Pediatric Case Study

Pediatric Case Study

By: Roline Delva

Data Collection

MC is an African American female who was admitted to University Community Hospital on 7/5/10. She was admitted to the pediatrics unit after having a lapinscopic cholecystectomy surgery.

MC admitting diagnosis was acute cholelithiasis. Acute cholelithiasis is a sudden inflammation of the gallbladder that causes severe abdominal pain. It causes bile to become trapped in the gallbladder. The buildup of the bile causes irritation and pressure in the gallbladder.

I. History and Physical

MC is an 18 year old female that was admitted to the pediatric unit at UCH after having a lapinscopic cholecystectomy surgery. Two days ago MC came into the ER complaining of abdominal pain. Previous weeks before she came into the ER complaining of the same problem and it was diagnosed to be gallstones. She was to have a follow up on surgery which she never did. At the time of her admission, her vitals were temperature 98 degrees, blood pressure 145/60, pulse 80, and respirations 18. She had a stomach ache x3 months and a history of cholecystitis. She has depression and bipolar problems.

II. Diagnostic Test

Ultrasound: the process of imaging deep structures of the body by measuring and recording the reflection of pulsed or continuous high-frequency sound waves. In MC's ultrasound there was multiple mobile gallstones seen within the gallbladder with mild gallbladder wall thickening. Her liver and right kidney was normal.

Blood Chemistry:

WBC: 9.0 th/uL (4.80-10.80)

RBC: 4.45 mill/uL (4.2-5.4)

HGB: 11.9 g/dL (12.0-16.0) - indicates poor oxygen level in the blood

HCT: 37.4% (36.0-48.0)

MCV: 84.0 fL (80-98)

MCH: 26.7 pg (27.0-31.0)

MCHC: 31.8(32.0-36.0)

RDW: 43.8% (39-59.0)

PLT: 431 th/uL (150-400) - indicates high clotting factors that can lead to blood clots

MPV: 10.36 fL(8.0-13.0)

Neut: 67.9% (36-66)

Lymph: 24.8% (22-44)

Mono: 7.2% (0-12)

Eos: 0.0% (0-4)

Baso: 0.1% (0.2)

III. Drug Cards

Abilify: Abilify is classified under antipsychotic. Usual dose is 10-15 mg/day given on a once-a-day schedule. The desired effect of this drug is treatment of schizophrenia and bipolar mania. Precautions are history of seizures, suicidal ideation, brain tumor, dementia, diabetes mellitus, and patients with known cardiovascular disease. Nursing implications is to monitor cardiovascular status, monitor diabetics for loss of glycemic control, and monitor body temperature.

Trileptal: Trileptal is classified under CNS agent and anticonvulsant. Usual dose is 8-10 mg/kg and not to exceed 300 mg twice a day. The desired effect of this drug is to decrease propagation of neuronal impulses. Precautions are older adults, renal impairment, children less than eight years old, and hyponatremia. Nursing implications is to monitor for and report S&S of: hyponatremia and CNS impairment.

Wellbutrin: Wellbutrin is classified under antidepressant and CNS agent. Usual dose is 150 mg/day in the morning. The desired effect of this drug is to treat major depressive episode. Precautions are cardiac disease, MI, hepatic disease, hypertension and bipolar disorder. Nursing implications are is to have close observation for worsening of depression or suicidal tendencies.

Focalin: Focalin is classified as vitamin B9. Usual dose is 250-1000 mcg/day until a hematologic response occurs. The desired effect is to stimulate production of RBCs, WBCs and platelets in patients with megaloblastic anemias. Precautions are pregnancy category A and lactation. Nursing implications are to obtain history of dietary intake and drug and alcohol usage prior to start