CHAPTER 10 PEDIATRIC DISORDERS CASE STUDY 104

Case Study 104

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 rewrite it.

▶ Scenario
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?

A parent has a child who does not speak or understand English an interpreter should be needed as
soon as possible. Working with the crisis situation, find a medical interpreter to accompany the mother and
child during the procedures. This will be a difficult time for the mother, and she needs to know what's going
on with her new baby, and the fact that she can't communicate without the help of a translator may add to
her anxiety. Another possible obstacle that one may encounter in this situation is a cultural barrier. Mrs. H.
only mentions a change in J.H.'s eating habits and sleep patterns in the case study, rather than a physical
symptom she then says her baby is "not normal" rather than "sick" or "ill." It's critical to consider Mrs. H's
perspective on health and what she thinks is going on with her baby. She did bring her baby to the ER,

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indicating that she most likely believes in Western medicine because she tried to get help on her own.

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
b. Pupils equal and +3
c. Temperature 36° C rectally
d. Heart rate: 85 beats/min
e. Positive Babinski's reflex
f. High-pitched cry
g. Refusal of PO intake per mom

Although the anterior fontanel can be felt, it should be soft and flat rather than tense. This "tense"
feeling could indicate fontanel bulging, which could indicate increased intracranial pressure, infection, or
hemorrhage. J.H.'s normal findings include equal and +3 pupils, a rectally measured temperature of 36
degrees Celsius, and a positive Babinski's reflex; these are all positive signs when it comes to neurological
activity and hydration status, which we're looking into because of the possibility of increased intracranial
pressure. A high-pitched cry and abnormal feedings are two other signs that this baby has high intracranial
pressure. The newborn's heart rate is also low, at 85 beats per minute when it should be between 100 and
160. Mrs. H has refused PO intake, which I would classify as "abnormal finding" and report to the ED
physician so that medications with alternative routes of administration are ordered.

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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 ■ Chart View
Emergency Department Orders
CBC with differential
Blood culture
Complete metabolic panel
(CMP) Urinalysis (UA)
ebrospinal 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.)

3.5 x100 =350

Since J.H. weights 3.5 kilograms, a therapeutic dose for him would be 350 milligrams per day
thus 350mg divided by two equals 175mg, it is safe.
 CHAPTER 10 PEDIATRIC DISORDERS CASE STUDY 104

5. Interpret J.H.'s lab findings, and explain the rationale for abnormal results.
■ Chart View

Laboratory Test Results

Urine
pH Color
7.2
Leukocytes
Clear Negative
Complete blood count
Hct
HgB WBC
Sodium 32%
10.5 g/dL
22,000/mm3
125 mEq/

The urine has a pH of 7.2 and is clear with negative leukocytes. These results appear to be normal,
indicating that the kidneys are functioning normally. Hct was 32%, HgB was 10.5g/dL, WBC was 22,000/mm3,
and sodium was 125mEq/L, according to the CBC. Due to J.H.'s infection, this white blood cell count indicates
leukocytes exceeding the range of 4,500-10,000. Newborns' leukocytes range from 9,000 to 30,000, with hgB
14-24 and Hct 44-64 %. We can determine that J.H.'s HgB and Hct are slightly low, but his WBCs are slightly

10 Pediatric
over normal. The HgB and Hct results indicate that red blood cell concentration is low, most likely due to fluid
volume excess. His sodium level of 125 is also slightly lower than the typical range of 135-145, which could
indicate that his body is retaining too much fluid and causing dilutional hyponatremia. 

6. Interpret the CSF findings. Would you suspect bacterial or viral meningitis? Why?
■ Chart View
Cerebrospinal Fluid Analysis
CSF Clear Pending
Gram stain Protein Leukocytes Glucose
30000 mg/dL (elevated)
1030 cells/microliter (elevated)
40 mg/dL (decreased)

The results of J.H.'s cerebrospinal fluid study were clear CSF, pending gram stain, 300 mg/dL protein
(elevated), leukocytes 1030 cells/microliter (elevated), and glucose 40 mg/dL (decreased). The elevated
protein level increased white blood cells, and decreased glucose level suggests that J.H. has bacterial
meningitis based on these findings. CSF protein levels greater than 250 mg/dL indicate bacterial meningitis,
while levels between 50 and 250 mg/dL indicate viral meningitis, white blood cell counts greater than 1000
indicate bacterial meningitis, while counts less than 1000 indicate viral meningitis, and CSF glucose levels
between 10 and 45 indicate bacterial meningitis.

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

Meningitis is caused by a variety of pathogens that are formed in different age groups. Group B
streptococcus, Escherichia coli, and Listeria monocytogenes are the most typical infections in neonates.
Neisseria meningitides (meningococcus), Streptococcus pneumonia (pneumococcus), and Haemophilus

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 PART 2 PEDIATRIC, MATERNITY, AND PSYCHIATRIC CASES

influenza type b (Hib) are the pathogens most typically seen in children older than three months.

Copyright © 2013 by Mosby, an affiliate of Elsevier

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

Interventions to control the neonate's pain should be included in the plan of care, such as swaddling,
oral sucrose administration, and further Tylenol administration. Antibiotic treatment, contact isolation and
droplet precautions, temperature monitoring, and proper infection prevention practices, such as hand
cleanliness, should all be used to manage infection. J.H.'s intake and output, hemoglobin, and hematocrit,
and assess fontanels are all monitored to keep him hydrated. Young newborns are at significant risk of
dehydration, especially if they become febrile, so it is crucial to assess fluid status. Every shift, a nurse should
check his hydration status and administer IV fluids as needed to maintain a proper fluid balance. To prevent
the newborn from going into shock, the nurse must carefully assess the fluid balance. Tachycardia, urine
output of less than 1ml/kg/hr, and a weak pulse are some of the indicators the nurse should check for.
However, administering fluids with high intracranial pressure can be challenging, and one must be careful
not to give excess fluids and worsen the edema. A nurse might raise the head of a patient's bed to relieve
pressure caused by elevated intracranial pressure. There are wedge-shaped beds available for such a young
infant, or a baby's bed can be elevated around 30 degrees and still be safe. Nurses can also help with
increased intracranial pressure by administering pressure-lowering drugs such as mannitol or hypertonic
saline solution, which are prescribed by doctors. The pediatric Glasgow coma scale can be used to assess a
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child's neurological condition, intracranial pressure, and reflexes. Once intracranial pressure has been
adjusted, a neurological examination should be performed half-hourly for two hours, hourly for four hours,
two-hourly for six hours, and four-hourly thereafter. The nurse may teach infection prevention and J.H.'s
medication routine to J.H.'s parents as part of his care instruction. This could be accomplished by using
resources written in their original language, as well as a translator to assure comprehension.

CASE STUDY PROGRESS

Mrs. H., through her translator, asks you what could have caused her baby to be sick since he had an immu-
nization 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 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. received 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

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

Hospitalization can have a variety of effects between J.H. and his mother separation during
hospitalization can be extremely distressing for J.H., and it can hinder the growth of their
connection. This may affect J.H.'s ability to meet developmental milestones and cause him to miss
out on motor skill development. This baby's schedule is also interrupted by his hospitalization,
which is challenging, especially when he was adjusting to life at home. J.H. may be affected by a
lack of stimulation, or loud noises, bright lights, and rapid movements in the hospital can be
distressing for such a young infant.

11. 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?

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Transmission prevention strategies such as good hand hygiene, covering nose and mouth
when sneezing, avoiding kissing J.H. on the mouth, or sharing utensils for eating and drinking are
some educational topics to discuss with Mrs. H. Educate about transmission prevention strategies,
including good hand hygiene to avoid direct transmission through contact with respiratory
secretions, and educate about transmission prevention strategies, including good hand hygiene to
avoid direct transmission through contact with respiratory secretions. It's a good idea to make sure
Mrs. H understands that J.H. needs to return in a month and a half so he can have his next
immunizations and prevent becoming sick. Mrs. H must know J.H.'s medicine schedule when he
returns home. J.H. will be discharged home with his parents after a week of PO antibiotics and a
home health visit for newborn care follow-up when he is eventually discharged. He is to see his
PCP in one week, or Mrs. H should contact the doctor if she has any concerns. The next step is to
evaluate J.H's progress after his one-week appointment with his PCP. I might even call Mrs. H
again, this time through a translator, to make sure she's following the medication routine and to
see if she has any concerns.

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 concerns.