PATIENT SCENARIO, CHAPTER 40, NURSING CARE OF A FAMILY WHEN

A CHILD HAS A RESPIRATORY DISORDER

AN ADOLESCENT WITH CYSTIC FIBROSIS

Billy Denman is a 16-year-old with cystic fibrosis admitted to your hospital unit.

CHIEF CONCERN:
“The usual; pneumonia for sure.”

HISTORY OF CHIEF CONCERN:

Billy was diagnosed as having cystic fibrosis at 8 months of age. He has been
hospitalized multiple previous times for pneumonia. The present complication began 3
days ago with elevated temperature (102°F), loss of energy, and persistent green-colored
sputum on postural drainage. He delayed reporting symptoms to mother because he
wanted to attend a school dance this evening; by midmorning this day, he realized he was
too sick to delay reporting symptoms any longer. Temperature is now 104°F; respiratory
rate is 28 breaths/min; pulse is 132 beats/min. Adolescent is coughing frequently, but
cough is nonproductive.

FAMILY PROFILE:
Billy lives with mother. His parents were divorced when he was 4 years old because
“father couldn’t stand knowing he had a kid with CF.” The father has never contributed
to Billy’s care despite the fact he lives in the city and knows of Billy’s large medical
bills. His mother is a nurse; history was obtained from Billy because she had not arrived
at hospital as yet. Billy rated their finances as “hanging in there.” The family lives in a
three-bedroom house; “one bedroom for mom, one for me, and one for a slant board.”
Billy does own postural drainage on anterior lobes with automatic vibrator; his mother
does posterior surface; a home care aide visits two times a week to supplement therapy.

HISTORY OF PAST ILLNESSES:

Billy had chickenpox at age 4 years (contracted while in hospital). He was aspirated on a
peanut when he was 4 years of age; it was removed by bronchoscopy with conscious
sedation. He had tonsillectomy of palatine tonsils at 6 years; no complications. His
hospital admissions for CF average four times a year because diagnosis; “severe”
congestion with heart failure two times in the last 2 years. He had one ER admission for
swallowing “too many aspirin” last May. He is treated with stomach lavage, 24-hour
observation, and discharged. The adolescent states episode occurred from “trying to stop
a headache, nothing else.” He received meningococcal vaccine 6 months ago.

PREGNANCY HISTORY:
Planned pregnancy; first pregnancy for mother; no complications. Difficulty with
respirations at birth; resuscitated successfully. No bowel movement for 30 hours
postbirth; then meconium plug was expelled. Billy was kept in hospital 3 extra days for
failure to regain birth weight and excessive jaundice.

DAY HISTORY:
Nutrition: 24-hour recall:
Breakfast: 2 eggs, 4 pieces sausage, 2 slices toast, 1 glass orange juice
Lunch: 1 hamburger with cheese, 1 serving French fries, 1 glass soda, 1 green salad with
ranch dressing
Dinner: 1 serving veal, 1 serving mashed potatoes, 1 serving eggplant, 1 piece carrot cake
with ice cream, 1 glass milk
Snack: 1 ham and cheese sandwich, 1 bowl tomato soup with crackers, 1 piece carrot
cake, 3 glasses milk
Sleep: Billy sleeps 8 hours nightly; occasionally wakes at night short of breath; relieved
by sitting up
Recreation: He participates in the school science and computer clubs; participates in no
school sports; maintains an active walking program; uses treadmill in home on rainy or
cold days. He states that he is normally able to “do things he wants to do”; admits to
using illness to not do things he does not want to do on occasion.
Growth and development: He was breastfed as an infant; weight gain continued to be
slow; bowel movements large and foul smelling. He was changed to formula at 3 months
in an attempt to increase weight gain; the weight and height both continued to follow
10th percentile. Infant and preschool motor milestones achieved late; he didn’t walk until
24 months. Language: he spoke in sentences by 2 years.
Currently attends high school in sophomore year (1 year behind); has had extra hours
tutoring to maintain school placement. He has regular household chores; cleans own
room and does own laundry; mows lawn with power mower.

HISTORY OF FAMILY ILLNESSES:

Billy’s maternal uncle has “much less severe cystic fibrosis”; his maternal grandmother
who lives in Switzerland had two infants die at birth for “unknown reasons.” His mother
had hysterectomy 3 years ago for dermoid cysts of ovaries. His father’s family history is
not known. His cousin has severe asthma treated with cromolyn sodium and zafirlukast
(Accolate).

REVIEW OF SYSTEMS:
Head: Occasional headaches when using computer too long
Eyes: Vision 20/50 L, 20/70 R; wears corrective glasses
Ears: No otitis media; hearing tested in school in eighth grade and found to be adequate
Nose: Occasional nosebleeds if in air-conditioned room
GI: Takes pancreatin with meals; no rectal prolapse
Integument: Had heat prostration in sixth grade from running in a foot race in hot sun;
treated with intravenous fluid in emergency room. Now more careful to reduce activities
in hot weather.
Neuropsychology: “Resigned” to having chronic illness although does experience
occasional episodes of depression thinking about future; mother concerned poisoning
episode last year was not a pure accident.

PHYSICAL EXAMINATION:
Height: 5 ft 4 in. (5%); weight: 92 lb (3%); MRI: 15.8
Blood pressure: 90/50 mmHg
General appearance: Underweight pale-appearing adolescent male; sad facial expression
Head: Normocephalic; two blackened comedones present on forehead
Eyes: Red reflex present; follows to all fields of vision; no erythema or discharge present
Ears: TMs reddened bilaterally; landmarks not distinct; hearing equal to examiner’s
Nose: Midline septum; mucous membrane reddened; yellow pustular discharge present
Mouth and throat: Prominent anterior overbite; no cavities; geographic tongue; yellow
drainage present on posterior throat; posterior palate slightly erythematous
Neck: Supple, no pain on forward flexion; midline trachea; no nodes palpable in thyroid;
three palpable lymph nodes on left; two on right in posterior cervical chains
Lungs: Scattered rhonchi in all lobes; decreased breath sounds in right lower lobes; moist
crackling in both lower lobes
Heart: Rate: 80 beats/min; third heart sound audible; marked sinus arrhythmia
Abdomen: Liver palpable 2 cm below right costal margin; no masses; bowel sounds at 2
to 3 per minute in all quadrants
Genitalia: Adolescent male; Tanner 5; testes descended; midline meatus
Extremities: Full ROM; poor muscle tone in upper extremities
Neurologic: Patellar and brachial reflexes 2+; sensory and motor nerves grossly intact

Billy is diagnosed as having pneumonia. He is hospitalized for intravenous antibiotic

therapy.