I. Days of Care Summary:
Student name: Juliana Leyda
Clinical date: 10/19
RN: Tracy
Patient initials: DL
Room#: 756
Age: 14
Admit date: 10/18, 1:00
Gender: F
Code status: Full
Estimated discharge date: 10/20 or 21
Admit Wt (kg): 54.9 kg
Current Wt (kg): 54.2 kg
Allergies: Cipro: causes a rash
Play needs: teens need social contact, especially with friends and peers. This
Developmental Stage:
patient is meeting her needs with: Cell phone [for text messages and phoning
Teenager: Identity vs Role
friends], TV [with access to movies], computer [for access to MySpace,] and some
confusion
human interaction because she is unable to leave her room and her mother is
unable to be present
Admitting diagnosis: Fever,
Neutropenia
Other active diagnoses: intrahepatic high grade undifferentiated embryonal
sarcoma s/p R hepatectomy and chemotherapy. Thrombocytopenia (per
lab values).
Primary Physician: C Jasik
Attending: E Robbins MD. Primary Oncologist: E Robbins, A Ward
Current immunization status (note source of info): Up to date
Medications/ dose:
Heparin 5 mL (100 units/mL) IV Q month
or after each time assessed: max 1 flush
(500 units)/day when in use.
Colace 250 mg PO BID, hold for loose
stools
Ceftazidime 2 gm IV Q 8 hrs
To prevent clotting in her port
Stool softener
Benadryl 25-50 mg PO Q6 (prn for n/v)
This pt is neutropenic: this antibiotic is used as a
prophylactic against infection while her immune system is
compromised
This is an antiviral used prophylactically: she uses this daily
outside of the hospital as well. Typically used to manage
symptoms of Herpes I or II infection, also 1 st line for new
HIV infection.
Used prophylactically against bacterial infection during her
episode of neutropenia
Available in case patient experiences n/v
Zofran 8 mg PO Q hr (prn for severe n/v)
Available in case patient experiences severe n/v
Lidocaine LMx4 Topical (prn 30 min prior
to phlebotomy or IV attempts)
A&D ointment to peri area prn irritation
To manage pain and discomfort during needle sticks—
however, this patient has a port and it may rarely be needed.
Patient feels a small sore spot near her urethra that is irritated
by peeing/wiping, A&D is for protecting and healing this
sore spot after voiding.
This shot is usually used as birth control, but also prevents
menstruation. It is used for this patient so that she does not
become more anemic from menstruating.
Valtrex 500 mg PO 2x/day
Septra 120 mg PO bid
Depo-provera IM shot q3mos (due on
11/7)
Brief pathophysiology summary of the primary and admitting diagnoses:
History: This patient presented January 2008 with an intrahepatic high grade, undifferentiated embryonal
sarcoma. She is status post a right hepatectomy in January and has completed her 34 th of 46 rounds of
chemotherapy with Isosphamide and Adriamycin, her last treatment being on 10/9. Yesterday, she
developed a fever of 38.1c and came to the emergency room per physician orders. She is neutropenic at
this time and is in the hospital for prophylactic antibiotics.
Intrahepatic high grade, undifferentiated embryonal sarcoma (UES): This sort of malignant tumor is
considered a “rare, highly malignant” hepatic cancer that usually appears in the pediatric population. It
usually presents with pain in the upper or lower right quadrant, in this patient, the pain also radiated to her
shoulder and neck. Typically the prognosis is poor, but studies are showing that “long-term survival is
possible after complete surgical resection with or without postoperative chemotherapy” (Sakellaridis et al.,
2006). According to Sakellaridis, et al. (2006) these are the third most common solid malignant tumors
found in children, and make up 2% of all pediatric cancers. These tumors also favor boys, and the
prognosis has extended from less than 1 year in 1976, to 3 years, and in rare cases: disease-free without
remission at 5 years post-treatment. This sort of tumor favors metastasis to the lung, peritoneum, and
occasionally the superior vena cava and heart (Sakellaridis et al., 2006). Current therapy has been more and
more successful at extending life, and in its most effective combination, includes radical resection
[meaning take the tumor, its blood and lymph supply, and surrounding tissue], and follow-up
chemotherapy.
This client’s neutropenia is due to chemotherapy and its damage to cancer and other rapidly dividing cells,
such as those in the bone marrow. Neutrophils, platelets and other blood cells are made in marrow and
affected by myelosuppression. Without neutrophils the immune system cannot adequately protect a patient
from infection, and patients are at risk for rapid sepsis which can be fatal. This patient has orders to come
to the hospital when she has a fever so that she can be treated preventatively with antibiotics for 2-3 days.
This patient has also been found to be thrombocytopenic due to myelosupression, and is at risk for
bleeding.
Diagnostic procedures/ tests recently done or ordered and indications/ findings:
CBC with differential and platelets on 10/17
BC (blood culture) on 10/18—still pending.
Lab data relevant to care (be specific) and interpretation:
Test (abnormal results)
WBC Count
RBC Count
Hemoglobin
Hematocrit
Platelets
Neutrophil
Lymphocyte
Oct 18th
0.30
2.98
9.60
28.10
26.00
0.02
0.20
Oct 19th
0.50
2.56
8.40
24.30
15.00
0.08
0.18
Normal Ranges
4.5 - 13.2
4 - 5.2
11.8 - 15.15
36 - 46
140 - 450
1.8 - 8
1 - 6.1
WBC’s, Lymphocytes, & Neutrophils low: mean that Dayzzie’s immune cells are in depleted numbers,
most likely do to her chemotherapy and its myelosupression. This means that she has very little immune
function to protect her from infections.
RBC Count, Hematocrit, Hemoglobin low: this is anemia, likely also due to chemotherapy and
corresponding myelosuppression. All these things cause Dayzzie’s blood to be inadequate in carrying
oxygen to her tissues.
Low platelets: thrombocytopenia, also a symptom of her myelosupression and anemia. Leaves her at
greater risk for bleeding and bruising.
Current immunization status (per chart or parent report): Up to date (per chart)
***First focused AM assessment (optimally done by 8AM):
Vital Signs Day 1
Pain scale used: OPS objective pain score [0-10]
Frequency ordered:
T: 37.2
0800
T: 37.1
1200
T:
1600
Vital Signs Day 2:
T:
0800
T:
1200
T:
1600
P: 90
P: 86
P:
R: 19
R: 16
R:
P:
P:
P:
R:
R:
R:
BP: 103/57
BP: 94/62
BP:
Frequency ordered:
BP:
BP:
BP:
Pain: 0/10
Pain: 0/10
Pain:
Pain:
Pain:
Pain:
Intake & Output
Previous 24 hr total intake: 2,775 mL
Dietary orders/ restrictions: no restrictions, and
surprisingly no neutropenic precautions (fresh
fruit/vegetables)
Day 1
Oral
IV
Previous 24 hr total output: 2,560 mL
0800
120 mL
0% of
breakfast
1200
NG
UOP/Stool
Suction /drains
400 mL
400 mL
600 mL UO
350 mL UO
Large soft stool
1600
Totals
Shift Totals
920mL
950 mL
Body system assessments:
Skin: seems pale for ethnicity, warm. Intact other than: small painful sore near urethra that is
irritated by urinating/wiping
Head & neck: alopecia, symmetrical.
Neuro: WNL, appropriate affect, appropriate to developmental stage
Musculoskeletal: movement WNL, very thin build. Client states she lost a lot of strength in her
feet at one point, but that she now only feels slight weakness.
Cardiovascular: dosal pedal pulses 2+ bilat, anemia, cap refill 2. Heart rate, heart sounds are
normal.
Respiratory: lung sounds clear, no SOB, no hx TOB use
GI: BS present Q quad, soft normal BM, ate no breakfast. History of malnourishment.
GU: Voids clear amber urine, ambulates to BR. Prescribed birth control to prevent menses. Small
painful sore near urethra that is irritated by urinating/wiping. Gravida: 0.
IV lines assessment: Port dressing appears dry, clean, and intact.
Isolation issues aside from universal precautions (Contact/ airborne), Special
precautions (neutropenia/ thrombocytopenia):
This patient seems to have modified neutropenic precautions: she has a private room and is not allowed to
leave it or walk the hall—if she walks the hall she will need a mask. However, fresh fruits and vegetables,
flowers, are not restricted.
Other Orders:
OOB ad lib, Strict I/O, VS Q 4hr.
Call MD if: HR 120+ or <60, SBP 140+ or <90, DBP 85+ or <50; Temp > 38c; UO: no void in 8 hr.
*Psych-Social needs family issues:
This patient is a very gentle fourteen year old who is well loved by the floor staff. Her family history is
complex: she has a younger brother of ten years, and a new baby half-brother. Her father was killed some
years ago in a drowning on a camping trip, which the patient witnessed. He was also involved in gang
violence, as were other family members: her uncle was killed in gang violence. The patient states that this
does not bother her. It would seem that until recently, her family’s environment was unstable: living in
Richmond, this patient became involved in gangs in middle school, and her brother was bullied by gangs.
Despite the medical complications during her school year, the patient did graduate 8 th grade. The family is
looking into educational options for her to begin high school, and the possibility of home-schooling.
Her mother bore another son in September: coincidently he was born at UCSF the same day his sister was
at the hospital receiving chemotherapy. The family recently moved to Daly City. The patient lives with her
siblings and her mother. The father of the newest sibling is described by the patient as her mother’s
“boyfriend, or uh, ex-boyfriend, whatever,” and does not live with them, however his sister lives in the
household with her own one month old son. When asked how this living arrangement [with two neonates]
works for her, the patient states: “it’s a place to live.” Her mother is unable to be present at the hospital for
more than an hour each day during this two to three day hospitalization, and the patient is understanding of
the demands her new brother puts on her mother. She says she does as much as she can to help her mom
with the new baby.
I was happy to spend time with this patient and ask her about her life, which she is forthcoming about,
especially given that she is socially isolated while in the hospital. She describes events like her graduation
from middle school in detail. She seemed quite habituated to hospital stays, and complained not at all. She
was content to sleep late, use the computer that is available to patients, and send text messages to her
friends.
*Resources utilized or potentially utilized outside the hospital:
www.grouploop.org : an online support group for teens with cancer
Kaplan Academy of California: what an amazing service: tuition free (for eligible students), all online
high school. They will also provide you with your own computer if needed. Offers individualized, one-onone instruction with teachers and access to all skill levels; honors, AP, etc.
Health Patterns Assessment:
Blue: Subjective
Black: Objective
Nutrition Metabolic:
Sleep Rest:
IVF: D5 ½ NS w/ 20 mEq KCl @ 100 mL/hr
BS present Q quad, soft normal BM
Ate no breakfast b/c she awoke late and felt that “it is all cold now.”
Records reveal history of malnourishment: pt explains that there was a point
in her treatment that her appetite was so poor that she had to have an NG
tube. However, she continued vomiting, and several failed attempts to wean
her from the NG tube occurred. Eventually eating normally was attempted
and the NG tube removed because it caused her discomfort. At this point the
patient began eating regularly again, and says that it helped to be at home,
around friends, and that she didn’t want to have the NG tube present for her
graduation ceremony, which was a motivator.
Says her mother accused her of an eating disorder at the outset of her illness
[when she was not eating and vomiting bile], and also when she suffered
anorexia during her treatment.
Pt says, “you wouldn’t recognize me before I got cancer: I was like a size 7 or
8.”
WBC’s, Lymphocytes, & Neutrophils low: mean that Dayzzie’s immune cells
are in depleted numbers, most likely do to her chemotherapy and its
myelosupression. This means that she has very little immune function to
protect her from infections.
RBC Count, Hematocrit, Hemoglobin low: this is anemia, likely also due to
chemotherapy and corresponding myelosuppression. All these things cause
Dayzzie’s blood to be inadequate in carrying oxygen to her tissues.
Low platelets: thrombocytopenia, also a symptom of her myelosupression
and anemia. Leaves her at greater risk for bleeding and bruising.
BC (blood culture) on 10/18—still pending.
Ceftazidime 2 gm IV Q 8 hrs, Valtrex 500 mg PO 2x/day, Septra 120 mg PO
bid [prophylactic against bacterial infection during neutropenia]. Valtrex 500
mg PO 2x/day [prophylactic against viral infection, also taken at home]
Benadryl 25-50 mg PO Q6 (prn for n/v), Zofran 8 mg PO Q hr (prn for severe
n/v)
Depo-provera IM shot q3mos (due on 11/7) [prevents anemia by stopping
menses]
ND: Risk for infection r/t neutropenia AEB fever and low neutrophil
count
Risk for injury r/t thrombocytopenia & anemia AEB lab values
Altered Nutrition: Less Than Body Requirements r/t hospitalization,
hospital food and not feeling great and/or lack of companionship AEB
little food eaten during morning shift
Pt slept until about 9 am. I would
consider this the normal sleep/wake
cycle of a teenager, especially an ill teen.
Nursing staff did not disturb her until she
was awake.
ND: Sleep patterns effective
Medical Diagnosis:
Admitting diagnosis: Fever, Neutropenia
Other active diagnoses: Intrahepatic,
high grade undifferentiated embryonal
sarcoma s/p R hepatectomy and
chemotherapy.
Other: thrombocytopenia, anemia (per
labs)
Self-Perception-Self-concept:
Alopecia due to chemotherapy: Pt states
that she has had little trouble adjusting to
her hair loss. She used to have long thick
black hair that she always wore in two
braids. Her hair was cut preemptively to
make a wig with. Her auntie bought her a
wig to see how she likes them and what
style her hair should be made into, but
the patient does not wear the wig after
all. She has decided she doesn’t need
one and not to go through the expense of
making one with her hair. Pt says, “you
wouldn’t recognize me before I got
cancer: I was like a size 7 or 8.”
Pt has a port for treatments, which
should lessen body image issues by
camouflaging hardware with skin.
Risk for body image disturbance r/t
alopecia, weight loss, port, AEB (only
my own suspicions about her
developmental stage)
Activity Exercise
Skin: seems pale for ethnicity, warm. Intact other than: small painful sore
near urethra that is irritated by urinating/wiping
Musculoskeletal: movement WNL, very thin build. Client states she lost a lot
of strength in her feet at one point, but that she now only feels slight
weakness.
Cardiovascular: dosal pedal pulses 2+ bilat, anemia, cap refill 2. Heart rate,
heart sounds normal.
Elimination:
A&D ointment to peri area prn irritation.
GU: Voids clear amber urine. Small
painful sore near urethra that is irritated
by urinating/wiping.
Colace 250 mg PO BID, hold for loose
stools
Respiratory: lung sounds clear, no SOB, no hx TOB use
Port dressing appears dry, clean, and intact.
This patient seems to have modified neutropenic precautions: she has a
private room and is not allowed to leave it or walk the hall. OOB ad lib.
Diversional Activity Deficit r/t hospitalization and neutropenic
precautions AEB pt cannot leave her room, friends and family are not
present (my thinking is that for teens, especially females, social contact is a
priority diversional activity.)
Risk for activity intolerance r/t anemia AEB lab values
ND: Impaired Skin Integrity & Pain r/t
wiping with baby wipes AEB small
sensitive sore on periurethral area
Coping Stress:
It would seem that until recently, her family’s environment was unstable: living in Richmond, this patient became involved in
gangs in middle school, and her brother was bullied by gangs. Her gang involvement ended with her diagnosis and moving to
Daly City.
The father of the newest sibling is described by the patient as her mother’s “boyfriend, or uh, ex-boyfriend, whatever,” and
does not live with them, however his sister lives in the household with her 1 month old son. When asked how this living
arrangement [with 2 neonates] works for her, the patient states: “it’s a place to live.”
Her mother is unable to be present at the hospital for more than an hour a day during this 2-3 day stay, and the patient is
understanding of the demands her new brother puts on her mother.
Her father was killed some years ago due to his involvement in gang violence. The patient states that this does not bother her.
In assessing this pt, I would say she has a long history of stressors. She appears at peace in talking about these things, but
she does not discuss her emotional states in relation to them—this is also normal of teens. I assume that there are things to
process in the future when her illness resolves when she reaches adulthood, but that this pattern of coping is appropriate for
her development, her circumstances, and does not seem to be negatively impacting her at this time. I suspect that later, her
feelings will be more accessible to her and she will want to explore some of these hardships. At this time, an amount of denial
and her appreciation for a slightly rocky home situation, in the environment of her illness, is probably a very effective coping
pattern.
ND: (mom) Caregiver Role Strain r/t ill daughter, newborn, and well child, and lack of another parent to share burden
with AEB inability to be present for her daughter’s hospitalization
Family Coping compromised r/t single mom, three kids [one newborn and one ill child] AEB subjective reports of
mom’s business with the new baby.
Role Relationship:
Health Maintenance-Perception:
Allergies: Cipro: causes a rash
Current immunization status (note source of info): Up to date per
chart
She is status post a right hepatectomy in January and has completed her
34th of 46 rounds of chemotherapy with Isosphamide and Adriamycin,
her last treatment being on 10/9
Neutropenia is due to chemotherapy, along w/ alopecia and anemia. Pt
copes with the side effects of her treatment with dignity and appears for
regular chemotherapy.
Effective Health Seeking Behaviors r/t chemotherapy for treatment
of cancer AEB pt reports for chemo appointments despite the
unpleasant effects, and reported this week for her fever as
requested by physician.
Developmental Stage: Teenager: Identity vs Role
confusion
Lives with single mom, a younger brother of 10
years, and a new baby half-brother.
Her father was killed some years ago due to his
involvement in gang violence.
New baby brother was born in September. This
infant keeps her mother busy: her mother is only
able to spend about an hour at the hosp with pt.
Pt states that she does what she can to help her
mom with the new baby.
Ineffective role performance r/t her family’s
needs for her to perform the role of an adult
instead of that of an ill teenager AEB patient
report that she helps take care of her siblings
rather than being taken care of.
Risk for Loneliness r/t leaving school, moving
away from friends & importance of peers in
teen years AEB (my theory)
Sexuality/Reproductive:
Cognitive Perceptual:
Play needs: teens need social contact, esp with friends and peers. This
patient is meeting her need with: Cell phone [for text messages and
phoning friends], TV [with access to movies], computer [for access to
MySpace,] and some human interaction because she is unable to leave
her room and her mother is unable to be present
Lidocaine LMx4 Topical (prn 30 min prior to phlebotomy or IV attempts),
A&D ointment to peri area prn irritation
Neuro: WNL, appropriate affect, appropriate to developmental stage
Despite the medical complications during her school year, the patient did
graduate 8th grade. The family is looking into educational options for her
to begin high school, and the possibility of home-schooling.
ND: Readiness for enhanced knowledge r/t formal education AEB
desire to start school again with whatever necessary modifications.
Gender: F
Gravida: 0. Pt did not volunteer if she is sexually
active.
Depo-provera IM shot q3mos (due on 11/7)
Prescribed birth control to prevent menses.
Sexual Patterns Effective
Value-Belief:
Chart states no designated spiritual beliefs.
ND: Readiness for enhanced self-concept r/t
pt’s stability of self concept and life choices
post diagnosis AEB pt is effectively planning
and prioritizing her education
III: Day of Care Plan:
Nursing Diagnosis 2: Risk for Infection related to chemo-induced neutropenia and
lympocytopenia as evidenced by fever and blood lab values.
Assessment/ functional pattern: This patient arrived to the ED with a fever of 38.1 and
neutropenia, confirmed by blood tests that also revealed low lymphocytes. Shortage of these
immune cells leaves the body without adequate defense against infection. In this patient’s fragile
state, an infection could kill her from sepsis very rapidly.
Nursing goals/ expected outcome: maintain antiseptic environment, administer prophylactic
medications as ordered, monitor and assess patient for signs of infection or improvement.
Nursing interventions: 'The
nursing student will..........'
1: Maintain universal precautions,
1. It is necessary to prevent pathogens from entering this
wash hands when leaving/entering
patient’s space while her immune system is compromised.
room, between procedures, wipe
If equipment is shared between patients [like a dynamap], it
down equipment when it is brought carries germs with it that can harm this patient.
into the room.
2. Administer prophylactic
2. Setpra, an antibiotic, and Valtrex, an antiviral, given
medications as ordered (Valtrex and prophylactically will offer this patient protection from
Septra)
bacterial and viral infections, respectively, that her body
would normally protect her from in a healthy state.
3. Monitor signs of developing
3. Despite the prophylaxis, she is so at risk that she could
infection: fever, sweating, lethargy, develop an infection in spite of treatment. She is in the
change in LOC, tachycardia,
hospital b/c an infection could cause rapid deterioration and
tachypnea, low UO, diarrhea
would need immediate intervention. (We cannot relate to
her care as “business as usual” and need to stay vigilant.)
4. Minimize guests in the room,
4. By decreasing the number of people contacting this
especially school-aged children.
patient, we lower the number of illnesses she will be
Minimize staff members contacting exposed to. School age children especially pose a risk due
patient, and traffic in and out of the to their developing immune systems and their daily contact
patient’s room (cluster care).
with many people. By clustering our care we manage time
Patient is best staying in her room,
effectively and also minimize periods of exposure. The
however she will need to wear a
patient needs to be protected with a mask from airborne
mask when she leaves.
infection if outside her room.
5. Monitor lab values
5. We would like to see her neutrophils and lymphocytes
increasing to assess the strength of her immune system at
the time of discharge.
5. Teach patient how to protect
5. This patient is likely to become neutropenic again, and
herself at home: hand washing for
lives with 5 other people, 3 of whom are children. Like
herself and others, frequent
any immune compromised patient, the household needs to
cleaning of surfaces, etc
take care to wash their hands when arriving home and use
good hygiene to prevent infection in themselves and this
at-risk patient.
Evaluation (can be current and/or prospective): This patient remained free of infection during
her hospitalization. Her neutrophil count did start rising slightly. No signs or symptoms of
infection developed. Patient was discharged at the expected time. No injury or infection occurred
during hospitalization.
Ineffective role performance related to her family’s needs for her to perform the role of an adult
instead of that of an ill teenager as evidenced by patient report that she helps take care of her
siblings rather than being taken care of.
Assessment/ functional pattern: This patient has a complex family history, and while her family
is intact in the same form that it has been since her father’s death, the distribution of
responsibilities and roles are not optimal. The patient is in the ‘eldest sibling’ position with a 10
year old brother and newborn brother. Her mother needs help with her duties as single-parent to
two kids and a newborn, and in a healthy environment it would be appropriate for this patient to
assist somewhat. This patient is very ill, likely facing a prognosis of a two or three years’
survival, and is out of school, away from friends, and without the ‘normal’ life experiences of a 14
year old: therefore, she needs a good deal of nurturing. However, her mother’s care is likely
absorbed by the new infant, and the patient is not getting to be the child in the situation, but rather
in the role of an extra (and certainly much-needed) adult.
Nursing goals/ expected outcome: That this patient finds the nurturing she needs from her mother,
other adults, friends and relatives.
Nursing interventions: 'The nursing student will..........'
1: Ask the patient who is most
1: Assess the patient’s preferred and available support
helpful to them, who has given
network
them good care, who is most
fulfilling to spend time with.
2. Ask the patient how she is doing 2. I could be wrong: this patient might not be troubled by
with being ill and giving her mom
her situation, may not want her mother’s attention.
help, hear her feelings, ask her what Conversely, she may not have a place to complain and vent,
she does to cope.
or may be denying her needs to herself.
3. Encourage patient to request time 3. Patient’s mother is probably feeling too busy, and needs
with mom and recommend options
time for herself too! She also probably has many errands
for how to spend time one on one
she is overwhelmed with. They could have time together if
with mom. Find out who can help
their housemate tended the baby while mom and patient get
with the baby during this time to
groceries, or mom and daughter could go do something fun
give mom some availability.
together to give mom some respite.
4: Encourage setting up regular
4: Sometimes people need motivation and advice to request
time to spend with supportive
help/attention from friends. This patient has a large group
people, inviting them to
of friends back in Richmond who likely can’t drive, but
hospital/home, ideas to solve
they may be able to visit her by setting up a carpool with a
transportation issues of long-range
parent or using public transportation. She might set up a
visits, how to create time with
weekly visit in or out of her home w/ friends or family to
friends living back in Richmond.
give her social time, support, and an opportunity to get out
of the house.
5. Praise patient’s kind heart,
5. This patient seems to want to ‘do right’ and is certainly
stoicism, and her willingness to
being generous given her circumstance—in fact, she does
help out at home, her empathy for
not behave like a stereotypical ‘self absorbed’ teen. This
her mother
part of her character deserves appreciation, which she may
or may not hear from others enough.
Evaluation: (prospective) this patient identified the people she considers her support. She left
the hospital having made some proposals to people that they spend time together, feels confident
and comfortable about asking for social time with her family and friends. She feels appreciated
for her helpfulness to her mom but also feels no guilt about asking for her own needs to be met.
She and her Richmond friends are creating time together with adequate transportation.
Medication Administration Worksheet
Show all calculations for at least 4 medications per 2 clinical days (at least 2 IV meds!): dose
range and maximum dose for weight, dose to be given, concentration of mixture and volume to
draw up, final dilution and rate to infuse)
1. Medication: Ceftazidime
Dose ordered: 2 gm IV
Pt’s current weight (kg): 54.2 kg
Frequency: Q 8 hrs, to run over 0.5 hour
What is the safe dosage
range** per day & dose:
Patient is on adult dose: 1–2 g q8–12h, up to 2 g q6h
If patient was <12 yo: 30–50 mg/kg/d q8h
Range: 1.6 g-2.7 g Q 8 hrs
What is the maximum dose
for this patient?
2 g Q 6 hrs
How is it reconstituted?
There is a little bottle of powder already attached to a
100mL piggy back bag
Is the ordered
dose safe?
Yes
How is it diluted?
2 gm of powder goes into 100mL D5W
How is it administered? (i.e. solutions, volumes and rate)
“Runs over 0.5 hours”: 100mL/0.5 hr= 200 mL/ hr rate
2. Medication: Valtrex
Dose ordered: 500 mg PO
Pt’s current weight (kg): 54.2
Frequency: 2x/day
What is the safe dosage
range** per day & dose:
For suppression: 1000 mg/ day—no peds ranges provided.
But if she happened to be fighting off chickenpox: 20 mg/kg/PO Q 8 hrs, it
would be 54.2x20 mg= 1,084 mg
What is the maximum dose
for this patient?
1000 mg
How is it reconstituted?
Is the ordered
dose safe?
Yes
How is it diluted?
How is it administered? (i.e. solutions, volumes and rate)
3. Medication: Colace
Dose ordered: 250 mg PO
Pt’s current weight (kg): 54.2
Frequency: BID
What is the safe dosage
range** per day & dose:
What is the maximum dose
for this patient?
How is it reconstituted?
for 6- 12 yo: 40-150 mg/day, no weight constraints.
This pt appears to be on adult dosing b/c she doesn’t fit the pediatric range for
this medication.
The adult dose; 50-500 mg/day
Is the ordered
500 mg/day [or 250 bid]
Yes
dose safe?
How is it diluted?
How is it administered? (i.e. solutions, volumes and rate)
4. Medication: Septra (trimethoprim-
Dose ordered: 120 mg
sulfamethoxazole): note: Septra dosing is usually
based on the amount of trimethoprim or “TMP”
Pt’s current weight (kg): 54.2
Frequency: PO bid
What is the safe dosage
range** per day & dose:
Prophylaxis: 150 mg/m2 TMP/750 mg/m2 SMZ b.i.d. for 3 consecutive d/wk
(max: 320 mg TMP/d) ---No range.
However, if she was being treated for the infection: 8–10 mg/kg/day TMP, or
have a range of 434-542 mg/day
What is the maximum dose
for this patient?
320 mg/day, she gets
240 mg/day
How is it reconstituted?
Is the ordered
dose safe?
Yes
How is it diluted?
How is it administered? (i.e. solutions, volumes and rate)
**(i.e. use the low to high mg/kg/day-or- mg/kg/dose range to calculate specific dose range for this patient,
weight):
References
Ackley, B, Ladwig, G., (2004). Nursing diagnosis handbook: A guide to planning care,
(6th Ed.) St. Louis: Mosby.
Carpenito, L. (2002). Nursing diagnosis: Application to clinical practice. Philadelphia
PA: Lippincott.
Hockenberry, M., Wilson, D. (2008). Wong’s nursing care of infants and children (8th
Edition). St. Louis, MO: Mosby Publishing Company
Sakellaridis, T, et al. (2006) Undifferentiated embryonal sarcoma of the liver mimicking
acute appendicitis. Case report and review of the literature. World Journal of
Surgical Oncology, 4:9.