Charles Weinberg Case Study - Nursing Assignment Help

Assignment Task:

Charles Weinberg 3 years old Background Charles Weinberg was born on 2 July 2011 and he would have been nearly seven years old by the time of the inquest. Charles was a beautiful healthy and happy little boy. 
History Charles developed a mild dry cough, but he was still in good spirits for his belated 3rd birthday party held on 12th July and spent at home with family and friends. Charles was reportedly a very active boy and had all his vaccination up to date. 
By Sunday 13 July 2014, Charles’s cough had worsened and Rebecca Weinberg (his mother) took him to the local Medical Centre where he saw Dr Shah Mohammed. Dr Mohammed’s notes record: 
- Few days moist cough, temp 36.6 
- Oral normal 
- Ears normal 
- Chest creps 
- Plan Panadol, oral AB 
Charles was prescribed Amoxicillin for a chest infection. In a statement from Dr Mohammed, he provided the opinion that Charles was suffering from Upper Respiratory Tract Infection on that date. Charles ended up only completing half the course of antibiotics, because he had loose stools. His cough had subsided and he appeared to recover well. Charles continued to be unwell at home. On the morning of Sunday 27 July, Charles’s parent were concerned that his condition was getting worse and they took Charles to their Local Private Hospital. After waiting in the ‘emergency’ area for about an hour, they saw a doctor who advised them that Charles should be driven immediately to Main Hospital Emergency Department (ED), which his parents then did. In the meantime, a doctor from the local Private Hospital called Main Hospital to notify them of Charles’s arrival and that he was unwell and hypoxic (oxygen deficient). That doctor spoke with Dr Andrea Bell, the Emergency Medicine specialist on duty at Main Hospital, who assembled a team including herself, Dr James Andrews, a Paediatric Registrar and nursing staff to be waiting for him in the ‘Resus’ (Resuscitation) bay. 
Arrival at Main Hospital – Day 1 
1. On arrival, Charles was triage Category 1 (the most urgent category) and was immediately assessed by Dr Bell and her team. On initial assessment Charles appeared to be very unwell. He was lethargic, pale and poorly responsive to medical and nursing interventions being performed. His heart rate, respiratory rate and temperature were elevated. He had reduced air entry at the left base and his oxygen saturations were low. There was evidence of dehydration with dry mucous membranes, prolonged capillary refill and decreased skin turgor. 
2. A cannula was inserted and urine and blood samples were taken. Charles was connected to monitoring and given an oxygen mask. 
3. Dr Andrea Bell clinical findings were consistent with sepsis likely secondary to left lower lobe pneumonia. Because Charles appeared dehydrated and shocked, Dr Bell initiated treatment with fluid resuscitation with 10mls/kg normal saline boluses. As there was no initial improvement following the first 10mls/kg fluid bolus, a second 10 mls/kg normal saline bolus was administered. Following the second fluid bolus some improvement in Charles’s peripheral perfusion was noted. As Charles clinically had not improved, she administered a further two 10ml/kg normal saline boluses over the next 20 minutes, whilst instituting intravenous antibiotic therapy for sepsis for “unknown source? Pneumonia”. 
4. Charles showed some improvement in heart rate, peripheral perfusion and alertness. A mobile chest X-ray was performed demonstrating the likely L lower lobe pneumonia. The antibiotics Cefotaxime, Gentamicin and Benzl-Penicillin were administered to treat severe sepsis/bacteraemia likely cause by pneumonia. 
5. Dr Bell contacted the on duty Paediatric Registrar, Dr Sanjay Singh, for urgent clinical review, and she arrived promptly. Dr Bell then discussed with Dr Singh the presentation, clinical course and management of Charles whilst in the Emergency Department.  
6. Dr Singh was then involved in discussed with the paediatric consultant on duty, Dr Christine Lau, which Dr Bell was not privy to. At 3.45 pm, nearly three hours after presentation, Charles was judged well enough to be transferred to the paediatric ward. Dr Andrews states that at that time, Charles was still looking unwell but he was alert and his observations had improved. 
 

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