A Case Analysis of Acute Gastroenteritis with moderate Dehydration

In Partial fulfillment in the Requirements in Nursing Care Management 104

Presented to level III instructors of Davao Doctors College

Presented by: Badayos, Analuza ; Balansag, Michael Jones; Balboa, Surschel; Basadre, Honey Grace; Bucay, Sittienor

March 2013 Introduction

Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Globally, most cases in children are caused by rotavirus. In adults, norovirus and Campylobacter are more common. Less common are infectious, although gastroenteritis may occur after ingestion of drugs and chemical toxins (eg, metals, plant substances). Acquisition may be foodborne, waterborne, or via person-to-person spread. Symptoms include anorexia, nausea, vomiting, diarrhea, and abdominal discomfort. Diagnosis is clinical or by stool culture, although PCR and immunoassays are increasingly used. The foundation of management is adequate hydration. Treatment is symptomatic, although some parasitic and some bacterial infections require specific antiinfective therapy. Gastroenteritis is usually uncomfortable but self-limited. Electrolyte and fluid loss is usually little more than an inconvenience to an otherwise healthy adult but can be grave for people who are very young, elderly, or debilitated or who have serious concomitant illnesses. Worldwide, an estimated 1.5 million children die each year from infectious gastroenteritis; although high, this number represents one half to one quarter of previous mortality. Improvements in water sanitation in many parts of the world and the appropriate use of oral rehydration therapy for infants with diarrhea are likely responsible for this decrease. Approximately 179 million cases of acute gastroenteritis (AGE) occur annually in the United States. Routine clinical diagnostics identified a pathogen in 42 (7.3%) of 572 specimens; inclusion of molecular viral testing increased pathogen detection to 15.7%. Community AGE incidence was 41,000 cases/100,000 person-years and outpatient incidence was 5,400/100,000 person-years. Norovirus was the most common pathogen, accounting for 6,500 (16%) and 640 (12%) per 100,000 person-years of community and outpatient AGE episodes, respectively. Nationally, 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. According to the DOH Secretary, Dr. Manuel Dayrit, a total of 2,778 cases of the said intestinal infection were recorded in just 45 days (from May 31 to July16, 2004). From the studies on the medical diagnoses of 81 cases, Dayrit concluded that infectious (transmittable) cholera disease was the main cause of the epidemic (www.doh.gov.ph). Locally here in Davao City, Diarrhea & Gastroenteritis is the 5 th leading cause of morbidity in year 2010 with an incidence of 4,205/100,000 person.

PATIENTS PROFILE

name

M.T.F

age

28 years old

sex

Female

civil status

Married

religion

Catholic

address

Davao City

Anatomy and Physiology

The human gastrointestinal tract is the stomach and intestine, sometimes including all the structures from the mouth to theanus. (The "digestive system" is a broader term that includes other structures, including the accessory organs of digestion). In an adult male human, the gastrointestinal (GI) tract is 5 meters (20 ft) long in a live subject, or up to 9 meters (30 ft) without the effect of muscle tone, and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract. The GI tract always releases hormones to help regulate the digestive process. These hormones, including gastrin, secretin, cholecystokinin, and grehlin, are mediated through either intracrine or autocrine mechanisms, indicating that the cells releasing these hormones are conserved structures throughout evolution.

The upper gastrointestinal tract consists of the esophagus, stomach, and duodenum. The exact demarcation between "upper" and "lower" can vary. Upon gross dissection, the duodenum may appear to be a unified organ, but it is often divided into two parts based upon function, arterial supply, or embryology. The lower gastrointestinal tract includes most of the small intestine and all of the large intestine. According to some sources, it also includes the anus. Small Intestine: Has three parts: Duodenum: Here the digestive juices from the pancreas (digestive enzymes) and hormones and the gall bladder (bile) mix. The digestive enzymes break down proteins and bile and emulsify fats into micelles. The duodenum contains Brunner's glands which produce bicarbonate. In combination with bicarbonate from pancreatic juice, this neutralizes HCl of the stomach. Jejunum: midsection of the intestine, connecting the duodenum to the ileum. It contains theplicae circulares, and villi to increase the surface area of the GI Tract. Products of digestion (sugars, amino acids, fatty acids) are absorbed into the bloodstream. Ileum: Has villi and absorbs mainly vitamin B12 and bile acids, and other nutrients. Large Intestine: Has three parts: Caecum: The Vermiform appendix is attached to the caecum. Colon: Includes the ascending colon, transverse colon, descending colon and sigmoid. The main function of the Colon is to absorb water, and it contains bacteria that produce beneficial vitamins like vitamin K. Rectum: the comparatively straight, terminal section of the intestine, ending in the anus. Anus: Passes fecal matter from the body.

Pathophysiology
Predisposing factor: Immuno-compromised Ingestion of contaminated food/water Precipitating factor: Poor sanitation Contaminated food and water

Pathogen enters gastrointestinal tract

Interrupted normal intestinal flora activity

Pathogens released endotoxin Irritation of intestinal mucosa

Stimulation and destruction of mucosal lining Increase secretion of fluid and electrolytes into intestinal lumen

---

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Ulceration

Bleeding

Increase secretion of Cl and HCO3 ions

Inhibition of Na reabsorption Increase secretion of protein-rich fluid

Inhibition of proteinrich fluid reabsorption DIARRHEA Loss of fluid and Electrolytes

Abdominal distention

DEHYDRATION

Pathophysiology Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one of the most common causes of acute gastroenteritis is E. histolytica. The pathologic process starts with ingestion of fecally contaminated food and water. The organism affects the body through direct invasion and by endotoxin being released by the organism. Through these two processes the bowel mucosal lining is stimulated and destroyed that eventually lead to attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the stomach. The client with acute gastroenteritis may also report excessive gas formation that may leads to abdominal distention and passing of flatus due to digestive and absorptive malfunction in the system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress to nausea and vomiting and increasing frequency of defecation. As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct invasion of the organism and the action of the hydrochloric acid of the stomach. Pain or tenderness of the abdomen can then be felt by the patient. When the burrows or ulceration reaches the blood vessels in the stomach, bleeding will be induced. Signs of bleeding may be observed also through hematemesis. As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes water and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride and bicarbonate ions in the bowel as the body try to get rid of the organism by increasing peristalsis and number of defecation. Sodium and water reabsorption in the bowel is inhibited with the lost of the two electrolytes. Mild diarrhea is characterized by 2-3 stool, borborygmic (hyperactive bowel sound), fluid and electrolyte imbalance and hypernatremia. When the condition continue to progress, protein in the body is excreted to the lumen that further decreases the reabsorption and the body become overwhelmed that leads to intense diarrhea with more than 10 watery stool. Serious fluid volume deficit may lead to hypovolemic shock and eventually death.

A. PERSONAL DATA Name: Michelle Tandora Fernandez Age:_28_ Sex:__Female_ Civil Status:_Married_ Date of Admission: March 03, 2013 Address: Prk. 10 Emerald St. Doa Salud Subd., Sasa, Davao City Chief Complain: ___LBM & Vomiting Diagnosis:Acute Gastrointeritis with mild dehydration Religion:_Roman Catholic Occupation: Call Center Representative Impression:Acute Gastroenteritis with mild dehydration

B. FAMILY BACKGROUND Mrs. Michelle Fernandez is the 3rd child in the family. She is a non-smoker and non-alcoholic drinker. On her mother side has a family history of hypertension while on the father side has asthma, fortunately she does not have this illnesses. She works as a call center representative on a graveyard shift and she has a 1 year old daughter. Patient has an allergy on ibuprofen, celecoxib, mefenamic acid, ketorolac, meloxicam but does not had food allergy. C. EFFECTS/EXPECTATIONS OF ILLNESS TO FAMILY AND SELF Mrs. Michelle Fernandez is very anxious when she was admitted to Davao Doctors Hospital because she thinks that even if she has a Phil. Health card the hospitalization will still cost them money. Her family was expecting that this ailment will be gone so that Mrs. Michelle Fernandez can continue to work. D. HISTORY OF PAST ILLNESS Mrs. Michelle Fernandez had no history of the present illness but has experience its signs and symptoms. She was hospitalized at year 2011 at (Davao Doctors Hospital) because of her first pregnancy (G1P1). E. HISTORY OF PRESENT ILLNESS Patient Michelle Fernandez was apparently well until few hours PTA when she noted sudden onset of Crampy abdominal pain, 8/10 in severity, associated with LBM of non-smelling stools x 4 episodes and vomiting x 4 episodes. Persistence prompted the admission. She verbalize that she only ate a left over on that night and she added that she smelled it and it does not smell spoiled.

FUNCTIONAL PATTERN

Guidelines I. MENTAL STATUS a. State of mental consciousness b. Orientation c. Attention span d. Ability to understand

Normal Assessment

On Going Assessment Day1 March 4, 2013

Day 2 March 5, 2013 Conscious Oriented to time, place and people. With long attention span Able to understand simple instructions

Conscious Oriented to time, place and people. With long attention span Able to understand simple

Conscious Oriented to time, place and people. With long attention span Able to understand simple instructions

ideas instructions II. STATUS OF SPECIAL SENSES a. Auditory perception Able to hear sounds b. Visual perception Able to see clearly without c. Speech perception d. Tactile perception e. Olfactory perception aid Able to speak without problem Able to feel sensations Able to distinguish different odor III. MOTOR ABILITY STATUS a. Current mobility Ambulatory at times b. Posture Good body posture c. Range of motion Has a good ROM d. Muscle and nervous

Able to hear sounds Able to see clearly without aid Able to speak without problem Able to feel sensations Able to distinguish different odor

Able to hear sounds Able to see clearly without aid Able to speak without problem Able to feel sensations Able to distinguish different odor

Ambulatory at times Good body posture Has a good ROM

Ambulatory at times Good body posture Has a good ROM

status e. Loss of extremities None IV. BODY TEMPERATURE STATUS a. Ranges 36.5 37.5 degree Celsius V. RESPIRATORY STATUS a. Character Clear b. Use of respiratory Does not use respiratory aids c. Interference of respiration d. Abnormal aids No interference of respiration No abnormal respiratory opening Regular

None 36.7 37.2 degree Celsius

None 36.2 36.3 degree Celsius

Clear Does not use respiratory aids No interference of respiration No abnormal respiratory opening

Clear Does not use respiratory aids No interference of respiration No abnormal respiratory opening

respiratory opening VI. CIRCULATORY STATUS a. Characteristics of arterial pulse b. Apical-radial pulse c. Blood pressure d. Pulse pressure e. Mean arterial pressure

Regular 83bpm 110/70 mmHg 83bpm 83.3 mmHg

Regular 82bpm 110/80 mmHg 82bpm 90.0 mmHg

80 120 bmp 120/80 mmhg 80 120 bmp MAP = [(2 x diastolic) +systolic] / 3 70 100 mmHg

f. Intravenous fluid Without IVF VII. NUTRITIONAL STATUS a. Condition of buccal Able to masticate food cavity served b. Digestion of food c. Weight Not assessed VIII. ELIMINATION STATUS a. Bowel Able to defecate at least 2-3 b. Bladder times/day Able to Urinate at least

PNSS @ 140 cc/hr Able to masticate food served Able to consume of food served Not assessed Able to defecate at least 3 times during my shift Able to Urinate at least 6 times during

Without IVF Able to masticate food served Able to consume of food served Not assessed Able to defecate at least 1 time during my shift Able to Urinate at least 4 times

30ml/hour c. Abnormalities None IX. FEMALE REPRODUCTIVE STATUS a. Age of menarche 9 15 years old b. Patterns of menses 4 6 days IX. STATE OF SKIN AND APPENDAGES a. Skin Has good skin turgor without b. Hair c. Nails lesions Evenly distributed hair Well-trimmed/With CRT of

my shift None 13 years old 6 days Has good skin turgor without lesions Evenly distributed hair Well-trimmed/With CRT of less than 2 seconds Able to sleep 3 hours in my shift No presence of discomfort None

during my shift None b. Bladder 6 days Has good skin turgor without lesions Evenly distributed hair Well-trimmed/With CRT of less than 2 seconds Able to sleep 2 hours in my shift No presence of discomfort None

less than 2 seconds X. STATE OF PHYSICAL REST AND COMFORT a. Sleep/rest pattern Able to sleep at least 8 b. Presence of pain/ discomfort c. Use of supportive hours/day No presence of discomfort None

aids XI. EMOTIONAL STATUS a. Emotional Able to verbalize emotional Reactions b. Body image c. Ability to relate to others XII. NURSING DIAGNOSIS feelings Good body image Able to follow simple instructions and able to related to others

Able to verbalize emotional feelings Good body image Able to follow simple instructions and able to related to others Acute Pain related to Inflammatory Process

Able to verbalize emotional feelings Good body image Able to follow simple instructions and able to related to others

Urinalysis EXAMINATION U/A color U/A character U/A reaction U/A spec. gravity U/A albumin U/A sugar U/A others WBCUL WBCHPF RBC UL RBC HPF ECUL ECHPF CASTUL BACTUL BACTHPF U/A remarks U/A pus cell U/A RBC U/A CAST U/A CRYSTAL U/A MUCUS THREAD RESULT YELLOW CLOUD 5.5 1.030 TRACE Negative 11 2 3 1 20 4 0 121 22 /ul /hpf /ul /hpf /ul /hpf /ul /ul /hpf /hpf /hpf /lpf 0-17 0-3 0-11 0-2 0-17 0-3 0-1 0-278 0-50 UNIT RANGE RESULT REMARKS

H H

U/A SQUAMOUS U/A RENAL BACTERIA

CBC EXAMINATION Hgb Hct Wbc Seg. Lymphocytes Monocytes EOSINOPHIL BASOPHIL ABSOLUTENEUTROPHIL ABSOLUTE LYMPHOCYTE ABSOLUTE MONOCYTE ABSOLUTE EOSINOHIL ABSOLUTE BASOPHIL RBC MCV MCH MCHC RDW MPV PH count RESULT 135 .42 22.80 .880 .060 .050 .010 .000 20.29 .87 1.2 .25 .21 4.62 92 29.20 316 11.70 7.30 413.00 UNIT g/l 10s9/l RANGE 120-140 .37-.45 5-10 .55-.65 .35-.45 .06-.12 .02-.04 0-0.020 1.8-7.8 1.0-4.8 0-.80 0-.45 0-.020 4.5-5.0 80-97 27-31.2 318-354 11.5-14.5 2-20 1470-440 RESULT REMARKS

H H L L L H L H H

10s9/l 10s9/l 10s9/l 10s9/l 10s9/l 10s12/L fl pg fl 10s9/l

GENERIC NAME / BRAND NAME/ CLASSIFICATIO N Generic Name Hyoscine-Nbutylbromide Brand Name Buscopan Classification Antispasmodics

MECHANISM OF ACTION it blocks the muscarinic receptors found on the smooth muscle walls which means its blocks the action of acetylcholine on the receptors found within the smooth muscle of the gastrointestin al and urinary tract and thus reduces the spasms and contractions. This relaxes the muscle and thus reduced the pain from the cramps and spasms.

INDICATIO N Spasm in the genitourinar y tract, Spasm in the gastrointesti nal tract, Spasm in the biliary tract, Colic

CONTR AINDIC ATION Myasthe nia gravies, megacol on, hyperse nsitivity to drug contents , narrow angle glaucom a, prostate hypertro phy with urinary retention , mechani cal stenosis in the GI tract, tachycar dia.

ADVERSE REACTION Constipatio n, Decreased, sweating, Mouth, skin, eye dryness, Blurred feeling, Bloating, Dysuria, Nausea or, vomiting, Lightheade dness, Headache, Weakness

DOSAGE

NURSING RESPONSIBILIT Y
Take this drug 30 minutes to 1 hour before meals Buscopan will potentiate the effect of alcohol and other CNS depressants. Avoid driving or operating machinery after parenteral dose. Avoid strict heat Raise side rails as a precaution

Rationale

Actual 1 amp IVTT

To minimize GI irritation

Usual Adult and child >6 y/o 1 to 2 tab TIDQID

Alcohol is prohibited

Because it can cause lightheadedness and blurred feelings. Because some patients become temporarily excited or disoriented and some develop amnesia or become drowsy. Tolerance may develop when therapy is prolonged

Reorient patient, as needed

Assessment Subjective: Masakit ang tyan ko as verbalized by the patient. Objective: Abdominal Pain Weak appearance Limited range of motion Verbalization of pain with a pain score of 6/10. Facial grimace Nursing Diagnosis: Acute Pain related to Inflammatory Process

Scientific Basis Gastroenteritis is the inflammation of the stomach and intestinal tract that primarily affects the small bowel. One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation, the bodys immune response, causing the release of cytokine and prostaglandin causing an increase in vascular permeability and causes pain, which felt by the patient in the abdomen.

Planning After my 6hours span of care the patient will be able to:
report pain is relieved from a pain scale of 6/10 to 2/10. Free from pain as evidence by demonstration of relaxation skills and diversional activities with the help of the SO.

Intervention
Monitor and record vital signs.

Rationale
To provide baseline data and note deviations from normal. Helpful in establishing diagnosis and treatment needs. To lessen / alleviate pain caused by various factors (administer meds via IV push). To reduce pain and promote relief/comfort. To promote healing. For clients comfort and relief from pain.

Evaluation Within my 6hours span of care the patient was able to:
Reported pain is relieved from a pain scale of 6/10 to 2/10. Free from pain as evidenced by demonstration of relaxation skills and diversional activities with the help of the SO.

Review factor that aggravate or alleviate pain. Instruct the SO to massage the area where pain is Elicited if not contraindicated.

Encourage pain reduction techniques. Provide adequate rest. Provide diversional activities like socialization.

Administer analgesics to maintain acceptable level of pain if not contraindicated.

To decrease pain.

Instruct client to perform deep breathing exercises (DBE)

Deep breathing exercises may reduce pain sensation/ used in pain