LICEO DE CAGAYAN UNIVERSITY

R.N. PELAEZ BLVD. KAUSWAGAN, CDO

COLLEGE OF NURSING
NCM501202

A Case Study of:

Jhunienne Matias
Name of the Patient

As Partial Requirement for NCM501202

Submitted by:
Tan, Kevin John T.
NCM501202 student
Group A2

March 19, 2009

1
 TABLE OF CONTENTS

I. Introduction
a. Overview of the case
b. Objective of the study
c. Scope and Limitation of the study
II. Profile of the patient
III. Developmental Data
IV. Health History
a. Family and Personal health history
b. History of Present Illness
V. Nursing Assessment (System Review & Nursing
Assessment II)
VI. Pathophysiology with Anatomy & Physiology
VII. Medical Management
a. Medical Orders and Rationale
b. Drug study
VIII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
IX. Referrals and Follow-up
X. Evaluation and Implications
XI. Bibliography

2
 I. Introduction
a. Overview of the Study

Acute diarrhea or gastroenteritis is the passage of loose stools more

frequently than what is normal for that individual. This increased frequency is often
associated with stools that are watery or semisolid, abdominal cramps and bloating.

Acute watery diarrhea is an extremely common problem, and can be fatal due to
severe dehydration, in both adults and children, especially in the very young and the
old or in those who have poor immunity such as individuals with HIV infection or
patients who are using certain medications that suppress the immune system.

Gastroenteritis means inflammation of the stomach and small and large

intestines. Viral gastroenteritis is an infection caused by a variety of viruses that
result in vomiting or diarrhea or both. It is often called the "stomach flu," although it is
not caused by the influenza viruses.

Persons can reduce their chance of getting infected by frequent

handwashing, prompt disinfection of contaminated surfaces with household chlorine
bleach-based cleaners, and prompt washing of soiled articles of clothing. If food or
water is thought to be contaminated, it should be avoided.

Since most cases of acute watery diarrhea are infectious, especially in

developing countries, the majority of such illnesses can be prevented by drinking
water or eating foods that are not contaminated with infectious agents. Washing
hands frequently with non-contaminated water, when caring for a patient with
diarrhea as also always before eating is important. Proper storage of food and water
is also important to prevent harmful bacteria from contaminating them.

3
 Other symptoms include nausea, vomiting, loss of appetite, belching, and
bloating. Occasionally, acute abdominal pain can be a presenting symptom. This is
the case in phlegm nous gastritis (gangrene of the stomach) where severe
abdominal pain accompanied by nausea and vomiting of potentially purulent gastric
contents can be the presenting symptoms. Fever, chills, and hiccups also may be
present.

The diagnosis of acute gastritis may be suspected from the patient's history
and can be confirmed histologically by biopsy specimens taken at endoscopy.

b. Objective of the Study

This study aims to:

• 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.

c. Scope and Limitation of the Study

This study includes the collection of information specifically to the patient’s

health condition. The study also includes the assessment of the physiological and
psychological status, adequacy of support systems and care given by the family as
well as other health care providers.

The scope of this study would include:

4
 a. Data collected via assessment, interviews with the patient, family members
and clinical records.
b. Actual and ideal problems for 3 days including the initial assessment and its
appropriate nursing intervention that would be applied within his stay in the
hospital at PGH hospital
c. Developing a plan of care that will reduce identified predicaments and
complications.
d. Coordinating and delegating interventions within the plan of care to assist the
client to reach maximum functional health.
e. Further evaluating the effectiveness of nursing interventions that have been
rendered to the client.

An array of factors influencing the limitations of this study includes:

a. Data collected is limited only to assessment and interview to the patient,
patient’s chart and nurse on duty.
b. The interaction, assessment and care were only limited to a total of 16 hours
(2 days clinical duty, 1 day assessment) with actual nursing intervention done.
c. The lack of complete family history obtained was due to lack of laboratory
examinations or diagnostic examinations results like x-ray which data or
results obtained is in the chart of the client during the time of care.

5
 II. Patients Profile

Client’s Name: Matias, Jhunienne

Age: 6 months old

Birthday: September 17, 2008

Address: Mambuaya, Cagayan de Oro City

Civil Status: Single

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Weight: 6.5 Kg.

Informant: Inalen Matias (Mother)

Date of admission: Febuary 15, 2009

Time of admission: 4:00 PM

Chief complaint: LBM

Admitting diagnosis: AGE with mild dehydration

Attending physician: Dr. Bacal

6
 III. Developmental Data

Developmental Task Theory of Robert Havighurst

A developmental task is a task which arises at or about a certain period in the
life of an individual. Havighurst has identified six major age periods: infancy and
early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18
years), early adulthood (19-29 years), middle adulthood (30-60 years), and later
maturity (61+).

Basing on Havighurst’s Theory, my patient belongs in the infancy and early

childhood stage wherein he is learning to distinguish right from wrong and
developing a conscience.

Psychosexual Theory of Sigmund Freud

The psychosexual stages of Sigmund Freud are five different developmental

periods during which the individual seeks pleasure from different areas of the body
associated with sexual feelings. These stages are as follows:

Oral Birth to to 1year

Anal 2 to 3years
Phallic 4 to 5years
Latency 6 to 12years
Genital 13 and Up

Basing on this theory, Jhunienne Matias belongs to the oral stage wherein an
infant’s pleasure centers are in the mouth. This is also the infant's first relationship
with its mother; it is a nutritive one.

7
Psychosocial Theory of Erik Erickson
Erik Erickson envisioned life as a sequence of levels of achievement. Each
stage signals a task that must be achieved. He believed that the greater that task
achievement, the healthier the personality of the person. Failure to achieve a task
influences the person’s ability to achieve the next task. Stages of Erikson’s
Psychosocial Theory are as follows:

Infancy Birth – 18 months Trust vs. Mistrust

Early Childhood 18 months – 3 years Autonomy vs. Shame
Late Childhood 3 – 5 years Initiative vs. Guilt
School Age 6 – 12 years Industry vs. Inferiority
Adolescence 12 – 20 years Identity vs. Role Confusion
Young Adulthood 18 – 25 years Intimacy vs. Isolation
Adulthood 25 – 65 years Generativity vs. Stagnation
Maturity 65 years to death Integrity vs. Despair

Basing on this theory, he is still belongs to Infancy based on Erikson’s theory

the child developmental task is the “TRUST vs. MISTRUST” Because an infant is
utterly dependent; the development of trust is based on the dependability and quality
of the child’s caregivers. If a child successfully develops trust, he or she will feel safe
and secure in the world. Caregivers who are inconsistent, emotionally unavailable,
or rejecting contribute to feelings of mistrust in the children they care for. Failure to
develop trust will result in fear and a belief that the world is inconsistent and
unpredictable.

As observed the child had already built trust to his mother and his
grandmother wherein he only allows his mother and grandmother to cuddled and
feed him.

8
Cognitive Theory of Jean Piaget
Cognitive development refers to how a person perceives, thinks, and gains
understanding of his or her world through the interaction and influence of genetic
and learning factors. This is divided into five major phases:

Sensorimotor Phase Birth to 2 years

Pre-conceptual Phase 2 – 3 years
Intuitive Thought Phase 4 – 6 years
Concrete Operations Phase 7 – 11 years
Formal Operational Phase 12 – adulthood

Basing on this theory, Jhunienne Matias belongs to the sensorimotor stage in

which inventions of new means through mental combinations. The patient uses
memory and imitation act, he can solve basic problems.

9
IV. HEALTH HISTORY

a. Family Health History

According to the father regarding the herido-familial history both her
mother and father side has a history of hypertension. On the father side
they had a history of cancer since the father’s aunt died last 2001 due to
cervical cancer.

b. Past Health History

The father claimed that his child past illnesses were a typical cough,
colds and fever that usually lasted for three days. Over the counter
medicines such as Paracetamol (Calpol) was used to treat for fever and
Dimetapp for colds. The father claimed that his child has not completed
the vaccination required and never experiencing major illness that
required hospitalization until this Febuary 15, 2008 wherein the patient has
been admitted at JRB Hospital having an acute diarrhea but the father
denied that his child does not have known allergies to drugs and foods nor
his child received a blood transfusion.
The patient was born in JRB Hospital through a normal spontaneous
vaginal delivery.

c. History of Present Illness

A case of Matias, Jhunienne, 6months old Male, Filipino, a resident of
Mambuaya Cagayan de Oro City, admitted for the first time at PGH
hospital with a chief complaint of LBM. Two days prior to admission he
had persistent LBM, vomiting, cough and fever.

10
 V. Nursing Assessment (System Review & Nursing
Assessment II)
Name: Jhunienne Matias Date: 02-15-09
Temp: 38.6ºC HR: 137bpm BP: N/A Height_____ Weight:6.5 kgsRR: 50cpm
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space
provided. Indicate the location of the problem in the figure using [X].

EENT:
[ ] impaired vision [ ] blind
[ ] pain reddened [ ] drainage Sunken eyes
[ ] gums [ ] hard of hearing [ ] deaf Poor appetite
[ ] burning [ ] edema [ ] lesion teeth Colds
Assess eyes, ears, nose throat Cough
For abnormality [ ] no problem Poor skin turgor
RESPIRATION:
[ ] asymmetric [ ] tachypnea [ ] barrel chest Hyperactive
[ ] apnea [ ] rales [x] cough bowel sounds
[ ] bradypnea [ ] shallow [ ] rhonchi
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotic
Assess resp. rate, rhythm, pulse blood
breath sounds, comfort [ ] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing
bowel sounds, comfort [x] no problem
GENITO-URINARY AND GYNE:
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia Hyperthermia
assess urine frequency, control, color, odor, comfort =38.6C
NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures hooked with
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors IVF of D5 0.3Nacl
[ ] confused [ ] vision [ ] grip 500cc
assess motor, function, sensation, LOC, strength
grip, gait, coordination, speech [x] no problem
MUSCULOSKELETAL AND SKIN: Watery Stools
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [x] poor turgor [ ] cool [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic/moist
assess mobility, motion, gait, alignment, joint function
skin color, texture, turgor, integrity [ ] no problem

11
 SUBJECTIVE OBJECTIVE

COMMUNICATION:
[ ] hearing difficulty Comments: “Wala man [ ] glasses [ ] languages
siya problema sa pandu [ ] contact lenses [ ] hearing difficulties due to age
[ ] visual changes
[ ] speech difficulties
[x] denied ngug ug pagtanaw” as Pupil size:R:3 mm L:3mm
verbalized by the Reaction: PERRLA (Pupil Equally Round Reactive
mother to Light and Accommodation)
OXYGENATION: Resp. [x] regular [ ] irregular
[ ] dyspnea Comments:”Naa jud siya Describe: RR is within normal range.
[ ] smoking history ubo nabalaka na jud ko
Non-smoker ani niya”as verbalized R: symmetrical to the left lung
L: symmetrical to the right lung
[x] cough by the mother.
[ ] sputum
[ ] denied

CIRCULATION:
[ ] chest pain Comments: ”Wala may Heart Rhythm [x ] regular [ ] irregular
sakit sa tiil ug dughan Ankle Edema: No ankle edema is present on both
[ ] leg pain
akong anak”as verbalized extremities
[ ] numbness of Pulse Car Rad. DP Fem*
by the mother.
R _______+______+_ __ + __not assessed
extremities
L _____+_____ +_ _____+ not assessed
[x ] denied Comments: Right and left pulses are equal; strong
and palpable.
NUTRITION:
Diet: Exclusive B.F Comments: ”Gina patutoy [ ]dentures [x]none
since Birth. Raman nako siya”
Character as verbalized by the Complete Incomplete
[ ] recent change in
mother.
weight Upper [] [x]
[ ] swallowing
Difficulty Lower [] [x]
[x] denied
ELIMINATION: Comments: ”magsunod Bowelsounds:
Usual bowel pattern [x] urinary frequency sunod jud siya ug hyperactive
5 loose stools per day Diaper kalibanga”as verbalize Abdominal Distention
[ ] constipation [ ] urgency by the mother. Present [ ] yes [x] no
remedy [ ] dysuria Urine* (color, consistency,
[ ] hematuria odor)
Date of last BM [ ] incontinence urine color is straw,
December 5, 2008 [ ] polyuria amber transparent and
[ ] foley in place faint aromatic odor.
[ x ] diarrhea [x] denied
[ ] constipation *if they are in place

MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to follow
[ ] alcohol [ x ] denied treatments (diet, meds, etc.) for chronic health
(amount & frequency) problems (if present).
________________________________________. N/A.

12
[ ] SBE: N/A Last Pap Smear: N/A

SUBJECTIVE OBJECTIVE
SKIN
Comments: [x] dry [ ] cold [ ] pale
INTEGRITY:
”Mala jud iya panit kay cige ra [ ] flushed [ ] warm
[x] dry ug kalibang” as verbalized by [ ] moist [ ] cyanotic
the mother. *rashes, ulcers, decubitus (describe size, location,
[ ] other
drainage: no rashes and ulcers found the the
patients body.
[ ] denied

ACTIVITY/
SAFETY: Comments: [x] LOC and orientation Patient is normal-
[ ] convulsion ”kalooy sa ginoo wala jud nag unconscious oriented
[ ] dizziness lipong-lipong akong anak ug Gait: [ ] walker [ ] cane [ ] other
[ ] limited motion maka lihok rapud siya” as
of verbalized by the mother. [x] steady [ ] unsteady_________
Joints [ ] sensory and motor losses in face or
extremities No sensory and motor losses on face or
Limitation in extremities
Ability to [x] ROM limitations: no ROM limitations
[ ] ambulate
[ ] bathe self
[ ] other
[x] denied
COMFORT/SLE
EP/ Comments: [x] facial grimaces
AWAKE: perminte ra siya ga mata mata [ ] guarding
[ ] pain tungod ni sa iyang kainit” as [ ] other signs of pain :
verbalized by the mother.
(location)
Frequency
Remedies
[ ] nocturia
[x]sleep
difficulties
[ x ] denied
COPING:
Occupation: N/A Observed non-verbal behavior: the patient is
Members of household: 2 members of household restless
Most supportive person: Karl William Matias(father) Phone number that can be reached anytime:
and Inalen Matias(mother) refused

SPECIAL PATIENT INFORMATION

Not ordered _Daily weight ____N/A___ PT/OT __ N/A __
_every 2hr ___BP q shift ____N/A___ Irradiation
____N/A___ _ Neuro vs __ done _Urine test ___________
____N/A_ _ CVP/SG Reading __N/A___ __No Order__24 hour Urine Collection

13
VI. ANATOMY AND PHYSIOLOGY:

DIGESTIVE SYSTEM

The digestive system consists of two linked parts: the alimentary canal and the
accessory digestive organs. The alimentary canal is essentially a tube, some 9
meters (30 feet) long, that extends from the mouth to anus, with its longest section-
the intestines- packed into the abdominal cavity. The lining of the alimentary canal is
continuous with the skin, so technically its cavity lies outside the body. The
alimentary ‘tube’ consist of linked organs that each play their own part in digestion:
mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The
accessory digestive organs consist of the teeth and tongue in the mouth; and the

14
salivary glands, liver, gallbladder, and pancreas, which are all linked by ducts to the
alimentary canal.

STOMACH

It is a J- shaped enlargement of the GI tract directly under the diaphragm in

the epigastric, umbilical and left hypochondriac regions of the abdomen. When
empty, it is about the size of a large sausage; the mucosa lies in large folds, called
RUGAE. Approximately 10 inches long but the diameter depends on how much food
it contains. When full, it can hold about 4 L ( 1 galloon) of food. Parts of the
stomach includes cardiac region which is defined as a position near the heart
surrounds the cardioesophageal sphincter through which food enters the stomach
from the esophagus; fundus which is the expanded part of the stomach lateral to the
cardia region; body is the mid portion; and the pylorus a funnel shaped which is the
terminal part of the stomach. The pylorus is continuous with the small intestine
through the pyloric sphincter, or valve.

With the gastric glands lined with several secreting cells the zymogenic
(peptic) cells secrete the principal gastric enzyme precursor, pepsinogen. The
parietal (oxyntic) cells produce hydrochloric acid, involved in conversion of
pepsinogen to the active enzyme pepsin, and intrinsic factor, involved in the
absorption of Vitamin B12 for the red blood cell production. Mucous cells secrete
mucus. Secretions of the zymogenic, parietal and mucus cells are collectively called
the gastric juice. Enteroendocrine cells secrete stomach gastrin, a hormone that
stimulates secretion of hydrochloric acid and pepsinogen, contracts the lower
esophageal sphincter, mildly increases motility of the GI tract, and relaxes the
pyloricsphincter. Most digestive activity occurs in the pyloric region of the stomach.
After food has been processed in the stomach, it resembles heavy cream and is
called CHYME. The chyme enters the small intestine through the pyloric sphincter.

15
 VI. Pathophysiology with Anatomy & Physiology

Name of the patient: Jhunienne Matias Diagnosis: AGE with mild DHN

Definition: Acute Gastritis is defined as diarrheal disease of rapid onset, often

with nausea, vomiting, fever, abdominal pain and loose bowel movement. It is
an inflammation of the mucous membranes of the stomach often caused by an
infection.

Predisposing Factors: Precipitating Factors:

 Environment ~ Age(6 Months)

 Hygiene ~ Gender(Male)
 Stress

Ingestion of E. Coli

Invasion of gastric
mucosa

Penetration of Gastric
mucosa

Signs & Symptoms:

Toxins producing
Watery stool
pathogens cause watery,
Fever
large volume diarrhea

16
 Irritation of the Gastric Signs & Symptoms:
Lining Vomiting

Fluid and Electrolyte imbalance too much Na+

and H2O are expelled from the body

Increased fluid loss

Signs & Symptoms:
Decrease skin turgor
Dehydration Sunken Eyes

17
 VII. MEDICAL MANAGEMENT
a. Medical Orders and Rationale
DOCTOR’S ORDER RATIONALE
02-15-09

 Please admit to pedia ward  For further management and

under the service of Dr. Bacal treatment of condition
 At par with age regular diet  To provide easy digestion of food
without experiencing pain upon
digestion
 Start D5 0.3NaCL 500ml @  To provide access for intravenous
100cc/hr medications.

 Labs:  To screen the patient’s blood

• CBC component and to detect any
abnormalities. This also serves as a
baseline data to evaluate
effectiveness of blood transfusions.

• Urinalysis  To screen the patient’s urine

components and to detect any
abnormalities.

• SE  To screen the patients feces & to

detect any abnormalities

 To measure daily I & O of the client

 I & O q shift
 To have baseline data and for
 v/s q4H
comparison of future data / for
monitoring of patient’s condition.

02-15-09
 To provide access for intravenous
 IVF with D5 0.3NaCl 500ml @

18
 100cc/hr
02-016-09
 Continue medications medications.
 For billing today
 IVF with D5 0.3 NaCl500cc @  To help for fast recovery
SR  Preparation for going home
02-16-09  To provide access for intravenous
 Continue medications medications.
 IVF D5 0.3 NaCl 500cc @ SR
 To help for fast recovery
 To provide access for intravenous
medications.

b. Laboratory Results

CBC

Hemoglobin 17.3 gms %

Hematocrit 49.6 vol %

White Cell Count 14,351/mm3

Fecalysis
Character: soft WBC/hpf: 4-6
Color: yellow RBC/hpf: 6-8
Parasite ascarasis: none seen cysts: positive
Trichuris: none seen trophosites: none seen
Hook worm: none seen

19
 c. Drug study

DRUG NAME
Paracetamol
DOSE/FREQUENCY/ROUTE
500 mg 1 tab q4h PRN for fever
CLASSIFICATION
Analgesic; antipyretic
MECHANISM OF ACTION
May produce analgesic effect by blocking pain impulses, by
inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by actingon
hypothalamic heat-regulating center. Relieves fever.
SPECIFIC INDICATION
For fever.
CONTRAINDICATION
Contraindicated in patients hypersensitive to drug or its
components.
SIDE EFFECTS
Anemia, jaundice, rash, urticaria.
NURSING PRECAUTION
Do not administer for fever that’s above 39.5° C, lasts longer than 3
days or recurs.

DRUG NAME
AMBROXOL
DOSE/FREQUENCY/ROUTE
0.75ml TID P.O
CLASSIFICATION
Cough and Cold Preparation
MECHANISM OF ACTION
Ambroxol is a mucolytic agent. It acts by increasing the respiratory
tract secretion of lower viscosity mucus and exerting a positive influence on the
alveolar surfactant system which leads to improved mucus flow and transport.
Expectoration of mucus is thus facilitated.
SPECIFIC INDICATION
Cough
CONTRAINDICATION
Hypersensitivity to ambroxol or any ingredient of Ambrolex.
SIDE EFFECTS
Mild GI side effects.
NURSING PRECAUTION
Should be taken with food.

20
DRUG NAME
GENTAMYCIN

DOSE/FREQUENCY/ROUTE
IVT q 8 ANST

CLASSIFICATION
Amino glycoside

MECHANISM OF ACTION
Broad-spectrum aminoglycoside antibiotic derived from
Micromonospora purpurea. Action is usually bacteriocidal.

SPECIFIC INDICATION
Parenteral use restricted to treatment of serious infections of GI

CONTRAINDICATION

History of hypersensitivity to or toxic reaction with any

aminoglycoside antibiotic. Safe use during pregnancy (category C) or lactation is
not established

SIDE EFFECTS
a. an allergic reaction (shortness of breath; closing of the throat; hives;
swelling of the lips, face, or tongue; rash; or fainting);
b. little or no urine;
c. decreased hearing or ringing in the ears;
d. dizziness, clumsiness, or unsteadiness;
e. numbness, skin tingling, muscle twitching, or seizures; or
f. severe watery diarrhea and abdominal cramps.

NURSING PRECAUTION

Draw blood specimens for peak serum gentamicin concentration

30 min–1h after IM administration, and 30 min after completion of a 30–60 min IV
infusion. Draw blood specimens for trough levels just before the next IM or IV dose.
Use nonheparinized tubes to collect blood.

21
 VIII. NURSING MANAGEMENT
Ideal Nursing Manangement - Risk for fluid volume deficit related to excessive
losses through normal routes (frequent diarrhea, vomiting)
INTERVENTIONS
INDEPENDENT
 Monitor Intake and Output. Note number,
character, and amount of stools; estimate
insensible fluid losses, e.g., diaphoresis. Measure
urine specific gravity; observe for oliguria.
 Assess vital signs (BP, pulse, temperature).
 Observe for excessively dry skin and mucous
membranes, decreased skin turgor, slowed
capillary refill.
 Weigh daily
 Maintain oral restrictions, bed rest.
 Observe for overt bleeding and test stool daily for
occult blood.
 Note generalized muscle weakness or cardiac
dysrhytmias.
COLLABORATIVE
 Administer parenteral fluids, blood transfusions as
indicated.
 Monitor laboratory studies, e.g., electrolytes
(especially potassium, magnesium) and ABGs
(acid-base balance).
 Administer medications as indicated:
 Antidiarrheal e.g., dipphenoxylate (Lomotil),
loperamide (Imodium), anodyne suppositories.
 Antiemetics, e.g., trimethobenzamide (Tigan),
hydroxyzine (Vistaril), prochlorperazine
(Comparazine);
 Antipyretics, e.g., acetaminophen (Tylenol);
 Electrolytes, e.g., potassium supplement (KCl-IV;K-
Lyte, Slow-K);
 Vitamin K (Mephyton)
RATIONALE
 Provides information about overall fluid balance,
renal function, and bowel disease control, as well as
guidelines for fluid replacement.
 Hypotension (including postural), tachycardia, fever
can indicate response to and/or effect of fluid loss.
 Indicates excessive fluid loss/resultant dehydration.
 Indicator of overall fluid and nutritional status.
 Colon is placed at rest for healing and to decreased
intestinal fluid losses.
 Inadequate diet and decreased absorption may lead
to vitamin K deficiency and defects in coagulation,
potentiating risk for hemorrhage.
 Excessive intestinal loss may lead to electrolyte
imbalance, e.g., potassium, which is necessary for
proper skeletal and cardiac muscle function. Minor
alterations in serum levels can result in profound
and/or life-threatening symptoms.
 Maintenance of bowel rest requires alternative fluid
replacement to correct losses/anemia. Note: fluids
containing sodium may be restricted in presence of
regional enteritis.
 Determines replacement needs and effectiveness of
therapy.
 Reduces fluid losses from intestines.
 Used to control nausea and vomiting in acute
exacerbations.
 Controls fever, reducing insensible losses.
 Electrolytes are lost in large amounts, especially in
bowel with denuded, ulcerated areas, and diarrhea
can also lead to metabolic acidosis through loss of
bicarbonate (HCO3).
 Stimulates hepatic formation of prothrombin,
stabilizing coagulation and reducing risk of
hemorrhage.
22
Knowledge deficient regarding condition, prognosis, treatment, self-care, and
discharge needs as related to unfamiliarity with resources and information
misinterpretation.

Desire outcomes/evaluation criteria- the significant others will:

Verbalize understanding of disease processes, possible complications.

INTERVENTION RATIONALE
INDEPENDENT
 Determine the mother’s perception  Establishes knowledge base and
of disease process. provides some insight into individual
learning needs.

 Review disease process,  Precipitating/aggravating factors are

cause/effect relationship of factors
that precipitate symptoms, and
identify ways to reduce contributing
factors. Encourage questions.
 Review medications, purpose,
frequency, dosage, and possible
side effects.
 Stress importance of good skin care,
e.g., proper handwashing
techniques and perineal skin care.
 Emphasize need for long-term
follow-up and periodic reevaluation.
individual; therefore, the mother
needs to be aware of what foods,
fluids, and lifestyle factors can
precipitate symptoms. Accurate
knowledge base provides opportunity
for the mother to make informed
decisions/choices about future and
control of chronic disease. Although
most others know about their own
disease process, they may have
outdated information or
misconceptions.
 Promotes understanding and may
enhance cooperation with regimen.
 Reduces spread of bacteria and risk
of skin irritation/breakdown, infection.
 Patients with IBD are at risk for
colon/rectal cancer, and regular
diagnostic evaluations may be
required..

IDEAL NURSING MANAGEMENT

23
 Hyperthermia related to dehydration as evidenced by increase in body
temperature higher than normal range.

Desired outcomes/evaluation criteria- patient will:

Demonstrate temperature within normal range, be free of chills.

INTERVENTION RATIONALE
Independent
 monitor patient  Temperature of 102F-106F (38.9C- 41.1C)
temperature(degree and suggests acute infectious disease process.
pattern); note shaking Fever pattern may aid in diagnosis; e.g.,
chills/profuse diaphoresis. sustained or continuous fever curves lasting
more than 24 hour suggest pneumococcal
pneumonia, scarlet or typhoid fever; remittent
fever (varying only a few degrees in either
direction) reflects pulmonary infections;
intermittent curves or fever that returns to
normal once in 24-hour period suggests
septic episode, septic endocarditis, or
tuberculosis (TB). Chills often precede
temperature spikes.
Note: Use of antipyretics alters fever patterns
and may be restricted until diagnosis is made or
if fever remains higher that 102F (38.9C).
 Monitor environmental  Room temperature/number of blankets
temperature; limit/add bed should be altered to maintain near-
linens as indicated. normal body temperature.
 Provide tepid sponge baths;  May help reduce fever. Note: use of ice
avoid use of alcohol. water/alcohol may cause chills, actually
elevating temperature. In addition,
Collaborative alcohol is very drying to skin.

 Administer antipyretics, e.g.,  Used to reduce fever by its central

acetylsalicylic acid (ASA) action on the hypothalamus; fever
(aspirin), acetaminophen should be controlled in patients who are
(Tylenol). neutropenic or asplenic. However, fever
may be benefial in limiting growth of
organisms and enhancing
autodestruction of infected cells.
 Provide cooling blanket.  Used to reduce fever, usually higher
than 104F-105F (39.5C-40C), when
brain damage/seizures can occur.

24
 b. Actual Nursing Management

Priority number 1

“Sa wala pa na admit akong anak, ge ubo na siya” as verbalized by the

S patient’s mother
• Productive cough
• Inability to expectorate secretions
O • Restlessness

A Ineffective Airway Clearance related to productive cough

Short Term: At the end of 8 hours, the patient will be able to maintain airway
P patency.

1. Elevated head of the bed by putting pillow under the head/changed

position frequently.
• To enhance drainage and ventilation to different lung
segments
2. Monitored infant for feeding intolerance, abdominal distention and
emotional stress.
• May compromise airway.
3. Encouraged mother to hydrate infant frequently.
• To loosen the secretions

I 4. Positioned appropriately and discouraged use of oil-based products

around the nose.
• To prevent vomiting with aspiration to lungs
Dependent:
5. Administered Ambroxol as prescribed.
• To loosen the secretions

E The goal has been met; the patient was able to maintain airway patency.

Priority number 2

25
 “Nangluspad naman gud akong anak tungod kai daghan na siya nasuka ug
S gekalibang” as verbalized by the patient’s mother
• Cool extremities
• Sunken eyes
• Dry skin
• Watery stool
• Persistent vomiting
O • Weight (Before = 7 kgs; Now = 6.5 kgs)
Fluid volume deficit related to excessive losses through GI tract secondary to
A diarrhea
Short term: At the end of 8 hours, the patient will be able to restore fluid and
P electrolyte imbalances
• Encouraged the mother to give oral fluid intake.
• To increase fluid intake
2. Monitored intake and output balance.
• To ensure accurate picture of fluid status
3. Observed for excessively dry skin and mucous membranes, decreased
skin turgor, slowed capillary refill.
• Indicates excessive fluid loss/resultant dehydration

I 4. Weighed daily
• Indicator of overall fluid and nutritional status

5. Monitored vital signs

• To note the changes in heart rate and respiration

Dependent:
6. Provided supplement fluids as indicated D5LR 500cc @ 28cc/hr
• Fluids may be given in this manner if patient is unable to take
oral fluid

E
Goal has been met; at the end of 8 hours, the patient was able to restore fluid
and electrolyte imbalances
Priority number 3

26
 “Sakit kayo ang tiyan sa bata sig era siya hilak sa kasakit. Basa pa gyud
S iya tae ug sige na siya kalibang” as verbalized by the patient’s mother

• Hyperactive bowel sounds

O • 3-5 loose liquid stools per day

A Diarrhea related to irritation of the GI tract

P Short Term: at the end of 8 hours, the patient will reestablish and
maintain normal pattern of bowel functioning.

1. Weighed infant’s diaper.

• To determine the amount of output and fluid replacement
needs
2. Encouraged oral fluid intake containing electrolytes.
• To maintain fluid and electrolyte balance
3. Provided prompt diaper changes and gentle cleansing
• Because, skin breakdown can occur quickly when

I diarrhea is present
4. Did auscultation of abdomen.
• To check for presence, location, and characteristics of
bowel sounds.
Dependent:
5. Administered antidiarrheal medications as prescribed.
• To treat infectious process and decrease motility and
minimize fluid losses

Goals were not met

E At the end of 8 hours, the patient was unable to manifest signs of

decrease fluid volume.

IX. Referrals and Follow-up

27
 Our further Inpatient care includes monitoring of changes in vital signs,
assessment of effectiveness of treatment regimen, reinforcement of dietary
advice(At par with age regular diet), and the advice regarding the importance of
adequate bed rest.
Our further Outpatient care includes instructions of Mr.& Mrs.Inalen Matias
dietary modification of their son, compliance with treatment regimen, and parents’
participation through reporting of adverse effects of medications to his physician.
The parent was also instructed to have a regular check-up at PGH Hospital with their
son in order to monitor the current condition.

X. Evaluation and Implications

Within the span of 2 day of rendering care to Jhunienne Matias. I was able to
identify potential problems and specific nursing interventions were provided. With the
help of health teachings and other interventions, Parents of Jhunienne Matias were
able to learn how to recognize signs and symptoms and other risk factors of the
condition of their son. The Parents of Jhunienne Matias was able to verbalized the
importance of giving medications to their son. They had also recognized the
importance of compliance to treatment regimen in order to manage the condition of
their son, Jhunienne Matias.

XI. BIBLIOGRAPHY:

28
o Luckman and Sorensen, Medical-Surgical Nursing. 3rd Edition W.B. Saunders
Company (1987)
o Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education South
Asia PTE LTD Philippines 2004
o Smeltzer, Medical-Surgical Nursing. 11th edition, Lippincott William & Wilkins,
2007
o Mosby, Mosby’s Nursing Drug Reference, Elesevier Mosby, 2005
o Doengoes, Nurse’s Pocket Guide. 9th edition, F.A. Davis, 2004
o www.wikipedia.org
o www.mims.com

29