Carrie Richards, a 3 ½ month old female, was admitted to the hospital with respiratory distress due to respiratory syncytial virus, long with dehydration and inadequate nutritional status. The mother expresses concern that Carrie Richards has lost weight and is “acting hungry.” Upon arrival in the Emergency Department Carrie Richards exhibited substernal retractions, nasal flaring, with oxygen saturation of 89% on room air, coarse respirations with wheezes and crackles noted in both lungs, T 99°F HR 156 RR 56. Carrie Richards weighed 4.5 kg. IV fluids was ordered D5 0.45 NS with 10 mEq of KCl/100 mL to run at 40 mL/hr. Carrie Richards provider also ordered monitoring oxygen saturation with pulse oximetry, Acetaminophen 45 mg q4H for temperature above 101 degrees or for irritability, Racemic epinephrine and Albuterol inhalation were ordered as well as laboratory workup for baseline information. Transmission-based precaution was ordered, Oxygen at 2 liters through nasal cannula, low oral suction as needed, vital signs every 4 hours.
Carrie Richards was admitted to the Pediatric Unit with additional orders for consultation with dietician to assess nutritional needs and possible teachings to the mother. Carrie Richards vital signs: Oxygen saturation at 96% on oxygen at 2 L/min via nasal cannula, T 98.5°F, HR 113, RR 47. The nurse conducted her assessment with the following findings in addition to her vital signs and oxygen saturation, Carrie Richards’ lungs clear bilaterally with no adventitious lung sounds, respiratory rate regular and even, pharynx mildly reddened, brachial and pedal pulses palpable, capillary refill at 3 seconds. Carrie Richards’ mother asked whether the IV is “feeding” her baby and if her baby will start gaining weight by IV alone.
1. Which characteristics of infants put them at a greater risk for hydration problems? Select all that apply.
_____ Infants have a larger body surface area, which results in greater fluid loss through the skin
_____ The metabolic rate of an infant is lower than that of an adult
_____ Infants have a higher percentage of water in extracellular fluid
_____ Infants are less able to concentrate urine
2. Which is the most reliable information that can be used to assess an infant’s hydration over time?
a. Weight of wet diapers
b. Daily weight
c. Urine osmolality readings
d. Assessment of oral mucous membranes
3. When weighing an infant, what practices will promote the most accurate readings? Select all that apply.
_____ Weigh at the same time each day
_____ Weigh after feedings
_____ Weigh with the infant in a diaper only
_____ Weigh the infant without clothing or diaper
4. Explain what is meant by oral rehydration therapy (ORT).
· Oral rehydration therapy is type of fluid replacement used to prevent dehydration. For example, patient has diarrhea so ORT can used. And involved drinking fluid sodium and potassium. Oral rehydration can be given by nasogastric tube.
5. Discuss the nursing responsibilities associated with IV fluid administration in infants. (Hint: Remember that IV fluid is treated as a medication administration.)
· Nursing responsibility to ensure that the patient receive the ordered solution and additives at the order rate. Hourly checks for IV fluid side. Monitor intake and output.
6. What should the nurse be looking for when assessing an IV site?
· Assessing an IV site for infection, redness
7. What topics should be included in the discharge instructions for the parents of an infant who has been hospitalized with bronchiolitis?
· Make sure child drink of fluids to prevent dehydration.
· Try to child head elevated for adequate breath
· Wash your hand before and after childcare
· Give all medication as direction
8. What important hydration assessment parameters can you use with Carrie Richards that would not be available with an older child?
· Skin turgor
· Mucous membrane
9. When evaluating Carrie Richards’ output, the nurse recognizes that she should have at least __2__ wet diapers per day.
10. What would you tell Carrie Richards’ mother about adequate hydration? How will she know whether or not her baby is getting enough fluids?
11. Carrie Richards is receiving an IV infusion with potassium added. Explain what she is receiving. Discuss the nurse’s responsibilities related to potassium administration to an infant.
· Check for Heart rhythm, Urinary output, Electrolyte levels
· Evaluate renal function, cardiac and fluid status, and any factors contributing to altered potassium concentrations prior to therapy.
12. What can Carrie Richards’ mother do regarding management of the IV? What could you ask her to do while still maintaining safe care and fulfilling your legal responsibility?
13. Can Carrie Richards be given acetaminophen? If so, for what reason?
· Yes, she given acetaminophen for temperature above 101 degrees or for irritability
14. What should you assess before you prepare the medication? (Hint: Consider the specific need for this medication, as well as the nursing responsibilities before administering any medication.)
· Assess pain ,oxygen saturation with pulse oximetry and temperature before prepare the medication
15. Is the ordered dose of this medication appropriate for Carrie Richards? Why or why not?
16. Assume that Carrie Richards has an order for an antibiotic that reads “40 mg/kg/day PO in divided doses every 8 hours.” How much would you give for each dose?
17. What are the appropriate methods of administering oral medications to an infant?
18. Carrie Richards’ mother needs to know how to give medication to her child at home. How will you determine whether she is skillful and comfortable enough giving her baby medication?
19. How would you respond to the following concern: “The nurse is supposed to give the medication, so how can the nurse allow a parent to administer medication?” (Hint: To answer this, you need to think through the nurse’s legal responsibilities.)
20. The only vaccine Carrie Richards has received is for hepatitis B. What teaching does Carrie Richards’ mother need with regard to immunization?
21. What other kinds of information would you want from Carrie Richards’ mother? (Hint: Explore other factors contributing to her behavior and decision making regarding her infant’s immunization.)
22. Suppose that Carrie Richards’ mother expresses concern about pain. She says that she avoids bringing her daughter in for sots because of this fear. You have shared this information, and the RN has requested an order for EMLA cream to be applied prior to any injections. What information does Carrie Richards’ mother need in order to use EMLA cream?