QuestionPediatric Clinical Reasoning Case Study: Sickle Cell Crisis Created… Pediatric Clinical Re

QuestionPediatric Clinical Reasoning Case Study: Sickle Cell Crisis Created… Pediatric Clinical Reasoning Case Study: Sickle Cell CrisisCreated by Kathleen Mixson, RN, MS, JDI. Data CollectionChief complaint/History of Present Illness:  You are admitting Tia who is a 14-year-old young woman with Sickle Cell disease who presented to the emergency room early this morning with a 2-week history of worsening headache and 2-day history of diffuse back pain. The headache started after she participated in a week of basketball camp.  Tia reports that she has been “sensitive to light.” She denies having had any vision change, although Tia reports that yesterday while still at home she had some tingling in the right side of her face and in her right arm and leg.   She has not had any respiratory symptoms and she has not had fever.  She had a CBC, UA with culture, and type and crossmatch in the ER.  She is to receive packed cells when the blood is ready.     What data is relevant to this patient that must be recognized as clinically significant to the nurse?Worsening headache, back pain, sensitivity to light and tingling at the right side of face, arm and leg Rationale:These symptoms are associated with a stroke. Ischemic stroke my occur to inadequate supple of oxygen to the brain due to the defective red blood cells in sickle cell disease Personal/Social History: Lives with parents. Is in the eighth grade.PMH:  Mother reports that Tia’s sickle cell clinical course has been mild. She has never had a painful crisis per Mom.  She has never had acute chest syndrome. Tia has a history of recurrent urinary tract infections and nasal allergies. Current Medications: Tia and Mother report that Tia’s medications are Tylenol; an iron supplement; Allegra; and folic acid. What is the relationship of your patient’s past medical history (PMH) and current medications?(Which medication treats which disease? Connect PMH disease with the correct medication)  Patient Care Begins: You are waiting for the lab to send the packed red blood cells for the transfusion.  You also need to inform the patient that the MRI will be done later in the morning after the blood is infused..Your Initial VS:T:  99.4P:  98R:  24BP:  134/62O2 sats: 98%Pain:  4/5 on Verbal Analog ScaleWeight: 77.2 kg (170 lb 3.1 oz) Height: 179.1 cm (5′ 10.5″)   What VS data is relevant to this patient that must be recognized as clinically significant to the nurse?Temp, respirations, blood pressure, pain level, weight  Rationale:    Your Initial Nursing Assessment:GENERAL APPEARANCE: Large for age and appearing older than chronological age.. Appears to be in moderate distress with head down and hand on forehead.  Cooperative with assessment.RESPIRATORY:  Denies SOB or chest pain. Breath sounds equal and with good aeration bilaterally. CARDIAC: Pulses 3+ throughout. No edema in extremities. Heart rate regular-S1 S2  Very soft systolic murmur. NEUROLOGIC:   Alert and oriented x4. Complaining of diffuse lower back pain and severe headache and tingling right arm and leg.ABDOMEN/GI: Abdomen soft, non-tender with active bowel sounds. No guarding or tenderness present.GENITOURINARY: Urine clear and yellow. EXTREMITIES/SKIN:  Skin is warm and dry-normal for color of skin.  IV 20 gauge in right antecubital infusing D5 ½ NS with 10 mEq. KCL.  Site without redness or edema.  Mucus membranes moist and pale. What assessment data is relevant that must be recognized as clinically significant to the nurse?  Rationale:II. Clinical Reasoning Begins…1.     What is the most likely medical problem that your patient is presenting with?   2.     What is the underlying cause /pathophysiology of this concern?   3.     What is your primary nursing priority right now?   4.     What nursing diagnostic statement will guide your plan of care?   5.     What interventions will you initiate based on this priority?   6.     What is the worst possible complication to anticipate?   7.     What nursing assessment(s) will you need to identify and respond if this complication develops?    8.     What are nursing concerns and responsibilities regarding the administration of blood products?       Medical Management: Rationale for Treatment & Expected Outcomes Physician orders: Weight on admission and daily VS q 4 hr with neuro checks Strict hourly I & O Regular diet Bedrest with BRP D5 ½ NS with 10 mEq KCL at 110 ml/hr   Repeat CBC and lytes after PRBC infused MRI brain w/o contrast Rationale: Expected Outcome: 9.    Dosage Calculation:Medicationmorphine (pf) 1 mg/mL injection 4 mg   Freq: EVERY 2 HOURS PRN Route: IV amoxicillin-clavulanate (AUGMENTIN) 875mg-125mg tablet 875 mgFreq: every 12 hours PO acetaminophen-HYDROcodone 325mg-5mg tablet 10 mg  Freq: EVERY 4 HOURS Route: PO  Alternate with ibuprofen ibuprofen tablet 600 mgDose: 600 mg Freq: EVERY 4 HOURS Route: PO Alternate with Norco oxymetazoline 0.05 % nasal spray 2 SprayDose: 2 Spray Freq: DAILY Route: NA senna tablet 2 TabDose: 2 Tab Freq: 2 TIMES DAILY Route: PO Safe dosage calculation:Mechanism of action and Nursing implications: IV Push:Volume every 15 sec? Radiology Reports:  MRI brain w/o contrast:  IMPRESSION: 1. Mild diffuse cerebral atrophy. Otherwise no significant abnormality is identified on current MRI of the brain as detailed above.  2. Limited MR angiogram due to susceptibility artifact.  FINDINGS: Evaluation of orbit and maxillofacial region is not possible due to severe magnetic susceptibility artifacts from dental braces. Diffusion weighted images are nondiagnostic due to artifacts resulted from dental braces.  The midline structures are normally formed.  The corpus callosum is of normal size and signal intensity.  No cerebellar tonsillar ectopia is present.  The sella is normal in size. The T1 shortening of neurohypophysis is normal in position. The anterior pituitary is normal in size.  The fourth ventricle is midline and normal in size. The third and lateral ventricles are normal in caliber. The basal cisterns are patent.   There is mild diffuse cerebral atrophy bilaterally resulting in prominent cerebral sulci. Small focus on increased T2 signal within right frontal white matter, likely represents a small focus of gliosis. Otherwise there are no abnormal focal white matter lesions. Overall signal intensities of the brain stem, cerebellum, cerebrum, basal ganglia and thalami are normal.  No shift of the midline structures, intracranial hemorrhage, cerebral edema, cortical infarction or mass effect is seen.    Normal signal voids are seen in the visualized intracranial vessels and dural venous sinuses, consistent with patency. There is normal aeration of the middle ear cavities, mastoid air cells.   There is diffuse low signal of the calvarium, likely related to patient’s history of sickle cell anemia.  MRA of the brain demonstrates normal anatomy. Cavernous and supraclinoid portion of the internal carotid arteries are not evaluated due to severe susceptibility artifacts resulted from dental braces. The remaining visualized internal carotid arteries, middle cerebral arteries, anterior cerebral arteries, vertebral arteries, basilar artery and posterior cerebral arteries show normal flow-related enhancement. No evidence of significant stenosis, vascular occlusion, aneurysm or arteriovenous malformation  is seen within resolution limitation of MRA.   What data above is relevant to this patient that must be recognized as clinically significant to the nurse?  How do these radiology findings relate to primary problem? Lab Results:CBCCurrent   ERWBC (4.5-11.0)13.816.8RBC  (3.042.33HGB (12-16)9.87.4PLTS (140-440)431407Neuts. % (42-72)4885Lymphs % (20-44) 3919Reticulocytes (0.5-1.5)3227.9Anisocytosis   (neg)          1+Polychromasia  (neg)                1+Hypochromia       (neg)            1+Microcytes   (neg)          1+Ovalocytes      (neg)             1+Target Cells     (neg)              1_Sickle Cells     (neg)              2+Schistocytes       (neg)            1+Tear Drop Cells  (neg)          1+                   Identify the relevant lab results to this patient and their clinical significance:          Which labs when trended are showing improvement and/or reveal concerning potential complications?    Basic Metabolic panelCurrent       ERSodium (135-145)139144Potassium (3.5-5.1)4.44.9Glucose (65-100)126104Creatinine (0.5-1.5) 0.5      Identify the relevant lab results to this patient and their clinical significance:     Which labs when trended are showing improvement and/or reveal concerning potential complications?  UACurrentColor (yellow)YellowClarity (clear)ClearSp. Grav (1.002-1.030)1.013Protein (neg)NegGlucose (neg)NegKetones (neg)NegBlood (neg)NegNitrate (neg)NegLeukocytes (neg)TraceRBC’s (0-2)4WBC’s (0-5)19Bacteria (0-few)ManyEpithelial (0-few)Few              Identify the relevant lab results to this patient and their clinical significance:    Application9. Choose two of the most relevant abnormal labs for your patient and address the following: Lab  Value  High/Low      RelevanceNormal value  Critical valueWhat caused derangement?TreatmentNsg. Assessments/interventions required:  Lab  Value  High/Low      RelevanceNormal value  Critical valueWhat caused derangement?TreatmentNsg. Assessments/interventions required:     III. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management.Eight hours later…VS:                                                     8 Hour Shift I & OT:  98.2P:  72                                            Intake  IV                     888R:  18                                                        enteral             1850BP:  118/60                                   Output                         2385O2 sats: 98%Pain:  1/5  Verbal Analog Scale What VS data is relevant to this patient that must be recognized as clinically significant to the nurse?   Rationale:  Nursing Assessment:GENERAL APPEARANCE: Resting comfortably. Denies pain unless very specifically asked, then admits to slight headache and backache.RESPIRATORY:  Denies SOB or chest pain. Breath sounds equal and with good aeration bilaterally. CARDIAC: Pulses 2+ throughout. No edema in extremities. Heart rate regular-S1S2. Soft systolic murmur.NEUROLOGIC:   Alert and oriented x4. States pain much less.  Denies tingling or numbness in right side.ABDOMEN/GI: Abdomen soft, non-tender with active bowel sounds. No guarding or tenderness present.GENITOURINARY: Urine clear and yellow. EXTREMITIES/SKIN:  Skin is warm and dry-normal for color of skin.  IV 20 gauge in right antecubital infusing D5 ½ NS with 10 mEq. KCL.  Site without redness or edema.  Mucus membranes moist and pale. What assessment data is relevant to this patient that must be recognized as clinically significant to the nurse?  Rationale:  Has the status of the patient improved or not as expected to this point?  What data supports this evaluation assessment?  Based on this assessment data, now what will be your nursing priorities and current plan of care?    Your knowledge and application of the pathophysiology of sickle cell disease have allowed you to make a series of needed assessments and judgments that have facilitated the treatment and care of your patient. You have made a difference at the bedside!  Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the oncoming nurse who will be caring for this patient:(QSEN-Teamwork & Collaboration/Safety) Situation: Background: Assessment:       Recommendation: Optional QSEN Questions to Incorporate Into Case Study: Patient Centered CareWhat can you do to demonstrate intentional caring and promote patient centered care with sensitivity and respect for your patient in the context of this clinical presentation?(QSEN-Patient Centered care) How can you ensure and assess the effectiveness of communication with the patient and family?(QSEN-Patient Centered care) How can you integrate your patient’s preferences/values as you coordinate your plan of care or provide any needed education?(QSEN-Patient Centered care) How can you ensure that your patient is an active partner while under your care and promote self-care once they are discharged? (QSEN-Patient Centered care) Teamwork & CollaborationWhat can you do to facilitate safe and effective update/report to the physician or oncoming nurse?(QSEN-Teamwork and Collaboration) What would you do if you were not comfortable performing any new skill that was required to take care of this patient?(QSEN-Teamwork and Collaboration) Evidence Based PracticeAs a new nurse, what resources could you utilize to provide current, evidence based and individualized care planning based on the needs of this patient?(QSEN-Evidence Based Practice) Safety/Quality ImprovementWhat would you as the nurse do if you almost gave the wrong dose of one of the ordered medications because of a similarity in the label provided by pharmacy to another drug?(QSEN-Safety/Quality Improvement) InformaticsWhat medical electronic data bases are available in your clinical setting that would be a resource if needed to obtain needed information on a medication you have not given before or an illness/surgery you have never seen before?(QSEN-Informatics) Health ScienceScienceNursingNUR NUR252Share Question

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