Brendan Berry Student number 230075113 Case study #2 Part 1 1) What are your impressions of Tony s diagnostic values?

(normal) (Pagana and Pagana, 2009) y Hemoglobin 180 g/l high(100-155 g/L) but not a critical value of over 200g/L. Potentially due to decreased plasma volume, erythrocytosis, being prescribed gentamicin and may indicate Chronic Obstructive Pulmonary disease (COPD) and dehydration. y Hematrocit 51% high (32-44%) but not a critical value of over 60%. Increase potentially due to erythrocytosis, elevated white blood cell (WBC) count and dehydration and may be due to COPD. y White blood cell (WBC) count 15,000/mm3 high (5,000-10,000) but not critical value of over 30,000/mm3. May be due to infection, stress and inflammation. y Platelets 250, 000/mm3 normal (150,000-400,000). Maintains adequate number of fragments that are necessary for clotting to occur. y Red blood cell (RBC) count 5.1x10^12/L normal (4.0-5.5x10^12/L). Count of number of circulating red blood cells (RBC) and helps indicate proper bone marrow function. y Serum glucose 6.2 mmol/L High (4.2-6.1). Slight increase may be due to time of day test taken, meal or snack prior to test, stress and receiving IV fluids. y Potassium 4.0 normal (3.4-4.7). Important for many cellular and metabolic functions, necessary for transmission and conduction of nerve impulses, maintenance of normal cardiac rhythms and skeletal and smooth muscle contraction.

Sodium 130 mmol/L low (136-145 mmol/L). May be caused by sodium free IV fluids, dietary intake and third-space loss of sodium. Signs of hyponatremia include weakness, stupor and confusion.

Chloride 90 mmol/L normal (90-110 mmol/L). Low levels may be caused by respiratory acidosis and metabolic alkalosis.

Blood urea nitrogen (BUN) 14 mg/dL normal (5-18mg/dL). Measures the amount of urea nitrogen in the blood.

y y

Creatine 68 umol/L normal (53-106 umol/L). Measures the amount of creatinine in the blood. X-ray shows consolidation on his right lower and middle lobes potential obstruction, most likely from over productive of thick sticky mucous in the airways or airway infection.

Pulmonary function test (PFT) 45% low (less than 60% of normal). May be due to pulmonary fibrosis, chronic bronchitis and airway infection.

My impressions of these labs would lead to believing that Tony is at risk fir developing pulmonary infections, demonstrating increased haemoglobin, hematricut, WBC count and a low PFT. 2) Discuss Tony s risks for developing pulmonary infections. To maintain gas exchange and prevent infection, clearing mucus from the lungs is an important part of a client s daily regime. Postural drainage and percussion of the lungs loosen secretions to encourage coughing and expectoration (Gardner, 2007). The airway of a client with Cystic Fibrosis (CF) exhibit decreased chloride and excess sodium transport from the mucus. Water follows the sodium, resulting in volume depletion and dehydration secretions. Viscous mucus is difficult to clear from the respiratory tract and creates a medium for various pathogens to grow (Wiehe and Arndt, 2010) 3) Most pertinent questions for your assessment of this child.

Any and what type of cough (secretions, colour of secretions, dry, how often...) Any repeated episodes of bronchitis and/or bronchopneumonia Any cyanosis Access for inadequate nutrition (although says receives adequate, appears thin) Any sick family members/friends at school. Maintaining adequate fluid and nutrition intake while febrile. Ensure remains sitting up to promote easier breathing (tri-pod position if needed) 4) What microorganisms commonly cause respiratory infections in children with Cystic Fibrosis (CF)? Pseudomonas aeruginosa and staphylococcus aureus are the two most common pulmonary pathogens. These bacterial infections induce neutrophil recruitment that leads to tissue damage and ciliary dysfunction, creating increased susceptibility to further infection (Wiehe and Arndt, 2010). 5) What is the relationship between Tony s condition and his oxygen saturation level? Abnormally dilated and thick-walled bronchi that are chronically inflamed and infected promote airway obstruction which causes altered ventilation-perfusion and gas exchange. 6) Tony is prescribed ceftazidime 2g IV q8h, gentamicin 160mg IV q8H, and vancomycin 650 mg IV q8h. a) Ceftazidime:reason: anti-infective, for respiratory infections. Side effects that should be monitored for are pseudomembranous colitis, diarrhea, nausea, vomiting, rashes, phlebitis at IV site, anaphylaxis and serum sickness. This dose is appropriate for Tony because he is experiencing a severe infection (Deglin, Vallerand, 2009). Some nursing implications for providing this medication include observing client for

signs and symptoms of anaphylaxis, may cause increased BUN, creatine. Assess for infection at beginning and throughout therapy. b) Gentamicin: reason: anti-infective, treatment of serious gram negative and staphylococci bacteria. Side effects that should be monitored for include ataxia, ototoxicity, nephrotoxicity and apnea. This dose is inappropriate for Tony as it far passes the maximum safe recommended dose for a child over 5 years old with cystic fibrosis which is 99mg q8h (2.5-3.3 mg/kg q8h) (Deglin, Vallerand, 2009). Nursing implications for providing these medications include assessing for infections before and during treatment, evaluate eighth cranial nerve function by audiometry before and throughout therapy, monitor intake and output and daily weight to assess hydration status and renal function, assess client for signs of superin c) fection (most notably upper respiratory infection), may increase BUN, bilirubin and creatinine, may decrease serum calcium, magnesium, potassium and sodium concentrations. d) Vancomycin: reason: anti-infective, treatment of potentially life-threatening infections, particularly staphylococcal infections. Side effects to be monitored include nephrptoxicity, phlebitis, anaphelaxis, red man syndrome with rapid infusion. This is an appropriate dose for Tony, being less than 4 mg daily (Deglin, Vallerand, 2009). Nursing implications relevant to providing these medications include assess client for infection at beginning and throughout therapy, monitor and rotate infusion site, monitor eighth cranial nerve function, monitor intake and output ratios and daily weight and monitor for signs of superinfection. 7) What are two appropriate priority nursing diagnosis for Tony at this point, given the information provided?

a)

Impaired gas exchange related to recurring lung infections

b) Imbalanced nutrition: less than body requirements related to dietary intolerances, intestinal gas, and altered pancreatic enzyme production. 8) What is an appropriate nursing goal or outcome for each of these nursing diagnoses? a) Reduced risk factors associated with respiratory infections b) Adequate nutritional support to maintain appropriate BMI 9) List 2 nursing interventions (evidenced-based, with references) that you will provide to achieve each nursing goal. a) Refer for chest physiotherapy to clear chest secretions (Gardner, 2007) that create a medium for various pathogens to grow. Provide a flutter mucus clearance device to help clear airways and include daily physical exercise as tolerated to stimulate mucus expectoration (Gardner, 2007). b) Short term supplemental enteral (or parenteral) nutrition to meet nutritional needs (Wiehe and Arndt, 2010). Supplemental fat-soluble vitamins to replace losses due to malabsorption (strawhacker and Wellendorf, 2004). 10) Tony will be in hospital for 3 weeks. How can you foster his development during the hospitalization? Aid in ensuring that Tony has access to assignments and work materials related to school (Strawhacker andWellendorf, 2004). Peripheral catheters and medication ports may become necessary to allow for easier access, less pain (associated with frequent injections) and mobility. Assist Tony in mobilizing frequently, promoting good circulation, expectoration of lungs and decreasing chance of muscle tissue loss due to increased bed rest.

Take opportunities to teach Tony about his disease. Although parents may know alot about CF, Tony s knowledge may be limited or incomplete (Strawhacker andWellendorf, 2004). Educate about puberty changes and how CF affects the reproductive system by having a late-onset of puberty and chance of altered menstrual cycle (Wiehe and Arndt, 2010). 11) What are you discharge criteria for Tony? Temperature to return to a normal range (35.8-37.3) Signs of infection absent and non-febrile. Clear lung sounds and absence of consolidation in lungs upon x-ray Weight gain of at least 15 kg (above 50th percentile for age of approx 45kg) Increase oxygen saturation for above 90% at least (95% ideal) 12) Provide 2 other appropriate nursing diagnoses for Tony or his family during this hospitalization, given the information you have. Ineffective airway clearance related to abundant, thick bronchial mucus, weakness, and fatigue related to increased work of breathing and malnutrition. Ineffective breathing pattern related to bronchoconstriction, airway obstruction, anxiety, and fatigue.

Part 2 1) Identify the priority nursing diagnoses for Tony following the transplant. Risk for infection and malignancies related to possible organ rejection. 2) Discuss the common immunosuppressant agents used to prevent organ rejection. (London health science centre, 2007)

Cyclosporine: Cyclosporine is a very potent immunosuppressant, which patients usually have to take for the rest of their life. Common side effects may include

tremors in the hands (which diminish over time), hair growth on the face or upper body, growth of the gums, headaches, blurred vision, high blood pressure, elevated potassium levels, and decreased kidney function. All immunosuppressive drugs can increase the risk of infection because they suppress the immune system. Grapefruit and grapefruit juice can cause cyclosporine blood levels to increase. Prednisone: Prednisone doses are usually high after the transplant, and are slowly tapered to a lower dose. The body produces its own form of prednisone called cortisol (hels the body deal with stress) and when prednisone is taken, the body produces less cortisol. Clients should not stop taking prednisone suddenly or they may become very ill. Prednisone may cause some stomach irritation, and it is best taken with food. Other side effects may include moodiness, round face ("cushingoid"), fluid retention or ankle swelling, weight gain, acne, thin skin, easy bruising, poor wound healing, cataracts, high blood sugar, and weakening of the bones (osteoporosis). Azathioprine: Azathioprine can cause stomach irritation so it should be taken with food. It may also lower some blood cell counts, mainly the white blood cells that help the body fight infection and the platelets that help the blood clot. If patients experience fever or chills, mouth sores, unusual bleeding or bruising, bloody or tarry stools, blood in the urine, skin rash, or jaundice, they should contact their physician immediately.

3) Tonyreceived a single lung transplant. Mom asks what the risk are for his cystic fibrosis recurring in his transplant lung. You provide the teaching: Transplanted lungs won t have the defective gene that produces thick, tenacious mucus, but the condition of other organs won t be improved by the transplant.

Other disadvantages include possible surgical complications and having to take immunosuppressant drugs to prevent organ transplant rejection, increasing risk of infections and malignancies. 95% of lung transplant recipients with CF survive over 1 year after the transplant and most (90%) are very happy to have undergone the transplant procedure. 4) Recovery is going well. Tony asks when he can go home. Explain discharge criteria and identify teaching needing to be done. Most clients stay in hospital for 2-3 weeks, Follow up appointments for assessment in place. Have immunosuppressant drugs adjusted properly for Tony and ensure that available. Remain on ventilator until lungs functioning well, which can take anywhere from one day to 2-3 weeks and several months for full lung capacity. Teaching and education done regarding importance of taking immunosuppressant drugs to prevent organ rejection, side effects, signs of organ rejection and living with a transplant. Undergo exercise rehabilitation program to regain strength 5) Discuss the implications of having CF, and of a lung transplant, for healthy growth and development as Tony goes through his teens. CF is the most common lethal genetic illness among Caucasian children and currently has a median survival age of 33.4 years. Important for Tony to attend school as regularly as possible for developing social interactions and academic achievement. Teaching on how CF effects development into manhood , most likely unable to have children (approximately95-99% of males with CF are infertile (Wiehe& Arndt, 2010)). Extremely important to continue taking immunosuppressant drugs to prevent organ rejection and to monitor for rejection of new lung.

Important to continue aggressive pulmonary therapy, including chest percussion and postural drainage during the postoperative stage (Wiehe& Arndt, 2010). Care needs to be taken to prevent gastroesophageal reflux disease (GERD) cause by chronic coughing and forced respiration during chest physiotherapy (Gardner, 2010) Important to put into place psychosocial support as Tony develops, at his age, he is starting to understand that he can die of the disease and as he grows and comes to understand more about his disease, it is important to collaborate with him on his care (Gardner, 2010). Instruct on future danger of diabetes. Poor nutrition and advancing age can promot CFrelated diabetes where the primary cause is insulin deficiency but also can be caused by impaired glucose metabolism (Garnder, 2010).

References Deglin, J.H., Vallerand, A.H. (2009). Davis s drug guide for nurses.(11th ed.). Philadelphia, PA: F.A. Davis company. Gardner, J. (2007). What you need to know about cystic fibrosis. Nursing, 37(7), 52-55. Pagana, K. &Pagana, T. (2009). Mosby s diagnostic and laboratory test reference.(9th ed.). St. Louis, Missouri: Mosby Elsevier.

London health centre. (2007). Multi organ transplant program: pharmacy. London, Ontario. Retrieved from http://www.lhsc.on.ca/Patients_Families_Visitors/MOTP/Pharmacy/index.htm on March 1, 2011. StrawHacker, M., &Wellendorf, K. (2004). Caring for children with cystic fibrosis: a collaborative clinical and school approach. Journal of school Nursing (Allen Press Publishing Services Inc.) 20(1), 5-15. Wiehe, M., & Arndt, K. (2010). Cystic fibrosis: a systems review. AANA Journal, 78(3), 246-251.