Student- Rapid-Cystic Fibrosis 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 5 th 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: School-aged boy (7), Dx of cystic fibrosis, Fever 38.9 X 2days, Fatigued, Productive cough with thick yellow mucus, Right lower lobe pneumonia, Implanted port for vascular access, Frequent respiratory infections with IV abx usage, 5th percentile height & weight (113cm & 18.6kg), G-tube with nightly feedings RELEVANT Data from Social History: Lives at home with parents, 5yr old brother, active health insurance, missed frequent days at school due to illness, gets teased by school kids due to small size

Clinical Significance: Active infection, below average for height & weight, malnutrition, increased nutrients needed, possible resistance to certain antibiotic medications due to frequent infections

Clinical Significance: Risk for mental illness due to chronic illness, teasing, and possible increased stress

Patient Care Begins: Current VS:

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

T: 102.6 F/39.2 C (oral)

Provoking/Palliative: Justin states he does not have any pain when assessed using the Wong-Baker FACES Pain Rating Scale Quality: Region/Radiation: Severity: Timing:

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

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: T: 39.2 R: 26 O2 sat: 89% room air

Clinical Significance: Elevated temperature indicative of infection Normal to elevated respiratory rate due to impaired airway and coughing Impaired lung function, hypoxic

Current Assessment:

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GENERAL APPEARANCE: RESP:

CARDIAC:

NEURO/MENTAL: GI: GU: SKIN:

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 head “yes” “no.” Sitting between his parents. 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. 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. 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. 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 Voiding without difficulty, urine clear/yellow 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: GA: 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 head “yes” “no.” Sitting between his parents.

Clinical Significance: Signs of iron deficiency anemia, developmental delays, anxious/shy

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.

Ineffective airway clearance evident by wheezing, crackles, and moderate sub-costal retractions. Poor oxygenation and perfusion evident by clubbing and bluish hue on nails.

CARDIAC: Pale, warm & moist forehead. Implanted port central venous access device at the left upper chest.

Frequent administration of fluids, blood products, medication, and other therapies to the bloodstream.

NEURO/MENTAL: Appears to be moderately anxious, listening intently to provider and nurse but not speaking, holding on to Dad’s hand. GI: PEG tube in place with expected healing around tube/site. Cardiac Telemetry Strip:

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Developmental delay, shy, scared, nervous

Route for enteral feeding, hydration, and medication administration, likely to have prolonged inadequate or absent oral intake.

Interpretation: Sinus tachycardia Clinical Significance: Patient has an increased HR but normal sinus rhythm. Possibly due to anxiety, pain, possible infection, fever, and/or possible underlying cardiac condition.

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: 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 .

Clinical Significance: Poor oxygenation, poor gas exchange, systemic vascular resistance, right side of heart is having to work harder as a result and hyperinflation of the lungs related to COPD.

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? HIGH WNL LOW WNL

Prior to Admission: 10.0 70 10.4 400

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

RELEVANT Lab(s): WBC: 20.5 Neutrophil: 88 Hgb: 10.3

Clinical Significance:

TREND: Improve/Worsening/Stable: Worsening Worsening Worsening

Indicative of infection/inflammation Poor oxygenation and/or blood loss

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? WNL WNL WNL WNL

Prior to Admission: 139 4.5 72 0.66

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

RELEVANT Lab(s): Glucose: 80 Creatinine: 0.7

Clinical Significance: Possible evidence of underlying diabetes, poor kidney function

© 2018 Keith Rischer/www.KeithRN.com

TREND: Improve/Worsening/Stable: Stable but worsening

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)

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

High/Low/WNL? WNL LOW HIGH HIGH WNL WNL

Prior to Admission:

1

WNL

0.9

1.6 9.0 185 230 0.7 >60 mL/min

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

RELEVANT Lab(s): Amylase: 180

Clinical Significance:

TREND: Improve/Worsening/Stable: Improving

Possible evidence of underlying diabetes, possible concerns regarding pancreas.

Lipase: 200 Liver Function Test (LFT:) Albumin (3.5–5.5 g/dL) Total Bilirubin (0.1–1.0 mg/dL) Alkaline Phosphatase male:

Current: 2.8 0.5 40

High/Low/WNL? LOW WNL WNL

Prior to Admission: 3.0 0.8 42

38–126 U/l female: 70–230 U/l

ALT (8–20 U/L) 12 WNL 10 AST (8–20 U/L) 10 WNL 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:

Albumin: 2.8

Indicative of inflammation, shock, and/or malnutrition

Improve/Worsening/Stable: Worsening

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