129084924 case study of age with moderate dehydration

7/24/2019 129084924 CASE STUDY of AGE With Moderate Dehydration

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Arellano University

College of Nursing

Pasay City

ase Study of Patient with Dehydration

SUBMITTED BY:

FACISTOL GIAN MARIE V.

SUBMITTED TO:

MS. EVELYN BAUTISTA R.N. MAN


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I. Introduction

DEHYDRATION (hypohydration) is defined as the excessive loss ofbody fluid. It is literally the removal ofwater .

Inphysiological terms, it entails a deficiency of fluid within an organism. Dehydration ofskin andmucous membranes can

be calledmedical dryness.Dehydration can be mild, moderate, or severe based on how much of the body's fluid is lost ornot replenished. When it is severe, dehydration is a life-threatening emergency. Water is a critical element of the body,

and adequate hydration is a must to allow the body to function. Up to 75% of the body's weight is made up of water. Most

of the water is found within the cells of the body (intracellular space). The rest is found in the extracellular space, which

consists of the blood vessels (intravascular space) and the spaces between cells (interstitial space).

There are three types of dehydration: hypotonic or hyponatremic (primarily a loss of electrolytes,sodium in particular),

hypertonic or hypernatremia (primarily a loss of water), and isotonic or isonatremic (equal loss of water and electrolytes).

In humans, the most commonly seen type of dehydration by far is isotonic (isonatraemic) dehydration which effectively

equates withhypovolemia,but the distinction of isotonic from hypotonic or hypertonic dehydration may be important when

treating people who become dehydrated. Physiologically, dehydration, despite the name, does not simply mean loss of

water, as water and solutes (mainly sodium) are usually lost in roughly equal quantities to how they exist inblood plasma.

In hypotonic dehydration,intravascular water shifts to theextravascular space,exaggerating intravascular volume

depletion for a given amount of total body water loss. Neurological complications can occur in hypotonic and hypertonic

states. The former can lead toseizures,while the latter can lead toosmotic cerebral edema upon rapid rehydration.

Dehydration occurs when the amount of water leaving the body is greater than the amount being taken in. The body is

very dynamic and always changing. This is especially true with water in the body. We lose water routinely when we:

breathe and humidified air leaves the body (this can be seen on a cold day (the breath you see in the air is water

that has been exhaled)

sweat to cool the body
http://en.wikipedia.org/wiki/Body_fluidhttp://en.wikipedia.org/wiki/Waterhttp://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Human_skinhttp://en.wikipedia.org/wiki/Mucous_membraneshttp://en.wikipedia.org/wiki/Dryness_(medical)http://en.wikipedia.org/wiki/Sodiumhttp://en.wikipedia.org/wiki/Hypovolemiahttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Intravascular_waterhttp://en.wikipedia.org/wiki/Extravascular_spacehttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Osmotic_cerebral_edemahttp://en.wikipedia.org/wiki/Osmotic_cerebral_edemahttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Extravascular_spacehttp://en.wikipedia.org/wiki/Intravascular_waterhttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Hypovolemiahttp://en.wikipedia.org/wiki/Sodiumhttp://en.wikipedia.org/wiki/Dryness_(medical)http://en.wikipedia.org/wiki/Mucous_membraneshttp://en.wikipedia.org/wiki/Human_skinhttp://en.wikipedia.org/wiki/Physiologyhttp://en.wikipedia.org/wiki/Waterhttp://en.wikipedia.org/wiki/Body_fluid


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Eliminate waste by urinating or having a bowel movement.

In a normal day, a person has to drink a significant amount of water to replace this routine loss.

Table 1 Daily Fluid Requirement

The body is able to monitor the amount of fluid it needs to function. The thirst mechanism signals the body to drink water

when the body is dry. As well, hormones like anti-diuretic hormone (ADH) work with the kidney to limit the amount of water

lost in the urine when the body needs to conserve water.

Dehydration is commonly caused by loss of body fluids through prolonged vomiting, diarrhea, sweating, and frequent

urination. The immediate causes of dehydration include not enough water, too much water loss, or some combination of

the two. Sometimes it is not possible to consume enough fluids because we are too busy, lack the facilities or strength to

drink, or are in an area without potable water.

Body weight Daily fluid requirements (approximate)

10 pounds 15 ounces

20 pounds 30 ounces

30 pounds 40 ounces

40 pounds 45 ounces

50 pounds 50 ounces

75 pounds 55 ounces

100 pounds 50 ounces




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The signs and symptoms of dehydration range from minor to severe and include:

II. Significance of the Study:

This study will enable the students to understand better about dehydration and the different risk factors for developing the

disease. May this case study would help the students to understand and describe normal laboratory values for commonly

ordered dehydration. Since we are client- centered we really should consider our patients comfort and this study will give

the students sufficient knowledge that will help them to plan and implement nursing care plans that will satisfy patientsneeds.

III. Objectives

A.General Objectives

This study aims to convey familiarity and to provide an effective nursing care to a patient diagnosed with dehydration

through understanding the patient history, disease process and management.

B. Specific Objectives1. To discuss the anatomy and physiology, pathophysiology of the patients condition, usual clinical manifestations and

possible complications of this condition.

2. To have knowledge to the client medication and be familiar to that medication.

3. To formulate a workable nursing care plan on the subjective and objective cues gathered through nurse-patient

interaction to be able to help the patient recover.

Increased thirst Weakness Palpitation

Sluggishness fainting Inability to sweat

Dry mouth and swollen tongue Dizziness Confusion Fainting Decreased urine output


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IV. PatientsProfile

A. Biographical Data

DATE OF ADMISSION: June 26, 2012 CLINICAL AREA:MS Ward Room 505

NAME: Mr. JMPA ADDRESS: 930 San Agustin St. Brgy Biwas Tanza Cavite

GENDER: Male AGE: 17 years old

CIVIL STATUS: Single DATE OF BIRTH:December 07,1994

OCCUPATION:Student BIRTH PLACE: Cavite

NATIONALITY: Filipino RELIGIOUS PREFERENCES:Roman Catholic

B. Chief Complaint

The client was complaining abdominal pain in his right lower quadrant, dizziness and suffering watery stool, thats

why they rushed the client to the hospital.

C. Final Diagnosis

Acute Gastroenteritis with moderate Dehydration; S/P ileostomy (1994)


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V. Health History

A. History of Present illness

Prior to admission, the client was complaining abdominal pain in his right lower quadrant, dizziness and

suffering watery stool. At first, they consult to the clinic they gave medication Buscopan IM, Metronidazole.

But after drinking the medications. The client still complaining abdominal pain so the family decided to rush

the client at Divine Grace Medical Center the next day.

B. History of Past illness

The client had fever, cough and colds. He had completed all vaccination including BCG, DPT, Oral Polio

Vaccine, MMR and Hepatitis B vaccine. The patient had no history of accident or any injury. The patient had

never been any of the childhood disease such as measles, mumps and chicken pox. He was hospitalized in

year 1994 ileostomy at birth due the ruptured of the ileus at Philippine General Hospital.


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VI. Laboratory Findings

COMPLETE BLOOD COUNT Date Requested: June 26, 2012

RESULT UNITS REFERENCE VALUE

HEMOGLOBIN 14.9 *HIGH g/ dL 12-14

HEMATOCRIT 0.44 *HIGH % 0.37-0.42

RBC COUNT 4.70 mil/mm3 4-5.5.0

WBC COUNT 5300 /mm3 5000-10000

PLATELET COUNT 222,000 150-400,000

DIFFERENTIAL COUNTSEGMENTERS 0.73 *HIGH /mm3 0.55-0.65

LYMPHOCYTES 0.27 /mm3 0.23-0.35

MONOCYTES

ESR mm/hr 0-20

PROTINE 13-17

CONTROL

% ACTIVITY % 70-120INR 0.9-1.2

APTT sec 23-33

RATION


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INTERPRETATION:

HIGH HEMOGLOBINIndicates an above-average concentration of oxygen-carrying proteins in your blood. The main component of red blood

cells. Hemoglobin count also referred to as hemoglobin level indicates your blood's oxygen-carrying capacity. A high

hemoglobin count is somewhat different from a high red blood cell count, because each cell may not have the same

amount of hemoglobin proteins.

INTERPRETATION:

HIGH HEMATOCRIT

High hematocrits can be seen in people living at high altitudes and inchronic smokers.Dehydration produces a falsely

high hematocrit that disappears when proper fluid balance is restored.

INTERPRETATION:

HIGH SEGMENTERS

One of the types of neutrophils found in the blood. They would be elevated if the overall white count is up, usually due tosome kind of infection.
http://www.medicinenet.com/script/main/art.asp?articlekey=11299http://www.medicinenet.com/script/main/art.asp?articlekey=339http://www.medicinenet.com/script/main/art.asp?articlekey=339http://www.medicinenet.com/script/main/art.asp?articlekey=11299


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URINALYSIS Date Requested: June 26, 2012

Rountine Results Normal Values

Color Yellow Light yellow to amber

Characteristic SL. Hazy Clear

Reaction 6.0 4.0-7.0

S.P Gravity 1.010 1.010-1.030

Sugar Negative (-) Negative

Protein Trace * Negative

RBC 2-3 *HIGH 0-2/ hpf

Pus Cells 8-10 *HIGH 0-2/hpf

Epithelial Urates

Amorphous Phosphate

Bacteria Few

Mucus Thread


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INTERPRETATION:

PROTEIN: TRACE

Protein in your urine, as trace amounts of protein are excreted in your urine as part of normal urine production. Theconcern is when you have too much protein in your urine. This is a symptom known as proteinuria.

INTERPRETATION:

HIGH RBC

Hematuria is the presence of abnormal numbers of red cells in urine due to: glomerular damage, tumors which erode the

urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upperand lower Uri urinary tract infections, nephrotoxins, and physical stress.

INTERPRETATION:

HIGH PUS CELLS

A few pus cells or a white blood cell in urine is quite normal. But too many of them may signal a problem somewhere in

yoururinary tract,the commonest of which is a urinary tract infection (UTI). Your lab will usually report the result asnumber of cells counted per high power field of the microscope (hpf) or number of WBCs/mL of urine. A high number of

pus cells in urine are called pyuria.
http://www.healthcaremagic.com/articles/The-Urinary-Tract/8110http://www.healthcaremagic.com/topics/uti/9955?iL=truehttp://www.healthcaremagic.com/topics/uti/9955?iL=truehttp://www.healthcaremagic.com/articles/The-Urinary-Tract/8110


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VII. ANATOMY AND PHYSIOLOGY

DIGESTIVE SYSTEM


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The human digestive system is a complex series of organs and glands that processes food. In order to use the food we

eat our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of

the digestive organs (like the stomach and intestine) are tube-like and contain the food as it makes its way through the

body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other

organs (like the liver and pancreas) that produce or store digestive chemicals.

The Digestive Process

The start of the process - the mouth:

The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical

action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches intosmaller molecules).

On the way to the stomach: the esophagus

- After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the

mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into

the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down.

In the stomach

- The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the

stomach that is partly digested and mixed with stomach acids is called chyme.

In the small intestine

- After being in the stomach, food enters the duodenum, the f irst part of the small intestine. It then enters the jejunum and

then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall


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bladder),pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the

breakdown of food.

In the large intestine

- After passing through the small intestine, food passes into the large intestine. In the large intestine, some of

the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides,

Lactobacillus acidophilus, Escherichia coli and Klebsiella) in the large intestine help in the digestion process. The first part

of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in

the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other

side of the body in the descending colon, and then through the sigmoid colon.

The end of the process

- Solid waste is then stored in the rectum until it is excreted via the anus


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Digestive System Glossary

Anus

- The opening at the end of the digestive system from which feces (waste) exits the body.

Appendix

- A small sac located on the cecum.

Ascending colon

- The part of the large intestine that run upwards; it is located after the cecum.

Bile

- A digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine.

Cecum

- The first part of the large intestine; the appendix is connected to the cecum.

Chyme

- Food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for

further digestion.

Descending colon

- The part of the large intestine that run downwards after the transverse colon and before the sigmoid colon.

Duodenum

- The first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum.


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Epiglottis

- The flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you

swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the

windpipe.

Esophagus

- The long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food

from the throat into the stomach.

Gall bladder

- A small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in

the liver) into the small intestine.

Ileum

- The last part of the small intestine before the large intestine begins.

Jejunum

- The long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.

Liver

- A large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks

down fats) and some blood proteins.

Mouth

- The first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the

beginning of the digestive process (breaking down the food).


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Pancreas

- An enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in

the digestion of carbohydrates, fats and proteins in the small intestine.

Peristalsis

- Rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary

- you cannot control it. It is also what allows you to eat and drink while upside-down.

Rectum

- The lower part of the large intestine, where feces are stored before they are excreted.

Salivary glands

- Glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into

smaller molecules.

Sigmoid colon

- The part of the large intestine between the descending colon and the rectum.

Stomach

- a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in

the stomach.When food enters the stomach; it is churned in a bath of acids and enzymes.

Transverse colon

- The part of the large intestine that runs horizontally across the abdomen


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VIII. PATHOPHYSIOLOGY


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IX. DRUG STUDY

Drug Name Uses Classification Action Contraindication Side effects NursingInterventionBrand Name Generic

NameRanitidineHydrochloride

Apo-Ranitidine,Gen-Ranitidine,Novo-Ranitidine,Nu-Ranit,PMS-Ranitidine,

Rhoxal-Ranitidine

-Short termtreatment ofactive, benigngastric ulcer andmaintenanceafter healing ofthe acute ulcer- treatment ofGERD

- treatment ofendoscopicallydiagnosederosiveesophagitis andfor maintenanceof healing oferosiveesophagus- prevent

paclitaxelhypersensitivity;reduce theincidence of GIhemorrhageassociated withstress-relatedulcers.

Histamine H2receptorblocking drug

Competitivelygastric acidsecretion byblocking theeffect ofhistamine H2receptors.

Cirrhosis of theliver, impairedrenal or hepaticfunction.

Headache,AbdominalPain,Constipation,Diarrhea, andNausea andVomiting.

Do not confuseZantac with Xanax(An antianxiety drug)or with Zyrtec (an H1receptor blocker). Donot confuse ranitidinewith rimantadine (Anantiviral)


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GentamicinSulfate

Alcomicin,Minims,Gentamicin,Ratio-Gentamicin

-Infection includeGI tract.

-Used to fight awide variety of

infectionscaused bybacteria, such asinfection in theears,eyes,chest(includinglungs),urinary tract(includingkidneys andbladder)andblood.

-It also used totreat severebacterialinfectionsinnewborn babies, and to preventinfection in earsand eyes afterthey have beendamaged.

-It is a type ofaminoglycosideantibiotic.

-It is used to killthe bacteria andclear up theinfection.

In general thisdrug is used to

Antibiotic A powerfulantibioticproduced byMicro-monosporapurpurea as amixture ofthree maincomponentsCalledgentamicinC1, C1, andC2. Theydiffer slightlystructurally,and displayapproximately the sameantibioticActivity.

History ofhypersensitivity toor toxic reactionwith anyaminoglycosideantibiotic. Safeuse duringpregnancy(category C) orlactation is notestablished

Feeling sickand beingsick

Inflammation

of the liningof any part ofthemouth,such ascheeks,gums,tongue, throat andlips

Hearing loss

Damage to

the part of theear thatcontrolsbalance,giving rise todizziness, aspinningsensationandunsteadiness

Kidneydamage

Allergic(hypersensitivity) reactions,such as rash

Convulsions

Liver

-Avoid long-termtherapies because ofincreased risk oftoxicities. ReductioninDose may beclinically indicated.-Patients with edemaor ascites may havelower peakconcentrations due toexpandedextracellular fluidvolume.-Cleanse area beforeapplication ofdermatologicpreparations.-Ensure adequatehydration of patientbefore and duringtherapy.-Monitor renalfunction tests, CBCs,serum drug levelsduring long-termtherapy.Consult withprescriber to adjustdosage.
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fight infectionsby susceptiblebacteria.

-Benefits of

being on thisdrug can includetreatment ofinfectionscaused bybacteria andprevention ofbacterialinfections in eyesand ears that

have beendamaged andreliefofpain causedby suchinfections.

problems.
http://www.webmd.boots.com/pain-management/default.htmhttp://www.webmd.boots.com/pain-management/default.htm


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X. NURSING CARE PLAN

Problem: Fluid Volume Deficit / Fluid Loss

Assessment Diagnosis Planning Implementation EvaluationData CollectionCues

CollaborativeProblem

Goal/Objectives NursingIntervention

Rationale for NursingIntervention

Expected Patientoutcome

SubjectiveCue:Masakit angtyan ko atnahihilo.Nagtatae din

ako asverbalized bythe patient.

Objective Cue:Patientmanifested:-Weakness-Dry Skin-Irritability

-Poor SkinTurgor

V/ST: 36.0 CPR: 64 bpmRR: 23 cpmBP: 120/70mmHg

Fluid VolumeDeficit Related toDehydration asevidenced byDecreased UrineOutput, and

weight loss.

Within 8 hours ofthe nursinginterventionThe patient willbe able tomaintain

adequate fluidvolume asevidenced by:urine output of50-60ml/hr, moistskin, and goodskin Turgor

Independent:

Provide rapportto the patient.

Monitored vitalsigns; noted

changes in bodyTemperature.

Observed forpostural BPchanges;encouragedgradualPosition changes.

Palpatedperipheral pulsesassessedcapillary refill,mucousmembranes, andskin Turgor.

To gain trust and fullof cooperation of thepatient.

Increased HR along

with decreased BPandelevatedtemperature,is present inconditions with fluidVolume deficit.Increased bodytemperature alsoincreases fluid loss

by increasingmetabolism.

Patients mayexperience varyingdegrees of posturalhypotensiondepending

After 8 hours of thenursing interventionthe Patient will ableto maintainedadequate fluidvolume as

evidenced by Urineoutput of 50-60ml/hr,moist skin, good skinTurgor Goal Met.


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Observed forchanges inmental status.

Encouragedincrease in fluidintake andconsumption offoods high in fluidcontent.

Turned patientq2hand providedsupportFor bodyprominences.

Dependent:

Administered IV

fluids as ordered.

on degree of fluid

Excessive fluid lossthrough regulatorymechanisms failuremay result in severedehydration,circulatory collapse,and shock.

Decreased cerebralperfusion may resultin changes inmentation.

Relieves thirst andaids in body fluidReplacement.

Patients with fluidvolume deficit are

more at risk for skinBreakdown.

Aggressive fluidreplacement may berequired to correctfluid volume deficit.


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XI. DISCHARGE PLANNING

Medication Instruct patient to take all the prescribed medications at the proper time and dosage forthe specific duration as the doctor has ordered.

Co-trimaxole - 800mg tab

-Take 1 tablet twice a day for three days

-Take the drug at the same time each day.

-Avoid using 2-4 hours after taking other medications.

-Take the medication after meals.

Erceflora vial - Take 1 vial twice a day to consume seven more vials

-Take the medication after meals.

Zinc Syrup -Take 15 mL once a day for two weeks

-Vitamins supplements that he will take for two weeks.

Environment/Exercise Walking Exercise: Is most basic and best exercise for the children to help get fresh air,and to maintain body regularly.

Environment:

- Get out of direct sunlight and lie down in a cool spot, such as in the shade or an air

conditioned area.


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Treatment - Increase Oral Fluid intake, to helps prevent Dehydration- -Co-trimaxole - 800mg tab BID

- Walking Exercise.

Health Teaching - Explain the Dehydration to the Patient.- Inform them to do walking exercise to help get fresh air, and to maintain their

body regularly.

- Instruct patient to take all the prescribed medications at the proper time and

dosage for the specific duration.

- Tell to them to get out of the direct sunlight.

- Make sure that they can engage physical exercise, and advise them to eat foods

that a lots of vitamins and minerals to enhance body immunity.

Out Patient (follow up

consultation)

- Instruct the patient to return to the Attending Physician for follow up check-up and

for emergency medical assistance.

Diet - Diet as Tolerated- Increase oral fluid intake: To prevent the dehydration.- Avoid juices and coffee, To prevent abdominal pain

Spiritual - Advise the patient to encourage praying to God as the Family does every day andto strengthen their faith.

129084924 case study of age with moderate dehydration

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