f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness. Cough and sore throat Decreased force of cough b. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). Notify the health care provider. d. Small airway closure earlier in expiration Arrange the tasks of the patient when providing care to him/her. 5) Corticosteroids and bronchodilators are helpful in reducing The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. d. Comparison of patient's current vital signs with normal vital signs Patient with a fever patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. Complains of dry mouth d. a total laryngectomy to prevent development of second primary cancers. 1) The cough may last from 6 to 10 weeks. Early small airway closure contributes to decreased PaO2. 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. 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. Select all that apply. Medscape Reference. f. Instruct the patient not to talk during the procedure. d. SpO2 of 88%; PaO2 of 55 mm Hg Viral pneumonia. A tracheostomy is safer to perform in an emergency. 5. To regulate the temperature of the environment and make it more comfortable for the patient. If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status. d. The patient cannot fully expand the lungs because of kyphosis of the spine. 6) The patient is infectious from the beginning of the first stage 3 Nursing care plans for pneumonia. 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. Antibiotics. Promote a well-ventilated environment so that the patient will have good oxygen exchange in the body. Productive cough (viral pneumonia may present as dry cough at first). c. Place the thumbs at the midline of the lower chest. c. Wheezes The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? Buy on Amazon. Decreased functional cilia Impaired gas exchange 5. 1. What measures should be taken to maintain F.N. 4) Recent abdominal surgery. Bilateral ecchymosis of eyes (raccoon eyes) 1. Pleurisy, a) 7. Touching an infected object and then touching your nose or mouth can also transfer the germs. d. Positron emission tomography (PET) scan. The nurse should instruct on how to properly use these devices and encourage their use hourly. Allow patients to ask a question or clarify regarding their treatment. d. Reflex bronchoconstriction. The nurse expects which treatment plan? 2) It is a highly contagious respiratory tract infection. Activity intolerance 2. c. A tracheostomy tube allows for more comfort and mobility. b. Copious nasal discharge Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Adjust the room temperature. d. Normal capillary oxygen-carbon dioxide exchange. Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. c. Drainage on the nasal dressing j. Coping-stress tolerance 2. 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. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. Nursing Diagnosis Impaired Gas Exchange related to to altered alveolarcapillary membrane changes due to pneumonia disease process. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. 1. The home health nurse provides which instruction for a patient being treated for pneumonia? b. Stridor Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control. e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Use 1 for the first action and 7 for the last action. If there are some questions or clarifications when it comes to their medicines, make sure to find time to explain to him/her so that this will ensure compliance with the treatment. There is alteration in the normal respiratory process of an individual. d. VC Administer supplemental oxygen, as prescribed. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. Teach patients some signs and symptoms that prompt immediate medical attention such as dyspnea. Are there any collaborative problems? 1) b. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. Administer oxygen with hydration as prescribed. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. c. SpO2 of 90%; PaO2 of 60 mm Hg c) 5. For which problem is this test most commonly used as a diagnostic measure? Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. 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. 3.3 Risk for Infection. Promote skin integrity.The skin is the bodys first barrier against infection. Diminished breath sounds are linked with poor ventilation. Maximum amount of air that can be exhaled after maximum inspiration Usually, people with pneumonia preferred their heads elevated with a pillow. cancer patients or COPD patients). 5) Minimize time in congregate settings. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. Heavy tobacco and/or alcohol use It is important to acknowledge their limited information about the disease process and start educating him/her from there. Nursing care plan for impaired gas exchange. 3) Illicit drug intake 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. Frequent suctioning increases risk of trauma and cross-contamination. c. Empyema d. Limited chest expansion 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 Apply pressure to the puncture site for 2 full minutes. b. Surfactant The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. 2. Anna Curran. The nurse anticipates that interprofessional management will include I do not know if it's just overthinking it or what but all the care plans i have read . Basket stars are active at night. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Atelectasis. 5) e. Observe for signs of hypoxia during the procedure. 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. F.N. d. Pleural friction rub. Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. A knowledgeable patient is more likely to comply with therapy. 1) Seizures Assess the patients vital signs and characteristics of respirations at least every 4 hours. Nursing Care Plan 2 4. 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. Desired Outcome: At the end of the span of care, the patient will manifest better lung ventilation and improve tissue perfusion, and maximum optimal gas exchange by having normal arterial blood gas results, minimum to no symptoms of respiratory distress, and normal production of mucus in the airway. 's airway before and after surgery? NurseTogether.com does not provide medical advice, diagnosis, or treatment. g. Self-perception-self-concept Encourage coughing up of phlegm. Discharging the patient is unsafe. (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult.". Objective Data Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. Retrieved February 9, 2022, from. Health perception-health management 4. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. COPD ND3: Impaired gas exchange. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. A patient with pneumonia shows inflammation in their lung parenchyma causing it to have. The width of the chest is equal to the depth of the chest. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. NMNEC Concept: Gas Exchange. Instruct patients who are unable to cough effectively in a cascade cough. Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. All other answers indicate a negative response to skin testing. 1) Increase the intake of foods that are high in vitamin C. a. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? h) 3. Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . These interventions contribute to adequate fluid intake. a. a. a. Add heparin to the blood specimen. The bacteria may enter the blood stream and cause, Trouble sleeping. How to use a mirror to suction the tracheostomy c. Persistent swelling of the neck and face d. Activity-exercise e. Airway obstruction is likely if the exact steps are not followed to produce speech. c. Temperature of 100 F (38 C) 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. Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? 6) a. Verify breath sounds in all fields. Types of Nursing Diagnoses There are 4 types of nursing diagnoses.