PEDIATRIC CASE STUDY: GI
Kara Dazkevich, Caitlin Melluzzo, Stacey Roy
SUMMARY STATEMENT: Marty is a 9-year-old boy who presents to the office today with a 3-day history of diarrhea, which has been progressively worsening since onset, now with 8-12 episodes of watery diarrhea/day. + for nausea with vomiting 4 days ago. Now refusing PO food and fluids. + for fever with tmax 102.8 F orally. – urine output x 24 hours. + disinterest in play. Presents today quiet and listless, poor skin turgor, and abdomen soft, but diffusely tender to all quadrants on palpation. – HSM or palpable mass. Febrile to 101.6 F with tachycardia (HR 110) and tachypnea (RR 38) at the time of the visit. + for sick contact at school. No significant/contributory PMH.
LEADING DIAGNOSIS: Viral gastroenteritis with hypovolemia
DDx #1: Bacterial gastroenteritis (with hypovolemia)
DDx #2: Salmonella sepsis
PLAN OF CARE RATIONALE
Diagnostics (cost included)
-Obtain bedside finger stick glucose ($9) – done in office
Tests to likely be done in the ED:
-CBC with diff ($23)
-Basic metabolic panel ($25)
-Stool culture ($28)
-C. difficile toxin ($72)
-blood cultures ($48)
-Lactic acid ($31)
-Abdominal x-ray ($51)
(Healthcare Bluebook, 2019)
Finger stick: Patient has had poor PO intake and is listless, which can be a sign of hypoglycemia.
Because the patient is ill-appearing (i.e. listless, quiet, poor skin turgor) we will obtain a broader panel of labs to rule out potentially life-threatening complications such as sepsis.
The patient appears severely dehydrated with poor skin turgor, oliguria, poor PO intake so we will assess for electrolyte imbalances or a possible acute kidney injury. Also, with profound GI losses the patient is at risk for a non-anion gap metabolic acidosis due to bicarbonate losses in stool. We will assess the bicarbonate level in the basic metabolic panel.
CBC with diff: evaluate for an elevated white count (infection), Hgb/Hct (low Hgb/Hct seen with anemia 2/2 blood loss through GI tract, high Hgb/Hct seen in severe dehydration), low platelet count (seen in sepsis) (Pagana & Pagana, 2011).
BMP- evaluate for electrolyte imbalances 2/2 losses from diarrhea, BUN/Cr for possible prerenal acute kidney injury due to dehydration, BUN/creat ratio to evaluate for dehydration (increased BUN with stable creatinine is suggestive for hypovolemia), evaluate for metabolic acidosis by calculating the patients anion gap ([sodium + potassium] – [chloride + bicarb]) (seen in sepsis and lactic acidosis) – assess for non-anion gap acidosis in the setting of significant bicarb loss 2/2 diarrhea (Pagana & Pagana, 2011)
Stool culture- obtaining a stool culture is helpful in identifying the pathogen behind this childs symptoms. Infectious bacterial, protozoal, or parasitic organisms would be identified in this way and would further dictate treatment. Examples of organisms that may be found on examination of a stool culture include Clostridium difficile (cdiff), E.coli, Campylobacter, Strongyloides (tapeworm), and Giardia (Pagana & Pagana, 2011).
Cdiff toxin- while Cdiff may be identified in the stool culture, the culture often takes longer to result, and may delay diagnosis. In addition to obtaining a stool culture, a Cdiff toxin assay would provide the NP with results specific to this pathogen more rapidly (Pagana & Pagana, 2011). It is important to note that when obtaining a cdiff toxoid sample, the patient must be placed on contact isolation precautions to prevent the possible spread of this contaminant to others (Pagana & Pagana, 2011).
Blood culture and sensitivity- Two samples from two different sites should be drawn to detect the presence of bacteremia. If one sample is positive for the presence of bacteria, while the other sample is not, is considered safe to assume that the positive sample was contaminated, thus warranting the need to draw two samples and confirm bacteremia with the presence of organisms in both sets of cultures (Pagana & Pagana, 2011). Blood cultures should be obtained prior to the start of antibiotic treatment, and should not be obtained through an existing IV catheter, arterial line, or central venous line to reduce the risk of contamination (Pagana & Pagana, 2011). In drawing blood cultures, both anaerobic and aerobic samples are drawn from each site (for a total of four vials) to identify the presence of bacterial growth. Bacteremia is present if both sets of blood cultures are positive, and treatment is aimed at targeting the specific organism identified (Pagana & Pagana, 2011).
Lactic acid-A lactic acid level is drawn in this patient to identify the level of shock, sepsis, or hypoxia that may be present 2/2 infection and hypovolemia (Pagana & Pagana, 2011). If the BMP was suggestive of metabolic acidosis, the presence of an elevated lactate level would be highly suggestive of sepsis (Pagana & Pagana, 2011).
Abdominal X-Ray-identify toxic megacolon, peritonitis, or the presence of free air suggesting bowel perforation (Fleisher, 2019)
Interventions (cost included)
-Peripheral IV insertion ($45) (MacArthur, 2017)
-Isotonic IV fluid bolus- LR or 0.9%NS 20ml/kg/hr for 2-4 hours (~$91 per liter of IV fluids) (Bernstein, 2013).
-With clinical improvement after fluid boluses- e.g. improved urine output, improved skin turgor, we will transition to maintenance fluids at 64mL/hour (Medscape, 2019).
-Repletion of electrolytes as needed
-Treat fever with intravenous Tylenol 10-15mg/kg q6 hours, which in this case will be about 320mg q6 hours IV (Farinde, 2019). $40/dose (Johnson, 2018).
-Addition of probiotics once adequately hydrated and able to take PO ($23.99 for 30 count) (CVS, 2019)
-Maintain nutrition once able to tolerate PO Fluid bolus: The patient is showing signs of severe dehydration with oliguria, poor skin turgor, tachycardia in the setting of profuse watery diarrhea and fever. The patient requires a fluid bolus (Burns et al., 2017).
Maintenance fluids: Once rehydration therapy is complete, maintenance fluids based on ongoing losses, plus recommended daily fluid requirements should be given. The patients daily fluid requirement is calculated at 1535.4 mL based on a weight of 48lbs, which comes out to approximately 64mL/hour. However, additional losses from ongoing diarrhea and insensible losses from fever must be factored in as well (Medscape, 2019).
-Hypokalemia is particularly common in severe dehydration due to diarrhea as the potassium concentration in stool water is high (Emmett & Palmer, 2019).
-Treating the underlying fever will improve the patients comfort, will reduce continued insensible fluid losses and reduce the risk of further complications, including febrile seizures (Fleisher, 2019).
-Although more research needs to be done, probiotics have been associated with reduction of watery diarrhea by 1-2 days. They may also help prevent recurrence of diarrhea (Ebach, 2018; Churgay & Aftab, 2012).
-Resuming early refeeding, defined as, intake during or immediately after rehydration. This allows the contents of the bowel to stimulate growth of enterocytes needed to facilitate mucosal repair following injury (Burns et al., 2017).
-Educate the mother to not give the patient any anti-diarrheals at this time (Burns et al., 2017).
-Hygiene strategies and prevention of
-Ensure that infants in close contact with child are up to date with the administration of the Rotavirus vaccination
-Antidiarrheal medications are not recommended for the treatment of acute diarrhea because toxins need to be expelled from the body (Burns et al., 2017)
-Hygiene and public health strategies recommended, most importantly handwashing. It is important to educate Marty that viral gastroenteritis is highly contagious. He should be educated about proper hand washing with soap and hot water, and encouraged to dry his hands with paper towels. Marty should specifically be educated to thoroughly wash his hands after using the toilet, before eating, and before & after preparing food, handling garbage, and handling animals. He should also be instructed to avoid swimming and other water activities with other people while symptomatic (Ebach, 2018). Recommended exclusion from school is 24 hours after the last episode of diarrhea (Prasad, 2019)
While proper hand washing can reduce the spread of viral gastroenteritis, it is not specifically helpful in reducing the spread of Rotavirus, which is a significant contributor to the spread of viral gastroenteritis (Churgay & Aftab, 2012). The CDC recommends that vaccination series for Rotavirus begin at 2 months of age, and be completed by 8 months of age, either in a 2 dose or 3 dose series injection, depending on the formulary used (CDC, 2019). While Marty is out of the window for receiving the Rotavirus vaccination, if he hasnt already, it is important to assess his close contacts and identify significant risk. If Marty is in close contact with any infants under 8 months old (i.e. siblings, family members, day care), it is important to educate the family to ensure proper and timely vaccination of the Rotavirus vaccine in those children to reduce further risk, and to avoid close contact with Marty during this time of acute illness as viral gastroenteritis is highly contagious (Churgay & Aftab , 2012).
-Thoroughly cook all meats, poultry, seafood, eggs (Burns et al., 2017)
– BRAT (bananas, rice, applesauce, toast) diet recommended
-Avoidance of beverages such as apple juice with high sugar content
-Frequent small feedings every 3-4 hours
-After diarrhea stops, consume 1 more meal than usual, for at least 2 weeks
-Consider low lactose diet until diarrhea resolves- severe/prolonged diarrhea can lead to a secondary lactose intolerance in children (Jimenez & Grow, 2015)
-The patient will be transported to the Emergency Department immediately via EMS as he is severely dehydrated.
-Discharge from hospital -According to Ebach (2018), Martys symptoms of lethargy, inability to drink, tachypnea, tachycardia, poor skin turgor, and oliguria put him in the severely dehydrated category. This is important to note because the usual initial treatment of Oral Rehydration Solution, would not be indicated with his presentation (Ebach, 2018). Use of clinical dehydration scale using 4 categories can help determine the need for IVF and length of stay in children with acute gastroenteritis (Ebach, 2018).
-Discharge from hospital would be considered when the following criteria has been met: Weight gain or clinical presentation demonstrates adequate hydration, IVF no longer indicated, oral intake>losses, and follow-up assured with office visit (Ebach, 2018).
Follow up with the patient in the office within one week of discharge.
-If symptoms persist and diarrhea becomes chronic despite conservative treatment, consider GI referral. The primary care FNP is responsible for the coordination of care for the patient across the continuum. It is important to follow up with the FNP within one week after hospital discharge to ensure proper medication reconciliation and ensure a safe and comprehensive plan of care for the patient. The FNP ensures there are no conflicting plans of care, confusing instructions, or new medication contraindications or interactions (Marder, 2017).
-If symptoms do not improve, or worsen, within 5 days, consider alternative causes for diarrhea. Continuously re-evaluate symptoms to assess for any new or worsening symptoms. Educate the family to seek emergency medical attention with any decrease in mental status, worsening lethargy, increased irritability, or confusion, as these may be signs of worsening dehydration and CNS changes (Fleisher, 2019).
-If symptoms become chronic and preliminary lab work is inconclusive for a cause of persistent diarrhea, consider referral to GI to further evaluate. Further workup by GI would likely aim to rule out chronic causes for persistent diarrhea, including Crohns disease, Ulcerative Colitis, food sensitivities and intolerances, and IBS (Burns et al., 2017).
ADDED EFFECT VALUE OF FNP
The FNP has advanced practice training and will recognize the acutely ill child requiring a higher level of care. The FNP will give a clear handoff to EMS using SBAR format.
The FNP is trained in the nursing model, which emphasizes the holistic and comprehensive patient centered care. The FNP is adept to recognize the medical needs of the child but also will consider the psychosocial effects this illness can have on the child and family unit.
The FNP will provide personalized education to mother and patient. The FNPs advanced practice education emphasizes patient education. Additionally, the FNP likely has prior experience as an RN which provided opportunity to hone education skills. The FNP will instruct the mother to recognize signs of illness that require immediate medical attention. In addition, the FNP will instruct her on proper hygiene to prevent transmission of illness to the rest of the family as well as disinfection of household items. The FNP will also provide anticipatory guidance about what to expect at the hospital.
At follow up appointments the FNP will ensure that holistic care is provided. The FNP will address all questions, ensure education is provided in an understandable manner, and will ensure comprehension from the patient and caregiver(s).
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