What are the admission orders for a patient with acute gastroenteritis (inflammation of the stomach and intestines) and severe dehydration?

Admission Orders for Acute Gastroenteritis with Severe Dehydration

For patients with acute gastroenteritis and severe dehydration (≥10% fluid deficit), initiate immediate intravenous rehydration with isotonic crystalloid (lactated Ringer's or normal saline) using boluses of 20 mL/kg body weight until pulse, perfusion, and mental status normalize. 1

Initial Resuscitation

Fluid Resuscitation

• Administer isotonic crystalloid boluses (lactated Ringer's or normal saline) at 20 mL/kg over 15-30 minutes 1
• Repeat boluses until vital signs stabilize: pulse normalizes, perfusion improves (capillary refill <2 seconds), and mental status clears 1
• For malnourished infants, use smaller-volume frequent boluses of 10 mL/kg due to reduced cardiac capacity 1
• Continue IV rehydration until the patient awakens, has no aspiration risk, and demonstrates no evidence of ileus 1

Monitoring During Resuscitation

• Assess pulse, blood pressure, capillary refill, mental status, and urine output every 15-30 minutes during initial resuscitation 1
• Obtain baseline electrolytes (sodium, potassium, chloride, bicarbonate), glucose, and renal function 1
• Monitor for signs of fluid overload (pulmonary edema, peripheral edema) particularly in patients with cardiac or renal comorbidities 1

Transition to Maintenance Phase

Oral Rehydration Transition

• Once pulse, perfusion, and mental status normalize, transition remaining fluid deficit to oral rehydration solution (ORS) 1
• If patient cannot tolerate oral intake, consider nasogastric administration of ORS 1
• If ileus or persistent vomiting despite adequate hydration, continue IV fluids with 5% dextrose 0.25 normal saline with 20 mEq/L potassium chloride 1

Replacement of Ongoing Losses

• For children <10 kg: administer 60-120 mL ORS for each diarrheal stool or vomiting episode (up to ~500 mL/day) 1, 2
• For children >10 kg: administer 120-240 mL ORS for each diarrheal stool or vomiting episode (up to ~1 L/day) 1, 2
• For adolescents and adults: ad libitum ORS up to ~2 L/day 1, 2

Nutritional Management

Feeding Orders

• Continue human milk feeding in infants throughout the diarrheal episode 1, 2
• Resume age-appropriate usual diet immediately after rehydration is complete or during the rehydration process 1, 3
• Do not use diluted formula or lactose-free feeds routinely—previously tolerated formula can be continued 1

Adjunctive Therapies

Antiemetics

• Consider ondansetron for children >4 years of age with severe vomiting to facilitate oral rehydration tolerance 1, 2
• Ondansetron may reduce need for IV fluids and hospitalization 4

Medications to Avoid

• Do NOT administer antimotility drugs (loperamide) to children <18 years of age 1, 3
• Do NOT give loperamide if fever or bloody diarrhea is present at any age due to risk of toxic megacolon 1

Laboratory and Diagnostic Orders

Initial Laboratory Studies

• Serum electrolytes (sodium, potassium, chloride, bicarbonate) 1, 5
• Blood glucose (particularly important if ketonemia suspected) 1
• Blood urea nitrogen and creatinine 1
• Note: Serum bicarbonate ≤13 mEq/L predicts higher likelihood of treatment failure and need for prolonged IV therapy 5

Stool Studies (if indicated)

• Consider stool culture only if bloody diarrhea, fever, severe abdominal pain, or immunocompromised status 1
• Routine stool studies are not indicated for uncomplicated acute gastroenteritis 1

Infection Control Orders

Isolation Precautions

• Implement contact precautions with gloves and gowns 1
• Hand hygiene with soap and water (preferred over alcohol-based sanitizers for certain pathogens like norovirus and C. difficile) 1
• Place patient in private room if available 1

Reassessment and Disposition Planning

Clinical Reassessment

• Reassess hydration status every 2-4 hours: skin turgor, mucous membranes, mental status, urine output 2
• Monitor weight changes to ensure adequate rehydration 3
• Criteria for discharge: patient tolerates oral fluids, maintains adequate hydration with ORS, no ongoing severe losses, and caregiver demonstrates understanding of home management 5

Red Flags Requiring Continued Hospitalization

• Persistent inability to tolerate oral fluids after adequate IV rehydration 5
• Serum bicarbonate ≤13 mEq/L (associated with higher failure rate of outpatient management) 5
• Ongoing severe diarrheal losses exceeding oral replacement capacity 1
• Altered mental status or signs of shock despite initial resuscitation 1