Admitting Orders for 1-Year-Old with Moderate Dehydration
For this 8.3kg child with moderate dehydration from fever and vomiting, initiate oral rehydration therapy with 830mL of low-osmolarity ORS (100 mL/kg) administered over 3-4 hours, with nasogastric administration if oral intake is refused or not tolerated. 1
Initial Assessment and Documentation
- Document baseline weight (8.3kg) immediately - this is mandatory before initiating treatment and serves as the most accurate assessment of fluid status 2
- Assess dehydration severity using clinical signs: skin turgor (prolonged tenting >2 seconds), perfusion status (capillary refill, extremity temperature), mental status, and respiratory pattern 2
- Moderate dehydration (6-9% fluid deficit) is characterized by loss of skin turgor, tenting of skin when pinched, and dry mucous membranes 2
Rehydration Phase Orders
Primary Rehydration Strategy
- Administer low-osmolarity oral rehydration solution (ORS): 830mL total over 3-4 hours (calculated as 100 mL/kg for moderate dehydration) 1
- Acceptable commercial formulations include Pedialyte, CeraLyte, or Enfalac Lytren 1
- Do NOT use apple juice, Gatorade, or commercial soft drinks - these are inappropriate for rehydration 1, 3
If Oral Intake Not Tolerated
- Nasogastric ORS administration at 125 mL/hour (15 mL/kg/hour for this 8.3kg infant) if the child refuses to drink adequately or cannot tolerate oral intake 4
- For vomiting: administer small, frequent volumes (teaspoonful every 1-2 minutes) to improve tolerance 3
- Consider ondansetron (if >4 years old per guidelines, though this patient is 1 year) to facilitate oral rehydration tolerance 1, 5
Escalation Criteria to IV Therapy
- Switch to IV isotonic fluids (lactated Ringer's or normal saline) if:
- IV bolus: 20 mL/kg (166mL for this child) until pulse, perfusion, and mental status normalize 2
Maintenance Phase Orders
Once Rehydration Complete (After 3-4 Hours)
- Reassess hydration status - check weight, clinical signs, urine output 4
- Resume age-appropriate normal diet immediately - do not delay feeding 1
- Continue breastfeeding if applicable throughout the illness 1
- Replace ongoing losses: 60-120 mL ORS for each diarrheal stool or vomiting episode (for <10kg body weight), up to ~500 mL/day 1
Monitoring Orders
- Vital signs every 2-4 hours initially 4
- Strict intake and output documentation 4
- Daily weights 2
- Monitor for signs of worsening: continued high stool output, persistent thirst, fever, altered mental status 4
Nutritional Orders
- Resume regular diet as soon as rehydration is complete - this shortens the duration of diarrhea 1, 3
- If formula-fed, continue regular lactose-containing formula (diluted formula offers no benefit) 1
- If breastfed, continue nursing throughout illness 1
Medications to AVOID
- No antimotility drugs (loperamide) - contraindicated in children <18 years with acute diarrhea 1
- Antidiarrheal drugs do not prevent dehydration and should not be used 3
Discharge Criteria
- Successfully tolerated at least 25 mL/kg of ORS (approximately 200mL for this child) during observation period 6
- Adequate urine output documented 7
- Weight gain achieved 7
- No severe emesis (>5 mL/kg) 7
- Improved clinical dehydration signs 7
- Caregiver demonstrates understanding of home ORS administration 3
Common Pitfalls to Avoid
- Do not rely solely on sunken fontanelle or absence of tears - these are less reliable indicators of dehydration 2
- Do not rush to IV therapy - ORT is as effective as IV rehydration for moderate dehydration and has lower complication rates 1, 7
- Do not withhold feeding - early refeeding shortens illness duration 1, 3
- Capillary refill can be misleading in the presence of fever or in very young infants 2