Nursing management of pneumonia ppt is an acute inflammatory disorder of lung parenchyma that results in edema of lung tissues and. d. Activity-exercise 2. Adjust the room temperature. Encouraging oral fluids will mobilize respiratory secretions. Oxygen is administered when O2 saturation or ABG results show hypoxemia. e) 1. However, it is highly unlikely that TB has spread to the liver. The bacteria may enter the blood stream and cause, Trouble sleeping. Impaired Gas Exchange Nursing Diagnosis & Care Plan - NurseTogether Provide factual information about the disease process in a written or verbal form. c. Lateral sequence c. Percussion Turbinates warm and moisturize inhaled air. Select all that apply. 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. NANDA Nursing Diagnosis for Respiratory Disorders - Nurseship.com Nursing Diagnosis 1: Risk for fluid volume deficit related to increased fluid losses secondary to diarrhea and decreased fluid intake; Nursing Diagnosis 2: Impaired gas exchange related to pneumonia and decreased oxygen saturation levels; 2. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Outcomes are influenced by the age of the patient, the extent of the disease process, the underlying disease, and the pathogen involved. 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. d. Comparison of patient's current vital signs with normal vital signs. 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). Treatment for pneumonia needs to be complied with completely to ensure a good prognosis and improve health. Assess intake and output (I&O). The width of the chest is equal to the depth of the chest. Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. Nursing care plans: Diagnoses, interventions, & outcomes. Other bacteria that can cause pneumonia include H. influenzae, Mycoplasma pneumonia, Legionella pneumonia, and Chlamydia pneumoniae. Arrange the tasks of the patient when providing care to him/her. How to use a mirror to suction the tracheostomy 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. Nursing Diagnosis related to --- as evidence by---Impaired gas exchange related to inflammation of airways, fluid-filled alveoli, and collection of mucus in the airway as evidenced by dyspnea and tachypnea (Carpenito, 2021). Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. Attend to the patients queries regarding their pneumonia treatment. The nurse expects which treatment plan? 5. 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. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. Impaired Gas Exchange Nursing Diagnosis & Care Plan Nursing care plan pneumonia - StuDocu A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. Reports facial pain at a level of 6 on a 10-point scale b. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. 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. Medscape Reference. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. Normally the AP diameter should be 13 to 12 the side-to-side diameter. impaired gas exchange nursing care plan scribd The nurse is preparing the patient for and will assist the health care provider with a thoracentesis in the patient's room. As the patients condition worsens, sputum may become more abundant and change color from clear/white to yellow and/or green, or it may exhibit other discolorations characteristic of an underlying bacterial infection (e.g., rust-colored; currant jelly). b. Avoid instillation of saline during suctioning. 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. Usually, people with pneumonia preferred their heads elevated with a pillow. h. Role-relationship: Loss of roles at work or home, exposure to respiratory toxins at work e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. Base to apex If they cannot, sputum can be obtained via suctioning. 3) Treatment usually includes macrolide antibiotics. ncp-pcap_compress.pdf - Nursing Care Plan Patient's Name: a. Oximetry: May reveal decreased O2 saturation (92% or less). 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. g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem Match the descriptions or possible causes with the appropriate abnormal assessment findings. 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home 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. Position the patient on the side. Respiratory distress requires immediate medical intervention. a. 1. The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. c. Place the patient in high Fowler's position. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. A prominent protrusion of the sternum is the pectus carinatum and diminished movement of both sides of the chest indicates decreased chest excursion. Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. d. Thoracic cage. Pneumonia Nursing Diagnosis & Care Plan | NurseTogether a. treatment with antibiotics. 2. A) Pneumonia Page . Touching an infected object and then touching your nose or mouth can also transfer the germs. A less severe form of bacterial pneumonia is called walking or atypical pneumonia, in which the symptoms are very mild and the infected person can do his/her activities of daily living as normal. The cough with pertussis may last from 6 to 10 weeks. b. Palpation Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). Order stat ABGs to confirm the SpO2 with a SaO2. Administer analgesics 1/2 hour prior to deep breathing exercises. 3.2 Impaired Gas Exchange. Nursing Diagnosis: Ineffective Airway Clearance. Is elevated in bacterial pneumonias (greater than 12,000/mm3). Instruct patients who are unable to cough effectively in a cascade cough. Decreased skin turgor and dry mucous membranes as a result of dehydration. Help the patient get into a comfortable position, usually the half-Fowler position. List Priorities from Highest to Lowest ! Give 2 Nursing Diagnosis 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. 1. c. Check the position of the probe on the finger or earlobe. Corticosteroids and bronchodilators are not useful in reducing symptoms. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. c. Percussion A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. Chronic hypoxemia Stop feeding when the patient is lying flat. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. 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. c. TLC: (2) Maximum amount of air lungs can contain Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. d. The patient cannot fully expand the lungs because of kyphosis of the spine. Document the results in the patient's record. 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. Finger clubbing and accessory muscle use are identified with inspection. Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. h. Absent breath sounds The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. d) 8. d. Auscultation. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. 4. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. 2023 Nursing Diagnosis Guide | Examples, List & Types - Nurse.org Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public. 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. Advised the patient to dispose of and let out the secretions. 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. d. Pleural friction rub. c. Take the specimen immediately to the laboratory in an iced container. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. 7) c. Send labeled specimen containers to the laboratory. Care plan pneumonia, sepsis 2 - 1# Priority Nursing Diagnosis Goal Coarse crackling sounds are a sign that the patient is coughing. 6. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. a. Suction the tracheostomy. Otherwise, scroll down to view this completed care plan. A) Admit the patient to the intensive care unit. Trend and rate of development of the hyperkalemia 3.3 Risk for Infection. Preoperative education, explanation, and demonstration of pulmonary activities used postoperatively to prevent respiratory infections. There is alteration in the normal respiratory process of an individual. 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) "I will need to have a follow-up chest x-ray in six to. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. oxygen. Identify patients at increased risk for aspiration. 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. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. Normal or low leukocyte counts (less than 4000/mm3) may occur in viral or mycoplasma pneumonia. Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. Maximum rate of airflow during forced expiration Learn how your comment data is processed. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. The width of the chest is equal to the depth of the chest. Our website services and content are for informational purposes only. d. Pleural friction rub Put the palms of the hands against the chest wall. Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site. Hospital-Acquired Pneumonia. What is included in the nursing care of the patient with a cuffed tracheostomy tube? General physical assessment findingsof pneumonia. b. Have an initial assessment of the patients respiratory rate, rhythm, and oxygen saturation every 4 hours or depending on the need. 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 c. Tracheal deviation 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 . Care Plan for Ineffective Gas Exchange, Ineffective Airway Clearance A) Inform the patient that it is one of the side effects of Samples for ABGs must be iced to keep the gases dissolved in the blood (unless the specimen is to be analyzed in <1 minute) and taken directly to the laboratory. This is an expected finding with pneumonia, but should not continue to rise with treatment. b. It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems. Bronchoconstriction e. Teach the patient about home tracheostomy care. patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. Amount of air that can be quickly and forcefully exhaled after maximum inspiration Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. Pinch the soft part of the nose. c. Explain the test before the patient signs the informed consent form. What action should the nurse take? g) 4. Nasal flaring Abnormal breathing rate, depth, and rhythm Hypoxemia Restlessness Confusion A headache after waking up Elevated blood pressure and heart rate Somnolence and visual disturbances Nursing Assessment for Impaired Gas Exchange symptoms The home health nurse provides which instruction for a patient being treated for pneumonia? c. Send labeled specimen containers to the laboratory. Elevate the head of the bed and assist the patient to assume semi-Fowlers position. Nutrition reviews, 68(8), 439458. Lung consolidation with fluid or exudate a. - 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. What is a primary nursing responsibility after obtaining a blood specimen for ABGs? Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. 3. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. 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 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. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. Fever and vomiting are not manifestations of a lung abscess. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. e. Posterior then anterior. 3) Illicit drug intake d. Reflex bronchoconstriction. Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. "You should get the inactivated influenza vaccine that is injected every year." Etiology The most common cause for this condition is poor oxygen levels. Putting diagnoses in priority order? Help! - Nursing - allnurses Important sounds may be missed if the other strategies are used first. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives. Start asking what they know about the disease and further discuss it with the patient. Use the antibiotic to treat the bacterial pneumonia, which is the underlying cause of the patients hyperthermia. To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. 6) Minimize time on public transportation. Keep skin clean and dry through frequent perineal care or linen changes. Remove unnecessary lines as soon as possible. b. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. Sputum samples can be cultured to appropriately treat the type of bacteria causing infection. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Pink, frothy sputum would be present in CHF and pulmonary edema. Major nursing care planning goals for COVID-19 may include: Establishing goals, interventions. 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. Alveolar-capillary membrane changes (inflammatory effects) A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. 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. 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.
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