The patient reports a sudden onset of shortness of breath, slight chest pain, and that "something is wrong." 3. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. a. Trachea Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. 1) Increase the intake of foods that are high in vitamin C. The following diagnoses are usually made when caring for patients with pneumonia: Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Knowledge deficit/Deficient knowledge Activity intolerance Risk for infection Risk for nutritional imbalance: less than body requirements b. The nurse can also teach coughing and deep breathing exercises. (2022, January 26). In addition, have the patient upright and leaning forward to prevent swallowing blood. 3) Illicit drug intake Pneumonia may increase sputum production causing difficulty in clearing the airways. What is the first patient assessment the nurse should make? 6. 5. Nursing care plan for impaired gas exchange. Water, hydration, and health. Match the descriptions or possible causes with the appropriate abnormal assessment findings. The treatment and medication should be prescribed by the attending physician and do not take meds that are not prescribed to prevent unnecessary drug interaction. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. d. Reflex bronchoconstriction. b. d. Patient receiving oxygen therapy. d) 8. Consider using a closed suction system; replace closed suction system according to agency guidelines. Cough suppressants. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? k. Value-belief, Risk Factor for or Response to Respiratory Problem e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? 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. a. An ET tube has a higher risk of tracheal pressure necrosis. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. 2) Guillain-Barr syndrome c. Empyema Immobile patients or those who need assistance should be turned every 2 hours, assisted into an upright position, or transferred into a chair to promote lung expansion. St. Louis, MO: Elsevier. The nurse expects which treatment plan? Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. 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). Monitor cuff pressure every 8 hours. The patient has been diagnosed with an early vocal cord cancer. The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. a. radiation therapy that preserves the quality of the voice. b. Filtration of air The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. If the patient is having increased mucous production, encourage him or her to clear the airway. The epiglottis is a small flap closing over the larynx during swallowing. 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. Maximum amount of air lungs can contain Reporting complications of hyperinflation therapy to the health care provider. c. Mucociliary clearance Outcomes Interventions Rationale with reference Eval of goal/outcomes Gas r/t alveolar- membrane AEB Positive for strep Bi-pap to maintain rhonchi diminished breath bilaterally. NMNEC Concept: Gas Exchange. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. Expected outcomes It may also cause hepatitis. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. Before other measures are taken, the nurse should check the probe site. There is an induration of only 5 mm at the injection site. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? Weigh patient daily at same time of day and on same scale; record weight. Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. a. SpO2 of 92%; PaO2 of 65 mm Hg The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. e. Posterior then anterior. Hospital-Acquired Pneumonia. Attend to the patients queries regarding their pneumonia treatment. Saunders comprehensive review for the NCLEX-RN examination. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Provide factual information about the disease process in a written or verbal form. Report significant findings. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. Aspiration is one of the two leading causes of nosocomial pneumonia. b. Suction the mouth or the oral airway as needed. 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. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. 4. 1. Important sounds may be missed if the other strategies are used first. c. Comparison of patient's SpO2 values with the normal values The nurse should instruct on how to properly use these devices and encourage their use hourly. a. Assess the patient for iodine allergy. Atelectasis CASE STUDY: Rhinoplasty What do these findings indicate? Because antibody production in response to infection with the tuberculosis (TB) bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, 2-step testing is recommended for individuals likely to be tested often, such as health care professionals. Examine sputum for volume, odor, color, and consistency; document findings. 2. Select all that apply. A) Pneumonia What action should the nurse take? What are possible explanations for this behavior? 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. d. Normal capillary oxygen-carbon dioxide exchange. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. 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. Fatigue 4. Impaired gas exchange 5. Priority: Management of pneumonia and dehydration. e. Teach the patient about home tracheostomy care. Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. a. Decreased force of cough Try to use words that can be understood by normal people. While the nurse is feeding a patient, the patient appears to choke on the food. a. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives. Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Watch for signs and symptoms of respiratory distress and report them promptly. c. Terminal structures of the respiratory tract Level of the patient's pain 6. F.N. d. Pulmonary embolism. Please read our disclaimer. 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]. 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. b. Palpation d. Dyspnea and severe sinus pain Arterial blood gas (ABG) values: May vary depending on extent of pulmonary involvement or other coexisting conditions. 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. Line the lung pleura g. Position the patient sitting upright with the elbows on an over-the-bed table. Fungal pneumonia. Nursing Diagnosis: Impaired gas exchange related to alveolar-capillary membrane changes secondary to COPD as evidenced by oxygen saturation 79%, heart rate 112 bpm, and patient reports of dyspnea. 6. a. 2) d. Direct the family members to the waiting room. The oxygenation status with a stress test would not assist the nurse in caring for the patient now. 2. Most people with pneumonia are preferred to be placed on a moderate high back rest (also called semi-Fowlers position) or placed pillows on the back. d. Chronic herpes simplex infections of the mouth and lips. d. The patient cannot fully expand the lungs because of kyphosis of the spine. c. Place the thumbs at the midline of the lower chest. 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. Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . 2. Nursing care plans: Diagnoses, interventions, & outcomes. d. Comparison of patient's current vital signs with normal vital signs. Nurses should assess for and encourage pneumonia vaccines for eligible populations. Always wear gloves on both hands for suctioning. This intervention decreases pain during coughing, thereby promoting a more effective cough. Associated with altered oxygenation and alveolar-capillary membrane changes resulting from the inflammatory process and exudate in the lungs. a. Thoracentesis 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. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. This is an expected finding with pneumonia, but should not continue to rise with treatment. Checking the respiratory status depending on the need will help know the impending respiratory changes of the patient. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. g) 4. 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. Identify and avoid triggers of the allergic reaction. A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of cerebrospinal fluid and stimulates an increase in the respiratory rate. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. - Pertussis is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis. As a result of the inflammation, the lung tissue becomes edematous and the air spaces fill with exudate (consolidation), gas exchange cannot occur, and non-oxygenated blood is diverted into the vascular system, resulting in hypoxemia. They will further understand the topic since they already have an idea of what is it about. What is the most appropriate action by the nurse? 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. c. Place the patient in high Fowler's position. Partial obstruction of trachea or larynx a. Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? Base to apex b. Ensure that the patient performs deep breathing with coughing exercises at least every 2 hours. 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. c. Place the thumbs at the midline of the lower chest. 8. a. A) Use a cool mist humidifier to help with breathing. 8. Promote fluid intake (at least 2.5 L/day in unrestricted patients). e. Sleep-rest: Sleep apnea. a. Undergo weekly immunotherapy. 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. Increase heat and humidity if patient has persistent secretions. 3.3 Risk for Infection. d. Positron emission tomography (PET) scan. Amount of air remaining in lungs after forced expiration A) Teaching the patient how to cough effectively and. a. Verify breath sounds in all fields. Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. Identify the ability of the patient to perform self-care and do activities of daily living. A tracheostomy is safer to perform in an emergency. d. Limited chest expansion 4) Cough suppressants and antihistamines should not be used. 5) e. Observe for signs of hypoxia during the procedure. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. b. Finger clubbing j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems Airway obstruction is most often diagnosed with pulmonary function testing. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. c. It has two tubings with one opening just above the cuff. Hospital associated Nosocomial pneumonias, Pneumonia in the immunocompromised individual, Risk for Infection (nosocomial pneumonia), Impaired Gas Exchange due to pneumonic condition, 5 Nursing care plans for anemia | Anemia nursing interventions, 5 Nursing diagnosis of pneumonia and care plans, Nursing Care Plans Stroke with Nursing Diagnosis. Alveolar-capillary membrane changes (inflammatory effects) Pinch the soft part of the nose. Has been NPO since midnight in preparation for surgery If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. 8 . A) Inform the patient that it is one of the side effects of The prognosis of a patient with PE is good if therapy is started immediately. c. Check the position of the probe on the finger or earlobe. h. FRC Amount of air exhaled in first second of forced vital capacity 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. d. Use over-the-counter antihistamines and decongestants during an acute attack. h. Role-relationship 3.5 Acute Pain. c. The need for frequent, vigorous coughing in the first 24 hours postoperatively 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. j. Coping-stress tolerance Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Always maintain sterility or aseptic techniques when performing any invasive procedure. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. e. Airway obstruction is likely if the exact steps are not followed to produce speech. Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. d. CO2 directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. Administer the prescribed airway medications (e.g. - Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. A patient presents to the emergency department with a temperature of 101.4F (38.6C) and a productive cough with rust-colored sputum. 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. Objective Data Encourage coughing up of phlegm. b. f. PEFR: (6) Maximum rate of airflow during forced expiration d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. 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. a. Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. b. Impaired Gas Exchange Assessment 1. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. The tissue changes of TB and cancer of the lung may be diagnosed by chest x-ray or CT scan, MRI, or positron emission tomography (PET) scans. Administer nebulizer treatments and other medications.Nebulizer treatments can loosen secretions in the lungs while mucolytics and expectorants can help thin mucus and make it easier to cough up. cancer patients or COPD patients). c. a radical neck dissection that removes possible sites of metastasis. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. "Only health care workers in contact with high-risk patients should be immunized each year." c. Lateral sequence a. No signs or symptoms of tuberculosis or allergies are evident. Shetty, K., & Brusch, J. L. (2021, April 15). Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). Early small airway closure contributes to decreased PaO2. All other answers indicate a negative response to skin testing. Match the following pulmonary capacities and function tests with their descriptions. To help clear thick phlegm that the patient is unable to expectorate. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. b. b. No interventions are necessary for these findings. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Abnormal. Administer supplemental oxygen, as prescribed. Consider sources of infection.Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. 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. Health perception-health management: Tobacco use history, gradual change in health status, family history of lung disease, sputum production, no immunizations for influenza or pneumococcal pneumonia received, travel to developing countries Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. (2020, June 15). a. Buy on Amazon. Help the patient get into a comfortable position, usually the half-Fowler position. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. a. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Give supplemental oxygen treatment when needed.

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