Pediatric Grand Rounds

Taylor Brunke, Ashley Smith, &

Emily Womack
 Table of Contents

01 02
Introduction Client History
A brief introduction. Client history, developmental
stage, & assessment data.

03 04
Plan of Care Research
Concept map, interventions, Epinephrine Auto-
expected outcomes, & discharge Injectors.
planning.
Introduction
C.S is a 6 year old Caucasian male who has
a peanut allergy and was brought to the
emergency department by his aunt and
uncle due to having difficulty with
breathing after he accidently ate a cookie
containing peanuts.
Health History
● C.S.
● Male
● DOB: 5/5/2014 (6yr)
● Height: 120cm
● Weight: 21kg
● Allergies: Peanuts, perfumes, and dyes
● No known health problems
● Immunizations up to date

Psychosocial History
● Mother and father are both serving
overseas in the military
● Currently living with aunt and uncle
Cultural Considerations

● Catholic
○ Source of support?
○ Dietary practices?
○ Practices and traditions that restrict types of care?
● Military culture
○ Frequent moves
○ Separation from parents
○ Separation from other family members
● Speaks English
○ No interpreter needed
 Anaphylaxis

Pathophysiology Signs and Symptoms

● Anaphylaxis is a severe, acute, atopic reaction to an allergen.
● Urticaria
● After initial exposure to an antigen, the immune system produces
● Stridor, wheezing, rhonchi
specific immunoglobulin (Ig) antibodies in the lymph nodes.
● Dyspnea
● The antibodies (IgE) then bind to membrane receptors located on
● Tachycardia
mast cells and basophils.
● Confusion
● Reencounter with the antigen: the IgE antibodies recognize the
● Nausea, Diarrhea
antigen as foreign→ activates the release of powerful chemical ● Headache
mediators (histamine, leukotrienes, prostaglandins, and platelet- ● Hypotension
aggravating factor)
IgG or IgM enters into the reaction and activates the release of
●
complement factors.
Complications
● Results in: smooth muscle spasms in the respiratory and ● Hypoxemia
gastrointestinal tract, vasodilation, increased vascular permeability, ● Systemic vascular collapse
and stimulation of sensory nerve endings occur. ● Hypotension
● Pharyngeal edema
● Cardiac arrest
● Death
(Anaphylaxis, n.d.) ● Respiratory obstruction
 Treatment Plan
Interventions
● Airway maintenance
● Cardiac/ apnea monitor
● Continuous pulse ox
● Oxygen administration:
○ Nasal cannula 2L O2/min OR
nonrebreather mask, titrating
O2 to maintain SpO2 > 94%
● Vitals q 5 min
● Position patient upright
Medications/ Fluids
● Epinephrine (1:10,000) 0.3 mg IV stat
○ Relaxes bronchial smooth muscles
and increases BP
● Diphenhydramine 25 mg IV stat
○ Prevents histamine- mediated
responses
● Ranitidine 20 mg IV stat
○ Competitively inhibits action of
histamine at H2- receptor sites of
parietal cells
● Methylprednisolone 10 mg IV
○ Decreases inflammation
● Normal Saline 420 mL IV bolus over 30 min
○ Extracellular fluid replacement for
hypotension
 Developmental Stage
Preschool Age School Age
- Pre-operational Stage: - Concrete Operational Stage:
- Child remains egocentric and is only able to - Able to see things from another person’s point
approach a problem from one point of view of view
- Intuitive thought process - Think through an action, anticipating its
- Uses appropriate words consequences
- Communication - Able to use stored memories of past
- Persons outside of the family can understand experiences to evaluate and interpret present
the child’s speech situations
- Can recall parts of a story - Communication
- Speech is grammatically correct - Culturally specific words are used
- Learns to read and reading efficiency improves
language skills

The patient met the norms because his cognitive processes and communication skills were
appropriate for his age.

Developmental theory was used by communicating with the child in words he would understand,
explaining each procedure to the child, and offering the child a toy during the interaction.
(Kyle & Carman, 2020)
 Assessment Data
- Sinus tachycardia
- Heart rate: 156 bpm
- Respirations: 30
- Blood Pressure: 98/65 mmHg
- SpO2: 91%
- Patient reported feeling ‘out of breath’
- Audible wheezing and coughing
- Retractions visible
- Prolonged expiration phase
- Increased respiratory effort

- After medication administration

- Heart rate increased to 204 bpm
- Blood pressure: 155/122 mmHg
- Respirations: 17
- SpO2: 99%
- Patient stated ‘I feel better’
Concept Map
1. Ineffective airway clearance
Related To: laryngeal edema and
bronchospasm
As Evidenced By: coughing and
wheezing; SpO2 87%; BP 98/65 mm
Hg; HR 156 bpm
2. Ineffective breathing pattern
Related To: inflammatory process
As Evidenced By: dyspnea,
retractions, and a prolonged
expiratory phase; SpO2 87%; BP
98/65 mm Hg; HR 156 bpm
Allergen-specific immunoglobulin E is increased in relation to production of IgE, the
antibody that primarily responds to conditions that stimulate an allergic reaction.
Results will be invalid for patient already taking corticosteroids.
4. Fear
Related To: difficulty breathing and
interrupted family process
As Evidenced By: patient stating “I
can’t breathing! Please help me!”
5. Interrupted Family Process
Related To: displacement of family
3. Risk for Ineffective Cerebral Tissue As Evidenced By: patient is staying
Perfusion with aunt and uncle while his parents
are serving overseas in the military
Related to: decreased blood flow,
hypotension, and possible shock
(Carpenito, 2017)
Interventions & Expected Outcomes
Ineffective Airway Clearance
● Reposition patient (upright)
● Administer bronchodilator
● Administer *antihistamines
● Administer supplemental oxygen
● Suction secretions (if necessary)
● Avoid engaging patient in
unnecessary conversation
● Coordinate with RT
Ineffective Breathing Pattern
● Reposition patient (upright)
● Administer corticosteroid
● Administer supplemental oxygen
● Implement relaxation techniques
● Avoid engaging patient in
unnecessary conversation
● Coordinate with RT
Expected Outcomes
● Within 15 minutes after
administering bronchodilator
and antihistamines, patient’s
systole and diastole will increase
by at least 20 mmHg and
coughing/wheezing will cease.
● By end of shift (on 7/22), patient’s
SpO2 will be at least 95%.
Expected Outcomes
● Within 1 hour after administering
corticosteroid, patient will not
have retractions or prolonged
expiratory phase.
● By end of shift (on 7/22), patient’s
SpO2 will be at least 95%.
(Carpenito, 2017)
 Risk for Ineffective Cerebral Tissue Perfusion Expected Outcomes
● Administer fluids ● Ineffective cerebral tissue perfusion
● Administer corticosteroid will not occur during hospitalization or
● Implement methods to decrease incidences of by end of shift (on 7/22).
orthostatic hypotension
● Provide adequate periods of rest
● Monitor VS, LOC, speech abnormalities, & muscle
strength
Fear Expected Outcomes
● Provide comfort measures (stuffed animal) ● Patient will report (verbalize) reduced
● Maintain a quiet environment fear related to difficulty breathing by
● Provide adequate periods of rest end of shift (on 7/22).
● Use simple language that is easy to understand
● Educate patient and family
Interrupted Family Process Expected Outcomes
● Empathize with patient ● Patient will teach-back or
● Avoid false reassurances (be truthful!) demonstrate coping strategy by end
● Educate patient on developmentally appropriate of shift (on 7/22).
coping strategies

(Carpenito, 2017)
Psychosocial &
Developmental Discharge Planning
StrategieS

EDUCATE patient and family on the clinical

01. manifestations of anaphylaxis; how to use injectable
epinephrine; and appropriate food choices.

EDUCATE patient and family on other

02.
medications (use & side effects).

CREATE an action plan for the child at

03.
their school or day care center.

ENCOURAGE the child to wear a

04. medical ID alert bracelet or necklace
at all times.

(Kyle & Carman, 2021, pp. 143-168)

(Kyle & Carman, 2021, p. 923)
 Research
“Epinephrine Auto-Injectors for
Anaphylaxis Treatment in the
School Setting”
By: Tarr Cooke & Meize-
Grochowski
 Research
The most common cause of anaphylaxis in children is food ingestion.

Common offending foods:

Peanuts
Tree nuts
Shellfish
Milk
Eggs

About 1 in 13 children (or 2 children per classroom) have food allergies.

30.4% have multiple allergies; 38.7% have a previous history of severe food reactions or
anaphylaxis.

11% of schools with stock EAIs (epinephrine auto-injectors) reported an anaphylactic event.

(Tarr Cooke & Meize-Grochowski, 2019)

 Research
Nurses have a key role as interventionists by planning, responding, educating, and
advocating for anaphylaxis emergency responses for children with known or unknown
allergies.

School nurses can do this by:

● Implementing and maintaining stock EAIs
● Be versed in early recognition of anaphylaxis
● Give prompt treatment because milk symptoms can escalate rapidly

Advocacy is key when providing care to individuals, groups, communities, or populations.

(Tarr Cooke & Meize-Grochowski, 2019)

 Thank You!
Do you have any questions?

“I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as
cheating or plagiarism. I am aware that as a member of the academic community it is my responsibility to turn in all suspected violations of the
Taylor Brunke, Ashley Smith & Emily Womack
Honor Code.”
 References
Anaphylaxis. (n.d.). Retrieved July 26, 2020, from https://advisor-edu.lww.com/lna/document.do?bid=4

Carpenito, L.J. (2017). Nursing care plans: Transitional patient and family centered care. Philadelphia, PA: Wolters Kluwer.

Kyle, T. & Carman, S. (2021). Essentials of Pediatric Nursing, 4th ed. Philadelphia, PA: Wolters Kluwer.
Kyle, T., Carman, S. Lippincott CoursePoint Enhanced for Kyle & Carman's Essentials of Pediatric Nursing. [CoursePoint]. Retrieved from
https://coursepoint.vitalsource.com/#/books/9781975156060/

Tarr Cooke, A., & Meize-Grochowski, R. (2019). Epinephrine Auto-Injectors for Anaphylaxis Treatment in the School Setting: A Discussion
Paper. SAGE Open Nursing, 5, 2377960819845246