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. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. 1) SpO2 of 85% 2) PaCO2 of 65 mm Hg 3) Thick yellow mucus expectorant 4) Respiratory rate of 24 breaths/minute 5) Dullness to percussion over the affected area Click the card to flip Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. 2. Chronic hypoxemia This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. 3.1 Ineffective airway clearance. There is alteration in the normal respiratory process of an individual. Preventing the spread of coronavirus infection to the patient's family members, community, and healthcare providers. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Her experience spans almost 30 years in nursing, starting as an LVN in 1993. c. TLC The postoperative use of nonverbal communication techniques 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. A) Pneumonia Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual. d. Notify the health care provider of the change in baseline PaO2. A transesophageal puncture a. Assess the patient for iodine allergy. a. Assess the patients knowledge about Pneumonia. To help clear thick phlegm that the patient is unable to expectorate. 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. Position the patient to be comfortable (usually in the half-Fowler position). Nursing Diagnosis. 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. Weight changes of 1-1.5 kg/day may occur with fluid excess or deficit. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. Assess the need for hyperinflation therapy. These critically ill patients have a high mortality rate of 25-50%. Impaired Gas Exchange Assessment 1. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. There is an induration of only 5 mm at the injection site. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. Monitor cuff pressure every 8 hours. What is the reason for delaying repair of F.N. Decreased compliance contributes to barrel chest appearance. 3.5 Acute Pain. 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. Primary care, with acute or intensive care hospitalization due to complications. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). e. Posterior then anterior Priority: Management of pneumonia and dehydration. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness. a. 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. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. b. Diminished breath sounds are linked with poor ventilation. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? c. Mucociliary clearance (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. Respiratory infection 3. Level of the patient's pain 2. of . Let the patient do a return demonstration when giving lectures about medication and therapeutic regimens. Place or install an air filter in the room to prevent the accumulation of dust inside. d. Patient receiving oxygen therapy. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. 28: Obstructive Pulmonary Diseases. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. This patient is older and short of breath. f. Use of accessory muscles. 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 width of the chest is equal to the depth of the chest. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. CASE STUDY: Rhinoplasty Steroids: To reduce the inflammation in the lungs. 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. The following signs and symptoms show the presence of impaired gas exchange: Abnormal breathing rate, rhythm, and depth Nasal flaring Hypoxemia Cyanosis in neonates decreases carbon dioxide Confusion Elevated blood pressure and heart rate A headache after waking up Restlessness Somnolence and visual disturbances Looking For Custom Nursing Paper? Functional Health Pattern Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. Buy on Amazon. Which action does the nurse take next? Learn how your comment data is processed. Which instructions does the nurse provide to a patient with acute bronchitis? 1. a. Undergo weekly immunotherapy. A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. d. Limited chest expansion a. 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. It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. d. Pulmonary embolism. c. Inadequate delivery of oxygen to the tissues Teach the proper technique of doing pursed-lip breathing, various ways of relaxation, and abdominal breathing. d. Oxygen saturation by pulse oximetry. Always maintain sterility or aseptic techniques when performing any invasive procedure. Hopefully the family will have some time to discuss this before they are instructed to leave the room, unless it is an emergency. This work is the product of the Help the patient get into a comfortable position, usually the half-Fowler position. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? Adjust the room temperature. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. b. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. Nurses also play a role in preventing pneumonia through education. The palms are placed against the chest wall to assess tactile fremitus. c. Elimination Why is the air pollution produced by human activities a concern? It may also cause hepatitis. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). Before other measures are taken, the nurse should check the probe site. Nutrition reviews, 68(8), 439458. If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status. a. Suction the tracheostomy. The nurse suspects which diagnosis? b. Long-term denture use 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. 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. RR 24 The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. Impaired gas exchange is closely tied to Ineffective airway clearance. Respiratory distress requires immediate medical intervention. c. SpO2 of 90%; PaO2 of 60 mm Hg d. Reflex bronchoconstriction. This can be due to a compromised respiratory system or due to lung disease. 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. Report significant findings. b. 1. f. Hyperresonance 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. d. CO2 directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. Start asking what they know about the disease and further discuss it with the patient. b. d. Direct the family members to the waiting room. Which values indicate a need for the use of continuous oxygen therapy? What measures should be taken to maintain F.N. It involves the inflammation of the air sacs called alveoli. c. Persistent swelling of the neck and face What accurately describes the alveolar sacs? Page . 4. The nurse can also teach him or her to use the bedside table with a pillow and lean on it. Keep the patient in the semi-Fowler's position at all times. 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. In addition, have the patient upright and leaning forward to prevent swallowing blood. Select all that apply. Report significant findings. c. Terminal structures of the respiratory tract 3. Pneumonia can be mild but can also be fatal if left untreated. What covers the larynx during swallowing? This also increases the risk for aspiration pneumonia. After the intervention, the patients airway is free of incidental breath sounds. 3. To facilitate the body in cooling down and to provide comfort. 5. 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. Discuss to him/her the different pros and cons of complying with the treatment regimen. c. Check the position of the probe on the finger or earlobe. c. An electrolarynx held to the neck Select all that apply. As an Amazon Associate I earn from qualifying purchases. c. a throat culture or rapid strep antigen test. Obtain the supplies that will be used. Select all that apply. c. Have the patient hyperextend the neck. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. d. Auscultation. Nursing Diagnosis Impaired Gas Exchange related to to altered alveolarcapillary membrane changes due to pneumonia disease process. Hyperkalemia is not occurring and will not directly affect oxygenation initially. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. They will further understand the topic since they already have an idea of what is it about. 2. It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. Stridor is identified with auscultation. St. Louis, MO: Elsevier. Save my name, email, and website in this browser for the next time I comment. Pinch the soft part of the nose. Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. a. A) Use a cool mist humidifier to help with breathing. ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. Document the results in the patient's record. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems Suction secretions as needed. Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. b. Surfactant A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. Try to use words that can be understood by normal people. a. The patient receives 1 point for each criterion: confusion (compared to baseline); BUN greater than 20 mg/dL; respiratory rate greater than or equal to 30 breaths/min; systolic BP of less than 90 mm Hg; and age greater than or equal to 65 yrs. c. A nasogastric tube with orders for tube feedings 4. Maximum amount of air lungs can contain Always change the suction system between patients. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. 2) Ensure that the home is well ventilated. Nursing management of pneumonia ppt is an acute inflammatory disorder of lung parenchyma that results in edema of lung tissues and. For which problem is this test most commonly used as a diagnostic measure? The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. d. Oxygen saturation by pulse oximetry b. CO2 causes an increase in the amount of hydrogen ions available in the body. Activity intolerance 2. b. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. This examination detects the presence of random breath sounds (e.g., crackles, wheezes). 5) Minimize time in congregate settings. An ET tube has a higher risk of tracheal pressure necrosis. 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 All of the assessments are appropriate, but the most important is the patient's oxygen status. c. A tracheostomy tube allows for more comfort and mobility. 1. A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. Atelectasis Assess the patients vital signs at least every 4 hours. b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity Use a sterile catheter for each suctioning procedure. b. A) Seizures What is the first patient assessment the nurse should make? Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). It must include the local 911 numbers, hospitals, and immediate keen of the patient. c. Determine the need for suctioning. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. Bronchodilators: To dilate or relax the muscles on the airways. 2) d. Direct the family members to the waiting room. The prognosis of a patient with PE is good if therapy is started immediately. Document the results in the patient's record. a. Stridor Stridor is a continuous musical or crowing sound and unrelated to pneumonia. a. 2. Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. NMNEC Concept: Gas Exchange. a. Saunders comprehensive review for the NCLEX-RN examination. Breath sounds in all lobes are verified to be sure that there was no damage to the lung. What are possible explanations for this behavior? During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? Treatment for pneumonia needs to be complied with completely to ensure a good prognosis and improve health. Start oxygen administration by nasal cannula at 2 L/min. 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). Viral pneumonia. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. This is an expected finding with pneumonia, but should not continue to rise with treatment. Patient's temperature 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. Teach the patient to use the incentive spirometer as advised by their attending physician. Assess lab values.An elevated white blood count is indicative of infection. - 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. The treatment and medication should be prescribed by the attending physician and do not take meds that are not prescribed to prevent unnecessary drug interaction. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. Tachycardia (resting heart rate [HR] more than 100 bpm). a. Verify breath sounds in all fields. b. 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. f. PEFR Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). Administer oxygen with hydration as prescribed. Antibiotics: To treat bacterial pneumonia. Put the palms of the hands against the chest wall. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter.