A CASE STUDY IN ACUTE GASTROENTERITIS WITH MILD DEHYDRATION

In Partial Fulfillment of the Requirement for Related Learning Experience Second Semester 2012 – 2013

Submitted By: Jarin, Mary Joy BSN 2A

Submitted to: Sir Paul John Carvajal R.N. Clinical Instructor

February 13, 2013

but children. but some viruses may last up to a week. The risk of dehydration increases as symptoms are prolonged. Regardless of the cause. and abdominal cramps. low fever. or parasites.9 °C] or above). and severe abdominal pain or swelling. However. nausea and vomiting. and anyone with an underlying disease are more vulnerable to complications such as dehydration. certain bacteria. Adults usually recover without problem. The loss of fluids through diarrhea and vomiting can upset the body's electrolyte balance. blood in the vomit. Certain medications and excessive alcohol can irritate the digestive tract to the point of inducing gastroenteritis. a person may use over-the-counter medications such as Pepto Bismol to relieve the symptoms. the symptoms last only two to three days. These medications work by altering the ability of the intestine to move or secrete spontaneously. leading to potentially lifethreatening problems such as heart beat abnormalities (arrhythmia). Gastroenteritis typically lasts about three days. 2|Page . the elderly. medical treatment is essential if symptoms worsen or if there are complications. Introduction Gastroenteritis is a catchall term for infection or irritation of the digestive tract. These symptoms require prompt medical attention. and abdominal pain and cramps. although the influenza virus is not associated with this illness. and persons with underlying disease require special attention in this regard. Food that has spoiled may also cause illness. These symptoms are sometimes also accompanied by fever and overall weakness. Major symptoms include nausea and vomiting. Gastroenteritis arises from ingestion of viruses. for comfort and convenience. Gastroenteritis is a self-limiting illness which will resolve by itself.I. Symptoms of great concern include a high fever (102 ° F [38. the symptoms of gastroenteritis include diarrhea. and overall tiredness. The greatest danger presented by gastroenteritis is dehydration. blood or mucus in the diarrhea. It is frequently referred to as the stomach or intestinal flu. absorbing toxins and water. A usual bout of gastroenteritis shouldn't require a visit to the doctor. Dehydration should be suspected if a dry mouth. the elderly. Some over-the-counter medicines use more than one element to treat symptoms. or altering intestinal micro flora. Sufferers may also experience bloating. Infants. diarrhea. young children. increased or excessive thirst. However. or scanty urination is experienced. particularly the stomach and intestine. Typically. If symptoms do not resolve within a week. an infection or disorder more serious than gastroenteritis may be involved.

Having stomach pain right after eating may not be just a simple side effect of not eating on time. the patient and specific others shall have: acquired knowledge on the risk factors that have contributed to the development of Acute Gastrioentertis. This serves as a chance for me to provide information and assess him and his significant others to understand the disease process. 2013 with chief complaints of fever – 39. 1yr and 7 months of age was admitted at St. vomiting and diarrhea for 2 days already. comfort and good progression of the disease condition o To demonstrate independence or self-care and home management upon discharge 3|Page . I chose this case because I want to acquire knowledge and understanding of the development of Acute Gastroenteritis and the other complications that may arise with the disease. Dominic Medical Center last January 21. This case study will serve as an opportunity for me to learn more about the said case and to extend help to the patient and the family.E. medical and nursing management o To receive the best possible medical and nursing care. it might already be a sign of a gastrointestinal disease like acute gastroenteritis. gain understanding and demonstrate compliance on the treatment and management rendered by the health care team to present reoccurrence of disease. risk factors. leading to a feeling of security. Patient M. its development. Objectives a) General Objectives: During the course of the study. b) Specific Objectives: o To build a trusting and cooperative relationship with the nurse researchers as well as with the other members of the health care team o To gain knowledge on the definition of Gastroenteritis.2˚C.The researcher chose this study to help even the health care providers’ become aware of their condition that they ignore.A.

His fever and vomiting started a few hours after he was brought to the clinic. yellowish to brown in color with no blood stained. Yung dumi niya. vomiting and diarrhea for 2 days already. kulay dilaw at matubig. Kaya isinugod na naming sa dito sa ospital” as verbalized by the mother. Christine S. the staff nurses. His mother said that M. and the family. the problem was not resolved. However. 4|Page . The vomiting started on the same time with fever. tapos nagtatae siya. pero wala namang dugo. per rectally and antiemetic drugs to reduce his fever and vomiting. Demographic (Biographical) Data o Client’s Name or Initial: M. There was no history of changing formula milk. o “Tatlong araw na kasi siyang nilalagnat. No cough or runny nose.I. His mother described the amount of vomitus was about half of cup. o Admission Date: 01/21/2013 o Time Admitted: 11:17 pm o Attending Physician: Dr. he had loss appetite and only ate a little amount of foods and drinks.07 pm. contained fluid but no blood or bilious with slight offensive smell. His mother said that there was no rash or joint pain and no episode of fit since he had the fever. She brought him back to the same medical center at night on the same day. HEALTH HISTORY A. His mother measured the temperature at home and it was 39. History of Present Illness Patient M. It occurred once and is nonprojectile. Since then. He was then referred to SDMC and his parents brought him to ER around 9:30 pm and was admitted to ward 314-B1 at 11.A was well 2 days prior to admission when he started to develop diarrhea.2˚C (high grade fever) with no rigor. C. The doctor gave M.2˚C.E. It started at 2 am and it was a sudden onset and occurred about 4-5 times a day. Caringal o Admitting Diagnosis: Acute Gastroenteritis rule out UTI with some Dehydration o Final Diagnosis: Acute Gastroenteritis with mild Dehydration B. There was no recent history of taking outside food and travelling. Reason for Seeking Care o Fever – 39. D.A appeared lethargic and less active than usual during that period.A o Gender (Sex) : Male o Age: 1yr/7mos. The diarrhea was watery in nature.E.E. his mother brought him to the medical center and the doctor prescribed him Oral Rehydration Salt (ORS).E.A. Source and Reliability of Information o The sources of information are the patient’s chart. On Saturday morning which was 2 days after diarrhea occurred.

Past Medical History The patient was delivers NSD at one of the lying-in in Manila and was fully immunized. circle and cross line without seeing how it is done. 000 /month. Regional Examination – September 18. RR: 20-30 cpm (+) Weight Loss T: 36-37. o They have enough resources for their needs and leisure. skip and climb. Impression : Development milestones is corresponding to his chronological age. Vaccine BCG Hepa B Vitamin K DPT OPV AMV F. run. Developmental History (Based on Erick Erickson’s Psychosocial Development Theory) o Stage: Infancy – Birth to 18 months Ego Development Outcome: Trust vs.P30.): 9-22 lbs. I. H.5˚C (+) Altered sleeping pattern Wt. Personal & Social: Plays with people around him.5 Wt: 21 lbs. Review of Systems 1. G. 5|Page Age of Vaccination At birth At birth At birth 6 weeks 6 weeks 9 months System  General . Mistrust Basic strength: Drive and Hope Gross Motor: He’s able to walk. can talk constantly in 2-3 words and understand command. 2012 Normal Findings Actual Findings Vital Signs for infants: PR: 134 bpm Systolic BP: 50-70 RR: 26 cpm PR: 80-140 bpm T: 37. FAMILY HISTORY  No significant family history. (lbs.E. Vision & fine motor: He’s able to draw straight line. Speech & Language: He knows his age. Socio-Economic o The client’s mother is a pure housewife while his father call center agent in Alabang who earns more or less . o The mother usually cooks food for her children.

Solid. she gives home remedies in which if does not alleviate maker her decide to bring him on private clinics. She ensures that she is focused on the patient's health.32 % iron deficiency due to menstruation 5.0 (g/dL) 10.00 – 10.36 – 0. 2013 0. Eyes  Integumentary  Mouth & Throat:  Gastrointestinal  Urinary  Musculoskeletal 2.15. She assures that the patient receives enough nutrition and is alert to any abnormal condition his son is experiencing. express as a percentage of the total blood volume.4 (g/dL) January 21. 6|Page .43% . Whenever her son has cough. WBC This is used to determine if there is infection present.0 .08 increase infection * Health Perception and Health Management The mother considers the patient's health so important.dehydration (+) Weakness Procedure Date Indication Normal Findings / Values Actual Findings Significance / Interpretation Explanations of the Findings (as too High or Low) iron deficiency due to menstruation Hgb The oxygen-carrying pigment of red blood cells that gives them their red color and serves to convey oxygen to the tissues Hct A measure of the packed cell volume of red cells. Light Brown Light Yellow Urine (+) Sunken and tearless (+) Reduced skin turgority (+) Dry lips (+) Loss of Appetite (+) Vomiting – Non-projectile (+) Yellowish to brown in Color .00 4. FUNCTIONAL ASSESSMENT 12. Laboratory Studies / Diagnostics Stool .

* Sleep rest pattern He sleeps in the morning up to lunch. Her mother then gave him formula mil and its brand is Pediasure. the patient defecates three times a date with yellow colored stool. * Cognitive-Perception The patient is active and is oriented with the people around him. He sleeps on and off for about every two hours at night and just take naps if not disturbed. two naps in the afternoon and sleeps in the whole night. soft and slightly formed. He is fond of playing with people around him.A is exclusively breastfed from birth up to six months old. He reduces his stress by entertaining himself with the different things around him. * Activities of daily living (ADL) According to the mother.E. 7|Page . he started to east solid foods like rice and biscuits such as Marie and Bravo. His appetite is good according to the mother. her mother then changes his diaper two times a day and his stool is watery. They don’t actively participate in the activities in their church. copes up to his condition very well. He is not easily irritated and is even a jolly kid. this routine was changed since he's no longer fond of eating fruits and drinking water but is still given with formula milk. According to the mother. The mother verbalized that they don’t always attend worship sessions. his sleep pattern changed. The consistency of his stool is condensed. He recognizes the people around him and play with them. he is a very active child and does not cry easily. When he was hospitalized. * Elimination pattern The mother changes his diaper three-four times a day. When he is 6 months old. he wants to walk but needs assistance. He can cope easily with other person. When he was hospitalized. He does not eat salty foods yet fond of eating fruits like orange and banana. He plays many toys but he loses eagerness and gets easily tired and plays another toy. * Coping and Stress Tolerance Patient M.* Nutritional and Metabolic Pattern Patient M.A. * Values – Belief Pattern Their religion is Roman Catholic. When he was hospitalized. He drinks a lot of water. He could recognize his mother and father. * Role-Relationship Pattern (while confined) According to the mother.E.

PATHOPHYSIOLOGY (Book Base) 8|Page .

like noroviruses. The epithelial cell synthesizes and secretes numerous cytokines and chemokines. which leads to a Ca2+ -dependent Cl. The current knowledge on the mechanisms leading to diarrheal disease by rotavirus is as follows: * Rotavirus infections induce maldigestion of carbohydrates. Viral attachment and entry into the epithelial cell without cell death may be enough to initiate diarrhea. 9|Page .Narrative Viral spread from person to person occurs by fecal-oral transmission of contaminated food and water. Rotaviruses attach and enter mature enterocytes at the tips of small intestinal villi. including villus shortening and mononuclear inflammatory infiltrate in the lamina propria. Clinical manifestations are related to intestinal infection. promoting active chloride secretion mediated through increases in intracellular calcium concentration. They cause structural changes to the small bowel mucosa. Toxin-mediated diarrhea would explain the observation that villus injury is not necessarily linked to diarrhea. Some viruses. can lead to a malabsorption component of diarrhea. and their accumulation in the intestinal lumen.secretory mechanism. NSP4. may be transmitted by an airborne route. Mobilization of intracellular calcium associated with NSP4 expressed endogenously or added exogenously is known to induce transient chloride secretion. * Rotavirus secretes an enterotoxin. Studies also suggest that one of the nonstructural viral proteins may act as an enterotoxin. as well as a malabsorption of nutrients and a concomitant inhibition of water reabsorption. which can direct the host immune response and potentially regulate cell morphology and function. The most extensive studies have been done with rotavirus. Morphologic abnormalities can be minimal. and studies demonstrate that rotavirus can be released from infected epithelial cells without destroying them. but the exact mechanism of the induction of diarrhea is not clear.

CONCEPT MAPPING Key Problem #1 Acute pain related to irritation due to of gastric acid.6 Key Problem #3 Deficient fluid volume related to dehydration as manifested by dark yellow urine Key Problem #4 Alteration of body thermoregulation 10 | P a g e .P. Key Problem #2 Imbalanced nutrition due to loss of appetite Key Demographic Data: Clients initial: P. Dehydration and alteration of body thermo regulation Key Assessments: RR: 25 PR: 96 Temp: 38. loss of appetite.P Age: 1 y/o 7 months Gender: Male Assessment of Patient: Increase of gastric acid.

37. 2. Deficient fluid volume related to dehydration as manifested by yellowish to brownish urine 4. ACTUAL or active Problem No.PROBLEM LIST a. The patient improves appetite and lessens the dryness of his lips. 1. Alteration of body thermoregulation 11 | P a g e . Problem Acute pain related to irritation due to acid of gastric Remarks Client shows feelings of comfort and relief. Imbalanced nutrition due to loss of appetite or anorexia 3. The patient partially maintains his fluid volume at a functional level The patient maintained core temperature within normal range.

NURSING CARE PLANS Acute pain Assessment VS: PR: 96 Diagnosis Acute pain related to Planning At the end of the shift the Intervention Evaluation At the end of Establish rapport Rationale: to facilitate cooperation as well as to gain patient's trust  Express a feeling of comfort and relief from pain   Assess for signs and symptoms of pain Rationale: To prevent possible complications Promote comfort for the client Rationale: To regain strength and to reduce anxiety Dependent:  Administer Ranitidine  Client shows feelings of comfort and relief the shift the goal was met as evidenced by:  inflammation of patient will be gastric mucosa  Patient holding abdominal area face is grimace able to : 12 | P a g e .

electrolytes and total protein and pre albumin 13 | P a g e . including petroleum jelly for lips Rationale: To note presence of dehydration Evaluation At the end of the shift the patient was able to:    Eat foods at least 50% of the meal Free of signs of malnutrition The lips at least lessen it dryness  The goal was met.Imbalanced nutrition less than body requirements Assessment VS: Weight: 52 kg50 kg     Dry lips Poor skin turgor Loss of appetite Body weakness Diagnosis Imbalanced nutrition related to vomiting and irregularities to body perception Planning At the end of the shift the patient will be able to :    Eat foods at least 50% of the meal Be free of signs of malnutrition The lips at least lessen it dryness Intervention Independent:  Monitor tolerance of fluid and food intake when resumed. nothing abdominal distention. hemoglobin / hematocrit. 1L for 16 hours Collaborative:   Collaborate with nutritional team and dietician as indicated Monitor the laboratory results. Dependent:  Administer D5LR. report of increase pain or cramping and vomiting Rationale: To evaluate changes as related to fluid status Provide oral hygiene on a regular frequent basis.

Rationale: to maintain high-level of wellbeing  Monitor vital signs. PR. clammy skin  Dry lips  Vital signs taken: BP: 80/60 PR: 96 Diagnosis Deficient fluid volume may be related to active fluid loss – vomiting. p. Following the pharmacological approach. fluid  Monitor administration of IV Fluids by regulating it  Laboratory studies specifically serum electrolytes Rationale: To assure that the body receives accurate amount of fluids and electrolyte  Encourage the patient to have an adequate skin and oral care. the nurse plays an important role in the curative side as well as in the prevention of potential complications arising from IV fluid infusion 14 | P a g e . After 8 hours Independent: of nursing  Monitor I & O intervention.Fluid Volume Deficit Assessment Objective:  Dry mucus membrane  Pale. Observe for temperature elevations/fever. replace the 2008. Rationale: BP. RR often increases when either fluid deficit or excess is present Collaboration:  Monitoring Laboratory studies specifically serum electrolytes Rationale: IV flow rate monitoring and regulation seeks to infuse the proper dose and exact amount of fluids required by the patient. Planning Intervention Evaluation At the end of our duty. 377).” (Ackley & Ladwig. the patient will demonstrate adequate hydration. Note presence/degree of postural BP changes. Rationale: “Accurately measuring intake the patient and output is vital for the client with fluid will be able to volume overload.

the patient will maintain core temperature within normal range 36 – 37 ᶱ C Intervention Independent:  Provide TSB Rationale: To relieve pain and provide comfort.Hyperthermia Assessment Objective:  Flushed skin  Warm to touch  Restlessness Diagnosis Hyperthermia related to present condition Planning After 4 hour of nursing interventions.6 15 | P a g e .2 Vital sign Temp.  Monitor vital sign Rationale: To prevent possible complications  Promote surface cooling. after doing consecutive TSB. encourage relaxation skill Rationale: To regain strength and to reduce anxiety  Increase oral fluid intake Rationale: To facilitate hydration Dependent:  Administer Paracetamol every 4 hours Rationale: To decrease the temperature within normal range.: 38. loosen clothing and cool environment Rationale: Fever is usually reduced by the cool atmosphere of the mist tent  Promote bed rest. 36-37C  If the symptom persist report to the charge nurse / doctor Evaluation After 30 minutes of nursing interventions. The water has the initial effect of depressing body systems. 37. the temperature of the patient went back to core temperature within normal range.

Indication GN (BN) (Client Specific) Classification Dosage & Stock Frequency Paracetamol Class: Analgesic / Antipyretics Relief of mild to moderate pain.Inform the relatives of the patient that the urine may become dark brown as a result of phenacetin (metabolite of acetaminophen) . headache. intensity.DERM Skin rashes -ENDO Liver Damage Nursing Responsibilities includes health teaching and implications (PRE.Dizziness 16 | P a g e . fatigue. including drug history and any known allergies.II. . INTRA.Assess the patient’s fever or pain. Pharmacotherapeutics /Medicines (IV-Fluids. fever.Assess allergic reactions: rash. Dosage: 150 mg BID Reversibly and competitively blocks histamine at H2 receptors. temperature . urticaria: if these occur drug may have to discontinue . treatment for fever Dosage: 7 mg Frequency: Every 4 hours Mechanism of Action * Decreases Fever * Inhibiting the effects of pyrogens on the hypothalamic heat regulating center * A hypothalamic action Ranitidine Class: Histamine H2 antagonist Prevention of upper gastrointestinal bleeding. leading to inhibition of gastric acid secretion. . mouth sores. Drugs) Side Effect Adverse Reactions .Notify physician if patient develops hypotension. particularly those in gastric parietal cells. duration.Obtain patient history. vomiting. . POST) .Inform patient that the drug can cause drowsiness and to use caution while performing tasks requiring mental alertness. . type of location. dizziness. nausea.Instruct the patient to maintain adequate fluid statusand avoid excess dehydration or overdehydration.

It raises intravascular osmotic pressure and provides fluid. Dosage: 15 mg OD -Anorexia -Vomiting -Dark stool .Probiotics + Prebiotics 1 sachet OD to be mixed with formula .Monitor color of stool.Tell the patient that the drug can cause stomach upset.Treatment for persons needing extra calories who cannot tolerate fluid overload. .Check vital signs frequently.Evaluate Hgb and Hct count during therapy. vomiting. parenteral fluid.D5LR Class: HypertonicNonpyrogenic. .Identify foods to include for iron-rich diet. electrolytes and calories for energy Provides/replaces elemental iron essential component information on RBC development -Increased serum osmolality -Hypernatremia -Hypokalemia -Altered thermoregulation . III.Tell the patient that drug may cause black stools.Ferrous Sulfate 2ml OD Strategy Compliance M Medication * Inform the parents on the side effects of the following drugs given * Instruct the mother to properly comply on the following medications * Give emphasis on the right time and right dose of every drug to be given 17 | P a g e . .Paracetamol 170 mg q4 for fever ≥ 37 . . DISCHARGE HEALTH-TEACHINGS Content Instruct the parents to administer the following medications as prescribed by the doctor: . Dosage: 20 drops/ minute Hypertonic Solutions are those that have an effective osmolarity greater than the body fluids. . Report adverse reactions. including drug history and any known allergies. constipation or diarrhea and to report anorexia. Ferrous Sulfate Class: Dietary / Nutritional Preparations Prevention and treatment of iron-deficiency anemia. instruct the patient to take the drug after meals. electrolyte and nutrient plenisher . nausea.Obtain patient history.Zinc Drop 1ml OD x 14 days . This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume.

Teach the parents the best nutrition that fits to the client’s needs at the same time the appropriate time and number of hours for time and rest Go to the outpatient department to associate and investigate. avoid eating street foods and to start eating fruits and vegetables. . O OPD Before you discharge.Teach the mother the proper hand as well as the family and most especially the client .E Exercise * Encourage the mother to have some walk with her child especially early morning. eating healthy everyday . .The importance with complying with .Teach family/significant others to foster independence. D Diet Follow the BRAT diet Instruct the mother to increase the fluid intake of the patient. .The importance of a clean environment. and increased fluid intake. S Sign and symptoms 18 | P a g e .Teach the proper food handling prescribed medications. do not hesitate to go to the hospital immediately. when and how to get these kinds of microorganisms .Teach the family the susceptible microorganism that can cause diseases to the GI tract including where. It’s better to be safe than sorry. * Play with the child * Encourage to have a stretching of the hands and feet * Advice the mother to visit their barangay health center for further observations * Teach the mother to keep an eye on the appearance of the client’s stool T Treatment Continue the medications that have been prescribed by the doctor H Health Teaching .The significance of bed rest.Encourage patient to comply with foods. to know if are ok to discharge. go to the OPD. medications given. If discomfort is felt and pain arises again. and to intervene if the patient is unable to perform task or becomess excessively frustrated. .Instruct the family/significant others to observe proper hygiene such as taking a bath .

Spratto.php?keyword=lysmix&keybrand=Lysmix&id=20071208 http://www. Murr Nursing Care Plans 8th Edition Davi's Nursing Resource Center George R. gastric cancer.com/Gastro/statistics.com/diseases/gastritis/622#Statistics http://www.gastro. Woods.com/search-drugdetails. Adrienne L. 2011.sciencedaily.nationmaster. Web 19 | P a g e ." www.virtualmedicalcentre.com Lifespan.thefilipinodoctor. 2 Feb. 2013 www.com/graph/mor_gas_and_duo-mortality-gastritis-and-duodenitis http://www.virtualmedicalcentre. ulcer disease.aspx http://www.peoples-health. Doenges. PDR Nurse’s Drug Handbook.Bibliography: Marilyn E. "Potential vaccine to prevent gastritis.com/gastritis.htm www. Mary Frances Moorhouse.com.com http://www. 2008 Edition.virtualmedicalcentre. Thomson Delmar Learning Online Sources Retrieve Date: February 11. Alice C.

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