Pediatric Clinical Reasoning Case Study: Poison IngestionCreated by Kathleen Mixson, RN, MS, JDI. Data CollectionChief complaint/History of Present Illness: Brandy is a 22 month .old female presenting with ingestion at 10:30 pm yesterday of estimated 1/2 tsp of solder flux and immediately had vomiting of about 12 times, taken immediately to the emergency room. No vomiting since around 3 am but continues to have gagging and retching. No diarrhea. Has raspy voice, fussiness. Had chemistries, LFTs, CBC, IV started in ER. Acute ingestion of zinc chloride-containing solder flux (contains 30-36% zinc chloride), which is caustic to GI tract, skin, and eyes. Also if significant systemic absorption occurs, systemic toxicity may include altered mental status, renal insufficiency. Patient to be admitted for observation and monitoring for systemic effects. If no respiratory distress or abnormal labs the plan is to discharge this afternoon. What data is relevant to this patient that must be recognized as clinically significant to the nurse?
Personal/Social History: Mom and dad at bedside. Lives with parents. English speaking
PMH: Allergic rhinitis, night-time cough, thought to have seasonal allergies as a cause of chronic vomiting. Born at 36 weeks gestation, no complications, SVD.
Current Medications: None
Patient Care Begins:Your Initial VS:T: 97.9º FP: 118R: 38BP: 100/76O2 sats: 98% on 2L per NC Weight: 15,2 kgPain: 3/10 FLACC
What VS data is relevant to this patient that must be recognized as clinically significant to the nurse?
Your Initial Nursing Assessment:GENERAL APPEARANCE: Fussy, irritable and requiring frequent comforting from parents.RESPIRATORY: Breath sounds equal and with good aeration bilaterally. No stridor or nasal flaring. Mom states continued raspy voice.CARDIAC: Heart rate regular-S1S2. Pulses palpable and equal bilaterally. Capillary refill less than 3 seconds.NEUROLOGIC: Alert with normal muscle tone and movement of extremities.ABDOMEN/GI: Currently NPO. Mouth and throat red and raw looking. Abdomen soft, non-tender with active bowel sounds all four quads. GENITOURINARY: Voiding per diaper. EXTREMITIES/SKIN: Skin is warm and dry-normal for color of skin. IV in place to right hand, infusing D5 ½NS at 42 per hour. Site without redness or edema. Hands equal bilaterally.
What assessment data is relevant that must be recognized as clinically significant to the nurse?
II. Clinical Reasoning BeginsWhat is the most likely medical problem that your patient is presenting with?
What is the underlying cause /pathophysiology of this concern?
What is your primary nursing priority right now?