- Imbalanced Nutrition less than Body Requirements related to Malabsorption and nutrient deficiencies as evidenced by Foul-smelling and greasy stools and Poor weight gain
- Impaired Gas Exchange related to accumulation of tenacious secretions and Inflammation of airways as evidenced by Abnormal ABGs and Altered respiratory pattern
- Impaired Spontaneous Ventilation related to excessive mucus production and Respiratory fatigue as evidenced by Accessory muscle use and Shortness of breath
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalizes that unable to eat properly Objective Data: Foul-smelling and greasy stools Poor weight gain Intestinal obstructions Abdominal distention or bloating | Imbalanced Nutrition less than Body Requirements related to Malabsorption and nutrient deficiencies as evidenced by Foul-smelling and greasy stools and Poor weight gain | Patient will display improvement in nutritional status as evidenced by lab work. Patient will demonstrate weight gain of 10% within three months. Patient will adhere to enzymes and supplements to improve nutrition. | 1. Administer pancreatic enzymes. Pancreatic enzymes help the body digest carbs, fats, and protein. These should be taken before eating to aid digestion. 2. Provide a high protein diet. Patients require high-calorie and high-protein diets. Encourage dairy, breaded meats, peanut butter, pasta, and eggs. 3. Teach the patient and family. Children with CF may be less inclined to follow diet and enzyme guidelines. Children should be encouraged to eat anytime they are hungry. Adhering to set mealtimes may not be feasible and flexibility should be encouraged. Involve the child in taking their enzymes by opening the capsules and sprinkling the beads on their food. 4. Collaborate with a dietician. Dieticians can assist with finding the correct number of enzymes required as well as recommending additional vitamins and supplements and adding calories to the diet. | Patient displayed improvement in nutritional status as evidenced by lab work. Patient demonstrated weight gain of 10% within three months. Patient adhered to enzymes and supplements to improve nutrition. |
| Subjective data: Dyspnoea Diaphoresis Headaches Objective data: -Altered respiratory patterns -Cyanosis -Lab values -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Impaired Gas Exchange Related to accumulation of tenacious secretions and Inflammation of airways as evidenced by Abnormal ABGs and Altered respiratory pattern | Patient will display adequate ventilation and oxygenation as evidenced by blood gas levels within normal limits. Patient will display clear lung sounds and remain free of respiratory distress. | 1. Administer oxygen. Supplemental oxygen maintains adequate oxygenation and decreases the work of breathing. Consider humidified oxygen to loosen and thin respiratory secretions. 2. Cluster care to maximize rest. Minimize interruptions by clustering nursing care and interventions to allow for rest and reduce oxygen demand. 3. Administer medications. Administer bronchodilators to open the airways, mucolytics to break up thick mucus and facilitate effective clearance, and antibiotics to treat pulmonary infections. 4. Continually monitor ABGs. ABGs should be assessed routinely to monitor for worsening hypoxia or alterations in acid-base balance. | Patient displayed adequate ventilation and oxygenation as evidenced by blood gas levels within normal limits. Patient displayed clear lung sounds and remained free of respiratory distress. |
| Subjective Data: Verbalizes unable to breath normally Objective Data: -Accessory muscle use -Shortness of breath -Apprehension -Decreased cooperation -Restlessness | Impaired Spontaneous Ventilation related to excessive mucus production and Respiratory fatigue as evidenced by Accessory muscle use and Shortness of breath | Patient will be free of signs of respiratory distress, such as restlessness or accessory muscle use. Patient will demonstrate effective airway clearance techniques. Patient will exhibit clear breath sounds. | 1. Administer oxygen. If oxygen saturation drops below 95% or the client displays symptoms of impaired ventilation, apply supplemental oxygen. 2. Maintain head of bed elevation with regular position changes. Keep the head of the bed elevated to achieve maximum chest expansion and encourage repositioning and ambulation as applicable to prevent atelectasis. 3. Provide suctioning. Suction oral or oropharyngeal secretions as necessary to prevent accumulation that could result in aspiration. 4. Assist with airway clearance techniques. Airway clearance is crucial in CF. Chest PT with postural drainage and using devices like positive expiratory pressure therapy (PEP) helps clear mucus. 5. Discuss the possibility of lung transplantation. End-stage lung disease with CF often requires lung transplantation, which may not lengthen survival but improves quality of life. | Patient is free from signs of respiratory distress, such as restlessness or accessory muscle use. Patient demonstrated effective airway clearance techniques. Patient exhibited clear breath sounds. |