fainal case pres

8/7/2019 fainal case pres

1/10

I. Demographic Data:The clients name is Levy Anastacio Alvarado, a 5- month- old baby boy who was born on August 10

2010 via cesarean section due to oligohydramnios. He is currently residing with his parents and other relatives

at Unit 7 Sitio Sto. Nio Pagrai Mayamot. This pure blooded Filipino is a baptized Roman Catholic and wasadmitted last January 28, 2011 at 1:50 pm under the care of Dra. Cornel. His aunt was the secondary source of

data in this presentation who was interviewed on the 29th

day of January year 2011 at 9:00 am inside thepediatric ward of the Antipolo Medical City Hospital.

Chief Complaint:

Diarrhea and vomiting

Medical Diagnosis:

Acute Gastroenteritis with signs of Dehydration

II. Patient HistoryHistory of Present Illness:

Three days prior to admission, the clients mother noticed that LAA started to have productive cough

with no other accompanying manifestations therefore, they did not consult a physician nor take any medicationfor the said condition. The cough persisted for two days but this time, it is accompanied by three episodes of

loose watery stool. The client also vomited twice and a fever was noted at the 38 C level. These made theclients family decide to take LAA for a consultation with a private doctor who prescribed zinc, freeflora, and

oral rehydrating solution. However, all the symptoms persisted despite the given medications. This prompted

the clients family to take him in a hospital.

Past Health History:

The clients aunt claimed that LAA has no allergic reaction to any drug. The only food he is currently

taking is cerelac which he shows no allergic reaction to as well. However, he is sensitive to dust and animal fur.There also came a time that his physician banned applying powder and cologne to the client. LAA has neverbeen confined in a hospital until now. He has not experience any childhood illness yet and has already received

BCG and DPT vaccines. His MMR immunization is due this February.


2/10

Family History:

Legend:

Male

Female

+ Deceased

Stroke

hypertensive

Diabetes mellitus

Polio

Client

On the clients maternal side, his grandfather died because of an unknown cause. It was said that

after drinking with some friends, he went home then suddenly vomited uncontrollably then died afterwards. Hisgrandmother is still alive but is suffering from hypertension and diabetes. Meanwhile, on the paternal side, his

grandfather was also deceased because a robber broke into their home and killed the man. When it comes to theclients parents, his mother is a polio victim but other than that, she has no other health disorder. his father is in

perfect health as well.

Past Medical History:

+

+


3/10


4/10

Drug Study:Medication Drug Indication Drug Actions Contraindications: Nursing Responsibility

Generic

Name:Paracetamol

Brand Name:

*Calpol

*Neo-

Kiddielets

*Biogesic

*Tempra

Classification:

Analgesic and

Antipyretic

Relief of fever, minor

aches, and pains.

Dosage for pediatric

patients:

Doses repeated 4-5

times/day, do not exceed 5

doses in 24hrs.

Age Dosage

(mg)

0-3 mo 40

4-11 mo 80

12-23mo 120

2-3yr 160

4-5yr 240

6-8yr 320

9-10yr 400

11 yr 480

Analgesia:

Produces

Analgesia by

blocking pain

impulses

by

inhibiting

synthesis

of prostaglandin

in the CNS

or other

substances that

sensitize receptors

of

stimulation.

Antipyrexia:

Reduces fever by

acting directly on

the hypothalamic

heat-regulating

center to

cause vasodilation

and sweating,

which helps

dissipate heat.

Anemia, heart and

pulmonary disease.Hepatic/severe

renal disease.

*Use liquid form forchildren and

patients who havedifficulty

swallowing.*In children, dont

exceed five doses in 24hours.

*Advise patient thatdrug is only for short

term use and to consultthe physician if giving

to children for

longer than 5 days oradults for longer than10 days.

* Advise patient orcaregiver that

many over the counterproducts

contain acetaminophen;be aware

of this when calculatingtotal daily

dose.*Warn patient that

high doses orunsupervised long term

use cancause liver damage.


5/10

DRUG DOSAGE MOA INDICATION CONTRAINDICATION SIDE

EFFECTS

Salbutamol(Albuterol) Usual Dosage:

2 inhalations

repeated every4 to 6 hours

Albuterol mayreducechemical

mediatorrelease from

pulmonarymast cells and

improve abilityof cilia to clear

mucus.

Albuterol is adirect-acting

agent thatrelaxes smooth

muscle wallsof the bronchi,

uterus, andskeletal muscle

vascular bed.

To relievebronchospasmassociated with

acute or chronicasthma,

bronchitis, orother reversible

obstructiveairway diseases.

Also used toprevent

exercise-induced

bronchospasm.

Contraindicated inpatients hypersensitiveto drug or its

ingredients.

Use cautiously inpatients with

CV disorders (includingcoronary

insufficiency andhypertension),

hyperthyroidism, ordiabetes

mellitus and in thosewho are unusually

responsive toadrenergics.

Use extended-release

tablets cautiously inpatients with GI

narrowing.

Cardiac sideeffects are notprominent.

Muscle tremorsare the dose

related sideeffects.

>Bad taste>blurred vision

>urinaryretension

>palpitation>ankle edema

can also occur.


6/10

DRUG DOSAGE MOA INDICATION CONTRAINDICATION SIDEEFFECTS

GENTAMICINBrand Name:

AlcomicinApogen

BristagenG-Mycin

G-MyticinGaramycin

Garamycin

INFANTS:

(Birth-12

months)

3 mg/kg

every 12

hours

Aminoglycosidesirreversibly bind to

specific 30S-subunit proteins

and 16S rRNA.Specifically,

gentamicin bindsto four nucleotides

of the 16S rRNAand one amino

acid in proteinS12.

This interfereswith

decoding nearnucleotide 1400 in

16S rRNA of the30S subunit,

interfering with theformation of an

initiation complex,causing

misreading ofmRNA so that

incorrect aminoacids are insertedinto the

polypeptideleading to

nonfunctional ortoxic peptides and

the breakup ofpolysomes into

nonfunctionalMonosomes.

For treatment ofserious infections

caused bysusceptible

strains of thefollowing

microorganisms:P.

aeruginosa,Proteus

species (indole-positive and

indole-negative), E. coli,

Klebsiella-Enterobactor-

Serratiaspecies,

Citrobacterspecies and

Staphylococcusspecies

(coagulase-positive and

coagulase-negative).

Hypersensitivity toGentamicin or to

otheraminoglycosides.

Because ofototoxicity and

nephrotoxichazards of

extendedadministration,

Gentamicin, likeother

aminoglycosideantibiotics is

generally notindicated in long

term therapy

Serious Side

Effects:

An allergic

reaction:

(shortness of

breath;

closing

of the throat;

hives;

swelling

of the lips,

face, or

tongue; rash;

or fainting);

little or no

urine;

decreased

hearing or

ringing in theears;

dizziness,

clumsiness, or

unsteadiness;

numbness,

skin tingling,

muscle

twitching, or

seizures; or

severe watery

diarrhea andabdominal

cramps.

Less Serious

Side Effects:

increased

thirst; loss of

appetite;

nausea or


7/10

vomiting; a

rash.


8/10

Medication MOA Indication Contraindications: Side effect

ampicillin Inhibit cell wall synthesis

during bacterialmultiplication.

Treatment of

infections cause by

susceptible strains

of the designated

organism.

Patient with

allergic reaction to

penicillin

Patient with

hypersensitivity to

drugs and patient

with viruses

belonging to

herpes group.

Skin rashes,

Nausea,Vomiting,

Diarrhea,

And pain to injectionsite.


9/10

DISCHARGE PLAN:

Clients with Acute Gastroenteritis, watchers are instructed to take the following plan fordischarge:

M- Medications should be taken regularly as prescribed , on exact dosage, time, & frequency,making sure that the purpose of medications is fully disclosed by the health care provider.

E- Exercise should be promoted in a way by stretching hand and feet every morning andexercise burping every after bottle feeding.

T- Treatment after discharge is expected for patients and watcher with Acute Gastroenteritisto fully participate in continuous treatment.

H- Hygiene must be maintained for patients with Acute Gastroenteritis. Promotion ofpersonal hygiene should be encouraged such as, daily bathing and changing of diaperswhen soiled.

O- OPD such as regular follow-up check-ups should be greatly encouraged to clients whetherwith Acute Gastroenteritis as ordered by physician to ensure the continuing management

and treatment.

D- Diet should be promoted, since, during admission, the patient was on NPO. Properselection of milk that are suitable for babies will help enhance immunity.

S- Signs and Symptoms.-Clinical manifestations vary depending on the pathologic organism and the level of GI tract involved. AGEproduces symptoms such as: diarrhea, abdominal discomfort, nausea and vomiting, fever, body malaise

-In children and elderly and debilitated people, AGE produces the same symptoms, but the inability of thepatient to tolerate electrolyte losses leads to a higher mortality.


10/10

Pathophysiology of gastroenteritis

fainal case pres

Documents