Pediatric Gastroenteritis
UNFOLDING Reasoning
Harper Anderson, 5 months old
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
1. Inflammation
2. Perfusion
3. Fluid and Electrolyte Balance
4. Acid-Base Balance
5. Thermoregulation
6. Clinical Judgment
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Pediatric Gastroenteritis
History of Present Problem:
Harper Anderson is a 5-month-old female who was brought into the physician’s office for diarrhea and vomiting over the
past two days. She had two loose large loose stools the first day and now her mother reports that she has been less active,
is not interested in playing, and has been more sleepy today. She is unable to keep any feedings down today. She has had
four loose, watery stools and emesis x3 this morning. She has not had a wet diaper since yesterday evening. She is 25
,inches (63.5 cm) in length and weighs 14 pounds, 2 ounces (6.4 kg). She weighed 15 pounds, 2 ounces (6.86 kg) at her
last office visit two weeks ago. Harper is a direct admit to the pediatric unit where you are the nurse responsible for her
care.
Personal/Social History:
Harper’s mother Nicole is 21 years old. She is a single mother and this is her first child. Nicole is not currently working
and lives with her parents. Though she has strong social support from her parents, she feels consistently overwhelmed as a
new mother.
Past Medical History (PMH):
∙ Healthy full-term infant that weighed 6 pounds 10 ounces (3.0 kg) at birth.
∙ No current health problems. Mom is no longer breast feeding and Harper is on formula.
∙ Mother had no complications with pregnancy.
∙ Has not had any immunizations from birth, including rotavirus
RELEVANT Data from Present Problem: Clinical Significance:
1. Diarrhea and vomiting over the The patient is presenting with signs of dehydration and
past two days infection
2. Less active, not interested in
playing
3. Unable to keep any feedings today
4. Four loose, watery stools and
emesis x3 this morning
5. No wet diaper since yesterday
evening
6. Today's weight is 14lb, 2oz. Last
office visit, 2 weeks ago, weight
was 15lb, 2oz.
RELEVANT Data from Social History: Clinical Significance:
1. Mother is 21 years old, single, and Mother is young and single, this is where a support system must be
this is her first child established. Mother is not working, lives with her parents, but is
2. Mother is not working and lives constantly overwhelmed as a new mother, there may be a financial
with parents stressor and mother may be experiencing postpartum
3. Even with support, the mother is depression/blues.
consistently overwhelmed as a new
mother
Patient Care Begins:
Current VS: Pain Assessment – FLACC Behavioral Pain Scale
T: 102.2 F/39.0 C (axillary) Face: 1
P: 158 Legs: 0
R: 38 Activity: 1
, BP: 62/42 Cry: 1
O2 sat: 95% RA Consolability: 2/Total score: 5/10
© 2016 Keith Rischer/www.KeithRN.com
FLACC Behavioral Pain Scale
0 1 2
Face Relaxed or smile Occasional grimace, Frequent frown, clenched jaw, quivering chin
frown, withdrawn
Legs Relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, Squirming, tense Arched, rigid, or jerking
moves easily
Cry No cry (awake Moans, whimpers. Crying, sobs, screams, frequent complaints
or asleep) Occasional complaints
Consolability Content or Easy to console, distractible Difficult to console or comfort
relaxed
Each of the five categories is scored from 0-2, resulting in a total of 0-10
What VS data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
1. Temperature: 102.2F An elevation in temperature indicates infection and a low BP indicates
2. BP: 62/42 dehydration. Rest of Vital signs are WNL.
Current Assessment:
GENERAL Irritable when awake, alternates with lethargy once quiet, when awake and
APPEARANCE: crying, tears are not present
RESP: Breath sounds clear with equal aeration bilaterally, non-labored
CARDIAC: Skin is pale, cool to touch, cap refill 3–4 seconds in both hands, brachial
pulses palpable bilaterally
NEURO: Lethargic, does not maintain eye contact with mom or caregiver
UNFOLDING Reasoning
Harper Anderson, 5 months old
Primary Concept
Infection
Interrelated Concepts (In order of emphasis)
1. Inflammation
2. Perfusion
3. Fluid and Electrolyte Balance
4. Acid-Base Balance
5. Thermoregulation
6. Clinical Judgment
7. Communication
8. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Pediatric Gastroenteritis
History of Present Problem:
Harper Anderson is a 5-month-old female who was brought into the physician’s office for diarrhea and vomiting over the
past two days. She had two loose large loose stools the first day and now her mother reports that she has been less active,
is not interested in playing, and has been more sleepy today. She is unable to keep any feedings down today. She has had
four loose, watery stools and emesis x3 this morning. She has not had a wet diaper since yesterday evening. She is 25
,inches (63.5 cm) in length and weighs 14 pounds, 2 ounces (6.4 kg). She weighed 15 pounds, 2 ounces (6.86 kg) at her
last office visit two weeks ago. Harper is a direct admit to the pediatric unit where you are the nurse responsible for her
care.
Personal/Social History:
Harper’s mother Nicole is 21 years old. She is a single mother and this is her first child. Nicole is not currently working
and lives with her parents. Though she has strong social support from her parents, she feels consistently overwhelmed as a
new mother.
Past Medical History (PMH):
∙ Healthy full-term infant that weighed 6 pounds 10 ounces (3.0 kg) at birth.
∙ No current health problems. Mom is no longer breast feeding and Harper is on formula.
∙ Mother had no complications with pregnancy.
∙ Has not had any immunizations from birth, including rotavirus
RELEVANT Data from Present Problem: Clinical Significance:
1. Diarrhea and vomiting over the The patient is presenting with signs of dehydration and
past two days infection
2. Less active, not interested in
playing
3. Unable to keep any feedings today
4. Four loose, watery stools and
emesis x3 this morning
5. No wet diaper since yesterday
evening
6. Today's weight is 14lb, 2oz. Last
office visit, 2 weeks ago, weight
was 15lb, 2oz.
RELEVANT Data from Social History: Clinical Significance:
1. Mother is 21 years old, single, and Mother is young and single, this is where a support system must be
this is her first child established. Mother is not working, lives with her parents, but is
2. Mother is not working and lives constantly overwhelmed as a new mother, there may be a financial
with parents stressor and mother may be experiencing postpartum
3. Even with support, the mother is depression/blues.
consistently overwhelmed as a new
mother
Patient Care Begins:
Current VS: Pain Assessment – FLACC Behavioral Pain Scale
T: 102.2 F/39.0 C (axillary) Face: 1
P: 158 Legs: 0
R: 38 Activity: 1
, BP: 62/42 Cry: 1
O2 sat: 95% RA Consolability: 2/Total score: 5/10
© 2016 Keith Rischer/www.KeithRN.com
FLACC Behavioral Pain Scale
0 1 2
Face Relaxed or smile Occasional grimace, Frequent frown, clenched jaw, quivering chin
frown, withdrawn
Legs Relaxed Uneasy, restless, tense Kicking or legs drawn up
Activity Lying quietly, Squirming, tense Arched, rigid, or jerking
moves easily
Cry No cry (awake Moans, whimpers. Crying, sobs, screams, frequent complaints
or asleep) Occasional complaints
Consolability Content or Easy to console, distractible Difficult to console or comfort
relaxed
Each of the five categories is scored from 0-2, resulting in a total of 0-10
What VS data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
1. Temperature: 102.2F An elevation in temperature indicates infection and a low BP indicates
2. BP: 62/42 dehydration. Rest of Vital signs are WNL.
Current Assessment:
GENERAL Irritable when awake, alternates with lethargy once quiet, when awake and
APPEARANCE: crying, tears are not present
RESP: Breath sounds clear with equal aeration bilaterally, non-labored
CARDIAC: Skin is pale, cool to touch, cap refill 3–4 seconds in both hands, brachial
pulses palpable bilaterally
NEURO: Lethargic, does not maintain eye contact with mom or caregiver
