C DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) ▪ Cystic Fibrosis - A chronic, progressive, inherited and incurable disease affecting exocrine (mucus-secreting) glands and transmitted as an
autosomal recessive trait that affects chromosome 7. It is characterized by major aberrations in sweat gland, respiratory, and pancreatic insufficiency, with the lungs being the primary organ affected. - Pathophysiology: Two mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene lead to decreased secretion of chloride & increased reabsorption of sodium & water across epithelial cells, resulting in thick, viscous secretions. The thickness of mucous gland secretions increases which can affect the liver, pancreas, lungs, intestines & reproductive tract. Furthermore, bacteria are able to stick more readily to the thickened secretions, which leads to inflammation and infection. The accumulation of thick & tenacious secretions in the bronchioles & alveoli causes respiratory changes, eventually leading to severe atelectasis and emphysema. Pancreatic insufficiency results in malabsorption of fat and protein, including lack of absorption of fat-soluble vitamins. ●
Involuntary Weight Loss - A process that involves a person to unintentionally lose weight, without dieting or exercising, usually in a short amount of time. -
Pathophysiology: The precise mechanism of weight loss is unknown in many patients. Caloric intake, absorption, utilization & loss are key components that determine an individual's weight. Alteration in the balance of these components affects a patient's ability to maintain weight. Absorption may be modified by altered gastrointestinal motility, exocrine pancreatic function, mucosal absorptive capacity, luminal bacteria and medications, among other factors. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)
▪ Electrolyte Levels - This test measures for any fluid or electrolyte imbalances in the body, such as potassium, calcium, phosphate, magnesium & sodium levels. Since this pt. is currently diagnosed with cystic fibrosis, it is best to monitor the pts. electrolyte levels to ensure there are no abnormal values or imbalances, especially with his sodium & chloride levels due to being at risk for experiencing hyponatremia or hypochloremia. Since the pt. is also using nasogastric tube feeding, this puts the pt. even more at risk for electrolyte imbalances. The pts. electrolytes were all within normal limits except for his creatinine level which was 0.3, which is low & his chloride level was on the lower end at 102, but is still in the normal range. ▪ Arterial Blood Gas Panel- This test measures the amounts of arterial gases, such as oxygen, carbon dioxide, bicarbonate and pH levels and gives a huge indicator to any impaired or abnormal gas exchanges that are occurring. Due to the pts. cystic fibrosis diagnosis, this pt. is at risk for experiencing impaired gas exchange between his carbon dioxide and oxygen levels and possibly experience hypoxemia. The pt. did not have a ABG panel done, but it is something that I would have recommended to the provider. ▪ Hepatic Function Panel - This test measures the amount of albumin in serum. It helps determine whether a patient has liver disease or kidney disease, whether enough protein is being absorbed by the body, to assess overall health & also assess nutritional status. Since this pt. is underweight and has a BMI of 17.3 & has reported having a loss of appetite, this test serves as being important. Eating enough protein, fat and carbohydrates would help the pt. obtain the nutritional level he needs to be at for his height. The pts. albumin level was 3, which is considered to be low & his prealbumin level was 20, which is within normal range. The pts. protein level, however, was 5.8, which is low. ▪ Chest X-Ray - A chest x-ray may show signs of hyperinflation & shows any other abnormalities associated with cystic fibrosis. In the case of this pt. however, the x-ray was done to see if his nasogastric tubing was correctly placed in his thorax.
PATIENT INFORMATION
C.P. is an 18 yr. old white male who is a college student & has been diagnosed with cystic fibrosis since he was a child. C.P. currently lives at his dormitory with a roommate and has a single mother and 2 other younger siblings. C.P. was diagnosed with cystic fibrosis as a child and has been frequently hospitalized recently. The pts. mother visited him at college & was concerned with his health. Tht pt. stated feeling fatigued and had unintentionally lost 6 kg in a span of 1 week. The pts. mother took him to his primary care provider & admitted him to this hospital. The pt. currently weighs 124 lbs with a BMI of 17.3, indicating he is underweight. The pt. has reported not having any pain, however he reports not having much of an appetite in the past few weeks. He does not partake in smoking or drinking.
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Abnormal ABG labs showing impaired gas exchange Decreased BP Knowledge Deficits on nutrition & diet Dry mucous membranes Dehydration Impaired hepatic function Pallor & cyanosis of the skin Low albumin & protein levels Thin extremities Decreased I&O
ANTICIPATED PHYSICAL FINDINGS
ANTICIPATED NURSING INTERVENTIONS ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪
Perform a complete Neurological Assessment to determine LOC and level of sensory functions. Assess skin turgor and signs of dehydration every 2 hours. Perform a complete Respiratory Assessment to monitor for any abnormal or adventitious breath sounds. Monitor vital signs (BP, Oxygen, Pulse, Temperature) every 4 hours. Monitor I&O and assess for amount, color and frequency of urine/stool. Educate pt. on diet & nutrition. Educate pt. on nasogastric tube feedings & its complications/risks. Monitor ABG labs to identify any abnormalities and report any changes to HCP. Provide a high calorie, high fat & high carbohydrate diet as indicated by HCP. Administer fluids nutrition as indicated by HCP to maintain adequate hydration. Set up a consult with a nutritionist to discuss diet & maintenance of nutrition. Educate pt. on BMI & how it can affect his health. Educate pt. on the risks of aspiration while using a nasogastric tube for feeding.
vSim ISBAR ACTIVITY INTRODUCTION
STUDENT WORKSHEET My name is Karina Rodriguez and I am a Registered Nurse. I currently work on the medical surgical unit at Memorial Hospital. I am calling about Christopher Parrish in room 354.
Your name, position (RN), unit you are working on
SITUATION Patient’s name, age, specific reason for visit
BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient
ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs
RECOMMENDATION Any orders or recommendations you may have for this patient
He is an 18-yr-old white male who was admitted into this hospital earlier today by his primary doctor due to feeling fatigued, experiencing unintended weight loss of 6kg in 1 week and lost off appetite. The pt. reports feeling tired and weak. The pt. was admitted earlier today on 11/03/2020 at 0826. The pts. primary diagnosis is cystic fibrosis and has been diagnosed since he was a child. The pt. has had frequent hospitalizations frequently & has been experiencing symptoms for a couple of weeks since he moved into his college dormitory. The pt. had an 8-Fr, 42 inch nasogastric tube feeding placed on the previous shift by an RN on his right nares at around 2213. He does not smoke or drink. He has been placed on a high calorie, high fat & high carbohydrate diet by his provider. He currently takes 2 tablets of multivitamins PO every morning at 8am. He also takes 5 capsules of pancrelipase PO before every meal & before tube feedings. He has 1.5kCal/mL of fluid nutrition ordered in NG tube with a total of 720 kCal over 8 hrs. The pancrelipase is also ordered as a PRN with 3 capsules PO before snacks. There is an order for daily I&O & weight to be taken & vital signs to be taken every 4 hrs. The pt. has an AP & lateral chest x-ray scheduled for tomorrow & also has a nutrition consult. Pts. vital signs were taken at 2310. BP is 118/70 & was taken on the left upper arm, HR is at 85 bpm, temp. is at 99F & RR is at 12 breath/min. Pedal pulse is strong at 85 bpm. Capillary refill is less than 2 secs. Pt. is oriented x3 & has no known allergies. Pts. labs were assessed & his creatinine levels were low at 0.3 & his chloride level was at 102, which is on the lower end, but within normal range. Pt. CBC levels were all within normal range. Albumin levels were low at 3 & protein levels were also low at 5.8. Pt. vitamin D level was at 10, which is low. Pt. reports having no pain. Pt. was given 5 capsules PO before his NG tube feeding at 2325. Pt. was started on fluid nutrition (1.5 kCal/min) at 2327 at a rate of 60 mL/hr with a total dose of 480 mL (720 kCal) over 8 hours. Pt. SpO2 level is at 97%. He was repositioned at 2315 to semi-fowler’s to accommodate airway clearance. His skin shows no signs of cyanosis, is dry & intact. Mucous membranes show no signs of dehydration & NG tube access was assessed & is also dry, intact & shows no signs of infection. NG tube was aspirated & flushed at 2335.
The pt. should remain on NG tube feeding to maintain fluid nutrition & prevent dehydration. Pt. should have ABG labs done to monitor for any impaired gas exchanges. The pt. should remain in semi-fowlers position to prevent aspiration. Vital signs should be taken every 4 hrs & Head-to-toe assessment should be performed to assess skin color/pallor every 2 hrs. Pt. should be provided a high calorie, high fat & high carb diet with multivitamins & enzymes being taken before meals as indicated. Pt. should be educated on diet, nutrition & NG tube feeding. Pt. should be set up on a consult with a nutritionist to discuss diet planning and management.
PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: Pancrelipase 5 capsules PO before meals & NG tube feedings Pancrelipase 3 capsules PO with snacks CLASSIFICATION: Therapeutic: digestive agent Pharmacologic: pancreatic enzymes PROTOTYPE: Digestive Agent SAFE DOSE OR DOSE RANGE, SAFE ROUTE For adults, the safe range & route is to initiate with 500 lipase units/kg/meal; dose should be adjusted based on weight, clinical symptoms & stool fat content. The maximum dose = 2500 lipase units/kg/meal (or 10,000 lipase units/kg/day). If pt. eats 4 meals a day with 500 lipase per capsule, it would equal to 2,500 lipase per meal. Multiply 2,500 x4 which equals 10,000 lipase units per day and is considered to be a safe dose & route. PURPOSE FOR TAKING THIS MEDICATION ▪ Contains lipolytic, amylolytic and proteolytic activity. ▪ Increased digestion of fats, carbohydrates and proteins in the GI tract.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Encourage pt. to comply with diet recommendations of HCP (generally high calorie, high-protein, low-fat). Dose should be adjusted for fat content of diet. Usually 300 mg of pancrelipase is necessary to digest every 17 g of dietary fat. If a dose is missed, it should be omitted & next dose taken with next snack, as directed. ▪ Instruct pt. not to chew tablets & to swallow them quickly with plenty of liquid to present mouth & throat irritation. Sit upright to enhance swallowing. Eating immediately after taking medication helps further ensure that the medication is swallowed & does not remain in contact with mouth & esophagus for a prolonged period. ▪ Advise pts. & caregivers to notify HCP if symptoms of fibrosing colonopathy (abdominal pain, distention, vomiting, constipation) occur. ▪ Instruct pt. to notify HCP if experiencing joint pain, swelling of legs, gastric distress or rash occurs.
Resource: Davis’s Drug Guide
Date: 11/3/2020 Initials: C.P.
Student Name: Karina Rodriguez Diagnosis: Cystic Fibrosis Unintentional Weight Loss
Age: M/F: M Code Status: Full Code
Length of Stay: 0.2 days Allergies: NKA
HCP:
Clinical Worksheet Isolation: Standard Precautions
Assigned vSim: Christopher Parrish IV Type: Nasogastric Tube Feeding
Richard Barlowe Consults: Nutrition Consult
Fall Risk: Morse Fall Risk Score: 15 (Low Risk)
Transfer: Pt. reports weakness & fatigue, but does not need assistance in transferring, ambulating or positioning.
Locatio n: Right Nares
Fluid/Rate: 1.5 kCal/mL (60 mL/hr) for total of 720 kCal (480 mL) over 8 hrs.
Critical Labs: Electrolytes: Creatinine - 0.3 (low) Hepatic Function: Albumin - 3 (low) Protein - 5.8 (low) Miscellaneous: Vitamin D - 10 (low)
Other Services: Chest X-ray
Consults Needed: Nutritionist/Dietician
CBC Panel Test Sputum Culture
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Pt. has been admitted by his primary care physician due to feeling fatigued & losing 6 kg in 1 week after moving into his college dormitory. Pt. is diagnosed with cystic fibrosis & had an NG gastric tube applied to his right nares upon admission. Health History/Comorbidities (that relate to this hospitalization): Pt. is currently diagnosed with cystic fibrosis & unintended weight loss. The pt. has had cystic fibrosis since he was a child & has had frequent hospital visits recently. Pt. reported feeling fatigued & has had a loss of appetite for about a week. The pt. has poor appetite & has a BMI of 17.3 which is considered underweight. All immunizations are up to date. Pt. does not smoke and does not drink. Pt. reports exercising 2-3x a week for 30 minutes with mild intensity. Pt. has a low vitamin D lab of 10, albumin level of 3 and protein level of 5.8 which are both low. Shift Goals/ Patient Education Needs: 1. Pt. will be provided with a high carb, high fat & high protein diet to improve protein & albumin lab levels for every meal throughout shift. 2. Pt. will be educated on nutrition & diet and how it will impact pts. health and weight prior to the end of the shift. 3. Pt. will be provided vitamin D supplements with permission of the provider to increase vitamin D levels. 4. Pt. will be educated on NG tube feeding and its risks & complications of aspiration. 5. Pt. will have weight recorded 2x per day and I&O recorded every hour to monitor for any abnormalities. Path to Discharge: Pt. will be seen by a nutritionist/dietician to discuss diet planning & maintenance of nutritional needs. Pt. will be given multivitamins to take to maintain adequate nutrition. Pt. & caregiver will be educated on BMI & how being underweight can affect pt. health Path to Death or Injury: Pt. & caregiver will be educated on NG tube feeding & risks of aspiration. Pt. & caregiver will be educated on I&O and the normal values of how much an adult should be voiding/intaking. Pt. will be educated on the risks of having fluid volume excess when fluid nutrition is not monitored by hospital protocol. Pt. will have vital signs & labs monitored every 4 hours for any changes/shifts or abnormalities. Pt. will be given fluids to prevent dehydration & supple skin turgor.
Alerts: What are you on alert for with this patient? (Signs & Symptoms)
Management of Care: What needs to be done for this Patient Today?
1. Assess & monitor vital signs every 4 hrs.
1. Change of LOC or mental state related to developing infection. 2. Provide pt. with a high calorie, high fat & high protein diet as tolerated. 2. Change of respiratory rate of 20 breaths/min or higher or 12 breaths/min or lower 3. Meet w/ a nutritionist to discuss BMI & diet planning. 3. Having O2 saturation fall below 92%. 4. Abnormal shift of ABG & CBC lab values, especially in pH, PCO2, HCO3 & PO2 levels. 5. Increased temperature higher than 101.4F 6. Change in skin integrity due to warm and sweaty skin. 7. Pt. reporting chest pain level of 6 or higher.
What Assessments will focus on for this patient? (How will I identify the above signs & symptoms?) 1. Neurological Assessment to assess LOC & detect any changes in mental state.
4. Perform a head-to-toe assessment to assess skin integrity and turgor. 5. Educate pt. on diet & nutrition. 6. Apply fluid nutrition of 60 mL/hr for 8 hrs through NG tube feeding. 7. Give 5 capsules of pancrelipase PO before each meal & tube feedings. Priorities for Managing the Patient’s Care Today 1. Pt. will have lungs auscultated every 2 hours to monitor for change of RR or adventitious breath sounds. 2. Pt. will use incentive spirometer 10x every hour to improve deep breathing. 3. Pt. will have vital signs taken every 4 hours to monitor for any abnormal findings.
2. Inspection of skin integrity every 2 hours to assess change in edema, color & temperature of skin.
4. Pt. will be encouraged to eat & given fluids to stay hydrated.
3. Respiratory Assessment every 2 hours to assess respiratory rate & lung sounds.
5. Pt. will have nasal cannula 3 L/min applied throughout the shift.
4. Perform vital signs assessment every 4 hours with emphasis on cardiac and respiratory vitals. 5. Perform a pain assessment every 4 hours.
6. Pt. will have a cardiac assessment performed every 2 hours to monitor HR & BP. 7. Pt. will have cold therapy applied to reduce symptoms of fever. 8. Assess pt. pain level every 4 hours What aspects of the patient care can be Delegated and who can do it?
List Complications may occur related to dx, procedure, comorbidities: 1. Pt. may develop resistance to antibiotics prescribed. 2. Pt. may go into respiratory failure if pneumonia is not properly treated. 3. Pt. skin integrity may be compromised due to fever, warmth & diaphoresis of epidermis. 4. Pt. may go into cardiac arrest if HR & BP remain elevated.
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Taking vital signs periodically & retrieving lab values from the lab for the patient can be delegated to a UAP & LPN. Recording & collecting I&O information can be delegated to a UAP & LPN. Recording daily weight can be delegated to a UAP & LPN. Providing fluids and food for the pt. can be delegated to a UAP & LPN. Providing education about diet & nutrition can be delegated to a nutritionist.
What nursing or medical interventions may prevent the above Alert or complications? 1. RN will perform a respiratory assessment every 2 hrs to monitor for adventitious breath sounds or abnormal changes in respiratory rate & CO2 levels. 2. RN will perform head-to-toe assessment & assess skin integrity to prevent pressure injury formation and monitor for signs of dehydration. 3. RN will have pt. use incentive spirometer 10x every hour to improve deep breathing and lung expansion. 4. RN will monitor ABG, CBC & Electrolyte values for increased signs of infection, impaired gas exchange or changes in O2 levels. 5. RN will provide cold therapy to diminish pyrexia in pt. 6. RN will keep pt. hydrated by providing fluids and preventing dehydration. 7. RN will keep pt. on nasal cannula 3 L/min to maintain O2 saturation levels at 94% or greater.
