NUR 4220 Module 3 Dehydration Paper: Oral Rehydration, Ondansetron and Preferred Fluids Example

Five Milliliters Every Five Minutes: Oral Rehydration for a Toddler With Gastroenteritis

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-4220: Nursing Care of Infants, Children, and Adolescents

Mentor Name

Month Day, Year

Five Milliliters Every Five Minutes: Oral Rehydration for a Toddler With Gastroenteritis

The Patient

Lily is invented for this paper. She is 2 and attends a home daycare where several children have been sick. Since yesterday she has thrown up six times and passed eight watery stools. Only two diapers have been wet in the last day. In the emergency department she was tired but alert, with dry lips, few tears and a capillary refill of about two seconds. Her weight was 11.2 kilograms; her weight at a checkup two weeks ago was 11.9 kilograms. Her mother was worried she would need an IV.

Assessing Dehydration

Children lose fluid quickly from vomiting and diarrhea, and toddlers have less reserve than adults. The most accurate measure of dehydration is the change in weight from a recent known weight. Lily's loss of 0.7 kilograms suggested about 6 percent dehydration, in the moderate range. Clinical signs such as dry mucous membranes, reduced tears, decreased urine and prolonged capillary refill support the estimate. Severe dehydration, with lethargy, poor perfusion or very little urine, needs intravenous fluids.

Oral or Intravenous

Hartling et al. (2006) pooled 17 trials that compared rehydrating children by mouth and by vein during gastroenteritis. There were no important clinical differences in effectiveness. About one in 25 children treated orally needed to switch to intravenous fluids. Oral rehydration was associated with shorter hospital stays, and intravenous treatment carried risks such as phlebitis. The authors favored starting with oral rehydration when dehydration is mild or moderate.

Stopping the Vomiting

Freedman et al. (2006) randomly assigned more than 200 children between six months and ten years old, all with gastroenteritis and some dehydration but not severe, in a pediatric emergency department to receive either ondansetron by mouth or a placebo once, before starting oral fluids. Children given ondansetron vomited less during rehydration, 14 percent compared with 35 percent, took in more fluid and were less likely to need intravenous fluids, 14 percent compared with 31 percent.

What to Drink for Mild Illness

Freedman et al. (2016) studied children aged 6 to 60 months with mild gastroenteritis and minimal dehydration. Children who drank apple juice diluted by half, then whatever fluids they liked, had fewer treatment failures, including needing intravenous fluids or hospitalization, than those given an electrolyte maintenance solution, 16.7 percent compared with 25.0 percent. The authors suggested that for mildly dehydrated children, palatable fluids that children will drink can be as good as or better than electrolyte solutions.

Nursing Diagnoses

Diagnoses included deficient fluid volume from losses through vomiting and stools, risk for electrolyte imbalance and anxiety in the parent related to the child's illness and fear of procedures.

Rehydration in Practice

Because Lily was moderately dehydrated, the plan was oral rehydration solution rather than juice. The nurse gave a dose of ondansetron by mouth as ordered. Twenty minutes later, the student began giving 5 mL of oral rehydration solution every five minutes with a syringe, a pace a nauseated toddler can tolerate. The student showed her mother how to give it and kept a running tally. A popsicle made of the solution helped when Lily refused the cup. Over four hours she took in about 600 mL, roughly 50 mL per kilogram, the replacement amount for moderate dehydration, and the student recorded her output.

Monitoring

The student checked her vital signs, alertness and urine output every hour and reweighed her before discharge. If she had vomited repeatedly despite ondansetron or become more lethargic, the plan was to change to intravenous fluids. She produced a wet diaper after two hours and was more playful by three.

Feeding and Home Care

The student explained that children should resume their usual age-appropriate diet as soon as they are rehydrated, rather than waiting for diarrhea to stop, and that very sweet drinks, like full-strength juice or soda, may make diarrhea worse when dehydration is more than mild. Her mother learned to continue small, frequent fluids at home and to replace each watery stool with about 10 mL per kilogram of oral rehydration solution.

Preventing Spread

The student taught handwashing after diaper changes and before preparing food, cleaning surfaces with a bleach solution and keeping Lily home from daycare until 24 hours after the diarrhea stopped. Rotavirus vaccination status was checked; she was up to date.

Why Weight Matters

Lily's recent clinic weight made a precise estimate possible. Without it, the team would have relied on signs alone, which can overestimate or underestimate fluid loss. The student weighed her on the same scale, without her diaper, before and after rehydration, so that progress could be measured rather than guessed.

Her Mother's Role

Lily would take fluid from her mother more readily than from a stranger. The student showed her how to give 5 mL with the syringe, set a phone timer for every five minutes and kept a simple tally sheet. By the second hour her mother was managing the rehydration herself, which also prepared her to continue at home.

Evaluation

Lily left the emergency department after five hours without an IV. When the nurse phoned the next day, Lily was drinking well and passing fewer stools.

Limits

The apple juice trial included only mildly dehydrated children. Ondansetron is not recommended for every child, and its use depends on local guidelines. A student assists with rehydration and teaching but does not order medications. Lily is invented.

Conclusion

Hartling and colleagues showed that oral rehydration works for most children, Freedman and colleagues showed that ondansetron makes it easier and that palatable fluids suit mild illness. For Lily, accurate assessment by weight, a dose of ondansetron, small and frequent fluids, close monitoring and practical home teaching spared her an IV and sent her home safely.

References

Freedman, S. B., Adler, M., Seshadri, R., & Powell, E. C. (2006). Oral ondansetron for gastroenteritis in a pediatric emergency department. New England Journal of Medicine, 354(16), 1698-1705. https://doi.org/10.1056/NEJMoa055119

Freedman, S. B., Willan, A. R., Boutis, K., & 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. JAMA, 315(18), 1966-1974. https://doi.org/10.1001/jama.2016.5352

Hartling, L., Bellemare, S., Wiebe, N., Russell, K. F., Klassen, T. P., & Craig, W. R. (2006). Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database of Systematic Reviews, (3), Article CD004390. https://doi.org/10.1002/14651858.CD004390.pub2