MAY 8, 2011

Table of Contents

I. INTRODUCTION

II. OBJECTIVES

III. BIOGRAPHICAL DATA

IV. CHIEF COMPLAINT

V. HISTORY OF PRESENT ILLNESS

VI. PAST MEDICAL HISTORY

VII. FAMILY MEDICAL HISTORY

VIII. PERSONAL AND SOCIAL HISTORY

IX. COURSE IN THE WARD

X. REVIEW OF SYSTEMS

XI. PHYSICAL ASSESSMENT

XII. DIAGNOSIS

XIII. DIFFERENTIAL DIAGNOSIS

XIV. ANATOMY AND PHYSIOLOGY

XV. PATHOPHYSIOLOGY

XVI. LABORATORY RESULT

XVII. NURSING CARE PLAN

XVIII. DRUG STUDY

XIX. DISCHARGE PLANNING

I. IntroductionGastroenteritis is the infection or irritation of the digestive tract, particularly the stomach and the intestines. It is also known as gastric flu/ stomach flu, although it is not related to influenza. It is usually consist of mild to severe diarrhea that may be accompanied by loss of appetite, nausea, vomiting, cramps and discomfort in the abdomen. Although Gastroenteritis usually is not serious for healthy adults, it can cause life-threatening dehydration and electrolyte imbalance in very ill, the very young and the very old. (Merck Manual)Gastroenteritis is a very common disease; most people are at some risk to encounter the wide-spread causes (mainly viral and bacterial). This risk is due to poor hygiene of a few people with the disease that may be encountered frequently in daily living (for example, infants, children, or some food handlers). Some people have higher risk for infection; for example, individuals on cruise ships or those that live or work in crowded conditions like child care centers, dorms, or barracks, because of the higher chance that an infected person will come in contact with many other people, and rapidly spread the causative agent. (www.medicinenet.com)According to the then NSO survey, 572, 259 infants, young and old were affected by diarrheal diseases during 2006. Because of severe dehydration and diarrhea, 914 case of Acute Gastroenteritis specifically infants hospitalize and eventually die. ) Locally, In July 22, 2004, the Department of Health (DOH), Philippines declared an epidemic (outbreak) of a water/food-borne disease called acute gastroenteritis in 45 towns in Central Pangasinan. Acute gastroenteritis is a human enteric (intestinal) disease primarily caused by ingestion of spoiled or bacterial contaminated water or food.(www.census.gov.ph)

II. ObjectivesA. General Objectives

To understand the underlying disease of the patient and identify the significant physiological, psychological and socioeconomic needs to provide appropriate care.

B. Specific Objectives

1. To know the anatomy of the G.I. tract and pathophysiology of Acute Gastroenteritis. 2. To learn about the major etiologic agent of AGE.3. To determine the previous and present medical history of the patient.4. To perform physical assessment with special attention on the systems focus. 5. To show the laboratory examination results with the corresponding normal values, actual result from the patient, and its interpretation6. To learn the basic principle of medical management of AGE.7. To gain information through Nurse-Patient interaction, identify problems from the client and provide the appropriate nursing care plan.8. To understand the pharmacological management set on the client and provide nursing interventions. 9. To identify the discharge plan for the patients rehabilitation to conduct an evaluation of the clients condition from admission to present.

III. Biographical DataPatients Name:SMPAge:1 year oldGender:MaleStatus:SingleDate of Birth:May 9, 2010Place of Birth:La Union (lying-in)Nationality:FilipinoReligion:Roman CatholicAddress:Makati CityDate of Admission:April 25, 2011 (11:12AM)Hospital:Ospital ng MakatiInformant:MotherPercentage of Reliability:80%

IV. Chief ComplaintMasyado na kasing liquid yung tae na lumalabas sa colostomy bag niya as verbalized by the mother

V. History of Present IllnessThe patient is a known case of intussusception, s/p exploratory laparotomy, ileal resection with ileostomy, appendectomy. (December 19, 2010)History revealed that 10 days prior to admission, patient was discharge for acute gastroenteritis. Prior to discharge, the consistency of the stool was soft, non-bloody, and the patient was active, no fever and vomiting.On the 9th day until the 2nd day prior to admission, the patient didnt experience any signs of further symptoms of acute gastroenteritis.One day prior to admission, patient had loose watery yellowish stools via ileostomy bag. He had fever of 39oC, 3-4 episodes of vomiting of milk amounted 2-3 tbs.Symptoms persisted until few hours prior to admission; patient was noted to be irritable. Thus patient brought to Ospital ng Makati for re-admission.

VI. Past Medical HistoryThe patient was delivered NSD at one of the lying-in at La Union and was fully immunized. He had previous case of intussusceptions, s/p exploratory laparotomy, ileal resection with ileostomy, appendectomy last December 19, 2010.VACCINEAge of Vaccination

BCGAt birth

Hepa BAt birth

Vit. KAt birth

DPT6 weeks

OPV6weeks

AMV9 months

VII. Family Medical HistoryNo significant family medical history.

VIII. Personal and Social HistoryA. Health Perception and Health Management PatternThe mother considers the patients health so important. She assures that the patient receives enough nutrition and is alert to any abnormal condition his son is experiencing. Whenever her son has cough, she gives him home remedies in which if does not alleviate makes her decide to bring him on private clinics. She ensures that she is focused on the patients health. B. Nutritional and Metabolic Pattern Patient SMP is exclusively breastfed from birth up to 6 months old. When he is 6 months old, he started to eat solid foods like rice and biscuits such as wafer, eggnog, breadstick and bravo. His appetite is good. He is not eating salty foods yet fond of eating fruits like orange and banana. Her mother then gave him formula milk and its brand is Pediasure. He drinks a lot of water. When he was hospitalized, this routine was changed since hes no longer fond of eating fruits and drinking water but is still given formula milk.

C. Elimination patternThe mother changes his diaper three times a day. According to the mother, the patient defecates three times a day with yellow colored stool. The consistency of his stool is condensed, soft and slightly formed. When he was hospitalized, her mother then changes his diaper two times a day and his stool is watery.

D. Activity and Exercise PatternAccording to the mother, he wants to walk but needs assistance. He plays many toys but he loses eagerness and gets easily tired and plays another toy. E. Sleep and Rest PatternHe sleeps in the morning up to lunch, two naps in the afternoon and sleeps in the whole night. When he was hospitalized, his sleep pattern changed. He sleeps on and off for about every two hours at night and just take naps if not disturbed.

F. Cognitive and Perceptual PatternThe patient is active and is oriented with the people around him. He could recognize his mother and father.

G. Role and Relationship PatternAccording to the mother, he is a very active child and does not cry easily. He recognizes the people around him and play with them. He has one elder brother and they kept on playing with each other when he was around. He can cope easily with other person.

H. Sexuality and Reproductive PatternNot applicable to age

I. Coping and Stress TolerancePatient SMP copes up to his condition very well. He is not easily irritated and is even a jolly kid. He is fond of playing with people around him. He reduces his stress by entertaining himself with the different things around him. He has also good appetite despite of his condition.

J. Value and Belief PatternTheir religion is Roman Catholic.

K. Self-Perception and Self-Concept Pattern Not applicable to age

General

(+) altered sleeping pattern

Integumentary System

(+) pruritus around the skin barrier of ileostomy bag

Gastrointestinal System

Stool from ileostomy bag was yellowish in colour, ~ half of plastic cup as amount and drain twice a day

XI. Physical Assessment (MAY 10, 2011)

GENERAL APPEARANCEAwake, conscious, active and looks as an infant (1 yr old).

CEPHALOCAUDAL EXAMINATIONFindingsReference Value

Anthropometric measurementHeight : 69 cmWeight : 8.5 kgWeight Percentile Rank: 9%Height Percentile Rank: