To detect presence of hypernatremia, hyperglycemia, and/or dehydration. c. Keep a same-size or larger replacement tube at the bedside. When taking care of a patient with pneumonia, it is important to ensure the environment is well ventilated, conducive for good rest, and accessible when the patient needs assistance or help. A Code Blue would not be called unless the patient experiences a loss of pulse and/or respirations. b. Cyanosis The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. Pinch the soft part of the nose. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. Immunosuppression and neutropenia are predisposing factors for the development of nosocomial pneumonia caused by common and uncommon pathogens. Coughing and difficulty of breathing may cause. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. b. Repeat the ABGs within an hour to validate the findings. Complications include hyperventilation, gastric hyperinflation, headache, hypotension, and signs and symptoms of pneumothorax (shortness of breath, stabbing chest pain, decreased breath sounds on one side, dyspnea, cough). Retrieved February 9, 2022, from. b. What testing is indicated? Observing for hypoxia is done to keep the HCP informed. If he or she can not do it, then provide a suction machine always at the bedside. 1. d. Testing causes a 10-mm red, indurated area at the injection site. Auscultation of breath sounds every 2 to 4 hours (or depending on the patients condition) and reporting of changes in the patients ability to secrete lung secretions. Respiratory infection 3. - Patients with sputum smear-positive TB are considered infectious for the first 2 weeks after starting treatment. e. Observe for signs of hypoxia during the procedure. Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. a. Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. a. Are there any collaborative problems? 3.7 Risk for Deficient Fluid Volume. Smoking does not directly affect filtration of air, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. 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. 1. c. Mucociliary clearance The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. 2. Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues. b. Surfactant 3. 2. 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. 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 Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? d. Pleural friction rub d. Oxygen saturation by pulse oximetry 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. 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. b. Finger clubbing e. Airway obstruction is likely if the exact steps are not followed to produce speech. The oxygenation status with a stress test would not assist the nurse in caring for the patient now. Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. Retrieved February 9, 2022, from, Pneumonia: Symptoms, Treatment, Causes & Prevention. Warm and moisturize inhaled air e. Decreased functional immunoglobulin A (IgA). 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. Stridor is identified with auscultation. Allow 90 minutes for. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? Educating him/her to use the incentive spirometer will encourage him/her to exercise deep inspiration that will help get more oxygen in the lungs and prevent hypoxia. Teach the importance of complying with the prescribed treatment and medication. Suctioning keeps the airway clear by removing secretions. Amount of air exhaled in first second of forced vital capacity Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. a. Assess the patient for iodine allergy. b. What is the first patient assessment the nurse should make? Place the patient in a comfortable position. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. For best yield, blood cultures should be obtained before antibiotics are administered. 2 8 Nursing diagnosis for pneumonia. This work is the product of the What Are Some Nursing Diagnosis for COPD? b. Start oxygen administration by nasal cannula at 2 L/min. Bronchoconstriction 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. a. Undergo weekly immunotherapy. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? The nurse anticipates that interprofessional management will include Discontinue if SpO2 level is above the target range, or as ordered by the physician. 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. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. Complains of dry mouth The width of the chest is equal to the depth of the chest. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. 3.5 Acute Pain. 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. Provide tracheostomy care. d. Dyspnea and severe sinus pain (n.d.). Learning to apply information through a return demonstration is more helpful than verbal instruction alone. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. Assist with respiratory devices and techniques.Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. a. e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). 2018.03.29 NMNEC Leadership Council. Select all that apply. a. radiation therapy that preserves the quality of the voice. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. Change ventilation tubing according to agency guidelines. c. Ventilation-perfusion scan Hospital-Acquired Pneumonia. b. RR 24 With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? Breath sounds in all lobes are verified to be sure that there was no damage to the lung. Assist the patient with position changes every 2 hours. Discharging the patient is unsafe. c. Send labeled specimen containers to the laboratory. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. Discussion Questions This is most common in intensive care units usually resulting from intubation and ventilation support. b. c. Perform mouth care every 12 hours. 1) Increase the intake of foods that are high in vitamin C. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. Allow the patient to have enough bed rest and avoid strenuous activities. h. FRC This assessment monitors the trend in fluid volume. Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. Which instructions does the nurse provide to a patient with acute bronchitis? If the patients condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection. Functional Health Pattern 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. Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. 2. 3. Encouraging oral fluids will mobilize respiratory secretions. Techniques that will be used to alleviate a dry mouth and prevent stomatitis b. Health perception-health management Decreased compliance contributes to barrel chest appearance. How does the nurse respond? Why is the air pollution produced by human activities a concern? It must include the local 911 numbers, hospitals, and immediate keen of the patient. What covers the larynx during swallowing? 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. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. 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. Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Ciliary action impaired by smoking and increased mucus production may be caused by the irritants in tobacco smoke, leading to impairment of the mucociliary clearance system. f. Hyperresonance Try to use words that can be understood by normal people. Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? 3. A) Seizures b. a. Stridor b. Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. d. Pleural friction rub An ET tube has a higher risk of tracheal pressure necrosis. Before other measures are taken, the nurse should check the probe site. Encourage to always change position to facilitate mucous drainage in the lungs. A closed-wound drainage system 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. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. The nurse should instruct on how to properly use these devices and encourage their use hourly. b. k. Value-belief, Risk Factor for or Response to Respiratory Problem No interventions are necessary for these findings. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. c. TLC Assist the patient when they are doing their activities of daily living. f. Cognitive-perceptual 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." 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. COPD ND3: Impaired gas exchange. Fungal pneumonia. a. 4. A repeat skin test is also positive. - The patient's clinical picture is most likely pulmonary embolism (PE), and the first action the nurse should take is to assist with the patient's respirations. Administer the prescribed antibiotic and anti-pyretic medications. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? c. A negative skin test is followed by a negative chest x-ray. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. 26: Upper Respiratory Problems / CH. Corticosteroids and bronchodilators are not useful in reducing symptoms. Examine sputum for volume, odor, color, and consistency; document findings. Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake. f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. Decreased functional cilia Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. 8. a. To facilitate the body in cooling down and to provide comfort. As an Amazon Associate I earn from qualifying purchases. Impaired gas exchange is a risk nursing diagnosis for pneumonia. They will further understand the topic since they already have an idea of what is it about. 's airway before and after surgery? The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. c. Check the position of the probe on the finger or earlobe. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. 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. This patient is older and short of breath. impaired Gas Exchange may be related to decreased oxygen-carrying capacity of blood, reduced RBC life span, abnormal RBC structure, increased blood viscosity, predisposition to bacterial pneumonia/pulmonary infarcts, possibly evidenced by dyspnea, use of accessory muscles, cyanosis/signs of hypoxia, tachycardia, changes in mentation, and . 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. There is an induration of only 5 mm at the injection site. c. Terminal structures of the respiratory tract Treatment for pneumonia needs to be complied with completely to ensure a good prognosis and improve health. 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. Steroids: To reduce the inflammation in the lungs. Tuberculosis frequently presents with a dry cough. Give supplemental oxygen treatment when needed. ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. 2018.01.18 NMNEC Curriculum Committee. Use 1 for the first action and 7 for the last action. d. Pulmonary embolism Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Pockets of pus may form inside the lungs or on their outer layers. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection. Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. a. Subjective Data Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma. Notify the health care provider. d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult.". a. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. e. Sleep-rest Trend and rate of development of the hyperkalemia d. Assess the patient's swallowing ability. - 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. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. 1. Consider using a closed suction system; replace closed suction system according to agency guidelines. c. Determine the need for suctioning. Is elevated in bacterial pneumonias (greater than 12,000/mm3). Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion. Frequent suctioning increases risk of trauma and cross-contamination. Assess the need for hyperinflation therapy. Administer analgesics 1/2 hour prior to deep breathing exercises. The manifestations of viral, fungal, and bacterial infections are similar, and appearance is not diagnostic except when the white, irregular patches on the oropharynx suggest that candidiasis is present. Diminished breath sounds are linked with poor ventilation. She found a passion in the ER and has stayed in this department for 30 years. 1) The cough may last from 6 to 10 weeks. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). c. "An annual vaccination is not necessary because previous immunity will protect you for several years." b. What measures should be taken to maintain F.N. 3.4 Activity Intolerance. 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. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? b. Etiology The most common cause for this condition is poor oxygen levels. b. Epiglottis This can be due to a compromised respiratory system or due to lung disease. Medscape Reference. e. FVC 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. a. The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. Pneumonia is an infection itself but a risk for infection nursing diagnosis is appropriate as untreated pneumonia can progress into a secondary infection or sepsis. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).