Pediatric Gastroenteritis UNFOLDING Reasoning

Pediatric Gastroenteritis UNFOLDING Reasoning Harper Anderson, 5 months old Primary Concept Infection Interrelated Concepts (In order of emphasis) 1. Inflammation 2. Perfusion 3. Fluid and Electrolyte Balance 4. ...

Pediatric Gastroenteritis UNFOLDING Reasoning Harper Anderson, 5 months old Primary 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: 1. Diarrhea and vomiting over the past two days 2. Less active, not interested in playing 3. Unable to keep any feedings today 4. Four loose, watery stools and emesis x3 this morning 5. No wet diaper since yesterday evening 6. Today's weight is 14lb, 2oz. Last office visit, 2 weeks ago, weight was 15lb, 2oz. The patient is presenting with signs of dehydration and infection RELEVANT Data from Social History: Clinical Significance: 1. Mother is 21 years old, single, and this is her first child 2. Mother is not working and lives with parents 3. Even with support, the mother is consistently overwhelmed as a new mother Mother is young and single, this is where a support system must be established. Mother is not working, lives with her parents, but is constantly overwhelmed as a new mother, there may be a financial stressor and mother may be experiencing postpartum depression/blues. 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 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 What VS data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: 1. Temperature: 102.2F 2. BP: 62/42 An elevation in temperature indicates infection and a low BP indicates dehydration. Rest of Vital signs are WNL. 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 What assessment data are RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: 1. Alternates with lethargy once quiet 2. Tears are not present when crying 3. Skin is pale, cool to touch, cap refill is 3-4 sec in both hands 4. Hyperactive BS x4 Quadrants 5. 5 mL dark amber, cloudy urine 6. Anterior fontanel depressed, eyes slightly sunken, lips and tongue are dry, skin is tented for 2-3 seconds When the patient is lethargic once quiet, and has dark amber and cloudy urine, it is a sign of infection. Tears not being present when crying, Skin pale, cool to touch, capillary refill that is late, tented skin, dry lips and tongue, sunken eyes, all indicate dehydration. Hyperact