University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

#64 Aurora Blvd., Brgy. Dona Imelda, Sta. Mesa, Quezon City
COLLEGE OF NURSING

NAME: JANOYOG, Mark Vincent R. DATE: November 13, 2019

SECTION: N2B SUBJECT: NCM 109

1. Identify relevant risk factors in the development of possible Diarrhea and Acute Gastroenteritis.

MODIFIABLE NON-MODIFIABLE
A. Environment A. Age
B. Diet B. Past health history
C. Lifestyle
D. Pathogens

2. Trace the pathophysiology of acute gastroenteritis. Be sure to include all relevant assessment cues
present in the case. (You may have a separate sheet of paper)

3. Explain the possible problems associated with increase body temperature, sunken eyeball, vomiting
and soft watery stool.

 The patient could be experiencing dehydration due to vomiting and diarrhea.

4. Provide 3 prioritized nursing diagnosis that are well supported with your assessment cues.

ASSESSMENT CUES NURSING DIAGNOSIS

First:
- vomiting for 2 days Deficient fluid volume related to active fluid loss
- sunken eyes
- dry skin turgor
- soft watery stool for 2 days
- Temperature 39.2 Second
- RR 35 Hyperthermia related to dehydration
- PR 120
- Loss of appetite
- Sunken eyes
- Soft watery stool for 2 days
- Dry skin turgor
- soft watery stool for 2 days Third
- sunken eyes Diarrhea related to gastrointestinal inflammation
- dry skin turgor
- hypoactive bowel sounds
5. The doctor suspects acute gastroenteritis. Explain how this can be developed.

 Acute Gastroenteritis also known as stomach flu is an inflammation of stomach and intestines.
The cause is typically a virus or bacterial infection. It can be acquired through ingestion of
contaminated food or water, contact with someone who has the virus and unwashed hands
after going to the bathroom or changing diaper.

6. What are the laboratories to be tested? State the indication and your nursing responsibility before
and after the test.

LABORATORY TEST PURPOSE/INDICATION NURSING RESPONSIBILITIES

1. CBC Determines white blood cell
levels that would determine the
presence of an infection
2. Urinalysis Determines severity of
dehydration and to check for
signs of bladder infection
3. Fecalysis Diagnose certain conditions
affecting the digestive tract
Explain procedure and purposes
to the patient and patient’s
significant other
Inform the patient about
procedure, purposes, results
and its indications
Inform the patient about
procedure, purposes, results
and its indications

7. List two medications that are helpful in hydrating the patient and describe their actions.

MEDICATION ACTION NURSING RESPONSIBILITIES

Hydralyte Replaces lost fluid and Continue giving Hydralyte as
electrolytes ordered by the physician and
explain the purpose of the
medication
Oresol Replaces lost fluid and Continue giving oresol as
electrolytes ordered by the physician and
explain the purpose of the
medication

8. Provide nursing plan of care for the prioritized nursing problem.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

CUES
- vomiting Deficient Short term Independent: Short term
for 2 fluid volume
goal: goal:
days related to 1. Monitor To have
- sunken active fluid After 4 hours And record baseline data After 4 hours
eyes loss of nursing vital signs of nursing
- dry skin interventions interventions
turgor patient’s 2. Monitor To determine patient’s
- soft significant patient’s input daily output significant
watery others will be and output and intake others was
stool for able to (Urine & Stool) able to
2 days verbalize ways verbalize ways
on how to 3. Encourage on how to
prevent acute patient’s To avoid prevent acute
gastroenteritis significant dehydration gastroenteritis
others to give
fluid Long term
frequently in
goal:
small amounts
Long term After 2-3 days
4. Educate To educate hours of
goal:
patient’s patient nursing
After 2-3 days significant interventions
hours of others about patient’s
nursing possible cause significant
interventions and effect of others was
patient’s fluid loses or able to give
significant decreased proper
others will be fluid intake. nutrition and
able to give hydration to
proper 5. Provide infant.
nutrition and Health
hydration to teaching
infant.
Dependent:

1. Insert Plain
NSS 500CC To replace
using G24 IV loss fluids
cannula as
ordered by the
physician

2. Administer
Oresol as
order by the
physician

Collaborative:

Refer patient’s
sIgnificant
others to
dietitian for
appropriate
nutritional
plan for infant
9. What are the procedures that have been ordered for the patient?

 Insert Orogastric tube Fr. 8

Purposes:
- To administer tube feedings & medications
- To remove gastric contents
- To cleanse the stomach

What are the different cases where we can execute these procedures?

 Burn in face, Diarrhea

What are the possible complications of each procedure?

- Gasping and choking

What are the equipment needed for each procedure?

- Emesin basin
- Closed system
- Gastric lavage tray or equivalent
- Ewald or gastric evacuation tube
- 2 Normal saline or sterile water
- Water soluble lubricant
- Micropore
- 10 mL irrigation syringe w/ catheter tip
- Stethoscope
- Sterile gloves
- Clean towel or sterile gauze and cotton balls

What are the principles to consider in performing the procedure?

 Right medication
 Right dose
 Right Patient
 Right Route
  Right Time
 Right Documentation
Write in chronological order the steps in performing the procedure.

- Validate the physician’s order by checking the order sheet and counter check with nurses’
Kardex
- Identify the right client by calling the patient’s full name
- Establishes rapport with the mother and significant others and secures consent
- Explains indications, purposes and step by step procedure of oro/nasogastric tube insertion.
(restrain if needed)
- Prepares supplies needed and checks proper functioning of equipment
- Determine the correct size of the orogastric tube
- Performs organize systematic and timely procedure
- Provide privacy
- Wash hands
- Assist the client in a comfortable position
- Raise the bed in high fowlers position
- Cover the chest of the patient with towel and put the emesis basin on the bedside
- Don sterile gloves
- Measure the tube form the tip of the nose to the earlobe. And from the ear lobe to the tip of
the xyphiod process and mark the length of the tube
- Lubricate the tip of the tube
- Gently hyperextend the head of the baby
- Gently insert the tube in the back of the tongue
- Directs orogastric tube downward through the posterior pharynx
- Advance tube without force as the patient swallow as until desired length had been inserted
- Remove tube if it has resistance or patient has signs of respiratory distress signs
- Confirm placement of the tube by aspirating gastric contents and checking its pH level. And
introducing air in the tube while auscultating over the stomach for swoosh or burp sound
- Secure tube properly
- Provide health teachings on how to perform oral care to significant others
- Evaluate patient’s response to the procedure
- Document: date, time, patient’s status after insertion and untoward responses
ASSESSMEN DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO
T S N
Loose Deficient After 8 Independent 1. Unstable Vs Patient was
watery Fluid hours of 1. Monitor my indicate able to show
stools signs Volume nursing And record vital fluid signs of
of related to intervention signs volume adequate
dehydration loss of , patient will deficit or fluid volume
Excessive fluid be able to 2. Monitor electrolyte through
vomiting through show signs Intake and imbalance good skin
fever excessive of adequate output 2. To turgor, and
abdominal vomiting fluid volume 3. Give determine output equal
cramps and through oral/mouth if output as intake,
diarrhea good skin care exceeds and stable
turgor, and 4. Monitor 3. To avoid and normal
output and dehydratio vital signs.
equal as regulate IV n mucous
intake, and fluids membranes
stable and 5. Provide
normal vital Health To educate
signs teaching patient
Dependent
To replace
1. Administer loss fluids
IV fluids as
ordered
2. Administer
medication
s To evaluate
Collaborative and
monitor
1. Submit and fluid and
test and electrolyte
monitor for imbalance
urinalysis
and
fecalysis
Purpose of the procedures.

Stool test – To collect stool samples to help diagnose certain conditions affecting the GI tract

Urinalysis - To identify specific fluids that are being eliminated from the body

Different cases where we can execute these procedures?

If the patient is suffering from bacterial infection in the GI tract

If the patient is having blood in the urine, urinalysis should be done

What are possible complications in each procedures?

For the stool test the stool is contaminated therefore it contains contagious pathogens that can be
spread to others

For the urinalysis it contains also toxic in our body but there are no risks associated with urine test

What is the equipment needed for each procedures

Stool test - Stool container/fecalyzer, microscope

Urinalysis – POC chemistry analyzer, POC Coag analyzers, POC Glucose Analyzers, Urinalysis strips

What are the principles to consider in performing the procedure?

Avoid contact with the specimen, always practice PPE everytime you perform different labs

Steps in performing the procedure

Stool test – stool is collected in a clean container

 Microscopic examination

Chemical test

Microbiologic tests

The stool will be checked for color, consistency, amount,shape,odor, and the presence of
mucus

Urinalysis – Comment on the colour and clarity of the sample. Upon removing the cap also comment if
there is any odour

Immerse the strip fully in the urine, ensuring all the test areas are covered

Discard the strip, your gloves and apron in the clinical waste bin.