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. Pulmonary function tests are noninvasive. Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. Surfactant is a lipoprotein that lowers the surface tension in the alveoli. Encourage coughing up of phlegm. is a 28-year-old male patient who sustained bilateral fractures of the nose, 3 rib fractures, and a comminuted fracture of the tibia in an automobile crash 5 days ago. Bronchodilators: To dilate or relax the muscles on the airways. What is a nursing diagnosis for impaired gas exchange? This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. Respiratory distress requires immediate medical intervention. Subjective Data e) 1. 6. d. Assess the patient's swallowing ability. d. Small airway closure earlier in expiration a. Esophageal speech Care Plan for Ineffective Gas Exchange, Ineffective Airway Clearance Document the results in the patient's record. Poor peripheral perfusion that occurs with hypovolemia or other conditions that cause peripheral vasoconstriction will cause inaccurate pulse oximetry, and ABGs may have to be used to monitor oxygenation status and ventilation status in these patients. 8 . The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. Pleurisy, a) 7. The patient will have improved gas exchange. 2023 Nursing Diagnosis Guide | Examples, List & Types - Nurse.org Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being. Saunders comprehensive review for the NCLEX-RN examination. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. Shetty, K., & Brusch, J. L. (2021, April 15). I have a list of nursing diagnoses like acute pain r/t surgery, ineffective peripheral tissue perfusion r/t immobility or abdominal surgery, anxiety r/t change in health, impaired gas exchange r/t decreased functional lung tissue, ineffective airway clearance r/t inflammation and presence of secretion, i also have risk for infection - invasive Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. Acid-fast stains and cultures: To rule out tuberculosis. 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. Remove unnecessary lines as soon as possible. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. St. Louis, MO: Elsevier. The treatment and medication should be prescribed by the attending physician and do not take meds that are not prescribed to prevent unnecessary drug interaction. 6) a. Verify breath sounds in all fields. Medications such as paracetamol, ibuprofen, and. To regulate the temperature of the environment and make it more comfortable for the patient. b. Cyanosis Maximum amount of air lungs can contain F.N. f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. Assess intake and output (I&O). 2018.03.29 NMNEC Leadership Council. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. 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 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? It may also cause hepatitis. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? Monitor oximetry values; report O2 saturation of 92% or less. 3. patients with pneumonia need assistance when performing activities of daily living. The immunity will not protect for several years, as new strains of influenza may develop each year. Select all that apply. g) 4. 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. A) Sit the patient up in bed as tolerated and apply A patient with a 10-year history of regular (three beers per week) alcohol consumption began taking rifampin to treat tuberculosis (TB). The patient has been diagnosed with an early vocal cord cancer. c. "An annual vaccination is not necessary because previous immunity will protect you for several years." This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days. d. Notify the health care provider of the change in baseline PaO2. 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 Breath sounds in all lobes are verified to be sure that there was no damage to the lung. The turbinates in the nose warm and moisturize inhaled air. a. Apex to base 2 8 Nursing diagnosis for pneumonia. It may also stimulate coughing. c. There is equal but diminished movement of the 2 sides of the chest. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. h. Role-relationship Before other measures are taken, the nurse should check the probe site. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. Thorough hand hygiene before and after patient contact (even if gloves are worn). Provide tracheostomy care. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. 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. 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. It involves the inflammation of the air sacs called alveoli. Pink, frothy sputum would be present in CHF and pulmonary edema. A) Inform the patient that it is one of the side effects of e. FVC Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. 1. 7) c. Send labeled specimen containers to the laboratory. 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. a. Weigh patient daily at same time of day and on same scale; record weight. Pneumonia can be mild but can also be fatal if left untreated. A prominent protrusion of the sternum is the pectus carinatum and diminished movement of both sides of the chest indicates decreased chest excursion. 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. Nursing Care Plan Patient's Name: Baby M Medical Diagnosis: Pediatric Community Acquired Pneumonia Nursing Diagnosis: Impaired gas exchange r/t collection of secretions affecting oxygen exchange across alveolar membrane. 2/21/2019 Compiled by C Settley 10. Exercise and activity help mobilize secretions to facilitate airway clearance. Stop feeding when the patient is lying flat. e. Increased tactile fremitus 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. d. Parietal pleura. c. Turbinates b. Copious nasal discharge 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). Which action does the nurse take next? This produces an area of low ventilation with normal perfusion. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. b. 2) d. Direct the family members to the waiting room. Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. The nurse should keep the patient on bed rest in a semi-Fowler's position to facilitate breathing. Bacteremia. 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. 3.2 Impaired Gas Exchange. e. Increased tactile fremitus Assess for mental status changes.Poor oxygenation leads to decreased perfusion to the brain resulting in a decreased level of consciousness, restlessness, agitation, and lethargy. Impaired Gas Exchange: A Case Study | ipl.org - Internet Public Library Learning to apply information through a return demonstration is more helpful than verbal instruction alone. a. Suction the tracheostomy. Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. 2. c. Mucociliary clearance d. Patient receiving oxygen therapy. Select all that apply. Assess for mental status changes. c. Terminal structures of the respiratory tract b. Smoking does not directly affect filtration of air, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody).