level of the

they are anxious.

related to

from

parents.

asked

babys

anxiety.

questions

condition

regarding

and

the
condition

Mother

Explain in

EVALUA

Explained

TION
Parents are

free from anxiety as

evidenced by good

regarding the need for

interaction of

detail about the babys

hospitalization and

parents with other

condition and

treatment.

people and

prognosis

treatment.

Reassure the

Reassured the

parents by introducing

improved facial
expression.

and

parents by introducing

same diseased babies

prognosis of

parents of babies with

who are regained health.

the baby.

same condition, who

are regained health.

Objective

data:

Mother
looks dull,

Explain the

Explained

about the need of

need for separation of

separation of the baby

the baby from parents.

from parents.

Describe

Described

sad and

about the treatment and about the treatment and

worried.

follow up care.

psychological support

psychological support to

to the parents

the parents.

Provide

follow up care in detail.

Provided

NURSIN
ASSESSME
NT
Objective
data:

PLANNING
OBJECTI

DIAGN
OSIS
Risk for

VE
Baby will

INTERVEN

Reassess the

achieve

skin

skin

and

condition.

and scaly.

integrity

maintain

Check for the

Baby had 5-6

related to

good skin

skin turgor

dry and

texture and

and texture.

episodes of

EVALUA

TATION

TIONS

impaired

Skin is dry

IMPLEMEN

Skin is dry
and scaly.

TION
Babys
skin

texture

Baby has poor

and turgor

turgor.

improved
to

diarrhea

scaly

turgor.

Avoid

skin.

significant

environment

level.

al irritants.

Applied

Apply

glycerin to

glycerin for

maintain skin

skin.

moistness.

Administer

Administered

prescribed

IVF to

drugs

maintain
hydration of
the skin.

ASSESSME
NT
Objective
data

NURSIN
G
DIAGN
OSIS
High risk

PLANNING
OBJECTI
VE

INTERVEN
TIONS

Baby will

Assess for

IMPLEMEN
TATION

EVALUA
TION

Baby is free

Baby is

for

be free

any infection

from

prevented

nosocomi

from

after the

hazardous

from

month old

al

potential

disease

infection.

nosocomi

and kept in

infection

infections.

occurrences.

IV line to

related to

maintain

immature

Baby is one

Assess the
immunizatio

al

Baby received

infections

OPV and

hydration

immune

n status of

BCG vaccines

level.

mechanis

the baby.

at birth.

m.

Maintain the

Maintained

aseptic

the aseptic

precautions

precautions

during

during

administratio

administration

n of

of medication

medication

and other

and other

procedures.

procedures.
Keep the
child clean
and hygiene.
Restrict the
visitors.

Maintained
the hygiene of
the baby.
Restricted all
the visitors
Educated the

parents

Educate the

regarding the

parents

importance of

regarding the

immunization

importance

of the baby in

of

preventing the

immunizatio
n of the baby
in preventing
the
infections.

infections.