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. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. Stridor is a continuous musical or crowing sound and unrelated to pneumonia. Priority: Sleep management Antibiotics: To treat bacterial pneumonia. Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. Change ventilation tubing according to agency guidelines. Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. To help clear thick phlegm that the patient is unable to expectorate. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. Identify the ability of the patient to perform self-care and do activities of daily living. What is the best response by the nurse? The trachea connects the larynx and the bronchi. 3. However, with increasing respiratory distress, respiratory acidosis may occur. d. VC g. FEV1 What is included in the nursing care of the patient with a cuffed tracheostomy tube? (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. This produces an area of low ventilation with normal perfusion. Pockets of pus may form inside the lungs or on their outer layers. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. Why is the air pollution produced by human activities a concern? Put the index fingers on either side of the trachea. Periorbital and facial edema reduced by about half since second hospital day c. Keep a same-size or larger replacement tube at the bedside. Decreased compliance contributes to barrel chest appearance. d. Initiate pulse oximetry for continuous monitoring of the patient's oxygen status. Pleurisy, a) 7. c. Wheezing Activity intolerance 2. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. a. Suction the tracheostomy. Weigh patient daily at same time of day and on same scale; record weight. 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. Changes in oxygen therapy or interventions should be avoided for 15 minutes before the specimen is drawn because these changes might alter blood gas values. A) Sit the patient up in bed as tolerated and apply Impaired gas exchange is closely tied to Ineffective airway clearance. Remove unnecessary lines as soon as possible. 5) Minimize time in congregate settings. a. nursing diagnosis based on the assessment data the major nursing diagnoses for meconium aspiration syndrome are hyperthermia related to inflammatory process hypermetabolic state as evidenced by an increase in body temperature warm skin and tachycardia fluid volume . Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. b. 2. 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. 1. d. Contain dead air that is not available for gas exchange. Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. Assist the patient with position changes every 2 hours. d. Pulmonary embolism. Remove excessive clothing, blankets and linens. Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. h. Role-relationship Steroids: To reduce the inflammation in the lungs. Allow patients to ask a question or clarify regarding their treatment. d. Pleural friction rub This type of pneumonia refers to getting the infection at home, in the workplace, in school, or other places in the community outside a hospital or care facility. 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. Oximetry: May reveal decreased O2 saturation (92% or less). g. Fine crackles Hospital acquired pneumonia may be due to an infected. b) 6. d. SpO2 of 88%; PaO2 of 55 mm Hg. Learning to apply information through a return demonstration is more helpful than verbal instruction alone. Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . The immunity will not protect for several years, as new strains of influenza may develop each year. Amount of air exhaled in first second of forced vital capacity 7. Bilateral ecchymosis of eyes (raccoon eyes) Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? Select all that apply. Promote a well-ventilated environment so that the patient will have good oxygen exchange in the body. Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues. 1. a. SpO2 of 92%; PaO2 of 65 mm Hg What process would they have needed to complete in order to have been successful? St. Louis, MO: Elsevier. Trend and rate of development of the hyperkalemia Better Health Channel. Cough and sore throat RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Study Resources . (2020, June 15). When F.N. c. Tracheal deviation Allow the patient to have enough bed rest and avoid strenuous activities. 3. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). A) Increasing fluids to at least 6 to 10 glasses/day, unless. Chronic hypoxemia c. Turbinates Change the tube every 3 days. What priority discharge teaching should the nurse provide? All of the assessments are appropriate, but the most important is the patient's oxygen status. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. Which values indicate a need for the use of continuous oxygen therapy? See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. i. Sexuality-reproductive Monitor cuff pressure every 8 hours. a. Stridor 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. Alveolar-capillary membrane changes (inflammatory effects) 3. Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae. Order stat ABGs to confirm the SpO2 with a SaO2. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? Assess lung sounds and vital signs. If there is airway obstruction this will only block and cause problems in gas exchange. d. Dyspnea and severe sinus pain c. A nasogastric tube with orders for tube feedings The nurse expects which treatment plan? NurseTogether.com does not provide medical advice, diagnosis, or treatment. Select all that apply. Tuberculosis frequently presents with a dry cough. Techniques that will be used to alleviate a dry mouth and prevent stomatitis 7) c. Send labeled specimen containers to the laboratory. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. c. Persistent swelling of the neck and face Examine sputum for volume, odor, color, and consistency; document findings. Preventing the spread of coronavirus infection to the patient's family members, community, and healthcare providers. b. Copious nasal discharge a. Stridor Identify and avoid triggers of the allergic reaction. Watch for signs and symptoms of respiratory distress and report them promptly. CH. Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. e. Posterior then anterior. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. Patient with a fever The parietal pleura is a membrane that lines the chest cavity. Severely immunosuppressed patients are affected not only by bacteria but also by viruses (cytomegalovirus) and fungi (Candida, Aspergillus, Pneumocystis jirovecii). Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. a. (2022, January 26). b. d. Testing causes a 10-mm red, indurated area at the injection site. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. I do not know if it's just overthinking it or what but all the care plans i have read . Page . What is the first patient assessment the nurse should make? If the patient is ambulatory, walking should be encouraged within the patients tolerance. c. An electrolarynx held to the neck a. Oxygen is administered when O2 saturation or ABG results show hypoxemia. d. Chronic herpes simplex infections of the mouth and lips. Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up. b. Cyanosis c. Check the position of the probe on the finger or earlobe. Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . a. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion. Base to apex There is an induration of only 5 mm at the injection site. Pulmonary function test d. Pulmonary embolism The patient will have improved gas exchange. a. Assess the patient for iodine allergy. c. Use cromolyn nasal spray prophylactically year-round. The home health nurse provides which instruction for a patient being treated for pneumonia? Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. What do these findings indicate? These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. c. SpO2 of 90%; PaO2 of 60 mm Hg Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. Atelectasis. 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. Goal. A Code Blue would not be called unless the patient experiences a loss of pulse and/or respirations. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. 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 oxygen. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. What testing is indicated? Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma. Avoid instillation of saline during suctioning. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. Dyspnea and severe sinus pain as well as tender swollen glands, severe ear pain, or significantly worsening symptoms or changes in sputum characteristics in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. Basket stars are active at night. a. TB F.N. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. Save my name, email, and website in this browser for the next time I comment. 27 - Lower Respiratory Problems, Coronary Artery Disease & Acute Coronary Synd, Integumentary System (Lewis Med-Surg CH.22 &, Barbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh, 1.1 (Anatomy) Functional Organization of the. b. SpO2 of 95%; PaO2 of 70 mm Hg 5. a. 2 8 Nursing diagnosis for pneumonia. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection. Put the palms of the hands against the chest wall. 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. Antibiotics. The postoperative use of nonverbal communication techniques To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? At the end of the span of care, the patient will be able to have an effective, regular, and improved respiratory pattern within a normal range (12-20 cycles per minute). Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. Hypoxemia was the characteristic that presented the best measures of accuracy. 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. 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 However, it is highly unlikely that TB has spread to the liver. Impaired Gas Exchange Nursing Diagnosis & Care Plan Related Factors Physiological damage to the alveoli Circulatory compromise Lack of oxygen supply Insufficient availability of blood (carrier of oxygen) Subjective Data: patient's feelings, perceptions, and concerns. 3 Nursing care plans for pneumonia. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? 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. She received her RN license in 1997. Elevate the head of the bed and assist the patient to assume semi-Fowlers position. Number the following actions in the order the nurse should complete them. 2. of . d. Testing causes a 10-mm red, indurated area at the injection site. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? c. a throat culture or rapid strep antigen test. Keep the patient in the semi-Fowler's position at all times. a. 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). To avoid the formation of a mucus plug, suction it as needed. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. Keep skin clean and dry through frequent perineal care or linen changes. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. What the oxygenation status is with a stress test d. Parietal pleura. She found a passion in the ER and has stayed in this department for 30 years. Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. Viral pneumonia. c. The necessity of never covering the laryngectomy stoma a. Suction the tracheostomy. Frequent suctioning increases risk of trauma and cross-contamination. 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. 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. Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. d. Patient can speak with an attached air source with the cuff inflated. One way to have a good prognosis and help fasten recovery is to comply with the prescribed treatment. b. Nutritional-metabolic c) 5. Assess the patients knowledge about Pneumonia. The nurse should instruct on how to properly use these devices and encourage their use hourly. (Symptoms) Reports of feeling short of breath Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. Lung consolidation with fluid or exudate Expresses concern about his facial appearance b. What accurately describes the alveolar sacs? The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. 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. 3) Treatment usually includes macrolide antibiotics. b. treatment with antifungal agents. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. a. 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. - Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. This intervention decreases pain during coughing, thereby promoting a more effective cough. 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. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, Poor peripheral perfusion that occurs with hypovolemia or other conditions that cause peripheral vasoconstriction will cause inaccurate pulse oximetry, and ABGs may have to be used to monitor oxygenation status and ventilation status in these patients. Nursing Diagnosis for Pleural Effusion Impaired Gas Exchange r/t decreased function of lung tissue Ineffective Breathing Pattern r/t compromised lung expansion Acute Pain r/t inflammatory process Anxiety r/t inability to take deep breaths Risk for infection r/t pooling of fluid in the lung space Nursing Care Plans for Pleural Effusion Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? She earned her BSN at Western Governors University. 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. Desired Outcome: At the end of the span of care, the patient will be able to understand the transmission, disease process, and available treatments for pneumonia. Also called nosocomial pneumonia, this type of pneumonia originates from being admitted in the hospital. Anna Curran. c. Place the thumbs at the midline of the lower chest. Always maintain sterility or aseptic techniques when performing any invasive procedure. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Stop feeding when the patient is lying flat. A) "I will need to have a follow-up chest x-ray in six to.
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