course materials

1. Discussion: Leukemia Pediatric
Discussion: Leukemia Pediatric ON Discussion: Leukemia PediatricAnswer all questions in
the Ariana Case Study. Ensure that all questions are correctly answered and the provided
tables are filled. Ensure that all questions are accurate and follow the provided rubric
Discussion: Leukemia PediatricThe attached materials and the “Maternal-Newborn Nursing:
The Critical Components of Nursing Care” should be of assistance in answering
itariana_case_study_quizez.docxariana_case_study_rubrUnformatted Attachment
PreviewPediatric Case Study Name_____________________________ Purpose: The purpose of this
assignment is to help you to achieve the following Course Student Learning Outcomes. You
will review Situation Awareness and Antibiotic Stewardship principles and put them into
action in the service of a pediatric patient. Program SLOs 1 PatientCentered Care Course
SLOs 1.1 Uses components of the nursing process appropriate to the health care needs of
the pediatric patient and family. 1.4* Provides holistic care that addresses the needs of
diverse pediatric populations. 2 Professionalism 2.2 Demonstrates an awareness of the
professional standards of practice that apply to the practice of pediatric nursing. 3
Leadership 3.2 Demonstrates critical thinking and problem-solving process when caring for
a pediatric patient. 7 Teamwork & 7.6* Functions competently within own scope of practice
as a student member of Collaboration the healthcare team. 8 Safety 8.1 Identifies factors
involved in prevention of infection, injury, and errors in the pediatric setting. 10 Evidence-
based 10.1 Uses Evidence-Based Practice (EBP) as it pertains to patient care. Practice *
Clinical Student Learning Outcomes Situation: Ten-year-old Ariana Merchante’s parents
bring her to the Emergency Department (ED). They report to the triage nurse that for the
last 24 hours Ariana has had a sore throat and a fever. The parents appear to be anxious and
very concerned about their daughter. Because Ariana’s attempts at movement were weak
and uncoordinated, her father used a hospital wheelchair to bring her into the ED from the
car. 1. What are your first thoughts about Ariana’s situation? A. SITUATION AWARENESS:
PERCEPTION1: The Triage Nurse collects more information from the parents. Ariana’s fever
has been as high as 100.4?F (38?C). She has taken acetaminophen 325 mg by mouth every 6
hours since the onset of her fever, but it has not had any effect. Ariana was diagnosed with
Acute Lymphoblastic Leukemia (ALL) three months ago, and she has been receiving
chemotherapy. Her last treatment in the Remission Induction Phase was completed ten
days ago. She has a Central Venous Access Device (CVAD) in place for the delivery of her
chemotherapy. Her chemotherapy drugs include Cyclophosphamide, Methotrexate, and
Cytarabine. Ariana is 51.5 inches tall and weighs 52 pounds (23.6 kg). BMI 13.8 is at 3rd

2. percentile for age. Discussion: Leukemia PediatricShe has no known allergies to
medications. Vital signs are: TPR: 101.5?F orally (38.6?C)/112/24 BP 102/54. Lungs clear
bilaterally, nonlabored respiratory effort. Oxygen saturation 96% on room air. Skin pale,
cool. Capillary refill is 4 seconds on chest. Pedal pulses 2+ and equal. Three 1-to 2-
centimeter inflamed lesions in the mouth and oropharynx. CVAD site: no redness, swelling,
exudate or lesions. The nurse notes these behaviors: Lethargic, slumped position in
wheelchair. “Can’t walk. No strength.” Confused and drowsy. Parents answer questions.
Voided 80 mL on arrival. Last void was 4 hours ago, per mother. COMPREHENSION1: The
Triage Nurse has just completed training on the ED’s new Sepsis Protocol, and quickly
identifies aspects of Ariana’s assessment that strongly suggest the presence of sepsis. 2. On
the Sepsis Algorithm, highlight any of Ariana’s assessment data that you find there. 3. What
elements of Ariana’s history indicate high risk for sepsis? History Significance to Risk for
Sepsis 4. List here the assessment data that you have circled on the Sepsis Algorithm. From
the Algorithm, state why these assessments are significant for the presence of sepsis. I’ve
done the first one for you. Assessment Data Oral Temp 38.6? C Significance for Presence of
Sepsis A temperature of < 36?C or > 38.3?C is a criteria for Systemic Inflammation
Syndrome (SIRS) – precursor to Sepsis. PROJECTION1: 5. What is the likely outcome of this
situation if appropriate action is not taken? DECISION/ACTION1: The Triage Nurse fast-
tracks Ariana’s admission to the ED. In collaboration with Ariana’s primary nurse and the
ED physician, the decision is quickly made to implement the Pediatric Sepsis Protocol. 6.
Finish the table with the two remaining rescue interventions from the Initial Stabilization
Phase of the PALS Septic Shock Protocol. State the goals of care for these elements from the
PALS Protocol. Intervention Monitor and Airway, Breathing, and Circulation. Monitor
heart rate, blood pressure, and pulse oximetry. Establish vascular access. Goal Assure
adequate oxygenation and circulation. Monitor patient’s response to therapy and quickly
identify deterioration of her condition. Monitor patient’s response to therapy and quickly
identify deterioration of her condition Allow drawing of blood cultures and other labs. –
ideally before starting rescue interventions, but do not delay these interventions.
PERCEPTION2/COMPREHENSION2: 7. Lab results are quickly available. Analyze the results
in the usual way. Discussion: Leukemia PediatricTest CBC WBCs Neutrophils Bands ANC*
Hemoglobin Hematocrit Platelets Electrolytes Sodium Potassium Renal Function BUN
Creatinine ABGs pH PaCO2 HCO3 Other Glucose ALT PT INR Lactate Urinalysis Specific
Normal Range Result 4.5-11/mm3 40-60% 3-5% > 1500 Critical <500 12-16 g/dL 36-40%
150-450k/µL 7.4 28% 78K 136-145mEq/L 3.5-5.0 mEq/L 150 3.5 7-25 mg/dL 0.6-1.2
mg/dL 26 1.4 7.35-7.45 35-45 22-26 7.2 30 20 70-110 mg/dL 8-20U/L 11-13.5 sec <1.1 < 2
mmol/L 74 22 12.5 1.0 2.2 1.015-1.030 1.5 20 4 360 1.042 Discussion If abnormal – Reason
for abnormal results. If normal, what is ruled out? gravity Reference: * ANC = ABSOLUTE
NEUTROPHIL COUNT CHECK OUT THIS ARTICLE ON NEUTROPENIC FEVER! 2 2 2 2
COMPREHENSION /PROJECTION /DECISION /ACTION : 8. Highlight any of Ariana’s lab
results that you find on the Sepsis Algorithm. 9. Fill in the table for these three high-priority
problems identified by the laboratory results. Problem Lab Result Sodium Urine SG WBC’s
Neutrophils ANC Platelets 150 1.042 1.5K 20% What could happen? (Worst case scenario.)
What action should be taken? 360 78K Physician Orders: 10. On the order table below,

3. answer the questions in the right column. Pediatric Sepsis Protocol Orders Order May use
CVAD for IV fluids & blood draws Fluid boluses: 20 mL/kg rapid infusion over 10 minutes.
Assess effect and repeat as needed. No response required. Calculate the fluid volume for a
single bolus for Ariana. Why do we use the “pull-push” method for delivery? After fluid
bolus completion, IV D5NS at 2 mL/kg/hour Obtain cultures before starting antibiotics if
possible: Throat CVAD Blood Urine Cefepime IV 50 mg/kg/every 8 hours. Infuse over 20
minutes. First dose STAT after cultures obtained. Vancomycin IV 40 mg/kg/day divided
every 6 hours Infuse over 60 minutes. First dose STAT after 1st Cefepime dose. Transfer
patient to Pedi ICU or Pedi Oncology Unit ASAP Calculate the rate for Ariana in mL/hour.
Neutropenic Precautions Define Neutropenic Precautions and describe protective
interventions. Discussion: Leukemia PediatricIf getting the cultures drawn/collected first
would delay fluid and antibiotic deliver beyond the recommended one-hour window, what
would you do and why? Calculate the dose for Ariana. The dose is mixed in 50 mL NS.
Calculate the IV rate in mL/hour. Calculate the dose for Ariana. The dose is mixed in 100 mL
NS. Calculate the IV rate in mL/hour. What is the rationale for moving Ariana out of the ED
as soon as possible? B. Continued Situation Awareness Physician’s Orders include
interventions to monitor for change in status. We expect status improvement as the patient
responds to protocol interventions. We are also constantly vigilant for indications that the
patient is not responding, or that her status is worsening. 11. The tables below shows the
nurse’s assessment of Ariana before and after the first and second fluid bolus. Each time,
you must decide whether Ariana needs another fluid bolus (based on the nurse’s
assessment) or if we should begin to deliver the maintenance IV solution at the ordered
rate. Be specific about which assessment data influenced your decision! Normal vital signs
for a 10-year-old child are as follows (per PALS): Heart rate: 75-118 Respiratory rate: 18-25
Blood Pressure: 97-115/57-76 Temperature: < 38?C O2 sat: ? 94% on room air Urine
output: ? 24 mL/hour Peripheral pulses: 3+ st Assessments before 1 bolus Assessments
after 1st bolus TPR: 38.3?C/120/26 BP 96/54 TPR: 38.1?C/110/22 BP 102/52 EKG – Sinus
tachycardia EKG – Sinus tachycardia O2 sat – 92% on O2 @ 2L/min O2 sat – 96% on 2L/min
O2 Central cap refill 4 seconds Central cap refill 4 seconds Peripheral pulses 1+ Peripheral
pulses 2+ Urine Output – 4 mL/15 min Urine Output – 5 mL/15 min Neuro – lethargic,
confused Neuro – drowsy, intermittently alert and confused. Lungs CTA Lungs CTA
Evaluation Improving/Stable/Worsening (Circle one) Plan: (Select one and give rationale.)
___Repeat fluid bolus – why? ___Begin maintenance fluids – why? (The presence of a 2nd
table should not be taken to mean that a 2nd bolus is required. Base your evaluation on the
post-bolus assessment.) Discussion: Leukemia PediatricAssessments before 2nd bolus TPR:
38.1?C/110/22 BP 102/52 EKG – Sinus tachycardia O2 sat – 96% on 2L/min O2 Central cap
refill 4 seconds Peripheral pulses 2+ Urine Output – 5 mL/15 min Neuro – drowsy,
intermittently alert and confused. Lungs CTA Assessments after 2nd bolus TPR:
37.8?C/98/18 BP 112/60 EKG – Normal Sinus Rhythm O2 sat – 96% on room air Central
cap refill 3 seconds Peripheral pulses 3+ Urine Output – 7 mL/15 min Neuro –alert and
oriented. Evaluation Improving/Stable/Worsening (Circle one) Lungs CTA ___Begin
maintenance fluids – why? Plan: (Select one and give rationale.) ___Repeat fluid bolus –
why? (The absence of a 3rd table should not be taken to mean that a 3rd bolus is not

4. required. Base your evaluation on the post-bolus assessment.) Resolution: The team has
successfully implemented the PALS plan for the first hour response to pediatric sepsis, and
Ariana is well on her way to recovery. Fluids were started within 15 minutes of recognition
of sepsis, and antibiotics were initiated within the first hour. Ariana has been transferred to
the Pediatric ICU, and her parents are now with her. Antibiotic Stewardship: Forty-eight
hours after they were collected, the culture results are back. The team holds an “Antibiotic
TimeOut” meeting. 12. a. What is the purpose of this discussion? b. Why is it so important to
Ariana’s outcome? c. What does de-escalation mean in this context? Cultures reveal the
presence of strep pharyngitis that will respond to Cefipime. In consultation with Ariana’s
oncologist, the team decides it is safe to de-escalate Ariana’s treatment by stopping the
Vancomycin and continuing with Cefipime IV for a total of 7 days of therapy. Psychosocial
Concerns: Imagine that Ariana is your child. You have always been transparent with her and
provided as much developmentally appropriate information as possible. During the
induction phase of her chemotherapy, Ariana appeared to understand that because the
chemotherapy drugs would cause her white blood cell count to be very low, she would be at
risk for a serious infection. Your family has observed the precautions necessary to reduce
her risk, but she became seriously ill nonetheless. 13. Now that she’s feeling better, Ariana
asks you (her parent – not her nurse!), Discussion: Leukemia Pediatric“This has been so
scary. What’s going to happen to me?” After reading “What to tell your child” from
Childhood Leukemia: A Guide for Families, Friends, and Caregivers, compose a response to
your child’s question. Ariana Case Study Rubric Student________________________ Criteria Initial
Appraisal of the Situation 1 State your initial appraisal based on limited information and
cues available. Perception1 and Comprehension1 2 Identify data relevant to a Sepsis
diagnosis & highlight it on the Sepsis Algorithm 3 Identify history data relevant to Sepsis
diagnosis and state the significance of the data. 4 Identify assessment data relevant to
Sepsis diagnosis and state the significance of the data. Projection1/Decision1/Action1 5
Project the likely outcome of this situation. 6 Fill in the two PALS Septic Shock Protocol
essential rescue interventions and state the goals of these actions. Perception2 and
Comprehension2 7 a. Identify what normal lab findings rule out. b. Explain the cause of
abnormal lab results within the context of the patient’s situation and condition. 8 Highlight
abnormal results on the Sepsis Algorithm. 2 2 2 Pts. /4 /4 /6 /6 /4 /8 /10 /4 2
Comprehension /Projection /Decision /Action 9 Identify the patient’s three highest-priority
problems ed by the laboratory results, project their potential outcomes, and state actions
required to avert the projected outcomes. Physician’s Orders Comprehension 10 Answer
questions regarding physician’s orders which are essential elements of the Sepsis Protocol.
Implementation of Fluid Resuscitation 11 Evaluate the patient’s response to each fluid bolus
and decide if an additional bolus is needed. Give your rationale for the decision. Antibiotic
Stewardship 12 a. Define Antibiotic Timeout b. Explain why it is so important in Ariana’s
situation. c. Explain De-escalation. Psychosocial Concerns 13 Compose an effective and
compassionate response to Ariana’s question using the principles advanced in the required
reading. Writing Mechanics Complete sentences Cohesive paragraphs Correct grammar,
spelling Scholarship Sufficient In-text citations in APA format Bibliography in APA format
Total /10 /10 /10 /6 /10 /4 /4 /100 Notes