MRN: 4639700 Room: 249 Health Care Provider: B Scott, MD Aaron Jackson
Case Study MRN: Room: 249 Health Care Provider: B Scott, MD Name: Aaron Jackson Sex: M Weight: 16 lbs 9 oz Age: 9 M Height: 2' 4" BMI: 14.9 Code Status: Full code Hospital Floor: Pediatric Isolation: none Food Allergies:NKA Drug Allergies:NKA Aaron Jackson is a 9-month-old male diagnosed with Hirschsprung disease when he was 2 months old, at which time he received a colostomy. He was seen in the emergency department 8 hours ago due to increased output from his colostomy. Aaron was then transferred to the medical-surgical unit for further evaluation at 1400. Aaron Jackson is a 9-month-old male with a history of Hirschsprung disease with colostomy placement. Aaron's mother noticed that Aaron's appetite seemed to have decreased over the past 48 hours. Additionally, Aaron's colostomy was emitting more waste than normal and the consistency was like water. Ms. Jackson became concerned and brought the patient to the emergency room earlier today. The emergency room was extremely busy. Aaron Jackson did not have any labs drawn and no medication was administered. Aaron was admitted to the medical-surgical unit several hours later for further evaluation. Aaron was hospitalized 6 weeks ago for a similar issue. At that time, he was diagnosed with dehydration. Otherwise, he is healthy. Patient Chart Patient Monitoring Chart Time Mon 14:00 Temperature (F) 98 Pulse (Beats/min) 120 Respiration (Resp/min) 32 Blood Pressure (mmHg) 85/52 Oxygen Saturation (%) 92 Pain: Mon | 16:00 FLACC pain level: 3 Problem List Medical Diagnosis: Primary Diagnosis: Hirschsprung disease Secondary Diagnosis: Ostomy Active Invasive Items IV Lines: Mon | 14:00 Left Dorsal Venous Arch (Hand) Peripheral ORDERS Mon 14:00 1. Admit patient to pediatric unit. 2. Patient is a full code. 3. Monitor vital signs every 4 hours 5. Dextrose 5% in 1/2 normal saline with 20 mEq potassium chloride per 100 mL IV to run at 32 mL/hr if urine output less than 1 mL/kg/hr or intake less than 32 mL/hour in four hours. 6. Notify provider if stool output is greater than 20 mL/kg. History and Physical Patient Information Chief Informant: Lakeisha Jackson, Mother Chief Complaint: Increased ostomy output and decreased appetite History of Current Problem: Diagnosed with Hirschsprung Disease at 2 months of age. Received a colostomy at this time. No other pertinent medical history. Allergies: NKDA Family History: Mother has hypertension. Past Medical History Birth History (pregnancy, labor, delivery, perinatal history): Born via cesarean section at 38 weeks because of mother's worsening hypertension. No complications at birth. Previous Illnesses: Hospitalized 6 weeks ago for dehydration Contagious Diseases: None Injuries or Trauma: None Surgical History: Colostomy at 2 months of age Dietary History: Breast milk supplemented with formula and soft foods; rice cereals, chewables Current Medications Current Medications: None Activities of Daily Living (ADLs) Sleep: 8 hours at night with a 2 hour nap during the day Exercise and Activities: Slightly delayed, just now sitting up on own Elimination of Stool and Urine: Stool is usually green and foul smelling from colostomy, normal urinary tract Safety Assessment and Issues:Nothing remarkable Mon 14:00 Patient was seen in the emergency department for increased ostomy output and decreased appetite. Patient was monitored for 2 hours and is stable. No interventions completed. Admitting patient to the pediatric floor for further observation, evaluation, and rehydration. MAR / Large Volume Intravenous Order Start: Mon 14:00 Order Stop: Sun 23:59 Rate: 32 ml/hr Frequency: Continuous Dextrose 5% in 0.45% Sodium Chloride with Potassium Chloride 20 mEq/1000 mL (D5 1/2NS with 20 mEq KCL/1000 mL) Phase 1 Monday 18:15 Aaron Jackson arrived on the unit a few hours ago after being transferred from the emergency department. The nurse manager performed the admission assessment. You have just come on shift and received report. You go to the patient's room to meet him and his mother and to take vital signs and perform an assessment. You perform double identifiers of the patient and ask permission to perform an assessment. Ms. Jackson states, "It's fine for you take vital signs, but can you please wait to perform an assessment? Aaron is worn out and is sleeping so soundly that I hate to wake him." You reply, "Yes, that's no problem. I'll take his vitals and come back later to perform the assessment. May I get you anything while I'm here?" Ms. Jackson says, "Thank you, honey, but I'm ok right now." Vital Signs: Temperature: 99.8 degrees Fahrenheit, tympanic... Heart Rate: 130, radial... Respirations: 34, even, unlabored... Blood Pressure: 90/60 mmHg, right arm, supine using a manual cuff... Oxygen Saturation: 95% via room air per finger probe... Phase 2 Monday 18:35 Ms. Jackson calls you and states, "Aaron is awake now. You may come back in the room to see him." You gather venipuncture supplies and enter the room, perform hand hygiene, and introduce yourself to Aaron Jackson. You tell the patient that you're just going to check him over. Aaron Jackson has a 24-gauge IV in his left hand that was inserted in the emergency department. It is secure and dressed with a transparent dressing. You flush the IV and it is patent. The site looks clean and dry; there are no signs of redness or swelling. The patient does not seem bothered by his IV or your intervention. Aaron Jackson's physical assessment is unremarkable except for his gastrointestinal focused assessment. The mouth/gums/teeth are in good condition. His abdomen is round but tender with light palpation. His tenderness is generalized. Bowel sounds are hyperactive. He is incontinent with a colostomy present in his right inguinal region. It currently has a small amount of loose, green, watery, foul-smelling stool in the bag. The stoma appears to be pink with a little swelling. The peri-stoma area is red. Ms. Jackson denies that the patient suffers from any nausea or vomiting, but she does say he has reflux issues sometimes after he eats. Aaron Jackson does not have any rectal problems. He tolerates your assessment well. You explain to Aaron Jackson's mother that no labs were ordered in the emergency department and Dr. Scott would like you to draw a BMP, CBC, CRP, and collect a stool sample. Ms. Jackson asks, "What does this test for?" You state, "It looks at his electrolytes, blood counts, and checks to see if there is an infection or to see if Aaron may be dehydrated." Ms. Jackson understands and allows you to draw the patient's blood. You perform hand hygiene and put on clean gloves. You collect blood from Aaron Jackson's right hand on your first attempt. You need to walk out of the room to send the blood to the lab. You tell the patient and his mother that you will be right back to collect his stool sample. Mrs. Jackson says, "Oh, wonderful. It is time for his colostomy bag to be emptied and changed anyway." 1- Document the patient education You go back in the room as promised to change and empty the colostomy bag and collect the stool sample. You perform hand hygiene and put on clean gloves. Upon assessment, you find the bag is leaking and the seal is no longer intact. You decide it is best to change the bag. You ask Aaron Jackson's mother if she would prefer to change the bag, or if she would rather you do it. She answers, "Could you please do it?" You empty the bag into the stool specimen container and discard the rest. Aaron Jackson has a total of 150 mL of loose, green, watery stool inside. You provide ostomy, stoma, and skin care and replace the bag. The stoma still appears to be pink with a little swelling and the peri-stoma is also reddened. The patient tolerates the procedure well. 2-Chart a Nursing note of your care you just completed. 3- Document the patient's ostomy output in ML While you are collecting the stool sample, Ms. Jackson tells you that she just lost her job and that she is very worried about how to care for Aaron since she is a single mother. Ms. Jackson laments that her health insurance will run out eventually and if she doesn't find a new job soon, she doesn't know how she'll manage. You ask a co-worker to send the stool sample so that you can continue to talk with Ms. Jackson. You listen very carefully to Ms. Jackson and state, "I'm so sorry this is such a stressful time for you. I can see that your plate is very full. Would you like for me to call the social worker to come talk to you about this further? She may be able to help you identify some community resources that can help. She is also great with parents and can help you with problem-solving." Ms. Jackson states, "Yes, I'd like that. Thank you." You ask, "Is there anything else I can do for you right now?" Ms. Jackson stated, "No, thank you." You leave the room to call the social worker. 4- Document your discussion with Ms. Jackson in a Nursing Note.] Phase 4, Monday 1900 The call button is pushed by Ms. Jackson. You respond. Ms. Jackson states, "I think my son is in pain." You say, "I will be right there." You go to Aaron Jackson's room to meet him and his mother and to take vital signs and perform a pain assessment. You perform double identifiers of the patient and ask permission to perform the assessment. Ms. Jackson agrees and you begin by gathering vital signs. Vital Signs: Temperature: 101.1 degrees Fahrenheit, tympanic... Heart Rate: 175, radial... Respirations: 44, even, unlabored... Blood Pressure: 110/75 mmHg, right arm, supine using a manual cuff... Oxygen saturation: 95% via room air per finger probe... After you obtain his vital signs, you notice that Aaron Jackson's legs are drawn up and he seems tense. He is withdrawn and uninterested. He is difficult to console and is crying. His face grimaces when you touch his belly. You tell Ms. Jackson, "I agree with you. He looks like he is in pain and he has a fever. Let me got look at his chart to see if anything has been ordered for pain." "Thank you so much. Tylenol usually works very well for him," Ms. Jackson states. "I will go look at his chart and return shortly," you say. 6- Document your pain assessment Phase 5 Monday 20:55 You look at his MAR to see if there is any pain medication ordered. You notice there are no medications listed. At this time you also notice that some of the lab results (partial results) from earlier in the evening are now available. BMP Calcium 8.6 Cholride 106 Glucose 60 Potassium 5.2 Sodium 135 CBC Hemoglobin 10 Hematocrit 32 WBC 20,000 Platelet Count 200,000 CRP C- reactive Protein - 15 7- Are there any abnormal labs and if so what do you think they mean? List any possible interventions? You decide to call the provider to get some pain medication and tell her about the lab results and the patient's fever. You page Dr. Taylor. Using SBAR communication, you inform her of your findings. She provides you with new orders. 8- Document your SBAR communication with the patient's provider.] S B A R You decide to call the provider to get some pain medication and tell her about the lab results and the patient's fever. You page Dr. Taylor. Using SBAR communication, you inform her of your findings. She provides you with new orders. 1. Acetaminophen oral solution 10 mg/kg every 4 hours PRN for pain 2. Vancomycin IV solution 10 mg/kg every 8 hours, first dose now 3. Gentamicin IV 7.5 mg/kg every 24 hours 4. Gentamicin peak after third dose and trough before fourth dose 5. Kidney, ureter, and bladder (KUB) x-ray to evaluate bowel 6. Blood culture 7. Urine culture You gather the Tylenol and vancomycin from the pharmacy. You take the medications into Aaron Jackson's room. You perform hand hygiene. Ms. Jackson asks, "What medications do you have?" You answer, "Tylenol and vancomycin." "He has had Tylenol before, but I do not know what vancomycin is," she states. You explain to her, "Some of Aaron's lab work came back and it showed that Aaron has an infection. He did not have any antibiotics ordered, so I called Dr. Taylor. She ordered vancomycin. I will be happy to tech you about vancomycin if you would like." "Yes, I would like that. Thank you," Ms. Jackson says. 9- Document your education on Vancomycin to Ms. Jackson Using the 5 rights of medication administration you give Aaron Jackson the Tylenol orally and then the vancomycin in the patent 24-gauge left hand IV that is already in place from the emergency department. The site and dressing are clean and dry and the patient tolerates the assessment well. Thirty minutes later, you go back in the room and ask permission to reassess his pain. You perform double identifiers and start your assessment. The patient is resting comfortably in a normal position. His lets out an occasional cry, but is quickly calmed by his mother. He does have an occasional grimace. 10-Document your new FLACC pain assessment findings.] 11- Your Shift is now over, Using an SBAR report to the oncoming nurse S B A R
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Seminole State College
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MRN: 4639700 Room: 249
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- July 28, 2021
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mrn 4639700 room 249 health care provider b scott
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aaron jackson is a 9 month old male diagnosed with hirschsprung disease when he was 2 months old
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at which time he received a colostomy he
