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Assess the need for hyperinflation therapy. How to use a mirror to suction the tracheostomy Change ventilation tubing according to agency guidelines. 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. To facilitate the body in cooling down and to provide comfort. What priority discharge teaching should the nurse provide? c. Airway obstruction 3. 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. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. General physical assessment findingsof pneumonia. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. These interventions help facilitate optimum lung expansion and improve lungs ventilation. c. Perform mouth care every 12 hours. Consider using a closed suction system; replace closed suction system according to agency guidelines. Pink, frothy sputum would be present in CHF and pulmonary edema. d. Dyspnea and severe sinus pain. Chronic hypoxemia b. Palpation Awakening with dyspnea, wheezing, or cough. They are as follows: Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Risk for Infection Acute Pain Decreased Activity Tolerance Hyperthermia Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition: Less Than Body Requirements 3. Number the following actions in the order the nurse should complete them. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. Short-term Goal: at the end of my shift, the patient's condition will lighten and minimal formation of secretion will . Impaired gas exchange is closely tied to Ineffective airway clearance. However, it is highly unlikely that TB has spread to the liver. Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion. e) 1. d. Use over-the-counter antihistamines and decongestants during an acute attack. A 73-year-old patient has an SpO2 of 70%. c. Send labeled specimen containers to the laboratory. Coarse crackling sounds are a sign that the patient is coughing. Rest lowers the oxygen demand of a patient whose reserves are likely to be limited. 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 Volcanic eruptions and other natural events result in air pollution. c. Course crackles Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? 2. Assessment findings include a new onset of confusion, a respiratory rate of 42 breaths/minute, a blood urea nitrogen (BUN) of 24 mg/dL, and a BP of 80/50 mm Hg. Aspiration is one of the two leading causes of nosocomial pneumonia. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. 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. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. St. Louis, MO: Elsevier. Health perception-health management Excess CO2 does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid. Discussion Questions Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. 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. Pulse oximetry would not be affected by fever or anesthesia and is a method of monitoring arterial oxygen saturation in patients who are receiving oxygen therapy. Advised the patient to dispose of and let out the secretions. a. SpO2 of 92%; PaO2 of 65 mm Hg d. Patient can speak with an attached air source with the cuff inflated. Skin breakdown allows pathogens to enter the body. Expected outcomes a. Stridor Impaired Gas Exchange; May be related to. 1) b. a. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. Base to apex b. Surfactant a. TB Coughing and difficulty of breathing may cause. Assess the patients vital signs and characteristics of respirations at least every 4 hours. Notify the health care provider. Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? Viral pneumonia. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. Most people with pneumonia are preferred to be placed on a moderate high back rest (also called semi-Fowlers position) or placed pillows on the back. A) Sit the patient up in bed as tolerated and apply Amount of air that can be quickly and forcefully exhaled after maximum inspiration 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. The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. Inhalation of toxic fumes/chemical irritants can damage cilia and lung tissue and is a factor in increasing the likelihood of pneumonia. 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. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. The turbinates in the nose warm and moisturize inhaled air. d. Oxygen saturation by pulse oximetry. A) Use a cool mist humidifier to help with breathing. Signs and symptoms of respiratory distress include agitation, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory respiratory muscles. Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. The nurse should instruct on how to properly use these devices and encourage their use hourly. Assess for mental status changes. Adjust the room temperature. 2) Ensure that the home is well ventilated. f. Instruct the patient not to talk during the procedure. b. CO2 causes an increase in the amount of hydrogen ions available in the body. 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. Retrieved February 9, 2022, from. The patient must have enough rest so that the body will not be exhausted and avoid an increase in the oxygen demand. d. Parietal pleura. Observing for hypoxia is done to keep the HCP informed. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. The home health nurse provides which instruction for a patient being treated for pneumonia? Learning to apply information through a return demonstration is more helpful than verbal instruction alone. Corticosteroids and bronchodilators are not useful in reducing symptoms. The epiglottis is a small flap closing over the larynx during swallowing. a. 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. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? Report weight changes of 1-1.5 kg/day. Maximum amount of air lungs can contain Sleep disturbance related to dyspnea or discomfort 6. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. 3. Put the index fingers on either side of the trachea. a. 3) Treatment usually includes macrolide antibiotics. Pockets of pus may form inside the lungs or on their outer layers. Impaired gas exchange is the state in which there is an excess or deficit in oxygenation or in the elimination of carbon dioxide at the level of the alveolocapillary membrane. An increased anterior-posterior (AP) diameter is characteristic of a barrel chest, in which the AP diameter is about equal to the side-to-side diameter. 6) Minimize time on public transportation. Bronchophony occurs with pneumonia but is a spoken or whispered word that is more distinct than normal on auscultation. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. Aspiration precautions include maintaining a 30-degree elevation of the HOB, turning the patient onto his or her side rather than back, and using continuous rather than bolus feeding when the patient is enteral. Basket stars are active at night. What keeps alveoli from collapsing? If O2 saturation does not increase to an acceptable level (greater than 92%), FiO2 is increased in small increments while simultaneously checking O2 saturation or obtaining ABG values. Usually, people with pneumonia preferred their heads elevated with a pillow. Use 1 for the first action and 7 for the last action. 3.4 Activity Intolerance. Encouraging oral fluids will mobilize respiratory secretions. Respiratory distress requires immediate medical intervention. No signs or symptoms of tuberculosis or allergies are evident. Teach the proper technique of doing pursed-lip breathing, various ways of relaxation, and abdominal breathing. 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 other options do not maintain inflation of the alveoli. c. Place the thumbs at the midline of the lower chest. d. Place 1 hand on the lower anterior chest and 1 hand on the upper abdomen. a. Otherwise, scroll down to view this completed care plan. The patient will further understand their disease when they understand why they have it and it will help him/her better comply with the treatment regimen. What testing is indicated? To assess the extent and symmetry of chest movement, the nurse places the hands over the lower anterior chest wall along the costal margin and moves them inward until the thumbs meet at the midline and then asks the patient to breathe deeply and observes the movement of the thumbs away from each other. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. F. A. Davis Company. c. Percussion Lung consolidation with fluid or exudate This can lead to hypoxia (lack of oxygen), and possibly tissue damage. a. Undergo weekly immunotherapy. 3.2 Impaired Gas Exchange. A closed-wound drainage system impaired gas exchange nursing care plan scribd. cancer patients or COPD patients). Discuss to him/her the different pros and cons of complying with the treatment regimen. c. There is equal but diminished movement of the 2 sides of the chest. Page . It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Discontinue if SpO2 level is above the target range, or as ordered by the physician. Treatment for pneumonia needs to be complied with completely to ensure a good prognosis and improve health. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. d. Comparison of patient's current vital signs with normal vital signs. Keep the patient in the semi-Fowler's position at all times. Position the patient on the side. 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. Promote oral hygiene, including lip and tongue care. a. Apex to base e. Posterior then anterior. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. Partial obstruction of trachea or larynx g) 4. e. Sleep-rest a. Stridor Provide tracheostomy care. Partial obstruction of trachea or larynx c. Patient in hypovolemic shock Nursing Care Plan 2 However, with increasing respiratory distress, respiratory acidosis may occur. a. Obtain the supplies that will be used. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? 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. Which action does the nurse take next? 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)? Saunders comprehensive review for the NCLEX-RN examination.