History of PresentIllness

J. Patterson (J.P.) was born at 38 weeks gestation and diagnosed with Trisomy 21 (Down Syndrome). At his one-week well checkup at the pediatrician’s office, a prominent heart murmur was auscultated. An echocardiogram revealed a large ventricular septal defect immediately below the aorta. A referral was made to a cardiologist who suggested no immediate interventions because J.P. did not appear to be in any distress.

Three weeks later at his second cardiologist appointment, his parents report that J.P. seems to be sleeping more. He seems to have times when he breathes faster than usual and becomes sweaty when he breastfeeds. His weight is 4 kg. At his last visit three weeks ago, he weighed 4.4 kg. The cardiologist prescribed 12 mcg digoxin every 12 hours (0.05mg/ml solution is received from the pharmacy) and 8 mg furosemide every day (10mg/ml oral solution is received from pharmacy).

What data from thehistories are RELEVANT and mustbe NOTICED as clinically significant?

RELEVANT Data:

Clinical Significance:

J.P.’s 5-month visit:

J.P. has been seen monthly by the cardiologist. Appointments at three and four months were unremarkable. At his five-month visit, his dosage of digoxin was increased to 22 mcg two times a day and furosemide increased also to 14.4 mg because his weight increased to 7.2 kg. Is this a safe dose for both medications? Calculate the safe dose range for this medication and the amount you would give per dose.

Present Problem:Two Weeks Later…

His mother brings J.P., now 5 ½ months old, to the emergency department (ED). She is extremely anxious and states, “Something is wrong with my son. I can’t get him to keep any of his feedings down. Please help him!” The triage nurse obtains a history from the mother and finds out that he has vomited repeatedly the past 24 hours and had several loose stools. She reportsthat J.P. has been sleepierthe last couple of hours.

He was started on digoxin and furosemide four months ago to managehis heart failure secondary to a VSD that was diagnosed when he was one month old. When asked if she checks J.P.’s heart rate before giving digoxin, his mom admits that she forgot and has not checked his HR the past week. Education given about the need to check J.P.’s heart rate before each dose of digoxin and not to give the medicine if the heart rate is below 90beats per minute.

What data from the history is RELEVANT and why is it clinically significant?

RELEVANT Data from Present Problem:

Clinical Significance:

Patient Assessment

Current VS:

FLACC Score:

T: 37.0 rectal(C)

Faces:

P: 85(regular)

Legs:

R: 36(regular)

Activity:

BP: 74/50 left leg

Crying:

O2 sat: 98% on RA

Consolability:

What VS data are RELEVANT and why or what is the clinical significance?

RELEVANT VS Data:

Clinical Significance:

Current Head to Toe Nursing Assessment:

GENERAL SURVEY:

Arouses easily but falls back to sleep

NEUROLOGICAL:

Patient opens eyes when Mom talks to him, but closes eyes quickly

HEENT:

Eyes PERRLA, Headwithout obvious deformities, Lipsdry

RESPIRATORY:

Breath sounds equal and clear posteriorly and anteriorly

CARDIAC:

Circulation: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal. Capillary refillon toes 3 to 4 seconds

ABDOMEN:

Abdomen round, soft, and nontender. BS active in all4 quadrants

GU:

No wet diaper in 6 hoursper parent

INTEGUMENTARY:

Skin cool, dry, intact, normalcolor for ethnicity. Skin turgor decreased

GI:

Vomiting, diarrhea, decreased appetite

What assessment data is RELEVANTand why is it clinically significant (rationale)?

RELEVANT Assessment Data:

Clinical Significance:

What additional data is needed to identify the priority problem and nursing priorities?

Likely Problems:

Additional Clinical Data Needed:

While awaiting lab results, the primary care provider ordersthe following:

Care Provider Orders:

Rationale:

Expected Outcome:

Establish peripheral IV

0.9% NS 10 mL/kg over 15 minutes

Place on cardiac monitor

Lab Results: What lab resultsare RELEVANT and must berecognized as clinically significant?

WBC

HGB

PLTs

% Neuts

Normal Range:

6.1-17.5 g/dL(1

to 23 months)

9.3-13.3 mmol/L

(3 to 11 months)

275-565 x10 to

the 3𝑟𝑑/microL (3 to 6 months

male)

1.9-5.4 absolute

value (1 to 23 months)

Current:

8.5

12.5

290

2.5

2 months ago:

7.5

11.9

280

2.4

RELEVANT Lab(s):

Clinical Significance:

TREND:

Improve/Worsening/Stable:

Basic Metabolic Panel (BMP)

Gluc.

Creat.

BUN

Normal Range:

134-142 (2 to 5

months)

3.5-5.6 (1 to 5

months)

30-100 (2 days

to 2 years)

0.31-0.71 (infant)

4-15 mg/dL (less than 2 years)

Current:

134 mEq/L

2.9 mmol/L

90 mg/dL

0.5 mg/dl

16 mg/dL

2 Months ago:

136 mEq/L

3.7 mmol/L

88 mg/dL

0.45 mg/dl

6 mg/dL

RELEVANT Lab(s):

Clinical Significance:

TREND:

Improve/Worsening/Stable:

Misc.

Digoxin

Normal Range:

0.5-2 ng/ml

Current:

2.5 ng/mL

2 months ago:

1.7 ng/mL

RELEVANT Lab(s):

Clinical Significance:

TREND:

Improve/Worsening/Stable:

Rank the most likely problems by priority. Which problem is priority? Why?

Problems:

Priority Problem:

Rationale:

State the rationale and expected outcomesfor the medical plan of care.

Care Provider Orders:

Rationale:

Expected Outcome:

Admit to PICU Cardiac Monitor Maintenance IV fluids StrictI & O

Hold digoxin

Complete metabolic panel (CMP) in AM

Digoxin levelin AM

Complete Answer: