Scenarios for interview

Pediatric Critical Care Columnist · Jan 31, 2015

I'll bite...

1) You're setting up for an admission. The patient is an 8 year old post MVC with a traumatic brain injury. What will you have ready at your bedside?

2) Your patient is a 9 month old with sepsis. Which is of greater concern and why?

a) HR 158

b) RR 40 and SaO2 96%

c) NIBP 74/40 (51)

d) T 38.7Â°C rectal

3) Your patient is a 4 month old s/p Norwood procedure admitted to your PICU with respiratory distress. The plan is to transfer

to a hospital with a cardiac unit but in the meantime you need to stabilize the child. What will your interventions likely include?

4) Your patient is a 10 month old with biliary atresia otherwise known as a "failed Kasai". Which laboratory findings would you expect to see in this patient? Select all that apply.

a) bilirubin 27 mg/dL

b) albumin 3.1 g/dL

c) arterial pH 7.28

d) INR 1.1

5) Your patient is a 5 year old with a history of global developmental delay, spastic diplegia and seizure. He was admitted with respiratory distress and has been intubated for mechanical ventilation. What are your most important interventions for this child?

6) The patient from the above question is starting to recover and it's time to restart his feeds. His mother tells you he's fed 250 mL Pediasure with fibre over 15 minutes q6h. What do you think of this and what do you say to the mom?

GO!

AnnieOaklyRN, BSN, RN, EMT-P · Feb 1, 2015

I'll bite...
1) You're setting up for an admission. The patient is an 8 year old post MVC with a traumatic brain injury. What will you have ready at your bedside?
2) Your patient is a 9 month old with sepsis. Which is of greater concern and why?
a) HR 158
b) RR 40 and SaO2 96%
c) NIBP 74/40 (51)
d) T 38.7Â°C rectal
3) Your patient is a 4 month old s/p Norwood procedure admitted to your PICU with respiratory distress. The plan is to transfer
to a hospital with a cardiac unit but in the meantime you need to stabilize the child. What will your interventions likely include?
4) Your patient is a 10 month old with biliary atresia otherwise known as a "failed Kasai". Which laboratory findings would you expect to see in this patient? Select all that apply.
a) bilirubin 27 mg/dL
b) albumin 3.1 g/dL
c) arterial pH 7.28
d) INR 1.1
5) Your patient is a 5 year old with a history of global developmental delay, spastic diplegia and seizure. He was admitted with respiratory distress and has been intubated for mechanical ventilation. What are your most important interventions for this child?
6) The patient from the above question is starting to recover and it's time to restart his feeds. His mother tells you he's fed 250 mL Pediasure with fibre over 15 minutes q6h. What do you think of this and what do you say to the mom?
GO!

Ok here goes, and thank you...

#1 For the head injured 8 year old I would have suction ready, intubation equipment if not already present, appropriate oxygen delivery device. I would have equipment ready just in a case a bolt is needed (although I have never set up for one of these so I would need help), ICP monitoring equipment. Appropriate BP Cuff, EKG leads, pulse ox probe, and end-tidal monitoring equipment. I would also have a set up for a central line and perhaps an art line just in case they don't already have that in place. I would also have otoscope for ears and pupillary checks. reflex hammer. stethoscope. .... ?? How was that???

#2 This one is tough. The only one that is concerning is the fever of 101.6, but I wouldn't go crazy about it. The HR is fast, but I would expect that because of the fever. The respiratory rate is a little fast as well with the oxygen being just a little low, but I would expect a fast RR given the fever again. The BP does not bother me. hmmmm I would say the fever and the RR of 40 with a lower oxygen saturation, but that isn't even that bad. ??

#3 The Norwood is for hypo plastic left heart which equates to a bad day for the patient and parents. I would guess that they would come out of this vented so I will have an infant size BVM, appropriate suction catheter, pressers perhaps, central line and art line setup, although I would imagine they come out of the OR with those. Doppler for pulses. Appropriate BP cuff and monitoring equipment. ??

#4 I am guessing on this one, as I could not look up information since my internet connection is acting up. I would say both A and B?

#5 Reassure the patient at his level. Monitor his airway and suction as needed. Regular assessment of lung sounds. Provide adequate sedation. Apply pads to the rails in case of seizure. Turn every hour to prevent skin breakdown and cushion pressure areas with pillows. Provide nutrition in some form although he may have a PEG or G tube.

#6 Presumably he is still intubated when he starts feeding. 250 mLs of feed is to fast for a patent who is both intubated, laying down, and who has not taken in nutrition for a couple of days presumably. I would recommend slowing the feedings significantly and assessing residuals, elevating the HOB, and educating mom on the increased risk of aspiration. I would also suggest slowing the feedings down on a regular basis as he may of aspirated at home, thus resulting in his pneumonia.

How did I do? :zombie:

Pediatric Critical Care Columnist · Feb 1, 2015

Overall, you did very well!

#1) You could add a laser level for ensuring the EVD - if placed - is at the correct height. Saline only for IV fluids, mixing your drips and so on. Sandbags for maintaining C-spine precautions and for keeping the head in midline even without C-spine precautions. Cooling apparatus on standby. Some sort of sedation or lidocaine for suctioning.

#2) Actually, I'd be most concerned with that BP. Remember that the low end of acceptable SBP in kids is 75 + 2 times the age of the child in years. So it's borderline. Hypotension is a late sign of compensation in children. With that temp and HR, cardiac output will already be falling and the BP bears watching closely. The other VS are as to be expected in a sepsis patient.

#3) The key here is that the kid is 3 months old and has had a Norwood - which is usually done around the 7th day of life. You told me in another thread that you're not going to a unit that does cardiac surgeries, so I wanted you to think about what you could do to stabilize this kiddo for transfer to a unit that does. Why do you think he has respiratory distress and what would you do about it?

#4) You would see a and c only. I'd be surprised if the bili wasn't higher than that. Serum albumin is low in patients with liver failure, 3.1 being borderline. I'd expect it to be more like about 2. Because liver failure brings ascites (which is where the albumin goes) the kiddo's diaphragm is pushed up, not only by the ascites but also by the huge liver. Resps are shallower than normal and CO2 clearance is decreased. And INR is a sensitive measure of liver function since the liver is where many clotting factors are synthesized.

#5) Remember that spasticity increases metabolic rate as do seizures, so an elevated temperature isn't always indicative of infection. Positioning is the BIG thing for these kids, as you've noted. You may have to be very creative with pillows, rolls and other items to keep them in good alignment. Spastic diplegia affects the lower limbs, so hips, knees and ankles need cushioning. There's also a high risk for friction related to spastic movements. Avoid rapid position changes, especially of the lower limbs, to decrease reflexive spasticity. Wherever possible you want to make use of the child's own orthoses to help with positioning. Head of the bed elevation for VAP prevention is a challenge too. Make sure you ask the family what positions he likes best and if there are any tricks to help him be more comfortable.

#6) Dingdingdingdingding! It may be standard practice on the unit where you're interviewing to feed all patients via NJ tube, even in the presence of a G-Tube. (Our unit almost never uses gastric feeds for our kids, intubated or not.) If an NJ will be used, feeds will have to be continuous. Even for a kiddie like this, continuous feeds might be best while in hospital. You're quite right about the rate of feed being too fast and that the precipitating event was probably aspiration.

My comments are purely for additional information. I think you answered well enough that you'd be viewed quite positively in your interview. (Although I'd like you to think about the Norwood a bit more. Kids with cardiac defects are admitted to non-cardiac units all the time and you need a bit of awareness of what to do with them.) Strong work!

AnnieOaklyRN, BSN, RN, EMT-P · Feb 4, 2015

Hi Primtime,

Thanks again for all the input. I don't think we will be seeing any heart patients as the number one in the country pediatric cardiac center is about 10 minutes down the road. I guess you never know though.

Here is another question:

I left my ER job in December because I was miserable there. Poor staffing, poor moral, and dangerous nurse to patient ratios consistently, and poor management. I left truly because I did not want to risk my license anymore as it was so dangerously understaffed with both nurses and physicians. I also offered to work 4 hours a week since they were critically low on staffing and they were only willing to take me 8 hours a week as a per-diem, nothing less. So my question is how should I explain this without being negative towards this hospital, as I know that is a big no no during an interview. I left on good terms and gave them three weeks notice.

HPRN

Pediatric Critical Care Columnist · Feb 4, 2015

Fair enough on the Norwood question. (Never give a complex cardiac patient 100% O2... accept sats in the 80s.)

Of course you don't want to overtly criticize the ER you left. That kind of thing reflects more on you than on the bad working conditions in the minds of the interviewers. You could say something like you learned after a reasonably short time that you wanted to have more of a long-term impact on your patients' care than the ER provides, to see the follow-through of sicker patients. You can also say that your experience has shown you that you really enjoy looking after children and families but don't want to completely lose your hard-won critical care skills. You could say that the opportunity to leave the ER on good terms presented itself and then make a little joke about being with family for Christmas.

With all the prep you're doing for this interview, I'll be shocked if they don't hire you.