Emergency Department Case Study: Neonate and Pediatric Presentations

This assignment analyzes a case study involving a six-week-old baby presenting to the emergency department with a high fever, diarrhea, and vomiting. The student is tasked with determining the appropriate triage score based on the baby's condition, which includes slightly blue lips, a sunken fontanel, and reduced responsiveness. The assignment requires listing potential diagnoses, considering factors such as viral or bacterial infections, and the risk of dehydration. It also involves outlining key elements of a pediatric history, including the presentation of complaints, history of the present illness, birth history, feeding history, and developmental milestones. The student must recommend whether antipyretic therapy is suitable and justify the decision. Moreover, the assignment addresses the critical parameters for assessing fluid and electrolyte imbalances, emphasizing the use of blood and urine tests, and the methods for accurately obtaining this data. The student references relevant literature to support the analysis and recommendations, focusing on the Australian healthcare system.

Running head: NEONATE AND PEDIATRIC PRESENTATIONS
Discussion: She is so hot, I am really worried
Name
Instructions

2
NEONATE AND PEDIATRIC PRESENTATIONS
1. What Triage score would you give this patient?
In this case, I would give the baby ATS category 4. This is because the baby was suffering from
a high fever, diarrhoea and vomiting. The category suggests that treatment and assessment
should commence within a period of one hour (Hodge, Hugman, Varndell & Howes, 2013). The
baby’s condition potentially serious as the situation can worsen, or result in adverse outcome if
treatment and assessment is not carried out within 60 minutes of arrival in the Emergency
Department (ED).
2. List the provisional diagnosis/potential problems?
The baby’s condition can be attributed to a lot of factors such as a virus infection, parasite or
bacteria. The baby could have picked up germs when it came into contact with unclean water or
food or contact from dirty surfaces and then put their hands into their mouths. The infection can
be from viruses such as rotavirus, bacteria like salmonella. According to Roque (2019), rotavirus
is very dangerous for infants and is the most common cause of diarrheal problems among babies
(Habib, Kazi, Khan & Zia, 2014). Almost every child worldwide is infected with rotavirus at
least before the age of five (5) years.
Moreover, the baby’s fever, vomiting, and diarrhoea cause loss of body fluids and leads to
dehydration, which is significantly dangerous, especially for infants and young children.
Rotavirus is highly contagious and this could explain why the mother’s 3 years old son has the
same illness. Rotavirus passes easily from one person to another. The virus can be easily passed
through the stool of an infected person prior to and after showing symptoms. Furthermore,
children can acquire the infection when they put hands in their mouths after coming into contact
with a contaminated surface such as toys. Comparatively, this could have happened if the 3 years

3
NEONATE AND PEDIATRIC PRESENTATIONS
older baby did not wash his hands, especially after using the toilet and before eating. The fault
could also lie on the parent, those who care for the infants, including childcare and health care
workers, can also spread the virus, especially if they fail to clean their hands after changing
diapers. Failure to wash hands carefully after changing diapers, before handling food, and using
the bathroom can have adverse effects. Washing your hands often is the best way to stop
spreading of the virus.
3. Name at least 5 key elements when taking a history for paediatric presentations
i. Presentation of the complaints: this is done in parent’s own words in
chronological order. Chronology in nursing highlights all the information
provided by the parent in sequence (Excelas1, 2019). This order is very
important and can help the healthcare provider and legal nurse consultant in
locating the records later.
ii. History of the present illness: first, the nurse enquires about when the baby
was entirely well. Second, complains are presented in accordance to time,
place, quality, alleviative factors (seasonal or diurnal), associated symptoms,
and treatment if any. The third step involves a systemic inquiry of weight,
CVS, respiratory system, gastrointestinal system, CNS, genitourinary system,
and rheumatological system.
iii. Birth history: this is usually important in neonatal cases to inquire about the
antenatal history which involves the mother’s health, nutrition status, and
illnesses during pregnancy. The natal history is also taken to identify the place
of birth, type of delivery, gestation time, etc. the postnatal history follows to
identify the basic problems, fevers, procedures, convulsions, and birth weight.

4
NEONATE AND PEDIATRIC PRESENTATIONS
iv. Feeding history and Immunization: this is important for children below the
age of 2 years to identify the onset of feeding, type of feed, weaning,
supplements, and current diet. The nurse also checks the vaccination cord to
determine the types of vaccination given, age at which they started, as well as
doses and adverse effects.
v. Developmental history: involves asking parents to recall significant
milestones such as sitting up and crawling. This can be used to compare with
the siblings or peers.
4. Would antipyretic therapy be recommended why or why not?
In this case, I would recommend antipyretic therapy to reduce fever. Antipyretics causes the
hypothalamus to overrule a ‘prostaglandin-induced’ temperature increase (Ebi web team, 2019).
If the baby’s temperature is above 38.3°C (101°F), antipyretic therapy will be a good call to
regulate the temperatures and improve the baby’s comfort in general (Nelson, Ostapenko, Zorc
& Balamuth, 2018). Even though only 13% of healthcare providers particularly cite discomfort
as the main attestation use of antipyretic therapy, this objective is commonly implied in their
suggestions. Antipyretics work by reducing the levels of PGE (2) and supressing the enzyme
cyclooxygenase within the hypothalamus. Notably, fever is a multiplex physiologic response
initiated by aseptic or infectious stimuli. Body temperature elevations take place when
prostaglandin E (2) (PGE (2) concentrations rise exceeding certain areas of the brain. This
increased rise changes the neurons firing rate which is responsible for controlling
thermoregulation in the hypothalamus (Pereira, Dagostini & Dal Pizzol, 2012). Pereira et al.
(2012) argues that even though fever benefits the nonspecific immune response to attacking
microorganisms, it is also perceived as a significant source of discomfort among infants and is

5
NEONATE AND PEDIATRIC PRESENTATIONS
can be easily curbed by use of antipyretic medication. The use antipyretics such as aspirin have
been widely used for many years, however, their fever relieving mechanisms have only been
documented in the last few decades.
5. What is the most important parameter to be collected for actual and potential fluid
and electrolyte imbalances? How do you accurately obtain this data?
In this case, blood and urine are the most important parameters used to identify electrolyte
imbalance and further evaluate its severity. To accurately obtain the data, a paediatrician can use
an electrolyte panel to screen for electrolytes imbalances in the blood as well as identify the
kidney function and acid-base balance (McLafferty, Johnstone, Hendry & Farley, 2014).
The 24-hr number is approximately divided into hourly rates for convenience
‘100 ml/kg/24-hours = 4 ml/kg/hr for the 1st 10 kg.
50 ml/kg/24-hours = 2 ml/kg/hr for the 2nd 10 kg.
20 ml/kg/24-hours = 1 ml/kg/hr for the remainder’
Notably, this test can also be used to monitor the treatment’s progress in relation to a known
imbalance. The pediatrician can also use the electrolyte panel in routine physical exam which
can be carried out on its own or as part of a range of tests. To ensure accuracy, the levels are
gauged in millimoles per liter ‘mmol/L’ with the use of concentration of blood electrolytes.
Comparatively, disorders relating to electrolytes are in most cases brought about by bodily fluids
loss through diarrhea, sweating, or vomiting which could be the case for this baby. These tests

6
NEONATE AND PEDIATRIC PRESENTATIONS
can be carried out using urine and blood samples depending on the baby’s condition. With
reference to the tests results, all the underlying health conditions the child may have are
identified. Further, a befitting treatment plan can be structured to adjust the electrolyte and fluid
imbalance and prevent further complications.

7
NEONATE AND PEDIATRIC PRESENTATIONS
References
Excelas1com. (2019). Excelas. Retrieved 1 October, 2019, from
https://excelas1.com/service/medical-chronology/
Habib, M. I., Kazi, S. G., Khan, K. M. A., & Zia, N. (2014). Rota virus diarrhea in hospitalized
children. Journal of the College of Physicians and Surgeons Pakistan, 24(2), 114.
Hodge, A., Hugman, A., Varndell, W., & Howes, K. (2013). A review of the quality assurance
processes for the Australasian Triage Scale (ATS) and implications for future
practice. Australasian Emergency Nursing Journal, 16(1), 21-29.
McLafferty, E., Johnstone, C., Hendry, C., & Farley, A. (2014). Fluid and electrolyte
balance. Nursing Standard, 28(29).
Nelson, C. E., Ostapenko, S., Zorc, J. J., & Balamuth, F. (2018). Utilization of Antipyretics for
Nonurgent Fever in a Pediatric Emergency Department. Clinical pediatrics, 57(6), 722-
726.
Pereira, G. L., Dagostini, J. M. C., & Dal Pizzol, T. D. S. (2012). Alternating antipyretics in the
treatment of fever in children: a systematic review of randomized clinical trials. Jornal
de pediatria, 88(4), 289-296.
Roque, C. (2019). Kidshealthorg. Retrieved 1 October, 2019, from
https://kidshealth.org/en/parents/rotavirus.html