A.B. Is an 11 Year Old Asian Female. She Was a Full Term Infant Born Via Vaginal Delivery

Case Study

A.B. is an 11 year old Asian female. She was a full term infant born via vaginal delivery. Her past history is significant for Biliary Atresia. She had a Kasai procedure at 2 months of age in attempt to treat her condition. There is no significant family history. She has a healthy 6 year old sister.

She received an orthotopic liver transplant at age 9, secondary to end stage liver disease. Over the course of the year and a half prior to transplant, she had elevated liver enzymes (AST, ALT, GGT, Bilirubin (unconjugated and conjugated), elevated PT, PTT and INR, unstable electrolytes (increased potassium and decreased magnesium), jaundice, pruritus, ascites, failure to thrive, hepatosplenomegaly. She was evaluated for end stage liver disease secondary to extrahepatic Biliary Atresia. She received a percutaneous needle liver biopsy and abdominal ultrasound with Doppler which demonstrated worsening liver function. She underwent a full transplant evaluation and the decision was made to proceed with listing for liver transplantation. Prior to transplant, a G-Button was placed to facilitate the administration of bolus feeds to optimize nutritional status.

Today she is a well developed, active 11 year old. The father’s concerns include apparent weight loss (patient has lost three pounds since previous visit), possible non-compliance with her medication regimen and concerns that she is spending time with a “bad crowd”, requesting a navel piercing and constant requests to “go tanning”. She is reportedly a picky eater and often skips breakfast. She eats lunch at school and reports that this usually consists of soda, and pizza or chicken nuggets. Her dad reports that she eats a lot of “junk food” and does not drink much water or other clear liquids. Father complains that although she is doing well in school and is active in other activities, including cheerleading and FFA (Future Farmers of America) where she is raising a calf, she does not want to eat dinner with her family or participate in family activities. Her current prescribed medication regimen includes Prograf and Magnesium. She admits to “sometimes” forgetting her medicines which lead to fights with parents. There are currently no complaints of jaundice, pruritus, fever, cough, congestion, bleeding, bruising, nausea, vomiting, diarrhea, constipation, tremors, or pain.

Child, s/p solid organ transplant

Nursing Diagnosis: Nutrition, altered, less than body requirements

Nursing Diagnosis: Body image disturbance, risk for

Nursing Diagnosis: Self esteem disturbance, risk for

Plan: Assess current growth and develop

Review diet history for past three days

Determine patient/family knowledge of pre-teen nutritional needs

Evaluate current view of self (patient)

Implementation: Discuss current height/weight expected for age with pt/family

Refer to transplant dietitian to review current dietary intake and educate patient/family on appropriate food choices and caloric intake

Provide patient/family with dietary intake and weight tracking tool

Set weight and intake goals

Consult Child Life Specialist (or other appropriate team member) to offer tools to increase self esteem for patient and family

Offer information about patient and family support groups

Encourage patient to attend transplant camp or other activities to interact with transplant patients

Evaluation: Review diet tracking tool with patient and family in one week

Monitor weight monthly and discuss results with family Feedback from parents and patient

Achievement of goals

Attendance at support group or other activities

Nursing Diagnosis: Non-compliance, risk for

Nursing Diagnosis: Health maintenance, altered

Nursing Diagnosis: Knowledge deficit, medical regimen

Nursing Diagnosis: Caregiver role strain, high risk for

Nursing Diagnosis: Family processes, altered

Plan: Assess patient knowledge of current medical regimen

Evaluate patient and family understanding of risks associated with non-compliance with medical regimen

Assess coping skills of patient and family

Implementation: Provide medication tracking tool/calendar

Patient to verbalizes plan to “remember” medications

Discuss signs and symptoms of rejection

Discuss appropriate family activities

Refer parents to support group

Refer patient and family to transplant social worker for psychosocial evaluation and support

Offer communication tools to family

Discuss consequences of inappropriate behavior

Evaluation: Patient and family feedback

Review tracking tool for medication compliance

Attendance at support groups

Patient verbalizes risks of non-compliance

Feedback from social worker

Nursing Diagnosis: Infection, high risk for

Nursing Diagnosis: Knowledge deficit, therapeutic regimen

Plan: Identify high risk behaviors in the immunosuppressed patient

Discuss signs and symptoms of infection

Implementation: Discuss high risk behaviors (piercings, tattoos, fungal spores associated with hay, contact with animal feces) with patient and family

Review signs/symptoms of infection

Offer alternative activities

Encourage hand washing and other infection preventative measures

Review increased risk of cancer in post transplant patient

Encourage use of sunscreen, hats, and sunglasses

Evaluation: Feedback from patient/family

Verbalize signs/symptoms of infection

Avoidance of high risk activities

Evaluate patient’s utilization of sunscreen

Additional information

Nursing Diagnosis