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). Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. What do these findings indicate? A) Use a cool mist humidifier to help with breathing. Otherwise, scroll down to view this completed care plan. Administer oxygen with hydration as prescribed. The pH is also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in venous blood (PvCO2). A patient presents to the emergency department with a temperature of 101.4F (38.6C) and a productive cough with rust-colored sputum. Assist patient in a comfortable position. To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses. 1. a. Cough and sore throat The nurse anticipates that interprofessional management will include Consider sources of infection.Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. Attempt to replace the tube. Interstitial edema b. To care for the tracheostomy appropriately, what should the nurse do? f. Instruct the patient not to talk during the procedure. 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. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. 's nasal packing is removed in 24 hours, and he is to be discharged. Select all that apply. St. Louis, MO: Elsevier. Night sweats Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. c) 5. It is important to acknowledge their limited information about the disease process and start educating him/her from there. Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. Arterial blood gas (ABG) values: May vary depending on extent of pulmonary involvement or other coexisting conditions. b. The patient will have improved gas exchange. 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. It may also cause hepatitis. These interventions help facilitate optimum lung expansion and improve lungs ventilation. The other options do not maintain inflation of the alveoli. b. 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. If there is airway obstruction this will only block and cause problems in gas exchange. b. c. The necessity of never covering the laryngectomy stoma Normally the AP diameter should be 13 to 12 the side-to-side diameter. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). Expected outcomes c. "An annual vaccination is not necessary because previous immunity will protect you for several years." 3. Put the index fingers on either side of the trachea. 7. A) Purulent sputum that has a foul odor The manifestations of viral, fungal, and bacterial infections are similar, and appearance is not diagnostic except when the white, irregular patches on the oropharynx suggest that candidiasis is present. The patient may have a limit to visitors to prevent the transmission of infections. 1# Priority Nursing Diagnosis. Exercise and activity help mobilize secretions to facilitate airway clearance. b. Finger clubbing Which instructions does the nurse provide for the patient? (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. Provide tracheostomy care. Patient's temperature d. Normal capillary oxygen-carbon dioxide exchange. How does the nurse assess the patient's chest expansion? Which action does the nurse take next? What is included in the nursing care of the patient with a cuffed tracheostomy tube? Her experience spans almost 30 years in nursing, starting as an LVN in 1993. 3. a. Give supplemental oxygen treatment when needed. nursing diagnosis based on the assessment data the major nursing diagnoses for meconium aspiration syndrome are hyperthermia related to inflammatory process hypermetabolic state as evidenced by an increase in body temperature warm skin and tachycardia fluid volume . c. Perform mouth care every 12 hours. b. Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae. Preventing the spread of coronavirus infection to the patient's family members, community, and healthcare providers. a. Finger clubbing Pockets of pus may form inside the lungs or on their outer layers. One way to have a good prognosis and help fasten recovery is to comply with the prescribed treatment. Decreased immunoglobulin A (IgA) decreases the resistance to infection. Findings may show hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg) with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease. e. Observe for signs of hypoxia during the procedure. Decreased functional cilia b. Cyanosis high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. If they cannot, sputum can be obtained via suctioning. This is needed to help the patient conserve his or her energy and also effective relaxation when the patient feels anxious and having a hard time concentrating and breathing. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Supplemental oxygen will help in the increased demand of the body and will lower the risk of having respiratory distress and low oxygen perfusion in the body. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. Sepsis Alliance. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. 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. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. a. Stridor Is elevated in bacterial pneumonias (greater than 12,000/mm3). NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. Which medication therapy does the nurse anticipate will be prescribed? e. Increased tactile fremitus h. Absent breath sounds Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. 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. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. a. 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. 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. 2. A transesophageal puncture However, with increasing respiratory distress, respiratory acidosis may occur. Priority Decision: A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG) results: pH 7.40, partial pressure of oxygen in arterial blood (PaO2) 74 mm Hg, arterial oxygen saturation (SaO2) 92%, partial pressure of carbon dioxide in arterial blood (PaCO2) 40 mm Hg. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. 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. b. Unstable hemodynamics Blood tests elevated white blood cell count may be a sign of an ongoing infection, Sputum culture to determine the causative agent, Imaging chest X-ray to determine active infection and its severity; bronchoscopy to check any blockage of the airways; CT scan for a more detailed lung imaging, Arterial blood gas (ABG) test using an arterial blood sample to measure the oxygen level, Pleural fluid culture taking a pleural fluid sample by inserting a needle between the pleural cavity and the ribs in order to determine the causative agent. Facilitate coordination within the care team to allow rest periods between care activities. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. a. Stridor Since the patient is manifesting impaired gas exchange, one of the good indications that the oxygen absorption inside the body is not improving is through the skin changes, nail bed discoloration, and mucous production. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. a. Esophageal speech These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. c. Course crackles For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. There is alteration in the normal respiratory process of an individual. This is an expected finding with pneumonia, but should not continue to rise with treatment. a. Deflate the cuff, then remove and suction the inner cannula. Instruct patients who are unable to cough effectively in a cascade cough. No signs or symptoms of tuberculosis or allergies are evident. To avoid the formation of a mucus plug, suction it as needed. 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). What action should the nurse take? 26: Upper Respiratory Problems / CH. 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. Proper nutrition promotes energy and supports the immune system. These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Interstitial edema c. It has two tubings with one opening just above the cuff. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. Productive cough (viral pneumonia may present as dry cough at first). c. Tracheal deviation Early small airway closure contributes to decreased PaO2. c. Remove the inner cannula if the patient shows signs of airway obstruction. Air trapping a. Vt f. PEFR A relative increase in antibody titers indicates viral infection. 3.5 Acute Pain. Discontinue if SpO2 level is above the target range, or as ordered by the physician. c. Patient in hypovolemic shock The patient needs to be able to effectively remove these secretions to maintain a patent airway. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Ciliary action impaired by smoking and increased mucus production may be caused by the irritants in tobacco smoke, leading to impairment of the mucociliary clearance system. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. 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. Pneumonia is an infection of the lungs caused by a bacteria or virus. Study Resources . 6) Minimize time on public transportation. - It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. Adjust the room temperature. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. The visceral pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. A patient develops epistaxis after removal of a nasogastric tube. Nursing Diagnosis for Pleural Effusion Impaired Gas Exchange r/t decreased function of lung tissue Ineffective Breathing Pattern r/t compromised lung expansion Acute Pain r/t inflammatory process Anxiety r/t inability to take deep breaths Risk for infection r/t pooling of fluid in the lung space Nursing Care Plans for Pleural Effusion Fever and vomiting are not manifestations of a lung abscess. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. The palms are placed against the chest wall to assess tactile fremitus. b. Sleep disturbance related to dyspnea or discomfort 6. c. Place the thumbs at the midline of the lower chest. Use 1 for the first action and 7 for the last action. Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. Always wear gloves on both hands for suctioning. Given a square matrix [A], write a single line MATLAB command that will create a new matrix [Aug] that consists of the original matrix [A] augmented by an identity matrix [I]. d. Chronic herpes simplex infections of the mouth and lips. Usually, people with pneumonia preferred their heads elevated with a pillow. Encourage the patient to see their medical attending physician for approval and safe treatment. Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. As an Amazon Associate I earn from qualifying purchases. Provide tracheostomy care. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. Pulmonary function test d. Thoracic cage. d. The patient cannot fully expand the lungs because of kyphosis of the spine. Retrieved February 9, 2022, from, Pneumonia: Symptoms, Treatment, Causes & Prevention. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). Trend and rate of development of the hyperkalemia 3. Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. c. Mucociliary clearance Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. Obtain the supplies that will be used. Teach the proper technique of doing pursed-lip breathing, various ways of relaxation, and abdominal breathing. Objective Data 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). Assess the need for hyperinflation therapy. The most common. d. Use over-the-counter antihistamines and decongestants during an acute attack. Pinch the soft part of the nose. The nurse expects which treatment plan? Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. Hopefully the family will have some time to discuss this before they are instructed to leave the room, unless it is an emergency. A patient's initial purified protein derivative (PPD) skin test result is positive. What is the first action the nurse should take? c. Wheezing Lung consolidation with fluid or exudate 3. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, To facilitate the body in cooling down and to provide comfort. d. Pleural friction rub Nursing diagnoses handbook: An evidence-based guide to planning care. c. Mucociliary clearance Promote a well-ventilated environment so that the patient will have good oxygen exchange in the body. Impaired Gas Exchange Assessment 1. d. An ET tube is more likely to lead to lower respiratory tract infection. Stridor is identified with auscultation. 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. Encouraging oral fluids will mobilize respiratory secretions. Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. 2) Ensure that the home is well ventilated. Subjective Data b. Stridor Discussion Questions These practices further reduce the risk of contamination. Also called nosocomial pneumonia, this type of pneumonia originates from being admitted in the hospital. Fill fluid containers immediately before use (not well in advance). Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. a. Trachea The nurse explains that usual treatment includes Nursing Diagnosis: Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and increased PCO2. Increase heat and humidity if patient has persistent secretions. d. Oxygen saturation by pulse oximetry. a. a. Nursing Care Plan 2 1) Seizures The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. 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). b. Copious nasal discharge The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. The patient will further understand their disease when they understand why they have it and it will help him/her better comply with the treatment regimen. d. Self-help groups and community resources for patients with cancer of the larynx, When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. a. Assess the patient for iodine allergy. A cascade cough removes secretions and improves ventilation through a sequence of shorter and more forceful exhalations than is the case with the usual coughing exercise. 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. 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. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Decreased skin turgor and dry mucous membranes as a result of dehydration. Always maintain sterility or aseptic techniques when performing any invasive procedure. If the patients condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection. The parietal pleura is a membrane that lines the chest cavity. 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 Pulse oximetry would not be affected by fever or anesthesia and is a method of monitoring arterial oxygen saturation in patients who are receiving oxygen therapy. After the intervention, the patients airway is free of incidental breath sounds. Impaired gas improved or presence of retained secretions client: exchange ventilation and adventitious sound -Demonstrated adequate improved wheezes oxygenation of -Decrease of ventilation and tissues by ABG of: -Palpate for fremitus vibratory tremors adequate pH:7.35-7.45 suggest fluid oxygenation of What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. This is done before sending the sample to the laboratory if there is no one else who can send the sample to the laboratory. 2018.01.18 NMNEC Curriculum Committee. Abnormal. 1. 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. Before other measures are taken, the nurse should check the probe site. 3 Nursing care plans for pneumonia. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. The patient must understand the importance of seeing an attending physician and not rely on what they see or hear on the internet. For best yield, blood cultures should be obtained before antibiotics are administered. At the end of the span of care, the patient will be able to have an effective, regular, and improved respiratory pattern within a normal range (12-20 cycles per minute). c. Explain the test before the patient signs the informed consent form. Skin breakdown allows pathogens to enter the body. 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. 6) a. Verify breath sounds in all fields. All of the assessments are appropriate, but the most important is the patient's oxygen status. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public. Collaboration: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the registered nurse (RN) may delegate which interventions to the licensed practical/vocational nurse (LPN/VN) (select all that apply)? 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. Start oxygen administration by nasal cannula at 2 L/min. 3.3 Risk for Infection. The cuff passively fills with air. g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. a. Carina This position provides comfort and facilitates the ease and effectiveness of these exercises by promoting better lung expansion (less compression of the lungs by the abdominal organs) and better gas exchange. Observing for hypoxia is done to keep the HCP informed. c. Airway obstruction Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. These interventions contribute to adequate fluid intake. Smoking does not directly affect filtration of air, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages.