PEDIATRIC GRAND

ROUNDS
Danielle Beard
OLD DOMINION UNIVERSITY
INTRODUCTION

T.D., 13 year old Caucasian male

with Cystic fibrosis
 Overview of cystic fibrosis
■ A genetic disorder that causes a buildup of thick, sticky mucous in the lungs,
pancreas, liver, and other organs
■ The thick secretions hold on to bacteria and other microorganisms, causing chronic
lung infections
■ The median survival age is almost 40 years old
■ Symptoms include
– Salty skin
– Poor weight gain despite eating well
– Frothy stools
■ In order for the disease to be passed on, both parents must have the defective C.F.
gene, called the CFTR gene
 Treatment of Cystic Fibrosis

■ Airway clearance therapy aka chest P.T.

■ Nebulizer or inhaler
■ Dornase alpha
■ Pancreatic enzyme replacement therapies
■ Need to take fat soluble vitamins every day as they are not able to be absorbed as
they normally should be
■ Antibiotics for frequent infections – can be taken orally, inhaled, or given through an
IV
 First diagnosed with cystic fibrosis
when he was 3 years old
Admitted to the hospital on 06/08/18
with exacerbation of C.F.
• Came in to the ED with SOB, anorexia, fatigue, and general
malaise
• Had a respiratory infection that was not responding to

Patient
traditional antibiotics and therefore had to be admitted

Secondary medical diagnoses

• Liver disease related to C.F.

History
• Chronic pancreatitis related to C.F.
• GERD
• Asthma
• ADHD
• Anemia

Social History
• Mother abandoned him with his stepfather after he was
diagnosed with C.F.
• His step-father is still in the picture and the patient’s step-
grandparents have full custordy
 Cultural Considerations
■ A chronic disease in children, such as C.F., affects social interaction with their peers,
developmental growth, and others factors due to
– Frequent hospitalizations
– Feeling as though they did something wrong to bring about their illness
– Inability to cope with the illness because of their age and cognitive abilities
■ They feel “different” than other kids – can lead to social isolation and loneliness
■ Fragmented family state
 Developmental staging
■ T.D. is a 13 year old male that is developmentally appropriate
■ Piaget: Formal operational stage
– He was able to logically reason through why he was getting certain medicines
■ Erikson staging: Adolescent
– Ages 12-18 years – has just now entered this stage
– Identity vs. Role confusion
– He is trying to discover who he is, where he fits in the world, etc.
– This can be a struggle for him as he spends quite a bit of time in the hospital due to his
chronic disease – he may feel as though he does not fit in or is not accepted by those around
him
■ Impact on communication and care
– I treated him much like an adult and explained things in a logical and reasonable way so that
he understood what I was telling him
– Communicate understanding and empathy for the patient’s situation
 Physical assessment data
■ Coarse crackles bilaterally
■ Pt. underweight and weak
■ Elevated WBC
– Due to uncontrolled infection
■ Low hemoglobin
– The patient is anemic
■ Decreased FEV1
CONCEPT MAP
 Ineffective Airway Clearance
■ Related to:
– Increased mucus production and mucus plugging r/t CF diagnosis and respiratory infection
■ Data:
– Bronc wash: showed gram positive cocci in pairs and clusters
– Chest x-ray: opacities in both L and R lung bases – indicating bronchiectasis
– Coarse crackles heard on auscultation
– Pt.’s cough does not clear airway/lung sounds – is fairly non-productive
■ Goals:
– Pt. will be able to clear airway with coughing after two days of treatment
– Pt. will take bronchodilators and other respiratory medications as ordered by next med round
■ Interventions:
– Chest PT to break up secretions
– Playing/walking around the unit and/or playroom to help mobilize secretions in the lungs
– Administer albuterol and other respiratory treatments as ordered
■ Medications:
– 2.5 mg Albuterol QID
– 2 puffs of dulera BID
– Fluticasone, 220 mcg, 2 puffs BID
 Imbalanced nutrition: Less than body
requirements
■ Related to:
– An increase in caloric needs due to increased respiratory difficulty
– Inability to absorb fat soluble vitamins and other mal-absorptive symptoms of C.F.
■ Data:
– Pt. underweight for age – 36.5 kg
– Pt. unwilling to eat
– History of GERD
– Vitamin deficiency
■ Goals:
– Pt. will drink 2 ensures per day continuously
– Pt. will increase body weight by 10% in the next month
■ Interventions:
– Pt. receiving ensure with meals
– Encourage consumption of favorite foods so he feels excited to eat
– Multivitamins, digestive enzymes, fat-soluble vitamin supplements
 Infection
■ Related to:
– Inability to get rid of secretions via cough due to thick sticky mucus (ineffective airway clearance)
 Allows infectious agents to sit in the lungs and grow – leads to respiratory infection
■ Data:
– Thick, yellow-green secretions
– Elevated WBC
– Desensitized to ceftazidime (an antibiotic)
■ Outcomes:
– Within 7 days, WBC comes down to be WNL
– Pt. is taken off antibiotics and is infection free within one week
– Pt. is able to clear excess secretions within one hour of CPT
■ Interventions:
– Place pt. on contact isolation
– Antibiotics: Pt. on meropenem, tigecycline
– CPT to break up secretions in the lungs and hopefully cough out bacteria caught in mucus
– Fluids to prevent dehydration
 Collaborative Practice
■ Animal therapy
– It has been shown that therapy dogs help children feel comforted, have a better
sense of well-being, participate in activities such as therapy without it feeling like a
“task”, and others
■ Child life
– Ability to go to the playroom allows for social interaction and development of
relationships with other children who have chronic diseases -- decreases loneliness
and isolation
– Encourages movement and activity which helps mobilize secretions in the lungs
■ Physicians
■ Respiratory therapists
 Teaching and Discharge Education

■ Information about any new medications they may be sent

home with
■ The importance of eating a balanced meal and taking in
enough fluids
■ Infection prevention measures
■ Regular exercise
 Nursing research
■ Hospital-Based Therapy Dog Walking for Adolescents with Orthopedic
Limitations: A Pilot Study
■ Summary:
– Aim of the study:
1. To examine the feasibility of a therapy dog-walking program to improve physical activity levels in
adolescents with an orthopedic limitation
2. To see whether or not a therapy dog-walking program helped to increase participation and commitment
to physical activity
– Sample: A group of adolescent children diagnosed with an orthopedic limitation such as SCFE and
Blount’s disease
– Conclusion: The findings indicated that participant activity levels (measure via a step counter) increased
during the weeks that the dog walking sessions occurred
■ How this impacts my patient, T.D. :
– He is resistant to participating in recreational therapy or going to the child life playroom – likes to stay in
bed and play video games
– Loves dogs
– If a therapy dog-walking program was implemented, it would encourage T.D. to walk around and
participate in physical activity without feeling like it is a ”chore”
– Would help to mobilize secretions and make the patient feel and breathe better w/o medical intervention

Vitztum, C., Kelly, P. J., & Cheng, A. (2016). Hospital-Based Therapy Dog Walking for Adolescents with Orthopedic Limitations: A Pilot Study. Comprehensive Child & Adolescent
Nursing, 39(4), 256-271. doi:10.1080/24694193.2016.1196266
 References
AACAP. (2015, October). Chronic Illness and Children. Retrieved from
https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/The-
Child-With-A-Long-Term-Illness-019.aspx
American Lung Association. (n.d.). Diagnosing and Treating Cystic Fibrosis. Retrieved from
http://www.lung.org/lung-health-and-diseases/lung-disease-lookup/cystic-
fibrosis/diagnosing-and-treating-cf.html
Cognitive Development Theory. (2016, September 03). Retrieved from https://www.learning-
theories.com/piagets-stage-theory-of-cognitive-development.html
Cystic Fibrosis Foundation. (n.d.). About Cystic Fibrosis. Retrieved from https://www.cff.org/What-is-
CF/About-Cystic-Fibrosis/
Erikson's Stages of Development. (2016, September 30). Retrieved from https://www.learning-
theories.com/eriksons-stages-of-development.html
Grossman, S., & Grossman, L. (2005). Pathophysiology of cystic fibrosis. Critical Care Nurse,24(4).
Patient Education. (n.d.). Retrieved from
https://www.fairview.org/sitecore/content/Fairview/Home/Patient-
Education/Articles/English/d/i/s/c/h/Discharge_Instructions_for_Cystic_Fibro sis_86325
Vitztum, C., Kelly, P. J., & Cheng, A. (2016). Hospital-Based Therapy Dog Walking for Adolescents with
Orthopedic Limitations: A Pilot Study. Comprehensive Child & Adolescent Nursing, 39(4),
256-271. doi:10.1080/24694193.2016.1196266