amoebiasis case presentation

8/10/2019 amoebiasis case presentation

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AMOEBIASIS

CASE

PRESENTATION(SAN LORENZO RUIZ WOMENS HOSPITA


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Description Result Normal Value

Hemoglobin 115.60 Male:130180 g/L

Hematocrit 0.34 Female:120

160 g/LMale:0.400.54 g/L

RBC Count 3.64 Female:0.380.47

Male:4.66.2 x 10/L

WBC Count 11.4 Female:4.24.4 x 10/L

Male:510 x 10/L

Platelet Adequate 150400 x 10/L

Lab Results:

All of the following tests were conducted on June 28, 2009.

Complete Blood Count:


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Differential Count:

Description Result Normal Value

Neutrophil 0.50 0.55

Lymphocytes 0.48 0.34

Basophils - 0.01

Monocytes - 0.03

Eosinophils 0.02 0.03

Stabs - 0.00

Juvenile - 0.01


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Description ResultColor Yellowish

Consistency Mucoidal

Description Result

RBC 1

3/ hpfWBC 24/ hpf

Fat Globules None found

Bacteria +3

Stool Exam:

Microscopic Exam of Stool:


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Others:

Entamoeba histolytica cyst 0 -2/

hpf

Entamoeba histolytica trophozoites 01/

hpf


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PATHOPHYSIOLOGY


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Anatomy & Physiology:

The Digestive System performs the

mechanical and chemical process of

digestion, absorption of nutrients, andelimination of wastes. It consists of the

mouth, esophagus, stomach,

intestines, and accessory organs.


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A. Oral Structures

include the lips, teeth, gingivae and oral mucosa, tongue, hardpalate, soft palate, pharynx and salivary glands.

B. The esophagusis a muscular tube extending from the pharynx to the stomach.

C. The Stomach

is a muscular pouch situated in the upper abdomen under the liverand diaphragm. The

stomach consists of three anatomic areas: the fundus, body (i.e.,corpus), and antrum (i.e., pylorus)

D. Sphincters

The LES allows food to enter the stomach and prevents refluxinto the esophagus. The pyloric sphincter regulates flow of stomachcontents (chyme) into the duodenum.

E. The small intestine,

a coiled tube, extends from the pyloric sphincter to theileocecal valve at the large intestine. Sections of the small intestineinclude the duodenum, jejunum and ileum


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F. The large intestine

is a shorter, wider tube beginning at the ileocecal valveand ending at the anus. The large intestine consists of three

sections:1. The cecum is a blind pouch that extends from the ileocecalvalve to the vermiform appendix.

2. The colon, which is the main portion of the large intestine,is divided into four anatomic sections: ascending, transverse,

descending and sigmoid.

3. The rectum extends from the sigmoid colon to the anus.

G. The ileocecal valve

prevents the return of feces from the cecum into thesmall intestine and lies at the upper border of the cecum.

H. The appendix,

which collects lymphoid tissues, arises from the cecum.


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I. The GI tract

is composed of four layers.

1. An inner mucosal layer

lubricates and protects the inner surface of thealimentary canal.

2. A submucosal layeris responsible for secreting digestive enzymes.

3. A layer of circular and longitudinal smooth musclefibers are responsible for movement of the GI tract.

(Muscularis)

4. The peritoneum, an outer serosal layer, covers the entire abdomen and is composed of the

parietal and visceral layers.


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CHAPTER 3

Patients Profile


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CASE SCENARIO

C.A., a 9 month old infant weighs 7kg and

was admitted at the isolation ward of San

Lorenzo Ruiz Womens Hospital. His mother is

complaining that C.A. is suffering from consistent

vomiting and diarrhea for three days. He wasgiven an antiemetic drug . After few hours,

diarrhea is still positive and vomiting stopped.

There is no noted allergies and asthma. His skin

goes back slowly and has sunken eyeballs.There is no lymphadenopathy and breath sounds

are clear. Upon reading the patients chart, the

attending nurse learned that the patient is

diagnosed with dehydration secondary to

amoebiasis.


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While taking the vital signs of C.A., the student

nurse interviewed the mother. The mother sayskaya ko siya dinala dito kasi palagi siya

dumudumi at nagsusuka. Napansin ko na

sobrang sakit iyon sa kanya kasi sobrang lakas

ng iyak niya at sumisigaw. Yung dinedede niyaparang ganun din karami ung sinusuka niya.

Tapos ayaw na niya dumede ng gatas kaya

pinapainom ko ng am. Napansin ko din na

parang nagdedehydrate siya kasi lubog yungmga mata niya at namumutla ung balat. Isa pa,

sobra ang iyak niya kapag dumudumi


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The student nurse also learned that their houseis still under construction and the flooring of theirhouse is not cemented. Also, the familyscomfort room is very near the kitchen wherethey prepare their food. The mother stopped

breastfeeding after seven months of C.A.s birth.They are boiling water from the faucet(NAWASA) given to C.A. for his milk for only 3minutes. They are also not boiling the spoonand fork theyre using. The mother says that if

she knows the proper way of proper sanitationand boiling water, she will apply it to avoidanother incident of diarrhea and topromoteC.A.shealth. The nurse recognizes theclients learning needs.


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Demographic Data:

Name: C.A.B. Address: Malabon City

Age: 9 months

Gender: male Race: Filipino

Marital Status: Single

Religious Orientation: Roman Catholic

Date of Admission: June 28, 2009

Attending Physician:


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PHYSICAL ASSESSMENT:

Chief complaint :

The patient was admitted because of

three consecutive days of diarrhea andvomiting occurrence.


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PHYSICAL EXAMINATION:

Skin (-) active skin lesion

Skin goes backslowly

Head-EENTAnicteric sclerae Pinkinsh palpipral

Conjunctiva

(+) sunken eyeballsLymph nodes

(-) lymphadenopathy

Chest/Lungs Clear breath sounds

(-) wheezes

(-) retractive

Abdomen Flat; softAdmitting

Impression AGE w/ some

signs of DHN


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GORDONS FUNCTIONAL

HEALTH PATTERNis also a good method in presenting physicalexaminations data; we sorted out the appropriatefunctional pattern for the patient:

Health Perception and Management Pattern

Upon patients admission, the mother keeps her

baby self medicated and increasing OFI to preventdehydration and eat banana to stop diarrhea.

His mother doesnt know the cause of A.Cs illnessbut she did bring him to the hospital for check up.

Nutritional and Metabolic Pattern After vomiting, the patient doesnt like to drink milk

from bottle but he drinks am.

He doesnt have skin lesions


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Bowel-Elimination Pattern

The mother verbalizedminsanpatak lang yung

dumi niya. Minsan naman sobrang dami. Peromadalas siya dumumi.

The patients bowel frequency is over the normal,the bowels consistency is watery and the color isyellowish.

Activity Exercise Pattern The patient responds to activities that stimulates his

senses like peak-a-boo.

The patients perceived ability is level IV(dependent and does not participate).

Sleep Rest Pattern

According to the mother, patient sleeps 9 hrs atnights

He take naps at morning and afternoon


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PAST HISTORY

NO known past history


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PRESENT HISTORY

Patient has LBM, positive vomitingand watery stool.

Noted some DHN


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ALLERGIES

No noted allergies from the day ofadmission.


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COURSE IN THE WARD


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NURSING

CARE PLAN


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amoebiasis case presentation

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