Case Study 82

\CRANIAL REGULATIUN N Class/Group Daty Scel ght to the emergency department (ED) by his mott « The mother is young and appears frightened dnd"" Who s H._has not been eating, sleeps all of the time, and is * ndnx'“(:s Thre s ot normg|» ‘9 ome of the N icles you need to consider, recognizing that M Mrs, H., 1. Whatares i i Br By erform your primary assessment and question Mrs. H. with a translat ator. Whij chf 2. Youp re abnormal and need to be upumd? \],_ -t all that apply and sta g~ te @Hn.h pitched cry s}"mlfln* ,Ugt\ ‘-vtC LQJ rationale, d+3 Ild,n;‘\ b. l’urlluqunl an ¢. Heart rate: 85 d. Positive Babinski reflex () Refusal of PO intake per mother e shoulfd B2 sw KISC tan 4 (T Anterior fontanel palpable and te Temperature 3 36° C (96. 8° F) rectally indieae ‘1 fow - 6 Intracranial Regulat 3. Place an X where you would assess the Babinski reflex on an infant 368

C HAPTER 6 INTRACS AL REGU 10 A J /82 - mnlh'l“ulh('uu dical unit with 1 with the diacne g ac JH P \,\l"“"”““ shown in the chart ,art View ",”,(.,“ y Department Orders nersg (B with { culture ch differential A ”“,h,mpnul fluid (CSF) for culture, glucose prot otein, ce| (Rocephin) 260 mg IV count ( B IV now (loading dos, unt (after lumbar puncture) .vllll.l\mll‘ jcillin 400 mg IV now and then every 6 | rs on 5 ' > ,(.phx n 50 mg per rectum for irrit ability x > Y X 1 dose cetam!? 504 NS to Infuse at 15 mL/hr -w 0.4 the order of your interventio ns, with | being your first 5 Ist action 7 and 7 being your last rion . _ Administer ceftriaxone and Ampicil] n 1 ? 2. Place IV i 3. sgrqxght catheterization for urine specime; . Place on contact isolation and droplet p (.” Assist with lumbar puncture - Administer acetaminophen ~ Obtain blood culture, CMP [FINN E)\ N o : jcult time plac . [V 5 e i .‘h le y } e the IV line, and the physic one IM while you wait for the vascular access team "')th” f‘]‘”“" an order to give the ce the [V. Name the appropriate 5 .n IM injection for an infant. \ Vistus Iemlis ) dministering the ceftriaxone and Ampicillin e o X 6. \ic range is for Rocephin 100 mg/kg loadi »You verify the dose with another RN. The t : 6 ing dose and then 80 to 100 mg/kg daily. The ic range for Ampicillin is 200 to 400 mg/k . 2 : /kg/day in 4 divi : : e of 12 g/day. J.H. weighs 3.5 kg. I the | 2, ivided doses with a maximum 8 7 i I oading 4 3 7 Is the ordered dose for Ampicillin, “-g"'k'ni‘\’::; ::icrcd f(w;' Ru:;;»i)lhm safe? I: urs, safe and therapeutic? gyl S Ll 035 j_s Efio% L\(’O"“fi:’T\OL?% | S S e oud {’N“\Pflkkc 100\ 0 dni\y ‘ Woab = Q0 - WY . L0 & Ll(\“ &‘XU\B(\(’ 7 —— v