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A Case Analysis of Acute Gastroenteritis with moderate Dehydration
In Partial fulfillment in the
Requirements in
Nursing Care Management 104
Presented to level III instructors of
Davao Doctors College
Presented by:
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y
Gastroenteritis is inflammation of the lining of the stomach and small and
large intestines. Globally, most cases in children are caused by rotavirus. In
adults, norovirus and Campylobacter are more common. Less common are
infectious, although gastroenteritis may occur after ingestion of drugs and
chemical toxins (eg, metals, plant substances). Acquisition may be foodborne,
waterborne, or via person-to-person spread. Symptoms include anorexia,
nausea, vomiting, diarrhea, and abdominal discomfort. Diagnosis is clinical or by
stool culture, although PCR and immunoassays are increasingly used. The
foundation of management is adequate hydration. Treatment is symptomatic,
although some parasitic and some bacterial infections require specific anti-
infective therapy.
Gastroenteritis is usually uncomfortable but self-limited. Electrolyte and
fluid loss is usually little more than an inconvenience to an otherwise healthy
adult but can be grave for people who are very young, elderly, or debilitated or
who have serious concomitant illnesses.
Worldwide, an estimated 1.5 million children die each year from infectious
gastroenteritis; although high, this number represents one half to one quarter of
previous mortality. Improvements in water sanitation in many parts of the world
and the appropriate use of oral rehydration therapy for infants with diarrhea are
likely responsible for this decrease
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human enteric (intestinal) disease primarily caused by ingestion of spoiled or
bacterial contaminated water or food.
According to the DOH Secretary, Dr. Manuel Dayrit, a total of 2,778 cases
of the said intestinal infection were recorded in just 45 days (from May 31 to
July16, 2004). From the studies on the medical diagnoses of 81 cases, Dayrit
concluded that infectious (transmittable) cholera disease was the main cause of
the epidemic (www.doh.gov.ph).
Locally here in Davao City, Diarrhea & Gastroenteritis is the 5 th leading
cause of morbidity in year 2010 with an incidence of 4,205/100,000 person.
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name M.T.F
age 28 years old
sex Female
civil status Married
religion Catholic
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The human gastrointestinal tract is the stomach and intestine, sometimesincluding all the structures from the mouth to theanus. (The "digestive system" is
a broader term that includes other structures, including the accessory organs of
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The upper gastrointestinal tract consists of the esophagus, stomach, and
duodenum. The exact demarcation between "upper" and "lower" can vary. Upon
gross dissection, the duodenum may appear to be a unified organ, but it is often
divided into two parts based upon function, arterial supply, or embryology.
The lower gastrointestinal tract includes most of the small intestine and all
of the large intestine. According to some sources, it also includes the anus.
Small Intestine: Has three parts:
Duodenum: Here the digestive juices from the pancreas (digestive
enzymes) and hormones and the gall bladder(bile) mix. The
digestive enzymes break down proteins and bile and emulsify fats
into micelles. The duodenum contains Brunner's glands which
produce bicarbonate. In combination with bicarbonate from
pancreatic juice, this neutralizes HCl of the stomach.
Jejunum: midsection of the intestine, connecting the duodenum to
the ileum. It contains theplicae circulares, and villi to increase the
surface area of the GI Tract. Products of digestion (sugars, amino
acids, fatty acids) are absorbed into the bloodstream.
Ileum: Has villi and absorbs mainly vitamin B12 andbile acids, and
th t i t
http://en.wikipedia.org/wiki/Small_Intestinehttp://en.wikipedia.org/wiki/Duodenumhttp://en.wikipedia.org/wiki/Pancreashttp://en.wikipedia.org/wiki/Digestive_enzymeshttp://en.wikipedia.org/wiki/Digestive_enzymeshttp://en.wikipedia.org/wiki/Gall_bladderhttp://en.wikipedia.org/wiki/Bilehttp://en.wikipedia.org/wiki/Emulsifyhttp://en.wikipedia.org/wiki/Micelleshttp://en.wikipedia.org/wiki/Duodenumhttp://en.wikipedia.org/wiki/Brunner's_glandshttp://en.wikipedia.org/wiki/HClhttp://en.wikipedia.org/wiki/Jejunumhttp://en.wikipedia.org/wiki/Plicae_circulareshttp://en.wikipedia.org/wiki/Intestinal_villushttp://en.wikipedia.org/wiki/Ileumhttp://en.wikipedia.org/wiki/Intestinal_villushttp://en.wikipedia.org/wiki/Vitamin_B12http://en.wikipedia.org/wiki/Bile_acidshttp://en.wikipedia.org/wiki/Bile_acidshttp://en.wikipedia.org/wiki/Duodenumhttp://en.wikipedia.org/wiki/Pancreashttp://en.wikipedia.org/wiki/Digestive_enzymeshttp://en.wikipedia.org/wiki/Digestive_enzymeshttp://en.wikipedia.org/wiki/Gall_bladderhttp://en.wikipedia.org/wiki/Bilehttp://en.wikipedia.org/wiki/Emulsifyhttp://en.wikipedia.org/wiki/Micelleshttp://en.wikipedia.org/wiki/Duodenumhttp://en.wikipedia.org/wiki/Brunner's_glandshttp://en.wikipedia.org/wiki/HClhttp://en.wikipedia.org/wiki/Jejunumhttp://en.wikipedia.org/wiki/Plicae_circulareshttp://en.wikipedia.org/wiki/Intestinal_villushttp://en.wikipedia.org/wiki/Ileumhttp://en.wikipedia.org/wiki/Intestinal_villushttp://en.wikipedia.org/wiki/Vitamin_B12http://en.wikipedia.org/wiki/Bile_acidshttp://en.wikipedia.org/wiki/Small_Intestine8/22/2019 PArtial COmplete Baxh Nalng Kulang
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Pathophysiology
--- ---
Precipitating factor:Poor sanitationContaminated foodand water
Bleeding
Interrupted normal intestinalflora activity
Pathogen enters
gastrointestinal tract
Irritation ofintestinalmucosa
Increase secretion of fluidand electrolytes into
intestinal lumen
Stimulation anddestruction of mucosal
lining
Pathogens released
endotoxin
Ingestion ofcontaminated food/water
Predisposing factor:Immuno-compromised
Ulceration
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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 fecally 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 that 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 distention 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.
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. Pain or tenderness of the abdomen can then be felt by the patient.
When the burrows or ulceration reaches the blood vessels in the stomach,
bleeding will be induced. Signs of bleeding may be observed also through
hematemesis As the bowel is stimulated by the organism and its toxin the
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A. PERSONAL DATA
Name: Michelle Tandora Fernandez Age:_28_ Sex:__Female_ Civil Status:_Married_ Date of Admission: March 03, 2013
Address: Prk. 10 Emerald St. Doa Salud Subd., Sasa, Davao City Religion:_Roman Catholic
Chief Complain: ___LBM & Vomiting Occupation: Call Center Representative
Diagnosis:Acute Gastrointeritis with mild dehydration Impression:Acute Gastroenteritis with mild dehydration
B. FAMILY BACKGROUND
Mrs. Michelle Fernandez is the 3rd child in the family. She is a non-smoker and non-alcoholic drinker. On her mother side has a
family history of hypertension while on the father side has asthma, fortunately she does not have this illnesses. She works as a call
center representative on a graveyard shift and she has a 1 year old daughter. Patient has an allergy on ibuprofen, celecoxib,
mefenamic acid, ketorolac, meloxicam but does not had food allergy.
C. EFFECTS/EXPECTATIONS OF ILLNESS TO FAMILY AND SELF
Mrs. Michelle Fernandez is very anxious when she was admitted to Davao Doctors Hospital because she thinks that even if she
has a Phil. Health card the hospitalization will still cost them money. Her family was expecting that this ailment will be gone so that
Mrs. Michelle Fernandez can continue to work.
D. HISTORY OF PAST ILLNESS
Mrs. Michelle Fernandez had no history of the present illness but has experience its signs and symptoms. She was hospitalized at
year 2011 at (Davao Doctors Hospital) because of her first pregnancy (G1P1).
E. HISTORY OF PRESENT ILLNESS
Patient Michelle Fernandez was apparently well until few hours PTA when she noted sudden onset of Crampy abdominal pain,
8/10 in severity, associated with LBM of non-smelling stools x 4 episodes and vomiting x 4 episodes. Persistence prompted the
admission. She verbalize that she only ate a left over on that night and she added that she smelled it and it does not smell spoiled.
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FUNCTIONAL PATTERN
On Going Assessment
Guidelines Normal Assessment Day1
March 4, 2013
Day 2
March 5, 2013
I. MENTAL STATUSa. State of mental
consciousness
Conscious Conscious Conscious
b. Orientation Oriented to time, place and
people.
Oriented to time, place and people. Oriented to time, place and people.
c. Attention span With long attention span With long attention span With long attention span
d. Ability to understandideas
Able to understand simpleinstructions
Able to understand simple instructions Able to understand simpleinstructions
II. STATUS OF SPECIAL SENSES
a. Auditory perception Able to hear sounds Able to hear sounds Able to hear soundsb. Visual perception Able to see clearly without
aid
Able to see clearly without aid Able to see clearly without aid
c. Speech perception Able to speak without
problem
Able to speak without problem Able to speak without problem
d. Tactile perception Able to feel sensations Able to feel sensations Able to feel sensationse. Olfactory perception Able to distinguish different
odor
Able to distinguish different odor Able to distinguish different odor
III. MOTOR ABILITY STATUSa. Current mobility Ambulatory at times Ambulatory at times Ambulatory at timesb. Posture Good body posture Good body posture Good body posture
c. Range of motion Has a good ROM Has a good ROM Has a good ROMd. Muscle and nervous
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statuse. Loss of extremities None None None
IV. BODY TEMPERATURE STATUSa. Ranges 36.5 37.5 degree Celsius 36.7 37.2 degree Celsius 36.2 36.3 degree Celsius
V. RESPIRATORY STATUSa. Character Clear Clear Clear b. Use of respiratory
aids
Does not use respiratory
aids
Does not use respiratory aids Does not use respiratory aids
c. Interference of
respiration
No interference of
respiration
No interference of respiration No interference of respiration
d. Abnormal
respiratory opening
No abnormal respiratory
opening
No abnormal respiratory opening No abnormal respiratory opening
VI. CIRCULATORY STATUS
a. Characteristics of
arterial pulse
Regular Regular Regular
b. Apical-radial pulse 80 120 bmp 83bpm 82bpmc. Blood pressure 120/80 mmhg 110/70 mmHg 110/80 mmHg
d. Pulse pressure 80 120 bmp 83bpm 82bpme. Mean arterial
pressure
MAP = [(2 x diastolic)
+systolic] / 3
70 100 mmHg
83.3 mmHg 90.0 mmHg
f. Intravenous fluid Without IVF PNSS @ 140 cc/hr Without IVF
VII. NUTRITIONAL STATUS
a. Condition of buccalcavity
Able to masticate foodserved
Able to masticate food served Able to masticate food served
b. Digestion of food Able to consume of food served Able to consume of food servedc. Weight Not assessed Not assessed Not assessedVIII. ELIMINATION STATUS
a. Bowel Able to defecate at least 2-3
times/day
Able to defecate at least 3 times during
my shift
Able to defecate at least 1 time
during my shiftb. Bladder Able to Urinate at least Able to Urinate at least 6 times during Able to Urinate at least 4 times
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30ml/hour my shift during my shiftc. Abnormalities None None None
IX. FEMALE REPRODUCTIVE STATUSa. Age of menarche 9 15 years old 13 years old b. Bladder
b. Patterns of menses 4 6 days 6 days 6 daysIX. STATE OF SKIN AND APPENDAGESa. Skin Has good skin turgor without
lesions
Has good skin turgor without lesions Has good skin turgor without lesions
b. Hair Evenly distributed hair Evenly distributed hair Evenly distributed hair c. Nails Well-trimmed/With CRT of
less than 2 seconds
Well-trimmed/With CRT of less than 2
seconds
Well-trimmed/With CRT of less than
2 seconds
X. STATE OF PHYSICAL REST AND COMFORTa. Sleep/rest pattern Able to sleep at least 8
hours/day
Able to sleep 3 hours in my shift Able to sleep 2 hours in my shift
b. Presence of pain/
discomfort
No presence of discomfort No presence of discomfort No presence of discomfort
c. Use of supportiveaids
None None None
XI. EMOTIONAL STATUSa. Emotional
Reactions
Able to verbalize emotional
feelings
Able to verbalize emotional feelings Able to verbalize emotional feelings
b. Body image Good body image Good body image Good body imagec. Ability to relate to
others
Able to follow simple
instructions and able to
related to others
Able to follow simple instructions and
able to related to others
Able to follow simple instructions and
able to related to others
XII. NURSING
DIAGNOSIS
Acute Pain related to InflammatoryProcess
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Urinalysis
EXAMINATION RESULT UNIT RANGE RESULT REMARKS
U/A color YELLOW
U/A character CLOUDU/A reaction 5.5
U/A spec. gravity 1.030U/A albumin TRACEU/A sugar Negative
U/A othersWBCUL 11 /ul 0-17
WBCHPF 2 /hpf 0-3RBC UL 3 /ul 0-11
RBC HPF 1 /hpf 0-2
ECUL 20 /ul 0-17 HECHPF 4 /hpf 0-3 H
CASTUL 0 /ul 0-1BACTUL 121 /ul 0-278
BACTHPF 22 /hpf 0-50
U/A remarksU/A pus cell /hpf
U/A RBC /hpf U/A CAST /lpf
U/A CRYSTALU/A MUCUS THREAD
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U/A SQUAMOUSU/A RENAL
BACTERIA
CBC
EXAMINATION RESULT UNIT RANGE RESULT REMARKS
Hgb 135 g/l 120-140
Hct .42 .37-.45Wbc 22.80 10s9/l 5-10 HSeg. .880 .55-.65 H
Lymphocytes .060 .35-.45 LMonocytes .050 .06-.12 L
EOSINOPHIL .010 .02-.04 LBASOPHIL .000 0-0.020
ABSOLUTENEUTROPHIL 20.29 10s9/l 1.8-7.8 H
ABSOLUTE LYMPHOCYTE .87 10s9/l 1.0-4.8 LABSOLUTE MONOCYTE 1.2 10s9/l 0-.80 H
ABSOLUTE EOSINOHIL .25 10s9/l 0-.45ABSOLUTE BASOPHIL .21 10s9/l 0-.020 H
RBC 4.62 10s12/L 4.5-5.0
MCV 92 fl 80-97MCH 29.20 pg 27-31.2
MCHC 316 318-354RDW 11.70 11.5-14.5
MPV 7.30 fl 2-20PH count 413.00 10s9/l 1470-440
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GENERIC NAME/ BRAND NAME/CLASSIFICATIO
N
MECHANISMOF ACTION
INDICATION
CONTRAINDICATION
ADVERSEREACTION
DOSAGE NURSINGRESPONSIBILIT
Y
Rationale
Generic NameHyoscine-N-butylbromide
Brand NameBuscopan
ClassificationAntispasmodics
it blocks themuscarinicreceptorsfound on the
smoothmuscle wallswhich meansits blocks theaction ofacetylcholineon thereceptorsfound withinthe smooth
muscle of thegastrointestinal and urinarytract and thusreduces thespasms andcontractions.This relaxesthe muscleand thus
reduced thepain from thecramps andspasms.
Spasm inthegenitourinary tract,
Spasm inthegastrointestinal tract,Spasm inthe biliarytract, Colic
Myastheniagravies,megacol
on,hypersensitivityto drugcontents, narrowangleglaucoma,prostate
hypertrophy withurinaryretention,mechanicalstenosisin the GItract,
tachycardia.
Constipation,Decreased,sweating,
Mouth, skin,eyedryness,Blurredfeeling,Bloating,Dysuria,Nausea or,vomiting,Lightheade
dness,Headache,Weakness
Actual1 ampIVTT
UsualAdult andchild >6y/o 1 to 2tab TID-QID
Take this drug
30 minutes to
1 hour before
meals
Buscopan will
potentiate the
effect of
alcohol and
other CNS
depressants.
Avoid driving
or operating
machinery
after parenteraldose.
Avoid strict
heat Raise
side rails as a
precaution
Reorient
patient, as
needed
To minimize GI
irritation
Alcohol is
prohibited
Because it can
cause
lightheadedness
and blurredfeelings.
Because some
patients become
temporarily excited
or disoriented and
some develop
amnesia or become
drowsy.
Tolerance may
develop when
therapy is
prolonged
Assessment Scientific Basis Planning Intervention Rationale Evaluation
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Assessment Scientific Basis Planning Intervention Rationale EvaluationSubjective:Masakit ang tyan koas verbalized by thepatient.
Objective:
Abdominal Pain
Weakappearance
Limited range ofmotion
Verbalization ofpain with a painscore of 6/10.
Facial grimace
Nursing Diagnosis:Acute Pain related to
Inflammatory Process
Gastroenteritis isthe inflammationof the stomachand intestinaltract thatprimarily affectsthe small bowel.One of themanifestations ofgastroenteritis isabdominal pain.During thecourse ofinflammation, thebodys immuneresponse,causing therelease ofcytokine and
prostaglandincausing anincrease invascularpermeability andcauses pain,which felt by thepatient in theabdomen.
After my 6hoursspan of care thepatient will beable to: report pain is
relieved from apain scale of6/10 to 2/10.
Free from painas evidence bydemonstrationof relaxationskills anddiversionalactivities withthe help of theSO.
Monitor and recordvital signs.
Review factor thataggravate oralleviate pain.
Instruct the SO tomassage the areawhere pain isElicited if notcontraindicated.
Encourage painreductiontechniques.
Provide adequaterest.
Providediversionalactivities likesocialization.
Administeranalgesics tomaintainacceptable level ofpain if notcontraindicated.
Instruct client to
perform deepbreathingexercises (DBE)
To providebaseline dataand notedeviations fromnormal.
Helpful inestablishingdiagnosis andtreatment
needs. To lessen /
alleviate paincaused byvarious factors(administermeds via IVpush).
To reduce painand promote
relief/comfort.
To promotehealing.
For clientscomfort andrelief from pain.
To decreasepain.
Deep breathing
exercises mayreduce painsensation/ usedin painmana ement
Within my 6hoursspan of care thepatient was ableto: Reported pain is
relieved from apain scale of6/10 to 2/10.
Free from painas evidenced bydemonstration ofrelaxation skillsand diversionalactivities with thehelp of the SO.
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