I.

INTRODUCTION Upper respiratory tract infection (URI) is a nonspecific term used todescribe acute infections involving the nose, paranasal sinuses, pharynx, larynx,trachea, and bronchi. The prototype is the illness known as the common cold,which will be discussed here, in addition to pharyngitis, sinusitis, andtracheobronchitis. Influenza is a systemic illness that involves the upper respiratory tract and should be differentiated from other URIs.Viruses cause most URIs, with rhinovirus, parainfluenza virus,coronavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenzavirus accounting for most cases. Human metapneumovirus is a newly discoveredagent causing URIs. Group A beta-hemolytic streptococci (GABHS) cause 5% to10% of cases of pharyngitis in adults. Other less common causes of bacterialpharyngitis include group C beta-hemolytic streptococci, Corynebacteriumdiphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniae , and herpes simplex virus. Streptococcus pneumoniae, Haemophilus influenzae , and Moraxella catarrhalis are the most common organisms that cause the bacterial superinfection of viralacute sinusitis. Less than 10% of cases of acute tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae, or C. pneumoniae

Most URIs occurs more frequently during the cold winter months, becauseof overcrowding. Adults develop an average of two to four colds annually.Antigenic variation of hundreds of respiratory viruses results in repeatedcirculation in the community. A coryza syndrome is by far the most commoncause of physician visits in the United States. Acute pharyngitis accounts for 1%to 2% of all visits to outpatient and emergency departments, resulting in 7 millionannual visits by adults alone. Acute bacterial sinusitis develops in 0.5% to 2% of cases of viral URIs. Approximately 20 million cases of acute sinusitis occur annually in the United States. About 12 million individuals are diagnosed withacute tracheobronchitis annually, accounting for one third of patients presenting with acute cough. The estimated economic impact of noninfluenza-related URIsis $40 billion annually. Influenza epidemics occur every year between November and March inthe Northern Hemisphere. Approximately two thirds of those infected withinfluenza virus exhibit clinical illness, 25 million seek health care, 100,000 to200,000 require hospitalization, and 40,000 to 60,000 die each year as a result of related complications. The average cost of each influenza epidemic is $12million, including the direct cost of medical care and indirect cost resulting fromlost work days. Pandemics in the 20th century claimed the lives of more than

21million people. A widespread H5N1 pandemic in birds is ongoing, with threats of a human pandemic. It is projected that such a pandemic would cost the UnitedStates $70 to $160 billion. B. OBJECTIVES OF THE STUDY This individual case study provides goals or objectives which can be used as aninstrument in assessing the patients health status and in his present conditions: 1. Use to obtain a complete heath data and can be used in follow up care. 2. Impart knowledge by conducting health teaching about the necessaryinformation pertaining in the disease condition. 3. Understands the course and essence of the chosen care study. C. SCOPE AND LIMITATION OF THE STUDYThe study includes all the data gathered during the interview and theobservation claimed by the patient as well as the significant others. It also dealswith the several factors observed and gathered during the interview. Thatinformation gathered was the exact answer and the problems of the people in thecommunity and not just basing in the opinions of the students conducting theinterview of the students.The limitation of this study is limited in the place of interaction itself whichis in the hospital. This study was completed in 2 days by the interaction of thestudent and the patient.

II. HEALTH HISTORY: A.Profile of the Patient NAME: AGE:SEX: RELIGION: BIRTH DATE: CIVIL STATUS: Single NATIONALITY: Filipino ADDRESS: tagloanDATE OF ADMISSION: November 18, 2008 TIME OF ADMISSION: 9:05pm VITAL SIGNS ASSESMENTTEMPERATURE:36.6 PULSE RATE: 86 bpm RESPIRATORY RATE: 100 bpm HEIGHT: 94 cm WEIGTH: 12.7 kg ALLERGY: No allergy

B.FAMILY AND PERSONAL HEALTH HISTORY Jurey was born on November 18, 2007. He was delivered NSVD in thePolymedic General Hospital. He was a healthy and a lovable boy. One monthafter birth Jurey experienced diarrhea lasting for two days, her mother panicand admitted him into the Polymedic General hospital. He was thendiagnosed of having a diarrhea having a watery stool, Jurey stayed in thehospital for almost a day. A week after, Jurey had a fever due to infection. Her mother gave him paracetamol and she had performed a tepid sponge both onhim. After giving the medications and performing tipid sponge bath thetemperature of Jurey drop from 38 c to 36.8 c.

C.HISTORY OF PRESENT ILLNESS: The case of 2 years old male, Roman Catholic lived in Taguluan,camein Sabal Hospital CDOC at 12:50 pm on November 18 , 2008 with a chief complains of Loss bowel movement (LBM) and vomiting. Jurey had a coughlasting for 6 days.On that day, Jurey had LBM three consecutive defecation within aninterval of 30minutes with watery, nonblood seen associated with vomiting atleast two times after such intake of foods/fluids as stated by the mother whereprompt to admission. There was no associated symptom like fever during thatday.Jurey was diagnosed to have an acute gastroenteritis with milddehydration (AGE). D.CHIEF COMPLAINS The chief complain of the patient is loss bowel movement andvomiting last November 18, 2008 at 12:05 pm III. DEVELOPMENTAL DATA: Sigmund Freuds Psychosocial Development:According to Freud, the source of bodily pleasure is concentrated in zonesaround the musculocutaneous junctions. These erotogenic zones displace oneanother in sequence as the child matures. Initially, the infants erotogenic zone isthe mouth, thus gratification of the id is derived through oral satisfaction. Duringthe first 6 months of life, the infant is in the oral dependent or oral passive stage,as evidenced by sucking. After the first teeth erupt at about 5 to 7 months of age,the infant enters the oral aggressive stage with biting and sucking as the meansof gratification.Infants enjoy sucking and later biting anything that touches the erogenouszone of the lips and mouth. Some infants enjoy this oral activity more than theothers. While some may be satisfied by sucking at the breast or bottle, othersrequire pacifiers, toys or other objects that can be orally manipulated.The young infant operates on the basis of primary narssism or self-love,wanting what is wanted immediately and unable to tolerate a delay ingratification. This process, the pleasure principle, later becomes a part of the egostructure that operates on the reality principle, giving up what is wanted now for something better in the future. If the mother or her substitute always sees to itthat the infants need before there is evidence of these needs, the infant will feelno control over the environment. On the other hand, if required to wait too longafter expressing a need, the infant will feel unable to control the environment andthus learns to mistrust the caregiver

IV. MEDICAL MANAGEMENTMEDICAL ORDERS/RATIONALE/MEDICINE/LABORATORY: MEDICINE ORDERED DATE ORDERED RATIONALE o Cotrimoxazole 125mg/5mlsuspension 4.0ml BID (8-6) November 18,2008 Antibacterial for Shigellosis or UTIscaused bysusceptible strainsof Escherichia coli,Proteus (in dolepositive or negative),Klebsiella,or Enterobacter species. o Metronidazole 125mg/5mlsuspension 4.0ml TID(8-1-6) November 18, 2008 Amoebicides &Antiprotozoals intestinal Amebiasis o Prozinc drops 1.3ml OD(once daily) Food supplement -contains zinc anessential mineralthat stimulates theactivities of manyenzymes promotingnormal biochemicalreaction in the body.Strengthen theimmune system,support normalgrowth and drugsand help preventretardation. o FecalysisNovember 18, 2008 To check for abnormalities. o UrinalysisNovember 18, 2008 To check for abnormalities

o HemochromeNovember 18, 2008

To check for abnormalities.

DRUG STUDYGENERIC NAME OF THE DRUG: CETTRIAXONE DATE ORDERED : November 18, 2008 CLASSIFICATION:Cephalosporin DOSE AND FREQUENCY:MECHANISM OF ACTION:SFECIFIC INDICATION: Lower respiratory tract infection, skin and skin structureinfection due to s.aureus SIDE EFFECTS: Increases in the serum creatine presence of cast in the urine,alternation of PFs. NURSING PRECAUTION: 1.IM injection should be deep in the body of the large muscle. 2. IV infusion should contain concentrations of 40 mg/mL of sterile water. 3.Do not mix the drug with other antibiotics
V.ANATOMYANDPHYSIOLOGY: Acute gastroenteritis Viruses and bacteria from the contaminated food It produces toxins that react with the small intestine mucosa Dysentery caused by bacteria which affects the colon Abdominal cramping, diarrhea and vomiting Fluid electrolytes imbalance Parasites invade the circulation and localize in theGastrointestinal tract Inflammation Watery stools and vomiting occur

THE DIGESTIVE SYSTEM Consists of (1) an alimentary canal- a long muscular tube beginning at thelips and ending at the anus, including the mouth, pharynx (oral and laryngealportions), esophagus, stomach, and small and large intestine, and (2) accessoryglands that empty secretions into the tube- salivary glands, pancreas, liver, andgallbladder. 1.Teeth a.Crown projects above the gum, root below. Dentin (bulk of tooth)surrounds pulp cavity. Enamel covers dentin of crown; cementumcovers dentin of root and anchors tooth to periodontal ligament. b.Each quadrant of mouth has eight teeth-two incisors, one canine,two premolars, and three molars. 2.Esophagusa. a.Mucous membrane lined with stratified squamous epithelium rather than simple columnar epithelium, as in stomach and intestine, b.Muscular layer of upper third, striated; lower third, smooth; middle,both striated and smooth. c.Segment above stomach (indistinguishable anatomically fromremainder of esophagus) functions as sphincter, remaining closeduntil reflexively relaxed as peristaltic wave approaches,