CASE PRESENTATION

on
Acute Gastroenteritis with
Moderate Severe
Dehydration
Group 5
Somoray, Jude Edmund
Sosing, Melissa
Sumpingan, SIttie Ainah
Tan, Ruel
Tenedero, Daina Rose
Tome, Liezel
Zaspa, Kenneth

LEARNING OBJECTIVES
General Objective:
This case presentation aims to identify and determine the general health problem and
needs of the patient with Acute Gastroenteritis with Moderate Severe Dehydration. This
presentation also intends to help promote health and medical understanding of such
condition through the application of the nursing skills and for the students to gain needed
knowledge, skills and attitude in dealing with clients with pneumonia.
Specific Objectives:
The group presenters will be able to:
KNOWLEDGE:

Present a pediatric comprehensive health history of the patient: patients personal

profile, chief complaints, present illness, past medical history, feeding history, and
growth and development history through visual presentation.

Know the latest facts and keep ourselves updated with the new information about
Acute Gastroenteritis with Moderate Severe Dehydration.

Present a case for sequential changes in the normal anatomy and physiology of the
systems involved in the disease process stating its implication on the laboratory
findings.

Describe the disease process and identify medical management through presenting
the pathophysiology, medical and nursing interventions.

Discuss the scientific action, indication, side effects, contraindication most especially
the nursing responsibilities of the different drugs used in treating patients disease.

SKILLS:

Demonstrate a thorough physical assessment and review of system for the comparison
of patients condition from the normal anatomy and physiology.

Implement medical and nursing interventions appropriately indicated to clients with

Acute Gastroenteritis with Moderate Severe Dehydration.

Master the pharmacologic and therapeutic regimen for the patients with Acute
Gastroenteritis with Moderate Severe Dehydration.

Formulate nursing diagnosis and care plan through obtaining comprehensive health
history of the patient.

Evaluate SO and patients responses to the care rendered and revise care as
necessary to give appropriate and quality nursing care.

ATTITUDE:

Establish a collective sense of teamwork through proper communication within the

group to promote a harmonious relationship.

Show confidence while presenting our part in the case presentation in order for us to
catch their attention and for them to listen and actively participate during the
presentation.

Be open to the suggestions, questions and comments from the students and clinical
instructors for the improvement of the case presentation.

Motivate students to present their cases in a creative way of presentation after

observing our case presentation.

Observe confidentiality whatever been discussed during the case presentation for the
right of the patients.

INTRODUCTION
Our group is assigned to have a case study on a patient admitted in the Pediatrics
Ward of Northern Samar Provincial Hospital. Due to confidentiality purposes, we chose to
address our patient as Patient G5.
Patient G5 is a 1 year and 4 months old female infant, a resident of Brgy. Sampaguita,
Catarman, Northern Samar. She was admitted on February 2, 2013 at 02:10 pm with a
medical diagnosis of Acute Gastroenteritis with Moderate Severe Dehydration.
Gastroenteritis is
the gastrointestinal

medical

tract that

intestine ("entero"-),

involves

both

in

some

resulting

and abdominal pain

and

condition

characterized

by inflammation ("-itis")

the stomach ("gastro"-)

combination

cramping. Gastroenteritis

has

also

and

of

the small

of diarrhea, vomiting,
been

referred

to

as gastro, stomach bug, and stomach virus. Although unrelated to influenza, it has also been
called stomach flu and gastric flu.
Globally,

most

cases

in

children

are

caused

by rotavirus. In

adults, norovirus and Campylobacter are more common. Less common causes include
other bacteria (or their toxins) and parasites. Transmission may occur due to consumption of
improperly prepared foods or contaminated water or via close contact with individuals who
are infectious.
The foundation of management is adequate hydration. For mild or moderate cases,
this can typically be achieved via oral rehydration solution. For more severe cases,
intravenous fluids may be needed. Gastroenteritis primarily affects children and those in the
developing world.
Signs and symptoms
Gastroenteritis

typically

involves

both diarrhea and vomiting, or

less

commonly,

presents with only one or the other. Abdominal cramping may also be present. Signs and
symptoms usually begin 1272 hours after contracting the infectious agent. If due to a viral
agent, the condition usually resolves within one week. Some viral causes may also be
associated with fever, fatigue, headache, and muscle pain. If the stool is bloody, the cause
is less likely to be viral and more likely to be bacterial. Some bacterial infections may be
associated with severe abdominal pain and may persist for several weeks.
Children infected with rotavirus usually make a full recovery within three to eight
days. However, in poor countries treatment for severe infections is often out of reach and
persistent diarrhea is common. Dehydration is a common complication of diarrhea, and a
child with a significant degree of dehydration may have a prolonged capillary refill, poor skin

turgor, and abnormal breathing. Repeat infections are typically seen in areas with poor
sanitation, and malnutrition, stunted growth, and long-term cognitive delays can result.
Reactive

arthritis occurs

in

1%

of

people

following

infections

with Campylobacter species, and Guillain-Barre syndrome occurs in 0.1%. Hemolytic uremic
syndrome (HUS) may occur due to infection with Shiga toxin-producing Escherichia
coli or Shigella species, causing low platelet counts, poor kidney function, and low red blood
cell count (due to their breakdown). Children are more predisposed to getting HUS than
adults.[12] Some viral infections may produce benign infantile seizures.
Cause
Viruses (particularly rotavirus)

and

the

bacteria Escherichia

coli and Campylobacter species are the primary causes of gastroenteritis. There are,
however, many other infectious agents that can cause this syndrome. Non-infectious causes
are seen on occasion, but they are less likely than a viral or bacterial cause. Risk of infection
is higher in children due to their lack of immunity and relatively poor hygiene.
Viral
Rotavirus, norovirus, adenovirus,

and astrovirus are

known

to

cause viral

gastroenteritis. Rotavirus is the most common cause of gastroenteritis in children, and

produces similar incidence rates in both the developed and developing world. Viruses cause
about 70% of episodes of infectious diarrhea in the pediatric age group. Rotavirus is a less
common cause in adults due to acquired immunity.
Norovirus is the leading cause of gastroenteritis among adults in America, causing greater
than 90% of outbreaks. These localized epidemics typically occur when groups of people
spend time in close physical proximity to each other, such as on cruise ships, in hospitals, or in
restaurants. People may remain infectious even after their diarrhea has ended. Norovirus is
the cause of about 10% of cases in children.
Bacterial
In

the

developed

world Campylobacter

jejuni is

the

primary

cause

of

bacterial

gastroenteritis, with half of these cases associated with exposure to poultry. In children,
bacteria are the cause in about 15% of cases, with the most common types
being Escherichia coli, Salmonella, Shigella, and Campylobacter species. If food becomes
contaminated with bacteria and remains at room temperature for a period of several hours,
the bacteria multiply and increase the risk of infection in those who consume the food. Some
foods commonly associated with illness include raw or undercooked meat, poultry, seafood,
and eggs; raw sprouts; unpasteurized milk and soft cheeses; and fruit and vegetable
juices. In the developing world, especially sub-Saharan Africa and Asia, cholera is a

common cause of gastroenteritis. This infection is usually transmitted by contaminated water

or food.
Toxigenic Clostridium difficile is an important cause of diarrhea that occurs more often in the
elderly. Infants can carry these bacteria without developing symptoms. It is a common
cause of diarrhea in those who are hospitalized and is frequently associated with antibiotic
use. Staphylococcus aureus infectious diarrhea may also occur in those who have used
antibiotics. "Traveler's diarrhea" is usually a type of bacterial gastroenteritis. Acid-suppressing
medication appears to increase the risk of significant infection after exposure to a number of
organisms, including Clostridium difficile, Salmonella, and Campylobacter species. The risk is
greater in those taking proton pump inhibitors than with H2 antagonists.
Parasitic
A number of protozoans can cause gastroenteritis most commonly Giardia lamblia
but Entamoeba histolytica and Cryptosporidium species have also been implicated. As a
group, these agents comprise about 10% of cases in children. Giardia occurs more
commonly in the developing world, but this etiologic agent causes this type of illness to some
degree nearly everywhere. It occurs more commonly in persons who have traveled to areas
with high prevalence, children who attend day care, men who have sex with men, and
following disasters.
Transmission
Transmission may occur via consumption of contaminated water, or when people share
personal objects. In places with wet and dry seasons, water quality typically worsens during
the wet season, and this correlates with the time of outbreaks. In areas of the world with
seasons, infections are more common in the winter. Bottle-feeding of babies with improperly
sanitized bottles is a significant cause on a global scale. Transmission rates are also related to
poor hygiene, especially among children, in crowded households, and in those with preexisting poor nutritional status. After developing tolerance, adults may carry certain
organisms without exhibiting signs or symptoms, and thus act as natural reservoirs of
contagion. While some agents (such as Shigella) only occur in primates, others may occur in
a wide variety of animals (such as Giardia).
Non-infectious
There are a number of non-infectious causes of inflammation of the gastrointestinal
tract. Some of the more common include medications (like NSAIDs), certain foods such
as lactose (in those who are intolerant), and gluten (in those with celiac disease). Crohn's
disease is also a non-infection source of (often severe) gastroenteritis. Disease secondary
to toxins may also occur. Some food related conditions associated with nausea, vomiting,

and diarrhea include: ciguatera poisoning due to consumption of contaminated predatory

fish, scombroid associated with the consumption of certain types of spoiled fish, tetrodotoxin
poisoning from the consumption of puffer fish among others, and botulism typically due to
improperly preserved food.
Prevention
Lifestyle
A supply of easily accessible uncontaminated water and good sanitation practices are
important for reducing rates of infection and clinically significant gastroenteritis. Personal
measures (such as hand washing) have been found to decrease incidence and prevalence
rates of gastroenteritis in both the developing and developed world by as much as
30%. Alcohol-based gels may also be effective. Breastfeeding is important, especially in
places with poor hygiene, as is improvement of hygiene generally. Breast milk reduces both
the frequency of infections and their duration. Avoiding contaminated food or drink should
also be effective.
Vaccination
Due to both its effectiveness and safety, in 2009 the World Health Organization
recommended

that

the rotavirus

vaccine be

offered

to

all

children

globally. Two

commercial rotavirus vaccines exist and several more are in development. In Africa and Asia
these vaccines reduced severe disease among infants and countries that have put in place
national immunization programs have seen a decline in the rates and severity of disease. This
vaccine may also prevent illness in non-vaccinated children by reducing the number of
circulating infections. Since 2000, the implementation of a rotavirus vaccination program in
the United States has substantially decreased the number of cases of diarrhea by as much
as 80 percent. The first dose of vaccine should be given to infants between 6 and 15 weeks
of age. The oral cholera vaccine has been found to be 5060% effective over 2 years.
Management
Gastroenteritis is usually an acute and self-limiting disease that does not require
medication. The preferred treatment in those with mild to moderate dehydration is oral
rehydration therapy (ORT). Metoclopramide and/or ondansetron, however, may be helpful
in some children, and butylscopolamine is useful in treating abdominal pain.
Rehydration
The primary treatment of gastroenteritis in both children and adults is rehydration. This is
preferably achieved by oral rehydration therapy, although intravenous delivery may be
required if a there is a decreased level of consciousness or if dehydration is severe. Oral

replacement therapy products made with complex carbohydrates (i.e. those made from
wheat or rice) may be superior to those based on simple sugars. Drinks especially high in
simple sugars, such as soft drinks and fruit juices, are not recommended in children under 5
years of age as they may increase diarrhea. Plain water may be used if more specific and
effective ORT preparations are unavailable or are not palatable. A nasogastric tube can be
used in young children to administer fluids if warranted.
Dietary
It is recommended that breast-fed infants continue to be nursed in the usual fashion, and
that formula-fed infants continue their formula immediately after rehydration with
ORT. Lactose-free or lactose-reduced formulas usually are not necessary. Children should
continue their usual diet during episodes of diarrhea with the exception that foods high
in simple sugars should be avoided. The BRAT diet (bananas, rice, applesauce, toast and
tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over
normal feeding. Some probiotics have been shown to be beneficial in reducing both the
duration of illness and the frequency of stools. They may also be useful in preventing and
treating antibiotic associated diarrhea. Fermented milk products (such as yogurt) are
similarly beneficial. Zinc supplementation appears to be effective in both treating and
preventing diarrhea among children in the developing world.
Antiemetics
Antiemetic medications may be helpful for treating vomiting in children. Ondansetron has
some utility, with a single dose being associated with less need for intravenous fluids, fewer
hospitalizations, and decreased vomiting. Metoclopramide might also be helpful. However,
the use of ondansetron might possibly be linked to an increased rate of return to hospital in
children. The intravenous preparation of ondansetron may be given orally if clinical
judgment warrants. Dimenhydrinate, while reducing vomiting, does not appear to have a
significant clinical benefit.
Antibiotics
Antibiotics are not usually used for gastroenteritis, although they are sometimes
recommended if symptoms are particularly severe or if a susceptible bacterial cause is
isolated or suspected. If antibiotics are to be employed, a macrolide (such as azithromycin)
is

preferred

over

a fluoroquinolone due

to

higher

rates

of

resistance

to

the

latter. Pseudomembranous colitis, usually caused by antibiotic use, is managed by

discontinuing

the

causative

agent

and

treating

it

with

either metronidazole or vancomycin. Bacteria and protozoans that are amenable to

treatment

include Shigella Salmonella

typhi, and Giardia species. In

those

with Giardia species or Entamoeba histolytica, tinidazole treatment is recommended and

superior to metronidazole. The World Health Organization (WHO) recommends the use of
antibiotics in young children who have both bloody diarrhea and fever.
Antimotility agents
Antimotility medication has a theoretical risk of causing complications, and although clinical
experience has shown this to be unlikely, these drugs are discouraged in people with bloody
diarrhea or diarrhea that is complicated by fever. Loperamide, an opioid analogue, is
commonly

used

for

the

symptomatic

treatment

of

diarrhea. Loperamide

is

not

recommended in children, however, as it may cross the immature bloodbrain barrier and
cause toxicity. Bismuth subsalicylate, an insoluble complex of trivalent bismuth and salicylate,
can be used in mild to moderate cases, but salicylate toxicity is theoretically possible.
Epidemiology
It is estimated that three to five billion cases of gastroenteritis occur globally on an
annual basis, primarily affecting children and those in the developing world. It resulted in
about 1.3 million deaths in children less than five as of 2008, with most of these occurring in
the world's poorest nations. More than 450,000 of these fatalities are due to rotavirus in
children under 5 years of age. Cholera causes about three to five million cases of disease
and kills approximately 100,000 people yearly. In the developing world children less than two
years of age frequently get six or more infections a year that result in clinically significant
gastroenteritis. It is less common in adults, partly due to the development of acquired
immunity.
In 1980, gastroenteritis from all causes caused 4.6 million deaths in children, with the
majority occurring in the developing world. Death rates were reduced significantly (to
approximately 1.5 million deaths annually) by the year 2000, largely due to the introduction
and widespread use of oral rehydration therapy. In the US, infections causing gastroenteritis
are the second most common infection (after the common cold), and they result in
between 200 and 375 million cases of acute diarrhea and approximately ten thousand
deaths annually, with 150 to 300 of these deaths in children less than five years of age.

PATIENTS PROFILE
NAME:

Patient G5

AGE:

1 yr. and 4 mos.

GENDER:

Female

BIRTHDATE:

September 25, 2011

BIRTHPLACE:

Brgy. Sampaguita, Catarman, Northern Samar

ADDRESS:

Brgy. Sampaguita, Catarman, Northern Samar

RELIGION:

Iglesia ni Cristo

DATE OF ADMISSION:

February 2, 2013

TIME OF ADMISSION:

02:10 pm

ADMITTING DIAGNOSIS:

Acute Gastroentiritis with Moderate Severe Dehydration

ATTENDING PHYSICIAN:

Dr. J. Nochete

DIET:

Breastfeeding with Strict Aspiration Precaution

CHIEF COMPLAINT:

Low Bowel Movement

MOTHERS NAME:

Vivian Cornico

FATHERS NAME:

Sandy Cornico

SOURCE OF INFORMATION:

Mother

DATE OF INTERVIEW:

February 5, 2013

CASE NUMBER:

160127

PEDIATRIC COMPREHENSIVE HEALTH HISTORY

CHIEF COMPLAINT:
LBM
PRESENT ILLNESS:
Prior to admission, according to mother the patient suffers from LBM for 3 times a day
with yellow, watery stool. According also to the mother, the patient always cries whenever
she feels pain in her stomach. They dont know what to do so they decided to go to the

hospital and was admitted last February 2, 2013 and diagnosed with Acute Gastroenteritis
with Moderate Severe Dehydration.
PAST MEDICAL HISTORY:
Prenatal:
The patients mother states that she had her skin infection when she was 9 months
pregnant and did not consult a doctor. She didnt take any medication and just
treated it with coconut oil. She also states that she dont experience any illness during
her pregnancy except for her skin infection. She doesnt have any prenatal checkup
during her pregnancy.
Birth History:
At birth, the patient hasnt suffered from any illness or disease.
Natal:
She states that she didnt feel any difficulty during her delivery. She delivered her child
in their home with a trained hilot.
Neonatal:
She doesnt have any experiences of illness during her postpartum period.
FEEDING HISTORY:
Infancy:
She said that she breastfed her baby up to 8 months old. She started feeding her baby
with semi-solid food when her baby was 6 months old. She fed her baby with soft
biscuits, porridge, and meat. She didnt give any vitamin supplement because of lack
of income.
Childhood:
Clients mother states that when her baby got 1 year old, herbaby didnt want to eat
soft food anymore like porridge, breads, etc. Her child started to like toasted bread.
GROWTH AND DEVELOPMENT HISTORY:
Physical Growth:
First tooth eruption when her baby was 6 months old. Her baby was still starting to walk.

Developmental Milestones:
States that her baby started to sit with support when her baby was 4 months old and
started to stand with support at 4 months old. Her baby can speak now, mama,
tata and bebe.
SOCIAL DEVELOPMENT:
The mother stated that her baby usually sleeps at night at around 8 oclock and
waking up at 6am. Her child doesnt want to sleep during siesta time. She said that her baby
just want to play with them.
CHILDHOOD ILLNESS:
Patient did not experience any childhood illness as stated by the mother except for
the usual cough and common colds.
IMMUNIZATION:
Her baby did not get immunized since birth.
SCREENING PROCEDURE:
No screening done.
OPERATIONS/INJURIES/HOSPITALIZATIONS:
According to mother, her child had first hospitalized last February, 2012, when her
baby was 5 months old with the same chief complaint.
ALLERGIES:
There are no known allergies discovered by her mother, either in any food,
environment or medication.
FAMILY HISTORY:
The mother of the patient is 19 years old, and stopped at an elementary level of
education, while her father is 26 years old and stopped at a high school level of education.
The mother is a housewife, while the father is a farmer. According to the mother, they dont
have any history of allergies and illnesses or diseases.

REVIEW OF SYSTEM
GENERAL APPEARANCE:
Patient is lying on bed wearing pink dress and diapers with white shorts. She appears
restless. She has an ongoing IVF of D5 0.3 NaCl at 36 mcgtts/min at Left cephalic vein.
Vital Signs: Temperature 37.6 oC
Respiratory Rate 56 breaths per minute
Apical Pulse 140 bpm
INTEGUMENTARY:
> Brown Complexion
> Warm to Touch
> Soft, Smooth Skin
> (+) Scars
> (-) Skin Lesions
HAIR:
> Thin, Black, Soft, Shiny Hair
> Evenly Distributed on Scalp
> Absence of Lice
NAILS:
> No Clubbing Noted
> Dirty, Untrimmed Nails
> Pink Nail Beds
> Intacked Cuticle
HEENT:
Head
> Sunken Fontanelles
> Absence of Nodules, Masses or Tenderness
> Symmetric
Eyes
> Sunken Eyeballs
> PERRLA
> Symmetric
Ears

> Symmetric
> Auricle Aligned with Outer Canthus of Eye
> Able to Hear
> Proportional to the size of head
> Absence of Discharge, Nodules, Lesions, Masses
Nose and Sinuses
> Nasal Mucosa is pink and moist
> (+) Nasal Flaring
Tongue
> Even Pink Color
> Symmetric
MOUTH and PHARYNX
> Slightly Pale
> Dry Lips
> Without Lesions
> Incomplete Teeth
NECK
> Symmetric
> Absence of Nodules and Masses
> Non Palpable Lymph Nodes
BREAST
> Symmetric
> Absence of Masses or Tenderness
RESPIRATORY
> RR: 56 breaths per min
> (+) Crackles, Wheezes
CARDIOVASCULAR
> AP: 140 bpm
> Absence of Adventitious Sounds
> Normal Heart Beat
MUSCOSKELETAL
> Body Weakness

> Irritable
> Restless
> Can Sit Alone
> Can Stand Up with Help of SO
> Firm and Non Tender
> Extremities Symmetric
> No Deformities
GASTROINTESTINAL
> Round and Distended Abdomen
> No Reactive Bowel Sounds
> (-) Flatus
> (+) Bowel Movement
> Stool: Yellowish and Watery

COURSE IN THE WARD

Date
February 2, 2013

Medical Management
>

Patient

admitted

at

Indication

Patients Response

was > Patient was admitted >

Patient

was

the due to LBM. Patient was brought to Pediatrics

Emergency Room to assesses by the Doctor. Ward still in LBM.

the Pediatrics Ward.

Past

medical

history > Comfortably lying

and

present

history

health on bed.

was

taken. >

Significant

others

Patient with significant provided the needed

others were oriented to treatment
the unit.
> Secure consent.

and

laboratory exams.

> Consent care signed. > Consent secured.

Informed

attending

physician and SO about

the admission.
> TPR q8h

>

To

determine

abnormalities

any > V/S monitored for

in

the any abnormalities.

patients vital signs.

> DFA

>

To

determine

discomforts

or

any >

Patient

other instructed

complications.

and

SO

that

she

can eat any meal as

she tolerates.

>

Diagnostics: >

CBC/PLT, U/A, F/A

Need

to

be > Diagnostics done.

facilitated immediately
to serve for base line
data and for treatment
management.

> Start with Plain LR > For IV Homeostasis

> To replace fluid loss

120 cc FD, then IVF of

due to LBM.

1 L D5 0.3 NaCl at 36
mcgtts,

V/V

replacement of PLR.
> Paracetamol 60 mg >
IVTT q4h.

Analgesic

decrease pain.

> Cefuroxime 200 mg >

IVTT q8h.

to > Pain decreases.

Antibiotic, > Still having LBM.

Bactericidal
synthesis

inhibits

of

bacterial

cell wall.
> V/S q2h

>

To

determine

abnormalities

in

any > V/S monitored for

the any abnormalities.

patients vital signs.

February 3, 2013

> Continue prescribed >

For

continuous > Still having LBM.

management.

management.

> Monitor V/S q4h.

>

To

determine

abnormalities

in

any > V/S monitored for

the any abnormalities.

patients vital signs.

February 4, 2013

> Start with Salbutamol > Salbutamol was given > Patient suffers from
Nebulization q15 x 3 as

treatment

for cough

doses, then Salbutmol bronchospasm

+

due

which environment

Ipratropium improve ventilation.

to

in

the

hospital and to be

nebulization q4h.

followed up by Dr.
Nochete for further
evaluation.

> Continue meds.

>

For

continuous > Still having LBM.

management.
> Serve O2 Inhalation >

To

improve >

via nasal cannula 1-2 ventilation.

Ventilation

provided.

LPM.
> Close watch.
February 5, 2013

> Refer PCOD.

>

For

further > Having DOB.

examination.
>

See

for

CXR

ordered.

as > To serve as a patients >

Results

to

be

baseline data and as a followed up.

guide

for

the

pts

management as well.
> Start Gentamicin 18 > Antibiotic that treats
mg IVTT q12h ( ).
>

Salbutamol

serious infections.
+ >

An

anticholinergic

Ipratropium

agent

that

inhibits

nebulization q6h.

vagally-mediated
reflexes

by

antagonizing the action

of acetylcholine
February 6, 2013

> Continue present IV >

For

continuous > Patient decreases

meds.

management.

> Continue 02.

>

For

LBM and starting to

continuous have

management.
> Monitor V/S q1h.

>

To

but

determine

abnormalities
> Start Hydrocortisone >

in

24 mg IVTT q6h.

Initiates

the
many

complex reactions that

are responsible for its
anti-inflammatory,

stools

she

any experience DOB.

patients vital signs.

09:30 am

normal

still

immunosuppressive and
salt-retaining actions.
> Budesonide Respule > Inhalation suspension:
1 Respule q12h.

maintenance
treatment

and

prophylaxis therapy of
asthma in children 12
mos. 18 years.
> Continue meds.

>

For

continuous

management.
February 7, 2013

> Continue meds.

>

For

continuous > Patient does not

management.
> O2 inhalation at

>

To

2 LPM.

ventilation.

> Monitor V/S q4h.

>

To

experience LBM but

improve experiences DOB.

determine

abnormalities

in

any
the

patients vital signs.

> Repeat CBC q4h.

> Make sure to report

AP

for

any

abnormalities for further

evaluation

and

treatment.
> Monitor O2 at 1-2 >
LPM

via

To

improve

nasal ventilation.

cannula.
February 8, 2013

> Continue meds.

>

For

continuous > Patient is having

management.
>

Continue

O2 >

inhalation.
12 NN

To

DOB

ventilation.

specific packed WBC AP

any

for 4 then after blood for

further

abnormalities
evaluation

and treatment.

> Hold IVF when BT.

> Furosemide 2.5 mg > Inhibits the absorption
IVTT post BT.

of Na and Cl from the

proximide

secured

improve with WBC after BT.

> Prepare 55 cc type > Make sure to report to

typing, close watch.

and

and

distal

tubules and ascending

limb of the loop of

Henle leading to a Na
rich diuresis.
> Repeat Hgb Hct q6h
post BT.
> Continue meds.

>

For

continuous

management.
February 9, 2013

> Still for BT.

> Patient is still for BT

> Continue meds.

>

For

continuous but the SO is well

management.

informed as ordered.

> Refer Hgb Hct q6h

for PCOD med.
February 10, 2013

> Continue meds.

>

For

continuous >

management.

Patient

and

follows

SO

doctors

orders.
February 11, 2013

> Continue meds.

>

For

continuous > Patient is already

management.
> Ferlin 1.0 mL OD PO.
08:00 pm

>

feeling better.

Prevention

&

treatment

of Fe

deficiency

anemia in

infants & child.

> Vit. C 1.0 mL OD PO.

>

Vitamin

which

fundamental
synthesis
and

of

in

is
the

collagen

intercellular

materials.
> Refused IVF follow
up.
February 12, 2013

> MGH

> Patient does not suffer > Patient does not

> Amoxicillin q8h x 7 from LBM and already have

days

have normal stools. She anymore

> Continue oral meds doesnt

at home.

the

disease

and

may

experience go home with good

DOB

anymore. prognosis with home

Instructed SO to comply meds

given

and

with home meds given ordered by the AP.

and

for

follow

up

checkup after 4 days.

LABORATORY TESTS
February 2, 2013

COMPLETE BLOOD COUNT

Parameters

Normal Values

Result

Interpretation

Hematocrit

0.30 0.32

0.34

Increased

White Cell Count

5- 10 x 109 L

3.7

Decreased

Neutrophils

0.55 0.75

0.56

Normal

Lymphocytes

0.35 0.55

0.44

Normal

February 6, 2013
URINALYSIS
Parameters

Result

Color

Yellow

Transparency

Turbid

Reaction

^.5

Specific Gravity

1.015

Protein

Sugar

Pus Cells

2.4

Epithelial Cells

++

Mucus Threas

Bacteria

++++

FECALYSIS
Parameters

Result

Color

Yellow

Consistency
Others:

Soft
Y Cells

Rare

Bacteria

++

February 7, 2013
COMPLETE BLOOD COUNT
Parameters

Normal Values

Result

Interpretation

Hematocrit

0.30 0.32

0.26

Decreased

White Cell Count

5- 10 x 109 L

9.9

Normal

Neutrophils

0.55 0.75

0.64

Normal

Lymphocytes

0.35 0.55

0.36

Normal

February 8, 2013
CROSS MATCHING FORM PACKED WBC

Parameters

Result

Blood Type

Serial Number

NVBSP 2013 2014

Volume

200 cc

Screening

NVSBSP Screened

Cross Matching

Compatible

February 9, 2013
HEMATOLOGY
Parameters
Hemoglobin

Normal Values

Result

Interpretation

120 150 g/L

121.18

Normal

ANATOMY AND PHYSIOLOGY

Introduction to the gastrointestinal system
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral
cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach
and intestines to the rectum and anus, where food is expelled. There are various accessory
organs that assist the tract by secreting enzymes to help break down food into its
component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have
important functions in the digestive system. Food is propelled along the length of the GIT by
peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break food down into nutrients,
which can be absorbed into the body to provide energy. First food must be ingested into the
mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in
the stomach and small intestine where proteins, fats and carbohydrates are chemically

broken down into their basic building blocks. Smaller molecules are then absorbed across
the epithelium of the small intestine and subsequently enter the circulation. The large
intestine plays a key role in reabsorbing excess water. Finally, undigested material and
secreted waste products are excreted from the body via defecation (passing of feces).
In the case of gastrointestinal disease or disorders, these functions of the
gastrointestinal tract are not achieved successfully. Patients may develop symptoms
of nausea, vomiting, diarrhea, malabsorption, constipation or obstruction. Gastrointestinal
problems are very common and most people will have experienced some of the above
symptoms several times throughout their lives.

Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells, called
epithelium. The contents of the tube are
considered external to the body and are in
continuity with the outside world at the
mouth and the anus. Although each section
of the tract has specialized functions, the
entire tract has a similar basic structure with
regional variations.
The wall is divided into four layers as
follows:
Mucosa
The innermost layer of the digestive tract has specialized epithelial cells supported by
an underlying connective tissue layer called the lamina propria. The lamina propria contains
blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its
function, the epithelium may be simple (a single layer) or stratified (multiple layers).
Areas such as the mouth and esophagus are covered by a stratified squamous (flat)
epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or
glandular epithelium lines the stomach and intestines to aid secretion and absorption. The
inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas
of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of
smooth muscle which can contract to change the shape of the lumen.
Submucosa

The submucosa surrounds the muscularis mucosa and consists of fat, fibrous
connective tissue and larger vessels and nerves. At its outer margin there is a specialized
nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and
submucosa.
Muscularis externa
This smooth muscle layer has inner circular and outer longitudinal layers of muscle
fibers separated by the myenteric plexus or Auerbach plexus. Neural innervations control the
contraction of these muscles and hence the mechanical breakdown and peristalsis of the
food within the lumen.
Serosa/mesentery
The outer layer of the GIT is formed by fat and another layer of epithelial cells called
mesothelium.
Individual components of the gastrointestinal system
Oral cavity
The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified
squamous oral mucosa with keratin covering those areas subject to significant abrasion,
such as the tongue, hard palate and roof of the mouth. Mastication refers to the
mechanical breakdown of food by chewing and chopping actions of the teeth. The tongue,
a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is
also the sensing organ of the mouth for touch, temperature and taste using its specialized
sensors known as papillae.
Insalivation refers to the mixing of the oral cavity contents with salivary gland
secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays
a limited role in the digestion of carbohydrates. The enzyme serum amylase, a component of
saliva, starts the process of digestion of complex carbohydrates. The final function of the oral
cavity is absorption of small molecules such as glucose and water, across the mucosa. From
the mouth, food passes through the pharynx and esophagus via the action of swallowing.
Salivary glands
Three pairs of salivary glands communicate with the oral cavity. Each is a complex
gland with numerous acini lined by secretory epithelium. The acini secrete their contents into
specialized ducts. Each gland is divided into smaller segments called lobes. Salivation occurs
in response to the taste, smell or even appearance of food. This occurs due to nerve signals
that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each pair of
salivary glands secretes saliva with slightly different compositions.

Parotids

The parotid glands are large,

irregular shaped glands located
under the skin on the side of the
face. They secrete 25% of saliva.
They are situated below the
zygomatic

arch

(cheekbone)

and cover part of the mandible

(lower jaw bone). An enlarged
parotid gland can be easier felt
when one clenches their teeth. The parotids produce a watery secretion which is also rich in
proteins. Immunoglobins are secreted help to fight microorganisms and a-amylase proteins
start to break down complex carbohydrates.

Submandibular

The submandibular glands secrete 70% of the saliva in the mouth. They are found in the floor
of the mouth, in a groove along the inner surface of the mandible. These glands produce a
more viscid (thick) secretion, rich in mucin and with a smaller amount of protein. Mucin is a
glycoprotein that acts as a lubricant.

Sublingual

The sublinguals are the smallest salivary glands, covered by a thin layer of tissue at the floor
of the mouth. They produce approximately 5% of the saliva and their secretions are very
sticky due to the large concentration of mucin. The main functions are to provide buffers
and lubrication.
Esophagus
The esophagus is a muscular tube of approximately 25cm in length and 2cm in
diameter. It extends from the pharynx to the stomach after passing through an opening in
the diaphragm. The wall of the esophagus is made up of inner circular and outer longitudinal
layers of muscle that are supplied by the esophageal nerve plexus. This nerve plexus
surrounds the lower portion of the esophagus. The esophagus functions primarily as a
transport medium between compartments.
Stomach
The stomach is a J shaped expanded bag, located just left of the midline between the
esophagus and small intestine. It is divided into four main regions and has two borders called
the greater and lesser curvatures. The first section is the cardia which surrounds the cardial

orifice where the esophagus enters the stomach. The fundus is the superior, dilated portion of
the stomach that has contact with the left dome of the diaphragm. The body is the largest
section between the fundus and the curved portion of the J.
This is where most gastric glands are located and where most mixing of the food
occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are expelled
into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is
contracted into numerous longitudinal folds called rugae. These allow the stomach to
stretch and expand when food enters. The stomach can hold up to 1.5 liters of material. The
functions of the stomach include:
1. The short-term storage of ingested food.
2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some

absorption

of

substances such as alcohol.

Most of these functions are
achieved

by

the

secretion

of

stomach juices by gastric glands in

the body and fundus. Some cells
are responsible for secreting acid
and others secrete enzymes to
break down proteins.
Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages
approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileocaecal valve separating the ileum from the cecum. The small intestine is compressed into
numerous folds and occupies a large proportion of the abdominal cavity.
The duodenum is the proximal C-shaped section that curves around the head of the
pancreas. The duodenum serves a mixing function as it combines digestive secretions from
the pancreas and liver with the contents expelled from the stomach. The start of the jejunum
is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority
of digestion and absorption occurs. The final portion, the ileum, is the longest segment and
empties into the cecum at the ileocecal junction.
The small intestine performs the majority of digestion and absorption of nutrients. Partly
digested food from the stomach is further broken down by enzymes from the pancreas and

bile salts from the liver and

gallbladder.

These

secretions

enter

duodenum

the

at

the

Ampulla of Vater. After

further

digestion,

constituents
proteins,

food

such
fats,

as
and

carbohydrates are broken down to small building blocks and absorbed into the body's
blood stream.
The lining of the small intestine is made up of numerous permanent folds called plicae
circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by
epithelium with projecting microvilli (brush border). This increases the surface area for
absorption by a factor of several hundred. The mucosa of the small intestine contains several
specialized cells. Some are responsible for absorption, whilst others secrete digestive
enzymes and mucous to protect the intestinal lining from digestive actions.
Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like a
frame. It consists of the appendix, cecum, ascending, transverse, descending and sigmoid
colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm.
The cecum is the expanded pouch that receives material from the ileum and starts to
compress food products into fecal material. Food then travels along the colon. The wall of
the colon is made up of several pouches (haustra) that are held under tension by three thick
bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal matter
before it passes through the anorectal canal to the anus. Thick bands of muscle, known as
sphincters, control the passage of feces.
The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal
surface is flat with several deep intestinal glands. Numerous goblet cells line the glands that
secrete mucous to lubricate fecal matter as it solidifies. The functions of the large intestine
can be summarized as:
1. The accumulation of unabsorbed material to form feces.
2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal
gas.
3. Reabsorption of water, salts, sugar and vitamins.

Liver
The liver is a large, reddish-brown organ situated in the right upper quadrant of the
abdomen. It is surrounded by a strong capsule and divided into four lobes namely the right,
left, caudate and quadrate lobes. The liver has several important functions. It acts as a
mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several
metabolites including the breakdown of bilirubin and estrogen. In addition, the liver has
synthetic functions, producing albumin and blood clotting factors. However, its main roles in
digestion are in the production of bile and metabolism of nutrients. All nutrients absorbed by
the intestines pass through the liver and are processed before traveling to the rest of the
body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here,
bile salts break down lipids into smaller particles so there is a greater surface area for
digestive enzymes to act.
Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on the
posterior surface of the liver's right lobe. It consists of a fundus, body and neck. It empties via
the cystic duct into the biliary duct system. The main functions of the gall bladder are
storage and concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve
fat in the intestines. Bile is produced by the liver but stored in the gallbladder until it is
needed. Bile is released from the gall bladder by contraction of its muscular walls in response
to hormone signals from the duodenum in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its
head communicates with the duodenum and its tail extends to the spleen. The organ is
approximately 15cm in length with a long, slender body connecting the head and tail
segments. The pancreas has both exocrine and endocrine functions. Endocrine refers to
production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin,
glucagon and other substances and these are the areas damaged in diabetes mellitus. The
exocrine (secretrory) portion makes up 80-85% of the pancreas and is the area relevant to
the gastrointestinal tract.
It is made up of numerous acini (small glands) that secrete contents into ducts which
eventually lead to the duodenum. The pancreas secretes fluid rich in carbohydrates and
inactive enzymes. Secretion is triggered by the hormones released by the duodenum in the
presence of food. Pancreatic enzymes include carbohydrases, lipases, nucleases and
proteolytic enzymes that can break down different components of food. These are secreted
in an inactive form to prevent digestion of the pancreas itself. The enzymes become active
once they reach the duodenum.

PATHOPHYSIOLOGY
Acute gastroenteritis is usually caused by bacteria and protozoan. In the Philippines, one of
the most common causes of acute gastroenteritis is E. histolytica. The pathologic process
starts with ingestion of fecally contaminated food and water. The organism affects the body
through direct invasion and by endotoxin being released by the organism. Through these two
processes the bowel mucosal lining is stimulated and destroyed the eventually lead to
attempted defecation or tenesmus as the body tries to get rid of the foreign organism in the
stomach.
The client with acute gastroenteritis may also report excessive gas formation that may leads to
abdominal distention and passing of flatus due to digestive and absorptive malfunction in the
system. Feeling of fullness and the increase motility of the gastrointestinal tract may progress
to nausea and vomiting and increasing frequency of defecation. Abdominal pain and feeling of
fullness maybe relieved only when the patient is able to pass a flatus.
As the destruction of the bowel continues the mucosal lining erodes due to toxin, direct
invasion of the organism and the action of the hydrochloric acid of the stomach. As the
protective coating of the stomach erodesthe digestive capabilities of the acid helps in
destroying the stomach lining. Pain or tenderness of the abdomenis then felt by the patient.
When the burrows or ulceration reaches the blood vessels in the stomach bleeding will be
induced. Dysentery may be characterized by melena or hematochezia depending on the site
and quantity of bleeding that may ensue. Signs of bleeding may be observed also
through hematemesis.
As the bowel is stimulated by the organism and its toxin, the intestinal tract secretes water
and electrolytes in the intestinal lumen. The body secretes and therefore lost Chloride
and bicarbonate ions in the bowel as the body try to get rid of the organism by increasing
peristalsis and number of defecation. Sodium and water reabsorption in the bowel is inhibited
with the loss of the two electrolytes.
Mild diarrhea is characterized by 2-3 stool, borborygmi (hyperactive bowel sound), fluid
and electrolyte imbalance and hypernatremia. When the condition continue to progress,
protein in the body is excreted to the lumen that further decreases the reabsorption and

the body become overwhelmed that leads to intense diarrhea with more than 10 watery stool.
Serious fluid volume deficit may lead to hypovolemic shock and eventually death.

PROGNOSIS
In most cases, gastroenteritis is a self-limited condition with an excellent prognosis.
Symptoms of gastroenteritis usually subside within 3 to 5 days. Failure to improve within 2
weeks should bring the diagnosis into question. The duration of travelers diarrhea caused by
E. coli or Shigella infection can be significantly shortened with antibiotic therapy.
Although infectious gastroenteritis is usually acute (rapid onset with a short duration),
certain parasites such as Giardia can cause chronic diarrhea. For more severe or prolonged
cases, the prognosis depends on the organism causing the gastroenteritis and the
effectiveness of treatment. Recovery can be delayed by an extensive infection, unusual

reactions to medicines, or infection from bacteria that produce a more powerful toxin.
Without replacement, extreme loss of body fluid and electrolytes can lead to shock, coma,
or death.
The prognosis for prolonged (more than 2 weeks) noninfectious gastroenteritis
depends upon accurate identification and treatment of the underlying cause and ranges
from good (food intolerances, allergies, medication side effects) to fair or poor (heavy metal
toxicity, cytomegalovirus infection in HIV-compromised individuals).
The international mortality rate for gastroenteritis is estimated to be 3 to 10 million
individuals each year, primarily from dehydration secondary to diarrhea.

HEALTH TEACHINGS
1. Good hand washing technique after defecation and before handling food.
2. Obtaining available vaccinations against bacterial and viral gastroenteritis
3. Encourage cleanliness and sanitation as well as proper food handling, preparation and
storage techniques.
4. Not allowing food to sit at room temperature for long periods.
5. Warn client not to eat food containing raw eggs and to refrain from buying cans, boxes
or jars that are damaged.
6. Advise clients to avoid the use of antibiotics over a long time.
7. Avoid dirty waters, raw meats or unsafe sea foods, and foods that cannot be cooked or
peeled.
8. Increase fluid intake, breastfeeding for babies to promote hydration.
9. Emphasized proper hygiene to prevent invasion of microorganisms.
10. Instruct to eat nutritious foods, like green leafy vegetables, protein rich foods, vitamins
supplements to boost immune system and prevention of occurrence of disease.