impaired gas exchange nursing diagnosis pneumoniaimpaired gas exchange nursing diagnosis pneumonia
Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. 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. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. c. Determine the need for suctioning. Impaired Gas Exchange Nursing Diagnosis & Care Plan Related Factors Physiological damage to the alveoli Circulatory compromise Lack of oxygen supply Insufficient availability of blood (carrier of oxygen) Subjective Data: patient's feelings, perceptions, and concerns. Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. Identify patients at increased risk for aspiration. There is alteration in the normal respiratory process of an individual. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. These measures ensure consistency and accuracy of weight measurements. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. Obtain the supplies that will be used. Medical-surgical nursing: Concepts for interprofessional collaborative care. c. Persistent swelling of the neck and face The patient must understand the importance of seeing an attending physician and not rely on what they see or hear on the internet. c. Terminal structures of the respiratory tract c. Wheezing b. d. Auscultation. Interstitial edema Decreased functional cilia 6. a. Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. It involves the inflammation of the air sacs called alveoli. The patient reports a sudden onset of shortness of breath, slight chest pain, and that "something is wrong." 2) d. Direct the family members to the waiting room. Line the lung pleura Impaired cardiac output Document the results in the patient's record. Provide tracheostomy care. Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. This is needed to help the patient conserve his or her energy and also effective relaxation when the patient feels anxious and having a hard time concentrating and breathing. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). Report significant findings. a. Better Health Channel. St. Louis, MO: Elsevier. However, here are some potential NANDA nursing diagnoses that may be applicable: Impaired gas exchange related to decreased lung expansion and ventilation-perfusion imbalance; . 1. Give health teachings about the importance of taking prescribed medication on time and with the right dose. A patient presents to the emergency department with a temperature of 101.4F (38.6C) and a productive cough with rust-colored sputum. e. Posterior then anterior d. Normal capillary oxygen-carbon dioxide exchange. c. Turbinates Cleveland Clinic. a. Thoracentesis d. Pleural friction rub. Monitor cuff pressure every 8 hours. After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. 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. Buy on Amazon, Silvestri, L. A. a. Trachea Amount of air that can be quickly and forcefully exhaled after maximum inspiration b. Allow 90 minutes for. 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. 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. Examine sputum for volume, odor, color, and consistency; document findings. If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues. Aspiration is one of the two leading causes of nosocomial pneumonia. c. a throat culture or rapid strep antigen test. Fine crackles at the base of the lungs are likely to disappear with deep breathing. 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 . 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 If sepsis is suspected, a blood culture can be obtained. d. VC Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. Impaired Gas Exchange Assessment 1. Amount of air remaining in lungs after forced expiration Administer the prescribed airway medications (e.g. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. 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. Which immediate action does the nurse take? d. Avoid any changes in oxygen intervention for 15 minutes following the procedure. If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. What covers the larynx during swallowing? h. Absent breath sounds It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. c. Take the specimen immediately to the laboratory in an iced container. 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 Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. The following signs and symptoms show the presence of impaired gas exchange: Abnormal breathing rate, rhythm, and depth Nasal flaring Hypoxemia Cyanosis in neonates decreases carbon dioxide Confusion Elevated blood pressure and heart rate A headache after waking up Restlessness Somnolence and visual disturbances Looking For Custom Nursing Paper? Airway obstruction is most often diagnosed with pulmonary function testing. Encourage the patient to see their medical attending physician for approval and safe treatment. d. Testing causes a 10-mm red, indurated area at the injection site. c. Airway obstruction For which problem is this test most commonly used as a diagnostic measure? b. f) 2. was admitted, examination of his nose revealed clear drainage. When does the nurse record the presence of an increased anteroposterior (AP) diameter of the chest? When F.N. b. Select all that apply. a. At the end of the span of care, the patient will be able to have an effective, regular, and improved respiratory pattern within a normal range (12-20 cycles per minute). e. Observe for signs of hypoxia during the procedure. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung parenchyma (alveolar spaces and interstitial tissue). It may also cause hepatitis. Visualize and note some changes when it comes to the color of the skin, quality of mucous production, and nail beds. Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. Fever and vomiting are not manifestations of a lung abscess. 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. St. Louis, MO: Elsevier. Dont forget to include some emergency contact numbers just in case there is an emergency. Provide tracheostomy care every 24 hours. d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. Volume of air inhaled and exhaled with each breath Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. As an Amazon Associate I earn from qualifying purchases. c. Percussion Atelectasis How does the nurse assess the patient's chest expansion? 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 . 5. Outcomes Interventions Rationale with reference Eval of goal/outcomes Gas r/t alveolar- membrane AEB Positive for strep Bi-pap to maintain rhonchi diminished breath bilaterally. Drug therapy is an alternative to avoidance of the allergens, but long-term use of decongestants can cause rebound nasal congestion. b. c. Remove the inner cannula if the patient shows signs of airway obstruction. The turbinates in the nose warm and moisturize inhaled air. a. Deflate the cuff, then remove and suction the inner cannula. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. 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. The other options do not maintain inflation of the alveoli. The syringe used to obtain the specimen is rinsed with heparin before the specimen is taken and pressure is applied to the arterial puncture site for 5 minutes after obtaining the specimen. What is the first patient assessment the nurse should make? This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. 1. RR 24 Select all that apply. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. 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. b. Filtration of air 's airway before and after surgery? d. Pulmonary embolism h. Role-relationship: Loss of roles at work or home, exposure to respiratory toxins at work F. A. Davis Company. 5. c. Take the specimen immediately to the laboratory in an iced container. HR 68 bpm Since the patients body is having difficulty with gas exchange due to pneumonia, it will benefit him/her to have some supplementary oxygen treatment to assist in the demands of the body. Increasing the intake of foods that are high in vitamin C does not decrease exposure to others. Associated with altered oxygenation and alveolar-capillary membrane changes resulting from the inflammatory process and exudate in the lungs. For best yield, blood cultures should be obtained before antibiotics are administered. b. RV: (7) Amount of air remaining in lungs after forced expiration 1. 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. No signs or symptoms of tuberculosis or allergies are evident. A nasal ET tube in place d. Dyspnea and severe sinus pain Viral pneumonia. A 73-year-old patient has an SpO2 of 70%. Shetty, K., & Brusch, J. L. (2021, April 15). Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. 1) b. Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. Assist the patient with position changes every 2 hours. Amount of air exhaled in first second of forced vital capacity Use 1 for the first action and 7 for the last action. Have an initial assessment of the patients respiratory rate, rhythm, and oxygen saturation every 4 hours or depending on the need. h) 3. What priority discharge teaching should the nurse provide? Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. The nurse will gather the supplies as soon as the order to do a thoracentesis is given. Partial obstruction of trachea or larynx This work is the product of the Promote a well-ventilated environment so that the patient will have good oxygen exchange in the body. 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. These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. Teach the importance of complying with the prescribed treatment and medication. This assessment helps ensure that surgical patients remain infection-free, as nosocomial pneumonia has a high morbidity and mortality rate. b. Impaired Gas Exchange; May be related to. d. An electrolarynx placed in the mouth. 3) Illicit drug intake 1) Seizures Allow patients to ask a question or clarify regarding their treatment. Lack of lung expansion caused by kyphosis of the spine results in shallow breathing with decreased chest expansion. Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . 28: Obstructive Pulmonary Diseases. Avoid instillation of saline during suctioning. g. Fine crackles Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. b. Cuff pressure monitoring is not required. When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? Patient with a fever d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult.". Administer analgesics 1/2 hour prior to deep breathing exercises. Ensure that the patient performs deep breathing with coughing exercises at least every 2 hours. All other answers indicate a negative response to skin testing. a. A) Inform the patient that it is one of the side effects of c. Tracheal deviation 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. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. b. A transesophageal puncture The patient has been diagnosed with an early vocal cord cancer. 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. Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). e) 1. 1. Avoid environmental irritants inside the patients room. (2022, January 26). "You should get the inactivated influenza vaccine that is injected every year." All of the assessments are appropriate, but the most important is the patient's oxygen status. Promote oral hygiene, including lip and tongue care. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? To obtain the most information, auscultate the posterior to avoid breast tissue and start at the base because of her respiratory difficulty and the chance that she will tire easily. b. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Steroids: To reduce the inflammation in the lungs. The nurse suspects which diagnosis? 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 Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. - It requires identification of specific, personalized risk factors, such as smoking, advanced age, and obesity. A patient develops epistaxis after removal of a nasogastric tube. Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. f. Use of accessory muscles. When inflamed, the air sacs may produce fluid or pus which can cause productive cough and difficulty breathing.
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