d) 8. Proper nutrition promotes energy and supports the immune system. c. Percussion Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? Touching an infected object and then touching your nose or mouth can also transfer the germs. She earned her BSN at Western Governors University. Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up. Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. 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. (Symptoms) Reports of feeling short of breath 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. 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. 4. associated with increased fluid loss in the presence of tachypnea, fever, or diaphoresis Desired outcome: at least 24 hours before hospital discharge, the patient is normovolemic, i.e., has a urine output of 30 mL/h or greater, stable weight, heart rate less than 100 bpm, blood pressure greater than 90 mm Hg, fluid intake equal to fluid excretion, moist mucous membranes, and normal skin turgor. 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) What are possible explanations for this behavior? A) Teaching the patient how to cough effectively and. 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). Watch for signs and symptoms of respiratory distress and report them promptly. 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. In addition, have the patient upright and leaning forward to prevent swallowing blood. Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. h. Role-relationship: Loss of roles at work or home, exposure to respiratory toxins at work However, with increasing respiratory distress, respiratory acidosis may occur. COPD ND3: Impaired gas exchange. d. Patient can speak with an attached air source with the cuff inflated. 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. (2020). There is no redness or induration at the injection site. 4. So to avoid that, they must be assisted in any activities to help conserve their energy. d. Apply an ice pack to the back of the neck. Saunders comprehensive review for the NCLEX-RN examination. This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions. Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. Viral pneumonia. Notify the health care provider. If the patient is ambulatory, walking should be encouraged within the patients tolerance. The nurse explains that usual treatment includes These critically ill patients have a high mortality rate of 25-50%. Administer oxygen with hydration as prescribed. d. An ET tube is more likely to lead to lower respiratory tract infection. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Productive cough (viral pneumonia may present as dry cough at first). b. Remove excessive clothing, blankets and linens. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, Surfactant is a lipoprotein that lowers the surface tension in the alveoli. d. Testing causes a 10-mm red, indurated area at the injection site. Tylenol) administered. Related to: As evidenced by: This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. d. Self-help groups and community resources for patients with cancer of the larynx, When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. b. d. Assess the patient's swallowing ability. h. Absent breath sounds CASE STUDY: Rhinoplasty 3. Hospital acquired pneumonia may be due to an infected. Decreased compliance contributes to barrel chest appearance. - Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. 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. To avoid the formation of a mucus plug, suction it as needed. Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. Maintain intravenous (IV) fluid therapy as prescribed. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). b. Warm and moisturize inhaled air Long-term denture use Assess lung sounds and vital signs. 7) c. Send labeled specimen containers to the laboratory. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. Signs and symptoms of respiratory distress include agitation, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory respiratory muscles. Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. Impaired gas improved or presence of retained secretions client: exchange ventilation and adventitious sound -Demonstrated adequate improved wheezes oxygenation of -Decrease of ventilation and tissues by ABG of: -Palpate for fremitus vibratory tremors adequate pH:7.35-7.45 suggest fluid oxygenation of a. d. SpO2 of 88%; PaO2 of 55 mm Hg The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. Pneumonia will be one of the most frequent infections the nurse will encounter and treat. Select all that apply. oxygen. 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. Attempt to replace the tube. After the intervention, the patients airway is free of incidental breath sounds. c. Comparison of patient's SpO2 values with the normal values symptoms. h. FRC Nursing Care Plan for: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. a. Examine sputum for volume, odor, color, and consistency; document findings. Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. The nurse should instruct on how to properly use these devices and encourage their use hourly. Tachycardia (resting heart rate [HR] more than 100 bpm). 1. Pneumonia may increase sputum production causing difficulty in clearing the airways. Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. d. The patient cannot fully expand the lungs because of kyphosis of the spine. Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. a. Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue? Assess for mental status changes. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. g. FEV1 patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. 3.7 Risk for Deficient Fluid Volume. Assess the patients knowledge about Pneumonia. Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. 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. Hyperkalemia is not occurring and will not directly affect oxygenation initially. Please follow your facilities guidelines, policies, and procedures. 4) f. Instruct the patient not to talk during the procedure. If the patients condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection. g) 4. c. TLC: (2) Maximum amount of air lungs can contain c. Use cromolyn nasal spray prophylactically year-round. All other answers indicate a negative response to skin testing. 2. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? With severe pneumonia, the patient needs a higher level of care than general medical-surgical. j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems Nursing Care Plan 2 A) Sit the patient up in bed as tolerated and apply Assess lab values.An elevated white blood count is indicative of infection. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. b. Epiglottis Let the patient do a return demonstration when giving lectures about medication and therapeutic regimens. - It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity. b. Give supplemental oxygen treatment when needed. b. SpO2 of 95%; PaO2 of 70 mm Hg 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. 3.6 Risk for imbalanced nutrition: less than body requirements. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. 2. Bronchoconstriction Wear gloves on both hands when handling the cannula or when handling ventilation tubing. 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. 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. Which medication therapy does the nurse anticipate will be prescribed? b. b. Interstitial edema b. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. 's nose for several days after the trauma? Severely immunosuppressed patients are affected not only by bacteria but also by viruses (cytomegalovirus) and fungi (Candida, Aspergillus, Pneumocystis jirovecii). Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . c. Check the position of the probe on the finger or earlobe. Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. A) Purulent sputum that has a foul odor b. c. A negative skin test is followed by a negative chest x-ray. 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. Water, hydration, and health. Priority: Sleep management b. Cuff pressure monitoring is not required. A patient with pneumonia shows inflammation in their lung parenchyma causing it to have. 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. Major nursing care planning goals for COVID-19 may include: Establishing goals, interventions. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. 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. Retrieved February 9, 2022, from, Pneumonia: Symptoms, Treatment, Causes & Prevention. What accurately describes the alveolar sacs? Identify up to what extent does the patient knows about pneumonia. Assessment findings include a new onset of confusion, a respiratory rate of 42 breaths/minute, a blood urea nitrogen (BUN) of 24 mg/dL, and a BP of 80/50 mm Hg. To increase the oxygen level and achieve an SpO2 value of at least 96%. Usually, people with pneumonia preferred their heads elevated with a pillow. This also increases the risk for aspiration pneumonia. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. d. SpO2 of 88%; PaO2 of 55 mm Hg. A patient with a 10-year history of regular (three beers per week) alcohol consumption began taking rifampin to treat tuberculosis (TB). The palms are placed against the chest wall to assess tactile fremitus. Patient's temperature Maegan Wagner is a registered nurse with over 10 years of healthcare experience. 2. A closed-wound drainage system Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. Changes in behavior and mental status can be early signs of impaired gas exchange. The nurse can also teach coughing and deep breathing exercises. f. Instruct the patient not to talk during the procedure. The epiglottis is a small flap closing over the larynx during swallowing. Skin breakdown allows pathogens to enter the body. d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. 3.4 Activity Intolerance. 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. 2. of . Fill fluid containers immediately before use (not well in advance). Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. a. Assess the patient for iodine allergy. 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 . c. Perform mouth care every 12 hours. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). 5. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. A tracheostomy is safer to perform in an emergency. A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. c. A nasogastric tube with orders for tube feedings 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 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. The oxygenation status with a stress test would not assist the nurse in caring for the patient now. This produces an area of low ventilation with normal perfusion. 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]. a. radiation therapy that preserves the quality of the voice. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. This assessment monitors the trend in fluid volume. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. Fine crackles at the base of the lungs are likely to disappear with deep breathing. 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. Teach the patient to use the incentive spirometer as advised by their attending physician. This is most common in intensive care units usually resulting from intubation and ventilation support. Alveolar-capillary membrane changes (inflammatory effects) 2. 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. A) 2, 3, 4, 5, 6 b. Volcanic eruptions and other natural events result in air pollution. Bacterial Pneumonia. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. b. Palpation c. An electrolarynx held to the neck b. The home health nurse provides which instruction for a patient being treated for pneumonia? This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Decreased skin turgor and dry mucous membranes as a result of dehydration. Health perception-health management 4. 3. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. 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. d. Oxygen saturation by pulse oximetry Partial obstruction of trachea or larynx Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. A patient develops epistaxis after removal of a nasogastric tube. Medical-surgical nursing: Concepts for interprofessional collaborative care. Stridor is a continuous musical or crowing sound and unrelated to pneumonia. The turbinates in the nose warm and moisturize inhaled air. What testing is indicated? a. a. Carina Instruct patients who are unable to cough effectively in a cascade cough. 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. 3 Nursing care plans for pneumonia. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives. b. Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. d. Comparison of patient's current vital signs with normal vital signs. Help the patient get into a comfortable position, usually the half-Fowler position. g. FEV1: (1) Amount of air exhaled in first second of forced vital capacity If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues. Document the results in the patient's record. Decreased functional cilia c. Patient in hypovolemic shock 6) a. Verify breath sounds in all fields. Always change the suction system between patients. Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site. Anna Curran. Put the palms of the hands against the chest wall. Immunosuppression and neutropenia are predisposing factors for the development of nosocomial pneumonia caused by common and uncommon pathogens. Shetty, K., & Brusch, J. L. (2021, April 15). The cuff passively fills with air. Oxygen is administered when O2 saturation or ABG results show hypoxemia. This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. 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. Coarse crackling sounds are a sign that the patient is coughing. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). d. a total laryngectomy to prevent development of second primary cancers. a. Vt 3 Pneumonia in the immunocompromised individual 4 Assessment of pneumonia 5 Diagnostic test for pneumonia 6 Nursing Diagnosis of pneumonia 6.1 Risk for Infection (nosocomial pneumonia) 6.2 Impaired Gas Exchange due to pneumonic condition 6.3 Ineffective clearance of the airway 6.4 Deficient fluid volume Community acquired pneumonias Match the descriptions or possible causes with the appropriate abnormal assessment findings. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. 8. a. Undergo weekly immunotherapy. d. Small airway closure earlier in expiration a. This patient is older and short of breath. d. Pulmonary embolism Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. a. Change the tube every 3 days. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. b. Copious nasal discharge It must include the local 911 numbers, hospitals, and immediate keen of the patient. d. Notify the health care provider of the change in baseline PaO2. Heavy tobacco and/or alcohol use Cough reflex (2020, June 15). Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion. Keep skin clean and dry through frequent perineal care or linen changes. Observing for hypoxia is done to keep the HCP informed. a. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? Impaired Gas Exchange; May be related to. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. d. Parietal pleura. d. Thoracic cage. e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration a. Stridor Select all that apply. Chronic hypoxemia Hospital-Acquired Pneumonia. Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? Dyspnea and severe sinus pain as well as tender swollen glands, severe ear pain, or significantly worsening symptoms or changes in sputum characteristics in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. 27: Lower Respiratory Problems / CH. e. Observe for signs of hypoxia during the procedure. d. Pleural friction rub.