Radiology Reports Chest X-RAY AP and lateral

History of Present Problem: Justin Ewing is a seven-year-old boy with a history of cystic fibrosis (CF) who for the past two days has had a fever of 102.1 F (38.9 C) and has felt more tired. His cough has become more frequent, and he is bringing up thick yellow mucus. His mother brought Justin to his CF clinic where he is diagnosed with a right lower lobe pneumonia. Justin is admitted to the pediatric unit for IV antibiotics, and you will be the nurse responsible for his care. Justin has an implanted port for vascular access since he frequently needs IV antibiotics for respiratory infections. Justin is below the 5th percentile for his weight at 41 pounds (18.6 kg) and is at the 5th percentile for height at 44.5 inches (113 cm). He has a G-tube in place for night feedings. Personal/Social History: Justin is in the second grade and lives at home with both parents and his 5-year-old brother who is in good health. His mother is a stay-at-home mom, and his father works as a computer software engineer. The family has health insurance through the father’s employer. He receives Medicaid because of his chronic illness. He has missed many days attending school due to CF but has a tutor provided by the school district. He told his parents that sometimes the kids at school tease because he is so small. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: 1. Fever of 102.1 and feeling tired 2. Coughing up thick yellow mucus 3. Below 5th percentile for weight and at 5th percentile for height 4. G-tube in place for night feedings 1. A fever indicates a potential infection. 2. Coughing up thick yellow mucus indicates exacerbation of CF and the presence of an infection. 3. Below average weight can indicate potential nutritional imbalances and will affect the amount of medication given, especially for a pediatric patient. 4. Having a G-tube will hopefully help address potential nutritional concerns the nurse may have for the patient. RELEVANT Data from Social History: Clinical Significance: 1. His mother is a stay at home mom and his dad is a computer software engineer. 1. It sounds like Justin has a good support system from his family. Being a stay at home mom should allow his mother to spend additional time with Justin when needed. The family’s and Justin’s health insurance should also relieve some of the burden of dealing with CF. It will be important to make sure Justin continues to have a strong support system at home since he occasionally has difficulty from being teased at school. © 2018 Keith Rischer/www.KeithRN.com Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 102.6 F/39.2 C (oral) Provoking/Palliative: Justin states he does not have any pain when assessed using the Wong-Baker FACES Pain Rating Scale P: 116 (reg) Quality: R: 26 (reg) Region/Radiation: BP: 92/60 (normal for age) Severity: O2 sat: 89% room air Timing: What VS data are RELEVANT and must be