Pediatric Clinical Problem - Article Example

Clinical reasoning paper: A pediatric clinical problem This is a clinical reasoning paper of a pediatric case that involves an analysis that includes the nursing, path physiology, pharmacology, primary health, and psychosocial science.  The case under discussion is of Ellen Shields two years old born of Australian parents at normal gestational age. Ellen is admitted to the Accident and Emergency (A&E) Department of a small country hospital. As per Mrs. Shields, Ellen usually has a good appetite but has experienced intermittent bouts of diarrhea since commencing solid food. These bouts generally last for 24 hours and resolve themselves. Ellen’s usual weight is 9.8 kg and height 86 cm. in this particular case Ellen developed diarrhea two days previously, which did not resolve as earlier. The next day Mrs. Shields visited the chemist who advised her to give Ellen, whose weight was then 9 kg, oral  rehydrating solution (ORS) 80 mls per hours over four hours and to stop  solid food for 24 hours. Ellen had drunk only around 30  mls per hour over the four hours as she seemed to dislike the taste and ultimately showed minimal improvement. Then as per her neighbors suggestion gave Ellen flat lemonade at around 60 mls per hour. Ellen drank this willing but neither her diarrhea (which increased) nor her condition improved. By 10.00 on the day Mrs. Shields felt that Ellen was sicker and although wanted to sleep most of the time was did wake during her frequent nappy changes for loose smelly stools. On admission her parameters were T 388 P 140 Resp 36 weight 8 kg. Medical officer ordered by phone: Oral Panadol for pyrexia, tepid sponge PRN, 100 ml/kg of ORS to be administered over four hours with an additional 10 mls per kilogram for each  additional stool. The RN administered the Panadol and commences a tepid  sponge. MO indicated that Ellen’s condition was to be reviewed hourly throughout these four hours. The MO also stated that Ellen was to be discharged if her condition improved with instructions to inform mother of the maintenance fluid requirement, continue a normal diet and to see MO in 24 hours or to contact either the hospital or the clinic if she was worried about Ellen. Assessment criteria to be carried out and its importance in Ellen’s management: Literature’s view: Diarrhea is a condition of frequent passing of loose or watery or unformed stools. It can be said as one of nature’s way to throw off the unwanted things out of the system. Roughly on a estimate passage of three of or four stools a day. Diarrhea is estimated to be one of the most common diseases in infants and young children. Acute diarrhea is one that exists less than two week and chronic is the one that exist more than two week. It may be mainly due to malnutrition, unhygienic condition and poor health. In many countries it is the leading cause of death.(Bhakru,2000) The diarrhea is of two types, simple, that may be accompanied by gripping pain in stomach and vomiting. This may be due to any reason as colitis or intolerance or any type of gut disorder. This most of the times revert back by itself. Infective diarrhea on other hand is the most common form of diarrhea occurring in kids. This may be due to any organism as bacteria, virus and other pathogens. This type of infection is mainly due to food or water contamination. The infectious diarrhea is of two types, first form with a slow onset with gradual and loosened bowel with five to ten times of motion a day. Thin traces of mucus may occur in with fever. It may run an mild course or may eventually turn out to a inflammatory condition. The second form on other hand is of sudden onset with marked vomiting, fever, with large green mucous stools that may contain blood . (Richard,2004) The symptoms of acute infectious diarrhea is described as mild stomach upset for a day or two to severe watery diarrhea for a week or longer. Crampy pain in the abdomen may be noticed, that may ease out with each bout of diarrhea or vomiting may persist along with fever and headache. Diarrhea though in milder problem is not of much threaten but in prolonged periods can lead to certain definite complications. Among these, dehydration poses a serious problem, especially when disease is accompanied by vomiting. It can even be fatal if not treated early. Dehydration is characterized by hot, dry skin over the abdomen, sunken eyes, dry mouth, intense thirst and reduced flow of urine. In severe infectious diarrhea hemolytic uremic disorder, reactive complication, spread of infection , the kindle of irritable bowel syndrome may occur. (Bander’s & Dupont , 1999) Critical analysis: Thus from the critical study of literature and with the observations gathered from the case, it could be seen that Ellen from the time of commencement of solid food had an episode of diarrhea which got over by itself. Thus it can be considered as the infant’s new food syndrome, where with the introduction of solids as peas and carrot, the kid tends to have some mild stomach upset which sets back by itself. But this type as Mrs. Shield describes, the diarrhea persists for two days. From the initial diagnosis it is seen that the child is suffering from acute diarrhea with no episode of vomiting being reported. The parameters, at the time of admission show a mild dehydration and high temperature and slightly high respiratory rate. This suggests that the child might have acute infectious diarrhea- probably the Acute Gastritis the most common infectious disease among children. Literature review: The main cause of acute infectious disease is usually, Viral gastrointestinal infection: mainly rotavirus but others include echo and enteroviruses. Bacterial gastrointestinal infection: Bacterial infection is suggested by high pyrexia and bloody diarrhea. Common bacterial pathogens include Shigella, Salmonella and Campylobacter. Protozoan infection: Chronic infections might suggest protozoa’s, for example Giardia lamblia. Systemic infection, e.g. urinary tract infection, pneumonia, otitis media, meningitis, septicemia. Antibiotic associated: and rarely pseudo membranous colitis. Dietary: food allergy or intolerance (lactose, cow's milk protein); starvation stools. Surgical conditions include: appendicitis; intussusceptions; partial bowel obstruction, e.g. volvulus, Hirschsprung's disease; Meckel's Diverticulum; short bowel syndrome. Malabsorption: cystic fibrosis, Coeliac disease. Inflammation: Ulcerative colitis, Crohn's disease. Miscellaneous: constipation with overflow, haemolytic-uraemic syndrome, toddler diarrhea. Viral pathogens account for approximately 70% of episodes of acute infectious diarrhea in children, and rotaviruses are most commonly implicated. Bacterial infections account for about 15% of episodes and occur less often in developed than in developing communities. Overall, Campylobacter and Salmonella species are the most commonly reported bacterial infections in Australia, although atypical enter pathogenic Escherichia coli are emerging as important pathogens.8 Infections with Shiga-toxin-producing E. coli are rare in Australia, but may be complicated by the haemolytic–uraemic syndrome (HUS).9 Increasingly, E. coli infection, typhoid and shigellosis are reported in Australian children who have traveled abroad (Mather’s , 2004) Critical analysis: Of this the scenario of viral neither infected gastritis suits the picture as no bloody stool nor is thick mucus presence seen. The other assessment criteria that could have been done are: Physical examination ,that could tell the state of dehydration as state of skin , capillary return, fontanelle , eyes –the level of sunking, peripheral pulse and mental state Collection of other relevant information as any new food introduced, travel to any countries, any water contamination as usage of swimming pool etc. Stool culture: including examination for ova, cysts and parasites and mucus. The common virus that infects - Rotavirus antigen tests: false-negative rate is approximately 50%, and false-positive results occur, particularly in the presence of blood in the stools. Adenovirus (serotype 40 and 41) antigen can be detected by enzyme immunoassay. White cell count is usually normal but may be raised in some bacterial infections. Renal function and electrolytes. Occasionally a protein-losing enteropathy may lead to a low serum albumin. Measurement of electrolytes in particular as serum electrolyte, blood urea and creatinine and for signs of hypernatremia and hypokaelemia. Other investigations will depend on individual situation. Further investigations may include endomysial antibodies, intestinal biopsy (Coeliac disease), sweat test (cystic fibrosis) if indicated, especially if diarrhoea persists. Radiological studies are rarely useful but barium meal and follow-through will exclude malrotation and may occasionally demonstrate a blind loop. Endoscopy of the upper and lower gastrointestinal tract, with biopsies, may be required. The other diverse diagnosis as symptom of cough, dyspnea, tachnea that may indicate the presence of pneumonia , any urinary frequency or urinary pain etc. The main factor to be checked is presence and absence of fever and quantity of emesis . (Armon & Mc Fall,2001) The last of three might not be important. These diagnosis is important to rule out any probability of serious or chronic infections. The next major condition to be assessed is the degree of dehydration. Children presenting with acute gastroenteritis should be assessed to determine the presence and severity of dehydration, as this will influence the choice of therapy. The likelihood of dehydration is increased in children with a history of frequent, severe watery diarrhea and in children less than 6 months of age. Percentage weight loss gives the best estimate of the degree of dehydration, but this information is not always available and may not apply to all populations. Clinical assessment of dehydration can be difficult, particularly in young infants, and rarely predicts the exact degree of dehydration accurately. Clinical signs will not be present until the child has lost at least 5% of body weight (ie, 5% dehydrated). The World Health Organization has simplified its classification of dehydration, and the clinical signs and percentage loss of body weight associated with different grades of dehydration severe and mild to moderate. A recent systematic review supports this classification, showing that prolonged capillary refill time, abnormal skin turgor and abnormal respiratory pattern were the three best clinical signs for identifying dehydration, whereas laboratory tests were often unhelpful and non-specific. (Brester,2002) Adequacy of fluid regime for the patient: The chemist suggested ORS of 80 ml per hour over four hour and neighbor suggested flat lemonade at 60 ml per hour which further increased the diarrhea. On admission the medical officer suggested antipyretic, tepid sponge and ORS at the rate of 100ml per hour for four hour. The Oral Rehydrating solution, prescribed by the chemist is the best and foremost remedy for diarrhea. The main aim of this treatment is to prevent dehydration. To prevent dehydration and to balance the loss of electrolyte the child with diarrhea should replace the fluid loss. The re-hydrating solution is a powder available in sachet as prescribed the WHO. All these ORS contain glucose, sodium, potassium and sodium in varying quantity. Many other ORS as hydrolyte, rehydralyte, pedialyte, Generic pediatric solution, lytren, resol, infalyte, ricelyte are available. Generally the best home based ORS is equal quantity of salt and sugar in water and 1:4 ratio of fruit juice to water. All the dehydration preparation contains glucose polymer as carbohydrate, the Osmolality changing with variation with sodium content. The WHO ORS contains highest Osmolality. (gavin etal.,1996) The lemonade suggested by the neighbor is given when no other alternate is available in 1:4 proportions. Generally lemonade and other clear fluids as water, carbonated fruit drinks with glucose electrolyte solutions are not advised as physiological studies shows that these drinks – which has low sodium and potassium but high sugar content osmolarity, exacerbate diarrhea and dehydration and causes electrolyte disturbance. But it can be used in mild dehydration but no children with significant dehydration. The inappropriate use of liquids or soft drinks tat has very low sodium contents may transfer a mild isotonic dehydration into complex hyper or hypotronic dehydration. (American academy of Pediatric, 1996) The administration of panadol and tepid sponge PRN suggested by the MO for fever effectively helps in controlling temperature. The tepid sponge is physically done to reduce the temperature. The ORS suggested by the MO is effective to check the dehydration that would have been passed by acute gastritis, with 100ml per kg over 4 hrs with additional 10ml per kg for additional stools. This is best method of rehydration for mild to moderate dehydration is oral substitution than intravenous or nasogastric. The intravenous rehydration is un necessary in treating acute gastritis, which may on improper fluid management cause iatrogenic hyponatraemia. Additionally they also cause emotional and physical trauma in children. Further researches have shown there is no much significant difference in oral and intravenous rehydration. Nasogastric can be implemented when the child refuses to take oral rehydration and it is well tolerated and safer than IV. (Hams etal.,2004) The Education need for mother about gastroenteritis: The diarrhea is the condition that has many and various causes like contaminated milk or a infection in alimentary canal, in breast fed babies infection from mother, poor hygiene careless preparation of food. Other causes may be nervous irritability excessive in take of laxative, viral attacking infection or wrong food, etc. The acute gastritis accounts for more than 1000 children hospitalize in US for every year. The morbidity rate is 3 million per year. It is a condition of infection of guts, the severity may range from mild to severe. Many virus bacteria and other germs can cause this. The commonest viruses infection is Rotavirus infection. Food poisoning and water contamination are main sources. A good water supply, good nutrition, reasonable cleanliness and appropriate disposal of human waste is important. Most of gastroenteritis is self-limited. (Glass etal.,1991) On discharge the mother can be advised about the importance of dehydration, on mild dehydration can give 100ml per kg of ORS for first 4 hrs and then reevaluate. To give an additional fluid of 50 to 100 ml for children under 2 yr for every liquid bowel movement. To give adequate juices and water and continue ORS to replace too loss even if there is no dehydration. If the patient is stable them 2 supply of ORS would be enough. Generally 1 half of the daily requirement is given over 8 hrs while remaining is given over 16 hrs. The mother can give the child clear fluids. If the baby is bottle or breast fed, it can be asked to continue. Fruit juices can be given, the child usual food can be given if the child eats normally and feels hungry. (Holiday,1996) The mother should be cautioned to watch for signs of dehydration and if found any, to contact the doctor as Dry mouth and tongue. Not passing urine Sunken eyes. Cold hands and feets. More sleepy than usual. The mother can be enlightened to check the spread of gastro to other people by Making sure that every one in the family washed their hand regularly especially after going to the toiler before they eat. To wash the child’s hand with water and soap after the use of toilet and after they eat. To wash the mother’s hand before she feeds the baby and changes the nappies. Keeping the baby away from other babies until the diarrhea stops. Regularly cleaning the toilet with disinfectant. No drugs is necessary before the age of 12, which may lead to complication. The gastro entities can be prevented by washing The hands after going to toilet and changing the nappies. Before touching food and after handling the raw meat. After Gardening. After playing with pets. (Synder,1994) Gastro enteritis Causes Viral, Bacterial or germs infection Symptoms Diarrhea for a week with fever, Vomiting and dehydration Medication IF found to be mild to moderate dehydration ORS can be started but anti emetic is not necessary. ORS-weight of the kid into 10ml per kg. Prevention By having clear water clean food and hygienic environment Thus the critical analysis could be understood with the help of relevant literature. Bibliography 1. Dr. H.K.Bakhru ,2000, Nature Cure For Children's Diseases http://www.healthlibrary.com/reading/nature/chap2.html 2. Richard E Frye , 2004 ,Childhood diarrhoea; on eMedicine 3. Bandres JC, Dupont H. Approach to the patient with diarrhea. In: Gorbach SL, Bartlett JG, Blacklow NR, eds. Infectious diseases. Philadelphia: Saunders, 1992:572-5. 4. Mathers C. Diarrhoeal diseases and gastroenteritis: Australia. Australian Institute of Health and Welfare. Burden of disease and disease expenditure. Available at: www.aihw.gov.au/bod/bod_yld_by_disease/index.html (via a linked spreadsheet — A4 Diarrhoea www.aihw.gov.au/bod/bod_yld_by_disease/a_infectious/a4_diarrhoea.xls>) (accessed May 2004). 5. Armon K, Stephenson T, MacFaul R, et al. An evidence and consensus based guideline for acute diarrhoea management. Arch Dis Child 2001; 85: 132-142. 6. Brewster D. Dehydration in acute gastroenteritis. J Paediatr Child Health 2002; 38: 219-222. 7. Gavin N, Merrick N, Davidson B. Efficacy of glucose-based oral rehydration therapy. Pediatrics 1996;98:45-51. 8. Practice parameter: the management of acute gastroenteritis in young children. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Acute Gastroenteritis. Pediatrics 1996; 97: 424-435. 9. Hahn S, Kim S, Garner P. Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children (Cochrane Review). The Cochrane Library. Issue 2, 2004. Chichester, UK: John Wiley & Sons 10. Glass RI, Lew JF, Gangarosa RE, LeBaron CW, Ho MS. Estimates of morbidity and mortality rates for diarrheal diseases in American children. J Pediatr 1991;118(4 pt 2):S27-33. 11. Holliday M. The evolution of therapy for dehydration: should deficit therapy still be taught? Pediatrics 1996;98(2 pt 1):171-7. 12. Snyder JD. Evaluation and treatment of diarrhea. Semin Gastrointest Dis 1994;5:47-52. Read More