impaired gas exchange nursing diagnosis pneumonia

Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. a. Acid-fast stains and cultures: To rule out tuberculosis. f. Cognitive-perceptual See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. Pink, frothy sputum would be present in CHF and pulmonary edema. A prominent protrusion of the sternum is the pectus carinatum and diminished movement of both sides of the chest indicates decreased chest excursion. 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. In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. a. 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 5) Corticosteroids and bronchodilators are helpful in reducing 4) Spend as much time as possible outdoors. e. Teach the patient about home tracheostomy care. a. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. Cough, sore throat, low-grade elevated temperature, myalgia, and purulent nasal drainage at the end of a cold are common symptoms of viral rhinitis and influenza. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. 1. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Chronic hypoxemia Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Provide tracheostomy care. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. To care for the tracheostomy appropriately, what should the nurse do? A) Seizures 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. Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. a. Nurses should assess for and encourage pneumonia vaccines for eligible populations. Airway obstruction is most often diagnosed with pulmonary function testing. Aspiration is one of the two leading causes of nosocomial pneumonia. Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. Learning to apply information through a return demonstration is more helpful than verbal instruction alone. A patient's initial purified protein derivative (PPD) skin test result is positive. Teach the importance of complying with the prescribed treatment and medication. a. Assess for mental status changes. d) 8. c. Keep a same-size or larger replacement tube at the bedside. The patient will have improved gas exchange. Assess lab values.An elevated white blood count is indicative of infection. 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 nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? What is the best response by the nurse? Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Nursing Diagnosis. 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. a. 1) The cough may last from 6 to 10 weeks. Discussion Questions On inspection, the throat is reddened and edematous with patchy yellow exudates. 1) Increase the intake of foods that are high in vitamin C. patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. c. Temperature of 100 F (38 C) Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. Cough and sore throat Administer supplemental oxygen, as prescribed. - 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. Assess lung sounds and vital signs. The nurse identifies which factor that places a patient at risk for aspiration pneumonia? c. Take the specimen immediately to the laboratory in an iced container. c. Send labeled specimen containers to the laboratory. Nursing care plan for impaired gas exchange. b. A bronchoscopy requires NPO status for 6 to 12 hours before the test, and invasive tests (e.g., bronchoscopy, mediastinoscopy, biopsies) require informed consent that the HCP should obtain from the patient. St. Louis, MO: Elsevier. Impaired Gas Exchange This COPD nursing diagnosis may be related to bronchospasm, air-trapping and obstruction of airways, alveoli destruction, and changes in the alveolar-capillary membrane. the medication. d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult.". e. FVC: (5) Amount of air that can be quickly and forcefully exhaled after maximum inspiration 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). NurseTogether.com does not provide medical advice, diagnosis, or treatment. St. Louis, MO: Elsevier. Line the lung pleura Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. Assess the patients vital signs and characteristics of respirations at least every 4 hours. 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. b. Stridor Summarize why people were unsuccessful over 1,000 years ago when they tried to transform lead into gold. 3. The width of the chest is equal to the depth of the chest. 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. Inform the patient that radiation isolation for 24 hours after the test is necessary. Anna Curran. a. Finger clubbing Consider imperceptible losses if the patient is diaphoretic and tachypneic. Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. 5. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. "You should get the inactivated influenza vaccine that is injected every year." A repeat skin test is also positive. Report weight changes of 1-1.5 kg/day. What is included in the nursing care of the patient with a cuffed tracheostomy tube? 1. 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. 3.3 Risk for Infection. impaired gas exchange nursing care plan scribd. A) Sit the patient up in bed as tolerated and apply A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. Teach patients some signs and symptoms that prompt immediate medical attention such as dyspnea. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Activity intolerance 2. How does the nurse respond? d. Assess the patient's swallowing ability. She earned her BSN at Western Governors University. This is an expected finding with pneumonia, but should not continue to rise with treatment. St. Louis, MO: Elsevier. c. Explain the test before the patient signs the informed consent form. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . Impaired gas exchange is a risk nursing diagnosis for pneumonia. cancer patients or COPD patients). Cleveland Clinic. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. Patients who are weak or lack a cough reflex may not be able to do so. Assess intake and output (I&O). 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. d. Pulmonary embolism. c. Terminal structures of the respiratory tract Nursing Diagnosis: Ineffective Airway Clearance. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. 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. The epiglottis is a small flap closing over the larynx during swallowing. c. Elimination A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. It is important to acknowledge their limited information about the disease process and start educating him/her from there. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. A) 2, 3, 4, 5, 6 A) Admit the patient to the intensive care unit. Use narcotics and sedatives with caution.Narcotics for pain control or anti-anxiety medications should be monitored closely as they can further suppress the respiratory system. Cancer of the lung e. Sleep-rest: Sleep apnea. a. radiation therapy that preserves the quality of the voice. 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. Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. 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. d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. Interstitial edema b. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Assess the patients knowledge about Pneumonia. Finger clubbing and accessory muscle use are identified with inspection. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. a. c. Mucociliary clearance This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. a. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Fine crackles at the base of the lungs are likely to disappear with deep breathing. Always maintain sterility or aseptic techniques when performing any invasive procedure. In addition, have the patient upright and leaning forward to prevent swallowing blood. The following signs and symptoms show the presence of impaired gas exchange: Abnormal breathing rate, rhythm, and depth Nasal flaring Hypoxemia Cyanosis in neonates decreases carbon dioxide Confusion Elevated blood pressure and heart rate A headache after waking up Restlessness Somnolence and visual disturbances Looking For Custom Nursing Paper? Discuss to him/her the different pros and cons of complying with the treatment regimen. Changes in behavior and mental status can be early signs of impaired gas exchange. There is no redness or induration at the injection site. d. Normal capillary oxygen-carbon dioxide exchange. Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. c. The necessity of never covering the laryngectomy stoma h. Absent breath sounds d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. d. Chronic herpes simplex infections of the mouth and lips. Change ventilation tubing according to agency guidelines. Decreased force of cough Impaired gas exchange is closely tied to Ineffective airway clearance. 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. Our website services and content are for informational purposes only. d. Reflex bronchoconstriction. The nurse expects which treatment plan? Normally the AP diameter should be 13 to 12 the side-to-side diameter. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. F.N. b. Administer oxygen with hydration as prescribed. Organizing the tasks will provide a sufficient rest period for the patient. It is important to have an initial assessment of the patient and use it as a comparison for future reference or referral. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. Sputum for Gram stain and culture and sensitivity tests: Sputum is obtained from the lower respiratory tract before starting antibiotic therapy to identify the causative organisms. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? b. 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. Examine sputum for volume, odor, color, and consistency; document findings. Elevate the head of the bed and assist the patient to assume semi-Fowlers position. Pneumonia: Bacterial or viral infections in the lungs . What Are Some Nursing Diagnosis for COPD? Warm and moisturize inhaled air c. Check the position of the probe on the finger or earlobe. 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. Skin breakdown allows pathogens to enter the body. What is the first patient assessment the nurse should make? a. Apex to base Her experience spans almost 30 years in nursing, starting as an LVN in 1993. a. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. b. 2. b. Surfactant 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. How does the nurse assess the patient's chest expansion? c. a throat culture or rapid strep antigen test. Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. c. Ventilation-perfusion scan 's nose for several days after the trauma? Which instructions does the nurse provide for the patient? 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. Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. 6. a. 2) d. Direct the family members to the waiting room. What should be the nurse's first action? A) Purulent sputum that has a foul odor Keep the patient in the semi-Fowler's position at all times. b. Copious nasal discharge "You should get the inactivated influenza vaccine that is injected every year." To help clear thick phlegm that the patient is unable to expectorate. Select all that apply. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. Give health teachings about the importance of taking prescribed medication on time and with the right dose. 2018.03.29 NMNEC Leadership Council. c. a radical neck dissection that removes possible sites of metastasis. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. 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. Teach the patient to use the incentive spirometer as advised by their attending physician. 4) f. Instruct the patient not to talk during the procedure. b. a. d. Dyspnea and severe sinus pain. Pneumonia. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? This can lead to hypoxia (lack of oxygen), and possibly tissue damage. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. 3. Priority: Sleep management This type of pneumonia refers to getting the infection at home, in the workplace, in school, or other places in the community outside a hospital or care facility. The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? Which immediate action does the nurse take? e. Posterior then anterior. Medications such as paracetamol, ibuprofen, and. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. Monitor oximetry values; report O2 saturation of 92% or less. c. Persistent swelling of the neck and face Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. COPD ND3: Impaired gas exchange. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. 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. 6. Steroids: To reduce the inflammation in the lungs. Suction the mouth or the oral airway as needed. 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. b. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Encourage the patient to see their medical attending physician for approval and safe treatment. b. Basket stars are active at night. d. Oxygen saturation by pulse oximetry. The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. Maintain intravenous (IV) fluid therapy as prescribed. - Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. Level of the patient's pain Subjective Data

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