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Patient Profile

Patient Profile

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Published by: bangus08 on Jul 15, 2009
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General Objectives

The purpose of this is to present a general picture of Acute Gastroenteritis through effective nurse-patient interaction and relevant researches with critical, competent, and collaborative application of the nursing process.

Specific Objectives:
 To obtain pertinent information about the patient’s demographic and socioeconomic profile.  To be well – informed on the patient’s history including the past and present hospitalization.  To be knowledgeable on the different diagnostic procedure to be ruled – out acute gastroenteritis, focusing on the nursing responsibilities and patients teaching.  To be familiar with the structure of stomach and function of its parts.  To educate our selves about the pathophysiology of acute gastroenteritis, its pathogenesis, causes and its clinical manifestation.  To identify the medical and surgical management indicated for the patient.  To be acquainted with the medications prescribed for the patient noting there therapeutic effects and adverse reactions.  To established appropriate nursing care plan that includes the dependent, independent and collaborative nursing; and lastly  To formulate necessary discharge planning and health teachings essential for the patients fast recovery and prevention of possible complication.

PATIENT PROFILE
Name: Mika Mamburan Address: Mangaldan, Pangasinan Civil Status: Single Religion: Roman Catholic Chief Complain: LBM Date/Time of Admission: July 09, 2009 Attending Physician: Dr. Esperanza Age: 6 months Nationality: Filipino

GENERAL DATA:
A care of Mika Mamburan, 6mo. Old infant, female, Filipino, born on Dec. 16, 2008 residing of Mangaldan, Pangasinan and admitted for the 1st time at Region 1 Medical Center on July 09, 2009 around 10:30 am. Informant: Mother Reliability: 85% Chief Complain: LBM

HPI:
Patient was apparently well until a day prior to admission, patient had LBM, episodes, of watery consistency, yellowish in color. Her condition was accompanied by fever, undocumented, remittent. No consultation was done but the mother gave paracetamol offering no relief. Few hours prior to admission, the informant noticed loss of appetite and the above mentioned condition was persisted, thus prompted the mother o seek consult, hence the admission.

Past Personal History:
*The Prenatal History
The mother was 28y/o, G2 p1 (1001), cognizant of pregnancy ay 2mons. AOG due to amenorrhea confirmed by (+) pregnancy test. Prenatal checkups were done at health center for 5 times with regular intake of multivitamins. Patient’s mother had LBM of unknown mos. AOG during her pregnancy, the informant claimed that she took cotrimoxale given by the midwife. No other complications noted like HPN, bleeding, trauma.

Natal History:
Patient was born via NSO, cephalic, term, home delivered assisted by midwife after 4hrs. of labor, cries immediately. Birth weight - undocumented.

Neonatal History:
There was no cyanosis at birth, no jaundice noticed on the first 24hrs. of life. No convulsion. No umbilical stamp fell off after 2weeks.

Feeding History:
Patient was on a formula feeding, (2;1) on a per demand type. No allergic noted on the type of milk given, Bonamil.

Immunizations:
The following vaccines were given of unrecalled month of administration. 1 dose of BCG.

Past History:
No history of illness, hospitalization, trauma & major operation. No allergies to foods and drugs.

Family History:
Mother: 28 y/o, vendor, healthy Father: 34 y/o, vendor, healthy Denies any heredofamilial diseases like DM, HPN, asthma, carcinoma. No exposure to TB.

*Growth and Developmental Milestone*
(+) head control (+) hands together (+) rolls over

Social and Environmental History:
Patient lives in a cement type house, owned. Source of drinking water is from mineral water their garbage are collected.

Patient of Systems:
General: weak looking, poor appetite HEENT: (-) head injury, redness, epistaxis, gum bleeding (+) no tears Chest and Lungs: (-) dyspnea Hearth: (-) palpitations GIT: see HPI Cut: (-) hematuria Neurologic: (-) seizures

Physical Examination:
Patient is conscious, febrile, weak looking, irritable, mild cardio pulmonary distress Vital Signs: CR: 109 RR:102 Temp.:40 WT:6KG HO:41 CC;39 AC:40

Skin: No rashes, po0r skin turgor, dry skin HEENT: Pink palpebral conjuncture, anisteric sclerae, deep eyeball, no discharges. Chest & lungs: Symmetrical chest expansion, (+) retraction, (+) crackles Hearth: Dynamic precardium, no murmur Abdomen: Glubural, soft, non-tender Extremities: grossly normal

Assessment:
Age with Severe Dehydration

MEDICAL DIAGNOSIS ACUTE GASTROENTERITIS WITH SEVERE DEHYDRATION
WHAT IS AN ACUTE GASTROENTERITIS?
Gastroenteritis is the irritation and inflammation of the digestive tract. This condition may cause abdominal pain, vomiting and diarrhea. Severe cases of gastroenteritis can result in dehydration. In such cases, fluid replacement is the primary factor in treatment. All ages and both sexes may be affected yet the most severe symptoms are experienced by infants and those individuals over sixty years old. The use of certain drugs such as aspirin, antibiotics or cortisone drugs may increase risk for this condition. Food poisoning, stress, excessive alcohol or tobacco use, viral infections, food allergies, improper diet, certain drugs, food consumed in foreign countries and intestinal parasites are all possible causes for this condition.

What causes it?
Gastroenteritis can be caused by viral, bacterial, or parasitic infections. Viral gastroenteritis is highly contagious and is responsible for the majority of outbreaks in developed countries. Common routes of infection include:
• • • • •

Food (especially seafood) Contaminated water Contact with an infected person Unwashed hands Dirty utensils

In less developed countries, gastroenteritis is more often spread through contaminated food or water.

What are the symptoms of gastroenteritis?
The main symptom of gastroenteritis is diarrhea. When the colon (large intestine) becomes infected during gastroenteritis, it loses its ability to retain fluids, which causes the person’s feces to become watery. Other symptoms include:
• • • • • • • • • •

Abdominal pain or cramping Nausea Vomiting Fever Poor feeding (in infants) Unintentional weight loss (may be a sign of dehydration) Excessive sweating Clammy skin Muscle pain or joint stiffness Incontinence (loss of stool control)

Because of the symptoms of vomiting and diarrhea, people who have gastroenteritis can become dehydrated very quickly. It is very important to watch for signs of dehydration, which include:
• • • • • •

Extreme thirst Urine that is darker in color Dry skin Dry mouth Sunken cheeks or eyes In infants, dry diapers (for more than 4-6 hours)

How common is gastroenteritis?
Because gastroenteritis is so similar to diarrhea, and because so many cases do not require hospitalization, it is difficult to determine how many cases of gastroenteritis occur per year. Worldwide, it is estimated that three to five billion cases of acute diarrhea (which can be caused by many other diseases besides gastroenteritis) occur per year, with about 100 million cases in the United States (roughly one to 2.5 cases of diarrhea per child). Gastroenteritis is estimated to cause about 5 to 10 million deaths per year worldwide, and about 10,000 deaths per year in the United States.

Who is at risk for gastroenteritis?
Anyone can get the disease. People who are at a higher risk include:
• • • •

children in daycare students living in dormitories military personnel, and travelers

People with immune systems that are weakened by disease or medications or not fully developed (i.e., infants) are usually affected most severely.

How is gastroenteritis diagnosed?
The doctor will take a medical history to make sure that nothing else is causing the symptoms. Also, the doctor might perform a rectal or abdominal examination to exclude the possibilities of inflammatory bowel disease (e.g., Crohn’s disease) and pelvic abscesses (pockets of pus). A stool culture (a laboratory test to identify bacteria and other organisms from a sample of feces) can be used to determine the specific virus or germ that is causing gastroenteritis. Other diseases that could cause diarrhea and vomiting are pneumonia, septicemia (a disease caused by toxic bacteria in the bloodstream), urinary tract infection, and

meningitis (an infection that causes inflammation of the membranes of the spinal cord or brain). Also, conditions that require surgery, such as appendicitis (an inflammation of the appendix), intussusception (a condition in which the intestine folds into itself, causing blockage) and Hirschsprung’s disease (a condition where nerve cells in the intestinal walls do not develop properly) can cause symptoms similar to gastroenteritis.

How is gastroenteritis treated?
The body can usually fight off the disease on its own. The most important factor when treating gastroenteritis is the replacement of fluids and electrolytes that are lost because of the diarrhea and vomiting. Foods that contain electrolytes and complex carbohydrates, such as potatoes, lean meats (e.g., chicken), and whole grains can help replace nutrients. You can also buy electrolyte and fluid replacement solutions at food and drug stores. Or, if hospitalization is required, the nutrients can be replaced intravenously (injected directly into the veins).

How can gastroenteritis be prevented?
There are several steps that you can take to reduce your risk of getting gastroenteritis, including:

Washing your hands frequently, especially after going to the bathroom and when you are working with food; Cleaning and disinfecting kitchen surfaces, especially when working with raw meat or eggs; Keeping raw meat, eggs, and poultry away from foods that are eaten raw Drinking bottled water and avoiding ice cubes when traveling

• •

Stomach
Anatomy
The stomach is a “J” shaped hollow, muscular organ suspended under the diaphragm. The upper larger portion of the stomach or Fundus is situated in the upper left quadrant of the abdomen and entrance to the stomach is gained through the esophagus through the Gastroesophageal Juncture (GE juncture or sometimes called the cardiac sphincter). Anatomically its structure narrows as it gradually slopes downward towards the midepigastric right hand quadrant, where it eventually passes into the pyloric sphincter and empties into the 1st phase of the small intestine- the duodenum. The major portions of the stomach include the fundus (upper), body (middle), and antrum (lower). Sometimes a fourth area is identified immediately upon entry into the stomach as the cardiac region . As the stomach descends to the right quadrant the upper smaller angulation is termed the lesser curvature whereas the lower much longer angulation is termed the greater curvature . On average the adult stomach can hold about 5 to 8 pints, and weighs about 4.5 ounces.

Ventral aspect of the exterior of the stomach; Ventral aspect of the posterior mucosa of the stomach. 1 Esophagus 2 Cardiac Notch 3 Cardiac part of the stomach 4 Lesser Curvature 5 Pyloric Sphincter 6 Angular Notch 7-8 Antrum 9 Fundus 10 Greater Curvature 11 Body 12 Gastric Folds Tissue There are three layers of muscle utilized in the functioning of the stomach: an outer longitudinal muscle layer, a middle circular muscle layer, and an inner oblique muscle layer. These muscles are used in peristalsis and digestion of chyme (food and gastric enzymes). The oblique layer muscle is covered with a mucous membrane. This membrane contains many gastric glands designed with different regulatory functions. The shape of this membrane is distinguished by its convolutions called rugae , which in appearance are similar to the convolutions of the brain and seem to wane as the wall of the stomach expand.

Vessels and Nerves
Blood is supplied to the stomach via the gastric, pyloric and branches of the splenic arteries. The left side of the stomach is drained via the gastric vein and the right side is drained via the splenic vein and superior mesenteric vein. The stomach is innervated by both sympathetic fibers of the celiac plexus and parasympathetic fibers of the gastric branch of the vagus nerve.

Function
The function of the stomach is to receive food from the esophagus and churn it with digestive juices into a pasty substance called chyme. The convolutions noted in the stomach are from gastric glands in the mucosal lining of the stomach. These glands also known as “pits” contain several secretory cells :

Gland Mucous Cell Parietal Cells

Product Alkalytic mucous Hydrochloric Acid Intrinsic factor

Function Protective Barrier on stomach Acidic area for action of pepsin Intestinal absorption of B 12 Precursor to Pepsin (converted In the presence of pH < 5.0; HCL)

Chief Cell

Pepsinogen

There are 3 phases of gastric juice secretion:
Cephalic phase
The sensory phase where stimuli are received thru the senses (tasting, chewing and swallowing) This phase is under the direction of the vagus nerve and its release of Ach for activation of the parietal and chief cells, which in turn secrete Acid and Pepsinogen. This phase may also fall under the response of insulin secretion from hyperglycemia

Gastric Phase
Is initiated when food actually enters the stomach which distends the stomach or when digested proteins are detected. These proteins are broken down from the enzyme Pepsin. Gastrin is released which causes enhanced secretory effects.

Intestinal Phase
The movement of chyme into the duodenum. The acidity from the chyme causes a release of a hormone cholecystokinin pancreozymin, which inhibits Gastrin stimulated acid production and inactivates pepsin thus ending the cycle. At rest, gastric secretion in the stomach averages about 50 milliliters of fluid

Urinary Result:
Mika mamburan Pedia Color: yellow Transparency: Sligthly turbid pH: no rgt Specific gravity: no rgt Protein: no rgt Sugar: no rgt Lab. Test No. Age: 6 mos. Epithelial cell: same Pus cell: 1-3/hpf RBC: 2-3/hpf Amorphous (urates): few Sex: F

Fecalysis Result:
Color: yellow Consistency: mucoid RBC: 0-1/hpf Pus cells: 0-1/hpf Others: fat globules #

Hematology Result:
Exam Name: WBC count Neutrophilis Hemoglobin Hematocrit Platelet Result 16.9 0.59 110 0.34 496 10^9/L g/dl Unit 10^9/L Normal Values 6.0-14.0 0.36-0.66 105-140 0.32-0.42 140-440 10^9/L

Blood Chemistry Report:
Normal Values Sodium Potassium Chloride 151mmol/L 4.79mmol/L 131.6mmol/L 135.0-148.0mol/L 3.5-5.3mmol/L 95-103mmol/L

Medication
Ampicillin 150mg IVF q6 hours Paracetamol 150mg/ml 0.4ml q6 hours Probiotics 1 sachet OD Zinc 10mg/ml 1ml OD Ceftriaxone 300mg IVF q 12 hours

Doctor’s Order
(7/9/09) 9:15am >please admit patient to PICU, green service >secure consent for admission and management >TPR q shift and recorded CR-102 RRT-40 Wt.=6kg >NPO # LBM >Diagnostics: -CBG, PLT -U/A -SE -Serum Na, K+ 150cc/hr >hook to D5LRS 500ml TRA 150ugtts/min x 6hr. from Dra. c/o PNOD >IV hook 60cc PNSS now >Ampicillin 150g IVF q 6hrs. if temp>38c >Probiotics 1 sachet OD >Zinc 10mg/ml 0.14ml q 6hrs. ANST (-) >TSB if persistently febrile >Watch out for persistent LBM an Tx >Volume for for volume replacement with PNSS >Monitor V/S q 1hr. and record > I and O q shift and recorded, shift >Refer accordingly >O2 inhalation at 1-2 LPM via nasal cannula Dr. Estrada/Esperanza

07/09/09 2:10 (+)LBM=ix (+)sunken (+)dry lips

>Discontinue Ampicillin >Start Ceftriaxone 300g IVF q 12hr. ANST (-) >Decrease IVF to 100 ugtts/min. x 6hrs. >Ff. u[ CBC, pH, serum Na, K+ results >Refer accordingly Dr. Estrada refer to PNOD and NA >Continue volume per volume replacement with PNSS

5:45pm

>Decrease IVF to 50 ugtts/min. x 6hr. from Dr. Estrada c/o PNOD Dr. Estrada

7/10/09

>Same IVF @ SR >May start fluids with SAP >D/c o2 inhalation >May transfer patient to regular ward >Con’t. meds. IVF accordingly >Refer accordingly Dr. Estrada

7/11/09 8:20am

>IVF to follow D5IMB 500cc TRA 25 ugtts/min. >Con’t. BF with SAP >Con’t. Medications and monitoring >Refer accordingly Dr. Estrada

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