diarrhea er

8/3/2019 Diarrhea ER

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UNIVERSIDAD DE MANILA(Formerly City College of Manila)

Mehan Garden, ManilaCollege of Nursing

Case Study in a Patient with Diarrhea

IN PARTIAL FULFILLMENTOF THE REQUIREMENTS IN

NCM 105

(RELATED LEARNING EXPERIENCE)

III

Submitted by:

Robles, Ceelin T.

Nr-42/Group IV

Submitted to:

Mr.Ben O. De Paz, RN MANClinical Instructor

Date Submitted:



Table of Contents

I. Introduction

II. Objectives

III. Patient's Health History

a. Demographic Data

b. Admission Data

c. Chief complaint

d. History of Present Illness

e. Past medical History

f. Family Medical History

IV. Gordon's Functional Health Pattern

V. Physical Examination

VI. Laboratory Examinations

VII. Drugs Study

VIII. Nursing Care Plan

IX. Anatomy and Physiology

X. Pathophysiology

I. Introduction



Diarrhea is the passage of loose and watery stools (more than 3

bowel movements per day) often associated with gassiness, bloating,

and abdominal pain. It may also be accompanied by nausea, vomiting,

and fever.

Diarrhea results to loss of body fluids and salts leading to

dehydration of varying severity. Severe dehydration may cause death

especially in children and the elderly.

Diarrhea can be brought by different etiologic causes such as

infection due to: virus (Rotavirus, Hepatitis B virus), bacteria (Cholera,

Shigella), and intestinal parasites (E. histolytical, ponworm), these

microorganisms are usually spread by contaminated hands, or through

food and water. Food intolerance (lactose deficiency, spicy food) and

use of laxative and antacid (magnesium hydroxide) can also be a

cause. In addition the use of antibiotics like tetracycline and

cephalosporins, an inflammatory bowel disease (ulcerative colitis) can

brought diarrhea. Moreover emotional stress

and a cancer of the colon (characterized by alternating diarrhea andconstipation) can also be included in the factors that causes diarrhea.

Diarrhea is classified as either acute or chronic. Acute diarrhea is

the sudden onset of abnormally frequent watery stools accompanied

by weakness, flatulence (farting), abdominal pain and sometimes fever

and vomiting. It may be caused by eating spoiled food. This lasts for 2

to 5 days.

Chronic diarrhea lasts for more than 2 weeks and is associated

with weight loss and anemia. This is usually caused by chronic use of

laxatives or amoebiasis.

A patient should consult a physician if he/she is less than 3 years

old; if the patient is a pregnant woman; if diarrhea is associated with



fever and dehydration; if diarrhea continues for more than 3 days; if

diarrhea is associated with bloody, mucoid stools (dysentery); and if

diarrhea is associated with abdominal tenderness and cramping.

Diarrhea can be managed through prevention of excessive los of and sodium that if severe can leads to dehydration and loss of salts. To

prevent these life threatening problems particularly in children and the

elderly, oral rehydration solution must be given as early as possible.

The cause of the diarrhea should be identified and treated especially if

the diarrhea was caused by bacteria (Shigella, Enterotoxigenic

Escherichia coli) should be treated with antibiotics like cotrimoxazole

and fluoroquinolones. Diarrhea caused by protozoa (Entamoeba

histolytica and Giardia lamblia) should be treated with metronidazole

in combination with other anti-amoebic drugs.

Provide symptomatic relief in adults, antidiarrheal agents like

loperamide and attapulgite may help in reducing the frequency of

bowel movement and in improving the consistency of stool of stools.

Consult your doctor if diarrhea is severe especially in children

and the elderly.

Always remember that one should to eat to prevent or minimize

nutritional damage, should also drink water during their illness,

especially if they have fever. Clients should be monitored closely,

particularly children who do not show a clear improvement within 2

days after beginning treatment with an effective antibiotic. Since most

of diarrhea-causing micro-organisms are spread by contaminated

hands, thorough hand washing with soap and water and careful

cleaning of all parts of the hand is an important measure to prevent

diarrhea.

II. Objectives



General Objectives

At the end of our case study, the researchers will be able to

develop and enhance our nursing skills and responsibilities on how to

care for a patient with Diarrhea and be able to identify the nursing

interventions that will be appropriate with the client.

Specific Objectives

1) To be able to assess the client with Diarrhea and know the disease

process using the established assessment.

2) To be able to understand the pathophysiology of Diarrhea in relation

to client’s condition.

3) To be able to make a Nursing Care Plan based from the obtained

datas from the client.

4) To be able to determine the appropriate interventions for the

client’s specific condition.

5) To be able to determine complications associated with Diarrhea that

requires further assessment and treatment.

III. Patient History

A. Demographic Data

A case of a 8 months old, female, single, Roman Catholic and

currently residing at Paco, Manila.



B. Admission Data

The client was admitted for the second time at Ospital ng

Maynila Medical Center, admitted last September 4, 2011, 1:00 am.When he arrived she was accompanied by her mother. During nurse-

client interaction with the help of her mother, the client was conscious.

C. Chief Complaint

The client was admitted with a chief complaint of fever of 38.5

and diarrhea.

D. History of Presnt Illness

5 days prior to admission, the client started to have watery stool

and consumed 12 diapers a day. According to the mother the client is

irritable, had difficulty in sleeping and had a on and off fever of 38.5 C.

They consulted at Valentina Health Center, and gave them Oresol, Zinc

Vitamins and Paracetamol drops for fever.

E. Past Medical History

According to the mother when the client was 5 months old she

had UTI and occasional fever. There was no injury nor accident and no

allergies to food and drugs as well. She had been vaccinated with BCG,

Hepa A and B, DPT and OPV at Valentina Health Center. Her current

mediactions are Ascorbic Acid (Ceelin) and Growee oral drops.

F. Family Medical History

The client’s mother is 30 years old and has asthma for 12 years

while her father is 30 years old and apparently well. Her older sister

who is now 2 years old has an allergy to chocolate and milk.



Asthma

Allergy:

Chocolate &Milk

Legend:

Female

Male

Client

IV. Gordon’s Functional Health Pattern

HealthPattern

BeforeHospitalization

DuringHospitalization

Analysis

Health

Perception

Health

Management

Not Applicable Not Applicable Not Applicable

30 30

8 mos. 2



Pattern

Nutritional

metabolic

Pattern

The client’

mother stated

that client ate

three-five times

a day and ate

what her mother

prepared for her

like mashed

potato, banana,

and carrots. She

had increased in

appetite. She

consumes 8-10bottles of milk (6

oz) per day.

Now, the client

decreased

appetite. The

client has dry

lips, sunken

eyes and

depressed

fontanels. D5IMB

500 mL was

inserted on

clients left foot

for fluid and

electrolytereplacement.

The client’s

nutritional and

metabolic

pattern

changed

because of the

client’s current

condition.

Elimination

Pattern

According to the

mother of the

client, she had

regular bowel

habit. She

defecated once

to twice a day

and it is

characterized by

semi- solid,

yellowish brown

in color and soft.

She also had

good bladder

habit; she

usuallyconsumed 6-8

diaper a day it is

described as

light yellow in

color and

moderate

Now, the clients

consumed 12

diapers per day

with soft watery

stool.

Elimination

pattern was

affected

because of the

client’s current

condition.



amount.

Activity

Exercise

The client was

able to do the

following with

the help of the

mother since her

physical ability is

limited due to

her is still a

baby: eating,

bathing,

dressing and

toileting. Her

mother regularlymassages her

lower

extremities.

Now, the client

has less energy,

and cannot

further more do

activities like

rolling, crawling.

Activity and

exercise is

being

influenced by

present health

condition of

patient itself.

Sleep Rest

Pattern

According to the

mother, client

had total of 8-12

hours of sleep

and seems to be

felt rested after

sleep.

Now, the client

usually has 6-8

hours of sleep,

experiencing

awakening at

night and

difficulty of

sleeping. The

method that the

mother used to

promote sleep is

positioning her

comfortably.

Sleep rest

pattern is being

altered due to

the client’s

present health

condition.

Cognitive

Perception

Pattern


Self Perception Not Applicable Not Applicable Not Applicable



Self Concept

Pattern

Role

Relationship

Pattern


Sexuality

Reproductive

Pattern


Coping Stress

Tolerance

Pattern


Value Belief

Pattern


V. Physical assessment



General Survey

The client is an 8 months old female. Appears and behaves to be

as his apparent age. She has a light brown skin complexion; she is

clean and neat as well. The client is appeared irritable, has a good

posture and has coordinated body movement.

Interaction and answering of questions was done with the help of

his mother; the one who accompanied him in the hospital.

Vital signs

The client’s vital signs prior to the physical examination were

temperature of 38.4 oC, pulse rate of 123 bpm, and respiratory rate of

54 bpm.

Head to toe Physical Examination

Area of Assessment

Type of Assessment

UsedFindings

Skin - Inspection and

Palpation

The client has light brown color of

the skin with dry poor skin turgor. It

is warm to touch which was noted to

be similar on the both sides of his

body. The client’s skin is free from

lesion, abrasion nor inflammation.

The body hair is evenly distributed



Head

Eyes

Ears

- Inspection and

palpation

- Inspection

- Inspection and

Palpation

and No edema present.

The client’s head is round and

proportionate to his body, There are

no areas of tenderness in the scalp

noted. There are no presence of

nodules, masses and has depressed

fontanel. He has a few black colored

hair and smooth.

The client’s eyebrow is evenly

distributed, with intact skin, and

symmetrically aligned. Eyelids have

effectively closure. The blink

response is bilateral and no

discharge noted. He has pale

conjunctiva with some evident

capillaries. Sclera appears white and

clear. Cornea is transparent; details

of iris are visible which is round and

with brown in color. Pupils are equal

in size and equally round. Sunken

eyes noted.

The color of the ear is the same as

the color of the facial skin and it is

symmetrical. The auricles are aligned

to the outer canthus of the eyes. The



Nose

Mouth

Neck

Chest and

Lungs

Abdomen

- Inspection and

Palpation

- Inspection

- Inspection and

Palpation

Inspection,

palpation and

Auscultation

Inspection,

Palpation and

Auscultation

pinnas are mobile firm and elastic

and recoil when folded. The auditory

canal contains some cerumen, and

no discharge noted.

The client’s septum is in the midline.

The nostrils are both patent, nasal

flaring noted. No swelling and

discharges noted.

The client has dry, cracked and pale

lips. The buccal mucosa is pink, the

gum is pale, the tongue is in the

midline. The color of the hard and

soft palate is pale. And it is intact.

Saliva is present as well as the gag

reflex. Only two teeth at the front.

There is no tenderness noted in the

client’s neck and it is movable. The

trachea is in the midline. Thyroid

gland is visible during inspection,

gland ascends during swallowing.

Carotid pulsation is visible.

There is absence of intercostals

retraction, chest wall are



Upper

extremities

Lower

Extremities

- Inspection and

Palpation

- Inspection and

Palpation

symmetrical, and the chest

expansion is symmetrical as well.

There were no abnormal sounds

heard during auscultation.

The abdomen of the client has flat

contour. It is smooth and uniform to

the color of the skin. The liver, kidney

and spleen were not palpable.

Abdominal cramps, distention and

intestinal rumbling noted.

The client has muscle grade of 5/5,

and his peripheral pulses were equal.

The client has good capillary refill.

Palm has normal color and it is

smooth.

The client has complete lower

extremities. He has muscle grade of

5/5, able to move his both lower

extremities. The IV line was inserted

on his left foot.



VI. Laboratory Examinations

Clinical Chemistry

Date: September 3, 2011

TEst Result Units Normal Rate

BUN

Creatinine

Na

K

4.6

84

128

3.1

mmol/L

umol/L

mmol/L

mmol/L

3.0-7.2

50-100

135-145

3.5-5.3

Analysis: based on the above data, there is a decrease in Na and K

since there is an excessive fluid loss due to diarrhea.



Urinalysis

Date: June 28, 2008

Color: Yellow

Appearance: Clear

Specific gravity: 1.029

Protein (Albumin): Negative

Glucose: Negative

Bacteria: Negative

Analysis: Since the specific gravity is not in a normal range, it

indicates that the client has concentrated urine that maybe the result

of dehydration and fever.

Fecalysis

Date: September 2, 2011

Macroscopic appearance:

Color: yellow

Consistency: Soft

Microscopic appearance:

Pus cells: none seen /hpf

RBC: none seen /hpf

Fat globules: none seen / hpf

Bacteria: Few



Analysis: Fecalysis indicates that there is few bacteria presented in

the fecal, this may indicate that it is positive in infection.

IX. Anatomy and Physiology

THE DIGESTIVE SYSTEM

Consists of (1) an alimentary canal- a long muscular tube beginning at

the lips and ending at the anus, including the mouth, pharynx (oral and

laryngeal portions), esophagus, stomach, and small and large

intestine, and (2) accessory glands that empty secretions into the

tube- salivary glands, pancreas, liver, and gallbladder.

1. Teeth

a. Crown projects above the gum, root below. Dentin (bulk of tooth)

surrounds pulp cavity. Enamel covers dentin of crown;

cementum covers dentin of root and anchors tooth to periodontal

ligament.



b. Each quadrant of mouth has eight teeth-two incisors, one canine,

two premolars, and three molars.

1. Esophagus

a. Mucous membrane lined with stratified squamous epitheliumrather than simple columnar epithelium, as in stomach and

intestine,

b. Muscular layer of upper third, striated; lower third, smooth;

middle, both striated and smooth.

c. Segment above stomach (indistinguishable anatomically from

remainder of esophagus) functions as sphincter, remaining

closed until reflexively relaxed as peristaltic wave approaches,

1. Stomacha. Consists of upper fundus, central body, and constricted lower

pyloric portion (antrum).

b. Musculature contains an oblique inner layer of smooth muscle in

addition to external longitudinal and underlying circular smooth

muscle layers found elsewhere in digestive tract.

c. Thick circular muscle in pyloric portion forms pyloric sphincter.

d. Openings: cardia, between esophagus and stomach; pylorus,

between stomach and duodenum.

1. Small Intestine

a. Divided into duodenum, jejunum,

and ileum.

b. Surface area, serving absorptive

function, increased by:

1. Circular folds (plicae circulares)-

permanent, transverse folds.

2. Villi – fingerlike projections

3. Microvilli- processes on freesurface of epithelial cells that

form the brush order.

a. Invagination of ileum into cecum –

the first part of the large intestine

–forms ileocecal valve, which

opens rhymthmically during



digestion, permitting gradual emptying of ileum and preventing

regurgitation.

5. Large Intestine

a. Extends from the end of the ileum to the anus and is divisible

into the cecum, colon, rectum, and anal canal. The major part is the

colon, which consists of ascending, transverse, descending, and

sigmoid portions.

b. The longitudinal muscle of the cecum and colon forms three

conspicuous bands(taeniae coli).

c. Thickene circular smooth muscle of anal canal forms the internal

anal sphincter. Surrounding skeletal muscle forms the external

sphincter.

6.Salivary Glands

a. Three pairs (parotid, submaxillary, and sublingual), with ducts

opening into the mouth.

b. Two types of secretions:

1. Serous containing ptyalin –enzyme initiating digestion of the

starch.



2. Mucous – viscous, containing mucus, which facilitates

mastication.

7. Pancreas

a. Two types of secretory cells in

exocrine pancreas:

1. Enzyme- secreting acinar cells.

2. Bicarbonate-and-water-secreting

–intralobular duct cells.

b. Pancreatic duct empties

pancreatic juice into duodenum.

8. Liver and Gallbladder

a. Bile secreted by liver is essential

for normal absorption of digested

lipids. Bile salts combine with

products of lipid digestion to formwater-soluble complexes (micelles)

which are absorbed by intestinal cells.

b. Gallbladder concentrates and stores bile.

c. Hepatic duct, formed from the bile duct system of liver, joins

cystic duct of gallbladder to form common bile duct, which empties

into duodenum.

Motility of Digestive Tract

1. Swallowing

a. In buccal stage (voluntary) bolus pushed toward pharynx.



b. In pharyngeal and esophageal stages (involuntary) bolus

passes through pharynx into esophagus and through

esophagus into stomach.

c. Reflexes raise soft palate, raise larynx, adduct aryepiglottic

folds and true and false vocal cords, and inhibit respiration.

When food enters the pharynx, reflex contraction of the

superior constrictor muscle initiates peristalsis, propelling

the food, and relaxation of the upper and lower esophageal

sphincters allows food to pass first into the esophagus and

then into the stomach.

1. Peristalsis in Stomach

a. Mixes contents and forces chime through pylorus.

b. Three waves each beginning every 20 seconds near

midpoint of stomach, lasting about one minute, and ending

with contraction of pyloric sphincter travel down stomachat one time.

c. Rate of emptying determined largely by strength of

contractions.

d. Feedback from duodenum regulates gastric emptying. Two

control mechanisms, one neuronal (enterogastric reflex),

the other hormonal (mediated mainly by enterogastrone),

inhibit gastric motility.

1. Contractions of the Small Intestine

a. Segmenting: rhythmic contractions along a section

dividing it into segments: primarily mixing action.

b. Peristaltic waves superimposed upon segmenting

contractions.

c. Ingestion of food increases ileal peristalsis and frequency

of opening of ileocecal valve (gastroileal reflex).

1. Contractions of Large Intestine

a. Simultaneous contraction of circular and longitudinal

muscle, forming haustra,

b. Infrequent usually two or three times daily of most mass

movements transferring contents from proximal to distalcolon and into rectum. Most commonly occur shortly after

a meal (gastrocolic reflex).

1. Defecation reflex

a. Distention of rectum triggers intense peristaltic

contractions of colon and rectum and relaxation of internal

anal sphincter.



b. Reflex preceded by voluntary relaxation of external

sphincter and compression of abdominal contents.

Digestion

1. Mouth

a. Enzymatic action: initiation of the digestion of carbohydrate by

ptyalin, which splits starch into the disaccharide maltose. Action

in mouth slight, but continues in stomach until acid medium

inactivates ptyalin.

b. Regulation: exclusively nervous- impulses transmitted from

center in medulla activated principally by taste, smell, or sight of

food to salivary glands by parasymphatetic nerve fibers.

1. Stomach

a. Enzymatic action: initiation of protein digestion by pepsin,

producing proteoses, peptones, and polypeptides. Pepsinogensecreted by chief cells converted to pepsin by autoactivation

process in presence of acid secreted by parietal cells.

b. Regulation

1. Cephalic phase- initiated by taste, sight, or smell of food;

secretion stimulated directly or indirectly by the hormone

gastrin. Gastrin, released from so called G cells in the pyloric

region of the stomach, stimulates the secretion of an acid-rich

gastric juice.

2. Gastric phase- initiated by food in stomach; secretion triggered

directly or indirectly, as in cephalic phase.

3. Intestinal phase- initiated by digestive products in upper small

intestine; mediated by hormone released by duodenum acting on

stomach.

4. Inhibition- strong acid in antrum inhibits gastrin release. Fat,

acid, or hypertonic salt solutions in duodenum stimulate release

of hormones which inhibit gastric secretion.



1. Intestine

a. Enzymatic action- fat digestion and continuation of carbohydrate

and protein digestion.

1. Pancreatic lipase splits fat into monoglycerides, fatty acids, andglycerol.

2. Pancreatic amylase converts starch and glycogen into maltose.

Intestinal disaccharidases split maltose, sucrose, and lactose into

their constituent monosaccharides,

3. Pancreatic enzymes trypsin and chymotrypsin both

endopeptidases split proteins and the products of pepsin

digestion into peptides. Peptidases split peptides into amino

acids.

b.. Regulation of pancreatic secretion: by vagus nerve during

cephalic and gastric phase of gastric secretion and by two duodenal

hormones-cholecystokinin-pancreozymin and sectetin. Vagus

stimulation and cholecystokinin-pancreaozymin stimulate enzyme

secretion; secretin stimulates bicarbonate secretion.

Absorption

1. Occurs almost exclusively in the small intestine.

2. Simple sugars, amino acids, short-chain fatty acids, and glycerol

are absorbed into blood stream via capillary network of villi.

Products of lipid digestion are absorbed as chylomicrons into

intestinal lymphatics via central lacteal of villi.

Digestion process- the digestive system prepares food for

consumption by the cells through five basic activities:

1. Ingestion- is an active, voluntary process of taking in food. Food

must be placed in the mouth before it can be acted on.

2. Propulsion is movement of food along the digestive tract.

Swallowing is one example of food movement that depends

largely on the propulsive process called peristalsis. Peristalsis is



involuntary and involves alternating waves of contraction and

relaxation of the muscles in the organ wall to squeeze food along

the tract.

3. Digestion- the breakdown of food by both chemical and

mechanical processes.

4. Absorption- the passage of digested food from the digestive tract

into the cardiovascular and lymphatic systems for distribution to

cells. For absorption to occur, the digested foods must first enter

the mucosal cells by active or passive transport processes. The

small intestine is the major absorptive site.

5. Defecation- the elimination of indigestible substances from the

body.

X. Pathophysiology

(+)Staphylococcus aureus

toxin binds to mucosal cells

secretory diarrhea mediated by cyclic AMP

Increased production of fluids and electrolytes by the intestinal mucos

Increased secretion of fluids and electrolytes by the intestinal mucos

diarrhea er

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