Week 1 - Nursing Care of Patients with Respiratory Problems Influenza, Atelectasis, Pneumonia, TB, & Expert Help. 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. Pockets of pus may form inside the lungs or on their outer layers. 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. A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). c. Empyema 1) b. It is important to have an initial assessment of the patient and use it as a comparison for future reference or referral. 8. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Exercise and activity help mobilize secretions to facilitate airway clearance. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. 1# Priority Nursing Diagnosis. a. a. Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. Which instructions does the nurse provide to the patient to minimize exposure to close contacts and household members? The patient is admitted with pneumonia, and the nurse hears a grating sound when she assesses the patient. In healthy individuals, pneumonia is not usually life-threatening and does not require hospitalization. Serologic studies: Acute and convalescent antibody titers determined for the diagnosis of viral pneumonia. A patient's initial purified protein derivative (PPD) skin test result is positive. 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. f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted. What is the first action the nurse should take? Select all that apply. 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. g. Fine crackles This type of pneumonia can spread through droplet transmission, that is, when an infected person sneezes or coughs, and the other person breathes the air droplets through the nasal or oral airways. 3. 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. 2. a. This is done before sending the sample to the laboratory if there is no one else who can send the sample to the laboratory. Which values indicate a need for the use of continuous oxygen therapy? Document the results in the patient's record. Nursing diagnoses handbook: An evidence-based guide to planning care. 1. Thorough hand hygiene before and after patient contact (even if gloves are worn). A) Admit the patient to the intensive care unit. 4) Cough suppressants and antihistamines should not be used. b. 8. e. FVC If the patient is ambulatory, walking should be encouraged within the patients tolerance. a. This position provides comfort, promotes descent of the diaphragm, maximizes inspiration, and decreases work of breathing. Stridor is identified with auscultation. d. Limited chest expansion Nursing Diagnosis: Ineffective Airway Clearance. c. TLC Nursing care plans: Diagnoses, interventions, & outcomes. Please follow your facilities guidelines, policies, and procedures. Pinch the soft part of the nose. Keep the head end of the bed at a height of 30 to 45 degrees and turn the patient to the lateral position. k. Value-belief, Risk Factor for or Response to Respiratory Problem The patient needs to be able to effectively remove these secretions to maintain a patent airway. Impaired gas exchange is a risk nursing diagnosis for pneumonia. Administer the prescribed antibiotic and anti-pyretic medications. Encourage plenty of rest without interruption in a calm environment, and space out activities such as bathing or therapy to limit oxygen consumption. A) Seizures Amount of air exhaled in first second of forced vital capacity Normal or low leukocyte counts (less than 4000/mm3) may occur in viral or mycoplasma pneumonia. The nurse should instruct on how to properly use these devices and encourage their use hourly. It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Lung consolidation with fluid or exudate Impaired gas exchange 5. Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. a. a. Suction the tracheostomy. arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period? d. Positron emission tomography (PET) scan. Visualize and note some changes when it comes to the color of the skin, quality of mucous production, and nail beds. Decreased functional cilia Maegan Wagner is a registered nurse with over 10 years of healthcare experience. e. Posterior then anterior. c. a radical neck dissection that removes possible sites of metastasis. f. Use of accessory muscles. Are there any collaborative problems? b. Epiglottis 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? In patients with unilateral pneumonia, positioning on the unaffected side (i.e., good side down) promotes ventilation to perfusion adaptation. Remove the inner cannula and replace it per institutional guidelines. If there is no improvement with the symptoms, the doctor may prescribe a different type of antibiotic. 4. j. Coping-stress tolerance a. It may also stimulate coughing. To detect presence of hypernatremia, hyperglycemia, and/or dehydration. Nutrition reviews, 68(8), 439458. Promote fluid intake (at least 2.5 L/day in unrestricted patients). Which nursing intervention assists a patient with pneumonia in managing thick secretions and fatigue? Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. Assessment findings include a new onset of confusion, a respiratory rate of 42 breaths/minute, a blood urea nitrogen (BUN) of 24 mg/dL, and a BP of 80/50 mm Hg. Consider imperceptible losses if the patient is diaphoretic and tachypneic. No signs or symptoms of tuberculosis or allergies are evident. 3 Nursing care plans for pneumonia. For which problem is this test most commonly used as a diagnostic measure? She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. d. a total laryngectomy to prevent development of second primary cancers. Amount of air that can be quickly and forcefully exhaled after maximum inspiration 1. 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. Patient who is anesthetized Respiratory infection 3. Goal. 1. c. Keep a same-size or larger replacement tube at the bedside. 3.1 Ineffective airway clearance. The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. b. Although inadequately treated -hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. Early small airway closure contributes to decreased PaO2. c. Wheezing Give health teachings about the importance of taking prescribed medication on time and with the right dose. - 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. Study Resources . Pneumonia: Bacterial or viral infections in the lungs . NurseTogether.com does not provide medical advice, diagnosis, or treatment. 3. Unless contraindicated, promote fluid intake (2.5 L/day or more). Nurses also play a role in preventing pneumonia through education. Decreased force of cough d. Inform the patient that radiation isolation for 24 hours after the test is necessary. c. Ventilation-perfusion scan Bilateral ecchymosis of eyes (raccoon eyes) c. Turbinates 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. b. 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. "Only health care workers in contact with high-risk patients should be immunized each year." Select all that apply. The process of gas exchange, called diffusion, happens between the alveoli and the pulmonary capillaries. This can be due to a compromised respiratory system or due to lung disease. The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. Major nursing care planning goals for COVID-19 may include: Establishing goals, interventions. 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. d. Pleural friction rub c. There is equal but diminished movement of the 2 sides of the chest. 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. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. Encouraging oral fluids will mobilize respiratory secretions. CASE STUDY: Rhinoplasty A patient develops epistaxis after removal of a nasogastric tube. 3.5 Acute Pain. Expresses concern about his facial appearance 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. 4) Spend as much time as possible outdoors. If the patient is enteral fed, recommend continuous rather than bolus feeding. Bronchoconstriction 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.

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