Age

Acute Gastroenteritis

Health History

Demographic Data

Demographic Data

Client’s Name: Baby LC

Gender: Male

Age/ Birth Date/ Birthplace: 5 months old/

February 25, 2011/ Manila

Civil Status: Single (Child)

Demographic Data

Race/ Nationality: Filipino

Religion: Roman Catholic

Address: Kawit, Cavite

Usual Source of Medical Care: Hospital -

Philhealth

Source & Reliability ofInformation

Source & Reliability of Information

Patient’s chart

Patient’s mother

Patient himself

Reason for Seeking Care

Reason for Seeking Care

10 episodes of diarrhea

History of Present Illness

History of Present Illness

Few days prior to Baby LC’s admission, he defecated more than 10 times. His mother described his stool as watery in consistency and transparent to yellowish in color. His mother reported 1 episode of blood-streaked stool.

Past Medical History

Past Medical History

Injuries/ Accidents: None

Hospitalization: None

Immunizations: Hepa B Vaccine, DPT, OPV, BCG

Allergy No Known Allergy

Last Examination Date: July 6, 2011 (SDMC)

Family History

Developmental History


Sigmund Freud’s Psychosexual Development

Oral (birth – 1 year old) Anal (1-3 years old)

Phallic (3 – 6 years old) Latency (6 – puberty)

Genital (puberty – death)


Stage Task Patient’s Description

Oral

(Birth – 1 year)

Infant's mouth is the focus of libidinal gratification derived from the pleasure of feeding at the mother's breast, and from the oral exploration of his or her environment

Baby LC is taking formula milk instead of breastmilk. At the same time, his current condition (AGE) usually derived from sucking dirty things

Review of Systems

Review of Systems

Regional Examinations

General/ Overall Health State 5 months old 7.5 kg in weight Vital signs of 36.2°C (temperature),

33 bpm (respiratory rate), 110 bpm (pulse rate)

Review of Systems

Regional Examinations

Integument Skin rashes are covering half of his

buttocks * Skin rashes – pinkish to reddish in

color and approximately 3-5 cm in circumference each circle

Review of Systems

Laboratory Results:Procedure Normal Values Findings Interpretation

Hemoglobin 140-180 116 Low Iron intake

Hematocrit 0.42-0.54 0.35 Low Iron intake

WBC 5-10 10.36 Infection

Lymphocytes 25-40% 51.8 Viral infection

Functional Assessment

Functional Assessment

Elimination

Baby LC defecated 2 times from 6 o’clock in the morning up to 12 o’clock in the afternoon. The color of his stool is yellowish and semi-formed in consistency

Pathophysiology

Concept mapping

Impaired skin integrity r/t

irritation of the skin from

excessive moist aeb skin rashes

Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6

hours

Baby LC

Dx: Acute Gastroenteritis

Signs & Symptoms:

*defecated 2x

*watery to semi-formed stool

*skin rashes (pinkish to reddish)

1 2

Problem list

Problem List

Actual

Number Problem

1 Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes

Potential

Number Problem

1 Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6 hours

Nursing care plan

Impaired Skin Integrity

Assessment Diagnosis Planning Nursing Intervention

Evaluation

S: No verbal cues O: defecated 2xwatery to semi-formed stoolskin rashes (pinkish to reddish, 3-5 cm in circumference each circle) located at the buttocks

Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes

At the end of the entire shift, the patient will lessen his skin irritation due to excessive moist

•Assessed site of skin impairment•Advised the patient’s mother to lessen the positioning on the affected area•Advised the patient’s mother to check most of the time the affected area and report immediately if the condition worsen•Advised the patient’s mother to change immediately the diaper especially when soaked •Advised the patient’s mother to use topical cream

At the end of the entire shift, the patient’s skin irritation was lessened

Risk for Fluid Volume Deficit

Assessment Diagnosis Planning Nursing Intervention

Evaluation

S: No verbal cuesO: defecated

2x watery to

semi-formed stool

Risk for fluid volume

deficit r/t diarrhea aeb 2x defecation

in 6 hours

At the end of the entire shift, the patient will be free from fluid volume deficiency

•Monitored intake and output•Advised the patient’s mother to increase oral fluid intake of Baby LC•Hydrated the patient with water mixed with Protexin•Administered IVF

At the end of the entire shift, the patient has no signs of fluid volume deficiency or mild dehydration. No depressed fontanel and sunken eyeballs noted

Medical-surgicalmanagement

Drug Study

Name of Drug & Action

Classification Adverse effect Indication Contraindication Nursing Responsibilities

Protexin (Restore)Helps to improve the balance of microorganism in the intestinal tract

Vitamin for growth and health. It helps the body use carbohydrates, fats and protein. It also strengthens blood vessel walls

Probiotic Nausea and vomiting, stomach pain, severe diarrhea, dehydration

Prolonged diarrhea, prolonged infection, prolonged fever, intestinal disease, stress

Blood problems, Glucose-6-phosphate dehydrogenase (G6PD) deficiency

•Observe the 5 rights in giving medication•Advise the patient’s mother to:

-Strictly follow the doctor’s advise on how much to take and how often

-May be taken with or without food

-Try not to miss any doses



Zinc Sulfate (E-Zinc)

Contributes to the recovery of the intestinal microbial flora and maintenance of skin hydration

Trace element

Nausea and vomiting, dizziness, fever, stomach pain, incoordination, restless

Acute diarrhea

Immuno- compromised patients

•Observe the 5 rights in giving medication•Shake drug well before administra-tion•Monitor patient for any unusual effect



Benzal-konium ( Drapolene)

It cleans and disinfect skin or surrounding tissues

Antiseptic Localized dermatitis, pruritus

Nappy rash & Urinary rash

Hypersensitivity to benzalkonium chloride, cetrimide or lanolin

•Store below 25°C•Tell the patient’s mother that it is for external use only•Advise the patient’s mother to discontinue the topical cream if adverse reaction occur



Ampicillin (Liferzin)

It stop microorganisms from multiplying

Antibiotic Anemia, Restlessness, fever

Treatment of infection caused by susceptible strains

Allergic to penicillin, cephalosporins

•Take the drug around-the-clock•Take the full course of therapy•It should not be used to self-treat other infections aside from what the doctor stated•Advise to report N/V, diarrhea

Discharge healthteaching

Discharge Health Teaching

Medication

Advise the patient’s mother to continue his medication regimen especially the antibiotic/s

Instruct patient’s mother to comply with the drugs as prescribed by the doctor and do not abruptly stop the drug without doctor’s consent


Exercise

Advise the patient’s mother to allow and support Baby LC in playing and moving- around because it serves as his ADL


Treatment

Continue medication as prescribed by the doctor and follow doctor’s advise


Health Teaching

Advise the patient’s mother to perform proper hygiene for Baby LC (bathing)

Emphasize to the patient’s mother the importance of proper caring and cleaning of the mouth and genital Before performing any cleaning or changing, make sure to

do hand washing Ensure that the new diaper fits perfectly Advise to change the diaper immediately especially when

soaked with urine and stool Gently pat dry the skin with wipes after washing and

cleaning


OPD

Advise the patient’s mother to seek follow-up check-ups for Baby LC


Diet

There are no dietary restrictions (milk feeding as tolerated)


Signs & Symptoms

Be sure to call the physician if these signs & symptoms occur: Fever Diarrhea or vomiting Swelling of the buttocks

Thank You

Presented by: Arrian L. Dabu

Age

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