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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_Intestine


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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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