I spoke with the patient’s primary care provider, neurologist, neurosurgeon, and ophthalmologist one month after the patient was discharged. The patient was doing well at home, but occasionally had “bad dreams” that would awaken him at night. He attributed these to the events that took place after his injury.
He is also afraid of walking alone and near the park. His wound continues to heal without signs of infection. Neurologically, he has had no seizures or complaints. His left visual fi eld still remains slightly affected, and he will need an MRI in the near future (D2, C1, PO D, E).
Very little is known about the psychological outcomes of serious injury in children and adolescents. The association of risk factors for PTSD and inci- dence rates that have been studied in injured adults may be different in injured children and adolescents. A literature review suggests that developmentally sensitive assessment of symptoms after trauma may be more valid than the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, because symptoms of PTSD differ substantially between children and adults. These studies suggest that many children are underdiag- nosed because of the utilization of current DSM-IV criteria. Because injury is the leading cause of death and morbidity in patients 19 years and younger and injury accounts for more hospitalizations and outpatient treatment than any other health condition, healthcare professionals need to be cognizant of the risk factors associated with PTSD in children for appropriate detection (McIntosh & Mata, 2008).
CEBM, level 3.
COMPETENCY DEFENSE
Domain 1, Competency 3. Formulate differential diagnoses and diagnostic strategies and therapeutic interventions with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy
Chapter 9 Adolescent Male With Traumatic Brain Injury
115
for patients who present with new conditions and those with ambiguous or incomplete data, complex illnesses, comorbid conditions, and multiple diag- noses in all clinical settings.
Defense. This patient’s differential diagnoses were essentially based on the history and physical. Clinical fi ndings of ataxia, headache, and an old trau- matic wound led me to obtain a diagnostic head CT scan, which ultimately led to the diagnosis of a gunshot wound to the head.
Domain 1, Competency 4. Appraise acuity of patient condition, deter- mine need to transfer patient to higher acuity setting, coordinate, and manage transfer to optimize patient outcomes.
Defense. Based on trauma protocols, a gunshot wound to the head deems a heightened acuity and the involvement of subspecialty services such as neurosurgery.
Domain 1, Competency 5. Evaluate and direct care during hospitaliza- tion, and design a comprehensive discharge plan for patients from an acute care setting.
Defense. With the collaboration of inpatient specialists, formulating an outpatient plan was essential for the recovery of this patient. The input from each team member aided in the care during and after hospitalization. Without that team network, care would have been compromised. I was able to coor- dinate communication between these specialists so that comprehensive care was delivered.
Domain 3, Competency 1. Construct and evaluate outcomes of a cultur- ally sensitive, individualized intervention that addresses the specifi c needs of a patient in the context of family and community.
Defense. Hmong culture roots its beliefs in naturopathic remedies for ailments that are likely caused from evil spirits. Understanding this concept allowed me to address my fi ndings in a culturally sensitive way that under- lined the urgency and importance of this diagnosis and the treatment needed.
If I had not been able to recognize and communicate, this case might have turned out differently and shared decision-making would not have been achieved.
Domain 2, Competency 1. Assemble a collaborative interdisciplinary network, and refer and consult appropriately while maintaining primary responsibility for comprehensive patient care.
Defense. Collaborative care was needed with specialty services for this patient because he suffered visual acuity loss, an operation, and possible post-traumatic stress. I maintained primary responsibility while working with this team to provide comprehensive care for this child and his family.
Medications
Drug: Phenytoin (Dilantin)
Dose range
Loading dose: 15–20 mg/kg; based on phenytoin serum concentrations and recent dosing history.
(continued)
Maintenance dose: Same as IV maintenance dose per day listed previously.
Divide daily dose into 3 doses per day when using suspension, chewable tablets, or nonextended release preparations.
Method of administration in this case: IV and PO.
Mechanism of action: Stabilizes neuronal membranes and decreases sei- zure activity by increasing effl ux or decreasing infl ux of sodium ions across cell membranes in the motor cortex during generation of nerve impulses.
Clinical uses: Management of generalized tonic-clonic (grand mal), simple partial, and complex partial seizures; prevention of seizures following head trauma or neurosurgery.
Side effects
Common: Slurred speech, dizziness, drowsiness, lethargy, nausea, vomiting.
Serious: Heart block, bradycardia, Stevens-Johnson syndrome, coma, ataxia, dyskinesia.
Drug: Acetaminophen with Codeine (Tylenol)
Dose range
Codeine: 0.5–1 mg/kg/dose every 4–6 hours; maximum dose: 60 mg/dose.
Acetaminophen: 10–15 mg/kg/dose every 4–6 hours; do not exceed 5 doses in 24 hours; maximum dose for children ≥ 12 years: 4 g every 24 hours.
Method of Administration in this case: PO.
Mechanism of action: Inhibits the synthesis of prostaglandins in the cen- tral nervous system (CNS) and peripherally blocks pain impulse genera- tion; produces antipyresis from inhibition of hypothalamic heat-regulating center; binds to opiate receptors in the CNS, causing inhibition of ascend- ing pain pathways, altering the perception of and response to pain; causes cough suppression by direct central action in the medulla; produces gener- alized CNS depression. Caffeine (contained in some non-U.S. formulations) is a CNS stimulant; use with acetaminophen and codeine increases the level of analgesia provided by each agent.
Clinical uses:Relief of mild-to-moderate pain.
Side effects
Common: Nausea, vomiting, constipation.
Serious: Hepatic toxicity, respiratory depression, bradycardia, elevated intracranial pressure.
Drug: Cefazolin (Ancef)
Dose range
Infants and children: 25–100 mg/kg/day divided every 6–8 hours; maximum dose: 6 g/day.
Mild-to-moderately-severe infections: 25–50 mg/kg/day divided every
6–8 hours. (continued)
Chapter 9 Adolescent Male With Traumatic Brain Injury
117
Severe infections: 100 mg/kg/day divided every 6–8 hours.
Method of Administration in this case: IV.
Mechanism of action: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins and interfering with the fi nal trans- peptidation step of peptidoglycan synthesis resulting in cell wall death.
Clinical uses:Treatment of respiratory tract, skin and skin structure, urinary tract, biliary tract, bone and joint infections, and septicemia due to susceptible gram-positive cocci (except Enterococcus); some gram-negative bacilli, includ- ingEscherichia coli, Proteus, andKlebsiella, may be susceptible; perioperative prophylaxis; bacterial endocarditis prophylaxis for dental procedures.
Side effects
Common: Urticaria, transient elevation of ALT, AST, and alkaline phos- phatase, diarrhea, nausea, vomiting.
Serious: Anaphylaxis, seizures, renal failure.
Drug: Docusate Sodium (Colace)
Dose range
6–12 years: 40–150 mg/day in 1–4 divided doses.
Adolescents and adults: 50–400 mg/day in 1–4 divided doses.
Method of Administration in this case: PO.
Mechanism of action: Reduces surface tension of the oil-water interface of the stool, resulting in enhanced incorporation of water and fat and allowing for stool softening.
Clinical uses: Stool softener in patients who should avoid straining during defecation and constipation associated with hard, dry stools; prophylaxis for straining (Valsalva) following myocardial infarction. A safe agent to be used in elderly; some evidence that doses < 200 mg are ineffective; stool softeners are unnecessary if stool is well hydrated or “mushy” and soft;
shown to be ineffective used long-term.
Side effects
Common: Rash, diarrhea, abdominal cramping.
Serious: Intestinal obstruction.
Drug: Ondansetron (Zofran)
Dose range: Children 6 months to 18 years: 0.15 mg/kg/dose infused 30 minutes before the start of emetogenic chemotherapy, with subsequent doses administered 4 and 8 hours after the fi rst dose.
Method of administration in this case: IV.
Mechanism of action: 5-HT3 receptor antagonist. It works by blocking the action of serotonin, a natural substance that may cause nausea and vomiting.
Clinical uses: To prevent nausea and vomiting.
(continued)
References
Berlin, E., & Fowkes, W. (1982). A teaching framework for cross-cultural health care. Western Journal of Medicine, 139, 934–938.
Guerrini, R. (2006). Epilepsy in children. Lancet, 367, 499–524.
Helsel, D., Mochel, M., & Bauer, R. (2005). Chronic illness and Hmong shamans. Journal of Transcultural Nursing, 15, 150–154.
Her, C., & Culhane-Pera, K.A. (2004). Culturally responsive care for Hmong patients. Collabo- ration is a key treatment component. Postgraduate Medicine, 116, 51–53.
Linder, S.L. (2007). Post traumatic headache. Current Pain and Headache Reports, 11, 396–400.
McIntosh, S., & Mata, M. (2008). Early detection of post traumatic stress disorder in children.
Journal of Trauma Nursing, 15, 126–130.
Stein, S.C., Burnett, M.G., & Glick, H.A. (2006). Indications for CT scanning in mild traumatic brain injury: A cost-effectiveness study. Journal of Trauma, Infection and Critical Care, 61, 558–566.
Taketomo, C.K., Hodding, J.H., & Kraus, D.M. (2008). Pediatric dosage handbook. Hudson, OH:
Lexi Comp.
Twiss, S.B. (2006). On cross cultural confl ict and pediatric intervention. Journal of Religious Ethics, 34, 163–175.
Young, K.D., Okada, P.J., Sokolove, P.E., Palchak, M.J., Panacek, E.A., Baren, J.M., Huff, K.R., McBride, D.Q., Inkelis, S.H., & Lewis, R.J. (2004). A randomized, double-blinded, placebo- controlled trial of phenytoin for the prevention of early posttraumatic seizures in children with moderate to severe blunt head injury. Annals of Emergency Medicine, 43, 435–446.
Side effects
Common: Constipation, diarrhea, abdominal pain, fl ushing.
Serious: Weakness, musculoskeletal pain, tremor, twitching, ataxia, acute dystonic reaction (rare), hypokalemia (rare). (Taketomo, Hodding, & Kraus, 2008).
119
Neonate With a Rare Congenital Lung Anomaly
I have selected this case to document the comprehensive management of a pediatric patient diagnosed with a rare congenital lung anomaly, who presented with respiratory distress in the neonatal period. The patient was initially seen at an academic medical center and has commercial insurance. The following case focuses on three encounters that occurred over a one-month period in both inpatient and outpatient settings. This case narrative demonstrates my ability to meet the following Columbia University School of Nursing Doctoral Competencies for Comprehensive Direct Patient Care.
DOMAIN 1, COMPETENCY 1
Evaluate patient needs based on age, developmental age, family history, ethnicity, and individual risk including genetic profi le to formulate plans for health promotion, anticipatory guidance, counseling, and disease preven- tion services for healthy or sick patients and their families in any clinical setting.
10
Sabrina Opiola McCauleyPO A. Identify a potential genetic risk.
PO C. Evaluate individual patient needs based on age, developmental stage, family history, ethnicity, and individual risk.
PO D. Formulate a plan that addresses health promotion, anticipatory guid- ance, and/or disease prevention for the family.
DOMAIN 1, COMPETENCY 3
Formulate differential diagnoses, diagnostic strategies, and therapeutic interventions with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy for patients who present with new conditions and those with ambiguous or incomplete data, complex illnesses, comorbid conditions, and multiple diagnoses in all clinical settings.
PO A. Formulate a differential diagnosis for a patient who presents with new undifferentiated signs and symptoms.
PO C. Discuss the rationale for the differential diagnosis.
PO D. Discuss the rationale for the diagnostic evaluation with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adher- ence, and effi cacy.
DOMAIN 1, COMPETENCY 4
Appraise acuity of patient condition, determine need to transfer patient to higher acuity setting, coordinate and manage transfer to optimize patient outcomes.
PO A. Assess the acuity of patient status.
PO B. Determine the most appropriate treatment setting based on level of acuity.
PO D. Implement plan to transfer the patient to a higher level of care utilizing written and oral communication.
PO E. Coordinate care during transition to the higher acuity setting.
DOMAIN 1, COMPETENCY 5
Evaluate and direct care during hospitalization, and design a comprehensive discharge plan for patients from an acute care setting.
PO A. Assess the acuity of patient’s condition and determine the most appropriate inpatient treatment setting based on level of acuity.
PO B. Actively participate in the admission process to the appropriate inpatient treatment setting.
PO C. Actively co-manage patient care during hospitalization.
PO D. Formulate plan for ongoing care to be provided in a subacute setting such as long-term care facility, rehabilitation facility, home, or community setting.
PO E. Coordinate ongoing comprehensive care to be provided in sub-acute set- ting such as long-term care facility, rehabilitation facility, home or community setting.
Chapter 10 Neonate With a Rare Congenital Lung Anomaly
121
DOMAIN 2, COMPETENCY 1
Assemble a collaborative interdisciplinary network, refer and consult appropri- ately while maintaining primary responsibility for comprehensive patient care.
PO A. Initiate referral to other healthcare professionals while maintaining primary responsibility for patient care.