Kyle is a nine-year-old boy with a history of cystic fibrosis (CF) who for the past two days has had a fever of 101.9 F and has felt more tired. His cough has become more frequent, and he is bringing up thick yellow mucus. His mother brought Kyle to his CF clinic where he is diagnosed with a left lower lobe pneumonia. Kyle is admitted to the pediatric unit for IV antibiotics. Kyle has a Broviac line for vascular access since he frequently needs IV antibiotics for respiratory infections. Kyle is below the 5th percentile for his weight at 41 pounds (18.6 kg) and is at the 5th percentile for height at 44.5 inches (113 cm). He has a G-tube in place for night feedings. Kyle is in 4th grade and lives at home with both parents. His mother is a stay-at-home mom, and his father works as an IT tech. The family has health insurance through the fatherâ€™s employer. He receives Medicaid because of his chronic illness. He has missed many days attending school due to CF. The kids at school tease because he is so small.
- What patient history has clinical significance to the nurse and why?
The most recent vital signs were:
T: 102.6 F/39.2 C (oral)
P: 122 (reg)
R: 28 (reg)
O2 sat: 86% on room air
- What patient vital signs have clinical significance to the nurse and why?
- 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 â€œyesâ€ â€œno.â€ Sitting between his parents.
- RESP: Respiratory efforts moderately labored with increased rate. Breath sounds coarse crackles and wheezing throughout lung fields bilaterally with fine crackles heard on inspiration at right base. Moderate subcostal retractions noted, nail beds have a bluish hue in color and have pronounced clubbing.
- 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 Justin has an implanted Broviac line 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 Dadâ€™s hand.
- GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants. Liver non-palpable, PEG tube in place with expected healing around tube/site
- GU: Voiding without difficulty, urine clear/yellow
- SKIN: Skin integrity intact, skin turgor elastic, no tenting present
- What patient assessment findings have clinical significance to the nurse and why?
- What is the nursing priority at this time?
- What nursing interventions will the nurse initiate based on the priority at this time?