Jack Hammond, 10 -year old boy who was admitted last night for cystic
fibrosis exacerbation and possible pneumonia. He has an IV of D5 NS infusing
to his right arm at 75 mL/hour. Oxygen per nasal cannula is in place at
...
Jack Hammond, 10 -year old boy who was admitted last night for cystic
fibrosis exacerbation and possible pneumonia. He has an IV of D5 NS infusing
to his right arm at 75 mL/hour. Oxygen per nasal cannula is in place at 3
L/min, chest x-ray results and sputum culture are pending. He is alert and
oriented, both parents are currently at the bedside. He does complain of
intercostal pain, especially with coughing. Current oxygen saturation is 94%
You responded correctly to 5 out of 6 evaluations:
Category
Your
response Explanation
Health Increased
acuity
Exacerbation of cystic fibrosis and possible
pneumonia
LOC Normal
acuity
The child is reported as alert and oriented
Pain level Increased
acuity
The child reports pain with coughing
Psychological Normal There is no mention of increased psychological
Needs acuity needs
Safety Normal
acuity
There is no mention of safety concerns in the report
Educational Increased
acuity
The child is admitted for an exacerbation of his
cystic fibrosis, education is needed to help manage
this chronic
Physiological
Description
Your
Respons
e Explanation
Activity
intolerance
TRUE The child has an exacerbation of
cystic fibrosis and requires
supplemental oxygen
Disturbed sensory
perception
False Cystic fibrosis does not adversely
affect sensory perceptionImbalanced TRUE With cystic fibrosis, the bodyDescription
Your
Respons
e Explanation
nutrition, less than
body requirements
does not produce pancreatic
enzymes leading to nutritional
deficits
Impaired gas
exchange
TRUE Damage from cystic fibrosis and
possible pneumonia will decrease
the body’s ability for gas
exchange
Impaired skin
integrity
False Cyst
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