Apply pressure to the puncture site for 2 full minutes. b. This produces an area of low ventilation with normal perfusion. The nurse can install an air filter machine that will help create a dust-free environment that will be ideal for a patient with pneumonia. What are possible explanations for this behavior? Tylenol) administered. Tachycardia (resting heart rate [HR] more than 100 bpm). During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. a. Thoracentesis The nurse selects Ineffective Breathing Pattern after validating this patient is demonstrating the associated signs and symptoms related to this nursing diagnosis: Dyspnea Increase in anterior-posterior chest diameter (e.g., barrel chest) Nasal flaring Orthopnea Prolonged expiration phase Pursed-lip breathing Tachypnea was admitted, examination of his nose revealed clear drainage. h. FRC: (8) Volume of air in lungs after normal exhalation. Changes in behavior and mental status can be early signs of impaired gas exchange. To avoid the formation of a mucus plug, suction it as needed. What action should the nurse take? Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. a. 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. 3.1 Ineffective airway clearance. 3) Illicit drug intake This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. b. A) Purulent sputum that has a foul odor 2. Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control. Periorbital and facial edema reduced by about half since second hospital day Promote skin integrity.The skin is the bodys first barrier against infection. The prognosis of a patient with PE is good if therapy is started immediately. St. Louis, MO: Elsevier. 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. The live attenuated influenza vaccine is given intranasally and is recommended for all healthy people between the ages of 2 and 49 years but not for those at increased risk of complications or HCPs. It is very important to take and record the patients respiratory assessment to make it a basis if there are any abnormal findings in the future. Select all that apply. nursing diagnosis based on the assessment data the major nursing diagnoses for meconium aspiration syndrome are hyperthermia related to inflammatory process hypermetabolic state as evidenced by an increase in body temperature warm skin and tachycardia fluid volume . Smoking further increases the risk of developing pneumonia and should be avoided. Steroids: To reduce the inflammation in the lungs. Pulmonary function tests are noninvasive. Document the results in the patient's record. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. a. SpO2 of 92%; PaO2 of 65 mm Hg Impaired cardiac output Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum 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 Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. h. Absent breath sounds Number the following actions in the order the nurse should complete them. b. treatment with antifungal agents. Pulmonary function test a. The nurse can also teach coughing and deep breathing exercises. c. Check the position of the probe on the finger or earlobe. Respiratory infection 3. e. Sleep-rest: Sleep apnea. b. Nutritional-metabolic Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. Remove the inner cannula and replace it per institutional guidelines. The syringe used to obtain the specimen is rinsed with heparin before the specimen is taken and pressure is applied to the arterial puncture site for 5 minutes after obtaining the specimen. Use 1 for the first action and 7 for the last action. 2. HR 68 bpm An increased anterior-posterior (AP) diameter is characteristic of a barrel chest, in which the AP diameter is about equal to the side-to-side diameter. Amount of air exhaled in first second of forced vital capacity b. Also, they will effectively help spread the disease process since they know the mode of transmission and how to break the cycle of transmitting it to other family members. Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. Air trapping Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Decreased force of cough It is also inappropriate to advise the patient to stop taking antitubercular drugs. Priority: Sleep management Obtain the supplies that will be used. Lower Respiratory Tract Infections and Disord, Lewis Ch. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. A) Seizures Finger clubbing and accessory muscle use are identified with inspection. What should be the nurse's first action? To assess the extent and symmetry of chest movement, the nurse places the hands over the lower anterior chest wall along the costal margin and moves them inward until the thumbs meet at the midline and then asks the patient to breathe deeply and observes the movement of the thumbs away from each other. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. During the day, basket stars curl up their arms and become a compact mass. 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. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. a. 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. The patient may have a limit to visitors to prevent the transmission of infections. e. Increased tactile fremitus Select all that apply. It is important to have an initial assessment of the patient and use it as a comparison for future reference or referral. This type of pneumonia can spread through droplet transmission, that is, when an infected person sneezes or coughs, and the other person breathes the air droplets through the nasal or oral airways. Related to: As evidenced by: a. Assess the patient for iodine allergy. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. e. Rapid respiratory rate. Signs and Symptoms of impaired gas exchange dyspnea, SOB cough hemoptysis: coughing up blood abnormal breathing patterns: tachypnea, diabetic ketoacidosis, kusbal respirations (diabetic ketoacidosis leads to hypoxemia through kusbal resp trying to get rid of extra CO2) hypoventilation hyperventilation cyanosis (late sign) 3) Sleep alone. What measures should be taken to maintain F.N. St. Louis, MO: Elsevier. - Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. 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) 5. Sleep disturbance related to dyspnea or discomfort 6. associated with inadequate primary defenses (e.g., decreased ciliary activity), invasive procedures (e.g., intubation), and/or chronic disease Desired outcome: patient is free of infection as evidenced by normothermia, a leukocyte count of 12,000/mm3 or less, and clear to whitish sputum. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. 7. b. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. CASE STUDY: Rhinoplasty 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. RR 24 d. Positron emission tomography (PET) scan. I have a list of nursing diagnoses like acute pain r/t surgery, ineffective peripheral tissue perfusion r/t immobility or abdominal surgery, anxiety r/t change in health, impaired gas exchange r/t decreased functional lung tissue, ineffective airway clearance r/t inflammation and presence of secretion, i also have risk for infection - invasive 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. 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. Allow the patient to have enough bed rest and avoid strenuous activities. Encourage to always change position to facilitate mucous drainage in the lungs. c. Lateral sequence f. PEFR Save my name, email, and website in this browser for the next time I comment. A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. a. The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. F.N. b. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. b. Teach patients some signs and symptoms that prompt immediate medical attention such as dyspnea. Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. b. The patient receives 1 point for each criterion: confusion (compared to baseline); BUN greater than 20 mg/dL; respiratory rate greater than or equal to 30 breaths/min; systolic BP of less than 90 mm Hg; and age greater than or equal to 65 yrs. This is most common in intensive care units usually resulting from intubation and ventilation support. Decreased compliance contributes to barrel chest appearance. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. Trend and rate of development of the hyperkalemia 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. Buy on Amazon. 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. 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. i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms a. c. Take the specimen immediately to the laboratory in an iced container. 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. Corticosteroids and bronchodilators are not useful in reducing symptoms. Adjust the room temperature. Patient with a fever 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. e. Teach the patient about home tracheostomy care. 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. 2) It is a highly contagious respiratory tract infection. Nursing Care Plan 2 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. Which respiratory defense mechanism is most impaired by smoking? d. An ET tube is more likely to lead to lower respiratory tract infection. Nursing diagnoses handbook: An evidence-based guide to planning care. c. a throat culture or rapid strep antigen test. 2018.01.18 NMNEC Curriculum Committee. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. Notify the health care provider. 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. A) 2, 3, 4, 5, 6 These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. Suction secretions as needed. Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. . There is a prominent protrusion of the sternum. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days.
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