Introduction

Acute gastroenteritis is a very common problem in infants and children and is usually caused by a stomach virus, such as the rotavirus, or food poisoning. Symptoms include a fever, stomachache, vomiting and diarrhea. Although the vomiting typically lasts only two to three days, the diarrhea can last for one to two weeks before it finally resolves. Acute Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). The most common symptoms are fever, diarrhea, crampy abdominal pain, nausea, and vomiting. Many people also refer to gastroenteritis as "stomach flu." Viral infections such as Norovirus and Rotavirus are the most common cause of gastroenteritis but bacteria (Escherichia coli , Salmonella, Shigella and Campylobacter ), parasites(Giardia, Cryptosporidium) and food-borne illnesses (such as shellfish) can also be the offending agents. Many people who experience vomiting and diarrhea that develops from these types of infections or irritations think they have "food poisoning," when they actually may have a food-borne illness. The main problem from having diarrhea and vomiting is that it can lead your child to getting dehydrated. The first sign of dehydration is that a child will urinate less frequently (a child should be urinating every six to eight hours). Other signs include a dry mouth, not having tears when crying, sunken eyes, weight loss, and decreased activity or increased irritability. If a child has persistent diarrhea and vomiting, but is still urinating regularly and has a moist mouth then there is little danger that he is getting dehydrated. Oral rehydration therapy should be the initial treatment because it is as effective as intravenous therapy in rehydrating and replacing electrolytes in children with mild to moderate dehydration and an age-appropriate diet should be continued in children with diarrhea who are not dehydrated, and an age-appropriate diet should be resumed as soon as rehydration is accomplished in children with mild to moderate dehydration.

Demographic Profile
Patients Name: Age: Sex: Nationality Religion: Date of Admission: Chief Complaint: Final Diagnosis: L.A.D.T 8 years old Male Filipino Roman Catholic June 15, 2011 Abdominal pain Acute Gastroenteritis

Admitting Diagnosis: ATP, Acute Gastritis with Mild DHN

Diagnostic and Laboratory

Salmonella Salmonella IgG Salmonella IgM Result 2.5 1.6 Cut-off Value 0.80 0.95

June 16, 2011 Remark Positive Positive

*Positive Salmonella Remark may be due to infected food, often gaining an unusual color, odor, or chewiness, that is then introduced into the stream of commerce; Poor kitchen hygiene, especially problematic in institutional kitchens and restaurants because this can lead to a significant outbreak; Excretions from either sick or infected but apparently clinically healthy people and animals (especially endangered are caregivers and animals);Polluted surface water and standing water (such as in shower hoses or unused water dispensers). Urinalysis

June 17, 2011 Color Transparency pH Specific gravity Pus cells Red blood cells Epithelial cells Protein Sugar Amorphous Urates Amorphous Phosphates Mucus Threads Bacteria Light yellow Hazy 6.0 1.010 1-2/ HPF 1-3/ HPF Rare Negative Negative Few No result No result No result

June 16, 2011 Yellow Hazy 7.0 1.005 0-1/ HPF None seen Rare Negative Negative No result Moderate No result No result

June 15, 2011 Dark yellow Slightly turbid 6.5 1.010 2-4/ HPF 0-2/ HPF Rare Negative Negative Moderate No result No result No result

Normal Value Pale yellow to amber Clear to slightly hazy 4.5-8.0 1.015-1.025 Few Negative or rare Few or rare Negative Negative Few Few Few Few

*Dark Yellow Urine Color causes include dehydration, intake of foods such as asparagus and presence of high level of B complex vitamins. Dark yellow urine means that there might be probable chances of the onset of medical conditions such as jaundice, hemolytic anemia and hematuria. *Cloudy urine color possibly suggests that the person is suffering from a urinary tract infection (UTI) or kidney stones. However, only the occurrence of cloudy urine does not necessarily indicate any of these diseases until there are other symptoms as well. *Low Specific gravity possibly suggests electrolyte imbalance and dehydration from diarrhea.

Hematology Hemoglobin June 17, 2011 124 g/L June 16, 2011 123 g/L Normal Value Male: 140 180 g/L

Hematocrit RBC Count WBC Count Platelet Count Differential Count Neutrophil Lymphocyte

0.39 g/L 4.17 million/mm3 10.3 /mm3 240 /mm3 0.85 0.15

0.37 g/L 3.96 million/mm3 13.8 /mm3 272 /mm3 0.85 0.15

Female: 120-116 g/L Male: 0.40 180 g/L Female: 0.37 0.47 Male: 4.5-6.5 million/mm3 Female: 4.0 5.5 million/mm3 4 000 12 000 /mm3 142 000 = 424 000 /mm3 0.51 0.67 0.25 0.33

*Low RBC Count possibly suggest anemia, malnutrition, chronic inflammation and acute or chronic blood loss. Nutritional deficiencies including those of iron, copper, vitamin B12, or vitamin B6 are the other low red blood cell count causes. *Elevated WBC Count and Neutrophil suggest infection within the body and deficiency of vitamins and minerals *Low Lymphocyte Count is a warning sign of an impending health problem. It is a sign that there is some trouble with the immune system which must be looked into immediately.

Anatomy and Physiology

Oral cavity The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping actions of the teeth. The tongue, a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialized sensors known as papillae. Salivary glands Three pairs of salivary glands communicate with the oral cavity. Each is a complex gland with numerous acini lined by secretory epithelium. The acini secrete their contents into specialised ducts. Each gland is divided into smaller segments called lobes. Salivation occurs in response to the taste, smell or even appearance of food. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each pair of salivary glands secretes saliva with slightly different compositions. Esophagus The esophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It extends from the pharynx to the stomach after passing through an opening in the diaphragm. The wall of the esophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by the esophageal nerve plexus. This nerve plexus surrounds the lower portion of the esophagus. The esophagus functions primarily as a transport medium between compartments.

Stomach The stomach is a J shaped expanded bag, located just left of the midline between the esophagus and small intestine. It is divided into four main regions and has two borders called the greater and lesser curvatures. The first section is the cardia which surrounds the cardial orifice where the esophagus enters the stomach. The fundus is the superior, dilated portion of the stomach that has contact with the left dome of the diaphragm. The body is the largest section between the fundus and the curved portion of the J. This is where most gastric glands are located and where most mixing of the food occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted into numerous longitudinal folds called rugae. These allow the stomach to stretch and expand when food enters. The stomach can hold up to 1.5 litres of material. The functions of the stomach include: 1. The short-term storage of ingested food. 2. Mechanical breakdown of food by churning and mixing motions. 3. Chemical digestion of proteins by acids and enzymes. 4. Stomach acid kills bugs and germs. 5. Some absorption of substances such as alcohol. Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and fundus. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins. Small intestine The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the cecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents

such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream. Large intestine The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, cecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The cecum is the expanded pouch that receives material from the ileum and starts to compress food products into fecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli). The functions of the large intestine can be summarized as: 1. The accumulation of unabsorbed material to form feces. 2. gas. 3. Reabsorption of water, salts, sugar and vitamins. Liver The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen. It is surrounded by a strong capsule and divided into four lobes namely the right, left, caudate and quadrate lobes. The liver has several important functions. It acts as a mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several metabolites including the breakdown of bilirubin and oestrogen. In addition, the liver has synthetic functions, producing albumin and blood clotting factors. However, its main roles in digestion are in the production of bile and metabolism of nutrients. All nutrients absorbed by the intestines pass through the liver and are processed before traveling to the rest of the body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here, bile salts break down lipids into smaller particles so there is a greater surface area for digestive enzymes to act. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal

Gall bladder

The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the liver's right lobe. It consists of a fundus, body and neck. It empties via the cystic duct into the biliary duct system. The main functions of the gall bladder are storage and concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored in the gallbladder until it is needed. Bile is released from the gall bladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food. Pancreas Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the spleen. The organ is approximately 15cm in length with a long, slender body connecting the head and tail segments. The pancreas has both exocrine and endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin, glucagon and other substances and these are the areas damaged in diabetes mellitus. The exocrine (secretrory) portion makes up 8085% of the pancreas and is the area relevant to the gastrointestinal tract. Rectum The rectum acts as a temporary storage facility for feces. As the rectal walls expand due to the materials filling it from within, stretch receptors from the nervous system located in the rectal walls stimulate the desire to defecate. If the urge is not acted upon, the material in the rectum is often returned to the colon where more water is absorbed. If defecation is delayed for a prolonged period, constipation and hardened feces results. Anal Canal. When the rectum is full the increase in intrarectal pressure forces the walls of the anal canal apart allowing the fecal matter to enter the canal. The rectum shortens as material is forced into the anal canal and peristaltic waves propel the feces out of the rectum. The internal and external sphincter allows the feces to be passed by muscles pulling the anus up over the exiting feces.

Pathophysiology

Modifiable Factors -Environment -Hygiene -Stress

Non-modifiable Factors -Age -Gender (more common in males)

Microorganism -Virus (Norovirus, Rotavirus) -Bacteria (Escherichia coli, Salmonella, Shigella, Camphylobacter) -Parasites (Giardia, Cryptosporidium)

Irritation of gastrointestinal tract Inflammation of gastrointestinal tract Increased gastrointestinal motility

Vomiting Fever

Decreased water absorption

Increased defecation of soft watery stool

Decreased digestion and absorption

Modifiable Factors -Environment -Hygiene -Stress

Non-modifiable Factors -Age -Gender (more common in males)

Microorganism -Virus (Norovirus, Rotavirus) -Bacteria (Escherichia coli, Salmonella, Shigella, Camphylobacter) -Parasites (Giardia, Cryptosporidium)

Irritation of gastrointestinal tract Inflammation of gastrointestinal tract Increased gastrointestinal motility

Vomiting Fever

Decreased water absorption

Increased defecation of soft watery stool

Decreased digestion and absorption

-Poor skin turgor -Sunken eyeballs -Body weakness -Dry mouth -Dry skin -Dry mucous membrane

Diarrhea Dehydration

Drug Study

Brand Name and Generic Name Generic Name: Ceftin Brand Name: Cefuroxime

Mode of Action

Mechanism of Action

Dosage and Adverse Reaction Dosage: 250 mg IV q 8 Adverse Reaction: Antibiotic associated colitis and other superinfections that may result from altered bacterial balance. Nephrotoxicity may occur, especially patients with preexisting renal disease. Severe pruritus, angioedema, bronchospasm, and anaphylaxis.

Indication And Contraindication Indication: Ampicillin-resistant Influenza, bacterial meningitis, early lyme disease, GI tract, gynecologic, skin and bone infections and other gonococcal infections. Contraindication: History of anaphylactic reaction to Penicillins or hypersensitivity to cephalosporins. pregnancy.

Nursing Responsibilities -Ask patient for history of allergies particularly cephalosporins, penicillins -Monitor bowel activity and stool consistency. -Monitor I&O, renal function. -Be alert for superinfection, severe genital/ anal pruritus, abdominal pain, severe mouth soreness, moderate to severe diarrhea -Instruct patient that discomfort may occur with IM injection -Continue antibiotic therapy for full length of time. -May cause GI upset (may take with foor or milk)

Antibiotic, Antebacterial

A second generation cephalosporin that binds to bacterial cell wall synthesis.

Drug Study

Brand Name and Generic Name Generic Name: Dexamethasone Brand Name: Maxitrol

Mode of Action

Mechanism of Action

Dosage and Adverse Reaction Dosage: 2 drops (ophthalmic) TID Adverse Reaction: Decreased vision, watering of eyes, eye pain, burning, stinging, redness of eye, nausea, vomiting.

Indication And Contraindication Indication: Anti-inflammatory, cerebral edema, nausea and vomiting in chemotherapy patients, ocular inflammatory conditions. Contraindication: Active untreated infections, fungal, tuberculosis, viral diseases of the eye, pregnancy.

Nursing Responsibilities -Ask patient for history of any corticosteroid. -Monitor vital signs. -Monitor I&O, daily weight. -Assess for edema. -Report hypersensitivity promptly. -Be alert for to infection, sore throat, fever, vague symptoms. -Monitor serum electrolytes. -Monitor for hypercalcemia (muscle twitching, cramps), hypokalemia (weakness, muscle cramps, numbness or tingling, especially lower extremities) -Assess emotional status, ability to sleep.

Corticosteroid, Antiemetic, croup (An inflammatory affection of the larynx or trachea, accompanied by a hoarse, ringing cough)

A long acting glucocorticoid that inhibits accumulation of inflammatory cells at inflammation sites, phagocytosis, lysosomal enzyme release and synthesis and release of mediators of inflammation

Drug Study

Brand Name and Generic Name Generic Name: Ranitidine Brand Name: Zantac

Mode of Action

Mechanism of Action

Dosage and Adverse Reaction Dosage: amp IV q 8 Adverse Reaction: Diarrhea, constipation, headache

Indication And Contraindication Indication: Duodenal ulcers, gastric ulers, GERD, erosive esophagitis, hypersecretory conditions. Contraindication: History of acute porphyria

Nursing Responsibilities -Obtain baseline liver/ renal function tests. -Monitor serum AST, ALT levels. -Assess mental status in elderly. -Transient burning/ itching may occur with IV administration. -Ask patient to report headache.

Histamine H2 receptor antagonist, antiulcer

An antiulcer agent that inhibits histamine action at histamine 2 receptors of gastric parietal cells. Inhibits gastric acid secretion when fasting at night or when stimulated by food, caffeine or insulin. Reduces volume and hydrogen ion concentration of gastric juice

Drug Study

Brand Name and Generic Name Generic Name: Tobramycin Sulfate Brand Name: TobraDex

Mode of Action

Mechanism of Action

Dosage and Adverse Reaction Dosage: 2 gtts on both eyes TID Adverse Reaction:

Indication And Contraindication Indication: . Contraindication:

Nursing Responsibilities

Antibiotic

An aminoglycoside antibiotic that irreversibly binds to protein on bacterial ribosomes.