Question

Prebrief

Name: Jerwanda Dryfus        DOB: 03/12/20YY 5 mo old Female         Wt: 17.8 lbs

MRN: 664281                         Code Status: Full Code                                   Allergies:   PCN

SBAR

Situation: 5 month old female admitted to pediatric medical unit from the emergency department with gastroenteritis and dehydration.   Her parents brought her to the ED last night due to persistent vomiting, diarrhea, and lethargy.

Background: She as a three day history of vomiting and diarrhea. The parents have been in daily contact with their provider’s office. They were trying to prevent admission by pushing oral fluids and antipyretics as prescribed. She has been unable to keep anything down for the last 12 hours and has had no wet diapers for the last 8 hours. Her diet is normally Enfamil and rice cereal. Parents have been giving her Pedialyte since the symptoms started.

The parents are exhausted and very worried.   One of them might have to go into work today.

Past medical hx: Premature delivery at 35 weeks gestation. Immunizations are up to date, no day care except nursery at church.

Assessment: Growth/Development appropriate for chronological age. Head Circumference is 37 cm.

She is lethargic with dark circles around her eyes. She has pale and dry mucous membranes, no tears present when crying. Hyperactive bowel sounds, abdomen round and non-distended. Fontanel is flat.

Vital Signs from ED on admission: HR 140, R 36, B/P 80/46, Temp 101.4 F temporal SaO2 92% RA.

Vital Signs (10 minutes prior to their arrival on this unit): HR 130, RR 36, T 99.2F, Sa02 98% on RA.

She has an IV in the right antecubital space with NS infusing at 40 mL/hour

Pertinent labs ordered: CBC, BMP. Stool to be sent for rota virus, culture and sensitivity, ova and parasites, and a urinalysis

Recommendation/request: She had acetaminophen 120 mg rectal suppository in the triage area 4 hours ago.

Labs have been sent but we are still waiting on a urine and stool sample. A U-Bag was placed to catch a urine specimen. She has 3 small watery greenish stools in ED but we didn’t get a sample sent.

A fluid bolus of 10 ml/kg was given in ED of 150 ml of NS. She might need a second bolus if she does not void in the next hour. Notify the provider for orders if she does not void. She has an order to change her IV fluids to D5 0.25% NS with 10 mEq KCl at 30 mL/hr after she voids.

Provider's Orders

Admit to medical floor, Dx gastroenteritis, dehydration

Contact Isolation

IV 0.9% Sodium Chloride at 40 ml/hr

Repeat bolus of NS 20 mg/kg if she has not voided at next VS check.

NPO

Meds:

D5 0.25% NS with 10m Eq KCl at 30 ml/hour after the patient voids

Phenergan 4.25 mg slow IVP q 6-8 hour PRN Nausea/vomiting

Tylenol 15mg/kg/dose PO/PR PRN for fever > 101.5 every 4 hours

Laboratory Report

Name: Jerwanda Dryfus        DOB: 03/12/20YY 5 mo old Female         Wt: 17.8 lbs

MRN: 664281                         Code Status: Full Code                                   Allergies:   PCN

Draw Time: Today        Result Time: Today

Complete Blood Count

test	value	normal range
RBC	4.0	2.7-4.5 million/mm3
WBC	14	4.5-17 thousand/mm3
Hgb	14	9.5-14.1 g/dL
Hct	38	29-41%
Platelets	257	150-450 thousand/mL

BMP

test	value	normal range
Na	132	135-145 mEq/dL
K	3.4	3.7-5.6 mEq/L
CL	104	95-105 mEq/dL

Glu		65-99 mg/dL
BUN	42	8-28 mg/dL
Cr	1.4	0.12-1.06 mg/dL
CO2	28	18-27 mmol/L

Stool Culture: Pending

Urinalysis: Pending

1. What are the key assessments to make? Why?

2. What signs and symptoms will require interventions for this patient? (What are you watching for?

3. What are at least two interventions you expect to make and how will you adjust them for the developmental age of the child?

4. List 2 medications you might expect to give and common side effects you would be watching for.

5. Consider what education may be needed for family and patient and how you would provide it.

Answer 1

1.Key assessment to make for the 5 month old female with diarrhea and vomiting are the level of consciousness,vital signs, signs of dehydration, abdominal examination,fontanelle and mucous membranes,skin turgor,urine volume,capillary refill time ,activity along with blood sugar level, serum electrolytes and blood urea nitrogen , her feeding formula preparation and providing method.These key assessments will provide the details to provide emergency treatment,formulate a diagnosis and plan interventions.Also signs of ingestion to be noted because green stools may be present due to indigestion.There are multiple signs of dehydration present, the possibility of severe dehydration should be considered and treated appropriately.

2.Lack of urine, tears, and diarrhea,vomiting has depleted her body's fluids for which intravenous fluids should be administered.As she is dehydrated evidenced by dry mucous membranes ,etc after giving IV fluids she may be able to pass urine .She is lethargic because of dehydration and dark circle around eyes denote sleep deprivation.She is febrile because this diarrhea may be due to any infection or because of the feeding .Mother as she is working and busy , may be didnot prepare the feeds in a clean way or not provided the infant with a fresh formula.

3.Educate the mother about the benefits of breast feeding and encourage her to breast feed the baby.Breast milk is the only unique complete food for an infant which can be easily digested.

Spend time with the child which is essential for good sleep and good nutrition of the infant.

If giving formula feeding mother should wash her hands ,sterilize the feeding bottles and prepare a fresh feed to provide the child.

4.Antibiotics are not recommended for an infant but as she is febrile antibiotics may be provided along with low osmolality ORS .Anti diarrheal medications are strictly prohibited.

5.Mother should be made to breast feed the baby , advice parents to follow cleanliness and sanitation inside and outside home.