Presented to the Clinical Instructor ofThe Notre Dame of Tacurong CollegeCollege of Nursing

ACUTE GASTROENTERITIS with MODERATE DEHYDRATION_________________________________________________

Mr. Richard DeoRoxAlave, RNClinical Instructor

In Partial Fulfillment of the CourseRequirements in NURSING CARE MANAGEMENT 107 RLE

Submitted by:

BAI SANDRA M. SINAGANDALBSN 4 STUDENT

Date:

TABLE OF CONTENTS

I. IntroductionII. Objectives of the StudyIII. Vital informationIV. Family BackgroundV. History of Past IllnessVI. History of Present IllnessVII. Effects and ExpectationsVIII. GenogramIX. Developmental DataX. Physical AssessmentXI. Textbook Discussion/ Anatomy & PhysiologyXII. Definition of TermsXIII. Etiology/ SymptomatologyXIV. PathophysiologyXV. Doctors OrderXVI. Laboratory ResultsXVII. List of DrugsXVIII. Drugs StudyXIX. List of Prioritized ProblemXX. Nursing Care PlanXXI. PrognosisXXII. ReferencesOBJECTIVESGeneral Objectives:After 1 hour of reading the case, the readers will be able to gain adequate knowledge on Acute Gastroenteritis (AGE) and enhance knowledge and skills in dealing with patients having this kind of condition , hence allowing listeners to apply their learning appropriately in clinical setting and develop positive attitude in caring for patients with the same condition.

Specific Objectives:

After 1 hour of reading the case, the readers will be able to: Discuss the brief summary of the introduction about the disease involved. Enumerate completely the general and specific objectives. Identify correctly with important information regarding patients data by presenting the following: Vital Information History of present and past Illness Family Background Effects and Expectations of illness to self and family Genogram Growth and Development Data Discuss the result of Physical Assessment Cephaloucaudically. Identify completely with Review of System. Discuss comprehensive with complete diagnosed of the patient based on textbook discussion. Relate the Anatomy and Physiology of the systems involved in AGE. Enumerate the predisposing and precipitating factors involved with the diagnosis clearly. Enumerate the etiology of AGE. Discuss the pathophysiology of AGE. Identify the laboratory test undergone by the patient and interpret the result accurately. Discuss the doctors order for patient wellness and rationalize properly. Rationalize the drugs that the physicians ordered and discuss the mechanisms of action, side and adverse effects, contraindication, special precaution and drug interaction precisely. Prioritized nursing diagnosis of patient and enumerate applicable nursing interventions correctly. Enumerate the references/bibliography precisely.

Acute Gastroenteritis INTRODUCTIONThis is a case of baby J, a 4 years old male patient of South Cotabato Provincial Hospital. He was admitted last January 18, 2015 at 7:45am with admitting diagnosis of Acute Gastroenteritis with moderate dehydration, under the service of Dr. San.Acute Gastroenteritis is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine and resulting in acute diarrhea. The inflammation is caused most often by infection with certain viruses, less often by bacteria or their toxins, parasites, or adverse reaction to something in the diet or medication. At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus.Different species of bacteria can cause gastroenteritis, including Salmonella, Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, and others. Each organism causes slightly different symptoms but all result in diarrhea. Colitis, inflammation of the large intestine, may also be present. Some types of acute gastroenteritis will not resolve without antibiotic treatment, especially when bacteria or exposure to parasites are the cause. Physicians may want to diagnose the cause by analyzing a stool sample, when stomach symptoms remain problematic.According to the World Health Organization (WHO) and UNICEF, there are about two billion cases of diarrheal disease worldwide every year, and 1.9 million children younger than 5 years of age perish from diarrhea each year, mostly in developing countries. This amounts to 18% of all the deaths of children under the age of five and means that more than 5000 children are dying every day as a result of diarrheal diseases. Of all child deaths from diarrhea, 78% occur in the African and South-East Asian regions. Each child under 5 years of age experiences an average of three annual episodes of acute diarrhea. Globally in this age group, acute diarrhea is the second leading cause of death (after pneumonia), and both the incidence and the risk of mortality from diarrheal diseases are greatest among children in this age group, particularly during infancy thereafter, rates decline incrementally. Other direct consequences of diarrhea in children include growth faltering, malnutrition, and impaired cognitive development in resource-limited countries.In the Philippine Health Statistic, gastroenteritis range as number 10 in the ten leading causes of infant mortality, with the rate of 0.5 and percentage of 4.1 cases in the Philippines by the year 2004 this was updated last February 12, 2008.Significance of the study:This study will enable the students to understand better about acute gastroenteritis and will explain the different risk factors for developing the disease, including consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation 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 patients needs.

PATIENTS DATAVital InformationPatients Name:Baby JAge:2 years oldSex:MaleBirth Date:October 25, 2012Birth Place:Koronadal City, South CotabatoAddress:Sitio Mani, topland (Bo.7) Koronadal South CotabatoOccupation:noneTribe:IlonggoCitizenship:FilipinoReligion:Roman CatholicCivil Status:SingleBody weight:25.5 kgEducational Attainment: noneName of Institution:South Cotabato Provincial HospitalDate and Time of Admission: January 18, 2015 @ 7:45 pmChief Compliant: ga tae-tae siya kag suka as verbalize by the Pt.s mother

Admitting Diagnosis:Acute Gastroenteritis with Moderate Dehydration

Attending Physician:Dr. San

Parents Name:1. Mrs. K 27housewife2. Mr. L 32Tricycle Driver Sibling:1. Kaye 5Student2. Pt. J 2 noneSource of Information:1. Mrs. K 2. Pt.s Chart

Family backgroundPt. J was born on October 25, 2012 at Koronadal City, South Cotabato. He is an affiliate of Roman Catholic. He lived in Sitio Mani, Topland Bo.7, koronadal city South Cotabato. He is a Second son of the family. According to his mother, only Mr. L is the one who worked for the family because no one will take care of their kids except Mrs. K. Mrs. K stated that baby J completed his immunizations such as BCG1, OPV3, DPT3, Hepa-b3, MMR1. He was breastfeed until he is 1 year old, and now he is already bottle feed. Based on their diet,Mrs. L cook food such as fish and vegetable, they rarely eat meat because according to Mrs. L it is too expensive. She also stated that Pt. baby J is so hard to make him eat his food that is why he is under weight for his age. According to Mrs. L they do not have any hereditary diseases. Baby Js grandparents are both alive.Their house was made of half cement and half kalakat, it has one room, kitchen and a living room. The comfort room is outside their house. Their water source is nawasa and poso. They have pets in the house, 1 dog and 2 cats.Based on their finances, Mr. L has a 250 per day for his boundary because the tricycle he drive is not owned by Mr. L. So, he gets 7,500 per month plus 1,400 pesos a month by the government subsidy which is the 4 Ps (pantawid pamilyang Pilipino program).According to Mrs.L, whenever they got sick they do not directly consult the doctor, instead they just go to health center and ask for a medicine such as, Paracetamol for fever, Biogesic for head ache, neozep for flu and lagundi capsule for cough.

History of Past IllnessAccording to Mrs. L having a diarrhea is not the first time of baby J, when he was 7 months old he also experience diarrhea. But 6 months prior to admission Pt. baby J doesnt experience any type of disease. History of Present IllnessOn the day prior to admission Pt. baby J experienced 3days of diarrhea, watery yellow stool, He also experience vomiting. He also stated that he is having stomach pain. He was rushed to hospital at South Cotabato Provincial Hospital. He was admitted to the hospital around 7:45 pm with the admitting diagnosis of acute gastroenteritis with moderate dehydration under the service of Dr. San, MD.

Effect and Expectations of Illness to Self and FamilyTo Self:No verbalization.To family:Family verbalized that they are worried about the patients condition and expect that the patient will recovered soon so that the expenses will be lessen. According to Mrs. L due to his sons illness he loses his weights. The family expects that the patient will recover soon.

DEVELOPMENTAL DATADevelopmental task theory of Robert HavighurstA developmental task is a task which arises at or about a certain period in the life ofanindividual. Havighurst hasidentifiedsix majorage periods:infancy and early childhood (0-5 years), middle childhood (6-12 years), adolescence (13-18years), early adulthood (19-29 years), middle adulthood (30-60 years), and latermaturity (61+)

Based on Havighurst s Theory, The patient developmental theory is in Infancy and early chidhoodTheory TaskJustificationRemarks

Robert Havighurst(infancy and early childhood)

Learning to walk

Learning to take solid foods

Learning to talk

Learn to control the elimination of body waste

Learning sex differences and sexual modesty Forming concepts and learning language to describe social and physical reality. Getting ready to readAccording to Mrs. L, his son baby J learned to walk when he was 9 m0nth old.Accondong to Mrs. L, baby J started to eat solid food when he is 9 month old.According to Mrs. L baby J learns to talk and can say a different words when he was 1 year and 4 monthsAccording to Mrs. L baby J learn to control his body waste when he is 1 years and 6 months, whenever he wants to pee he calls his mother right away.According to Mrs. L baby J knows that he is a boy and his sister is a girl.According to Mrs. L baby J can differenciate his parents by calling them as mama and papa.

According to Mrs. L baby J loves to check the book of his sister and he can describe the picture on it. Achieved

Achieved

Achieved

Achieved

Achieved

Achieved

Achieved

PSYCHOSOCIAL THEORYErik Erikson He envisions life as a sequenceof level of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial or unsuccessfully. Erikson believes that the greater the task achievement, the healthier the personality of the person failure to achieve the task influences the ability of the person to achieve the next task. This developmental task can be viewed as a series of crisis and unsuccessful resolution of this crisis is damaging to the ego. After attaining ones stage, the person may fall back and need to approach it again. TheoryTaskJustificationRemarks

Erik Erikson(will)Autonomy vs. shame and doubt According to Mrs. L sometimes baby J wanted to do things on its own like eating foods, bathing, playing his toys, choosing clothes he wears and etcAchieved

PHYSICAL ASSESSMENT

Date and time:January 11,20157:45 PMGeneral Appearance:The patient is a young male, with IVF D5LR 160 gtts/hr hooked at right basillic vein, patent and infusing well. Patient is conscious, hair is not well-fixed, The patient wears striped sando and wears diaper. Vital signs:T- 37 CRR- 20 cpmPR-72 bpm

Head/Hair/Scalp:Inspection: Head is proportional to the body and skull is rounded and symmetrical, no dandruff and lice noted, hair is evenly distributed, gray in color with dry texture.Palpation: No tenderness and masses noted.Face:The face is symmetrical; skin is brown in complexion and has poor skin turgor.

Eyes:Eyes are symmetrical, eyebrows are black in color. Yellowish discharges noted. Pupils are equal in size and reacts to light. Eye opening is good. Conjunctiva is pinkish in color and sclera is well lubricated.Nose:Inspection: The external nose is symmetrical, align at the midline, nasogastric tube noted inserted through the right nostril, mucosa is moist, nasal septum is intact, no lesions and nose deformities noted.Palpation: There is no tenderness noted.Ears:Inspection: Ears are symmetrical, normal in size with equal color to the body complexion, no lesions noted, small amount of dirt accumulates at the external ear, earwax noted, auricle has no deformities, pinna recoils when folded.Palpation: No tenderness and nodules noted.Mouth and Lips:Inspection: Lips are pale in with dry and flaky texture, no presence of stomatitis, no lesions noted, the tongue is pinkish in color with white spots. Incomplete set of teeth and yellow-orange color of the teeth is noted. Gums and mucosa is light pink and no lesion noted. Tonsils are not inflamed; uvula is bell in shape, pinkish in color, and at the midline.Neck:Inspection: Jugular veins are not inflamed and no stiffness noted.Palpation: Lymph nodes at the neck are not palpable.Breast:Inspection: Brown areola and nipple noted, areola are equal in size.Palpation: No tenderness and masses noted.Lungs:Auscultation: Breathing pattern is normal and no irregular rhythm noted. Heart:Auscultation: No abnormal sound noted.Abdomen:Inspection: No scars noted upon inspection. No lesion noted.Auscultation: Gurgling sound noted. 7 gurgling sound/min.Palpation: No tenderness noted, no masses noted.Extremities:Inspection: Extremities are proportionate to the trunk; skin is brown in complexion, symmetrical on both upper and lower extremities. Immobility noted on the right leg and arms. No withdrawal even on evoked pain stimulus.Skin:Inspection: Skin is dry and flaky, no lesions noted. Skin has poor skin turgor.Palpation: No masses and tenderness noted. Cool to touch.Nails Inspection: Nails are dirty, and pinkish in color. Capillary refills after 3 seconds.Anatomy and PhysiologyTHE DIGESTIVE SYSTEM

The digestive system is a group of organs working together to convert food into energy and basic nutrients to feed the entire body. Food passes through a long tube inside the body known as the alimentary canal or the gastrointestinal tract (GI tract). The alimentary canal is made up of the oral cavity, pharynx, esophagus, stomach, small intestines, and large intestines. In addition to the alimentary canal, there are several important accessory organs that help your body to digest foodbut do not have food pass through them. Accessory organs of the digestive system include the teeth, tongue, salivary glands, liver, gallbladder, and pancreas. To achieve the goal of providing energy and nutrients to the body, six major functions take place in the digestive system:

-Ingestion-Secretion-Mixing and movement-Digestion-Absorption-Excretion

Digestive System AnatomyMouthFood begins its journey through the digestive system in the mouth, also known as theoral cavity. Inside the mouth are many accessory organs that aid in the digestion of foodthe tongue, teeth, and salivary glands. Teeth chop food into small pieces, which are moistened by saliva before the tongue and other muscles push the food into the pharynx. Teeth. Theteethare 32 small, hard organs found along the anterior and lateral edges of the mouth. Each tooth is made of a bone-like substance called dentin and covered in a layer of enamelthe hardest substance in the body. Teeth are living organs and contain blood vessels and nerves under the dentin in a soft region known as the pulp. The teeth are designed for cutting and grinding food into smaller pieces. Tongue.Thetongueis located on the inferior portion of the mouth just posterior and medial to the teeth. It is a small organ made up of several pairs ofmusclescovered in a thin, bumpy, skin-like layer. The outside of the tongue contains many rough papillae for gripping food as it is moved by the tongues muscles. The taste buds on the surface of the tongue detect taste molecules in food and connect to nerves in the tongue to send taste information to the brain. The tongue also helps to push food toward the posterior part of the mouth for swallowing. Salivary Glands. Surrounding the mouth are 3 sets of salivary glands. The salivary glands are accessory organs that produce a watery secretion known as saliva. Saliva helps to moisten food and begins the digestion of carbohydrates. The body also uses saliva to lubricate food as it passes through the mouth, pharynx, and esophagus.

PharynxThe pharynx, or throat, is a funnel-shaped tube connected to the posterior end of the mouth. The pharynx is responsible for the passing of masses of chewed food from the mouth to the esophagus. The pharynx also plays an important role in the respiratory system, as air from the nasal cavity passes through the pharynx on its way to the larynx and eventually thelungs. Because the pharynx serves two different functions, it contains a flap of tissue known as theepiglottisthat acts as a switch to route food to the esophagus and air to thelarynx.

EsophagusTheesophagusis a muscular tube connecting the pharynx to the stomach that is part of theupper gastrointestinal tract. It carries swallowed masses of chewed food along its length. At the inferior end of the esophagus is a muscular ring called the loweresophageal sphincter or cardiac sphincter. The function of this sphincter is to close of the end of the esophagus and trap food in the stomach.

StomachThestomachis a muscular sac that is located on the left side of the abdominal cavity, just inferior to thediaphragm. In an average person, the stomach is about the size of their two fists placed next to each other. This major organ acts as a storage tank for food so that the body has time to digest large meals properly. The stomach also contains hydrochloric acid and digestive enzymes that continue the digestion of food that began in the mouth.

Small IntestineThesmall intestineis a long, thin tube about 1 inch in diameter and about 10 feet long that is part of thelower gastrointestinal tract. It is located just inferior to the stomach and takes up most of the space in the abdominal cavity. The entire small intestine is coiled like a hose and the inside surface is full of many ridges and folds. These folds are used to maximize the digestion of food and absorption of nutrients. By the time food leaves the small intestine, around 90% of all nutrients have been extracted from the food that entered it.

Liver and GallbladderTheliveris a roughly triangular accessory organ of the digestive system located to the right of the stomach, just inferior to the diaphragm and superior to the small intestine. The liver weighs about 3 pounds and is the second largest organ in the body. The liver has many different functions in the body, but the main function of the liver in digestion is the production of bile and its secretion into the small intestine. Thegallbladderis a small, pear-shaped organ located just posterior to the liver. The gallbladder is used to store and recycle excess bile from the small intestine so that it can be reused for the digestion of subsequent meals.

PancreasThepancreasis a large gland located just inferior and posterior to the stomach. It is about 6 inches long and shaped like short, lumpy snake with its head connected to the duodenum and its tail pointing to the left wall of the abdominal cavity. The pancreas secretes digestive enzymes into the small intestine to complete the chemical digestion of foods.

Large IntestineThelarge intestineis a long, thick tube about 2 inches in diameter and about 5 feet long. It is located just inferior to the stomach and wraps around the superior and lateral border of the small intestine. The large intestine absorbs water and contains many symbiotic bacteria that aid in the breaking down of wastes to extract some small amounts of nutrients. Feces in the large intestine exit the body through the anal canal.

Digestive System PhysiologyThe digestive system is responsible for taking whole foods and turning them into energy and nutrients to allow the body to function, grow, and repair itself. The six primary processes of the digestive system include:1. Ingestion of food2. Secretion of fluids and digestive enzymes3. Mixing and movement of food and wastes through the body4. Digestion of food into smaller pieces5. Absorption of nutrients6. Excretion of wastes

IngestionThe first function of the digestive system is ingestion, or the intake of food. The mouth is responsible for this function, as it is the orifice through which all food enters the body. The mouth and stomach are also responsible for the storage of food as it is waiting to be digested. This storage capacity allows the body to eat only a few times each day and to ingest more food than it can process at one time.

SecretionIn the course of a day, the digestive system secretes around 7 liters of fluids. These fluids include saliva, mucus, hydrochloric acid, enzymes, and bile. Saliva moistens dry food and contains salivary amylase, a digestive enzyme that begins the digestion of carbohydrates. Mucus serves as a protective barrier and lubricant inside of the GI tract. Hydrochloric acid helps to digest food chemically and protects the body by killing bacteria present in our food. Enzymes are like tiny biochemical machines that disassemble large macromolecules likeproteins, carbohydrates, and lipidsinto their smaller components. Finally, bile is used to emulsify large masses of lipids into tiny globules for easy digestion.

Mixing and MovementThe digestive system uses 3 main processes to move and mix food: Swallowing. Swallowing is the process of using smooth and skeletal muscles in the mouth, tongue, and pharynx to push food out of the mouth, through the pharynx, and into the esophagus. Peristalsis. Peristalsis is a muscular wave that travels the length of the GI tract, moving partially digested food a short distance down the tract. It takes many waves of peristalsis for food to travel from the esophagus, through the stomach and intestines, and reach the end of the GI tract. Segmentation. Segmentation occurs only in the small intestine as short segments of intestine contract like hands squeezing a toothpaste tube. Segmentation helps to increase the absorption of nutrients by mixing food and increasing its contact with the walls of the intestine.DigestionDigestion is the process of turning large pieces of food into its component chemicals. Mechanical digestion is the physical breakdown of large pieces of food into smaller pieces. This mode of digestion begins with the chewing of food by the teeth and is continued through the muscular mixing of food by the stomach and intestines. Bile produced by the liver is also used to mechanically break fats into smaller globules. While food is being mechanically digested it is also being chemically digested as larger and more complex molecules are being broken down into smaller molecules that are easier to absorb. Chemical digestion begins in the mouth with salivary amylase in saliva splitting complex carbohydrates into simple carbohydrates. The enzymes and acid in the stomach continue chemical digestion, but the bulk of chemical digestion takes place in the small intestine thanks to the action of the pancreas. The pancreas secretes an incredibly strong digestive cocktail known as pancreatic juice, which is capable of digesting lipids, carbohydrates, proteins and nucleic acids. By the time food has left theduodenum, it has been reduced to its chemical building blocksfatty acids, amino acids, monosaccharides, and nucleotides.

AbsorptionOnce food has been reduced to its building blocks, it is ready for the body to absorb. Absorption begins in the stomach with simple molecules like water and alcohol being absorbed directly into the bloodstream. Most absorption takes place in the walls of the small intestine, which are densely folded to maximize the surface area in contact with digested food. Small blood and lymphatic vessels in the intestinal wall pick up the molecules and carry them to the rest of the body. The large intestine is also involved in the absorption ofwaterand vitamins B and K before feces leave the body.

ExcretionThe final function of the digestive system is the excretion of waste in a process known as defecation. Defecation removes indigestible substances from the body so that they do not accumulate inside the gut. The timing of defecation is controlled voluntarily bthe conscious part of the brain, but must be accomplished on a regular basis to prevent a backup of indigestible materials.

http://www.innerbody.com/image/digeov.html

TEXTBOOK DISCCUSSIONAcute Gastroenteritis

Gastroenteritisorinfectious diarrheais a medical condition frominflammation("-itis") of thegastrointestinal tractthat involves both the stomach("gastro"-) and thesmall intestine("entero"-). It causes some combination ofdiarrhea,vomiting, andabdominalpain and cramping.[1]Dehydration may occur as a result. Gastroenteritis has been referred to asgastro,stomach bug, andstomach virus. Although unrelated toinfluenza, it has also been calledstomach fluandgastric flu.http://en.wikipedia.org/wiki/Gastroenteritis

Acute gastroenteritis is a common cause of morbidity and mortality worldwide. Conservative estimates put diarrhea in the top 5 causes of deaths worldwide, with most occurring in young children in nonindustrialized countries. In industrialized countries, diarrheal diseases are a significant cause for morbidity across all age groups. Etiologies include bacteria, viruses, parasites, toxins, and drugs. Viruses are responsible for a significant percentage of cases affecting patients of all ages. Viral gastroenteritis ranges from a self-limited watery diarrheal illness (usually < 1 wk) associated with symptoms of nausea, vomiting, anorexia, malaise, or fever, to severe dehydration resulting in hospitalization or even death. The clinician encounters acute viral gastroenteritis in 3 settings. The first is sporadic gastroenteritis in infants, which most frequently is caused by rotavirus.[1]The second is epidemic gastroenteritis, which occurs either in semiclosed communities (eg, families, institutions, ships, vacation spots) or as a result of classic food-borne or water-borne pathogens.[2]Most of these infections are caused by caliciviruses. The third is sporadic acute gastroenteritis of adults, which most likely is caused by caliciviruses, rotaviruses, astroviruses, or adenoviruses.http://emedicine.medscape.com/article/176515-overview

Acute gastroenteritis is an extremely common illness among infants and children worldwide. According to the Centers for Disease Control and Prevention (CDC), acute diarrhea among children in the United States accounts for more than 1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths per year. In developing countries, diarrhea is a common cause of mortality among children younger than age 5 years, with an estimated 2 million deaths each year. American children younger than 5 years have an average of two episodes of gastroenteritis per year, leading to 2 million to 3 million office visits and 10% of all pediatric hospital admissions. Furthermore, approximately one third of all hospitalizations for diarrhea in children younger than 5 years are due to rotavirus, with an associated direct cost of $250 million annually.

http://pedsinreview.aappublications.org/content/33/11/487.full

ETIOLOGY

Precipitating factor

Factor Rationale Remarks

Age (2 y/o)

Gender (male)

According to the World Health Organization (WHO) and UNICEF, there are about two billion cases of diarrheal disease worldwide every year, and 1.9 million children younger than 5 years of age perish from diarrhea each year, mostly in developing countries.

Present

Predisposing factor

FactorRationaleRemarks

Environment

Hygiene

stressAccording to World Health Organization of all child deaths from diarrhea, 78% occur in the African and South-East Asian regions. Each child under 5 years of age experiences an average of three annual episodes of acute diarrhea.

According to Mrs. L, baby J is fund of playing outside their house with the other kids in their compound

Present

IV. LABORATORY EXAMINATIONURINALYSISUrinalysis- is the physical, chemical & microscopic examinations of urine. It involves a number of tests to detect & measure various compounds that pass through the urine.Date:1/12/15PARAMETERSACTUAL FINDINGSNORMAL FINDINGSINTERPRETATIONANALYSIS

ColorLight YellowPale yellownormal

TransparencySlightly TurbidClear to slightly turbidnormal

Specific Gravity1.0201.015-1.025normal

Albuminnegativenegativenormal

Sugarnegativenegativenormal

pH6.07.35-7.45decreasedacidic

Pus cells2-3/hpf2-3 hpfnormal

RBC0-2/hpf2-4 hpfnormal

Epithelial CellsFewfewnormal

BacteriaOccassionalAbsent

abnormalNormally absent, if present it indicates infection.

Mucus ThreadsFewFewnormal

Amorphous MaterialsModerateFewabnormalToo much crystals in the urine is an indication of having kidney stones.

FecalysisDate: 1/12/15PARAMETERSACTUAL FINDINGSNORMAL FINDINGSINTERPRETATIONANALYSIS

Color YellowishYellowishnormal

ConsistencySoftSoftnormal

Pus Cells0-3/hpf0abnormalInvasion of microorganisms.

RBC0-1/hpf0-5/hpfnormal

PROGNOSIS

CriteriaGoodFairPoorJustification

Onset of Illness

It is Pt. jays first hospitalization due to Acute gastroenteritis.

Duration of Illness

Pt. Jay got this disease for the first time.

Hygiene

The patients hygiene is fair because he can take a bath and do his activity of daily living.

Diet

Pt. jays diet is good because he eats a lot and drink.

Age

At this age they dont mind their food they eat as long as it as the taste is good.

Computation:

Good: 2/5x 100% = 40%Fair: 3/5 x 100% = 60%Bad: 0/5 x 100% = 0% Total: 100%

The interpretation of the Prognosis is Fair, because the pt. still having a diarrhea with moderate dehydration.

Bibliography: https://www.google.com.ph/?gfe_rd=cr&ei=xo_aVP7MG-aK8QeuzIHoCA#safe=off&q=predisposing+factors+of+gastroenteritis+on+adolescents 2011 LIPPINCOTTS NURSING DRUG HANDBOOK MEDICAL SURGICAL NURSING BY UDAN WWW.GOOGLE.COM WWW.MEDSCAPE.COM/ACUTEGASTROENTERITIS