Initial Physical Assessment Priority
1. Initial Physical Assessment Priority
Based on the situation where Tommy may have ingested an unknown amount of amoxicillin and is showing signs of abdominal guarding and discomfort, I need to proceed as though he has ingested the medication. Amoxicillin, a penicillin-class antibiotic, can cause toxicity that ranges from mild to severe. Mild to moderate toxicity usually manifests with gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal pain, as well as possible skin rashes. Severe toxicity, especially from high intravenous doses, can lead to central nervous system effects like seizures, encephalopathy, and even cardiac arrest. Acute renal failure, crystalluria, and hematuria can also occur, particularly in cases of high-dose ingestion. Therefore, my initial assessment priority should be to check for signs of respiratory distress, abnormal vital signs, altered mental status, or any evidence of toxicity. ?(Penicillin G Benzathine/ Penicillin G Procaine, 2024)
2. Assessing Pain in a Non-Verbal 3-year-old Child
For a non-verbal, cognitively impaired child, pain should be assessed using non-verbal pain assessment tools. According to a study by Hoot et al., for cognitively impaired patients who can self-report their pain, the Numerical Rating Scale (NRS) and the Color-Enhanced Visual Analog Scale (CAS) are most effective. The NRS uses a 0-10 scale, with 0 indicating no pain and 10 indicating the worst pain. The CAS requires patients to mark their pain level on a 150-mm colored scale, which starts with a white section labeled “no pain” at the bottom and gradually darkens to deep red at the top, labeled “worst pain.” The distance from the bottom to the marked point is measured in millimeters, with scores ranging from 0 to 150.
If Tommy’s cognitive level does not allow him to participate in self-report pain assessments, a non-verbal pain assessment like the FLACC scale (Face, Legs, Activity, Cry, Consolability) should be used. The FLACC scale evaluates pain based on observations of facial expressions, leg movements, activity levels (such as restlessness), crying, and the child’s response to being comforted. Each category is scored from 0-2, and the total score from the five categories provides the final FLACC pain score. (FLACC Pain Scale, 2013)
3. Top Three Differential Diagnoses
T36.0X1A – Poisoning by penicillins, accidental, initial encounter
R10.9 – Unspecified abdominal pain
L50.0 – Urticardia (hives) due to ingestion of penicillin, allergic reaction to penicillin
4. Treatment Approach for Poisonings Related to Toxic Ingestions in Pediatric Patients
Treatment for penicillin toxicity in mild to moderate symptoms are managed with IV fluids and antiemetics, while hypersensitivity reactions require antihistamines, corticosteroids, or epinephrine. In severe cases, airway management and aggressive treatment for anaphylaxis or seizures may be necessary. Patients with significant symptoms should be monitored closely, with particular attention to renal function and electrolytes. Hemodialysis may be used for drug removal in rare, severe cases. ?(Penicillin G Benzathine/ Penicillin G Procaine, 2024)
5. Top 3 Highest Priority Items in Patient Education
Educate the mother and all adults in the family on the importance of storing medications securely using childproof containers, out of reach of children such as in the high cabinets and locked cabinet doors.
Educate all adults in the family on the proper disposal of leftover or expired medications to prevent accidental ingestion.
Provide information on how to contact the Poison Control Center (1-800-222-1222) or call 911 to get to the nearest hospital in case of accidental ingestion of toxic substance.
6. Follow-Up Visit
A follow-up visit should be scheduled within 24-48 hours to reassess Tommy\’s condition, and provide additional education and support to the family.
References
FLACC pain scale. (2013, January 21). Australian department of health and aged care. https://www1.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-pain~triageqrg-FLACC
Hoot, M. R., Khokhar, B., & Walker, W. C. (2019). Self-report pain scale reliability in veterans and service members with traumatic brain injuries undergoing inpatient rehabilitation. Military Medicine, 185(3-4), 370–376. https://doi.org/10.1093/milmed/usz272
Penicillin G benzathine/ penicillin G procaine. (2024). Dynamed. https://www.dynamed.com/drug-monograph/penicillin-g-benzathine-penicillin-g-procaine#GUID-7FAA15E4-3717-4AE5-A78F-71C939E65B03
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