Chapter 16: The child with altered respiratory statusdownloads.lww.com/wolterskluwer_vitalstream_com/sample... · Web viewKey Terms apnea atelectasis atopy cor pulmonale cyanosis
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Bowden, Chapter 16: Supplemental Information
Key Terms
apnea
atelectasis
atopy
cor pulmonale
cyanosis
dyspnea
hemoptysis
hypercarbia
hypoxemia
hypoxia
pallor
respiratory distress
respiratory failure
retractions
subcutaneous emphysema
tachypnea
ventilation-perfusion mismatch
1
Summary of Key Concepts
Certain anatomic and structural features of the respiratory tract in infants and young
children predispose them to develop respiratory distress more readily than older children
or adults.
Respiratory illnesses and exacerbations of chronic respiratory conditions are the most
common reasons for pediatric hospital admissions and ambulatory center visits, especially
during winter and early spring.
Viral and bacterial infections of the respiratory system are common and relatively
unavoidable during childhood.
Children with chronic conditions, especially conditions that involve the respiratory or
cardiac systems, are at highest risk for serious morbidity or mortality associated with
common childhood respiratory infections.
Worsening respiratory distress can be identified by frequent and thorough respiratory
assessments. Early recognition and prompt intervention for respiratory distress are key to
prevent respiratory failure.
Parents of children with chronic respiratory conditions must be educated to recognize
signs and symptoms of respiratory compromise and to notify their healthcare provider
immediately when they occur. Good decision making skills are an essential component of
daily disease management. The nurse must teach these parents how to manage
emergency situations in the home
Children with chronic respiratory conditions require regular follow-up visits with
healthcare providers and use of proactive and preventive measures.
2
Evidence-Based Practice Guidelines
American Academy of Pediatrics. (2001). Clinical practice guideline: Management of sinusitis.
Pediatrics, 108 (3), 798-808.
American Academy of Pediatrics (AAP). (2003). Apnea, Sudden Infant Death Syndrome, and
home monitoring. Pediatrics, 111, 914-917.
American Association for Respiratory Care (AARC). (2007). Removal of the endotracheal tube
—2007 revision & update. Respiratory Care, 52, 81-93.
American Thoracic Society. (2007). An Official ATS Workshop Report: Issues in Screening for
Asthma in Children. Available at
http://www.thoracic.org/sections/publications/statements/
American Thoracic Society. (2007). An Official ATS/ERS Statement: Pulmonary Function
Testing in Preschool Children. Available at
http://www.thoracic.org/sections/publications/statements/
American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. Available at
http://www.thoracic.org/sections/publications/statements/
Cincinnati Children’s Hospital Medical Center. (2006). Evidence-based clinical practice
guideline for medical management of bronchiolitis in infants less than 1 year of age
presenting with a first time episode. Cincinnati, OH: Author. Available at
www.guideline.gov.
Kelley, L., & Allen, P. (2007). Managing acute cough in children: Evidenced –based guidelines.
Pediatric Nursing, 33, 515-524.
3
Organizations
Allergy & Asthma Network Mothers of Asthmatics
www.breatherville.org
American Academy of Allergy, Asthma and Immunology
www.aaaai.org
American Association for Respiratory Care (AARC)
www.aarc.org
American Cleft Palate-Craniofacial Association
www.cleftline.org
American College of Allergy, Asthma, and Immunology
www.Acaai.org
American Lung Association
www.lungusa.org
American Thoracic Society
www.thoracic.org
Association of Asthma Educators
4
www.asthmaeducators.org
Asthma and Allergy Foundation of America (AAFA)
www.aafa.org
Centers of Disease Control and Prevention (CDC)
www.cdc.gov
Cystic Fibrosis Foundation
www.cff.org
Cystic Fibrosis Worldwide
www.cfww.org
Environmental Protection Agency, Office of Children’s Health Protection
http// yosemite.epa.gov/ochp/ochpweb.nsf/homepage
Food Allergy & Anaphylaxis Network
www.foodallergy.org
National Asthma Education and Prevention Program, NHLBI Information Center
www.nhlbi.nih.gov/about/naepp/
5
National Heart, Lung and Blood Institute Information Center
www.nhlbi.nih.gov
National Jewish Medical and Research Center
www.njc.org
Respiratory Nursing Society
www.respiratorynursingsociety.org
6
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and prenatal carrier screening for cystic fibrosis: Clinical and laboratory guidelines.
Washington, DC: American College of Obstetricians and Gynecologists.
Bennett, A.D. (2002). Home apnea monitoring for infants. Advance for Nurse Practitioners, 10,
47-54.
Berge, J., & Patterson, J. (2004). Cystic fibrosis and the family: A review and critique of the
literature. Families, Systems, & Health, 22, 74-100.
Bjornson, C., & Johnson, D. (2005). Croup-Treatment update. Pediatric Emergency Care,
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Carpenter, D.R. & Narsavage, G.L. (2004). One breath at a time: Living with cystic fibrosis.
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clearance. Pediatric Nursing, 28, 107-111.
7
Ebbinghaus, S. & Bahrainwala, A.H. (2003). Asthma management by an inpatient asthma care
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Franzese, C.B. & Schweinfurth, J.M. (2002). Delayed diagnosis of a pediatric airway
foreign body: Case report and review of the literature. Ear, Nose & Throat
Journal, 81, 655-656.
Grosse, S.D., Boyle, C.A., Botkin, J.R., et al (2004). Newborn screening for Cystic
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Heijerman, H. (2005). Infection and inflammation in cystic fibrosis: A short review. Journal of
Cystic Fibrosis, 4, 3-5.
Horner, S.D., Surratt, D. & Smith, S.B. (2002). The impact of asthma risk factors on home
management of childhood asthma. Journal of Pediatric Nursing, 17, 211-221.
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cystic fibrosis: A center based analysis. Chest, 123, 20-27.
Kotagal, S. (2005). Childhood obstructive sleep apnoea (editorial). British Medical Journal,
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Korppi, M. (2003). Community-acquired pneumonia in children: Issues in optimizing
antibacterial treatment. Pediatric Drugs, 5(12), 821-832.
Lee, E., Parker, V., DuBose, L., Gwinn, J., & Logan, B. (2006). Demands and resources: Parents
of school-age children with asthma. Journal of Pediatric Nursing, 21, 425-433.
McCarthy, M.J., Herbert, R., Brimacombe, M., Hansen, J., Wong, D. & Zelman,
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M. (2002). Empowering parents through asthma education. Pediatric
Nursing, 28, 465-473.
Meissner, H.C. & Rennels, M.B. (2004). Unpredictable patterns of viral respiratory
disease in children. Pediatrics. 113, 1814-1816.
Millman, R.P. & Working Group on Sleepiness in Adolescents/Young Adults; and AAP
Committee on Adolescence (2005). Excessive sleepiness in adolescents and
young adults: Causes, consequences, and treatment strategies. Pediatrics, 115,
1774-1786.
Patterson, E.E., Brennan, M.P., Linskey, K.M., et al (2005). A cluster randomized
intervention trial of asthma clubs to improve quality of life in primary school
children: The School Care and Asthma Management Project (SCAMP).
Archives of Diseases in Childhood, 90, 786-791.
Pediatric Tuberculosis Collaborative Group (2004). Targeted Tuberculin skin
testing and treatment of latent Tuberculosis infection in children and adolescents.
Pediatrics, 114, 1175-1201.
Peeke, K., Hershberger, M., & Marriner, J. (2006). Obstructive sleep apnea syndrome in
children. Pediatric Nursing, 32, 489-494.
Rotta, A.T. & Wiryawan, B. (2003). Respiratory emergencies in children. Respiratory Care, 48,
248-260.
Sander, N., (2002). Making the grade with asthma, allergies, and anaphylaxis. Pediatric
Nursing, 28, 593-598.
9
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airway management in isolated Pierre robin sequence. Plastic and Reconstructive
Surgery, 113, 1113-1125.
Schibli, S., Durie, P. & Tullis, E. (2002). Proper usage of pancreatic enzymes. Current Opinion
in Pulmonary Medicine, 8(6), 542-546.
Schuster, M., Franke T., & Pham C.(2002). Smoking patterns of household members and
visitors in homes with children in United States. Archives of Pediatric Adolescent
Medicine, 156, 1094-1100.
Society for Adolescent Medicine (2003). Transtion to adult healthcare for adolescents and
young adults with chronic conditions. Journal of Adolescent Health, 33309-311.
Sterling, Y., & El-Dahr, J. (2006). Wheezing and asthma in early childhood: An update.
Pediatirc Nursing, 32(1), 27-31.
Trollvik, A., & Severinsson, E. (2005). Influence of an asthma education program on parents
with children suffering from asthma. Nursing and Health Sciences, 7, 157-163.
Velissariou, I., & Papadopoulos, N. (2006). The role of respiratory viruses in the pathogenesis of
pediatric asthma. Pediatric Annals, 35, 637-642.
Velsor-Friedrich, B., Pigott, T.D. & Louloudes, A. (2004). The effects of a school-based
intervention on the self-care and health of African-American inner-city children
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Weiland, J., Schoettker, P.J., Byczkowski, T., Britto, M.T., Pandzik, G. & Kotagal, U.R.
(2003). Individualized daily schedules for hospitalized adolescents with cystic
fibrosis. Journal of Pediatric Healthcare, 17, 284-289.
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10
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11
Addenda
Care Path 16-1 - An Interdisciplinary Plan Of Care for the Child with Apnea
Nursing Diagnosis: Ineffective breathing pattern related to apneic episodes.
Child/Family Outcomes: Child will have effective breathing pattern without apneic spells
throughout hospitalization.
Nursing Diagnosis: Impaired home maintenance related to change in home care regimen.
Child/Family Outcomes: Parents will verbalize understanding of necessary diagnostic
tests and consultations.
Parents will describe and demonstrate understanding of CPR and home apnea monitor
prior to discharge.
Nursing Diagnosis: Interrupted family processes related to anxiety associated with threat
of infant death.
Child/Family Outcomes: Parents will develop open communication with healthcare team
and receive patient information in a timely manner.
Parents will verbalize understanding of need to develop support system to provide respite
care.
Care Intervention
Categories
Admission Transition to
Discharge
Discharge to
Community
Consults Social service
Specialty services
such as
Pulmonary and
Gastroenterology
Teach
parent/family
members CPR
(basic life
support) and
12
evaluate return
demonstration
Nursing
Assessment and
Care Management
Check vital signs
every 4 hr
Daily weights.
Height on
admission
Complete
assessment, with
emphasis on
respiratory
system
Cardiorespiratory
monitor (Apnea
monitor)
Pulse oximetry
Keep head of bed
elevated.
Avoid
hyperflexion of
neck.
Initiate
documentation of
Vital signs every
4 hr
Pulse oximetry
spot checks.
Assess and
document
respiratory
responses to care.
Pulse oximetry
spot checks.
Keep child
upright for 30-45
minutes following
feeding.
Position on
abdomen between
feedings.
Discontinue pulse
oximetry.
Place home monitoring
device on child.
Assess response to reflux
precautions.
13
apneic episodes.
Diagnostic Tests &
Procedures
Possible tests
include CBC,
capillary blood
gases, calcium,
electrolytes,
glucose, septic
work-up
Aminophylline
requires blood
level monitoring.
Chest radiograph
ECG, EEG
Pneumogram
(pneumocardiogra
m)
If history
indicates, upper
GI series, reflux
scan, Ph probe,
polysomnography
Repeat diagnostic
tests as indicated
by child’s
condition.
Pharmacologic
Management
As ordered by
healthcare
As ordered by
healthcare
Continue with
medications, as ordered
14
professional
Gastroesophageal
reflux
medications, if
indicated
professional
Gastroesophageal
reflux
medications, if
indicated
Nutrition Accurate intake
and output
Reflux
precautions if
diagnosed with
reflux.
Diet for age as
tolerated.
Maintain reflux
precautions if
needed.
Diet for age as tolerated.
Maintain reflux
precautions if needed.
Discharge
planning / Teaching
Orient family to
hospital and
primary
caregivers.
Have family
verbalize
understanding of
monitors and
diagnostic
studies.
Notify discharge
planner of need
for home nursing
referral at time of
discharge.
Find out whether
family has
telephone.
Advise family of
home nursing
Hold discharge
conference with parents
to review teaching needs,
follow-up clinic visits,
equipment needs, and
financial resources.
Instruct parents to keep
log of apneic episodes to
include time, child’s
activity at time of
15
Have family
verbalize
understanding of
infant's
cardiopulmonary
system.
Have family
demonstrate
reflux
precautions,
medication
administration,
monitor
application, steps
to answer monitor
alarms.
referral.
Complete home
healthcare
referral.
Contact home
health agency.
Begin CPR
teaching.
Have family
demonstrate use
of home monitor.
Have family
demonstrate CPR.
Review
guidelines for
using home
monitoring with
parents.
Suggest educating
secondary care
providers
regarding
episode, and
interventions to stimulate
the child.
Provide parents with
information on support
group or name of other
family with child on
apnea monitoring at
home.
Have parents notify
neighborhood EMT of
child’s status.
Home visit by home care
agency is scheduled.
Follow up appointments
scheduled.
16
monitor use and
CPR.
CBC, complete blood count; CPR, cardiopulmonary resuscitation; EEG,
electroencephalogram; ECG, electrocardiogram; EMT, emergency medical technicians;
GI, gastrointestinal.
Care Path 16-2 - An Interdisciplinary Plan of Care for the Child with Bronchiolitis
Nursing Diagnosis: Ineffective breathing pattern related to bronchospasm, mucosal
edema, and accumulation of mucus.
Child/Family Outcomes: Child will demonstrate improved breathing pattern, as
evidenced by absence of tachypnea, retractions, nasal flaring, grunting, wheezing,
cyanosis, or cough.
Nursing Diagnosis: Impaired gas exchange related to bronchiolar obstruction, atelectasis,
and hyperinflation.
Child/Family Outcomes: Child will demonstrate adequate oxygenation and ventilation,
as evidenced by oxygen saturation >92% and decreased work of breathing.
Nursing Diagnosis: Deficient fluid volume related to dyspnea, tachypnea, and decreased
oral intake.
Child/Family Outcomes: The child will maintain adequate intake and output for age and
weight.
The child will maintain adequate hydration, as evidenced by moist mucous membranes,
good skin turgor, and serum electrolytes within normal range.
Nursing Diagnosis: Deficient knowledge related to home management of bronchiolitis.
17
Child/Family Outcomes: Family will demonstrate knowledge of and adherence to home
treatment plan.
Care
Intervention
Categories
Admission Transition to
Discharge
Discharge to
Community
Consults Pediatric
pulmonologist prior
to initiation of
ribavirin, if needed
Infection control
specialist
Nursing
Assessments and
Care
Management
Vital signs and pain
q 2-4 hours based
on acuity
Blood pressure on
admission
Strict intake and
output
Cardiopulmonary
monitor
Continuous pulse
oximetry
Keep head of bed
Vital signs and pain
every 4 hours
Pulse oximetry spot
checks with
respiratory
treatments and PRN
for respiratory
distress
Keep head of bed
elevated.
Activity as
tolerated
Discontinue
cardiopulmonary
monitor.
Discontinue pulse
oximetry.
Activity as tolerated
Discontinue isolation.
18
elevated.
Activity as
tolerated
Bulb suction with
normal saline PRN
for congestion.
Suction with
catheter and saline
only for airway
obstruction causing
substantial
respiratory
compromise.
Contact isolation
during non-
epidemic period;
contact precautions
plus droplet
precautions during
RSV epidemic
periods
Bulb suction with
normal saline PRN
for congestion.
Suction with
catheter and saline
only for airway
obstruction causing
substantial
respiratory
compromise.
Contact isolation
during non-
epidemic period;
contact precautions
plus droplet
precautions during
RSV epidemic
periods
Diagnostic Tests
& Procedures
CBC with
differential
Repeat diagnostic
tests as indicated by
19
Blood culture if
child appears very
ill or temperature is
>102F
Consider blood gas
measurements
Nasal washing for
RSV panel (if
indicated)
Chest Radiograph
(if indicated)
child’s condition
Pharmacologic
Management
IV antibiotics if
strong suspicion or
evidence of
bacterial infection
Acetaminophen15
mg/kg PO/PR every
4 hrs p.r.n. (if fever
1010F or mild
pain);max dose =
75 mg/kg/day or 4
gm/day; whichever
is less
Maintain IV fluids
if not taking PO
feeds well or
change to
heparin/saline lock.
Discontinue IV.
Room air
20
Ibuprofen 10 mg/kg
PO every 6 hrs (if
fever >1010F or
discomfort) if
acetaminophen is
not effective; max
dose+ 400 mg
Neo-Synephrine
1/8%; 2-3 drops
each nostril every 6
hrs PRN for nasal
congestion
IV fluids at
maintenance if
clinically
dehydrated or not
taking PO feeds
Nutrition NPO if in
respiratory distress
PO feedings if
RR<60
Diet for age
Encourage PO
feeds and fluid
intake.
Diet for age
21
Psychosocial Parental support for
anxiety
Rest for parent if
sleep deprived
Respiratory Suction prn, before
feedings and before
inhalation therapy.
Oxygen to keep O2
saturation >92% or
for severe
respiratory distress
Begin weaning
oxygen to keep O2
saturation >94%.
Discontinue O2.
Room Air
Discharge
planning /
Teaching
Teach family to use
bulb syringe and
watch them
practice.
Teach about home
medication
administration.
Ensure family
understands dosing
and purpose of
medications.
Home nebulizer, if
needed
Assess smoking
status in home,
refer family for
Discharge if Ribavirin
therapy not needed.
Return to clinic if
signs/symptoms of
respiratory distress
recur.
22
smoking cessation
and encourage
smoke-free homes
and cars.
ADLs, activities of daily living; CBC, complete blood count; ECG, electrocardiogram;
IM, intramuscular; IV intravenous; NPO, nothing by mouth; PO, by mouth; RR,
respiratory rate; RSV, Respiratory Syncytial virus
Care Path 16-3 - An Interdisciplinary Plan of Care for the Child with Pneumonia
Nursing Diagnosis: Ineffective breathing pattern related to an inflammatory infection of
the lower airway
Child/Family Outcomes: Child will demonstrate and maintain an improved breathing
pattern throughout hospitalization, as evidenced by lessening or absence of tachypnea,
retractions, nasal flaring, grunting, wheezing, cyanosis, and/or cough.
Nursing Diagnosis: Deficient knowledge related to disease process and home
management of child upon discharge
Child/Family Outcomes: Family will verbalize understanding of illness and rationale for
treatment plan.
By discharge, family will verbalize/demonstrate an understanding of how to administer
medication at home, how to perform PD&P, how to use a bulb syringe and an MDI as
appropriate, and when to notify physician of changes in respiratory status.
23
Care
Intervention
Categories
Admission Transition to
Discharge
Discharge to
Community
Nursing
Assessment and
Care
Management
Check vital
signs every 4 hr
Strict intake and
output
Consider apnea
monitor for
infants <6 mo
with moderate
to severe
respiratory
distress.
SpO2 check
once, and then
check p.r.n. for
respiratory
distress.
Activity as
tolerated
Vital signs every 4 hr
I&O every shift
Apnea monitor as
indicated
SpO2 p.r.n. for
respiratory distress
Activity as tolerated
Maintain contact
isolation.
Discontinue apnea
monitor.
Activity as tolerated
Discontinue isolation
24
Contact
isolation
Diagnostic Tests
& Procedures
CBC with
differential
Consider blood
culture and cold
agglutinins.
Chest
radiograph
Spirometry for
children (> 6
yrs) with co-
morbid
conditions (e.g.,
CF, asthma,
neuromuscular,
etc.)
Repeat diagnostic
tests as indicated by
child’s condition.
Pharmacologic
Management
Ampicillin 200
mg/kg/day IV q
6 hrs
(maximum 2
g/dose)
Or
Once PO intake is
consistently 75% or
more of maintenance,
switch to
heparin/saline lock
IV
Discontinue Neo-
Synephrine (>3 day use
not recommended).
Change to oral
antibiotics.
25
Cefuroxime 75-
150 mg/kg/day
IV q 8 hr for
bacterial
pneumonia
(maximum
dose, 1.5
g/dose)
Neo-Synephrine
1/8%, 2-3 drops
each nostril
every 6 hr,
p.r.n. for nasal
congestion.
Acetaminophen
15 mg/kg (max
dose 650 mg)
PO/PR every 4
hours PRN
T>101F or
discomfort
For bacterial pneumonia,
discharge on PO
antibiotics to complete a
10-day course.
Discontinue
heparin/saline lock.
26
Ibuprofen 10
mg/kg (max
dose 400 mg)
PO every 6
hours PRN
T>101F or
discomfort if
acetaminophen
is not effective.
Heparin/saline
lock or consider
IV fluids at
maintenance if
unable to take
PO feeds.
Nutrition NPO if
respiratory
distress
symptoms or
vomiting
Diet for age;
encourage fluids
(clear); avoid dairy
products
Diet for age as tolerated
Respiratory Oxygen to keep Encourage deep Discontinue oxygen.
27
saturation >92%
Bulb or wall
suction p.r.n.
PD&P with
nebulized
treatments, if
clinically
indicated
(atelectasis or
lobar
pneumonia
identified by
chest
radiograph)
Albuterol 0.15
mg/kg in 2 mL
normal saline
via nebulizer
every 2-4 hr and
p.r.n. (minimum
diluted dose
0.25 mL)
breathing and
directed cough every
4 hours while awake.
Consider weaning
oxygen.
Consider alternating
nebulized treatments
with MDI treatment.
Or
Discontinue
nebulized treatments
and use albuterol
MDI 2-4 puffs every
4-6 hr, if clinically
indicated.
Wean oxygen as
tolerated.
Room air
Discontinue nebulized
treatments.
Use albuterol MDI 2-4
puffs via aerochamber
every 4-6 hr, if clinically
indicated.
Discharge Provide Review all teaching Discharge to home if on
28
Planning /
Teaching
education on
how to
recognize
worsening
respiratory
distress, signs
of inadequate
PO intake; how
to use a bulb
syringe (for
infants and
toddlers), and
how to do
respiratory
treatments.
content. Provide
information on home
medication
administration,
including
discontinuation and
follow-up
instructions.
room air, respiratory
treatment not needed
more than every 4-6 hr,
and tolerating PO feeds.
Instruct parent to call
physician if respiratory
distress is noted.
Ensure that parent makes
a follow-up appointment
within 1 week of
discharge.
I&O, input and output; MDI, metered-dose inhaler; NPO, nothing by mouth; PD&P,
postural drainage and percussion; PO, by mouth; SpO2, arterial blood oxygen saturation.
Care Path 16-4 - An Interdisciplinary Plan of Care for the Child with
Cystic Fibrosis
29
Nursing Diagnosis: Impaired gas exchange related to increase pulmonary
secretions.
Child/Family Outcomes: From baseline at admission, the child will demonstrate
improved gas exchange with improved airway clearance measured by:
-Decreased respiratory rate
-Decreased use of accessory muscles.
– Decreased secretions
– Increased airway clearance
– Improved or back to baseline PFTs
– Increased 02 saturation/baseline
– Decreased cough
– Increased exercise tolerance.
.
Nursing Diagnosis: Imbalance nutrition: less than body requirements related to
interference with enzyme production, compromised respiratory status, increased
metabolic requirements due to work of breathing, infection, and malabsorption
and/or decreased appetite.
Child/Family Outcomes: Child will ingest adequate nutrients based on
individual needs.
Child will have stools of normal consistency, frequency, and color.
Nursing Diagnosis: Potential for nonadherence to self-care related to chronic
nature of condition and developmental level.
Child/Family Outcomes: Child and family will attain and maintain behavior
30
that is consistent with goals of therapy.
-
Nursing Diagnosis: Potential for ineffective coping related to chronic illness
and the risk of life-threatening complications.
Child/Family Outcomes: Family members will verbalize feelings about the
illness and its effect on their lives; will identify family and community
resources, social support.
Nursing Diagnosis: Readiness for enhanced self concept related to appearance,
treatment regimen, and limitations on activities.
Child/Family Outcomes: Child will have a positive self-concept and value
personal strengths.
Child will express feelings about the disease and limitations it imposes.
Child will demonstrate accomplishments in areas of interests.
Care Intervention
Categories
Admission Transition to
Discharge
Discharge to
Community
Consults CF Team and
specialists as
needed (e.g.,
endocrine)
Social Work
Nursing Assessment
and Care
Management
Admission
weight
Vital signs and
Weight daily
Vital signs and
Discontinue
calorie count
31
pain assessment
q 4 hr
Respiratory
assessment.
Monitor stool
pattern
Calorie count
p.r.n.
Spot pulse
oximetry for O2
saturations>92
%
Continuous
pulse oximetry
for O2
saturations<
92%
Ad lib ADL’s
Reverse
isolation to
pain assessment q
4 hr
Monitor stool
pattern
Calorie count
p.r.n.
Spot pulse
oximetry for O2
saturations>92%
Continuous pulse
oximetry for O2
saturations< 92%
Ad lib ADL’s
Continue reverse
isolation.
Avoid contact
with other CF
patients.
Discontinue
pulse oximetry.
Ad lib ADL’s
Discontinue
isolation
32
prevent
infection with
multiple
resistant
organisms
Avoid contact
with other CF
patients.
Diagnostic Tests &
Procedures
CBC with
differential
Sputum culture
and sensitivity
labeled for CF
Basic
biochemical
panel, including
renal and liver
functions and
glucose
Other
laboratory tests
p.r.n.; UA,
AFB, sputum
Assess
aminoglycoside
therapy.
Levels with third
to fourth dose;
repeat if dose
adjusted
Follow up on
abnormal
laboratory values.
Assess culture
results and
sensitivities.
Consider work-up
for allergic
33
for fungal
cultures, IgE,
HbA1c
Chest
Radiograph post
anterior and
lateral views
Spirometry
PFTs for >5
years
ABG as
indicated
bronchopulmonar
y aspergillosis
(ABPA).
Consider workup
for cor
pulmonale, ECG,
O2 desaturation
study as indicated
by clinical status.
Pharmacologic
Management
Determine
venous access
option: initiate
IV, PICC, or
access
implanted
venous access
device.
Standard IV
solution for
pediatric
Continue with
medications as
ordered.
Heparin flush as
indicated for
PICC or central
line
Continue with
medications as
ordered.
Discontinue IV.
Heparin flush as
indicated for
PICC or central
line
maintenance at
34
patients, unless
patient has
glucose
intolerance
Heparin/saline
lock may be
used.
Pulmonary
medications/aer
osolized/antibio
tics/DNase
Pediatric
enzymes
Vitamins
H2 blockers
Prokinetic
agents
Antibiotics
NSAID’s/
analgesics
home
Nutrition Regular diet
(high calories)
Regular diet (high
calories)
Regular diet
(high calories)
35
Snacks t.i.d.
Night
supplemental
feeds for 10-12
hours as
indicated
Snacks t.i.d.
Night
supplemental
feeds for 10-12
hours as indicated
Assess need for
home enteral
program and
placement of
gastrostomy tube.
Snacks t.i.d.
Night
supplemental
feeds if
indicated
Psychosocial
Social Service
Play therapy/school
Initiate
therapeutic
play/recreationa
l activities as
appropriate.
Incorporate
schoolwork into
daily schedule.
Continue
therapeutic
play/recreational
activities as
appropriate.
Continue to
incorporate
schoolwork into
daily schedule.
Resume school
activities upon
discharge.
Respiratory PD&P and
ACT’s while
awake
PD&P and ACT’s
while awake
O2 as indicated
Return to usual
home treatment,
unless
36
O2 as indicated exacerbation
requires
additional
respiratory
support in the
home (e.g.,
oxygen, more
frequent PD&P)
Discharge planning /
Teaching
Assess self-care
behaviors and
provide age-
appropriate
education for
self-
management.
Assess home
and community
resources.
Assess/instruct in
adherence to
treatments/medica
tion/nutrition
plan.
Provide education
on symptom
management.
Identify home
care needs and
initiate referrals:
-Nutritional/
enteral
supplements
-Respiratory
Confirm
understanding
of discharge:
-Follow-up
plan/ medical
appointment
-Return to
school/work
Obtain
prescription for
discharge
needs.
37
durable medical
equipment for
airway clearance,
O2; etc.
-Home IV
antibiotics and
labs
Track progress of
education for new
home care skills.
Consider home
health referral.
ABG, arterial blood gases; ACT, airway clearance technique; AFB, acid-fast
bacilli; ADLs, activities of daily living; CBC, complete blood count; CF, cystic
fibrosis; ECG, electrocardiogram; HbA1c hemoglobin A1c , IgE,
immunoglobulin E; NSAID, nonsteroidal anti-inflammatory drug; O2, oxygen;
PD&P, postural drainage and percussion; PFT, pulmonary function tests; PICC,
peripherally inserted central catheter; UA, urinalysis.
38
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