Wesleyan University-Philippines

Mabini Extension, Cabanatuan City, Nueva Ecija

College of Nursing & Allied Medical Sciences

Acute Gastroenteritis

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Submitted by: Mariano, Christine A. Sebastian, Emanuelle BSN II Block 6 Group 4 Submitted to: Maam Genielyn Lee Clinical Instructor

Gastroenteritis Overview
Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). The most common symptoms are

diarrhea, crampy abdominal pain, nausea, and vomiting.

Many people also refer to gastroenteritis as "stomach flu." This can sometimes be confusing because influenza (flu) symptoms include

headache, muscle aches and pains, and respiratory symptoms, but influenza does not involve the gastrointestinal tract.

The term stomach flu presumes a viral infection, even though there may be other causes of infection. Viral infections are the most common cause of gastroenteritis but bacteria, parasites, and foodborne illnesses (such as shellfish) can also be the offending agents. Many people who experience vomiting and diarrhea that develops from these types of infections or irritations think they have "food poisoning," when they actually may have a food-borne illness. Travelers to foreign countries may experience "traveler's diarrhea" from contaminated food and unclean water. The severity of infectious gastroenteritis depends on the immune system's ability to resist the infection. Electrolytes (these include essential elements of sodium and potassium) may be lost as the affected individual vomits and experiences diarrhea. Most people recover easily from a short episode of vomiting and diarrhea by drinking fluids and gradually progressing to a normal diet. But for others, such as infants and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration, which is a life-threatening illness unless the condition is treated and fluids restored.

Gastroenteritis Causes

Gastroenteritis has many causes. Viruses and bacteria are the most common. Viruses and bacteria are very contagious and can spread through contaminated food or water. In up to 50% of diarrheal outbreaks, no specific agent is found. The infection can spread from person to person because of improper handwashing following a bowel movement or handling a soiled diaper. Gastroenteritis caused by viruses may last one to two days. However, some bacterial cases can continue for a longer period of time.

Viruses
Norovirus - Fifty to seventy percent of cases of gastroenteritis in adults are caused by the noroviruses (genus Norovirus, family Caliciviridae. This virus is highly contagious and spreads rapidly. Norovirus is the most common cause of gastroenteritis in the United States.

Noroviruses can be transmitted and infect individuals by o contaminated food and liquids,
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touching objects contaminated with norovirus and then placing the hands or fingers in the mouth, direct contact with an infected individual (for example, exposure to norovirus when caring or sharing foods, drinks, eating utensils with an affected individual, and exposure to infected individuals and objects in daycare centers and nursing homes.

Norovirus is often in the news when cruise ship passengers contract the virus, which causes gastroenteritis.

Rotavirus - According to the CDC, "Rotavirus was also the leading cause of severe diarrhea in U.S. infants and young children before rotavirus vaccine was introduced for U.S. infants in 2006. Prior to that, almost all children in the United States were infected with rotavirus before their 5th birthday. Each year in the United States in the pre-vaccine period, rotavirus was responsible for more than 400,000 doctor visits; more than 200,000 emergency room visits; 55,000 to 70,000 hospitalizations; and 20 to 60 deaths in children younger than 5 years of age." Other viruses that cause gastrointestinal symptoms include:

Adenoviruses - This virus most commonly causes respiratory illness; however, other illnesses may be caused by adenoviruses such as gastroenteritis, bladder infections, and rash illnesses. Parvoviruses - The human bocavirus (HBoV), which can cause gastroenteritis belongs to the family Parvoviridae.
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Astroviruses - Astrovirus infection is the third most frequent cause of gastroenteritis in infants.

Bacteria
Bacteria may cause gastroenteritis directly by infecting the lining of the stomach and intestine. Some bacteria such as Staphylococcus aureus produce a toxin that is the cause of the symptoms. Staph is a common type of food poisoning. Escherichia coli infection can cause significant complications. E. coli O157:H7 (one type of the bacteria) can cause complications in approximately 10% of affected individuals (for example, kidney failure in children [hemolytic-uremic syndrome or HUS), bloody diarrhea, and thrombotic thrombocytopenic purpura (TTP) in the elderly. Salmonella, Shigella and Campylobacter Salmonella, Shigella and Campylobacter are also common causes of illness.

Salmonella is contracted by ingesting the bacteria in contaminated food or water, and by handling poultry or reptiles such as turtles that carry the germs. Campylobacter occurs by the consumption of raw or undercooked poultry meat and cross-contamination of other foods. Infants may contract the infection by contact with poultry packages in shopping carts. Campylobacter is also associated with unpasteurized milk or contaminated water. The infection can be spread to humans by contact with infected stool of an ill pet (for example, cats or dogs). It is generally not passed from human to human. Shigella bacteria generally spreads from an infected person to another person. Shigella are in diarrheal stools of infected individuals while they are ill, and for up to one to two weeks after contracting the infection. Shigella infection also may be contracted from eating contaminated food, drinking contaminated water, or swimming or playing in contaminated water (for example, wading pools, shallow play fountains). Shigella can also be spread among men who have sex with men.

Clostridium difficile Clostridium difficile (C difficile) bacteria may overgrow in the large intestine after a person has been on antibiotics for an infection. The most common antibiotics that pose a potential risk factor for C difficile include

clindamycin (for example, Cleocin), fluoroquinolones (for example, levofloxacin [Levaquin'], ciprofloxacin [Cipro, Cirpo XR, Proquin XR]),

penicillins, and cephalosporins.

Other risk factors for C difficile infection are hospitalization, individuals 65 years of age or greater, and existing chronic medical conditions.

Parasites and Protozoans

These tiny organisms are less frequently responsible for intestinal irritation. A person may become infected by one of these by drinking contaminated water. Swimming pools are common places to come in contact with these parasites. Common parasites include

Giardia is the most frequent cause of waterborne diarrhea, causing giardiasis. Often, people become infected after swallowing water that has been contaminated by animal feces (poop). This may occur by drinking infected water from river or lakes but giardia may also be found in swimming pools, wells and cisterns. Cryptosporidium (Crypto) is a parasite that lives in the intestine of affected individuals or animals. The infected individual or animal sheds the Cryptosporidium parasite in the stool. Crypto may also be found in food, water, soil, or contaminated surfaces (swallowing contaminated recreational water, beverages, uncooked food, unwashed fruits and vegetables, touching contaminated surfaces such as bathroom fixtures, toys, diaper pails, changing tables, changing diapers, caring for an infected individual or handling an infected cow or calf). Those at risk for serious disease are individuals with weakened immune systems.

Other Common Causes of Gastroenteritis

Gastroenteritis that is not contagious to others can be caused by chemical toxins, most often found in seafood, food allergies, heavy metals, antibiotics, and other medications.

Gastroenteritis Symptoms
By definition, gastroenteritis affects both the stomach and the intestines, resulting in both vomiting and diarrhea. Common gastroenteritis symptoms

Low grade fever to 100 F (37.7 C) Nausea with or without vomiting Mild-to-moderate diarrhea
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Crampy painful abdominal bloating (The cramps may come in cycles, increasing in severity until a loose bowel movement occurs and the pain resolves somewhat.)

More serious symptoms of gastroenteritis

Blood in vomit or stool (Blood in vomit or stool is never normal and the affected individual should call or a visit a health care practitioner.) Vomiting more than 48 hours Fever higher than 101 F (40 C) Swollen abdomen or abdominal pain

Dehydration - weakness, lightheadedness, decreased urination, dry skin, dry mouth and lack of sweat and tears are characteristic signs and symptoms Medical Management: Most often gastroenteritis is self-limiting, but it can cause significant problems with dehydration. Should that be a concern, contacting a primary care provider is reasonable. Vomiting blood or having bloody or black bowel movements are not normal, and emergency care should be sought. Some medications such as iron or bismuth subsalicylate (Pepto-Bismol) can turn stool black in color.
Fever, increasing severity of abdominal pain, and persistent symptoms should not be ignored and seeking medical care should be considered

ANATOMY

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PHYSIOLOGY

DIGESTIVE SYSTEM
The digestive system consists of two linked parts: the alimentary canal and the accessory digestive organs. The alimentary canal is essentially a tube, some 9 meters (30 feet) long that extends from the mouth to anus, with its longest section-the intestines- packed into the abdominal cavity. The lining of the alimentary canal is c o n t i n u o u s w i t h t h e s k i n , s o t e c h n i c a l l y i t s c a v i t y l i e s o u t s i d e t h e b o d y. T h e alimentary tube consists of linked organs that each play their own part in digestion: mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The accessory digestive organs consist of the teeth and tongue in the mouth; and the

salivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the alimentary canal. STOMACH It is a J- shaped enlargement of the GI tract directly under the diaphragm in the epigastric, umbilical and left hypochondriac regions of the abdomen. When empty, it is about the size of a large sausage; the mucosa lies in large folds, called RUGAE. Approximately 10 inches long but the diameter depends on how much food i t c o n t a i n s . W h e n f u l l , i t c a n h o l d a b o u t 4 L ( 1 g a l l o o n ) o f f o o d . P a r t s o f t h e stomach includes cardiac region w h i c h i s d e f i n e d a s a p o s i t i o n n e a r t h e h e a r t surrounds the cardio esophageal sphincter through which food enters the stomach from the esophagus; fundus which is the expanded part of the stomach lateral to the cardiac region; body is the mid portion; and the pylorus a funnel shaped which is the terminal part of the stomach. The pylorus is continuous with the small intestine through the pyloric sphincter, or valve. With the gastric glands lined with several secreting cells the zymogenic (peptic) cells secrete the principal gastric enzyme precursor, pepsinogen. The p a r i e t a l ( o x yn t i c ) c e l l s p r o d u c e h yd r o c h l o r i c a c i d ,
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i n v o l v e d i n c o n v e r s i o n o f p e p s i n o g e n t o t h e a c t i v e e n z ym e p e p s i n , a n d i n t r i n s i c f a c t o r , i n v o l v e d i n t h e absorption of Vitamin B12 for the red blood cell production. Mucous cells secrete mucus. Secretions of the zymogenic, parietal and mucus cells are collectively called the gastric juice. Enteroendocrine cells secrete stomach gastrin, a hormone that s t i m u l a t e s s e c r e t i o n o f h yd r o c h l o r i c a c i d a n d p e p s i n o g e n , c o n t r a c t s t h e l o w e r esophageal sphincter, mildly increases motility of the GI tract, and relaxes the pyloric sphincter. Most digestive activity occurs in the pyloric region of the stomach. After food has been processed in the stomach; it resembles heavy cream and is called CHYME. The chyme enters the small intestine through the pyloric sphincter.

PATHOPHYSIOLOGY
Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts with ingestion of focally contaminated food and water. The organism affects the body through direct invasion and by endotoxin being released by the organism. Through these two processes the bowel mucosal lining is stimulated and destroyed the eventually lead to attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the stomach. The client with acute gastroenteritis may also report excessive gas formation that may leads to abdominal detention and passing of flatus due to digestive and absorptive malfunction in the system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress to nausea and vomiting and increasing frequency of defecation. Abdominal pain and feeling of fullness maybe relieved only when the patient is able to pass a flatus. As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct invasion of the organism and the action of the hydrochloric acid of the stomach. As the protective coating of the stomach erodes the digestive capabilities of the acid helps in destroying the stomach lining. Pain or tenderness of the abdomen is then felt by the patient. When the burrows or ulceration reaches the blood vessels in the stomach bleeding will be induced. Dysentery may be characterized by melena or hematochezia depending on the site and quantity of bleeding that may ensue. Signs of bleeding may be observed also through hematemesis. As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes water and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride and bicarbonate ions in the bowel as the body try to get rid of the organism by increasing peristalsis and number of defecation. Sodium and water reabsorption in the bowel is inhibited with the lost of the two electrolytes. Mild diarrhea is characterized by 23 stool, borborygmi (hyperactive bowel sound), fluid and electrolyte imbalance and hypernatremia. When the condition continue to progress, protein in the body is excreted to the lumen that further decreases the reabsorption and the body become overwhelmed that leads to intense diarrheawith more than 10 watery stool. Serious fluid volume deficit may lead to hypovolemic shock and eventually death

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I.

DEMOGRAPHIC DATA Name Age Gender Civil Status Religion Date and Time of Admission Attending Physician Diagnosis Weight Informant Patient X 6 months old Male Single Roman Catholic February 15, 2012 Dr. Baca AGE with mild dehydration 6.5 kg Mother

Chief Complaint LBM verbalized by the mother

II. HISTORY History of Present Illness A case of Patient X, 6months old Male, Filipino, a resident of B o n g a b o n , R i z a l , N . E , a d m i t t e d f o r t h e f i r s t t i m e a t B o n g a b o n D i s t r i c t hospital with a chief complaint of LBM. Two days prior to admission he had persistent LBM, vomiting, cough and fever

Past Medical History The father claimed that his child past illnesses were a typical cough, c o l d s a n d f e v e r t h a t u s u a l l y l a s t e d f o r t h r e e d a ys . O v e r t h e c o u n t e r medicines such as Paracetamol (Calpol) was used to treat for fever and Dimetapp for colds. The father claimed that his child has not completed t h e v a c c i n a t i o n r e q u i r e d a n d n e v e r e x p e r i e n c i n g m a j o r i l l n e s s t h a t required hospitalization until this February 15, 2012 wherein the patient has been admitted at JRB Hospital having an acute diarrhea but the father denied that his child does not have known allergies to drugs and foods nor his child received a blood transfusion. The patient was born in JRB Hospital through a normal spontaneous vaginal delivery. Family History of Illness According to the father regarding the herido-familial history both her mother and father side has died last 2001 due to cervical cancer.
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III. LABORATORY RESULTS

Hemoglobin Hematocrit White Blood Cell Count

17.3gms % 49.6 vol. % 14,351/mm3

Fecalysis Character: soft WBC/hpf: 4-6 Parasite ascarasis:none seen Trichuris: none seen Hook worm: none seen IV. DRUG STUDY
Generic Name Brand Name Classification Action Dosag e Indicati ons Adverse Reactions Nursing Responsibilities

Color: yellow RBC/ hpf: 6-8 cysts: positive trophosites: none seen

Paracetamol

Analgesic; antipyretic

May produce analgesic effect by blocking pain impulses, byinhibiting prostaglandin or pain receptor sensitizers. May relieve fever by actingonhypothala mic heatregulating center. Relieves fever. It acts by increasing the respiratory tract secretion of lower viscosity mucus
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500 mg 1 tab q4h PRN for fever

For fever

Anemia, jaundice, rash, urticaria.

Do not administer for fever thats above 39.5 C, lasts longer than 3days or recurs

AMBROXOL

Cough and Cold Preparation

0.75ml Cough Mild GI side Should be taken TID effects with food. . P.O

GENTAMYCIN

Amino glycoside

and exerting a positive influence on the alveolar surfactant system which leads to improved mucus flow and transport. Expectoration of mucus is thus facilitated. Broad-spectrum IVT aminoglycoside q8 antibiotic derived ANS from T Micromonospor a purpurea. Action is usually bacteriocidal

Parent eral use restrict ed to treatm ent of serious infecti ons of GI

Allergic reaction, decreased hearing, numbness, skin tingling, muscle twitching

Draw blood specimens for peak serum gentamicin concentration 30 min1h after IM administration, and 30 min after completion of a 3060 min IVinfusion. Draw blood specimens for trough levels just before the next IM or IV dose.Use non heparinized tubes to collect blood.

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V: NURSING CARE PLAN

ASSESSMENT S> Oo, mahilig

DIAGNOSIS

PLANNING

INTERVENTIONS

EVALUATION

ngayan magsubo ng kahit anong mahawakan nya, as stated by mother > sa halos 1 week naming na stay dito sa ospital, 3-4 times ko sya pinaliguan dito, as stated by mother O > very playful > does not wash often > age =11/12 months old > dirty nails

Risk for Infection

The client will be able to demonstrate no signs of infection (fever) until discharge

>Demonstrate & Goal Met teach proper hand AEB afebrile until washing discharged technique and stress its importance > Instruct in daily bath/shower, regular cutting of nails > Limit visitors > Advise to avoid opening of door or going out the room too much > Instruct mother to neglect her child from putting hands or objects on mouth > Suggest techniques for safe food preparation and presentation microbial growth

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Gastroenteritis Treatment Gastroenteritis Self-Care and Home Remedies

The treatment of gastroenteritis is aimed at hydration and home remedies that address keeping fluid in the body are key to recovery. Since most causes of gastroenteritis are due to viruses, replacing the fluid lost because of vomiting and diarrhea allows the body to recuperate and fight the infection. Dehydration can also intensify the symptoms of nausea and vomiting. The critical step is replacing fluids when the affected individual is nauseous and doesn't want to drink (hydrate). This is especially difficult with infants and children. Small frequent offerings of clear fluids, sometimes only a mouthful at a time, may be enough to replenish the body's fluid stores and prevent an admission to the hospital for intravenous (IV) fluid administration. In general, clear fluids (anything you can see through), may be tolerated in small amounts. Think of it as adding just an ounce or less to the saliva that the patient is already swallowing. However, giving too much fluid at one time may cause increased nausea due to a distended stomach, which causes additional irritation. Clear fluids do not include carbonated beverages but colas or ginger ale with the fizz gone is often well tolerated. Coke syrup may also be helpful in settling the stomach. Jello and popsicles may be "solid food" alternatives to clear fluids in children who aren't interested in clear fluids.

Dehydration in children
Oral rehydration therapy using balanced electrolyte solutions such as Pedialyte or Gatorade/PowerAde may be all that is needed to replenish the fluid supply in an infant or child. Plain water is not recommended because it can dilute the electrolytes in the body and cause complications such as seizures due to low sodium. The key to oral rehydration is small frequent feedings. If offered free access to a bottle, infants especially may drink quickly to quench their thirst and then vomit. Instead it may be best to limit the amount of fluid given at one time. There are a variety of regimens that are used and they follow a basic format:

Offer 1/3 of an ounce (5 to 10 cc) of fluid at one time. Wait 5 to 10 minutes then repeat. If this amount is tolerated without vomiting, increase the amount of fluid to 2/3 of an ounce (10 to 20 cc). Wait and repeat. If tolerated, increase the fluid offered to 1 ounce (30 cc) at a time.
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If vomiting occurs, go back to the 1/3 of an ounce (5 to 10 cc) and restart. Once the child is tolerating significant fluids by mouth, a more solid diet can be offered.

The important thing to remember is that the goal is to provide fluid to the child and not necessarily calories. In the short term, hydration is more important than nutrition. For infants and children, fluid status can be monitored by

whether they are urinating, if they have saliva in their mouths, tears in their eyes, and sweat in their armpits or groin.

If the child's baseline weight is known, dehydration can be measured by comparing weight. Medical care should be accessed immediately, if the child is listless, floppy or does not seem to be acting like they normally do.

Gastroenteritis Medical Treatment

Upon seeking medical attention, if the patient cannot take fluids by mouth because of vomiting, the health care practitioner may insert an IV replace fluid back into the body (rehydration). In infants, depending upon the level of dehydration, intravenous fluids may be delayed to consider trying oral rehydration therapy. Frequent feedings, as small as a 1/6 ounce (5 cc) at a time, may be used to restore hydration. Antibiotics are usually not prescribed until a bacteria or parasite has been identified as the cause of the infection. Antibiotics may be given for certain bacteria, specifically Campylobacter, Shigella, and Vibrio cholerae, if properly identified through laboratory tests. Otherwise, using any antibiotic or the wrong antibiotic can worsen some infections or make them last longer. Antibiotics are not used to treat virus infections. Some infections, such as salmonella, are not treated with antibiotics. With supportive care of fluids and rest, the body is able to fight and resolve the infection without antibiotics. For adults, the health care practitioner may prescribe medications to stop the vomiting (antiemetics) such as promethazine (Phenergan, Anergan), prochlorperazine (Compazine), or ondansetron (Zofran). Sometimes these medications are prescribed as a suppository. Doctors
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usually do not recommend antiemetics for infants, but depending upon the situation, older children may be prescribed an antiemetic (antinausea) medication in a lower dosage. Antidiarrhea medications are not usually recommended if the infection is associated with a toxin that causes the diarrhea. The most common antidiarrheal agents for people older than 3 years of age include over-the-counter (OTC) medications such as diphenoxylate atropine (Lomotil, Lofene, Lonox) or loperamide hydrochloride (Imodium).

Gastroenteritis Prevention
With most infections, the key is to block the spread of the organism.

Always wash your hands. Eat properly prepared and stored food. Bleach soiled laundry.

Vaccinations for Vibrio cholerae, and rotavirus have been developed. Rotavirus vaccination is recommended for infants in the U.S.. Vaccines for V. cholerae may be administered to individuals traveling in at-risk areas

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