impaired gas exchange nursing diagnosis pneumonia

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). Urinary antigen test: To detect Legionella pneumophila and Streptococcus pneumoniae. 3.2 Impaired Gas Exchange. 3. 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 Intervene quickly if respiratory rate increases, breathing becomes labored, accessory muscles are used, or oxygen saturation levels drop. As an Amazon Associate I earn from qualifying purchases. d. Patient receiving oxygen therapy. The nurse expects which treatment plan? 2) d. Direct the family members to the waiting room. Order stat ABGs to confirm the SpO2 with a SaO2. d. Patient can speak with an attached air source with the cuff inflated. Maximum rate of airflow during forced expiration Bronchodilators: To dilate or relax the muscles on the airways. 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. Has been NPO since midnight in preparation for surgery patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. Expected outcomes Partial obstruction of trachea or larynx Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. A patient develops epistaxis after removal of a nasogastric tube. 1) The cough may last from 6 to 10 weeks. These critically ill patients have a high mortality rate of 25-50%. Long-term denture use What is the first patient assessment the nurse should make? 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. d. Contain dead air that is not available for gas exchange. The arterial oxygen saturation by pulse oximetry (SpO2) compared with normal values will not be helpful in this older patient or in a patient with respiratory disease as the patient's expected normal will not be the same as standard normal values. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. Fever reducers and pain relievers. a. Provide tracheostomy care every 24 hours. Which instructions does the nurse provide for the patient? Inspection F.N. d. Testing causes a 10-mm red, indurated area at the injection site. A 73-year-old patient has an SpO2 of 70%. These interventions contribute to adequate fluid intake. Place or install an air filter in the room to prevent the accumulation of dust inside. a. 4. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. A nasal ET tube in place Nursing Diagnosis: Impaired Gas Exchange related to decreased lung compliance and altered level of consciousness as evidence by dyspnea on exertion, decreased oxygen content, decreased oxygen saturation, and increased PCO2. 3.7 Risk for Deficient Fluid Volume. Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. Types of Nursing Diagnoses There are 4 types of nursing diagnoses. Antibiotics: To treat bacterial pneumonia. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. Impaired gas exchange 5. 3.1 Ineffective airway clearance. a. A patient's initial purified protein derivative (PPD) skin test result is positive. 2. Obtain the supplies that will be used. 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 transesophageal puncture d. The need to use baths instead of showers for personal hygiene, What is the most normal functioning method of speech restoration for the patient with a total laryngectomy? Apply pressure to the puncture site for 2 full minutes. The position of the oximeter should also be assessed. 2. A) Purulent sputum that has a foul odor b. Our website services and content are for informational purposes only. A less severe form of bacterial pneumonia is called walking or atypical pneumonia, in which the symptoms are very mild and the infected person can do his/her activities of daily living as normal. Administer oxygen with hydration as prescribed. Please read our disclaimer. c. Take the specimen immediately to the laboratory in an iced container. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. Provide tracheostomy care. c. Drainage on the nasal dressing Oxygen is administered when O2 saturation or ABG results show hypoxemia. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. 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. Oximetry: May reveal decreased O2 saturation (92% or less). Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. Give supplemental oxygen treatment when needed. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. 2/21/2019 Compiled by C Settley 10. 4. Chronic hypoxemia g. Self-perception-self-concept: Chest pain or pain with breathing Inability to maintain lifestyle, altered self-esteem Turbinates warm and moisturize inhaled air. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. How does the nurse respond? 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. (2020, June 15). She earned her BSN at Western Governors University. Elevate the head of the bed and assist the patient to assume semi-Fowlers position. Nursing diagnosis: Deficient knowledge about the disease process and treatment of pneumonia related to lack of information as evidenced by failure to comply with treatment. The nurse presents education about pertussis for a group of nursing students and includes which information? Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. 3. 1) Increase the intake of foods that are high in vitamin C. If the patient is having increased mucous production, encourage him or her to clear the airway. d. Apply an ice pack to the back of the neck. 1. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. See Table 25.8 for more thorough descriptions of these sounds and their possible etiologies and significance. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. The prognosis of a patient with PE is good if therapy is started immediately. Adjust the room temperature. Avoid instillation of saline during suctioning. 2. h. FRC: (8) Volume of air in lungs after normal exhalation. Decreased force of cough Position the patient on the side. Proper nutrition promotes energy and supports the immune system. The other options contribute to other age-related changes. Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. The nurse should instruct on how to properly use these devices and encourage their use hourly. b. Impaired gas improved or presence of retained secretions client: exchange ventilation and adventitious sound -Demonstrated adequate improved wheezes oxygenation of -Decrease of ventilation and tissues by ABG of: -Palpate for fremitus vibratory tremors adequate pH:7.35-7.45 suggest fluid oxygenation of d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration What should be the nurse's first action? Teach the patient some useful relaxation techniques and diversional activities such as proper deep breathing exercises. d) 8. d. Assess the patient's swallowing ability. In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity Changes in behavior and mental status can be early signs of impaired gas exchange. Impaired cardiac output He or she will also comply and participate in the special treatment program designed for his or her condition. d. A tracheostomy tube and mechanical ventilation, What should the nurse include in discharge teaching for the patient with a total laryngectomy? Wear gloves on both hands when handling the cannula or when handling ventilation tubing. 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. Corticosteroids and bronchodilators are not useful in reducing symptoms. Nursing care plan for impaired gas exchange. Pneumonia Nursing Care Plan 4 Impaired Gas Exchange Nursing Diagnosis: Impaired Gas Exchange related to the overproduction of mucus in the airway passage secondary to pneumonia as evidenced by cyanosis, restlessness, and irritability. a. c. Use cromolyn nasal spray prophylactically year-round. Decreased functional cilia Pneumonia can be hospital-acquired, which presents after the patient has been admitted for 2 days. c. Inadequate delivery of oxygen to the tissues It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. f. Use of accessory muscles. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. a. Stridor A) Increasing fluids to at least 6 to 10 glasses/day, unless. 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. Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. c. TLC a. Nutrition reviews, 68(8), 439458. d. SpO2 of 88%; PaO2 of 55 mm Hg b. treatment with antifungal agents. Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. b. The postoperative use of nonverbal communication techniques 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. Medications such as paracetamol, ibuprofen, and. 27: Lower Respiratory Problems / CH. Obtain a sputum sample for culture.If the patient can cough, have them expectorate sputum for testing. 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 Etiology The most common cause for this condition is poor oxygen levels. Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. 1. What covers the larynx during swallowing? Changes in oxygen therapy or interventions should be avoided for 15 minutes before the specimen is drawn because these changes might alter blood gas values. Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? 1) b. 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. Preventing the spread of coronavirus infection to the patient's family members, community, and healthcare providers. 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. Thorough hand hygiene before and after patient contact (even if gloves are worn). b. Impaired gas exchange is a risk nursing diagnosis for pneumonia. The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? Document the results in the patient's record. c. Explain the test before the patient signs the informed consent form. It is very important to take and record the patients respiratory assessment to make it a basis if there are any abnormal findings in the future. 3.6 Risk for imbalanced nutrition: less than body requirements. d. Use over-the-counter antihistamines and decongestants during an acute attack. The home health nurse provides which instruction for a patient being treated for pneumonia? a. Apex to base 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 . A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. 7. Nursing Diagnosis related to --- as evidence by---Impaired gas exchange related to inflammation of airways, fluid-filled alveoli, and collection of mucus in the airway as evidenced by dyspnea and tachypnea (Carpenito, 2021). 7. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. c. Empyema Assess the need for hyperinflation therapy. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. Discuss to him/her the different pros and cons of complying with the treatment regimen. It reduces the pressure needed to inflate the alveoli and decreases the tendency of the alveoli to collapse. Aspiration pneumonia is a nonbacterial (anaerobic) cause of hospital-associated pneumonia that results from aspiration of gastric contents. The visceral pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. What is a primary nursing responsibility after obtaining a blood specimen for ABGs? Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). She found a passion in the ER and has stayed in this department for 30 years. b. Discussion Questions A repeat skin test is also positive. Place the patient in a comfortable position. Allow 90 minutes for. symptoms. Diminished breath sounds are linked with poor ventilation. A knowledgeable patient is more likely to comply with therapy. c. An electrolarynx held to the neck 56 Skip to document Ask an Expert Sign inRegister Sign inRegister Home Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. 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. c. a throat culture or rapid strep antigen test. These interventions help ensure that the patient has the appropriate knowledge and is able to perform these activities. 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. c. Encourage deep breathing and coughing to open the alveoli. Pulmonary function test This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. Water, hydration, and health. Nursing diagnoses handbook: An evidence-based guide to planning care. A) Pneumonia Respiratory infection 3. 26: Upper Respiratory Problems / CH. What the oxygenation status is with a stress test "You should get the inactivated influenza vaccine that is injected every year." 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. Which immediate action does the nurse take? b. Increase heat and humidity if patient has persistent secretions. b. Surfactant This is most common in intensive care units usually resulting from intubation and ventilation support. e. Increased tactile fremitus Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. Decreased skin turgor and dry mucous membranes as a result of dehydration. As a result of the inflammation, the lung tissue becomes edematous and the air spaces fill with exudate (consolidation), gas exchange cannot occur, and non-oxygenated blood is diverted into the vascular system, resulting in hypoxemia. A patient started treatment for sputum smear-positive tuberculosis (TB) 1 week prior to the home health nurse's visit. Fever and vomiting are not manifestations of a lung abscess. Amount of air that can be quickly and forcefully exhaled after maximum inspiration Major nursing care planning goals for COVID-19 may include: Establishing goals, interventions. 3. To help alleviate cough and allow the patient to rest, cough suppressants may be given at low doses. Before other measures are taken, the nurse should check the probe site. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. cancer patients or COPD patients). b. Ventilation-perfusion scans and positron emission tomography (PET) scans involve injections, but no manipulation of the respiratory tract is involved. 3. St. Louis, MO: Elsevier. (n.d.). Decreased functional cilia 3.5 Acute Pain. 1. d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult.". 1. 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. Priority: Management of pneumonia and dehydration. 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. Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Stridor is a continuous musical or crowing sound and unrelated to pneumonia. 2. Immunosuppression and neutropenia are predisposing factors for the development of nosocomial pneumonia caused by common and uncommon pathogens. Maximum amount of air lungs can contain Administer analgesics 1/2 hour prior to deep breathing exercises. d. Comparison of patient's current vital signs with normal vital signs Normal findings in arterial blood gases (ABGs) in the older adult include a small decrease in PaO2 and arterial oxygen saturation (SaO2) but normal pH and PaCO2. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). A) Use a cool mist humidifier to help with breathing. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. Consider using a closed suction system; replace closed suction system according to agency guidelines. The patient will have improved gas exchange. The nurse identifies which factor that places a patient at risk for aspiration pneumonia? e. Decreased functional immunoglobulin A (IgA). (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. If there is airway obstruction this will only block and cause problems in gas exchange. c. Elimination Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue? 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. d. Bradycardia Exercise most especially in the lungs plays the importance in promoting respiratory conditioning and it is also vital for the patients well-being.

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