Our Lady of Fatima University

120 McArthur Highway, Valenzuela City

College of Nursing
Nursing Care Management 107B

ACUT GASTROENTERI E TIS

A Case Study

Submitted By:

Cruz, Nikki John N. Cuison, Desirie R. Devilles, Rocel V. Enriquez, April Lyn M. Felipe, Jam Marie S. Ferrer, Kathreen Alexis C.
BSN4Y2-2A

Submitted to: Mrs. Bernadette Antonio RN, MAN

Clinical Instructor

Introduction
Gastroenteristis is a medical condition characterized by inflammation or irritation of the gastrointestinal tract that particularly involves the stomach and the small intestines. It is also referred to as the stomach flu or intestinal flu, although the influenza virus is not associated with the illness. Viruses, particularly rotavirus, and the bacteria Escherichia Coli and Campylobacter species are the primary causes of gastroenteritis. There are, however, many other infectious agents that can cause this syndrome. Non-infectious causes are seen in occasion, Food that has spoiled may also cause illness. Certain medications and excessive alcohol can irritate the digestive tract to the point of inducing gastroenteritis, but they are less likely than a viral or bacterial cause. Risk of infection is higher in children due to their lack of immunity and relatively poor hygiene. Major symptoms include nausea and vomiting, diarrhea, abdominal pain and cramps. Sufferers may also experience bloating, low fever, and overall tiredness. Typically, the symptoms last only two to three days, but some viruses may last up to a week. A usual bout of gastroenteritis shouldn't require a visit to the doctor. Adults usually recover without problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to complications. The greatest danger presented by gastroenteritis is dehydration. The loss of fluids through diarrhea and vomiting can upset the body's electrolyte balance, leading to potentially life-threatening problems such as heart beat abnormalities (arrhythmia). The risk of dehydration increases as symptoms are prolonged. The symptoms of gastroenteritis are usually enough to identify the illness. Unless there is an outbreak affecting several people of complications is encountered in a particular case, identifying the specific cause of the illness is not a priority. However, if identification of the infectious agent is required, a stool sample will be collected and analyzed for the presence of viruses, disease-causing (pathogenic) bacteria, or parasites. Blood tests, electrolyte test could also be done in relation to diagnosing the

illness. Management of the illness particularly involves hydration, replacing loss fluids and electrolytes, with such intravenous fluids will be administered after assessment of the patient status.

Patient Profile
Patient M.V.S., 35 years old, female on status post low transvere cesarean section, with no known history of hypertension, diabetes mellitus, tuberculosis, asthma, and cancer, was admitted in the institution at 05:30am of December 03, 2013, with a complaint of severe loose bowel movement associated with vomiting and hypotension. Dr. Agulo and Dr. Mavata was the attending physician. One day prior to admission, patient felt pain on the abdomen upon ingestion of tap water and spoiled food, with persistent vomiting and diarrhea (loose watery stools). Patient was then diagnosed with hypovolemic shock secondary to sepsis, acute gastroenteritis, and severe syndrome of dehydration.

Anatomy and Physiology

Gastrointestinal System The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls. The primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and

subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces). In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of nausea, vomiting, diarrhea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.

Oral Cavity: The oral cavity or mouth is responsible for the intake of food. Its function is the absorption of small molecules such as glucose and water, across the mucosa. From the mouth, food passes through the pharynx and esophagus via the action of swallowing.

Salivary Glands: Each is a complex gland with numerous acini lined by secretory epithelium. Salivation occurs in response to the taste, smell or even appearance of food. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth.

Esophagus: The esophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It functions primarily as a transport medium between compartments. Stomach: The stomach is a J shaped expanded bag, located just left of the midline between the esophagus and small intestine. The stomach can hold up to 1.5 litres of material. The functions of the stomach include: the short-term storage of ingested food, mechanical breakdown of food by churning and mixing motions, chemical digestion of proteins by acids and enzymes, stomach acid kills bugs and germs, some absorption of substances such as alcohol. Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and

fundus. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins. Small Intestine: The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. The mucosa of the small intestine contains several specialized cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions. Large Intestine: The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The functions of the large intestine can be summarized as: the accumulation of unabsorbed material to form faeces, some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas, reabsorption of water, salts, sugar and vitamins. Liver: The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen. It acts as a mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several metabolites including the breakdown of bilirubin and estrogen. In addition, the liver has synthetic functions, producing albumin and blood clotting factors. Gall Bladder: The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the liver's right lobe. The main functions of the gall bladder are storage and concentration of bile. Pancreas: the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the spleen. The pancreas has both exocrine and endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The exocrine (secretrory) portion makes up 80-85% of the pancreas and is the area relevant to the gastrointestinal tract. Pancreatic enzymes include carbohydrases, lipases, nucleases and proteolytic enzymes that can break down different components of food.

Pathophysiology

Ingestion of tap water and spoiled foods

Bacterial attack in G.I causing Acute Gastroenteritis

Abdominal pain

Vomiting

Diarrhea

Increased WBC

Widened blood vessels to accommodate increase in blood components

Decreased fluid volume in the body / Decreased intravascular volume

Decreased cardiac output (hypotension, decreased blood flow)

Dehydration

ADH, Aldosterone secretion (decreased urine output)

Shift of interstitial fluid (poor skin turgor, sunken eyeballs)

Activation of the sympathetic nervous system

Increased fluid volume

Release of cathecholamines

Increased

Increased systemic

Increased cardiac output Compensatory mechanism fails

Continued volume loss

Decreased systemic pressure (decreased bp)

Decreased pulmonary pressure

Decreased cardiac output

Decreased tissue perfusion

Impaired cellular metabolism

Hypovolemic shock

Physical Assessment
Assessment Head Hair Facial Features Eyes Ears Nose Lips Neck Skin Color Turgor Temperature Chest Abdomen Upper Extremities Fingernails Lower Extremities Toenails Findings Normocephalic and symmetric Black; evenly distributed Symmetric Sunken eyeballs Symmetric Symmetric; no discharge Dry Normal; head centered Dry Brown; uniform When pinched, skin springs back to previous state Slightly cold Symmetric; no lesions found; spine vertically aligned Slightly distended Normal; symmetric; no lesions found No clubbing; capillary refill < 2 seconds Normal; symmetric; no lesions found No clubbing

Course in the Ward

Patient M.V.L. was brought to the emergency room at 2:00 am of December 3, 2013. She was examined by Dr. Agullo and Dr. Navata. Diagnostic work-ups were requested and done. She was hooked with PLR 1L x 6 hours. She was given Piperacillin + Tazobactam 4.5 g then 2.25 g every 8 hours; Omeprazole 40 g TIV OD; Paracetamol 500 g/tab every 4 hours for temperature of greater than 37.8 degree Celcius and Metoclopramide every 8 hours as needed. At 5:00 am, PNSS 1L x 6 hours was hooked. At 6:00 am, she was given her second bottle of PLR 1L x 6 hours and D5W 500 cc + 2 vials Dobutamine 20 gtts/min. At 8:00 am, she was admitted at OBS-

Adult bed 1 then transferred to bed 7. Vital signs were monitored every 2 hours and intake and output Result 38.6 H10 7/1 6.94 H 1012/1 213 H g/1 0.638 H 1/1 Platelet 394 107/1 was measured by 2:00 pm. CBC White blood cell Red blood cell Hemoglobin Hematocrit Reference 5.0-10.0 4.50-5 125-160 0.3800.500 150-400 Remark Leukocytosis -Infection Polycythemia Polycythemia Polycythemia Normal Name MCV MCH MCHC RDW MPV Result 92 fl 30.7 pg 334 g/l 13.1 % 7.8 fl Reference 80-100 27.0-32.0 320-360 11.5-14.5 6.0-10.0 Remark Normal Normal Normal Normal Normal

Related Treatments Laboratory Results

Complete BloodCount

Implication: A high number of WBCs is called leukocytosis it may be due to tissue damage. Higher-thannormal numbers of RBCs may be due to: Dehydration (such as from severe diarrhea). If blood tests indicate high red blood cells, hematocrit and hemoglobin it may be an indication of dehydration there is diarrhea.

Urinalysis PHYSICAL Color Result Dark Green Soft Remark Increase Bile in the stool Normal CHEMICAL Occult blood Result Remark

Consistency MICROSCOPIC RBC Pus cells Yeast cells Fat globules

others Ova/Parasites/Cysts Ascaris Lumbricoides Trichuris Trichiura Hook Worm Trichomonas Hominis

No ova/ Parasite seen No ova/ Parasite seen No ova/ Parasite seen No ova/ Parasite

Normal Normal Normal Normal

Muscle Fiber Vegetable Fiber Bacteria Others

Entamoeba Coli Entamoeba Histolytica (+) Infection Endolimax Nana Blastocystis Hominis

seen No ova/ Parasite seen No ova/ Parasite seen No ova/ Parasite seen No ova/ Parasite seen

Normal Normal Normal Normal

Implication: If stool passes through the intestine too quickly, there might not be enough time for bile to be digested and broken down to provide the normal brownish stool color. It takes time for the bile to degrade and turn brown in the intestine and if the transit time is short, the stool remains green colored. This is why diarrhea is often greenish in color. Bacteria are present because of severe LBM.

Serum Electrolytes Serum Electrolytes Sodium Potassium Chloride Result 137.30 5.51 107.10 Unit Mmol/L Mmol/L Mmol/L Remark Normal Hyperkalemia Hyperchloremia Reference 135-148 3.50-5.30 98-107

Implication: High blood potassium, or hyperkalemia, often indicates that the body is producing too much potassium or that the kidneys can no longer remove excess potassium properly. Hyperkalemia can indicate kidney failure and infection. High levels of chlorine in the blood can be a symptom of high blood pressure.

BUN and Creatinine Test BUN Creatinine-S ALT/SGPT Full Name Blood urea nitrogen Creatinine ALT Result 13.49 243.1 150.3 Unit Mmol/L Umol/L U/L Remark Kidney Failure Kidney Failure Liver Problem Reference 2.50-6.50 61.9-121.1 0.0-34.0

Implication: a high creatinine level may mean your kidneys are not working properly. A BUN-tocreatinine ratio can help your doctor check for problems, such as dehydration, that may cause abnormal BUN and creatinine levels. Elevated liver enzymes may indicate inflammation or damage to cells in the

liver. Inflamed or injured liver cells leak higher than normal amounts of certain chemicals, including liver enzymes, into the bloodstream, which can result in elevated liver enzymes on blood tests.

Urinalysis (2)

Physical Color Transparency Reaction Specific Gravity Microscopic Casts Pus cell casts RBC Granular Cast (fine) Granular Cast (coarse) Hyaline Cast Waxy Cast Cells RBC Pus cells Yeast Cells Sperm Cells Pregnancy Test

Result Beer Brown Cloudy 1.030

Remark UTI UTI Normal

Chemical Albumin Sugar Urobilinogen Ketones Crystals Amorphous urates Calcium Oxales Uric Acid Amorphous Phosphates Tyrosine

Result (-) (-)

Remark Normal Normal

Some

Normal

1-2 2-3

Hematuria -UTI Infection

Epithelium Squamous Cels Renal Cells Mucus Threads Bacteria Trichomonas Vaginalis

few

Normal

few

Normal

Implication: Brown urine is an indication of a serious condition. It could be caused by liver disease or hepatitis. Cloudy and Presence of pus in the urine is a sign of a urinary tract infection, which may also cause a bad smell. Milky urine may also be caused by bacteria in the urine

Discharge Planning

The patient was ordered to go home with advised of her physician to continue her prescribed medications such as Omeprazole 40 g once a day and Metoclopromide every 8 hours. She was encouraged to drink lots of water every day to correct fluid losses from vomiting and diarrhea and to maintain hydration status. She was encouraged to have at least 15-30 minutes of exercise every morning. Patient was instructed about signs and symptoms of complications of diarrhea: cardiac dysrhythmias due to fluid and electrolyte (potassium) imbalance, urinary output less than 30 cc/hr, muscle weakness, paresthesia, hypotension, anorexia, and drowsiness. She was also encouraged to follow a perianal skin care routine to decrease irritation and excoriation. Adequate rest was advised to avoid fatigue. She was advised to follow up when she experienced abdominal pain and severe headache unrelieved by the prescribed medications; continuous vomiting or frequent watery stools. Patient was recommended to have Complete Blood Test every 1 to 2 months. She was also instructed to restrict intake of milk products, fat, whole grain products, fresh fruits, and vegetable for several days. And she was then instructed to develop spiritual self, like meditating or praying, which can help to relieve her stress.