Nursing Diagnosis – Cystic Fibrosis Respiratory Failure
- Increase oxygenation and respiratory function
- Reducing the severity and frequency of symptoms related to respiratory problems
- Maintain or improve the patient’s level of activity and participation in daily activities
- Prescribed medications such as mucolytics and bronchodilators should be administered according to the instructions
- Encourage patients to utilize airway clearance methods such as chest physical and incentive spirometry.
- Regularly monitor vital signs and oxygen saturation levels
- Assessment and management of respiratory distress. Supplemental oxygen may be used if needed.
- The patient’s family should be educated about the importance to follow treatment.
- As appropriate, refer the patient to pulmonary rehabilitation
- Collaborate with the healthcare team to develop a plan of care that addresses the patient’s physical, emotional, and social needs
- The patient’s respiratory function and oxygenation improve, as evidenced by improved vital signs, oxygen saturation levels, and ability to participate in daily activities
- Patient reports a decrease in severity and frequency for respiratory symptoms
- This patient is able to demonstrate proper airway clearance and self-care.
Nursing Diagnosis – Fluid and Electrolyte Imbalance relating to weight loss or decreased urine output
- Increase hydration and balance
- Keep an eye out for weight gain and take preventative measures to stop it from happening again
- As prescribed, administer fluids and electrolytes, such as IV fluids, oral solutions to electrolyte problems, and enteral nutrition, as necessary
- Monitoring daily weight, intake and outflow, as well as laboratory values (such a electrolyte level and specific gravity of urine) is important.
- The patient’s family should be educated about proper nutrition and fluid balance.
- Collaborate with the healthcare team to develop a plan of care that addresses the patient’s nutritional needs
- It is important to monitor for signs of overhydration.
- The patient’s hydration status and electrolyte balance improve, as evidenced by improved laboratory values, weight stability, and urine output
- As evidenced by mucous membrane moisture and normal skin turgor, the patient has a proper fluid and electrolyte equilibrium.
- Family members and patients understand the importance and necessity of nutrition and water.
Nursing Diagnosis: Spasticity or muscle weakness is a sign of impaired physical mobility
- Enhance physical mobility and functional efficiency
- Promote the patient’s independence in self-care activities
- Increase or maintain muscle flexibility and strength
- As directed, administer prescribed medication to reduce spasticity and increase muscle function
- As needed, encourage the use of assistive equipment such as braces, braces and walkers.
- Assist with the patient’s mobility needs, including transferring, walking and exercising.
- The patient’s family should be educated about ways to prevent and improve mobility.