Pediatric Patient Scenario With Questions Olivia Rylan

Pediatric Patient Scenario With Questions Olivia Rylan is a 3-month-old, healthy girl, weighing 5.5 kg. Her parents brought her to the doctor’s office yesterday with a 2-day history of runny nose, tachypnea, and fever. Her mother also reports she has not been breastfeeding as much or as often as usual. On examination, she was found to have increased work of breathing and was admitted to the inpatient pediatric unit for further observation. A nasopharyngeal swab was done. Both parents are with Olivia at the bedside. Olivia has received her routine 2-month immunizations but has not received palivizumab (Synagis) injections. Growth & Development Olivia is a healthy 3-month-old baby girl weighing 5.5 kg. She was born prematurely at 35 weeks and spent 1 week in the NICU at birth on oxygen. Olivia has met all developmental milestones. She is exclusively breastfed and feeds approximately every 3 hours, although mom reports she is starting to go longer between feeds at night. Olivia is an only child to her parents Marie-José and Richard. Marie-José’s first language is French. She is of Chinese ancestry from Mauritius. Richard is White and was born and raised in the Ottawa area. Part 1-Emergency Room Admission Data: VS: RR 54, HR 150, O2 sat 91% in room air, BP 80/54, T 38.7C HEENT: runny nose with clear discharge, anterior fontanelle slightly sunken, dry mucous membranes Neurological: PERL and brisk, sleepy, decreased interaction with parents and environment Respiratory: coarse crackles heard bilaterally, decreased breath sounds to both bases, moderate work of breathing with nasal flaring, intercostal and subcostal retractions, nasopharyngeal swab positive for RSV Cardiac: normal S1 & S2, no murmurs, peripheral pulses palpable, cap refill = 2 seconds GI/GU: abdomen soft, bowel sounds present x 4 quadrants, urine output low (1.5 ml/kg/hour) MSK: moving all 4 limbs with normal ROM, normal tone Skin: skin warm to touch, slightly pale in colour, decreased skin turgor noted Orders 2L oxygen by NP Notify MD/NP if oxygen saturation less than 91% PIV NS bolus 20 ml/kg over 2 hours, then 10ml/hr Breastfeed ad lib Accurate intake & output Continuous O2 sat monitoring VS q4h Tylenol 80 mg PO/PR q4h PRN Droplet/contact precautions Part 2 – The next day The next day, Olivia continues to get worse. VS: RR 74, HR 178, O2 sat 90% on 35% oxygen by face mask, BP 78/52, T 39.0C Neurological: lethargic, not awakening for feeds, PERL and brisk, decreased interaction with parents and environment Respiratory: wheezing and coarse crackles heard bilaterally, decreased breath sounds to both bases, severe increased work of breathing with nasal flaring, intercostal and subcostal retractions, chest x-ray confirms pneumonia Cardiac: normal S1 & S2, no murmurs, peripheral pulses weak, cap refill = 3 seconds GI/GU: abdomen soft, bowel sounds present x 4 quadrants, urine output low (0.8 ml/kg/hour), no wet diaper in last 6 hours MSK: moving all 4 limbs with normal ROM, decreased tone Skin: skin warm to touch centrally and cool peripherally, pale in colour Orders NPO IV bolus NS 110 ml over 1 hour, then NS at 22 ml/hr Continuous HR, RR, O2 sat monitoring Epinephrine nebulizer 2.5 mg 1/1000 solution in 3ml NS q4h PRN Consult PACE/Critical Care Response Team Critical Thinking Questions What is going on? What is your nursing impression and what are your priority nursing interventions and why? (Tee) What do you think of the above orders? What other orders might you ask for? How does advocacy fit with this client/family situation?

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