Roosevelt College System Institute of Nursing and Health Education Sumulong Hi-way Cainta, Rizal

Case Study of Acute Gastroenteritis with Some Dehydration

Submitted By: Avila, Lyka M. -BSN 3-

Submitted to: Ms. Rovie V. Gonzales RN, MAN -Clinical instructor-

I. INTRODUCTION

Acute gastroenteritis remains a common illness among infants and children throughout the world. It could be more simply called as long, potential lethal stomach flu. The most common symptoms are diarrhea, abdominal pain, vomiting, headache, fever and chills. It is quite common among children, though it is certainly possible for adults to suffer from it as well. While most cases of gastroenteritis last a few days, acute gastroenteritis can last for weeks and months. Some types of acute gastroenteritis will not resolve without antibiotic treatment, especially when bacteria or exposure to parasites are the cause. 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 then eventually lead to attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the stomach. Some forms of acute gastroenteritis mimic appendicitis, which may require emergency treatment. As well, young children run an especially high risk of becoming dehydrated during a long course of the stomach flu. Sometimes children, those with compromised immune systems, and the elderly may require hospitalization and intravenous fluids. Dehydration can actually cause greater nausea, and can begin to cause organ shut down if not properly addressed. Even though causes for acute gastroenteritis vary, methods of transmission from one person to another usually remain the same. Generally, contact with the fecal matter of a person with the condition and improper washing or not washing the hands causes acute gastroenteritis to be quite contagious. Proper hand washing for both the ill person and well people in the family is always encouraged. Other methods of transmission of acute gastroenteritis can include eating food or drinking liquids contaminated with bacteria or parasites. Drinking improperly treated water, or drinking from streams and lakes can expose one to giardia, which can leave one ill for many weeks, without treatment.

Significance of the study:

This study will enable the students to understand better about acute gastroenteritis and will explain the different risk factors for developing the disease, including consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation Since we are client-centered, we really should consider our patients comfort and this study will give the students sufficient knowledge that will help them to plan and implement nursing care plans that will satisfy patients needs.

II. PATIENTS PROFILE

A. Biographical Data

Name Address Date of Birth Place of Birth Age Nationality Religion Date of Admission Time of Admission

: Baby JT : Sitio Upper Manalite Cogeo, Antipolo, City : Jan. 28, 2012 : San Fernado La-Union : 1 y/o : Filipino : Roman Catholic : 1/13/12 : 10pm

Attending Physician : Dra. Serquia

Diagnosis

: AGE with Some Dehydration

B. Chief Complaint Vomiting, LBM

III. HEALTH HISTORY

A. History of Present Illness 1 day prior to admission, the patient had history of loose watery stools associated with vomiting of freshly ingested Milk Feed. The mother decided to bring the patient to the hospital and was admitted due to perceived dehydration.

B. Past History Patient had a history of positive G6PD (Glucose-6 Phosphate Dehydrogenase Deficiency) An inherited disorder in which the body lacks an enzyme that normally protects red blood cells from toxic chemicals. The patient had no history of accident or any injury. She does not have allergy in any food or drug.

C. Family History According to the patients mother. They have a familial disease of asthma, both on her father and mother side.

IV. LABORATORY EXAMINATION

URINALYSIS

Urinalysis- is the physical, chemical & microscopic examinations of urine. It involves a number of tests to detect & measure various compounds that pass through the urine. Date:1/14/13 PARAMETERS Color Transparency Specific Gravity Albumin Sugar pH Pus cells RBC Epithelial Cells Bacteria Mucus Threads Amorphous Materials ACTUAL FINDINGS Light Yellow Slightly Turbid 1.020 negative negative 6.0 2-3/hpf 0-2/hpf Few Occassional Few Moderate NORMAL FINDINGS Pale yellow Clear to slightly turbid 1.015-1.025 negative negative 7.35-7.45 2-3 hpf 2-4 hpf few Absent Few Few INTERPRETATIO N normal normal normal normal normal decreased normal normal normal abnormal normal abnormal ANALYSIS

acidic

Normally absent, if present it indicates infection. Too much crystals in the urine is an indication of having kidney stones.

Fecalysis Date: 1/14/13 PARAMETERS Color Consistency Pus Cells RBC ACTUAL FINDINGS Yellowish Soft 0-3/hpf 0-1/hpf NORMAL FINDINGS Yellowish Soft 0 0-5/hpf INTERPRETATION normal normal abnormal normal ANALYSIS

Invasion of microorganisms.