Pediatric Clinical Reasoning Case Study:Neonatal Sepsis

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?