VELEZ COLLEGE

COLLEGE OF NURSING
F. Ramos St. Cebu City

A CASE STUDY ON CLIENT J.J., 18-MONTH-OLD, MALE, DIAGNOSED WITH ACUTE GASTROENTERITIS with
SEVERE DEHYDRATION

Submitted by:
Arriesgado, Myangel Loise
Atillo, Charles Edward
Casirayan, Angel mae
Cinco, Lauren Benedique
Federizo, Enlil Joshua
Gotico, Angela Margarette Tricia
Marcos, Althea Blaise
Pocoy, Trixie Gwen
Pugosa, Emil Joshua
Taraya, Frank
Uy, Laica Pauline
Vizcarra, Alyanna Justine

BSN 2A
 Submitted to:
Mrs. Raquel Ann N. Batayola, RN

INTRODUCTION
INSERT CLIENT IN CONTEXT

INTRODUCTION OF DISEASE
Acute Gastroenteritis

Definition: Acute Gastroenteritis, or in other terms “infectious diarrhea” and “gastro”, is a disease state that occurs when either food or water
that is contaminated with pathogenic microorganisms or their toxins is consumed. Acute gastroenteritis occurs when the gastrointestinal tract -
the stomach and the intestines - becomes inflamed or swells and becomes irritated and can cause nausea, vomiting, diarrhea and/or abdominal
pain that lasts less than 14 days.

Causes: Gastroenteritis is most commonly caused by either viral or bacterial infection and is less commonly caused by parasitic infection,
chemical toxins, and drugs.

Viral Infection
● Norovirus: Most common cause of diarrhea in infants and young children. Affects both adults and children and is also the most common
cause of foodborne illness worldwide. It is most likely to spread among people in confined and tight spaces. It may be acquired through
the ingestion of contaminated food or water or through direct contact with an infected person.
● Rotavirus: The most common cause of serious gastroenteritis and also foodborne diseases. Worldwide, this is the most common cause
of viral gastroenteritis in children. This is acquired when children put their fingers or other objects with the virus into their mouths.
Adults infected with this virus may be asymptomatic, but can still unknowingly spread the illness
● Astrovirus:can infect people of all ages but usually infects infants and young children; infection is most common during winter and is
spread by fecal-oral transmission.
● Adenovirus: most commonly affects children less than 2 years of age. Infections are spread by fecal-oral transmission.

Bacterial Infection: Bacterial gastroenteritis can result from poor hygiene, direct contact with animals, or consuming food or water contaminated
with bacteria. UNDERLINE CAUSATIVE AGENT IN YOUR CLIENT’S CASE
● Escherichia coli: found in ground beef and salads
 ● Campylobacter jejuni: found in meat and poultry
● Salmonella: found in meat, dairy products, and eggs
● Shigella dysenteriae: comes from the Shigella family that causes Shigella gastroenteritis or can also be called Shigellosis, Shigella
infection, Shigella enteritis, and bacillary dysentery. Infection as acquired either through ingestion of the bacteria, direct contact with an
infected person, or indirect contact with contaminated food or water

Parasitic Infection
● Giardia: Giardia intestinalis (G. lamblia), adhere to or invade the intestinal mucosa which causes nausea, vomiting, diarrhea, and general
malaise. The infection can become chronic and would eventually lead to a malabsorption syndrome. The infection is usually acquired in
direct contact from an infected person, usually in daycare centers, or from the ingestion of contaminated water.
● Cryptosporidium: Cryptosporidium parvum, is usually acquired through the ingestion of contaminated water and is the most common
cause of recreational waterborne illness in the United States.

Other less common causes

● Heavy metals in drinking water such as arsenic, cadmium, lead, or mercury
● Eating a lot of acidic foods, like citrus fruits and tomatoes
● Toxins that might be found in certain seafood
● Medications such as antibiotics, antacids, laxatives, and chemotherapy drugs

Signs and Symptoms: Depending on the causes, symptoms may appear within 1-3 days after infection and it can range from mild to severe. They
usually last for 1-2 days, but may occasionally last for up to 10 days

Viral Gastroenteritis Bacterial Gastroenteritis Parasitic Gastroenteritis

Rotavirus Gastroenteritis Salmonella ● Subacute or chronic

● In infants and young children, it may last from 5 to ● Fever diarrhea
7 days ● Prostration ● nonbloody diarrhea
● Vomiting occurs in 90% of the patients ● Bloody diarrhea ● Fatigue and weight loss
● Fever of >39° C (>102.2° F) occurs in about 30% of are common when
the patients Escherichia coli diarrhea is persistent
 ● Infection usually begins with water
Norovirus Gastroenteritis diarrhea that lasts for 1-2 days
● Acute onset of vomiting, abdominal cramps, and ● Bloody diarrhea usually follows
diarrhea ● Fever is either low grade or absent
● Symptoms usually lasts 1-2 days
● In children: vomiting is more prominent than diarrhea
● In adults: diarrhea is more predominant Shigella UNDERLINE
● Fever ● Diarrhea which may contain traces of
● Headache
pus, mucus, or blood
● Myalgia
● Fever
Adenovirus Gastroenteritis
● abdominal cramps
● Hallmark symptom: diarrhea lasting 1-2 weeks
● Infants and children: mild vomiting that typically ● Nausea
starts 1-2 days after the onset of diarrhea ● Vomiting
● Low grade fever occurs in 50% of patients ● Dizziness
● Presence of respiratory symptoms
Astrovirus Gastroenteritis
● Similar to mild rotavirus infection

Risk Factors:
● Infants and young children with an immature immune system
● The Elderly, who have less efficient immune system
● Children in daycare, school children, and students living in dormitories
● Anyone with a weakened immune system: People with HIV/AIDS or people receiving chemotherapy
● Travellers

Complications:
● Dehydration: too little fluid in the body
➔ Danger signs of dehydration:
- Soft spot on the head is sunken
- Eyes are sunken
- No tears when they cry
- Mouth is dry
 - Not producing much urine
- Have reduced alertness and energy (lethargy)
● Metabolic Acidosis
● Electrolyte Imbalance (hypernatremia, hyponatremia, hypokalemia)
● Carbohydrate (lactose, glucose) intolerance
● Susceptibility to reinfection
● Development of food intolerance (cow’s milk, soy protein)
● Hemolytic uraemic syndrome
● Death

Diagnostic Tests:
● Complete History
● Stool testing: guided by clinical findings and the organisms that are suspected based on patient history and epidemiologic factors such
as, immunosuppression, exposure to a known outbreak, recent travel, and recent antibiotic use. Cases are usually categorized into:
1. Acute watery diarrhea: probably viral and testing is not indicated unless the diarrhea persists
2. Subacute or chronic watery diarrhea: requires testing for parasitic causes, typically with microscopic stool examination for ova
and parasites; fecal antigen tests are available for Giardia, Cryptosporidium, and Entamoeba histolytica and are more sensitive than
microscopic stool examination.
3. Acute inflammatory diarrhea with gross blood: can be recognized by the presence of WBCs on stool examination; Patients should
have stool culture for typical enteric pathogens (eg, Salmonella, Shigella, Campylobacter, E. coli).
4. Acute inflammatory diarrhea without gross blood: should prompt testing specifically for E. coli O157:H7; alternatively, a rapid
enzyme for the detection of Shiga toxin in stool can be done
● General Tests:
1. Serum Electrolytes, Blood Urea Nitrogen (BUN), and creatinine should be obtained.
2. Complete Blood Count (CBC)
3. Renal Function Test

Treatment and Management:

● Oral or IV Hydration
➔ Most children do not become dehydrated and can be managed at home
➔ Dehydration, metabolic acidosis, and electrolyte imbalance can be treated with fluid therapy.
 ➔ Most children with mild-moderate dehydration can be treated with oral or enteral rehydration using low osmolarity oral
rehydration solutions
➔ Severely dehydrated or shocked children usually need intravenous fluids and hospital admission
● Antibiotic (in select cases only)
● For most patients, supportive treatment is all that is needed.
● Bed rest with convenient access to a toilet or bedpan is desirable
● Drugs are usually unnecessary and may do harm
Treatment for Shigella Gastroenteritis
● Plenty of fluids
● Oral rehydration drinks
● Intravenous fluids (in severe cases)
● Eating solid foods
● Avoiding anti-vomiting or anti-diarrhea drugs unless prescribed or recommended by the doctor
● Taking appropriate antibiotics when prescribed

Prevention:
● Two vaccines are available to prevent rotavirus infection and these are recommended infant vaccination schedules.
● Children who are old enough should be taught to wash their hands and to avoid improperly stored foods and contaminated water.
● Caretakers should properly wash hands especially after changing diapers.
● Breastfeeding: simple and effective way to help prevent gastroenteritis in infants.

Take Precautions when Travelling

● Drink water only from well-sealed bottled or carbonated water
● Avoid iced cubes. They may be made from contaminated water.
● Use bottled water to brush your teeth.
● Avoid eating raw foods like peeled fruits, raw vegetables, and salads that has been touched by human hands.
● Avoid undercooked meat and fish.

Prevention of Shigella Gastroenteritis

● Wash hands thoroughly with soap and hot water after going to the toilet or changing nappies, and before preparing food or eating.
● Use disposable paper towels to dry your hands rather than cloth towels, since the bacteria can survive for some time on cloth.
● Keep cold foods cold (below 5 °C) and hot foods hot (above 60 °C) to discourage the growth of bacteria.
● Make sure foods are thoroughly cooked.
 ● Thoroughly wash raw vegetables before eating.
● Reheat food until the internal temperature of the food reaches at least 75 °C.
● Clean the toilet and bathroom regularly, including the toilet seat, door handles and taps, by using a cleaning product that is able to kill
bacteria, such as a product containing chlorine.
● Clean baby change tables regularly.
● Water from rivers and lakes may be contaminated by human faeces. Boil water from these sources before drinking.
ANATOMY AND PHYSIOLOGY

Functions:
1. Ingestion: The active voluntary process that involves food that must be placed in the mouth before it can be acted upon.
2. Propulsion: Movement of food from one organ to another. Swallowing is one of the common examples of propulsion.
3. Peristalsis: Involuntary contraction of waves and relaxation of muscles in the organ wall.
4. Food Breakdown (Mechanical Digestion): Process prepares food for further degradation by enzymes by physically fragmenting the foods
into smaller pieces.
5. Food Breakdown (Chemical Digestion): The sequence of steps in which the large food molecules are broken down into their building
blocks
6. Absorption: Transport of digested end products from the lumen of the GI tract to the blood or lymph is absorption. Absorption enters
the mucosal cells by active or passive transport.
7. Defecation: Removal of indigestible residues by the form of feces.

Anatomy of the Gastrointestinal System

1. Mouth: The mouth and accessory organs, which include the lips, cheeks, gums, tongue, palate, and salivary glands, perform the initial phases
of digestion, which are ingestion, mastication, and salivation.

2. Ingestion and Mastication

- The mouth is the beginning of the alimentary canal and is the means for ingestion and entry of nutrients.
- The teeth cut, grind, and mix food, transforming it into a form suitable for swallowing and increasing the surface area of food available
to mix with salivary secretions.
 - Healthy dentition is vital for this process.
- Mucous glands located behind the tip of the tongue and serous glands located at the back of the tongue aid in the lubrication of food
and in its distribution over the taste buds.

3. Salivation
Salivation has an important role in the first stage of digestion because saliva lubricates the mouth, facilitates the movement of the lips and the
tongue during swallowing, and washes away bacteria.
- Saliva consists of approximately 99.5% water which contains a large amount of ions:
● Potassium
● Chloride
● Bicarbonate
● Thiocyanate
● Hydrogen
● Immunoglobulin A

The three major salivary glands are:

● Submandibular glands
● Sublingual glands
● Parotid glands.

- Parotid gland secretions are enzymatic, containing amylase (ptyalin), which begins the chemical breakdown of large polysaccharides into
dextrins and sugars. The mouth and pharynx also are lined with minor salivary glands that provide additional lubrication.

The salivary glands are regulated by the autonomic nervous system, with parasympathetic effects being predominant. Increased
parasympathetic stimulation results in profuse secretions of watery saliva, whereas decreased parasympathetic stimulation results in inhibition
of salivation.

4. Esophagus
● The esophagus has two sphincters:
- The upper esophageal sphincter: Inhibits air from entering the esophagus during respiration
- The lower esophageal sphincter: Controls the passage of food into the stomach and prevents reflux of gastric contents.
 ● Swallowing:
- The functions of the esophagus are to accept a bolus of food from the oropharynx, to transport the bolus through the esophageal body
by gravity and peristalsis, and to release the bolus into the stomach through the lower esophageal sphincter.
1. This process is known as swallowing.
2. Peristalsis consists of waves of circular muscle contractions and relaxations.
- Peristalsis that is initiated by swallowing is known as primary peristalsis.
- Peristalsis that is initiated by esophageal distention is known as secondary peristalsis.
3. Peristaltic waves begin in the pharynx and move distally at a rate of 2 to 6 cm per second

5. Stomach
The stomach is an elongated pouch that is approximately 25 to 30 cm long and 10 to 15 cm wide at the maximal transverse diameter. It lies
obliquely beneath the cardiac sphincter at the esophagogastric junction and above the pyloric sphincter, next to the small intestine.
The anatomic divisions of the stomach are:
1. Cardia (proximal end)
2. Fundus (portion above and to the left of the cardiac sphincter)
3. Body (middle portion)
4. Antrum (elongated, constricted portion)
5. Pylorus (distal end connecting the antrum to the duodenum)
The greater curvature, which begins at the cardiac orifice and arches backward and upward around the fundus, is in contact with the transverse
colon and the pancreas at the posterior edge. The lesser curvature extends from the cardia to the pylorus.

Two sphincters control the rate of food passage:

- The lower esophageal sphincter at the esophagogastric junction
- The pyloric sphincter at the gastroduodenal junction.
The esophagus is a hollow muscular tube that lacks cartilage. In adults, it is 23 to 25 cm (9 to 10 inches) long and 2 to 3 cm (1 inch) wide.
- It is the narrowest part of the digestive tube and lies posterior to the trachea and the heart, with attachments at the hypopharynx and at
the cardiac portion of the stomach below the diaphragm. It begins at the level of the C6 to T1 vertebrae and extends vertically through
the mediastinum and diaphragm to the level of T11.
The stomach wall has four layers:
1. The outermost layer, the serous layer (serosa), consists of squamous epithelial tissue and continues as a double fold from the lower edge
of the stomach to cover the intestine.
2. The second layer, the muscular layer (muscularis), extends from the fundus to the antrum and consists of three smooth muscle layers,
which are the longitudinal layer, the circular layer, and the oblique layer.
3. The third layer, the submucosal layer (submucosa), consists of connective tissue that contains blood vessels, lymphatics, and nerve
plexuses.
4. The innermost layer, the mucous layer (mucosa), consists of a muscular layer that is arranged in longitudinal folds, or rugae, that can
expand as the stomach fills.6 This layer also contains glands that secrete about 1500 mL of gastric juice per day.
6. Pancreas: Only the pancreas produces enzymes that break down all categories of digestible foods.

- Location: The pancreas is a soft, pink triangular gland that extends across the abdomen from the spleen to the duodenum; but most of
the pancreas lies posterior to the parietal peritoneum, hence its location is referred to as retroperitoneal.
- Pancreatic enzymes: The pancreatic enzymes are secreted into the duodenum in an alkaline fluid that neutralizes the acidic chyme
coming in from the stomach.
 - Endocrine function: The pancreas also has an endocrine function; it produces hormones insulin and glucagon.

7. Liver: The liver is the largest gland in the body.

- Location: Located under the diaphragm, more to the right side of the body, it overlies and almost completely covers the stomach.
- Falciform ligament: The liver has four lobes and is suspended from the diaphragm and abdominal wall by a delicate mesentery cord, the
falciform ligament.
- Function: The liver’s digestive function is to produce bile.
- Bile: Bile is a yellow-to-green, watery solution containing bile salts, bile pigments, cholesterol, phospholipids, and a variety of
electrolytes.
- Bile salts: Bile does not contain enzymes but its bile salts emulsify fats by physically breaking large fat globules into smaller ones, thus
providing more surface area for the fat-digesting enzymes to work on.

8. Gallbladder: While in the gallbladder, bile is concentrated by the removal of water.

- Location: The gallbladder is a small, thin-walled green sac that snuggles in a shallow fossa in the inferior surface of the liver.
- Cystic duct. When food digestion is not occurring, bile backs up the cystic duct and enters the gallbladder to be stored.
9. Small Intestine:

Food Breakdown and Absorption

- Digestion: Food reaching the small intestine is only partially digested; carbohydrate and protein digestion has begun, but virtually no
fats have been digested up to this point.
- Brush border enzyme: The microvilli of small intestine cells bears a few important enzymes, the so-called brush border enzymes, that
break down double sugars into simple sugars and complete protein digestion.
 - Pancreatic juice: Foods entering the small intestine are literally deluged with enzyme-rich pancreatic juice ducted in from the pancreas,
as well as bile from the liver; pancreatic juice contains enzymes that, along with brush border enzymes, complete the digestion of starch,
carry out about half of the protein digestion, and are totally responsible for fat digestion and digestion of nucleic acids.
- Chyme stimulation. When chyme enters the small intestine, it stimulates the mucosa cells to produce several hormones; two of these
are secretin and cholecystokinin which influence the release of pancreatic juice and bile.
- Absorption. Absorption of water and of the end products of digestion occurs all along the length of the small intestine; most substances
are absorbed through the intestinal cell plasma membranes by the process of active transport.
- Diffusion. Lipids or fats are absorbed passively by the process of diffusion.
- Debris. At the end of the ileum, all that remains are some water, indigestible food materials, and large amounts of bacteria; this debris
enters the large intestine through the ileocecal valve.

10. Large Intestine

The activities of the large intestine are food breakdown and absorption and defecation.

1. Metabolism: The “resident” bacteria that live in its lumen metabolize some of the remaining nutrients and release gases.
- (methane and hydrogen sulfide) that contribute to the odor of feces.
2. Flatus: About 50 ml of gas (flatus) is produced each day, much more when certain carbohydrate-rich foods are eaten.
3. Absorption: The large intestine is limited to
- Vitamin K, some B vitamins, some ions, and most of the remaining water.
4. Feces: The more or less solid product delivered to the rectum, contains undigested food residues, mucus, millions of bacteria, and just
enough water to allow their smooth passage.
When presented with residue, the colon becomes mobile, but its contractions are sluggish or short-lived.

● Haustral contractions: The movements most seen in the colon are haustral contractions, slow segmenting movements lasting about
one minute that occur every 30 minutes or so.
● Propulsion: As the haustrum fills with food residue, the distension stimulates its muscle to contract, which propels the luminal
contents into the next haustrum.
● Mass movements: Mass movements are long, slow-moving, but powerful contractile waves that move over large areas of the colon
three or four times daily and force the contents toward the rectum.
● Rectum: The rectum is generally empty, but when feces are forced into it by mass movements and its wall is stretched, the
defecation reflex is initiated.
● Defecation reflex: The defecation reflex is a spinal (sacral region) reflex that causes the walls of the sigmoid colon and the rectum to
contract and anal sphincters to relax.
● Impulses: As the feces is forced into the anal canal, messages reach the brain giving us time to make a decision as to whether the
external voluntary sphincter should remain open or be constricted to stop passage of feces.
● Relaxation: Within a few seconds, the reflex contractions end and rectal walls relax; with the next mass movement, the defecation
reflex is initiated again.

PATHOPHYSIOLOGY
 CLIENT - IN - CONTEXT PRESENT STATE

PEDIATRIC ASSESSMENT PHYSICAL EXAM

Introduction of the Client HEAD-TO-TOE PHYSICAL EXAM
Client J.J. is an 18 month old male who was born on November 10,
2019. The client can be found in room 201 bed number 01. He was Date Performed: May 8, 2021
admitted on May 08, 2021 at 2PM. This is the client’s first admission
GENERAL APPEARANCE: Seen patient awake, . .
in CVGH. He and his parents live in Lahug, Cebu City. His parents are
Roman Catholic. Both of his parents are teachers in Lahug Elementary BP: 100/75 PR: 110bpm RR: 25cpm T: 37.0 degrees Celsius
School. He is a Filipino. The client was assessed on May 08, 2021 and
the information was obtained from the client’s mother. Skin: Brown even skin tone, warm, dry, with a slightly diminished skin
turgor in all extremities. No swelling noted
Chief Complaint
In for complaints of diarrhea and vomiting associated with liquid and Scalp and Hair: Scalp is clean. Hair is smooth, firm, black, and
foul smelling stool, with mucous, slime or blood noted, and vomiting distributed evenly.
after every feeding.
Nails: Nails are smooth, clean and hard. Nail beds return pink in less
History of Present Condition than 3 seconds, after applying pressure.
2 days PTA, client experienced intermittent and mild fever with
recorded temperature of 37.8 C/axilla accompanied by 4 episodes of Head and Face: Anterior fontanelle is closed, head is symmetric,
vomiting and 6 episodes of diarrhea with liquid and foul smelling round, erect, hard, smooth, and no lesions are visible. There is no
stool. swelling and tenderness with movement in TMJ. Mouth opens and
closes fully. No involuntary facial movements.
1 day PTA, there was a recurrence of the above-mentioned symptoms
accompanied by 5 episodes of diarrhea and 4 episodes of vomiting Eyes and Vision: Eyes are symmetrical, rounded and aligned in
amounting to about half a cup and unable to keep anything down, sockets. Sinking of eyes noted. Upper lid covers the upper portion of
vomiting after every feeding. the cornea. Eyes are free of swelling, and lesions. White sclerae,
cornea is transparent, and moist with a dark iris and black pupil.
Morning PTA, client is afebrile with recorded temperature of 37.0 Minimal tears noted when crying. Pupils are equally round and
C/axilla accompanied by 4 episodes of vomiting and 6 episodes of responsive to light. Light is seen in the exact same spot on each
diarrhea with liquid and foul smelling stool with mucous, slime or cornea and are parallelly aligned.
blood noted. His mother reports that he is not feeding well and his
activity level is decreased. Client seems weak and tired. Thus Ears and Hearing: Ears are equal in size bilaterally. Auricle aligns with
prompted SO to seek consult or seek medical help. the corner of each eye and within 10-degree angle of the vertical pos.
Earlobes are free, attached, or soldered. Skin is smooth, with no
Past Medical History lesions, lumps, and color is consistent with facial color. There is a
Client J.J. has no history of previous hospitalizations and no history of small amount of yellow, soft cerumen on both ears. Canal walls are
concurrent health problems. Client has no known allergies and no pink and smooth without nodules.
childhood illness. Client did not undergo any transfusion.
Immunization status of the client includes 1st dose of BCG, 3rd Dose Nose and Sinuses: Nose is smooth and symmetric; color is consistent
of DPT, 3rd Dose of Hep B and 1st dose of Measles Vaccine. Client with the rest of the face. Able to sniff and blow in each nostril. Nasal
currently does not take any prescription medications or maintenance mucosa is dark pink in color and is moist and free of exudate. Clear
medications. The client’s parents do not use herbal medicines. frontal and maxillary sinuses upon transillumination and are non-
tender to palpation and percussion.
Prenatal History
GTPAL score of G2P1102. First prenatal check-up was between 7-12 Mouth and Pharynx: Lips are dry without any oral lesions. Client has
weeks AOG. Prenatal check-ups were done once a month in the first 12 whitish teeth. Jaws are aligned with no deviation seen when biting
trimester and twice a month in the second trimester. Prescriptions down. Gums are pink, moist, and firm. Longitudinal fissures are
include folic-iron supplements once a day 1-2 hours after meals, and visible. The frenulum is midline; wharton ducts are visible, with
the fourth dose of tetanus toxoid. salivary flow or moistness in the area. The client has no swelling,
redness, or pain.
Labor and Delivery History
Age of gestation at time of labor was 37 weeks. The duration of labor Neck: The client’s neck is symmetric with head at the center without
lasted 6 hours. The delivery was spontaneous and done in a hospital any bulging masses. Neck movement is smooth lateral abduction and
assisted by an obstetrician. The type of delivery was NSVD. 70-degree rotation. Thyroid gland is palpable when the client
swallows and no bruit sounds heard. Trachea is located medially.
Birth History Lymph nodes are nonpalpable and nontender when palpated.
The client had a birth weight of 7.5lbs and 5oz. Presentation at birth
was cephalic. The client was born full term with no unusualities and Chest and Lungs: Scapulae is symmetric and non-protruding. No
respiratory effort was unassisted. retractions, bulging, tenderness, swelling and pain noted. As client
breathes, client has normal breathing patterns and no nasal flaring
Feeding History noted. During auscultation client breathes, no flat or dull sounds are
Feeding was done through breastfeeding. And bottle feeding. No heard
feeding unusuality. Mixed feeding is done.REPHRASE The frequency
of bottle feeding is done more than breastfeeding. The amount is 12- Heart and Peripheral Vasculature: Client has mild tachycardia. Apical
15 oz a day of formula or breastmilk. For feeding habits, the mother pulse of 167 bpm with regular rhythm. S1 was best heard at tricuspid
washes her hands before breastfeeding, washes the baby bottles after point. S2 was best heard at 2nd left intercostal space. S2 was best
every use and burps the baby. heard at 2nd left intercostal space. No abnormal pulsations and pulse
deficit noted. pulse deficit noted. No extra heart sounds, S3 & S4,
Elimination History were heard. No murmurs are heard.
The client usually defecates 1 to 2 times a day in the morning and at
night. His stools are usually dark or light brown in color and are
usually like a sausage (smooth and soft). Client J.J. usually urinates 5 Peripheral Pulse R L
to 7 times a day containing half to a whole cup per elimination. His
usual urine color is light to dark yellow, clear and odorless. Temporal 167 167

Carotid 167 167

His current condition has caused him to urinate very little. Client has 6
episodes of diarrhea per day and his current stools are liquid and foul Brachial 167 167
smelling, with mucous, slime or blood. UNDERLINE
Radial 167 167
Developmental milestones Popliteal 166 166
INCLUDE REFERENCE FOR EXPECTED DEVELOPMENT
Client’s age: 18 months old Posterior Tibialis 166 166

Dorsalis Pedis 166 166

Gross motor:
Expected: Toddlers at 18 months are able to run and jump in place.
They can also walk up and down stairs holding onto a person’s hand
Abdomen: His abdomen is flat, soft, and non-tender with hyperactive
or railing. Toddlers at 18 months can place both feet on one step bowel sounds. No visible mass, bulging, lesions, and hernias found.
before advancing. Pain is noted. Umbilical skin tones are similar to surrounding
Actual: The toddler can walk, jump, and run without difficulty. The abdominal skin tones. Umbilical is midline at lateral line.
toddler can walk and place both feet on one step before advancing.
The toddler can move both his upper and lower extremities without Rectum: No bulging or lesions visible
difficulty.
Genitalia: Testes are descended, non-swollen, non-tender and no
rashes present.
Fine Motor:
Expected: Toddlers should be able to eat with a spoon without Back and Extremities (Musculoskeletal): Posture comfortable for age.
rotating it to bring it to their mouths. The toddler can also drink from Evenly distributed weight. Spine is aligned. Shoulders are
a cup, stack two objects or blocks, and can hold crayons and can symmetrically round. Scapulae are even and symmetric. Elbows are
scribble. symmetric. Wrists are symmetric. Hips are stable. Knees are
symmetric and hollows present on both sides of patella. No bulge of
Actual: Prior to the client’s condition, the mother stated that he
fluid appears on the medial side of the knee.REMOVE Client is able to
attends daycare during the day, he can grasp the pencil well, can do upper and lower extremities ROMs. No deformities, lesions, or
scribble, and can make lines on the paper. swelling noted.

Language: Neurological Assessment

Expected: They are able to speak 7-20 words, expressing autonomy by
saying “no”, uses jargoning, and can name a body part. Mental Status/Cerebral Function: Client is alert and responsive. Can
maintain eye contact and show facial expressions. Can voice out
Actual: The toddler responds when his name is called. How did the
simple words such as “yayay”. Stand from a crawling position without
client respond?The toddler’s vocabulary is limited but can still express
holding onto anything. Hold a cup by themselves. Like to press
what he wants. Toddler usually says “no” to his mom when he was buttons, move handles, and turn knobs.
asked to sit still for the physical examination.
Motor/Cerebellar Function: Can turn palms up and down. Touches
Play: finger to thumb and could grasp objects. No fasciculation, tics, or
Expected: All children during the toddler stage exhibit parallel play, a tremors, noted.
type of play in which a child plays besides other children, not with
Sensory Function: Client is stimulated and responds when touched in
them. sensitive areas such as the soles of the feet and stomach. A
Actual: The toddler, according to his mother, likes to play beside stimulation in balance is also observed upon vestibular stimulation.
other classmates from the daycare. One of the toddler’s favourite
toys is a set of legos. This implies that during this stage, toddlers enjoy Cranial Nerve Testing:
toys they can manipulate or control — giving them a sense of
autonomy. CN I (olfactory): Client is able to distinguish the smell of the orange
and milk.

Theoretical Development CN II (optic): Bilateral illuminated pupils constrict simultaneously.

Pupil opposite the one illuminated constricts simultaneously.
Client’s age: 18 months old
CN III, IV, & VI (oculomotor, trochlear, abducens): Client is able to fix
Freud’s Psychosexual Development: and follow on an object. Eyes demonstrate conjugate movement in
Expected: Anal stage. Child’s pleasure focuses on anus and from the opposite direction of the head movement, when the doll's eye
elimination. Toilet training is a crucial task during this stage. At this maneuver is done.
stage, toddlers must have control of rectal and urethral sphincters,
CN V (trigeminal): Corneal reflex present; identifies light, sharp & dull
must have a cognitive understanding of what it means to hold urine touch to forehead, cheek & chin; clenches teeth.
and stools until they can release them at the right place and right
time, and must have a desire to delay immediate gratification. CN VII (facial): Client is able to smile, frown, wrinkle forehead, show
Actual: At home, the toddler can control his urge to urinate and teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes
defecate as per mother’s information. At the hospital, the toddler against resistance.
expresses his uncomfortability in wetting his diapers by saying
CN VIII (vestibulocochlear): Client turns head and eyes towards the
“Mommy, poo”.
sound.

Erikson’s Psychosocial Development CN IX & X (glossopharyngeal & vagus): Client’s quality and strength of
Expected: Sense of autonomy versus shame or doubt. The child at this cry shows no abnormalities.
stage should have learned to trust themselves and are expected to to
develop a sense of independence. Deep Tendon Reflex:
Actual: As per mother’s statement, prior to his current condition, the
toddler is usually active, eager to play outdoors on a playground. At Grading Deep Tendon Reflexes
the hospital, the toddler stated that he wants to eat his favourite food
which is hard-boiled egg. This implies that the toddler achieved a +4 - hyperactive, very brisk, rhythmic oscillations (clonus); abnormal
and inactive disorder
sense of autonomy since the child did not have any difficulty
expressing what he likes. +3 - more brisk and active than normal, but not indicative of
disorder
Piaget’s Cognitive Development
Expected: Between 18 and 24 months of age, the toddler enters the +2 - normal, usual response
sixth stage under sensorimotor. This is the stage where there is an
+1 - decreased, less active than normal
invention of new means through mental combination. Toddlers can
try out various actions mentally rather than having to actually
0 - no response
perform those tasks. They may begin to develop problem solving or
symbolic thought. At this stage, children are expected to have faulty
R L
reasoning leading to illogical conclusions. Toddlers at this stage also
have a hard time differentiating objects. They also tend to remember Biceps +2 +2
an action and imitate it later. This concept is called deferred imitation.
Patellar +2 +2
Children at this stage tend to develop egocentric thinking and
discover the concept of object permanence. This is also the Triceps +2 +2
transitional phase to preoperational thought period and begin to use
a process called assimilation. Achilles +2 +2
Actual: The toddler has difficulty viewing one object as being different Brachioradialis +2 +2
from another. For instance, when the mother shows a picture of a
leopard, the toddler identifies it as a cat.

Kohlberg’s Moral Development

Expected: Punishment/obedience orientation, also known as
heteronymous morality. Toddlers enter the preconventional level,
stage 1 of Kohlberg’s Moral Development. In this stage, toddlers do
right because a parent tells them to and to avoid punishment. Their
moral decisions are based on fear of punishment.
Actual: As per mother’s statement, the child obeys her rules because
of the fear of punishment. When the toddler refuses to sleep, the
mother would prohibit the toddler from playing with his favourite
toys. Since then, the toddler would always follow her mother’s orders
to avoid punishment.

HISTORY OF PRESENT ILLNESS

Present Health
Client J.J. is brought to the emergency department with a chief
complaint of diarrhea and vomiting for 2 days. His mother describes
stools as liquid and foul smelling, with mucous, slime or blood noted.
He reportedly is unable to keep anything down, vomiting after every
feeding, even water. He has about 6 episodes of diarrhea and 4
episodes of vomiting per day. His mother reports that he is not
feeding well and his activity level is decreased.

According to the client’s mother, she first noticed watery stools in his
diaper when she was changing it in the morning two days ago. The
stools are described as liquid and foul smelling. A few hours later, he
started vomiting after feeding. Since then, he was unable to keep
anything down, even water. Before midnight of the same day, the
client’s stools have been observed to have mucous, slime, or blood, in
addition to being liquid and foul smelling. By the second day, the
client started to appear weak and tired according to his parents. In
total, he had about 6 episodes of diarrhea and 4 episodes of vomiting
that day. The client also had the same number of vomiting and
diarrhea episodes on the second day.

Past Health History

Client J.J. has had no history of previous hospitalizations aside from
his birth. He has no known allergies so far and he does not have any
previous experience with anesthesia nor had a blood transfusion in
the past. The client has a family history of Hypertension and Diabetes
mellitus.

GORDON’S FUNCTIONAL HEALTH PATTERN

I. Health Perception – Health Management Pattern

According to the client's mother, he does not live with anyone who
smokes. He uses safety devices such as a car seat when travelling. He
currently does not take any prescription medications or maintenance
medications. The client’s parents do not use herbal medicines or
alternative treatment modalities.

The client has regular health check-ups. These check-ups are usually
complete physical exams following the schedule that their
pediatrician instructed them to follow. His last exam was 3 months
ago and all the findings were normal.

The client is up to date on his current vaccinations.

Client J.J. and his family live in an apartment in an urban locality. The
area is described by his mother as flood-prone. Their current housing
unit and lot is rented. The construction materials used for their house
are a mix of light and strong materials. It has been 7 years since the
construction of their apartment. Their apartment only contains one
storey with one properly installed door with direct access outside.
They have two windows that ventilate the home. Their apartment has
a fixed shower, a toilet, and a kitchen. There are two rooms for
sleeping. There is no household crowding. Their toilet type is a flush
type toilet and is privately owned. Their apartment complex has a
closed drainage system. For their waste disposal, their garbage
containers are covered and are collected by a garbage truck every
week. Client J.J. and his family source their water from the Metro
Cebu Water District (MCWD). For drinking, they buy distilled water
from a nearby refilling station. For general household use, they make
use of the piped system of MCWD. Their house has electricity from
the Visayan Electric Company (VECO). They do not have a home
phone. Their medications, household chemicals, matches, and sharp
objects are not under lock and key but are placed out of reach of
children. They do not have a pet. The client’s parents often clean their
house once a week, and do a deep clean every other month. They live
5 minutes away from the main road, 7 minutes away from the nearest
health center, barangay hall, and fire station, 10 minutes away from
the nearest grocery store and drug store, 15 minutes away from the
nearest church, and 20 minutes away from the nearest hospital.
There are no factories nearby. Client J.J.’s mother states that she feels
safe in their neighborhood because no crimes have happened ever
since they started living there.

The client’s parents provide for him from their wages. Their income is
adequate for food, water, housing, clothing, medications, and other
healthcare expenses. The client does not have medical insurance.

II. Nutritional – Metabolic Pattern

 Meal of 24-Hour Diet Recall Usual/Typical Diet
Day

Breakfast Time last taken: 7:30 AM Usual time taken: 7:30

Meal taken at: Home AM
Components of meal: Usual components of
1 cup of milk meal:
1 slice of bread with 1 cup milk/juice/water
peanut butter 2 slices of bread with
spread

Lunch Time last taken: 1PM Usual time taken: 1PM

Meal taken at: Home Usual components of
Components of meal: meal:
1 cup of orange juice 1 cup juice/water
1 ½ hard boiled eggs ½ cup rice
2 eggs/ 3 thumb sized
portions of viand

Dinner Time last taken: 6:30 PM Usual time taken: 6:30

Meal taken at: Home PM
Components of meal: Usual components of
1 cup of water meal:
½ cup sliced roasted 1 cup juice/water
chicken ½ cup rice
3 thumb sized portions
of viand

AM Snacks N/A Usual time taken: 9:30

AM
Usual components of
meal:
1 cup juice/water
 1 cup sliced fruits

PM snacks Time last taken: 3 PM Usual time taken: 3 PM

Meal taken at: Home Usual components of
Components of meal: meal:
½ cup milk 1 cup milk/juice/water
1 cup sliced
fruits/yoghurt

The client does not eat condiments with food. He usually drinks 1 to 4
cups of water daily. He does not drink coffee or carbonated
beverages.

Client J.J.’s appetite is usually good. He is not following a certain diet,

nor does he have any dietary restrictions. His mother has observed
that he has a preference for sweet food and dislikes most vegetables
except cooked carrots. Most of his meals are home cooked and he
rarely eats fast food. Their family does not have any religious beliefs
affecting their diet or meal preparation. The client always eats with
family. His mother usually shops for food items. His father and his
mother take turns cooking food at home. Their food is usually
obtained from supermarkets in malls and is stored in cupboards or
the refrigerator. The client is not taking any vitamins or mineral
supplements.

Client J.J.’s last weight at his 15 month check-up was 25 pounds. He

has recently lost weight (SPECIFY), and is currently experiencing a
change in appetite and GI distress.UNDERLINE

III. Elimination Pattern

The client usually defecates 1 to 2 times a day in the morning and at
night. His stools are usually dark or light brown in color and are
usually like a sausage (smooth and soft) or have the appearance of
soft blobs with clear cut edges. The client has experienced
constipation before, and is usually managed by his parents through
lots of fluids and fruits in his diet.

His current stools are liquid and foul smelling, with mucous, slime or
blood. The client does not have an ostomy.UNDERLINE

Client J.J. usually urinates 5 to 7 times a day containing half to a

whole cup per elimination. His usual urine color is light to dark yellow
and is clear. His parents state that his urine is usually odorless. The
client does not have a urinary catheter. When the client needs his
diaper changed, his parents wipe his genitalia from front to back.
His current condition has caused him to urinate very little.
UNDERLINE

IV. Activity – Exercise Pattern

The client usually wakes up after 7 AM but before 8 AM. His parents
feed him breakfast around 7:30 AM. After breakfast, he takes a bath
and is dressed up for daycare. After a 15 minute trip, he is dropped off
in his daycare. Most days he gets upset after his parents drop him off,
but sometimes he does not get upset. He spends a few hours in the
daycare playing with other children or being entertained by the
daycare staff. At 9:30 AM, the daycare staff usually feed him and the
other children their morning snacks. At 12 PM, his mother, who only
works part time, picks him up and brings him home. They have lunch
at 1 PM. After lunch, client J.J. takes a nap which lasts 1 to 2 hours,
depending on how stressful his day was. When he wakes up, he
watches movies or videos for children, or he plays mentally
stimulating games with his mother. He eats his afternoon snacks at 3
PM and then goes back to playing. At 6:30 PM he eats dinner with
both of his parents and then spends time with the whole family after.
By 8:30 PM his father gets him ready to go to bed and reads him a
bedtime story. When the story is finished, they both recite a bedtime
prayer. The client is asleep by 9PM to 9:30 PM.

The client has the same activities on the weekends, but instead of
going to his daycare in the morning, he stays at home with his family.

Client J.J. does not require assistive devices.

The client is not enrolled in a formal exercise program and does not
have an exercise routine.

The client usually plays with his toys, watches movies or videos, or
spends time with his family. He spends most of his time doing the
aforementioned activities. The client has not given upon a hobby due
to a health condition. His present condition has caused him to be less
enthusiastic and less active in his usual activities. His parents have
also observed his movements weakening.

V. Sleep – Rest Pattern

The client’s usual bedtime is at 9 to 9:30 PM and usually wakes up
from 7 to 8 AM. He takes daytime naps everyday, lasting from 1 to 2
hours. The client usually falls asleep immediately at night. He usually
gets 8 to 10 hours of sleep at night. His weekend sleep patterns do
not differ during weekends. His sleep is usually undisturbed and he
does not have any trouble staying or getting back to sleep. Upon
waking up, the client is observed to be rested.

The client sleeps in a small, quiet room with his own electric fan. The
lights in his room are turned off but he has a nightlight turned on
when he goes to sleep at night. He has 3 pillows and a single blanket.
Before going to sleep, his father helps him brush his teeth and change
into comfortable sleep clothes. After that, his father reads him a
bedtime story. When the story is finished, they both say a prayer
before his father turns on his nightlight and turns off the other lights
in his room and bids him good night. The client does not use any sleep
aids or any medication to fall asleep.

VI. Cognitive – Perceptual Pattern

According to the client’s parents, he is able to comprehend
instructions, recall short-term memories and make choices. He is able
to understand the use of simple words in English and Bisaya, and goes
to daycare in the morning. Client’s potential barriers to learning is his
short attention span. Parents reported that the client’s general
responsiveness is good but has declined since the first episode of
diarrhea and vomiting. They stated that the client responds when his
name is called, especially by his mother, he does not respond well to
loud sounds, and is not very fond of people who he is not familiar
with, touching him.

When the client wants a certain object, he points to its direction but if
he knows what it is, he verbalizes it as he knows several single words.
He is able to express his needs, as well as answer to yes or no
questions by nodding or shaking his head. Parents mentioned that the
client likes to play games such as catching or throwing a ball, he also
likes chasing after or being chased. When asked, client can say his
name. Parents stated that client is unable to verbalize what kind of
pain he feels but is able to express his discomfort by pointing to his
stomach and saying “yayay”.

VII. Self-Perception – Self Concept Pattern

Client’s parents stated that he is usually bubbly and cheerful,
especially around close family members. Client is friendly and playful
around other children that are his age, as well as those who are in
charge in his daycare but still prefers to be around his parents.
Parents mentioned that he is behaved when he is left alone but there
are certain times when he throws tantrums (when he is not given
what he wants, or when he is told not to do something). Client gets
lonely if not paid attention to very often, he has separation anxiety so
he cannot be without a parent for more than 15 minutes or he will
cry. Client’s parents mentioned that an accomplishment of his is being
able to walk as well as speak a few words at a time with his
vocabulary still expanding.

VIII. Role – Relationship Pattern

Client’s immediate and significant family members would be his
father and mother. They stated that they have a tight-knit, nuclear
family type and he has no other siblings so he is the youngest at their
home. His parents stated that they both are in charge of the child-
rearing practices, disciplining, and health matters. His father is in
charge of the major purchases, and daily household expenses
whereas his mother is in charge of the household activities and social
activities. Major decisions in the family are usually decided through
discussions, and if there is any sort of conflict, it can be managed with
a sit-down talk. The client’s parents mentioned that even with just the
three of them, their family feels complete.

Client has separation anxiety so while in the daycare, he only feels

comfortable if his parents are in his sight. Client can play by himself
as long as he knows he is not alone. He feels comfortable around
other children that are his age because of an unspoken bond that he
has with them and even plays with them when he wants to but the
parents mentioned that he has a little trouble with sharing. If a toy is
taken from him, he will throw a tantrum or cry. Client smiles or
giggles when his parents or someone he is familiar with tries to make
him laugh.
IX. Sexuality – Reproductive Pattern
Client is aware of his sex and verbalized that he is a boy. Parents
stated that the toys that are bought for him are either gender neutral
or appeal to male children.

X. Coping – Stress Tolerance

Parents of the client stated that they are able to tell when client is
about to get upset or cry, he usually keeps his arms crossed and
avoids their gaze. They try to divert his attention before it happens by
distracting him with a toy or making him laugh.

Client’s parents mentioned that the client often throws tantrums by

biting or hitting when he does not get what he wants or when he is
told not to do something. Parents observed that he also throws
tantrums when he does not know how to express himself so he feels
frustrated that it comes out as a tantrum. The client’s parents are
able to handle the situation by diverting his attention before/during a
tantrum or by simply ignoring him as it makes him less likely to do it
again. When the client cries, the parents hold him close and gently
pat his back to calm him down.

XI. Value – Belief Pattern

Client’s parents mentioned that the values they are teaching him are
respect - especially to those who are older than him, sharing and
taking turns with his toys, and kindness. Parent's current goal for him
is that he becomes more open and independent, as well as being able
to express himself more. Client follows the rules that are set for him
and dislikes breaking them as he does not want to be disciplined.
Parents mentioned that they only give him attention and reward him
when he shows good/positive behavior.

Client’s parents mentioned that they are religious and go to church as

a family. Client was taught to do the sign of the cross when they have
a prayer before meals. The client attempts to sing along with the
church songs and tries to recite prayers with single words but he does
not understand the meaning of them.

NURSING CARE PLAN

NURSING DIAGNOSIS INTERVENTIONS OUTCOME

Should be in past tense, start with
assessment

Nursing Diagnosis: Independent Interventions Desired Outcome:

Diarrhea related to bacterial infection as 1. Evaluate the pattern of defecation After 8 hours of nursing intervention,
evidenced by 6 episodes of diarrhea per day rephrase to monitored bowel The client will experience only 1-2 episodes of
and liquid, foul smelling, with mucous, slime movements passing stool with soft, log-shaped, and
or blood in stool secondary to acute R: to help direct treatment brown characteristics.
gastroenteritis. 2. Weigh patient daily and note
decreased weight Actual Outcome:
Scientific Basis: R: The baby’s body weight can be an After 8 hours of nursing intervention, the
Shigella bacteria cause an infection called important indicator of fluid balance in client experienced only 2 episodes of passing
shigellosis. Most people with Shigella the body. stool in a day with soft, log-shaped, and
infection have diarrhea (sometimes bloody), 3. Encourage mother or family to have a brown characteristics.
fever, and stomach cramps. Symptoms diary that includes time of day of
usually begin 1–2 days after infection and last defecation, amount, consistency,
7 days. Most people recover without needing amount, and characteristics of stool.
antibiotics. R: This will help direct treatment
4. Give antidiarrheal medications as
Reference: ordered. Transfer to collaborative
Shigella – Shigellosis. (2021). R: Most antidiarrheal drugs suppress
https://www.cdc.gov/shigella/index.html#:~:t gastrointestinal motility and allows
ext=Shigella%20bacteria%20cause%20an more fluid absorption.
%20infection,people%20recover%20without 5. Evaluate dehydration by observing
%20needing%20antibiotics. skin turgor over sternum.
R: Severe diarrhea can cause deficient
fluid volume with extreme weakness
and may cause death in young
children.
6. Monitor and record intake and
output; note oliguria and dark,
concentrated urine.
R: Dark, concentrated urine, along
with a high specific gravity of urine is
an indication of deficient fluid
volume.
7. Encourage increase in intake of fluids
for each loose stool.
R: Increased fluid intake replaces the
fluid that is lost in the liquid stool.
8. Provide perianal care after each
bowel movement.
R: Mild cleansing of the perianal skin
after each bowel movement will
prevent excoriation. Barrier creams
can be used to protect the skin.
9. Educate the mother or SO on how to
prepare food properly and the
importance of good sanitation
practices and handwashing.
10. Weigh infant’s diapers
R: to determine the amount of output
 and fluid replacement needs

PEDIALYTE ADMINISTRATION
Collaborative Interventions
1. Administer IV fluids, electrolytes, and
parenteral fluids as indicated.
R: IV fluids may be needed either
short term or to restore hydration
status.

Nursing Diagnosis: Independent Interventions Desired Outcome:

Fluid volume deficit related to frequent 1. Assess the patient's condition. After 8 hours of nursing intervention, the
passage of diarrheal stool and vomiting as R: To monitor for other signs and client will be able to maintain fluid volume at
evidenced by 6 episodes of diarrhea and 4 symptoms. a functional level as evidenced by ability to
episodes of vomiting per day secondary to 2. Assess and document amount, color, tolerate oral feeding, moist mucous
severe dehydration. frequency, and characteristics of membranes, good skin turgor, and normal
vomitus and diarrhea. capillary refill test.
Scientific Basis: R: Vomiting and diarrhea is
Dehydration is the loss of body fluids which associated with fluid loss. Actual Outcome:
are made up of water and salts. When 3. Assess skin turgor. After 8 hours of nursing intervention, the
children vomit or have diarrhea, this causes a R: A loss of interstitial fluid causes client was able to maintain fluid volume at a
loss of large amounts of salts and water from the loss of skin turgor. This test functional level as evidenced by ability to
their bodies which results in dehydration. If indicates the hydration status of the tolerate oral feeding, moist mucous
this is not treated properly, and water and patient. membranes, good skin turgor, and normal
salts are not replaced, severe dehydration 4. Assess and document vital signs and capillary refill test at less than 2 seconds.
may occur and hospitalization may be noted strength of peripheral pulses.
necessary. R: To evaluate degree of fluid deficit.
5. Weigh and document the patient's
Reference: weight at the same time daily.
Dehydration and diarrhea. (2003). Paediatrics R: Changes in weight can provide
& child health, 8(7), 459–468. information in fluid balance and the
https://doi.org/10.1093/pch/8.7.459 adequacy of fluid volume
replacement.
 6. Instruct the parents of the patient to
resume breastfeeding once vomiting
is not noted.
R: To maintain nutrition and
hydration status.
7. Monitored I&O .
R: To assess hydration status.
8. Reviewed laboratory data.
R: To determine any replacement
needs.
9. Emphasize to the patient’s parents
the importance of oral hygiene.
R: Fluid deficit can cause a dry, sticky
mouth. Attention to mouth care
promotes interest in drinking and
reduces discomfort of dry mucous
membranes.
10. Provide perianal care after each
bowel movement.
R: Mild cleansing of the perianal skin
after each bowel movement will
prevent excoriation. Barrier creams
can be used to protect the skin.

Collaborative Interventions
1. Administer parenteral fluids as
prescribed.
R: Fluids are necessary to maintain
hydration status.

Nursing Diagnosis: Independent Interventions Desired Outcome:

Imbalanced Nutrition related to insufficient 1. Note real, exact weight; do not After 8 hours of nursing intervention, the
food intake as evidenced by vomiting after estimate. client will be able to feed properly without
every feeding and weight loss specify R: These anthropometric assessments vomiting and have an increase in weight.
 are vital that they be accurate. These
Scientific Basis: will be used as a basis for caloric and Actual Outcome:
Children with gastroenteritis may not have all nutrient requirements. After 8 hours of nursing intervention, the
symptoms, but these may include vomiting 2. Take a nutritional history with the client was able to feed properly without
and loss of appetite. participation of significant others. vomiting and has had a 0.2 kg increase in
R: Family members may provide more weight.
Reference: accurate details on the client’s eating
Gastroenteritis in children | habits.
betterhealth.vic.gov.au. (2021). Vic.gov.au. 3. Provide a pleasant environment.
https://www.betterhealth.vic.gov.au/health/c R: A pleasing atmosphere helps in
onditionsandtreatments/gastroenteritis-in- decreasing the stress and is more
children favorable to feeding.
4. Promote proper positioning.
R: When breastfeeding, ensure that
the toddler is positioned correctly to
promote feeding. When bottle-
feeding, elevate the head of the bed
30 degrees to aid in swallowing and
reduce the risk for aspiration when
feeding.
5. Because the patient is fatigued,
schedule rest periods before meals
and assist in holding the bottle when
bottle-feeding.
R: Nursing assistance with ADLs will
conserve the client’s energy for other
activities.
6. Consider the possible need for
enteral or parenteral nutritional
support with the patient, family,
caregiver, as appropriate. REMOVE
R: Nutritional support may be
recommended for patients who are
 unable to maintain nutritional intake
by the oral route.
7. Once discharged, help the client’s
family identify areas to change that
will make the greatest contribution to
improved nutrition. TRANSFER TO
DISCHARGE INSTRUCTION
R: Change is difficult. Multiple
changes may be overwhelming.
8. Consider the use of seasoning for
patients with changes in their sense
of taste; if not contraindicated.
R: This can improve the flavor of the
food and attract eating. REMOVE
9. Consider 6 small nutrient dense
meals instead of 3 large meals to
lessen the feeling of fullness.
R: Eating small, frequent meals
lessens the feeling of fullness and
decreases the stimulus to vomit.
10. Provide good oral hygiene and
dentition.
R: Oral hygiene has a positive effect
on appetite and on the taste of the
food.

Collaborative Intervention
1. Ascertain healthy body weight for age
and height. Refer to dietitian for
complete nutrition assessment and
methods for nutritional support.
R: Experts like a dietician can
determine nitrogen balance as a
 measure of the nutritional status of
the patient.

Nursing Diagnosis: Independent Interventions Desired Outcome:

Fatigue related to inadequate nutrition as 1. Assess for possible causes of fatigue. After 8 hours of nursing intervention, the
evidenced by decreased activity level R: Identifying the related factors with client will have improved energy as evidenced
fatigue can aid in determining by increased activity level and improved
Scientific Basis: possible causes and establishing a nutritional intake.
Fatigue mimics the exhaustion of the collaborative plan of care.
metabolic reserves of the individual. 2. Assess and monitor vital signs. Actual Outcome:
Inadequate nutrition is associated with R: To evaluate fluid status and After 8 hours of nursing intervention, the
reduced physical performance leading to cardiopulmonary response to activity. client was able to have improved energy as
fatigue. It results in weight loss and 3. Assess the patient’s sleep patterns for evidenced by increased activity level and
nutritional deficiencies leading to fatigue by quality, and quantity. improved nutritional intake.
means of “lack of energy” (a key concept of R: Changes in the patient’s sleep
fatigue). pattern may be a contributing factor
in the development of fatigue.
Reference: 4. Assess the characteristics of fatigue.
Azzolino, D., Arosio, B., Marzetti, E., Calvani, R: To compare changes in the
R., & Cesari, M. (2020, February 10). patient’s fatigue level over time.
Nutritional status as a mediator of fatigue 5. Assess the patient’s nutritional intake
and its underlying mechanisms in older for adequate energy sources and
people. metabolic requirements.
https://www.ncbi.nlm.nih.gov/pmc/articles/P R: The patient may need adequate
MC7071235/. intake of carbohydrates, protein,
vitamins, and minerals to provide
energy resources. Fatigue may be a
symptom of other underlying
conditions.
6. Encourage the patient’s parents to
keep a 24-hour fatigue/activity log or
diary.
R: Recognizing relationships between
specific activities and levels of fatigue
 can help identify excessive energy
expenditure and may indicate times
of day when the patient feels the
least fatigued.
7. Minimize environmental stimuli
especially during planned times for
rest and sleep.
R: Bright lighting, noise, visitors, and
frequent distractions can inhibit
relaxation, interrupt rest/sleep, and
contribute to fatigue.
8. Promote sufficient nutritional intake.
R: The patient will need properly
balanced intake of fats,
carbohydrates, proteins, vitamins,
and minerals to provide energy
resources.
9. Note daily energy patterns.
R: This is helpful in determining
pattern or timing of activity.
10. Encourage the use of assistive
devices, as needed.REMOVE
R: To extend active time or conserve
energy for other tasks.

Collaborative Interventions REMOVE

1. Refer patient to an occupational
therapist.
R: The occupational therapist can
provide the patient with assistive
devices and may teach the parents
how to make the patient complete
desired activities without adding to
 levels of fatigue.

Nursing Diagnosis: Independent Interventions Desired Outcome:

Risk for impaired skin integrity related to 1. Clean, dry and moisturize skin, After 8 hours of nursing intervention, the
presence of diarrheal stool on skin particularly in bony prominences, client will maintain skin integrity in the
twice daily or as indicated. perianal area as evidenced by absence of skin
Scientific Basis: R: Smooth, supple skin is more breakdown of the perianal area and SO’s
Balancing skin hydration levels is important as resistant to injury. ability to demonstrate perianal care properly.
any disruption in skin integrity will result in 2. Educate parents and caregivers about
disturbance of the dermal water balance. proper skin care. Actual Outcome:
R: Educating caregivers methods to After 8 hours of nursing intervention, the
Reference: maintain skin integrity prevents skin client maintained skin integrity in the perianal
Ousey, K., Cutting, K. F., Rogers, A. A., & breakdown. area as evidenced by absence of skin
Rippon, M. G. (2016). The importance of 3. Encourage adequate nutrition and breakdown of the perianal area and SO’s
hydration in wound healing: reinvigorating hydration. ability to demonstrate perianal care properly.
the clinical perspective. Journal of Wound R: Sufficient hydration and nutrition
Care, 25(3), 122–130. help maintain skin turgor, moisture,
https://doi.org/10.12968/jowc.2016.25.3.122 and suppleness which provide
resilience to damage caused by
pressure.
4. Be observant of when the client has
passed stool, and change the client’s
diaper.
R: Changing the diaper keeps the
baby’s skin dry, supple, and resistant
to damage.
5. Encourage ambulation if the client is
able.
R: Ambulation reduces pressure on
the skin from immobility thus
lessening the factors that may result
in impaired skin integrity.
6. Educate the patient’s parents about
the proper perianal skin care.
 R: Educating the parents about
methods to maintain skin integrity
prevents skin breakdown of the
perianal area exposed to diarrheal
stool.
7. Apply barrier creams around the
perianal area.
R: To help maintain the skin’s physical
barrier against irritation from body
fluids and prevents the skin from
drying out.
8. Assess the patient's nutritional status.
R: Inadequate nutritional intake
places individuals at risk for skin
breakdown and compromises
healing.
9. Educate the patient's parents on how
to apply barrier creams on the
patient’s perianal area.
R: Early intervention helps prevent
serious problems from developing,
resulting to impaired skin integrity or
perianal excoriation.
10. Monitor skin condition for color or
texture changes, or lesions.
R: To identify impending problems
early.

Collaborative Interventions:
1. Refer a patient to a dermatologist.
R: To help determine the causes of
diarrhea and provide interventions
and preventions of impaired skin
 integrity around the perianal area.

DISCHARGE INSTRUCTIONS

Medications
● Instructed the parents of the client to continue administration of 5 mL of Pedialyte (oral rehydration solution) every 15 minutes as
prescribed by doctor until diarrhea and vomiting ceases to treat dehydration, metabolic acidosis, and electrolyte imbalance.
● Instructed the parents of the client to administer 1 teaspoon of Ciproflaxin oral liquid twice each day, once in the morning and once in
the evening for the treatment of dysentery.
● Instructed the parents of the client to give their child the following prescribed medications for relief of symptoms:
➢ Zinc
- reduces the duration and severity of diarrhoeal episodes and likelihood of subsequent infections
- Recommended dose: 10-20 mg given daily for 10-14 days
- Administration: Oral
➢ Ondansetron (Zofran)
- reduces the frequency of vomiting and IV fluid administration in infants and children six months to 12 years of age with
mild to moderate dehydration
- Recommended dose: 2 mg every 8 hours as needed based on child’s current weight
- Administration: Oral
➢ Acetaminophen (Tylenol)
- reduces aches, pain, sore throat, and fever in children with a cold or the flu
- Recommended dose: 5 mL every 4 to 6 hours as needed (up to 5 doses in 24 hours)
- Administration: Oral
● Instructed the parents not to give aspirin to the patient. Reye syndrome may develop with intake of aspirin. Reye syndrome can cause
life-threatening brain and liver damage. The patient’s medicine labels must be checked for aspirin, salicylates, or oil of wintergreen.
● Instructed the parents of the client to discuss with the child's doctor the possible side effects of the medications being taken by the
client and the certain foods that can change the blood level of medications.
● Instructed the parents of the client to follow the doctor’s orders in the administering antibiotics and avoid increasing the frequency and
dosage of medications.
 ● Instructed the parents of the client not to give the child any over-the-counter medicine for treatment of the child’s symptoms without
talking with the child’s healthcare provider first.
● Instructed the parents of the client to contact their child’s physician if complications with antibiotic therapy occur.

Environment
● Instructed the parents of the client on how to prepare food properly and the importance of good sanitation practices and handwashing.
● Instructed the parents of the client to provide a pleasant environment for the patient. A pleasing atmosphere helps in decreasing the
stress and is more favorable to feeding.
● Instructed the parents of the client to minimize environmental stimuli especially during planned times for rest and sleep.
● Instructed the parents of the client to avoid having bright lighting, noise, visitors, and frequent distractions that inhibit relaxation and
interrupt the rest/sleep of the child, and contribute to fatigue.
● Instructed the parents of the client to give the child easy access to the toilet or a bedpan during bed time.
● Instructed the parents of the client to clean the toilet and bathroom regularly, including toilet seat, door handles and taps, by using a
cleaning product that is able to kill bacteria, viruses, and parasites.
● Instructed the parents of the client to clean the surfaces of the home with antibacterial cleaner or bleach. The client’s clothes and towels
should be washed separately from the rest of the laundry.
● Instructed the parents of the client to be watchful during camping or travelling. The client must only be giving clean, purified water, not
water from rivers or lakes unless purified or boiled.

Treatment
● Encouraged the patient to be compliant in taking medications.
● Instructed the patient to have more rest periods and have adequate 8 hours of sleep every night.
● Instructed the parents of the client to have the child drink a sufficient amount of 8 glasses of water a day to increase his urine output
and prevent dehydration.
● Instructed the parents of the client to schedule rest periods before meals.
● Encouraged the mother in breastfeeding the child more than bottle-feeding to provide the child with proper nutrition and strengthen his
immunity against infections. Breastfeeding is a simple and effective way to help prevent gastroenteritis in children.
● Instructed the mother of the patient to breastfeed once vomiting is not present to maintain nutrition and hydration status.
● Instructed the parents of the client that antibiotics should be taken by the child in the right dose and frequency to treat the presence of
blood in the stools since diarrheal onset.
● Emphasized to the parents of the client that the patient’s bloody diarrhea caused by Shigella bacteria is associated with considerable
mortality and should be treated with antibiotic therapy.
 ● Encouraged the parents of the client to have a diary that includes time of day of defecation, amount, consistency, amount, and
characteristics of stool, which will help direct treatment.
● Instructed the parents of the client to discuss supportive therapy for the treatment of the child with the client's healthcare provider.
● Instructed the parents of the client to have a follow-up appointment with the child’s healthcare provider to evaluate the child’s
condition and treatment.

Health Teachings
● Encourage the patient to wash his hands regularly.
● Instructed the patient to communicate any type of discomfort to parents or family members.
● Encouraged the patient to drink more water in small amounts to replace the water that he lost.
● Instructed the patient and the parents of the client to wash hands thoroughly with soap and hot water after going to the toilet or
changing nappies, and before preparing food or eating.
● Instructed the parents of the client to have the child eat 6 to 8 small meals during the day and a snack at bedtime when he feels
nauseous.
● Instructed the parents of the client to avoid giving improperly stored foods to the child and ensure that drinking water given is pure and
not contaminated.
● Instructed the parents of the client to avoid giving the child ice cubes, which can be made from contaminated water.
● Instructed the parents of the client to keep cold foods below 5°C and hot foods above 60°C to discourage bacterial growth.
● Instructed the parents of the client to avoid giving raw foods like peeled fruits, raw veggies, and salads that are not properly washed,
and undercooked meat and fish.
● Instructed the parents of the client to change the client’s diaper immediately after the client has passed stool. Changing the diaper keeps
the baby’s skin dry, supple, and resistant to damage.
● Instructed the parents of the client to provide perianal care after each bowel movement. Mild cleansing of the perianal skin after each
bowel movement will prevent excoriation.
● Advised the parents to use barrier creams to protect the child’s perianal skin and reduce the risk for skin infection.
● Instructed the parents of the client to clean, dry and moisturize skin, particularly in bony prominences, twice daily or as indicated.
Smooth, supple skin is more resistant to injury.
● Instructed the parents of the client that the use of antibiotics for non-bloody diarrheal episodes in children are likely of limited efficacy
or even dangerous. However, bloody diarrheal episodes caused by Shigella are associated with considerable mortality and should be
properly treated with antibiotic therapy.
● Encouraged the patient’s parents to keep a 24-hour fatigue/activity log or diary to recognize the relationships between specific activities
and levels of fatigue of the child and help manage the child’s energy expenditure.
 ● Instructed the patient’s parents about the proper perianal skin care to maintain skin integrity and prevent skin breakdown of the
perianal area exposed to diarrheal stool.
● Instructed the parents of the client to provide the child with good oral hygiene and dentition. Oral hygiene has a positive effect on
appetite and on the taste of the food. Fluid deficit can cause a dry, sticky mouth. Attention to mouth care promotes interest in drinking
and reduces discomfort of dry mucous membranes.
● Instructed the parents of the client to get medical care as soon as signs of infection or complication occur.

Observable Signs & Symptoms - Instructed SO to seek consultation if the following signs and symptoms are noted

Signs & Symptoms of Acute Gastroenteritis:

● Loss of appetite
● Nausea
● Vomiting
● Abdominal cramps
● Abdominal pain
● Bloating
● Diarrhea
● Bloody stools – in some cases
● Pus in the stools – in some cases
● Generally feeling unwell – including lethargy and body aches

Signs & Symptoms of Diarrhea:

● Bloody stools
● Chills
● Fever
● Loss of control of bowel movements
● Nausea or vomiting
● Pain or cramping in the abdomen
● Dehydration

Signs & Symptoms of Dehydration:

● Thirst
● Urinating less than usual
 ● Lack of energy
● Dry mouth
● No tears when crying
● Decreased skin turgor
● Sunken eyes, cheeks, or soft spot in the skull

Signs & Symptoms of Dysentery:

● Severe diarrhea
● Blood and mucus in the stool
● Abdominal cramps or pain
● Nausea
● Vomiting
● Fever of 100.4°F (38°C) or higher
● Dehydration

Signs & Symptoms of Shigellosis:

● Diarrhea (often containing blood or mucus)
● Stomach pain or cramps
● Fever
● Nausea or vomiting

Signs & Symptoms of Metabolic Acidosis:

● Dyspnea or rapid and shallow breathing
● Confusion
● Fatigue
● Headache
● Sleepiness
● Lack of appetite
● Jaundice
● Tachycardia or increased heart rate
● Breath that smells fruity, which is a sign of diabetic acidosis (ketoacidosis)
Diet
● Instructed the parents of the client to have the child drink a sufficient amount of 8 glasses of water a day in small amounts to make up
for the body’s lost fluids due to dehydration, diarrhea, and vomiting.
● Instructed the mother of the child to breastfeed the child for short periods of time to provide the child with proper nutrition.
● Instructed the mother of the child to give the oral rehydration solution at the start of diarrhea along with continuous regular feedings of
breast milk or formula. After dehydration has been corrected, the child may return to normal breastfeeding or formula feedings.
● Instructed the parents of the client to avoid giving the child the following foods and drinks:
➢ Caffeine
➢ Fatty foods
➢ Spicy foods
➢ Highly seasoned foods
➢ Sugary foods
➢ Carbonated beverages
➢ Juices and juice drinks (All juices are high in sugar. They should generally be avoided or consumed in moderation if your child has
gastroenteritis.)
➢ Gelatin
➢ Sugary drinks, such as soft drinks or sports drinks
● Advised the parents of the client to provide the client with a healthy balanced diet as soon as tolerated to compensate for lost caloric
intake during the acute illness. A balanced diet should consist of:
➢ Carbohydrates
Carbohydrates provide energy and are found in foods such as potatoes, bread, pasta and rice. Wholegrain versions of these
foods provide extra vitamins, minerals and fiber (which helps to remove waste from the body).
➢ Fats
Fats can be found in oils, oily fish, nuts and seeds. Fats help us to absorb nutrients including some important vitamins and keep
us warm. They help keep our cells healthy and give us energy.
➢ Proteins
Proteins build and support our muscles, hormones, enzymes, red blood cells and immune system. Protein is in dairy foods such
as milk and cheese, and in meat, fish, tofu, beans, lentils and eggs.
➢ Vegetable and fruit
Vegetables and fruit of various colors provide vitamins and minerals. They also help protect us from infection, damage to our
cells and diseases. Currently it is recommended that we aim to eat at least five portions of vegetables or fruit per day (one
portion is roughly a handful).
 ● Instructed the parents of the client to continue giving the client their usual diet such as semisolid or solid foods during episodes of
diarrhea. The client should as best as possible maintain caloric intake during acute episodes, and subsequently receive additional
nutrition to compensate for any shortfalls arising during the illness.

References:

Acute Gastroenteritis. (n.d.). Science Direct. Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/acute-gastroenteritis

Boyce, T. G. (2019). Gastroenteritis. MSD Manual. Retrieved from https://www.msdmanuals.com/professional/gastrointestinal-

disorders/gastroenteritis/gastroenteritis#:~:text=Parasitic%20gastroenteritis,-The%20parasites%20most&text=The%20infection%20can
%20become%20chronic,cramps%2C%20nausea%2C%20and%20vomiting.

Bruzzese, E., Giannattasio, A., & Guarino, A. (2018). Antibiotic treatment of acute gastroenteritis in children.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814741/

Developmental milestones 18 to 24 months. (n.d.). Children's Minnesota. Retrieved May 12, 2021, from
https://www.childrensmn.org/educationmaterials/childrensmn/article/15315/developmental-milestones-18-to-24-months/

Kerr, S. (n.d). Gastroenteritis Diet. https://www.wnyurology.com/content.aspx?chunkiid=648850

Khatri, M. (2020). Gastroenteritis (“Stomach Flu”). WebMD. Retrieved from https://www.webmd.com/digestive-disorders/gastroenteritis

Mayo Clinic Staff. (2018). Viral Gastroenteritis (Stomach Flu). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/viral-
gastroenteritis/symptoms-causes/syc-20378847#:~:text=A%20number%20of%20viruses%20can,sweep%20through%20families%20and
%20communities.

Silbert-Flagg, J. (2018). Maternal and child health nursing: care of the childbearing & childrearing family (8th ed.). Lippincott Williams &
Wilkins.

Southerncross. (2018). Gastroenteritis - causes, symptoms, treatment. (Web Page). Retrieved from
https://www.southerncross.co.nz/group/medical-library/gastroenteritis-causes-symptoms-treatment
Staywell, K. (n.d.). Patient Education. Retrieved from
https://www.mhealth.org/Patient-
Education/Articles/English/p/e/d/i/a/Pediatric_Gastroenteritis_Discharge_Instructions_Emergency_Department_522182

Belleza, M. (2017, May 16). Digestive System Anatomy and Physiology - Nurseslabs. Nurseslabs. https://nurseslabs.com/digestive-

system/

Gastrointestinal Anatomy and Physiology. (2015, March 7). Clinical Gate. https://clinicalgate.com/gastrointestinal-anatomy-and-

physiology/

MD, I. H. R. (2018). Gastrointestinal System - Anatomy And Physiology. Rnspeak.com. https://rnspeak.com/gastrointestinal-system-

anatomy-and-physiology/

West, H. (2018, April 19). The 10 Best Foods That Are High In Zinc. https://www.healthline.com/nutrition/best-foods-high-in-zinc