RATIONALE

For all individuals, mental, physical and social healths are vital and interwoven strands of life. As our understanding of this relationship grows, it becomes ever more apparent that mental health is crucial to the overall well-being of individuals, societies and countries. The leukodystrophies are rare diseases that affect the cells of the brain. Specifically, the diseases affect the myelin sheath, the material that surrounds and protects nerve cells. Damage to this sheath slows down or blocks messages between the brain and the rest of the body. This leads to problems with movement, speaking, vision, hearing, mental and physical development. Acute Gastroenteritis is common in children and in developing countries. It is marked by inflammation of the gastrointestinal tract involving both the stomach and small intestine resulting in diarrhea, vomiting and abdominal cramps. In the pediatric population acute gastroenteritis remains a significant cause of pediatric patient morbidity and mortality. For these patients, oral rehydration therapy is an intervention that should be initiated with the first signs and symptoms. Hand washing is the most basic practice in preventing infection. Gastrointestinal infections are infectious diseases that can spread from one person to another by contaminated hands. Washing hands properly after using the toilet, handling animals and before and after handling food helps prevent a range of diseases, including various forms of gastroenteritis. Some forms of gastroenteritis can cause serious complications, especially for young children, the elderly, or those with a weakened immune system. Our group has been exposed to Holy Child Ward for our Pediatric rotation. In our three weeks duty we are expected to have a client as a subject for case study. We chose our client V.C. because he was having a condition that is new to us. He was diagnosed with leukodystrophy, acute gastroenteritis with mild dehydration. Our group wants to have a case that is not common to challenge us and to learn new things. We want to have a case that will practice our research abilities. Our patients parents were very cooperative and they permitted us that their child will be the subject of our case study.

Mental and neurological disorders are highly prevalent worldwide. The Global Burden of Disease report drew the attention of the international health community to the fact that the burden of mental and neurological disorders has been seriously underestimated by traditional epidemiological methods that took into account only mortality, but not disability

rates. This report specifically showed that while the mental and neurological disorders are responsible for about one per cent of deaths, they account for almost 11 per cent of disease burden the world over. (www.who.int) In the Philippines there is an extrapolated prevalence of 862 all in the estimated population used which is 86,241,697. (www.rightdiagnosis.com)
Worldwide, Acute Gastroenteritis (AGE) provokes an estimated 125 million physician visits, 9 million hospital admissions and 1.8 million annual deaths in children less than 5 years of age. Although worldwide mortality from this illness remains a significant challenge, pediatric death rates from diarrheal illnesses have recently been substantially reduced, largely secondary to worldwide campaigns for treatment of affected children with oral rehydration therapy. (www.medscape.com) In the Philippines there are 562 cases of AGE in male and 449 in female, there is a total of 1,038 in both sexes having Acute gastroenteritis in 100,000 population and a percentage of 12.18 in the year 2006. (www.doh.gov.ph) Diarrhea and Gastroenteritis are one of the leading causes of morbidity in all ages here in Davao City. There are 4,205 reported cases in 100,000 populations with a rate of 310.7 last 2010 according to the City Health Office. (www.davaohealth.brinkster.net) In the context of nursing education this study can contribute new learning regarding patients having leukodystrophy and acute gastroenteritis. This study is significant in nursing research because it trains us to become better researchers whose study could be of good use at present and future studies. Furthermore this study enables us to know and learn new information that will be of help to us in the future. This case study can be used as a data for research and future reference. By having this case study it practices our ability in doing research and it also gains us new learning.

OBJECTIVES
General objectives After a 3-week span of pediatric rotation; our group the BSN 2a group3 subgroup1 of San Pedro College starting to learn more about pediatric patients by finishing our case study that will also improve our knowledge, skills, and attitude.

Specific objectives 1. Formulate specific, measurable, attainable, realistic and time-bounded goals and objectives for this study; 2. select a suitable client for our pediatric concept; 3. establish an environment with good working and therapeutic relationship as well as trust with the patient and with his significant others; 4. gather necessary data about the patients recent condition as well as his health history; 5. trace the clients family history up to the 3rd generation; 6. discuss the patients developmental data according to Erik Erikson and Robert Havighursts theories; 7. define the diagnosis of the patients condition; 8. perform a cephalocaudal and neurological assessment to determine the patients current condition; 9. present the Anatomy and Physiology of the systems involved in the condition of the patient; 10. list down the actual diagnostic examinations of our client; 11.present all the medications given and administered to the patient; 12. enumerate the medical management rendered to the patient upon hospitalization 13. identify specific needs of the patient and provide specific nursing interventions; 14.present recommendations and further health teachings pertinent to the patient and family; 15.evaluate the prognosis with its justification regarding the clients health condition in relation with compliance, age, environment and family support and;

16. list the references used in the completion of this case study.

ANATOMY AND PHYSIOLOGY

Overview of the Digestive System Overall, the digestive system performs six basic processes.

1. Ingestion. This process involves taking liquids and foods into the mouth.

2. Secretion. Process of producing a substance from the cells and discharging it. Each day, cells within the walls of the GI tract and accessory digestive organs secrete a total of about 7 liters of water, acid, buffers and enzymes into the lumen of the tract. 3. Mixing and propulsion. Alternating contractions and relaxations of the smooth muscle in the walls of the GI tract mix food and secretions and propel them towards the anus. This capability of the GI tract to mix and move material along its length is called motility.

4. Digestion. Mechanical and chemical processes break down ingested food into small molecules. In mechanical digestion the teeth cut and grind food before it is swallowed, and then smooth muscles of the stomach and small intestine churn the food. As a result, food molecules become dissolved and thoroughly mixed with digestive enzymes. In chemical digestion the large carbohydrate, lipid, protein and nucleic acid molecules in food are split into smaller molecules by hydrolysis. Digestive enzymes produce by the salivary glands, toungue, stomach, pancreas and small intestine catalyze these catabolic reactions. A few substances in food can be absorbed without chemical digestion. These include vitamins, ions, cholesterol and water.

5. Absorption. The entrance of ingested and secreted fluids, ions, and the products of digestion into the epithelial cells lining the lumen of the GI tract is called absorption. The absorbed substances pass into blood or lymph and circulate to cells throughout the body.

6. Defecation. Wastes, indigestible substances, bacteria, cells sloughed from the lining of the GI tract, and digested materials that were not absorbed in their journey through the digestive tract leave the body through the anus in a process call defecation. The eliminated material is termed feces.

THE MOUTH The mouth is the reservoir for the chewing and mixing of food with saliva. As food particles become smaller and move around in the mouth, the taste buds and olfactory nerves are continuously stimulated, adding to the satisfaction of eating. The tongues surface contains thousands of chemoreceptors, or taste buds, which can distinguish salty, sour, bitter and sweet tastes. Tastes and food odors help to initiate salivation and the secretion of gastric juice in the stomach. There are 32 permanent teeth in the adult mouth, and they are important for speech and mastication.

THE TONGUE The tongue is an accessory digestive organ composed of skeletal muscle covered with mucous membrane. On the upper surface of the tongue are small projections called papillae, many of which contain taste buds. Together with its associated muscles, it forms the floor of the oral cavity. The tongue is divided into symmetrical lateral halves by a median septum that extends its entire length, and it is attached inferiorly to the hyoid bone, styloid process of the temporal bone and mandible.

THE TEETH The teeth or dentes are accessory digestive organs located in sockets of the alveolar processes of the mandible and maxillae. The alveolar processes are covered by the gingivae or gums which extend slightly into each socket. The sockets are lined by the periodontal ligament or membrane, which consists of dense fibrous connective tissue that anchors the teeth to the socket walls.

SALIVATION The three pairs of salivary glands, the submandibular, sublingual, and parotid glands secrete about 1 L of saliva per day. Saliva consists mostly of water with mucus, sodium, bicarbonate, chloride, potassium, and salivary a-amylase (ptyalin), and enzyme that initiates carbohydrate digestion in the mouth and stomach.

SWALLOWING The esophagus is a hollow, muscular tube approximately 25cm long that conducts substances from the oropharynx to the stomach. Swallowed food is moved to the stomach by peristalsis, the sequential contraction and relaxation of outer longitudinal and inner circular layers of muscles. Each end of the esophagus is opened and closed by a sphincter. The upper esophageal sphincter keeps air from entering the esophagus during sphincter respiration. (cardiac The lower esophageal prevents sphincter)

regurgitation from the stomach.

ESOPHAGUS The esophagus is a muscular tube that takes food from the pharynx to the stomach; no

digestion takes place here. Peristalsis of the esophagus propels food in one direction and ensures that food gets to the stomach even if the body is horizontal or upside down. The esophagus is a collapsible muscular tube, about 25cm long, that lies posterior to the trachea. The esophagus begins at the inferior end of the laryngopharynx and passes through the mediastinum anterior to the vertebral column, then it pierces the diaphragm through and opening called the esophageal hiatus, and ends in the superior portion of the stomach protrudes above the diaphragm through the esophageal hiatus.

STOMACH The stomach is a J-shaped enlargement of the GI tract directly inferior to the diaphragm in the epigastric, umbilical and left hypochondriac regions of the abdomen. The stomach connects the esophagus to the duodenum, the first part of the small intestine. Because a meal can e eaten much more quickly than the intestines can digest and absorb it. The stomach has four main regions: the cardia, fundus, body and pylorus. The cardia surrounds the superior opening of the stomach. The rounded portion superior to and to the left of the cardia is the fundus. Inferior to the fundus is the large central portion of the stomach called the body. The region of the stomach that connects to the duodenum is the pylorus; it has two parts, the pyloric antrum which connects to the body of the stomach, and the pyloric canal, which leads into the duodenum. When the stomach is empty, the mucosa lies in large folds called rugae. The pylorus communicates with the duodenum of the small intestine via a sphincter called the pyloric sphincter. The concave medial border of the stomach is called the lesser curvature and the convex lateral border is called the greater curvature.

PANCREAS

The pancreas is located in the upper left abdominal quadrant between the curve of the duodenum and the spleen and is about 6 inches (15 cm) in length. The exocrine glands of the pancreas are called acini. They produce enzymes that are involved in the digestion of all three types of complex food molecules. The pancreatic enzyme amylase digests starch to maltose. Lipase converts emulsified fats to fatty acids and glycerol. Trypsinogen is an inactive enzyme that is changed to active trypsin in the duodenum. Trypsin digests polypeptides to shorter chains of amino acids.

SMALL INTESTINE The major events of digestion and absortion occur in a long tube called small intestine. Its length alone provides a large surface area for digestion and absorption and that area is further increased by circular folds, villi and microvilli. The small intestine ifs dived into 3 regions. It is composed of duodenum, jejunum and ileum.

LARGE INTESTINE The large intestine is the terminal portion of the GI tract. The overall functions of the large intestine are the completion of absortion, the production of certain vitamins, the formation of feces, and the expulsion of feces from the body. It is about 1.5m long and 6.5cm in diameter, extends form ileum to anus. It is attached to the posterior abdominal wall by its mesocolon, which is a double layer of a peritoneum. Structurally the four major regions of the large intestine are the cecum, colon, rectum and anal canal.

Summary
The processes of the digestion of food and the absorption of nutrients enable the body to use complex food molecules for many purposes. Much of the food we eat literally becomes part of us. The body synthesizes proteins and lipids for the growth and repair of tissues and produces enzymes to catalyze all of the reactions that contribute to homeostasis. Some of our food provides the energy required for growth, repair, movement, sensation, and thinking. In the next chapter we will discuss the chemical basis of energy production from food and consider the relationship of energy production to the maintenance of body temperature.

Overview of the Nervous System The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body.

Nerve Cells
Neurons Neurons can be distinguished from other cells in a number of ways, but their most fundamental property is that they communicate with other cells via synapses, which are membrane-to-membrane junctions containing molecular machinery that allows rapid transmission of signals, either electrical or chemical Many types of neuron possess an axon, a protoplasmic protrusion that can extend to distant parts of the body and make thousands of synaptic contacts. Axons frequently travel through the body in bundles called nerves. a. Dendrites- are the branched projections of a neuron that act to conduct the electrochemical stimulation received from other neural cells to the cell body, or soma, of the neuron from which the dendrites project.

b. Soma- is the central part of the neuron. It contains the nucleus of the cell, and therefore is where most protein synthesis occurs. The nucleus ranges from 3 to 18 micrometers in diameter. c. Axon- is a finer, cable-like projection that can extend tens, hundreds, or even tens of thousands of times the diameter of the soma in length. The axon carries nerve signals away from the soma (and also carries some types of information back to it). d. Axon terminal- contains synapses, specialized structures where neurotransmitter chemicals are released to communicate with target neurons.

Glial Cells
are non-neuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and participate in signal transmission in the nervous system. [9] In the human brain, it is estimated that the total number of glia roughly equals the number of neurons, although the proportions vary in different brain areas. A very important type of glial cell (oligodendrocytes in the central nervous system, and Schwann cells in the peripheral nervous system) generates layers of a fatty substance called myelin that wraps around axons and provides electrical insulation which allows them to transmit action potentials much more rapidly and efficiently.

2 Parts of the Nervous System 1. Central Nervous System

The central nervous system (CNS) is the largest part, and includes the brain andspinal cord. The spinal cavity contains the spinal cord, while the head contains the brain. The CNS is enclosed and protected by meninges, a three-layered system of membranes, including a tough, leathery outer layer called the dura mater. The brain is also protected by the skull, and the

spinal cord by the vertebrae. Its main job is to get the information from the body and send out instructions. Brain The brain keeps the body in order. It helps to control all of the body systems and organs, keeping them working like they should. The brain also allows us to think, feel, remember and imagine. In general, the brain is what makes us behave as human beings. The brain communicates with the rest of the body through the spinal cord and the nerves. They tell the brain what is going on in the body at all times. This system also gives instructions to all parts of the body about what to do and when to do it. The brain is made of three main parts: the forebrain, midbrain, and hindbrain. The forebrain consists of the cerebrum, thalamus, and hypothalamus (part of the limbic system). The midbrain consists of the tectum and tegmentum. The hindbrain is made of the cerebellum, pons and medulla. Often the midbrain, pons, and medulla are referred to together as the brainstem. a. Ventricles- The ventricles are four cavities within the brain: two lateral ventricles, the third ventricle, and the fourth ventricle. Each ventricle contains a capillary network called a choroid plexus, which forms cerebrospinal fluid (CSF) from blood plasma. Cerebrospinal fluid is the tissue fluid of the central nervous system. b. Medulla- The medulla extends from the spinal cord to the pons and is anterior to the cerebellum. Its functions are those we think of as vital (as in vital signs). The medulla contains cardiac centers that regulate heart rate, vasomotor centers that regulate the diameter of blood vessels and, thereby, blood pressure, and respiratory centers that regulate breathing. e. Pons- bulges anteriorly from the upper part of the medulla. Within the pons are two respiratory centers that work with those in the medulla to produce a normal breathing rhythm. d. Midbrain- extends from the pons to the hypothalamus and encloses the cerebral aqueduct, a tunnel that connects the third and fourth ventricles.

e. Cerebellum- separated from the medulla and pons by the fourth ventricle and is inferior to the occipital lobes of the cerebrum. Many of the functions of the cerebellum are concerned with movement. f. Hypothalamus- Located superior to the pituitary gland and inferior to the thalamus, the hypothalamus is a small area of the brain. It produces the growth hormone releasing hormone (GHRH), antidiuretic hormone (ADH) and oxytocin. It regulates the body temperature and stimulates the visceral responses during emotional situations. It regulates the body rhythms such as secretion ofhormones, sleep cycles, changes in mood, or mental alertness. g. Thalamus- It is superior to the hypothalamus and inferior to the cerebrum. Many of the functions of the thalamus are concerned with sensation. h. Cerebrum- The largest part of the human brain is the cerebrum, which consists of two hemispheres separated by the longitudinal fissure. Cerebral cortex is the gray matter surface of the cerebrum. Frontal Lobes- are the motor areas that generate the impulses for voluntary movement. Parietal Lobes- The general sensory areas in the parietal lobes receive impulses from receptors in the skin and feel and interpret the cutaneous sensations. Temporal Lobes- The olfactory areas in the temporal lobes receive impulses from receptors in the nasal cavities for the sense of smell. Occipital Lobes- Impulses from the retinas of the eyes travel along the optic nerves to the visual areas in the occipital lobes. Basal Ganglia- are paired masses of gray matter within the white matter of the cerebral hemispheres. Their functions are certain subconscious aspects of voluntary movement, and they work with the cerebellum. Corpus Callosum- is a band of nerve fibers that connects the left and right cerebral hemispheres. Spinal cord

Nerves divide many times as they leave the spinal cord so that they may reach all parts of the body. The thickest nerve is 1 inch thick and the thinnest is thinner than a human hair. Each nerve is a bundle of hundreds or thousands of neurons (nerve cells). The spinal cord runs down a tunnel of holes in your backbone or spine. The bones protect it from damage. The cord is a thick bundle of nerves, connecting your brain to the rest of your body. Spinal Nerves There are 31 pairs of spinal nerves, those that emerge from the spinal cord. The nerves are named according to their respective vertebrae: 8 cervical pairs, 12 thoracic pairs, 5 lumbar pairs, 5 sacral pairs, and 1 very small coccygeal pair. Nerve Phrenic Radial Median Ulnar Intercostal Femoral Sciatic Spinal Nerves That Contribute C3C5 C5C8, T1 C5C8, T1 C8, T1 T2T12 L2L4 L4S3 Diaphragm Skin and muscles of posterior arm, forearm, and hand; thumb and first 2 fingers Skin and muscles of anterior arm, forearm, and hand Skin and muscles of anterior arm, forearm, and hand Intercostal muscles, abdominal muscles; skin of trunk Skin and muscles of anterior thigh, medial leg, and foot Skin and muscles of posterior thigh, leg and foot Distribution

Table 83 MAJOR PERIPHERAL NERVES

2. Peripheral nervous system

The peripheral nervous system (PNS) is a collective term for the nervous system structures that do not lie within the CNS. The large majority of the axon bundles called nerves are considered to belong to the PNS, even when the cell bodies of the neurons to which they belong

reside within the brain or spinal cord. The PNS is divided into somatic and visceral parts. The somatic part consists of the nerves that innervate the skin, joints, and muscles. The cell bodies of somatic sensory neurons lie in dorsal root ganglia of the spinal cord. The visceral part, also known as the autonomic nervous system, contains neurons that innervate the internal organs, blood vessels, and glands. The autonomic nervous system itself consists of two parts: the sympathetic nervous system and the parasympathetic nervous system. Some authors also include sensory neurons whose cell bodies lie in the periphery (for senses such as hearing) as part of the PNS; others, however, omit them.

2 Areas of the Nervous System

Grey matter (which is only grey in preserved tissue, and is better described as pink or light brown in living tissue) contains a high proportion of cell bodies of neurons. White matter is composed mainly of myelinated axons, and takes its color from the myelin. White matter includes all of the nerves, and much of the interior of the brain and spinal cord. Grey matter is found in clusters of neurons in the brain and spinal cord, and in cortical layers that line their surfaces. There is an anatomical convention that a cluster of neurons in the brain or spinal cord is called a nucleus, whereas a cluster of neurons in the periphery is called a ganglion. There are, however, a few exceptions to this rule, notably including the part of the forebrain called the basal ganglia.

Meninges and Cerebrospinal Fluid

Meninges- the connective tissue membranes that cover the brain and spinal cord. a. dura mater- the thick outermost layer, made of fibrous connective tissue, which lines the skull and vertebral canal. b. arachnoid membrane- is in the middle which is made of web-like strands of connective tissue. c. pia mater in the innermost part which is the very thin membrane on the surface of the spinal cord and brain.

Cranial Nerves
The 12 pairs of cranial nerves emerge from the brain stem or other parts of the brain. The name cranial indicates their origin, and many of them do carry impulses for functions involving the head. Some, however, have more far-reaching destinations.

Number and Name I Olfactory II Optic III Oculomotor Sense of smell Sense of sight

Function(s)

Movement of the eyeball; constriction of pupil in bright light or for near vision

IV Trochlear V Trigeminal VI Abducens VII Facial VIII Acoustic (vestibulocochlear) IX Glossopharyngeal

Movement of eyeball Sensation in face, scalp, and teeth; contraction of chewing muscles Movement of the eyeball Sense of taste; contraction of facial muscles; secretion of saliva Sense of hearing; sense of equilibrium

Sense of taste; sensory for cardiac, respiratory, and blood pressure reflexes; contraction of pharynx; secretion of saliva

X Vagus

Sensory in cardiac, respiratory, and blood pressure reflexes; sensory and motor to larynx (speaking); decreases heart rate; contraction of alimentary tube (peristalsis); increases digestive secretions

XI Accessory

Contraction of neck and shoulder muscles; motor to larynx (speaking)

XII Hypoglossal

Movement of the tongue

Autonomic Nervous System

The autonomic nervous system (ANS) is actually part of the peripheral nervous system in that it consists of motor portions of some cranial and spinal nerves. Two divisions: a. sympathetic- Another name for the sympathetic division is thoracolumbar division. The sympathetic division is dominant in stressful situations, which include anger, fear, or anxiety, as well as exercise. b. parasympathetic- The other name for the parasympathetic division is the craniosacral division. The parasympathetic division dominates in relaxed (non-stress) situations to promote normal functioning. of several organ systems. Digestion will be efficient, with increased secretions and peristalsis; defecation and urination may occur; and the heart will beat at a normal resting rate. Neurotransmitters It enables nerve impulses to cross synapses. Acetylcholine is the transmitter released by all preganglionic neurons, both sympathetic and parasympathetic; it is inactivated by cholinesterase in postganglionic neurons.

Summary
The nervous system regulates many of our simplest and our most complex activities. The impulses generated and carried by the nervous system are an example of the chemical level of organization of the body. These nerve impulses then regulate the functioning of tissues, organs, and organ systems, which permits us to perceive and respond to the world around us and the changes within us.

PATHOPHYSIOLOGY

Intestinal Flora

Antibiotic

Harmful Bacteria and

Causes damage and inflammation through invading and destroying Bleeding and

Releases

Stimulates mucosal lining of Greater secretion of water and electrolytes in the Active secretion of sodium carbonate and Inhibits reabsorption of Large amounts of protein rich fluids are secreted into

Balance excess Overwhelming of large bowels ability to Diarrhe

REFERENCES
Ackley, Betty J. (2009); Medical-Surgical Nursing: Clinical Management for Positive Outcomes; 8th edition; St. Louis, Missouri; Elsevier Inc. Black, Joyce M. (2008); Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care; St. Louis Missouri; Mosby Inc. Scanlon, Valerie (2007); Essentials of Anatomy and Physiology; 5th edition; Arch Street Philadelphia; F.A. Davis Company Woolley, Wendy L. (2009); retrieve on February 28, 2012 from www.medscape.com