Pediatric Clinical Reasoning Case Study: Poison IngestionCreated by Kathleen Mixson, RN, MS, JDI. Data CollectionChief complaint/History of Present Illness: Brandy is a 22 month .old female presenti

Pediatric Clinical Reasoning Case Study: Poison Ingestion

Created by Kathleen Mixson, RN, MS, JD

I. Data Collection

Chief complaint/History of Present Illness: Brandy is a 22 month .old female presenting with ingestion at 10:30 pm yesterday of estimated 1/2 tsp of solder flux and immediately had vomiting of about 12 times, taken immediately to the emergency room. No vomiting since around 3 am but continues to have gagging and retching. No diarrhea. Has raspy voice, fussiness. Had chemistries, LFTs, CBC, IV started in ER. Acute ingestion of zinc chloride-containing solder flux (contains 30-36% zinc chloride), which is caustic to GI tract, skin, and eyes. Also if significant systemic absorption occurs, systemic toxicity may include altered mental status, renal insufficiency. Patient to be admitted for observation and monitoring for systemic effects. If no respiratory distress or abnormal labs the plan is to discharge this afternoon.

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

Rationale:

Personal/Social History: Mom and dad at bedside. Lives with parents. English speaking

PMH: Allergic rhinitis, night-time cough, thought to have seasonal allergies as a cause of chronic vomiting. Born at 36 weeks gestation, no complications, SVD.

Current Medications: None

Patient Care Begins:

Your Initial VS:

T: 97.9º F

P: 118

R: 38

BP: 100/76

O2 sats: 98% on 2L per NC

Weight: 15,2 kg

Pain: 3/10 FLACC

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

Rationale:

Your Initial Nursing Assessment:

GENERAL APPEARANCE: Fussy, irritable and requiring frequent comforting from parents.

RESPIRATORY: Breath sounds equal and with good aeration bilaterally. No stridor or nasal flaring. Mom states continued raspy voice.

CARDIAC: Heart rate regular-S1S2. Pulses palpable and equal bilaterally. Capillary refill less than 3 seconds.

NEUROLOGIC: Alert with normal muscle tone and movement of extremities.

ABDOMEN/GI: Currently NPO. Mouth and throat red and raw looking. Abdomen soft, non-tender with active bowel sounds all four quads.

GENITOURINARY: Voiding per diaper.

EXTREMITIES/SKIN: Skin is warm and dry-normal for color of skin. IV in place to right hand, infusing D5 ½NS at 42 per hour. Site without redness or edema. Hands equal bilaterally.

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

Rationale:

II. Clinical Reasoning Begins…

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

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

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?

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

Medical Management: Rationale for Treatment & Expected Outcomes

Radiology Reports: Chest X-ray: Cardiac silhouette is not enlarged. Aortic arch is left-sided. Lungs are clear of confluent infiltrate or pleural fluid. Osseous structures are normal. The upper abdomen is demonstrates no evidence of obstruction.

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?

Application

8. Choose two of the most relevant labs or assessment data for your patient and address the following:

Two hours later… Mom calls the nurse and is very distraught. She states that the baby is very hungry and won’t stop crying. She has not eaten since yesterday evening and can she please give the baby some juice or something.

VS: I & O

T: 96.2 Intake IV 366

P: 98 enteral 224

R: 26

BP: 98/58 Output 588

O2 sats: 100% on room air

Pain: 0/10 FLACC

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

Rationale:

Your knowledge of growth and development allow you to evaluate the needs of your patient during your shift. Based on this knowledge of the needs of your patient. you need a physician’s order. What will you concisely state to update the physician at this time?

(QSEN-Teamwork & Collaboration/Safety)

Situation:

Background:

Assessment:

Recommendation

You receive orders to advance diet for age as tolerated. Discontinue IV and change to saline lock when taking adequate fluids.

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.

Six hours later…

VS: I & O

T: 96.2 Intake IV 366

P: 98 enteral 324

R: 26

BP: 98/58 Output 588

O2 sats: 100% on room air

Pain: 0/10 FLACC

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

Rationale:

Nursing Assessment:

GENERAL APPEARANCE: Resting comfortably. Playing with toys in the crib.

RESPIRATORY: Breath sounds equal and with good aeration bilaterally. No stridor or nasal flaring.

CARDIAC: Heart rate regular-S1S2. Pulses palpable and equal bilaterally. Capillary refill less than 3 seconds.

NEUROLOGIC: Alert with normal muscle tone and movement of extremities.

ABDOMEN/GI: Taking clear fluids without any dysphagia with order to advance diet. Mouth and throat slightly inflamed. Abdomen soft, non-tender with active bowel sounds all four quads. Intake 690 enteral and IV for shift.

GENITOURINARY: Voiding per diaper. Output 588 for shift.

EXTREMITIES/SKIN: Skin is warm and dry-normal for color of skin. IV to right hand changed to saline lock. Site without redness or edema, dressing dry and intact. Hands equal bilaterally.

What VS 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?

1. Based on this assessment data, now what will be your nursing priorities and current plan of care?

1. What discharge teaching is needed for this family?

:

Your knowledge and application of the pathophysiology of poison ingestion have allowed you to make a series of needed assessments and judgments that have facilitated the treatment and care of your patient. You have made a difference at the bedside! Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the oncoming nurse who will be caring for this patient:

(QSEN-Teamwork & Collaboration/Safety)

Situation:

Background:

Assessment:

Recommendation:

QSEN Questions to Incorporate Into 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?

(QSEN-Patient Centered care)

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

(QSEN-Patient Centered care)

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

(QSEN-Patient Centered care)

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

(QSEN-Patient Centered care)

Teamwork & Collaboration

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

(QSEN-Teamwork and Collaboration)

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

(QSEN-Teamwork and Collaboration)

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?

(QSEN-Evidence Based Practice)

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?

(QSEN-Safety/Quality Improvement)

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?

(QSEN-Informatics)