Assess

the lungs for any Monitor pulmonary Administer bronchodilators as Administer pancreatic enzymes before all Provide a high-calorie, Monitor daily weights for
adventitious sounds. function testing. ordered before therapy (ACT). meals containing fat or protein as ordered. high-protein diet. any increase.

Administering bronchodilators CF patients need pancreatic enzyme Any sick pt has increased caloric Weight gain would indicate
These sounds would indicate Improvements on PFT mean the pt
will help improve her airway supplementation to help their body needs, especially CF patients. improved nutritional status.
inflammation and possible has improved airway clearance and
clearance before ACT. digest/metabolize fats & proteins.
infection. a decrease in pulmonary secretions.


Outcome not yet met. Outcome not yet met.
Nursing Diagnosis 1: Ineffective Airway Clearance r/t decreased energy, fatigue, Patient has not Patient hasnt displayed Nursing Diagnosis 2: Imbalanced Nutrition Less than body requirements r/t
and increased sputum production and mucous in response to increased bacterial
maintained a clear open adequate nutritional poor nutritional status resulting from anorexia, chronic malabsorption, inability
growth in airways. airway. status or weight gain. to metabolize foods, and increased caloric needs caused by disease process.

Outcome: Patient maintains clear, open airways with normal breath sounds, Outcome: Patient will maintain adequate nutritional status or demonstrate
normal rate and depth of respirations, and an airway free of secretions, with weight gain on trajectory to adequate nutritional status by the end of shift

effective cough by the end of shift (1400). (1400).
Cystic Fibrosis
AEB
with pulmonary AEB
Usual Dosage: exacerbation Usual Dosage: 3-
Usual Dosage: 2.5
Usual Dosage: 2.5 400-250 mg 2 -Coarse, diminished breath sounds bilaterally Weight: 44.9 kg 6 mg/kg/day in
mg 3-4 times a day mg 3-4 times a day times a day in bases, no wheezing noted -Ferrous
BMI: 17.53 two doses
-Pulmonary Function Test (PFT): 54 (patients -2.3 kg decrease since admitted Sulfate 325 mg
-Low BMI kg/m2
normal baseline is 80) tablet. 1 tablet
-Albuterol -Albuterol -Lumacaftor- -Pt coughed up small amount of frothy sputum -Iron: 16 (low) oral two times
Usual Dosage: For

(Proventil Ipratropium (Duo- Ivacaftor 200- -O2 Sat: 88 -Vitamin D 25 Hydroxy: 29.9
Cystic Fibrosis a day
ng/mL (low) Usual Dosage:
Ventolin) Neb) Nebulizer. 125 mg tablet. -WBC: 15.2 k/uL (high) pediatric pts, 400-
-Lipase: 24 u/L (low) 500-2,500

Nebulizer. 2.5-0.5 mg/3 mL
2 tablets oral -Pt states she is unable to sleep at night due to
units/kg/meal 10,000 units per day
severe coughing spells -Pt states she has no appetite
2.5 mg four every four hours twice a day
times a day

PRN -Ergocalciferol
Nursing Diagnosis 3: Disturbed body image r/t situational -Lipase-Protease-Amylase (Zenpep) 8,000- 50,000 units
changes and alterations in bodily structure and/or function. unit capsule. 3 capsules oral three times a oral every 7
LEGEND -Pt has a G tube in abdomen. Dressing clean, day w/ meals
AEB days
dry, & intact
-Pt has a left chest port access. Dressing clean,
Outcome: Patient demonstrates enhanced body image and

Care problem AEB
self-esteem by the ability to look at, touch, and talk about
dry, & intact
-Pt appears very thin the altered body part/function with other people by the end
Nursing Diagnosis Outcome met by discussing her
-Pt has 4 scars (healed) on lower abdomen from of shift (1400).
previous surgeries Erikson: Identity vs. feelings/experiences about her G tube
Assessment Data
Role Confusion and chest port with student nurse and
Weight Data Changes in body image can have a huge another patient.
Adolescents may struggle with changes in the
impact on the pts everyday life. Especially Children suffering from similar
Developmental Data structure/function of their bodies. Especially
at a time when their friends/social life are very when it comes to their social life and problems can relate and offer advice
important to them. friends. and support to each other. -Pt states that she wishes her grandmother didnt
Medications
have to always care for her when she is sick
Interventions -Pt states she is self-conscious about the G tube
Assess the impact of body image Assess the perceived impact of change on Refer the patient and caregivers to in her abdomen as well as her chest port
Evaluation -Pt states that she wishes she could spend more
disturbance in relation to the patients ADLs, social behavior, personal support groups composed of time around other normal kids her age
Rationale developmental stage. relationships, and occupational activities. individuals with similar alterations.