Jack Hammond Room 305
Jack Hammond, 10 -year old boy who was admitted last night for cystic fibrosis exacerbation and possible pneumonia. He has an IV of D5 NS infusing
to his right arm at 75 mL/hour. Oxygen per nasal cannula is in place at 3 L/min, chest x-ray results and sputum culture are pending. He is alert and oriented, both parents are currently at the bedside. He does complain of intercostal pain, especially with coughing. Current oxygen saturation is 94%
You responded correctly to 5 out of 6 evaluations:
CategoryYour
response Explanation
HealthIncreased acuityExacerbation of cystic fibrosis and possible pneumonia
LOCNormal
acuityThe child is reported as alert and oriented
Pain levelIncreased acuityThe child reports pain with coughing
PsychologicalNormalThere is no mention of increased psychological
Needsacuityneeds
SafetyNormal
acuityThere is no mention of safety concerns in the report
EducationalIncreased acuityThe child is admitted for an exacerbation of his
cystic fibrosis, education is needed to help manage this chronic
Physiological
DescriptionYour
Respons
eExplanation
Activity intoleranceTRUEThe child has an exacerbation of
cystic fibrosis and requires
supplemental oxygen
Disturbed sensory
perceptionFalseCystic fibrosis does not adversely
affect sensory perception
Imbalanced TRUEWith cystic fibrosis, the body DescriptionYour
Respons
eExplanation
nutrition, less than
body requirementsdoes not produce pancreatic enzymes leading to nutritional
deficits
Impaired gas
exchangeTRUEDamage from cystic fibrosis and possible pneumonia will decrease
the body’s ability for gas
exchange
Impaired skin integrityFalseCystic fibrosis affects the pancreas, GI system, respiratory system, and increased sodium
loss through excessive perspiration
Impaired swallowingFalseThere is no indication of impaired
swallowing with cystic fibrosis
Ineffective airway
clearanceTRUECystic fibrosis leads to increased production of thick mucous, making it more difficult for
airway clearance
Ineffective health
maintenanceTRUEThe child is admitted with an
exacerbation of his chronic health problem, cystic fibrosis
Risk for infectionFalseThe child has a current infection,
and is at risk for further infection
Safety
Descriptio
n
Self- care deficitYour
Response Explanation
FalseA 10- year old child is capable of bathing, dressing and grooming self
Scenario 1
The nurse enters the room, washes hands, and introduces self to Jack and his parents. Visual assessment of Jack demonstrates the use of accessory muscles with breathing, he is sitting in a tenting position, Oxygen is being delivered via nasal cannula. Jack coughs up thick green mucous into a tissue, and grimaces when coughing. Vital signs are Temp 101*F, B/P 115/74, HR 84, Respiratory rate 28 and labored, Oxygen saturation 89%. Orders are written for nebulizer treatments PRN, chest physiotherapy QID, Pancrease (pancreatic enzymes) with each meal and snack, Oxygen via nasal cannula.
Jack Hammond, 10 -year old boy who was admitted last night for cystic fibrosis exacerbation and possible pneumonia. He has an IV of D5 NS infusing
to his right arm at 75 mL/hour. Oxygen per nasal cannula is in place at 3 L/min, chest x-ray results and sputum culture are pending. He is alert and oriented, both parents are currently at the bedside. He does complain of intercostal pain, especially with coughing. Current oxygen saturation is 94%
You responded correctly to 5 out of 6 evaluations:
CategoryYour
response Explanation
HealthIncreased acuityExacerbation of cystic fibrosis and possible pneumonia
LOCNormal
acuityThe child is reported as alert and oriented
Pain levelIncreased acuityThe child reports pain with coughing
PsychologicalNormalThere is no mention of increased psychological
Needsacuityneeds
SafetyNormal
acuityThere is no mention of safety concerns in the report
EducationalIncreased acuityThe child is admitted for an exacerbation of his
cystic fibrosis, education is needed to help manage this chronic
Physiological
DescriptionYour
Respons
eExplanation
Activity intoleranceTRUEThe child has an exacerbation of
cystic fibrosis and requires
supplemental oxygen
Disturbed sensory
perceptionFalseCystic fibrosis does not adversely
affect sensory perception
Imbalanced TRUEWith cystic fibrosis, the body DescriptionYour
Respons
eExplanation
nutrition, less than
body requirementsdoes not produce pancreatic enzymes leading to nutritional
deficits
Impaired gas
exchangeTRUEDamage from cystic fibrosis and possible pneumonia will decrease
the body’s ability for gas
exchange
Impaired skin integrityFalseCystic fibrosis affects the pancreas, GI system, respiratory system, and increased sodium
loss through excessive perspiration
Impaired swallowingFalseThere is no indication of impaired
swallowing with cystic fibrosis
Ineffective airway
clearanceTRUECystic fibrosis leads to increased production of thick mucous, making it more difficult for
airway clearance
Ineffective health
maintenanceTRUEThe child is admitted with an
exacerbation of his chronic health problem, cystic fibrosis
Risk for infectionFalseThe child has a current infection,
and is at risk for further infection
Safety
Descriptio
n
Self- care deficitYour
Response Explanation
FalseA 10- year old child is capable of bathing, dressing and grooming self
Scenario 1
The nurse enters the room, washes hands, and introduces self to Jack and his parents. Visual assessment of Jack demonstrates the use of accessory muscles with breathing, he is sitting in a tenting position, Oxygen is being delivered via nasal cannula. Jack coughs up thick green mucous into a tissue, and grimaces when coughing. Vital signs are Temp 101*F, B/P 115/74, HR 84, Respiratory rate 28 and labored, Oxygen saturation 89%. Orders are written for nebulizer treatments PRN, chest physiotherapy QID, Pancrease (pancreatic enzymes) with each meal and snack, Oxygen via nasal cannula.
