ACEP ID:

Pediatric Emergency Medicine

Pediatric Oral Rehydration Therapy (ORT)

OHSU 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, from http://www.guidelines.gov/summary/summary.aspx
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.

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