Section P - Group 1 E.C.S. - Pediatric Ward Mr. Ralph P. Pilapil, R.N. Clinical Instructor
Section P - Group 1 E.C.S. - Pediatric Ward Mr. Ralph P. Pilapil, R.N. Clinical Instructor
Section P - Group 1 E.C.S. - Pediatric Ward Mr. Ralph P. Pilapil, R.N. Clinical Instructor
Pediatric Ward
RLE (Period covered: July 27-Aug. 1,2009)
A. Nursing History
Identifying Data
Name of Patient Sex Age Civil Status Nationality Religion Address Occupation Date Admitted Time
Informant Age Physician Room
: : : : : : : : : :
: : : :
Patient X Male 16 years old Single Filipino R.C. Sta. Cruz, Guizo Mandaue City Student July 27, 2009 8:10 p.m.
Mother 30 years old Dr. Pitogo Pediatric Ward
Admission Data
Source of Information Mode of Admission : Mother : Ambulatory
Vital Signs on Admission Temperature : 36.6C Heart Rate : 60 bpm Respiratory Rate : 18 cpm Blood Pressure : 120/70 mm Hg Weight : 56 kg Height : 5 4 Chief of Complaints: LBM, pain and vomiting
Injuries:
No previous injuries
Operation:
No minor and major operation were performed
Physical Assessment
1. EENT
Eye functioned well and responsive to light accommodation (3-4mm) tonsils are pink and in normal size
2.
3.
4.
Respiratory System
symmetric chest expansion clear breath sound
5.
Gastrointestinal System
presence of hyperactive bowel sound excessive bowel elimination (five times/day) facial grimacing noted during defecation palpated with soft abdomen/tender pain sensation at anal area due to irritation from frequent defecation excessive loose / watery stool with fecal particles Dry skin & poor skin turgor Sunken eye ball
6.
Genito-Urinary System
disturbed sleeping pattern due to nocturnal urination low urine output (25ml/hour) reddish urine color
7.
Integumentary System
poor skin turgor rough / dry skin responsive to pain
8.
Musculoskeletal System
can stand and sit on his own with signs of weakness poor tendon reflex
Laboratories Performed
Date Ordered: July 27, 2009
FECALYSIS
Diagnostic Color Normal Value Yellow Result Reddish Significance Presence of components that indicates infection
Consistency
Cellular Findings RBC Pus Cells Bacteria Yeast Cells
Soft
Watery
Sign of dehydration
Normal Normal Infection is present Normal
URINALYSIS
Diagnostic
Color Transparency Ph Specific Gravity Protein Sugar Microscopic Exam: Pus Cells RBC Epithelial Cells A. Urates 0-2 0-1 3-6 0-1 Few Few Infection present Normal Normal Normal
Normal Value
Clear Clear 6-7.5 1.010-1.025 Negative Negative
Result
Yellow Clear 6.0 1.025 Negative Trace
Significance
A. Phosphates Bacteria
Mucus Thread Ca Oxalates
Moderate
Few Moderate
Infection
Normal Normal
Digestive System
ESOPHAGUS Approximately 25 cm (10inches long) but its diameter depends on how much food it contains. When its full, it can hold about 4 liters of food; when empty, it collapses and its mucosa is thrown into large folds called rugae. Esophageal peristalsis propels the bolus of food into the stomach through the cardiac sphincter
STOMACH
A distendible pouch with a capacity of about 1500 mL 4 anatomic regions Stores and mixes food with the enzymecontaining gastric juice. Produces protein digesting enzymes pepsinogen, mucus, intrinsic factor and hydrochloric acid. Food stays from a half hour to several hours Chyme, which is food mixed with secretions enters the small intestine through the pyloric sphincter
The small intestine is the longest and most convoluted portion of the digestive tract Measuring 16 to 19 feet ( 5 to 6m) in length in an adult. Composed of three different regions: - duodenum, - jejunum, and - ileum. The inner surface of the small intestine has a velvety appearance because of numerous mucous membrane finger like projections called intestinal villi. Pancreatic secretions: trypsin, amylase and lipase Intestinal glands secrete mucus, hormones and electrolytes that coats the
Function:
Three main functions:
movement (mixing and peristalsis) digestion absorption
LARGE INTESTINE
about 5 to 6 feet in length from the ileocecal valve to the anus lined with columnar epithelium that has absorptive and mucous cells. it begins with the cecum, a dilated pouchlike structure that is inferior to the ileocecal opening. the large intestine then extends upward from the cecum as the colon. the colon consist of four divisions: - ascending colon - transverse colon - descending colon - sigmoid colon.
Function:
Three Main Functions:
Absorption Elimination Movement
C. Pathophysiology
Precipitating Factors: Poor sanitation during warm months Crowded living conditions Risk Factors: Children Older adults Familial tendency
Etiology
Bacteria
Signs and Symptoms Watery stools Intestinal rumblings Abdominal pain Distention Vomiting Fever Diagnostic Evaluation Fecalysis Urinalysis Specimen Data Report
OUTCOME
HYPOVOLEMIA
PROGNOSIS
DEATH
The epithelium of the digestive tube is protected from insult by a number of mechanisms constituting the gastrointestinal barrier, but like many barriers, it can be breached. Disruption of the epithelium of the intestine due to microbial or viral pathogens is a very common cause of diarrhea in all species. Destruction of the epithelium results not only in exudation of serum and blood into the lumen but often is associated with widespread destruction of absorptive epithelium. In such cases, absorption of water occurs very inefficiently and diarrhea results.
Vomiting
Explanation:
Vomiting in diarrhea can occur when the lining of the intestines or stomach is irritated by an infection. Usually the infection is caused by a virus or bacteria. Diarrhea and vomiting can drain water and salts from the patient. These need to be replaced to prevent the patient from becoming dehydrated (dry).
D. Medical Managements
I. DIAGNOSTIC / LABORATORY PROCEDURES Ideal:
Complete Blood Count Urinalysis Routine stool examination Stool Culture Barium enema
Actual:
Urinalysis Fecalysis
Ranitidine HCl (Zantac) 80mg slow IVTT q8h Antiulcer Agent Ciprofloxacin HCL 500mg 1tab BID PO PC - Anti Infective Agent Aluminum Magnesium Hydroxide(Isopan) 20 ml 1pc 2 H.S. - Antacid Agent
III. TREATMENT
Ideal: Oral rehydration therapy Antimicrobial therapy E coli: Antibiotic treatment Actual: D5LR 1 Liter @ 30 gtts/min Monitoring of urine and stool V/S q shift
IV. EXERCISES AND ACTIVITIES Ambulate by himself w/o the assistance of S.O.
V. DIET Ideal: The bland diet Introduce lean meats and clear fluids as soon as possible. Actual: DAT
MEDICATIONS
Medications are substances used in the diagnosis, treatment, cure, relief, or prevention of health alterations. This is the primary treatment client associate with restoration of health.
Date Ordered
Classification
7/27/09
Specific Indication
Side Effects
Nursing Implications
Before : Assess patient for abdominal pain, note for presence of blood & emesis & stool. During: Administer IVTT slowly. After: Monitor patient for adverse reaction. Store IV injection @ 30 degrees After dilution solution is stable for 48 hrs. @ room temperature. After taking the medication advise pt to report immediately any adverse reactions.
Gastro esophageal CNS: vertigo, reflux disease malaise, headache. EENT: blurred vision Contraindications: -patient with Hepatic: jaundice hypersensitive to Other: burning and drug & those with itching @ injection phorphyria. site anaphylaxis, -Use cautiously in patient with hepatic angioedema.
dysfunction. -adjust dosage in patient with impaired renal function
Classification
Anti -Infective
Mechanism of Action
Inhibits bacterial DNA, an enzyme needed for bacterial replication.
Specific Indication
Complicated intraabdominal infection.
Side Effects
EENT: local burning or discomfort, foreign body sensation, itching. GI: bad or better taste in mouth.
Nursing Implications
Before: -Assess vital sign. -Assess lab. Results and the causative agent. During: -Stop drug @ first sign of any hypersensitivity. After: -Prolonged use may result in overgrowth of susceptible organisms. -Assess for adverse reaction.
Contraindications: -Hypersensitive to a ciproflaxacin. --its unknown if drug appears in breast milk after application.
Name of Drug Generic (Brand) Aluminum Magnesium Hydroxide (Isopan) Mechanism of Action
Reduces total acid load in GI tract, elevates gastric ph to reduce pepsin activity strengthens gastric mucosal barrier, and increases esophageal sphincter tone.
Classification
antacids
Specific Indication
Acid indigestion . Contraindications: Severe renal disease. Use cautiously in patients with mild renal impairment.
Side Effects
GI: mild constipation, diarrhea. GU: increased urine ph. Metabolic: hypokalemia
Nursing Implications
Before: -Assess patient with renal failure. -Instruct patient not to take suspension or liquid well and follow dose with water. During: -monitor magnesium level in patient with mild renal impairment. After : -Urge patient to notify prescriber about the signs or symptoms of GI bleeding, such as tarry stools & coffee ground vomiting.
Nursing Management
Acute Pain
I.
II.
III.
II.
III.
OBJECTIVE:
excessive loose / watery stool Dry skin & poor skin turgor Sunken eye ball excessive bowel elimination (five times/day)
NSG DIAGNOSIS:
Fluid volume deficit related to diarrhea secondary to acute gastroenteritis.
Scientific Basis:
Decreased intravascular, interstitial and/ intracellular fluid. This refers to dehydration, water loss alone without change in sodium.
NSG GOAL:
After 2-4 hours nursing interventions, the patient will be able to maintain fluid volume at functional level as evidenced by stable vital signs, moist mucous membranes & good skin turgor.
OUTCOME CRITERIA:
Independent: After 2-4 hours of nursing interventions, patient will experience adequate fluid volume and electrolyte balance as evidenced by: urine output greater than 30 ml/hr, normal blood pressure, heart rate of 60-100 beats/ min, respiratory rate of 12-20 cycles/min,normal skin turgor. Pt. will maintain afebrile state. Pt. will initiate rehydration. Pt. will increase fluid intake of more than 2 liters. Dependent: Patient will follow medication on time. Collaborative: Patient will eat food prepared for him as advised by dietician.
NSG INTERVENTION
INDEPENDENT:
RATIONALE This can help with making the various nursing interventions Most fluids enter the body through drinking water in foods & water.
Obtain patient history to ascertain the probable cause of the fluid disturbance Evaluate fluid status in relation to dietary intake.
Monitor temperature .
Provide oral fluids that are preferred by the patient and place it at bedside, within reach. Ensure that it is fresh.
Client needs to understand the importance of drinking extra fluid during bouts of diarrhea.
DEPENDENT:
OBJECTIVE:
Hyperactive bowel sounds (6 sounds in 20 seconds) Abdominal distention Facial grimacing and guarding. pain sensation at anal area due to irritation from frequent defecation Pain scale of 7 out of 10.
NSG DIAGNOSES: Pain related to injuring agents (physical inflammation of GI tract) secondary to Acute Gastroenteritis Scientific Basis:
Acute infectious diarrhea results to increase frequency and fluid content of stool. The patient usually has abdominal distention and hyperactive bowel sounds. Painful spasmodic contraction of the anus and ineffectual straining may occur with each defecation.
NSG GOAL:
After 30 mins 1hour of nursing interventions, the patient will report relief of pain from a pain scale of 7/10 to a pain scale of 4/10.
OUTCOME CRITERIA:
Independent: After 30 mins 1hour of nursing interventions, the patient will report relief of pain from scale 7 to 4. Pt. will verbalize lesser episodes of pain. Dependent: Patient will follow medication on time. Collaborative: Patient will eat food prepared for him as advised by dietician.
NSG INTERVENTION
INDEPENDENT:
RATIONALE
Serves as part of baseline data. Facilitates timely intervention. Provides nonpharmacological pain management.
Encourage adequate rest period. Instruct patient to report intense pain as soon as it begins
DEPENDENT:
Prevents fatigue. Timely intervention is more likely to be successful in alleviating pain. Relieves pain
OBJECTIVE:
Poor muscle tone Hyperactive bowel sounds Aversion to eating Food served remained untouched
Scientific Basis:
Nutrition is imbalanced to a relative absolute deficiency of one or more essential nutrients. This may be manifested as undernutrition.
NSG GOAL:
After 8 hrs of nursing intervention, patient will exhibit progressive signs of appetite as evidenced by increased food intake.
OUTCOME CRITERIA:
Independent:
After 8 hours of student nurse patient intervention , patient will brush teeth every after meals, pt will verbalize satiety of food by evidence of at least consumption one half cup of rice.
Dependent:
Patient will eat food prepared for him as advised by dietician. Patient will cooperate with the S/O and nurse to determine proper way of selecting nutritional food
NSG INTERVENTION
INDEPENDENT:
RATIONALE
Clean mouth can enhance the taste of food Pleasant environment aids in reducing stress and is more conducive to eating Individual tolerance varies, depending on stage of disease and area of bowel affected.
Avoid/ limit foods that might cause/exacerbate abdominal cramping and flatulence
Decreased metabolic needs aids in preventing caloric depletion and conserve energy.
DEPENDENT:
Coordinate with dietician Health teachings to pt and S.O. on proper nutrition and hygienic preparation of food.
G. Discharge Planning
MEDICATIONS:
Follow strictly medication regimen such as oral rehydration solution or as prescribed by the physician and report immediately of adverse reactions.
EXERCISE:
Carry out daily activities as tolerated. Do activities of daily living as tolerated.
TREATMENT:
Take medications as scheduled and as prescribed for fast recovery.
HEALTH TEACHING:
Observe proper personal hygiene to avoid complication; frequent hand washing is advised. Observe proper food preparation and handling to avoid reinfection.
OUT-PATIENT:
Advise patient to visit for check-up to the doctor for further follow-up of health status.
DIET:
Follow religiously the prescribed diet to regain strength and improve health status; these include BRAT (banana, rice, apple, tea) diet.
SPIRITUAL:
Advise family to ask assistance and guidance from the divine providence for speedy recovery.