Pediatric Vomiting: Management (Nursing)

by Jackie Calhoun, DNP, RN, CPNP-AC, CCRN

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    00:00 So now, how do we manage pediatric vomiting? The first thing we want to do if someone's vomiting is to make sure especially if their neurologic status isn't normal is to make sure that they're not vomiting into their airways.

    00:16 we need to make sure their airway remains patent.

    00:19 The next thing we'll do is evaluate their total fluid losses.

    00:23 This goes back to calculating those ins and outs that we talked about comparing how much they're putting out with how much they're putting in and seeing how those compare.

    00:33 As we mentioned, we're going to calculate the total amount of emesis.

    00:36 The total amount of urine output and compare it to the intake.

    00:41 And then if a patient as we're seen as having a lot of stool, particularly if it's diarrhea, you probably want to include that too, because that contains a lot of water.

    00:49 That will affect this calculation.

    00:51 We're going to review those electrolyte imbalances from our lab results.

    00:57 And these are the labs that you're going to draw that the provider has ordered that you need to know the results of.

    01:03 And then we're going to potentially, if this patient has a lot of vomiting, we can't explain it.

    01:10 They might need some abdominal imaging.

    01:12 They might need an X-ray of their abdomen to see if there's a foreign body or any abnormal intestinal findings.

    01:21 An abdominal ultrasound might happen next, if that X-ray doesn't show anything.

    01:27 And then the last step in the management is to rehydrate these patients.

    01:32 So they're most likely going to be dehydrated, especially if they have been vomiting a lot or for a long time.

    01:38 As with almost anything in medicine, we always like to use the patient's natural ability.

    01:44 So we'd like them to be orally hydrated first if they can.

    01:48 We don't necessarily just start with IV rehydration.

    01:51 But if the patient isn't tolerating taking stuff by mouth, then we'll give them to it with an IV.

    01:58 Great. So now let's wrap everything that we've learned up into the clinical judgment model.

    02:03 We'll focus on layers two and three.

    02:06 And we'll start by recognizing the cues.

    02:09 And remember, the queues are the signs and symptoms of pediatric vomiting that we talked about.

    02:15 So this is that forceful ejection of stomach contents out through the mouth.

    02:20 So not dribbling, not drooling, not slow.

    02:24 But this involuntary, like uncontrolled, forceful ejection of stomach contents.

    02:32 And then those signs and symptoms of dehydration that are important to remember, are looking at the patient's mental status.

    02:40 So are they alert? Do they respond to you? Or are they really sleepier than you would expect? Are they making tears to their mucous membranes look normal? Or do they look dry or tacky? Does their skin turgor look normal? Is it tenting when you pinch one of the skin folds? Or does it go back to the regular shape pretty easily? The next part of the model is to analyze those cues.

    03:09 And one of the ways we're going to do this is by first doing a thorough physical exam.

    03:14 So especially focusing on that mental status.

    03:16 So especially focusing on that mental status.

    03:18 We're going to listen to their breath sounds, we're going to make sure we do a good cardiovascular exam, particularly focusing on their signs of perfusion.

    03:26 So they're capillary refill, their pulses.

    03:31 And then we're going to pay attention to their abdomen.

    03:33 And remember the order of how we're going to examine the abdomen.

    03:37 First, we're going to inspect it.

    03:39 And then we're going to listen to it in all four quarters, no matter how small the size of the patient is.

    03:46 And then we're going to palpate it and we're going to pay close attention to whether the patient seems to be in any pain in any part of the abdomen or if we feel any masses in any part of the abdomen.

    04:00 How we're going to analyze these clues is by looking at those laboratory studies that were ordered.

    04:06 How are my patients electrolytes? How are their pH? One of the concerns with pediatric vomiting is that they might develop that metabolic alkalosis with a pH greater than 7.45.

    04:20 And then we want to pay close attention to their fluid balance.

    04:24 So once again, remembering how those ins and outs compare to each other and making sure that we include everything we should in the ins.

    04:32 So anything they're eating, drinking, or IV fluids compared to the outs, which is any vomiting, urine, or very liquidy stool.

    04:42 So we're gonna prioritize our hypotheses next.

    04:45 And by doing this, we're gonna say, why is this patient experienced in vomiting? And do we think this is a viral infection? They've only been vomiting for a day or so and they have a fever, and they have sick contacts? Or has this been going on for a while and their abdomen looks pretty distended.

    05:04 And you notice that the battery is missing from one of the toys.

    05:07 Maybe they have a foreign body.

    05:10 And then the next thing we want to look at is are whether or not they're dehydrated? So do they have physical exam findings that we talked about that could be concerning for this? Or did we notice that they're really not taking in nearly as much fluid as they're putting out? After all, that now, we can develop our action plan.

    05:33 And this we are going to give rehydration.

    05:37 Remember, oral is preferred.

    05:40 But in some cases, we may have to give IV rehydration, and then antiemetic medications.

    05:47 And these are medications that are ordered by a provider that can help make it have less of an urge to vomit.

    05:54 And then we're going to use nursing interventions for comfort.

    05:58 So I'm sure you've experienced how it feels to vomit, it doesn't feel good.

    06:02 But there's a lot of things that we can do as nurses to help make our pediatric patients feel better.

    06:08 We can provide them with their favorite toys or stuffed animals, make sure that they have a show on that they want to watch.

    06:15 Let them have their tablet.

    06:17 Make sure the room is a good temperature, give them hot packs or cold packs, depending on how they feel.

    06:23 There's a lot you can do to help make your patient feel better in a situation in which they probably don't feel very good.

    06:31 And then lastly, let's evaluate the outcomes of our interventions.

    06:35 So there's three parts of this.

    06:36 We want to make sure their physical exam looks normal again.

    06:40 So is their mental status back to normal? Are there signs of perfusion looking good like they're the blood flow is getting back into their fingers normally. Their pulses feel great everywhere, And is their abdominal exam normal? Like those bowel sounds have gone back to normal, their abdomen doesn't look distended.

    06:59 Then lastly, those signs of dehydration.

    07:01 So we make sure those they're making good tears, they have nice and moist mucous membranes.

    07:07 And that their mental status once again is fine.

    07:10 We make sure the lab studies are back to normal.

    07:13 So any electrolytes that were either high or low before are now getting back into a normal range.

    07:20 And then lastly, that their fluid balance is more even, or if they're ins might be slightly more than their outs.

    07:30 So that was our talk about pediatric vomiting.

    07:33 And I hope that you learned something today, and I'm really glad that you listened. Thank you.

    About the Lecture

    The lecture Pediatric Vomiting: Management (Nursing) by Jackie Calhoun, DNP, RN, CPNP-AC, CCRN is from the course Gastrointestinal Disorders – Pediatric Nursing.

    Included Quiz Questions

    1. Maintaining a patent airway.
    2. Obtaining intravenous access.
    3. Preventing fluid loss.
    4. Ruling out abdominal pathology.
    1. Calculate the total emesis and urine output and compare it to intake.
    2. Calculate the total emesis and compare it to intake.
    3. Check skin turgor and capillary refill.
    4. Check skin turgor, capillary refill, and amount of emesis.
    1. Oral rehydration
    2. Intravenous rehydration
    3. Rectal rehydration
    4. Subcutaneous rehydration

    Author of lecture Pediatric Vomiting: Management (Nursing)

     Jackie Calhoun, DNP, RN, CPNP-AC, CCRN

    Jackie Calhoun, DNP, RN, CPNP-AC, CCRN

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