Question

Present Illness - cystic fibrosis/acute pulmonary exacerbation. Positive for Burkholderia cepaci

Patient profile - 15 year old child with cystic fibrosis. Biological parents divorced. Mother remarried. Custody with mother and stepfather. Only child.

Past medical history- 40 week normal spontaneous vaginal delivery; failure to thrive. Diagnosis of cystic fibrosis at 2 years of age. PEG tube placement for feedings this year due to inadequate weight maintenance. Multiple hospitalizations.

2 Separate Care Plan related to the patient above

CARE PLAN - Nursing Diagnosis (in priority order, related to, evidence by), Subjective, Objective

Patient-centered-goals - ( short term goal and long term goal)

Nursing Interventions & Rationale

Evaluation - (met or not met with reasons)

Answer 1

¤Assessment

Subjective data: cystic fibrosis

Objective data:pulmonary exacerbation

Nursing diagnosis

Ineffective breathing pattern related to thick mucus,decreased lung function as evidenced by pulmonary exacerbation, positive Burkholderia cepaci

Goal:

Short term goal:To relieve shortness of breath

Long term goal: To prevent bacterial infection and complications during to the current infection

Nursing interventions and rationale

• Administer combination antibiotic therapy to control infection
• Administer oxygen to relieve shortness of breath
• Administer corticosteroid to reduce any inflammation and ease breathing difficulty

Evaluation

The patient will be able to breath easily

¤Assessment

Subjective data:

Inadequate weight maintainance

Objective data:

PEG feeding

Goal :

Short term goal

To initiate feeding and prevent malnutrition or nutritional deficiency

Long term goal

To maintain normal weight to age

Nursing intervention and rationale

• Administer feed every second hourly or as per advice to maintain nutritional status
• Make diet plan ,to feed the patient with right calorie and nutrients
• Monitor weight of the patient ,to know the progress

Evaluation

The patient weight has increased gradually