Analysis of Paediatric Gastroenteritis - Case Study Example

Analysis of Paediatric Gastroenteritis Introduction The care of any patient is based on adequate assessment, diagnostic, planning, and intervention measures. Across the life-span, various guidelines are applicable for the care of patients. During the initial learning in this course, assessment and therapeutic interventions in health care have been learned. This assignment will consider the knowledge of assessment and therapeutic interventions relevant to children and child development in order to establish episodic nursing care of sick children and families. The purpose of this study is to provide students with the opportunity to plan and organize care of a sick child and their family using clinical practice guidelines and other supporting literature, before participating in a simulation for recognition of the sick child. It shall consider the case of Kane, who is a young boy presenting to the emergency department with his parents. Upon admission, the records establish that Kane is a four year old male child who has been suffering for 24 hours (prior to consultation) from diarrhoea and vomiting. He is also: pale with peripheral warmth; with RR of 30/min (without wheezing on auscultation); HR of 140/min at rest; temperature of 39.4 degrees Celsius; with dry tongue; tearfulness; lethargy; and with weight at 15.4 kg. He has mild intermittent asthma managed with salbutamol prn. Parents express that the child has been vomiting sporadically, is not able to keep fluids down, and refuses to drink. He also has had four episodes of watery offensive stool in the last 12 hours PTC. The physician diagnosed the child with possible gastroenteritis, and the plan of care was to try fluids orally if tolerated and if not, to consider IV cannula. The child was admitted to the children’s ward and scheduled for reassessment after 12 hours. This study shall now consider two clinical guidelines related to paediatric gastroenteritis. Search method The relevant literature taken from another country was searched using the internet, more particularly, Google Scholar. The search words paediatric gastroenteritis was entered and specific inclusive years (10 years) were specified in the advanced scholar search page. Relevant literature was reviewed based on the publishers and the credibility of authors. Australian sources were excluded in the search. Literature which matched the current case was reviewed and the specific journal was chosen based on relevance, reliability, and validity. Immediate Priorities for Kane’s care: To assess and manage the patient’s level of dehydration To reduce or totally end his diarrhoea and vomiting Plan and intervention for patient’s care Assessment and management of patient’s level of dehydration Based on the NSW Clinical Guidelines, the assessment of patient’s level of dehydration is based on three levels: mild, moderate, and severe. The care of the dehydrated patient subsequently follows based on the level of dehydration. Based on the patient’s symptoms, Kane is moderately dehydrated based on his following symptoms: elevated heart rate, elevated breath rate, pallor, dry mucous membrane, and lethargy (NSW Health, 2010, p. 7). These are all symptoms which signal moderate dehydration. The replacement fluid rate shall therefore be nasogastric therapy: one Oral Rehydration Solution (Gastrolyte); or it may be intravenous through (rapid or standard speed). The IV shall be 0.9% NaCl + 2.5% Glucose or 0.9% NaCl + 2.5% Glucose or 0.45% NaCl + 2.5% Glucose (NSW Health, 2010, p. 7). The Canadian Clinical Guidelines presented with slightly different details. Firstly, the child is also moderately dehydrated under these guidelines as assessed from the child’s exhibited symptoms, including dry mucous membrane, elevated heart rate, and lethargy (Gysler, 2011, p. 3). For moderate dehydration, the oral rehydration therapy is recommended where the patient can be rehydrated with ORS (100ml/kg for 4 hours); as well as replacement of losses with ORS; and finally age-appropriate diet after rehydration (Gysler, 2011, p. 3). The hydration status of the patient shall also be assessed atleast every 30 minutes. When the ORT is successful, the patient can be discharged after proper assessment by the physician. When the ORT is not successful, Oral Ondansetron shall be considered and the ORT shall be carried out before other blood work or tests shall be carried out (Gysler, 2011, p. 3). A reassessment of the patient’s status shall be implemented after Ondansetron and ORT. When ORT proves to be successful, the patient would be dismissed, and if not, the ORT shall have to be repeated and other blood work shall have to be considered. Compare and contrast the guidelines The two clinical guidelines have some similarities and differences. They are different in terms of the recommended therapy where the NSW Health guideline prescribes treatment for moderate dehydration to be IV fluid therapy and nasogastric therapy. For the Canadian Clinical Guidelines, the recommended therapy is Oral Rehydration Therapy with the oral administration of ORS. In essence, however, the goals for both guidelines are more or less similar to each other. Nursing care which supports the development of child Various clinical signs can establish the severity of a patient’s dehydration. For infants, assessing the anterior fontanel can help establish dehydration; however this method can sometimes lead to false results (King, et.al., 2003, p. 7). A lower blood pressure among infants and children can be considered late signs of dehydration which, if unreversed can lead to shock. Higher heart rates and cold, clammy peripheries can also mean moderate dehydration. Lower urine output can also be a nonspecific sign (King, et.al., 2003, p. 7). Based on the CDC’s guidelines, mild dehydration is dehydration at 3% to 5% fluid deficiency, moderate at 6% to 9% deficiency, and severe at 10% and more fluid deficiency, along with shock or near shock symptoms (King, et.al., 2003, p. 7). Other means of classification are forwarded by other groups including the WHO, the European Society of Paediatric Gastroenterology, Hepatology and Nutrition. It is important to carry out assessment processes because it serves as a starting point for treatment. It can also help determine the patients which can be sent home for no or mild therapy, and which ones need observation, IV therapy, or more intense therapy. Paediatric practitioners often discuss with the adults the patient’s medical history which, in terms of dehydration, would include the number of wet diapers, amount of oral intake, diarrhoea and vomiting, and other related symptoms. The caregivers also have to report whether the child drinks vigorously as if he was very thirsty (Steiner, et.al., 2004, p. 2746). Nurses can interview the parents and ask them whether fluids have been given to the child or if the child has had medical consult prior to the child’s current consultation. The value of the child’s most recent weight prior to the gastroenteritis would also be essential. It may sometimes be difficult to gather information from parents who may be distraught over their child’s condition. It is therefore important for the nurse to apply non-intrusive means of assessing the patient’s condition (Steiner, et.al., 2004, p. 2746). The assessment of the child can start with the patient sitting comfortably in front of the nurse, preferably cuddled by the parent. In this position, the nurse can already make physical observations of the child from this position by checking the child’s eyes (are they sunken or not?); the child’s breathing (is is elevated or not? Or is it deep and rapid?); the child’s colouring (is he pale or not?); and the child’s general energy (is he lethargic or not?). While the child is cuddled by the parent, the child’s heart rate, peripheral warmth, blood pressure, temperature, skin rigidity, capillary filling time, can be carried out while the patient is in a position of comfort (Steiner, et.al., 2004, p. 2746). To reduce or totally stop his vomiting and diarrhoea In order to stop the child’s vomiting, anti-emetics can be administered by the nurse to the child based on the physician’s orders (Leung and Robson, 2007, p. 176). He can be given biscuits and small amounts of water at regular intervals in order to prevent further dehydration at the same time control his vomiting (State Government of Victoria, n.d, p. 1). The administration of anti-diarhoeal medications will also have to be carried out by the nurse in order to control and manage the child’s diarrhoea. The study by Hartling, et.al., (2010, p. 11) established that there is no significant difference between IV therapy and ORT in reducing dehydration among children. It is reasonable to first treat patients first admitted with mild to moderate dehydration via ORT, and when the child is not adequately rehydrated, IV therapy may be applied. In effect, it is important for the nurse to monitor the child for possible signs of dehydration and shock, signs which may imply a further deterioration of the child’s condition. Nurses must therefore regularly monitor the child’s fluid intake, as well as amount of urine, and other signs which can be used to monitor levels of dehydration. Possible shifts from ORT to IV therapy must be considered depending on the patient’s condition and recovery (Hartling, et.al., 2010, p. 11). Nurses must therefore be knowledgeable in the assessment and monitoring of the dehydrated patients. Signs which indicate progression of dehydration needs immediate attention and the nurse must be ready to act on these signs to ensure speedy and adequate care being made available to the patient. It is also important for the nurse to be knowledgeable of the normal weight for the child, based on his age and height (Nairne, 2005, p. 130). The normal exhibited physiological process must also be seen. Based on Erik Erikson’s stages of development, a four year old child is in his pre-school years and must therefore be developed in terms of his speech and mental development. He is also in his years of play where the child has an extreme desire to copy adults and take an initiative in carrying out play roles (Nairne, 2005, p. 130). The child would make up stories with his toys and play out roles in a pretend situation. The fact that the child is not playing at all due to weakness and lethargy implies that there is something wrong with him. Efforts therefore to assist the child in fulfilling his development goals must be made by the nurse. Observation units can also be used in order to treat and manage children with gastroenteritis. In a study by Mallory and Zebrack, (2006, p. 3), the authors were able to establish support for the use of observation units for gastroenteritis patients. These units can be utilized to start oral rehydration therapy and prevent patient admission. The study was able to establish that the use of OUs proved cheaper that the traditional inpatient set-up for children afflicted with gastroenteritis. Patients who are dehydrated are suitable candidates for paediatric OUs because the patients are more comfortable and are able to receive adequate care based on their health needs and circumstances. Appropriate strategies for communication with children and families In order to establish adequate communication with children and their families, it is important for the nurse to apply appropriate processes of communication – processes which would make the consultation process and interaction with the patient and their families easier for all parties concerned. Kane is a pre-school child and is at the stage of play. In communicating with him, it is appropriate for the nurse to incorporate play or a light-hearted attitude in the care process, from the assessment, until the patient’s discharge. Informative play is one of the means by which children can easily understand what is happening to them and what the doctors and nurses are doing to him. In a study Forsner, et.al., (2005, p. 153) the authors carried out an assessment of children on their experience of being ill. They expressed how they sometimes felt scared, sad, and hurt while being sick and under the care of physicians and nurses. They also expressed that the nurses and physicians who made an effort to playfully explain to them about their illness, the procedures being undertaken, and their treatment proved to be very engaging and less intimidating to them. They even found out that the more they understood what was going on with them, the more they felt sad, hurt, or scared by their illness and by the nurses and physicians caring for their needs. Playful art therapy also assists in communicating with children because it assisted it helps establish simple and relatable learning for both the patient and the health practitioner (Wikstrom, 2005, p. 482). Just as art can be used to communicate with patients, patients can also communicate with their carers through art therapy. In communicating with the child’s family, it is also important to involve the parents in the child’s care as much as possible. Allowing the parents to be involved in the child’s care can help them feel more in control of their child’s condition (Lam, Chang, and Morrissey, 2006, p. 535). It can minimize their worries and helplessness in relation to their child’s care and recovery. Conclusion and recommendations Based on the above discussion, the patient Kane is moderately dehydrated and therefore needs rehydration therapy. The NSW Clinical Guidelines recommends IV therapy for the patient, including monitoring every 30 minutes by the nurse. According to the Canadian Clinical Guidelines, the patient needs ORT. Based on the patient’s current condition, there is a need to apply IV therapy in order to ensure adequate rehydration. The child is having difficulty maintaining fluids and therefore needs adequate therapy in order to reverse dehydration and ensure patient recovery. These two clinical guidelines are different from each other, but they both qualify the patient’s condition to be in the moderately dehydrated stage. As such, they recommend rehydration for the patient, but only through different means. Based on the two issues chosen for this patient, it is important to assess and manage the patient’s dehydration through rehydration therapy, either through IV or oral therapy. Since the child has low tolerance for fluids, IV therapy is the recommended intervention. It is also important to stop the vomiting and diarrhoea of the patient through the administration of anti-emetics and anti-diarrhoeals as recommended by the physician. Feeding the child small and frequent meals can also help manage the patient’s vomiting and diarrhoea. Recommendations Based on the above discussion, caring for the child involves specific interventions which fit the child’s tolerance and condition. The nurse must therefore establish the patient’s stage in the developmental process and then determine the appropriate interventions and means of administering the interventions. Using play and art therapy can ease the learning process and help ensure that the child would be more cooperative and less traumatized by the hospital care. The immediate management of a child’s dehydration is important because due to their smaller body size, they can dehydrate faster than adults. Appropriate interventions must therefore be implemented at the soonest possible time. Works Cited Forsner, M., Jansson, L., Sorlie, V. (2005), The experience of being ill as narrated by hospitalized children aged 7-10 years with short-term illness, J Child Health Care, volume 9(2), pp. 153-165. Gysler, M. (2011), Paediatric Gastroenteritis CPG, The Credit Valley Hospital – Clinical Practice Guidelines Hartling, L., Bellemare, S., Wiebe, N., Russell, K., Klassen, T., & Craig, W. (2010), Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children, The Cochrane Library, viewed 21 August 2011 from http://www.thecochranelibrary.com/SpringboardWebApp/userfiles/ccoch/file/CD004390.pdf King, C., Glass, R., Bresee, J., Duggan, C. (2003), Managing Acute Gastroenteritis Among Children Oral Rehydration, Maintenance, and Nutritional Therapy, Recommendations and Reports, 52(RR16);1-16, viewed 21 August 2011 from http://www.cdc.gov/MMWR/PREVIEW/mmwrhtml/rr5216a1.htm Lam, L., Chang, A., & Morrissey, J. (2006), Parents’ experiences of participation in the care of hospitalised children: A qualitative study, International Journal of Nursing Studies, volume 43(5), pp. 535-545. Leung, A., Robson, W. (2007), Acute Gastroenteritis in Children: Role of Anti-Emetic Medication for Gastroenteritis-Related Vomiting, Pediatric Drugs, volume 9(3), pp. 175-184(10). Mallory, M. & Zebrack, M. (2006), Use of a Pediatric Observation Unit for Treatment of Children With Dehydration Caused by Gastroenteritis, Pediatric Emergency Care, volume 22(1), pp. 1-6. Nairne, J. (2005), Psychology: The Adaptive Mind, California: Cengage Learning. New South Wales (2010), Children and Infants with Gastroenteritis - Acute Management, New South Wales, Department of Health, Policy Directive State Government of Victoria (n.d), Gastroenteritis in children, viewed 21 August 2011 from http://www.health.vic.gov.au/edfactsheets/gastro-kids.pdf Steiner, M., DeWalt, D., & Byerley, J. (2004), Is This Child Dehydrated? JAMA, volume 291(22), pp. 2746-2754. Wikstrom, B. (2005), Communicating via Expressive Arts: The Natural Medium of Self- Expression for Hospitalized Children, Pediatric Nursing, volume 31(6), pp. 480-485. Read More