Pediatric Case Studies



Pediatric Disorders

Case Study 111 : Osteotomy

Diffi culty: Advanced

Setting: Hospital

Index Words: cerebral palsy, spastic, hip spica cast, osteotomy, nutrition, epidural pain management, risk factors, parental and child education, skin care, immobility and associated risk factors

Scenario

T.M. is an 8-year-old with cerebral palsy who has been admitted to your unit following surgery for a femoral osteotomy and tendon lengthening to stabilize hip joints and to help reduce spasticity. He is admitted to your unit with a hip spica cast, an epidural for pain management, a Foley catheter, and a gastrostomy tube (in place before the orthopedic surgery).

1. What are issues common to cerebral palsy that you should consider when planning and providing care to T.M.? [k/c]

There are 4 types of cerebral palsy. Some issues are common to all types, whereas other issues are type specific. Generally, it is common for children with cerebral palsy to have delayed growth and development, visual defects, hearing loss, delayed language or speech impediment, seizures, mental retardation, feeding difficulties, persistent hypertonia, rigidity leading to contractions and possible abnormal contractures of the spine, impaired voluntary muscle control, spastic movements, and exaggerated posturing.

2. What should be your top five priorities in providing nursing care to T.M.? [k/c]

• Assessing T.M.’s physiologic status, including VS, respiratory status, LOC, neurovascular checks of the lower extremities; observing for bleeding on and under the cast

• Assessing and managing pain

• Assessing for and managing environment and physiologic status to prevent injury secondary to spasms, uncontrolled movements, and possible seizures

• Assessing respiratory status; managing care to prevent respiratory complications

• Assessing neurovascular status

• Assessing for altered skin integrity around hip spica cast and bony prominences; providing interventions to prevent skin breakdown

• Assessing for and promoting nutrition to foster healing and continued growth

• Assessing for and providing education to T.M. and his parents regarding surgery and postoperative course

• Assessing for impaired communication; using strategies to facilitate effective communication

• Assessing neurologic status; monitoring and managing seizure activity

• Assessing for delayed growth and development; providing activities to promote growth and development

CASE STUDY PROGRESS

T.M. is 16 hours postop and is crying and extremely agitated, but is unable to communicate about what the problem is. His mother asks you to give him some diazepam.

3. What information should you gather from Mrs. M. to better understand her request for the medication? [c]

It will be important to ascertain if T.M. is spastic and the frequency and duration of spasms, use of medications at home to treat spasticity (name and dosage), and alternative strategies used to help decrease the spasticity and to improve comfort.

4. What is the most likely reason Mrs. M. is requesting the diazepam? [c]

She is concerned that T.M. is having painful spasms. Mrs. M. has most likely dealt with this type of situation previously and has key information and experience that the nurse should draw on.

5. What should your next priority nursing intervention be? [ap]

To contact the orthopedic surgeon and obtain an order for medication to treat the spasms. (It will be important to alert the care provider regarding the medication used at home and Mrs. M.’s request.).

6. It is 3 days since T.M. had surgery, and there is an order to remove his Foley catheter.

What should your education and nursing plan include for T.M. and his mother? [c/ap]

An explanation of how the Foley will be removed, the need to continue monitoring and measuring urinary output, and techniques for diapering to promote skin integrity (contain stool and urine) and prevent contamination and damage to the spica cast

7. You are discussing discharge plans with T.M. and his mother. What should be included in your discharge teaching? [c/ap]

• Mrs. M. and T.M. should be taught about monitoring skin integrity, positioning, transfer techniques, cast care, medication administration (including proactive pain management, identification of adverse effects of analgesic therapy [e.g., constipation]), identification of S/S of complications from surgery (infection, neurovascular compromise), the importance of F/U provider care, the importance of fluids and nutrition (to prevent constipation and promote healing and normal growth). You should also answer any questions.

• T.M. has a gastrostomy tube and should have received an RD consult for MNT because he will most likely have increased nutritional needs for healing following surgery.

Case Study 107 Bronchiolitis

Diffi culty: Intermediate

Setting: Hospital, emergency department

Index Words: bronchiolitis, viral versus bacterial infection, assessment, risk identification and nursing management, medication administration, associated nursing responsibilities and care

Scenario

E.M., a 5-month-old girl, has been admitted for respiratory distress, hypoxia, and fever. Her viral respiratory panel shows that she has respiratory syncytial virus (RSV). In the emergency department (ED), her SaO2 was 78% on room air, and she was placed on 1.5 L oxygen (O2). On admission to the floor, the patient is fussy and difficult to console. Vital signs (VS) are 130/72, 188, 83, 38.4° C (rectal), and SaO2 94% on 1.5 L O2.

1. Based on the patient’s diagnosis, what else would be important to assess? [k]

Breath sounds, intercostal and sternal retractions, color, diaper for urine, presence or absence of tears, LOC, secretions

2. You provide nasopharyngeal suction for the patient and obtain a moderate amount of thick secretions. After allowing the patient to recover, you reassess the patient’s respiratory status.

The respiratory rate and retractions have not changed significantly. The breath sounds are less coarse, but they are diminished in the bases. The Sao2 is now 90% on 1.5 L O2.

E.M.’s mother asks if she can feed the patient, since she has not eaten much for the past 3 days. You tell her that with the patient’s respiratory rate greater than 65 breaths/min, she should not be fed. What is the rationale for holding feeds? [ap]

The patient may aspirate.

3. When you call the primary care provider (PCP), you are given orders for an albuterol nebulizer trial, IV bolus, and acetaminophen for the fever. What is the rationale for the albuterol trial? [c]

Albuterol is a bronchodilator that opens the airway of a small percentage of bronchiolitis patients.

Administering a trial will help to determine patient response and will provide information regarding continuance of the medication.

4. How will an IV bolus improve E.M.’s respiratory status? [c]

The increased hydration will thin respiratory secretions and increase the likelihood of expectorating the secretions with coughing.

5. Prioritize the following doctor’s orders, and give your rationale. [c]

A. Acetaminophen 60 mg PO for fever

B. D5LR 80 ml IV bolus

C. Albuterol 2.5 mg inhaled

Answers

A. 3; B. 2; C. 1

Rationale

A. Acetaminophen is the last priority because it is a comfort measure.

B. The IV bolus is the second priority because it may improve the airway indirectly by facilitating the removal of secretions that block the airway.

C. Give the albuterol treatment first because it dilates the patient’s airway and may improve oxygenation.

6. Mrs. M. asks why the physician is not prescribing antibiotics. What would you tell her? [c]

RSV is a virus, and antibiotics do not affect viruses. Using antibiotics when they are not needed leads to resistant bacteria.

CASE STUDY PROGRESS

After the albuterol treatment, the respiratory rate is 23 breaths/min, and the retractions have increased. The SaO2 is 89% on 2 L of O2. E.M. is pale and listless and does not cry when the IV is placed.

7. Why is the respiratory rate significantly lower even though other signs of respiratory distress have increased? [an]

E.M. is tiring from being tachypneic for so long, and she no longer has the energy to maintain the higher respiratory rate.

CASE STUDY PROGRESS

The PCP orders a portable chest x-ray (CXR) and capillary blood gas (CBG). The CXR is consistent with bronchiolitis with atelectasis. The CBG was pH 7.31, PCO2 72 mm Hg, HCO2 29 mEq/L.

8. Is the patient in acidosis or alkalosis? Respiratory or metabolic? Explain the results based on the patient’s condition. [an]

E.M. is experiencing respiratory acidosis. She is retaining CO2 due to inflamed airways and secretions.

The increased CO2 levels decrease the pH. The HCO2 is high because the patient’s body is trying to compensate for the respiratory acidosis.

CASE STUDY PROGRESS

E.M. is placed on a continuous positive airway pressure (CPAP) machine. You know from experience that patients are usually on CPAP for a couple days before they are ready to be taken off and continue to improve until they are ready for discharge. However, Mrs. M. is very distressed and asks you, “When is my baby going to die?” When you tell her that the patient is very sick but not dying, she says emphatically, “You can tell me. When is my baby going to die?”

9. What would you say to her? [an/ap]

Empathize with her feelings of being overwhelmed and concerned with the patient’s condition.

Explain the pathophysiology of bronchiolitis and the role of CPAP in recovery. Point out any improvements in patient condition since CPAP was initiated to help the mother understand that the patient is doing better. Educate Mrs. M. about the signs and symptoms of both improved and worsening patient condition so she can identify how the patient is doing. Reassure her that the outcome or normal disease process of bronchiolitis is that patients eventually recover.

Case Study 104 Cystic Fibrosis

Diffi culty: Intermediate

Setting: Hospital outpatient clinic

Index Words: risk factors associated with cystic fibrosis, growth and development, nutritional needs (malabsorption), respiratory status, daily respiratory care, pulmonary clean out, assessment, routine care, lung transplantation

Scenario

J.R., a 13-year-old with cystic fibrosis, is being seen in the outpatient clinic for a biannual evaluation.

J.R. lives at home with his parents and 7-year-old sister, C.R., who also has cystic fibrosis. J.R. reports that he “doesn’t feel good,” explaining that he has missed the last week of school, doesn’t have any energy, is coughing more, and is having “a hard time breathing.”

1. What additional data should be obtained from J.R. and his parents? [k/c]

• J.R.’s daily respiratory routine (frequency of chest PT and inhalation treatments, including medications used), medication management, supplemental vitamins, etc.

• Nutritional and GI assessment (intake; use of supplements, including pancreatic enzymes), a description of his bowel movements (float or sink), date of last hospitalization

• Exercise (type, frequency, duration)

• Last illness, school attendance (number of days missed due to illness)

CASE STUDY PROGRESS

J.R. is admitted to the hospital for a pulmonary “clean-out.” Your assessment includes the following:

color pale pink with bluish tinged nail beds; respiratory rate 28 breaths/min and somewhat labored; temperature 38.8° C (oral); SaO2 88%; rhonchi noted throughout; thorax has a barrel chest appearance; appears thin, weighs 30 kg.

2. Why is J.R. at risk for developing pulmonary infections? [k/c]

Cystic fibrosis is a common inherited genetic disorder of the exocrine glands that results in fibrotic changes in the respiratory, GI, and reproductive systems. Chloride secretion is decreased, sodium absorption is increased, and water flow across cells is decreased; these changes result in viscous and dry mucus. Mucous plugs form within and damage the respiratory, GI (pancreas, liver, intestines), and reproductive systems. The lungs become filled with this thick, sticky mucus (stasis), causing air trapping, hyperinflation, atelectasis, and a medium for bacterial growth, resulting in respiratory infections.

3. What are the common microorganisms that cause respiratory infections in children with cystic fibrosis? [k]

Most children with cystic fibrosis colonize multiple organisms. These include Haemophilus influenzae, Staphylococcus aureus, Pseudomonas aeruginosa, Pseudomonas cepacia (aka Burkholderia cepacia), and Serratia and Klebsiella organisms.

4. J.R.’s physician orders ceftazidime 2 g IV q8h, gentamicin 160 mg IV q8h, and vancomycin 650 mg IV q8h. What should you do before administering these drugs? [c/ap]

• Check and verify dosage and timing of medications.

• Evaluate for possible allergies or hypersensitivities.

• Identify any potential incompatibilities with other medications.

• Evaluate renal status (urinary output, BUN, creatinine, creatinine clearance).

• Determine whether there is a history for altered hearing (eighth cranial nerve involvement).

CASE STUDY PROGRESS

The following are recommended dosages:

Ceftazidime

Infants and children: 90 to 150 mg/kg q8h

Adults: 1 to 2 g q8h; maximum of 2 g q6h

Minimum: 90 ¥ 30 = 2700 mg/day = 900 mg/dose

Maximum: 150 ¥ 30 = 4500 mg/day = 1500 mg/dose

Gentamicin

Infants and children: 7.5 to 10.5 mg/kg q8h

Minimum: 7.5 mg ¥ 30 = 225 mg/day = 75 mg/dose

Maximum: 10.5 ¥ 30 = 315 mg/day = 105 mg/dose

Vancomycin

Infants and children: 40 mg/kg q8h

Adults: 500 mg q6h

Dosage: 40 ¥ 30 = 1200 mg/day = 400 mg/dose

5. Are the dosages prescribed for J.R. within a safe range? What factor will affect the selection of antibiotics and their dosages? [ap/an]

All medication dosages are above the recommended maximum. Due to the high resistance of the bacteria associated with cystic fibrosis, it is not uncommon to prescribe above the recommended maximum.

6. What are other commonly prescribed medications that children with cystic fibrosis take on a daily basis? Why are these important? [k/c]

Treatment of cystic fibrosis is aimed at maximizing pulmonary function while supporting and enhancing nutrition. To promote expectoration of secretions, recombinant human DNase (deoxyribonuclease) is used, as well as aerosol bronchodilators. Sodium to replace perspiration losses, pancreatic enzymes, fat-soluble vitamins (vitamins A, D, E, and K), and iron supplements are also taken daily. Lactulose may be given to help prevent intestinal obstruction.

7. J.R.’s weight is below the 5th percentile. He has been on a high-calorie, high-protein diet at home; however, he reports that he hasn’t been hungry and really hasn’t been eating much. What is the link between malnutrition and cystic fi brosis? [k/c]

The thick, sticky mucus that plugs the GI system causes poor absorption of essential nutrients.

Additionally, the pancreas is unable to secrete adequate amounts of pancreatic enzymes necessary for absorbing essential nutrients. These 2 factors put children with cystic fibrosis at risk for malnutrition and poor life outcomes. Children with cystic fibrosis who have adequate nutrition have a longer life span.

8. What clinical sign assists in determining the effective dosage of pancreatic enzymes? [k]

Assess the stool; stools that sink have less fat (it has been absorbed), whereas stools that fl oat have more fat (has not been absorbed). Stool should not float if dosage is correct.

9. J.R. will be spending 14 to 21 days in the hospital for his pulmonary clean-out. How will this hospitalization affect J.R.’s normal development? How can you foster his development while he is hospitalized? [c/ap]

• Attending school and meeting with peers are important aspects of a child’s growth and development. Missing school assignments may put J.R. behind his classmates in achieving the desired school progress and acquiring knowledge and skills. School is also an important place for social development and peer relationships. Lack of peer contact may cause feelings of self-doubt or discomfort around his classmates.

• Encouraging J.R. to participate in his care, including the decision-making process regarding respiratory treatments, antibiotic therapy, nutritional support, and physical activity, will help him feel that he is making decisions and caring for himself.

• You or his parents can contact his teachers and arrange for school work to be delivered. If possible, a few friends may be able to deliver the assignments and stay for a supervised visit.

10. Identify four long-term complications associated with cystic fi brosis. [k/c]

The 2 most common complications of cystic fibrosis are heart and lung failure. Additional complications include malnutrition, depression, sterility or infertility, and DM.

11. Is lung transplantation successful for children with cystic fibrosis? [c]

Although lung transplantation may be successful in the short term, the physiologic alterations that adversely affected the respiratory, GI, and reproductive systems in the beginning will not stop, and the process will resume.

Case Study 102 Pyloric Stenosis

Difficulty: Intermediate

Setting: Hospital

Index Words: pyloric stenosis, assessment, preoperative care, postoperative care, parental support, care of hospitalized child, resource management, dehydration, metabolic alkalosis, parental education

Scenario

S.B. is the only child of Mr. and Mrs. B. The family has been living out of their car for the past 2 months; Mr. B. lost his job 2 weeks after S.B.’s birth and looks for work every day. Mrs. B. takes advantage of the good weather and spends most of the day playing with S.B. in the park. As the triage nurse in the emergency department (ED), you ask why they have brought S.B. to the hospital. Mrs. B. states that S.B. breast fed well for the first couple of weeks, but since then “throws up all the time like he’s forcing all his feedings out. He looks skinny and sick, and he cries and is fussy all the time.”

1. What additional information will you need to obtain from Mr. and Mrs. B.? [c/ap]

• S.B.’s birth weight

• S.B.’s eating patterns: how often does S.B. feed, duration of each feed

• Number of wet diapers

• Color, amount (may need to use circle sizes to identify amount), and consistency of S.B.’s stools

• S.B.’s exposure to any illnesses or infections

• Presence of a fever or other symptoms of illness

• Mrs. B.’s eating pattern and types of food consumed

• Family history of food intolerance

2. What would you include in your physical assessment of S.B.? [k/c]

Length and weight, VS, general appearance and movement, neurologic status (LOC, PERRLA, fontanel, OFC), color, respiratory effort and breath sounds, abdominal assessment (note distention, abdominal girth, bowel sounds, pain and discomfort), mucous membranes, presence of tears, urine in the diaper

3. The emergency physician orders lab work and x-rays. What labs would you expect to be ordered, and what results would you expect to find knowing that S.B. has been vomiting frequently and that he may be diagnosed with dehydration and metabolic alkalosis? [ap]

The physician would likely order a CBC, CMP, UA, and blood pH. It is likely that you would see an increase in the bicarbonate and pH, elevated CO2, and decreased K (occurs simultaneously with metabolic alkalosis).

4. What is the underlying cause for S.B.’s diagnosis of metabolic alkalosis? [c]

Metabolic alkalosis occurs when there is a loss of metabolic acids, caused in this case by S.B. frequently vomiting his feedings.

5. What physical assessment findings occur with metabolic alkalosis? [k/c]

Clinical manifestations include decreased respiratory rate and depth, increased neuromuscular irritability, weakness, lethargy, tetany, seizures, confusion, and coma.

6. What additional assessment findings might reflect the consequences of frequent vomiting in the infant? [k/c]

Irritability, weight loss, decreased urinary output, dry mucous membranes, lack of tearing, sunken fontanel (depends on infant’s age), poor skin turgor (may be affected by nutritional status), lethargy (can change to coma), esophageal bleeding, pain (esophageal), decreased BP and change in pulse rate (rapid, weak, to nonpalpable), change in rate and pattern of respirations as dehydration worsens, delayed capillary refill, extremities becoming cool and discolored

CASE STUDY PROGRESS

S.B. is diagnosed with pyloric stenosis, admitted to the pediatric unit, and scheduled for surgery. S.B.’s parents are worried because they have no insurance and “don’t want anything bad to happen to our baby.”

7. What are your responsibilities as you admit S.B. and get him ready for surgery? [k/c]

• A major responsibility will be to verify that S.B.’s parents understand the purpose and basics of the surgical procedure (explained by surgeon).

• Provide education regarding nursing care that will be provided postoperatively, and provide support to help lessen their anxiety and fear.

• Get social services involved immediately to help with financial concerns.

• Complete the admission, take VS, continue monitoring, and carry out medical orders.

8. What are the implications of the family’s homelessness, financial situation, and lack of insurance? [c/ap]

Children in families with social and financial issues are at additional risk. Beside the inability to pay for acute health care, there is no money or ability to access health promotion services.

Immunization; well baby checks; dental and eye screenings; safety assessment (no car seat, exposure to environmental risks, etc.); access to adequate nutrition (fresh fruits and vegetables; adequate protein and complex CHO); and educational opportunities are frequently not available to children of low-income families.

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