Question

Jordan is a 9 year old boy who is a direct admission for observation. He has a hx of vomiting and diarrhea for 48hrs.

Subjective Data:

N/V/D x 48hrs

reports haven’t voided today

unable to tolerate oral fluids

Obj Data:

VS: T 37.8 C (100 F) HR 120 RR 24bpm BP 110/60

wt: 34.2 kg

BS hyperactive x 4 quads

lethargic, poor skin turgor

What assessment data is most concerning to the RN? What other assessment data would be useful? Describe the 3 phases of parenteral rehydration associated with moderate dehydration. What are the priority outcomes? What interventions/rationale should the nurse implement? What is the best way to approach Jordan regarding the ordered IVF? What would be good diversional activities for him? When should the discharge teaching begin and what should be included?

Answer 1

#. The assessment data which is most concerning to the RN is the temperature of 100°F which indicates that the dehydration is associated with an infection .

#. The other assessment data that would be useful are lethargic , poor skin turgor , hyperactive bowel sounds which is helping in determining the degree of dehydration .

#. 3 phases of parenteral rehydration associated with moderate dehydration :-

Phase 1: expand ECF volume quickly; isotonic solution given at 20mL/kg given as an IV bolus over 20 minutes, repeat if necessary

Phase 2: replace deficits, meet maintenance water and electrolyte requirements, catch up with ongoing losses

Phase 3: Begin oral fluids slowly and advance as tolerated to full feedings (no BRATT diet)

#. Priority outcomes :-

- To rehydrate the child

- To reduce the temperature

#. Nursing interventions :-

- give oral fluids in frequent small amounts every1 to 2 hours

- provide comfort measures

- oral hygiene, lip skin moisturizer

- during enteral feeding provide additional plain water boluses

- Give medication to control nausea, vomiting diarrhea and fever

- prometazine Phenergan antiemetic

- lorepamide Imodium antidiarrheal

- Antipyuretic -tylenol, ibuprofen

- Monitor patient receiving i v therapy for signs and symptoms of fluid overload to evaluate response to therapy

- monitor vital signs every 2 hours

- monitor pulse rate pressure and quality to evaluate response to therapy

- measure urine output and daily weight every 8 hours

- monitor for bounding pulses difficulty breathing and neck vein distention