Acute Gastro Entritis

Section P– Group 1 E.C.S. – Pediatric Ward

RLE (Period covered: July 27-Aug. 1,2009)

Mr. Ralph P. Pilapil, R.N. Clinical Instructor

A. Nursing History

Identifying Data

Name of Patient Sex Age Civil Status Nationality Religion Address Occupation Date Admitted Time Informant Age Physician Room : : : : : : : : : : : : : : Patient X Male 16 years old Single Filipino R.C. Sta. Cruz, Guizo Mandaue City Student July 27, 2009 8:10 p.m. Mother 30 years old Dr. Pitogo Pediatric Ward

Admission Data

Source of Information Mode of Admission : Mother : Ambulatory

Vital Signs on Admission Temperature: 36.6°C Heart Rate : 60 bpm Respiratory Rate : 18 cpm Blood Pressure : 120/70 mm Hg Weight : 56 kg Height : 5’ 4” Chief of Complaints: LBM, pain and vomiting

History of Present Illness

Two days PTA, The patient defecated watery stools more than 5 times with nausea and vomiting. The following day, Monday, client still defecated watery stool in succession and was partially relieved after taking Diatabs. After several hours LBM reoccur with occasional vomiting. Thus, patient’s mother saught medical advise resulting to his admission.

Past Medical History

The client experienced severe diarrhea last January 2004 and was hospitalized.

Injuries:

• No previous injuries

Operation:

• No minor and major operation were performed

Family Medical History:

Negative in: Heart Disease Diabetes Mellitus Hypertension Cancer Congenital Anomalies Obesity Arthritis Seizure Tuberculosis

Physical Assessment

1. EENT

  Eye functioned well and responsive to light accommodation 4mm) tonsils are pink and in normal size (3-

2.

Central Nervous System

    able to speak the words clearly (responsive) irritability noted negative presence of seizure or tremors weak hand grasping and movement

3.

Cardio Vascular System

   weak capillary refill blood pressure of 100/60 regular heart rhythm

4.

Respiratory System

  symmetric chest expansion clear...