Nursing Diagnoses

Nursing Diagnosis 1:

Ineffective airway clearance r/t inability to clear mucus AEB productive cough, wheezing, SOB.

Goal: Patient will maintain clear airway for remainder of hospital stay.

Interventions:
1. Encourage activity to promote complete expansion of bronchioles.
2. Use mucolytic agents and do not administer cough suppressants (cough is needed to clear secretions).
3. Provide aerosol therapy 3-4 times a day or as prescribed.
4. Provide moistened oxygen to correct hypoxia and acidosis.


Nursing Diagnosis 2:

Altered nutrition less than body requirements R/T inability to digest fat AEB poor weight gain, steatorrhea.

Goal: Patient will not maintain current weight/gain weight during remainder of hospital stay.

Interventions:
1. Provide a high calorie, high protein, moderate fat diet.
2. Supplement vitamins ADEK as water-miscible forms.
3. Make sure the room temperature is always below 72 degrees F to prevent excessive perspiration (salt loss).
4. Supplement with synthetic pancreatic enzymes before each snack and meal.


Nursing Diagnosis 3:

Risk for altered skin integrity r/t acid stools AEB meconium.

Goal: Patient will maintain skin that is clean, dry, and intact for the remainder of the hospital stay.

Interventions:
1. In infants: change diaper immediately after stool is passed.
2. Check the rectum after bowel movement to see if it has prolapsed.
3. If prolapse is present, replace it gently with a gloved lubricated finger.
4. After replacement, tape the buttocks together to maintain gentle pressure.


Nursing Diagnosis 4:

High risk for ineffective family coping r/t chronic illness of child AEB distress, anger, crying, etc.

Goal: Family will demonstrate effective coping strategies by the end of the shift.

Interventions:
1. Teach proper home care of the CF patient. 
2. Schedule regular follow-up visits with the patient and family.
3. Arrange for home schooling or tutor as needed.
4. Encourage all family members to participate in care to reduce caregiver strain.


Nursing Diagnosis 5:

Impaired gas exchange r/t airway obstruction by nasal obstruction AEB productive cough/sputum.

Goal: Patient will achieve oxygen saturation of 95 or higher by the end of shift. 

Interventions:
1. Encourage exercise appropriate to the physical ability of the patient.
2. Maintain a patent airway.
3. Monitor vital signs, ABGs, and pulse oximetry to detect/prevent hypoxemia.
4. Provide supplemental oxygen according to the provisions/requirements. 



References:

http://nanda-nursing-care-plan.blogspot.com/2014/05/3-nursing-diagnosis-and-interventions.html

http://www.nursing-help.com/2011/08/cystic-fibrosis-nursing-diagnosis-and-care-plan.html