Case Presentation Gastroenteritis

CASE PRESENTATION OBJECTIVES

CASE PRESENTATION OBJECTIVES

General Objectives

After an hour and a half of case presentation:

The presenters, the audience, and the clinical instructors will be acquainted with the vital information; patients health history; normal anatomy and physiology of gastrointestinal system; pathophysiology of the disease; clinical manifestations; medical and surgical managements; diagnostic tests; nursing care plan; and discharge plan of a client with gastroenteritis.

Specific ObjectivesFor the presenterThe presenter will be able to:

Impart the patients vital information and health history;Elaborate the normal anatomy and physiology of the gastrointestinal system;Illustrate the pathophysiology of gastroenteritis;Discuss the clinical manifestations;Explain the medical and surgical management;Differentiate the normal and abnormal values of laboratory and diagnostic tests;Prioritize the identified problems; andOutline the discharge plan.

For the studentsThe students will be able to:

Comprehend the patients vital information and health history;Relate the normal anatomy and physiology of the gastrointestinal system;Create a diagram of the pathophysiology of gastroenteritis;Distinguish the clinical manifestations;Appreciate the importance of medical and surgical management;Contrast normal from abnormal values of laboratory and diagnostic tests:Critique the nursing care plan; andApply the discharge plan.

For the Clinical InstructorsThe clinical instructors will be able to:

Ask questions regarding the normal anatomy and physiology of the gastrointestinal system;Critique the pathophysiology of gastroenteritis;Differentiate the clinical manifestations of gastroenteritis;Critique the nursing care plan; andModify the discharge plan.

INTRODUCTIONGastroenteritis, or enteritis, is an inflammation of the stomach and small intestine. Enteritis may be caused by bacteria, viruses, parasites, or toxins. Upper GI manifestations such as anorexia, nausea, and vomiting are common. Diarrhea of varying intensity and abdominal discomfort are nearly universal features of gastroenteritis. (LeMone, 2010)

The infectious organism usually enters the body in contaminated water or food. For this reason, gastroenteritis often is called food poisoning. Viruses commonly cause acute diarrheal illness. Diarrhea due to rotaviruses or the Norwalk virus occurs year-round in both adults and children. These illnesses are generally mild and self-limited, but can have severe consequences in the very young, the very old, or in people with impaired immune function. (LeMone, 2010)

In our case study for this morning, we are focusing about our patient which is an infant. Although often considered a benign disease, gastroenteritis remains a major cause of morbidity and mortality in children around the world, accounting for 1.34 million deaths annually in children younger than 5 years, or roughly 15% of all child deaths.. As the disease severity depends on the degree of fluid loss, accurately assessing dehydration status remains a crucial step in preventing mortality. Luckily, most cases of dehydration in children can be accurately diagnosed by a careful clinical examination and treated with simple, cost-effective measures. Although dehydration technically refers to pure water loss and can be associated with euvolemic or even hypervolemic states in certain pediatric disorders, the term is used in its more general sense to mean overall fluid or volume loss due to diarrhea. (http://emedicine.medscape.com)

Specific Types of Gastrointestinal Infections: (LeMone, 2010)

Travelers Diarrhea - People traveling to another country frequently develop diarrhea within 2 to 10 days, particularly when there is a significant difference in climate, sanitation standards, or food or drink. Strains of enterotoxin-producing E. coli, Shigella species, Salmonella, and Campylobacter are the most frequent causes of travelers diarrhea (Yates, 2005). Other bacteria and viruses also may cause travelers diarrhea. Up to 10 or more loose stools per day and abdominal cramping are common manifestations. Nausea and vomiting are less frequent; fever is rare. Manifestations usually resolve within 2 to 5 days. Complications are rare.

Escherichia Coli Hemorrhagic Colitis - most pathologic forms of E. coli bacteria cause little more than common travelers diarrhea. However, some strains, such as serotype 0157:H7, produce a potent enterotoxin in the large intestine after being ingested. This toxin damages bowel mucosa and the endothelial cells of blood vessels as well, such as those of the kidney.The onset of hemorrhagic colitis is abrupt, with severe abdominal cramping and watery diarrhea that becomes grossly bloody within 24 hours. Fever may be present. Hemolytic uremic syndrome and thrombotic thrombocytopenic purpura are significant complications of E. coli hemorrhagic colitis.

Staphylococcal Food Poisoning - Certain foods provide an excellent medium for staphylococcal growth when contaminated and left at room temperature. Examples include meats and fish, dairy products, and bakery products. The organism itself does not affect the bowel; the toxin it produces, however, impairs intestinal absorption and acts on receptors in the gut, stimulating the medullary center to produce vomiting.The onset of staphylococcal food poisoning is abrupt, occurring within 2 to 8 hours after consuming the contaminated food. Nausea and vomiting are severe. Manifestations typically last 3 to 6 hours, and include abdominal cramping, diarrhea, headache, and fever. Complications such as fluid and electrolyte imbalances are rare, but may develop in older adults and people with underlying chronic disease processes.

Cholera - is an acute diarrheal illness caused by strains of Vibrio cholerae. It is endemic in parts of Asia, Middle East, and Africa. Cholera is spread by the fecal-oral route through contaminated water or food. The organism produces an enterotoxin, enzymes, and other substances that affect the entire small intestine. Water and electrolytes are secreted into the bowel lumen in response to the toxin. The enzymes and other substances produced by the bacteria may affect mucous protection of bowel endothelium.

Clostridium Difficile Colitis - is associated with antibiotic therapy. Treatment with antibiotics predisposes to interference with the normal protective bacteria of the colon, leading to colonization by C. difficile by the oral-fecal route. Subsequent release of toxins by the bacteria causes mucous damage and inflammation. This is primarily a problem in hospitalized patients, causing diarrhea and abdominal cramping. These manifestations commonly begin within 1 to 2 weeks of antibiotic treatment. It is also being seen in the community in healthy adults. The bacteria can be identified in the stool.

Salmonellosis - is food poisoning caused by ingesting raw or improperly cooked foods contaminated with Salmonella bacteria. Meat, poultry, eggs, and dairy products commonly are implicated in Salmonellosis; recent outbreaks have been linked to products such as peanuts and alfalfa sprouts. These bacteria cause superficial infection of the GI tract, rarely invading further. They do not produce toxin. Manifestations develop 8 to 48 hours after ingesting the bacteria. Diarrhea may be violent with abdominal cramping, nausea, and vomiting. A low-grade fever, chills, and weakness may accompany GI manifestations.

Shigellosis (Bacillary Dysentery) - Occurs worldwide, and may be endemic or occur in epidemics. Humans are the reservoir for Shigella organisms, which are spread directly via fecal-oral route or indirectly through contaminated food, fomites, and vectors (such as fleas). The incubation period for shigellosis is 1 to 4 days.

Norovirus - is a highly contagious disease that often occurs in outbreaks within an institution or facility. It is characterized by acute vomiting, watery, non-bloody diarrhea, abdominal cramps, and nausea. Systemic manifestations such as myalgia, malaise, headache, and low-grade fever are common.

MANIFESTATIONS

Gastrointestinal Effects:

Anorexia, nausea and vomitingAbdominal pain and crampingBorborygmiDiarrhea

General Effects:

Malaise, weakness, and muscle achesHeadacheDry skin and mucous membranesPoor skin turgorOrthostatic hypotension, tachycardiaFever

Although the manifestations of bacterial and viral enteritis vary according to the organism involved, several features are common. Anorexia, nausea, and vomiting are caused by distention of the upper GI tract by unabsorbed chime and excess water. Bowel distention, along with irritation of the bowel mucosa and gas production due to fermentation of undigested food, lead to abdominal pain and cramping. Borborygmi, excessively loud and hyperactive bowel sounds, are another result. The abdomen is often distended and tender. Diarrhea is usually predominant with enteritis. Fluid is secreted into the bowel lumen, and the unabsorbed chyme and electrolytes create an osmotic pull of fluid into the bowel. Motility is stimulated, and stools become watery and frequent. Loss of fluids and electrolytes through diarrhea can lead to most serious manifestations of enteritis. Fluid volume can be rapidly depleted, leading to dehydration and hypovolemia. Orthostatic hypotension and fever may be noted initially. If fluid loss continues, hypovolemic shock may develop. (LeMone, 2010)

COMPLICATIONSElectrolyte and acid-base imbalances may result from gastroenteritis. Extensive vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach. When diarrhea predominates, metabolic acidosis is more likely. Potassium is lost in either case, leading to hypokalemia. Hyponatremia may develop if fluids are replaced with pure water. Headache, cardiac irregularities, changes in respiratory rate and pattern, malaise and weakness, muscle aching, and signs of neuromuscular irritability are the possible manifestations of these disturbances in homeostasis. (LeMone, 2010)

RISK FACTORS (http://www.patient.co.uk)

Poor hygiene and lack of sanitationCompromised immune systemPoorly cooked food, cooked food that has been left too long at room temperature or from uncooked food. Insufficient reheating of food not only fails to kill bacteria but may speed up multiplication and increase the bacterial load ingested. Even if reheating of cooked food kills bacteria, enterotoxins such as staphylococcal exotoxin are not destroyed.

MANAGEMENTS (http://www.patient.co.uk)

Fluid managementContinue breast-feeding and other milk feedsEncourage fluid intakeDiscourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydrationOffer oral rehydration salt (ORS) solution as supplemental fluid to those at increased risk of dehydration

Nutritional managementDuring rehydration therapy:

Continue breast-feedingDo not give solid foodsIn children with mild cases, do not routinely give oral fluids other than ORS solution; however, consider supplementation with the child's usual fluids (including milk feeds or water but not fruit juices or carbonated drinks) if they consistently refuse ORS solutionIn children with severe cases, do not give oral fluids other than ORS solution

DrugsAntibiotic therapy should not be used routinely but should be given:

For suspected or confirmed septicemiaWith extra-intestinal spread of bacterial infection.When younger than 6 months with salmonella gastroenteritis.In those who are malnourished or immunocompromised with salmonella gastroenteritis.Where there is C. difficile-associated pseudomembranous enterocolitis, giardiasis, bacillary dysentery, amoebiasis or cholera.

PREVENTION

Breast-feeding confers some protection against gastroenteritis.Rotavirus vaccineWashing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis.Hands should be washed after going to the toilet or changing nappies (parents) and before preparing, serving or eating food.

DEFINITION OF TERMS

1. Borborygmi- a rumbling or gurgling sound caused by the movement of gas in the intestines.2. Norwalk Virus- A family of small round viruses that are an important cause of viral gastroenteritis (viral inflammation of the stomach and intestines). Norwalk disease is a significant contributor to illness in the US.

3. Chyme- The semifluid mass into which food is converted by gastric secretion and which passes from the stomach into the small intestine.4. Distention- Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth of the stomach and waist.5. Enteritis- Enteritis is the inflammation of your small intestine. In some cases, the inflammation includes the stomach and large intestine.

6. Enterotoxins- a toxin specific for the cells of the intestinal mucosa.7. Fermentation- Fermentation is a form of biological energy production and "fermented" is the end result of the process I present below.8. Hydrochloric Acid- HCL is the medical friendly, water and acid soluble, salt version of an amine. Amines are converted to a salt form for their standardized and predictable rates of solubility and absorption.

9. Hypokalemia- Hypokalemia is a condition of below normal levels of potassium in the blood serum.10. Hyponatremia- is defined as a low sodium concentration in the blood.11. Hypovolemia- is a state of decreased blood volume; more specifically, decrease in volume of blood plasma.12. Lumen- The inner open space or cavity of a tubular organ, as of a blood vessel or an intestine.13. Metabolic Alkalosis- Metabolic alkalosis is a pH imbalance in which the body has accumulated too much of an alkaline substance, such as bicarbonate, and does not have enough acid to effectively neutralize the effects of the alkali.14. Mucosa- The mucous membrane, or the thin layer which lines body cavities and passages.15. Orthostatic- Is a form of low blood pressure that happens when you stand up from sitting or lying down.16. Osmotic- Diffusion of fluid through a semipermeable membrane from a solution with a low solute concentration to a solution with a higher solute concentration until there is an equal solute concentration on both sides of the membrane.

17. Rotavirus- Any of a group of wheel-shaped viruses, of the genus Rotavirus, that causes gastroenteritis and diarrhea in children and animals.18. Vibrio Cholerae- One of the Vibrio bacteria, V. cholerae (as the name implies) is the agent of cholera, a devastating and sometimes lethal disease with profuse watery diarrhea.

VITAL INFORMATIONName: Ms. DiamondRoom Number: 242 Bed 5Age: 4 months oldGender: FemaleCivil Status: ChildDate of Birth: November 10, 2014Birthplace: Iligan CityCultural Group: IliganonPrimary Language: BisayaReligion: Roman CatholicHighest Educational Attainment: N/AOccupation: N/AUsual Health Care Provider: Dr. Uy HospitalReason for Health Contact: Fever & LBMDate of Confinement: March 7, 2015Source of History: Patients motherAttending Physician/s: Dr. Yvette NadalAdmitting Impression: Acute Infectious Diarrhea Moderate DehydrationFinal Diagnosis: Acute Gastroenteritis with Severe Dehydration and Electrolyte Imbalance Hyponatremia, HypocalcemiaDescription of Patient: Awake, lying on bed, alert, with patent IVF of D5IMB via IV pump @20cc/hr, no episodes of bowel movement, afebrile during initial visit.

HISTORY OF PRESENT ILLNESSAccording to the patients mother, five days before admission, patient had experienced an onset of intermittent fever. The patient was given Paracetamol drops 0.25 ml every 4 hours for her fever which afforded temporary relief. Nagpadayon man gihapon iyang hilanat so gi-admit namo siya sa Dr. Uy Hospital adtong Monday last week (March 2, 2015) kay didto man namo siya sige ipa check-up. Si Dr. Mariano iyang doctor didto. as verbalized by the mother. The patient was given medications such as Napran and Ener-E vitamins. Last March 4, 2015, patient was discharged from Dr. Uy Hospital. Last Thursday (March 5, 2015), the fever recurred. The next day, the fever was already associated with LBM with watery stools, yellow green in color as stated by the mother. The patient experienced diarrhea continuously for 1 days and was already dehydrated as manifested by sunken eyes with pallor skin, thus prompted admission at AMC-Iligan Hospital.

PAST MEDICAL HISTORYThe patient had received immunizations such as BCG, Hepa B (3 doses), Pentavalent (3 doses), Rotavirus (2 doses), and OPV (3 doses). As stated by the mother, the child hasnt experienced any illnesses before such as measles, mumps, rubella, chicken pox, dengue fever, typhoid fever, etc. She had Tiki-tiki and Ceelin as her vitamins before. No history of accidents or injuries. Patient was admitted at Dr. Uy Hospital before, with her attending physician, Dr. Mariano. She was then transferred to AMC-Iligan Hospital due to recurrence of fever with LBM. No previous operations or any surgeries. No allergies as claimed by the patients mother.

NORMAL ANATOMY AND PHYSIOLOGYGastrointestinal SystemThe GI system is composed of one continuous tube that begins at the mouth, progresses through the esophagus, stomach and small and large intestines and ends at the anus. The pancreas, liver and gallbladder are accessory glands that support the functions of the GI system.

StructuresThe tube that comprises the GI tract is continuous with the external environment, opening at the mouth and again at the anus. Because of this GI tract contains many foreign agents and bacteria that are not found in the rest of the body.

Accessory Organs

Pancreas Deposits digestive enzymes and sodium bicarbonate into the beginning of small intestine to neutralize acid from the stomach and to further facilitate digestionGallbladderWhen gallbladder is stimulated to contract by the presence of fats, all of the nutrients absorbed from the small intestine pass into the liver Liver Produces bile (very important in the digestion of fats), which stored in the gallbladder.

Four Layers of the Gastrointestinal TractMucosal LayerThe mucosa is the innermost layer of the gastrointestinal tract that is surrounding thelumen, or open space within the tube. This layer comes in direct contact with digested food (chyme). The mucosa is made up of:

Epithelium - innermost layer. Responsible for most digestive, absorptive and secretory processes.Lamina propria - a layer of connective tissue. Unusually cellular compared to most connective tissueMuscularis mucosae - a thin layer of smooth muscle that aids the passing of material and enhances the interaction between the epithelial layer and the contents of the lumen by agitation andperistalsis.

Nerve Plexus LayerThe nerve plexus has two layers of nerves- one submucosal layer and myenteric layer. This nerves allow GI tract have control over movement, secretions and digestion. The nerve respond to local stimuli and act on the concepts of GI tract accordingly. Muscularis Mucosa LayerThe muscularis consists of an inner circular layer and alongitudinalouter muscular layer. The circular muscle layer prevents food from traveling backward and the longitudinal layer shortens the tract.

Adventitia LayerThe adventitia is the outer layer of the GI tract. It serves as a supportive layer and helps the tube maintain its shape and position.

Gastrointestinal Four Major ActivitiesSecretions The GI tract secretes various compounds to aid the movement of the food bolus through the GI tube, to protect the inner layer of the GI from injury and to facilitate digestion and absorption of nutrients. Absorption Absorption is the active process of removing water, nutrients and other elements from the GI tract and delivering them to the bloodstream for use by the body.

Digestion Digestion is the process of breaking food into usable and absorbable nutrients.

Motility Motility is the movement of food and secretions through the system. The basic movement seen in the esophagus is peristalsis, a constant wave of contraction that moves from the top to the bottom of the esophagus. The act of swallowing, a response to a food bolus in the back of the throat, stimulates the peristaltic movement that directs the food bolus into the stomach.

MEDICAL & SURGICAL MANAGMENTSAcute enteritis usually solves spontaneously, and no drug treatment required. If the patient is severe ill and manifestations are prolonged, medication maybe prescribed. Antibiotic therapy specific the organisms maybe use to treat bacterial colitis, cholera, salmonellosis, or shigellosis. Ciprofloxacin (Cipro), Clarithromycin (Biaxin), erythromycin, amoxicillin/clavulanate (Augmentin) or another antibiotic may prescribed. Stool culture is obtained prior to starting antibiotics.

Nutrition and FluidsReplacing the loss of fluid and electrolytes is vital when vomiting and/or diarrhea are severe or prolonged. In many cases of enteritis, fluid and electrolyte replacement are all that is required until infection resolves. Oral rehydration is preferred for replacing physiologic fluids. An oral glucose-electrolyte solution is often well tolerated in sips, even when vomiting is present. Intravenous rehydration may be necessary with severe diarrhea and fluid loss.

Gastric LavageGastric Lavage and catharsis- in effect, washing outthe stomach and intestines- may be performed to remove unabsorbed toxin from GI tract if botulism is suspected. The patient with botulism is closely observed for signs of respiratory distress. Respiratory support with endotracheal intubation or tracheostomy and mechanical ventilation may be required.PlasmapheresisPlasmapheresis (plasma exchange therapy) may be performed to remove circulating toxins for hemorrhagic colitis caused by E-coli. Potential complications include those associated with intravenous catheters, shifts in fluid balance, and altered blood clotting.

DialysisAcute tubular necrosis and renal failure associated with hemorrhagic colitis may necessitate dialysis to remove wastes and prevent severe fluid and electrolyte imbalances and metabolic acidosis. Although acute renal failure often resolves spontaneously and renal function resumes, dialysis can be lifesaving. Either hemodialysis or peritoneal dialysis may be used, generally as a temporary measure.

DISCHARGE PLAN & TEACHING

Special Instructions: Hand washingIncrease fluid intakeHealth teachings:Instruct the mother to clean the bottles or any containers used in feeding the baby.Encourage the parents to do hand washing before and after giving the milk to the baby.Instruct them to comply religiously the medication with their baby to the period of time as prescribed.Demonstrate to the parents the different ways of burping for the baby. OPD Visits/ Referrals: Follow up check up on March 17, 2015 at DR. Nadals ClinicDiet: Milk Formula for ageSpiritual care: Be grateful for all the things that God has been given to us. For He never forget to bless and shower His graces. Humbly we bow ourselves unto Him and give respect for He is the King of kings and Lord of all lords. All things are made because of His will, thank God for His protection and guidance in our everyday journey in life.

PROGNOSISThe prognosis for complete recovery is excellent in most people infected with viral and bacterial caused by gastroenteritis, as long as the person keeps well hydrated. Their prognosis depends on how dehydrated they become and how effective are the attempts to rehydrate the patient. Prevention of the recurrence of the disease is also important.

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