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The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. If sepsis is suspected, a blood culture can be obtained. It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Attend to the patients queries regarding their pneumonia treatment. Identify up to what extent does the patient knows about pneumonia. b. A patient presents to the emergency department with a temperature of 101.4F (38.6C) and a productive cough with rust-colored sputum. Administer the prescribed antibiotic and anti-pyretic medications. Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. Match the descriptions or possible causes with the appropriate abnormal assessment findings. d. Contain dead air that is not available for gas exchange. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. b. Cough and sore throat 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. 3) Illicit drug intake k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? 3. Decreased force of cough In addition, have the patient upright and leaning forward to prevent swallowing blood. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. b. Stridor It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. Otherwise, scroll down to view this completed care plan. 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. An ET tube has a higher risk of tracheal pressure necrosis. 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. Has been NPO since midnight in preparation for surgery This type of pneumonia refers to getting the infection at home, in the workplace, in school, or other places in the community outside a hospital or care facility. 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. COPD ND3: Impaired gas exchange. Steroids: To reduce the inflammation in the lungs. 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. If the patient is having increased mucous production, encourage him or her to clear the airway. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, Patients who are weak or lack a cough reflex may not be able to do so. c. Comparison of patient's SpO2 values with the normal values The cough with pertussis may last from 6 to 10 weeks. a. Signs and Symptoms of impaired gas exchange dyspnea, SOB cough hemoptysis: coughing up blood abnormal breathing patterns: tachypnea, diabetic ketoacidosis, kusbal respirations (diabetic ketoacidosis leads to hypoxemia through kusbal resp trying to get rid of extra CO2) hypoventilation hyperventilation cyanosis (late sign) Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma. The thoracic cage is formed by the ribs and protects the thoracic organs. Order stat ABGs to confirm the SpO2 with a SaO2. b. 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. 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. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. 8 . Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. When is the nurse considered infected? b. Night sweats The patient may have a limit to visitors to prevent the transmission of infections. Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. There is no redness or induration at the injection site. Smoking further increases the risk of developing pneumonia and should be avoided. No signs or symptoms of tuberculosis or allergies are evident. In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. A knowledgeable patient is more likely to comply with therapy. Position the patient to be comfortable (usually in the half-Fowler position). It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). She has worked in Medical-Surgical, Telemetry, ICU and the ER. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. Encourage coughing up of phlegm. They will further understand the topic since they already have an idea of what is it about. Pneumonia may increase sputum production causing difficulty in clearing the airways. b. d. a total laryngectomy to prevent development of second primary cancers. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. What is the reason for delaying repair of F.N. Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Shetty, K., & Brusch, J. L. (2021, April 15). 2. b. Epiglottis Which respiratory defense mechanism is most impaired by smoking? The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. a. radiation therapy that preserves the quality of the voice. c. Terminal structures of the respiratory tract This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Assess the patients knowledge about Pneumonia. 1) b. d. Chronic herpes simplex infections of the mouth and lips. What is included in the nursing care of the patient with a cuffed tracheostomy tube? Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. 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. Allow patients to ask a question or clarify regarding their treatment. Corticosteroids and bronchodilators are not useful in reducing symptoms. c. A tracheostomy tube allows for more comfort and mobility. Medications such as paracetamol, ibuprofen, and. 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. The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. Suction the mouth or the oral airway as needed. Immobile patients or those who need assistance should be turned every 2 hours, assisted into an upright position, or transferred into a chair to promote lung expansion. d. Reflex bronchoconstriction. 3. Cancer of the lung 4) f. Instruct the patient not to talk during the procedure. c. Check the position of the probe on the finger or earlobe. b. 7. Touching an infected object and then touching your nose or mouth can also transfer the germs. The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. d. Comparison of patient's current vital signs with normal vital signs. This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time spent in congregate settings or on public transportation. If he or she can not do it, then provide a suction machine always at the bedside. Elevate the head of the bed and assist the patient to assume semi-Fowlers position. 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. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. Match the following pulmonary capacities and function tests with their descriptions. Finger clubbing and accessory muscle use are identified with inspection. 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. A patient's initial purified protein derivative (PPD) skin test result is positive. Start asking what they know about the disease and further discuss it with the patient. There is a prominent protrusion of the sternum. Identify the ability of the patient to perform self-care and do activities of daily living. A patient's ABGs include a PaO2 of 88 mm Hg and a PaCO2 of 38 mm Hg, and mixed venous blood gases include a partial pressure of oxygen in venous blood (PvO2) of 40 mm Hg and partial pressure of carbon dioxide in venous blood (PvCO2) of 46 mm Hg. 2. The nurse can also teach him or her to use the bedside table with a pillow and lean on it. Chronic hypoxemia b. What is the first action the nurse should take? The patient has been diagnosed with an early vocal cord cancer. Pinch the soft part of the nose. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. a. Thoracentesis f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. This is most common in intensive care units usually resulting from intubation and ventilation support. A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody). Amount of air that can be quickly and forcefully exhaled after maximum inspiration 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. 3) Sleep alone. b. Surfactant The nurse will gather the supplies as soon as the order to do a thoracentesis is given. b. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration a. b. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public. Consider imperceptible losses if the patient is diaphoretic and tachypneic. Pleurisy, a) 7. Buy on Amazon, Silvestri, L. A. d. Testing causes a 10-mm red, indurated area at the injection site. Help the patient get into a comfortable position, usually the half-Fowler position. Hospital acquired pneumonia may be due to an infected. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. a. Stridor 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. "You should get the inactivated influenza vaccine that is injected every year." 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. 3.3 Risk for Infection. A) Seizures Monitor for worsening signs of infection or sepsis.Dropping blood pressure, hypothermia or hyperthermia, elevated heart rate, and tachypnea are signs of sepsis that require immediate attention. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. 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. Although inadequately treated -hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. Also, they will effectively help spread the disease process since they know the mode of transmission and how to break the cycle of transmitting it to other family members. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. d. Pulmonary embolism 3) Treatment usually includes macrolide antibiotics. c. Encourage deep breathing and coughing to open the alveoli. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. a. Carina Base to apex Homes should be well ventilated, especially the areas where the infected person spends a lot of time. d. Notify the health care provider of the change in baseline PaO2. Cleveland Clinic. 1) The cough may last from 6 to 10 weeks. a. Suction the tracheostomy. Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control. a. Suction the tracheostomy. Empyema is a collection of pus in the thoracic cavity. 3 Nursing care plans for pneumonia. e. Posterior then anterior c. Have the patient hyperextend the neck. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. Maximum amount of air lungs can contain St. Louis, MO: Elsevier. If the patients condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection. The patient is positioned and instructed not to talk or cough to avoid damage to the lung. 2) d. Direct the family members to the waiting room. 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. (n.d.). What is the first patient assessment the nurse should make? d. An electrolarynx placed in the mouth. Have an initial assessment of the patients respiratory rate, rhythm, and oxygen saturation every 4 hours or depending on the need. Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. Other antibiotics that may be used for pneumonia include doxycycline, levofloxacin, and combination of macrolide and beta-lactam (amoxicillin or amoxicillin/clavulanate known as Augmentin). Bacterial Pneumonia. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. h. FRC d. SpO2 of 88%; PaO2 of 55 mm Hg Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. She earned her BSN at Western Governors University. This assessment monitors the trend in fluid volume. "You should get the inactivated influenza vaccine that is injected every year." document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Breath sounds in all lobes are verified to be sure that there was no damage to the lung. Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? Respiratory infection 3. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. Unless contraindicated, promote fluid intake (2.5 L/day or more). During a follow-up visit one week after starting the medication, the patient tells the nurse, "In the last week, my urine turned orange, and I am very worried about it." h) 3. 4. Before other measures are taken, the nurse should check the probe site. b. Encourage the patient to see their medical attending physician for approval and safe treatment. Goal. This patient is older and short of breath. c. Ventilation-perfusion scan The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Lower Respiratory Tract Infections and Disord, Lewis Ch. A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. e. Sleep-rest Our website services and content are for informational purposes only. b. Use a sterile catheter for each suctioning procedure. All of the assessments are appropriate, but the most important is the patient's oxygen status. Impaired Gas Exchange is a NANDA nursing diagnosis that is used for conditions where there is an alteration in the balance between the exchange of gases in the lungs. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . Are there any collaborative problems? Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. Select all that apply. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. 5. 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)? 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. Level of the patient's pain c. a throat culture or rapid strep antigen test. Fungal pneumonia. A third type is pneumonia in immunocompromised individuals. Which instructions does the nurse provide to a patient with acute bronchitis? c. Drainage on the nasal dressing Nursing Diagnosis Impaired Gas Exchange related to to altered alveolarcapillary membrane changes due to pneumonia disease process. Air trapping To detect presence of hypernatremia, hyperglycemia, and/or dehydration. d. Normal capillary oxygen-carbon dioxide exchange. These interventions contribute to adequate fluid intake. Nursing Diagnosis: Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and increased PCO2. impaired Gas Exchange may be related to decreased oxygen-carrying capacity of blood, reduced RBC life span, abnormal RBC structure, increased blood viscosity, predisposition to bacterial pneumonia/pulmonary infarcts, possibly evidenced by dyspnea, use of accessory muscles, cyanosis/signs of hypoxia, tachycardia, changes in mentation, and . The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. Suctioning keeps the airway clear by removing secretions. a. c. Elimination: Constipation, incontinence j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems c. "An annual vaccination is not necessary because previous immunity will protect you for several years." Select all that apply. c. A nasogastric tube with orders for tube feedings If O2 saturation does not increase to an acceptable level (greater than 92%), FiO2 is increased in small increments while simultaneously checking O2 saturation or obtaining ABG values. The immunity will not protect for several years, as new strains of influenza may develop each year. 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. c. Take the specimen immediately to the laboratory in an iced container. The position of the oximeter should also be assessed. c. Check the position of the probe on the finger or earlobe. 2018.01.18 NMNEC Curriculum Committee. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. b. RV 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. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. 26: Upper Respiratory Problems / CH. Goal/Desired Outcome Short-term goal: The patient will remain free from signs of respiratory distress and her oxygen saturation will remain higher than 96% for the duration of the shift. Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. Since the patient is manifesting impaired gas exchange, one of the good indications that the oxygen absorption inside the body is not improving is through the skin changes, nail bed discoloration, and mucous production. Fatigue 4. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. Pneumonia: Bacterial or viral infections in the lungs . 4. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). d. Inform the patient that radiation isolation for 24 hours after the test is necessary. Which values indicate a need for the use of continuous oxygen therapy? A) Teaching the patient how to cough effectively and. 1. a. A tracheostomy is safer to perform in an emergency. How to use esophageal speech to communicate Inspection Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. Learn how your comment data is processed. Community-acquired pneumonia occurs outside of the hospital or facility setting. 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. Report weight changes of 1-1.5 kg/day. d. Dyspnea and severe sinus pain Impaired gas exchange is closely tied to Ineffective airway clearance. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. Assess lung sounds and vital signs.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. She received her RN license in 1997. d. Assess arterial blood gases every 8 hours. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. a. Assess the patient for iodine allergy. Assess for mental status changes. e. Increased tactile fremitus - The patient's clinical picture is most likely pulmonary embolism (PE), and the first action the nurse should take is to assist with the patient's respirations. Patient who is anesthetized d. Dyspnea and severe sinus pain. How does the nurse assess the patient's chest expansion? Adjust the room temperature. - 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. As an Amazon Associate I earn from qualifying purchases. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. 3.2 Impaired Gas Exchange. NurseTogether.com does not provide medical advice, diagnosis, or treatment. 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. What measures should be taken to maintain F.N. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. Nurses should assess for and encourage pneumonia vaccines for eligible populations. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. b. Cyanosis Identify and avoid triggers of the allergic reaction. Put the index fingers on either side of the trachea. symptoms. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. Assess for mental status changes.Poor oxygenation leads to decreased perfusion to the brain resulting in a decreased level of consciousness, restlessness, agitation, and lethargy. 3. Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. Teach the importance of complying with the prescribed treatment and medication. Important sounds may be missed if the other strategies are used first. A nasal ET tube in place Provide tracheostomy care every 24 hours. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. It must include the local 911 numbers, hospitals, and immediate keen of the patient. Auscultate breath sounds at least every 2 to 4 hours or as the patients condition dictates. Partial obstruction of trachea or larynx 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. Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration, and the nurse should monitor the patient's respiratory rate and rhythm and SpO2. Visualize and note some changes when it comes to the color of the skin, quality of mucous production, and nail beds. g) 4. Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.