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Question:

Discuss about the Paediatric Nursing.
 
 

Answer:

Assessment findings and Pathophysiology:

Heart rate in 2 year children should be between 98 – 140 beats per minute. However, in case of Molly recorded heart rate is 155 beats per minute. Abnormal condition like thready pulse is observed in Molly. Thready pulse indicates rapid pulse rate which can be rarely detected. Thready pulse gives feeling of fine mobile thread beneath the palpating finger. Systolic and diastolic blood pressure should be between 86 - 106 mmHg and 42 – 63 mmHg respectively in the children of Molly’s age. However, recorded blood pressure in Molly is 80/42  mmHg. It indicates, hypotension if Molly (Leon et al., 2011).  

Respiratory rate should be between 22- 37 breaths per minute in children below 2 years. In case of Molly, observed breathing rate is 30 breaths per minute. It indicates normal breathing rate in Molly. Normal body temperature should be between 36.1 to 37.9?C in 2 years children. However, recorded body temperature for Molly is 38.1 ?C which indicates hyperthermia in Molly. Normal capillary refill time should be between 2 – 3 seconds, however measured capillary refill time in Molly is 4 seconds. This prolonged capillary refill time in Molly indicates possibility of peripheral artery disease (Kliegman, 2015).

 


Gastroenteritis mainly occurs due to infection of the small or large bowel and vomiting and diarrhea are the prominent indications of the gastroenteritis. Optimum fluid balance in the humans is depended on the release and reabsorption of the consumed fluids and electrolytes in the gastrointestinal tract. When intestinal fluid output overcomes the absorption capability of the intestine, there can be occurrence of diarrhea. In case of Molly also watery stool is observed with some amount of mucous, without blood. Molly is having 6 incidences of water stool in the past 24 hours and vomiting also. She is also refusing intake of solid fluid. This may occur due to the malabsorption of the food in the gastrointestinal tract. In gastroenteritis, malabsorption of intestinal contents mainly occurs due to the damage of the villous brush border of the intestine. This malabsorption in the gastrointestinal tract can lead to the osmotic diarrhea (Graves, 2013).

Released toxins in the in intestine bind to certain electrolyte receptors which results in the release of chloride ions in the intestine and consequently secretary or watery diarrhea occurs. Watery diarrhea leads to dehydration in Molly. This dehydration is indicated by prolonged duration of  capillary refill time. In children, diarrhea also can lead to the abnormal lung functioning and breathing impairement. However, in case of Molly this condition is not evident. Diarrhea can also lead to the decreased activity in children and Molly also exhibiting lethargic symptom due to dehydration. Infection in the gastroenteritis patients can lead to the occurrence of fever and Molly also exhibiting increased temperature (Noguera et al., 2014). Measurement of vital signs like temperature, blood pressure, heart rate and respiratory rate are indicators for the assessing degree of dehydration in children. In Molly, dehydration alters her temperature, heart rate and blood pressure, however her breathing rate is normal. Due to dehydration, there can be insufficient amount of fluid in the blood and this deficiency of fluid can be sensed by brain. As a result heart tries to pump more amount of blood. This leads to the increase in the heart rate in children with dehydration. This increase in the heart rate is termed as tachycardia. Less amount of fluid in the capillaries as result of dehydration also results in the decreased pressure against blood vessel walls. In Molly also decreased blood pressure is observed. Blood vessels initiate compensatory mechanisms to raise blood pressure and heart beats at faster rate. This compensatory mechanism leads to the reduced supply of blood to the body tissue. This leads to the less metabolic activity in the tissue which results in the fatigue and lethargy. Molly also exhibiting lethargy (Tam et al., 2014).    

 

Fluid and electrolyte management in Molly:

Fluid and electrolyte management should be done very carefully in Molly because along with diarrhea, she is also suffering through vomiting. Hence, oral administration of the fluids would be difficult in her. She should be allowed to sip small quantity of water, carbohydrate and electrolyte drinks, sports drinks and readymade rehydration solutions. She should be allowed to suck ice lollies and ice chips. Fever is also evident in Molly. Hence more precautions should be taken because increase in body temperature can exaggerate dehydration. She should avoid heat exposure and should be cooled down. Hence, sweating would be prevented as it would be helpful in avoiding further loss in electrolytes. In diarrhea, there would be blockage of electrolyte receptors, however sodium receptors remain intact in diarrhea. Hence, sodium and water reabsoprtion can be efficient in Molly. Oral rehydration solution (ORS) containing 1:1 proportion of sodium to glucose should be administered in Molly. ORS can increase sodium reabsorption through sodium-glucose transporter (SGLT-1) and consequently passive reabsorption of water. Rice and cereal-based ORS can also be useful in Molly as these works through sodium-amino acid transporters and increase reabsorption of fluid and electrolytes (Pelc et al., 2014).

Maintenance fluid should be administered in Molly to avoid ongoing losses of the electrolytes. Volume of maintenance fluid like ORS can be decided based on the Holliday-Seger method. According to this method volume of ORS can be administered both on hour and per kg body weight basis. After the administration of the maintenance fluid, Molly should be administered with the deficit fluids. These deficit fluids should be administered to make up the loss occurred prior to initiation of the treatment. Volume of deficit fluid should be administered by calculating degree of dehydration. Degree of dehydration can be calculated by measuring reduced body weight. 1 kg reduction in body weight is generally considered as 1L fluid loss. Accordingly, deficit fluid should be administered in Molly. Milk, juice, soda, tea, and sports beverage should not be administered as the deficit fluids because these fluids dosen’t contain sufficient amount of electrolytes. Commercially available fluids like ORS can be used as deficit fluids in Molly. Molly is refusing to take food and fluid, hence family members should assist and encourage her to take it. Due to dehydration, Molly might be weak and unable to take food and fluid independently. Fluids should be administered to Molly, which she is interested to take because due to vomiting she might lost sense of taste. In this case, she would prefer to take fluids which she likes. Molly should be promoted to maintain oral hygiene because due to dehydration there might be sticky and dry mouth. This can lead to discomfort in taking fluids. Molly should be administered with IV saline because IV fluid would be helpful in avoiding hypovolemic shock in Molly (Freedman et al., 2014).

There are more chances of electrolyte loss through diarrhea and it can be prevented by administering anti-diarrheal drugs. Molly is suffering through fever and antipyretic drugs should be administered to her. Antipyretic drugs can be helpful in reducing fluid loss by decreasing temperature and consequent fluid losses due to diaphoresis. Fluids should be administered to Molly in advance, even if fluid loss is stopped. This continuous administration of fluid can be useful in improving interest of taking food. Nurse should monitor for the signs and symptoms like mucosal dryness and urinary concentration which are related to the fluid and electrolyte balance. Nurse should monitor for the change in body weight because it is estimated that approximately 1 litre fluid loss can occur with 1 kg loss in body weight. Nurse should monitor intake and output in Molly. This early identification of the imbalance in fluid and electrolyte balance would be helpful in taking timely corrective measures. Ongoing fluid loss should be maintained with administering 10 ml/kg body weight ORS for every loose stool and 2 ml/kg body weight ORS for each episode of vomiting. Fluid deficit in Molly can be prevented in Molly by administering 50 – 100 ml/kg ORS after 2 – 4 hours (Simpson and Teach, 2011).  

 

Nutritional requirements:

Normal amount of food should be administered to child with gastroenteritis as it would be helpful in maintaining lining of the intestine and help to recover fast. Avoiding food intake can prolong diarrhea in Molly and also impairs electrolyte balance. Molly should be administered with small amount of food in the initial period and it should be increased gradually based on the appetite and improvement in the condition. Molly should be always kept on rehydration by allowing her to drink more water or rehydration solution. Molly should be administered with approximately 500 mL/day. Molly should be allowed to drink cordial fluid, soup, fruit juice and fizzy drinks. Molly should be administered with electrolyte solutions such as Gastrolyte or Pedialyte. Molly should be administered with starchy simple foods like bread or toast, porridge, rice, potatoes, plain biscuits, yoghurt, and milk pudding. In the studies, it is evident that administration of half-strength apple juice followed by juice of children’s choice is helpful in preventing failure of treatment. This formula should be used in Molly because it is validated in clinical studies. This formula proved more useful as compared to the ORS (Freedman et al., 2016).

Molly should be administered with polymer based ORS. This polymer based ORS is prepared by using rice, wheat, and maize. This polymer based ORS would be useful in reducing number of stools and duration of diarrhea in comparison to the glucose-based ORS. These polymers based ORS facilitate slow digestion of glucose in the intestine and this release of glucose aid uptake of sodium. Molly should return to normal diet as early as possible. Administration of fluid in the initial phase is useful in reducing illness and improving nutritional outcome in Molly. Foods with high content of fats and simple sugars should be avoided in Molly. BRAT diet comprising of bananas, rice, applesauce, and toast should be administered to Molly. This diet is helpful in making stool firmer due to its binding properties and it replaces nutrients lost due to diarrhea and vomiting. BRAT diet doesn’t produce any irritation to stomach and it would be helpful in returning to normal diet in Molly.  Solid food should be avoided in Molly until and unless vomiting continues in her. BRAT doesn’t have all the nutritional requirements, hence Molly should be returned to normal fruits, vegetable and diet within 24 hours of vomiting and diarrhea (More, 2013; Carroll, 2016).

 

Nursing considerations:

Nurse should monitor vital signs, elastic turgor, mucous membrane of lips and consistency and frequency of bowel movements. Nurse should also monitor signs like change in body weight, urinary concentration and amount of fluid intake and output. Molly should be advised to maintain hand hygiene while taking food and she should be in the bed most of the time. Molly should change sitting and sleeping position every 2 – 3 hours. Nurse should assess abdominal pain, hyperactive bowel sounds and frequency and urgency bowel empting because Molly may not be able to verbalize it properly due to her age. Molly should maintain perianal hygiene after each bowel movement. Molly should be isolated from other children until diarrhea and vomiting persists. Children of Molly’s age can be affected significantly due to small change in the body fluid. Hence, nurse should maintain adequate rehydration in Molly to prevent dehydration. There may be development of activity intolerance in Molly due to dehydration, however children’s of her age prefer to play with their peers. Hence, nurse should try to stop her from playing until good recovery from dehydration (Glasper et al., 2015; Hockenberry and Wilson, 2014).  

 

References:

Carroll, W. (2016). Gastroenterology & Nutrition: Prepare for the MRCPCH. Elsevier Health Sciences.

Freedman, S.B., Willan, A.R., Boutis, K., and Schuh, S. (2016). Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. Journal of the American Medical Association, 315(18), 1966-74.

Freedman, S.B., DeGroot, J.M., and Parkin, P.C. (2014). Successful discharge of children with gastroenteritis requiring intravenous rehydration. Journal of Emergency Medicine, 46(1), 9-20.

Glasper, E. A., McEwing, G., Richardson, J. (2015). Oxford Handbook of Children's and Young People's Nursing. Oxford University Press.

Graves, N.S. (2013). Acute gastroenteritis. Primary Care, 40(3), 727-41.

Hockenberry, M. J., and  Wilson, D. (2014). Wong's Nursing Care of Infants and Children.

Elsevier Health Sciences.

Kliegman, R.M.. (2015). Nelson Textbook of Pediatrics, 20th Edition. Philadelphia, PA. Elsevier.

Leon, C., Samson, R. A., Schexnayder, S. M., and Hazinski, M. F. (2011). Pediatric Advanced Life Support Provider Manual: Professional Edition. United States of America: American Heart Association.

More, J. (2013). Infant, Child and Adolescent Nutrition: A Practical Handbook. CRC Press.

Noguera, T., Wotring, R., Melville, C.R, Hargraves, K., Kumm, J., and Morton, J.M. (2014). Resolution of acute gastroenteritis symptoms in children and adults treated with a novel polyphenol-based prebiotic. World Journal of Gastroenterology, 20(34), 12301-7.

Pelc, R., Redant, S., Julliand, S., Llor, J., Lorrot, M., et al. (2014). Pediatric gastroenteritis in the emergency department: practice evaluation in Belgium, France, The Netherlands and Switzerland. BMC Pediatrics, 14, 125. doi: 10.1186/1471-2431-14-125.

Simpson, J.N., and Teach, S.J. (2011). Pediatric rapid fluid resuscitation. Current Opinion in Pediatrics, 23(3), 286-92.

Tam, R.K., Wong, H., Plint, A., Lepage, N., and Filler G. (2014). Comparison of clinical and biochemical markers of dehydration with the clinical dehydration scale in children: a case comparison trial. BMC Pediatrics, 14, 149. doi: 10.1186/1471-2431-14-149.

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