1

GRAND ROUND PRESENTATION

NUR 4355
Isabel Barradas 01/16/2014
I.D: 18 months old Hispanic male
Chief Complains: Diarrhea, vomiting and abdominal pain
Admitting Diagnoses: Dehydration/Gastroenteritis
1.-Deficient fluid volume R/t: excessive GI fluid loss (vomiting, diarrhea) and poor
oral intake. AEB: moderate dehydration, decreased skin turgor, dry skin and mucous
membranes, weakness, decreased urinary output, decreased pulse volume, increased
pulse rate.
2. - Imbalanced nutrition: less than body requirements R/t: Inability to ingest and
digest foods. AEB: NPO status, nausea, vomiting, diarrhea, anorexia, abdominal
cramps.
3. - Risk for Impaired skin integrity.
Birth history: Cesarean section delivery after failing induction procedure at 40 weeks.
APGAR score 9 at 1 and 5 minutes
Past medical/surgical history (contributory):
One episode of common cold in the past year
Review of systems and physical assessment
Moderate dehydration evidenced by dry mucosae membranes, restless, irritability, sunken
eyes, skin pinch goes back slowly, thirsty and drinks eagerly, decreased level of activity.
Abdominal cramps, hyperactive bowel sounds in the four quadrants.
Vital signs

Respiratory rate: 28 per min

Apical heart rate: 128 per min
Radial and femoral pulses: +3
Blood pressure: 95/58
Rectal temperature: 100.06 F
Nutritional status, growth and development:
Combined breast and formula (Enfamil) feedings until 6mos then formula only until 1
year of age.
Current dietary intake consists of a balanced full diet.
Clinical examination shows evidence of adequate nutrition
Weight 27 lbs (50th percentile)
Height 32 inches (50th percentile)
Held head at 3m, sat at 5m, crawled at 8m, walk without assistance at 12 m.
Plan of care:
GOAL: Child will exhibit signs of rehydration and will maintain hydrated, begin to tolerate Oral
fluids within 24hs.
INTERVENTIONS AND RATIONALES:
1. Calculate total volume deficit:
Mild dehydration (<5%):
50 mL/kg + 10 mL/kg additional volume for each diarrhea stool
Moderate dehydration (5-10%):
100 mL/kg + 10 mL/kg additional volume for each diarrhea stool

2. Monitor intake and output, document each voiding/vomiting. Will

determine if output exceeds input. Long periods of time without urine output
can be an early indicator of poor renal function. A child should produce 1 mL
of urine/kg/hr.
3. Compare admission weight to preadmission weight and assess weight

daily. The degree of dehydration can be determined by the percentage of

weight loss. Daily weights aid in determining progress toward rehydration.
4. Assess level of consciousness, skin turgor, mucous membranes, skin color

and temperature, capillary refill, eyes every 4 hours. Will determine

degree of hydration and adequacy of interventions.
5. Oral Rehydration Therapy: Less invasive than IV fluids. Provides for

replacement of essential fluids and electrolytes as tolerated. First hour

Therapy: Instruct the patient or caregiver to administer 5 ml (for a total of
150cc) of Oral Rehydration Solution (ORS) every 2 minutes. Provide
caregiver with Oral Rehydration Therapy (ORT) Teaching. Once oral volume
taken, rest patient for 15 minutes. Second hour: Increase the ORS amount to
6-10 ml of ORS every 2 minutes determined by the patient's tolerance. Parents
should be instructed to continue providing maintenance ORS fluids at home as
needed. Children should be encouraged to return to a regular diet as rapidly as
possible.
6. Use of IV replacement is based on: the degree of dehydration, ongoing
losses, insensible water losses and electrolyte results.

DISCHARGE PLANNING
1. Parents should be instructed to look for the various signs of dehydration
such as change in mental status, decreased urine output, sunken eyes,
absence of tears, dry mucous membranes, and slow return of abdominal
skin pinch.
2. Parents should seek medical attention if dehydration returns, oral intake
is inadequate, or if their child develops worsening abdominal pain, fever
>101F, or prolonged diarrhea lasting longer than 14 days.
3. Reassurance of good prognosis to the parents
4. Prevention of transmission: School/day care exclusion until symptoms
resolve. Teach about enteric precautions and effective Hand washing.
5. Fluid intake encouragement to prevent dehydration. Avoid fluids high in
sodium and encourage reintroducing normal diet of easily digested foods
as child tolerates.
6. The US Advisory Committee on Immunization Practices recommends
routine vaccination of US infants with rotavirus vaccine to protect
against rotavirus gastroenteritis.
EXPECTED OUTCOME: The child has normal fluid and electrolyte balance as indicated
by laboratory evaluation and physical examination: adequate hydration and increased
level of activity.

Children with acute gastroenteritis rarely require intravenous access. In those presenting
with circulatory collapse due to severe dehydration or sepsis, intravenous access should be
obtained and followed by an immediate 20 mL/kg bolus of normal saline.
Inpatient admission should be considered for all children with acute gastroenteritis in the
following situations:
1.

Signs of severe dehydration are present.

2.

Caregivers are unable to manage oral rehydration or provide

adequate care at home.

3.

Substantial difficulties exist in administering ORS, such as

intractable vomiting or

4.

inadequate ORS intake.

Failure of treatment occurs, such as worsening diarrhea or

dehydration, despite adequate ORS intake.

Factors are present necessitating closer observation, such as young age, decreased mental
status, or uncertainty of diagnosis.
Children with mild-moderate dehydration, age < 6 months, or high frequency of
stools/vomits should be monitored in the emergency department for a minimum of 4-6 hours
before discharge.
Oral rehydration solution (ORS). The American Academy of Pediatrics, the European
Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and the World Health
Organization (WHO) all recommend oral rehydration solution (ORS) as the treatment of choice
for children with mild to moderate gastroenteritis, including those in industrialized countries and
in developing nations, based on the results of dozens of randomized, controlled trials and several
large meta-analyses.

References
Centers for Disease Control and Prevention (CDC) (2009). Clinical growth charts. Retrieved
from http://www.cdc.gov/growthcharts/clinical_charts.htm
Cortese, M.M., Para, U.D.(2009) Prevention of rotavirus gastroenteritis among infants and
children: recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR Recomm Rep. 58:1-25.
Fonseca, B.K., Holdgate, A., Craig, J.C. (2004) Enteral vs intravenous rehydration therapy for
children with gastroenteritis: a meta-analysis of randomized controlled trials. Arch
Pediatr Adolesc Med. 158(5):483-90.
Hockenberry, W. (2011). Wong's Nursing care of infants and children. (9th ed.). St. Louis: Mosby.
Linhares, A.C., Velazquez, F.R., Perez-Schael, I., et al. (2008). Efficacy and safety of an oral
live attenuated human rotavirus vaccine against rotavirus gastroenteritis during the first 2
years of life in Latin American infants: a randomised, double-blind, placebo-controlled
phase III study. Lancet. 371(9619):1181-9.
Luxner, K.L.(2005). Delmars pediatric nursing care plans.(3rd. ed.). Clifton Park. N.Y.
Thompson Delmar Learning
Steiner, M.J., DeWalt,D.A., Byerley, J.S.(2004). Is this child dehydrated?. JAMA. 291(22):274654.