Pediatric Case Study #1

1. Pediatric Case Study #1 By Carmen Valdez and Fion Kung

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. Complication • Pleural effusion • Empyema • Lung abscess • Pneumothorax • Obstructive airway due to secretions • Hypoperfusion • Sepsis

13. 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

14. Consultations • RT • Nursing manager/case manager • MD • Dietitian • Social worker • Speech therapy

15. 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

16. 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!

17. 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 linezolidandvancomycin 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/967822-treatment#aw2aab6b6b5