The Heart-Lung Connection
True or False: If a patient is having signs of a blood transfusion reaction, you would first notify the doctor before stopping the transfusion.
False.
See Blood and Blood Products Administration Policy
Your 4-year-old patient is diagnosed with ALL. Patient has a low WBC count. State one teaching point that is most important to provide to the parents.
Acceptable answers: Reinforce the importance of handwashing, avoid crowded areas (ex. malls, theme parks), and notify provider immediately if patient has a fever.
State the priority intervention for a child experiencing a seizure.
Protecting the patient/patient safety.
Examples: Loosen constrictive clothing. Do not try to move the patient during seizure. Guide patient movements. Do not restrain patient. Keep side rails up. If patient is being monitored by audio-visual equipment, remember to avoid blocking the camera. Never try to pry open jaw or insert object into patient's mouth.
Seizures, Management of Patient, PolicyStat ID 12501683
You require a urine culture on your 2-year-old patient.
True or False: The best way to obtain a culture with accurate results would be to instruct the parent on how to obtain a first-void urine specimen.
False.
The most accurate way to perform urine culture tests in children younger than two years old or situations where a clean catch cannot be reliably obtain is to perform bladder catheterization as other methods have a higher incidence of sample contamination.
Your shift just started. You observe your 18-year-old patient on a morphine PCA asleep while taking shallow breaths, has a respiratory rate of 7, and when you call his name and shake his arm to arouse him, he just moans. The parent at bedside sees your concern and says "Don't worry, he's just a heavy sleeper."
True or False: You decide there is no intervention required and move on to see your next patient.
False.
The patient is likely experiencing respiratory depression in the setting of opioid overdose and may require naloxone (narcan). Never assume the patient is "just a heavy sleeper," especially when opioids are involved. Perform a thorough assessment, voice your concerns, and ask for help if needed.
In the event of respiratory depression or over sedation:
Pediatric Patient-Controlled Analgesia: IV, Subcutaneous, PolicyStat ID 14949753
Name three signs that indicates a child is experiencing respiratory distress.
Acceptable answers: Intercostal retractions, use of accessory muscles, head bobbing, nasal flaring, color change, tripoding.
The PCT tells you upon completing vitals for your high risk patient, the patient has a new fever of 38.8C. You suspect sepsis without organ dysfunction. Arrange the following tasks in order of completion.
1. Send relevant labs.
2. Administer antipyretic.
3. Administer antibiotics.
Correct order: 1, 3, 2
See Sepsis Inpatient Pathway.
Your 9-year-old patient was admitted following a head injury. Here are your findings:
BP 110/60 mmHg
HR 78 bpm
Dilated, nonreactive pupils
Slow verbal response to name
State the finding that is most concerning.
Dilated, non reactive pupils as this can indicate anoxia or ischemia of the brain.
Your shift just started. Which patient do you assess first?
Patient A: 3-year-old female admitted for dehydration and has a net volume of -600 from the previous shift.
Patient B: 10-year-old male newly diagnosed with ALL going for line placement today who has questions about the procedure.
Patient A should be assessed first.
Refer to Maslow's heirarchy of needs (physiological, safety, love, esteem, and self-actualization).
Your shift just started. Which patient do you assess first?
Patient A: 2-year-old female who is vomiting.
Patient B: 2-year-old female with a new temperature of 39.5C.
Patient B should be assessed first.
Although most children with a fever will have a self-limiting illness, a minority will have a serious or even life-threatening illness. Febrile seizure (NICE Clinical Guidelines, No. 47.).
Name a vital sign that is a late sign of shock.
Hypotension OR tachypnea.
Signs of early (compensated) shock: tachycardia, cool/dry skin, delayed capillary refill.
Signs of late (decompensated) shock: low blood pressure, tachypnea, cool/clammy skin, altered mental status.
You admit a patient with sickle cell disease actively in a sickle cell pain crisis with a hemoglobin of 8 g/dl. Arrange the following in priority order.
1. Administer analgesics
2. Incentive spirometer
3. Administer fluids
Correct: 1, 3, 2
Priority nursing intervention would be to administer analgesics to control the patient's pain. Next would be to administer fluids to promote hemodilution and maintain electrolyte balance. Finally, the nurse would administer blood products if clinically indicated.
Your 7-year-old patient has been placed in a cast for a fractured right arm. A few hours into your shift and you have exhausted all pain management options, including PRN opioids, but he will not stop crying. On assessment you note he has difficulty straightening the fingers on his right arm.
State the complication that is likely occurring and your priority nursing action.
Compartment syndrome, therefore the nurse should immediately notify the physician.
Compartment syndrome can occur as a result of systemic disorders or local limb trauma in a pediatric patient and is a MEDICAL EMERGENCY! Left uncorrected, muscle and nerve ischemia can lead to profound disability and limb loss. Clinical signs include the 5 Ps: pain, paresthesia, paralysis, pallor, pulseless. Circumferential casts can decrease the ability of a limb to accommodate increased pressures and following surgery soft tissue swelling can occur that might not have been present during the cast application; this may lead to compartment syndrome. If this is the case, the first intervention should be relieving the circumferential pressure by splitting the cast.
Your shift just started. Which patient do you assess first?
Patient A: 9-year-old admitted with appendicitis who is happily reporting their severe abdominal pain suddenly stopped
Patient B: 10-year-old patient admitted for constipation reporting an increase of their pain from a 6/10 to a 7/10.
Patient A.
Sudden cessation of abdominal pain for a patient with appendicitis may be indicative of perforation of the appendix. This requires emergent surgical intervention.
Your patient actively receiving vancomycin develops an erythematous rash on the face. Arrange the following interventions in order of priority.
1. Call the provider.
2. Stop the infusion.
3. Document your findings.
Correct: 2, 1, 3
Vancomycin infusion reaction (VIR)," previously known as "red man syndrome," occurs principally with parenteral administration of vancomycin and may develop with the first administration of vancomycin. It is characterized by flushing, erythema, and pruritus, usually affecting the upper body, neck, and face more than the lower body. Prevention of VIR involves the use of slower infusion rates and, in some situations, premedication. However, other symptoms such as pains and muscle spasms in the back and chest, dyspnea, and hypotension may also occur, and in these cases it may be difficult or impossible to distinguish severe VIR from anaphylaxis; this is why it is important to stop the infusion first then call the provider. If it is true VIR, treatment can range from simply restarting the infusion at a slower rate or doing this in combination with diphenhydramine, famotidine, and/or fluids if hypotension is present.
Your shift just started. Which patient do you assess first?
Patient A: 2-year-old male admitted 3 days ago for bronchiolitis on HFNC (15L, 28%) and has been stable, but mom is complaining he is fussy.
Patient B: 7-year-old girl admitted last night for asthma exacerbation. Respiratory scores overnight as follows: 2am - 7, 4am - 6, 6am - 9.
Patient B should be assessed first.
See ED & Inpatient Clinical Asthma Pathway.
Your patient with sickle cell disease admitted for a sickle cell crisis asks you for cold packs because "they really help the pain go away."
State your reply to the patient and include your rationale.
Cold packs should not be administered, but rather warm packs as warm packs promote vasodilation and perfusion, providing pain relief and comfort. Cold packs are not indicated for patients with sickle cell disease as they cause vasoconstriction and may precipitate more sickling of the red blood cells.
Your patient who has been diagnosed with a brain tumor is now complaining of both headache and dizziness, and is notably more irritable. State the adverse event that is likely occurring.
Increased intracranial pressure (ICP).
Your patient receiving TPN calls you to notify you the tubing disconnected. You notice half of the bag has emptied onto the floor.
How should the nurse proceed?
The nurse should proceed by notifying the physician as the patient will need an alternative glucose containing solution as a sudden discontinuation of TPN may result in an abrupt drop in blood sugar. This can be avoided by gradually reducing rate, or tapering, to allow the body to adapt to the sudden lost of a highly concentrated solution containing a variety of nutrients. Furthermore, it is unsanitary to reconnect the tubing, even if the line and the tubing is cleaned with alcohol.
Strawberry tongue, desquamation of the hands and feet, and irritability are tell tale signs of what disease process.
Kawasaki disease.
Kawasaki disease is predominantly seen in children with an unknown etiology. Typically the condition is self-limited, with fever and manifestations of acute inflammation lasting for an average of 12 days without therapy. Oral mucous membrane findings are seen in approximately 90 percent of cases, polymorphous rash in 70 to 90 percent, extremity changes in 50 to 85 percent, and irritability occurring in 50 percent with lethargy being more common in older children.
https://www.uptodate.com/contents/kawasaki-disease-clinical-features-and-diagnosis
Read the following progress note:
7-year-old child admitted from ED. Oxygen via simple mask at 4L/min. Frequent, tight cough. A&O x3. Shortness of breath while talking to mom. Lungs with bilateral wheezing to bases. Denies pain. Abdomen soft with active bowel sounds and moving all extremities well.
State the patient's suspected diagnosis.
Asthma/acute asthma exacerbation.
State the priority intervention for a child with hemophilia admitted with an acutely bruised leg.
Administer the required clotting factor.
While it is also important to apply pressure, apply cool compresses, and ensure the extremity is immobilized, the only way to stop the active bleeding is to administer the required clotting factor.
Your 20-year-old male patient who sustained a femur fracture 24 hours ago is now experiencing dyspnea, tachypnea, and chest pain.
State the most likely complication the patient is experiencing.
Fat embolism.
While the list of pulmonary complications following a femur fracture consist of pulmonary embolism, acute respiratory distress syndrome fat embolism, and pneumonia, majority of cases of FE are due to long bone and pelvic fractures as the bone marrow contains a higher content of fat compared to other marrow-containing bones (i.e. ribs).
https://www.uptodate.com/contents/fat-embolism/syndrome?topicRef=228&source=seelink#H5336128
You receive a patient admitted for sepsis two days ago who was treated with aggressive fluid resuscitation over the last 48 hours. Later on in your shift the patient's oxygen saturations drop to the 80s and ends up requiring use of a non-rebreather, she has an increased respiratory rate, and she complains that it is getting harder to breathe.
State the most likely adverse event that is occurring with this patient.
Pleural effusion.
Pleural effusions are commonly seen in critically ill patients and can result from volume overload following aggressive fluid resuscitation (Kelm et al., 2016). Interventions such as performing strict intake and output or daily weights in similar cases is crucial to identifying fluid overload early on.
A healthy afebrile 1-year-old child with sudden onset of respiratory distress associated with coughing and wheezing comes into the ED. As you begin to assess the patient, mom says "This happened so suddenly? Could it be asthma?" On assessment you observe inspiratory wheezing and suprasternal retractions.
1. What is the most likely diagnosis?
2. What would be your nursing interventions?
As the nurse your priority intervention would be to put the patient on a monitor, notify MD, do a complete respiratory assessment, prepare for x-ray, contact ENT, possibly prepare patient for OR.
Based on history, age, and presentation, this is most likely a partial foreign body aspiration (FBA).
A full assessment is needed prior to preparing treatment. Never make assumptions before taking the patient history and completing an assessment. Clues in the presentation are more likely indicative of a foreign body aspiration rather than asthma. Children with FBA commonly present with partial airway obstruction showing signs such as cough, followed by tachypnea and stridor, often with focal monophonic wheezing or decreased air entry. A complete airway obstruction will leave the patient unable to speak or cough.