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Care of the Pediatric Patient with Cystic Fibrosis
OBJECTIVES Introduction of patient/PMH Cultural Considerations Reason for Hospitalization Primary/Secondary Medical Diagnosis Developmental Considerations &
related theory Exceptions to the norms Nursing dx and Care plans Teaching and discharge planning Research
Introduction T.R.D is a 9 y.o. Caucasian male patient Admission date: 28 Oct14 Diagnosed with CF exacerbation/MRSA
Secondary dx: Positive Rhino Virus Isolation:
Contact & Droplet Full Code Allergies:
Claritin, Chloraprep, Seasonal Allergies, Cestazidine, Ceftazidime, Tape,
Tubes/Equipment: RAC (20 gauge), CVAD R chest 22 gauge, GT feeding tube
Past Pertinent Health History History of CF: dx at 3
y.o., Multiple
hospitalizations: Cholecystectomy at 2
years Bronchoscopy at 4 y.o. G-tube feeding: pt. will
only eat certain food. Family/Psychosocial:
under full custody of grandparents (always at bedside)
Cultural ConsiderationsDivorce household
Under full custody of grandparents since childhood
GT tube feeding
CVAD R chest
Reason for hospitalization Sent home from school d/t excessive
coughing since Florida vacation. PFT poor results during clinic admission. c/o LL back flank pain
Admission Vitals: 36.8*C (PO), HR: 112, RR, 24, BP 120/94
Primary dx: CF tune up/exacerbation/MRSA Secondary dx: Positive Rhino Virus
Extravasation of Contrast dye
Pathophysiology of Cystic Fibrosis
Inherited disease that affects many organs and lethally impairs pulmonary function.
Error in Chloride transport which results in Increased viscosity of
mucous gland secretions Affects multiple body
organs: lungs, pancreas, liver, salivary glands, testes.
Common complications: pneumothorax, arterial erosion, hemorrhage
Main cause of death: RESPIRATORY FAILURE
Diagnostic test: SWEAT CHLORIDE TEST
Organs affected in CF
Treatment Plan Goals: Treatment of Infections, Airway
Clearance, Increased Oxygenation, Prevention of malnutrition:
Antibiotics Therapy CPT, Bronchodilators, Nebulizer Supplemental O2 PRN Continued G-Tube feeding, Pancrelipase Routine Vitals infection Tylenol: PRN Hot compress: RUE extravasation
Treatments continued….
Clinical Manifestations of CF Often Malnourish; Failure to thrive:
appear thinner and smaller Vitamin deficiencies: especially fat-
soluble vitamins (A,D,E,K) Possible development of DM as
pancreas declines Pulmonary manifestations CXR: persistent infiltrates and increased
anterior posterior (AP) diameter.
Relationship of Secondary dx
Dx of MRSA on admission day
Dx of Rhino Virus: 7th day of hospitalization
Developmental Stage and Developmental Theory to Care
Erikson’s Psychosocial Theory: 4th stage Industry vs. Inferiority (6-12 years old)
Enjoys working with others; tends to follow rules; forming social relationships takes on greater importance. Norms meet? Why or why not? Application of theory to
care and communication
Personal/social/cognition: Likes to play & compete More sociable
Speech/language: Give similarities/differences Understand concepts of
space Fine motor/adaptive:
Looks after own needs Likes school, answer
questions Gross motor:
Always on the go; jumps Likely to overdo; hard to
quiet down
Exceptions to the Norms Appears lethargic “slept remainder of the day”
Grand parents (day prior admission) Vitals:
BP (141/83 mmHg); HR: 112 bpm Pain: 6/10 Face Scale
Poor eating habits/wt. gain
Infections: MRSA/Rhinovirus
Extravasation of CT dye: RUE
Nursing Diagnosis #1: Acute/Chronic Pain Supporting Data:
--r/o hx of pancreatitis;-- extravasation of CT dye--LL flank pain: 6/10 hx of pancreatitis --RUE swelling/pain: 6/10 (CT dye extravasation) gallstone -- HR: 112 bpm; BP: 141/83 mm Hg
Meds: Phytonadione, Ursodiol(prophylactic), Warm compress, Tylenol PRN, Child life specialist (bedside/CAT scan)
Acute Pain: Holistic Nursing care and Interventions
Assess pain characteristics q4h/PRN (use pain scale: 6/10)
Observe non-verbal cues
Respond immediately to c/o of pain
Prophylactic treatment: Ursodiol (gallstones)
Distraction Technique
Expected Outcome:Pt will have decreased swelling of RUE and pain level will be in satisfactory level (2/10 face scale) Evaluation: Not met: Pt. level went down but still 4/10 on FACE scale. BP still remains elevated during pt. care.
Nursing Diagnosis #2: Ineffective Airway
Clearance/Impaired Gas Exchange
Supporting data: Hx of CF, coughing
Medications: Albuterol, CPT (qid), Flovent, Advair, Dornase, Pantanase
Ineffective Airway clearance/Impaired Gas Exchange Holistic Nursing Care & Interventions
Monitor RR, breathing effort & areas of cyanosis q4hrs
Assess O2 Sat and administer supplemental O2 PRN
Auscultate lung sounds q4hr
Continued pulmonary treatment QID
Flovent & Advair bid(2puffs)
Expected Outcome:Pt.’s SpO2 will be maintained at >/= 92% RA throughout hospitalization.
Evaluation: Met Pt. SpO2 was 100% RA before end of shift.
Nursing Diagnosis #3: Imbalance Nutrition less than
body requirements/GI Supporting Data:Decreased appetite, pt. refused to eat, NPO, fever, constipation, increased metabolic need due to CF, constipation
Meds: 5 cans of ensure (115 ml/hr)night time feeding via GT tube, pancrelipase, vitamins, Miralax, Pt. gaining wt.
Imbalanced Nutrition: less than body requirements Holistic Nursing care and Interventions Assess daily wt. Monitor attitudes
towards eating/food Pancrelipase enzymes Tube feed at
115mL/hr(night time feed)
Multivitamins BID Miralax for constipation High fat, calorie, protein
diet
Expected Outcome:Pt. will maintain or gain more than admission body wt. before discharge.
Evaluation: Met Pt. gains 0.2 kg during 9th day of hospitalization
Nursing diagnosis #4: Infection
Supporting data: Positive Rhino Virus, MRSA, mucus in the lungs, Isolation(contact/droplet), RAC, Central IV (portacath), GT tube feeding
Medications:CPT, Tobramycin, Meropenem, Levofloxacin, Linezolid
Infection Holistic Nursing Care and Interventions
Assess for signs of infection q4h
Encourage & promote hand washing and other aseptic interventions (PPE), Contact/Droplet
Isolation
Antibiotic treatment
Expected Outcome:Pt. temperature will stay within normal parameters (36.4*C-37.4*C)based on age during hospitalization. Evaluation: MetPt. temp remain within accepted parameters:36.3*C 1330; 36.9*C 1500 before and during end of shift.
Nursing Diagnosis #5: Anxiety
Supporting data:--Pt. verbalizes fear of telling pain “I don’t want to tell the doctors I’m on pain because the more I get hurt”--Patient uncooperative with tx/interventions(refused to eat) --CT dye extravasation Meds: Sertraline, Adderall Alternative Therapy: pt. playing games with
Child life volunteer, interacting/playing with RN, Child life volunteer (at bedside & CT scan procedure)
Anxiety Holistic Nursing Care and Interventions
Acknowledge pt.’s anxiety
Coping strategies
Reduce sensory stimuli
Maintain a calm manner
Expected Outcome:Pt. will be more open to discuss feelings and fears (pain level) about medical condition during hospitalization Evaluation: Partially
MetPt. more truthful about pain level measures, however still uncertain pt’s openness to discuss feelings
Discharge Teaching & Planning Continue to monitor and assess pt. pain level Continue to monitor patients breathing pattern
or any signs of decreased SpO2 (cyanosis etc) Prevent exhaustion (too much playing, moving
around) Maintain adequate nutrition/feeding pattern Continue to monitor patient vital signs and
document abnormal parameters and administer PRN meds (Tylenol)
Continue to assess and monitor pain level:noting any discrepancy between facial and verbal response.
Encourage more open communication with pt. through play method
Research
Name of Journal: Journal of Pediatric Nursing
Title of Research: Distraction Techniques for Children Undergoing Procedures: A Critical Review of Pediatric Research
Conclusion
References Gulanick , M., & Myers , J. (2011). Nursing care plans: Diagnosis,
interventions, and outcomes . (7 ed., pp. 1-991). St Louis, MO: Elsevier Mosby
Hockenberry, M. & Wilson, D. (2010). Nursing care of infants and children, (9th ed.). St. Louis, MO: Elsevier Mosby
Ignatavicius, D. D., & Workman, M. L. (2013). Medical surgical nursing (7th ed.). ST. Louis, MO: Elsevier Mosby.
Koller, D., Goldman, R. D., (2012). Distraction techniques for children undergoing procedures: A critical review of pediatric research. Journal of Pediatric Nursing, 27, 652-681.