Match the following pulmonary capacities and function tests with their descriptions. Impaired Gas Exchange Thisnursing diagnosis for asthma relates to the decreased amount of air that is exchanged during inspiration and expiration. Being aware of the patient's condition, what approach should the nurse use to assess the patient's lungs (select all that apply)? Maximum amount of air that can be exhaled after maximum inspiration 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. d. Inform the patient that radiation isolation for 24 hours after the test is necessary. Encourage rest and limit exertion.Patients may not be able to tolerate too much activity. Her experience spans almost 30 years in nursing, starting as an LVN in 1993. c. TLC How does the nurse respond? The patient may have a limit to visitors to prevent the transmission of infections. f. PEFR: (6) Maximum rate of airflow during forced expiration Select all that apply. Fatigue 4. b. CO2 causes an increase in the amount of hydrogen ions available in the body. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. a. b. Epiglottis A patient's initial purified protein derivative (PPD) skin test result is positive. Apply pressure to the puncture site for 2 full minutes. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. d. VC: (4) Maximum amount of air that can be exhaled after maximum inspiration What do these findings indicate? Dont forget to include some emergency contact numbers just in case there is an emergency. 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 . Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs. Nurses should assess for and encourage pneumonia vaccines for eligible populations. b. Identify patients at increased risk for aspiration. a. c. Turbinates Obtain the supplies that will be used. Avoid environmental irritants inside the patients room. 5) Corticosteroids and bronchodilators are helpful in reducing 3. 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. 3.7 Risk for Deficient Fluid Volume. Health perception-health management However, it is highly unlikely that TB has spread to the liver. Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention. 6. a. c. Lateral sequence 5) Minimize time in congregate settings. 8 . 's nose for several days after the trauma? a. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. c. Tracheal deviation Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Impaired gas exchange is closely tied to Ineffective airway clearance. Allow the patient to have enough bed rest and avoid strenuous activities. A closed-wound drainage system d. Direct the family members to the waiting room. Advise individuals who smoke to stop smoking, especially during the preoperative and postoperative periods. 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. Desired Outcome: At the end of the span of care, the patient will be able to understand the transmission, disease process, and available treatments for pneumonia. 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. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature. 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. Decreased skin turgor and dry mucous membranes as a result of dehydration. Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. The patient may demonstrate abnormal breathing, difficulty breathing (dyspnea), restlessness, and inability to tolerate activity. 2. Shetty, K., & Brusch, J. L. (2021, April 15). Assess breath sounds, respiratory rate and depth, sp02, blood pressure and heart rate, and capillary refill to monitor for signs of hypoxia and changes in perfusion. This is an expected finding with pneumonia, but should not continue to rise with treatment. Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO2 and an increased PaCO2. Wear gloves on both hands when handling the cannula or when handling ventilation tubing. 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. b. b. treatment with antifungal agents. The nurse suspects which diagnosis? 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. 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. To assess the extent and symmetry of chest movement, the nurse places the hands over the lower anterior chest wall along the costal margin and moves them inward until the thumbs meet at the midline and then asks the patient to breathe deeply and observes the movement of the thumbs away from each other. i. Sexuality-reproductive b. Epiglottis The other options contribute to other age-related changes. One way to have a good prognosis and help fasten recovery is to comply with the prescribed treatment. It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. What keeps alveoli from collapsing? Impaired gas exchange 5. The width of the chest is equal to the depth of the chest. What is the significance of the drainage? a. Esophageal speech Viral pneumonia. Give health teachings about the importance of taking prescribed medication on time and with the right dose. c. Determine the need for suctioning. If O2 saturation does not increase to an acceptable level (greater than 92%), FiO2 is increased in small increments while simultaneously checking O2 saturation or obtaining ABG values. 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. The trachea connects the larynx and the bronchi. Etiology The most common cause for this condition is poor oxygen levels. Implement NPO orders for 6 to 12 hours before the test. 3) g. Position the patient sitting upright with the elbows on an over-the-bed table. Always maintain sterility or aseptic techniques when performing any invasive procedure. Assist the patient with position changes every 2 hours. c. Inadequate delivery of oxygen to the tissues 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. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. A tracheostomy is safer to perform in an emergency. 1. Encourage movement and positioning.Mobile patients should be encouraged to ambulate several times a day to mobilize secretions. b. Unstable hemodynamics Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. presence of nasal bleeding and exhalation grunting. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Community-Acquired Pneumonia. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. Respiratory infection 3. 6) Minimize time on public transportation. The immunity will not protect for several years, as new strains of influenza may develop each year. c. Mucociliary clearance To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. 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 Assess for mental status changes. 3. d. Self-help groups and community resources for patients with cancer of the larynx, When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? The most common. Order stat ABGs to confirm the SpO2 with a SaO2. 27: Lower Respiratory Problems / CH. The bacteria may enter the blood stream and cause, Trouble sleeping. 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. h. FRC: (8) Volume of air in lungs after normal exhalation. b. Antibiotics: To treat bacterial pneumonia. What is the first action the nurse should take? Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. a. Undergo weekly immunotherapy. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. F.N. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. 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. - Sputum associated with pneumonia may be green, yellow, or even rust colored (bloody). Palpation identifies tracheal deviation, limited chest expansion, and increased tactile fremitus. Promote fluid intake (at least 2.5 L/day in unrestricted patients). Adjust the room temperature. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time. The nurse provides care for a patient with a suspected lung abscess and expects which assessment finding? 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. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Coarse crackling sounds are a sign that the patient is coughing. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). c. Check the position of the probe on the finger or earlobe. Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. What accurately describes the alveolar sacs? This assessment monitors the trend in fluid volume. 3. e. Teach the patient about home tracheostomy care. g. Fine crackles b. Cyanosis c. Comparison of patient's SpO2 values with the normal values a. b. d. Contain dead air that is not available for gas exchange. What covers the larynx during swallowing? Pulse oximetry is inaccurate if the probe is loose, if there is low perfusion, or when skin color is dark. A relative increase in antibody titers indicates viral infection. Hospital acquired pneumonia may be due to an infected. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. 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). 2. Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake. These interventions contribute to adequate fluid intake. Periorbital and facial edema reduced by about half since second hospital day Because antibody production in response to infection with the tuberculosis (TB) bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, 2-step testing is recommended for individuals likely to be tested often, such as health care professionals. Assess the patients knowledge about Pneumonia. Turbinates warm and moisturize inhaled air. 6) a. Verify breath sounds in all fields. a. Carina The bacteria or virus is often spread by droplets through coughing or sneezing that the person then inhales. Administer the prescribed airway medications (e.g. d. Positron emission tomography (PET) scan. - Pertussis is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis. Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). 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. d. Thoracic cage. Gram-negative pneumonia is associated with a high mortality rate, even with appropriate antibiotic therapy. 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. Try to use words that can be understood by normal people. A knowledgeable patient is more likely to comply with therapy. To detect presence of hypernatremia, hyperglycemia, and/or dehydration. 2) It is a highly contagious respiratory tract infection. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. Liver damage can lead to jaundice, which usually presents as yellowish discoloration of urine and sclera. oxygen. b. a. TB Coughing and difficulty of breathing may cause. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. When inflamed, the air sacs may produce fluid or pus which can cause productive cough and difficulty breathing. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. Decreased functional cilia 4. Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. To care for the tracheostomy appropriately, what should the nurse do? a. However, with increasing respiratory distress, respiratory acidosis may occur. Impaired Gas Exchange Assessment 1. 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. c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. The patient will also be able to reach maximum lung expansion with proper ventilation to keep up with the demands of the body. Breath sounds in all lobes are verified to be sure that there was no damage to the lung. Thorough hand hygiene before and after patient contact (even if gloves are worn). A) Teaching the patient how to cough effectively and. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. d. Apply an ice pack to the back of the neck. b. RV a. a. Thoracentesis Support (splint) the surgical wound with hands, pillows, or a folded blanket placed firmly over the incision site. 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. a. Change ventilation tubing according to agency guidelines. Complications include hyperventilation, gastric hyperinflation, headache, hypotension, and signs and symptoms of pneumothorax (shortness of breath, stabbing chest pain, decreased breath sounds on one side, dyspnea, cough). Use a sterile catheter for each suctioning procedure. The alcohol intake of the patient is within normal limits, so it is not correct to say that alcohol may have damaged the liver. 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 c. Course crackles Arrange the tasks of the patient when providing care to him/her. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? How to use a mirror to suction the tracheostomy The nurse expects which treatment plan? Assessing altered skin integrity risks, fatigue, impaired comfort, gas exchange, nutritional needs, and nausea. Objective Data This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. 2. Activity intolerance 2. A Code Blue would not be called unless the patient experiences a loss of pulse and/or respirations. Identify up to what extent does the patient knows about pneumonia. Pleural friction rub occurs with pneumonia and is a grating or creaking sound. a. Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. c. Decreased chest wall compliance Primary care, with acute or intensive care hospitalization due to complications. Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. Which action does the nurse take next? Interstitial edema Examine sputum for volume, odor, color, and consistency; document findings. c. Take the specimen immediately to the laboratory in an iced container. b. Provide tracheostomy care. e. Sleep-rest Nursing Care Plan for: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. The nurse anticipates that interprofessional management will include When planning care for a patient with pneumonia, the nurse recognizes that which is a high-priority intervention? arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period? 7) c. Send labeled specimen containers to the laboratory. Which medication therapy does the nurse anticipate will be prescribed? Pneumonia causing increased pus and mucus in the alveoli will interfere with gas exchange and oxygenation. a. The patient will also be able to demonstrate and verbalize understanding about the desired therapeutic regimen. - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. e. Airway obstruction is likely if the exact steps are not followed to produce speech. A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. During a follow-up visit one week after starting the medication, the patient tells the nurse, "In the last week, my urine turned orange, and I am very worried about it." c. "An annual vaccination is not necessary because previous immunity will protect you for several years." When F.N. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. Palpation is the assessment technique used to find which abnormal assessment findings (select all that apply)? Complains of dry mouth Patient Profile F.N. Has been NPO since midnight in preparation for surgery Cough suppressants. d. Comparison of patient's current vital signs with normal vital signs What measures should be taken to maintain F.N. NANDA Nursing diagnosis for Pneumonia Pneumonia ND1: Ineffective airway clearance. 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. Attempt to replace the tube. With severe pneumonia, the patient needs a higher level of care than general medical-surgical. What is a primary nursing responsibility after obtaining a blood specimen for ABGs? There is no redness or induration at the injection site. Preoperative education, explanation, and demonstration of pulmonary activities used postoperatively to prevent respiratory infections. Why is the air pollution produced by human activities a concern? What process would they have needed to complete in order to have been successful? high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. The most common causes of community-acquired pneumonia (CAP) is S. pneumoniae followed by Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. b. Palpation Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis Rationale An infection triggers alveolar inflammation and edema. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. Lung consolidation with fluid or exudate She received her RN license in 1997. Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. Since the patient is manifesting impaired gas exchange, one of the good indications that the oxygen absorption inside the body is not improving is through the skin changes, nail bed discoloration, and mucous production. c. Take the specimen immediately to the laboratory in an iced container. c. Terminal structures of the respiratory tract a. CO2 displaces oxygen on hemoglobin, leading to a decreased PaO2. Assess the patients vital signs at least every 4 hours. Respiratory distress requires immediate medical intervention. d. Oxygen saturation by pulse oximetry. nursing diagnosis based on the assessment data the major nursing diagnoses for meconium aspiration syndrome are hyperthermia related to inflammatory process hypermetabolic state as evidenced by an increase in body temperature warm skin and tachycardia fluid volume . Patient who is anesthetized 2. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Macrolide antibiotics such as azithromycin and clarithromycin are commonly used as first-line drugs for pneumonia. The patient will most likely feel comfortable and easy to breathe when their head is elevated in bed. Patient with a fever To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. 2) d. Direct the family members to the waiting room. c. Terminal structures of the respiratory tract a. Decreased immunoglobulin A (IgA) decreases the resistance to infection. Pneumonia may increase sputum production causing difficulty in clearing the airways. Oral hygiene moisturizes dehydrated tissues and mucous membranes in patients with fluid deficit. Pulse oximetry would not be affected by fever or anesthesia and is a method of monitoring arterial oxygen saturation in patients who are receiving oxygen therapy. 8. General physical assessment findingsof pneumonia. When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? ineffective airway clearance related to pneumonia and copd impaired gas exchange related to acute and chronic lung. Impaired gas exchange is the state in which there is an excess or deficit in oxygenation or in the elimination of carbon dioxide at the level of the alveolocapillary membrane.