What are the admitting orders for a 10-year-old female with acute gastroenteritis (AGE) and moderate dehydration, suspected urinary tract infection (UTI) or pyelonephritis, and lower respiratory tract infection (LRTI)?

Admitting Orders for 10-Year-Old Female with AGE, Moderate Dehydration, and Suspected UTI/Pyelonephritis

Immediate Rehydration Orders

Initiate oral rehydration solution (ORS) at 100 mL/kg (3,700 mL total) administered over 2-4 hours for moderate dehydration (6-9% fluid deficit). 1

• Start with small volumes using a syringe or medicine dropper, gradually increasing as tolerated, given the persistent vomiting. 1
• Use commercially available low-osmolarity ORS containing 50-90 mEq/L sodium. 1, 2
• Replace ongoing losses: administer 10 mL/kg (370 mL) ORS for each watery stool and 2 mL/kg (74 mL) for each vomiting episode. 1
• Reassess hydration status after 2-4 hours; if still dehydrated, reestimate deficit and restart rehydration. 1

Consider ondansetron 0.15 mg/kg PO/IV (max 8 mg) to facilitate oral rehydration given significant vomiting. 2, 3

• Ondansetron reduces vomiting, improves oral intake success, and decreases need for IV therapy in children >4 years. 3, 4

If ORS fails or patient cannot tolerate oral intake, initiate IV rehydration with isotonic fluids (lactated Ringer's or normal saline) at 20 mL/kg bolus over 30 minutes, then transition back to ORS. 2, 3

Diagnostic Workup

Obtain urinalysis with microscopy and urine culture to confirm UTI/pyelonephritis.

• Given urinary symptoms (reduced volume, increased frequency) and abdominal pain, rule out pyelonephritis as priority.
• Blood cultures if febrile or toxic-appearing.

Check serum electrolytes (sodium, potassium, bicarbonate) and renal function (BUN, creatinine) given moderate dehydration and inability to tolerate oral intake. 1

• Low serum bicarbonate combined with clinical parameters helps confirm dehydration severity. 4

Complete blood count to assess for anemia (pale conjunctivae noted) and leukocytosis.

Chest X-ray if respiratory symptoms present to evaluate LRTI.

Stool culture NOT indicated - only needed for bloody diarrhea (dysentery), not routine watery diarrhea. 1, 2

Antibiotic Management

DO NOT start empiric antibiotics for AGE. 2, 5

• Viral agents cause most AGE; antimicrobial therapy has limited usefulness and shifts focus away from appropriate fluid/electrolyte therapy. 2
• Empiric antimicrobial therapy is not recommended for acute watery diarrhea without recent international travel. 5

Start empiric antibiotics ONLY for confirmed/suspected pyelonephritis after obtaining urine culture:

• Ceftriaxone 50-75 mg/kg IV once daily (max 2g) OR
• Cefotaxime 50 mg/kg IV every 8 hours (max 2g per dose)
• Co-amoxiclav has no established role in typical gastroenteritis pathogens and should be avoided. 5

Plan antibiotic de-escalation: Modify or discontinue antimicrobials when culture results return; narrow to pathogen-specific therapy based on susceptibilities. 5

Nutritional Management

Resume age-appropriate diet immediately after rehydration is achieved; do not fast or restrict diet. 1, 2, 3

• Early refeeding reduces symptom duration and improves outcomes. 2
• Avoid foods high in simple sugars (soft drinks, undiluted apple juice) as they exacerbate diarrhea through osmotic effects. 2

Monitoring Orders

Strict intake and output monitoring:

• Document all oral/IV fluid intake
• Measure and record each stool and vomiting episode
• Monitor urine output (goal >1 mL/kg/hr)

Vital signs every 2-4 hours:

• Assess capillary refill, skin turgor, mental status, mucous membrane moisture. 2, 3
• Monitor for signs of worsening dehydration or progression to severe dehydration (≥10% deficit). 1

Daily weights to track rehydration progress. 1

Medications to AVOID

Do NOT administer loperamide or other antimotility agents - contraindicated in children <18 years with acute diarrhea. 2, 3

Do NOT use adsorbents, antisecretory drugs, or toxin binders - they do not reduce diarrhea volume or duration. 2

Infection Control Measures

Implement contact precautions:

• Gloves and gowns for all patient care. 2, 3
• Hand hygiene before and after patient contact. 2, 3
• Clean and disinfect contaminated surfaces promptly. 3
• Maintain isolation until at least 2 days after symptom resolution. 3

Disposition Planning

Hospitalization criteria met given inability to tolerate oral intake, moderate dehydration, and need to rule out pyelonephritis. 6

• ORT failure rate is approximately 50% in moderately dehydrated children, with 30-50% requiring hospitalization. 6
• Plan discharge when: tolerating oral intake, producing urine, clinically rehydrated, and afebrile for 24 hours (if pyelonephritis confirmed).