Arellano University

College of Nursing

Pasay City

Case Study of Patient with Dehydration

SUBMITTED BY:

FACISTOL, GIAN MARIE V.

SUBMITTED TO:

MS. EVELYN BAUTISTA, R.N., MAN

I. Introduction

DEHYDRATION (hypohydration) is defined as the excessive loss of body fluid.  It is literally the removal of water . In physiological terms, it entails a deficiency of fluid within an organism. Dehydration of skin and mucous membranes can be called medical dryness. Dehydration can be mild, moderate, or severe based on how much of the body's fluid is lost or not replenished. When it is severe, dehydration is a life-threatening emergency. Water is a critical element of the body, and adequate hydration is a must to allow the body to function. Up to 75% of the body's weight is made up of water. Most of the water is found within the cells of the body (intracellular space). The rest is found in the extracellular space, which consists of the blood vessels (intravascular space) and the spaces between cells (interstitial space).

There are three types of dehydration: hypotonic or hyponatremic (primarily a loss of electrolytes, sodium in particular), hypertonic or hypernatremia (primarily a loss of water), and isotonic or isonatremic (equal loss of water and electrolytes). In humans, the most commonly seen type of dehydration by far is isotonic (isonatraemic) dehydration which effectively equates with hypovolemia, but the distinction of isotonic from hypotonic or hypertonic dehydration may be important when treating people who become dehydrated. Physiologically, dehydration, despite the name, does not simply mean loss of water, as water and solutes (mainly sodium) are usually lost in roughly equal quantities to how they exist in blood plasma. In hypotonic dehydration, intravascular water shifts to the extravascular space, exaggerating intravascular volume depletion for a given amount of total body water loss. Neurological complications can occur in hypotonic and hypertonic states. The former can lead to seizures, while the latter can lead to osmotic cerebral edema upon rapid rehydration.

Dehydration occurs when the amount of water leaving the body is greater than the amount being taken in. The body is very dynamic and always changing. This is especially true with water in the body. We lose water routinely when we:

breathe and humidified air leaves the body (this can be seen on a cold day (the breath you see in the air is water that has been exhaled)

sweat to cool the body

Eliminate waste by urinating or having a bowel movement.

In a normal day, a person has to drink a significant amount of water to replace this routine loss.

Table 1 Daily Fluid Requirement

Body weight Daily fluid requirements (approximate)

10 pounds 15 ounces

20 pounds 30 ounces

30 pounds 40 ounces

40 pounds 45 ounces

50 pounds 50 ounces

75 pounds 55 ounces

100 pounds 50 ounces

150 pounds 65 ounces

200 pounds 70 ounces

The body is able to monitor the amount of fluid it needs to function. The thirst mechanism signals the body to drink water when the body is dry. As well, hormones like anti-diuretic hormone (ADH) work with the kidney to limit the amount of water lost in the urine when the body needs to conserve water.

Dehydration is commonly caused by loss of body fluids through prolonged vomiting, diarrhea, sweating, and frequent urination. The immediate causes of dehydration include not enough water, too much water loss, or some combination of the two. Sometimes it is not possible to consume enough fluids because we are too busy, lack the facilities or strength to drink, or are in an area without potable water.

The signs and symptoms of dehydration range from minor to severe and include:

Increased thirst Weakness Palpitation Sluggishness fainting Inability to sweat

Dry mouth and swollen tongue Dizziness Confusion Fainting Decreased urine output

II. Significance of the Study:

This study will enable the students to understand better about dehydration and the different risk factors for developing the disease. May this case study would help the students to understand and describe normal laboratory values for commonly ordered dehydration. Since we are client- centered we really should consider our patient’s comfort and this study will give the students sufficient knowledge that will help them to plan and implement nursing care plans that will satisfy patient’s needs.

III. ObjectivesA. General Objectives

This study aims to convey familiarity and to provide an effective nursing care to a patient diagnosed with dehydration through understanding the patient history, disease process and management.

B. Specific Objectives

1. To discuss the anatomy and physiology, pathophysiology of the patient’s condition, usual clinical manifestations and possible complications of this condition.

2. To have knowledge to the client medication and be familiar to that medication.

3. To formulate a workable nursing care plan on the subjective and objective cues gathered through nurse-patient interaction to be able to help the patient recover.

IV. Patient’s Profile

 A. Biographical Data

DATE OF ADMISSION: June 26, 2012 CLINICAL AREA: MS Ward Room 505

NAME: Mr. JMPA ADDRESS: 930 San Agustin St. Brgy Biwas Tanza Cavite

GENDER: Male AGE: 17 years old

CIVIL STATUS: Single DATE OF BIRTH: December 07,1994

OCCUPATION: Student BIRTH PLACE: Cavite

NATIONALITY: Filipino RELIGIOUS PREFERENCES: Roman Catholic

B. Chief Complaint

The client was complaining abdominal pain in his right lower quadrant, dizziness and suffering watery stool, that’s why they rushed the client to the hospital.

C. Final Diagnosis

Acute Gastroenteritis with moderate Dehydration; S/P ileostomy (1994)

V. Health History

A. History of Present illness

Prior to admission, the client was complaining abdominal pain in his right lower quadrant, dizziness and suffering watery stool. At first, they consult to the clinic they gave medication Buscopan IM, Metronidazole. But after drinking the medications. The client still complaining abdominal pain so the family decided to rush the client at Divine Grace Medical Center the next day.

B. History of Past illness

The client had fever, cough and colds. He had completed all vaccination including BCG, DPT, Oral Polio Vaccine, MMR and Hepatitis B vaccine. The patient had no history of accident or any injury. The patient had never been any of the childhood disease such as measles, mumps and chicken pox. He was hospitalized in year 1994 ileostomy at birth due the ruptured of the ileus at Philippine General Hospital.

VI. Laboratory Findings

RESULT UNITS REFERENCE VALUE

HEMOGLOBIN 14.9 *HIGH g/ dL 12-14

HEMATOCRIT 0.44 *HIGH % 0.37-0.42

RBC COUNT 4.70 mil/mm3 4-5.5.0

WBC COUNT 5300 /mm3 5000-10000

PLATELET COUNT 222,000 150-400,000

DIFFERENTIAL COUNT

SEGMENTERS 0.73 *HIGH /mm3 0.55-0.65

LYMPHOCYTES 0.27 /mm3 0.23-0.35

MONOCYTES

ESR mm/hr 0-20

PROTINE 13-17

CONTROL

% ACTIVITY % 70-120INR 0.9-1.2

APTT sec 23-33

RATION

COMPLETE BLOOD COUNT Date Requested: June 26, 2012

INTERPRETATION:

HIGH HEMOGLOBIN

Indicates an above-average concentration of oxygen-carrying proteins in your blood. The main component of red blood cells. Hemoglobin count also referred to as hemoglobin level indicates your blood's oxygen-carrying capacity. A high hemoglobin count is somewhat different from a high red blood cell count, because each cell may not have the same amount of hemoglobin proteins.

INTERPRETATION:

HIGH HEMATOCRIT

High hematocrits can be seen in people living at high altitudes and in chronic smokers. Dehydration produces a falsely high hematocrit that disappears when proper fluid balance is restored.

INTERPRETATION:

HIGH SEGMENTERS

One of the types of neutrophils found in the blood. They would be elevated if the overall white count is up, usually due to some kind of infection.

URINALYSIS Date Requested: June 26, 2012

Rountine Results Normal Values

Color Yellow Light yellow to amber

Characteristic SL. Hazy Clear

Reaction 6.0 4.0-7.0

S.P Gravity 1.010 1.010-1.030

Sugar Negative (-) Negative

Protein Trace * Negative

RBC 2-3 *HIGH 0-2/ hpf

Pus Cells 8-10 *HIGH 0-2/hpf

Epithelial Urates

Amorphous Phosphate

Bacteria Few

Mucus Thread

INTERPRETATION:

PROTEIN: TRACE

Protein in your urine, as trace amounts of protein are excreted in your urine as part of normal urine production. The concern is when you have too much protein in your urine. This is a symptom known as proteinuria.

INTERPRETATION:

HIGH RBC

Hematuria is the presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors which erode the urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and lower Uri urinary tract infections, nephrotoxins, and physical stress.

INTERPRETATION:

HIGH PUS CELLS

 A few pus cells or a white blood cell in urine is quite normal.  But too many of them may signal a problem somewhere in your urinary tract, the commonest of which is a urinary tract infection (UTI). Your lab will usually report the result as number of cells counted per high power field of the microscope (hpf) or number of WBCs/mL of urine. A high number of pus cells in urine are called pyuria.

VII. ANATOMY AND PHYSIOLOGY

DIGESTIVE SYSTEM

 The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestine) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals.

The Digestive Process

The start of the process - the mouth:

The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus

- After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down.

In the stomach

- The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme.

In the small intestine

- After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder),pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food.

In the large intestine

- After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon.

The end of the process

- Solid waste is then stored in the rectum until it is excreted via the anus

Digestive System Glossary

Anus

- The opening at the end of the digestive system from which feces (waste) exits the body.

Appendix

- A small sac located on the cecum.

Ascending colon

- The part of the large intestine that run upwards; it is located after the cecum.

Bile

- A digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine.

Cecum

- The first part of the large intestine; the appendix is connected to the cecum.

Chyme

- Food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion.

Descending colon

- The part of the large intestine that run downwards after the transverse colon and before the sigmoid colon.

Duodenum

- The first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum.

Epiglottis

- The flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe.

Esophagus

- The long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach.

Gall bladder 

- A small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine.

Ileum

- The last part of the small intestine before the large intestine begins.

 Jejunum

- The long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.

Liver 

- A large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins.

Mouth

- The first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food).

Pancreas

- An enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine.

Peristalsis

- Rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside-down.

Rectum

- The lower part of the large intestine, where feces are stored before they are excreted.

Salivary glands

- Glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules.

Sigmoid colon

- The part of the large intestine between the descending colon and the rectum.

Stomach

- a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach.When food enters the stomach; it is churned in a bath of acids and enzymes.

Transverse colon

- The part of the large intestine that runs horizontally across the abdomen

VIII. PATHOPHYSIOLOGY

IX. DRUG STUDY

Drug Name Uses Classification Action Contraindication Side effects NursingInterventionBrand Name Generic

NameRanitidine Hydrochloride

Apo-Ranitidine, Gen-Ranitidine, Novo-Ranitidine, Nu-Ranit, PMS-Ranitidine, Rhoxal- Ranitidine

-Short term treatment of active, benign gastric ulcer and maintenance after healing of the acute ulcer- treatment of GERD- treatment of endoscopically diagnosed erosive esophagitis and for maintenance of healing of erosive esophagus- prevent paclitaxel hypersensitivity; reduce the incidence of GI hemorrhage associated with stress-related ulcers.

Histamine H2 receptor blocking drug

Competitively gastric acid secretion by blocking the effect of histamine H2 receptors.

Cirrhosis of the liver, impaired renal or hepatic function.

Headache, Abdominal Pain, Constipation, Diarrhea, and Nausea and Vomiting.

Do not confuse Zantac with Xanax (An antianxiety drug) or with Zyrtec (an H1 receptor blocker). Do not confuse ranitidine with rimantadine (An antiviral)

GentamicinSulfate

Alcomicin, Minims,

-Infection include GI tract.

Antibiotic A powerful antibiotic

History of hypersensitivity to

Feeling sick and being

-Avoid long-term therapies because of

Gentamicin, Ratio-Gentamicin

-Used to fight a wide variety of infections caused by bacteria, such as infection in the ears, eyes, chest (including lungs), urinary tract (including kidneys and bladder) and blood.-It also used to treat severe bacterial infections in newborn babies, and to prevent infection in ears and eyes after they have been damaged.-It is a type of aminoglycoside antibiotic.-It is used to kill the bacteria and clear up the infection.In general this drug is used to fight infections by susceptible

produced by Micro-monosporapurpurea as a mixture of three main componentsCalled gentamicin C1, C1, and C2. They differ slightlystructurally, and display approximately the same antibioticActivity.

or toxic reaction with any aminoglycoside antibiotic. Safe use during pregnancy (category C) or lactation is not established

sickInflammation of the lining of any part of the mouth, such as cheeks, gums, tongue, throat and lipsHearing lossDamage to the part of the ear that controls balance, giving rise to dizziness, a spinning sensation and unsteadinessKidney damageAllergic (hypersensitivity) reactions, such as rashConvulsionsLiver problems.

increased risk of toxicities. Reduction inDose may be clinically indicated.-Patients with edema or ascites may have lower peak concentrations due toexpanded extracellular fluid volume.-Cleanse area before application of dermatologic preparations.-Ensure adequate hydration of patient before and during therapy.-Monitor renal function tests, CBCs, serum drug levels during long-term therapy.Consult with prescriber to adjust dosage.

bacteria.-Benefits of being on this drug can include treatment of infections caused by bacteria and prevention of bacterial infections in eyes and ears that have been damaged and relief of pain caused by such infections.

X. NURSING CARE PLAN

Problem: Fluid Volume Deficit / Fluid Loss

Assessment Diagnosis Planning Implementation EvaluationData Collection Cues

Collaborative Problem

Goal/Objectives Nursing Intervention

Rationale for Nursing Intervention

Expected Patient outcome

Subjective Cue:“Masakit ang tyan ko at nahihilo. Nagtatae din ako” as verbalized by the patient.

Objective Cue:Patient manifested:-Weakness-Dry Skin-Irritability-Poor Skin Turgor

V/ST: 36.0 CPR: 64 bpmRR: 23 cpmBP: 120/70 mmHg

Fluid Volume Deficit Related to Dehydration as evidenced by Decreased Urine Output, and weight loss.

Within 8 hours of the nursing interventionThe patient will be able to maintain adequate fluid volume as evidenced by:urine output of 50-60ml/hr, moist skin, and good skin Turgor

Independent:

Provide rapport to the patient.

Monitored vital signs; noted changes in body Temperature.

Observed for postural BP changes; encouraged gradualPosition changes.

Palpated peripheral pulses assessed capillary refill, mucous membranes, and skin Turgor.

Observed for

To gain trust and full of cooperation of the patient.

Increased HR alongwith decreased BP andelevated temperature,is present inconditions with fluidVolume deficit. Increased body temperature also increases fluid loss by increasing metabolism.

Patients may experience varying degrees of posturalhypotension dependingon degree of fluid

After 8 hours of the nursing intervention the Patient will able to maintained adequate fluid volume as evidenced by Urine output of 50-60ml/hr, moist skin, good skin Turgor Goal Met.

changes in mental status.

Encouraged increase in fluid intake and consumption of foods high in fluid content.

Turned patient q2hand provided supportFor body prominences.

Dependent:

Administered IV fluids as ordered.

Excessive fluid loss through regulatory mechanisms failure may result in severe dehydration, circulatory collapse, and shock.

Decreased cerebral perfusion may result in changes in mentation.

Relieves thirst andaids in body fluidReplacement.

Patients with fluidvolume deficit aremore at risk for skinBreakdown.

Aggressive fluid replacement may be required to correct fluid volume deficit.

XI. DISCHARGE PLANNING

Medication Instruct patient to take all the prescribed medications at the proper time and dosage for the specific duration as the doctor has ordered.

Co-trimaxole - 800mg tab

-Take 1 tablet twice a day for three days

-Take the drug at the same time each day.

-Avoid using 2-4 hours after taking other medications.

-Take the medication after meals.

Erceflora vial - Take 1 vial twice a day to consume seven more vials

-Take the medication after meals.

Zinc Syrup -Take 15 mL once a day for two weeks

-Vitamins supplements that he will take for two weeks.

Environment/Exercise Walking Exercise: Is most basic and best exercise for the children to help get fresh air, and to maintain body regularly.

Environment:

- Get out of direct sunlight and lie down in a cool spot, such as in the shade or an air-conditioned area.

Treatment - Increase Oral Fluid intake, to helps prevent Dehydration

- -Co-trimaxole - 800mg tab BID

- Walking Exercise.

Health Teaching - Explain the Dehydration to the Patient.

- Inform them to do walking exercise to help get fresh air, and to maintain their body regularly.

- Instruct patient to take all the prescribed medications at the proper time and dosage for the specific duration.

- Tell to them to get out of the direct sunlight.

- Make sure that they can engage physical exercise, and advise them to eat foods that a lots of vitamins and minerals to enhance body immunity.

Out Patient (follow up consultation)

- Instruct the patient to return to the Attending Physician for follow up check-up and for emergency medical assistance.

Diet - Diet as Tolerated- Increase oral fluid intake: To prevent the dehydration.- Avoid juices and coffee, To prevent abdominal pain

Spiritual - Advise the patient to encourage praying to God as the Family does every day and to strengthen their faith.