Situation Patient’s name, age, specific reason for visit Christopher Parrish is an 18-year-old male who was admitted at 1900 today. His mother visited him at his college dormitory and was very concerned with his health; he seemed weak and had lost weight since she last saw him. She took him to see his primary care provider, and the provider admitted him and has ordered a tube feeding. I placed an 8-Fr, 42-inch feeding tube in his right nares about an hour ago, and x-ray just called and confirmed placement in the stomach. The pump is in his room. He is up to the bathroom prn; otherwise bed rest.
Background Patient’s primary diagnosis, date of admission, current orders of patient
Christopher was diagnosed with cystic fibrosis as a child and has had frequent hospitalizations previously. He reports fatigue and has recently lost 6 kg (13 lb) after he registered at the local college and moved to live in a dormitory. January 30, 2021 admission date. Orders of patient are to start on pump 720 kilocalories over 8 hours overnight , administer pancreatic enzyme orally before tube feeding, asses his diet and reinforce patient education on nutrition. Three capsules orally with snack, multivitamin 2 tablets orally every morning. Monitor vitals every 4 hours, provide weight and intake and
output. Flush and aspirate ng tube.
Assessment Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs
Christopher is awake and alert. His heart rate and rhythm are regular at 83/min. Breath sounds are fine with a respiratory rate at 12/min. His color is a bit pale. Blood pressure is 120/72 mm Hg. Temperature is 99 F. He reports no pain and states he's not had much appetite the past few weeks. His belly is flat and nontender. Bowel sounds are normoactive 96.
Recommendation Any orders or recommendations you may have for this patient
I would educate the patient better about diet, bmi, intake and output, diagnostics and also how to take care of himself better with his condition CF. And make him feel comfortable with asking questions to clear his doubts.
Patient Education Worksheet
Name of medication, classification
Medication: Pancrelipase Enzyme
Patient education while taking this medication Pancrelipase Enzyme - Pancrelipase acts in place of the enzymes normally made by the pancreas. It works to decrease fatty bowel movements and to improve nutrition by breaking down fats, proteins, and starches from food into smaller substances that can be absorbed from the intestine.
Multivitamins - Multivitamins are used to provide vitamins that are not taken in through the diet. Multivitamins are also used to treat vitamin deficiencies caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions.
Fluid nutrition- Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth.
Concept Map Worksheet
Describe disease process affecting patient (include pathophysiology of disease process)
Christopher parrish has Cystic Fibrosis. Cystic fibrosis is caused by defects in the cystic fibrosis gene, which codes for a protein transmembrane conductance regulator ( CFTR ) that functions as a chloride channel and is regulated by cyclic adenosine monophosphate (cAMP). Mutations in the CFTR gene result in abnormalities of cAMP-regulated chloride transport across epithelial cells on mucosal surfaces. Most patients with cystic fibrosis have severe chronic lung disease and exocrine pancreatic insufficiency.
Diagnostic test (reason for test and results) Blood analysis: Hb - HCT- Platelets- WBC-7.
Electrolytes: K+ - Na+ - Creatinine- 0. Cl- - 102 Urea nitrogen ( BUN) – 8
Hepatic Function: Albumin – 3 Prealbumin- 20 Protein – 5.
Miscellaneous: Glucose- 80 VITAMIN D- 10
Christopher Parrish 18 years old, white male has cystic fibrosis reports fatigue and weight loss. Lost 13 lbs.
Anticipated physical findings - Fatigue
