Transcript File
PEDIATRIC CASE STUDY #1 By Carmen Valdez and Fion Kung Scenario • Jennifer is a 13 year old female who came to the ER from a chronic living facility and is now admitted to a med/surg floor. • Diagnosis: Pneumonia • Her weight is 45.2kg • Medical history: • Chronic recurrent pneumonia • Cardiomegaly • Severe autism and developmental delay (non-verbal) • Pulmonary hypertension • Trach/PEG Vitals upon admission • Temperature: 97.9 axillary • Blood pressure: 94/52 • Pulse: 70-115 • RR: 24-28 • O2: 95% on 40% oxygen via trach collar Tests and labs • Chest x-ray show either infiltrates vs. edema • MRSA screen positive • UA normal • Lab: • WBC: 13,000 • Chemistry normal except glucose of 133 Medications • Linezolid (Zyvox) 600 mg IV q12h • Ciprofloxacin 400 mg IV q 12h • DuoNeb aerosols 3mL NEB q4h/ q2h PRN • Pulmozyme 2.5 mg NEB BID • Tobi aerosols 300 mg NEB BID • Advair • Solumedrol 44 mg IV q6h • Aspirin 81 mg oral tablet daily • Albuterol 2.5 mg/3mL NEB q4h/ q3h PRN Orders • Pediasure 3xdaily PO/PEG and puree diet • Bedrest • VS every 4 hours • Weight daily • Repeat chest x-ray in AM • Call MD for increased respiratory distress or oxygen demand over 50% • Continuous pulse oximetry • Keep oxygen sat > 92% • Contact/Droplet precaution Assessment in the afternoon • Blood pressure: 122/78, Temperature: 98.1 axillary, pulse: 122, RR: 30 • Coarse rhonchi and wheezing throughout her lungs • Strong cough and purulent sputum via trach • Regular heart rhythm and 2+ pulses x 4 extremities • <2-3 second cap refill • Pulse oximetry is 86% • Sitter at bedside inform she has been coughing more and it is waking her up from her sleep • Patient is arousable and follow some instructions Interventions • Elevate the head of bed • Increase oxygen to 50% as ordered by physician. • Suction • Continue to monitor patient for S/S of respiratory distress • Have Ambu bag available by the bedside • Call RT for breathing treatment • Assess patient before and after respiratory treatment • Keep physician updated about patient’s condition Assessment after intervention • O2 sat went up to 93% • Patient still on 50% oxygen via trach • No rhonchi present at this time. • Patient is resting with head of the bed elevated • Patient is not coughing at this time • No S/S of respiratory distress at this time Phone Call • Hello Dr. Kung, this is Carmen from medical surgical floor calling on regards of Jennifer, a 13 year old girl admitted to ER for pneumonia. • Today she had a episode of respiratory distress. Her O2 sats dropped from 95% to 86%. There were rhonchi and wheezing present in all lobes. She also had a strong cough and purulent sputum. Patient was arousable and able to follow some instructions. • I increased the oxygen level from 40% to 50% as ordered, suctioned her and elevated head of the bed. • After the intervention, I listened to her lungs and there were no rhonchi present. Her O2 sats went up to 93%. • I contacted RT to come for breathing treatment. Physician Order • Ok. Good. Now I would like you to: • Observe patient for S/S of respiratory distress • Collect a sputum culture and let me know what the results are • Hydrate patient with NS at 75 ml/hr • Assess vital signs including lung sound every hour • Call me if O2 sat drops <92% or if there is any change in vital signs Complication • Pleural effusion • Empyema • Lung abscess • Pneumothorax • Obstructive airway due to secretions • Hypoperfusion • Sepsis Preventing complications • Monitor vital signs closely • Assess LOC • Assess for respiratory distress (retraction, nasal flaring, tachypnea, cyanosis) • Assess lung sound • Maintain hydration • Practice good hand hygiene • Do not smoke • Get plenty of rest, healthy diet and moderate exercise • Drink plenty of fluids Consultations • RT • Nursing manager/case manager • MD • Dietitian • Social worker • Speech therapy Patient teaching • • • • • • • • • • • Assess readiness to learn Assess patient’s knowledge about disease Take all the antibiotics as ordered Proper hand washing Continue to encourage adequate fluid intake Encourage patient to get plenty of rest No smoking around patient Get flu shot every year Get pneumonia vaccine Call the physician if experiencing symptoms of respiratory distress Have patient verbalize the teaching Appropriate Documentation • Interventions: • Suction • Increase oxygen level to 50% • Vital signs change • Update physician about vital signs change • Assessment before and after respiratory treatment • Medication administration • LOC, lung sound, heart sound changes If it is not documented, it was never done! References • Cardinale, Fabio., Cappiello, R.A., Mastrototaro, M.F., Pignatelli, M., & Esposito, S. (2013). Community-acquired pneumonia in children. Early Human Development 89 (3), 49-52. http://dx.doi.org/10.1016/j.earlhumdev.2013.07.023 • Chavanet, P. (2013). The ZEPHyR study: A randomized comparison of linezolidand vancomycin for MRSA pneumonia. Médecine et maladies infectieuses 43 (2013) 451–455. http://dx.doi.org/10.1016/j.medmal.2013.09.011 • Medscape. (2014). Pediatric pneumonia treatment & management. Retrieved from http://emedicine.medscape.com/article/967822treatment#aw2aab6b6b5