Case Study #1
- Read the report listed below.
- Complete the documentation for steps 1-2 within a word document
- This assignment will be graded using the rubric in D2L.
- Include an APA reference page with your assignment to show the evidence used to guide your care.
- Due: Saturday, October 16, 2021 by 23:30
History of Present Problem:
Thomas Redding is a seven-year-old boy with a history of cystic fibrosis (CF) who for the past two days has had a fever of 102.1 F (38.9 C) and has felt more tired. His cough has become more frequent, and he is bringing up thick yellow mucus. His mother brought Thomas to his CF clinic where he is diagnosed with a right lower lobe pneumonia.
Thomas is admitted to the pediatric unit for IV antibiotics, and you will be the nurse responsible for his care. Thomas has an implanted port for vascular access since he frequently needs IB antibiotics for respiratory infections. Thomas is below the 5th percentile for his weight at 41 pounds and is at the 5th percentile for height at 44.5 inches. He has a g-tube in place for night feedings.
Thomas is in the second grade and lives at home with both parents and his 5-year-old brother who is in good health. His mother is a stay-at-home mom, and his father works as a computer software engineer. The family has health insurance through the father’s employer. He receives Medicaid because of his chronic illness. He has missed many days attending school due to CF but has a tutor provided by the school district. He told his parents that sometimes the kids at school tease because he is so small.
T: 102.6 F/39.2 C (oral)
P: 116 (reg)
R: 26 (reg)
O2 sat: 89% room air
FACES – 4
HEENT: Head symmetric, no recent trauma, hair fine, no drainage from ears, interior appears normal, hearing intact. Denies pain to ears. Sclera are clear/normal, symmetric. Average convergence. Teeth present, oral mucosa pale and dry.
General appearance: Slightly anxious appearing and very quiet. Skin is pale with dark circles under both eyes. Appears much younger than age due to slow growth. Does not speak except for nodding head “yes” “no.” Sitting between his parents.
Respiratory: Respiratory efforts moderately labored with increased rate. Breath sounds course crackles and wheezing throughout lung fields bilaterally with fine crackles heard on inspiration at right base. Moderate sub-costal retractions noted, nail beds have a blueish hue in color and have pronounced clubbing. Thick yellow mucous.
Cardiac: Pale, warm & moist forehead. No edema, heart sounds regular with elevated rate, no abnormal beats, and pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill noted at forehead Thomas has an implanted port central venous access device at the left upper chest. The site is clean and dry with a small scar at the insertion site.
Neuro/Mental: Alert & oriented to person, place, time, and situation (x4). Appears to be moderately anxious, listening intently to provider and nurse but not speaking, holding on to Dad’s hand. Moves all extremities spontaneously. Pupils 2 mm and reactive bilat. Obeys commands.
Musculoskeletal: No muscle or joint pain, normal movement/strength in upper and lower extremities. Gait appeared unsteady when climbing onto bed.
Gastrointestinal: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Liver non-palpable, PEG tube 14 French in place with expected healing around tube/site left of the umbilicus.
Genitourinary: Voiding without difficulty, urine clear/yellow
Skin: Skin integrity intact, skin turgor elastic, no tenting present
GFR > 60ml/minute
Sputum: positive for Haemophilus influenza and Pseudomonas aeruginosa
Right lower lobe pneumonia as well as chronic obstructive pulmonary disease with an increase in anteroposterior chest diameter. The right side of the heart is slightly enlarged.
- Vital signs every 4 hours with continuous oxygen saturation monitoring
- Start IV fluids via CVAD (implanted port) of normal saline at 30 mL/hr
- O2 to keep saturations > 93%
- Albuterol 2.5 mg (0.5 mL) in 3 mL of 0.9%NaCl four times a day before chest physical therapy
- Gentamicin 2.5 mg/kg/dose IV every 8 hours
- Piperacillin 400 mg/kg/day IV every 4 hours
- Pulmozyme via inhalation once per day
Step 1. Document the following five notes.
- Note 1 (label as such): Write the cause/pathophysiology of the primary AND underlying problem in your own words. You should have a textbook citation.
- Note 2: Review the lab values. List the lab values that are high and low and what that value indicates. I recommend using Nursing Central’s Davis’s Lab and Diagnostic Tests. In Davis’s Labs, the measurement for Lactose is different than posted in this case study. In addition, it is labeled under lactate dehydrogenase. Use the normal reference value of 0.5 – 2.2 mml/L.
- Note 3: What are the four nursing priorities (listed in order of significance) that will guide your plan of care?
- Note 4: Calculate how much Gentamicin and Piperacillin will be given for the first dose and indicate why each of the antibiotics are being given.
- Note 5: What are possible/most likely complications to anticipate? How you monitor these signs?
- Note 6: Discuss the dietary needs of Thomas considering his underlying condition. How will you know that he is adequately hydrated?
- Note 7: Write a discharge plan using the mnemonic DISCHARGE
- Diet changes that will need to occur
- Instructions will need on medical diagnoses and treatments
- Supplies needed to care for self
- Consults needed to improve condition
- Home environment changes that may be needed
- Appointments needed for follow-up care
- Rx – Prescriptions may need
- Gait assistive devices or other types of assistive devices
- Encouragement support including physical, emotional, and financial interpretation of current clinical status
Step 2. Develop a care plan.
You need to identify the priority nursing diagnosis in a three-part statement (related to and as evidence by statement. Be sure the ‘related to’ describes the pathophysiology as the etiology and you include specific abnormal data as the AEB) Be specific with the evidence; include YOUR assessment data, lab results etc. that support the problem (nursing dx).
- Do NOT use “Risk for”
- Does the assessment support the nursing diagnosis? Did you choose a priority nursing dx?
Expected Outcomes/Goals – SMART – must include measurement and time frame in notes box
SMART = specific to goal, measurable, achievable, relevant, and time limited
Goals are specific, not vague. Make sure the goal/outcome statement is measurable – Think of using numeric, descriptive, quantity and quality terms.
Document three goals.
Document all interventions needed to meet the goals. Remember there are no “set number” of interventions. The objective of the interventions is to do what is necessary to achieve the goals. Examples of interventions include basic physical care, specific nutrition, activity, teaching, treatments, administration of medications, referrals and monitoring relevant lab data.
Frequency of interventions must be included.
Rationales – use rationale box next to the “frequency box” – Rationales must be scientific. Provide a reference for each scientific rationale. Reference should be from your peds textbook or other valid source. Rationales explain why the intervention is needed.
You do not need to complete the evaluation.
|Three Part Nursing Diagnosis|
|Expected outcomes (SMART format)
|Nursing Interventions||Frequency||Scientific Rationale||Reference|
|Collaborative Interventions||Frequency||Scientific Rationale||Reference|
|Clinical Reasoning||(8 points)
Demonstrated accurate clinical reasoning in determining in own words pathophysiology, rationales for abnormal data, and rationales for treatments/procedures.
Demonstrated accurate clinical reasoning in determining pathophysiology, rationales for abnormal data, and rationales for treatments/procedures; however, not in own words.
Clinical reasoning evident throughout the case study although not consistently accurate.
Clinical reasoning not overall evident throughout the case study as evidence by consistently inaccurate information.
Clinical reasoning not evident
|Care Planning||(15 points)
Correct priority 3-part nursing diagnosis, SMART goals, adequate shift and discharge goals, adequate collaborative and independent interventions to meet the goals, and evaluated the goals.
A 2nd priority nursing diagnosis identified and the remainder of the plan fits that diagnosis and has sufficient substance to improve the problem identified.
Nursing diagnosis fits the data; however, missing some formatting such as not using a 3-part diagnosis, SMART goals, and/or collaborative and independent interventions. Care plan has sufficient substance to improve the problem identified.
Nursing diagnosis fits the data; however, is a non-priority nursing diagnosis. OR the care plan does not flow well OR does not include sufficient care to improve the problem.
Nursing diagnosis does not fit the data or the plan of care is so disjointed as to be non-therapeutic.
Cited sources, used pathophysiology and/or medical-surgical textbook as source, used reputable sources, and provided reference list in APA 7th edition format.
Met criteria for Exemplary except APA needed improvement.
Did not meet any of the criteria under Exemplary