CASE PRESENTATION OBJECTIVES

General Objectives
After an hour and a half of case presentation:
The presenters, the audience, and the clinical
instructors will be acquainted with the vital
information; patients health history; normal
anatomy and physiology of gastrointestinal
system; pathophysiology of the disease; clinical
manifestations; medical and surgical
managements; diagnostic tests; nursing care
plan; and discharge plan of a client with
gastroenteritis.

Specific Objectives
For the presenter
The presenter will be able to:

Impart the patients vital information and health

history;
Elaborate the normal anatomy and physiology of the
gastrointestinal system;
Illustrate the pathophysiology of gastroenteritis;
Discuss the clinical manifestations;
Explain the medical and surgical management;
Differentiate the normal and abnormal values of
laboratory and diagnostic tests;
Prioritize the identified problems; and
Outline the discharge plan.

For the students

The students will be able to:

Comprehend the patients vital information and health history;

Relate the normal anatomy and physiology of the
gastrointestinal system;
Create a diagram of the pathophysiology of gastroenteritis;
Distinguish the clinical manifestations;
Appreciate the importance of medical and surgical
management;
Contrast normal from abnormal values of laboratory and
diagnostic tests:
Critique the nursing care plan; and
Apply the discharge plan.

For the Clinical Instructors

The clinical instructors will be able to:

Ask questions regarding the normal anatomy

and physiology of the gastrointestinal system;
Critique the pathophysiology of gastroenteritis;
Differentiate the clinical manifestations of
gastroenteritis;
Critique the nursing care plan; and
Modify the discharge plan.

INTRODUCTION
Gastroenteritis, or enteritis, is an
inflammation of the stomach and small
intestine. Enteritis may be caused by
bacteria, viruses, parasites, or toxins.
Upper GI manifestations such as
anorexia, nausea, and vomiting are
common. Diarrhea of varying intensity
and abdominal discomfort are nearly
universal features of gastroenteritis.
(LeMone, 2010)

The infectious organism usually enters the

body in contaminated water or food. For this
reason, gastroenteritis often is called food
poisoning. Viruses commonly cause acute
diarrheal illness. Diarrhea due to rotaviruses
or the Norwalk virus occurs year-round in
both adults and children. These illnesses are
generally mild and self-limited, but can have
severe consequences in the very young, the
very old, or in people with impaired immune
function. (LeMone, 2010)

In our case study for this morning,

we are focusing about our patient
which is an infant. Although often
considered a benign disease,
gastroenteritis remains a major cause
of morbidity and mortality in children
around the world, accounting for 1.34
million deaths annually in children
younger than 5 years, or roughly 15%
of all child deaths.

As the disease severity depends on

the degree of fluid loss, accurately
assessing dehydration status remains a
crucial step in preventing mortality.
Luckily, most cases of dehydration in
children can be accurately diagnosed
by a careful clinical examination and
treated with simple, cost-effective
measures.

Although dehydration technically

refers to pure water loss and can be
associated with euvolemic or even
hypervolemic states in certain pediatric
disorders, the term is used in its more
general sense to mean overall fluid or
volume loss due to diarrhea. (
http://emedicine.medscape.com)

Specific Types of Gastrointestinal Infections:

(LeMone, 2010)

Travelers Diarrhea - People traveling to another

country frequently develop diarrhea within 2 to 10
days, particularly when there is a significant
difference in climate, sanitation standards, or food
or drink. Strains of enterotoxin-producing E. coli,
Shigella species, Salmonella, and Campylobacter
are the most frequent causes of travelers diarrhea
(Yates, 2005). Other bacteria and viruses also may
cause travelers diarrhea. Up to 10 or more loose
stools per day and abdominal cramping are
common manifestations. Nausea and vomiting are
less frequent; fever is rare. Manifestations usually
resolve within 2 to 5 days. Complications are rare.

Escherichia Coli Hemorrhagic Colitis

- most pathologic forms of E. coli
bacteria cause little more than common
travelers diarrhea. However, some
strains, such as serotype 0157:H7,
produce a potent enterotoxin in the large
intestine after being ingested. This toxin
damages bowel mucosa and the
endothelial cells of blood vessels as well,
such as those of the kidney.

The onset of hemorrhagic colitis is

abrupt, with severe abdominal
cramping and watery diarrhea that
becomes grossly bloody within 24
hours. Fever may be present.
Hemolytic uremic syndrome and
thrombotic thrombocytopenic purpura
are significant complications of E. coli
hemorrhagic colitis.

Staphylococcal Food Poisoning - Certain

foods provide an excellent medium for
staphylococcal growth when contaminated
and left at room temperature. Examples
include meats and fish, dairy products, and
bakery products. The organism itself does
not affect the bowel; the toxin it produces,
however, impairs intestinal absorption and
acts on receptors in the gut, stimulating the
medullary center to produce vomiting.

The onset of staphylococcal food

poisoning is abrupt, occurring within 2
to 8 hours after consuming the
contaminated food. Nausea and
vomiting are severe. Manifestations
typically last 3 to 6 hours, and include
abdominal cramping, diarrhea,
headache, and fever. Complications
such as fluid and electrolyte imbalances
are rare, but may develop in older
adults and people with underlying
chronic disease processes.

Cholera - is an acute diarrheal illness

caused by strains of Vibrio cholerae. It is
endemic in parts of Asia, Middle East, and
Africa. Cholera is spread by the fecal-oral
route through contaminated water or
food. The organism produces an
enterotoxin, enzymes, and other
substances that affect the entire small
intestine. Water and electrolytes are
secreted into the bowel lumen in response
to the toxin. The enzymes and other
substances produced by the bacteria may
affect mucous protection of bowel
endothelium.

Clostridium Difficile Colitis - is associated

with antibiotic therapy. Treatment with
antibiotics predisposes to interference with
the normal protective bacteria of the colon,
leading to colonization by C. difficile by the
oral-fecal route. Subsequent release of toxins
by the bacteria causes mucous damage and
inflammation. This is primarily a problem in
hospitalized patients, causing diarrhea and
abdominal cramping. These manifestations
commonly begin within 1 to 2 weeks of
antibiotic treatment. It is also being seen in
the community in healthy adults. The
bacteria can be identified in the stool.

Salmonellosis - is food poisoning caused by

ingesting raw or improperly cooked foods
contaminated with Salmonella bacteria. Meat,
poultry, eggs, and dairy products commonly
are implicated in Salmonellosis; recent
outbreaks have been linked to products such
as peanuts and alfalfa sprouts. These bacteria
cause superficial infection of the GI tract,
rarely invading further. They do not produce
toxin. Manifestations develop 8 to 48 hours
after ingesting the bacteria. Diarrhea may be
violent with abdominal cramping, nausea, and
vomiting. A low-grade fever, chills, and
weakness may accompany GI manifestations.

Shigellosis (Bacillary Dysentery) Occurs worldwide, and may be

endemic or occur in epidemics.
Humans are the reservoir for Shigella
organisms, which are spread directly
via fecal-oral route or indirectly
through contaminated food, fomites,
and vectors (such as fleas). The
incubation period for shigellosis is 1 to
4 days.

Norovirus - is a highly contagious

disease that often occurs in outbreaks
within an institution or facility. It is
characterized by acute vomiting,
watery, non-bloody diarrhea,
abdominal cramps, and nausea.
Systemic manifestations such as
myalgia, malaise, headache, and lowgrade fever are common.

MANIFESTATIONS
Gastrointestinal Effects:

Anorexia, nausea and vomiting

Abdominal pain and cramping
Borborygmi
Diarrhea

General Effects:

Malaise, weakness, and muscle aches

Headache
Dry skin and mucous membranes
Poor skin turgor
Orthostatic hypotension, tachycardia
Fever

Although the manifestations of bacterial

and viral enteritis vary according to the
organism involved, several features are
common. Anorexia, nausea, and
vomiting are caused by distention of the
upper GI tract by unabsorbed chime
and excess water. Bowel distention,
along with irritation of the bowel
mucosa and gas production due to
fermentation of undigested food, lead
to abdominal pain and cramping.

Borborygmi, excessively loud and

hyperactive bowel sounds, are another
result. The abdomen is often distended
and tender. Diarrhea is usually
predominant with enteritis. Fluid is
secreted into the bowel lumen, and the
unabsorbed chyme and electrolytes
create an osmotic pull of fluid into the
bowel.

Motility is stimulated, and stools

become watery and frequent. Loss of
fluids and electrolytes through diarrhea
can lead to most serious
manifestations of enteritis. Fluid
volume can be rapidly depleted,
leading to dehydration and
hypovolemia. Orthostatic hypotension
and fever may be noted initially. If fluid
loss continues, hypovolemic shock may
develop. (LeMone, 2010)

COMPLICATIONS
Electrolyte and acid-base imbalances may
result from gastroenteritis. Extensive vomiting
can lead to metabolic alkalosis due to the
loss of hydrochloric acid from the stomach.
When diarrhea predominates, metabolic
acidosis is more likely. Potassium is lost in
either case, leading to hypokalemia.
Hyponatremia may develop if fluids are
replaced with pure water. Headache, cardiac
irregularities, changes in respiratory rate and
pattern, malaise and weakness, muscle aching,
and signs of neuromuscular irritability are the
possible manifestations of these disturbances
in homeostasis. (LeMone, 2010)

RISK FACTORS (http://www.patient.co.uk)

Poor hygiene and lack of sanitation

Compromised immune system
Poorly cooked food, cooked food that has
been left too long at room temperature or
from uncooked food. Insufficient reheating
of food not only fails to kill bacteria but
may speed up multiplication and increase
the bacterial load ingested. Even if
reheating of cooked food kills bacteria,
enterotoxins such as staphylococcal
exotoxin are not destroyed.

MANAGEMENTS (http://www.patient.co.uk)
Fluid management
Continue breast-feeding and other milk
feeds
Encourage fluid intake
Discourage the drinking of fruit juices and
carbonated drinks, especially in those at
increased risk of dehydration
Offer oral rehydration salt (ORS) solution
as supplemental fluid to those at
increased risk of dehydration

Nutritional management
During rehydration therapy:

Continue breast-feeding
Do not give solid foods
In children with mild cases, do not routinely
give oral fluids other than ORS solution;
however, consider supplementation with the
child's usual fluids (including milk feeds or
water but not fruit juices or carbonated drinks)
if they consistently refuse ORS solution
In children with severe cases, do not give oral
fluids other than ORS solution

Drugs
Antibiotic therapy should not be used routinely but
should be given:

For suspected or confirmed septicemia

With extra-intestinal spread of bacterial
infection.
When younger than 6 months with salmonella
gastroenteritis.
In those who are malnourished or
immunocompromised with salmonella
gastroenteritis.
Where there is C. difficile-associated
pseudomembranous enterocolitis, giardiasis,
bacillary dysentery, amoebiasis or cholera.

PREVENTION

Breast-feeding confers some protection

against gastroenteritis.
Rotavirus vaccine
Washing hands with soap (liquid if possible)
in warm running water and careful drying
are the most important factors in
preventing the spread of gastroenteritis.
Hands should be washed after going to the
toilet or changing nappies (parents) and
before preparing, serving or eating food.

DEFINITION OF TERMS
1. Borborygmi- a rumbling or gurgling
sound caused by the movement of gas
in the intestines.
2. Norwalk Virus- A family of small
round viruses that are an important
cause of viral gastroenteritis (viral
inflammation of the stomach and
intestines). Norwalk disease is a
significant contributor to illness in the
US.

3. Chyme- The semifluid mass into which

food is converted by gastric secretion and
which passes from the stomach into the
small intestine.
4. Distention- Abdominal distension occurs
when substances, such as air (gas) or
fluid, accumulate in the abdomen causing
its outward expansion beyond the normal
girth of the stomach and waist.
5. Enteritis- Enteritis is the inflammation of
your small intestine. In some cases, the
inflammation includes the stomach and
large intestine.

6. Enterotoxins- a toxin specific for the

cells of the intestinal mucosa.
7. Fermentation- Fermentation is a
form of biological energy production
and "fermented" is the end result of
the process I present below.
8. Hydrochloric Acid- HCL is the
medical friendly, water and acid
soluble, salt version of an amine.
Amines are converted to a salt form for
their standardized and predictable
rates of solubility and absorption.

9. Hypokalemia- Hypokalemia is a condition of

below normal levels of potassium in the blood
serum.
10. Hyponatremia- is defined as a low sodium
concentration in the blood.
11. Hypovolemia- is a state of decreased blood
volume; more specifically, decrease in volume of
blood plasma.
12. Lumen- The inner open space or cavity of a
tubular organ, as of a blood vessel or an intestine.
13. Metabolic Alkalosis- Metabolic alkalosis is a pH
imbalance in which the body has accumulated too
much of an alkaline substance, such as
bicarbonate, and does not have enough acid to
effectively neutralize the effects of the alkali.

14. Mucosa- The mucous membrane, or

the thin layer which lines body cavities
and passages.
15. Orthostatic- Is a form of low blood
pressure that happens when you stand
up from sitting or lying down.
16. Osmotic- Diffusion of fluid through a
semipermeable membrane from a
solution with a low solute concentration
to a solution with a higher solute
concentration until there is an equal
solute concentration on both sides of
the membrane.

17. Rotavirus- Any of a group of wheelshaped viruses, of the genus Rotavirus,

that causes gastroenteritis and
diarrhea in children and animals.
18. Vibrio Cholerae- One of the Vibrio
bacteria, V. cholerae (as the name
implies) is the agent of cholera, a
devastating and sometimes lethal
disease with profuse watery diarrhea.

VITAL INFORMATION

Name: Ms. Diamond

Room Number: 242 Bed 5
Age: 4 months old
Gender: Female
Civil Status: Child
Date of Birth: November 10, 2014
Birthplace: Iligan City
Cultural Group: Iliganon
Primary Language: Bisaya
Religion: Roman Catholic
Highest Educational Attainment: N/A
Occupation: N/A
Usual Health Care Provider: Dr. Uy Hospital
Reason for Health Contact: Fever & LBM
Date of Confinement: March 7, 2015
Source of History: Patients mother
Attending Physician/s: Dr. Yvette Nadal
Admitting Impression: Acute Infectious Diarrhea Moderate Dehydration
Final Diagnosis: Acute Gastroenteritis with Severe Dehydration and
Electrolyte Imbalance Hyponatremia, Hypocalcemia
Description of Patient: Awake, lying on bed, alert, with patent IVF of
D5IMB via IV pump @20cc/hr, no episodes of bowel movement, afebrile

HISTORY OF PRESENT ILLNESS

According to the patients mother, five days before
admission, patient had experienced an onset of intermittent
fever. The patient was given Paracetamol drops 0.25 ml
every 4 hours for her fever which afforded temporary relief.
Nagpadayon man gihapon iyang hilanat so gi-admit namo
siya sa Dr. Uy Hospital adtong Monday last week (March 2,
2015) kay didto man namo siya sige ipa check-up. Si Dr.
Mariano iyang doctor didto. as verbalized by the mother.
The patient was given medications such as Napran and
Ener-E vitamins. Last March 4, 2015, patient was discharged
from Dr. Uy Hospital. Last Thursday (March 5, 2015), the
fever recurred. The next day, the fever was already
associated with LBM with watery stools, yellow green in
color as stated by the mother. The patient experienced
diarrhea continuously for 1 days and was already
dehydrated as manifested by sunken eyes with pallor skin,
thus prompted admission at AMC-Iligan Hospital.

PAST MEDICAL HISTORY

The patient had received immunizations such as
BCG, Hepa B (3 doses), Pentavalent (3 doses),
Rotavirus (2 doses), and OPV (3 doses). As
stated by the mother, the child hasnt
experienced any illnesses before such as
measles, mumps, rubella, chicken pox, dengue
fever, typhoid fever, etc. She had Tiki-tiki and
Ceelin as her vitamins before. No history of
accidents or injuries. Patient was admitted at Dr.
Uy Hospital before, with her attending physician,
Dr. Mariano. She was then transferred to AMCIligan Hospital due to recurrence of fever with
LBM. No previous operations or any surgeries. No
allergies as claimed by the patients mother.

NORMAL ANATOMY AND PHYSIOLOGY

Gastrointestinal System
The GI system is composed of one continuous
tube that begins at the mouth, progresses through
the esophagus, stomach and small and large
intestines and ends at the anus. The pancreas,
liver and gallbladder are accessory glands that
support the functions of the GI system.

Structures
The tube that comprises the GI tract
is continuous with the external
environment, opening at the mouth
and again at the anus. Because of this
GI tract contains many foreign agents
and bacteria that are not found in the
rest of the body.

Accessory Organs
Pancreas
Deposits digestive enzymes and sodium
bicarbonate into the beginning of small intestine
to neutralize acid from the stomach and to
further facilitate digestion
Gallbladder
When gallbladder is stimulated to contract by
the presence of fats, all of the nutrients
absorbed from the small intestine pass into the
liver
Liver
Produces bile (very important in the digestion of
fats), which stored in the gallbladder.

Four Layers of the Gastrointestinal Tract

Mucosal Layer
The mucosa is the innermost layer of the
gastrointestinal tract that is surrounding thelumen, or
open space within the tube. This layer comes in direct
contact with digested food (chyme). The mucosa is
made up of:

Epithelium - innermost layer. Responsible for most

digestive, absorptive and secretory processes.
Lamina propria - a layer of connective tissue.
Unusually cellular compared to most connective tissue
Muscularis mucosae - a thin layer of smooth muscle
that aids the passing of material and enhances the
interaction between the epithelial layer and the
contents of the lumen by agitation andperistalsis.

Nerve Plexus Layer

The nerve plexus has two layers of nervesone submucosal layer and myenteric layer.
This nerves allow GI tract have control over
movement, secretions and digestion. The
nerve respond to local stimuli and act on
the concepts of GI tract accordingly.
Muscularis Mucosa Layer
The muscularis consists of an inner circular
layer and alongitudinalouter muscular
layer. The circular muscle layer prevents
food from traveling backward and the
longitudinal layer shortens the tract.

Adventitia Layer
The adventitia is the outer layer of
the GI tract. It serves as a supportive
layer and helps the tube maintain its
shape and position.

Gastrointestinal Four Major Activities

Secretions
The GI tract secretes various compounds to
aid the movement of the food bolus through
the GI tube, to protect the inner layer of the
GI from injury and to facilitate digestion and
absorption of nutrients.
Absorption
Absorption is the active process of removing
water, nutrients and other elements from
the GI tract and delivering them to the
bloodstream for use by the body.

Digestion
Digestion is the process of breaking food
into usable and absorbable nutrients.
Motility
Motility is the movement of food and
secretions through the system. The basic
movement seen in the esophagus is
peristalsis, a constant wave of contraction
that moves from the top to the bottom of
the esophagus. The act of swallowing, a
response to a food bolus in the back of the
throat, stimulates the peristaltic movement
that directs the food bolus into the stomach.

MEDICAL & SURGICAL MANAGMENTS

Acute enteritis usually solves spontaneously,
and no drug treatment required. If the
patient is severe ill and manifestations are
prolonged, medication maybe prescribed.
Antibiotic therapy specific the organisms
maybe use to treat bacterial colitis, cholera,
salmonellosis, or shigellosis. Ciprofloxacin
(Cipro), Clarithromycin (Biaxin),
erythromycin, amoxicillin/clavulanate
(Augmentin) or another antibiotic may
prescribed. Stool culture is obtained prior to
starting antibiotics.

Nutrition and Fluids

Replacing the loss of fluid and electrolytes
is vital when vomiting and/or diarrhea are
severe or prolonged. In many cases of
enteritis, fluid and electrolyte replacement
are all that is required until infection
resolves.
Oral rehydration is preferred for replacing
physiologic fluids. An oral glucoseelectrolyte solution is often well tolerated
in sips, even when vomiting is present.
Intravenous rehydration may be necessary
with severe diarrhea and fluid loss.

Gastric Lavage
Gastric Lavage and catharsis- in effect, washing
outthe stomach and intestines- may be
performed to remove unabsorbed toxin from GI
tract if botulism is suspected. The patient with
botulism is closely observed for signs of
respiratory distress. Respiratory support with
endotracheal intubation or tracheostomy and
mechanical ventilation may be required.
Plasmapheresis
Plasmapheresis (plasma exchange therapy) may
be performed to remove circulating toxins for
hemorrhagic colitis caused by E-coli. Potential
complications include those associated with
intravenous catheters, shifts in fluid balance, and
altered blood clotting.

Dialysis
Acute tubular necrosis and renal
failure associated with hemorrhagic
colitis may necessitate dialysis to
remove wastes and prevent severe
fluid and electrolyte imbalances and
metabolic acidosis. Although acute
renal failure often resolves
spontaneously and renal function
resumes, dialysis can be lifesaving.
Either hemodialysis or peritoneal
dialysis may be used, generally as a
temporary measure.

DISCHARGE PLAN &

TEACHING

Special Instructions:
Hand washing
Increase fluid intake

Health teachings:
Instruct the mother to clean the bottles or any containers used in feeding
the baby.
Encourage the parents to do hand washing before and after giving the milk
to the baby.
Instruct them to comply religiously the medication with their baby to the
period of time as prescribed.
Demonstrate to the parents the different ways of burping for the baby.

OPD Visits/ Referrals:

Follow up check up on March 17, 2015 at DR. Nadals Clinic

Diet:
Milk Formula for age

Spiritual care:
Be grateful for all the things that God has been given to us. For He never
forget to bless and shower His graces. Humbly we bow ourselves unto Him
and give respect for He is the King of kings and Lord of all lords. All things
are made because of His will, thank God for His protection and guidance in

PROGNOSIS
The prognosis for complete recovery
is excellent in most people infected
with viral and bacterial caused by
gastroenteritis, as long as the person
keeps well hydrated. Their prognosis
depends on how dehydrated they
become and how effective are the
attempts to rehydrate the patient.
Prevention of the recurrence of the
disease is also important.

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LeMone et.al. (2010) Medical-Surgical Nursing
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McFarland, M. (2014) Nursing Implications of
Laboratory Tests 2nd Edition. Delmar Publishers Inc.
MIMS 140th edition 2014
Nurses Quick Check Diagnostic Tests
Nursing 2006 Drug Hand Book 26 th edition.
Philadelphia. Lippincott Williams & Wilkins
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