Patient's Profile

Name: Ms. Elliah Smith

Age:3y/o

Sex: Female

3 weeks prior to admission, PTs parents notice their child have persistent coughing and observe that their child is not gaining weight even PT
has a big appetite. They also observe that the PT has a salty skin. 2hrs PTC patient begin to experience shortness of breathing. Examination
revealed patient has a height of 33 inch , weight of 10kg, pt also have cold and clammy skin, noisy breathing. skin is pale. BP of 88/45bpm, RR
of 33cycle/mins, and T 35.2C. Have 63mml/L of chloride detected using sweat test. Patient have a sticky and thick mucus as observe using
Sputum test, PT requires to take antibiotics as prescribe by attending physician.
 ASSESSMENT Nursing Background Planning Nursing Rationale Evaluation
Diagnosis Knowledge Intervention

Name: Ms. Elliah Pt has an CFTR Gene defect After 5-7 hrs. 1.)Maintaining 1 .Use effective After 5hr – 7hr of
Smith ineffective airway Patient will have Patent Airways & airway clearance nursing care,
Age:3y/o clearance r/t comfortable and Improving Gas techniques such as patient regain
Sex: Female bronchial Triggers normal breathing Exchange chest physical normal vital signs
constriction due to as evidence by: therapy and and negative
Subjective: acute exacerbation inhalation therapy complaint of
PT parents stated as evidence by Entering of RR: 27-30 to mobilize and shortness of
their child is over production of bacteria such as cycle/min remove mucus and breathing.
having a shortness sticky and thick P.Aeruginosa BP: 92/75 ensure adequate
of breath and mucus and patient T: 36.5C airflow. Patient will still
persistent having shortness continue the
coughing of breath Bronchi producing 2.)Administering 2. Medications are administered
thick and sticky Medications of essential in medication coming
Objective: mucus antibiotic as managing cystic from its AP.
BP: 88/45bpm ordered by fibrosis (CF),
RR: 33cycle/min Attending addressing
T: 35.2C Irritation of throat Physician digestion, airway
Sweat test result: and airways function, and
63mml/L infections. From
Sputum test result: pancreatic enzyme
Have unusual Coughing replacement
sticky and thick therapy to
mucus. bronchodilators,
Ineffective airway mucolytics, CFTR
clearance modulators, and
antibiotics, these
tailored
medications aim to
optimize health
outcomes and
improve the
 quality of life for
CF patients.
3.)Monitoring
Diagnostic 3. Monitoring
Procedures and Diagnostic
Laboratory Studies Procedures and
Laboratory studies
will help the nurse
to better
understand and
offer better ways
on how to address
patient response
to its illness.

4.)Promoting
Infection Control & 4.)Promoting
Management infection control
such as making
sure environment
of pt is clean and
well ventilated,
patient can avoid
further
complication from
its present illness
of cystic fibrosis. Pt
and its family
would be able to
prevent
complication and
can handle it
independently.
Patient's Profile

Name: Ms. Elliah Smith

Age:3y/o

Sex: Female

3 weeks prior to admission, PTs parents notice their child have persistent coughing and observe that their child is not gaining weight even PT
has a big appetite. They also observe that the PT has a salty skin. 2hrs PTC patient begin to experience shortness of breathing. Examination
revealed patient has a height of 33 inch , weight of 10kg, pt also have cold and clammy skin, noisy breathing. skin is pale. BP of 88/45bpm, RR
of 33cycle/mins, and T 35.2C. Have 63mml/L of chloride detected using sweat test. Patient have a sticky and thick mucus as observe using
Sputum test, PT requires to take antibiotics as prescribe by attending physician.
 ASSESSMENT Nursing Background Planning Nursing Rationale Evaluation
Diagnosis Knowledge Intervention

Name: Ms. Elliah Pt has a risk of CFTR Gene defect After 1 month of After 1 month of
Smith disproportionate proper nutrients 1.) Administering 1.) Medications nursing care,
Age:3y/o growth in r/t the and medication Medications for are essential in patient regain
Sex: Female blockage of Defective ion patient will gain healthy diet and managing cystic normal vital signs
absorption of transport 2kg for normal that is prescribe by fibrosis (CF), and due to proper
Subjective: nutrients in the weight of a 3 y/o AP or Dietetian addressing medication and
PT parents stated intestine that digestion. From diet Patient was
their child is not causes slow Dehydrate mucus pancreatic enzyme able to gain 2kg
gaining weight growth and in digestive system replacement that is normal for 3
despite of its big difficulty of gaining therapy to y/o
appetite weight. bronchodilators,
Unable to digest mucolytics, CFTR Patient will still
Objective: the food due to modulators, and continue the
Height 33 inch blockage cause by antibiotics, these administered
Weight 10kg thick mucus tailored medication coming
medications aim to from its AP.
optimize health
No enough outcomes and
nutrients improve the
quality of life for
CF patients.
Difficulty of weight
gain 2.)Monitoring 2. Monitoring
Diagnostic Diagnostic
Procedures and Procedures and
Laboratory Studies Laboratory studies
will help the nurse
to better
understand and
offer better ways
on how to address
 patient response
to its illness.

3.) Promoting 3.)Due to

Optimal Nutrition malnutrition and
increased energy
expenditure,
patients frequently
need more calories
and nutrients.

4.)Educate parents Healthcare

about available professionals can
resources for ensure that the
home care. care given at home
is consistent with
the care given in
medical settings by
educating parents
about these
resources, so
fostering
continuity and
consistency in the
child's treatment
plan.
5.) Emotional and 5.)Giving CF patients and
psychological their families access to
support networks,
support counseling programs, and
mental health specialists
can help them deal with
the emotional effects of
the condition.