1
Bowden, Chapter 16: Supplemental Information
Key Terms
apnea
atelectasis
atopy
cor pulmonale
cyanosis
dyspnea
hemoptysis
hypercarbia
hypoxemia
hypoxia
pallor
respiratory distress
respiratory failure
retractions
subcutaneous emphysema
tachypnea
ventilation-perfusion mismatch
2
Summary of Key Concepts

Certain anatomic and structural features of the respiratory tract in infants and young
children predispose them to develop respiratory distress more readily than older children
or adults.

Respiratory illnesses and exacerbations of chronic respiratory conditions are the most
common reasons for pediatric hospital admissions and ambulatory center visits, especially
during winter and early spring.

Viral and bacterial infections of the respiratory system are common and relatively
unavoidable during childhood.

Children with chronic conditions, especially conditions that involve the respiratory or
cardiac systems, are at highest risk for serious morbidity or mortality associated with
common childhood respiratory infections.

Worsening respiratory distress can be identified by frequent and thorough respiratory
assessments. Early recognition and prompt intervention for respiratory distress are key to
prevent respiratory failure.

Parents of children with chronic respiratory conditions must be educated to recognize
signs and symptoms of respiratory compromise and to notify their healthcare provider
immediately when they occur. Good decision making skills are an essential component of
daily disease management. The nurse must teach these parents how to manage
emergency situations in the home

Children with chronic respiratory conditions require regular follow-up visits with
healthcare providers and use of proactive and preventive measures.
3
Evidence-Based Practice Guidelines
American Academy of Pediatrics. (2001). Clinical practice guideline: Management of sinusitis.
Pediatrics, 108 (3), 798-808.
American Academy of Pediatrics (AAP). (2003). Apnea, Sudden Infant Death Syndrome, and
home monitoring. Pediatrics, 111, 914-917.
American Association for Respiratory Care (AARC). (2007). Removal of the endotracheal
tube—2007 revision & update. Respiratory Care, 52, 81-93.
American Thoracic Society. (2007). An Official ATS Workshop Report: Issues in Screening for
Asthma in Children. Available at
http://www.thoracic.org/sections/publications/statements/
American Thoracic Society. (2007). An Official ATS/ERS Statement: Pulmonary Function
Testing in Preschool Children. Available at
http://www.thoracic.org/sections/publications/statements/
American Thoracic Society. (2000). Care of the child with a chronic tracheostomy. Available at
http://www.thoracic.org/sections/publications/statements/
Cincinnati Children’s Hospital Medical Center. (2006). Evidence-based clinical practice
guideline for medical management of bronchiolitis in infants less than 1 year of age
presenting with a first time episode. Cincinnati, OH: Author. Available at
www.guideline.gov.
Kelley, L., & Allen, P. (2007). Managing acute cough in children: Evidenced –based guidelines.
Pediatric Nursing, 33, 515-524.
4
Organizations
Allergy & Asthma Network Mothers of Asthmatics
www.breatherville.org
American Academy of Allergy, Asthma and Immunology
www.aaaai.org
American Association for Respiratory Care (AARC)
www.aarc.org
American Cleft Palate-Craniofacial Association
www.cleftline.org
American College of Allergy, Asthma, and Immunology
www.Acaai.org
American Lung Association
www.lungusa.org
American Thoracic Society
www.thoracic.org
Association of Asthma Educators
5
www.asthmaeducators.org
Asthma and Allergy Foundation of America (AAFA)
www.aafa.org
Centers of Disease Control and Prevention (CDC)
www.cdc.gov
Cystic Fibrosis Foundation
www.cff.org
Cystic Fibrosis Worldwide
www.cfww.org
Environmental Protection Agency, Office of Children’s Health Protection
http//yosemite.epa.gov/ochp/ochpweb.nsf/homepage
Food Allergy & Anaphylaxis Network
www.foodallergy.org
National Asthma Education and Prevention Program, NHLBI Information Center
www.nhlbi.nih.gov/about/naepp/
6
National Heart, Lung and Blood Institute Information Center
www.nhlbi.nih.gov
National Jewish Medical and Research Center
www.njc.org
Respiratory Nursing Society
www.respiratorynursingsociety.org
7
Bibliography
American Academy of Pediatrics (AAP). (2001). Clinical practice guidelines: Management of
sinusitis. Pediatrics, 108, 798-808.
American College of Obstetricians and Gynecologists (ACOG) (2001). Preconception
and prenatal carrier screening for cystic fibrosis: Clinical and laboratory guidelines.
Washington, DC: American College of Obstetricians and Gynecologists.
Bennett, A.D. (2002). Home apnea monitoring for infants. Advance for Nurse Practitioners, 10,
47-54.
Berge, J., & Patterson, J. (2004). Cystic fibrosis and the family: A review and critique of the
literature. Families, Systems, & Health, 22, 74-100.
Bjornson, C., & Johnson, D. (2005). Croup-Treatment update. Pediatric Emergency Care,
21(12), 863-873.
Carpenter, D.R. & Narsavage, G.L. (2004). One breath at a time: Living with cystic fibrosis.
Journal of Pediatric Nursing, 19, 25-32.
Conway, S. (2004). Transition programs in cystic fibrosis centers. Pediatric Pulmonary,
37. 1-3.
Cooper, K.E. (2001). The effectiveness of ribavirin in the treatment of RSV. Pediatric Nursing,
27, 95-98.
Darrow, D., & Siemens, C. (2002). Indications for tonsillectomy and adenoidectomy.
Laryngoscope, 112(8), 6-10.
Donahue, M. (2002). “Spare the cough, spoil the airway:” Back to the basics in airway
clearance. Pediatric Nursing, 28, 107-111.
8
Ebbinghaus, S. & Bahrainwala, A.H. (2003). Asthma management by an inpatient asthma care
team. Pediatric Nursing, 29, 177-192.
Flume, P.A., Taylor, L.A., Anderson, D.L., Gray, S. & Turner, D. (2004). Transition programs
in cystic fibrosis centers: Perceptions of team members. Pediatric Pulmonary, 37, 1-3.
Franzese, C.B. & Schweinfurth, J.M. (2002). Delayed diagnosis of a pediatric airway
foreign body: Case report and review of the literature. Ear, Nose & Throat
Journal, 81, 655-656.
Grosse, S.D., Boyle, C.A., Botkin, J.R., et al (2004). Newborn screening for Cystic
Fibrosis. Morbidity and Mortality Weekly Reports: Recommendations and
Reports, 53, 1-36.
Heijerman, H. (2005). Infection and inflammation in cystic fibrosis: A short review. Journal of
Cystic Fibrosis, 4, 3-5.
Horner, S.D., Surratt, D. & Smith, S.B. (2002). The impact of asthma risk factors on home
management of childhood asthma. Journal of Pediatric Nursing, 17, 211-221.
Johnson, C., Butler, S.M., Konstan, M.W. et al, (2003). Factors influencing outcomes in
cystic fibrosis: A center based analysis. Chest, 123, 20-27.
Kotagal, S. (2005). Childhood obstructive sleep apnoea (editorial). British Medical Journal,
330, 978-979.
Korppi, M. (2003). Community-acquired pneumonia in children: Issues in optimizing
antibacterial treatment. Pediatric Drugs, 5(12), 821-832.
Lee, E., Parker, V., DuBose, L., Gwinn, J., & Logan, B. (2006). Demands and resources: Parents
of school-age children with asthma. Journal of Pediatric Nursing, 21, 425-433.
McCarthy, M.J., Herbert, R., Brimacombe, M., Hansen, J., Wong, D. & Zelman,
9
M. (2002). Empowering parents through asthma education. Pediatric
Nursing, 28, 465-473.
Meissner, H.C. & Rennels, M.B. (2004). Unpredictable patterns of viral respiratory
disease in children. Pediatrics. 113, 1814-1816.
Millman, R.P. & Working Group on Sleepiness in Adolescents/Young Adults; and AAP
Committee on Adolescence (2005). Excessive sleepiness in adolescents and
young adults: Causes, consequences, and treatment strategies. Pediatrics, 115,
1774-1786.
Patterson, E.E., Brennan, M.P., Linskey, K.M., et al (2005). A cluster randomized
intervention trial of asthma clubs to improve quality of life in primary school
children: The School Care and Asthma Management Project (SCAMP).
Archives of Diseases in Childhood, 90, 786-791.
Pediatric Tuberculosis Collaborative Group (2004). Targeted Tuberculin skin
testing and treatment of latent Tuberculosis infection in children and adolescents.
Pediatrics, 114, 1175-1201.
Peeke, K., Hershberger, M., & Marriner, J. (2006). Obstructive sleep apnea syndrome in
children. Pediatric Nursing, 32, 489-494.
Rotta, A.T. & Wiryawan, B. (2003). Respiratory emergencies in children. Respiratory Care, 48,
248-260.
Sander, N., (2002). Making the grade with asthma, allergies, and anaphylaxis. Pediatric
Nursing, 28, 593-598.
10
Schaefer, R., Stadler, J., & Gosain, A. (2003). To distract or not to distract: An algorithm for
airway management in isolated Pierre robin sequence. Plastic and Reconstructive
Surgery, 113, 1113-1125.
Schibli, S., Durie, P. & Tullis, E. (2002). Proper usage of pancreatic enzymes. Current Opinion
in Pulmonary Medicine, 8(6), 542-546.
Schuster, M., Franke T., & Pham C.(2002). Smoking patterns of household members and
visitors in homes with children in United States. Archives of Pediatric Adolescent
Medicine, 156, 1094-1100.
Society for Adolescent Medicine (2003). Transtion to adult healthcare for adolescents and
young adults with chronic conditions. Journal of Adolescent Health, 33309-311.
Sterling, Y., & El-Dahr, J. (2006). Wheezing and asthma in early childhood: An update.
Pediatirc Nursing, 32(1), 27-31.
Trollvik, A., & Severinsson, E. (2005). Influence of an asthma education program on parents
with children suffering from asthma. Nursing and Health Sciences, 7, 157-163.
Velissariou, I., & Papadopoulos, N. (2006). The role of respiratory viruses in the pathogenesis of
pediatric asthma. Pediatric Annals, 35, 637-642.
Velsor-Friedrich, B., Pigott, T.D. & Louloudes, A. (2004). The effects of a school-based
intervention on the self-care and health of African-American inner-city children
with asthma. Journal of Pediatric Nursing, 19, 247-256.
Weiland, J., Schoettker, P.J., Byczkowski, T., Britto, M.T., Pandzik, G. & Kotagal, U.R.
(2003). Individualized daily schedules for hospitalized adolescents with cystic
fibrosis. Journal of Pediatric Healthcare, 17, 284-289.
Yankaskas, J.R., Marshall, B.C., Sufian, B., Simon, R.H. & Rodman. D. (2004). Cystic
11
Fibrosis adult care: Consensus conference report. Chest, 125, 1S-39S.
12
Addenda
Care Path 16-1 - An Interdisciplinary Plan Of Care for the Child with Apnea
Nursing Diagnosis: Ineffective breathing pattern related to apneic episodes.
Child/Family Outcomes: Child will have effective breathing pattern without apneic spells
throughout hospitalization.
Nursing Diagnosis: Impaired home maintenance related to change in home care regimen.
Child/Family Outcomes: Parents will verbalize understanding of necessary diagnostic
tests and consultations.
Parents will describe and demonstrate understanding of CPR and home apnea monitor
prior to discharge.
Nursing Diagnosis: Interrupted family processes related to anxiety associated with threat
of infant death.
Child/Family Outcomes: Parents will develop open communication with healthcare team
and receive patient information in a timely manner.
Parents will verbalize understanding of need to develop support system to provide respite
care.
Care Intervention
Admission
Categories
Consults
Transition to
Discharge to
Discharge
Community
Social service
Teach
Specialty services
parent/family
such as
members CPR
Pulmonary and
(basic life
Gastroenterology
support) and
13
evaluate return
demonstration
Nursing
Check vital signs
Vital signs every
Discontinue pulse
Assessment and
every 4 hr
4 hr
oximetry.
Care Management
Daily weights.
Pulse oximetry
Place home monitoring
Height on
spot checks.
device on child.
admission
Assess and
Assess response to reflux
Complete
document
precautions.
assessment, with
respiratory
emphasis on
responses to care.
respiratory
Pulse oximetry
system
spot checks.
Cardiorespiratory
Keep child
monitor (Apnea
upright for 30-45
monitor)
minutes following
Pulse oximetry
feeding.
Keep head of bed
Position on
elevated.
abdomen between
Avoid
feedings.
hyperflexion of
neck.
Initiate
documentation of
14
apneic episodes.
Diagnostic Tests &
Possible tests
Repeat diagnostic
Procedures
include CBC,
tests as indicated
capillary blood
by child’s
gases, calcium,
condition.
electrolytes,
glucose, septic
work-up
Aminophylline
requires blood
level monitoring.
Chest radiograph
ECG, EEG
Pneumogram
(pneumocardiogra
m)
If history
indicates, upper
GI series, reflux
scan, Ph probe,
polysomnography
Pharmacologic
As ordered by
As ordered by
Continue with
Management
healthcare
healthcare
medications, as ordered
15
Nutrition
professional
professional
Gastroesophageal
Gastroesophageal
reflux
reflux
medications, if
medications, if
indicated
indicated
Accurate intake
Diet for age as
and output
tolerated.
Diet for age as tolerated.
Maintain reflux
Reflux
Maintain reflux
precautions if
precautions if
diagnosed with
needed.
precautions if needed.
reflux.
Discharge planning
Orient family to
Notify discharge
Hold discharge
/ Teaching
hospital and
planner of need
conference with parents
primary
for home nursing
to review teaching needs,
caregivers.
referral at time of
follow-up clinic visits,
Have family
discharge.
equipment needs, and
verbalize
Find out whether
financial resources.
understanding of
family has
Instruct parents to keep
monitors and
telephone.
log of apneic episodes to
diagnostic
Advise family of
include time, child’s
studies.
home nursing
activity at time of
16
Have family
referral.
episode, and
verbalize
Complete home
interventions to stimulate
understanding of
healthcare
the child.
infant's
referral.
Provide parents with
cardiopulmonary
Contact home
information on support
system.
health agency.
group or name of other
Have family
family with child on
demonstrate
Begin CPR
apnea monitoring at
reflux
teaching.
home.
precautions,
Have family
Have parents notify
medication
demonstrate use
neighborhood EMT of
administration,
of home monitor.
child’s status.
monitor
Have family
Home visit by home care
application, steps
demonstrate CPR. agency is scheduled.
to answer monitor Review
Follow up appointments
alarms.
scheduled.
guidelines for
using home
monitoring with
parents.
Suggest educating
secondary care
providers
regarding
17
monitor use and
CPR.
CBC, complete blood count; CPR, cardiopulmonary resuscitation; EEG,
electroencephalogram; ECG, electrocardiogram; EMT, emergency medical technicians;
GI, gastrointestinal.
Care Path 16-2 - An Interdisciplinary Plan of Care for the Child with Bronchiolitis
Nursing Diagnosis: Ineffective breathing pattern related to bronchospasm, mucosal
edema, and accumulation of mucus.
Child/Family Outcomes: Child will demonstrate improved breathing pattern, as
evidenced by absence of tachypnea, retractions, nasal flaring, grunting, wheezing,
cyanosis, or cough.
Nursing Diagnosis: Impaired gas exchange related to bronchiolar obstruction, atelectasis,
and hyperinflation.
Child/Family Outcomes: Child will demonstrate adequate oxygenation and ventilation,
as evidenced by oxygen saturation >92% and decreased work of breathing.
Nursing Diagnosis: Deficient fluid volume related to dyspnea, tachypnea, and decreased
oral intake.
Child/Family Outcomes: The child will maintain adequate intake and output for age and
weight.
The child will maintain adequate hydration, as evidenced by moist mucous membranes,
good skin turgor, and serum electrolytes within normal range.
18
Nursing Diagnosis: Deficient knowledge related to home management of bronchiolitis.
Child/Family Outcomes: Family will demonstrate knowledge of and adherence to home
treatment plan.
Care
Admission
Intervention
Transition to
Discharge to
Discharge
Community
Categories
Consults
Pediatric
pulmonologist prior
to initiation of
ribavirin, if needed
Infection control
specialist
Nursing
Vital signs and pain
Vital signs and pain
Discontinue
Assessments and
q 2-4 hours based
every 4 hours
cardiopulmonary
Care
on acuity
Pulse oximetry spot
monitor.
Management
Blood pressure on
checks with
Discontinue pulse
admission
respiratory
oximetry.
Strict intake and
treatments and PRN Activity as tolerated
output
for respiratory
Cardiopulmonary
distress
monitor
Keep head of bed
Continuous pulse
elevated.
oximetry
Activity as
Discontinue isolation.
19
Keep head of bed
tolerated
elevated.
Bulb suction with
Activity as
normal saline PRN
tolerated
for congestion.
Bulb suction with
Suction with
normal saline PRN
catheter and saline
for congestion.
only for airway
Suction with
obstruction causing
catheter and saline
substantial
only for airway
respiratory
obstruction causing
compromise.
substantial
Contact isolation
respiratory
during non-
compromise.
epidemic period;
Contact isolation
contact precautions
during non-
plus droplet
epidemic period;
precautions during
contact precautions
RSV epidemic
plus droplet
periods
precautions during
RSV epidemic
periods
Diagnostic Tests
CBC with
Repeat diagnostic
20
& Procedures
differential
tests as indicated by
Blood culture if
child’s condition
child appears very
ill or temperature is
>102F
Consider blood gas
measurements
Nasal washing for
RSV panel (if
indicated)
Chest Radiograph
(if indicated)
Pharmacologic
IV antibiotics if
Maintain IV fluids
Management
strong suspicion or
if not taking PO
evidence of
feeds well or
bacterial infection
change to
Acetaminophen15
heparin/saline lock.
mg/kg PO/PR every
4 hrs p.r.n. (if fever
1010F or mild
pain);max dose =
75 mg/kg/day or 4
gm/day; whichever
Discontinue IV.
Room air
21
is less
Ibuprofen 10 mg/kg
PO every 6 hrs (if
fever >1010F or
discomfort) if
acetaminophen is
not effective; max
dose+ 400 mg
Neo-Synephrine
1/8%; 2-3 drops
each nostril every 6
hrs PRN for nasal
congestion
IV fluids at
maintenance if
clinically
dehydrated or not
taking PO feeds
Nutrition
NPO if in
Diet for age
respiratory distress
Encourage PO
PO feedings if
feeds and fluid
Diet for age
22
RR<60
Psychosocial
intake.
Parental support for
anxiety
Rest for parent if
sleep deprived
Respiratory
Suction prn, before
Begin weaning
Discontinue O2.
feedings and before
oxygen to keep O2
Room Air
inhalation therapy.
saturation >94%.
Oxygen to keep O2
saturation >92% or
for severe
respiratory distress
Discharge
Teach family to use
Teach about home
Discharge if Ribavirin
planning /
bulb syringe and
medication
therapy not needed.
Teaching
watch them
administration.
Return to clinic if
practice.
Ensure family
signs/symptoms of
understands dosing
respiratory distress
and purpose of
recur.
medications.
Home nebulizer, if
needed
Assess smoking
status in home,
23
refer family for
smoking cessation
and encourage
smoke-free homes
and cars.
ADLs, activities of daily living; CBC, complete blood count; ECG, electrocardiogram;
IM, intramuscular; IV intravenous; NPO, nothing by mouth; PO, by mouth; RR,
respiratory rate; RSV, Respiratory Syncytial virus
Care Path 16-3 - An Interdisciplinary Plan of Care for the Child with Pneumonia
Nursing Diagnosis: Ineffective breathing pattern related to an inflammatory infection of
the lower airway
Child/Family Outcomes: Child will demonstrate and maintain an improved breathing
pattern throughout hospitalization, as evidenced by lessening or absence of tachypnea,
retractions, nasal flaring, grunting, wheezing, cyanosis, and/or cough.
Nursing Diagnosis: Deficient knowledge related to disease process and home
management of child upon discharge
Child/Family Outcomes: Family will verbalize understanding of illness and rationale for
treatment plan.
By discharge, family will verbalize/demonstrate an understanding of how to administer
medication at home, how to perform PD&P, how to use a bulb syringe and an MDI as
appropriate, and when to notify physician of changes in respiratory status.
24
Care
Admission
Intervention
Transition to
Discharge to
Discharge
Community
Categories
Nursing
Check vital
Vital signs every 4 hr
Discontinue apnea
Assessment and
signs every 4 hr
I&O every shift
monitor.
Care
Strict intake and Apnea monitor as
Activity as tolerated
Management
output
indicated
Discontinue isolation
Consider apnea
SpO2 p.r.n. for
monitor for
respiratory distress
infants <6 mo
Activity as tolerated
with moderate
Maintain contact
to severe
isolation.
respiratory
distress.
SpO2 check
once, and then
check p.r.n. for
respiratory
distress.
25
Activity as
tolerated
Contact
isolation
Diagnostic Tests
CBC with
Repeat diagnostic
& Procedures
differential
tests as indicated by
Consider blood
child’s condition.
culture and cold
agglutinins.
Chest
radiograph
Spirometry for
children (> 6
yrs) with comorbid
conditions (e.g.,
CF, asthma,
neuromuscular,
etc.)
Pharmacologic
Ampicillin 200
Once PO intake is
Discontinue Neo-
Management
mg/kg/day IV q
consistently 75% or
Synephrine (>3 day use
6 hrs
more of maintenance,
not recommended).
26
(maximum 2
switch to
g/dose)
heparin/saline lock
Change to oral
Or
IV
antibiotics.
Cefuroxime 75-
For bacterial pneumonia,
150 mg/kg/day
discharge on PO
IV q 8 hr for
antibiotics to complete a
bacterial
10-day course.
pneumonia
(maximum
Discontinue
dose, 1.5
heparin/saline lock.
g/dose)
Neo-Synephrine
1/8%, 2-3 drops
each nostril
every 6 hr,
p.r.n. for nasal
congestion.
Acetaminophen
15 mg/kg (max
dose 650 mg)
PO/PR every 4
27
hours PRN
T>101F or
discomfort
Ibuprofen 10
mg/kg (max
dose 400 mg)
PO every 6
hours PRN
T>101F or
discomfort if
acetaminophen
is not effective.
Heparin/saline
lock or consider
IV fluids at
maintenance if
unable to take
PO feeds.
Nutrition
NPO if
Diet for age;
respiratory
encourage fluids
distress
(clear); avoid dairy
Diet for age as tolerated
28
symptoms or
products
vomiting
Respiratory
Oxygen to keep
Encourage deep
Discontinue oxygen.
saturation >92% breathing and
Room air
Bulb or wall
directed cough every
Discontinue nebulized
suction p.r.n.
4 hours while awake.
treatments.
PD&P with
Consider weaning
Use albuterol MDI 2-4
nebulized
oxygen.
puffs via aerochamber
treatments, if
Consider alternating
every 4-6 hr, if clinically
clinically
nebulized treatments
indicated.
indicated
with MDI treatment.
(atelectasis or
Or
lobar
Discontinue
pneumonia
nebulized treatments
identified by
and use albuterol
chest
MDI 2-4 puffs every
radiograph)
4-6 hr, if clinically
Albuterol 0.15
indicated.
mg/kg in 2 mL
Wean oxygen as
normal saline
tolerated.
via nebulizer
every 2-4 hr and
p.r.n. (minimum
29
diluted dose
0.25 mL)
Discharge
Provide
Review all teaching
Discharge to home if on
Planning /
education on
content. Provide
room air, respiratory
Teaching
how to
information on home
treatment not needed
recognize
medication
more than every 4-6 hr,
worsening
administration,
and tolerating PO feeds.
respiratory
including
Instruct parent to call
distress, signs
discontinuation and
physician if respiratory
of inadequate
follow-up
distress is noted.
PO intake; how
instructions.
Ensure that parent makes
to use a bulb
a follow-up appointment
syringe (for
within 1 week of
infants and
discharge.
toddlers), and
how to do
respiratory
treatments.
I&O, input and output; MDI, metered-dose inhaler; NPO, nothing by mouth; PD&P,
postural drainage and percussion; PO, by mouth; SpO2, arterial blood oxygen saturation.
30
Care Path 16-4 - An Interdisciplinary Plan of Care for the Child with
Cystic Fibrosis
Nursing Diagnosis: Impaired gas exchange related to increase pulmonary
secretions.
Child/Family Outcomes: From baseline at admission, the child will demonstrate
improved gas exchange with improved airway clearance measured by:
-Decreased respiratory rate
-Decreased use of accessory muscles.
– Decreased secretions
– Increased airway clearance
– Improved or back to baseline PFTs
– Increased 02 saturation/baseline
– Decreased cough
– Increased exercise tolerance.
.
Nursing Diagnosis: Imbalance nutrition: less than body requirements related to
interference with enzyme production, compromised respiratory status, increased
metabolic requirements due to work of breathing, infection, and malabsorption
and/or decreased appetite.
Child/Family Outcomes: Child will ingest adequate nutrients based on
individual needs.
31
Child will have stools of normal consistency, frequency, and color.
Nursing Diagnosis: Potential for nonadherence to self-care related to chronic
nature of condition and developmental level.
Child/Family Outcomes: Child and family will attain and maintain behavior
that is consistent with goals of therapy.
Nursing Diagnosis: Potential for ineffective coping related to chronic illness
and the risk of life-threatening complications.
Child/Family Outcomes: Family members will verbalize feelings about the
illness and its effect on their lives; will identify family and community
resources, social support.
Nursing Diagnosis: Readiness for enhanced self concept related to appearance,
treatment regimen, and limitations on activities.
Child/Family Outcomes: Child will have a positive self-concept and value
personal strengths.
Child will express feelings about the disease and limitations it imposes.
Child will demonstrate accomplishments in areas of interests.
Care Intervention
Admission
Categories
Consults
CF Team and
Transition to
Discharge to
Discharge
Community
Social Work
32
specialists as
needed (e.g.,
endocrine)
Nursing Assessment
Admission
Weight daily
Discontinue
and Care
weight
Management
Vital signs and
Vital signs and
pain assessment
pain assessment q
Discontinue
q 4 hr
4 hr
pulse oximetry.
Monitor stool
Ad lib ADL’s
calorie count
Respiratory
assessment.
pattern
Monitor stool
Calorie count
Discontinue
pattern
p.r.n.
isolation
Calorie count
Spot pulse
p.r.n.
oximetry for O2
Spot pulse
saturations>92%
oximetry for O2
Continuous pulse
saturations>92
oximetry for O2
%
saturations< 92%
Continuous
pulse oximetry
Ad lib ADL’s
for O2
saturations<
Continue reverse
33
92%
isolation.
Avoid contact
Ad lib ADL’s
with other CF
patients.
Reverse
isolation to
prevent
infection with
multiple
resistant
organisms
Avoid contact
with other CF
patients.
Diagnostic Tests &
CBC with
Assess
Procedures
differential
aminoglycoside
Sputum culture
therapy.
and sensitivity
Levels with third
labeled for CF
to fourth dose;
Basic
repeat if dose
biochemical
adjusted
panel, including
Follow up on
renal and liver
abnormal
34
functions and
laboratory values.
glucose
Assess culture
Other
results and
laboratory tests
sensitivities.
p.r.n.; UA,
Consider work-up
AFB, sputum
for allergic
for fungal
bronchopulmonar
cultures, IgE,
y aspergillosis
HbA1c
(ABPA).
Chest
Consider workup
Radiograph post for cor
anterior and
pulmonale, ECG,
lateral views
O2 desaturation
Spirometry
study as indicated
PFTs for >5
by clinical status.
years
ABG as
indicated
Pharmacologic
Determine
Continue with
Continue with
Management
venous access
medications as
medications as
option: initiate
ordered.
ordered.
IV, PICC, or
Heparin flush as
access
indicated for
Discontinue IV.
35
implanted
PICC or central
venous access
line
Heparin flush as
device.
indicated for
Standard IV
PICC or central
solution for
line
pediatric
maintenance at
patients, unless
home
patient has
glucose
intolerance
Heparin/saline
lock may be
used.
Pulmonary
medications/aer
osolized/antibio
tics/DNase
Pediatric
enzymes
Vitamins
H2 blockers
Prokinetic
agents
36
Antibiotics
NSAID’s/
analgesics
Nutrition
Regular diet
Regular diet (high Regular diet
(high calories)
calories)
(high calories)
Snacks t.i.d.
Snacks t.i.d.
Snacks t.i.d.
Night
Night
Night
supplemental
supplemental
supplemental
feeds for 10-12
feeds for 10-12
feeds if
hours as
hours as indicated
indicated
indicated
Assess need for
home enteral
program and
placement of
gastrostomy tube.
Psychosocial
Initiate
Continue
Resume school
Social Service
therapeutic
therapeutic
activities upon
Play therapy/school
play/recreationa
play/recreational
discharge.
l activities as
activities as
appropriate.
appropriate.
Incorporate
Continue to
schoolwork into
incorporate
37
daily schedule.
schoolwork into
daily schedule.
Respiratory
PD&P and
PD&P and ACT’s Return to usual
ACT’s while
while awake
home treatment,
awake
O2 as indicated
unless
O2 as indicated
exacerbation
requires
additional
respiratory
support in the
home (e.g.,
oxygen, more
frequent PD&P)
Discharge planning /
Assess self-care
Assess/instruct in
Confirm
Teaching
behaviors and
adherence to
understanding
provide age-
treatments/medica of discharge:
appropriate
tion/nutrition
-Follow-up
education for
plan.
plan/ medical
Provide education
appointment
on symptom
-Return to
management.
school/work
selfmanagement.
Assess home
38
and community
Identify home
Obtain
resources.
care needs and
prescription for
initiate referrals:
discharge
-
needs.
Nutritional/entera
l supplements
-Respiratory
durable medical
equipment for
airway clearance,
O2; etc.
-Home IV
antibiotics and
labs
Track progress of
education for new
home care skills.
Consider home
health referral.
ABG, arterial blood gases; ACT, airway clearance technique; AFB, acid-fast
bacilli; ADLs, activities of daily living; CBC, complete blood count; CF, cystic
fibrosis; ECG, electrocardiogram; HbA1c hemoglobin A1c , IgE,
39
immunoglobulin E; NSAID, nonsteroidal anti-inflammatory drug; O2, oxygen;
PD&P, postural drainage and percussion; PFT, pulmonary function tests; PICC,
peripherally inserted central catheter; UA, urinalysis.