Case Study:

Acute Gastroenteritis

Submitted by:
Cabrera, Alexander
BSN – 3D

Submitted to:
Ms. Mendoza
I. INTRODUCTION:

Acute Gastroenteritis
Acute gastroenteritis could be more simply called a long, and potentially
lethal bout of stomach flu. The most common symptoms are diarrhea, vomiting
and stomach pain, because whatever causes the condition inflames the
gastrointestinal tract. Acute gastroenteritis is quite common among children,
though it is certainly possible for adults to suffer from it as well. While most cases
of gastroenteritis last a few days, acute gastroenteritis can last for weeks and
months.
Numerous things may cause acute gastroenteritis. Bacterial infection is
frequently a factor, and infection by parasites like giardia can cause acute
gastroenteritis to last for several weeks. Viruses can also cause lengthy stomach
flu, particularly rotaviruses and noroviruses. Accidental poisoning or exposure to
toxins may also instigate acute gastroenteritis as well.
Acute gastroenteritis remains a serious health issue, and is responsible for over
50,000 hospitalizations of children. In developing countries, acute gastroenteritis
is the leading cause of death for infants. Acute gastroenteritis should thus be
taken seriously, and people should not hesitate to seek medical treatment for
especially seniors and children who have been ill for more than a day.
In the Philippine Health Statistic, gastroenteritis range as number 10 in the ten
leading causes of infant mortality, with the rate of 0.5 and percentage of 4.1
cases in the Philippines by the year 2004 this was updated last February 12,
2008.
The case is about 11months old baby who has been diagnosed with AGE with
some dehydration. He was admitted last March 13, 2010.

II. OBJECTIVES:
A. General Objectives:

• This study aims to convey familiarity and to provide an effective nursing

care to a patient diagnosed with Acute Gastroenteritis through
understanding the patient history, disease process and
management.
B. Specific Objectives:

• Conduct and evaluate an assessment for the client

 • Determine the causes, predisposing and precipitating factors that
constitute the onset of the disease process.
• Render series of nursing interventions for the client’s care
• Provide and disseminate important information as teachings to the client
and the significant others to boost the knowing and understanding of the
nature of the said health condition.
• Improve skills and knowledge as health care providers in the clinical area.

III. Significance of the study:

Student Nurse:
• This study will enable the students to understand better about acute
gastroenteritis and will explain the different risk factors for developing the
disease, including consumption of improperly prepared foods or
contaminated water and travel or residence in areas of poor sanitation
Patient’s Mother:
• Will be able to gain knowledge & additional information with regards the
cause of developing the disease.
Clinical instructor:
• This study is significant to our clinical instructor for us student to share
with them experiences in handling a client with this kind of situation
supplemented by correlated theories with the hope to add their expertise.
Significant Others:
• This will serve as additional information about AGE specifically the causes
of developing this disease.

IV. Scope and Delimitation:

The study was done while our group BSN C-2, was having our duty at Rizal
Provincial Hospital. I have named him patient PDY, not his true name, to
conceal his real identity so as to keep up the privacy of client. Patient PDY was
admitted last march 13, 2010 with sever vomiting and LBM.
This study focuses about AGE and the care of baby having diagnosed with AGE.

V. Theoretical Framework:

I use of Orem’s Self-care Theory, because as we all know infants are dependent
on their parents for them to attained their basic needs.

Self-care theory is based on four concepts:

1. Self-care which refers to those activities an individual performs
independently throughout life to promote and maintain personal well-
being.
2. Self-care agency is the individual’s ability to perform self-care activities.
 3. Therapeutic self-care demand refers to all self-care activities required to
meet actions to maintain health and well-being.
4. Self-care deficit results when self-care agency is not adequate to meet the
known self-care demand

Orem’s self-care deficit theory explains not only when nursing is needed but also
how people can be assisted through 5 methods of helping 1. acting or doing for
2. guiding 3. teaching 4. supporting 5. providing an environment that promotes
the individuals ability to meet current and future demands.

Orem identifies 3 types of nursing systems

• wholly compensatory systems are required for individuals who are unable
to control and monitor their environment and process information
• partly compensatory systems are designed for individuals who are unable
to perform some, but not at all, self-care activities
• supportive-educative (developmental) systems are designed for persons
who need to learn to perform self-care measures and need assistance to
do so

VI. Nursing Assessment:

A. Biographical Data
Name: Patient PDY
Address: Sitio Malalim, Baras, Rizal
Date of Birth: March 28, 2009
Age: 11months
Sex: Male
Civil Status: Single
Nationality: Filipino
Religious Preferences: Catholic
Health care financing: None
Date of Admission: March 13, 2010
Diagnosis: Acute Gastroenteritis with signs of dehydration

B. Chief Complaint

• According to the significant patient’s mother, the client was vomiting and
defecating that’s why they rushed her to the hospital.
C. Admitting Diagnosis: AGE with Dehydration

D. Final Diagnosis: AGE with Dehydration

E. HEALTH HISTORY
A. History of Present Illness
• Prior to admission, the client was vomiting and defecating. Her stool was
watery and its color is yellow.
 B. Past History
• The client had fever, cough and colds. She had completed all vaccinations
including BCG, DPT, Oral Polio Vaccine, MMR and Hepatitis B vaccine.
The patient had never been any of the childhood disease such as
measles, mumps and chicken pox. The patient had no history of accident
or any injury. He does not have allergy in any food or drug.
C. Family History
According to the mother of Pt. they have a familial disease of asthma, both on
her father and mother's side. And an incident of hypertension on his father's side.

F. PHYSICAL ASSESSMENT

BODY
NORMAL ACTUAL INTERPRETATIO
PARTS TECHNIQUES
FINDINGS FINDINGS N
ASSESSED
1.Skin
a. Moisture Palpation Moisture in skin Dry skin Deviated due to
folds and axillae slight dehydration
B Texture Palpation Smooth Rough Deviated due to
slight dehydration
c. Turgor Inspection and Springs back Moves back Deviated due to
Palpation immediately to slowly slight dehydration
previous state
2. Eyes
Eyes Inspection Parallel to each Parallel to each d/t dehydration
other other but sunken

Visual Acuity Inspection PERRLA- Pupils PERRLA- Pupils Normal

(penlight) equally round equally round
react to light and react to light and
accommodation accommodation
Eyebrows Inspection Symmetrical in Symmetrical in Normal
size, extension, size, extension,
hair texture and hair texture and
movement movement
Eyelashes Inspection Distributed evenly Distributed evenly Normal
and curved and curved
outward outward

Pink in color, soft

moist, smooth
3. Mouth Deviated due to
Inspection texture, Dry lips
a. Lips slight dehydration
symmetrical no
tenderness, no
lesions
b. Mucosa Inspection and Uniform pink color Dry and slightly Deviated from
Palpation pink in color normal due to
slight dehydration
c. Gums Inspection and Pink gums, moist, Pink gums, dry, Deviated from
Palpation firm texture firm texture normal due to
slight dehydration
4.Thorax Auscultation Clear breath Clear breath Normal
and Lungs sounds sounds

5. Abdomen Auscultation Audible bowel Hyperactive Deviated due to

Bowel sounds bowel sound diarrhea
sounds

VII. Gordon Functional Health Pattern.

Nutritional-Metabolic Pattern

 Before his hospitalization, according to patient’s mother he drinks about 5-7

bottle of milk a day with meal. And vitamins.

 During his hospitalization, his appetite decreased, he drinks about 3-4 bottle
of milk.

Elimination Pattern

 Before his hospitalization, the patient used to eliminate 4 times a day with a
semi-solid consistency and is brownish in color. He usually urinates 2 times a
day with the normal light yellow color and aromatic odor.
 During is hospitalization; the patient’s stool is watery with a yellowish color.
He urinates 2-3 times a day.

Activity-Exercise Pattern

 Before his hospitalization, he used to play outside with his cousins. They
usually play toy cars and the usual games of his age. He stops playing when
he feels tired.

 During his hospitalization, he used his time playing the cell phone of his
father. Most of his time was spent for resting and sleeping.
Sleep-Rest Pattern

 Before his hospitalization, he usually sleeps 10-11 hours.

 During his hospitalization, the patient sleeps early but has sleep disturbances
when the nurses take his vital signs, administer medicines and also due to the
environment.

Cognitive-Perception Pattern

 Before his hospitalization, the patient is normal in terms of his cognitive

abilities. He has no problems with his senses.

 During his hospitalization, he relates to me actively.

Self-Perception/ Self-Concept Pattern

 N/A

Role-Relationship Pattern

 The patient has a close relationship with his family, but he is closer to his
father.

Sexual-Reproductive Pattern

 Prior to his age, the patient is not yet oriented with any sexual matters.

Value-Belief Pattern

He is a Roman Catholic. They attend mass regularly. According to his mother

VIII. ANATOMY AND PHYSIOLOGY

The human digestive system is a complex series of organs and glands that
processes food. In order to use the food we eat, our body has to break the
food down into smaller molecules that it can process; it also has to excrete
waste.
Most of the digestive organs (like the stomach and intestines) are tube-like and
contain the food as it makes its way through the body. The digestive system is
essentially a long, twisting tube that runs from the mouth to the anus, plus a few
other organs (like the liver and pancreas) that produce or store digestive
chemicals.

The Digestive Process:

The start of the process - the mouth: The digestive process begins in the
mouth. Food is partly broken down by the process of chewing and by the
chemical action of salivary enzymes (these enzymes are produced by the
salivary glands and break down starches into smaller molecules).
On the way to the stomach: the esophagus - After being chewed and
swallowed, the food enters the esophagus. The esophagus is a long tube
that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle
movements (called peristalsis) to force food from the throat into the stomach.
This muscle movement gives us the ability to eat or drink even when we're
upside-down.

In the stomach - The stomach is a large, sack-like organ that churns the food
and bathes it in a very strong acid (gastric acid). Food in the stomach that is
partly digested and mixed with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the duodenum,
the first part of the small intestine. It then enters the jejunum and then the ileum
(the final part of the small intestine). In the small intestine, bile (produced in the
liver and stored in the gall bladder), pancreatic enzymes, and other digestive
enzymes produced by the inner wall of the small intestine help in the breakdown
of food.

In the large intestine - After passing through the small intestine, food passes
into the large intestine. In the large intestine, some of the water and
electrolytes (chemicals like sodium) are removed from the food. Many microbes
(bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and
Klebsiella) in the large intestine help in the digestion process. The first part of the
large intestine is called the cecum (the appendix is connected to the cecum).
Food then travels upward in the ascending colon. The food travels across the
abdomen in the transverse colon, goes back down the other side of the body
in the descending colon, and then through the sigmoid colon.

The large intestine is made up of three parts:

1. The cecum is a pouch at the beginning of the large intestine that joins the
small intestine to the large intestine. This transition area allows food to
travel from the small intestine to the large intestine.
2. The appendix, a small, hollow, finger-like pouch, hangs off the cecum.
Doctors believe the appendix is left over from a previous time in human
evolution. It no longer appears to be useful to the digestive process.
3. The colon extends from the cecum up the right side of the abdomen,
across the upper abdomen, and then down the left side of the abdomen,
finally connecting to the rectum. The colon has three parts: the ascending
colon and transverse colon, which absorb water and salts, and the
descending colon, which holds the resulting waste. Bacteria in the colon
help to digest the remaining food products.
The rectum is where feces are stored until they leave the digestive system
through the anus as a bowel movement.
The end of the process - Solid waste is then stored in the rectum until it is
excreted via the anus.

X
. Discharge Plan
Medications:
Advised the patient to continue the medication prescribed by the doctor such as:
• OMX 1Cap BID x 5amp
• Zinc drop 1ml, OD
• Vitamin A 100000 “u”, PO
The patient already stayed for 2 days in the hospital. She’ll continue her
medications at home.

Exercise:
• Advised the pt mother to let their children play like solving simple puzzle.

Treatment:
• No further treatment was ordered by the doctor

Health Teaching:
• Advised the pt.mother about proper and strict supervision of child until
balance, gait, and coordination is gained.
• Proper hygiene of both child and parent are very important as defense
from infection.
• Advise to restrict child from handling items or objects especially if
unfamiliar and not edible. Emphasize importance of hand washing and nail
care.

Out – patient follow up:

• Advise the mother that infant nutrition is an important topic and she should
always feel free to discuss at health care visits.

Diet:
• Increased vitamin C intake, to provide antioxidants that will prevent
possible cell damage.
• Encourage pt. Mother to prepare a balanced diet meal for his baby.

Spiritual:
• Advised the mother to develop a closed relationship with their baby and
always attend mass regularly.
 LABORATORY RESULTS

HEMATOLOGY RESULTS

Normal Value Results Analysis

WBC 5-10 x 10 g/L 4.5 Decreased
Hgb M 13-16 g/dl 10.3 Normal
F 12-16 g/dl
Hct M 39%-54% 33% Decreased
F 37%-48%
Differential Count
Segmenters .40-.60 .32 Decreased
Lymphocytes .20-.40 .68 Increased

FECALYSIS

Results Analysis
Physical properties:
Color Yellow Normal
Consistency Soft d/t profuse secretion of
water and electrolytes

URINALYSIS

Results Analysis
Color Yellow Normal
Transparency Slightly turbid d/t increased urine
concentration
Reaction 6.0 Normal
Specific gravity 1.030 Decreased: d/t
dehydration
Sugar Negative Normal
Protein Trace Normal