Case study - Poisoning (pediatric): Nursing

Nurse. Olivia works on a pediatric inpatient unit and is caring for Daisy a two year old who was admitted yesterday for observation after accidentally ingesting acetaminophen in collaboration with the registered nurse, a an Tamika nurse.

Olivia goes through the steps of the clinical judgment measurement model to make clinical decisions about Daisy's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions taking action and evaluating outcomes.

First, nurse, Olivia recognizes important cues including Daisy's vital signs which are temperature 98.6 °F or 37 °C heart rate 118 BPM, respiratory rate, 27 breaths per minute and BP.

92/52 of nurse Olivia notes Daisy is pale and is restless at times but easily consoled by Ellen her caregiver. Nurse, Olivia determines Daisy's pain rating is three out of 10 according to the face legs, activity, cry and consolability or flak scale.

Gentle abdominal palpation reveals no tenderness which is consistent with RN Tamika's previous assessment. Next, nurse Olivia analyzes these cues.

She reviews the electronic health record or EHR and learns that prior to admission, Daisy consumed an unknown quantity of acetaminophen pills while Ellen was busy preparing dinner.

After counting the remaining pills in the bottle, Ellen realized Daisy ingested about 13 pills and immediately contacted poison control who told her to bring Daisy to the emergency department.

Nurse Olivia notes that Daisy's weight is 12.7 kg or 28 lbs. She also knows that the toxic dose of acetaminophen is 150 mgs per kilogram in Children.

And since Daisy ingested 13, 160 mg pills, she exceeded the toxicity level for her age and weight. Nurse Olivia recognizes that an overdose of acetaminophen can cause hepatotoxicity.

And the clinical course progresses over time based on Daisy's presentation and history of acetaminophen ingestion. Nurse Olivia determines that Daisy needs effective management of her acetaminophen poisoning to prevent hepatic injury.

Using the information she's gathered. Nurse Olivia reports her findings to RN Tamika.

And together they select a priority hypothesis of risk for impaired liver function. Then nurse Olivia collaborates with RN Tamika to generate solutions to address this problem and they established the expected outcome that after intervening Daisy will show no signs of hepatic injury.

Nurse Olivia then takes action to implement these solutions. She reviews the EHR and notes Daisy's serum acetaminophen level is elevated and her liver enzymes are normal.

She also sees that RN Tamika has administered Daisy's third scheduled dose of intravenous N acetylcysteine, which is the antidote for acetaminophen poisoning and it's infusing along with continuous fluids to maintain hydration.

Nurse Olivia re enter the room to check on Daisy and Ellen, she notes Daisy is napping comfortably in the bed. Holding Ellen's hand, Ellen.

How are you doing? I'm ok.

I was so scared. I don't want this to happen ever again.

I understand that must have been very frightening when you're ready. We can review the prevention strategies.

Nurse Tamika went over with you earlier. Yes, that would be great to do while Daisy is sleeping.

I've been so stressed. It was hard to concentrate on new information that's understandable to prevent this from happening in the future.

It's important to keep all medications locked out of Daisy's reach like in a high bathroom cabinet or you can install childproof locks on the cabinet doors.

Also after taking medications yourself, remember to replace the childproof cap before engaging in other tasks. It's also important to avoid referring to any medicine as candy as this can make young Children more interested in taking them on their own.

Ok, I will be more careful in the future. Thank you for helping us.

You are welcome. Nurse Olivia then exits the room to update RN Tamika about Daisy's condition and they contact poison control to provide an update about Daisy's response to treatment.

Later at the end of her shift, nurse Olivia evaluates the outcomes of her actions. She checks the EHR and sees that Daisy's latest liver enzyme results remain normal and her acetaminophen level is undetectable then she takes Daisy's vital signs which are temperature 98.9 °F or 37.2 °C, heart rate, 98 BPM, respiratory rate, 22 breaths per minute and BP, 102/60 millimeters of mercury.

Nurse, Olivia sees that Daisy appears comfortable, relaxed and is sitting up in the bed drinking from a juice box. Nurse, Olivia determines that Daisy hasn't experienced signs of hepatic injury.

All right. As a quick recap, nurse, Olivia recognized and analyzed cues related to Daisy's risk for impaired liver function and in collaboration with RN Tamika prioritized hypotheses and generated solutions to address this problem.

Nurse Olivia then implemented measures to manage Daisy's acetaminophen poisoning and evaluated outcomes comparing them to the expected outcome since Daisy didn't experience signs of progressing hepatic injury.

Nurse Olivia determined that the plan of care was