Angeles University Foundation

Angeles City

College of Nursing

A.Y. 2009-2010

A Case Study on Acute Gastroenteritis with

Dehydration
In Partial Fulfilment of the Requirements in

Related Learning Experience III

Presented by:

Cambronero, Karen B.

De Leon, Michaela Joyce C.

Jimenez, Donna Krishna B.

BSN III-14
GROUP-55
Subgroup #1

Presented to:

Mr. Edwin Y. Balatbat, R.N.

July 6, 2009
 I. INTRODUCTION

Gastrointestinal problems are very common in childhood. Numbers of

medical and surgical problems are found among children. GI disturbances are
influenced by the problems of liver and pancreas. Digestion, absorption and
metabolism are combined actions of gastrointestinal and hepatopancreative
system. Functions of the GI systems are also related to combined actions of
many functional systems. Disturbances in any one, affects GI system leasing
to various problems. For example diarrhea develops due to increased
overload of fluid from small intestines into the colon following maldigestion
and active secretions. Defect of intestinal mucosal immunity may lead to
intestinal infections. Intestinal obstruction follows loss of normal intestinal
motility. Problems of digestion and absorption may cause complaints, failure
to thrive and weight loss.

GI problems are manifested commonly with vomiting, diarrhea or

constipation, pain abdomen, anorexia, nausea, abdominal distension, etc.
Problems of maldigestion and malabsorption are presented as poor general
health and growth retardation. Fluid electrolyte imbalance, circulatory
disturbances, renal disorders, GI bleeding, nutritional deficiency diseases
may develop in association with GI disorders.

The GI tract is imperative for our well being and our life-long health. A
non-functioning or poorly functioning GI tract can be the source of many
chronic health problems that can interfere with your quality of life. In many
instances the death of a person begins in the intestines.

There are many diseases involving the gastrointestinal system one of

which is acute gastroenteritis. Gastroenteritis is a nonspecific term for
various pathologic states of the gastrointestinal tract. A universal definition of
diarrhea does not exist, although most definitions center on the frequency,
consistency, and water content of stools, this is preferably define as diarrhea
in which stools takes the shape of their container.
 The severity of illness may vary from mild and inconvenient to severe
and life threatening. Appropriate management requires extensive history and
assessment and appropriate, general supportive treatment that is often
ethiology specific.

Gastroenteritis is likely to arise anywhere people congregate, such as

schools, cruise ships, campgrounds, and dormitories. People who travel
throughout the developing world are also likely to develop the condition due
to food contamination or a lack of hygiene. Moreover, severity of the disease
can vary widely depending on the volume of fluid loss, accurately assessing
and treating dehydration in children presenting with acute gastroenteritis
remains a critical skill for every emergency physician. Luckily, most cases of
dehydration in children can be accurately diagnosed by a careful clinical
examination and treated with simple, cost-effective measures.

Special Diagnostic procedures related to GI diseases include barium

meal, endoscopy, pH monitoring, stool examination, enzyme estimation, USG,
abdominal X-ray etc.

A. CURRENT TRENDS ABOUT THE DISEASE CONDITION

OVERVIEW OF THE DISEASE

Gastroenteritis means irritation and inflammation of the

gastrointestinal tract, which includes the stomach and small and large
intestines. The condition is usually due to bacteria, food poisoning, parasites,
or viruses, and it often results in diarrhea, abdominal pain, nausea, and
vomiting. Gastroenteritis is commonly called gastric flu or stomach flu
although it has no relation to the influenza virus.

Bacterial causes of gastroenteritis include E. Coli (from traveler's

diarrhea, food poisoning, dysentery, colitis, or uremic syndrome), Salmonella
(from typhoid or improperly handling poultry or reptiles), Campylobacter
(from undercooked meat or unpasteurized milk), and Shigella (from
dysentery). A study found that 10% of children's diarrhea cases are caused
by E. Coli.
 Additional causes of gastroenteritis arise from parasites or protozoans
such as Giardia and Cryptosporidium, chemical toxins, heavy metals such as
arsenic, lead, and mercury, and medications such as antibiotics, aspirin,
caffeine, steroids, and laxatives. Lactose intolerance - the inability to digest
the milk sugar lactose - is also a common cause of gastroenteritis.

HOW GASTROENTERITIS CAN BE PREVENTED?

To stop infections from spreading, it is recommended that you wash

your hands, eat properly washed, cooked, or prepared foods, bleach soiled
laundry, and acquire the necessary vaccinations for Salmonella typhi, Vibrio
cholera, and rotavirus if traveling to a high risk area. A study showed that
pentavalent an oral rotavirus vaccine reduced hospitalisations and accident
and emergency (A&E) department visits related to rotavirus gastroenteritis
(RVGE) by up to 100%.

Most people recover easily from a short bout with vomiting and diarrhea
by drinking fluids and easing back into a normal diet. But for others, such as
babies and the elderly, loss of bodily fluid with gastroenteritis can cause
dehydration, which is a life-threatening illness unless the condition is treated
and fluids restored.

B. REASONS FOR CHOOSING SUCH CASE FOR PRESENTATION

The group decided to accomplish a case study about Acute Gastroenteritis

in order to acquire some in-depth knowledge about Acute Gastroenteritis and
be familiar with the different aspects related to this disease condition. In this
case, we will be able to impart awareness the preventive measures
applicable to the society to reduce or eliminate this certain kind illness. The
group also found it to be useful if they would gain the following information
about this disease: its etiology, pathophysiology, clinical manifestation,
diagnostic procedures and its management. It is also important that we know
how to state and recognize nursing diagnoses and related expected patient
are outcomes usually applicable to a patient with Acute Gastroenteritis as
well as to clarify the basis for assessment of nursing care provided to a
patient with Acute Gastroenteritis. For the group’s future encounter with this
kind of disease, they would be knowledgeable and skilled enough to manage
this disease and facilitate patients in attaining their finest level of
performance.

II. NURSING ASSESSMENT

1. PERSONAL DATA
June 18, 2009, at exactly 5:40 in the afternoon, a three-month old baby was
admitted in Ospital Ning Angeles. He is Baby Pooh (not his real name). He
was born on March 29, 2009 at Dra. Bacud’s clinic and was baptized as a
Roman Catholic. He is a Filipino citizen. He is the youngest son of Mr. and
Mrs. X who currently resides at Phase 1, Camatchiles Resettlement in
Mabalacat Pampanga.
On June 29, 2009 he was discharged.

Note: Personal informations were obtained with the permission of the mother
of Baby Pooh.

2. PERTINENT FAMILY HISTORY

X family is a nuclear type which is composed of six (6) family

members, 4 siblings and the parents. Baby Pooh was born via Normal
Spontaneous delivery like his other siblings. But among them, he is the only
one who was born in a clinic, unlike his other siblings who were born in a
hospital.
The obstetrical history of Mrs. X is G4P4T3P1A0L4M0. She has delivered
one preterm baby and three full term babies. According to her, she is very
supportive on her children. She doesn’t want anyone of them to be in harm.

According to the mother their house is made up of concrete materials,

with two rooms. They also have a kitchen, comfort room, and six windows
made up of jalousies. Mrs. X is currently not working, and her husband is the
one who is working for their family. He works as a construction worker.
 Regarding the cultural beliefs of the family, the mother stated that she
believes in “hilot” and herbolarios. She believes that after delivery, a woman
must not take a bath. At the time that we got to know her in the hospital
when we were attending to the needs of his son, she stated that she’s not
feeling well for the past few days, and she said that she was “nabinat”. She
also said that she knew these beliefs from her mother.

Mr. and Mrs. X use herbal medicines in treating mild conditions like
cough, colds, in treating wound, etc. And if a serious condition arises, that’s
the time that she will go to a hospital.

FAMILY HEALTH HISTORY

GRAND MR. X GRAND BABY POOH GRAND MRS. X GRAND

FATHER MOTHER FATHER MOTHER
(35 y/o, still alive and (3 months
BABYold,
BABY with an (26 y/o, still alive and
TINKY
DIPSY
LALA
(asthma)
has no present(old age) illness(3
ofy/o)
(6
(5 (heart attack)
AGE with has no present(Diabetes
illness) DHN) illness) Mellitus)
About the diagram:
As you can see, there is no history showing that AGE happened from
the family of Baby Pooh. On his father side, his grandfather died because of
he had asthma. While his grandmother, she died because of old age. On the
mother side, his grandfather died because he had a heart attack and his
grandmother, because of having Diabetes Mellitus. Her mother and father are
still alive including his other siblings. His siblings had a history of mild
illnesses like fever, cough, and none of them developed a severe illness
except for Baby Pooh.

3. PERSONAL HISTORY

According to Mrs. X, when she is pregnant, she still does household chores,
but only those that are easy to accomplish. She also walks every morning as
a form of her exercise. She said that there was a time that she lost her
appetite and she really craved for a certain food. And also, she narrated that
she is very irritable when she is pregnant. Her mother advised her of some
don’ts during pregnancy like avoiding preserved foods and even the eggplant
must not be eaten by pregnant women.

With regards to the labor, Mrs. X delivered her first three babies in a hospital,
and without anesthesia. While on her last baby, anesthesia was used. And it
took 4 hours to deliver a full term, 6.6-pound baby boy (Baby Pooh). There
were no complications happened after the delivery. According to her, during
her first baby, she tried feeding her child with breast milk, but because of
being uncomfortable and having pain on her breasts, she stopped feeding her
baby with breast milk. And until now, she doesn’t provide breast milk to her
other babies.

Growth and development:

ERIK ERIKSON
Trust vs. Mistrust (from birth-18 months)
 The first stage is the infant, approximately the first year or year and a
half of life. The task is to develop trust without completely eliminating the
capacity for mistrust.
If mom and dad can give the newborn a degree of familiarity, consistency,
and continuity, then the child will develop the feeling that the world --
especially the social world -- is a safe place to be, that people are reliable and
loving. Through the parents' responses, the child also learns to trust his or
her own body and the biological urges that go with it.
If the proper balance is achieved, the child will develop the virtue hope, the
strong belief that, even when things are not going well, they will work out
well in the end. One of the signs that a child is doing well in the first stage is
when the child isn't overly upset by the need to wait a moment for the
satisfaction of his or her needs: Mom or dad don't have to be perfect; I trust
them enough to believe that, if they can't be here immediately, they will be
here soon; Things may be tough now, but they will work out. This is the same
ability that, in later life, gets us through disappointments in love, our careers,
and many other domains of life.

From the title itself, TRUST vs. MISTRUST, it states that the growing child
develops trust from what he sees from his parents or even on his
surroundings. If the parents are unreliable and inadequate, if they reject the
infant or harm him, if other interests cause both parents to turn away from
the infants needs to satisfy their own instead, then the infant will develop
mistrust. He or she will be apprehensive and suspicious around people.
According to the mother of Baby Pooh, they always play with the baby,
providing him comfort and safety. In that way, the baby will develop trust to
the parents and there is also a possibility that when someone approaches
him, he will cry. This is because he is not familiar with that person which is a
form of mistrust.
JEAN PIAGET
Sensorimotor Stage (0-2years old)
Object Permanence
 The sensorimotor stage is the first of the four stages Piaget uses to
define cognitive development. Piaget designated the first two years of an
infants life as the sensorimotor stage.
During this period, infants are busy discovering relationships between their
bodies and the environment. Researchers have discovered that infants have
relatively well developed sensory abilities. The child relies on seeing,
touching, sucking, feeling, and using their senses to learn things about
themselves and the environment. Piaget calls this the sensorimotor stage
because the early manifestations of intelligence appear from sensory
perceptions and motor activities.
Through countless informal experiments, infants develop the concept of
separate selves, that is, the infant realizes that the external world is not an
extension of themselves.
Infants realize that an object can be moved by a hand (concept of causality),
and develop notions of displacement and events. An important discovery
during the latter part of the sensorimotor stage is the concept of "object
permanence".
Object permanence is the awareness that an object continues to exist even
when it is not in view. In young infants, when a toy is covered by a piece of
paper, the infant immediately stops and appears to lose interest in the toy. In
older infants, when a toy is covered the child will actively search for the
object, realizing that the object continues to exist.
After a child has mastered the concept of object permanence, the emergence
of "directed groping" begins to take place. With directed groping, the child
begins to perform motor experiments in order to see what will happen.
During directed groping, a child will vary his movements to observe how the
results will differ. The child learns to use new means to achieve an end. The
child discovers he can pull objects toward himself with the aid of a stick or
string, or tilt objects to get them through the bars of his playpen.

In relation to Baby Pooh, there are signs of touching, sucking, feeling, and
using his senses to learn things about themselves and the environment.
According to the mother, whenever she shows a certain object to her child,
Baby Pooh will grab it. The child is very fond of playing with objects.
SIGMUND FREUD
The Oral Stage (0-18 months)

The oral stage begins at birth, when the oral cavity is the primary focus
of libidal energy. The child, of course, preoccupies himself with nursing, with
the pleasure of sucking and accepting things into the mouth. The oral
character who is frustrated at this stage, whose mother refused to nurse him
on demand or who truncated nursing sessions early, is characterized by
pessimism, envy, suspicion and sarcasm. The overindulged oral character,
whose nursing urges were always and often excessively satisfied, is
optimistic, gullible, and is full of admiration for others around him. The stage
culminates in the primary conflict of weaning, which both deprives the child
of the sensory pleasures of nursing and of the psychological pleasure of being
cared for, mothered, and held. The stage lasts approximately one and one-
half years.

This theory states about the character of a child towards an object. Based on
our observations to Baby Pooh, whatever thing that he touches, he puts it in
his mouth as if he is biting it. But the mother must be aware of this trait
because this may be a possible cause of acquiring a disease.

ANNA FREUD
Psychoanalysis
Anna Freud moved away from the classical position of her father, who was
concentrating on the unconscious Id (a perspective she found to be
restrictive) and instead emphasized the importance of the ego, the constant
struggle and conflict it is experiencing by the need to answer contradicting
wishes, desires, values and demands of reality. By this, she established the
importance of the ego functions and the concept of defense mechanisms.
Focusing on research, observation and treatment of children, Freud
established a group of prominent child developmental analysts (which
included Eric Erikson, Edith Jacobson and Margaret Mahler) who noticed that
children's symptoms were ultimately analogue to personality disorders
among adults and thus often related to developmental stages. At that time,
these ideas were revolutionary and Anna provided us with a comprehensive
developmental theory and the concept of developmental lines, which
combined her father's important drive model with more recent object
relations theories of development, which emphasize the importance of
parents in child development processes.
As such, the formation of the fields of child psychoanalysis and child
developmental psychology can be attributed to Anna Freud. Anna Freud
furthermore developed different techniques of assessment and treatment of
children disorders, thereby contributing to our understanding of anxiety and
depression as significant problems among children.
Anna Freud's theory of child development is based upon the view that there
is a normal sequence of libidinal phases (oral, anal and genital) and that a
child who is going to be a harmonious personality should, at each stage of
libidinal development, reach a corresponding stage of emotional maturity,
physical independence, companionship and creative play.

Immunization Status:
No. of
Type of vaccine Date Dosage doses
given

BCG At birth 0.05 ml once

DPT 6th, 10th, 14th 0.5 ml 3x

 week

6th, 10th, 14th 3x

OPV 2 drops
week

1st dose: At birth 3x

2nd dose:6
weeks after the
Hepa B first dose 0.5 ml
3rd dose: 8
weeks from the
2nd dose

Measles 9 months 0.5 ml once

• All of the siblings of Mr. and Mrs. X have received complete vaccines,
including Baby Pooh, which has received vaccines that are appropriate
for his age.

4. HISTORY OF PAST ILLNESS

According to the mother, Baby Pooh has no previous hospitalizations.
The child only experienced some mild illness like fever and colds which were
cured by further home managements.

5. HISTORY OF PRESENT ILLNESS

It started a week prior to the admission. The mother noticed some
changes in the stool of Baby Pooh, greenish and watery stool, a rise in his
temperature, and also accompanied by vomiting. These manifestations were
observed for a week, when the mother realized that Baby Pooh needs further
check-up about the signs that were being manifested by Baby Pooh. At 5:40
in the afternoon, Baby Pooh was brought to the emergency room. She was
assessed by the nurses in the emergency room, and there was also an
attending physician who assessed his general condition and further diagnosis
was made. Baby Pooh was diagnosed with Acute Gastroenteritis with
Dehydration.
6. PHYSICAL EXAMINATION (Cephalocaudal Approach)

Upon Admission: June 18, 2009, 5:40 pm

Chief Complaints: Vomiting, Loose and greenish stools for almost one week

Temperature: 37.4°C
Cardiac rate: 115 bpm
Respiratory rate: 63 cpm
Wt.: 5.5 kg
HEENT:
 Pink palpebral conjunctiva
 anicteric sclera
CHEST and LUNGS:
 symmetric lung expansion
 (-) retraction
HEART:
 (-) murmur
ABDOMEN:
 Flat
 NABS
 Non-tender
GENITALIA:
 No given description
EXTREMITIES:
 Normal
IMPRESSION: Acute Gastroenteritis with Dehydration

June 25, 2009

INTEGUMENT
 Warm to touch
 Absence of lesions
HEAD and FACE
  presence of reddish spots on the face and on the occipital portion
 sunken fontanel
 sunken eyes
 pale palpebral conjunctiva
 dry lips
 hair is evenly distributed
 symmetric eye movement
CHEST and LUNGS
 symmetrical chest expansion
 crackles due to secretions
 (-) murmur
ABDOMEN
 Absence of lesions
 hyperactive bowel sounds

GENITALIA
 With rashes on the posterior part
EXTREMITIES
 symmetrical

June 26, 2009

INTEGUMENT
 warm to touch
 absence of lesions
HEAD and FACE
 presence of reddish spots on the face
 sunken fontanel
 sunken eyes
 pale palpebral conjunctiva
 moist lips
 symmetric eye movement
CHEST and LUNGS
  non tender
 symmetrical chest expansion
 (-) murmur
ABDOMEN
 Hyperactive bowel sounds
 Absence of lesions
GENITALIA
 With rashes on the posterior part
EXTREMITIES
 Symmetrical

June 27, 2009

INTEGUMENT
 Warm to touch
 Absence of lesions
HEAD and FACE
 Eyes in good condition
 Moist mucous membranes
 Pinkish lips
 Normal fontanel
NOSE
 no nasal discharge
 Symmetrical nares
MOUTH
 Slightly pink lips
 Slightly moist oral mucosa
CHEST and LUNGS
 non tender
 symmetrical chest expansion
 (-) murmur
ABDOMEN
 No presence of lesions
GENITALIA
 With rashes on the posterior part
 No discharge
EXTREMITIES
 Symmetrical
7. DIAGNOSTIC and LABORATORY PROCEDURES

DIAGNOSTI
C/ DATE
ANALYSIS
LABORATO ORDERED INDICATION(S) OR NORMAL
RESULTS AND
RY DATE PURPOSE(S) VALUES
INTERPRETATION
PROCEDURE RESULT(S) IN
S

FECALYSIS Date ordered: Fecalysis or stool Color: Color: Greenish discoloration of the
06/18/09 analysis is Greenish Brownish urine is caused by Biliverdin/
performed to oral antibiotics.
Date of results: identify the
06/18/09 composition of the Consistency Consistency: Presence of Pus cells and
stool that causes : Soft some microorganisms make
some alterations in Mucoid the stool mucoid in
the bowel consistency.
movement. Routine
fecal examination
includes Pus cells/HPF:
macroscopic, Pus None Presence of pus in the urine
microscopic, and cells/HPF: indicates an infection.
chemical analyses 18-25
for the early
detection of
Entamoeba
gastrointestinal Entamoeba histolytica E. histolytica is the cause of
bleeding, liver and histolytica: Cyst human amebic dysentery.
biliary duct Cyst None Presence of this can cause
disorders, 2-4 amoebiasis.
maldigestion/malabs Trophozoite
orption syndromes, Trophozoite None
and inflammation. 0-3
DIAGNOSTI
C/
DATE ANALYSIS
LABORATO
ORDERED INDICATION(S) RESULT NORMAL AND
RY
DATE OR PURPOSE(S) S VALUES INTERPRETATION
PROCEDUR
RESULT(S) IN
ES
Date ordered: This is performed Hgb: M: 140-180g/L Haemoglobin is within normal
06/18/09 to know the 112 F: 120-60g/L range.
number of red
Date of blood cells, white WBC: 5-10x109/L Increase in white blood cells
Hematology Results: blood cells, and 14.7 means there is a possible
06/19/09 platelets in a infection.
given unit of Hct: M: 0.40-0.54 L/L
blood. For blood 0.42 F: 0.37-0.47 L/L Hematocrit is within normal
diseases, range.
hematologists RBC: M: 4.5-
12
may also be 4.08 6.3x10 /L
called on to F: 4.2-5.4x1012/L Red blood cells are within normal
diagnose other Platelet: range.
150-400x109/L
types of 379
disorders. Platelets are within normal range.
DIAGNOSTI
C/ DATE
ANALYSIS
LABORATOR ORDERED
INDICATION(S) OR RESULTS NORMAL AND
Y DATE
PURPOSE(S) VALUES INTERPRETATION
PROCEDURE RESULT(S)
S IN

FECALYSIS Date Ordered: Fecalysis or stool Color: Color: Greenish discoloration of the
06/18/09 analysis is performed to Greenish Brownish urine is caused by Biliverdin/
identify the composition oral antibiotics.
Date of of the stool that causes
Results: some alterations in the Consistenc Consistency: Presence of white blood cells
06/19/09 bowel movement. y: Soft and some microorganisms
Routine fecal Watery make the stool mucoid in
examination includes mucoid consistency. This indicated
macroscopic, infection or irritation of the
microscopic, and GI.
chemical analyses for Pus
the early detection of Pus cells/HPF: Presence of pus in the stool
gastrointestinal cells/HPF: None indicates infection.
bleeding, liver and 2+
biliary duct disorders,
maldigestion/malabsorpt RBC/HPF: RBC/HPF: Presence of Red blood cells
ion syndromes, and 3-4 none in the stool indicates
 inflammation bleeding in the lower GI
tract.

DIAGNOSTI
DATE
C/
ORDERED ANALYSIS
LABORATOR INDICATION(S) OR
DATE NORMAL AND
Y PURPOSE(S) RESULTS
RESULT(S) VALUES INTERPRETATION
PROCEDURE
IN
S

Date ordered: To check for 135 135-150 The result is within normal
Na 06/18/09 components of the fluid mEq/L range.
inside our body.
Date of
Results:
06/19/09

Date ordered: To check for 3.54 3.5-5.2mEq/L The result is within normal
K 06/18/09 components of the fluid range.
inside our body.
Date of
Results:
06/19/09
DIAGNOSTI
DATE
C/
ORDERED ANALYSIS
LABORATO INDICATION(S) OR
DATE NORMAL AND
RY PURPOSE(S) RESULTS
RESULT(S) VALUES INTERPRETATION
PROCEDUR
IN
ES
Greenish discoloration of the
FECALYSIS Date Ordered: Fecalysis or stool Color: Color: urine is caused by Biliverdin/
06/18/09 analysis is performed to Greenish Brownish oral antibiotics.
identify the composition
Date of of the stool that causes Consistenc Consistency: The stool has a normal
Results: some alterations in the y: Soft consistency.
06/20/09 bowel movement. Soft
Routine fecal
examination includes
macroscopic, Pus cells/HPF:
microscopic, and Pus None Presence of pus in the stool
chemical analyses for cells/HPF: indicates infection.
the early detection of 30-40
gastrointestinal
bleeding, liver and
biliary duct disorders, RBC/HPF:
maldigestion/malabsorpt none Presence of Red blood cells
ion syndromes, and RBC/HPF: in the stool indicates
inflammation. 0.2 bleeding in the lower GI
tract.
DIAGNOSTI
DATE
C/
ORDERED
LABORATOR ANALYSIS
DATE NORMAL
Y INDICATION(S) OR RESULTS AND
RESULT(S) VALUES
PROCEDURE PURPOSE(S) INTERPRETATION
IN
S

Date Ordered: Urinalysis or urine Color: Color: The urine color is normal.
06/18/09 analysis is performed to Light Yellow
check the overall yellow or Amber
function of the kidneys.
URINALYSIS Date of It also performed to Transparency: Most commonly encountered
Results: know if there are some Transpare Clear pathologic causes of
06/23/09 pathogens or other ncy: turbidity in a fresh specimen
microorganisms Slightly are RBC’s, white blood cells,
contributing to the turbid and bacteria. Other less
disease condition of the frequently encountered
client. It is also include abnormal amounts
performed to note for of nonsquamous epithelial
any alterations from the cells, yeast, abnormal
normal values. crystal, lymph fluid, and
 pH: lipids.
4.5-8
The pH is within normal
pH: range.
6.0 Specific
gravity:
1.010-1.030
Specific The specific gravity is within
gravity: Pus cells/HPF: normal range.
1.010 None
Presence of pus cells in the
Pus RBC/HPF: urine indicates an infection.
cells/HPF: None
20-25 Findings of RBC in the urine
indicate bleeding from an
RBC/HPF: area within the genitourinary
1-2 tract. Presence of RBC casts
associated with glomerular
damage is usually
Epithelial associated with proteinuria
cells: and dysmorphic
None erythrocytes.

Epithelial Casts containing RTE cells

cells: represent the presence of
Rare advanced tubular
destruction, producing
urinary stasis along with
disruption of the tubular
Mucus linings. Similarly to RTE cells,
Threads: they are associated with
None heavy metal and chemical or
drug-induced toxicity, viral
Mucus infections, and allograft
threads: rejection.
few

Little clinical significance is

attached to the presence of
mucus in the urinary
sediment, although it may
be increased with some
inflammatory conditions and
irritation to the genitourinary
tract.
 NURSING RESPONSIBILITIES

1. URINALYSIS

Before:

• Check the doctor’s order to verify if the client is in need for urinalysis.
• Inform the patient that she must obtain urine sample for the procedure
• Explain to the patient that this test to be performed will help in the
identification of the overall function of the kidneys, and also to identify any
abnormalities causing a disease.
• Instruct the patient on how to get a urine sample.
• Take note for the medications taken by the patient so as not to interfere with
the results of the test.
During:

• Provide privacy

• For the patients who cannot get out of bed, offer a urinal, and get a sample.

• Make sure that the urinal is not dirty, and also the container for the urine, to
avoid contamination.
• If the patient is to perform the collection, explain the proper collection of
specimen.
After:

• After getting the sample, cover it immediately to avoid the entrance of

microorganisms.
• Ensure that the specimen label and laboratory requisition form are filled out
correctly
• Submit the collected specimen to the laboratory.
• Instruct the patient to resume his normal diet and medication as ordered by
the doctor.
• Document.
2. FECALYSIS

Before:

• Check the doctor’s order to verify if the client is in need for stool analysis.
• Identify the patient
• Inform the patient she/he is going to undergo stool analysis
• Explain the purpose of the test
• Teach the client on how to get a stool sample.
• If the client cannot get out of bed, get a bed pan.
During:

• Provide privacy.
• Give time for the patient to defecate.
• Make sure that the bed pan is not dirty, and also the container for the stool,
to avoid contamination.
• Instruct the patient to use an applicator in getting a stool sample.
After:

• After getting the sample, cover it immediately to avoid the entrance of

microorganisms.
• Ensure that the specimen label and laboratory requisition form are filled out
correctly
• Submit the collected specimen to the laboratory.
• Instruct the patient to resume his normal diet and medication as ordered by
the doctor.
• Document.
3. HEMATOLOGY

Before:

• Check the doctor’s order to verify if the client is in need for blood analysis.
• Identify the client
• Inform the patient that she/he is going to undergo a procedure
• Explain the procedure to the client.
• Inform the patient that nothing is to be avoided before the procedure
• Explain to the patient that this test will identify any changes in the blood
composition
During:

• Instruct the patient that this procedure is quite painful because it needs
pricking.
• Instruct the client to stay still
After:

• Provide cotton for the site.

• Apply pressure to the puncture site to avoid much bleeding.

• Observe for excessive bleeding in the puncture site.

• Document.
III. ANATOMY AND PHYSIOLOGY

The organs of the digestive system are specialized for the digestion and
absorption of food. The digestive system consists of a tubular gastrointestinal tract
and accessory digestive organs.

Food is necessary to sustain life. It provides the essential nutrients the body cannot
produce for itself. The food is utilized at the cellular level, where nutrients are
required for chemical reactions involving synthesis of enzymes, cellular division and
growth, repair, and the production of heat energy. Most of the food we eat however
is not suitable for cellular utilization until it is mechanically and chemically reduced
to forms that can be absorbed through the intestinal wall and transported to the
cells by the blood. Ingested food is not technically inside the body until it is
absorbed; and, in fact, a large portion of this food remains undigested and passes
through the body as waste material. The principal function of the digestive system
is to prepare food for the cellular utilization.

This involves the following activities:

1. INGESTION
-the taking of food into the mouth
2. MASTICATION
-chewing movements to pulverize food and mix it with saliva
3. DEGLUTITION
-the swallowing of food to move it from the mouth to the pharynx and into the
esophagus
4. DIGESTION
-the mechanical breakdown of food material to prepare it for absorption
5. ABSORPTION
-the passage of molecules of food through the mucous membrane of the small
intestine and into the blood or lymph for distribution to cells
6. PERISTALSIS
-rhythmic, wavelike intestinal contractions that move food through the
gastrointestinal tract
7. DEFECATION
-the discharge of indigestible wastes, called feces, from the gastrointestinal tract

Anatomically and functionally, the digestive system can be divided into tubular
gastrointestinal tract (GI tract), or digestive tract, and accessory digestive
organs. The GI tract, which extends form the mouth to the anus, is a continuous
tube approximately 9m (30 ft) long. It transverses the thoracic cavity ad enters the
abdominal cavity at the level of the diaphragm,
It usually takes about 24-48 hours for food to travel the length of the GI tract. Food
ingested through the mouth passes in assembly-line fashion through tract, where
complex molecules are progressively broken down. Each region of the GI tract has
specific functions in preparing food for utilization.

The Mouth and Pharynx

Mechanical breakdown begins in the mouth by chewing (teeth) and actions of the
tongue. Chemical breakdown of starch by production of salivary amylase from the
salivary glands. This mixture of food and saliva is then pushed into the pharynx and
esophagus. The esophagus is a muscular tube whose muscular contractions
(peristalsis) propel food to the stomach.
In the mouth, teeth, jaws and the tongue begin the mechanical breakdown of food
into smaller particles. Most vertebrates, except birds (who have lost their teeth to a
hardened bill), have teeth for tearing, grinding and chewing food. The tongue
manipulates food during chewing and swallowing; mammals have tastebuds
clustered on their tongues.
Salivary glands secrete salivary amylase, an enzyme that begins the breakdown of
starch into glucose. Mucus moistens food and lubricates the esophagus.
Bicarbonate ions in saliva neutralize the acids in foods.
Swallowing moves food from the mouth through the pharynx into the esophagus
and then to the stomach.

• Step 1: A mass of chewed, moistened food, a bolus, is moved to the back of

the moth by the tongue. In the pharynx, the bolus triggers an involuntary
swallowing reflex that prevents food from entering the lungs, and directs the
bolus into the esophagus.
• Step 2: Muscles in the esophagus propel the bolus by waves of involuntary
muscular contractions (peristalsis) of smooth muscle lining the esophagus.
• Step 3: The bolus passes through the gastroesophogeal sphincter, into the
stomach. Heartburn results from irritation of the esophagus by gastric juices
that leak through this sphincter.
 The Stomach

During a meal, the stomach gradually fills to a capacity of 1 liter, from an empty
capacity of 50-100 milliliters. At a price of discomfort, the stomach can distend to
hold 2 liters or more.
Epithelial cells line inner surface of the stomach, and secrete about 2 liters of
gastric juices per day. Gastric juice contains hydrochloric acid, pepsinogen, and
mucus; ingredients important in digestion. Secretions are controlled by nervous
(smells, thoughts, and caffeine) and endocrine signals. The stomach secretes
hydrochloric acid and pepsin. Hydrochloric acid (HCl) lowers pH of the stomach so
pepsin is activated. Pepsin is an enzyme that controls the hydrolysis of proteins into
peptides. The stomach also mechanically churns the food. Chyme, the mix of acid
and food in the stomach, leaves the stomach and enters the small intestine.
Hydrochloric acid does not directly function in digestion: it kills microorganisms,
lowers the stomach pH to between 1.5 and 2.5; and activates pepsinogen.
Pepsinogen is an enzyme that starts protein digestion. Pepsinogen is produced in
cells that line the gastric pits. It is activated by cleaving off a portion of the
molecule, producing the enzyme pepsin that splits off fragments of peptides from a
protein molecule during digestion in the stomach.
Carbohydrate digestion, begun by salivary amylase in the mouth, continues in the
bolus as it passes to the stomach. The bolus is broken down into acid chyme in the
lower third of the stomach, allowing the stomach's acidity to inhibit further
carbohydrate breakdown. Protein digestion by pepsin begins.
Alcohol and aspirin are absorbed through the stomach lining into the blood.
Epithelial cells secrete mucus that forms a protective barrier between the cells and
the stomach acids. Pepsin is inactivated when it comes into contact with the mucus.
Bicarbonate ions reduce acidity near the cells lining the stomach. Tight junctions
link the epithelial stomach-lining cells together, further reducing or preventing
stomach acids from passing.

The Small Intestine

The small intestine is where final digestion and absorption occur. The small intestine
is a coiled tube over 3 meters long. Coils and folding plus villi give this 3m tube the
surface area of a 500-600m long tube. Final digestion of proteins and carbohydrates
must occur, and fats have not yet been digested. Villi have cells that produce
intestinal enzymes which complete the digestion of peptides and sugars. The
absorption process also occurs in the small intestine. Food has been broken down
into particles small enough to pass into the small intestine. Sugars and amino acids
go into the bloodstream via capillaries in each villus. Glycerol and fatty acids go into
the lymphatic system. Absorption is an active transport, requiring cellular energy.

The Liver and Gall Bladder

The liver produces and sends bile to the small intestine via the hepatic duct. Bile
contains bile salts, which emulsify fats, making them susceptible to enzymatic
breakdown. In addition to digestive functions, the liver plays several other roles: 1)
detoxification of blood; 2) synthesis of blood proteins; 3) destruction of old
erythrocytes and conversion of hemoglobin into a component of bile; 4) production
of bile; 5) storage of glucose as glycogen, and its release when blood sugar levels
drop; and 6) production of urea from amino groups and ammonia.
The gall bladder stores excess bile for release at a later time. We can live without
our gall bladders, in fact many people have had theirs removed. The drawback,
however, is a need to be aware of the amount of fats in the food they eat since the
stored bile of the gall bladder is no longer available.
Glycogen is a polysaccharide made of chains of glucose molecules. In plants starch
is the storage form of glucose, while animals use glycogen for the same purpose.
Low glucose levels in the blood cause the release of hormones, such as glucagon,
that travel to the liver and stimulate the breakdown of glycogen into glucose, which
is then released into the blood(raising blood glucose levels). When no glucose or
glycogen is available, amino acids are converted into glucose in the liver. The
process of deamination removes the amino groups from amino acids. Urea is
formed and passed through the blood to the kidney for export from the body.
Conversely, the hormone insulin promotes the take-up of glusose into liver cells and
its formation into glycogen.
The Pancreas
The pancreas sends pancreatic juice, which neutralizes the chyme, to the small
intestive through the pancreatic duct. In addition to this digestive function, the
pancrease is the site of production of several hormones, such as glucagon and
insulin.
The pancreas contains exocrine cells that secrete digestive enzymes into the small
intestine and clusters of endocrine cells (the pancreatic islets). The islets secrete
the hormones insulin and glucagon, which regulate blood glucose levels.
After a meal, blood glucose levels rise, prompting the release of insulin, which
causes cells to take up glucose, and liver and skeletal muscle cells to form the
carbohydrate glycogen. As glucose levels in the blood fall, further insulin production
is inhibited. Glucagon causes the breakdown of glycogen into glucose, which in turn
is released into the blood to maintain glucose levels within a homeostatic range.
Glucagon production is stimulated when blood glucose levels fall, and inhibited
when they rise.
Diabetes results from inadequate levels of insulin. Type I diabetes is characterized
by inadequate levels of insulin secretion, often due to a genetic cause. Type II
usually develops in adults from both genetic and environmental causes. Loss of
response of targets to insulin rather than lack of insulin causes this type of diabetes.
Diabetes may cause impairment in the functioning of the eyes, circulatory system,
nervous system, and failure of the kidneys. Diabetes is the second leading cause of
blindness in the United States. Treatments might involve daily injections of insulin,
oral medications such as metformin, monitoring of blood glucose levels, and a
controlled diet. Type I diabetes may one day be cured by advances in gene
therapy/stem cell research. On recently recognized condition is known as
prediabetes, in which the body gradually loses its sensitivity to insulin, leading
eventually to Type II diabetes. Ora; medications, diet and behavior (in other words
EXERCISE!!!) changes are thought to delay if not outright postpone the onset of
diabetes if corrected soon enough.
The fifth leading cause of cancer death in the United States is from pancreatic
cancer, which is nearly always fatal. Scientists estimate that 25,000 people may die
from this disease each year. Standard treatments are ineffective, although some
promising avenues may open with advances in genomics and molecular biology of
cancer cells.
 The Large Intestine

The large intestine is made up by the colon, cecum, appendix, and rectum. Material
in the large intestine is mostly indigestible residue and liquid. Movements are due
to involuntary contractions that shuffle contents back and forth and propulsive
contractions that move material through the large intestine. The large intestine
performs three basic functions in vertebrates: 1) recovery of water and electrolytes
from digested food; 2) formation and storage of feces; and 3) microbial
fermentation: The large intestine supports an amazing flora of microbes. Those
microbes produce enzymes that can digest many of molecules indigestible by
vertebrates.
Secretions in the large intestine are an alkaline mucus that protects epithelial
tissues and neutralizes acids produced by bacterial metabolism. Water, salts, and
vitamins are absorbed, the remaining contents in the lumen form feces (mostly
cellulose, bacteria, bilirubin). Bacteria in the large intestine, such as E. coli, produce
vitamins (including vitamin K) that are absorbed.

Digestive System Glossary:

anus - the opening at the end of the digestive system from which feces (waste)
exits the body.
appendix - a small sac located on the cecum.
ascending colon - the part of the large intestine that run upwards; it is located
after the cecum.
bile - a digestive chemical that is produced in the liver, stored in the gall bladder,
and secreted into the small intestine.
cecum - the first part of the large intestine; the appendix is connected to the
cecum.
chyme - food in the stomach that is partly digested and mixed with stomach acids.
Chyme goes on to the small intestine for further digestion.
descending colon - the part of the large intestine that run downwards after the
transverse colon and before the sigmoid colon.
duodenum - the first part of the small intestine; it is C-shaped and runs from the
stomach to the jejunum.
epiglottis - the flap at the back of the tongue that keeps chewed food from going
down the windpipe to the lungs. When you swallow, the epiglottis automatically
closes. When you breathe, the epiglottis opens so that air can go in and out of the
windpipe.
esophagus - the long tube between the mouth and the stomach. It uses rhythmic
muscle movements (called peristalsis) to force food from the throat into the
stomach.
gall bladder - a small, sac-like organ located by the duodenum. It stores and
releases bile (a digestive chemical which is produced in the liver) into the small
intestine.
ileum - the last part of the small intestine before the large intestine begins.
jejunum - the long, coiled mid-section of the small intestine; it is between the
duodenum and the ileum.
liver - a large organ located above and in front of the stomach. It filters toxins from
the blood, and makes bile (which breaks down fats) and some blood proteins.
mouth - the first part of the digestive system, where food enters the body. Chewing
and salivary enzymes in the mouth are the beginning of the digestive process
(breaking down the food).
pancreas - an enzyme-producing gland located below the stomach and above the
intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats
and proteins in the small intestine.
peristalsis - rhythmic muscle movements that force food in the esophagus from
the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is
also what allows you to eat and drink while upside-down.
rectum - the lower part of the large intestine, where feces are stored before they
are excreted.
salivary glands - glands located in the mouth that produce saliva. Saliva contains
enzymes that break down carbohydrates (starch) into smaller molecules.
sigmoid colon - the part of the large intestine between the descending colon and
the rectum.
stomach - a sack-like, muscular organ that is attached to the esophagus. Both
chemical and mechanical digestion takes place in the stomach. When food enters
the stomach, it is churned in a bath of acids and enzymes.
transverse colon - the part of the large intestine that runs horizontally across the
abdomen.

IV. THE PATIENT’S ILLNESS

1. Definition of the disease

Gastroenteritis is an inflammation of the stomach and intestinal tract that

primarily affects the small bowel. It is frequently referred to as the stomach or
intestinal flu, although the influenza virus is not associated with this illness. The
major clinical manifestations are diarrhea of varying degrees and abdominal pain
and cramping. Associated clinical manifestations are nausea, vomiting, fever,
anorexia, distention, tenesmus (straining on defecation), and borborygmi
(hyperactive bowel sounds.
Gastroenteritis occurs throughout the world, often in epidemic outbreaks.
Contaminated food and water are major sources of this disease and cause
thousands of deaths yearly. The incidence of infections caused by food-borne
disease is rising.

2. Predisposing/Precipitating factors
Pathogens that cause GI disease are transmitted by the fecal-oral route, from
person to person, and through ingestion of focally contaminated food and water. GI
infections are often referred to as “food poisoning” because food is frequently the
vehicle for transmission of actively growing microbes and their toxins. Common
bacterial sources of contaminated foods are eggs, (Salmonella), fresh greens and
raw or undercooked meat (E. coli), and chicken (Campylobacter jejuni). Outbreaks
of food-borne viral infections are almost entirely caused by focally contaminated
shellfish. Unpasteurized milk, apple juice, ice cream, and mayonnaise are also
sources of food-borne infection. Other causative agents are Vibrio cholerae,
(cholera), Shigella bacilli (dysentery), Staphylococcus aureus (staphylococcal food
poisoning), and Listeria. The incubation period for all viral ad bacterial infections
ranges from 6 hours to 4 to 5 days.

3. Signs and Symptoms

 Diarrhea
frequent passage of abnormally loose, watery stool. Diarrhea usually develops
suddenly and may last from several hours to a few days. It is often accompanied
by abdominal pains, low fever, nausea, and vomiting. If the attacks are severe or
increasingly frequent, exhaustion and dehydration can result. In normal
digestion the large intestine absorbs excess water from liquid food residues
produced by earlier phases of the digestive process before excreting semisolid
stools. When the mucous membrane lining the large intestine is irritated or
inflamed, food residues move through the large intestine too quickly and the
resulting stool is watery because the large intestine cannot absorb the excess
water.
Diarrhea is not a disease. It is a symptom of numerous disorders, such as food
poisoning from contaminated foods or beverages, infections by viruses and
 bacteria, or anxiety. Chronic diarrhea, which lasts weeks or months, may be
caused by amoebic dysentery (intestinal infection), tumors, and other serious
intestinal disorders such as Crohn’s disease, ulcerative colitis, or irritable bowel
syndrome. Except in the case of irritable bowel syndrome, the stool may contain
blood or pus.

 Nausea and vomiting lasting 1-2 days

Vomiting, expulsion of the contents of the stomach through the mouth. Vomiting is
often preceded by nausea, sweating, and excessive salivation, although it can occur
without warning. It is controlled by a specific part of the brain stem, called the
vomiting center, that can be stimulated in several ways. Most commonly, the center
is excited by nerve impulses sent from the gastrointestinal tract (the mouth,
esophagus, stomach, and intestines) when any part of the tract is overly distended
(swollen), irritated, or excited. Nerve impulses may also come from the balancing
mechanism of the inner ear. The vomiting center then sends impulses to the
abdominal muscles involved in vomiting. The muscles of the abdomen contract and
the diaphragm (the muscular partition between the chest and abdominal cavities)
pushes downward. These contractions compress the stomach, raising the internal
pressure. The esophageal sphincter (muscle between the stomach and the
esophagus) then relaxes, forcing up the contents of the stomach.
Vomiting associated with irritation of the gastrointestinal tract can occur as the
result of improper eating; food poisoning; stomach irritations brought about by
chemicals, drugs, or excessive amounts of alcohol; gastrointestinal obstructions;
and many infectious diseases. It also may occur during pregnancy, usually from the
5th or 6th week through the 12th week, and is most likely caused by fluctuating
hormone levels.
 Abdominal pain (belly pain)
Abdominal pain is a key symptom of both minor ailments and serious diseases.
Indigestion is the most common cause of abdominal pain in both adults and
children. Additional common causes include inflammation of the lining of the
stomach and intestinal tract, constipation.
Serious causes of abdominal pain include appendicitis; gallbladder or kidney stones;
ulcers of the stomach and small intestine; diverticulitis (inflammation of pouchlike
tissue in the large intestine); hepatitis; inflammation of a kidney, a fallopian tube,
the bladder, or the pancreas; an ectopic (tubal) pregnancy; an ovarian cyst; an
aortic aneurysm (abnormal widening of the aorta caused by weakness in the vessel
wall); and cancer. With these conditions, pain often comes in waves, accompanied
by vomiting, sweating, and tenderness of the abdomen when touched.
 Fever (sometimes)
Fever, also known as pyrexia, rise in the body’s temperature, as measured in the
mouth, above 37° C (98.6° F). Fever is a symptom of many disorders, such as
infection by a virus or a bacterium, and it is not itself a disease. The term fever is
also used to name certain diseases, such as relapsing fever, rheumatic fever,
scarlet fever, undulant fever, and yellow fever, in which high fever is a major
symptom. The first signs of fever may be chilly sensations, with associated periods
of flushed or warm feelings. The temperature may rise slowly or rapidly and may
fluctuate. A rise in temperature may be accompanied by shaking chills. A falling
temperature may bring on heavy sweating.

Although people have survived temperatures over 43° C (110° F), a fever higher
than 41° C (106° F) typically results in convulsions, particularly in babies or the
elderly.

The normal healthy body constantly produces heat as cells burn food for energy. At
the same time, the body loses heat through the skin and through breathing. The
temperature of the body is a measure of the balance between heat produced and
heat lost. This fever mechanism helps the body to fight off infection, and in some
cases a very high fever may actually kill the bacteria causing the infection.
4. Health Promotion and Preventive aspect of the disease
If a baby has gastroenteritis, be especially careful to wash your hands after
changing nappies and before preparing food. Ideally, use liquid soap in warm
running water, but any soap is better than none. Dry properly after washing. For
older children, whilst they have gastroenteritis, the following are recommended:.
• Regularly clean the toilets used. Also, wipe the flush handle and toilet seat
with disinfectant (such as household bleach) after each time they use the
toilet.
 • Make sure they wash their hands after going to the toilet. Ideally, use liquid
soap in warm running water, but any soap is better than none. Dry properly
after washing.
• Don't share towels and flannels.
• Do not let them help to prepare food for others.
• They should stay off school, nursery, etc, until at least 48 hours after the last
episode of diarrhoea or vomiting.
• They should not swim in swimming pools for two weeks after the last episode
of diarrhoea.
The advice given in the previous section is mainly aimed at preventing the spread
of infection to other people. But, even when we are not in contact with someone
with gastroenteritis, proper storage, preparation and cooking of food, and good
hygiene help to prevent gastroenteritis. In particular, always wash your hands, and
teach children to wash theirs:
• After going to the toilet (and after changing nappies).
• Before touching food. And also, between handling raw meat and food ready
to be eaten. (There may be some bacteria on raw meat.)
• After gardening.
• After playing with pets (healthy animals can carry certain harmful bacteria).
The simple measure of washing hands regularly and properly is known to make a
big difference to the chance of developing gastroenteritis.
 V. PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

a) IVF

DATE ORDERED

MEDICAL DATE
PERFORMED GENERAL INDICATION(S)
MANAGEMENT/ CLIENT’S RESPONSE TO TREATMENT
DESCRIPTION OR PURPOSE(S)
TREATMENT

DATE CHANGED

D5 O.3 NacL 500cc O: 06 – 18 – 09 A hypotonic Purpose of No side effects were noted.

regulated @ 21 solution that hypotonic
mggts/min has greater solution is to
P: 06 – 18 – 09 concentration give up their
of free water water to a
molecules that dehydrated cell
are found so it can return
C: 06 – 19 – 09 inside the cell to isotonic
rather than on equilibrium
its surrounding
D5 O.3 NacL 500cc O: 06 – 19 – 09
regulated @ 21
mggts/min
P: 06 – 19 – 09

C: 06 – 20 – 09

D5 O.3 NacL 500cc O: 06 – 20 – 09

regulated @ 21
mggts/min
P: 06 – 20 – 09

C: 06 - 21 – 09

D5 O.3 NacL 500cc O: 06 – 21 – 09

regulated @ 21
mggts/min
P: 06 – 21 – 09

C: 06 – 22 – 09
D5 O.3 NacL 500cc O: 06 – 22 – 09
regulated @ 21
mggts/min
P: 06 – 22 – 09

C: 06 – 23 – 09

D5 O.3 NacL 500cc O: 06 – 23 – 09

regulated @ 21
mggts/min
P: 06 – 23 – 09

C: 06 – 24 – 09

D5 O.3 NacL 500cc O: 06 – 24 – 09

regulated @ 21
mggts/min
P: 06 – 24 – 09

C: 06 – 25 – 09
D5 O.3 NacL 500cc O: 06 – 25 – 09
regulated @ 21
mggts/min
P: 06 – 25 – 09

C: 06 – 26 – 09

D5 O.3 NacL 500cc O: 06 – 26 – 09

regulated @ 21
mggts/min
P: 06 – 26 – 09

C: 06 – 27 – 09

D5 O.3 NacL 500cc O: 06 – 27 – 09

regulated @ 21
mggts/min
P: 06 – 27 – 09

C: 06 – 28 – 09
Preparing the Patient:

• Prepare the necessary equipment.

• Explain the procedure to the patient/SO.
• Verify the IV ordered by the physician.
• Prepare the IV solution.

Performing the procedure:

• Provide comfort.
• Regulate IV as ordered.

After Insertion:

• Inspect the patient for complications.

• Observe the IV site.
 GEBERAL
CLIENT’S
ROUTE ACTION
DATE ORDERED, RESPONSE TO THE
NAME OF FUNCTIONAL INDICATIONS MEICATION
TAKEN/GIVEN, DOSAGE
DRUGS CLASSIFICATIO OR PURPOSE
CHANGED/ D/C W/ ACTUAL SIDE
FREQUENCY N MECHANISM
EFFECTS
OF ACTION

ampicillin DO: 06 – 18 – 09 140mg IV q antibiotic Treatment for The patient did not
6° infections show any adverse
DG: 06 – 18 to 27 – 09 effects such as
nausea and
vomiting, rashes, or
any allergic
reactions.

Serious The patient did not

Gentamicin DO: 06 – 18 – 09 bactericidal show any adverse
infections when
20mg IV q effects such as
DG: 06 – 18 to 27 – 09 causative nausea and
12°
organisms are vomiting, rashes, or
any allergic
not known
reactions.
paracetamol DO: 06 – 18 – 09 Analgesic Common cold, The patient did not
show any adverse
flu, other viral
60mg IV q 4° Antipyretic effects such as
and bacterial nausea and
T ≥ 38°C infections with vomiting, rashes, or
any allergic
pain and fever.
reactions.

Common cold,
paracetamol DO: 06 – 18 – 09 Analgesic The patient did not
flu, other viral show any adverse
drops
DG: 06 – 27 – 09 0.5mL q 4° Antipyeretic and bacterial effects such as
infections with nausea and
T ≥ 37.8°C vomiting, rashes, or
pain and fever. any allergic
reactions.
metronidazole Acute infection The patient did not
with susceptible show any adverse
DO: 06–18– 09 Antibacterial effects such as
anaerobic
nausea and
DG: 06 – 18 to 27 – 09 60mg IV q 8° Antibiotic bacteria; Acute vomiting, rashes, or
intestinal any allergic
Antiprotozoal reactions.
amebiasis.

Acute infection
The patient did not
metronidazole with susceptible show any adverse
drops anaerobic effects such as
DO: 06–18– 09 Antibacterial nausea and
bacteria; Acute
120mg/5mL, vomiting, rashes, or
DG: 06 – 18 to 27 – 09 1.8mL q 8° Antibiotic intestinal any allergic
amebiasis. reactions.
Antiprotozoal
 Short term The patient did not
treatment of show any adverse
ranitidine active duodenal effects such as
Histamine 2 ulcer nausea and
DO: 06–18– 09 vomiting, rashes, or
antagonist
any allergic
DG: 06 – 19 - 09 reactions.

DC: 06 – 20 – 09
NURSING RESPONSIBILITIES FOR MEDICATIONS:

Prior to:

1) Check for the doctor’s orders.

2) Prepare the necessary equipments that you will be using.
3) Always was your hand before and after a procedure.
4) Prepare the dosage as ordered.
5) Keep the medication card with you as you are preparing the
patients medication.
6) Be sure your equipment is in good working condition.

During:

1) Identify your patient. Ask patient’s name. Do not rely on his

room and bed number.
2) Stay with the patient until he has taken his medication
3) Observe the patient for any reactions of the drug he has
received.
4) Elevate the head of the bed to aid the patient in swallowing the
medication.

After:

1) Chart a medication only after you have administered it.

2) Advise patient or SO to report any abnormalities that might
happen.
NURSING RESPONSIBILITIES FOR DRUGS
Ampicillin
• Culture infected area before treatment; reculture area if response is not as
expected.
• Check IV site carefully for signs of thrombosis or drug reaction.
• Do not give IM injections in the same site; atrophy can occur. Monitor
injection site.
• Administer oral drug on empty stomach, 1 hour before or 2 hour after meals
with a full glass of water; do not give with fruit juice or soft drinks.
Gentamicin
• Give IM route if at all possible; give by deep IM injection.
• Culture infected area before therapy.
• Avoid long-term therapies because of increased risk of toxicities. Reduction in
dose may be clinically indicated.
• Patients with edema or ascites may have lower peak concentration due to
expanded extracellular fluid volume.
• Ensure adequate hydration of patient before and during therapy.

Paracetamol
• Do not exceed the recommended dosage.
• Consult physician if needed for children less than 3 years; if needed for
longer than 10 days; if continued fever, severe or recurrent pain occurs
(possible serious illness).
• Reduce dosage with hepatic impairement.
• Avoid using multiply preparations containing acetaminophen. Carefully check
all OTC products.
• Give drug with food if GI upset occurs.
• Discontinue drug if hypersensitive reaction occur.
Metronidazole
• Do not stop taking this drug unless instructed to do so.
• Provide continual cardiac monitoring for patients receiving IV dose.
Ranitidine
• Decrease doses in renal and liver failure.
• Administer oral drug with meals and at bed time.
• Provide concurrent antacid therapy to relieve pain.
• Administer IM dose undiluted, deep into large muscle group.
• Arrange for regular follow-up, including blood tests, to evaluate effects.
 c) DIET

DATE ORDERED

CLIENT’S
GENERAL INDICATION(S) or SPECIFIC FOODS RESPONSE OR
TYPE OF DIET DATE STARTED
DESCRIPTION PURPOSE(S) TAKEN REACTION TO
THE DIET

DATE CHANGED

NPO DO: 06 – 18 - 09 Withhold oral To prevent None The patient’s SO

food and fluids aspiration complied with the
for a certain pneumonia; ordered diet of
DS: 06 – 18 – 09 period of time.
the patient.

DC: 06 – 19 – 09

Milk Feeding
DO: 06 – 19 – 09

DS: 06 – 19 - 09
NURSING RESPONSIBILITIES FOR THE DIET

• Explained the importance of the diet so that the pt and SO will understand it.
• Emphasized strict compliance of the diet regimen
• Instruct the pt to comply with the diet
• Teach the SO in proper positioning of the pt when breastfeeding.
 NURSING CARE PLANS
Problem # 1: Altered nutrition: Less than body requirements
Nursing
Nursing Scientific
Assessment Objectives Intervention Rationale Evaluation
Diagnosis Explanation
s
S> Ø Altered In normal Short term: >Establish >To gain Short term:
O > patient nutrition: Less digestion the After 3 hours rapport patient’s trust After 3 hours
may than body large intestine of NI, SO will and of NI, SO shall
manifest the requirements absorbs excess be able to participation. have
following: related to water from liquid verbalize >Assess >To obtain verbalized
inability to food residues understanding condition of baseline data. understanding
>Loss of digest food or produced by of the health the patient. of the health
weight with absorb earlier phases of teachings. >Monitor and > To teachings.
adequate nutrients the digestive record vital recognize
intake because of process before Long term: signs. abnormal Long term:
>lack of biological excreting After 4 days of signs of the After 4 days of
interest in factors AEB semisolid stools. NI, patient will > Assess patient’s NI, patient
food vomiting and When the meet and history of food status. shall have met
>vomiting diarrhea in mucous maintain intake, >Provides and
>diarrhea younger membrane lining weight financial and information maintained
>dysphagia children the large parameters cultural needed to height and
>inability of intestine is based on influences, evaluate weight
infant to suck irritated or individual vitamin/miner nutritional parameters
and swallow inflamed, food determination. al supplement, pattern, habits based on
>malabsorpti residues move and food and adequacy. individual
on through the allergies. determination.
syndromes large intestine >Assess >Provides
too quickly and abdominal information
the resulting girth, stool about ability
stool is watery characteristics to absorb
because the , presence of foods
large intestine diarrhea,
cannot absorb bowel sounds
the excess water for increased
and nutrients. motility
>Encourage
the SO to >Provides
place infant in most
position of appropriate
comfort for position to
feeding/meals enhance
movement of
formula/solid
food by
gravity and
peristalsis and
prevent
>Encourage vomiting
SO to observe and/or
cleanliness aspiration
>To prevent
>Encourage transmission
SO to avoid of m.o.
excessive
handling of an >Prevents
infant after possible
feeding vomiting from
>Teach the increased
mother about stimuli
the proper
administration >To ensure
of meds that the
patient will
>Maintain get the exact
NPO status if amount of
prescribed, medication as
provide infant prescribed.
non-nutritional >Provide rest
sucking for
gastrointestin
al tract
needed
 because of
vomiting,
diarrhea.

Problem # 2: Deficient Fluid Volume r/t Active Fluid Loss

Assessme
Nursing Scientific Nursing Expected
nt Objectives Rationale
Diagnosis Explanation Interventions Outcome

S> Ø Deficient Because of their Short term: >Establish rapport >To gain Short term:
Fluid smaller body After 4 patient’s trust After 4 hours
O> Patient Volume r/t weights and hours of NI, and of NI,
may Active Fluid higher turnover patient’s participation. patient’s
manifest Loss AEB rates for water SO(s) will >Monitor and > To note for SO(s) shall
the Decreased and electrolytes, demonstrat record vital signs. any alterations have
following: skin/tongue infants and e from normal demonstrate
turgor, dry children are more behaviours >Assess patient’s >To get d behaviours
>Decrease skin/mucou susceptible to to monitor condition baseline data to monitor
urine s dehydration than and correct and correct
output membrane adults. In deficit, as >Note for the >To know deficit, as
>poor skin s gastroenteritis, indicated possible causes of what caused indicated
turgor there is a the deficiency in the present
malfunction of the Long term: fluids condition Long term:
>Increase intestines After 3 days After 3 days
body temp because it is of NI, >Watch trends in >To give a of NI, patient
being irritated patient will output for 3 days valid picture of shall have
>Dry and inflamed. manifest client’s manifested
mucous Nutrients cannot signs of hydration signs of
membrane be absorbed rehydration status rehydration
properly by our AEB moist AEB moist
>Body intestines, and mucous >Maintain a record > To evaluate mucous
Malaise this causes membranes of the I/O the membranes,
indigestion and , normal effectiveness normal skin
>Slow often, vomiting. skin turgor, of the turgor, and
capillary and afebrile interventions afebrile
refill
>Alternate ORS >To provide
Problem # 3: Diarrhea r/t inflammation, irritation
Assessme Nursing Scientific Objectives Nursing Rationale Evaluation
nt Diagnosis Explanation Intervention
S> Ø Diarrhea When the Short term: >Establish rapport >To gain Short term:
O> the related to mucous After 5 patient’s trust After 5 hours of
patient inflammati membrane lining hours of and nursing
may on, the large nursing participation. interventions,
manifest irritation of intestine is intervention the SO shall
the ffg: the gastric irritated or s, the SO >Assess condition >To obtain have
>increase mucosa inflamed, food will of the patient. baseline data. demonstrated
frequency AEB residues move demonstrat appropriate
of bowel passing out through the large e >Monitor and > To recognize behaviour to
elimination of at least intestine too appropriate record vital signs. abnormal assist with the
and bowel three loose quickly and the behaviour to signs of the resolution of
sounds liquid resulting stool is assist with patient’s causative
>loose stools per watery because the status. factors. (proper
liquid stools day the large resolution of >Assess normal food
>poor skin intestine cannot causative pattern of bowel >Provides preparations.
turgor absorb the factors. elimination and information
>dry excess water. (proper food characteristics of about baseline Long term:
mucous preparations stool. parameters for After 6 days of
membranes ) comparison NI, patient shall
>lethargic manifested
due to Long term: >Assess for fluid resolution of
possible After 6 days loss with a light >Indicates diarrhea with
dehydration of NI, weight loss, dry possible establishment
patient will skin and mucous dehydration of pattern of
manifest membranes, poor associated soft formed
resolution of skin turgor, serum with fluid/ stool
diarrhea potassium, sodium electrolyte loss elimination
with for decreases from frequent
establishme watery stools
nt of pattern and vomiting
of soft and insensible
formed stool fluid loss from
elimination fever that
leads to
metabolic
>Instruct parent(s) acidosis
and child about
precautions >Prevents
including transmission
handwashing or spread of
technique after microorganism
bowel movement s causing
and before meals, diarrhea to
of linens and others
articles
contaminated by
excrement,

>Instruct SO on
procedures to >Provides
collect stool specimen
specimen and take examination to
to laboratory identify cause
labelled properly of diarrhea
(if prescribed)

>Place on NPO,
administer and >Allows bowel
monitor IV fluid and to rest and IV
electrolytes(if replaces lost
prescribed) fluids and
electrolytes
>Administer
antibacterial meds >To inhibit
(if prescribed) growth of m.o.
causing
 diarrhea.

Problem # 4: Impaired skin integrity related to impaired metabolic and nutritional state; changes in
fluid status
Assessme Nursing Scientific Nursing Expected
Objectives Rationale
nt Diagnosis Explanation Interventions Outcome
S> Ø Impaired Dehydration Short term: >Establish rapport >To gain Short term:
O>the pt. skin causes many After 3-5 patient’s trust After 3-5 hrs. of
manifested integrity changes in the hrs. of NI, and NI, SO shall
the ff: related to condition of the SO will be participation. have verbalized
>dry skin impaired skin. If a person able to understanding
>dry metabolic is dehydrated, verbalize >Assess condition >To obtain of individual
mucous and you will notice understandi of the patient. baseline data. factors that
membrane nutritional that the skin ng of contribute to
>pale lips state; changes. It will individual >Monitor and > To note for skin integrity
>lethargic changes in look like it’s factors that record vital signs. any changes impairment and
>sunken fluid status atrophied due to contribute in the normal takes steps to
fontanel the imbalance of to skin ranges. correct the
fluid in our body. integrity >Assess site of skin >For proper situation.
And this results impairment impairment and administration
to poor skin and takes determine etiology of NI Long term:
turgor, which is steps to After 2-4 days
an alteration correct the >Instruct the SO to >To avoid of NI, the pt.
from the normal situation. always wet the lips cracking of shall have
condition of the of the patient lips maintained
skin. Long term: optimal
After 5-6 >Encourage the SO nutrition/physic
days of NI, monitor fluid output >To assess for al well-being.
the pt. will the amount of
be able to fluid loss
maintain >Encourage the
optimal mother to feed the >To avoid
nutrition/ph baby, especially dehydration.
ysical well- fluids This causes
being. drying of the
skin.
>Inform the SO
about the >To have an
characteristics of a idea about the
normal skin changes on
the patient’s
skin
>Administer
antipyretics if fever >To maintain
arises(as normal body
prescribed) temp.
Problem # 5: Risk for Infection
 Nursing
Nursing Scientific Expected
Assessment Objectives Intervention Rationale
Diagnosis Explanation Outcome
s

S> Ø Risk for The immune Short term: >Establish >To gain patient’s Short term:
infection r/t system is d After 3-4 hours rapport trust and After 3-4
O> Patient malnutrition body’s of NI, patient’s participation. hours of NI,
may manifest and defense SO will be able patient’s SO
the following: immature against to verbalize >Monitor and > To note for any shall have
>restless and immune bacteria, understanding record vital changes in the verbalized
irritable system viruses, and of individual signs. normal ranges. understandin
>Hyperthermi other foreign causative/risk g of individual
a organisms or factors. > Observe for > To know the causative/risk
>increase in harmful the factors that may factors.
WBC count chemicals. It is Long term: environment contribute to the
very complex After 5 days of infection Long term:
and it has to nursing > Provide a >To provide After 5 days
work properly interventions, comfortable adequate rest for of nursing
to protect us there will be no environment the patient interventions,
from the signs of there shall
harmful infections. have no signs
bacteria and >Teach the > To avoid cross of infections.
other SO about contamination
organisms in proper hand
the washing
environment >To increase the
which may >Encourage resistance of the
infect our SO to give patient
body. If the foods rich in
immune Vit. C
system is > To provide
compromised, >Teach the nutrition which is
ACTUAL SOAPIEs

JUNE 25, 2009

Problem: Diarrhea

S> ø

O> received lying flat on bed sleeping and with an IVF # 8 of D50.0NaCl 500cc @
100cc level regulated @ 21uggts/min infusing well over the left hand.

> voided 4x in the shift

> BM 4x with yellowish color and soft in consistency; hyperactive bowel sounds

> good skin turgor; dry skin

> afebrile; (-) DOB, (-) cyanosis

> Vital Signs taken:

Temperature: 36.7° Celsius

Pulse rate: 135 bpm

Respiratory rate: 35cpm

A> Diarrhea related to intestinal parasite as evidenced by more than 3 stools per
day.

P> After 3° of Nursing interventions, the patient will reestablish normal pattern of
bowel functioning.

I> Established rapport

Monitored and recorded vital signs

Assessed consistency of the stool

Noted physical signs of dehydration

Provided rest periods

 Encouraged frequent hand washing

Instructed SO to keep patient’s mouth wet

Assisted patients in rendering Care

Changed clothing to loose light fitting clothes

Due meds given

E> Goal not met as evidenced by no significant changes.

R> Reinforce previous plan of care

JUNE 26, 2009

Problem: risk for imbalance body temperature

S> ø

O> received on lying position and conscious with an IVF # 9 of D50.0NaCl 500cc @
150cc level regulated @ 21uggts/min infusing well over the right hand.

> good skin turgor

> dry skin

>(-) DOB, (-) cyanosis

> Vital Signs taken:

Temperature: 37.1˚Celsius

Pulse rate: 141 bpm

Respiratory rate: 32cpm

A> Risk for imbalanced body temperature related to abnormal Lab result.
P> After 4˚ of Nursing interventions, the patient will manifest maintained body
temperature within normal range.

I> Established rapport

Assessed patient condition

Monitored and recorded vital signs

Assessed nutritional status

Monitored core body temperature

Monitored lab results

Discussed potential problem/ individual risk factors with client’s/ SO

Maintained comfortable ambient environment as indicated

Encourage to follow the prescribed diet

PM care rendered

E> Goal not met.

JUNE 27, 2009

Problem: Hyperthermia

S> ø

O> received sitting on bed with ongoing IVF # 10 of D50.0NaCl 500cc @ 100cc level
regulated @ 21uggts/min infusing well over the left hand.

> dry skin and warm to touch; Febrile

> appears weak and irritable

> (-) DOB

> (-) cyanosis

> Vital Signs taken:

 Temperature: 37.5˚Celsius

Pulse rate: 139 bpm

Respiratory rate: 30cpm

A> Hyperthermia

P> After 3 ˚ of Nursing interventions, the patient will maintain body temperature
within normal range.

I> Established rapport

Monitored and recorded vital sign

Assessed patient general condition

Instructed SO to perform TSB

Encourage SO to loosen clothing

Encourage SO to change soiled clothing regularly

Kept back dry

Emphasized the importance of the prescribed diet

Assisted client in changing soiled clothing

Emphasized the importance of good personal hygiene

Due meds given

E> Goal not met AEB no significant changes

R> Reinforced previous plan of care.

CLIENT”S DAILY PROGRESS CHART

06/ 06/ 06/

ADMISSIO DISCHAR
DAYS 061909 06/20/09 06/23/09 25/ 26/ 27/
N GE
09 09 09
NURSING PROBLEMS:
1. Altered nutrition: Less
than body requirements
2. Deficient Fluid Volume
r/t Active Fluid Loss
3. Diarrhea r/t
inflammation, irritation
4. Impaired skin integrity
related to impaired
metabolic and nutritional
state; changes in fluid
status
5. Risk for Infection
VITAL SIGNS:
Temperature(°C) 37.4°C 36. 36. 37.
Cardiac rate (bpm) 115 bpm 7 7 1
Respiratory rate (cpm) 63 cpm 13 13 83
0 5 36
34 35

LABORATORY Color: Color: Color:

PROCEDURES Greenish Greenish Greenish
1. Fecalysis Consistency Consistency: Consistenc
: Watery y
Mucoid mucoid Soft
Pus Pus Pus
cells/HPF: cells/HPF: cells/HPF:
18-25 2+ 30-40
Entamoeba RBC/HPF: RBC/HPF:
histolytica: 3-4 0.2
Cyst
2-4
Trophozoite
0-3

Color:
2. Urinalysis Light yellow
Transparenc
y
Slightly
turbid
pH:
6.0
Specific
 gravity:
1.010
Pus
cells/HPF:
20-25
RBC/HPF:
1-2
Epithelial
cells:
Rare
Hgb: Mucus
3. Hematology 112 threads:
Few
WBC:
14.7

Hct:
0.42

RBC:
4.08

Platelet:
379
 4. Na 135
5. K 3. 54
MEDICAL MANAGEMENT
IVF (D5 0.3 NaCl @
21ugtts/min)
DRUGS
Ampicillin 140mg IV
Gentamycin 20mg IV
Ranitidine 5mg IV
Paracetamol 60mg IV
(PRN)
Paracetamol drops 0.6ml
RN)
DIET
NPO (4°)
Milk feeding
EXERCISE / / / / / / /
VII. Conclusion and Recommendation
Viral gastroenteritis is an infection caused by a variety of viruses that results in
vomiting or diarrhea or both. It is often called the "stomach flu," although it is not
caused by the influenza viruses.

Almost everyone has had, or will have, what many people call stomach flu. The
technical term for this is "gastroenteritis", which means irritation of the stomach
and the intestines. Although it often goes away by itself in a couple of days (thus
the term "24-hour flu"), it sometimes lasts longer -- and having it is a miserable
experience for everyone concerned. The symptoms can vary depending on the
cause of the illness, but the "classic" signs of stomach flu are a combination of
diarrhea, fever, and vomiting. Vomiting and fever may or may not occur, but
diarrhea is almost always part of the picture.

Gastroenteritis has many causes. Viruses and bacteria are the most common.
Viruses and bacteria are very contagious and can spread through contaminated
food or water. In up to 50% of diarrheal outbreaks, no specific agent is found.
Improper hand washing following a bowel movement or handling a diaper can
spread the disease from person to person.

Gastroenteritis caused by viruses may last one to two days. On the other hand,
bacterial cases can last for a longer period of time.

Viral gastroenteritis affects people in all parts of the world. Each virus has its own
seasonal activity. For example, in the United States, rotavirus and astrovirus
infections occur during the cooler months of the year (October to April), whereas
adenovirus infections occur throughout the year. Norovirus outbreaks can occur in
institutional settings, such as schools, child care facilities, and nursing homes, and
can occur in other group settings, such as banquet halls, cruise ships, dormitories,
and campgrounds. Although gastroenteritis occurs as outbreaks among groups that
have a common source, for example, on cruise ships, it also may occur sporadically
in individuals.

Generally, viral gastroenteritis is diagnosed by a physician on the basis of the

symptoms and medical examination of the patient. Rotavirus infection can be
diagnosed by laboratory testing of a stool specimen. Tests to detect other viruses
that cause gastroenteritis are not in routine use, but the viral gastroenteritis unit at
CDC can assist with special analysis upon request.

The most important of treating viral gastroenteritis in children and adults is to

prevent severe loss of fluids (dehydration). This treatment should begin at home.
Your physician may give you specific instructions about what kinds of fluid to give.
CDC recommends that families with infants and young children keep a supply of
oral rehydration solution (ORS) at home at all times and use the solution when
diarrhea first occurs in the child. ORS is available at pharmacies without a
prescription. Follow the written directions on the ORS package, and use clean or
boiled water. Medications, including antibiotics (which have no effect on viruses)
and other treatments, should be avoided unless specifically recommended by a
physician.

The group recommends that acute gastroenteritis should be further

researched and studied by those professionals and students who are in the
medical field including parents as well as their children in every family because
we are all at risk of the uncertainty of gaining this kind of illness. This case
study was made to make each of us aware of the effects this diagnosis can bring
to people’s lives and through this study of health teaching and promotion we are
hoping for their responsiveness of prevention towards protecting their health for
the betterment of each lives. If we would take the necessary precautions, we
would prevent or minimize the occurrence of not only this kind of illness but also
with other existing factors that leads to the danger of our health.

BIBLIOGRAPHY:

 http://www.enchantedlearning.com/subjects/anatomy/digestive/
 http://www.merck.com/mmpe/sec02/ch016/ch016a.html#sec02-ch016-
ch016a-924
 http://baby.about.com/od/growthanddevelopment/p/physical_development_n
ewborns.htm
 Microsoft Student Encarta Premium 2009
 Microsoft Encarta 2006
 http://www.leeds.ac.uk/chb/lectures/anatomy8.html
 http://www.emc.maricopa.edu/faculty/farabee/BIOBK/BioBookDIGEST.html
 http://nosubject.com/Anna_Freud
 http://www.medicinenet.com/gastroenteritis/article.htm#tocb
 http://www.drreddy.com/gastro.html
 http://www.emedicinehealth.com/gastroenteritis/page2_em.htm#Gastroenter
itis%20Causes
 http://emedicine.medscape.com/article/801948-overview

 http://www.merck.com/mmpe/sec02/ch016/ch016a.html
 http://www.scribd.com/doc/12445474/NCP-Risk-for-Impaired-skin-integrity-rt-
dry-skin-and-behaviors-that-may-lead-to-skin-integrity-impairment-AEB-
scratching-of-scabs
BOOKS:
 Pediatric Nursing
o Parul Datta
 Medical and Surgical Nursing (2nd Edition) Volume 2
 Nursing Diagnosis Handbook (A Guide to Planning Care) 5th Edition
o sAckley Ladwig
 Urinalysis and Body fluids Edition 4
o Copyright © 2001 by F.A. Davis Company
 Medical-Surgical Nursing Volume 1 (8th edition)
o Joyce M. Black, Jane Hokanson Hawks; Copyright © 2008
 Wong’s Clinical Manual of Pediatric Nursing (6th Edition)
o Marilyn J. Hockenberry; Copyright © 2004
 Nurse’s Pocket Guide (11th edition)
o Marilynn Doengens, Mary Frences Moorhouse, Alice Murr, Copyright
© 2008

 Van De Graaff’s Human Anatomy Fifth Edition

 2009 Lippincott’s Nursing Drug Guide