Personal DataName: Amistad, Limuel Tamayo Age: 1 year 10 months old Birthdate: 03-22-10 Sex: Male Religion: Roman Catholic Chief Complaints: Vomiting Final Diagnosis: Acute Gastroenteritis with moderate dehydration, Acute Bronchopneumonia I. Family Background This is a case of a 1 year 10 months old male patient, Limuel Tamayo Amistad, admitted at Pines City Doctors Hospital on February 11, 2012at 3:05 PM with an admitting diagnosis of acute gastroenteritis with moderate dehydration and congenital heart disease. He’s the first child of Mr. and Mrs. Slim Amistad. They are currently residing at 27 A Bayan Park, Aurora Hill, and Baguio City. II. Development Data (based on Havighurst and Erikson’s life and developmental task/psycho) According to Erik Erikson’s stage of development, Limuel Tamayo Amistad belongs to early childhood and has a central task of autonomy versus shame and doubt. He indicate positive resolution of self-control without loss of self-esteem, ability to cooperate and to express oneself most specially to his mother, grandmother and primary care takers. III. Health History A) History of Past Illness and Present Illness Past Illness History: Limuel was diagnosed with congenital heart disease. Present Illness History: Patient has congenital heart disease, has episode of vomiting not accompanied by fever and abdominal pain, stool is watery, patient had occasional cough few days. B) Pathophysiology of Present Illness/Surgeries Gastroenteritis Predisposing Factors Etiology Factors Age Lifestyle-improper prepared foods -contaminated water Poor sanitation Unknown Diarrheal Osmotic Motile Microorganisms Cytotoxin Enterocyte Affects the predominant cells in the small intestine Caused by intestinal motility disorders May produce toxins that facilitates infection Production by bacteria Excessive intake or diminished absorption Results in mucosal cells destruction that leads to bloody stools with inflammatory cells Signs and Symptoms Nausea and vomiting Diarrhea Loss of appetite Fever Abdominal pain Weakness Etiologic factors are usually unknown, but there are certain predisposing factors which includes the age, lifestyle and poor sanitation. There may lead then to diarrheal which may possibly leads to osmotic, motile, cytotoxin and affected enterocyte. These results from the presence of bacteria especially in the GI tract. Signs and symptoms includes nausea and vomiting, diarrhea (watery stool), loss of appetite, fever, abdominal pain and weakness. C) Inclusive Period of Hospitalization Admission Date: February 11, 2012 at 3:05 Pm D) Health Agency Patient was admitted in Pines City Doctors Hospital located at Magsaysay Avenue, Baguio City. IV. Medical treatment and management inclusive procedures and its implication to nursing A. Medical Treatment Chloramphenicol 150 mg Iv q 6 hours B. Management including procedures and its implication to nursing Vital signs assessment -Every 2 hours to check or monitor the function of the body, general and note progress on the patient’s condition. Positioning the patient to more comfortable position -To facilitate comfort and relaxation of the patient and to facilitate easy breathing of the child. Physical examination -To establish nursing diagnosis and interventions and to determine the general health status of the patient. It is also done to detect some abnormalities or deficiencies. Urinalysis Macroscopic examination: Color: Yellow Transparency: Slight turbid Reaction: Acidic Specific gravity: 1.015 Albumin:Negative Sugar: Negative Microscopic Examination: Epithelial cells: Moderate Prater/ PO4: Occasional Mucous Thread: Occasional WBC/ Pus Cells: 1-3 RBC: 0-1 Bacteria: Occasional -The result is normal. Urinalysis provides baseline data about the patient’s health. It is performed to assess the abnormal substances which- has accumulated in the urine. Hematology Test Results Normal Values Hematocrit 0.68 0.42-0.53 Hemoglobin 226 g/L 155+/- 20g/L WBC count 21.6 x /L 5-10 x /L Platelet count Adequate 150-450 x /L -The result of the hematology test of the patient indicates elevated hematocrit and hemoglobin which signifies dehydration and polycythemia, also may signifies that there is an increased volume of cell in 100 ml of blood. It also increases white blood cell count which indicates infection. Radiologic Result -Perililar haziness is noted in both lungs -Heart is not enlarged however appears globular shape -bones are intact Schillings Differential Count Result Normal Values Neutrophilic Segmenters 0.91 0.43-0.76 Lymphocytes 0.06 0.17-0.41 Monocytes 0.03 0.04-0.10 RBC Morphology: Mostly normocytic, normochromic -The schillings differential count of the patient indicates an elevated neutrophilic segmenters which may signifies acute bacterial infection, tumor inflammation, stress or drug reaction. Also indicates decreased lymphocytes and monocytes which may signifies aplastic anemia, leukemia, systemic lupus erythematosus and immunodeficiency and usage of corticosteroidsmof medications. This test is used to measure the 24 hour urinary excretion of labeled vitamin B12 and to document decrease absorption of vitamin B12. Fecalysis Microscopic Examination: Macroscopic Examination: Color: Yellow Consistency: Semi- formed Ova or Parasites: None found Cyst or trophozoites: None FOund -Fecalysis provides baseline data about the patient’s health. It is perform to detect presence of abnormal substance like bacteria in the stool. The result is not normal. Normally the stools consistency should be formed. VII. Evaluation and Implication of the Study to: A) Nursing Practice: The hope and intent of the study was to boolster or repute current interventions currently done by the nursing profession and it seeks to validate, what is currently done to intercede and may be an avenue providing and finding various types of intervention of care which may be provided to same type patients and how they respond to those various types of intervention: My patient is Limuel Amistad, male, 1 year and 10 months old and was admitted last February 11, 2012at 3:05 PM due to vomiting. He was diagnosed to have acute gastroenteritis with moderate dehydration and acute bronchopneumonia and has a congenital heart disease; transposition of great vessels, pulmonary HPN, and patent foramen oral. I managed my nursing interventions by means of vital signs taking and recording, rendering bedside care, monitoring IV replacement therapy, do bronchial tapping, promoted rest and comfort, attended to needs, seen at interval’s and ensured safety. I also encouraged the care provider to give warm fluid to the child and also for the mother to give child foods rich in vitamin C. I also give health teaching regarding the proper care of a child suffering from acute gastroenteritis and acute bronchopneumonia. B) Nursing Education: Through this study, some of my questions regarding the disease especially acute bronchopneumonia and acute gastroenteritis was answered. It broadens and appends my knowledge about the condition, most especially the causes and factors associated to the development and occurrence of the said disease. It also enhances my communication and interaction skills, same as through with provision of comfort, care and therapeutic interventions. C) Nursing Research Researchers done on the past regarding the treatment of acute gastroenteritis and acute bronchopneumonia are still being utilize at the hospital at present. The nurse should study research finding and utilize it in practice. It will also serves as a baseline for promoting treatment and recovery of the patient. In relation to this case, I want to dig deeper on the ff: Possible complications of the condition if left untreated Incidence and occurrence of the condition among pedia. Nature of the problem VIII. Referral and Follow-up Patient Limuel Tamayo Amistad is still confined at Pines City Doctor Hospital for further care and management. The patient is under the care of Dotora Loria, M.