Cystic Fibrosis case study PDF

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History of Present Problem: Justin Ewing is a seven-year-old boy with a history of cystic fibrosis (CF) who for the past two days has had a fever of 102.1 F (38.9 C) and has felt more tired. His cough has become more frequent, and he is bringing up thick yellow mucus. His mother brought Justin to his CF clinic where he is diagnosed with a right lower lobe pneumonia. Justin is admitted to the pediatric unit for IV antibiotics, and you will be the nurse responsible for his care. Justin has an implanted port for vascular access since he frequently needs IV antibiotics for respiratory infections. Justin is below the 5th percentile for his weight at 41 pounds (18.6 kg) and is at the 5th percentile for height at 44.5 inches (113 cm). He has a G-tube in place for night feedings.

Personal/Social History: Justin is in the second grade and lives at home with both parents and his 5-year-old brother who is in good health. His mother is a stay-at-home mom, and his father works as a computer software engineer. The family has health insurance through the father’s employer. He receives Medicaid because of his chronic illness. He has missed many days attending school due to CF but has a tutor provided by the school district. He told his parents that sometimes the kids at school tease because he is so small. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem:

Clinical Significance:

7 year old boy with hx of cystic fibrosis fever 102.1 frequent cough, while bringing up thick yellow mucus diagnosed with right lower lobe pneumonia implanted port for vascular access 5th percentile in height and weight G-tube in place for night feedings

fever could be from the present pneumonia as well as the frequent cough, with mucus. A hx of CF makes these symptoms more pronounced.

RELEVANT Data from Social History:

Clinical Significance:

mom is a stay at home mom; dad works as a computer software engineer misses many days of school due to his CF kids at school tease him because he is so small

Should talk to the child about how he feels when the kids at school tease him and reassure and validate his feelings. Also see how he feels about missing so much school, and if he feels the tutoring is a good fit for his educational and emotional needs.

CF causes children to be smaller in height and weight for their age G-tube feedings are relevant for supplemental meals as well as a night time feeding to make sure the child gets adequate nutrition.

Patient Care Begins: Current VS:

P-Q-R-S-T Pain Assessment:

T: 102.6 F/39.2 C (oral)

Provoking/Palliative:

P: 116 (reg) R: 26 (reg) BP: 92/60 O2 sat: 89% room air

Quality: Region/Radiation: Severity: Timing:

Justin states he does not have any pain when assessed using the Wong-Baker FACES Pain Rating Scale

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

Clinical Significance:

T - 102.6 Pulse - 116 R - 26 O2 - 89% on room air No pain assessed using the PQRST pain scale

Temperature elevated due to possible bacterial pneumonia Pulse is in the normal range, could possibly be elevated due to increased difficulty breathing RR are on the high end of normal 89% on room air is very low. He should be connected to oxygen to bring up his stats

© 2018 Keith Rischer/www.KeithRN.com

Current Assessment: GENERAL Slightly anxious appearing and very quiet. Skin is pale with dark circles under both eyes. Appears much younger than age due to slow growth. Does not speak except for nodding APPEARANCE: head “yes” “no.” Sitting between his parents. RESP: Respiratory efforts moderately labored with increased rate. Breath sounds course crackles and wheezing throughout lung fields bilaterally with fine crackles heard on inspiration at right base. Moderate sub-costal retractions noted, nail beds have a blueish hue in color and have pronounced clubbing. CARDIAC: Pale, warm & moist forehead. No edema, heart sounds regular with elevated rate, no abnormal beats, and pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill noted at forehead Justin has an implanted port central venous access device at the left upper chest. The site is clean and dry with a small scar at the insertion site. NEURO/MENTAL: Alert & oriented to person, place, time, and situation (x4). Appears to be moderately anxious, listening intently to provider and nurse but not speaking, holding on to Dad’s hand. GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Liver non-palpable, PEG tube in place with expected healing around tube/site GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT Assessment Data:

Clinical Significance:

Gen: Slightly anxious appearing and very quiet. Skin pale with dark circles under both eyes. Appears younger due to slow growth. Resp: efforts moderately labored with increased rate. Breath sounds course crackles and wheezing through out lungs bilaterally, with fine crackles heard on inspiration at right base. sub-costal retractions noted, nail beds bluish hue, with pronounced clubbing. Cardiac: Pale, warm & moist forehead. implanted port central venous access device at the left upper chest. GI: Peg tube in place

Slow growth due to cystic fibrosis the child appears to be having difficulty breathing. nail beds with a bluish hue, with pronounced clubbing can be an indication of hypoxia - often occurs in cystic fibrosis. Pale, warm moist forehead could be a symptom of the child's fever and difficulty breathing

Cardiac Telemetry Strip:

Interpretation:

sinus tachycardia 160bpm Clinical Significance:

this is a normal finding with a child with cystic fibrosis because the heart has to work harder since the lungs are working harder to help the child breath. © 2018 Keith Rischer/www.KeithRN.com

Radiology Reports: Chest X-RAY AP and lateral: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Results:

Clinical Significance:

Right lower lobe pneumonia as well as chronic obstructive pulmonary disease with an increase in anteroposterior chest diameter. The right side of the heart is slightly enlarged.

The right side of the heart being slightly enlarged could be a complication of the cystic fibrosis. The heart has to work extra hard to provide the lungs with the added blood and oxygen they need to perform.

Lab Results: Complete Blood Count (CBC :) WBC (4.5–11.0 mm 3) Neutrophil % (42–72) Hgb (12–16 g/dL) Platelets (150-450 x103/µl)

Current: 20.5 88 10.3 450

High/Low/WNL?

Prior to Admission: 10.0 70 10.4 400

High

High Low WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

WBC - 20.5 Neutrophil % - 88 Hgb - 10.3 Platelets - 450

A CBC is performed to identify possible infections, worsening worsening by evaluating the different components in the stable blood. worsening

Basic Metabolic Panel (BMP :) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) Creatinine (0.6–1.2 mg/dL)

Current: 137 4.0 80 0.7

High/Low/WNL?

Prior to Admission: 139 4.5 72 0.66

WNL

WNL WNL WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Sodium Potassium Glucose Creatinine

low end of normal WNL WNL low end of normal

Misc. Labs: Magnesium (1.6–2.0 mEq/L) Calcium (8.8-10.6 mg/dL) Amylase (25–125 U/l) Lipase (3–73 units/L) Lactate (0.5–2.2 mmol/L) GFR (>60 mL/minute) Coags: PT/INR (0.9–1.1 nmol/L) © 2018 Keith Rischer/www.KeithRN.com

Current: 1.8 8.0 180 200 U 0.6 >60 mL/min 1

worsening worsening improve stable High/Low/WNL?

Prior to Admission:

WNL

1.6 9.0 185 230 0.7 >60 mL/min

WNL

0.9

WNL Low

High High

WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Calcium Amylase Lipase

an elevated amylase and lipase level could mean Worsening the pancreas is possible damaged. Stable Improve

Liver Function Test (LFT:) Albumin (3.5–5.5 g/dL) Total Bilirubin (0.1–1.0 mg/dL) Alkaline Phosphatase

Current: 2.8 0.5 40

male: 38–126 U/l female: 70–230 U/l

ALT (8–20 U/L) AST (8–20 U/L)

12 10

High/Low/WNL? Low WNL

WNL WNL WNL

Prior to Admission: 3.0 0.8 42 10 9

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Albumin Alkaline Phosphatase ALT AST

low albumin levels could indicate inflammation, shock, and malnutrition. (Low end) (Low end) (Low end)

Urine Analysis (UA:) Color (yellow) Clarity (clear) Specific Gravity (1.015-1.030) Nitrate (neg) LET (Leukocyte Esterase) (neg) MICRO: RBC’s (...