Pediatric Oral Rehydration Therapy (ORT)

HSU Health Care System Patient Care Services Division - Nursing Policy and Procedure Manual

Emergency Department Nursing Assessment and Action Documentation Guidelines

Indications

Pediatric patients (6 months to 4 years of age) with signs and symptoms of mild to moderate dehydration and history of diarrhea, nausea, and vomiting.

Exclusion Criteria for ORT

• Children <6 months of age
• Bilious vomit
• Hematemesis
• Bloody diarrhea
• Ventriculoperitoneal (VP) shunt
• Recent head trauma
• Focal RLQ abdominal pain and/or temp over 38.5 Celcius (indicating possible appendicitis)
• Evidence of intestinal obstruction (abdominal distension and tenderness, decreased bowel sounds)
• Any patient with complex past medical history (refer decision to MD)
• Severe dehydration (>100 mL/kg), as evidenced by rapid, thready pulse, marked hypotension, obtunded mental status, and/or capillary refill time >3 seconds
• If child vomits 3 or more times after initiation of ORT in the ED

Documentation

• NEURO - level of responsiveness, recent changes in behavior/mental status
• HEENT - absence of tears, dry mucous membranes, sunken fontanels
• CV - tachycardia, thready pulse, hypotension
• PV - increased capillary refill time (>3 sec.)
• GI - assess for bloody diarrhea as well as blood-tinged and/or bilious vomitus and frequency of each; assess abdominal distension, tenderness, bowel sounds
• GU - decreased urine output
• SKIN - fever, decreased elasticity, pallor
• PAIN - onset/location/duration/severity/pain scale 0-10 if applicable
• VS - per policy to include body weight
• PSYCH/SOCIAL - ascertain home therapy thus far (types of fluid, amounts, frequencies, successes/failures)
• Document reassessment after intervention.

Interventions

Triage patient as Urgent or Level 3 or 4 according to Triage Guidelines. If no beds are available, ORT will be initiated by Triage RN and administered by parent/caregiver in the waiting room until a bed is available. Obtain complete set of vitals, including body weight. Initiate ORT: Obtain ORT caddy (one in Acute, one in Triage, and one in Peds/MC). Complete parent/caregiver ORT instruction sheet using reference sheet in ORT Notebook. Instruct parent/caregiver how to administer the ORT solution (Pedialyte). Whether the child receives ORT or intravenous rehydration therapy, emphasize to the parent/caregiver the importance of initiating ORT at home to prevent future visits. Document reassessment after intervention.

References

• National Guideline Clearinghouse. (2004). Evidence based clinical practice guideline for children with acute gastroenteritis (AGE). Retrieved April 29, 2004.
• Newberry, L. (Ed.). (2003). Sheehy's emergency nursing: principles and practice (5th ed.). St. Louis: Mosby.
• ]The University of Chicago Dept. of Pediatrics. (2004). Pediatric emergency department clinical guideline: dehydration-rehydration. Retrieved April 29, 2004.