PATIENT’S PROFILE

Name: N P

Address: Urbiz, Tondo, Pangasinan

Age: 2 y/o

Gender: Male

Birth Date: December 31, 2008

Birth Place: Urbiz, Tondo, Pangasinan

Religion: Roman Catholic

Weight: 8 kg

Date and Time of Admission: January 9, 2011/ 12:35 pm

Chief Complaints: Diarrhea and vomiting few hours after admission.

Admitting Diagnosis: Acute Gastroenteritis with signs of dehydration

History of Present Illness

-According to the patient’s mother, seven hours before admission patient was
experiencing loose bowel movement and is also vomiting for several times, thus bringing the
patient to Mangatarem District Hospital.

Past Medical History

- The mother reported that their child past experience of illnesses were just cough, colds
and fever that does not last for several days. Over the counter medicines such as Paracetamol
(Calpol) was used to treat for fever and Lagundi for colds. The patient has not completed his
immunization according to his mother but had never experienced an illness that required
hospitalization, child does not have known allergies to drugs and foods.
-The patient was born also in Mangatarem District Hospital through a normal
spontaneous vaginal delivery.

Family and Social Environment

- According to the mother, she and the child’s father has both a family history of
hypertension, other than that there are no more other major diseases such as diabetes, cancer, and
others. Patient was born December 31, 2008. He was the first child of his parents. Her mother is
a housewife and takes care of him most of the time while his father works as a tricycle driver and
has just enough income to support their basic needs. Their home environment according to his
parents is not that very comfortable and is not good for the child’s health.
PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors

Environment Age(2 years old)

Hygiene Gender(Male)
Stress

Ingestion of E. Coli

Invasion of gastric mucosa

Hyperthermia related to Disease Process

Penetration of Gastric
mucosa

Toxins producing pathogens Signs & Symptoms:

cause watery, large volume Watery stool
diarrhea Fever

Irritation of the Gastric Signs & Symptoms:

Lining 1. Vomiting

Fluid and Electrolyte imbalance too much Na+ and H2O are
expelled from the body

Increased fluid loss

Signs & Symptoms:
Decrease skin turgor
Dehydration Sunken Eyes
DRUG STUDY

1. Generic Name: Paracetamol

Brand Name: Biogesic

Classification: Anti-pyretic, Anti-inflammatory

Indication: Symptomatic relief of pain and fever.

Nursing Considerations:
 Use liquid form for children and patients who have difficulty swallowing.
 In children, don’t exceed five doses in 24 hours.
 Advise patient that drug is only for short term use and to consult the physician if
giving to children for longer than 5 days or adults for longer than 10 days.
 Advise patient or caregiver that many over the counter products contain
acetaminophen; be aware of this when calculating total daily dose.
 Warn patient that high doses or unsupervised long term.

2. Generic Name: Metoclopramide

Brand Name: Maxolon

Classification: Antiemetic, GI stimulant

Indication: -Relief of symptoms of acute and recurrent diabetic gastroparesis

-Disturbances of GI motility

Nursing Considerations:
 Assess History: allergy to metoclopramide, GI hemorrhage, mechanical
obstruction or perforation, depression, epilepsy, lactation, previously detected
breast cancer
 Assess Physical: orientation, reflexes, affect, bowel sounds, normal output, EEG
 Monitor BP carefully during IV administration.
 Monitor diabetic patients, arrange for alterations in insulin dose or timing if
diabetic control is compromised by alterations in timing of food absorption.

3. Generic Name: Ampicillin

Brand Name: Omnipen

Classification: Antibiotic penicillin

Indication: Treatment of infections caused by susceptible strains of E.coli.

Nursing Considerations:

 Culture infected area before treatment; reculture area if response is not as

expected.
 Check IV site carefully for signs of thrombosis or drug reaction.
 Do not give IM injections in the same site; atrophy can occur. Monitor injection
site.
 Administer oral drug on an empty stomach, 1 hr before or 2 hrs after meals with
full glass of water, do not give with fruit juice or soft drinks.