Nursing Care Plan (NCP) for Cystic Fibrosis

Watch More! Unlock the full videos with a FREE trial

Add to Study plan
Master

Included In This Lesson

Study Tools

Cystic Fibrosis Pathochart (Cheat Sheet)
Example Care Plan_Cystic Fibrosis (Cheat Sheet)
Blank Nursing Care Plan_CS (Cheat Sheet)
Cystic Fibrosis Interventions (Picmonic)
Cystic Fibrosis Assessment (Picmonic)

Access More! View the full outline and transcript with a FREE trial

Transcript

Today we are going to be tackling cystic fibrosis. Cystic fibrosis is a genetic disorder of the secretary of glands. So the glands that secrete different mucus and sweat. It causes it to overproduce mucus, sweat, and it causes it to affect the lungs, pancreas, liver, intestines, and sex organs. The mucus is very thick and it impedes the normal processes of the body. So instead of lubricating the lungs and other organs, it actually clogs the airways and the ducts; the most, frequently affected organs are the pancreas and the liver. Some things we want to look for, we want to look for signs of infection. These patients tend to have some respiratory infections. We also want to just think in the back of our mind vest therapy, that's some therapy that the cystic fibrosis patients undertake. We're going to monitor the vital signs. 

We're going to draw some labs. We're going to administer medications as ordered. We're going to do a good abdominal assessment, and we're going to do a glucose check because the blocked pancreas is also affected and that can cause some diabetes. And also we're going to monitor their fluid intake. This patient is going to maintain adequate ventilation and respiratory status as well as have optimal, nutritional status. And the cystic fibrosis patient is going to be free of infection. 

So cystic fibrosis: subjective. What is the patient telling us? Well, the patient is going to have some exercise intolerance. They're going to get tired and that's because a lot of their ducts are blocked. So their lungs are going to be tired. They're going to have some nasal congestion. Remember the thick mucus. They're also going to have some constipation because their GI tract is going to also be blocked and they are going to have some abdominal pain. 

Okay. Um, some objective things that we're going to observe as nurses, we're going to see coughing, but it's going to be non productive. Or if it's productive, it's going to be thick sputum. They're going to have what we call meconium ileus. If you remember, meconium is that first stool that is passed as a child. So they're going to have ileus, which is, it's not going to come. They're going to have a failure to thrive. These patients also have what we call a salty taste to the skin, and they're going to have oily stools and some abdominal distention. So what are some things that we can do as nurses and intervene? Well, the first thing I think we should do is assess the respiratory status. Very important that we note a few things. We want to note the rate, the rhythm and the quality of breathing, because those things can give us some good information. 

So cystic fibrosis patients tend to get frequent respiratory infections because of the thick mucus that traps bacteria. We want to perform chest physical therapy or vest therapy, two to four to four times a day. And that's all based on the facility's protocol. We're going to look at the abdomen. We're going to do a good abdominal assessment. We're going to feel or palpate for signs of constipation. In these patients, the mucus that usually lubricates the GI tract becomes an area for distension and constipation. Okay. We're going to monitor their blood sugar. These patients tend to have increased blood glucose levels. CF related diabetes is very common. 

We're going to, again, assess for signs of infection. So because lung infections are common, we're going to culture the sputum. We're going to have determined which bacteria is involved. If an infection is present, because we want to be able to pick the correct antibiotics in order to develop a course of treatment. Last, but certainly not least, we are going to monitor for signs of dehydration, and we're going to encourage fluid and salt intake. So patients with cystic fibrosis tend to lose an excess amount of fluids and salt. So salt leaves and fluid goes right behind it. They can become dehydrated or develop hyponatremia, which is another word for low sodium. They can develop low sodium and that develops quickly. We want to avoid all of those complications. We talked about this, but we want to make sure that we perform the vest therapy two to four times a day. Like I said, per the protocol, this technique is just shaking up the body and loosening up that thick mucus and making it easy to either suction out or expel with a cough. 

Here are some key points that we want to focus on when we are taking care of the cystic fibrosis patient. Okay. Remember, cystic fibrosis is an autosomal, recessive genetic disorder. Okay. It just makes your secretary glands produce thick mucus. Okay. The subjective and objective details that we want to focus on are subjective. These patients are going to have some exercise and tolerance, constipation, abdominal pain, and congestion. Objective: we're going to notice a few things. Few of them, a meconium ileus, and abdominal distension, as well as increased blood sugar. So let's add that here. Increase B G blood glucose. We're going to monitor glucose for CF related diabetes and best therapies should be done two to four times per day. That's going to help break up that thick mucus. We love you guys; go out and be your best self today. And, as always, happy nursing.

 
View the FULL Transcript

When you start a FREE trial you gain access to the full outline as well as:

  • SIMCLEX (NCLEX Simulator)
  • 6,500+ Practice NCLEX Questions
  • 2,000+ HD Videos
  • 300+ Nursing Cheatsheets

“Would suggest to all nursing students . . . Guaranteed to ease the stress!”

~Jordan