NUR322 The Child Client

Paediatric case study – Oesophageal Stenosis

Prati is a 6 -month-old baby girl who presented to the paediatric emergency department (ED) with pallor and lethargy. She had increased vomiting for the last week and had not been tolerating oral feeds. She had been previously been diagnosed with oesophageal stenosis and is managed with thickened fluids and a proton pump inhibitor while awaiting interventional management. On examination, the patient’s abdomen was soft and non-tender. Vomit was yellow-tinged when on clear fluids. The patient was ordered and commenced on continuous nasogastric (NG) feeds of Hydrolyte at 30 mls/hr. Prati was provisionally diagnosed with exacerbation of oesophageal stenosis and admitted to the paediatric inpatient unit.

Prati was monitored overnight by nursing staff and had further episodes of vomiting documented in the patient chart. RN Lee managed the NG feeds overnight in response to the patient’s vomiting and stopped the feeds for some time and then recommenced these at 20mls/hr. Prati was noted to be pale but alert. Patient observations were documented 1-2 hourly however nurses said that they were reviewing the patient every 30 to 60 minutes. Sarita was concerned overnight and was regularly checking on Prati. No pain assessment was performed but the nurse said they saw no evidence of pain. Prati initially had minimal urine output but by the morning had passed 200mls of urine.

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At 6am on the day after admission, Prati’s NG tube was noted to be no longer in place. While awaiting the routine arrival of Dr Boucher, RN Sharma decided to commence the patient on small amounts of oral hydrolyte to trial the patient’s tolerance to this.

Rn Sharma continued to monitor the patient with observations documented 1 -2 hourly. Prati continued to have episodes of vomiting and did not seem to be tolerating oral fluids. The morning shift was busy that day and the nurses were waiting for the regular doctor’s round for Prati to be reviewed.

Dr Boucher’s routine arrival was delayed until 10am when she commenced reviewing the most critically ill patients on the ward. Bibek approached Dr Boucher at 10:30am to express concern about Prati’s health. When Dr Boucher reviewed Prati, she was pale, lethargic and had decreased bowel sounds. Further examination suggested signs of severe dehydration and haemodynamic instability. Prati required urgent fluid resuscitation and was hospitalised for 3 more days.

When Prati was ready to be discharged home, it was determined that she should continue to have a NG tube for feeding supplementation. Bibek & Sarita started learning to insert a NG tube and manage the NG feeds during Prati’s admission. They were nervous about managing this independently at home and RN Sharma ensured that referrals were made to support services to ensure ongoing care and support.

People involved

Patient: Prati Pokhrel

Parents: Bibek (father) & Sarita (mother) Pokhrel

Nurses:

RN Lee (overnight nurse)

RN Sharma (morning nurse)

Prescribing doctor: Dr Boucher

Task:

  1. What are the relevant health policies or models of care for this case and how could they have been applied in the provision of care?
  2. What are the key issues or problems with the provision of care within this case? How might they have impacted on the patient’s situation or outcome?
  3. What evidence-based recommendations could be made for effective solutions or strategies for the key issues or problems? How could these have impacted healthcare provision and patient outcomes?
  4. What roles do members of the multidisciplinary team have in the shared care of the child client in this scenario? Discuss the role of team members in the care of the patient and their family.

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