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OBJECTIVES: General Objectives: After 2 hours of case presentation, the students will be able to acquire knowledge, formulate and develop attitude and enhance their skills towards caring of the patient with gastrointestinal problems that results to diarrhea and dehydration. Specific Objectives: At the end of the presentation, the student will be able to: Knowledge 1. Identify the precipitating and predisposing factors. 2. Enumerate the signs and symptoms of the diseases manifested by the client. 3. Trace the pathophysiology of the diseases. 4. Identify the significance of laboratory and diagnostic examinations in the disease process. 5. Identify the nursing responsibilities in drug administration. Skills 1. Perform appropriate dependent and collaborative interventions to the client with acute diarrhea. 2. Demonstrate physical assessment to a patient with diarrheal problems. Attitudes 1. Establish rapport to client and folks. 2. Encourage folks to cooperate in the interventions being performed to the client. 3. Recognize the value of emotional, psychological and spiritual aspects of care regarding the patients disease process and its complications. II. PATIENT PROFILE AND HISTORY A. Patient Profile NAME: A.L.P AGE: 82Y1M11D SEX: Female DATE OF BIRTH: May 12, 1929 ROOM NO.: Bed 5 PHYSICIAN: Dr. J., M.D. CHIEF COMPLAINT: Loose Bowel Movement DIAGNOSIS: Acute infectious diarrhea with severe dehydration DATE OF ADMISSION: June 17, 2011 DATE OF ASSESSMENT: June 24, 2011 B. Nursing History 1. Past Medical History Patient was admitted last 2010 with the complaint of Loose Bowel Movement and was diagnosed with Amoebiasis. 2. Childhood Illnesses No major past illnesses. Experiences cough; sneezing and mild fever at times and opts for herbal medications. 3. Present Medical History 6 days prior to admission, patient experienced 2 episodes of loose bowel movements with watery stools noted, patient feels warm to folks. 2 days later, yellowish and mucoid consistency of foul-odor stools was noted. Patient and folks opted for herbal medicine and used kahoy-kahoy: Starapple and Avocado through boiling and was given to the patient. Patient had taken Loperamide (Imodium) 1
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tablet during episodes of water stools, at 4 hours minimum intervals between doses and Paracetamol every 500 mg tablet, 1 tablet every 4 hours or when fever is verbalized by patient. Fluid intake is maintained 10 8-ounce glasses per day. Patient condition did not improve, with 3 5 diarrheal episodes daily (no blood on the stool noted). 1 day prior to admission, patient felt generalized body malaise, with diarrheal episodes and fever. Folks noted weight loss upon lifting the patient. On the day of admission, patient condition severed and opted admission on this institution for management. 4. Family History of Illness ( - ) Diabetes Mellitus both sides (-) Hypertension both sides ( - ) Cancer both sides ( - ) Kidney Disease both sides 5. Social History ALP is lives in a makeshift house with her 2 children. She is unemployed. She stays at home with her 2 daughter. They engage on a basket-making entrepreneurship and small scale farming as the source of their family income which is 5000 7000 per month on the average. This income is allotted for their daily needs. Main food source is from the surrounding fruits and vegetables. They utilize the stand posts as their water source; folks and patient unaware of water potability examination. If budget permits, they buy distilled water for drinking and cooking. ALPs husband died 5 years ago due to Cerebrovascular accident (stroke).

III. PHYSICAL ASSESSMENT Vital Signs Parameter Temperature Pulse Rate Respiration Rate Blood Pressure On Assessment June 22, 2011 37.1oC 75 bpm 19 rpm 110 /70 mmHg

General Appearance Physical Patient awake lying on bed, conversant to folks and health care providers. Patient of average height, ectomorphic, appears to be in her stated chronological age, 82, female with fair complexion, dressed appropriately. Patient not able to change positions without assistance of folks. Psychological Patient cooperative; answers questions appropriately. No slurring is speech noted; aware of time, place, and reason of admission. Dependent to folks for her grooming, personal hygiene and needs. Skin and Nails Palms pale, dry and scaling. Dark brown spots noted. Nails without clubbing. No masses and lesions noted. Capillary refill within 3 4 seconds. Skin pinch goes back after 3 seconds. Head and Face Normocephalic. Hair of average texture, straight, evenly-distributed. Scalp without lesions or flaking. Face symmetric, color similar to the extremities. No masses noted upon palpation. Able to smile, frown, show teeth, raise eyebrows and close eyes (CN VII intact).
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Eyes Eyes open simultaneously. Able to see clearly without blurring of vision. Palpebral and bulbar conjunctiva pinkish without discharges noted. Eyes sunken. Pupil equal, round, responds to light and accommodation. Papillary diameter: 2 cm. Eye symmetrical. Eyelashes and eyebrows of average distribution for age. Corneal reflex (+). Ears No deformities and discharges noted. Able to hear 2 out of 5 words at hearing test. Auricle bilaterally equal, firm and elastic. No pain felt upon palpation. No tenderness noted on the mastoid process. Nose Nose symmetric, airflow through the nostrils patent. Maxillary and frontal sinuses non-tender. Mucosa pink, septum midline. Patient able to identify smell of objects presented. Mouth and Oropharynx Lips pale and dry. Teeth brownish yellow. Gingiva pinkish. No prosthesis. Tongue in midline, pinkish, with presence of white spots. Buccal mucosa pinkish, uvula rises when patient says a syllable, no swollen interdental papillae noted. Uvula midline. Tonsils 1+. No lesions and inflammation noted. Neck Neck symmetric, no masses and swelling noted. ROM good. No masses noted, thyroid gland midline and palpable. Lymph nodes not palpable. Carotid pulse barely palpable, no bruits noted on auscultation. Chest Chest symmetrical with good excursion. Lungs resonant. Diaphragm descends bilaterally, without use of accessory muscles during breathing. No bone deformity and superficial veins noted. Chest wall expansion is symmetrical; respiration pattern even, 19-20 bpm and unlabored. Breast saggy with no abnormal breast mass noted upon palpation. Resonance noted upon percussion. Apical pulse = 76 bpm. No crackling or abnormal breath sounds heard. Back Color is the same as the surrounding skin. Spinal curvature normal. No discolorations noted. No masses noted upon palpation. Abdomen Abdomen flat, symmetric, without lesions, scars, and striae. 25-30 bowel sounds noted per minute on auscultation. No bruits noted. No enlargement, tenderness, and pain noted on palpation. Tympany noted upon percussion. Upper Extremity Arms warm with IVF of PNSS 1 Li x 31-32 gtts/min, patent and infusing well at the left metacarpal vein. No pain, redness and swelling on the IV site. Extremities symmetrical with good ROM. Brown semicircular skin pigmentation noted. No masses, edema or lumps noted. Slow capillary refill. Radial pulse (75 bpm) and brachial pulse palpable (75bpm). Lower Extremity Symmetrical, no masses, edema, lumps or lesions noted. Good ROM. No ulcers noted. Capillary refill within 3 seconds. Dorsalis pedis pulse and posterior tibial pulse palpable. No varicosities and tenderness noted.
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Genito-anal Patient voids via foley catheter attached to a urobag draining to a straw-colored urine, 100 cc per hour at the average. No pain felt on urination Genitalia with sparse pubic hair, with no lesions and secretions noted. Patient defecates brownish stool with pasty consistency. No blood streaks and pain noted upon defecation. IV. LABORATORY AND DIAGNOSTIC PROCEDURES HEMATOLOGY TEST NAME Hemoglobin Erythrocyte volume fraction Erythrocyte number concentration Leukocyte number concentration Neutrophils number fraction Lymphocyte Number Concentration NORMAL VALUE F:120-160 g/L F:0.40-0.54 Li/Li F:4.2-5.4 x 109/L 4.5-11 x 109/L 0.60-0.70x 109/L
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RESULT (06/18/11) N 122 g/L 0.36 Li/Li 3.5 x109/L 11.4 x109/L N .61x 109/L
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CLINICAL SIGNIFICANCE Normal Decrease in level related to the presence of E. histolytica. Suggestive of anemia. Decrease in level related to the presence of E. histolytica, suggestive of fatigue and difficulty of breathing. Increase in level related to the presence of E. hystolytica. High leukocyte number concentration signifies presence of infection. Normal Increase in level related to the presence of E. histolytica. (High lymphocyte number concentration maybe caused by either viral, bacterial, protozoal, and fungal infections)

0.22-0.30 x 10 /L

0.39x 10 /L

BLOOD CHEMISTRY TEST NAME NORMAL VALUE RESULTS (06/18/11) CLINICAL SIGNIFICANCE Decreased serum level related to diarrhea secondary to E. histolytica infection. Sodium is excreted when water is excreted during episodes of watery stools. Decreased serum level related to diarrhea related to the presence of E. Hystolica. Potassium reabsorption in the intestine is decreased related to Amebiasis. Increased level related to fluid volume deficit. Suggestive of the inability of the kidney to secrete Creatinine as a metabolic waste.

Sodium

133-143 mEq/L

119.4 meq/L

Potassium

3.0-4.5 mEq/L

2.12 mEq/L

Serum Creatinine

88.4 -176.8umol/L

191.89 umol/L

FECALYSIS RESULTS (06/18/11) Physical Properties Color Consistency Dark Brown Mucoid SIGNIFICANCE Normal Due to inflammatory condition and increased intestinal motility due to irritation of the colon by foreign organisms. Confirms presence of E. histolytica Normal. Indicates presence of normal intestinal flora.

E. histolytica Bacteria

5-8/hpf Many

V. OVERVIEW OF THE SYSTEM The GI (Gastrointestinal) or Digestive System is consist of the oral structures, esophagus, stomach, small intestine, large intestine and associated structures. The GI performs two major functions: digestion and elimination. Chewing of food in the mouth Esophagus

Stomach: Secretion of gastric juice, containing hydrochloric acid

Mixing and churning through peristaltic action

Chyme passes the duodenum

Nutrient Absorption in the Small intestine

Passage of Stool

Normal Functioning of the Gastrointestinal System

VI. PATHOPHYSIOLOGY OF DISEASE

Predisposing Factors (Non-modifiable) Age (82 years old) Common in tropical regions

Precipitating Factors (modifiable) Unexamined water source Contaminated water Person to Person contact

Entrance of Entamoeba histolytica to the body through the mouth

Enterotoxin production

Destruction of Epithelial Cells

Systemic Invasion

Interacts with mucosa

Superficial ulceration of the mucosa

Inflammation of layer of tissue beneath epithelium of mucosa

Profuse secretion of water and electrolytes

Blood mucous in stool

Edema

DIARRHEA

Excretion of interstitial fluid

DEHYDRATION

Serum Na+, K + Creatinine Clearance Urine Specific Gravity

Low blood pressure Fatigue and fainting Poor skin turgor Sunken eyeballs Rapid, thread pulse

Weakness

VII. DRUG THERAPY RANITIDINE HYDROCHLORIDE Generic Name: Ranitidine Hydrochloride Dosage: 50 mg IVTT q 8hrs Drug Class: Histamine-2 Antagonist Therapeutic Actions: Competitively inhibits the action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin. Indications y Short- term treatment of active duodenal ulcer and GERD y Pathologic hypersecretory conditions y Treatment of erosive esophagitis y Treatment of heartburn, acid indigestion, sour stomach Contraindications and Cautions y Contraindicated with allergy to ranitidine, lactation. y Use cautiously with impaired renal or hepatic function, pregnancy. Adverse Effects y CNS: Headache, malaise, dizziness, somnolence, insomnia, vertigo y CV: Tachycardia, bradycardia, PVCs (rapid IV administration) y Dermatologic: Rash, alopecia. y GI: Constipation, diarrhea, nausea, vomiting, abdominal pain, hepatitis, increased ALT levels. y GU: Gynecomastia, impotence or decreased libido. y Hematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia. y Local: Pain at IM site, local burning or itching at IV site. Interaction y Drug-drug: Increased effects of warfarin, TCAs, monitor patient closely and adjust dosage as needed. Nursing Considerations Assessment y History: Allergy to ranitidine, impaired renal or hepatic function, lactation, pregnancy. y Physical: Skin lesions; orientation, affect; pulse, baseline ECG; liver evaluation, abdominal examination, normal output; CBC, LFTs, renal function tests. Interventions y Administer oral drug with meals or at bedtime y Decrease doses in renal and liver failure. Teaching Points y Take drugs with meals or at bedtime. y If you also are using an antacid, take it exactly as prescribed, being careful of the times of administration. y Avoid becoming pregnancy while taking this drug, use of contraceptive is advised. y Report sore throat, fever, unusual bruising or bleeding, tarry stools, confusion, hallucinations, dizziness, severe headache, muscle or joint pain.

METRONIDAZOLE Generic Name: Metronidazole Dosage: 500 mg IVTT q8h ANST Drug Classes: Amebicide, Antibacterial, Antibiotic, Antiprotozoal Therapeutic Actions: Bactericidal: Inhibits DNA synthesis in specific (obligate) anaerobes, causing cell death; Antiprotozoal: Biochemical mechanism is not known. Indications y Acute infection with susceptible anaerobic bacteria y Acute intestinal amoebiasis, Amebic liver abscess y Bacterial vaginosis, Trichomoniasis (Acute and partners of patients with acute infection) Contraindications and Cautions y Contraindicated with hypersensitivity to Metronidazole. y Use cautiously with CNS diseases, hepatic disease, candidiasis, blood dyscrasias. Adverse Effects y CNS: Headache, dizziness, ataxia, vertigo, incoordination, seizures, peripheral neuropathy, fatigue y GI: Unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps y GU: Dysuria, incontinence, darkening of the urine y Local: Thrombophlebitis (IV); redness, burning, dryness, and skin irritation y Others: Candidiasis (superinfection) Interactions y Drug-drug: Decreased effectiveness with barbiturates; Disulfram-like reaction with alcohol; Psychosis if taken with disulfram; Increased bleeding tendencies with oral anticoagulants. y Drug-lab test: False-low values in AST, ALT, LDH, triglycerides, hexokinase glucose tests. Nursing Considerations Assessment y History: CNS or hepatic disease, blood dyscrasias. y Physical: Reflexes, affect: skin lesions, color; abdominal examination, liver palpation; urinalysis, CBC, LFTs. Intervention y Adverse oral doses with food. y Reduce doses in hepatic disease. Teaching Points y Take full course of drug therapy. y Do not drink alcohol (beverages containing alcohol, cough syrups) for 24-72 hr of drug use; severe reactions may occur. y Urine may be darker in color than usual. y May experience dry mouth with strange metallic taste. (mouth care, sucking sugarless candies may help) y May experience nausea, vomiting and diarrhea (eat frequent small meals) y Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills.

POTASSIUM CHLORIDE Generic Name: Potassium chloride Brand Name: Kalium Durule Dosage: 2 tabs TID Drug classes: Electrolyte Indication y Prevention and correction of potassium deficiency; when associated with alkalosis, use potassium chloride; when associated with acidosis, use potassium acetate, bicarbonate, citrate, or gluconate. Contraindications and Cautions: y Potassium supplements are contraindicated in patients with hyperkalemia since a further increase in serum potassium concentration in such patients can produce cardiac arrest. y Use cautiously with cardiac disorders, especially if treated with digitalis, pregnancy, lactation. Adverse Effects: y GI: Nausea, vomiting, diarrhea, abdominal discomfort, GI obstruction, GI bleeding, GI ulceration or perforation. y Hematologic: Hyperkalemia--increased serum K+, ECG changes (peaking of T waves, loss of P waves, depression of ST segment, prolongation of QT interval) Interaction y Increased risk of hyperkalemia with potassium-sparing diuretics, salt substitutes using potassium. Nursing Consideration Assessment y History: Allergy to tartrazine, aspirin; severe renal impairment; untreated Addison's disease; hyperkalemia; acute dehydration; heat cramps, GI disorders that cause delay in passage in the GI tract, cardiac disorders, lactation. y Physical: Skin color, lesions, turgor; injection sites; P, baseline ECG; bowel sounds, abdominal exam; urinary output; serum electrolytes, serum bicarbonate. Intervention y Arrange for serial serum potassium levels before and during therapy.. y Administer liquid form to any patient with delayed GI emptying. y Administer oral drug after meals or with food and a full glass of water to decrease GI upset. y Arrange for further dilution or dose reduction if GI effects are severe. Teaching Points y Take drug after meals or with food and a full glass of water to decrease GI upset. y Do not chew or crush tablets, swallow tablets whole. Mix or dissolve oral liquids, soluble powders, and effervescent tablets completely in 3---8 oz of cold water, juice, or other suitable beverage, and drink it slowly. y Take the drug as prescribed; do not take more than prescribed. y Have periodic blood tests and medical evaluation. VIII. PRIORITIZATION OF THE PROBLEM ACTUAL: 1. Fluid volume deficit related to diarrhea as manifested by loose watery stools, capillary refill greater than 2 seconds, poor skin turgor and sunken eyeballs 2. Altered Nutrition: Less than body requirements related to diarrhea as manifested by loss of appetite. 3. Disturbed sleep pattern as evidenced by verbal report of lack of sleep POTENTIAL: 1. Risk for impaired skin integrity related to immobilization. 2. Risk for injury due to developmental age. 3. Risk for infection related to insufficient knowledge to avoid exposure to pathogens.
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