City of Manila UNIVERSIDAD DE MANILA (Formerly City College of Manila) A.J Villegas St.

Mehan Gardens, Manila COLLEGE OF NURSING

A CASE STUDY ON

ACUTE GASTROENTERITIS (AGE ) With Severe dehydration

Submitted By: Senen, Maharlika Solinap, Zaldy Fe Sorilla, Rachel V. Tindugan, Princess Rosana NR42 Group 1 Submitted To: Pastora M. Baro RN, MAN

Chapter I 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 loses 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. . Minimal laboratory testing is generally required. Treatment is primary supportive and is directed at preventing or treating dehydration. When positive, an agesupportive 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. Antiemetic and anti-diarrheal medications are generally not indicated and may contribute to complications.

A. Background of Study
The first group (2nd batch) of NR-42 made a case study to the chosen client in Medicine Ward at Ospital ng Maynila Medical Center that provides significant information to yield a comprehensive discussion of the disease process of the patient. Being exposed to the said hospital, the group came to the decision of doing the case study of Acute Gastroenteritis with Severe Dehydration to a particular patient.

B. Significance of the Study The study is significant to the following people, the client, the clients family, the researchers, nursing student, and future researchers. The study is significant to the client, because it enlightens the clients perception and doubts regarding his condition. Allowing him to understand the situation of his present state, this would allow him to follow the importance of the treatment regimen. Clients family must also be aware of the clients condition. With this study, the clients family will be able to participate in the clients treatment regimen and they will realize the importance of the support system. The study is also important to the researchers, since it allows them to explore the clients condition, giving them firsthand experience observing the manifestations of the disease condition and allowing them to apply theoretical knowledge. Nursing students or future researchers may use this study for future reference or basis in planning an intervention.

C. Scope and limitation of the Study

This study will present about Acute Gastroenteritis with Severe Dehydration especially on the case of Mr X. it includes essential concepts in relation to the said condition such as the patients profile and health history, nursing assessment and clinical manifestations, drug study, and diagnostic exam done. The anatomy and physiology is also included as well as the pathophysiology with its associated factors. The areas of concerns are limited to the discussions of AGE with severe dehydration and the quality of nursing care to the patient. The quantity and quality of the information are limited to the data gathered from the client, significant others and his medical records. Immediate family background is limited because the client has difficulty in speaking due to fatigue and difficulty recalling necessary information that would aid in the data gathering.

Chapter II NURSING SUMMARY A. Nursing Health History 1. Personal Data

Patients Name: Age: Gender: Address: Date of Birth: Civil Status: Religion: Nationality: Dialect: Date of Admission: Time Admitted: Attending Physician: Chief Complaint: Admitting Diagnosis: Final Diagnosis: LBM & vomiting; body weakness AGE with Severe Dehydration AGE with Severe Dehydration 9:50 AM Roman Catholic Filipino Ilocano Male Mr. X

PRESENT HEALTH HISTORY

Four days prior to admission the patient had vomiting for 3 times associated with abdominal pain and passage of watery stool and body weakness, he thought that this will subside when he take a rest but the next day he experience the same symptoms and experience body weakness, he remember ingesting street food four days ago so he thought this will subside if he take over the counter drug (paracetamol). Prior to admission the patient still experience the same symptom with extreme weakness still with vomiting and passage of watery stool. And last, March 15, 2013 he was rushed to due to severe weakness and severe abdominal pain.

PAST HEALTH HISTORY

The patient has known to have allergies on seafood particularly on shrimp. He usually take medication for the allergy if he has accidentally eaten a shrimp.

FAMILY HEALTH HISTORY

According to the patients relative, 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.

Chapter III GORDONS 11 FUNCTIONAL PATTERN

Functional Pattern Prior to Admission The patient now rates his Describes 1. Health Perception/ Health Management Pattern The patient believes that the cause of this illness is due to the food The he ate from street food one day ago before he experienced any symptoms. The patient rate his health staus with a scale of 5/10, 10 being the highest. Before going being hospitalized he never consult a doctor usually medications 2. Nutritional and Meatabolic unprescribed. Prior to admission He patient usually needs assisitance Describes the clients pattern of food and fluid and take patient in now the to He cooperates now to his therapeutic regimen. participates entire regimen him. health status with a scale of 7/10. the clients perceived pattern of health and well being and how health is managed (Kozier and Erbs Fundamentals of Nursing Vol.1, 8th edition pg.190) During Hospitalization Analysis and Interpretation

therapeutic given

when eating and his

had 3 meals a day and drink 67 glasses of water a day. He is not a picky eater and can eat almost everything.

diet is low salt low fat. Now that he is hospitalized he takes about 2 meals per day and his water consumption increased. is

consumption relative to metabolic need and pattern indications of local nutrient supply. (Kozier and Erbs Fundamentals of Nursing Vol. 1, 8th edition pg.190) The food intake is decreased primarily because pattern of of of Erbs

3. Elimination Pattern

weakness. Prior experiencing In the first few days of Describes the any symptoms, the patient has a regular urinates times a day. When symptoms presented, defactes watery and he five stools urinates a the the bowel 6-7 He urinates four times a day with yellow urine Before output. he movement and his hospitalization his defacation decreases from 4 times a day to 2 times.

excretory function (Kozier and

bowel, bladder and skin. Fundamentals of Nursing Vol. 1 8th edition, pg. 190) experience

symptoms the client has a regular bowel movement, but when the symptoms presented he defecates two times the usual with watery stools

times a day with

four times 4. Activity and Tolerance

day. Prior experiencing He has generalized body Describes any very symptoms active weakness and is the client is a unable to even stand because of the pain

pattern

of

exercise, activity, leisure and recreation (Kozier & Erbs Fundamentals of

person. He is a retired construction worker. When he has a free time he, he likes to watch sports program.

he is experiencing.

Nursing vol.1, 8th edition pg .190) The patient has a generalized body weakness because of the fluids he loss by his frequent defecation that lead him to experience pain when moving.

5. Sleep Rest Pattern

He usually sleeps During exactly 12:00pm wake and up the

hospitalization Describes the pattern of sleep, patient of has the for vital Environmental of a person factors can affect the sleeping pattern rest (Kozier and & relaxation. Erbs

difficulty in sleeping because interruptions therapeutics, signs monitoring

Fundamentals of Nursing Vol.1 8th edition pg.190)

5:00am with a total of 6 hours of sleep. Has no history taking medication 6. Cognitive and Perceptual Pattern of any for

sleeping. Prior to admission, He patient has understanding where he got the disease but has about disease itself. no understanding

was understand

able

to Cognitive-perceptual his describes cognitive (Kozier&Erbs

pattern and patterns.

sensory

condition through the explanation of health care provider.

Fundamentals of Nursing vol.2, 8th edition pg 190)

the He still can recall past Fatigue can affect of how fast events but with slow pacing if it was asks the person can remember things.

clearly He can easily recall past events that 7. Self-Perception and SelfConcept Pattern happened. Prior to admission He he thought that his condition was worse. as thinks condition long complies

and

asks

elaboratedly

that as with

his Describes the clients selfconcept pattern & he the perceptions of self (e.g self-conception/worth, comfort, (Kozier&Erbs of Nursing body image, feeling state) Fundamentals vol.1, 8th

improved

therapeutic ordered.

regimen

edition pg.190) The patient is his optimistic condition

regarding

and believes that he will 8. Role and Relationship Pattern be cured. He has a nuclear During his admission, he Describes the clients pattern type of family, with four children. Three are male and 1 is female. He has already all of their them has own was accompanied by his wife. While his children grandchildren frequently visit him during the day. The client has not become a burden because to his his family children and of role and relationship (Kozier&Erbs Fundamentals of Nursing vol.1, 8th edition pg.190)

family already. He has a good

respect him. relationship with the entire

member and he is consider as the head of the family where decision making is being brought upon. 9.Sexuality and Due to aging, he Reproductive has less interest Pattern in sexual activity. Describe the clients pattern of satisfaction dissatisfaction sexuality describes patterns. and with pattern; reproductive (Kozier&Erbs

Fundamentals of Nursing vol.1, 8th edition pg.190) To cope with stress He just talk to his wife Describe the clients general 10. Coping and Stress Tolerance Pattern he usually just spend time with his grandchildren. Sometimes drink with his friends to cope up with stress The patient has an effective coping as evidence by talking to someone when he wants to talk them out and the doctor in charge if he is feeling any doubts. coping in pattern of & the stress effectiveness of the pattern terms tolerance. (Kozier&Erbs of Nursing Fundamentals vol.1, 8th

edition pg.190)

He 11. Values and Belief Pattern

is

Roman He perceive the same Describes when it comes to his values and beliefs.

the

paterns

of

Catholic and he occasionally go to church. He believes in God and that every challenge has a reason.

values, beliefs (including spiritual) and goals that guide the clients choices or decisions (Kozier&Erbs Fundamentals of Nursing vol.1, 8th edition pg.190)

The patient has a positive outlook condition. despites his

Chapter IV ADULT PHYSICAL ASSESSMENT

Name: ___________________________________________________ Date: _______________ Diagnosis: ________________________________________________ Age: ________________ Vital Signs: BP: ______ Temp: ______ Pulse: _________ Resp.: _________

General Appearance:

Integument:

Skin:

Hair:

Nails:

Head:

Eyes:

Ears:

Nose: Mouth: Neck: Thorax and Lungs: Cardiovascular: Heart: Peripheral Vascular System: Abdomen:

Musculoskeletal; Genitals:

Rectum / Anus:

Chapter V 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

Chapter VI 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.

Chapter VII PATHOPHYSIOLOGY (GASTROENTERITIS with SEVERE DEHYDRATION)

Predisposing Factors
Age Environment

Precipitating Factors
Lifestyle Poor Hygiene Diet

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

Profusesecretion secretionof offluids water Profuse and electrolytes

Abdominal cramps abdominal pain pain Abdominal

Blood, mucus in stool

Diarrhea Diarrhea

Abdominal cramps General weakness General Weakness Excretion of Interstitial fluids Access to Systemic circulation Infection in other part of the body

Fluid and electrolytes loss

Severe Dehydration Deterioration and collapse DEATH Septicemia Meningitis

Chapter VIII 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 After thirty minutes, goal was met as evidence by maintaining a normal temperature.

Monitor heart rate and rhythm.

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

Ensuring patients

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.

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 r/t IV therapy

At the end of 30 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. Visible sings of infection enable the

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.

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.

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.