Case Study #3
John Doe
DOB: 06/04
PMH
Cerebral Palsy, immobile, non-verbal. Pre-mature birth @ 25 wks. Bowel
Perforation in NICU, G-Tube dependent, illeostomy. Long term endotracheal
intubation at birth, chronic respiratory disease, tracheostomydecannulation @ 4yo . Allergies: peanuts (anaphylaxis), shellfish
(anaphylaxis)
Assessment
Awake/ alert. Breath sounds: Clear, RRR, no increased WOB/ signs of
Distress on room air. Bowel sounds hypoactive x 4, distended/ soft/ signs
of tenderness to palpation; Heart sounds S1, S2 no mummers; Pulses regular
and equal bilaterally.
VS: T = 38.3 C BP = 120/80 HR = 110 RR = 25 O2 Sat = 99 on RA Patient
appears uncomfortable
Medications:
1. Ranitidine 10mg/kg GT q12 hours
2. Miralax 1 capful qMorning with AM feed
3. Saline Nebulizer x1 PRN thickened secretions, difficulty clearing
airway
4. Albuterol/ Atrovent neb x1 for moderate expiratory wheeze
5. Albuterol MDI give 2 Puffs PRN wheeze/ difficulty breathing
6. EpiPen Give IM x1 PRN anaphylaxis
Treatments:
1. Tracheal Suctioning PRN
2. O2 .5 L Nasal Cannula at night- can titrate up to 1L to keep SpO2
above 90%
3. Feedings: Formula: Neocate Jr. 17kcal/oz Amount: give 110ml with
120ml at 0900/1300/1700.Continuous overnight feed of 300ml formula
with 150ml water at 50-60ml/hour based on patient tolerance., Rate:
50-60ml/hour
1. Which pain scale would you utilize on this patient?
2. What other subjective or objective information would you want?
3. You have completed this assessment prior to administering the morning feeding. How will you proceed?