Overview of the Case

Patient Demilyn was suffering from loose watery stools 5 days prior to admission with some episodes of vomiting, no direct causative factor can be pointed out for her condition. With her present condition, which is being pregnant for 14 weeks she decided to seek medical attention. That is where she was diagnosed with having AGE with some dehydration.

Now what is AGE? We should first define the disease I order for us to truly understand the condition of our patient. Acute diarrhea or gastroenteritis is the passage of loose stools more frequently than what is normal for that individual. This increased frequency is often associated with stools that are watery or semisolid, abdominal cramps and bloating. Acute watery diarrhea is an extremely common problem, and can be fatal due to severe dehydration, in both adults and children, especially in the very young and the old or in those who have poor immunity such as individuals with HIV infection orpatients who are using certain medications that suppress the immune system. Gastroenteritis means inflammation of the stomach

Objective
The objective in making this case study is to identify the problem of our patient which is Acute Gastroenteritis and to determine what are the factors that contribute to the disease so that specific actions should be done and rendered to our patient. The group has selected the patient having this kind of disease because the primary concept that should fit our study is all about abnormalities pertaining obstetric and gynecologic nursing. Having this kind of case study is a privilege for us because it would be a good learning process by adding new knowledge and concept about different kinds of diseases that may be present in some patients. By making this case study we can identify the disease step by step, its nature on how this

SCOPE and LIMITATIONS of the STUDY

The study was conducted at Northern Mindanao Medical Center Hospital, Cagayan de Oro City in which observation, analyzing and understanding the patients condition was done. The study is also limited to the condition of the patient which is Acute Gastroenteritis and its effect during pregnancy. The study focuses only on obtaining the patients profile, health history and present health condition; assessing, recording, and gathering of pertinent data about the patient. Estimating the nursing needs and coping capacity of the patient; finding the primary health problems of the patient and the appropriate nursing interventions to solve the condition of the patient.

DATA BASE AND HISTORY

Name of Patient:____Demilyn Cantil__ Sex:__F_ Age:_20_______ Religion:_RC___________ Civil Status:_______Married___ Income:__4,100___________ Nationality:___Filipino________ Date Admission:__November 26, 2011__ Time:_7:00____ Informant:__Patient_______________ Temperature:_____36.7 C__ Pulse:__96 BPM__ Resp. Rate:__21 CPM__ BP:_110/80 mmHg__ Height:___________154 cm__________________ Weight:____71 kg____________________ Chief Complaint and History of Present Illness: _5 days PTA watery stool, yellowish in color, non-mucous, non-blood, non-foul odor 4 episodes of vomiting LMP 08/15/2011 AOG = 14 weeks_

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic Name: metronidazole Brand Name: Classification: -antibiotic Dosage: Route: PO Frequency: TID

MECHANIS M OF ACTION

INDICATION

NURSING RESPONSIBILITIES/ PRECAUTIONS

CONTRAINDICATI ADVERSE EFFECTS OF ONS THE DRUG

Acute gastroenteritis

Contraindicat ed ity with hypersensitiv

CNS:Headache, dizziness, taxia,vertigo, incoordination,

Avoid necessary. is rodents.

use in

unless some

Bactericid al: Inhibits DNA synthesis

Metronidazole

carcinogenic

insomnia, seizures, to

Administer oral doses with food. Reduce dosage in hepatic disease

metronidazol peripheral neuropathy, e; pregnancyfatigue (do for trichomoniasi not use GI:Unpleasant

in specific (obligate) anaerobes , causing cell death; antiprotoz oaltrichomon acidal, amoebicid al: Biochemic al mechanis m action not known. of is

metallic taste, s in first anorexia, nausea, trimester). vomiting, diarrhea,GI Use cautiously with diseases, hepatic disease, candidiasis (moniliasis), blood Local:Thrombophlebiti s (IV);redness, CNS upset, cramps. GU:Dysuria, incontinence,darkeni ng of the urine .

Inform patient urine may appear dark.

NURSING CARE PLAN

Cues Subjective Date: mata gabei kay Nursing Diagnoses Objectives Interventions eyeduring sleep. when exercisesand relaxation. Rationale minutes to learn she of the the on can well the Evaluation

Alteration in comfortAt the end of 30Independent: dsleeping pattern intervention theplace patient will able about sleep despite of to how earplugs,

Cge ko mata-related to disturbedminutes man gud plastar ang pagkatulog, dayon medyo saba pod, as verbalize by the patient. Objective Data: Patient looks tired Lethargic Quite inspite of disposition Room crowded with lots of patient and there are 2 more patient with her in one bed. irritable happy

1. Advice patient to1. To promote comfortAt the end of 30 becover and put on loose tosleeping. therelaxation patient was able techniques sleep despite

learnclothing

well2. Teach patient on2. To promote comforthow like sitting quietly with

environmental the ward.

condition insideback supported.

3. To promote venousenvironmental

3. Teach the patientreturn and circulation. condition. about sleeping position she could have like sims or side lying 4. To reduce fatigue compensate for position if possible.

4. Advise patient toand

have at least take 30-lack of sleep during 60 nap during the day. night time. Dependent: 5. Determine has to any5. To let the patient be takeshe has to wake up for the meds to be taken.

medications that theaware the time that patient during night time.

Actual nursing management (DAR) D >received awake and sitting on bed >afebrile with temp. 36.7 C A >vital signs taken and recorded > auscultated abdomen DAT > consumed share with fair appetite > due medications given > needs attended Health teachings imparted with emphasis on: > the importance of proper hand washing >increase fluid intake > intake and output monitored and recorded R > endorsed to the nurse on duty

REFERRALS AND FOLLOW-UP:

Outpatient (check-up): advised the mother to see physician, Dr. Morie Kathleen C. Sormen at Nothern Mindanao Medical Center if there are any unusualities observed on the patients body one week after discharge

EVALUATION AND IMPLICATIONS:

This care study enables us to further our learning association with disease condition of the patient. From it, we have gained knowledge in the progression of the disease and the reaction of the body to maintain homeostasis and how eventually it causes harm. Through this, we actually improved our understanding and skills in the management of the patient through the experiences weve had in implementing our care. It also enhanced our confidence in intervening because of the input gained form our research. Case studies are a way of getting familiar or get acquainted not only with the patient but also on his or her condition. It provides concrete examples of how the theoretical knowledge learned during lectures was applied. How the concepts of the various disease condition were manifested through the client. It allows the opportunity to facilitate the acquisition of knowledge through the experiences gained in management and in caring for the patient. As a result, it is a must that case studies should be made not just for requirement purposes but also for the pursuit of knowledge. In general, the case study promoted learning through the research and actual experiences and made us more knowledgeable