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.