NRNP 6541 WK 7 IHUMAN
SAMANTHA GRAVES
I-Human Samantha
Graves Catherine
Miller RN, BSN
October 12, 2021
NRNP 6541C
Primary Care of Adolescents
&
... [Show More] Children
I-Human Samantha Graves
Catherine Miller RN, BSN
October 12, 2021
NRNP 6541C
Primary Care of Adolescents & Children
Patient Information: SG, 18-month-old, African-American, Female
Subjective:
CC (chief complaint): Vomiting and diarrhea
HPI: Samantha is an 18-month-old female who presents today with her mother with complaints
ofvomiting and diarrhea times 2 days. Sister recently had similar symptoms. Her mother reports
that Samantha has vomited 4-5 times daily for the past two days and had 3-4 episodes of liquid
diarrhea daily for the past two days. Vomit is liquid with some partially digested food. Diarrhea
is liquid. Denies coffee-ground emesis or blood in stool or vomit. No fever, cough, decreased
activity. The mother does report concerns over decreased appetite. Had been taking Pedialyte
and tolerating small amounts of Pedialyte and milk. Physical exam without signs of dehydration,
abdominal pain, or rebound tenderness.
Current meds: None
Allergies: NKDA
Pertinent PMHx: Samantha is in general good health. No pertinent past medical history noted.
She is up to date on immunizations and has regular check-ups. She has met all developmental
milestones for her age and is at the 75th percentile for height and weight.
Immunizations:
Birth: Hep B
2 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B
4 months: DTaP, IPV, HIB, PCV13, Rotavirus,
6 months: DTaP, IPV, HIB, PCV13, Rotavirus, Hep B, Influenza 1st dose
7 months: Influenza 2nd dose
12 months: MMR, Varicella, Hep A 1st dose
15 months: DTaP, HIB, PCV13, due today
Social hex: Lives in an apartment with her parents and 4-year-old sister. Her mother is a
teacherand her father is an engineer.
Fam Hex:
1. Mother, 32-years-old, healthy
2. Father, 36-years-old, healthy
History Questions Asked:
1. How can I help her today?
2. When did her nausea and/or vomiting start?
3. What are the events surrounding the start of her nausea and/or vomiting?
4. Does anything make her nausea and/or vomiting better or worse?
5. Does she have any pain or other symptoms associated with her nausea and/or
vomiting?
6. How severe is her nausea and/or vomiting?
7. Has she vomited so forcefully that the vomit went to the other side of the room?
8. Do you have any pain in your abdomen?
9. Does she have diarrhea?
10. Does she have bloody stools?
11. Does she have black tar-like or foul smelling stools?
12. When did her diarrhea start?
13. Do her symptoms persist if she stops eating?
14. Does she have any pain or other symptoms associated with her diarrhea?
15. Does her diarrhea keep her from sleeping?
16. Has she had diarrhea like this before?
17. Has there been any change in her diarrhea over time?
18. Does anyone in her family have diarrhea?
19. What treatments has she had for her diarrhea?
20. What does her vomit look like?
21. Is anyone in her family also suffering with nausea and/or vomiting?
22. What treatments has she had for her nausea and/or vomiting?
23. Does she have any allergies?
24. Is she taking any prescription medications?
25. Is she taking any over-the-counter or herbal medications?
26. Can she swallow pills?
27. Are her immunizations up to date?
28. Any diet changes since her last appointment?
29. How much water/fluids does she drink in a day?
30. What childhood illnesses has she had?
31. Was she a colicky baby?
32. Has she ever been hospitalized?
33. Has she ingested anything caustic?
34. Has she been having fevers?
35. How is her overall health?
36. Has she lost weight?
37. Do milk or dairy products worsen her symptoms?
38. Do her symptoms occur after eating rye, wheat, or barley?
39. Has she had nausea and/or vomiting like this before?
40. How quickly does her nausea and/or vomiting come on?
41. Does she have any pain in her abdomen?
42. Does she have any abdominal bloating?
43. Does she pull her knees up to her chest when crying or in pain?
44. Does she have any pain in her rectum?
45. Has there been any change in her nausea and/or vomiting over time?
46. Does her nausea and/or vomiting come and go?
47. How often is she nauseas or vomiting?
48. Does her diarrhea come and go?
49. How frequently does she have diarrhea like this?
50. Is there any patter to her diarrhea?
51. How quickly does her diarrhea come on?
52. How severe is her diarrhea?
53. Does she have medical insurance?
54. Is she belching?
55. How many bowel movements does she have in a day?
56. Has she passed gas?
ROS:
GENERAL: Alert, active.
HEENT: No runny nose, eye or ear discharge. No conjunctivitis.
SKIN: No rashes, bruising or petechiae.
CARDIOVASCULAR: No history of murmurs, gallops or rubs. RESPIRATORY:
Denies any SOB, cough, wheezing or difficulty breathing. GASTROINTESTINAL: Nausea,
vomiting and diarrhea x 2 days. Decreased appetite.
GENITOURINARY: Urinates normally. No history of UTI’s. 6-7 wet diapers a day.
NEUROLOGICAL: No history of seizures or headaches.
MUSCULOSKELETAL: No recent trauma, weakness, or limping.
LYMPHATICS: Denies any lymph node enlargement.
HEMATOLOGIC: Denies anemia, unexplained bruising or bleeding.
PSYCHIATRIC: Denies any abnormal mental health issues, happy child per mother.
ENDOCRINOLOGIC: Denies excessive sweating, thirst, or urination. Denies heat or
cold intolerance.
ALLERGIES: Denies frequent or re-occurring infections or hives. Up to date on
immunizations.
Physical exam:
Vital signs: P 102 and regular, T 98.6,
Orally; RR 19 non-labored, 94% on room air; Wt.: 26 lbs.; Hit: 2’8”; BMI: 17.9
General: Well-developed 18-month-old female, interactive.
HEENT: PERRLA, normal conjunctivae OU. Normocephalic.
Chest/Lungs: Clear to auscultation in all lung fields.
Cardiovascular: Regular rate and rhythm. No murmur, rub, or gallops noted.
Abdomen: Abdomen is flat and symmetric, no scars or deformities. BS hyperactive X4
quadrants, non-tender, soft, no rebound tenderness or guarding noted.
Musculoskeletal: Well developed, no abnormal findings.
Neurological: Awake and alert. Normal balance/gait. Moves extremities well.
Skin: Well hydrated, normal turgor and color. No bruises noted.
Diagnostic Results:
Stool culture - this patient's test results were negative.
Stool examination for ova and parasites - this patient's test results were negative.
Assessment/Plan:
Primary Diagnosis and ICD-10 code: (Also include any procedural codes).
Viral Gastroenteritis; A09
Viral gastroenteritis is an infection of the gastrointestinal tract by a virus. Viruses account for
approximately 70% - 87% of episodes of acute gastroenteritis in children, with rotavirus being
the most common identifiable cause. Gastroenteritis is common is children under the age of 5
and is easily transmitted from person to person. Patients present with non-bloody diarrhea that
may contain mucous and vomiting. They may also show signs of dehydration, decreased weight,
low grade fever and abdominal pain (La Saux, 2018).
Differential Diagnoses:
1. Bacterial Gastroenteritis - Often clinically indistinguishable from viral gastroenteritis
however bacterial etiology may include fever >102.2°F, bloody diarrhea, significant abdominal
tenderness, and toxicity (CDC, 2019).
2. Parasitic Gastroenteritis – Parasitic gastroenteritis is uncommon however likely parasites
such as Giardia intestinalis, Entamoeba histolytica, and Di entamoeba can cause gastroenteritis.
Parasitic gastroenteritis is more likely the cause if diarrhea lasts >14 days and the child has been
to an endemic area (Shane, et al., 2017).
3. Intussusception – This is a common cause of intestinal obstruction that occurs when a
portion of the bowels prolapse/fold over onto themselves. Most commonly occurs in infants
between the ages of 3 and 12 months and presents with colicky abdominal pain, flexing of the
legs vomiting, and passage of "currant-jelly" stool/bloody stool (Sutcliffe, 2020).
Intussusception can be a medical emergency because if not corrected early part of the bowel may
begin to necrose.
4. Dehydration - dehydration occurs when there is a total body water deficit. Children are more
susceptible to dehydration with the most common cause of dehydration being gastroenteritis,
which can lead to severe volume depletion (Freedman, et al., 2015).
5. Appendicitis - obstruction of the lumen of the appendix is the main cause of acute
appendicitis. It typically occurs in adolescence or early adulthood and presents with RLQ pain,
anorexia, diminished bowel sounds, fever, nausea, tachycardia, and a positive roving, psoas, and
obturator signs (Jones, Lopez, & Depen, 2021).
Additional laboratory and diagnostic tests: None necessary at this time.
Consults: None necessary at this time.
Pharmacological - Ondansetron - children 8-15 kg: 2 mg orally as a single dose. It should only
be considered when vomiting interferes with oral rehydration therapy.
Nonpharmacological – The cornerstone of management is the use of oral rehydration therapy
(ORT) with appropriate oral rehydration solutions. For patient with mild dehydration ORT
should be 50ml/kg over 4 hours. Age-appropriate diet along with ORT. Give extra fluids in
frequent, small sips, especially if the child is vomiting. Give popsicles, ice chips, and cereal
mixed with milk for added water or fluid.
Health Promotion: This patient’s immunizations are up to date. Advise mother on the
importance of getting the current seasons flu vaccination. Immunization of infants as early as 6
weeks of age and completion of the schedule by 8 months ago with rotavirus vaccine is
recommended. Talk to the mother about appropriate child safety restraint seating for Samantha.
Also discuss water/pool safety, falls and supervision.
Patient education: Her symptoms are likely due to viral gastroenteritis and will resolve with
supportive care within a few days. The mother is concerned about the decreased appetite.
Reassure her that this is normal, and her appetite will return once the virus resolves. Caregivers
should be instructed to take her to return to the clinic if her symptoms do not resolve or become
worse in 1 week. They should take her to the ED or urgent care if she is crying without
producing tears, fever greater than 102, passing blood in her stool or vomiting blood (or coffee
ground appearing emesis), decrease in wet diapers in a 24-hour period. Good hygiene is very
important to prevent the spread of the virus among household members. This includes frequent
handwashing with soap, careful diaper disposal, and proper preparation and storage of food.
Disposition/follow-up instructions:
Patient’s disposition is good. With proper treatment, the prognosis is excellent. Viral
gastroenteritis is self-limited and typically resolves in 3 to 7 days. They should return to the
clinic if her symptoms do not improve with supportive care. If the patient’s vomiting interferes
with oral rehydration therapy, they may need to call the clinic for a prescription for ondansetron.
References
Centers for Disease Control and Prevention. (2019, January 29). Controlling the Spread of
Infections in Evacuation Centers. Retrieved from
Freedman, S., Vanderveer, B., & Milne, A., et al; (2015). Pediatric Emergency Research Canada
Gastroenteritis Study Group. Diagnosing clinically significant dehydration in children with
acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatric. 166:908-916.
Jones MW, Lopez RA, Depen JG. (2021, February 8). Appendicitis. Stat Pearls [Internet].
Treasure Island (FL): Stat Pearls Publishing; Retrieved
Le Saux, N. (2018, October). Recommendations for the use of rotavirus vaccines in infants,
Pediatrics & Child Health, Volume 22, Issue 5, Pages 290–294, [Show Less]