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e. Sleep-rest: Sleep apnea. 1) Increase the intake of foods that are high in vitamin C. h) 3. Cough, sore throat, low-grade elevated temperature, myalgia, and purulent nasal drainage at the end of a cold are common symptoms of viral rhinitis and influenza. Select all that apply. high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. 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. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. Obtain the supplies that will be used. Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. causing a clinical illness o Mandatory testing for health care professionals o Usually performed twice o Priority Nursing Diagnoses: Ineffective breathing pattern Ineffective airway clearance Impaired Gas . Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. A) Use a cool mist humidifier to help with breathing. Wear gloves on both hands when handling the cannula or when handling ventilation tubing. These measures ensure consistency and accuracy of weight measurements. 2. This also increases the risk for aspiration pneumonia. To increase the oxygen level and achieve an SpO2 value of at least 96%. Recognize the risk factors for infection in patients with tracheostomy and take the following actions: Risk factors include the presence of underlying pulmonary disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased bacterial access to the lower airway, and cross-contamination from manipulation of the tracheostomy tube. 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. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion. e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration a. Stridor 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. A less severe form of bacterial pneumonia is called walking or atypical pneumonia, in which the symptoms are very mild and the infected person can do his/her activities of daily living as normal. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. It may also stimulate coughing. Frequent suctioning increases risk of trauma and cross-contamination. Preoperative education, explanation, and demonstration of pulmonary activities used postoperatively to prevent respiratory infections. 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 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. 27: Lower Respiratory Problems / CH. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. F. A. Davis Company. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. Patient Profile F.N. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. Excess CO2 does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). Assess the patients knowledge about Pneumonia. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. 3. 2. of . However, it is highly unlikely that TB has spread to the liver. was admitted, examination of his nose revealed clear drainage. Pinch the soft part of the nose. b. treatment with antifungal agents. Usually, people with pneumonia preferred their heads elevated with a pillow. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. j. Coping-stress tolerance A nasal ET tube in place a. a. b. Cyanosis c. Percussion The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. A patient develops epistaxis after removal of a nasogastric 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. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. 1) Seizures A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of cerebrospinal fluid and stimulates an increase in the respiratory rate. Discuss to him/her the different pros and cons of complying with the treatment regimen. Promote oral hygiene, including lip and tongue care. 's nose for several days after the trauma? 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. Partial obstruction of trachea or larynx b. Also, they will effectively help spread the disease process since they know the mode of transmission and how to break the cycle of transmitting it to other family members. Ventilation is impaired in spite of adequate perfusion in the lungs. Remove unnecessary lines as soon as possible. is a 28-year-old male patient who sustained bilateral fractures of the nose, 3 rib fractures, and a comminuted fracture of the tibia in an automobile crash 5 days ago. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. For best yield, blood cultures should be obtained before antibiotics are administered. Nursing Diagnosis. c. Remove the inner cannula if the patient shows signs of airway obstruction. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. Why is the air pollution produced by human activities a concern? b. Epiglottis e. Increased tactile fremitus The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. c. "An annual vaccination is not necessary because previous immunity will protect you for several years." How does the nurse respond? Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. Which instructions does the nurse provide to a patient with acute bronchitis? Assist with respiratory devices and techniques.Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. Provide tracheostomy care. Patient with a fever 4. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. b. Copious nasal discharge 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. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). Teach the importance of complying with the prescribed treatment and medication. a. 5. c. Turbinates Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). c. An electrolarynx held to the neck 7. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. 1) The cough may last from 6 to 10 weeks. f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. Instruct patients who are unable to cough effectively in a cascade cough. Identify the ability of the patient to perform self-care and do activities of daily living. Cough suppressants. Add heparin to the blood specimen. Apply pressure to the puncture site for 2 full minutes. a. NMNEC Concept: Gas Exchange. A) Sit the patient up in bed as tolerated and apply Retrieved February 9, 2022, from. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem d. Anterior then posterior Pneumonia can be mild but can also be fatal if left untreated. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that results from aspiration of gastric contents. Impaired gas exchange is closely tied to Ineffective airway clearance. Please read our disclaimer. What keeps alveoli from collapsing? RR 24 Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. d. VC Breath sounds in all lobes are verified to be sure that there was no damage to the lung. 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. Is elevated in bacterial pneumonias (greater than 12,000/mm3). d. Comparison of patient's current vital signs with normal vital signs To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. impaired gas exchange nursing care plan scribd. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. 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. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. a. The nurse presents education about pertussis for a group of nursing students and includes which information? 's airway before and after surgery? nursing care plan for pneumonia nursing care plan for stroke nursing care . Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum d. The patient cannot fully expand the lungs because of kyphosis of the spine. a. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. presence of nasal bleeding and exhalation grunting. This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. b. Interstitial edema c. Course crackles Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. Pneumonia: Bacterial or viral infections in the lungs . Primary care, with acute or intensive care hospitalization due to complications. c. Percussion The parietal pleura is a membrane that lines the chest cavity. If he or she cannot do it alone, make sure to place suction secretions at the bedside to use anytime. Respiratory distress requires immediate medical intervention. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. Anna Curran. Assess the patients vital signs and characteristics of respirations at least every 4 hours. Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. Try to use words that can be understood by normal people. 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. 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. (Symptoms) Reports of feeling short of breath d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. Organizing the tasks will provide a sufficient rest period for the patient. Objective Data 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. 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 Let the patient do a return demonstration when giving lectures about medication and therapeutic regimens. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. Which respiratory defense mechanism is most impaired by smoking? 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. The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. patients with pneumonia need assistance when performing activities of daily living. 6. Major nursing care planning goals for COVID-19 may include: Establishing goals, interventions. Warm and moisturize inhaled air She found a passion in the ER and has stayed in this department for 30 years. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. 6. 1. 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. 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. 2. c. Persistent swelling of the neck and face Decreased force of cough Save my name, email, and website in this browser for the next time I comment. Consider sources of infection.Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. 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. c. Elimination: Constipation, incontinence c. a throat culture or rapid strep antigen test. Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. There is an induration of only 5 mm at the injection site. Pneumonia Nursing Care Plan 4 Impaired Gas Exchange Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. c. There is equal but diminished movement of the 2 sides of the chest. b. To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses. The cough with pertussis may last from 6 to 10 weeks. Place the patient in a comfortable position. What is included in the nursing care of the patient with a cuffed tracheostomy tube? Elevate the head of the bed and assist the patient to assume semi-Fowlers position. A) 2, 3, 4, 5, 6 After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. Use a sterile catheter for each suctioning procedure. 5) Minimize time in congregate settings. 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. Goal/Desired Outcome Short-term goal: The patient will remain free from signs of respiratory distress and her oxygen saturation will remain higher than 96% for the duration of the shift. c. Keep a same-size or larger replacement tube at the bedside. Atelectasis Assess lung sounds and vital signs. Severely immunosuppressed patients are affected not only by bacteria but also by viruses (cytomegalovirus) and fungi (Candida, Aspergillus, Pneumocystis jirovecii). This is an expected finding with pneumonia, but should not continue to rise with treatment. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. Attempt to replace the tube. Select all that apply. 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. Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication.