Serrano, Alyssa Marie C.

BSN-II/19-1527
MCN - LEC

Acute poisoning: 4-year-old male brought to the ED by his mother

Subjective Data;
Mother states “My son was playing with his best friend who went home 3 hours ago.”
“He started vomiting about 1 hour ago, right after I found an empty Children’s Tylenol bottle on his
bedroom floor. I usually keep it in my purse in case he has a ‘boo boo’ when we’re out.”
"He must have taken all of it about 4 hours ago.”
Child states: “I hurt my arm so I took my medicine all by myself!!”
Objective Data
Nursing Assessments
• Vomiting
Vital Signs
Blood pressure: 80/55 mm Hg
Temperature: 98.6°F
Heart rate: 100 bpm
Respiratory rate: 28 rpm
Lab Results
CBC, ALT, AST: all normal
Serum acetaminophen concentration: 300 mcg/mL
Health-Care Provider’s Orders
• Admit to pediatrics
• Begin IV D5W ½ NS
• IV acetylcysteine 150 mg/kg over 60 min
• THEN 12.5 mg/kg per hour for 4 hr
• THEN 6.25 mg/kg per hour for next 16 hr
• Zofran (ondansetron) 0.1 mg/kg IV STAT
• Repeat CBC, ALT, and AST in a.m.
Questions:

Which subjective assessments are important in this scenario?

• “He started vomiting about 1 hour ago”

• “I found an empty children’s Tylenol bottle on his bedroom floor”
• “I usually keep it in my purse in case he has a ‘boo boo’ when we’re out”
• “He must have taken all of it about 4 hours ago”

Which objective assessments are important in this scenario?

• Vomiting
• Vital signs are within normal; and laboratory test results are all normal: CBC (complete
blood count), ALT (alanine aminotransferase) and AST (aspartate aminotransferase)
• Serum acetaminophen concentration: 300 mcg/mL (>200mcg/mL 4 hours after ingestion
is associated with toxicity and liver damage)

After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign
to this client?

• Risk for injury related to acute poisoning with children’s Tylenol. (Risk for injury because
it can cause toxicity and liver damage if not treated)
• Risk for deficient fluid volume related to vomiting.

What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
(Provide 5)

1. Assess the child weight to calculate before administering IV infusion and administer IV
infusion as ordered by the primary health care provider/physician.
2. Check and implement the six rights of medication administration before administering
the medication ordered. Properly calculate dosage for safe administration.
 3. Verify and implement the six rights of medication administration before the
administration of Zofran STAT or 30 mins within the time it is ordered. Zofran is used or
administered to prevent nausea and vomiting.
4. Request for the repeat laboratory test of CBC, ALT and AST in the morning or as
ordered.
5. Educate the mother about placing the medications away from children and keeping
them locked in the medication cabinets at home. As well as the risk of potential
poisoning of children when they are not around.

What client outcomes should the nurse evaluate regarding the effectiveness of the nursing
interventions? (Provide 5)

1. After the administration of Zofran, assess if the child has stops from vomiting. Monitor
for any adverse effect present.
2. The site of IV infusion did not cause any irritation and is not swelling; also check for the
infusion rate at least every hour.
3. Evaluate the patient’s response to the medication administered, the therapeutic and
adverse effect to the patient after the appropriate time frame.
4. Evaluate the mother’s response about the teaching/education given regarding safety
measures to prevent poisoning.
5. Review and compare the repeat laboratory test results with the first laboratory results
or with the normal values.

What physiological characteristics should the child exhibit before being discharged home?

• The child’s laboratory test results are within normal values.

• The child does not show any signs and symptoms of toxicity and liver damage.
• There are no complaint of adverse effect or complications from the medications
administered.