Case Presentation of Patient

with Acute Gastroenteritis

Presented by:

BSN 103-A/ Group A2

Flores, Ma. Fe
Gabriel, Ivy
Garcia, Kesselyn
Garingo, Jeovina
Gumasing, Mary Janine
Gutierrez, Sunshine
Hernandez, Baby Jane
Lamurena, Jacquelyn
Lopez, Christine Anne
Lualhati, Richard
Mapiscay, Ma. Richel
Mendoza, Rosa Mia
Nicolas, Jean Therese
ASSESSMENT
I. Patient’s Biographical Data
NAME : Mrs. Green
ADDRESS : NHV, Tigbe, Norzagaray, Bulacan
DATE OF BIRTH : November 26, 1946
BIRTHPLACE : Leyte
BIRTH HISTORY : Home Birth
AGE : 62 years old
SEX : Female
HEIGHT : 5’1”
WEIGHT : 42 kgs.
FATHER’S NAME : Deceased
MOTHER’S NAME : Deceased
NO. of SIBLINGS : Six (6)
ORDINAL POSITION IN
THE FAMILY : Eldest
CIVIL STATUS : Widowed
NATIONALITY : Filipino
MEDICAL DIAGNOSIS : Acute Gastroenteritis
CHIEF COMPLAINT : Loose watery stool and vomiting
HISTORY OF PRESENT ILLNESS
Prior to admission, the patient complains
of loose watery stool and vomiting.

HISTORY OF PAST ILLNESS

The patient reported that she had been
hospitalized before with the same medical
diagnosis of Acute Gastroenteritis.
II. General Physical Assessment
V/S: temp=36.5˚C, P=62bpm, R=19cpm, BP=120/80

SKIN: The patient’s skin’s moisture is dry due to dehydration. The

texture is rough due to aging and signs of dehydration.

HEAD: The patient’s head was round and in proportion w/ the body.
Hair color is white and has no dandruff and lice. The patient’s
general appearance of face indicates a feeling of weakness.

NECK and SHOULDERS: The veins and clavicle are visible. The
shoulders are asymmetrical. The neck muscles are weak.

EYES: The patient’s eyes are symmetrical to the ears. She manifested a
blurred vision due to aging. Pale conjunctivae was noted. Sunken
eyes was observed. The eyes appeared dry due to dehydration.
EARS: The client’s ear manifested a good hearing balance. There were
no discharges noted.

NOSE: The client’s nasal septum is intact and in the midline. There were
no discharges noted. Airs move freely as the client breathes through
the nose.

MOUTH and THROAT: The client’s mouth has presence of lesions due
to frequent vomiting. The lips were dry due to dehydration. The throat
was functioning well. No dentures. (+) tartar. There is a black
discoloration in the enamel. (+) breath odor.

CHEST: The chest is symmetric. The skin was sagged. The thorax is
elliptical.

ABDOMEN: The skin of the abdomen is unblemished and uniform in

color. Symmetric abdominal contour flattened and rounded. Audible
bowel sounds. Symmetric movements cause by respiration. No
tenderness noted.
EXTREMITIES: The fingers in both hands and feet are complete. The
shape of the nails is spoon-shape, the consistency is smooth and the
color is pinkish white.

SPINE: The spine of the patient is slightly curved. No presence of

defects.
III. Significant Health Patterns
A. SLEEP
Prior to Hospitalization:
Her sleeping pattern before was normal. She was able to consume normal 8-hour
sleeping time.
During Hospitalization:
During her stay at the hospital she said that she was experiencing difficulty of sleeping.

B. ACTIVITY AND EXERCISE

Prior to Hospitalization:
Mrs. Green was a street sweeper and a hog-raiser.
During Hospitalization:
During her stay at the hospital, she was not able to perform activities because of
restlessness due to her illness.
C. NUTRITION
Prior to Hospitalization:
She has good appetite.
During Hospitalization:
During her stay at the hospital, she
loses her appetite because of her
illness.
IV. Work-ups and Interpretations
A. LABORATORY EXAMINATIONS
URINALYSIS
Color
Base on the result the color of the urine is yellow. The
normal color of the urine must be transparent yellow or amber. Since
the color of the urine is yellow it may indicate, food pigments or high-
solute concentration.
pH
The pH of the patient’s urine is 8.0. Urinary pH is
measured to determine the relative acidity or alkalinity of urine and
assess the client’s acid- base status. Urine is normally slightly acidic.
Less than 7 (acidic), greater than 7 (alkaline), 7 (neutral).
 Specific Gravity
The specific gravity of the patient’s
urine is 1.010. The specific gravity of urine
normally ranges from 1.010 to 1.025. If the
specific gravity increase urine becomes more
concentrated.
BLOOD CHEMISTRY
Blood Urea Nitrogen
The BUN of the patient is 48.3 mg/dl, the normal
findings is 8-25 mg/dl. There is an increase in BUN
that may cause dehydration, BUN measures amount
of urea in blood. Directly related to metabolic function
of the liver.

Creatinine
The creatinine of the patient is 0.6 mg/dl, the normal
finding of the creatinine is 0.5-1.7 mg/dl. Creatinine is
exerted entirely in kidney and therefore directly
proportional to glomerular filtration rate.
HEMATOLOGY
Hemoglobin
The hemoglobin of the patient is 90g/L. The
normal findings of hemoglobin is 115 to 155g/L. There
is a decrease in hemoglobin that may possibly cause
hemolytic anemia and bone marrow suppression.

Hematocrit
The hematocrit of the patient is 26%, the
normal finding is 36 to 46%. Hematocrit measures the
percentage of red blood cells in the total blood volume.
It reported as percentage because it is the proportion of
RBC’s to the plasma. There is also a decrease in
hematocrit that may possibly cause diet deficiency
anemia.
 WBC Count
The WBC count of the patient is 5.0 x 10g/L, the
normal findings of WBC is 4 to 11x10g/L. High WBC count are
often seen in the presence of bacterial infection; by contrast,
WBC count may be low if a viral infection is present.

RBC Count
The RBC count of patient is 3.11 x 10 g/L, the
normal finding of RBC is 4-7 x 10 g/L. Her RBC count
decreases and the possible cause of this is Iron Deficiency
Anemia.

Differential Count
The result of the patient lymphocyte is 19%, the
normal value is 25-35%. There is a decrease in lymphocyte that
may cause severe malnutrition.
The result of patient monocytes is 4%, the normal
value is 2-5%.
ANATOMY AND PHYSIOLOGY
DIGESTIVE SYSTEM

The human digestive system is a

complex series of organs and glands that
processes food. In order to use the food we
eat, our body has to break the food down
into smaller molecules that it can process;
it also has to excrete waste.
Most of the digestive organs (like the
stomach and intestines) are tube-like and
contain the food as it makes its way
through the body. The digestive system is
essentially a long, twisting tube that runs
from the mouth to the anus, plus a few
other organs (like the liver and pancreas)
that produce or store digestive chemicals.
The Digestive Process:
The start of the process - the
mouth:
The digestive process begins in the
mouth. Food is partly broken down by
the process of chewing and by the
chemical action of salivary enzymes
(these enzymes are produced by the
salivary glands and break down
starches into smaller molecules).
On the way to the stomach: the
esophagus –
After being chewed and swallowed,
the food enters the esophagus. The
esophagus is a long tube that runs
from the mouth to the stomach. It
uses rhythmic, wave-like muscle
movements (called peristalsis) to
force food from the throat into the
stomach. This muscle movement gives
us the ability to eat or drink even
when we're upside-down.
In the stomach –
The stomach is a large, sack-like
organ that churns the food and
bathes it in a very strong acid (gastric
acid). Food in the stomach that is
partly digested and mixed with
stomach acids is called chyme.
In the small intestine –
After being in the stomach, food
enters the duodenum, the first part of
the small intestine. It then enters the
jejunum and then the ileum (the
final part of the small intestine). In
the small intestine, bile (produced in
the liver and stored in the gall
bladder), pancreatic enzymes, and
other digestive enzymes produced by
the inner wall of the small intestine
help in the breakdown of food.
In the large intestine –
After passing through the small intestine, food passes into
the large intestine. In the large intestine, some of the water and
electrolytes (chemicals like sodium) are removed from the food.
Many microbes (bacteria like Bacteroides, Lactobacillus
acidophilus, Escherichia coli, and Klebsiella) in the large intestine
help in the digestion process. The first part of the large intestine
is called the cecum (the appendix is connected to the cecum).
Food then travels upward in the ascending colon. The food
travels across the abdomen in the transverse colon, goes back
down the other side of the body in the descending colon, and
then through the sigmoid colon.

The end of the process –

Solid waste is then stored in the rectum until it is excreted via
the anus.
Digestive System Glossary:
anus - the opening at the end of the digestive system from which feces (waste)
exits the body.
appendix - a small sac located on the cecum.
ascending colon - the part of the large intestine that run upwards; it is located
after the cecum.
bile - a digestive chemical that is produced in the liver, stored in the gall bladder,
and secreted into the small intestine.
cecum - the first part of the large intestine; the appendix is connected to the
cecum.
chyme - food in the stomach that is partly digested and mixed with stomach
acids. Chyme goes on to the small intestine for further digestion.
descending colon - the part of the large intestine that run downwards after the
transverse colon and before the sigmoid colon.
duodenum - the first part of the small intestine; it is C-shaped and runs from the
stomach to the jejunum.
epiglottis - the flap at the back of the tongue that keeps chewed food from
going down the windpipe to the lungs. When you swallow, the epiglottis
automatically closes. When you breathe, the epiglottis opens so that air can
go in and out of the windpipe.
esophagus - the long tube between the mouth and the stomach. It uses
rhythmic muscle movements (called peristalsis) to force food from the throat into
the stomach.
gall bladder - a small, sac-like organ located by the duodenum. It stores and
releases bile (a digestive chemical which is produced in the liver) into the
small intestine.
 ileum - the last part of the small intestine before the large intestine begins.
jejunum - the long, coiled mid-section of the small intestine; it is between the
duodenum and the ileum.
liver - a large organ located above and in front of the stomach. It filters toxins
from the blood, and makes bile (which breaks down fats) and some
blood proteins.
mouth - the first part of the digestive system, where food enters the body.
Chewing and salivary enzymes in the mouth are the beginning of the
digestive process (breaking down the food).
pancreas - an enzyme-producing gland located below the stomach and above
the intestines. Enzymes from the pancreas help in the digestion
of carbohydrates, fats and proteins in the small intestine.
peristalsis - rhythmic muscle movements that force food in the esophagus
from the throat into the stomach. Peristalsis is involuntary - you cannot
control it. It is also what allows you to eat and drink while upside- down.
rectum - the lower part of the large intestine, where feces are stored before
they are excreted.
salivary glands - glands located in the mouth that produce saliva. Saliva
contains enzymes that break down carbohydrates (starch) into smaller
molecules.
sigmoid colon - the part of the large intestine between the descending colon
and the rectum.
stomach - a sack-like, muscular organ that is attached to the esophagus. Both
chemical and mechanical digestion takes place in the stomach.
When food enters the stomach, it is churned in a bath of acids and enzymes.
transverse colon - the part of the large intestine that runs horizontally
across the abdomen.

PATHOPHYSIOLOGY
 Non-modifiable Factor: Age Modifiable Factors: Lifestyle; Diet; Hygiene

Etiology: E. Hystolytica, Salmonella, Shigella,

Campylobacter jejuni, E. Coli, Norovirus, Adenovirus

Person to person (hands) Contaminated food and/or water

Ingestion of Pathogens

Direct invasion of the bowel wall Endotoxins are released

Nausea and Vomiting

Stimulation and destruction of
mucosal lining of the bowel wall
F & E Imbalance
Digestive and absorptive malfunction GI Distention
Dehydration
Secretion of fluid &
electrolytes in the Excessive Gas Formation
intestinal lumen
Dry lips, dry mouth,
fatigue, irritability

Increased Peristaltic
Movement

Diarrhea
DRUG STUDY
 Drugs Mechanism Indication Contraindication Adverse Nursing
of action effect consideration

Generic Variables Chronic stable Hypersensitivity, CV; Do not confuse

name; effects on angina with out lactation Peripheral nifedipine with
NIFEDIPINE AV Vasospasm And Nicardipine (they
Node including Pulmonary also a calcium
Brand name; effective angina edema, channel blocker)
Nifediac cc and due to Hypotensio
Functional increases , palpitation,
Classification; Refractory effort, And
Calcium period. especially tachycardia.
channel in client, who
Blocker cannot take
beta
Dosage; blockers or
5mg PRN nitrates who
Remain
Symptomatic
following
clinical
doses of this
drugs.
Essential to
hypertension
 Drugs Mechanism Indication Contraindication Adverse Nursing
of action effect Consideration
Generic name; One-third to Lower Increase in . IM injection should
Ceftriaxone two-thirds respiratory serum be deep into the
excreted tract infection creatinine body of a large
Brand name; unchanged due to presence of muscles.
Rocephin in the urine streptococcus casts in the
pneumonia, urine. . do not mixed drug
Classification; staphylococcus with other
Cephalosporin aureus. antibiotics.
Skin and skin
Dosage; structure .stability of solutions
1ampule= infections for IM or IV use
50 ml varies depending on
TIV q12 the diluents used.
Check package
insert carefully.
 Drugs Mechanism Indications Contraindications Adverse Nursing
of action effect consideration
Generic name; Competitively Short-term Cirrhosis of the GI; . do not confuse
Ranitidine inhibits gastric and liver, impaired renal Constipation zantac with
acid secretion maintenance or hepatic function. , nausea and xanax or zyrtex.
Brand name; zantac blocking the treatment of vomiting,
effect of duodenal diarrhea,
Classifications; histamine on ulcer. abdominal
histamine H2 histamine H2 Short term of pain,pancrea
receptor blocking receptors. treatment of titis
drug. Food active
increases the benign
Dosage; bioavailability. gastric ulcer.
1 ampule TIV q8
 Drugs Mechanism Indications Contraindica Adverse Nursing
of action tions Effect Considerations

Generic
name; Decrease Control of Renal Few when . do not exceed
Paracetamol fever by pain due to insufficiency taken in usual dose of 4g/24hour
Hypothalamic headache, anemia, therapeutic in adults and
Brand name; effect Dysmenorrh clients with doses. 75mg/kg/day in
Acetaminophen leading to ea, cardiac or Chronic and children.
sweating muscular pulmonary even acute
and pain and disease are toxicity can .do not
Classification vasodilation. Arthritis To more develop after take for more than
reduce susceptible to long syptom- 5 days for pain in
non-narcotic fever in acetaminophen free usage children, 10days
analgesicDos bacterial or toxicity. for pain in adults,
age; adults; viral or more than 3
325-650mg infections. days for fever in
every 4 adults or children
hour(per without consulting
orem)Caplets provider.
, capsules,
oral liquid, or .take
syrup extended relief
product with water;
do not crush, chew
or dissolve before
swallowing.
 Drugs Mechanism Indications Contraindications Adverse Nursing considerations
of action effect
Generic name; Dopamine Parenteral; Gastrointestinal CNS; . inject slowly IV order 1-
Metoclopramide antagonist facilitates hemorrhage, restlessness, 2mins to prevent
that acts small obstruction or drowsiness, transient feelings of
Brand name; by bowel perforation; fatigue, anxiety and restlessness.
reglan increasing intubation, epilepsy. anxiety, Check packaged insert if
sensitivity Stim insomnia, drugs is to be admixed.
Classifications; to gastric headache,
gastrointestinal Acetylchol emptying, dizziness
stimulant ine results and
in Increase
Dosage; increased intestinal
10mg motility of Transit of
IV q8 the upper barium to
GI tract aid in
and radiologic
relaxation Examinatio
of the n of
pyloric stomach.
sphincter
and
duodenal
bulb.
Gastric
emptying
time and
GI transit
time are
shortened.
 Drugs Mechanism Indications Contraindications Adverse Nursing consideration
of action effect
Generic name; Iron is .prophylaxis Hemosiderosis, Constipation, . For infants and young
Ferrous sulfate absorbed and peptic ulcer, gastric children, administer liquid
from the treatment of irritation, preparation with a
Brand name; duodenum iron nausea, dropper. Deposit liquid
feosol and upper deficiency abdominal well back against the
Classification; jejunum by and iron cramps, cheek.
anti anemic iron active deficiency anorexia, . Eggs and milk and
mechanism anemias. vomiting, coffee and tea consumed
Dosage; adults, through the .dietary diarrhea, dark with a meal or 1hour after
150-250mg (1-2 mucosal supplement colored may significantly inhibit
time per day) cells where it for iron. stools. absorption of dietary iron.
Per orem combines . Do not crash or chew
with the sustained release
protein products.
Transferrin.
NURSING CARE
PLAN
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subj. data: LTG: Goal was met.

“ Madalas akong Deficient Fluid After 72 hrs. After 72 hrs. of
dumumi at Volume related of nsg. nsg. Intervention
nasusuka ako”. As to frequent Intervention, the patient was
verbalized by the elimination of the patient will
patient. loose watery be able to able to maintain
stool and maintain the her fluid volume
vomiting fluid volume at in functional
Obj. data:
functional level level as
-dry skin, lips by:
-body malaise evidenced by:
-sunken eyes 1.)Health
-paleness teaching on
-poor skin turgor patient on how -The patient
to attain -Giving advice on the -To promote demonstrated
-restlessness
normal patient to increase understanding proper
hydration fluid intake. and avoid understanding
V/S: status. rercurrence of on the
T- 36.6˚C
Illness health teaching
P- 63 bpm
R- 19 cpm 2.)Maintain
BP- 120/80 mmHg normal fluid
volume and -Fluid volume
replace fluid -Encourage -To reduce risk was normalized
loss. increase oral fluid of skin
intake breakdown
STG: STG:
After 8 hrs. of After 8hrs. of
nsg.
nsg.
Intervertion
Intervention, the the patient
patient will be improved her
able to body fluid
improve her volume,
body fluid evidenced by:
Volume at
functional level:

1.)Note the -The cause of

-Elderly
cause of fluid -Determine the fluid volume
volume deficit. individuals are at deficit was
effects of age.
high risk determined
because of
decreasing
response/
effectiveness of
compensatory
Mechanism
2.)Note physical -Physical signs
signs associated -Compare usual -Indicator of associated with
with dehydration. and current overall fluid dehydration is
nutritional status noted and
weight
Examined

.
3.)Establish 24 -Advice intake -To provide -Establish 24
hrs. fluid of foods with hydration hrs. fluid
replacement, high fluid replacement,
needs, and content needs, as
routes, as ordered
ordered.

4.)Evaluate the -Measure -To ensure -The degree of

degree of fluid client’s output accurate data of fluid is
deficit fluid status evaluated

5.)Promote -Encourage -To prevent -Comfort and

comfort and change in stasis and safety of the
safety of the position reduce risk of patient was
patient frequently tissue injury Promoted

6.)Promote -Provide optimal -To prevent -Wellness

wellness skin care injury from promoted
Dryness

-Provide -To prevent

frequent injury from
oral and eye dryness
care
-Discuss factors -To educate the
and ways to patient
prevent
dehydration

-Assist client to -Help determine

measure her baseline
own intake and symptoms
output

-Recommend -To prevent

restriction of frequent
caffeine and Urination
Alcohol

DEPENDENT

-Administer IV -Fluids may be

fluids as given in this
Indicated manner, if client
is unable to take
oral fluid, or
when rapid
fluid
resuscitation is
required.
-Administer Antiemetics or
medications as antidiarrheals
ordered limit gastric/intestinal
losses

-Review -To evaluate degree

laboratory data of fluid and
electrolyte
imbalance and
response to
therapist
DISCHARGE PLAN
Patients with Acute Gastroenteritis, watchers
are instructed to take the following plan for
discharge:
M- Medications should be taken regularly as prescribed , on exact
dosage, time, & frequency, making sure that the purpose of
medications is fully disclosed by the health care provider.
- Home medication : Ranitidine tablet (Zantac)
E- Exercise should be promoted in a way by stretching hand and
feet every morning and exercise burping every after meal.
T- Treatment after discharge is expected for patients and watcher
with Acute Gastroenteritis to fully participate in continuous
treatment.
- Usually supportive, treatment consists of nutritional support
and increase fluid intake.
H- Hygiene must be maintained for patients with Acute
Gastroenteritis. Promotion of personal hygiene should be
encouraged such as, daily bathing and always wash hands w/
warm water and soap handling foods, esp. after using the bathroom
O- OPD such as regular follow-up check-ups should be
greatly encouraged to clients watcher with Acute
Gastroenteritis as ordered by physician to ensure the
continuing management and treatment.
D- Diet should be promoted, such as soft and bland
diet that cannot irritate the GI tract.
S- Signs and Symptoms.
-Clinical manifestations vary depending on the
pathologic organism and the level of GI tract
involved. AGE produces symptoms such as:
diarrhea, abdominal discomfort, nausea and
vomiting, fever, body malaise
-In children and elderly and debilitated people,
AGE produces the same symptoms, but the
inability of the patient to tolerate electrolyte
losses leads to a higher mortality.
-THE END-