Personal Data

Name: Amistad, Limuel Tamayo

Age: 1 year 10 months old
Birthdate: 03-22-10
Sex: Male
Religion: Roman Catholic

Chief Complaints:
Vomiting


Final Diagnosis:
Acute Gastroenteritis with moderate dehydration, Acute Bronchopneumonia


I. Family Background
This is a case of a 1 year 10 months old male patient, Limuel Tamayo Amistad, admitted at
Pines City Doctors Hospital on February 11, 2012at 3:05 PM with an admitting diagnosis of
acute gastroenteritis with moderate dehydration and congenital heart disease. Hes the first
child of Mr. and Mrs. Slim Amistad. They are currently residing at 27 A Bayan Park, Aurora
Hill, and Baguio City.

II. Development Data (based on Havighurst and Eriksons life and developmental
task/psycho)

According to Erik Eriksons stage of development, Limuel Tamayo Amistad belongs to
early childhood and has a central task of autonomy versus shame and doubt. He indicate
positive resolution of self-control without loss of self-esteem, ability to cooperate and to
express oneself most specially to his mother, grandmother and primary care takers.

III. Health History
A) History of Past Illness and Present Illness

Past Illness History:
Limuel was diagnosed with congenital heart disease.

Present Illness History:
Patient has congenital heart disease, has episode of vomiting not accompanied by
fever and abdominal pain, stool is watery, patient had occasional cough few days.


















B) Pathophysiology of Present Illness/Surgeries

Gastroenteritis


















































Predisposing
Factors

Etiology Factors

Age
Lifestyle-improper
prepared foods
-contaminated
water
Poor sanitation
Unknown

Diarrheal
Osmotic


Motile

Microorganisms

Cytotoxin

Enterocyte

Affects the
predominant
cells in the
small
intestine
Caused by
intestinal
motility
disorders
May produce
toxins that
facilitates
infection
Production
by
bacteria
Excessive
intake or
diminished
absorption
Results in
mucosal cells
destruction
that leads to
bloody stools
with
inflammatory
cells
Signs and Symptoms
Nausea and vomiting
Diarrhea
Loss of appetite
Fever
Abdominal pain
Weakness

Etiologic factors are usually unknown, but there are certain predisposing factors which includes
the age, lifestyle and poor sanitation. There may lead then to diarrheal which may possibly leads
to osmotic, motile, cytotoxin and affected enterocyte. These results from the presence of bacteria
especially in the GI tract. Signs and symptoms includes nausea and vomiting, diarrhea (watery
stool), loss of appetite, fever, abdominal pain and weakness.






C) Inclusive Period of Hospitalization
Admission Date: February 11, 2012 at 3:05 Pm

D) Health Agency
Patient was admitted in Pines City Doctors Hospital located at Magsaysay
Avenue, Baguio City.

IV. Medical treatment and management inclusive procedures and its implication to nursing
A. Medical Treatment
Chloramphenicol 150 mg Iv q 6 hours
B. Management including procedures and its implication to nursing
Vital signs assessment
-Every 2 hours to check or monitor the function of the body, general and note
progress on the patients condition.
Positioning the patient to more comfortable position
-To facilitate comfort and relaxation of the patient and to facilitate easy breathing of
the child.
Physical examination
-To establish nursing diagnosis and interventions and to determine the general health
status of the patient. It is also done to detect some abnormalities or deficiencies.
Urinalysis
Macroscopic examination:
Color: Yellow
Transparency: Slight turbid
Reaction: Acidic
Specific gravity: 1.015
Albumin:Negative
Sugar: Negative

Microscopic Examination:

Epithelial cells: Moderate
Prater/ PO4: Occasional
Mucous Thread: Occasional
WBC/ Pus Cells: 1-3
RBC: 0-1
Bacteria: Occasional

-The result is normal. Urinalysis provides baseline data about the patients health. It is performed
to assess the abnormal substances which- has accumulated in the urine.

Hematology Test
Results Normal Values
Hematocrit 0.68 0.42-0.53
Hemoglobin 226 g/L 155+/- 20g/L
WBC count 21.6 x

/L 5-10 x

/L
Platelet count Adequate 150-450 x

/L
-The result of the hematology test of the patient indicates elevated hematocrit and hemoglobin
which signifies dehydration and polycythemia, also may signifies that there is an increased
volume of cell in 100 ml of blood. It also increases white blood cell count which indicates
infection.

Radiologic Result
-Perililar haziness is noted in both lungs
-Heart is not enlarged however appears globular shape
-bones are intact

Schillings Differential Count
Result Normal Values
Neutrophilic Segmenters 0.91 0.43-0.76
Lymphocytes 0.06 0.17-0.41
Monocytes 0.03 0.04-0.10
RBC Morphology: Mostly normocytic, normochromic

-The schillings differential count of the patient indicates an elevated neutrophilic segmenters
which may signifies acute bacterial infection, tumor inflammation, stress or drug reaction. Also
indicates decreased lymphocytes and monocytes which may signifies aplastic anemia, leukemia,
systemic lupus erythematosus and immunodeficiency and usage of corticosteroidsmof
medications. This test is used to measure the 24 hour urinary excretion of labeled vitamin B12
and to document decrease absorption of vitamin B12.

Fecalysis
Microscopic Examination:
Macroscopic Examination:
Color: Yellow
Consistency: Semi- formed

Ova or Parasites: None found
Cyst or trophozoites: None FOund

-Fecalysis provides baseline data about the patients health. It is perform to detect presence of
abnormal substance like bacteria in the stool. The result is not normal. Normally the stools
consistency should be formed.


























VII. Evaluation and Implication of the Study to:

A) Nursing Practice:
The hope and intent of the study was to boolster or repute current interventions
currently done by the nursing profession and it seeks to validate, what is currently done to
intercede and may be an avenue providing and finding various types of intervention of care
which may be provided to same type patients and how they respond to those various types of
intervention:
My patient is Limuel Amistad, male, 1 year and 10 months old and was admitted last
February 11, 2012at 3:05 PM due to vomiting. He was diagnosed to have acute
gastroenteritis with moderate dehydration and acute bronchopneumonia and has a congenital
heart disease; transposition of great vessels, pulmonary HPN, and patent foramen oral.
I managed my nursing interventions by means of vital signs taking and recording,
rendering bedside care, monitoring IV replacement therapy, do bronchial tapping, promoted
rest and comfort, attended to needs, seen at intervals and ensured safety. I also encouraged
the care provider to give warm fluid to the child and also for the mother to give child foods
rich in vitamin C. I also give health teaching regarding the proper care of a child suffering
from acute gastroenteritis and acute bronchopneumonia.

B) Nursing Education:
Through this study, some of my questions regarding the disease especially acute
bronchopneumonia and acute gastroenteritis was answered. It broadens and appends my
knowledge about the condition, most especially the causes and factors associated to the
development and occurrence of the said disease. It also enhances my communication and
interaction skills, same as through with provision of comfort, care and therapeutic
interventions.

C) Nursing Research
Researchers done on the past regarding the treatment of acute gastroenteritis and
acute bronchopneumonia are still being utilize at the hospital at present. The nurse should
study research finding and utilize it in practice. It will also serves as a baseline for
promoting treatment and recovery of the patient.
In relation to this case, I want to dig deeper on the ff:
Possible complications of the condition if left untreated
Incidence and occurrence of the condition among pedia.
Nature of the problem

VIII. Referral and Follow-up
Patient Limuel Tamayo Amistad is still confined at Pines City Doctor Hospital for further
care and management. The patient is under the care of Dotora Loria, M.