Antibiotics: To treat bacterial pneumonia. b. treatment with antifungal agents. If the patient is enteral fed, recommend continuous rather than bolus feeding. arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period? Why is the air pollution produced by human activities a concern? Administer the prescribed airway medications (e.g. c. It has two tubings with one opening just above the cuff. Cough reflex They will further understand the topic since they already have an idea of what is it about. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. a. 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. The nurse expects which treatment plan? Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. e. Rapid respiratory rate. 3. Nursing Diagnosis. Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. Impaired gas exchange is closely tied to Ineffective airway clearance. 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. c. Drainage on the nasal dressing b. Finger clubbing The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? Assist with respiratory devices and techniques.Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. 3 Pneumonia in the immunocompromised individual 4 Assessment of pneumonia 5 Diagnostic test for pneumonia 6 Nursing Diagnosis of pneumonia 6.1 Risk for Infection (nosocomial pneumonia) 6.2 Impaired Gas Exchange due to pneumonic condition 6.3 Ineffective clearance of the airway 6.4 Deficient fluid volume Community acquired pneumonias a. Vt Hypoxemia was the characteristic that presented the best measures of accuracy. b. Copious nasal discharge NurseTogether.com does not provide medical advice, diagnosis, or treatment. . Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Use narcotics and sedatives with caution.Narcotics for pain control or anti-anxiety medications should be monitored closely as they can further suppress the respiratory system. Keep skin clean and dry through frequent perineal care or linen changes. It must include the local 911 numbers, hospitals, and immediate keen of the patient. 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. Expresses concern about his facial appearance c. Have the patient hyperextend the neck. The patient is positioned and instructed not to talk or cough to avoid damage to the lung. 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. Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. Basket stars are active at night. Advised the patient to dispose of and let out the secretions. 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. Provide tracheostomy care. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). Etiology The most common cause for this condition is poor oxygen levels. c) 5. 26: Upper Respiratory Problems / CH. b. Epiglottis c. Tracheal deviation A patient's ABGs include a PaO2 of 88 mm Hg and a PaCO2 of 38 mm Hg, and mixed venous blood gases include a partial pressure of oxygen in venous blood (PvO2) of 40 mm Hg and partial pressure of carbon dioxide in venous blood (PvCO2) of 46 mm Hg. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. Sleep disturbance related to dyspnea or discomfort 6. a. SpO2 of 92%; PaO2 of 65 mm Hg Impaired Gas Exchange is a NANDA nursing diagnosis that is used for conditions where there is an alteration in the balance between the exchange of gases in the lungs. impaired Gas Exchange may be related to decreased oxygen-carrying capacity of blood, reduced RBC life span, abnormal RBC structure, increased blood viscosity, predisposition to bacterial pneumonia/pulmonary infarcts, possibly evidenced by dyspnea, use of accessory muscles, cyanosis/signs of hypoxia, tachycardia, changes in mentation, and . What is the first action the nurse should take? c. Remove the inner cannula if the patient shows signs of airway obstruction. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. b. 8. d. Comparison of patient's current vital signs with normal vital signs. Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). Study Resources . 2) Guillain-Barr syndrome Identify patients at increased risk for aspiration. 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. 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. c. Send labeled specimen containers to the laboratory. Interstitial edema These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. impaired gas exchange nursing care plan scribd. i. Sexuality-reproductive Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). Individuals with depressed level of consciousness, advanced age, dysphagia, or a nasogastric (NG) or enteral tube are at increased risk for aspiration, which predisposes them to pneumonia. The turbinates in the nose warm and moisturize inhaled air. 1. 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. One way to have a good prognosis and help fasten recovery is to comply with the prescribed treatment. 2. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. Lung consolidation with fluid or exudate The live attenuated influenza vaccine is given intranasally and is recommended for all healthy people between the ages of 2 and 49 years but not for those at increased risk of complications or HCPs. b. Epiglottis 5) e. Observe for signs of hypoxia during the procedure. The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Techniques that will be used to alleviate a dry mouth and prevent stomatitis The patient is infectious from the beginning of the first stage through the third week after onset of symptoms or until five days after antibiotic therapy has been started. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. 1. The nurse suspects which diagnosis? 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. Dont forget to include some emergency contact numbers just in case there is an emergency. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. Priority: Sleep management Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. 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 Health perception-health management Respiratory distress requires immediate medical intervention. What the oxygenation status is with a stress test What priority discharge teaching should the nurse provide? is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance. c. Empyema Discontinue if SpO2 level is above the target range, or as ordered by the physician. Amount of air that can be quickly and forcefully exhaled after maximum inspiration Discharging the patient is unsafe. Ventilation is impaired in spite of adequate perfusion in the lungs. b. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). Administer analgesics 1/2 hour prior to deep breathing exercises. She found a passion in the ER and has stayed in this department for 30 years. Arterial blood gas (ABG) values: May vary depending on extent of pulmonary involvement or other coexisting conditions. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. a. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. d. Comparison of patient's current vital signs with normal vital signs Page . Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. d. Auscultation. Patients who are weak or lack a cough reflex may not be able to do so. Provide factual information about the disease process in a written or verbal form. Impaired gas exchange 5. Pneumonia may increase sputum production causing difficulty in clearing the airways. Medscape Reference. While the nurse is feeding a patient, the patient appears to choke on the food. c. A negative skin test is followed by a negative chest x-ray. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? Teach the patient to use the incentive spirometer as advised by their attending physician. 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. Identify and avoid triggers of the allergic reaction. b. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. 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. Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Add heparin to the blood specimen. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. 4) Spend as much time as possible outdoors. Select all that apply. a. Stridor Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection. 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). 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? Identify the ability of the patient to perform self-care and do activities of daily living. The width of the chest is equal to the depth of the chest. 3.1 Ineffective airway clearance. Productive cough (viral pneumonia may present as dry cough at first). Promote oral hygiene, including lip and tongue care. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. b. A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. Base to apex Treatment for pneumonia needs to be complied with completely to ensure a good prognosis and improve health. e) 1. Usual PaO2 levels are expected in patients 60 years of age or younger. Report significant findings. Assess intake and output (I&O). Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nurses should assess for and encourage pneumonia vaccines for eligible populations. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. cancer patients or COPD patients). Monitor cuff pressure every 8 hours. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. Aspiration precautions include maintaining a 30-degree elevation of the HOB, turning the patient onto his or her side rather than back, and using continuous rather than bolus feeding when the patient is enteral. Decreased force of cough Anna Curran. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. 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. 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. 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. 6) a. Verify breath sounds in all fields. Bilateral ecchymosis of eyes (raccoon eyes) The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. The patient may have a limit to visitors to prevent the transmission of infections. 3. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. 3. She earned her BSN at Western Governors University. 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. a. Apex to base Partial obstruction of trachea or larynx b. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). d. Pleural friction rub. c. Keep a same-size or larger replacement tube at the bedside. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. (n.d.). b. CO2 causes an increase in the amount of hydrogen ions available in the body. a. a. b. Cyanosis a. Abnormal. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). c. Percussion Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. a. Suction the tracheostomy. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. Buy on Amazon. 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. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. d. Reflex bronchoconstriction. Night sweats Reporting complications of hyperinflation therapy to the health care provider. What should the nurse do when preparing a patient for a pulmonary angiogram? Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. Select all that apply. a. Thoracentesis c. Take the specimen immediately to the laboratory in an iced container. A) Use a cool mist humidifier to help with breathing. c. Terminal structures of the respiratory tract Select all that apply. Pneumonia can be mild but can also be fatal if left untreated. Watch for signs and symptoms of respiratory distress and report them promptly. How does the nurse assess the patient's chest expansion? Cough suppressants. patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. Complications include hyperventilation, gastric hyperinflation, headache, hypotension, and signs and symptoms of pneumothorax (shortness of breath, stabbing chest pain, decreased breath sounds on one side, dyspnea, cough). Lung consolidation with fluid or exudate The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. The palms are placed against the chest wall to assess tactile fremitus. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. St. Louis, MO: Elsevier. 3.6 Risk for imbalanced nutrition: less than body requirements. Acid-fast stains and cultures: To rule out tuberculosis. This assessment monitors the trend in fluid volume. b. Stridor c. Patient in hypovolemic shock Partial obstruction of trachea or larynx Medical-surgical nursing: Concepts for interprofessional collaborative care. d. Chronic herpes simplex infections of the mouth and lips. Before other measures are taken, the nurse should check the probe site. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. It may also stimulate coughing. Summarize why people were unsuccessful over 1,000 years ago when they tried to transform lead into gold. Bronchodilators: To dilate or relax the muscles on the airways. F. A. Davis Company. 4. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. - According to the Expanded CURB-65 scale, which is used as a supplement to clinical judgment to determine the severity of pneumonia, the patient's score is a 5; placement in the intensive care unit is recommended. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time spent in congregate settings or on public transportation. As an Amazon Associate I earn from qualifying purchases. Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). Stridor is a continuous musical or crowing sound and unrelated to pneumonia. What measures should be taken to maintain F.N. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration, and the nurse should monitor the patient's respiratory rate and rhythm and SpO2.