Pediatric Clinical Reasoning Case Study Key: Neonatal Sepsis
Created by: Kathleen Mixson RN, MS, JD
I. Data Collection
Chief complaint/History of Present Illness: Rennie is a 28-day-old female presenting to ER during the night with presenting complaint of apneic episodes approximately 2/day with changing color to blue. Apneic episodes lasts 1-2 minutes, resolves with stimulation, chest rub, or gentle shaking. Apneic episodes not associated with vomiting/spit ups. Baby completely recovers to her baseline with stimulation. Baby always sleeps on her back, no family history of SIDS. The current episode started more than 1 week ago. The problem occurs intermittently. The problem has not changed since onset. Nothing relieves the symptoms. Nothing aggravates the symptoms. Pertinent negatives include no fever, no stridor, and no intake of a foreign body. She had a lumbar puncture and chest X-ray as well as venous blood gases and lytes done in ER. Urinalysis and culture have been done. Ceftriaxone 380mg IV was given in ER after culture obtained.
What data is relevant to this patient that must be recognized as clinically significant to the nurse?
The baby is having apneic episodes with color changes that resolve with stimulation. The episodes have been occurring for a week. Lumbar puncture, cultures, ABX in ER.
Rationale: Apneic episodes are non specific indicators of many potential problems. The diagnostics indicate sepsis workup in progress. Symptoms for one week could indicate possible impairment in mother’s response to baby’s distress.
Personal/Social History: Family lives/stays sometimes in a friend’s place (who does not let the baby’s dad in) and a homeless shelter (the dad stays in a shelter and is allowed to bring family in). Mother says she is a medical assistant, currently unemployed. Both parents smoke, they state they do not smoke around the baby.