Marquez, C.

BSN 2B
Case Study 104
J.H. is a 2-week-old infant brought to the emergency department (ED) by his mother, who speaks little
English. Her husband is at work. She is young and appears frightened and anxious. Through a translator,
Mrs. H. reports that J.H. has not been eating, sleeps all of the time, and is “not normal.”
1. What are some of the obstacles you need to consider, recognizing that Mrs. H. does not speak or
understand English well?
Due to the lack of knowledge and ability to communicate, language barriers restrict people’s ability to
learn from their environment. The nurse may not be able to thoroughly understand Mrs. H, which
significantly decreases the ability of the nurse to conduct and provide effective care to meet patient's
needs. Understanding language obstacles can aid nurses in developing suitable methods to overcome
them and, as a result, improve the quality of care provided to patients with language difficulties in any
clinical setting in any healthcare system. An interpreter is needed in this type of situation. A medical
interpreter helps patients and nurses communicate across cultural barriers.
2. You perform your primary assessment and question Mrs. H. with a translator. Which of these findings
are abnormal and need to be reported? (Select all that apply and state rationale.)
a. Anterior fontanel palpable and tense
- Although the anterior fontanel can be felt, it should be soft and flat rather than tense. This "tense"
feeling might suggest fontanel bulging, which could imply increased intracranial pressure,
infection, or bleeding. Infection of the membranes that cover the brain results in a bulging
fontanel. With the bulging of the fontanels, the brain expands, leaving less space for fluid
circulation.
b. Pupils equal and +3
c. Temperature 36° C rectally
d. Heart rate: 85 beats/min
- Symptoms of sepsis include: a temperature of 96.8ºF (36ºC) and fast heart rate.
e. Positive Babinski's reflex
f. High-pitched cry
- A high-pitched cry may indicate increased intracranial pressure.
g. Refusal of PO intake per mom
- A sick child will normally be reluctant to take in fluid. The patient is unable to verbalize this but
exhibits these symptoms by not eating and drinking. This is considered not normal because when a
person doesn't eat, his body doesn’t obtain the fuel he needs, and his organs and body components
may suffer as a result.

J.H. is admitted to the medical unit with the diagnoses of meningitis and rule out sepsis.
The ED physician orders the following:
Emergency Department Orders
CBC with differential
Blood culture
Complete metabolic panel (CMP)
Urinalysis (UA)
Cerebrospinal fluid (CSF) for culture, glucose, protein, cell count (following lumbar puncture)
Ceftriaxone (Rocephin) 260 mg IV ow (loading dose)
Acetaminophen (Tylenol) 50 mg suppository per rectum for irritability

3. Prioritize the order of your interventions, with 1 being your first action and 7 being your last action.
6 Administer ceftriaxone (Rocephin)
4 Place IV
5 Straight catheterization for urine specimen
1 Place for contact isolation and droplet precautions
 2 Assist with lumbar puncture
7 Administer Tylenol
3 Obtain blood culture, CMP

4. Before administering the ceftriaxone (Rocephin), you must verify the dose with another RN. The
therapeutic range is 100 mg/kg/day divided in two doses. J.H. weighs 3.5 kg. Is the dose ordered
safe? (Show your work.)
The therapeutic range of ceftriaxone (Rocephin) is 100 mg/kg/day divided in two doses. Since the
patient’s weight is 3.5 kg:
3.5 kg x 100 mg/kg/day = 350 mg/day
350 mg / 2 doses = 175 mg/dose
175 mg/dose is therapeutic range.
The loading dose is 260 mg in two divided doses, meaning 130 mg per dose which is safe for the
patient.

5. Interpret J.H.'s lab findings, and explain the rationale for abnormal result
Laboratory Test Results
Urine
pH - 7.2: normal
Color - Clear: normal
Leukocytes - Negative: normal
Complete Blood Count
HCT 32%: low
- HCT Normal Range for 0–1-month-old: 42-65%
- A lower-than-normal hematocrit may indicate an insufficient supply of healthy red blood cells.
HgB 10.5 g/dL: low
- HgB Normal Range for 0–1-month-old: 13.4-19.9 gm/dL
- Most infants have some anemia in the first few months of life because the baby's body is
growing fast and it takes time for red blood cell production to catch up.
WBC 22,000/mm 3: high
- WBC Normal Range for 0–1-month-old:
- High white blood cell count (leukocytosis) means having too many leukocytes circulating in the
blood, usually from having an infection. 
Sodium 125 mEq/L: low
- The normal range for blood sodium levels is 135 to 145 milliequivalents per liter (mEq/L).
- Low sodium level may indicate hyponatremia which is an electrolyte abnormality that occurs in
infancy due to a variety of inherited and acquired disorders. Infants with hyponatremia can
present with neurologic symptoms such as vomiting, weakness, and seizures.

6. Interpret the CSF findings. Would you suspect bacterial or viral meningitis? Why?
Cerebrospinal Fluid Analysis
CSF Clear
Gram stain Pending
Protein 300 mg/dL – elevated (Normal Range: 15-45 mg/dL) Raises with bacterial as left over
from bacteria metabolizing glucose. Protein stays normal with virus.
Leukocytes 1030 cells/microliter – elevated (Normal Range: 0-20)
Glucose 40 mg/dL – decreased (Normal Range: 50-75 mg/dL)

Based on these data, J.H. has bacterial meningitis, as evidenced by the high protein level, increased
white blood cells, and decreased glucose level (Edwards, 2013). CSF protein levels greater than
250 mg/dL indicate bacterial meningitis, while levels between 50 and 250 mg/dL indicate viral
meningitis; white blood cells greater than 1000 indicate bacterial meningitis, while less than 1000
 indicate viral meningitis; and a CSF glucose level between 10 and 45 indicates bacterial meningitis,
according to the article ‘Meningitis in Children' (Richard, 2013).

7. What are the most common pathogens in this age group?

Several strains of bacteria can cause acute bacterial meningitis, most commonly:
 Streptococcus pneumoniae (pneumococcus)
 Neisseria meningitidis (meningococcus)
 Haemophilus influenzae (haemophilus)
 Listeria monocytogenes (listeria)

J.H. is diagnosed with Escherichia coli meningitis. His medical care plan will include 14 to 21 days of
antibiotic therapy. You are developing his nursing plan of care.
8. Outline a plan of care for J.H., describing nursing interventions that would be appropriate for
managing pain and infection, maintaining hydration, assisting with increased intracranial pressure
(ICP), and teaching to review with his parents.

ASSESSMENT PLANNING INTERVENTION RATIONALE

S – “J.H. has not been Short-term goal  Manage pain and  to enhance muscle
eating, sleeps all of the infection with relaxation and
time, and is “not Wholly compensatory
medications as reduce discomfort
normal”.”
After 21 days of ordered, and  This is a first-line
O- intervention, the provide defense against
 Anterior patient’s pain and nonpharmacological healthcare-
fontanel infection will be interventions if associated
palpable and managed, maintained needed. infections (HAIs).
tense hydration, assisted
 Practice and  Hydration can help
 Temperature with increased
intracranial pressure emphasize constant prevent the
36° C rectally
 Heart rate: 85 (ICP), and gave and proper hand accumulation of
beats/min teachings to review hygiene. Wear viscous secretions
 High-pitched with his parents. gloves to minimize and improve
cry contamination of secretion
 Refusal of PO hands, and discard clearance.
intake after each client.  To reverse/correct
Wash hands after contributing
glove removal. factors of bacterial
Instruct the meningitis.
client/significant  The beliefs of
other (SO)/visitors individuals directly
to wash hands. involved with the
 Increase fluid intake client and the
to at least 2,000 situation are
mL/day within important to
cardiac tolerance understanding the
(may require IV in new roles
acutely ill, individuals are
hospitalized client). undertaking.
Encourage/provide
warm versus cold
 liquids as
appropriate.
Provide
supplemental
humidification, if
needed (ultrasonic
nebulizer or room
humidifier).
 Provide seizure
precautions and
antiseizure
medication, as
indicated.
 Interview SO(s)
regarding their
perceptions and
expectations.

Mrs. H., through her translator, asks you what could have caused her baby to be sick since he had an
immunization when he was born. She asks whether he should get “more shots” so this won't happen
again. You reinforce to Mrs. H. that infants have immature immune systems, and they are vulnerable
to infections until they have been immunized. Mrs. H. asks when J.H. will get more shots and what
will they be?
9. According to the CDC immunization schedule, which of the following immunizations will J.H. receive
at 2 months?
a. Hib
b. MMR
c. OPV
d. IPV
e. Rotavirus
f. DTaP
g. Varicella
h. Hep B
i. Pneumococcal

10. What is the impact of hospitalization on J.H.'s growth and development?

Children who receive long-term critical care may be exposed to many types of trauma, which can
impair their cognitive, emotional, and psychosocial development. Sleep problems, separation anxiety,
and reversion to lower developmental stages are all affected by longer hospitalizations.

11. J.H. is being discharged after 3 weeks of IV antibiotic therapy. What educational topics will be
important to discuss with J.H.'s parents when he is discharged?
Educate parents on ways to minimize transmission, such as maintaining good hygiene to avoid direct
contact with respiratory secretions (Caple, 2013). Also, make sure that J.H. receives immunizations to
prevent future illnesses. Follow-up visits must be recommended to monitor the patient’s progress.
CASE STUDY OUTCOME
J.H. is discharged to home with his parents. He will continue PO antibiotics for 1 week and receive a
home health visit for infant care follow-up. He is to return to his PCP in 1 week or call for any
concerns.

References:
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Separation Anxiety" (2020). Nursing | Senior Theses. 17.
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table.pdf
Schupak, A. (2016). Here’s Exactly What the Color of Your Pee Says About Your Health. Retrieved from
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Virgo, P. (n.d.) Children’s Reference Ranges for FBC. Retrieved from
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