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Nursing care plan for impaired gas exchange. Please read our disclaimer. Order stat ABGs to confirm the SpO2 with a SaO2. The arterial oxygen saturation by pulse oximetry (SpO2) compared with normal values will not be helpful in this older patient or in a patient with respiratory disease as the patient's expected normal will not be the same as standard normal values. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. e. Sleep-rest: Sleep apnea. Instruct patients who are unable to cough effectively in a cascade cough. b. Cyanosis 4. d. Initiate pulse oximetry for continuous monitoring of the patient's oxygen status. They will further understand the topic since they already have an idea of what is it about. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia, https://my.clevelandclinic.org/health/diseases/4471-pneumonia, https://doi.org/10.1111/j.1753-4887.2010.00304.x, https://emedicine.medscape.com/article/234753-overview#a4, Hypertension Nursing Diagnosis & Care Plan, The ABCs of Evidence-Based Practice in Nursing, Diminished lung sounds or crackles/rhonchi, Patient will demonstrate appropriate airway clearance techniques, Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate, Hypoventilation causing a lack of oxygen delivery, Patient will display appropriate oxygenation through ABGs within normal limits, Patient will demonstrate appropriate actions to promote ventilation and oxygenation, Inadequate primary defenses: decreased ciliary action, respiratory secretions, Invasive procedures: suctioning, intubation, Patient will not develop a secondary infection or sepsis, Patient will display improvement in infection evidenced by vital signs and lab values within normal limits. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. d. Small airway closure earlier in expiration Promote skin integrity.The skin is the bodys first barrier against infection. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. 3.3 Risk for Infection. 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 . To avoid the formation of a mucus plug, suction it as needed. Periorbital and facial edema reduced by about half since second hospital day d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. 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. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. 1) Increase the intake of foods that are high in vitamin C. 3.4 Activity Intolerance. Checking the respiratory status depending on the need will help know the impending respiratory changes of the patient. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. Avoid environmental irritants inside the patients room. Acid-fast stains and cultures: To rule out tuberculosis. A patient presents to the emergency department with a temperature of 101.4F (38.6C) and a productive cough with rust-colored sputum. The width of the chest is equal to the depth of the chest. a. Night sweats Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. Bronchodilators: To dilate or relax the muscles on the airways. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Cleveland Clinic. b. d. SpO2 of 88%; PaO2 of 55 mm Hg. Attend to the patients queries regarding their pneumonia treatment. 3.6 Risk for imbalanced nutrition: less than body requirements. 2. What should the nurse do when preparing a patient for a pulmonary angiogram? Why is the air pollution produced by human activities a concern? - It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity. The home health nurse provides which instruction for a patient being treated for pneumonia? Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. Nurses should assess for and encourage pneumonia vaccines for eligible populations. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. d. CO2 directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. 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. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance. Maintain intravenous (IV) fluid therapy as prescribed. g. Fine crackles The prognosis of a patient with PE is good if therapy is started immediately. 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. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. Partial obstruction of trachea or larynx 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. 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. Activity intolerance 2. c. Percussion Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. a. 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. c. SpO2 of 90%; PaO2 of 60 mm Hg 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. Elevate the head of the bed and assist the patient to assume semi-Fowlers position. c. Wheezes There is alteration in the normal respiratory process of an individual. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. Volcanic eruptions and other natural events result in air pollution. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. Which respiratory defense mechanism is most impaired by smoking? Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. Which instructions does the nurse provide to a patient with acute bronchitis? c. Ventilation-perfusion scan Saunders comprehensive review for the NCLEX-RN examination. Patients with compromised immune systems such as those with COPD, HIV, or autoimmune diseases should be educated on the risk and how to protect themselves. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. Encourage to always change position to facilitate mucous drainage in the lungs. A knowledgeable patient is more likely to comply with therapy. What is included in the nursing care of the patient with a cuffed tracheostomy tube? A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. No signs or symptoms of tuberculosis or allergies are evident. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. b. Start asking what they know about the disease and further discuss it with the patient. When F.N. Fine crackles at the base of the lungs are likely to disappear with deep breathing. Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. Use a sterile catheter for each suctioning procedure. COPD ND3: Impaired gas exchange. 3.7 Risk for Deficient Fluid Volume. b. 1. Fever and vomiting are not manifestations of a lung abscess. c. a radical neck dissection that removes possible sites of metastasis. Teach the patient to use the incentive spirometer as advised by their attending physician. b. Auscultation of breath sounds every 2 to 4 hours (or depending on the patients condition) and reporting of changes in the patients ability to secrete lung secretions. 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. Tachycardia (resting heart rate [HR] more than 100 bpm). The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. Assist the patient when they are doing their activities of daily living. Nursing Diagnosis Impaired Gas Exchange related to to altered alveolarcapillary membrane changes due to pneumonia disease process. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. NMNEC Concept: Gas Exchange. b. The cuff passively fills with air. Assess intake and output (I&O). Moisture helps minimize convective moisture loss during oxygen therapy. Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. The patient may have a limit to visitors to prevent the transmission of infections. It is also inappropriate to advise the patient to stop taking antitubercular drugs. This is an expected finding with pneumonia, but should not continue to rise with treatment. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. b. c. Mucociliary clearance Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. 6. a. Most commonly, P. jirovecii occurs in individuals with human immunodeficiency virus infection or in individuals who are therapeutically immunosuppressed after organ transplantation. c. A tracheostomy tube allows for more comfort and mobility. 4. Remove excessive clothing, blankets and linens. c. The necessity of never covering the laryngectomy stoma Apply pressure to the puncture site for 2 full minutes. c. TLC Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . Select all that apply. b. What is the most appropriate action by the nurse? The patient will have improved gas exchange. 5) Minimize time in congregate settings. 2 8 Nursing diagnosis for pneumonia. 's nasal packing is removed in 24 hours, and he is to be discharged. k. Value-belief, Risk Factor for or Response to Respiratory Problem 2) Ensure that the home is well ventilated. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. 1. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. The width of the chest is equal to the depth of the chest. Buy on Amazon, Silvestri, L. A. 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. - 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 most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. c. Keep a same-size or larger replacement tube at the bedside. 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. b. 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. RR 24 Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath Use only sterile fluids and dispense with sterile technique. Heavy tobacco and/or alcohol use The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? There is no redness or induration at the injection site. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. a. Thoracentesis Weigh patient daily at same time of day and on same scale; record weight. What is the first patient assessment the nurse should make? Fatigue 4. 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. Match the descriptions or possible causes with the appropriate abnormal assessment findings. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. a. Finger clubbing Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. a. Most of the problems in connection to the reoccurrence of pneumonia are poor compliance to the prescribed treatment. b. 3. e. Posterior then anterior Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. When taking care of a patient with pneumonia, it is important to ensure the environment is well ventilated, conducive for good rest, and accessible when the patient needs assistance or help. Identify and avoid triggers of the allergic reaction. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. c. Send labeled specimen containers to the laboratory. Increase heat and humidity if patient has persistent secretions. d. Pleural friction rub. 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). Administer oxygen with hydration as prescribed. Arterial blood gas (ABG) values: May vary depending on extent of pulmonary involvement or other coexisting conditions. b. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? What keeps alveoli from collapsing? c. The need for frequent, vigorous coughing in the first 24 hours postoperatively These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. Tuberculosis frequently presents with a dry cough. b. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. 3. Allow the patient to have enough bed rest and avoid strenuous activities. d. Pleural friction rub 1. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? Our website services and content are for informational purposes only. Consider using a closed suction system; replace closed suction system according to agency guidelines. e. Decreased functional immunoglobulin A (IgA). c. Persistent swelling of the neck and face The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. 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 d. Pleural friction rub g. Self-perception-self-concept A) 1, 2, 3, 4 7) c. Send labeled specimen containers to the laboratory. 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. Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae. d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? 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. Exercise and activity help mobilize secretions to facilitate airway clearance. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. a. Esophageal speech 6. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. Pink, frothy sputum would be present in CHF and pulmonary edema. All of the assessments are appropriate, but the most important is the patient's oxygen status. 27 - Lower Respiratory Problems, Coronary Artery Disease & Acute Coronary Synd, Integumentary System (Lewis Med-Surg CH.22 &, Barbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh, 1.1 (Anatomy) Functional Organization of the. A patient with pneumonia shows inflammation in their lung parenchyma causing it to have. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that results from aspiration of gastric contents. Learn how your comment data is processed. b. Allow patients to ask a question or clarify regarding their treatment. Put the index fingers on either side of the trachea. Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. Lung consolidation with fluid or exudate b. Nutritional-metabolic The immunity will not protect for several years, as new strains of influenza may develop each year. 1. This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. Base to apex The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. c. Empyema a. Before other measures are taken, the nurse should check the probe site. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. Chronic hypoxemia The patient is infectious from the beginning of the first stage through the third week after onset of symptoms or until five days after antibiotic therapy has been started. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. h) 3. Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody). The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? The nurse explains that usual treatment includes Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? Empyema is a collection of pus in the thoracic cavity. associated with increased fluid loss in the presence of tachypnea, fever, or diaphoresis Desired outcome: at least 24 hours before hospital discharge, the patient is normovolemic, i.e., has a urine output of 30 mL/h or greater, stable weight, heart rate less than 100 bpm, blood pressure greater than 90 mm Hg, fluid intake equal to fluid excretion, moist mucous membranes, and normal skin turgor. Monitor cuff pressure every 8 hours. Lower Respiratory Tract Infections and Disord, Lewis Ch. The nurse can also teach coughing and deep breathing exercises. If sepsis is suspected, a blood culture can be obtained. 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 The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. a. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. b. Epiglottis Select all that apply. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. Pulmonary function tests are noninvasive. The patient has been diagnosed with an early vocal cord cancer. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. Decreased immunoglobulin A (IgA) decreases the resistance to infection. Pinch the soft part of the nose. A patient with a 10-year history of regular (three beers per week) alcohol consumption began taking rifampin to treat tuberculosis (TB). Inspection A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Decreased functional cilia Promote fluid intake (at least 2.5 L/day in unrestricted patients). Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. Long-term denture use Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. d. Patient receiving oxygen therapy. d. Anterior then posterior A patient's initial purified protein derivative (PPD) skin test result is positive. 4) Recent abdominal surgery. It involves the inflammation of the air sacs called alveoli. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. e. Sleep-rest a. 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. - The patient's clinical picture is most likely pulmonary embolism (PE), and the first action the nurse should take is to assist with the patient's respirations. a. SpO2 of 92%; PaO2 of 65 mm Hg With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. Identify patients at increased risk for aspiration. 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. Usually, people with pneumonia preferred their heads elevated with a pillow. This produces an area of low ventilation with normal perfusion. What covers the larynx during swallowing?