Which respiratory defense mechanism is most impaired by smoking? The nurse should assess the patient's cardiopulmonary status with careful monitoring of vital signs, cardiac rhythm, pulse oximetry, arterial blood gases (ABGs), and lung sounds. The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? Inspection b. 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. b. treatment with antifungal agents. A) Increasing fluids to at least 6 to 10 glasses/day, unless. 8. Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. Impaired Gas Exchange Assessment 1. What is included in the nursing care of the patient with a cuffed tracheostomy tube? Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Long-term denture use Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath 2018.01.18 NMNEC Curriculum Committee. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. (n.d.). 3. It is also inappropriate to advise the patient to stop taking antitubercular drugs. Attend to the patients queries regarding their pneumonia treatment. 4. f) 2. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. This also increases the risk for aspiration pneumonia. 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. What testing is indicated? c. Terminal structures of the respiratory tract Primary care, with acute or intensive care hospitalization due to complications. 3. b. A knowledgeable patient is more likely to comply with therapy. Advised the patient to dispose of and let out the secretions. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. b. It may also stimulate coughing. 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. 2. of . Promote oral hygiene, including lip and tongue care. Retrieved February 9, 2022, from, Pneumonia: Symptoms, Treatment, Causes & Prevention. The position of the oximeter should also be assessed. a. 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. a. Diminished breath sounds are linked with poor ventilation. Hyperkalemia is not occurring and will not directly affect oxygenation initially. Otherwise, scroll down to view this completed care plan. d. Initiate pulse oximetry for continuous monitoring of the patient's oxygen status. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. If they cannot, sputum can be obtained via suctioning. Allow patients to ask a question or clarify regarding their treatment. Reports facial pain at a level of 6 on a 10-point scale PDF NMNEC Concept: Gas Exchange 2. Nursing Diagnosis and Care Plans for COPD | Med-Health.net b. Copious nasal discharge The turbinates in the nose warm and moisturize inhaled air. The nurse can also teach coughing and deep breathing exercises. 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. b. These interventions contribute to adequate fluid intake. d. Dyspnea and severe sinus pain. f. Instruct the patient not to talk during the procedure. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. b. SpO2 of 95%; PaO2 of 70 mm Hg Nursing Management of COVID-19 | EveryNurse.org Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. F.N. However, it is highly unlikely that TB has spread to the liver. This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. Impaired gas exchange is a risk nursing diagnosis for pneumonia. Pneumonia Concept_Map RUA226.pptx - Pneumonia Concept Map d. Thoracic cage. This is an expected finding with pneumonia, but should not continue to rise with treatment. e. Increased tactile fremitus Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. There is a prominent protrusion of the sternum. a. Apex to base The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. NurseTogether.com does not provide medical advice, diagnosis, or treatment. h. FRC: (8) Volume of air in lungs after normal exhalation. Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. Nasal flaring Abnormal breathing rate, depth, and rhythm Hypoxemia Restlessness Confusion A headache after waking up Elevated blood pressure and heart rate Somnolence and visual disturbances Nursing Assessment for Impaired Gas Exchange symptoms 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. c. Perform mouth care every 12 hours. a. 3. These practices further reduce the risk of contamination. Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. 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. Thorough hand hygiene before and after patient contact (even if gloves are worn). deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). All of the assessments are appropriate, but the most important is the patient's oxygen status. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. 3.4 Activity Intolerance. a. Carina d. Oxygen saturation by pulse oximetry. St. Louis, MO: Elsevier. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. 1. 1) Increase the intake of foods that are high in vitamin C. To facilitate the body in cooling down and to provide comfort. Which immediate action does the nurse take? c. A nasogastric tube with orders for tube feedings The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. Priority Decision: F.N. h. Absent breath sounds Wear gloves on both hands when handling the cannula or when handling ventilation tubing. Nursing Diagnosis. d. Auscultation. d. Reflex bronchoconstriction. 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. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? The patient has been diagnosed with an early vocal cord cancer. b. Surfactant No signs or symptoms of tuberculosis or allergies are evident. It is important to have an initial assessment of the patient and use it as a comparison for future reference or referral. d. Positron emission tomography (PET) scan. Pneumonia Nursing Diagnosis & Care Plan - NurseStudy.Net 6) The patient is infectious from the beginning of the first stage Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. PDF Nursing Care Plan For Meconium Aspiration Syndrome c. Elimination This is most common in intensive care units usually resulting from intubation and ventilation support. The other options contribute to other age-related changes. What measures should be taken to maintain F.N. Oxygen is administered when O2 saturation or ABG results show hypoxemia. Alveolar-capillary membrane changes (inflammatory effects) 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. Which medication therapy does the nurse anticipate will be prescribed? RR 24 The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. What keeps alveoli from collapsing? b. Cyanosis Impaired Gas Exchange Nursing Diagnosis & Care Plan The other options do not maintain inflation of the alveoli. d. Limited chest expansion If he or she cannot do it alone, make sure to place suction secretions at the bedside to use anytime. 8. 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. Skin breakdown allows pathogens to enter the body. Assist the patient when they are doing their activities of daily living. As an Amazon Associate I earn from qualifying purchases. Encourage the patient to see their medical attending physician for approval and safe treatment. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. Cleveland Clinic. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. Use 1 for the first action and 7 for the last action. b. Finger clubbing d. Apply an ice pack to the back of the neck. 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. Attempt to replace the tube. It is important to assess the ability of the patient to do self-care ost especially if he or she is having respiratory symptoms. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that results from aspiration of gastric contents. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans.

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