I.

Demographic Data:

The client’s name is Levy Anastacio Alvarado, a 5- month- old baby boy who was born on August 10,
2010 via cesarean section due to oligohydramnios. He is currently residing with his parents and other relatives
at Unit 7 Sitio Sto. Niño Pagrai Mayamot. This pure blooded Filipino is a baptized Roman Catholic and was
admitted last January 28, 2011 at 1:50 pm under the care of Dra. Cornel. His aunt was the secondary source of
data in this presentation who was interviewed on the 29 th day of January year 2011 at 9:00 am inside the
pediatric ward of the Antipolo Medical City Hospital.

Chief Complaint:

Diarrhea and vomiting

Medical Diagnosis:

Acute Gastroenteritis with signs of Dehydration

II. Patient History

History of Present Illness:

Three days prior to admission, the client’s mother noticed that LAA started to have productive cough
with no other accompanying manifestations therefore, they did not consult a physician nor take any medication
for the said condition. The cough persisted for two days but this time, it is accompanied by three episodes of
loose watery stool. The client also vomited twice and a fever was noted at the 38 C level. These made the
client’s family decide to take LAA for a consultation with a private doctor who prescribed zinc, freeflora, and
oral rehydrating solution. However, all the symptoms persisted despite the given medications. This prompted
the client’s family to take him in a hospital.

Past Health History:

The client’s aunt claimed that LAA has no allergic reaction to any drug. The only food he is currently
taking is cerelac which he shows no allergic reaction to as well. However, he is sensitive to dust and animal fur.
There also came a time that his physician banned applying powder and cologne to the client. LAA has never
been confined in a hospital until now. He has not experience any childhood illness yet and has already received
BCG and DPT vaccines. His MMR immunization is due this February.
Family History:

+ ● + ♥▲

■ ■

Legend:

Male

Female

+ Deceased

● Stroke

♥ hypertensive

▲ Diabetes mellitus

■ Polio

♦ Client

On the client’s maternal side, his grandfather died because of an unknown cause. It was said that
after drinking with some friends, he went home then suddenly vomited uncontrollably then died afterwards. His
grandmother is still alive but is suffering from hypertension and diabetes. Meanwhile, on the paternal side, his
grandfather was also deceased because a robber broke into their home and killed the man. When it comes to the
client’s parents, his mother is a polio victim but other than that, she has no other health disorder. his father is in
perfect health as well.

Past Medical History:

 Antenatal History:
During pregnancy, the client’s mother took the regular prenatal vitamins needed by expecting
women. She also took something for the baby to stay in utero. However, the source of data failed to recall the
exact name of the drug. The client is also the first born child of his parents.

Perinatal History:
The client’s aunt cannot recall the baby’s apgar score upon birth but she claimed that he weighed
3.6 pounds. He was delivered via cesarean birth because of oligohydramnios.

Postnatal History
The client was breastfed until two months of age but was transferred to bottle feeding after that
because his mother needs to go back to work.

Feeding History:

Client LAA is bottlefed using the formula named nestogen. He consumes about three bottles containing
7ml formula milk diluted in wilkins distilled water. He also eats cerelac and takes celeen and nutrilin as vitamin
supplements.

Developmental Status:

The client has a social smile by age one month. He is now five months old and can hold his own bottle.
He can turn to his side and be on his abdomen while holding his head upright.

Immunization:

The client already received BCG and DPT vaccines courtesy of their local health center. He will be
getting his MMR this coming February 16.

Social History:

The client's mother is an elementary school teacher while his father is unemployed at the moment. They
are currently staying with LAA's grandmother and aunt who look after him as well. The client usually sleeps
with his caregivers than his parents making him closer to them. They have a bird and a cat as household pets.
This also may be the reason why the client developed sensitivity to dust and animal fur. He is not exposed to
any toxic substances such as cigarette smoke because no one in the house is a smoker. It is only when his uncles
come to visit that he inhales such smoke. The client uses Wilkins purified water in drinking and when preparing
food. 
Drug Study:
Medication Drug Indication Drug Actions Contraindications: Nursing Responsibility

Generic Relief of fever, minor Analgesia: Anemia, heart and *Use liquid form for
Produces children and
Name: aches, and pains. pulmonary disease. patients who have
Analgesia by
Paracetamol Hepatic/severe difficulty
blocking pain
Dosage for pediatric renal disease. swallowing.
impulses
*In children, don’t
Brand Name: patients: by exceed five doses in 24
*Calpol Doses repeated 4-5 inhibiting hours.
*Neo- times/day, do not exceed 5 synthesis *Advise patient that
of prostaglandin drug is only for short
Kiddielets doses in 24hrs.
in the CNS term use and to consult
*Biogesic or other the physician if giving
*Tempra Age Dosage substances that to children for
(mg) sensitize receptors longer than 5 days or
of adults for longer than
0-3 mo 40 10 days.
stimulation.
Classification: 4-11 mo 80 * Advise patient or
Analgesic and 12-23mo 120 caregiver that
Antipyrexia: many over the counter
Antipyretic 2-3yr 160 Reduces fever by products
4-5yr 240 acting directly on contain acetaminophen;
6-8yr 320 be aware
the hypothalamic of this when calculating
9-10yr 400 heat-regulating total daily
11 yr 480 center to dose.
*Warn patient that
cause vasodilation high doses or
and sweating, unsupervised long term
which helps use can
cause liver damage.
dissipate heat.
DRUG DOSAGE MOA INDICATION CONTRAINDICATIO SIDE
N EFFECTS
Salbutamol Albuterol may To relieve Contraindicated in Cardiac side
(Albuterol) Usual Dosage: reduce bronchospasm patients hypersensitive effects are not
2 inhalations chemical associated with to drug or its prominent.
repeated every mediator acute or chronic ingredients. Muscle tremors
4 to 6 hours release from asthma, are the dose
pulmonary bronchitis, or Use cautiously in related side
mast cells and other reversible patients with effects.
improve ability obstructive CV disorders (including >Bad taste
of cilia to clear airway diseases. coronary >blurred vision
mucus. Also used to insufficiency and >urinary
prevent hypertension), retension
Albuterol is a exercise- hyperthyroidism, or >palpitation
direct-acting induced diabetes >ankle edema
agent that bronchospasm. mellitus and in those can also occur.
relaxes smooth who are unusually
muscle walls responsive to
of the bronchi, adrenergics.
uterus, and
skeletal muscle Use extended-release
vascular bed. tablets cautiously in
patients with GI
narrowing.
DRUG DOSAGE MOA INDICATION CONTRAINDICATION SIDE
EFFECTS
GENTAMICIN Aminoglycosides For treatment of Hypersensitivity to Serious Side
Brand Name: INFANTS: irreversibly bind to serious infections Gentamicin or to
Alcomicin specific 30S- caused by other Effects:
Apogen (Birth-12 subunit proteins susceptible aminoglycosides. An allergic
Bristagen months) and 16S rRNA. strains of the Because of reaction:
G-Mycin Specifically, following ototoxicity and (shortness of
3 mg/kg
G-Myticin gentamicin binds microorganisms: nephrotoxic breath;
every 12 closing
Garamycin to four nucleotides P. hazards of
Garamycin hours of the 16S rRNA aeruginosa, extended of the throat;
and one amino Proteus administration, hives;
acid in protein species (indole- Gentamicin, like swelling
S12. positive and other of the lips,
This interferes indole- aminoglycoside face, or
with negative), E. coli, antibiotics is tongue; rash;
decoding near Klebsiella- generally not or fainting);
nucleotide 1400 in Enterobactor- indicated in long little or no
16S rRNA of the Serratia term therapy urine;
30S subunit, species, decreased
interfering with Citrobacter hearing or
the species and ringing in the
formation of an Staphylococcus ears;
initiation complex, species dizziness,
causing (coagulase-
clumsiness, or
misreading of positive and
unsteadiness;
mRNA so that coagulase-
numbness,
incorrect amino negative).
acids are inserted skin tingling,
into the muscle
polypeptide twitching, or
leading to seizures; or
nonfunctional or severe watery
toxic peptides and diarrhea and
the breakup of abdominal
polysomes into cramps.
nonfunctional Less Serious
Monosomes.
Side Effects:
increased
thirst; loss of
appetite;
nausea or
 vomiting; a
rash.

Medication MOA Indication Contraindications: Side effect

ampicillin Inhibit cell wall synthesis Treatment of Patient with Skin rashes,
during bacterial Nausea,
multiplication. infections cause by allergic reaction to Vomiting,
susceptible strains penicillin Diarrhea,
of the designated And pain to injection
site.
organism. Patient with
hypersensitivity to
drugs and patient
with viruses
belonging to
herpes group.
DISCHARGE PLAN:

Clients with Acute Gastroenteritis, watchers are instructed to take the following plan for

discharge:

M- Medications should be taken regularly as prescribed , on exact dosage, time, & frequency,

making sure that the purpose of medications is fully disclosed by the health care provider.

E- Exercise should be promoted in a way by stretching hand and feet every morning and

exercise burping every after bottle feeding.

T- Treatment after discharge is expected for patients and watcher with Acute Gastroenteritis

to fully participate in continuous treatment.

H- Hygiene must be maintained for patients with Acute Gastroenteritis. Promotion of

personal hygiene should be encouraged such as, daily bathing and changing of diapers
when soiled.

O- OPD such as regular follow-up check-ups should be greatly encouraged to clients whether

with Acute Gastroenteritis as ordered by physician to ensure the continuing management
and treatment.

D- Diet should be promoted, since, during admission, the patient was on NPO. Proper

selection of milk that are suitable for babies will help enhance immunity.

S- Signs and Symptoms.

-Clinical manifestations vary depending on the pathologic organism and the level of GI tract involved. AGE
produces symptoms such as: diarrhea, abdominal discomfort, nausea and vomiting, fever, body malaise
-In children and elderly and debilitated people, AGE produces the same symptoms, but the inability of the
patient to tolerate electrolyte losses leads to a higher mortality.

Pathophysiology of gastroenteritis