NURSING INTERVENTIONS

For Nursing Students and Nurses caring for the patient with Cystic Fibrosis...


Diagnoses:

1. Ineffective airway clearance, related to accumulation of mucus.
2. Imbalanced nutrition, less than body requirements, related to malabsorption from ineffective production of pancreatic enzymes
3. Deficient knowledge, related to the diagnosis and condition of child.
4. Risk of infection, related to bacterial invasion of respiratory system.
5. Ineffective coping related to new diagnosis and management of disease.


More specific diagnosis with what you can do as a nurse to help!

Diagnosis:  
                    Ineffective airway clearance, related to accumulation of mucus.

PLAN/ OUTCOME

NURSING INTERVENTION

-absence of dyspnea and tachypnea (breathing improved to normal range based on age) -can effectively remove mucus from lungs through coughing -improved heart rate for age -maintain oxygen saturation above 93%

ASSESSMENTS: -lung sounds -breathing rate and rhythm -heart rate -oxygen saturation THERAPY/TREATMENT: -assist with chest physiotherapy ·      Chest percussion and drainage ·      Apply external percussion vest ·      Use of airway oscillating device -administer medications per orders ·      Bronchodilators ·      Nebulizers ·      Antibiotics ·      Anti-inflammatories -provide oxygen as needed based on saturations EDUCATION: -breathing exercises -medications MONITOR AND REASSESS: -effectiveness of treatment

References:

Price, D., & Gwin, J. (2008). Respiratory Disorders. In Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F A Davis Company.

http://www.elsevieradvantage.com/samplechapters/9781437717099/9781437717099.pdf