Patient Scenario, Chapter 40, Nursing Care of a Family When a Child Has a Respiratory Disorder AN ADOLESCENT WITH CYSTIC

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Patient Scenario, Chapter 40, Nursing Care of a Family When a
Child Has a Respiratory Disorder AN ADOLESCENT WITH CYSTIC FIBROSIS
Billy Denman is a 16-year-old with cystic fibrosis admitted to your
hospital unit. CHIEF CONCERN: “The usual; pneumonia for sure.”
HISTORY OF CHIEF CONCERN: Billy was diagnosed as having cystic
fibrosis at 8 months of age. He has been hospitalized multiple
previous times for pneumonia. The present complication began 3 days
ago with elevated temperature (102°F), loss of energy, and
persistent green-colored sputum on postural drainage. He delayed
reporting symptoms to mother because he wanted to attend a school
dance this evening; by midmorning this day, he realized he was too
sick to delay reporting symptoms any longer. Temperature is now
104°F; respiratory rate is 28 breaths/min; pulse is 132 beats/min.
Adolescent is coughing frequently, but cough is nonproductive.
FAMILY PROFILE: Billy lives with mother. His parents were divorced
when he was 4 years old because “father couldn’t stand know¬ing he
had a kid with CF.” The father has never contributed to Billy’s
care despite the fact he lives in the city and knows of Billy’s
large medical bills. His mother is a nurse; history was obtained
from Billy because she had not arrived at hospital as yet. Billy
rated their finances as “hanging in there.” The family lives in a
three-bedroom house; “one bedroom for mom, one for me, and one for
a slant board.” Billy does own postural drainage on anterior lobes
with automatic vibrator; his mother does posterior surface; a home
care aide visits two times a week to supplement therapy. HISTORY OF
PAST ILLNESSES: Billy had chickenpox at age 4 years (contracted
while in hospital). He was aspirated on a peanut when he was 4
years of age; it was removed by bronchoscopy with conscious
sedation. He had tonsillectomy of palatine tonsils at 6 years; no
complications. His hospital admissions for CF average four times a
year because diagnosis; “severe” congestion with heart failure two
times in the last 2 years. He had one ER admission for swallowing
“too many aspirin” last May. He is treated with stomach lavage,
24-hour observation, and discharged. The adolescent states episode
occurred from “trying to stop a headache, nothing else.” He
received meningococcal vaccine 6 months ago. PREGNANCY HISTORY:
Planned pregnancy; first pregnancy for mother; no complications.
Difficulty with respirations at birth; resuscitated successfully.
No bowel movement for 30 hours postbirth; then meconium plug was
expelled. Billy was kept in hospital 3 extra days for failure to
regain birth weight and excessive jaundice. DAY HISTORY: Nutrition:
24-hour recall: Breakfast: 2 eggs, 4 pieces sausage, 2 slices
toast, 1 glass orange juice Lunch: 1 hamburger with cheese, 1
serving French fries, 1 glass soda, 1 green salad with ranch
dressing Dinner: 1 serving veal, 1 serving mashed potatoes, 1
serving eggplant, 1 piece carrot cake with ice cream, 1 glass milk
Snack: 1 ham and cheese sandwich, 1 bowl tomato soup with crackers,
1 piece carrot cake, 3 glasses milk Sleep: Billy sleeps 8 hours
nightly; occasionally wakes at night short of breath; relieved by
sitting up Recreation: He participates in the school science and
computer clubs; participates in no school sports; maintains an
active walking program; uses treadmill in home on rainy or cold
days. He states that he is normally able to “do things he wants to
do”; admits to using illness to not do things he does not want to
do on occasion. Growth and development: He was breastfed as an
infant; weight gain continued to be slow; bowel movements large and
foul smell¬ing. He was changed to formula at 3 months in an attempt
to increase weight gain; the weight and height both continued to
follow 10th percentile. Infant and preschool motor milestones
achieved late; he didn’t walk until 24 months. Language: he spoke
in sentences by 2 years. Currently attends high school in sophomore
year (1 year behind); has had extra hours tutoring to maintain
school placement. He has regular household chores; cleans own room
and does own laundry; mows lawn with power mower. HISTORY OF FAMILY
ILLNESSES: Billy’s maternal uncle has “much less severe cystic
fibrosis”; his maternal grandmother who lives in Switzerland had
two infants die at birth for “unknown reasons.” His mother had
hysterec¬tomy 3 years ago for dermoid cysts of ovaries. His
father’s family history is not known. His cousin has severe asthma
treated with cromolyn sodium and zafirlukast (Accolate). REVIEW OF
SYSTEMS: Head: Occasional headaches when using computer too long
Eyes: Vision 20/50 L, 20/70 R; wears corrective glasses Ears: No
otitis media; hearing tested in school in eighth grade and found to
be adequate Nose: Occasional nosebleeds if in air-conditioned room
GI: Takes pancreatin with meals; no rectal prolapse Integument: Had
heat prostration in sixth grade from running in a foot race in hot
sun; treated with intravenous fluid in emergency room. Now more
careful to reduce activities in hot weather. Neuropsychology:
“Resigned” to having chronic illness although does experience
occasional episodes of depression thinking about future; mother
concerned poisoning episode last year was not a pure accident.
PHYSICAL EXAMINATION: Height: 5 ft 4 in. (5%); weight: 92 lb (3%);
MRI: 15.8 Blood pressure: 90/50 mmHg General appearance:
Underweight pale-appearing adolescent male; sad facial expression
Head: Normocephalic; two blackened comedones present on forehead
Eyes: Red reflex present; follows to all fields of vision; no
erythema or discharge present Ears: TMs reddened bilaterally;
landmarks not distinct; hearing equal to examiner’s Nose: Midline
septum; mucous membrane reddened; yellow pustular discharge present
Mouth and throat: Prominent anterior overbite; no cavities;
geo¬graphic tongue; yellow drainage present on posterior throat;
posterior palate slightly erythematous Neck: Supple, no pain on
forward flexion; midline trachea; no nodes palpable in thyroid;
three palpable lymph nodes on left; two on right in posterior
cervical chains Lungs: Scattered rhonchi in all lobes; decreased
breath sounds in right lower lobes; moist crackling in both lower
lobes Heart: Rate: 80 beats/min; third heart sound audible; marked
sinus arrhythmia Abdomen: Liver palpable 2 cm below right costal
margin; no masses; bowel sounds at 2 to 3 per minute in all
quadrants Genitalia: Adolescent male; Tanner 5; testes descended;
midline meatus Extremities: Full ROM; poor muscle tone in upper
extremities Neurologic: Patellar and brachial reflexes 2+; sensory
and motor nerves grossly intact Billy is diagnosed as having
pneumonia. He is hospitalized for intravenous antibiotic therapy.
STUDY QUESTIONS: 1. Billy had difficulty breathing at birth, and a
deficiency in surfactant was initially suspected. What is the role
of surfactant in lung function? a. It propels inhaled particles out
of the bronchi. b. It destroys viral invaders that enter the
alveoli. c. It prevents complete collapse of alveoli on expiration.
d. It allows alveoli to expand to their full limit on inspiration.
2. Billy aspirated a peanut when he was 3 years old. Where on a
chest radiograph would you have expected to have seen this foreign
body lodged? a. In his right chest b. Behind the sternum c. In his
left chest d. Just above the stomach bubble 3. Why is aspiration of
a peanut a particular dangerous type of aspiration? a. Peanuts
become enveloped in a tubercle. b. A lipid pneumonia can develop.
c. It can cause the onset of an autoimmune disease. d. He may
develop an allergy to peanuts. 4. What aspect of Billy’s history
would you identify as a risk factor that may have contributed to
his cystic fibrosis? a. His mother received sporadic prenatal care.
b. He was born in a region with poor air quality. c. His family has
a history of allergies. d. He has an uncle with the disease. 5.
Billy’s family is planning a vacation. Which location would be most
conducive to his health needs? a. The Caribbean, because the
temperature is consistently warm b. Manhattan, because there so
many people to meet c. Alaska, because the cold air will invigorate
his lungs d. Northern California, because of its temperate climate
6. Suppose Billy’s pH was 7.30, his PaCO2 was 52 mmHg, and his HCO3
was 32 mEq/L. You would interpret these results as suggestive of
what health problem? a. Respiratory acidosis from oxygen pooling b.
Respiratory alkalosis with oxygen want c. Partially compensated
respiratory acidosis d. Fully compensated metabolic acidosis 7.
Billy is diagnosed as having right lower lobe pneumonia in addition
to cystic fibrosis. When planning care, you should be aware that
pneumonia is defined as which of the following? a. Acute infection
of the alveoli of the lung b. Infection of the major bronchi with
exudate c. A contagious disease that affects the trachea d. A
fibrous membrane which coats the alveoli 8. Your most recent
assessment of Billy reveals that he has been producing blood-tinged
sputum. Why may hemoptysis occur with pneumonia? a. His nose is
likely to be bleeding from coughing. b. His inflamed tonsils are
irritated and bleeding. c. Red blood cells have invaded his
alveoli. d. Lymphocytes have oxidized in his lungs. 9. Your
auscultation reveals that Billy lacks audible breath sounds in his
right lower lobe. What is the most likely cause of this assessment
finding? a. He has developed emphysema. b. Airflow is shunting from
his right lung to his left lung. c. He may be experiencing apneic
spells. d. The lobe is filled with so many secretions that air
cannot enter. 10. You are reading Billy’s electronic health record,
and one of your colleagues has documented the presence of rales in
his upper left lobe. Rales indicate which of the following? a. Lung
consolidation b. The presence of fluid in his alveoli c. Surfactant
deficiency d. An irregular respiratory rate 11. Billy’s mother has
been vigilant about maintaining his vaccinations, including
pneumococcal vaccine. What is the typical course of pneumococcal
pneumonia? a. The disease has an insidious onset and is
characterized by infrequent exacerbations. b. The signs and
symptoms mimic those of asthma and gradually increase in severity.
c. The illness is accompanied by gastrointestinal symptoms in
addition to respiratory distress. d. The onset is abrupt and
follows an upper respiratory tract infection. 12. Billy had
multiple respiratory illnesses as an infant, including
bronchiolitis. You should recognize what characteristic of
bronchiolitis? a. It involves inflammation of the alveoli. b. It is
a subtype of bacterial influenza. c. It involves inflammation of
the small bronchi. d. It is a form of oxygen toxicity. 13. When
Billy had bronchiolitis, his sputum culture would most likely have
revealed the presence of what microorganism? a. Streptococcus A b.
Chlamydia c. Pneumococcus bacteria d. Respiratory syncytial virus
14. A particularly serious respiratory distress when Billy was a
preschooler necessitated a tracheostomy. Which of the following is
a safety precaution to take with a child with a tracheostomy? a.
Avoid moving the child. b. Don’t allow him to sleep supine. c.
Implement infection control measures. d. Encourage the child to
play indoors. 15. Billy has frequent episodes of epistaxis. Which
intervention would be best for this? a. Elevate his head slightly
and apply pressure to the forehead. b. Sit him upright and apply
pressure to the sides of his nose. c. Turn his head to the side and
massage the skin below his nose. d. Keep him flat and apply
pressure to the bridge of his nose. 16. Billy had croup
(laryngotracheobronchitis) as a preschooler. Which observation
would have most clearly suggested that airway occlusion was
occurring? a. He slept more than normal. b. His respiratory rate
was gradually increasing. c. His cough was becoming more
“bark-like.” d. His nasal discharge was increasing. 17. Which
measure would have been most effective to address the
bronchodilation that accompanies croup? a. Push fluids. b.
Administer a prescribed oral corticosteroid. c. Teach Billy to
perform incentive spirometry. d. Administer racemic epinephrine by
nebulizer. 18. Billy needs postural drainage four times a day. How
should you perform this intervention while he is in the hospital?
a. Schedule it immediately after a meal so Billy has optimal
energy. b. Caution Billy not to cough during the procedure to avoid
lung damage. c. Position Billy sitting upright and use vibration to
drain his upper alveoli. d. Caution Billy he may be too old to be
using a slant board. 19. Billy has a cousin who has asthma. Asthma
is mainly a problem of: a. Inspiration because of narrowed alveoli.
b. Expiration because of narrowed bronchi. c. Inspiration because
alveoli are already full. d. Expiration because rhonchi are
present. 20. Which statement by Billy’s cousin would assure you he
understands how to use cromolyn sodium best? a. “I should take it
as soon as an asthma attack starts.” b. “I can’t take it if I have
a fever more than 101°F.” c. “I should take it to prevent attacks
from occurring.” d. “I should use it for only 24 hours after an
attack.” OPEN-ENDED QUESTIONS: 21. What if a preschooler who is not
breathing well refuses to let you put an oxygen mask into place on
his face because “only bad guys wear masks.” What would you do? 22.
What if a mother tells you she’s happy to learn her child has
bronchiolitis rather than pneumonia because she knows pneumonia is
fatal? Would you agree with her? FILL IN THE BLANK QUESTIONS: 23.
The purpose of the upper respiratory tract is to __________ and
_______ air. 24. Perspiration in children with cystic fibrosis is
abnormally high in chloride and ___________. MULTIPLE RESPONSE
QUESTION: 25. Teaching to avoid aspiration is important with all
children, especially those who are young. Which of the following
teaching points should you convey to parents? (Select all that
apply.) a. Children younger than 10 years old should not be served
peanuts. b. Eating should always be supervised. c. Small batteries
from toys pose a risk. d. Abdominal thrusts should be performed if
the child cannot dislodge an aspirated object.