Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual. 1. 6. Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. a. Carina 1. c) 5. Which values indicate a need for the use of continuous oxygen therapy? 3 Pneumonia in the immunocompromised individual 4 Assessment of pneumonia 5 Diagnostic test for pneumonia 6 Nursing Diagnosis of pneumonia 6.1 Risk for Infection (nosocomial pneumonia) 6.2 Impaired Gas Exchange due to pneumonic condition 6.3 Ineffective clearance of the airway 6.4 Deficient fluid volume Community acquired pneumonias Impaired gas exchange is caused by conditions such as pneumonia, chronic obstructive pulmonary disease (COPD), or asthma. f. Instruct the patient not to talk during the procedure. g. FEV1: (1) Amount of air exhaled in first second of forced vital capacity 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. 3. 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. Refer to a community-based smoking cessation program or offer nicotine replacement therapy as needed. Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. If the patient is enteral fed, recommend continuous rather than bolus feeding. There is no redness or induration at the injection site. 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). In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. c. Keep a same-size or larger replacement tube at the bedside. Assess intake and output (I&O). a. c. Take the specimen immediately to the laboratory in an iced container. e. Increased tactile fremitus 5) e. Observe for signs of hypoxia during the procedure. Provide tracheostomy care every 24 hours. What is the reason for delaying repair of F.N. Why is the air pollution produced by human activities a concern? A) Inform the patient that it is one of the side effects of Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. a. Stridor Pockets of pus may form inside the lungs or on their outer layers. patients with pneumonia need assistance when performing activities of daily living. Change ventilation tubing according to agency guidelines. b. Consider imperceptible losses if the patient is diaphoretic and tachypneic. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. Bronchodilators: To dilate or relax the muscles on the airways. Assess the patients vital signs and characteristics of respirations at least every 4 hours. Assess the need for hyperinflation therapy. 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 Health perception-health management c. Place the thumbs at the midline of the lower chest. a. Thoracentesis Nursing care plans: Diagnoses, interventions, & outcomes. Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. To facilitate the body in cooling down and to provide comfort. The patient needs to be able to effectively remove these secretions to maintain a patent airway. d. Testing causes a 10-mm red, indurated area at the injection site. 2. Avoid environmental irritants inside the patients room. Please follow your facilities guidelines, policies, and procedures. When F.N. To help clear thick phlegm that the patient is unable to expectorate. Tylenol) administered. b. Unstable hemodynamics 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. These measures ensure consistency and accuracy of weight measurements. The patient is positioned and instructed not to talk or cough to avoid damage to the lung. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. Lung abscess. Nursing Care Plan 2 The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. 1. b. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance. a. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. Make sure to avoid flowers, strong smell scents, dust, and other allergens that are present in the room. e. Sleep-rest: Sleep apnea. Observing for hypoxia is done to keep the HCP informed. Place the patient in a comfortable position. Select all that apply. Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. Touching an infected object and then touching your nose or mouth can also transfer the germs. Antibiotics: To treat bacterial pneumonia. Decreased or random breath sounds (e.g., crackles, wheezes) may indicate possible respiratory failure, which would further exacerbate hypoxia and require immediate intervention. Change the tube every 3 days. c. Check the position of the probe on the finger or earlobe. 2) It is a highly contagious respiratory tract infection. 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). If there are some questions or clarifications when it comes to their medicines, make sure to find time to explain to him/her so that this will ensure compliance with the treatment. 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. Give health teachings about the importance of taking prescribed medication on time and with the right dose. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. 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. Abnormal. It must include the local 911 numbers, hospitals, and immediate keen of the patient. With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. A) 1, 2, 3, 4 Individuals with depressed level of consciousness, advanced age, dysphagia, or a nasogastric (NG) or enteral tube are at increased risk for aspiration, which predisposes them to pneumonia. patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. d. Comparison of patient's current vital signs with normal vital signs. Volcanic eruptions and other natural events result in air pollution. Start asking what they know about the disease and further discuss it with the patient. 8. Assess lab values.An elevated white blood count is indicative of infection. The available treatments of pneumonia can give a good prognosis to the patient for as long as he or she complies with it. 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. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. Patient Profile F.N. An SpO2 of 88% and a PaO2 of 55 mm Hg indicate inadequate oxygenation and are the criteria for continuous oxygen therapy (see Table 25.10). 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). Reports facial pain at a level of 6 on a 10-point scale RR 24 Air trapping Notify the health care provider. Help the patient get into a comfortable position, usually the half-Fowler position. b. b. Palpation 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. c. TLC: (2) Maximum amount of air lungs can contain c. Terminal structures of the respiratory tract Administer antibiotics.A diagnosis of pneumonia will warrant antibiotic treatment. Maximum amount of air that can be exhaled after maximum inspiration Pneumonia will be one of the most frequent infections the nurse will encounter and treat. a. 1. Complains of dry mouth Most of the cases of poor prognosis of pneumonia are undertreatment or not being able to be assessed earlier. This intervention decreases pain during coughing, thereby promoting a more effective cough. Finger clubbing and accessory muscle use are identified with inspection. After which diagnostic study should the nurse observe the patient for symptoms of a pneumothorax? c. Wheezing Pneumonia can be mild but can also be fatal if left untreated. Report significant findings. General physical assessment findingsof pneumonia. a. Suction the tracheostomy. c. a throat culture or rapid strep antigen test. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung.