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The position of the oximeter should also be assessed. The injected inactivated influenza vaccine is recommended for individuals 6 months of age and older and those at increased risk for influenza-related complications, such as people with chronic medical conditions or those who are immunocompromised, residents of long-term care facilities, health care workers, and providers of care to at-risk persons. 3. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Preoperative education, explanation, and demonstration of pulmonary activities used postoperatively to prevent respiratory infections. Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue? b. To determine the tracheal position, the nurse places the index fingers on either side of the trachea just above the suprasternal notch and gently presses backward. Remove excessive clothing, blankets and linens. 5. Select all that apply. Coarse crackling sounds are a sign that the patient is coughing. Preventing the spread of coronavirus infection to the patient's family members, community, and healthcare providers. b. Unstable hemodynamics c. Tracheal deviation Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. The most common. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. 2. Proper nutrition promotes energy and supports the immune system. HR 68 bpm Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. To assess the extent and symmetry of chest movement, the nurse places the hands over the lower anterior chest wall along the costal margin and moves them inward until the thumbs meet at the midline and then asks the patient to breathe deeply and observes the movement of the thumbs away from each other. Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site. Amount of air exhaled in first second of forced vital capacity The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. The nurse should instruct on how to properly use these devices and encourage their use hourly. Observing for hypoxia is done to keep the HCP informed. How does the nurse respond? No signs or symptoms of tuberculosis or allergies are evident. d. Patient can speak with an attached air source with the cuff inflated. b. Arrange the tasks of the patient when providing care to him/her. Impaired Gas Exchange This COPD nursing diagnosis may be related to bronchospasm, air-trapping and obstruction of airways, alveoli destruction, and changes in the alveolar-capillary membrane. 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. c. Place the patient in high Fowler's position. This is most common in intensive care units usually resulting from intubation and ventilation support. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. If the patient is having increased mucous production, encourage him or her to clear the airway. 3. A) Purulent sputum that has a foul odor a. "Only health care workers in contact with high-risk patients should be immunized each year." When F.N. Level of the patient's pain The patient will have improved gas exchange. To regulate the temperature of the environment and make it more comfortable for the patient. What action should the nurse take? 2/21/2019 Compiled by C Settley 10. Consider using a closed suction system; replace closed suction system according to agency guidelines. The nurse can also teach coughing and deep breathing exercises. Patients who are weak or lack a cough reflex may not be able to do so. Discussion Questions The immunity will not protect for several years, as new strains of influenza may develop each year. 2. A closed-wound drainage system Nursing diagnoses handbook: An evidence-based guide to planning care. Productive cough (viral pneumonia may present as dry cough at first). The trachea connects the larynx and the bronchi. Auscultation of breath sounds every 2 to 4 hours (or depending on the patients condition) and reporting of changes in the patients ability to secrete lung secretions. b. treatment with antifungal agents. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. An open reduction and internal fixation of the tibia were performed the day of the trauma. 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. Learn how your comment data is processed. Related to: As evidenced by: Antibiotics: To treat bacterial pneumonia. A patient's initial purified protein derivative (PPD) skin test result is positive. Empyema is a collection of pus in the thoracic cavity. a. Smoking does not directly affect filtration of air, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages. F.N. 8. This also increases the risk for aspiration pneumonia. The oxygenation status with a stress test would not assist the nurse in caring for the patient now. A) Increasing fluids to at least 6 to 10 glasses/day, unless. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur but will affect the patients' activity tolerance. It involves the inflammation of the air sacs called alveoli. Identify and avoid triggers of the allergic reaction. g. FEV1 A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? For which problem is this test most commonly used as a diagnostic measure? Assist the patient when they are doing their activities of daily living. If the patient is ambulatory, walking should be encouraged within the patients tolerance. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. While the nurse is feeding a patient, the patient appears to choke on the food. 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? The patient reports a sudden onset of shortness of breath, slight chest pain, and that "something is wrong." Cleveland Clinic. To obtain the most information, auscultate the posterior to avoid breast tissue and start at the base because of her respiratory difficulty and the chance that she will tire easily. 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. b. Epiglottis Sepsis Alliance. 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. 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. Concept Map-AHI - Concept Mapping Nursing diagnosis: Impaired gas exchange pertaining to medical - Studocu concept mapping concept mapping nursing diagnosis: impaired gas exchange pertaining to medical diagnosis of coughing, copd and pneumonia and smoking history. CASE STUDY: Rhinoplasty 3 Nursing care plans for pneumonia. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. Long-term denture use d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration Severely immunosuppressed patients are affected not only by bacteria but also by viruses (cytomegalovirus) and fungi (Candida, Aspergillus, Pneumocystis jirovecii). Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. a. Stridor The cuff passively fills with air. Document the results in the patient's record. b. Cuff pressure monitoring is not required. 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. c. Patient in hypovolemic shock It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. 2. Monitor cuff pressure every 8 hours. 3) Illicit drug intake a. Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). What process would they have needed to complete in order to have been successful? What keeps alveoli from collapsing? 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. 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. 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 Health perception-health management: Tobacco use history, gradual change in health status, family history of lung disease, sputum production, no immunizations for influenza or pneumococcal pneumonia received, travel to developing countries Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. b. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. What is the most appropriate action by the nurse? Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? b. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. The 150 mL of air is dead space in the trachea and bronchi. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. d. Anterior then posterior b. Epiglottis a. Assess the patient for iodine allergy. 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. ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. a. Esophageal speech 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. What is the first action the nurse should take? Number the following actions in the order the nurse should complete them. e. Increased tactile fremitus Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. 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. Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. Which respiratory defense mechanism is most impaired by smoking? a. Use a sterile catheter for each suctioning procedure. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. How does the nurse assess the patient's chest expansion? Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. f. Cognitive-perceptual Nursing diagnosis: Deficient knowledge about the disease process and treatment of pneumonia related to lack of information as evidenced by failure to comply with treatment. 3. Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. 3.1 Ineffective airway clearance. The epiglottis is a small flap closing over the larynx during swallowing. 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. 6. Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. h. Role-relationship a. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? 1. 2. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Base to apex Administer the prescribed antibiotic and anti-pyretic medications. Report weight changes of 1-1.5 kg/day. Select all that apply. a. e. FVC g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem Hypoxemia was the characteristic that presented the best measures of accuracy. Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. 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. What is included in the nursing care of the patient with a cuffed tracheostomy tube? a. Stridor Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. This intervention decreases pain during coughing, thereby promoting a more effective cough. The nurse is preparing the patient for and will assist the health care provider with a thoracentesis in the patient's room. d. Pulmonary embolism. c. Course crackles Usually, people with pneumonia preferred their heads elevated with a pillow. Cough and sore throat 5) Minimize time in congregate settings. b. If he or she can not do it, then provide a suction machine always at the bedside. d. Limited chest expansion Start oxygen administration by nasal cannula at 2 L/min. Moisture helps minimize convective moisture loss during oxygen therapy. What is the reason for delaying repair of F.N. c. Take the specimen immediately to the laboratory in an iced container. a. Undergo weekly immunotherapy. k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? c. Inadequate delivery of oxygen to the tissues Health perception-health management Line the lung pleura 3.2 Impaired Gas Exchange. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. The patient receives 1 point for each criterion: confusion (compared to baseline); BUN greater than 20 mg/dL; respiratory rate greater than or equal to 30 breaths/min; systolic BP of less than 90 mm Hg; and age greater than or equal to 65 yrs. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. Weigh patient daily at same time of day and on same scale; record weight. 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? Wear gloves on both hands when handling the cannula or when handling ventilation tubing. 3. d. Dyspnea and severe sinus pain Blood tests elevated white blood cell count may be a sign of an ongoing infection, Sputum culture to determine the causative agent, Imaging chest X-ray to determine active infection and its severity; bronchoscopy to check any blockage of the airways; CT scan for a more detailed lung imaging, Arterial blood gas (ABG) test using an arterial blood sample to measure the oxygen level, Pleural fluid culture taking a pleural fluid sample by inserting a needle between the pleural cavity and the ribs in order to determine the causative agent.