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I.

INTRODUCTION

Acute gastroenteritis could be more simply called a long, and potentially lethal
bout of stomach flu. The most common symptoms are diarrhea, vomiting and
stomach pain, because whatever causes the condition inflames the gastrointestinal
tract. Acute gastroenteritis is quite common among children, though it is certainly
possible for adults to suffer from it as well. While most cases of gastroenteritis last a
few days, acute gastroenteritis can last for weeks and months.

Numerous things may cause acute gastroenteritis. Bacterial infection is


frequently a factor, and infection by parasites like giardia can
cause acute gastroenteritis to last for several weeks. Viruses can also cause
lengthy stomach flu, particularly rotaviruses and noroviruses. Accidental poisoning or
exposure to toxins may also instigate acute gastroenteritis as well.

When a person does not recover from stomach flu symptoms within a day or
so, it is usually a good idea to see a doctor. Some types of acute gastroenteritis will
not resolve without antibiotic treatment, especially when bacteria or exposure to
parasites are the cause. Physicians may want to diagnose the cause by analyzing a
stool sample, when stomach symptoms remain problematic.

Another reason to seek medical treatment is that some forms


of acute gastroenteritis mimic appendicitis, which may require emergency treatment.
As well, young children run an especially high risk of becoming dehydrated during a
long course of the stomach flu. One should receive directions regarding how to help
affected kids or adults get more fluids. Sometimes children, those with
compromised immune systems, and the elderly may require hospitalization
and intravenous fluids. Dehydration can actually cause greater nausea, and can
begin to cause organ shut down if not properly addressed.

Even through causes for acute gastroenteritis vary, methods


of transmission from one person to another usually remain the same. Generally,
contact with the fecal matter of a person with the condition and then improperly
washing or not washing the hands causes acute gastroenteritis to be quite
contagious. Proper hand washing for both the ill person, and well people in the family
is always encouraged.

Other methods of transmission of acute gastroenteritis can include eating food


or drinking liquids contaminated with bacteria or parasites. For example, poorly
cooked hamburger might result in a very severe case of acute gastroenteritis due to
exposure to E. coli, a sometimes lethal bacterial infection in young
childrenAcute gastroenteritis remains a serious health issue, and is responsible for
over 50,000 hospitalizations of children in the US each year. In developing
countries, acute gastroenteritis is the leading cause of death for
infants. Acute gastroenteritis should thus be taken seriously, and people should not
hesitate to seek medical treatment for especially seniors and children who have
been ill for more than a day.
II. Patient Profile

Ward: Room 209 C


Date of Admission: July 15, 2010
Patient Name: Mr. X
Address: Blk 10 lot 6 Cattleya St. Villa de Primasona Buhay na Tubig, Imus, Cavite
Age: 3 yrs old
Gender: Male
Birth Date: August 14, 2006
Educational Status: Preparatory
Religion: Roman Catholic
Nationality: Filipino
Civil Status: Child
Occupation: N/A
Health Care Financing: Caritas
Informant: Patient
Reliability: The primary source of data is the patient’ s chart and patient’ s mother

Admission Data
Chief Complaint: Cough and cold
Admitting Diagnosis: AGE w. some signs of dehydration
Attending Physician: Dr. Reyes
III. Patient History/ Nursing History

History of Present Illness


2 weeks PTA- (+) cough
(+) colds
(+) fever
Self meds: Ascof lagundi
4 days PTA- (+) still w/ above s/sx
(+) watery stool
2 days PTA- (+) still w/ above s/sx

Past Medical History


Immunization HX:
BCG
Hepa B
DPT
MMR
Hepa A
IV. Gordon's Functional Health Pattern

Level Of Before During


Analysis/Inference
Functioning Hospitalization Hospitalization
Nutritional and The patient eats The patient eats His eating pattern
Metabolic Pattern hotdog, eggs etc. the hospital food. normal before
hospitalization.
Elimination Pattern He has watery His elimination His elimination
stools. pattern is not pattern is affected
normal. because of his
illness.
Activity - Exercise He is playing psp, The patient has no The exercise of the
Pattern watching tv and exercise because patient is also
playing with his he is only lying on affected because of
older brother. bed. the illness

Sleep – Rest The sleep pattern The patient’ s sleep The patient sleep
Pattern of the patient is pattern is normal. and rest is enough.
normal.
Role – Relationship The patient is living The patient is living The patient cares fo
Pattern with his parents. with his parents his mother but he
doesn’t have
enough money to
support his mother.

Coping – Stress He always plays He always plays His mother always


Tolerance psp psp supports him.
Pattern

Value – Belief Roman Catholic Roman Catholic There will be no


Pattern Always consulting Always consulting problem in terms of
a doctor everytime a doctor everytime medical assistance
he's not feeling he's not feeling due to her belief
well well
V. PHYSICAL ASSESSMENT:

AREAS FINDINGS
1. PHYSICAL
1.1 Head Normocephalic, (-) headache, (-)
dizziness, (-) head injury
1.2 Eyes Symmetrical, (-) discharge
1.3 Ears Symmetrical, (-) discharge
1.4 Nose Symmetric and straight, (-) discharge, (-)
nosebleeds
1.5 Mouth and Throat (-) bleeding gums, tongue in central
position, tongue moves freely,
1.6 Neck Head centered, (-) lumps, (+) stiffness in
neck
1.7 Breast and Auxiliary (-) pain, (-) lumps
1.8 Chest Chest symmetric, skin intact, (-) pain
1.9 Abdomen (-) abdominal pain
1.10 Extremities (-)weakness
1.11 Skin (-)itchy
1.12 Hair hair evenly distributed,
1.13 Nails short fingernails, smooth texture
1.14 Respiratory (+) cough
1.15 Cardiovascular (-) chest pain
1.16 Gastrointestinal Tract (-) bowel movement on day of PE
1.17 Urinary Frequently urinating 7× a day
1.18 Musculoskeletal (+)weakness on lower extremities
1.19 Neurologic Recognizes common object
1.20 Cranial Nerves
1.20.1 Olfactory Can identify different smell such as
alcohol and orange
1.20.2 Optic
1.20.3 Occulomotor Eyes can move freely
1.20.4 Trochlear Eyes can move freely. Can look upward
and downward
1.20.5 Trigeminal Patient was able to clench his teeth and
determine different sensation applied on
her face
1.20.6 Abducen Eyes can move laterally
1.20.7 Facial Can smile, lift eyebrows, close eyes
1.20.8 Auditory She was able to repeat words accurately,
able to hear
1.20.9 Glosopharyngeal Able to swallow, gag reflex present
1.20.10 Vagus Able to swallow
1.20.11 Accesory Can rotate the head
1.20.12 Hypoglossal Able to move her tongue
VI. ANATOMY & PHYSIOLOGY

Liver- is a vital organ present in vertebrates and some other animals. It has a wide
range of functions, including detoxification, protein synthesis, and production of bio
chemicals necessary for digestion. The liver is necessary for survival; there is
currently no way to compensate for the absence of liver function.

Gallbladder- is a small organ that aids digestion and stores bile produced by
the liver. In humans the loss of the gallbladder is usually easily tolerated.
Large intestine- s the second to last part of the digestive system the final stage of the
alimentary canal is the anus in vertebrate animals. Its function is to absorb water
from the remaining indigestible food matter, and then to pass useless waste
material from the body. This article is primarily about the human gut, though the
information about its processes are directly applicable to most mammals.

Stomach- is a muscular, hollow, dilated part of the alimentary canal which functions
as the primary organ of the digestive tract. It is involved in the second phase
of digestion, following mastication (chewing). The stomach is located between
the esophagus and the small intestine.

Small intestine- is the part of the gastrointestinal tract (gut) following the
stomach and followed by the large intestine, and is where the vast majority
of digestion and absorption of food takes place. In invertebrates such as worms, the
terms "gastrointestinal tract" and "large intestine" are often used to describe the
entire intestine. This article is primarily about the human gut, though the information
about its processes are directly applicable to most mammals. ( A major exception to
this are cows; for information about digestion in cows and other similar mammals,
see ruminants.)

VIII. Diagnostics/ Laboratory

July 15, 2010

Examinations Reference Results


Hemoglobin M 140- 190 g/L 130 g/L
Hematocrit M 0.40- 0.54 0.40
RBC count M 4.5- 6.5x 10/L 4.28
WBC count 5.0- 10.0x 108/L 6.2
Platelet count 142- 424 324

Differential count
Neutrophil 0.51- 0.67 0.48
Lymphocyte 0.25- 0.33 0.46
Monocyte 0.02- 0.06 0.04
Eusinophil 0.01- 0.03 0.02

July 15, 2010

Stool Examination
Physical
Color brown
Consistency Loose

Microscopic
Pus cells 0- 1/ HPF
Red Blood Cells 0- 2/ HPF
Others: No ova or parasite seen
Urinalysis
Physical
Color yellow
Transparency Hazy
PH 5.0
Spec. Gravity 1.025

Microscopic
Pus cells 0- 2/ HPF
RBC 0- 1/ HPF
Epithelial cells: rare
XII. Discharge Planning

M- Medications should be taken regularly as prescribed , on exact dosage,


time, & frequency,
making sure that the purpose of medications is fully disclosed by the health care
provider.

E- Exercise should be promoted in a way by stretching hand and feet every


morning and
exercise burping every after bottle feeding.

T- Treatment after discharge is expected for patients and watcher with Acute
Gastroenteritis
to fully participate in continuous treatment.

H- Hygiene must be maintained for patients with Acute

Gastroenteritis. Promotion of
personal hygiene should be encouraged such as, daily bathing and changing of
diapers
when soiled.

O- OPD such as regular follow-up check-ups should be greatly encouraged to

clients wather
with Acute Gastroenteritis as ordered by physician to ensure
the continuing management
and treatment.

D- Diet should be promoted, since, during admission, the patient was on NPO.

Proper
selection of milk that are suitable for babies will help enhance immunity
EMILIO AGUINALDO COLLEGE
School of Nursing and Midwifery
Congressional Road Burol Main, Dasmariñas, Cavite
(046) 416-4340, (046) 416-4341

Case Presentation
Acute Gastro Enteritis

Submitted by:
Lea Gizelle A. Poblete
BSNIV-2
Group3

Submitted to:
Mrs. Wendy Lyn Trasporto