Nursing Care Plan

Name: Jammille C. Elnar Course, Year, and Block: BSN1B

CYSTIC FIBROSIS
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective Short Term Independent: Short Term
Data: Goal: Goal
Ineffective After 4 to 8 Check and Vital signs Evaluation:
“My cough
Airway hours of note vital provide
doesn’t subside Clearance nursing signs essential Goals are met
at all and I related to intervention: particularly information
noticed that it excessive the patient the PR, RR, and baseline After 4 hours of
gets worse. I mucus will be able and O2 sat data for nursing
have difficulty in
production to perform every 4 assessing intervention: the
coughing the
and alveolar correct hours. alterations and patient was able
phlegm which
exudate coughing and evaluating the to perform
makes it harder secondary to deep effectiveness correct coughing
for me to breath”mutated breathing of nursing and deep
as verbalized by CFTR gene as techniques; interventions. breathing
the patient. evidenced by and will be techniques; the
ineffective able to breath Auscultate Crackles, patient was able
Objective Data: cough with w/o lungs and stridor, to breath w/o
purulent difficulty. document wheezes and having difficulty.
Ineffectiv sputum and for existence the like are
e Cough inspiratory Long term of normal indicative of Long Term
and crackles over Goal: and any respiratory Goal
Purulent the upper zone After 1 to 2 abnormal distress and/or Evaluation:
Sputum of both lungs. weeks of lung sounds accumulation
Inspirator nursing every 1 to 4 of secretions. Goals are met
y crackles intervention: hours
over the the patient After 1 week of
upper will be able Assess and Flaring of the nursing
zone of to monitor nostrils, intervention the
both demonstrate respiratory dyspnea, use of patient was able
lungs behaviors to depth, rate, accessory to demonstrate
Labored improve clear quality and muscles, behaviors to
Breathing airway; and pattern. tachypnea improve clear
maintain and/or apnea airway and
Relevant VS: normal are all signs of maintained
breathing severe distress normal breathing
PR: 110 bpm pattern. that require pattern.
RR: 32 immediate
breaths/min intervention.
O2 sat. 84%
Raise the Upright
head of the Position limits
bed 30 to 45 abdominal
degrees and contents from
properly pushing
place the upward and
patient in inhibiting lung
upright expansion.
position if This position
tolerated. encourages
better lung
expansion and
enhanced air
exchange.

Assist the Ambulation

patient to promotes lung
ambulate expansion,
and change allows the
position movement of
every 2 secretions, and
hours. reduces the
possibility of
lung collapse.

Teach and The most

encourage appropriate
the patient way to get rid
the correct of most
manner of secretions is
coughing, through
deep coughing.
breathing, Deep breathing
and aids in
splinting oxygenation
techniques. before
controlled
coughing.
Moreover, it is
important to
guide and help
the patient
 during those
activities.

Increase Hydration can

fluid intake help liquify
to at least viscous
2000 secretions and
mL/day improve
within secretion
cardiac clearance.
tolerance.

Dependent:
Give Expectorants
expectorants and
or bronchodilator
bronchodilat s promote
ors as clearance of
prescribed airway
by the secretions and
physician. may reduce
airway
resistance.

Administer Early
supplementa supplemental
l oxygen oxygen is
ordered by significant in
the all trauma
physician. patients since
early mortality
is associated
with
inadequate
delivery of
oxygenated
blood to brain
and vital
organs.
Collaborative:
Collaborate Chest
with a physiotherapy
respiratory includes the
therapist for techniques of
chest postural
physiothera drainage and
py and chest
nebulizer percussion to
managemen mobilize
t as secretions from
recommend smaller
er. airways that
cannot be
eliminated by
means of
coughing or
suctioning.