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(1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. Better Health Channel. It is very important to take and record the patients respiratory assessment to make it a basis if there are any abnormal findings in the future. A) Purulent sputum that has a foul odor The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. Select all that apply. Chronic hypoxemia In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. 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. d. Pleural friction rub Encouraging oral fluids will mobilize respiratory secretions. It is also inappropriate to advise the patient to stop taking antitubercular drugs. Give health teachings about the importance of taking prescribed medication on time and with the right dose. These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. Why is the air pollution produced by human activities a concern? Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). 4. c. The need for frequent, vigorous coughing in the first 24 hours postoperatively The epiglottis is a small flap closing over the larynx during swallowing. No interventions are necessary for these findings. Concept Map-AHI - Concept Mapping Nursing diagnosis: Impaired gas A) Pneumonia Increase heat and humidity if patient has persistent secretions. c. Determine the need for suctioning. However, it is highly unlikely that TB has spread to the liver. c. Comparison of patient's SpO2 values with the normal values Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. impaired gas exchange nursing care plan scribd Turbinates warm and moisturize inhaled air. Nursing care plan pneumonia - StuDocu Add heparin to the blood specimen. Remove the inner cannula and replace it per institutional guidelines. Amount of air remaining in lungs after forced expiration oxygen. c. Decreased chest wall compliance Bronchodilators: To dilate or relax the muscles on the airways. d. Oxygen saturation by pulse oximetry Nursing Diagnosis for COPD | Nursing Care Plan & Interventions for COPD The immunity will not protect for several years, as new strains of influenza may develop each year. Discontinue if SpO2 level is above the target range, or as ordered by the physician. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. 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. Thorough hand hygiene before and after patient contact (even if gloves are worn). An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. 's nasal packing is removed in 24 hours, and he is to be discharged. d. Pulmonary embolism The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. Avoid instillation of saline during suctioning. a. Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. Allow patients to ask a question or clarify regarding their treatment. Use only sterile fluids and dispense with sterile technique. d. Pulmonary embolism. She received her RN license in 1997. Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. A patient started treatment for sputum smear-positive tuberculosis (TB) 1 week prior to the home health nurse's visit. Care Plan for Ineffective Gas Exchange, Ineffective Airway Clearance Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. Number the following actions in the order the nurse should complete them. 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. Report significant findings. b. Epiglottis d. Testing causes a 10-mm red, indurated area at the injection site. b. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. b. Impaired Gas Exchange Symptoms Care Plan | Nursing Diagnosis Writing Nursing Diagnosis: Ineffective Airway Clearance. g. Position the patient sitting upright with the elbows on an over-the-bed table. 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. 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. Always change the suction system between patients. c. Persistent swelling of the neck and face Assist the patient with position changes every 2 hours. Patient's temperature 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. Interstitial edema When F.N. Sleep disturbance related to dyspnea or discomfort 6. Implement NPO orders for 6 to 12 hours before the test. All of the assessments are appropriate, but the most important is the patient's oxygen status. b. There is a prominent protrusion of the sternum. a. A pulmonary angiogram involves the injection of an iodine-based radiopaque dye, and iodine or shellfish allergies should be assessed before injection. Select all that apply. Goal. 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. The postoperative use of nonverbal communication techniques c. It has two tubings with one opening just above the cuff. b. Unstable hemodynamics Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. 4. e. Posterior then anterior. The nurse presents education about pertussis for a group of nursing students and includes which information? The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. F. A. Davis Company. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. c. a throat culture or rapid strep antigen test. h. Absent breath sounds Pleural Effusion Nursing Diagnosis & Care Plan - RNlessons Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum Select all that apply. 4. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Always wear gloves on both hands for suctioning. Maintain intravenous (IV) fluid therapy as prescribed. The patient will have improved gas exchange. Long-term denture use This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. c. A negative skin test is followed by a negative chest x-ray. Nurses also play a role in preventing pneumonia through education. When inflamed, the air sacs may produce fluid or pus which can cause productive cough and difficulty breathing. b. Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. b. A) Admit the patient to the intensive care unit. 2) Ensure that the home is well ventilated. On inspection, the throat is reddened and edematous with patchy yellow exudates. 3 Nursing care plans for pneumonia. d. Assess the patient's swallowing ability. NurseTogether.com does not provide medical advice, diagnosis, or treatment. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. Place or install an air filter in the room to prevent the accumulation of dust inside. a. Assess the patient for iodine allergy. d. Limited chest expansion Decreased force of cough 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. The assessment findings include a temperature of 98.4F (36.9C), BP 130/88 mm Hg, respirations 36 breaths/min, and an oxygen saturation reading of 91% on room air. Pneumonia. To facilitate the body in cooling down and to provide comfort. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms The nurse should instruct on how to properly use these devices and encourage their use hourly. c. Empyema c. A tracheostomy tube allows for more comfort and mobility. 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. Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? c. Percussion Most commonly, P. jirovecii occurs in individuals with human immunodeficiency virus infection or in individuals who are therapeutically immunosuppressed after organ transplantation. What is the best response by the nurse? b. Finger clubbing Nursing Diagnosis: Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and increased PCO2. Assess for mental status changes. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. d. Initiate pulse oximetry for continuous monitoring of the patient's oxygen status. So to avoid that, they must be assisted in any activities to help conserve their energy. - Pertussis is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis. Impaired Gas Exchange Nursing Diagnosis & Care Plan - NurseTogether A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. a. Antibiotics. It involves the inflammation of the air sacs called alveoli. When does the nurse record the presence of an increased anteroposterior (AP) diameter of the chest? a. This is an expected finding with pneumonia, but should not continue to rise with treatment. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. The prognosis of a patient with PE is good if therapy is started immediately. Fine crackles at the base of the lungs are likely to disappear with deep breathing. This work is the product of the Collaboration: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the registered nurse (RN) may delegate which interventions to the licensed practical/vocational nurse (LPN/VN) (select all that apply)? It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. Buy on Amazon. d. Small airway closure earlier in expiration a. Stridor 3. a. Trachea Maximum amount of air that can be exhaled after maximum inspiration Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. Pneumonia can be mild but can also be fatal if left untreated. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? j. Coping-stress tolerance Assist patient in a comfortable position. Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). Empyema is a collection of pus in the thoracic cavity. I have a list of nursing diagnoses like acute pain r/t surgery, ineffective peripheral tissue perfusion r/t immobility or abdominal surgery, anxiety r/t change in health, impaired gas exchange r/t decreased functional lung tissue, ineffective airway clearance r/t inflammation and presence of secretion, i also have risk for infection - invasive c. Elimination Nursing diagnoses handbook: An evidence-based guide to planning care. If there are some questions or clarifications when it comes to their medicines, make sure to find time to explain to him/her so that this will ensure compliance with the treatment. Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae. Buy on Amazon, Silvestri, L. A. St. Louis, MO: Elsevier. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. Suctioning keeps the airway clear by removing secretions. d. Normal capillary oxygen-carbon dioxide exchange. was admitted, examination of his nose revealed clear drainage. 1. 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. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia, https://my.clevelandclinic.org/health/diseases/4471-pneumonia, https://doi.org/10.1111/j.1753-4887.2010.00304.x, https://emedicine.medscape.com/article/234753-overview#a4, Hypertension Nursing Diagnosis & Care Plan, The ABCs of Evidence-Based Practice in Nursing, Diminished lung sounds or crackles/rhonchi, Patient will demonstrate appropriate airway clearance techniques, Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate, Hypoventilation causing a lack of oxygen delivery, Patient will display appropriate oxygenation through ABGs within normal limits, Patient will demonstrate appropriate actions to promote ventilation and oxygenation, Inadequate primary defenses: decreased ciliary action, respiratory secretions, Invasive procedures: suctioning, intubation, Patient will not develop a secondary infection or sepsis, Patient will display improvement in infection evidenced by vital signs and lab values within normal limits. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). Impaired Gas Exchange Care Plan Writing Services a. A patient with a 10-year history of regular (three beers per week) alcohol consumption began taking rifampin to treat tuberculosis (TB). Impaired Gas Exchange Assessment 1. Antibiotics: To treat bacterial pneumonia. Wear gloves on both hands when handling the cannula or when handling ventilation tubing. c. Patient in hypovolemic shock Related to: As evidenced by: A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. Etiology The most common cause for this condition is poor oxygen levels. 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. a. Proper nutrition promotes energy and supports the immune system. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. b. Copious nasal discharge Most of the cases of poor prognosis of pneumonia are undertreatment or not being able to be assessed earlier. What is included in the nursing care of the patient with a cuffed tracheostomy tube? - 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. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. Coarse crackling sounds are a sign that the patient is coughing. 2018.01.18 NMNEC Curriculum Committee. Cough reflex Position the patient on the side. Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. Discussion Questions c. Send labeled specimen containers to the laboratory. Priority Decision: A pulse oximetry monitor indicates that the patient has a drop in arterial oxygen saturation by pulse oximetry (SpO2) from 95% to 85% over several hours.