© 2016 Keith Rischer/www.KeithRN.com
Pediatric Gastroenteritis
UNFOLDING Reasoning
Harper Anderson, 5 months old
Primary
... [Show More] Concept
Infection
Interrelated Concepts (In order of emphasis)
1. Inflammation
2. Perfusion
3. Fluid and Electrolyte Balance
4. Acid-Base Balance
5. Thermoregulation
6. Clinical Judgment
7. Communication
8. Collaboration© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Pediatric Gastroenteritis
History of Present Problem:
Harper Anderson is a 5-month-old female who was brought into the physician’s office for diarrhea and vomiting over the
past two days. She had two loose large loose stools the first day and now her mother reports that she has been less active,
is not interested in playing, and has been more sleepy today. She is unable to keep any feedings down today. She has had
four loose, watery stools and emesis x3 this morning. She has not had a wet diaper since yesterday evening. She is 25
inches (63.5 cm) in length and weighs 14 pounds, 2 ounces (6.4 kg). She weighed 15 pounds, 2 ounces (6.86 kg) at her
last office visit two weeks ago. Harper is a direct admit to the pediatric unit where you are the nurse responsible for her
care.
Personal/Social History:
Harper’s mother Nicole is 21 years old. She is a single mother and this is her first child. Nicole is not currently working
and lives with her parents. Though she has strong social support from her parents, she feels consistently overwhelmed as a
new mother.
Past Medical History (PMH):
Healthy full-term infant that weighed 6 pounds 10 ounces (3.0 kg) at birth.
No current health problems. Mom is no longer breast feeding and Harper is on formula.
Mother had no complications with pregnancy.
Has not had any immunizations from birth, including rotavirus
RELEVANT Data from Present Problem: Clinical Significance:
RELEVANT Data from Social History: Clinical Significance:
Patient Care Begins:
Current VS: Pain Assessment – FLACC Behavioral Pain Scale
T: 102.2 F/39.0 C (axillary) Face: 1
P: 158 Legs: 0
R: 38 Activity: 1
BP: 62/42 Cry: 1
O2 sat: 95% RA Consolability: 2/Total score: 5/10© 2016 Keith Rischer/www.KeithRN.com
FLACC Behavioral Pain Scale
What VS data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
What assessment data are RELEVANT that must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
0 1 2
Face Relaxed or smile Occasional grimace, frown,
withdrawn
Frequent frown, clenched jaw, quivering chin
Legs Relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly,
moves easily
Squirming, tense Arched, rigid, or jerking
Cry No cry (awake or
asleep)
Moans, whimpers. Occasional
complaints
Crying, sobs, screams, frequent complaints
Consolability Content or
relaxed
Easy to console, distractible Difficult to console or comfort
Each of the five categories is scored from 0-2, resulting in a total of 0-10
Current Assessment:
GENERAL
APPEARANCE:
Irritable when awake, alternates with lethargy once quiet, when awake and crying,
tears are not present
RESP: Breath sounds clear with equal aeration bilaterally, non-labored
CARDIAC: Skin is pale, cool to touch, cap refill 3–4 seconds in both hands, brachial pulses
palpable bilaterally
NEURO: Lethargic, does not maintain eye contact with mom or caregiver
GI: Abdomen soft with hyperactive BS x4 quadrants, no apparent tenderness to
palpation
GU: 5 mL dark amber, cloudy urine noted in urine collection bag-sent to lab
SKIN: Anterior fontanel depressed, eyes slightly sunken, lips and tongue are dry with no
shiny saliva present, when skin over abd. is pinched, remains tented for 2–3 seconds© 2016 Keith Rischer/www.KeithRN.com
Dehydration Assessment Scale for Pediatrics
Circle all assessment findings RELEVANT to Harper. What degree of dehydration is present?
Assessment Data: Minimal Dehydration: Mild to Mod. Dehydration Severe Dehydration
Mental status Alert Restless, irritable Lethargic, unconscious
Thirst Drinks normally Drinks eagerly Drinks poorly
Heart rate Normal Normal to increased Tachycardia
Quality of pulses Normal Normal to decreased Weak or non-palpable
Breathing Normal Normal or fast Deep
Eyes Normal Slightly sunken Deeply sunken
Tears Present Decreased Absent
Mouth and tongue Moist Dry Parched
Skin fold Instant recoil Recoil < 2 seconds Recoil >2 seconds
Capillary refill Normal Prolonged Prolonged or minimal
Extremities Warm Cool Cold, mottled, cyanotic
Urine output Normal Decreased Minimal
Lab/Diagnostic Results: (Note: Lab norms are for a 5-month infant)
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
Basic Metabolic Panel (BMP) Current High/Low/WNL? Previous:
Sodium (133–150 mEq/L) 151 138
Potassium (3.3–6.0 mEq/L) 3.1 3.8
Chloride (96–106 mEq/L) 92 101
CO2 (Bicarb) (20–28 mmol/L) 15 22
Glucose (60–110 mg/dL) 102 105
BUN (4–17 mg/dl) 48 15
Creatinine (0.2–0.7 mg/dL) 1.4 0.6
Complete Blood Count (CBC) Current High/Low/WNL? Previous:
WBC (5–19.5 mm 3) 19.8 12.5
Hgb (10.7–17 g/dL) 15.2 16.5
Hematocrit (30–49%) 54 48
Platelets (150–475x 103/µl) 225 221
Neutrophil % (15–35) 88 34© 2016 Keith Rischer/www.KeithRN.com
What lab results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
RELEVANT Lab(s): Clinical Significance:
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal
Value:
Clinical Significance: Nursing Assessments/Interventions Required:
Creatinine
Value:
1.4
Critical
Value:
(in peds)
Urine Analysis (UA:) Current: WNL/Abnormal?
Color (yellow) Yellow
Clarity (clear) Cloudy
Specific Gravity (1.015-1.030) 1.033
Protein (neg) Neg
Glucose (neg) Neg
Ketones (neg) Neg
Bilirubin (neg) Neg
Blood (neg) none
Nitrite (neg) Pos
LET (Leukocyte Esterase) (neg) Pos
MICRO:
RBC’s (<5) 2
WBC’s (<5) >100
Bacteria (neg) few
Epithelial (neg) 0© 2016 Keith Rischer/www.KeithRN.com
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
2. What is the underlying cause/pathophysiology of this concern?
Collaborative Care: Medical Management
Care Provider Orders: Rationale: Expected Outcome:
Admit to peds w/contact
precautions
Daily weight with strict I&O
Establish peripheral IV
0.9% NS @ 20 mL/kg bolus
over 30-60 minutes, then
maintenance of D5 0.9% NS @
4 mL/kg/hour
NPO if vomiting-may advance
small feedings of Pedialyte as
tolerated if no vomiting
Acetaminophen 15 mg/kg
PO/rectal every 4 hours PRN
for temp >101
Trimethoprim/sulfamethoxazole
po 5 mg/kg every 12 hours© 2016 Keith Rischer/www.KeithRN.com
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders: Order of Priority: Rationale:
1. Stool culture for rotavirus
2. Daily weight with strict I&O
3. Establish peripheral IV and start
0.9% NS @ 20 mL/kg bolus
over 30-60 minutes, then
maintenance of D5 0.9% NS @
4 mL/kg/hour
4. NPO if vomiting-may advance
small feedings of Pedialyte as
tolerated if no vomiting
5. Acetaminophen 15 mg/kg
PO/rectal every 4 hours PRN for
temp >101
6. Trimethoprim/sulfamethoxazole
PO 5 mg/kg every 12 hours
Medication Dosage Calculation:
Medication/Dose: Mechanism of Action: Dosage to Administer: Nursing Assessment/Considerations:
Acetaminophen
15 mg/kg
Weight: 6.4 kg
Weight: 6.4 kg
Concentration of
acetaminophen:
80 mg/0.8 mL
Dose to administer:
Amount:
*
Additional Pediatric Dosage Calculations:
Weight 14 pounds, 2 ounces. Convert to kilograms:
0.9% NS @ 20 mL/kg bolus over 1 hour. Bolus amount:
IV maintenance @ 4 mL/kg/hour. Maintenance rate:
Collaborative Care: Nursing
3. What nursing priority(s) will guide your plan of care? (If more than one, list in order of PRIORITY)© 2016 Keith Rischer/www.KeithRN.com
4. What interventions will you initiate based on this priority?
Nursing Interventions: Rationale: Expected Outcome:
5. What body system(s) will you most thoroughly assess based on the primary/priority concern?
6. What is the worst possible/most likely complication to anticipate?
7. What nursing assessment(s) will you need to initiate to identify this complication if it develops?
8. What nursing interventions will you initiate if this complication develops?
9. What psychosocial needs will this family likely have that will need to be addressed?
10. How can the nurse address these psychosocial needs?© 2016 Keith Rischer/www.KeithRN.com
Evaluation:
Two Hours Later…
All orders have been implemented, including the IV bolus and medications. Harper has not had
an emesis since she was admitted. She appears to be resting comfortably and appears to be
sleeping. The nurse obtains the following:
1. What clinical data are RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Clinical Significance:
RELEVANT Assessment Data: Clinical Significance:
2. Has the status improved or not as expected to this point?
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Current VS: Most Recent:
T: 96.8 F/36.8 C (ax) T: 102.2 F/39.0 C (ax)
P: 150 P: 158
R: 42 R: 38
BP: 68/46 BP: 62/42
O2 sat: 98% RA O2 sat: 95% RA
Current Assessment:
GENERAL
APPEARANCE:
Calm and quiet, no longer irritable
RESP: Breath sounds clear with equal aeration bilaterally, non-labored
CARDIAC: Skin is pale, cool to touch, cap refill 3–4 seconds in both hands, brachial pulses palpable
bilaterally
NEURO: Lethargic, arouses to physical stimuli
GI: Abdomen soft with active BS x4 quadrants, no apparent tenderness to palpation
GU: Diaper dry
SKIN: Anterior fontanel not as depressed, lips are moist but tongue is dry with no shiny saliva
present, eyes remain slightly sunken© 2016 Keith Rischer/www.KeithRN.com
The nurse recognizes the significance of this change of status and contacts the primary care
provider and communicates the following SBAR:
Situation:
Name/age:
BRIEF summary of primary problem:
Background:
Primary problem/diagnosis:
RELEVANT past medical history:
RELEVANT background data:
Assessment:
Most recent vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
How have you advanced the plan of care?
Patient response:
INTERPRETATION of current clinical status (stable/unstable/worsening):
Recommendation:
Suggestions to advance plan of care:© 2016 Keith Rischer/www.KeithRN.com
In response to your SBAR, the primary care provider orders the following:
Care Provider Orders: Rationale: Expected Outcome:
Blood culture x2 sites
Lactate
Repeat 0.9% NS @ 20
mL/kg bolus over 15 minutes
Ceftriaxone 240 mg IVPB
every 12 hours
(after blood cultures drawn)
Vancomycin 85 mg IVPB
every 8 hours
(after blood cultures drawn)
Transfer to PICU stat.
Your hospital has a pediatric ICU, the bed is ready and will be transferred shortly.
Caring and the “Art” of Nursing
1. What is the mother likely experiencing/feeling right now in this situation?
2. What psychosocial interventions will be of benefit based on the age of Harper to promote her well-being in this
situation and as she recovers? (Remember Erikson? Situate it here…)
3. What can I do to engage myself with this family’s experience, and show that they matter to me as a person?
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
2. How can I use what has been learned from this scenario to improve patient care in the future? [Show Less]