Section P– Group 1

E.C.S. – Pediatric WardRLE (Period covered: July 27-Aug. 1,2009)

Mr. Ralph P. Pilapil, R.N.

Clinical Instructor

A. Nursing HistoryIdentifying Data

Name of Patient : Patient XSex : MaleAge : 16 years oldCivil Status : SingleNationality : FilipinoReligion : R.C.Address : Sta. Cruz, Guizo Mandaue CityOccupation : StudentDate Admitted : July 27, 2009 Time : 8:10 p.m.

Informant : MotherAge : 30 years oldPhysician : Dr. PitogoRoom : Pediatric Ward

Admission Data

Source of Information : MotherMode of Admission : Ambulatory

Vital Signs on Admission Temperature : 36.6°CHeart Rate : 60 bpmRespiratory Rate : 18 cpmBlood Pressure : 120/70 mm HgWeight : 56 kgHeight : 5’ 4”Chief of Complaints: LBM, pain and vomiting

History of Present Illness

Two days PTA, The patient defecated watery stools more than 5 times with nausea and vomiting. The following day, Monday, client still defecated watery stool in succession and was partially relieved after taking Diatabs. After several hours LBM reoccur with occasional vomiting. Thus, patient’s mother saught medical advise resulting to his admission.

Past Medical History

The client experienced severe diarrhea last January 2004 and was hospitalized.

Injuries:• No previous injuries

Operation:• No minor and major operation were performed

Family Medical History:

Negative in: Heart Disease Diabetes Mellitus

Hypertension Cancer

Congenital Anomalies Obesity Arthritis Seizure Tuberculosis

Physical Assessment

1. EENT Eye functioned well and responsive to light accommodation

(3-4mm) tonsils are pink and in normal size

2. Central Nervous System able to speak the words clearly (responsive) irritability noted negative presence of seizure or tremors weak hand grasping and movement

3. Cardio Vascular System weak capillary refill blood pressure of 100/60 regular heart rhythm

4. Respiratory System symmetric chest expansion clear breath sound

5. Gastrointestinal System presence of hyperactive bowel sound excessive bowel elimination (five times/day) facial grimacing noted during defecation palpated with soft abdomen/tender pain sensation at anal area due to irritation from frequent defecation excessive loose / watery stool with fecal particles Dry skin & poor skin turgor Sunken eye ball

6. Genito-Urinary System disturbed sleeping pattern due to nocturnal urination low urine output (25ml/hour) reddish urine color

7. Integumentary System poor skin turgor rough / dry skin responsive to pain

8. Musculoskeletal System can stand and sit on his own with signs of weakness poor tendon reflex

Laboratories PerformedDate Ordered: July 27, 2009

FecalysisUrinalysisSpecimen Data Report

Diagnostic Normal Value Result Significance

Color Yellow Reddish Presence of components that indicates infection

Consistency Soft Watery Sign of dehydration

Cellular Findings

RBC None Not Seen Normal

Pus Cells 0-2 0-1/Hpf Normal

Bacteria None Many Infection is present

Yeast Cells Rare Normal

FECALYSISFECALYSIS

Diagnostic Normal Value Result Significance

Color Clear Yellow

Transparency Clear Clear

Ph 6-7.5 6.0 Normal

Specific Gravity 1.010-1.025 1.025 Normal

Protein Negative Negative Normal

Sugar Negative Trace w/in normal range

Microscopic Exam:

Pus Cells 0-2 3-6 Infection present

RBC 0-1 0-1 Normal

Epithelial Cells - Few Normal

A. Urates - Few Normal

A. Phosphates - - -

Bacteria - Moderate Infection

Mucus Thread - Few Normal

Ca Oxalates - Moderate Normal

URINALYSISURINALYSIS

Diagnostic Normal Value Result Significance

WBC 5-10/109L 14.0 Increased WBC count indicates infection

SPECIMEN DATA REPORTSPECIMEN DATA REPORT

B. Anatomy & Physiology

• Organs affected

• Functions

• Growth and development according to the age of client

Digestive SystemDigestive System

ESOPHAGUS• Approximately 25 cm (10inches long) but its

diameter depends on how much food it contains.

• When its full, it can hold about 4 liters of food; when empty, it collapses and its mucosa is thrown into large folds called rugae.

• Esophageal peristalsis propels the bolus of food into the stomach through the cardiac sphincter

– A distendible pouch with a capacity of about 1500 mL

– 4 anatomic regions– Stores and mixes food with the enzyme-

containing gastric juice.– Produces protein digesting enzymes –

pepsinogen, mucus, intrinsic factor and hydrochloric acid.

– Food stays from a half hour to several hours– Chyme, which is food mixed with secretions

enters the small intestine through the pyloric sphincter

STOMACH

The small intestine is the longest and most convoluted portion of the digestive tract

• Measuring 16 to 19 feet ( 5 to 6m) in length in an adult. • Composed of three different regions:

- duodenum,- jejunum, and - ileum.

• The inner surface of the small intestine has a velvety appearance because of numerous mucous membrane finger like projections called intestinal villi.

• Pancreatic secretions: trypsin, amylase and lipase• Intestinal glands secrete mucus, hormones and

electrolytes that coats the

Function:

Three main functions: – movement (mixing and peristalsis)

– digestion

– absorption

LARGE INTESTINE

– about 5 to 6 feet in length from the ileocecal valve to the anus

– lined with columnar epithelium that has absorptive and mucous cells.

– it begins with the cecum, a dilated pouchlike structure that is inferior to the ileocecal opening.

– the large intestine then extends upward from the cecum as the colon.

– the colon consist of four divisions:- ascending colon

- transverse colon - descending colon

- sigmoid colon.

Function:

Three Main Functions:– Absorption

– Elimination

– Movement

GASTROENTERITIS:

• Is an increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract.

• Primarily affects the small bowel and can be either viral or bacterial origin.

DIAGNOSIS AND DEFINITION

C. Pathophysiology

Precipitating Factors:•Poor sanitation during warm months•Crowded living conditions

Risk Factors:•Children•Older adults•Familial tendency

DIAGNOSISAcute Gastroenteritis

Signs and Symptoms•Watery stools•Intestinal rumblings•Abdominal pain•Distention•Vomiting•Fever

Diagnostic Evaluation•Fecalysis•Urinalysis•Specimen Data Report

Etiology

Bacteria

Release of enterotoxins and attachment of organism to mucosal epithelium

GI wall irritation and destruction of intestinal villi

Fluid secreted into lumen

Increased fluid in the GI lumen and reduction of absorption

OUTCOME

HYPOVOLEMIA

Complications•SHOCK - renal failure - irreversible acidosis

PROGNOSIS

DEATH

The pt. was responsive to the therapeutic mgt.

Signs and Symptoms:– Diarrhea

Explanation:

The epithelium of the digestive tube is protected from insult by a number of mechanisms constituting the gastrointestinal barrier, but like many barriers, it can be breached. Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species. Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results.

Abdominal pain or cramp

Explanation:The pain associated with obstruction of a hollow viscus (as opposed to peritoneal and solid organ pain) is often intermittent or "colicky", coinciding with the peristaltic waves of the organ. Such cramps are exactly what is experienced with early acute appendicitis and gastroenteritis and are somewhat relieved by writhing

and massage

Vomiting

Explanation:Vomiting in diarrhea can occur when the lining of the intestines or stomach is irritated by an infection.   Usually the infection is caused by a virus or bacteria.  Diarrhea and vomiting can drain water and salts from the patient. These need to be replaced to prevent the patient from becoming dehydrated (dry).

D. Medical ManagementsI. DIAGNOSTIC / LABORATORY

PROCEDURES

Ideal:• Complete Blood Count• Urinalysis• Routine stool examination• Stool Culture• Barium enema

Actual:• Urinalysis• Fecalysis

II. MEDICATIONS

Actual:

• Ranitidine HCl (Zantac) 80mg slow IVTT q8h – Antiulcer Agent

• Ciprofloxacin HCL 500mg 1tab BID PO PC - Anti Infective Agent

• Aluminum Magnesium Hydroxide(Isopan) 20 ml 1pc 2 H.S. - Antacid Agent

III. TREATMENT

Ideal:• Oral rehydration therapy • Antimicrobial therapy• E coli: Antibiotic treatment

Actual:• D5LR 1 Liter @ 30 gtts/min• Monitoring of urine and stool• V/S q shift

IV. EXERCISES AND ACTIVITIES

• Ambulate by himself w/o the assistance of S.O.

V. DIET

Ideal:

• The bland diet

• Introduce lean meats and clear fluids as soon as possible.

Actual:

• DAT

MEDICATIONS

Medications are substances used in the diagnosis, treatment, cure, relief, or prevention of health alterations. This is the primary treatment client associate with restoration of health.

Name of Drug

Generic (Brand)

Date

Ordered

Classification Dose Frequency

Route

Ranitidine HCL

(Zantac)

7/27/09 Anti ulcer drug 80 mg, slow IVTT q8 hr

Mechanism of Action

Specific Indication

Side Effects Nursing Implications

Competitively inhibits action of histamine on the H2 @ receptor sites , parietal cells decreasing gastric secretion.

Gastro esophageal reflux disease

Contraindications:

-patient with hypersensitive to drug & those with phorphyria.

-Use cautiously in patient with hepatic dysfunction.

-adjust dosage in patient with impaired renal function

CNS: vertigo, malaise, headache.

EENT: blurred vision

Hepatic: jaundice

Other: burning and itching @ injection site anaphylaxis, angioedema.

Before :

Assess patient for abdominal pain, note for presence of blood & emesis & stool.

During:

Administer IVTT slowly.

After:

Monitor patient for adverse reaction.

Store IV injection @ 30 degrees

After dilution solution is stable for 48 hrs. @ room temperature.

After taking the medication advise pt to report immediately any adverse reactions.

Name of Drug Generic

(Brand)

Date

Ordered

Classification Dose Frequency

Route

Ciproflaxacin HCL

7/27/09 Anti -Infective 500 mg/tab BID PO pc

Mechanism of Action

Specific Indication

Side Effects Nursing Implications

Inhibits bacterial DNA, an enzyme needed for bacterial replication.

Complicated intra-abdominal infection.

Contraindications:-Hypersensitive to a ciproflaxacin.--it’s unknown if drug appears in breast milk after application.

EENT: local burning or discomfort, foreign body sensation, itching.

GI: bad or better taste in mouth.

Before:

-Assess vital sign.

-Assess lab. Results and the causative agent.

During:

-Stop drug @ first sign of any hypersensitivity.

After:

-Prolonged use may result in overgrowth of susceptible organisms.

-Assess for adverse reaction.

Name of Drug Generic

(Brand)

Date

Ordered

Classification Dose Frequency

Route

Aluminum Magnesium Hydroxide

(Isopan)

7/27/09 antacids Susp. 20 ml pc 2 H.S.

Mechanism of Action

Specific Indication

Side Effects Nursing Implications

Reduces total acid load in GI tract, elevates gastric ph to reduce pepsin activity strengthens gastric mucosal barrier, and increases esophageal sphincter tone.

Acid indigestion .

Contraindications:•Severe renal disease.•Use cautiously in patients with mild renal impairment.

GI: mild constipation, diarrhea.

GU: increased urine ph.

Metabolic: hypokalemia

Before:

-Assess patient with renal failure.

-Instruct patient not to take suspension or liquid well and follow dose with water.

During:

-monitor magnesium level in patient with mild renal impairment.

After :

-Urge patient to notify prescriber about the signs or symptoms of GI bleeding, such as tarry stools & coffee ground vomiting.

Nursing Management

Deficient Fluid VolumeI. Goal of Care: To assess causative/precipitating factors:

– Determine effects of age.

II. Goal of Care: To correct/replace losses to reverse pathophysiological mechanisms.– Establish 24 hour fluid replacement needs and routes to be

used.

III.Goal of Care: To promote comfort and safety:– Provide frequent oral care as well as eye care.– Administer medications.

Acute Pain

I. Goal of Care: To evaluate client’s response to pain:

– Perform pain assessment each time pain occurs.

– Accept client’s description of pain.– Assess for referred pain as appropriate..

II. Goal of Care: To assist client to explore methods for alleviation/control of pain:

– Review/expectations and tell client when treatment will hurt.– Administer analgesics as indicated to maximal dosage as

needed.– Assist client to alter drug regimen, based on individual

needs.

III. Goal of Care: To promote wellness (Teaching/Discharge Considerations):

– Encourage adequate rest periods.– Provide for individualized physical therapy/ exercise program

that can be continued by the client when discharged.

Risk for Imbalanced Nutrition

I. Goal of Care: To assess causative/contributing factors:

– Ascertain understanding of individual nutritional needs.

– Discuss eating habits, including food preferences, intolerance /aversions.

– Assess drug interactions, disease effects, allergies, use of laxative, diuretics.

– Determine psychological factors/perform psychological assessment as indicated.

II. Goal of Care: To establish a nutritional plan that meets individual needs:

– Assist in developing individualized regimen.– Consult dietitian/nutritional team as indicated.– Limit fiber/bulk if indicated.– Prevent/minimize unpleasant odors/sights.– Encourage client to choose foods that are appealing.

III. Goal of Care: To promote wellness (Teaching/Discharge Considerations):

– Weigh weekly and document results– Refer to home health resources and so on – Consult with dietitian/nutritional support team as necessary

Nursing Care Plan 1ASSESSMENT SUBJECTIVE:

– “tubig gihapon ako gikalibang” as verbalized by the pt.

OBJECTIVE: – excessive loose / watery stool– Dry skin & poor skin turgor – Sunken eye ball– excessive bowel elimination (five times/day)

NSG DIAGNOSIS:

Fluid volume deficit related to diarrhea secondary to acute gastroenteritis.

Scientific Basis:

Decreased intravascular, interstitial and/ intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

NSG GOAL:After 2-4 hours nursing interventions, the patient will be able to maintain fluid volume at functional level as evidenced by stable vital signs, moist mucous membranes & good skin turgor.

OUTCOME CRITERIA:Independent: After 2-4 hours of nursing interventions, patient will experience adequate fluid

volume and electrolyte balance as evidenced by: urine output greater than 30 ml/hr, normal blood pressure, heart rate of 60-100 beats/ min, respiratory rate of 12-20 cycles/min,normal skin turgor.

Pt. will maintain afebrile state. Pt. will initiate rehydration. Pt. will increase fluid intake of more than 2 liters.

Dependent: Patient will follow medication on time.

Collaborative: Patient will eat food prepared for him as advised by dietician.

NSG INTERVENTION

INDEPENDENT:

• Obtain patient history to ascertain the probable cause of the fluid disturbance

• Evaluate fluid status in relation to dietary intake.

• Monitor temperature .

RATIONALE

• This can help with making the various nursing interventions

• Most fluids enter the body through drinking water in foods & water.

• Febrile states decrease body fluids through perspiration.

• Encourage oral hygiene

• Encourage oral intake of small amounts of fluids and bland foods.

• Provide oral fluids that are preferred by the patient and place it at bedside, within reach. Ensure that it is fresh.

• This promotes interest in drinking, leading to rehydration

• Eating small amounts can be helpful because it is more easily absorbed.

• Be creative in

providing oral fluids to promote and encourage intake.

• Teach interventions to prevent future episodes of dehydration/inadequate intake.

DEPENDENT:

• Administer medications and IV fluids as ordered.

• Client needs to understand the importance of drinking extra fluid during bouts of diarrhea.

Nursing Care Plan 2

ASSESSMENT

SUBJECTIVE: – “Sige ug sakit-sakit akong tiyan” as verbalized by the pt.

OBJECTIVE: – Hyperactive bowel sounds (6 sounds in 20 seconds) – Abdominal distention– Facial grimacing and guarding.– pain sensation at anal area due to irritation from frequent

defecation– Pain scale of 7 out of 10.

NSG DIAGNOSES:

Pain related to injuring agents (physical – inflammation of GI tract) secondary to Acute Gastroenteritis

Scientific Basis:

Acute infectious diarrhea results to increase frequency and fluid content of stool. The patient usually has abdominal distention and hyperactive bowel sounds. Painful spasmodic contraction of the anus and ineffectual straining may occur with each defecation.

NSG GOAL:After 30 mins – 1hour of nursing interventions, the patient will report relief of pain from a pain scale of 7/10 to a pain scale of 4/10.

OUTCOME CRITERIA:Independent: After 30 mins – 1hour of nursing interventions, the patient will report relief

of pain from scale 7 to 4. Pt. will verbalize lesser episodes of pain.

Dependent: Patient will follow medication on time.

Collaborative: Patient will eat food prepared for him as advised by dietician.

NSG INTERVENTION

INDEPENDENT:

• Assess pain scale.

• Encourage verbalization of feelings about pain.

• Provide comfort measures (back rub, change of position)

RATIONALE

• Serves as part of baseline data.

• Facilitates timely intervention.

• Provides non-pharmacological pain management.

• Encourage adequate rest period.

• Instruct patient to report intense pain as soon as it begins

DEPENDENT:

• Administer analgesics as ordered.

• Prevents fatigue.

• Timely intervention is more likely to be successful in alleviating pain.

• Relieves pain

Nursing Care Plan 3

ASSESSMENT

SUBJECTIVE: – “Dili ko ganahan mokaon” as verbalized by the pt.

OBJECTIVE: – Poor muscle tone– Hyperactive bowel sounds– Aversion to eating– Food served remained untouched

NSG DIAGNOSES:

Risk for Imbalanced nutrition: less than body requirements related to inadequate intake with nutrients secondary to acute gastroenteritis.

Scientific Basis:Nutrition is imbalanced to a relative absolute

deficiency of one or more essential nutrients. This may be manifested as undernutrition.

NSG GOAL:After 8 hrs of nursing intervention, patient will exhibit progressive signs of appetite as evidenced by increased food intake.

OUTCOME CRITERIA:• Independent:

After 8 hours of student nurse patient intervention , patient will brush teeth every after meals, pt will

verbalize satiety of food by evidence of at least consumption one half cup of rice.

• Dependent:

Patient will follow medication on time.• Collaborative:

Patient will eat food prepared for him as advised by dietician.Patient will cooperate with the S/O and nurse to

determine proper way of selecting nutritional food

NSG INTERVENTION

INDEPENDENT:

• Provide oral hygiene

• Serve food in well-ventilated,

pleasant surroundings.

• Avoid/ limit foods that might cause/exacerbate abdominal cramping and flatulence

RATIONALE

• Clean mouth can enhance the taste of food

• Pleasant environment aids in reducing stress and is more conducive to eating

• Individual tolerance varies, depending on stage of disease and area of bowel affected.

• Encourage bed rest and/ limit activity

DEPENDENT:

• Administer medication as specified by the doctor.

COLLABORATIVE:

• Coordinate with dietician• Health teachings to pt and

S.O. on proper nutrition and hygienic preparation of food.

• Decreased metabolic needs aids in preventing caloric depletion and conserve energy.

F. Progress and Prognosis

The actual progress and prognosis of the disease of the patient X can be referred to as “Fair”. The patient was discharged last July 30, 2009. The main s/sx or the course of illness had been relieved by medication therapy and treatment instituted. It was successful but it was considered as fair because generally, the prognosis is dependent upon compliance of the prescribed treatment regimen.

G. Discharge Planning

MEDICATIONS:– Follow strictly medication regimen such as oral rehydration

solution or as prescribed by the physician and report immediately of adverse reactions.

EXERCISE:– Carry out daily activities as tolerated.– Do activities of daily living as tolerated.

TREATMENT:– Take medications as scheduled and as prescribed for fast

recovery.

HEALTH TEACHING:– Observe proper personal hygiene to avoid complication; frequent

hand washing is advised.– Observe proper food preparation and handling to avoid reinfection.

OUT-PATIENT:– Advise patient to visit for check-up to the doctor for further

follow-up of health status.

DIET:– Follow religiously the prescribed diet to regain strength and

improve health status; these include BRAT (banana, rice, apple, tea) diet.

SPIRITUAL:– Advise family to ask assistance and guidance from the divine

providence for speedy recovery.