NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. Obtain the supplies that will be used. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. 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). d) 8. Bronchodilators: To dilate or relax the muscles on the airways. Match the following pulmonary capacities and function tests with their descriptions. Concept Map-AHI - Concept Mapping Nursing diagnosis: Impaired gas Medications such as paracetamol, ibuprofen, and. There is a prominent protrusion of the sternum. An open reduction and internal fixation of the tibia were performed the day of the trauma. Trend and rate of development of the hyperkalemia When F.N. Suction the mouth or the oral airway as needed. There is no redness or induration at the injection site. This is an expected finding with pneumonia, but should not continue to rise with treatment. Samples for ABGs must be iced to keep the gases dissolved in the blood (unless the specimen is to be analyzed in <1 minute) and taken directly to the laboratory. Decreased skin turgor and dry mucous membranes as a result of dehydration. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? 1. d. Oxygen saturation by pulse oximetry. e. Teach the patient about home tracheostomy care. d. Direct the family members to the waiting room. Document the results in the patient's record. The position of the oximeter should also be assessed. Consider using a closed suction system; replace closed suction system according to agency guidelines. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. The patient will have improved gas exchange. The nurse can also teach coughing and deep breathing exercises. NurseTogether.com does not provide medical advice, diagnosis, or treatment. Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. Nursing Diagnosis. Pulmonary function tests are noninvasive. Techniques that will be used to alleviate a dry mouth and prevent stomatitis 6. The other options do not maintain inflation of the alveoli. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. g) 4. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. d. Testing causes a 10-mm red, indurated area at the injection site. b. Promote oral hygiene, including lip and tongue care. 2018.01.18 NMNEC Curriculum Committee. Appendix N3: Nursing Diagnoses Grouped by Diseases/Disorders 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. e. Posterior then anterior Save my name, email, and website in this browser for the next time I comment. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. The immunity will not protect for several years, as new strains of influenza may develop each year. The turbinates in the nose warm and moisturize inhaled air. Assess lung sounds and vital signs.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. Always maintain sterility or aseptic techniques when performing any invasive procedure. Remove unnecessary lines as soon as possible. b. Change the tube every 3 days. 1. d. Pulmonary embolism These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur but will affect the patients' activity tolerance. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. e) 1. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. Chronic hypoxemia How to use esophageal speech to communicate f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. b. d. Pulmonary embolism. 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). c. The necessity of never covering the laryngectomy stoma She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. 3) Illicit drug intake A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. What is the significance of the drainage? Assist with respiratory devices and techniques.Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. The carina is the point of bifurcation of the trachea into the right and left bronchi. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. Select all that apply. k. Value-belief, Risk Factor for or Response to Respiratory Problem 2. What should the nurse do when preparing a patient for a pulmonary angiogram? The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. - Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Pneumonia may increase sputum production causing difficulty in clearing the airways. b. Epiglottis Medical-surgical nursing: Concepts for interprofessional collaborative care. Provide tracheostomy care. b. Nasal flaring Abnormal breathing rate, depth, and rhythm Hypoxemia Restlessness Confusion A headache after waking up Elevated blood pressure and heart rate Somnolence and visual disturbances Nursing Assessment for Impaired Gas Exchange symptoms Summarize why people were unsuccessful over 1,000 years ago when they tried to transform lead into gold. Identify and avoid triggers of the allergic reaction. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. Let the patient do a return demonstration when giving lectures about medication and therapeutic regimens. d. Comparison of patient's current vital signs with normal vital signs After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. Pneumonia can be mild but can also be fatal if left untreated. It involves the inflammation of the air sacs called alveoli. Learn how your comment data is processed. Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. Promote skin integrity.The skin is the bodys first barrier against infection. (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. 4. 5. h. Role-relationship: Loss of roles at work or home, exposure to respiratory toxins at work What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? a. To care for the tracheostomy appropriately, what should the nurse do? Select all that apply. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Which respiratory defense mechanism is most impaired by smoking? c. Tracheal deviation Breath sounds in all lobes are verified to be sure that there was no damage to the lung. Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. 3) Treatment usually includes macrolide antibiotics. b. d. a total laryngectomy to prevent development of second primary cancers. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. Impaired Gas Exchange Nursing Diagnosis, Care Plan, Interventions Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. d. Small airway closure earlier in expiration It must include the local 911 numbers, hospitals, and immediate keen of the patient. The nurse explains that usual treatment includes It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. e. Airway obstruction is likely if the exact steps are not followed to produce speech. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. 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. A tracheostomy is safer to perform in an emergency. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. The syringe used to obtain the specimen is rinsed with heparin before the specimen is taken and pressure is applied to the arterial puncture site for 5 minutes after obtaining the specimen. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. impaired gas exchange nursing care plan scribd. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). Visualize and note some changes when it comes to the color of the skin, quality of mucous production, and nail beds. Periorbital and facial edema reduced by about half since second hospital day The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath Cough suppressants. 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. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. Give supplemental oxygen treatment when needed. b. Cuff pressure monitoring is not required. a. radiation therapy that preserves the quality of the voice. A transesophageal puncture This assessment monitors the trend in fluid volume. Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. a. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. c. Persistent swelling of the neck and face 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. 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. Discussion Questions The width of the chest is equal to the depth of the chest. Which values indicate a need for the use of continuous oxygen therapy? "You should get the inactivated influenza vaccine that is injected every year." d. Patient receiving oxygen therapy. d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Pinch the soft part of the nose. What is the reason for delaying repair of F.N. Suctioning keeps the airway clear by removing secretions. Retrieved February 9, 2022, from. NMNEC Concept: Gas Exchange. Viruses such as RSV (common cause in infants age 1 and below), flu and cold viruses can cause viral pneumonia, which is the second most common type of pneumonia. Saunders comprehensive review for the NCLEX-RN examination. b. Finger clubbing Examine sputum for volume, odor, color, and consistency; document findings. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. Line the lung pleura a. Vt Chronic hypoxemia For which problem is this test most commonly used as a diagnostic measure? Shetty, K., & Brusch, J. L. (2021, April 15). Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). The pH is also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in venous blood (PvCO2). h. Absent breath sounds Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? Provide tracheostomy care. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. d. Notify the health care provider of the change in baseline PaO2. c. Drainage on the nasal dressing Maximum amount of air lungs can contain - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody). Patient Profile F.N. Turbinates warm and moisturize inhaled air. 7. The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. Assess the patients knowledge about Pneumonia. f. Use of accessory muscles. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. b. Obtain the supplies that will be used. 1. b. RV Add heparin to the blood specimen. Care plan pneumonia, sepsis 2 - 1# Priority Nursing Diagnosis Goal a. Nursing Diagnosis 1: Risk for fluid volume deficit related to increased fluid losses secondary to diarrhea and decreased fluid intake; Nursing Diagnosis 2: Impaired gas exchange related to pneumonia and decreased oxygen saturation levels; 2. A 73-year-old patient has an SpO2 of 70%. 2. 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. Viral pneumonia. A) Purulent sputum that has a foul odor b. RV: (7) Amount of air remaining in lungs after forced expiration Identify the ability of the patient to perform self-care and do activities of daily living. Administer the prescribed antibiotic and anti-pyretic medications. Sleep disturbance related to dyspnea or discomfort 6. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? If sepsis is suspected, a blood culture can be obtained. a. Stridor Change ventilation tubing according to agency guidelines. 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. 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. c. Check the position of the probe on the finger or earlobe. Ventilation is impaired in spite of adequate perfusion in the lungs. Assist the patient when they are doing their activities of daily living. j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems a. b. Filtration of air A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. d. Normal capillary oxygen-carbon dioxide exchange. 3.4 Activity Intolerance. Start oxygen administration by nasal cannula at 2 L/min. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. 6) a. Verify breath sounds in all fields. 2. Problems of Oxygenation: Ventilation (Lewis Med-Surg Section 6) - Quizlet Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . This produces an area of low ventilation with normal perfusion. Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum CASE STUDY: Rhinoplasty An ET tube has a higher risk of tracheal pressure necrosis. 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. b. Surfactant Since the patients body is having difficulty with gas exchange due to pneumonia, it will benefit him/her to have some supplementary oxygen treatment to assist in the demands of the body. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. 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. Assess for mental status changes. e. FVC Which instructions does the nurse provide to a patient with acute bronchitis? It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Assess lab values.An elevated white blood count is indicative of infection. 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. Water, hydration, and health. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period? Observing for hypoxia is done to keep the HCP informed. Report significant findings. List Priorities from Highest to Lowest ! Give 2 Nursing Diagnosis b. Unstable hemodynamics Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). was admitted, examination of his nose revealed clear drainage. 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. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? b. Fever and vomiting are not manifestations of a lung abscess. Avoid environmental irritants inside the patients room. f. Instruct the patient not to talk during the procedure. 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. Stridor is a continuous musical or crowing sound and unrelated to pneumonia. Hopefully the family will have some time to discuss this before they are instructed to leave the room, unless it is an emergency. The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. 3. g. Self-perception-self-concept a. 3. c. Terminal structures of the respiratory tract St. Louis, MO: Elsevier. Page . oxygen. 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home What keeps alveoli from collapsing? It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. F. A. Davis Company. a. c. Empyema a. d. Limited chest expansion Week 1 - Respiratory.docx - Week 1 - Nursing Care of a. Assess the patient for iodine allergy. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. Impaired gas exchange is a risk nursing diagnosis for pneumonia. c. Explain the test before the patient signs the informed consent form. Patient's temperature 6. 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. Impaired gas exchange is the state in which there is an excess or deficit in oxygenation or in the elimination of carbon dioxide at the level of the alveolocapillary membrane. Better Health Channel. CH. Base to apex What is the most appropriate action by the nurse? 3.1 Ineffective airway clearance. . Are there any collaborative problems? Place the patient in a comfortable position. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. Heavy tobacco and/or alcohol use If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues. The parietal pleura is a membrane that lines the chest cavity. These practices further reduce the risk of contamination. 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. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. 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. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. Notify the health care provider. Remove the inner cannula and replace it per institutional guidelines. Decreased functional cilia Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. d. Pleural friction rub d. Comparison of patient's current vital signs with normal vital signs. Administer the prescribed airway medications (e.g. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. Empyema is a collection of pus in the thoracic cavity. Impaired Gas Exchange Assessment 1. 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). Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. 6. Suction secretions as needed. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. b. Copious nasal discharge 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. The visceral pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. Put the index fingers on either side of the trachea. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. Unless contraindicated, promote fluid intake (2.5 L/day or more). Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. a. Impaired Gas Exchange - Nursing Diagnosis & Care Plan Amount of air exhaled in first second of forced vital capacity 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). Increase heat and humidity if patient has persistent secretions. c. Turbinates d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult.". Attend to the patients queries regarding their pneumonia treatment. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Fatigue 4. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. a. Finger clubbing Encourage to always change position to facilitate mucous drainage in the lungs. The patient reports a sudden onset of shortness of breath, slight chest pain, and that "something is wrong." e. Increased tactile fremitus A) Sit the patient up in bed as tolerated and apply c. "An annual vaccination is not necessary because previous immunity will protect you for several years." Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. e. Posterior then anterior. In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? (2020). 2. The following diagnoses are usually made when caring for patients with pneumonia: Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Knowledge deficit/Deficient knowledge Activity intolerance Risk for infection Risk for nutritional imbalance: less than body requirements 1) Seizures Immunosuppression and neutropenia are predisposing factors for the development of nosocomial pneumonia caused by common and uncommon pathogens. Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs.
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