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Table of Contents

I

A Introduction

B Objectives of the study

C Scope and Limitation

II Patientrsquos profile

III Health history

IV Developmental data

o PSYCHOSOCIAL THEORY OF ERIK ERICKSON

o COGNITIVE THEORY OF JEAN PIAGET

o FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT

V Medical Management

A Doctorrsquos Order with Rationale

B Laboratory Resultsignificance

VI Pathophysiology with Anatomy and Physiology

A Anatomy and Physiology

B Pathophysiology

VII Nursing Assessment(system review chart)

VIII Nursing Management

IX Health teachings

X Prognosis

XI Referrals and follow up

XII Evaluation

XIII Implication

XIV Bibliograph

Introduction

Nursing involves an interrelationship of many people concerned with a

clientrsquos responses to potential or actual problems Health is changing evolving

concept that is basic to nursing For centuries the concept of disease was the

yardstick by which was measured Now there is an increasing emphasis on

health and wellness Most people want to be healthy and feel a sense of loss

when they are not

In the case of our patient who is suffering from acute gastroenteritis (AGE)

the etiology is to determine it is said that unlike other abdominal disorder AGE is

the most occurring abdominal dysfunction especially among the children It is

most often results from any non-inflammatory or inflammatory infection of the

colon or either in the upper part of the small bowel It can range from mild

dysfunction to severe complication and the most common is dehydration due to

diarrheal reaction of the body

Usually this is caused by an infection[2] but this is not always the case It

usually is of acute onset normally lasting less than 10 days and self-limiting

Sometimes it is referred to simply as gastro It is often called the stomach flu or

gastric flu even though it is not related to influenza

Bacterial gastroenteritis is frequently a result of poor sanitation the lack of

safe drinking water or contaminated food-conditions common in developing

nations Natural or man-made disasters can make underlying problems in

sanitation and food safety worse In developed nations the modern food

production system potentially exposes millions of people to disease-causing

bacteria through its intensive production and distribution methods Common

types of bacterial gastroenteritis can be linked

to Salmonella andCampylobacter bacteria however Escherichia coli 0157

and Listeria monocytogenes are creating increased concern in developed

nations Cholera and Shigella remain two diseases of great concern in

Introduction

Nursing involves an interrelationship of many people concerned with a

clientrsquos responses to potential or actual problems Health is changing evolving

concept that is basic to nursing For centuries the concept of disease was the

yardstick by which was measured Now there is an increasing emphasis on

health and wellness Most people want to be healthy and feel a sense of loss

when they are not

In the case of our patient who is suffering from acute gastroenteritis (AGE)

the etiology is to determine it is said that unlike other abdominal disorder AGE is

the most occurring abdominal dysfunction especially among the children It is

most often results from any non-inflammatory or inflammatory infection of the

colon or either in the upper part of the small bowel It can range from mild

dysfunction to severe complication and the most common is dehydration due to

diarrheal reaction of the body

Usually this is caused by an infection[2] but this is not always the case It

usually is of acute onset normally lasting less than 10 days and self-limiting

Sometimes it is referred to simply as gastro It is often called the stomach flu or

gastric flu even though it is not related to influenza

Bacterial gastroenteritis is frequently a result of poor sanitation the lack of

safe drinking water or contaminated food-conditions common in developing

nations Natural or man-made disasters can make underlying problems in

sanitation and food safety worse In developed nations the modern food

production system potentially exposes millions of people to disease-causing

bacteria through its intensive production and distribution methods Common

types of bacterial gastroenteritis can be linked

to Salmonella andCampylobacter bacteria however Escherichia coli 0157

and Listeria monocytogenes are creating increased concern in developed

nations Cholera and Shigella remain two diseases of great concern in

developing countries and research to develop long-term vaccines against them

is underway

Non-bacterial gastroenteritis is a syndrome that affects a broad

segment of the population throughout the world Several studies have

proved that causative agents could be established only in about 30

of cases[3] and it leads to the suggestion that the virus may be the

aetiological agent Rota virus has been reported as the commonest

cause of acute non-bacterial diarrhoeal illness[1] Therefore this study

was undertaken to find out the incidence of Rota virus in acute

diarrhoea cases

As an NCM501202 students this care study helps us not just to pass this

said requirement but also to evaluate our efficacy upon rendering our services in

the optimum capacity or the ability to care to a patient suffering this kind of

illness This study also provide information on actual handling caring and an

overview of the patients nutritional status and dietary management with acute

gastroenteritis

Objectives of the study

A case study is designed to determine health problems or possible

health threats arising in a specific client As student nurses this would serve as a

tool for our training ground from what we had learned in classroom discussions

and be able to apply these in community setting such as this case

This case study focuses to accomplish the following objectives on

hypertension

1 To ascertain the content on the nursing assessment diagnosis planning

implementation and evaluation for these specific disease conditions

2 To comprehend on the underlying causes and health history on our

clientrsquos medical diagnosis upon admission

3 To compare amp contrast the ideal and actual nursing care management for

these specific disease conditions

4 Identify the development theory of my patient

5 Identify history of present illness

6 Discuss pathophysiology of the disease

7 Enumerate and discuss the nursing management

8 Discuss the discharge plan which includes health teachings

Scope and Limitations

The scope of this study covers from the patientrsquos health history

developmental data and as well as with his medical and nursing management

Based upon the assessment done appropriate interventions were implemented

to have a proper care for the clientrsquos health

The study is limited from the information being collected from the patient

The data gathering through objective and subjective assessment was limited

based upon our interview (From the mother) and nursing assessment The

patient was being assessed for 2 days from the time we had our ward duty

exposure

I Patientrsquos Profile

Name Eurey Lambaco

Age 1month old

Sex Male

Nationality Filipino

Highest educational attainment na

Occupation na

Monthly income na

Civil Status Child

Religion Roman Catholic

Birth Day December 152009

Address Lapasan Cagayan de Oro City

Vital Signs

Temp 377 c Pulse rate 130 BPM

Resp rate 35CPM

II Patientrsquos Health History

The Patient X A 1 month old baby has been experiencing Loose Bowel

Movement (LBM) accompanied with dehydration last January 23 2010

Two days prior to admission Patient X encountered onset of loose watery

stools brownish in color and characterized by non-mucoid and non-blood

streaked for about 4-6 times a day The client then brought to Sabal hospitals

emergency room Patientrsquos mother claimed that she is not exclusively

breastfeeding her child rather she sometimes bottle feed her child And she

doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the

child is using when eating

The client has the chief complaint of loose bowel movement upon his

admission Patientrsquos mother claimed that it was the first admission of the patient

III DEVELOPMENTAL DATA

PSYCHOSOCIAL THEORY OF ERIK ERICKSON

Erik Erickson envisioned life as a sequence of levels of achievement Each stage

signals a task that must be achieved He believed that the greater that task achievement

the healthier the personality of the person Failure to achieve a task influences the

personrsquos ability to achieve the next task

FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT

According to Freudrsquos theory of psychosexual development the personality develops

in five overlapping stages from birth to adulthood The libido changes its location of

emphasis within the body from one stage to another Therefore a particular body area has

special significance to a client to a particular stage The first three stages (oral anal

phallic) are called pregenital stages The culminating stage is genital stage

If the individual does not achieve a satisfactory resolution at each stage the personality

becomes fixated at that stage Fixation is immobilization or the inability of the

personality to proceed to the next stage because of anxiety The patient belongs to early

childhood where the center of pleasure is in the anus

COGNITIVE THEORY OF JEAN PIAGET

Cognitive development refers to how a person perceives thinks and gain

understanding of his or her world through the interaction and influence of genetic and

learning factors Birth- 2years differentiates self from objects Recognizes self as agent of

action and begins to act intentionally Achieves object permanence

IV MEDICAL MANAGEMENT

A Doctorrsquos Order with Rationale

DATE AND TIME ORDER RATIONALE

January 23 2010

900 am

Pls Admit to room of

choice

gtTo provide care and

proper medical

management

TPR every 4 hours gtTo further monitor the

condition of client

CFACS-V gtTo check the

characteristics frequency

amount color stool and

vomitus of the patient

Diet as tolerated with

aspiration precaution

gtPrescribed food for the

client and prevent aspiration

of foods

Labs

Stool Exam

Urinalysis

CBC

gtTo help physician in

diagnosing his present

health condition and give

specific treatment with

regards to his condition

gtA laboratory test to

determine if a stool sample

contains parasites or eggs

(ova) that are associated

with intestinal infection

gtUsed to detect excessive

protein escaping into the

urine to help evaluate and

monitor kidney function

and to detect kidney

damage affected by his

disease

gtto determine if clients

blood components are

elevated which could

further help he doctor in

prescribing appropriate

medicatios

PLR 1L 40gttshr gtmaintain fluid and

electrolytes balance

Time tape IVF gtTo monitor the IV fluids

of the patient

Monitor hydration status

every 4 hours

gtTo monitor patients

reaction

Medications

E-zinc Drops 1ml OD PO

gtRequired for normal

development and

maintenance of immune

system

B Laboratory Resultsignificance

Datediagnostic

exam done

Lab result Normal

values

Significance

1242010

CBC(HEMATOLOGY)

Hgb113gm

Hct 34 vol

WBC

7700mm3

Lymphocytes

40

Segmenters

13-18gm

42-51 vol

5000-

10000mm3

25-35

55-85

2-4

gtDecreased in renal

and liver disease

hypoxia

gtDecreased in renal

and liver disease

gtno significance

gtsignifies presence of

parasite and adrenal

44

Monocytes 4

Eosinophils 12

Platelet

498000

2-3

150-350mm3

hypofunction

gtDecreased in renal

and liver disease

gt no significance

gtsignifies presence of

parasite and adrenal

hypofunction

gtsignifies renal

diseaseanemia

1242010

Blood chemistry

BUN285

Createnin

088

Potassium35

Sodium13920

150-

510mgs

08-14 mgs

34-53mEqL

135-

155mEqL

gtno significance

normal

gtat the borderline no

significance

gtno significance

Normal

gt no significance

Normal

Datediagnostic

exam done

Lab result Normal values Significance

1242010

URINALYSIS

(RANDOM

SAMPLING)

Color yellow

Appearance

clear

Glucose neg

Protein neg

Reaction GS

Spe Gravity01-

010

Wbc2-4

Rbc 0-2

Epi Cell 0-2

Mucous cells

none

Urate none

Bacterianone

1242010

Hgb

Hct

Hgb 98

Hct 300

13-18gm

42-51 vol

gtDecreased in

renal and liver

disease

gtDecreased in

renal and liver

disease

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

Religion Roman Catholic

Birth Day December 152009

Address Lapasan Cagayan de Oro City

Vital Signs

Temp 377 c Pulse rate 130 BPM

Resp rate 35CPM

II Patientrsquos Health History

The Patient X A 1 month old baby has been experiencing Loose Bowel

Movement (LBM) accompanied with dehydration last January 23 2010

Two days prior to admission Patient X encountered onset of loose watery

stools brownish in color and characterized by non-mucoid and non-blood

streaked for about 4-6 times a day The client then brought to Sabal hospitals

emergency room Patientrsquos mother claimed that she is not exclusively

breastfeeding her child rather she sometimes bottle feed her child And she

doesnrsquot always sterilized the childrsquos belongings specifically the utensils which the

child is using when eating

The client has the chief complaint of loose bowel movement upon his

admission Patientrsquos mother claimed that it was the first admission of the patient

III DEVELOPMENTAL DATA

PSYCHOSOCIAL THEORY OF ERIK ERICKSON

Erik Erickson envisioned life as a sequence of levels of achievement Each stage

signals a task that must be achieved He believed that the greater that task achievement

the healthier the personality of the person Failure to achieve a task influences the

personrsquos ability to achieve the next task

FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT

According to Freudrsquos theory of psychosexual development the personality develops

in five overlapping stages from birth to adulthood The libido changes its location of

emphasis within the body from one stage to another Therefore a particular body area has

special significance to a client to a particular stage The first three stages (oral anal

phallic) are called pregenital stages The culminating stage is genital stage

If the individual does not achieve a satisfactory resolution at each stage the personality

becomes fixated at that stage Fixation is immobilization or the inability of the

personality to proceed to the next stage because of anxiety The patient belongs to early

childhood where the center of pleasure is in the anus

COGNITIVE THEORY OF JEAN PIAGET

Cognitive development refers to how a person perceives thinks and gain

understanding of his or her world through the interaction and influence of genetic and

learning factors Birth- 2years differentiates self from objects Recognizes self as agent of

action and begins to act intentionally Achieves object permanence

IV MEDICAL MANAGEMENT

A Doctorrsquos Order with Rationale

DATE AND TIME ORDER RATIONALE

January 23 2010

900 am

Pls Admit to room of

choice

gtTo provide care and

proper medical

management

TPR every 4 hours gtTo further monitor the

condition of client

CFACS-V gtTo check the

characteristics frequency

amount color stool and

vomitus of the patient

Diet as tolerated with

aspiration precaution

gtPrescribed food for the

client and prevent aspiration

of foods

Labs

Stool Exam

Urinalysis

CBC

gtTo help physician in

diagnosing his present

health condition and give

specific treatment with

regards to his condition

gtA laboratory test to

determine if a stool sample

contains parasites or eggs

(ova) that are associated

with intestinal infection

gtUsed to detect excessive

protein escaping into the

urine to help evaluate and

monitor kidney function

and to detect kidney

damage affected by his

disease

gtto determine if clients

blood components are

elevated which could

further help he doctor in

prescribing appropriate

medicatios

PLR 1L 40gttshr gtmaintain fluid and

electrolytes balance

Time tape IVF gtTo monitor the IV fluids

of the patient

Monitor hydration status

every 4 hours

gtTo monitor patients

reaction

Medications

E-zinc Drops 1ml OD PO

gtRequired for normal

development and

maintenance of immune

system

B Laboratory Resultsignificance

Datediagnostic

exam done

Lab result Normal

values

Significance

1242010

CBC(HEMATOLOGY)

Hgb113gm

Hct 34 vol

WBC

7700mm3

Lymphocytes

40

Segmenters

13-18gm

42-51 vol

5000-

10000mm3

25-35

55-85

2-4

gtDecreased in renal

and liver disease

hypoxia

gtDecreased in renal

and liver disease

gtno significance

gtsignifies presence of

parasite and adrenal

44

Monocytes 4

Eosinophils 12

Platelet

498000

2-3

150-350mm3

hypofunction

gtDecreased in renal

and liver disease

gt no significance

gtsignifies presence of

parasite and adrenal

hypofunction

gtsignifies renal

diseaseanemia

1242010

Blood chemistry

BUN285

Createnin

088

Potassium35

Sodium13920

150-

510mgs

08-14 mgs

34-53mEqL

135-

155mEqL

gtno significance

normal

gtat the borderline no

significance

gtno significance

Normal

gt no significance

Normal

Datediagnostic

exam done

Lab result Normal values Significance

1242010

URINALYSIS

(RANDOM

SAMPLING)

Color yellow

Appearance

clear

Glucose neg

Protein neg

Reaction GS

Spe Gravity01-

010

Wbc2-4

Rbc 0-2

Epi Cell 0-2

Mucous cells

none

Urate none

Bacterianone

1242010

Hgb

Hct

Hgb 98

Hct 300

13-18gm

42-51 vol

gtDecreased in

renal and liver

disease

gtDecreased in

renal and liver

disease

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

the healthier the personality of the person Failure to achieve a task influences the

personrsquos ability to achieve the next task

FREUDrsquoS THEORY OF PSYCHOSEXUAL DEVELOPMENT

According to Freudrsquos theory of psychosexual development the personality develops

in five overlapping stages from birth to adulthood The libido changes its location of

emphasis within the body from one stage to another Therefore a particular body area has

special significance to a client to a particular stage The first three stages (oral anal

phallic) are called pregenital stages The culminating stage is genital stage

If the individual does not achieve a satisfactory resolution at each stage the personality

becomes fixated at that stage Fixation is immobilization or the inability of the

personality to proceed to the next stage because of anxiety The patient belongs to early

childhood where the center of pleasure is in the anus

COGNITIVE THEORY OF JEAN PIAGET

Cognitive development refers to how a person perceives thinks and gain

understanding of his or her world through the interaction and influence of genetic and

learning factors Birth- 2years differentiates self from objects Recognizes self as agent of

action and begins to act intentionally Achieves object permanence

IV MEDICAL MANAGEMENT

A Doctorrsquos Order with Rationale

DATE AND TIME ORDER RATIONALE

January 23 2010

900 am

Pls Admit to room of

choice

gtTo provide care and

proper medical

management

TPR every 4 hours gtTo further monitor the

condition of client

CFACS-V gtTo check the

characteristics frequency

amount color stool and

vomitus of the patient

Diet as tolerated with

aspiration precaution

gtPrescribed food for the

client and prevent aspiration

of foods

Labs

Stool Exam

Urinalysis

CBC

gtTo help physician in

diagnosing his present

health condition and give

specific treatment with

regards to his condition

gtA laboratory test to

determine if a stool sample

contains parasites or eggs

(ova) that are associated

with intestinal infection

gtUsed to detect excessive

protein escaping into the

urine to help evaluate and

monitor kidney function

and to detect kidney

damage affected by his

disease

gtto determine if clients

blood components are

elevated which could

further help he doctor in

prescribing appropriate

medicatios

PLR 1L 40gttshr gtmaintain fluid and

electrolytes balance

Time tape IVF gtTo monitor the IV fluids

of the patient

Monitor hydration status

every 4 hours

gtTo monitor patients

reaction

Medications

E-zinc Drops 1ml OD PO

gtRequired for normal

development and

maintenance of immune

system

B Laboratory Resultsignificance

Datediagnostic

exam done

Lab result Normal

values

Significance

1242010

CBC(HEMATOLOGY)

Hgb113gm

Hct 34 vol

WBC

7700mm3

Lymphocytes

40

Segmenters

13-18gm

42-51 vol

5000-

10000mm3

25-35

55-85

2-4

gtDecreased in renal

and liver disease

hypoxia

gtDecreased in renal

and liver disease

gtno significance

gtsignifies presence of

parasite and adrenal

44

Monocytes 4

Eosinophils 12

Platelet

498000

2-3

150-350mm3

hypofunction

gtDecreased in renal

and liver disease

gt no significance

gtsignifies presence of

parasite and adrenal

hypofunction

gtsignifies renal

diseaseanemia

1242010

Blood chemistry

BUN285

Createnin

088

Potassium35

Sodium13920

150-

510mgs

08-14 mgs

34-53mEqL

135-

155mEqL

gtno significance

normal

gtat the borderline no

significance

gtno significance

Normal

gt no significance

Normal

Datediagnostic

exam done

Lab result Normal values Significance

1242010

URINALYSIS

(RANDOM

SAMPLING)

Color yellow

Appearance

clear

Glucose neg

Protein neg

Reaction GS

Spe Gravity01-

010

Wbc2-4

Rbc 0-2

Epi Cell 0-2

Mucous cells

none

Urate none

Bacterianone

1242010

Hgb

Hct

Hgb 98

Hct 300

13-18gm

42-51 vol

gtDecreased in

renal and liver

disease

gtDecreased in

renal and liver

disease

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

TPR every 4 hours gtTo further monitor the

condition of client

CFACS-V gtTo check the

characteristics frequency

amount color stool and

vomitus of the patient

Diet as tolerated with

aspiration precaution

gtPrescribed food for the

client and prevent aspiration

of foods

Labs

Stool Exam

Urinalysis

CBC

gtTo help physician in

diagnosing his present

health condition and give

specific treatment with

regards to his condition

gtA laboratory test to

determine if a stool sample

contains parasites or eggs

(ova) that are associated

with intestinal infection

gtUsed to detect excessive

protein escaping into the

urine to help evaluate and

monitor kidney function

and to detect kidney

damage affected by his

disease

gtto determine if clients

blood components are

elevated which could

further help he doctor in

prescribing appropriate

medicatios

PLR 1L 40gttshr gtmaintain fluid and

electrolytes balance

Time tape IVF gtTo monitor the IV fluids

of the patient

Monitor hydration status

every 4 hours

gtTo monitor patients

reaction

Medications

E-zinc Drops 1ml OD PO

gtRequired for normal

development and

maintenance of immune

system

B Laboratory Resultsignificance

Datediagnostic

exam done

Lab result Normal

values

Significance

1242010

CBC(HEMATOLOGY)

Hgb113gm

Hct 34 vol

WBC

7700mm3

Lymphocytes

40

Segmenters

13-18gm

42-51 vol

5000-

10000mm3

25-35

55-85

2-4

gtDecreased in renal

and liver disease

hypoxia

gtDecreased in renal

and liver disease

gtno significance

gtsignifies presence of

parasite and adrenal

44

Monocytes 4

Eosinophils 12

Platelet

498000

2-3

150-350mm3

hypofunction

gtDecreased in renal

and liver disease

gt no significance

gtsignifies presence of

parasite and adrenal

hypofunction

gtsignifies renal

diseaseanemia

1242010

Blood chemistry

BUN285

Createnin

088

Potassium35

Sodium13920

150-

510mgs

08-14 mgs

34-53mEqL

135-

155mEqL

gtno significance

normal

gtat the borderline no

significance

gtno significance

Normal

gt no significance

Normal

Datediagnostic

exam done

Lab result Normal values Significance

1242010

URINALYSIS

(RANDOM

SAMPLING)

Color yellow

Appearance

clear

Glucose neg

Protein neg

Reaction GS

Spe Gravity01-

010

Wbc2-4

Rbc 0-2

Epi Cell 0-2

Mucous cells

none

Urate none

Bacterianone

1242010

Hgb

Hct

Hgb 98

Hct 300

13-18gm

42-51 vol

gtDecreased in

renal and liver

disease

gtDecreased in

renal and liver

disease

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

blood components are

elevated which could

further help he doctor in

prescribing appropriate

medicatios

PLR 1L 40gttshr gtmaintain fluid and

electrolytes balance

Time tape IVF gtTo monitor the IV fluids

of the patient

Monitor hydration status

every 4 hours

gtTo monitor patients

reaction

Medications

E-zinc Drops 1ml OD PO

gtRequired for normal

development and

maintenance of immune

system

B Laboratory Resultsignificance

Datediagnostic

exam done

Lab result Normal

values

Significance

1242010

CBC(HEMATOLOGY)

Hgb113gm

Hct 34 vol

WBC

7700mm3

Lymphocytes

40

Segmenters

13-18gm

42-51 vol

5000-

10000mm3

25-35

55-85

2-4

gtDecreased in renal

and liver disease

hypoxia

gtDecreased in renal

and liver disease

gtno significance

gtsignifies presence of

parasite and adrenal

44

Monocytes 4

Eosinophils 12

Platelet

498000

2-3

150-350mm3

hypofunction

gtDecreased in renal

and liver disease

gt no significance

gtsignifies presence of

parasite and adrenal

hypofunction

gtsignifies renal

diseaseanemia

1242010

Blood chemistry

BUN285

Createnin

088

Potassium35

Sodium13920

150-

510mgs

08-14 mgs

34-53mEqL

135-

155mEqL

gtno significance

normal

gtat the borderline no

significance

gtno significance

Normal

gt no significance

Normal

Datediagnostic

exam done

Lab result Normal values Significance

1242010

URINALYSIS

(RANDOM

SAMPLING)

Color yellow

Appearance

clear

Glucose neg

Protein neg

Reaction GS

Spe Gravity01-

010

Wbc2-4

Rbc 0-2

Epi Cell 0-2

Mucous cells

none

Urate none

Bacterianone

1242010

Hgb

Hct

Hgb 98

Hct 300

13-18gm

42-51 vol

gtDecreased in

renal and liver

disease

gtDecreased in

renal and liver

disease

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

44

Monocytes 4

Eosinophils 12

Platelet

498000

2-3

150-350mm3

hypofunction

gtDecreased in renal

and liver disease

gt no significance

gtsignifies presence of

parasite and adrenal

hypofunction

gtsignifies renal

diseaseanemia

1242010

Blood chemistry

BUN285

Createnin

088

Potassium35

Sodium13920

150-

510mgs

08-14 mgs

34-53mEqL

135-

155mEqL

gtno significance

normal

gtat the borderline no

significance

gtno significance

Normal

gt no significance

Normal

Datediagnostic

exam done

Lab result Normal values Significance

1242010

URINALYSIS

(RANDOM

SAMPLING)

Color yellow

Appearance

clear

Glucose neg

Protein neg

Reaction GS

Spe Gravity01-

010

Wbc2-4

Rbc 0-2

Epi Cell 0-2

Mucous cells

none

Urate none

Bacterianone

1242010

Hgb

Hct

Hgb 98

Hct 300

13-18gm

42-51 vol

gtDecreased in

renal and liver

disease

gtDecreased in

renal and liver

disease

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

1242010

URINALYSIS

(RANDOM

SAMPLING)

Color yellow

Appearance

clear

Glucose neg

Protein neg

Reaction GS

Spe Gravity01-

010

Wbc2-4

Rbc 0-2

Epi Cell 0-2

Mucous cells

none

Urate none

Bacterianone

1242010

Hgb

Hct

Hgb 98

Hct 300

13-18gm

42-51 vol

gtDecreased in

renal and liver

disease

gtDecreased in

renal and liver

disease

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

V PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A ANATOMY AND PHYSIOLOGY

The stomach is an expanded section of the digestive tube between the esophagus and

small intestine Its characteristic shape is shown

along with terms used to describe the major regions

of the stomach The right side of the stomach is

called the greater curvature and the left the lesser

curvature The most distal and narrow section of the

stomach is termed the pylorus - as food is liquefied

in the stomach it passes through the pyloric canal

into the small intestine

The wall of the stomach is structurally similar to other parts of the digestive tube with

the exception that the stomach has an extra oblique layer of smooth muscle inside the

circular layer which aids in performance of complex grinding motions

In the empty state the stomach is contracted and its mucosa and submucosa are thrown

up into distinct folds called rugae when distended with food the rugae are ironed out

and flat The image below shows rugae on the surface of a dogs stomach

Within the stomach there is an abrupt transition from stratified squamous epithelium

extending from the esophagus to a columnar epithelium dedicated to secretion In most

species this transition is very close to the esophageal orifice but in some particular

horses and rodents stratified squamous cells line much of the fundus and part of the

body

The image below is of the mucosal surface of an equine stomach showing esophageal

epithelium (top) and glandular epithelium (bottom) The creatures attached to the surface

are bots larval forms of Gasterophilus

If the lining of the stomach is examined with a hand lens one can see that it is covered

with numerous small holes These are the openings of gastric pits which extend into the

mucosa as straight and branched tubules forming gastric glands

B PATHOPHYSIOLOGY

ACUTE GASTROENTERITIS

Definition

Gastroenteritis is the irritation and inflammation of the digestive tract This

condition may cause abdominal pain vomiting and diarrhea Severe cases of

gastroenteritis can result in dehydration In such cases fluid replacement is the

primary factor in treatment All ages and both sexes may be affected yet the most

severe symptoms are experienced by infants and those individuals over sixty

years old The use of certain drugs such as aspirin antibiotics or cortisone drugs

may increase risk for this condition

Food poisoning stress excessive alcohol or tobacco use viral infections food

allergies improper diet certain drugs food consumed in foreign countries and

intestinal parasites are all possible causes for this condition

Gastroenteritis caused by viral infection or bacteria is easily passed from one

person to another Care should always be taken to wash the hands often

especially when preparing food and after bowel movements Hand washing after

bowel movements is important since the organism that causes this condition lives

in the digestive tract

Contaminated food and water unhygienic lifestyle

Food eaten irritates stomach

Increase peristalsis movement of the intestines (Inflammatory response to mucous

membrane lining is destroyed due to excessive production of intestinal fluids)

SSX

Nausea and vomiting

Diarrhea

Loss of appetite

Fever

Abnormal flatulence

Abdominal cramps

Bloody stools

Fainting and Weakness

Predisposing Factor

Age (1month old)

Precipitating Factors

gtEnvironmental Sanitation gtPersonal Hygiene

gtImproper handling of foods gtunsterilized utensils

Contaminated food and water unhygienic lifestyle

Food eaten irritates stomach

Increase peristalsis movement of the intestines (Inflammatory response to mucous

membrane lining is destroyed due to excessive production of intestinal fluids)

SSX

Nausea and vomiting

Diarrhea

Loss of appetite

Fever

Abnormal flatulence

Abdominal cramps

Bloody stools

Fainting and Weakness

Predisposing Factor

Age (1month old)

Precipitating Factors

gtEnvironmental Sanitation gtPersonal Hygiene

gtImproper handling of foods gtunsterilized utensils

Effect to produce hyperemia (vascular dilatation with local increase in blood flow of

theintestinal mucosa)

Hyperistalsis in the intestine

Fluid loss dehydration

Acute Gastroenteritis

16

VI NURSING ASSESSMENT REVIEW CHART

VI Nursing system review chart

Name Lambaco Eurey Date March 23 2010 Vital signs

Pulse130bpm Temperature377 C Resp35 cpm

Instructions Place an [x]in the area of abnormality Comment at the space provided

Indicate the location of the problem in the figure EENT

[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and

p p osterior fontanels are still open

[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain

[x] no problem Abdominal cramps Respiration IV site

[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet

[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing

Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood

Expectoration of [] breath sounds and comfort [x] no problem

sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness

Mildly elevated [] diminished pulses [] edema [] fatigue

blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain

[x] assess heart sounds rate rhythm pulse Condom catheter in

blood pressure circulation fluid retention and comfort place [x] no problem

17

Gastrointestinal tract

Posterior tibial and

[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain

[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss

Genito-urinary and Gyne

[] pain [] urine [] color [] vaginal bleeding

[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery

stool Neuro

[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors

[] confused [] vision [] grip [] assess motor function sensation LOC and strength

Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin

extremities

[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage

[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist

needs assistance [] asses mobility motion gait alignment joint function

on ambulation [x] skin color texture turgor integrity [] no problem

Nursing Assessment II

SUBJECTIVE OBJECTIVE

COMMUNICATION

[] hearing loss Comments ldquowala man pud

problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya

[ ] visual changes

[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties

Pupil size 2mm

Reaction Pupils are equally rounded and reactive to

18

[ x ] denied light and accommodation

OXYGENATION

[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo

[] smoking history

[ ] cough [] sputum [x] denied

Respiration [x] regular [ ] irregular Description Regular breathing pattern

Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung

CIRCULATION

[ ] chest pain Comments ldquoNo subjective cue

gathered since the patient is an infantrdquo

[ ] leg pain [ ] numbness of extremities [ x] denied

Heart rhythm [x] regular [ ] irregular Ankle edema None

PulseCarotidRadialDorsalis pedisFemoral + + +

Right + + + Left Comments Heart beat and heart rhythm are normal

NUTRITION

Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo

[ ] vomiting character

[ x ] recent change in weight appetit [] swallowing

difficulty [ ] denied

[ ] dentures [x] none

FullPartial

upper [ ] [x] [ ]

lower [ ] [x] [ ]

ELIMINATION

Usual bowel pattern [ ] urinary frequency 2x a day3x a day

[ ] constipation remedy [ ] urgency [ ] dysuria

Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria

Watery stool yellowish in color [ ] denied

Comments loose passive Watery stool yellowish in

color and in moderate amount Bowel sounds hyperactive (2x3-5sec)

Abdominal distention [ ] yes [x] no

Urine (color odor Consistency) light colored in moderate amount

19

MANAGEMENT OF HEALTH AND

ILLNESS

[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable

[ ] Last menstrual period not applicable

Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic

health problems Patients mother is supportive to treatment regimen

and patient is cooperative

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY

[x] dry [ ] itching

[x ] other Poor skin turgor [ ] denied

[x] dry [ ] cold [ ] pale

[ ] flushed [x] warm [ ] moist [ ] cyanotic

Rashes ulcers decubitus (describe size location and drainage) None

ACTIVITY SAFETY

[ ] convulsion Comments ldquoluya jud

kaayo siya karon sugod pa atong nag kalibanga siyardquo

[ ] dizziness [ ] limited motion of joints

Limitation in the ability to

[x] ambulate [ ] bathe self [ ] other

[ ] denied

Level of consciousness and orientation

Patient is 11 months old Gait [ ] walker [ ] cane [x] others

[ ] steady [x] unsteady [ ] sensory losses in face or extremities

None

[ ] Range of motion limitation Patient is still unable

COMFORT SLEEP AWAKE

[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo

frequency remedies) [ ] nocturia [ x] sleep difficulties

[] denied

[x] facial grimace

[ ] guarding [ ] other signs of pain patient is Frequently

crying [ ] siderail release form signed (60+ years)

Not applicable

COPING

Occupation Not applicable since the patient is infant Most supportive person the mother and

father

Observed non-verbal behavior none

The person and his phone number that can be reached anytime

09063064576- patients father

20

VII Nursing Management

Nursing Diagnosis

Intervention Rationale

Hyperthermia related to dehydration as

evidence by flushed skin and warm to

touch

Independent

promote surface cooling by

means of tepid sponge bath

maintain bed rest

increase fluid intake (PO)

Collaborative

administer antipyretic

(paracetamol) as ordered

To lower down body temperature

To prevent energy consumption

To maintain fluid and electrolytes balance in the body

To lower down body temperature

21

Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to

excessive losses through normal

routes

Monitor intake and output note

number character and amout of

stools

Assess vital signs changes

Observe for excessively dry skin

and mucous membrane dry skin

turgor

Weigh daily

Administer parenteral as

indicated

Provide information about over

all fluid balance renal function

and bowel diseases control as

well as guidelines for fluid

replacement

Hypotension tachycardia and

fever can indicate response of

fluid loss

Indicates dehydration

Indicator of overall fluid and

nutritional status

Maintenance of bowel rest that

will require alternate fluid

replacement to correct losses

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

16

VI NURSING ASSESSMENT REVIEW CHART

VI Nursing system review chart

Name Lambaco Eurey Date March 23 2010 Vital signs

Pulse130bpm Temperature377 C Resp35 cpm

Instructions Place an [x]in the area of abnormality Comment at the space provided

Indicate the location of the problem in the figure EENT

[]impaired vision [] blind [] pain reddened [] drainage sunken fontanels Forehead and neck are Temp 377c [] gums [] hard of hearing [] deaf [] burning anterior and

p p osterior fontanels are still open

[] edema [] lesion on teeth RR 35cpm [] assess the eyes ears nose and throat for abnormality Poor skin turgor Unable to talk clearly Abdominal pain

[x] no problem Abdominal cramps Respiration IV site

[] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [] cough [] bradypnea [] shallow Tolerates soft diet

[] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing

Unable to hear well [] pain [] cyanotic [] assess respiratory rate rhythm pulse blood

Expectoration of [] breath sounds and comfort [x] no problem

sputum Cardiovascular [] arrhythmia [] tachycardia [] numbness

Mildly elevated [] diminished pulses [] edema [] fatigue

blood pressure [] irregular [] bradycardia[] murmur [] tingling [] absent pulses [] pain

[x] assess heart sounds rate rhythm pulse Condom catheter in

blood pressure circulation fluid retention and comfort place [x] no problem

17

Gastrointestinal tract

Posterior tibial and

[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain

[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss

Genito-urinary and Gyne

[] pain [] urine [] color [] vaginal bleeding

[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery

stool Neuro

[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors

[] confused [] vision [] grip [] assess motor function sensation LOC and strength

Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin

extremities

[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage

[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist

needs assistance [] asses mobility motion gait alignment joint function

on ambulation [x] skin color texture turgor integrity [] no problem

Nursing Assessment II

SUBJECTIVE OBJECTIVE

COMMUNICATION

[] hearing loss Comments ldquowala man pud

problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya

[ ] visual changes

[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties

Pupil size 2mm

Reaction Pupils are equally rounded and reactive to

18

[ x ] denied light and accommodation

OXYGENATION

[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo

[] smoking history

[ ] cough [] sputum [x] denied

Respiration [x] regular [ ] irregular Description Regular breathing pattern

Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung

CIRCULATION

[ ] chest pain Comments ldquoNo subjective cue

gathered since the patient is an infantrdquo

[ ] leg pain [ ] numbness of extremities [ x] denied

Heart rhythm [x] regular [ ] irregular Ankle edema None

PulseCarotidRadialDorsalis pedisFemoral + + +

Right + + + Left Comments Heart beat and heart rhythm are normal

NUTRITION

Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo

[ ] vomiting character

[ x ] recent change in weight appetit [] swallowing

difficulty [ ] denied

[ ] dentures [x] none

FullPartial

upper [ ] [x] [ ]

lower [ ] [x] [ ]

ELIMINATION

Usual bowel pattern [ ] urinary frequency 2x a day3x a day

[ ] constipation remedy [ ] urgency [ ] dysuria

Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria

Watery stool yellowish in color [ ] denied

Comments loose passive Watery stool yellowish in

color and in moderate amount Bowel sounds hyperactive (2x3-5sec)

Abdominal distention [ ] yes [x] no

Urine (color odor Consistency) light colored in moderate amount

19

MANAGEMENT OF HEALTH AND

ILLNESS

[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable

[ ] Last menstrual period not applicable

Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic

health problems Patients mother is supportive to treatment regimen

and patient is cooperative

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY

[x] dry [ ] itching

[x ] other Poor skin turgor [ ] denied

[x] dry [ ] cold [ ] pale

[ ] flushed [x] warm [ ] moist [ ] cyanotic

Rashes ulcers decubitus (describe size location and drainage) None

ACTIVITY SAFETY

[ ] convulsion Comments ldquoluya jud

kaayo siya karon sugod pa atong nag kalibanga siyardquo

[ ] dizziness [ ] limited motion of joints

Limitation in the ability to

[x] ambulate [ ] bathe self [ ] other

[ ] denied

Level of consciousness and orientation

Patient is 11 months old Gait [ ] walker [ ] cane [x] others

[ ] steady [x] unsteady [ ] sensory losses in face or extremities

None

[ ] Range of motion limitation Patient is still unable

COMFORT SLEEP AWAKE

[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo

frequency remedies) [ ] nocturia [ x] sleep difficulties

[] denied

[x] facial grimace

[ ] guarding [ ] other signs of pain patient is Frequently

crying [ ] siderail release form signed (60+ years)

Not applicable

COPING

Occupation Not applicable since the patient is infant Most supportive person the mother and

father

Observed non-verbal behavior none

The person and his phone number that can be reached anytime

09063064576- patients father

20

VII Nursing Management

Nursing Diagnosis

Intervention Rationale

Hyperthermia related to dehydration as

evidence by flushed skin and warm to

touch

Independent

promote surface cooling by

means of tepid sponge bath

maintain bed rest

increase fluid intake (PO)

Collaborative

administer antipyretic

(paracetamol) as ordered

To lower down body temperature

To prevent energy consumption

To maintain fluid and electrolytes balance in the body

To lower down body temperature

21

Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to

excessive losses through normal

routes

Monitor intake and output note

number character and amout of

stools

Assess vital signs changes

Observe for excessively dry skin

and mucous membrane dry skin

turgor

Weigh daily

Administer parenteral as

indicated

Provide information about over

all fluid balance renal function

and bowel diseases control as

well as guidelines for fluid

replacement

Hypotension tachycardia and

fever can indicate response of

fluid loss

Indicates dehydration

Indicator of overall fluid and

nutritional status

Maintenance of bowel rest that

will require alternate fluid

replacement to correct losses

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

17

Gastrointestinal tract

Posterior tibial and

[] obese [] distention [] mass [] dysphagia [] rigidity [x] pain

[] assess the abdomen bowel habits and swallowing pulses are not [] bowel sounds and comfort [] no problem weight loss

Genito-urinary and Gyne

[] pain [] urine [] color [] vaginal bleeding

[] hematuria [] discharge [] nocturia body weakness [] assess urine frequency control color odor and comfort [] gyne bleeding discharge [x] no problem Diarrhea watery

stool Neuro

[] paralysis [] stuporous [] unsteady [] seizures Skin is hot to touch [] lethargic [] comatose [] vertigo [] tremors

[] confused [] vision [] grip [] assess motor function sensation LOC and strength

Non-pitting edema grip gait coordination and speech [x] no problem Musculo-skeletal and skin

extremities

[] appliance [] stiffness [] itching [] petechiae [] hot [] drainage

[] prosthesis [] swelling [] lesion [] poor turgor [] cool [] flushed Unsteady - patient [] atrophy [] pain [] ecchymosis [] diaphoretic []moist

needs assistance [] asses mobility motion gait alignment joint function

on ambulation [x] skin color texture turgor integrity [] no problem

Nursing Assessment II

SUBJECTIVE OBJECTIVE

COMMUNICATION

[] hearing loss Comments ldquowala man pud

problema iyang pandugog kay pag amu siyang tawgon mlingi man pud siya

[ ] visual changes

[ ] glasses [ ] language [ ] contact lens [ ] hearing aid [ ] speech difficulties

Pupil size 2mm

Reaction Pupils are equally rounded and reactive to

18

[ x ] denied light and accommodation

OXYGENATION

[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo

[] smoking history

[ ] cough [] sputum [x] denied

Respiration [x] regular [ ] irregular Description Regular breathing pattern

Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung

CIRCULATION

[ ] chest pain Comments ldquoNo subjective cue

gathered since the patient is an infantrdquo

[ ] leg pain [ ] numbness of extremities [ x] denied

Heart rhythm [x] regular [ ] irregular Ankle edema None

PulseCarotidRadialDorsalis pedisFemoral + + +

Right + + + Left Comments Heart beat and heart rhythm are normal

NUTRITION

Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo

[ ] vomiting character

[ x ] recent change in weight appetit [] swallowing

difficulty [ ] denied

[ ] dentures [x] none

FullPartial

upper [ ] [x] [ ]

lower [ ] [x] [ ]

ELIMINATION

Usual bowel pattern [ ] urinary frequency 2x a day3x a day

[ ] constipation remedy [ ] urgency [ ] dysuria

Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria

Watery stool yellowish in color [ ] denied

Comments loose passive Watery stool yellowish in

color and in moderate amount Bowel sounds hyperactive (2x3-5sec)

Abdominal distention [ ] yes [x] no

Urine (color odor Consistency) light colored in moderate amount

19

MANAGEMENT OF HEALTH AND

ILLNESS

[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable

[ ] Last menstrual period not applicable

Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic

health problems Patients mother is supportive to treatment regimen

and patient is cooperative

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY

[x] dry [ ] itching

[x ] other Poor skin turgor [ ] denied

[x] dry [ ] cold [ ] pale

[ ] flushed [x] warm [ ] moist [ ] cyanotic

Rashes ulcers decubitus (describe size location and drainage) None

ACTIVITY SAFETY

[ ] convulsion Comments ldquoluya jud

kaayo siya karon sugod pa atong nag kalibanga siyardquo

[ ] dizziness [ ] limited motion of joints

Limitation in the ability to

[x] ambulate [ ] bathe self [ ] other

[ ] denied

Level of consciousness and orientation

Patient is 11 months old Gait [ ] walker [ ] cane [x] others

[ ] steady [x] unsteady [ ] sensory losses in face or extremities

None

[ ] Range of motion limitation Patient is still unable

COMFORT SLEEP AWAKE

[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo

frequency remedies) [ ] nocturia [ x] sleep difficulties

[] denied

[x] facial grimace

[ ] guarding [ ] other signs of pain patient is Frequently

crying [ ] siderail release form signed (60+ years)

Not applicable

COPING

Occupation Not applicable since the patient is infant Most supportive person the mother and

father

Observed non-verbal behavior none

The person and his phone number that can be reached anytime

09063064576- patients father

20

VII Nursing Management

Nursing Diagnosis

Intervention Rationale

Hyperthermia related to dehydration as

evidence by flushed skin and warm to

touch

Independent

promote surface cooling by

means of tepid sponge bath

maintain bed rest

increase fluid intake (PO)

Collaborative

administer antipyretic

(paracetamol) as ordered

To lower down body temperature

To prevent energy consumption

To maintain fluid and electrolytes balance in the body

To lower down body temperature

21

Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to

excessive losses through normal

routes

Monitor intake and output note

number character and amout of

stools

Assess vital signs changes

Observe for excessively dry skin

and mucous membrane dry skin

turgor

Weigh daily

Administer parenteral as

indicated

Provide information about over

all fluid balance renal function

and bowel diseases control as

well as guidelines for fluid

replacement

Hypotension tachycardia and

fever can indicate response of

fluid loss

Indicates dehydration

Indicator of overall fluid and

nutritional status

Maintenance of bowel rest that

will require alternate fluid

replacement to correct losses

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

18

[ x ] denied light and accommodation

OXYGENATION

[ ] dyspnea Comments ldquowala man pud Hinuon siya gi ubordquo

[] smoking history

[ ] cough [] sputum [x] denied

Respiration [x] regular [ ] irregular Description Regular breathing pattern

Right Right lung is symmetrical to left lung Left Left lung is symmetrical to right lung

CIRCULATION

[ ] chest pain Comments ldquoNo subjective cue

gathered since the patient is an infantrdquo

[ ] leg pain [ ] numbness of extremities [ x] denied

Heart rhythm [x] regular [ ] irregular Ankle edema None

PulseCarotidRadialDorsalis pedisFemoral + + +

Right + + + Left Comments Heart beat and heart rhythm are normal

NUTRITION

Diet Diet for Age with aspiration precaution [ ] nausea Comments ldquoginagmay lang jud iyang ga kan-onrdquo

[ ] vomiting character

[ x ] recent change in weight appetit [] swallowing

difficulty [ ] denied

[ ] dentures [x] none

FullPartial

upper [ ] [x] [ ]

lower [ ] [x] [ ]

ELIMINATION

Usual bowel pattern [ ] urinary frequency 2x a day3x a day

[ ] constipation remedy [ ] urgency [ ] dysuria

Date of last BM [ ] hematuria March 23 2010 [ ] incontinence [ x ] diarrhea character [ ] polyuria

Watery stool yellowish in color [ ] denied

Comments loose passive Watery stool yellowish in

color and in moderate amount Bowel sounds hyperactive (2x3-5sec)

Abdominal distention [ ] yes [x] no

Urine (color odor Consistency) light colored in moderate amount

19

MANAGEMENT OF HEALTH AND

ILLNESS

[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable

[ ] Last menstrual period not applicable

Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic

health problems Patients mother is supportive to treatment regimen

and patient is cooperative

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY

[x] dry [ ] itching

[x ] other Poor skin turgor [ ] denied

[x] dry [ ] cold [ ] pale

[ ] flushed [x] warm [ ] moist [ ] cyanotic

Rashes ulcers decubitus (describe size location and drainage) None

ACTIVITY SAFETY

[ ] convulsion Comments ldquoluya jud

kaayo siya karon sugod pa atong nag kalibanga siyardquo

[ ] dizziness [ ] limited motion of joints

Limitation in the ability to

[x] ambulate [ ] bathe self [ ] other

[ ] denied

Level of consciousness and orientation

Patient is 11 months old Gait [ ] walker [ ] cane [x] others

[ ] steady [x] unsteady [ ] sensory losses in face or extremities

None

[ ] Range of motion limitation Patient is still unable

COMFORT SLEEP AWAKE

[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo

frequency remedies) [ ] nocturia [ x] sleep difficulties

[] denied

[x] facial grimace

[ ] guarding [ ] other signs of pain patient is Frequently

crying [ ] siderail release form signed (60+ years)

Not applicable

COPING

Occupation Not applicable since the patient is infant Most supportive person the mother and

father

Observed non-verbal behavior none

The person and his phone number that can be reached anytime

09063064576- patients father

20

VII Nursing Management

Nursing Diagnosis

Intervention Rationale

Hyperthermia related to dehydration as

evidence by flushed skin and warm to

touch

Independent

promote surface cooling by

means of tepid sponge bath

maintain bed rest

increase fluid intake (PO)

Collaborative

administer antipyretic

(paracetamol) as ordered

To lower down body temperature

To prevent energy consumption

To maintain fluid and electrolytes balance in the body

To lower down body temperature

21

Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to

excessive losses through normal

routes

Monitor intake and output note

number character and amout of

stools

Assess vital signs changes

Observe for excessively dry skin

and mucous membrane dry skin

turgor

Weigh daily

Administer parenteral as

indicated

Provide information about over

all fluid balance renal function

and bowel diseases control as

well as guidelines for fluid

replacement

Hypotension tachycardia and

fever can indicate response of

fluid loss

Indicates dehydration

Indicator of overall fluid and

nutritional status

Maintenance of bowel rest that

will require alternate fluid

replacement to correct losses

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

19

MANAGEMENT OF HEALTH AND

ILLNESS

[ ] alcohol (amount and frequency) [x] denied [ ] SBE Last pap smear not applicable

[ ] Last menstrual period not applicable

Briefly describe the patientrsquos ability to follow treatments (diet Medications etc) for chronic

health problems Patients mother is supportive to treatment regimen

and patient is cooperative

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY

[x] dry [ ] itching

[x ] other Poor skin turgor [ ] denied

[x] dry [ ] cold [ ] pale

[ ] flushed [x] warm [ ] moist [ ] cyanotic

Rashes ulcers decubitus (describe size location and drainage) None

ACTIVITY SAFETY

[ ] convulsion Comments ldquoluya jud

kaayo siya karon sugod pa atong nag kalibanga siyardquo

[ ] dizziness [ ] limited motion of joints

Limitation in the ability to

[x] ambulate [ ] bathe self [ ] other

[ ] denied

Level of consciousness and orientation

Patient is 11 months old Gait [ ] walker [ ] cane [x] others

[ ] steady [x] unsteady [ ] sensory losses in face or extremities

None

[ ] Range of motion limitation Patient is still unable

COMFORT SLEEP AWAKE

[x] pain Comments ldquosige siya ug hilak ga sakit jud siguro iyang tiyan anirdquo

frequency remedies) [ ] nocturia [ x] sleep difficulties

[] denied

[x] facial grimace

[ ] guarding [ ] other signs of pain patient is Frequently

crying [ ] siderail release form signed (60+ years)

Not applicable

COPING

Occupation Not applicable since the patient is infant Most supportive person the mother and

father

Observed non-verbal behavior none

The person and his phone number that can be reached anytime

09063064576- patients father

20

VII Nursing Management

Nursing Diagnosis

Intervention Rationale

Hyperthermia related to dehydration as

evidence by flushed skin and warm to

touch

Independent

promote surface cooling by

means of tepid sponge bath

maintain bed rest

increase fluid intake (PO)

Collaborative

administer antipyretic

(paracetamol) as ordered

To lower down body temperature

To prevent energy consumption

To maintain fluid and electrolytes balance in the body

To lower down body temperature

21

Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to

excessive losses through normal

routes

Monitor intake and output note

number character and amout of

stools

Assess vital signs changes

Observe for excessively dry skin

and mucous membrane dry skin

turgor

Weigh daily

Administer parenteral as

indicated

Provide information about over

all fluid balance renal function

and bowel diseases control as

well as guidelines for fluid

replacement

Hypotension tachycardia and

fever can indicate response of

fluid loss

Indicates dehydration

Indicator of overall fluid and

nutritional status

Maintenance of bowel rest that

will require alternate fluid

replacement to correct losses

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

20

VII Nursing Management

Nursing Diagnosis

Intervention Rationale

Hyperthermia related to dehydration as

evidence by flushed skin and warm to

touch

Independent

promote surface cooling by

means of tepid sponge bath

maintain bed rest

increase fluid intake (PO)

Collaborative

administer antipyretic

(paracetamol) as ordered

To lower down body temperature

To prevent energy consumption

To maintain fluid and electrolytes balance in the body

To lower down body temperature

21

Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to

excessive losses through normal

routes

Monitor intake and output note

number character and amout of

stools

Assess vital signs changes

Observe for excessively dry skin

and mucous membrane dry skin

turgor

Weigh daily

Administer parenteral as

indicated

Provide information about over

all fluid balance renal function

and bowel diseases control as

well as guidelines for fluid

replacement

Hypotension tachycardia and

fever can indicate response of

fluid loss

Indicates dehydration

Indicator of overall fluid and

nutritional status

Maintenance of bowel rest that

will require alternate fluid

replacement to correct losses

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

21

Nursing Diagnosis Intervention Rationale

Fluid volume deficient related to

excessive losses through normal

routes

Monitor intake and output note

number character and amout of

stools

Assess vital signs changes

Observe for excessively dry skin

and mucous membrane dry skin

turgor

Weigh daily

Administer parenteral as

indicated

Provide information about over

all fluid balance renal function

and bowel diseases control as

well as guidelines for fluid

replacement

Hypotension tachycardia and

fever can indicate response of

fluid loss

Indicates dehydration

Indicator of overall fluid and

nutritional status

Maintenance of bowel rest that

will require alternate fluid

replacement to correct losses

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

22

Nursing Diagnosis Interventions Rationale

Nutrition altered Less than body

requirements related to altered

absorption of nutrients and hyper

metabolic state

Weigh daily

Encourage bed rest or limited

activity during acute phase of

illness

Record intake changes in

symptomalogy

Provide oral hygiene

Keep NPO and administer

medication as indicated

Provide information about

dietary needs

Decreasing metabolic rate

needs aid in preventing caloric

depletion and conserves

energy

Useful in identifying specific

deficiency and determining GI

response to foods

Clean mouth can enhance the

taste of foods

Promote tissue

healingregeneration Prevent

treat anemia oral route for iron

supplement is ineffective

because of intestinal alteration

that for absorption of nutrients

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

23

Nursing Diagnosis Intervention Rationale

Acute pain related to hyper peristalsis

prolonged diarrhea skintissue

irritation peri rectal fissures fistulas

Note non verbal cues

Permit patient to assume

position of comfort

Cleans rectal area with mild

soap and water wipes after

defecating

Record abdominal distention

increase temperature and

decrease blood pressure

Implement prescribe dietary

modifications administer

medication as indicated

Non verbal cues may be used in

conjunction with verbal cues to

identify extent of the problem

Reduce abdominal tension and

sense of control

Protect skin from undigested

bowel contents preventing

excoriation

May indicate developing

intestinal obstruction from

inflammation

Complete bowel rest can reduce

pain and cramping

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

24

S NA

O -sudden loss of weight

-weak

-sunken fontanels

-consumes half of share

A Imbalanced Nutrition less than body requirements as evidenced by sudden change in

weight

P Long term At the end of an 16 hours of rendering nursing care the patient will be able

to maintain weight

Short term At the end of 8 hours the patient regain appetite

I 1 Monitored bowel sounds

2 Promoted pleasant relaxing environment

3 Checked stools

4 Consulted dietitian

5 Monitored laboratory studies

E After giving an intervention the patient have a good appetite and regain his weight

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

25

S

NA

O

-Frequently cries

-Restless

- facial grimaced

A

-Acute pain related to physiologic response of the stomach due to over stimulation

of the gastric acid

P

Long term At the end of 16 hours rendering nursing care patient will be able to be

relieved from pain as evidence by

Appears calm and comfortable

Short term At the end of 8 hours rendering nursing care the patient will be able to

demonstrate relief from pain

I

1 Provided with cool and well-ventilated room

2 Monitored vital signs of the patient to check for stability upon pain occur

3 Given some materials to divert his feeling of pain

4 Administered with anti-ulcer drugs or anti-pyretic drug as ordered

E

After 8 hours of intervention that has been given the patient able to be relived from

pain

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

26

S NA

O -sudden change of weight

-poor skin turgor

-dry mucous membranes

A Risk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement

P Long term At the end of 8 hours rendering nursing care the patient will

demonstrate a normal pattern of bowel function

Short term At the end of 5 hours rendering nursing care the patient will be able

to attain normal bowel pattern

I 1 Monitor intake and output

2 Increased fluid intake

3 Assessed vital signs skin turgor and mucous membrane

4 Checked and compare laboratory values

5 Provide IV Fluids with the doctorrsquos prescription

E After giving nursing intervention patient attain normal pattern of bowel

function

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

27

VIII Health Teaching

Medication

Before the patient is discharge patients mother was instructed to comply all

of his medication regimen as prescribe by the attending physician(DrBejarasco)

This medication is E-zinc Drops 1ml OD PO

Exercise

Patients mother was instructed to ambulate client and deep breathing

excercise and do ADLrsquos as tolerated by patient Tolerable excercises will promote

blood circulation and sense of well being and promote fast healing Relaxation

exercise may do

Treatment

Patients mother instructed to increased fluid intake of client This is to

promote regain of electrolytes and fluid balance Treatment regimen such as

some diet restriction exercise compliance on medication and to submit self 1

week after being discharge from the hospital Encouraged to maintain good

hygiene of client

Out-patient check-up

Patients mother was instructed to come back 1 week after or if symptoms

persist with Dr Bejarascorsquos clinic at sabal hospitalThis is to check the progress

of the patientrsquos treatment and to monitor any signs of further medical assistance

Diet

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

28

Patients mother encouraged to let client eat foods with high protein content such

as the egg whites and lean meats and also vegetable and encourage increased

fluid intake

IX Prognosis

PROGNOSTIC INDICATORS POOR GOOD

A Onset of illness X

B Duration of Illness X

C Attitude and willingness

to take medication

X

D Precipitating Factors X

F Family Support X

X REFERRALS AND FOLLOW UP

Before the patient is discharged from the hospital mother was suggested

to return the patient to his physician Dr Bejarasco one week after discharge for

follow up check-up for further evaluation instructions and care

The recovery of patientrsquos wounds depends on medications and treatment

regimen if it was followed religiously as ordered by his physician

XI Evaluation

At the end of two days of nursing care rendered to patient the patient showed

some sort of progress as evidence by

Clients stool is semi-formed

Has good appetite eating

Active and regained his strength

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

29

XII Implication

This study will serve as a reference material in rendering and competent

care to our patient especially those with similar conditions Through this we will

be able to develop our knowledge as well as our skills and attitudes in applying

the prescribed procedures to improve the health status of the patient

This study will act as a baseline data as well as guide for coming up with a

good reliable accurate and comprehensive research paper dealing with issues

commonly experienced by patients in the hospital setting This may aid the

researchers to widen the scope of the study in relation to more or less similar

cases

XIII Bibliography

WEBSITE

1 httpenwikipediaorgwindexphptitle=Piaget27s_cognitive_developm

entampaction=edit

2 httpwwwpatientcoukshowdoc40000681

3 httpenwikipediaorgwikiEriksons_stages_of_psychosocial_developme

ntMiddle_Adulthood_2835-60_Years29

4 httpenwikipediaorgwikiErikson27s_stages_of_psychosocial_develo

pment

5 Category Developmental psychology

6 ^ a b Murray PR Pfaller MA Rosenthal KS Medical Microbiology Mosby

2005 ISBN 0323033032

7 ^ Seven Surfing Sicknesses

8 ^ a b c d e The Oxford Textbook of Medicine Edited by David A Warrell

Timothy M Cox and John D Firth with Edward J Benz Fourth Edition

(2003) Oxford University Press ISBN 0-19-262922-0

9 ^ Haffejee IE (1991) The pathophysiology clinical features and

management of rotavirus diarrhoea Q J Med 79 (288) 289ndash

99 PMID 1649479

30

10 Patel MM Tate JE Selvarangan R et al (2007) Routine laboratory

testing data for surveillance of rotavirus hospitalizations to evaluate the

impact of vaccination (Subscription required) Pediatr Infect Dis

J 26 (10) 914ndash9 doi101097INF0b013e31812e52fd PMID 17901797

11 Pediatric ROTavirus European CommitTee (PROTECT) (2006) The

paediatric burden of rotavirus disease in Europe Epidemiol

Infect 134 (5) 908ndash

16doi101017S0950268806006091 PMID 16650331

12 Beards GM (1988) Laboratory diagnosis of viral gastroenteritis Eur J

Clin Microbiol Infect Dis 7 (1) 11ndash

3 doi101007BF01962164 PMID 3132369

BOOKS

1 Erikson Erik H Childhood and Society New York Norton

1950

2 Erikson Erik H Identity and the Life Cycle New York

International Universities Press 1959

3 Medical Surgical Nursing by Smeltzer

4 Nursing Pocket Guide by Sheesy Gail

5 NCP by Doenges 2nd ed pp423-430

6 Modern Medical Guide by Harold shryock MD pp 285-287

7 Maternal and Child Health Nursing by Adele Pillitteri pp

1264-1265

8 Texbook of Medical- Surgical Nursing by Brunner and

suddarthrsquos pp 1020-1033