Question

Background Information: Alison is a 12 month old who has been vomiting for the past 12 hours. Since waking at 6 AM she has "not held anything down." It is now 5:30 PM and Alison's mother is becoming concerned. She calls the primary care office and the nurse recommends that Alison be brought into the office for evaluation. On initial assessment, Alison is lethargic and very quiet. Her lips and skin are dry. She is crying at times, but does not produce tears. Her diaper is dry; her mother says that she has not needed to change her diaper since 7 AM.

Alison lies very quietly on the examination table. Her vital signs are: Temperature: 101O F Apical Rate: 150 bpm Respiratory Rate: 40 breaths per minute Blood pressure 90/48 Birth weight: 8 lbs Current weight: 21 lbs 6 oz Weight at 12 month visit 2 weeks ago: 24 lbs 2 oz

Alison's mother reports that she loves her milk and usually drinks about 40 ounces per day. However, for the past 24 hours she has not wanted anything to eat or drink. Her mother wants to know if there is anything that the nurse can give Alison to help stop the vomiting.

The nurse obtains the additional physical assessment data and completes dependent nursing interventions:
o Patient ID band placement
o Patient weight and vital signs
" Weight is 21 lbs or 9.5 Kg
" Temperature 102O F rectally, Heart rate 145, Respiratory rate 39, BP 92/45
" Physical assessment of patient
" Chest congestion and bilateral coarseness with a slight expiratory wheeze, dry cough, nasal congestion, left tympanic membrane is bulging and erythematous and Alison seems bothered when the nurse touches her ears
o Urine catherization
o Assess for need of antipyretics at this time
o Draw lab work as ordered
" CBC, CMP, blood cultures, sed rate, urinalysis, urine culture
o Obtain peripheral IV access
o Spinal tap with proper preparations and aseptic technique prior to collecting cultures

During the insertion of a peripheral IV, Alison lies quietly throughout the procedure.

A fluid bolus is ordered by the physician and after administration of the bolus; Alison perks up a little bit. The doctor then orders Tylenol for the patient. The order reads as follows:

Acetaminophen 650.0mg prn pain/fever q 4 hours

Is this order appropriate for Alison?

Using the pediatric reference guide, determine if this is a safe dosage for Alison?

What would be appropriate actions for the nurse to take at this time? Why?

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Calculate Alison's daily maintenance fluid requirements and expected hourly output.

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After notifying the doctor of the medication dosage, he changes the order to read:

Acetaminophen 120 mg prn for pain/fever q 4 hours; NSS bolus.

He also orders a 250 cc NSS IV bolus stat. Would this bolus be appropriate for Alison? Why or Why not? What actions would the nurse take? Why? Are there any factors to consider if the physician orders IV fluids with additives in them such as K+? Why or why not?

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What are the nursing responsibilities when administering medications?

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After administering the Acetaminophen, the nurse discovers that Alison's temperature is now at 100.4o F rectally and she has a wet diaper. She is beginning to cry and her mother asks for a bottle. She hands the bottle to Alison and Alison refuses to hold her own bottle. When asked, her mother says, "Oh she is just lazy. She won't stand up on her own either!"

Why does this concern the nurse?

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Answer 1

1. According to the pediatric dosage reference , the dosage with respect to the age of the infant is 120 mg per dose .

For 18 to 23 lbs it's 120 mg that is 3.75 ml of Tylenol syrup.

The nurse should appropriate action is to double check the dose with the physician because :-

- It might lead to drug overdose

- Increase in side effects

- Medical negligence

2. Daily maintenance fluid requirement a infant of 9.6 kg ( 21 lbs 6 ounze = 9.6 kg ) is 100 ml / kg

The normal or expected urine output is 1to 2 ml /kg / hr means 9.6 to 19.2 ml

3. No, the action was not appropriate, total fluid volume for fluid replacement is given in divided doses. 100 ml /kg is the maintainable fluid requirement for a day . Again she should dou let check the fluid dose with physician because it will lead to hypervolemia in infants .

Yes ,the physicians might order additives in the fluid like potassium due replace the lose of electrolytes due to dehydration .

4. Nursing responsibilities during administration of medications are :-

Following the 6R's :-

- Right patient

- Right drug

- Right route

- Right dose

- Right time

- Right documentation

Explain the patient before administration of medicine about the actions ,side effects etc .

Double check the dose with the second nurse before administration

Check the expiry date of the medications.