Teach the importance of complying with the prescribed treatment and medication. To help clear thick phlegm that the patient is unable to expectorate. b. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. 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. Select all that apply. Patient who is anesthetized "You should get the inactivated influenza vaccine that is injected every year." Select all that apply. Before other measures are taken, the nurse should check the probe site. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. 26: Upper Respiratory Problems / CH. c) 5. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives. Nursing Diagnosis: Ineffective Airway Clearance related to the disease process of bacterial pneumonia as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm. Nursing Diagnosis Impaired Gas Exchange related to to altered alveolarcapillary membrane changes due to pneumonia disease process. F. A. Davis Company. Impaired gas exchange is the state in which there is an excess or deficit in oxygenation or in the elimination of carbon dioxide at the level of the alveolocapillary membrane. high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. It is important to have an initial assessment of the patient and use it as a comparison for future reference or referral. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. Normal or low leukocyte counts (less than 4000/mm3) may occur in viral or mycoplasma pneumonia. Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. Fever reducers and pain relievers. Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment. Supplemental oxygen will help in the increased demand of the body and will lower the risk of having respiratory distress and low oxygen perfusion in the body. Priority: Sleep management So to avoid that, they must be assisted in any activities to help conserve their energy. b. Surfactant If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. - Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. Primary care, with acute or intensive care hospitalization due to complications. b. Nutritional-metabolic When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? c. A tracheostomy tube allows for more comfort and mobility. Suctioning keeps the airway clear by removing secretions. 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. On inspection, the throat is reddened and edematous with patchy yellow exudates. Interstitial edema All other answers indicate a negative response to skin testing. 4. Important sounds may be missed if the other strategies are used first. Change the tube every 3 days. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. Productive cough (viral pneumonia may present as dry cough at first). c. Encourage deep breathing and coughing to open the alveoli. What accurately describes the alveolar sacs? Maximum amount of air that can be exhaled after maximum inspiration Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. What is the first action the nurse should take? Always maintain sterility or aseptic techniques when performing any invasive procedure. Page . The nurse expects which treatment plan? Etiology The most common cause for this condition is poor oxygen levels. Desired Outcome: At the end of the span of care, the patient will manifest better lung ventilation and improve tissue perfusion, and maximum optimal gas exchange by having normal arterial blood gas results, minimum to no symptoms of respiratory distress, and normal production of mucus in the airway. There is a prominent protrusion of the sternum. d. CO2 directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. 2) d. Direct the family members to the waiting room. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. 2) Ensure that the home is well ventilated. Saunders comprehensive review for the NCLEX-RN examination. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. c. Elimination: Constipation, incontinence A cascade cough removes secretions and improves ventilation through a sequence of shorter and more forceful exhalations than is the case with the usual coughing exercise. Recognize the risk factors for infection in patients with tracheostomy and take the following actions: Risk factors include the presence of underlying pulmonary disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased bacterial access to the lower airway, and cross-contamination from manipulation of the tracheostomy tube. d. Dyspnea and severe sinus pain. A 73-year-old patient has an SpO2 of 70%. Steroids: To reduce the inflammation in the lungs. 3. Preoperative education, explanation, and demonstration of pulmonary activities used postoperatively to prevent respiratory infections. Assess intake and output (I&O). 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). g. Self-perception-self-concept Examine sputum for volume, odor, color, and consistency; document findings. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. a. Esophageal speech Facilitate coordination within the care team to allow rest periods between care activities. b. Epiglottis Warm and moisturize inhaled air 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. 1. Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. 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. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Remove the inner cannula and replace it per institutional guidelines. a. Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. 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. e. Posterior then anterior 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. Patients who are weak or lack a cough reflex may not be able to do so. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. Avoid instillation of saline during suctioning. How does the nurse assess the patient's chest expansion? Empyema is a collection of pus in the thoracic cavity. c. Keep a same-size or larger replacement tube at the bedside. Save my name, email, and website in this browser for the next time I comment. The nurse suspects which diagnosis? There is alteration in the normal respiratory process of an individual. a. SpO2 of 92%; PaO2 of 65 mm Hg Administer the prescribed antibiotic and anti-pyretic medications. Coarse crackling sounds are a sign that the patient is coughing. Which instructions does the nurse provide for the patient? Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. Hyperkalemia is not occurring and will not directly affect oxygenation initially. Place the patient in a comfortable position. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? a. 2. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. b. To regulate the temperature of the environment and make it more comfortable for the patient. COPD ND3: Impaired gas exchange. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. a. d. Pleural friction rub 5. b. Position the patient to be comfortable (usually in the half-Fowler position). d. Small airway closure earlier in expiration 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. The nurse presents education about pertussis for a group of nursing students and includes which information? Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. Pinch the soft part of the nose. 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. 3) Illicit drug intake The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. 1. - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody). d. SpO2 of 88%; PaO2 of 55 mm Hg. 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. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. b. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. 5. c. Decreased chest wall compliance 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. c. SpO2 of 90%; PaO2 of 60 mm Hg Community-Acquired Pneumonia. a. Deflate the cuff, then remove and suction the inner cannula. i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms e. Airway obstruction is likely if the exact steps are not followed to produce speech. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? d. VC d. Patient receiving oxygen therapy. b. Copious nasal discharge Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. Priority Decision: When F.N. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. c. Check the position of the probe on the finger or earlobe. d. Pulmonary embolism. 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 Antibiotics: To treat bacterial pneumonia. A closed-wound drainage system Otherwise, scroll down to view this completed care plan. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. It may also cause hepatitis. Trend and rate of development of the hyperkalemia c. Mucociliary clearance 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. Notify the health care provider. The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. c. Percussion a. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. The nurse identifies which factor that places a patient at risk for aspiration pneumonia? NMNEC Concept: Gas Exchange. Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. Priority Decision: A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG) results: pH 7.40, partial pressure of oxygen in arterial blood (PaO2) 74 mm Hg, arterial oxygen saturation (SaO2) 92%, partial pressure of carbon dioxide in arterial blood (PaCO2) 40 mm Hg. 4. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. A Code Blue would not be called unless the patient experiences a loss of pulse and/or respirations. Hospital-Acquired Pneumonia. When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? a. Stridor What process would they have needed to complete in order to have been successful? Which values indicate a need for the use of continuous oxygen therapy? Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). It is also inappropriate to advise the patient to stop taking antitubercular drugs. Patient Profile F.N. A knowledgeable patient is more likely to comply with therapy. She received her RN license in 1997. 2. b. Hospital acquired pneumonia may be due to an infected. The thoracic cage is formed by the ribs and protects the thoracic organs. A) Pneumonia Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. What is the significance of the drainage? 2) Guillain-Barr syndrome A) Inform the patient that it is one of the side effects of Skin breakdown allows pathogens to enter the body. It may also stimulate coughing. e. Rapid respiratory rate. Pulse oximetry would not be affected by fever or anesthesia and is a method of monitoring arterial oxygen saturation in patients who are receiving oxygen therapy. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. Discharging the patient is unsafe. Atelectasis What should be the nurse's first action? 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. 3. Nursing Diagnosis related to --- as evidence by---Impaired gas exchange related to inflammation of airways, fluid-filled alveoli, and collection of mucus in the airway as evidenced by dyspnea and tachypnea (Carpenito, 2021). Maximum rate of airflow during forced expiration 6. What should the nurse do when preparing a patient for a pulmonary angiogram? d. Limited chest expansion The most common. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? c. Take the specimen immediately to the laboratory in an iced container. How does the nurse respond? d. Contain dead air that is not available for gas exchange. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. c. Course crackles Shetty, K., & Brusch, J. L. (2021, April 15). Oximetry: May reveal decreased O2 saturation (92% or less). A tracheostomy is safer to perform in an emergency. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? 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. Checking the respiratory status depending on the need will help know the impending respiratory changes of the patient. Weigh patient daily at same time of day and on same scale; record weight. Avoid environmental irritants inside the patients room. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. f. Instruct the patient not to talk during the procedure. Administer analgesics 1/2 hour prior to deep breathing exercises. h. FRC 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. e. Increased tactile fremitus c. Terminal structures of the respiratory tract document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. 5) Minimize time in congregate settings. An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. Changes in behavior and mental status can be early signs of impaired gas exchange. Select all that apply. 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. b. c. An electrolarynx held to the neck To avoid the formation of a mucus plug, suction it as needed. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. b. Finger clubbing Teach the proper technique of doing pursed-lip breathing, various ways of relaxation, and abdominal breathing. Fatigue 4. Promote oral hygiene, including lip and tongue care. St. Louis, MO: Elsevier. Suction the mouth or the oral airway as needed. Oxygen is administered when O2 saturation or ABG results show hypoxemia. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. 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. 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? 4) Recent abdominal surgery. Aspiration is one of the two leading causes of nosocomial pneumonia. 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. - 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. The home health nurse provides which instruction for a patient being treated for pneumonia? Stridor is a continuous musical or crowing sound and unrelated to pneumonia. b. Nursing Care Plan 2 Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? If the patient is enteral fed, recommend continuous rather than bolus feeding. What are possible explanations for this behavior? h. Role-relationship The nurse will gather the supplies as soon as the order to do a thoracentesis is given. b. Viral pneumonia. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. h. Absent breath sounds Unless contraindicated, promote fluid intake (2.5 L/day or more). These critically ill patients have a high mortality rate of 25-50%. The tissue changes of TB and cancer of the lung may be diagnosed by chest x-ray or CT scan, MRI, or positron emission tomography (PET) scans. b. g. FEV1: (1) Amount of air exhaled in first second of forced vital capacity Administer oxygen with hydration as prescribed. This position provides comfort and facilitates the ease and effectiveness of these exercises by promoting better lung expansion (less compression of the lungs by the abdominal organs) and better gas exchange.
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