Bowden, Chapter 16: Supplemental Information

Key Terms

apnea

atelectasis

atopy

cor pulmonale

cyanosis

dyspnea

hemoptysis

hypercarbia

hypoxemia

hypoxia

pallor

respiratory distress

respiratory failure

retractions

subcutaneous emphysema

tachypnea

ventilation-perfusion mismatch

1

Summary of Key Concepts

Certain anatomic and structural features of the respiratory tract in infants and young

children predispose them to develop respiratory distress more readily than older children

or adults.

Respiratory illnesses and exacerbations of chronic respiratory conditions are the most

common reasons for pediatric hospital admissions and ambulatory center visits, especially

during winter and early spring.

Viral and bacterial infections of the respiratory system are common and relatively

unavoidable during childhood.

Children with chronic conditions, especially conditions that involve the respiratory or

cardiac systems, are at highest risk for serious morbidity or mortality associated with

common childhood respiratory infections.

Worsening respiratory distress can be identified by frequent and thorough respiratory

assessments. Early recognition and prompt intervention for respiratory distress are key to

prevent respiratory failure.

Parents of children with chronic respiratory conditions must be educated to recognize

signs and symptoms of respiratory compromise and to notify their healthcare provider

immediately when they occur. Good decision making skills are an essential component of

daily disease management. The nurse must teach these parents how to manage

emergency situations in the home

Children with chronic respiratory conditions require regular follow-up visits with

healthcare providers and use of proactive and preventive measures.

2

Evidence-Based Practice Guidelines

American Academy of Pediatrics. (2001). Clinical practice guideline: Management of sinusitis.

Pediatrics, 108 (3), 798-808.

American Academy of Pediatrics (AAP). (2003). Apnea, Sudden Infant Death Syndrome, and

home monitoring. Pediatrics, 111, 914-917.

American Association for Respiratory Care (AARC). (2007). Removal of the endotracheal tube

—2007 revision & update. Respiratory Care, 52, 81-93.

American Thoracic Society. (2007). An Official ATS Workshop Report: Issues in Screening for

Asthma in Children. Available at

http://www.thoracic.org/sections/publications/statements/

American Thoracic Society. (2007). An Official ATS/ERS Statement: Pulmonary Function

Testing in Preschool Children. Available at

http://www.thoracic.org/sections/publications/statements/

American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. Available at

http://www.thoracic.org/sections/publications/statements/

Cincinnati Children’s Hospital Medical Center. (2006). Evidence-based clinical practice

guideline for medical management of bronchiolitis in infants less than 1 year of age

presenting with a first time episode. Cincinnati, OH: Author. Available at

www.guideline.gov.

Kelley, L., & Allen, P. (2007). Managing acute cough in children: Evidenced –based guidelines.

Pediatric Nursing, 33, 515-524.

3

Organizations

Allergy & Asthma Network Mothers of Asthmatics

www.breatherville.org

American Academy of Allergy, Asthma and Immunology

www.aaaai.org

American Association for Respiratory Care (AARC)

www.aarc.org

American Cleft Palate-Craniofacial Association

www.cleftline.org

American College of Allergy, Asthma, and Immunology

www.Acaai.org

American Lung Association

www.lungusa.org

American Thoracic Society

www.thoracic.org

Association of Asthma Educators

4

www.asthmaeducators.org

Asthma and Allergy Foundation of America (AAFA)

www.aafa.org

Centers of Disease Control and Prevention (CDC)

www.cdc.gov

Cystic Fibrosis Foundation

www.cff.org

Cystic Fibrosis Worldwide

www.cfww.org

Environmental Protection Agency, Office of Children’s Health Protection

http// yosemite.epa.gov/ochp/ochpweb.nsf/homepage

Food Allergy & Anaphylaxis Network

www.foodallergy.org

National Asthma Education and Prevention Program, NHLBI Information Center

www.nhlbi.nih.gov/about/naepp/

5

National Heart, Lung and Blood Institute Information Center

www.nhlbi.nih.gov

National Jewish Medical and Research Center

www.njc.org

Respiratory Nursing Society

www.respiratorynursingsociety.org

6

Bibliography

American Academy of Pediatrics (AAP). (2001). Clinical practice guidelines: Management of

sinusitis. Pediatrics, 108, 798-808.

American College of Obstetricians and Gynecologists (ACOG) (2001). Preconception

and prenatal carrier screening for cystic fibrosis: Clinical and laboratory guidelines.

Washington, DC: American College of Obstetricians and Gynecologists.

Bennett, A.D. (2002). Home apnea monitoring for infants. Advance for Nurse Practitioners, 10,

47-54.

Berge, J., & Patterson, J. (2004). Cystic fibrosis and the family: A review and critique of the

literature. Families, Systems, & Health, 22, 74-100.

Bjornson, C., & Johnson, D. (2005). Croup-Treatment update. Pediatric Emergency Care,

21(12), 863-873.

Carpenter, D.R. & Narsavage, G.L. (2004). One breath at a time: Living with cystic fibrosis.

Journal of Pediatric Nursing, 19, 25-32.

Conway, S. (2004). Transition programs in cystic fibrosis centers. Pediatric Pulmonary,

37. 1-3.

Cooper, K.E. (2001). The effectiveness of ribavirin in the treatment of RSV. Pediatric Nursing,

27, 95-98.

Darrow, D., & Siemens, C. (2002). Indications for tonsillectomy and adenoidectomy.

Laryngoscope, 112(8), 6-10.

Donahue, M. (2002). “Spare the cough, spoil the airway:” Back to the basics in airway

clearance. Pediatric Nursing, 28, 107-111.

7

Ebbinghaus, S. & Bahrainwala, A.H. (2003). Asthma management by an inpatient asthma care

team. Pediatric Nursing, 29, 177-192.

Flume, P.A., Taylor, L.A., Anderson, D.L., Gray, S. & Turner, D. (2004). Transition programs

in cystic fibrosis centers: Perceptions of team members. Pediatric Pulmonary, 37, 1-3.

Franzese, C.B. & Schweinfurth, J.M. (2002). Delayed diagnosis of a pediatric airway

foreign body: Case report and review of the literature. Ear, Nose & Throat

Journal, 81, 655-656.

Grosse, S.D., Boyle, C.A., Botkin, J.R., et al (2004). Newborn screening for Cystic

Fibrosis. Morbidity and Mortality Weekly Reports: Recommendations and

Reports, 53, 1-36.

Heijerman, H. (2005). Infection and inflammation in cystic fibrosis: A short review. Journal of

Cystic Fibrosis, 4, 3-5.

Horner, S.D., Surratt, D. & Smith, S.B. (2002). The impact of asthma risk factors on home

management of childhood asthma. Journal of Pediatric Nursing, 17, 211-221.

Johnson, C., Butler, S.M., Konstan, M.W. et al, (2003). Factors influencing outcomes in

cystic fibrosis: A center based analysis. Chest, 123, 20-27.

Kotagal, S. (2005). Childhood obstructive sleep apnoea (editorial). British Medical Journal,

330, 978-979.

Korppi, M. (2003). Community-acquired pneumonia in children: Issues in optimizing

antibacterial treatment. Pediatric Drugs, 5(12), 821-832.

Lee, E., Parker, V., DuBose, L., Gwinn, J., & Logan, B. (2006). Demands and resources: Parents

of school-age children with asthma. Journal of Pediatric Nursing, 21, 425-433.

McCarthy, M.J., Herbert, R., Brimacombe, M., Hansen, J., Wong, D. & Zelman,

8

M. (2002). Empowering parents through asthma education. Pediatric

Nursing, 28, 465-473.

Meissner, H.C. & Rennels, M.B. (2004). Unpredictable patterns of viral respiratory

disease in children. Pediatrics. 113, 1814-1816.

Millman, R.P. & Working Group on Sleepiness in Adolescents/Young Adults; and AAP

Committee on Adolescence (2005). Excessive sleepiness in adolescents and

young adults: Causes, consequences, and treatment strategies. Pediatrics, 115,

1774-1786.

Patterson, E.E., Brennan, M.P., Linskey, K.M., et al (2005). A cluster randomized

intervention trial of asthma clubs to improve quality of life in primary school

children: The School Care and Asthma Management Project (SCAMP).

Archives of Diseases in Childhood, 90, 786-791.

Pediatric Tuberculosis Collaborative Group (2004). Targeted Tuberculin skin

testing and treatment of latent Tuberculosis infection in children and adolescents.

Pediatrics, 114, 1175-1201.

Peeke, K., Hershberger, M., & Marriner, J. (2006). Obstructive sleep apnea syndrome in

children. Pediatric Nursing, 32, 489-494.

Rotta, A.T. & Wiryawan, B. (2003). Respiratory emergencies in children. Respiratory Care, 48,

248-260.

Sander, N., (2002). Making the grade with asthma, allergies, and anaphylaxis. Pediatric

Nursing, 28, 593-598.

9

Schaefer, R., Stadler, J., & Gosain, A. (2003). To distract or not to distract: An algorithm for

airway management in isolated Pierre robin sequence. Plastic and Reconstructive

Surgery, 113, 1113-1125.

Schibli, S., Durie, P. & Tullis, E. (2002). Proper usage of pancreatic enzymes. Current Opinion

in Pulmonary Medicine, 8(6), 542-546.

Schuster, M., Franke T., & Pham C.(2002). Smoking patterns of household members and

visitors in homes with children in United States.  Archives of Pediatric Adolescent

Medicine, 156, 1094-1100.

Society for Adolescent Medicine (2003). Transtion to adult healthcare for adolescents and

young adults with chronic conditions. Journal of Adolescent Health, 33309-311.

Sterling, Y., & El-Dahr, J. (2006). Wheezing and asthma in early childhood: An update.

Pediatirc Nursing, 32(1), 27-31.

Trollvik, A., & Severinsson, E. (2005). Influence of an asthma education program on parents

with children suffering from asthma. Nursing and Health Sciences, 7, 157-163.

Velissariou, I., & Papadopoulos, N. (2006). The role of respiratory viruses in the pathogenesis of

pediatric asthma. Pediatric Annals, 35, 637-642.

Velsor-Friedrich, B., Pigott, T.D. & Louloudes, A. (2004). The effects of a school-based

intervention on the self-care and health of African-American inner-city children

with asthma. Journal of Pediatric Nursing, 19, 247-256.

Weiland, J., Schoettker, P.J., Byczkowski, T., Britto, M.T., Pandzik, G. & Kotagal, U.R.

(2003). Individualized daily schedules for hospitalized adolescents with cystic

fibrosis. Journal of Pediatric Healthcare, 17, 284-289.

Yankaskas, J.R., Marshall, B.C., Sufian, B., Simon, R.H. & Rodman. D. (2004). Cystic

10

Fibrosis adult care: Consensus conference report. Chest, 125, 1S-39S.

11

Addenda

Care Path 16-1 - An Interdisciplinary Plan Of Care for the Child with Apnea

Nursing Diagnosis: Ineffective breathing pattern related to apneic episodes.

Child/Family Outcomes: Child will have effective breathing pattern without apneic spells

throughout hospitalization.

Nursing Diagnosis: Impaired home maintenance related to change in home care regimen.

Child/Family Outcomes: Parents will verbalize understanding of necessary diagnostic

tests and consultations.

Parents will describe and demonstrate understanding of CPR and home apnea monitor

prior to discharge.

Nursing Diagnosis: Interrupted family processes related to anxiety associated with threat

of infant death.

Child/Family Outcomes: Parents will develop open communication with healthcare team

and receive patient information in a timely manner.

Parents will verbalize understanding of need to develop support system to provide respite

care.

Care Intervention

Categories

Admission Transition to

Discharge

Discharge to

Community

Consults Social service

Specialty services

such as

Pulmonary and

Gastroenterology

Teach

parent/family

members CPR

(basic life

support) and

12

evaluate return

demonstration

Nursing

Assessment and

Care Management

Check vital signs

every 4 hr

Daily weights.

Height on

admission

Complete

assessment, with

emphasis on

respiratory

system

Cardiorespiratory

monitor (Apnea

monitor)

Pulse oximetry

Keep head of bed

elevated.

Avoid

hyperflexion of

neck.

Initiate

documentation of

Vital signs every

4 hr

Pulse oximetry

spot checks.

Assess and

document

respiratory

responses to care.

Pulse oximetry

spot checks.

Keep child

upright for 30-45

minutes following

feeding.

Position on

abdomen between

feedings.

Discontinue pulse

oximetry.

Place home monitoring

device on child.

Assess response to reflux

precautions.

13

apneic episodes.

Diagnostic Tests &

Procedures

Possible tests

include CBC,

capillary blood

gases, calcium,

electrolytes,

glucose, septic

work-up

Aminophylline

requires blood

level monitoring.

Chest radiograph

ECG, EEG

Pneumogram

(pneumocardiogra

m)

If history

indicates, upper

GI series, reflux

scan, Ph probe,

polysomnography

Repeat diagnostic

tests as indicated

by child’s

condition.

Pharmacologic

Management

As ordered by

healthcare

As ordered by

healthcare

Continue with

medications, as ordered

14

professional

Gastroesophageal

reflux

medications, if

indicated

professional

Gastroesophageal

reflux

medications, if

indicated

Nutrition Accurate intake

and output

Reflux

precautions if

diagnosed with

reflux.

Diet for age as

tolerated.

Maintain reflux

precautions if

needed.

Diet for age as tolerated.

Maintain reflux

precautions if needed.

Discharge

planning / Teaching

Orient family to

hospital and

primary

caregivers.

Have family

verbalize

understanding of

monitors and

diagnostic

studies.

Notify discharge

planner of need

for home nursing

referral at time of

discharge.

Find out whether

family has

telephone.

Advise family of

home nursing

Hold discharge

conference with parents

to review teaching needs,

follow-up clinic visits,

equipment needs, and

financial resources.

Instruct parents to keep

log of apneic episodes to

include time, child’s

activity at time of

15

Have family

verbalize

understanding of

infant's

cardiopulmonary

system.

Have family

demonstrate

reflux

precautions,

medication

administration,

monitor

application, steps

to answer monitor

alarms.

referral.

Complete home

healthcare

referral.

Contact home

health agency.

Begin CPR

teaching.

Have family

demonstrate use

of home monitor.

Have family

demonstrate CPR.

Review

guidelines for

using home

monitoring with

parents.

Suggest educating

secondary care

providers

regarding

episode, and

interventions to stimulate

the child.

Provide parents with

information on support

group or name of other

family with child on

apnea monitoring at

home.

Have parents notify

neighborhood EMT of

child’s status.

Home visit by home care

agency is scheduled.

Follow up appointments

scheduled.

16

monitor use and

CPR.

CBC, complete blood count; CPR, cardiopulmonary resuscitation; EEG,

electroencephalogram; ECG, electrocardiogram; EMT, emergency medical technicians;

GI, gastrointestinal.

Care Path 16-2 - An Interdisciplinary Plan of Care for the Child with Bronchiolitis

Nursing Diagnosis: Ineffective breathing pattern related to bronchospasm, mucosal

edema, and accumulation of mucus.

Child/Family Outcomes: Child will demonstrate improved breathing pattern, as

evidenced by absence of tachypnea, retractions, nasal flaring, grunting, wheezing,

cyanosis, or cough.

Nursing Diagnosis: Impaired gas exchange related to bronchiolar obstruction, atelectasis,

and hyperinflation.

Child/Family Outcomes: Child will demonstrate adequate oxygenation and ventilation,

as evidenced by oxygen saturation >92% and decreased work of breathing.

Nursing Diagnosis: Deficient fluid volume related to dyspnea, tachypnea, and decreased

oral intake.

Child/Family Outcomes: The child will maintain adequate intake and output for age and

weight.

The child will maintain adequate hydration, as evidenced by moist mucous membranes,

good skin turgor, and serum electrolytes within normal range.

Nursing Diagnosis: Deficient knowledge related to home management of bronchiolitis.

17

Child/Family Outcomes: Family will demonstrate knowledge of and adherence to home

treatment plan.

Care

Intervention

Categories

Admission Transition to

Discharge

Discharge to

Community

Consults Pediatric

pulmonologist prior

to initiation of

ribavirin, if needed

Infection control

specialist

Nursing

Assessments and

Care

Management

Vital signs and pain

q 2-4 hours based

on acuity

Blood pressure on

admission

Strict intake and

output

Cardiopulmonary

monitor

Continuous pulse

oximetry

Keep head of bed

Vital signs and pain

every 4 hours

Pulse oximetry spot

checks with

respiratory

treatments and PRN

for respiratory

distress

Keep head of bed

elevated.

Activity as

tolerated

Discontinue

cardiopulmonary

monitor.

Discontinue pulse

oximetry.

Activity as tolerated

Discontinue isolation.

18

elevated.

Activity as

tolerated

Bulb suction with

normal saline PRN

for congestion.

Suction with

catheter and saline

only for airway

obstruction causing

substantial

respiratory

compromise.

Contact isolation

during non-

epidemic period;

contact precautions

plus droplet

precautions during

RSV epidemic

periods

Bulb suction with

normal saline PRN

for congestion.

Suction with

catheter and saline

only for airway

obstruction causing

substantial

respiratory

compromise.

Contact isolation

during non-

epidemic period;

contact precautions

plus droplet

precautions during

RSV epidemic

periods

Diagnostic Tests

& Procedures

CBC with

differential

Repeat diagnostic

tests as indicated by

19

Blood culture if

child appears very

ill or temperature is

>102F

Consider blood gas

measurements

Nasal washing for

RSV panel (if

indicated)

Chest Radiograph

(if indicated)

child’s condition

Pharmacologic

Management

IV antibiotics if

strong suspicion or

evidence of

bacterial infection

Acetaminophen15

mg/kg PO/PR every

4 hrs p.r.n. (if fever

1010F or mild

pain);max dose =

75 mg/kg/day or 4

gm/day; whichever

is less

Maintain IV fluids

if not taking PO

feeds well or

change to

heparin/saline lock.

Discontinue IV.

Room air

20

Ibuprofen 10 mg/kg

PO every 6 hrs (if

fever >1010F or

discomfort) if

acetaminophen is

not effective; max

dose+ 400 mg

Neo-Synephrine

1/8%; 2-3 drops

each nostril every 6

hrs PRN for nasal

congestion

IV fluids at

maintenance if

clinically

dehydrated or not

taking PO feeds

Nutrition NPO if in

respiratory distress

PO feedings if

RR<60

Diet for age

Encourage PO

feeds and fluid

intake.

Diet for age

21

Psychosocial Parental support for

anxiety

Rest for parent if

sleep deprived

Respiratory Suction prn, before

feedings and before

inhalation therapy.

Oxygen to keep O2

saturation >92% or

for severe

respiratory distress

Begin weaning

oxygen to keep O2

saturation >94%.

Discontinue O2.

Room Air

Discharge

planning /

Teaching

Teach family to use

bulb syringe and

watch them

practice.

Teach about home

medication

administration.

Ensure family

understands dosing

and purpose of

medications.

Home nebulizer, if

needed

Assess smoking

status in home,

refer family for

Discharge if Ribavirin

therapy not needed.

Return to clinic if

signs/symptoms of

respiratory distress

recur.

22

smoking cessation

and encourage

smoke-free homes

and cars.

ADLs, activities of daily living; CBC, complete blood count; ECG, electrocardiogram;

IM, intramuscular; IV intravenous; NPO, nothing by mouth; PO, by mouth; RR,

respiratory rate; RSV, Respiratory Syncytial virus

Care Path 16-3 - An Interdisciplinary Plan of Care for the Child with Pneumonia

Nursing Diagnosis: Ineffective breathing pattern related to an inflammatory infection of

the lower airway

Child/Family Outcomes: Child will demonstrate and maintain an improved breathing

pattern throughout hospitalization, as evidenced by lessening or absence of tachypnea,

retractions, nasal flaring, grunting, wheezing, cyanosis, and/or cough.

Nursing Diagnosis: Deficient knowledge related to disease process and home

management of child upon discharge

Child/Family Outcomes: Family will verbalize understanding of illness and rationale for

treatment plan.

By discharge, family will verbalize/demonstrate an understanding of how to administer

medication at home, how to perform PD&P, how to use a bulb syringe and an MDI as

appropriate, and when to notify physician of changes in respiratory status.

23

Care

Intervention

Categories

Admission Transition to

Discharge

Discharge to

Community

Nursing

Assessment and

Care

Management

Check vital

signs every 4 hr

Strict intake and

output

Consider apnea

monitor for

infants <6 mo

with moderate

to severe

respiratory

distress.

SpO2 check

once, and then

check p.r.n. for

respiratory

distress.

Activity as

tolerated

Vital signs every 4 hr

I&O every shift

Apnea monitor as

indicated

SpO2 p.r.n. for

respiratory distress

Activity as tolerated

Maintain contact

isolation.

Discontinue apnea

monitor.

Activity as tolerated

Discontinue isolation

24

Contact

isolation

Diagnostic Tests

& Procedures

CBC with

differential

Consider blood

culture and cold

agglutinins.

Chest

radiograph

Spirometry for

children (> 6

yrs) with co-

morbid

conditions (e.g.,

CF, asthma,

neuromuscular,

etc.)

Repeat diagnostic

tests as indicated by

child’s condition.

Pharmacologic

Management

Ampicillin 200

mg/kg/day IV q

6 hrs

(maximum 2

g/dose)

Or

Once PO intake is

consistently 75% or

more of maintenance,

switch to

heparin/saline lock

IV

Discontinue Neo-

Synephrine (>3 day use

not recommended).

Change to oral

antibiotics.

25

Cefuroxime 75-

150 mg/kg/day

IV q 8 hr for

bacterial

pneumonia

(maximum

dose, 1.5

g/dose)

Neo-Synephrine

1/8%, 2-3 drops

each nostril

every 6 hr,

p.r.n. for nasal

congestion.

Acetaminophen

15 mg/kg (max

dose 650 mg)

PO/PR every 4

hours PRN

T>101F or

discomfort

For bacterial pneumonia,

discharge on PO

antibiotics to complete a

10-day course.

Discontinue

heparin/saline lock.

26

Ibuprofen 10

mg/kg (max

dose 400 mg)

PO every 6

hours PRN

T>101F or

discomfort if

acetaminophen

is not effective.

Heparin/saline

lock or consider

IV fluids at

maintenance if

unable to take

PO feeds.

Nutrition NPO if

respiratory

distress

symptoms or

vomiting

Diet for age;

encourage fluids

(clear); avoid dairy

products

Diet for age as tolerated

Respiratory Oxygen to keep Encourage deep Discontinue oxygen.

27

saturation >92%

Bulb or wall

suction p.r.n.

PD&P with

nebulized

treatments, if

clinically

indicated

(atelectasis or

lobar

pneumonia

identified by

chest

radiograph)

Albuterol 0.15

mg/kg in 2 mL

normal saline

via nebulizer

every 2-4 hr and

p.r.n. (minimum

diluted dose

0.25 mL)

breathing and

directed cough every

4 hours while awake.

Consider weaning

oxygen.

Consider alternating

nebulized treatments

with MDI treatment.

Or

Discontinue

nebulized treatments

and use albuterol

MDI 2-4 puffs every

4-6 hr, if clinically

indicated.

Wean oxygen as

tolerated.

Room air

Discontinue nebulized

treatments.

Use albuterol MDI 2-4

puffs via aerochamber

every 4-6 hr, if clinically

indicated.

Discharge Provide Review all teaching Discharge to home if on

28

Planning /

Teaching

education on

how to

recognize

worsening

respiratory

distress, signs

of inadequate

PO intake; how

to use a bulb

syringe (for

infants and

toddlers), and

how to do

respiratory

treatments.

content. Provide

information on home

medication

administration,

including

discontinuation and

follow-up

instructions.

room air, respiratory

treatment not needed

more than every 4-6 hr,

and tolerating PO feeds.

Instruct parent to call

physician if respiratory

distress is noted.

Ensure that parent makes

a follow-up appointment

within 1 week of

discharge.

I&O, input and output; MDI, metered-dose inhaler; NPO, nothing by mouth; PD&P,

postural drainage and percussion; PO, by mouth; SpO2, arterial blood oxygen saturation.

Care Path 16-4 - An Interdisciplinary Plan of Care for the Child with

Cystic Fibrosis

29

Nursing Diagnosis: Impaired gas exchange related to increase pulmonary

secretions.

Child/Family Outcomes: From baseline at admission, the child will demonstrate

improved gas exchange with improved airway clearance measured by:

-Decreased respiratory rate

-Decreased use of accessory muscles.

– Decreased secretions

– Increased airway clearance

– Improved or back to baseline PFTs

– Increased 02 saturation/baseline

– Decreased cough

– Increased exercise tolerance.

.

Nursing Diagnosis: Imbalance nutrition: less than body requirements related to

interference with enzyme production, compromised respiratory status, increased

metabolic requirements due to work of breathing, infection, and malabsorption

and/or decreased appetite.

Child/Family Outcomes: Child will ingest adequate nutrients based on

individual needs.

Child will have stools of normal consistency, frequency, and color.

Nursing Diagnosis: Potential for nonadherence to self-care related to chronic

nature of condition and developmental level.

Child/Family Outcomes: Child and family will attain and maintain behavior

30

that is consistent with goals of therapy.

-

Nursing Diagnosis: Potential for ineffective coping related to chronic illness

and the risk of life-threatening complications.

Child/Family Outcomes: Family members will verbalize feelings about the

illness and its effect on their lives; will identify family and community

resources, social support.

Nursing Diagnosis: Readiness for enhanced self concept related to appearance,

treatment regimen, and limitations on activities.

Child/Family Outcomes: Child will have a positive self-concept and value

personal strengths.

Child will express feelings about the disease and limitations it imposes.

Child will demonstrate accomplishments in areas of interests.

Care Intervention

Categories

Admission Transition to

Discharge

Discharge to

Community

Consults CF Team and

specialists as

needed (e.g.,

endocrine)

Social Work

Nursing Assessment

and Care

Management

Admission

weight

Vital signs and

Weight daily

Vital signs and

Discontinue

calorie count

31

pain assessment

q 4 hr

Respiratory

assessment.

Monitor stool

pattern

Calorie count

p.r.n.

Spot pulse

oximetry for O2

saturations>92

%

Continuous

pulse oximetry

for O2

saturations<

92%

Ad lib ADL’s

Reverse

isolation to

pain assessment q

4 hr

Monitor stool

pattern

Calorie count

p.r.n.

Spot pulse

oximetry for O2

saturations>92%

Continuous pulse

oximetry for O2

saturations< 92%

Ad lib ADL’s

Continue reverse

isolation.

Avoid contact

with other CF

patients.

Discontinue

pulse oximetry.

Ad lib ADL’s

Discontinue

isolation

32

prevent

infection with

multiple

resistant

organisms

Avoid contact

with other CF

patients.

Diagnostic Tests &

Procedures

CBC with

differential

Sputum culture

and sensitivity

labeled for CF

Basic

biochemical

panel, including

renal and liver

functions and

glucose

Other

laboratory tests

p.r.n.; UA,

AFB, sputum

Assess

aminoglycoside

therapy.

Levels with third

to fourth dose;

repeat if dose

adjusted

Follow up on

abnormal

laboratory values.

Assess culture

results and

sensitivities.

Consider work-up

for allergic

33

for fungal

cultures, IgE,

HbA1c

Chest

Radiograph post

anterior and

lateral views

Spirometry

PFTs for >5

years

ABG as

indicated

bronchopulmonar

y aspergillosis

(ABPA).

Consider workup

for cor

pulmonale, ECG,

O2 desaturation

study as indicated

by clinical status.

Pharmacologic

Management

Determine

venous access

option: initiate

IV, PICC, or

access

implanted

venous access

device.

Standard IV

solution for

pediatric

Continue with

medications as

ordered.

Heparin flush as

indicated for

PICC or central

line

Continue with

medications as

ordered.

Discontinue IV.

Heparin flush as

indicated for

PICC or central

line

maintenance at

34

patients, unless

patient has

glucose

intolerance

Heparin/saline

lock may be

used.

Pulmonary

medications/aer

osolized/antibio

tics/DNase

Pediatric

enzymes

Vitamins

H2 blockers

Prokinetic

agents

Antibiotics

NSAID’s/

analgesics

home

Nutrition Regular diet

(high calories)

Regular diet (high

calories)

Regular diet

(high calories)

35

Snacks t.i.d.

Night

supplemental

feeds for 10-12

hours as

indicated

Snacks t.i.d.

Night

supplemental

feeds for 10-12

hours as indicated

Assess need for

home enteral

program and

placement of

gastrostomy tube.

Snacks t.i.d.

Night

supplemental

feeds if

indicated

Psychosocial

Social Service

Play therapy/school

Initiate

therapeutic

play/recreationa

l activities as

appropriate.

Incorporate

schoolwork into

daily schedule.

Continue

therapeutic

play/recreational

activities as

appropriate.

Continue to

incorporate

schoolwork into

daily schedule.

Resume school

activities upon

discharge.

Respiratory PD&P and

ACT’s while

awake

PD&P and ACT’s

while awake

O2 as indicated

Return to usual

home treatment,

unless

36

O2 as indicated exacerbation

requires

additional

respiratory

support in the

home (e.g.,

oxygen, more

frequent PD&P)

Discharge planning /

Teaching

Assess self-care

behaviors and

provide age-

appropriate

education for

self-

management.

Assess home

and community

resources.

Assess/instruct in

adherence to

treatments/medica

tion/nutrition

plan.

Provide education

on symptom

management.

Identify home

care needs and

initiate referrals:

-Nutritional/

enteral

supplements

-Respiratory

Confirm

understanding

of discharge:

-Follow-up

plan/ medical

appointment

-Return to

school/work

Obtain

prescription for

discharge

needs.

37

durable medical

equipment for

airway clearance,

O2; etc.

-Home IV

antibiotics and

labs

Track progress of

education for new

home care skills.

Consider home

health referral.

ABG, arterial blood gases; ACT, airway clearance technique; AFB, acid-fast

bacilli; ADLs, activities of daily living; CBC, complete blood count; CF, cystic

fibrosis; ECG, electrocardiogram; HbA1c hemoglobin A1c , IgE,

immunoglobulin E; NSAID, nonsteroidal anti-inflammatory drug; O2, oxygen;

PD&P, postural drainage and percussion; PFT, pulmonary function tests; PICC,

peripherally inserted central catheter; UA, urinalysis.

38