NURSING CASE STUDY ADMISSION FINAL DIAGNOSIS I. HEALTH HISTORY A. DEMOGRAHIC DATA (BIOLOGICAL DATA) 1. Clients Initial: J.A.

L 2. Gender: Male 3. Age: 3 months and 22 days 4. Religion: Catholic 5. Usual Source of Care: UPHMC 6. Date of Admission: January 13, 2012 7. Admission/Initial Diagnosis: T/C Acute Bronchitis, Intestinal Amoebiasis B. SOURCE AND REALIBILTY OF INFORMATION The source of valuable information taken is from patients mother, the patients chart records and lab result.

C. REASONS FOR SEEKING CARE OR CHIEF COMPLAIN o Watery Stool for 1 week o Dry Cough and colds for 2 days o Moderate Dehydration D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH One (1) week prior to admission, patient J.A.L experiences a watery stool with vomiting. Patients mother said that her son dont have any fever. Two (2) days prior to admission, J.A.L already has a dry cough and colds and experiences a fever. Night prior to admission, patient J.A.L experienced a 2 episodes of soft water stool, greenish in color with mucous and blood with foul smell. On January 13, 2012, patient J.A.L together with his mother, he was brought to hospital for admission. The attending physician decided to admit the patient at around 5:00am. Patient was admitted at the room 335 in the KTU 3rd floor under Dr. Bueno with a initial diagnosis of T/C Acute Bronchitis, Intestinal Amoebiasis with Moderate Dehydration.

E. PAST MEDICAL HISTORY OR PAST HEALTH The patient mother said that J.A.L was born via NSD. He was able to comply in Expanded Immunization Process. As of now, he was on the 2nd dose of Hepa-B Vaccine, DPT, and Oral Polio Vaccine. F. DEVELOPMENTAL HISTORY Patient J.A.L is 3 months and 22 days old. He falls under Trust Versus Mistrust of Erik Erikson Developmental Theory. Eriksons Developmental Theory reflects positive and negative aspect of the critical life periods. J.A.L is learning to trust the health care provider and the student nurse. G. FAMILY HISTORY

Father

Mother

ANATOMY AND PHYSIOLOGY

The GI System consists of the oral structures, esophagus, stomach, small intestine, large intestine and associated structures. A. Oral Structures include the lips, teeth, gingivae and oral mucosa, tongue, hard palate, soft palate, pharynx and salivary glands. B. The esophagus is a muscular tube extending from the pharynx to the stomach. 1. Esophageal openings include: a. The upper esophageal sphincter at the cricopharyngeal muscle. b. The lower esophageal sphincter (LES), or cardiac sphincter, which normally remains closed and opens only to pass food into the stomach. C. The Stomach is a muscular pouch situated in the upper abdomen under the liver and diaphragm. Te stomach consists of three anatomic areas: the fundus, body (i.e., corpus), and antrum (i.e., pylorus) D. Sphincters. The LES allows food to enter the stomach and prevents reflux into the esophagus. The pyloric sphincter regulates flow of stomach contents (chyme) into the duodenum. E. The small intestine, a coiled tube, extends from the pyloric sphincter to the ileocecal valve at the large intestine. Sections of the small intestine include the duodenum, jejunum and ileum F. The large intestine is a shorter, wider tube beginning at the ileocecal valve and ending at the anus. The large intestine consists of three sections: 1. The cecum is a blind pouch that extends from the ileocecal valve to the vermiform appendix. 2. The colon, which is the main portion of the large intestine, is divided into four anatomic sections: ascending, transverse, descending and sigmoid. 3. The rectum extends from the sigmoid colon to the anus. G. The ileocecal valve prevents the return of feces from the cecum into the small intestine and lies at the upper border of the cecum. H. The appendix, which collects lymphoid tissues, arises from the cecum. I. the GI tract is composed of five layers.

1. An inner mucosal layer lubricates and protects the inner surface of the alimentary canal. 2. A submucosal layer is responsible for secreting digestive enzymes. 3. A layer of circular smooth muscle fibers is responsible for movement of the GI tract. 4. A layer of longitudinal smooth muscle fibers also facilitates movement of the GI tract. 5. The peritoneum, an outer serosal layer, covers the entire abdomen and is composed of the parietal and visceral layers. II. Function. The GI system performs two major body functions: digestion and elimination. A. Digestion of food and fluid, with absorption of nutrients into the bloodstream, occurs in the upper GI tract, stomach and small intestines. 1. Digestion begins in the mouth with chewing and the action of ptyalin, an enzyme contained in saliva that breaks down starch. 2. Swallowed food passes through the esophagus to the stomach, where digestion continues by several processes. a. Secretion of gastric juice, containing hydrochloric acid and the enzymes pepsin and lipase ( and renin in infants) b. Mixing and churning through peristaltic action 3. From the pylorus, the mixed stomach contents (i.e. chyme) pass into the duodenum through the pyloric valve. 4. In the small intestine, food digestion is completed, and most nutrient absorption occurs. Digestion results from the action of numerous pancreatic and intestinal enzymes (e.g., trypsin, lipase, amylase, lactase, maltase, sucrase( and bile. B. Elimination of waste products through defacation occurs in the large intestines and rectum. In the large intestine, the cecum and ascending colon absorb water and electrolytes from the now completely digested material. The rectum stores feces for elimination.

PATHOPHYSIOLOGY

Predisposing Factor Age Race

Precipitating Factor Environment Food

Amoebiasis

-LBM -fever