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. For best yield, blood cultures should be obtained before antibiotics are administered. 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. Teach the proper technique of doing pursed-lip breathing, various ways of relaxation, and abdominal breathing. This position provides comfort and facilitates the ease and effectiveness of these exercises by promoting better lung expansion (less compression of the lungs by the abdominal organs) and better gas exchange. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Tachycardia (resting heart rate [HR] more than 100 bpm). How should the nurse document this sound? 1. a. Let the patient do a return demonstration when giving lectures about medication and therapeutic regimens. Nursing Care Plan (NCP) for Impaired Gas Exchange | NRSNG Nursing Course a. Deflate the cuff, then remove and suction the inner cannula. Maximum rate of airflow during forced expiration Before other measures are taken, the nurse should check the probe site. Assess the patients knowledge about Pneumonia. 3. d. Contain dead air that is not available for gas exchange. This work is the product of the If the patient is enteral fed, recommend continuous rather than bolus feeding. Impaired gas exchange diagnosis was present in 42.6% of the children in the first assessment. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. Problems of Oxygenation: Ventilation (Lewis Med-Surg Section 6) - Quizlet Impaired gas exchange is a nursing diagnosis that describes the inability of your body to oxygenate blood adequately. 28: Obstructive Pulmonary Diseases. b. c. Keep a same-size or larger replacement tube at the bedside. A) Seizures The patient must understand the importance of seeing an attending physician and not rely on what they see or hear on the internet. Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures secondary to CHF as evidenced by shortness of breath, Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. Better Health Channel. Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. Since the patient is manifesting impaired gas exchange, one of the good indications that the oxygen absorption inside the body is not improving is through the skin changes, nail bed discoloration, and mucous production. a. Vt Amount of air remaining in lungs after forced expiration c. Tracheal deviation 2018.01.18 NMNEC Curriculum Committee. St. Louis, MO: Elsevier. Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma. 2) It is a highly contagious respiratory tract infection. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. a. SpO2 of 92%; PaO2 of 65 mm Hg Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. 3) Illicit drug intake Which immediate action does the nurse take? Facilitate coordination within the care team to allow rest periods between care activities. As an Amazon Associate I earn from qualifying purchases. a. A patient's ABGs include a PaO2 of 88 mm Hg and a PaCO2 of 38 mm Hg, and mixed venous blood gases include a partial pressure of oxygen in venous blood (PvO2) of 40 mm Hg and partial pressure of carbon dioxide in venous blood (PvCO2) of 46 mm Hg. List Priorities from Highest to Lowest ! Give 2 Nursing Diagnosis A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. d. An ET tube is more likely to lead to lower respiratory tract infection. 3 the nursing process diagnosis - SlideShare The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. Major nursing care planning goals for COVID-19 may include: Establishing goals, interventions. Medications such as paracetamol, ibuprofen, and. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . Nursing Diagnosis and Care Plans for COPD | Med-Health.net Administer the prescribed airway medications (e.g. A tracheostomy is safer to perform in an emergency. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? 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. The other options contribute to other age-related changes. This examination detects the presence of random breath sounds (e.g., crackles, wheezes). 1. 6) a. Verify breath sounds in all fields. Nutrition reviews, 68(8), 439458. 6) The patient is infectious from the beginning of the first stage Select all that apply. 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. Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. Pneumonia will be one of the most frequent infections the nurse will encounter and treat. Volcanic eruptions and other natural events result in air pollution. 1. a. c. Percussion 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. b. 4) Recent abdominal surgery. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. f. Use of accessory muscles. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. She found a passion in the ER and has stayed in this department for 30 years. 1. Keep skin clean and dry through frequent perineal care or linen changes. 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 b. Cancer of the lung Pneumonia is an infection of the lungs caused by a bacteria or virus. Retrieved February 9, 2022, from. c. Mucociliary clearance Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. What accurately describes the alveolar sacs? 3 Nursing care plans for pneumonia. It can be obtained by coughing, aspiration, transtracheal aspiration, bronchoscopy or open lung biopsy. This is an expected finding with pneumonia, but should not continue to rise with treatment. Decreased functional cilia It is important to acknowledge their limited information about the disease process and start educating him/her from there. d. Auscultation. 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. b. c. Check the position of the probe on the finger or earlobe. Expected outcomes Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). b. Cuff pressure monitoring is not required. This can lead to hypoxia (lack of oxygen), and possibly tissue damage. Nursing care plan pneumonia - Nursing care plan: Pneumonia Pneumonia is an inflammation of the lung - Studocu care plan pneumonia nursing care plan: pneumonia pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair Skip to document Ask an Expert Sign inRegister Sign inRegister Home 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. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. a. d. Patient can speak with an attached air source with the cuff inflated. Implement NPO orders for 6 to 12 hours before the test. 2. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. c. Wheezes 27 - Lower Respiratory Problems, Coronary Artery Disease & Acute Coronary Synd, Integumentary System (Lewis Med-Surg CH.22 &, Barbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh, 1.1 (Anatomy) Functional Organization of the. Respiratory distress requires immediate medical intervention. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. Remove the inner cannula and replace it per institutional guidelines. h. FRC What Are Some Nursing Diagnosis for COPD? c. Patient in hypovolemic shock 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. Teach the patient to use the incentive spirometer as advised by their attending physician. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. When inflamed, the air sacs may produce fluid or pus which can cause productive cough and difficulty breathing. - 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. Week 1 - Respiratory.docx - Week 1 - Nursing Care of Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. A closed-wound drainage system The patient will have a big chance to remember how to administer or perform any therapeutic regimen if they are given the chance to demonstrate and have him/her verbalize their understanding about it. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance. 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 c. An electrolarynx held to the neck j. Coping-stress tolerance: Dyspnea-anxiety-dyspnea cycle, poor coping with stress of chronic respiratory problems Chronic hypoxemia What should be the nurse's first action? This is done before sending the sample to the laboratory if there is no one else who can send the sample to the laboratory. d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. Change ventilation tubing according to agency guidelines. a. Important sounds may be missed if the other strategies are used first. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. It may also cause hepatitis. Interstitial edema b. Cyanosis Nursing Diagnosis for COPD | Nursing Care Plan & Interventions for COPD The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? Collaboration: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the registered nurse (RN) may delegate which interventions to the licensed practical/vocational nurse (LPN/VN) (select all that apply)? The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. Increase heat and humidity if patient has persistent secretions. Lung consolidation with fluid or exudate b. Filtration of air This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? c. Elimination Assess lung sounds and vital signs.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. These measures ensure consistency and accuracy of weight measurements. Anna Curran. a. It involves the inflammation of the air sacs called alveoli. f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. b. When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors? Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. What should the nurse do when preparing a patient for a pulmonary angiogram? Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? These interventions contribute to adequate fluid intake. a. 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. a. Assess the patient for iodine allergy. a. 1. Add heparin to the blood specimen. d. Apply an ice pack to the back of the neck. e. Increased tactile fremitus d. An electrolarynx placed in the mouth. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). These practices further reduce the risk of contamination. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. Assess intake and output (I&O). b. Identify the ability of the patient to perform self-care and do activities of daily living. NurseTogether.com does not provide medical advice, diagnosis, or treatment. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Arrange the tasks of the patient when providing care to him/her. It is also inappropriate to advise the patient to stop taking antitubercular drugs. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. a. b. Decreased functional cilia c. The necessity of never covering the laryngectomy stoma Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. Chest x-ray examination: To confirm presence of pneumonia (i.e., infiltrate appearing on the film). The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Fill fluid containers immediately before use (not well in advance). All other answers indicate a negative response to skin testing. Allow patients to ask a question or clarify regarding their treatment. NANDA Nursing Diagnosis for Respiratory Disorders - Nurseship.com What the oxygenation status is with a stress test 2) Ensure that the home is well ventilated. Decreased skin turgor and dry mucous membranes as a result of dehydration. (2022, January 26). Examine sputum for volume, odor, color, and consistency; document findings. Pneumonia may increase sputum production causing difficulty in clearing the airways. The prognosis of a patient with PE is good if therapy is started immediately. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. Remove unnecessary lines as soon as possible. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that results from aspiration of gastric contents. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. This assessment monitors the trend in fluid volume. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. Antibiotics: To treat bacterial pneumonia. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. 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. Surgical incisions and any skin breakdown should be monitored for redness, warmth, drainage, or odor that signals an infection. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. Use 1 for the first action and 7 for the last action. Give health teachings about the importance of taking prescribed medication on time and with the right dose. Base to apex Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. How to use esophageal speech to communicate Assess the patients vital signs at least every 4 hours. b. Epiglottis b. Epiglottis Air trapping Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion. 3. Which values indicate a need for the use of continuous oxygen therapy? What keeps alveoli from collapsing? 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. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. Most commonly, P. jirovecii occurs in individuals with human immunodeficiency virus infection or in individuals who are therapeutically immunosuppressed after organ transplantation. e. Rapid respiratory rate. d. Dyspnea and severe sinus pain Reports facial pain at a level of 6 on a 10-point scale PDF Nursing Care Plan For Meconium Aspiration Syndrome A transesophageal puncture In addition, have the patient upright and leaning forward to prevent swallowing blood. a. 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. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. Retrieved February 9, 2022, from, Testing for Sepsis. j. Coping-stress tolerance The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Impaired Gas Exchange: A Case Study | ipl.org - Internet Public Library Environmental irritants such as flowers, dust, and strong perfume smell or any strong smelling substance will only worsen the patients condition. Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Suction the mouth or the oral airway as needed. Risk for Impaired Gas Exchange - Simple Nursing f. PEFR: (6) Maximum rate of airflow during forced expiration These interventions help facilitate optimum lung expansion and improve lungs ventilation. Has been NPO since midnight in preparation for surgery Changes in behavior and mental status can be early signs of impaired gas exchange. Pneumonia can be mild but can also be fatal if left untreated. Most of the problems in connection to the reoccurrence of pneumonia are poor compliance to the prescribed treatment. c. Empyema d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. Fine crackles at the base of the lungs are likely to disappear with deep breathing. a. Thoracentesis 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. Goal/Desired Outcome Short-term goal: The patient will remain free from signs of respiratory distress and her oxygen saturation will remain higher than 96% for the duration of the shift. Keep the patient in the semi-Fowler's position at all times. a. Why is the air pollution produced by human activities a concern? 4. 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. Findings may show hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg) with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. A cascade cough removes secretions and improves ventilation through a sequence of shorter and more forceful exhalations than is the case with the usual coughing exercise. Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. A patient's initial purified protein derivative (PPD) skin test result is positive. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. Pleurisy d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. Night sweats i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms e. Observe for signs of hypoxia during the procedure. Try to use words that can be understood by normal people. Always maintain sterility or aseptic techniques when performing any invasive procedure. d. Assess the patient's swallowing ability. These critically ill patients have a high mortality rate of 25-50%. Nursing Diagnosis and Care Plan for COPD- A Student's Guide - Tutorsploit 5) Corticosteroids and bronchodilators are helpful in reducing The nurse should instruct on how to properly use these devices and encourage their use hourly. A) Inform the patient that it is one of the side effects of Dont forget to include some emergency contact numbers just in case there is an emergency. c. Tracheal deviation Obtain the supplies that will be used. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Which age-related changes in the respiratory system cause decreased secretion clearance (select all that apply)? 7. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small and no radiation precautions are indicated for the patient. 6. a. Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? Priority Decision: When F.N. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration Page . ncp-pcap_compress.pdf - Nursing Care Plan Patient's Name: Consider imperceptible losses if the patient is diaphoretic and tachypneic. Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion. 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. c. Check the position of the probe on the finger or earlobe. Number the following actions in the order the nurse should complete them. c. It has two tubings with one opening just above the cuff. Advised the patient that he or she will be evaluated if he or she can tolerate exercise and develop a special exercise to help his or her recovery. b. a hemilaryngectomy that prevents the need for a tracheostomy. c. Inadequate delivery of oxygen to the tissues The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. Which respiratory defense mechanism is most impaired by smoking? Buy on Amazon, Silvestri, L. A. c. Comparison of patient's SpO2 values with the normal values a. Stridor 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. The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. Appendix N3: Nursing Diagnoses Grouped by Diseases/Disorders 8 . Promote a well-ventilated environment so that the patient will have good oxygen exchange in the body. a. Stridor It is important to have an initial assessment of the patient and use it as a comparison for future reference or referral. This also increases the risk for aspiration pneumonia. "You should get the inactivated influenza vaccine that is injected every year." FON-Chapter7-Case Study Practices and Critical thinking Questions c. Take the specimen immediately to the laboratory in an iced container.