Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. The width of the chest is equal to the depth of the chest. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. 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. Select all that apply. d. Parietal pleura. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? d. Patient can speak with an attached air source with the cuff inflated. Start asking what they know about the disease and further discuss it with the patient. Remove excessive clothing, blankets and linens. d. Contain dead air that is not available for gas exchange. Reports facial pain at a level of 6 on a 10-point scale The home health nurse provides which instruction for a patient being treated for pneumonia? Bilateral ecchymosis of eyes (raccoon eyes) A) 1, 2, 3, 4 a. Stridor 1. Antibiotics: To treat bacterial pneumonia. 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. 4. Obtain the supplies that will be used. i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms d. The patient cannot fully expand the lungs because of kyphosis of the spine. Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. A tracheostomy is safer to perform in an emergency. c. Airway obstruction Priority: Sleep management e. Posterior then anterior. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). Pneumonia: Bacterial or viral infections in the lungs . b. treatment with antifungal agents. The patient needs to be able to effectively remove these secretions to maintain a patent airway. Match the descriptions or possible causes with the appropriate abnormal assessment findings. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). h. Absent breath sounds a. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. 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. g. Fine crackles Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. a. SpO2 of 92%; PaO2 of 65 mm Hg Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. Pinch the soft part of the nose. b. CO2 causes an increase in the amount of hydrogen ions available in the body. On inspection, the throat is reddened and edematous with patchy yellow exudates. The nurse should instruct on how to properly use these devices and encourage their use hourly. d) 8. Tuberculosis frequently presents with a dry cough. 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. 6. Lung abscess. 3. Learning to apply information through a return demonstration is more helpful than verbal instruction alone. Administer supplemental oxygen, as prescribed. 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. Decreased immunoglobulin A (IgA) decreases the resistance to infection. Change ventilation tubing according to agency guidelines. Most people with pneumonia are preferred to be placed on a moderate high back rest (also called semi-Fowlers position) or placed pillows on the back. The patient may have a limit to visitors to prevent the transmission of infections. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. Nursing diagnosis Related factors Defining characteristics Examples of this type of nursing diagnosis include: Decreased cardiac output Chronic functional constipation Impaired gas exchange Problem-focused nursing diagnoses are typically based on signs and symptoms present in the patient. 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. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. (2022, January 26). b. a. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? d. Patient receiving oxygen therapy. Buy on Amazon, Silvestri, L. A. Patients with compromised immune systems such as those with COPD, HIV, or autoimmune diseases should be educated on the risk and how to protect themselves. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. Pneumonia can be mild but can also be fatal if left untreated. 1) The cough may last from 6 to 10 weeks. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. 's nasal packing is removed in 24 hours, and he is to be discharged. A relative increase in antibody titers indicates viral infection. In addition, have the patient upright and leaning forward to prevent swallowing blood. Reporting complications of hyperinflation therapy to the health care provider. 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)? g. Self-perception-self-concept 3) Illicit drug intake Assess intake and output (I&O). 1. Impaired cardiac output d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? d. Limited chest expansion The patient will further understand their disease when they understand why they have it and it will help him/her better comply with the treatment regimen. A) Seizures 28: Obstructive Pulmonary Diseases. It is important to assess the ability of the patient to do self-care ost especially if he or she is having respiratory symptoms. f) 2. The epiglottis is a small flap closing over the larynx during swallowing. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, c. The necessity of never covering the laryngectomy stoma ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. b. Nutritional-metabolic d. Positron emission tomography (PET) scan. Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma. Finger clubbing and accessory muscle use are identified with inspection. Empyema is a collection of pus in the thoracic cavity. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? 3.3 Risk for Infection. Priority: Management of pneumonia and dehydration. 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. a. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. Administer the prescribed antibiotic and anti-pyretic medications. 2. Nursing Care Plan 2 Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. a. Turbinates warm and moisturize inhaled air. 1. Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. b. Retrieved February 9, 2022, from. 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. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. g) 4. Decreased force of cough Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. Retrieved February 9, 2022, from https://www.sepsis.org/sepsis-basics/testing-for-sepsis/, Yang, Fang1#; Yang, Yi1#; Zeng, Lingchan2; Chen, Yiwei1; Zeng, Gucheng1 Nutrition Metabolism and Infections, Infectious Microbes & Diseases: September 2021 Volume 3 Issue 3 p 134-141 doi: 10.1097/IM9.0000000000000061 (Pneumonia: Symptoms, Treatment, Causes & Prevention, 2020). 25: Assessment: Respiratory System / CH. 1) Seizures The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. e. Increased tactile fremitus Discontinue if SpO2 level is above the target range, or as ordered by the physician. 3. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. These critically ill patients have a high mortality rate of 25-50%. Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? To increase the oxygen level and achieve an SpO2 value of at least 96%. Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Has been NPO since midnight in preparation for surgery Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue? 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. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. This is done before sending the sample to the laboratory if there is no one else who can send the sample to the laboratory. c. It has two tubings with one opening just above the cuff. Consider imperceptible losses if the patient is diaphoretic and tachypneic. HR 68 bpm 3. b. Abnormal. Antibiotics. The pH is also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in venous blood (PvCO2). a. 3. Respiratory distress requires immediate medical intervention. 3.1 Ineffective airway clearance. Nursing care plan pneumonia - Nursing care plan: Pneumonia Pneumonia is an inflammation of the lung - Studocu care plan pneumonia nursing care plan: pneumonia pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair Skip to document Ask an Expert Sign inRegister Sign inRegister Home Expected outcomes Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). Community-Acquired Pneumonia. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. Provide factual information about the disease process in a written or verbal form. So to avoid that, they must be assisted in any activities to help conserve their energy. h) 3. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? a. Finger clubbing The nurse can also teach coughing and deep breathing exercises. Allow the patient to have enough bed rest and avoid strenuous activities. b. Assess for mental status changes.Poor oxygenation leads to decreased perfusion to the brain resulting in a decreased level of consciousness, restlessness, agitation, and lethargy. Atelectasis Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. 1. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. b. RV: (7) Amount of air remaining in lungs after forced expiration 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. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. Page . The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? This produces an area of low ventilation with normal perfusion. Avoid environmental irritants inside the patients room. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. The nurse selects Ineffective Breathing Pattern after validating this patient is demonstrating the associated signs and symptoms related to this nursing diagnosis: Dyspnea Increase in anterior-posterior chest diameter (e.g., barrel chest) Nasal flaring Orthopnea Prolonged expiration phase Pursed-lip breathing Tachypnea b. SpO2 of 95%; PaO2 of 70 mm Hg If O2 saturation does not increase to an acceptable level (greater than 92%), FiO2 is increased in small increments while simultaneously checking O2 saturation or obtaining ABG values. Pneumonia will be one of the most frequent infections the nurse will encounter and treat. Goal. What is the best response by the nurse? Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. As the patients condition worsens, sputum may become more abundant and change color from clear/white to yellow and/or green, or it may exhibit other discolorations characteristic of an underlying bacterial infection (e.g., rust-colored; currant jelly). How should the nurse document this sound? Which immediate action does the nurse take? When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen. Etiology The most common cause for this condition is poor oxygen levels. The nurse expects which treatment plan? Decreased skin turgor and dry mucous membranes as a result of dehydration. Report significant findings. The trachea connects the larynx and the bronchi. Observing for hypoxia is done to keep the HCP informed. patients with pneumonia need assistance when performing activities of daily living. To facilitate the body in cooling down and to provide comfort. d. Auscultation. Impaired gas exchange 5. The other options do not maintain inflation of the alveoli. Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . Patient with a fever The oxygenation status with a stress test would not assist the nurse in caring for the patient now. c. Mucociliary clearance F. A. Davis Company. b. b. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. b. Respiratory infection 3. 2. Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? 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.