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Subjective and
objective data
that is pertinent
to the nursing
diagnosis.
Nursing
Diagnosis
R/T & AEB
Subjective
-Patient
mentioned it was
hard for him to
breath in the
morning with
thick secretions.
-Mother said
patient had a
decreased PFT,
and was
hospitalized for a
clean out.
Objective:
-Patient’s
secretions were
thick and green.
- Crackles were
auscultated in
both lobes.
Ineffective
airway
clearance
R/T thick
mucous
secretions
AEB
decreased
pulmonary
function
test,
crackles
auscultated
in lungs, CPT
every 4
hours.
Short and long
term
measurable and
realistic patient
goals &
outcomes
Short term:
Patient will
maintain O2
saturation
above 94%
throughout the
day.
Nursing interventions (Including all
assessments, treatments, medications). Be
specific.
1. Assess and document RR, depth and lung
sounds after CPT treatment; more frequently
if patient has increased secretions.
2. Observe breathing efforts (accessory
muscles or retractions), respirations (normal
range), nasal flaring, breath sounds and wet
cough during assessment and anytime
entering room.
3. Position child with head of the bed
Long term:
Patient will have elevated at a 45 degree angle.
4. Follow up with respiratory therapist to see
an increased
PFT by discharge that CPT therapy is performed Q 4 hours and
encourage pt to breathe deeply and cough
day.
(huff) hourly.
5. Make sure RT administered nebulizer
medication such as 2.5 mg of Albuterol, 4 mL
of warm hypertonic saline solution every 4
hours and Dnase 2.5 mg daily.
6. Administer antibiotics such as 1400 mg of
Q 6 hrs Fortaz and 230 mg of Tobramycin
once daily.
7. Have bag and mask at the bedside.
8. Check O2 every 4 hours (on intermittent
pulse oximetry).
9. Encourage patient to get out of bed and
use his tricycle and other toys he has in room,
blow bubbles with clown volunteer.
10. Encourage patient to drink fluids at least
20
Documented rationale for your
interventions and references (must
include reference for rationale-author and
page number)
1. Early detection of respiratory
deficiency or adventitious lung sounds is
important for effective intervention
(LeMone, 2011, p. 1223)
2. Use of accessory muscles indicates
breathing difficulty and wet cough
indicates secretions which may obstruct
the airway causing respiratory distress
(Lemone, 2011, p. 1251).
3. Positioning patient with elevated head
of
bed will maximize breathing effort
(LeMone,2011, p. 1251).
4.
The high frequency chest wall
shaking
helps loosen and clear mucous huffing
helps move mucus away from small
airways and coughing forcefully expels
secretions out of large airways (LeMone,
2011, p. 1250).
5. Bronchodilators dilate bronchi to ease
expectoration of mucus. Dnase thins out
the mucus for easier removal, hypertonic
saline moistens the airways and aids in
clearing mucus (Hockenberry, 2011, p.
1284).
6. Antibiotics are used to treat or
decrease
Evaluation of goals:
achieved or
measurable changes?
How would you
evaluate to determine
if goals were met?
Short term
Goal Met: O2 was
maintained above
94% throughout day.
Long Term
Goal not met: To
meet goal an order
for a PFT would be
needed and then
evaluated to make
sure PFT was
increased and at an
appropriate level to
discharge patient.
1560 mL/day (65mL/hr).
bacteria that grow easily in the high
volumes of mucus produced. It can cause
inflammation and complications by
obstructing airway (Hockenberry, 2011, p.
1224).
7. Supplemental oxygen may be necessary
to maintain adequate oxygenation
(LeMone, 2011, p. 1279).
8. To ensure treatment has been efficient
and to attain the oxygenation status of the
patient (Doenges, 2010, p. 153)
9. Activity stimulates secretion excretions,
Increase ventilation and blood flow to the
lungs (Hockenberry, 2011, p. 1284).
10. Fluids help reduce mucus viscosity
(LeMone , 2011, p. 1250)
21
Subjective and
objective data
that is pertinent
to the nursing
diagnosis.
Nursing
Diagnosis R/T
& AEB
Short and long
term
measurable and
realistic patient
goals &
outcomes
Nursing interventions (Including all
assessments, treatments, medications). Be
specific.
Documented rationale for your interventions
and references (must include reference for
rationale-author and page number)
Subjective:
Patient saying he
wasn’t hungry
and only wanted
a boost for
breakfast.
-Mom reporting
that’s patient
does not always
have a good
appetite.
Objective: Fatty
and odorous
stools, odorous
patient is taking
enzymes to help
absorption of
nutrients; weight
in 50th%-ile.
Altered
nutrition less
than body
requirements
R/T inability
to absorb fat
& protein
AEB weight in
50th %-ile,
fatty stools &
poor
appetite.
Short term:
Patient will
drink entire (8
oz) strawberry
boost before
every meal.
Long term:
Patient will gain
2 pounds within
the next week
before being
discharged,
1.Provide the patient with options of high
protein/ calorie foods such as meats,
cheese, potatoes, avocado , etc.
2. Offer supplemental boost shakes
between meals.
3.Administer 2 PancreaLipase before each
meal and and 1 before Q snack.
4. Administer supplemental vitamins
including Aquadeks and Cholecalciferol
daily.
5. Make sure room is at a comfortable
temperature to prevent pt. from sweating.
6. Administer antacid medication Prilosec
(20mg) once daily.
7. Monitor consistency and appearance of
stools.
8. Assess weight every other day.
9. Monitor blood labs such as platelets and
HCT.
1.Mucus plugs pancreas and production of
pancreatic enzymes is decreased, nutrients
are not readily absorbed putting pt. at risk for
weight loss which can affect lung function
(Hockenberry, 2011, p. 1286).
2. High calorie/protein snacks are needed to
compensate for malabsorption of nutrients
and maintain healthy body weight
(Hockenberry, 2011, p. 1286).
3. In CF production of pancreatic enzymes is
decreased, supplements are needed to aid in
digesting fats in the small bowel so it can be
absorbed by the body (Hockenberry, 2011, p.
1285).
4. Body needs extra vitamins to help with
normal growth and health. Patients w/ CF
have trouble absorbing fat soluble vitamins
resulting in deficiency in these vitamins which
is why supplemental vitamins are needed
(Hockenberry, 2011, p. 1285).
5.CF patient has a chloride channel defect in
sweat glands impeding reabsorption of
sodium and chloride causing abnormal
amount of salt loss through sweat glands, by
providing a comfortable temperature
sweating and dehydration is reduced
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Evaluation of goals:
achieved or
measurable
changes? How
would you
evaluate to
determine if goals
were met?
Short term
Goal Met: Patient
drank entire boost
between meals
(given an hour
before meal, so
that he wasn’t too
full when his meal
arrived).
Long Term
Goal not met: Was
not there to assess
patient’s weight at
discharge but I
would have
compared previous
or admission
weight to weight at
discharge.
(Hockenberry, 2011).
6. Reduce the acidic environment in the
bowel so that enzymes are better activated
(Hockenberry, 2011, p. 1285).
7.Patient is unable to absorb fats and
nutrients. Food passes undigested making
stools bulky and fatty. Floating BMs indicate a
high loss in fats (Hockenberry, 2011, p. 1282 ).
8. Very little nutrients are absorbed from the
bowel affecting the child’s weight
(Hockenberry, 2011, p.1282)
9. Because patient is unable to absorb vitamin
K patient may be at risk for bleeding and
anemia (Hockenberry, 2011, p. 1282).
23
Subjective and
objective data
that is pertinent
to the nursing
diagnosis.
Nursing
Diagnosis
R/T & AEB
Short and long
term
measurable and
realistic patient
goals &
outcomes
Nursing interventions (Including all
assessments, treatments, medications). Be
specific.
Documented rationale for your interventions
and references (must include reference for
rationale-author and page number)
Subjective:
-Mother
explained that
she worries
about him
getting
respiratory
infections in
school and
daycare
environment
Objective:
-Pt is on contact
precautions for
MRSA
-Patient is
receiving
antibiotics to
fight off
respiratory
infection.
Infection
R/T high
volumes of
mucus and
PICC line
AEB
antibiotics
being taken
by pt.,
contact,
precautions,
mother
explaining
he is at
higher risk
of
contracting
resp.
infection
compared
to normal
child.
Short term:
Patient will
wash hands
after using the
restroom and
before Q meal.
1.Assess temperature for a fever every shift
or more often if nurse feels is needed.
2.Use proper hand hygiene, wash hands
often and use sanitizer when entering and
exiting room and implement droplet
precautions, by wearing mask gloves and
gown.
3.Use aseptic technique when administering
medications through PICC line and when
changing dressing.
4. Assess skin every 4 hours at PICC line site
for signs of inflammation such as redness,
pain, swelling, and pus.
5.Administer antibiotics such as 1400 mg of Q
6 hrs Fortaz and 230 mg of Tobramycin once
daily.
6.Administer antipyretic and anti
inflammation medication such as 230 mg of
Ibuprofen every 6 hrs as needed. If patient
gets a fever or has pain (determined by
asking patient to rate pain score on a Faces
scale 1-10).
1. Fever is part of an acute response to
infection. Cytokines stimulate the
hypothalamus, temperature rises to fight and
kill off infection (McCance, 2010, p. 297).
2. Helps reduce spreading bacteria found in
hospital that can lead to infection in
patient.(Hockenberry, 2011, p. 1224). Patient
is susceptible to bacterial infections as a
result of over production of mucus which
facilitates bacterial adherence and growth
(LeMone,, 2010 p. 150).
3. Patient has a PICC line. It is an open wound
and if not careful microorganism may enter
through the open wound causing an infection
or sepsis (Hockenberry, 2011, p. 362).
4. We are monitoring for redness, swelling,
pain, or pus (neutrophils are first cells to
arrive to damaged site) (McCance, 2010, p.
187).
5. Patient is at increased risk for infection due
to the increased amount of mucus,
antibiotics eliminate and reduce
microorganisms and serve as prevention of
infection (McCance, 2010, p. 1338).
6. Medication used to reduce fever,
inflammation or provide comfort if in any
Long term:
Pt. will
demonstrate
appropriate
hygienic
measures such
as washing
hands and oral
care by
discharge date.
24
Evaluation of
goals: achieved or
measurable
changes? How
would you
evaluate to
determine if goals
were met?
Short term
Goal met: Patient
washed hands
before eating and
after every time
he used the
restroom.
Long term
Goal not met: Not
present to
evaluate goal. But
would make sure
patient
demonstrated
appropriate hand
and oral hygiene
before being
discharged.
pain. Inflammation caused by infection can
lead to complications, airway obstruction
and lung damage (Hockenberry, 2011, p.
1224).
25
Subjective and
objective data
that is pertinent
to the nursing
diagnosis.
Nursing
Diagnosis
R/T & AEB
Short and long
term
measurable and
realistic patient
goals &
outcomes
Subjective:
Mother said
patient usually
naps after a busy
day. She tries to
keep him active
but he fatigues
easily especially
at the end of day
before
treatment.
-Patient reports
SOB after
jumping on
tramp
Objective:
Patient had
sudden energy
spurts and would
quickly fatigue
(looked pale
breathing
rapidly) and sit
back in bed and
play on iPad.
Activity
Intolerance
R/T reduces
oxygen
transport
due to thick
mucous
secretions
AEB pallor,
reporting
SOB, taking
naps or
having to
rest after
experiencing
high activity
levels.
Short term:
Patient will get
out of bed and
maintain
moderate
activity (with
PT) for 30
minutes today.
Long term:
Patient will
increase
duration in
activity to 40
mins by
discharge date
(next week).
Nursing interventions (Including all
assessments, treatments, medications).
Be specific.
Evaluation of
goals: achieved or
measurable
changes? How
would you
evaluate to
determine if goals
were met?
1. Monitor vital signs, breath sounds
1. Increased work load of the heart due to
Short Term
(wheezing, wet cough) and apical pulse
impaired oxygenation (caused by thick secretions) Goal Met: Patient
(Increased pulse) during activity outside. can affect the blood pressure, heart, and
went outside with
2. Encourage patient to drink entire
respiratory rate. Increased blood flow can lead to PT to play for 30
boost and at least half of meals.
heart murmur or abnormal heart sounds
minutes, after his
3. Stop or decrease activity level
(Lemone, 2011, p. 1082).
treatment was
tachypnea, dyspnea, bradycardia,
2. Adequate nutrition is needed to maintain
complete and he
breathlessness, or decreased BP is noted. weight and help in healing. Also decreases fatigue was feeling well.
4. Let patient rest between CPT
and increases energy (LeMone, 2011, p. 1010).
Long Term
treatment and change of PICC line
3. These changes may signify cardiac
Goal not met: Not
dressing.
decompensation due to insufficient O2 caused by present to
5. Administer O2 when O2 saturations go blockage of airways by thick, sticky secretions
evaluate goal.
decrease below 94%.
(LeMone, 2011, p. 1082).
When discharged I
6. Encourage patient to get out of bed
4. O2 is impaired by mucus, rest periods reduce would see if
and stretch, ride tricycle in room, hop, do
O2 demand and fatigue
patient was able
jumping jacks and play with toys in room. (LeMone, 2011, p. 1224).
to maintain
7. Encourage patient to sleep 8- 10 hours 5. Patient’s O2 levels may decrease as a result
moderate activity
of sleep at night.
of the secretions obstructing the bronchi and
level for 40 mins.
8. Talk to physical therapy about
supplemental O2 can help improve oxygenation
exercises that can be done in bed or in
and reduce activity & exercise intolerance.
room .
(LeMone, 2011, p. 1224)
6. Exercise improves physical and emotional
well-being as well as improves mucus clearance
and lung function, increases exercise tolerance
and promotes better sleep (LeMone, 2011, p.
1224).
26
Documented rationale for your interventions
and references (must include reference for
rationale-author and page number)
7. Rest decreases oxygen demands and
increases available energy for morning and during
the day activities ( LeMone, 2011, p. 1083)
8. Exercise helps improve strength and muscle
mass especially since he is in room all day and
gets little exercise (LeMone, 2011, 1010)
27
Subjective and
objective data that is
pertinent to the
nursing diagnosis.
Nursing
Diagnosis R/T
& AEB
Short and long term
measurable and
realistic patient
goals & outcomes
Nursing interventions (Including all
assessments, treatments, medications).
Be specific.
Documented rationale for your
interventions and references (must
include reference for rationale-author
and page number)
Subjective:
-Mother expressed
uncertainty about
the effects illness will
have on son in the
future.
-She expressed
sadness about moving
far away from her
family.
-Mother expressed
concern about
younger son feeling
unimportant and
resentful towards R,B.
Objective:
-Mother seems to be
extremely easy going
with R, B when he
refuses to breathe
deeply when asked by
RT.
Compromised
family coping
r/t son’s
disease and
upcoming life
changes AEB
uncertainty
about effects
illness will have
on son,
overwhelmed
feelings about
moving away
from family
and
relationship
with younger
son.
Short term:
During interview
mother will identify
people she trusts
and counts on for
support that she can
discuss her feelings
with.
Long term:
Mother will join
support group in
Ohio to prevent her
from feeling alone
and has someone
she can relate to.
1. Assess interactions between patient
and mother/ brother.
2. Assess the effect the illness has had on
family (ex. Relationship between younger
brother and patient/mother).
3. Encourage mom to express her
feelings during interview by asking how
she feels and how she’s coping (as a nurse
be neutral & avoid judging feelings.
4. Encourage mother to participate
during breathing exercises and treatment.
(Patient was not breathing deep and slow
enough. RT asked mom to help her
encourage him and she responded by
saying “he’s the same way at home I can’t
get him to do it either.”
5. Ask patient and mother when best
time for PICC line dressing change would
be and whether he preferred to take
shower before or after.6.
6. Encourage visits from the family and
younger son.
1. Assessing helps identify desired
and destructive behaviors or other
factors that may be causing the
problem (LeMone, 2011, p. 1247).
2. Assessment of family chemistry,
roles and relationships help in planning
appropriate interventions to reduce
resentment of younger sibling towards
R,B (LeMone, 2011, p. 1247)
3. It’s important for the nurse to
remain objective to maintain an open,
trusting and therapeutic relationship
with patient and parents (LeMone,
2011, p. 1247)4.
4. This helps develop skills for when
he refuses to do what he is asked at
home (LeMone, 2011, p. 1247)
5. This gives patient and family a
sense of control (LeMone, 2011, p.
1251).
6. Family visits helps with coping and
reduces anxiety by distracting her.
Mother will be able to spend time with
both children (LeMone, 2011, p. 1272)
28
Evaluation of
goals: achieved or
measurable
changes? How
would you
evaluate to
determine if goals
were met?
Short term
Goal met: Mother
identified her
mother, father
and her in laws as
her support
system and said
she could go to
them for anything
but at times puts
he feelings aside
because her son
has bigger
concerns.
Long Term
Goal not met:
Mother has not
moved but
sounded
determined to
find a support
group when she
moved.
References
Bunn H.F. (2013). Hematocrit. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003646.htm.
Doenges, M.E., Moorhouse, M.F., Murr, A.C. (2010). Philadelphia, PA: F.A.Davis Company.
Hockenberry, M. & Wilson, D. (2011). Wong's nursing care of infants and children. (9th ed.) St. Louis: Elsevier Mosby
LeMone, P. Burke, B, Bauldoff, G. (2011). Medical-surgical nursing: Critical thinking in patient care. Upper Saddle
River, NJ: Pearson Education Inc
McCance, K.L., Huether, S.E., Brashers, V.L., Rote, N.S. (2010). Pathophysiology: The biologic basis for
disease in adults and children. Maryland Heights, Missouri: Mosby Elsevier
29