# A 2-year-old child is admitted to the pediatric unit with severe diarrhea for the past 3 days. The child appears lethargic, has sunken eyes, and decreased skin turgor. Vital signs are: temperature 101.2°F (38.4°C), heart rate 140 bpm, respiratory rate 28/min, blood pressure 85/50 mmHg. Laboratory results show: sodium 150 mEq/L, potassium 3.0 mEq/L, chloride 110 mEq/L, BUN 45 mg/dL, creatinine 1.2 mg/dL. What is the nurse's priority intervention?

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## 문제

A 2-year-old child is admitted to the pediatric unit with severe diarrhea for the past 3 days. The child appears lethargic, has sunken eyes, and decreased skin turgor. Vital signs are: temperature 101.2°F (38.4°C), heart rate 140 bpm, respiratory rate 28/min, blood pressure 85/50 mmHg. Laboratory results show: sodium 150 mEq/L, potassium 3.0 mEq/L, chloride 110 mEq/L, BUN 45 mg/dL, creatinine 1.2 mg/dL. What is the nurse's priority intervention?

## 보기

1. Administer oral rehydration solution immediately
2. Establish intravenous access and initiate fluid resuscitation **✔ 정답**
3. Obtain stool culture and begin antibiotic therapy
4. Apply cooling measures to reduce fever

**정답: 2**

## 해설

The child shows signs of severe dehydration with hypernatremia and hemodynamic instability, requiring immediate IV fluid resuscitation as the priority. Other options address less urgent aspects like oral rehydration, fever, or antibiotics.

## 심화 해설

Clinical Presentation Analysis

This 2-year-old child presents with a 3-day history of severe diarrhea and now exhibits classic signs of significant dehydration. The lethargy, sunken eyes, and decreased skin turgor are key physical indicators of fluid volume deficit. When you assess the vital signs, the picture becomes more urgent: the heart rate is 140 bpm (tachycardia for age), and the blood pressure is 85/50 mmHg, which is hypotensive for a 2-year-old. These findings are not just signs of dehydration; they are clinical indicators of inadequate perfusion and compensated shock.

Interpreting the Laboratory Data

The laboratory results confirm a state of hypernatremic dehydration. The serum sodium is 150 mEq/L (hypernatremia), the BUN is elevated at 45 mg/dL, and the creatinine is 1.2 mg/dL, indicating prerenal azotemia due to decreased renal perfusion. The potassium is low at 3.0 mEq/L. This combination of hypernatremia and hypokalemia is a dangerous electrolyte imbalance that can predispose the child to cardiac arrhythmias and neurological complications, including cerebral edema if fluids are corrected too rapidly. However, the immediate threat is not the specific electrolyte derangement but the profound hypovolemia.

Prioritizing the Nursing Intervention

The priority intervention is to establish intravenous access and initiate fluid resuscitation. According to the foundational principle of pediatric fluid management, emergent intravenous fluid administration is required when there is evidence of inadequate or poor perfusion [1]. This child's tachycardia, hypotension, and altered mental status (lethargy) are direct signs of compromised perfusion. The assessment must first prioritize the child’s general appearance, responsiveness, respiratory status, and vital signs to guide the level of urgency, and this clinical picture dictates an emergent response [1]. Early and appropriate fluid administration is essential because it improves outcomes and reduces mortality in critically ill children [1].

Let's examine why the other options are not the priority in this moment. Administering oral rehydration solution (Option 1) is contraindicated in a lethargic child with signs of shock due to the high risk of aspiration and the inability of the compromised gastrointestinal tract to absorb fluids rapidly enough. While obtaining a stool culture (Option 3) is an important diagnostic step, it is a secondary intervention that does not address the immediate life-threatening hypovolemia. Applying cooling measures for the fever (Option 4) may provide comfort, but the fever of 101.2°F (38.4°C) is not the primary threat; the circulatory collapse is. The nurse’s immediate action must be to secure IV access and begin isotonic fluid resuscitation to restore circulating volume and tissue perfusion, guided by the principle that assessment of perfusion status directly determines the need for emergent intravenous intervention [1].References (research sources)

- [1]Pediatric Fluid ManagementResearch articleWaseem M, Shah M. (2026)

## 임상 시나리오

A 2-year-old child with severe diarrhea, lethargy, sunken eyes, tachycardia, and hypotension requires immediate intervention. The presence of hypernatremia (Na 150 mEq/L) and prerenal azotemia confirms hypovolemic shock. The priority is to restore circulating volume.

Clinical Decision Guide for Pediatric Hypovolemic Shock

- **Recognize the Signs:** Lethargy, sunken eyes, decreased skin turgor, tachycardia, and hypotension in a child with fluid loss indicate progression from dehydration to compensated shock.

- **Secure IV Access Immediately:** This is the first step. For a critically ill child, intraosseous (IO) access is an alternative if IV access cannot be established within 90 seconds.

- **Initiate Fluid Resuscitation:** Administer isotonic crystalloid (e.g., 0.9% normal saline or Lactated Ringer's) as a rapid 20 mL/kg bolus over 5-20 minutes. Reassess and repeat boluses as needed for clinical response.

- **Avoid Oral Rehydration:** Oral rehydration solution is contraindicated in patients with altered mental status, shock, or severe dehydration due to the risk of aspiration and inadequate absorption.

- **Monitor for Complications:** In hypernatremic dehydration, correct the fluid deficit slowly (over 48 hours) after initial shock resuscitation to prevent cerebral edema. Monitor serum sodium frequently.

The initial fluid bolus addresses the life-threatening hypovolemia. Once perfusion is stabilized, the team can address the underlying cause, correct electrolyte imbalances gradually, and manage fever.

## 핵심 개념

- **Hypernatremic Dehydration** — A type of dehydration where serum sodium exceeds 145 mEq/L, often resulting from water loss exceeding sodium loss, leading to cellular dehydration and neurological risks.
- **Prerenal Azotemia** — Elevated BUN and creatinine levels caused by decreased renal perfusion due to hypovolemia, rather than intrinsic kidney damage.
- **Compensated Shock** — The early stage of shock where the body's compensatory mechanisms, such as tachycardia, maintain blood pressure within a normal range, though hypoperfusion is present.
- **Pediatric Tachycardia** — A heart rate above the normal range for a child's age; for a 2-year-old, a rate of 140 bpm is tachycardic and can indicate fever, pain, or hypovolemia.
- **Skin Turgor** — The skin's elasticity; decreased turgor, where pinched skin returns slowly, is a key physical sign of moderate to severe dehydration.

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