Case Study

Ellie Mae, a 5-month-old female, presents to the emergency department with respiratory
distress, hypoxia, and fever. Her parents state that she has had cold symptoms for a few days.
She has fed poorly over the last few days with a decreased number of wet diapers. You take
her vital signs and a complete initial assessment.

Chart View
Vital Signs
Blood Pressure 130/72 mm Hg
Respiratory Rate 83 breaths/min
Heart Rate 188 beats/min
Temperature 38.4°C (101.1°F)
SaO2 88% on room air
Weight 8 kg

Initial Assessment
Neurologic Alert, fussy, consoles briefly, anterior fontanelle soft and
slightly depressed
Cardiovascular Tachycardia; capillary refill less than 3 seconds
Respiratory Upper airway congestion; coarse cough; tachypnea,
transient bilateral wheezing; breath sounds coarse and
decreased slightly at bases; mild intercostal retractions
GI + bowel sounds; last BM yesterday
GU decreased urine output (per history); no urine output in
the last 4 hours
Skin no rashes; slightly flushed
Other Mucous membranes “sticky”; decreased tearing

Emergency Department Orders

Acetaminophen (Tylenol) 60 mg PO for fever
Normal Saline (NS) bolus 20mL/kg IV bolus
Oxygen to keep saturations greater than 93%
Nebulizer trial of albuterol (Proventil) 2.5 mg

1- Review the ED orders. Prioritize your interventions with rationales.

2- Based on Ellie Mae’s vital signs and assessment, what diagnostic tests would you
anticipate being ordered?

3- Calculate how much normal saline Ellie Mae will receive as a bolus.
Case Study Progress
Ellie Mae begins coughing and has copious secretions. You provide nasopharyngeal suctioning
and obtain a large amount of thick secretions. She is allowed to recover and is reassessed.
The respiratory rate and retractions have not changed significantly. Her breath sounds are less
coarse but are diminished in the bases. The Sao 2 is now 92% to 93% on 1.5 L oxygen. After
Ellie Mae settles, her mother asks whether she can feed her because she has not eaten much
for the past few days. You tell her that with a current respiratory rate of greater than 65
breaths/min, she should not be fed.

4- What is the rationale for holding any feedings?

5- When Ellie Mae’s respiratory rate decreases, what teaching would you provide the
parents concerning her feedings?

Case Study Progress

Ellie Mae’s mother calls you to the room because her baby is “not right.” You note that Ellie
Mae’s respiratory rate is 23 breaths/min, and the retractions have increased. The SaO 2 is 89%
on 1.5 L of oxygen. She is pale and listless and does not cry with stimulation

6- Why is the respiratory rate significantly lower even though other signs of respiratory
distress have increased?

Case Study Progress

You are concerned and call the Rapid Response Team. The Senior Resident orders a portable
chest x-ray (CXR) and capillary blood gas (CBG). The CXR is consistent with bronchiolitis with
atelectasis.
Ellie Mae is transferred to the pediatric ICU and is placed on a continuous positive airway
pressure (CPAP) machine. You know from experience that patients are usually on CPAP for a
couple of days before they are ready to be taken off and continue to improve until they are
ready for discharge. You explain this to her parents who are very distressed.

7- What resources might you seek for Ellie Mae’s parents during this unanticipated change
in her status?
Case Study Progress
Following 2 days in the PICU, Ellie Mae is transferred back to your unit. You note that she is
taking increased oral fluids ad requiring less suctioning. Her SpO 2 is 96% to 98% on room air.
As you are preparing the parents for discharge, they want to know how they can prevent this ij
the future. They ask whether there is a “shot” Ellie Mae can get to avoid getting this again.

8- How would you address their concerns?

9- Mr. and Mrs. Matthews ask you for instructions about the treatment of cold symptoms if
Ellie Mae develops them again. Which answer is your best reply?
a. “Over-the-counter cough suppressants may be safely administered at night.”
b. “If a fever is present, you can treat the fever with baby aspirin.”
c. “Saline nose drops and bulb suctioning can be done before feedings.”
d. “You do not need to worry if she is not drinking; intake should improve in a day
or so.”