PLT COLLEGE, INC.

BAYOMBONG, NUEVA VIZCAYA

SCHOOL OF HEALTH SCIENCES – COLLEGE OF NURSING

In partial fulfillment of the requirements in

RELATED LEARNING EDUCATION

An Individual Case Study on

ACUTE GASTROENTERITIS

Presented to:
MR. PHILBERT LABITARIO, RN
(Clinical Instructor)

Presented by:
BALBIN, CRIZLE ELLEN A.
(Student Nurse)
TABLE OF CONTENTS

I. Introduction

II. Patient’s Profile

III. Nursing History

IV. Physical Assessment

V. Anatomy and Physiology

VI. Brief Description

VII.Pathophysiology

VIII. Laboratory Results

IX. Drug Study

X. Nursing Care Plan

XI. Discharge Planning

 I. Introduction:
Acute infectious stomach and intestine syndrome known as gastroenteritis. It is
characterized by vomiting, diarrhea, and cramps in the abdomen. There may also be other signs
like nausea, fever, and chills. The degree of dehydration that results from severe gastroenteritis
can range from an abrupt but brief attack of diarrhea. Gastroenteritis may be brought on by a
variety of viruses, bacteria, and parasites. Microorganisms can cause gastroenteritis by either
directly invading the gut and causing inflammation that upsets the balance between nutrient
absorption and waste secretion, leading to excessive water and electrolyte loss and watery
diarrhea.
The most prevalent causes of viral gastroenteritis, also known as viral diarrhea, include
rotaviruses, caliciviruses, Norwalk viruses, and adenoviruses. Other types of gastroenteritis
include food poisoning, cholera, and traveler's diarrhea, which appears a short time after arriving
in a place with unhygienic food or water. Traveler's diarrhea is caused by exposure to
enterotoxin-producing strains of the common intestinal bacterium Escherichia coli.
Depending on the underlying cause and the severity of the symptoms, antibiotics or only
supportive care may be used to treat gastroenteritis. Older people tend to have milder cases of the
disease than do children and the very old, who are at risk of dehydration due to vomiting and
loose stool.
 II. PATIENT’S PROFILE

Name: Itas, Joyren

Address: Kaifucal, Dupax, Del Norte
Birthday: August 28, 2017
Age: 5 years old
Occupation: None
Religion: UCCP
Marital Status: None
Nationality: Filipino
Educational Attainment:
Chief Complaint: Vomiting x 7 episodes
Admitting Diagnosis: Acute Gastroenteritis with moderate dehydration
Final Diagnosis: Acute Gastroenteritis
Date & Time of Admission: March 3, 2023
Date & Time of Discharge: March 6, 2023
Attending Physician: Dr. Villabor
No. Of Days Stayed at Hospital: 4
 III. NURSING HISTORY

HISTORY OF PAST ILLNESS

According to the parents that she has previously admitted for vomiting and was also
managed as acute gastroenteritis.

HISTORY OF PRESENT ILLNESS

1 day prior to admission, parents reported eating cocoa followed with vomiting and
episodes of loose stools: resistance of vomiting consult and was positive.

IV. PHYSICAL ASSESSMENT

Date of Assessment: March 6, 202

Time of Assessment: 1:00 PM

General Survey:

During the examination, the patient was alert and cooperative. The patient is dehydrated
as evidenced by the assessment. She also has 5 canker sores in her mouth, which causes her to
struggle to speak. Uveitis and scleritis are present in his eyes.

Initial Vital Signs Normal Ranges Result Interpretation

Pulse Rate 60 - 100 bpm 102 bpm Increased

Temperature 36.1℃ - 37.2℃ 36.9℃ Normal

Respiratory Rate 12- 20 cpm 23cpm Increased

Blood Pressure 120/80 mmHg 90/60 Normal

HEIGHT AND WEIGHT

Area to be Assessed Actual Findings Analysis/Interpretation

Height 104’cm Normal

Weight 17kg Normal (However, there is a
weight loss due to diarrhea)

Body Mass Index (BMI) 15.7kg Underweight

 V. ANATOMY AND PHYSIOLOGY

The affected human body in Acute Gastroenteritis is the digestive system. The digestive
system is the group of organs that break down food to absorb its nutrients. The nutrients in food
are used by the body as fuel to keep all the body systems working. The leftover parts of food that
cannot be broken down, digested, or absorbed are excreted as bowel movements (stool).
The digestive system is made up of the gastrointestinal tract-mouth, esophagus, stomach,
small & large intestine, and rectum.
 Mouth: As you chew and swallow,
your tongue pushes food into your
throat. A small piece of tissue called the
epiglottis covers your windpipe. The
epiglottis prevents choking.
 Esophagus: Food travels down a
hollow tube called the esophagus. At
the bottom, your esophageal sphincter
relaxes to let food pass to your stomach.
(A sphincter is a ring-shaped muscle
that tightens and loosens.)
 Stomach: Your stomach creates
digestive juices and breaks down food.
It holds food until it is ready to empty
into your small intestine.
 Small intestine: Food mixes with the
digestive juices from your intestine,
liver and pancreas. Your intestinal walls
absorb nutrients and water from food
and send waste products to the large intestine.
 Large intestine: Your large intestine turns waste products into stool. It pushes the stool
into your rectum.
 Rectum: The rectum is the lower portion of your large intestine. It stores stool until you
have a bowel movement.
What is the stomach’s function?
Your stomach’s purpose is to digest food and send it to your small intestine. It has three
functions:
 Temporarily store food.
 Contract and relax to mix and break down food.
 Produce enzymes and other specialized cells to digest food.
Where is the stomach located?
Your stomach sits in your upper abdomen on the left side of your body. The top of your
stomach connects to a valve called the esophageal sphincter (a muscle at the end of your
esophagus). The bottom of your stomach connects to your small intestine.
What are the parts of the stomach’s anatomy?
Your stomach has five distinct sections:
 The cardia is the top part of your stomach. It contains the cardiac sphincter, which
prevents food from traveling back up your esophagus.
 The fundus is a rounded section next to the cardia. It's below your diaphragm (the dome-
shaped muscle that helps you breathe).
 The body (corpus) is the largest section of your stomach. In the body, your stomach
contracts and begins to mix food.
 The antrum lies below the body. It holds food until your stomach is ready to send it to
your small intestine.
 The pylorus is the bottom part of your stomach. It includes the pyloric sphincter. This
ring of tissue controls when and how your stomach contents move to your small intestine.
What is the stomach’s structure?
Several layers of muscle and other tissues make up your stomach:
 Mucosa is your stomach’s inner lining. When your stomach is empty, the mucosa has
small ridges (rugae). When your stomach is full, the mucosa expands, and the ridges
flatten.
 Submucosa contains connective tissue, blood vessels, lymph vessels (part of your
lymphatic system) and nerve cells. It covers and protects the mucosa.
 Muscularis externa is the primary muscle of your stomach. It has three layers that
contract and relax to break down food.
 Serosa is a layer of membrane that covers your stomach.
VI. BRIEF DESCRIPTION

Gastroenteritis, also known as infectious diarrhea and gastro, is inflammation of the

gastrointestinal tract the stomach and intestine. Symptoms may include diarrhea, vomiting
and abdominal pain. Fever, lack of energy and dehydration may also occur. This typically
lasts less than two weeks. The most common way to develop viral gastroenteritis often called
stomach flu is through contact with an infected person or by consuming contaminated food
or water. If you're otherwise healthy, you'll likely recover without complications. But for
infants, older adults and people with compromised immune systems, viral gastroenteritis can
be deadly.

Depending on the cause, viral gastroenteritis symptoms may appear within 1-3 days after
you're infected and can range from mild to severe. Symptoms usually last just a day or two,
but occasionally they may last up to 14 days. Because the symptoms are similar, it's easy to
confuse viral diarrhea with diarrhea caused by bacteria, such as Clostridioides difficile,
salmonella and Escherichia coli, or parasites, such as giardia.

RISK FACTORS/CONTRIBUTING FACTORS

SIGN/SYMPTOMS

 Watery, usually non bloody diarrhea — bloody diarrhea usually means you have a
different, more severe infection.
 Nausea, vomiting or both.
 Stomach cramps and pain
 Occasional muscle aches or headache
 Low-grade fever

COMPLICATIONS

 Blood in vomit or stool

 Swollen abdomen and increasingly severe abdominal pain
 Dehydration due to loss of water
 Death
 PHARMACOLOGICAL TREATMENTS

 Ampicillin Antibiotic/Penicillin 450mg IV q 6hrs

 Oral Rehydration Solution as needed.
 Diphenhydramine 20mg IV every 8hrs PRN
 Zinc Sulfate Syrup 5ml OD
 Paracetamol 250mg PRN
 Probiotics OD x 5days

DIAGNOSTIC PROCEDURES

 Complete blood Count

 Fecalysis
 Urinalysis
 Serum Electroly

VII. PATHOPHYSIOLOGY

PRECIPITATING
ETIOLOGY PREDISPOSING
- Poor sanitation/hygiene
- Virus, Bacteria, and - Age
indigestion - Excessive ingestion of tea, coffee.
- immune-compromised Cocoa powder
of drugs and chemical toxins
- using of NSAIDS

Indigestion of excessive amount of cocoa

Excessive amount of caffeine can cause

stomach upset.

Pathogen releasing endotoxins.

 Invasion of clostridium perfringens into the
mucosal lining of the stomach

Inflammation of the stomach lining and to the gastrointestinal lining.

Stimulation of the Increase of permeability of Infection of the mucosal lining in the GI

mucosal lining. the blood vessels tract

Increased absorption in the Fluid leak out of Nausea and Vomiting

mucosal lining. capillaries into GI tract
wall causes swelling.

Watery diarrhea.
Abdominal
cramping.

VIII. LABORATORY RESULTS

IMMUNOLOGY SEROLOGY

TEST RESULT
SARS-CoV2 (COVID 19) ANTIGEN NEGATIVE

URINALYSIS
DATE AND TIME: March 5, 2023
NORMAL
EXAMINATION RESULTS INTREPRETATION/ANALYSIS
RANGE
Color Clear, Pale, Pale yellow Normal
Transparent Pale yellow indicates normal
yellow findings. It should free and clear
of clouds or particles. Dark urine
 indicates having urinary tract
infection.
Appearance/Transparency Clear and SI turbid The urine that is freshly
Transparent harvested, but with an unclear
and murky appearance. Anytime
the urine does not have the
characteristic clear appearance it
is referred to as cloudy, murky,
turbid or foamy urine.

Specific Gravity 1.010-1.025 1.025 Normal

High specific gravity may
indicate dehydration. Low
specific gravity may indicate the
presence of diabetes.
pH 4.5-8 6.0 Normal
High urine indicates having
urinary tract infection, and kidney
stones.
Protein Negative Negative Normal
There must be no protein or a
small amount of protein in the
urine. A negative result indicates
normal findings.
Epithelial Cells Few/Rare Rare Normal
A healthy urine must consist of
small epithelial cells. As increase
number of epithelial cells may
indicate having urinary tract
infection, inflammation, and
malignancies.
Bacteria No bacteria Rare Normal
When a significant of bacteria
show up in the urine, this is called
“bacteriuria”. Finding bacteria in
the urine can mean there is an
infection somewhere in the
urinary tract.

HEMATOLOGY

DATE: March 5, 2023

EXAMINATION NORMAL FINDINGS INTREPRETATION/ANALYSIS

 RANGE
Hemoglobin (Hgb) 110-160 g/L 140g/L Normal
Hemoglobin is a protein in your
cells that carries oxygen to your
body’s organ and tissues and
transports carbon dioxide from
your organs and tissues back to
your lungs. If a hemoglobin test
reveals that your hemoglobin level
is lower than normal , it means you
have a low red blood ell count
(anemia)
Hematocrit (Hct) 37-54% 42.0 Normal
RBC Count 3.50-4.50 X 4.70 Normal
10
WBC Count 4.0-10.0’9 10 Normal
Platelet count 150- 236/L Normal
400x10^9/L

IX. DRUG STUDY

DRUG MODE OF INDICATI CONTRAI ADVERSE DRUG NURSING

INFORMATI ACTION ON NDICATI AND SIDE INTERACTI RESPONSIBILITI
ON ONS EFFECT ON ES

Paracetamol Used to Contraindic Nausea Amobarbital Do not exceed the

Brand Name: (acetaminophen) temporarily ated with recommended
Panadol, is generally relieve allergy to Mild Diflunisal dosage.
Tylenol considered to be mild-to- acetaminop stomach
a weak inhibitor moderate hen pain Isoniazid Paracetamol may be
Generic of the synthesis pain, fever, taken every 4 to 6
Name: of prostaglandins and Diarrhea Carbamazepine hours. Leave at least
Paracetamol (PGs). headaches. 4 hours between
Headaches Warfarin doses.
 Drug
Classification Heartburn Avoid using multiple
: preparations
Analgesics containing
acetaminophen.
Doctors
Order Carefully check all
OTC products.
Dose:
450mg PRN Give drug with food
if GI upset occurs.
Route:
Oral

DRUG MODE OF INDICATI CONTRAI ADVERSE DRUG NURSING

INFORMATI ACTION ON NDICATI AND SIDE INTERACTI RESPONSIBILITI
ON ONS EFFECT ON ES

Mineral elements Zinc sulfate Contraindic GI: Nausea Cephalexin Give with food if GI
Brand Name: that is essential is used to ated for and upset occurs, bean
Orazinc 110, for growth and treat and pregnancy Vomiting Cortisone and other high-fiber
Orazinc 220, tissue repair, acts prevent and food, calcium and
Verazinc, as an integral zinc lactation Dexamethason phosphates that may
Zincate part of essential deficiencies e interfere with
enzymes in . absorption.
Generic protein and Ferrous Sulfate
 Name: carbohydrate Ensure that the
Zinc Sulfate metabolism Prednisone patient receives only
the prescribed
Drug Tetracycline dosage.
Classification
: Voclosporin Report severe
Minerals and nausea and
Electrolytes vomiting,
restlessness, fatigue
Doctors and lethargy.
Order:

Dose:
5ml OD

Route:
Oral

DRUG MODE OF INDICATI CONTRAI ADVERSE DRUG NURSING

INFORMATI ACTION ON NDICATI AND SIDE INTERACTI RESPONSIBILITI
ON ONS EFFECT ON ES

Competitively Active and Contraindic CNS: Atenolol Administer with

Brand Name: blocks the effects prophylacti ated with drowsiness, food if GI upset
Benadryl of histamine at c treatment allergy to sedation, Atropine occurs.
H-receptor sites, of motion any dizziness,
 Generic has atropine like, sickness. antihistami fatigue, Azatadine Take as prescribed,
Name: anti-pruritic and ne confusion, avoid excessive
Diphenhydra sedative effects. restlessness Diazepam dosage.
mine , tremor
Fentanyl Report difficulty of
Drug CV: breathing,
Classification palpitation, Loperamide hallucinations
: bradycardia tremors, loss of
Antihistamine , coordinate, unusual
, tachycardia bleeding or bruising,
visual disturbances,
Doctors GI: irregular heartbeat.
Order: anorexia,
nausea and
Dose: vomiting,
20mg every diarrhea or
8hrs PRN constipatio
n
Route:
IV injection GU:
Dysuria,
urinary
retention

DRUG MODE OF INDICATI CONTRAI ADVERSE DRUG NURSING

INFORMATI ACTION ON NDICATI AND SIDE INTERACTI RESPONSIBILITI
ON ONS EFFECT ON ES

Bacterial action Treatment Contraindic CNS: Azithromycin Check IV site

Brand Name: against sensitive of infection ated with Lethargy, carefully for signs of
Principen, organisms; caused by allergy to hallucinatio BCG thrombosis or drug
Omnipen inhibits susceptible penicillin ns, and reaction.
synthesis of strains of seizure. Balsalazide
Generic bacterial cell shigella, Report pain or
Name: wall, causing salmonella, GI: nausea Heparin discomfort at sites,
Ampicillin cell death. E. coli and unusual bleeding or
 Drug vomiting, Tetracycline bruising, mouth
Classification: abdominal sores, rash, hives,
Antibiotic/ pain, fever, itching, severe
Penicillin bloody diarrhea and
diarrhea difficulty of
Doctors breathing.
Order: GU:
nephritis

Dose:
450mg q6hrs

Route:
IV injection

DRUG MODE OF INDICATIO CONTRAIN ADVERS DRUG NURSING

INFORMAT ACTION N DICATIONS E AND INTERAC RESPONSIBIL
ION SIDE TION TIES
EFFECT

Lactobacillus Lactobacillus Contraindicati No adverse No Assess amoun

Brand acidophilus (L. acidophilus ons effects significant consistency, an
Name: acidophilus) is a has been Hypersensitivi drug color of stool
Acidophilus type of probiotic used in ty to milk or interactions produced.
("good" alternative lactose
Generic bacteria) found medicine as a products
Name: in the human likely
Lactobacillus gut, mouth, and effective aid
acidophil vagina, and in in treating
certain foods. diarrhea in
Drug "Good" bacteria children with
Classificatio such as L. rotavirus.
n: acidophilus can
Probiotics, help break down
Antidiarrheal food, absorb
 s nutrients, and
fight off "bad"
Doctors organisms that
Order: might cause
diseases.
Dose:
1 tab/day

Route:
Oral

DRUG MODE OF INDICATIO CONTRAIN ADVERS DRUG NURSING

INFORMAT ACTION N DICATIONS E AND INTERAC RESPONSIBI
ION SIDE TION TIES
EFFECT

Oral rehydration Used to treat Hypersensitivi Headaches No Advice the pare

Brand solutions (ORS) or prevent ty to significant that the oral
Name: treat dehydration medicines Dizziness drug rehydration
TGP - ORS dehydration (the loss of interactions therapy does n
associated with too much Sleepiness stop the diarrhe
Generic diarrhea. water from but it replaces t
Name: Several the body) Decrease in lost fluids and
Oral formulations are that may urination. essential salts th
Rehydration possible, but the occur with preventing or
Solution basic severe Dark treating
ingredients are diarrhea, yellow or dehydration an
Drug almost always especially in amber reducing the
Classificatio clean water, babies and colored danger.
n: sodium, and young urine
glucose. They children. Monitor the
Doctors work because Decreased patient if the
Order: Na+/glucose co- skin eyelids becom
Dose: transport elasticity. puffy during th
 100-200ml proteins on the
brush border Dry mouth treatment: sto
Route: cells of the and ORS, and just g
Oral intestinal lumen mucous plain water.
pull sodium and membrane
glucose from (lips, gums,
the gut into the nostrils)
cells. As the
osmolarity of Low blood
the cells pressure
increases (due
to the influx of
sodium and
glucose
molecules),
water is
reabsorbed out
of the gut and
into the body.

.
X. NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUAT

DIAGNOSIS INTERVENTION

Subjective: Imbalanced After 48hrs Independent:

Nutrition: hrs of Assess for patient’s For baseline data
“nagsusuka po Less Than nursing vital signs. After 1-2 d
siya 3x after Body intervention To assess if they are of nursin
niya kumain ng Requirements the patient Assess the patient losing too much interventio
cocoa” as related to will weight regularly. weight attributable to patient turn
verbalized by vomiting. consume dehydration. normal sta
the mother. more wellness an
Keep track of the Vomiting is a goal was m
nutrients
amount and frequency common symptom of
from foods
Objective: of vomiting. gastroenteritis and
and
measuring the
supplements
volume and
VS as follows: and have
frequency is vital
 less nausea since this information
BP: and will aid in initiating
70/50mmHg vomiting nursing activities and
T: 36 subsequent therapy.
PR: 115bpm Monitor food intake.
RR: 26cpm To determine how
spO2: 97% much food the patient
HT: 104cm consumes.
WT: 17kg Dependent:

Administer D5MB
1/2L AT 200cc as For alternative fluid
ordered by the replacement
physician.

Administer
To relieve headaches
paracetamol 250mg
and fever
PRN as ordered by the
physician

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUA

DIAGNOSIS INTERVENTION
 Subjective Short term: Independent:
Data:
After 8 hours of Establish rapport To gain trust from the After 48h
“Sobrang sakit Acute nursing from the patient. patient. nursin
daw po ng tiyan abdominal intervention the interventi
niya at tae siya pain related patient will be To measure the goal was
ng tae ng basa” to prolonged able to Assess report for intensity of pain and and the p
as verbalized by diarrhea as understand the abdominal pain. management should was abl
mother. evidenced by cause of her be given. verbalize
restlessness condition and be the pain
and pallor Assess for patient’s For baseline data
Pain scale: able to verbalize relieved an
vital signs.
8/10 that the pain on able to re
her abdomen Encourage patient For it helps to reduce and re
Objective: subsides from appropria
to be in comfort abdominal tension
the scale of 8/10 position (knees and promotes sense
Restlessness
to 6/10 flexed) of control.
Pallor To avoid dehydration
Encourage patient due to diarrhea.
Long term: to increase fluid
Guarding
behavior intake.
After 48hrs of
nursing Dependent:
VS as follows:
intervention the
patient will be Administer ORS as To treat and prevent
BP:
able to ordered by the dehydration
70/50mmHg
T: 36 understand the physician.
PR: 115bpm cause of pain and
RR: 26cpm be able to
spO2: 97% verbalize that the
HT: 104cm pain had
WT: 17kg subsides from
6/10 to 3/10
ASSESSMEN NURSING PLANNIN NURSING RATIONALE EVALUATIO
T DIAGNOSI G INTERVENTIO N
S N

Subjective Long term: Independent:

Data: Fluid
Volume After 2-3 Assess vital signs; To evaluate After 2-3 days
“Nanghihina po deficit related days of note strength of degree of fluid of nursing
siya dahil sa to watery nursing peripheral pulses. deficit. intervention the
pagtatae naka stool intervention goal was met,
tatlo (3) dumi” (Diarrhea) as the patient and the patient
as verbalized by evidenced by will be able had maintained
the mother of thirst, to maintain To her fluid volume
Keep fluids within
the patient. weakness, adequate correct/replace and her skin
patient reach and
decreased fluid volume losses to reverse turn into normal
encourage frequent
urine output, and the skin pathophysiologi state.
intake as
poor skin started to appropriate. c mechanisms.
Objective:
turgor. moisturize.
Poor Skin
Turgor

Decreased Dependent:
Urine output Administer D5MB For alternative
1/2L AT 200cc as fluid
V/S: replacement to
ordered by the
physician. correct losses.
VS as follows:

BP:
70/50mmHg
T: 36
PR: 115bpm
RR: 26cpm
spO2: 97%
HT: 104cm
WT: 17kg

XI. DISCHARGE PLANNING

Medications
  Probiotics OD x 5 days
 Zinc Sulfate syrup, 5ml OD
Treatment
1. Continue the medication as prescribe by physician.
2. Patient must have plenty of rest.

Health Teaching
1. The patient should be reminded about his follow-up check up with the physician after 1
week upon being discharged.
2. Instruct the patient and family for the correct dosage, frequency, and time to take the
prescribed medications.
3. Advice the patient to eat bland foods to help prevent stomach upset and irritation.
4. Advice the patient to drink plenty of water.
5. Advice the patient to avoid foods that can upset and irritate the stomach.

Diet
Diet as Tolerated was ordered by the physician and stress the importance of low-fiber
diet and more fluid intakes for digestion.

Date of Admission: March 03, 2023

Discharge Date: March 06, 2023