Lasalle University: School of Nursing and Health Sciences

La Salle University: School of Nursing and Health Sciences Pediatric Simulation and Unfolding Case Study: NUL 405 Nursing Care of Children and Adolescents Immersion Day Anne McGrorty, RN, MSN, CPNP Kristine Ellis, MSN, RN

Strategy Overview: This pediatric simulation and unfolding case study takes place in the Nursing Learning Resource Center and is scheduled early in the Nursing Care of Children and Adolescents course. It stands as an immersion day experience that is comprehensive and interactive. The simulation and unfolding case study is aimed at promoting creative and critical thinking. It specifies the learning objectives, equipment, and an unfolding case study of an ill infant. Students demonstrate skills using Sim-baby. Patient data are presented as the situation progresses. Questions are posed to encourage decision making.

Simulation Objectives: At the end of this simulation scenario, the learner will be able to:

1. Implement Joint Commission safety standards in the care of an acutely ill pediatric patient. 2. Use situational, background, assessment, and recommendations (SBAR) during the patient transfer. 3. Provide safe nursing care to the newly admitted pediatric patient with multiple health care needs. 4. Demonstrate evidence-based safe care for the pediatric patient receiving IV therapy and medications. 5. Calculate accurate medication doses based on the pediatric patient’s weight. 6. Perform a systematic physical assessment on a simulated, acutely ill, pediatric patient. 7. Differentiate developmentally appropriate and inappropriate responses to nursing care. 8. Analyze pediatric laboratory values and their influence on patient care decisions. 9. Demonstrate professional behaviors during the simulation. 10. Recognize the importance of family-centered care. 11. Demonstrate adherence to infection control standards when performing nursing care.

Learning Objectives:

Core-Competency: Patient Centered Care This teaching strategy is designed to evaluate the following KSAs:

Knowledge: Integrates understanding of family-centered care for the pediatric population and involving parents/siblings in all aspects of patient care including plans of care, communication, education, and emotional support.

Attitude: Encourages parental involvement in patient care Recognizes the need for emotional support of family members.

Skills: Acknowledges family as a part of patient care and outcomes through effective communication and evaluation of parental involvement and knowledge of care.

Core-Competency: Safety This teaching strategy is designed to evaluate the following KSAs:

Knowledge: Describes the nurse’s role in providing safe, effective patient care and the impact of Joint Commission standards on nursing care.

Attitude: Seeks to provide safe patient care and educate the patient and family about safety throughout the hospital stay.

Skills: Implements Joint Commission standards of safe patient care through the use of medication reconciliation, communication, error reporting, patient identifiers, medication safe doses, abbreviations, SBAR technique during patient transfer, and the five rights of medication administration.

Core Competency: Team and Collaboration This teaching strategy is designed to evaluate the following KSAs:

Knowledge: Recognizes the importance of effective communication among different healthcare providers (nurse to nurse, nurse to physician).

Attitude: Identifies the importance of effective communication with physicians and other members of the healthcare team to ensure patient safety and positive outcomes.

Skills: Gives report for a patient using SBAR technique. Communicates safety threats to physicians who prescribed medication orders.

Core Competency: Evidence-Based Practice This teaching strategy is designed to evaluate the following KSAs:

Knowledge: Differentiates between clinical opinion and scientific evidence while performing specific diagnostic tests and assessments.

Attitude: Values continuous improvement in the clinical setting.

Skills: Identifies potential medical errors and possible conflicts with other health care providers.

Equipment needed to run simulation scenario:

Student Name Tag Calculator Vital Sim Baby Stethoscope Pediatric Blood Pressure Cuff Thermometer Pulse Oximeter and Probe Scale IV tubing IV pump and pole NSS 250 mL bag IV flush (3mL NSS) IV infusor Oral syringe Tympanic Membrane model Otoscope Pediatric catheter Acetaminophen 80mg/0.8mL Denver Kit Growth Charts

Pediatric Simulation

Background Information: Alison is a 12 month old who has been vomiting for the past 12 hours. Since waking at 6 AM she has “not held anything down.” It is now 5:30 PM and Alison’s mother is becoming concerned. She calls the primary care office and the nurse recommends that Alison be brought into the office for evaluation. On initial assessment, Alison is lethargic and very quiet. Her lips and skin are dry. She is crying at times, but does not produce tears. Her diaper is dry; her mother says that she has not needed to change her diaper since 7 AM.

What are the nurse’s primary concerns based on these findings?

 dry diaper for greater than 8 hours  absence of tears and dry mucous membranes  lethargic and quiet while in the office  unable to keep anything down all day  age of patient

Alison lies very quietly on the examination table. Her vital signs are: Temperature: 101O F Apical Rate: 150 bpm Respiratory Rate: 40 breaths per minute Blood pressure 90/48 Birth weight: 8 lbs Current weight: 21 lbs 6 oz Weight at 12 month visit 2 weeks ago: 24 lbs 2 oz What is the nurse concerned with now?

 Temperature of 101O F o Could indicate infection or virus  Apical Rate and respiratory rate elevated  Recent weight loss  Birth weight should be tripled by year 1

Alison’s mother reports that she loves her milk and usually drinks about 40 ounces per day. However, for the past 24 hours she has not wanted anything to eat or drink. Her mother wants to know if there is anything that the nurse can give Alison to help stop the vomiting.

What questions does the nurse need to ask mother at this point?

 When was the last time the nurse received a wet diaper from Alison? o This will determine how long the child has been dehydrated and what the severity level of her condition.  Has she been showing any signs or symptoms in the past 24-48 hours such as pulling on ears, increased irritability, inability to get comfortable when lying down, waking frequently during sleep, foul smelling urine, any new onset rashes, respiratory distress, cough? o All of these symptoms could indicate another underlying illness such as ear infection, urinary tract infection, pneumonia, etc. All of these diagnoses could be the reason for her vomiting.  What vaccinations did Alison receive at her 12 month visit 2 weeks ago? o To verify if her fever could be from recent immunizations  Does Alison have any allergies, and if so, what are her reactions like? o This will help to prevent any further injury to the patient and alert physicians and nurses while ordering treatments and medications for Alison  Does Alison take any medications at home on a daily basis? o To complete a medication reconciliation as defined by Quality and Safety Education for Nurses  Has Alison traveled outside of the United States in the past few weeks?  What are Alison’s normal eating habits?  Where does Alison live?  Is she currently using the Women, Infants and Children (WIC) program?  Are there any other sick contacts at home?  Does she attend daycare? If so, how often?  N.B. A 40 oz per day milk intake is excessive

How does the nurse ensure that Alison is correctly identified?  2 Patient Identifiers o National Patient Safety Goal presented by the Joint Commission . Purpose  Reliably identify the individual as the person for whom the service or treatment is intended  To match the service or treatment to that individual  They must be in the same location (patient wristband or chart label) o Name, ID number, telephone number, date of birth, or other person-specific identifier (Joint Commission, 2008)

What care does Alison need at this point?

 Alison is dehydrated and is in need of IV fluids. She needs to be referred to the nearest hospital  As the ED nurse who admits Alison, what nursing interventions are appropriate at this time?

Sim-baby Exercise:

 Using Sim-baby complete the following assessments/interventions: o Patient ID band placement o Patient weight and vital signs . Weight is 21 lbs or 9.5 Kg . Temperature 102O F rectally, Heart rate 145, Respiratory rate 39, BP 92/45 o Physical assessment of patient (Using Sim-baby and tympanic membrane model) . Chest congestion and bilateral coarseness with a slight expiratory wheeze, dry cough, nasal congestion, left tympanic membrane is bulging and erythematous and Alison seems bothered when the nurse touches her ears o Urine catherization o Assess for need of antipyretics at this time o Draw lab work as ordered . CBC, CMP, blood cultures, sed rate, urinalysis, urine culture o Obtain peripheral IV access o Spinal tap with proper preparations and aseptic technique prior to collecting cultures

During the insertion of a peripheral IV, Alison lies quietly throughout the procedure. A. What concerns does the nurse have? B. Why does the nurse need to repeat the weight when she just had one done in the office?  A. An alert 12 month old should be very upset and irritable while having an IV placed. Sometimes the child will require that several nurses physically restrain the child while this is being done.  B. It is always good to get an accurate weight at the nurse’s facility to ensure that the nurse has a correct reading. It can be dangerous to take measurements from other facilities because all medications and IV fluids are calculated based on the patient’s weight. If the nurse directly asks the mother, she may forget and give him/her an estimated number. Also, a new nurse will not know if the weight was taken with clothes off, and if there is a slight difference in the actual scale measurements.

What diagnostic tests are warranted by these findings?

 Chest X-ray to rule out pneumonia  Pulse oximetry to determine oxygen saturation levels  Oxygen and respiratory treatments if needed  RSV nasal washing and Rapid Respiratory Panel if needed

A fluid bolus is ordered by the physician and after administration of the bolus; Alison perks up a little bit. The doctor then orders Tylenol for the patient. The order reads as follows:

Acetaminophen 650.0mg prn pain/fever q 4 hours

Is this order appropriate for Alison?

Using the pediatric reference guide, determine if this is a safe dosage for Alison?  The safe dose for Acetaminophen is 10-15 mg/Kg/dose q 4 hours. Therefore, Alison should receive 95-142 mg per dose. This is not a safe dose.

What would be appropriate actions for the nurse to take at this time?

 Calculate the medication dosage for Alison  Since the safe dosage for Alison is 95-142 mg per dose, the doctor should be notified of the error so he can change the order.  Also, according to Joint Commission National Safety Goals there should be no trailing zeroes in medication orders so the nurse needs to verify the dosage again with the doctor. After all, this 650.0 mg could be interpreted as 6500 mg if the nurse fails to see the decimal point.

Calculate Alison’s daily maintenance fluid requirements and expected hourly output.

 Based on her weight being 9.5 Kg Alison should be receiving 100 mL/Kg/day o This comes out to 950 mL/day or 40 mL/hour  The hourly output for an infant should be 2-3 mL/Kg o This comes out to 19-29 cc/hour

After notifying the doctor of the medication dosage, he changes the order to read:

Acetaminophen 120 mg prn for pain/fever q 4 hours; NSS bolus.

He also orders a 250 cc NSS IV bolus stat. Would this bolus be appropriate for Alison? What actions would the nurse take? Are there any factors to consider if the physician orders IV fluids with additives in them such as K+?

 Administer the Acetaminophen  Recheck temperature within 90 minutes of administration to ensure that the medication is working  Measure the patient’s output to measure hydration status.  The nurse always needs to check for urine output prior to administering fluids with additives such as K+. This is important in the prevention of toxic buildup of electrolytes in the body and the knowledge that the kidneys are functioning properly.

What are the nursing responsibilities when administering medications?  Any known drug allergies?  Rights of Medication Administration o Right patient, route, dose, time, medication, right to refuse, and DOCUMENTATION!  2 Patient Identifiers o DOB and first and last name

After administering the Acetaminophen, the nurse discovers that Alison’s temperature is now at 100.4o F rectally and she has a wet diaper. She is beginning to cry and her mother asks for a bottle. She hands the bottle to Alison and Alison refuses to hold her own bottle. When asked, her mother says, “Oh she is just lazy. She won’t stand up on her own either!” Why does this concern the nurse?  The patient is 12 months old and her mother is stating that she is unable to stand up on her own or hold her own bottle  Her mother may have unrealistic expectations for her sick child. o Developmental monitoring and parental counseling may be needed to ensure that the safety of the child and to evaluate the need for further testing. Possible consult for a social worker to come speak with Alison’s mother and evaluate the child/parent relationship. o Early Intervention. o Mother’s knowledge deficit of developmental levels.

Alison’s laboratory values come back as follows: (students will have lab sheet)  Hgb-11 Gm  WBC-10,000 mm3  Potassium- 4.2 mEq/L  Sed rate- 10 mm/hr  Creatinine-5 mg/dL  BUN-7 mg/dL  CO2-15 mEq/L  UA-small amount of leukocytes, negative nitrites, large ketones  Blood and Urine cultures-pending  Blood glucose-75 mg/dL

What laboratory values are concerning?

 The most concerning lab values for this patient are the UA and the serum CO2. o Leukocytes present in the urine could indicate a urinary tract infection . Another urinalysis could be sent to rule out contamination of the specimen. The nurse should also await urine culture results for final verification of bacteria present and sensitivity o Ketones present in the urine indicate dehydration in the child . The doctor will continue IV therapy until the ketones clear. The nurse should be checking for ketones with a urine dipstick on each diaper change. o C02- indicates dehydration o Hgb/anemia may be related to excessive milk consumption; teaching opportunity with mother

Alison is stabilized at this time. The nurse sends a repeat UA and the doctor orders an antibiotic for the patient. Her temperature is now at 99.2O F rectally and her chest X-ray is positive for left lower lobe pneumonia. The doctor decides to admit Alison for observation and IV fluid therapy. For which diagnoses is Alison being admitted? What should the doctor consider when ordering medication for Alison?

 Diagnoses probably include left otitis media, UTI, pneumonia, and dehydration. The vomiting may be from a viral gastroenteritis or the UTI, upper respiratory infection, and otitis media combined.  The physician should make sure that the patient is able to tolerate PO intake prior to ordering a PO medication. If she is still vomiting, it will be difficult for her to keep the medication down. He may have to consider IV antibiotics until she is better or Acetaminophen rectally instead of orally.  The mother may benefit from increased knowledge about the administration of antiemetics to a vomiting child

The nurse calls the pediatric unit to give report. She uses the SBAR technique. Using SBAR communication strategy how does the ER nurse provide a safe handoff of Alison to the unit nurse? How would the nurse give report with the SBAR technique for Alison?

 S-Situation (Describe what is going on)  B-Background (Concise history)  A-Assessment (Present status)  R-Recommendation (What needs to happen?)  Have students give report to each other using SBAR technique and then share with the group.

After receiving report, the floor nurse admits Alison to the pediatric unit. What assessments and immediate interventions should be performed with Alison? What education or teaching should the nurse give to the mother?

 Plan of care for Alison  Patient safety and use of crib rails in room  Orientation to room and unit  Medication reconciliation  Patient identification  Renewal of all assessments and physician’s orders for verification

Alison is stabilized and she is now napping in the room. Her mother is settled and the nurse goes to the Nurses’ Station to fill out the correct admission paperwork. A secretary at the front desk looks at the chart and says, “Hey, I know this family. They live right up the street from me. What is she here for?” What would be an appropriate answer for the nurse to give?

 A. “She is here for dehydration. Her mother seems to be anxious and even had the nerve to call her ‘lazy’ down in the ER.”  B. “I am sorry, but because of HIPAA (Health Insurance Portability and Accountability Act) privacy rule, I am unable to discuss any patient information with you at this time.”  C. “Yes her name is Alison. Would you like to review her chart for yourself?”  Answer is B. This answer follows the Health Insurance Portability and Accountability Act privacy rule.

The Health Insurance Portability and Accountability Act privacy rule is a part of the US Department of Health and Human Services Office for Civil Rights. This law gives you rights to your health information, sets rules and limits on who can look at and receive your information, and protects the privacy of your health information.  All healthcare providers, health insurance companies, Medicare and Medicaid programs, and any person working in patient care settings must comply with this law  This law helps to protect healthcare information such as… o Information from the medical record, conversations carried out between patients and providers, information in healthcare computer systems, patient billing information, most other health information about you held by those who must follow this law (U.S. Department of Health and Human Services Office for Civil Rights, 2007)

References

Quality and Safety Education for Nurses (2007). Quality and Safety Competencies. Retrieved on April 17, 2008 from www.qsen.org/competencydomains

Joint Commission (2008). Facts About Patient Safety: Safety Initiatives. Retrieved April 24, 2008 from http://www.jointcommission.org/PatientSafety/

U.S. Department of Health and Human Services for Civil Rights. (2007). Medical privacy-National standards to protect the privacy of personal health information. Retrieved on April 17, 2008 from http://www.hhs.gov/ocr/hipaa/finalreg.html