Preoperative Care of the Patient Scheduled

for a Cholecystectomy
Preparation Questions

Identify the signs and symptoms of dehydration in pediatric patients.

Weight is the most important determinant of the percent of total body fluid loss in infants
and younger children. However, often the pre-illness weight is unknown. Other
predictors of fluid loss include a changing level of consciousness (irritability to lethargy),
altered response to stimuli, decreased skin elasticity and turgor, prolonged capillary refill
(>2 seconds), increased heart rate, and sunken eyes and fontanels. The earliest detectable
sign is usually tachycardia followed by dry skin and mucous membranes, sunken
fontanels, signs of circulatory failure (coolness and mottling of extremities), loss of skin
elasticity, and prolonged capillary filling time (Table 22-4). There is evidence that the
clinical signs of prolonged capillary refill time, abnormal skin turgor, and abnormal
respiratory pattern are most useful in predicting dehydration in children

What are considered early signs and late signs?

Early signs: precipitating conditions in which fluid loss are likely to occur, including
diarrhea, vomiting, burns, diabetes, trauma, and fever. Change using urine output, and
specific gravity (James, Nelson, & Ashwill, 2013).
Late signs: increase in heart rate, increase in respiratory rate, changes in mental status,
changes in capillary refill, parched mucous membranes, markedly depressed fontanel, and a
severe decrease in weight (James, Nelson, & Ashwill, 2013).

Differentiate between mild, moderate and severe dehydration in the pediatric patient.

MILD TO
CLINICAL MINIMAL OR NO MODERATE SEVERE
SIGNS DEHYDRATION DEHYDRATION DEHYDRATION

Weight loss <3% <5%-10% >10%

Vital signs

Tachycardic,
Normal to increased, bradycardic in most
Pulse Normal weak severe cases; thread

Respiratory rate Normal Normal to fast Rapid and deep

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 Preoperative Care of the Patient Scheduled
for a Cholecystectomy
Markedly decreased as a
sign of hypovolemic
Blood pressure Normal Normal shock

Apathetic, lethargic,
Well, alert; drinks Fatigued, restless, unconscious; drinks
General normally, might refuse irritable; thirsty and poorly or unable to
appearance liquids eager to drink drink

Mucous
membranes Normally moist Dry Parched

Anterior
fontanel Normal Sunken Markedly depressed

Slightly sunken, tears Markedly sunken, tears

Eyes Normal, tears present decreased absent

Prolonged, minimal;
<2 sec; extremities feel Prolonged; extremities extremities cold;
Capillary refill warm cool mottled or cyanotic

Skin turgor Normal Prolonged recoil Tenting

Decreased,
Urine output Mildly decreased concentrated urine Minimal

Explain the pathophysiological relationship between diarrhea, fluid and electrolyte imbalance and
dehydration.
Increased motility and rapid emptying of the intestines result in impaired absorption of nutrients and water and an
electrolyte imbalance. Water, sodium, potassium, and bicarbonate are drawn from the extracellular space into the stool,
resulting in dehydration, electrolyte depletion, and metabolic acidosis (James et al., 2013, p. 347).
Diarrhea occurs when there is excess fluid in the small intestine. This condition can result from a number of
processes: (James et al., 2013, p. 347)
Bacterial toxins stimulating active transport of electrolytes into the small intestine, cells in the mucosal lining of the
intestines are irritated and secrete increased amounts of water and electrolytes (James et al., 2013, p. 347)
Organisms invading and destroying intestinal mucosal cells, decreasing intestinal surface area, and impairing the intestines
capacity to absorb fluids and electrolytes (James et al., 2013, p. 347).
Inflammation which decreased the intestines ability to absorb fluid, electrolytes, and nutrients. This condition occurs in
malabsorption syndromes (James et al., 2013, p. 347).
Increased intestinal motility, resulting in impaired intestinal absorption (James et al., 2013, p. 347).

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 Preoperative Care of the Patient Scheduled
for a Cholecystectomy

Describe common methods of treatment for dehydration and diarrhea in young children, including oral
rehydration solutions, medications and intravenous fluid replacement.
Oral Rehydration Therapy (ORT): this therapy is the provision of an electrolyte containing solution that is low in osmolality
referred to as an oral rehydration solution. These commercial solutions have been shown to be more effective for fluid and
electrolyte replacements, then sports drinks such as Gatorade, and PowerAde (James et al., 2013).
Parenteral Fluid and Electrolyte Therapy: this therapy consists of either lactated ringers solution, or 0.9% sodium chloride
solution through intravenous infusion. His infusion may be continuous or given them boluses, and can be given with ORT if
tolerated by the patient. After the patient has had urination return to an acceptable level potassium may be ordered as
well (James et al., 2013).
Feeding: provision of food to a child suffering from diarrhea has not been shown to lengthen the episode. In fact, the
ingestion of food will provide necessary nutrients, and energy to the child whose system is already stressed with absorption
problems (James et al., 2013).
Medications: if the cause of the diarrhea is suspected to be bacterial, parasitic or fungi than antibiotics may be ordered.
Antidiarrheal medications are not recommended for children as they do not shorten the course of the diarrhea, and if the
cause of the diarrhea is a pathogen, they may actually inhibit the bodys own efforts to expel the invader (James et al.,
2013).

What are the indications for each?

The use of ORT, and feeding in the case of the child the dehydration or diarrhea is mainly decided by the ability of the child
to take in oral substances. Parenteral fluid and electrolyte therapy is really only recommended for severe dehydration, and
when oral intake is not tolerated or recommended. Medications are determined highly by the cause of the current episode,
and whether the illness is caused by a pathogen or not (James et al., 2013)

Discuss the differences between the types of oral rehydration solutions.

While there are multiple different kinds of commercial ORS products, the main difference seems to be the amount of ORS
that is administered per the age group that is administered to. The recommended homemade ORS consists of 8 teaspoons
of sugar, 1 teaspoon of salt, and 5 cups of sterilized water. For an infant 2 5 mL of the solution is recommended every few
minutes until the infant is capable of taking more of the solution, and is urinating appropriately (Smith & Schub, 2011). For
children over the age of two. The recommended dose is 23-45 mL per pound of bodyweight every five minutes until the child
is urinating 4 to 5 times daily (Smith & Schub, 2011).

Why has the banana, rice, applesauce, toast or tea (BRAT) diet lost favor among treatment options?
Like with the antidiarrheal medication, certain components of the BRAT diet act as binders and may inhibit the bodys own
efforts to evacuate a pathogen. Along with this. The diet is unnecessarily restrictive and does not provide adequate nutrition
for the patient (Smith & Schub, 2013).

Explain the rationale for rehydration rates for children with mild, moderate and severe levels of
dehydration.
The rehydration rates and their differences tween mild, moderate and severe dehydration are due to balance a possible fluid
volume overload, dangers of dehydration itself, and maintenance of acceptable electrolyte levels (James et al., 2013).

What assessment findings indicate improvement in the dehydrated child?

The child is more alert, the urine output is appropriate for age with a specific gravity within normal limits, the skin is elastic
and soft, the mucous membranes are moist, and serum pH and electrolyte levels are within normal limits (James et al.,
2013).

What is the benefit of early reintroduction of normal diet?

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 Preoperative Care of the Patient Scheduled
for a Cholecystectomy
Either the feeding of solids or formula will not prolong the duration of the diarrhea, although it may increase the volume of the
stools, and will provide the child the opportunity to absorb necessary nutrients and calories (James et al., 2013).

Discuss Vietnamese cultural practices related to gastrointestinal illness.

A distinct nomadic people of Vietnam known as the Hmong people practice health beliefs very similar to the rest of the
population that calls for soul calling, ancestor worship, herbs, or teas be used in collaboration with a religion based
practitioner referred to as a Shaman (Allen & Cabrera, 2012).

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