University of La Salette, Inc.

COLLEGE OF NURSING, PUBLIC HEALTH AND MIDWIFERY

A case Study on Acute Gastroenteritis (AGE)

In partial Fulfillment of the Requirements in
Maternal and Child Health Nursing- Related Learning Experience

Submitted by:
Soriano, Paul Simon
 I. CASE DESCRIPTION
Acute gastroenteritis is an inflammation and/or irritation of the digestive tract that
can cause nausea, vomiting, diarrhea, and/or abdominal pain that lasts less than 14
days. When symptoms last 14 to 30 days, the condition is considered persistent
gastroenteritis. When symptoms last longer than 30 days, it is considered chronic. It is
sometimes referred to as the "stomach flu" or food poisoning though it usually is
neither.
RISK FACTORS
 Ingestion of contaminated food and water
 Bad hygiene
 Immunodeficiency
COMPLICATIONS
Complications of acute gastroenteritis may include:
 Dehydration
 Malabsorption of nutrients
 Organ damage
SIGNS AND SYMPTOMS
 Diarrhea
 Nausea and vomiting
 Abdominal Pain
 Fever
HOW IS ACUTE GASTROENTERITIES DIAGNOSED?
A doctor will use history and any test results to determine if the patient have
gastroenteritis, and if the cause is viral or bacterial. These includes:
 Serum Electrolytes
 Fecalysis
 Hematology/complete blood count
 Urinalysis
 CXR
MANAGEMENT
 Oral rehydration solution
 IV rehydration
 Proper nutrition
 Medication such as antibiotic
II. ANATOMY AND PHYSIOLOGY
The gastro-intestinal system is essentially a long tube running right
through the body, with specialized sections that are capable of digesting material
put in at the top end and extracting any useful components from it, then expelling
the waste products at the bottom end. The whole system is under hormonal
control, with the presence of food in the mouth triggering off a cascade of
hormonal actions; when there is food in the stomach, different hormones activate
acid secretion, increased gut motility, and enzyme release.
 Mouth-The mouth is the beginning of the digestive tract; and, in fact, digestion starts
here when taking the first bite of food. Chewing breaks the food into pieces that are more
easily digested, while saliva mixes with food to begin the process of breaking it down
into a form your body can absorb and use.
Oesophagus- Once food has been chewed and mixed with saliva in the mouth, it is
swallowed and passes down the oesophagus.
Liver-to process the nutrients absorbed from the small intestine. Bile from the liver
secreted into the small intestine also plays an important role in digesting fat. In addition,
the liver is the body's chemical "factory." It takes the raw materials absorbed by the
intestine and makes all the various chemicals the body needs to function. The liver also
detoxifies potentially harmful chemicals. It breaks down and secretes many drugs.
Stomach-Located in your throat near your trachea (windpipe), the oesophagus receives
food from your mouth when you swallow. By means of a series of muscular contractions
called peristalsis, the oesophagus delivers food to your stomach. The stomach has five
major functions:
 Temporary food storage
 Control the rate at which food enters the duodenum
 Acid secretion and antibacterial action
 Fluidization of stomach contents
 Preliminary digestion with pepsin, lipases etc.
Gallbladder-The gallbladder stores and concentrates bile, and then releases it into the
duodenum to help absorb and digest fats.
Small Intestines- The small intestine is the site where most of the chemical and
mechanical digestion is carried out, and where virtually all of the absorption of useful
materials is carried out. The intestine also has a smooth muscle wall with two layers of
muscle; rhythmical contractions force products of digestion through the intestine
(peristalsis). There are three main sections to the small intestine;
 Duodenum- the first and shortest segment of the small intestine. It receives partially
digested food (known as chyme) from the stomach and plays a vital role in the chemical
digestion of chime in preparation for absorption in the small intestine.
 Jejunum- makes up about two-fifths of the small intestine. The main function of the
jejunum is absorption of important nutrients such as sugars, fatty acids and amino acids.
 Ileum- Final and longest segment of the small intestine. It is specifically responsible for
the reabsorption of conjugated bile salts.
Pancreas- The pancreas consists mainly of exocrine glands that secrete enzymes to aid in
the digestion of food in the small intestine. The main enzymes produced are lipases,
peptidases and amylases for fats, proteins and carbohydrates respectively.
Large Intestines-The colon is a 6-foot long muscular tube that connects the small
intestine to the rectum. The large intestine is made up of the cecum, the ascending (right)
colon, the transverse (across) colon, the descending (left) colon, and the sigmoid colon,
which connects to the rectum. 
Rectum-The rectum (Latin for "straight") is an 8-inch chamber that connects the colon to
the anus. It is the rectum's job to receive stool from the colon, to let the person know that
there is stool to be evacuated, and to hold the stool until evacuation happens. When
anything (gas or stool) comes into the rectum, sensors send a message to the brain. The
brain then decides if the rectal contents can be released or not. If they can, the sphincters
relax and the rectum contracts, disposing its contents. If the contents cannot be disposed,
the sphincter contracts and the rectum accommodates so that the sensation temporarily
goes away.

Anus-The anus is the last part of the digestive tract. It is a 2-inch long canal
consisting of the pelvic floor muscles and the two anal sphincters (internal and
external). The lining of the upper anus is specialized to detect rectal contents. It lets
you know whether the contents are liquid, gas, or solid. The anus is surrounded by
sphincter muscles that are important in allowing control of stool. 

Villi in the small intestine. Millions of tiny finger-like structures called villi project

inwards from the lining of the small intestine. The large surface area they present allows
for rapid absorption of digestion products.
III. NURSING HISTORY
A.DEMOGRAPHIC DATA

Name: Patient A

Sex: Female

Age: 9 months old

Civil status: Child

Address: Ramon, Isabela

Religion: Roman Catholic

Date of Admission: February 9, 2020 at 5:30 pm

Weight: 7.6 kg

Height: 70cm

Chief Complaint: Diarrhea

Admitting Diagnosis: AGE with moderate dehydration, UTI

Admitting Phycisian: Dr. Manalo

B. PAST HEALTH HISTORY

The s/o stated that the patient has no history of hospitalization, has no allergy, and no
other diseases been observed

C. HISTORY OF PRESENT ILLNESS

5 days PTA there is fever and colds. Upon admission, they give paracetamol and
ceterizine. Few hours later, there is a positive sign of LBM 4x watery and yellowish stool
and the patient vomits every after feeding.

D. FAMILIAL HISTORY
There is no familial history
 GORDON’S FUNCTIONAL PATTERN
1. Health Perception/Health management
Before During
The s/o stated that they only give The s/o stated that they only take
paracetamol calpol to the patient whatever medicine the doctor ordered
whenever it has fever and oregano for for them.
cough and neozep for colds.

2. Nutritional-Metabolic
Before During
The s/o stated that they feed the patient The s/o stated that they feed the patient
with rice and soup, sometimes with only with congee
chicken and vegetables.

3. Elimination
Before During
The s/o stated that the patient uses 2 The s/o stated that the patient urinates 3
diapers a day and 1 time for defecation. times a day and 1 time for defecation.

4. Activity-Exercise
Before During
The s/o stated that the patient is The s/o stated that the patient only
crawling, standing and holding on crawls.
things around her.

5. Cognitive-Perceptual
Before During
The s/o stated that they talk to the The s/o stated that they speak to
patient in tagalog language. patient in tagalong language

6. Sleep-Rest

Before During
The s/o stated that the patient sleeps at The s/o stated that the patient sleeps at
6 in the afternoon and wakes up in 6 in 7 in the evening and wakes up 4 or 5 in
the morning. the morning.

7. Self-Perception/Self-Concept
Before During
The s/o stated that the patient was The s/o stated that the patient keeps on
energetic. moving.

8. Role-Relationship
Before
The s/o stated that the patient is close to
its grandmother and it usually plays
inside their home together with other
kids.
During
The s/o stated that only the
grandmother and her (mother) is
looking after the patient.

9. Sexuality-Reproductive

 9 months old
 Female

10. Coping-Stress Tolerance

Before During
The s/o stated that they give bottle of The s/o stated that they give bottle of
milk to the patient whenever it is crying. milk to patient whenever it is crying.

11. Value-Belief
Before During
The s/o stated that they are roman The s/o stated that they can’t attend
catholics, they always attend masses masses since they are in the hospital.
every Sunday.
 IV. PHYSICAL ASSESSMENT February 12, 2020
The patient was lying on bed, wearing a sando and a diaper. He is active and
conscious. He weighs 7.2 kilograms with a height of 70 cm with vital signs of:
T= 37.7 ℃
CR= 132beats per minute
RR= 35cycles/min

AREAS METHODS FINDINGS INTERPRETATION

1. HEAD Hair Inspection  Hair is  Normal
Scalp evenly
Face distributed
 No lesions  Normal
  Sunken  Due to
Anterior excessive fluid
fontanel loss

 The face is  Normal

smooth
Palpation

Eyes and Inspection  The pupils  Normal

vision constrict
upon
inspection
using a
penlight.
 Sunken  Excessive fluid
eyeballs loss
 The pupils  Normal
are
symmetrical
and has no
abnormaliti
es
Ears and Inspection  Symmetrica  Normal
Hearing l in size
 Can
distinguish  Normal
sound
 No lesions
 Normal
Nose Inspection  No lesions  Normal
Mouth and Inspection  Dry mucous  Excessive fluid
oropharynx membrane loss

 Dry lips  Excessive fluid

loss
2. NECK Muscles Inspection  Can freely  Normal
move
Lymph Palpation  Not  Normal
Nodes palpable
Thyroid Inspection  Not visible  Normal
Gland
Palpation  Not  Normal
palpable
3. UPPER Skin and
EXTREMITIES nails Inspection  Nails were  Poor hygiene
long and
dirty

 Poor skin  Due to

turgor excessive fluid
loss

Palpation  Capillary  Due to

refill (>3 excessive fluid
seconds) loss

Muscle Inspection  Can freely  Normal

Strength move
and tone
Palpation  Can grasp  Normal

Joint ROM Inspection  Can freely  Normal

move
Brachial Palpation  Not  Normal
and radial palpable
pulse
Sensation Palpation  Was able to  Normal
distinguish
touch
4. CHEST AND Skin Inspection  Dry skin  Due to
BACK excessive fluid
loss
  Presence of  Due to
lesions excessive fluid
loss

Thorax Inspection  Chest is not  Normal

Shape and enlarged
size
Lungs Auscultation  Resonant  Normal
sound
 Absence of  Normal
Percussion adventitious
breath
sounds
Heart Auscultation  Normal CR  Normal
of 140bpm

Spinal Inspection  No  Normal

Column deformities
Breast and Inspection  No lesions  Normal
axillae

5. ABDOMEN Skin Inspection  Distended  Due to the

abdomen infection

Auscultation  Hyperactive  Due to too

increase
peristalsis that
can lead to
diarrhea

Percussion  Tympanic  Normal

Palpation  Tender  Due to the

abdomen infection
6. EXTERNAL Genital Inspection  No  Normal
 GENITALIA enlargement
of testicles
7. ANUS Inspection  Redness in  Irritation due
the area to LBM
8. LOWER Skin and Inspection  Long and  Poor hygiene
EXTREMITIES toenails dirty nails

Palpation  Capillary  Due to

refill (>3) excessive fluid
loss

 Poor skin  Due to

turgor Excessive fluid
loss
Joint ROM Inspection  Can freely  Normal
move
Popliteal, Palpation  Not  Normal
posterior palpable
tubial,
dorsalis
pedis pulses

X.DISCHARGE PLANNING
MEDICATION
 The medicine should be taken regularly as prescribed, strictly follow the dosage and
frequency before taking and make sure that the family members should understand the
importance of taking medicines.
 Instruct significant others to watch out for any adverse effects and report it immediately
to the hospital.
HEALTH TEACHING
 Educate the s/o about the importance of good hygiene
 Educate the s/o about the importance of breastfeeding
 Educate the s/o and other family members about the proper hand washing
 Educate the s/o about the food pyramid that a child must eat
OUTPATIENT
 Remind family members that having a check-up is very important to improve the
patient’s condition and in order to have optimum level of wellness.
  Inform significant others to report immediately any abnormalities to prevent further
complications to the patient.
DIET
 Encourage the significant others to give vitamins to the patient and give milk.