BRITTANY VSIM

Brittany VSIM
Brittany Long is a 5-year-old African American female with a history of sickle cell anemia (HbSS) treated with regular folic acid supplement who came in yesterday with an acute vaso-occlusive pain crisis. Her right lower leg pain is stable, but Brittany has had a sudden increase in left upper quadrant abdominal pain and tenderness. Her spleen is palpated 3 cm below the left costal margin. She rated her abdominal pain a 5 on the FACES Scale and received morphine sulfate. She continues to receive intravenous maintenance fluids at 52 mL/hr and is on a nasal cannula with oxygen 2 L/min. She is pale and weak and just wants to sleep. Her mother is concerned about her increasing fatigue. Her urinary output is decreased, and she no longer wants to take fluids by mouth, not even for mom. Her vital signs have been taken every 2 hours, and she had labs drawn twice. Her last hemoglobin was decreased by 1.3 g/dL, and is now 7.5 g/dL; platelets are also decreasing and are 200; her reticulocyte count is increasing and is 7.5. Legal consent to give blood products has been obtained from the mother.

This is Brittany simulation

You arrived at the child.
0:00 You introduced yourself.
?? 0:07 You washed your hands. To maintain patient safety it is important to wash your hands as soon as you enter the room.
0:10 Child status ECG: Sinus tachycardia. Heart rate: 158. Pulse: Present. Blood pressure: 98/76 mmHg. Respiration: 34. Conscious state: Appropriate. SpO2: 97%. Temp: 37.6 C
?? 0:35 You identified the child. To maintain patient safety it is important that you quickly identify the child.
?? 0:47 You identified the relatives. This is important, as the patient is below 18 years of age.
?? 1:04 You obtained legal consent from the childs relative. This was reasonable.
1:10 Child status ECG: Sinus tachycardia. Heart rate: 158. Pulse: Present. Blood pressure: 96/75 mmHg. Respiration: 34. Conscious state: Appropriate. SpO2: 97%. Temp: 37.6 C
?? 2:09 You asked the parent: Does she have any known allergies? The parent replied: ‘No. I dont think so.
2:10 Child status ECG: Sinus tachycardia. Heart rate: 164. Pulse: Present. Blood pressure: 88/70 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 97%. Temp: 37.5 C
?? 2:24 You looked for normal breathing. She is breathing at 35 breaths per minute. The chest is moving equally.
?? 2:48 You attached the pulse oximeter. This was indicated by order.
?? 2:57 You checked the pulse at the brachial artery. The pulse is strong, 175 per minute and regular. It is correct to assess the childs vital signs.
3:10 Child status ECG: Sinus tachycardia. Heart rate: 172. Pulse: Present. Blood pressure: 88/70 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 97%. Temp: 37.5 C
?? 3:19 You measured the temperature in the ear. The temperature was 37.5 C.
3:36 You examined the childs skin. There is tenting sign of the skin. Her skin is quite cold.
3:48 You examined the childs abdomen and pelvis. The spleen is enlarged and the abdomen is generally tender. You should always use the look, listen, and feel approach in the clinical situation.
?? 4:03 You asked the child if she had any pain. (In pain) She replied: ‘Yes…
4:10 Child status ECG: Sinus tachycardia. Heart rate: 172. Pulse: Present. Blood pressure: 89/70 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 97%. Temp: 37.5 C
?? 4:18 You assessed the pain level using the FACES scale. The child answered 3 on the FACES pain scale with a range of 0 to 5.
4:29 You asked the child if she needed anything for the pain. (In pain) She replied: ‘Yes please.
?? 4:50 You identified the child. If you are in doubt, it is always a good idea to repeat the identification.
?? 5:08 You administered 2 mg of morphine IV. It is important to use the basic rights of medication administration to ensure proper drug therapy. It was reasonable to give an opioid here.
5:10 Child status ECG: Sinus tachycardia. Heart rate: 171. Pulse: Present. Blood pressure: 87/70 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 97%. Temp: 37.5 C
?? 5:20 You provided patient education. This is correct. It is important to use every opportunity to provide patient education.
?? Consider providing education to relatives whenever possible.
?? You should try to comfort the child by offering a toy.
5:31 You looked for normal breathing. She is breathing at 35 breaths per minute. The chest is moving equally.
?? 5:56 You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the child continuously.
?? 6:09 You phoned the provider in order to discuss the patient.
6:10 Child status ECG: Sinus tachycardia. Heart rate: 168. Pulse: Present. Blood pressure: 89/70 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
7:10 Child status ECG: Sinus tachycardia. Heart rate: 166. Pulse: Present. Blood pressure: 84/67 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
?? 7:59 You started a bolus of 320 mL of normal saline IV, given over 30 minutes. This was indicated by order.
8:10 Child status ECG: Sinus tachycardia. Heart rate: 164. Pulse: Present. Blood pressure: 85/67 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
?? 8:43 You verified the blood, patient id, and type and cross match by two nurses. This is very important to ensure patient safety.
9:10 Child status ECG: Sinus tachycardia. Heart rate: 163. Pulse: Present. Blood pressure: 87/68 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
?? 9:49 You started infusing packed red blood cells at 28 mL/hr. This is reasonable. it is important to recheck the blood pressure within 15 minutes after blood products have started infusing, then per hospital protocol, to assess for transfusion complications.
10:10 Child status ECG: Sinus tachycardia. Heart rate: 162. Pulse: Present. Blood pressure: 85/67 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
?? 10:30 You assessed the childs IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the child has is always important.
?? 10:45 You provided patient education.
?? 11:07 You provided patient education.
11:10 Child status ECG: Sinus tachycardia. Heart rate: 161. Pulse: Present. Blood pressure: 85/68 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
?? 11:19 You provided education to the relative regarding the childs condition. This is correct. It is important to use every opportunity to provide education.
???? You should reassess the childs breathing at this point.
11:37 You asked the child if she had any pain. She replied: ‘Yes… She replied: ‘No, I dont have any pain.
11:41 You asked the child if she had any pain. She replied: ‘Yes… She replied: ‘No, I dont have any pain.
?? 12:07 You gave the child a sip of juice. Comforting the child with a favorite drink is advisable.
12:10 Child status ECG: Sinus tachycardia. Heart rate: 160. Pulse: Present. Blood pressure: 86/68 mmHg. Respiration: 35. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
?? 12:18 You phoned the provider in order to discuss the patient.
13:10 Child status ECG: Sinus tachycardia. Heart rate: 159. Pulse: Present. Blood pressure: 85/68 mmHg. Respiration: 36. Conscious state: Appropriate. SpO2: 96%. Temp: 37.5 C
?? 13:31 A patient handoff was performed.
The treatment of acute splenic sequestration complication (ASSC) involves immediate correction of hypovolemia and restoration of circulating blood volume. This is accomplished by an IV normal saline (20 mL/kg) bolus and/or 1.5 times maintenance fluid requirements in mild-to-moderate cases. In more severe cases, in addition to fluid replacement, the administration of packed red blood cell transfusion is an emergent part of the treatment. As a rule of thumb, the transfusion volume may be calculated as follows: Hgb x weight over 4 hours; in this scenario: 7.5 g/dL x 16 kg = 120 mL over 4 hours.[newline][newline]Once fluids and red blood cell transfusion are employed, red blood cells sequestered in the spleen are remobilized, the splenomegaly regresses, and the blood counts return to baseline. Clinical signs of hypovolemia and shock (rapid pulse, decreased BP, decreased LOC and urine output) and of cardiovascular compromise must be monitored throughout.[newline][newline]Because ASSC has approximately a 50% recurrence rate, parents should be taught to recognize the signs and symptoms, how to palpate the spleen, and the importance of seeking medical attention promptly. The options for follow-up are observation, chronic transfusion, or splenectomy.
Please use the introduction info and simulation to answer the questions.

1) What is the relationship between fluid and oxygen therapy in the treatment of sickle cell anemia?
2) What methods of pain management did you use and what other methods should be considered for Brittany, based on the latest evidence-based practice?
3) How did the findings from Brittanys physical assessment and diagnostic studies affect decisions you made about the administration of intravenous (IV) fluids and blood products?
4) Reflect on ways to improve safety and quality of care based on your experience with Brittanys case.

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