This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). Dont forget to include some emergency contact numbers just in case there is an emergency. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia, https://my.clevelandclinic.org/health/diseases/4471-pneumonia, https://doi.org/10.1111/j.1753-4887.2010.00304.x, https://emedicine.medscape.com/article/234753-overview#a4, Hypertension Nursing Diagnosis & Care Plan, The ABCs of Evidence-Based Practice in Nursing, Diminished lung sounds or crackles/rhonchi, Patient will demonstrate appropriate airway clearance techniques, Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate, Hypoventilation causing a lack of oxygen delivery, Patient will display appropriate oxygenation through ABGs within normal limits, Patient will demonstrate appropriate actions to promote ventilation and oxygenation, Inadequate primary defenses: decreased ciliary action, respiratory secretions, Invasive procedures: suctioning, intubation, Patient will not develop a secondary infection or sepsis, Patient will display improvement in infection evidenced by vital signs and lab values within normal limits. Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Save my name, email, and website in this browser for the next time I comment. The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. b. The pH is also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in venous blood (PvCO2). The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. Discharging the patient is unsafe. A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. b) 6. These interventions contribute to adequate fluid intake. arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period? Notify the health care provider. Remove unnecessary lines as soon as possible. 3.4 Activity Intolerance. - 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. b. (2020). 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 is the first patient assessment the nurse should make? Stridor is identified with auscultation. 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home Productive cough (viral pneumonia may present as dry cough at first). Administer the prescribed antibiotic and anti-pyretic medications. 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. 1# Priority Nursing Diagnosis. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. g. Self-perception-self-concept Partial obstruction of trachea or larynx The patient needs to be able to effectively remove these secretions to maintain a patent airway. When is the nurse considered infected? 1. Supplemental oxygen will help in the increased demand of the body and will lower the risk of having respiratory distress and low oxygen perfusion in the body. d. Positron emission tomography (PET) scan. b. Finger clubbing 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. Tachycardia (resting heart rate [HR] more than 100 bpm). 3. Acid-fast stains and cultures: To rule out tuberculosis. 3.2 Impaired Gas Exchange. a. 4) Recent abdominal surgery. b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. Hopefully the family will have some time to discuss this before they are instructed to leave the room, unless it is an emergency. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. 3.7 Risk for Deficient Fluid Volume. 3. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? Decreased skin turgor and dry mucous membranes as a result of dehydration. 2 8 Nursing diagnosis for pneumonia. Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Bronchodilators: To dilate or relax the muscles on the airways. 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. 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. b. b. Changes in behavior and mental status can be early signs of impaired gas exchange. This patient is older and short of breath. It is also inappropriate to advise the patient to stop taking antitubercular drugs. Are there any collaborative problems? The nurse should assess the patient's cardiopulmonary status with careful monitoring of vital signs, cardiac rhythm, pulse oximetry, arterial blood gases (ABGs), and lung sounds. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. f) 2. Weigh patient daily at same time of day and on same scale; record weight. Suction secretions as needed. RR 24 There is alteration in the normal respiratory process of an individual. This intervention decreases pain during coughing, thereby promoting a more effective cough. 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. Decreased compliance contributes to barrel chest appearance. Impaired Gas Exchange: A Case Study | ipl.org - Internet Public Library f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. 2. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? - 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. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. e. FVC d. Oxygen saturation by pulse oximetry If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. b. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. e. Decreased functional immunoglobulin A (IgA). e. Sleep-rest Basket stars are active at night. d. Testing causes a 10-mm red, indurated area at the injection site. Concept Map-AHI - Concept Mapping Nursing diagnosis: Impaired gas The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. c. Mucociliary clearance 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. 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. Select all that apply. Report significant findings. Bacterial Pneumonia. Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, have respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96%, and verbalize ease of breathing. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Periorbital and facial edema reduced by about half since second hospital day The nurse must understand how to monitor for worsening infection, complications, and the rationales for treatment. This also increases the risk for aspiration pneumonia. Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. 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. b. a. Pockets of pus may form inside the lungs or on their outer layers. 26: Upper Respiratory Problems / CH. Impaired Gas Exchange Symptoms Care Plan | Nursing Diagnosis Writing e. Increased tactile fremitus Impaired Gas Exchange This COPD nursing diagnosis may be related to bronchospasm, air-trapping and obstruction of airways, alveoli destruction, and changes in the alveolar-capillary membrane. Suctioning keeps the airway clear by removing secretions. Respiratory infection 3. a. If the patient is ambulatory, walking should be encouraged within the patients tolerance. Unless contraindicated, promote fluid intake (2.5 L/day or more). Consider sources of infection.Any inserted lines such as IVs, urinary catheters, feedings tubes, suction tubing, or ventilation tubes are potential sources of infection. a. Assess the patient for iodine allergy. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives. 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. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. What other assessment should the nurse consider before making a judgment about the adequacy of the patient's oxygenation? a. Esophageal speech Always wear gloves on both hands for suctioning. Educating him/her to use the incentive spirometer will encourage him/her to exercise deep inspiration that will help get more oxygen in the lungs and prevent hypoxia. c. An electrolarynx held to the neck Signs and symptoms of respiratory distress include agitation, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory respiratory muscles. Match the following pulmonary capacities and function tests with their descriptions. Priority: Management of pneumonia and dehydration. Subjective Data b. Filtration of air An ET tube has a higher risk of tracheal pressure necrosis. c. Percussion A pulmonary angiogram involves the injection of an iodine-based radiopaque dye, and iodine or shellfish allergies should be assessed before injection. Expresses concern about his facial appearance Nursing Management of COVID-19 | EveryNurse.org 3. Always change the suction system between patients. 1) The cough may last from 6 to 10 weeks. 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. a. Stridor 6) The patient is infectious from the beginning of the first stage c. Mucociliary clearance b. SpO2 of 95%; PaO2 of 70 mm Hg Bronchoconstriction 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. (2022, January 26). k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. Assist the patient when they are doing their activities of daily living. a. 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. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. i. Sexuality-reproductive: Sexual activity altered by respiratory symptoms Medscape Reference. Discuss to the patient the different types of pneumonia and the difference between him/her. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. F. A. Davis Company. b. b. Surfactant 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 Learn how your comment data is processed. Impaired gas exchange is a nursing diagnosis for a patient suffering current or future problems with oxygen/carbon dioxide balance (unknown, 2012). g. FEV1 If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. f. A physician performs the first tracheostomy tube change 2 days after the tracheostomy. 5. c. Ventilation-perfusion scan 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. Facilitate coordination within the care team to allow rest periods between care activities. Pneumonia may increase sputum production causing difficulty in clearing the airways. Expected outcomes When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? Dyspnea and severe sinus pain as well as tender swollen glands, severe ear pain, or significantly worsening symptoms or changes in sputum characteristics in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. a. b. a hemilaryngectomy that prevents the need for a tracheostomy. Start oxygen administration by nasal cannula at 2 L/min. Assess intake and output (I&O). 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. 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. Volume of air in lungs after normal exhalation, a. Vt: (3) Volume of air inhaled and exhaled with each breath Pneumonia Nursing Care Plans - 11 Nursing Diagnosis - Nurseslabs Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. Nursing diagnosis Related factors Defining characteristics Examples of this type of nursing diagnosis include: Decreased cardiac output Chronic functional constipation Impaired gas exchange Problem-focused nursing diagnoses are typically based on signs and symptoms present in the patient. Provide tracheostomy care. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. Hyperkalemia is not occurring and will not directly affect oxygenation initially. (n.d.). b. The 150 mL of air is dead space in the trachea and bronchi. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. 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. What action should the nurse take? A repeat skin test is also positive. Major nursing care planning goals for COVID-19 may include: Establishing goals, interventions. Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. A specimen of the sputum, which is yellow, has been obtained, but the laboratory results are pending. During the day, basket stars curl up their arms and become a compact mass. Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. Atelectasis a. The patient is infectious from the beginning of the first stage through the third week after onset of symptoms or until five days after antibiotic therapy has been started. 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. a. Pneumonia Nursing Care Plan & Management - RNpedia d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. Cleveland Clinic. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. b. Buy on Amazon. a. impaired gas exchange nursing care plan scribd Add heparin to the blood specimen. c. Decreased chest wall compliance Impaired Gas Exchange; May be related to. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. 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 Pneumonia Nursing Diagnosis & Care Plan | NurseTogether Adjust the room temperature. The nurse presents education about pertussis for a group of nursing students and includes which information? 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). Encourage coughing up of phlegm. d. Pleural friction rub. It involves the inflammation of the air sacs called alveoli. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. The immunity will not protect for several years, as new strains of influenza may develop each year. Severe pneumonia can be life-threatening for patients who are very young, very old (age 65 and above), and immunocompromised (e.g. b. Cyanosis Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. 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. d. Dyspnea and severe sinus pain 6. 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. Community-Acquired Pneumonia. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. Empyema is a collection of pus in the thoracic cavity. 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. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? c. Wheezes (2020, June 15). Pneumonia. 3. 7. The patient may have a limit to visitors to prevent the transmission of infections. An open reduction and internal fixation of the tibia were performed the day of the trauma. 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. Health perception-health management Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. a. Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. b. Epiglottis through the second week after the onset of symptoms. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. a. d. Auscultation. 2018.03.29 NMNEC Leadership Council. b. RV: (7) Amount of air remaining in lungs after forced expiration Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. a. When does the nurse record the presence of an increased anteroposterior (AP) diameter of the chest? Elevate the head of the bed and assist the patient to assume semi-Fowlers position. Remove excessive clothing, blankets and linens. Assess the ability and effectiveness of cough.Pneumonia infection causes inflammation and increased sputum production. What keeps alveoli from collapsing? nursing care plan for pneumonia nursing care plan for stroke nursing care . Discuss to him/her the different pros and cons of complying with the treatment regimen. A bronchoscopy requires NPO status for 6 to 12 hours before the test, and invasive tests (e.g., bronchoscopy, mediastinoscopy, biopsies) require informed consent that the HCP should obtain from the patient. The bacteria may enter the blood stream and cause, Trouble sleeping. The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. Associated with altered oxygenation and alveolar-capillary membrane changes resulting from the inflammatory process and exudate in the lungs. symptoms. 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. He or she will also comply and participate in the special treatment program designed for his or her condition. b. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? a. Stridor d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). Sleep disturbance related to dyspnea or discomfort 6. b. Surfactant c. Lateral sequence Recognize the risk factors for infection in patients with tracheostomy and take the following actions: Risk factors include the presence of underlying pulmonary disease or other serious illness, increased colonization of the oropharynx or trachea by aerobic gram-negative bacteria, increased bacterial access to the lower airway, and cross-contamination from manipulation of the tracheostomy tube. What measures should be taken to maintain F.N. F.N. e. Teach the patient about home tracheostomy care. Touching an infected object and then touching your nose or mouth can also transfer the germs. associated with increased fluid loss in the presence of tachypnea, fever, or diaphoresis Desired outcome: at least 24 hours before hospital discharge, the patient is normovolemic, i.e., has a urine output of 30 mL/h or greater, stable weight, heart rate less than 100 bpm, blood pressure greater than 90 mm Hg, fluid intake equal to fluid excretion, moist mucous membranes, and normal skin turgor. 2. Pleural Effusion Nursing Diagnosis & Care Plan - RNlessons Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. Provide tracheostomy care. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. 2) It is a highly contagious respiratory tract infection. Visualize and note some changes when it comes to the color of the skin, quality of mucous production, and nail beds. Identify up to what extent does the patient knows about pneumonia. 5) Minimize time in congregate settings. Amount of air that can be quickly and forcefully exhaled after maximum inspiration Also called nosocomial pneumonia, this type of pneumonia originates from being admitted in the hospital. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case.