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
Nursing Diagnosis / Risk Factors / Outcomes / Nursing InterventionsRisk for infection / Depressed immune system
Immunosuppression medications
Potential for high risk behavior(s)
Potential for exposure to pathogens (animals)
Frequent use of tanning bed / Verbalize signs and symptoms of infection
Will understand importance of prophylactic medication complicance
Patient will demonstrate appropriate hand washing techniques
Patient and family will verbalize appropriate oral care
Patient and family will verbalize high risk behaviors / Teach signs and symptoms of infection (ie. warmth, erythema, fever, discharge)
Review dosage and administration of prophylactic medications
Instruct and educate on avoidance of high risk behaviors (tatoos, piercings, sexual activities, tanning)
Encourage frequent and appropriate handwashing and instruct on appropriate daily hygiene (oral care and bathing) and use of sunscreen
Avoid large crowds and ill contacts
Avoid high risk animals/excrement/hay
Review immunization schedule for patient and sibling
Altered nutrition: less than body requirements / Inadequate food intake
Unwillingness to eat
Lack of information or misconception / Pt and family understand nutritional requirements
Consume adequate nutrition
Maintain appropriate weight for height (BMI)
Patient participates in family meals
Patient verbalizes appropriate food choices / Refer to dietitian for nutritional assessment and education
Monitor weight weekly and instruct on appropriate technique (same scale, same time)
Review need for increased fluid intake with activity
Encourage appropriate nutritional intake
Encourage appropriate clear liquid intake
Encourage frequent small meals
Body image disturbance / Change in social behavior
Change in lifestyle
Fear of reaction of peers
Negative feelings about appearance
Feeling of powerlessness / Verbalizes ability to adjust to changes in body due to developmental stage
Will make positive body image statements
Will voice concerns with peer reactions
Identifies factors that are
uncontrollable
Participates in plan of care
Makes decisions regarding care and treatment when possible / Acknowlege patient’s feelings to changes in body and life-style
Observe coping mechanisms during times of stress
Review with family alternative coping techniques
Identify and explore patient’s strengths
Allow patient to participate in plan of care
Assess family level of acceptance of patient’s body changes
Encourage family to provide positive feedback related to body image
Encourage appropriate peer interaction
Noncompliance with prescribed regimen / Lack of knowledge of need for ongoing medication
Health beliefs
Feelings of powerlessness / Will verbalize understanding of need for long term treatment and medications
Describes consequence of non-compliance
Family and patient actively involved in treatment plan
States appropriate health goals / Discuss implications related to non-compliance
Review medication regimen with patient and family
Work with client to develop tool for tracking medication administration
Identify and discuss concerns that patient has with regimen or side effects of medication
Monitor patient’s ability to follow directions and problem solve
Encourage family to allow patient to actively participate in plan of care
Involve family in providing positive feedback to patient