Chapter 1: Assessment

A. Nursing Health History

Bio Data:

Name: Walastik!!! Age: 4 mos. old

Sex: Male Weight : 5.2 kgs.

Birthdate: November 12, 2011 Address: Saguin, San Fernando

Nationality: Filipino

Present Health History

One week prior to admission, patient experienced on and off fever,

no consultation and medicines given to the patient at home. Until 3 days prior to
admission patient was positive of several episodes of LBM, yellowish to greenish in
color, mucoid, non blood streaked and positive fever again no consultation done. Upon
admission, the patient experienced 2 episodes of upward rolling of eyeballs with cycling
motion of extremities at the ER. With admitting vital signs of CR- 140bpm, RR- 58cpm,
Temp- 36.4˚C.

Review of System

Psychosocial

Patient was conscious but lethargic as observed. Therefore, communicating is

difficult to achieve.

Elimination

In medical history patient vomits 3-5 times a day and defecated more than 6

times a day with watery stool.
Rest & Sleep

Patient is having adequate sleep to replenish energy being depleted due to

dehydration and illness.

Spiritual

Patient is spiritually guided by the family with encouragement and motivation.

Oxygenation

Patient is given adequate room ventilation. Oxygen therapy is ready to be

provided if necessary by the hospital.

Nutrition

Patient has capillary refill of five seconds, with poor skin turgor. His skin was
pale and dry. Patient has sunken eyeballs due to dehydration.

B. Physical Examination

Upon admission, patient was placed on NPO. Admitting weight was

5.2kg. Patient was lethargic as observed by NOD. Patient has capillary refill of
five seconds an untrimmed finger nails with poor skin turgor. His skin was pale and dry.
Patient has sunken eyeballs due to dehydration. In medical history patient vomits 3-5
times a day and defecated more than 6 times a day with watery stool.

C. Diagnostic Procedures

No specific diagnostic tests are required in most patients with simple

gastroenteritis. If symptoms including fever, bloody stool and diarrhea persist for two
weeks or more, examination of stool for Clostridium deficile may be advisable along with
cultures for bacteria including Salmonella, Shigella, Campylobacter and enterotoxic
Escherichia coli. Microscopy for parasites, ova and cysts may also be helpful.

A complete medical history may be helpful in diagnosing gastroenteritis. A

complete and accurate medical history of the patient includes information on travel
history, exposure to poisons or other irritants, diet change, food preparation habits or
storage and medications. Patients who travel may be exposed to E. Coli infections or
parasite infections contacted from beverages or food. Swimming in contaminated water
or drinking from suspicious fresh water such as mountain streams or wells may indicate
infection from Giardia - an organism found in water that causes diarrhea.

1. Medical History Taking

The medical history or anamnesis of a patient is information gained by

a physician by asking specific questions, either of the patient or of other people who
know the person and can give suitable information (in this case, it is sometimes
called hetero-anamnesis), with the aim of obtaining information useful in formulating a
diagnosis and providing medical care to the patient. The medically relevant complaints
reported by the patient or others familiar with the patient are referred to as symptoms, in
contrast with clinical signs, which are ascertained by direct examination on the part of
medical personnel. Most health encounters will result in some form of history being
taken. Medical histories vary in their depth and focus. The information obtained in this
way, together with clinical examination, enables the physician to form
a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis
may be formulated, and other possibilities (the differential diagnoses) may be added,
listed in order of likelihood by convention. The treatment plan may then include further
investigations to clarify the diagnosis.

2. Stool Examination

Test procedure

 You will receive one or more sterile containers in which to collect your stool
sample at home.
 You defecate directly into the container and seal it. Your doctor will tell you if you
must collect more than one sample. You do not need to handle the stool, and it
need not be refrigerated.
 You deliver the stool sample to the doctor's office or laboratory within 12 hours.
  The sample is observed for evidence of parasites. A slide may be prepared for
microscopic examination.

After the test

 You are free to resume normal activities.

 If your test is positive, your doctor will recommend that members of your
household and other close contacts be tested as well.

Factors affecting results

Delay in submitting sample.

Interpretation

A positive test means that a particular parasite or its ova are present.

Advantages

 It's quick, painless, and inexpensive.

 It's simple but effective.

Disadvantages

 Some people find collecting and transporting the sample unpleasant.

 The parasite may be present but not show up in a particular sample.
D. Anatomy & Physiology

The gastro-intestinal (GI) tract (alimentary canal) is a continuous tube with two

openings, the mouth and the anus. It includes the mouth, pharynx, esophagus,
stomach, small intestine, and large intestine. Food passing through the internal cavity,
or lumen, of the GI tract does not technically enter the body until it is absorbed through
the walls of the GI tract and passes into blood or lymphatic vessels.

The treatment of food in the digestive system involves the following seven processes:

 Ingestion is the process of eating.

  Propulsion is the movement of food along the digestive tract. The major means of
propulsion is peristalsis, a series of alternating contractions and relaxations of
smooth muscle that lines the walls of the digestive organs and that forces food to
move forward.

 Secretion of digestive enzymes and other substances liquefies, adjusts the pH of,
and chemically breaks down the food.

 Mechanical digestion is the process of physically breaking down food into smaller
pieces. This process begins with the chewing of food and continues with the
muscular churning of the stomach. Additional churning occurs in the small
intestine through muscular constriction of the intestinal wall. This process, called
segmentation, is similar to peristalsis, except that the rhythmic timing of the
muscle constrictions forces the food backward and forward rather than forward
only.

 Chemical digestion is the process of chemically breaking down food into simpler
molecules. The process is carried out by enzymes in the stomach and small
intestines.

 Absorption is the movement of molecules (by passive diffusion or active

transport) from the digestive tract to adjacent blood and lymphatic vessels.
Absorption is the entrance of the digested food into the body.

 Defecation is the process of eliminating undigested material through the anus.

Mouth
The mouth plays a role in digestion, speech, and breathing. Digestion begins
when food enters the mouth. Teeth break down food and the muscular tongue pushes
food back toward the pharynx, or throat. Three salivary glands—the sublingual gland,
the sub-mandibular gland, and the parotid gland—secrete enzymes that partially digest
food into a soft, moist, round lump. Muscles in the pharynx swallow the food, pushing it
into the esophagus, a muscular tube that passes food into the stomach. The epiglottis
prevents food from entering the trachea, or windpipe, during swallowing.
Esophagus
The presence of food in the pharynx stimulates swallowing, which squeezes
the food into the esophagus. The esophagus, a muscular tube about 25 cm (10 in)long,
passes behind the trachea and heart and penetrates the diaphragm (muscular wall
between the chest and abdomen) before reaching the stomach. Food advances through
the alimentary canal by means of rhythmic muscle contractions (tightenings) known as
peristalsis. The process begins when circular muscles in the esophagus wall
contract and relax (widen) one after the other, squeezing food downward toward
the stomach. Food travels the length of the esophagus in two to three seconds.

A circular muscle called the esophageal sphincter separates the esophagus

and the stomach. As food is swallowed, this muscle relaxes, forming an opening
through which the food can pass into the stomach. Then the muscle contracts
closing the opening to prevent food from moving back into the esophagus. The
esophageal sphincter is the first of several such muscles along the alimentary canal.
These muscles act as valves to regulate the passage of food and keep it from
moving backward.
Stomach
The stomach, located in the upper abdomen just below the diaphragm, is a sac
like structure with strong, muscular walls. The stomach can expand significantly to store
all the food from a meal for both mechanical and chemical processing. The
stomach contracts about three times per minute, churning the food and mixing it with
gastric juice. This fluid, secreted by thousands of gastric glands in the lining of
the stomach, consists of water, hydrochloric acid, an enzyme called pepsin, and
mucin (the main component of mucus). Hydrochloric acid creates the acidic
environment that pepsin needs to begin breaking down proteins. It also kills
microorganisms that may have been ingested in the food. Mucin coats the stomach,
protecting it from the effects of the acid and pepsin. About four hours or less after a
meal, food processed by the stomach, called chyme, begins passing a little at a time
through the pyloric sphincter into the duodenum, the first portion of the small intestine.
Liver
The liver is the largest internal organ in the human body, located at the top of
the abdomen on the right side of the body. A dark red organ with a spongy texture,
the liver is divided into right and left lobes by the falciform ligament. The liver performs
more than 500 functions, including the production of a digestive liquid called bile that
plays a role in the breakdown of fats in food. Bile from the liver passes through
the hepatic duct into the gallbladder, where it is stored. During digestion bile passes
from the gallbladder through bile ducts to the small intestine, where it breaks down fatty
food so that it can be absorbed into the body. Nutrient-rich blood passes from the small
intestine to the liver, where nutrients are further processed and stored. Deoxygenated
blood leaves the liver via the hepatic vein to return to the heart.
Small Intestine
Most digestion, as well as absorption of digested food, occurs in the small
intestine. This narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of
the lower abdomen, extending about 6 m (20 ft) in length. Over a period of three to six
hours, peristalsis moves chyme through the duodenum into the next portion of the small
intestine, the jejunum, and finally into the ileum, the last section of the small intestine.
During this time, the liver secretes bile into the small intestine through the bile duct. Bile
breaks large fat globules into small droplets, which enzymes in the small intestine can
act upon. Pancreatic juice, secreted by the pancreas, enters the small intestine through
the pancreatic duct. Pancreatic juice contains enzymes that break down sugars
and starches into simple sugars, fats into fatty acids and glycerol, and proteins into
amino acids. Glands in the intestinal walls secrete additional enzymes that break down
starches and complex sugars into nutrients that the intestine absorbs. Structures called
Brunner’s glands secrete mucus to protect the intestinal walls from the acid effects of
digestive juices.

The small intestine’s capacity for absorption is increased by millions of finger like

projections called villi, which line the inner walls of the small intestine. Each villus is
about 0.5 to 1.5 mm (0.02 to 0.06 in) long and covered with a single layer of cells. Even
tinier fingerlike projections called microvilli cover the cell surfaces. This combination of
villi and microvilli increases the surface area of the small intestine’s lining by about 150
times, multiplying its capacity for absorption. Beneath the villi’s single layer of cells are
capillaries (tiny vessels) of the bloodstream and the lymphatic system. These capillaries
allow nutrients produced by digestion to travel to the cells of the body. Simple sugars
and amino acids pass through the capillaries to enter the bloodstream. Fatty
acids and glycerol pass through to the lymphatic system.
Large Intestine
A watery residue of indigestible food and digestive juices remains
unabsorbed. This residue leaves the ileum of the small intestine and moves by
peristalsis into the large intestine, where it spends 12 to 24 hours. The large
intestine forms an inverted U over the coils of the small intestine. It starts on the lower
right-hand side of the body and ends on the lower left-hand side. The large intestine is
1.5 to 1.8 m (5 to 6 ft) long and about 6 cm (2.5 in) in diameter.
The large intestine serves several important functions. It absorbs water—about 6
liters (1.6 gallons) daily—as well as dissolved salts from the residue passed on
by the small intestine. In addition, bacteria in the large intestine promote the breakdown
of undigested materials and make several vitamins, notably vitamin K,
which the body needs for blood clotting. The large intestine moves its remaining
contents toward the rectum, which makes up the final 15 to 20 cm (6 to 8 in) of the
alimentary canal. The rectum stores the feces—waste material that consists largely of
undigested food, digestive juices, bacteria, and mucus—until elimination. Then, muscle
contractions in the walls of the rectum push the feces toward the anus. When sphincters
between the rectum and anus relax, the feces pass out of the body.
E. Pathophysiology & Disease Process

Entrant of Pathogens by Mouth

Endotoxins release of pathogens

Causing damage & inflammation

Stimulation of mucosal lining

(greater secretion of water & electrolytes to intestinal lumen)

Sodium Active secretion of chloride & bicarbonate

Re-absorption Ions in small intestine

Large amounts of protein rich fluids

are secreted into the bowel
(To balance excess sodium)

Large bowel’s ability to reabsorb

the fluid is overwhelmed

Diarrhea
 (Pathogens also cause damage and inflammation by invading & destroying the
mucosal lining of the bowel, resulting in bleeding & ulceration.)

 When the integrity of the GI tract is impaired, its ability to carry out digestive &
absorptive functions can be affected.

Chapter 2: Planning

A. List of Prioritized Nursing Diagnosis

Nursing Diagnosis: Interventions Rationale

1. Fluid volume deficit Maintained accurate For evaluative purposes.

related to illness Intake and Output
(AGE), as evidenced
by dehydration.
Monitored v/s, comparing In order to monitor progress
with patient’s normal/ or severity of dehydration.
previous readings

Administered fluids as To replenish fluid &

indicated electrolytes lost by the
body.

2. Nutritional imbalance Maintain I&O For evaluative purposes of

related to inability to the progress or severity of
absorb nutrients the illness.
(AGE), as evidenced
by loss of body Provide adequate nutrition To replenish & correct
weight. nutritional imbalance.
 Provide medications as As per doctor’s order to
prescribed hasten cure.

3. Activity intolerance Monitor Vital signs For evaluative purposes of

related to illness the illness.
(dehydration, fluid
imbalance, & Educate patient the need In order to understand
malnutrion) as for rest & relaxation importance of R&R and its
evidenced by easy importance to the situation.
fatigability.
Provide adequate bed rest To replenish energy and
hasten cure.

B. Treatment
 The treatment of gastroenteritis is aimed at hydration and home remedies that
address keeping fluid in the body are key to recovery.

Since most causes of gastroenteritis are due to viruses, replacing the fluid lost
because of vomiting and diarrhea allows the body to recuperate and fight the infection.
Dehydration can also intensify the symptoms of nausea and vomiting. The critical step
is replacing fluids when the affected individual is nauseous and doesn't want to drink
(hydrate). This is especially difficult with infants and children. Small frequent offerings of
clear fluids, sometimes only a mouthful at a time, may be enough to replenish the
body's fluid stores and prevent an admission to the hospital for intravenous (IV) fluid
administration.

In general, clear fluids (anything you can see through), may be tolerated in small
amounts. Think of it as adding just an ounce or less to the saliva that the patient is
already swallowing. However, giving too much fluid at one time may cause increased
nausea due to a distended stomach, which causes additional irritation.

Clear fluids do not include carbonated beverages but colas or ginger ale with the
fizz gone is often well tolerated. Coke syrup may also be helpful in settling the stomach.

Jello and popsicles may be "solid food" alternatives to clear fluids in children who
aren't interested in clear fluids.

Dehydration in children

Oral rehydration therapy using balanced electrolyte solutions such as Pedialyte

or Gatorade/Powerade may be all that is needed to replenish the fluid supply in an
infant or child. Plain water is not recommended because it can dilute the electrolytes in
the body and cause complications such as seizures due to low sodium.

The key to oral rehydration is small frequent feedings. If offered free access to a
bottle, infants especially may drink quickly to quench their thirst and then vomit. Instead
it may be best to limit the amount of fluid given at one time. There are a variety of
regimens that are used and they follow a basic format:
 Offer 1/3 of an ounce (5 to 10 cc) of fluid at one time. Wait 5 to 10 minutes then
repeat. 

 If this amount is tolerated without vomiting, increase the amount of fluid to 2/3 of
an ounce (10 to 20 cc). Wait and repeat.

 If tolerated, increase the fluid offered to 1 ounce (30 cc) at a time.

 If vomiting occurs, go back to the 1/3 of an ounce (5 to 10 cc) and restart.

 Once the child is tolerating significant fluids by mouth, a more solid diet can be
offered.

The important thing to remember is that the goal is to provide fluid to the child
and not necessarily calories. In the short term, hydration is more important than nutrition.

For infants and children, fluid status can be monitored by

 whether they are urinating, 

 if they have saliva in their mouths, 

 tears in their eyes, and 

 sweat in their armpits or groin.

If the child's baseline weight is known, dehydration can be measured by

comparing weight.

Medical care should be accessed immediately, if the child is listless, floppy or

does not seem to be acting like they normally do.

Dehydration in adults
 Although adults and adolescents have a larger electrolyte reserve than children,
electrolyte imbalance and dehydration may still occur as fluid is lost through vomiting
and diarrhea. Severe symptoms and dehydration usually develop as complications of
medication use or chronic diseases such as diabetes or kidney failure; however,
symptoms may occur in healthy people.

 Clear fluids are appropriate for the first 24 hours to maintain adequate
hydration. 

 After 24 hours of fluid diet without vomiting, begin a soft-bland solid diet such as
the BRAT diet (bananas, rice, apples, toast) and then progress the diet to other foods
as tolerated.

Gastroenteritis Medical Treatment

Upon seeking medical attention, if the patient cannot take fluids by mouth
because of vomiting, the health care practitioner may insert an IV replace fluid back into
the body (rehydration).

In infants, depending upon the level of dehydration, intravenous fluids may be

delayed to consider trying oral rehydration therapy. Frequent feedings, as small as a 1/6
ounce (5 cc) at a time, may be used to restore hydration.

Gastroenteritis Medications

Antibiotics are usually not prescribed until a bacteria or parasite has been
identified as the cause of the infection. Antibiotics may be given for certain bacteria,
specifically Campylobacter, Shigella, and Vibrio-cholerae, if properly identified through
laboratory tests. Otherwise, using any antibiotic or the wrong antibiotic can worsen
some infections or make them last longer.

Antibiotics are not used to treat virus infections.

 Some infections, such as salmonella, are not treated with antibiotics. With
supportive care of fluids and rest, the body is able to fight and resolve the infection
without antibiotics.

For adults, the health care practitioner may prescribe medications to stop the
vomiting (anti-emetics) such as promethazine (Phenergan, Anergan), prochlorperazine
(Compazine), or ondansetron (Zofran). Sometimes these medications are prescribed as
a suppository. Doctors usually do not recommend anti-emetics for infants, but
depending upon the situation, older children may be prescribed an antiemetic (anti-
nausea) medication in a lower dosage.

Anti-diarrhea medications are not usually recommended if the infection is

associated with a toxin that causes the diarrhea. The most common anti-diarrheal
agents for people older than 3 years of age include over-the-counter (OTC) medications
such as diphenoxylate atropine (Lomotil, Lofene, Lonox) or loperamidehydrochloride
(Imodium).

Chapter 4 Evaluation

A. Narrative Evaluation of actual Nursing. Problems

Goal partially met. Nursing problems were monitored, evaluated & managed but
were just partially returned to normal values due to insufficient duty time.

B. DISCHARGE PLAN
Clients with Acute Gastroenteritis, watchers are instructed to take the following plan for
discharge:
M - Medications should be taken regularly as prescribed, on exact dosage, time, &
frequency, making sure that the purpose of medications is fully disclosed by the health
care provider.
E- Exercise should be promoted in a way by stretching hand and feet every
morning and exercise burping every after bottle feeding.
T - Treatment after discharge is expected for patients and watcher with Acute
Gastroenteritis to fully participate in continuous treatment.
H - Hygiene must be maintained for patients with Acute Gastroenteritis. Promotion of
personal hygiene should be encouraged such as, daily bathing and changing of diapers
when soiled.
O - OPD such as regular follow-up check-ups should be greatly encouraged to clients
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.
In partial fulfillment in the course requirement in

Nursing Care Management 104

(Related Learning Experience)

A CASE STUDY OF

ACUTE GASTROENTERITIS

Submitted By:

Agent J

Submitted To:

The Nutty Professor

Submitted On:

2012

F U Zoo Shit!!!!