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Care of the Pediatric Patient with Cystic Fibrosis
Good Morning everyone! Today we are going to discuss on how to care for a patient with cystic Fibrosis.
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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
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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
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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)
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Cultural Considerations
Divorce household Under full custody of grandparents since childhood GT tube feeding CVAD R chest
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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 On the morning of 26 Oct 14 patient TRD was admitted in their local clinic due to extensive coughing. Besides the fact that my patient had an exacerbation of his CF, another reason for his admission was his c/o LL Back pain. According to his grandparents TRD had a hx of pancreatitis, and they were worried that it is recurring again due to his complaint of pain. human rhinovirus (HRV), a member of the family Picornaviridae, has been described. Although some studies have suggested a substantial pathogenic role for these viruses (3), controversy still exists (4). Previous studies of respiratory virus infections in CF patients provided conflicting results on the potential effect of rhinovirus. Smyth et al (15), who evaluated respiratory exacerbations in CF patients, identified rhinovirus as the leading agent, with exacerbations following a more benign course but resulting in greater use of intravenous antimicrobial drugs (15). Olesen et al. (4) studied 75 CF patients for 1 year and used PCR to investigate the presence of 7 different viruses in sputum or laryngeal aspirates. The group reported that viral infections did not reduce lung function or increase respiratory symptoms. Rhinovirus was by far the leading agent identified throughout their study
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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
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Organs affected in CF
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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
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Treatments continued….
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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.
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Relationship of Secondary dx
Dx of MRSA on admission day Dx of Rhino Virus: 7th day of hospitalization
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Developmental Stage and Developmental Theory to Care
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 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
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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
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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)
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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.
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Nursing Diagnosis #2: Ineffective Airway Clearance/Impaired Gas Exchange
Supporting data: Hx of CF, coughing Medications: Albuterol, CPT (qid), Flovent, Advair, Dornase, Pantanase
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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.
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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. Pancrelipase (creon): digestive enzyme that is use (sprinkile) in his meal to help digest food since his pancreas is block and not able to produce the enzyme body needs. Miralax: to help prevent constipation
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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
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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 The role of bacterial infections in CF is well established, and most treatments focus on eradication or suppression of bacterial infections (mainly those caused by Pseudomonas aeruginosa) Tobramycin: aminoglycosides/antibiotic tx: interferes with protein synthesis of susceptible bacteria Meropenem: inhibits bacterial cell wall synthesis Levofloxacin, Linezolid
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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: Met Pt. temp remain within accepted parameters: 36.3*C 1330; 36.9*C 1500 before and during end of shift.
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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) Sertraline: antidepressant, OCD adjunct, Anxiolytic ( daily PO) Adderall: CNS stimulant for ADHD and Narcolepsy. Affect chemical reaction in the brain and nerves that contributes hyperactivity and impulse control.
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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 Met Pt. more truthful about pain level measures, however still uncertain pt’s openness to discuss feelings
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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
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Research Name of Journal: Journal of Pediatric Nursing Title of Research: Distraction Techniques for Children Undergoing Procedures: A Critical Review of Pediatric Research
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Conclusion
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References Gulanick , M., & Myers , J. (2011). Nursing care plans: Diagnosis, interventions, and outcomes . (7 ed., pp ). 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,
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