Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual. Subjective Data Patient who is anesthetized Heavy tobacco and/or alcohol use The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. 6) The patient is infectious from the beginning of the first stage Complications include hyperventilation, gastric hyperinflation, headache, hypotension, and signs and symptoms of pneumothorax (shortness of breath, stabbing chest pain, decreased breath sounds on one side, dyspnea, cough). b. arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period? nursing care plan for pneumonia nursing care plan for stroke nursing care . What measures should be taken to maintain F.N. Always change the suction system between patients. 2018.01.18 NMNEC Curriculum Committee. Nursing Care Plan 2 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. b. CO2 causes an increase in the amount of hydrogen ions available in the body. They are as follows: Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Risk for Infection Acute Pain Decreased Activity Tolerance Hyperthermia Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition: Less Than Body Requirements The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. - 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 patient reports a sudden onset of shortness of breath, slight chest pain, and that "something is wrong." The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. 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. d. Apply an ice pack to the back of the neck. What is the most appropriate action by the nurse? Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment. What is the first patient assessment the nurse should make? Respiratory infection 3. h. FRC: (8) Volume of air in lungs after normal exhalation. a. Vt a. d. Pleural friction rub. Facilitate coordination within the care team to allow rest periods between care activities. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion secondary to pneumonia as evidenced by a respiratory rate of 22, usage of accessory muscles, and labored breathing. What priority discharge teaching should the nurse provide? 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. The bacteria may enter the blood stream and cause, Trouble sleeping. Alveolar-capillary membrane changes (inflammatory effects) Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake. c. Wheezing d. Pulmonary embolism. To avoid the formation of a mucus plug, suction it as needed. F. A. Davis Company. Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. Hopefully the family will have some time to discuss this before they are instructed to leave the room, unless it is an emergency. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. The patient needs to be able to effectively remove these secretions to maintain a patent airway. Normally the AP diameter should be 13 to 12 the side-to-side diameter. d. CO2 directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. If sepsis is suspected, a blood culture can be obtained. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen. j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems With severe pneumonia, the patient needs a higher level of care than general medical-surgical. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. If he or she can not do it, then provide a suction machine always at the bedside. A patient presents to the emergency department with a temperature of 101.4F (38.6C) and a productive cough with rust-colored sputum. 2 8 Nursing diagnosis for pneumonia. The palms are placed against the chest wall to assess tactile fremitus. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. c. Empyema Pinch the soft part of the nose. 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 This is most common in intensive care units usually resulting from intubation and ventilation support. a. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. 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). - 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. A) Admit the patient to the intensive care unit. Warm and moisturize inhaled air Stridor is identified with auscultation. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Identify candidates for surgical intervention who are at increased risk for nosocomial 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. 's nasal packing is removed in 24 hours, and he is to be discharged. the medication. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. Pulmonary function tests are noninvasive. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. k. Value-belief, Risk Factor for or Response to Respiratory Problem The most common. 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. c. Check the position of the probe on the finger or earlobe. When inflamed, the air sacs may produce fluid or pus which can cause productive cough and difficulty breathing. Promote oral hygiene, including lip and tongue care. Inspection This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . 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). Educating him/her to use the incentive spirometer will encourage him/her to exercise deep inspiration that will help get more oxygen in the lungs and prevent hypoxia. This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions. 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. Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. Antibiotics: To treat bacterial pneumonia. Encourage the patient to see their medical attending physician for approval and safe treatment. The postoperative use of nonverbal communication techniques Expected outcomes c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. 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. usually occur after aspiration of oral pharyngeal flora or gastric contents in persons whose resistance is altered or whose cough mechanism is impaired, Bacteria enter the lower respiratory tract via three routes. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. 3. c. Temperature of 100 F (38 C) Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Acid-fast stains and cultures: To rule out tuberculosis. Usually, people with pneumonia preferred their heads elevated with a pillow. If the patient is enteral fed, recommend continuous rather than bolus feeding. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. The home health nurse provides which instruction for a patient being treated for pneumonia? a. a. radiation therapy that preserves the quality of the voice. Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. Which values indicate a need for the use of continuous oxygen therapy? Pleurisy, a) 7. The nurse should instruct on how to properly use these devices and encourage their use hourly. presence of nasal bleeding and exhalation grunting. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. Increase heat and humidity if patient has persistent secretions. a. Verify breath sounds in all fields. It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. 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. No signs or symptoms of tuberculosis or allergies are evident. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). b. Airway obstruction is most often diagnosed with pulmonary function testing. While the nurse is feeding a patient, the patient appears to choke on the food. Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? c. There is equal but diminished movement of the 2 sides of the chest. The patient will have improved gas exchange. Hypoxemia was the characteristic that presented the best measures of accuracy. 3.4 Activity Intolerance. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. d. The need to use baths instead of showers for personal hygiene, What is the most normal functioning method of speech restoration for the patient with a total laryngectomy? Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. b. Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and arterial oxygen saturation (SaO2) but normal pH and PaCO2. For best yield, blood cultures should be obtained before antibiotics are administered. a. Learn how your comment data is processed. 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. The epiglottis is a small flap closing over the larynx during swallowing. Moisture helps minimize convective moisture loss during oxygen therapy. Monitor cuff pressure every 8 hours. c. Tracheal deviation Medical-surgical nursing: Concepts for interprofessional collaborative care. Techniques that will be used to alleviate a dry mouth and prevent stomatitis a. d. Chronic herpes simplex infections of the mouth and lips. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. What Are Some Nursing Diagnosis for COPD? Use only sterile fluids and dispense with sterile technique. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. General physical assessment findingsof pneumonia. Report significant findings. 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. b. Volcanic eruptions and other natural events result in air pollution. Nursing Diagnosis: Ineffective Airway Clearance related to the disease process of bacterial pneumonia as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm. What is included in the nursing care of the patient with a cuffed tracheostomy tube? When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? c. Elimination d. Auscultation. Amount of air remaining in lungs after forced expiration Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. Associated with altered oxygenation and alveolar-capillary membrane changes resulting from the inflammatory process and exudate in the lungs. Promote fluid intake (at least 2.5 L/day in unrestricted patients). The carina is the point of bifurcation of the trachea into the right and left bronchi. Ventilation is impaired in spite of adequate perfusion in the lungs. Allow the patient to have enough bed rest and avoid strenuous activities. 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. Corticosteroids and bronchodilators are not useful in reducing symptoms. Assess for mental status changes. d. An electrolarynx placed in the mouth. 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 . 6. 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. Our website services and content are for informational purposes only. e. Posterior then anterior. One way to have a good prognosis and help fasten recovery is to comply with the prescribed treatment. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. Weigh patient daily at same time of day and on same scale; record weight. Which immediate action does the nurse take? c. An electrolarynx held to the neck 2) Guillain-Barr syndrome Nursing care plan for impaired gas exchange. Suction the mouth or the oral airway as needed. Sleep disturbance related to dyspnea or discomfort 6. Base to apex NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Which instructions does the nurse provide to a patient with acute bronchitis? Perform steam inhalation or nebulization as required/ prescribed. The patient has been diagnosed with an early vocal cord cancer. c. Check the position of the probe on the finger or earlobe. Most commonly, P. jirovecii occurs in individuals with human immunodeficiency virus infection or in individuals who are therapeutically immunosuppressed after organ transplantation. a. Undergo weekly immunotherapy. 4) f. Instruct the patient not to talk during the procedure. 3) Treatment usually includes macrolide antibiotics. 6) Minimize time on public transportation. Viral pneumonia. Level of the patient's pain 1. Cough suppressants. 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). After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. Volume of air inhaled and exhaled with each breath A) Increasing fluids to at least 6 to 10 glasses/day, unless. Lung consolidation with fluid or exudate Discuss to the patient the different types of pneumonia and the difference between him/her. For which problem is this test most commonly used as a diagnostic measure? A) Seizures She has worked in Medical-Surgical, Telemetry, ICU and the ER. What is the first action the nurse should take? Nursing diagnosis: Deficient knowledge about the disease process and treatment of pneumonia related to lack of information as evidenced by failure to comply with treatment. A relative increase in antibody titers indicates viral infection. A) 2, 3, 4, 5, 6 d. An ET tube is more likely to lead to lower respiratory tract infection. Proper nutrition promotes energy and supports the immune system. All of the assessments are appropriate, but the most important is the patient's oxygen status. Respiratory distress requires immediate medical intervention. Tylenol) administered. Anna Curran. a. TB a. If they cannot, sputum can be obtained via suctioning. The other options do not maintain inflation of the alveoli. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. 1. Page . The patient will have a big chance to remember how to administer or perform any therapeutic regimen if they are given the chance to demonstrate and have him/her verbalize their understanding about it. c. Use cromolyn nasal spray prophylactically year-round. 1. A patient develops epistaxis after removal of a nasogastric tube. If the patient is ambulatory, walking should be encouraged within the patients tolerance. 2. During a follow-up visit one week after starting the medication, the patient tells the nurse, "In the last week, my urine turned orange, and I am very worried about it." Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. d. Direct the family members to the waiting room. 3) Illicit drug intake "You should get the inactivated influenza vaccine that is injected every year." Give health teachings about the importance of taking prescribed medication on time and with the right dose. A) Inform the patient that it is one of the side effects of Aspiration is one of the two leading causes of nosocomial pneumonia. Hyperkalemia is not occurring and will not directly affect oxygenation initially. Put the index fingers on either side of the trachea. Summarize why people were unsuccessful over 1,000 years ago when they tried to transform lead into gold. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. A knowledgeable patient is more likely to comply with therapy. Discussion Questions 1. What is a primary nursing responsibility after obtaining a blood specimen for ABGs? Consider using a closed suction system; replace closed suction system according to agency guidelines. 's airway before and after surgery? This is an expected finding with pneumonia, but should not continue to rise with treatment. Weight changes of 1-1.5 kg/day may occur with fluid excess or deficit. Why does a patient's respiratory rate increase when there is an excess of carbon dioxide in the blood? What are possible explanations for this behavior? d. Parietal pleura. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance.