CHAPTER 10 PEDIATRIC DISORDERS CASE STUDY 104

Case Study 104

Name Avendaño, Rica Marie A. Class/Group 9 Date
Group Members
INSTRUCTIONS All questions apply to this case study.Your responses should be brief and to the point. When asked
to provide several answers, list them in order of priority or significance. Do not assume information that is not
provided. Please print or write clearly. If your response is not legible, it will be marked as? and you will need to
rewriteit.

J.H. is a 2-week-old infant brought to the emergency department (ED) by his mother, who speaks little
English. Her husband is at work. She is young and appears frightened and anxious. Through a translator,
Mrs. H. reports that J.H. has not been eating, sleeps all of the time, and is “not normal.”

1. What are some of the obstacles you need to consider, recognizing that Mrs. H. does not speak
or understand English well?
• The obstacles that I need to consider recognizing that Mrs. H does not speak or
understand English well are, Language barrier since she is not that good in English
so I will wait for the translator to obtain information, deficient knowledge because
she is still young, Fear because she maybe an illegal immigrant, and since she seems
to be a foreigner also consider for her cultural practices.

10 Pediatric
2. You perform your primary assessment and question Mrs. H. with a translator. Which of
these findings are abnormal and need to be reported? (Select all that apply and state
rationale.)
a. Anterior fontanel palpable and tense: could mean increased ICP
b. Pupils equal and +3
c. Temperature 36° C rectally: Could be a sign of sepsis
d. Heart rate: 85 beats/min: Normal HR for newborn is 120-160 beats/min
e. Positive Babinski's reflex
f. High-pitched cry: May indicate that the baby is in pain
g. Refusal of PO intake per mom: Sign that something isn’t quite right

CASE STUDY PROGRESS

J.H. is admitted to the medical unit with the diagnoses of meningitis and rule out sepsis.
The ED physician orders the following:

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 PART 2 PEDIATRIC, MATERNITY, AND PSYCHIATRIC CASES

◼ Chart View

CBC with differential Blood culture

Complete metabolic panel (CMP)
Urinalysis (UA)
Cerebrospinal fluid (CSF) for culture, glucose, protein, cell count (following lumbar puncture)
Ceftriaxone (Rocephin) 260 mg IV now (loading dose)
Acetaminophen (Tylenol) 50 mg suppository per rectum for irritability

3. Prioritize the order of your interventions, with 1 being your first action and 7 being your last
action.
6 Administer ceftriaxone (Rocephin)
4 Place IV
5 Straight catheterization for urine specimen
1 Place on contact isolation and droplet precautions
2 Assist with lumbar puncture
7 Administer Tylenol
3 Obtain blood culture, CMP
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4. Before administering the ceftriaxone (Rocephin), you must verify the dose with another RN.
The therapeutic range is 100 mg/kg/day divided in two doses. J.H. weighs 3.5 kg. Is the dose
ordered safe? (Show your work.)
• The therapeutic range of ceftriaxone (Rocephin)= 100 mg/kg/day divided in two doses.
Weight of the patient= 3.5 kg
= 3.5X100 = 350 mg per day = 350/2= 175 mg
175/dose is therapeutic range.
Ordered is 260 mg in two divided doses. means 130 mg per dose.

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 CHAPTER 10 PEDIATRIC DISORDERS CASE STUDY 104

5. Interpret J.H.'s lab findings and explain the rationale for abnormal results.
• Laboratory Test Results:
Urine pH 7.2: normal
Color Clear: normal
Leukocytes Negative: normal
Complete blood count Hct 32%: low – Normal Hct in newborn is 55% - 68%
HgB 10.5 g/dL: low – Normal Hgb in newborn is 14 – 24g/dL
WBC 22,000/mm 3: high – The WBC of the baby is too high that indicates infection
Sodium 125 mEq/L: low - Hyponatremia (Low Level of Sodium in the Blood)

◼ Chart View
Laboratory Test Results
Urine
p .
C Cl
Leukocytes Negative
Complete blood count
t
gB . g/
WBC /

10 Pediatric
S E /

6. Interpret the CSF findings. Would you suspect bacterial or viral meningitis? Why?
• CSF: Clear - Findings are suggestive of bacterial meningitis.
• Gram stain: Pending - The specimen is usually clear slightly cloudy.
• Protein: 300 mg/dL (elevated) - With bacterial origin will find decreased glucose
increased protein and primarily polymorphonuclear leukocytes. Raises with
bacterial as leftovers from bacteria metabolizing glucose. Protein stays normal in
virus.
• Leukocytes: 1030 cells/microliter (elevated)
• Glucose: 40 mg/dL (decreased) - A viral origin usually causes a normal or slightly
increased protein and normal glucose.

◼ Chart View
Cerebrospinal Fluid Analysis
CS Cl a
tain n ng
t n / l at
uk / (elevated)
Glucose

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 PART 2 PEDIATRIC, MATERNITY, AND PSYCHIATRIC CASES

7. What are the most common pathogens in this age group?

- The most common causes of bacterial meningitis in this age group are group B
streptococci and Escherichia Coli. The introduction of Haemophilus influenzae type b
(hib) and Streptococcus pneumoniae (pneumococcal) vaccines have greatly reduced
the incidence of meningitis from these pathogens.

CASE STUDY PROGRESS

J.H. is diagnosed with Escherichia coli meningitis. His medical care plan will include 14 to 21 days of anti-
biotic therapy. You are developing his nursing plan of care.

8. Outline a plan of care for J.H., describing nursing interventions that would be appropriate for
managing pain and infection, maintaining hydration, assisting with increased intracranial
pressure (ICP), and teaching to review with his parents.
- Pain
Assess every 4 hours using the FLACC(2-7 yo) scale.
Administer pain medication as ordered.
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Keep stimulation at a minimum with a quiet environment and dim lights.

-Hydration
Strict intake and Output
Monitor perfusion: cap refill,BP, pulses<mottling, anterior fontanel.
Daily weights
Patient will be NPO initially and diet advanced as tolerated with improved status.
-Infection
Maintain isolation precautions
Administer antibiotics are ordered
Monitor laboratory values and culture.
-Increased ICP
Assess for signs and symptoms of increased ICP increased irritability, change in level of
consciousness (LOC)
Frontal occipital circumference every shift.
Observe seizure precautions and monitor for seizure activity.
-Parent of Education
Explain disease process and treatment plan.
Educate on need for isolation precautions.
Assess support system and allow for questions.
Encourage comfort measures, bonding and participation in care.

CASE STUDY PROGRESS

Mrs. H., through her translator, asks you what could have caused her baby to be sick since he had an
immunization when he was born. She asks whether he should get “more shots” so this won't happen
again. You reinforce to Mrs. H. that infants have immature immune systems, and they are vulnerable to
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468 Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
 CHAPTER 10 PEDIATRIC DISORDERS CASE STUDY 104

infections until they have been immunized. Mrs. H. asks when J.H. will get more shots and what will they
be?

9. According to the CDC immunization schedule, which of the following immunizations will
J.H. receive at 2 months? You can refer to the current immunization schedules posted at
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm.
a. Hib
b. MMR
c. OPV
d. IPV
e. Rotavirus
f. DTaP
g. Varicella
h. Hep B
i. Pneumococcal
- It should be verified whether J.H. received his hepatitis B vaccination 1 at birth. According
to the current immunization schedule, J.H. will receive these recommended vaccinations at
2 months. If he has not yet received his hepatitis B vaccination, this could be administered
before discharge, and he would receive vaccination 2 on the schedule at 2 months.

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10. What is the impact of hospitalization on J.H.'s growth and development?

-Stages of J.H trust and mistrust. His basic needs are such diapering, feeding,
comforting must be met on a consistent basis. Having his parents participates in his
care will help meet. J.H’s developmental needs, reinforce their parenting role, and
promote their comfort level. It will also promote parent infant bonding.

J.H. is being discharged after 3 weeks of IV antibiotic therapy. What educational topics will be
important to discuss with J.H.'s parents when he is discharged?
• We need to have a good hygiene that most important for all.
• How to take a temperature.
• Safety
• Nutrition
• Immunization
• Administering acetaminophen, giving fluids, when to call the physician

CASE STUDY OUTCOME

J.H. is discharged to home with his parents. He will continue PO antibiotics for 1 week and receive a home
health visit for infant care follow-up. He is to return to his PCP in 1 week or call for any concern.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.

Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 469
 PART 2 PEDIATRIC, MATERNITY, AND PSYCHIATRIC CASES

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.

470 Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.