PEDIATRIC CASE STUDY #1

By Carmen Valdez and Fion Kung

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

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

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

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

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

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

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

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

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.

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

Complication

• Pleural effusion

• Empyema

• Lung abscess

• Pneumothorax

• Obstructive airway due to secretions

• Hypoperfusion

• Sepsis

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

Consultations• RT

• Nursing manager/case manager

• MD

• Dietitian

• Social worker

• Speech therapy

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

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!

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 linezolidand vancomycin 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