| THE DIGESTIVE SYSTEM |
| Overview: This case requires knowledge of infant feeding, association between preterm birth and gastroesophageal reflux as well as an understanding of the client’s background, personal situation, and mother-child attachment relationship. |
Client Profile
Beth is a 4 month old infant who was delivered by Cesarean section at 35 weeks’ gestation, weighing 2.3 kg (5 lb) and measuring 42.5 cm (17 in.) in length. She is the first child for Robert and Janice Carter. Since birth Beth has been a “fussy” baby who frequently “throws up after almost every feeding and cries all the time”. Janice stays home and cares for Beth while Robert works; however, when he comes home from work each day, he helps with Beth’s care. Beth is clean and obviously well cared for by her parents, who appear to have bonded well with her and love her very much. During her recent 4 month check-up Beth was diagnosed with gastroesophageal reflux (GER) following a battery of diagnostic tests in response to Beth’s history of frequent regurgitation following feedings. Janice’s parents live in the same town as Janice and Robert and his parents live a 30 minute driving distance away.
Case Study
Janice and Robert bring Beth in for a 2 week weight check at the pediatrician’s office. During the nurse’s family assessment, Janice and Robert appear exhausted and anxious. Janice comments, “I feel like it’s my fault that Beth is not gaining weight as she should. I get so frustrated because she is still throwing up after at least two breastfeedings a day. I try but I don’t think I’m a very good mother. Maybe I should give up breastfeeding and give her a bottle”. Robert further states that his family has a history of gastric ulcer disease and asked if he “gave this stomach problem to her”. The couple comment that they are not sure they are doing the right things for Beth and question how they are going to manage caring for her. At this visit Beth weighs 3.4 kg (7.5 lb), her posterior fontanel is closed, and her posterior fontanel is closed, and her anterior fontanel remains opened and level with suture lines.
Questions
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- Discuss your impressions about the above situation.
- Identify at least 4 nursing diagnoses for Beth and her parents.
- Discuss the relationship between Beth being preterm, her birth weight, and her current weight.
- How would you respond to Janice’s concern about breastfeeding and Beth’s GER?
- During the nurse’s assessment of Beth’s growth and development, she finds that Beth can put her hand to her mouth, lift her head up from a prone position, turn and look for sounds, focus on the face of the person speaking to her, and that the head lag is present when she is pulled to sitting position. Beth’s rooting reflex is not present, nor is the moro reflex and tonic neck. Her sucking reflex is still present as well as her step, Babinski, ciliary, and grasp reflexes. How would you interpret these findings?
- How would you respond to Janice and Robert’s concerns about how Beth developed GER and their feelings of blame?
- Discuss the teaching plan for Beth and her parents.
- What suggestions could you offer Janice and Robert to provide them with support as they care for Beth at home?
| THE ENDOCRINE SYSTEM |
| Overview: This case requires knowledge of diabetes mellitus, nutritional needs of adolescence, as well as an understanding of the client’s background, personal situation, and family relationship. |
Client Profile
Jessica is a 13 year old high school student who lives with her parents and younger brother Jonathan (11 years old) in a middle-class neighborhood. Both Mr. and Mrs. Morris work in the community where they live. Jessica has had diabetes mellitus type 1( insulin-dependent diabetes mellitus [IDDM]) since the age of 7, which has been well controlled with morning and evening injections of NPH Humulin insulin, diet, and exercise. Jessica has been staying up later in the evenings studying for her end-of-year (EOY) exams, and is also the pitcher on her school’s softball team, which is playing in the semifinals. Her heavy schedule has contributed to changes in her eating and sleeping habits.
Case Study
Jessica developed a cough, nasal congestion, and a low-grade temperature 3 days ago, but told her parents she felt well enough to go to school and didn’t want to miss any of her classes or softball practice. Today Jessica felt worse, so her mother called Jessica’s pediatrician, Dr. Sheila Jones, who told Mrs. Morris to bring Jessica into her office. Dr. Jones recommended that Mrs. Morris take Jessica to the emergency department of the hospital, at which point she noted that Jessica’s pulse and respirations were elevated, her breath had a fruity odor, and her capillary blood sugar level was elevated. At the emergency department, Jessica’s diagnostic test findings are as follows:
Chemistry profile: glucose, 480 mg/dL; sodium, 130 mEq/L; chloride, 79 mEq/L; and
potassium, 3.3 mEq/L
Arterial blood gases: pH, 7. 19; PaCO2, 25 mm Hg; HCO3, 10 mEq/L; PaO2, 92 mm Hg; oxygen
saturation, 97%
Questions
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- Explain all the abnormal lab values.
- What factors place Jessica at risk for diabetic ketoacidosis (DKA)
- What other data would be helpful to determine whether she has developed other complications of either her DKA or her flu-like symptoms/
- Identify at least 4 nursing diagnoses that would apply to Jessica’s case.
- After Jessica has received 2 L of intravenous fluids and her blood glucose level decreases 240 mg/dL, the health care provider prescribes adding 5% dextrose to her intravenous solution. Should you question this prescription? Why or why not?
- What nursing interventions should be utilized to facilitate Jessica’s recovery?
- Discuss the potential complications for Jessica if she is not compliant with her medical regimen when she goes home.
- What are the teaching priorities for Jessica and her parents prior to discharge?
