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INTRODUCTION
Acute gastroenteritis could be more simply called a long, and potentially lethal
bout of stomach flu. The most common symptoms are diarrhea, vomiting and
stomach pain, because whatever causes the condition inflames the gastrointestinal
tract. Acute gastroenteritis is quite common among children, though it is certainly
possible for adults to suffer from it as well. While most cases of gastroenteritis last a
few days, acute gastroenteritis can last for weeks and months.
When a person does not recover from stomach flu symptoms within a day or
so, it is usually a good idea to see a doctor. Some types of acute gastroenteritis will
not resolve without antibiotic treatment, especially when bacteria or exposure to
parasites are the cause. Physicians may want to diagnose the cause by analyzing a
stool sample, when stomach symptoms remain problematic.
Admission Data
Chief Complaint: Cough and cold
Admitting Diagnosis: AGE w. some signs of dehydration
Attending Physician: Dr. Reyes
III. Patient History/ Nursing History
Sleep – Rest The sleep pattern The patient’ s sleep The patient sleep
Pattern of the patient is pattern is normal. and rest is enough.
normal.
Role – Relationship The patient is living The patient is living The patient cares fo
Pattern with his parents. with his parents his mother but he
doesn’t have
enough money to
support his mother.
AREAS FINDINGS
1. PHYSICAL
1.1 Head Normocephalic, (-) headache, (-)
dizziness, (-) head injury
1.2 Eyes Symmetrical, (-) discharge
1.3 Ears Symmetrical, (-) discharge
1.4 Nose Symmetric and straight, (-) discharge, (-)
nosebleeds
1.5 Mouth and Throat (-) bleeding gums, tongue in central
position, tongue moves freely,
1.6 Neck Head centered, (-) lumps, (+) stiffness in
neck
1.7 Breast and Auxiliary (-) pain, (-) lumps
1.8 Chest Chest symmetric, skin intact, (-) pain
1.9 Abdomen (-) abdominal pain
1.10 Extremities (-)weakness
1.11 Skin (-)itchy
1.12 Hair hair evenly distributed,
1.13 Nails short fingernails, smooth texture
1.14 Respiratory (+) cough
1.15 Cardiovascular (-) chest pain
1.16 Gastrointestinal Tract (-) bowel movement on day of PE
1.17 Urinary Frequently urinating 7× a day
1.18 Musculoskeletal (+)weakness on lower extremities
1.19 Neurologic Recognizes common object
1.20 Cranial Nerves
1.20.1 Olfactory Can identify different smell such as
alcohol and orange
1.20.2 Optic
1.20.3 Occulomotor Eyes can move freely
1.20.4 Trochlear Eyes can move freely. Can look upward
and downward
1.20.5 Trigeminal Patient was able to clench his teeth and
determine different sensation applied on
her face
1.20.6 Abducen Eyes can move laterally
1.20.7 Facial Can smile, lift eyebrows, close eyes
1.20.8 Auditory She was able to repeat words accurately,
able to hear
1.20.9 Glosopharyngeal Able to swallow, gag reflex present
1.20.10 Vagus Able to swallow
1.20.11 Accesory Can rotate the head
1.20.12 Hypoglossal Able to move her tongue
VI. ANATOMY & PHYSIOLOGY
Liver- is a vital organ present in vertebrates and some other animals. It has a wide
range of functions, including detoxification, protein synthesis, and production of bio
chemicals necessary for digestion. The liver is necessary for survival; there is
currently no way to compensate for the absence of liver function.
Gallbladder- is a small organ that aids digestion and stores bile produced by
the liver. In humans the loss of the gallbladder is usually easily tolerated.
Large intestine- s the second to last part of the digestive system the final stage of the
alimentary canal is the anus in vertebrate animals. Its function is to absorb water
from the remaining indigestible food matter, and then to pass useless waste
material from the body. This article is primarily about the human gut, though the
information about its processes are directly applicable to most mammals.
Stomach- is a muscular, hollow, dilated part of the alimentary canal which functions
as the primary organ of the digestive tract. It is involved in the second phase
of digestion, following mastication (chewing). The stomach is located between
the esophagus and the small intestine.
Small intestine- is the part of the gastrointestinal tract (gut) following the
stomach and followed by the large intestine, and is where the vast majority
of digestion and absorption of food takes place. In invertebrates such as worms, the
terms "gastrointestinal tract" and "large intestine" are often used to describe the
entire intestine. This article is primarily about the human gut, though the information
about its processes are directly applicable to most mammals. ( A major exception to
this are cows; for information about digestion in cows and other similar mammals,
see ruminants.)
Differential count
Neutrophil 0.51- 0.67 0.48
Lymphocyte 0.25- 0.33 0.46
Monocyte 0.02- 0.06 0.04
Eusinophil 0.01- 0.03 0.02
Stool Examination
Physical
Color brown
Consistency Loose
Microscopic
Pus cells 0- 1/ HPF
Red Blood Cells 0- 2/ HPF
Others: No ova or parasite seen
Urinalysis
Physical
Color yellow
Transparency Hazy
PH 5.0
Spec. Gravity 1.025
Microscopic
Pus cells 0- 2/ HPF
RBC 0- 1/ HPF
Epithelial cells: rare
XII. Discharge Planning
T- Treatment after discharge is expected for patients and watcher with Acute
Gastroenteritis
to fully participate in continuous treatment.
Gastroenteritis. Promotion of
personal hygiene should be encouraged such as, daily bathing and changing of
diapers
when soiled.
clients wather
with Acute Gastroenteritis as ordered by physician to ensure
the continuing management
and treatment.
D- Diet should be promoted, since, during admission, the patient was on NPO.
Proper
selection of milk that are suitable for babies will help enhance immunity
EMILIO AGUINALDO COLLEGE
School of Nursing and Midwifery
Congressional Road Burol Main, Dasmariñas, Cavite
(046) 416-4340, (046) 416-4341
Case Presentation
Acute Gastro Enteritis
Submitted by:
Lea Gizelle A. Poblete
BSNIV-2
Group3
Submitted to:
Mrs. Wendy Lyn Trasporto