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.