Question

Nursing Concerns: __List ALL NURSING CONCERNS/INTERVENTIONS THAT WILL BE FOR PATIENT WITH CYSTIC FIBROSIS.

List in numerical order

Answer 1

1. Impaired gas exchange

- Monitor respiratory rate.

- Assess for any respiratory changes like cyanosis , laboured breathing and tachypnea.

- Monitor arterial blood gas and oxygen saturation.

- Provide adequate rest .

- Semi -fowler's position increases lung expansion and reduces airway collapse.

- Administer oxygen therapy.

2. Ineffective airway clearance

- Assess the cough for adequate airway clearance.

- Assess sputum colour , amount and consistency to find any improvement in exacerbation.

- Monitor oxygen saturation.

- Do pulmonary function test.

- Encourage exercise and physical therapy to loosen the mucus and facilitating effective coughing.

- Administer mucolytics , bronchodilators and pain medication.

- Encourage frequent and effective cough to clear airway mucus.

3. Imbalanced nutrition less than body requirements.

- Monitor stool patterns.

- Assess skin colour , integrity and turgor.

- Monitor weight and serum chemistry.

- Encourage fluid and high fiber diet.

- Encourage high protein , high calorie diet and all fat soluble vitamins.

4. Infection related to invading viral organism .

- Assess for general signs and symptoms of infection.

- Do culture and sensitivity of sputum.

- Monitor white blood cell count .

- Administer antipyretics and antibiotics as per order.

5. Deficient knowledge .

- Assess the client's baseline knowledge of the disease.

- Assess the knowledge of nutritional needs .

- Assess the knowledge of infection control.

- Assess the knowledge of airway clearance therapies and medications.