Running head: Case Study: Martin, Sara
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Case Study:
Respiratory Synctical Virus
Texas Children’s Hospital
A Case Study: Module 1
Presented To
Dr. Eva Stephens
THE UNIVERSITY OF TEXAS SCHOOL
OF NURSING AT GALVESTON
In Partial Fulfillment
Of the Requirements for the Course
GNRS 5310: Advance Clinical
By
Sara C. Martin
February 22, 2015
Case Study: Martin, Sara
Introduction
Respiratory Syncytial Virus, more commonly referred to as RSV, is a leading
cause of bronchiolitis in children under the age of two. It is estimated that more than 80%
of infants are exposed to this condition by their first birthday, but only a small percentage
of children experience severe disease. For most children, RSV is self-limiting and can be
treated on an outpatient basis. Bronchiolitis is a respiratory syndrome characterized by
inflammation and mucus production in the bronchioles of the lung (Centers for Disease
Control [CDC], 2010). It often begins in the upper respiratory tract but can invade lower
airway structures. If not treated appropriately, complications such as pneumonia and
respiratory failure may occur. Children with underlying cardiac, pulmonary, or immune
system deficiencies are at an increased risk of developing life-threatening complications.
RSV can pose a serious health risk to chronically ill children in the pediatric program
since the majority of the patients served have health conditions affecting their
neuromuscular, cardiac, and/or pulmonary systems. Clinicians must be able to promptly
identify symptoms and worsening conditions, intervene appropriate, and prevent the
spread of infection from one patient to another.
Chief Complaint (CC)
Baby P’s mother stated that the baby was a preemie and is a triplet. The mother
explained baby P was transferred because she has RSV and a Staph infection.
Baby P is a former 28 week and 3 day premature infant who is now day of life 69
and 38 weeks and 1 day post gestation. Baby P was admitted to pediatric intensive care
unit for + RSV, + staph aureus bacteremia and acute respiratory distress. Baby P was
transferred from an outlying hospital for higher level of care. Baby P is a triplet and the
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other two siblings are still hospitalized in the outlying facility. Baby P is in contact
isolation and will remain in this room till discharge. Mother stayed overnight and is at the
bedside this morning. Mom is leaving to visit the other two babies and will return this
evening.
History of Present Illness (HPI)
Patient’s Explanatory Model
During the acute care phase of RSV the goal is to rapidly assess the infant and
provide effective treatment to decrease further respiratory compromise. The treatment is
supportive and serves to restore and maintain adequate oxygenation, ventilation, and
hydration (AAP, 2010). Baby P is in the acute infection phase of RSV and is closely
monitored by the nurse and physicians at the bedside. The goal is to prevent hypoxemia
and prevent further respiratory distress. Baby P has increase respiratory distress and
increase apnea and was intubated by transport team at the referring facility. On
admission baby P had an elevated respiratory rate and increase work of breathing with a
fever. Baby P is NPO at this time and receiving maintenance fluids.
Past Medical History (PMH)
Baby P is a former 28 week triplet born via C-section with Apgar’s 2, 9 and
severe IUGR. Received surfactant x 1 dose at 17 minutes of life and was weaned to nasal
cannula by day of life 55. Currently Baby P is intubated and requiring 100% oxygen.
Baby P is critically ill with Positive blood cultures for RSV and staph aureus.
Screening Tests
At Discharge Baby P will need a hearing screen, car seat study and eye
exam to assess retinopathy of prematurity.
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Use of Safety Measures
Isolation and Contact precautions are in place to decrease the spread of the
infection to other patients in the unit. Along with good hand washing from the medical
staff and family.
Diet
Baby P is NPO and currently receiving total parental nutrition and lipids for
nutritional support. Maintenance IVF with TPN/Lipids at 160ml/kg/day.
Urine Output
116ml – 1.9ml/kg/hr over last 24 hours= 44.7ml/kg/day
Stools
X2
Medications, Allergies, Immunizations:
At this time there are no known drug allergies for baby P.
MedicationsGiven IV through right arm PICC line.
Lasix IV-2mg/kg/dose every 12 hours- diuretic for positive edema noted in lower
extremeties
Hydrocortisone IV 13mg/m2 X 1 dose today- to help with respiratory distress
Epinephrine Drip continuous 0.1mcg/kg-started today
Vancomycin IV- 20mg/kg/dose every 18 hours- to treat staph infection
Nafcillin IV – 25mg/kg/dose every 8 hours-to treat staph infection
Immunizations
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Baby P did receive one dose of the synangis vaccine five days ago at the
transferring facility. Unfortunately the infant contacted RSV before the next dose. Baby P
has received Prevnar, HiB, and Pediarix.
Review of Systems (ROS)
Day of Life: 72 Corrected Age 38 5/7 weeks WT: 1020g Length: 31cm FOC 26.5cm
General Appearance: Baby P is currently intubated and on SIMV with a PEEP of 5 RR
40 and FIO2 of 100%.
Blood Gas: PH 7.16, HCO3 17, BE -10
Skin: Mom states that Baby P has had a diaper rash and is healing. No other skin
breakdown or pressure ulcers. Position changed every 2 hours.
Head: No history of brain bleed or IVH, Head is normal shape and within normal limits
for size
Eyes: Clear with no discharge
Nose: Nares patent with no breakdown
Ears: Hearing screen due at discharge. Mom believes that baby P can hear and knows her
voice.
Mouth and Throat: ETT tube in place with positive secretions that require frequent
suctioning
Neck: Within normal limits
Chest: No audible wheezing at this time.
Heart: Baby p’s mom stated that she is aware that her little girl has a murmur.
Gastrointestinal: Baby P is stooling and is NPO with no vomiting.
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Genitourinary: The infant has positive urine output but has decreased since admission and
is now on hydrochlorothiazide.
Allergy: No known food or drug allergies
Endocrine: Newborn screens are negative for thyroid disease
Neuromuscular: No previous history of seizures or IVH
Behavioral History: Before admission to the PICU mother stated baby P was awake, alert
and would smile in the open crib.
Nutritional History: Mom’s stated that before baby P became sick she was taking a bottle
two times a day and tolerating all feeds.
Physical Examination
Before the examination I put on isolation gown, mask and washed hands.
Skin, Hair, and Nails: Positive cap refill on exam, patient is well perfused with slight
edema noted in lower extremities.
Head/Neck: Anterior fontanels soft and flat, did not palpate lymph nodes
Eyes: history of ROP zone 11, stage 3 with + bilaterally,
Ears: With in normal limits , no drainage noted
Nose: Increase secretions through nares white mucus noted. No skin breakdown
Mouth: Ett taped in place to right side of mouth no cuff, ambu bag and suction available
at bedside
Chest: Audible wheezing bilaterally with stethoscope with mild subcostal retractions.
Heart: Regular rate and rhythm, no murmur auscultated, pulses equal x4 extremities
Abdomen: Decrease bowel sounds (NPO), no abdominal distention, and soft to touch.
Genitalia: Normal Female genitalia, positive urine output during exam, diaper changed
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Anus and Rectum: Positive redness but no bleeding or breakdown, diaper rash is healing
Extremities: No deformities noted. Did not perform range of motion r/t acute illness
Back and Spine: No skin breakdown noted.
Diagnostic Studies:
Retinal Exam x 3 results show immature retina bilaterally
Cranial Ultrasound x2 WNL
Echo of Heart x1 related to an audible murmur showed tiny PDA and small PFO. At this
time there is no audible murmur and Echo scheduled for follow up before discharge
Discharge Medications:
There are no discharge medications ordered at this time. Baby P is not being
discharged this week.
Parental Information and Family History
Stressful Life Events and Impact on Family:
Baby P’s mother is currently in a very stressful situation. Baby P’s mom is
currently separated from the father and has just delivered three premature babies. Mother
is in need of a strong support system. Baby P’s mother has noted that the maternal
grandmother is going to stay when the babies are discharged home. Baby P’s mother did
not discuss income and was tearful at the bedside.
Psychosocial History
Tobacco:
Information from the electronic medical record for baby P states that
neither mom nor father use tobacco. Baby P’s mom denied any family member with a
history of tobacco use.
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Alcohol/drugs:
Mom denies any history of drug and/or alcohol abuse in the family.
Parental and Family Education
The goal to help Baby P’s family during this crisis will include assuring the mom
and dad that the best care is being given to their baby and to help the parents feel
accepted by the hospital staff. The parents need support to increase their feelings that
there is hope and honesty regarding the prognosis. It is important to maintain
communication with the parents regarding the medical treatment baby P is receiving but
in terms that the family understands. The healthcare team needs to reassure the family it
is all right to leave for a while to visit the other babies and encourage rest. To understand
how the client was being treated medically.
The AACN'S Advocacy (American association of critical nurses) states the
critical care nurse must respect and support the right of the patient or the patient's
designated Surrogate to autonomous informed decision-making, intervene when the best
interest of the patient is in question, help the patient obtain necessary care, and respect
the values, beliefs, and rights of the patient and patient families. It is important that the
nurse listens to baby P’s family and takes time to try and meet the needs of the parents
during the hospital stay.
Practices to promote health and decrease risk of contracting RSV after Discharge:
The family must promote good hand washing in their home to decrease germs
from spreading. The family must not have cigarette smoke in the house or breathe in the
odor of cigarette smoke. The family needs to promote adequate sleep time for the infant
and provide plenty of fluid. The nurse will instruct the mom on good suctioning
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techniques. It is also important to be aware of signs and symptoms to call the doctor or
visit the closet emergency room
Impact of RSV to Baby P that reflect a chronic illness
RSV outbreaks occur during the fall and winter months beginning in November.
RSV peaks in late January and begins to subside by early spring. The average outbreak
cycle is approximately 16 weeks (American Academy of Pediatrics [AAP], 2006). RSV
can occur in all age groups but is most prevalent in the infantile population. When RSV
occurs in the older child, or adult population, symptoms and disease progression are often
mild and may be comparing to symptoms of a “common cold.” Infection rates peak in
infants between the ages of 6 weeks to 12 months. Approximately 30% of children with
RSV develop pneumonia. Research reports that up to 125,000 children in the United
States under the age of one year require hospitalization for RSV and related
complications with an average cost of more than $40,000.00 per hospitalization (CDC,
2010). Globally, RSV is the most common cause of childhood acute lower respiratory
infection and remains a major cause of acute care admissions. In 2005, there were 33.8
million cases worldwide with 3.4 million hospital admissions (Nair et al., 2010).
Mortality rates for RSV are estimated at 5% (Centers for Disease Control (CDC), 2014)
Community Agencies and Resources: Home Health Agency and Pediatric Home Health
Nurses
Nursing management in the home health setting is focused on improving
respiratory function, preventing dehydration, and promptly identifying worsening
respiratory function. Prompt assessment and reporting of the patient’s health status is
needed. Increasing respiratory rate, labored breathing, fewer wet diapers or decreased
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urinary output, and an overall worsening appearance should be reported to the physician
and case manager immediately (Checchia, 2008).
The home health nurse can continue educating the parents after discharge from
the acute care setting. Parent teaching should promote education regarding the correct
patient positions that promote comfort and breathing. In addition, Baby P’s caregiver
should decrease activities which induce agitation and lead to oxygen desaturations. The
goal is to keep Baby P’s oxygen saturations above 92% which may require administration
of oxygen therapy at home. (Cooper, Banasiak & Allen, 2003).
Additional interventions used to manage RSV in the home include therapeutic
measures such as the use of a cool mist vaporizer and the use of steam to alleviate severe
coughing episodes. Respiratory Therapy Bronchodilator therapy is common, but its
effectiveness is not routinely supported in the literature (AAP, 2006). AAP Guidelines
clearly recommend that bronchodilators should not be used routinely in the management
of bronchiolitis; however, it may be used on a case-by-case basis, particularly in children
with restrictive airway disease.
Ethics, Legal and Economic Factors
Ethics
Ethical issues in acute care commonly occur when the nurse is caught in the
middle between clients, physicians, administrators, and other nurses. The nurse and/or
family may feel powerless and unsure of how to change or fix a situation. Ethical distress
can lead to negative consequences for everyone involved. Nurses are often called on to
assist families in making informed decisions about client care, and they must be familiar
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with ethical, legal, economic, and emotional factors that affect the family's decision.
Legal
Nurses have more responsibility today than in the past. The expanded roles in
nursing have open doors to greater legal risk. Proper documentation is crucial to serve as
evidence of the quality of nursing care provided. The court still assumes that if something
was not noted in a chart, it was not done. The nurse needs to document the specific
nursing actions taken and the patient or family response. If an unusual event occurs, a
nurse needs to complete an incident report. The benefit of incident reports are to allow an
analysis of an adverse events. Incident reports are not to be treated as a punitive activity
but rather as a method of promoting quality care and risk management.
Economic
Baby P’s family are in need of assistance with childcare, medical bills, and baby
supplies for the triplets. It is important to connect the mother with social workers to help
establish a plan for discharge.
Reference
American Academy of Pediatrics. [AAP]. (2006) Diagnosis and management of
Bronchiolitis. Pediatrics. 118:1774-1793.
Centers for Disease Control. (2010). Respiratory syncytial virus activity. Centers for
Disease Control and Prevention. MMWR, 59(8): 230-233.
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Cooper, A., Banasiak, N., Allen, P. (2003). Management and prevention strategies for
respiratory syncytial virus bronchiolitis in infants and young children: A review
of Evidence-based practice interventions. Pediatric Nursing; 29(6): 425-456.
Checchia, P. (2008). Identification and management of severe respiratory syncytial virus.
American Journal of Health System Pharmacology; 65(8): S7-S12.
Kleinman, Arthur. Patients and Healers in the Context of Culture. Berkeley, CA: Univ of
California Press, 1980
Nair,H. , Nokes, J., Gessner, B., Dherani, D., Madhi, S., O’Brien, K. , et al. (2010).
Global burden of acute lower respiratory infections due to respiratory syncytial
virus in young children: A systematic review and meta-analysis. Lancet. 375
(9725): 1545-1555.