MAY 8, 2011
Table of Contents
I. INTRODUCTION
II. OBJECTIVES
III. BIOGRAPHICAL DATA
IV. CHIEF COMPLAINT
V. HISTORY OF PRESENT ILLNESS
VI. PAST MEDICAL HISTORY
VII. FAMILY MEDICAL HISTORY
VIII. PERSONAL AND SOCIAL HISTORY
IX. COURSE IN THE WARD
X. REVIEW OF SYSTEMS
XI. PHYSICAL ASSESSMENT
XII. DIAGNOSIS
XIII. DIFFERENTIAL DIAGNOSIS
XIV. ANATOMY AND PHYSIOLOGY
XV. PATHOPHYSIOLOGY
XVI. LABORATORY RESULT
XVII. NURSING CARE PLAN
XVIII. DRUG STUDY
XIX. DISCHARGE PLANNING
I. IntroductionGastroenteritis is the infection or irritation of
the digestive tract, particularly the stomach and the intestines.
It is also known as gastric flu/ stomach flu, although it is not
related to influenza. It is usually consist of mild to severe
diarrhea that may be accompanied by loss of appetite, nausea,
vomiting, cramps and discomfort in the abdomen. Although
Gastroenteritis usually is not serious for healthy adults, it can
cause life-threatening dehydration and electrolyte imbalance in
very ill, the very young and the very old. (Merck
Manual)Gastroenteritis is a very common disease; most people are at
some risk to encounter the wide-spread causes (mainly viral and
bacterial). This risk is due to poor hygiene of a few people with
the disease that may be encountered frequently in daily living (for
example, infants, children, or some food handlers). Some people
have higher risk for infection; for example, individuals on cruise
ships or those that live or work in crowded conditions like child
care centers, dorms, or barracks, because of the higher chance that
an infected person will come in contact with many other people, and
rapidly spread the causative agent. (www.medicinenet.com)According
to the then NSO survey, 572, 259 infants, young and old were
affected by diarrheal diseases during 2006. Because of severe
dehydration and diarrhea, 914 case of Acute Gastroenteritis
specifically infants hospitalize and eventually die. ) Locally, In
July 22, 2004, the Department of Health (DOH), Philippines declared
an epidemic (outbreak) of a water/food-borne disease called acute
gastroenteritis in 45 towns in Central Pangasinan. Acute
gastroenteritis is a human enteric (intestinal) disease primarily
caused by ingestion of spoiled or bacterial contaminated water or
food.(www.census.gov.ph)
II. ObjectivesA. General Objectives
To understand the underlying disease of the patient and identify
the significant physiological, psychological and socioeconomic
needs to provide appropriate care.
B. Specific Objectives
1. To know the anatomy of the G.I. tract and pathophysiology of
Acute Gastroenteritis. 2. To learn about the major etiologic agent
of AGE.3. To determine the previous and present medical history of
the patient.4. To perform physical assessment with special
attention on the systems focus. 5. To show the laboratory
examination results with the corresponding normal values, actual
result from the patient, and its interpretation6. To learn the
basic principle of medical management of AGE.7. To gain information
through Nurse-Patient interaction, identify problems from the
client and provide the appropriate nursing care plan.8. To
understand the pharmacological management set on the client and
provide nursing interventions. 9. To identify the discharge plan
for the patients rehabilitation to conduct an evaluation of the
clients condition from admission to present.
III. Biographical DataPatients Name:SMPAge:1 year
oldGender:MaleStatus:SingleDate of Birth:May 9, 2010Place of
Birth:La Union (lying-in)Nationality:FilipinoReligion:Roman
CatholicAddress:Makati CityDate of Admission:April 25, 2011
(11:12AM)Hospital:Ospital ng MakatiInformant:MotherPercentage of
Reliability:80%
IV. Chief ComplaintMasyado na kasing liquid yung tae na
lumalabas sa colostomy bag niya as verbalized by the mother
V. History of Present IllnessThe patient is a known case of
intussusception, s/p exploratory laparotomy, ileal resection with
ileostomy, appendectomy. (December 19, 2010)History revealed that
10 days prior to admission, patient was discharge for acute
gastroenteritis. Prior to discharge, the consistency of the stool
was soft, non-bloody, and the patient was active, no fever and
vomiting.On the 9th day until the 2nd day prior to admission, the
patient didnt experience any signs of further symptoms of acute
gastroenteritis.One day prior to admission, patient had loose
watery yellowish stools via ileostomy bag. He had fever of 39oC,
3-4 episodes of vomiting of milk amounted 2-3 tbs.Symptoms
persisted until few hours prior to admission; patient was noted to
be irritable. Thus patient brought to Ospital ng Makati for
re-admission.
VI. Past Medical HistoryThe patient was delivered NSD at one of
the lying-in at La Union and was fully immunized. He had previous
case of intussusceptions, s/p exploratory laparotomy, ileal
resection with ileostomy, appendectomy last December 19,
2010.VACCINEAge of Vaccination
BCGAt birth
Hepa BAt birth
Vit. KAt birth
DPT6 weeks
OPV6weeks
AMV9 months
VII. Family Medical HistoryNo significant family medical
history.
VIII. Personal and Social HistoryA. Health Perception and Health
Management PatternThe mother considers the patients health so
important. She assures that the patient receives enough nutrition
and is alert to any abnormal condition his son is experiencing.
Whenever her son has cough, she gives him home remedies in which if
does not alleviate makes her decide to bring him on private
clinics. She ensures that she is focused on the patients health. B.
Nutritional and Metabolic Pattern Patient SMP is exclusively
breastfed from birth up to 6 months old. When he is 6 months old,
he started to eat solid foods like rice and biscuits such as wafer,
eggnog, breadstick and bravo. His appetite is good. He is not
eating salty foods yet fond of eating fruits like orange and
banana. Her mother then gave him formula milk and its brand is
Pediasure. He drinks a lot of water. When he was hospitalized, this
routine was changed since hes no longer fond of eating fruits and
drinking water but is still given formula milk.
C. Elimination patternThe mother changes his diaper three times
a day. According to the mother, the patient defecates three times a
day with yellow colored stool. The consistency of his stool is
condensed, soft and slightly formed. When he was hospitalized, her
mother then changes his diaper two times a day and his stool is
watery.
D. Activity and Exercise PatternAccording to the mother, he
wants to walk but needs assistance. He plays many toys but he loses
eagerness and gets easily tired and plays another toy. E. Sleep and
Rest PatternHe sleeps in the morning up to lunch, two naps in the
afternoon and sleeps in the whole night. When he was hospitalized,
his sleep pattern changed. He sleeps on and off for about every two
hours at night and just take naps if not disturbed.
F. Cognitive and Perceptual PatternThe patient is active and is
oriented with the people around him. He could recognize his mother
and father.
G. Role and Relationship PatternAccording to the mother, he is a
very active child and does not cry easily. He recognizes the people
around him and play with them. He has one elder brother and they
kept on playing with each other when he was around. He can cope
easily with other person.
H. Sexuality and Reproductive PatternNot applicable to age
I. Coping and Stress TolerancePatient SMP copes up to his
condition very well. He is not easily irritated and is even a jolly
kid. He is fond of playing with people around him. He reduces his
stress by entertaining himself with the different things around
him. He has also good appetite despite of his condition.
J. Value and Belief PatternTheir religion is Roman Catholic.
K. Self-Perception and Self-Concept Pattern Not applicable to
age
General
(+) altered sleeping pattern
Integumentary System
(+) pruritus around the skin barrier of ileostomy bag
Gastrointestinal System
Stool from ileostomy bag was yellowish in colour, ~ half of
plastic cup as amount and drain twice a day
XI. Physical Assessment (MAY 10, 2011)
GENERAL APPEARANCEAwake, conscious, active and looks as an
infant (1 yr old).
CEPHALOCAUDAL EXAMINATIONFindingsReference Value
Anthropometric measurementHeight : 69 cmWeight : 8.5 kgWeight
Percentile Rank: 9%Height Percentile Rank: