Haley is a 5-month old Caucasian female of Dr. Smith who is a direct admit from her pediatrician’s office for dehydration. Upon admission, her parents reported that her oral intake has decreased over the past few days. Haley’s medical history includes an uneventful pregnancy. She was born at 38 weeks with no complications. Health care providers should ask Haley’s parents how many wet diapers she has produced since they noticed her becoming ill, how Haley’s activity level has been, and if they have noticed any struggle breathing. It should also be assessed if Haley has had any incidents of vomiting or diarrhea. Finally, the health care provider should ask Haley’s parents if she is up to date with all her vaccinations and acquire a list of vaccinations from her doctor’s office to confirm that she is.
Haley’s vital signs consist of a temperature of 99.2 degrees Fahrenheit, a heart rate of 125 beats per minute, a blood pressure reading of 85/44, a respiratory rate of 62, and an oxygen saturation of 92% on Room Air. Her heart rate is regular and no murmur is heard. Upon auscultation of the lungs, crackles are heard bilaterally. While breathing, intercostal retractions are present. Bowel sounds are present in all four quadrants.
With the primary diagnosis of dehydration, certain other details of Haley’s assessment would be present. It would be expected for Haley’s parents to confirm a decrease in the amount of wet diapers she has produced since they have noticed her decrease in oral fluid intake. With dehydration, her body will produce less and less diapers as her tissues absorb the fluid and replenish themselves. Furthermore, with severe dehydration, Haley’s mucus membranes would be dry, her skin turgor would be inadequate, and she would not be able to produce tears if she should cry. A thorough assessment would include looking at Haley’s eyes and mouth to confirm they are adequately moist and to observe Haley if and when she should cry. Haley may also be increasingly fussy, and sleeping more than usual.
Haley’s main cause for concern are the crackles heard in her lungs bilaterally. These adventitious breath sounds point to a respiratory illness. Haley’s intercostal retractions to breath also indicate she is struggling to breath, further indicating a respiratory infection. When children develop respiratory infections, they compensate for the decreased oxygen perfusion by increasing their respiratory rate (Hockenberry & Wilson). The increase in respiratory rate prevents adequate oral fluid intake. Children may refuse the bottle because they know they need to increase their respiratory rate and would rather breathe than drink their bottle. Furthermore, as an individual breathes, water is lost, leading to insensible water loss. If Haley is breathing faster than normal, she is losing more water than normal, further adding to her dehydration (Hockenberry & Wilson). Haley’s low-grade temperature also contributes to her fluid deficit. As her temperature would increase, Haley’s tissues would require more and more fluid to remain healthy. If Haley does in fact have a respiratory illness, she may also have nasal secretions (Hockenberry & Wilson). If these secretions are blocking her nasal passages, Haley’s respiratory rate would increase and she would not be able to tolerate oral feedings because she would not be able to breathe while she is drinking her formula (Hockenberry & Wilson).
Haley’s parents should be questioned to see if they have received their vaccinations, particularly the Pertussis vaccination. Adults around small children can unknowingly infect these children with pertussis (Pertussis (Whooping Cough) Vaccination). In adults, pertussis can be a normal cough. However, in children pertussis is a very serious condition, leading to a respiratory infection and difficulty breathing. Haley’s parents should be questioned if they have had any recent respiratory infections or if they have noticed a characteristic cough from Haley (Pertussis (Whooping Cough) Vaccination).
Interventions
Haley’s treatment would also include addressing her respiratory infection. It should first be determined if her illness is of bacterial or viral origin. From there, it would be determined how to treat the illness. If her infection is caused by a bacteria, antibiotics would be useful in treating the infection. If her infection is caused by a virus, her symptoms would be treated, but no antibiotics would be used. To increase Haley’s oxygen perfusion, she may be placed underneath a cool-mist vaporizer with humidified air to open up her respiratory tract (Caserta). Furthermore, if Haley is producing nasal secretions, these would be removed with a rubber suction bulb to allow Haley to breathe while she is being fed. If Haley’s temperature would persist or begin to increase, ibuprofen would be given to reduce her fever and lower her need for increased fluids (Caserta).
Diagnostics
A Chest X-Ray would be ordered to determine how extensive the respiratory infection is, where the consolidation lies, and to more accurately diagnose the infection (Caserta). A positive CXR would show fluid build-up in the lower lobes of the lungs, indicating a respiratory infection. Blood tests may or may not be taken from the child. Blood tests would be useful in determining if there is an electrolyte imbalance. Using these results, the physicians can create a more specialized plan of care and determine what fluids would be best in rehydrating Haley. A urinalysis may also be taken to determine how severe the dehydration has become (Caserta).
Children of this age should also be screened for Respiratory Syncytial Virus Infection, or RSV (Respiratory Syncytial Virus Infection). In children younger than 1 year of age, this infection is the most common cause of bronchiolitis and pneumonia. Symptoms of RSV are very similar to those of other respiratory infections. If RSV is suspected, the nasal secretions can be tested to confirm the diagnosis. There are no specific treatments for the RSV infection, so symptoms will be managed. The goal of infection management would be to increase oxygen perfusion by suctioning nasal secretions and providing supplemental oxygen if needed (Respiratory Syncytial Virus Infection).
Evaluation
Haley may be placed under a mist tent and receive IV fluids until all her tests have been collected and the results have been interpreted. Haley should begin to show signs of improvement within the first 24 hours of admission. At first, Haley will not produce many wet diapers because the fluids she is given will restore the fluids lost in her tissues. Once her tissues are sufficiently rehydrated, Haley would begin to produce wet diapers, proving her tissues have been replenished.
Haley’s respiratory infection should be treated, increasing her oxygen perfusion, and decreasing its effect on her hydration status. Her respiratory rate would begin to decrease and she would cease to show signs of labored breathing, as evidenced by a termination of her intercostal retractions. In Haley’s case, just looking at her vital signs, I do not suspect that Haley has RSV. However, all the necessary testing should be done to rule out RSV because it is so dangerous in young children. I also suggest that it be assessed if Haley has pertussis. If Haley has pertussis, she will exhibit the characteristic cough that ends with a whooping sound (Pertussis (Whooping Cough) Vaccination.
If it confirmed that Haley has a respiratory infection caused by a bacteria, she will begin antibiotic therapy. Haley will show signs of improvement within the first 24 hours. If Haley does not have a bacterial infection, and it is thought her infection is caused by a virus, Haley will continue to receive therapy to control her symptoms and should be assessed that her breath sounds are becoming clearer and there are no signs of respiratory distress or fever.
References
Caserta, M. T. (n.d.). Overview of Viral Respiratory Tract Infections in Children - Children's
Health Issues. Retrieved February 23, 2016, from https://www.merckmanuals.com/home/children's-health-issues/viral-infections-in-infants-and-children/overview-of-viral-respiratory-tract-infections-in-children
Dehydration. (2014, April 12). Retrieved February 23, 2016, from
http://www.mayoclinic.org/diseases-conditions/dehydration/basics/definition/con-
20030056
Hockenberry, Marilyn, David Wilson. Wong's Essentials of Pediatric Nursing, 9th Edition.
Mosby, 2013. VitalBook file.
Pertussis (Whooping Cough) Vaccine. (n.d.). Retrieved February 26, 2016, from
http://www.vaccines.gov/diseases/pertussis/#
Respiratory Syncytial Virus Infection. (2014, November 04). Retrieved February 26, 2016, from
http://www.cdc.gov/rsv/about/index.html
