I need assistance with the attached homework, which entails 3 medical case studies.

Pediatric Clinical Reasoning Case Study: Tonsilllitis

Kathleen Mixson RN, MS, JD

I. Data Collection

Chief complaint/History of Present Illness: Jaxon is a 4-year old African American male admitted yesterday from ER with a 1 day history of fever, sore throat for 3 days and swelling in the right neck. His diagnosis is tonsillitis with retropharyngeal cellulitis. He was admitted to PICU for a question of airway compromise and transferred to the floor last evening. Mom reports a history of increasing difficulty eating and denies trauma to the neck. He has Clindamycin and Unasyn IV ordered. He has a weighted NGT in the right nare with orders for Pediasure every 6 hours but has been NPO since 2:00 AM for repeat CT scan this morning. He is very uncomfortable and has been medicated with IV morphine 3 mg several times during the night for pain in the throat and neck, last time 3 hours ago. Resp WNL, Bowel sounds are present all 4 quads, IV 24 g R FA infusing D5 1/2 with KCl 20 mEq/L at 49 ml/hr. IV site without redness or edema. Today’s weight is 14.9kg, down 3 tenths from admission weight yesterday.

What data is relevant to this patient that must be recognized as clinically significant to the nurse?

Rationale:

Looking through his chart you note the following in his past medical history:

Jaxon is a previously healthy African American male. Per mother, for approximately 6 months, Jaxon has exhibited symptoms of reflux with meals and taking longer to eat meals (at times, up to 1 hour to complete a meal). Mother thinks he has lost weight in the past few weeks.

Admit Wt: 15.2 kg Current Height: Height: 101 cm (39.76") 21.81% of growth percentile based on stature-for-age. BMI: Body mass index is 13.97 kg/(m^2). 7.15% of growth percentile based on BMI-for-age.

What information in his medical history is relevant to the presenting problem?

Rationale:

Patient Care Begins: You enter the room and complete your initial physical assessment. Neuro: WNL. CV: WNL+ 2 pulses in all extremities. Capillary refill < 3 seconds. Resp: Breath sounds clear on room air all lobes except coarse sounds in bases bilat, no retractions or upper airway noise, good aeration. GI: bowel sounds present all quads, Gastric tube, weighted R nare. GU: WNL. Integ: Pink and intact except for IV 24 g R FA infusing D5 1/2 with kcl 20 mEq/L at 49 ml/hr., site w/o rednessor edema; puncture wounds from lab draws. MS: WNL. ENT : MM moist and intact. Pain FACES 3/5 neck and throat. PEWS 1. VS: BP 124/70, Temp 37 (98.6), Heart rate 95, Resp rate 24 , O2 sat 100%

You inform the family that the CT scan is scheduled for this morning. Jaxon asks for breakfast and something for pain. You explain that he cannot have anything to eat until after the CT scan and give him morphine 3mg IV per syringe pump. Within 35 minutes he is crying because he is hungry, still having pain, drooling, and cannot turn his head.

You notice nasal flaring and drooling. You check his O2 sats one more time and they are 94%. You reposition Jaxon by elevating the head of the bed. You check his O2 sats and they are now 91% with a heart rate of 108/minute that correlates with the oximeter reading. Respirations are now 40.

II. Clinical Reasoning Begins…

1. What is the medical problem that your patient is presenting with?

Airway obstruction caused by tonsillitis

1. What is the underlying cause /pathophysiology of this concern?

Tonsillitis, inflammatory infection of the tonsils caused by invasion of the mucous membrane by microorganisms, usually hemolytic streptococci or viruses. The infection may extend upward into the nose, sinuses, and ears or downward into the larynx, trachea, and bronchi. Locally, virulent bacteria may spread from the infected tonsil to the adjoining tissues, resulting in a peritonsillar abscess.

1. What is your primary nursing priority right now?

1. What nursing diagnostic statement will guide your plan of care?

1. What interventions will you initiate based on this priority?

1. What is the worst possible complication to anticipate?

More serious are two distant complications—acute nephritis (kidney inflammation) and acute rheumatic fever, with or without heart involvement. 

1. What nursing assessment(s) will you need to identify and what responses if this complication develops?

1. What are three age appropriate nonpharmacologic nursing interventions to help manage pain and discomfort?

After your interventions, his O2 sats are now 97% respirations are regular and no flaring, drooling, or retractions are present. Patient transport arrives to take Jaxon to the CT scan. Anticipating that the NPO status will be removed when Jaxon returns to the floor and his tube feedings re-established you calculate his nutritional needs. Pediasure 30 kcal/oz, 240 ml every six hours per NGT is ordered.

1. Calculate Jaxon’s caloric requirements. A child this age needs 75-85 kcal/kg/day. Is the child receiving an adequate amount of calories with this nutritional order? As the patient advocate, is there anything you need to do for the patient? If so, what?

1. What is the rationale for giving oral instead of intravenous pain medications?

Medical Management: Rationale for Treatment & Expected Outcomes

Dosage Calculations:

Radiology Reports: Chest X-Ray Single frontal view of the chest demonstrates normal cardiac and mediastinal contours. There is no confluent infiltrate, pleural effusion, or pneumothorax. Pneumomediastinum within the superior mediastinum as seen on the CT neck performed on the same day is not well-seen radiographically. The upper abdomen is nonobstructed. The bones are normal in appearance. IMPRESSION: No acute process in the chest. Pneumomediastinum is not seen radiographically

CT Neck: IMPRESSION: Extensive tonsilar and retropharyngeal cellulitis with widespread retropharyngeal air standing from the level of the nasopharynx into the superior mediastinum. There are poorly defined low density areas in the retropharynx at the level of the oropharynx and hypopharynx without a dominant walled off collection. There is associated mediastinitis. The retropharyngeal air is most concerning for gas forming organism although could also be seen with perforating injury to the airway.

What data above is relevant to this patient that must be recognized as clinically significant to the nurse?

How do these radiology findings relate to primary problem?

Lab Results:

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

Identify the relevant lab results to this patient and their clinical significance:

Which labs when trended are showing improvement and/or reveal concerning potential complications?

New Radiology Reports:

KUB: A feeding tube is positioned at the left upper quadrant.

CT: Neck: Extensive retropharyngeal and tonsilar cellulitis with widespread retropharyngeal air standing from the level of the nasopharynx into the superior mediastinum. There are poorly defined low density areas in the retropharynx at the level of the oropharynx and hypopharynx without a dominant walled off collection. There is associated mediastinitis. The retropharyngeal air is most concerning for gas forming organism although could also be seen with perforating injury to the airway.

What data above is relevant to this patient that must be recognized as clinically significant to the nurse?

How do these radiology findings relate to primary problem?

Application

9. Choose two of the most relevant abnormal labs or assessment findings for your patient and address the following:

III. Evaluation:

Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management.

Eight hours later…

VS: I & O for shift

T: 36.4 I IV: 387

P: 88 Enteral: 737

R: 24

BP: 94/56 O Urine/stool: 683

O2 sats: 98 %

Nursing Assessment: Neuro: WNL. CV: WNL. Resp: WNL Breath sounds clear all lobes A&P, no retractions or upper airway noise, good aeration. GI: bowel sounds present all quads. Gastric tube, weighted, R nare. GU: WNL. Integ: Pink and intact except for IV 24 g R FA saline locked, site w/o redness, edema; puncture wounds from labs draws. MS: WNL. ENT: MM moist and intact. Pain FACES 0/5 PEWS 0 or 1

What assessment data is relevant to this patient that must be recognized as clinically significant to the nurse?

Rationale:

1. Has the status of the patient improved or not as expected to this point?

1. What data supports this evaluation assessment?

The physician orders a PICC line insertion for continuation of antibiotic therapy with clindamycin.

What pre-procedure teaching is needed for Jaxon and his family regarding the PICC insertion? What age appropriate techniques should be used for the teacning?

What discharge teaching is needed for Jaxon and his family regarding the PICC line care and antibiotic therapy?

Jaxon is going home also with the NGT for continuation of enteral feedings until his swallowing difficulties have resolved and he can again eat regular food. Pediasure 30 kcal/oz 320 ml four times a day is ordered. He may have full liquids ad lib. Home health nurse is ordered for PICC line care teaching reinforcement and evaluation of readiness for NGT removal. He is to return to the clinic in one week.

What discharge teaching is needed for Jaxon and his family regarding the care of the NGT, the enteral feedings, and follow up care?

QSEN Questions Related to Case Study:

Patient Centered Care

What can you do to demonstrate intentional caring and promote patient centered care with sensitivity and respect for your patient in the context of this clinical presentation?

How can you ensure and assess the effectiveness of communication with the patient and family?

How can you integrate your patient’s preferences/values as you coordinate your plan of care or provide any needed education?

How can you ensure that your patient is an active partner while under your care and promote self-care once they are discharged?

Teamwork & Collaboration

What can you do to facilitate safe and effective update/report to the physician or oncoming nurse?

What would you do if you were not comfortable performing any new skill that was required to take care of this patient?

Evidence Based Practice

As a new nurse, what resources could you utilize to provide current, evidence based and individualized care planning based on the needs of this patient?

Safety/Quality Improvement

What would you as the nurse do if you almost gave the wrong dose of one of the ordered medications because of a similarity in the label provided by pharmacy to another drug?

Informatics

What medical electronic data bases are available in your clinical setting that would be a resource if needed to obtain needed information on a medication you have not given before or an illness/surgery you have never seen before?