Princess Levie Ceniza BSN 2A GROUP 1 Case study 104

SCENARIO

J. H is a 2-week old infant brought to the emergency department (ED) by his

mother, who speaks a 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 with a child who is does not speak or understand English well needs an
interpreter as soon as possible. Well working with the crises situation, obtain a person
who is a medical interpreter to be with the mother and child throughout the period
where there will be testing and procedures. This will be a very distressing time and
the mother needs to understand what is happening and why.

2. You perform your primary 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 a rationale)

a.Anterior fontanel palpable and tense. - the bulging fontanel occurs from infection of
the membranes covering the brain. The brain swells leaving less room for the fluid
circulation with bulging of the fontanels.
b.Pupils equal - Childs pupils are equal is size and respond at a +3 amount of
pupillary restriction to light.
c.Temp 36 degree C rectally. - Meningitis usually will cause an elevated fever.
d. Heart rate: 85 beats/min - the normal heart rate for a two week old is between 140-
180 and meningitis will exhibit a fast heart rate.
e. Positive Babinski’s reflex -  Children have a sign that occurs when their neck is
bent and their knees automatically come toward the body called the Brudzinski sign.
f. High-pitched cry. - This is a typical cry with meningitis.
g. Refusal of PO intake per mom. - a sick child will normally be reluctant to take in
fluids due to feeling nauseous. The child is unable to verbalize this but exhibits this
symptom by not eating and drinking.

The anterior fontanel should be soft and flat. A tense or bulging fontanel can
indicate increased intracranial pressure (ICP). The posterior fontanel might be
palpable until 2 months of age. A rectal temp of 36 degree C (96.8 degree F) is
hypothermic and abnormal. The pupil assessment and pulse of 85 are within
normal limits. A positive Bambinski reflex is normal until 12-18 months.
Irritability,high-pitched crying, and refusal of feeding.

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 catherization for urine specimen
__1___Place on contact isolation and droplet precautions
__2___Assist with lumbar puncture
__7___Administer Tylenol
__3___Obtain blood culture ,CMP

4. Before administering the ceftriaxone (Rocephin),you must verify the dose with
another RN.The therapeutic range is 100mg/kg/day divided in two doses. J.H. weighs
3.5kg. Is the dose ordered safe?

- Calculate the therapeutic loading dose: 3.5 kg × 100 mg/kg = 350 mg loading dose. 

5. Interpret J.H.'s lab findings, and explain the rationale for abnormal results
Laboratory Test Results

Urine

pH 7.2
Color clear
Leukocytes negative

Complete blood count

Hct 32%
HgB 10.5 g/dL
WBC 2 000/mm
Sodium 125mEq/1

- The urine is normal. Hgb and Hct are normal. The WBC count is elevated in
response to an infection; sodium might be low, depending on his hydration status and
any vomiting.

6.Interpret the CSF findings. Would you suspect bacterial or viral meningitis? Why?

•CSF -Clear
•Gram stain -Pending
•Protein -300 mg/dL (elevated)
•Leukocytes -1030 cells/microliter (elevated)
•Glucose -40 mg/dL (decreased)

- The CSF findings are suggestive of bacterial meningitis. The specimen is usually
clear or slightly cloudy. With a bacterial origin you will find decreased glucose,
increased protein, and primarily polymorphonuclear leukocytes. A viral origin usually
causes a normal or slightly increased protein
and normal glucose.
7. What are the most common pathogens in this age group?

- •The most common causes of bacterial meningitis in the neonate are group B
streptococci and Escherichia coli. The introduction of the Haemophilus influenzae
type b (Hib) and the Streptococcus pneumoniae (pneumococcal) vaccines have greatly
reduced the incidence of meningitis from these pathogens.

K. H. is diagnosed with Escherichia coli meningitis. His medical care plan will
include 14 to 21 days of antibiotic 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.

Pain
• Assess pain every 4 hours using the FLACC scale.
• Administer pain medication as ordered.
• Keep stimulation at a minimum with a quiet environment and dim lights.
Hydration
• Strict intake and output.
• Monitor perfusion: cap refill, BP, pulses, mottling, anterior fontanel.
• Daily weights.
• Patient will be NPO initially and diet advanced as tolerated with improved status.
• Maintain and monitor IV. Might need to advocate for peripherally inserted central
catheter (PICC)
line for long-term antibiotic therapy.
• Monitor for complications such as syndrome of inappropriate antidiuretic hormone
(SIADH).
Infection
• Maintain isolation precautions.
• Administer antibiotics as ordered.
• Monitor laboratory values and cultures.
Increased ICP
• Assess for signs and symptoms of increased ICP: increased irritability, change in
level of
consciousness (LOC).
• FOC (frontal occipital circumference) every shift.
• Observe seizure precautions and monitor for seizure activity.
Parent education
• Explain disease process and treatment plan.
• Educate on need for isolation precautions.
• Assess support system and allow for questions.
• Encourage comfort measures, bonding, and participation in care.
Mrs. H., through her translator, asks you what could have caused her baby to be sick
since he had an immunization 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. receive at 2 months? You can refer to the current
immunization schedules posted at http://www.cdc.gov/vaccines/recs/sche dules/child-
schedule.htm.

a. Hib
b. MMR
b. OPV
c. IPV
d. Rotavirus
e. DTaP
f. Varicella
g. Hep B
h. Pneumococcal

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

- J.H. is in Erikson's stage of trust versus mistrust. His basic needs (diapering,
feeding, comforting) must be met on a consistent basis. Having his parents participate
in his care will help meet J.H.'s developmental needs, reinforce their parenting role,
and promote their comfort level. It will also promote parent-infant bonding.

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?

- S/S of infection and dehydration: fever (how to take a temperature), poor feeding,
increased
sleeping, irritability
-  What to do if S/S occur (administering acetaminophen, giving fluids, when to call
the physician)
- Safety (car seat, sleeping on his back, water safety, temperature, not leaving him
alone, heights)
-  Nutrition
- Immunizations

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.