Case Presentation - Acute Gastroentiritis

INTRODUCTION
We, group 1 of Level III section 1, have chosen this case to gain knowledge and
to familiarize in disease process, etiology, manifestations and managements about
metabolic alteration that cause seizures. We also want to improve our knowledge and
skills in dealing with individuals with this kind of disease, especially in preventing the
occurrence of episodes of seizures and its complication. Our patient J.M. is a 3 years
old male who is diagnosed of acute gastroenteritis with seizures.
Tidy, C. (2012) Gastroenteritis is an infection of the gut. It causes diarrhea, and
may also cause vomiting, tummy pain and other symptoms. In most cases the infection
clears within a few days, but sometimes takes longer. The main risk is dehydration. The
main treatment is rehydration, encourage the child to eat as normally as possible.
Many children have more than one episode in a year. The severity can range
from a mild tummy upset for a day or two with some mild diarrhea, to severe diarrhea
and vomiting for several days or longer. Many viruses, bacteria and other microbes
(germs) can cause gastroenteritis.
Although often considered a benign disease, acute 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.
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In most children, the symptoms are mild and they tend to get better within a few
days. If vomiting occurs, it often lasts only a day or so, but sometimes longer. Diarrhea
often continues after the vomiting stops and commonly lasts for between 5 to 7 days.
Slightly loose stools may persist for a week or so further before a normal pattern
returns. Sometimes the symptoms last longer.
Armin, et.al (2007) Diarrheal diseases are one of the leading causes of mortality
and morbidity in children and convulsions are one of the complications. Children may
develop febrile seizures if fever accompanies the diarrhea. Sometimes afebrile seizures
have been known to occur in association with dehydration, electrolyte imbalance,
hypoglycemia or hypocalcaemia and complicated acute gastroenteritis; however the
occurrence of afebrile seizures during viral gastroenteritis without dehydration or
electrolyte imbalance has also been reported.
Seizure is believed to affect 1% to 2% of the population; approximately 2 million
people have been diagnosed with this disorder (Lippincott Williams & Wilkins 2007).
The incidence is highest in childhood and old age.
Considering the fact that seizure associated with gastroenteritis may be
attributable to fever, the type of bacteria, dehydration, or electrolyte imbalance, we
designed this study to evaluate the relation between some paraclinical and clinical
finding, estimating the risk of occurrence and to assist in its prompt diagnosis and
preventive measures.
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I.
A.
B.
C.
D.
E.
F.
G.
H.
I.
DEMOGRAPHIC DATA
Initials of Clients Name: J.M.
Date of Admission: January 7, 2014
Address: Naic Cavite
Time of Admission:10:15 pm
Age: 3 years old
Birth Date: November 15, 2010
Date of Interview: January 21, 2014
Birth Place: Naic Cavite
Primary Informant: Patients Mother
Gender: Male
Other Data Sources: Patients Chart
Civil Status: Single
Religion: Roman Catholic
Fathers Occupation: Farmer
Mothers Occupation: Housewife
J. Medical support: Phil Health (Patient J.Ms Mother was the PhilHealth Member)
II.
CHIEF COMPLAINT
Patient had experience diarrhea for 2 day prior to hospitalization. One day
prior to admission, the patient had a fever and experienced vomiting and an episode
of seizure for almost 3 minutes. He was very pale and lethargic.
III.
HISTORY OF PRESENT ILLNESS

According to his mother, Patient JM started having diarrhea two days prior to
hospitalization, he defecates thrice a day with yellowish watery stool, no solid

pieces, entirely liquid and white parasitic worms have seen. Patient J.M also vomits
characterized by yellowish liquid discharge every time he was fed by his mother. The
patient complains pain in the abdomen. One day prior to admission, the patient
experienced fever (38. 9C) and vomiting and after that an episode of seizure occurs
for almost 3 minutes so they have decided to seek medical advice. The next day,
Patient JM became very irritated and doesnt want to eat. Eventually, there is weight
loss from 11 kg to 10 kg taken on January 21, 2014. He looks pale and lethargic.
IV.
PAST MEDICAL HISTORY

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He only got 1 dose of BCG, 1 dose Hepa B, 2 doses of DPT, one dose of
OPV and Measles vaccine. The patient didnt encounter any accidents or fall thus
he didnt have any fracture in the past, doesnt have any allergy and first time to
seek medical care. According to Public Health Nursing, a child is said to be Fully
Immunized Child when a child receives one dose of BCG, 3 doses of OPV with an
interval between doses of 4 weeks, 3 doses of DPT with an interval between doses
of 4 weeks, 3 doses of HEPA B with 6 weeks interval from 1 st dose to 2nd dose and 8
weeks interval from 2nd dose to 3rd dose.
Patient JMs mother claimed that he did experience common illnesses like
fever, cough and colds. The patient had a chickenpox when he was 1 year old and
measles when he was 8 months. She claimed that patient JM has no known
allergies in foods and in medications. They didnt rely that much in over the counter
drugs because for her it will just make more dependent in synthetic remedies and
she claimed that she usually uses lagundi and oregano as herbal medicine. Also,
he is not taking any vitamins. Two days prior to admission the patient experienced
diarrhea, he defecates thrice a day with yellowish watery stool, no solid pieces,
entirely liquid with seen white parasitic worms and accompanied by abdominal pain.
Patient J.M also vomits characterized by yellowish liquid discharge every time he
was fed by his mother. His mother also claimed that in their family, there are no
history of hereditary diseases such as diabetes and hypertension. The patient didnt
encounter any accidents or fall thus he didnt have any fracture in the past. Patient
JMs mother claimed that it is his first time to be hospitalized.
V. HEREDO- FAMILIAL HISTORY
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Interpretation:
The genogram is a pictorial display of patients J.Ms family relationship and
medical history. It shows the three-generation family of the patient. The diagram
includes the current ages and current health status of each family member from the
three generation from the patient.
The paternal and maternal side of the patient in both of her grandparents were
dead but the mother was not sure for the exact cause of her death.
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In Second Generation, most of the family members were alive and well. They
dont have any diseases that were hereditary.
For the third generation, his older sister died in the 2009 because of sepsis.
VI.
DEVELOPMENTAL HISTORY
Erik Eriksons Psychosocial Development Theory

Stage
Specific Task(s)
Autonomy vs.
Developmental task is to form a
Shame and
Doubt
(Toddler)
sense personal control over

physical skills and a sense of
independence. Success leads
to feelings of autonomy, failure
Evidences of Milestone
Achievement
As stated by his mother, the patient
begins to imitate parents doing
household chores. Mahilig siyang
maglaro at kapag naglalaba ako
namimilit siyang maglaba din. He
results in feelings of shame and knows his own name and already
doubt.
knows to choose what kind of
clothes should he wear or what kind
of toys should he play. He frequently
uses no especially when he
doesnt want it.
Sigmund Freuds Psychoanalytic Development Theory

Stage
Anal Stage
(18 months-3
The child has to learn to
Achievement
According to the patients mother,
control his or her bodily needs.
Kapag natatae o naiihi siya
Specific Task(s)
years old)
nagasasabi siya sa akin at

sinasamahan ko. His parents
utilize praise and rewards for
using the toilet.
Jean Piagets Cognitive Development Theory
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Pre-operational
Toddlers learn through
Achievement
According to his mother, Mahilig
Thought
pretend play but still struggle
siya makipaglaro minsan
with logic and taking the point
malawak yung imagination niya.
of view of other people.
Ginagaya niya yung tatay niya
Stage
Specific Task(s)
palagi kapag nakikipagkulitan.

According to his mother, the
patient has a wide imagination,
likes to discover new things. He
is starting to become curious in
something he sees, likes to
question and investigate new
things. His thoughts become
more symbolic. He uses an
object to represent something
else, such as pretending a broom
is a horse, a box is a table and a
piece of paper is being plate. He
plays with the others and creates
elaborate plots and characters
culminate in the understanding of
representational thoughts and
activities.
Lawrence Kohlbergs Moral Development Theory
Stage
Preconventional
Stage
(Toddler)
Achievement
Toddler have little concept of Patients mother stated that the
any motivating force beyond patient is responsive to rules
that of their parents. Toddler
but views them in terms of
learns that when they do
certain actions, parents give pleasant consequences of
Specific Task(s)
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affection and approval; for

other actions, parents scold
and label the behavior
bad. It is important in this
stage to praise a toddler for
doing what he or she has
been asked to do.
actions. She verbalized, Kapag

namimilit siyang maglaba rin
kapag naglalaba ako,
sinasabihan ko lang siyang
magbehave. Kapag nagbehave
siya bibigyan ko siya ng
premyo. Minsan tatahimik lang
siya. Pero may mga araw ring
nagpupumilit siya at nag-iiyak.
VII.
GORDONS 11 FUNCTIONAL HEALTH PATTERNS
A. Health Perception- Health Management

She claimed that the patient did experience common illnesses like fever,
cough and colds. At the age of 1 the patient stops drinking milk but instead he is
drinking coffee. His mother claimed that whenever he got sick, they didnt already
take him to the hospital because of lack of money. They are using herbal
medicines for medications like oregano and lagundi. They rather prefer herbal
medicines as a remedy whenever he got sick. The patient is not taking any
vitamins.
At present, the mother perceives that the general health of his son was
compromised. The mother claimed that it is the first time that the patient had a
serious condition and hospitalized for almost 3 weeks.
B. Nutritional-Metabolic Pattern
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According to his mother, the patient used to breastfeed then he started

drinking formulated milk at 1 year old.
According to his mother, he likes to drink
coffee; he started drinking when he was 1 year old because sometimes they
were not able to purchase milk. He used to eat fruits, vegetables, meat, and rice
daily. He ate three times a day and that includes breakfast, lunch, and dinner. His
typical daily fluid intake is 3-4 glasses of water. The source of their water came
from the faucet and didnt boil it. The patient also eats with bare hand without
washing it after playing in the farm.
When he was hospitalized, the patient had loss appetite and lack of
interest on eating, and sometimes he just usually ate bread and coffee for the
whole day. His mother also claimed that whenever he eats he suddenly vomits
with yellowish discharge. Upon physical examination, there are 3 dental caries: 1
at the left lower molar, 1 in right lower molar and 1 in premolar. The patient didnt
take any vitamins or supplements.
The patient doesnt have any problem on chewing and swallowing. He
also had dry skin and poor skin turgor which indicates dehydration. According to
the doctors order he is maintained on feed with SAP. He also decreases body
weight from 11kg to 10kg as taken upon physical examination. The patient has
an IV infusion of D5IMB solution in 500ml, regulated at 48-49 uggts on his left
metacarpal vein. It indicated for the maintenance of fluid and electrolytes
especially to patients who need calories and hydration. The IV line was infusing
well and no air and back flow seen.
C. Elimination
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Before hospitalization, according to patients mother he used to defecate

regularly for about 3 times a week. The fecal characteristic was brown in color,
slightly soft with separated lumps with semisolid texture. He does not have any
difficulty or problems in controlling and informs her mother when to urinate and
defecate. He urinates 3 to 4 times daily with light yellow in color. According to
Fundamentals of Nursing 7th Edition by Kozier, characteristic of normal stool is
yellow in color, formed, soft, semisolid and moist.
January 5-6, 2014, Two days prior to admission the patient defecates thrice a
day with yellowish watery stool, no solid pieces, entirely liquid and white parasitic
worms have seen accompanied by abdominal pain. Patient J.M also vomits
characterized by yellowish liquid discharge every time he was fed by his mother.
At the 1st and 2nd day of hospitalization which is January 7-8, 2014, the patient
defecates twice a day with yellowish mushy stool with semi solid particle and
vomited once with still yellowish discharge. During in our 2:00-10:00 pm shift,
January 20, 2014, the patient has difficulty in defecation thus he didnt pass stool
for almost 2 days. No episodes of vomiting had occurred. He urinated 2 times a
day with yellow urine output of 250cc and 200cc. Upon observation, the patient
had profuse sweating as evidenced by wet bed linens and clothes but with no
unusual odor.
D. Activity- Exercise Pattern

According to his u mother, before hospitalization the level of his activity
can be described as very active because he used to play outside in the farm with
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his friend and sibling every day. When he is at home, he usually watches
television before going to sleep. Because he is still young he doesnt have any
form of exercises.
When he was hospitalized, he felt very weak and tired due to excess
vomits and defecating. He looks pale and lethargic. His physical activity lessens
and he always tends to sleep for conservation of his energy. Also, he needs
assistance whenever going to the bathroom or even standing up in preventing
accidents especially fall.
The patient also become irritable and cries frequently especially when he
sees a person dressed in white uniform and doing the rounds which is us,
student nurses and the registered nurses it was called White Coat Anxiety. Stress
and anxiety play a huge role in the development of white coat syndrome. If you
had a bad experience with medical diagnosis and treatment in your childhood, its
very possible that now you are subconsciously afraid of all doctors because they
remind you of your past trauma. In the next few days the patient shows no
interest in playing, he become more irritable and weak.
Katz Index of Independence in Activities of Daily Living
Activities
Bathing
Dressing
Toileting
Transferring
``Continence
Independence (1)
Dependence (0)
0
0
0
0
0
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Feeding
TOTAL
POINTS:
0
0
Interpretation:
The patient was fully dependent to his mother. He seeks guidance
and assistance with his mother.
E. Sleep-Rest
According to the patients mother, JM almost spends his whole day
sleeping. He usually wakes up 6 am and sleeps 10 pm. The duration of his sleep
is just enough for his development. During spare time, she spends it by playing
with his friends and cousins and he always take an afternoon nap from 12 pm to
4pm.
During hospitalization, the mother claimed that he doesnt have any
enough sleep especially when the nurses were doing their rounds and taking vital
signs. The patient usually sleeps 5 hours for evening then has a nap for 2 hours
in the afternoon. His sleeping disturbances were his abdominal pain and hot
room temperature. Before going to sleep he always prayed as his mother
teaches him.
His mother stated that he always smiles after waking unlike now that he
usually cries when he wakes up and when her mother leaves him while he was
still sleeping. The most comfortable sleeping position of Patient J.M was side
lying position with 1 pillow on the head and doesnt want a blanket.
F. Cognitive Perceptual
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Before hospitalization, patient JM has no problem in smell, vision and

hearing even though he was exposed on loud noise at their homes. He is a very
playful person and very friendly with others.
Patient J.M easily focuses attention especially when he watches
television. He can also easily remember names, places and numbers. He can
also follow and understand directions.
During hospitalization and upon thorough physical examination, Patient
JM has no problem with his hearing, smell and with his vision but had changes in
taste of foods as evidenced by loss of appetite and choosing a viand. The patient
had experienced pain in the abdomen and shows guarding behavior and
irritability.
G. Self-Perception - Self-concept Pattern

The patient is 3 years old, currently experiencing pain and was not able to
say anything about himself. As stated by the mother, patient J.M as a cheerful,
naughty, a loving son and brother. Before hospitalization, he was able to gain
trust to anyone but when he was started to admitted, he easily gets irritated
because of the ambiance in the hospital as well as when the nurse doing their
rounds because he cannot rest well. The mother also claimed that she knew that
the patients health was then compromised and was not able to play like before.
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H. Role Relationship
Patient JM is the youngest among the children of his parents. He lives
with his loving parent and sibling. According to his mother, he always makes
them happy whenever he smiles and always playing with his older brothers. His
parents usually visit and take good care of him because they said that their child
was very important to them. The person who spends long period of time with the
patient is his mother and it is evidenced that the patient is receiving enough care
and love.
During the interview his parents was totally worrying about the patients
condition. It seems that they really care in their youngest child. They manage the
patient by giving an extra care to help him recover by his illness. As of now, their
income was not enough for the hospital expenses, because his fathers job was
insufficient for their daily life. They trust God that their son will be healed.
I. Value Belief Pattern

According to his mother, Patient JM was baptized as Roman Catholic and
every Sunday they went to church with his family. He practices praying before
sleeping at night. His mother said that God helps them to get through with their
problems in life. Religion for them was very important. They trust and gain strength
by God. They believed that their son will be healed someday.
During hospitalization, Patient JM is not active in going to church because he
is still in hospital and the patient needs guardian. Despite of it, his mother and
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patient J.M were still praying for his fast recovery. In terms of medical approaches,
his mother relies into the herbal medicines and claimed that she doesnt rely too
much on the over the counter drugs. They also believe in quack doctors and
believed in superstitious as evidenced by getting the height of the patient while he
was sleeping but the mother rejected because she believes that it is like getting the
size of the coffin. As a student nurse, we understand and respected their culture and
beliefs.
In the near future, they want their child to become successful and finished his
studies someday. The most important things in their life were Patient J.M and their
family.
VIII. COMPREHENSIVE PHYSICAL EXAMINATION

A. Vital Signs
January 20, 2014
TIME
2:00pm
4:00pm
6:00pm
8:00pm
Temperature Rate
(C)
36.5 C
36.4C
36.5 C
36.3C
Pulse Rate
(bpm)
100 bpm
98 bpm
110 bpm
105 bpm
Respiration Rate
(cpm)
27 cpm
25 cpm
25 cpm
28 cpm
Temperature Rate Pulse Rate

(C)
(bpm)
36.5 C
98 bpm
37.9 C
110 bpm
37.3C
100 bpm
36.5C
110 bpm
Respiration Rate
(cpm)
25 cpm
28 cpm
25 cpm
30 cpm
January 21, 2014

TIME
2:00pm
4:00pm
6:00pm
8:00pm
B. Anthropometric Data:
a Head Circumference: 49 cm
b Chest Circumference: 53 cm
c Abdomen Circumference: 51 cm
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d Height: 98 cm
e Weight:11 kg
Body Mass Index:
Formula: (Base on MCN 5th ed. by Pilliteri-Appendix E, Growth Charts pg.1799
For 3 years old: Boy)
BMI= Weight (kg) / Stature (cm) / Stature (cm) x 10,000
Or Weight (lb) / Stature (in) / Stature (in) x 703
Solution:
BMI= Weight (kg) / Stature (cm) / Stature (cm) x 10,000
= 11 kg / 98 cm / 98 cm / x 10,000
BMI= 11.454 or under nourish
C. GENERAL APPEARANCE:
Patient JM generally looks pale and lethargic. The body was light built with small
joint and his muscle was lean. Flaccidity was evident with the patient and was not
relaxed. The skin was clean, nails were neat. He has no unusual body and breath odor.
Patient JM has comprehensible thoughts and his voice can be heard in moderate
pace.
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Cephalocaudal Assessment
(Based on the Children Variations)
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D. Cephalocaudal Assessment:
(Based on the Children Variations)
Body Part
Examined
Normal Finding
Actual Finding
Clinical Significance
INTEGUMENTARY SYSTEM
Skin:
I: skin color,
>Skin color ranges

from pale white
with pink, yellow,
or olive tones to
dark brown or
black.
I: *skin color is
brown
*flushed skin
Inspection reveals evenly

colored skin tones, without
unusual discolorations.
According to Webber &
Kelley Health Assessment in
Nursing 3rd edition that
Small amount of melanin
are common in whiter skins,
while large amounts of
melanin are common in
olive and darker skins.
Carotene accounts for a
yellow cast.
Abnormal finding: Flushed
skin due to increase body
temperature.
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odor,
>No strong odor

should be evident.
I: *no strong
odor
*profuse
sweating
and lesions.
>skin should be
lesion free.
I: *with lesions in
the both lower
extremities
*with itchiness
Palpate for
temperature,
>Skin is normally
Pa: * warm to
warm temperature. touch
*37.90C
(January 21,
2014)
>Skin surfaces
Pa: *decreased
vary from moist to moisture
dry depending on
the area
assessed.
>Skin pinches
Pa: *poor skin
easily and
turgor
immediately
returns to its
original position.
moisture,
turgor,
According to Health &

Physical Assessment in
Nursing by DAmico and
Barbarito that >Diaphoresis
(profuse sweating) occurs
during exertion, pain, and
emotional stress.
>LAB: Increase level of
Creatinine in 116.59umol/L
cause dehydration or
inadequate water intake
such as sweating can cause
blood concentration and
reduced blood flow in the
kidneys. creatinine will
increase.
having lesions in the skin
was due to insect bites.
According to Weber and
Kelly- Health Assessment in
Nursing; 3rd ed. That Very
warm skin may indicate a
febrile state.
According to Weber and
Kelly- Health Assessment in
Nursing; 3rd ed. That
decreased moisture occurs
with dehydration.
Nursing 3rd edition that skin
is not quickly a return to
original shape after being
pinched. Poor skin turgor
indicates dehydration.
>LABS: A lower-than-normal
level of chloride (88.5
mmol/L) is called
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and edema.
Hair:
I: evenness of
growth,
thickness, color,
texture
Oiliness,
infection or
infestation
Body hair
P: smoothness
hypochloremia. It may be
due to Dehydration.
-Dehydration or a diet high
in protein can make your
BUN level higher (23.20/L).
- A lower-than-normal level
of chloride (88.5 mmol/L) is
called hypochloremia. It
may be due to Dehydration.
Nursing 3rd edition is
Absence of edema may
indicate a descent skin
condition.
>Skin rebounds
and does not
remain indented
when pressure is
released.
Pa: *no edema
>Evenly
distributed, thick
and smooth hair.
I: *Equal
distributed
*black in color
*thin hair

Nursing 3rd edition that hair
color is determined by the
amount of melanin present.
>Sparse dandruff
may be visible and
small amount
oiliness. Scalp is
clean and dry.
I: *no oiliness
and infection or
infestation
present.
>Varying amounts
of terminal hair
cover the scalp,
axillary, body, and
pubic areas
according to
normal gender
distribution.
>Hair is smooth
and firm,
somewhat elastic.
I: *Fine vellus
hair

Infested hair may indicate a
need for client teaching
about poor hygiene or
assistance with activities of
daily living.
Nursing 3rd edition that Fine
vellus hair covers the entire
body except for soles,
palms, lips, and nipples.
Pa: *smooth and

even

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smooth and even hair is

normal.
Nail:
I: bed color
>Pink tones
should be seen.
Some longitudinal
ridging is normal.
I: *pink in color

Nursing 3rd edition that Pale
or cyanotic nails may
indicate hypoxia or anemia.
Yellow discoloration may be
seen in fungal infections or
psoriasis. Nail pitting is
common in psoriasis.
texture
>Nails are hard
I: *clean
and basically
fingernails
immobile.
Nursing 3rd edition that nails
are smooth and firm; nail
plate should be firmly
attached to nail bed.
plate shape
>Round or square I: *smooth and
nail shape
firm
according to the
Nursing 3rd edition that the
cuticle. There is
normal shape should be
normally 160round with 160 degree
degree angle
because other than this can
between the nail
contributes to any
base and the skin.
complications.
P: blanch test
>Pink tones
Pa: *color
returns
returns
immediately to
immediately into Nursing 3rd edition that If
blanched nail beds normal
there is slow (greater than 3
when pressure is
*1-2 seconds
sec.) capillary refill,
released.
indicates of respiratory or
cardiovascular diseases that
cause hypoxia which is an
abnormal finding.
H E E N T (Head, Eyes, Ears, Nose Throat)
Head, Neck, and Cervical Lymph Nodes
Head. Note the
>Head is
I:
shape and
normocephalic,
*normocephalic
symmetry
symmetric and in
*symmetric
midline with no
*round
Head size and shape vary,
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lesion present.
*erect
Pa:*no lesion
Test head
control, head
posture, range
of motion.
>Full range of
motionup, down,
and sidewaysis
normal.
I: * Full range of
motionup,
down, and
sideways
*can control
the head
Face. Note the

appearance,
symmetry, and
movement.
Palpate the
parotid glands
for swelling.
>Face is normally
proportionate and
symmetric.
>Movements are
equal bilaterally.
Parotid glands are
normal size.
I: *irritable
*crying
*round face
*symmetric
*no abnormal
movements
Pa: *no swelling
or tenderness
Neck. Palpate
the thyroid gland
and the trachea.
Also inspect and
palpate the
cervical lymph
nodes for
swelling,
mobility,
temperature,
and tenderness.
Eyes
External eye.
>The neck is
usually short with
skin folds between
the head
>The isthmus is
the only portion of
the thyroid that
should be
palpable.
>The trachea is
midline.
>Lymph nodes are
usually no
palpable in infants.
>Inner canthus
I: *symmetric
*no abnormal
movements.
Pa: *no
enlargement of
lymph nodes
was noted.
*no swelling or
tenderness
*trachea is
midline
I: * no epicanthal
especially in accord with

ethnicity. Usually the head is
symmetric, round, erect,
and midline. No lesions are
visible.
Full range of motion is up,
down and sidewaysis
normal because limited
range motion may indicate
torticollis which is abnormal.
face is symmetric, round
and erect, in midline. No
lesions and edema should
be visible and no unusual
movements should be
noted.
Crying and irritability occurs
due to the disease condition
experienced by the patient.
neck is symmetric with head
centred and without bulging
masses. Normally neck
movement should be
smooth and controlled with
flexion, extension, lateral
abduction and rotation. And
the trachea should be in
midline. No enlargement or
tenderness is present.

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Note the
position, slant,
and epicanthal
folds of the
external eye.
distance
approximately 2.5
cm, horizontal
slant, and no
epicanthal folds.
>Outer canthus
aligns with tips of
the pinnas.
>No swelling,
discharge, or
lesion of eyelids.
folds
*Inner canthus
is horizontally
slant
*Outer canthus
aligns with tips of
the pinnas

inner canthus distance
approximately horizontal
slant and outer canthus
aligns with tips of the pinnas
with no epicanthal folds.
I: *no edema
*absence of
tears
*no swelling
*lesion free
*no discharge
Inspect the
sclera and
conjunctiva for
color, discharge,
lesion, redness,
and laceration.
>Sclera and
conjunctiva are
clear and free of
discharge, lesion,
redness, or
lacerations.
I: *clear
*no discharge
*lesion free
*no redness or
laceration.
I: iris and the

pupils.
>Pupils are equal,

round, and
reactive to light
and
accommodation
(PERRLA).
Finally inspect
the eyebrow and
eyelashes.
>Eyebrows
should be
symmetric in
I: *equal
* reactive to
light and
accommodation
*normal and
equal in size
*iris-round, flat,
and evenly
colored
*pupil- round
with regular
border, is
centred in iris.
I: *evenly
distributed
*eyebrows

upper and lower lids close
easily and meet completely
when closed. Skin on both
eyelids is without redness,
swelling, or lesions or
discharges.
Bulbar conjunctiva is clear,
moist, and smooth.
Underlying structures are
clearly visible. Sclera is
white.
iris is typically round, flat,
and evenly colored. The
pupil, round with a regular
border, is centred on the iris.
I: eyelid
placement,
swelling.
Discharge and
lesion.

23 | P a g e
shape and
movement. They
should not meet
in midline.
>Eyelashes
should be evenly
distributed and
curled outward.
Ears and Hearing
I: auricles for
>The ears are
color, symmetry
evenly colored. It
and position
is equal in size
bilaterally.
does not meet in

the midline
*symmetric in
shape and
movement.
eyebrows should be
symmetric in shape and
movement.
I: *auricle aligns
with the corner of
each eye
* bilaterally
equal in size
*color is
consistent with
facial color

color, position and the
symmetry of the ears should
be identical and uniformly
colored. The alignment of
the auricle make straight to
the corner of the eye.
: external canal >A small amount
I: *Normal
for cerumen
of odorless
amount of
cerumen is the
yellowish
Nursing 3rd edition that there
only discharge
cerumen upon
should be no excessive
normally present. assessment in
cerumen.
her ear.
Foul-smelling, sticky, yellow
dischargeotitis externa or
impacted foreign body.
lesions, pus or
>The canal walls
I: *no lesions,
blood
should be pink
pus or blood
and smooth and
present as seen
Nursing 3rd edition that nonwithout nodules.
with the use of
appearance of lesions and
penlight.
blood is normal. Bloody,
*no discharge purulent dischargeotitis
present
media with ruptured
tympanic membrane.
P: auricles for
>The skin is
Pa: *The auricles According to Webber &
texture, elasticity smooth with no
are smooth. It is
and areas of
lesions, lumps, or somewhat elastic Nursing 3rd edition that a
tenderness
nodules. Normally
*no
painful auricle is associated
the auricle is not
tenderness
with otitis externa or a post
tender.
auricular cyst.
Nose and Sinuses.
24 | P a g e
I: nose deviation
in shape, size,
color, flaring,
discharge
> Color is the

same as the rest
of the face; the
nasal structure is
smooth and
symmetric.
: nasal mucosa
for redness,
swelling, growth
or discharge
> The nasal

mucosa is dark
pink, moist, and
free of exudates.
The nasal septum
is intact and free
of ulcers or
perforations.
Palpate the
>No tenderness
sinuses in older
palpated over
children if
sinuses.
sinusitis is
suspected.
Mouth and Throat
I: lips and
>Lips are smooth
mucous
and moist without
membranes for
lesions or
symmetry of
swelling.
contour, color,
>Pink lips are
texture, moisture, normal in lightlesion
skinned clients as
are bluish or
freckled lips in
some darkskinned clients.
I: *The nose is
symmetric/ is in
midline of the
face.
* Color is the
same as the
face. *No flaring
(redness) or
discharge
present
I: *No redness,
swelling, or
discharges of
nasal mucosa.
*pink in color
Pa: *no
tenderness
I: *Dry lips and

mucous
membrane
*lip color is light
pink
* No lesions
are present.

color in external nose is
same as the rest of the face;
the nasal structure is
smooth and symmetric.
Because, Flaring or
discharges is an abnormal
signs.
nasal mucosa is dark pink,
moist, and free of exudates.
The nasal septum is intact
and free of ulcer or
perforations.
Excessive accumulation of
mucus secretion results to
colds.
Nursing 3rd edition that if
there is a tender sinuses
suggest sinusitis.
Dryness of lips and mucous
membrane is due to
dehydration or insufficient
fluid intake.
>LABS: A lower-than-normal
level of chloride (88.5
mmol/L) is called
hypochloremia. It may be
due to Dehydration.
-Dehydration or a diet high
in protein can make your
25 | P a g e
: teeth for
alignment, loss,
dental fillings and
caries.
: gums for
bleeding, color,
retraction,
lesions, swelling
: tongue for
position, color &
texture
>Decidous teeth
begin to develop
between 4 and 6
months; also 20
erupt by 36
months; teeth
begin to fall out
around 6 years,
when permanent
tooth eruption and
progresses until
all 32 have
erupted.
> Gums are pink,
moist, and firm
with tight margins
to the tooth. >No
lesions or
masses.
I: *3 dental
caries, 1 at the
left lower molar
and 1 in right
lower molar; 1 in
premolar
> Tongue should

be pink, moist, a
moderate size
with papillae
present, and
symmetric in
position.
I: * tongue was
pink in color with
white coloration,
moist, and
symmetric.
*There is a
presence of
papillae on it.
I: * pinkish gums,
without the
presence of
bleeding,
lesions, swelling,
or gum retraction
as observed.
BUN level higher (23.20/L).

- A lower-than-normal level
of chloride (88.5 mmol/L) is
called hypochloremia. It
may be due to Dehydration.
tooth decay (caries) may
appear as brown dots or
cover more extensive areas
of chewing surface. A chalky
white area in the tooth
surface is a cavity that will
turn darker with time.

Nursing 3rd edition that Red,
swollen gums that bleed
easily are seen in gingivitis,
scurvy (vitamin C
deficiency), and leukemia.
Receding red gums with
loss of teeth are seen in
periodontitis. It is abnormal
in younger clients.
among possible
abnormalities are deep
longitudinal fissures seen in
dehydration; a black tongue
indicative of bismuth
toxicity: black, hairy tongue;
a smooth, reddish, shiny
tongue without papillae
indicative of niacin or B12
26 | P a g e
deficiencies, certain anemia,

and antineoplastic therapy.
I: * tongue
moves when
instructing the
patient to move
Decreased tongue strength
it.
may occur with a defect of
the XII cranial nerve
(hypoglossal) or with a short
frenulum that limits motion.
I: * soft palate
--pinkish and
smooth
Nursing 3rd edition that A
*hard
candidal infection may
palate--- firm and appear as thick white
has the presence plaques on the hard palate.
of transverse
rugae.
I: * The uvula is
symmetric and
moves when
saying aaah.
palate fails to rise and uvula
deviates to normal side, it
indicates with cranial nerve
X (vagus) paralysis.
movement
> The tongue

offer strong
resistance.
: palates for
color, shape,
texture, presence
of bony
prominences
> The hard palate

is pale or whitish
with firm,
transverse rugae.
: uvula for
position &
mobility
> The uvula is a

fleshly, solid
structure that
hangs freely in
the midline.
> No redness of
or exudates from
uvula and
symmetric
elevation of the
soft palate.
>Tonsils are
I: *Tonsils are
easily seen by
normally pink
age 6 when they
and symmetric.
increase to adult
*No exudate or both tonsils are found
dimensions.
lesions.
behind the pillars.
CARDIOVASCULAR SYSTEM
Note the
condition of the
throat and tonsils
Heart
Precordium.
Note lifts,
heaves, and
apical impulse.
>The apical
impulse is at 4th
intercostal space
(ICS) until the age
of 7 years, when
I: *Apical
impulses may
not be visible
Pa: *no pulsation

Nursing 3rd edition that a
systolic heave if may
indicate-right ventricular
27 | P a g e
it drops to the 5th.

>It is to the left of
the midclavicular
line (MCL) until
age 4.
Note rate rhythm
of the apical
impulse.
Thorax
Inspect the
shape of the
thorax.
Children under 7
years old are
abdominal
breathers.
or vibrations are enlargement. Apical pulse

palpated in areas that is not in proper location
of apex
for age may indicate
cardiomyopathy,
pneumothorax, or
diaphragmatic hernia.
>Awake and
Pa: Pulse Rate:
resting rates vary (January 20,
with the age of
2014)
the child:
02pm: 100 bpm
Pulse may be altered by
2 years to 10
04pm: 98 bpm
apprehension or anxiety,
years: 70-110
06pm: 110 bpm
medications, activity, and
bpm
08pm: 105 bpm
pain, as well as pathologic
conditions.
(January 21,
2014)
02pm: 98 bpm
04pm: 110 bpm
06pm: 100 bpm
08pm: 110 bpm
*Pulse Rate is in
normal range
RESPIRATORY SYSTEM
>Thorax is
smooth, rounded,
and symmetric.
I: *smooth
*rounded
*symmetric
>Respirations
should be
unlabored and
regular in all
ages.
I: *Respiratory
Rate:
(January 20,
2014)
02pm: 27 cpm
04pm: 25 cpm
06pm: 25 cpm
08pm: 28 cpm

abnormal shapes of the
thorax may indicate of
pectus excavatum and
pectus corinatum.
Respiration should be, 2
years to 10 years: 20-28
breaths per minute.
(January 21,
28 | P a g e
2014)
02pm: 25 cpm
04pm: 28 cpm
06pm: 25 cpm
08pm: 30 cpm
Pe: *with Hyper
resonance
Chest. During
percussion of the
lungs, note tone
elicited.
>Hyper
resonance is the
normal tone
elicited in young
children.
Auscultate for
breath sound
and adventitious
sound.
>Breath sound
*no adventitious
may seem louder sounds heard
and hasher in
young children of
their thin chest
walls.
> No adventitious
sounds should be
heard although
transmitted upper
airway sounds
may be heard on
auscultation of
thorax.
DIGESTIVE SYSTEM
>In children up to I: * prominent in
4 years of age,
supine position
the abdomen is
*lesion free
prominent in
*rounded or
standing and
protuberant
supine positions.
abdomen
Inspect the
shape of the
abdomen.
Note the color,

discharge,
evident
herniation of the
umbilicus.
>Umbilicus is
pink, no
discharge, odor,
redness, or
herniation.
I: *Umbilicus is
pink
*no discharge,
odor, redness, or
herniation

Nursing 3rd edition that it is
Normal due to the thinness
of the chest wallThis
diminishes as the child ages
and the chest wall develops.
diminished breath sounds
suggest respiratory
disorders such as
pneumonia or atelectasis.

abdomen is generalized
protuberant or distended
abdomen indicates of
malnutrition.
Umbilicus is similar skin
tone to the surrounding in
abdomen with evenly
pinkish. And it is in the
29 | P a g e
Auscultate bowel
sounds.
Palpate
abdomen for
softness or
hardness.
Palpate the
bladder.
> They sound like

clicks, gurgles, or
growls.
>Bruits is not
normally heard
A: *positive
bowel sounds
*with Gurgle
sounds present
*no bruits
heard
>Abdomen is soft Pa: *no masses
to palpation and
* no
without masses or tenderness
tenderness.
*soft to
palpate
>Bladder may be
slightly palpable
in small children.
Pa: *Urinary
Bladder slightly
palpable
Anus and Rectum

The anus should >The anal
I: *lesion free
be inspected in
opening should
*moist
children.
be visible and
*smooth
moist.
*tightly closed
>Perianal skin
*no redness,
should be smooth lumps, ulcers,
and free of
rashes.
lesions.
>Perianal skin
tags may be
noted.
REPRODUCTIVE SYSTEM
Breast
Note shape,
>There are no
I: *no lesion, or
symmetry, color, palpable masses discharge
tenderness,
in the breast.
present
discharge,
>Areola varies
*Nipples and
lesion, and
from dark pink to
areola are nearly
masses
dark brown,
bilaterally equal
midline at lateral line.

sound like clicks, gurgles, or
growls. Bruit is not normally
heard.
Nursing 3rd edition that soft
to palpation and without
masses or tenderness are
normal findings within the
age of the patient.
there is an enlarged bladder
may indicate of urinary
retention but may be due to
a mass.
area is normally smooth and
free of redness, and moist.

If there is redness, edema,
and tenderness it indicates
of mastitis.
30 | P a g e
depending on the
patients skin
tone.
>Nipples are
nearly equal
bilaterally in size
and are same
location on each
breast.
>Breast is flat and
symmetric in
prepubertal
children. Obese
children may
appear to have
breast tissue.
Male Genitalia
Inspect the
>Penis is normal
genitalia,
size for age, and
observing size
no lesions are
for age and any
seen.
lesions.
>The foreskin is
retractable in
uncircumcised
child.
>Urinary meatus
is at tip of glands
penis and has no
discharge or
redness.
>Penis may
appear small in
obese boys
because of
overlapping skin
folds.
Inspect and
>Scrotum is free
palpate scrotum
of lesions.
and testes.
>Testes are
palpable in
scrotum with the
in size and color

pink.
*flat breast
Pa: *no palpable
masses
*not tender
I: *small in size
*lesion free
*no discharge
*no redness
*uncircumcised

findings of small size, no
discharge, no redness,
uncircumcised and lesion
free is Normal with the age
of the patient.
I: *no lesion
*equal in size

lesion free, equal in size,
smooth, mobile, and testes
Pa: *testes are

palpable in
31 | P a g e
Inspect and
palpate inguinal
area for hernias.
Note symmetry,
shape, and
movement. And
positioning of the
feet, legs, arms
and hands.
left testicle
usually lower than
the right.
>Testes are equal
in size, smooth,
mobile and free of
masses.
>No inguinal
hernias are
present
scrotum
*smooth to
palpate
*mobile and
free of masses
are palpable in scrotum is

normal with the age of the
patient.
I: *no noted
inguinal hernias

Nursing 3rd edition that no
inguinal hernias are should
be noted.
Pa: *no any

bulge in the
inguinal area is
suspected
MUSCULOSKELETAL SYSTEM
>Feet and leg are I: *extremities
symmetric in size, are symmetric
shape and
*No swelling or Nursing 3rd edition that
movement.
deformities
having a lesions in the skin
>Extremities
*with lesions in is abnormal due to insect
should be warm
the both lower
bites.
and mobile with
extremities
While the rest are normal as
adequate
*scratching
evident of no swelling and
capillary refill.
due to itchiness
no edema present with good
>This is an
movement and alignment.
inward (pointing
Pa: *non-tender
toward center of
and without
the body)
nodules.
positioning of the
*Feet are
forefoot with the
alignment with
heel in normal
the lower leg.
straight position; it
*Smooth,
resolves
rounded medial
spontaneously.
malleolar
>Tibia; torsion,
prominences
also common in
with prominent
infants and
heels and
toddlers, consist
metatarsophalan
of twisting of the
geal joint.
tibia inward or
*no pain, heat,
outward on its
and swelling
32 | P a g e
Spinal
alignment.
Observe spine
and posture.
Joints. Note
range of motion,
swelling,
redness, and
tenderness.
Muscles. Note
size and
strength.
long axis, and is

usually caused by
intrauterine
positioning; this
typically corrects
itself by the time
child is 2 years
old.
> Smooth,
rounded medial
malleolar
prominences with
prominent heels
and
metatarsophalang
eal joint.
>By 12-18
months, the
lumbar curve
develops.
Toddlers display
lordotic posture.
Findings in older
children and
adolescent are
similar to those in
adults.
>Full range of
motion and no
swelling, redness
or tenderness.
>Muscle size and

strength should
be adequate for
the particular age
and should be
equal bilaterally.
I: *no abnormal
posture noted

finding of no abnormal
posture is noted.
I: *Full range of
motion
*no swelling,
redness

Nursing 3rd edition that no
limited for range of motion
are Normal findings in the
age of the patient.
Pa: no
tenderness
I: *equal
bilaterally
*equal
coordination of
movement

equal bilaterally in muscle
size and strength is Normal
with the age of the patient.
33 | P a g e
Diagnostic Tests
(Laboratory Results)
34 | P a g e
HEMATOLOGY REPORT
TEST
NORMAL FINDINGS
ACTUAL FINDINGS
DATE
ANALYSIS
White Blood Cells
5-10 x 10^3u/L
8.35
Jan
.8, 2014
WBCs, which are produced in the bone marrow, are an important part of your immune
system and your bodys natural weapon to fight off bacteria, viruses and other germs.
Specific causes of high white blood cell count include:
Drugs, such as corticosteroids and epinephrine
Certain bacterial infections
Certain viral infections
Stress, such as severe emotional or physical stress
11.46
Jan.
17, 2014
10.32
Jan.
19, 2014
35 | P a g e
Red Blood Cells

4.7-6.1x 10^6u/L
4.11
Jan.
8, 2014
Red blood cells perform the most important blood duty. A single drop of blood contains
millions of red blood cells which are constantly traveling through your body delivering
oxygen and removing waste.
If your red blood count results are below the standard range, it may be due to:
Anemia
Excessive bleeding
Malnutrition
Nutritional deficiencies: iron, copper, folate, vitamins B6 and B12
3.93
Jan.
17, 2014
4.63
Jan.
19, 2014
Hemoglobin
135-160 G/L
107
Jan.
8, 2014
36 | P a g e
The hemoglobin molecule fills up the red blood cells. It carries oxygen and gives the
blood cell its red color. The hemoglobin test measures the amount of hemoglobin in
blood and is a good measure of the blood's ability to carry oxygen throughout the body.
A low hemoglobin count is a commonly seen blood test result. In many cases, a low
hemoglobin count is only slightly lower than normal, isn't considered significant and
causes no symptoms. A low hemoglobin count can also be caused by an abnormality or
disease. In these situations, a low hemoglobin count is referred to as anemia
100
Jan.
17, 2014
167.0
Jan.
19, 2014
Hematocrit
42.0-52.0%
29.4
Jan.
8, 2014
Haematocrit test measures the amount of space (volume) red blood cells take up in the
blood. The value is given as a percentage of red blood cells in a volume of blood.
30.4
Jan.
17, 2014
Low hematocrit may be due to:
Anemia
Bleeding
37 | P a g e
Destruction of red blood cells
Leukemia
Malnutrition
Nutritional deficiencies of iron, folate, vitamin B12, and vitamin B6
Overhydration
33.7
Jan.
19, 2014
MCV
M: 80- 94femtoliters
71.5
Jan.
8, 2014
The MCV (mean corpuscular volume) is an index of the size of the RBCs. Increase or
decrease in both MCV levels are used to determine vitamin B6 or mineral (copper or
iron) deficiencies and/or excess B12 and folic acid. The most common causes
of microcytic anemia are iron deficiency (due to
inadequate dietary intake, , sideroblastic anemia or chronic disease.
77.4
Jan.
17, 2014
38 | P a g e
72.8
Jan.
19, 2014
MCH
27-31 pitogram
26.0
Jan.8, 2014
The mean corpuscular hemoglobin concentration, a measure of the concentration

of hemoglobin in a given volume of packed red blood cells. It is reported as part of a
standard complete blood count. The MCH level can be too low because of blood loss
over time, too little iron in the body, or microcytic anemia.
25.4
Jan.
17, 2014
25.3
Jan.
9, 2014
MCHC
33.0-37.0g/dL
36.4
Jan.
8, 2014
The MCHC is dependent upon the size of the RBC as well as the amount of hemoglobin
in each cell. Certain diseases and anemias will alter the RBC count and/or the amount
of hemoglobin in the cell. The MCHC is not as dependent upon the RBC count as the
other tests in this section.
39 | P a g e
32.9
Jan.
17, 2014
34.7
Jan.
19, 2014
Neutrophil
50-70%
67.1
Jan.
8, 2014
Neutrophils are essential in protecting the body against disease and infections by
removing and destroying some types of bacteria, wastes, foreign substances, and other
cells.
46.9
Jan.
17, 2014
74.7
Jan.
19, 2014
Lymphocytes
25-40%
20.6
Jan.
8, 2014
40 | P a g e
Lymphocytes, an alternative name for white blood cells, are one of the cell types of the
immune system of vertebrates. These cells protect the body from becoming infected by
bacteria and viruses and also fight off bacterial and viral infections. There are three
main types of lymphocytes: B cells, T cells, and natural killer (NK) cells. Viral or bacterial
infections can decrease lymphocyte levels, but in most cases the level rises, once the
infection subsides.
33.6
Jan.
17, 2014
12.3
Jan.
19, 2014
Monocyte
3.0-11.0%
11.9
Jan.
8, 2014
Monocytes are white blood cells that help other white blood cells to remove dead or
damaged tissues, destroy cancer cells, and regulate immunity against foreign
substances. An increased number of monocytes in the blood (monocytosis) occurs in
response to chronic infections, in autoimmune disorders, in blood disorders, and in
cancers.
An increased percentage of monocytes may indicate:
Chronic inflammatory disease
Parasitic infection
Tuberculosis
Viral infection (for example, infectious mononucleosis, mumps, measles)
41 | P a g e
9.1
Jan.17, 2014
8.4
Jan.
19, 2014
Eosinophils
1.0-4.0%
0.1
Jan.
8, 2014
An eosinophil count is a type of blood test that measures the quantity of eosinophils(a
type of white blood cell) in your body. Eosinophils have two distinct functions in your
immune system. First, they destroy invading germs like viruses, bacteria, or parasites
such as Giardia and pinworm. Eosinophils also create an inflammatory response.
An abnormally low eosinophil count can be caused by intoxication from alcohol or
excessive production of cortisol (a steroid produced naturally in the body).
An abnormally high eosinophils count may be cause by a variety of conditions, diseases
and factors, including:
Parasitic and fungal diseases
Allergies, including to medications or food
Adrenal conditions
Skin disorders
Toxins
Autoimmune diseases
10.1
42 | P a g e
Jan.
17, 2014
3.9
Jan.
19, 2014
Basophils
0.0-1.0%
0.1
Jan.
8, 2014
Normal relative (%) content of basophils .

Basophils are a type of white blood cell that are involved in
inflammatory reactions in your body, especially those related to allergies and asthma.
When stimulated, basophils release histamine and other enzymes that can lead
to inflammation, bronchoconstriction, and asthma symptoms.
0.3
Jan.
17, 2014
0.5
Jan.
19, 2014
RDW-CV
11.5-14.5%
13.2
Jan.
8, 2014
43 | P a g e
RDW- CV is the relative distribution width of red blood cells by volume, coefficient of
variation. MCV goes hand in hand with red blood cell distribution width (RDW) in terms
of anemia and other hematology disorders, and the values of both are influenced by
each other.
Normal RDW and low MCV is associated with the following conditions:
Anemia of chronic disease

Heterozygous thalassemia
Hemoglobin E trait
Elevated RDW and low MCV is associated with the following conditions:
Iron deficiency
Sickle cell--thalassemia
12.9
Jan.
17, 2014
15.5
Jan.
19, 2014
Platelet Count
150-450 x 16^3 u/L
266
Jan.
8, 2014
A platelet count is a test to measure how many platelets you have in your blood.
Platelets help the blood clot. They are smaller than red or white blood cells.
Conditions or factors that can cause a high platelet count are:
Iron-deficiency anemia (uh-NEE-me-uh)

44 | P a g e
Hemolytic (HEE-moh-lit-ick) anemia
Absence of a spleen (after surgery to remove this organ)
Cancer
Inflammatory or infectious diseases
667
Jan.
17, 2014
763
Jan.
19, 2014
MPV
7.2-11.1
1L
9.0
Jan.
8, 2014
a machine-calculated measurement of the average size of platelets found in blood and

is typically included in blood tests as part of the CBC. Since the average platelet size is
larger when the body is producing increased numbers of platelets the MPV test results
can be used to make inferences about platelet production in bone marrow or platelet
destruction problems
8.0
45 | P a g e
Jan.
17, 2014
46 | P a g e
CLINICAL CHEMISTRY
Date: January 8, 2014
TEST
Creatinine
NORMAL
FINDINGS
62-106
umol/L
ACTUAL
FINDINGS
116.59umol/L
ANALYSIS
Creatinine consists of serum creatinine and
urine creatinine and it often refers to serum
creatinine which is an important indicator to
reflect kidney functions for CKD patients.
Persistently high creatinine levels are most
possibly caused by kidney problems.
Causes of high creatinine levels
1. Dehydration or inadequate water intake
such as high fever, sweating, diuresis can
cause blood concentration and reduced
blood flow in the kidneys. Creatinine will
increase.
2. Over-tiredness, lack of rest can cause
elevation of creatinine level.
3. Urine abnormalities such as long term
hematuria, proteinuria can be accompanied
by high creatinine.
4. Intake of drugs that have renal toxicity
can cause high creatinine which can even
be irreversible.
5. If renal dysfunction patients have
infections such as cold, pneumonia,
intestinal infection, urinary tract infections
can increase creatinine level in short time.
BUN
2.14-7.14
mmol/L
23.20/L
A blood urea nitrogen (BUN) test measures

the amount of nitrogen in your blood that
comes from the waste product urea. Urea is
47 | P a g e
made when protein is broken down in your

body. Urea is made in the liver and passed
out of your body in the urine.
Heart failure, dehydration, or a diet high in
protein can make your BUN level higher
CLINICAL CHEMISTRY
Time: 9:15 am
TEST
Sodium
Potassium
NORMAL
FINDINGS
135148umol/L
ACTUAL
FINDINGS
125.3umol/L
3.6-5.5
mmol/L
5.17 mmol/L
ANALYSIS
Sodium is one of the most important
electrolytes affected by dehydration.
Gastroenteritis can cause hyponatremia, or
low sodium levels, results when the body
loses more sodium than water, especially in
cases of severe vomiting and diarrhea.
Signs of hyponatremia include headache,
confusion and lethargy
Potassium is mostly found inside the body's
cells, so small changes in the potassium
level in the bloodstream can have a
significant impact in a person with
gastroenteritis. High potassium can cause
dangerous arrhythmias, or abnormal heart
rhythms. In particular, it can cause
ventricular fibrillation, a condition in which
the heart quivers instead of beats, thereby
decreasing its ability to deliver blood to the
brain and the body
48 | P a g e
ELECTROLYTES
Time: 6:10 am
TEST
Sodium
Potassium
NORMAL
FINDINGS
135148umol/L
ACTUAL
FINDINGS
128.1umol/
L
ANALYSIS
3.6-5.5
mmol/L
3.19
mmol/L
Potassium is mostly found inside the body's

cells, so small changes in the potassium level
in the bloodstream can have a significant
impact in a person with gastroenteritis.
88.5
mmol/L
96-106
mmol/L
A chloride test measures the level of chloride

in your blood or urine. Chloride is one of the
most important electrolytes in the blood. It
helps keep the amount of fluid inside and
outside of your cells in balance. It also helps
maintain proper blood volume, blood pressure,
and pH of your body fluids
A lower-than-normal level of chloride is called
hypochloremia. It may be due to:
Sodium is one of the most important

electrolytes affected by dehydration.
Gastroenteritis can cause hyponatremia, or
low sodium levels, results when the body loses
more sodium than water, especially in cases of
severe vomiting and diarrhea. Signs of
hyponatremia include headache, confusion
and lethargy
Chloride
Addison's disease
Congestive heart failure
Dehydration
49 | P a g e
Ionized
Calcium
1.17
mmol/L
1.13-1.51
mmol/L
Excessive sweating
Gastric suction
Hyperaldosteronism
Metabolic alkalosis
Respiratory acidosis (compensated)
Vomiting
Ionized calcium is calcium in your blood that is

not attached to proteins. It is also called free
calcium.
All cells need calcium in order to work.
Calcium helps build strong bones and teeth. It
is important for heart function. It also helps
with muscle contraction, nerve signaling, and
blood clotting.
URINALYSIS
Time: 02:30 pm
TEST
NORMAL
FINDINGS
Macroscopic
Color
Yellow
ACTUAL
ANALYSIS
FINDINGS
Light Yellow
Many things affect urine color, including fluid
balance, diet, medicines, and diseases. How dark
or light the color is tells you how much water is in it.
Vitamin B supplements can turn urine bright yellow.
Some medicines, blackberries, beets, rhubarb, or
blood in the urine can turn urine red-brown.
50 | P a g e
Transpar
ency
Clear
Slightly
Turbid
Reaction
Slightly
Acidic(4.5 8.0.
Average is
6.0)
Acidic
Specific
Gravity
1.005 to
1.025
1.010
Albumin
none
+2
Sugar
none
Negative
The turbidity of the urine is gauged subjectively and

reported as clear, slightly cloudy, cloudy, opaque or
flocculent. Normally fresh urine is clear to very
slightly cloudy. Excess turbidity results from the
presence of suspended particles in the urine
A highly acidic urine pH occurs in: Respiratory
diseases in which carbon dioxide retention occurs
and acidosis develops
Specific Gravity will increase with the amount of

dissolved particles (concentrated) in it. Specific
gravity will decrease when the water content is high
and the dissolved particles are low (less
concentrated). Low specific gravity (<1.005) is
characteristic of diabetes insipidus, nephrogenic
diabetes insipidus, acute tubular necrosis, or
pyelonephritis. Fixed specific gravity, in which
values remain 1.010 regardless of fluid intake,
occurs in chronic glomerulonephritis with severe
renal damage. High specific gravity(>1.035) occurs
in nephrotic syndrome, dehydration, acute
glomerulonephritis, heart failure, liver failure, or
shock.
Albumin is a type of protein found in large amounts
in the blood. Because it is a small molecule in size,
it is one of the first proteins able to pass through the
kidneys into the urine when there are kidney
problems. This presence of small amounts of
albumin in the urine is the condition called
microalbuminuria. It may indicate kidney failure and
children with dehydration are at high risk in
developing kidney failure.
Sugar in urine is an abnormal finding. Normally, the
kidney filters blood in such a way that it holds on to
blood sugar, keeping it in the blood. No glucose
should be present in the urine under normal
circumstances. Sugar can be found in urine in
conditions where the blood glucose levels are high,
hyperglycemia, as occurs with diabetes mellitus.
51 | P a g e
Microscopic
Pus cells
0-5/hpf
1-3/hpf
RBC
<5/hpf
0-1 /hpf
---
Rare
Ephitelial
cells
Finding a few pus cells or white blood cells (WBCs)

in urine is quite normal. But too many of them may
signal a problem somewhere in your urinary tract,
the commonest of which is a urinary tract infection
(UTI). Lab will usually report the result as number of
cells counted per high power field of the microscope
(hpf) or number of WBCs/mL of urine. Usually, 5 to
10 pus cells/hpf or 105 WBCs/mL of urine is
considered normal. A high number of pus cells in
urine is called pyuria. When a large number of
WBCs are present in urine, they may also be
detected on a urine dipstick test for leukocyte
esterase.
Gross bleeding into the urine is usually obvious. On
lab exam of the urine, numerous, many, and gross
are terms used to describe the amount of blood in
gross bleeding. However, all bleeding is not that
obvious. In order to detect slower bleeding and
inflammation in the urinary tract, the microscopic
exam is needed. In some normal conditions, a very
few RBC's may get into the urine. When a level of
more than 3 RBC's are found, a disease condition is
often present. One of the most common causes of
RBC's in the urine, is infection or inflammation of
the urinary tract itself (i.e., cystitis). Trauma and
several other conditions may also cause bleeding
into the urine
Epithelial cells often are present in the urinary
sediment. Squamous epithelial cells are large and
irregularly shaped, with a small nucleus and fine
granular cytoplasm; their presence suggests
contamination. The presence of transitional
epithelial cells is normal. These cells are smaller
and rounder than squamous cells, and they have
larger nuclei. The presence of renal tubule cells
indicates significant renal pathology Erythrocytes
are best visualized under high-power magnification.
Dysmorphic erythrocytes, which have odd shapes
because of their passage through an abnormal
glomerulus, suggest glomerular disease.
52 | P a g e
Amorpho
us Urates
--
Many
Uric acid crystallizes in the orthorombic system.

Uric acid crystals can appear under several shapes.
The classic crystals are thin rhombus shaped plates
with more or less eroded tops. The other forms are
the hexagonal plate, the needle and the
rosette. Uric acid crystals usually have a
characteristic yellow color. The intensity of the color
depends on the thickness of the crystal, thus very
thin plates seem colorless, while the massive
crystals have a color that tends to be brown. Under
polarized light, uric acid shows a polarization color,
and with thicker crystals, a series of concentric
black lines. The color variation seen under polarized
light is quite typical of uric acid. With rare
exceptions, uric acid crystals are of little clinical
value and represent a punctual situation.
ARTERIAL BLOOD GAS

Time: 3:45 pm
Arterial
Blood Gas
pH
Actual
Finding
7.44
Normal
Finding
7.35 7.45
Clinical Significance
pCO2
19.7 mmHg
35-45 mmHg
A low pCO2 indicates hyper-or-over

ventilation
pO2
114.0
mmHg
80-100
mmHg
Normal
A high pO2 indicates Increased

oxygen levels in the inhaled air
53 | P a g e
HCO3
15.2 mEq/L
22-26 mEq/L
Base Excess
8.2 mEq/L
+/-2 mEq/L
Oxygen
Saturation
98 %
100%
The HCO3 ion indicates whether a

metabolic problem is present (such
as ketoacidosis). A low HCO3
indicates metabolic acidosis
Patients may notice a subjective
sensation of dyspnoea caused by
stimulation of the respiratory centre
in an attempt to 'blow off' CO2 and
increase blood pH. Nausea,
vomiting and anorexia are
frequently present, particularly in
children. Metabolic acidosis
occurring in children is very rarely
due to an inborn error of
metabolism conditions such as
moderately severe gastroenteritis
being more common).
Excess bicarbonate in the blood
indicates metabolic alkalosis
Low oxygen in blood or hypoxemia
54 | P a g e
Case Management
A. Pharmacologic Intervention
-
Lists of drugs prescribed to Patient JM . (Based on the Drs. Order and Medication
Sheet Record)
Ceftriaxone
Phenobarbital
Diazepam
Paracetamol
55 | P a g e
Gentamicin
Ranitidine
January 8 2014
Ceftriaxone
Phenobarbital
Diazepam
Paracetamol
Gentamicin
January 16 2014
Ranitidine
Diazepam
Paracetamol
Phenobarbital
56 | P a g e
VISION
A premier university in historic Cavite
recognized for excellence in the
development of morally upright and globally
competitive individuals.
Republic of the Philippines

CAVITE STATE UNIVERSITY
Don Severino Delas Alas Campus
Indang, Cavite
MISSION
Cavite State University shall provide excellent,
equitable and relevant educational opportunities
in the arts, science and technology through
quality instruction and relevant research and
development activities. It shall produce
professional, skilled and morally upright
individuals for global competitiveness.
Drug Study
DRUG
FEATURES
Generic Name:
Diazepam
Brand Name:
Valium
Classification:
Anxiolytics /
Anticonvulsants
Dosage:
2.5 mg
Route:
Parenteral (IV)
Frequency:
PRN
Form:
Ampule
Color:
Clear
MECHANISM
OF ACTION
Exact
mechanism of
action not
understood; acts
mainly at the
limbic system
and reticular
formation; may
act in spinal
cord and at
supraspinal
sites to produce
skeletal muscle
relaxation;
potentiates the
effects of GABA,
an inhibitory
neurotransmitter
; anxiolytic
effects occur at
doses well
below those
necessary to
cause sedation,
INDICATION
CONTRAINDICATION
ADVERSE EFFECTS
Management
of anxiety
disorders or
for short-term
relief of
symptoms of
anxiety
Contraindicated with
hypersensitivity to
benzodiazepines;
psychoses, acute
narrow-angle
glaucoma, shock,
coma, acute alcoholic
intoxication; pregnancy
(cleft lip or palate,
ingunal hernia, cardiac
defects, microcephaly,
pyloric stenosis when
used in first trimester;
neonatal withdrawal
syndrome reported in
newborns); lactation.
CNS: transient mild

drowsiness, initially;
sedation, lethargy,
depression, apathy,
fatigue,
disorientation, light-
headedness,
restlessness,
confusion, crying,
delirium, headache,
slurred speech,
dysarthria, stupor,
rigidity, tremor,
dystonia, vertigo,
euphoria,
nervousness,
difficulty in
concentration, vivid
dreams, psychomotor
retardation,
extrapyramidal
symptoms; mild
paradoxical
excitatory reactions
during first 2 wk of
treatment, visual and
auditory
acute alcohol
withdrawal;
may be
useful in
symptomatic
relief of acute
agitation,
tremor,
delirium
tremens,
hallucinosis
muscle
relaxant:
adjunct for
relief of reflex
skeletal
muscle
spasm due to
Use cautiously with

elderly or debilitated
patients; impaired liver
or renal function; and
in patients with history
of substance abuse.
SIDE EFFECTS
Drowsiness
Fatigue
ataxia (loss of
balance)
Rarely:
excitability
muscle spasm
Lack of sleep
rage
NURSING
RESPONSIBILITIES
History:
hypersensitivity to
Benzodiazepines;
psychoses, acute
narrow-angle
glaucoma, shock ,
coma, acute
alcoholic intoxication;
elderly or debilitated
patients; impaired
liver or renal
function; pregnancy,
lactation
Physical: weight;
skin color, lesions;
orientation, affect,
reflexes, sensory
nerve function,
opthalmologic
examination ; P,
BP,R, adventitious
sounds; bowel
sounds, normal
output, liver
57 | P a g e
ataxia; has little

effect on cortical
function.
local
pathology
(inflammatory
of muscle or
joints) or
secondary to
trua;
spasticity
caused by
upper
motoneuron
disorders
(cerebral
palsy and
paraplegia);
athetosis,
stiff-man
syndrome
Parenteral:
treatment of
tetanus
Antiepileptic:
adjunct in
status
epilepticus
and severe
recurrent
convulsive
seizures
(parenteral);
adjunct in
seizure
disorders
(oral)
Preoperative
(parenteral):
relief of
disturbances,
diplopia, nystagmus,
depressed hearing ,
nasal congestion
evaluation; normal
output; LFTs, renal
function tests, CBC
Confusion
depression
CV:bradycardia,
tachycardia, CV
collapse,
speech problems
hypertension and
hypotension,
palpitations , edema double vision
dependence:drug
dependence with
withdrawal syndrome
when drug is
discontinued 9
common with abrupt
discontinuation of
higher dosage used
for longer than 4 mo);
IV diazepam: 1.7 %
incidence of fatalities;
oral benzodiazepines
ingested alone, no
well-documented
fatal overdoses
-Diazepam can
lead to addiction
(dependency),
In patients
addicted to
diazepam or after
prolonged use,
abrupt
discontinuation
may cause
symptoms of
withdrawal:
Dermatologic:
urticaria, pruritus,
insomnia
skin, rash, dermatitis
headache
Nausea
GI:constipation,
diarrhea, dry mouth; Vomiting
salivation,; nausea; Lightheadedness
anorexia; vomiting; Sweating
elevations of blood Anxiety
enzyme-LDH,
and fatigue
alkaline,
phosphatase, AST,
-Seizures can
58 | P a g e
anxiety and
tension and
to lessen
recall in
patients prior
to surgical
procedures,
cardioversion
, and
endoscopic
procedures
Rectal:
management
of selected ,
refractory
patients with
epilepsy who
require
intermittent
use to control
bouts of
increased
seizure
activity
ALT; hepatic
impairement;
jaundice
GU: Incontinence,
urinary retention ,
changes in libido,
menstrual
irregularities
hematologic:
decreased hct, blood
dyscrasias
occur in more
severe cases of
withdrawal.
Therefore, after
extended use,
diazepam should
be slowly tapered
under a doctor's
supervision rather
than abruptly
stopped.
other: phlebitis and

thrombosis at IV
injection sites,
hiccups, fever,
diaphoresis,
parathesias,
muscular
disturbances,
gynecomasta; pain
burning, and redness
after IM injection
unlabeled
use:
treatment of
night terrors
59 | P a g e
VISION

Indang, Cavite
MISSION
Drug Study
DRUG
FEATURES
Generic Name:
Phenobarbital
Brand Name:
Elixir
Classification:
Anticonvulsant
s
Dosage:
20 mg
Route:
Parenteral (IV)
Frequency:
Q12
Form:
Vial
Color:
White
MECHANISM
OF ACTION
General CNS
depressant;
barbiturates
inhibit impulse
conduction in
the ascending
RAS, depress
the cerebral
cortex, alter
cerebral
function,
depress motor
output, and
can produce
excitation,
sedation,
hypnosis,
anesthesia,
and deep
coma; at subhypnotic
doses, has
anti-seizure
activity,
making it
suitable for
long term use
INDICATION
CONTRAINDICATION
-oral or parenteral:
Sedative
Contraindicated with
hypersenstivity to
barbiturates, manifest,
or latent porphyria,
marked liver
impairment, nephritis,
severe respiratory
distress, previous
addiction to sedative
hypnotic drugs (may
be ineffective and may
contribute to further
addiction), pregnancy
(fetal damage,
neonatal withdrawal
syndrome).
-oral or
parenteral:hypnoti
c, treatment of
insomia for up to 2
week
-oral: Long term
treatment of
generalized tonicclonic and cortical
focal seizure
-oral: emergency
control of certain
acute seizures
(e.g. those
associated with
status epilepticus,
eclampsia,
meningitis, tetanus
and toxic reactions
to strychnine or
local anesthetics.
-use cautiously with

acute or chronic pain
(drug may cause
paradoxical
excitement or mask
important symptoms);
seizure disorders
(abrupt discontinuation
of daily doses can
result in epilepticus);
ADVERSE
EFFECTS
CNS: somnolence,
agitation,
confusion,
hyperkinesia,
ataxia, vertigo,
CNS depression,
nightmares,
lethargy, residual
sedation
(hangover),
paradoxical
excitement,
nervousness,psychi
atric disturbance,
hallucinations,inso
mnia, anxiety,
dizziness, thinking
abnormality
CV:Bradycardia,
hypotension,
syncope
GI: nausea,
vomiting,
constipation,
diarrhea, epigastric
SIDE EFFECTS
serious side
effects:
restless muscle
movements in
your eyes,
tongue, jaw,
or neck;
slow heartbeat
shallow
breathing
feeling lightheaded
fainting
a fever or a sore
throat
sores in your
mouth
easy bruising or
bleeding or
broken blood
vessels under
your skin.
Less serious
side effects may
include:
NURSING
RESPONSIBILITIES
History;
hypersensitivity to
barbituarates,
manifest or latent
porphyria, marked
liver impairment,
nephritis, severe
respiratory distress,
previous addiction to
sedative-hypnotic
drugs, pregnancy,
acute or chronic
pain, seizure
disorders, lactation,
fever,
hyperthyroidism,
diabetes mellitus,
anemia, cardiac
disease, shck,
uremia, impaired
liver or renal
function, debiliation
Physical: weight, T,
skin olor, lesions;
60 | P a g e
as an
antiepileptic.
-Parenteral:
Preanesthetic
-Parenteral:
tretment of
generalized tonicclonic and cortical
focal seizures
-Parenteral:
emergency control
of acute seizures
(epilepticus,
eclampsia,
tetanus)
lactation (secrreted in
breast milk;
drowainess in nursing
infants); fever,
hyperthyroidism,
diabetes mellitus ,
sever anemia ,
pulmonary or cardiac
disease, status
asthmaticus, shock,
uremia, impaired liver
or renal function,
debilitation
pain
drowsiness or
-Hypersensivity:
dizziness
rashes,
problems with
angioneurotic
memory or
edema, serum
concentration
sickness,
excitement,
morbiliform rash,
irritability,
urticaria; rarely,
aggression, or
exfoliative
confusion
dermatitis, Steven(especially in
Johnson
children or
syndrome
older adults)
loss of balance
-Resipratory:
or coordination;
hypoventilation,
nausea
apnea, respiratory
constipation
depression,
headache;
laryngospasm,
or-"hangover"
brochospasm,
effect
circulatory
(drowsiness the
collapse
day after a
dose).
other: tolerance,
psychological and
physical
dependence,
withdrawal
syndrome
orientation, affect,
reflexes; P,BP,
orthostatic BP; R,
adventitious sounds,
bowel sounds,
normal output, liver
evaluation; LFTs,
renal function test
blood and urine
glucose, BUN
61 | P a g e
VISION

Indang, Cavite
MISSION
Drug Study
DRUG
FEATURES
Generic Name:
Ceftriaxone
Sodium
Brand Name:
Rocephin
Classification:
Cephalosphorin
Dosage:
1 mg
Route:
Parenteral (IV)
Frequency:
OD
Form:
Vial
Color:
White
MECHANISM OF
ACTION
Works by inhibiting
the mucopeptide
synthesis in the
bacterial cell wall.
The beta-lactam
moiety of
Ceftriaxone binds
to
carboxypeptidases
, endopeptidases,
and
transpeptidases in
the bacterial
cytoplasmic
membrane. These
enzymes are
involved in cell-wall
synthesis and cell
division. By binding
to these enzymes,
Ceftriaxone results
in the formation of
of defective cell
walls and cell
INDICATION
CONTRAINDICATION
ADVERSE
EFFECTS
Treatment of
infections of
the lower
respiratory
tract, acute
bacterial
otitis media,
skin & skin
structure
infection,
UTI,
uncomplicate
d gonorrhea,
pelvic
inflammatory
disease,
bacterial
septicemia,
bone & joint
infections,
intraabdominal
infections,
meningitis.
Hypersensitivity to
cephalosporins.
Hypersensitivity to
lidocaine (IM injection)
Induration
Phlebitis
Thrombocyto
sis
Leucopenia
Glossitis
Respiratory
superinfectio
ns
SIDE EFFECTS
Nausea and
Vomiting
Diarrhea
Pain at IM site
Rashes
Diarrhea
NURSING
RESPONSIBILITIES
Assess patients
previous sensitivity
reaction to penicillin
or other
cephalosphorins.
Assess patient for
signs and symptoms
of infection before
and during the
treatment
Obtain C&S before
beginning drug
therapy to identify if
correct treatment has
been initiated.
Assess for allergic
reaction.
Monitor
hematologic,electroly
tes, renal and hepatic
function.
Assess for possible
superinfection:
itching fever, malaise,
redness, diarrhea
62 | P a g e
death.
VISION

Indang, Cavite
Drug Study
DRUG
FEATURES
Generic Name:
Ranitidine HCl
Brand Name:
Zantac
Classification:
Antacid
Dosage:
10 mg
Route:
Parenteral (IV)
Frequency:
Q8
Form:
Vial
Color:
Clear
MECHANISM
OF ACTION
Competitively
inhibits action
of histamine
at H2receptor sites
of parietal
cells,
decreasing
gastric and
acid
secretion.
INDICATION
Active duodenal
and gastric ulcer
Maintenance
therapy for
duodenal and
gastric ulcer
Gastroesophageal
reflux disorder
Erosive
esophagitis
Heartburn
CONTRAINDICATION
Contraindicated in
patients
hypersensitive to
drug and in those
with acute
porphyria.
Use cautiously in
patients with
hepatic
dysfunction. Adjust
dosage in patients
with impaired renal
function.
MISSION
ADVERSE
EFFECTS
CNS:
headache,
malaise,
vertigo
EENT:
blurred
vision
Hepatic:
Jaundice
Other:
anaphylaxis,
angioedema
, burning
and itching
at injection
site.
Adverse
Effects:
Diarrhea,
dizziness,
tiredness,
headache &
rash.
SIDE EFFECTS
chest pain
fever
feeling short of
breath
coughing up
green or
yellow
mucus
easy bruising or
bleeding
unusual
weakness
fast or slow
heart rate
problems with
your vision
sore throat
headache
with a severe
blistering,
peeling
red skin rash or
stomach pain
NURSING
RESPONSIBILITIES
Monitor vital signs
of the patient.
Administer
medication as
prescribed by the
physician.
Assist the patient
when
administering the
medication.
Advise patient to
report abdominal
pain, blood in stool
or emesis, black,
tarry stools, or
coffee-ground
emesis.
Assess patient for
abdominal pain.
Note presence of
blood in emesis,
63 | P a g e
Reversible
confusional
state. Fever,
arthralgia,
myalgia,
blood & CV
disorders
low fever
loss of appetite
dark urine
clay-colored
stools
jaundice
(yellowing of
the skin or
eyes)
stool, or gastric
aspirate.
Less serious
side effects
may include:
headache (may
be severe)
drowsiness
dizziness
sleep problems
(insomnia)
nausea
vomiting
stomach pain
diarrhea
constipation.
64 | P a g e
VISION
MISSION

Indang, Cavite
Drug Study
DRUG
FEATURES
Generic Name:
Gentamicin
Sulfate
Brand Name:
Gentamicin
Classification:
Antibiotic
Dosage:
35 mg
Route:
Parenteral (IV)
Frequency:
OD
Form:
Ampule
Color:
Clear
MECHANISM
OF ACTION
Inhibits
protein
synthesis in
susceptible
strains of
gram
negative
bacteria;
appears to
disrupt
functional
integrity of
bacterial cell
membrane,
causing cell
death.
INDICATION
Serious
infection when
causative
organisms are
not known.
Treatment of
superficial
ocular
infections due
to strains of
microorganism
susceptible to
gentamicin.
CONTRAINDICATION
ADVERSE
EFFECTS
Use cautiously with
CNS:
Ototoxicity,
renal or hepatic disease
tinnitus,
sulfite sensitivity;
dizziness,
preexisting hearing
vertigo,
loss; active infection
deafness,
with herpes, vaccinia,
vestibular
and fungal infection.
paralysis,
confusion,
lethargy
CV:
Palpitation,
Hypotension
GI: Hepatic
toxicity,
nausea,
vomiting,
anorexia,
weight loss
GU:
Nephrotoxicity
SIDE EFFECT
Numbness or
tingling
muscle
twitching
weakness
seizure
persistent
diarrhea
abdominal or
stomach
pain/cramping
blood/mucus in
your stool
rash,
itching/swelling
(especially of
the
face/tongue/thr
oat)
severe
dizziness
Trouble
breathing.
NURSING
RESPONSIBILITIES
Monitor serum
concentration when
feasible to avoid
potentially toxic
levels.
Assess patient for
signs and symptoms
of infection before
and during the
treatment
Culture infected area
before therapy
Assess for allergic
reaction.
Avoid long tren
therapies because of
increased risk of
toxicities.
65 | P a g e
VISION

Indang, Cavite
MISSION
Drug Study
DRUG
FEATURES
Generic Name:
Paracetamol
Brand Name:
Aeknil
Classification:
Analgesics
Dosage:
110 mg
Route:
Parenteral (IV)
Frequency:
PRN
Form:
Ampule
Color:
MECHANISM
OF ACTION
Produces
analgesia by
raising the
threshold of the
pain center in
the brain and by
obstructing
impulses at the
pain-mediating
chemoreceptors
. The drug
produces
antipyresis by
an action on the
hypothalamus;
heat dissipation
is increased as
a result of
vasodilation and
increased
INDICATION
To relieve
mild to
moderate
pain due to
things such
as headache,
muscle and
joint pain
backache and
period pains.
It is also used
to bring down
a high
temperature.
For this
reason,
paracetamol
can be given
to children
after
vaccinations
CONTRAINDICATION
Hypersensitivity to
acetaminophen or
phenacetin; use with
alcohol.
ADVERSE
EFFECTS
Hematologic:
hemolytic anemia,
leukopenia,
neutropenia,
pancytopenia,
thrombocytopenia.
Hepatic:
liver damage,
jaundice
Metabolic:
hypoglycemia
Skin: rash, urticuria
SIDE
EFFECTS
Dyspepsia
skin rash
itching
hives
NURSING
RESPONSIBILITIES
Assessment & Drug
Effects
-Monitor for S&S of:
hepatotoxicity, even with
moderate acetaminophen
doses, especially in
individuals with poor
nutrition.
Patient & Family
Education
-Do not take other
medications (e.g., cold
preparations) containing
acetaminophen without
medical advice;
overdosing and chronic
use can cause liver
damage and other toxic
effects.
-Do not self-medicate
children for pain more
66 | P a g e
Clear
peripheral blood
flow.
to prevent
postimmunization
pyrexia (high
temperature).
Paracetamol
is often
included in
cough, cold
and flu
remedies.
than 5 d without
consulting a physician.
-Do not use for fever
persisting longer than 3
d, fever over 39.5 C (103
F), or recurrent fever.
- Do not give children
more than 5 doses in 24
h unless prescribed by
physician.
67 | P a g e
B. Dietary Prescription/ Restriction

According to the doctors order, Patient J.M should be maintained Feed with
Strict Aspiration.
C. Hospital Procedures
Procedures
Indication
Findings
Nursing
Oxygen
The use of oxygen
Patient J.M was
Responsibilities
The Nurse should
Administration
concentrators is
given an oxygen
provide an adequate
another means of
delivery system as a
support to the
providing varying
relief for breathing.
cannula. Cleanliness
amounts of oxygen.
The patient was
of the surface should
Nasal Cannula has
given oxygen
be maintained to
suggested flow rate
inhalator via nasal
avoid contamination
of 1-6 L/min.
cannula as needed
that could result to
prior to admission.
infection. Also, nasal
The nasal cannula
cannula causes nasal
delivers 10% to 40%
mucosa drying.
at 4-5L per minute.
Intravenous Fluid
IV Catheterization
Intravenous Fluids
provide fluid
replacement,
parental nutrition
and administration
of antibiotics,
analgesics and
chemotherapy
agent.
Is technique in
The IV line was

infusing well and no
air and back flow
seen.
Intravenous Fluids
should be regulated
accurately according
to the doctors order.
Patient JM was
The Nurse should

68 | P a g e
which a cannula is
placed inside a vein
to provide venous
access.
Venous access
allows sampling of
blood as well as
administration of
fluids, medications,
parenteral nutrition,
chemotherapy, and
blood products.
catheterized with no.

33 D5IMB regulated
at 48-49 ugtts on her
left metacarpal vein.
assess the IV site to

check if there is
embolism,
misplacement of IV
Cannula or other
problems in relation to
IV Therapy.
69 | P a g e
Overview
Anatomy and Physiology
70 | P a g e
ANATOMY AND PHYSIOLOGY

GASTROINTESTINAL TRACT
The human gastrointestinal tract (GI tract), refers to the stomach and intestine,
and is divided into the upper and lower gastrointestinal tracts. It can also include all the
structures from the mouth to the anus.
The whole digestive tract is about nine metres long. The tract may also be
divided into foregut, midgut, and hindgut, reflecting the embryologicalorigin of each
segment of the tract.
The GI tract constantly releases hormones to help regulate the digestive process.
These hormones, including gastrin, secretin, cholecystokinin, and ghrelin, are mediated
through either intracrine or autocrine mechanisms, indicating that the cells releasing
these hormones are conserved structures throughout evolution.
ANATOMY
Upper gastrointestinal tract

The upper gastrointestinal tract consists of the esophagus, stomach,
and duodenum. The exact demarcation between the upper and lower tracts can vary.
Upon 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 suspensory muscle of duodenum is an important anatomical landmark which
shows the formal division between the duodenum and the jejunum, the first and second
parts of the small intestine, respectively. This is a thin muscle which is derived from
the embryonic mesoderm.
Lower gastrointestinal tract
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The lower gastrointestinal tract includes most of the small intestine and all of
the large intestine.
Bowel or intestine
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 a mucus-rich
alkaline secretion containing bicarbonate , which In combination with
bicarbonate from the pancreas neutralizes HCl of the stomach.
Jejunum: This is the midsection of the intestine, connecting the

duodenum to the ileum. It contains the plicae circulares, and villi that
increase the surface area of this part of the GI Tract. Products of digestion
(sugars, amino acids, and fatty acids) are absorbed into the bloodstream
here.
Ileum: Has villi similar to the jejunum, and absorbs mainly vitamin
B12 and bile acids, as well as any other remaining 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 Flexure: The main function of the Colon is to absorb

water,
but
it
also
beneficial vitamins like vitamin K.
Rectum
contains bacteria that
produce
Anal canal: The terminal part of the large intestine.
PHYSIOLOGY
The time taken for food or other ingested objects to transit through the
gastrointestinal tract varies depending on many factors, but roughly, it takes less than
an hour after a meal for 50% of stomach contents to empty into the intestines and total
emptying of the stomach takes around 2 hours. Subsequently, 50% emptying of the
small intestine takes 1 to 2 hours. Finally, transit through the colon takes 12 to 50 hours
with wide variation between individuals.
72 | P a g e
Immune function
The gastrointestinal tract is also a prominent part of the immune system. The
surface area of the digestive tract is estimated to be the surface area of a football field.
With such a large exposure, the immune system must work hard to prevent pathogens
from entering into blood and lymph.
The low pH (ranging from 1 to 4) of the stomach is fatal for
many microorganisms that enter it. Similarly, mucus (containing IgA antibodies)
neutralizes many of these microorganisms. Other factors in the GI tract help with
immune function as well, including enzymes in saliva and bile. Enzymes such as
Cyp3A4, along with the antiporter activities, also are instrumental in the intestine's role
of detoxification of antigens and xenobiotics, such as drugs, involved in first pass
metabolism.
Health-enhancing intestinal bacteria serve to prevent the overgrowth of
potentially harmful bacteria in the gut. These two types of bacteria compete for space
and "food," as there are limited resources within the intestinal tract. A ratio of 80-85%
beneficial to 15-20% potentially harmful bacteria generally is considered normal within
the intestines. Microorganisms also are kept at bay by an extensive immune system
comprising the gut-associated lymphoid tissue (GALT).
BRAIN
The brain is one of the most complex and magnificent organs in the human body.
Our brain gives us awareness of ourselves and of our environment, processing a
constant stream of sensory data. It controls our muscle movements, the secretions of
our glands, and even our breathing and internal temperature. Every creative thought,
feeling, and plan is developed by our brain. The brains neurons record the memory of
every event in our lives.
ANATOMY
73 | P a g e
There are different ways of dividing the brain anatomically into regions. Lets use
a common method and divide the brain into three main regions based on embryonic
development: the forebrain, midbrain and hindbrain. Under these divisions:
The forebrain (or prosencephalon) is made up of our incredible cerebrum,
thalamus, hypothalamus and pineal gland among other features. Neuroanatomists call
the cerebral area the telencephalon and use the term diencephalon (or interbrain) to
refer to the area where our thalamus, hypothalamus and pineal gland reside.
The midbrain (or mesencephalon), located near the very center of the brain
between the interbrain and the hindbrain, is composed of a portion of the brainstem.
The hindbrain (or rhombencephalon) consists of the remaining brainstem as
well as our cerebellum and pons. Neuroanatomists have a word to describe the
brainstem sub-region of our hindbrain, calling it the myelencephalon, while they use the
wordmetencephalon in reference to our cerebellum and pons collectively.
Before exploring these different regions of the brain, first lets define the important types
of cells and tissues that are the building blocks of them all.
Histology
Brain cells can be broken into two groups: neurons and neuroglia.
Neurons, or nerve cells, are the cells that perform all of the communication and
processing within the brain. Sensory neurons entering the brain from the peripheral
nervous system deliver information about the condition of the body and its surroundings.
Most of the neurons in the brains gray matter are interneurons, which are responsible
74 | P a g e
for integrating and processing information delivered to the brain by sensory neurons.
Interneurons send signals to motor neurons, which carry signals to muscles and glands.
Neuroglia, or glial cells, act as the helper cells of the brain; they support and
protect the neurons. In the brain there are four types of glial cells: astrocytes,
oligodendrocytes, microglia, and ependymal cells.
Astrocytes protect neurons by filtering nutrients out of the blood and preventing
chemicals and pathogens from leaving the capillaries of the brain.
Oligodendrocytes wrap the axons of neurons in the brain to produce the
insulation known as myelin. Myelinated axons transmit nerve signals much faster than
unmyelinated axons, so oligodendrocytes accelerate the communication speed of the
brain.
Microglia act much like white blood cells by attacking and destroying pathogens
that invade the brain.
Ependymal cells line the capillaries of the choroid plexuses and filter blood
plasma to produce cerebrospinal fluid.
The tissue of the brain can be broken down into two major classes: gray matter and
white matter.
Gray matter is made of mostly unmyelinated neurons, most of which are
interneurons. The gray matter regions are the areas of nerve connections and
processing.
White matter is made of mostly myelinated neurons that connect the regions of
gray matter to each other and to the rest of the body. Myelinated neurons transmit nerve
signals much faster than unmyelinated axons do. The white matter acts as the
information highway of the brain to speed the connections between distant parts of the
brain and body.
HINDBRAIN (RHOMBENCEPHALON)
Brainstem
Connecting the brain to the spinal cord, the brainstem is the most inferior portion
of our brain. Many of the most basic survival functions of the brain are controlled by the
brainstem.
The brainstem is made of three regions: the medulla oblongata, the pons, and
the midbrain. A net-like structure of mixed gray and white matter known as the reticular
formation is found in all three regions of the brainstem. The reticular formation controls
muscle tone in the body and acts as the switch between consciousness and sleep in the
brain.
The medulla oblongata is a roughly cylindrical mass of nervous tissue that
connects to the spinal cord on its inferior border and to the pons on its superior border.
The medulla contains mostly white matter that carries nerve signals ascending into the
brain and descending into the spinal cord. Within the medulla are several regions of
gray matter that process involuntary body functions related to homeostasis. The
75 | P a g e
cardiovascular center of the medulla monitors blood pressure and oxygen levels and
regulates heart rate to provide sufficient oxygen supplies to the bodys tissues. The
medullary rhythmicity center controls the rate of breathing to provide oxygen to the
body. Vomiting, sneezing, coughing, and swallowing reflexes are coordinated in this
region of the brain as well.
The pons is the region of the brainstem found superior to the medulla oblongata,
inferior to the midbrain, and anterior to the cerebellum. Together with the cerebellum, it
forms what is called the metencephalon. About an inch long and somewhat larger and
wider than the medulla, the pons acts as the bridge for nerve signals traveling to and
from the cerebellum and carries signals between the superior regions of the brain and
the medulla and spinal cord.
Cerebellum
The cerebellum is a wrinkled, hemispherical region of the brain located posterior
to the brainstem and inferior to the cerebrum. The outer layer of the cerebellum, known
as the cerebellar cortex, is made of tightly folded gray matter that provides the
processing power of the cerebellum. Deep to the cerebellar cortex is a tree-shaped
layer of white matter called the arbor vitae, which means tree of life. The arbor vitae
connects the processing regions of cerebellar cortex to the rest of the brain and body.
The cerebellum helps to control motor functions such as balance, posture, and
coordination of complex muscle activities. The cerebellum receives sensory inputs from
the muscles and joints of the body and uses this information to keep the body balanced
and to maintain posture. The cerebellum also controls the timing and finesse of complex
motor actions such as walking, writing, and speech.
MIDBRAIN (MESENCEPHALON)
The midbrain, also known as the mesencephalon, is the most superior region of
the brainstem. Found between the pons and the diencephalon, the midbrain can be
further subdivided into 2 main regions: the tectum and the cerebral peduncles.
The tectum is the posterior region of the midbrain, containing relays for reflexes
that involve auditory and visual information. The pupillary reflex (adjustment for light
intensity), accommodation reflex (focus on near or far away objects), and startle
reflexes are among the many reflexes relayed through this region.
Forming the anterior region of the midbrain, the cerebral peduncles contain
many nerve tracts and the substantia nigra. Nerve tracts passing through the cerebral
peduncles connect regions of the cerebrum and thalamus to the spinal cord and lower
regions of the brainstem. The substantia nigra is a region of dark melanin-containing
neurons that is involved in the inhibition of movement. Degeneration of the substantia
nigra leads to a loss of motor control known as Parkinsons disease.
76 | P a g e
FOREBRAIN (PROSENCEPHALON)
Diencephalon
Superior and anterior to the midbrain is the region known as the interbrain, or
diencephalon. The thalamus, hypothalamus, and pineal glands make up the major
regions of the diencephalon.
The thalamus consists of a pair of oval masses of gray matter inferior to the
lateral ventricles and surrounding the third ventricle. Sensory neurons entering the brain
from the peripheral nervous system form relays with neurons in the thalamus that
continue on to the cerebral cortex. In this way the thalamus acts like the switchboard
operator of the brain by routing sensory inputs to the correct regions of the cerebral
cortex. The thalamus has an important role in learning by routing sensory information
into processing and memory centers of the cerebrum.
The hypothalamus is a region of the brain located inferior to the thalamus and
superior to the pituitary gland. The hypothalamus acts as the brains control center for
body temperature, hunger, thirst, blood pressure, heart rate, and the production of
hormones. In response to changes in the condition of the body detected by sensory
receptors, the hypothalamus sends signals to glands, smooth muscles, and the heart to
counteract these changes. For example, in response to increases in body temperature,
the hypothalamus stimulates the secretion of sweat by sweat glands in the skin. The
hypothalamus also sends signals to the cerebral cortex to produce the feelings of
hunger and thirst when the body is lacking food or water. These signals stimulate the
conscious mind to seek out food or water to correct this situation. The hypothalamus
also directly controls the pituitary gland by producing hormones. Some of these
hormones, such as oxytocin and antidiuretic hormone, are produced in the
hypothalamus and stored in the posterior pituitary gland. Other hormones, such as
releasing and inhibiting hormones, are secreted into the blood to stimulate or inhibit
hormone production in the anterior pituitary gland.
The pineal gland is a small gland located posterior to the thalamus in a subregion called the epithalamus. The pineal gland produces the hormone melatonin. Light
striking the retina of the eyes sends signals to inhibit the function of the pineal gland. In
the dark, the pineal gland secretes melatonin, which has a sedative effect on the brain
and helps to induce sleep. This function of the pineal gland helps to explain why
darkness is sleep-inducing and light tends to disturb sleep. Babies produce large
amounts of melatonin, allowing them to sleep as long as 16 hours per day. The pineal
gland produces less melatonin as people age, resulting in difficulty sleeping during
adulthood.
Cerebrum
The largest region of the human brain, our cerebrum controls higher brain
functions such as language, logic, reasoning, and creativity. The cerebrum surrounds
the diencephalon and is located superior to the cerebellum and brainstem. A deep
furrow known as the longitudinal fissure runs midsagittally down the center of the
cerebrum, dividing the cerebrum into the left and right hemispheres. Each hemisphere
77 | P a g e
can be further divided into 4 lobes: frontal, parietal, temporal, and occipital. The lobes
are named for the skull bones that cover them.
The surface of the cerebrum is a convoluted layer of gray matter known as
the cerebral cortex. Most of the processing of the cerebrum takes place within the
cerebral cortex. The bulges of cortex are called gyri (singular: gyrus) while the
indentations are calledsulci (singular: sulcus).
Deep to the cerebral cortex is a layer of cerebral white matter. White matter
contains the connections between the regions of the cerebrum as well as between the
cerebrum and the rest of the body. A band of white matter called the corpus callosum
connects the left and right hemispheres of the cerebrum and allows the hemispheres to
communicate with each other.
Deep within the cerebral white matter are several regions of gray matter that
make up the basal nuclei and the limbic system. The basal nuclei, including the globus
pallidus, striatum, and subthalamic nucleus, work together with the substantia nigra of
the midbrain to regulate and control muscle movements. Specifically, these regions help
to control muscle tone, posture, and subconscious skeletal muscle. The limbic system is
another group of deep gray matter regions, including the hippocampus and amygdala,
which are involved in memory, survival, and emotions. The limbic system helps the body
to react to emergency and highly emotional situations with fast, almost involuntary
actions.
Meninges
Three layers of tissue, collectively known as the meninges, surround and protect the
brain and spinal cord.
The dura mater forms the leathery, outermost layer of the meninges. Dense
irregular connective tissue made of tough collagen fibers gives the dura mater its
strength. The dura mater forms a pocket around the brain and spinal cord to hold the
cerebrospinal fluid and prevent mechanical damage to the soft nervous tissue. The
name dura mater comes from the Latin for tough mother, due to its protective nature.
The arachnoid mater is found lining the inside of the dura mater. Much thinner
and more delicate than the dura mater, it contains many thin fibers that connect the dura
mater and pia mater. The name arachnoid mater comes from the Latin for spider-like
mother, as its fibers resemble a spider web. Beneath the arachnoid mater is a fluidfilled region known as the subarachnoid space.
As the innermost of the meningeal layers, the pia mater rests directly on the
surface of the brain and spinal cord. The pia maters many blood vessels provide
nutrients and oxygen to the nervous tissue of the brain. The pia mater also helps to
regulate the flow of materials from the bloodstream and cerebrospinal fluid into nervous
tissue.
Cerebrospinal Fluid
Cerebrospinal fluid (CSF) a clear fluid that surrounds the brain and spinal
78 | P a g e
cord provides many important functions to the central nervous system. Rather than
being firmly anchored to their surrounding bones, the brain and spinal cord float within
the CSF. CSF fills the subarachnoid space and exerts pressure on the outside of the
brain and spinal cord. The pressure of the CSF acts as a stabilizer and shock absorber
for the brain and spinal cord as they float within the hollow spaces of the skull and
vertebrae. Inside of the brain, small CSF-filled cavities called ventricles expand under
the pressure of CSF to lift and inflate the soft brain tissue.
Cerebrospinal fluid is produced in the brain by capillaries lined with ependymal
cells known as choroid plexuses. Blood plasma passing through the capillaries is filtered
by the ependymal cells and released into the subarachnoid space as CSF. The CSF
contains glucose, oxygen, and ions, which it helps to distribute throughout the nervous
tissue. CSF also transports waste products away from nervous tissues.
After circulating around the brain and spinal cord, CSF enters small structures
known as arachnoid villi where it is reabsorbed into the bloodstream. Arachnoid villi are
finger-like extensions of the arachnoid mater that pass through the dura mater and into
the superior sagittal sinus. The superior sagittal sinus is a vein that runs through the
longitudinal fissure of the brain and carries blood and cerebrospinal fluid from the brain
back to the heart.
PHYSIOLOGY
Metabolism
Despite weighing only about 3 pounds, the brain consumes as much as 20% of
the oxygen and glucose taken in by the body. Nervous tissue in the brain has a very
high metabolic rate due to the sheer number of decisions and processes taking place
within the brain at any given time. Large volumes of blood must be constantly delivered
to the brain in order to maintain proper brain function. Any interruption in the delivery of
blood to the brain leads very quickly to dizziness, disorientation, and eventually
unconsciousness.
Sensory
The brain receives information about the bodys condition and surroundings from
all of the sensory receptors in the body. All of this information is fed into sensory areas
of the brain, which put this information together to create a perception of the bodys
internal and external conditions. Some of this sensory information is autonomic sensory
information that tells the brain subconsciously about the condition of the body. Body
temperature, heart rate, and blood pressure are all autonomic senses that the body
receives. Other information is somatic sensory information that the brain is consciously
aware of. Touch, sight, sound, and hearing are all examples of somatic senses.
Motor Control
Our brain directly controls almost all movement in the body. A region of the
cerebral cortex known as the motor area sends signals to the skeletal muscles to
produce all voluntary movements. The basal nuclei of the cerebrum and gray matter in
79 | P a g e
the brainstem help to control these movements subconsciously and prevent extraneous
motions that are undesired. The cerebellum helps with the timing and coordination of
these movements during complex motions. Finally, smooth muscle tissue, cardiac
muscle tissue, and glands are stimulated by motor outputs of the autonomic regions of
the brain.
Processing
Once sensory information has entered the brain, the association areas of the
brain go to work processing and analyzing this information. Sensory information is
combined, evaluated, and compared to prior experiences, providing the brain with an
accurate picture of its conditions. The association areas also work to develop plans of
action that are sent to the brains motor regions in order to produce a change in the
body through muscles or glands. Association areas also work to create our thoughts,
plans, and personality.
Learning and Memory
The brain needs to store many different types of information that it receives from
the senses and that it develops through thinking in the association areas. Information in
the brain is stored in a few different ways depending on its source and how long it is
needed. Our brain maintains short-term memory to keep track of the tasks in which the
brain is currently engaged. Short-term memory is believed to consist of a group of
neurons that stimulate each other in a loop to keep data in the brains memory. New
information replaces the old information in short-term memory within a few seconds or
minutes, unless the information gets moved to long-term memory.
Long-term memory is stored in the brain by the hippocampus. The hippocampus
transfers information from short-term memory to memory-storage regions of the brain,
particularly in the cerebral cortex of the temporal lobes. Memory related to motor skills
(known as procedural memory) is stored by the cerebellum and basal nuclei.
Homeostasis
The brain acts as the bodys control center by maintaining the homeostasis of
many diverse functions such as breathing, heart rate, body temperature, and hunger.
The brainstem and the hypothalamus are the brain structures most concerned with
homeostasis.
In the brainstem, the medulla oblongata contains the cardiovascular center that
monitors the levels of dissolved carbon dioxide and oxygen in the blood, along with
blood pressure. The cardiovascular center adjusts the heart rate and blood vessel
dilation to maintain healthy levels of dissolved gases in the blood and to maintain a
healthy blood pressure. The medullary rhythmicity center of the medulla monitors
oxygen and carbon dioxide levels in the blood and adjusts the rate of breathing to keep
these levels in balance.
The hypothalamus controls the homeostasis of body temperature, blood
pressure, sleep, thirst, and hunger. Many autonomic sensory receptors for temperature,
80 | P a g e
pressure, and chemicals feed into the hypothalamus. The hypothalamus processes the
sensory information that it receives and sends the output to autonomic effectors in the
body such as sweat glands, the heart, and the kidneys.
Sleep
While sleep may seem to be a time of rest for the brain, this organ is actually
extremely active during sleep. The hypothalamus maintains the bodys 24 hour
biological clock, known as the circadian clock. When the circadian clock indicates that
the time for sleep has arrived, it sends signals to the reticular activating system of the
brainstem to reduce its stimulation of the cerebral cortex. Reduction in the stimulation of
the cerebral cortex leads to a sense of sleepiness and eventually leads to sleep.
In a state of sleep, the brain stops maintaining consciousness, reduces some of
its sensitivity to sensory input, relaxes skeletal muscles, and completes many
administrative functions. These administrative functions include the consolidation and
storage of memory, dreaming, and development of nervous tissue.
There are two main stages of sleep: rapid eye movement (REM) and non-rapid
eye movement (NREM). During REM sleep, the body becomes paralyzed while the
eyes move back and forth quickly. Dreaming is common during REM sleep and it is
believed that some memories are stored during this phase. NREM sleep is a period of
slow eye movement or no eye movement, culminating in a deep sleep of low brain
electrical activity. Dreaming during NREM sleep is rare, but memories are still
processed and stored during this time.
Reflexes
A reflex is a fast, involuntary reaction to a form of internal or external stimulus.
Many reflexes in the body are integrated in the brain, including the pupillary light reflex,
coughing, and sneezing. Many reflexes protect the body from harm. For instance,
coughing and sneezing clear the airways of the lungs. Other reflexes help the body
respond to stimuli, such as adjusting the pupils to bright or dim light. All reflexes happen
quickly by bypassing the control centers of the cerebral cortex and integrating in the
lower regions of the brain such as the midbrain or limbic system.
81 | P a g e
Concept Map
(Pathophysiology)
82 | P a g e
Non-potable drinking
water
Pathogenic microorganism
(Entamoeba histolytica) enters
the system
Microorganism release
endotoxin
Hyperstimulation of
intestinal lining
Disruption of cell
membrane
Increased water and
electrolyte secretion
Release of chemical
mediators
Activation of nociceptors
Active secretion of chloride

and bicarbonate ions
Inhibition of Sodium and
water reabsorption
Nerve impulse sent to CNS

CNS response: Vasodilation
Increased cell permeability
Increased Protein-rich fluid

secretion
Abdominal cramping
Overwhelms large bowels

ability to reabsorb fluid
Abdominal distention
Increased fluid volume and

decreased intestinal motility
Stimulation of vomiting in the

center of the brain
Watery stool, hyperactive

bowel sound
Nausea and Vomiting
Continuous and active fluid

loss
Inadequate hydration
Dry lips and mucous
membrane, sunken eyeballs,
poor skin turgor
Increased biochemical
stimuli: stress due to active
fluid loss and nausea and
vomiting
Increased excitability and
lowered threshold for
stimulation of epileptogenic
focus
83 | P a g e
Abnormal spontaneous
electrical discharge
Spread to brainstem
(centrocephalic system)
Electrical discharge in
cerebral cortex
Spread of epileptic discharge
Sensory cortex
numbness
tingling
pain
Impaired awareness
Motor cortex
slurred speech
clonus
muscle
stiffness
Hypoperfusion of the
bilateral frontal and parietal
association cortex
Transsynaptic mechanism
Spread of epileptic discharge
Anterograde amnesia
Loss of consciousness
84 | P a g e
Nursing Management
85 | P a g e
Lists of Prioritized Nursing Problems

-
Prioritization of problems using (Airway, Breathing, Circulation)
Prioritization
Problem No.1
Nursing Problem
Abdominal Pain
Problem No.2
Hyperthermia
Problem No.3
Fluid and Electrolyte

Imbalance
Problem No.4
Undernourished
Problem No.5
Impaired Comfort
Problem No.6
Disturbed sleep pattern
Nursing Diagnosis
Acute Pain related to abdominal
cramping secondary to
distraction of abdominal wall due
to irritation and inflammation of
the stomach and intestine.
Increased body temperature
related to continuous and active
fluid loss that release pyrogens
secondary to bacterial infection.
Deficient Fluid Volume related to
loss of fluids and other
electrolytes secondary to
bacterial infection
Imbalanced nutrition less than
body requirements related to
inability to reabsorbed fluid and
nutrients
Impaired Comfort related to
abdominal pain and cramping
due to hyper stimulation in the
intestinal cavity due to bacterial
infection.
Disturbed sleep pattern related to
environmental stimulation and
discomfort.
86 | P a g e
87 | P a g e
ACUTE PAIN
CUES AND
DATA
Objective:
-with guarding
behaviour
-with
continuous
complaints of
pain.
-with facial
grimace
-restlesness
-left Upper
Quadrant pain
scored 5
moderate pain
using pain
scale 1-10.
NURSING
DIAGNOSIS
Acute Pain
related to
abdominal
cramping
secondary to
distraction of
abdominal wall
due to irritation
and
inflammation of
the stomach
and intestine.
SCIENTIFIC
RATIONALE
Ingestion of
contaminated
food/water
Microorganism
release
endotoxin
Hyperstimulation
of intestinal
cavity
Disruption of cell
membrane
Release of
chemical
mediators
Activation of
nociceptors.
PLANNING
After rendering
effective
nursing care
with the help of
medical
management
the patient
level of pain
will reduced
from pain
scored 5 to 3
tolerable level
INTERVENTION
INDEPENDENT:
- Established
Rapport.
-
Provided
comfort
measures
such as:
*Repositioning
*Maintaining a
complete
environment.
-
Nerve impulse
send to CNS
Observed
Record and
report
presence and
character of
pain and
discomfort.
Encouraged
the use of
distracting
activities such
as music,
reading or
meditation.
SCIENTIFIC
RATIONALE
-
To decreased
patient
anxiety.
Provides
baseline to
detect further
deterioration
of status and
to evaluate
intervention
This
promotes non
pharmacologi
cal pain
management.
Distraction
may limit the
perception of
pain.
EVALUATION
After rendering
effective
nursing
intervention the
clients level of
pain partially
subside from
pain scored 5
moderate pain
to pain scored 3
tolerable
GOAL WAS
MET.
88 | P a g e
CNS response:
vasodilation
Increased
Permeability
Abdominal
cramping
ACUTE PAIN
Encouraged
adequate rest
periods.
DEPENDENT:
- Administered
medication as
ordered by the
doctor:
Paracetamol
110 mg IV
PRN( as
needed)
-
-produces
analgesia by
raising the
threshold of the
pain centre in
the brain and by
obstructing
impulses at the
pain-mediating
chemoreceptors.
89 | P a g e
INCREASED BODY TEMPERATURE

CUES and
DATA
Objective:
-Patient JM 3
years old.
-Initial
temperature
taken (Jan.21,
2014)
4:00PM:
37.9 C
-skin warm to
touch
-flushed skin
-irritable
-dry lips and
mucous
membrane
-poor skin turgor
-profuse
sweating
NURSING
DIAGNOSIS
Increased body
temperature
related to
continuous and
active fluid loss
that release
pyrogens
secondary to
bacterial
infection.
SCIENTIFIC
RATIONALE
Ingestion of infected
food/water
Microorganism
release endotoxin
Hyperstimulation of
intestinal cavity
Disruption of cell
membrane
Increased water and
Watery stool,
hyperactive bowel
sound
PLANNING
After 4 hours of
rendering
effective
nursing care
with the help of
medical
management
patients
temperature
will decrease
from 37.2 to
37.0 or below
as manifested
by good skin
turgor and not
flushed skin.
NURSING
INTERVENTIONS
INDEPENDENT:
-Re assessed
patients status.
-Monitored Vital
Signs.
-Performed TSB
-Provided proper
ventilation
Continuous and
active fluid loss
Inadequate hydration
Dry lips and mucous
membrane, poor skin
turgor
-Increased the Oral

Fluid Intake.
-Changed patient
clothing to light
SCIENTIFIC
RATIONALE
-To determine
the extent of
clients
condition.
-Serves as
baseline data
for further
nursing
actions.
- lowers body
heat through
process of
conduction.
EVALUATION
After rendering
effective nursing
care the clients
temperature
lowers from 37.9
to 37.3 taken
after 30 minutes
and patient was
not warm to
touch.
GOAL WAS
MET.
-lowers body
heat through
process of
convection.
- lowers body
heat through
process of
conduction.
-Lowers body
heat through
process of
90 | P a g e
Pyrogen Production
Signals to the
Hypothalamus
INCREASED BODY
TEMPERATURE
clothing.
evaporation
DEPENDENT:
-Administered
medication as
ordered by the
doctor: Paracetamol
100mg IV for fever
37.5 and above.
- Decreases
fever by a
hypothalamic
effect leading
to sweating
and
vasodilation.
-Replaces the
fluids that loss
from the body.
-Regulated IV fluid
as per doctors
order.
91 | P a g e
DEFICIENT FLUID VOLUME

CUES and
DATA
Objective:
-irritable
-poor skin
turgor
-skin warm
to touch
-impacted
stool
-10 kg taken
at 01-21-14
Laboratory
Findings:
01-18-14
Na125.3umol/L
K- 5.17
mmol/L
NURSING
DIAGNOSIS
Deficient
Fluid Volume
related to
loss of fluids
and other
electrolytes
secondary to
bacterial
infection
SCIENTIFIC
PLANNING
RATIONALE
Ingestion of infected After rendering
food/water
effective
nursing care
Microorganism
with the help of
release endotoxin medical
management
Hyperstimulation of patients fluid
intestinal cavity
volume will be
at functional
Disruption of cell
level as
membrane
evidenced by
good skin
Increased water
turgor, stable
and electrolyte
vital signs able
secretion
to pass stool.
Watery stool,
hyperactive bowel
sound
NURSING
INTERVENTIONS
INDEPENDENT:
SCIENTIFIC
RATIONALE
-Re assessed
patients status.
-To
determine
the extent of
clients
condition.
-Change in
vital signs
are
associated
with fluid
volume loss.
- lowers
body heat
through
process of
conduction.
-Prevents
-Monitored Vital
Signs.
-Performed TSB
-Administered
EVALUATION
After 2 days of
rendering
effective
nursing care
the clients
vital signs
become
stable, from
temperature
37.9 to
temperature
37.3 moist
mucous
membranes
and good
capillary refill.
GOAL WAS
PARTIALLY
92 | P a g e
-(Jan.21,
2014)
4:00PM:
37.9 C
110 bpm
28 cpm
4:30PM:
37.3C
Continuous and
active fluid loss
Inadequate
hydration
Dry lips and
mucous membrane,
poor skin turgor
DEFICIENT FLUID
VOLUME
parenteral fluids
and
replacements.
-Changed position
frequently
-Provided oral
care and eye
care.
the peaks
and valleys
in fluid level.
- to reduce
pressure on
fragile skin
and tissues
- To prevent
injury from
dryness.
MET.
DEPENDENT:
-Administered
medication as
ordered by the
doctor:
Paracetamol
500mg for fever
37.5 and above.
-Inhibits
prostaglandi
n synthesis
and lowers
body heat
through
process of
vasodilation
signaled to
the
hypothalamu
s.
-inhibits
-Gentamicin 55mg protein
IV OD
synthesis in
susceptible
93 | P a g e
strains of
gram (-)
bacteria;
disrupt
functional
cell of the
bacteria
causing cell
death.
IMBALANCED NUTRITION LESS THAN BODY

REQUIREMENTS
CUES and
DATA
Objective:
-irritable
-dry skin
-skin warm
to touch
-hypo active
bowel
sounds.
-abdominal
NURSING
DIAGNOSIS
Imbalanced
nutrition less
than body
requirements
related to
inability to
reabsorbed
fluid and
nutrients
SCIENTIFIC
RATIONALE
Ingestion of
contaminated
food/water
Microorganism
release endotoxin
Hyperstimulation of
intestinal cavity
PLANNING
After
rendering
effective
nursing care
with the help
of medical
management
patient will be
able to
display
NURSING
INTERVENTIONS
INDEPENDENT:
SCIENTIFIC
RATIONALE
-Re assessed
patients status.
-To
determine
the extent of
clients
condition.
-Helps
reduce
fatigue
- Encourage a
rest period of
1hour before and
after meals.
EVALUATION
After rendering
effective
nursing care
with the help
of medical
management
patient was
able to display
normalization
of laboratory
94 | P a g e
cramping
-impacted
stool
Laboratory
Findings:
01-18-14
Na125.3umol/L
K- 5.17
mmol/L
-WBC: 10.32
x 10^3u/L
(01-19-14)
-10 kg taken
at 01-21-14
-Vital signs
taken as
follows:
-(Jan.21,
2014)
4:00PM:
37.9 C
110 bpm
28 cpm
Disruption of cell
membrane
Increased water and
Active secretion of
chloride and
bicarbonate ions
Inhibition of Sodium
and water
reabsorption
normalization
of laboratory
values and
free from
signs of
malnutrition
such as poor
skin turgor,
dry lips and
skin and
fever.
Provide frequent
small feedings.
-Avoid gasproducing foods

and carbonated
beverages.
Overwhelms large
bowels ability to
reabsorb fluid
Increased fluid
volume and
decreased intestinal
motility
Continuous and
active fluid loss
IMBALANCED
NUTRITION LESS
THAN BODY
DEPENDENT:
-regulated IV as
per doctors order.
-Check laboratory
values and blood
during
mealtime,
and provides
opportunity
to increased
respiratory
total caloric
intake ---Can
produce
abdominal
distention,
which
hampers
abdominal
breathing
and
diaphragmati
c movement
and can
increase
dyspnea.
values and
free from signs
of malnutrition
such as poor
skin turgor, dry
lips and skin
and fever.
GOAL WAS
MET.
-Parenteral
fluids replace
fluid loss.
-To
determine
95 | P a g e
REQUIREMENTS
exam done by a
medical
technologist.
whether the
datas
improve or
worsen.
IMPAIRED COMFORT
CUES AND
DATA
Objective:
-irritable
-crying
-evident
facial
NURSING
DIAGNOSIS
Impaired
Comfort
related to
abdominal
pain and
SCIENTIFIC
RATIONALE
Ingestion of
contaminated
food/water
Microorganism
PLANNING
After
rendering
effective
nursing care
with the help
NURSING
SCIENTIFIC
INTERVENTIONS RATIONALE
INDEPENDENT:
-Re assessed
- To
patients condition
determine
the severity
and the
EVALUATION
At the end of
the shift and
after rendering
effective
nursing care
96 | P a g e
grimace
-skin warm
to touch
cramping
due to hyper
stimulation in
the intestinal
cavity due to
bacterial
infection.
release endotoxin
Hyperstimulation of
intestinal cavity
Disruption of cell
membrane
Release of
chemical mediators
Activation of
nociceptors.
Nerve impulse send
to CNS
CNS response:
vasodilation
Increased
Permeability
Abdominal
Cramping
of medical
intent of
management
patients
patient will be
impaired
able to
comfort.
enhance
-Established
- To decrease
comfort and
patient
relaxation and Rapport
anxiety
will feel soothe
and
- To provide
-Identified the
contentment.
the relevant
factors that cause
data what
Discomfort.
measures
will be done
to provide
comfort.
the patient
does not
complained of
any discomfort
and the nurse
was able to
assess the
patient well.
GOAL WAS
MET.
- To provide
-Provided the
patients
patient ways on
comfort and
how he can be
to reduce
comfortable.
the
Straightening
incidence of
the bed linens.
crying.
Regulating the
contraptions as
per doctors
order.
Encouraged to
avoid straining
to reduce
97 | P a g e
Impaired Comfort
abdominal
discomfort
Emphasized
diversional
activities like
listening music,
playing a game
using a phone
to divert
attention to
pain.
DISTURBED SLEEP PATTERN

CUES AND
DATA
NURSING
DIAGNOSIS
SCIENTIFIC
RATIONALE
PLANNING
INTERVENTION
SCIENTIFIC
RATIONALE
EVALUATION
98 | P a g e
Objective:
- Irritable
- Crying
- Looks pale
and
lethargic
- Usually
sleeps 5
hours for
evening
then has a
nap for 2
hours in the
afternoon.
- Anxious
and restless
Disturbed
sleep pattern
related to
environmental
stimulation and
discomfort.
Sustained
environmental
stimulation
Uncomfortable
sleep and
prolonged
discomfort
DISTURBED
SLEEP
PATTERN
INDEPENDENT:
- Established
Rapport.
After rendering
effective
nursing care
with the help of medical
management
patient will be
able to
improved sleep
and enhance
comfort.
-
Re assessed patients
status.
Review
medications
being taken
and their
effects on
sleep.
Suggest
abstaining
from daytime
naps.
To decreased
patient
anxiety.
To determine
the severity and
the intent of
patients
disturbed sleep
pattern.
Some effects of
medications are
found to be
interfering.
At the end of
the shift and
after rendering
effective
nursing care
the patient does
better sleep
and promotes
comfort.
GOAL WAS
PARTIALLY
MET.
May impair
ability to
sleep at
night.
DEPENDENT:
-
-Parenteral fluids
Regulated IV
as per doctors replace fluid
loss.
order.
99 | P a g e
Teaching Plan
100 | P a g e
Name of patient: JM
Date of Admission: January 7, 2014
Age: 3 y/o
Diagnosis: Seizure, Acute Gastroenteritis
Sex: Male
Take the medicine as directed:

Tell the patients mother to take prescribed medications for fever. Inform the
patients mother to call a primary healthcare provider if the medicine is not helping or
experience side effects and allergic to any medicine. The relative should keep a list of
the medicines take. Include the amounts, and when and why he takes them. Bring the
list or the pill bottles to follow-up visits. Carry the medicine list in case of an emergency.
Name of Drug
Paracetamol
(Calpol)
Dosage and
Frequency
Route
100 mg
IV
Curative Effects
Side Effects
Antipyretics,
nonopioid
analgesics.
GI: hepatic failure,
For mild pain

and fever.
GU: renal failure
hepatotoxicity
(overdose).
(high doses/chronic
use).
Hemat:
neutropenia,
pancytopenia,
leukopenia.
Derm: rash,
urticaria
101 | P a g e
Exercise/Activity:
Advice to patients relative to avoid strenuous activity to conserve energy.
Have plenty of rest for him to recover easily and to prevent the occurrence of
gastroenteritis advice the mother of the patient to practice her son to perform
hand washing before and after meals at their home.
Treatment:
Take paracetamol as needed if the patient has a fever associated with abdominal
cramp or pain to relieve pain and reduce fever.
OPD/Follow-up:
Follow-up visits for continuing care, treatments and other necessary information
needed for the patients condition.
Diet:
Soft Diet/ liquid diet
Drink fluids such as gatorade or clear fruit juices. Wait at least 30 minutes after
vomiting and then start fluids in small, frequent sips.
(soft cooked, poached or hard-boiled or scrambled eggs, tender meat, fish or

poultry, soft cake or cookies without nuts or raisins, butter, cream or margarine,
jelly, cooked or ready-to-eat cereal, boiled or mashed potatoe, bananas or seedless
melon)
BRAT Diet (Banana, Raisins, Apple, Toast)
Dos
Adequate rest
Perform proper hygiene, especially hand washing to avoid the spread of
disease (AGE)
Eat potassium-rich foods such as BRAT diet (banana, raisins, apple, toast).
Increase fluid intake (2L/day) as much as possible for rehydration
102 | P a g e
Donts
Avoid all milk products, other juices, coffee or other caffeinated beverages,
aspirin and alcohol.
Avoid eating raw or half cooked foods
Bibliography
I.
Anne M. Van Leeuwen, Debra J. Poelhuis- Leth. Davis

Comprehensive Handbook of Laboratory and Diagnostic Tests with
Nursing Implications 3rd edition.
103 | P a g e
II.
David Shier,Jackie Butler,Ricki Lewis 2009. Holes Essentials of

Human Anatomy and Physiology 10th edition. Mc-Graw Hill, NY.
III.
Janet Weber and Janet Kelley; Health Assessment in Nursing- 3 rd

edition. Wolters Kluwer Health | Lippincott Williams & Wilkins.
IV.
Lippincott Manual of Nursing Practice Series Pathophysiology 2007.
V.
Suzanne Smelter, Brenda Bare, Janice Hinkle, Kerry Cheever 2010.

Textbook of Medical- Surgical Nursing; Brunner and Suddarths 12 th
edition. Wolters Kluwer Health | Lippincott Williams & Wilkins.
104 | P a g e

Case Presentation - Acute Gastroentiritis

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Case Presentation - Acute Gastroentiritis

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INTRODUCTION

HISTORY OF PRESENT ILLNESS

hospitalization, he defecates thrice a day with yellowish watery stool, no solid

PAST MEDICAL HISTORY

Erik Eriksons Psychosocial Development Theory

Developmental task is to form a

sense personal control over

Sigmund Freuds Psychoanalytic Development Theory

The child has to learn to

control his or her bodily needs.

Kapag natatae o naiihi siya

nagasasabi siya sa akin at

Jean Piagets Cognitive Development Theory

Toddlers learn through

pretend play but still struggle

siya makipaglaro minsan

with logic and taking the point

malawak yung imagination niya.

of view of other people.

Ginagaya niya yung tatay niya

palagi kapag nakikipagkulitan.

affection and approval; for

actions. She verbalized, Kapag

GORDONS 11 FUNCTIONAL HEALTH PATTERNS

A. Health Perception- Health Management

According to his mother, the patient used to breastfeed then he started

According to his mother, he likes to drink

Before hospitalization, according to patients mother he used to defecate

D. Activity- Exercise Pattern

Katz Index of Independence in Activities of Daily Living

Before hospitalization, patient JM has no problem in smell, vision and

G. Self-Perception - Self-concept Pattern

I. Value Belief Pattern

VIII. COMPREHENSIVE PHYSICAL EXAMINATION

Temperature Rate Pulse Rate

January 21, 2014

>Skin color ranges

Inspection reveals evenly

>No strong odor

According to Health &

Pa: *no edema

According to Webber &

According to Webber &

Pa: *smooth and

According to Webber &

smooth and even hair is

According to Webber &

Face. Note the

especially in accord with

According to Webber &

Kelley Health Assessment in

I: iris and the

>Pupils are equal,

According to Webber &

According to Webber &

does not meet in

According to Webber &

> Color is the

> The nasal

I: *Dry lips and

According to Webber &

> Tongue should

BUN level higher (23.20/L).

According to Webber &

deficiencies, certain anemia,

> The tongue

> The hard palate