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. Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. Discuss to him/her the different pros and cons of complying with the treatment regimen. Identify the ability of the patient to perform self-care and do activities of daily living. b. Buy on Amazon, Silvestri, L. A. Better Health Channel. Techniques that will be used to alleviate a dry mouth and prevent stomatitis Priority Decision: F.N. b. Impaired gas exchange is closely tied to Ineffective airway clearance. Bilateral ecchymosis of eyes (raccoon eyes) d. Activity-exercise: Decreased exercise or activity tolerance, dyspnea on rest or exertion, sedentary habits Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. However, with increasing respiratory distress, respiratory acidosis may occur. c. Take the specimen immediately to the laboratory in an iced container. How does the nurse respond? When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? Obtain the supplies that will be used. g. Self-perception-self-concept 3.5 Acute Pain. Fever and vomiting are not manifestations of a lung abscess. Administer the prescribed antibiotic and anti-pyretic medications. Aspiration is one of the two leading causes of nosocomial pneumonia. 1. The manifestations of viral, fungal, and bacterial infections are similar, and appearance is not diagnostic except when the white, irregular patches on the oropharynx suggest that candidiasis is present. Discuss to the patient the different types of pneumonia and the difference between him/her. Impaired Gas Exchange Nursing Diagnosis & Care Plan - Nurseslabs What the oxygenation status is with a stress test Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. Periorbital and facial edema reduced by about half since second hospital day a. SpO2 of 92%; PaO2 of 65 mm Hg Implement NPO orders for 6 to 12 hours before the test. The bacteria causing hospital-acquired pneumonia may be antibiotic-resistant, rendering this disease more difficult to treat than community-acquired pneumonia. 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. Also called nosocomial pneumonia, this type of pneumonia originates from being admitted in the hospital. c. Turbinates Steroids: To reduce the inflammation in the lungs. This is most common in intensive care units usually resulting from intubation and ventilation support. Assess the patients knowledge about Pneumonia. b. CO2 causes an increase in the amount of hydrogen ions available in the body. This is an expected finding with pneumonia, but should not continue to rise with treatment. The turbinates in the nose warm and moisturize inhaled air. As the patients condition worsens, sputum may become more abundant and change color from clear/white to yellow and/or green, or it may exhibit other discolorations characteristic of an underlying bacterial infection (e.g., rust-colored; currant jelly). 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. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Factors associated with aspiration pneumonia include old age, impaired gag reflex, surgical procedures, debilitating disease, and decreased level of consciousness. Assist with respiratory devices and techniques.Flutter valves mobilize secretions facilitating airway clearance while incentive spirometers expand the lungs. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. 2. of . c. Have the patient hyperextend the neck. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. It is important to assess the ability of the patient to do self-care ost especially if he or she is having respiratory symptoms. Assess lab values.An elevated white blood count is indicative of infection. d. An ET tube is more likely to lead to lower respiratory tract infection. e. Teach the patient about home tracheostomy care. Assist patient in a comfortable position. through the second week after the onset of symptoms. causing a clinical illness o Mandatory testing for health care professionals o Usually performed twice o Priority Nursing Diagnoses: Ineffective breathing pattern Ineffective airway clearance Impaired Gas . The nurse expects which treatment plan? PDF NMNEC Concept: Gas Exchange What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? What is a nursing diagnosis for impaired gas exchange? Which respiratory defense mechanism is most impaired by smoking? Touching an infected object and then touching your nose or mouth can also transfer the germs. 8. Which immediate action does the nurse take? Early small airway closure contributes to decreased PaO2. Symptoms of an abscess caused by aerobic bacteria develop more acutely and resemble bacterial pneumonia. The nurse can install an air filter machine that will help create a dust-free environment that will be ideal for a patient with pneumonia. Take an initial assessment of the patients respiratory rate and blood oxygen saturation using a pulse oximeter. The nurse explains that usual treatment includes Provide factual information about the disease process in a written or verbal form. Activity intolerance 2. 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 Weigh patient daily at same time of day and on same scale; record weight. 2. 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 patient with a 10-year history of regular (three beers per week) alcohol consumption began taking rifampin to treat tuberculosis (TB). Keep the patient in the semi-Fowler's position at all times. Place or install an air filter in the room to prevent the accumulation of dust inside. 3 Sample Nursing Care Plans for Pneumonia |Scenario-based Example Symptoms Altered consciousness Anxiety Changes in arterial blood gases (ABGs) Chest Tightness Coughing, with yellow sticky sputum If the patient is complaining about the difficulty of breathing, provide supplemental oxygen as ordered. 1. As such, here are the signs and symptoms that demonstrate the presence of impaired gas exchange. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Keep skin clean and dry through frequent perineal care or linen changes. d. Direct the family members to the waiting room. b. Consider imperceptible losses if the patient is diaphoretic and tachypneic. nursing care plan for pneumonia nursing care plan for stroke nursing care . 3. 6. The most common causes of HCAP and HAP are MRSA (methicillin-resistant Staphylococcus aureus) and Pseudomonas aeruginosa respectively. c. Tracheal deviation b. . Cough reflex Monitor patient's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. All other answers indicate a negative response to skin testing. Suction secretions as needed. Normally the AP diameter should be 13 to 12 the side-to-side diameter. Has been NPO since midnight in preparation for surgery 3) Sleep alone. Dyspnea and severe sinus pain as well as tender swollen glands, severe ear pain, or significantly worsening symptoms or changes in sputum characteristics in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. Select all that apply. To care for the tracheostomy appropriately, what should the nurse do? The trachea connects the larynx and the bronchi. A significant increase in oxygen demand to maintain O2 saturation greater than 92% should be reported immediately. f. Use of accessory muscles. Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. Volcanic eruptions and other natural events result in air pollution. Guillain-Barr syndrome, illicit drug use, and recent abdominal surgery do not put the patient at an increased risk for aspiration pneumonia. The patient will also be able to fully understand how pneumonia is being transmitted to avoid having the disease transfer from other family members. k. Value-belief: Noncompliance with treatment plan, conflict with values, The abnormal assessment findings of dullness and hyperresonance are found with which assessment technique? a. i. Sexuality-reproductive The prognosis of a patient with PE is good if therapy is started immediately. c. Patient in hypovolemic shock Suctioning keeps the airway clear by removing secretions. Pinch the soft part of the nose. Start asking what they know about the disease and further discuss it with the patient. a. Assess the patient for iodine allergy. 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. Try to use words that can be understood by normal people. Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. Blood tests elevated white blood cell count may be a sign of an ongoing infection, Sputum culture to determine the causative agent, Imaging chest X-ray to determine active infection and its severity; bronchoscopy to check any blockage of the airways; CT scan for a more detailed lung imaging, Arterial blood gas (ABG) test using an arterial blood sample to measure the oxygen level, Pleural fluid culture taking a pleural fluid sample by inserting a needle between the pleural cavity and the ribs in order to determine the causative agent. Generally, two types of pneumonia are distinguished: community-acquired and hospital-associated (nosocomial). Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. Monitor and document vital signs (VS) every 2 to 4 hours or as the patients condition requires. Subjective Data: Pt family member tells you that the patient has been sleeping constantly for 2 weeks. b. Cuff pressure monitoring is not required. 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. St. Louis, MO: Elsevier. Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. The visceral pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. Assisting the patient in moderate-high backrest will facilitate better lung expansion thus they can breathe better and would feel comfortable. Administer oxygen.Supplemental oxygen may be needed to support oxygenation and to maintain sp02 levels. Increase heat and humidity if patient has persistent secretions. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. 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. Fungal pneumonia. Risk - Examines the patient's vulnerability for developing an undesirable response to a health condition or life process. d. Assess arterial blood gases every 8 hours. c. Drainage on the nasal dressing There is no redness or induration at the injection site. b. Pneumonia Nursing Care Plans - 11 Nursing Diagnosis - Nurseslabs People with community-acquired pneumonia usually do not need to be hospitalized unless an underlying condition such as chronic obstructive pulmonary disease (COPD), heart disease or diabetes mellitus, or a weakened immune system complicates the disease. A patient who is being treated at home for pneumonia reports fatigue to the home health nurse. The patient may have a limit to visitors to prevent the transmission of infections. b. Stridor Pneumonia Nursing Diagnosis & Care Plan - NurseStudy.Net 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. Pneumonia Nursing Diagnosis & Care Plan | NurseTogether On inspection, the throat is reddened and edematous with patchy yellow exudates. 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. d. Dyspnea and severe sinus pain b. RV: (7) Amount of air remaining in lungs after forced expiration Findings may show hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg) with resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease. Allow 90 minutes for. f. Hyperresonance These practices further reduce the risk of contamination. Monitor for worsening signs of infection or sepsis.Dropping blood pressure, hypothermia or hyperthermia, elevated heart rate, and tachypnea are signs of sepsis that require immediate attention. Notify the health care provider. Assess the patients vital signs and characteristics of respirations at least every 4 hours. 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. a. Stridor The 150 mL of air is dead space in the trachea and bronchi. Please read our disclaimer. Coughing and difficulty of breathing may cause. 5) Minimize time in congregate settings. These symptoms are very crucial and the patient must be given immediate care and intervention to avoid hypoxia. Encourage coughing up of phlegm. patients will better understand the health teachings if there is a written or oral guide for him/her to look back to. Base to apex 5. Pockets of pus may form inside the lungs or on their outer layers. b. Nutritional-metabolic: Decreased fluid intake, anorexia and rapid weight loss, obesity 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. b. b. Avoid instillation of saline during suctioning. Impaired gas exchange is a condition that occurs when there is an insufficient amount of oxygen in the blood. How to use esophageal speech to communicate The cuff passively fills with air. g. FEV1 Wheezing is a sign of airway obstruction that requires immediate intervention to ensure effective gas exchange. Viral pneumonia. Base to apex CASE STUDY: Rhinoplasty If sepsis is suspected, a blood culture can be obtained. Air trapping Nursing Care Plan (NCP) for Impaired Gas Exchange | NRSNG Nursing Course Chronic hypoxemia 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 Nursing Diagnosis for COPD | Nursing Care Plan & Interventions for COPD d. Oxygen saturation by pulse oximetry. a. Apex to base 3. 1# Priority Nursing Diagnosis. 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. The immunity will not protect for several years, as new strains of influenza may develop each year. Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. Patient Profile F.N. What is the first patient assessment the nurse should make? a. Fatigue 4. These interventions help facilitate optimum lung expansion and improve lungs ventilation. d. Small airway closure earlier in expiration c. Use cromolyn nasal spray prophylactically year-round. Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology. Impaired gas exchange 5. Are there any collaborative problems? Pneumonia can be mild but can also be fatal if left untreated. Normal mixed venous blood gases also have much lower partial pressure of oxygen in venous blood (PvO2) and venous oxygen saturation (SvO2) than ABGs. If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues. deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). d. Patient receiving oxygen therapy. b. Unstable hemodynamics d. SpO2 of 88%; PaO2 of 55 mm Hg. Encourage to always change position to facilitate mucous drainage in the lungs. Identify 1 specific finding identified by the nurse during assessment of each of the patient's functional health patterns that indicates a risk factor for respiratory problems or a patient response to an actual respiratory problem. 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). a. TB d. Parietal pleura. A) Seizures The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. d. Assess the patient's swallowing ability. c. A negative skin test is followed by a negative chest x-ray. 6. a. 6. Concept Map-AHI - Concept Mapping Nursing diagnosis: Impaired gas During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? Thorough hand hygiene before and after patient contact (even if gloves are worn). Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. c. The necessity of never covering the laryngectomy stoma 's airway before and after surgery? It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. She received her RN license in 1997. b. Alveolar-capillary membrane changes (inflammatory effects) Nurses should assess for and encourage pneumonia vaccines for eligible populations. It is important to let the patient know the pros of taking an accurate dosage and the right timing of medication for fast recovery. a. Finger clubbing d. Comparison of patient's current vital signs with normal vital signs. What is included in the nursing care of the patient with a cuffed tracheostomy tube? Visualize and note some changes when it comes to the color of the skin, quality of mucous production, and nail beds. impaired gas exchange nursing care plan scribd Impaired Gas Exchange Nursing Diagnosis & Care Plan - NurseTogether Help the patient get into a comfortable position, usually the half-Fowler position. 4) Recent abdominal surgery. Saline instillation can cause bacteria to shift to the lower lung areas, increasing the risk of inflammation and invasion of sterile tissues. Medications such as paracetamol, ibuprofen, and. 2) It is a highly contagious respiratory tract infection. Usually, people with pneumonia preferred their heads elevated with a pillow. Observing for hypoxia is done to keep the HCP informed. Decreased functional cilia and decreased force of cough from declining muscle strength cause decreased secretion clearance. Pneumonia is an infection itself but a risk for infection nursing diagnosis is appropriate as untreated pneumonia can progress into a secondary infection or sepsis. The respiratory rate, pulse rate, and BP will all increase with decreased oxygenation when compared to the patient's own normal results. The nurse anticipates that interprofessional management will include Also, they will effectively help spread the disease process since they know the mode of transmission and how to break the cycle of transmitting it to other family members. Select all that apply. The patient will have improved gas exchange. 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. d. Thoracic cage. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). d) 8. 2. c. Mucociliary clearance b. 1. 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. However, it is highly unlikely that TB has spread to the liver. 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? - Pertussis is a highly contagious infection of the respiratory tract caused by the gram-negative bacillus Bordetella pertussis. Our website services and content are for informational purposes only. Change ventilation tubing according to agency guidelines. was admitted, examination of his nose revealed clear drainage. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. b. 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." The nurse can also teach coughing and deep breathing exercises. b. b. Otherwise, scroll down to view this completed care plan. A patient develops epistaxis after removal of a nasogastric tube. a. Deflate the cuff, then remove and suction the inner cannula. I do not know if it's just overthinking it or what but all the care plans i have read . Here are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). Pink, frothy sputum would be present in CHF and pulmonary edema. Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. Fungal pneumonia is caused by inhaling fungal spores that can come from dust, soil, and droppings of rodents, bats, birds or other animals. Health perception-health management Place some timetable as to when each medication should be administered to ensure compliance and timely administration of medication. d. Inform the patient that radiation isolation for 24 hours after the test is necessary. a. Save my name, email, and website in this browser for the next time I comment. All of the assessments are appropriate, but the most important is the patient's oxygen status. 3. Goal/Desired Outcome Short-term goal: The patient will remain free from signs of respiratory distress and her oxygen saturation will remain higher than 96% for the duration of the shift. Corticosteroids and bronchodilators are not useful in reducing symptoms. h. Absent breath sounds This also increases the risk for aspiration pneumonia. Promote oral hygiene, including lip and tongue care. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. What keeps alveoli from collapsing? Air trapping Nursing diagnosis for pleural effusion may vary depending on the patient's individual symptoms and condition. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, have respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96%, and verbalize ease of breathing. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia, https://my.clevelandclinic.org/health/diseases/4471-pneumonia, https://doi.org/10.1111/j.1753-4887.2010.00304.x, https://emedicine.medscape.com/article/234753-overview#a4, Hypertension Nursing Diagnosis & Care Plan, The ABCs of Evidence-Based Practice in Nursing, Diminished lung sounds or crackles/rhonchi, Patient will demonstrate appropriate airway clearance techniques, Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate, Hypoventilation causing a lack of oxygen delivery, Patient will display appropriate oxygenation through ABGs within normal limits, Patient will demonstrate appropriate actions to promote ventilation and oxygenation, Inadequate primary defenses: decreased ciliary action, respiratory secretions, Invasive procedures: suctioning, intubation, Patient will not develop a secondary infection or sepsis, Patient will display improvement in infection evidenced by vital signs and lab values within normal limits. Pulmonary function test Ventilator-associated pneumonia is one of the subtypes of hospital-acquired pneumonia. a. The injected inactivated influenza vaccine is recommended for individuals 6 months of age and older and those at increased risk for influenza-related complications, such as people with chronic medical conditions or those who are immunocompromised, residents of long-term care facilities, health care workers, and providers of care to at-risk persons. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. 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.