Liceo de Cagayan UniversityR.N. Pelaez Blvd., Carmen, CDOC

COLLEGE OF NURSING

CASE STUDY

(Role – In Infectious Diarrhea and Oral Thrush)

In Partial Fulfillment for the Requirements

of the Course NCM501200

Submitted by:

Artajo, Agusto Cesar C. Bual, Sunshine Jane D.Berol, Maria Katrina V. Patlunag, Shiela Mae V.Bersamen, Maya Mae A. Roa, Xyza Loise Rae N.Berse, Tiffany Hazel D. Roxas, Marlo A.Buagas, Ruth L. Olape, Manelyn

Tumulak, April Regina D.

Submitted to:

Mrs. Livia B. Dato, RN, MNClinical Instructor

March 14, 2009

Chapter I

INTRODUCTION

A. Overview of the case

Health is the absence of any illnesses. It is also defined by World Health

Organization (WHO) that health is a state of complete physical, mental and social well-

being not merely the absence of disease. However, illnesses are the abnormalities or

disorders that any one can have. These might be fatal or not. And being healthy is one

of the rights of every individual, thus when an individual becomes ill, he/she demands

for quality health care.

This is a case study of a child named James Gabriel Lugsanay, 2 years and 3

months of age, a Roman Catholic admitted at Polymedic General Hospital, Velez St.

Cagayan de Oro City. His chief complaints are Loose Bowel Movement (LBM), oral

ulcers, fever, and loss of appetite. Three days prior to admission, James has acute

onset and moderate grade fever associated with loose watery stool, moderate and

blood stricked every two (2) hours. And two (2) days prior to admission, James has

onset oral ulcers associated with anorexia persistent of condition –admission.

James Gabriel was diagnosed with Role-In Infectious Diarrhea and Oral Thrush.

Infectious diarrhea is an alteration of normal bowel habits, usually characterized by

increased stool frequency and liquid consistency, which is caused by infectious

bacteria, viruses or protozoa that infect the intestinal tracts of humans and animals. The

infectious organisms are normally contracted by ingestion of contaminated water or

food. Some of the more well-known organisms causing infectious diarrhea include

Campylobacter, enterotoxigenic or Shiga toxin-producing E. coli, Salmonella, Shigella,

Clostridium, Cryptosporidium, Giardia, Cyclospora and rotavirus. Acute cases of

infectious diarrhea can, however, lead to dehydration and even death. Persistent or

chronic diarrhea often associated with intestinal protozoan infections can also cause

serious long-term consequences, including malnutrition and impairment of physical or

cognitive development. (www.houstonhealthcare.com)

Oral thrush is a condition in which the fungus Candida albicans accumulates on

the lining of your mouth. Oral thrush causes creamy white lesions, usually on your

tongue or inner cheeks. The lesions can be painful and may bleed slightly when you

scrape them or brush your teeth. Sometimes oral thrush may spread to the roof of your

mouth, your gums, tonsils or the back of your throat. Although oral thrush can affect

anyone, it occurs most often in babies and toddlers, older adults, and in people with

compromised immune systems. Oral thrush is a minor problem for healthy children and

adults, but for those with weakened immune systems, symptoms of oral thrush may be

more severe, widespread and difficult to control. (20 August 2007,

www.mayoclinic.com)

B. Objectives of the study

The case study is designed to identify health problems or potential health threats

that could arise in our patient. As a student nurses, it is expected from us that we will

apply what we have learned from our class lectures in the actual settings.

The study focuses to accomplish the following objectives to our patient with Role-

In Infectious Diarrhea and Oral Thrush.

To understand the underlying causes of the patient’s health condition;

To learn its medications and treatments;

Implement nursing interventions, having the skills of an efficient and effective

nurse, depending on assessment done;

To provide the patient specific information with regards to infectious diarrhea

and oral thrush; and

To develop a case study appropriately.

C. Scope and Limitation of the study

The study focuses on the admitting diagnosis of patient James Gabriel Lugsanay

which is the Role-in Infectious Diarrhea and Oral Thrush, where he was confined at

room 305 in Polymedic General Hospital in Velez, Cagayan de Oro City.

The study covers the patient’s health history, present illness, developmental

data, and medical and nursing management.

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

his personal chart. The data gathering was also limited during the confinement of the

patient last February 16, 2009.

Chapter II

HEALTH HISTORY

A. Profile of the patient

Name: James Gabriel Lugsanay

Age: 2 years and 3 months old

Sex: male

Address: Gusa, Cagayan de Oro City

Civil Status: child

Birth date: November 22, 2006

Birth place: Cagayan de Oro City

Religion: Roman Catholic

Nationality: Filipino

Parent: Mrs. Florie Fe Lugsanay (mother, 2nd child pregnant)

Mr. Lugsanay (father)

Date and Time Admitted: February 15, 2009 @ 7:00 pm

Allergies: none

Baseline Vital Signs upon admission:

Temperature: 38.6 °C Respiratory rate: 33 cpm

Pulse rate: ----

Condition upon condition:

Chief Complaint: LBM, oral ulcers, fever, anorexia (loss of appetite)

Admitting Diagnosis: Role-In (RI) Infectious Diarrhea and Oral Thrush

Admitting Physician: Dr. Guangco

B. Family and Personal Health History

Upon interview, the mother of the patient admitted that her child James Gabriel

loves to put anything he holds into his mouth. Before admission, the child already had a

cough, fever and started to loss his appetite because of the oral ulcers in his mouth.

C. Chief Complaint and History of Present Illness

The patient’s chief complaint was Loose Bowel Movement (LBM), oral ulcers,

fever, and loss of appetite. Three (3) days prior to admission, patient James Gabriel

was having an acute onset and moderate grade fever associated with loose watery

stool, moderate and blood stricked every two (2) hours. Two (2) days prior to admission,

patient James Gabriel has onset oral ulcers with loss of appetite persistent of condition.

Then the patient was admitted with diagnosis RI Infectious Diarrhea and Oral Thrush.

Chapter III

DEVELOPMENTAL THEORY

ERIK ERIKSON

Toddler (18 months to 3 years)

Psychosocial Crisis: Autonomy vs. shame and doubt

Related Elements in Society: Law (legitimizes and provides boundaries for

autonomy)

If denied independence, the child will turn against his/her urges to manipulate

and discriminate; shame develops with the child’s self-consciousness. Doubt has to do

with having a forth and back – a “behind” subject to its own rules. Left over doubt may

become paranoia. The sense of autonomy fostered in the child and modified as life

progresses serves the preservation in economic and political life of a sense of justice.

Ego quality: will

When a child reaches the age of one to the age of three, Erikson explains, the

child is developing a sense of autonomy, during this age; the toddler discovers he/she is

no longer attached to the primary caregiver but is a separate individual. Autonomy is the

independence a toddler strives for from caregivers. Toddler’s autonomous behavior is a

way of forming their own identify away from their caregivers. This stage is a time where

a toddler has the “will” to become independent. Shame and doubt are likely to occur

when the toddler is not given any choices or boundaries because the toddler is

determined to become independent. The strong will of a toddler may cause conflict

between the child and caregiver. Many parents are unaware of how to properly handle

difficult situations in which they find themselves. Parents who are assertive and too

demanding may find themselves in power struggle with their toddler.

ROBERT HAVIGHURST

Infancy and early childhood (0-5 years old)

Attached theory is primarily an evolutionary and ethological theory whereby the

infant or child seeks proximity to a specified attachment figure in situations of alarm or

distress, for the purpose of survival. The forming of attachments is considered to be the

foundation of the infant/child’s capacity to form and conduct relationships throughout

life. Attachment and attachment behaviors tend to develop between the ages of 6

months and 3 years. Infants become attached to adults who are sensitive and

responsive in social interactions with the infant, and who remain as consistent

caregivers for some time. Parental responses lead to the development of patterns of

attachment which in turn lead to “internal working models” which will guide the

individual’s feelings, thoughts, and expectations in later relationships. There are number

of attachment “style” namely “secure”, “anxious-ambivalent”, “anxious-avoidant”, (all

“organized”) and “disorganized”, some of which are more problematic than others. A

lack of attachment or a seriously disrupted capacity for attachment could potentially

amount to serious disorders.

Neonates

A human infant less than a month old is a newborn or a neonate. The term

“newborn” includes premature infants, post mature infants, and full term newborns.

Toddlers

Upon reaching the age of one or beginning to walk, infants are referred to as

“toddlers” (generally 12-36 months).

Infants cry as a form of basic instinctive communication. A crying infant may be

trying to express a variety of feelings including hunger, discomfort, over stimulation,

boredom, wanting something, or loneliness.

1. Task that arise from physical maturation.

For example, learning to walk, talk, and behave an acceptably with the opposite

sex during adolescence; adjusting to menopause during middle age.

2. Tasks that from personal resources.

For example, those emerge from the maturing personality and take the forms of

personal values and aspirations, such as learning the necessary skills for job

success.

3. Tasks that have their source in the pressures of society.

For example, learning to read or learning the role of a responsible citizen.

Havighurst has identified six major age periods:

infancy and early childhood (0-5 years)

middle childhood (6-12 years)

adolescence (13-18 years)

early adulthood (19-29 years)

middle adulthood (30-60 years); and

later maturity (61 and above)

Chapter V

PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A. Pathophysiology of Diarrhea

Diarrhea is an increase in the volume of stool or frequency of defecation. It is one

of the most common clinical signs of gastrointestinal disease, but also can reflect

primary disorders outside of the digestive system. Certainly, disorders affecting either

the small or large bowel can lead to diarrhea. For many people, diarrhea represents an

occasional inconvenience or annoyance, yet at least 2 million people in the world,

mostly children, die from the consequences of diarrhea each year. There are numerous

causes of diarrhea, but in almost all cases, this disorder is a manifestation of one of the

four basic mechanisms described below. (R. Bowen.,July 27, 2006.

http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/smallgut/diarrhea.html).

DIGESTION PROCESSES:

INGESTION(Voluntary process of taking foods)

PROPULSION(Movement of food along the digestive tract)

DIGESTION(Breakdown of foods)

ABSORPTION(The passage of digested foods from

digestive tract and distributed to other body system)

DEFECATION(Elimination)

Fig.1 The Digestive system

All segments of intestine from duodenum to distal colon have mechanisms for

both absorbing and secreting water and electrolytes. Diarrhea results when the

remarkable efficiency of the gut for absorbing water, electrolyte, and nutrients is

impaired. About 9-10 liters of water and electrolyte enter the upper jejunum daily, of

which one liter is delivered to the cecum, and one-tenth of a liter is delivered to the

outside world. Decreasing this efficiency from 99% to 98% would double fecal water to

produce potentially a wetter stool. A great variety of drugs, toxins, pathogens, and food

stuffs can impair the efficiency of salt and water absorption. (Lonny M. Hecker, M.D.,

David R. Saunders, M.D., and David Losh, M.D.

http://www.uwgi.org/guidelines/ch_04/CH04TXT.HTM)

The chief contribution of the stomach to digestion and absorption is metered

delivery of food and drink to the small intestine so that the absorptive capacity of the

upper small intestine is not overwhelmed.

Carbohydrate and protein in the small and large intestines are especially

important in increasing the efficiency of sodium and water absorption. Soluble starches

are digested by pancreatic amylase into small chains of glucose molecules which,

together with the ingested disaccharides (lactose and sucrose), are hydrolyzed to

monomers by brush border enzymes.

Absorption of sodium (and water) is coupled to the absorption of glucose and

galactose, especially in the duodenum and jejunum. Much of the available sugars have

been absorbed when chyme arrives in the ileum, where sodium absorption relies on

sodium/hydrogen and chloride/bicarbonate exhangers. Carbohydrate which escapes

absorption in the small intestine is fermented by colonic bacteria to short-chain fatty

acids whose colonic absorption enhances sodium (and water) transport and provides

nutrients for colonic absorptive cells. By the time feces reach the left colon, most of the

available carbohydrate has been fermented so that sodium absorption becomes

dependent on exhangers and on sodium - channels.

Dietary protein also enhances sodium and water absorption by mechanisms

similar to those described for carbohydrate. Amino acids and sodium are absorbed by

coupled transport, and short-chain fatty acids derived from amino acids in the right

colon enhance sodium (and water) absorption.

Colonic bacteria do not salvage appreciable amounts of unabsorbed long-chain

fatty acids (LCFA). In fact, the double bonds of dietary LCFA may be hydroxylated so

that the excreted LCFA bears little resemblance to the dietary LCFA, and they may

become more potent inhibitors of colonic absorption.

A final consideration is the mouth-to-anus transit time which can be derived by

measuring the transit of the head of the meal (HOMTT), or of the whole meal (WMTT).

WMTT involves ingesting a number of radio-opaque, or isotopically-labeled pellets

whose average mouth-to-anus transit time is calculated. WMTT is 48-72 hours in

normal subjects [Cummings, 1976], [Metcalf, 1987]. Pellets have the longest residence

in the colon, and fecal weights are inversely proportional to the time of colonic residence

[Vassallo, 1992]. Head of meal transit time (HOMTT) is measured with a poorly-

absorbed colored substance, and it is the time between ingestion and the first

appearance of the color in the stools. HOMTT averaged 36 hours after 14 healthy

subjects ingested carmine red with an English breakfast; diarrhea ensued when the

HOMTT was experimentally reduced to less than 12 hours.

The punch-line: the overall balance for the absorption of sodium is 99%; of

starch, 99%; of protein, 95%; and of LCFA, 95%, and these remarkable efficiencies

depend on adequate lumenal digestion, absorptive cell surface, and transit time.

Mechanistically, absorption may be impaired by poorly absorbed, osmotically

active solutes in the intestinal lumen, by alteration in absorptive cell function, by

increases in crypt cell secretion, and by too rapid transit of intestinal contents. Most

often, absorption is impaired by mechanisms acting in concert. For example, excessive

volume of intestinal contents can speed intestinal transit; cytokines from mural

inflammatory cells can enhance cryptal secretion, and can influence the enteric nervous

system to speed transit; bile salts, and long-chain fatty acids, malabsorbed in the small

intestine, can block water and electrolyte absorption in the colon.

The colon employs several mechanisms to ensure it delivers to the rectosigmoid a

formed stool, probably the most important factor in fecal continence. The colon has

reserve capacity by which it can absorb 2-3 extra liters of water and electrolyte

delivered from the small intestine in a day [Debongnie, 1978].

Colonic bacteria ferment soluble carbohydrate and protein, which escaped small

intestinal absorption, into absorbable gases and short-chain fatty acids. Otherwise,

these unfermented, unabsorbed solutes would be osmotically active in colonic contents,

and would cause diarrhea.

B. Pathophysiology of Oral thrush

C albicans causes thrush when normal host immunity or normal host flora is

disrupted. Overgrowth of yeast on the oral mucosa leads to desquamation of epithelial

cells and accumulation of bacteria, keratin, and necrotic tissue. This debris combines to

form a pseudomembrane, which may closely adhere to the mucosa. This membrane is

usually not large but may rarely involve extensive areas of edema, ulceration, and

necrosis of the underlying mucosa.

Affected neonates are typically colonized by C albicans during passage through

the birth canal. Hence, the risk for thrush is increased when the mother has an active

vaginal yeast infection. Other sources of transmission to neonates include colonized

breasts (for breastfed infants), hands, and/or improperly cleaned bottle nipples. Kissing

has also been implicated.

C albicans frequently and asymptomatically inhabits the GI tract of many children

and adults, and the GI tract has been implicated as a reservoir for yeast contamination

of the perineum. Thus, candidal diaper rash frequently occurs in conjunction with thrush.

(Robert W Tolan Jr, MD, Jan 23, 2009 http://emedicine.medscape.com/article/969147-

overview )

HEALTH TEACHINGS IN RI INFECTIOUS DIARRHEA

MEDICATION

The patient is advised to follow and take the prescribed

medication regimen needed to the fast recovery and

effective treatment. Teachings and information about

medicines and its side effects are also given. The following

medications were prescribed as follows:

Nifuroxazide (Ercefuryl) susp. ml BID

Bacillus clausii (Erceflora) vial OD

EXERCISE

The patient was encouraged to have complete care and

rest and intake of plenty of fluids to replace the lost liquids

in the body.

TREATMENT

The patient was encouraged to wash hands well and

often to prevent the passing of infectious germs, must stay

nourished and well hydrated and take medications exactly

as directed by the physician.

OUT- PATIENT/

FOLLOW- UP

The patient was instructed to report to his physician a

week after the discharge for a follow-up check-up. Also to

take medications promptly as directed.

DIET

The patients was advised to encourage frequent intake

of soft, easily digested foods such as bananas, wheat,

potatoes, and also encourage hydration with fruit drinks

and water.

HEALTH TEACHINGS IN ORAL THRUSH

MEDICATION

The patient is advised to follow and take the medication

regimen needed to the fast recovery and effective

treatment. Teachings and information about the medicines

and its side effects are also given. The following

medication was prescribed as follows:

Miconazole (Daktarin) Oral gel, apply 2x a day over

oral thrush

EXERCISE The patient was taught to have his rest and complete

care.

TREATMENT

The patient was encouraged to practice good oral

hygiene, wash hands after playing with toys, and cleaning

the toys used after using them and proper compliance of

home medications should be followed as prescribed by the

doctor.

OUT- PATIENT/

FOLLOW- UP

The patient was instructed to report to his physician

after consuming the medications for a follow-up check-up

and for further treatments and /or medications. Also to take

medicines promptly.

DIET

The patient is advised to try limiting the amount of

sugar and yeast-containing foods that may encourage the

growth of Candida (yeast germ).

Chapter VII

NURSING MANAGEMENT

A. IDEAL NURSING CARE PLAN

1.) Diarrhea: Increased bowel movement

Interventions: Rationale:

Observe and record stool frequency,

characteristics, amount and precipitating

factors.

Identify foods and fluid intake that

precipitate diarrhea.

Restart and fluid intake gradually. Offer

clear liquids hourly; avoid cold fluids.

Help differentiates individual disease and

assesses severity of episodes.

Avoiding intestinal irritants and promote

intestinal rest.

Provides colon rest by omitting or

decreasing the stimulus of foods/fluids.

Gradual resumption of liquids may prevent

cramping and recurrence of diarrhea.

However, cold fluids can increase

intestinal motility.

2.) Self-care deficit: Oral hygiene and Acute pain

Interventions: Rationale:

Assess abilities and level of deficit

(through scaling) per performing ADLS.

Encourage SO to allow patient to help in

proper hygiene as much as possible.

Aids in participating/planning for meeting

individual needs.

Reestablish ----- of well care and help in

promoting proper oral hygiene.

3.) Nutrition Imbalanced: Less than body requirements

Interventions: Rationale:

Assess nutritional status continually,

during daily nursing care, noting energy

level; condition of oral cavity; desire to eat.

Provides the opportunity to observe

deviations from normal patient baseline;

and influence choice of intervention.

4.) Hyperthermia

Interventions: Rationale:

To assess causative/contributing factors.

To evaluate effects/degree of

hyperthermia.

To assist with measures to reduce/restore

normal body temperature and functions.

Identify the underlying cause.

Identify and determine the effects.

To maintain normal range of body

temperature.

B. ACTUAL NURSING CARE PLAN

Patient’s Name: JAMES GABRIEL LUGSANAY

CUES: NURSING DX: OBJECTIVES: INTERVENTIONS: RATIONALE: EVALUATIONS:

Subjective:

“Sakit iyang tiyan, basa iyang tae, sige kaibang” as verbalized by the mother.

Objectives:

watery stool

bowel movement 5x a day

poor skin turgor

flushed skin

Fluid volume deficit related to excessive bowel movement from normal route.

At the end of nursing care, the patient will be able to report reduction in frequency of stool.

1.) Observe and record stool frequency, characteristics and amount.

2.) Monitor intake and output.

3.) Prepare oral Rehydration solution (ORS).

4.) Instruct SO to refrain drinking water with unsafe faucet.

5.) Administer medications as indicated.

It helps the normal frequency of stool and assesses severity of episodes.

To identify about information on overall fluid balance.

To replace lost of fluid in non-dehydrated child.

To minimize contamination.

To minimize infections.

After nursing care, the patient was able to minimize the frequency of stool.

CUES: NURSING DX: OBJECTIVES: INTERVENTIONS: RATIONALE: EVALUATIONS:

Subjective:

“ init iyang panit, taas iyang temperature” as verbalized by the mother.

Objective:

fever: 38.6 ºC

RR: 33 cpm

Flushed skin

Hyperthermia related to oral thrush.

At the end of 30 min., the patient’s temperature will lower down to 38 ºC.

1. Monitor patient’s temperature.

2. Provide Tepid Sponge Bath (TSB).

3. Provide cold drinks.

4. medication: oral gel

To determine the patient’s temperature.

Help reduce fever.

To replenish body fluid and prevent dryness of the mouth.

To lessen oral thrush.

After the intervention was given, the patient’s temperature lowered down to 38.1 ºC.

CUES: NURSING DX: OBJECTIVES: INTERVENTIONS: RATIONALE: EVALUATIONS:

Subjective:

“Gapula iyang baba, ug ga dugo. Sakit pud daw.” As verbalized by the mother.

Objective:

swollen gums

presence of blood

inflammation in the mouth

facial grimaces

Acute Pain related to milky curds, lesions and blisters in the mouth.

At the end of the nursing care, the patient’s pain will be minimized

1. Promote oral hygiene.

2. Divert the patient’s attention to relaxing activities.

3. medication: oral gel.

To lessen infection.

To divert and lessen pain.

To lessen oral thrush.

After the nursing care, the patient’s pain was minimized.

CUES: NURSING DX: OBJECTIVES: INTERVENTIONS: RATIONALE: EVALUATIONS:

Subjective:

“Dili ga kaon, sakitan siya kung mo didi sa beberon, ug dili ka tulon” as verbalized by the mother.

Objective:

loss of appetite

Altered nutrition related to inadequate food intake due to oral thrush.

At the end of the nursing care, the patient shall regain his appetite slowly.

1. Promote proper oral hygiene.

2. Instruct SO to sterilize feeding bottles.

3. Instruct SO to clean all materials used including the toys.

4. Encourage soft diet.

To minimize oral thrush.

To prevent contamination.

To prevent contamination,

To promote nutrition balance.

Outcome slightly met and still improving after the nursing care.

Chapter VIII

REFERRAL AND FOLLOW-UP

The mother of the patient has been always given detailed instructions to become

proficient in special care needs by her son when they are discharged. We advised the

mother of the patient to refer to his attending physician, and arrange schedule of

appointments regarding her son’s follow-ups and possible home medications.

We also reminded the mother of the patient to follow promptly the medications

prescribed by the physician to her son and to report any side effects or adverse

reactions may observed. Avoid contaminated foods that would trigger his condition.

Chapter X

DOCUMENTATION

Chapter XI

BIBLIOGRAPHY

http://www.ecureme.com/emyhealth/data/Infectious_Diarrhea.asp

http://www.mayoclinic.com/health/oral-thrush/DS00408

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=symptoms

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=causes

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=risk%2Dfactors

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=when%2Dto%2Dseek%2Dmedical%2Dadvice

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=tests%2Dand%2Ddiagnosis

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=complications

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=treatments%2Dand%2Ddrugs

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=prevention

http://www.mayoclinic.com/health/oral-thrush/DS00408/DSECTION=lifestyle%2Dand%2Dhome%2Dremedies

R. Bowen.,July 27, 2006. http://arbl.cvmbs.colostate.edu/hbooks/pathphys/digestion/smallgut/diarrhea.html

Lonny M. Hecker, M.D., David R. Saunders, M.D., and David Losh, M.D. http://www.uwgi.org/guidelines/ch_04/CH04TXT.HTM

Robert W Tolan Jr, MD, Jan 23, 2009 http://emedicine.medscape.com/article/969147-overview