Pediatric Clinical Reasoning Case Study:Neonatal Sepsis I. Data Collection Chief complaint/History of Present Illness: Rennie is a 28-day-old female presenting to ER during thenight with presentin

Pediatric Clinical Reasoning Case Study:Neonatal Sepsis

I.   Data Collection

Chief complaint/History of Present Illness: Rennie is a 28-day-old female presenting to ER during thenight with presenting complaint of apneic episodes approximately 2/day with changing color to blue.Apneic episodes lasts 1-2 minutes, resolves with stimulation, chest rub, or gentle shaking. Apneicepisodes not associated with vomiting/spit ups. Baby completely recovers to her baseline withstimulation. Baby always sleeps on her back, no family history of SIDS. The current episode startedmore than 1 week ago. The problem occurs intermittently. The problem has not changed since onset. Nothing relieves the symptoms. Nothing aggravates the symptoms. Pertinent negatives include no fever, no stridor, and no intake of a foreign body. She had a lumbar puncture and chest X-ray as well as venous blood gases and lytes done in ER. Urinalysis and culture have been done. Ceftriaxone 380mg IV was given in ER after culture obtained.

What data is relevant to this patient that must be recognized as clinically significant to the nurse?

Rationale:

Personal/Social History: Family lives/stays sometimes in a friend’s place (who does not let the baby’sdad in) and a homeless shelter (the dad stays in a shelter and is allowed to bring family in). Mothersays she is a medical assistant, currently unemployed. Both parents smoke, they state they do notsmoke around the baby.

PMH:   Born 39 weeks, C/S (FTP) 8lbs. 8oz, no birth/nursery complications. Medical historysignificant for GERD, hiccups, and weight loss thought to be due to lactose intolerance, she has since been placed on soy formula with rice cereal added to the formula. Has been in ED x4 for umbilical bleeding (resolved), GERD (improved on Zantac), thrush (put on nystatin) and conjunctivitis (resolved).

Current Medications:

ampicillin 200 mg IV every 6 hoursceftriaxone 380 mg IV q 24 hours

nystatin 100,000 unit/mL suspension po every 24 hoursnystatin (MYCOSTATIN) cream topical 3 times a dayranitidine syrup 8 mg po twice daily

What is the relationship of your patient’s past medical history (PMH) and current medications?

(Which medication treats which disease?)

Patient Care Begins: When you walk into the room for your initial assessment, you areoverwhelmed with the smell of dirty feet, which appears to be from dad since he is barefoot, and his Timberline boots are under the crib. The baby is whimpering and neither parent seems to notice. You ask when the baby last ate, and Dad tells you he doesn’t know but probably not since the middle of the night as he just woke up. You pick up the baby and notice a cold soggy wet diaper that you immediately change. You tell the parents that a renal sonogram is scheduled for the morning, as well as several consults.

Throughout the morning you observe the mother sleeping most of the time and dad is engrossed with his laptop. Two grandmothers are in the room talking most of the day. Neither parents norgrandmothers seem to pick up on the baby’s cues for feeding or wet diapers and the baby does notcry very much. Other patients are complaining about the smell in the hallway by your baby’s room.

Your Initial VS:

T: 36.6 (97.8)

P: 164

R: 58

BP: 80/42

O2 sats: 95% on room air

Weight: 3.81kg (8.3lbs)

What initial data is relevant to this patient that must be recognized as clinically significant to the nurse?

Rationale:

Your Initial Nursing Assessment:

Gen: Asleep, comfortable, reactive to stimulation. Resp: no congestion or nasal discharge, MMM.Slightly increased WOB, nasal flaring, no retractions, lungs clear bilaterally A&P, no wheezing. CV:RRR, brachial and femoral pulses 2+ equal bilat, cap refill <3s. Ab: Soft, active BS, small amountspit up.  Ext: WNL, no edema or cyanosis, moves all extremities equally. Neuro: normal grasp andsuck, normal tone, normal strength. Skin: mild diaper rash, cold wet diaper. IV infusing 24 g. D5 1/2NS with 20 mEq. KCL at 15 ml/hr per pump, in right hand. Site without redness or edema. PainFLACC 1/10                 PEWS 1

What physical assessment data is relevant that must be recognized as clinically significant to the nurse?

–        Patient has evidence of work of breath, showing nasal flaring. Skin integrity has signs of breakage due to diaper rash.

Rationale:

II.   Clinical Reasoning Begins…

1.     What is the most likely medical problem that your patient is presenting with?

2.     What is the underlying cause /pathophysiology of this concern?

3.     What is your primary nursing priority right now?

4.     What nursing diagnostic statement will guide your plan of care?

5.     What interventions will you initiate based on this priority?

6.     What is the worst possible complication to anticipate?

7.     What nursing assessment(s) will you need to identify and what responses if this complication develops?

Medical Management: Rationale for Treatment & Expected Outcomes

Physicianorders:

Weight onadmission anddaily

Cardiac/apneamonitor with VSevery 4 hours

Titrate O2 tokeep sats above94%

Similac Advancead lib

May DC IV whentaking po fluids

Strict I & O everyhour

Activity ad lib

DropletPrecautions

RefluxPrecautions

Rationale:

Expected Outcome:

8.    Dosage Calculation:

Medication

Safe dosage range calculations:

Mechanism of action and Nursingimplications:

ampicillin 200 mgIV every 6 hours

cefTRIAXone 380mg IV q 24 hours

Started in ER

nystatin 100,000unit/mLsuspension poevery 24 hours

nystatin(MYCOSTATIN)

cream topical 3times a day

ranitidine syrup 8mg po twice daily

IVF dex 5%-nacl0.45%- infusion

at 15 ml/hr

Maintenance fluid calculation:

Radiology Reports: Chest X-Ray IMPRESSION: Mild strandy and hazy pulmonary opacitiesdiffusely within both lungs. This patient remains within the upper age range of the neonatal period and neonatal pneumonia remains within the differential diagnosis. Bronchiolitis related to a viralinfection is in additional possibility.

What data above is relevant to this patient that must be recognized as clinically significant to the nurse?

How do these radiology findings relate to primary problem?

Lab Results:

CBC

Current

WBC (4.5-11.0)

12.1

HGB (12-16)

13.8

PLTS (140-440)

574

Neuts. % (42-72)

68

Bands % (0 – 5)

14

Lymphs % (46-76)

20

Mono% ( 1-10 )

8

Eosinophiles % (0-5)

0

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

Basic Metabolic Panel

Current

Sodium (134-146)

143

Potassium (3.0-6.3)

4.8

Chloride ( 98-106 )

106

Glucose (74-127)

78

BUN (7-25)

8

Creatinine (0.5-1.3)

0.2

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

UA

Current

Color (yellow)

Light yellow

Clarity (clear)

Cloudy

Sp. Grav (1.002-1.030)

1.006

Protein (neg)

Neg

Glucose (neg)

Neg

Ketones (neg)

Trace

Blood (neg)

Trace

Nitrate (neg)

Neg

RBC’s (0-2)

1

WBC’s (0-5)

4

Bacteria (0-few)

Few

Epithelial (0-few)

Few

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

Appearance CSF (clear)

Bloody

Polys CSF (0-30)

15

Lymphs CSF (0-100):

75

Monos CSF (0-100):

8

Eosinophiles CSF (0-1):

1

Glucose CSF (50-80):

55

Protein CSF (10-45)

109

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

Venous Blood Gases

Current

Initial

pH (7.35-7.45)

7.38

7.37

pO2 (80-100)

99

100%

pCO2 (35-45)

45

48

HCO3 (18-26)

27

24

O2 sats (>92%)

98%

100%

Oxygen delivery

.21%

0.5L

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

Radiology Reports: Complete Abdominal Ultrusound: The liver is homogeneous inechogenicity. No focal hepatic mass or intrahepatic ductal dilatation is identified. The gallbladder isnot abnormally distended. There are no gallstones, wall thickening or pericholecystic fluid. Thecommon duct measures less than 1 mm. No significant sonographic abnormality of the pancreatichead, neck or body is identified. The spleen is homogeneous in echogenicity, measuring 4.2 cm inlength. The right kidney is normal in echogenicity relative to liver. The right kidney measures 4.7 cmin length. Corticomedullary differentiation is preserved. There is no right-sided renal mass, calculus or hydronephrosis. The left kidney measures 4.5 cm in length. Corticomedullary differentiation ispreserved. There is no left-sided renal mass, calculus or hydronephrosis. The bladder is partiallydistended with urine and demonstrates a small amount of debris.

Doppler evaluation demonstrates normal monophasic hepatopetal flow within the main portal vein. The visualized portions of the aorta and IVC demonstrate normal gray scale and color Doppler appearance.

Normal renal lengths for age range from 4.0 to 6.0 cm. IMPRESSION:

1.  Small debris in bladder.

2.  Otherwise, normal abdominal ultrasound.

What data above is relevant to this patient that must be recognized as clinically significant to the nurse?

How do these radiology findings relate to primary problem?

Application

9. Choose two of the most relevant abnormal labs for your patient and address the following:

Lab

Value

High/Low

Relevance

Normal value

Critical value

What causedderangement?

Treatment

Nsg. Assessments/interventionsrequired:

Lab

Value

High/Low

Relevance

Normal value

Critical value

What causedderangement?

Treatment

Nsg. Assessments/interventionsrequired:

III.   Evaluation:

Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management.

Eight hours later…

VS:

I & O

T: 36.1

I

IV:

180

P: 134

Enteral:

265

R: 48

BP: 96/54

O

Urine/stool:

277

O2 sats: 98 %

Emesis:

60

What data is most relevant to this patient that must be recognized as clinically significant to the nurse?

Rationale:

Nursing Assessment:

Gen: Asleep, comfortable, reactive to stimulation. Resp: no congestion or nasal discharge, MMM.No increased WOB, no nasal flaring or retractions, lungs clear bilaterally A&P, no wheezing. CV:RRR, brachial and femoral pulses 2+ equal bilat, cap refill <3s. Ab: Soft, active BS, less spit up.Feeding well every 2-3 hours with prompts from staff. Ext: WNL, no edema or cyanosis, moves allextremities equally. Neuro: normal grasp and suck, normal tone, normal strength. Skin: diaper rashclearing up. SL in right hand. Site without redness or edema. Mom paying more attention to baby,more responsive to cues and crying. Pain FLACC 1/10                                                 PEWS 1

What assessment data is relevant to this patient that must be recognized as clinically significant to thenurse?

Rationale:

1.     Has the status of the patient improved or not as expected to this point?

2.     What data supports this evaluation assessment?

3.     Based on this assessment data, now what will be your nursing priorities and current plan of care?

Pediatric Clinical Reasoning Case Study:Neonatal Sepsis I. Data Collection Chief complaint/History of Present Illness: Rennie is a 28-day-old female presenting to ER during thenight with presentin
Pediatric Clinical Reasoning Case Study: Neonatal Sepsis Data Collection Chief complaint/History of Present Illness: Rennie is a 28-day-old female presenting to ER during the night with presenting complaint of apneic episodes approximately 2/day with changing color to blue. Apneic episodes lasts 1-2 minutes, resolves with stimulation, chest rub, or gentle shaking. Apneic episodes not associated with vomiting/spit ups. Baby completely recovers to her baseline with stimulation. Baby always sleeps on her back, no family history of SIDS. The current episode started more than 1 week ago. The problem occurs intermittently. The problem has not changed since onset. Nothing relieves the symptoms. Nothing aggravates the symptoms. Pertinent negatives include no fever, no stridor, and no intake of a foreign body. She had a lumbar puncture and chest X-ray as well as venous blood gases and lytes done in ER. Urinalysis and culture have been done. Ceftriaxone 380mg IV was given in ER after culture obtained. What data is relevant to this patient that must be recognized as clinically significant to the nurse? The infant is having apneic episodes with color change. Each apneic episode last 1-2 minutes that resolves with stimulation. The episodes have been occurring for 2 days. The infant had a lumbar puncture, chest x-ray, venous blood gas and electrolytes done in ER. Patient is receiving Ceftriaxone 380mg IV after culture obtained. Rationale: Apneic episodes are non-specific indicators of many potential factors. The diagnostics procedures done indicates sepsis development. Symptoms for 2 days suggest a potential impairment in parent’s response to the infant’s distress. Personal/Social History: Family lives/stays sometimes in a friend’s place (who does not let the baby’s dad in) and a homeless shelter (the dad stays in a shelter and is allowed to bring family in). Mother says she is a medical assistant, currently unemployed. Both parents smoke, they state they do not smoke around the baby. PMH: Born 39 weeks, C/S (FTP) 8lbs. 8oz, no birth/nursery complications. Medical history significant for GERD, hiccups, and weight loss thought to be due to lactose intolerance, she has since been placed on soy formula with rice cereal added to the formula. Has been in ED x4 for umbilical bleeding (resolved), GERD (improved on Zantac), thrush (put on nystatin) and conjunctivitis (resolved). Current Medications: ampicillin 200 mg IV every 6 hours ceftriaxone 380 mg IV q 24 hours nystatin 100,000 unit/mL suspension po every 24 hours nystatin (MYCOSTATIN) cream topical 3 times a day ranitidine syrup 8 mg po twice daily What is the relationship of your patient’s past medical history (PMH) and current medications? (Which medication treats which disease?) Due to patient having GERD as well as thrush, her current medication is to treat the acid and infections. Both ampicillin and ceftriaxone are antibiotics with patient’s current diagnosis. Nystatin and hoursnystatin are to treat fungal infections. Finally, ranitidine is to treat GERD. Patient Care Begins: When you walk into the room for your initial assessment, you are overwhelmed with the smell of dirty feet, which appears to be from dad since he is barefoot, and his Timberline boots are under the crib. The baby is whimpering and neither parent seems to notice. You ask when the baby last ate, and Dad tells you he doesn’t know but probably not since the middle of the night as he just woke up. You pick up the baby and notice a cold soggy wet diaper that you immediately change. You tell the parents that a renal sonogram is scheduled for the morning, as well as several consults. Throughout the morning you observe the mother sleeping most of the time and dad is engrossed with his laptop. Two grandmothers are in the room talking most of the day. Neither parents nor grandmothers seem to pick up on the baby’s cues for feeding or wet diapers and the baby does not cry very much. Other patients are complaining about the smell in the hallway by your baby’s room. Your Initial VS: T: 36.6 (97.8) P: 164 R: 58 BP: 80/42 O2 sats: 95% on room air Weight: 3.81kg (8.3lbs) What initial data is relevant to this patient that must be recognized as clinically significant to the nurse? Patient’s temperature is low, expected level is 37.5 (99.5). Her Respiratory is 58 making her tachypnea, normal range is 30 -35bpm. She is also experiencing high blood pressure, normal range: systolic 65 to 78 and diastolic 41 to 52 (ATI, 2019). Rationale: Your Initial Nursing Assessment: Gen: Asleep, comfortable, reactive to stimulation. Resp: no congestion or nasal discharge, MMM. Slightly increased WOB, nasal flaring, no retractions, lungs clear bilaterally A&P, no wheezing. CV: RRR, brachial and femoral pulses 2+ equal bilat, cap refill <3s. Ab: Soft, active BS, small amount spit up. Ext: WNL, no edema or cyanosis, moves all extremities equally. Neuro: normal grasp and suck, normal tone, normal strength. Skin: mild diaper rash, cold wet diaper. IV infusing 24 g. D5 1/2 NS with 20 mEq. KCL at 15 ml/hr per pump, in right hand. Site without redness or edema. Pain FLACC 1/10 PEWS 1 What physical assessment data is relevant that must be recognized as clinically significant to the nurse? Patient has evidence of work of breath, showing nasal flaring. Skin integrity has signs of breakage due to diaper rash. Rationale: Clinical Reasoning Begins… What is the most likely medical problem that your patient is presenting with? What is the underlying cause /pathophysiology of this concern? What is your primary nursing priority right now? What nursing diagnostic statement will guide your plan of care? What interventions will you initiate based on this priority? What is the worst possible complication to anticipate? What nursing assessment(s) will you need to identify and what responses if this complication develops? Medical Management: Rationale for Treatment & Expected Outcomes Physician orders: Weight on admission and daily Cardiac/apnea monitor with VS every 4 hours Titrate O2 to keep sats above 94% Similac Advance ad lib May DC IV when taking po fluids Strict I & O every hour Activity ad lib Droplet Precautions Reflux Precautions Rationale: Expected Outcome: Dosage Calculation: Medication Safe dosage range calculations: Mechanism of action and Nursing implications: ampicillin 200 mg IV every 6 hours cefTRIAXone 380 mg IV q 24 hours Started in ER nystatin 100,000 unit/mL suspension po every 24 hours nystatin (MYCOSTATIN) cream topical 3 times a day ranitidine syrup 8 mg po twice daily IVF dex 5%-nacl 0.45%- infusion at 15 ml/hr Maintenance fluid calculation: Radiology Reports: Chest X-Ray IMPRESSION: Mild strandy and hazy pulmonary opacities diffusely within both lungs. This patient remains within the upper age range of the neonatal period and neonatal pneumonia remains within the differential diagnosis. Bronchiolitis related to a viral infection is in additional possibility. What data above is relevant to this patient that must be recognized as clinically significant to the nurse? How do these radiology findings relate to primary problem? Lab Results: CBC Current WBC (4.5-11.0) 12.1 HGB (12-16) 13.8 PLTS (140-440) 574 Neuts. % (42-72) 68 Bands % (0 - 5) 14 Lymphs % (46-76) 20 Mono% ( 1-10 ) Eosinophiles % (0-5) Identify the relevant lab results to this patient and their clinical significance: Which labs when trended are showing improvement and/or reveal concerning potential complications? Basic Metabolic Panel Current Sodium (134-146) 143 Potassium (3.0-6.3) 4.8 Chloride ( 98-106 ) 106 Glucose (74-127) 78 BUN (7-25) Creatinine (0.5-1.3) 0.2 Identify the relevant lab results to this patient and their clinical significance: Which labs when trended are showing improvement and/or reveal concerning potential complications? UA Current Color (yellow) Light yellow Clarity (clear) Cloudy Sp. Grav (1.002-1.030) 1.006 Protein (neg) Neg Glucose (neg) Neg Ketones (neg) Trace Blood (neg) Trace Nitrate (neg) Neg RBC’s (0-2) WBC’s (0-5) Bacteria (0-few) Few Epithelial (0-few) Few Identify the relevant lab results to this patient and their clinical significance: Which labs when trended are showing improvement and/or reveal concerning potential complications? Appearance CSF (clear) Bloody Polys CSF (0-30) 15 Lymphs CSF (0-100): 75 Monos CSF (0-100): Eosinophiles CSF (0-1): Glucose CSF (50-80): 55 Protein CSF (10-45) 109 Identify the relevant lab results to this patient and their clinical significance: Which labs when trended are showing improvement and/or reveal concerning potential complications? Venous Blood Gases Current Initial pH (7.35-7.45) 7.38 7.37 pO2 (80-100) 99 100% pCO2 (35-45) 45 48 HCO3 (18-26) 27 24 O2 sats (>92%) 98% 100% Oxygen delivery .21% 0.5L Identify the relevant lab results to this patient and their clinical significance: Which labs when trended are showing improvement and/or reveal concerning potential complications? Radiology Reports: Complete Abdominal Ultrusound: The liver is homogeneous in echogenicity. No focal hepatic mass or intrahepatic ductal dilatation is identified. The gallbladder is not abnormally distended. There are no gallstones, wall thickening or pericholecystic fluid. The common duct measures less than 1 mm. No significant sonographic abnormality of the pancreatic head, neck or body is identified. The spleen is homogeneous in echogenicity, measuring 4.2 cm in length. The right kidney is normal in echogenicity relative to liver. The right kidney measures 4.7 cm in length. Corticomedullary differentiation is preserved. There is no right-sided renal mass, calculus or hydronephrosis. The left kidney measures 4.5 cm in length. Corticomedullary differentiation is preserved. There is no left-sided renal mass, calculus or hydronephrosis. The bladder is partially distended with urine and demonstrates a small amount of debris. Doppler evaluation demonstrates normal monophasic hepatopetal flow within the main portal vein. The visualized portions of the aorta and IVC demonstrate normal gray scale and color Doppler appearance. Normal renal lengths for age range from 4.0 to 6.0 cm. IMPRESSION: Small debris in bladder. Otherwise, normal abdominal ultrasound. What data above is relevant to this patient that must be recognized as clinically significant to the nurse? How do these radiology findings relate to primary problem? Application 9. Choose two of the most relevant abnormal labs for your patient and address the following: Lab Value High/Low Relevance Normal value Critical value What caused derangement? Treatment Nsg. Assessments/interventions required: Lab Value High/Low Relevance Normal value Critical value What caused derangement? Treatment Nsg. Assessments/interventions required: Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Eight hours later… VS: I & O T: 36.1 IV: 180 P: 134 Enteral: 265 R: 48 BP: 96/54 Urine/stool: 277 O2 sats: 98 % Emesis: 60 What data is most relevant to this patient that must be recognized as clinically significant to the nurse? Rationale: Nursing Assessment: Gen: Asleep, comfortable, reactive to stimulation. Resp: no congestion or nasal discharge, MMM. No increased WOB, no nasal flaring or retractions, lungs clear bilaterally A&P, no wheezing. CV: RRR, brachial and femoral pulses 2+ equal bilat, cap refill <3s. Ab: Soft, active BS, less spit up. Feeding well every 2-3 hours with prompts from staff. Ext: WNL, no edema or cyanosis, moves all extremities equally. Neuro: normal grasp and suck, normal tone, normal strength. Skin: diaper rash clearing up. SL in right hand. Site without redness or edema. Mom paying more attention to baby, more responsive to cues and crying. Pain FLACC 1/10 PEWS 1 What assessment data is relevant to this patient that must be recognized as clinically significant to the nurse? Rationale: Has the status of the patient improved or not as expected to this point? What data supports this evaluation assessment? Based on this assessment data, now what will be your nursing priorities and current plan of care? Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the oncoming nurse who will be caring for this patient: (QSEN-Teamwork & Collaboration/Safety) Situation: Background: Assessment: Recommendation: QSEN Questions to Incorporate into Case Study: Patient Centered Care What can you do to demonstrate intentional caring and promote patient centered care with sensitivity and respect for your patient and family in the context of this clinical presentation? (QSEN-Patient Centered care) How can you ensure and assess the effectiveness of communication with the patient and family? (QSEN-Patient Centered care) How can you integrate your patient’s/family’s preferences/values as you coordinate your plan of care or provide any needed education? (QSEN-Patient Centered care) How can you ensure that your patient’s family is an active partner while under your care and promote self-care once they are discharged? (QSEN-Patient Centered care) Teamwork & Collaboration What can you do to facilitate safe and effective update/report to the physician or oncoming nurse? (QSEN-Teamwork and Collaboration) What would you do if you were not comfortable performing any new skill that was required to take care of this patient? (QSEN-Teamwork and Collaboration) Evidence Based Practice As a new nurse, what resources could you utilize to provide current, evidence based, and individualized care planning based on the needs of this patient? (QSEN-Evidence Based Practice) Safety/Quality Improvement What would you as the nurse do if you almost gave the wrong dose of one of the ordered medications because of a similarity in the label provided by pharmacy to another drug? (QSEN-Safety/Quality Improvement) Informatics What medical electronic data bases are available in your clinical setting that would be a resource if needed to obtain needed information on a medication you have not given before or an illness/surgery you have never seen before? (QSEN-Informatics)

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