CAGAYAN COLLEGES TUGUEGARAO COLLEGE OF HEALTH

A CASE STUDY ON

ACUTE GASTROENTERITIS (AGE)

Submitted by: Dennis Gallardo

INTRODUCTION
Acute gastroenteritis (AGE) is an acute infectious process affecting gastrointestinal tract caused by virus, bacteria and parasites. The disease is transmitted by ingestion of contaminated food, water, or by contaminated hands, linens, equipments, and supplies. Most serious complication is dehydration and electrolyte losses which may lead to metabolic acidosis and death. The primary manifestation of gastroenteritis is diarrhea, but it may be accompanied by nausea, vomiting, and abdominal pain. The vomiting usually settles in a day or so. The diarrhea may last for up to 10 days, but usually lasts only to 2 or 3 days. If there is fever, or blood and mucus in the stools it is more likely to be contagious. Gastroenteritis is contagious as the organism lives in the gastrointestinal tract, so it is important to wash hands thoroughly after going to the toilet and before preparing food. Acute gastroenteritis is associated with significant morbidity in developed countries and each year is the cause of death of several million children in developing countries. Estimates of the overall incidence of acute gastroenteritis range from 1.3 to 2.3 episodes of diarrhea per year in children under five years of age. Each year, more than 300 U.S. children die from this illness. In the United States alone, gastroenteritis accounts for more than 220,000 hospital admissions per year in children less than five years of age, or approximately 10 percent of hospitalizations in this age group. Acute gastroenteritis is a common and costly clinical problem in children. It is a largely self-limited disease with many etiologies. The evaluation of the child with acute gastroenteritis requires a careful history and a complete physical examination to uncover other illness with similar presentations. Minimal laboratory testing is generally required. Treatment is primary supportive and is directed at preventing or treating dehydration. When positive, an age-supportive diet and fluids should be continued. Oral rehydration therapy using a commercial pediatric oral rehydration solution is preferred approach to mild or moderate dehydration. The traditional approach using clear liquids is inadequate. Severe dehydration requires the prompt restoration of intravascular volume through the intravenous administration of fluids followed by oral rehydration therapy. When rehydration is achieved, an aged-appropriate diet should be promptly resumed. Anti-emetic and anti-diarrheal medications are generally not indicated and may contribute to complications. On its mortality and morbidity, AGE is a leading cause of infant mortality throughout the world. By age 3 years, virtually all children become infected with the most common agents. Severe cases are seen in the elderly, infant and immunosuppressed population including transplant patients. Last July 05, 2007, we encountered a patient with such kind of infection. This patient has caught our attention and has given the opportunity to study his case. The objective of this study is to help us understand the disease process of gastroenteritis and to orient ourselves for appropriate nursing interventions that we could offer to the patient. This approach enables us to exercise our duties as student nurses which is to render care. I

was given the chance to improve the quality of care I can offer and to pursue our chosen profession as future nurses.

PATIENTS PROFILE
Patients Name: Budong Age: 4 years & 7 months Gender: Male Address: Carig Sur, Tuguegarao City Date of Birth: December 3, 2002 Civil Status: Single Religion: Roman Catholic Nationality: Filipino Dialect: Ilocano Date of Admission: July 5, 2007

Time Admitted: 9:50 AM Attending Physician: Dra. M. Velarde Chief Complaint: LBM & vomiting Admitting Diagnosis: AGE with Dehydration Final Diagnosis: AGE with Dehydration

NURSING HISTORY OF ILLNESS PRESENT HEALTH HISTORY

Two days prior to admission (July 3, 2007 in the evening), the patient had vomiting for 3 times associated with abdominal pain and passage of watery stool due to his intake of ice-cold coke and water according to his mother. A day prior to admission (July 4, 2007), the patient still attended his classes but still with vomiting and passage of watery stool. And last July 5, 2007, he was rushed to St. Paul Hospital due to weakness and severe abdominal pain.

PAST HEALTH HISTORY

According to the patients mother, the patient has his complete immunizations. He is taking his vitamin supplements but still he is very slim and never liked vegetables. The patient was first hospitalized due to asthma. His second hospitalization was due to bronchopneumonia and the latest was due to AGE.

FAMILY HEALTH HISTORY

According to the patients mother, their family have history of Hypertension, Diabetes mellitus, Bronchial Asthma and Cancer. Hypertension is evident on the patients grandfather and uncle, while Cancer is evident on the patients aunt.

GORDONS 11 FUNCTIONAL PATTERN Health Perception-Health Management Pattern

Before his hospitalization, the patient perceives health in a way that he is not suffering from any disease. He takes vitamins for him to improve his health and to protect him from acquiring any disease. During his hospitalization, the patient feels so unhealthy according to his mother because of his hospitalization. He is obedient in taking his medications and is participative in all the nurses interventions.

Nutritional-Metabolic Pattern
Before his hospitalization, the patient takes his meal three times a day without any restrictions. According to his mother, he has food preferences on fatty and oily foods. Her mother even shared that when they eat adobo, he prefers to eat the fat rather than the muscle because he gets irritated with foods between his teeth. He has no difficulty in swallowing and he usually eat junk foods when its snack time. He drinks 4-5 glasses of water a day and takes Clusivol to improve his appetite. During his hospitalization, his appetite decreased. He was restricted from eating dairy products. His fluid intake increased for about 5-7 glasses of water a day.

Elimination Pattern
Before his hospitalization, the patient used to eliminate once a day every morning before going to school 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. He also perspires every time he plays. During is hospitalization, the patients stool is watery with a yellowish color. He urinates 2-3 times a day. He also perspires but its due to the hot environment not from any activity since he just stays on bed.

Activity-Exercise Pattern
Before his hospitalization, especially during the weekend, 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 8-9 hours. He is fond of watching the TV series Super Twins before going to bed when it was still showing. 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. His mother even shared to us that he is already capable of writing his name and is capable of reading the alphabet and numbers. During his hospitalization, he relates to us actively. He responded to our questions enthusiastically. He also related to us some of his school activities.

Self-Perception/ Self-Concept Pattern

According to the patients mother, hes a good son though sometimes he tends to disobey his parents. She said this is normal for his age. He is the eldest but according to her mother he acts as if he is the youngest.

Role-Relationship Pattern
The patient has a close relationship with his family, but he is closer to his father. He has a 2 year old sister, but according to his mother, he does not play the role of an elder brother. His mother even added that his sister ie more obedient than he is. But during his confinement, he is more obedient because he wanted to get well immediately.

Sexual-Reproductive Pattern
Prior to his age, the patient is not yet oriented with any sexual matters. According to hid mother, he has not yet undergone circumcision.

Coping Stress- Tolerance Pattern

According to his mother, when he has problems he always approach his parents. She even added that when he gets scolded, he just stays in his room. When he is bullied or when his cousins get his toys, he does not quarrel with them but instead he reports it to his parents. During his hospitalization, he feels unsafe with people when his mother is not with him. He cries without the sight of his mother.

Value-Belief Pattern
He is a Roman Catholic. They attend mass regularly. He afraid to do something bad because he believes that God will punish him. According to his mother, before they consult the doctors or the hospital, they first consult the quack doctors.

PHYSICAL ASSESSMENT
Date assessed: July 06, 2007 General assessment: neat, conscious and coherent Initial vital signs: T=37.9, RR=20, BP=80/60, PR=95 Area Assessed Skin Color Technique Inspection Normal Findings Light brown, tanned skin (vary according to race) Lighter colored palms, soles, lips and nail beds Skin normally dry Normally warm Smooth, soft and flexible palms and soles (thicker) Skin snaps back immediately Transparent, smooth and convex Pinkish Firm White color of nail bed under pressure should return to pink within 2-3 seconds Evenly distributed Black Smooth Parallel to each other PERRLA- Pupils equally round react Actual Findings Tanned skin Lighter colored palms, soles, lips and nail beds Skin normally dry 37.9 o C Smooth, soft and flexible palms and soles (thicker) Skin snaps back immediately Transparent, smooth and convex Pinkish Firm White color of nail bed under pressure returned to pink within 2-3 seconds Evenly distributed Black Smooth Parallel to each other but sunken PERRLA- Pupils equally round react Evaluation Normal

Lips, nail beds, soles and palms Moisture Temperature

Inspection Inspection/ Palpation Palpation Palpation Palpation

Normal Normal d/t hyperthermia Normal Normal

Texture Turgor Skin appendages a. Nails Nail beds Nail base

Inspection Inspection Inspection Inspection/ Palpation Inspection Inspection Inspection/ Palpation Inspection Inspection (penlight)

Normal Normal Normal Normal

Capillary refill b. Hair Distribution Color Texture Eyes Eyes Visual Acuity

Normal Normal Normal d/t dehydration Normal

Eyebrows

Inspection

Eyelashes Eyelids

Inspection Inspection

to light and to light and accommodation accommodation Symmetrical in size, Symmetrical in size, extension, hair extension, hair texture and texture and movement movement Distributed evenly Distributed evenly and curved outward and curved outward Same color as the Same color as the skin skin Blinks involuntarily and bilaterally up to 20 times per minute Do not cover the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge of inflammation Canal walls pink Client normally hears words when whispered Smooth, symmetric with same color as the face Close to midline, thicker anteriorly than posteriorly Oval, symmetric and without discharge Blinks involuntarily and bilaterally up to 16 times per minute Do not cover the pupil and the sclera, lids normally close symmetrically Transparent with light pink color Color is white Transparent, shiny Black, constrict briskly Clearly visible Free of lesions, discharge of inflammation Canal walls pink Client normally hears words when whispered Smooth, symmetric with same color as the face Close to midline, thicker anteriorly than posteriorly Oval, symmetric and without discharge

Normal

Normal Normal

Normal

Normal Normal Normal Normal Normal Normal Normal

Conjunctiva Sclera Cornea Pupils Iris Ears Ear canal opening

Inspection Inspection Inspection Inspection Inspection Inspection

Normal Normal

Hearing Acuity Nose Shape, size and skin color Nasal septum

Inspection

Inspection Inspection

Normal Normal

Nares

Inspection

Normal

Mouth and Pharynx Lips Buccal mucosa Gums Tongue

Inspection Inspection Inspection Inspection

Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny Hard palate- domeshaped Soft Palate- light pink Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Midline Clear breath sounds Skin same color with the rest of the body Clicks or gurling sounds occur irregularly and range from 5-35 per minute Fully conscious,

Pink, moist symmetric Glistening pink soft moist Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface medium or dull red Firmly set, shiny No tooth decay Hard palate- domeshaped Soft Palate- light pink Neck is slightly hyper extended, without masses or asymmetry Neck moves freely, without discomfort Rises freely with swallowing Midline Clear breath sounds Skin same color with the rest of the body Clicks or gurling sounds occur irregularly and range from 5-35 per minute Fully conscious,

Normal Normal Normal Normal Normal Normal

Teeth Hard and soft palate Neck Symmetry of neck muscles, alignment of trachea Neck Rom Thyroid gland Trachea Thorax and Lungs Abdomen

Inspection Inspection

Inspection Inspection Palpation Inspection Auscultation Inspection

Normal Normal Normal Normal Normal Normal

Bowel sounds

Auscultation

Normal

Neurology system Level of

Inspection

consciousness

respond to respond to questions questions quickly, quickly perceptive perceptive of events of events Inspection Makes eye contact with examiner, hyperactive expresses feelings with response to the situation Makes eye contact with examiner, hyperactive expresses feelings with response to the situation

Normal

Behavior and appearance

Normal

LABORATORY RESULTS
HEMATOLOGY RESULTS
WBC Hgb Hct Differential Count Lymphocytes Segmenters Normal Value 5-10 x 10 g/L M 13-16 g/dl F 12-16 g/dl M 39%-54% F 37%-48% 20%-40% 60%-70% Results 7.8 11 33% 31% 69% Analysis Normal Decreased Decreased Normal Normal

FECALYSIS
Method used: Direct Smear Results Physical properties: Color Consistency Light brown Watery Analysis Normal d/t profuse secretion of water and electrolytes

Remarks: No oral intestinal parasite seen

URINALYSIS
Color Transparency Reaction Specific gravity Sugar Protein Results Yellow Slightly turbid 6.0 -1.020 Negative Trace Analysis Normal d/t increased urine concentration Normal Decreased: d/t dehydration Normal Normal

MICROSCOPIC EXAM
Round epithelial cells Mucus thread RBC Pus cells Amorp urates/phosphates Result Occasional Many 0-1 1-2 Few Analysis Normal Normal Normal Normal Normal

ANATOMY AND PHYSIOLOGY

THE DIGESTIVE SYSTEM

Every morsel of food we eat has to be broken down into nutrients that can be absorbed by the body, which is why it takes hours to fully digest food. In humans, protein must be broken down into amino acids, starches into simple sugars, and fats into fatty acids and glycerol. The water in our food and drink is also absorbed into the bloodstream to provide the body with the fluid it needs. The digestive system is made up of the alimentary canal and the other abdominal organs that play a part in digestion, such as the liver and pancreas. The alimentary canal (also called the digestive tract) is the long tube of organs including the esophagus, the stomach, and the intestines that runs from the mouth to the anus. An adult's digestive tract is about 30 feet long. Digestion begins in the mouth, well before food reaches the stomach. When we see, smell, taste, or even imagine a tasty snack, our salivary glands, which are located under the tongue and near the lower jaw, begin producing saliva. This flow of saliva is set in motion by a brain reflex that's triggered when we sense food or even think about eating. In response to this sensory stimulation, the brain sends impulses through the nerves that control the salivary glands, telling them to prepare for a meal. As the teeth tear and chop the food, saliva moistens it for easy swallowing. A digestive enzyme called amylase, which is found in saliva, starts to break down some of the carbohydrates (starches and sugars) in the food even before it leaves the mouth. Swallowing, which is accomplished by muscle movements in the tongue and mouth, moves the food into the throat, or pharynx. The pharynx (pronounced: fair-inks), a passageway for food and air, is about 5 inches long. A flexible flap of tissue called the epiglottis reflexively closes over the windpipe when we swallow to prevent choking. From the throat, food travels down a muscular tube in the chest called the esophagus. Waves of muscle contractions called peristalsis force food down through the esophagus to the stomach. A person normally isn't aware of the movements of the esophagus, stomach, and intestine that take place as food passes through the digestive tract. At the end of the esophagus, a muscular ring called a sphincter allows food to enter the stomach and then squeezes shut to keep food or fluid from flowing back up into the esophagus. The stomach muscles churn and mix the food with acids and enzymes, breaking it into much smaller, more digestible pieces. An acidic environment is needed for the digestion that takes place in the stomach. Glands in the stomach lining produce about 3 quarts of these digestive juices each day. Most substances in the food we eat need further digestion and must travel into the intestine before being absorbed. When it's empty, an adult's stomach has a volume of one fifth of a cup, but it can expand to hold more than 8 cups of food after a large meal.

By the time food is ready to leave the stomach, it has been processed into a thick liquid called chyme. A walnut-sized muscular tube at the outlet of the stomach called the pylorus keeps chyme in the stomach until it reaches the right consistency to pass into the small intestine. Chyme is then squirted down into the small intestine, where digestion of food continues so the body can absorb the nutrients into the bloodstream. The small intestine is made up of three parts: 1. the duodenum, the C-shaped first part 2. the jejunum, the coiled midsection 3. the ileum, the final section that leads into the large intestine The inner wall of the small intestine is covered with millions of microscopic, fingerlike projections called villi. The villi are the vehicles through which nutrients can be absorbed into the body. The liver (located under the ribcage in the right upper part of the abdomen), the gallbladder (hidden just below the liver), and the pancreas (beneath the stomach) are not part of the alimentary canal, but these organs are still important for healthy digestion. The pancreas produces enzymes that help digest proteins, fats, and carbohydrates. It also makes a substance that neutralizes stomach acid. The liver produces bile, which helps the body absorb fat. Bile is stored in the gallbladder until it is needed. These enzymes and bile travel through special channels (called ducts) directly into the small intestine, where they help to break down food. The liver also plays a major role in the handling and processing of nutrients. These nutrients are carried to the liver in the blood from the small intestine. From the small intestine, food that has not been digested (and some water) travels to the large intestine through a valve that prevents food from returning to the small intestine. By the time food reaches the large intestine, the work of absorbing nutrients is nearly finished. The large intestine's main function is to remove water from the undigested matter and form solid waste that can be excreted. 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. 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. 2. 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.

3. The rectum is where feces are stored until they leave the digestive system through the anus as a bowel movement.

PATHOPHYSIOLOGY (GASTROENTERITIS)

Predisposing Factors
Age Environment

Precipitating Factors
Lifestyle Poor Hygiene Diet

Etiology: infants/young children: Haemophilus influenzae

Person to person (hands)

Contaminated food/water

Animal pets

Ingestion of Pathogens

Invasion of the GIT

Enterotoxin production

Affects the vomit receptors Vomiting center in the brain is stimulated Vomiting Vomiting

Destruction of epithelial cells Superficial ulceration of mucosa abdominal spasm to limit mucosal injury

reduced absorption of fluid & electrolytes

Systemic Invasion

Interacts with mucosal lining

Inflammation of layer of tissue beneath epithelium of mucosa Cellular metabolism d/t underlying injury to GI Hyperthermia and edema

Alters permeability

Profuse secretion of water Profuse secretion of fluids and electrolytes

Abdominal cramps Abdominal pain abdominal pain

Blood, mucus in stool

Abdominal cramps Diarrhea General weakness Fluid and electrolytes loss Infection in other part of the body Excretion of Interstitial fluids Access to Systemic circulation

Dehydration Deterioration and collapse DEATH Septicemia Meningitis

NURSING CARE PLANS

ASSESSMENT Subjective data: Mainit po ang pakiramdam ko as verbalize by the patient Objective data: T= 37.9 o C Skin is warm to touch RR= 20 NURSING DIAGNOSIS Hyperthermia r/t exposure to hot environment PLANNING At the end of thirty minutes, the patient will maintain a core temperature within normal. NURSING INTERVENTIONS Provide proper ventilation. RATIONALE Proper ventilation may reduce the temperature of the patient. Dysrhythmias are common due to electrolyte imbalance, dehydration, and direct effects of hyperthermia on blood and cardiac tissue. Heat loss by convention. EVALUATION

Monitor heart rate and rhythm.

Promote surface cooling by means of cool environment and/or fans.

 Promote client safety. Encourage patients participation in ways to protect oneself from excessive exposure to hot environment. Instruct client/SO to increase fluid intake. Review sings and symptoms of hyperthermia.

Ensuring patients safety prevents other problems. Self-care awareness help in the prevention and control of hyperthermia.

Adequate fluid intake prevents dehydration. These may indicate prompt interventions.

Objective data: Decreased immunity

Risk for infection At the end of 30 r/t IV therapy minutes, the client will verbalize understanding of individual causative and risk factors.

Note risk factors for the occurrence of infection.

Identifying the possible causative factors helps prevent/control the occurrence of infection.

 Observe for localized sings for infection at insertion sites. Assess skin conditions around insertion sites of pins, wires, and tongs, noting inflammation and drainage. Stress proper hand washing techniques by all caregivers and SOs of the patient. Instruct client/SO in techniques to protect the integrity of the skin.

Visible sings of infection enable the management of more severe infections. The skin is our primary defense against infectious diseases.

Hand washing technique is a firstline defense against nosocomial infections. Care for the skin integrity prevents the occurrence of infection.

Subjective data: Nagsuka siya at nagtae, as verbalized by her mother

Fluid volume deficit related to increase metabolic demand and insensible Objective data: fluid loss Dry mucous through membranes vomiting and increased and lips body Sunken temperature eyeballs

At the end of the shift, the patient will be able to: - Achieve adequate hydration as evidenced by good skin turgor, moist mucous membranes and lips, no alteration in mentation

Assessed vital signs and degree of hydration and level of consciousness

Provides baseline data and information; this is also important in the evaluating clients condition an success of intervention Adequate fluids will replace fluid lost through insensible water loss due to hyper metabolic state and vomiting

Encouraged adequate fluid intake as tolerated by the patient. Instructed SO to provide fluids in the bedside Regulated IVF according to specified flow rates basing on the physicians order

Regulation of fluid is critical in maintaining adequate circulating fluids to recover for the amount of water loss through fever and vomiting Urine output serves

 Monitored frequency of urination and amount of excreted urine

as an important parameter in assessing clients ability to conserve fluids

DRUG STUDY
METRONIDAZOLE
Generic name: Metronidazole Brand name: Flagyl Classification: Trichomonacide, amebicide Action: Effective against anaerobic bacteria and protozoa. Specifically inhibits growth by binding to DNA, resulting in loss of helical structure, strand breakage, inhibition of nucleic acid synthesis and cell death. Side Effects: GI: nausea, dry mouth, metallic taste, vomiting, abdominal discomfort, andominal pain CNS: headache, dizziness Nursing Responsibilities: Monitor stool number and character. With IV therapy, assess for sodium retention.

METOCLOPRAMIDE
Generic name: Metoclopramide Brand name: Reglan Classification: gastrointestinal stimulant Action: Dopamine antagonist that acts by increasing sensitivity to acetylcholine; results in increased motility of the upper GI tract and relaxation of the pyloric sphincter and duodenal bulb. Side Effects: GI: nausea, bowel disturbances CNS: restlessness, drowsiness, fatigue, headache, dizziness Nursing Responsibilities: Inject slowly IV to prevent transient feelings of anxiety and restlessness. Assess abdomen for bowel sounds and distention.

AMPICILLIN Generic name: Ampicillin Brand name: Unasyn Classification: Antiboitic, penicillin Action: Synthetic, broad-spectrum antibiotic suitable for gram-negative bacteria. Side Effects: GI: diarrhea, abdominal distention CNS: fatigue, headache GU: dysuria, urinary retention At the site of infection: pain and thrombo-phlebities Nursing Responsibilities: Note history of sensitivity/reactions to these or related drugs. Monitor CBC, liver, and renal function Monitor urinary output and serum potassium levels RANITIDINE Generic name: Ranitidine Brand name: Zantac Classification: histamine H2 receptor blocking drug Action: Competitively inhibits gastric acid secretion by blocking the effect of histamine on histamine H2 receptors. Side Effects: GI: constipation, diarrhea, abdominal pain CNS: dizziness, headache, insomnia, anxiety Nursing Responsibilities: Assess patient GI condition before starting therapy and regularly thereafter to monitor the doing effectiveness. Be alert for adverse reaction and drug interaction. Assess patients and family knowledge of the drug therapy.