This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. Saunders comprehensive review for the NCLEX-RN examination. It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. A 73-year-old patient has an SpO2 of 70%. Suction secretions as needed. Most of the problems in connection to the reoccurrence of pneumonia are poor compliance to the prescribed treatment. h. Absent breath sounds The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? However, it is highly unlikely that TB has spread to the liver. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. Document the results in the patient's record. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. Select all that apply. Building up secretions in the airway will only cause a problem since it will obstruct the airflow from going in and out of the body. In addition, have the patient upright and leaning forward to prevent swallowing blood. How to use esophageal speech to communicate What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? c. The need for frequent, vigorous coughing in the first 24 hours postoperatively Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. Auscultate breath sounds at least every 2 to 4 hours or as the patients condition dictates. 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. CASE STUDY: Rhinoplasty 3. What measures should be taken to maintain F.N. Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. 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. - 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. 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. Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. Tylenol) administered. The patient is positioned and instructed not to talk or cough to avoid damage to the lung. Partial obstruction of trachea or larynx 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. 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. Administer analgesics 1/2 hour prior to deep breathing exercises. The nurse identifies which factor that places a patient at risk for aspiration pneumonia? Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. c. Wheezing a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. f. Hyperresonance In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. 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. Checking the respiratory status depending on the need will help know the impending respiratory changes of the patient. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. 1. The other options do not maintain inflation of the alveoli. To detect presence of hypernatremia, hyperglycemia, and/or dehydration. This is most common in intensive care units usually resulting from intubation and ventilation support. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. The width of the chest is equal to the depth of the chest. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? Encourage coughing up of phlegm. Fine crackles at the base of the lungs are likely to disappear with deep breathing. Our website services and content are for informational purposes only. c. Patient in hypovolemic shock Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. Identify 1 specific finding identified by the nurse during assessment of each of the patient's functional health patterns that indicates a risk factor for respiratory problems or a patient response to an actual respiratory problem. Functional Health Pattern Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? 4. was admitted, examination of his nose revealed clear drainage. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. c. SpO2 of 90%; PaO2 of 60 mm Hg How does the nurse respond? Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Nursing Diagnosis: Ineffective Airway Clearance. What priority discharge teaching should the nurse provide? Priority: Sleep management Have an initial assessment of the patients respiratory rate, rhythm, and oxygen saturation every 4 hours or depending on the need. 3. c. Patient in hypovolemic shock What should be the nurse's first action? Patient who is anesthetized An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. "You should get the inactivated influenza vaccine that is injected every year." c. The necessity of never covering the laryngectomy stoma Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. (Symptoms) Reports of feeling short of breath Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Which respiratory defense mechanism is most impaired by smoking? Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. Proper nutrition promotes energy and supports the immune system. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). The postoperative use of nonverbal communication techniques 2. 3.5 Acute Pain. It must include the local 911 numbers, hospitals, and immediate keen of the patient. d. An ET tube is more likely to lead to lower respiratory tract infection. b. Palpation The cuff passively fills with air. Amount of air remaining in lungs after forced expiration 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. St. Louis, MO: Elsevier. The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. A) 2, 3, 4, 5, 6 Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. a. Finger clubbing Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? k. Value-belief, Risk Factor for or Response to Respiratory Problem It may also stimulate coughing. d. Oxygen saturation by pulse oximetry Sleep disturbance related to dyspnea or discomfort 6. Use 1 for the first action and 7 for the last action. This can lead to hypoxia (lack of oxygen), and possibly tissue damage. These interventions help facilitate optimum lung expansion and improve lungs ventilation. d. Assess arterial blood gases every 8 hours. - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody). Base to apex b. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. How to use a mirror to suction the tracheostomy d. Auscultation. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. d. Oxygen saturation by pulse oximetry. e. Airway obstruction is likely if the exact steps are not followed to produce speech. Visualize and note some changes when it comes to the color of the skin, quality of mucous production, and nail beds. Usual PaO2 levels are expected in patients 60 years of age or younger. Consider using a closed suction system; replace closed suction system according to agency guidelines. d. Direct the family members to the waiting room. Goal/Desired Outcome Short-term goal: The patient will remain free from signs of respiratory distress and her oxygen saturation will remain higher than 96% for the duration of the shift. a. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). Administer the prescribed airway medications (e.g. The patients blood oxygen saturation (SpO2) will also be within the target levels set by the physician (usually 96 to 100 percent; 88 to 92% for most. c. Explain the test before the patient signs the informed consent form. It involves the inflammation of the air sacs called alveoli. 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. Page . Pulmonary function test 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. Fungal pneumonia. Medications such as paracetamol, ibuprofen, and. 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. Subjective Data 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). Avoid environmental irritants inside the patients room. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. A transesophageal puncture Perform steam inhalation or nebulization as required/ prescribed. 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. 3. Put the palms of the hands against the chest wall. a. a. When is the nurse considered infected? 3) Sleep alone. a. Apex to base Fill fluid containers immediately before use (not well in advance). 3 Pneumonia in the immunocompromised individual 4 Assessment of pneumonia 5 Diagnostic test for pneumonia 6 Nursing Diagnosis of pneumonia 6.1 Risk for Infection (nosocomial pneumonia) 6.2 Impaired Gas Exchange due to pneumonic condition 6.3 Ineffective clearance of the airway 6.4 Deficient fluid volume Community acquired pneumonias Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual. 3) Treatment usually includes macrolide antibiotics. c. It has two tubings with one opening just above the cuff. c. A nasogastric tube with orders for tube feedings Administer oxygen with hydration as prescribed. b. Nutrition reviews, 68(8), 439458. A tracheostomy is safer to perform in an emergency. Implement NPO orders for 6 to 12 hours before the test. This examination detects the presence of random breath sounds (e.g., crackles, wheezes). c. Remove the inner cannula if the patient shows signs of airway obstruction. 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. This intervention provides oxygenation while reducing convective moisture loss and helping to mobilize secretions. Nurses also play a role in preventing pneumonia through education. People with community-acquired pneumonia usually do not need to be hospitalized unless an underlying condition such as chronic obstructive pulmonary disease (COPD), heart disease or diabetes mellitus, or a weakened immune system complicates the disease. d. Testing causes a 10-mm red, indurated area at the injection site. Decreased immunoglobulin A (IgA) decreases the resistance to infection. c. Place the thumbs at the midline of the lower chest. 4) Cough suppressants and antihistamines should not be used. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. Teach the patient to use the incentive spirometer as advised by their attending physician. b. a hemilaryngectomy that prevents the need for a tracheostomy. Trend and rate of development of the hyperkalemia Discussion Questions HR 68 bpm c. Perform mouth care every 12 hours. What covers the larynx during swallowing? A) Use a cool mist humidifier to help with breathing. 2. Hyperkalemia is not occurring and will not directly affect oxygenation initially. Severely immunosuppressed patients are affected not only by bacteria but also by viruses (cytomegalovirus) and fungi (Candida, Aspergillus, Pneumocystis jirovecii). - It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity. Cleveland Clinic. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Before other measures are taken, the nurse should check the probe site. A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. a. Assess the patient for iodine allergy. Fever reducers and pain relievers. d. Positron emission tomography (PET) scan. Changes in oxygen therapy or interventions should be avoided for 15 minutes before the specimen is drawn because these changes might alter blood gas values. Which values indicate a need for the use of continuous oxygen therapy? Encouraging oral fluids will mobilize respiratory secretions. 8 . I do not know if it's just overthinking it or what but all the care plans i have read . 6. a. Please follow your facilities guidelines, policies, and procedures. g. Position the patient sitting upright with the elbows on an over-the-bed table. 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. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? a. Stridor For which problem is this test most commonly used as a diagnostic measure? What is a primary nursing responsibility after obtaining a blood specimen for ABGs? Impaired gas exchange is closely tied to Ineffective airway clearance. 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." 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 a. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. Start asking what they know about the disease and further discuss it with the patient. e. Decreased functional immunoglobulin A (IgA). Night sweats Report significant findings. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. - 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. a. Carina A) Sit the patient up in bed as tolerated and apply Decreased compliance contributes to barrel chest appearance. symptoms. 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. Pneumonia is an infection of the lungs caused by a bacteria or virus. d. Pulmonary embolism 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. c. Check the position of the probe on the finger or earlobe. For best yield, blood cultures should be obtained before antibiotics are administered. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. A patient presents to the emergency department with a temperature of 101.4F (38.6C) and a productive cough with rust-colored sputum. Bronchoconstriction Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. a. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. a. (2022, January 26). i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms Identify up to what extent does the patient knows about pneumonia. k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? d. The patient cannot fully expand the lungs because of kyphosis of the spine. To increase the oxygen level and achieve an SpO2 value of at least 96%. Encourage to always change position to facilitate mucous drainage in the lungs. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). Wear gloves on both hands when handling the cannula or when handling ventilation tubing. Pockets of pus may form inside the lungs or on their outer layers. e. Increased tactile fremitus d. Contain dead air that is not available for gas exchange. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. Touching an infected object and then touching your nose or mouth can also transfer the germs. Atelectasis. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Save my name, email, and website in this browser for the next time I comment. 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. The prognosis of a patient with PE is good if therapy is started immediately.