Question

An overall healthy, 10-year-old child with Cystic fibrosis

Respiratory-Wheezing heard throughout, productive cough.

Gastrointestinal: Hyperactive bowel sounds, loose frothy stools (multiple per day)

Measurements, wt 32 (kg) 70. 4(lb)

Self-concept: Appropriate for development Level school-age child.

Activity/ Exercise: School physical education and softball 3-4 times a week.

Sleep/rest: 9 hours / night.

Nutrition: Diet as tolerated.

Live with parents

Recommendations: Educate on physical, diet, exercise, medications, respiratory therapy.

Four separate Nursing Diagnosis for 10 years ago with cystic fibrosis based on Nanda nursing diagnosis (In priority order subjective/Objective)

Patients Centered goals (Short term goal/ Long term goal.)

Nursing interventions/ Rationales

Evaluation (Mets OR not Mets with reasons)

Answer 1

Cystic fibrosis is an inherited condition which causes sticky mucus to build up in the lungs and digestive system.

1.Objective data : wheezing heard throughout.

Subjective data : complains of productive cough.

The patient will maintain optimal gas exchange evidences by arterial blood gas within normal range and oxygen saturation above 90%.

1. Impaired gas exchange related to airway inflammation.

- Monitor respiratory rate.

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

- Monitor arterial blood gas and oxygen saturation.

- Provide adequate rest . ( activity increases oxygen needs )

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

- Administer oxygen therapy. ( decreases the work of breathing )

2. Objective data : decline in pulmonary function testing.

Subjective data : ineffective cough

The patient will maintain clear open airway as evidence by airway free of secretions with an effective cough.

2. Ineffective airway clearance related to increased mucopurulent production.

- Assess the cough for adequate airway clearance. ( important for adequate airway clearance ) .

- Assess sputum colour , amount and consistency. ( thinner sputum indicates 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. ( mucolytics decrease viscosity of sputum )

- Encourage frequent and effective cough( to clear airway mucus.)

3. Objective data : hyperactive bowel sounds .

Subjective data : complains of loose frothy stools.

The child will be free of signs and symptoms of malabsorption.

3. Imbalanced nutrition less than body requirements related to abnormal stool patterns.

- Assess the bowel sounds  

- Monitor stool patterns.

- Assess skin colour , integrity and turgor. ( malnutrition results an alteration in skin integrity)

- Monitor weight and serum chemistry.

- Encourage fluid and high fiber diet.

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

4. Objective data : wheezing

Subjective data : increased cough and sputum.

The child will experience improvement in infection as evidence by decreased cough

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.

- Educate about medications.