Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and arterial oxygen saturation (SaO2) but normal pH and PaCO2. Ensure that the patient performs deep breathing with coughing exercises at least every 2 hours. Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. A nasal ET tube in place Obtain the supplies that will be used. a. 2) Guillain-Barr syndrome A patient started treatment for sputum smear-positive tuberculosis (TB) 1 week prior to the home health nurse's visit. Facilitate coordination within the care team to allow rest periods between care activities. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Which respiratory defense mechanism is most impaired by smoking? The most common. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up. 1. Identify 1 specific finding identified by the nurse during assessment of each of the patient's functional health patterns that indicates a risk factor for respiratory problems or a patient response to an actual respiratory problem. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? d. Oxygen saturation by pulse oximetry c. Wheezing The nurse can also teach him or her to use the bedside table with a pillow and lean on it. A) Inform the patient that it is one of the side effects of Select all that apply. Turbinates warm and moisturize inhaled air. b. 2. Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. Lower Respiratory Tract Infections and Disord, Lewis Ch. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. Priority Decision: When F.N. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. Decreased immunoglobulin A (IgA) decreases the resistance to infection. d. An electrolarynx placed in the mouth. 4) f. Instruct the patient not to talk during the procedure. The patient needs to be able to effectively remove these secretions to maintain a patent airway. c. The need for frequent, vigorous coughing in the first 24 hours postoperatively Identify up to what extent does the patient knows about pneumonia. e. Increased tactile fremitus d. Small airway closure earlier in expiration e. Increased tactile fremitus a. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. Cleveland Clinic. a. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. 1. If there is airway obstruction this will only block and cause problems in gas exchange. Changes in behavior and mental status can be early signs of impaired gas exchange. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). Atrial Fibrillation Nursing Diagnosis and Nursing Care Plan, Readiness for Enhanced Coping Nursing Diagnosis and Nursing Care Plans, Cystic Fibrosis Nursing Diagnosis Care Plan - NurseStudy.Net. Maximum amount of air that can be exhaled after maximum inspiration a. b. b. Filtration of air Identify and avoid triggers of the allergic reaction. Anna Curran. Administer supplemental oxygen, as prescribed. Promote skin integrity.The skin is the bodys first barrier against infection. This also increases the risk for aspiration pneumonia. b. Auscultate breath sounds at least every 2 to 4 hours or as the patients condition dictates. Weight changes of 1-1.5 kg/day may occur with fluid excess or deficit. This produces an area of low ventilation with normal perfusion. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. 3.3 Risk for Infection. To care for the tracheostomy appropriately, what should the nurse do? Assess intake and output (I&O). 3. e. Posterior then anterior. This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions. Please follow your facilities guidelines, policies, and procedures. Nutrition reviews, 68(8), 439458. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. 2018.01.18 NMNEC Curriculum Committee. A) "I will need to have a follow-up chest x-ray in six to. k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. Promote oral hygiene, including lip and tongue care. b. Oximetry: May reveal decreased O2 saturation (92% or less). Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath Tylenol) administered. Dont forget to include some emergency contact numbers just in case there is an emergency. Arrange the tasks of the patient when providing care to him/her. 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? c. Perform mouth care every 12 hours. This assessment monitors the trend in fluid volume. 3.6 Risk for imbalanced nutrition: less than body requirements. 1) Increase the intake of foods that are high in vitamin C. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. There is a prominent protrusion of the sternum. How to use esophageal speech to communicate Are there any collaborative problems? Pneumonia: Bacterial or viral infections in the lungs . c. Explain the test before the patient signs the informed consent form. Maintain intravenous (IV) fluid therapy as prescribed. Cough and sore throat Nursing care plan pneumonia - Nursing care plan: Pneumonia Pneumonia is an inflammation of the lung - Studocu care plan pneumonia nursing care plan: pneumonia pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair Skip to document Ask an Expert Sign inRegister Sign inRegister Home Thorough hand hygiene before and after patient contact (even if gloves are worn). Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. c. a throat culture or rapid strep antigen test. the medication. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. Tachycardia (resting heart rate [HR] more than 100 bpm). Use a sterile catheter for each suctioning procedure. Techniques that will be used to alleviate a dry mouth and prevent stomatitis The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Fungal pneumonia. Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. b. Finger clubbing Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. a. Undergo weekly immunotherapy. g. FEV1: (1) Amount of air exhaled in first second of forced vital capacity a. treatment with antibiotics. These interventions help facilitate optimum lung expansion and improve lungs ventilation. b. Bronchophony d. Normal capillary oxygen-carbon dioxide exchange. Our website services and content are for informational purposes only. The oxygenation status with a stress test would not assist the nurse in caring for the patient now. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. (Symptoms) Reports of feeling short of breath In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. 6. Help the patient get into a comfortable position, usually the half-Fowler position. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. Which instructions does the nurse provide for the patient? k. Value-belief, Risk Factor for or Response to Respiratory Problem A) Sit the patient up in bed as tolerated and apply Nursing Diagnosis: Impaired gas exchange related to alveolar-capillary membrane changes secondary to COPD as evidenced by oxygen saturation 79%, heart rate 112 bpm, and patient reports of dyspnea. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. b. RV: (7) Amount of air remaining in lungs after forced expiration Ventilation is impaired in spite of adequate perfusion in the lungs. The syringe used to obtain the specimen is rinsed with heparin before the specimen is taken and pressure is applied to the arterial puncture site for 5 minutes after obtaining the specimen. Implement NPO orders for 6 to 12 hours before the test. 's nose for several days after the trauma? Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Suction the mouth or the oral airway as needed. 4) Cough suppressants and antihistamines should not be used. Allow the patient to have enough bed rest and avoid strenuous activities. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Nursing diagnosis Related factors Defining characteristics Examples of this type of nursing diagnosis include: Decreased cardiac output Chronic functional constipation Impaired gas exchange Problem-focused nursing diagnoses are typically based on signs and symptoms present in the patient. b. SpO2 of 95%; PaO2 of 70 mm Hg Impaired gas exchange is the state in which there is an excess or deficit in oxygenation or in the elimination of carbon dioxide at the level of the alveolocapillary membrane. (n.d.). Retrieved February 9, 2022, from, Pneumonia: Symptoms, Treatment, Causes & Prevention. The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. a. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . d. SpO2 of 88%; PaO2 of 55 mm Hg. Change the tube every 3 days. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. a. Document the results in the patient's record. Always wear gloves on both hands for suctioning. Antibiotics. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. The patient must understand the importance of seeing an attending physician and not rely on what they see or hear on the internet. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Diminished breath sounds are linked with poor ventilation. Findings may show hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg) with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease. What keeps alveoli from collapsing? The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. d. VC 6. Objective Data A prominent protrusion of the sternum is the pectus carinatum and diminished movement of both sides of the chest indicates decreased chest excursion. Empyema is a collection of pus in the thoracic cavity. c. Drainage on the nasal dressing These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. Atelectasis 6) a. Verify breath sounds in all fields. Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion. c) 5. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). Productive cough (viral pneumonia may present as dry cough at first). Suctioning keeps the airway clear by removing secretions. Partial obstruction of trachea or larynx e. Increased tactile fremitus Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma. 3. a. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. If he or she can not do it, then provide a suction machine always at the bedside. Patient's temperature e. Teach the patient about home tracheostomy care. 26: Upper Respiratory Problems / CH. COPD ND3: Impaired gas exchange. A patient's initial purified protein derivative (PPD) skin test result is positive. This is done before sending the sample to the laboratory if there is no one else who can send the sample to the laboratory. Medications such as paracetamol, ibuprofen, and. The trachea connects the larynx and the bronchi. Provide tracheostomy care. b. How does the nurse assess the patient's chest expansion? F.N. Functional Health Pattern The 150 mL of air is dead space in the trachea and bronchi. Nursing care plan for impaired gas exchange. e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration Use only sterile fluids and dispense with sterile technique. - Pertussis is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis. Poor peripheral perfusion that occurs with hypovolemia or other conditions that cause peripheral vasoconstriction will cause inaccurate pulse oximetry, and ABGs may have to be used to monitor oxygenation status and ventilation status in these patients. d. Thoracic cage. St. Louis, MO: Elsevier. b. The nurse suspects which diagnosis? Lung consolidation with fluid or exudate Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). What is the first patient assessment the nurse should make? To determine the tracheal position, the nurse places the index fingers on either side of the trachea just above the suprasternal notch and gently presses backward. The nurse is preparing the patient for and will assist the health care provider with a thoracentesis in the patient's room. The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. 27: Lower Respiratory Problems / CH. The parietal pleura is a membrane that lines the chest cavity. The patient is infectious from the beginning of the first stage through the third week after onset of symptoms or until five days after antibiotic therapy has been started. d. Comparison of patient's current vital signs with normal vital signs d. Comparison of patient's current vital signs with normal vital signs. The nurse can also teach coughing and deep breathing exercises. c. Percussion 's nasal packing is removed in 24 hours, and he is to be discharged. Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. 5) Minimize time in congregate settings. 2. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Saunders comprehensive review for the NCLEX-RN examination. He or she will also comply and participate in the special treatment program designed for his or her condition. A bronchoscopy requires NPO status for 6 to 12 hours before the test, and invasive tests (e.g., bronchoscopy, mediastinoscopy, biopsies) require informed consent that the HCP should obtain from the patient. d. a total laryngectomy to prevent development of second primary cancers. Proper nutrition promotes energy and supports the immune system. What is the best response by the nurse? Types of Nursing Diagnoses There are 4 types of nursing diagnoses. On inspection, the throat is reddened and edematous with patchy yellow exudates. Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. c. Terminal structures of the respiratory tract 5. Document the results in the patient's record. a. The patient will have a big chance to remember how to administer or perform any therapeutic regimen if they are given the chance to demonstrate and have him/her verbalize their understanding about it. d. Use over-the-counter antihistamines and decongestants during an acute attack. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. Advised the patient that he or she will be evaluated if he or she can tolerate exercise and develop a special exercise to help his or her recovery. Nursing Diagnosis. What measures should be taken to maintain F.N. A pulmonary angiogram involves the injection of an iodine-based radiopaque dye, and iodine or shellfish allergies should be assessed before injection. Patient with a fever d. An ET tube is more likely to lead to lower respiratory tract infection. The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. Building up secretions in the airway will only cause a problem since it will obstruct the airflow from going in and out of the body. The prognosis of a patient with PE is good if therapy is started immediately. b. c. Take the specimen immediately to the laboratory in an iced container. Nursing Diagnosis: Ineffective Airway Clearance. Pinch the soft part of the nose. b. Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment. j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems d. Limited chest expansion A patient develops epistaxis after removal of a nasogastric tube. Perform steam inhalation or nebulization as required/ prescribed. e. FVC Cough, sore throat, low-grade elevated temperature, myalgia, and purulent nasal drainage at the end of a cold are common symptoms of viral rhinitis and influenza. Cancer of the lung Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion. Desired Outcome: At the end of the span of care, the patient will be able to understand the transmission, disease process, and available treatments for pneumonia. Patients with compromised immune systems such as those with COPD, HIV, or autoimmune diseases should be educated on the risk and how to protect themselves. Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention. a. Vt The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. If the patients condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection. a. c. Tracheal deviation Impaired Gas Exchange Assessment 1. d. Activity-exercise: Decreased exercise or activity tolerance, dyspnea on rest or exertion, sedentary habits Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. b. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. Discuss to him/her the different pros and cons of complying with the treatment regimen. One way to have a good prognosis and help fasten recovery is to comply with the prescribed treatment. 1. b. The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? d. Apply an ice pack to the back of the neck. b. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. During the day, basket stars curl up their arms and become a compact mass. Decreased force of cough c. Ventilation-perfusion scan Basket stars are active at night. How to use a mirror to suction the tracheostomy 7. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? 5) Corticosteroids and bronchodilators are helpful in reducing Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. Assist with respiratory devices and techniques.Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. a. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration
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