Case Study
A.B. is an 11 year old Asian female. She was a full term infant born via vaginal delivery.
Her past history is significant for Biliary Atresia. She had a Kasai procedure at 2 months
of age in attempt to treat her condition. There is no significant family history. She has a
healthy 6 year old sister.
She received an orthotopic liver transplant at age 9, secondary to end stage liver
disease. Over the course of the year and a half prior to transplant, she had elevated liver
enzymes (AST, ALT, GGT, Bilirubin (unconjugated and conjugated), elevated PT, PTT
and INR, unstable electrolytes (increased potassium and decreased magnesium), jaundice,
pruritus, ascites, failure to thrive, hepatosplenomegaly. She was evaluated for end stage
liver disease secondary to extrahepatic Biliary Atresia. She received a percutaneous
needle liver biopsy and abdominal ultrasound with Doppler which demonstrated
worsening liver function. She underwent a full transplant evaluation and the decision
was made to proceed with listing for liver transplantation. Prior to transplant, a G-Button
was placed to facilitate the administration of bolus feeds to optimize nutritional status.
Today she is a well developed, active 11 year old. The father’s concerns include
apparent weight loss (patient has lost three pounds since previous visit), possible noncompliance with her medication regimen and concerns that she is spending time with a
“bad crowd”, requesting a navel piercing and constant requests to “go tanning”. She is
reportedly a picky eater and often skips breakfast. She eats lunch at school and reports
that this usually consists of soda, and pizza or chicken nuggets. Her dad reports that she
eats a lot of “junk food” and does not drink much water or other clear liquids. Father
complains that although she is doing well in school and is active in other activities,
including cheerleading and FFA (Future Farmers of America) where she is raising a calf,
she does not want to eat dinner with her family or participate in family activities. Her
current prescribed medication regimen includes Prograf and Magnesium. She admits to
“sometimes” forgetting her medicines which lead to fights with parents. There are
currently no complaints of jaundice, pruritus, fever, cough, congestion, bleeding,
bruising, nausea, vomiting, diarrhea, constipation, tremors, or pain.
Child, s/p solid organ transplant
Nursing Diagnosis: Nutrition, altered, less than body requirements
Nursing Diagnosis: Body image disturbance, risk for
Nursing Diagnosis: Self esteem disturbance, risk for
Plan:
Assess current growth and develop
Review diet history for past three days
Determine patient/family knowledge of pre-teen nutritional needs
Evaluate current view of self (patient)
Implementation:
Discuss current height/weight expected for age with pt/family
Refer to transplant dietitian to review current dietary intake and
educate patient/family on appropriate food choices and caloric
intake
Provide patient/family with dietary intake and weight tracking tool
Set weight and intake goals
Consult Child Life Specialist (or other appropriate team member)
to offer tools to increase self esteem for patient and family
Offer information about patient and family support groups
Encourage patient to attend transplant camp or other activities to
interact with transplant patients
Evaluation:
Nursing Diagnosis:
Nursing Diagnosis:
Nursing Diagnosis:
Nursing Diagnosis:
Nursing Diagnosis:
Review diet tracking tool with patient and family in one week
Monitor weight monthly and discuss results with family
Feedback from parents and patient
Achievement of goals
Attendance at support group or other activities
Non-compliance, risk for
Health maintenance, altered
Knowledge deficit, medical regimen
Caregiver role strain, high risk for
Family processes, altered
Plan:
Assess patient knowledge of current medical regimen
Evaluate patient and family understanding of risks associated with
non-compliance with medical regimen
Assess coping skills of patient and family
Implementation:
Provide medication tracking tool/calendar
Patient to verbalizes plan to “remember” medications
Discuss signs and symptoms of rejection
Discuss appropriate family activities
Refer parents to support group
Refer patient and family to transplant social worker for
psychosocial evaluation and support
Offer communication tools to family
Discuss consequences of inappropriate behavior
Evaluation:
Patient and family feedback
Review tracking tool for medication compliance
Attendance at support groups
Patient verbalizes risks of non-compliance
Feedback from social worker
Nursing Diagnosis: Infection, high risk for
Nursing Diagnosis: Knowledge deficit, therapeutic regimen
Plan:
Identify high risk behaviors in the immunosuppressed patient
Discuss signs and symptoms of infection
Implementation:
Discuss high risk behaviors (piercings, tattoos, fungal spores
associated with hay, contact with animal feces) with patient and
family
Review signs/symptoms of infection
Offer alternative activities
Encourage hand washing and other infection preventative
measures
Review increased risk of cancer in post transplant patient
Encourage use of sunscreen, hats, and sunglasses
Evaluation:
Feedback from patient/family
Verbalize signs/symptoms of infection
Avoidance of high risk activities
Evaluate patient’s utilization of sunscreen
Additional information
Nursing Diagnosis
Nursing Diagnosis
Risk Factors
Outcomes
Nursing Interventions
Risk for infection
Depressed immune system
Immunosuppression
medications
Potential for high risk
behavior(s)
Potential for exposure to
pathogens (animals)
Frequent use of tanning bed
Verbalize signs and symptoms Teach signs and
of infection
symptoms of infection
(ie. warmth, erythema,
Will understand importance of fever, discharge)
prophylactic medication
complicance
Review dosage and
administration of
Patient will demonstrate
prophylactic
appropriate hand washing
medications
techniques
Instruct and educate on
Patient and family will
avoidance of high risk
verbalize appropriate oral care behaviors (tatoos,
piercings, sexual
Patient and family will
activities, tanning)
verbalize high risk behaviors
Encourage frequent and
appropriate
handwashing and
instruct on appropriate
daily hygiene (oral care
and bathing) and use of
sunscreen
Avoid large crowds and
ill contacts
Avoid high risk
animals/excrement/hay
Review immunization
schedule for patient and
sibling
Altered nutrition: less
than body requirements
Inadequate food intake
Unwillingness to eat
Pt and family understand
nutritional requirements
Refer to dietitian for
nutritional assessment
and education
Consume adequate nutrition
Lack of information or
misconception
Maintain appropriate weight
for height (BMI)
Patient participates in family
meals
Patient verbalizes appropriate
food choices
Monitor weight weekly
and instruct on
appropriate technique
(same scale, same time)
Review need for
increased fluid intake
with activity
Encourage appropriate
nutritional intake
Encourage appropriate
clear liquid intake
Encourage frequent
small meals
Body image
disturbance
Change in social behavior
Change in lifestyle
Fear of reaction of peers
Negative feelings about
appearance
Feeling of powerlessness
Verbalizes ability to adjust to Acknowlege patient’s
changes in body due to
feelings to changes in
developmental stage
body and life-style
Will make positive body
image statements
Observe coping
mechanisms during
times of stress
Will voice concerns with peer
reactions
Review with family
alternative coping
Identifies factors that are
techniques
uncontrollable
Identify and explore
Participates in plan of care
patient’s strengths
Makes decisions regarding
care and treatment when
possible
Allow patient to
participate in plan of
care
Assess family level of
acceptance of patient’s
body changes
Encourage family to
provide positive
feedback related to body
image
Noncompliance with
prescribed regimen
Lack of knowledge of need
for ongoing medication
Will verbalize understanding
of need for long term
treatment and medications
Encourage appropriate
peer interaction
Discuss implications
related to noncompliance
Health beliefs
Feelings of powerlessness
Describes consequence of
non-compliance
Family and patient actively
involved in treatment plan
States appropriate health goals
Review medication
regimen with patient
and family
Work with client to
develop tool for
tracking medication
administration
Identify and discuss
concerns that patient
has with regimen or
side effects of
medication
Monitor patient’s
ability to follow
directions and problem
solve
Encourage family to
allow patient to
actively participate in
plan of care
Involve family in
providing positive
feedback to patient