Pediatric Concept Map

Pathophysiology

A.R was admitted to the hospital with a diagnosis of acute Croup. Croup, also known as laryngotracheobronchitis and laryngotracheitis, can be considered an upper and lower respiratory infection that is typical cause by Human Parainfluenza Virus (hPIV) (Ricci, Kyle, & Carman, 2017). The most common serotype of HPIV that causes Viral Croup is hPIV-1. This subset of the parainfluenza virus is an animal virus that is a non-segmented single-strand RNA genome (Pawełczyk &Kowalski, 2017). Due to the structure of this virus it initially replicates itself in the respiratory epithelial cells, which infect the nose and nasopharynx (Mejias & Ramilo, 2018). These anatomical areas result in a perfect breeding ground for this virus to replicate. Replication of this virus causes proinflammatory and tissue remodeling cytokines to be released, resulting in prolonged inflammation and edema of the upper respiratory structures (Mejias & Ramilo, 2018). Additionally, the damage to the epithelial cells in the upper airway, causes an increase in mucus production furthering airway obstruction. Due to the inflammation, edema, and increase mucus production in the larynx and trachea, the patient will present with a “barking” cough, inspiratory stridor, and suprasternal retractions (Ricci, Kyle, & Carman, 2017). Abedi et al. (2014) stated “Croup is considered “the signature clinical manifestations” of PIV infections.”

Croup

Typically, there are no true identifying lab results that lead to the diagnosis of Croup. This condition is normally diagnosed through patient assessment and clinical presentations during the time of infection. For patient A.R. the only diagnostic test that was completed was a chest and neck x-ray. However, there are other diagnostic testing that can be done that would help with treatment and diagnosis of Croup patients. All lab value normal ranges are specific to children ages 1-3 years old

Chest/Neck X-ray:

R.A.’s chest/neck x-ray was positive, showing narrowing of the of the upper trachea also known as the “steeple sign” which is consistently found in children with Croup. All lobes bilaterally showed no infiltrations, narrowing, or abnormalities.

RT-PCR (reverse transcription polymerase chain reaction):

Could be positive for the presence of the viral genome consistent with fHPIV-1 infection. This is a specific test that can determine the different subtypes of Parainfluenza viruses.

Viral Culture (nasopharyngeal aspirate):

Using immunofluorescence of a nasopharyngeal swab could show the presence of viral antigens in the respiratory secretions, showing that the infection was viral and not bacterial. This helps direct the plan of care for the patient by not administering antibiotics and basing care through treating the patient’s symptoms.

White Blood Cell Count (serum): Children age 1-3; Normal 5,000-10,000/mm3

Patient WBC count could be elevated, showing that there is an infection present. This test does will not delineate between a viral or bacterial infection, but an increase in WBC count would be present with a patient who has a parainfluenza viral infection.

White Blood Cell Differential (serum):

Neutrophils (total): Normal 50-70%; Patient with viral Croup could have increased serum levels of total neutrophil count which indicates an acute infection.

Neutrophil (Bands): Normal 5-11%; Patient with viral Croup could have increased total band present in blood serum.

Neutrophil (Segments): Normal 13-33%; Patient with viral Croup would have an increased serum level of segments due to the body’s reaction to presence of a viral infection.

Pulse Oximetry (O2%):

Normal 94-100%; Children with sever Croup can present with decreased oxygen saturation resulting in lower levels during pulse oximetry diagnostics. If levels can not be increased with the use supplemental oxygen, additional arterial blood gas (ABG) levels may need to be done to determine true oxygenation status. A.R. present with pulse oximetry levels between 98-99% on room air, so there would be no need to obtain ABG levels.

Labs

Neurological:

Patient was awake and alert when nursing staff was present in room. Was able to obey commands by the nursing staff or his mother. Verbal responses were limited to incomprehensible words which showed some developmental delays for his age. Mother noted that he only says two or three words at home. PERRLA was noted, and motor function was appropriate for his age. Patient was shy and showed stranger anxiety when staff was in the room which is developmentally appropriate for his age.

Cardiovascular:

Heart rhythm was typically normal sinus and would occasionally have sinus tachycardia. S1 and S2 were heard during auscultation. Radial and pedal pulses were easily palpable. Capillary refill on toes and finger nails were less than two seconds.

Respiratory:

Breath sounds were clear bilaterally during auscultation, with equal rise and fall of the chest. A.R presented with increased work of breathing that was noted by inward movement of the sternal bone, increased respirations, and skin sucking in between the ribs during inhalation. Additionally, inspiratory stridor was audible without auscultation when patient would cry or become agitated. Stridor would resolve once the patient calmed down and was not present during sleeping. Trachea was midline. Patient presented with a “barking” cough that did not produce any mucus. A.R. presented with congestion, runny nose, and watery eyes, which is consistent with an upper respiratory infection.

GI/GU:

Patient had active bowel sounds in all four quadrants. Stomach was soft, round, and non-tender when palpated. Patient stooled at 08:30 and had regular wet dippers resulting in 250ml output for the 8 hours shift. Patient had an appropriate appetite for his age and was able to consume fluids orally resulting in 200ml intake during the 8-hour shift.

Skin:

Skin was dry and intact with no signs of breakdown. Mucus membranes were pink and moist with a little redness under the nostrils due to increased mucus secretions, and the needing to clean the nares.

Musculoskeletal:

Patient weight was appropriate for his age, weighing 14.5 kg. Patient’s grip strength was appropriate for his age. A.R. was able to walk appropriately for his age, with no notable issues with his gate. His facial structures and extremities were symmetrical to his body. Both anterior and posterior frontalis were closed. Patients gross motor and fine motor skills were appropriate for his age.

Vital Signs:

V/S (08:00): Temperature: 98.5 degree Celcius BP: 116/80, HR: 140 RR: 28 O2: 98% on room air

V/S (12:00): Temperature 98.9 degree celcisu BP: 105/ 75 HR: 120 RR: 25 O2: 99% on room air

Assessment

A.R.'s Admitting Information

Patient Information

• Patient A.R. is a 2 year old Hispanic male.
• Brought to Banner Emergency department by his mother on 9/14/2019 at 21:00 with difficulty breathing.
• A.R. was given 2 doses of Resmic Epi and Dexamethasone in the Emergency Department and on D5 .
• A.R. has been admitted to Banner Medical Center three times for Croup within the last year.
• Patient was admitted to the Pediatric Medical Surgical Unit (D5) for observation.
• Patient has no additional medical history.
• Code weight 14.5 kg
• Full Code
• No Known Allergies

Nursing Dx #2

Nursing

Diagnosis

#2

Family process, altered, related to child’s illness, multiple hospitalizations, and single parent house hold, as evidence by family presence in the hospital, A.R.’s mother stating, “I need to go to work, I have already missed to many shifts” and the patient's mother stating, “I am the primary care taker of A.R., I also get help from my mother who lives close to me.”

Nursing Dx #1

Ineffective airway clearance related to inflammation and edema of larynx, as evidence by tachypnea (increased respirations), inhalation stridor during times of agitation, and increased work of breathing (retractions).

Nursing

Diagnosis

#1

STG #2

Patient will exhibit reduced work of breathing within three days, that is evidenced by the absence of retractions and increased respirations during times of agitation.

Short Term Goal #2

Intervention

Evaluation

The nurse will educate the family members about keeping the patient calm by reading him a book or sing to him to help reduce their anxiety and prevent episodes of crying that can increase the patients WOB (Wood, 2019).

This goal was not met becasue the patient was discharged the same day. However, due to his postive progression I would assume he would be able to meet this goal

STG #1

Patient will maintain a patent airway throughout the 12-hour shift that is evidenced by clear breath sounds.

Short Term Goal #1

Intervention

Evaluation

The nurse will educate the family members about keeping the patient in a Semi-Fowler position to help maintain a patent airway (Wood, 2019).

The intervention for this patient was effective which was evidence by the pateint have an O2% of 98% on room air, have not additional symptoms of airway obstruciton, and remaning calm throughout the 12-hour shift.

LTG #1

Long Term Goal #1

Patient will see an ENT specialist and obtain an appointment to have bronchoscopy procedure to evaluate any anatomical or physiological problems with their upper or lower airway that could be causing recurrent Croup infections, within one month, evident by the patient’s mother verbalizing that she has made the appointment.

Intervention

Evaluation

The nurse will use members of the interdisciplinary team, case management, to help the patient’s mother obtain an appointment with a pediatric ENT specialist for further evaluation of the patient’s recurring Croup infections (Wright & Bush, 2016).

The goal was partially met due to the pateint's mother verbalizing during discharge that she had scheduled an appointment with the ENT specalist within the next two weeks. However, due to the patient being discharged I am unsure if he was able to have the bronchoscopy procedure. However, I would assume that this would be schedule once the patient was seen by the ENT specalist.

STG #1

The patient’s mother will be able to go to work without feeling stressed during the rest of the 12-hour shift.

Short Term Goal #1

Intervention

Evaluation

This goal was partially met. The patients mother was able to go to work for a half shift, but came back to the hospital since the patient was being discharged and that she wanted to be present during that time.

The nurse will encourage the patient’s mother to discuss her concerns to ensure that her needs are being met and that she feels comfortable with leaving her child, so she can go to work (Franck, Ferguson, Fryda, & Rubin, 2015).

LTG #1

Patient will be Croup free for one year to ensure that the family process is not altered, and the mother is able to work her regular schedule, that is evidenced by no re-hospitalizations within that year.

Long Term Goal #1

Intervention

Evaluation

This goal was not meet due to the goal being established over a year. However, due to the patient's mother being attentive during discharge, and being proactive with scheduling the ENT appointment, I would assume that this goal would be met within the time frame given.

The patient’s mother will be educated about ways to reduce the risk of infection to her son, such as: proper hand hygiene, having all members of the family get the flu vaccine, and limiting the time her son spends around individuals who have upper respiratory infections (Woods, 2019).

STG #2

The patient’s grandmother will be present at bedside throughout the remainder of the 12-hour shift to ensure that the patient stays calm and comfortable.

Short Term Goal #2

Intervention

Evaluation

The nurse will ensure that there are appropriate accommodations in the patient’s room, such as a sofa, reclining chair, and extra blankets to establish a comfortable and quite setting for the patient and their family members (Franck, Ferguson, Fryda, & Rubin, 2015).

This goal was met, due to the grandmother coming to the hospital to stay with the patient until he was discharged. Additionally, the patinet did not have any additionl tatrums during the shift, which is evidence that the intervention was effective.

STG #1

Short Term Goal #1

Patient’s mother will be ready for education by the end of the 12-hour shift regarding ways to seek resources to help improve the patient developmental language delay.

Intervention

Evaluation

This goal was met due to the patient's mother being present during discharge and being able to verbalize that she was going to setup an appointment with AZIP, which can help her son wiht his developmental delay.

The nurse, with the help of case management, will educate the patient’s mother about Arizona Early Interventions Program (AzEIP) and use the teach-back method to ensure the mother has learned about how this program can help her son (Khetani, Richardson, & McManus, 2017).

LTG #1

Long Term Goal #1

The patient will continue to progress towards developmental milestones for his age within 1 year that is evidenced by him speaking 50 words and verbalizing 3-word sentences.

Intervention

Evaluation

The nurse and case manager will educate the patient’s mother on how to obtain early intervention (EI) services from a speech therapist once the patient is discharged to help her son progress towards age appropriate developmental milestones (Khetani, Richardson, & McManus, 2017).

This goal was not met due to it being a long term goal. However, I would assume that he would be able to meet this goal in the time given due to his mother being proactive in wanting to get him help. Additionally, I feel this goal would realistically be met is due to the fact that the patient's mother had already made an appointment with AZIP to have her son evaluated for his language delay.

STG #2

The patient will be able to say one word to the nursing staff within 24-hours of being hospitalized.

Short Term Goal #2

Intervention

Evaluation

The nurse will use therapeutic communication when talking to the patient’s family member to help model age-appropriate communication, as well as to ensure the patient feels comfortable around the nursing staff (Feraco et al., 2016).

This goal was met as evidenced by the patient saying "goodbye" to me and the nurse I was precepting with, after we had finished giving his mother the discharge paperwork.

Nursing Dx #3

Delayed development, related to language, as evidence by not meeting expected milestones for current age, such as: patient not speaking coherent words to nursing staff, and patient’s mother stating, “he has only been able to say two or three words.”

Nursing

Diagnosis

#3

Dexamethasone (DexPack):

Pharm Class: Steroidal anti-inflammatory

Action: This medication reduces the inflammatory and immune response in individuals with upper respiratory infection.

Dose (children): PO- 0.5-2 mg/kg/day divided q 6 hours per doses.

A.R. revived one does at 3.625mg/ 3.625ml Oral Solution in the emergency department.

Specifically, for A.R.’s diagnosis of Croup, this medication will help reduce the inflammation in the larynx and trachea helping to reduce work of breathing and help facilitate inspiratory oxygenation to the lungs.

Racemic Epinephrine: Combination of dextro-epinephrine (1.125%) and levo-epinephrine (1.125%)

Pharm Class: Adrenergic and Vasopressor

Action: Has alpha adrenergic agonist properties that causes beta-adrenergic receptors to vasoconstrict the blood vessels in the upper airway reducing edema of the laryngeal mucosal. Also causes bronchodilation and relaxation of the laryngeal muscles to help reduce airway obstruction. This is effective for Croup patients because it will reduce stridor, WOB, and help facilitate oxygenation to lungs.

Dose (inhalation nebulizer): Children <4 years of age; 0.5ml of 2.25% solution diluted in 3ml normal saline q 4 hours.

A.R. received 1 dose (as stated above) in the emergency department at 21:48 and then another does 02:00 during admission to the D5 pediatric department.

Normal Saline (0.9% sodium chloride)

Pharm Class: mineral and electrolyte isotonic crystalloid solution.

Action: Acts a similar to the concentration of fluid in the intervascular space, allowing for an appropriate balance between the concentrations of the intercellular and extracellular compartments of the body, resulting in homeostasis.

Dose (IV): Dependent on child’s weight: Formula used is 100ml/kg for first 10kg, 50ml/kg for next 10kg, 20ml/kg for remaining kg’s, add total ml's and divide by 24 hours to get ml/hr.

A.R. did not need intravenous fluid resuscitation because he was able to ingest fluids orally. However, children who present with sever croup are at risk for aspiration as well as not being able to tolerate oral intake. Therefore, IV fluid resuscitation would be necessary to ensure an adequate hydration status.

Medications

References

Abedi, G. R., Prill, M. M., Langley, G. E., Wikswo, M. E., Weinberg, G. A., Curns, A. T., & Schneider, E. (2014). Estimates of Parainfluenza Virus-Associated hospitalizations and cost among children aged less than 5 years in the United States, 1998–2010. Journal of the Pediatric Infectious Diseases Society, 5(1), 7-13. doi:10.1093/jpids/piu047

Feraco, A. M., Brand, S. R., Mack, J. W., Kesselheim, J. C., Block, S. D., & Wolfe, J. (2016). Communication skills training in pediatric oncology: Moving beyond role modeling. Pediatric Blood & Cancer, 63(6), 966-972. doi:10.1002/pbc.25918

Franck, L. S., Ferguson, D., Fryda, S., & Rubin, N. (2015). The child and family hospital experience: Is it influenced by family accommodation? Medical Care Research and Review, 72(4), 419-437. doi:10.1177/1077558715579667

Khetani, M. A., Richardson, Z., & McManus, B. M. (2017). Social disparities in early intervention service use and provider-reported outcomes. Journal of Developmental & Behavioral Pediatrics, 38(7), 501-509. doi:10.1097/dbp.0000000000000474

Mejías, A., & Ramilo, O. (2018). Parainfluenza viruses. In Principles and Practice of pediatric infectious disease (5th ed., p. 1152). Retrieved from https://doi.org/10.1016/B978-0-323-40181-4.00223-1

Pawełczyk, M., & Kowalski, M. L. (2017). The role of human parainfluenza virus infections in the immunopathology of the respiratory tract. Current Allergy and Asthma Reports, 17(3). doi:10.1007/s11882-017-0685-2

Ricci, S. S., Kyle, T., & Carmen, S. (2017). Maternity and pediatric nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.

Wood, C. R. (2019). Patient education: Croup in infants and children (Beyond the Basics). UpToDate. Retrieved from https://www.uptodate.com/contents/croup-in-infants-and-children-beyond-the-basics#H21

Wright, M., & Bush, A. (2016). Assessment and management of viral croup in children. Prescriber, 27(8), 32-37. doi:10.1002/psb.1490

References

By:

Joshua Berger