Case study - Poisoning (pediatric): Nursing

Nurse Olivia works in a pediatric inpatient unit and is caring for Daisy, a 2-year-old who was admitted yesterday for observation after accidentally ingesting acetaminophen. In collaboration with the registered nurse, RN 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 beats per minute, respiratory rate 27 breaths per minute, and blood pressure 92/52 mmHg. 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 3 out of 10 according to the Face, Legs, Activity, Cry, and Consolability, or FLACC, 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 kilograms, or 28 pounds. She also knows that the toxic dose of acetaminophen is 150 milligrams per kilogram in children, and since Daisy ingested 13, 160 milligram 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 establish 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-enters the room to check on Daisy and Ellen. She notes Daisy is napping comfortably in the bed holding Ellen’s hand.

Nurse Olivia: Ellen, how are you doing?