The purpose of this paper is to define Gastroenteritis and its involvement in the health and wellness of patient Baby K. Baby K is 14 months of age and presents with vomiting, diarrhea, and severe abdominal pain. On assessment it is noted that the patient ingested improperly stored milk custard. Staphylococcus aureus is suspected.
Gastroenteritis effects both the gastric mucosa of the stomach and the intestines in the inflammatory process causing each to appear red, inflamed, and edematous (Hubert & VanMeter, 2018). Anorexia, nausea, vomiting, and diarrhea are present with Gastroenteritis and vary in severity. Anorexia, or loss of appetite, often precedes nausea which is stimulated by inflammation or irritation of the digestive tract. The sensation of nausea often is paired with increase sweating and salivation. It is said that the increase in salivation helps lubricate the esophagus before vomiting occurs. Vomiting, or emesis, is the forceful expulsion of stomach and sometimes intestinal contents to include stomach acids and ingested materials. Diarrhea is an excessive number of frequent stools that are usually thin consistency. The loss of fluids in the stool can contribute to dehydration, electrolyte imbalances, acidosis, and malnutrition. Diarrhea is typically associated with nausea and vomiting with inflammation and irritation is present in the digestive tract (Hubert & VanMeter, 2018).
Multiple causative agents exist for acute onset of Gastroenteritis, but most causes are of infectious etiology. A foodborne infection typically manifests as a combination of nausea, vomiting, diarrhea, and abdominal discomfort. If a foodborne illness is suspected, identifying the particular food exposure and timing of symptoms can be informative in determining the pathogen. Foodborne pathogens such as Staphylococcus aureus cause illness within hours of ingestion whereas other pathogens may take up to seven days to show symptoms (LaRocque & Harris, 2019).
Patient Baby K presents with vomiting, diarrhea, and severe abdominal pain. It is believed that the patient ingested poorly kept custard. The suspicion of Staphylococcus aureus is plausible because foods not cooked after handling such as custards, pastries, and sandwiches are highly susceptible to be contaminated with Staph (CDC, 2020). As mentioned, the incubation period is 2-4 hours on average and manifests as sudden severe nausea, vomiting, abdominal cramps, and diarrhea (Hubert & VanMeter, 2018). Knowing that baby K ingested custard and the time in which the food was ingested will help solidify Staphylococcus aureus as a causative agent.
The APRN working in pediatrics will often come in contact with patients experiencing gastrointestinal upset such as with Gastroenteritis like baby K due to the increase risk of hypovolemia (dehydration) in infants and children. This increased risk is due to the higher prevalence of Gastroenteritis in children versus adults, the infant’s higher volume of insensible losses, and the infant’s inability to communicate their need for increased fluids (Somers, 2020). Severe nausea, vomiting, and diarrhea need to be corrected quickly to avoid severe dehydration and other clinical complications associated with extreme fluid loss. Signs of dehydration in an infant can be measured as mild, moderate, or severe and will need to be determined as part of the initial assessment plan. Signs of dehydration that will need to be assessed for severity will include pulse, systolic blood pressure, rate of respirations, buccal mucosa, anterior fontanelle (if age appropriate), eyes, skin turgor and temperature, urine output, and systemic signs such as activity level, increased thirst, and tear production (Somers, 2020).
Assessment of volume depletion aids in determining the appropriate route to rehydrate and replenish volume. Laboratory testing will include serum sodium, serum potassium, serum bicarbonate, and urine concentration levels. Hypernatremia levels may be present due to insensible water losses causing greater loss of fluids than sodium often found in infants; however, diarrhea cause by gastroenteritis may lead to isonatremia as fluid and sodium are normally lost equally. Infants with gastroenteritis will commonly experience hypokalemia due to the loss of potassium in the diarrheal stool as well as a low serum bicarbonate concentration for the same reason. A higher urine concentration is present in hypovolemic patients due to most fluid loss taking place through the gastrointestinal tract (Somers, 2020).
Whether the rehydration takes place as oral rehydration therapy (ORT) or via intravenous (IV) therapy (depending on severity), the electrolytes will need to be replaced. More severe cases will require 2-step IV therapy for fluid replenishment. The first step is to increase volume alone through the use of isotonic solution or 0.9% normal saline. This therapy is more rapid to increase volume. It is recommended that isotonic solution is used for fluid replacement in infants and children with hypovolemia due to Gastroenteritis that have normal sodium levels. The second step of rehydration will be to focus on volume and on electrolytes and may be done via IV or ORT. Hypertonic solutions will be more appropriate for patients with lower serum levels and should be given at a slower rate as to avoid rebound effects. If ORT is being used, fluids such as Pedialyte are recommended for use until the patient can return to normal volume and electrolyte status (Somers, 2020).
Hepatitis B and Cirrhosis
Hepatitis is the inflammation of the liver which can be idiopathic such as with a fatty liver, local infection due to viral hepatitis, an infection at various locations within the body, or can be caused by chemicals or drug toxicity. The effects of hepatitis on the body varies, and can result in mild or severe inflammation and necrosis. Mild inflammation impairs hepatocyte function and severe inflammation may lead to obstruction of blood and bile flow in the liver, causing an impairment of liver cell function (Hubert and VanMeter, 2018). The case study that will be discussed is J.B., a 35 year old with chronic hepatitis B for nine years, with an unknown origin of acute infection.
There are several types of hepatitis, including Hepatitis A, B, C, D, and E. Hepatitis can also be caused by chemical exposure at the workplace, such as carbon tetrachloride, toluence, or ethanol or from drug toxicity, including large amounts of acetaminophen, halothane, phenothiazines, and tetracycline. Exposure to these chemicals and drugs can cause inflammation and necrosis of the liver (Hubert and VanMeter, 2018). The purpose of this case study is to discuss the pathophysiology, signs and symptoms, and treatment recommendations for hepatitis B.
Pathophysiology of acute hepatitis B infection
Hepatitis B is a double-stranded DNA virus, and the whole virion is referred to as Sane particle, consisting of two core antigens, HBcAg and HBeAG, and one surface antigen, HBsAg. The antigens cause a stimulation of the antibody production in the body which is useful for diagnosing and managing the virus. The incubation period of hepatitis B is about two months, but individuals can be asymptomatic and still remain contagious, which is referred to as a carrier state. There is a lag time of development of symptoms or serum markers which prevents detection of the virus, but it can still be transmitted to others. Hepatitis can be transferred by contact with infected blood such as during a blood transfusion, body secretions, and intravenous drug use, sexual contact, and hemodialysis, passage to the fetus during pregnancy, tattooing, and body piercing. Health care providers are at an increased risk of contracting hepatitis B from treating infected patients (Hubert and VanMeter, 2018).
At the time of exposure, there are no recommendations for treatment for the virus. Individuals are treated for their symptoms, but usually medications are not initiated for the infection. There is no cure for hepatitis B, but there are treatment options for the symptoms to assist with protecting the liver. Individuals are encouraged to refrain from alcohol and tobacco and certain hepatotoxic medications, and to see their health care provider regularly or liver specialist. Medications that are used to treat hepatitis B are immune modulators to boost the immune system and antivirals to stop the replication of the virus in order to reduce inflammation and damage to the liver (Hepatitis B Foundation, 2020). Treatment with medications is not generally implemented until there are signs of acute liver disease. Regular monitoring and evaluation of the individual is pertinent in the form of physical exams, blood tests, and imaging studies to manage the virus.
Signs of the preicteric and icteric stages of acute hepatitis B infection
During the preicteric or prodromal stage, the liver becomes inflamed, liver enzymes become elevated, and the individual may report right upper quadrant abdominal pain. The stage is characterized by a gradual onset of anorexia, malaise, and fatigue. During the icteric stage, the individual may experience liver tenderness and jaundice, dark-colored urine and lighter-colored stools, nausea and vomiting, and pruritus (Samji, 2017).
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