You are working with your mentor and sharing the care of five patients. Your mentor asks you to calculate the daily and hourly fluid requirements for these patients.

• Arthur is 2 years old and weighs 12 kg.
• Daisy is 8 years old and weighs 31 kg.
• Mohammad is 7 months old and weighs 7.5 kg.
• Isabelle is 14 years old and weighs 49 kg.
• Elyshia is 5 years old and weighs 18 kg.

Daisy and Elyshia are fluid restricted to an 80 per cent daily fluid allowance. Based on their daily fluid requirements, calculate what 80 per cent would be.

Answer:

See: www.nice.org.uk/guidance/cg84/evidence

• How many articles were reviewed in Chapter 5 ‘Fluid management’, before the recommendations on treating dehydration were made?
• : On page 55 of the guideline, it states that 363 articles and abstracts on treating dehydration were identified, with 27 articles downloaded as hard copy for review. The majority of these were randomised controlled trials (RCTs), which come high up on the hierarchy of evidence and would therefore be considered reliable. 
• Are you surprised by the detail in this guideline?
• : The number of articles identified would be in accordance with the number identified for a systematic review. If you scroll up and down to the subsections on either side, you will see 206 articles identified on preventing dehydration, of which 20 were reviewed and a further 403 articles were identified on optimal composition and administration of oral fluids, with 139 articles being reviewed. The National Institute for Health and Care Excellence (NICE) use the best available evidence in developing their recommendations which are then used to guide decisions in health and social care.

Albert is 18 months old and is brought to the emergency department by his parents, following a three-day history of diarrhoea and vomiting. Albert’s parents noticed his symptoms had become worse in the last 24 hours. In response to your questions, they inform you that mum and Albert’s 3-year-old sibling have both had an ‘upset stomach’ recently. Examinations indicate:

1. – self ventilating in air with saturations >95 per cent
2. – respiratory rate: 45 breaths per minute
3. – heart rate: 140 beats per minute; blood pressure 90/45; capillary refill time 2 secs
4. – Albert is irritable
5. – temperature: 37.1°C
6. – reduced skin turgor, dry mucous membranes and his eyes appear sunken

When asked, Albert’s mum tells you he hasn’t had a wet nappy since yesterday evening.

• Using the assessment of dehydration tool in Table 28.3, how dehydrated is Albert?

Answer: Albert has the signs and symptoms of clinical dehydration.

• What are your key nursing care priorities for Albert?

Answer:

• Isolation – the medical history of an ‘upset stomach’ in the family suggests that Albert has infectious diarrhoea and vomiting. He should be nursed in isolation with his family to prevent the spread of disease to other children and their families.
• Family-centred care – although it is appropriate for a parent to stay in hospital with Albert, visitors should be kept to a minimum. This is to restrict the spread of infection. The family should also be informed that any family members with diarrhoea and vomiting should not visit as they risk spreading infection to other patients and their families.
• Hand washing – strict hand washing should be carried out by all in contact with Albert, including family and visitors. Hand washing equipment should be provided and access to soap, basins and hand towels maintained.
• Rehydration – discuss with medical staff and mentor as oral rehydration salts/intravenous therapy will be needed to rehydrate Albert.
• Diet – oral fluids should continue to be encouraged, with the re-introduction of diet as tolerated.
• Skin integrity – Albert’s reduced skin turgor increases the risk of skin damage from pressure areas, including any intravenous sites.
• Mouth care – mouth care should be offered to Albert in the form of sips of water or via a moistened oral sponge. Care should be taken when using oral sponge that the sponge is not bitten off. If Albert’s lips are dry, a soft paraffin ointment can be used – care needs to be taken with soft paraffin ointment as it is flammable in the presence of oxygen. Albert will likely have some teeth by this stage – tooth brushing should not be carried out immediately after vomiting as vomit is acidic and brushing teeth immediately will increase the damage caused to the tooth enamel.
• Play – play remains important for children, even when they are ill. The infectious nature of Albert’s illness means he should only be offered toys that are easy to clean to prevent the spread of infection to other children.

Chelsea is 9 months old and has been admitted to the emergency department by her mother and grandmother. She has jittery movements, decreased consciousness, no history of diarrhoea or vomiting, but her urea and electrolytes show a high sodium level. Chelsea is formula fed and was weaned three months ago.  Chelsea’s grandmother tells you that she makes all of Chelsea’s food as ‘babies should be encouraged to eat the same food as the rest of the family’.

• What do you think might be the cause of Chelsea’s hypernatremia?

Answer:  If Chelsea is being given food eaten by the rest of the family, it may contain high levels of salt. Solid food intended for young children should not have salt added. However, some parents may not realise this. Deliberate salt poisoning (where salt is added to food in the knowledge that it may cause harm) is very rare, but it should not be ruled out. Chelsea’s mother and grandmother should be asked questions in a sensitive manner about the types of solids she is being offered. In addition, Chelsea is formula fed, so it’s important to check that her formula feeds are being made up correctly, with the right amount of powder to the right amount of fluid.

• What health promotion may be needed for this family?

Answer: The health visitor should be contacted so that they can arrange a visit to discuss Chelsea’s diet and to help with parental education in the use of salt in food. The health visitor could also check that Chelsea’s parents are making her formula feeds correctly.

http://news.bbc.co.uk/1/hi/uk/404667.stm

www.theguardian.com/lifeandstyle/1999/jul/28/familyandrelationships.features101

The factors that contributed to Leroy’s death were:

• Weaning at 3 months – this is earlier than the recommended 6 months of age.
• Swapping expensive baby food for cheaper adult alternatives – in this case baby rice for Ready Brek porridge cereal.
• Gravy and mash as a weaning food – gravy is high in salt

It must be stressed that Leroy’s parents did not intend to cause him harm. Their decisions around weaning were made with the best intentions, but unfortunately, a misunderstanding of the differences between the products’ ingredients led to incorrect decision making.

What weaning advice would you give to parents?

• Wean at around 6 months of age as per Department of Health guidelines
• Follow the advice available at NHS choices: www.nhs.uk/chq/pages/812.aspx?categoryid=62
• Use food specially prepared for weaning – jars or packets
• Do not substitute baby food for processed adult food due to the higher salt content
• If preparing home cooked food for weaning, do not add salt

Write a plan of care for a child with diarrhoea and vomiting, taking into consideration fluid management and infection control needs. Annotate your care plan with available evidence and discuss this with your mentor. Your care plan could be used as evidence towards achieving your learning competencies while in placement.

Answer: When writing your care plan, you should first consider the aim of the care plan and goal you intend to achieve.

For example, your aim might read:

Treat the symptoms of diarrhoea and vomiting and to minimise the spread of infection

And your goal might be:

Maintain adequate hydration and urine output and prevent further dehydration 

Minimise the spread of infection through barrier nursing and effective handwashing

Tips to include in your care plan

Your actions should indicate what nursing care you intend to deliver in order to achieve your aims and goals. This might include offering sips of water, offering ORS as prescribed, weighing nappies/measuring output, assess stools against the Bristol Stool Chart and document your findings. For each action, you should also provide a rationale to explain the purpose and evidence base behind your action.

You might find it helpful to separate the care plan into two separate plans – one for fluid management and the other for infection control.

After you have written your care plan, compare it with the core care plans used by your placement area and discuss this with your mentor