You are on page 1of 72

bjbjqPqP

INTRODUCTION

Gastroenteritis among children is most often due to viral infections. These include
ìrotaviruses, which are usually abundant in winter time, enteroviruses which are common
in summer and adenovirus which can occur year-round. There are also bacteria that
cause gastroenteritis which are usually due to poor sanitation settings. There are also
chemical factor that contribute to gastroenteritis this is due to lactose intolerance where
lactose is not digested and creating irritations to stomach and intestines that cause
diarrhea and abdominal pain. This is common with infants.
A Current trend About AGE
Rotavirus Vaccine
Fighting a Common Pediatric Disease
ó The FDA has now approved a vaccine that protects against rotavirus gastroenteritis, a
pediatric disease that causes severe diarrhea, vomiting, and dehydration. RotaTeq, as the
vaccine is known, took 26 years to develop and test. Infectious disease experts expect the
vaccine to drastically reduce the hundreds of thousands of ER visits and hospitalization --
and the dozens of deaths -- the virus causes every year.

Full Story...
BACKGROUND: The FDA has announced a new oral vaccine against the Rotavirus, a
highly contagious virus that is the most common cause of severe dehydrating diarrhea in
infants and young children. Each year many U.S. infants are hospitalized because of
Rotavirus. The vaccine is a liquid given at two, four and six months. Between 2001 and
2004, the developing company -- Merck & Co. -- conducted one of the largest clinical
trials of a vaccine ever performed, involving more than 70,000 infants from 70 different
countries. The data from those trials demonstrated that the vaccine is both safe and
effective.
THE MAKING OF A VACCINE: Whenever a disease-causing micro-organism enters
the body, the immune system mounts a defense, producing proteins to fight off the
foreign substance. Vaccines stimulate the body's immune system by introducing a
weakened form of a particular germ or virus, making the body think it is being invaded
by a foreign organism. If a person who has been vaccinated is exposed later to the virus,
he or she will be protected because the body already has the necessary antibodies to ward
off infection. Merck's new vaccine uses a strain of

Rotavirus called WC3, co-infected with other human Rotavirus strains to create the best
protection against the disease.
ABOUT ROTAVIRUS: Rotavirus is an infection of the digestive tract, caused by wheel-
shaped viruses that infect the intestine. Infection begins with fever and vomiting,
followed by diarrhea, which can last anywhere from 3 to 9 days. Those with severe
diarrhea, especially children, can lose body fluids so quickly they become dangerously
dehydrated. Apart from vaccination, there is no other means of completely eliminating
the spread of infection. But maintaining strict hygienic practices can reduce it, even if
soaps and cleaners don't kill the virus. For instance, wash hands after using the bathroom,
changing diapers, and before preparing or serving food.
Source; http://www.sciencedaily.com/videos/2006-11-05/

B. Reason for choosing such case for Presentation

The group started their duty at the pediatric ward in one of the hospital in
Pampanga last May 08, 2007 and found out that most cases or diagnosis among their
patients are Pneumonia, dehydration, parasitism and Acute Gastro Enteritis or AGE.
With this, the group decided to make use of AGE for their case study for the following
reasons: First, to be more knowledgeable in relation to what AGE is which is so prevalent
in our country particularly among children. Second, the group wants to know the
different options of treatment that the patient can undergo because this can provide the
group the knowledge in order for them to give the appropriate care and interventions to
the patients because with little knowledge about the disease they know that they wouldnít
be able to render quality care for the patients, thus, they wouldnít function effectively as a
health care provider.
II. NURSING ASSESSMENT

PERSONAL DATA

Baby Potpot is a patient from pediatric ward in one of the government hospitals in
Pampanga. Based from the data gathered from mother A, Baby Potpot is Eight months
old, male and a natural-born Filipino. He is the youngest among the three children of
Mother A and Father B. they are faithful Roman Catholic and currently residing at Acli
Mexico. He was born on August 25, 2006 at Home by a Midwife. Baby Potpot was
brought to the hospital and was admitted last May 01, 2007 at 11:45am with diagnosis of
AGE (Acute Gastro Enteritis) with some dehydration.

*Informant: Mother A (mother)

PERTINENT FAMILY HISTORY

Based on the interview conducted with Mother A and Father B Baby Potpotís grandfather
on the paternal side died of Diabetes Mellitus. His grandmother is still alive and
currently residing in Acli Mexico. His two uncles are still alive and also residing in Acli
Mexico. His father, Father B didnít have any past and present history of illness.

On the maternal side, his grandfather and grandmother died of old age. Her aunt Josefa is
still alive but has hypertension. Her mother didnít have any past and present history of
illness.

Baby Potpotís family is characterized as a nuclear type of family which consists of a


father, mother, and their three children living together in one house located at Acli
Mexico.
b. Obstetrical History

The obstetrical history of Mother A is G3P3 T3P0A0L3. She stated that she had her
complete dose of Tetanus Toxoid at their health center within their barangay. The
following are the previous pregnancies of Mother A including Baby Potpot.

Mother A gave birth to a full term baby via normal spontaneous delivery, it was a home
delivery. During her pregnancy with her first baby, she sought for monthly pre-natal
check-up in the health center where she was given Tetanus Toxoid vaccinations. During
the delivery, a midwife assisted her in their barangay. No complications were noted after
the delivery on both mother and the child

.Second baby was delivered full term via normal spontaneous delivery. Same as with the
eldest, it was a home delivery. Mother A stated that she had difficulty in delivering her
2nd baby and she had a complication of profused bleeding after the delivery. Because of
financial problems, she sought alternative medicine advice instead of going to the
hospital. She recovered after 2 days of drinking medicinal plant decoction. The informant
wasnít able to identify the herbal plants used.

The Youngest child, Baby Potpot was delivered full term via normal spontaneous
delivery at home by a Midwife. No complications were noted after the delivery of the
child. The child is presently suffering from AGE with some dehydration.

According to Mother A, during her pregnancy to her three children, she usually walks
early in the morning around for exercise. On the other hand, she also verbalized that
usually, she does not eat enough nutritious foods because of their socio-economic
situation.
c. Family Living Condition

Father B, the 35 years old head of the family, works as a contractual laborer. His income
is more or less 3500 pesos a month. While Mother A., 33 years of age is a pure house
wife but sometimes collects dirty clothes among their neighbors and hand wash them to
earn extra money. Basically she earns 500 pesos. The monthly income of both the father
and the mother is spent mostly for food. They donít have means for providing proper
hygiene and supplemental care to their children since their monthly income is not enough
to support the financial needs of the family.

The family is in poor living condition and has poor environmental sanitation. Mother A
stated that their family lives in a bungalow type of wooden house with two bedrooms and
a small living room. Both parents and Baby Potpot sleep together inside one bedroom and
her siblings, sleep in the other room.

d. Cultural Factors Affecting the Health of the Family


The family is affiliated with the Roman Catholic religion but they do not attend
mass regularly. Based from the interview with Mother A., the family follows
superstitious beliefs such as resuming bathing within 1 month after pregnancy can lead to
sickness on both mother and child. They also believe in ìmanghihilotî whom they seek
whenever a member of their family is sick. In addition, they also use herbal plants as their
sources of medicines.

As with common ailments, they do self-medication. If they have extra money,


they buy generic medications such as paracetamol for fever. But in most cases, they seek
to the medicinal plants advised by the ìmanghihilotî to relieve their illness. Mother A
also stated that if simple illness cannot be manageable she will go to barangay or nearest
hospital to seek professional help.
PERSONAL HISTORY

a) Birth History

Mother A has practiced breastfeeding for all her children. The mother stated that she had
her complete dose of Tetanus Toxoid at their health center within their barangay. She
also always makes sure that her monthly check-up is updated. And because of her
pregnancy that increases the level of estrogen in her body, her eating habits increases,
thus making her plump.

She also narrates that her labor usually last for about 3 hours and said that she can
tolerate the pain it causes her. In her previous pregnancy, she delivered her 1st at home in
an NSD, so as with her 2nd pregnancy. And the youngest child Baby Potpot was
delivered via normal spontaneous delivery at home by a midwife last August 25, 2006.
She was full term baby no post partum complications on both the child and the mother
were noted.

b) Feeding

Baby Potpot had breast milk feeding for 3 months, and then, has been continuously given
processed milk up to this time. The mother makes use of Nido and/or Milo in bottle-
feeding her child.

c) Growth and Development

In terms of his behavior in reference to the different theories of growth and development,
he was able to perform each stage of the proposed theories of the different psychologists.
Such us when he thumb sucks, according to Sigmund Freud, this behavior is a way of
satisfying the oral stage which is evident upon birth to 1 and a half years of age. By
thumb sucking, he finds pleasure and it is also at this stage when infants find security as a
need, that is, Baby Potpot would always want to be held by his mother or the person he
recognizes. According to Erik Erickson, Infancy stage is met upon birth until 18 months
wherein infants would learn to trust other ìTrust vs. Mistrust.î The patient manifested this
behavior when he sees nurses or student nurses coming into his area, he cries since he
knew that heíd be injected with something that would hurt him, and if another person will
handle him, heíll surely cry and try to show some withdrawal behaviors. In terms of Jean
Piagetís theory, it exemplifies the stage of coordinating secondary reaction which is met
upon 8 months old to 12 months, wherein an infant would recognize shapes and sizes of
familiar objects and would tend to search for and retrieve a toy or an object that
disappears from his view. He manifested this behavior when he saw an ID for the first
time; he grabbed it and tried to play with it. Another object came to his view, a
nameplate, he switched his attention to the nameplate, since the object would seem new
to his eyes. All of these behaviors were encountered during the Nurse-Patient interaction.

d) Immunization Status

According to her mother, Baby Potpot received each vaccine as scheduled at their
barangay health center in Acli Mexico. No pertinent complications were noted after each
vaccine. Side effects of DPT vaccine such as fever was noted but was relieved after a
day.

History of Past Illness

According to the mother A, the patient has only experienced episodes of fever in the past
and has never been inflicted with a much serious disease. It was only his first time to be
admitted in the hospital due to diarrhea and vomiting.

Mother A. also added that baby Potpot has never been hospitalized before. However, he
did had cough, and colds sometimes.

History of Present Illness

According to Mother A, four days prior to Confinement at the hospital Baby Potpot is
having fever with accompanying vomiting of previous ingested foods. Patient also had
three times greenish, soft, mucoid, foul smelling stool but no medications given and no
consult done. Aside from these, he also manifested abdominal pains, weakness, slightly
sunken eyeballs and dry oral mucosa which could serve as early signs of dehydration due
to excessive fluid loss brought about by diarrhea.

The following day Baby Potpot still with the above symptoms this prompted
Mother A to consult at the Hospital. Then, Baby Potpot was given amoxicillin (1ml tid)
but provided no relief.

And one day prior to confinement signs and symptoms persisted, Baby Potpot was
admitted at the hospital last May 01, 2007 with the diagnosis of AGE with some
dehydration.

Physical Examination

May 1, 2007
Upon admission (From Chart)

Vital Signs:

Temperature = oC / axillae
Pulse Rate = bpm
Respiratory Rate = bpm

Head : Normal head contour

EENT : Anicteric Sclerae and Pink Palpebral Conjunctiva

Cardiovascular : Normal Rate and Regular Rhythm

Lungs : Symmetrical chest expansion, with rales,

Abdomen : globular distention and with normal abdominal bowel


sounds

Extremities : No abrasions or lesions, no rashes noted

Skin : Without jaundice, poor skin turgor and integrity.


May 8, 2007 (Tuesday)

Vital Signs:

Pulse Rate = bpm


Respiratory Rate = bpm
Temperature = oC / axillae

Physical Examination

HEAD and FACE


Hair- straight and short, evenly distributed, black in color, smooth and shiny
Scalp- absence of flaking or dandruff, absence of infestations
Skull- normal skull configuration, rounded, smooth skull contour, absence of nodules or
masses
Face- symmetrical in shape with appropriate facial expressions
EYES
General- symmetrical, sunken eyeballs, absence of discharges, or abnormal discharges,
with parallel eye movement
Eyebrows- hair growth evenly distributed, symmetric
Eyelashes- equally distributed, slightly curled outward
Eyelids- skin intact, with slight tears production
Palpebral conjunctiva- pinkish in color
Pupils- black in color; equal in size; with pupils equally round and reactive to light.

EARS
External ñ color of auricles is same as face, symmetrical, tip of the ear is aligned with the
outer canthus of the eye; pinna recoils after it†is folded

NOSE
symmetrical nares
with discharges
same color of skin as face
intact nasal septum

MOUTH AND OROPHARYNX


Lips ñ pale pink in color and slightly dry due to the hot weather
Gums - gums pink in color
Tongue- pink in color, moist, looks rough and with veins not prominent, tongue have
slight or thin white coating
Palates and Uvula- light pink, absence of swelling, uvula is positioned midline of soft
palate
Throat- no soreness and no inflammation.

NECK
head is centered, there is no difficulty of head mobility
absence of palpable lymph nodes, no distention of neck veins

INTEGUMENTARY
Skin- fair complexion, dry and warm to touch, with poor skin turgor
Nails- clean and short, smooth-textured; light pink in color; blanch test < 3 seconds; there
is no clubbing of fingernails.

CHEST
Lungs- rales on both lung lobes
Chest- symmetric, no lumps, masses and lesions noted, with full chest expansion

CARDIOVASCULAR
Heart- normal rate and rhythm
Peripheral pulses- full pulsations

GASTROINTESTINAL
Abdomen- no lesions, globular distention and with smooth texture, no lumps and no
masses noted, with normal bowel sounds as auscultated.

MUSCULOSKELETAL
Upper Extremities - Both arms are symmetrical, with capillary refill of 2 seconds.
Lower Extremities - Both legs are symmetrical, with capillary refill of 2 seconds.

May 9, 2007 (Wednesday)

Vital Signs:

Pulse Rate = 46 bpm


Respiratory Rate = 116 bpm
Temperature = 38. 2oC / axillae

Physical Examination

HEAD and FACE


Hair- straight and short, evenly distributed, black in color, smooth and shiny
Scalp- absence of flaking or dandruff, absence of infestations
Skull- normal skull configuration, rounded, smooth skull contour, absence of nodules or
masses
Face- symmetrical in shape with appropriate facial expressions

EYES
General- symmetrical, sunken eyeballs, absence of discharges, or abnormal discharges,
with parallel eye movement
Eyebrows- hair growth evenly distributed, symmetric
Eyelashes- equally distributed, slightly curled outward
Eyelids- skin intact, with slight tears production
Palpebral conjunctiva- pinkish in color
Pupils- black in color; equal in size; with pupils equally round and reactive to light.

EARS
External ñ color of auricles is same as face, symmetrical, tip of the ear is aligned with the
outer canthus of the eye; pinna recoils after it†is folded

NOSE
symmetrical nares
with discharges
same color of skin as face
intact nasal septum

MOUTH AND OROPHARYNX


Lips ñ pale pink in color and slightly dry due to the hot weather
Gums - gums pink in color
Tongue- pink in color, moist, looks rough and with veins not prominent, tongue have
slight or thin white coating
Palates and Uvula- light pink, absence of swelling, uvula is positioned midline of soft
palate
Throat- no soreness and no inflammation.

NECK
head is centered, there is no difficulty of head mobility
absence of palpable lymph nodes, no distention of neck veins

INTEGUMENTARY
Skin- fair complexion, dry and warm to touch, with poor skin turgor
Nails- clean and short, smooth-textured; light pink in color; blanch test < 3 seconds; there
is no clubbing of fingernails.

CHEST
Lungs- rales on both lung lobes
Chest- symmetric, no lumps, masses and lesions noted, with full chest expansion

CARDIOVASCULAR
Heart- normal rate and rhythm
Peripheral pulses- full pulsations

GASTROINTESTINAL
Abdomen- no lesions, globular distention and with smooth texture, no lumps and no
masses noted, with normal bowel sounds as auscultated.

MUSCULOSKELETAL
Upper Extremities - Both arms are symmetrical, with capillary refill of 2 seconds.
Lower Extremities - Both legs are symmetrical, with capillary refill of 2 seconds.

May 10, 2007 (Thursday)

Vital Signs:

Pulse Rate = 37.4 bpm


Respiratory Rate = 104 bpm
Temperature = 44 oC / axillae

Physical Examination

HEAD and FACE


Hair- straight and short, evenly distributed, black in color, smooth and shiny
Scalp- absence of flaking or dandruff, absence of infestations
Skull- normal skull configuration, rounded, smooth skull contour, absence of nodules or
masses
Face- symmetrical in shape with appropriate facial expressions

EYES
General- symmetrical, sunken eyeballs, absence of discharges, or abnormal discharges,
with parallel eye movement
Eyebrows- hair growth evenly distributed, symmetric
Eyelashes- equally distributed, slightly curled outward
Eyelids- skin intact, with slight tears production
Palpebral conjunctiva- pinkish in color
Pupils- black in color; equal in size; with pupils equally round and reactive to light.

EARS
External ñ color of auricles is same as face, symmetrical, tip of the ear is aligned with the
outer canthus of the eye; pinna recoils after it†is folded

NOSE
symmetrical nares
with discharges
same color of skin as face
intact nasal septum

MOUTH AND OROPHARYNX


Lips ñ pale pink in color and slightly dry due to the hot weather
Gums - gums pink in color
Tongue- pink in color, moist, looks rough and with veins not prominent, tongue have
slight or thin white coating
Palates and Uvula- light pink, absence of swelling, uvula is positioned midline of soft
palate
Throat- no soreness and no inflammation.

NECK
head is centered, there is no difficulty of head mobility
absence of palpable lymph nodes, no distention of neck veins

INTEGUMENTARY
Skin- fair complexion, dry and warm to touch, with poor skin turgor
Nails- clean and short, smooth-textured; light pink in color; blanch test < 3 seconds; there
is no clubbing of fingernails.

CHEST
Lungs- rales on both lung lobes
Chest- symmetric, no lumps, masses and lesions noted, with full chest expansion
CARDIOVASCULAR
Heart- normal rate and rhythm
Peripheral pulses- full pulsations

GASTROINTESTINAL
Abdomen- no lesions, globular distention and with smooth texture, no lumps and no
masses noted, with normal bowel sounds as auscultated.

MUSCULOSKELETAL
Upper Extremities - Both arms are symmetrical, with capillary refill of 2 seconds.
Lower Extremities - Both legs are symmetrical, with capillary refill of 2 seconds.

DIAGNOSTIC TEST

Diagnostic
Procedures

Date ordered
Date Results in

Indication(s) or
Purposes

Results

Normal value

Analysis and Interpretation of results

Hemoglobin
DO: 05/01/07
DP: 05/01/07

Use to evaluate the hemoglobin content of erythrocytes in a given volume of oxygen


capacity of RBC

126g/L

140-180g/L

The results are below normal range This indicate that there is no enough hemoglobin in
red blood cell. There will be possible hemoconcentration from polycythemia.

WBC

DO: 05/01/07
DP: 05/01/07

It is used to detect infection or inflammation and to monitor a clientís response.

11.9

5-10x109/L

The results are above normal range indicating that there is an infection due to
inflammation.

It is now within normal range, indicating absence of possible infection.

Hematocrit
Lymphocytes

DO: 05/01/07
DP: 05/01/07

DO: 05/01/07
DP: 05/01/07

Often used in place of RBC count

Measure of the volume of Rbcís in whole blood.

Indicates if there is infection in the body

0.26

0.14

0.40 ñ 0.54 L/L

0.1 - 02

Within the normal range, indicates absence of anemia, polycythemia and abnormal
hydration state.
An increase in this component will indicate an infection.

Nursing Responsibilities:

PREPARING THE CLIENT:

Explain procedure to the patient and the purpose of the procedure


Inform the patientís SO that there is no food / fluid restriction needed.
Inform the patientís SO that the test requires blood sample, tell who will do the test and
when.
Inform that there will be a discomfort from needle puncture and pressure from the
tourniquet.

PERFORMING THE PROCEDURE:

Instruct the patientís SO not to move the arm and to remain still upon the insertion of the
needle.
Inform the patientís SO upon the insertion of the needle.

AFTER THE TEST:


Apply pressure to the punctured side
Observe the venipuncture site for bleeding.
Explain that some bruising, discomfort and / or swelling may be experienced at the site.
Instruct to apply warm compress.
Sent the specimen immediately to the laboratory.

Diagnostic
Procedures

Date ordered
Date Results in

Indication(s) or
Purposes

Results

Normal value

Analysis and Interpretation of results


Urinalysis

Color

Transparency

Specific gravity

Pus Cells

DO: 05/01/07
DP: 05/01/07

Used to detect substances or cellular material in the urine associated with different
metabolic disorders of the urinary tract

Indicates the concentration of the urine

Determines cloudiness of urine, also called opacity or turbidity

Measures urine density, Detects presence of protein in the urine

Detects urinary tract conditions such as infections, inflammation, and malignancies.

yellow
turbid

1.030

2-3 hpf

Colorless-dark yellow

turbid

1.010-1.025

0-1

The results reveals normal urine color result which indicates the patientís urine is not
concentrated

The results is increase within normal range indicating the urine is concentrated
The test reveals presence of infection

NURSING RESPONSIBILITIES:

PREPARING THE CLIENT:

Check the physicianís request.


Check the patientís name, identification, band.
Explain that this test is to look for problems with the urine and the organs that help form
it.
Advise the patientís SO to wash the perineal area prior to collecting the specimen to
avoid contamination with vaginal secretions or stool.
Inform the patientís SO that a specimen from the first morning urination is preferred
since it is usually concentrated and more likely to reveal abnormalities and formed
substances.
Describe the procedure for collecting a clean-catch or midstream specimen if indicated.

PERFORMING THE PROCEDURE:

Collect approximately 50 mL of urine, freshly voided into a clean, dry container. A fresh
specimen may be taken from a urinary catheter according to the agency policy.
Wear gloves when collecting and transferring urine specimen.
Collect a clean-catch or midstream specimen if the specimen is likely to be contaminated
by vaginal discharge, bleeding, or feces.
Seal the lid tighter, label, and place in a biohazard.
Submit the specimen immediately to the laboratory to prevent the growth of
bacteria/changes.
Follow manufacturerís instructions when using reagent or dipstick methods to test urine
for glucose, ketones, erythrocytes or leukocytes (leukocyte esterase test).

AFTER THE TEST:

Note the appearance of the specimen and document this according to policy.
Review the specimen collection process with the client (pediatric: instruct the S.O.) to
rule out contamination with other substances.
Assess the client for signs and symptoms of urinary tract infection such as dysuria,
urgency and frequency.
Evaluate related tests such as the microscopic analysis, renal ultrasound, serum glucose,
renal arteriogram, cystogram, cystourethrogram, and urine culture and sensitivity.

Diagnostic
Procedures

Date ordered
Date Results in

Indication(s) or
Purposes

Results

Normal value

Analysis and Interpretation of results

Fecalysis

DO: 05/01/07
DP: 05/01/07

Done to assess/ determine the presence of parasites in the stool.

Color:†yellow

Consistency:†Soft, watery

Ascarcis Ova: 0-1

Brown

Bulky

There should be no parasites present in the stool.

Sometimes it is normal to have a yellow color of stool.


Passage of loose watery stool indicates diarrhea. This happens because there is the
presence of bacteria in the GI tract that tries to inhibit the normal function of the GI.
Bacteria seen in the stool are indicative of parasitism.
NURSING RESPONSIBILITIES:

PREPARING THE CLIENT:

Check the physicianís request.


Check the clientís name, identification band.
Explain that the test will help find the reason for the clientís symptoms of diarrhea, gas,
or stomach pain.
Collect a stool specimen on three (3) consecutive days.
Ask the patientís SO regarding the dietary pattern, recent antibiotic therapy, or recent out-
of-the-country travel.
Instruct the client to avoid mixing urine or toilet paper with the specimen for it may alter
results.

PERFORMING THE PROCEDURE:


Instruct the client to obtain the stool specimen in a clean bedpan or specimen container.
Of the client is non-ambulatory or incontinent, collect the specimen in a clean bedpan or
from the clientís diaper. Be sure that the specimen has not been contaminated with urine.
To collect a specimen from the rectum, insert a sterile applicator past the anal sphincter,
rotate the applicator gently and allow thirty (30) seconds for the applicator to absorb the
organisms, remove the applicator, and place it in a sterile container. This method is far
less effective in obtaining an adequate specimen for analysis.
Place a one (1)-inch diameter stool specimen into a sterile container using a sterile
wooden tongue blade.
Label the specimen including the date and time of collection, suspected cause of enteritis,
and current antibiotic therapy.
Send the specimen immediately into the laboratory. If there is to be a delay of 2-3 hours,
the specimen must be put into a transport medium such as buffered saline-glycol or
alkaline peptone water.

AFTER THE TEST:

Monitor the clientís temperature if a pathogenic organism is suspected.


Place the client in isolation if the test is positive for Salmonella, Shigella, Campylobacter,
Yersinia, Vibrio, or Clostridium.
Monitor consistency and amount of stool.
Monitor for signs and symptoms of dehydration and electrolyte depletion if the client is
having diarrhea.

III. ANATOMY AND PHYSIOLOGY


THE DIGESTIVE SYSTEM

The digestive tract is basically a hollow muscular tube, mucosal epithelium lining the
inner surface, and circular and longitudinal muscle comprising the walls. The mucosa,
forming the inner lining of the tract, is supplied with a rich network of blood vessels,
nerve fibres and endocrine cells. Epithelial cells (specialized for both absorption and
secretion depending on their location in the digestive tract) cover this mucosal layer. The
serosa is a layer of connective tissue covering the tract on the outside.
In the mouth, food is broken down to small pieces and worked upon by digestive
enzymes in the saliva. After chewing, the food is passed along the digestive tract by
muscular action and mixed with further enzymes. These enzymes digest carbohydrates,
fats and proteins. The end products of digestion include glucose, amino acids, fats,
glycerol and fatty acids. These are absorbed through the gut wall and transported to the
cells by the blood stream. The movement and mixing of food in the digestive tract, and its
elimination, is brought about primarily by the contractions of smooth muscle. Striated
muscle, however, is involved in the mouth, pharynx and upper esophagus and external
anal sphincter.
The Oral Cavity
Oral mucosa lines the oral cavity. A layer of keratinized cells covers the upper
surface of the tongue and the hard palate. The mucosa lining the cheeks, undersurface of
the tongue and lips is quite thin and delicate. Nutrient absorption does not occur in the
mouth but drugs such as nitroglycerine can be administered via the mucosa inferior to the
tongue. Hard and soft palates form the roof of the mouth. The tongue forms the floor.
Three pairs of salivary glands secrete into the oral cavity. Saliva is mainly water. It also
contains electrolytes, buffers, proteins, antibodies, enzymes and waste products. Saliva
has several functions. These include:
Cleansing of the oral cavity.
Maintenance of pH preventing acid build up produced through bacterial action.
The control of bacterial population. Reduction in saliva can lead to infection.
The Esophagus
The esophagus is a thin walled tube attaching the pharynx to the stomach. It
consists of striated muscle at the top and smooth muscle at the bottom. When food is
swallowed, the sphincter in the upper portion of the esophagus relaxes and peristalsis
propels food through the esophagus. If food particles remain in the esophagus following
this wave of peristalsis, another wave of peristalsis is stimulated which sweeps food
through into the stomach. The sphincter at the upper end of the stomach prevents the
regurgitation of food from the stomach back into the esophagus. The final few
centimeters of the esophagus are actually in the abdominal cavity. Therefore, when
abdominal pressure increases e.g. when coughing, this terminal section of the esophagus
is compressed and stomach contents are not forced to enter into the esophagus.
Stomach
The stomach is divided into three areas:
The fundus
The body
The pyloric antrum.
The fundus and body are quite thin walled and act as a reservoir for ingested food.
The pyloric antrum has thick walls and strong waves of contraction occur during the
digestion of a meal. The food is mixed with gastric juices and then passes from the
stomach to the duodenum via the pyloric canal. A band of smooth muscle circles this
canal and is called the pyloric sphincter.
Following ingestion of a meal, the body and fundus distend. Ripples of
contraction (occurring about three times a minute) then begin in the middle of the
stomach forcing the food towards the pyloric antrum and pyloric canal. These peristaltic
waves occur approximately three times a minute and become greater in intensity as they
reach the pyloric canal. Therefore, every twenty seconds, a portion of the stomach
contents is pushed towards the pyloric canal. It is then propelled into the intestine. As the
pyloric sphincter contracts, the mixture is pushed back into the body of the stomach. This
mixture becomes reduced into chyme, a semi-fluid substance and each minute, 6-10ml of
chyme is emptied into the intestine.
Small Intestine
The small intestine is approximately 6 metres in length and is divided into:
Duodenum (the section closest to the stomach)
Jejunum
Ileum (the last segment of the small intestine)
Nearly all the nutrient absorption occurs in the small intestine. Segmentation,
rather than peristalsis, is seen in the small intestine. As a result of the contraction of
circular muscle at several points along this structure, the small intestine is divided into a
number of sacs. The circular muscles then contract at different places and this causes the
chyme to be pushed backwards and forwards and mixed with digestive enzymes.
Longitudinal muscles also contract and relax and massage the contents of the intestine.
The movement of chyme through the small intestine is very slow. This allows digestion
and absorption of food. The first food residues reach the end of the small intestine about
three to four hours following ingestion.
Large Intestine
The large intestine is approximately 1.5 m long and 7.5cm wide. It is comprised
of three parts:
Caecum
Colon
Rectum
The ascending colon travels up the right side of the abdomen towards the inferior
surface of the liver. It then turns sharply to the left and becomes the transverse colon. As
the transverse colon reaches the left side of the body, and nears the spleen, it turns down
the left side of the abdomen and becomes the descending colon. This then becomes the
pelvic colon, the rectum and finally the anus. Each day approximately 500ml of food
material, or chyme, enter the caecum. The longitudinal muscle of the large intestine
forms three strips. These muscles are not as long as the colon itself. Therefore, the wall of
the intestine becomes puckered and pouches called haustra are formed. Peristaltic
movements of the large intestine tend to be slow, and non-propulsive. This aids
absorption and storage functions. Haustral contractions, occurring at intervals of
approximately thirty minutes, shuffle the contents of the intestine back and forth. Large
contractions called mass movements occur three to four times a day. This drives the
colonic contents forward for storage in the rectum.
The large intestine actively absorbs sodium from the ascending and transverse
colon. This is then followed by the passive absorption of chloride and water. About
350ml is absorbed from the 500ml of chyme entering the colon, 150g of faecal material
then has to be eliminated. This includes 100g of water and 50g of solids. The length of
time the food residue remains in the large intestine will determine the amount of water
absorbed.The large intestine also secretes an alkaline mucus. This lubricates the faeces
and facilitates their passage through the intestine. The mucus also contains bicarbonate
which maintains colonic pH. The mucosa is also protected by the bicarbonate, which
neutralizes acids produced by bacterial fermentation.
Defecation
Stretch receptors of the rectal walls are stimulated as a result of mass movements.
This initiates the defecation reflex. Defecation occurs when relaxation of the smooth
muscle of the internal anal sphincter, and relaxation of the skeletal muscle of the external
anal sphincter occurs. Voluntary control of the skeletal muscle of the external sphincter
allows an individual to prevent defecation.
Bacterial activity
Many bacterial species colonise the large intestine and form a symbiotic
relationship with man each deriving some benefit from the other. However, this natural
flora can become pathogenic if introduced into other parts of the body. Thus, their
presence distorts the normal functioning of the digestive tract which may lead to the
development of the symptoms of gastrointestinal disorders such as nausea, vomiting,
diarrhea, etc.
IV. THE PATIENTíS ILLNESS

A. Schematic Diagram (Book-Based)

Predisposing Factor
Precipitating Factor
Age- children & elderly
Environment

Antibiotic Therapy
Food Handling
Increase motility Microorganisms attach and enter mature enterocytes
serotonin release
of intestines at the tips of small intestinal villi

stimulates
chemoreceptor
PAIN Structural changes to the small bowel mucosa and
trigger zone
& BORBORYGMIA inflammation of the lamina propria

VOMITING
BACTEREMIA Bacteria invades blood stream across lamina propria
Increase WBC
Mucosal Cell Destruction Bacteria releases endotoxin Releases
pyrogens that stimulates hypothalamus
Bloody Stools Increase amount of diarrheal Fluid
FEVER
Active Secretion of Chloride
Inhibition of Na & water reabsorption
& Bicarbonate Ions

DIARRHEA
Schematic Diagram (Patient-centered)

Predisposing Factor
Precipitating Factor
Age (children) -8 months old
Environment (poor sanitation)
Food Handling (dirty finger nails)
Increase motility Microorganisms attach and enter mature
enterocytes serotonin release
of intestines at the tips of small intestinal villi

stimulates
chemoreceptor
PAIN Structural changes to the small bowel mucosa and
trigger zone
(April 29- May 02, 2007) inflammation of the lamina propria

VOMITING (April 27- May 4, 2007))

BACTEREMIA Bacteria invades blood stream across


lamina propria Increase WBC 12.2 x 109/L
(May 01, 2007)
Bacteria releases endotoxin Releases
pyrogens that stimulates hypothalamus
Increase amount of diarrheal Fluid
FEVER (April 27- 4,9, 2007)

Active Secretion of Chloride


Inhibition of Na & water reabsorption
& Bicarbonate Ions

DIARRHEA
(April 27- May 9, 2007)
SYNTHESIS OF THE DISEASE

DEFINITION OF THE DISESE (Book-based)

Acute Gastroenteritis (AGE) a ìdiarrhealî disease of rapid onset, with or without


accompanying symptoms or signs such as nausea, vomiting, fever, or abdominal pain.
The hallmark of the disease is increased stool frequency with alteration of stool
consistency. It is also called ìinflammation of the GITî. It is an illness of fever, diarrhea,
and or vomiting caused by an infectious virus, bacterium or parasite. It is usually of acute
onset, normally lasting less than 10 days and self-limiting. Pathogens that cause the
disease (AGE) are transmitted by the fecal-oral route, from person to person, and through
ingestion of fecally contaminated food and water. GI infections such as AGE are often
referred to as ìfood poisoningî because food is frequently the vehicle for transmission of
actively growing microbes or their toxins. Common bacterial sources of contaminated
foods are eggs (salmonella), raw or undercooked meat (E-coli) and chicken
(campylobacter jejuni). Unpasteurized milk, apple juice, ice cream, and mayonnaise are
also sources of food borne infection such as AGE. Other causative organisms are Vibrio
cholerae (cholera), shigella bacilli (dysentery), and staphylococcus food poisoning). The
incubation period for all viral and bacterial infections ranges from 6hrs. to 4 - 5 days.
Other factors that increase the risk of acute gastroenteritis in children include at day care
centers and impoverished living conditions with poor sanitation.

PREDISPOSING/ PRECIPITATING FACTORS (Patient-centered)

The disease started with the predisposing factors ñ age of the patient (since he is just 8
months old which is the Oral Stage wherein infants like our patient are satisfying their
pleasure of oral phase so they tend to eat everything they see and would recognize as
food for them and his immune system is still in its maturation state; thus, he still has
decreased capacity to fully protect herself from possible illness). As with the
precipitating factors, socio-economic as in one reason since the family does not have
means for providing proper hygiene and supplemental care to the patient. Another would
be their poor environmental sanitation. Cleanliness in a household and sanitary ways of
food preparation, Mother A has a dirty fingernails which she doesnít mind when she
prepares the foods that they eat ([predisposing factors that could lead to the clientís
condition is mainly in the exposure of microorganism such as E.coli, Shigella,
Salmonella, Clostridium and Campylobacter jejuni. Such microorganism can be present
due to improper food cooking and preparation of food) can eliminate possible illness and
will help the childís immune system fight pathogens. In the case of Baby Potpot, limited
space of living condition, eating non-nutritious food due to financial crisis and lack of
knowledge of the parents regarding the prevention of disease.

When the foreign object, such as a certain microorganism enters the body of the
patient, this microorganism (bacteria) then secretes endotoxins which will invade and
destroy the epithelial cells of the intestine. The mucosal cell will stimulate fluid cells and
electrolytes, thus destroying the parietal cells of the intestines causing the gastrointestinal
tract to be irritated. The destruction of the parietal cells will lead to a sudden decrease in
the production of intrinsic factor. This factor usually absorbs vitamin B12, and if there is
decrease in its production then there will also be decreased absorption of Vitamin B12. In
terms of the change in gastric motility, as a compensatory mechanism of the body, the
stomach will be inflamed so as to expel the toxins secreted by the microorganism.

SIGNS AND SYMPTOMS

Book-based: The major clinical manifestations of AGE are diarrhea of varying


degrees and abdominal pain and cramping. Associated with clinical manifestations are
nausea, vomiting, fever, anorexia, distention, tenesmus (staining on defecation), and
borborygmi (hyperactive bowel sound). In terms of the varying degrees of diarrhea, it
may be mild (2 to 3 stools per day) or intense more than 10 watery stools per day. While
nausea, vomiting and anorexia may be a result of abdominal distention caused by
increased fluid content and undigested food. Abdominal pain, cramping and borborygmi
may occur from gas released from undigested food, irritation of bowel mucosa, and
distention of the intestines. The client may have a fever, depending on the causative
organism as well as mucus and varying amounts of blood.

PATIENT-CENTERED:

Signs and Symptoms with Rationale

Before Baby Potpotís admission to a government hospital in City of San


Fernando, he was experiencing intermittent fever with accompanying vomiting of
previous ingested food. AGE also had three times greenish, soft, mucoid, foul smelling
stool. Aside from these, he also manifested slightly sunken eyeballs and dry oral mucosa
which could serve as early signs of dehydration due to excessive fluid loss brought about
by diarrhea. Abdominal pains, weakness and increase in WBC count were also evident in
the laboratory test and other signs and symptoms manifested by the clientís condition
includes:

Nausea and vomiting results from conditions an increase tension in the walls of the
stomach, duodenum, or lower end of the esophagus.
Loose bowel movement can be caused by increased peristalsis resulting from and
increased gastrocotic reflex or from the effort of the stomach and intestine to eliminate a
local irritation.
Since our patient has continued episodes of diarrhea and vomiting, he
became dehydrated since his bodyís compensatory mechanism failed to restore
blood volume and the needed fluids and electrolytes for proper functioning.
Thus, the patient is also risk for an impending anemia since there was a
decrease value in his hematocrit which is 0.30 (normal value is 0.42 ñ 0.57), also
in his hemoglobin count of 100 g/L (normal value is 140 ñ 180g/L)
Dehydration is due to excessive loss of fluid through unmonitored severe vomiting and
diarrhea.
Abdominal pain because of the pain that starts in the epigastrium or periumbilical region.
It then shifts to the right lower quadrant as the inflammatory process spreads to involve
the serosa layers of the bowel, thereby bringing the inflammatory process into contact
with the peritoneum.
Fever / Hyperthermia is the bodyís defense mechanism in order to combat an infection.

HEALTH PROMOTION AND PREVENTIVE ASPECTS OF THE DISEASE

Health promotion actions for avoiding the disease involve instructing clients
about (1.) good hand-washing technique after defecation and before handling food and
(2.) obtaining available vaccinations against bacterial and viral gastroenteritis.
Encouraging cleanliness and sanitation as well as proper food handling, preparation and
storage techniques such as cooking meats to 150 degrees F, cooking chicken 170 degrees
F, and not allowing food to sit at room temperature for long periods are ways of
preventing the occurrence of the disease. Also, warning the clients not to eat food
containing raw eggs and to refrain from buying cans, boxes, or jars that are damaged is
good preventive measure. Advise clients to avoid the use of antibiotics over a long period
of time, to prevent more serious complications.

Health maintenance activities include the assessment of the clients who are
receiving high or continued doses of antibiotics for manifestations of GI infections such
as AGE secondary to antibiotic use. Health restoration interventions involve clients to
follow their medication regimen and to call their health care provider if 1.)
Manifestations continue for several days, 2.) They might be dehydrated, or 3.) Body
temperature is higher than 100 degrees F; are ways to help them maintain good health
condition. Promoting bowel rest and replacement of fluids and electrolytes as needed as
an important consideration.
V. The Patient and His Care

1. Medical Management

A. IVF, Oxygen Therapy and Traction

MEDICAL MANAGEMENT

DATE ORDERED
DATE PERFORMED
DATE CHANGED
GENERAL DESCRIPTION

INDICATION/
PURPOSES

CLIENTíS RESPONSE TO THE TREATMENT

IVF

D5L.3NaCl
45-47 ugtts/min

D5IMB
24-25 ugtts/min

DO: 05/01/07
DP: 05/01/07
DC:05/03/07
DO: 05/03/07
DP: 05/03/07

This solution is considered hypertonic if not introduced inside the body, but a hypotonic
once inside the body.†Have less osmolarity than serum (i.e., it has less sodium ion
concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water
is then pulled from the vascular compartment into the interstitial fluid compartment.

Hypertonic solution that exerts less osmotic pressure than that of blood plasma. This
solution draws water from the intracellular compartments to the extra cellular
compartment and causes cells to shrink

>Use as a route in administration of Intravenous medications.


>To maintain Fluid and electrolyte imbalance and for hyponatremia

> It is indicated to replace fluid loss due to consecutive fever and is given to help meet
caloric requirements and as a means for administering medications.

The patient maintained a normal hydration status.


The patient maintained a normal hydration status.

NURSING RESPONSIBILITIES:

When inserting an IV line to a patient, always prepare all the materials to be used prior to
the insertion.
Wash hands thoroughly before performing the procedure.
Identify the correct patient by checking the name on the chart or by asking directly the
patient.
Explain the procedure to the patient.
Insert the IV catheter accordingly.
Regulate and monitor infusion rate.
Monitor patientís therapeutic response to treatment.
Check the IV insertion site for signs of infiltration, bulging, heat, pain and redness.
B. DRUGS

NAME OF DRUGS:
GEN. NAME
BRAND NAME
DATE ORDERED DATE TAKEN DATE CHANGED

ROUTE, DOSAGE & FREQUENCY


GEN.ACTION
FXNAL CLASSíN MECHANISM OF ACTION

INDICATION(S)/ PURPOSE(S)

CLIENTS RESPONSE TO MED.W/ACT-UAL SIDE EFX

AMPICILLIN
( Ampicin )

DO: 05-01-07
DT: 05-01-07 to
05-08-07
(Start at 1:30 pm)

RDA: IV
DFA: 250 mg q6
ANST (-)

ANTIBIOTIC/ ANTIINFECTIVE
Inhibits cell wall synthesis during bacterial multiplications.

Used for infections of GI. (Used parenteral route only for moderately severe to severe
infections.

Client responded to medication with some diarrhea, agitation, nausea and vomiting, and
vein irritation.

PARACETAMOL
ACETAMINO-PHEN OR DICLOFENAC SODIUM
(Aspirin,Tempra)
DO: 05-01-07
DT: 05-01-07
05-02-07
05-03-07
05-04-07
05-09-07

RDA: IV
DFA: 75 mg q4
Fever (PRN)

ANTIPYRETIC
Reduces fever by direct action on hypothalamus heat regulating center with consequent
peripheral vasodilation, sweating, dissipation of heat

Used for fever reduction

Since pt.sí temperature is within normal range, the drug was not administered.

NAME OF DRUGS:
GEN. NAME
BRAND NAME
DATE ORDERED DATE TAKEN DATE CHANGED

ROUTE, DOSAGE & FREQUENCY


GEN.ACTION
FXNAL CLASSíN MECHANISM OF ACTION

INDICATION(S)/ PURPOSE(S)

CLIENTS RESPONSE TO MED.W/ACT-UAL SIDE EFX

AMIKACIN SULFATE ( Amikin )

DO: 05-01-07
DT: 05-02-07 to
05-05-07

DC: 05-06-07
RDA: IV
DFA: 75 mg q12

AMINOGLYCOSIDE Inhibits protein synthesis by binding directly to the 30S ribosomal


subunit; bactericidal.

Used for serious infections of GI.

The patient did not experience signs of side effects or any adverse reactions aside from
vein irritation from the drug.

GENTAMICIN SULFATE
( Garamycin )

DO: 05-01-07
DT: 05-01-07 to
05-08-07
(start at 10 am)

RDA: IV
DFA: 55 mg q12
ANST (-)

ANTIBIOTIC
Action is usually bactericidal. Active against gram (-) such as E. coli and gram (+) such
as Aureus.

Parenteral; use restricted to treatment of serious infections of G.I. Has been used in
combination with other antibiotics.

Patient may respond to med. By manifesting effects such as nausea and vomiting and
rash.

NURSING RESPONSIBILITIES FOR DRUGS (AMPICILLIN):

PRIOR TO ADMISSION:
Monitor vital signs. Before therapy begins, determine previous hypersensitivity reactions
to penicillins, cephalosporins and other allergens.
Culture and sensitivity test should be done before administration.
IV preparation: Ampicillin may be reconstituted with sterile or bacteriostatic water for
injection. Solutions for direct IV should be administered within 1 hour after preparation.
The reconstituted solution must be added to suitable IV fluid such as 0.9 NaCl or LRS.
Verify correct IV concentration with physician.

DURING ADMININISTRATION:
Culture and sensitivity test should be done periodically during therapy.
Administration of drug by direct IV should be done slowly over at least 10-15mins. Drug
maybe further diluted and given over is 30mins. Rapid administration can result in
seizures.
Administer drug by considering right drug, right route, right time and right dosage.
Observe right patient, right drug, right dose, right route and right time of drug
administration.

AFTER ADMINISTRATION:
Inspect skin daily and instruct patientís SO to do the same. The appearance of a rash
should be carefully evaluated to differentiate an ampicillin rash from hypersensitivity
reaction. Report promptly to physician if it appears.
Observe for more serious adverse effects of the drug and consult physician immediately.
Advice patientís SO to report diarrhea with a detailed onset duration and character of
stools, associated symptoms, patientís temperature, and weight to note any possibility of
drug-induced potentially fatal pseudomembranous colitis.
If no improvement is noted within a few days after therapy is started, physician should be
notified.
Nursing Responsibilities for Drugs (PARACETAMOL):

PRIOR TO ADMISSION:
Monitor vital signs
Observe aseptic technique of drug administration.
Prepare all materials needed for administration.
Explain procedure to patientís SO.

DURING ADMINISTRATION:
Observe right patient, right drug, right dose, right time and right route of drug
administration.
For IV push: administer the drug at least 1-7mins. So as to lessen pain for the patient.

AFTER ADMINISTRATION:
With high doses or long term therapy, periodic tests of hepatic, renal and hamatopoitic
function are advised.
The drug should not be used for self-medication of pain of more than 5 days in children
and for fever persisting longer than 3days and never for the fever over 39.5C or for
current fever without medical direction.
No more than 5 doses should be given to children unless prescribed by physician.
Note for presence of adverse effects and notify physician promptly.
Nursing Responsibilities for Drugs (AMIKACIN SULFATE):

PRIOR TO ADMINISTRATION:
Monitor vital signs
Observe aseptic technique of drug administration.
Prepare all materials needed for administration.
Explain procedure to patientís SO.
Amount of infusion fluid may be proportionately smaller depending on patientís needs
but should be sufficient to be infused over the same time period as for adults.

DURING ADMINISTRATION:
Observe right patient, right drug, right dose, right time and right route of drug
administration.
Cultured and susceptibility test should be performed initially and periodically during
continued therapy. Therapy may begin pending results.
Observe aseptic technique in giving the medication.

AFTER ADMINISTRATION:
Monitor IO report oliguria, unusual appearance of urine, change in IO ratio or pattern and
presence of edema.
Report untoward reactions or adverse response to physician immediately.

Nursing Responsibilities for Drugs (GENTAMICIN SULFATE):

PRIOR TO ADMINISTRATION:
Monitor vital signs
Observe aseptic technique of drug administration.
Prepare all materials needed for administration.
Explain procedure to patientís SO.
Amount of infusion fluid may be proportionately smaller depending on patientís needs
but should be sufficient to be infused over the same time period as for adults.
Gentamicin is stable for 24hrs at room temperature in 0.9% NaCl or 5% dextrose
injection or other IV fluids recommended by manufacturer.
Gentamicin for IV is clear and colorless or slightly yellow. Do not use solutions that are
discolored or that contain particulate matter.

DURING ADMINISTRATION:
Observe right patient, right drug, right dose, right time and right route of drug
administration.
Cultured and susceptibility test should be performed initially and periodically during
continued therapy. Therapy may begin pending results.
Observe aseptic technique in giving the medication.
AFTER ADMINISTRATION:
Monitor IO report oliguria, unusual appearance of urine, change in IO ratio or pattern and
presence of edema.
Blood specimens for peak serum gentamicin concentrations are general drawn 30min
after completion of a 30-60min IV infusion.
Report untoward reactions or adverse response to physician immediately.
C. DIET

Type of Diet

Date Ordered
Date Started

General Description

Indication/
Purpose

Specific foods taken

Clientís response to the treatment

Diarrheal Diet

DO: 05/02/07
DP: 05/02/07

Patient is allowed to eat foods that are sufficient enough in calorie to nourish the body:
BRAT diet

It is indicated for the patient to provide nutrition and for the patient to have adequate
materials for fast recovery.

The patient was able to eat well in moderation the foods available and maintain
hydration.

NURSING RESPONSIBILITIES:

Explain why diet is desired to client.


Instruct patient and SO to eat healthy foods to promote wellness except those allergic to
the patient.
Explain to the patient foods that are good for fast recovery.
Instruct SO to observe strictly the diet to improve the nutrition of the patient.

Type of Diet

Date Ordered
Date Started
Date Changed

General Description

Indication/
Purpose

Specific foods taken

Clientís response to the treatment

NPO

DO: 05/01/07
DP: 05/01/07

Foods and fluids are restricted.

To decrease gastric acid of the patient.

Compliant to treatment.
NURSING RESPONSIBILITIES:

Instruct patient or SO not to allow the patient to drink or eat.


Explain the procedure to the client/SO.
Instruct SO to wet lips of the patient with the use of cotton to prevent drying of the lips.
Instruct to provide mouthwash for oral care.

D. EXERCISE

Type of Exercise

Date Ordered
Date Performed

General Description

Indication/
Purpose

Clientís response to the treatment

Complete bed rest

DO: 05/01/07
DP: 05/01/07
It requires the patient to rest in bed.

To help the patient maintain energy level due to the loss of essential electrolytes.

The patient stayed on bed.

NURSING RESPONSIBILITIES:

When instructing a patient on complete bed rest, tell him that he has to stay in bed as
ordered by the doctor.
Explain to the patient the purpose of the order given by the doctor.
Instruct the SO to assist patient to frequently change position at least every 2 hours to
prevent ulcers and to promote circulation and perfusion. Thus, maintaining the traction in
place.
Instruct the patientís SO on the voiding of the patient.
Encourage divertional activities to prevent boredom.
B. Nursing Management

1. Nursing Care Plans

Problem #1: Ineffective airway clearance related to obstructed airway due to secretions of
the bronchi.
Assessment
Nursing Diagnosis
Scientific Explanation

Objective
Nursing Intervention

Rationale
Expected Outcome

S> èЍ
O:the patient may manifest the ff:
>Dyspnea
>Changes in respiratory rate and rhythm
>Abnormal breath sounds
>Use of accessory muscles
>Productive cough
>Restlessness
>(+) rales
>Nasal discharge

Ineffective airway clearance related to obstructed⁡楲睡礠


d airway due to retained secretions in the bronchi.

The inflammation and increased secretions make it difficult to maintain a patent airway.
Alveolar exudates tend to consolidate, so it is increasingly difficult to expectorate.

Short Term:
After 4 hours of nursing interventions, patientís SO will be able to identify behaviors to
achieve airway clearance.

Long Term:
After 1 week of nursing interventions, patient will demonstrate patent airway with breath
sounds clearing, absence of dyspnea.

>Establish rapport

>Monitor Vital signs

>Assess rate/depth of respirations and chest movement.

>Elevate head of bed, change position frequently.

>Assist patient with frequent deep-breathing exercises.


>Administer medications as indicated.

>Regulate IV as ordered
>To obtain ptís trust

>To obtain baseline data

>Tachypnea, shallow respirations, and asymmetric chest movement are frequently


present because of discomfort of moving chest wall and/or fluid in lung.

>Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization


and expectoration of secretions.
>Deep breathing facilitates maximum expansion of lungs/smaller airways.
>Aids in reduction of bronchospasm as well as mobilization of secretions.
>to replace fluid loss

Short Term:
After 4 hours of nursing interventions, patientís SO shall have identified behaviors to
achieve airway clearance.
Long Term:
After 1 week of nursing interventions, The patient shall have demonstrated patent airway
with breath sounds clearing, absence of dy
yspnea,

Problem #2: Hyperthermia related to Dehydration

Assessment
Nursing Diagnosis
Scientific Explanation
Objective
Nursing Intervention
Rationale
Expected Outcome

S:èЍ
O: the pt. manifest the ff:

>Skin warm to touch

>Appears weak

>Flushed skin

>Increase RR
>Colds
>T- from 36.4ÚȠto 39Úɣ

Hyperthermia related to dehydration

Increase in body temperature was caused by infection. These organisms induce most cells
to produce fever. The substance produces increase in temperature stimulation of 桹灯瑨

hypothalamic thermo regulatory center and produce action of prostaglandin.

Short term:

After 6 hrs. of NI, pt. will maintain core temperature within normal range.

Long term:
After 3 days of NI, the pt. will be free of seizure activity

>Establish rapport

>Monitor Vital signs

>Monitor Temperature

>Provide TSB

>Loosen tight clothing

>Maintain bedrest

>Increase fluid intake


>Administer antipyretics

>Regulated IV as ordered

>To obtain ptís trust

>To obtain baseline data

>To evaluate degree of hyperthermia

>To promote heat loss

>To promote heat loss

>Promote relaxation and comfort

>To prevent DHN

>To reduce fever

>to replace fluid loss

Short term:

After 6 hrs. of NI, pt. shall have maintained core temperature within normal range.

Long term:

After 3 days of NI, The patient shall have free of seizure activity

Problem #3:†Fluid Volume Deficit


Assessment
Nursing Diagnosis
Scientific Explanation
Objective
Nursing Intervention
Rationale
Expected Outcome

S: ÿ
O:patient manifeste
ed:
>pale and weak in appearance
>decreased skin turgor
>pale conjunctiva and mucous membrane
>dry skin and mucous membrane
>poor muscle tone
>weight loss
> episodes of semi solid bowel movement
> with vital sign as follow:
T- 36.4˚c
RR- 35 breaths/min.
PR㠹戠洯
- 98 b/min.

Fluid volume deficit R/T active fluid volume loss secondary to acute gastroenteritis

The pathophysiology of dehydration is seen when the normal compensation for fluid loss
in the bloodstream cannot be corrected by stored fluids elsewhere.†When fluids are lost
from the intravascular spaces due to lack of intake or excess loss, interstitial fluids move
in to restore vascular volume.†Because the actual volume of fluid in the interstitial space
is limited, other compensation systems are initiated to restore volume.†ADH and
aldosterone secretion increase to reabsorb water and sodium in the kidney.†Fluids are
also reabsorbed from the ileum and large colon.†The baroreceptor sense low blood
pressure, and the sympathetic nervous system is stimulated to increase peripheral
vasoconstriction and heart rate.†Vasoconstriction moves fluids from the periphery into
circulation.†When fluid losses continue or when the compensation fails to restore blood
volume, the person becomes dehydrated.

Short term:
After 4 hours of NI, the SO will be able to verbalize and demonstrate behaviors needed to
monitor and correct deficit

Long term:
After 3 days of NI, the pt. will be able to maintain fluid volume at a functional level

>Establish rapport

>Monitor and record VS

>Assess pt.ís general condition

>Encourage increase in fluid intake


>Emphasize proper food handling

>Provide skin care with emollients

>Provide frequent oral care

>Administer medications as indicated

>Regulate IVF as indicated

>Instruct on DAT diet as ordered.

>In order to gain the pt.ís and SOís trust

>To obtain baseline data

>To determine plan of care for the patient

>To replace fluid losses and prevent dehydration

>To aid in Diarrhea that causes excessive fluid loss

>Prevent food contamination and prevent further infection in the GIT

>To lessen dryness of skin

>To prevent injury from dryness

>To promote recovery and provide comfort to pt.

>To replace fluid losses and to prevent dehydration

Short term:
After 4 hours of NI, the SO shall have verbalized and demonstrated behaviors needed to
monitor and correct deficit
Long term:
After 3 days of NI, the pt. have maintained fluid volume at a functional level
Problem #4:†Diarrhea
Assessment
Nursing Diagnosis
Scientific Explanation
Objective
Nursing Intervention
Rationale
Expected Outcome

S:>ìMatubig nga yung tae nya ehî


O:Patient manifested:
>passed out loose watery stools 3-4 times a day
>abdominal pain upon palpation
>pale conjunctiva and mucous membranes
>dry skin and mucous membranes

Diarrhea R/T inflammation in the GIT

Inflammation or irritation in the intestine (GIT) is caused by increased peristalsis


resulting from an increased gastro colic reflex or from the effort of the stomach and small
intestines to eliminate local irritant.†Pathogens that cause tissue damage and
inflammation by releasing endotoxins stimulate the mucosal lining of the intestine,
resulting in greater secretion of water and electrolytes into the intestinal lumen.†The
active secretion of chloride and bicarbonate ions in the small bowel leads to inhibition of
Na reabsorption.†To balance the excess sodium, large amounts of protein-rich fluids are
secreted in the bowel, overwhelming the large bowelís ability to reabsorb the fluid and
leading to diarrhea.

Short term:
After 2 hours of NI, the pt.ís SO will be able to verbalize understanding of causative
factors and rationale for treatment regimen.

Long term:
After 1 day of NI, the pt.ís SO will be able to demonstrate appropriate behavior to assist
with resolution of causative factors

>Establish rapport

>Monitor and record VS


>Assess pt.ís general status

>Restrict solid food if indicated

>Provide for changes in dietary intake

>Encourage increase intake of fluids

>Emphasize proper food preparation (proper food preparation and avoidance of irritating
foods)

>Review causative factors and appropriate interventions

>Administer medications as indicated

>Regulate IVF as indicated

>In order to gain the pt.ís and SOís trust

>To obtain baseline data

>To determine the plan of care for the patient

>To allow for bowel rest/ reduce intestinal workload

>To avoid foods that precipitate diarrhea

>Replace fluid and electrolyte losses and to prevent dehydration

>To prevent food contamination and prevent further infection in the GIT

>To prevent recurrence of the problem

>To promote recovery, provide comfort and decrease gastrointestinal motility

>To replace fluid losses

Short term:
After 2 hours of NI, the pt.ís SO shall have verbalized understanding of causative factors
and rationale for treatment regimen.
Long term:
After 1 day of NI, he pt.ís SO shall have demonstrated appropriate behavior to assist with
resolution of causative factors (proper food preparation and avoidance of irritating foods)

Problem #5:†Imbalanced Nutrition, less than body requirements


Assessment
Nursing Diagnosis
Scientific Explanation
Objective
Nursing Intervention
Rationale
Expected Outcome

S:> ìmeyayat ya pin ehî


O: patient manifested:
>pale conjunctiva and mucous membranes
>dry skin and mucous membranes
>weight loss
> decreased subcutaneous fat

Imbalanced nutrition less than body requirements R/T inability to digest food.

Malnutrition is usually associated with the presence of acute or chronic disease.†It could
also be related to socio-economic factors, physiologic changes in nutrient absorption or
nutrient requirements, or medical therapies used to treat disease.†Malnutrition can
develop over weeks to months, or it can develop more quickly when coupled with severe
stress and illness.†When the primary deficit is in energy balance, the result is, first, the
depletion of adipose tissue or fat stores, with eventual loss of lean body tissue and
fatigue.†This deficit is reflected in weight loss.

Short term:
After 2 hours of NI, the SO will be able to verbalize and demonstrate understanding of
health teachings given.
Long term:
After 2 days of NI, the SO will be able to demonstrate behaviors or lifestyle changes to
regain/ maintain pt.ís appropriate weight.

>Establish rapport

>Monitor and record VS


>Assess pt.ís general status

>Determine factors that may affect appetite

>Assess the pt.ís wt. and body built

>Instruct the mother to give cheap but nutritious foods

>Encourage client to choose foods that are appealing

>Avoid foods that cause intolerances/ increase gastric motility.

>Promote relaxing, pleasant environment

>Prevent/ minimize unpleasant odors/sights

>Assist in developing individualized regimen

>Administer medications as indicated

>Regulate IVF as indicated

>In order to gain the pt.ís and SOís trust

>To obtain baseline data

>To determine plan of care for the patient

>Eliminate factors that may cause pt.ís poor appetite

>To obtain comparative data

>In order to regain and maintain pt.ís appropriate weight

>To stimulate appetite

>Such foods could hinder the absorption of nutrients

>To enhance intake and stimulate appetite

>May have a negative effect on appetite/eating habits


>To correct/control underlying causative factors

>To provide comfort and promote recovery

>To replace fluid and electrolyte losses

Short term:
After 2 hours of NI, the SO shall have verbalized and demonstrate understanding of
health teachings given.
Long term:
>After 2 days of NI, The SO shall have demonstrated behaviors or lifestyle changes to
regain/maintain pt.ís appropriate weight.
.

Problem #6:†Bowel Incontinence


Assessment
Nursing Diagnosis
Scientific Explanation
Objective
Nursing Intervention
Rationale
Expected Outcome

S: ÿ
O: patient manifested:
>fecal odor
>fecal staining of clothing/ bedding
>inability to recognize the urge to defecate
>hyperactive bowel sound
> loose liquid stools per day
>abdominal pain

Bowel Incontinence R/T diarrhea

Diarrhea or passage of loose liquid stools for more than 3 times in one day is caused by a
gastrointestinal inflammation or irritation.†The consistency of stool causes bowel
incontinence

Short term:
>After 2 hours of NI, the SO will be able to verbalize understanding of the causative
factors and identify appropriate interventions needed.
Long term:
>After 2 days of NI, the SO will be able participate in therapeutic regimen to control
incontinence

>Establish rapport

>Monitor and record VS

>Assess pt.ís general condition

>Note stool characteristics (color, odor, consistency, amount, frequency)

>Encourage SO to record time at which incontinence occurs

>Provide for changes in dietary intake

>Encourage increase in fluid intake

>Emphasize proper food preparation

>Review causative factors and appropriate interventions

>Provide incontinence paces/aids

>Provide pericare

>Administer medications as indicated

>Regulate IVF as indicated

>Instruct on DAT diet as ordered.

>In order to gain the pt.ís and SOís trust


>To obtain baseline data

>To determine plan of care for the patient

>To obtain comparative data

>To note relationship to meals, activity, and clientís behavior

>To avoid foods that precipitate diarrhea

>To replace fluid and electrolyte losses and prevent dehydration

>To prevent food contamination and prevent further infection of the GIT
>To prevent recurrence

>To prevent fecal staining of clothing/ beddings

>To prevent excoriation of the area

>To promote recovery, provide comfort for the pt., to decrease gastrointestinal motility

>To replace fluid and electrolyte losses and prevent dehydration

>To increase bulk/fiber

Short term:
>After 2 hours of NI, the SO shall have verbalized understanding of the causative factors
and identify appropriate interventions needed.
Long term:
> After 2 days of NI, the patientís SO shall have participated in therapeutic regimen to
control incontinence.

ACTUAL SOAPIE

MAY 9, 2007

S>O

O > Received patient on bed with ongoing IVF of D5IMB @ 200cc level regulated @
24-25 ugtts/min infusing well on the right hand with flushed skin, febrile, skin warm to
touch, with poor skin turgor, with capillary refill 2 seconds and with rales, with vital
signs taken and recorded as follows: T: 38.2∞C†/ axilla†††PR: 116 bpm††RR: 46 bpm††

A > Hyperthermia

P > After 5 hours of nursing interventions, the patientís temperature will be maintain at
normal level.

I > Established rapport.
† > Monitored and recorded vital signs especially temperature.
† > Assessed condition.
† > Provided environment conducive for relaxation.
† > Encouraged adequate rest periods.
† > Performed TSB.
††> IVF regulated as ordered.
† > Administered antipyretic as ordered.

E > Goal met AEB the patients temperature was maintain to a normal body temperature.

MAY 10, 2007



S>O

O > Received patient on bed with ongoing IVF of D5IMB @ 300cc level regulated @
24-25 ugtts/min infusing well on the right hand with flushed skin, febrile, skin warm to
touch, with poor skin turgor, with capillary refill 2 seconds and with rales, with
productive cough, with vital signs taken and recorded as follows: T: 37.4∞C†/
axilla†††PR: 104 bpm††RR: 44 bpm††

A > Ineffective Airway Clearance r/t retained secretions

P > After 5 hours of nursing interventions, the patientís SO will verbalize understanding
on the health teachings given.

I > Established rapport.
† > Monitored and recorded vital signs especially temperature.
† > Assessed condition.
† > Provided environment conducive for relaxation.
† > Encouraged adequate rest periods.
† > Auscultated lungs for breath sound.
††> IVF regulated as ordered.
† > Administered antipyretic as ordered.

E > Goal met AEB the patientís SO verbalization of understanding on the health
teachings given.
VII. CLIENTíS DAILY PROGRESS IN THE HOSPITAL
A. Clientís Daily Progress Chart

ADMISSION
May 1, 2007
May 2, 2007
May 3, 2007
May 4, 2007
May 5, 2007
May 6, 2007
May
7,
2007
May
8,
2007
May
9, 2007
May
10,
2007
May
11,
2007

NURSING PROBLEMS:

1.) Ineffective airway clearance related to obstructed airway due to secretions of the
bronchi.

2.) Hyperthermia related to Dehydration

3.) Fluid Volume Deficit

4.) Diarrhea

5.) Imbalanced Nutrition, less than body requirements

6) Bowel Incontinence r/t diarrhea.

Ä∍
Ä∍
Ä∍Ä∍Ä∍
Ä∇
Ä∍

Ä∍
Ä∍Ä∍Ä∍
Ä∇
Ä∍

Ä∍
Ä∍Ä∍Ä∍
Ä∍

Ä∍

Ä∍
Ä∍Ä∍Ä∍
Ä∇
Ä∍

Ä∍Ä∍Ä∍
Ä∇
Ä∍

Ä∍Ä∍Ä∍
Ä∇
Ä∍

Ä∍Ä∍Ä∍
Ä∇
Ä∍

Ä∍Ä∍Ä∍
Ä∇
Ä∍
Ä∍
Ä∍Ä∍Ä∍
Ä∇

Ä∍Ä∍Ä∍
Ä∇

Ä∇
VITAL SIGNS:
PR: 90
RR: 55
T: 37(C
PR: 84
RR: 43
T:37.4
(C
PR: 100
RR: 45
T:38.2
(C
PR: 101
RR: 45
T:37.9
(C
PR: 102
RR: 44
T:37.3(C
PR: 108
RR: 50
T:37.3(C
PR: 107
RR: 48
T:37(C
PR: 116
RR: 46
T:37.2(C
PR: 114
RR: 38
T:38.4(C
PR: 104
RR: 44
T:37.2(C
PR: 102
RR: 42
T:37.4(C

LAB PROCEDURES:

1.) CBC

2.) UA

3.) FA

Ä∍Ä∍Ä∇
MEDICAL MANAGEMENT:
1.) IVF
a.) D5L.3NaCl
45-47 ugtts/min

b.) D5IMB
24-25 ugtts/min

Ä∍
Ä∍

Ä∍
Ä∍

Ä∍

Ä∍

Ä∍

Ä∍
Ä∍

Ä∍

Ä∍

Ä∍

DRUGS

1.)Ampicillin

2.) Paracetamol

3.) Amikacin

4.)Gentamicin Sulfate
May 1, 2007

Ä∍

Ä∇May
2, 2007
Ä∍
Ä∍Ä∇May 3, 2007
Ä∍Ä∍Ä∍Ä∇May 4, 2007
Ä∍Ä∍Ä∍ Ä∇May 5, 2007
Ä∍
Ä∍Ä∇May
6,
2007
Ä∍

Ä∇May
7,
2007
Ä∍

Ä∇May
8, 2007
Ä∍

Ä∇May
9, 2007

May
10,
2007

May
11,
2007
DIET
1.) Diarrheal Diet
Ä∇Ä∇Ä∇Ä∇Ä∇Ä∇Ä∇Ä∇Ä∇Ä∇Ä∇
ACTIVITY/ EXERCISE
1.)Complete Bed Rest w/ head of bed elevated

Ä∇
Ä∇
Ä∇
Ä∍

Ä∇

Ä∍

Ä∇

Ä∇

Ä∇

Ä∇

Ä∇
CONCLUSION AND RECOMMENDATIONS

Acute Gastroenteritis became a common and costly clinical problem in children. It is a


largely self-limited disease with many etiologies. Thus, we recommend a care history and
complete physical examination in evaluating a child with AGE to uncover other illnesses
with similar presentations. Also, minimal laboratory testing is required. Treatment is
primarily supportive and is directed at preventing or treating dehydration. Hence, oral
rehydration therapy using a commercial pediatric oral rehydration solution is preferred
approach to mild or moderate dehydration. The traditional approach using ìclear liquidsî
is inadequate. In terms of severe dehydration, this requires the prompt restriction of
intravascular volume through the IV administration of fluids followed by oral rehydration
therapy. When rehydration is achieved, an age-appropriate diet should be promptly
resumed. Antiemetic and antidiarrheal medications are generally not indicated and may
contribute to complications. The use of antibiotic still remains controversial.

In terms of development of safe and effective oral rehydration solutions as an


alternative to have remedies of doubtful benefit or the use of IV regimens has
dramatically changed the management of AGE in young children. Nonetheless, ORT is
still underutilized on the developed world. Thus, family physicians have the chance of
changing the situation by becoming familiar with the guidelines for ORT and instructing
patients and SO in its appropriate use. It is also greatly recommended that there should be
patient education regarding the disease on how to prevent and treat it. Thus, if this
happens, there will be a reduction of medication use but an increase in the application of
ORT in the clinical practice of the HCP. Indeed, this thorough patient teaching,
physicians not only contribute to the reduction of out patient morbidity but also lessen the
inconvenience and costs associated in the emergency department and in patient treatment
of AGE.

In terms of th
}m`RARA/A#
q_q_q_q_q_q_q_
{íjU@U@U
tötÖöÖbÖötTtCTCT
}–}–}lXLX<
t`t`Ht/
{j[O[O[{¿j{
n`n^nO
e maintenance in diet therapy, this depends of the age and diet history of the patient.
Breast fed infants should continue nursing on demand. Formula fed infants should
continue their usual formula immediately upon rehydration in amounts sufficient to
satisfy energy and nutrient requirements. Children receiving semi-solid or solid foods
should continue to receive their usual diet during episodes of diarrhea. Foods high in
simple sugars should be avoided because the osmotic load might worsen diarrhea.
Therefore substantial amounts of carbonated soft drinks, juice, gelatines, desserts and
other highly sugared liquids should be avoided. Certain guidelines have recommended
avoiding fatty foods, but maintaining adequate calories without fat is difficult and fat may
have a beneficial effect of reducing intestinal motility. The proactive of withholding food
for >24 hours is inappropriate. Thus, early feeding decreases changes in intestinal
permeability cause by infection, reduces illness duration and improves nutritional
outcomes. Indeed, BRAT or highly specific diets have been commonly recommended.

In terms of the learning that we were able to achieve includes the ability to
describe and identify the factors that led to AGE by eliciting patientís present illness
history and performing physical assessment and the use of laboratory tests that could
justify the diagnosis. Thus, the child develops microorganisms in his GI tract that greatly
lead to frequent episodes of diarrhea and vomiting, placing him in a state of moderate
dehydration. The change of milk formula, contributed to the change in gastric motility
that made him pass loose watery stools. Thus, the medical management and appropriate
nursing interventions were also cited and made through NCPs and SOAPIEs.
Accordingly, early detection of the disease is appropriate so as to treat immediately the
impending signs and symptoms which if untreated could be fatal.

IX. BIBLIOGRAPHY

BOOKS:

Black, Joyce M. and Hawks, Jane Hokanson (2005), Medical Surgical Nursing. 7th
edition, Elsevier Saunders.

Kozier, Barbara, et. at., Fundamentals of Nursing Practice, 7th edition, PearsonPrentice
Hall.

REFERENCE:

A case study on Chronic Gastritis SIP CVA, By Goupr 23 of BSN 4-6, January 19, 2006.

ELECTRONIC SOURCE:

http//www.dreddis.com/gastro.html.
224¯¯˙'(,˜¯˚™Øªìñùú†®ux~QRTegjâãçDEF¸˝˛
b~IDATx^Ì} É£Fí
M
v
L7äQjQ∆f[yzj‡·
DwQt
H\∆™nP°ΩbåNeÌPqn…ë€K^mõk]1F~≈$Óeáu{2¯ıbî’”M

$ØÈò´≈(.W2‡$˜∑&€]-Fi
cvWãQë./w3
#
Eæ%[›hÓD–ÛÆíéb{#Ÿ˚/õ͸≈cmdg∏çÍA◊IG[)H
V
mâït≠tD»®®F cùÀÀA⁄Ã∫~)RW)◊EêSÓåWy>W
p?:UNd#&0
(øÄËì¬ sã|U‰.DpI5
TooUP€o$FÏ
:faHæáˇ
Oê$/•∏ã1
]ònHâ#/C¨3
Ftµ
IjS0=Ua~Ûˆ>ó>Ü_Í
?~:0ê<åø¡
a ¡”dWuŸ:c3{.Kª˙
^sÉ„J1bz¢yDY
0
.)FN8™"]lj@OÏÇ

(_fis^Y∑AKWOGߺ
mg–!
j0:L±nfl%nY[WÃÚ
\=^⁄Û‡8{kv6X^Ÿ
J6QÆY%÷XîbUj
zg::9†6ö,€Ë
sEh∞
R¨3ûÍ]1:[ ÊNÂŒc/ô5.
L-
}
#g•n‘π,‹˘@™",2@7x
W¯%µ‹LkPu!-#ÿ
;fˆj‰?˛V
cî˙µw^1k¯ŒU‚NP%YM†+øCÇ
KôË'Ä∏!F'{%•H}
1vf>%sfÅGÿ
<H|ÌÉEhrh=
lz«
QD
m7~
EóñIò>≈w?=rfÁ¨hT%
uóm$Ÿ≠ã—∂fi=>ù
FéΩ&FÒi£Hªu1äWhök\˛∂pN8N±*FÒF
:F>™4ZT
da˘GPbg flËzM[
iG‰»}Óâ=ÇÇ4´T®á5bm—Icmå–¬w=`"?Â
DN9a3"td
y8œƒqÔ≥tf:®AehîHi'7 ÒXN2|‹∫
KÖàh8x5,⁄·12Yg/fvΓ—
ZKz≤ß<DXTˇU*{
IFU◊$÷9;a]h
9(}GZÎ<öÿ2<¸⁄Í3:*Ÿ
1;d
4Ï7ˇfiÀl7~;fA}~´éo
FiQCr|
|AvSˇ'ad
"
:n
{‡o{w?`q
~˙VU
h›¯:lr6»:=^7h∞{
9sU^wF
:(È
Nd
{§và∆Ú&§vZÔ `Ñ|rîMı22Zóé:Q‹√èö÷Px±%@kk?
j+¸=::ÓˆTTp+
S|*˛fl
}∑-ßGm:˙ÍqqÓ∞kR∑B"6h_<±
9x»+p(a|
bS
(} ,∞?ÊZëyù#ñc…ô\+™5;~
a
|jHÖ
MJÁ–#Ç¢A¯ú9PM≤8S¬}*]
9˚KOr«
-
47jè6F$C
c
27Ö}éZÊ
/
z }˘BzVµS%
MÅ•¶Nnˆd?æE}„g
#b"etƒl
Ax˜M"&{"
#z.x‹p£m
UR`…
c¢¿6•^&sê'm1w
eBiÄ"
SÊ|E{
*
$o¥!HçN%·}b¸–Ÿtzdu
v5Í
-=

[pVıÚJeÄRov`p9am©2€Å‰~Yæ]BÑñ”∑)¡
~
> ÅÙ¸àEÊìCX\>/P
p,[A=z
a`.◊6!TörÅ&\K

aqsv5Ò7˘Â¡ñ[U;iπAf*Fc∆#Å
qa˙>xÑÀy;y2(Z

$∞˙Ñ4$ÚÌ(B#m0]
-MQg√∑o{!™
L‘88G˙=˝73`PπÅ
<@&W¸bwEKªhí`_ÑUhOìX
D8_@d7
#¯À∏Ú⁄*!L<ß>HM
__w]qm
>
>F,¡èmN#Bªv-hƒBPu»–
)ÖŒA Q"£4‚ê’î˘Ò_ö∏·aC\W´mÏFDL
#Q9HOGRyU™µ°
ie3a`{
O
"∑Ë5Ò:`©W {OcvW
GU1zûR¬wUåXfi$≠pBLfl
-=qƎ
oO5>´Jkz
1p\
C“€!k@"1Í÷pXFp¬Bß
Hc^
N
R¥ÿOøMà5¬÷Qµ⁄kó∏Õ a©E∑‰ƒ…&m/J!4
E{(¶5ˇ≈ê—í5ÿë9|2æ∞y>ZtV
k(ànl∞|j˘Ç6Ud~XNY]k
.E∏õC-@`6u
Rÿ$ÑFp
8∞W%0yå6z,
2^duUpS¥
3NGd?$
uR
q
LX1‰.u_&
C´˜∑ÇBaúØë•¢≈HñXÁòµ!z≠JDf±NkC
J¶å•0¬8&˙j!}R=uMyâ¥Ó
>G@â
aDÜ°z∏}=ƒ¸ÿÌ#"HQf‘bC
kôp++g‡AªU[X79Ÿ=¨1
DÑau 9®y∞E0Bd~¯
m
]∞õTKX{q*I
#hŸ6˛¢—h,Õ,å`Œ˙,Ë©f∂o◊Ÿ/#œ√k©∆ )IPi¬6ê°Zkô`D
|=í3;Xvö_W
SÊãu
+5a`i
@“ª ®1r$JC\
0t.5
#0
L^
b6V)'¬6-
\Mr
Q1[^.)
j€îu;Ú-
<≥œ«hg8eyû;m%il*∫·#v>j≈N!MtπÅj‹8Âv£
u∆|)zD6^;◊
[[
`S'\
~
G
F@Bêtwnz
|`vº™Ò[YA5jÚA1,IˆF
f
v}^'B
`»—˘fiÖÆ;ÚzQ4W«_F¯fB
3#œZO∆Bgc¨!wt
t ¸#;(z,
0
4
t ¸#;(z,
0
4
t ¸#;(z,
0
4
X ‹#`'‰*£.'2
X ‹#`'‰*£.'2
X ‹#`'‰*£.'2
X ‹#`'‰*£.'2
X ‹#`'‰*£.'2
BD21301_
BD21301_
`PLTEˇˇˇÍÍÍÁÁ÷¿¿¿ÃÃÿ¿¿≠©êôôôÜÜÜwwwfffUUUMMMBBB999333)))
cmPPJCmp0712
T∏ø≈±∑Ú`iJŒ-n~ùrJ
Normal
Normal
Heading 1
Heading 1
Heading 2
Heading 2
Heading 3
Heading 3
Heading 4
Heading 4
Heading 6
Heading 6
Default Paragraph Font
Default Paragraph Font
Table Normal
Table Normal
No List
No List
Normal (Web)
Normal (Web)
Emphasis
Emphasis
HTML Preformatted
HTML Preformatted
Body Text Indent 3
Body Text Indent 3
Body Text
Body Text
body_text
body_text
boldened
boldened
Hyperlink
Hyperlink
Table Grid
Table Grid
table08
table09
table0A
table0B
table08
table09
table0A
table0B
_PictureBulletsÉ
*Äurn:schemas-microsoft-com:office:smarttags
*Äurn:schemas-microsoft-com:office:smarttags
*Äurn:schemas-microsoft-com:office:smarttags
City0Ähttp://www.5iamas-microsoft-com:office:smarttagsV
*Äurn:schemas-microsoft-com:office:smarttags
http://www.5iantlavalamp.com/B
*Äurn:schemas-microsoft-com:office:smarttags
country-region
Minute
î㨁'㠹(㠹)㠹)㠹+㠹+㠹,㠹,㠹.㠹/㠹1㠹2㠹4㠹5㠹8㠹
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

V/KW*™6|
Unknownÿ!
Times New Roman
Times New Roman
Symbol
Symbol
Arial Unicode MS
Arial Unicode MS
Batang
Batang
Lucida Sans Unicode
Lucida Sans Unicode
Courier New
Courier New
Wingdings
Wingdings
Normal
Microsoft Office Word
Root Entry
1Table
1Table
WordDocument
WordDocument
SummaryInformation
SummaryInformation
DocumentSummaryInformation
DocumentSummaryInformation
CompObj
CompObj
Microsoft Office Word Document
MSWordDoc
Word.Document.8