Keith RN Gastroenteritis Case Study PDF

Preview

Summary

Peds Lab Case Study...

Description

Pediatric Gastroenteritis UNFOLDING Reasoning

Harper Anderson, 5 months old

Primary Concept Infection Interrelated Concepts (In order of emphasis) 1. Inflammation 2. Perfusion 3. Fluid and Electrolyte Balance 4. Acid-Base Balance 5. Thermoregulation 6. Clinical Judgment 7. Communication 8. Collaboration

© 2016 Keith Rischer/www.KeithRN.com

UNFOLDING Reasoning Case Study: STUDENT

Pediatric Gastroenteritis History of Present Problem: Harper Anderson is a 5-month-old female who was brought into the physician’s office for diarrhea and vomiting over the past two days. She had two loose large loose stools the first day and now her mother reports that she has been less active, is not interested in playing, and has been more sleepy today. She is unable to keep any feedings down today. She has had four loose, watery stools and emesis x3 this morning. She has not had a wet diaper since yesterday evening. She is 25

inches (63.5 cm) in length and weighs 14 pounds, 2 ounces (6.4 kg). She weighed 15 pounds, 2 ounces (6.86 kg) at her last office visit two weeks ago. Harper is a direct admit to the pediatric unit where you are the nurse responsible for her care.

Personal/Social History: Harper’s mother Nicole is 21 years old. She is a single mother and this is her first child. Nicole is not currently working and lives with her parents. Though she has strong social support from her parents, she feels consistently overwhelmed as a new mother.

Past Medical History (PMH): ∙ Healthy full-term infant that weighed 6 pounds 10 ounces (3.0 kg) at birth. ∙ No current health problems. Mom is no longer breast feeding and Harper is on formula. ∙ Mother had no complications with pregnancy. ∙ Has not had any immunizations from birth, including rotavirus RELEVANT Data from Present Problem: ● ● ● ● ●

5 mo female w worsening vomiting and diarrhea X2 days Pt unable to hols food down Has not urinated since yesterday Loss of 1 lb since last visit Pt lethargic per mom

Clinical Significance: Pt as risk for F&E imbalance and dehydration d/t decreased intake and increased output of stool and emesis

RELEVANT Data from Social History: ● ● ●

Single mom feeling overwhelmed w first baby Baby is now on formula Baby has not been vaccinated including rota virus

Clinical Significance: If mom is overwhelmed it can have baby feeling overwhelmed Baby is not receiving passive immunity from mom Baby is not receiving active immunity d/t no being vaccinated Pt is presenting with illness like rotavirus

Patient Care Begins: Current VS:

Pain Assessment – FLACC Behavioral Pain Scale

T: 102.2 F/39.0 C (axillary)

Face:

1

P: 158

Legs:

0

R: 38

Activity:

1

BP: 62/42

Cry:

1

O2 sat: 95% RA

Consolability:

2/Total score: 5/10

© 2016 Keith Rischer/www.KeithRN.com

FLACC Behavioral Pain Scale

0 Face

Relaxed or smile

1 Occasional grimace, frown, withdrawn

2 Frequent frown, clenched jaw, quivering chin

Legs

Relaxed

Uneasy, restless, tense

Kicking or legs drawn up

Activity

Lying quietly, moves easily

Squirming, tense

Arched, rigid, or jerking

Cry

No cry (awake or asleep)

Moans, whimpers. Occasional complaints

Crying, sobs, screams, frequent complaints

Consolability

Content or relaxed

Easy to console, distractible

Difficult to console or comfort

Each of the five categories is scored from 0-2, resulting in a total of 0-10

What VS data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT VS Data: ● ●

Clinical Significance:

Pt w elevated temp: 102.2 FLACC score of 5/10

The elevated temp indicates infection Pt w visible signs of discomfort/pain

Current Assessment: GENERAL APPEARANCE:

Irritable when awake, alternates with lethargy once quiet, when awake and crying, tears are not present

RESP:

Breath sounds clear with equal aeration bilaterally, non-labored

CARDIAC:

Skin is pale, cool to touch, cap refill 3–4 seconds in both hands, brachial pulses palpable bilaterally

NEURO:

Lethargic, does not maintain eye contact with mom or caregiver

GI:

Abdomen soft with hyperactive BS x4 quadrants, no apparent tenderness to palpation

GU:

5 mL dark amber, cloudy urine noted in urine collection bag-sent to lab

SKIN:

Anterior fontanel depressed, eyes slightly sunken, lips and tongue are dry with no shiny saliva present, when skin over abd. is pinched, remains tented for 2–3 seconds

What assessment data are RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: ● ● ● ● ●

Pt is irritable, lethargic, crying when awake w no tears Skin: pale, cool, cap refill greater than 4 seconds Hyperactive bowel sounds X4 Dark urine Sunken eyes, dry, lips and tongue, tenting present

Clinical Significance: Pt is presenting with obvious signs of dehydration and GI problems Pt is exhausted from course of illness and is in obvious discomfort

© 2016 Keith Rischer/www.KeithRN.com

Dehydration Assessment Scale for Pediatrics Circle all assessment findings RELEVANT to Harper. What degree of dehydration is present? Assessment Data:

Minimal Dehydration:

Mild to Mod. Dehydration

Severe Dehydration

Mental status

Alert

Restless, irritable

Lethargic, unconscious

Thirst

Drinks normally

Drinks eagerly

Drinks poorly

Heart rate

Normal

Normal to increased

Tachycardia

Quality of pulses

Normal

Normal to decreased

Weak or non-palpable

Breathing

Normal

Normal or fast

Deep

Eyes

Normal

Slightly sunken

Deeply sunken

Tears

Present

Decreased

Absent

Mouth and tongue

Moist

Dry

Parched

Skin fold

Instant recoil

Recoil < 2 seconds

Recoil >2 seconds

Capillary refill

Normal

Prolonged

Prolonged or minimal

Extremities

Warm

Cool

Cold, mottled, cyanotic

Urine output

Normal

Decreased

Minimal

Lab/Diagnostic Results: (Note: Lab norms are for a 5-month infant) Basic Metabolic Panel (BMP)

Current

High/Low/WNL?

Previous:

Sodium (133–150 mEq/L)

151

high

138

Potassium (3.3–6.0 mEq/L)

3.1

low

3.8

Chloride (96–106 mEq/L)

92

low

101

CO2 (Bicarb) (20–28 mmol/L)

15

low

22

Glucose (60–110 mg/dL)

102

WNL

105

BUN (4–17 mg/dl)

48

high

15

Creatinine (0.2–0.7 mg/dL)

1.4

high

0.6

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Increased ● Sodium ● BUN ● Creatinine Decreased ● Potassium ● Chloride ● CO2

The increased labs show evidence of dehydration and poss impairment of the kidneys The decreased labs show (F&E imbalance and Acid base imbalance) ● Potassium is low d/t excessive vomiting/diarrhea ● Chloride d/t dehydration ● CO2 d/t excessive vomiting/diarrhea lead to alkalosis

Complete Blood Count (CBC)

Current

High/Low/WNL?

WBC (5–19.5 mm 3)

19.8

high

12.5

Hgb (10.7–17 g/dL)

15.2

WNL

16.5

Hematocrit (30–49%)

54

high

48

Platelets (150–475x 103/µl)

225

WNL

221

Neutrophil % (15–35)

88

high

34

Worsening

Previous:

© 2016 Keith Rischer/www.KeithRN.com

What lab results are RELEVANT that must be recognized as clinically significant to the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Increased WBC Increased Hematocrit Increased Neutrophil

High amounts of WBC and neutrophils indicate infection HIgh amounts of hematocrit indicate dehydration

Urine Analysis (UA:)

Current:

WNL/Abnormal?

Color (yellow)

Yellow

WNL

Clarity (clear)

Cloudy

Abnormal

Specific Gravity (1.015-1.030)

1.033

Abnormal

Protein (neg)

Neg

WNL

Glucose (neg)

Neg

WNL

Ketones (neg)

Neg

WNL

Bilirubin (neg)

Neg

WNL

Blood (neg)

none

WNL

Nitrite (neg)

Pos

Abnormal

LET (Leukocyte Esterase) (neg)

Pos

Abnormal

RBC’s (101

Trimethoprim/sulfamethoxaz ole po 5 mg/kg every 12 hours

© 2016 Keith Rischer/www.KeithRN.com

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders:

Order of Priority:

Rationale:

1. Stool culture for rotavirus 2. Daily weight with strict I&O 3. Establish peripheral IV and start 0.9% NS @ 20 mL/kg bolus over 30-60 minutes, then maintenance of D5 0.9% NS @ 4 mL/kg/hour

1. 2. 3. 4. 5. 6.

IV and fluids Stool culture Antibiotics Antipyretic NPO Weight and I&Os

●

● ● ● ●

4. NPO if vomiting-may advance small feedings of Pedialyte as tolerated if no vomiting

●

Pt is very dehydrated and needs fluids ASAP regardless of what the culture says We need the culture to confirm source of infection Fight the bacteria and hopefully improve symptoms Reduce fever Try oral hydration if tolerated and to increase electrolytes Monitor effectiveness of hydration supplementation

5. Acetaminophen 15 mg/kg PO/rectal every 4 hours PRN for temp >101 6. Trimethoprim/sulfamethoxazole PO 5 mg/kg every 12 hours

Medication Dosage Calculation: Medication/Dose:

Mechanism of Action:

Acetaminophe n 15 mg/kg

Analgesic and antipyretic Cox 2 inhibitor Inhibits synthesis of prostaglandins that may serve as mediators of pain and fevers

Weight: 6.4 kg

Dosage to Administer:

Nursing Assessment/Considerations:

Weight: 6.4 kg

Use with caution in pt’s with hepatic/renal disease Do not exceed max dose

Concentration of acetaminophen:

80 mg/0.8 mL Dose to administer: 0.96 mL 1mL Amount:

Additional Pediatric Dosage Calculations: ∙ Weight 14 pounds, 2 ounces. Convert to kilograms: 6.42 ∙ 0.9% NS @ 20 mL/kg bolus over 1 hour. Bolus amount: 128.4 ml ∙ IV maintenance @ 4 mL/kg/hour. Maintenance rate: 25.68 ml/hr

Collaborative Care: Nursing 3. What nursing priority(s) will guide your plan of care? (If more than one, list in order of PRIORITY) Promote hydration Monitor I&Os and weight

Once able to encourage intake of pedialyte to increase electrolytes

© 2016 Keith Rischer/www.KeithRN.com

4. What interventions will you initiate based on this priority? Nursing Interventions: Promote hydration Monitor hydration weights I&Os When possible encourage PO pedialyte if tolerated

Rationale: We need to get this pt hydrated the pt has physical signs and symptoms of dehydration and it is visible in lab work as well pt is declining d/t lack of fluid and electrolytes We need to monitor if we are adequately hydrating with I&Os

5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

GI, GU, Integumentary

6. What is the worst possible/most likely complication to anticipate?

Hypovolemic shock d/t severe dehydration

Expected Outcome: We will restore F&E imbalance and get the pt feeling better

7. What nursing assessment(s) will you need to initiate to identify this complication if it develops?

BP, neuro, SPO2 monitoring

8. What nursing interventions will you initiate if this complication develops?

Trendelenburg, fluid resuscitation, O2

9. What psychosocial needs will this family likely have that will need to be addressed? They are overwhelmed their child is becoming unresponsive and needs intense medical care

10. How can the nurse address these psychosocial needs?

Have someone explain to them what is happening, call a chaplain

© 2016 Keith Rischer/www.KeithRN.com

Evaluation: Two Hours Later… All orders have been implemented, including the IV bolus and medications. Harper has not had an emesis since she was admitted. She appears to be resting comfortably and appears to be sleeping. The nurse obtains the following:

Current VS:

Most Recent:

T: 96.8 F/36.8 C (ax)

T: 102.2 F/39.0 C (ax)

P: 150

P: 158

R: 42

R: 38

BP: 68/46

BP: 62/42

O2 sat: 98% RA

O2 sat: 95% RA

Current Assessment: GENERAL APPEARANCE:

Calm and quiet, no longer irritable

RESP:

Breath sounds clear with equal aeration bilaterally, non-labored

CARDIAC:

Skin is pale, cool to touch, cap refill 3–4 seconds in both hands, brachial pulses palpable bilaterally

NEURO:

Lethargic, arouses to physical stimuli

GI:

Abdomen soft with active BS x4 quadrants, no apparent tenderness to palpation

GU:

Diaper dry

SKIN:

Anterior fontanel not as depressed, lips are moist but tongue is dry with no shiny saliva present, eyes remain slightly sunken

1. What clinical data are RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Elevated RR

RELEVANT Assessment Data: Skin: pale, cool, prolonged cap refill Lethargy only aroused to physical stimuli Dry diaper Improved but still: sunken eyes, dry tongue no saliva

Clinical Significance: Increased WOB

Clinical Significance: Pt is still not perfusing adequate, dehydration is still present, there is a decrease in LOC

2. Has the status improved or not as expected to this point? Not as expected, in some aspects with dehydration there are some improvements, however this pt is still not perfusing adequately and there is decrease in LOC

3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

We need to continue the same but notify DR

4. Based on your current evaluation, what are your nursing priorities and plan of care?

The same but notify doctor

SBAR Template Virtual SBAR Report Hyperlink

© 2016 Keith Rischer/www.KeithRN.com

www.vocaroo.com Your hyperlink: Situation Name/age: Our pt is Harper a 5 mof. BRIEF summary of primary problem: Mom brought her in with worsening and increasing numbers of emesis and watery diarrhea X2 days. Mom states baby hasn't been able to keep anything down and has not had a wet diaper since the day prior. Pt presents with severe signs of dehydration, GI symptoms and lethargy. Pt has lost 1lb since last weigh in. Day of admission/post-op #: Background Primary problem/diagnosis: severe dehydration secondary to rotavirus RELEVANT past medical history: Pt is unvaccinated and on formula only RELEVANT background data: n/a Assessment Current vital signs: T: 102.2 O2: 95% HR: 158 RR: 38 BP: 62/42 FLACC pain scale: 5/10 RELEVANT body system nursing assessment data: Pt is irritable, lethargic, and crying w no tears present. Oral mucosa and tongue is dry, eyes are sunken in, skin is cool with pallor,

tenting and prolonged cap refill, Urine is dark in color and hyperactive bowel sounds present X4 RELEVANT lab values: Sodium: 151, Potassium: 3.1, WBC: 19.8, Hematocrit: 54, Neutrophil: 88, Creatinine: 1.4 TREND of any abnormal clinical data (stable-increasing/decreasing): worsening How have you advanced the plan of care? initiated ABX, fluid replacement, antipyretics, pedialyte as tolerated Patient response: Pt is afebrile, no longer having bouts of emesis, oral mucosa, tongue and lips less dry but LOC has decreased and pt is not adequately prefusing AEB prolonged cap refill INTERPRETATION of current clinical status (stable/unstable/worsening): worsening Recommendation Suggestions to advance plan of care: Move pt to PICU, continue promotion of hydration and electrolyte intake, monitoring strict I&O’s, daily weights, ABX’s, continuous VS monitoring and monitor for signs of shock

The nurse recognizes the significance of this change of status and contacts the primary care provider and communicates the following SBAR:

Situation: Name/age: BRIEF summary of primary problem:

Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data:

Assessment:

Most recent vital signs: RELEVANT body system nursing assessment data:

RELEVANT lab values:

How have you advanced the plan of care? Patient response: INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation: Suggestions to advance plan of care:

© 2016 Keith Rischer/www.KeithRN.com

In response to your SBAR, the primary care provider orders the following: Care Provider Orders: Blood culture x2 sites

Lactate

Repeat 0.9% NS @ 20 mL/kg bolus over 15 minutes

Ceftriaxone 240 mg IVPB every 12 hours (after blood cultures drawn)

Vancomycin 85 mg IVPB every 8 hours (after blood cultures drawn) Transfer to PICU

Rationale: ● ● ● ● ●

Looking to see if there is an infection in the blood Looking to see if the pt is in lactic acidosis Increase hydration Antibiotics to treat infection Pt’s LOC is decreasing and needs higher level of care

Expected Outcome: ●

Pt’s perfusion and LOC is decreasing and needs more care, we need to see if there is also an infection in the blood, we have to continue hydration, and try to combat infection w ABX, pt needs higher level of caresh

stat.

Your hospital has a pediatric ICU, the bed is ready and will be transferred shortly.

Caring and the “Art” of Nursing 1. What is the mother likely experiencing/feeling right no...