AMOEBIASIS

CASE
PRESENTATION

(SAN LORENZO RUIZ WOMENS HOSPITAL

Lab Results:
All of the following tests were conducted on June 28, 2009.

Complete Blood Count:

Description

Result

Normal Value

Hemoglobin

115.60

Hematocrit

0.34

Female: 120 160 g/L

Male: 0.40 0.54 g/L

RBC Count

3.64

Female: 0.38 0.47

Male: 4.6 6.2 x 10/L

WBC Count

11.4

Female: 4.2 4.4 x 10/L

Male: 5 10 x 10/L

Platelet

Adequate

Male: 130 180 g/L

150 400 x 10/L

Differential Count:

Description

Result

Normal Value

Neutrophil

0.50

0.55

Lymphocytes

0.48

0.34

Basophils

0.01

Monocytes

0.03

Eosinophils

0.02

0.03

Stabs

0.00

Juvenile

0.01

Stool Exam:
Description
Color
Consistency

Result
Yellowish
Mucoidal

Microscopic Exam of Stool:

Description
RBC
WBC
Fat Globules
Bacteria

Result
1 3/ hpf
2 4/ hpf
None found
+3

Others:
Entamoeba histolytica cyst
hpf
Entamoeba histolytica trophozoites
hpf

0 -2/
0 1/

PATHOPHYSIOLOGY

Anatomy & Physiology:

The Digestive System performs the

mechanical and chemical process of
digestion, absorption of nutrients, and
elimination of wastes. It consists of the
mouth, esophagus, stomach,
intestines, and accessory organs.

A. Oral Structures
include the lips, teeth, gingivae and oral mucosa, tongue, hard
palate, soft palate, pharynx and salivary glands.

B. The esophagus
is a muscular tube extending from the pharynx to the stomach.

C. The Stomach
is a muscular pouch situated in the upper abdomen under the liver
and diaphragm. The
stomach consists of three anatomic areas: the fundus, body (i.e.,
corpus), and antrum (i.e., pylorus)

D. Sphincters
The LES allows food to enter the stomach and prevents reflux
into the esophagus. The pyloric sphincter regulates flow of stomach
contents (chyme) into the duodenum.

E. The small intestine,

a coiled tube, extends from the pyloric sphincter to the
ileocecal valve at the large intestine. Sections of the small intestine
include the duodenum, jejunum and ileum

F. The large intestine

is a shorter, wider tube beginning at the ileocecal valve
and ending at the anus. The large intestine consists of three
sections:
1. The cecum is a blind pouch that extends from the ileocecal
valve to the vermiform appendix.
2. The colon, which is the main portion of the large intestine,
is divided into four anatomic sections: ascending, transverse,
descending and sigmoid.
3. The rectum extends from the sigmoid colon to the anus.
G. The ileocecal valve
prevents the return of feces from the cecum into the
small intestine and lies at the upper border of the cecum.

H. The appendix,
which collects lymphoid tissues, arises from the cecum.

I. The GI tract
is composed of four layers.

1. An inner mucosal layer

lubricates and protects the inner surface of the
alimentary canal.

2. A submucosal layer
is responsible for secreting digestive enzymes.

3. A layer of circular and longitudinal smooth muscle

fibers are responsible for movement of the GI tract.
(Muscularis)

4. The peritoneum, an outer serosal layer,

covers the entire abdomen and is composed of the
parietal and visceral layers.

Patients Profile

CHAPTER 3

CASE SCENARIO
C.A., a 9 month old infant weighs 7kg and
was admitted at the isolation ward of San
Lorenzo Ruiz Womens Hospital. His mother is
complaining that C.A. is suffering from consistent
vomiting and diarrhea for three days. He was
given an antiemetic drug . After few hours,
diarrhea is still positive and vomiting stopped.
There is no noted allergies and asthma. His skin
goes back slowly and has sunken eyeballs.
There is no lymphadenopathy and breath sounds
are clear. Upon reading the patients chart, the
attending nurse learned that the patient is
diagnosed with dehydration secondary to
amoebiasis.

While taking the vital signs of C.A., the student

nurse interviewed the mother. The mother says
kaya ko siya dinala dito kasi palagi siya
dumudumi at nagsusuka. Napansin ko na
sobrang sakit iyon sa kanya kasi sobrang lakas
ng iyak niya at sumisigaw. Yung dinedede niya
parang ganun din karami ung sinusuka niya.
Tapos ayaw na niya dumede ng gatas kaya
pinapainom ko ng am. Napansin ko din na
parang nagdedehydrate siya kasi lubog yung
mga mata niya at namumutla ung balat. Isa pa,
sobra ang iyak niya kapag dumudumi

The student nurse also learned that their house

is still under construction and the flooring of their
house is not cemented. Also, the familys
comfort room is very near the kitchen where
they prepare their food. The mother stopped
breastfeeding after seven months of C.A.s birth.
They are boiling water from the faucet
(NAWASA) given to C.A. for his milk for only 3
minutes. They are also not boiling the spoon
and fork theyre using. The mother says that if
she knows the proper way of proper sanitation
and boiling water, she will apply it to avoid
another incident of diarrhea and to
promoteC.A.s health. The nurse recognizes the
clients learning needs.

Demographic Data:
Name: C.A.B.
Address: Malabon City
Age: 9 months
Gender: male
Race: Filipino
Marital Status: Single
Religious Orientation: Roman Catholic
Date of Admission: June 28, 2009
Attending Physician:

PHYSICAL ASSESSMENT:
Chief complaint:

The patient was admitted because of

three consecutive days of diarrhea and
vomiting occurrence.

PHYSICAL EXAMINATION:
Skin
(-) active skin lesion
Skin goes back
slowly
Head-EENT
Anicteric sclerae
Pinkinsh palpipral
Conjunctiva
(+) sunken eyeballs
Lymph nodes
(-) lymphadenopathy

Chest/Lungs
Clear breath sounds
(-) wheezes
(-) retractive
Abdomen
Flat; soft
Admitting
Impression

AGE w/ some
signs of DHN

GORDONS FUNCTIONAL
HEALTH PATTERN
is also a good method in presenting physical
examinations data; we sorted out the appropriate
functional pattern for the patient:
Health Perception and Management Pattern
Upon patients admission, the mother keeps her
baby self medicated and increasing OFI to prevent
dehydration and eat banana to stop diarrhea.
His mother doesnt know the cause of A.Cs illness
but she did bring him to the hospital for check up.
Nutritional and Metabolic Pattern
After vomiting, the patient doesnt like to drink milk
from bottle but he drinks am.
He doesnt have skin lesions

Bowel-Elimination Pattern
The mother verbalizedminsan patak lang yung
dumi niya. Minsan naman sobrang dami. Pero
madalas siya dumumi.
The patients bowel frequency is over the normal,
the bowels consistency is watery and the color is
yellowish.
Activity Exercise Pattern
The patient responds to activities that stimulates his
senses like peak-a-boo.
The patients perceived ability is level IV
(dependent and does not participate).
Sleep Rest Pattern
According to the mother, patient sleeps 9 hrs at
nights
He take naps at morning and afternoon

PAST HISTORY
NO known past history

PRESENT HISTORY
Patient has LBM, positive vomiting
and watery stool.
Noted some DHN

ALLERGIES

No noted allergies from the day of

admission.

COURSE IN THE WARD

NURSING
CARE PLAN