Case Study 104

Name; Maasin, Jonah Rosalie A. Class/Group; BSN2A GRP3 Date

Group Members

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.

JH is a 2-week-old infant brought to the emergency department (ED) by his mother (MH), 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.”

⦁ 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 crisis's 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.

⦁ 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.)

⦁ 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.

⦁ Pupils equal and +3

⦁ Temperature 36° C rectally

⦁ Heart rate: 85 beats/min

⦁ Positive Babinski's reflex

⦁ High-pitched cry

This is a typical cry with meningitis.

⦁ 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.
 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:

⦁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

⦁Prioritize the order of your interventions, with 1 being your first action and 7 being your last action.

6 Administer ceftriaxone (Rocephin)

5 Place IV

4 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

⦁ 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.)

175/dose is therapeutic range. Ordered is 260. Yes it is safe.

⦁ Interpret J.H.'s lab findings, and explain the rationale for abnormal results.

Chart View

Laboratory Test Results

Urine pH 7.2: normal

Color Clear: normal

Leukocytes Negative: normal

Complete blood count

Hct 32%: low

HgB 10.5 g/dL: low

WBC 22,000/mm 3: high

Sodium 125 mEq/L: low. Could signal dehydration

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

Chart View

Cerebrospinal Fluid Analysis

CSF Clear

Gram stain Pending

Leukocytes 1030 cells/microliter. Normally have a few WBC in CSF. Normal 0-20.

Protein 300 mg/dL 15-45 mg/dL. Raises with bacterial as left overs from bacteria

metabolizing glucose. Protein stays normal with virus.

Glucose 40 mg/dL 50-75 mg/dL. Drops with bacterial.

⦁ What are the most common pathogens in this age group?

Hib, Neisseria meningitidis, streptococcus pneumonia, group B strep, E. coli.

 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.

⦁ 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.

Make sure that all doses of the antibiotics are taken correctly and completely. Keep on isolation for 24
hours of Abx. Manage his pain before it gets severe. Use flacc pain scale. Provide quiet calm
environment. If he is unable to take oral hydration give him IV fluids. Maintain IV infusion. Assess daily
weights. Consider a PICC line because they can go home on IV antibiotics with a PICC line. They are less
likely to pull them out. More stable line that they can have for longer amount of time. Assess fontanels
for increase pressure. Monitor head circumference. Place on seizure precautions. Parent education
about isolation and treatment plans

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?

⦁ 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/schedules/child-schedule.htm.

⦁ Hib

⦁ MMR

⦁ OPV

⦁ IPV

⦁ Rotavirus

⦁ DTaP

⦁ varicella10 Pediatric

⦁ Varicella

⦁ Hep B

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

Make sure the parents are taking care of him as much as they can to develop the trust mechanisms.

⦁ 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?

It is important for him to receive his Hib vaccine when appropriate and his meningococcal
vaccine when it is time. Hand washing. Going to follow up visits and safety

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.