By Carmen Valdez and Fion Kung Pediatric Case Study #1 By Carmen Valdez and Fion Kung

Scenario Jennifer is a 13 year old female who came to the ER from a chronic living facility and is now admitted to a med/surg floor. Diagnosis: Pneumonia Her weight is 45.2kg Medical history: Chronic recurrent pneumonia Cardiomegaly Severe autism and developmental delay (non-verbal) Pulmonary hypertension Trach/PEG

Vitals upon admission Temperature: 97.9 axillary Blood pressure: 94/52 Pulse: 70-115 RR: 24-28 O2: 95% on 40% oxygen via trach collar

Tests and labs Chest x-ray show either infiltrates vs. edema MRSA screen positive UA normal Lab: WBC: 13,000 Chemistry normal except glucose of 133 89% segs is increase 8% lymps is low (risk for infection) 4% monos is normal

Medications Linezolid (Zyvox) 600 mg IV q12h Ciprofloxacin 400 mg IV q 12h DuoNeb aerosols 3mL NEB q4h/ q2h PRN Pulmozyme 2.5 mg NEB BID Tobi aerosols 300 mg NEB BID Advair Solumedrol 44 mg IV q6h Aspirin 81 mg oral tablet daily Albuterol 2.5 mg/3mL NEB q4h/ q3h PRN Linezolid (Zyvox) is an antibiotics for pneumonia Ciprofloxacin is a second-generation fluoroquinolone antibiotic for pneumonia DuoNeb aerosols is an Anticholinergic + beta-2 agonist Pulmozyme is Tobi aersols is an antibiotic used to treat lung infections Advair: Prevents symptoms of asthma or COPD (chronic obstructive pulmonary disease), including chronic bronchitis and emphysema. This medicine is a combination of a steroid and a bronchodilator. Solumedrol: is a corticosteroid for inflammation Aspirin: Albuterol: is a bronchodilator.  It used to treat wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases

Orders Pediasure 3xdaily PO/PEG and puree diet Bedrest VS every 4 hours Weight daily Repeat chest x-ray in AM Call MD for increased respiratory distress or oxygen demand over 50% Continuous pulse oximetry Keep oxygen sat > 92% Contact/Droplet precaution

Assessment in the afternoon Blood pressure: 122/78, Temperature: 98.1 axillary, pulse: 122, RR: 30 Coarse rhonchi and wheezing throughout her lungs Strong cough and purulent sputum via trach Regular heart rhythm and 2+ pulses x 4 extremities <2-3 second cap refill Pulse oximetry is 86% Sitter at bedside inform she has been coughing more and it is waking her up from her sleep Patient is arousable and follow some instructions

Interventions Elevate the head of bed Increase oxygen to 50% as ordered by physician. Suction Continue to monitor patient for S/S of respiratory distress Have Ambu bag available by the bedside Call RT for breathing treatment Assess patient before and after respiratory treatment Keep physician updated about patient’s condition

Assessment after intervention O2 sat went up to 93% Patient still on 50% oxygen via trach No rhonchi present at this time. Patient is resting with head of the bed elevated Patient is not coughing at this time No S/S of respiratory distress at this time

Phone Call Hello Dr. Kung, this is Carmen from medical surgical floor calling on regards of Jennifer, a 13 year old girl admitted to ER for pneumonia. Today she had a episode of respiratory distress. Her O2 sats dropped from 95% to 86%. There were rhonchi and wheezing present in all lobes. She also had a strong cough and purulent sputum. Patient was arousable and able to follow some instructions. I increased the oxygen level from 40% to 50% as ordered, suctioned her and elevated head of the bed. After the intervention, I listened to her lungs and there were no rhonchi present. Her O2 sats went up to 93%. I contacted RT to come for breathing treatment.

Physician Order Ok. Good. Now I would like you to: Observe patient for S/S of respiratory distress Collect a sputum culture and let me know what the results are Hydrate patient with NS at 75 ml/hr Assess vital signs including lung sound every hour Call me if O2 sat drops <92% or if there is any change in vital signs Start an IV to maintain hydration Encorage to drink oral fluid to thin the secretions Elevated the head of the bed to promote aeration of the lungs

Complication Pleural effusion Empyema Lung abscess Pneumothorax Obstructive airway due to secretions Hypoperfusion Sepsis Pleural effusion: pneumonia can cause fluid to build up around lungs. If the fluid become infected, might need to have it drained through a chest tube or removed with surgery. Empyema: a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space) Lung abscess: it happen if pus forms in cavity in the lung. Sepsis: cause organ failure

Preventing complications Monitor vital signs closely Assess LOC Assess for respiratory distress (retraction, nasal flaring, tachypnea, cyanosis) Assess lung sound Maintain hydration Practice good hand hygiene Do not smoke Get plenty of rest, healthy diet and moderate exercise Drink plenty of fluids

Consultations RT Nursing manager/case manager MD Dietitian Social worker Speech therapy RT for respiratory treatment Nursing manager to keep them update Social worker Speech therapy for autism

Patient teaching Assess readiness to learn Assess patient’s knowledge about disease Take all the antibiotics as ordered Proper hand washing Continue to encourage adequate fluid intake Encourage patient to get plenty of rest No smoking around patient Get flu shot every year Get pneumonia vaccine Call the physician if experiencing symptoms of respiratory distress Have patient verbalize the teaching Tobacco smoke aggravates lung problems and prolongs recovery Smoke can also make the coughing or breathing worse.

Appropriate Documentation Interventions: Suction Increase oxygen level to 50% Vital signs change Update physician about vital signs change Assessment before and after respiratory treatment Medication administration LOC, lung sound, heart sound changes If it is not documented, it was never done!

References Cardinale, Fabio., Cappiello, R.A., Mastrototaro, M.F., Pignatelli, M., & Esposito, S. (2013). Community-acquired pneumonia in children. Early Human Development 89 (3), 49-52. http://dx.doi.org/10.1016/j.earlhumdev.2013.07.023 Chavanet, P. (2013). The ZEPHyR study: A randomized comparison of linezolidand vancomycin for MRSA pneumonia. Médecine et maladies infectieuses 43 (2013) 451–455. http://dx.doi.org/10.1016/j.medmal.2013.09.011 Medscape. (2014). Pediatric pneumonia treatment & management. Retrieved from http://emedicine.medscape.com/article/967822- treatment#aw2aab6b6b5