Running Head: PLANNING THE CARE
Varnier 1
Planning the care of a patient with ineffective airway clearance related to Cystic Fibrosis
Laura M. Varnier
Duke University School of Nursing
Planning The Care
Varnier 2
Table of Contents
Introduction………………………………………………………………………………………………………………3
Clinical Database…………………………………………………………………………………………………….4-5
Physical Assessment………..…………………………………………………………………………………………6
Physical Plan of Care……………………………………………………………………………………………...7-10
Psychological Plan of Care………………………………………………………………………………………...11
Evidence Base Practice Article Review…………………………………………………………………12-13
Conclusion………………………………………………………………………………………………………………..14
Anticipatory Guidance……………………………………………………………………………………………….15
References…………………………………………………………………………………………………………...16-17
Duke Standard of Care Information…………………………………….................................................18-20
Evidence Based Article………...………………………………………………………………….attached to email
Growth Charts (statue for age, BMI, weight for age)……………...scanned and attached to email
Planning The Care
Varnier 3
Introduction
During the second week of my pediatric clinical experience, I worked with a 17-year old,
white female, admitted five days prior (9/12/2011) with a CF exacerbation with increased work of
breathing. The patient’s mother began to notice her daughter becoming increasingly sick, the patient
displayed trouble breathing, and the mother suspected pneumonia. The mother called the
adolescent’s primary care provider and she was instructed to take her daughter to the ER at Duke
University Medical Center.
The patient’s medical history includes several hospitalizations for CF exacerbations, G-Tube
placement, Infusaport placement and a RUL lobectomy. Regarding her CF, the patient has been
compliant in completing daily physical therapy sessions while at the hospital, but could not
communicate medication or PT regimen that she completes at home. Currently, her CF is
pharmacologically managed, with enzymes, and physically managed with a Hill-Rom vest, which she
wears twice a day to mobilize secretions as a form of chest PT. Currently, the adolescent is 3-days
status post bronchoscopy and in the process of five 7-day antibiotics, that were susceptible to the
cultures found in her sputum.
The patient is a junior in home school and an active adolescent involved in several outside
activities; her main interest is in drama club and recently played the lead role in the local production
of Snow White. C. M. is an animated child that displays an extroverted nature and good interpersonal
relationship with friends through stories she relays and phone calls she received throughout the shift I
spent with her. Her family has not been present since their C.M.’s admission, though the patient
relays a close relationship with parents and two siblings, an older brother (20) and a younger brother
(12). The patient displays no need for assistive devices.
Planning the Care
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N221 Pediatric Nursing --- Clinical Database
De-identified Patient Information
Patient's Age: 17 LOS: 5 days
Gender: F
Reason for Admission: CF exacerbation with increased WOB
Past Medical History: CF, pancreatic insufficiency, RUL lobectomy, GT placement and infusaport placement.
Surgical Procedure: Bronchoscopy POD #3.
Unique Code
Student Initials: LMV
Week: 2
Name of Agency: Duke 5300 F/Sat
Advance Directives:
DNR Status: Full Code
Source of Information: Patient
Family Composition: Father and
Mother household with older brother
to patient (20) and younger brother to
patient (12).
Treatments: CPT vest treatment with RT 4X daily; Isosource 1.5 at 100mL / h; antibiotic therapy.
Assistive Devices: No assistive assistance necessary.
Pertinent Diagnostic TestsTobramycin 1.4 mcg/mL (normal 0.5-10 mcg/mL); Sodium 137 mmol/L (normal 135-145 mmol/L); Potassium
3.7 mmol/L (normal 3.8-5.2 mmol/L); Chloride 102 mmol/L (normal 98-108 mmol/L); Carbon Dioxide 29
mmol/L (normal 21-30 mmol/L); BUN 8 mg/dL (normal is 7-20 mg/dL); Creatinine 0.5 mg/dL (normal is 0.3-1.1
mg/dL); Calcium 0.5 mg/dL (normal 8.7-10.2 mg/dL); Glucose 199 mg/dL (normal is 70-140 mg/dL).
PFT on 9-15-2011: FVC 2.51 L which is 74% of predicted, FEV-1 is 1.73 L which is 57% of predicted, FEV1/FVC ratio is 69% compared to last test on 8-1-2011: FVC 2.81 L which is 83% of predicted and FEV-1 was
1.97 L which is 65% of predicted. (levels of most current test were worse than previous levels)
Pathology Report or Infection Precautions: Contact and Droplet precaution; 9/16/2011 Bronchoscopy reported
positive for 4+ Gram Negative rods, 1+ Oropharyngeal flora
Allergies- Medications and Food: Cefotaxime (anaphylaxis), Colistimethate sodium (anaphylaxis), and Colistin (anaphylaxis)
Medications: Fexofenadine 180mg PO Q day; Prozac 60 mg PO q day; Flonase 2 sprays intranasal Q day; Magnesium Oxide 400mg PO Q 12 hours;
Multivitamin Source CF tablet Q day; Pancrealipase 5 capsules taken with meal PO Q TID; Protonix 40 mg PO Q BID; Phytonadione Tab 5 mg PO
Q day; Miralax 8.5 mg PO Q day; Minocin 200 mg PO Q 12 hours; Ticarcillin Clavulanate IV 3.1 g Q 6 hours; Tobramycin Sulfate 500mg PO Q 12
hours; Azithromycin 500mg PO Q day; Itraconazole 250mg VT Q day
Level of Development Prior to Admission:
Prior to admission, Pt stated that she had “nothing wrong other than my CF”; patient displays intact gross and fine motor skills, intact language and
communication skills and relays stories of socialization outside the hospital in interactions with friends and family members.
Current Level of Development: Adolescent female; no assistance required to complete ADLs; patient displays intact gross and fine motor skills,
intact language and communication skills and relays stories of socialization outside the hospital in interactions with friends and family members.
Mobility: Pt is ambulatory without need for assistive aids and completes ADLs independently.
Psychosocial Assessment: Patient displays age-appropriate physical, communication, emotional, and cognitive skills; Pt displays struggle in identity
vs. role confusion and displays signs of increased peer influence and separation from parental guidance; family unit consist of mother and father,
older brother (20) and younger brother (12). Family lives in a two story house and patient states that both her and her brother have “master
Planning the Care
5
bedrooms in the house”; patient states that she gets “along well with both my brothers” and with her parents; father is a construction worker;
mother is primary care provider to adolescent and homeschool teacher; no visitors were present during care provided by student nurse; Pt states
compliance with all scheduled doctor’s appointment, but has displayed current and past problems with medication compliance as evidenced by
patient stating that she forgets to take her “enzymes with her meals”, could not state to the emergency department intake nurse any of the
medications that she is taking, and cannot state her chest PT schedule as manifested by patient’s several hospitalizations in recent years. Pt does not
state difficulty in adapting to illness but does display behaviors, such as non-compliance with medication and frustration with constant “trips to the
hospital” which keep the adolescent from other activities; Pt does not state that she feels scared or threatened in any way; Pt does not report any
other stressors.
Risk Assessment: Braden score of 28 (low risk for pressure ulcers); Low falls risk according to the Morse falls risk scale (score 20). High risk for
nutritional deficiencies due to CF leading to decreased absorption of nutrients and fat and increased work of breathing, however BMI of 22.3.
Planning the Care
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*N221 Pediatric Nursing --- Physical Assessment
Chief Complaints: “I felt a little dizzy when taking my medications
this morning.”
Current Level of Independence: Full independence; pt states she
turns self when she “needs to”. Pt displays full ability to complete
fine and gross motor skills to complete ADLs.
Respiratory System
SpO2= 99% RA; Lt lobes CTA, Rt upper lobe absent, right middle and lower
lobes clear; infrequent, strong productive cough with small amounts of
yellow/green sputum, natural airway, relaxed depth, symmetric chest
movement, breathing RRR; Inspiration to expiration ratio 1:1; AP: Transverse
2:1. No accessory muscle use; no nasal flaring; no grunting; no wheezing.
Activity Order: OOB 2 times a day; exercises with PT once daily.
Cardiovascular System
Neurological System
HR 87 at 0800. Cap refill < 3 sec bilaterally in all extremities, nail bed color
pink with apparent clubbing of the nails; skin warm and dry; S1, S2 audible, no
audible S3 or S4 or murmurs; no edema; all pulses intact bilaterally in all
extremities 2+. No audible bruits; No JVD at 45 degrees. Apical pulse RRR;
no pulsations, lifts, or thrills.
A&OX4; Pt alert, awake and calm, follows tiered commands, pupils PERRL,
motor intact in all extremities, sensory intact in all extremities, sensation intact,
all deep tendon reflexes intact. CN 2-12 motor and sensory intact.
Speech/voice clear.
Gastrointestinal System
No N/V. Flat abdominal contour; soft, nontender abdomen, active bowel
sounds in all 4 quadrants; no guarding upon palpation; pt denies flatus; rectal
elimination route; last BM at 0600 on 9/17/2011, pt reported feces sunk; High
calorie/High protein diet, feeds by mouth; GT feeds overnight (2145-0745)
Isosource 1.5 at 100 ml/hr.
Genitourinary System
Frequently voids clear, yellow urine into commode; per MD order patient
reports occurrences; pt reported 3 voids and 2 BM over 8 hour shift. IV fluid
intake total 220 in 8 hours. TANNER stage 5.
Vital Signs
Time: 0800 B/P: 116/70; T: 36.6 Oral; P: 87; R: 26; O2: 99%
Height: 155 cm Weight: 53.6 kg HC___N/A__ (< 36 mos.)
Musculoskeletal
Active ROM in all extremities with no discomfort noted; L=R strong handgrips
(3+), L=R strong dorsiflexion (3+); active movement, steady gait.
EENT
Pt. denies use of glasses; PERRL, peripheral vision intact; no tearing; no vision
lesions. Ears contained intact outer structures, no lesions or excess cerumen;
conversational hearing intact. Nose mucosa pink and clear, no lesions or excess
mucus, both nostrils patent. Lips pink and dry with no cracking. Mouth moist
and pink, no lesions, good tonsillary pillar movement, no erythema. Teeth
intact without dental caries, gums pink and moist, no tongue lesions; uvula
midline.
Integumentary System
Skin color appropriate for race, Braden score of 21 (low risk for pressure
ulcers); Skin dry, intact, warm, no tenting or tenderness. Clubbing present in
nail beds.
Wt Percentile: 40th Ht Percentile: 10th
BMI Percentile: appr. 60th (> 2 y.o)
IV Access: D5 ½ NS + 20 KCL at 5 ml/hr through Iport Midchest (CDI with occlusive dressing); dressing change 9/18/2011.
Planning the Care
7
N221 Pediatric Nursing --- Concept Map Plan of Care- Physical
Collaborative Problem list: Cystic Fibrosis; RUL lobectomy; G-tube placement; Infusaport placement; Ineffective airway clearance related to increased production of thick mucus
as manifested by change in level of consciousness during activity; Activity intolerance related to imbalance between oxygen supply and demand as manifested by change in level
of consciousness related to activity; Anxiety related to dyspnea, oxygen deprivation manifested by patient display of fearful behavior; Chronic sorrow related to presence of
chronic disease manifested by feelings related to CF; Disturbed body image related to changes in physical appearance, treatment of chronic lung disease (clubbing, barrel chest,
home oxygen and vest therapy, manifested by patient comments about physical changes; Imbalanced nutrition (less than body requirements) related to decreased absorption of
nutrients and increased work of breathing manifested by 30th percentile ranking on CDC weight-for-age chart; impaired home maintenance related to extensive daily treatment and
medication regimens manifested by current infection; Risk for fluid volume deficit related to decreased fluid intake and increased work of breathing manifested by patient constant
request for more fluids; Risk for infection related to thick mucus harboring bacteria and Immunocompromised state manifested by pathology report results; Risk for skin
breakdown related to malnutrition manifested by 30th percentile ranking on CDC weight-for-age chart; impaired social interactions and social isolation related to forced separation
from peers manifested by need to constantly be interacting with others in person, on the phone or on the computer; Ineffective coping related to daily medication demands and
Eriksonian stage of development manifested by patient non-compliance to medication regimen.
Identified Priority of Care
Key Problem / Nursing Diagnosis: Ineffective airway clearance related to CF etiology of increased production of thick mucus as manifested by change in level of consciousness
during activity and excessive production of sputum.
Supporting Subjective and Objective Data: Pt displays work of breathing between taking morning medications. Pt. displays several spontaneous, productive coughs and expels
greenish/brown sputum into cup. Pt. assessment reveals signs of nail clubbing and increased work of breathing, approximately 26 times per minute. Pt states that she is able to “spit
out secretions” but that this task is easier once she has worn her vest (which helps to mobilize secretions).
Goals
General Goal to achieve through Nursing Interventions: Pt will be able to effectively expel secretions, verbalize decreased work of breathing and maintain SpO2 levels >93%.
Patient Behavioral Outcome Objective(s): The patient will maintain respiratory rate within 12 to 20 breaths per minute; pt response to interventions will be gauged based on
auscultation of breath sounds and patient response; Patient will maintain SpO2 levels greater than 93% throughout the day; Pt will display proper return demonstration of incentive
spirometry and express reasoning behind use; Pt will maintain HOB greater than 45 degrees and express reasoning behind the intervention; Pt will complete all 4 sessions of Hill
Rom vest chest PT and communicate reasoning for the benefits of completing each session of chest PT. pt will display activity tolerance with PRN and PT exercises; pt will
maintain adequate fluid intake to help mobilize secretions.
Patient Educational Needs: Educate on signs and feelings of ineffective airway clearance and strategies to help manage this problem; Pt will maintain an arsenal of ideas to relieve
ineffective airway clearance and can select the intervention that works most appropriately; Pt will be able to cough and deep breathe effectively.
Plan and Interventions
Nursing Interventions
Monitor respiratory patterns, including rate,
depth, and effort, q 4 hours during vitals checks
and before and after interventions.
Scientific Rationale
“A normal respiratory rate for an adult without
dyspnea is 12-16 breaths per minute. With secretions
in the airway, the respiratory rate will increase”
(Simpson, 2006).
Patient Response/evaluation
During 0800 vitals, Pt displayed regular rhythm and rate in
respirations with increased work of breathing at 24 breaths
per minute. After chest PT, respirations decreased to 18
breaths per minute. Pt reported that chest PT helps slow her
breathing and help her to cough up secretions.
During 1200 vitals, Pt again displayed an increase in
respiratory rate at 20 breaths per minute. Response was
expected.
Planning the Care
Auscultate lung sounds for baseline measures
during morning assessment at 0800 and before/
after interventions.
Monitor pulse oxygen saturation levels q 4 hours
with vital checks and before/after interventions.
Encourage the client to use incentive spirometry
every commercial break in her television show
for 1 hour (approximately q 15 minutes). Pt will
be showed proper use of equipment and will
return demonstrate the activity.
Monitor Hill Rom Vest compliance as instructed
by PT, as a form of chest PT, at a vest pressure
of 4, frequency of 13, time 25 minutes, four times
a day, before meals and before bedtime. Educate
patient on need for Hill-Rom chest PT and the
benefits of this procedure to help assist sputum
excretion, typical of CF patients.
Position patient with head of bed elevated at
least 45 degrees to allow for maximal lung
expansion and optimal respirations, throughout
the day; patient can be at 15-20 degrees at night,
but should not be lying flat.
Encourage activity and ambulation, without
causing exhaustion, as tolerated and PRN.
8
Breath sounds are normally clear or scattered fine
crackles at bases. These crackles typically clear when
the patient is asked to deep breathe or cough.
“The presence of coarse crackles during late
inspiration indicates fluid in the airway; wheezing
indicates a narrowed airway” (Simpson, 2006).
“An oxygen saturation of less than 90% (normal is
95-100%) … indicates significant oxygenation
problems” (Clark, Giuliano & Chen, 2006).
“The incentive spirometer is an effective tool that can
help prevent atelectasis and retention of bronchial
secretions” (Guimaraes & Atallah, 2007).
Return demonstration is one way to evaluate
learning related to a psychomotor skill (Bastable,
2008).
“High-frequency chest-wall compression is a
commonly used airway-clearance technique with
efficacy similar, if not superior to conventional
manual percussion and postural drainage”
(Kempainen et al, 2010).
“The Vest Airway Clearance System facilitates
mobilization and removal of secretions from the
lungs. The device utilizes an Air Pulse Generator and
a Single Patient Use disposable, inflatable vest to
deliver high-frequency chest wall oscillation
(HFCWO). HFCWO creates oscillatory airflow that
has been found to loosen and mobilize pulmonary
secretions… indications for use of the Vest Airway
Clearance System… diagnosis of disease such as
cystic fibrosis” (Duke Nursing Process Standards,
2009).
“An upright position allows for maximal lung
expansion; lying flat causes abdominal organs to
shift toward the chest, which crowds the lungs and
makes it more difficult to breathe” (Ackley, 2008).
“Body movement help mobilize secretions and can be
a powerful means to maintain lung health” (Pruitt,
2006).
At 0800, all left lobes, right middle and lower lobes were
clear to auscultation during the 0800 assessment and
remained clear both before and after Hill-Rom vest chest
PT. Response was expected.
Pt oxygenation remained above 95% throughout the day;
specifically, 99% at 0800 and 98% at 1200. Response was
expected.
Pt responded well to return demonstration, teaching another
person how to use the equipment, how incentive spirometry
helps, and how often machine needs to be used to be
effective. Pt stated that during her 1 hour television show
she used the incentive spirometer during each commercial
break. Pt expressed that it helped to have a goal of each
commercial break to gauge frequency. Response was better
than expected.
Patient complied with each session of chest PT using the Hill
Rom vest; during the first session of the day, patient finished
with 8 productive coughs of green, dime sized sputum.
Patient states that the procedure does not hurt but does take
“a lot of time.” Patient correctly identifies reasoning behind
the procedure and the need to complete the chest PT.
Pt HOB remained greater than 60 degrees throughout the
day and expressed that she likes to sleep at approximately 45
degrees at night. She relayed that she sleeps on 3 pillows
when sleeping in her own bed. Response was expected
Pt able to ambulate throughout her room and participate in
PT activities without expressed exhaustion; SpO2 remained
greater than 95% throughout activity. Education provided
on the importance of activity to mobilize secretions and pt
expressed understanding by repeating. Response was better
Planning the Care
9
Encourage fluid intake of 2000 mL/day or more
as requested.
“Fluids help minimize mucosal drying and maximize
ciliary action to help move secretions” (Smith-Sims,
2001).
than expected.
Pt intake of 1200mL of water and 246 mL of IV fluids
throughout 8 hour shift. Pt expressed drinking “a lot” of
water both in and out of the hospital; praise and reasoning
given for the benefits of this practice. Response was better
than expected.
Summary of Patient Progress / Overall Goal Evaluation
What is your impression of your patient's progress toward goal from your nursing care? How might you change the plan of care to improve patient outcomes?
My patient responded well to the ideas I wanted to implement and displayed positive responses to the implemented nursing interventions. The patient was able
to return demonstrate and re-teach many of the interventions back to me, which showed that not only could she use the skill, but she could verbalize what she was doing
and what type of positive effect the intervention could have.
On future care plans, I would like to implement the “huff technique” that I discovered through my research. This technique, specifically targeted to respiratory
disorders such as CF, asks the client to use forced expiratory coughing while saying the word “huff” to “prevent the glottis from closing during the cough and is effective
in clearing secretions from the central airway” (Goodfellow & Jones, 2002).
Planning the Care
10
N221 Pediatric Nursing --- Concept Map Plan of Care- Psychosocial
Collaborative Problem list: Cystic Fibrosis; RUL lobectomy; G-tube placement; Infusaport placement; Ineffective airway clearance related to increased production of thick mucus
as manifested by change in level of consciousness during activity; Activity intolerance related to imbalance between oxygen supply and demand as manifested by change in level
of consciousness related to activity; Anxiety related to dyspnea, oxygen deprivation manifested by patient display of fearful behavior; Chronic sorrow related to presence of
chronic disease manifested by feelings related to CF; Disturbed body image related to changes in physical appearance, treatment of chronic lung disease (clubbing, barrel chest,
home oxygen and vest therapy, manifested by patient comments about physical changes; Imbalanced nutrition (less than body requirements) related to decreased absorption of
nutrients and increased work of breathing manifested by 30 th percentile ranking on CDC weight-for-age chart; impaired home maintenance related to extensive daily treatment and
medication regimens manifested by current infection; Risk for fluid volume deficit related to decreased fluid intake and increased work of breathing manifested by patient constant
request for more fluids; Risk for infection related to thick mucus harboring bacteria and Immunocompromised state manifested by pathology report results; Risk for skin
breakdown related to malnutrition manifested by 30th percentile ranking on CDC weight-for-age chart; impaired social interactions and social isolation related to forced separation
from peers manifested by need to constantly be interacting with others in person, on the phone or on the computer; Ineffective coping related to daily medication demands and
Eriksonian stage of development manifested by patient non-compliance to medication regimen.
Identified Priority of Care
Key Problem / Nursing Diagnosis: Impaired social interactions and social isolation related to forced separation from peers manifested by need to constantly be interacting with
others in person, on the phone or on the computer.
Supporting Subjective and Objective Data: Pt spent time with student nurse communicating stories of friends and family; Pt would ask nurse “when are you coming back?” and
“do you have to leave?”; Pt also spoke online and on the phone with friends. Pt did not have support system at bedside, since the first night she was admitted.
Goals
General Goal to achieve through Nursing Interventions: Pt will identify and express feelings of social isolation and verbalize methods to combat/cope with social isolation.
Patient Behavioral Outcome Objective(s): The patient will establish a therapeutic relationship with student nurse and be able to express feelings regarding illness and
hospitalization; pt will take medication for depression as prescribed; patient will utilize computer and telephone as forms of communication with friends and family to reduce
feelings of social isolation; the client will invite friends and family members to the hospital when she feels visitation is the best way to combat social isolation.
Patient Educational Needs: Pt will be able to know what social isolation feels like; pt will understand visitation policy and the benefit friends and family can have on feelings of
social isolation; patient will understand the importance of medication and the role SSRI medications play in combating depression.
Plan and Interventions
Nursing Interventions
Establish a therapeutic relationship by being
emotionally present and authentic at the
beginning of the shift.
Scientific Rationale
“Being emotionally present and authentic fosters
growth in relationships and decreases isolation”
(Jordan, 2000).
Provide computers and Internet access to
children with chronic disabilities that limit
“Computers and ICT may be the solution to
support development in children in need of
Patient Response/evaluation
The student nurse and patient were able to begin a relationship
immediately through common interest and developing a
comfortable relationship from the beginning of the shift.
Response was better than expected.
Student nurse encouraged computer use of pt to speak with
friends and entertain other interest. Adolescent expressed that
Planning the Care
socialization throughout the shift at the child’s
request.
Discuss causes of perceived or actual isolation
with the adolescent through conversation
throughout the shift.
Encourage visitation for a client who is
hospitalized by both friends and family as
warranted by the patient and staff at the
facility, as the patient feels necessary.
11
special support if the technology is used as an
integrating tool hospitals and acute care
facilities” (Brodin & Lindstrand, 2004).
“The individual’s experience of illness; the
circumstances of everyday living that influence
quality of life; and emotions, fear and concerns
all have a bearing on the way illness is managed”
(Anderson, 1991).
“Visits from those in an emotionally close
network were associated with perceived support,
and this was associated with a decrease in
depression” (Oxman & Hull, 2001).
Establish trust one on one and then gradually
introduce the client to others. Allow the client
the opportunities to introduce issues and to
describe his or her daily life.
“Individualization of care, or tailoring of care,
involves taking into account the client’s
individuality and allowing that individuality to
determine interpersonal approaches and healthillness management actions” (Brown, 1994).
Medicate, as prescribed at 0900, to help
adolescent with feelings of depression or
isolation.
“The FDA suicidality warning was associated
with an overall decrease in antidepressant
treatment for youth with a clinician-reported
diagnosis of depression, but not for those with
MDD. Also, following the warning,
psychotherapy without medication increased”
(Valluri et. al., 2010).
she G-mail chats with most of her friends and uses Skype to
virtual chat with her parents. Response was better than expected.
Pt seemed please that she was able to utilize this option.
Student nurse questioned adolescent’s feelings of isolation from
friends and family members throughout her hospital stay and
outside of the hospital. Pt reports that she feels “alone when she
is in the hospital by herself”, but that her family and friends
“visit a lot, when they can”. Response was expected.
Upon conversation about perceived isolation, student nurse
encouraged visitation from friends and family to help avoid
social isolation. Pt stated that her family was “coming tomorrow”
and that her friend was hoping to come “next week”. Pt
displayed excitement with the upcoming visitation from friends
and family. Response was not effective.
Encouraged patient to describe daily routine and daily life with
CF. By ascertaining information on daily schedule and interests,
student nurse able to customize care plan; for example,
incorporate incentive spirometry into commercial breaks of
favorite television shows, develop a plan to maintain medication
compliance within lifestyle, etc. Response was not effective.
Administered SSRI medication as prescribed, according to the 6
rights of medication administration, for depression related to
chronic disease and social isolation. Response was expected.
Summary of Patient Progress / Overall Goal Evaluation
What is your impression of your patient's progress toward goal from your nursing care? How might you change the plan of care to improve patient outcomes?
The patient responded positively to conversations that were had and made a plan to implement several of the suggestions into her daily routine in order to
avoid social isolation and feelings of being alone.
Regarding social interactions, there are several other implementation methods I could have considered; for example, music therapy, distraction, guided
imagery and writing/typing feelings and desires down could have acted as a distraction from social isolation.
Planning the Care
12
Evidence Based Practice Review- Investigating High-Frequency Chest Wall Compression
Control Most Advantageous to CF patients
One of the most rigorous responsibilities of all CF patients, along with medication
compliance, is adhering to strict physical/respiratory therapy prescriptions of chest physiotherapy to
assist with expectoration of secretions. If RT/PT is unavailable, it is the nurse’s responsibility to
follow the prescribed system regimen and administer the procedure (Duke Hospital Protocol, 2009).
In recent years, it was determined that “high-frequency chest-wall compression is a
commonly used airway-clearance technique with efficacy similar, if not superior to conventional
manual percussion and postural drainage” (Kempainen, 2010). Through modern use of
technology, Hill-Rom created a vest that produces a mimicking of chest wall PT at a higher
frequency. Furthermore, Duke Hospital protocol supports the use of the Vest Airway Clearance
System, particularly in CF patients “to facilitate mobilization and removal of secretions from the
lungs… creating oscillatory airflow that has been found to loosen and mobilize pulmonary
secretions” (2009). However, with this new technology, the “Vest® Airway Clearance System
[only] received FDA clearance to market for bronchial secretion clearance in 1988 and for
sputum induction in 2000” alluding to the fact that large amounts of research particular to
disease etiology needs to be conducted to determine optimal control settings for the Vest
expectoration system (Hill-Rom, 2011).
In 2010, Kempainen, Milla, Dunitz, et al. attempted to determine the optimal control
settings in pressure and frequency that allow for maximum efficacy particularly in CF patients,
by assessing higher-pressure (6-10 on the Hill-Rom vest 1-10 scale) with variable mid-frequency
(8, 9 ,10 and Hz, plus 18, 19, and 20 Hz) chest wall compression compared to lower-pressure (5
Planning the Care
13
on the 1-10 scale) paired with constant mid-frequency settings (14-16 Hz). The controlled
randomized crossover study chose 16 individuals, over 18 years of age that had been diagnosed
with CF according to the Cystic Fibrosis Foundation criteria. The participants were asked to use
the vest system, while remaining uninformed to which chest wall settings were being utilized.
Effectiveness of each frequency method was assessed using sputum weight, incentive
spirometry, pulmonary function test and lung viscoelasticity.
The researchers found that the “use of the higher-pressure/variable-frequency settings
resulted in significantly greater median sputum wet weight expectoration (6.4 g, range 0.4922.0g, versus 4.8 g, range 0.24-15.0g for lower-pressure/mid-frequency HFCWC, P=0.02)”
(Kempainen, Milla, Dunitz, et al, 2010). Both pressure and frequency systems produced similar
results in incentive spirometry, PFT’s and lung viscoelasticity measures. The researchers made it
a point to note the small sample size of the study, the mild-to-moderate nature of the
participant’s CF, and that all subjects were adults (over the age of 18).
My 17-year-old patient’s Hill-Rom chest PT settings were set at a vest pressure of 4 and a
frequency of 13, utilizing the lower-pressure, constant mid-frequency parameters. As an active
member in patient care, as an administrator of the vest system and as an advocate for my patient,
I would like to encourage prescribers, RT, PT and hospital authorities to investigate the evidence
regarding higher pressure/variable frequency chest wall compression, specifically for CF
patients, using the Hill-Rom Vest Clearance system. To provide the best care for our patients, we
need to investigate the most appropriate, evidenced-based information for Vest control, specific
to disease etiology and patient constraints, and begin implementing these control adjustments
into hospital-wide policy.
Planning the Care
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Closing Comments
The link between classroom knowledge and implementation of skills surfaced throughout
my interactions with my pediatric patient. With this patient, I was able to spend time sitting and
talking, while gathering assessment data simultaneously. By viewing this patient from a
developmental standpoint, I could apply Erikson’s stage of identity vs. role confusion in her
attempts to separate from parents by staying at the hospital independently (at my patient’s
request), the importance of connection with peers through interpersonal stories and interpret her
non-compliance with medication as a form of rebellion, typical in this age group and
characteristic of adolescents with progressive, chronic diseases.
Through a developmental lens, I was able to ascertain the information that I needed while
acquiring the best way to connect with her. I could identify the role her peers play in her life and
note the shift from parental influence to peer influence. Also, a developmental perspective
allowed me to build a quick rapport, by relating to something that she was interested in and
allowing her to tell me about her interests.
Finally, working with this patient allowed me to get outside of the textbook and apply
concepts and theories first-hand into my interactions with my patient. This approach led me to
subsequent success in establishing trust with my patient and provided an overall positive feeling
regarding our interactions.
Planning the Care
15
Anticipatory Guidance with a 17-year-old
Patient Initials: C. M.
Child Age- 17 years 5 months
Date of Assessment: 9-17-2011
What activities child can currently perform (according to category):




Personal Social skills
o Pt engages in stories of relationships with friends and family.
o Pt reflects extroverted personality by engaging in a school play, participating in
conversations with caregivers and friends, and displaying
Fine Motor Adaptive skills
o Pt displays fine motor skills through computer skills and personal care activities.
Language skills
o Speech is understandable and clear, with a wide range of vocabulary and intonation.
o Pt has developed age-specific jargon and jargon within peer group.
Gross Motor
o Pt able to walk, perform physical therapy, and initiate all self-care activities.
Anticipatory Guidance:
Pt will continue in Erickson’s psychosocial skill of identity vs. role confusion by appearing
concerned with how they appear to others and role identification within groups, personal, sexual roles,
and emotional situations. Pt may display an increase in sleep and may develop acne. The adolescent will
need adequate amounts of sleep, approximately 10-12 hours. Adolescents will develop high frontal lobe
cognitive functions and continue to achieve independence from parent; begin asking for or needing
guidance regarding personal behaviors such as sex education, STD, stress reduction; screening for
anorexia, obesity, and mental health concerns; remain up to date on immunizations and continue to
receive regular yearly checkups; needs education on the risk of risky behaviors such as substance abuse,
tattoos, teen pregnancy. The adolescent responds best to praise. Adolescent may show signs of resistance
to authority and impulsivity; more influence from peer groups than from adults at this age.
Safety Concerns with 17 year-olds:
Parents aware of the leading causes of death for this age group, including 1) unintentional injury
including motor vehicles accidents, 2)homicides, and 3) suicide; parents need to be informed on the
importance of proper gun storage and firearm safety and children need to know the dangers of firearm;
aware of the risk of sports injuries. Prevention is the most effective tool to implement to avoid injury.
Patient’s assessed developmental age: 17 years (appropriate developmental age corresponds to numeric
age).
Planning the Care
16
References
Ackley, B. & Ladwig, G. (2008). Nursing diagnostic handbook: an evidence-based guide to
planning care. St. Louis, MO: Mosby, Inc.
Anderson, J. M. (1991). Immigrant women speak of chronic illness: the social construction of the
devalued self. Journal of Advanced Nursing, 16, 710.
Bastable, S. B. (2008). Nurse as educator: principles of teaching and learning for nursing
practice. Sudbury, MA: Jones and Bartlett Publishers.
Brodin, J. & Lindstrand, P. (2004). Are computers the solution to support development in
children in need of special support? Technology and Disability, 16, 137-145.
Brown, S. (1994). Communication strategies used by an expert nurse. Clinical Nursing
Research, 3 (1), 43.
Clark, A. P., Giuliano, K., & Chen, H. M. (2006). Pulse oximetry revisited: “but his O (2) sat
was normal!”. Clinical Nursing Specialist, 20 (6), 268-272.
Duke Nursing Process Standards (2009). Vest airway clearance system procedure. Durham, NC:
Duke University Health System.
Goodfellow, L. T. & Jones, M. (2002). Bronchial hygiene therapy. American Journal of Nursing,
102 (1), 37-43.
Guimaraes, M. F., Atallah, A. N., & El Dib, R. P. (2007). Incentive spirometer for prevention of
postoperative pulmonary complications in upper abdominal surgery. Cochrane Database
of Systematic Reviews (2): CD0068058.
Hill-Rom Services Inc. (2011). The vest airway clearance system. Research and Evidence.
http://www.thevest.com/research/.
Planning the Care
17
Jordan, J. V. (2000). The role of mutual empathy in relational/cultural therapy. Journal of
Clinical Psychology, 56 (8), 1005.
Kempainen, R. R., Milla, C., Dunitz, J., Savik, K., Hazelwood, A., Williams, C., Rubin, B. K., &
Billings, J. (2010). Comparison of settings used for high-frequency chest-wall
compression in cystic fibrosis. Respiratory Care, 55 (6), 695-701.
Oxman, T. E. & Hull, J. G. (2001). Social support and treatment response in older depressed
primary care patients. Journal of Gerontology Series B, Psychological Sciences and
Social Sciences, 56 (1), P35.
Pruitt, B. (2005). Help your patient combat postoperative atelectasis. Nursing, 35 (5), 64.
Simpson, H. (2006). Respiratory assessment. British Journal of Nursing, 15 (9), 484-488.
Smith-Sims, K. (2001). Hospital-acquired pneumonia. American Journal of Nursing, 101 (1), 24.
Valluri, S., Zito, J., Safer, D., Zuckerman, I., Mullins, C., & Korelitz, J. (2010). Impact of the
2004 food and drug administration pediatric suicidality warning on antidepressant and
psychotherapy treatment for new-onset depression. Medical Care, 48(11), 947-954.
doi:10.1097/MLR.0b013e3181ef9d2b
Planning the Care
Neurosciences Services Procedure
Title: Vest® Airway Clearance System Procedure
Effective Date: June 2008
Revised: January 2009, December 2009
Purpose: To ensure appropriate and safe use of The Hill-Rom Vest to assist appropriate
neurological
patients with airway clearance.
Level: * Interdependent. MD Order for PT consult for Airway Clearance required.
PT may recommend the Vest after patient evaluation. Refer to Physical Therapy Airway
Clearance
Decision Process for Neurologically impaired patients.
Supportive Data: The Vest® Airway Clearance System facilitates mobilization and
removal of secretions from the lungs. The device utilizes an Air Pulse Generator and a
Single Patient Use disposable, inflatable vest to deliver High-Frequency Chest Wall
Oscillation (HFCWO). HFCWO creates oscillatory airflow that has been found to loosen
and mobilize pulmonary secretions.
Content: Determine patient eligibility for use of the Hill-Rom Vest (Refer to Vest
Decision Process Algorithim)
Indication for use of The Vest® Airway Clearance System:
1. Documented need for airway clearance as defined by the American Association
for Respiratory Care (AARC) 1 clinical practice guidelines. These guidelines
include:
a. Evidence of difficulty with secretion clearance.
b. Difficulty clearing secretions with expectorated sputum production.
c. Evidence or suggestion of retained secretions in the presence of an
artificial airway.
d. Presence of atelectasis caused by or suspected of being caused by mucus
plugging
e. Diagnosis of disease such as cystic fibrosis, bronchiectasis, or cavitating
lung disease
f. Need for sputum sample for diagnostic evaluation
Absolute Contraindications:
1. The Vest® Airway Clearance System is contraindicated if the following
conditions are present.
a. Mechanical Ventilation.
b. Unstable Head /neck/spine injury.
c. Active hemorrhage with hemodynamic.
Relative Contraindications:
The decision to use The Vest® Airway Clearance System for airway clearance therapy in
the presence of the conditions listed below requires careful consideration and assessment
of the individual patient’s case.
a. Intracranial pressure (ICP) >20 mm Hg, or patients in whom increased
intracranial pressure is to be avoided.
b. Uncontrolled hypertension.
c. Hemodynamic instability.
d. Pulmonary edema associated with congestive heart failure.
18
Planning the Care
e. Bronchopleural fistula.
f. Subcutaneous emphysema.
g. Large pleural effusions or empyema.
h. Recent esophageal surgery.
i. Active or recent gross hemoptysis.
j. Pulmonary embolism.
k. Uncontrolled airway at risk for aspiration such as tube feeding or recent
meal.
l. Distended abdomen.
m. Bronchospasm.
n. Suspected pulmonary tuberculosis.
o. Recently placed transvenous pacemaker or subcutaneous pacemaker.
p. Recent epidural spinal infusion or spinal anesthesia.
q. Recent spinal surgery or acute spinal injury.
r. Rib fractures, with or without flail chest.
s. Surgical wound, healing tissue, recent skin grafts, or flaps on the thorax.
t. Burns, open wounds, and skin infections on the thorax.
u. Lung contusion.
v. Osteomyelitis of the ribs.
w. Osteoporosis.
x. Coagulopathy.
y. Complaint of chest wall pain.
z. Chest or thoracic circumference measurements outside of the
recommended minimum or maximum dimensions for each size vest.
Reportable Conditions:
1. Use of The Vest® Airway Clearance System should be evaluated or modified if
the following circumstances occur:
a. Pulmonary hemorrhage.
b. Hypoxia.
c. Increased intracranial pressure.
d. Vomiting and aspiration.
e. Acute hypotension during the procedure.
f. Bronchospasm.
g. Pain or injury to muscles, ribs or spine.
h. Cardiac dysrhythmias.
Equipment
1. Single patient use Wrap SPU Vest.
2. Air Pulse Generator.
3. Air Hoses (to connect the Single Patient Use disposable, inflatable vest to the Air Pulse
Generator).
Procedure
1. Verify order required: PT consult for Airway Clearance.
2. Plug Air Pulse Generator (Model 205) into a known good, properly grounded
power outlet.
3. Instruct patient about the treatment that will be performed.
4. At initial therapy measure patient for appropriately sized vest to assure proper fit
19
Planning the Care
and confirm proper thoracic dimensions.
5. With the Wrap SPU Vest deflated, adjust the inflatable vest to fit comfortably
close to the underarms. Have the patient take a deep breath and secure the hookandloop fasteners to close the Wrap SPU Vest. Adherence to these steps should
be followed as closely as the user’s condition allows.
6. Connect the Air Hoses to the Air Pulse Generator and to the Air Hose Ports of the
inflatable vest.
7. Assemble nebulizer and other equipment needed for the delivery of aerosol
therapy, if prescribed.
8. . Enter the prescribed settings for the Frequency, Pressure, and Time.
9. *Begin aerosol therapy, if prescribed.
10. Initiate therapy with The Vest® Airway Clearance System as directed by
physician’s order.
11. Maintain observation of patient during treatment
12. Unless directed otherwise by the prescribing physician, after completing 5 to 10
minutes of therapy, pause the Air Pulse Generator by pressing the OFF button or
squeezing the Remote Control one time. Have the patient cough or suction to
clear loosened secretions.
13. To continue treatment, press the ON button, or squeeze the Remote Control once.
Treatments commonly involve 10 to 30 minutes of actual HFCWO (oscillation).
14. Press the OFF button one time when no time remains in the treatment session or
two times during a session to end the treatment.
15. . Disconnect the Air Hoses from the inflatable vest, and then from the Air Pulse
Generator.
16. Loosen the hook-and-loop fasteners and remove the inflatable vest from the user.
17. Store vest wrap in The Vest wrap is single patient use.
18. Discard when patient no longer requires treatment patient room for next
treatment.
References:
1. Hill-Rom, The Vest Airway Clearance System , www.thevest.com
2. AARC Clinical Practice Guideline: Postural Drainage Therapy, Respiratory Care
1991;36:1418-1426. (2007)
3. Brierly S, Adams C, et al, 2003. Safety And Tolerance Of High-Frequency Chest Wall
Oscillation (HFCWO) In Hospitalized Critical Care Patients. Respiratory Care 48 (11):
1112
4. Lange D J, Lechtzin N, et al, 2006. High-frequency chest wall oscillation in ALS.
Neurology 2006:67:991-997.
Approval: Duke Neuroscience CPC, Duke Neuroscience NLC, Duke Physical
Therapy
Distribution : 4100, 4200, 4300
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