This is an offshoot of another thread that strayed far off its path.
I will be posting questions that spring from situations I see on my quaternary level PICU to test your knowledge of critical care topics that apply to children. As we know, children are not small adults and the reasons they are admitted to ICU are very different from those of adults. For example, PICUs see virtually NO life-style related comorbidities such as COPD from a 2 pack-per-day cigarette habit, cardiovascular disease from a 10 Big-Mac-per-week habit or end-stage cirrhosis from a 6-drink-per-day habit. Congenital anomalies, trauma (accidental and non-accidental), metabolic disorders, ingestions and respiratory infections are our biggest offenders.
Question #1:
Name the 4 main treatments for JET (junctional ectopic tachycardia).
Specializes in NICU, PICU, PCVICU and peds oncology.
Jan, I love these posts...but gosh as a second year student, I dont understand this all..I feel like I'm lacking putting everything together..
I'm sure it seems like so much gobbledegook to you right now and I wouldn't expect you to be able to make much sense of these scenarios. One thing they will do for you though is help you to really understand anatomy and physiology. Nursing isn't a static state, it's continually evolving as we learn new things, see unusual illnesses, develop new skills and experience life. Being a good nurse partly intellectual (knowledge base and experience), partly psychometric (hands-on skills) and partly instinct.
As I've said many times before, no learning is ever wasted. One day you'll find yourself in a situation where your patient has some sort of issue that you'll recognize from what you've read here or in any of a hundred other threads that will allow you to make suggestions for diagnosis or treatment and that'll be wonderful. For now, maybe you could just concentrate on the individual pieces of the puzzle and not the end result. Think about the A&P in the scenarios. Trying to figure out the rest of it is more than you're ready for right now. Come back in 5 years and reread things - you'll be gratified at how much easier it is to "get it". That you're reading this thread in the first place tells me you're going to go far.
Specializes in NICU, PICU, PCVICU and peds oncology.
Okay, I think I've got one!
You're admitting a patient from one of the medical in-patient units whose working diagnosis is respiratory distress with septic shock. The patient is a 14 year old 60 kg girl whose medical history includes severe recurrent migraine. She had presented to the ED two days previous with a sore throat and fever. Since admission, her sore throat has worsened, her oral mucosa is bright red with denuded areas on her tongue. She has a number of erythematous blisters on her face and trunk. Her temperature has remained >38.5 despite adequate doses of both acetaminophen and ibuprofen. BP has been trending down and now is 82/40 following a 1 L Plasmalyte fluid bolus. Blood cultures have so far been negative.
Her medicine reconciliation form from the ward reads:
piperacillin-tazobactam 2.25 g IV q6h
ciprofloxacin 200 mg IV q12h
methylprednisolone 30 mg IV q6h
chlorhexadine mouthwash 30 mL swish-and-spit q4h and prn
bacitracin ung topically to affected areas QID
carbamazepine extended release 100 mg PO q12h
Your primary survey reveals an ill-appearing mildly obese aboriginal girl. She has multiple blistered areas on her face, including the margins of her eyelids, nares and lips; many of the blisters have deroofed and are oozing clear fluid. Her respiratory rate is 40, sats on 2 L per nasal cannula 93%; you note accessory muscle use, nasal flaring, tracheal tug and a mild grunt. She has two peripheral IVs infusing. You establish cardiorespiratory monitoring and note large, irregular, purplish bullous lesions on her chest and back. When moving the neck of her gown aside, the ties rubbed against the side of her neck. Within minutes, the rubbed area has also blistered.
What clues do you have that will help determine what is happening with this girl?
What do you anticipate doing for her in the coming hours?
What new medications do you anticipate adding to her treatment plan?
Intractable temp, resp. distress and nonpurulent, contact blistering. Have you gotten an LP? Hm, the Zosyn.. um...PCXR. CBC. First have to stabilise respiratory to get rid of secondary symptoms. What's the immunization history? Consider Tegretol hypersensitive, Penicillin hypersensitive. Really need a good med history.
Tegretol and Medrol need to be reconciled. I have no idea; you totally just blew my mind.
It almost sounds like a severe allergic reaction, and the respiratory/septic appearing decline could be a result. What are her allergies? What does her CBC look like?
Also, I would have the docs wean the Tegretol and switch to something else for the migraine control. I'd probably ask for some hydrocortisone cream for the lesions. What about plasmapheresis?
Specializes in NICU, PICU, PCVICU and peds oncology.
You're both on the right track.
She has no known allergies. CBC shows a mild anemia, elevated WBC with lymphocytosis and normal platelets. BUN is 11.3, creatinine 69. HCO3 is 21.2 and serum glucose is trending upward, now at 240.
In the several hours since her admission, the blistering has worsened and now they're coalescing. They extend over most of her face, head, neck, chest and back. At yuor last pupil check you noted an ulceration of both corneas. She has been intubated and sedated. You have suctioned a quantity of frankly sanguinous secretions from her ETT and note that the tapes are lifting. Dentistry has been consulted to wire the tube to her teeth and plastics is on their way. The NG has drained about 200 mL of dark maroon fluid.
Speaking with her mother, you find that she had been started on carbamazepine for her migraines only 11 days before she became ill. Before that she had been taking propranolol without effect. The evening before her admission to hospital she had been complaining of a sore throat, headache, a mild cough and "not feeling good".
What nursing interventions are you initiating at this point?
What orders do you anticipate from plastic surgery?
Specializes in NICU, PICU, PCVICU and peds oncology.
It could be Stevens Johnson syndrome, but it's not. And you're already giving systemic corticosteroids. You've been given an order to discontinue the carbamazepine. Since it was not being used for seizure control, there's no need for weaning.
NotReady4PrimeTime, RN
5 Articles; 7,358 Posts
I'm sure it seems like so much gobbledegook to you right now and I wouldn't expect you to be able to make much sense of these scenarios. One thing they will do for you though is help you to really understand anatomy and physiology. Nursing isn't a static state, it's continually evolving as we learn new things, see unusual illnesses, develop new skills and experience life. Being a good nurse partly intellectual (knowledge base and experience), partly psychometric (hands-on skills) and partly instinct.
As I've said many times before, no learning is ever wasted. One day you'll find yourself in a situation where your patient has some sort of issue that you'll recognize from what you've read here or in any of a hundred other threads that will allow you to make suggestions for diagnosis or treatment and that'll be wonderful. For now, maybe you could just concentrate on the individual pieces of the puzzle and not the end result. Think about the A&P in the scenarios. Trying to figure out the rest of it is more than you're ready for right now. Come back in 5 years and reread things - you'll be gratified at how much easier it is to "get it". That you're reading this thread in the first place tells me you're going to go far.