f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. On inspection, the throat is reddened and edematous with patchy yellow exudates. b. Surfactant d. Contain dead air that is not available for gas exchange. Increase heat and humidity if patient has persistent secretions. The other options do not maintain inflation of the alveoli. Blood tests elevated white blood cell count may be a sign of an ongoing infection, Sputum culture to determine the causative agent, Imaging chest X-ray to determine active infection and its severity; bronchoscopy to check any blockage of the airways; CT scan for a more detailed lung imaging, Arterial blood gas (ABG) test using an arterial blood sample to measure the oxygen level, Pleural fluid culture taking a pleural fluid sample by inserting a needle between the pleural cavity and the ribs in order to determine the causative agent. Signs and symptoms of respiratory distress include agitation, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory respiratory muscles. The treatment and medication should be prescribed by the attending physician and do not take meds that are not prescribed to prevent unnecessary drug interaction. Retrieved February 9, 2022, from, Pneumonia: Symptoms, Treatment, Causes & Prevention. Which action does the nurse take next? Base to apex Types of Nursing Diagnoses There are 4 types of nursing diagnoses. - 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. Encourage coughing up of phlegm. Select all that apply. Position the patient on the side. This is an expected finding with pneumonia, but should not continue to rise with treatment. Has been NPO since midnight in preparation for surgery If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. a. To avoid the formation of a mucus plug, suction it as needed. 27: Lower Respiratory Problems / CH. What do these findings indicate? Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. Pneumonia Nursing Care Plan 4 Impaired Gas Exchange Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. d. Pulmonary embolism the medication. Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). Pleurisy This also increases the risk for aspiration pneumonia. Pulmonary function tests are noninvasive. 3.1 Ineffective airway clearance. Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? Ensure that the patient performs deep breathing with coughing exercises at least every 2 hours. Immunosuppression and neutropenia are predisposing factors for the development of nosocomial pneumonia caused by common and uncommon pathogens. b. 3. 1. 1. Cough suppressants. 3.2 Impaired Gas Exchange. c. SpO2 of 90%; PaO2 of 60 mm Hg b. Unstable hemodynamics b. This produces an area of low ventilation with normal perfusion. When taking care of a patient with pneumonia, it is important to ensure the environment is well ventilated, conducive for good rest, and accessible when the patient needs assistance or help. b. Epiglottis A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. c. Use cromolyn nasal spray prophylactically year-round. The nurse suspects which diagnosis? Periorbital and facial edema reduced by about half since second hospital day Provide tracheostomy care every 24 hours. Monitor oximetry values; report O2 saturation of 92% or less. 3. Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues. NurseTogether.com does not provide medical advice, diagnosis, or treatment. Allow 90 minutes for. Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion secondary to pneumonia as evidenced by a respiratory rate of 22, usage of accessory muscles, and labored breathing. a. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. presence of nasal bleeding and exhalation grunting. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. Please read our disclaimer. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Start oxygen administration by nasal cannula at 2 L/min. Pinch the soft part of the nose. 6) The patient is infectious from the beginning of the first stage 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. The arterial oxygen saturation by pulse oximetry (SpO2) compared with normal values will not be helpful in this older patient or in a patient with respiratory disease as the patient's expected normal will not be the same as standard normal values. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? Volume of air inhaled and exhaled with each breath The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. Reports facial pain at a level of 6 on a 10-point scale Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. Buy on Amazon, Silvestri, L. A. She earned her BSN at Western Governors University. The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. a. Carina c. Patient in hypovolemic shock Teach patients some signs and symptoms that prompt immediate medical attention such as dyspnea. 3 Nursing care plans for pneumonia. a. 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. So to avoid that, they must be assisted in any activities to help conserve their energy. The nurse selects Ineffective Breathing Pattern after validating this patient is demonstrating the associated signs and symptoms related to this nursing diagnosis: Dyspnea Increase in anterior-posterior chest diameter (e.g., barrel chest) Nasal flaring Orthopnea Prolonged expiration phase Pursed-lip breathing Tachypnea Changes in oxygen therapy or interventions should be avoided for 15 minutes before the specimen is drawn because these changes might alter blood gas values. c. Mucociliary clearance b. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. What measures should be taken to maintain F.N. c. Check the position of the probe on the finger or earlobe. Why is the air pollution produced by human activities a concern? Have an initial assessment of the patients respiratory rate, rhythm, and oxygen saturation every 4 hours or depending on the need. a. Esophageal speech When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. a. g. Position the patient sitting upright with the elbows on an over-the-bed table. d. SpO2 of 88%; PaO2 of 55 mm Hg. Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. c. Elimination: Constipation, incontinence If there is airway obstruction this will only block and cause problems in gas exchange. Teach the proper technique of doing pursed-lip breathing, various ways of relaxation, and abdominal breathing. 2018.03.29 NMNEC Leadership Council. How to use a mirror to suction the tracheostomy It is important to acknowledge their limited information about the disease process and start educating him/her from there. c. Patient in hypovolemic shock Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Partial obstruction of trachea or larynx Document the results in the patient's record. Avoid instillation of saline during suctioning. What covers the larynx during swallowing? This assessment monitors the trend in fluid volume. Which respiratory defense mechanism is most impaired by smoking? This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. The width of the chest is equal to the depth of the chest. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . a. Apex to base Assess the patients knowledge about Pneumonia. a. Select all that apply. Wear gloves on both hands when handling the cannula or when handling ventilation tubing. Our website services and content are for informational purposes only. 4. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. d. SpO2 of 88%; PaO2 of 55 mm Hg What process would they have needed to complete in order to have been successful? Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. Administer nebulizer treatments and other medications.Nebulizer treatments can loosen secretions in the lungs while mucolytics and expectorants can help thin mucus and make it easier to cough up. Skin breakdown allows pathogens to enter the body. NMNEC Concept: Gas Exchange. a. Empyema is a collection of pus in the thoracic cavity. The 150 mL of air is dead space in the trachea and bronchi. Nursing Diagnosis. Educating him/her to use the incentive spirometer will encourage him/her to exercise deep inspiration that will help get more oxygen in the lungs and prevent hypoxia. Teach the importance of complying with the prescribed treatment and medication. Most of the problems in connection to the reoccurrence of pneumonia are poor compliance to the prescribed treatment. 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. b. Copious nasal discharge Lung abscess. Hospital associated Nosocomial pneumonias, Pneumonia in the immunocompromised individual, Risk for Infection (nosocomial pneumonia), Impaired Gas Exchange due to pneumonic condition, 5 Nursing care plans for anemia | Anemia nursing interventions, 5 Nursing diagnosis of pneumonia and care plans, Nursing Care Plans Stroke with Nursing Diagnosis. 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 Homes should be well ventilated, especially the areas where the infected person spends a lot of time. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. Goal. c. Remove the inner cannula if the patient shows signs of airway obstruction. Report significant findings. A) "I will need to have a follow-up chest x-ray in six to. Which values indicate a need for the use of continuous oxygen therapy? c. Have the patient hyperextend the neck. Administer the prescribed antibiotic and anti-pyretic medications. Amount of air that can be quickly and forcefully exhaled after maximum inspiration 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. c. Percussion c. A nasogastric tube with orders for tube feedings Coughing and difficulty of breathing may cause. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. Pneumonia is an infection itself but a risk for infection nursing diagnosis is appropriate as untreated pneumonia can progress into a secondary infection or sepsis. What accurately describes the alveolar sacs? Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. Most of the cases of poor prognosis of pneumonia are undertreatment or not being able to be assessed earlier. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Bronchodilators: To dilate or relax the muscles on the airways. Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. To help clear thick phlegm that the patient is unable to expectorate. Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control. Retrieved February 9, 2022, from. Keep the patient in the semi-Fowler's position at all times. b. e. Sleep-rest: Sleep apnea. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness. The patient is positioned and instructed not to talk or cough to avoid damage to the lung.
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