Uses components of the nursing process appropriate to the health care needs of the pediatric patient and family.

Pediatric Case Study

 

Name_____________________________

 

Purpose:  The purpose of this assignment is to help you to achieve the following Course Student Learning Outcomes.  You will review Situation Awarenessand Antibiotic Stewardship principles and put them into action in the service of a pediatric patient.

 

Program SLOs Course SLOs
1 Patient-Centered Care 1.1 Uses components of the nursing process appropriate to the health care needs of the pediatric patient and family.
1.4* Provides holistic care that addresses the needs of diverse pediatric populations.
2 Professionalism 2.2 Demonstrates an awareness of the professional standards of practice that apply to the practice of pediatric nursing.
3 Leadership 3.2 Demonstrates critical thinking and problem-solving process when caring for a pediatric patient.
7 Teamwork & Collaboration 7.6* Functions competently within own scope of practice as a student member of the healthcare team.
8 Safety 8.1 Identifies factors involved in prevention of infection, injury, and errors in the pediatric setting.
10 Evidence-based Practice 10.1 Uses Evidence-Based Practice (EBP) as it pertains to patient care.

* Clinical Student Learning Outcomes

 

 

Situation:Ten-year-old Ariana Merchante’s parents bring her to the Emergency Department (ED).  They report to the triage nurse that for the last 24 hours Ariana has had a sore throat and a fever.  The parents appear to be anxious and very concerned about their daughter.  Because Ariana’s attempts at movement were weak and uncoordinated, her father used a hospital wheelchair to bring her into the ED from the car.

 

 

 

 

  1. What are your first thoughts about Ariana’s situation?

 

 

 

 

  1. Situation Awareness:

 

Perception1:

The Triage Nurse collects more information from the parents.  Ariana’s fever has been as high as 100.4˚F (38˚C).  She has taken acetaminophen 325 mg by mouth every 6 hours since the onset of her fever, but it has not had any effect.

 

Ariana was diagnosed with Acute Lymphoblastic Leukemia (ALL) three months ago, and she has been receiving chemotherapy.  Her last treatment in the Remission Induction Phase was completed ten days ago.  She has a Central Venous Access Device (CVAD) in place for the delivery of her chemotherapy.  Her chemotherapy drugs include Cyclophosphamide, Methotrexate, and Cytarabine.

 

Ariana is 51.5 inches tall and weighs 52 pounds (23.6 kg).  BMI 13.8 is at 3rd percentile for age.

She has no known allergies to medications.

Vital signs are:  TPR: 101.5˚F orally (38.6˚C)/112/24     BP 102/54.

Lungs clear bilaterally, nonlabored respiratory effort. Oxygen saturation 96% on room air.

Skin pale, cool. Capillary refill is 4 seconds on chest.

Pedal pulses 2+ and equal.

Three 1-to 2-centimeter inflamed lesions in the mouth and oropharynx.

CVAD site: no redness, swelling, exudate or lesions.

The nurse notes these behaviors:

Lethargic, slumped position in wheelchair.

“Can’t walk.  No strength.”

Confused and drowsy.  Parents answer questions.

Voided 80 mL on arrival.  Last void was 4 hours ago, per mother.

 

 

Comprehension1:

The Triage Nurse has just completed training on the ED’s new Sepsis Protocol, and quickly identifies aspects of Ariana’s assessment that strongly suggest the presence of sepsis.

 

  1. On the Sepsis Algorithm, highlight any of Ariana’s assessment data that you find there.

 

  1. What elements of Ariana’s history indicate high risk for sepsis?

 

History Significance to Risk for Sepsis
   
   
   

 

  1. List here the assessment data that you have circled on the Sepsis Algorithm. From the Algorithm, state why these assessments are significant for the presence of sepsis.  I’ve done the first one for you.

 

Assessment Data Significance for Presence of Sepsis
Oral Temp 38.6˚ C A temperature of  < 36˚C or > 38.3˚C is a criteria for Systemic Inflammation Syndrome (SIRS) – precursor to Sepsis.
   
   
   
   
   

 

Projection1:

  1. What is the likely outcome of this situation if appropriate action is not taken?

 

 

 

 

Decision/Action1:

The Triage Nurse fast-tracks Ariana’s admission to the ED.  In collaboration with Ariana’s primary nurse and the ED physician, the decision is quickly made to implement thePediatric Sepsis Protocol.

 

 

 

  1. Finish the table with the two remaining rescue interventions fromthe Initial Stabilization Phase of the PALS Septic Shock Protocol. State the goals of care for these elements from the PALS Protocol.

 

Intervention Goal
Monitor and support Airway, Breathing, and Circulation. Assure adequate oxygenation and circulation.  Monitor patient’s response to therapy and quickly identify deterioration of her condition.
Monitor heart rate, blood pressure, and pulse oximetry. Monitor patient’s response to therapy and quickly identify deterioration of her condition
Establish vascular access. Allow drawing of blood cultures and other labs. – ideally before starting rescue interventions, but do not delay these interventions.
 

 

 
 

 

 

 

 

Perception2/Comprehension2:

  1. Lab results are quickly available. Analyze the results in the usual way.

 

Test Normal

Range

Result Discussion

If abnormal – Reason for abnormal results.

If normal, what is ruled out?

CBC      
  WBCs 4.5-11/mm3 1.5  
  Neutrophils 40-60% 20  
  Bands 3-5% 4  
  ANC* > 1500

Critical <500

360  
  Hemoglobin 12-16 g/dL 7.4  
  Hematocrit 36-40% 28%  
  Platelets 150-450k/µL 78K  
Electrolytes      
  Sodium 136-145mEq/L 150  
  Potassium 3.5-5.0 mEq/L 3.5  
Renal Function      
  BUN 7-25 mg/dL 26  
  Creatinine 0.6-1.2 mg/dL 1.4  
ABGs      
  pH 7.35-7.45 7.2  
  PaCO2 35-45 30  
  HCO3 22-26 20  
Other      
  Glucose 70-110 mg/dL 74  
  ALT 8-20U/L 22  
  PT 11-13.5 sec 12.5  
  INR <1.1 1.0  
  Lactate < 2 mmol/L 2.2  
Urinalysis      
  Specific gravity 1.015-1.030 1.042  
Reference:  

* ANC = Absolute Neutrophil Count

Check out this Article on Neutropenic Fever!

Comprehension2/Projection2/Decision2/Action2:

 

  1. Highlight any of Ariana’s lab results that you find on the Sepsis Algorithm.

 

  1. Fill in the table for these three high-priority problems identified by the laboratory results.

 

  Problem What could happen?

(Worst case scenario.)

What action should be taken?
Lab Result      
Sodium 150      
Urine SG 1.042
WBC’s 1.5K      
Neutro-phils 20%
ANC 360
Platelets 78K      

 

 

 

Physician Orders:

 

  1. On the order table below, answer the questions in the right column.

 

Pediatric Sepsis Protocol Orders
Order  
May use CVAD for IV fluids & blood draws No response required.
Fluid boluses: 20 mL/kg rapid infusion over 10 minutes.  Assess effect and repeat as needed. Calculate the fluid volume for a single bolusfor Ariana.

 

Why do we use the “pull-push” method for delivery?

 

 

 

After fluid bolus completion, IV D5NS at 2 mL/kg/hour Calculate the rate for Ariana in mL/hour.
Obtain cultures before starting antibiotics if possible:

Throat

CVAD

Blood

Urine

If getting the cultures drawn/collected first would delay fluid and antibiotic deliver beyond the recommended one-hour window, what would you do and why?
Cefepime IV 50 mg/kg/every 8 hours. Infuse over 20 minutes.

First dose STAT after cultures obtained.

Calculate the dose for Ariana.

 

 

The dose is mixed in 50 mL NS.

Calculate the IV rate in mL/hour.

 

Vancomycin IV  40 mg/kg/day divided every 6 hours Infuse over 60 minutes.

First dose STAT after 1st Cefepime dose.

Calculate the dose for Ariana.

 

 

The dose is mixed in 100 mL NS.

Calculate the IV rate in mL/hour.

 

Transfer patient to Pedi ICU or Pedi Oncology Unit ASAP What is the rationale for moving Ariana out of the ED as soon as possible?

 

Neutropenic Precautions

 

DefineNeutropenic Precautions and describe protective interventions.

 

 

 

  1. Continued Situation Awareness

 

Physician’s Orders include interventions to monitor for change in status. We expect status improvement as the patient responds to protocol interventions.  We are also constantly vigilant for indications that the patient is not responding, or that her status is worsening.

 

  1. The tables below shows the nurse’s assessment of Ariana before and after the first and second fluid bolus. Each time, you must decide whether Ariana needs another fluid bolus (based on the nurse’s assessment) or if we should begin to deliver the maintenance IV solution at the ordered rate.  Be specific about which assessment data influenced your decision!

 

Normal vital signs for a 10-year-old child are as follows (per PALS):

Heart rate:                  75-118

Respiratory rate:         18-25

Blood Pressure:           97-115/57-76

Temperature:              < 38˚C

O2 sat:                         ≥ 94%  on room air

Urine output:               ≥24 mL/hour

Peripheral pulses:       3+

Assessments before 1stbolus Assessments after 1stbolus Evaluation
TPR: 38.3˚C/120/26  BP96/54

EKG – Sinus tachycardia

O2 sat – 92% on O2 @ 2L/min

Central cap refill 4 seconds

Peripheral pulses 1+

Urine Output – 4 mL/15 min

Neuro – lethargic,confused

 

 

Lungs CTA

TPR: 38.1˚C/110/22 BP102/52

EKG – Sinus tachycardia

O2 sat – 96% on 2L/min O2

Central cap refill 4 seconds

Peripheral pulses 2+

Urine Output – 5 mL/15 min

Neuro –drowsy, intermittently alert and confused.

 

Lungs CTA

Improving/Stable/Worsening

(Circle one)

 

Plan: (Select one and give rationale.)

 

___Repeat fluid bolus – why?

 

 

 

___Begin maintenance fluids – why?

 

 

 

 

(The presence of a 2nd table should not be taken to mean that a 2nd bolus is required.  Base your evaluation on the post-bolus assessment.)

 

Assessments before 2nd bolus Assessments after 2nd bolus Evaluation
TPR: 38.1˚C/110/22  BP102/52

EKG – Sinus tachycardia

O2 sat – 96% on 2L/min O2

Central cap refill 4 seconds

Peripheral pulses 2+

Urine Output – 5 mL/15 min

Neuro –drowsy, intermittently alert and confused.

Lungs CTA

TPR: 37.8˚C/98/18BP 112/60

EKG – Normal Sinus Rhythm

O2 sat – 96% on room air

Central cap refill 3 seconds

Peripheral pulses 3+

Urine Output – 7 mL/15 min

Neuro –alert and oriented.

 

Lungs CTA

Improving/Stable/Worsening

(Circle one)

 

Plan: (Select one and give rationale.)

 

___Repeat fluid bolus – why?

 

 

___Begin maintenance fluids – why?

 

 

 

 

(The absence of a 3rd table should not be taken to mean that a 3rd bolus is not required.  Base your evaluation on the post-bolus assessment.)

 

 

Resolution:

The team has successfully implemented the PALS plan for the first hour response to pediatric sepsis, and Ariana is well on her way to recovery.  Fluids were started within 15 minutes of recognition of sepsis, and antibiotics were initiated within the first hour.  Ariana has been transferred to the Pediatric ICU, and her parents are now with her.

 

Antibiotic Stewardship:

Forty-eight hours after they were collected, the culture results are back.  The team holds an “Antibiotic Time-Out” meeting.

 

  1. a. What is the purpose of this discussion?

 

  1. Why is it so important to Ariana’s outcome?

 

  1. What does de-escalation mean in this context?

 

 

Cultures reveal the presence of strep pharyngitis that will respond toCefipime.  In consultation with Ariana’s oncologist, the team decides it is safe to de-escalate Ariana’s treatment by stopping the Vancomycin and continuing with Cefipime IV for a total of 7 days of therapy.

 

 

Psychosocial Concerns:

Imagine that Ariana is your child.You have always been transparent with her and provided as much developmentally appropriate information as possible.   During the induction phase of her chemotherapy, Ariana appeared to understand that because the chemotherapy drugs would cause her white blood cell count to be very low, she would be at risk for a serious infection. Your family has observed the precautions necessary to reduce her risk, but she became seriously ill nonetheless.

 

13.Now that she’s feeling better,Ariana asks you (her parent– not her nurse!), “This has been so scary. What’s going to happen to me?”  After reading “What to tell your child” from Childhood Leukemia: A Guide for Families, Friends, and Caregivers, compose a response to your child’s question.