care plan for cystic fibrosis with major hemoptysis

[patsy peppermint]

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help. i need advice for my 4th semester student nurse care plan. i have a cystic fibrosis child with major hemoptysis. i t is thought to be caused by a ruptured bronchial artery due to the pressure of coughing. any ideas on the priority nursing diagnosis? i was thinking ineffective airway clearance or deficient fluid volume. i was also thinking risk for infection, but sometimes teachers don't like risk for. i would really love to impress my teacher.

[Daytonite, BSN, RN]

is hemoptysis your only symptom? what other symptoms involving the respiratory or circulatory systems do you have? choosing any diagnosis (ineffective airway clearance [[color=#3366ff]ineffective airway clearance] or deficient fluid volume [deficient fluid volume]) means you have evidence (symptoms) to back it up. what have you got besides hemoptysis to back either of these up? to stimulate your thinking on this, because i think you've missed some things during your assessment of the patient, read the defining characteristics listed with these diagnoses (i provided links to webpages with that information for you).

did you read everything you could find about cystic fibrosis? what specific dietary problems do children with cf get? i don't see impaired gas exchange ([color=#3366ff]impaired gas exchange), activity intolerance (activity intolerance) or imbalanced nutrition: less than body requirements ([color=#3366ff]imbalanced nutrition: less than body requirements) in your list of diagnoses. here's what i found:

• http://www.merck.com/mmpe/sec19/ch278/ch278a.html
  
• http://www.fpnotebook.com/lung/peds/cystcfbrs.htm
  
• http://www.medicinenet.com/cystic_fibrosis/article.htm
  
• http://www.webmd.com/parenting/understanding-cystic-fibrosis-basics
  
• http://www.mayoclinic.com/health/cystic-fibrosis/ds00287
  
• http://kidshealth.org/kid/health_problems/heart/cystic_fibrosis.html - kid's level information
  
• http://kidshealth.org/teen/diseases_conditions/digestive/cystic_fibrosis.html - teen level information

when sitting down to write a care plan, follow these steps and activities:

• assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  • a physical assessment of the patient
    
  • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    
  • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    
  • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
    
  • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

  [*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

  • it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
    
  • your instructors might have given it to you.
    
  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
    
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
    
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
    
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
    • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
      
    • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

  [*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
      
    • stabilize it
      
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

  [*]implementation (initiate the care plan)

  [*]evaluation (determine if goals/outcomes have been met)

[patsy peppermint]

I hae plenty of objective and subjective info. I was just trying to see what came to mind when thinking of the hemoptysis. I really appreciate your suggestions and links. I am ready to start it . thank you!

[Daytonite, BSN, RN]

Hemoptysis + cystic fibrosis = Ineffective Airway Clearance R/T retained and excessive secretions secondary to CF

[patsy peppermint]

thanks, sounds great!

[thefabulousmrst]

I am a nursing student working on a sample care plan for an imaginary eight year old patient with CF. My instructor has given me a nursing diagnosis of impaired gas exchange. Would tenacious secretions or bronchoconstriction be appropriate for the RT w/ that stem? I have hypoxia, hypercapnia, unability to move secretions, restlessness, and irritability as supportive data. Any suggestions?

[thefabulousmrst]

I think I found my answer, lol. I am still open to suggestions

https://allnurses.com/general-nursing-student/asthma-impaired-gas-302401.html

[Daytonite, BSN, RN]

i am a nursing student working on a sample care plan for an imaginary eight year old patient with cf. my instructor has given me a nursing diagnosis of impaired gas exchange. would tenacious secretions or bronchoconstriction be appropriate for the rt w/ that stem? i have hypoxia, hypercapnia, unability to move secretions, restlessness, and irritability as supportive data. any suggestions?

no. there are only two related factors that nanda lists for this diagnosis. only two things interfere with exchange of gases at the alveolar level: anatomical changes and gunky buildups. bronchospasms are way out of the ballpark and occur at another part of the respiratory anatomy. another nursing diagnosis is used when they are occurring. tenacious secretions are the result of all the gunky buildup and are supportive data. you need to consult the taxonomy: impaired gas exchange. do a little research about this disease as well as the related factors (etiology) for this diagnosis.

• alveolar-capillary membrane changes - quite simply means that the membrane, or tissue, that separates the wall of the air sac (alveoli) and the capillary (vessel) walls has changed from it's normal anatomical structure and has become abnormal, or pathological, because there is disease present. this occurs in lung conditions such as one of the copds, fibrosis, tb, invasive cancer and others where permanent damage to the alveoli take place that is not reversible resulting in loss of valuable surface area that is used for oxygen/carbon dioxide gas exchange
  
• ventilation perfusion imbalance - an imbalance between oxygen and carbon dioxide exchange exists and there is either more oxygen or more carbon dioxide being exchanged than is normally supposed to occur. the usual reason for this is some sort of temporary blockage at the level of the alveoli. do not make the mistake of diagnosing a blockage in the bronchioles as being responsible for impaired gas exchange because oxygen and carbon dioxide are not exchanged in the blood vessels of the bronchi. ventilation perfusion imbalances occur when the alveoli are clogged with debris, exudates or built up sputum as in pneumonia, congestive heart failure or atelectasis following surgery.
  

an appropriate diagnostic statement from the information you gave would be impaired gas exchange r/t ventilation perfusion imbalance secondary to cf aeb hypoxia, hypercapnia, restlessness, and irritability.

[thefabulousmrst]

Thank you so much!