case presentation on Acute gastro enteritis with moderate Dehydration.docx

8/18/2019 case presentation on Acute gastro enteritis with moderate Dehydration.docx

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I. BIOGRAPHICAL INFORMATION

Name : B/o Lavanya Sharma

Age : 1 month 2 days

Sex : Male

Addre : S/o Mr. Suresh Bhind

Re!"g"on : Hindu

IP No. :

Adm" "on #n"$ : Pediatric ICU

%a$e o& adm" "on : 11/01/10%a$e o& h" $ory $a'"ng : 13/01/10

In&orman$ : Mother

II. %IAGNOSIS : A(#$e Ga $ro )n$er"$" *"$h Modera$e %ehydra$"on

III PR)S)NT HISTOR+


2/27

III PR)S)NT HISTOR+

H/o e"er since one day mild to moderate de(ree does not decrease #ith medication*associated #ith re usal o eeds and decreased acti"ity.

Had history o one e$isode o e cessi"e cry lastin( or one hour.

I-. PAST M)%ICAL HISTOR+

Pa $ "!!ne ho ,"$a!" a$"on :Has history o abdominal distention and reason isun no#n.

A!!erg"e : N"!

Med"(a$"on : NS

-. BIRTH HISTOR+

An$ena$a! : Premature ru$ture o membrane

Na$a! 0 P!a(e o& B"r$h : Hos$ital

Mode o& %e!"very : !SCS

Ge $a$"ona! Age : months 22 days


3/27

+0 yrs 52 yrs 3 yrs 3- yrs

21 yrs 2 yrs

1 month

-II. GRO1TH AN% %)-)LOPM)NT

$$ro$riate to the a(e o 1 month.

-III. IMM2NI3ATION

Name o& $he a(("ne T"me Remar'


4/27

7= Ho#r %"e$ Re(a!!:• Baby o !a"anya is in 4P) since last 25 hours.

• Baby recei"ed I7& Isolyte P 108 2 ml at the rate o 12 ml/hr.

• lso recei"ed ) 9"e $ac ed cells and re$laced by %!.

• t 2 am baby recei"ed &resh &ro:en Plasma 2+ ml.

%egree o& Ma!n#$r"$"on :

;e(ree o malnutrition < actual #ei(ht/e $ected #ei(ht = 100

< 3 ( /3.+ ( = 100

< +. 8

I ;e(ree malnutrition

I. SL))PING PATT)RN

Baby slee$ decreased due to dehydration.

PH+SICAL ) AMINATION


5/27

Head C"r(#m&eren(e : 3 cms

Che $ C"r(#m&eren(e : 3+cms

=. S'"n And M#(# Mem>rane

Co!or : 4ormal bro#n

)dema : bsent

Mo" $#re : Mild drynessTem,era$#re : Increased

T#rgor : Im$aired. Has s in $inch (reater than 2 sec.

Any A>norma! %" (harge : 4il

6ually distributed and blac in color.

L"(e : bsent

8. Na"!Change "n A,,earan(e : 4il

Cyano " : 4o


6/27

Symme$ry : Symmetrical

Movemen$ : 4ormal

. )ye

)x,re "on : ;ull

La(r"ma$"on : 4ormal

Con #n($"va : Clear S(!era : ?hite

Cornea : Moist and round

P#,"! : %eacti"e to li(ht

45. )arA,,earan(e : 4ormal and symmetrical

%" (harge : 4il

Le "on : 4il

Any A>norma!"$"e : 4il

44. No e

A earan(e : 4ormal


7/27

4;. Ne('

Genera! A,,earan(e : 4ormal

Tra(hea : Centrally located

Lym,h Node : 4o enlar(ement

Thyro"d G!and : 4on tender* irm

Sa!"vary G!and : 4ot $al$able

4=. Che $ And Re ,"ra$ory Sy $em

In ,e($"on : Barrel chest

Pa!,a$"on : 4o s#ellin(

Per(# "on : ;ullA# (#!$a$"on : 4o abnormal sounds

4


8/27

Tenderne : 4o tenderness

4@. Gen"$a!"a

4ormal male (enitalia

4 . )x$rem"$"e

%e&orm"$"e : 4oS*e!!"ng/ )dema : bsent

M# (!e : Stren(thenin(

Lym,h Node : 4o enlar(ement

o"n$ : 4ormal mo"ements

F"nger and Toe : 4o abnormalities

75. Cen$ra! Nervo# Sy $em

B"r$h In #r"e : 4il

Se" #re : bsent

Sen ory Mo$or Change : %es$ond to shout and $ain ul stimuliGa"$ Change : $$ro$riate to a(e

Cogn"$"ve Change : $$ro$riate to a(e


9/27

B!eed"ng : 4)

1orm In&e $a$"on : 4o

7;. P y(ho o("a! H" $ory

Genera! S$a$# o& $he Fam"!y:

'he baby belon(s to a middle class amily* #hose ather is doin( business andmother is $rimary school teacher* #ith the income abo"e %s 10000/ month. 'hey areli"in( in their o#n house #ith $ro$er li(ht and "entilation.

Re!a$"on h", *"$h $he &r"end and &am"!y:

Baby is the irst born male and lo"ed A ta en care by amily members.

7=. La>ora$ory "nve $"ga$"on

S!.No.

Inve $"ga$"on Re #!$ Norma! va!#e Remar'

4.7.;.

B!ood $e $Gro#, and RhHemog!o>"nSod"#m

O D ve

.8E475 me /d!

999999947948gm/d!4;


10/27

M)%ICATIONS

Med"(a$"on name %o age Fre #en(y Ro#$e A($"on S"de e&&e($ N#r "ng re ,on ">"!"$"e1. I7& Isolyte P

2. In . Ce tra one

3. In mi acin

5. In . Metro(yl

+. In . denosine

-. In . 7it

. &&P. Pac ed Cell

trans usion. In . %antac

12ml/hr

1+0m(

2+m(

1+m(

1 m(

30 ml

-0 ml

3 m(

>"eryhourly

Bd

Bd

'id

'id

,,,,

,,,,,

Bd

I7

I7

I7

I7

I7

I7

I7

I7

I7

%e$lacement o luidelectrolytes

ntibiotic

ntibiotic

ntimicrobial

Coa(ulant

%e$lacement

%e$lacement

ntacid

&luid o"erload 4ausea and "omitin(

S#ellin(* redness* $ain*or soreness* loss oa$$etite* nausea*"omitin(* diarrhea*#ea ness

;i::iness* headache*diarrhea* nausea*

stomach $ain*ller(ic reactionD

Itchin( or hi"es*s#ellin( in your ace orhands* s#ellin( ortin(lin( in mouth orthroat* chest ti(htness .

Pain* s#ellin( and

tenderness at the site.ller(ic reactions*

4ausea* "omitin(

Calculate the luid re6uirementand administer at re6uired rate.&ollo# the sa ety $rinci$les odru( administration.Maintain ase$tic $recautionsdurin( dru( administration.

dminister the I7 in ections asslo#ly as $rescribed.Continuous monitorin( o "italsi(ns.

)bser"e the baby continuously orside e ects o dru(s.Ins$ect the site o in ectionre(ularly.


11/27

AC2T) GASTRO)NT)RITIS 1ITH %)H+%RATION

INTRO%2CTION

In de"elo$in( countries o the #orld* in ectious diarrhea ills about 5 million $eo$le $er year. In the United States* it is estimated that children youn(er than + years o a(e e $eriencemore than 20 million e$isodes o diarrheal diseases each year* #ith about 500 deaths $er year attributed to such e$isodes. ;ehydration is the most im$ortant actor or the morbidity andmortality associated #ith diarrheal disease in India also. ;ehydration is lar(ely controllable byusin( rehydration thera$y E@uerrant A Steiner* 2000F.

%)FINITION OF GASTRO)NT)RITIS

n in ection or irritation o the stomach and intestines* caused by bacteria or $arasitesrom s$oiled ood or unclean #ater

short $ain ul illness a ectin( your stomach and intestines that is caused by bacteria inood or a "irus and that ma es you (o to the toilet re6uently

%"arrhea: &re6uent* loose* and #atery bo#el mo"ements. Common causes include(astrointestinal in ections* irritable bo#el syndrome* medicines* and malabsor$tion.

CA2S)S OF GASTRO)NT)RITISIn many cases* the cause o diarrhea cannot be ound. 'he ma or in ection causin( a(ents are

• Bacteria


12/27

RIS FACTORS

• >atin( ood that irritates the stomach linin(

• &ood intolerances. Some $eo$le are unable to di(est a com$onent o ood* such aslactose* the su(ar ound in mil .

• >motional u$sets such as an(er* ear* or stress.

•

%eaction to medicines* such as antibiotics* blood $ressure medications* and antacidscontainin( ma(nesium.

• Intestinal diseases* li e in lammatory bo#el disease or celiac disease.

• &unctional bo#el disorders* such as irritable bo#el syndrome* in #hich the intestines donot #or normally.

• Some $eo$le de"elo$ diarrhea a ter stomach sur(ery or remo"al o the (allbladder.

• 'he reason may be a chan(e in ho# 6uic ly ood mo"es throu(h the di(esti"e systema ter stomach sur(ery or an increase in bile in the colon that can occur a ter (allbladder sur(ery.

s lon( as diarrhea (oes a#ay on its o#n* an e tensi"e search or the cause is not usuallynecessary.

SIGNS AN% S+MPTOMS OF GASTRO)NT)RITIS

B ' "($# P $" $ "($#


13/27

disease.

;e$endin( on the cause* a $erson may ha"e bloody stools.

4o im$ro"ement e"en a ter 25 hours.

%"arrhea "n "n&an$

;iarrhea can be dan(erous in ne#borns and in ants. In

small children* se"ere diarrhea lastin( ust a day or t#ocan lead to dehydration. Because a child can die rom

dehydration #ithin a e# days.

Si(ns o dehydration in children includeD

• ;ry mouth and ton(ue.

•

4o tears #hen cryin(.• 4o #et dia$ers or 3 hours or more.

• Sun en abdomen* eyes* or chee s.

• Hi(h e"er.

• !istlessness or irritability.

• S in that does not latten #hen $inched and released.

Se"ere dehydration may re6uire hos$itali:ation.

)ne e$isode o bloody stool.

4o im$ro"ement.

Moderate ;ehydration $resent

;ry Mouth and !i$s.

4o tears #hen cryin(

4o #et dia$ers since 3,5 hour

Sun en eyes

Hi(h e"er 102 o&

Poor tur(or


14/27

causin( the diarrhea.

Si(moidosco$y and Colonosco$y. ,,,,,,COMPLICATIONS

;ehydration.

>lectrolyte disturbances.

Hy$er or hy$onatremia* hy$o alemia* metabolic acidosis.

'ransient* due to "illous dama(e.

TR)ATM)NT

A e men$ o& dehydra$"on

M"!d dehydra$"on ;0


15/27

G#"de!"ne &or F!#"d Managemen$ o& %ehydra$"on Re $ore "n$rava (#!ar vo!#me

4ormal salineD 20ml/ ( o"er 20min E%e$eat until intra"ascular "olumerestoredF.

Ca!(#!a$e 7=9hr *a$er need

Calculate maintenance #ater Calculate de icit #ater < Percent dehydration #ei(ht

Ca!(#!a$e 7=9hr e!e($ro!y$e needCalculate maintenance sodium and $otassiumCalculate de icit sodium and $otassium

Sodium de icit < #ater de icit 0 me6/lPotassium de icit < ?ater de icit 30 me6/l

Se!e($ an a,,ro,r"a$e &!#"d >a ed on $o$a! *a$er and e!e($ro!y$e needdminister hal the calculated luid durin( the irst hr* irst subtractin( any

boluses rom this amountdminister the remainder o"er the ne t 1- hr

Re,!a(e ongo"ng !o e a $hey o((#r


16/27

@i"e boluses o 10,20ml/ ( o normal E0. 8F saline* #hich may be re$eated.;o not include this luid "olume in any subse6uent calculations.

Children #ith se"ere dehydration re6uire maintenance luids. 'hey may also need e trato re$lace luid de icit due to dehydration* and $ossibly more luid to re$lace abnormal on(oin(losses Ee( rom drain sitesF.

Ma"n$enan(e• !ess i in a basal state Eie "ery inacti"e lyin( in bedF. ,2+8

• !ess in children on mechanical "entilation #ith humidi ied (ases. ,2+8

• More in children #ith e"er. 910 to 208

• !ess in children #ith e cessi"e secretion o ntidiuretic Hormone E ;HFe( $neumonia*

menin(itis 7aries E,20 to 508F• More i unable to concentrate urine Ee( some renal diseases* ;iabetes insi$idusF 7aries

Ch"!dren *"$h modera$e $o m"!d dehydra$"on

F!#"d need

?ell children #ith normal hydration but no oral inta e re6uire an amount o luid that iso ten termed KmaintenanceK.

M i t l id i th t " l d il l id i t #hi h $l th i ibl l


17/27

'he ollo#in( table may be used to estimate maintenance luid re6uirements.

1$ 'g = 8 @ 45 47 4= 48 75 ;5 =5


18/27

N2RSING %IAGNOSIS D

;ehydration related to e cessi"e loss o luid.

Hy$erthermia related to in ectious $rocess.

;isturbed bo#el elimination $attern related to (astrointestinal in ection.

Im$aired $arental bondin( related to isolation o baby.Parental an iety related to childLs condition and its $ro(nosis.

%is or im$aired s in inte(rity related to dry and scaly s in.

Hi(h ris or urther in ection related to immature immune mechanism.


19/27

N2RSING CAR) PLAN

ASS)SS

M)NT

N2RSING

%IAGNOSIS

PLANNING IMPL)M)N

TATION

)-AL2A

TION

OB )CTI-)

INT)R-)NTIONS

O> e($"veda$aPoor s intur(or.Increased

$ulse 1-2 bts/min.

;ecreasedelectrolytele"eli.e.sodium120me6/dl

$otassium3.1 me6/dl

;ehydration relatedto loss o

luid.

Baby#illachie"eandmaintainnormalhydration

status.

ssess thehydration status andde(ree o dehydration.

Calculatethe total #ater andelectrolyte loss in the

baby.

Monitor blood electrolyte le"el.

%estrict theenteral eedin(.

dministernormal saline as a

bolus to meet theimmediate luid andelectrolyte need o the

baby.dminister

the I7 luids tomaintain the normalhydration status.

ssessed thatchild has moderatedehydration .

Baby had -,108 o #ater loss.

Baby iselectrolyte le"el is lo#.

%estrictedenteral eedin(

dministered-0 ml o 4S in 20

minutes.

dministeredI7& Isolyte P 108 at therate o 12ml/hr.

Babyachie"ednormalhydrationstatus ase"idenced

by

im$ro"eds intur(or andnormalelectrolytele"el.Sodium133me6/dlPotassium

+.1me6/dl


20/27

ASS)SSM)NT

N2RSIN

G%IAGN

OSIS

PLANNING

IMPL)M)NTATION

)-AL2ATION

OB )CTI-)

INT)R-)NTIONS

O> e($"veda$aIncreased

bodytem$erature.'em$102 o &

Hy$erthermiarelated toin ectious

$rocess.

Baby #illachie"enormal

bodytem$erature.

ssess the"ital si(ns.

Set the lo#

tem$eratur e in theradiant#armer.

Maintain $ro$er"entilation.

Maintainthehydrationstatus.

Pro"idecoldcom$ress.

ssessed that'em$,102 &

%adiant#armer is set

to thetem$eratureo o &

Maintainedthe normalroomtem$erature.

Maintainednormalhydrationstatus.

,,,,,

dministered

Babytem$erature reducedto .- o &.


21/27

dminister anti,$yreticandantibioticsas

$rescribed.

In . Ce tra one

dministered.

ASS)SSM)

NT

N2RSIN

G

%IAGN

OSIS

PLANNING

IMPL)M)N

TATION

)-AL2A

TION OB )CTI

-)

INT)R-)N

TIONS

O> e($"ve

da$a

Baby is

admitted in 4ICU and

se$arated

rom the

mother.

lso

Im$aired

$arental

bondin(

related toisolation

o the

baby

Mother

#ill

achie"e

$ro$er bondin(

#ith the

baby.

ssess the

bondin(

le"el o

mother and baby.

llo# the

mother to see

'he baby is

one month

old* so it is

the im$ortant $eriod in

de"elo$in(

the bondin(

#ith the

mother.

Mother

understoo

d the

conditiono the

baby and

need o

maternal

bondin(.


22/27

restricted the

breast

eedin(.

the baby as

re6uently as

$ossible.

> $lain themother about

the

im$ortance

o bondin(

bet#een

them.

> $lain the

mother

re(ardin( the

need or

isolation in

the $resent

condition o

the baby.

> $lain the

reason or

restrictin(

the breast

Mother sa#

the baby once

in 2,3 hours.

>ducated the

mother

re(ardin( the

im$ortance o

maternal

bondin(.

> $lained

mother

re(ardin( the

need or

isolation.

> $lained thereason behind

restriction o

breast

eedin(.


23/27

eedin(.

ASS)SSM)

NT

N2RSIN

G

%IAGN

OSIS

PLANNING

IMPL)M)N

TATION

)-AL2A

TION OB )CTI

-)

INT)R-)N

TIONS

S#> e($"ve

da$a

Mother

as ed6uestions

re(ardin(

the

condition

and

$ro(nosis o

the baby.

O> e($"ve

da$a:

Mother

loo s dull*

Parental

an iety

related to

babyLscondition

and

$ro(nosis

.

Parents #ill

be ree

rom

an iety.

ssess the

an iety le"el o the

$arents.

> $lain indetail about the babyLs

condition and

treatment.

%eassure the

$arents by introducin(

$arents o babies #ith

same condition* #ho

are re(ained health.

> $lain the

need or se$aration o

the baby rom $arents.

;escribe

ssessed that*

they are an ious.

> $lained

re(ardin( the need orhos$itali:ation and

treatment.

%eassured the

$arents by introducin(

same diseased babies

#ho are re(ained health.

> $lained

about the need o

se$aration o the baby

rom $arents.

;escribed

Parents are

ree rom an iety as

e"idenced by (ood

interaction o $arents #ith other

$eo$le and

im$ro"ed acial

e $ression.


24/27

sad and

#orried.

about the treatment and

ollo# u$ care.

Pro"ide

$sycholo(ical su$$ortto the $arents

about the treatment and

ollo# u$ care in detail.

Pro"ided

$sycholo(ical su$$ort tothe $arents.

ASS)SSM)

NT

N2RSIN

G

%IAGN

OSIS

PLANNING

IMPL)M)N

TATION

)-AL2A

TION OB )CTI

-)

INT)R-)N

TIONS

O> e($"ve

da$a:

S in is dry

and scaly.

Baby had +,-

e$isodes o

%is or

im$aired

s in

inte(rity

related to

dry and

Baby #ill

achie"e

and

maintain

(ood s in

te ture and

%eassess the

s in

condition.

Chec or the

s in tur(or

and te ture.

S in is dry

and scaly.

Baby has $oor

tur(or.

BabyLs

s in

te ture

and tur(or

im$ro"ed

to


25/27

diarrhea scaly

s in.

tur(or. "oid

en"ironment

al irritants.

$$ly(lycerin or

s in.

dminister

$rescribed

dru(s

$$lied

(lycerin to

maintain s in

moistness.

dministered

I7& to

maintain

hydration o

the s in.

si(ni icant

le"el.

ASS)SSM)NT

N2RSING

%IAGNOSIS

PLANNING IMPL)M)N

TATION

)-AL2ATION

OB )CTI-)

INT)R-)NTIONS

O> e($"ve

da$a

Baby is one

month old

and e$t in

I7 line to

maintain

Hi(h ris

or

nosocomi

al

in ection

related to

immature

Baby #ill

be ree

rom

$otential

in ections.

ssess or

any in ection

a ter the

disease

occurrences.

ssess the

immuni:atio

Baby is ree

rom

ha:ardous

in ection.

Baby recei"ed

)P7 and

Baby is

$re"ented

rom

nosocomi

al

in ections


26/27

hydration

le"el .

immune

mechanis

m.

n status o

the baby.

Maintain the

ase$tic $recautions

durin(

administratio

n o

medication

and other

$rocedures.

ee$ the

child clean

and hy(iene.

%estrict the

"isitors.

>ducate the

$arents

re(ardin( the

im$ortance

o

BC@ "accines

at birth.

Maintained

the ase$tic $recautions

durin(

administration

o medication

and other

$rocedures.

Maintained

the hy(iene o

the baby.

%estricted all

the "isitors

>ducated the

$arentsre(ardin( the

im$ortance o

immuni:ation

o the baby in

$re"entin( the


27/27

immuni:atio

n o the baby

in $re"entin(

thein ections.

in ections.

Documents

case presentation on Acute gastro enteritis with moderate Dehydration.docx