a. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. The width of the chest is equal to the depth of the chest. Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae. e. Increased tactile fremitus 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. 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. Level of the patient's pain 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. 2. of . To care for the tracheostomy appropriately, what should the nurse do? Learn how your comment data is processed. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. 2. d. Notify the health care provider of the change in baseline PaO2. What is the most appropriate action by the nurse? Learning to apply information through a return demonstration is more helpful than verbal instruction alone. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Have an initial assessment of the patients respiratory rate, rhythm, and oxygen saturation every 4 hours or depending on the need. The patient may have a limit to visitors to prevent the transmission of infections. Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. Usual PaO2 levels are expected in patients 60 years of age or younger. A) Sit the patient up in bed as tolerated and apply j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems d. Pleural friction rub a. Priority Decision: F.N. This can be due to a compromised respiratory system or due to lung disease. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. e. FVC b. Stridor 1. k. Value-belief, Risk Factor for or Response to Respiratory Problem Proper nutrition promotes energy and supports the immune system. a. b. Filtration of air To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. a. d. Thoracic cage. b. Nursing Diagnosis. Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, have respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96%, and verbalize ease of breathing. Assess lung sounds and vital signs. Signs and symptoms of respiratory distress include agitation, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory respiratory muscles. To regulate the temperature of the environment and make it more comfortable for the patient. 3 Nursing care plans for pneumonia. Activity intolerance 2. 3.6 Risk for imbalanced nutrition: less than body requirements. Anna Curran. Implement NPO orders for 6 to 12 hours before the test. Decreased compliance contributes to barrel chest appearance. c. Send labeled specimen containers to the laboratory. Nursing Diagnosis: Ineffective Airway Clearance. b. 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. Since the patients body is having difficulty with gas exchange due to pneumonia, it will benefit him/her to have some supplementary oxygen treatment to assist in the demands of the body. c. Percussion Coughing and difficulty of breathing may cause. Number the following actions in the order the nurse should complete them. Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . d. Pleural friction rub It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. The turbinates in the nose warm and moisturize inhaled air. Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. The nurse suspects which diagnosis? Air trapping Impaired Gas Exchange; May be related to. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. 2. Amount of air remaining in lungs after forced expiration Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. a. Thoracentesis b. What should be the nurse's first action? d. Normal capillary oxygen-carbon dioxide exchange. So to avoid that, they must be assisted in any activities to help conserve their energy. 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 c. Mucociliary clearance Breath sounds in all lobes are verified to be sure that there was no damage to the lung. What is a primary nursing responsibility after obtaining a blood specimen for ABGs? Advised the patient to dispose of and let out the secretions. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake. e. Sleep-rest COPD ND3: Impaired gas exchange. b. The nurse can also teach coughing and deep breathing exercises. 3. Coarse crackling sounds are a sign that the patient is coughing. 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. 's airway before and after surgery? See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual. Avoid instillation of saline during suctioning. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. It is important to acknowledge their limited information about the disease process and start educating him/her from there. Start oxygen administration by nasal cannula at 2 L/min. This is an expected finding with pneumonia, but should not continue to rise with treatment. Encourage the patient to see their medical attending physician for approval and safe treatment. Hospital-Acquired Pneumonia. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. d. Parietal pleura. d. Comparison of patient's current vital signs with normal vital signs. This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. d. An ET tube is more likely to lead to lower respiratory tract infection. A relative increase in antibody titers indicates viral infection. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. Always maintain sterility or aseptic techniques when performing any invasive procedure. a. Vt Pneumonia: Bacterial or viral infections in the lungs . Alveolar-capillary membrane changes (inflammatory effects) These interventions contribute to adequate fluid intake. Respiratory infection 3. 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. c. Drainage on the nasal dressing Hopefully the family will have some time to discuss this before they are instructed to leave the room, unless it is an emergency. a. Amount of air that can be quickly and forcefully exhaled after maximum inspiration Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. 1. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. What the oxygenation status is with a stress test Allow patients to ask a question or clarify regarding their treatment. a. Assess the patient for iodine allergy. Study Resources . A repeat skin test is also positive. Which action does the nurse take next? b. Cleveland Clinic. Sepsis Alliance. The live attenuated influenza vaccine is given intranasally and is recommended for all healthy people between the ages of 2 and 49 years but not for those at increased risk of complications or HCPs. Respiratory distress requires immediate medical intervention. Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. A transesophageal puncture The following signs and symptoms show the presence of impaired gas exchange: Abnormal breathing rate, rhythm, and depth Nasal flaring Hypoxemia Cyanosis in neonates decreases carbon dioxide Confusion Elevated blood pressure and heart rate A headache after waking up Restlessness Somnolence and visual disturbances Looking For Custom Nursing Paper? i. Sexuality-reproductive An increased anterior-posterior (AP) diameter is characteristic of a barrel chest, in which the AP diameter is about equal to the side-to-side diameter. Impaired cardiac output 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. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. There is a prominent protrusion of the sternum. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. a. 1. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. a. Interstitial edema Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. Administer the prescribed antibiotic and anti-pyretic medications. This produces an area of low ventilation with normal perfusion. A) 2, 3, 4, 5, 6 Dont forget to include some emergency contact numbers just in case there is an emergency. A) "I will need to have a follow-up chest x-ray in six to. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. d. Assess the patient's swallowing ability. 2. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. A) Increasing fluids to at least 6 to 10 glasses/day, unless. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? b. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. If he or she can not do it, then provide a suction machine always at the bedside. 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. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. Remove unnecessary lines as soon as possible. She has worked in Medical-Surgical, Telemetry, ICU and the ER. 5. A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. Identify the ability of the patient to perform self-care and do activities of daily living. 3. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? If they cannot, sputum can be obtained via suctioning. 8 . 2. Weigh patient daily at same time of day and on same scale; record weight. Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. c. Check the position of the probe on the finger or earlobe. These critically ill patients have a high mortality rate of 25-50%. Identify patients at increased risk for aspiration. c. Determine the need for suctioning. e. Increased tactile fremitus She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. h. Role-relationship: Loss of roles at work or home, exposure to respiratory toxins at work c. Temperature of 100 F (38 C) Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. causing a clinical illness o Mandatory testing for health care professionals o Usually performed twice o Priority Nursing Diagnoses: Ineffective breathing pattern Ineffective airway clearance Impaired Gas . Goal. Finger clubbing and accessory muscle use are identified with inspection. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. Maximum rate of airflow during forced expiration In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. Decreased skin turgor and dry mucous membranes as a result of dehydration. Partial obstruction of trachea or larynx A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. Pink, frothy sputum would be present in CHF and pulmonary edema. Acid-fast stains and cultures: To rule out tuberculosis. a. Finger clubbing 1) SpO2 of 85% 2) PaCO2 of 65 mm Hg 3) Thick yellow mucus expectorant 4) Respiratory rate of 24 breaths/minute 5) Dullness to percussion over the affected area Click the card to flip d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. a. Trachea d. Bradycardia f. Hyperresonance Retrieved February 9, 2022, from, Testing for Sepsis. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. 's nose for several days after the trauma? Tylenol) administered. 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.
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