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I. INTRODUCTION
Overview of the Study . . . .
Objectives of the Study . . . .
Scope and Limitations . . . .
II. Health History
A. Profile of patient . . .
B. Family and Personal .
Health History
C. History of Present Illness
D. Chief Complaint . . . .
III. DEVELOPMENTAL DATA . . . .
IV. ANATOMY AND PHYSIOLOGY . . .
V. PATHOPHYSIOLOGY . . . . .
VI. DOCTOR’S ORDER
Laboratory Results. . . . . .
Drug Study . . . . . .
VII. NURSING SYSTEM REVIEW CHART . .
VIII. NURSING MANAGEMENT . . . .
Ideal Nursing Management
Actual Nursing Management
IX. HEALTH TEACHINGS . . . . .
X. REFERRALS AND FOLLOW-UP . . .
XI. EVALUATION . . . . . .
XII. BIBLIOGRAPHY . . . .
I. INTRODUCTION
Most URIs occurs more frequently during the cold winter months, because
of overcrowding. Adults develop an average of two to four colds annually.
Antigenic variation of hundreds of respiratory viruses results in repeated
circulation in the community. A coryza syndrome is by far the most common
cause 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 million
annual 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 with
acute tracheobronchitis annually, accounting for one third of patients presenting
with acute cough. The estimated economic impact of non–influenza-related URIs
is $40 billion annually.
Sinusitis
An infection of the cranial sinuses is called sinusitis. Only about 1-3% of URI's
are accompanied by sinusitis. This "sinus infection" develops when nasal
congestion blocks off the tiny openings that lead to the sinuses. Some symptoms
include: post nasal discharge, facial pain that worsens when bending forward, and
sometimes even tooth pain can be a symptom. Successful treatment depends on
restoring the proper drainage of the sinuses. Taking a hot shower or sleeping
upright can be very helpful. Otherwise, using a spray decongestant or sometimes a
prescribed antibiotic will be necessary.
Otitis Media
Otitis media in an infection of the middle ear. Even though the middle ear is not
part of the respiratory tract, it is discussed here because it is often a complication
seen in children who has a nasal infection. The infection can be spread by way of
the 'auditory (Eustachian) tube that leads form the nasopharynx to the middle ear.
The main symptom is usually pain. Sometimes though, vertigo, hearing loss, and
dizziness may be present. Antibiotics can be prescribed and tubes are placed in
the eardrum to prevent the buildup of pressure in the middle ear and the
possibility of hearing loss.
Tonsillitis
Tonsillitis occurs when the tonsils become swollen and inflamed. The tonsils
located in the posterior wall of the nasopharynx are often referred to as adenoids.
If you suffer from tonsillitis frequently and breathing becomes difficult, they can
be removed surgically in a procedure called a tonsillectomy.
Laryngitis
An infection of the larynx is called laryngitis. It is accompanied by hoarseness
and being unable to speak in an audible voice. Usually, laryngitis disappears with
treatment of the URI. Persistent hoarseness without a URI is a warning sign of
cancer, and should be checked into by your physician.
This individual case study provides goals or objectives which can be used as an
instrument in assessing the patient’s health status and in his present conditions:
1. Use to obtain a complete heath data and can be used in follow up care.
The study includes all the data gathered during the interview and the
observation claimed by the patient as well as the significant others. It also deals
with the several factors observed and gathered during the interview. That
information gathered was the exact answer and the problems of the patient in the
Hospital and not just basing in the opinions of other people.
The limitation of this study is limited in the place of interaction itself which
is in the hospital. This study was completed in 2 days by the interaction of the
student and the patient.
II. HEALTH HISTORY:
A. Profile of the Patient
SEX: Male
NATIONALITY: Filipino
TEMPERATURE: 37.8
HEIGHT: 45cm
WEIGTH: 22.5 kg
ALLERGY: No allergy
B. Family and Personal Health History
The patient mother’s name is Mrs. Bordado a business women and
father’s name is Mr. Bordado, a Private employee. They have 3 members of
the family including the said patient. The family have the common problem on
their health like fever, common colds, headache and cough and they just
taking medication like paracetamol, robitossin, and neosep,
6 Days Prior to Admission fever was noted occasional cough and a throat
pain. Few days patient was seen by physician and given antibiotic for
tonsillitis and resistance for fever with vomiting.
D. CHIEF COMPLAINS
The chief complain of the patient was Fever for 6 days and vomiting
last January 22, 2011.
III. DEVELOPMENTAL DATA OF THEORY
The Respiratory System is crucial to every human being. Without it, we would
cease to live outside of the womb. Let us begin by taking a look at the structure
of the respiratory system and how vital it is to life. During inhalation or exhalation
air is pulled towards or away from the lungs, by several cavities, tubes, and
openings.
The organs of the respiratory system make sure that oxygen enters our bodies
and carbon dioxide leaves our bodies.
The respiratory tract is the path of air from the nose to the lungs. It is divided into
two sections: Upper Respiratory Tract and the Lower Respiratory Tract.
Included in the upper respiratory tract are the Nostrils, Nasal Cavities,
Pharynx, Epiglottis, and the Larynx. The lower respiratory tract consists of the
Trachea, Bronchi, Bronchioles, and the Lungs.
As air moves along the respiratory tract it is warmed, moistened and filtered.
The body is able to stay at the dimensions of the lungs because of the
relationship of the lungs to the thoracic wall. Each lung is completely enclosed in
a sac called the pleural sac. Two structures contribute to the formation of this
sac. The parietal pleura is attached to the thoracic wall where as the visceral
pleura is attached to the lung itself. In-between these two membranes is a thin
layer of intrapleural fluid. The intrapleural fluid completely surrounds the lungs
and lubricates the two surfaces so that they can slide across each other.
Changing the pressure of this fluid also allows the lungs and the thoracic wall to
move together during normal breathing. Much the way two glass slides with
water in-between them are difficult to pull apart, such is the relationship of the
lungs to the thoracic wall.
The rhythm of ventilation is also controlled by the "Respiratory Center" which is
located largely in the medulla oblongata of the brain stem. This is part of the
autonomic system and as such is not controlled voluntarily (one can increase or
decrease breathing rate voluntarily, but that involves a different part of the brain).
While resting, the respiratory center sends out action potentials that travel along
the phrenic nerves into the diaphragm and the external intercostal muscles of the
rib cage, causing inhalation. Relaxed exhalation occurs between impulses when
the muscles relax. Normal adults have a breathing rate of 12-20 respirations per
minute.
When one breathes air in at sea level, the inhalation is composed of different
gases. These gases and their quantities are Oxygen which makes up 21%,
Nitrogen which is 78%, Carbon Dioxide with 0.04% and others with significantly
smaller portions.
In the process of breathing, air enters into the nasal cavity through the nostrils
and is filtered by coarse hairs (vibrissae) and mucous that are found there. The
vibrissae filter macroparticles, which are particles of large size. Dust, pollen,
smoke, and fine particles are trapped in the mucous that lines the nasal cavities
(hollow spaces within the bones of the skull that warm, moisten, and filter the air).
There are three bony projections inside the nasal cavity. The superior, middle,
and inferior nasal conchae. Air passes between these conchae via the nasal
meatuses.
Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which
are the three portions that make up the pharynx. The pharynx is a funnel-shaped
tube that connects our nasal and oral cavities to the larynx. The tonsils which
are part of the lymphatic system, form a ring at the connection of the oral cavity
and the pharynx. Here, they protect against foreign invasion of antigens.
Therefore the respiratory tract aids the immune system through this protection.
Then the air travels through the larynx. The larynx closes at the epiglottis to
prevent the passage of food or drink as a protection to our trachea and lungs.
The larynx is also our voicebox; it contains vocal cords, in which it produces
sound. Sound is produced from the vibration of the vocal cords when air passes
through them.
The trachea, which is also known as our windpipe, has ciliated cells and mucous
secreting cells lining it, and is held open by C-shaped cartilage rings. One of its
functions is similar to the larynx and nasal cavity, by way of protection from dust
and other particles. The dust will adhere to the sticky mucous and the cilia helps
propel it back up the trachea, to where it is either swallowed or coughed up. The
mucociliary escalator extends from the top of the trachea all the way down to
the bronchioles, which we will discuss later. Through the trachea, the air is now
able to pass into the bronchi.
Inspiration
As the diaphragm contracts inferiorly and thoracic muscles pull the chest wall
outwardly, the volume of the thoracic cavity increases. The lungs are held to the
thoracic wall by negative pressure in the pleural cavity, a very thin space filled
with a few milliliters of lubricating pleural fluid. The negative pressure in the
pleural cavity is enough to hold the lungs open in spite of the inherent elasticity of
the tissue. Hence, as the thoracic cavity increases in volume the lungs are pulled
from all sides to expand, causing a drop in the pressure (a partial vacuum) within
the lung itself (but note that this negative pressure is still not as great as the
negative pressure within the pleural cavity--otherwise the lungs would pull away
from the chest wall). Assuming the airway is open, air from the external
environment then follows its pressure gradient down and expands the alveoli of
the lungs, where gas exchange with the blood takes place. As long as pressure
within the alveoli is lower than atmospheric pressure air will continue to move
inwardly, but as soon as the pressure is stabilized air movement stops.
Expiration
During quiet breathing, expiration is normally a passive process and does not
require muscles to work (rather it is the result of the muscles relaxing). When the
lungs are stretched and expanded, stretch receptors within the alveoli send
inhibitory nerve impulses to the medulla oblongata, causing it to stop sending
signals to the rib cage and diaphragm to contract. The muscles of respiration and
the lungs themselves are elastic, so when the diaphragm and intercostal muscles
relax there is an elastic recoil, which creates a positive pressure (pressure in the
lungs becomes greater than atmospheric pressure), and air moves out of the
lungs by flowing down its pressure gradient.
When under physical or emotional stress, more frequent and deep breathing is
needed, and both inspiration and expiration will work as active processes.
Additional muscles in the rib cage forcefully contract and push air quickly out of
the lungs. In addition to deeper breathing, when coughing or sneezing we exhale
forcibly. Our abdominal muscles will contract suddenly (when there is an urge to
cough or sneeze), raising the abdominal pressure. The rapid increase in
pressure pushes the relaxed diaphragm up against the pleural cavity. This
causes air to be forced out of the lungs.
Lung Compliance
The upper respiratory tract consists of the nose and the pharynx. Its primary
function is to receive the air from the external environment and filter, warm, and
humidify it before it reaches the delicate lungs where gas exchange will occur.
Air enters through the nostrils of the nose and is partially filtered by the nose
hairs, then flows into the nasal cavity. The nasal cavity is lined with epithelial
tissue, containing blood vessels, which help warm the air; and secrete mucous,
which further filters the air. The endothelial lining of the nasal cavity also contains
tiny hairlike projections, called cilia. The cilia serve to transport dust and other
foreign particles, trapped in mucous, to the back of the nasal cavity and to the
pharynx. There the mucus is either coughed out, or swallowed and digested by
powerful stomach acids. After passing through the nasal cavity, the air flows
down the pharynx to the larynx.
The lower respiratory tract starts with the larynx, and includes the trachea, the
two bronchi that branch from the trachea, and the lungs themselves. This is
where gas exchange actually takes place.
1. Larynx
The larynx (plural larynges), colloquially known as the voice box, is an organ in
our neck involved in protection of the trachea and sound production. The larynx
houses the vocal cords, and is situated just below where the tract of the pharynx
splits into the trachea and the esophagus. The larynx contains two important
structures: the epiglottis and the vocal cords.
The epiglottis is a flap of cartilage located at the opening to the larynx. During
swallowing, the larynx (at the epiglottis and at the glottis) closes to prevent
swallowed material from entering the lungs; the larynx is also pulled upwards to
assist this process. Stimulation of the larynx by ingested matter produces a
strong cough reflex to protect the lungs. Note: choking occurs when the epiglottis
fails to cover the trachea, and food becomes lodged in our windpipe.
The vocal cords consist of two folds of connective tissue that stretch and vibrate
when air passes through them, causing vocalization. The length the vocal cords
are stretched determines what pitch the sound will have. The strength of
expiration from the lungs also contributes to the loudness of the sound. Our
ability to have some voluntary control over the respiratory system enables us to
sing and to speak. In order for the larynx to function and produce sound, we need
air. That is why we can't talk when we're swallowing.
1. Trachea
2. Bronchi
3. Lungs
The Right Primary Bronchus is the first portion we come to, it then
branches off into the Lobar (secondary) Bronchi, Segmental (tertiary)
Bronchi, then to the Bronchioles which have little cartilage and are lined by
simple cuboidal epithelium (See fig. 1). The bronchi are lined by
pseudostratified columnar epithelium. Objects will likely lodge here at the
junction of the Carina and the Right Primary Bronchus because of the
vertical structure. Items have a tendency to fall in it, where as the Left
Primary Bronchus has more of a curve to it which would make it hard to
have things lodge there.
The Left Primary Bronchus has the same setup as the right with the lobar,
segmental bronchi and the bronchioles.
The lungs are attached to the heart and trachea through structures that
are called the roots of the lungs. The roots of the lungs are the bronchi,
pulmonary vessels, bronchial vessels, lymphatic vessels, and nerves.
These structures enter and leave at the hilus of the lung which is "the
depression in the medial surface of a lung that forms the opening through
which the bronchus, blood vessels, and nerves pass" (medlineplus.gov).
I. MEDICAL MANAGEMENT
Meds:
- Cilostazol 100 mg 1 tab,
½ tab BID
- Clopedogrel 75 mg 1 tab - prevention of thrombin
OD formation
- prevention of thrombin
- Citicoline 500 mg 1 tab formation or aggregation
BID that may cause more
- Imidapril + HCTZ 1 cerebral infarction.
tablet OD -
- Amlodipine 5mg 1 tab, -
OD - Decrease cardiac action.
- Colcichine 500 mg 1 tab - prevent rise of uric acid
2* a day in the blood
- Alluporinol 3oo mg 1 tab
OD - antigout drug
- Zucon 20 mg 1 tab, ½ -
1/04/2011 tablet OD - May indicate distress
9 AM - Watch out for decrease
sensorium - To provide appropriate
- Will inform AP interventions
- Refer as needed - To provide appropriate
- Add PU hook to 02 @ 21 interventions
pm in nasal cannula. -
- Insert NGT 16
- Give paracetamol 500 mg - Aid in providing food and
every 4 hours or IVT or fluids
PRN for fever - For fever
- Give dulcolax 1 tab per
NGT now - Soften stool, avoid
- Give vastarel MR 35g 1 constipation
tab BID/NGT 1 dose now
2:35 PM - Paracetamol 300mg - Anti-anginal drug
IVTT now
5:20 PM - Give NaCl 1tab TID - Faster fever relief
6:00 PM - Sodium supplementation,
- Start cerebrolysin 00000 correct Na deficiency
- Improves the efficiency of
1/06/2011 aerobic energy
2:55 PM metabolism in the brain,
improves the
7 PM - 50 cc plain NSS to intracellular protein
consume for 1 hour synthesis in the developing
please use soluset and aging brain.
- IVT TF with PNSS 1L @
30 gtts/min - Ensure accuracy of infusion
1/07/2011 - Give Lantus 5 “units”
- Hydration and fluid needs
5:25 PM - Give monrapid 6 “units”
- Long-acting insulin to control
hyperglycemia
- 4 units actuapid SQ - Rapid-acting insulin to control
before feeding hyperglycemia
- Give lantus 20 “units” SQ
before feeding - Rapid-acting insulin to control
hyperglycemia
- Control hyperglycemia
- Control hyperglycemia
DRUG STUDY
NURSING PRECAUTION:
1. Before giving the medication ask the client about allergic reactions
to penicillin, allergy is no guarantee.
2. If large dose are given, if therapy is prolonged bacteria or fungal
super infection may occur especially in elderly, debilitated or
immune suppressed patient.
NURSING PRECAUTION:
1. Use liquid form for children a patient’s who have difficulty
swallowing.
vomiting
URTI
Tonsilitis
Gastritis
EENT:
Impaired vision blind
Pain reddened drainage
Gums hard of hearing deaf
Burning edema lesion teeth
Assess eyes, ears, nose
Throat for abnormality no problem
RESP:
Asymmetric tachypnea
Apnea rales cough barrel chest
Bradypnea shallow rhoneht
Sputum diminished dyspnea
Orthopnea labored wheezing
Pain cyanotic
Assess resp. rate, rhythm, depth, pattern
Breath sound, comfort no problem
CARDIO VASCULAR:
Arrhythmia tachycardia numbness
Diminished pulse edema fatigue
Irregular bradycardia murmur
Tingling absent pulses pain
Assess heart sounds rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
No problem
GASTRO INTESTINAL TRACT:
Obese distention mass
Dysphagia rigidity pain
Assess abdomen, bowel habits, swallowing
Bowel sounds, comfort no problem
GENITO URINARY AND GYNE
pain urine color vaginal bleeding
Hematuria discharge noctoria
Assess urine freq., control, odor color, comfort/
Gyn-bleeding, discharge no problem
NEURO
Paralysis Stuporous unsteady seizures
Lethargic comatose vertigo tremors
Confused vision grip
Assess motor function, sensation, LOC, strength,
Grip,galt, coordination, orientation, speech
No Problem
MUSCULOSKELETAL AND SKIN
Appliance stiffness itching petechiae
Hot drainage prosthesis swelling
Lesion poor turgor cool deformity
Wound rash skin color flushed
Atrophy pain ecchymosis
Diaphoretic moist
Assess mobility, motion, gait, alignment, joint function
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
COMMUNICATION:
Hearing
Glasses Loss Comments __”wala man, clear
Language
Visual changes man ako panan-aw, ok ra pud
Contact lens
Denied akongHearing
pang dongod” as
aide
xR x L verbalized by the
Pupil Size ____3mm_____ pt.________________
Speech difficulties
Reaction _PERRLA_ __________________________
__________________________
OXYGENATION:
Dyspnea Comments _”nag ubo
Resp. Regular Irregular
Smoking history raman na siya tong nag
______________
Describe: chills siya–”24
__Normal, regular respiration ascpm_______
verbalized
by the pt.’s mother_____
________________________________________________
Cough ______________________
Sputum ________________________
R _R lung symmetrical to left _____________
Denied ________________________
L _L lung symmetrical to right____________
CIRCULATION:
Comments _”wala man pud ok
Heart
Chest
Rhythm
pain Regular Irregular
Leg pain raman ko” _ as verbalized by
Ankle the pt.__________________
Edema _N-O-N-E___________________________
Numbness of
Pulse Car.
extremities Rad. DP __________________________
Fem
Denied __________________________
__________________________
R _84 bpm +____84 bpm___+______+_______________
__________________________
L _84 bpm +____84 bpm___+______+_______________
Comments:_pt. have a normal heart__________________________
rhthm @ regular with nor-
mal and regulation pulsation site__________________________
(pulse & radical 84bpm)_____
*If applicable
NUTRITION:
DietDentures None
__soft diet__________________________
N V Comments _”ganahan man
Character Full Partial ko ug
With
eat Patient
” as _ verbalized
Recent change in by the pt.______________
Upper _______________________
weight, appetite
Swallowing difficulty _______________________
Lower _______________________
Denied
ELIMINATION:
Usual bowel_Patient
Comments pattern had a_ Urinary
Bowel frequency
sounds _Fair normal
___once
normal a day_____
bowel movement ___5-6 times
hypoactive / day
bowel _______
sound
pattern 1-2 day__________ Urgency
Constipation Abdominal
________________________ Dysuria Distention
remedy
_________________________ Present yes no
Hematuria
__N-O-N-E____
_________________________ Urine* (color, consistency,
Incontinence
_________________________ odor)
Polyuria
Date of last BM
_________________________ _Urinate 4-5 times per
_______________ day;
Folywith yellow aromatic
in place
_________________________
_________________________ urine__________________
Denied
Diarrhea
_________________________ _______________________
character
_________________________ _______________________
__N-O-N-E____
_________________________ *If they are in place?
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
Dry Cold Comments _”walaPale man ko nag
Dry
Flushed Warm katul katul” as ___ _______ _
Moist Cyanotic
verbalized by the pt._________
Itching
_________________________
*rashes, ulcers, decubitus (describe size,
____________________________
location, drainage) _Patient has a dry and pale skin
Other (scars)
____________________________
and warm to touch__________________________________
____________________________
Denied
______________________________________
____________________________
ACTIVITY/SAFETY:
LOC and orientation _Patient is conscious and coherent,
Convulsion and _”wala
Comments
oriented to time, day, and present man siya
past happening____
Dizziness
Gait: walker canenakaother
experience ana” as
Limited
Steady motion of
Unsteady _________
verbalized by the__ patient’s
joints and motor losses inmother
Sensory face or______________________
extremities _N-O-N-E
no Limitation
sensory and in motor losses____________________________
in faces and extremities___
ability to
___________________________________________________
____________________________
Ambulate
____________________________________________________
____________________________
ROMBath
limitation
self _Patient has ____________________________
limited movement especially
Other
@ the right arm in her IVF_________________________
____________________________
Denied
______________________________________________
____________________________
____________________________
COMFORT/SLEEP/AWAKE:
Pain
Facial grimaces Comments _”strsight straight
Guarding
(location man akong sleep” as verbalize
Other signs
frequency of pain __Patient is felt in pain @ the ® arm
by the patient______________
___________________in
remedies the IVF ___________________
___________________________
______________________________________________
____________________________
Nocturia
____________________________
Side rail
Sleep release form signed (60+ years)
difficulties
____________________________
Denied
____________________________________________________
____________________________
________________________
_______________________
COPING:
Occupation
Observed non-verbal behavior _Pt. giggles whenever I asked
_NONE______________________
him something____________________________________
Member of household ___3 Family Member___
_______________________________________
_____________________________________________________
_______________________________________
____________
Most
The person
supportive
and his
person
phone
____Eldanobe
number thatFecanAlbar__________
be reached any
time _elsalvador, CDOC
___________________________________________________
________________________________________ _______
________________________________________________
________________
_______________________
SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)
__________ Daily Weight __________ PT/OT _______________
___________ BP q Shift __________ Irradiation
__________ Neuro vs __________ Urine Test _____________
__________ CVP/SG. Reading _____ __________ 24 hour Urine Collection
INDEPENDENT
Encouraged patient to increase oral To maximize intake and replace fluid
intake. lost.
Monitor intake and output To be insensible to fluid loses to
Weigh client with the same clothe ensure accurate picture of fluid
and weighing scale. status.
To compare the recent and past
weight if client is losing to much
Monitor client’s vital sign. weigh.
To monitor client’s condition to check
if further complication occur.
INTERVENTION RATIONALE
INDEPENDENT
Determine the mother’s perception Establishing knowledge regarding
of disease process. the disease condition of her child .
Emphasize need for long-term Patients with IBD are at risk for
follow-up and periodic colon/rectal cancer, and regular
reevaluation. diagnostic evaluations may be
required..
Dependent:
In the case of Jurey, Immediate intervention was given because Jurey was
admitted to the Sabal Hospital after experiencing loss bowel movement and
vomiting. History was taken to document the onset and frequency of diarrhea.
Exposure to contaminated food or water is initiated with the patient where
drinking water might be contaminated. Physical examination helps the physician
to identify underlying systemic disease. The doctor ordered for some diagnostic
tests to find the cause of diarrhea which include the fecalysis where positively
amoebiasis was detected. Urinalysis and hemochrome was also ordered to
provide more specific data.
XI. REFERRALS:
No one can escape from having this kind of disease Children are very
susceptible to illness that is why I imparted knowledge to Mrs. Tumacas to
continue giving nutritious foods, and vitamins. As much as possible report to the
physician immediately if there are any unusualities may observe because
diarrhea can be dangerous in newborns and infants. Children, especially those
younger than 6 months of age and those with other health risks, need special
attention when they have diarrhea because they can become dehydrated.
Because a child can die from dehydration within a few days, the main treatment
for diarrhea in children is dehydration. Quickly Careful observation of the child's
appearance and how much fluid he or she is drinking can help prevent problems.
And lastly I told her to follow-up the rural health center for his complete
immunization.
XII. BIBLIOGRAPHY:
>://www.google.com/search?
hl=en&q=case+study+acute+gastroenteritis&btnG=Search
>Smeltzer, S, et al Medical-Surgical Nursing. 10th Edition Lippincott Williams and
Wilkins (2004)