Care Plan

Student: Makenna Tracy Date: 03/04/2020

Course: NSG-434 CC Instructor: Alisa Kurth

Clincial Site: Phoenix Children’s Hospital Client Identifier: JS Age: 2 months,

4 weeks

Reason for Admission:

JS was admitted to Phoenix Children’s Hospital (PCH) on January 8th, 2020 for a liver biopsy. The liver biopsy was needed because JS was born
with jaundiced skin which did not subside. The liver biopsy did not determine the causitive factor so JS has resided in the NICU since the day
of his admission. He is still jaundiced and also pale. He is currently undergoing a cholestasis genetic panel because Alagille Syndrome is
suspected.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Alagille Syndrome JS Clinical Manifestations:
Pathophysiology: This is a genetic disorder which mainly affect  Jaundice
the liver and heart. It causes abnormalities of the bile duct to  Pallor
occur which causes liver damage, in turn. If the liver is affected,  Prominent forehead
bile will build up in the liver and cause scaring which will impair  Deep-set eyes
the liver from filtering waste products out of the blood. If the heart  Diarrhea
is affected, pulmonic stenosis or impaired blood flow from the
heart to the lungs will occur. Alagille syndrome can cause other Expected Clinical Manifestations (US National Library of
heart abnormalities like ventricular septal defects as well. Other Medicine, 2020):
systems which are less commonly affected are the central nervous  Jaundice
system and the kidneys. Issues associated with this disorder are  Itchy skin
usually evident in infancy and the effects range from patient to  Xanthomos
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
 patient.  Prominent forehead
Risk Factors: Alagille syndrome is a genetic disorder so risk  Pointed chin
factors only include the patient having at least one carrier parent or  Deep-set eyes
random excess genetic material on chromosome 20.  Straight nose
 Cardiac murmur
(US National Library of Medicine, 2020)

Assessment Data
Subjective Data: JS is a fussy baby and likes to be swaddled tightly and likes to be in his swing. He also calms down when he is help and given
cuddles. When is is upset, he will turn bright red. Also, it should be expected that he will wimper throughout the shift.
VS: Labs: Diagnostics:
T: 37.4°C CBC (03/02/2020) Liver Biopsy
BP: 93/39 Potassium 5.6  Date: 01/08/2020
HR: 147  Impression: no presence of common bile duct
 Normal: 3.5-5.0
RR: 64  Rationale: dietary salt substitute (DEKA Chest XR
Essential multivitamin) & acidosis (Daly
O2 Sat: 97% NC 0.1L &  Date: 02/14/2020
& Farrington, 2013)
30% FiO2  Impression: mild interval aeration of lungs with
AST 72 residual bilateral interstitial and alveolar airspace
opacities which may represent pulmonary edema
 Normal: 10-34
or atelectasis
 Rationale: cirrhosis possibly caused by
Alagille syndrome (Benioff Children’s Chest & Abdomen XR
Hospital, 2019)
 Date: 02/14/2020
Bilirubin 4.4  Impression: probably increased atelectatsis
secondary to high endotracheal tube placement;
 Normal: <1.0
dilated loops of bowel with either ascites or bowel
 Rationale:liver malfunction caused by
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 possible Alagille syndrome (Mayo wall thickening; question bone dysplasia
Clinic, 2018)
Cholestasis Genetic Panel
ABG (02/17/2020)
 Date: 03/02/2020
pH 7.32  Impression: Pending
 Normal: 7.35-7.45
 Rationale: possible atelectasis or
pulmonary edema (MedlinePlus
Encyclopedia, 2020)
pCO2 57
 Normal: 35-45
 Rationale: possible atelectasis or
pulmonary edema (MedlinePlus
Encyclopedia, 2020)
HCO3 29
 Normal: 22-26
 Rationale: compensation for respiratory
acidosis (MedlinePlus Encyclopedia,
2020)

Assessment: Orders:
PMH: IUGR, jaundice from day of birth to present day, no bile duct, Vital Signs q4h
osteopenia, ulnar fracture, was on TPN for 1 month and is now
BP q12h
discontinued, suspected Alagille syndrome
Medium chain triglycerides q8h with feeds
Weight: 2.256 kg (0.4 kg decrease from previous day)
DEKAs Essential multivitamin for electrolyte balance
Neuro:
Continuous cardiac monitoring
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Fussy, awake Chlorohexadine bath q3days
Reflexes – babinski, palmer, rooting, startle reflexes are intact; sucking CBC as needed
reflex is uncoordinate
Lower HR limit - 90 bpm
Pupils are reactive to light bilaterally
Strict I&Os and daily weights
Will look just past object or look just before object which should be
Head circunferance and height qSunday
focused on
Abdominal girth qshift
Respiratory:
Consult with speech and lactation
Clear lung sounds in all lobes bilaterally
Keep O2 sat > 94%
Oxygen status – 97% NC 0.1L on 30% FiO2
If > 2L supplemental O2 is needed, notify the provider
Cardiac:
Ween of O2
Normal sinus rhythm
Fragile bones precaution
Good perfusion – capillary refill < 3 seconds bilaterally
Hearing Screen (ABAER)
S1 and S2 sounds are present; no S3, S4, or murmurs present
Admission status - level 2
Femoral pulses 2+ bilaterally, brachial pulses 2+ bilaterally
No edema noted
HR 64
BP 93/39, MAP 56
GI/GU:
Abdominal girth – 29
Diet – 48 mL q3h PO/NG tube over 90 minutes; 5 mL PO first, then
give the rest through NG tube

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Last BM: 03/02/2020 at 1700, this was the sixth bowel movement of the
shift; stool was watery and grayish
Bowels were irritated and JS was passing flatulence throughout the shift
Integumentary:
Appearance – jaundice, pallor; slight redness around liver biopsy site
Status – warm, dry, intact
Lines:
Peripheral IV 22 gauge in left scalp, saline locked, no phlebitis or
redness and flushes with ease
NG tube 6.5 F at 20 in the right nare; recieves feedings and medications

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 Medications
ALLERGIES: NKDA Weight: 2.256 kg

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Calcium Carbonate 62.5 PO/NG Q6h Antacid effect for GI Most Frequent: arrythmias, When used as an
mg/kg liquid irritation; supplements hypercalcemia, antacid, assess for
calcium for bone growth constipation indigestion and
due to history of Other: tingling, abdominal pain,
osteopenia bradycardia, diarrhea, N/V, inspect abdomen,
calculi, hypercalciuria auscultate bowel
(Synoski & Vallerand, sounds throughout
2017) therapy;
Monitor BP, HR,
and ECG
throughout therapy
because
vasodilation
causing
hypotension,
bradycardia,
arrythmias, and
cardiac arrest can
occur
(Synoski &
Vallerand, 2017)
Ferrous Sulfate 6 mg/kg PO/NG QD Prevention of iron Most Frequent: Assess bowel
liquid deficient anemia constipation, dark stools, function for
diarrhea, epigastric pain constipation or
Other: GI bleeding, diarrhea and take
staining of teeth appropriate nursing
(Synoski & Vallerand, countermeasures;
2017) Monitor
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 hemoglobin and
hematocrit prior to
and throughout
therapy;
Advise parents of
the possible stool
color changes
(Synoski &
Vallerand, 2017)
Ursodiol 30 mg/kg PO/NG Q12h Prevent gall stone Most Frequent: HA, N/V, Notify PCP if
suspensio formation; lipid in diet constipation, diarrhea, changes in behavior
n emulsifier flatulence occur;
Other: anxiety, depression, Assess for signs of
fatigue, sleep disorder, hair GI irritation
thinning, pruritus, throughout therapy
rash, abdominal pain, (N/V, diarrhea,
increased liver enzymes, constipation,
stomatitis, arthralgias, flatulence,
myalgia, cough, rhinitis abdominal pain)
(Mayo Clincic, 2020) (Mayo Clinic,
2020)
Acetominophen 18 mg/kg PO/NG Q6h PRN Temp > 38°C Life threatening: Assess pain type,
(Tylenol) liquid Mild pain hepatotoxicity, acute location, and
generalized exanthematous intensity before and
pustulosis, Stevens- 30-60 minutes after
Johnson syndrome, toxic administration;
epidermal necrolysis Assess temperature
Other: increased liver before and after
enzymes, renal failure, administration
neutropenia, pancypenia, (Synoski &
rash, urticaria Vallerand, 2017)
(Synoski & Vallerand,
2017)

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8
 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Imbalanced Nutrition: less than body’s requirements related to inability to digest food as evidenced by uncoordinated
sucking reflex and grayish stool from blocked bile and missing common bile duct.
This is the priority diagnosis because nutrition is one of the basic needs on Maslow’s hierarchy of needs. Therefore, it
should take first priority when caring for patients (McLeod, 2018).
JS will demonstrate JS will not lose more than 1. Obtain JS’s weight at the 1. To ensure early The goal was met. As
effective feeding 10% of their weight sae time each day, using the recognition of excessive opposed to the day
techniques and take as during the shift. same scale weight loss before, JS did not lose
much feeding by mouth 2. Regularly assess JS’s 2. To help eliminate more than 10% of his
without burning too much sucking pattern and try to ongoing difficulties weight during the shift.
energy. correct ineffective patterns 3. To identify the need for 1. JS’s daily weights
3. Assess JS for neurologic more extensive evaluation were obtained so any
or other physical causes of (Ralph & Taylor, 2017) weight loss would be
ineffective sucking caught early.
(Ralph & Taylor, 2017) 2. JS’s sucking reflex
was assessed with each
feeding and corrctive
action was taken,
however it remained
uncoordinated.
3. JS was assessed for
possible causes of the
uncoordinated sucking
reflex and it was
determined that he needs
more extensive
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 evaluation.
Secondary Nursing Diagnosis:
Diarrhea related to lack of bile due to missing a common bile duct as evidenced by excessive bowel movements of loose,
unformed stool.
JS’s diarrheal episodes JS’s amount of bowel 1. Monitor and record 1. To monitor treatment The goal was not met.
will decline or disappear. movements will decline to frequency and effectiveness Because JS continued to
1 or 2 per day before shift characteristics of stools 2. To improve body have diarrheal episodes
change. 2. Admister antidiarrheal function, promote comfort, throughout the shift.
measures should be and balance body fluids, 1. JS’s bowel movements
executed as ordered salts, and acid-base levels were assessed and
3. Administer replacement 3. To ensure balanced monitored to determine
electrolytes as prescribed fluid I&Os treatment effectiveness.
(Ralph & Taylor, 2017) (Ralph & Taylor, 2017) 2. Besides continuing to
give fortified breastmilk,
other antidiarrheal
measures were not ordered
by the physician
3. DEKAs essential
multivitamin was given to
ensure balanced
electrolytes and I&Os
Although these
interventions were
implemented, JS did not
respond so his bowel
movement count remained
increased.
Tertiary Nursing Diagnosis (Psychosocial):
Disorganized Infant Behavior related to prematurity and feeding intolerance as evidenced by fussy, irrtable affect and
excessive crying.
JS will begin to show JS’s parents will learn to 1. Explain to the parents 1. To help them The goal was met. JS’s
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appropriate signs of identify and understand his that infant maturation is a
maturation. cues during the shift. developmental process and
that their participation is
crucial
2. Explain to the parents
that infants give
behavioral cues that
indicate their needs;
discuss appropriate ways
to respond to these cues
3. Provide the parents with
information on sources of
support and special infant
services
(Ralph & Taylor, 2017)
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”
understand the importance
of nurturing the infant
2. To help them recognize
and adjust their response
patterns; to help them
understand that JS may
respond negatively to their
efforts and this reaction is
normal
3. To help them cope with
their infant’s long-term
needs
(Ralph & Taylor, 2017)
parents modified their
responses to him so his
behavior started to
improve.
1. The importance of the
parents’ participation in
developing JS’s
maturation was explained
so they understood the
gravity of their position.
2. The meanings of JS’s
behavioral cues were
explained to his parents
and this helped them to
respond more
appropriately
3. JS’s parents were able
to cope with his long-term
needs because they were
offered helpful resources
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 References

Benioff Children’s Hospital. (2019). AST: medical tests. Retrieved March 5, 2020, from

https://www.ucsfbenioffchildrens.org/tests/003472.html

Daly, K., & Farrington, E. (2013). Hypokalemia and Hyperkalemia in Infants and Children: Pathophysiology and Treatment.

Retrieved March 5, 2020, from https://www.jpedhc.org/article/S0891-5245(13)00281-2/fulltext#sec2

Mayo Clinic. (2018, August 30). Infant jaundice. Retrieved March 5, 2020, from https://www.mayoclinic.org/diseases-

conditions/infant-jaundice/symptoms-causes/syc-20373865

Mayo Clinic. (2020, February 1). Ursodiol (oral route). Retrieved March 5, 2020, from https://www.mayoclinic.org/drugs-

supplements/ursodiol-oral-route/proper-use/drg-20066618

McLeod, S. (2018, May 21). Maslow's Hierarchy of Needs. Retrieved January 31, 2020, from

https://www.simplypsychology.org/maslow.html

MedlinePlus Encyclopedia. (2020, March 4). Acidosis. Retrieved March 5, 2020, from

https://medlineplus.gov/ency/article/001181.htm

Ralph, S. S., & Taylor, C. M. (2017). Nursing diagnosis reference manual. Philadelphia: Wolters Kluwer Health/Lippincott Williams

& Wilkins.

Synoski, C. A., & Vallerand, A. H. (2017). Davis's drug guide for nurses 15th Edition. F.A. Davis Company.

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US National Library of Medicine. (2020, March 3). Alagille syndrome . Retrieved March 5, 2020, from

https://ghr.nlm.nih.gov/condition/alagille-syndrome#

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