April Peters, 10 years old Primary Concept Cellular Regulation Interrelated Concepts (In order of em. Question
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April Peters, 10 years old Primary Concept Cellular Regulation Interrelated Concepts (In order of emphasis) 1. Infection 2. Perfusion 3. Clinical Judgment 4. Thermoregulation 5. Communication 6. Collaboration 7. Patient Education © 2016 Keith Rischer/www.KeithRN.com UNFOLDING Reasoning: STUDENT Acute Lymphoblastic Leukemia History of Present Problem: April Peters is a 10-year-old female with acute lymphoblastic leukemia (ALL) who presents to the emergency department with a temperature of 38.4 degrees C. (101.2 F.) and a complaint of a sore throat. She has been receiving chemotherapy since her diagnosis three months ago. April’s mother reports that her fever has been unresponsive to acetaminophen and she is two days out from her most recent chemotherapy treatment. No reports of nausea, vomiting, or diarrhea noted. A CBC is drawn immediately from April’s central venous access device (CVAD) and April is admitted directly to the pediatric oncology unit where you are the nurse responsible for her care. She weighs 57 lbs. (25.9 kg), is 51.5 inches (128.8 cm.) and has NKDA. Personal/Social History: April lives at home with her mother Cindy, her father Tom, and her 6-year-old sister Maggie. Tom works full-time as an engineer while Cindy stays home with the children because of April’s diagnosis and resulting hospitalizations and treatment. April has missed quite a few days of school. Although her school system has provided April with a tutor to keep up with her studies, April does not return telephone calls from her friends and refuses their visits. Past Medical History (PMH): Cindy’s pregnancy was uneventful and April was born via an uncomplicated vaginal delivery at 40 weeks and weighed 7 lbs., 1oz. (3.2 kg.) Tonsillectomy at 3 years old under general anesthesia. ALL diagnosis 3 month ago following a short history of headaches and pallor. April’s WBC count at diagnosis was 469,000 FYI: Hyperleukocytosis is defined as a peripheral white blood cell count greater than 100,000/mm3 and is a pediatric oncologic emergency. These white blood cells are immature blast cells not normal cells. Hyperleukocytosis can progress to capillary obstruction, microinfarction, and organ dysfunction, which can lead to respiratory distress and cyanosis. Children may also experience changes in neurologic function, including an altered level of consciousness, visual disturbances, confusion, and ataxia. What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: © 2016 Keith Rischer/www.KeithRN.com What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Mechanism of Action Nursing Considerations 1. Leukemia 2. Chemotherapy 3. Chemotherapy side effects: Constipation Nausea Fever/comfort SulfamethoxazoleTrimethoprim Ranitidine Docusate Sodium Ondansetron Cyclophosphamide Methotrexate Cytarabine Acetaminophen Patient Care Begins: What VS data are RELEVANT that must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 100.8 F/38.2 C (oral) Provoking/Palliative: “My throat hurts” P: 112 (reg) Quality: “Bad” R: 24 (reg) Region/Radiation: Throat BP: 102/66 Severity: “I don’t know.” O2 sat: 96% on room air Timing: Ongoing © 2016 Keith Rischer/www.KeithRN.com What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Current Assessment: GENERAL APPEARANCE: Resting in bed with eyes closed, pale in appearance. RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Skin is pale, cool to touch. Cap. refill 3-4 seconds in both hands. No edema noted, heart sounds regular with no abnormal beats, radial and pedal pulses present and strong. NEURO: Patient appears lethargic, drowsy, oriented x4 GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Last BM yesterday evening GU: Voiding without difficulty. SKIN: Skin integrity intact. Central venous access device (CVAD) in place, dressing intact Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5-11.0 mm 3) 0.2 0.3 Hgb (12-16 g/dL) 7.4 8.2 Platelets (150-450 x103/µl) 54 61 Neutrophil % (42-72) 1 0 Band forms (3-5%) 0 0 Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous: Sodium (135-145 mEq/L) 130 129 Potassium (3.5-5.0 mEq/L) 3.5 3.3 Glucose (70-110 mg/dL) 70 82 BUN (7-25 mg/dl) 26 17 Creatinine (0.6-1.2 mg/dL) 1.4 1.1 © 2016 Keith Rischer/www.KeithRN.com What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Misc. Labs: Current: High/Low/WNL? Previous: Magnesium (1.6-2.0 mEq/L) 1.9 2.0 Ionized Calcium (1.05-1.46 mmol/L) 1.05 1.11 Amylase (25-125 U/l) 29 31 Lipase (3-73 units/L) 27 39 Lactate (0.5-2.2 mmol/L) 1.8 1.7 Coags: PT/INR (0.9-1.1 nmol/L) 0.9 0.9 Liver Function Test (LFT:) Current: High/Low/WNL? Previous: Albumin (3.5-5.5 g/dL) 3.5 3.9 Total Bilirubin (0.1-1.0 mg/dL) 1.0 0.9 Alkaline Phosphatase male: 38-126 U/l female: 70-230 U/l 75 79 ALT (8-20 U/L) 22 20 AST (8-20 U/L) 29 21 © 2016 Keith Rischer/www.KeithRN.com What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: Creatinine Value: 1.4 Critical Value: Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? 2. What is the underlying cause/pathophysiology of this concern? Urine Analysis (UA:) Current: WNL/Abnormal? Color (yellow) Amber Clarity (clear) Clear Specific Gravity (1.015-1.030) 1.042 Protein (neg) Neg Glucose (neg) Neg Ketones (neg) Neg Bilirubin (neg) Neg Blood (neg) Neg Nitrite (neg) Neg LET (Leukocyte Esterase) (neg) Neg MICRO: RBC’s (<5) 0 WBC's (<5) 0 Bacteria (neg) Neg Epithelial (neg) Neg © 2016 Keith Rischer/www.KeithRN.com Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Admit to Pediatric Oncology unit with strict neutropenic precautions. Daily weight Strict I & 0 0.9% NS bolus @ 20mL/kg over 60 minutes then D5.45 NaCl with 20 mEq/L KCL at 2 mL/kg/hr Daily blood cultures from all CVAD lumens. Vital signs every 2 hours and as needed Acetaminophen (160 mg/5 mL) 5 mL PO every 4 hours for temp > 100.4 F. (38.0 C.) Ceftriaxone 75 mg/kg IV every 24 hours. Rapid strep/throat culture Vancomycin 15 mg/kg/day, divided every 6 hours © 2016 Keith Rischer/www.KeithRN.com PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 0.9% NS bolus @ 20 mL/kg over 60 minutes then Vital signs every 4 hours Acetaminophen (160 mg/5 ml) 5ml PO every 4 hours for temp > 100.4 F. (38.0 C.) Ceftriaxone 75mg/kg IV every 24 hours. Additional Pediatric Dosage Calculations: 1. Convert most recent weight from pounds to kilograms: 2. 0.9% NS @ 20 mL/kg bolus over 60 minutes. Bolus amount: 3. IV maintenance @ 2 mL/kg/hour. Maintenance rate: 2 x 25.9 = 4. Ceftriaxone 75 mg/kg IV every 24 hours. Calculate dose to be given: 75 x 25.9 = 5. Vancomycin 15 mg/kg/day, divided q6h. Calculate dose to be given: 15 x 25.9 = Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one, list in order of PRIORITY) 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 5. What body system(s) will you most thoroughly assess based on the primary/priority concern? 6. What is the worst possible/most likely complication to anticipate? 7. What nursing assessments will identify this complication EARLY if it develops? © 2016 Keith Rischer/www.KeithRN.com 8. What nursing interventions will you initiate if this complication develops? 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? 10. How can the nurse address these psychosocial needs? Evaluation: Two hours later… All orders have been implemented, including blood cultures, medications, and IV fluid orders. April is sitting up in her bed visiting with her mother. Evaluate April’s response to the nursing and medical interventions implemented during your shift: RELEVANT VS Data: Clinical Significance: Current VS: Most Recent VS: Current PQRST: T: 37.3 C. (99.1 F.) (oral) T: 38.8 C. (101.8 F.) (oral) Provoking/Palliative: “My throat feels a little better.” P: 104 (reg) P: 132 (reg) Quality: “Hurts” R: 20 (reg) R: 24 (reg) Region/Radiation: Throat BP: 102/80 BP: 82/46 Severity: “Not as bad.” O2 sat: 97% on room air O2 sat: 96% on room air Timing: “Off and on.” Current Assessment: GENERAL APPEARANCE: Sitting up in bed, interacting with mother, appears in no acute distress RESP: Breath sounds clear with equal aeration bilaterally, nonlabored respiratory effort CARDIAC: Skin is pale, cool to touch. Cap refill 2 seconds in both hands. No edema noted, heart sounds regular with no abnormal beats, radial and pedal pulses present and strong. NEURO: Awake, alert, and oriented to person, place, time, and situation (x4). GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, 200 mL in last 2 hours, able to ambulate to toilet SKIN: Skin integrity intact. CVAD in place, dressing intact © 2016 Keith Rischer/www.KeithRN.com RELEVANT Assessment Data: Clinical Significance: 1. Has the status improved or not as expected to this point? 2. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? 3. Based on your current evaluation, what are your nursing priorities and plan of care? It is now the end of your shift. Effective and concise handoffs are essential to excellent care. A poor or incomplete handoff can adversely impact April’s care. You have done an excellent job to this point. Now finish strong and give the following SBAR report to the nurse who will be caring for this patient: Situation: Name/age: BRIEF summary of primary problem: Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data: . Assessment: Most recent vital signs: RELEVANT body system nursing assessment data: RELEVANT lab values: © 2016 Keith Rischer/www.KeithRN.com Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? 2. What can you do to engage yourself with this patient’s experience, and show that she matters to you as a person? Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? 2. How can I use what has been learned from this scenario to improve patient care in the future?
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April Peters, 10 years old Primary Concept Cellular Regulation Interrelated Concepts (In order of em
