CYSTIC FIBROSIS NURSING CARE PLAN (ADULT)

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION

 Very salty-tasting skin.  Impaired Gas Client will maintain  Monitor Goals are met
 Persistent coughing, at Exchange optimal gas exchange as respiratory and
times with phlegm. evidenced by oxygen heart rate for any
 Frequent lung May be related to saturation of 90% or changes.
infections including  Airway obstruction greater, arterial blood  Assess for changes
pneumonia or by nasal gasses (ABGs) within the in respiratory
bronchitis. obstruction. client’s usual range, status such as
 Wheezing or shortness  Airway and Alveoli relaxed breathing, baseline cyanosis, pallor,
of breath. inflammation. heart rate, alert response changes in the
 Poor growth or weight  Bronchiectasis mentation and no further level of
gain in spite of a good with decreased deterioration in the level consciousness,
appetite. surface area for of consciousness. labored breathing
 Frequent greasy, bulky gas exchange and and tachypnea.
stools or difficulty with loss of lung  Monitor
bowel movements. function. transcutaneous
 Male infertility  Infection with lung carbon dioxide as
consolidation, ordered.
alveolar collapse.  Monitor arterial
Possibly evidenced by blood gasses and
 Activity oxygen saturation
intolerance as indicated
 Cough  Provide for
 Dyspnea adequate rest
 Hypercapnia between activities
 Hypoxemia during the day,
 Irritability with a minimal
 Pale, cyanotic skin nighttime
color interruption in
 Restlessness sleep.
 Tachypnea  Place the client in
 Tachycardia a semi-Fowler’s
 position.
 Administer oxygen
therapy as
indicated. (Avoid
giving high oxygen
concentration in
clients with
chronic carbon
dioxide retention).
 Maintaining an
oxygen saturation
greater than 90%
is the goal.

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION

 Very salty-tasting  Ineffective Airway  Client will be  Assess cough for Goals are met
skin. Clearance proficient in using effectiveness
 Persistent coughing, effective airway  Assess respiratory rate,
at times with May be related to clearance work of breathing, use
phlegm.  Increased therapies to clear of accessory muscles,
 Frequent lung mucopurulent secretions on a and the presence of
infections including production and daily basis, as retractions.
pneumonia or mucous plugging evidenced by  Assess the chest wall for
bronchitis. in response to decreased work even chest expansion.
 Wheezing or new or increased of breathing and  Auscultate lung for
shortness of breath. airway bacterial improved adventitious sounds,
 Poor growth or growth. pulmonary and the degree of
weight gain in spite Possibly evidenced by function. aeration.
of a good appetite.  Abnormal chest x-  Client will  Assess sputum for color,
 Frequent greasy, ray film maintain clear, amount, and
 bulky stools or  A decline in open airway as consistency.
difficulty with bowel pulmonary evidenced by  Monitor oxygen
movements. function testing normal breath saturation.
 Male infertility (spirometry) sounds, normal  Monitor pulmonary
 An ineffective rate and depth of function testing.
cough respirations, and  Assess the client’s
 Chest pain an airway free of comfort level with and
 Crackles, rhonchi secretions, with adherence to
 Dyspnea an effective recommended airway
 Fatigue cough. clearance therapy (ACT).
 Labored breathing  Assess for barriers to
 Reduced breath ongoing airway
sounds clearance.
 Provide the opportunity
for exercise and physical
therapy.
 Encourage a frequent
and effective cough-
particularly
around airway clearance
therapy (ACT).
 Administer
bronchodilators before
ACT as ordered.
 Administer mucolytics as
ordered in concert with
ACT
 Administer
pain medication as
needed.
 Collaborate with the
client and staff to ensure
that the schedule for
therapy is amenable to
 all and does not
interfere with meals,
rest times, or
medications.

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION

 Very salty-tasting  Imbalanced Nutrition: Less  Client will  Assess the abdomen Goals are met
skin. Than Body Requirements maintain for bloating, fullness,
 Persistent adequate bowel sounds, or
coughing, at times May be related to nutritional status palpable stool mass.
with phlegm.  Chronic malabsorption or demonstrate Monitor stool patterns
 Frequent lung  Increased caloric needs weight gain on a for frequency, odor,
infections including  Poor nutritional status trajectory to consistency, and the
pneumonia or resulting from anorexia adequate presence of oil or
bronchitis. Possibly evidenced by nutritional status. grease.
 Wheezing or  Abnormal eating  Client will be free  Assess the skin’s color,
shortness of behaviors of integrity, and turgor
breath.  Abnormal stool patterns signs/symptoms  Monitor for an
 Poor growth or (diarrhea or of malabsorption. increase in weight and
weight gain in spite constipation) appetite.
of a good appetite.  Anemia  Monitor for excessive
 Frequent greasy,  Chronic abdominal thirst, urination, and
bulky stools or discomfort hunger. Obtain
difficulty with  Gastroesophageal reflux bedside
bowel movements.  Hypoalbuminemia blood glucose readings
 Male infertility  Low fat-soluble vitamin as ordered.
levels  Monitor serum
 Muscle wasting chemistry as ordered.
 Weight loss, weight  Encourage liberal
plateau hydration and high
 10% to 20% below ideal fiber intake.
weight  Encourage the liberal
use of salt or salty
food intake
 Encourage a high
protein, high-calorie
diet
 Administer all fat-
soluble vitamins with
meals and enzymes.
  Administer pancreatic
enzymes before all
meals and snack
containing fat or
protein as ordered.
 Collaborate with a
registered dietician in
obtaining a full
nutritional evaluation.

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION

 Very salty-  Deficient Knowledge  Client and family  Assess the client’s Goals are met
tasting skin. will verbalize baseline knowledge of
 Persistent May be related to understanding of the disease
coughing, at  First disease process, pathophysiology.
times with exacerbation/hospitalization treatment  Assess the client’s
phlegm. experience. recommendations, knowledge of
 Frequent lung  Ineffective or incomplete and goals of nutritional needs.
infections education in past. therapy.  Assess the client’s
including  Rapidly expanding clinical knowledge of infection
pneumonia or knowledge base with new control
bronchitis. interventions available. recommendations for
 Wheezing or Possibly evidenced by individuals with cystic
shortness of  Anxiety related to fibrosis.
breath. hospitalization  Assess the client’s
 Poor growth or  Frequent exacerbation knowledge of the
weight gain in  Inability to verbalize genetics of cystic
spite of a good treatment regimen or fibrosis.
appetite. rationale  Assess the client’s
 Frequent greasy,  Nonadherence to therapy knowledge of
bulky stools or  Uncertainty or questions medications, airway
difficulty with  Verbalized misconceptions clearance therapies,
bowel and equipment.
movements.  Assess the client’s
 Male infertility knowledge of
diagnostic testing,
including laboratory
evaluations,
pulmonary function
testing, airway
cultures, and
pathogens.
 Provide basic
information on CF
pathophysiology and
 treatment goals using
reliable resources.
 Provide information
about support groups.
 Review pulmonary
function testing and
individual trends.
 Review ACT and
breathing techniques
to dislodge mucus.
 Review infection
control
recommendations
 Review pulmonary
medications and
nutritional/digestive
medications and their
rationales.

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION

 Very salty-  Infection  Client will  Assess for the general Goals are met
tasting skin. experience signs and symptoms of
 Persistent May be related to improvement in infection such as
coughing, at  Growth plume of known infection and fever, cough, malaise,
times with colonized CF airway suppression of increased sputum,
phlegm. pathogens bacterial growth, weight loss,
 Frequent lung  Invading viral organism as evidenced by a tachypnea, and
infections  New acquisition of common decrease in a tachycardia.
including cystic fibrosis airway cough, mucus  Obtain a sputum
pneumonia or pathogens production to specimen for culture
bronchitis. Possibly evidenced by baseline, and sensitivity as
 Wheezing or  Decline in pulmonary normothermia, ordered.
shortness of function testing and normal white  Monitor oxygen
breath. (spirometry) blood cell count. saturation
 Poor growth or  Dyspnea/wheezing  Monitor the client’s
weight gain in  Elevated white blood cell immunoglobulin E
spite of a good count (IgE) as ordered.
appetite.  Fever  Monitor pending
 Frequent greasy,  Increased sputum culture and sensitivity
bulky stools or  Increased or a new cough results for drug
difficulty with  Malaise resistance.
bowel  Pathogenic microbes on  Monitor viral studies
movements. airway culture as ordered
 Male infertility  Monitor white blood
cell count as ordered
 Monitor the client’s
antibiotic levels as
ordered.
 Ensure that clients
with CF are not
cohorted.
 Administer
antipyretics as
ordered, avoiding
 nonsteroidal anti-
inflammatory drugs
(NSAIDs) in clients
receiving
IV aminoglycosides.
 Administer IV
antibiotics as ordered
in a timely manner.
 Consider an audiology
evaluation in clients
who have a history of
frequent IV
aminoglycoside use.
 Institute the
appropriate infection
control precautions.

CYSTIC FIBROSIS NURSING CARE PLAN (PEDIATRIC)

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION
 Meconium ileus as Ineffective airway clearance  Child will  Auscultate breath Goals are met
newborn related to thick tenacious mucous maintain a patent sounds every 2-4
Abdominal airway hours
distention vomiting,  Assist child to cough
failure to pass and expectorate
stoo,ls and mucous
development of  Monitor respiratory
dehydration pattern – rate and
 Gastrointestinal effort
Large, bulky, loose,  Provide nebulization
frothy stools  Suction PRN
(steatorrhea),  Perform chest
increased appetite physiotherapy
early in disease with  Teach child and family
loss of appetite to use bronchodilator
later, weight loss, medications
tissue wasting,  Teach child and family
failure to grow, to administer
sallow skin, mucolytic medications
deficiency of fat  Teach child and family
soluble vitamins to assess airway
 Respiratory status using peak flow
Initial meter
Wheezy
respirations Dry,
non-productive
chronic cough
Later
Increased dyspnea,
productive cough,
areas of atelectasis,
scarring of lung
tissue, overinflated
barrel like chest,
 cyanosis, clubbing
of fingers and toes,
repeated episodes
of bronchitis and
bronchopneumonia
, rhinitis, chronic
sinusitis
 Endocrine
Elevated serum
glucose levels,
development of
cystic-fibrosis
related diabetes

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION

 Immature Imbalanced Nutrition: Less than  Child will exhibit  Administer pancreatic Goals are met
developmental body requirements related to signs of adequate enzymes with meals
level for age inability to digest nutrients and digestion and and snacks
 Weight loss with loss of appetite appropriate  Teach child and family
adequate food height and weight appropriate
intake for age pancreatic enzyme
 Steatorrhea administration
 Abdominal a. Take with meals or
 Cramping snacks
 Hyperactive Bowel b. Capsules can be
Sounds swallowed whole or
opened and sprinkled
on food, but not
crushed or chewed.
 Encourage high
protein diet
 Observe frequency
and nature of stools
 Monitor child’s
physical development

ASSESSEMENT NURSING DIAGNOSES PLANNING INTERVENTION EVALUATION

 Child does not Knowledge deficit related to child  Will be able to  Begin discharge Goals are met
take medications and family unfamiliarity with verbalize planning as soon as
as ordered chronic disease management understanding of possible
 Child and family disease process  Assess for needed
do not adhere to  Express support systems
treatment plan understanding of  Arrange for home
 Child and family infection control health services to
verbalize lack of  Express help provide care if
understanding of understanding of possible
treatment plan Illness care  Instruct on reporting
 Verbalize and effectiveness of
demonstrate treatments and
knowledge of medications to
treatment physician
procedures  Involve child in self
care
 Encourage child’s
involvement in school
and sports
 Teach child to
recognize symptoms
of inadequate
therapy, signs and
symptoms of
respiratory infections,
and need for
physician follow-up
 Teach importance of
setting realistic goals
and expectations such
as increasing activity
level, school
attendance or
possible
hospitalizations