Name

Age

Date of Birth

Medical record number

Status; Pediatric floor:

Name of attending physician

Phone number of attending physician

Pediatric Vomiting/Diarrhea/Dehydration Contributing Diagnoses

Condition

Allergies

Crib

Bassinet

Bed

NPO

Formula/Breast

Age appropriate diet as tolerated

Vital signs: every 4 hrs

Tylenol (10mg/kg)____PO/PR every 4 hrs prn T > 101

Phenergan 12.5-25 mg PR 1 6-8 hrs prn n/v

Replacement 1/3 over first 4 hrs with Dextrose 5% win 1/2 normal saline

Replacement 1/3 over second 8 hrs with Dextrose 5% in 1/2 or 1/4 normal saline

Replacement 1/3 over third 12 hrs with D5.2 normal saline

Replace in addition to maintenance

Basal metabolic profile, CBC UA on admission; basal metabolic profile in a.m.

Stool for rotazyme, routine culture, O&P, yersinia

Call MD for

Signature

Print Name

Date and Time