UNIVERSIDAD DE MANILA (Formerly City College of Manila) Mehan Garden, Manila College of Nursing

Case Study in a Patient with Diarrhea

IN PARTIAL FULFILLMENTOF THE REQUIREMENTS IN NCM 105 (RELATED LEARNING EXPERIENCE) III

Submitted by: Robles, Ceelin T. Nr-42/Group IV Submitted to: Mr.Ben O. De Paz, RN MAN Clinical Instructor

Date Submitted:

Table of Contents

I. Introduction II. Objectives III. Patient's Health History a. Demographic Data b. Admission Data c. Chief complaint d. History of Present Illness e. Past medical History f. Family Medical History IV. Gordon's Functional Health Pattern V. Physical Examination VI. Laboratory Examinations VII. Drugs Study VIII. Nursing Care Plan IX. Anatomy and Physiology X. Pathophysiology I. Introduction

Diarrhea is the passage of loose and watery stools (more than 3 bowel movements per day) often associated with gassiness, bloating, and abdominal pain. It may also be accompanied by nausea, vomiting, and fever. Diarrhea results to loss of body fluids and salts leading to dehydration of varying severity. Severe dehydration may cause death especially in children and the elderly. Diarrhea can be brought by different etiologic causes such as infection due to: virus (Rotavirus, Hepatitis B virus), bacteria (Cholera, Shigella), and intestinal parasites (E. histolytical, ponworm), these microorganisms are usually spread by contaminated hands, or through food and water. Food intolerance (lactose deficiency, spicy food) and use of laxative and antacid (magnesium hydroxide) can also be a cause. In addition the use of antibiotics like tetracycline and cephalosporins, an inflammatory bowel disease (ulcerative colitis) can brought diarrhea. Moreover emotional stress and a cancer of the colon (characterized by alternating diarrhea and constipation) can also be included in the factors that causes diarrhea. Diarrhea is classified as either acute or chronic. Acute diarrhea is the sudden onset of abnormally frequent watery stools accompanied by weakness, flatulence (farting), abdominal pain and sometimes fever and vomiting. It may be caused by eating spoiled food. This lasts for 2 to 5 days. Chronic diarrhea lasts for more than 2 weeks and is associated with weight loss and anemia. This is usually caused by chronic use of laxatives or amoebiasis. A patient should consult a physician if he/she is less than 3 years old; if the patient is a pregnant woman; if diarrhea is associated with

fever and dehydration; if diarrhea continues for more than 3 days; if diarrhea is associated with bloody, mucoid stools (dysentery); and if diarrhea is associated with abdominal tenderness and cramping. Diarrhea can be managed through prevention of excessive los of and sodium that if severe can leads to dehydration and loss of salts. To prevent these life threatening problems particularly in children and the elderly, oral rehydration solution must be given as early as possible. The cause of the diarrhea should be identified and treated especially if the diarrhea was caused by bacteria (Shigella, Enterotoxigenic Escherichia coli) should be treated with antibiotics like cotrimoxazole and fluoroquinolones. Diarrhea caused by protozoa (Entamoeba histolytica and Giardia lamblia) should be treated with metronidazole in combination with other anti-amoebic drugs. Provide symptomatic relief in adults, antidiarrheal agents like loperamide and attapulgite may help in reducing the frequency of bowel movement and in improving the consistency of stool of stools. Consult your doctor if diarrhea is severe especially in children and the elderly. Always remember that one should to eat to prevent or minimize nutritional damage, should also drink water during their illness, especially if they have fever. Clients should be monitored closely, particularly children who do not show a clear improvement within 2 days after beginning treatment with an effective antibiotic. Since most of diarrhea-causing micro-organisms are spread by contaminated hands, thorough hand washing with soap and water and careful cleaning of all parts of the hand is an important measure to prevent diarrhea. II. Objectives

General Objectives At the end of our case study, the researchers will be able to develop and enhance our nursing skills and responsibilities on how to care for a patient with Diarrhea and be able to identify the nursing interventions that will be appropriate with the client. Specific Objectives
1) To be able to assess the client with Diarrhea and know the disease

process using the established assessment.

2) To be able to understand the pathophysiology of Diarrhea in relation

to clients condition.
3) To be able to make a Nursing Care Plan based from the obtained

datas from the client. 4) To be able to determine the appropriate interventions for the clients specific condition.
5) To be able to determine complications associated with Diarrhea that

requires further assessment and treatment.

III. Patient History A. Demographic Data A case of a 8 months old, female, single, Roman Catholic and currently residing at Paco, Manila.

B. Admission Data The client was admitted for the second time at Ospital ng Maynila Medical Center, admitted last September 4, 2011, 1:00 am. When he arrived she was accompanied by her mother. During nurseclient interaction with the help of her mother, the client was conscious.

C. Chief Complaint The client was admitted with a chief complaint of fever of 38.5 and diarrhea.

D. History of Presnt Illness 5 days prior to admission, the client started to have watery stool and consumed 12 diapers a day. According to the mother the client is irritable, had difficulty in sleeping and had a on and off fever of 38.5 C. They consulted at Valentina Health Center, and gave them Oresol, Zinc Vitamins and Paracetamol drops for fever.

E. Past Medical History According to the mother when the client was 5 months old she had UTI and occasional fever. There was no injury nor accident and no allergies to food and drugs as well. She had been vaccinated with BCG, Hepa A and B, DPT and OPV at Valentina Health Center. Her current mediactions are Ascorbic Acid (Ceelin) and Growee oral drops.

F. Family Medical History The clients mother is 30 years old and has asthma for 12 years while her father is 30 years old and apparently well. Her older sister who is now 2 years old has an allergy to chocolate and milk.

Asthma

30

30

8 mos.

2
Allergy:

Chocolate &Milk

Legend: Female

Male

Client

IV. Gordons Functional Health Pattern Health Pattern Health Perception Health Management Before Hospitalization Not Applicable During Hospitalization Not Applicable Analysis

Not Applicable

Pattern Nutritional metabolic Pattern The client mother stated that client ate three-five times a day and ate what her mother prepared for her like mashed potato, banana, and carrots. She had increased in appetite. She consumes 8-10 bottles of milk (6 oz) per day. According to the mother of the client, she had regular bowel habit. She defecated once to twice a day and it is characterized by semi- solid, yellowish brown in color and soft. She also had good bladder habit; she usually consumed 6-8 diaper a day it is described as light yellow in color and moderate Now, the client decreased appetite. The client has dry lips, sunken eyes and depressed fontanels. D5IMB 500 mL was inserted on clients left foot for fluid and electrolyte replacement. The clients nutritional and metabolic pattern changed because of the clients current condition.

Elimination Pattern

Now, the clients consumed 12 diapers per day with soft watery stool.

Elimination pattern was affected because of the clients current condition.

amount. Activity Exercise The client was able to do the following with the help of the mother since her physical ability is limited due to her is still a baby: eating, bathing, dressing and toileting. Her mother regularly massages her lower extremities. According to the mother, client had total of 8-12 hours of sleep and seems to be felt rested after sleep. Now, the client has less energy, and cannot further more do activities like rolling, crawling. Activity and exercise is being influenced by present health condition of patient itself.

Sleep Rest Pattern

Now, the client usually has 6-8 hours of sleep, experiencing awakening at night and difficulty of sleeping. The method that the mother used to promote sleep is positioning her comfortably.

Sleep rest pattern is being altered due to the clients present health condition.

Cognitive Perception Pattern

Not Applicable

Not Applicable

Not Applicable

Self Perception

Not Applicable

Not Applicable

Not Applicable

Self Concept Pattern Role Relationship Pattern Sexuality Reproductive Pattern Not Applicable Not Applicable Not Applicable

Not Applicable

Not Applicable

Not Applicable

Coping Stress Tolerance Pattern Value Belief Pattern

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Not Applicable

V. Physical assessment

 General Survey The client is an 8 months old female. Appears and behaves to be as his apparent age. She has a light brown skin complexion; she is clean and neat as well. The client is appeared irritable, has a good posture and has coordinated body movement. Interaction and answering of questions was done with the help of his mother; the one who accompanied him in the hospital. Vital signs The clients vital signs prior to the physical examination were temperature of 38.4 oC, pulse rate of 123 bpm, and respiratory rate of 54 bpm. Head to toe Physical Examination

Area of Assessment

Type of Assessment Used

Findings

Skin

- Inspection and Palpation

The client has light brown color of the skin with dry poor skin turgor. It is warm to touch which was noted to be similar on the both sides of his body. The clients skin is free from lesion, abrasion nor inflammation. The body hair is evenly distributed

and No edema present. Head - Inspection and palpation The clients head is round and proportionate to his body, There are no areas of tenderness in the scalp noted. There are no presence of nodules, masses and has depressed fontanel. He has a few black colored hair and smooth. Eyes - Inspection The clients eyebrow is evenly distributed, with intact skin, and symmetrically aligned. Eyelids have effectively closure. The blink response is bilateral and no discharge noted. He has pale conjunctiva with some evident capillaries. Sclera appears white and clear. Cornea is transparent; details of iris are visible which is round and with brown in color. Pupils are equal Ears - Inspection and Palpation in size and equally round. Sunken eyes noted.

The color of the ear is the same as the color of the facial skin and it is symmetrical. The auricles are aligned to the outer canthus of the eyes. The

pinnas are mobile firm and elastic Nose - Inspection and Palpation and recoil when folded. The auditory canal contains some cerumen, and no discharge noted.

Mouth

- Inspection

The clients septum is in the midline. The nostrils are both patent, nasal flaring noted. No swelling and discharges noted.

The client has dry, cracked and pale lips. The buccal mucosa is pink, the Neck - Inspection and Palpation gum is pale, the tongue is in the midline. The color of the hard and soft palate is pale. And it is intact. Saliva is present as well as the gag reflex. Only two teeth at the front.

There is no tenderness noted in the Chest and Lungs Inspection, palpation and Auscultation clients neck and it is movable. The trachea is in the midline. Thyroid gland is visible during inspection, gland ascends during swallowing. Carotid pulsation is visible. Inspection, Abdomen Palpation and Auscultation There is absence of intercostals retraction, chest wall are

symmetrical, and the chest expansion is symmetrical as well. There were no abnormal sounds heard during auscultation. - Inspection and Upper extremities Palpation The abdomen of the client has flat contour. It is smooth and uniform to the color of the skin. The liver, kidney and spleen were not palpable. Abdominal cramps, distention and intestinal rumbling noted. - Inspection and Lower Extremities Palpation The client has muscle grade of 5/5, and his peripheral pulses were equal. The client has good capillary refill. Palm has normal color and it is smooth.

The client has complete lower extremities. He has muscle grade of 5/5, able to move his both lower extremities. The IV line was inserted on his left foot.

VI. Laboratory Examinations

Clinical Chemistry Date: September 3, 2011

TEst

Result

Units

Normal Rate

BUN Creatinine Na K

4.6 84 128 3.1

mmol/L umol/L mmol/L mmol/L

3.0-7.2 50-100 135-145 3.5-5.3

Analysis: based on the above data, there is a decrease in Na and K since there is an excessive fluid loss due to diarrhea.

Urinalysis Date: June 28, 2008 Color: Yellow Appearance: Clear Specific gravity: 1.029 Protein (Albumin): Negative Glucose: Negative Bacteria: Negative Analysis: Since the specific gravity is not in a normal range, it indicates that the client has concentrated urine that maybe the result of dehydration and fever.

Fecalysis Date: September 2, 2011 Macroscopic appearance: Color: yellow Consistency: Soft Microscopic appearance: Pus cells: none seen /hpf RBC: none seen /hpf Fat globules: none seen / hpf Bacteria: Few

Analysis: Fecalysis indicates that there is few bacteria presented in the fecal, this may indicate that it is positive in infection. IX. Anatomy and Physiology THE DIGESTIVE SYSTEM

Consists of (1) an alimentary canal- a long muscular tube beginning at the lips and ending at the anus, including the mouth, pharynx (oral and laryngeal portions), esophagus, stomach, and small and large intestine, and (2) accessory glands that empty secretions into the tube- salivary glands, pancreas, liver, and gallbladder.

1. Teeth a. Crown projects above the gum, root below. Dentin (bulk of tooth) surrounds pulp cavity. Enamel covers dentin of crown; cementum covers dentin of root and anchors tooth to periodontal ligament.

b. Each quadrant of mouth has eight teeth-two incisors, one canine, two premolars, and three molars. 1. Esophagus a. Mucous membrane lined with stratified squamous epithelium rather than simple columnar epithelium, as in stomach and intestine, b. Muscular layer of upper third, striated; lower third, smooth; middle, both striated and smooth. c. Segment above stomach (indistinguishable anatomically from remainder of esophagus) functions as sphincter, remaining closed until reflexively relaxed as peristaltic wave approaches, 1. Stomach a. Consists of upper fundus, central body, and constricted lower pyloric portion (antrum). b. Musculature contains an oblique inner layer of smooth muscle in addition to external longitudinal and underlying circular smooth muscle layers found elsewhere in digestive tract. c. Thick circular muscle in pyloric portion forms pyloric sphincter. d. Openings: cardia, between esophagus and stomach; pylorus, between stomach and duodenum. 1. Small Intestine a. Divided into duodenum, jejunum, and ileum. b. Surface area, serving absorptive function, increased by: 1. Circular folds (plicae circulares)permanent, transverse folds. 2. Villi fingerlike projections 3. Microvilliprocesses on free surface of epithelial cells that form the brush order. a. Invagination of ileum into cecum the first part of the large intestine forms ileocecal valve, which opens rhymthmically during

digestion, permitting gradual emptying of ileum and preventing regurgitation. 5. Large Intestine a. Extends from the end of the ileum to the anus and is divisible into the cecum, colon, rectum, and anal canal. The major part is the colon, which consists of ascending, transverse, descending, and sigmoid portions. b. The longitudinal muscle of the cecum and colon forms three conspicuous bands(taeniae coli). c. Thickene circular smooth muscle of anal canal forms the internal anal sphincter. Surrounding skeletal muscle forms the external sphincter.

6.Salivary Glands a. Three pairs (parotid, submaxillary, and sublingual), with ducts opening into the mouth. b. Two types of secretions: 1. Serous containing ptyalin enzyme initiating digestion of the starch.

2. Mucous mastication.

viscous,

containing

mucus,

which

facilitates

7. Pancreas a. Two types of secretory cells in exocrine pancreas: 1. Enzyme- secreting acinar cells. 2. Bicarbonate-and-water-secreting intralobular duct cells. b. Pancreatic duct empties pancreatic juice into duodenum.

8. Liver and Gallbladder a. Bile secreted by liver is essential for normal absorption of digested lipids. Bile salts combine with products of lipid digestion to form water-soluble complexes (micelles) which are absorbed by intestinal cells. b. Gallbladder concentrates and stores bile. c. Hepatic duct, formed from the bile duct system of liver, joins cystic duct of gallbladder to form common bile duct, which empties into duodenum.

Motility of Digestive Tract

1. Swallowing a. In buccal stage (voluntary) bolus pushed toward pharynx.

b. In pharyngeal and esophageal stages (involuntary) bolus passes through pharynx into esophagus and through esophagus into stomach. c. Reflexes raise soft palate, raise larynx, adduct aryepiglottic folds and true and false vocal cords, and inhibit respiration. When food enters the pharynx, reflex contraction of the superior constrictor muscle initiates peristalsis, propelling the food, and relaxation of the upper and lower esophageal sphincters allows food to pass first into the esophagus and then into the stomach. 1. Peristalsis in Stomach a. Mixes contents and forces chime through pylorus. b. Three waves each beginning every 20 seconds near midpoint of stomach, lasting about one minute, and ending with contraction of pyloric sphincter travel down stomach at one time. c. Rate of emptying determined largely by strength of contractions. d. Feedback from duodenum regulates gastric emptying. Two control mechanisms, one neuronal (enterogastric reflex), the other hormonal (mediated mainly by enterogastrone), inhibit gastric motility. 1. Contractions of the Small Intestine a. Segmenting: rhythmic contractions along a section dividing it into segments: primarily mixing action. b. Peristaltic waves superimposed upon segmenting contractions. c. Ingestion of food increases ileal peristalsis and frequency of opening of ileocecal valve (gastroileal reflex). 1. Contractions of Large Intestine a. Simultaneous contraction of circular and longitudinal muscle, forming haustra, b. Infrequent usually two or three times daily of most mass movements transferring contents from proximal to distal colon and into rectum. Most commonly occur shortly after a meal (gastrocolic reflex). 1. Defecation reflex a. Distention of rectum triggers intense peristaltic contractions of colon and rectum and relaxation of internal anal sphincter.

b. Reflex preceded by voluntary relaxation of external sphincter and compression of abdominal contents.

Digestion 1. Mouth a. Enzymatic action: initiation of the digestion of carbohydrate by ptyalin, which splits starch into the disaccharide maltose. Action in mouth slight, but continues in stomach until acid medium inactivates ptyalin. b. Regulation: exclusively nervous- impulses transmitted from center in medulla activated principally by taste, smell, or sight of food to salivary glands by parasymphatetic nerve fibers. 1. Stomach a. Enzymatic action: initiation of protein digestion by pepsin, producing proteoses, peptones, and polypeptides. Pepsinogen secreted by chief cells converted to pepsin by autoactivation process in presence of acid secreted by parietal cells. b. Regulation 1. Cephalic phase- initiated by taste, sight, or smell of food; secretion stimulated directly or indirectly by the hormone gastrin. Gastrin, released from so called G cells in the pyloric region of the stomach, stimulates the secretion of an acid-rich gastric juice. 2. Gastric phase- initiated by food in stomach; secretion triggered directly or indirectly, as in cephalic phase. 3. Intestinal phase- initiated by digestive products in upper small intestine; mediated by hormone released by duodenum acting on stomach. 4. Inhibition- strong acid in antrum inhibits gastrin release. Fat, acid, or hypertonic salt solutions in duodenum stimulate release of hormones which inhibit gastric secretion.

1. Intestine a. Enzymatic action- fat digestion and continuation of carbohydrate and protein digestion. 1. Pancreatic lipase splits fat into monoglycerides, fatty acids, and glycerol. 2. Pancreatic amylase converts starch and glycogen into maltose. Intestinal disaccharidases split maltose, sucrose, and lactose into their constituent monosaccharides, 3. Pancreatic enzymes trypsin and chymotrypsin both endopeptidases split proteins and the products of pepsin digestion into peptides. Peptidases split peptides into amino acids. b.. Regulation of pancreatic secretion: by vagus nerve during cephalic and gastric phase of gastric secretion and by two duodenal hormones-cholecystokinin-pancreozymin and sectetin. Vagus stimulation and cholecystokinin-pancreaozymin stimulate enzyme secretion; secretin stimulates bicarbonate secretion.

Absorption 1. Occurs almost exclusively in the small intestine. 2. Simple sugars, amino acids, short-chain fatty acids, and glycerol are absorbed into blood stream via capillary network of villi. Products of lipid digestion are absorbed as chylomicrons into intestinal lymphatics via central lacteal of villi. Digestion process- the digestive system prepares consumption by the cells through five basic activities: food for

1. Ingestion- is an active, voluntary process of taking in food. Food must be placed in the mouth before it can be acted on. 2. Propulsion is movement of food along the digestive tract. Swallowing is one example of food movement that depends largely on the propulsive process called peristalsis. Peristalsis is

involuntary and involves alternating waves of contraction and relaxation of the muscles in the organ wall to squeeze food along the tract. 3. Digestion- the breakdown of food by both chemical and mechanical processes. 4. Absorption- the passage of digested food from the digestive tract into the cardiovascular and lymphatic systems for distribution to cells. For absorption to occur, the digested foods must first enter the mucosal cells by active or passive transport processes. The small intestine is the major absorptive site. 5. Defecation- the elimination of indigestible substances from the body.

X. Pathophysiology

(+)Staphylococcus

aureus

toxin binds to mucosal cells

secretory diarrhea mediated by cyclic AMP

Increased production of fluids and electrolytes by the intestinal mucosa

Increased secretion of fluids and electrolytes by the intestinal mucosa

abdominal pain

Watery stools

Intestinal rumbling

Low grade fever