Case Study 104



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Case Study 104:
J.H. is a 2-week-old infant brought to the emergency department (ED) by his mother, who speaks little English. She is young and appears frightened and anxious. Through a translator, Mrs. H reports that J.H. has not been eating, sleeps all of the time, and is “not normal”. An obstacle that one needs to consider, recognizing that Mrs. H does not speak or understand English well, is that she may not have access to information in her language about what may be going on with J.H. When someone who does not speak English comes to the ED they need a translator, and this language barrier between the patient and the nurse can be difficult in ensuring that the client understands exactly what is going on. This is especially important when the client is in a scared state like Mrs. H. She is frightened and trying to understand what is going on with her new baby; and the fact that she cannot communicate without a translator may add to her anxiety. Another obstacle that one may encounter in this situation is a cultural barrier. Notice in the case study that Mrs. H only describes the change in J.H.’s eating habits and sleep patterns rather than a physical symptom; she then states that her baby is “not normal” rather than “sick” or “ill”. It is crucial to consider what Mrs. H’s view on health is, and what she believes to be happening to her newborn. She did bring her baby to the ER, so this in itself shows that she most likely believes in Western medicine since she came in for help on her own.

After performing a primary assessment and questioning Mrs. H with a translator, one can report abnormal findings to the ED physician to start evaluating what is wrong with J.H. The infant’s anterior fontanel is palpable and tense, which is not a normal finding. The anterior fontanel is normally palpable, but it should be soft and flat rather than tense. This “tense” feeling may indicate bulging of the fontanel, which may be a sign of increased intracranial pressure, infection, or hemorrhage (Prater, 2013). Some other signs this baby shows of increased intracranial pressure are a high-pitched cry and abnormal feedings. The newborn’s heart rate is also fairly low at 85 beats per minute; a neonate’s heart rate should be between 100 and 160 beats per minute (Prater, 2013); when considering increased intracranial pressure, bradycardia should be recognized as a late stage symptom (Paul, 2013). J.H.’s normal findings include his pupils are equal and +3, his temperature is 36 degrees Celsius rectally, and he has a positive Babinski’s reflex; these are all good signs when considering neurological activity and hydration status, which we are considering because of the possibility of increased intracranial pressure. Mrs. H has refused PO intake, which I would consider to be an “abnormal finding” because I would report this to the ED physician to ensure that medications with other routes of administration are ordered.

From these findings J.H. has been admitted to the medical unit with the diagnoses of meningitis and rule out sepsis. Meningitis is an inflammation of the membranes surrounding the brain and the spinal cord: the dura mater, the arachnoid mater, and the pia mater, which are collectively known as the meninges. Meningitis can be life threatening because the inflammation so close to the central nervous system with increased intracranial pressure. The epidemiology of meningitis reports that the incidence of meningitis in neonates is approximately between 0.25 and 0.32 per 1000 live births (Edwards, 2014). It can be concluded that meningitis is rarely encountered, but there are several risk factors that increase newborns chances of getting meningitis; for example, low birth weight, preterm birth, premature rupture of membranes, fetal hypoxia, maternal infection, newborns with invasive group B streptococcal (GBS) disease, and neonates with bacteremia (Edwards, 2014). One report states that between 2003 and 2007 approximately 4100 cases of bacterial meningitis were reported in the U.S. causing approximately 500 deaths per year, including adults (Caple, 2013).

Meningitis can be caused by various types of pathogens, viral meningitis being the most common type, and bacterial being the more dangerous type. Bacterial meningitis approaches a 100% mortality rate if left untreated which is why it is so important to diagnose and treat the patient as quickly as possible (Richard, 2013). This is especially true for the case of 2-week old J.H., because bacterial meningitis is most commonly seen within the first month of life. The classic signs of meningitis such as neck stiffness and photophobia are not evident in neonates and infants; so, nurses must be on the lookout for nonspecific signs like decreased activity, feeding, abrupt onset of fever, and sleepiness. Infants are at greater risk for systemic disease, progressing to encephalitis with seizures or neurological damage (Richard, 2013). Also, the bulging fontanel which J.H. presented with is usually seen late in the illness, which further stresses the need for speedy treatment (ATI).


The ED physician has ordered CBC with differential, blood culture, complete metabolic panel (CMP), urinalysis (UA), cerebrospinal fluid (CSF) for culture, glucose, protein, cell count (following lumbar puncture), ceftriaxone (Rocephin), 260mg IV now (loading dose), and acetaminophen (Tylenol) 50mg suppository per rectum for irritability. When it comes to prioritizing interventions, I would first place J.H. on contact isolation and droplet precautions to maintain safety, which is of highest priority. Next, I would place an IV so I could have access to quickly take blood cultures and administer IV medications. I would then promptly proceed with obtaining a blood culture and CMP. The IDSA guidelines for treatment of meningitis recommend that antibiotics are ordered to be drawn up while blood cultures are being taken for early diagnosis of the disease. Next, I would straight catheterization for a urine specimen to perform a urinalysis. The HPSA guidelines state that meningitis is a medical emergency and prompt diagnosis and intervention are required. They also state that management priorities differ depending on the clinical presentation and that the quicker the patient receives antibiotics the better the chance of survival (Report of the Scientific Advisory, 2013). Another source states that their facility’s clinical guidelines “specify that patients with suspected meningitis presenting with severe mental status changes, focal neurologic deficits, or rapid deterioration should receive antibiotics within 20 minutes of entering the ED” (Determinants of timely management, 2013). Normally we are taught to perform all diagnostic tests before administering antibiotics; but because starting treatment can double the chance of patient survival and it is recommended in several sources, the antibiotics may be administered before the lumbar puncture is performed to obtain CSF. I would then administer the antibiotics and Tylenol for irritability so the patient is stable and comfortable, and I can assist with the lumbar puncture. A lumbar puncture is necessary for all infants less than 28 days old for the collection of cerebral spinal fluid (Richard, 2013).


Before I administer the ceftriaxone, I would verify the does with another RN. The therapeutic range is 100 mg/kg/day divided into two doses. Since J.H. weighs 3.5kg, this would mean that a therapeutic dose for him would be 350mg/day. The dose ordered, 260mg IV now, is within the therapeutic range; however, I may question this amount as a regular dose because the dose is normally divided into two. So, 350mg divided into two would be 175mg, which is less than the ordered dose of 260mg; however, the dose of 260mg IV that the physician has ordered is a loading dose. This is just a higher dose that is given to start off the medication that will eventually taper off to lower dosages, so it is okay in this situation.

J.H.’s lab results returned with the values from the urinalysis and the complete blood count. The urine pH is 7.2 and the urine is clear with negative leukocytes. These results seem to be normal indicating normal kidney function. The CBC revealed HgB of 10.5g/dL, Hct of 32%, and WBC of 22,000/mm3, and sodium of 125mEq/L. This white blood cell count indicates leukocytes exceeding the range of 4,500-10,000, which is due to J.H.’s infection. According to ATI, newborns leukocytes range from 9,000-30,000, hgB 14-24, Hct 44-64%. Keeping these normal values in mind, we can conclude that J.H.’s HgB and Hct are a little low, and WBC’s are on the higher side of normal. The HgB and Hct indicate that the concentration of red blood cells are low, probably from fluid volume excess. His sodium level of 125 is a little below the normal range of 135-145 as well, which may also be from the body retaining too much fluid and causing dilutional hyponatremia. I had a difficult time interpreting these results, but J.H.’s labs are not too far from normal.

J.H.’s cerebrospinal fluid analysis came back with the following results: clear CSF; a pending gram stain; 300mg/dL protein (elevated); leukocytes 1030 cells/microliter (elevated); glucose 40mg/dL (decreased). By looking at these results, one can expect from the high protein level, the increased white blood cells, and the decreased glucose level, that J.H. has bacterial meningitis (Edwards, 2013). This prediction can be confirmed from reading the article Meningitis in Children which states: the CSF protein levels greater than 250 mg/dL indicate bacterial meningitis while levels between 50 and 250 would indicate viral; white blood cells exceeding 1000 indicate bacterial and less may be viral; and a CSF glucose level between 10 and 45 is most commonly bacterial meningitis (Richard, 2013). There are various types of pathogens causing meningitis that are established within different age groups. The most common pathogens in this age group, neonates, are group B streptococcus, Escherichia coli and Listeria monocytogenes. The pathogens most often seen in children older than three months are Neisseria meningitides (meningococcus), streptococcus pneumonia (pneumococcus), and haemophilus influenza type b (Hib) (Paul, 2013).

J.H. has now been diagnosed with Escherichia coli meningitis and his medical care plan will include 14 to 21 days of antibiotic therapy. The plan of care should include interventions to manage the neonate’s pain, such as swaddling, oral sucrose administration, and further administration of Tylenol. Infection should be managed with antibiotic treatment, using contact isolation and droplet precautions, monitoring temperature, and proper techniques of preventing further infection, such as hand hygiene. In order to maintain hydration, J.H.’s intake and output, monitor hemoglobin and hematocrit, and assess fontanels. Young infants are at a very high risk of dehydration, especially if they become febrile, so it is crucial to assess fluid status. A nurse should assess his fluid status every shift and give prescribed IV fluids to ensure sufficient fluid balance. It is crucial that the nurse do a careful assessment of fluid balance so the infant does not go into shock. Some signs the nurse should look for are tachycardia, urine output of less than 1ml/kg/hr, and a weak pulse. Administering fluids with raised intracranial pressure can be tricky however, and one must be careful not to give excess fluids and exacerbate the swelling (Paul, 2013). In order to assist with increased intracranial pressure, a nurse might elevate the head of a patient’s bed to relieve pressure. For such a small infant, there are wedge shaped beds available or a baby’s bed can be elevated about 30 degrees while still remaining safe. Nurses can also assist with increased intracranial pressure by administering prescribed medications that decrease the pressure; for example, mannitol or hypertonic saline solution (Paul, 2013). A pediatric Glasgow coma scale can be helpful in evaluating the status of infant’s neurological status and intracranial pressure, as well as testing normal reflexes. A neurological assessment should be done half-hourly for two hours, hourly for four hours, two-hourly for six hours, and four-hourly thereafter until intracranial pressure is normalized (Paul, 2013). In teaching J.H.’s parents about his care, the nurse might provide teaching on infection prevention and J.H.’s medication regimen. This could be done using resources written in their primary language, and through the translator to ensure understanding.

Mrs. H, through her translator, has asked what could have caused her baby to be sick since he had am immunization when he was born, and she wonder whether he should get “more shots: so this won’t happen again. She is told that infants have immature immune systems and they are vulnerable to infections until they have been immunized. Mrs. H asks when J.H. will get more shots and what they will be. The correct response to her question is that at 2 months J.H. will receive his second dose of the Hep B vaccine, the first of Rotavirus, DTaP, Hib, Pneumococcal vaccine, and the IPV vaccine (Recommended immunization schedules, 2014).

Hospitalization can impact J.H in many different ways. One major affect on J.H. is that separation between J.H. and his mother during hospitalization can be very distressing, and it can hinder the development of their relationship. It can also impact J.H.’s ability to reach developmental milestones and delay his achievement of motor skills. Hospitalization also interrupts this baby’s routine, which is difficult especially because he was trying to adjust to life at home. A lack of stimulus may affect J.H., or on the other hand, loud noises or bright lights and sudden movements in the hospital can be traumatic for such a young infant (Impact of hospitalization, 2013).

Some educational topics to talk with Mrs. H about are transmission prevention strategies such as good hand hygiene, covering nose and mouth when sneezing, avoid kissing J.H. on the mouth or sharing utensils for eating and drinking, and Educate about transmission prevention strategies, including good hand hygiene to avoid direct transmission through contact with respiratory secretions (Caple, 2013). It is a good idea to make sure Mrs. H understands to come back in a month and a half so J.H. can get his next immunizations to prevent future illnesses. It is crucial that Mrs. H understands the medication regimen for J.H. when he goes home as well.

When J.H. is finally discharged home with his parents, he will continue PO antibiotics for 1 week and receive a home health visit for infant care follow-up. He is to return to his PCP in 1 week or Mrs. H should call with any concerns. The next steps are to evaluate J.H’s recovery upon his one week visit to his PCP. I might even make a follow up call with Mrs. H through a translator to ensure she is following the medication regimen and ask if she is having any concerns. Something that definitely needs further research and clearer guidelines is the order of performing nursing interventions. It was difficult for me to work between what I have learned in class and what I found while searching articles, especially regarding when to perform the lumbar puncture for early diagnosis and treatment.


References

Allan R. Tunkel, Barry J. Hartman, Sheldon L. Kaplan, Bruce A. Kaufman, Karen L. Roos, W. Michael Scheld, and Richard J. Whitle. (2004). Practice guidelines for the management of bacterial meningitis. (). (IDSA Guidelines)

Caple, C., & Schub, T. (2013). Meningitis, bacterial. Cinahl information systems.

Determinants of timely management of acute bacterial meningitis in the ED. (2013). The American Journal of Emergency Medicine, 31(7), 1056--1061. doi:http://dx.doi.org.libproxy.unh.edu/10.1016/j.ajem.2013.03.042

Edwards, M., & Baker, C. (2014). Bacterial meningitis in the neonate: Clinical features and diagnosis. Retrieved 02/22/14, 2014, from http://www.uptodate.com/contents/bacterial-meningitis-in-the-neonate-clinical-features-and-diagnosis

Impact of hospitalization on children and adolescents. Retrieved 02/23, 2013, from http://www.pics.org.au/Impactofhospitalisationonchildrenandadolescents

Paul, S., Smith, J., Green, J., Smith-Collins, A., & Chinthapalli, R. (2013). Managing children with raised intracranial pressure: Part one (introduction and meningitis). Nursing Children & Young People,25(10), 31--38. doi:http://dx.doi.org.libproxy.unh.edu/10.7748/ncyp2013.12.25.10.31.e214

Paul, S., Smith, J., Green, J., Smith-Collins, A., & Chinthapalli, R. (2014). Managing children with raised  intracranial pressure: Part two (brain  tumours and intracranial bleeds). Nursing Children & Young People, 26(1), 30--37.

Prater, D. (Ed.). (2013). RN maternal newborn nursing (9th ed.) Assessment Technologies Institute, LLC.

Recommended immunization schedules for persons aged 0 through 18 years. (2014). Retrieved 02/22, 2014, from http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-combined-schedule-bw.pdf



Report of the Scientific Advisory Committee of HPSC. (2012). Guidelines for the early clinical and public health management of bacterial meningitis (including meningococcal disease)   . ( No. 2).

Richard, G. C., & Lepe, M. (2013). Meningitis in children: Diagnosis and treatment for the emergency clinician. Clinical Pediatric Emergency Medicine, 14(2), 146-156.


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