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1. This type of pneumonia can spread through droplet transmission, that is, when an infected person sneezes or coughs, and the other person breathes the air droplets through the nasal or oral airways. A tracheostomy is safer to perform in an emergency. Select all that apply. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. In addition, have the patient upright and leaning forward to prevent swallowing blood. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. Allow the patient to have enough bed rest and avoid strenuous activities. Because antibody production in response to infection with the tuberculosis (TB) bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, 2-step testing is recommended for individuals likely to be tested often, such as health care professionals. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. cancer patients or COPD patients). Health perception-health management: Tobacco use history, gradual change in health status, family history of lung disease, sputum production, no immunizations for influenza or pneumococcal pneumonia received, travel to developing countries b. Epiglottis b. Surfactant b. Finger clubbing When does the nurse record the presence of an increased anteroposterior (AP) diameter of the chest? It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. b. Arrange the tasks of the patient when providing care to him/her. Aspiration precautions include maintaining a 30-degree elevation of the HOB, turning the patient onto his or her side rather than back, and using continuous rather than bolus feeding when the patient is enteral. Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. All of the assessments are appropriate, but the most important is the patient's oxygen status. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. b. a hemilaryngectomy that prevents the need for a tracheostomy. Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. 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. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. 2) It is a highly contagious respiratory tract infection. Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? e. Posterior then anterior. Goal. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. Save my name, email, and website in this browser for the next time I comment. These measures ensure consistency and accuracy of weight measurements. St. Louis, MO: Elsevier. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? Discussion Questions As a result of the inflammation, the lung tissue becomes edematous and the air spaces fill with exudate (consolidation), gas exchange cannot occur, and non-oxygenated blood is diverted into the vascular system, resulting in hypoxemia. A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems a. Stridor Given a square matrix [A], write a single line MATLAB command that will create a new matrix [Aug] that consists of the original matrix [A] augmented by an identity matrix [I]. This is an expected finding with pneumonia, but should not continue to rise with treatment. c. SpO2 of 90%; PaO2 of 60 mm Hg b. RV b. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. After the intervention, the patients airway is free of incidental breath sounds. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. a. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. b. SpO2 of 95%; PaO2 of 70 mm Hg 3.1 Ineffective airway clearance. h) 3. These critically ill patients have a high mortality rate of 25-50%. Shetty, K., & Brusch, J. L. (2021, April 15). Nursing Care Plan Patient's Name: Baby M Medical Diagnosis: Pediatric Community Acquired Pneumonia Nursing Diagnosis: Impaired gas exchange r/t collection of secretions affecting oxygen exchange across alveolar membrane. Avoid environmental irritants inside the patients room. Auscultate breath sounds at least every 2 to 4 hours or as the patients condition dictates. Change the tube every 3 days. For best yield, blood cultures should be obtained before antibiotics are administered. Priority Decision: When F.N. Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. Perform steam inhalation or nebulization as required/ prescribed. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. d. Anterior then posterior Partial obstruction of trachea or larynx Breath sounds in all lobes are verified to be sure that there was no damage to the lung. Base to apex 2. Complications include hyperventilation, gastric hyperinflation, headache, hypotension, and signs and symptoms of pneumothorax (shortness of breath, stabbing chest pain, decreased breath sounds on one side, dyspnea, cough). Priority: Management of pneumonia and dehydration. 8 . What process would they have needed to complete in order to have been successful? 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. Promote a well-ventilated environment so that the patient will have good oxygen exchange in the body. f) 2. Unless contraindicated, promote fluid intake (2.5 L/day or more). 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. (n.d.). She has worked in Medical-Surgical, Telemetry, ICU and the ER. Atelectasis The turbinates in the nose warm and moisturize inhaled air. 3.2 Impaired Gas Exchange. Maximum amount of air lungs can contain Teach the patient to use the incentive spirometer as advised by their attending physician. Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. d. Comparison of patient's current vital signs with normal vital signs. Learning to apply information through a return demonstration is more helpful than verbal instruction alone. 6. a. Discontinue if SpO2 level is above the target range, or as ordered by the physician. b. d. Testing causes a 10-mm red, indurated area at the injection site. Techniques that will be used to alleviate a dry mouth and prevent stomatitis Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. Outcomes Interventions Rationale with reference Eval of goal/outcomes Gas r/t alveolar- membrane AEB Positive for strep Bi-pap to maintain rhonchi diminished breath bilaterally. Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. "You should get the inactivated influenza vaccine that is injected every year." Coughing and difficulty of breathing may cause. Patient with a fever People with community-acquired pneumonia usually do not need to be hospitalized unless an underlying condition such as chronic obstructive pulmonary disease (COPD), heart disease or diabetes mellitus, or a weakened immune system complicates the disease. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. Administer the prescribed antibiotic and anti-pyretic medications. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. Amount of air that can be quickly and forcefully exhaled after maximum inspiration - Conditions that increase the risk for aspiration include a decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and insertion of nasogastric (NG) tubes with or without enteral feeding. b. Bronchophony d. Assess arterial blood gases every 8 hours. a. For which problem is this test most commonly used as a diagnostic measure? c. a radical neck dissection that removes possible sites of metastasis. Community-acquired pneumonia occurs outside of the hospital or facility setting. Cough and sore throat Nurses also play a role in preventing pneumonia through education. Moisture helps minimize convective moisture loss during oxygen therapy. 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 b. Unstable hemodynamics Start asking what they know about the disease and further discuss it with the patient. The most common. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Nursing care plan for impaired gas exchange. This patient is older and short of breath. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. c. Place the thumbs at the midline of the lower chest. Sputum for Gram stain and culture and sensitivity tests: Sputum is obtained from the lower respiratory tract before starting antibiotic therapy to identify the causative organisms. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). Buy on Amazon, Silvestri, L. A. 6. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. Encourage to always change position to facilitate mucous drainage in the lungs. Tylenol) administered. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). 1. An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. Which immediate action does the nurse take? A relative increase in antibody titers indicates viral infection. 8. Nursing Care Plan 2 b. Epiglottis Smoking does not directly affect filtration of air, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? Impaired Gas Exchange This COPD nursing diagnosis may be related to bronchospasm, air-trapping and obstruction of airways, alveoli destruction, and changes in the alveolar-capillary membrane. 26: Upper Respiratory Problems / CH. h. FRC When F.N. Level of the patient's pain This work is the product of the If there is airway obstruction this will only block and cause problems in gas exchange. 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. Which instructions does the nurse provide to a patient with acute bronchitis? Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Notify the health care provider. c. Elimination 4) Spend as much time as possible outdoors. Apply pressure to the puncture site for 2 full minutes. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. Use narcotics and sedatives with caution.Narcotics for pain control or anti-anxiety medications should be monitored closely as they can further suppress the respiratory system. d. Thoracic cage. Summarize why people were unsuccessful over 1,000 years ago when they tried to transform lead into gold. c. There is equal but diminished movement of the 2 sides of the chest. Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. (2020). Try to use words that can be understood by normal people. Auscultation of breath sounds every 2 to 4 hours (or depending on the patients condition) and reporting of changes in the patients ability to secrete lung secretions. Teach the importance of complying with the prescribed treatment and medication. What priority discharge teaching should the nurse provide? What is the first action the nurse should take? A less severe form of bacterial pneumonia is called walking or atypical pneumonia, in which the symptoms are very mild and the infected person can do his/her activities of daily living as normal. Page . Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. The bacteria may enter the blood stream and cause, Trouble sleeping. Assist the patient when they are doing their activities of daily living. Fatigue 4. Proper nutrition promotes energy and supports the immune system. A) Pneumonia 3.4 Activity Intolerance. d. Patient receiving oxygen therapy. c) 5. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. She earned her BSN at Western Governors University. 4) Cough suppressants and antihistamines should not be used. No signs or symptoms of tuberculosis or allergies are evident. Individuals with depressed level of consciousness, advanced age, dysphagia, or a nasogastric (NG) or enteral tube are at increased risk for aspiration, which predisposes them to pneumonia. A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of cerebrospinal fluid and stimulates an increase in the respiratory rate. Hyperkalemia is not occurring and will not directly affect oxygenation initially. Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. Put the index fingers on either side of the trachea. 8. c. Keep a same-size or larger replacement tube at the bedside. The patients blood oxygen saturation (SpO2) will also be within the target levels set by the physician (usually 96 to 100 percent; 88 to 92% for most. b. Encourage the patient to see their medical attending physician for approval and safe treatment. CH. Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. St. Louis, MO: Elsevier. Heavy tobacco and/or alcohol use Monitor cuff pressure every 8 hours. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). What the oxygenation status is with a stress test Medications such as paracetamol, ibuprofen, and. Pneumonia: Bacterial or viral infections in the lungs . Viruses such as RSV (common cause in infants age 1 and below), flu and cold viruses can cause viral pneumonia, which is the second most common type of pneumonia. The width of the chest is equal to the depth of the chest. 2. Report significant findings. To avoid the formation of a mucus plug, suction it as needed. b. RV: (7) Amount of air remaining in lungs after forced expiration Collaboration: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the registered nurse (RN) may delegate which interventions to the licensed practical/vocational nurse (LPN/VN) (select all that apply)? There is alteration in the normal respiratory process of an individual. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). Water, hydration, and health. d. Pulmonary embolism. a. Study Resources . b. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). If the patients condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection. Cough suppressants. c. TLC The position of the oximeter should also be assessed. a. b. The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. Chronic hypoxemia Lung consolidation with fluid or exudate Consider using a closed suction system; replace closed suction system according to agency guidelines. 3.7 Risk for Deficient Fluid Volume. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. Provide tracheostomy care. A nasal ET tube in place Suction secretions as needed. This position provides comfort and facilitates the ease and effectiveness of these exercises by promoting better lung expansion (less compression of the lungs by the abdominal organs) and better gas exchange. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. a. 1. A cascade cough removes secretions and improves ventilation through a sequence of shorter and more forceful exhalations than is the case with the usual coughing exercise. 2. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. c. Tracheal deviation In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. d. Pleural friction rub. Priority Decision: A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG) results: pH 7.40, partial pressure of oxygen in arterial blood (PaO2) 74 mm Hg, arterial oxygen saturation (SaO2) 92%, partial pressure of carbon dioxide in arterial blood (PaCO2) 40 mm Hg. Excess CO2 does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid. Ventilation is impaired in spite of adequate perfusion in the lungs. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. g. FEV1: (1) Amount of air exhaled in first second of forced vital capacity c. Inadequate delivery of oxygen to the tissues d. Reflex bronchoconstriction. Always maintain sterility or aseptic techniques when performing any invasive procedure. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. A) Purulent sputum that has a foul odor Anna Curran. The nurse should instruct on how to properly use these devices and encourage their use hourly. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. The assessment findings include a temperature of 98.4F (36.9C), BP 130/88 mm Hg, respirations 36 breaths/min, and an oxygen saturation reading of 91% on room air. Stop feeding when the patient is lying flat. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. Assess intake and output (I&O). b. "You should get the inactivated influenza vaccine that is injected every year." Obtain the supplies that will be used. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia, https://my.clevelandclinic.org/health/diseases/4471-pneumonia, https://doi.org/10.1111/j.1753-4887.2010.00304.x, https://emedicine.medscape.com/article/234753-overview#a4, Hypertension Nursing Diagnosis & Care Plan, The ABCs of Evidence-Based Practice in Nursing, Diminished lung sounds or crackles/rhonchi, Patient will demonstrate appropriate airway clearance techniques, Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate, Hypoventilation causing a lack of oxygen delivery, Patient will display appropriate oxygenation through ABGs within normal limits, Patient will demonstrate appropriate actions to promote ventilation and oxygenation, Inadequate primary defenses: decreased ciliary action, respiratory secretions, Invasive procedures: suctioning, intubation, Patient will not develop a secondary infection or sepsis, Patient will display improvement in infection evidenced by vital signs and lab values within normal limits. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration These interventions help facilitate optimum lung expansion and improve lungs ventilation. What action should the nurse take? 2018.01.18 NMNEC Curriculum Committee. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. Community-Acquired Pneumonia. Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. b. d. Pleural friction rub Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. The manifestations of viral, fungal, and bacterial infections are similar, and appearance is not diagnostic except when the white, irregular patches on the oropharynx suggest that candidiasis is present. Is elevated in bacterial pneumonias (greater than 12,000/mm3). During the day, basket stars curl up their arms and become a compact mass. The cough with pertussis may last from 6 to 10 weeks. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Attempt to replace the tube. k. Value-belief, Risk Factor for or Response to Respiratory Problem Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. 1. Nursing care plans: Diagnoses, interventions, & outcomes. Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. a. Which respiratory defense mechanism is most impaired by smoking? Hospital acquired pneumonia may be due to an infected. c. Explain the test before the patient signs the informed consent form. d. Positron emission tomography (PET) scan. A) Increasing fluids to at least 6 to 10 glasses/day, unless. Select all that apply. The epiglottis is a small flap closing over the larynx during swallowing. d. Use over-the-counter antihistamines and decongestants during an acute attack. a. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. There is no redness or induration at the injection site. The other options contribute to other age-related changes. f. Hyperresonance Homes should be well ventilated, especially the areas where the infected person spends a lot of time. a. Assess the patient for iodine allergy. 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. Amount of air remaining in lungs after forced expiration Ciliary action impaired by smoking and increased mucus production may be caused by the irritants in tobacco smoke, leading to impairment of the mucociliary clearance system. associated with inadequate primary defenses (e.g., decreased ciliary activity), invasive procedures (e.g., intubation), and/or chronic disease Desired outcome: patient is free of infection as evidenced by normothermia, a leukocyte count of 12,000/mm3 or less, and clear to whitish sputum. a. radiation therapy that preserves the quality of the voice. The immunity will not protect for several years, as new strains of influenza may develop each year. Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma.

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