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Transcript of Age
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Acute Gastroenteritis
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Health History
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Demographic Data
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Demographic Data
Client’s Name: Baby LC
Gender: Male
Age/ Birth Date/ Birthplace: 5 months old/
February 25, 2011/ Manila
Civil Status: Single (Child)
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Demographic Data
Race/ Nationality: Filipino
Religion: Roman Catholic
Address: Kawit, Cavite
Usual Source of Medical Care: Hospital -
Philhealth
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Source & Reliability ofInformation
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Source & Reliability of Information
Patient’s chart
Patient’s mother
Patient himself
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Reason for Seeking Care
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Reason for Seeking Care
10 episodes of diarrhea
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History of Present Illness
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History of Present Illness
Few days prior to Baby LC’s admission, he defecated more than 10 times. His mother described his stool as watery in consistency and transparent to yellowish in color. His mother reported 1 episode of blood-streaked stool.
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Past Medical History
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Past Medical History
Injuries/ Accidents: None
Hospitalization: None
Immunizations: Hepa B Vaccine, DPT, OPV, BCG
Allergy No Known Allergy
Last Examination Date: July 6, 2011 (SDMC)
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Family History
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Developmental History
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Developmental History
Sigmund Freud’s Psychosexual Development
Oral (birth – 1 year old) Anal (1-3 years old)
Phallic (3 – 6 years old) Latency (6 – puberty)
Genital (puberty – death)
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Developmental History
Stage Task Patient’s Description
Oral
(Birth – 1 year)
Infant's mouth is the focus of libidinal gratification derived from the pleasure of feeding at the mother's breast, and from the oral exploration of his or her environment
Baby LC is taking formula milk instead of breastmilk. At the same time, his current condition (AGE) usually derived from sucking dirty things
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Review of Systems
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Review of Systems
Regional Examinations
General/ Overall Health State 5 months old 7.5 kg in weight Vital signs of 36.2°C (temperature),
33 bpm (respiratory rate), 110 bpm (pulse rate)
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Review of Systems
Regional Examinations
Integument Skin rashes are covering half of his
buttocks * Skin rashes – pinkish to reddish in
color and approximately 3-5 cm in circumference each circle
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Review of Systems
Laboratory Results:Procedure Normal Values Findings Interpretation
Hemoglobin 140-180 116 Low Iron intake
Hematocrit 0.42-0.54 0.35 Low Iron intake
WBC 5-10 10.36 Infection
Lymphocytes 25-40% 51.8 Viral infection
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Functional Assessment
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Functional Assessment
Elimination
Baby LC defecated 2 times from 6 o’clock in the morning up to 12 o’clock in the afternoon. The color of his stool is yellowish and semi-formed in consistency
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Pathophysiology
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Concept mapping
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Impaired skin integrity r/t
irritation of the skin from
excessive moist aeb skin rashes
Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6
hours
Baby LC
Dx: Acute Gastroenteritis
Signs & Symptoms:
*defecated 2x
*watery to semi-formed stool
*skin rashes (pinkish to reddish)
1 2
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Problem list
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Problem List
Actual
Number Problem
1 Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes
Potential
Number Problem
1 Risk for fluid volume deficit r/t diarrhea aeb 2x defecation in 6 hours
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Nursing care plan
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Impaired Skin Integrity
Assessment Diagnosis Planning Nursing Intervention
Evaluation
S: No verbal cues O: defecated 2xwatery to semi-formed stoolskin rashes (pinkish to reddish, 3-5 cm in circumference each circle) located at the buttocks
Impaired skin integrity r/t irritation of the skin from excessive moist aeb skin rashes
At the end of the entire shift, the patient will lessen his skin irritation due to excessive moist
•Assessed site of skin impairment•Advised the patient’s mother to lessen the positioning on the affected area•Advised the patient’s mother to check most of the time the affected area and report immediately if the condition worsen•Advised the patient’s mother to change immediately the diaper especially when soaked •Advised the patient’s mother to use topical cream
At the end of the entire shift, the patient’s skin irritation was lessened
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Risk for Fluid Volume Deficit
Assessment Diagnosis Planning Nursing Intervention
Evaluation
S: No verbal cuesO: defecated
2x watery to
semi-formed stool
Risk for fluid volume
deficit r/t diarrhea aeb 2x defecation
in 6 hours
At the end of the entire shift, the patient will be free from fluid volume deficiency
•Monitored intake and output•Advised the patient’s mother to increase oral fluid intake of Baby LC•Hydrated the patient with water mixed with Protexin•Administered IVF
At the end of the entire shift, the patient has no signs of fluid volume deficiency or mild dehydration. No depressed fontanel and sunken eyeballs noted
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Medical-surgicalmanagement
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Drug Study
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Name of Drug & Action
Classification Adverse effect Indication Contraindication Nursing Responsibilities
Protexin (Restore)Helps to improve the balance of microorganism in the intestinal tract
Vitamin for growth and health. It helps the body use carbohydrates, fats and protein. It also strengthens blood vessel walls
Probiotic Nausea and vomiting, stomach pain, severe diarrhea, dehydration
Prolonged diarrhea, prolonged infection, prolonged fever, intestinal disease, stress
Blood problems, Glucose-6-phosphate dehydrogenase (G6PD) deficiency
•Observe the 5 rights in giving medication•Advise the patient’s mother to:
-Strictly follow the doctor’s advise on how much to take and how often
-May be taken with or without food
-Try not to miss any doses
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Name of Drug & Action
Classification Adverse effect Indication Contraindication Nursing Responsibilities
Zinc Sulfate (E-Zinc)
Contributes to the recovery of the intestinal microbial flora and maintenance of skin hydration
Trace element
Nausea and vomiting, dizziness, fever, stomach pain, incoordination, restless
Acute diarrhea
Immuno- compromised patients
•Observe the 5 rights in giving medication•Shake drug well before administra-tion•Monitor patient for any unusual effect
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Name of Drug & Action
Classification Adverse effect Indication Contraindication Nursing Responsibilities
Benzal-konium ( Drapolene)
It cleans and disinfect skin or surrounding tissues
Antiseptic Localized dermatitis, pruritus
Nappy rash & Urinary rash
Hypersensitivity to benzalkonium chloride, cetrimide or lanolin
•Store below 25°C•Tell the patient’s mother that it is for external use only•Advise the patient’s mother to discontinue the topical cream if adverse reaction occur
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Name of Drug & Action
Classification Adverse effect Indication Contraindication Nursing Responsibilities
Ampicillin (Liferzin)
It stop microorganisms from multiplying
Antibiotic Anemia, Restlessness, fever
Treatment of infection caused by susceptible strains
Allergic to penicillin, cephalosporins
•Take the drug around-the-clock•Take the full course of therapy•It should not be used to self-treat other infections aside from what the doctor stated•Advise to report N/V, diarrhea
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Discharge healthteaching
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Discharge Health Teaching
Medication
Advise the patient’s mother to continue his medication regimen especially the antibiotic/s
Instruct patient’s mother to comply with the drugs as prescribed by the doctor and do not abruptly stop the drug without doctor’s consent
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Discharge Health Teaching
Exercise
Advise the patient’s mother to allow and support Baby LC in playing and moving- around because it serves as his ADL
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Discharge Health Teaching
Treatment
Continue medication as prescribed by the doctor and follow doctor’s advise
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Discharge Health Teaching
Health Teaching
Advise the patient’s mother to perform proper hygiene for Baby LC (bathing)
Emphasize to the patient’s mother the importance of proper caring and cleaning of the mouth and genital Before performing any cleaning or changing, make sure to
do hand washing Ensure that the new diaper fits perfectly Advise to change the diaper immediately especially when
soaked with urine and stool Gently pat dry the skin with wipes after washing and
cleaning
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Discharge Health Teaching
OPD
Advise the patient’s mother to seek follow-up check-ups for Baby LC
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Discharge Health Teaching
Diet
There are no dietary restrictions (milk feeding as tolerated)
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Discharge Health Teaching
Signs & Symptoms
Be sure to call the physician if these signs & symptoms occur: Fever Diarrhea or vomiting Swelling of the buttocks
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Thank You
Presented by: Arrian L. Dabu