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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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!

17. References
Cardinale, Fabio., Cappiello, R.A., Mastrototaro, M.F., Pignatelli, M., & Esposito, S. (2013). Community-acquired pneumonia in children. Early Human Development 89 (3),
Chavanet, P. (2013). The ZEPHyR study: A randomized comparison of linezolidand vancomycin for MRSA pneumonia. Médecine et maladies infectieuses 43 (2013) 451–
Medscape. (2014). Pediatric pneumonia treatment & management. Retrieved from treatment#aw2aab6b6b5