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Table of Contents
I
A Introduction
B Objectives of the study
C Scope and Limitation
II Patientrsquos profile
III Health history
IV Developmental data
o PSYCHOSOCIAL THEORY OF ERIK ERICKSON
o COGNITIVE THEORY OF JEAN PIAGET
o FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
V Medical Management
A Doctorrsquos Order with Rationale
B Laboratory Resultsignificance
VI Pathophysiology with Anatomy and Physiology
A Anatomy and Physiology
B Pathophysiology
VII Nursing Assessment(system review chart)
VIII Nursing Management
IX Health teachings
X Prognosis
XI Referrals and follow up
XII Evaluation
XIII Implication
XIV Bibliograph
Introduction
Nursing involves an interrelationship of many people concerned with a
clientrsquos responses to potential or actual problems Health is changing evolving
concept that is basic to nursing For centuries the concept of disease was the
yardstick by which was measured Now there is an increasing emphasis on
health and wellness Most people want to be healthy and feel a sense of loss
when they are not
In the case of our patient who is suffering from acute gastroenteritis (AGE)
the etiology is to determine it is said that unlike other abdominal disorder AGE is
the most occurring abdominal dysfunction especially among the children It is
most often results from any non-inflammatory or inflammatory infection of the
colon or either in the upper part of the small bowel It can range from mild
dysfunction to severe complication and the most common is dehydration due to
diarrheal reaction of the body
Usually this is caused by an infection[2] but this is not always the case It
usually is of acute onset normally lasting less than 10 days and self-limiting
Sometimes it is referred to simply as gastro It is often called the stomach flu or
gastric flu even though it is not related to influenza
Bacterial gastroenteritis is frequently a result of poor sanitation the lack of
safe drinking water or contaminated food-conditions common in developing
nations Natural or man-made disasters can make underlying problems in
sanitation and food safety worse In developed nations the modern food
production system potentially exposes millions of people to disease-causing
bacteria through its intensive production and distribution methods Common
types of bacterial gastroenteritis can be linked
to Salmonella andCampylobacter bacteria however Escherichia coli 0157
and Listeria monocytogenes are creating increased concern in developed
nations Cholera and Shigella remain two diseases of great concern in
developing countries and research to develop long-term vaccines against them
is underway
Non-bacterial gastroenteritis is a syndrome that affects a broad
segment of the population throughout the world Several studies have
proved that causative agents could be established only in about 30
of cases[3] and it leads to the suggestion that the virus may be the
aetiological agent Rota virus has been reported as the commonest
cause of acute non-bacterial diarrhoeal illness[1] Therefore this study
was undertaken to find out the incidence of Rota virus in acute
diarrhoea cases
As an NCM501202 students this care study helps us not just to pass this
said requirement but also to evaluate our efficacy upon rendering our services in
the optimum capacity or the ability to care to a patient suffering this kind of
illness This study also provide information on actual handling caring and an
overview of the patients nutritional status and dietary management with acute
gastroenteritis
Objectives of the study
A case study is designed to determine health problems or possible
health threats arising in a specific client As student nurses this would serve as a
tool for our training ground from what we had learned in classroom discussions
and be able to apply these in community setting such as this case
This case study focuses to accomplish the following objectives on
hypertension
1 To ascertain the content on the nursing assessment diagnosis planning
implementation and evaluation for these specific disease conditions
2 To comprehend on the underlying causes and health history on our
clientrsquos medical diagnosis upon admission
3 To compare amp contrast the ideal and actual nursing care management for
these specific disease conditions
4 Identify the development theory of my patient
5 Identify history of present illness
6 Discuss pathophysiology of the disease
7 Enumerate and discuss the nursing management
8 Discuss the discharge plan which includes health teachings
Scope and Limitations
The scope of this study covers from the patientrsquos health history
developmental data and as well as with his medical and nursing management
Based upon the assessment done appropriate interventions were implemented
to have a proper care for the clientrsquos health
The study is limited from the information being collected from the patient
The data gathering through objective and subjective assessment was limited
based upon our interview (From the mother) and nursing assessment The
patient was being assessed for 2 days from the time we had our ward duty
exposure
I Patientrsquos Profile
Name Eurey Lambaco
Age 1month old
Sex Male
Nationality Filipino
Highest educational attainment na
Occupation na
Monthly income na
Civil Status Child
Religion Roman Catholic
Birth Day December 152009
Address Lapasan Cagayan de Oro City
Vital Signs
Temp 377 c Pulse rate 130 BPM
Resp rate 35CPM
II Patientrsquos Health History
The Patient X A 1 month old baby has been experiencing Loose Bowel
Movement (LBM) accompanied with dehydration last January 23 2010
Two days prior to admission Patient X encountered onset of loose watery
stools brownish in color and characterized by non-mucoid and non-blood
streaked for about 4-6 times a day The client then brought to Sabal hospitals
emergency room Patientrsquos mother claimed that she is not exclusively
breastfeeding her child rather she sometimes bottle feed her child And she
doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the
child is using when eating
The client has the chief complaint of loose bowel movement upon his
admission Patientrsquos mother claimed that it was the first admission of the patient
III DEVELOPMENTAL DATA
PSYCHOSOCIAL THEORY OF ERIK ERICKSON
Erik Erickson envisioned life as a sequence of levels of achievement Each stage
signals a task that must be achieved He believed that the greater that task achievement
the healthier the personality of the person Failure to achieve a task influences the
personrsquos ability to achieve the next task
FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
According to Freudrsquos theory of psychosexual development the personality develops
in five overlapping stages from birth to adulthood The libido changes its location of
emphasis within the body from one stage to another Therefore a particular body area has
special significance to a client to a particular stage The first three stages (oral anal
phallic) are called pregenital stages The culminating stage is genital stage
If the individual does not achieve a satisfactory resolution at each stage the personality
becomes fixated at that stage Fixation is immobilization or the inability of the
personality to proceed to the next stage because of anxiety The patient belongs to early
childhood where the center of pleasure is in the anus
COGNITIVE THEORY OF JEAN PIAGET
Cognitive development refers to how a person perceives thinks and gain
understanding of his or her world through the interaction and influence of genetic and
learning factors Birth- 2years differentiates self from objects Recognizes self as agent of
action and begins to act intentionally Achieves object permanence
IV MEDICAL MANAGEMENT
A Doctorrsquos Order with Rationale
DATE AND TIME ORDER RATIONALE
January 23 2010
900 am
Pls Admit to room of
choice
gtTo provide care and
proper medical
management
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
B Laboratory Resultsignificance
VI Pathophysiology with Anatomy and Physiology
A Anatomy and Physiology
B Pathophysiology
VII Nursing Assessment(system review chart)
VIII Nursing Management
IX Health teachings
X Prognosis
XI Referrals and follow up
XII Evaluation
XIII Implication
XIV Bibliograph
Introduction
Nursing involves an interrelationship of many people concerned with a
clientrsquos responses to potential or actual problems Health is changing evolving
concept that is basic to nursing For centuries the concept of disease was the
yardstick by which was measured Now there is an increasing emphasis on
health and wellness Most people want to be healthy and feel a sense of loss
when they are not
In the case of our patient who is suffering from acute gastroenteritis (AGE)
the etiology is to determine it is said that unlike other abdominal disorder AGE is
the most occurring abdominal dysfunction especially among the children It is
most often results from any non-inflammatory or inflammatory infection of the
colon or either in the upper part of the small bowel It can range from mild
dysfunction to severe complication and the most common is dehydration due to
diarrheal reaction of the body
Usually this is caused by an infection[2] but this is not always the case It
usually is of acute onset normally lasting less than 10 days and self-limiting
Sometimes it is referred to simply as gastro It is often called the stomach flu or
gastric flu even though it is not related to influenza
Bacterial gastroenteritis is frequently a result of poor sanitation the lack of
safe drinking water or contaminated food-conditions common in developing
nations Natural or man-made disasters can make underlying problems in
sanitation and food safety worse In developed nations the modern food
production system potentially exposes millions of people to disease-causing
bacteria through its intensive production and distribution methods Common
types of bacterial gastroenteritis can be linked
to Salmonella andCampylobacter bacteria however Escherichia coli 0157
and Listeria monocytogenes are creating increased concern in developed
nations Cholera and Shigella remain two diseases of great concern in
developing countries and research to develop long-term vaccines against them
is underway
Non-bacterial gastroenteritis is a syndrome that affects a broad
segment of the population throughout the world Several studies have
proved that causative agents could be established only in about 30
of cases[3] and it leads to the suggestion that the virus may be the
aetiological agent Rota virus has been reported as the commonest
cause of acute non-bacterial diarrhoeal illness[1] Therefore this study
was undertaken to find out the incidence of Rota virus in acute
diarrhoea cases
As an NCM501202 students this care study helps us not just to pass this
said requirement but also to evaluate our efficacy upon rendering our services in
the optimum capacity or the ability to care to a patient suffering this kind of
illness This study also provide information on actual handling caring and an
overview of the patients nutritional status and dietary management with acute
gastroenteritis
Objectives of the study
A case study is designed to determine health problems or possible
health threats arising in a specific client As student nurses this would serve as a
tool for our training ground from what we had learned in classroom discussions
and be able to apply these in community setting such as this case
This case study focuses to accomplish the following objectives on
hypertension
1 To ascertain the content on the nursing assessment diagnosis planning
implementation and evaluation for these specific disease conditions
2 To comprehend on the underlying causes and health history on our
clientrsquos medical diagnosis upon admission
3 To compare amp contrast the ideal and actual nursing care management for
these specific disease conditions
4 Identify the development theory of my patient
5 Identify history of present illness
6 Discuss pathophysiology of the disease
7 Enumerate and discuss the nursing management
8 Discuss the discharge plan which includes health teachings
Scope and Limitations
The scope of this study covers from the patientrsquos health history
developmental data and as well as with his medical and nursing management
Based upon the assessment done appropriate interventions were implemented
to have a proper care for the clientrsquos health
The study is limited from the information being collected from the patient
The data gathering through objective and subjective assessment was limited
based upon our interview (From the mother) and nursing assessment The
patient was being assessed for 2 days from the time we had our ward duty
exposure
I Patientrsquos Profile
Name Eurey Lambaco
Age 1month old
Sex Male
Nationality Filipino
Highest educational attainment na
Occupation na
Monthly income na
Civil Status Child
Religion Roman Catholic
Birth Day December 152009
Address Lapasan Cagayan de Oro City
Vital Signs
Temp 377 c Pulse rate 130 BPM
Resp rate 35CPM
II Patientrsquos Health History
The Patient X A 1 month old baby has been experiencing Loose Bowel
Movement (LBM) accompanied with dehydration last January 23 2010
Two days prior to admission Patient X encountered onset of loose watery
stools brownish in color and characterized by non-mucoid and non-blood
streaked for about 4-6 times a day The client then brought to Sabal hospitals
emergency room Patientrsquos mother claimed that she is not exclusively
breastfeeding her child rather she sometimes bottle feed her child And she
doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the
child is using when eating
The client has the chief complaint of loose bowel movement upon his
admission Patientrsquos mother claimed that it was the first admission of the patient
III DEVELOPMENTAL DATA
PSYCHOSOCIAL THEORY OF ERIK ERICKSON
Erik Erickson envisioned life as a sequence of levels of achievement Each stage
signals a task that must be achieved He believed that the greater that task achievement
the healthier the personality of the person Failure to achieve a task influences the
personrsquos ability to achieve the next task
FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
According to Freudrsquos theory of psychosexual development the personality develops
in five overlapping stages from birth to adulthood The libido changes its location of
emphasis within the body from one stage to another Therefore a particular body area has
special significance to a client to a particular stage The first three stages (oral anal
phallic) are called pregenital stages The culminating stage is genital stage
If the individual does not achieve a satisfactory resolution at each stage the personality
becomes fixated at that stage Fixation is immobilization or the inability of the
personality to proceed to the next stage because of anxiety The patient belongs to early
childhood where the center of pleasure is in the anus
COGNITIVE THEORY OF JEAN PIAGET
Cognitive development refers to how a person perceives thinks and gain
understanding of his or her world through the interaction and influence of genetic and
learning factors Birth- 2years differentiates self from objects Recognizes self as agent of
action and begins to act intentionally Achieves object permanence
IV MEDICAL MANAGEMENT
A Doctorrsquos Order with Rationale
DATE AND TIME ORDER RATIONALE
January 23 2010
900 am
Pls Admit to room of
choice
gtTo provide care and
proper medical
management
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
Introduction
Nursing involves an interrelationship of many people concerned with a
clientrsquos responses to potential or actual problems Health is changing evolving
concept that is basic to nursing For centuries the concept of disease was the
yardstick by which was measured Now there is an increasing emphasis on
health and wellness Most people want to be healthy and feel a sense of loss
when they are not
In the case of our patient who is suffering from acute gastroenteritis (AGE)
the etiology is to determine it is said that unlike other abdominal disorder AGE is
the most occurring abdominal dysfunction especially among the children It is
most often results from any non-inflammatory or inflammatory infection of the
colon or either in the upper part of the small bowel It can range from mild
dysfunction to severe complication and the most common is dehydration due to
diarrheal reaction of the body
Usually this is caused by an infection[2] but this is not always the case It
usually is of acute onset normally lasting less than 10 days and self-limiting
Sometimes it is referred to simply as gastro It is often called the stomach flu or
gastric flu even though it is not related to influenza
Bacterial gastroenteritis is frequently a result of poor sanitation the lack of
safe drinking water or contaminated food-conditions common in developing
nations Natural or man-made disasters can make underlying problems in
sanitation and food safety worse In developed nations the modern food
production system potentially exposes millions of people to disease-causing
bacteria through its intensive production and distribution methods Common
types of bacterial gastroenteritis can be linked
to Salmonella andCampylobacter bacteria however Escherichia coli 0157
and Listeria monocytogenes are creating increased concern in developed
nations Cholera and Shigella remain two diseases of great concern in
developing countries and research to develop long-term vaccines against them
is underway
Non-bacterial gastroenteritis is a syndrome that affects a broad
segment of the population throughout the world Several studies have
proved that causative agents could be established only in about 30
of cases[3] and it leads to the suggestion that the virus may be the
aetiological agent Rota virus has been reported as the commonest
cause of acute non-bacterial diarrhoeal illness[1] Therefore this study
was undertaken to find out the incidence of Rota virus in acute
diarrhoea cases
As an NCM501202 students this care study helps us not just to pass this
said requirement but also to evaluate our efficacy upon rendering our services in
the optimum capacity or the ability to care to a patient suffering this kind of
illness This study also provide information on actual handling caring and an
overview of the patients nutritional status and dietary management with acute
gastroenteritis
Objectives of the study
A case study is designed to determine health problems or possible
health threats arising in a specific client As student nurses this would serve as a
tool for our training ground from what we had learned in classroom discussions
and be able to apply these in community setting such as this case
This case study focuses to accomplish the following objectives on
hypertension
1 To ascertain the content on the nursing assessment diagnosis planning
implementation and evaluation for these specific disease conditions
2 To comprehend on the underlying causes and health history on our
clientrsquos medical diagnosis upon admission
3 To compare amp contrast the ideal and actual nursing care management for
these specific disease conditions
4 Identify the development theory of my patient
5 Identify history of present illness
6 Discuss pathophysiology of the disease
7 Enumerate and discuss the nursing management
8 Discuss the discharge plan which includes health teachings
Scope and Limitations
The scope of this study covers from the patientrsquos health history
developmental data and as well as with his medical and nursing management
Based upon the assessment done appropriate interventions were implemented
to have a proper care for the clientrsquos health
The study is limited from the information being collected from the patient
The data gathering through objective and subjective assessment was limited
based upon our interview (From the mother) and nursing assessment The
patient was being assessed for 2 days from the time we had our ward duty
exposure
I Patientrsquos Profile
Name Eurey Lambaco
Age 1month old
Sex Male
Nationality Filipino
Highest educational attainment na
Occupation na
Monthly income na
Civil Status Child
Religion Roman Catholic
Birth Day December 152009
Address Lapasan Cagayan de Oro City
Vital Signs
Temp 377 c Pulse rate 130 BPM
Resp rate 35CPM
II Patientrsquos Health History
The Patient X A 1 month old baby has been experiencing Loose Bowel
Movement (LBM) accompanied with dehydration last January 23 2010
Two days prior to admission Patient X encountered onset of loose watery
stools brownish in color and characterized by non-mucoid and non-blood
streaked for about 4-6 times a day The client then brought to Sabal hospitals
emergency room Patientrsquos mother claimed that she is not exclusively
breastfeeding her child rather she sometimes bottle feed her child And she
doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the
child is using when eating
The client has the chief complaint of loose bowel movement upon his
admission Patientrsquos mother claimed that it was the first admission of the patient
III DEVELOPMENTAL DATA
PSYCHOSOCIAL THEORY OF ERIK ERICKSON
Erik Erickson envisioned life as a sequence of levels of achievement Each stage
signals a task that must be achieved He believed that the greater that task achievement
the healthier the personality of the person Failure to achieve a task influences the
personrsquos ability to achieve the next task
FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
According to Freudrsquos theory of psychosexual development the personality develops
in five overlapping stages from birth to adulthood The libido changes its location of
emphasis within the body from one stage to another Therefore a particular body area has
special significance to a client to a particular stage The first three stages (oral anal
phallic) are called pregenital stages The culminating stage is genital stage
If the individual does not achieve a satisfactory resolution at each stage the personality
becomes fixated at that stage Fixation is immobilization or the inability of the
personality to proceed to the next stage because of anxiety The patient belongs to early
childhood where the center of pleasure is in the anus
COGNITIVE THEORY OF JEAN PIAGET
Cognitive development refers to how a person perceives thinks and gain
understanding of his or her world through the interaction and influence of genetic and
learning factors Birth- 2years differentiates self from objects Recognizes self as agent of
action and begins to act intentionally Achieves object permanence
IV MEDICAL MANAGEMENT
A Doctorrsquos Order with Rationale
DATE AND TIME ORDER RATIONALE
January 23 2010
900 am
Pls Admit to room of
choice
gtTo provide care and
proper medical
management
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
developing countries and research to develop long-term vaccines against them
is underway
Non-bacterial gastroenteritis is a syndrome that affects a broad
segment of the population throughout the world Several studies have
proved that causative agents could be established only in about 30
of cases[3] and it leads to the suggestion that the virus may be the
aetiological agent Rota virus has been reported as the commonest
cause of acute non-bacterial diarrhoeal illness[1] Therefore this study
was undertaken to find out the incidence of Rota virus in acute
diarrhoea cases
As an NCM501202 students this care study helps us not just to pass this
said requirement but also to evaluate our efficacy upon rendering our services in
the optimum capacity or the ability to care to a patient suffering this kind of
illness This study also provide information on actual handling caring and an
overview of the patients nutritional status and dietary management with acute
gastroenteritis
Objectives of the study
A case study is designed to determine health problems or possible
health threats arising in a specific client As student nurses this would serve as a
tool for our training ground from what we had learned in classroom discussions
and be able to apply these in community setting such as this case
This case study focuses to accomplish the following objectives on
hypertension
1 To ascertain the content on the nursing assessment diagnosis planning
implementation and evaluation for these specific disease conditions
2 To comprehend on the underlying causes and health history on our
clientrsquos medical diagnosis upon admission
3 To compare amp contrast the ideal and actual nursing care management for
these specific disease conditions
4 Identify the development theory of my patient
5 Identify history of present illness
6 Discuss pathophysiology of the disease
7 Enumerate and discuss the nursing management
8 Discuss the discharge plan which includes health teachings
Scope and Limitations
The scope of this study covers from the patientrsquos health history
developmental data and as well as with his medical and nursing management
Based upon the assessment done appropriate interventions were implemented
to have a proper care for the clientrsquos health
The study is limited from the information being collected from the patient
The data gathering through objective and subjective assessment was limited
based upon our interview (From the mother) and nursing assessment The
patient was being assessed for 2 days from the time we had our ward duty
exposure
I Patientrsquos Profile
Name Eurey Lambaco
Age 1month old
Sex Male
Nationality Filipino
Highest educational attainment na
Occupation na
Monthly income na
Civil Status Child
Religion Roman Catholic
Birth Day December 152009
Address Lapasan Cagayan de Oro City
Vital Signs
Temp 377 c Pulse rate 130 BPM
Resp rate 35CPM
II Patientrsquos Health History
The Patient X A 1 month old baby has been experiencing Loose Bowel
Movement (LBM) accompanied with dehydration last January 23 2010
Two days prior to admission Patient X encountered onset of loose watery
stools brownish in color and characterized by non-mucoid and non-blood
streaked for about 4-6 times a day The client then brought to Sabal hospitals
emergency room Patientrsquos mother claimed that she is not exclusively
breastfeeding her child rather she sometimes bottle feed her child And she
doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the
child is using when eating
The client has the chief complaint of loose bowel movement upon his
admission Patientrsquos mother claimed that it was the first admission of the patient
III DEVELOPMENTAL DATA
PSYCHOSOCIAL THEORY OF ERIK ERICKSON
Erik Erickson envisioned life as a sequence of levels of achievement Each stage
signals a task that must be achieved He believed that the greater that task achievement
the healthier the personality of the person Failure to achieve a task influences the
personrsquos ability to achieve the next task
FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
According to Freudrsquos theory of psychosexual development the personality develops
in five overlapping stages from birth to adulthood The libido changes its location of
emphasis within the body from one stage to another Therefore a particular body area has
special significance to a client to a particular stage The first three stages (oral anal
phallic) are called pregenital stages The culminating stage is genital stage
If the individual does not achieve a satisfactory resolution at each stage the personality
becomes fixated at that stage Fixation is immobilization or the inability of the
personality to proceed to the next stage because of anxiety The patient belongs to early
childhood where the center of pleasure is in the anus
COGNITIVE THEORY OF JEAN PIAGET
Cognitive development refers to how a person perceives thinks and gain
understanding of his or her world through the interaction and influence of genetic and
learning factors Birth- 2years differentiates self from objects Recognizes self as agent of
action and begins to act intentionally Achieves object permanence
IV MEDICAL MANAGEMENT
A Doctorrsquos Order with Rationale
DATE AND TIME ORDER RATIONALE
January 23 2010
900 am
Pls Admit to room of
choice
gtTo provide care and
proper medical
management
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
4 Identify the development theory of my patient
5 Identify history of present illness
6 Discuss pathophysiology of the disease
7 Enumerate and discuss the nursing management
8 Discuss the discharge plan which includes health teachings
Scope and Limitations
The scope of this study covers from the patientrsquos health history
developmental data and as well as with his medical and nursing management
Based upon the assessment done appropriate interventions were implemented
to have a proper care for the clientrsquos health
The study is limited from the information being collected from the patient
The data gathering through objective and subjective assessment was limited
based upon our interview (From the mother) and nursing assessment The
patient was being assessed for 2 days from the time we had our ward duty
exposure
I Patientrsquos Profile
Name Eurey Lambaco
Age 1month old
Sex Male
Nationality Filipino
Highest educational attainment na
Occupation na
Monthly income na
Civil Status Child
Religion Roman Catholic
Birth Day December 152009
Address Lapasan Cagayan de Oro City
Vital Signs
Temp 377 c Pulse rate 130 BPM
Resp rate 35CPM
II Patientrsquos Health History
The Patient X A 1 month old baby has been experiencing Loose Bowel
Movement (LBM) accompanied with dehydration last January 23 2010
Two days prior to admission Patient X encountered onset of loose watery
stools brownish in color and characterized by non-mucoid and non-blood
streaked for about 4-6 times a day The client then brought to Sabal hospitals
emergency room Patientrsquos mother claimed that she is not exclusively
breastfeeding her child rather she sometimes bottle feed her child And she
doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the
child is using when eating
The client has the chief complaint of loose bowel movement upon his
admission Patientrsquos mother claimed that it was the first admission of the patient
III DEVELOPMENTAL DATA
PSYCHOSOCIAL THEORY OF ERIK ERICKSON
Erik Erickson envisioned life as a sequence of levels of achievement Each stage
signals a task that must be achieved He believed that the greater that task achievement
the healthier the personality of the person Failure to achieve a task influences the
personrsquos ability to achieve the next task
FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
According to Freudrsquos theory of psychosexual development the personality develops
in five overlapping stages from birth to adulthood The libido changes its location of
emphasis within the body from one stage to another Therefore a particular body area has
special significance to a client to a particular stage The first three stages (oral anal
phallic) are called pregenital stages The culminating stage is genital stage
If the individual does not achieve a satisfactory resolution at each stage the personality
becomes fixated at that stage Fixation is immobilization or the inability of the
personality to proceed to the next stage because of anxiety The patient belongs to early
childhood where the center of pleasure is in the anus
COGNITIVE THEORY OF JEAN PIAGET
Cognitive development refers to how a person perceives thinks and gain
understanding of his or her world through the interaction and influence of genetic and
learning factors Birth- 2years differentiates self from objects Recognizes self as agent of
action and begins to act intentionally Achieves object permanence
IV MEDICAL MANAGEMENT
A Doctorrsquos Order with Rationale
DATE AND TIME ORDER RATIONALE
January 23 2010
900 am
Pls Admit to room of
choice
gtTo provide care and
proper medical
management
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
Religion Roman Catholic
Birth Day December 152009
Address Lapasan Cagayan de Oro City
Vital Signs
Temp 377 c Pulse rate 130 BPM
Resp rate 35CPM
II Patientrsquos Health History
The Patient X A 1 month old baby has been experiencing Loose Bowel
Movement (LBM) accompanied with dehydration last January 23 2010
Two days prior to admission Patient X encountered onset of loose watery
stools brownish in color and characterized by non-mucoid and non-blood
streaked for about 4-6 times a day The client then brought to Sabal hospitals
emergency room Patientrsquos mother claimed that she is not exclusively
breastfeeding her child rather she sometimes bottle feed her child And she
doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the
child is using when eating
The client has the chief complaint of loose bowel movement upon his
admission Patientrsquos mother claimed that it was the first admission of the patient
III DEVELOPMENTAL DATA
PSYCHOSOCIAL THEORY OF ERIK ERICKSON
Erik Erickson envisioned life as a sequence of levels of achievement Each stage
signals a task that must be achieved He believed that the greater that task achievement
the healthier the personality of the person Failure to achieve a task influences the
personrsquos ability to achieve the next task
FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
According to Freudrsquos theory of psychosexual development the personality develops
in five overlapping stages from birth to adulthood The libido changes its location of
emphasis within the body from one stage to another Therefore a particular body area has
special significance to a client to a particular stage The first three stages (oral anal
phallic) are called pregenital stages The culminating stage is genital stage
If the individual does not achieve a satisfactory resolution at each stage the personality
becomes fixated at that stage Fixation is immobilization or the inability of the
personality to proceed to the next stage because of anxiety The patient belongs to early
childhood where the center of pleasure is in the anus
COGNITIVE THEORY OF JEAN PIAGET
Cognitive development refers to how a person perceives thinks and gain
understanding of his or her world through the interaction and influence of genetic and
learning factors Birth- 2years differentiates self from objects Recognizes self as agent of
action and begins to act intentionally Achieves object permanence
IV MEDICAL MANAGEMENT
A Doctorrsquos Order with Rationale
DATE AND TIME ORDER RATIONALE
January 23 2010
900 am
Pls Admit to room of
choice
gtTo provide care and
proper medical
management
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
the healthier the personality of the person Failure to achieve a task influences the
personrsquos ability to achieve the next task
FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT
According to Freudrsquos theory of psychosexual development the personality develops
in five overlapping stages from birth to adulthood The libido changes its location of
emphasis within the body from one stage to another Therefore a particular body area has
special significance to a client to a particular stage The first three stages (oral anal
phallic) are called pregenital stages The culminating stage is genital stage
If the individual does not achieve a satisfactory resolution at each stage the personality
becomes fixated at that stage Fixation is immobilization or the inability of the
personality to proceed to the next stage because of anxiety The patient belongs to early
childhood where the center of pleasure is in the anus
COGNITIVE THEORY OF JEAN PIAGET
Cognitive development refers to how a person perceives thinks and gain
understanding of his or her world through the interaction and influence of genetic and
learning factors Birth- 2years differentiates self from objects Recognizes self as agent of
action and begins to act intentionally Achieves object permanence
IV MEDICAL MANAGEMENT
A Doctorrsquos Order with Rationale
DATE AND TIME ORDER RATIONALE
January 23 2010
900 am
Pls Admit to room of
choice
gtTo provide care and
proper medical
management
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
TPR every 4 hours gtTo further monitor the
condition of client
CFACS-V gtTo check the
characteristics frequency
amount color stool and
vomitus of the patient
Diet as tolerated with
aspiration precaution
gtPrescribed food for the
client and prevent aspiration
of foods
Labs
Stool Exam
Urinalysis
CBC
gtTo help physician in
diagnosing his present
health condition and give
specific treatment with
regards to his condition
gtA laboratory test to
determine if a stool sample
contains parasites or eggs
(ova) that are associated
with intestinal infection
gtUsed to detect excessive
protein escaping into the
urine to help evaluate and
monitor kidney function
and to detect kidney
damage affected by his
disease
gtto determine if clients
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
blood components are
elevated which could
further help he doctor in
prescribing appropriate
medicatios
PLR 1L 40gttshr gtmaintain fluid and
electrolytes balance
Time tape IVF gtTo monitor the IV fluids
of the patient
Monitor hydration status
every 4 hours
gtTo monitor patients
reaction
Medications
E-zinc Drops 1ml OD PO
gtRequired for normal
development and
maintenance of immune
system
B Laboratory Resultsignificance
Datediagnostic
exam done
Lab result Normal
values
Significance
1242010
CBC(HEMATOLOGY)
Hgb113gm
Hct 34 vol
WBC
7700mm3
Lymphocytes
40
Segmenters
13-18gm
42-51 vol
5000-
10000mm3
25-35
55-85
2-4
gtDecreased in renal
and liver disease
hypoxia
gtDecreased in renal
and liver disease
gtno significance
gtsignifies presence of
parasite and adrenal
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
44
Monocytes 4
Eosinophils 12
Platelet
498000
2-3
150-350mm3
hypofunction
gtDecreased in renal
and liver disease
gt no significance
gtsignifies presence of
parasite and adrenal
hypofunction
gtsignifies renal
diseaseanemia
1242010
Blood chemistry
BUN285
Createnin
088
Potassium35
Sodium13920
150-
510mgs
08-14 mgs
34-53mEqL
135-
155mEqL
gtno significance
normal
gtat the borderline no
significance
gtno significance
Normal
gt no significance
Normal
Datediagnostic
exam done
Lab result Normal values Significance
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
1242010
URINALYSIS
(RANDOM
SAMPLING)
Color yellow
Appearance
clear
Glucose neg
Protein neg
Reaction GS
Spe Gravity01-
010
Wbc2-4
Rbc 0-2
Epi Cell 0-2
Mucous cells
none
Urate none
Bacterianone
1242010
Hgb
Hct
Hgb 98
Hct 300
13-18gm
42-51 vol
gtDecreased in
renal and liver
disease
gtDecreased in
renal and liver
disease
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
A ANATOMY AND PHYSIOLOGY
The stomach is an expanded section of the digestive tube between the esophagus and
small intestine Its characteristic shape is shown
along with terms used to describe the major regions
of the stomach The right side of the stomach is
called the greater curvature and the left the lesser
curvature The most distal and narrow section of the
stomach is termed the pylorus - as food is liquefied
in the stomach it passes through the pyloric canal
into the small intestine
The wall of the stomach is structurally similar to other parts of the digestive tube with
the exception that the stomach has an extra oblique layer of smooth muscle inside the
circular layer which aids in performance of complex grinding motions
In the empty state the stomach is contracted and its mucosa and submucosa are thrown
up into distinct folds called rugae when distended with food the rugae are ironed out
and flat The image below shows rugae on the surface of a dogs stomach
Within the stomach there is an abrupt transition from stratified squamous epithelium
extending from the esophagus to a columnar epithelium dedicated to secretion In most
species this transition is very close to the esophageal orifice but in some particular
horses and rodents stratified squamous cells line much of the fundus and part of the
body
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
The image below is of the mucosal surface of an equine stomach showing esophageal
epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface
are bots larval forms of Gasterophilus
If the lining of the stomach is examined with a hand lens one can see that it is covered
with numerous small holes These are the openings of gastric pits which extend into the
mucosa as straight and branched tubules forming gastric glands
B PATHOPHYSIOLOGY
ACUTE GASTROENTERITIS
Definition
Gastroenteritis is the irritation and inflammation of the digestive tract This
condition may cause abdominal pain vomiting and diarrhea Severe cases of
gastroenteritis can result in dehydration In such cases fluid replacement is the
primary factor in treatment All ages and both sexes may be affected yet the most
severe symptoms are experienced by infants and those individuals over sixty
years old The use of certain drugs such as aspirin antibiotics or cortisone drugs
may increase risk for this condition
Food poisoning stress excessive alcohol or tobacco use viral infections food
allergies improper diet certain drugs food consumed in foreign countries and
intestinal parasites are all possible causes for this condition
Gastroenteritis caused by viral infection or bacteria is easily passed from one
person to another Care should always be taken to wash the hands often
especially when preparing food and after bowel movements Hand washing after
bowel movements is important since the organism that causes this condition lives
in the digestive tract
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
Contaminated food and water unhygienic lifestyle
Food eaten irritates stomach
Increase peristalsis movement of the intestines (Inflammatory response to mucous
membrane lining is destroyed due to excessive production of intestinal fluids)
SSX
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abnormal flatulence
Abdominal cramps
Bloody stools
Fainting and Weakness
Predisposing Factor
Age (1month old)
Precipitating Factors
gtEnvironmental Sanitation gtPersonal Hygiene
gtImproper handling of foods gtunsterilized utensils
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
Effect to produce hyperemia (vascular dilatation with local increase in blood flow of
theintestinal mucosa)
Hyperistalsis in the intestine
Fluid loss dehydration
Acute Gastroenteritis
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
16
VI NURSING ASSESSMENT REVIEW CHART
VI Nursing system review chart
Name Lambaco Eurey Date March 23 2010 Vital signs
Pulse130bpm Temperature377 C Resp35 cpm
Instructions Place an [x]in the area of abnormality Comment at the space provided
Indicate the location of the problem in the figure EENT
[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and
p p osterior fontanels are still open
[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain
[x] no problem Abdominal cramps Respiration IV site
[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet
[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing
Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood
Expectoration of [] breath sounds and comfort [x] no problem
sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness
Mildly elevated [] diminished pulses [] edema [] fatigue
blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain
[x] assess heart sounds rate rhythm pulse Condom catheter in
blood pressure circulation fluid retention and comfort place [x] no problem
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
17
Gastrointestinal tract
Posterior tibial and
[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain
[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss
Genito-urinary and Gyne
[] pain [] urine [] color [] vaginal bleeding
[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery
stool Neuro
[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors
[] confused [] vision [] grip [] assess motor function sensation LOC and strength
Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin
extremities
[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage
[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist
needs assistance [] asses mobility motion gait alignment joint function
on ambulation [x] skin color texture turgor integrity [] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
COMMUNICATION
[] hearing loss Comments ldquowala man pud
problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya
[ ] visual changes
[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties
Pupil size 2mm
Reaction Pupils are equally rounded and reactive to
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
18
[ x ] denied light and accommodation
OXYGENATION
[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo
[] smoking history
[ ] cough [] sputum [x] denied
Respiration [x] regular [ ] irregular Description Regular breathing pattern
Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung
CIRCULATION
[ ] chest pain Comments ldquoNo subjective cue
gathered since the patient is an infantrdquo
[ ] leg pain [ ] numbness of extremities [ x] denied
Heart rhythm [x] regular [ ] irregular Ankle edema None
PulseCarotidRadialDorsalis pedisFemoral + + +
Right + + + Left Comments Heart beat and heart rhythm are normal
NUTRITION
Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo
[ ] vomiting character
[ x ] recent change in weight appetit [] swallowing
difficulty [ ] denied
[ ] dentures [x] none
FullPartial
upper [ ] [x] [ ]
lower [ ] [x] [ ]
ELIMINATION
Usual bowel pattern [ ] urinary frequency 2x a day3x a day
[ ] constipation remedy [ ] urgency [ ] dysuria
Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria
Watery stool yellowish in color [ ] denied
Comments loose passive Watery stool yellowish in
color and in moderate amount Bowel sounds hyperactive (2x3-5sec)
Abdominal distention [ ] yes [x] no
Urine (color odor Consistency) light colored in moderate amount
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
19
MANAGEMENT OF HEALTH AND
ILLNESS
[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable
[ ] Last menstrual period not applicable
Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic
health problems Patients mother is supportive to treatment regimen
and patient is cooperative
SUBJECTIVE OBJECTIVE
SKIN INTEGRITY
[x] dry [ ] itching
[x ] other Poor skin turgor [ ] denied
[x] dry [ ] cold [ ] pale
[ ] flushed [x] warm [ ] moist [ ] cyanotic
Rashes ulcers decubitus (describe size location and drainage) None
ACTIVITY SAFETY
[ ] convulsion Comments ldquoluya jud
kaayo siya karon sugod pa atong nag kalibanga siyardquo
[ ] dizziness [ ] limited motion of joints
Limitation in the ability to
[x] ambulate [ ] bathe self [ ] other
[ ] denied
Level of consciousness and orientation
Patient is 11 months old Gait [ ] walker [ ] cane [x] others
[ ] steady [x] unsteady [ ] sensory losses in face or extremities
None
[ ] Range of motion limitation Patient is still unable
COMFORT SLEEP AWAKE
[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo
frequency remedies) [ ] nocturia [ x] sleep difficulties
[] denied
[x] facial grimace
[ ] guarding [ ] other signs of pain patient is Frequently
crying [ ] siderail release form signed (60+ years)
Not applicable
COPING
Occupation Not applicable since the patient is infant Most supportive person the mother and
father
Observed non-verbal behavior none
The person and his phone number that can be reached anytime
09063064576- patients father
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
20
VII Nursing Management
Nursing Diagnosis
Intervention Rationale
Hyperthermia related to dehydration as
evidence by flushed skin and warm to
touch
Independent
promote surface cooling by
means of tepid sponge bath
maintain bed rest
increase fluid intake (PO)
Collaborative
administer antipyretic
(paracetamol) as ordered
To lower down body temperature
To prevent energy consumption
To maintain fluid and electrolytes balance in the body
To lower down body temperature
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
21
Nursing Diagnosis Intervention Rationale
Fluid volume deficient related to
excessive losses through normal
routes
Monitor intake and output note
number character and amout of
stools
Assess vital signs changes
Observe for excessively dry skin
and mucous membrane dry skin
turgor
Weigh daily
Administer parenteral as
indicated
Provide information about over
all fluid balance renal function
and bowel diseases control as
well as guidelines for fluid
replacement
Hypotension tachycardia and
fever can indicate response of
fluid loss
Indicates dehydration
Indicator of overall fluid and
nutritional status
Maintenance of bowel rest that
will require alternate fluid
replacement to correct losses
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
22
Nursing Diagnosis Interventions Rationale
Nutrition altered Less than body
requirements related to altered
absorption of nutrients and hyper
metabolic state
Weigh daily
Encourage bed rest or limited
activity during acute phase of
illness
Record intake changes in
symptomalogy
Provide oral hygiene
Keep NPO and administer
medication as indicated
Provide information about
dietary needs
Decreasing metabolic rate
needs aid in preventing caloric
depletion and conserves
energy
Useful in identifying specific
deficiency and determining GI
response to foods
Clean mouth can enhance the
taste of foods
Promote tissue
healingregeneration Prevent
treat anemia oral route for iron
supplement is ineffective
because of intestinal alteration
that for absorption of nutrients
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
23
Nursing Diagnosis Intervention Rationale
Acute pain related to hyper peristalsis
prolonged diarrhea skintissue
irritation peri rectal fissures fistulas
Note non verbal cues
Permit patient to assume
position of comfort
Cleans rectal area with mild
soap and water wipes after
defecating
Record abdominal distention
increase temperature and
decrease blood pressure
Implement prescribe dietary
modifications administer
medication as indicated
Non verbal cues may be used in
conjunction with verbal cues to
identify extent of the problem
Reduce abdominal tension and
sense of control
Protect skin from undigested
bowel contents preventing
excoriation
May indicate developing
intestinal obstruction from
inflammation
Complete bowel rest can reduce
pain and cramping
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
24
S NA
O -sudden loss of weight
-weak
-sunken fontanels
-consumes half of share
A Imbalanced Nutrition less than body requirements as evidenced by sudden change in
weight
P Long term At the end of an 16 hours of rendering nursing care the patient will be able
to maintain weight
Short term At the end of 8 hours the patient regain appetite
I 1 Monitored bowel sounds
2 Promoted pleasant relaxing environment
3 Checked stools
4 Consulted dietitian
5 Monitored laboratory studies
E After giving an intervention the patient have a good appetite and regain his weight
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
25
S
NA
O
-Frequently cries
-Restless
- facial grimaced
A
-Acute pain related to physiologic response of the stomach due to over stimulation
of the gastric acid
P
Long term At the end of 16 hours rendering nursing care patient will be able to be
relieved from pain as evidence by
Appears calm and comfortable
Short term At the end of 8 hours rendering nursing care the patient will be able to
demonstrate relief from pain
I
1 Provided with cool and well-ventilated room
2 Monitored vital signs of the patient to check for stability upon pain occur
3 Given some materials to divert his feeling of pain
4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered
E
After 8 hours of intervention that has been given the patient able to be relived from
pain
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
26
S NA
O -sudden change of weight
-poor skin turgor
-dry mucous membranes
A Risk for fluid volume deficient as evidenced by sudden losses of weight and
loose bowel movement
P Long term At the end of 8 hours rendering nursing care the patient will
demonstrate a normal pattern of bowel function
Short term At the end of 5 hours rendering nursing care the patient will be able
to attain normal bowel pattern
I 1 Monitor intake and output
2 Increased fluid intake
3 Assessed vital signs skin turgor and mucous membrane
4 Checked and compare laboratory values
5 Provide IV Fluids with the doctorrsquos prescription
E After giving nursing intervention patient attain normal pattern of bowel
function
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
27
VIII Health Teaching
Medication
Before the patient is discharge patients mother was instructed to comply all
of his medication regimen as prescribe by the attending physician(DrBejarasco)
This medication is E-zinc Drops 1ml OD PO
Exercise
Patients mother was instructed to ambulate client and deep breathing
excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote
blood circulation and sense of well being and promote fast healing Relaxation
exercise may do
Treatment
Patients mother instructed to increased fluid intake of client This is to
promote regain of electrolytes and fluid balance Treatment regimen such as
some diet restriction exercise compliance on medication and to submit self 1
week after being discharge from the hospital Encouraged to maintain good
hygiene of client
Out-patient check-up
Patients mother was instructed to come back 1 week after or if symptoms
persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress
of the patientrsquos treatment and to monitor any signs of further medical assistance
Diet
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
28
Patients mother encouraged to let client eat foods with high protein content such
as the egg whites and lean meats and also vegetable and encourage increased
fluid intake
IX Prognosis
PROGNOSTIC INDICATORS POOR GOOD
A Onset of illness X
B Duration of Illness X
C Attitude and willingness
to take medication
X
D Precipitating Factors X
F Family Support X
X REFERRALS AND FOLLOW UP
Before the patient is discharged from the hospital mother was suggested
to return the patient to his physician Dr Bejarasco one week after discharge for
follow up check-up for further evaluation instructions and care
The recovery of patientrsquos wounds depends on medications and treatment
regimen if it was followed religiously as ordered by his physician
XI Evaluation
At the end of two days of nursing care rendered to patient the patient showed
some sort of progress as evidence by
Clients stool is semi-formed
Has good appetite eating
Active and regained his strength
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
29
XII Implication
This study will serve as a reference material in rendering and competent
care to our patient especially those with similar conditions Through this we will
be able to develop our knowledge as well as our skills and attitudes in applying
the prescribed procedures to improve the health status of the patient
This study will act as a baseline data as well as guide for coming up with a
good reliable accurate and comprehensive research paper dealing with issues
commonly experienced by patients in the hospital setting This may aid the
researchers to widen the scope of the study in relation to more or less similar
cases
XIII Bibliography
WEBSITE
1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm
entampaction=edit
2 httpwwwpatientcoukshowdoc40000681
3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme
ntMiddle_Adulthood_2835-60_Years29
4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo
pment
5 Category Developmental psychology
6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby
2005 ISBN 0323033032
7 ^ Seven Surfing Sicknesses
8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell
Timothy M Cox and John D Firth with Edward J Benz Fourth Edition
(2003) Oxford University Press ISBN 0-19-262922-0
9 ^ Haffejee IE (1991) The pathophysiology clinical features and
management of rotavirus diarrhoea Q J Med 79 (288) 289ndash
99 PMID 1649479
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033
30
10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory
testing data for surveillance of rotavirus hospitalizations to evaluate the
impact of vaccination (Subscription required) Pediatr Infect Dis
J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797
11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The
paediatric burden of rotavirus disease in Europe Epidemiol
Infect 134 (5) 908ndash
16doi101017S0950268806006091 PMID 16650331
12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J
Clin Microbiol Infect Dis 7 (1) 11ndash
3 doi101007BF01962164 PMID 3132369
BOOKS
1 Erikson Erik H Childhood and Society New York Norton
1950
2 Erikson Erik H Identity and the Life Cycle New York
International Universities Press 1959
3 Medical Surgical Nursing by Smeltzer
4 Nursing Pocket Guide by Sheesy Gail
5 NCP by Doenges 2nd ed pp423-430
6 Modern Medical Guide by Harold shryock MD pp 285-287
7 Maternal and Child Health Nursing by Adele Pillitteri pp
1264-1265
8 Texbook of Medical- Surgical Nursing by Brunner and
suddarthrsquos pp 1020-1033