Pediatric H1N1, pneumonia & sepsis scenario NURS

Pediatric H1N1, pneumonia & sepsis scenario NURS 4430/4435/4471 Questions to answer are in bold. The objective is for you to use your critical thinking skills to work through the possible problems the patient is having as well as treatments and expected outcomes. Resources that may be helpful to you in this scenario: Drugs.com for medications Pedihelp app for normal VS and drug doses. Alternatively look up online but the age ranges are larger and less accurate. The App is free. MDCalc.com Internet book of critical care chapter on sepsis https://emcrit.org/ibcc/sepsis/ Internet book of critical care chapter on influenza https://emcrit.org/ibcc/sepsis/ Internet book of critical care chapter on pneumonia https://emcrit.org/ibcc/pneumonia/ Most of the IBCC chapters also have podcasts if you prefer that over reading. Scenario Chase Korman DOB:10/21/2015 Pt is a 6 year old male who presented to the ER with his mother. She states that he has been “not feeling well” for several days. He has had a cough, sore throat, fever and hasn’t been eating much or drinking fluids. Yesterday his temperature was 101 so she kept him home from school. Last night he seemed to be having a hard time breathing so she brought him to the ER. Allergies: none Medications at home: ibuprofen, acetaminophen, albuterol as needed for seasonal asthma PMH: Occasional wheezing and cough treated with albuterol as needed. Otitis media as a baby with multiple rounds of ceftriaxone resulting in tympanostomy at the age of 18 months. VS on admit to the ER: temp 39.2 C, P 122, BP 92/45, RR 30, SpO2 92% RA, weight 25 KG Interventions in the ER: Respiratory PCR panel, blood cultures, chest xray positive for bilateral lower lobe pneumonia, 22 gauge IV RAC (multiple attempts distal due to dehydration) CBC, CMP, O2 @ 2 lpm NC, Albuterol via SVN, NS fluid bolus 250 ml then maintenance rate at 67 ml/hr, ceftriaxone 750 mg IVPB, ibuprofen 250 mg oral suspension Laboratory Results Test Result Units Reference Range CMP Glucose 132 mg/dL 65-99 BUN 27 mg/dL 5-26 Creatinine 1.20 mg/dL 0.76-1.27 Sodium 141 mmol/L 135-145 Potassium 4.8 mmol/L 3.5-5.0 Chloride 109 mmol/L 97-108 Protein, Total 7.0 g/dL 6.0-8.5 Albumin 5.0 g/dL 3.5-5.5 Bilirubin, Total 0.7 mg/dL 0.0-1.2 Alkaline phosphatase 73 IU/L 25-150 AST (SGOT) 22 IU/L 0.0-40 ALT (SGTP) 31 IU/L 0.0-55 Test Result Units Reference Range CBC WBC 22 X10E3/uL 4.0-10.5 RBC 4.12 X10E3/uL 4.10-5.60 Hemoglobin 13 X10E3/uL 12.5-17 Hematocrit 37.2 % 36-50 Platelets 259 X10E3/uL 140-415 Which labs are abnormal? What is their significance? Admit to pediatric unit. Diagnosis: pneumonia, dehydration, rule out influenza (test pending) Pt was admitted on the night shift at 0200. You are coming in on day shift and assess the patient at 0730. Assessment as follows: Room survey: sitting up in bed with HOB at 30 degrees, mildly lethargic, 2LPM NC in place, mom sitting at bedside, when you approach the patient he looks away and climbs into his mom’s lap Respiratory: Airway patent, mild subcostal retractions noted, breath sounds diminished in bases with crackles and expiratory wheezes. Cardiovascular: Skin pale, dry, capillary refill 2 seconds, pulses palpable. Neuro: somewhat somnolent but reacts appropriately per age GU: 20 ml dark yellow urine noted in hat in bathroom Current VS: temp 38.5, P119, BP 98/50, RR 30, SpO2 97% on 2LPM NC Respiratory PCR results: Influenza A (H1N1) positive, Influenza B negative, RSV negative, Rhinovirus negative What are the normal VS ranges for this patient? Which of your assessment and VS data is within normal limits? Which are abnormal? Are there any precautions you need to take? Look through your MAR provided below. What interventions and medications would you like to give now and why? Patient: Chase Korman MAR Allergy: none MRN: 998209743 DOB: 10/21/2015 Weight 25 kg Verify Order RN Initials Orders 0001-0700 0701-1900 0200 BR RT to give med neb treatments as per protocol or PRN wheezing Albuterol (VENTOLIN HFA) 2.5 ml SVN, Q 3 HOURS PRN, Wheezing, Cough 0020 SN ED 0345 BR 0200 BR Ceftriaxone 750 mg IVPB Q 12 hours 750 mg/50ml over 30 minutes 0115 SN ED 0200 BR Ibuprofen 250 mg suspension Q 8 hours, PRN, fever >38.4 C 0013 SN ED 0200 BR Acetaminophen 375 mg suspension Q 6 hours, PRN, fever >38.4 not controlled by ibuprofen, alternate. 0200 BR Na Cl 0.9% IV @ 67 mL/hr 0030 SN ED 0200 BR 0200 BR O2 to keep SpO2 >94% notify MD for increased O2 demand > 6lpm 0002 SN ED 0200 BR At 1330 you go in to start the second dose of ceftriaxone. What do you need to do before starting the medication? At that time his temp is 38.5 C and his lungs are diminished in the bases with crackles noted. Which meds should be given next? Around 1700 you enter the patient’s room. Assessment: Pt is sleeping next to mom who is also asleep. Mom awakens when you enter the room. Pt is lethargic and hard to wake up. He appears pale and cyanotic and is exhibiting respiratory distress with intercostal and supraclavicular retractions. Breath sounds are coarse with crackles and expiratory wheezing. NC in place, however, SpO2 is 88%, RR 48. Skin is hot centrally but cool extremities and pale. Pulse is rapid and faint. P135, BP 69/32. He opens his eyes and lets you complete the assessment without crying or pulling away. He is restless. What are your initial actions? What is the significance of him allowing you to complete the assessment without crying or pulling away? Mom is frantic and asks what is going on, what are you going to say to her and how will you help keep her calm while also caring for the patient? You called a rapid response, and the team arrives. Congratulations you are now the rapid response team, and you got a great report from yourself just now and are fully up to speed on what is going on. (Remember to use the resources listed in the resource section above) What are your shock possibilities for this patient? What are your initial actions? Admit to the ICU. VS as follows Temp 38.0, P140, BP 68/45, RR38, SpO2 93% on 15 L NRB You request a vasopressor to help with his blood pressure and receive an order for norepinephrine 0.1 mcg/kg/min, titrate to a systolic BP of 85. Norepinephrine comes mixed 4 mg/250ml D5. What is your initial dose? How many ml per hour should the pump read? The MD decides that the patient should be intubated and asks you to set up for intubation. What is the appropriately sized ETT tube for this patient? For induction he would like you to draw up ketamine 2 mg/kg (500mg/10ml) and rocuronium 1 mg/kg (100mg/10ml) and continued sedation of propofol 25 mcg/kg/min (1000mg/100ml) What is your ketamine dose in mg and ml? What is it being used for? What is your rocuronium dose in mg and ml? What is it being used for? What is your propofol dose in mcg/min and how many ml/hr on the pump? What is it being used for? Post intubation chest Xray shows ETT tube correctly placed with worsening of pneumonia from previous Xray. ABG is as follows pH 7.25, PaCO2 65, PaO2 50, HCO3 23, Base excess -4.9, Lactate 10 (not part of the ABG but you got one) What is your interpretation of the ABG (include compensated/uncompensated/partially, respiratory/metabolic, acidosis/alkalosis) What is the significance of the Base Excess? What does it mean? What is the significance of the lactate? You need to set up your ventilator and the respiratory therapist is not available. Your patient is ideal body weight for his height. Remember to review normal vital signs for your patient when setting up the ventilator (refer back to ventilator lecture) VT PEEP F (remember this is RR) FiO2 What is the max PIP and pPlat for this patient? Your patient’s blood pressure is now 79/53. What will you titrate the norepinephrine to? What is the mcg/kg/hr and what is the ml/hr for that titration? (Reference vasoactive drip ppt) You place an NG tube to help decompress the stomach and a foley catheter to monitor urine output. You get 30 ml dark yellow urine out. What is your target urine output in ml/hour for this patient? SCIENCE HEALTH SCIENCE NURSING NURS 4471

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