Student- Unfolding-Cystic Fibrosis PDF

Preview

Summary

Download Student- Unfolding-Cystic Fibrosis PDF

Description

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:

- temp 102.1 F - weight 18.6 kg, height 113 cm - hx of CF - cough with thick, yellow mucus - right lower lobe pneumonia - implanted port and g-tube

- fever is sign of infection - mucus buildup from CF - below proper percentile in height and weight, FTT

RELEVANT Data from Social History: - lives at home with parents and brother - missed many days at school, but has a tutor - teased at school - has Medicaid

Clinical Significance:

stress of chronic disease among whole family, at risk for depression due to chronic disease and being teased in school, should have adeuqate insurance

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 F/39.2 C P: 116 (high) R: 26 (high) O2 sat: 89%

- high temperature is a sign of infection, may need antipyretic - mucus buildup could be causing obstructions in airway - low O2 sat requires supplemental oxygen

© 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:

- pale, dark circles under eyes - anxious and quiet - moderately labored and increased respiratory rate - crackles and wheezing in lungs - moderate sub-costal retractions - bluish hue on nails and clubbing - pale and moist forehead - elastic skin turgor, no tenting

- ineffective airway clearance evident by wheezing, crackles, and moderate sub-costal retractions - lungs have fluid in them due to pneumonia - poor oxygenation and perfusion evident by clubbing and bluish hue on nails - Justin is experiencing anxiety, could be due to hospitalization or difficulty breathing - FTT

Cardiac Telemetry Strip:

Interpretation:

sinus tachycardia Clinical Significance:

increased HR but normal sinus rhythm

© 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.

- poor gas exchange, systemic vascular resistance - Justin is not oxygenated adequately, so right side of heart is having to work harder - hyperinflation of the lungs

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 high low WNL (on high side)

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):

Clinical Significance:

TREND:

- High WBC (20.5) - High Neutrophil (88) - Low Hgb (10.3)

high WBC and neutrophils indicative of infection low Hgb indicative of poor oxygenation

Improve/Worsening/Stable:

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?

labs are worsening

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:

glucose creatinine

glucose creatinine are trending upwards pancreas is not compromised at this time no evidence of diabetes

Improve/Worsening/Stable:

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

High/Low/WNL?

currently stable, but continue to monitor because some values are trending to abnormal values

Prior to Admission:

WNL low high high WNL WNL

1.6 9.0 185 230 0.7 >60 mL/min

WNL

0.9

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:

amylase lipase

Indicate abnormalities with pancreas and possible diabetes

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

High/Low/WNL?

Improving-both labs have gone down since admission and interventions Prior to Admission:

WNL

3.0 0.8 42

WNL WNL

10 9

low WNL

male: 38–126 U/l female: 70–230 U/l

ALT (8–20 U/L) AST (8–20 U/L)

12 10

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 ALT AST

Nutritional Status Break down Protein liver function

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