I.

INTRODUCTION

Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the stomach and intestine. It is frequently referred to as the stomach or intestinal flu, although the influenza virus is not associated with this illness. Major symptoms include nausea and vomiting, diarrhea, and abdominal cramps. These symptoms are sometimes also accompanied by fever and overall weakness. Gastroenteritis typically lasts about three days. Adults usually recover without problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to complications such as dehydration. (www.wikipedia.com)

Bacterial gastroenteritis is frequently a result of poor sanitation, the lack of safe drinking water, or contaminated food—conditions common in developing nations. Natural or man-made disasters can make underlying problems in sanitation and food safety worse. In developed nations, the modern food production system potentially exposes millions of people to disease-causing bacteria through its intensive production and distribution methods. Common types of bacterial gastroenteritis can be linked to Salmonella and Campylobacter bacteria; however, Escherichia coli 0157 and Listeria monocytogenes are creating increased concern in developed nations. Cholera and Shigella remain two diseases of great concern in developing countries, and research to develop long-term vaccines against them is underway.( www.emedicines.com)

Gastroenteritis is an uncomfortable and inconvenient ailment, but it is rarely life-threatening in the United States and other developed nations. However, an estimated 220,000 children younger than age five are hospitalized with gastroenteritis symptoms in the United States annually. Of these children, 300 die as a result of severe diarrhea and dehydration. In developing nations, diarrheal illnesses are a major source of mortality. In 1990, approximately three million deaths occurred worldwide as a result of diarrheal illness.(www.emedicines.com)

Locally, In July 22, 2004, the Department of Health (DOH), Philippines declared an epidemic (outbreak) of a water/food-borne disease called acute gastroenteritis in 45 towns in Central Pangasinan. Acute gastroenteritis is a 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 Tagum City, at Davao Regional Hospital pediatric department acute gastroenteritis was considered number 3 among the most common pediatric cases. It is common in this area because some of the people are not aware regarding the proper handling and preparation of food. Gastroenteritis is a general term referring to inflammation or infection of the gastrointestinal tract, primarily the stomach and intestines.[1] It can be caused by infection with bacteria, viruses, or other parasites, or less commonly reactions to new foods or medications. It often involves stomach pain (sometimes to the point of crippling), diarrhea and/or vomiting, with noninflammatory infection of the upper small bowel, or inflammatory infections of the colon. It usually is of acute onset, normally lasting fewer than 10 days and self-limiting. Sometimes it is referred to simply as 'gastro'. It is often called the stomach flu or gastric flu even though it is not related to influenza. If inflammation is limited to the stomach, the term gastritis is used, and if the small bowel alone is affected it is enteritis. As such, this has a relationship on the concept fluids and electrolyte. Because dehydration the most common complication of gastroenteritis if not treated or no immediate intervention done it could lead to shock and eventually can lead to death.

OBJECTIVES General: 1. To fully understand the underlying disease process of aplastic anemia. Specific: 1. To identify the epidemiological data of aplastic anemia globally, nationally and locally. 2. To learn about the major etiologies of aplastic anemia. 3. To determine the previous and present clinical history of the patient. 4. To perform physical assessment with special attention on the systems focus. 5. To show the laboratory examination results with the corresponding normal values, actual result from the patient, and it interpretation. 6. To understand the anatomy and physiology of the blood and blood formation and its pathology during aplastic anemia. 7. To trace and understand the pathophysiology of aplastic anemia. 8. To learn the basic principle of medical management of aplastic anemia.

9. To use the nursing process to identify nursing problems from the client and provide the appropriate nursing care plan. 10. To understand the pharmacological management set on the client and provide nursing interventions. 11. To identify the discharge plan for the patient’s rehabilitation to conduct an evaluation of the client’s condition from admission to present.

II. ASSESSMENT A. BIOGRAPHIC DATA

Name Case Number Age Sex

:

Bb. Zoo Sy : : : 185098 3 months old Male 43 kgs. Single January 8, 2007

Weight (upon admission) : Civil Status Birthdate Address Nationality Attending Physician : : :

Prk. 1 #96 Linoan Montevista, ComVal : : Filipino Dr. Dagooc

B. CHIEF COMPLAINT

Based on the patient’s chart, it appears that seizure, dyspnea, weakness, poor suckling, LBM with watery stool were the chief complaints experience by Bb. Zoo Sy which eventually made her family sought for admission.

C. HISTORY OF PRESENT ILLNESS

One week prior to admission, patient experienced on and off fever, no consultation and medicines given to the patient at home. Until 3 days prior to admission patient was positive of several episodes of LBM, yellowish to greenish in color, mucoid, non blood streaked and positive fever again no consultation done. Upon admission, the patient experienced 2 episodes of upward rolling of eyeballs with cycling motion of extremities at the ER. With admitting vital signs of BP- 70/50 mmHg, CR- 140bpm, RR- 58cpm, Temp- 36.4˚C, with pulse oxymeter reading of 96% O2 saturation.

D. PAST MEDICAL HISTORY

E. PERSONAL, FAMILY AND SOCIO-ECONOMIC

Bb. Zoo Sy was born January 8, 2007. He was the youngest of the 4 children in the family. Two weeks prior to admission Bb. Zoo Sy together with his siblings were left by their mother. While his father was a hardworking businessman who was then at GenSan. The income of his father is just enough to support their basic needs.

III. REVIEW OF SYSTEMS (PHYSICAL ASSESSMENT) A. GENERAL SURVEY

Bb. Zoo Sy was lying flat on bed, lethargic with sunken fontanels, sunken eyeballs, dry pale lips, dyspnea, and distended abdomen.

B. VITAL SIGNS

Date 05/03/0 7

Shift
11pm7am

Time
1:15 am

Temp
36.4

BP
70/50

RR
58

PR
140

Intak e

Outpu t

3:50am 5:00am 7:00am 7am3pm 8:50am 9:55 am 11:16 am 12:20pm 1:26 pm 2:55pm 3-11pm 5:00pm 6:15pm 7:15pm 8:20pm 9:50pm

36.2 36 36.5 36.4 36.8 37 37 36.9 37.6 37.3 37.4 37.5 37.6 37.2

70/50 70/50 70/50 70/50 90/60 80/50 80/50 90/60 90/50 100/60 90/60 100/60 90/50 90/50

56 42 38 42 48 48 46 49 52 43 43 33 37 40

156 132 123 120 127 130 134 128 136 118 120 115 103 130 u-200cc u-350cc

10:45 pm

37.2 36.9

90/50 90/50

38 34

100 133

05/04/0 7

11pm7am

12:30am

1:54 am 3:06 am 4:15am 5:50am 6:40am

36.8 36.8 36.8 36.5 36.5 37

90/60 90/50 80/50 90/60 80/50 90/60

43 40 37 37 40 38

124 109 118 129 110 112 u-290cc

05/04/0 7

7am3pm

8:39am

10:08am 11:35am 12:45pm 1:40pm 2:51pm

37..3 37 37.7 38.8 38.1 38

80/50 90/50 80/50 90/50 90/50 80/50

38 40 34 36 37 37

116 120 124 126 128 110 OF-30cc u-170cc

05/04/0 7

3-11pm

4:50pm

6:30pm 7:45pm 9:10pm 10:30pm

37.3 36.8 37 36.3 36.4

80/50 80/50 80/50 80/50 80/50

40 45 43 41 45

108 81 99 107 95 OF-30cc

u-110cc

05/05/0 7

11pm7am

12:25am

2:10am 4:20am 6:00am 7:00am

36.7 37.1 37.1 37

90/50 90/50 90/50

43 42 46 42

102 128 132 123
OF-30cc

u-130cc

05/05/0 7

7am3pm

8:42am

36.5

80/50

48

120

OGT-30cc

9:56am 10:54am 12:22pm 1:18pm 2:40pm

36.8 37 37.8 38.3 37 38.5

90/50 90/50 90/50

44 47 42 46

118 122 128 132 128 118
OGT-50cc OGT130cc OGT-50cc

u-80cc

90/50 90/50

40 49

05/05/0 7

3-11pm

4:48pm

6:13pm 7:27pm 8:34pm 10:31pm

38 37.3 37.7 37.5 37

90/50 90/60 90/60 90/50 90/60

42 45 40 45 48

135 110 137 120 125
Milk-50cc

u-100cc

05/06/0 7

11pm7am

12:55am

2:15am 3:40am 5:10am 6:30am

37 37 36.9 36.9 36.8

90/60 90/60 90/60 90/60 90/60

44 49 40 43 40

130 127 135 132 128
Milk-50cc

u-90cc

05/06/0 7

7am3pm

8:36am

10:25am 12:00pm

37.2 37 36.2

90/60 90/60 90/50

44 46 43

132 135 140
Milk-90cc H2O-10cc

u-100cc u-100cc

05/06/0 7 05/07/0 7

3-11pm

6:10pm

11pm7am

1:30pm

37.2

90/60

41

127

u-100cc

05/07/0 7 05/07/0 7 05/08/0 7

7am3pm 3-11pm

9:00pm

37.3

39

136

u-50cc

6:30pm

36.2

43

132

milk-90cc

u-90cc

11pm7am

12:00am

37

90/50

40

120

Milk-70cc

4:00am

37.2 36.4

90/60 90/50

36 38

115 108

u-100cc u-30cc

05/08/0 7

7am3pm

8:00pm

12:00pm 3-11pm 11pm7am 6:00 12:00 4:00

36 37 36.6 36.8 36.4

90/60 90/50 90/50 90/60 90/60

36 40 28 37 28

120 138 113 118 120
H2O-90cc H2O-180cc

u-90cc

u-340cc

05/09/0 7

7am3pm

8:00

u-60cc

12:00 3-11pm 3:00 1:30

36.8 37.1 37.1

90/60 90/60 90/50

34 39 40

125 140 142
H2O-90cc H2O-60cc

u-60cc u-100cc

05/10/0 7

11pm7am 7am3pm

9:30 1:50

36.5 38.9 90/60

40 42

143 148

H2O-407cc

u-100cc u-120cc

05/11/0 11pm7am 7
7am3pm 3-11pm

9:00 5:25 2:00

36.7 36.5 36.7

90/60 80/50 80/50

40 43 30

142 137 138

Milk-40cc

u-140cc u-110cc u-120cc

Milk-30cc Milk-2.5 oz

05/12/0 7

11pm7am 7am3pm

11:00

37.5

90/50

46

156

Milk-4 oz

u-350cc

6:15

36.8 37

90/60 90/50

29 45

135 133
Milk-2 oz

u-150cc u-100cc

05/13/0 7

11pm7am 7am3pm 3-11pm

12:50

10:00 6:30 1:45

37.1 37.3 36.9

90/60 80/50 90/60

48 32 34

160 130 136

Milk-8 oz

u-50cc u-130cc u-100cc

Milk-4 oz Milk-6 oz

05/14/0 7

11pm7am 7am3pm 3-11pm

10:30 5:45 8:10am

36.8 36.7 36.7

90/60 80/50 100/70

36 34 37

140 120 123

Milk-6 oz

u-120cc u-90cc u-200cc

Milk-3.5 oz Milk-70cc

05/15/0 7

7am3pm

12:30pm 3-11pm 5:30pm 1:30am

36.5 37.4 36.5

90/70 90/50 90/60

36 40 36

124 144 140

Milk-50cc Milk-3.5 0z Milk-4 oz

u-140cc u-90cc

05/16/0 7 05/16/0 7

11pm7am 7am3pm

8:00am

36.8

90/50

42

128

Milk-60cc

u-100cc

12:00pm

36.5

90/50

38

126

Milk-135cc

C. NUTRITIONAL STATUS

Upon admission, patient was placed on NPO with OGT F8 and keep distal and open. Admitting weight was 5.2kg. During our shift patient was on dropper feeding.

D. NEUROLOGIC STATUS

Patient was lethargic as observed by NOD.

E. INTEGUMENTARY SYSTEM

Fine and evenly distributed, thin and dry hair was noted. His nails were in convex shape, smooth in texture , capillary refill of five seconds an untrimmed finger nails with poor skin turgor. His skin was pale, dry, with fine and fare complexion

F. HEENT

The size of head was in proportion with the body. The eyes were symmetrical with the ears; with sunken fontanels and eyes. When the eyes were tested papillary reaction to light, the pupil constricted to 2mm. Ear had no discharges noted. Nasal septum were intact and in the midline. Patient had cleft lip. The throat was functioning well and in normal condition.

G. PULMONARY SYSTEM

Respiratory rate was 58 cpm and dyspnic. Upon auscultation, crackles were heard and with symmetrical chest expansion. With history of Pneumonia.

H. CARDIOVASCULAR SYSTEM

Patient’s CR was 140 bpm which is normal. No murmur heard upon auscultation. There was no history of cardiopulmonary disease.

I. GASTROINTESTINAL SYSTEM

The abdomen was distended, soft and there was no palpable mass felt upon palpation. Hypoactive bowel sound heard upon auscultation. The patient vomited 3-5 times a day and defecated more than 6 times a day with watery stool.

J. MUSCULOSKELETAL SYSTEM

The patient manifested good posture and moved voluntarily; he had symmetrical musculature on both sides of the body. Weakness was noted.

K. GENITO- URINARY SYSTEM

Patient voided 60 – 350 cc per shift as weighed and yellow in color.

IV. LABORATORY AND DIAGNOSTIC EXAMINATION LABORATORY EXAM Hemoglobin mass concentration Leukocyte number concentration Neutrophils Eusinophils NORMAL VALUE Male- 13.5-18 g/dl RESULT 83.3 INTERPRETATION This shows that the hemoglobin level is very low than normal that indicates decrease tissue pefusion. This indicates low level of sodium in the blood or hyponatremia Neutrophils is lower than normal which indicatates risk for infection. The eusinophils is higher than normal range which involved in allergic reactions(neutralizes histamine; digest foreign proteins). Lymphocytes is higher than normal range which may help in fighting against infection. This indicates that the level of sodium is slightly lower than normal. The potassium level is slightly below than normal range. This indicates that the level of calcium is lower than normal range. The RBS is just within the normal range. This shows that the erythrocyte volume fraction level is just within the normal range.

5-10x10 9/l 0.55-0.65 0.22-0.04

17.9 0.35 0.79

Lymphocytes

volume0.22

0.79

Sodium Potassium Calcium RBS Erythrocytes volume fraction Erythrocyte number concentration Stool exam Thrombocytes

1.35-148 mmol/L 3.5-5 mmol/L 1.13-1.32 mmol/L 3.9-6 mmol/L 0.25

130.4 mmol/L 3.15 mmol/L 0.84 mmol/L 0.84 mmol/L 0,25

7.5 mmol/L No ova found 150,000-

(Platelet)

450,000 /mm3

SYMPTOMATOLOGY

Clinical manifestations

Present in the patient

Rationale

Abdominal pain or cramping
Nausea

Decreased circulating oxygen in the body can lead to excessive blood loss & bone marrow destruction / / / / To compensate with the diminishing blood supply to all body systems.

Vomiting Fever Poor feeding Unintentional weight loss Excessive sweating Clammy skin Muscle pain or joint stiffness Incontinence (loss of bowel control) Extreme thirst

/

Due to the decreased platelets in the blood

Due to decreased platelets in the blood

Urine that is darker in color Dry skin / Due to decreased clotting factor in the blood

Dry mouth Sunken cheeks or eyes In infants, dry diapers (for more than 4-6 hrs)

/ /

V. ANATOMY AND PHYSIOLOGY

Anatomy of the Digestive System

If a human adult’s digestive tract were stretched out, it would be 6 to 9 m (20 to 30 ft) long. In humans, digestion begins in the mouth, where both mechanical and chemical digestion occur. The mouth quickly converts food into a soft, moist mass. The muscular tongue pushes the food against the teeth, which cut, chop, and grind the food. Glands in the cheek linings secrete mucus, which lubricates the food, making it easier to chew and swallow. Three pairs of glands empty saliva into the mouth through ducts to moisten the food. Saliva contains the enzyme ptyalin, which begins to hydrolyze (break down) starch—a carbohydrate manufactured by green plants. Once food has been reduced to a soft mass, it is ready to be swallowed. The tongue pushes this mass—called a bolus—to the back of the mouth and into the pharynx. This cavity between the mouth and windpipe serves as a passageway both for food on its way down the alimentary canal and for air passing into the windpipe. The epiglottis, a flap of cartilage, covers the trachea (windpipe) when a person swallows. This action of the epiglottis prevents choking by directing food from the windpipe and toward the stomach.

Mouth

The mouth plays a role in digestion, speech, and breathing. Digestion begins when food enters the mouth. Teeth break down food and the muscular tongue pushes food back toward the pharynx, or throat. Three salivary glands—the sublingual gland, the submandibular gland, and the parotid gland—secrete enzymes that partially digest food into a soft, moist, round lump. Muscles in the pharynx swallow the food, pushing it into the esophagus, a muscular tube that passes food into the stomach. The epiglottis prevents food from entering the trachea, or windpipe, during swallowing.

Esophagus

The presence of food in the pharynx stimulates swallowing, which squeezes the food into the esophagus. The esophagus, a muscular tube about 25 cm (10 in) long, passes behind the trachea and heart and penetrates the diaphragm (muscular wall between the chest and abdomen) before reaching the stomach. Food advances through the alimentary canal by means of rhythmic muscle contractions (tightenings) known as peristalsis. The process begins when circular muscles in the esophagus wall contract and relax (widen) one after the other, squeezing food downward toward the stomach. Food travels the length of the esophagus in two to three seconds. A circular muscle called the esophageal sphincter separates the esophagus and the stomach. As food is swallowed, this muscle relaxes, forming an opening through which the food can pass into the stomach. Then the muscle contracts, closing the opening to prevent food from moving back into the esophagus. The esophageal sphincter is the first of several such muscles along the alimentary canal. These muscles act as valves to regulate the passage of food and keep it from moving backward.

Stomach

The stomach, located in the upper abdomen just below the diaphragm, is a saclike structure with strong, muscular walls. The stomach can expand significantly to store all the food from a meal for both mechanical and chemical processing. The stomach contracts about three times per minute, churning the food and mixing it with gastric juice. This fluid, secreted by thousands of gastric glands in the lining of the stomach, consists of water, hydrochloric acid, an enzyme called pepsin, and mucin (the main component of mucus). Hydrochloric acid creates the acidic environment that pepsin needs to begin breaking down proteins. It also kills

microorganisms that may have been ingested in the food. Mucin coats the stomach, protecting it from the effects of the acid and pepsin. About four hours or less after a meal, food processed by the stomach, called chyme, begins passing a little at a time through the pyloric sphincter into the duodenum, the first portion of the small intestine.

Liver

The liver is the largest internal organ in the human body, located at the top of the abdomen on the right side of the body. A dark red organ with a spongy texture, the liver is divided into right and left lobes by the falciform ligament. The liver performs more than 500 functions, including the production of a digestive liquid called bile that plays a role in the breakdown of fats in food. Bile from the liver passes through the hepatic duct into the gallbladder, where it is stored. During digestion bile passes from the gallbladder through bile ducts to the small intestine, where it breaks down fatty food so that it can be absorbed into the body. Nutrientrich blood passes from the small intestine to the liver, where nutrients are further processed and stored. Deoxygenated blood leaves the liver via the hepatic vein to return to the heart.

Small Intestine

Most digestion, as well as absorption of digested food, occurs in the small intestine. This narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending about 6 m (20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through the duodenum into the next portion of the small intestine, the jejunum, and finally into the ileum, the last section of the small intestine. During this time, the liver secretes bile into the small intestine through the bile duct. Bile breaks large fat globules into small droplets, which enzymes in the small intestine can act upon. Pancreatic juice, secreted by the

pancreas, enters the small intestine through the pancreatic duct. Pancreatic juice contains enzymes that break down sugars and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids. Glands in the intestinal walls secrete additional enzymes that break down starches and complex sugars into nutrients that the intestine absorbs. Structures called Brunner’s glands secrete mucus to protect the intestinal walls from the acid effects of digestive juices. The small intestine’s capacity for absorption is increased by millions of fingerlike projections called villi, which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02 to 0.06 in) long and covered with a single layer of cells. Even tinier fingerlike projections called microvilli cover the cell surfaces. This combination of villi and microvilli increases the surface area of the small intestine’s lining by about 150 times, multiplying its capacity for absorption. Beneath the villi’s single layer of cells are capillaries (tiny vessels) of the bloodstream and the lymphatic system. These capillaries allow nutrients produced by digestion to travel to the cells of the body. Simple sugars and amino acids pass through the capillaries to enter the bloodstream. Fatty acids and glycerol pass through to the lymphatic system. Large Intestine

A watery residue of indigestible

food

and

digestive

juices

remains

unabsorbed. This residue leaves the ileum of the small intestine and moves by peristalsis into the large intestine, where it spends 12 to 24 hours. The large intestine forms an inverted U over the coils of the small intestine. It starts on the lower right-hand side of the body and ends on the lower left-hand side. The large intestine is 1.5 to 1.8 m (5 to 6 ft) long and about 6 cm (2.5 in) in diameter. The large intestine serves several important functions. It absorbs water— about 6 liters (1.6 gallons) daily—as well as dissolved salts from the residue passed on by the small intestine. In addition, bacteria in the large intestine promote the breakdown of undigested materials and make several vitamins, notably vitamin K, which the body needs for blood clotting. The large intestine moves its remaining contents toward the rectum, which makes up the final 15 to 20 cm (6 to 8 in) of the

alimentary canal. The rectum stores the feces—waste material that consists largely of undigested food, digestive juices, bacteria, and mucus—until elimination. Then, muscle contractions in the walls of the rectum push the feces toward the anus. When sphincters between the rectum and anus relax, the feces pass out of the bod

VII. PLANNING

A. COURSE IN THE WARD

DOCTORS ORDER May 3, 2007 2:30 am to CIU suction secretions now insert OGT F8 and keep distal end open O2 @ 4 Lpm via face mask Diazepam 1.5 mg IVTT now then PRN for frank seizures Give PLR 156 cc IV bolus now x 1 hr Admit to pedia ICU Secure signed consent to care NPO

Labs: -CBC, BT, U/A, CXR-APL, blood CS, S/E -RBS stat, ABG stat, serum electrolytes stat

Meds: 1. Ceftriaxone 500 mg IVTT now then OD 2. Ampicillin 260 mg IVTT every 6 hrs
3. Phenobarbital 104 mg IVTT now as LD then 13 mg IVTT q 12 hrs 4. Paracetamol 60mg IVTT q hrs, PRN for Temp=37.8 C

May 3, 2007 3:35am

Monitor vs q hourly and record I and O q shift and record Hook to pulse oximeter and maintain O2 sat >90% or =90% Maintain on MHBR Replace GI losses, v/v replacement, with PLR Refer accordingly Place under droplight. Keep thermoregulated. Secure 1 unit of FFP of patient’s blood type and transfuse 78 cc x 4 hrs x 3 cycles after proper retyping IVF to follow: PLR 156 cc to run for 1 hr then refer

-IVF to follow PLR to run @ 10 cc/hr x 2 hr then refer

May 3, 2007 6:00am -IVF to follow: D5LR 1L to run @ 86cc/hr x 6 hr then refer

May 3, 2007 7:00am -(Change present IVF to D5 IMB 500 cc + 10 mEq KCl @ 22 cc/hr x 24 hrs)-HOLD start Dopamine @ 2 cc/hr, hook to infusion pump follow up to FFP transfusion and all labs

- disregard all IVF to patient - give PLR 100cc IV bolus x 1 hr then refer - start another line with D5 0.3 NaCl @ KVO rate, sidedrip with Dopamine @ 2cc/hr -RBS monitoring q 6 hrs May 3, 2007 9:00am - give another PLR 100cc IV bolus x 1 hr then refer

10:00am

- give D10 water 10cc IV bolus now IVF to follow: D5LR 1L @32cc/hr x 8hrs then refer RBS 49mg/dL,for repeat RBS after 30 runs

4:15pm

- refer surgery for venous cutdown

8:20pm

- referred for IVF insertIion May not do cutdown

May 4, 2007 3:15pm IVF to follow D5 IMB @ 28-29 cc/hr x 6 hrs then refer cutdown drip D/C all IVF to follow IVF to follow: D5 IMB 500cc @ 20cc/hr, SD with Dopamine @ 2cc/hr, hook to infusion pump D/C D5 LR attach to heplock Refer to social worker for assistance and availability of meds (ceftriaxone) Still for U/A, ABG May have milk feeding @ 30cc q 3hrs per OGT

May 5, 2007

11:30 am

-

IVF to ff : D5 IMB 500 cc @ 3 cc/hr x 24 hours (50 kcal) increase milk feeding @ 50 cc @ 3 hours continue meds decrease 02 to 2 LPM via nasal cannula

9:40 pm

-

may have dropper feeding @ 50 cc every 3 hrs with SAP

May 6, 2007 7:45 am -

Transferred patient to GW-Gastro VS monitoring q 4 hours and meds D/C 02 inhalation IVF to ff D5IMB 500 cc to run @ 5 cc/hr x 24 Still for U/A and fecalysis D/C dopamine drip

-

May 7, 2007 8:30 am C/D IVF and attach to heplock continue meds

May 8, 2007 9:30 am continue meds increase dropper feeding + 70 cc/hr with SAP (71 kcal) Pls. ff up cranial CT scan, U/A, blood CS, fecalysis., serum electrolyte For repeat CBC plt. Today

May 9, 2007 10:40 am for LP today Pls. secure consent for LP Ff up cranial CT scan Continue meds Shift Phenobarbital IV to PO Phenobarbital 6 g/tab. Dissolve 1 Tab into 5 cc give it to BID

May 10, 2007 9:30 am Silver sulfadiazine cream apply to affected area TID Still for LP

-

Continue meds

May 11, 2007 9:55 am for LP today NPO x 4 hrs starting 12 pm Pls. give Diazepam 1.5 g IVTT prior to LP Continue meds

May 12, 2007 6:45 am -

Post LP order NPO x 4 hrs Feed on bed x 4 hrs For RBS stat Refer for cyanosis, apnea, dyspnea and other S/S Refer accordingly

-

May 13, 2007 9:30 am Transfer to neuroservice under Dr. Gazmen/Golingay

-

Continue meds

May 14, 2007 12:00 nn for compliance of Ceftriazone measure head circumference increase Ampicillin + 400 mg IVTT q 6hr for urine culture for repear CBC, plt FeSo4 (1 tab) 4 ml accordingly Multivita 0.3 ml accordingly Still for cranial CT scan Vit K 1 mg IM

May 15, 2007 9:30 am Ff up CSF culture result Continue meds Still for Vit. K 1 ml IM as previously ordered (5/14/07) Still for cranial CT scan

-

Measure head circumference pls and chart Still for repeat CBC, plt, pls facilitate

May 16, 2007 7:00 am NURSES’ NOTES May 3,2007 11pm-7am 1:15am>Admitted this 3 months old, male child, lethargic, afebrile, dyspneic in due to difficulty in breathing. Vital signs checked. Seen and examined by Dr. Dagooc with orders made. Lab exams requested. IVF of PLR IL @ 156 cc as IV bolus. OGT inserted. O2 inhalation @ 4 Lpm per face mask. Suctioning of secretions done. For CXR-ADL. Ushered to ward per wheelchair. Endorsed to NOD. Continue meds for cranial ultrasound pls give request facilitate repeat CBC plt Transfer to MR

2:50am>In from ER per wheelchair, stupurous. On NPO with Ogt distal end to bedside bottle. With an IVF of PLR, with ongoing infusion of 156ccx1hr. with O2 inhalation on @ 4Lpm via face mask. Ushered to room. Placed on bed comfortably. O2 inhalation continued. vs checked and recorded. Lab exams and medicines prescribed followed up. Watched for.

May 3,2007

7am-3pm 7:00am>On bed, stupurous. On NPO with OGT open to bedside bottle. With PLR @104cc in 2 hrs. with O2 inhalation @ 4Lpm via face mask. With pulse oximeter with O2 saturation @ 99%. To secure 1 unit Fresh Frozen Plasma for transfusion. Lab exams followed up. vs taken and recorded. Medicated. Seen and examined by Dr.Dagooc with orders made and carried out. Cared for. May 3,2007

3-11pm

3:00pm> on bed stupurous and afebrile. On NPO with Ogt open to bedside bottle. With IVF @ right arm D5 o.3 NaCl @ KVO rate, with side drip of dopamine @ 2 cc/hr via infusion pump. With D5 LR @ 32 cc/hr x 8 hrs, on KSS. Still for insertion. On O2 inhalation. Still to secure FFP for transfusion. Vs checked and recorded. Lab exams followed-up. due meds given. Watched for any unusualities. 4:15pm>Seen by Dr.Tiongco, ordered for IV cutdown, refer to surgery by Dr. Gazmen.

May 3,2007

11-7 am 7-3 pm

11:00pm> Received asleep on bed, afebrile. On NPO 7:00am> On bed awake, weak, pallor, coherent and responsive, on MHBR, with 02 inhalation @ 5 Lpm via face mask. With ongoing BT #2 FWB 500 cc with serial # 112-0723172 blood type A+. On left arm is PNSS 1L @ 200 cc/hr. Due meds given. With FBC to urobag. Endorsed to NOD.

3-11pm

3:00pm> Received lying on bed, awake, responsive, and coherent to verbal communication. On MHBR position. With droopy eyes noted. With pale lips, dry and warm skin noted, capillary refill less than 2 seconds. Established rapport. On NPO except medications. With 02 inhalaltion @ 5 lpm via nasal cannula. With double line IVF- #7 PNSS 1L @ 200 cc/hr infusing well @ L brachial vein, #8 PNSS 1L @ 100 cc/hr infusing well @ R basilica vein. With FBC attached to urobag draining amber colored urine. On CBR without BRP-reinstructed. 4:00pm> VS, I & O checked and recorded every hour. 4:25pm> Above IVF consumed and followed-up with #9 PNSS 1L @ KVO rate @ R basilic vein. 5:20pm> Temp. 37.8 C, NOD aware. TSB done 6:00pm> Above IVF consumed and followed-up with #9 PNSS 1L @ KVO rate @ R basilic vein. 10:00pm> Still to secure 6 units of platelet and 3 units of fresh whole blood. Advise for bone marrow biopsy, still undecided. 11:00pm> Watched and monitored for any unusualities. Endorsed to NOD.

May 4, 2007

11.7

11 pm> Received asleep on bed, afebrile, on milk feeding 30cc every 3 hours per OGT, With IVF of D5IMB @ 20 cc/hr with side of 2 cc/hr, with heplock @ left and right foot, with O2 @4 Lpm, to secure another unit of fresh frozen plasma followed-up, V/S checked, due meds given, cared and watched for.

May 5, 2007

7.3

7 am> On bed, on milk feeding/OGT 30cc every 1hr, # 4 D5IMB @ 20cc/hr, with side drip to run @ 2cc/hr, O2 @ 4cc/mask. To secure 1 unit Fresh Frozen Blood for transfusion. Watched and cared for. 3 pm> Received patient on bed awake, febrile. On milk feeding 30cc every 3hr per OGT, checked patency, with Ivf ofD5IMB 500cc @3cc/hr infusing well, withside drip dopamine @ 2cc/hr per infusion pump, with O2 inhalation @ 5Lpm via face mask, still to secre fresh frozen plasma followed-up. V/S checked once recorded. Watched and cared for. 11pm> On bed asleep, on dropperfeeding 50cc every 3hr, with IVF of D5IMB @ 3cc/hr x 24hr, infusing well @ the level of 400cc/hr, with side drip of dopamine @ 2cc/hr infusing via infusion pump. O2 @5 Lpm via face mask. Still to secure fresh frozen plasma for transfusion. V/S checked and recorded. Lab exams followed-up,due meds given. Watched for any unusualities.

3.11

11.7

May 6, 2007

7.3

7am> On bed asleep, on dropper feeding 50cc every 3hr, with IVF D5IMB @ 3cc/hr x 24hr, with attached O2 @ 5Lpm via face mask, to secure kit fresh frozen plasma for transfusion. Lab exams followed-up. V/S taken and checked. Endorsed to NOD. 7:45> seen and examined by Dr. Garingalao with orders made and carried out. Transferred to Cardio Ward as ordered.

3-11 3pm> On bed, asleep, dropper feeding, with IVF of D5IMB @ 5cc/hr. Still for blood CS. still to secure urine and stool exam. Followed up availability of fresh frozen plasma. V/S checked. Meds given. Endorsed to NOD.
11.7

11pm. Received on bed asleep, on dropper feeding 50cc every 3hr, with IVF of D5IMB @ 5cc/hr on KSS. V/S checked and recorded. Meds followed up. Cared for.

May 7, 2007

7.3

7am> on bed awake, dropper feeding, with IVF regulated infusing well. V/S checked and recorded. Meds cut off. Watched and cared for.

3-11 3pm> Received on bed awake, on dropper feeding, helock KSS, labs followed up. still to secure blood followed up. V/S checked and recorded, medicated, watched and cared for, 11-7 11pm> received lying on bed, awake, patient not in respiratory distress, minimal wheezes heard upon auscultation, with cleft lip, with good capillary refill, with good skin turgor, warm to touch, with heplock on right metatarsal vein. On dropper feeding, for blood CS, U/A, S/E, ABG. 12am> VS checked and recorded, afebrile. Bedside care done; linens stretched and tucked well. Health teachings rendered to mother such as increasing OFI, encouraged to promote

good hygiene. Instructed to keep child away from allergens such as dust, smoke, ect...instructed to refer any unusualities and to comply medical regimens. Infant was able to defecate 180cc- soft in characteristics and yellowish in color. 4am> V/S checked and recorded; afebrile; watched and cared for. 5am> morning care done. Intake and output summed up and recorded. 7am> Left on bed with watcher. Endorsed to NOD.

May 8, 2007

7.3

7:30am> received on bed awake with mother on side, with cleft lip palate, with heplock on right metatarsal vein; on on respiratory distress. On syringe feeding, able to consume milk feeding 50cc, able to defecate with semisolid character of stool and yellowish in color about 30cc. VS checked and recorded, afebrile T: 36.4, PR:109, RR:39, BP:90/50. Bedside care done. Instructed mother to increase OFI and to report for vomiting and type of stool and its consistency. V/S rechecked and documented. Give ample time for sleeping. 3pm> Health teaching given regarding proper hygiene, milk preparation, proper feeding techniques and burping of the baby after each feeding. Observed closely for sign of intolerance like vomiting and nausea.

3.11

3pm> Received on bed, awake on dropper feeding 70cc every 3hr, with heplock attached; still patent. V/S checked and recorded, afebrile; lab exams followed up. due meds given, watched and cared for.

11-7 11pm> Received on bed asleep ,with watcher on side, not in distress, with cleft lip, with good skin turgor and warm to touch, with heplock in right metatarsal; V/S checked and recorded afebrile; bedside care done. Linens stretched and properly tucked; left on bed comfortably. Health teachings rendered to watcher such as increasing OFI of patient, promote good ventilation and relaxation, encouraged mother to breastfed.

May 9, 2007

7.3

7am> Received patient on bed, sleeping with mother on side, with heplock @ right metatarsal vein, on bottle feeding, able to consumed 90cc. V/S checked and recorded, afebrile, T:36.4, PR:120, RR:28,BP:90/60. instructed mother to feed baby every 3-4 hours and should prepare milk formula using sterile or distilled water and to report any sign of dehydration such as cracked lips and sunken fontanels. 3pm> Endorsed to NOD.

3-11 3pm> received patient on bed awake, on dropper feeding, with heplock attached on; V/S taken and recorded, afebrile. Followed up availability of meds. Watched and cared for. 11-7 11pm> Received asleep on bed, afebrile; on dropper feeding with aspiration precaution, with heplock attached, still for lumbar puncture, with consent, lab exams followed up, meds followed up, V/S checked an recorded. Watched and cared for.

May 10, 2007

7-3

7am> On bed awake, on breast feeding with heplock, patent and intact. V/S checked and recorded, labs followed up, medicated, watched and cared for.

3-11

3pm> Received on bed, awake, on dropper feeding 70cc every 3hrs; with heplock attached. Still patent. V/S checked and recorded, afebrile. Lab exams followed up. Due meds given. Cared for.

11-7

11pm> Received on bed, asleep, on dropper feeding; with heplock attached; V/S checked and recorded; meds given, cared for.

May 11, 2007

7-3

7am> On bed, awake, on dropper feeding, with attached on. V/S checked and recorded, meds given. Cared for.

3-11 3pm> Lying on bed asleep, on NPO temporarily; for lumbar puncture any time today with consent. Still for cranial CT scan. V/S checked and recorded. Medicines provided, followed up intervention.

11-7 11pm> Received asleep on bed, afebrile, on dropper feeding, with heplock attached, still for LP with consent. Lab exams and medicines followed up. V/S checked, cared for.

May 12, 2007

7-3

7am> On bed awake, NPO for 4 hours reminded, flat on bed x 4 hours, instructed, with heplock, patent and intact, watched and cared for.

3-11 3pm> On bed asleep, on dropper feeding 79cc every 3 hours, with heplock attached on. V/S checked and recorded. Lab exams followed up. Due meds given; watched for.

11-7 11pm> received asleep on bed, afebrile; on dropper feeding, with strict aspiration precaution, with heplock attached, cranial ultrasound and lab exams followed up, V/S checked, meds followed up, cared for.

May 13, 2007

7-3

7am> On bed, awake, with heplock patent and intact, V/S checked and recorded, labs followed up, meds prescribed, watched and cared for.

3-11 3pm> Received on bed, awake; on dropper feeding every 3 hours. With heplock attached, still patent. V/S cheched and recorded; afebrile. Lab exams followed up. Due meds given. Cared for.

11-7 11pm> Received asleep on bed; afebrile, on dropper feeding, with heplock attached. Urinalysis and cranial ultrasound followed up, V/S checked, due meds given, cared for.

May 14, 2007

7-3

7am> Received patient cuddled by mother, awake. On breastfeeding, with heplock attached on. V/S taken and recorded. Afebrile. Medicated. Watched and cared for.

3.11

3pm> On bed, afebrile, dropper feeding, with heplock attached; followed up cranial ultrasound; urine CS followed up, fresh frozen plasma was available.

11-7 11pm> Received on bed, asleep, on dropper feeding, with heplock; V/S taken and recorded, meds given; cared for.

May 15, 2007

7.3

7am> Received lying flat on bed, asleep with watcher at bedside. With heplock attached to right metatarsal vein; still patent and intact. With cleft lip and dry skin warm to touched. With normal capillary refill less than 2 seconds, with good skin turgor. Instructed on dropper feeding every 3-4 hours. 8am> V/S checked and recorded; within normal ranges. Intake and output monitored closely as ordered. Instructed watcher to report any signs of dehydration such as dry lips and skin, sunken eyes and fontanels, vomiting, LBM, and weakness. 9am> Bed linen stretched and tucked well. Arranged things properly. Provided with restful environment conducive for sleep. Changed soiled diaper into clean one, with semi-solid stool, yellow in color weighing 70gs. 10am> Vitamin K given 1mg IM as ordered. Watched out for any signs of adverse reactions, not noted. Able to consumed 70cc of milk via bottle feeding. 10:40am> Changed soiled diaper into clean one, with semi- solid formed stool, yellow in color weighing 80gs. Measured head circumference as ordered: 40cm. health teaching imparted on proper hygiene, importance of proper feeding and burping after each feeding, and to observe for vomiting and LBM. IVTT meds given by NOD; watched out for any signs of adverse reaction, not noted.

12nn> V/S rechecked and recorded. Intake and output monitored closely as ordered. Watched out for any unusualities, not noted. Provided with restful environment conducive for sleep. Needs attended to and cared for. 3pm> Endorsed to NOD. 3-11 3pm> On bed asleep. On dropper feeding 70cc every 3 hours, with heplock attached. V/S checked and recorded. Watched and cared for.

11-7

11pm> Received on bed, asleep. On dropper feeding 70cc every 3 hours. With heplock attached. V/S checked and recorded. Meds given, cared for.

May 16, 2007

7-3

7am> Received carried by watcher per arm, awake andconscious. With no heplock attached. With cleft lip and dry skin warm to touch. With normal capillary refill less than 2 seconds, with good skin turgor. Instructed on dropper feeding every 3-4 hours. Still for cranial ultrasound; repeat CBC, platelet; for transfer to miscellaneous room. 8am> V/S checked and recorded; within normal ranges. Intake and output monitored closely as ordered. Bed linens stretched and tucked well. Provided with restful environment conducive for sleep. Able to consume 60cc of milk via bottle feeding with good appetite. Instructed watcher to report any signs of dehydration such as dry lips and skin, sunken fontanels, vomiting and diarrhea.

9am> Asleep; provided with restful and safe environment. 10am> Transferred to miscellaneous room as ordered. Bed linens stretched and tucked well. Arranged things in proper place.

11am> IVTT meds given by medicating NOD as ordered. Watched out for any signs of adverse reations, not noted. Instructed watcher to bottle feed within 3-4 hours.

12:30pm> V/S rechecked and recorded. Intake and output monitored closely as ordered. Watched out for any unusualities, not noted. Needs attended and cared for. 3pm> Endorsed to NOD.

NURSING CARE PLAN
Dat e Assessment Need Nursing Diagnosis
Fluid volume deficit r/t severe dehydration to consider

Objective of Care

Nursing Intervention

Evaluation

M A

S/O: • Watery,l oose

P h

Within 2 •Maintained accurate Intake days of and Output providing nursing care, -patient may reduce fluid

After 8 hrs of nursing care, GOAL

Y

stool(6x/day) in mod. amt • Vomited 5x/shift with sticky vomitus in scanty amount • Sunken fontanel noted

y s i o l o g i c Fluids & Electrolyte s

electrolyte imbalance 2˚ Acute Gastroenteritis Rationale: Acute Gastroenteritis is an inflammation on the stomach & GI tract which is manifested by diarrhea, abdominal pain associated with nausea, vomiting, fever, and abdominal distention& excessive elimination of waste caused electrolyte imbalance

, 2 0 0 7 7am – 3pm

• Sunken

eyeballs noted

will maintain intake during periods of fluid and crisis because of malaise, electrolytes anorexia,and so on. volume at a functional • Monitored v/s,comparing with patient’s normal/ level as previous readings evidenced by: - reduction of circulating blood volume can occur - will from ↑fluid loss resulting in defecate semi-formed hypotension and tachycardia stool at lest 2 times a day - there will be decrease occurrence of vomiting at least 12 times a day • Observed for fever, changes in LOC,skin turgor, dryness of skin and mucous membranes, pain. - symptoms reflective of DHN/ hemoconcentration with consequent vasoocclusive state.

PARTIALLY MET Patient regained and maintained fluid volume at a functional level as evidenced by: BP=110/70mmH g PR=96bpm Urine Output= 30cc/hr

• Dry lips & mucus membrane noted. • Distended abdomen noted • Poor sucking noted • Delayed capillary refill noted • Pale skin • Wt=5.2kgs.

• FFP @ 78ccx 4
hrs x 3 cycles. With serial # 111-06-13473 type B+

Reference:

Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

- will • Monitored v/s closely manifest during blood transfusions moist lips and noted presence of and mucous dyspnea, membranes crackles,ronchi,wheezes, and capillary diminished breath sounds refill in 2-3 cough and cyanosis. seconds - weight of 5.2 kgs will increase to 5.7 kgs - patient’s heart may be already weakened and prone to failure due to chronic demands,placed

• Serum Na=130.4mEq • Serum Ca= 0.84mEq • Serum K=3.15 mEq

- fever will subside with the temperature of less than 37.5

on it by the anemic state. Heart may be unable to tolerate the added fluid volume from the transfusions or rapid IV fluid administered to heart crisis/shock •Administered fluids as indicated - replaces losses/deficits. Fluids must be given immediately to decrease hemoconcentration and prevent further interaction

Dat e A P R I

Assessment
Subjective: “Dili man ko ganahan mulihok ky dali ra man ko kapuyon”, as verbalized.

Need

Nursing Diagnosis
Activity Intolerance r/t imbalance between O2 supply and demand 2˚ Hypovolemic shock

Objective of Care

Nursing Intervention

Evaluation
After 2 days of providing nursing care, GOAL PARTIALLY MET As evidenced

Safety

Within 8 hrs • Assessed the degree of dehydration. of nursepatient - to provide baseline interaction, information. will demonstrate • Established a 24 hour a ↓ in fluids and electrolytes replacement needs and physiologic

L 3 0, 2 0 0 7 3– 11pm

Objective: • Pale lips

& Security

Rationale: Hypovolemic shock results from loss of fluids & occurs more rapidly than fluid intake which results to the imbalance of O2 supply and demand to the body. This oftenly causes fatigue 7 weakness which can interfere with the individual’s ability to work.
Reference: Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

• Tachycardia (PR=101bpm)

• O2 inhalation @
5L/min via nasal cannula

Energy Mgt.

• Weakness,

body malaise,fatigue

• Administered IV fluids as indicated and regulated -PR,RR, & BP well at prescribed rate. will remain - to correct fluid losses. within normal • Administered one unit ranges fresh frozen plasma. -decrease in - to replace electrolyte fatigue losses. -increase ability to participate in activities, such as personal hygiene & nail care.

signs of intolerance as evidenced by:

routes (IV,PO) to be used. - prevents peak/valleys in fluid level.

by:

- defecated semi-solid stools at lest 2 times a day - vomited at least twice a day.

• Hemoglobin Mass Concentration= 20. • BP=80/60mmH g • RR=28cpm

- manifested moist lips and mucous membranes and • provided nutritious diet via capillary refill of NGT. at least 2-3 seconds.. - to meet the body’s nutrient requirements. - weight increased to 5.5 • administered anti- infective as ordered by the physician. kgs from 5.2 kgs - prevents the spread of enteropathogen Encougaged to properly sterilize water. -inhibits the growth of microorganism. Monitored the I & O, and weight everyday. - fever subsided with a temperature of

- to assess the fluid level. Administered Paracetamol for fever as ordered. - to lower down doy temperature to normal range. Instructed watcher to perform TSB. - provide comfort an lowered body temperature.

Dat e A

Assessment
Risk Factors: • Decreased

Need

Nursing Diagnosis
Risk for Infection r/t

Objective of Care

Nursing Intervention

Evaluation
After 8 hrs of

Within 8 hrs of •Washed hands before & nurse-patient after each care activity ,

P R I L 3 0, 2 0 0 7 3–

hemoglobin (20gm/dL) • Invasive procedures such as foley catheter insertion, blood transfusion, and starting double IV lines Objective:

inadequate secondary defenses 2˚ Aplastic Anemia

Safety & Security

Rationale: Aplastic anemia makes one susceptible to complications on RBCs, WBCs & platelets which gives high risk for infection. WBC, in particular, fights against foreign substances that enters the body.

interaction, even if sterile gloves were will participate used on -Reduces risk of cross interventions contamination to prevent/ reduce risk of • Inspected wounds/site of invasive devices daily, infection as paying particular attention evidenced by: to parenteral nutrition lines. Noted signs of local - Body inflammation/infection. temperature will be within normal ranges - May provide portal of entry for infection, primary infecting organisms,as well as early identification of secondary infections.

nursing care, GOAL MET Patient was able to identify interventions to prevent or reduce risk of infection as evidenced by: -Body temperature down to 37˚C -“kinahanglan jud d I na limpyo pirmi atong lawas”, as verbalized.

• Febrile @
37.8˚C • Not taken a bath for 2 days • Untrimmed fingernails

Infection Protection

-verbalization of understanding • Noted signs and symptoms on proper of sepsis (systemic hygiene infection): fever, altered LOC. -To assess causative/ contributing factors

Reference:

11pm

Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

• Monitored temperature trends. -fever (38.5ºC - 40˚C) is the result of endotoxin effect on the hypothalamus and

pyrogen-released endorphins •Instructed and educated to participate in hygienic care - facilitate in promoting personal wellness

B. DISCHARGE PLAN Clients with Acute Gastroenteritis, watchers are instructed to take the following plan for discharge:

M- Medications should be taken regularly as prescribed , on
exact dosage, time, & frequency, making sure that the purpose of medications is fully disclosed by the health care provider.

E- Exercise should be promoted in a way by stretching hand
and feet every morning and exercise burping every after bottle feeding.

T- Treatment after discharge is expected for patients and
watcher with Acute Gastroenteritis to fully participate in continuous treatment.

H- Hygiene must be maintained for patients with Acute
Gastroenteritis. Promotion of personal hygiene should be encouraged such as, daily bathing and changing of diapers when soiled.

O- OPD such as regular follow-up check-ups should be greatly
encouraged to clients wather with Acute Gastroenteritis as ordered by physician to ensure the continuing management and treatment.

D- Diet should be promoted, since, during admission, the
patient was on NPO. Proper selection of milk that are suitable for babies will help enhance immunity.

VIII. PHARMACOLOGICAL MANAGEMENT

Diazepam
a. Doctor’s Order: 1.5mg IVTT now then PRN for frank seizures b. Indication: Management of general anxiety disorder, panic

disorders, and provides pre- operative sedation.
c. Mechanism of Action: Depresses all levels of CNS, including the

limbic and reticular formation, probably through the increased action of GABA, which is a major inhibitory neurotransmitter in the brain. d. Nursing Responsibilities:  Assess effectiveness of therapy according to diagnosis – seizure.  Monitor RR, HR and BP.  Do not overuse or miss regularly scheduled doses. Administer drug properly as ordered.  If used or seizures, report immediately lack of seizure control.

Ceftriaxone

a. Doctor’s Order: 500mg IVTT now then OD b. Indication: Treatment for lower respiratory tract infection c. Mechanism of Action: Inhibits bacterial cell wall synthesis by

binding to one or more o the penicillin binding protein. d. Nursing Responsibilities:  Assess for previous history of reaction to other cephalosphorin or penicillin. Monitor for allergic reactions.  Assess for bowel function (if severe diarrhea occurs, discontinue drug).  Monitor urine output (if decreased, notify the physician)

Ampicillin
a. Doctor’s Order: 260mg IVTT q 6hrs b. Indication: For susceptible bacterial infections c. Mechanism of Action: Interferes with bacterial cell wall synthesis

during active multiplication, causing cell wall death and resultant bactericidal against susceptible bacteria.
d. Nursing Responsibilities:

 Monitor effectiveness of therapy and active reaction, including development of opportunistic infections. • Phenobarbital
a. Doctor’s Order: 104mg IVTT now as LB/13mg IVTT q 12hrs b. Indication: For generalized tonic clonic (grand mal) and partial

seizures.
c. Mechanism of Action: Interferes with transmission of impulses

from the thalamus to the cortex of the brain, resulting in an imbalance and facilitatory mechanism.
d. Nursing Responsibilities:

 Constant observation and frequent monitoring of BP, RR and HR.
 Monitor infusion site for irritating extravasations.

Paracetamol
a. Doctor’s Order: 60mg IVTT q 4hrs (PRN for temp ≥ 37.8 °C) b. Indication: For mild to moderate pain and fever. c. Mechanism of Action: Reduces fever by acting on the

hypothalamus to cause vasodilation and sweating.
d. Nursing Responsibilities:

 Monitor for effectiveness o therapy.  Recheck Temp 15minutes after administration. • Dopamine
a. Doctor’s Order: 2cc/°. b. Indication: Treatment of shock which persist after adequate fluid

volume replacement.
c. Mechanism of Action: Stimulates both adrenergic and

dopaminergic receptors, lower doses are mainly dopaminergic stimulating and produce renal and mesenteric vasodilation, higher doses also are both dopaminergic and Beta1 adrenergic stimulating and produce cardiac stimulation and renal vasodilation. d. Nursing Responsibilities:  Monitor infusion site for extravasation.  Monitor closely for AR and S/S of overdosage. • Silver Sulfadiazine
a. Doctor’s Order: Apply to affected area TID. b. Indication: prevention and treatment of infection and burns.

c. Mechanism of Action: Acts upon the bacterial cell wall and cell

membrane. d. Nursing Responsibilities:  Monitor development of granulation.
 Observe for hypersensitivity reactions (irritation, redness, burning or itching in unburned areas).

IX. EVALUATION

X. BIBLIOGRAPHY

A. BOOKS
 Doenges, Marielyn E., ET. Al. (2002) Nursing Care Plans,

Guidelines for Individualizing Patient Care. (6th Edition)

 Doenges, Marielyn E., ET. Al. (2004). Nurse’s Pocket Guide. (9th

Edition)
 Kozier, Barbara ET. Al. (2004). Fundamentals of Nursing,

Concepts, Process and Practice. (7th Edition)
 Marieb,Elaine N. (2004). Essential of Human Anatomy and

Physiology. (7th Edition).
 MIMS. (105th Edition, 2005)  Smeltzer, Suzanne C. ET. Al. (2000). Textbook of Medical-Surgical

Nursing. (9th Edition).
 Smeltzer, Suzanne C. ET. Al. (2000). Textbook of Medical-Surgical

Nursing. Volume 1 (10th Edition)  Turkoski, Beatrice B., ET. Al. Drug Information Handbook for Nursing including Assessment, Administration, Monitoring Guidelines and Patient Education (2000-01).

B. INTERNET
http://en.wikipedia.org/wiki/Aplastic_anemia

http://www.aamds.org

C. OTHERS Microsoft Encarta Encyclopedia 2007.

A Case Study On Aplastic Anemia ----------------------------------------------------Presented to:

Ms. Zosi Farah W. Fernandez, RN --------------------------------------------------------

In Partial Fulfillment of the Requirements In Related Learning Experience

Presented by: Cabibil, Ervin Rol C. Colita, Arven Troy L. Abundo, Jissa A. Albero, Karren Rose A. Aquino, Sunshine S. Benilan, Melody E. Cadiente, Joyce C. Haguyahay, Faith E. Hinay, Rodelyn B. Javier, Kathleen Alyce B. Legal, Chinki C. Travilla, Allen Rose Y. BSN3 A1

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