Nursing care plan for impaired gas exchange. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? 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 . Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. Chronic hypoxemia The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration, and the nurse should monitor the patient's respiratory rate and rhythm and SpO2. Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. c. It has two tubings with one opening just above the cuff. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. Pneumonia may increase sputum production causing difficulty in clearing the airways. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, d. An electrolarynx placed in the mouth. Monitor cuff pressure every 8 hours. f) 2. b. c. Place the patient in high Fowler's position. Tuberculosis frequently presents with a dry cough. 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. Desired Outcome: Within 1 hour of nursing interventions, the patient will have oxygen saturation of greater than 90%. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Antibiotics. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Auscultate breath sounds at least every 2 to 4 hours or as the patients condition dictates. 2. Assist the patient when they are doing their activities of daily living. Report significant findings. Priority Decision: When F.N. Cough reflex b. Surfactant To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Select all that apply. They will further understand the topic since they already have an idea of what is it about. NMNEC Concept: Gas Exchange. The pH is also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in venous blood (PvCO2). Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). c. Remove the inner cannula if the patient shows signs of airway obstruction. 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. c. Elimination: Constipation, incontinence 6. a. Match the descriptions or possible causes with the appropriate abnormal assessment findings. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). c. Determine the need for suctioning. Impaired Gas Exchange is a NANDA nursing diagnosis that is used for conditions where there is an alteration in the balance between the exchange of gases in the lungs. 4. (Symptoms) Reports of feeling short of breath The other options do not maintain inflation of the alveoli. Apply pressure to the puncture site for 2 full minutes. 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. The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. Aspiration is one of the two leading causes of nosocomial pneumonia. Is elevated in bacterial pneumonias (greater than 12,000/mm3). 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. Patient with a fever g. FEV1: (1) Amount of air exhaled in first second of forced vital capacity Discuss to the patient the different types of pneumonia and the difference between him/her. Awakening with dyspnea, wheezing, or cough. a. Assess the patient for iodine allergy. 4) f. Instruct the patient not to talk during the procedure. 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 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. Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. 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. Which medication therapy does the nurse anticipate will be prescribed? a. Stridor Assess intake and output (I&O). Maegan Wagner is a registered nurse with over 10 years of healthcare experience. f. PEFR: (6) Maximum rate of airflow during forced expiration The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. While the nurse is feeding a patient, the patient appears to choke on the food. c. Wheezes What the oxygenation status is with a stress test Periorbital and facial edema reduced by about half since second hospital day causing a clinical illness o Mandatory testing for health care professionals o Usually performed twice o Priority Nursing Diagnoses: Ineffective breathing pattern Ineffective airway clearance Impaired Gas . Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Cleveland Clinic. Nurses should assess for and encourage pneumonia vaccines for eligible populations. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). Base to apex Atelectasis Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. c. Encourage deep breathing and coughing to open the alveoli. Administer analgesics 1/2 hour prior to deep breathing exercises. d. SpO2 of 88%; PaO2 of 55 mm Hg f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. patients with pneumonia need assistance when performing activities of daily living. 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. 1. a. Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up. Most of the cases of poor prognosis of pneumonia are undertreatment or not being able to be assessed earlier. 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. The nurse expects which treatment plan? g. Self-perception-self-concept e. FVC Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. b. Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Reports facial pain at a level of 6 on a 10-point scale Fungal pneumonia. a. Carina c. Terminal structures of the respiratory tract Has been NPO since midnight in preparation for surgery The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. - Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. The turbinates in the nose warm and moisturize inhaled air. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. The greatest chance for a pneumothorax occurs with a thoracentesis because of the possibility of lung tissue injury during this procedure. The nurse is preparing the patient for and will assist the health care provider with a thoracentesis in the patient's room. The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Pneumonia will be one of the most frequent infections the nurse will encounter and treat. The patient has been diagnosed with an early vocal cord cancer. 3) Sleep alone. The cuff passively fills with air. Provide tracheostomy care every 24 hours. a. Undergo weekly immunotherapy. The prognosis of a patient with PE is good if therapy is started immediately. Try to use words that can be understood by normal people. Pneumonia. Decreased compliance contributes to barrel chest appearance. 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. A patient's initial purified protein derivative (PPD) skin test result is positive. Health perception-health management These interventions help facilitate optimum lung expansion and improve lungs ventilation. 3. This work is the product of the ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? She earned her BSN at Western Governors University. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? b. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. 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 Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. d. Activity-exercise This produces an area of low ventilation with normal perfusion. The palms are placed against the chest wall to assess tactile fremitus. Select all that apply. d. Testing causes a 10-mm red, indurated area at the injection site. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. e. Teach the patient about home tracheostomy care. j. Coping-stress tolerance Amount of air exhaled in first second of forced vital capacity d. Pleural friction rub It is important to have an initial assessment of the patient and use it as a comparison for future reference or referral. Chronic hypoxemia b. Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. Start asking what they know about the disease and further discuss it with the patient. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. 2) It is a highly contagious respiratory tract infection. c. Check the position of the probe on the finger or earlobe. Maximum amount of air lungs can contain The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. Complains of dry mouth Remove excessive clothing, blankets and linens. Which action does the nurse take next? It may also cause hepatitis. 6. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. Put the index fingers on either side of the trachea. - 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. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). There is an induration of only 5 mm at the injection site. To care for the tracheostomy appropriately, what should the nurse do? Community-Acquired Pneumonia. Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. 27: Lower Respiratory Problems / CH. Priority Decision: A pulse oximetry monitor indicates that the patient has a drop in arterial oxygen saturation by pulse oximetry (SpO2) from 95% to 85% over several hours. b. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? 5. Use 1 for the first action and 7 for the last action. b. b. Bronchophony c. Percussion The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. The immunity will not protect for several years, as new strains of influenza may develop each year. b. Finger clubbing 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. a. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. b. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness. Associated with the presence of tracheobronchial secretions that occur with infection Desired outcomes: The patient demonstrates an effective cough. 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. Other antibiotics that may be used for pneumonia include doxycycline, levofloxacin, and combination of macrolide and beta-lactam (amoxicillin or amoxicillin/clavulanate known as Augmentin). 7. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. (n.d.). Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. Identify the ability of the patient to perform self-care and do activities of daily living. c. Tracheal deviation Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). 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. b. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. Promote oral hygiene, including lip and tongue care. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. 25: Assessment: Respiratory System / CH. 1. Document the results in the patient's record. b. RV: (7) Amount of air remaining in lungs after forced expiration The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. 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 c. Ventilation-perfusion scan General physical assessment findingsof pneumonia. b. a hemilaryngectomy that prevents the need for a tracheostomy. Allow 90 minutes for. Allow the patient to have enough bed rest and avoid strenuous activities. Atrial Fibrillation Nursing Diagnosis and Nursing Care Plan, Readiness for Enhanced Coping Nursing Diagnosis and Nursing Care Plans, Cystic Fibrosis Nursing Diagnosis Care Plan - NurseStudy.Net. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. Discontinue if SpO2 level is above the target range, or as ordered by the physician. d. Limited chest expansion All other answers indicate a negative response to skin testing. a. The nurse identifies which factor that places a patient at risk for aspiration pneumonia? Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. Always wear gloves on both hands for suctioning. 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. d. VC Organizing the tasks will provide a sufficient rest period for the patient. 3. The thoracic cage is formed by the ribs and protects the thoracic organs. A) Teaching the patient how to cough effectively and. Assess the patients vital signs at least every 4 hours. c. Turbinates b. Stridor d. Self-help groups and community resources for patients with cancer of the larynx, When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. 6. 7. Nursing Care Plan for: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. The patients blood oxygen saturation (SpO2) will also be within the target levels set by the physician (usually 96 to 100 percent; 88 to 92% for most. d. Small airway closure earlier in expiration 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. Maintain intravenous (IV) fluid therapy as prescribed. Use only sterile fluids and dispense with sterile technique. - According to the Expanded CURB-65 scale, which is used as a supplement to clinical judgment to determine the severity of pneumonia, the patient's score is a 5; placement in the intensive care unit is recommended. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? 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. RR 24 3. The carina is the point of bifurcation of the trachea into the right and left bronchi. Preventing the spread of coronavirus infection to the patient's family members, community, and healthcare providers. Respiratory distress requires immediate medical intervention. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? a. Examine sputum for volume, odor, color, and consistency; document findings. Nursing Diagnosis. 3) Illicit drug intake Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. 28: Obstructive Pulmonary Diseases. 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.