A nurse is caring for the child the following day.

Exhibits

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Nurses' Notes

Day 2, 0730:

Drowsy and lethargic, but responsive to verbal stimuli. Nuchal rigidity present. Mucous membranes pink and moist. Cervical lymph slightly enlarged. Respirations are regular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial pulse 2+ bilateral. Capillary refill less than 2 seconds. Abdomen flat and non- distended. Bowel sounds active in all 4 quadrants. Extremities are warm and dry to touch. Good skin turgor.

Flow Sheet

Temperature 38.9° C (102° F)

Heart rate 104/min

Respiratory rate 24/min

Blood pressure 104/80 mm Hg

SpO2 98% on room air

• IV hydromorphone: This potent opioid analgesic is indicated for managing severe pain during vaso-occlusive crises in sickle cell disease, especially when pain reaches a level of 10/10 despite prior interventions. Rapid IV delivery ensures quicker pain relief.
• Pain: The child’s reported pain escalation from 7 to 10 out of 10, along with swelling and warmth of the knee, strongly indicates severe vaso-occlusive pain, which is a hallmark of sickle cell crisis requiring urgent analgesic management.

Rationale for Incorrect Choices:

• Oxygen at 2 L/min via nasal cannula: The child’s oxygen saturation remains normal at 96% on room air, indicating no current hypoxia. Supplemental oxygen is not necessary unless oxygen saturation drops or respiratory distress develops.
• Oral amoxicillin: There are no clinical signs or lab evidence of infection (e.g., normal WBC count, no fever), so antibiotics are not warranted. Prophylactic antibiotics may be used in certain sickle cell scenarios but are not indicated here.
• Hypoxia: The child maintains normal oxygenation, making hypoxia an unlikely contributing factor to the current presentation. Hypoxia would require both clinical signs (e.g., low SpO₂) and symptoms like shortness of breath.
• Signs of infection: The absence of fever, normal WBC count, and localized pain without erythema or drainage suggest that infection is not present at this time. Pain is due to vaso-occlusion, not infectious origin.

• Headache: Both conditions may present with headache; however, in meningitis, it is often severe and accompanied by neurological signs, whereas in influenza, it may result from systemic illness and fever.
• Brudzinski sign: A classic sign of meningeal irritation, where passive neck flexion leads to involuntary hip and knee flexion. Not seen in influenza.
• Head and neck ROM: Restricted neck movement with pain is common in meningitis due to inflammation of the meninges. Normal neck ROM is usually maintained in influenza.
• Light sensitivity: Photophobia is a hallmark of meningeal inflammation and increased intracranial pressure. It is not a typical feature of influenza.
• Temperature: Fever is a shared symptom due to systemic infection and inflammation in both meningitis and influenza.