Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

KAPIODURING CLINICAL:
Complete the following pages for the patient assigned to you for the clinical day.
All areas of the CIS MUST be completely filled out. If certain areas of the CIS is not applicable
then write in N/A.
Student Name: _______Todd Shumay________________ Date of care: ______12/03/15________
Date of admission: __11/24/15__ Age: __14 yr old Wt: __55_(kg)
Sex: __M___
Code Status: _Full Code___________ Allergies (and reaction to allergies:_Xolair (Omalizumab)_
Attending: _(Peds/FP/Surgical/Psych)_ ________________________________________________
Ht: ____152,5____(cm) ________% Wt: ___55__(kg)
_________%
Admitting diagnosis: _______Infection of port-a-cath leading to sepsis. Also had severe nausea and
vomiting on admission
Surgical Procedure: _______________________________________________________________
________________________________________________________________________________
History of Present Illness (What brought patient to the hospital? What were the signs and symptoms
that brought patient to hospital?): _Patient admitted d/t infection of his port-a-cath which lead to
sepsis. He was brought into the PICU where the sepsis resolved. He was then brought down to
inpatient d/t fungal infection of his lower left lobe. Confirmed of having Allergic Bronchopulmonary
Aspergillosis (ABPA). Patient was showing poor PFTs, dirty-green mucus secretions, bilateral
crackles, bilateral bronchiectasis with the left lobe more problematic.
Pertinent Past Medical History: Patient has a history of poorly managed cystic fibrosis, Port-a-cath
placement on right upper chest, and Umbilical G-tube.
Current Diet (Type and Route):
PO/GT/NGT/GJT/JT
Regular Diet with as needed Gtube feedings

IV maintenance calculation (ml/hr):

Body weight
1 10 kg
11 20 kg
mL/kg for each
>20 kg
each kg>20kg

Amount of fluid per day

100 mL/kg
1000 mL + 50
kg>10kg
1500 mL + 20 mL/kg for

Respiratory (oxygen
supplementation:
Respiratory Treatments:
Albuterol Treatments

1500+20(35)=2200 ml per day

91.6 ml/hr
IV location/size of catheter/type:
Left AC-22 gauge
Right FA-22 gauge

EXPECTED NORMAL VS FOR

CLIENTS AGE:
HR: 60-110
RR: 12-22
BP: 110-125/65-85
O2 Sats: >95%

IV fluids: (do not need to list IV

fluids in Medications section)

Isolation Type:
Enhanced Precautions

0.9% Normal Saline

Reason for Isolation:

Cystic Fibrosis with ABPA

Monitor Limits:
CRM HR and RR
HR: 60-140 RR: 12-35
Pulse Oximeter: <93%

Activity/Special Precautions
(Fall/Aspiration/Seizure/Skin
)
Normal Activity

Student Name: __Todd Shumway______________

Date of Care: ___12/03/15_______

Developmental:
Erikson
What stage is patient in according to age?
According to Eriksons stage of psychosocial development he is in the
Identity vs role confusion stage.
According to your references/resources, what is expected at this stage (i.e., gross
motor development, talking how many words, etc)?
Adolescents at this stage develop a sense of personal identity and come to view
themselves as unique individuals. They are highly influenced by their peer group. Gross
motor development is fully developed, sexual maturation occurs, and self-exploration
occurs.
After caring for patient, what did you assess? Did patient meet this stage? If
patient did not meet this stage, what stage does patient fit into?
I assessed that my patient was a normal adolescent boy physically and cognitively. He
was playing video games a lot through the morning, had comic books and the nurses
and him joked about girls he liked. He showed interest in his school, expressed how he
is failing math and needs help and being unsure about what he wants to do when he
grows up. He talked about his friends and their interest in video games as well. I would
say that my patient fits in the identity vs role confusion through his interest in his hobbies
and peer influence and really seeing himself as different not only by his medical
diagnosis but through his interests.
Piaget -

What stage is patient in according to age?

According to Piagets cognitive development he is in the formal operations stage.
According to your references/resources, what is expected at this stage (i.e., gross
motor development, talking how many words, etc)?
During this stage the adolescent is able to think through more than two categories of
variables concurrently, capable of evaluating the quality of their own thinking and able to
maintain attention for longer periods of time. They are highly imaginative and idealistic,
increasingly capable of using formal logic to make decisions, and think beyond current
circumstances, and able to understand how the actions of an individual influence others.
After caring for patient, what did you assess? Did patient meet this stage? If
patient did not meet this stage, what stage does patient fit into?
I assessed that cognitively this child is appropriate for this stage. He though
logically and was able to talk about his condition from his medication regimen,
reasons for the medications, and understanding of treatments. He was attentative
and maintained conversation for long periods of time. He also was talking about
how his plans to take summer school so that he can really understand math. I
would say he is in the correct stage of cognitive thought.

Student Name: __Todd Shumway______________

Date of Care: ___12/03/15_______

Patient education: List all possible areas of patient education you could teach patient while in
hospital and for planned discharge. (i.e., medications, disease process, safety,
immunizations, diet, physical restrictions, cast care, home care, outpatient resources, followup appointments etc) (What does patient need to know in or to be discharge?)
Encourage parents to participate in plan of care and reinforce I and Os, nutritional intake, and
medication timeliness- Parents and child showed minimal interest in adhering to the nurses/doctors
plan of care. Parents showed lack of parenting in reinforcing teachings and knowledge of importance
of maintaining/monitoring these areas.
Grief Counseling for the parents and possibly the child- Childs prognosis is poor and parents
could probably use grief counseling about possible complications that may arise. If/when the child
finds out more about his condition, he could benefit not only about his treatment and condition but
possible stress and psychological help.
Increasing Nutrition- Increasing calories and nutrition is important so that the child maintains body
weight and appropriate nutrients during his treatment.
Adhering to Medication Regimen and being aware and watchful for medication side effectsPatient is pretty aware and knowledgeable about taking his medication. But lacks understanding in
the importance of taking it in a timely manner. Patient waits hours to eat/doesnt eat, so some of his
medications are either delayed or provide no benefit if he does not eat. Being aware of the side
effects such as diarrhea from his antibiotics/antifungals is important teaching in conjunction with his I
and Os.
Proper positioning and maintaining airway clearance- Encouraging deep breathing and
maintaining productive cough can help decrease mucus build up in his lungs. Performing regular
chest physical therapy with parents can also be beneficial.
Respiratory therapy- Can help encourage effective airway clearance and adequate lung function,
oxygen saturation, and perfusion/oxygenation.
Physical Therapy- Increasing activity can benefit in GI motility, respiratory effort, cardiovascular, and
musculoskeletal systems.
Infection Control- Having the parents, the patient, and other staff frequently visiting the patient
perform good hand hygiene and proper infection control precautions can decrease chances for
nosocomial infections, leading to further immunological compromise.
Treatment Education- Educating patient and parents on plan of treatment with medications, MRI,
CT, and Biopsy. Lets family prepare for upcoming treatments.
Discharge disposition (home, care home, rehab, etc):
Adhering to Medication Regimen
Promoting good lung function
Increasing Nutrition
Aware of S/S of infection, respiratory distress, or Failure to Thrive
Respiratory percussion
Immunizations

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

LAB RESULTS: Include admission labs, and last 2 (two) days
Lab Test
Normal
Results & Dates
Rationale for Abnormal
Range
Lab Results
CBC
12/01
12/02
WBC
17.9 High
27.8 High
Patient is not only recovering
5.5-15.5
from having sepsis, but is
now fighting against a
difficult fungal infection in his
lungs. Patients immune
system is working extra hard
to fight the infections by
increasing the amount of
WBCs.
RBC
4.78
4.7
3.9-5.3
Hgb
12.7
12.4
11.0-14.0
Hct
38.9
38.4
33.0-42.0
MCV
81.4
81.7
73-88
MCHC
32.6
32.3
32-36
RDW
13.8
13.4
11.5-14.5
Platelets
453 High
430
Patients platelets might be
150-440
high due to the recent sepsis
and inflammation of his lungs
that signaled the bone
marrow to over produce
platelets.
Segs
35-80
68%
Bands

0-11

Lymphs

19%

30.1

9.7 Low

13.1 High

7.6

20-40
Monos
4-8

Due to the patients sepsis

and fungal infection the body
is working extra hard to
producte WBCS to fight the
infection. Due to the length
of infection/inflammation the
body is does not have
enough time to send out
mature WBCs, so it
compensates by producing
immature WBCs.
Since the bands are high it
will decrease lymphocytes in
this differential due to the
increase in immature WBCs.
Monocytes are the main
responders initially in an

Student Name: __Todd Shumway______________

Eos

3.2

Date of Care: ___12/03/15_______

infection to help rid and
digest foreign substances.
0.8

0.2

0.1

12/1

12/2

139

135

0-4
Baso
0-1
ELECTROLYTES/RENAL
PANEL/BASIC METABOLIC
PANEL
Na+
135-145
K+

3.5-5

4.9

4.7

Cl-

102-112

103

103

CO2-

32-48

BUN

5-25

30 Low

13

20

Creatinine

0.3-1.2

.69

.70

Glucose

60-105

115 High

126 High

Lab Test
COAGULATION
PT

Normal
Range
15-20 sec

PTT

Results & Dates

11/24
17.5
35

30-40
FDP
INR

1.5-3.0

LIVER FUNCTION

1.5

CO2 may be low due to poor

respiratory function. Patient
is tachypnic with a baseline
around 30 breaths per
minute. Hyperventilation
increases O2 and decrease
CO2 in the body.

Glucose is elevated possibly

due to bodys response to
inflammation and infection or
from this patients high caloric
diet. Having CF also
interferes with insulin release
due to blocked ducts. This
can elevate blood sugar
levels.
Rationale for Abnormal
Lab Results

Student Name: __Todd Shumway______________

Total Protein

Date of Care: ___12/03/15_______

6.2

6.2

6.2-7.9
0.1-1.2

0.2

0.2

Albumin

3.5-5.0

3.6

3.7

ALT

7-55

12

13

AST

8-48

15

13

45-115

209 High

214 High

Date
Obtained:

Date
Resulted:

URINE CULTURE
Reason for culture:

Date
Obtained:

Date
Resulted:

Result:

OTHER CULTURE
Reasong for culture:
Fungal Culture

Date
Obtained:

Date
Resulted:

Result:

N/A

N/A

Total Bili
Direct Bili

SGOT
Alk. Phos

BLOOD CULTURE
Site:

Patient has CF. CF can

contribute to blocked Ducts
and Malnutrition. The
blocked ducts may interfere
with liver function causing an
increases ALP.
Result:

Reason for culture:

*If you need more space, place on

back of paper

Aspergilosis

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

PERTINENT DIAGNOSTIC TESTS (i.e. EKG, CT SCAN, XRAYS, etc): *use back of page for more
Date
Diagnostic Test
Reason for test
Result/Impression:
Nursing Interventions
(i.e., teaching,
preparation etc)
Chest X-Ray
Suspected
Hyper inflated right
Proper Positioning,
Respiratory
lung, with decreased
Increase Fluids,
Infection.
left Lung volume
Productive cough,
Bilateral
Bilateral
Chest Physical
Pulmonary
bronchiectasis with
Therapy
11/24
crackles, green
the left side worse
mucus, and poor
Stable chest port
PFTs.

Chest X-Ray

11/27

Bilateral
Pulmonary
crackles, green
mucus, and poor
PFTs.
Decreased BM
activity

Fungal Infection
Pancreas Atrophy
Diffuse Colonic Stool
Retention

Laxative/Stool
Softener, Proper
Positioning, Increase
Fluids, Productive
cough, Chest Physical
Therapy

SCHEDULED MEDICATIONS
Reference Wt:____55.0______(kg)
For IV meds: Make sure it is compatible with ordered IV solutions and/or NS flush.
Medication
Trade Name
Generic Name
ORDER:
Dose/Route/
Frequency

Classification
Therapeutic
and
Pharmacologic

Pt. Reason for

Med and
Desired
Effect

Safe dose range

Show
CALCULATIONS

Side Effects
At least 3
common
and 2
serious/emergent

Voriconazole
(Vfend)
350mg Inj
IVPB q12h

Antifungal

Treat fungal
infection in the
lungs

6mg/kg IV q12h

Amikacin
(Amikin)
500mg sln
Inhalation BID

Antiobiotic
Aminoglycoside

Bactericidal
treat infection in
the lungs

15-30mg/kg/day
divided in q12-24h

N/V, diarrhea,
headache, joint
pain, weakness,
sore throat,
photophobia
Confusion,
depression,
numbness,
hematuria, renal
damage,
neurotoxicity

6(55)=330mg/q12
YES

15(55)-30(55)=
825-1,650mg/2=
412.5-825mg/q12
YES

Nursing
Interventions
(food
interactions,
can we crush,
lab results to
monitor etc)
Administer 1 hour
before or after
meals

Time
due:

Obtain C&S tests

before beginning
product.

0800
1600

0800
1600

Student Name: __Todd Shumway______________

Date of Care: ___12/03/15_______

Cetirizine (Zyrtec)
10mg tab
Oral Daily

Antihistamine
Piperazine, H1
histamine
antagonist

Allergy,
urticarial, rhinitis

5-10mg daily PO

Fluticasone
(Flonase)
50mcg spray
Nasal Daily

Corticosteroids
Astiasthmatic

Chronic asthma
- nasal
symptoms

88-660mcg BID

Notriptyline
(Pamelor)
25mg cap
Oral QHS

Antidepressant
Dibenzocyclohe
-ptene

Depression or
chronic pain
management

1-3mg/kg/day in 34 divided doses or

at bedtime

YES

NO, too low

1(55)-3(55)=
55-165mg/4=
13.7541.25mg/dose
Pancrelipase
(Creon)
5 ea cap
Oral TID with
meals

Digestant
Pancreatic
enzyme

Digestive aid for

CF(increases
protein, fat,
carbohydrate
digestion)

Albuterol HFA
(Ventolin)
90mcg aero
2 Puffs QID

Bronchodilator
Adrenergic B2
agonist

Increase ability
to breathe

Lansoprazole
(Prevacid
solutab)
30mg tab
Oral BID

Anti-ulcer proton
pump inhibitor
Benzimidazole

Pancrelipase
(Viokase)
2 tabs
Oral QHS

Digestant
Pancreatic
enzyme

Ondansetron
(Zofran)
8mg tab
Oral QHS

Antiemetic
5-HT receptor
antagonist

Reduces gastric
pain, swelling,
fullness used
for pathologic
hypersecretory
secretions
Digestive aid for
CF(increases
protein, fat,
carbohydrate
digestion)
For N/V

Ergocalciferol
(Drisdol)
5000 IU cap
Oral Qwed

Alpha
adrenergic
blocker
Ergot alkaloidamino acid
Anti-infective
tricyclic
glycopeptide

YES
500 lipase
units/kg/meal
YES
2 puffs q4-6h
YES
PO 60mg/day
YES

500 lipase
units/kg/meal
YES
0.15mg/kg/dose
0.15(55)=8.25mg
YES

Vancomycin
(Vancoled)
1000mg Inj
IVPB q6h

For headaches

Bactericidal

16mg/kg/dose
16(55)=880mg/dos
e

Headache,
fatigue, dry
mouth, thickening
of bronchial
secretions

Take on empty
stomach food
prolongs
absorption by
1.7hrs.

0800

Pharyngitis,
dizziness, oral
candidiasis,
bronchospasms,
angioedema

Take
bronchodilator
first. Do not use
for acute asthma
attack. Taper
down if using
long term.
Give with food or
milk to decrease
GI symptoms.
Store at room
temperature

0800

Anorexia, N/V,
diarrhea,
cramping,
bloating,
hyperuricemia

Give with 8oz of

water and sitting
up only; do not let
tab sit in mouth

0800
1200
1600

Tremors, anxiety,
hypertension,
tachycardia,
heartburn, N/V,
bronchospasm
CVA, MI, shock,
hematuria,
pneumonia, rash,
weight gain,
tinnitus,
depression
Anorexia, N/V,
diarrhea,
cramping,
bloating,
hyperuricemia
Headache,
diarrhea,
abdominal pain,
bronchospasm,
urinary retention
Numbness in
fingers and toes,
MI, weakness,
edema,
bradycardia
Ototoxicity,
cardiac arrest,
nephrotoxicity,
anaphylaxis,
nausea

Give after
shaking inhaler.
Allow at least 1
min. in between
breaths
Give 30 min prior
to breakfast and
dinner

0800
1200
1600
2000

Crushed and put

in GT

1800

Give 30 minutes
prior to
Clofazamine

1800

Dizziness,
drowsiness,
hypotension,
ARF, seizures,
dysrhythmias

1800

0800

Do not break,
crush, or chew.
Protect from
heat/light
Increase fluid
intake to
decrease risk of
nephrotoxicity

0800
1400

Student Name: __Todd Shumway______________

Micafungin
(Mycamine)
100mg Inj
IVPB q24h

Antifungal
Echinocandin

Dronabinol
(Marinol)
5mg cap
Oral BID-AC

Cannibinoids

Imipenem
(Primaxin)
750mg Inj
IVPB q6h

Anti-infective
Carbapenem

Direct damage
to fungal wall

Date of Care: ___12/03/15_______

NO, too high

1.5-2mg/kg/day
1.5(55)-2(55)=
82.5-110mg/day

For N/V. also

treat loss of
appetite and
weight loss
Bactericidal

YES
2.5-5mg/dose
YES
60-100mg/kg/day in
divided doses, max
4g/day

Headache,
anorexia, N/V,
convulsions,
anemia

Obtain C&S tests

before beginning
product.

Weakness,
stomach pain,
memory loss,
seizures,
tachycardia
Diarrhea, N/V,
seizures,
hepatitis, renal
toxicity, phlebitis

Give before lunch

and dinner.
Swallow capsules
whole, do not
crush, split, chew
Give dose over
20-30 min. do not
mix with other
antibiotics

1200
1800

N/V, anorexia,
abdominal
cramps, diarrhea,
flatulence, tetany

Administer on
empty stomach,
give with full
glass of water

0800
1600

Swelling, chills,
diarrhea,
bleeding, loss of
appetite, nausea
Chills, fever,
irregular
heartbeat,
muscle cramps,
weakness,
tiredness
Diarrhea,
nausea, stomach
cramps,
flatulence

Taken with a full

meal or liquid
nutritional
supplement
Flush before and
after with D5W

0700
1300
1900

60(55)100(55)=3,3005,500mg/day

Sennosides
(Senna)
8.6mg tab
Oral BID

Laxative
stimulant
anthraquinone

Decrease
constipation

Posaconazole
400mg tab
Oral q8h

Azole antifungal

Used to
prevent/treat
fungal infections

Liposomal
Amphotericin B
(Ambisome)
600mg Inj
IVPB q24h

Antifungal

Polyethylene
Glycol (Miralax)
17gm powder pkt
Gtube q24h

Osmotic laxative

Treats infections
caused by
fungus

750x4=3,000
NO, too low
8.6mg, not to
exceed 2 tabs
(17.2mg/day)
YES
300mg PO BID
YES
10mg/kg/day
10(55)=550mg/day
NO, too high

For constipation

One packet of 17
grams in any 4-8ox
of water, once a
day

Mix with 8oz of

fluid

1100

1100

YES

PRN MEDICATIONS

Reference Wt:__________(kg)

Medication
Trade Name
Generic Name
ORDER
Dose/Route/
Frequency

Classification
Therapeutic
and
Pharmacologic

Pt. Reason for

Med and
Desired
Effect

Safe dose range

and show
CALCULATIONS

Side Effects
At least 3
common
and 2
serious/emergent

Ondansetron
(Zofran)
8mg tab
Oral q8h PRN

Antiemetic
5-HT receptor
antagonist

For N/V

0.15mg/kg/dose

Headache,
diarrhea,
abdominal pain,
bronchospasm,
urinary retention

Pancrelipase
(Creon)

Digestant
Pancreatic

Digestive aid for

CF(increases

0.15(55)=8.25mg/
dose
YES
500 lipase
units/kg/meal

Anorexia, N/V,
diarrhea,

Nursing
Implication
(food
interactions,
can we crush,
lab results to
monitor etc)
Give 30 minutes
prior to
Clofazamine

Time
s last
given
:

Give with 8oz of

water and sitting

PRN

Q8h

Student Name: __Todd Shumway______________

3 ea cap
Oral PRN

enzyme

Ondansetron
(Zofran)
4mg 2mg/ml Inj
IV push q4h PRN

Antiemetic
5-HT receptor
antagonist

Acetaminophen
(Tylenol)
650mg tab
Oral q4h PRN

Nonopioid
analgesic
Nonsalicylate
paraaminophen
ol derivative

protein, fat,
carbohydrate
digestion)
For N/V

Date of Care: ___12/03/15_______

cramping,
bloating,
hyperuricemia

up only; do not let

tab sit in mouth
For nausea when
patient unable to
tolerate PO

Q4h

NO, too high

Headache,
diarrhea,
abdominal pain,
bronchospasm,
urinary retention

325-650mg q4-6h,
max 4g/day, max
single dose
1,000mg

Drowsiness,
hepatotoxicity, GI
bleeding, renal
failure, anemia

Give with food or

milk to decrease
GI upset. Give 30
min before or 2 hr
after meals

Q4h

YES
0.15mg/kg/dose
0.15(55)=8.25mg

For Fever/Pain

YES

Identified Nursing Priorities:

What are your top priorities (needs) in caring for this patient and family? List in order of importance
(most to least). Describe what nursing interventions you would implement to address your priorities.
Continue on another paper if more room is needed.
Identified Priority (nursing
diagnosis) in Caring for
child/family.

Ineffective airway clearance

related to thick mucus in lungs,
fungal infection in lower left
lobe and bilateral expiratory
crackles and bronchiectasis.

Nursing assessments and

interventions

Evaluation (Was this a valid

priority to identify; was the
order of prioritization correct;
did your interventions
address the need; were the
interventions appropriate?
What would you do different?)
ANSWER QUESTIONS ABOVE
ONLY
Chest percussion therapy
Yes this was a valid priority to
RT treatments- albuterol
identify. ABCS is always priority.
Encourage deep breathing and
The interventions were
productive cough
appropriate and helped facilitate
Monitor and assess sputum
mucus clearance, open airway,
Elevate HOB to facilitate
and >99% O2 saturation. The
increased lung expansion
only thing I would do different is
Increase activity to promote lung to really drive the point home
expansion and lung function
with the parents and get them
Provide hourly respiratory
involved in their childs care.
assessments- Rate and O2 sat,
and perfusion/oxygenation
assessments
Educate parents to reinforce
teaching

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

Increase calories in patients diet This was a valid priority to
Give preferred foods
identify. I feel his nutrition is a
Offer more frequent feedings
good third priority. The
and snacks
interventions did address his
Monitor I and Os
need but patient need consistent
Imbalanced Nutrition related to Monitor for s/s of imbalance
reinforcement in the importance
poor nutritional intake, and
nutrition or malabsorption
of nutrition. The interventions
need for increased calories to
Monitor weights, energy level,
were appropriate to the patients
meet metabolic demands.
and level of consciousness
needs. What I would do different
Take medication with meals to
to make sure that the patients I
enhance absorption and
and Os are strict and adhered
digestion of food.
to. Parental involvement was
Encourage parents to reinforce
poor so really reinforcing the
teachings
importance is needed.

Infection related to respiratory

fungal infection.

Administer
antifungals/antibiotics in a timely
manner
Monitor for s/s of medication
Interpret lab values/ diagnostic
procedures for effectiveness
Practice enhanced precautions
Encourage good hygiene for
patient, patients family and staff
Limit visitors and provide
clustered care
Monitor for s/s of increased
infection
Monitor vital signs such as
temp, HR, RR, and O2 Sat.

This was a valid priority to

identify. I feel that addressing his
infection is a good second
priority. My interventions did
address the patients condition
and progress. Interventions
were appropriate to patients
condition. What I would do
differently is to encourage
limited visitors. Patient had
many frequent visitors
throughout the day. It is hard to
monitor the cleanliness of each
individual going in and out of the
patients room.

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

TIME TABLE
0700
0800
0900
1000
Hourly Rounding
Hourly Rounding
Hourly Rounding
Hourly Rounding
IV =
____LeftAC_______
Inepenum- 150 ml/hr

1200
Hourly Rounding

IV =
___LeftAC_________
VS/Assessment
T = 98.3
HR = 131
RR = 31
BP = 115/70
O2 Sats = 99% RA
1300
Hourly Rounding

IV = ______________ IV = ______________
VS/Assessment
T=
HR =
RR =
BP =
O2 Sats =

IV =
________LeftAC_____
_

IV =
_____LeftAC________
_

Vancomycin-200ml/hr

NS- 49 ml/hr

1400
Hourly Rounding

Post Conference

IV = ______________

ASSESSMENT: Thorough head to toe assessment for each times.

0800
NEURO
Alert and oriented X3
Sleepy, Adequate responses, PERRLA, Good coordination and
movement,
CARDIOVASCULAR

S1, S2, Normal Sinus Rhythm (CMT), Tachycardic at 131 bpm, All
pulses palpable in upper and lower extremities, cap refill <3
seconds.

RESPIRATORY

Bilateral Expiratory Crackles in lower lobes, Left Lobe sounds

more diminished then right, Green mucus, Tachypnic at 31
breaths per minute.

GI/GU

Bowel sounds present in all quadrants, no pain on palpation,

Last BM/Void at 0530.

SKIN/MUSCULOSKELETAL

Skin clammy and warm to touch, Skin turgor <3 seconds, Good
coordination and movement, Body symmetrical, No signs on
impaired skin integrity.

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

REMEMBER TO DO CAREPLAN AND WEEKLY REFLECTION

NURS 320 MATERNAL-CHILD CLINICAL WEEKLY SELF REFLECTIONS:

This week in clinical I had the opportunity to be on the inpatient floor. The patient
that I was able to focus on was a 14-year-old boy with a respiratory fungal infection and
history of cystic fibrosis.
My patient was admitted to the PICU on the 24th for sepsis due to his infected porta-cath which was removed. After that resolved he came down to inpatient due to his
fungal infection. After getting report my nurse and I went in to the patients room. Since it
was still early and he was still sleeping, we aroused him, and did a quick respiratory
assessment. He has a continuous IV on his Left antecubital, stat lock on his right forearm,
G-tube through his umbilicus, had clammy skin, and had bilateral expiratory crackles on
both sides with his left side more diminished then the right. His respiratory rate was at
31 and heart rate of 131. This was typical for this child throughout the day. His dad was
also in the room sleeping on the chair.
After our quick assessment my nurse and I let him sleep a little while more. My
nurse then prepared a few medications for him and we went in to administer them at
breakfast. When we went in his mom had arrived and was performing chest
physiotherapy for her son which was producing some mucus expulsion He took his
medications with breakfast and we left them to relax. Throughout the day the child was
stable and required frequent hourly respiratory assessments which were consistent.
The childs condition was a lot more unusual than other patients that I have
experienced before. There was a lot of dynamics that came into play, which I will talk
about now.

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

As far as this patients condition goes, he is infected with a very powerful fungus
called aspergillos. His condition is called allergic bronchopulmonary aspergillosis which
tends to occur in children with cystic fibrosis. After many different treatments of
antifungal medications, nothing has seemed to be working. My nurse described the
pathophysiology of this condition as it being necrotic to lung tissue that can cause him to
bleed out and die. The prognosis of mortality of this condition is about 30-95%.
Unfortunately due to the severity of his condition and infection, the doctors are having a
difficult time in treating it. I had the opportunity to sit in on a doctors discussion of this
child as they spoke about and discussed possible treatment options. Although I feel like I
only understood half of what they were saying, it was very interesting being apart of
that. They were consulting top fungal experts and pulmonologists around the world, and
pretty much the conclusion of treatment is trial and error. They fear that this infection
will spread to his brain and further complications. So they have ordered MRI, CT scan,
Chest X-rays, and a lung biopsy (which is high risk for rupturing and bleeding out). I was
amazed on how hard each doctor is working to save this childs life. It was a very intense
feeling.
For this patients family, there was an interesting relationship between the child
and his parents. This child has a history of poorly managed cystic fibrosis partly/mostly
due to lack of parental involvement in managing his condition. In report it was said that
this child has been pretty much taking care of himself since he was 10 years old from
feeding himself to taking his own medication. His parents do not seem to be taking his
current condition or past medical history very serious and show lack of involvement and
lack of interest. I am not sure if they are just in denial or what, but their behavior and
actions are pointed at the childs fault for not managing his condition better, when in
reality he is just a kid. The family involves a mom and dad, the patient, and two younger

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

brothers. Financially, this family is doing poorly. My nurse was explaining that the parents
were going to spend over two thousand dollars on comic book collection rather than
spending their money on other necessities that this family needs, like shoes for the
middle child who has no shoes. They also go to the food bank every day so that their
family can eat. Its amazing to see such poor family structure and the lack of involvement
and impact that this patient is going through due to his neglectful parents.
A real problem for the nurses has been difficulty in the accurate I and Os and
nutritional intake. Even though there has been constant reinforcement stressing the
importance of I and Os and eating to the patient and family, it has been poorly recorded
and performed. Since the parents arent taking it serious, the child suffers and goes by
example of the parents. I can really see how difficult it is for a child to recover and
behave if the parents are not acting professional or serious.
Due to the poor prognosis of this childs condition, doctors had a family meeting
with the parents to discuss the poor outcomes of this childs status. An interesting aspect
of this is that the parents have known that their child is highly likely to pass any minute
from this fungal infection but have decided not to inform their son of his condition (as far
as my shift went). So this child does not know that he is essentially dying or how serious
his condition is. He is unaware of how hard nurses, doctors, and respiratory is working to
save his life. Ethically I feel that the child should know of his condition, but legally the
parents are not letting him know. On top of that, due to the lack of seriousness from the
parents, its even more frustrating knowing that they know his prognosis yet they have no
understanding that they are partly/mostly to blame of not managing their childs
condition. They are not participating in his plan of care and show no interest in preparing
the patient for possible outcomes (death). Heartbreaking to see.

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

I felt like I was inside a medical TV show. It had all the aspects of addressing
problematic conditions, ethical dilemmas, suspenseful twists, and ending with a to be
continued
The first SLO that I wish to address is applying the ANA code of Ethics to care of
families including clients rights, dilemmas between individual rights and the common
good, identification of choices and possible consequences. This day was filled with
ethical situations; from whether the patient should know the prognosis of his condition or
not, to the neglectful parental involvement with his care currently as well as past history,
to the decisions of treatments by the medically team in doing certain treatments or not,
such as the biopsy (high risk) or various fungal treatments.
The second SLO that I want to address is practice as a member of a
multidisciplinary health care team. Throughout the day I was able to speak and observe
with respiratory therapy, work with my nurse and other nurses, and sit-in on the doctors
rounds and discussion of my patient. It was awesome seeing my nurse as well as the
doctors have a pow wow about the treatment for this patient. They were consulting all
sorts of expert professionals and I really felt a sense of importance of the
multidisciplinary team.
For my final SLO, I will focus on recognizing benefits and limitations of community
and governmental support for family units and individual members with illness. Well the
dynamic with this family in particular was interesting with the choice in which they
decide to spend their money. They receive financial support through food stamps and I
am assuming military assistance. Yet they are still struggling financially with providing
food for their family. Considering the seriousness and severity of the patients condition,
doesnt seem like adequate nutritional intake for him. They decide to possibly spend a
couple thousand on comic books instead of shoes for their child. The ones ultimately

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

suffering from the poor decisions of the parents is the children, especially my patient
with CF.
Overall, my day was a lot to take in. From understanding his condition and possible
treatments, to the family dynamics, to all the ethical situations in-between, was intense
as much as it was interesting. It really opened my eyes to how important the family is in
the progress and condition of the patient. Ethically, the dilemma of the child not knowing
his condition was also eye opening. I have never seen a situation where doctors dont
know what to do. Its scary yet quite amazing on what they do to develop a plan of care.
Although there was so much going on, and not so much hands on nursing care to be
done (besides frequent assessments), I feel Ive learned and grown much from all the
interdisciplinary aspects, ethical dilemmas, nurse patient/family relationship, and overall
how much factors can influence a patients condition. Its crazy, and thats just for one
patient. In all I felt I not only appreciate the multidisciplinary team much more but how
important it is for a nurse to advocate for their patients, but to always interpret the
factors surrounding the child (family) and how it influences their condition. Overall great
day! (Sorry so long)

Student Name: Todd Shumway

Nursing Diagnosis: Ineffective airway clearance

Date of Care: 12/3/15

Date Submitt

Related to: lower left lobe fungal infection and chorionic cystic fibrosis

As manifested by: adventitious breath sounds of expiratory crackles bilaterally, productive cough, green sputum prod
of 31 breaths per minutes, and slightly diminished breath sounds in the lower left lobe compared to the right.

Scientific Rationale: Maintaining a clear airway is necessary for maintaining lung function, oxygenation, ventilation, an
neffective airway clearance can lead to respiratory distress and possible death.

Outcomes (measurable)

Short Term

Patient will maintain >95% O2

Interventions
1.Assess respiratory breath sounds,
pattern rate, depth, effort, O2

Rationale

Evaluation

1. Breath sounds are normally clear and the 1. Patients had bi

presence of adventitious breath sounds
crackles with lo

Student Name: __Todd Shumway______________ Date of Care: ___12/03/15_______

saturation and blood gas values every
can indicate respiratory distress or failure.
saturation, a productive cough, and
hour
Normal respiratory rate for this patient
espiratory rate within normal ranges
should be between 12-22. Secretions in
during 8 hour shift.

Long Term

2.Position patient from above 30-45

degrees.

Patient will have no signs or

symptoms of respiratory distress and
will maintain a clear effective airway
during and after hospitalization for 6 3.Perform chest physiotherapy and
months. Patient and parents will
postural drainage every 4 hours and
understand the need for an effective
encourage deep breathing and
airway clearance and perform daily
coughing techniques, and encourage
espiratory checks.
parental participation.

4.Administer antifungals, antibiotics and

bronchodilators.

5.Teach patient and family to adhere to

medication regimen.

6.Appropriate exercise, encourage rest,

and cluster care and limit visitors.

7. Have suction equipment and oxygen

available

8. Note characteristics of sputum

diminished then
rate was aroun
minute, shallow
the airway will cause the RR to increase.
above 99% on
Monitoring every hour is necessary to
CO2 level was
assess respiratory status (Gulanick and
tachypnea.
Myers, pg 12)
2. Patient had bed
2. Keeping the patient in an upright position
degrees for ent
allows for maximal air exchange and lung
constantly mov
expansion. Lying flat causes abdominal
position, and si
organs to shift toward the chest, which
crowds the lungs and makes it more
difficult to breath. (Gulanick and Myers, pg 3. Patients parent
13)
physiotherapy
3. Chest physiotherapy and postural
demonstrated a
drainage can facilitate mobilization of
breathing exerc
bronchial secretions making it easier to
expelled about
expel secretions. Performing deep
Patient and par
breathing and coughing exercises can
of importance t
strengthen diaphragmatic muscles,
secretions.
making the cough more forceful and
effective in secretion removal. Educating
parents on techniques can help reinforce 4. Nurse administ
teaching and compliance (Gulanick and
antibiotics throu
Myers, pg 13)
piggyback. Res
4. Antifungals can help reduce, stop, and
every 4 hours f
treat the spread of the fungal infection.
albuterol treatm
Bronchodilators can help decreases
treatments
airway resistance and open up airways to 5. Patient adhere
facilitate oxygenation.
and tolerated m

5. Adhering to medication regimen is

important to reduce the likelihood of the
fungal infection gaining resistance.
Resistance can lead to more
complications and stronger antifungals
6. Patient perform
that may contribute to worsening of
in bed, was up
patients condition.
frequently and
6. Having the patient perform appropriate
MRI/CT scan. P
exercises can help loosen bronchial
naps, and nurs
secretions. Exercse that is to stressful can
throughout shif
contribute to worsening of respiratory
visitors in patie
function. Encouraging rest and clustering
nurses, respira
care can increase patients energy and
housekeeping.
limiting visitors may help limit a secondary 7. Suction equipm
infection or spread of infection.
by patients bed
was not neede
7. Keeping suction equipment available by
the bedside can be useful for copious
amounts of mucus that may obstruct the
airway. Oxygen therapy by the bedside
used in situations of decreased oxygen
8. Sputum was gr
saturation. (Gulanick and Myers, pg 12)
throughout shif
odorous. Patien
8. Monitoring color, characteristic, amount,
infection and sp

Student Name: __Todd Shumway______________

9. Increase fluid intake

Date of Care: ___12/03/15_______

and odor of sputum can indicate current,
worsening or recovery from infection.
(Gulanick and Myers, pg 12)
9. Increasing fluid intake can help thin
secretions and ensure that the client is
hydrated. (Gulanick and Myers, pg 12)

Gulanick M., & Myers, J. (2014). Nursing care plans: diagnoses, interventions, and
outcomes. (8th ed.). Philadelphia, PA. Elsevier.

improvement.
9. Patient drank fr
and had a perip
NS continuous

CONTINUE INTER