Sample Case Study

Acute Gastro Enteritis

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Presented to

Lyceum Northwestern University

Dagupan City, Pangasinan

In Partial Fulfillment

Of The Requirements of RLE III – Pangasinan Provincial Hospital

Submitted to:

Miss Joyce Ferrer

Submitted by:

Pearl Morante

Rutalee Miranda

TABLE OF CONTENTS

ACKNOWLEDGEMENT

I. Objective

II. Introduction

III. Anatomy

IV. Pathophysiology

V. Patient’s Profile

VI. Laboratory Results

VII. Management

A. Nursing Management

- Nursing Care Plan

B. Medical Management

- Drug Study

VIII. Discharge Planning

IX. Significance of the study

X. Definition of Terms

XI. Appendices

A. Actual number of Census

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ACKNOWLEDGEMENT

“The hardest arithmetic to master is that which enables us to

count our blessings.” says Eric Hoffer….

In fulfilling our tasks as student nurses, especially in accomplishing our case study, we had received many blessings. . . Blessings such as meeting great people who helped us

By enlightening our mind in doing this case study. . .

Albert Schweitzer said, “At times our own light goes out and is rekindled by a

Spark from another person.

Each of us has cause to think with deep

Gratitude of those who have lighted the flame within us”

To those persons, we call you our angels. . . You helped us accomplish this task

Of doing our Case Study and more than that is learning more than we expected.

To our patient, whom we wish to call Child XX for confidentiality,

To his family, for giving us the information we needed,

To our Dean and the Faculty of Nursing who taught us well in preparation to a hospital duty,

To Mr. Ms. Joyce Ferrer, whose witt challenged our neurons work to its highest potential, and to his kindness in guiding us be better student nurses . . . even excellent future professional nurses.

To the staff of Pangasinan Provincial Hospital, who also guided us and helped us adjust and

Understand our patient,

Without all of you, this case study would not be made possible.

Thank you very much for being our Angels.

And because of all of you, our group has learned to value and to be thankful to each other as we work hand in hand in accomplishing this report.

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I. General Objective

Ø To be able to provide student nurses and other Health Care professionals with an overview of the condition process and the nursing implication of Acute Gastro Enteritis.

Specific Objectives

By the end of this case study, we will be able to:

Ø Identify AGE and its predisposing factors

Ø Identify the history and manifestations of the disease through research and observing a positively identified patient with Typhoid Fever.

Ø Identify the laboratory results undergone by the patient.

Ø Discuss the pathophysiology of AGE.

Ø Discuss ways of managing AGE

Ø Identify means of preventing AGE.

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II. Introduction

Write WHAT IS GASTROENTERITIS?

And its Symptoms and signs

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III. Anatomy and Physiology

Write the parts of the system and its functions

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I. PATHOPHYSIOLOGY

Food/Water/Medication infected with bacteria or Virus

• Salmonella,
• Shigella,
• Staphylococcus,
• Campylobacter jejuni,
• Clostridium,
• Escherichia coli,
• Yersinia,
• Etc.

Then*

Taken orally by an individual

Then*

Bacteria/Virus attack the stomach and small intestines

Then*

Inflammation occurs

Then*

Signs and Symptoms:

• Nausea and vomiting
• Diarrhea/LBM
• Loss of appetite
• Abdominal pain
• Abdominal cramps
• Bloody stools (dysentery - suggesting infection by amoeba, Campylobacter, Salmonella, Shigella or some pathogenic strains of Escherichia coli)
• Fainting and Weakness

*this should be an arrow down

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III. Laboratory Results

Laboratory Exam	Normal Value	Result	Interpretation
Hemoglobin Mass Concentration	Male : 13.5-1.8g/dl	83.3	Indicates decreased tissue perfusion
Leukocyte number concentration	5-10x10 g/l	17.9	Shows presence of infection
Neutrophils	.55-.65	.35	Shows presence of infection
Eosinophils	.02-.04	.75	Shows possible allergic reactions
Lymphocytes	.22	.79	Shows presence of infection
Sodium	135-146 mEq/L	132	Slightly Low
Potassium	3.5 - 5.5 mEq/L	3.3	Slightly Low
Calcium	8.5-10.3 mEq/dl	8.4	Slightly Low
RBS	3.9 - 5.2 mill/mcl	4.5	Normal
Erythrocytes Volume Fraction	.25	.25	Normal
Stool Exam		No ova found

Symptomatology:

Clinical Manifestation	Present in Patient	Rationale
Abdominal Pain or cramping
Nausea
Vomiting	/	Decreased circulating oxygen in the body (and decreased fluid and nutrients) can lead to excessive blood loss and bone marrow destruction
Fever	/	As a result of the diminishing blood supply/nourishment through out the body
Poor feeding	/
Unintentional Weight loss	/
Excessive sweating
Clammy skin	/	Due to decreased blood perfusion
Muscle pain or joint stiffness
Incontinence (loss of bowel control)
Extreme thirst
Urine that is darker in color
Dry skin	/	Sign of dehydration. Cells in the body are not supplied with enough nourishment.
Dry mouth	/
Sunken cheeks or eyes	/

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IV. Management

Nursing Management

1. Admitted a dyspneic, feverish patient with LBM to Pedia ICU.
2. Secured signed consent to care
3. Placed in bed comfortably - With Linen stretched.
4. Inserted and fed via OGT aseptically
5. Vital signs checked and monitored every four hours all through out the confinement in the hospital
6. Hooked to pulse oximeter and maintain O2 sat >90% as ordered by physician
7. Medications administered as ordered by the attending physician.
8. TSB provided
9. Intake and output monitored to ensure good hydration
10. Watched for any unusualities
11. Referred to social worker for assistance and availability of medicines

---------- insert Nursing Care Plan after this --------------

Medical Management

A. Rehydration:

IVT hooked – Plain LR

· For rehydration

· As a route for medication

B. Laboratory – as ordered, to check complete status of patient. Results shown above.

C. Diet Therapy – On NPO upon admission. Milk feeding allowed on the second day. Breast feeding was encouraged.

D. Medications ordered such as

Antibiotics:

1. Ceftriaxone 500 mg IVTT now then OD

2. Ampicillin 260 mg IVTT every 6 hours

Fever:

3. Paracetamol 60 mg IVTT every 4 hours, PRN for temp >37.8°C

Seizure:

4. Phenobarbital 104 mg IVTT now as LD then 13 mg IVTT every 12 hours

5. Diazepam 1.5 mg IVTT now the PRN for frank seizures

6. Dopamine @ 2 cc/hr.

---------------- insert Drug Study after this ----------------------

V. Discharge Planning

The patient with ACUTE GASTRO ENTERITIS was instructed to take the following plan of discharge:

M – Medications should be taken regularly as prescribed, on exact dosage, time and frequency, making sure that the purpose of medications is fully disclosed by the health care provider.

E - Exercise should be promoted in a way by stretching hand and feet every morning. Encourage the patient to keep active to adhere to exercise program and to remain as self-sufficient as possible.

T – Treatment after discharge is expected for the patient and watcher to participate in continues medication.

H – Health teachings regarding proper hygiene and hand washing, food and water preparation, intake of adequate vitamins especially vitamin C-rich foods to strengthen the immune response and increasing of oral fluid intake should be conveyed.

O – OPD such as regular follow-up check ups should be greatly encouraged to the patient as ordered by physician to ensure the continuing management and treatment.

D – Diet which is prescribed should be followed. Laxative containing food should be avoided. Laxative foods include most fruits and vegetables, and cereal foods and breads containing the whole of the cereal grain. To include fruits especially banana in the diet is signifant.

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VI. Definition of Terms

----------------------- most common words, also the difficult words and abbreviations-------

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VII. Appendices

Actual number of Census

INFANT MORTALITY

Infant Mortality: Ten (10) Leading Causes
Number & Rate/1000 Livebirths & Percentage Distribution
Philippines, 2004

Cause	Number	Rate	Percent
1. Bacterial sepsis of newborn	3,402	2.0	15.1
2. Respiratory distress of newborn	2,500	1.5	11.1
3. Pneumonia	1,940	1.1	8.6
4. Disorders related to short gestation and low birth weight, not elsewhere classified	1,750	1.0	7.8
5. Congenital Pneumonia	1,501	0.9	6.7
6. Congenital malformation of the heart	1,451	0.8	6.4
7. Neonatal aspiration syndrome	1,256	0.7	5.6
8. Other congenital malformation	1,082	0.6	4.8
9. Intrauterine hypoxia and birth asphyxia	1,030	0.6	4.6
10.Diarrhea and gastro-enterities of presumed infectious origin	914	0.5	4.1

Source: The 2004 Philippine Health Statistics (DOH)
* percent share from total infant deaths, all causes, Philippines
Last Update: February 12, 2008